Management interventions for amputation stump neuromas : evidence based review and cost-benefit analysis

Amputation is a common military and civilian surgery with high morbidity. Patients without prostheses due to neuroma pain lose productivity and lifelong contributions, which is often underestimated. The surgical and non-surgical treatment of painful stump neuromas is controversial. An evidence-based assessment and cost-benefit analysis of painful stump neuroma management modalities emphasizes institutional awareness and disruptive technologies. An Oxford Centre for Evidence Based Methodology critical appraisal and structured literature review were used in the research. We found 154 records using a reproducible literature search strategy that included electronic databases and references. A full review of 27 manuscripts after exclusion criteria yielded data for analysis. Surgical, injectable, and electromagnetic spectrum methods were used. Surgical interventions had longer follow-up times than injection and radiofrequency treatments, which affected outcomes. CEBM level 4 evidence dominated primary literature, indicating low quality. No therapy was superior, but the risks varied. Injection therapies like sclerosing alcohol had limited success and side effects. Despite limited evidence, electromagnetic spectrum modalities showed potential. Including direct and indirect costs, amputation stump refitting costs millions annually. Compared to outpatient non-surgical interventions, laser therapy could save a lot of money. According to the study, surgical interventions are common but expensive and have limited functional success. Low-risk non-surgical methods like co-ablation, pulsed radiofrequency, and transcutaneous laser therapy have mixed results. The short follow-up of all non-surgical studies seems to limit them. Follow-up duration is crucial to outcome assessment. Long-term, low-risk laser-induced thermotherapy is promising for future research. This study emphasizes the need for more research and the economic benefits of disruptive technologies in treating painful stump neuromas.peer-reviewe

Exploring the role of distributed simulation to advance the delivery of surgical education and teamwork training

Burns can represent devastating injuries surgically, psychologically and socially. A multidisciplinary team approach to patient management is requisite to successful patient management. Burns education is currently under-represented in national undergraduate surgical curricula with a resultant graduating workforce with sub-optimal burns management knowledge. There is therefore a drive to improve burns education nationally. In order to develop burns teams to perform with skill and efficiency, it is important to develop and advance their technical and non-technical skills. Simulation has proven to be a powerful modality to augment surgical training. Recreating authentic clinical challenges is crucial in optimising simulation-based team training. The majority of such team-based simulation takes place in dedicated simulation facilities or centres which are static and can be costly. This thesis presents eight peer-reviewed publications that chronologically represent a thematic series of publications in simulation and surgical education with an ultimate focus on burns education. The theoretical framework explores simulation strategies in light of educational theory, culminating in the development of "The Burns Suite" (TBS); a novel modality to advance the delivery of interprofessional burns education. TBS represents a low-cost, high-fidelity, portable, immersive simulation environment. It facilitates the delivery of an interprofessional realistic burn resuscitation scenario based on "advanced trauma and life support" (ALTS) and "emergency management of severe burns" (EMSB) principles. Scenarios were refined utilising expert opinion through cognitive task analyses. Participants considered TBS experience authentic due to its high psychological and social fidelity. This thesis contributes to burns surgical education by providing a better understanding of educational theory underpinning successful simulation and facilitating its interprofessional delivery via TBS. This approach can facilitate the design of future simulation scenarios that provide unique educational experiences where team members can learn with and from other specialties and professions in a safe, controlled environment. Addressing economic and practical limitations of current immersive surgical simulation is important. The low-cost approach of TBS has major implications for surgical education as a whole, particularly given increasing financial austerity. This thesis proposes that alternative, complex, and challenging scenarios and/or procedures can be recreated within TBS, providing a diverse educational immersive simulation experience that can be extrapolated into other surgical specialities and interprofessional arenas

Handover practice amongst core surgical trainees at the Oxford School of Surgery

Purpose: To date there are no United Kingdom (UK) studies specifically evaluating handovers amongst core surgical trainees (CSTs). The Oxford School of Surgery examined regional handover practice, aiming to assess and improve trainee perception of handover, its quality, and ultimately patient care. Methods: Based on two guidance documents ('Safe handover, safe patients' by the British Medical Association and 'Safe Surgical Practice' by the Royal College of Surgeons'), a 5-point Likert style questionnaire was designed, exploring handover practice, educational value, and satisfaction. This was given to 50 CSTs in 2010. Results: There were responses from 40 CSTs (80.0 %). The most striking findings revolved around perceived educational value, formal training, and auditing practice with regards to handover, which were all remarkably lower than expected. CST handover was thus targeted in the Department of Plastic Surgery at the University Hospital, with the suggestion and implementation of targeted changes to improve practice. Conclusion: In the EWTD era with many missed educational opportunities, daily handover represents an underused educational tool for CSTs, especially in light of competency-based and time-limited training. We recommend modifications based on our results and the literature and hope schools of surgery follow suit nationally by assessing and addressing handover practice

