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The shift from traditional apprenticeship models to competency-based curricula, compounded by working hour restrictions and rapid advances in surgical technology, has altered the delivery of early years surgical training. Simulation has been widely incorporated in other high-risk, high-reliability industries, but it has only just begun to be embedded in surgical programmes over the last two decades. In this article, we review key concepts in surgical simulation. Using Scotland's Core Surgical Training Programme as an example, we demonstrate the implementation of these concepts into a national integrated simulation strategy for early years surgical training. We highlight other global examples of simulation use in surgical curricula. The key messages for all stakeholders in surgical training are: (i) simulation is an adjunct to clinical training; (ii) simulation is a tool; however, it is not the tool that should be the main object of interest, but the learning for which it is used; and (iii) in the absence of a constructively aligned and purposeful programme that is valued by trainees, trainers and the training system, it is not enough to issue the kit, no matter how good the simulators are.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare type of non-Hodgkin T-cell lymphoma, recently defined in the 2016 World Health Organization (WHO) classification of lymphoid neoplasms. It occurs more commonly when textured implants are used and appears clinically as a late seroma. Cytologically, these lesions are composed of large atypical cells with pleomorphic nucleus and an immunophenotype positive for T cell markers and CD30, and negative for ALK1. We report a 56-years-old woman with breast implants who developed a periprosthetic seroma three years after surgery. A fine needle aspiration of the lesion was carried out. Cytology and the immunocytochemical study revealed cells compatible with BIA-ALCL. The flow cytometric study was negative. Excisional biopsy of the capsule was performed, observing that the neoplastic cells were confined to the inner surface of the capsule. Imaging studies did not find evidence of disseminated disease. The present case demonstrates the importance of the study of any late periprosthetic effusion, which can be performed using fine needle aspiration.

Coalitional politics have largely been examined across social and cultural differences that serve shared political commitments, and the rhetorical force of situated and material locations remains a...

The Environmental Justice working group took an engaged and intersectional approach, focusing on interconnections between affordable housing, transportation, and University of Nevada, Reno campus p...

Introduction One premise of the Improved Surgical Training (IST) pilot is delivery of better quality of early years surgical training. However, the quality of the trainee-trainer relationship can positively or negatively impact trainees’ experiences of the specialty. Trust is a key determinant of the relationship, which is influenced by trainers’ level of risk aversion and trainees’ motivation. Game theory provides a framework to understand cooperation amongst rational ‘players’. This study explores how trainee-trainer relationships impact trainees’ experiences through the IST curricular reform. Methods Using a qualitative case study approach, data were obtained from interviews with core surgical trainees across Scotland. Data coding and inductive thematic analysis were undertaken. Results Forty-six trainees participated. Trainees and trainers regularly interacting in clinical activities demonstrated growing levels of trust, aided by: specialty rotations of 6 months or more duration, working at junior registrar level with structured weekly clinical activities and direct consultant supervision, individual goal-setting and regular progress check, and meaningful and timely feedback. Cooperative relationships led to individual fulfilment, growth, and trainee autonomy. Factors hindering development of trust included: temporal and/or geographical distance between trainee-trainer, poor communication and understanding of expectations and training needs, and lack of interest and enthusiasm from either party. Conclusion Cohesive trainee-trainer relationships demonstrated cooperative equilibrium; both trainees and trainers met each other’s expectations and positively impacted on trainees’ experiences. On the contrary, ‘players’ in relationships deficient in trust achieved the minimum to ensure trainee progression. Addressing factors fostering a cooperative trainee-trainer relationship positively impacts trainees’ experiences.

