Cognitive aids used in simulated resuscitation: A systematic review.

Objectives: To compare the effectiveness of cognitive aid use during resuscitation with no use of cognitive aids on cardiopulmonary resuscitation quality and performance. Methods: This systematic review followed the PICOST format. All randomised controlled trials and non-randomised studies evaluating cognitive aid use during (simulated) resuscitation were included in any setting. Unpublished studies were excluded. We did not include studies that reported cognitive aid use during training for resuscitation alone. Medline, Embase and Cochrane databases were searched from inception until July 2019 (updated August 2022, November 2023, and 23 April 2024). We did not search trial registries. Title and abstract screening, full-text screening, data extraction, risk of bias assessment (using RoB2 and ROBINS-I), and certainty of evidence (using GRADE) were performed by two researchers. PRISMA reporting standards were followed, and registration (PROSPERO CRD42020159162, version 19 July 2022) was performed. No funding has been obtained. Results: The literature search identified 5029 citations. After removing 512 duplicates, reviewing the titles and abstracts of the remaining articles yielded 103 articles for full-text review. Hand-searching identified 3 more studies for full-text review. Of these, 29 studies were included in the final analysis. No clinical studies involving patients were identified. The review was limited to indirect evidence from simulation studies only. The results are presented in five different populations: healthcare professionals managing simulated resuscitations in neonates, children, adult advanced life support, and other emergencies; as well as lay providers managing resuscitations. Main outcomes were adherence to protocol or process, adherence to protocol or process assessed by performance score, CPR performance and retention, and feasibility of chatbot guidance. The risk of bias assessment ranged from low to high. Studies in neonatal, paediatric and adult life support delivered by healthcare professionals showed benefits of using cognitive aids, however, some studies evaluating resuscitations by lay providers reported undesirable effects. The performance of a meta-analysis was not possible due to significant methodological heterogeneity. The certainty of evidence was rated as moderate to very low due to serious indirectness, (very) serious risk of bias, serious inconsistency and (very) serious imprecision. Conclusion: Because of the very low certainty evidence from simulation studies, we suggest that cognitive aids should be used by healthcare professionals during resuscitation. In contrast, we do not suggest use of cognitive aids for lay providers, based on low certainty evidence.

Aerosol Box Use in Reducing Health Care Worker Contamination During Airway Procedures (AIRWAY) Study: Secondary Workload and Provider Outcomes in a Simulation-Based Trial.

OBJECTIVES: An aerosol box aims to reduce the risk of healthcare provider (HCP) exposure to infections during aerosol generating medical procedures (AGMPs), but little is known about its impact on workload of team members. We conducted a secondary analysis of data from a prospective, multicenter, randomized controlled trial evaluating the impact of aerosol box use on patterns of HCP contamination during AGMPs. The objectives of this study are to: 1) evaluate the effect of aerosol box use on HCP workload, 2) identify factors associated with HCP workload when using an aerosol box, and 3) describe the challenges perceived by HCPs of aerosol box use. DESIGN: Simulation-based randomized trial, conducted from May to December 2021. SETTING: Four pediatric simulation centers. SUBJECTS: Teams of two HCPs were randomly assigned to control (no aerosol box) or intervention groups (aerosol box). INTERVENTIONS: Each team performed three scenarios requiring different pediatric airway management (bag-valve-mask [BVM] ventilation, laryngeal mask airway [LMA] insertion, and endotracheal intubation [ETI] with video laryngoscopy) on a simulated COVID-19 patient. National Aeronautics and Space Administration-Task Load Index (NASA-TLX) is a standard tool that measures subjective workload with six subscales. MEASUREMENTS AND MAIN RESULTS: A total of 64 teams (128 participants) were recruited. The use of aerosol box was associated with significantly higher frustration during LMA insertion (28.71 vs. 17.42; mean difference, 11.29; 95% CI, 0.92-21.66; p = 0.033). For ETI, there was a significant increase in most subscales in the intervention group, but there was no significant difference for BMV. Average NASA-TLX scores were all in the "low" range for both groups (range: control BVM 23.06, sd 13.91 to intervention ETI 38.15; sd 20.45). The effect of provider role on workloads was statistically significant only for physical demand (p = 0.001). As the complexity of procedure increased (BVM → LMA → ETI), the workload increased in all six subscales (p < 0.05). CONCLUSIONS: The use of aerosol box increased workload during ETI but not with BVM and LMA insertion. Overall workload scores remained in the "low" range, and there was no significant difference between airway provider and assistant.

