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The Nuffield Department of Surgical Sciences is the academic department of surgery at the University of Oxford, and hosts a multidisciplinary team of senior clinical academic surgeons, senior scientists, junior clinicians and scientists in training.
Neurocardiology: translational advancements and potential.
In our original white paper published in the The Journal of Physiology in 2016, we set out our knowledge of the structural and functional organization of cardiac autonomic control, how it remodels during disease, and approaches to exploit such knowledge for autonomic regulation therapy. The aim of this update is to build on this original blueprint, highlighting the significant progress which has been made in the field since and major challenges and opportunities that exist with regard to translation. Imbalances in autonomic responses, while beneficial in the short term, ultimately contribute to the evolution of cardiac pathology. As our understanding emerges of where and how to target in terms of actuators (including the heart and intracardiac nervous system (ICNS), stellate ganglia, dorsal root ganglia (DRG), vagus nerve, brainstem, and even higher centres), there is also a need to develop sensor technology to respond to appropriate biomarkers (electrophysiological, mechanical, and molecular) such that closed-loop autonomic regulation therapies can evolve. The goal is to work with endogenous control systems, rather than in opposition to them, to improve outcomes.
Cutaneous adaptive immunity and uraemia: a narrative review
Chronic kidney disease affects 1 in 10 people globally, with a prevalence twenty times that of cancer. A subset of individuals will progress to end-stage renal disease (ESRD) where renal replacement therapy is required to maintain health. Cutaneous disease, including xerosis and pruritus, are endemic amongst patients with ESRD. In the uraemia-associated immune deficiency of ESRD, impaired circulating immune responses contribute to increased infection risk and poorer vaccination response. Clinical manifestations of dysregulated adaptive immunity within the skin have been well-described and have been posited to play a role in cutaneous features of ESRD. However, our understanding of the mechanisms by which adaptive immunity within the skin is affected by uraemia is relatively limited. We provide an overview of how the cutaneous adaptive immune system is impacted both directly and indirectly by uraemia, highlighting that much work has been extrapolated from the circulating immune system and often has not been directly evaluated in the skin compartment. We identify knowledge gaps which may be addressed by future research. Ultimately, greater understanding of these pathways may facilitate novel therapeutic approaches to ameliorate widespread cutaneous symptomatology in ESRD.
Multifocal, multiphenotypic tumours arising from an MTOR mutation acquired in early embryogenesis
Embryogenesis is a vulnerable time. Mutations in developmental cells can result in the wide dissemination of cells predisposed to disease within mature organs. We characterised the evolutionary history of four synchronous renal tumours from a 14-year-old girl using whole genome sequencing alongside single cell and bulk transcriptomic sequencing. Phylogenetic reconstruction timed the origin of all tumours to a multipotent embryonic cell committed to the right kidney, around 4 weeks post-conception. Biochemical and structural analysis of their shared MTOR mutation, absent from normal tissues, demonstrates enhanced protein flexibility, enabling a FAT domain hinge to dramatically increase activity of mTORC1 and mTORC2. Developmental mutations, not usually detected in traditional genetic screening, have vital clinical importance in guiding prognosis, targeted treatment, and family screening decisions for paediatric tumours.
Sonographic identification of needle tip by specialists and novices: a blinded comparison of 5 regional block needles in fresh human cadavers.
