Artificial intelligence and training physicians to perform technical procedures

Winkler-Schwartz et al have set out to determine if some combination of machine learning algorithms can differentiate participants according to their stage of practice (ie, neurosurgeon, fellow, senior or junior resident, or medical student) based on their performance of a complex simulated neurosurgical task. A total of 250 simulated surgical resections performed by 50 participants were studied using a prospective, observational case series design. The best-performing algorithm (K-nearest neighbor) had 90% accuracy for prediction and used 6 machine-selected metrics. Three of the 4 algorithms used in the study misclassified a medical student as a neurosurgeon

The effect of simulation-based training on initial performance of ultrasound-guided axillary brachial plexus blockade in a clinical setting – a pilot study

BACKGROUND: In preparing novice anesthesiologists to perform their first ultrasound-guided axillary brachial plexus blockade, we hypothesized that virtual reality simulation-based training offers an additional learning benefit over standard training. We carried out pilot testing of this hypothesis using a prospective, single blind, randomized controlled trial. METHODS: We planned to recruit 20 anesthesiologists who had no experience of performing ultrasound-guided regional anesthesia. Initial standardized training, reflecting current best available practice was provided to all participating trainees. Trainees were randomized into one of two groups; (i) to undertake additional simulation-based training or (ii) no further training. On completion of their assigned training, trainees attempted their first ultrasound-guided axillary brachial plexus blockade. Two experts, blinded to the trainees’ group allocation, assessed the performance of trainees using validated tools. RESULTS: This study was discontinued following a planned interim analysis, having recruited 10 trainees. This occurred because it became clear that the functionality of the available simulator was insufficient to meet our training requirements. There were no statistically significant difference in clinical performance, as assessed using the sum of a Global Rating Score and a checklist score, between simulation-based training [mean 32.9 (standard deviation 11.1)] and control trainees [31.5 (4.2)] (p = 0.885). CONCLUSIONS: We have described a methodology for assessing the effectiveness of a simulator, during its development, by means of a randomized controlled trial. We believe that the learning acquired will be useful if performing future trials on learning efficacy associated with simulation based training in procedural skills. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01965314. Registered October 17th 2013

A comparison of three techniques (local anesthetic deposited circumferential to vs. above vs. below the nerve) for ultrasound guided femoral nerve block

Background: Fractured neck of femur generally requires operative fixation and is a common cause of admission to hospital. The combination of femoral nerve block and spinal anesthesia is a common anesthetic technique used to facilitate the surgical procedure. The optimal disposition of local anesthetic (LA) relative the femoral nerve (FN) has not been defined. Our hypothesis was: that the deposition of LA relative to the FN influences the quality of analgesia for positioning of the patient for performance of spinal anesthesia. The primary outcome was verbal rating (VRS) pain scores 0–10 assessed immediately after positioning the patient to perform spinal anesthesia. Methods: With Institutional ethical approval and having obtained written informed consent from each, 52 patients were studied. The study was registered with ClinicalTrials.gov (NCT01527812). Patients were randomly allocated to undergo to one of three groups namely: intention to deposit lidocaine 2% (15 ml) i. above (Group A), ii. below (Group B), iii. circumferential (Group C) to the FN. A blinded observer assessed i. the sensory nerve block (cold) in the areas of the terminal branches of the FN and ii. VRS pain scores on passive movement from block completion at 5 minutes intervals for 30 minutes. Immediately after positioning the patient for spinal anesthesia, VRS pain scores were recorded. Results: Pain VRS scores during positioning were similar in the three groups [Above group/Below group/Circumferential group: 2(0–9)/0(0–10)/3(0–10), median(range), p:0.32]. The block was deemed to have failed in 20%, 47% and 12% in the Above group, Below group and Circumferential group respectively. The median number of needle passes was greater in the Circumferential group compared with the Above group (p:0.009). Patient satisfaction was greatest in the Circumferential group [mean satisfaction scores were 83.5(19.8)/88.1(20.5)/93.8(12.3), [mean(SD), p=0.04] in the Above, Below and Circumferential groups respectively. Conclusions: We conclude that there is no clinical advantage to attempting to deposit LA circumferential to the femoral nerve (relative to depositing LA either above or below the nerve), during femoral nerve block in this setting

Measuring deliberate reflection in residents: validation and psychometric properties of a measurement tool