Use of augmented and virtual reality in resuscitation training: A systematic review.

Objectives: To evaluate the effectiveness of augmented reality (AR) and virtual reality (VR), compared with other instructional methods, for basic and advanced life support training. Methods: This systematic review was part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR) and reported based on the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines and registered with PROSPERO (CRD42023376751). MEDLINE, EMBASE, and SCOPUS were searched from inception to January 16, 2024. We included all published studies comparing virtual or augmented reality to other methods of resuscitation training evaluating knowledge acquisition and retention, skills acquisition and retention, skill performance in real resuscitation, willingness to help, bystander CPR rate, and patients' survival. Results: Our initial literature search identified 1807 citations. After removing duplicates, reviewing the titles and abstracts of the remaining 1301 articles, full text review of 74 articles and searching references lists of relevant articles, 19 studies were identified for analysis. AR was used in 4 studies to provide real-time feedback during CPR, demonstrating improved CPR performance compared to groups trained with no feedback, but no difference when compared to other sources of CPR feedback. VR use in resuscitation training was explored in 15 studies, with the majority of studies that assessed CPR skills favoring other interventions over VR, or showing no difference between groups. Conclusion: Augmented and virtual reality can be used to support resuscitation training of lay people and healthcare professionals, however current evidence does not clearly demonstrate a consistent benefit when compared to other methods of training.

Mitochondria-associated endoplasmic reticulum membrane as a mediator of vanadium-induced endoplasmic reticulum quality control in duck brains.

Vanadium (V) plays a crucial role in normal cells, but excess V causes multi-organ toxicity, including neurotoxicity. Mitochondria-associated endoplasmic reticulum membrane (MAM) is a dynamic structure between endoplasmic reticulum (ER) and mitochondria that mediates ER quality control (ERQC). To explore the effects of excess V on MAM and ERQC in the brain, 72 ducks were randomly divided into two groups: the control group (basal diet) and the V group (30 mg V/kg basal diet). On days 22 and 44, brain tissues were collected for histomorphological observation and determination of trace element contents. In addition, the mRNA and protein levels of MAM and ERQC-related factors in the brain were analyzed. Results show that excessive V causes the imbalance of trace elements, the integrity disruption of MAM, rupture of ER and autophagosomes formation. Moreover, it inhibits IP3R and VDAC1 co-localization, down-regulates the expression levels of MAM-related factors, but up-regulates the expression levels of ERQC and autophagy related factors. Together, results indicate that V exposure causes disruption of MAM and activates ERQC, which is further causing autophagy.

The effect of scripted debriefing in resuscitation training: A scoping review.

Objectives: To evaluate the effectiveness of scripted debriefing relative to no use of script during debriefing in resuscitation training. Methods: This scoping review was undertaken as part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR) and based on the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) extension for scoping review. MEDLINE, EMBASE, and SCOPUS were searched from inception to January 2024. We included all published studies comparing scripted debriefing vs non-scripted debriefing evaluating patient outcomes, behaviour change of learners, learning outcomes for learners and cognitive load and teaching quality for instructors. Results: Our initial literature search identified 1238 citations. After removing 552 duplicates, reviewing the titles and abstracts of the remaining 686 articles yielded 11 for full-text review. Of these, six articles were selected for inclusion in the final analysis. The six studies described debriefing scripts varying in content, framework, scripted language and the integration of objective data. Scripted debriefing improved CPR performance, team leadership skills and knowledge acquisition, but showed no difference in teamwork performance compared to non-scripted debriefing. Scripted debriefing also improved debriefing quality and decreased cognitive load of the instructor during resuscitation training. Conclusion: The use of a debriefing script during resuscitation education can improve CPR performance, team leader performance, knowledge acquisition and reduce the debriefer's cognitive load. Future research should explore how debriefing scripts can be designed to optimize learning outcomes.

Herbal medicine for Hashimoto's thyroiditis: A systematic review and network meta-analysis.

