Simulation-Based Training in Flexible Bronchoscopy and Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA): A Systematic Review.

BACKGROUND: The use of simulators in a training programme for technically challenging procedures has the advantages of lowering the risk of patient complications while helping the trainees with the initial part of their learning curve. OBJECTIVES: The aim of this study was to perform a systematic review of simulation-based training in flexible bronchoscopy and endobronchial ultrasound (EBUS). METHODS: We identified 1,006 publications in the PubMed database and included publications on flexible bronchoscopy below the carina and EBUS involving hands-on simulation-based training. Publications were excluded if they were written in languages other than English, if paediatric airways were involved or if they were not journal articles. The screening process was performed by 2 individuals, and a third reviewer made the final decision in case of disagreement. RESULTS: We included 30 publications. The studies included participants of varying experience and most commonly used a virtual reality simulator as a training modality. Assessment of the participants' skills was based on simulator metrics or on an assessment tool. Some studies included performance on patients for assessment of the operator after training on a simulator. CONCLUSIONS: Simulation-based training was demonstrated to be more efficient than the traditional apprenticeship model. Physical models and virtual reality simulators complement each other. Simulation-based education should be based on a mastery learning approach and structured as directed self-regulated learning in a distributed training programme.

Cost-Effectiveness of Mobile App-Guided Training in Extended Focused Assessment with Sonography for Trauma (eFAST): A Randomized Trial.

PURPOSE: Ultrasound training is associated with a long learning curve and use of substantial faculty resources. Self-directed ultrasound training may decrease the need for faculty-led teaching. Mobile apps seem promising for use in self-directed ultrasound training, but no studies have examined the cost-effectiveness of mobile app-guided training versus traditional formats such as textbook-guided training. This study evaluated the cost-effectiveness of mobile app-guided versus textbook-guided ultrasound training. MATERIAL AND METHODS: First-year residents (n = 38) with no previous ultrasound experience were randomized into mobile app-guided versus textbook-guided self-directed ultrasound training groups. Participants completed a transfer test involving four patient cases and a theoretical test on diagnostic accuracy. Two ultrasound experts assessed the residents' performance using the Objective Structured Assessment of Ultrasound Skills (OSAUS) scale. The costs of developing mobile app and textbook material were calculated and used for the analysis of cost-effectiveness. RESULTS: 34 participants completed the transfer test. There was no statistically significant difference in test performance or diagnostic accuracy between the mobile app-guided (mean-OSAUS 42.3 % [95 %CI38.5 - 46.0 %]) and textbook-guided groups (mean-OSAUS 45.3 % [95 %CI39.3 - 51.3 %]) (d.f. [1.33] = 0.45, p = 0.41). However, development costs differed greatly for each instructional format. Textbook-guided training was significantly more cost-effective than mobile app-guided training (Incremental Cost Effectiveness Ratio -861 967 [95 %CI-1071.7 to-3.2] USD/pct. point change in OSAUS score). CONCLUSION: Mobile app-guided ultrasound training is less cost-effective than textbook-guided self-directed training. This study underlines the need for careful evaluation of cost-effectiveness when introducing technological innovations for clinical skills training.

High-pressure NIV for acute hypercapnic respiratory failure in COPD: improved survival in a retrospective cohort study.

INTRODUCTION: Updated treatment guidelines for acute hypercapnic respiratory failure (AHRF) in chronic obstructive pulmonary disease (COPD) with non-invasive ventilation (NIV) in 2016 recommended a rapid increase in inspiratory positive airway pressure (IPAP) to 20 cm H2O with possible further increase for patients not responding. Previous guidelines from 2006 suggested a more conservative algorithm and maximum IPAP of 20 cm H2O. AIM: To determine whether updated guidelines recommending higher IPAP during NIV were related with improved outcome in patients with COPD admitted with AHRF, compared with NIV with lower IPAP. METHODS: A retrospective cohort study comparing patients with COPD admitted with AHRF requiring NIV in 2012-2013 and 2017-2018. RESULTS: 101 patients were included in the 2012-2013 cohort with low IPAP regime and 80 patients in the 2017-2018 cohort with high IPAP regime. Baseline characteristics, including age, forced expiratory volume in 1 s (FEV1), pH and PaCO2 at initiation of NIV, were comparable. Median IPAP in the 2012-2013 cohort was 12 cm H2O (IQR 10-14) and 20 cm H2O (IQR 18-24) in the 2017-2018 cohort (p<0.001). In-hospital mortality was 40.5% in the 2012-2013 cohort and 13.8% in the 2017-2018 cohort (p<0.001). The 30-days and 1-year mortality were significantly lower in the 2017-2018 cohort. With a Cox model 1 year survival analysis, adjusted for age, sex, FEV1 and pH at NIV initiation, the HR was 0.45 (95% CI 0.27 to 0.74, p=0.002). CONCLUSION: Short-term and long-term survival rates were substantially higher in the cohort treated with higher IPAP. Our data support the current strategy of rapid increase and higher pressure.

