Objective Assessment of Cognitive Workload in Surgery: A Systematic Review.

OBJECTIVE: To systematically review technologies that objectively measure CWL in surgery, assessing their psychometric and methodological characteristics. SUMMARY BACKGROUND DATA: Surgical tasks involving concurrent clinical decision-making and the safe application of technical and non-technical skills require a substantial cognitive demand and resource utilization. Cognitive overload leads to impaired clinical decision-making and performance decline. Assessing cognitive workload (CWL) could enable interventions to alleviate burden and improve patient safety. METHODS: Ovid MEDLINE, OVID Embase, the Cochrane Library and IEEE Xplore databases were searched from inception to August 2023. Full-text, peer-reviewed original studies in a population of surgeons, anesthesiologists or interventional radiologists were considered, with no publication date constraints. Study population, task paradigm, stressor, Cognitive Load Theory (CLT) domain, objective and subjective parameters, statistical analysis and results were extracted. Studies were assessed for a) definition of CWL, b) details of the clinical task paradigm, and c) objective CWL assessment tool. Assessment tools were evaluated using psychometric and methodological characteristics. RESULTS: 10790 studies were identified; 9004 were screened; 269 full studies were assessed for eligibility, of which 67 met inclusion criteria. The most widely used assessment modalities were autonomic (32 eye studies and 24 cardiac). Intrinsic workload (e.g. task complexity) and germane workload (effect of training or expertize) were the most prevalent designs investigated. CWL was not defined in 30 of 67 studies (44.8%). Sensitivity was greatest for neurophysiological instruments (100% EEG, 80% fNIRS); and across modalities accuracy increased with multi-sensor recordings. Specificity was limited to cardiac and ocular metrics, and was found to be sub-optimal (50% and 66.67%). Cardiac sensors were the least intrusive, with 54.2% of studies conducted in naturalistic clinical environments (higher ecological validity). CONCLUSION: Physiological metrics provide an accessible, objective assessment of CWL, but dependence on autonomic function negates selectivity and diagnosticity. Neurophysiological measures demonstrate favorable sensitivity, directly measuring brain activation as a correlate of cognitive state. Lacking an objective gold standard at present, we recommend the concurrent use of multimodal objective sensors and subjective tools for cross-validation. A theoretical and technical framework for objective assessment of CWL is required to overcome the heterogeneity of methodological reporting, data processing, and analysis.

The Portuguese NHS 2024 reform: transformation through vertical integration.

Vertical integration models aim for the integration of services from different levels of care (e.g., primary, and secondary care) with the objective of increasing coordination and continuity of care as well as improving efficiency, quality, and access outcomes. This paper provides a view of the Portuguese National Health Service (NHS) healthcare providers' vertical integration, operationalized by the Portuguese NHS Executive Board during 2023 and 2024. This paper also aims to contribute to the discussion regarding the opportunities and constraints posed by public healthcare organizations vertical integration reforms. The Portuguese NHS operationalized the development and generalization of Local Health Units management model throughout the country. The same institutions are now responsible for both the primary care and the hospital care provided by public services in each geographic area, in an integrated manner. This 2024 reform also changed the NHS organic and organizational structures, opening paths to streamline the continuum of care. However, it will be important to ensure adequate monitoring and support, with the participation of healthcare services as well as community structures and other stakeholders, to promote an effective integration of care.

Impact of the cost-of-living crisis on patient preferences towards virtual consultations.

INTRODUCTION: Since 2021, the world has been facing a cost-of-living crisis which has negatively affected population health. Meanwhile, little is known about its impact on patients' preferences to access care. We aimed to analyse public preference for the modality of consultation (virtual vs face-to-face) before and after the onset of crisis and factors associated with these preferences. METHODS: An online cross-sectional survey was administered to the public in the United Kingdom, Germany, Italy and Sweden. McNemar tests were conducted to analyse pre- and post-crisis differences in preferences; logistic regression was used to examine the demographic factors associated with public preferences. RESULTS: Since the onset of crisis, the number of people choosing virtual consultations has increased in the United Kingdom (7.0% vs 9.5% P < 0.001), Germany (6.6% vs 8.6%, P < 0.008) and Italy (6.0% vs 9.8%, P < 0.001). Before the crisis, a stronger preference for virtual consultations was observed in people from urban areas (OR 1.28, 95% CI 1.05-1.56), while increasing age was associated with a lower preference for virtual care (OR 0.966, 95% CI 0.961-0.972). Younger people were more likely to switch to virtual care, while change to face-to-face was associated with younger age and lower income (OR 1.34, 95% CI 1.12-1.62). Older adults were less likely to change preference. CONCLUSIONS: Since the onset of the cost-of-living crisis, public preference for virtual consultations has increased, particularly in younger population. This contrasts with older adults and people with lower-than-average incomes. The rationale behind patients' preferences should be investigated to ensure patients can access their preferred modality of care.