BACKGROUND AND OBJECTIVES: Needle visibility using ultrasound remains problematic at steep insertion angles. Despite modified techniques, steep approaches are still needed, particularly in the obese, neuraxial anesthesia or pain blocks around the spine. We describe a novel technique for objective assessment of needle-tip identification and present data on a new needle. METHODS: Five needles were compared for accuracy of tip position identification. Pajunk facet-tipped, Tuohy-tipped, Polymedic Ultrasound, Hakko EchoStim, and a new intermittently textured needle (T). Static ultrasound images were obtained of the needles in first-thaw, unembalmed cadavers at shallow, moderate and steep angles. Actual tip position was defined. Images were presented in blinded, random order to 10 experienced and 10 novice anesthetists who estimated tip position. Distance between true tip position and estimated position was measured ("tip error"). Secondary objectives included subjective measures of visibility and differences between needles at shallower insertion angles and between novice and expert observers. RESULTS: At steep angles, study needles varied significantly with regard to tip error (P < 0.0001). Needle T scored highest for confidence and subjective visibility at moderate and steep angles. There was no significant difference between novice and experienced anesthetists for tip error or visibility. Experts were more confident in their estimates. CONCLUSIONS: Needle T demonstrated good properties even at steep insertion angles. Tip location was accurate, and observers rated it highly visible. Ability to identify needle-tip position can be objectively assessed.
Enhancing emergency care in low-income countries using mobile technology-based training tools.
In this paper, we discuss the role of mobile technology in developing training tools for health workers, with particular reference to low-income countries (LICs). The global and technological context is outlined, followed by a summary of approaches to using and evaluating mobile technology for learning in healthcare. Finally, recommendations are made for those developing and using such tools, based on current literature and the authors' involvement in the field.
Anesthesia Provider Training and Practice Models: A Survey of Africa.
BACKGROUND: In Africa, most countries have fewer than 1 physician anesthesiologist (PA) per 100,000 population. Nonphysician anesthesia providers (NPAPs) play a large role in the workforce of many low- and middle-income countries (LMICs), but little information has been systematically collected to describe existing human resources for anesthesia care models. An understanding of existing PA and NPAP training pathways and roles is needed to inform anesthesia workforce planning, especially for critically underresourced countries. METHODS: Between 2016 and 2018, we conducted electronic, phone, and in-person surveys of anesthesia providers in Africa. The surveys focused on the presence of anesthesia training programs, training program characteristics, and clinical scope of practice after graduation. RESULTS: One hundred thirty-one respondents completed surveys representing data for 51 of 55 countries in Africa. Most countries had both PA and NPAP training programs (57%; mean, 1.6 pathways per country). Thirty distinct training pathways to become an anesthesia provider could be discriminated on the basis of entry qualification, duration, and qualification gained. Of these 30 distinct pathways, 22 (73%) were for NPAPs. Physician and NPAP program durations were a median of 48 and 24 months (ranges: 36-72, 9-48), respectively. Sixty percent of NPAP pathways required a nursing background for entry, and 60% conferred a technical (eg, diploma/license) qualification after training. Physicians and NPAPs were trained to perform most anesthesia tasks independently, though few had subspecialty training (such as regional or cardiac anesthesia). CONCLUSIONS: Despite profound anesthesia provider shortages throughout Africa, most countries have both NPAP and PA training programs. NPAP training pathways, in particular, show significant heterogeneity despite relatively similar scopes of clinical practice for NPAPs after graduation. Such heterogeneity may reflect the varied needs and resources for different settings, though may also suggest lack of consensus on how to train the anesthesia workforce. Lack of consistent terminology to describe the anesthesia workforce is a significant challenge that must be addressed to accelerate workforce research and planning efforts.
Anesthetic implications for the parturient with hereditary hemorrhagic telangiectasia.
PURPOSE: To review the effects of hereditary hemorrhagic telangiectasia (HHT) in the parturient and the anesthetic management of such patients during pregnancy and delivery. SOURCE: A literature search (1966-2008) was performed using Medline and EMBASE databases. Bibliographies of retrieved articles were searched for additional sources. PRINCIPAL FINDINGS: Hereditary hemorrhagic telangiectasia affects 1 in 5000-8000 people. It is a genetic condition in which vascular dysplasia affects many organs particularly the pulmonary, cerebral, gastrointestinal, and spinal vasculature. A large proportion of women with HHT have uneventful pregnancies. However, women can present in pregnancy with clinically silent but potentially life-threatening features of the disorder including fatal hemorrhage from ruptured arteriovenous malformations (AVMs), systemic emboli, and high output cardiac failure secondary to arteriovenous shunting. Literature on the anesthetic management of HHT in pregnancy is limited. Both general and regional anesthetic techniques have been successfully performed in these patients, but are reliant on identifying the presence of specific AVMs; avoidance of cardiovascular instability; and prophylaxis against systemic emboli secondary to pulmonary AVM shunting. The presence of spinal AVMs is considered a relative contraindication to regional techniques. As with other systemic AVMs, these can develop and increase in size during pregnancy with implications for the timing of screening and surveillance. CONCLUSIONS: An understanding of the presence and potential development of life-threatening AVMs during pregnancy is imperative for anesthesiologists caring for parturients with HHT. Even in the asymptomatic patient, a high index of suspicion should be maintained, screening performed where possible and anesthetic technique adapted accordingly.