PURPOSE: Reflective capacity is the ability to understand critical analysis of knowledge and experience to achieve deeper meaning. In medicine, there is little provision for post-graduate medical education to teach deliberate reflection. The feasibility, scoring characteristics, reliability, validation, and adaptability of a modified previously validated instrument was examined for its usefulness assessing reflective capacity in residents as a step toward developing interventions for improvement. METHODS: Third-year residents and fellows from four anesthesia training programs were administered a slightly modified version of the Reflection Evaluation for Learners\u27 Enhanced Competencies Tool (REFLECT) in a prospective, observational study at the end of the 2019 academic year. Six written vignettes of imperfect anesthesia situations were created. Subjects recorded their perspectives on two randomly assigned vignettes. Responses were scored using a 5-element rubric; average scores were analyzed for psychometric properties. An independent self-report assessment method, the Cognitive Behavior Survey: Residency Level (rCBS) was used to examine construct validity. Internal consistency (ICR, Cronbach\u27s alpha) and interrater reliability (weighted kappa) were examined. Pearson correlations were used between the two measures of reflective capacity. RESULTS: 46/136 invited subjects completed 2/6 randomly assigned vignettes. Interrater agreement was high (k = 0.85). The overall average REFLECT score was 1.8 (1-4 scale) with good distribution across the range of scores. ICR for both the REFLECT score (mean 1.8, sd 0.5; α = 0.92) and the reflection scale of the rCBS (mean 4.5, sd 1.1; α = 0.94) were excellent. There was a significant correlation between REFLECT score and the rCBS reflection scale (r = .44, p \u3c 0.01). CONCLUSIONS: This study demonstrates feasibility, reliability, and sufficiently robust psychometric properties of a modified REFLECT rubric to assess graduate medical trainees\u27 reflective capacity and established construct/convergent validity to an independent measure. The instrument has the potential to assess the effectiveness of interventions intended to improve reflective capacity

Convergence and translation: attitudes to inter-professional learning and teaching of creative problem-solving among medical and engineering students and staff

Background: Healthcare worldwide needs translation of basic ideas from engineering into the clinic. Consequently, there is increasing demand for graduates equipped with the knowledge and skills to apply interdisciplinary medicine/engineering approaches to the development of novel solutions for healthcare. The literature provides little guidance regarding barriers to, and facilitators of, effective interdisciplinary learning for engineering and medical students in a team-based project context. Methods: A quantitative survey was distributed to engineering and medical students and staff in two universities, one in Ireland and one in Belgium, to chart knowledge and practice in interdisciplinary learning and teaching, and of the teaching of innovation. Results: We report important differences for staff and students between the disciplines regarding attitudes towards, and perceptions of, the relevance of interdisciplinary learning opportunities, and the role of creativity and innovation. There was agreement across groups concerning preferred learning, instructional styles, and module content. Medical students showed greater resistance to the use of structured creativity tools and interdisciplinary teams. Conclusions: The results of this international survey will help to define the optimal learning conditions under which undergraduate engineering and medicine students can learn to consider the diverse factors which determine the success or failure of a healthcare engineering solution

Using machine learning to identify patient characteristics to predict mortality of in-patients with COVID-19 in south Florida

IntroductionThe SARS-CoV-2 (COVID-19) pandemic has created substantial health and economic burdens in the US and worldwide. As new variants continuously emerge, predicting critical clinical events in the context of relevant individual risks is a promising option for reducing the overall burden of COVID-19. This study aims to train an AI-driven decision support system that helps build a model to understand the most important features that predict the “mortality” of patients hospitalized with COVID-19.MethodsWe conducted a retrospective analysis of “5,371” patients hospitalized for COVID-19-related symptoms from the South Florida Memorial Health Care System between March 14th, 2020, and January 16th, 2021. A data set comprising patients’ sociodemographic characteristics, pre-existing health information, and medication was analyzed. We trained Random Forest classifier to predict “mortality” for patients hospitalized with COVID-19.ResultsBased on the interpretability of the model, age emerged as the primary predictor of “mortality”, followed by diarrhea, diabetes, hypertension, BMI, early stages of kidney disease, smoking status, sex, pneumonia, and race in descending order of importance. Notably, individuals aged over 65 years (referred to as “older adults”), males, Whites, Hispanics, and current smokers were identified as being at higher risk of death. Additionally, BMI, specifically in the overweight and obese categories, significantly predicted “mortality”. These findings indicated that the model effectively learned from various categories, such as patients' sociodemographic characteristics, pre-hospital comorbidities, and medications, with a predominant focus on characterizing pre-hospital comorbidities. Consequently, the model demonstrated the ability to predict “mortality” with transparency and reliability.ConclusionAI can potentially provide healthcare workers with the ability to stratify patients and streamline optimal care solutions when time is of the essence and resources are limited. This work sets the platform for future work that forecasts patient responses to treatments at various levels of disease severity and assesses health disparities and patient conditions that promote improved health care in a broader context. This study contributed to one of the first predictive analyses applying AI/ML techniques to COVID-19 data using a vast sample from South Florida

