Emergency Undocking Curriculum in Robotic Surgery

Introduction Traditional instruction for robotic surgery is typically devoid of training that addresses the delineation of interprofessional roles for operating room personnel. An emergency undocking scenario was developed for robotic surgeons with the objectives of improving time to access the patient, provider knowledge of and confidence in emergency undocking, completion of predetermined critical actions, and delineation of operating room personnel roles. Methods Over one month, participants joined in three sessions: Session 1 - formative, Session 2 - review, and Session 3 - summative. Embedded standardized participants (ESPs) represented members of the interprofessional team. Prior to entering the operating room for Sessions 1 and 3, trainees were asked to complete a confidence survey and multiple choice questionnaire (MCQ) for knowledge assessment. Participants were randomized to one of two cases and participated in the reciprocal case for the final session four weeks later. Following Session 1, participants underwent an educational intervention, including the proper technique for emergency undocking, emphasis on operating room personnel roles, and hands-on practice. Obstetrics and Gynecology (OBGYN) residents in post-graduate Years 2-4 and attending physicians with robotics privileges at Summa Health Akron Campus or Cleveland Clinic Akron General Medical Center were invited to participate. A total of 21 participants enrolled and finished the study. Results Among the 21 participants, there was a significant increase in the baseline level of knowledge (p-value=0.001) and in the confidence of surgeons when faced with an emergency undocking after the completion of our curriculum (p-value=0.003). Additionally, an improvement in the undocking times (p-value<0.001) and an increase in the critical actions performed (p-value=0.002) were observed. Conclusion The results of this study demonstrate that incorporating this curriculum into the training programs of robotic surgeons is an effective way to improve the surgical skill of emergency undocking

Medical student‐led simulation in COVID‐19 crisis

Background: Simulation training is an effective tool for improving confidence in healthcare workers. During the recent COVID‐19 pandemic, large numbers of staff required re‐training to manage unfamiliar situations. We present a set of medical student‐led clinical simulation sessions and evaluate their effects on (i) confidence among redeployed healthcare workers managing COVID‐19 patients and (ii) medical students’ confidence as educators. / Methods: Half‐day simulation training sessions consisting of three COVID‐related clinical scenarios were devised by senior medical students and delivered to a group of approximately 150 healthcare workers over six repeated sessions prior to redeployment to COVID‐19 wards. We distributed an anonymous pre‐ and post‐simulation questionnaire to 36 participants in the final group exploring their experiences. The confidence scores were analysed using the Wilcoxon signed‐rank test. Following the delivery of teaching, medical students completed a questionnaire assessing their personal experiences of designing and delivering the exercises. / Results: Data are available for 35/36 participants approached. Respondents reported being significantly more confident after the training in all aspects of managing COVID‐19 patients, including triage, complex discharge, recognising deterioration, initiating basic life support, managing symptoms and advising on visiting policies (p < 0.001); 97% of respondents rated the training as useful. Thematic analysis of medical students’ responses demonstrated mutual benefit. / Discussion: This study demonstrates the strengths of simulation training in helping to build staff confidence in a rapidly evolving situation and highlights the value of medical students in supporting a hospital’s response to an outbreak. We recommend further studies of student‐led simulation exercises, including longer‐term follow‐up

Iatrogenic Critical Care Procedure Complication Boot Camp: A Simulation‐Based Pilot Study

