OBJECTIVE: Assess whether fully-immersive simulation training with structured debriefing of a standardized emergency thoracic endovascular aortic repair (TEVAR) scenario improves team-work performance of the lead surgeon. Secondary aims: assess whether technical skills (TS) and radiation safety behaviors (RSB) improved concurrently. DESIGN: Pre-post study. SETTING: UK-based training days. PARTICIPANTS: General and vascular surgical trainees (n = 16). INTERVENTION(S): Fully-immersive simulation training with structured debriefing of a standardized emergency TEVAR scenario. Following standardized emergency TEVAR technical training, trainees led 2 standardized fully-immersive endovascular surgery simulations, with scripted support from a passive surgical team. A non-TS (NTS) structured debrief was delivered following simulations. NTS were assessed using the validated observational teamwork assessment for surgery tool post hoc using video recordings of simulations. TS were assessed through time taken to complete each step of the procedure, as defined during technical training. RSB were assessed through checking for presence of pre-defined actions and the length of time fluoroscopy was used during each simulation. RESULTS: Total observational teamwork assessment for surgery scores improved following structured debrief (p = 0.005, median 52.55/90 vs 73.0/90), alongside all constituent domains - communication (p < 0.001, median 11.7/20 vs 16.6/20), coordination (p < 0.001, median 8.6/15 vs 13.4/15), cooperation (p < 0.001, median 13.15/20 vs 16.35/20), leadership (p < 0.001, median 8.70/15 vs 11.30/15) and monitoring (p < 0.001, median 9.85/20 vs 14.85/20). TS improved; time to complete 12 of 13 procedural steps improved (p < 0.027). Fluoroscopy time (seconds) decreased (p = 0.339, 543.6 vs 495.5), frequency lead surgeons checked the team were wearing leads increased (p = 0.125, 3 vs 7) and asked the team to step back before screening increased (p = 0.003, frequency team asked to step back/total angiography runs before = 2/36 vs after = 14/44). CONCLUSIONS: fully-immersive endovascular simulation with structured debrief is a robust tool to improve NTS and TS. Incorporation into surgical training may reduce operating theatres errors, increase efficiency, and improve RSB. However effective translation into the clinical workplace must be demonstrated to see these benefits. (C) 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Objectives: Estimating the likely success of limb revascularization in patients with lower-extremity arterial trauma is central to decisions between attempting limb salvage and amputation. However, the projected outcome is often unclear at the time these decisions need to be made, making them difficult and threatening sound judgement. The objective of this study was to develop and validate a prediction model that can quantify an individual patient's risk of failed revascularization. Methods: A BN prognostic model was developed using domain knowledge and data from the US joint trauma system. Performance (discrimination, calibration, and accuracy) was tested using ten-fold cross validation and externally validated on data from the UK Joint Theatre Trauma Registry. BN performance was compared to the mangled extremity severity score. Results: Rates of amputation performed because of nonviable limb tissue were 12.2% and 19.6% in the US joint trauma system (n = 508) and UK Joint Theatre Trauma Registry (n = 51) populations respectively. A 10-predictor BN accurately predicted failed revascularization: area under the receiver operating characteristic curve (AUROC) 0.95, calibration slope 1.96, Brier score (BS) 0.05, and Brier skill score 0.50. The model maintained excellent performance in an external validation population: AUROC 0.97, calibration slope 1.72, Brier score 0.08, Brier skill score 0.58, and had significantly better performance than mangled extremity severity score at predicting the need for amputation [AUROC 0.95 (0.92–0.98) vs 0.74 (0.67–0.80); P < 0.0001]. Conclusions: A BN (https://www.traumamodels.com) can accurately predict the outcome of limb revascularization at the time of initial wound evaluation. This information may complement clinical judgement, support rational and shared treatment decisions, and establish sensible treatment expectations.

Numerous problems have been identified with current UK surgical training. These include the balance between generalist and specialist practice, service provision and training time, and work-life balance. This article proposes modifications to the current training pathway. A three-stage training model is discussed using modular training to clearly identify training aims and endpoints and allow flexibility in training and working practices. This will help with workforce planning and work-life balance and support high quality patient-focused surgical training in the 21st century.

BACKGROUND Understanding of the cellular immune response to primary blast lung injury (PBLI) is limited, with only the neutrophil response well documented. Moreover, its impact on the immune response in distal organs remains poorly understood. In this study, a rodent model of isolated primary blast injury was used to investigate the acute cellular immune response to isolated PBLI in the circulation and lung, including the monocyte response, and investigate distal subacute immune effects in the spleen and liver 6 hours after injury.METHODS Rats were subjected to a shock wave (similar to 135 kPa overpressure, 2 ms duration) inducing PBLI or sham procedure. Rat physiology was monitored, and at 1, 3, and 6 hours thereafter, blood, lung, and bronchoalveolar lavage fluid (BALF) were collected and analyzed by flow cytometry, enzyme-linked immunosorbent assay, and histologic examination. In addition, at 6 hours, spleen and liver were collected and analyzed by flow cytometry.RESULTS Lung histology confirmed pulmonary barotrauma and inflammation. This was associated with rises in CXCL-1, interleukin 6 (IL-6), tumor necrosis factor and albumin protein in the BALF. Significant acute increases in blood and lung neutrophils and CD43Lo/His48Hi (classical) monocytes/macrophages were detected. No significant changes were seen in blood or lung nonclassical monocyte and in natural killler, B, or T cells. In the BALF, significant increases were seen in neutrophils, CD43Lo monocyte-macrophages and monocyte chemoattractant protein-1. Significant increases in CD43Lo and Hi monocyte-macrophages were detected in the spleen at 6 hours.CONCLUSION This study reveals a robust and selective response of CD43Lo/His48Hi (classical) monocytes, in addition to neutrophils, in blood and lung tissue following PBLI. An increase in monocyte-macrophages was also observed in the spleen at 6 hours. This profile of immune cells in the blood and BALF could present a new research tool for translational studies seeking to monitor, assess, or attenuate the immune response in blast-injured patients.