Introduction The COVID-19 pandemic brought widespread disruption to structured surgical education and training. The knee-jerk reaction is often pessimism about surgical training’s future, particularly in the Improved Surgical Training (IST) pilot’s context. However, Einstein famously once said, “In the midst of every crises lies great opportunity”. Unlocking growth during periods of high uncertainty is a premise of real options theory; one utilised by supply chain managers and decision scientists, but novel to medical education. This study explores the growth options that have resulted from new operational models during the pandemic. Method Using a qualitative case study approach, data were obtained from interviews with core surgical trainees across Scotland. Data coding and inductive thematic analysis were undertaken. Results Forty-six trainees participated. Analysis from trainees’ perspective revealed: unexpected fulfilment from redeployment to non-surgical specialties, benefits to personal development from the unintended broad-based training across surgical specialties, improved collaborative teamworking between specialties and allied healthcare professionals, and enhanced supervised learning opportunities. Institutional growth options reported by trainees included: rapid uptake of telemedicine and digital technology, implementation of single hospital episode encounters for minor conditions, streamlined processes in theatre and acute admissions, and changes in working culture towards rationalising and teamworking. Conclusions Growth options have been deliberately and unintentionally unlocked due to individual and institutional adaptions and innovations in response to the exogenous disruption. While some changes may be temporary, hopefully structured reflection on these changes and responders to them will drive surgical education and training into a new sustainable and resilient post-pandemic era.

Introduction Surgical simulation has been repeatedly shown to facilitate technical skill acquisition. However, trainee engagement with self-directed practice remains variable, despite access to resources. Understanding the motivators and barriers to participation is crucial to develop modules which can effectively meet the learning needs of current, and future, surgical trainees. The aim of this qualitative study was to examine factors which influence trainee engagement with home-based surgical skills simulation. Method A series of one-to-one semi-structured interviews were conducted remotely with ST3 vascular trainees who had previously consented to take part in a national programme of home-based technical skills simulation. Interview data was transcribed and thematically analysed. Results 12 trainees were interviewed during a 4-week period. Overall, trainees valued simulation but found it difficult to balance against clinical commitments and mandatory training requirements, particularly if there were limited opportunities for skill transfer to the real-world environment. Although simulation was acknowledged to be a safe environment for experiential learning, trainees alluded to an underlying culture of perfection which limited willingness to learn from mistakes, even within a simulated setting. In addition, traditional attitudes about the apprenticeship model of surgical training prevail, with simulation often viewed as inferior to learning “on the job” in theatre. Conclusions Trainee engagement with home-based surgical skills simulation may be influenced by a range of systemic factors. In future, formal certification of simulation modules, mandating simulated competencies and curricular integration may help improve participation, as well as supporting cultural shift towards recognition of simulation as a vital component of modern surgical training.

Worldwide, bees have an important role in ecosystem function and the provision of ecosystem services through their role as pollinators. The diversity of bee species in rural landscapes is influenced by the type of landscape features present, and by land-use and management practices. A key challenge is to understand and predict how species vary across the landscape; and the role of functional traits in determining compositional patterns. We systematically sampled wild bees in four types of landscape feature – open farmland, scattered farmland trees, roadside vegetation and streamside vegetation – in rural landscapes in southern Australia. Landscapes were selected to represent wooded or non-wooded combinations of these site types (e.g. roadside vegetation with or without trees), embedded in farmland with different land-uses (e.g. cropping, grazing). The species richness and abundance of bees was greater at sites containing little or no tree cover; and the cumulative richness of species was greater for tree-less sites than for those with trees. In contrast, species evenness was greatest in wooded site types, indicating these were less dominated by abundant generalist species. Open farmland and treeless roadsides had greater functional diversity (based on species traits) than wooded site types. Strong species trait associations were more numerous with open parts of the landscape, reflecting the greater functional diversity of open site types. These results suggest that a suite of the extant bee fauna can exploit large-scale transformation from former extensively wooded ecosystems to open agricultural landscapes. However, not all species are able to exploit modified landscapes and may disappear with further loss of wooded vegetation. Trait-based approaches provide insight into how changes in landscape pattern affect the bee fauna. Failure to adequately cater for multiple functional groups of bees across all landscape features could mean a substantial loss in species that rely on more natural cover, thus affecting ecosystem function.