Background Traditional medical education strategies teach learners how to correctly perform procedures while neglecting to provide formal training on iatrogenic error management. Error management training (EMT) requires active exploration as well as explicit encouragement for learners to make and learn from errors during training. Simulation provides an excellent methodology to execute a curriculum on iatrogenic procedural complication management. We hypothesize that a standardized simulation‐based EMT curriculum will improve learner's confidence, cognitive knowledge, and performance in iatrogenic injury management. Methods This was a pilot, prospective, observational study performed in a simulation center using a curriculum developed to educate resident physicians on iatrogenic procedural complication management. Pre‐ and post‐intervention assessments included confidence surveys, cognitive questionnaires, and critical action checklists for six simulated procedure complications. Assessment data were analyzed using medians, interquartile ranges, and the paired change scores were tested for median equality to zero via Wilcoxon signed rank tests with p<0.05 considered statistically significant. Results Eighteen residents participated in the study curriculum. The median confidence increased significantly by a summed score of 12.5 (8.75 –17.25) (p<0.001). Similarly, the median knowledge significantly increased by 6 points (3 –8) from the pre‐ to post‐intervention assessment (p<0.001). For each of the simulation cases, the number of critical actions performed increased significantly (p<0.001 to p=0.002). Conclusion We demonstrated significant improvement in the confidence, clinical knowledge, and performance of critical actions after the completion of this curriculum. This pilot study provides evidence that a structured EMT curriculum is an effective method to teach management of iatrogenic injuries

Left ventricular dysfunction after open repair of simple congenital heart defects in infants and children: Quantitation with the use of a conductance catheter immediately after bypass

AbstractObjective: Quantification of myocardial injury after the simplest pediatric operations by load-independent indices of left ventricular function, using conductance and Mikro-Tip pressure catheters (Millar Instruments, Inc., Houston, Tex.) inserted through the left ventricular apex. Methods: Sixteen infants and children with intact ventricular septum undergoing cardiac operations had left ventricular function measured, immediately before and after bypass. Real-time pressure-volume loops were generated by conductance and Mikro-Tip pressure catheters placed in the long-axis via the left ventricular apex, and preload was varied by transient snaring of the inferior vena cava. Results: Good quality pressure-volume loops were generated in 13 patients (atrial septal defects, n = 11; double-chambered right ventricle, n = 1; supravalvular aortic stenosis, n = 1; age 0.25 to 14.4 years, weight 3.1 to 46.4 kg). Their mean bypass time was 41 ± 14 minutes and mean aortic crossclamp time 27 ± 11 minutes. End-systolic elastance decreased by 40.7% from 0.34 ± 0.17 to 0.21 ± 0.15 mm Hg-1·ml-1·kg-1 (p < 0.001). There were no significant changes in the slope of the stroke work–end-diastolic volume relationship, end-diastolic elastance, time constant of isovolumic relaxation, and normalized values of the maxima and minima of the first derivative of developed left ventricular pressure. Conclusion: Load-independent indices of left ventricular function can be derived from left ventricular pressure-volume loops generated by conductance and Mikro-Tip pressure catheters during the perioperative period in infants and children undergoing cardiac operations. Incomplete myocardial protection was demonstrated by a deterioration in systolic function after even short bypass and crossclamp times.Ignorance of the cause of postoperative myocardial dysfunction in the immature heart is compounded by the incomplete myocardial protection afforded by current cardioplegic strategies.1,5 Investigations of the mechanisms and treatment of postoperative ventricular dysfunction are hampered by use of nonspecific clinical end points as indirect estimates of ventricular function, for example, requirement for inotropic agents, duration of ventilation, intensive care unit stay, and mortality. These clinical indices are relatively insensitive to changes in ventricular function and necessitate large cohorts of patients to detect even major differences in outcome from differing myocardial protective strategies.To measure left ventricular function optimally during the perioperative period, with its dramatic changes in loading conditions, necessitates the use of load-independent indices of systolic and diastolic function. In infants and children with an intact ventricular septum undergoing cardiac operations (mainly atrial septal defect closure), we report the changes in left ventricular function assessed from the pressure-volume plane with the use of a conductance catheter and Mikro-Tip pressure catheter (Millar Instruments, Inc., Houston, Tex). In animal and human studies the conductance catheter is placed in the long axis of the left ventricle, most commonly through the aortic valve, with the use of retrograde arterial cannulation or aortotomy.6-11 This is clearly impractical in children undergoing bypass procedures, and in this study we report the first clinical use of custom-built miniature catheters placed in the same long axis, but via the left ventricular apex

