Undergraduate surgical education is failing to prepare medical students to care for patients with surgical conditions, and has been significantly compromised by the COVID-19 pandemic. We performed a literature review and undertook semi-structured reflections on the current state of undergraduate surgical education across five countries: Egypt, Morocco, Somaliland, Kenya, and the UK. The main barriers to surgical education at medical school identified were (1) the lack of standardised surgical curricula with mandatory learning objectives and (2) the inadequacy of human resources for surgical education. COVID-19 has exacerbated these challenges by depleting the pool of surgical educators and reducing access to learning opportunities in clinical environments. To address the global need for a larger surgical workforce, specific attention must be paid to improving undergraduate surgical education. Solutions proposed include the development of a standard surgical curriculum with learning outcomes appropriate for local needs, the incentivisation of surgical educators, the incorporation of targeted online and simulation teaching, and the use of technology.

/pdf/undergraduate-surgical-education-a-global-perspective-535666b3d8.pdf

Undergraduate Surgical Education: a Global Perspective.

Abstract Background Students must be proficient in surgical skills according to General Medical Council and Royal College of Surgeons of England guidelines. If these skills are not appropriately taught, there is a risk of an incoming junior workforce with inadequate surgical skills. This paper aimed to review the literature relating to undergraduate teaching of surgical skills in the UK and summarize future suggested training methods. Methods The databases MEDLINE, Embase and SCOPUS were searched, and the existing literature relating to methodology of undergraduate teaching of surgical skills in the UK over the past 10 years was summarized. The Medical Education Research Quality Instrument was used to assess research quality. Results A total of 19 papers were included. Cross-sectional evaluations and survey-based studies highlight a clear deficit in surgical skills teaching in the UK. Medical students are currently unable to fulfil their own learning needs and meet requirements set out by the General Medical Council. This lack of surgical teaching appears to negatively affect student desire to pursue a surgical career. The three main themes for improvement are extracurricular surgical skills days, near-peer teaching and simulation. Each method appeared to improve learning, although no studies utilized medium- to long-term follow-up to demonstrate efficacy and there lacks a clear consensus as to the ‘standard’ of undergraduate surgical skill education. There was also potential for selection bias and response shift bias in many of the studies assessing pre- and postintervention confidence and opinions. Conclusion There is a concerning lack of surgical skills teaching that has resulted in medical students and junior doctors not having the necessary surgical skills as per General Medical Council guidance and students feel that their own learning needs are not met. This failure to address the learning deficit may be responsible for the fall in surgical competition ratios. While surgical skills teaching must be improved urgently, more robust evidence is required to evaluate the optimal ways of approaching this issue.