Introduction Box-trainers enable deliberate practice of laparoscopic skills and can be equipped with instrument tracking metrics to provide feedback. However, the relationship between metrics, assessment outcomes and practice are unclear. Method Core surgical trainees were provided take-home box trainers with SurgTrac™ instrument tracking metrics for practice (eoSurgical Ltd., Scotland, UK). Practice was incentivised by certification and video assessment of a basic task, peg capping. Assessment was by consultant general surgeons, using objective structured assessment of technical skills (OSATS). The following metrics were analysed: task duration, distance moved by instruments, average instrument speed, average instrument acceleration, left- or right-handedness and instrument smoothness. Metrics were correlated to OSATS scores using regression analysis. Threshold for significance was p = 0.05. Results During the study period, there were 1639 peg capping performances by 85 trainees; 103 video recordings were submitted for assessment. All metrics were significantly associated with OSATS score, except instrument acceleration. The multiple linear regression model was highly correlated with actual scores (Pearson correlation 0.658; p Conclusions Instrument tracking metrics reliably predict OSATS performance and practice improves predicted score. Trainees can use metrics in unsupervised practice and gauge whether they are improving as expected.

BackgroundThe transfer validity of portable laparoscopy simulation is well established. However, attempts to integrate take-home simulation into surgical training have met with inconsistent engagement, as reported in our 2014-15 study of an Incentivised Laparoscopy Practice (ILP) programme. Our subsequent multi-centre study examined barriers and facilitators, informing revisions of the programme for 2018-20. We now report engagement with the revised versions.MethodsIn ILP v2.1 and 2.2, two consecutive year-groups of new CSTs (n= 48 and 46) were loaned portable simulators. The 6-month programme included induction, technical support, and intermittent feedback. Six tasks were prescribed, with video instruction and charting of metric scores. Video uploads were required and scored by faculty. A pass resulted in an eCertificate, expected at Annual Review. ILP was set within a wider reform, “Improving Surgical Training”.ResultsILP v2.1 and 2.2 saw pass rates of 94% and 76% (45/48 and 35/46 trainees respectively), compared with only 26% (7/27) in v1, despite the v2.1 and v2.2 groups having less electronic gaming experience. In the ILP v2.2 group, 73% reported their engagement was adversely affected by COVID19 redeployments.ConclusionsSimply providing kit, no matter how good, is not enough. To achieve trainee engagement with take- home simulators, as in ILP v2, a whole programme is required, with motivated learning, individual and group practice, intermittent feedback, and clear goals and assessments. ILP is a complex intervention, best understood as a “reform within a reform, within a context.” This may explain why trainee engagement fell away during early pandemic conditions.WHAT IS ALREADY KNOWN ON THIS SUBJECTAttaining automation of motor skills is essential to free up operating surgeons’ attention for higher cognitive functions.Laparoscopic operating skills can transfer from simulation to the operating room, and deliberate practice is the most important variable in the development of expertise.Simply providing take-home portable simulators to surgical trainees, even with online training programmes, is insufficient to facilitate consistent deliberate practice by more than a minority of trainees.WHAT THIS STUDY ADDSA package of evidence-based reforms transformed participation of Core Surgical trainees in a 6-month programme of practice using take-home portable simulators, resulting in near- 100% engagement.Such reforms are complex, including motivators for learning, individual and group practice, intermittent feedback, clear goals and assessments, and adoption into a wider curriculum reform called “Improving Surgical Training”.The improved engagement with this form of remote simulation-based training did not continue in the face of a national “lockdown” for the COVID19 pandemic, where there was widespread redeployment of trainees.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare type of non-Hodgkin T-cell lymphoma, recently defined in the 2016 World Health Organization (WHO) classification of lymphoid neoplasms. It occurs more commonly when textured implants are used and appears clinically as a late seroma. Cytologically, these lesions are composed of large atypical cells with pleomorphic nucleus and an immunophenotype positive for T cell markers and CD30, and negative for ALK1. We report a 56-years-old woman with breast implants who developed a periprosthetic seroma three years after surgery. A fine needle aspiration of the lesion was carried out. Cytology and the immunocytochemical study revealed cells compatible with BIA-ALCL. The flow cytometric study was negative. Excisional biopsy of the capsule was performed, observing that the neoplastic cells were confined to the inner surface of the capsule. Imaging studies did not find evidence of disseminated disease. The present case demonstrates the importance of the study of any late periprosthetic effusion, which can be performed using fine needle aspiration.

