Operative Exposure Research Articles

An X-ray lead screen may be used to reduce an interventional radiologist's radiation exposure during CT-guided procedures.

The exposure of both patient and operator to radiation is one of the limitations of computed tomography (CT)-guided interventions, and it should be kept as low as reasonably possible. The purpose of the study was to evaluate the efficacy of a lead screen in reducing the radiation dose to an operator in the course of CT-guided interventions. This prospective study analysed data collected from 72 consecutive CT-guided procedures, all of which were performed with an X-ray protective lead screen placed between the scanner and the operator. Five dosimeters were placed in the CT scanning room, and accumulated radiation doses were measured for each dosimeter. The dosimeter placed on the gantry side of the lead screen revealed highest levels of radiation (11.33 ± 1.93 mSv), which were significantly higher than those at all other dosimeters. The radiation dose behind the lead screen was almost the same when measured by dosimeters on the CT scanner gantry side and 3 metres away from it. The presence of the screen caused no discomfort for operators. A lead screen reduces an operator's radiation exposure significantly, while not posing any obstacles or causing any discomfort while CT-guided procedures are carried out.

Cloud-based Fusion Imaging Improves Operative Metrics During Fenestrated Endovascular Aneurysm Repair

Endovascular treatment of complex aortic pathology is associated with increases in procedural-related metrics including operative time and radiation exposure. Three-dimensional fusion imaging technology has decreased radiation dose and iodinated contrast use in endovascular aneurysm repair. The aim of this study is to report our institutional experience with use of a cloud-based fusion imaging platform in fenestrated endovascular aneurysm repair (FEVAR). A retrospective review of a prospectively maintained aortic database was performed to identify all patients who underwent commercially-available FEVAR (Zenith Fenestrated, Cook Medical, Bloomington, Ind) between 2013 and 2020, as well as all endovascular aneurysm repairs performed using Cydar EV Intelligent Maps (Cydar Medical, Cambridge, UK). The Cydar EV cohort was reviewed further to select all FEVAR performed with intelligent map guidance. Patient demographics, clinical, and procedural-related metrics were analyzed, with comparative analysis of FEVAR performed without and with the Cydar EV imaging platform. Patients were excluded from the comparative analysis if incomplete in the data set, or if documented history of prior open or endovascular abdominal aortic aneurysm repair. Over the 7-year study period 191 FEVAR were performed. The Cydar EV imaging platform was implemented in 2018 and used in 124 complex endovascular aneurysm repairs, including 69 consecutive FEVAR. A complete dataset was available on 137 FEVAR. With exclusions to select for de novo FEVAR, comparative analysis was performed on 53 FEVAR without and 63 with Cydar EV. Cohorts were similar with respect to patient demographics, medical comorbidities, and aortic aneurysm characteristics. No significant difference was noted between groups on major adverse postoperative events, length of stay, or length of intensive care unit stay. Use of the Cydar EV resulted in nonsignificant decreases in mean fluoroscopy time (69.3 minutes vs 66.2 minutes; P = .598), and a positive trend toward shorter operative times (204.4 minutes vs 186 minutes; P = .278). Notably, a statistically significant decrease in both iodinated contrast volume (104.7 mL vs 83.8 mL; P = .005), and patient radiation exposure via dose-area product (1,049,841 mGy/cm2 vs 630,990; P < .001) was observed in patients undergoing FEVAR with Cydar EV Intelligent Maps. Our aortic center has observed a trend toward shorter operative times, and significant decreased in both iodinated contrast use and radiation exposure during FEVAR with the use of Cydar EV Intelligent Maps. Intelligent map guidance improves the efficiency of complex endovascular aneurysm repair, providing a safer intervention for both patient and practitioner.

Guidance on the assessment of exposure of operators, workers, residents and bystanders in risk assessment of plant protection products.

This guidance is designed to assist risk assessors and applicants when quantifying potential non‐dietary, systemic exposures as part of regulatory risk assessment for plant protection products (PPPs). It is based on the Scientific Opinion on ‘Preparation of a Guidance Document on Pesticide Exposure Assessment for Workers, Operators, Residents and Bystanders’ developed by the EFSA Panel on Plant Protection Products and their Residue (PPR) in 2010. Highlighting some inconsistencies between the approaches adopted by regulatory authorities, the PPR Panel proposed a number of changes to the practices in use (i.e. use of deterministic methods for individual PPPs; need to perform an acute risk assessment for PPPs that are acutely toxic; use of appropriate percentile for acute or longer term risk assessments). In the first version of the guidance, issued in 2014, several scenarios for outdoor uses were included, with an annexed calculator, as well as recommendations for further research. The guidance has been updated in 2021 with the inclusion of additional scenarios and revision of default values, on the basis of the evaluation of additional evidence. To support users in performing the assessment of exposure and risk, an online calculator, reflecting the guidance content, has been further developed.