A prospective study of the effect of video games on robotic surgery skills using the high-fidelity virtual reality RobotiX simulator.

BACKGROUND: Robot-assisted surgery is a growing field. Prior video game experience might give advantage to novice robotic surgeons. AIM: Assessing if prior video gaming experience gives advantage in performing high-fidelity virtual reality (VR)-simulated robotic surgery. METHODS: In this observational study, 30 medical students and 2 interns (17 females; 15 males) with median age 25 years (range, 24-26 years) were recruited and subsequently divided into groups according to prior gaming experience; gamers (≥6 video game hours/week) vs nongamers (<6 video game hours/week). Participants performed VR-simulated urethrovesical anastomosis on RobotiX Mentor, which measured performance parameters. Participants answered a questionnaire for demographics and gaming experience. Groups were compared using Mann-Whitney U and multiple regression. RESULTS: Gamers significantly outperformed nongamers in 3 of 24 performance metrics (p<0.05), and there was a trend toward better results for 7 of the 21 remaining metrics. Males outperformed females in 5 of 24 metrics (p<0.05) but were overrepresented among gamers. CONCLUSION: Prior video game experience >6 hrs/week might give advantage in simulated robotic surgery. We recommend future studies testing this hypothesis to develop simulator programs for certification of robotic surgeons.

[Acute neuropathy and liver injury following the abuse of nitrous oxide].

This is a case report about two young men with extensive recreational use of nitrous oxide (N2O) in bulbs. Vitamin B12 deficiency was found in the first patient as well as signs of myelopathy on magnetic resonance imaging, and the second patient had acute liver injury. Physical examinations showed severe pathology with loss of motor function and affected sensory function in both patients. Recreational use of N2O is increasing in Denmark, but the extent of N2O abuse is not known. Attention to these effects of N2O abuse may be important when treating patients with acute N2O-intoxication.

[Christmas article. When the hearth leads the way].

Situs inversus is a medical condition with transposition of the organs in chest and abdomen. The condition may cause misdiagnosis due to inverted location of the origin of acute abdominal pain in cases of e.g. acute appendicitis. In this case report, the condition was first found on a CT scan for urolithiasis. It was also visible on a previously performed X-ray of the patient's chest, where both the apex of the patient's heart and the apex of a jewelry heart were located to the patient's right side. If this is not a unique incident, we propose this finding to be named "goldsmith's sign".

Simulation in bronchoscopy: current and future perspectives.

OBJECTIVE: To provide an overview of current literature that informs how to approach simulation practice of bronchoscopy and discuss how findings from other simulation research can help inform the use of simulation in bronchoscopy training. SUMMARY: We conducted a literature search on simulation training of bronchoscopy and divided relevant studies in three categories: 1) structuring simulation training in bronchoscopy, 2) assessment of competence in bronchoscopy training, and 3) development of cheap alternatives for bronchoscopy simulation. CONCLUSION: Bronchoscopy simulation is effective, and the training should be structured as distributed practice with mastery learning criteria (ie, training until a certain level of competence is achieved). Dyad practice (training in pairs) is possible and may increase utility of available simulators. Trainee performance should be assessed with assessment tools with established validity. Three-dimensional printing is a promising new technology opening possibilities for developing cheap simulators with innovative features.