Background Simulation has an increasingly prominent role in modern vascular surgery training. However, it is important to understand how simulation is most effectively delivered to best use the time and resources available. The aim of this narrative review is therefore to critically appraise open technical skill acquisition in the operating room environment and provide recommendations for the future development of evidence-based simulation for open vascular surgery. Methods A systematic search strategy was used to retrieve relevant studies from PubMed, Medline, Web of Science, EMBASE, and the Cochrane databases in July 2019. Included papers were independently screened by two reviewers. Data were subsequently extracted using a standardized proforma and thematically analyzed. Results Thirteen studies were included. All demonstrated that simulation is effective in improving confidence and/or competence in performing open technical skills when assessed by previously validated metrics. However, not all participants or course schedules achieved equal benefit, with distributed practice for junior trainees over several weeks achieving a greater improvement in technical skill compared with senior trainees or longer course schedules for some tasks. Conclusions Simulation can be an effective adjunct to traditional operative experience for technical skill acquisition in open vascular surgery. Future work should focus on developing models to address a wider range of training needs, as well as further defining the optimum schedule for the style, content, and timing of simulation for specific learner groups.

Recently I was chatting with our environmental science faculty about a monarch butterfly project and the lead scientist exclaimed, “Citizen Science?! That’s a bad phrase around here.” Our conversat...

Treatment for patients with locally advanced low lying rectal cancer differs significantly from patients with rectal cancer restricted to the mesorectum. Surgical resection will be the straightforward option for the early ones but multimodality treatment, including preoperative chemo-radiation and extended surgical resection will be the options for advanced ones. Cylindrical abdominoperineal excision of rectum (C-APER) along with possible composite pelvic organ resection is a surgical method to remove an adequate circumferential margin so to reduce the local recurrence rate and improve long term survival. Adequate preoperative imaging of the pelvis is therefore important to identify these patients and effort should be made to select those patients with advanced tumours with no systemic spread. In this article, we reviewed some consecutive cases of advanced rectal cancer to their immediate surgical outcome.

Background Scottish Surgical Boot Camps are the induction course for new start Core Surgical Trainees (Residents) in Scotland. The aim is to capitalise on trainees’ receptiveness at a time of transition, and to give them a safe and “flying start.” At their inception, these were the first such courses in the UK to integrate technical and non-technical skills training. As well as knowledge and skills, trainees have learned norms and expectations of a community of professional practice. Methods Over 9 consecutive years of delivery and quality improvement, faculty have learned much about the safe use of simulation, as an adjuvant training modality for a range of competences required in the operating room, the clinic/office, the wards and other clinical domains. Conclusion In this paper we describe the development and content of the course, discuss the importance of the whole “activity system,” and present some evaluation data. We give tips for success, such as using simulations of escalating complexity, and the power of seemingly incidental Learning Outcomes.

BACKGROUND: Several regions in the UK and Ireland have delivered home-based laparoscopic simulation programmes in an attempt to progress surgical trainees' skills through deliberate practice. However, engagement with these programmes has been poor. This study aims to uncover the barriers to engagement with home-based simulation, with a view to developing an improved programme.METHODS: This was a qualitative study using focus groups with key stakeholders including junior surgical trainees, consultants/attendings and simulation faculty. Data were collected across four regions in three countries. Data were audio-recorded, transcribed and a thematic analysis was performed using NVivo software.RESULTS: Sixty-three individuals were interviewed in 12 focus groups (43 trainees, 20 trainers). Trainees cited competing commitments as a barrier to engaging with home-based simulation. They tended to focus on scoring 'points' towards career progression rather than viewing tasks as interesting, or associated with personal development. Their view was that this approach is perpetuated by the training system, which rewards trainees for publications and exams, but not for operative skill. Trainees were unsatisfied with metric feedback and wanted individual feedback from consultants (attendings). Trainees perceived consultants as lacking interest in the programmes and training in general. However, some consultants were unaware of the programmes being delivered and others felt lacking in confidence to deliver the necessary training.CONCLUSIONS: Scheduled simulation sessions which provide trainees with the opportunity for consultant feedback may improve engagement. Tackling the 'point-scoring' culture is more challenging. This could be addressed by modified assessment structures, greater recognition and accountability for trainers, and recognition and funding of simulation strategies including in-house skills sessions.

