Free tissue transfer has become routine practice in modern plastic surgery. The technique permits surgeons the flexibility to transfer the most suitable tissue for reconstruction. This has become possible largely due to the continued advances in microscope technology. There are however several drawbacks with even the newest traditional operating microscopes. They are usually large, heavy and although highly adjustable often require surgeons to adopt an unnatural and uncomfortable position which many of us have simply learned to live with. We describe the use of a new high-definition 3D camera system (Stortz VITOM 3D) in place of a traditional microscope to perform DIEP flap breast reconstructions in two patients. The use of this equipment has been described in other surgical specialities where a number of its benefits, including improved ergonomics for surgical team, have been highlighted. We explore the specific benefits and considerations for its use in free flap reconstruction of the breast .

Abstract Introduction Intravenous infusions are common practice but come with the risk of extravasation injury. Although overall incidence is low, in those undergoing chemotherapy and in children the risk is much greater (4.7% and 11-58% respectively). These injuries can have severe consequences ranging from skin necrosis to loss of function, some necessitating complex reconstruction. Prompt recognition and treatment reduces the chance of these outcomes. Whilst classically managed by plastic surgeons, many hospitals do not have such services locally. Time-delays introduced by remote referral or inadequate initial treatment result in poor outcomes. We describe a simple algorithm with accompanying video designed to enable confident immediate management. Method We devised a simple acronym describing the basic steps, based on the technique described by Gault. Accompanied by an instructional video demonstrating the technique they form a simple to follow guide. Results The initial treatment of an extravasation injury can be split into the following key steps: These steps, detailed in a simple poster, sit alongside a descriptive video which could be accessed through hospital intranets and video publishing platforms, such as Youtube and Vimeo, can allow potential users access on their portable devices. Conclusions The combination of the REACT! acronym and video provides an example of an easy-to-use teaching tool, when combined with local training, could improve the initial management of extravasation injuries in hospitals where plastic surgery input is not immediately available, reducing poor outcomes.

High-pressure injection injuries of the hand are uncommon but are associated with significant morbidity and require urgent surgical intervention. We describe a case of high-pressure injection of cement into the digit of a male patient while using an airless spray gun. We outline the initial assessment and surgical intervention, patient counselling regarding definitive management, and long-term outcomes of his injury. We also discuss mechanisms of high-pressure injection injuries, reconstructive options, and present a review of outcomes in patients sustaining similar injuries.

Flexor sheath infections (FSIs) are soft tissue infections affecting the hand, which, if mismanaged, can have devastating consequences. Clinical assessment is key to diagnosis, with many relying on Kanavel cardinal signs as an aid. To prevent unnecessary operative intervention and the associated post-operative combined patient and healthcare burden, it is key that patients with FSIs are correctly identified. It would also be useful to stratify severity of FSIs without surgical exploration. To date, there is no accepted method to assist clinicians in doing so. We retrospectively analysed data from a five-year period to see if we could identify pre-operatively (a) accurate predictors of FSIs and (b) severity of the FSIs. We established that only the presence of all four Kanavel cardinal signs significantly predicted the presence of an FSI. No other variable that was available prior to surgery could predict either presence or severity of infection.

Sentinel lymph node biopsies are a well-established component of the assessment and treatment pathway for patients with cutaneous melanoma in the UK. Commonly utilised techniques involve the use of blue dye which has an established risk of inducing allergic reactions in patients. Such reactions can be life-threatening, and this risk is important to highlight to patients. We conducted a retrospective review of all patients who had undergone this procedure at our melanoma centre in Cambridge, UK. From a group of 715 patients who received blue dye as part of the procedure, six patients suffered an allergic reaction (0.84%) with one of these treated as anaphylaxis. Our incidence of anaphylaxis is almost ten times greater than that reported in the NAP6 report led by the National Institute of Academic Anaesthesia and significantly higher than reported by others. We propose several reasons why our results differ from previous estimates. This study has focused only on patients undergoing a sentinel node procedure for melanoma, others have focused on such procedures performed on patients with breast cancer and some have combined the two. The administration technique, volume and anatomical distribution of disease all differ significantly from melanoma, possibly influencing rates and severity of allergic reactions.