Identifying barriers to outpatient appointment attendance in patient groups at risk of inequity: a mixed methods study in a London NHS trust.

BACKGROUND: There is significant health inequity in the United Kingdom (U.K.), with different populations facing challenges accessing health services, which can impact health outcomes. At one London National Health Service (NHS) Trust, data showed that patients from deprived areas and minority ethnic groups had a higher likelihood of missing their first outpatient appointment. This study's objectives were to understand barriers to specific patient populations attending first outpatient appointments, explore systemic factors and assess appointment awareness. METHODS: Five high-volume specialties identified as having inequitable access based on ethnicity and deprivation were selected as the study setting. Mixed methods were employed to understand barriers to outpatient attendance, including qualitative semi-structured interviews with patients and staff, observations of staff workflows and interrogation of quantitative data on appointment communication. To identify barriers, semi-structured interviews were conducted with patients who missed their appointment and were from a minority ethnic group or deprived area. Staff interviews and observations were carried out to further understand attendance barriers. Patient interview data were analysed using inductive thematic analysis to create a thematic framework and triangulated with staff data. Subthemes were mapped onto a behavioural science framework highlighting behaviours that could be targeted. Quantitative data from patient interviews were analysed to assess appointment awareness and communication. RESULTS: Twenty-six patients and 11 staff were interviewed, with four staff observed. Seven themes were identified as barriers - communication factors, communication methods, healthcare system, system errors, transport, appointment, and personal factors. Knowledge about appointments was an important identified behaviour, supported by eight out of 26 patients answering that they were unaware of their missed appointment. Environmental context and resources were other strongly represented behavioural factors, highlighting systemic barriers that prevent attendance. CONCLUSION: This study showed the barriers preventing patients from minority ethnic groups or living in deprived areas from attending their outpatient appointment. These barriers included communication factors, communication methods, healthcare the system, system errors, transport, appointment, and personal factors. Healthcare services should acknowledge this and work with public members from these communities to co-design solutions supporting attendance. Our work provides a basis for future intervention design, informed by behavioural science and community involvement.

Real-time classification of tumour and non-tumour tissue in colorectal cancer using diffuse reflectance spectroscopy and neural networks to aid margin assessment.

BACKGROUND: Colorectal cancer is the third most commonly diagnosed malignancy and the second leading cause of mortality worldwide. A positive resection margin following surgery for colorectal cancer is linked with higher rates of local recurrence and poorer survival. The authors investigated diffuse reflectance spectroscopy (DRS) to distinguish tumour and non-tumour tissue in ex-vivo colorectal specimens, to aid margin assessment and provide augmented visual maps to the surgeon in real-time. METHODS: Patients undergoing elective colorectal cancer resection surgery at a London-based hospital were prospectively recruited. A hand-held DRS probe was used on the surface of freshly resected ex-vivo colorectal tissue. Spectral data were acquired for tumour and non-tumour tissue. Binary classification was achieved using conventional machine learning classifiers and a convolutional neural network (CNN), which were evaluated in terms of sensitivity, specificity, accuracy and the area under the curve. RESULTS: A total of 7692 mean spectra were obtained for tumour and non-tumour colorectal tissue. The CNN-based classifier was the best performing machine learning algorithm, when compared to contrastive approaches, for differentiating tumour and non-tumour colorectal tissue, with an overall diagnostic accuracy of 90.8% and area under the curve of 96.8%. Live on-screen classification of tissue type was achieved using a graduated colourmap. CONCLUSION: A high diagnostic accuracy for a DRS probe and tracking system to differentiate ex-vivo tumour and non-tumour colorectal tissue in real-time with on-screen visual feedback was highlighted by this study. Further in-vivo studies are needed to ensure integration into a surgical workflow.

An introduction to digital determinants of health.