ETHNOPHARMACOLOGICAL RELEVANCE: Conventional treatments for Hashimoto's thyroiditis (HT) are limited. Herbal medicines (HM) are considered a potential intervention for the treatment of HT. AIM OF THE STUDY: This study aimed to investigate the efficacy and safety of HM for HT. MATERIALS AND METHODS: A Bayesian network meta-analysis was conducted for patients with HT in randomized controlled trials identified in PubMed, Cochrane Library, Web of Science, EMBASE, Chinese Clinical Trial Registry (Chi CTR), China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (the VIP), China Chinese Biomedical Database (CBM), and Wanfang Database were searched from their inception to Oct 1, 2022. Outcomes included the primary outcome (TPOAb), secondary outcomes (TSH, TGAb, FT3, FT4, and traditional Chinese medicine symptom scores), and adverse events. This study was registered in PROSPERO (CRD42022363640). RESULTS: Sixteen trials were reviewed and 16 HM formulae were compared. Compared with non-drug therapy (NDT), all therapies, except for Tiaoqi-Qingjie Therapy, reduced the primary outcome of TPOAb with different levels of effectiveness, ranging from 0.01 (95%CI 0.00, 0.02) to 0.92 (95%CI 0.56, 1.53). Ranking probability analysis indicated that Yiqi Huayu Recipe, Liqi Xiaoying decoction, and Shugan Sanjie therapy reduced thyroid antibody levels the most, including TPOAb (100.0%, 90.9%, and 90.3%, respectively) and TGAb (98.3%, 94.4%, and 87.3%, respectively). All HMs displayed a significant effect on the TCM Symptom score and possibly benefitted the treatment of HT, ranging from 6.62 (95% CI 2.06, 21.24) to 94.50 (95% CI 15.97, 559.14). No serious adverse events were reported. CONCLUSIONS: Herbal medicines may be effective in the treatment of HT, especially in reducing thyroid antibody levels and improving clinical symptoms without affecting thyroid function. However, these results should be considered preliminary and further verified using high-quality evidence.

Exploiting Hierarchical Interactions for Protein Surface Learning.

Predicting interactions between proteins is one of the most important yet challenging problems in structural bioinformatics. Intrinsically, potential function sites in protein surfaces are determined by both geometric and chemical features. However, existing works only consider handcrafted or individually learned chemical features from the atom type and extract geometric features independently. Here, we identify two key properties of effective protein surface learning: 1) relationship among atoms: atoms are linked with each other by covalent bonds to form biomolecules instead of appearing alone, leading to the significance of modeling the relationship among atoms in chemical feature learning. 2) hierarchical feature interaction: the neighboring residue effect validates the significance of hierarchical feature interaction among atoms and between surface points and atoms (or residues). In this paper, we present a principled framework based on deep learning techniques, namely Hierarchical Chemical and Geometric Feature Interaction Network (HCGNet), for protein surface analysis by bridging chemical and geometric features with hierarchical interactions. Extensive experiments demonstrate that our method outperforms the prior state-of-the-art method by 2.3% in site prediction task and 3.2 available at https://github.com/lyqun/HCGNet.

Society for Simulation in Healthcare Guidelines for Simulation Training.

BACKGROUND: Simulation has become a staple in the training of healthcare professionals with accumulating evidence on its effectiveness. However, guidelines for optimal methods of simulation training do not currently exist. METHODS: Systematic reviews of the literature on 16 identified key questions were conducted and expert panel consensus recommendations determined using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. OBJECTIVE: These evidence-based guidelines from the Society for Simulation in Healthcare intend to support healthcare professionals in decisions on the most effective methods for simulation training in healthcare. RESULTS: Twenty recommendations on 16 questions were determined using GRADE. Four expert recommendations were also provided. CONCLUSIONS: The first evidence-based guidelines for simulation training are provided to guide instructors and learners on the most effective use of simulation in healthcare.

Educational and Patient Care Impacts of In Situ Simulation in Healthcare: A Systematic Review.