Introduction: Treatment for patients with locally advanced low lying rectal cancer differs significantly from patients with rectal cancer restricted to the mesorectum. They require multimodality treatment, including preoperative chemo-radiation and extended surgical resection. Cylindrical abdominoperineal excision of rectum (C-APER) along with possible composite pelvic organ resection is a surgical method to remove an adequate circumferential margin. Method: Patients with the diagnosis of advanced rectal cancers over a period of 9 months are included in this study. Therapeutic approach of C-APER is taken for these patients with focus on multimodality treatment protocols to downstage the tumours and extended resections to enable complete removal of all tumour tissue with clear surgical margins. Consecutive review of cases of advanced rectal cancer to their immediate surgical outcome were done. Results: Five patients with compromised CRM in MRI of rectum, 4 were treated with Neoadjuvant FOLFOX 6 regimen chemotherapy 3 cycles and Short course Radiotherapy. All underwent surgery 6-8 weeks after treatment. The pelvic floor was repaired with biological mesh in 1 and synthetic mesh in 4. The pathological stage of disease remained T3 and above despite neoadjuvant treatment in majority of patients but none of them had positive CRM. The wound complication rates were high in the perineum with serous discharge in almost every patient and one patient needing long term vacuum assisted dressing in the community. Conclusion: The surgery is technically feasible with acceptable morbidity in short term with possible long term outcome of reduced loco-regional failure.

Technical communication scholars have tended to treat uncertainty as a lack of certainty rather than as a diverse range of strategies for talking about risk. This review employs Goodnight’s argument spheres to comprehend treatments of uncertainty in technical communication and closely related fields. The advantages of such an approach are demonstrated via a reanalysis of a recent risk communication study. The review finishes by identifying hybrid forums as productive sites for future research.

This study of ozone-hole controversy demonstrates an approach to translation that captures material-discursive elements of environmental risk. By adapting actor–network theory’s notion of translation with Goodnight’s spheres of argument model, the author’s results reveal how uncertainties created sites for scientists and their images to perform in ways that visualized risk in public forums. Citizens then responded to these risks through amplified uncertainties and counterimages that envisioned a hole in the skin of the body public.

This chapter constructs a topology of the year-long enactments of the loaded climate dice metaphor, largely associated with climate scientist and advocate, James Hansen. First, the method traces a network topology of the loaded dice metaphor by following it across Internet debates precipitated by extreme weather events in 2012—including record-breaking heat, extreme drought, and Hurricane Sandy. Second, the topology reveals that while the loaded dice metaphor provided a well-crafted shorthand for precautionary approaches to risk, its assumption of shared values limited its circulation and reinforced community norms. Thus, while the actors surrounding the loaded climate dice metaphor seek to deliberate danger, its limitations mean that they may also deliberate dangerously by avoiding engagements through difference and reinscribing a wait-and-see approach. By tracing the performative constraints of metaphors and mapping the discourse of communities, topologies can produce insights into deliberations over climate risk.

Acknowledgments The authors would like to thank The Clinical Skills Managed Educational Network for its financial support, without which this research would not have taken place. Ethics approval Ethics approval for this research study was sought and granted from the University of Aberdeen's College and Ethics Research Board (Application No. CERB/2013/1/837). All participants in the study gave informed written consent before taking part in the research. Data sharing statement The research was carried out as part of a Masters in Medical Education degree. The Masters dissertation includes extensive study data—whereas this article contains the most pertinent quantitative data. The full Masters thesis is available from the University of Dundee

This paper reports on the results of an intensive application development workshop held in the summer of 2015 during which a group of thirteen researchers came together to explore the use of machine-learning algorithms in technical communication. To do this we analyzed Amazon.com consumer electronic product customer reviews to reevaluate a central concept in North American Genre Theory: stable genre structures arise from recurring social actions ([1][2][3][4][5]). We discovered evidence of genre hybridity in the signals of instructional genres embedded into customer reviews. Our paper discusses the creation of a prototype web application, "Use What You Choose" (UWYC), which sorts the natural language text of Amazon reviews into two categories: instructionally-weighed reviews (e.g., reviews that contain operational information about products) and non-instructionally-weighed reviews (those that evaluate the quality of the product). Our results contribute to rhetorical genre theory and offer ideas on applying genre theory to inform application design for users of information services.

