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Michail Sideris,1,* Marios Nicolaides,2,* Jade Jagiello,3 Kathrine S Rallis,2 Elif Emin,1 Efthymia Theodorou,2 John Gerrard Hanrahan,4 Rebecca Mallick,5 Funlayo Odejinmi,6 Nikolaos Lymperopoulos,7 Apostolos Papalois,8 George Tsoulfas9 1Women’s Health Research Unit, Queen Mary University of London, London, UK; 2Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK; 3University College London Hospital, London, UK; 4Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK; 5Princess Royal Hospital, Brighton and Sussex University Hospitals NHS Trust, Haywards Heath, UK; 6Whipps Cross University Hospital, Barts Health NHS Trust, London, UK; 7Guy’s and St Thomas Hospitals NHS Foundation Trust, London, UK; 8Special Unit for Biomedical Research and Education, Aristotle University of Thessaloniki, Thessaloniki, Greece; 9Department of Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece*These authors contributed equally to this workCorrespondence: Michail SiderisWomen’s Health Research Unit, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London, E1 2AB, UKEmail m.sideris@qmul.ac.ukAbstract: An increasing emphasis on simulation has become evident in the last three decades following fundamental shifts in the medical profession. Simulation-based learning (SBL) is a wide term that encompasses several means for imitating a skill, attitude, or procedure to train personnel in a safe and adaptive environment. A classic example has been the use of live animal tissue, named in vivo SBL. We aimed to review all published evidence on in vivo SBL for undergraduate medical students; this includes both teaching concepts as well as focused assessment of students on those concepts. We performed a systematic review of published evidence on MEDLINE. We also incorporated evidence from a series of systematic reviews (eviCORE) focused on undergraduate education which have been outputs from our dedicated research network (eMERG). In vivo SBL has been shown to be valuable at undergraduate level and should be considered as a potential educational tool. Strict adherence to 3R (Reduce, Refine, Replace) principles in order to reduce animal tissue usage, should always be the basis of any curriculum. In vivo SBL could potentially grant an extra mile towards medical students’ inspiration and aspiration to become safe surgeons; however, it should be optimised and supported by a well-designed curriculum which enhances learning via multi-level fidelity SBL.Keywords: in vivo simulation-based learning, medical simulation, surgical education

Aim: This systematic review aimed to identify all published evidence on teaching suturing skills for medical students. We aimed to outline significant positive teaching outcomes and devise a comprehensive framework for the optimal teaching of suturing skills for medical students., Materials and Methods: We searched MEDLINE ® (via Ovid), EMBASE and SCOPUS databases until July 2019 with no language restriction using predefined 'Population, Intervention, Comparison, Outcome (PICO)' criteria. Data were summarised in discrete thematic axes using a qualitative synthesis approach., Results: Our search yielded a total of 2,562 articles, out of which 25 were included in the final data synthesis. We provide a structured breakdown of educational interventions including participants, instructors and nature of teaching intervention. We also describe discrete means for assessment of performance and retention of suturing skills. Based on those we propose a standardised framework on teaching suturing skills for novices., Conclusion: To our knowledge this is the first systematic review investigating teaching interventions used to teach suturing skills in medical students. After extraction of individual positive teaching outcomes and utilising widely known learning theories and principles, we devised a comprehensive framework for more efficient and cost-effective teaching of suturing skills to medical students in the future., (Copyright© 2021, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Energy enthusiasts in developed countries explore sustainable and efficient pathways for accomplishing zero carbon footprint through the H 2 economy. The major objective of the H 2 economy review series is to bring out the status, major issues, and opportunities associated with the key components such as H 2 production, storage, transportation, distribution, and applications in various energy sectors. Specifically, Part I discussed H 2 production methods including the futuristic ones such as photoelectrochemical for small, medium, and large-scale applications, while Part II dealt with the challenges and developments in H 2 storage, transportation, and distribution with national and international initiatives. Part III of the H 2 economy review discusses the developments and challenges in the areas of H 2 application in chemical/metallurgical industries, combustion, and fuel cells. Currently, the majority of H 2 is being utilized by a few chemical industries with >60% in the oil refineries sector, by producing grey H 2 by steam methane reforming on a large scale. In addition, the review also presents the challenges in various technologies for establishing greener and sustainable H 2 society., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2020 Hydrogen Energy Publications LLC. Published by Elsevier Ltd. All rights reserved.)