ABSTRACT: This systematic review was performed to assess the effectiveness of in situ simulation education. We searched databases including MEDLINE and Embase for studies comparing in situ simulation with other educational approaches. Two reviewers screened articles and extracted information. Sixty-two articles met inclusion criteria, of which 24 were synthesized quantitatively using random effects meta-analysis. When compared with current educational practices alone, the addition of in situ simulation to these practices was associated with small improvements in clinical outcomes, including mortality [odds ratio, 0.66; 95% confidence interval (CI), 0.55 to 0.78], care metrics (standardized mean difference, -0.34; 95% CI, -0.45 to -0.21), and nontechnical skills (standardized mean difference, -0.52; 95% CI, -0.99 to -0.05). Comparisons between in situ and traditional simulation showed mixed learner preference and knowledge improvement between groups, while technical skills showed improvement attributable to in situ simulation. In summary, available evidence suggests that adding in situ simulation to current educational practices may improve patient mortality and morbidity.

Completeness and accuracy of digital charting vs paper charting in simulated pediatric cardiac arrest: a randomized controlled trial.

OBJECTIVES: To determine if data collected through digital charting are more complete and more accurate compared to traditional paper-based charting during simulated pediatric cardiac arrest. METHODS: We performed a single-center simulation-based randomized controlled trial. Participants were randomized to a novel handheld digital charting device (intervention group) or to the standard resuscitation paper chart (control group). Participants documented two 15-min simulated pediatric cardiac arrest scenarios. We compared the charting completeness between the two groups. Completeness score (primary outcome) was established by calculating a completeness score for each group based on a list of pre-determined critical tasks. Charting accuracy (secondary outcome) was compared between the two groups, defined as the time interval between the real-time task performance and charted time. RESULTS: Charting data from 34 simulated cardiac arrest events were included in the analysis (n = 18 intervention; n = 16 control). The paper charting group had a higher completeness score (median (IQR) paper vs digital: 72.0% (66.4-76.9%) vs 65.0% (58.5-66.4%), p = 0.015). For accuracy, the digital charting group was superior to the paper charting group for all pre-established critical tasks. CONCLUSION: Compared to paper-based charting, digital charting group captured more critical tasks during pediatric simulated resuscitation and was more accurate in the time intervals between real-time tasks performance and charted time. For tasks charted, paper-based charting was significantly more complete and more detailed during simulated pediatric cardiac arrest.

RéSUMé: OBJECTIFS: Déterminer si les données recueillies au moyen de la cartographie numérique sont plus complètes et plus précises que celles recueillies sur papier lors d'un arrêt cardiaque pédiatrique simulé. MéTHODES: Nous avons réalisé un essai contrôlé randomisé basé sur une simulation à centre unique. Les participants ont été affectés par randomisation à un nouvel appareil de cartographie numérique portatif (groupe d'intervention) ou au tableau papier standard de réanimation (groupe témoin). Les participants ont documenté deux scénarios simulés d'arrêt cardiaque pédiatrique de 15 min. Nous avons comparé l'exhaustivité des dossiers entre les deux groupes. Le score d'exhaustivité (résultat principal) a été établi en calculant un score d'exhaustivité pour chaque groupe en fonction d'une liste de tâches critiques prédéterminées. La précision des graphiques (résultat secondaire) a été comparée entre les deux groupes, définie comme l'intervalle de temps entre la performance de la tâche en temps réel et le temps représenté sur la carte. RéSULTATS: Les données cartographiques de 34 arrêts cardiaques simulés ont été incluses dans l'analyse (n = 18 interventions; n = 16 contrôles). Le groupe de la cartographie papier avait un score d'exhaustivité plus élevé (papier médian (IQR) que numérique: 72,0% (66,4­76,9%) contre 65,0% (58,5­66,4%), p = 0,015). Pour des raisons de précision, le groupe de cartographie numérique était supérieur au groupe de cartographie papier pour toutes les tâches critiques préétablies. CONCLUSION: Par rapport à la cartographie sur papier, le groupe de cartographie numérique a capturé des tâches plus critiques lors de la réanimation pédiatrique simulée et était plus précis dans les intervalles de temps entre les performances des tâches en temps réel et le temps cartographié. Pour les tâches cartographiées, les dossiers papier étaient significativement plus complets et plus détaillés lors de l'arrêt cardiaque pédiatrique simulé.

Clinical efficacy and molecular mechanism of Chinese medicine in the treatment of autoimmune thyroiditis.

