The feasibility and usability of mixed reality teaching in a hospital setting based on self-reported perceptions of medical students.

BACKGROUND: Clinical teaching during encounters with real patients lies at the heart of medical education. Mixed reality (MR) using a Microsoft HoloLens 2 (HL2) offers the potential to address several challenges: including enabling remote learning; decreasing infection control risks; facilitating greater access to medical specialties; and enhancing learning by vertical integration of basic principles to clinical application. We aimed to assess the feasibility and usability of MR using the HL2 for teaching in a busy, tertiary referral university hospital. METHODS: This prospective observational study examined the use of the HL2 to facilitate a live two-way broadcast of a clinician-patient encounter, to remotely situated third and fourth year medical students. System Usability Scale (SUS) Scores were elicited from participating medical students, clinician, and technician. Feedback was also elicited from participating patients. A modified Evaluation of Technology-Enhanced Learning Materials: Learner Perceptions Questionnaire (mETELM) was completed by medical students and patients. RESULTS: This was a mixed methods prospective, observational study, undertaken in the Day of Surgery Assessment Unit. Forty-seven medical students participated. The mean SUS score for medical students was 71.4 (SD 15.4), clinician (SUS = 75) and technician (SUS = 70) indicating good usability. The mETELM Questionnaire using a 7-point Likert Scale demonstrated MR was perceived to be more beneficial than a PowerPoint presentation (Median = 7, Range 6-7). Opinion amongst the student cohort was divided as to whether the MR tutorial was as beneficial for learning as a live patient encounter would have been (Median = 5, Range 3-6). Students were positive about the prospect of incorporating of MR in future tutorials (Median = 7, Range 5-7). The patients' mETELM results indicate the HL2 did not affect communication with the clinician (Median = 7, Range 7-7). The MR tutorial was preferred to a format based on small group teaching at the bedside (Median = 6, Range 4-7). CONCLUSIONS: Our study findings indicate that MR teaching using the HL2 demonstrates good usability characteristics for providing education to medical students at least in a clinical setting and under conditions similar to those of our study. Also, it is feasible to deliver to remotely located students, although certain practical constraints apply including Wi-Fi and audio quality.

Delivering clinical tutorials to medical students using the Microsoft HoloLens 2: A mixed-methods evaluation.

BACKGROUND: Mixed reality offers potential educational advantages in the delivery of clinical teaching. Holographic artefacts can be rendered within a shared learning environment using devices such as the Microsoft HoloLens 2. In addition to facilitating remote access to clinical events, mixed reality may provide a means of sharing mental models, including the vertical and horizontal integration of curricular elements at the bedside. This study aimed to evaluate the feasibility of delivering clinical tutorials using the Microsoft HoloLens 2 and the learning efficacy achieved. METHODS: Following receipt of institutional ethical approval, tutorials on preoperative anaesthetic history taking and upper airway examination were facilitated by a tutor who wore the HoloLens device. The tutor interacted face to face with a patient and two-way audio-visual interaction was facilitated using the HoloLens 2 and Microsoft Teams with groups of students who were located in a separate tutorial room. Holographic functions were employed by the tutor. The tutor completed the System Usability Scale, the tutor, technical facilitator, patients, and students provided quantitative and qualitative feedback, and three students participated in semi-structured feedback interviews. Students completed pre- and post-tutorial, and end-of-year examinations on the tutorial topics. RESULTS: Twelve patients and 78 students participated across 12 separate tutorials. Five students did not complete the examinations and were excluded from efficacy calculations. Student feedback contained 90 positive comments, including the technology's ability to broadcast the tutor's point-of-vision, and 62 negative comments, where students noted issues with the audio-visual quality, and concerns that the tutorial was not as beneficial as traditional in-person clinical tutorials. The technology and tutorial structure were viewed favourably by the tutor, facilitator and patients. Significant improvement was observed between students' pre- and post-tutorial MCQ scores (mean 59.2% Vs 84.7%, p < 0.001). CONCLUSIONS: This study demonstrates the feasibility of using the HoloLens 2 to facilitate remote bedside tutorials which incorporate holographic learning artefacts. Students' examination performance supports substantial learning of the tutorial topics. The tutorial structure was agreeable to students, patients and tutor. Our results support the feasibility of offering effective clinical teaching and learning opportunities using the HoloLens 2. However, the technical limitations and costs of the device are significant, and further research is required to assess the effectiveness of this tutorial format against in-person tutorials before wider roll out of this technology can be recommended as a result of this study.