British Journal of Hospital MedicineVol. 80, No. 9 EditorialsOpen AccessCreative Commons Attribution, Non Commercial 4.0 LicenseWhy the General Medical Council's national training survey is so importantRobert N MantonRobert N Manton(E-mail Address: [email protected])Registrar, Department of Plastic and Reconstructive Surgery, The Lister Hospital, Stevenage SG1 4ABRobert N MantonPublished Online:9 Sep 2019https://doi.org/10.12968/hmed.2019.80.9.492AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail The General Medical Council's national training survey is viewed by many doctors as merely a tick-box exercise to 'get through' their annual review of competence progression. Many express concern about the anonymity of the survey. Career progression is important and doctors are conscious of the opinions of their seniors.Fellow junior doctors report that they have been told what they should write, and berated for comments they have left in the survey. As a General Medical Council clinical fellow, I have been working with the national training survey team to uncover its methods – previously, I had little understanding of what happened to the data from the survey, and was not alone in that.The national training survey is an annual survey of doctors within a formal training programme. The Medical Act 1983 mandates that the General Medical Council is responsible for ensuring, maintaining and improving standards of education, training and clinical practice. The national training survey is one method of collecting information to do this.Doctors are not required to complete the national training survey, but the General Medical Council really wants them to. It asks deaneries to help maximize the response rate. Often the deaneries' approach has been to make survey completion part of the essential requirements to pass the annual review of competence progression. The General Medical Council will not discipline doctors for ignoring the survey, but deaneries can prevent them from passing the annual review of competence progression.The statistics drawn from the survey are taken extremely seriously. The General Medical Council assumes the survey is undertaken earnestly and that the responses highlight both positive aspects and concerns about training and education.Who decides on the questions?Ideas for questions come from trainees contributing within the survey itself, and via submissions from focus groups of trainees and professional organizations (including Royal colleges). Many questions remain the same each year to allow detection of trends. The General Medical Council policy team feeds in ideas to aid understanding of emerging issues, like burnout in the 2018 survey.How are questions validated before being added?The General Medical Council does not unilaterally include questions. Focus groups containing junior doctors help with a screening process to check that questions are appropriate and make sense.When asked within the survey, approximately 10 000 trainees offered to help. A separate survey advisory group, comprising postgraduate deans, UK educational bodies, trainee, trainer and British Medical Association representatives, looks at potential changes. It advises how to report results to lead to useful actions and interventions.Is the survey anonymous?The survey is confidential rather than anonymous. Clearly when an individual logs into the survey, the General Medical Council identifies that individual. They know the grade, training programme and unit. The survey would be pointless without this information since the feedback could not be linked to the correct training environment. However, the respondent's identity is not included in published results; responses cannot be directly linked to the respondent.I am the only trainee in my department: everyone will know which responses were mineConfidentiality does not stop people guessing. Inevitably individuals can make assumptions about which trainees submitted particular comments. The General Medical Council insist that they will not respond to queries about the authors of specific responses. This should provide some reassurance that colleagues cannot and should not pressure trainees into writing specific responses. They are unable to check what individuals have and have not included in their responses.Where a department has fewer than three trainees, results will appear in the data set for that trust, but not by department. The responses from those trainees are taken into consideration in the same way as all others by the General Medical Council, they are just not published in the same manner. This is designed to avoid trainees being singled out for their responses to the survey.Figure 1 shows an example of departmental results where there are fewer than three audiovestibular medicine trainees in a single department.Figure 1. A sample of national training survey results for audio-vestibular medicine from 2018.Exceptions to confidentialityThe General Medical Council wants to assure junior doctors that confidentiality is of paramount importance. It is clear that some situations may require disclosure of identities. Answers to multiple choice questions are always confidential, regardless of the response. Free-text responses concerning patient safety, bullying and harassment are not. These can be shared within General Medical Council departments for investigation. The respondent's identity is not immediately shared but the training programme, grade and location data will be shared with the appropriate dean.Comments that raise serious concerns and require further investigation may necessitate trainee identification. The General Medical Council will inform the trainee before it does so. Such responses can be used by the fitness to practise team should they be relevant to an investigation. The survey reminds respondents that such comments can be used in this way.Are there other methods for doctors to raise concerns?Where a doctor is not comfortable raising a concern within the survey, several other options are open to them. The General Medical Council surveys