ETHNOPHARMACOLOGICAL RELEVANCE: Autoimmune Thyroiditis (AIT) is a common refractory autoimmune disease of the endocrine system that may eventually lead to complete loss of thyroid function, with subsequent severe effects on the metabolism. Because of the deficiency in current clinical management of AIT, the need for alternative therapies is highlighted. With its multi-component and multi-target characteristics, Chinese medicine has good potential as an alternative therapy for AIT. AIM OF THE STUDY: The aim of this study was to systematically summarize the clinical efficacy and safety evaluation of TCM and its active ingredients in the treatment and regulation of AIT. Additionally, we provide an in-depth discussion of the relevant mechanisms and molecular targets to understand the protective effects of traditional Chinese medicine on AIT and explore new ideas for clinical treatment. MATERIALS AND METHODS: The literature related to "Hashimoto", "autoimmune thyroiditis", "traditional Chinese medicine," and "Chinese herbal medicine" was systematically summarized and reviewed from Web of Science Core Collection, PubMed, CNKI, and other databases. Domestic and international literature were analyzed, compared, and reviewed. RESULTS: An increasing number of studies have demonstrated that herbal medicines can intervene in immunomodulation, with pharmacological effects such as antibody lowering, anti-inflammatory, anti-apoptotic thyroid follicular cells, regulation of intestinal flora, and regulation of estrogen and progesterone levels. The signaling pathways and molecular targets of the immunomodulatory effects of Chinese herbal medicine for AIT may include Fas/FasL, Caspase, BCL-2, and TLRs/MyD88/NF-κB et al. CONCLUSIONS: The use of Chinese herbs in the treatment and management of AIT is clinically experienced, satisfactory, and safe. Future studies may evaluate the influence of herbal medicines on the occurrence and development of AIT by modulating the interaction between immune factors and conventional signaling pathways.

Data-informed debriefing for cardiopulmonary arrest: A randomized controlled trial.

Aim: To determine if data-informed debriefing, compared to a traditional debriefing, improves the process of care provided by healthcare teams during a simulated pediatric cardiac arrest. Methods: We conducted a prospective, randomized trial. Participants were randomized to a traditional debriefing or a data-informed debriefing supported by a debriefing tool. Participant teams managed a 10-minute cardiac arrest simulation case, followed by a debriefing (i.e. traditional or data-informed), and then a second cardiac arrest case. The primary outcome was the percentage of overall excellent CPR. The secondary outcomes were compliance with AHA guidelines for depth and rate, chest compression (CC) fraction, peri-shock pause duration, and time to critical interventions. Results: A total of 21 teams (84 participants) were enrolled, with data from 20 teams (80 participants) analyzed. The data-informed debriefing group was significantly better in percentage of overall excellent CPR (control vs intervention: 53.8% vs 78.7%; MD 24.9%, 95%CI: 5.4 to 44.4%, p = 0.02), guideline-compliant depth (control vs. intervention: 60.4% vs 85.8%, MD 25.4%, 95%CI: 5.5 to 45.3%, p = 0.02), CC fraction (control vs intervention: 88.6% vs 92.6, MD 4.0%, 95%CI: 0.5 to 7.4%, p = 0.03), and peri-shock pause duration (control vs intervention: 5.8 s vs 3.7 s, MD -2.1 s, 95%CI: -3.5 to -0.8 s, p = 0.004) compared to the control group. There was no significant difference in time to critical interventions between groups. Conclusion: When compared with traditional debriefing, data-informed debriefing improves CPR quality and reduces pauses in CPR during simulated cardiac arrest, with no improvement in time to critical interventions.

Who is the real team leader? Comparing leadership performance of the team leader and CPR Coach during simulated cardiac arrest.