Operating Exposure to Weather, Earnings Predictability, and Analyst Forecast

Operating Exposure to Weather, Earnings Predictability, and Analyst Forecast

Generating Competent Special Operations Clinicians From Military Graduate Medical Education.

Units within the Special Operations Forces (SOF) community require medically competent and operationally proficient medical providers (physicians, physician assistants, and nurse practitioners, among others) to support complex mission sets. The expectations placed on providers who successfully assess for and are selected into these units are high. These providers are not only expected to be experts in their respective subspecialities, but also to serve as staff officers, provide medical direction for SOF medics, serve as medical advisors to the command team, and provide direct medical support for kinetic operations. They are expected to perform these functions with little oversight and guidance and when geographically separated from higher units. Graduates from military Graduate Medical Education (GME) programs are extremely well-educated and can provide high quality medical care. However, they often find themselves ill-prepared for the extra demands placed upon them by the Special Operations community due to a lack of operational exposure. The authors of this paper recognized this gap and propose that the Joint Emergency Medicine Exercise (JEMX) model can help augment the body of knowledge required to perform well as a provider in a Special Operations unit.

Optimization of biodiesel synthesis from Jojoba oil via supercritical methanol: A response surface methodology approach coupled with genetic algorithm

The most powerful approach to processing biodiesel is supercritical methanol transesterification. This process has several benefits over catalytic transesterification in that it produces a substantial biodiesel production in a brief span of time and removes the problems involved with catalyst processing segregation, and filtration. Besides that, the scMeOH transesterification process necessitates harsh operational exposure to extreme reactants pressure and temperature, as well as a significant volume of methanol. The influence of the key selected parameters (reaction temperature, methanol to oil ratio, reaction time, and pressure) on the production of biodiesel through the supercritical methanol transesterification process was studied using response surface methodology (RSM). As a fuel source, high fatty acid Jojoba oil has been utilized and the transesterification reaction was carried out in a pressure reactor within supercritical conditions. The genetic algorithm (GA) has been employed to optimize biodiesel production. The findings demonstrate that the supercritical methanol transesterification process produced the highest biodiesel production (95.67%) at the optimum conditions of 287 °C reaction temperature, 123 bar reaction pressure, 30:1 methanol to oil ratio, and 23 min reaction time.

Superficial Temporal Artery–Posterior Cerebral Artery Bypass Through Zygomatic Anterior Temporal Approach for Complex Posterior Cerebral Artery Aneurysm

Posterior cerebral artery (PCA) aneurysms are rare, and most are giant, dissecting, or fusiform in morphology. Proximal occlusion of the PCA without revascularization causes high risk of ischemic complications. This study aimed to evaluate the safety and validity of using superficial temporal artery (STA)-PCA bypass through zygomatic anterior temporal approach in complex PCA aneurysms. Trapping or resecting of aneurysms and reconstruction of distal PCA through a zygomatic anterior temporal approach were performed in 6 patients from June 2017 to August 2020. Postoperative angiography confirmed obliteration of aneurysms and patency of bypass artery. Neurological function was assessed by the modified Rankin Scale (mRS). Patients were 4 men and 2 women with a mean age of 43.8 years (range, 21-58 years). Subarachnoid hemorrhage occurred in 5 patients. Hunt and Hess grade was IV in 3 patients, III in 2 patients, and I in 1 patient. All PCA aneurysms were treated with trapping or resection of the aneurysms and revascularization of distal PCA. Postoperatively, all aneurysms were eliminated, and no new permanent neurological deficit was found. During follow-up, mRS score of all patients improved: 2 patients had mRS score 0, 1 patient had mRS score 1, 1 patient had mRS score 3, and 2 patients had mRS score 4. Long-term graft patency rate was 100%. STA-PCA bypass appears to be safe and effective for the treatment of complex PCA aneurysms requiring supplementation of blood flow in the area of the PCA. We established a surgical route, allowing the procedure to be done through the zygomatic anterior temporal approach. This approach provides adequate operative field exposure and reduces retraction of temporal lobe.