Objectives: The aim of this study is to evaluate a simulation-based team performance course for medical students and compare its low- and high-fidelity components., Study Design: This is a prospective crossover observational study. Groups participated in one low- and one high-fidelity session twice. Low-fidelity scenarios included management of an emergency case on a simulated-patient, whereas high-fidelity scenarios constituted of multiple-trauma cases where simulated-patients wore a hyper-realistic suit. Team performance was assessed objectively, using the TEAM™ tool, and subjectively using questionnaires. Questionnaires were also used to assess presence levels, stress levels and evaluate the course., Results: Participants' team performance was higher in the low-fidelity intervention as assessed by the TEAM™ tool. An overall mean increase in self-assessed confidence towards non-technical skills attitudes was noted after the course, however there was no difference in self-assessed performance between the two interventions. Both reported mean stress and presence levels were higher for the high-fidelity module. Evaluation scores for all individual items of the questionnaire were ≥4.60 in both NTS modules. Students have assessed the high-fidelity module higher (4.88 out of 5, SD = 0.29) compared to low-fidelity module (4.74 out of 5, SD = 0.67)., Conclusions: Both the low- and high-fidelity interventions demonstrated an improvement in team performance of the attending medical students. The high-fidelity intervention was more realistic, yet more stressful. Furthermore, it proved to be superior in harvesting leadership, teamwork and task management skills. Both modules were evaluated highly by the students, however, future research should address retention of the taught skills and adaptability of such interventions., Competing Interests: None declared., (© 2020 The Authors.)

Essential Skills in the Management of Surgical Cases (ESMSC) is an international wet lab simulation course aimed at undergraduate students. It combines basic science workshops, case-based lectures and ex vivo skills modules, as well as in vivo dissections using a swine model. This study aims to evaluate the effectiveness of high-fidelity In Vivo Simulation-Based Learning for undergraduate level trainees. Also our goal was to compare the skill-based performance of final year students vs. more junior-level ones. Forty undergraduate delegates at clinical rotation level (male = 28, female = 12, mean age = 23.12, 22-24, SD = 0.69) attended this 2-day course in Athens. N  = 1 (2.5 %) was year 3, N  = 4 (10 %) were year 4, N  = 23 (57.5 %) were year 5 and N  = 12 (30 %) were year 6. N  = 30 (75 %) came from Hellenic universities, N  = 8 (20 %) from the UK and N  = 2 (5 %) from Germany. N  = 20 (50 %) attended the in vivo dissections module first, and then the ex vivo one (type A rotation), whereas N  = 20 followed the reverse training sequence with the ex vivo dissection first, followed by the in vivo one (type B rotation). The mean global rating scores for type A rotation were better in both the in vivo by 0.10 (2.40 vs. 2.30) and ex vivo modules by 0.15 (2.85 vs. 2.70), though it did not reach statistical significance ( p  > 0.05). Furthermore, the mean improvement of performance, in the laparoscopic skills station for the type A rotation, was better compared to type B by 0.351 (2.00 vs. 1.65, p  = 0.003). Year 6 students performed better in the laparoscopic station (2.00 vs. 1.75, p  = 0.059), whereas years 3, 4 and 5 performed better in the in vivo (2.42 vs. 2.16, p  = 0.157) as well as the ex vivo dissections (2.78 vs. 2.75, p  = 0.832), though none of those comparisons reached statistical significance. Delegates seemed to appreciate and enjoy the in vivo dissections as reflected in the feedback (8.67/10, min = 6 and max = 10, SD = 1.79). Although medical students seem to appreciate in vivo dissections modules, currently, further evidence is needed to support their recommendation in the undergraduate level. Surgical skills should be part of the undergraduate curriculum to improve final year students' performance in the theatre., Competing Interests: Compliance with Ethical StandardsThis study was performed according to the European and National Legislation, Directive 63/2010, PD 56/Αpril 2013 [reference number of the license: Michail Ch. Sideris and Apostolos Papalois 7095/05-11-2014 (revised 884 28/4/2015)].Main contribution—all the authors have approved the current submission. Michail Ch. Sideris and Apostolos E. Papalois: equal contribution, lead of the project, and designers of the course curriculum, main editors of the manual. MS and AP drafted and edited the manuscript (discussion drafted by KT and edited by MS and AP), and statistical analysis by MS. Georgios Tsoulfas: faculty of the course, lead for the in vivo dissections (anatomy demonstration of the abdomen), conception and senior author of the study Korina Theodoraki: faculty member, literature search and editing of the discussion part of the manuscript Efstratios Koletsis: faculty of the course, lead for ex vivo dissections—ex vivo graft suturing Panagiotis Dedeilias: faculty of the course, lead for heart and transplant in vivo module Nikolaos Lymperopoulos and Konstantinos Imprialos: members of the faculty Savvas Papagrigoriadis: senior advisor of the course curriculum and manual Vassilios Papalois: senior advisor of the course curriculum and manual Georgios Zografos: senior advisor of the course curriculum and manual, lead of the scientific committee of the course All the qualified authors have contributed to data collection as well as assessors (workplace-based assessments of the medical students). Georgios Paparoidamis, Nikolaos Staikoglou and Ismini Tsagkaraki: medical students who set up promotion and smooth run of the course, data collection and assistants to senior assessors. GP has contributed with GT to the protocol.Essential Skills in the Management of the Surgical Patient—ESMSC is funded by the Experimental Research Centre ELPEN, and it is provided for free to medical students around Europe.The authors declare that they have no competing interests.

