Zendejas, Benjamin

Purpose Compare the effect of personalized feedback (PF) vs. task demonstration (TD), both delivered via video, on laparoscopic knot-tying skills and perceived workload; and evaluate the effect of repeated practice. Method General surgery interns and research fellows completed four repetitions of a simulated laparoscopic knot-tying task at one-month intervals. Midway between repetitions, participants received via e-mail either a TD video (demonstration by an expert) or a PF video (video of their own performance with voiceover from a blinded senior surgeon). Each participant received at least one video per format, with sequence randomly assigned. Outcomes included performance scores and NASA Task Load Index (NASA-TLX) scores. To evaluate the effectiveness of repeated practice, scores from these trainees on a separate delayed retention test were compared against historical controls who did not have scheduled repetitions. Results Twenty-one trainees completed the randomized study. Mean change in performance scores was significantly greater for those receiving PF (difference = 23.1 of 150 [95% confidence interval (CI): 0, 46.2], P = .05). Perceived workload was also significantly reduced (difference = −3.0 of 20 [95% CI: −5.8, −0.3], P = .04). Compared with historical controls (N = 93), the 21 with scheduled repeated practice had higher scores on the laparoscopic knot-tying assessment two weeks after the final repetition (difference = 1.5 of 10 [95% CI: 0.2, 2.8], P = .02). Conclusions Personalized video feedback improves trainees’ procedural performance and perceived workload compared with a task demonstration video. Brief monthly practice sessions support skill acquisition and retention.

Abstract Purpose: Data on laparoscopic totally extraperitoneal inguinal hernia repairs (TEP-IHRs) suggest that approximately 250 operations are needed to gain mastery, but the annual volume required to maintain high-quality outcomes is unknown. Materials and Methods: A retrospective review was performed of every patient undergoing a TEP-IHR at the Mayo Clinic (Rochester, MN) from 1995 to 2011. Analysis focused on the annual volume of 21 staff surgeons and their specific patient outcomes broken up into three groups: Group 1 (G1) ( n = 1 surgeon) performed >30 repairs per year; Group 2 (G2) ( n = 3 surgeons), 15–30 repairs; and Group 3 (G3) ( n = 17), <15 repairs. Results: In total, 1601 patients underwent 2410 TEP-IHRs, with no significant patient demographic differences among groups. Greater annual surgeon volume (G1 > G2 > G3) was associated with improved outcomes as shown by the respective rates for intra- (1%, 2.6%, and 5.6%) and postoperative (13%, 27%, and 36%) complications, need for overnight stay (17%, 23%, and 29%), and hernia recurrence (1%, 4%, and 4.3%) (all P < .05). Surgeons with greater annual operative volumes were more likely to operate on patients with bilateral and recurrent hernias. Surgeons performing at least 15 repairs per year (G1 and G2) showed improvements in quality metrics over time. Conclusions: Annual operative volumes of >30 repairs per year are associated with the highest quality outcomes for TEP-IHR. Operative volumes of at least 15 repairs per year are associated with improvements in quality metrics over time. Mentorship and operative assistance of low-volume TEP-IHR surgeons may be useful in improving patient outcomes.

Context Self‐regulated learning ( SRL ) requires an active learner who has developed a set of processes for managing the achievement of learning goals. Simulation‐based training is one context in which trainees can safely practise learning how to learn. Objectives The purpose of the present study was to evaluate, in the simulation‐based training context, the effectiveness of interventions designed to support trainees in SRL activities. We used the social‐cognitive model of SRL to guide a systematic review and meta‐analysis exploring the links between instructor supervision, supports or scaffolds for SRL , and educational outcomes. Methods We searched databases including MEDLINE and Scopus, and previous reviews, for material published until December 2011. Studies comparing simulation‐based SRL interventions with another intervention for teaching health professionals were included. Reviewers worked independently and in duplicate to extract information on learners, study quality and educational outcomes. We used random‐effects meta‐analysis to compare the effects of supervision (instructor present or absent) and SRL educational supports (e.g. goal‐setting study guides present or absent). Results From 11 064 articles, we included 32 studies enrolling 2482 trainees. Only eight of the 32 studies included educational supports for SRL . Compared with instructor‐supervised interventions, unsupervised interventions were associated with poorer immediate post‐test outcomes (pooled effect size: −0.34, p = 0.09; n = 19 studies) and negligible effects on delayed (i.e. > 1 week) retention tests (pooled effect size: 0.11, p = 0.63; n = 8 studies). Interventions including SRL supports were associated with small benefits compared with interventions without supports on both immediate post‐tests (pooled effect size: 0.23, p = 0.22; n = 5 studies) and delayed retention tests (pooled effect size: 0.44, p = 0.067; n = 3 studies). Conclusions Few studies in the simulation literature have designed SRL training to explicitly support trainees’ capacity to self‐regulate their learning. We recommend that educators and researchers shift from thinking about SRL as learning alone to thinking of SRL as comprising a shared responsibility between the trainee and the instructional designer (i.e. learning using designed supports that help prepare individuals for future learning).