Outcomes of cardiac surgical procedures performed by trainees versus consultants: A systematic review with meta-analysis

ObjectivesCardiac surgery is highly demanding and the ideal teaching method to reach competency is widely debated. Some studies have shown that surgical trainees can safely perform full operations with equivocal outcomes compared with their consultant colleagues while under supervision. We aimed to compare outcomes after cardiac surgery with supervised trainee involvement versus consultant-led procedures. MethodsWe systematically reviewed databases (PubMed/MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Google Scholar) and reference lists of relevant articles for studies that compared outcomes of cardiac surgery performed by trainees versus consultants. Primary end points included: operative mortality, coronary events, neurological/renal complications, reoperation, permanent pacemaker implantation, and sternal complications. Secondary outcomes included cardiopulmonary bypass and aortic cross-clamp times and intensive care/in-hospital length of stay. Random effects meta-analysis was performed. ResultsThirty-three observational studies that reported on a total of 81,616 patients (trainee: 20,154; consultant: 61,462) were included. There was a difference favoring trainees in terms of operative mortality in the main analysis and in an analysis restricted to propensity score-matched samples, whereas other outcomes were not consistently different in both analyses. Overall cardiopulmonary bypass and aortic cross-clamp times were longer in the trainee group but did not translate in longer intensive care unit or hospital stay. ConclusionsIn the right conditions, good outcomes are possible in cardiac surgery with trainee involvement. Carefully designed training programs ensuring graduated hands-on operative exposure as primary operator with appropriate supervision is fundamental to maintain high-quality training in the development of excellent cardiac surgeons.

Assessing intermittent saline inflows in urban water systems.

Urban water drainage systems' primary function is to transport sanitary or stormwater. The intrusion of saline waters has recognized detrimental effects. Especially in coastal areas, saline inflows can compromise performance by increasing the risk of untreated discharges, weakening the structural condition of concrete or metallic components, reducing the effectiveness of wastewater treatment processes and limiting the potential reuse for irrigation. Performance deterioration can be prevented by an early assessment of exposure to saline water, followed by timely actions to control its causes and consequences. The paper describes a procedure for diagnosing undue saline inflows. The procedure is based on the determination of saline inflow's magnitude, acceptance levels, and contribution to the system's performance. Contextual factors and performance indicators, and their reference values, are selected for the assessment. Options to address the problem are proposed, depending on the results. These options can relate to organizational, operational, and structural actions. Application to a case study allowed to validate the method and discuss the results. Here, saline volumes entering the system are quite relevant (almost 30%), posing problems regarding corrosion, treatment plant operation and significant concrete exposure to intermittent saline waters.

Hot corrosion of Fe and Ni-based alloys in Wase-to-energy environment at 850 °C

Boiler tube alloys in waste-to-energy (WTE) facilities suffer from significant corrosion, induced by metal chlorides and sulfates at high temperatures. This work aims to explore the effects of alloying elements (Ni and Cr) on the hot corrosion of boiler tube alloys, and clarify the role of elevated temperature and service time on their protective and failure mechanisms. Long-term hot corrosion experiments were performed on three typical corrosion resistance alloys (CRAs, including Inconel 625, 310S, and 00Cr30Mo2) in simulated WTE salts at 850 °C. Results confirmed that Cr2O3 is the main phase for corrosion protection of these alloys at 850 °C. The greatest hot corrosion resistance is demonstrated by 00Cr30Mo2, due to its highest Cr content among these three CRAs. Although the measured corrosion rates are all lower than the conventional “acceptable” corrosion rate of 1 mm/yr., the estimated penetration rates of these alloys range from 1.58 to 8.50 mm/yr. Therefore, none of the selected CRAs can be recommended for the WTE environment at 850 °C. Operating temperature and exposure time are also confirmed as two critical factors for the formed oxides, influencing the protective mechanism and corrosion behaviour. In addition, hot corrosion mechanisms of all alloys were revealed with the support of cross-sectional SEM and EDS analysis.

A narrative review of traumatic mediastinal injuries and their management: the thoracic surgeon perspective.