Undergraduate teaching of surgical skills in the UK: systematic review

Sir, We have received institutional review board approval from Chonbuk National University Hospital (CUH 2018-01-025) and obtained the patient’s written informed consent to publish the material. A 61-year-old woman with systemic lupus erythematosus (SLE) and secondary antiphospholipid syndrome (APS) presented with a right lower leg lesion that had developed 2 years previously. She was diagnosed with SLE and APS aged 53 years. She presented with facial rash, polyarthritis, leukopenia, thrombocytopenia, and positivity for antinuclear antibody, anti-dsDNA antibody, antiSm antibody, and antiphospholipid antibody. When she visited the hospital for leg ulceration, her disease activity was well controlled with hydroxychloroquine, low-dose steroid (2.5mg/d), and warfarin. Cutaneous ulceration developed after she scratched the lesion, and it had not healed with regular dressing; in addition, the ulcer had become enlarged and painful. She had undergone split thickness skin grafting (STSG) with skin harvested from her thigh in 2015 (Figure 1(a)); however, the lesion showed disruption and became aggravated after 6 months (Figure 1(b)). Subsequently, she underwent STSG again in 2016 (Figure 1(c)), but the wound disrupted again and suppurative inflammation worsened despite surgical debridement (Figure 1(d)). She rejected further surgical intervention and was examined 2 years after the development of the first lesion. Physical examination revealed a 5 4 cm ulcer on the right lower extremity, exhibiting yellowish exudates at the base and undetermined edges with surrounding violaceous, gray erythema. Her blood, urine, and wound cultures did not show any infectious etiology. Biopsy of the skin adjacent to the ulcer revealed diffuse neutrophilic infiltrates, which was non-specific but helpful in excluding other differential diagnoses, such as cutaneous malignancy, infection, or vascular disorders, and led to the diagnosis of pyoderma gangrenosum (PG). High-dose prednisolone (1mg/kg/d) and cyclosporine (2mg/kg/d) were immediately started. The wound substantially healed with re-epithelialization, and the overall diameter decreased to 1.5 cm (Figure 1(e) to (i)). This improvement remained stable at the 12month follow-up. PG is a cutaneous disease characterized by expanding ulcers, and considered an idiopathic neutrophilic dermatosis, possibly driven by a chronic autoinflammatory process of the skin. It has been described in association with systemic medical disorders like SLE. However, patients, especially those with lupus, may have a wide range of skin manifestations, making it difficult to diagnose PG without awareness of its possibility. Recently, diagnostic criteria were proposed by an international experts group, and this approach predominantly relies on clinical features. Furthermore, the PARACELSUS score, which is a new and clinically practical diagnostic scoring system, also includes the presence of systemic diseases as a scoring factor and emphasizes the characteristic clinical features. Therefore, it is important for clinicians to be aware of the possibility of PG in a patient with SLE to prevent misdiagnosis and delayed diagnosis. Currently, glucocorticoids and immunosuppressive agents are the mainstay of treatment on the basis of expert opinions. Surgical intervention has not been proven efficacious; even cases of ‘‘post-surgical pyoderma gangrenosum’’ emphasized that surgical intervention may lead to disease aggravation. Therefore, we present this case to share our experience of misdiagnosis and subsequent inappropriate therapeutic approach in PG and highlight the importance of recognizing this rare disease to enable timely and accurate diagnosis.

https://journals.sagepub.com/doi/pdf/10.1177/0961203318793705

Pyoderma gangrenosum masquerading as an ulcer related to antiphospholipid antibodies in a patient with systemic lupus erythematosus.

Pyoderma Gangrenosum After Facelift and Otoplasty Surgery: Case Presentations and Literature Review.