IntroductionPractice using simulators has been validated as a mean for surgical trainees to improve basic laparoscopic skills and free their attention for higher cognitive functions. However, mere provision of equipment does not result in frequent practice. This study assesses one approach to incentivising practice within core surgical training programmes and leads to further recommendations.Methods30 core surgical trainees (CST) starting laparoscopic-based specialties were recruited from East and West of Scotland CST programmes and given take-home laparoscopic simulators, with six training modules. Attainment of target metric scores generated an eCertificate, to be rewarded by progression in the live theatre. Questionnaires assessed confounding variables and explored CSTs’ anxieties about laparoscopy.Results27 trainees (90%) agreed to participate (mean age 28 years, range 24–25; 17 males). 13 CSTs (48%) were in the first year of surgical training. 11 (41%) had no previous simulation experience and 7 (32%) CSTs played video games >3 hours/week. 12 of 27 trainees (44%) completed ≥1 task and 7 completed all (26%).Performances improved in some participants, but overall engagement with the programme was poor. Reasons given included poor internet connectivity, busy rotations and examinations. CSTs who engaged in the study significantly reduced their anxiety (mean 4.96 vs 3.56, pConclusionsThe provision of take-home laparoscopic simulators with accompanying targets did not successfully incentivise CSTs to practise. However, the subgroup who did engage with the project reported performance improvements and significantly reduced anxiety. Proposals to overcome barriers to practising in simulation, including obligatory simulation-based assessments, are discussed.

The purpose of this study was to characterize medical students' learning behaviors and preferences related to information technology (IT) and assess their educational needs related to advances in IT and simulation in order to optimize curriculum and educational space design. An online survey was administered to all medical students enrolled in graduate medical education at Emory University School of Medicine. The survey assessed subjects' demographic data, current technology usage, and experiences and preferences related to: informatics, facilities, online learning, staff support and simulation. The response rate was 49% (214 of 440). 95% of respondents reported computer use of greater than 6 hours per week, and 75% reported owning and regularly using a laptop computer. Despite regularly seeking computer-based learning modalities, 55% of students reported being underprepared for the application of clinical informatics in their practice. 49% of students prefer group learning and prioritize large group learning areas with large desks. Health science libraries designed to address the preferences for portable technology and group learning may encourage the incorporation of the library into the medical student learning experience, allowing librarians to assume formal and informal roles in the curriculum as students learn to search and apply information resources.

Magnetic and electronic properties of high-purity trimetallic nitride endohedral fullerenes Er 3 N@C 80 , Lu 3 N@C 80 , Sc 3 N@C 80 diluted in a diamagnetic host were characterized by SQUID DC magnetometry and electron paramagnetic resonance (EPR) at multiple frequencies. The Er 3 N@C 80 sample followed the Curie–Weiss law with negligible Weiss temperature of 0.16 K. Based on temperature dependence and isothermal saturation magnetization the effective magnetic moment of Er 3 N@C 80 was estimated as 10.2 μ B . The magnetic behavior of these fullerenes is ascribed to quenching of the orbital moment of the metal ions due to interactions between the metal centers with the nitrogen and the fullerene cage.

High-performance liquid chromatography was used to isolate two new trimetallic nitride endohedral fullerenes, Gd3N@C2n (n = 42 and 44), and they were characterized by MALDI-TOF mass spectrometry, UV-vis-NIR, and cyclic voltammetry. It was found that their electronic HOMO-LUMO gaps depend pronouncedly on the size of the cage, from a large band gap for Gd3N@C80 (2.02 V) to a small band gap for Gd3N@C88 (1.49 V). The electrochemical properties also change dramatically with the size of the cage, going from irreversible for the C80 cage to reversible for Gd3N@C88. The latter is the largest trimetallic cluster inside C88 isolated and characterized to date. Gd3N@C88 has one of the lowest electrochemical energy gaps for a nonderivatized metallofullerene.

