Can I handle the scalpel?:Different views on critical subtask assessment between residents and expert surgeons

Background: Success of surgical procedures largely depends on good judgment and decision making and these skills are mostly taught implicitly in the OR. Cognitive task analysis (CTA) has been used successful to elicit tacit expert knowledge to determine the decision points in a medical procedure and then use this in medical skill instructions. For instructions to be effective, it is also important that they are timed properly, that is, during low mental workload in the resident. Aim(s): As a start for further research, we therefore asked residents to indicate their mental workload during the steps of an orthopaedic procedure. Because in the OR, residents are commonly guided by supervisors, we also investigated which steps supervisors find mentally demanding. Methods: A task analysis of a total hip replacement procedure was constructed. Subsequently we asked both 17 orthopedic surgeons (supervisors) and 21 residents to rate (5-point scale) how much mental effort they invest in each subtask. They were asked to explain ratings above average (>3). Results: Although there were subtasks where supervisors and residents disagreed on the level of attention required, overall, supervisors and residents agreed for most subtasks. High attention was related to subtasks that require decision making skills. However, the reasons were different. In residents, high ratings were associated with subtasks that they found difficult, or where they were anxious about doing it accurately. Supervisors’ ratings were more correlated with the evaluation of crucial, i.e., point-of-no-return steps where quality of execution has important consequences for later steps, end result or complications. Discussion/Conclusion: Supervisors pay more attention to steps that will become important later in the procedure, whereas residents are more anxious about their own performance in crucial steps. It may be useful for supervisors and residents to be aware of this difference in interpretation of “important steps”

Procalcitonin to guide taking blood cultures in the intensive care unit; a cluster-randomized controlled trial

Objectives: We aimed to study the safety and efficacy of procalcitonin in guiding blood cultures taking in critically ill patients with suspected infection. Methods: We performed a cluster-randomized, multi-centre, single-blinded, cross-over trial. Patients suspected of infection in whom taking blood for culture was indicated were included. The participating intensive care units were stratified and randomized by treatment regimen into a control group and a procalcitonin-guided group. All patients included in this trial followed the regimen that was allocated to the intensive care unit for that period. In both groups, blood was drawn at the same moment for a procalcitonin measurement and blood cultures. In the procalcitonin-guided group, blood cultures were sent to the department of medical microbiology when the procalcitonin was>0.25 ng/mL. The main outcome was safety, expressed as mortality at day 28 and day 90. Results: The control group included 288 patients and the procalcitonin-guided group included 276 patients. The 28- and 90-day mortality rates in the procalcitonin-guided group were 29% (80/276) and 38% (105/276), respectively. The mortality rates in the control group were 32% (92/288) at day 28 and 40% (115/288) at day 90. The intention-to-treat analysis showed hazard ratios of 0.85 (95% CI 0.62-1.17) and 0.89 (95% CI 0.67-1.17) for 28-day and 90-day mortality, respectively. The results were deemed non-inferior because the upper limit of the 95% CI was below the margin of 1.20. Conclusion: Applying procalcitonin to guide blood cultures in critically ill patients with suspected infection seems to be safe, but the benefits may be limited. Trial registration: . ClinicalTrials.gov identifier: ID . NCT01847079. Registered on 24 April 2013, retrospectively registered

Fingerprints of Teaching Interactions:Capturing and Quantifying How Supervisor Regulate Autonomy of Residents in the Operating Room

Objective: Supervisors and residents agree that entrusted autonomy is central to learning in the Operating Room (OR), but supervisors and residents hold different opinions about entrustment: residents regularly experience that they receive insufficient autonomy while supervisors feel their guiding is not appreciated as teaching. These opinions are commonly grounded on general experiences and perceptions, instead of real-time supervisors’ regulatory behaviors as procedures unfold. To close that gap, we captured and analyzed when and to what level supervisors award or restrain autonomy during procedures. Furthermore, we constructed fingerprints, an instrument to visualize entrustment of autonomy by supervisors in the OR that allows us to reflect on regulation of autonomy and discuss teaching interactions. Design: All interactions between supervisors and residents were captured by video and transcribed. Subsequently a multistage analysis was performed: (1) the procedure was broken down into 10 steps, (2) for each step, type and frequency of strategies by supervisors to regulate autonomy were scored, (3) the scores for each step were plotted into fingerprints, and (4) fingerprints were analyzed and compared. Setting: University Medical Centre Groningen (the Netherlands). Participants: Six different supervisor-resident dyads. Results: No fingerprint was alike: timing, frequency, and type of strategy that supervisors used to regulate autonomy varied within and between procedures. Comparing fingerprints revealed that supervisors B and D displayed more overall control over their program-year 5 residents than supervisors C and E over their program-year 4 residents. Furthermore, each supervisor restrained autonomy during steps 4 to 6 but with different intensities. Conclusions: Fingerprints show a high definition view on the unique dynamics of real-time autonomy regulation in the OR. One fingerprint functions as a snapshot and serves a purpose in one-off teaching and learning. Multiple snapshots of one resident quantify autonomy development over time, while multiple snapshots of supervisors may capture best teaching practices to feed train-the-trainer programs

Directional nanotopographic gradients:a high-throughput screening platform for cell contact guidance

A novel approach was developed using PDMS-substrates with surface-aligned nanotopography gradients, varying unidirectional in amplitude and wavelength, for studying cell behavior with regard to adhesion and alignment. The gradients target more surface feature parameters simultaneously and provide more information with fewer experiments and are therefore vastly superior with respect to individual topography substrates. Cellular adhesion experiments on non-gradient aligned nanowrinkled surfaces displayed a linear relationship of osteoblast cell adhesion with respect to topography aspect ratio. Additionally, an aspect ratio of 0.25 was found to be most efficient for cell alignment. Modification of the surface preparation method allowed us to develop an approach for creating surface nanotopography gradients which innovatively provided a superior data collection with fewer experiments showing that 1) low amplitude with small wavenumber is best for osteoblast cell adhesion 2) indeed higher aspect ratios are favorable for alignment however only with features between 80-180 nm in amplitude and 450-750 nm in wavelength with a clear transition between adhesion and alignment efficiency and 3) disproved a linear relationship of cell adhesion towards aspect ratio as was found for single feature substrate analysis

Levonorgestrel-releasing intrauterine system versus endometrial ablation for heavy menstrual bleeding

Acknowledgments: We thank all the women who participated in this trial; the participating general practitioners, gynecologists, and hospitals; the research nurses; and the staff of the Dutch Consortium for Studies in Women’s Health and Reproduction.Peer reviewedPublisher PD