Objectives Debriefing is a common feature of technology‐enhanced simulation ( TES ) education. However, evidence for its effectiveness remains unclear. We sought to characterise how debriefing is reported in the TES literature, identify debriefing features that are associated with improved outcomes, and evaluate the effectiveness of debriefing when combined with TES . Methods We systematically searched databases, including MEDLINE , EMBASE and Scopus, and reviewed previous bibliographies for original comparative studies investigating the use of TES with debriefing in training health care providers. Reviewers, in duplicate, evaluated study quality and abstracted information on instructional design, debriefing and outcomes. Effect sizes ( ES ) were pooled using random‐effects meta‐analysis. Results From 10 903 potentially eligible studies, we identified 177 studies (11 511 learners) that employed debriefing as part of TES . Key characteristics of debriefing (e.g. duration, educator presence and characteristics, content, structure/method, timing, use of video) were usually incompletely reported. A meta‐analysis of four studies demonstrated that video‐assisted debriefing has negligible and non‐significant effects for time skills ( ES = 0.10) compared with non‐video‐assisted debriefing. Meta‐analysis demonstrated non‐significant effects in favour of expert modelling with short debriefing in comparison with long debriefing (ES range = 0.21–0.74). Among studies comparing terminal with concurrent debriefing, results were variable depending on outcome measures and the context of training (e.g. medical resuscitation versus technical skills). Eight additional studies revealed insight into the roles of other debriefing‐related factors (e.g. multimedia debriefing, learner‐led debriefing, debriefing duration, content of debriefing). Among studies that compared simulation plus debriefing with no intervention, pooled ES s were favourable for all outcomes (ES range = 0.28–2.16). Conclusions Limited evidence suggests that video‐assisted debriefing yields outcomes similar to those of non‐video‐assisted debriefing. Other debriefing design features show mixed or non‐significant results. As debriefing characteristics are usually incompletely reported, future debriefing research should describe all the key debriefing characteristics along with their associated descriptors.

AbstractBackgroundBotulinum toxin A (BTX) confers flaccid paralysis and pain modulation when injected into a muscle. We hypothesized that long‐term paralysis of the abdominal wall musculature (i.e., chemical component paralysis, CCP) would benefit incisional hernia repair (IHR) by decreasing postoperative pain, the use of opioid analgesia, and thus opioid‐related side effects.MethodsAdult patients who underwent elective IHR with preoperative CCP (n = 22) were compared to concurrent matched controls (n = 66, 1:3 ratio) based on age (±5 years), sex, body mass index (±5 kg/m2), history of hernia recurrence (0 vs. ≥1), and type of repair (open vs. laparoscopic). BTX was injected under ultrasonographic guidance into the transversus abdominis and internal and external oblique muscles at three sites bilaterally (300 units total).ResultsPatients who underwent IHR with CCP used significantly less opioid analgesia (mean ± SD morphine equivalents) when compared to controls on hospital days (HDs) 2 and 5: HD2, 48 ± 27 versus 87 ± 41; HD5, 17 ± 16 versus 48 ± 45. Likewise, CCP patients reported significantly less pain (visual analogue scale 1–10) when compared to controls on HD2 (5.2 ± 1.5 vs. 6.8 ± 2) and HD4 (3.6 ± 1.2 vs. 5.2 ± 1.9): all p < 0.007 (Bonferroni adjusted). There was no difference in postoperative complications (surgical site, 9 vs. 14 %), opioid‐related adverse events (ileus 5 vs. 5 %), hospital stay (4 ± 3 vs. 3 ± 2 days), or hernia recurrence (18 months mean follow‐up: 9 vs. 9 %).ConclusionsDespite similar multimodality treatment of postoperative pain after IHR, patients who underwent CCP required significantly less opioid analgesia and reported less pain.

Purpose Contralateral prophylactic mastectomy (CPM) rates in women with unilateral breast cancer are increasing despite controversy regarding survival advantage. Current scrutiny of the medical costs led us to evaluate the cost-effectiveness of CPM versus routine surveillance as an alternative contralateral breast cancer (CBC) risk management strategy. Methods Using a Markov model, we simulated patients with breast cancer from mastectomy to death. Model parameters were gathered from published literature or national databases. Base-case analysis focused on patients with average-risk breast cancer, 45 years of age at treatment. Outcomes were valued in quality-adjusted life-years (QALYs). Patients' age, risk level of breast cancer, and quality of life (QOL) were varied to assess their impact on results. Results Mean costs of treatment for women age 45 years are comparable: $36,594 for the CPM and $35,182 for surveillance. CPM provides 21.22 mean QALYs compared with 20.93 for surveillance, resulting in an incremental cost-effectiveness ratio (ICER) of $4,869/QALY gained for CPM. To prevent one CBC, six CPMs would be needed. CPM is no longer cost-effective for patients older than 70 years (ICER $62,750/QALY). For BRCA-positive patients, CPM is clearly cost-effective, providing more QALYs while being less costly. In non-BRCA patients, cost-effectiveness of CPM is highly dependent on assumptions regarding QOL for CPM versus surveillance strategy. Conclusion CPM is cost-effective compared with surveillance for patients with breast cancer who are younger than 70 years. Results are sensitive to BRCA-positive status and assumptions of QOL differences between CPM and surveillance patients. This highlights the importance of tailoring treatment for individual patients.