Archives of Surgical Research

Letter to the Editor; Re: Utilities of Teaching EPAs: Expanding the Scope of EPAs Beyond Clinical Context

2022-07-20T04:23:28+00:00

We read with interest a recently published article by Iqbal et al. about the role of Entrustable Professional Activities (EPAs) in imparting skills in the medical field. This letter is a critical appraisal of the role of teaching EPAs in training in medicine and healthcare. The authors have detailed well about the utility of the EPAs and delineated the areas where teaching EPAs can be effective in not only training the clinical trainers but also endorsing their role as a trainer. The authors identified components of EPAs that are vital to the effectiveness of the teaching programs i.e., developing a framework of building teaching skills, reinforcing their personality development, and lastly credentialing the trainers. Teaching EPA frameworks can be used to design structured faculty development programs for specific teaching roles. Expanding the concept of EPAs beyond clinical practice is a unique concept that can revolutionize clinical teaching modalities. (Follow the Fulltext for more)

Entrustable Professional Activities (EPAs) as a Measure for General Surgery Resident Evaluation

2022-07-04T14:18:21+00:00

Surgical training is going through a continuous process of evolution and instead of relying on subjective methods of evaluation and cognitive assessments, we are gradually shifting toward competency-based modes of assessment. Entrustable Professional Activities (EPAs) are rapidly complementing and replacing other means of assessment in order to declare a surgeon competent. American Board of Surgery and Intercollegiate Board in the UK have laid down a path for such a process and would likely become the main tool for surgical skill assessment in the future. College of Physicians and Surgeons is in process and can definitely follow the principles and plans to augment their surgical resident assessment for enhancing the quality of assessment.

Utility of Workplace-Based Assessment Among Surgical Residents: A Systematic Literature Review

2022-06-27T15:01:28+00:00

IMPORTANCE This review article aims to assess the usefulness of Workplace-Based Assessment (WBA) among surgical residents. Multiple studies have been done in the past to determine the utility of WBAs across different fields of medicine. But it hasn’t been done among surgical specialties on large scale, and the present paper fills in this research gap.

METHODS Articles were searched using PubMed and Google Scholar databases up to 30th June 2022. Following headings were used for the literature search i.e work-based assessment or workplace-based assessment or WBAs or direct observation of procedural skills or DOPS or procedure-based assessments or PBA or Case-based discussion or CBD or clinical evaluation exercise or CEX or Mini CEX, and surgical training. The utility formula of Vleuten was used to assess the usefulness of WBA. It is a product of validity, reliability, educational impact, acceptability, cost-effectiveness, and feasibility.

RESULTS For reviewing purposes, 29 studies were selected. There were 8 studies on PBA, 2 on Mini-CEX, 2 on CBD, 6 on DOPS, and 11 studies on multiple methods of WBA. PBA had positive satisfaction levels and was valid, reliable, feasible, and acceptable. CBD. Mini-CEX and CBD had very few studies in which they were proved to be reliable and valid but had mixed responses in terms of satisfaction levels. DOPS had a level 1 educational impact and also proved to be valid. When all components of WBAs were used together, a negative level 1 educational impact was observed. The concerns that were identified include lack of time, training and evidence of validity, design of the tool, and perception of WBA as a summative tool.

DISCUSSION Work-based Assessments should be implemented and used properly after the training of faculty. The focus should be on the quality of the assessments, not on the quantity. Large-scale studies should be done to assess level 3 and 4 of educational impact from WBAs.

The Role of Tranexamic Acid in the Prevention of Perioperative Hemorrhage

2022-06-01T05:14:46+00:00

IMPORTANCE Significant blood loss can occur as a result of trauma, surgery, anticoagulation, obstetric complications, and hemostatic disorders. As there are many diverse causes of hemorrhage, the availability of a clinically safe and effective hemostatic agent is the need of the hour. Tranexamic acid is one of the most commonly used and widely researched anti-fibrinolytic agents. Its role in trauma-associated, postoperative, and postpartum hemorrhage has been well recognized. However, the utility of tranexamic acid goes farther than these common indications, supported by accruing data suggesting its ability to reduce blood loss along with improvement in clinical outcomes in many hemostatic challenges without increasing thromboembolic risk.

OBJECTIVE To review the clinical application and effectiveness of tranexamic acid in the prevention of intraoperative hemorrhage.

METHODS: Secondary data were selected by utilizing three steps; identification of 490 articles, recruitment of 116 articles, and selection of 61 articles for the systematic review. Inclusion and exclusion criteria were designed according to PRISMA protocol.

RESULTS Tranexamic acid has reduced perioperative hemorrhage and blood transfusion requirements in elective surgical procedures. Many studies established the efficacy of tranexamic acid and its safety without raising thromboembolic risk, precipitating kidney failure, or their complications.

CONCLUSION In multiple clinical scenarios, tranexamic acid has proven to prevent hemorrhage without increasing thromboembolic risk and has broad-spectrum clinical indications. However, more caution and regulatory guidelines need to be established to prevent the rare incidence of complications so as thromboembolism and seizures.

Proficiency-Based Progression Training: Key To Effective Clinical Procedural Teaching?

2022-07-24T14:48:03+00:00

IMPORTANCE Proficiency-Based Progression (PBP) training is a form of training in which the trainee has to achieve a benchmark that has been quantitatively defined. This is contrary to conventional training where progression benchmarks are arbitrary, This form of training may find its place in surgery and procedural medicine with some studies finding it to be effective while others claim to have seen no impact on trainees.

METHODS A systematic literature search was conducted on PubMed and Cochrane library and 15 eligible RCTs were extracted in which proficiency-based progression (PBP) training was compared with traditional surgical training methods.