Purpose: To describe the leadership performance of team leaders and CPR Coaches, and to determine if there is a correlation between leadership scores and CPR performance during management of simulated pediatric cardiac arrest events. Methods: This is a secondary analysis of data from a prior randomized controlled trial. We observed the performance of both team leaders and CPR coaches during the management of an 18-minute simulated cardiac arrest scenario which was run for 20 resuscitation teams comprised of CPR-certified professionals from four pediatric tertiary care centers. CPR Coaches were responsible for providing real-time verbal feedback of CPR performance to compressors. Two raters were trained to use the Behavioral Assessment Tool (BAT) to assess leadership performance of the team leader and CPR Coach. BAT scores of team leaders and CPR coaches were compared and linked with objective CPR performance. Results: There was no significant difference between the BAT scores of team leaders and CPR coaches (median score 27/40 vs 28.8/40, p = 0.16). Higher BAT scores of team leaders were significantly associated with higher percentage of excellent CPR (r = 0.52, p = 0.02), while higher BAT scores of CPR coaches were significantly associated with higher chest compression fraction (r = 0.48, p = 0.03). Conclusions: Both team leaders and CPR coaches have similarly high leadership performance during the management of simulated cardiac arrest. Leadership behaviors were associated with quality of CPR performance.Clinical Trial Registration: Registration ID: NCT02539238; https://www.clinicaltrials.gov.

Probiotic Fermentation of Herbal Medicine: Progress, Challenges, and Opportunities.

Fermentation is a processing method used in traditional Chinese medicine (TCM). However, traditional fermentation methods suffer from poor production control. In contrast, probiotic fermented herbal medicine (PFHM) offers advantages such as the use of pure strains, a controllable process, and the ability to produce a variety of active enzymes during fermentation. As a result, PFHM has become a research hotspot. This review focuses on the progress, challenges, and opportunities in the research of PFHM. The use of probiotic enzymes during fermentation alters the active ingredients of TCM, resulting in positive pharmacological effects such as increased active ingredients, reduced toxicity, new pharmacological effects, and the reuse of herbal residues. PFHM has the potential to transfer the metabolic transformation of the effective components of TCM by intestinal flora outside the body during production and preparation, which has a broad application prospect. However, due to the complexity of the chemical composition of TCM, the mechanism of PFHM requires further investigation. Finally, we discuss the prospects of industrializing PFHM, which is essential for promoting the innovation and modernization of TCM.

Compete to Win: Enhancing Pseudo Labels for Barely-Supervised Medical Image Segmentation.

This study investigates barely-supervised medical image segmentation where only few labeled data, i.e., single-digit cases are available. We observe the key limitation of the existing state-of-the-art semi-supervised solution cross pseudo supervision is the unsatisfactory precision of foreground classes, leading to a degenerated result under barely-supervised learning. In this paper, we propose a novel Compete-to-Win method (ComWin) to enhance the pseudo label quality. In contrast to directly using one model's predictions as pseudo labels, our key idea is that high-quality pseudo labels should be generated by comparing multiple confidence maps produced by different networks to select the most confident one (a compete-to-win strategy). To further refine pseudo labels at near-boundary areas, an enhanced version of ComWin, namely, ComWin + , is proposed by integrating a boundary-aware enhancement module. Experiments show that our method can achieve the best performance on three public medical image datasets for cardiac structure segmentation, pancreas segmentation and colon tumor segmentation, respectively. The source code is now available at https://github.com/Huiimin5/comwin.

The Reliability of the Resuscitation Assessment Tool (RAT) in Assessing Emergency Medicine Resident Competence in Pediatric Resuscitation Scenarios: A Prospective Observational Pilot Study.

Introduction Emergency medicine (EM) postgraduate medical education in Canada has transitioned from traditional time-based training to competency-based medical education (CBME). In order to promote residents through stages of training, simulated assessments are needed to evaluate residents in high-stakes but low-frequency medical emergencies. There remains a gap in the literature pertaining to the use of evaluative tools in simulation, such as the Resuscitation Assessment Tool (RAT) in the new CBME curriculum design. Methods We completed a pilot study of resident physicians in one Canadian EM training program to evaluate the effectiveness and reliability of a simulation-based RAT for pediatric resuscitation. We recorded 10 EM trainees completing simulated scenarios and had nine EM physicians use the RAT tool to evaluate their performances. Generalizability theory was used to evaluate the reliability of the RAT tool. Results The mean RAT score for the management of pediatric myocarditis, cardiac arrest, and septic shock (appendicitis) across raters was 3.70, 3.73, and 4.50, respectively. The overall generalizability coefficient for testing simulated pediatric performance competency was 0.77 for internal consistency and 0.75 for absolute agreement. The performance of senior participants was superior to that of junior participants in the management of pediatric myocarditis (p = 0.01) but not statistically significant in the management of pediatric septic shock (p=0.77) or cardiac arrest (p =0.61). Conclusion Overall, our findings suggest that with an appropriately chosen simulated scenario, the RAT tool can be used effectively for the simulation of high-stakes and low-frequency scenarios for practice to enhance the new CBME curriculum in emergency medicine training programs.