Objective The focus of simulation-based education (SBE) research has been limited to outcome and effectiveness studies. The effect of social and cultural influences on SBE is unclear and empirical work is lacking. Our objective in this study was to explore and understand the complexity of context and social factors at a surgical boot camp (BC). Methods A rapid ethnographic study, employing the theoretical lenses of complexity and activity theory and Bourdieu's concept of ‘capital’, to better understand the socio-cultural influences acting upon, and during, two surgical BCs, and their implications for SBE. Over two 4-day BCs held in Scotland, UK, an observer and two preceptors conducted 81 hours of observations, 14 field interviews and 11 formal interviews with faculty members (n = 10, including the lead faculty member, session leaders and junior faculty members) and participants (n = 19 core surgical trainees and early-stage residents). Results Data collection and inductive analysis for emergent themes proceeded iteratively. This paper focuses on three analytical themes. First, the complexity of the surgical training system and wider health care education context, and how this influenced the development of the BC. Second, participants’ views of the BC as a vehicle not just for learning skills but for gaining ‘insider information’ on how best to progress in surgical training. Finally, the explicit aim of faculty members to use the Scottish Surgical Bootcamp to welcome trainees and residents into the world of surgery, and how this occurred. Conclusions To the best of our knowledge, this is the first empirical study of a surgical BC that takes a socio-cultural approach to exploring and understanding context, complexities, uncertainties and learning associated with one example of SBE. Our findings suggest that a BC is as much about social and cultural processes as it is about individual, cognitive and acquisitive learning. Acknowledging this explicitly will help those planning similar enterprises and open up a new perspective on SBE research.

Objective The purpose of this study was to compare the effectiveness of a thorough sonographic oocyte retrieval to a routine in vitro fertilization retrieval to induce ovulation, pregnancy, and endocrine changes in patients with polycystic ovarian syndrome in their post–in vitro fertilization cycles. Study design Sixty-four patients from a tertiary infertility clinic, with clomiphene citrate–resistant polycystic ovarian syndrome and who were undergoing in vitro fertilization, were assigned randomly into 2 groups. Group 1 (n = 34) had a thorough (every possible follicle punctured) sonographic oocyte retrieval, and group 2 (n = 30) had a routine (only follicles that were likely to contain oocytes) in vitro fertilization retrieval. These patients who did not conceive in their in vitro fertilization cycle were monitored with ultrasound scanning for evidence of ovulation, pregnancy, before and after day 3 gonadotropin, and steroid hormone levels. Analysis of variance and the Student t test were used for statistical significance. Results Ovulation rates of 53% (18/34) and cumulative pregnancy rate of 44% (8/18) were observed in group 1, with no ovulations in group 2. Significant decreases in luteinizing hormone/FSH ratio (4.1 to 1.7) and testosterone (1.2 to 0.7 ng/mL) occurred after treatment in the thorough sonographic oocyte retrieval group, with no change after routine in vitro fertilization. Operating time was increased significantly in the thorough sonographic oocyte retrieval group (45 vs 24 minutes) in group 2. Conclusion Thorough sonographic oocyte retrieval during in vitro fertilization cycle can produce significant improvements in the endocrinologic abnormalities, ovulation, and pregnancies that are comparable with ovarian wedge resection in patients with clomiphene citrate–resistant polycystic ovarian syndrome.

As Georgia assumed independence from the former Union of Soviet Socialist Republics, healthcare institutions found themselves in need of foreign assistance. Through the U.S. Agency for International Development (USAID), much of the assistance from the United States took the form of partnership programs funded through the American International Health Alliance (AIHA). This article describes the development of the National Information Learning Center (NILC) and its role in the development of a new and sustainable health care system in Georgia. Specific steps in the project are described, including proposal development, planning, implementation, and evaluation and sustainability.

We thank Pucher and Aggarwal1 for their interest in our paper and their kind words on how our research adds to the literature on this topic. We welcome the opportunity to share more detail about our study in response to their three specific questions. The first question related to how specific distractions used in the study were chosen. These were selected after discussion with a number of local clinical colleagues, ranging from relatively junior doctors through to experienced senior consultants. The results from these focus groups indicated six common workplace distractions. These were the doctor's pager, dealing with ward telephone calls, background noise (such as the ward radio and a domestic's hoover), managing ad hoc prescription tasks and interacting with relatives. …