ObjectiveMediastinal injuries are uncommon, rarely encountered and depending on the institution, can be managed by various sub-specialties. The purpose of this narrative review is to present an overview of traumatic mediastinal injuries, their presentation, and management options from the perspective of a thoracic surgeon.BackgroundAlthough infrequent, traumatic mediastinal injuries can pose significant morbidity and mortality. The infrequency of these injuries limits operative exposure for thoracic surgeons and trainees. A concise overview of common presentations and management options is warranted to further solidify important concepts.MethodsA search of the literature was conducted using MEDLINE, PubMed, and Embase for relevant articles pertaining to anatomic injuries of the mediastinum. The presentation of mediastinal injuries along with indications for non-operative versus operative management in cardiac injuries, thoracic esophageal injuries, tracheobronchial injuries, and injuries to the lungs and pleura was conducted and literature summarized.ConclusionsIn providing this review it is hopeful to enhance knowledge and comfort in recognition and management of these uncommon yet potentially lethal injuries. Early involvement of thoracic surgery is recommended to ensure effective and efficient treatment.

Impact of COVID-19 on postgraduate education and mental wellbeing of surgical trainees: a systematic review

IntroductionCoronavirus disease COVID-19 is a global pandemic that has produced adverse effects on many facets of the health care system including surgical specialities. In this systematic review, we aimed to comprehensively analyze the global literature on the impact of COVID-19 on surgical education and the mental wellbeing of surgical trainees.MethodsWe searched PubMed, Scopus, LILACS, Ovid MEDLINE, Web of Science, Google Scholar and Cochrane CENTRAL between 1-January 2020 and 20-January 2021 and performed a systematic review of all observational and experimental studies on the impact of COVID-19 on postgraduate surgical trainees of all specialities. Operative and clinical exposure, surgical education and mental wellbeing were assessed as outcome measures.ResultsFifty-nine studies including 11544 surgical trainees were analyzed. The majority of the trainees were general surgical trainees [n=4435, 38.4%]. Most studies [n=40, 67.8%] were conducted at national level in high income countries [n=9480; 82.1%]. Most studies reported a significant reduction in the operative exposure [range 45.7-100%] including elective, emergency and other clinical encounters. The mental health of trainees was affected [11.3-100%] and depression [10.6- 40.8%], anxiety [31.7-69%] and burnout [7.1-68%] were noticed. Concerns on contraction and transmission of COVID-19 infection and delays in surgical training and career progression were also reported.ConclusionCOVID 19 pandemic had caused a considerable impact on surgical training, teaching, learning activities and mental well-being of the trainees. Measures should be taken to mitigate these effects to improve surgical training in the era of the COVID pandemic.

Effect of Market Risk and Operational Risk Exposures on Profitability of Life Insurance Companies in Kenya

Effect of Market Risk and Operational Risk Exposures on Profitability of Life Insurance Companies in Kenya

Effectiveness of a Real-Time X-ray Dosimetry Monitor in Reducing Radiation Exposure in Coronary Procedures: The ESPRESSO-Raysafe Randomized Trial.

Background—Several methods to reduce radiation exposure in the setting of coronary procedures are available on the market, and we previously showed that additional radiation shields reduce operator exposure during radial interventions. We set out to examine the efficacy of real-time personal dosimetry monitoring in a real-world setting of radial artery catheterization. Methods and Results—In an all-comer prospective, parallel study, consecutive coronary diagnostic and intervention procedures were performed with the use of standard radiation shield alone (control group) or with the addition of a real-time dosimetry monitoring system (Raysafe, Billdal, Sweden, monitoring group). The primary outcome was the difference in exposure of the primary operator among groups. Additional endpoints included patient, nurse, second operator exposure and fluoroscopy time. A total of 700 procedures were included in the analysis (n = 369 in the monitoring group). There were no differences among groups in patients’ body mass index (p = 0.232), type of procedure (intervention vs. diagnostic, p = 0.172), and patient sex (p = 0.784). Fluoroscopy time was shorter in the monitoring group (5.6 (5.1–6.2) min vs. 7.0 (6.1–7.7) min, p = 0.023). Radiation exposure was significantly lower in the monitoring group for the patient (135 (115–151) µSv vs. 208 (176–245) µSv, p < 0.0001) but not for the first operator (9 (7–11) µSv vs. 10 (8–11), p = 0.70) and the assistant (2 (1–2) µSv vs. 2 (1–2) µSv, p = 0.121). Conclusions—In clinical daily practice, the use of a real-time dosimetry monitoring device reduces patient radiation exposure and fluoroscopy time without an effect on operator radiation exposure.