Background: The role of prophylactic antibiotics in breast augmentation remains controversial. However, the majority of surgeons are administering antibiotics., Objective: To investigate the effect of antibiotic(s) use in the incidence of infection and capsular contracture following breast augmentation., Methods: From September 2004 to November 2010, 180 patients underwent primary bilateral breast augmentation. They were prospectively divided into two equal groups: in group A (n=90), no antibiotics were given and, in group B (n=90), only one intravenous dose of cephalosporin was administered during the induction of general anesthesia. Preoperative data included age, body mass index, smoking status, medical history and implant volume. All operations were performed by the same surgeon using the same surgical technique and implant type. No drains were used. Operative data included operative time and estimated blood loss. Patients were evaluated for complications such as infection, hematoma and capsular contracture. The study concluded when all of the patients underwent the one-year follow-up. The Student's t test was used to analyze the results., Results: All patients completed the study and both groups had similar demographic data. No differences in operative data were observed. The mean operative time was 35 min and the mean blood loss was found to be minimal. In group A, no implant infections were reported, while a wound infection that occurred was treated successfully with oral antibiotics. In group B, no implant or wound infection was noticed. No capsular contractures or hematomas were observed., Conclusions: The number of patients who underwent primary breast augmentation without antibiotics (n=90) was insufficient to draw any definitive conclusions. However, the present prospective study demonstrated that prophylactic use of antibiotics in breast augmentation had no significant effect on infection and capsular contracture rates. Further randomized clinical trials, in combination with guidelines from aesthetic plastic surgery societies, appear to be warranted.

Background: Essential Skills in the Management of Surgical Cases (ESMSC) is an international, animal model-based course. It combines interactive lectures with basic ex vivo stations and more advanced wet lab modules, that is, in vivo dissections and Heart Transplant Surgery on a swine model., Materials and Methods: Forty-nine medical students (male, N = 27, female N = 22, and mean age = 23.7 years) from King's College London (KCL) and Greek Medical Schools attended the course. Participants were assessed with Direct Observation of Procedural Skills (DOPS), as well as Multiple Choice Questions (MCQs). Paired t-test associations were used to evaluate whether there was statistically significant improvement in their performance., Aim: To evaluate the effectiveness of a combined applied surgical science and wet lab simulation course as a teaching model for surgical skills at the undergraduate level., Results: The mean MCQ score was improved by 2.33/32 (P < 0.005). Surgical skills competences, as defined by DOPS scores, were improved in a statically significant manner (P < 0.005 for all paired t-test correlations)., Conclusions: ESMSC seems to be an effective teaching model, which improves the understanding of the surgical approach and the basic surgical skills. In vivo models could be used potentially as a step further in the Undergraduate Surgical Education.

Objective: To assess the clinical outcomes and treatment costs of a regional adult burn service in northwest England., Methods: We retrospectively reviewed data on a five year cohort of 1075 patients treated by the Mersey Regional Burn Service between 2006 and 2010 to obtain age-stratified mortality estimates based on the lethal area 50 (LA50) measure. Treatment cost estimates were made for a one year cohort of 262 patients treated between April 2011 and April 2012., Results: 44 (4.1%) of the five year cohort died; 36 had suffered flame burns. Our LA50 was 71.08 for the 15-44 age group, 56.64 for the 45-64 age group, and 28.82 for the 65 and over age group. Mean treatment costs associated with patients allocated to different burn-specific healthcare resource groups ranged from £2527.77 to £31,870.95. Detailed cost estimates for three patients ranged from £12,553.23 to £66,029.33., Conclusion: The LA50 estimates for the Mersey Regional Burn Service compare favourably with previous reports in the literature. Our treatment costs were substantially lower compared to those reported previously in the United Kingdom. This study demonstrates that high quality and cost effective care can be delivered by a service that treats relatively few major burns (>70% TBSA)., (Copyright © 2013 Elsevier Ltd and ISBI. All rights reserved.)

There has been only one documented case in the English literature with the diagnosis of primary Squamous Cell Carcinoma (SCC) of the nipple; we present a further case of a primary SCC of the nipple, thus raising awareness to the skin or breast specialist of this possible presentation for SCC. We present the case of a 34 year old lady who presented to our plastic surgery unit with an erythematous, scaly lesion on her right Nipple Areola Complex (NAC). The lesion was histologically confirmed on biopsy to be an SCC and subsequently formally excised. Histology confirmed complete excision of the lesion with adequate margins with no lymphovascular or perineural invasion. This case report describes a rare presentation of a primary moderately differentiated SCC of the nipple. Although SCC of the nipple is a rare diagnosis, in view of its similar presentation to Paget disease of the nipple, it must be considered and careful examination of the histology must be performed in order to ascertain a definitive diagnosis. Patients presenting with lesions of the NAC cannot be assumed to have either Paget's disease or SCC and biopsy should be performed before arranging further investigations or treatment, as the pathways for the two conditions can be very different., (Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)