Anaesthesia in the prone position.
Prone positioning of patients during anaesthesia is required to provide operative access for a wide variety of surgical procedures. It is associated with predictable changes in physiology but also with a number of complications, and safe use of the prone position requires an understanding of both issues. We have reviewed the development of the prone position and its variants and the physiological changes which occur on prone positioning. The complications associated with this position and the published techniques for various practical procedures in this position will be discussed. The aim of this review is to identify the risks associated with prone positioning and how these risks may be anticipated and minimized.
Priorities for content for a short-course on postoperative care relevant for low- and middle-income countries: an e-Delphi process with training facilitators.
Most surgical and anaesthetic mortality and morbidity occurs postoperatively, disproportionately affecting low- and middle-income countries. Various short courses have been developed to improve patient outcomes in low- and middle-income countries, but none specifically to address postoperative care and complications. We aimed to identify key features of a proposed short-course addressing this topic using a Delphi process with low- and middle-income country anaesthesia providers trained as short-course facilitators. An initial questionnaire was co-developed from literature review and exploratory workshops to include 108 potential course features. Features included content; teaching method; appropriate participants; and appropriate faculty. Over three Delphi rounds (panellists numbered 86, 64 and 35 in successive cycles), panellists indicated which features they considered most important. Responses were analysed by geographical regions: Africa, the Americas, south-east Asia and Western Pacific. Ultimately, panellists identified 60, 40 and 54 core features for the proposed course in each region, respectively. There were high levels of consensus within regions on what constituted core course content, but not between regions. All panellists preferred the small group workshop teaching method irrespective of region. All regions considered anaesthetists to be key facilitators, while all agreed that both anaesthetists and operating theatre nurses were key participants. The African and Americas regional panels recommended more multidisciplinary healthcare professionals for participant roles. Faculty from high-income countries were not considered high priority. Our study highlights variability between geographical regions as to which course features were perceived as most locally relevant, supporting regional adaptation of short-course design rather than a one-size-fits-all model.
Next-generation Virtual and Augmented Reality in Surgical Education: A Narrative Review.
BACKGROUND: Virtual and Augmented Reality (VR/AR) has been used in surgery for several decades. Over the past 5-10 years, however, new technological advances, including high-resolution screens, mobile graphical processing units (mGPUs) and position-sensing technologies, have been incorporated into relatively low-cost VR and AR devices. This review focuses on the current impact of the application of these "Phase 2" VR/AR technology in surgical training. METHODS: A narrative literature review was undertaken using PubMed and Web of Science to identify comparative studies related to the impact of Phase 2 VR or AR tools on surgical training, defined in terms of the acquisition of technical surgical skills. Eleven studies on the effectiveness of VR/AR in surgical education were identified for full review. Further, the grey literature was searched for articles describing the current state of VR/AR in surgical education. A quality analysis using the Newcastle Ottawa scale showed a median score of 7 (out of a maximum achievable score of 9). RESULTS: All studies showed a positive association between the use of VR/AR in surgical training and skill acquisition in terms of improving the speed of acquisition of surgical skills, the surgeon's ability to multitask, the ability to perform a procedure accurately, hand-eye coordination and bimanual operation. The grey literature presented a common, positive theme of the benefits of VR/AR in surgical training. CONCLUSIONS: Based on the limited evidence available, VR/AR appears to have positive training benefits in improving the speed of acquisition of surgical skills. However, the significant heterogeneity in study methodology and the relative recency of wider VR/AR adoption in surgical training mean that only tentative conclusions can be drawn at this stage. Further research, ideally with large sample sizes, robust outcome measures and longer follow-up periods, is recommended.