In recent years, technology has been increasingly incorporated within healthcare for the provision of safe and efficient delivery of services. Although this can be attributed to the benefits that can be harnessed, digital technology has the potential to exacerbate and reinforce preexisting health disparities. Previous work has highlighted how sociodemographic, economic, and political factors affect individuals' interactions with digital health systems and are termed social determinants of health [SDOH]. But, there is a paucity of literature addressing how the intrinsic design, implementation, and use of technology interact with SDOH to influence health outcomes. Such interactions are termed digital determinants of health [DDOH]. This paper will, for the first time, propose a definition of DDOH and provide a conceptual model characterizing its influence on healthcare outcomes. Specifically, DDOH is implicit in the design of artificial intelligence systems, mobile phone applications, telemedicine, digital health literacy [DHL], and other forms of digital technology. A better appreciation of DDOH by the various stakeholders at the individual and societal levels can be channeled towards policies that are more digitally inclusive. In tandem with ongoing work to minimize the digital divide caused by existing SDOH, further work is necessary to recognize digital determinants as an important and distinct entity.

Patient safety incidents in endoscopy: a human factors analysis of nonprocedural significant harm incidents from the National Reporting and Learning System (NRLS).

BACKGROUND: Despite advances in understanding and reducing the risk of endoscopic procedures, there is little consideration of the safety of the wider endoscopy service. Patient safety incidents (PSIs) still occur. We sought to identify nonprocedural PSIs (nPSIs) and their causative factors from a human factors perspective and generate ideas for safety improvement. METHODS: Endoscopy-specific PSI reports were extracted from the National Reporting and Learning System (NRLS). A retrospective, cross-sectional human factors analysis of data was performed. Two independent researchers coded data using a hybrid thematic analysis approach. The Human Factors Analysis and Classification System (HFACS) was used to code contributory factors. Analysis informed creation of driver diagrams and key recommendations for safety improvement in endoscopy. RESULTS: From 2017 to 2019, 1181 endoscopy-specific PSIs of significant harm were reported across England and Wales, with 539 (45.6%) being nPSIs. Five categories accounted for over 80% of all incidents, with "follow-up and surveillance" being the largest (23.4% of all nPSIs). From the free-text incident reports, 487 human factors codes were identified. Decision-based errors were the most common act prior to PSI occurrence. Other frequent preconditions to incidents were focused on environmental factors, particularly overwhelmed resources, patient factors, and ineffective team communication. Lack of staffing, standard operating procedures, effective systems, and clinical pathways were also contributory. Seven key recommendations for improving safety have been made in response to our findings. CONCLUSIONS: This was the first national-level human factors analysis of endoscopy-specific PSIs. This work will inform safety improvement strategies and should empower individual services to review their approach to safety.

The impact of collaborative organisational models and general practice size on patient safety and quality of care in the English National Health Service: A systematic review.

Collaborative primary care has become an increasingly popular strategy to manage existing pressures on general practice. In England, the recent changes taking place in the primary care sector have included the formation of collaborative organisational models and a steady increase in practice size. The aim of this review was to summarise the available evidence on the impact of collaborative models and general practice size on patient safety and quality of care in England. We searched for quantitative and qualitative studies on the topic published between January 2010 and July 2023. The quality of articles was assessed using the Newcastle-Ottawa Scale and the Critical Appraisal Skills Programme checklist. We screened 6533 abstracts, with full-text screening performed on 76 records. A total of 29 articles were included in the review. 19 met the inclusion criteria following full-text screening, with seven identified through reverse citation searching and three through expert consultation. All studies were found to be of moderate or high quality. A predominantly positive impact on service delivery measures and patient-level outcomes was identified. Meanwhile, the evidence on the effect on pay-for-performance outcomes and hospital admissions is mixed, with continuity of care and access identified as a concern. While this review is limited to evidence from England, the findings provide insights for all health systems undergoing a transition towards collaborative primary care.

Identifying benefits and concerns with using digital health services during COVID-19: Evidence from a hospital-based patient survey.

Despite large-scale adoption during COVID-19, patient perceptions on the benefits and potential risks with receiving care through digital technologies have remained largely unexplored. A quantitative content analysis of responses to a questionnaire (N = 6766) conducted at a multi-site acute trust in London (UK), was adopted to identify commonly reported benefits and concerns. Patients reported a range of promising benefits beyond immediate usage during COVID-19, including ease of access; support for disease and care management; improved timeliness of access and treatment; and better prioritisation of healthcare resources. However, in addition to known risks such as data security and inequity in access, our findings also illuminate some less studied concerns, including perceptions of compromised safety; negative impacts on patient-clinician relationships; and difficulties in interpreting health information provided through electronic health records and mHealth apps. Implications for future research and practice are discussed.

