Healthcare simulators have been demonstrated to be a valuable resource for training several technical and nontechnical skills. A gap in the fidelity of tissues has been acknowledged as a barrier to ...application for current simulators; especially for interventional procedures. Inaccurate or unrealistic mechanical response of a simulated tissue to a given surgical tool motion may result in negative training transfer and/or prevents the "suspension of disbelief" necessary for a trainee to engage in the activity. Thus, where it is relevant to training outcomes, there should be an effort to create healthcare simulators with simulated tissue mechanical responses that match or represent those of biological tissues. Historically, this data is most often gathered from preserved (post mortem) tissue; however, there is a concern that the mechanical properties of preserved tissue, that lacks blood flow, may lack adequate accuracy to provide the necessary training efficacy of simulators.
This work explores the effect of the "state" of the tissue testing status on liver and peritoneal tissue by using a customized handheld grasper to measure the mechanical responses of representative porcine (Sus domesticus) tissues in n = 5 animals across five test conditions: in vivo, post mortem (in-situ), ex vivo (immediately removed from fresh porcine cadaver), post-refrigeration, and post-freeze-thaw cycle spanning up to 72 hours after death. No statistically significant difference was observed in the mechanical responses due to grasping between in vivo and post-freeze conditions for porcine liver and peritoneum tissue samples (p = 0.05 for derived stiffness at grasping force values F = 5N and 6.5N). Furthermore, variance between in vivo and post-freeze conditions within each animal, was comparable to the variance of the in vivo condition between animals.
Results of this study further validate the use of preserved tissue in the design of medical simulators via observing tissue mechanical responses of post-freeze tissue comparable to in vivo tissue. Therefore, the use of thawed preserved tissue for the further study and emulation of mechanical perturbation of the liver and peritoneum can be considered. Further work in this area should investigate these trends further, particularly in regard to other tissues and the potential effects varying preservation methods may yield.
The challenges of training and assessing endourologic skill have driven the development of new training systems. The Center for Research in Education and Simulation Technologies (CREST) has developed ...a team and a methodology to facilitate this development process.
Backwards design principles were applied. A panel of experts first defined desired clinical and educational outcomes. Outcomes were subsequently linked to learning objectives. Gross task deconstruction was performed, and the primary domain was classified as primarily involving decision-making, psychomotor skill, or communication. A more detailed cognitive task analysis was performed to elicit and prioritize relevant anatomy/tissues, metrics, and errors. Reference anatomy was created using a digital anatomist and clinician working off of a clinical data set. Three dimensional printing can facilitate this process. When possible, synthetic or virtual tissue behavior and textures were recreated using data derived from human tissue. Embedded sensors/markers and/or computer-based systems were used to facilitate the collection of objective metrics. A learning Verification and validation occurred throughout the engineering development process.
Nine endourology-relevant training systems were created by CREST with this approach. Systems include basic laparoscopic skills (BLUS), vesicourethral anastomosis, pyeloplasty, cystoscopic procedures, stent placement, rigid and flexible ureteroscopy, GreenLight PVP (GL Sim), Percutaneous access with C-arm (CAT), Nephrolithotomy (NLM), and a vascular injury model. Mixed modalities have been used, including "smart" physical models, virtual reality, augmented reality, and video. Substantial validity evidence for training and assessment has been collected on systems. An open source manikin-based modular platform is under development by CREST with the Department of Defense that will unify these and other commercial task trainers through the common physiology engine, learning management system, standard data connectors, and standards.
Using the CREST process has and will ensure that the systems we create meet the needs of training and assessing endourologic skills.
Our aim was assess whether an integrated Advanced Modular Manikin (AMM) provides improved participant experience compared with use of peripheral simulators alone during a standardized trauma team ...scenario. Simulation-based team training has been shown to improve team performance. To address limitations of existing manikin simulators, the AMM platform was created that enables interconnectedness, interoperability, and integration of multiple simulators (“peripherals”) into an adaptable, comprehensive training system.
A randomized single-blinded, crossover study with 2 conditions was used to assess learner experience differences when using the integrated AMM platform vs peripheral simulators. First responders, anesthesiologists, and surgeons rated their experience and workload with the conditions in a 3-scene standardized trauma scenario. Participant ratings were compared and focus groups conducted to obtain insight into participant experience.