Lessons from the design, development and implementation of a three-dimensional (3D) neonatal resuscitation training smartphone application: Life-saving Instruction for Emergencies (LIFE app).
Neonatal mortality remains disproportionately high in sub-Saharan Africa partly due to insufficient numbers of adequately trained and skilled front-line health workers. Opportunities for improving neonatal care may result from upskilling frontline health workers using innovative technological approaches. This practice paper describes the key steps involved in the design, development and implementation of an innovative smartphone-based training application using an agile, human-centred design approach. The Life-saving Instruction for Emergencies (LIFE) app is a three-dimension (3D) scenario-based mobile app for smartphones and is free to download. Two clinical modules are currently included with further scenarios planned. Whilst the focus of the practice paper is on the lessons learned during the design and development process, we also share key learning related to project management and sustainability plans, which we hope will help researchers working on similar projects.
Training non-physician anaesthetists in sub-Saharan Africa: a qualitative investigation of providers' perspectives.
OBJECTIVES: To explore the views of non-physician anaesthesia providers (NPAPs) and their colleagues regarding the effectiveness of NPAP training programmes in three contrasting sub-Saharan African countries. DESIGN: This was a qualitative exploratory descriptive study. Semistructured interviews were conducted online, recorded, transcribed and analysed thematically using NVivo. SETTING: Participants' homes or workplaces in Sierra Leone, Somaliland and Uganda. PARTICIPANTS: 15 NPAPs, physician anaesthetists and surgeons working in the countries concerned. RESULTS: Three major themes were identified: (1) discrepancy between urban training and rural practice, (2) prominent development of attitudes outside the curricular set during training, including approaches to learning and clinical responsibility and (3) the importance of interprofessional relationships developed during training for later practice. CONCLUSIONS: Anaesthesia providers in different cadres and very different country contexts in sub-Saharan Africa describe common themes in training which appear to be significant for their later practice. Not all these issues are explicitly planned for in current training programmes, although they are important in the view of providers. Subsequent programme development should consider these themes with a view to enhancing the safety and quality of anaesthesia practice in this context.
Evaluation of Adaptive Feedback in a Smartphone-Based Game on Health Care Providers' Learning Gain: Randomized Controlled Trial.
BACKGROUND: Although smartphone-based emergency care training is more affordable than traditional avenues of training, it is still in its infancy, remains poorly implemented, and its current implementation modes tend to be invariant to the evolving learning needs of the intended users. In resource-limited settings, the use of such platforms coupled with gamified approaches remains largely unexplored, despite the lack of traditional training opportunities, and high mortality rates in these settings. OBJECTIVE: The primary aim of this randomized experiment is to determine the effectiveness of offering adaptive versus standard feedback, on the learning gains of clinicians, through the use of a smartphone-based game that assessed their management of a simulated medical emergency. A secondary aim is to examine the effects of learner characteristics and learning spacing with repeated use of the game on the secondary outcome of individualized normalized learning gain. METHODS: The experiment is aimed at clinicians who provide bedside neonatal care in low-income settings. Data were captured through an Android app installed on the study participants' personal phones. The intervention, which was based on successful attempts at a learning task, included adaptive feedback provided within the app to the experimental arm, whereas the control arm received standardized feedback. The primary end point was completion of the second learning session. Of the 572 participants enrolled between February 2019 and July 2019, 247 (43.2%) reached the primary end point. The primary outcome was standardized relative change in learning gains between the study arms as measured by the Morris G effect size. The secondary outcomes were the participants individualized normalized learning gains. RESULTS: The effect of adaptive feedback on care providers' learning gain was found to be g=0.09 (95% CI -0.31 to 0.46; P=.47). In exploratory analysis, using normalized learning gains, when subject-treatment interaction and differential time effect was controlled for, this effect increased significantly to 0.644 (95% CI 0.35 to 0.94; P
Non-physician anaesthesia providers' perspectives on task sharing practices in Zambia and Somaliland: a qualitative study.