Learning analytics and the future of postgraduate medical training.

Confronted by the many barriers and deficiencies which currently face those responsible for the training of doctors, the concept of a logic model applied in real time may seem aspirational. However, several of the necessary of logic-based practices are already in place - these include quantified training effect and performance, learning analytics, and applied reflective practice. A nationally or internationally co-ordinated effort is required to harness these disciplines (which currently exist disparately) to create a sustainable and effective training system which is adaptive to its own performance and to society's changing needs. This will mean making better use of the data currently being generated by and around training, and its presentation in a timely and comprehensible form to the person(s) who is responsible, prepared, and able to use it to best effect.

The gut microbiota in persistent post-operative pain following breast cancer surgery.

Persistent post-surgical pain (PPSP) is defined as pain which continues after a surgical operation in a significant form for at least three months (and is not related to pre-existing painful conditions). PPSP is a common, under-recognised, and important clinical problem which affects millions of patients worldwide. Preventative measures which are currently available include the selection of a minimally invasive surgical technique and an aggressive multimodal perioperative analgesic regimen. More recently, a role for the gut microbiota in pain modulation has become increasingly apparent. This study aims to investigate any relationship between the gut microbiota and PPSP. A prospective observational study of 68 female adult patients undergoing surgery for management of breast cancer was carried out. Stool samples from 45 of these patients were obtained to analyse the composition of the gut microbiota. Measures of pain and state-trait anxiety were also taken to investigate further dimensions in any relationship between the gut microbiota and PPSP. At 12 weeks postoperatively, 21 patients (51.2%) did not have any pain and 20 patients (48.8%) reported feeling pain that persisted at that time. Analysis of the gut microbiota revealed significantly lower alpha diversity (using three measures) in those patients reporting severe pain at the 60 min post-operative and the 12 weeks post-operative timepoints. A cluster of taxa represented by Bifidobacterium longum, and Faecalibacterium prausnitzii was closely associated with those individuals reporting no pain at 12 weeks postoperatively, while Megamonas hypermegale, Bacteroides pectinophilus, Ruminococcus bromii, and Roseburia hominis clustered relatively closely in the group of patients fulfilling the criteria for persistent post-operative pain. We report for the first time specific associations between the gut microbiota composition and the presence or absence of PPSP. This may provide further insights into mechanisms behind the role of the gut microbiota in the development of PPSP and could inform future treatment strategies.

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' 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's 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 < 0.01). CONCLUSIONS: This study demonstrates feasibility, reliability, and sufficiently robust psychometric properties of a modified REFLECT rubric to assess graduate medical trainees' 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.

A consensus statement on the meaning, value and utility of training programme outcomes, with specific reference to anaesthesiology: A consensus statement on training programme outcomes.

It is timely and necessary to consider what Postgraduate Medical Training Programme outcomes are, how they are defined and revised over time, and how they can be used to align health professional performance with the healthcare needs of society. This article which addresses those issues, with specific reference to training in anaesthesiology, was prepared using a modified nominal group (or expert panel) approach.

Sex, pain, and the microbiome: The relationship between baseline gut microbiota composition, gender and somatic pain in healthy individuals.

