Background Robotic surgery offers advantages over conventional operative approaches, but may also be associated with higher costs and additional risks. Analyzing surgical flow disruptions (FDs), ...defined as “deviations from the natural progression of an operation,” can help target training techniques and identify opportunities for improvement. Materials and methods Thirty-two Robotic Surgery operations were observed over a six-week period at one 900-bed surgical center. FDs were recorded in detail and classified into one of 11 different categories. Procedure type, robot model, and resident involvement were also recorded. Linear regression analyses were used to evaluate the effects of these parameters on FDs and operative duration. Results Twenty-one prostatectomies, 8 sacrocolpopexies, and 3 nephrectomies were observed. The mean number of FDs was 48.2 (95% CI 38.6-54.8 FDs), and mean operative duration was 163 minutes (95% CI 148-179 minutes). Each FD added 2.4 minutes (p=0.025) to a case’s total operative duration. The number and rate of FDs were significantly affected by resident involvement (p=0.008 and p=0.006, respectively). Resident cases demonstrated mostly Training, Equipment, and Robot Switch FDs, whereas non-resident cases demonstrated mostly Equipment, Instrument Changes, and External Factors FDs. Conclusions Though the FDs encountered in resident training are more frequent, they may not significantly increase operative duration. Other FDs, such as Equipment or External Factors, may be more impactful. Limiting these specific FDs should be the focus of performance improvement efforts.
The COVID-19 pandemic has had significant ramifications for provider well-being. During these unprecedented and challenging times, one institution's Department of Surgery put in place several ...important initiatives for promoting the well-being of trainees as they were redeployed to provide care to COVID-19 patients. In this article, the authors describe these initiatives, which fall into 3 broad categories: redeploying faculty and trainees, ensuring provider safety, and promoting trainee wellness. The redeployment initiatives are the following: reframing the team mindset, creating a culture of grace and forgiveness, establishing a multidisciplinary wellness committee, promoting centralized leadership, providing clear communication, coordinating between departments and programs, implementing phased restructuring of the department's services, establishing scheduling flexibility and redundancy, adhering to training regulations, designating a trainee ombudsperson, assessing physical health risks for high-risk individuals, and planning for structured deimplementation. Initiatives specific to promoting provider safety are appointing a trainee safety advocate, guaranteeing personal protective equipment and relevant information about these materials, providing guidance regarding safe practices at home, and offering alternative housing options when necessary. Finally, the initiatives put in place to directly promote trainee wellness are establishing an environment of psychological safety, providing mental health resources, maintaining the educational missions, solidifying a sense of community by showing appreciation, being attentive to childcare, and using social media to promote community morale. The initiatives to carry out the department's strategy presented in this article, which were well received by both faculty and trainee members of the authors' community, may be employed in other departments and even outside the context of COVID-19. The authors hope that colleagues at other institutions and departments, independent of specialty, will find the initiatives described here helpful during, and perhaps after, the pandemic as they develop their own institution-specific strategies to promote trainee wellness.
Surgical coaching continues to gain momentum as an innovative method for continuous professional development. A tool to measure the performance of a surgical coach is needed to provide formative ...feedback to coaches for continued skill development and to assess the fidelity of a coaching intervention for future research and dissemination.
To evaluate the validity of the Wisconsin Surgical Coaching Rubric (WiSCoR), a novel tool to assess the performance of a peer surgical coach.
Surgical coaching sessions from November 2014 through February 2018 conducted by 2 statewide peer surgical coaching programs were audio recorded and transcribed. Twelve raters used WiSCoR to rate the performance of the surgical coach for each session. The study included peer surgical coaches in the Wisconsin Surgical Coaching Program (n = 8) and the Michigan Bariatric Surgery Collaborative coaching program (n = 15). The data were analyzed in 2019.
Use of WiSCoR to rate peer surgical coaching sessions.
There were 282 WiSCoR ratings from the 106 coaching sessions included in the study. WiSCoR was evaluated using a framework, including inter-rater reliability assessed with Gwet weighted agreement coefficent. Descriptive statistics of WiSCoR were calculated.
Eight coaches (35%) and 11 coachees (29%) were from the Wisconsin Surgical Program and 15 coaches (65%) and 27 coachees (71%) were from the Michigan Bariatric Surgery Collaborative. The validity of WiSCoR is supported by high interrater reliability (Gwet weighted agreement coefficient, 0.87) as well as a weakly positive correlation of WiSCoR to coachee ratings of coaches (r = 0.22; P = .04), rigorous content development, consistent rater training, and the association of WiSCoR with coach and coaching program development. The mean (SD) overall coach performance rating using WiSCoR was 3.23 (0.82; range, 1-5).