RESULT 15 RCTs were included (412 participants from all RCTs). The PBP group demonstrated a reduced number of procedural errors as compared to the non-PBP group (Weighted Mean Difference: —6.14 errors, 95% Confidence Interval (CI) —8.63 to —3.65, p < 0.00001), as well as a reduction in procedural time in the PBP group as compared to the non-PBP group (Weighted Mean Difference: —5.46, 95% Confidence Interval (CI) —8.56 to —2.37, p = 0.0005) but the non-PBP group performed more procedural steps than the PBP group (Weighted Mean Difference: 2.18, 95% Confidence Interval (CI) —1.31 to 5.66, p < 0.00001).

CONCLUSION Our meta-analysis shows that PBP-trained groups outperform their traditional counterparts by completing procedures quicker and making fewer errors. This model of training may be an effective training tool for the future.

Artificial Intelligence in Surgery: Dawn of New Era

2022-07-07T02:22:13+00:00

IMPORTANCE Artificial intelligence is rapidly reshaping science and healthcare. Approximately 37% of organizations have implemented some sub-entity of AI in their daily workings which include social networking, airplanes, robots, and deep learning computers and surgical science is no exclusion. This article aims to review and summarize major aspects of artificial intelligence (AI), along with its practical implementation, limitation, and potential in the field of surgery.

METHODS Published multidisciplinary literature search was conducted on artificial intelligence in medical science to recognize different techniques and prime concepts that are bringing about innovation across multiple industries, including surgery. Barriers and challenges of working with AI were also scrutinized.

RESULTS & DISCUSSION The major dimensions of AI include (1) Machine learning, (2) reasoning, (3) problem solving, (4) perception, and (5) language. Their current role and future implementation in surgical practice were introduced including big data sets and systems that aid in medical decisions. Besides this, the duty of surgeons in promoting and facilitating this technology to optimize clinical effectiveness was also brought into consideration.

CONCLUSION AI carries the potential and aptitude to revolutionize the way surgery is being taught and practiced over the past years. The surgeons themselves are eager and well-positioned in integrating AI into modern practice, however, in order to attain this, they require the expertise of data scientists.

PMC vs. PMDC Fiasco: A Legislative Chaos or an Effort for Quality Improvement?

2022-07-03T08:03:23+00:00

IMPORTANCE Rapid population growth and resulting economic crisis are posing challenges to maintaining and improving the quality of medical education in Pakistan. The health profession is governed and regulated by a single body in Pakistan since 1962, Pakistan Medical and Dental Council PMDC, which was transformed into Pakistan Medical Commission in 2020. Medical education and training are continuously evolving; several changes have to be incorporated at the undergraduate and postgraduate levels to keep pace with the world. PMC has introduced various changes in the running of the commission and educational regulation, which have been appreciated by some and criticized by others on the grounds of a non-inclusive change process. With recent political changes and the reversal of the PMDC act, there is enormous anxiety about the future of the body and its operational and policy-making processes. This is an opinion regarding this whole fiasco and how it would impact the future of the body and regulation of the healthcare system in Pakistan.

Nonfunctioning Pancreatic Neuroendocrine Tumour (NF-PNET) Presenting as Pancreatitis: A Rare Clinical Association

2022-06-28T16:10:16+00:00

IMPORTANCE Pancreatic neuroendocrine tumors are relatively rare tumors. They make up 2-5% of all pancreatic tumors. It is important to diagnose them in the early stage. They are found incidentally or if malignant with either epigastric pain or distant metastasis. Very rarely PNETs may present with pancreatitis. Only 30 such cases have been reported previously which did present with focal pancreatitis. Here we present such a rare case.

CASE PRESENTATION A 51-year-old female presented with a history of recurrent epigastric pain for the past 4 years. On Ultrasound and CT scan, a 2x2cm well-defined mass in the head of the pancreas was observed. The findings were confirmed with a CT scan. A modified Whipple procedure was done and a histopathological report showed WHO grade – I neuroendocrine tumor with chromogramin positive tumor cells.

DISCUSSION & CONCLUSION The association between neuroendocrine tumors and pancreatitis is very rare hence neuroendocrine tumors should be considered as a differential diagnosis while dealing with such cases.

Fatal Anaphylaxis Due to Atracurium without Cutaneous Manifestations: A Case Report

2022-02-18T10:22:11+00:00

Anaphylaxis or anaphylactic reaction is a medical emergency and it is a potentially life-threatening allergic reaction involving the various systems of the body, especially the cardiovascular and respiratory systems. It is usually triggered by an antigen with subsequent release of mediators from basophil and mast cells. Diagnosis is mainly clinical although laboratory investigations may help in further confirmation. Anaphylaxis during anesthesia is a rare event but could be life-threatening if not diagnosed and treated promptly. Among all the anesthetic agents, neuromuscular blockers are the most notorious to cause anaphylaxis. We are sharing a case of 44 years old female patient who underwent breast cancer surgery under general anesthesia and she developed anaphylaxis due to atracurium injection without cutaneous manifestations. She was managed actively with complete recovery and had her surgery done with the same general anesthesia.

Laparoscopic Completion Cholecystectomy for Residual Gallbladder: A Case Report and Literature Review

2022-06-28T15:54:41+00:00

IMPORTANCE Gallbladder infection can present with variable severity and in acute settings may compel surgeon to perform a relatively less complex, subtotal cholecystectomy in certain circumstances, which may lead to a residual portion of the gallbladder and associated complications in some cases. The reported incidence of such cases of subtotal cholecystectomy ranges from 0.4 to 3%, out of which 10% develop symptoms and present in healthcare centers with complications such as remnant cholecystitis and reoccurrence of cholecystolithiasis, or even gall bladder carcinoma. Here, we report a case of the residual gallbladder which was subsequently catered through a laparoscopic approach successfully