A Comparison of Spectroscopy and Imaging Techniques Utilizing Spectrally Resolved Diffusely Reflected Light for Intraoperative Margin Assessment in Breast-Conserving Surgery: A Systematic Review and Meta-Analysis.

Up to 19% of patients require re-excision surgery due to positive margins in breast-conserving surgery (BCS). Intraoperative margin assessment tools (IMAs) that incorporate tissue optical measurements could help reduce re-excision rates. This review focuses on methods that use and assess spectrally resolved diffusely reflected light for breast cancer detection in the intraoperative setting. Following PROSPERO registration (CRD42022356216), an electronic search was performed. The modalities searched for were diffuse reflectance spectroscopy (DRS), multispectral imaging (MSI), hyperspectral imaging (HSI), and spatial frequency domain imaging (SFDI). The inclusion criteria encompassed studies of human in vivo or ex vivo breast tissues, which presented data on accuracy. The exclusion criteria were contrast use, frozen samples, and other imaging adjuncts. 19 studies were selected following PRISMA guidelines. Studies were divided into point-based (spectroscopy) or whole field-of-view (imaging) techniques. A fixed-or random-effects model analysis generated pooled sensitivity/specificity for the different modalities, following heterogeneity calculations using the Q statistic. Overall, imaging-based techniques had better pooled sensitivity/specificity (0.90 (CI 0.76-1.03)/0.92 (CI 0.78-1.06)) compared with probe-based techniques (0.84 (CI 0.78-0.89)/0.85 (CI 0.79-0.91)). The use of spectrally resolved diffusely reflected light is a rapid, non-contact technique that confers accuracy in discriminating between normal and malignant breast tissue, and it constitutes a potential IMA tool.

Population health: transformation will happen at the speed of trust.

The societal shocks at the beginning of the 2020s have yet again brought into focus fundamental issues of inequality and distrust. These two corrosive and inter-related factors are the root cause of what inhibits our progress on issues such as improving population health and sustainable healthcare. Based on evidence, the authors provide their perspective to suggests three policy proposals; create a new power social movement for better health and equality; delegation of `old power' to City Mayors; handing over power and privilege to communities. This is the only way we will break the cycle of decreasing trust and increasing inequality and build a happier, healthier, and more resilient society.

Development of the "Teamwork in Endoscopy Assessment Module for Endoscopic Non-Technical Skills" (TEAM-ENTS) behavioral marker system.

BACKGROUND: Non-technical skills (NTS) are integral to team performance and subsequent quality and safety of care. Behavioral marker systems (BMSs) are now increasingly used in healthcare to support the training and assessment of team NTS. Within gastrointestinal endoscopy, this is an area of novel research. The aims of this study were to define the core relevant NTS for endoscopy teams and develop a preliminary framework for a team-based BMS known as TEAM-ENTS (Teamwork in Endoscopy Assessment Module for Endoscopic Non-Technical Skills). METHODS: This study was conducted in two phases. In phase 1, a literature review of team-based BMSs was performed to inform an interview study of core endoscopy team members. Cognitive task analysis was used to break down the NTS relevant to endoscopy teams. Framework analysis generated the structure for the preliminary TEAM-ENTS framework. In phase 2, a modified Delphi process was undertaken to refine the items of the framework. RESULTS: Seven consultant endoscopists and six nurses were interviewed. The final coding framework consisted of 88 codes grouped into five overarching categories. In total, 58 participants were recruited to the Delphi panel. In the first round, nine elements and 37 behavioral descriptors did not meet consensus. Following item adjustment, merging and deletion, all remaining items met consensus thresholds after the second round. The refined TEAM-ENTS BMS consists of five categories, 16 elements, and 47 behavioral descriptors. CONCLUSIONS: The refined TEAM-ENTS behavioral marker system was developed to reflect the core NTS relevant to endoscopy teams. Future studies will aim to fully validate this tool.

Optical neuroimaging and neurostimulation in surgical training and assessment: A state-of-the-art review.