Pesticide exposure of workers in apple growing in France

ObjectiveAlthough apple trees are heavily sprayed, few studies have assessed the pesticide exposure of operators and workers in apple orchards. However, these data are crucial for assessing the health impact of such exposures. The aim of this study was to measure pesticide exposure in apple growing according to tasks and body parts.MethodsA non-controlled field study was conducted in apple orchards in 4 regions of France during the 2016 and 2017 treatment seasons. Workers’ external contamination and their determinants were assessed over 156 working days corresponding to 30 treatment days, 68 re-entry days and 58 harvesting days. We measured pesticide dermal contamination during each task and made detailed observations of work characteristics throughout the day. Captan and dithianon were used as markers of exposure.ResultsThe median dermal contamination per day was 5.50 mg of captan and 3.33 mg of dithianon for operators, 24.39 mg of captan and 1.84 mg of dithianon for re-entry workers, and 5.82 mg of captan and 0.74 mg of dithianon for harvesters. Thus, workers performing re-entry tasks, especially thinning and anti-hail net opening, presented higher contamination, either equal to or higher than in operators. For these last ones, mixing/loading and equipment cleaning were the most contaminating tasks. Most of the contamination was observed on workers’ hands in all tasks, except for net-opening in which their heads accounted for the most daily contamination.ConclusionsThis study highlights the importance of taking indirect exposures into account during re-entry work in apple growing.

Augmented Reality (AR) in Orthopedics: Current Applications and Future Directions.

Imaging technologies (X-ray, CT, MRI, and ultrasound) have revolutionized orthopedic surgery, allowing for the more efficient diagnosis, monitoring, and treatment of musculoskeletal aliments. The current review investigates recent literature surrounding the impact of augmented reality (AR) imaging technologies on orthopedic surgery. In particular, it investigates the impact that AR technologies may have on provider cognitive burden, operative times, occupational radiation exposure, and surgical precision and outcomes. Many AR technologies have been shown to lower provider cognitive burden and reduce operative time and radiation exposure while improving surgical precision in pre-clinical cadaveric and sawbones models. So far, only a few platforms focusing on pedicle screw placement have been approved by the FDA. These technologies have been implemented clinically with mixed results when compared to traditional free-hand approaches. It remains to be seen if current AR technologies can deliver upon their multitude of promises, and the ability to do so seems contingent upon continued technological progress. Additionally, the impact of these platforms will likely be highly conditional on clinical indication and provider type. It remains unclear if AR will be broadly accepted and utilized or if it will be reserved for niche indications where it adds significant value. One thing is clear, orthopedics' high utilization of pre- and intra-operative imaging, combined with the relative ease of tracking rigid structures like bone as compared to soft tissues, has made it the clear beachhead market for AR technologies in medicine.

P.177 The Effect of the COVID 19 Pandemic on theTraining of Surgical Residents in Canada. A Survey of Residents and Program Directors.

Background: The coronavirus 2019 pandemic has led to restructuring of health care systems and has subsequently had secondary effects on medical education. This study examines the impact on training of surgical residents in Canada. Methods: The study consisted of a 25-question survey for residents and a 22-question survey for program directors, which were distributed electronically through program administrators on July 3rd- July 11th, 2020. Questions sought to elicit residents’ current experiences and gain insight into methods by which to enhance future training. Results: 108 residents and 21 program directors, from various surgical specialties across Canada, completed the survey. Operative exposures were reported to be reduced by 25-100% and 39% of residents were redeployed. However, 89% of residents reported accessing academic half days virtually and 57% had additional online modules. Despite lost time, 100% of program directors confirmed that residents did not require training extensions. Concerns regarding training, personal health, employability and fellowships were raised. 55-70% of residents and program directors advocated for alternative educational courses, increasing elective time, utilizing simulation for assessment and flexibility in crediting different training experiences. Conclusions: Canadian surgical residents had a significant reduction in operative experiences during the pandemic. Moving forward, it will be important to find alternative educational experiences.