Pain after upper limb surgery under peripheral nerve block is associated with gut microbiome composition and diversity

peer-reviewedGut microbiota play a role in certain pain states. Hence, these microbiota also influence somatic pain. We aimed to determine if there was an association between gut microbiota (composition and diversity) and postoperative pain. Patients (n = 20) undergoing surgical fixation of distal radius fracture under axillary brachial plexus block were studied. Gut microbiota diversity and abundance were analysed for association with: (i) a verbal pain rating scale of < 4/10 throughout the first 24 h after surgery (ii) a level of pain deemed “acceptable” by the patient during the first 24 h following surgery (iii) a maximum self-reported pain score during the first 24 h postoperatively and (iv) analgesic consumption during the first postoperative week. Analgesic consumption was inversely correlated with the Shannon index of alpha diversity. There were also significant differences, at the genus level (including Lachnospira), with respect to pain being “not acceptable” at 24 h postoperatively. Porphyromonas was more abundant in the group reporting an acceptable pain level at 24 h. An inverse correlation was noted between abundance of Collinsella and maximum self-reported pain score with movement. We have demonstrated for the first time that postoperative pain is associated with gut microbiota composition and diversity. Further work on the relationship between the gut microbiome and somatic pain may offer new therapeutic targets

Efficacy of sub-Tenon's block using an equal volume of local anaesthetic administered either as a single or as divided doses. A randomised clinical trial

<p>Abstract</p> <p>Background</p> <p>Sub-Tenon's anaesthetic is effective and reliable in producing both akinesia and anaesthesia for cataract surgery. Our clinical experience indicates that it is sometimes necessary when absolute akinesia is required during surgery to augment the block with 1–2 ml of local anaesthetic. Hypothesis was that after first injection some of the volume injected may spill out and before second injection the effect of hyaluronidase has taken place and second volume injectate will have desired effect.</p> <p>Methods</p> <p>A prospective, randomised, control trial in which patients were randomly allocated to one of two groups. In group 1, single injection of 5 ml of local anaesthetic was injected. In group 2, 3 ml of the same anaesthetic solution was injected followed by application of gentle orbital pressure for 2 minutes. A further 2 ml of the same anaesthetic solution was injected through the same conjunctival incision. Measurement of movement in four quadrants of eye was done by the surgeon at 3 and 6 minutes. Intraocular pressure, chemosis, and subconjuctival haemorrhage were also measured.</p> <p>Results</p> <p>Significant differences at 3 minutes between groups for overall movement, medial, superior, and lateral quadrants occurred. At 6 minutes no significant group differences emerged for the overall movement or for any of four quadrants.</p> <p>Conclusion</p> <p>Single injection of local anaesthesia for sub-Tenon's block with mixture of lignocaine with adrenaline, bupivacaine and hyaluronidase was found to be superior to provide akinesia of ocular muscles compared to divided dose given by two injections. No difference in groups in terms of haemorrhage, chemosis, patient's satisfaction and intraocular pressure was found.</p> <p>Trial registration</p> <p>Trial registration no-ISRCTN73431052</p

Matching energy intake to expenditure of isocaloric exercise at high- and moderate-intensities

Background Those seeking to manage their bodyweight use a variety of strategies, but the most common approaches involve attempting to exercise more and/or consume fewer calories. A poor comprehension of the energy cost of exercise and the energy content of food may contribute to weight-gain and the poor success rate of exercise weight-loss interventions. Purpose The purpose of this study is to investigate individuals' ability to consciously match energy intake with energy expenditure after isocaloric exercise at moderate and high intensities. Method In a counterbalanced cross-over study design, 14 low- to moderately-active, lean individuals (7 male, 7 female; mean age 23 ± 3 years; mean BMI 22.0 ± 3.2 kg·m− 2) completed both a moderate-intensity (60% VO2max, MOD) and a high-intensity (90% VO2max, HIGH) exercise bout on a treadmill, matched for energy expenditure, EE (450 kcal). Participants were blinded to the intensity and duration of each bout. Thirty minutes post-exercise, participants were presented with a buffet, where they were asked to consume food in an attempt to match energy intake with the energy expended during the exercise bout. This was termed the “matching task,” providing a matching task energy intake value (EIMATCH). Upon finishing the matching task, a verbal estimate of energy expenditure (EST) was obtained before the participant was allowed to return to the buffet to consume any more food, if desired. This intake was covertly measured and added to EIMATCH to obtain an ad libitum intake value (EIAD LIB). Results A significant condition × task interaction showed that, in MOD, EST was significantly lower than EE (298 ± 156 kcal vs. 443 ± 22 kcal, p = 0.01). In the HIGH condition, EE, EIMATCH and EST were similar. In both conditions, participants tended to over-eat to a similar degree, relative to EST, with EIMATCH 20% and 22% greater than EST in MOD and HIGH respectively. Between-condition comparisons demonstrated that EIMATCH and EST were significantly lower in MOD, compared with HIGH (374 ± 220 kcal vs. 530 ± 248 kcal, p = 0.002 and 298 ± 156 kcal vs. 431 ± 129 kcal, p = 0.002 respectively). For both conditions, EIAD LIB was approximately 2-fold greater than EE. Discussion Participants exhibited a strong ability to estimate exercise energy expenditure after high-intensity exercise. Participants appeared to perceive moderate-intensity exercise to be less energetic than an isocaloric bout of high-intensity exercise. This may have implications for exercise recommendations for weight-loss strategies, especially when casual approaches to exercise and attempting to eat less are being implemented