Introduction: Functional near-infrared spectroscopy (fNIRS) is a non-invasive optical neuroimaging technique used to assess surgeons' brain function. The aim of this narrative review is to outline the effect of expertise, stress, surgical technology, and neurostimulation on surgeons' neural activation patterns, and highlight key progress areas required in surgical neuroergonomics to modulate training and performance. Methods: A literature search of PubMed and Embase was conducted to identify neuroimaging studies using fNIRS and neurostimulation in surgeons performing simulated tasks. Results: Novice surgeons exhibit greater haemodynamic responses across the pre-frontal cortex than experts during simple surgical tasks, whilst expert surgical performance is characterized by relative prefrontal attenuation and upregulation of activation foci across other regions such as the supplementary motor area. The association between PFC activation and mental workload follows an inverted-U shaped curve, activation increasing then attenuating past a critical inflection point at which demands outstrip cognitive capacity Neuroimages are sensitive to the impact of laparoscopic and robotic tools on cognitive workload, helping inform the development of training programs which target neural learning curves. FNIRS differs in comparison to current tools to assess proficiency by depicting a cognitive state during surgery, enabling the development of cognitive benchmarks of expertise. Finally, neurostimulation using transcranial direct-current-stimulation may accelerate skill acquisition and enhance technical performance. Conclusion: FNIRS can inform the development of surgical training programs which modulate stress responses, cognitive learning curves, and motor skill performance. Improved data processing with machine learning offers the possibility of live feedback regarding surgeons' cognitive states during operative procedures.

Perceptions of Quality of Care Among Users of a Web-Based Patient Portal: Cross-sectional Survey Analysis.

BACKGROUND: Web-based patient portals enable patients access to, and interaction with, their personal electronic health records. However, little is known about the impact of patient portals on quality of care. Users of patient portals can contribute important insights toward addressing this knowledge gap. OBJECTIVE: We aimed to describe perceived changes in the quality of care among users of a web-based patient portal and to identify the characteristics of patients who perceive the greatest benefit of portal use. METHODS: A cross-sectional web-based survey study was conducted to understand patients' experiences with the Care Information Exchange (CIE) portal. Patient sociodemographic data were collected, including age, sex, ethnicity, educational level, health status, geographic location, motivation to self-manage, and digital health literacy (measured by the eHealth Literacy Scale). Patients with experience using CIE, who specified both age and sex, were included in these analyses. Relevant survey items (closed-ended questions) were mapped to the Institute of Medicine's 6 domains of quality of care. Users' responses were examined to understand their perceptions of how portal use has changed the overall quality of their care, different aspects of care related to the 6 domains of care quality, and patient's satisfaction with care. Multinomial logistic regression analyses were performed to identify patient characteristics associated with perceived improvements in overall care quality and greater satisfaction with care. RESULTS: Of 445 CIE users, 38.7% (n=172) reported that the overall quality of their care was better; 3.2% (n=14) said their care was worse. In the patient centeredness domain, 61.2% (273/445) of patients felt more in control of their health care, and 53.9% (240/445) felt able to play a greater role in decision-making. Regarding timeliness, 40.2% (179/445) of patients reported they could access appointments, diagnoses, and treatment more quickly. Approximately 30% of CIE users reported better care related to the domains of effectiveness (123/445, 27.6%), safety (138/445, 31%), and efficiency (174/445, 28.6%). Regarding equity, patients self-reporting higher digital health literacy (odds ratio 2.40, 95% CI 1.07-5.42; P=.03) and those belonging to ethnic minority groups (odds ratio 2.27, 95% CI 1.26-3.73; P<.005) were more likely to perceive improvements in care quality. Across ethnic groups, Asian and British Asian patients perceived the greatest benefits. Increased frequency of CIE use also predicted perceived better care quality and greater satisfaction with care. CONCLUSIONS: A large proportion of CIE users perceived better care quality and greater satisfaction with care, although many portal users reported no change. The most favorable perceived improvements related to the domain of patient centeredness. With national policy directed toward addressing health disparities, patient portals could be valuable in improving care quality for ethnic minority groups. Future research should test the causal relationship between patient portal use and care quality.

Non-invasive assessment of intestinal permeability in healthy volunteers using transcutaneous fluorescence spectroscopy.

