Nontechnical Skills in Postgraduate Surgical Education

Background: Surgeons’ nontechnical skills are critical for patient safety in the operating room (OR) and have been included in resident training requirements. The optimal approach to their training and assessment though is unknown. The goal of this thesis was to develop a structured approach to the training and assessment of nontechnical skills in surgical education. Methods: Objectives were: (1) to establish the prevalence of nontechnical training components in postgraduate curricula; (2) to develop a reliable tool for the criterion-referenced assessment of residents’ nontechnical performance; (3) to determine surgical residents’ innate nontechnical skills and how these relate to personality; (4) to evaluate the effectiveness of a strategy for competency-based training of nontechnical skills in surgical residency. Results: (1) One-third of responding residency programs reported nontechnical training components; (2) the Objective Structured Assessment of Nontechnical Skills (OSANTS) tool was developed to assess resident-specific skills. Good psychometric properties were demonstrated, both in simulation and in the real OR; (3) large inter-individual differences in nontechnical performance were found among 31 junior surgical residents. Some variability could be explained by personality traits; (4a) a basic skills curriculum was evaluated in a randomized trial. Curriculum trained first-year residents (n=11) outperformed conventionally trained peers (n=11) in knowledge and attitudes about nontechnical skills. Curriculum-trained residents’ performance in a simulated OR improved significantly from baseline to post-training (OSANTS: (median 23(interquartile range 17-28) vs. 31(25-33), p=0.012), while conventionally trained residents did not improve (OSANTS, 26(24-32) vs. 24(23-32), p=0.713); (4b) In an interrupted time-series study, observed nontechnical performance of senior residents (n=11) in the OR improved significantly following one debriefing and feedback session. Conclusion: Based on the results, a combined approach to nontechnical education in surgical postgraduate education is proposed, with a basic skills curriculum in the first year, and debriefing and feedback in formative assessments throughout residency training.Ph.D

Early Prosthetic Complications After Unipolar Hemiarthroplasty

Background In Australia the most frequently employed hemiarthroplasty prosthesis for the management of displaced intracapsular femoral neck fractures is the Uncemented Austin Moore (UAM). Despite concerns regarding poor functional outcomes and increased early revision rates associated with the UAM prosthesis, apprehension regarding the systemic side effects of polymethylmethacrylate cement implantation in the elderly patient continues to influence prosthesis selection. This study examines the incidence of early prosthesis related complications after UAM and Cemented Thompson (CT) hemiarthroplasty procedures for the management of femoral neck fractures. Methods A multicentre retrospective review of charts and radiographs was conducted in order to determine early prosthetic complications associated with the CT and UAM prostheses over a 6 year period in five Queensland public hospitals. Results Intraoperative periprosthetic fractures were sustained in 11.8% of UAM and 1.8% of CT implantations (p<0.0001). Intraoperative periprosthetic fractures were associated with an increased requirement for reoperation within 1 month of the index procedure (p=0.05). No statistical difference in the incidence of intraoperative periprosthetic fractures could be observed between the hospitals participating, regardless of the proportional use of each prosthesis. Early dislocation rates were similar for the UAM and CT prostheses. The intraoperative mortality rate attributable to the use of polymethylmethacrylate cement during hip hemiarthroplasty was 1/ 738 (0.14%). Conclusions The results of this study support the use of the CT prosthesis for the management of femoral neck fractures to reduce the high incidence of intraoperative periprosthetic fractures and associated requirements for early reoperation experienced with the UAM

Early Prosthetic Complications after Uncemented Austin Moore and Cemented Thompson Hemiarthroplasty. A Multicentre Review of 1118 Patients.

Introduction &amp; Aims For displaced intracapsular fractures of the femoral neck the most frequently employed hemiarthroplasty in Australia is the Uncemented Austin Moore (UAM) prosthesis. Despite concerns regarding the poor functional outcome and increased revision rates associated with the UAM prosthesis, apprehension about the systemic effects of PMMA acrylic cement implantation in the elderly patient continues to influence prosthesis selection. This study examines the incidence early prosthesis related complications after Uncemented Austin Moore (UAM) and Cemented Thompson (CT) hemiarthroplasty implantation for the management of femoral neck fractures

Differentially Expressed miRNAs in Ewing Sarcoma Compared to Mesenchymal Stem Cells: Low miR-31 Expression with Effects on Proliferation and Invasion

<div><p>Ewing sarcoma, the second most common bone tumor in children and young adults, is an aggressive malignancy with a strong potential to metastasize. Ewing sarcoma is characterised by translocations encoding fusion transcription factors with an EWSR1 transactivation domain fused to an ETS family DNA binding domain. microRNAs are post-transcriptional regulators of gene expression and aberrantly expressed microRNAs have been identified as tumor suppressors or oncogenes in most cancer types. To identify potential oncogenic and tumor suppressor microRNAs in Ewing sarcoma, we determined and compared the expression of 377 microRNAs in 40 Ewing sarcoma biopsies, 6 Ewing sarcoma cell lines and mesenchymal stem cells, the putative cellular origin of Ewing sarcoma, from 6 healthy donors. Of the 35 differentially expressed microRNAs identified (fold change >4 and q<0.05), 19 were higher and 16 lower expressed in Ewing sarcoma. In comparisons between Ewing sarcoma samples with EWS-FLI or EWS-ERG translocations, with differing dissemination characteristics and of primary samples and metastases no significantly differential expressed microRNAs were detected using various stringency criteria. For miR-31, the microRNA with lowest expression in comparison to mesenchymal stem cells, functional analyses were performed to determine its potential as a tumor suppressor in Ewing sarcoma. Two of four miR-31 transfected Ewing sarcoma cell lines showed a significantly reduced proliferation (19% and 33% reduction) due to increased apoptosis in one and increased length of G1-phase in the other cell line. All three tested miR-31 transfected Ewing sarcoma cell lines showed significantly reduced invasiveness (56% to 71% reduction). In summary, we identified 35 microRNAs differentially expressed in Ewing sarcoma and demonstrate that miR-31 affects proliferation and invasion of Ewing sarcoma cell lines in ex vivo assays.</p></div

Effects of miR-31 on invasiveness of ES cell lines.

<p>Effect of miR-31 on invasion of ES cell lines in ex vivo assays after 72 hours. Invasiveness was analysed in a two chamber cell culture system. After 30 hours or 48 hours cells attached to the membrane in the lower chamber were counted. Shown are average values of three independent experiments. As miR-31 reduced proliferation, cells in additional chambers were treated as the cells used to determine invasion and total cell numbers were counted to calculate a proliferation correction factor with which the numbers of migrated miR-31 transfected cells were multiplied.</p

miR-31 expression in mesenchymal stem cells and Ewing sarcomas with different clinicopathological features.

<p>miR-31 expression in 6 MSC samples and 40 ES biopsies was determined using TLDAs. Ct-values were normalized using U6 snRNA. The ES samples were dived into different groups based on tumor size (27 primary tumors, for 6 primary tumors this information was not available) or dissemination characteristics.</p