Fourteen teams (n = 42) participated. Team experience ratings were higher for the integrated AMM condition compared with peripherals (Cohen’s d = .25, p = 0.016). Participant experience varied by background with surgeons and first responders rating their experience significantly higher compared with anesthesiologists (p < 0.001). Higher workload ratings were observed with the integrated AMM condition (Cohen’s d = .35, p = 0.014) driven primarily by anesthesiologist ratings. Focus groups revealed that participants preferred the integrated AMM condition based on its increased realism, physiologic responsiveness, and feedback provided on their interventions.
This first comprehensive evaluation suggests that integration with the AMM platform provides benefits over individual peripheral simulators and has the potential to expand simulation-based learning opportunities and enhance learner experience, especially for surgeons.
Display omitted
Global sea level provides an important indicator of the state of the warming climate, but changes in regional sea level are most relevant for coastal communities around the world. With improvements ...to the sea‐level observing system, the knowledge of regional sea‐level change has advanced dramatically in recent years. Satellite measurements coupled with in situ observations have allowed for comprehensive study and improved understanding of the diverse set of drivers that lead to variations in sea level in space and time. Despite the advances, gaps in the understanding of contemporary sea‐level change remain and inhibit the ability to predict how the relevant processes may lead to future change. These gaps arise in part due to the complexity of the linkages between the drivers of sea‐level change. Here we review the individual processes which lead to sea‐level change and then describe how they combine and vary regionally. The intent of the paper is to provide an overview of the current state of understanding of the processes that cause regional sea‐level change and to identify and discuss limitations and uncertainty in our understanding of these processes. Areas where the lack of understanding or gaps in knowledge inhibit the ability to provide the needed information for comprehensive planning efforts are of particular focus. Finally, a goal of this paper is to highlight the role of the expanded sea‐level observation network—particularly as related to satellite observations—in the improved scientific understanding of the contributors to regional sea‐level change.
Plain Language Summary
This review paper addresses three important questions: (1) What do we currently know about the processes contributing to sea level change? (2) What observations do we use to gain this knowledge? and (3) Where are these gaps in our knowledge and the need for further improvement in our understanding of the drivers of regional sea level? By answering these specific questions in a focused manner, this paper should be a useful resource for other scientists, sea‐level stakeholders, and a broader audience of those interested in sea level and our changing climate.
Key Points
An overview of the current state of understanding of the processes that cause regional sea‐level change is provided
Areas where the lack of understanding or gaps in knowledge inhibit the ability to assess future sea‐level change are discussed
The role of the expanded sea‐level observation network in improving our understanding of sea‐level change is highlighted
Bronchiolitis obliterans syndrome (BOS) is a major complication of lung transplantation that is associated with poor survival. The International Society for Heart and Lung Transplantation, American ...Thoracic Society, and European Respiratory Society convened a committee of international experts to describe and/or provide recommendations for 1) the definition of BOS, 2) the risk factors for developing BOS, 3) the diagnosis of BOS, and 4) the management and prevention of BOS. A pragmatic evidence synthesis was performed to identify all unique citations related to BOS published from 1980 through to March, 2013. The expert committee discussed the available research evidence upon which the updated definition of BOS, identified risk factors and recommendations are based. The committee followed the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) approach to develop specific clinical recommendations. The term BOS should be used to describe a delayed allograft dysfunction with persistent decline in forced expiratory volume in 1 s that is not caused by other known and potentially reversible causes of post-transplant loss of lung function. The committee formulated specific recommendations about the use of systemic corticosteroids, cyclosporine, tacrolimus, azithromycin and about re-transplantation in patients with suspected and confirmed BOS. The diagnosis of BOS requires the careful exclusion of other post-transplant complications that can cause delayed lung allograft dysfunction, and several risk factors have been identified that have a significant association with the onset of BOS. Currently available therapies have not been proven to result in significant benefit in the prevention or treatment of BOS. Adequately designed and executed randomised controlled trials that properly measure and report all patient-important outcomes are needed to identify optimal therapies for established BOS and effective strategies for its prevention.
Introduction Simulation-based training is playing an increasingly important role in surgery. However, there is insufficient discussion among the surgical specialties regarding how simulation may best ...be leveraged for training. There is much to be learned from one another as we all strive to meet new requirements within the context of Undergraduate Medical Education, Graduate Medical Education, and Continuing Medical Education. Method To address this need, a panel was convened at the 6th Annual Meeting of the Consortium of the American College of Surgeons-Accredited Education Institutes consisting of key leaders in the field of simulation from 4 surgical subspecialties, namely, general surgery, orthopedic surgery, cardiothoracic surgery, urology, and otolaryngology. Conclusion An overview of how the 5 surgical specialties are using simulation-based training to meet a wide array of educational needs for all levels of learners is presented.