The permeability of the intestinal barrier is altered in a multitude of gastrointestinal conditions such as Crohn's and coeliac disease. However, the clinical utility of gut permeability is currently limited due to a lack of reliable diagnostic tests. To address this issue, we report a novel technique for rapid, non-invasive measurement of gut permeability based on transcutaneous ('through-the-skin') fluorescence spectroscopy. In this approach, participants drink an oral dose of a fluorescent dye (fluorescein) and a fibre-optic fluorescence spectrometer is attached to the finger to detect permeation of the dye from the gut into the blood stream in a non-invasive manner. To validate this technique, clinical trial measurements were performed in 11 healthy participants. First, after 6 h of fasting, participants ingested 500 mg of fluorescein dissolved in 100 ml of water and fluorescence measurements were recorded at the fingertip over the following 3 h. All participants were invited back for a repeat study, this time ingesting the same solution but with 60 g of sugar added (known to transiently increase intestinal permeability). Results from the two study datasets (without and with sugar respectively) were analysed and compared using a number of analysis procedures. This included both manual and automated calculation of a series of parameters designed for assessment of gut permeability. Calculated values were compared using Student's T-tests, which demonstrated significant differences between the two datasets. Thus, transcutaneous fluorescence spectroscopy shows promise in non-invasively discriminating between two differing states of gut permeability, demonstrating potential for future clinical use.

Real-time Tracking and Classification of Tumor and Nontumor Tissue in Upper Gastrointestinal Cancers Using Diffuse Reflectance Spectroscopy for Resection Margin Assessment.

Importance: Cancers of the upper gastrointestinal tract remain a major contributor to the global cancer burden. The accurate mapping of tumor margins is of particular importance for curative cancer resection and improvement in overall survival. Current mapping techniques preclude a full resection margin assessment in real time. Objective: To evaluate whether diffuse reflectance spectroscopy (DRS) on gastric and esophageal cancer specimens can differentiate tissue types and provide real-time feedback to the operator. Design, Setting, and Participants: This was a prospective ex vivo validation study. Patients undergoing esophageal or gastric cancer resection were prospectively recruited into the study between July 2020 and July 2021 at Hammersmith Hospital in London, United Kingdom. Tissue specimens were included for patients undergoing elective surgery for either esophageal carcinoma (adenocarcinoma or squamous cell carcinoma) or gastric adenocarcinoma. Exposures: A handheld DRS probe and tracking system was used on freshly resected ex vivo tissue to obtain spectral data. Binary classification, following histopathological validation, was performed using 4 supervised machine learning classifiers. Main Outcomes and Measures: Data were divided into training and testing sets using a stratified 5-fold cross-validation method. Machine learning classifiers were evaluated in terms of sensitivity, specificity, overall accuracy, and the area under the curve. Results: Of 34 included patients, 22 (65%) were male, and the median (range) age was 68 (35-89) years. A total of 14 097 mean spectra for normal and cancerous tissue were collected. For normal vs cancer tissue, the machine learning classifier achieved a mean (SD) overall diagnostic accuracy of 93.86% (0.66) for stomach tissue and 96.22% (0.50) for esophageal tissue and achieved a mean (SD) sensitivity and specificity of 91.31% (1.5) and 95.13% (0.8), respectively, for stomach tissue and of 94.60% (0.9) and 97.28% (0.6) for esophagus tissue. Real-time tissue tracking and classification was achieved and presented live on screen. Conclusions and Relevance: This study provides ex vivo validation of the DRS technology for real-time differentiation of gastric and esophageal cancer from healthy tissue using machine learning with high accuracy. As such, it is a step toward the development of a real-time in vivo tumor mapping tool for esophageal and gastric cancers that can aid decision-making of resection margins intraoperatively.

Visual gaze patterns in trainee endoscopists - a novel assessment tool.

BACKGROUND: Colonoscopy proficiency is significantly influenced by skills achieved during training. Although assessment scores exist, they do not evaluate the impact of visual search strategies and their use is time and labour intensive. Eye-tracking has shown significant differences in visual gaze patterns (VGPs) between expert endoscopists with varying polyp detection rates, so may provide a means of automated assessment and guidance for trainees. This study aimed to assess the feasibility of eye-tracking as a novel assessment method for trainee endoscopists. METHODS: Eye-tracking glasses were used to record 26 colonoscopies from 12 endoscopy trainees who were assessed with directly observed procedural scores (DOPS), devised by the Joint Advisory Group (JAG) on GI endoscopy, and a visual analogue score of overall competence. A 'total weighted procedure score' (TWPS) was calculated from 1 to 20. Primary outcomes of fixation duration (FixD) and fixation frequency (FixF) were analysed according to areas of interest (AOIs) with the bowel surface and lumen represented by three concentric rings. Correlation was assessed using Pearson's coefficient. Significance was set at p<.050. RESULTS: Trainees displayed a significant positive correlation between TWPS and FixD (R = 0.943, p<.0001) and FixF (R = 0.936, p<.0001) in the anatomical bowel mucosa peripheries. Conversely, they had significant negative correlations between TWPS and the anatomical bowel lumen (FixD: R= -0.546, p=.004; FixF: R= -0.568, p=.002). CONCLUSIONS: Higher objective performance scores were associated with VGPs focussing on bowel mucosa. This is consistent with prior analysis showing peripheral VGPs correspond with higher polyp detection rates. Analysis of VGPs, therefore, has potential for training and assessment in colonoscopy.