BACKGROUND AND AIM: Relative to men, women present with pain conditions more commonly. Although consistent differences exist between men and women in terms of physiological pain sensitivity, the underlying mechanisms are incompletely understood and yet could inform the development of effective sex specific treatments for pain. The gut microbiota can modulate nervous system functioning, including pain signaling pathways. We hypothesized that the gut microbiota and critical components of the gut-brain axis might influence electrical pain thresholds. Further, we hypothesized that sex, menstrual cycle, and hormonal contraceptive use might account for inter-sex differences in pain perception. METHODS: Healthy, non-obese males (N = 15) and females (N = 16), (nine of whom were using hormonal contraceptives), were recruited. Male subjects were invited to undergo testing once, whereas females were invited three times across the menstrual cycle, based on self-reported early follicular (EF), late follicular (LF), or mid-luteal (ML) phase. On test days, electrical stimulation on the right ankle was performed; salivary cortisol levels were measured in the morning; levels of lipopolysaccharide-binding protein (LBP), soluble CD14 (sCD14), pro-inflammatory cytokines were assessed in plasma, and microbiota composition and short-chain fatty acids (SCFAs) levels were determined in fecal samples. RESULTS: We observed that the pain tolerance threshold/pain sensation threshold (PTT/PST) ratio was significantly lesser in women than men, but not PST or PTT alone. Further, hormonal contraceptive use was associated with increased LBP levels (LF & ML phase), whilst sCD14 levels or inflammatory cytokines were not affected. Interestingly, in women, hormonal contraceptive use was associated with an increase in the relative abundance of Erysipelatoclostridium, and the relative abundances of certain bacterial genera correlated positively with pain sensation thresholds (Prevotella and Megasphera) during the LF phase and cortisol awakening response (Anaerofustis) during the ML phase. In comparison with men, women displayed overall stronger associations between i) SCFAs data, ii) cortisol data, iii) inflammatory cytokines and PTT and PST. DISCUSSION AND CONCLUSION: Our findings support the hypothesis that the gut microbiota may be one of the factors determining the physiological inter-sex differences in pain perception. Further research is needed to investigate the molecular mechanisms by which specific sex hormones and gut microbes modulate pain signaling pathways, but this study highlights the possibilities for innovative individual targeted therapies for pain management.

Characterization of Reflective Capacity of Anesthesiology Trainees in an Irish Tertiary Referral Teaching Hospital.

Background: Reflective practice is associated with improved accuracy of medical diagnosis and superior performance in complex situations. Systematic observation of trainees' reflective capacities constitutes a basis for an effective support of reflective practice within the training paradigm. We set out to examine the reflective capacity among anesthesiology trainees in a tertiary referral hospital. Methods: We invited 61 anesthesiology trainees in Cork University Hospitals, Ireland, to participate. Each trainee was invited to respond to 2 investigator-written vignettes prepared by the investigators and suitable for evaluation using the Reflection Evaluation for Learners' Enhanced Competencies Tool (REFLECT) and to produce and then respond to a written vignette based on their own experience. All responses were assessed by 2 independent assessors who had undergone training in the application of the REFLECT rubric, which gives quantifiable scores. Interrater reliability was assessed by weighted kappa coefficient. Association between years of training in medicine and level of reflective capacity was examined using correlation and multiple regression analyses, controlling for age. Results: Twenty-nine trainees agreed to participate, the overall REFLECT Level was 2.16 (SD 0.7), corresponding to "thoughtful action," indicating low to moderate reflective ability. Cronbach's alpha for the 5 items of the REFLECT scale was excellent (r = 0.92). Weighted kappa was very satisfactory (k = 0.81). A strong association was demonstrated between years in medicine and scores on REFLECT, controlling for age of participant (F = -2.57, Beta coefficient = -0.30). Respondents with less experience had greater mean REFLECT scores than respondents with more experience (F = 5.5, P = .02; post hoc mean difference = 0.7, P = .03 for ≤32 months vs ≥99 months). There was a significant effect for gender (t = -4.3, P = .001), with women's responses receiving greater REFLECT scores than men's responses (mean difference = 0.67, P = .001). Conclusions: Overall, participants demonstrated low to moderate reflective capacity, as assessed by the REFLECT rubric. Reflective capacity of the anesthesiology trainees appears to decrease as years of medical training progress. However, our respondents were not sampled over time to fully support this conclusion. Further research is needed on the psychometric properties of the REFLECT rubric and the generalizability of our findings.

The potential for artificial intelligence to predict clinical outcomes in patients who have acquired acute kidney injury during the perioperative period.

Acute kidney injury (AKI) is a common medical problem in hospitalised patients worldwide that may result in negative physiological, social and economic consequences. Amongst patients admitted to ICU with AKI, over 40% have had either elective or emergency surgery prior to admission. Predicting outcomes after AKI is difficult and the decision on whom to initiate RRT with a goal of renal recovery or predict a long-term survival benefit still poses a challenge for acute care physicians. With the increasing use of electronic healthcare records, artificial intelligence may allow postoperative AKI prognostication and aid clinical management. Patients will benefit if the data can be readily accessed andregulatory, ethical and human factors challenges can be overcome.

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

Gut 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.

Postoperative pain and the gut microbiome.