Cholinergic Modulation of General Anesthesia

Acetylcholine in the brain promotes arousal and facilitates cognitive functions. Cholinergic neurons in the mesopontine brainstem and basal forebrain are important for activation of the cerebral cortex, which is characterized by the suppression of irregular slow waves, an increase in gamma (30-100 Hz) activity in the electroencephalogram, and the appearance of a hippocampal theta rhythm. During general anesthesia, a decrease in acetylcholine release and cholinergic functions contribute to the desired outcomes of general anesthesia, such as amnesia, loss of awareness and consciousness, and immobility. Animal experiments indicate that inactivation, lesion, or genetic ablation of cholinergic neurons in the basal forebrain potentiated the effects of inhalational and injectable anesthetics, including isoflurane, halothane, propofol, pentobarbital, and in some cases, ketamine. Increased behavioral sensitivity to general anesthesia, faster induction time, and delayed recovery of a loss of righting reflex have been observed in rodents with basal forebrain cholinergic deficits. Cholinergic stimulation in the prefrontal cortex, thalamus, and basal forebrain hastens recovery from general anesthesia. Anticholinesterase accelerates emergence from general anesthesia, but with mixed success, in part depending on the anesthetic used. Cholinergic deficits may contribute to cognitive impairments after anesthesia and operations, which are severe in aged subjects. We propose a cholinergic hypothesis for postoperative cognitive disorder, in line with the cholinergic deficits and cognitive decline in aging and Alzheimer’s disease. The current animal literature suggests that brain cholinergic neurons can regulate the immune and inflammatory response after surgical operation and anesthetic exposure, and anticholinesterase and α7-nicotinic cholinergic agonists can alleviate postoperative inflammatory response and cognitive deficits.

P.181 High-Fidelity Simulation-Based Microsurgical Training for Neurosurgical Residents

Background: Microsurgical techniques remain a cornerstone of neurosurgical training. Despite this, neurosurgical microvascular case volumes are decreasing as endovascular and minimally invasive options expand. As such, educators are looking towards simulation to supplement operative exposure. We review a single institution’s experience with a comprehensive, longitudinal microsurgical simulation training program, and evaluate its effectiveness. Methods: Consecutive postgraduate year 2 (PGY-2) neurosurgery residents completed a one-year curriculum spanning 17 training sessions divided into 5 modules of increasing fidelity. Both perfused duck wing and live rat femoral vessel training modules were used. Trainee performance was video recorded and blindly graded using the Objective Structured Assessment of Technical Skills Global Rating Scale. Results: Eighteen participants completed 107 microvascular anastomoses during the study. There was significant improvement in six measurable skills during the curriculum. Mean overall score was significantly higher on the fifth attempt compared to the first attempt for all 3 live anastomotic modules (p&lt;0.001). Each module had a different improvement profile across the skills assessed. The greatest improvement was observed during artery-to-artery anastomosis. Conclusions: This high-fidelity microsurgical simulation curriculum demonstrated a significant improvement in the six microneurosurgical skills assessed, supporting its use as an effective teaching model. Transferability to the operative environment is actively being investigated.

SP2.2.18UK Surgical Training in the Independent Sector During COVID-19 – A Snapshot Survey

Abstract Aims In response to the COVID-19 pandemic and the cancellation of elective surgery, the Independent sector (IS) has been utilised to provide COVID-light sites. On average operative log book numbers have been reduced by 50% due to a reduction in operative exposure. The Four Educational Bodies continue to support training within the independent sector. This study aimed to qualitatively assess access and barriers to UK surgical training in the Independent Sector. Methods A snap-shot online survey was distributed to ASIT members of all training specialities and grades between 21/10/2020-11/11/2020 . Data measures included participant demographics, frequency of access, participation in training opportunities including outpatient clinic, theatre lists and endoscopy and any barriers encountered. A mixture of Likert scale and short answer questions were utilised. Results 249 complete responses representing all grades and specialities were included in the final analysis (34.29% CST and 56.3% HST). 35.7% of trainees reported access to the IS. 22.9% had access to at least one operating list whilst 70.3% had none. Access to outpatient clinics and endoscopy was negligible. 75% of trainees ‘strongly agreed’ that when access was achievable, it was beneficial to their training. Multiple barriers were identified including Human Resource requirements and local service provision. Conclusions Within the sample, access to the IS has been poor. There is wide variation in barriers to access across the 4 nations and IS providers. Trainees and Trainers should maximise training opportunities in the IS. Where barriers exist, they should be reported to local Training Programme Directors.