team is happy to receive direct communication from individual doctors who have questions or would like to raise a concern. The General Medical Council also has a confidential helpline (0161 923 6399) for those who wish to discuss a situation or event that they have been involved with.Who gets to see the data?The education survey team has exclusive access to the full survey results alongside respondents' details. These primary results are not available to other General Medical Council departments, including the fitness to practise team (see exceptions above).Results are published online in confidential form. Deanery quality leads, responsible for ensuring the quality of medical education locally, can access results 3 weeks before publication, to enable them to identify trusts needing urgent attention.Does the General Medical Council actually do anything with the data?Having participated in high level General Medical Council meetings, at first I could not believe how seriously the national training survey results are taken. Results are assumed to accurately represent training environments. The data are viewed as the 'trainee's voice', the survey being the only direct data source of trainee opinion of education and training.The General Medical Council has legal responsibility to ensure education and training standards. Decisions to enhance monitoring of trusts, place specific conditions on training posts and develop and update policy are heavily guided by the national training survey results. Results from East Kent Hospitals University NHS Foundation Trust in 2017 lead to enhanced monitoring of the trust by the General Medical Council. After closer inspection along with Health Education England, trainees were removed from an 'unsafe and unsupportive' environment where there were patient safety concerns (BBC News, 2017). The results really do matter.Why else is the survey useful?The General Medical Council publishes the survey results and performs its own analysis. The data have also been used to examine trainee satisfaction (Goulding and Passi, 2016; Gregory and Demartini, 2017) and effectiveness of competencies within specialities (Desai et al, 2018). The survey has prompted other speciality-specific organizations to run annual satisfaction surveys, some of which focus on aspects of training and the training environment. The Plastic Surgery Trainees Association UK runs its own national training survey and a separate survey focusing on discrimination, bullying and sexual harassment. These surveys provide this organization with data to represent UK plastic surgery trainees at speciality advisory committee meetings to drive improvement in training and training environments to meet trainees' needs.ConclusionsThe national training survey is one of the few ways the General Medical Council gets direct feedback from training environments. Doctors fill out plenty of forms; workplace-based assessments, 360° feedbacks, reflections and the rest. It is no wonder that this form is afforded no greater period of doctors' concentration. For the General Medical Council, it offers a unique opportunity to hear directly the experience from the 'front line'.Doctors are no strangers to confidentiality, and want reassurance that the General Medical Council will protect their data as clinicians would a patient's. Trainee identities will only be shared where concerns around patient safety, bullying or harassment exist. It is vital that the General Medical Council maintains confidentiality to help address behaviours which unfortunately are all too familiar.The General Medical Council knows that it needs to rebuild doctors' trust. Each year doctors pay a significant sum of money to the General Medical Council – completing the national training survey honestly and completely is one way to influence how it is spent. If doctors do not report problems, who will?KEY POINTSMany doctors view the survey as merely a tick-box exercise to 'get through' their annual review of competence progression.The General Medical Council believes that the results of the national training survey provide an accurate representation of training environments.Responses to the survey are confidential, although there are certain important exceptions around patient safety, bullying and harassment.The survey provides a valuable opportunity for trainees to feedback to the organization legally responsible for ensuring, maintaining and improving standards of education, training and clinical practice.This is an open access article distributed under the terms of the Creative Commons Attribution Noncommercial License (CC BY-NC 4.0, http://creativecommons.org/licenses/by-nc-nd/4.0/). References BBC News. 2017. Canterbury hospital junior doctors moved over lack of training. (accessed 9 May 2019) https://www.bbc.co.uk/news/uk-england-kent-39336675 Google ScholarDesai M, Davies O, Menon-Johansson A, Sethi GC. Higher specialty training in genitourinary medicine: A curriculum competencies-based approach. Int J STD AIDS. 2018 Jul;29(8):738-743. https://doi.org/10.1177/0956462418754970 Crossref, Medline, Google ScholarGoulding JM, Passi V. Evaluation of the educational climate for specialty trainees in dermatology. J Eur Acad Dermatol Venereol. 2016 Jun;30(6):951–955. https://doi.org/10.1111/jdv.13159 Crossref, Medline, Google ScholarGregory S, Demartini C. Satisfaction of doctors with their training: evidence from UK. BMC Health Serv Res. 2017 Dec 29;17(1):851. https://doi.org/10.1186/s12913-017-2792-0 Crossref, Medline, Google Scholar FiguresReferencesRelatedDetailsCited byThe GMC national training survey: Does it have an impact?16 October 2020 | Future Healthcare Journal, Vol. 7, No. 3 2 September 2019Volume 80Issue 9ISSN (print): 1750-8460ISSN (online): 1759-7390 Metrics History Published online 9 September 2019 Published in print 2 September 2019 Information© MA Healthcare LimitedCopyright © 2019 The Author(s). This is an Open Access article published by MA Healthcare Ltd and distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: CC BY-NC 4.0PDF download