As the prevalence of urolithiasis increases and ureteroscopy is used more frequently, the risks of uncommon complications such as ureteral stricture may become more notable. Our objective is to ...assess the rate and associated risk factors of ureteral stricture formation in patients undergoing ureteroscopy.
Utilizing the IBM MarketScan research database, we evaluated data from 2008 to 2019 and compared ureteral stricture rates and their management following ureteroscopy to subjects who had shock wave lithotripsy. Shock wave lithotripsy was used as a comparison group to represent the rate of stricture from stone disease alone. A third group of those having both shock wave lithotripsy and ureteroscopy was included. Patients and secondary procedures were identified using Current Procedural Terminology, and International Classification of Diseases-9 and -10 codes.
A total of 329,776 patients received ureteroscopy, shock wave lithotripsy, or shock wave lithotripsy+ureteroscopy between 2008 and 2019. Stricture developed in 2.9% of patients after ureteroscopy, 1.5% after shock wave lithotripsy, and 2.6% after shock wave lithotripsy+ureteroscopy. In the multivariable model, rates of stricture were 1.7-fold higher after ureteroscopy vs shock wave lithotripsy (OR:1.71, 95% CI 1.62-1.81). Preoperative hydronephrosis, age, prior stones/intervention, and concurrent kidney and ureteral stones were associated with increased risk of stricture. Of those with strictures incurred after ureteroscopy, 35% required drainage, 21% had endoscopic intervention, 4.8% required reconstructive surgery, and 1.7% underwent nephrectomy.
Ureteral stricture rate after ureteroscopy of nearly 3% was higher than expected and approximately twice the rate attributable to stone disease alone. Factors associated with the stone as well as instrumentation were found to be risk factors. The morbidity of stricture disease following ureteroscopy was significant.
Abstract
Severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), threatens global public health. The world needs rapid development of new ...antivirals and vaccines to control the current pandemic and to control the spread of the variants. Among the proteins synthesized by the SARS-CoV-2 genome, main protease (M
pro
also known as 3CL
pro
) is a primary drug target, due to its essential role in maturation of the viral polyproteins. In this study, we provide crystallographic evidence, along with some binding assay data, that three clinically approved anti hepatitis C virus drugs and two other drug-like compounds covalently bind to the M
pro
Cys145 catalytic residue in the active site. Also, molecular docking studies can provide additional insight for the design of new antiviral inhibitors for SARS-CoV-2 using these drugs as lead compounds. One might consider derivatives of these lead compounds with higher affinity to the M
pro
as potential COVID-19 therapeutics for further testing and possibly clinical trials.
Purpose The purpose of our study was to develop a low-fidelity surgical simulator for basic arthroscopic skills training, with the goal of creating a pretrained novice ready with the basic skills ...necessary for all joint arthroscopic procedures. Methods A panel of education, arthroscopy, and simulation experts designed and evaluated a basic arthroscopic skills training and testing box. Task deconstruction was used to create 2 modules, which incorporate core skills common to all arthroscopic procedures. Core metrics measured were time to completion, number of trials to steady state, and number of errors. Face validity was evaluated using a questionnaire. Construct validity was examined by comparing 8 medical students with 8 expert orthopaedic surgeons. Results Surgeons were faster than students on both module 1 ( P = .0013), simulating triangulation skills, and module 2 ( P = .0190) simulating object manipulation skills. Surgeons demonstrated fewer errors (6.9 errors versus 28.1; P = .0073). All surgeons were able to demonstrate steady state (i.e., perform 2 trials that were within 10% of each other for time to completion and errors) on both modules within 3 trials on each module. Only 2 novices were able to demonstrate steady state on either module, and both did so within 3 trials. Furthermore, face validity of the skills trainer was shown by the expert arthroscopists. Conclusions We describe a basic arthroscopy skills simulator that has face and construct validity. Our expert panel was able to design a simulator that differentiated between experienced arthroscopists and novices. Clinical Relevance Surgical simulation is an important part of efficient surgical education. This simulator shows good construct and face validity and provides a low-fidelity option for teaching the entry-level arthroscopist.
PDF