Original Research Article Background: de Quervain's disease has been described as an entrapment of the extensor pollicis brevis and abductor pollicis longus tendons in the first dorsal compartment of the wrist is a common cause of wrist and hand pain. Treatment of the disease consist of pharmacological & non-pharmacological. The non-Pharmacological includes immobilization, therapeutic heat and cold, electrical nerve stimulator, thumb stabilizer splint, postural correction at work and the adjustment of tools and equipment. The medication included non-steroidal Anti-inflammatory Drugs (NSAIDs) and analgesic, an injection of a steroid mixed with xylocaine into tendon sheaths. Objective: Main goal of this study is to evaluate the effect of Thumb spica splint in the management of de Quervain disease. Methods: This randomized clinical trial was performed in the Department of Physical Medicine and Rehabilitation, Chittagong Medical College Hospital, over a period of six months. Study population were the patients of de Quervain’s disease attending the outpatient department of Physical Medicine and Rehabilitation during the study period. Meticulous history taking, clinical examination and relevant investigations were done. Samples was selected by consecutive sampling from the population who are eligible as per inclusion and exclusion criteria from a definite date till desired sample size is reached and eligible participants were allocated into two groups, group A-experimental or interventional group and group B-control group by randomization with the help of lottery. Experimental group was managed by activities of daily living (ADLs) instructions, non-steroidal anti-inflammatory agents (NSAIDs), ultrasound therapy (UST), along with Thumb spica splint. Control group received previous management except Thumb spica splint. Here Tynor brand Thumb spica splint was advised to use to all patient in experimental group, same analgesic drugs Tab. Naproxen 250mg two times daily after meal was given to all patients along with proton pump inhibitors till acute condition was subside and all patients receive therapeutic ultrasound in a same dosage (1watt/ cm 2 /min) for 510minutes. So, there were six follow up visits and these evaluations were performed by the same investigator. In each visit, measurement of pain intensity and disability level were performed by using visual analogue scale (VAS), Tenderness Index and Patient rated wrist evaluation (PRWE) respectively. Results: There were 92.7% patients who had localized pain and only 7.3% had radiation. Most of the pain in the evening (56.4%) and rest had pain at night (43.6%). Most of the patients in both groups had constant and intermittent type of pain (47.5% and 45.5%) other types were sharp and dull. All patients in both groups had some aggravating factor but relieving factors were less (45.45%). Significant difference between Group A and Group B was found at week 5 and Week 6 follow up(P<0.05) whereas other early follow up was non-significant in VAS analysis(p>0.05). Significant difference between Group A and Group B was found at week 4, week 5 and week 6 follow up(P<0.05) regarding change of tender index in Group A then Group B. No significant difference between Group A and Group B was found at different weeks of follow up (P>0.05) regarding PRWE. Conclusions: Regarding treatment of de Quervain's tenosynovitis, present study shown that use of Thumb spica splint reduce the morbidity and relief of pain of patients when used along with other conventional treatment.

/pdf/effect-of-thumb-spica-splint-in-de-quervain-s-disease-46ulin0nb7.pdf

Effect of Thumb Spica Splint in de Quervain’s Disease

As illustrated by this case, cutaneous PG of the hand is a diagnosis of exclusion. Though rare, an index of suspicion should be maintained as PG can present similarly to other conditions in the hand such as fulminating infection and malignancy, that would traditionally be managed surgically. Inappropriate surgical debridement of PG in the hand can, however, lead to persistent and worsening ulceration and poor outcomes, such as digital amputation, so should be avoided. Although international diagnostic criteria are yet to be established, prompt diagnosis is essential in avoiding significant clinical consequences.

Cutaneous Pyoderma Gangrenosum of the Hand.

De Quervain’s tenosynovitis is a common cause of wrist pain in adults. It is characterised by atraumatic pain or tenderness along the radial side of the wrist and is often associated with overuse o...

De Quervain's tenosynovitis:

Introduction Medical students across the United Kingdom (UK) report poor satisfaction with surgical teaching. The Surgical Skills Day (SSD) begins to address this by exposing medical students to surgery through an easily accessible one-day practical workshop. This study shows how the SSD encourages undergraduate engagement in surgery. Method Feedback forms were emailed to attendees of the SSD and their anonymised responses were used to evaluate the SSD. Results A total of 144 students attended the SSD across three years and the feedback response rate was 74% (n = 107). Key findings were that 100% of respondents (n = 107) would like the SSD to be an annual event, 79% (n = 83) were more inclined to pursue a surgical career following the event, and 97% (n = 103) would like to see practical surgical skills incorporated into the curriculum. The SSD was able to engage undergraduates with surgery through mentorship, practical skills, specialty exposure, and teaching of the General Medical Council (GMC) mandated skills. Conclusions Undergraduate surgical teaching in the UK is insufficient. The student-led annual SSD showed improved engagement in practical surgical skills and increased enthusiasm for a surgical career. In light of this, the authors feel the SSD or similar event should be integrated into the UK medical school curriculum.

Surgical Skills Workshops Should Be a Part of the United Kingdom Undergraduate Medical Curriculum.

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Cutaneous Pyoderma Gangrenosum of the Hand.

De Quervain's tenosynovitis:

Surgical Skills Workshops Should Be a Part of the United Kingdom Undergraduate Medical Curriculum.