Aerosol Box Use in Reducing Health Care Worker Contamination During Airway Procedures (AIRWAY Study): A Simulation-Based Randomized Clinical Trial.

Importance: The aerosol box has been used during the management of patients with COVID-19 to reduce health care practitioner (HCP) exposure during aerosol-generating medical procedures (AGMPs). Little is known about the effect of aerosol box use on HCP contamination and AGMP procedure time. Objective: To investigate whether use of an aerosol box during AGMPs reduces HCP contamination or influences the time to successful completion and first-pass success rate for endotracheal intubation (ETI) and laryngeal mask airway (LMA) insertion. Design, Setting, and Participants: This multicenter, simulation-based, randomized clinical trial was conducted from May to December 2021 at tertiary care pediatric hospitals. Participant teams performed 3 simulated patient scenarios: bag-valve-mask ventilation, ETI, and LMA insertion. During the scenarios, aerosols were generated using Glo Germ. Teams of 2 HCPs were randomly assigned to control (no aerosol box) or intervention groups (aerosol box). Statistical analysis was performed from July 2022 to February 2023. Interventions: The aerosol box (or SplashGuard CG) is a transparent, plastic barrier covering the patient's head and shoulders with access ports allowing HCPs to manage the airway. Main Outcomes and Measures: The primary outcome was surface area of contamination (AOC) on participants. Secondary outcomes were time to successful completion and first-pass success rates for ETI and LMA insertion. Results: A total of 64 teams (128 participants) were enrolled, with data from 61 teams (122 participants) analyzed. Among the 122 participants analyzed, 79 (64.8%) were female and 85 (69.7%) were physicians. Use of an aerosol box was associated with a 77.5% overall decreased AOC to the torso (95% CI, -86.3% to -62.9%; P < .001) and a 60.7% overall decreased AOC to the facial area (95% CI, -75.2% to -37.8%; P < .001) in airway HCPs. There was no statistically significant difference in surface contamination after doffing personal protective equipment between groups. Time to completing ETI was longer in the aerosol box group compared with the control group (mean difference: 10.2 seconds; 95% CI, 0.2 to 20.2 seconds; P = .04), but there was no difference between groups for LMA insertion (mean difference: 2.4 seconds; 95% CI, -8.7 to 13.5 seconds; P = .67). Conclusions and Relevance: In this randomized clinical trial of aerosol box use in AGMPs, use of an aerosol box reduced contamination deposition on HCPs' torso and face predoffing; the use of an aerosol box delayed time to successful intubation. These results suggest that the incremental benefits of reduced surface contamination from aerosol box use should be weighed against delayed time to complete intubation, which may negatively affect patient outcome. Trial Registration: ClinicalTrials.gov Identifier: NCT04880668.

Integrative radiomics and transcriptomics analyses reveal subtype characterization of non-small cell lung cancer.

OBJECTIVES: To assess whether integrative radiomics and transcriptomics analyses could provide novel insights for radiomic features' molecular annotation and effective risk stratification in non-small cell lung cancer (NSCLC). METHODS: A total of 627 NSCLC patients from three datasets were included. Radiomics features were extracted from segmented 3-dimensional tumour volumes and were z-score normalized for further analysis. In transcriptomics level, 186 pathways and 28 types of immune cells were assessed by using the Gene Set Variation Analysis (GSVA) algorithm. NSCLC patients were categorized into subgroups based on their radiomic features and pathways enrichment scores using consensus clustering. Subgroup-specific radiomics features were used to validate clustering performance and prognostic value. Kaplan-Meier survival analysis with the log-rank test and univariable and multivariable Cox analyses were conducted to explore survival differences among the subgroups. RESULTS: Three radiotranscriptomics subtypes (RTSs) were identified based on the radiomics and pathways enrichment profiles. The three RTSs were characterized as having specific molecular hallmarks: RTS1 (proliferation subtype), RTS2 (metabolism subtype), and RTS3 (immune activation subtype). RTS3 showed increased infiltration of most immune cells. The RTS stratification strategy was validated in a validation cohort and showed significant prognostic value. Survival analysis demonstrated that the RTS strategy could stratify NSCLC patients according to prognosis (p = 0.009), and the RTS strategy remained an independent prognostic indicator after adjusting for other clinical parameters. CONCLUSIONS: This radiotranscriptomics study provides a stratification strategy for NSCLC that could provide information for radiomics feature molecular annotation and prognostic prediction. KEY POINTS: • Radiotranscriptomics subtypes (RTSs) could be used to stratify molecularly heterogeneous patients. • RTSs showed relationships between molecular phenotypes and radiomics features. • The RTS algorithm could be used to identify patients with poor prognosis.