WiSCoR is a reliable measure that can assess the performance of a surgical coach, inform fidelity to coaching principles, and provide formative feedback to surgical coaches. While coachee ratings may reflect coachee satisfaction, they are not able to determine the quality of a coach.
Biogeochemical maps of coastal regions can be used to identify important influences and inputs that define nearshore environments and biota. Biogeochemical tracers can also track animal movement and ...their diet, monitor human coastal development, and evaluate the condition of habitats and species. However, the beneficial applications of spatial biogeochemical analysis are hindered by a limited understanding of how tracer distribution is affected by different land and ocean-based influences. To help address these knowledge gaps, we determined the spatial trends of three stable isotopes (δ13C-carbon, δ15N-nitrogen, δ34S-sulfur) and 13 major and trace elements in an urbanized coastal embayment (Moreton Bay, Australia), as incorporated into the muscle tissue of a marine consumer, the eastern king prawn Melicertus plebejus. Results were used to identify unique biochemical regions within the bay and to discuss how spatial patterns in tracers could be used to indicate the relative importance of catchment, urban and offshore drivers in coastal bays. Discriminant analysis identified seven biogeochemical regions that were likely distinguished by variation in catchment, urban, and offshore input, and habitat type. δ13C and δ15N patterns suggested nearshore areas could be distinguished by increased sediment resuspension and higher wastewater inputs from catchments. High inshore lead (Pb) and copper (Cu) concentrations were likely the result of urban input. Arsenic (As) and cadmium (Cd) increased further from shore. This trend implied oceanic influences were a significant control over As and Cd bioavailability. Cobalt (Co) and rare earths were also used to differentiate some nearshore areas, but incongruent distribution patterns in Co suggested it may be less reliable. Overall, results indicated that δ15N, δ13C, Cd, Cu, Pb and rare earth elements were the most reliable tracers to differentiate nearshore and offshore environments, and catchment-based effects. We encourage future studies to consider using a similar multivariate approach in coastal spatial analysis, and to include unrelated tracers that reflect distinct coastal influences.
The estuarine crocodile (Crocodylus porosus) is one of the largest and most widespread crocodilians in the world. Although considered an apex species, the role of the estuarine crocodile in aquatic ...foodwebs is poorly understood; we know what crocodiles ingest, but not what nourishes them. In this study, we used a combination of stable isotope measurements (δ13C, δ15N, and δ34S) and direct feeding observations to identify the source of nutrition of estuarine crocodiles in Kakadu National Park, Northern Australia. Our results show that most crocodiles sampled (size 850 - 4200mm, with 76% of them being > 2.5 m) consume a large variety of prey, however a large proportion of their nutrition is derived from terrestrial prey. Introduced species such as water buffaloes (Bubalus bubalis) and pigs (Sus scrofa) could contribute between 53 and 84% to the nutrition of the sampled crocodiles. The isotopic composition of large crocodiles (total length > 3 m) suggested possible increase in marine prey consumption with size (R2 = 0.30; p = 0.005). Additionally, we found crocodiles sampled in the dry season had on average higher terrestrial contributions compared to crocodiles sampled during the wet season (84.1 ± 2.4% versus 55.4 ± 7.0%). Overall, we found that terrestrial prey are important source of nutrition for many crocodiles in this region where introduced herbivorous mammals are abundant.
Bulk stable isotope analysis provides information regarding food web interactions, and has been applied to several cetacean species for the study of migration ecology. One limitation in bulk stable ...isotope analysis arises when a species, such as Southern hemisphere humpback whales, utilises geographically distinct food webs with differing isotopic baselines. Migrations to areas with different baselines can result in isotopic changes that mimic changes in feeding relations, leading to ambiguous food web interpretations. Here, we demonstrate the novel application of radiocarbon measurement for the resolution of such ambiguities. Radiocarbon was measured in baleen plates from humpback whales stranded in Australia between 2007 and 2013, and in skin samples collected in Australia and Antarctica from stranded and free-ranging animals. Radiocarbon measurements showed lower values for Southern Ocean feeding than for extra-Antarctic feeding in Australian waters. While the whales mostly relied on Antarctic-derived energy stores during their annual migration, there was some evidence of feeding within temperate zone waters in some individuals. This work, to our knowledge, provides the first definitive biochemical evidence for supplementary feeding by southern hemisphere humpback whales within temperate waters during migration. Further, the work contributes a powerful new tool (radiocarbon) for tracing source regions and geographical feeding.