Initial fixation placement in face images is driven by top-down guidance

The eyes are often inspected first and for longer period during face exploration. To examine whether this saliency of the eye region at the early stage of face inspection is attributed to its local structure properties or to the knowledge of its essence in facial communication, in this study we investigated the pattern of eye movements produced by rhesus monkeys (Macaca mulatta) as they free viewed images of monkey faces. Eye positions were recorded accurately using implanted eye coils, while images of original faces, faces with scrambled eyes, and scrambled faces except for the eyes were presented on a computer screen. The eye region in the scrambled faces attracted the same proportion of viewing time and fixations as it did in the original faces, even the scrambled eyes attracted substantial proportion of viewing time and fixations. Furthermore, the monkeys often made the first saccade towards to the location of the eyes regardless of image content. Our results suggest that the initial fixation placement in faces is driven predominantly by ‘top-down’ or internal factors, such as the prior knowledge of the location of “eyes” within the context of a face

A context-dependent switch from sensing to feeling in the primate amygdala

The skin transmits affective signals that integrate into our social vocabulary. As the socio-affective aspects of touch are likely processed in the amygdala, we compare neural responses to social grooming and gentle airflow recorded from the amygdala and the primary somatosensory cortex of non-human primates. Neurons in the somatosensory cortex respond to both types of tactile stimuli. In the amygdala, however, neurons do not respond to individual grooming sweeps even though grooming elicits autonomic states indicative of positive affect. Instead, many show changes in baseline firing rates that persist throughout the grooming bout. Such baseline fluctuations are attributed to social context because the presence of the groomer alone can account for the observed changes in baseline activity. It appears, therefore, that during grooming, the amygdala stops responding to external inputs on a short timescale but remains responsive to social context (or the associated affective states) on longer time scales

Impact of Pharmacist-Led Diabetes Management in Primary Care Clinics

Purpose: Current literature supports that pharmacists effectively lower hemoglobin A1c (HbA1c) in diabetic patients. Little data exists on pharmacists’ effects on comorbidity management, patient satisfaction, or financial viability of these positions. This study looked to assess the impact of pharmacists on diabetes management compared to usual care. Methods: This multi-site, two-part study includes a retrospective chart review of patients referred to the pharmacist versus usual care within a large academic health system. The pharmacists collaborated under a consult agreement with primary care physicians. The second part of the study assessed patient satisfaction through an abbreviated CG-CAHPS survey. Results:A total of 206 patients with diabetes for an average of 12 years were included. The average patient age was 62 years with 60% of patients identifying as female and 81% as African-American. Patients were enrolled in a 2:1 fashion with 138 patients in the intervention group. Average baseline HbA1c was 10.1% in the intervention group and 9.3% in the control group (p= 0.0125). At 6 months, the mean change in HbA1c was -2.17% and 0.48% for the intervention and control groups respectively (p Conclusion: Pharmacists are effective at lowering HbA1c in primary care clinics, and patients were highly satisfied with these services. While direct revenue from this service did not meet cost, the pharmacist did positively affect outcomes that contribute to reimbursement. Treatment of Human Subjects: IRB review/approval required and obtained &nbsp; Type: Original Researc

Design of an Agile Unmanned Combat Vehicle - A Product of the DARPA UGCV Program

The unmanned ground combat vehicle (UGCV) design evolved by the SAIC team on the DARPA UGCV Program is summarized in this paper. This UGCV design provides exceptional performance against all of the program metrics and incorporates key attributes essential for high performance robotic combat vehicles. This performance includes protection against 7.62 mm threats, C130 and CH47 transportability, and the ability to accept several relevant weapons payloads, as well as advanced sensors and perception algorithms evolving from the PerceptOR program. The UGCV design incorporates a combination of technologies and design features, carefully selected through detailed trade studies, which provide optimum performance against mobility, payload, and endurance goals without sacrificing transportability, survivability, or life cycle cost. The design was optimized to maximize performance against all Category I metrics. In each case, the performance of this design was validated with detailed simulations, indicating that the vehicle exceeded the Category I metrics. Mobility metrics were analyzed using high fidelity VisualNastran vehicle models, which incorporate the suspension control algorithms and controller cycles times. DADS/Easy 5 3-D models and ADAMS simulations were also used to validate vehicle dynamics and control algorithms during obstacle negotiation