Hair extensions are an increasingly common hairstyling practice. Others have demonstrated these devices can lead to hair and scalp injuries. We describe a recent case where such an injury was narrowly avoided in a patient undergoing a long surgical procedure. We suggest that preoperative assessment procedures need to be aware of such devices and provide advice to patients accordingly.

Introduction: Breast reduction techniques differ according to skin incision and pedicle. Lower pole scarring is reduced through vertical or horizontal scars only. Vertical techniques are popular, but the scar may be less aesthetic and take time to settle, parenchymal excision is limited, and dog-ears may occur. Horizontal techniques were highlighted to the senior author in her Australian fellowship. When presented with a 19 year old with gigantomastia, grade 3 ptosis, Fitzpatrick type 6 skin and sternal notch to nipple distance of 50cm, rather than a Wise pattern with free nipple grafts, horizontal reduction was performed on an inferior pedicle. Following this success, other select patients have benefitted from the technique.

Objectives: Observed Structured Clinical Examinations (OSCEs) are a commonly used method of assessing clinical competence at all levels.Students commonly regard OSCEs as the most stressful component of examinations and they are associated with high levels of anxiety.Methods: A simulated mock OSCE was designed by a group of junior doctors at a district general hospital.Candidates were from a variety of UK medical schools in the final year of their medical degree program.A prospective study was undertaken with candidates anonymously surveyed before and after the mock OSCE.A Numeric Rating Scale of 1-10 was used to assess candidates' confidence and anxiety related to upcoming summative examinations.Qualitative analysis was also undertaken via written feedback.Results: There are 57 students took part in the mock OSCE over two years.Only 54 (95%) opted to take part in the study and provide feedback.Mean confidence level significantly increased from 6.26 pre to 7.76 post mock OSCE (1.41 point [12%] increase, P-value < 0.001).Mean anxiety level significantly reduced from 8.70 pre to 7.15 post (1.56 point reduction [12%], p-value < 0.001).There are 100% of students rated the mock OSCE as either 'Excellent' (n = 50) or 'Good' (n = 4).Seventy percent of candidates felt that examination stations were the most useful with 37% of candidates specifically mentioning the benefit of using real patients.Conclusions: OSCEs remain a beneficial tool for learning, revision and assessment.The present study demonstrates that mock OSCEs significantly improve medical student confidence and significantly reduce anxiety related summative examinations.

For trainees at the beginning of their microsurgery journey, skill acquisition is challenged by the need to navigate steep learning curves, with such opportunities often afforded during high-stake periods of procedures. Alternative opportunities, such as practice using tabletop training microscopes, are commonly limited by both their availability and access (i.e. out of hours) 1 Myers S.R. Froschauer S. Akelina Y. Tos P. Kim J.T. Ghanem A.M. Microsurgery training for the twenty-first century. Arch Plast Surg. 2013 Jul; 40: 302-303 Crossref PubMed Scopus (14) Google Scholar . Work by Ericsson, a leader in the field of expertise and skill acquisition, has identified the conditions required for reliable skill development towards expertise (coined deliberate practice [DP]) 2 Ericsson K.A. Deliberate practice and acquisition of expert performance: a general overview. Acad Emerg Med. 2008 Nov; 15: 988-994 Crossref PubMed Scopus (951) Google Scholar , 3 Ericsson K.A. Krampe R.T. Tesch-Römer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev Am Psychol Assoc. 1993 Jul 1; 100: 363-406 Google Scholar . Additional to factors such as the timing (optimal length/frequency) of practice sessions, individuals achieve significant improvements in performance when: 1)Tasks have well-defined goals 2)Provision for instant feedback 3)Access to practice environments of adequate fidelity, enabling repetition/refinement over time 4)Time spent practicing independently (solitary practice)

A 19-year-old male with a port wine stain on the base of his neck presented with a 5-month history of gradual thickening of the involved skin which interfered with clothing and caused repeated bleeding. The lesion was excised and histopathologic examination revealed angiolymphoid hyperplasia with eosinophilia (ALHE) arising from the pre-existing port wine stain-a rare finding with only one previously reported case. Additionally the lesion was associated with elevated serum renin levels which virtually normalized following excision of the lesion. We further demonstrated the expression of angiotensin converting enzyme and angiotensin II receptors 1 and 2 by the lesion and discuss the possible role of the renin-angiotensin system in this condition.