Numerous studies show empathic concern promotes altruistic motivation and prosocial behavior. Here, we discuss empathic concern, its relation to altruistic motivation, and how empathic concern is ...invoked in experimental studies. We do this with an eye toward applying laboratory techniques in the classroom, and everyday life, to foster empathic concern and altruistic responding. This goes beyond teaching about empathic concern to setting up conditions that help people experience this psychological state, and its benefits, firsthand. Smartphone-based ecological momentary interventions (EMIs) can help us do this by raising self- and other-awareness, and by promoting empathic states and practices in daily life. While smartphones often pull us away from direct personal interaction, we explore ways of using these devices to redirect our attention to those around us. We end by suggesting that these ways of helping people regularly experience and act upon empathic concern in daily life might help nurture a compassionate disposition.
Evaluating the impacts of climate and fishing on oceanic ecosystems requires an improved understanding of the trophodynamics of pelagic food webs. Our approach was to examine broad-scale spatial ...relationships among the stable N isotope values of copepods and yellowfin tuna (Thunnus albacares), and to quantify yellowfin tuna trophic status in the food web based on stable-isotope and stomach-contents analyses. Using a generalized additive model fitted to abundance-weighted-average delta 15N values of several omnivorous copepod species, we examined isotopic spatial relationships among yellowfin tuna and copepods. We found a broad-scale, uniform gradient in delta 15N values of copepods increasing from south to north in a region encompassing the eastern Pacific warm pool and parts of several current systems. Over the same region, a similar trend was observed for the delta 15N values in the white muscle of yellowfin tuna caught by the purse-seine fishery, implying limited movement behavior. Assuming the omnivorous copepods represent a proxy for the delta 15N values at the base of the food web, the isotopic difference between these two taxa, " YFT-COP," was interpreted as a trophic-position offset. Yellowfin tuna trophic-position estimates based on their bulk delta 15N values were not significantly different than independent estimates based on stomach contents, but are sensitive to errors in the trophic enrichment factor and the trophic position of copepods. An apparent inshore-offshore, east to west gradient in yellowfin tuna trophic position was corroborated using compound-specific isotope analysis of amino acids conducted on a subset of samples. The gradient was not explained by the distribution of yellowfin tuna of different sizes, by seasonal variability at the base of the food web, or by known ambit distances (i.e. movements). Yellowfin tuna stomach contents did not show a regular inshore-offshore gradient in trophic position during 2003-2005, but the trophic-position estimates based on both methods had similar scales of variability. We conclude that trophic status of yellowfin tuna increased significantly from east to west over the study area based on the spatial pattern of YFT-COP values and the difference between the delta 15N values of glutamic acid and glycine, "trophic" and "source" amino acids, respectively. These results provide improved depictions of trophic links and biomass flows for food-web models, effective tools to evaluate climate and fishing effects on exploited ecosystems.
The Breton Sound estuary in southern Louisiana receives large amounts of Mississippi River water via a controlled diversion structure at the upstream end of the estuary. We used stable isotopes to ...trace spatial and seasonal responses of the downstream food web to winter and spring introductions of river water. Analysis of δ¹³C, δ¹⁵N, and δ³⁴S in the common local consumers such as grass shrimp (Palaemonetes sp.), barnacles (Balanus sp.), and small plankton-feeding fish (bay anchovies, Anchoa mitchilli) showed that the diversion was associated with two of the five major source regimes that were supporting food webs: a river regime near the diversion and a river-influenced productive marsh regime farther away from the diversion. Mixing models identified a third river-influenced source regime at the marine end of the estuary where major natural discharge from the Bird's Foot Delta wraps around into estuarine waters. The remaining two source regimes represented typical estuarine conditions: local freshwater sources especially from precipitation and a brackish source regime representing higher salinity marine influences. Overall, the Mississippi River diversion accounted for 75% of food web support in the upper estuary and 25% in the middle estuary, with influence strongest along known flow pathways and closest to the diversion. Isotopes also traced seasonal changes in river contributions, and indicated increased plant community productivity along the major flow path of diversion water. In the Breton Sound estuary, bottom-up forcing of food webs is strongly linked to river introductions and discharge, occurring in spatial and temporal patterns predictable from known river input regimes and known hydrologic circulation patterns.
PDF