Introduction: Damage control laparotomy for trauma (DCL) entails immediate control of haemorrhage and contamination, temporary abdominal closure (TAC), a period of physiological stabilisation, then definitive repair of injuries. Although immediate primary fascial closure is desired, fascial retraction and visceral oedema may dictate an alternate approach. Our objectives were to systematically identify and compare methods for restoration of fascial continuity when primary closure is not possible following DCL for trauma, to simplify these into a standardised map, and describe the ideal measures of process and outcome for future studies.Methods: Cochrane, OVID (Medline, AMED, Embase, HMIC) and PubMed databases were accessed using terms: (traum*, damage control, abbreviated laparotomy, component separation, fascial traction, mesh closure, planned ventral hernia (PVH), and topical negative pressure (TNP)). Randomised Controlled Trials, Case Series and Cohort Studies reporting TAC and early definitive closure methods in trauma patients undergoing DCL were included. Outcomes were mortality, days to fascial closure, hospital length of stay, abdominal complications and delayed ventral herniation.Results: 26 studies described and compared early definitive closure methods; delayed primary closure (DPC), component separation (CS) and mesh repair (MR), among patients with an open abdomen after DCL for trauma. A three phase map was developed to describe the temporal and sequential attributes of each technique. Significant heterogeneity in nomenclature, terminology, and reporting of outcomes was identified. Estimates for abdominal complications in DPC, MR and CS groups were 17%, 41% and 17% respectively, while estimates for mortality in DPC and MR groups were 6% and 0.5% (data heterogeneity and requirement of fixed and random effects models prevented significance assessment). Estimates for abdominal closure in the MR and DPC groups differed; 6.30 (95% CI = 5.10-7.51), and 15.90 (95% CI = 9.22-22.58) days respectively. Reporting poverty prevented subgroup estimate generation for ventral hernia and hospital length of stay.Conclusion: Component separation or mesh repair may be valid alternatives to delayed primary closure following a trauma DCL. Comparisons were hampered by the lack of uniform reporting and bias. We propose a new system of standardised nomenclature and reporting for further investigation and management of the post-DCL open abdomen. Crown Copyright (C) 2015 Published by Elsevier Ltd. All rights reserved.

The rat is a commonly used model for immunological investigation. Yet basic research and characterisation of leukocyte populations and sub-sets lags far behind murine research, with inconsistency on reported leukocyte markers and their overlap. These shortcomings limit the opportunity for more complex and advanced rat immunology research. In this study, we developed a robust 9-colour flow-cytometric protocol to elucidate the major blood and tissue rat leukocyte populations, and validated it in a model of LPS-induced pulmonary inflammation. Blood and tissues (lung, BALF, spleen, liver, bone marrow) from naïve Sprague-Dawley rats were collected and analysed by flow cytometry (FCM). Rats were exposed to aerosolised saline or LPS (1 mg/mL), at 3 and 24 hrs thereafter blood, lung and BALF were collected and analysed using FCM and ELISA. Neutrophils, two monocyte subsets, NK Cells, B Cells, CD4+, CD8+ T Cells and alveolar macrophages can be identified simultaneously across different tissues using a 9-colour panel. Neutrophils and monocytes can be distinguished based upon differential expression of CD43 and His48. Neutrophils and CD43Lo/His48Hi monocyte-macrophages are elevated in the lung at 3 and 24 hrs during LPS-induced pulmonary inflammation. This validated method for leukocyte enumeration will offer a platform for greater consistency in future rat immunology and inflammation research.

Aims: A Trauma damage control laparotomy (DCL) entails immediate control of haemorrhage and contamination, laparostomy and physiological stabilisation, then completion of surgery and early primary closure (EPC).Failing early primary closure, temporary abdominal closure (TAC) techniques maintain abdominal integrity until early definitive closure (EDC).The aims were to identify and compare outcomes of early definitive closure methods in these patients.Methods: NICE, Cochrane, OVID (Medline, AMED, Embase, HMIC) and PubMed databases were accessed using (traum*, damage control, abbreviated laparotomy, component separation, fascial traction, mesh closure, planned ventral hernia (PVH), and topical negative pressure (TNP)).Randomised Controlled Trials, Case Series and Cohort Studies reporting TAC and early definitive closure methods in DCL trauma patients were included.Outcomes were mortality, days to fascial closure, hospital length of stay, abdominal complications and delayed ventral herniation.Results: 26 studies identified early primary closure (DPC, acute component separation (ACS) and acute mesh repair (AMR)) and TAC methods (Whitman patch (WP), topical negative pressure (TNP), temporary mesh (TM), fascial tension, Bogota bag and skin tension).Estimates for mortality and abdominal complications in AMR and DPC groups were 0.45% and 40.85%, and 6.07%, and 16.74% respectively; AMR ventral hernia / laxity was 51.1% at one year.Days to closure were 6.30, 21.10 and 15.90 in DPC, ACS and AMR groups, whilst hospital LOS in ACS and DPC groups was 17.5 versus 23.3 days.Conclusions: Acute component separation or mesh repair are alternative early definitive closure techniques to DPC following trauma DCL.Comparing outcomes is hampered by poverty of uniform reporting and bias.Recommendations for standardised reporting nomenclature and methodology are made.