In excess of 300 million surgical procedures are undertaken worldwide each year. Despite recognition of the prevalence of postoperative pain, and improvements in pain management techniques, poorly controlled postoperative pain remains a major unresolved challenge globally. An estimated 71% and 51% of patients experience moderate to severe pain after surgery in in-patient and outpatient settings, respectively. Inadequately controlled pain after surgery is associated with significant perioperative morbidity including myocardial infarction and pulmonary complications. As many as 20-56% of patients develop chronic pain after commonly performed procedures such as hernia repair, hysterectomy, and thoracotomy. Traditional analgesics and interventions are often ineffective or partially effective in the treatment of postoperative pain, resulting in a chronic pain condition with related socio-economic impacts and reduced quality of life for the patient. Such chronic pain which occurs after surgery is referred to as Persistent Post-Surgical Pain (PPSP). The complex ecosystem that is the gastrointestinal microbiota (including bacteria, fungi, viruses, phage) plays essential roles in the maintenance of the healthy state of the host. A disruption to the balance of this microbiome has been implicated not only in gastrointestinal disease but also neurological disorders including chronic pain. The influence of the gut microbiome is well documented in the context of visceral pain from the gastrointestinal tract while a greater understanding is emerging of the impact on inflammatory pain and neuropathic pain (both of which can occur during the perioperative period). The gut microbiome is an essential source for driving immune maturation and maintaining appropriate immune response. Given that inflammatory processes have been implicated in postoperative pain, aberrant microbiome profiles may play a role in the development of this type of pain. Furthermore, the microorganisms in our gut produce metabolites, neurotransmitters, and neuromodulators which interact with their receptors to regulate peripheral and central sensitisation associated with chronic pain. Microbiota-derived mediators can also regulate neuroinflammation, which is associated with activation of microglia as well as infiltration by immune cells, known to modulate the development and maintenance of central sensitisation. Moreover, risk factors for developing postoperative pain include anxiety, depression, and increased stress response. These central nervous system-related disorders have been associated with an altered gut microbiome and microbiome targeted intervention studies indicate improvements. Females are more likely to suffer from postoperative pain. As gonadal hormones are associated with a differential microbiome and pre-clinical studies show that male microbiome confers protection from inflammatory pain, it is possible that the composition of the microbiome and its by-products contribute to the increased risk for the development of postoperative pain. Very little evidence exists relating the microbiome to somatic pain. Here we discuss the potential role of the gut microbiome in the aetiology and pathophysiology of postoperative pain in the context of other somatic pain syndromes and what is known about microbe-neuron interactions. Investigations are needed to determine the specific role of the gut microbiome in this type of pain which may help inform the development of preventative interventions as well as management strategies to improve patient outcome.

A sono-anatomical and cadaveric study of ultrasound-guided retrolaminar block.

AIM: Retrolaminar block (RB) is known to confer chest wall analgesia but, its mechanism has not been established. Our primary objective was to determine if the spread of injectate following RB extends to the paravertebral space (PVS). Second-ary objectives were to determine the predefined anatomical areas and nervous tissues contacted by injectate; the effect of volume on spread; and the extent to which experts can predict PVS spread based on examination of US videos of the injection. MATERIAL AND METHODS: US-guided RB was performed on cadavers using a single injection technique of 10, 20 or 30 ml dye. Anatomical dissection was performed to identify the extent of spread of injectate to the retrolaminar, intercostal and PVS. Ultrasound recordings of the injection were independently evaluated by experts in US-guided regional anaesthesia. RESULTS: Spread of injectate to the ipsilateral PVS was identified in 6/10 dissected regions (0/1, 1/3 and 5/6 when injectate volumes of 10, 20 and 30ml were administered respectively). The extent of cephalad-caudad spread within the PVS varied from 1 to 3 levels. Expert interpretation of ultrasound images regarding spread to the PVS demonstrated poor correlation with dye staining observed on dissection. CONCLUSIONS: Injectate spread following RB demonstrated substantial variability. Inconsistent spread to the ipsilateral PVS may account for clinically occurring incomplete blocks. The likelihood of spread to the ipsilateral PVS was greater when a larger volume was injected. Expert evaluation of the dynamic ultrasound images obtained at injection can-not reliably predict spread to the PVS.

Distinguishing cerebral salt wasting syndrome and syndrome of inappropriate ADH in a patient with traumatic brain injury.