A video analysis of intra- and interprofessional leadership behaviors within “The Burns Suite”: Identifying key leadership models

Objective Leadership is particularly important in complex highly interprofessional health care contexts involving a number of staff, some from the same specialty (intraprofessional), and others from different specialties (interprofessional). The authors recently published the concept of “The Burns Suite” (TBS) as a novel simulation tool to deliver interprofessional and teamwork training. It is unclear which leadership behaviors are the most important in an interprofessional burns resuscitation scenario, and whether they can be modeled on to current leadership theory. The purpose of this study was to perform a comprehensive video analysis of leadership behaviors within TBS. Methods A total of 3 burns resuscitation simulations within TBS were recorded. The video analysis was grounded-theory inspired. Using predefined criteria, actions/interactions deemed as leadership behaviors were identified. Using an inductive iterative process, 8 main leadership behaviors were identified. Cohen’s κ coefficient was used to measure inter-rater agreement and calculated as κ = 0.7 (substantial agreement). Each video was watched 4 times, focusing on 1 of the 4 team members per viewing (senior surgeon, senior nurse, trainee surgeon, and trainee nurse). The frequency and types of leadership behavior of each of the 4 team members were recorded. Statistical significance to assess any differences was assessed using analysis of variance, whereby a p < 0.05 was taken to be significant. Leadership behaviors were triangulated with verbal cues and actions from the videos. Results All 3 scenarios were successfully completed. The mean scenario length was 22 minutes. A total of 362 leadership behaviors were recorded from the 12 participants. The most evident leadership behaviors of all team members were adhering to guidelines (which effectively equates to following Advanced Trauma and Life Support/Emergency Management of Severe Burns resuscitation guidelines and hence “maintaining standards”), followed by making decisions. Although in terms of total frequency the senior surgeon engaged in more leadership behaviors compared with the entire team, statistically there was no significant difference between all 4 members within the 8 leadership categories. This analysis highlights that “distributed leadership” was predominant, whereby leadership was “distributed” or “shared” among team members. The leadership behaviors within TBS also seemed to fall in line with the “direction, alignment, and commitment” ontology. Conclusions Effective leadership is essential for successful functioning of work teams and accomplishment of task goals. As the resuscitation of a patient with major burns is a dynamic event, team leaders require flexibility in their leadership behaviors to effectively adapt to changing situations. Understanding leadership behaviors of different team members within an authentic simulation can identify important behaviors required to optimize nontechnical skills in a major resuscitation. Furthermore, attempting to map these behaviors on to leadership models can help further our understanding of leadership theory. Collectively this can aid the development of refined simulation scenarios for team members, and can be extrapolated into other areas of simulation-based team training and interprofessional educatio

How Educational Theory Can Inform the Training and Practice of Plastic Surgeons

Summary:. It is important to optimize our current learning and teaching models, particularly in a climate of decreased clinical exposure. With technical advancements and clinical care now more accountable, traditional methods of skill acquisition need to be revisited. The past decade has seen changes in plastic surgery curricula. There has also been a shift toward competency-based training programs reflecting the growing emphasis on outcomes-based surgical education. This review explores the role of educational theory in promoting effective learning in practical skills teaching. Key models of educational theory are presented and their application to plastic surgery training to an expert level are highlighted. These models include (1) learning within communities of practice (Lave and Wenger’s theory); (2) the role of the zone of proximal development and importance of the availability of expert assistance (Vygotsky’s theory); (3) skill acquisition and retention (Dreyfus’ and Dreyfus’, and Fitts’ and Posner’s theories); (4) development of expertise after repeated practice and regular reinforcement (Ericsson’s theory); and (5) the assessment of competence (Miller’s triangle). Future plastic surgeons need to possess a thorough understanding of the technical and nontechnical skills required to manage patients effectively. Surgical educators are therefore compelled to develop practical training programs that can teach each of these skills in a safe, learner-centric manner. It is hoped that new approaches to surgical skills training are designed in light of our understanding of educational theory to optimize the training of the next generation of plastic surgeons