INTRODUCTION: The 68th World Health Assembly, in 2015, called for surgical and anaesthesia services strengthening. Acknowledging the healthcare staff shortages, they referred to task sharing, among others, as a more effective use of the healthcare workforce. While task sharing has been increasingly proposed as an important strategy to increase the reach and safety of anaesthesia as well as a means of supporting the workforce in low-resource settings, most data on task sharing relate to non-anaesthetic healthcare contexts. The aim of this study was to understand anaesthetic task sharing as currently experienced and/or envisaged by non-physician anaesthesia providers in Zambia and Somaliland. METHODS: An exploratory qualitative research methodology was used. Participants were recruited initially via contacts of the research team, then through snowballing using a purposive sampling strategy. There were 13 participants: 7 from Somaliland and 6 from Zambia. Semistructured interviews took place synchronously, then were recorded, anonymised, transcribed and analysed thematically. Triangulation and respondents' validation were used to maximise data validity. RESULTS: Four major themes were identified in relation to task sharing practices: (1) participants recognised variable components of task sharing in their practice; (2) access to task sharing depends both on sources and resources; (3) implicit barriers may inhibit task sharing practices; (4) there is an appetite among participants for amelioration of current task sharing practices. CONCLUSIONS: Empowering task sharing practices can be achieved only by understanding how these practices work, by identifying gaps and areas of improvement, and by addressing them. The findings from this exploratory study could help the global community understand how anaesthetic task sharing in low-resource settings works and inspire further research on the field. This could inform future modelling of workforce planning strategies in low-resource settings to maximise the effectiveness and professional well-being of the workforce.
Anaesthesia care providers employed in humanitarian settings by Médecins Sans Frontières: a retrospective observational study of 173 084 surgical cases over 10 years.
OBJECTIVE: To describe the extent to which different categories of anaesthesia provider are used in humanitarian surgical projects and to explore the volume and nature of their surgical workload. DESIGN: Descriptive analysis using 10 years (2008-2017) of routine case-level data linked with routine programme-level data from surgical projects run exclusively by Médecins Sans Frontières-Operational Centre Brussels (MSF-OCB). SETTING: Projects were in contexts of natural disaster (ND, entire expatriate team deployed by MSF-OCB), active conflict (AC) and stable healthcare gaps (HG). In AC and HG settings, MSF-OCB support pre-existing local facilities. Hospital facilities ranged from basic health centres with surgical capabilities to tertiary referral centres. PARTICIPANTS: The full dataset included 178 814 surgical cases. These were categorised by most senior anaesthetic provider for the project, according to qualification: specialist physician anaesthesiologists, qualified nurse anaesthetists and uncertified anaesthesia providers. PRIMARY OUTCOME MEASURE: Volume and nature of surgical workload of different anaesthesia providers. RESULTS: Full routine data were available for 173 084 cases (96.8%): 2518 in ND, 42 225 in AC, 126 936 in HG. Anaesthesia was predominantly led by physician anaesthesiologists (100% in ND, 66% in AC and HG), then nurse anaesthetists (19% in AC and HG) or uncertified anaesthesia providers (15% in AC and HG). Across all settings and provider groups, patients were mostly healthy young adults (median age range 24-27 years), with predominantly females in HG contexts, and males in AC contexts. Overall intra-operative mortality was 0.2%. CONCLUSION: Our findings contribute to existing knowledge of the nature of anaesthetic provision in humanitarian settings, while demonstrating the value of high-quality, routine data collection at scale in this sector. Further evaluation of perioperative outcomes associated with different models of humanitarian anaesthetic provision is required.