A previously healthy 48-year-old woman was referred to our intensive care unit (ICU) from a neurosurgical ward due to deterioration of her conscious level. She had a road traffic accident 6 days earlier. On admission to the hospital, a brain CT demonstrated subarachnoid haemorrhage which was considered not amenable to surgical intervention. A second CT brain performed shortly after admission to ICU showed no change in comparison to the initial CT. Serum sodium level on ICU admission was 108 mEq/L; serum and urine osmolalities were 223 mOsm/kg and 438 mOsm/kg, respectively. Her hyponatraemia was initially attributed to syndrome of inappropriate antidiuretic hormone. However, a clinical impression of low volume status raised the suspicion of cerebral salt wasting syndrome. She was managed by infusion of hypertonic saline and fluids for 5 days and discharged from ICU after improvement of her conscious level and normalisation of serum sodium.

Anaesthetic management of a patient with eosinophilic granulomatosis with polyangiitis for internal fixation of a fractured femur.

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare disease with an estimated annual incidence of 0.5-6.8 per million. It is characterised by necrotising vasculitis with multiorgan eosinophilic infiltration. Pulmonary manifestations are the most common presentation of EGPA, and cardiac complications are the most common cause of death. Anaesthetic management of EGPA is challenging due to perioperative pulmonary complications, multiorgan involvement and greater risk of cholinesterase enzyme deficiency. We are reporting the anaesthetic management of a 58-year-old woman, diagnosed with EGPA 3 years ago, who underwent urgent intramedullary nail insertion for a femur fracture. The anaesthetic technique comprised femoral nerve block and spinal anaesthesia, thereby avoiding (1) the need for upper airway manipulation, (2) potential adverse effects of anticholinesterase drugs (for reversal of neuromuscular blockade) and (3) histamine release associated with morphine administration perioperatively. Surgery and anaesthesia were uneventful.

European Section/Board of Anaesthesiology/European Society of Anaesthesiology consensus statement on competency-based education and training in anaesthesiology.

: The change from time-based to competency-based medical education has been driven by society's requirement for greater accountability of medical practitioners and those who train them. The European Society of Anaesthesiology and European Section/Board of Anaesthesiology (Anaesthesiology Section of the European Union Medical Specialists) endorse the general principles of competency-based medical education and training (CBMET) outlined by the international competency-based medical education collaborators. A CBMET curriculum is built on unambiguously defined learning objectives, each of which offers a measurable outcome, amenable to assessment using valid and reliable tools. The European training requirements laid out by the European Board of Anaesthesiology define four 'Generic Competences', namely expert clinician, professional leader, academic scholar and inspired humanitarian. A CBMET programme should clearly document core competencies, defined end-points, proficiency standards, practical descriptions of teaching and assessment practices and an assessment plan. The assessment plan should balance the need to provide regular, multidimensional formative feedback to the trainee with the need to inform high stakes decisions. A trainee who has not achieved a proficiency standard should be provided with an individualised training plan to address specific competencies or deficits. Programme formats will inevitably differ given the constraints of scale and resource that apply in different settings. The resources necessary to develop and maintain a CBMET programme in anaesthesiology include human capital, access to clinical learning opportunities, information technology and physical infrastructure dedicated to training and education. Simulation facilities and faculty development require specific attention. Reflective practice is an important programme element that supports wellbeing, resilience and achievement of professional goals. CBMET programmes should enable establishment of a culture of lifelong learning for the anaesthesiology community.

Pulmonary embolism occurring early after major trauma.

Pulmonary embolism (PE) secondary to trauma is the third most common cause of death in trauma patients who have survived 24 hours following injury. We describe a case of PE diagnosed within 3 hours of a major trauma in a previously well adolescent female. The early occurrence of PE in this case is at odds with what is generally reported (3-5 days) after major trauma. General consensus is that patients who suffer major trauma move from an initial hypocoaguable state, with increased risk of bleeding, to normocoagulable or hypercoaguable state, with a subsequent increased risk of venothromboembolism. However, Sumislawski et al recently demonstrated that a marginally greater proportion of trauma patients were in fact hypercoaguable rather than hypocoaguable on arrival to hospital and that trauma-induced coagulopathy tended to resolve within 24 hours; such data cause us to re-evaluate when to commence thromboprophylaxis for major trauma patients.