Molecular hallmarks of breast multiparametric magnetic resonance imaging during neoadjuvant chemotherapy.

PURPOSE: To identify molecular basis of four parameters obtained from dynamic contrast-enhanced magnetic resonance imaging, including functional tumor volume (FTV), longest diameter (LD), sphericity, and contralateral background parenchymal enhancement (BPE). MATERIAL AND METHODS: Pretreatment-available gene expression profiling and different treatment timepoints MRI features were integrated for Spearman correlation analysis. MRI feature-related genes were submitted to hypergeometric distribution-based gene functional enrichment analysis to identify related Kyoto Encyclopedia of Genes and Genomes annotation. Gene set variation analysis was utilized to assess the infiltration of distinct immune cells, which were used to determine relationships between immune phenotypes and medical imaging phenotypes. The clinical significance of MRI and relevant molecular features were analyzed to identify their prediction performance of neoadjuvant chemotherapy (NAC) and prognostic impact. RESULTS: Three hundred and eighty-three patients were included for integrative analysis of MRI features and molecular information. FTV, LD, and sphericity measurements were most positively significantly correlated with proliferation-, signal transmission-, and immune-related pathways, respectively. However, BPE did not show marked correlation relationships with gene expression alteration status. FTV, LD and sphericity all showed significant positively or negatively correlated with some immune-related processes and immune cell infiltration levels. Sphericity decreased at 3 cycles after treatment initiation was also markedly negatively related to baseline sphericity measurements and immune signatures. Its decreased status could act as a predictor for prediction of response to NAC. CONCLUSION: Different MRI features capture different tumor molecular characteristics that could explain their corresponding clinical significance.

Quantifying Simulated Contamination Deposition on Healthcare Providers Using Image Analysis.

INTRODUCTION: Simulation-based research has played an important role in improving care for communicable diseases. Unfortunately, few studies have attempted to quantify the level of contamination in these simulation activities. We aim to assess the feasibility and provide validity evidence for using integrated density values and area of contamination (AOC) to differentiate various levels of simulated contamination. METHODS: An increasing number of simulated contamination spots using fluorescent marker were applied on a manikin chest to simulate a contaminated healthcare provider. An ultraviolet light was used to illuminate the manikin to highlight the simulated contamination. Images of increasing contamination levels were captured using a camera with different exposure settings. Image processing software was used to measure 2 outcomes: (1) natural logarithm of integrated density; and (2) AOC. Mixed-effects linear regression models were used to assess the effect of contamination levels and exposure settings on both outcome measures. A standardized "proof-of-concept" exercise was set up to calibrate and formalize the process for human subjects. RESULTS: A total of 140 images were included in the analyses. Dose-response relationships were observed between contamination levels and both outcome measures. For each increment in the number of contaminated simulation spots (ie, simulated contaminated area increased by 38.5 mm 2 ), on average, log-integrated density increased by 0.009 (95% confidence interval, 0.006-0.012; P < 0.001) and measured AOC increased by 37.8 mm 2 (95% confidence interval, 36.7-38.8 mm 2 ; P < 0.001), which is very close to actual value (38.5 mm 2 ). The "proof-of-concept" demonstration further verified results. CONCLUSIONS: Integrated density and AOC measured by image processing can differentiate various levels of simulated, fluorescent contamination. The AOC measured highly agrees with the actual value. This method should be optimized and used in the future research to detect simulated contamination deposited on healthcare providers.