Machine learning for technical skill assessment in surgery: a systematic review.

Accurate and objective performance assessment is essential for both trainees and certified surgeons. However, existing methods can be time consuming, labor intensive, and subject to bias. Machine learning (ML) has the potential to provide rapid, automated, and reproducible feedback without the need for expert reviewers. We aimed to systematically review the literature and determine the ML techniques used for technical surgical skill assessment and identify challenges and barriers in the field. A systematic literature search, in accordance with the PRISMA statement, was performed to identify studies detailing the use of ML for technical skill assessment in surgery. Of the 1896 studies that were retrieved, 66 studies were included. The most common ML methods used were Hidden Markov Models (HMM, 14/66), Support Vector Machines (SVM, 17/66), and Artificial Neural Networks (ANN, 17/66). 40/66 studies used kinematic data, 19/66 used video or image data, and 7/66 used both. Studies assessed the performance of benchtop tasks (48/66), simulator tasks (10/66), and real-life surgery (8/66). Accuracy rates of over 80% were achieved, although tasks and participants varied between studies. Barriers to progress in the field included a focus on basic tasks, lack of standardization between studies, and lack of datasets. ML has the potential to produce accurate and objective surgical skill assessment through the use of methods including HMM, SVM, and ANN. Future ML-based assessment tools should move beyond the assessment of basic tasks and towards real-life surgery and provide interpretable feedback with clinical value for the surgeon.PROSPERO: CRD42020226071.

Real-time tracking of a diffuse reflectance spectroscopy probe used to aid histological validation of margin assessment in upper gastrointestinal cancer resection surgery.

SIGNIFICANCE: Diffuse reflectance spectroscopy (DRS) allows discrimination of tissue type. Its application is limited by the inability to mark the scanned tissue and the lack of real-time measurements. AIM: This study aimed to develop a real-time tracking system to enable localization of a DRS probe to aid the classification of tumor and non-tumor tissue. APPROACH: A green-colored marker attached to the DRS probe was detected using hue-saturation-value (HSV) segmentation. A live, augmented view of tracked optical biopsy sites was recorded in real time. Supervised classifiers were evaluated in terms of sensitivity, specificity, and overall accuracy. A developed software was used for data collection, processing, and statistical analysis. RESULTS: The measured root mean square error (RMSE) of DRS probe tip tracking was 1.18 ± 0.58 mm and 1.05 ± 0.28 mm for the x and y dimensions, respectively. The diagnostic accuracy of the system to classify tumor and non-tumor tissue in real time was 94% for stomach and 96% for the esophagus. CONCLUSIONS: We have successfully developed a real-time tracking and classification system for a DRS probe. When used on stomach and esophageal tissue for tumor detection, the accuracy derived demonstrates the strength and clinical value of the technique to aid margin assessment in cancer resection surgery.

A case for improved assessment of gut permeability: a meta-analysis quantifying the lactulose:mannitol ratio in coeliac and Crohn's disease.

BACKGROUND: A widely used method in assessing small bowel permeability is the lactulose:mannitol test, where the lactulose:mannitol ratio (LMR) is measured. However, there is discrepancy in how the test is conducted and in the values of LMR obtained across studies. This meta-analysis aims to determine LMR in healthy subjects, coeliac and Crohn's disease. METHODS: A literature search was performed using PRISMA guidance to identify studies assessing LMR in coeliac or Crohn's disease. 19 studies included in the meta-analysis measured gut permeability in coeliac disease, 17 studies in Crohn's disease. Outcomes of interest were LMR values and comparisons of standard mean difference (SMD) and weighted mean difference (WMD) in healthy controls, inactive Crohn's, active Crohn's, treated coeliac and untreated coeliac. Pooled estimates of differences in LMR were calculated using the random effects model. RESULTS: Pooled LMR in healthy controls was 0.014 (95% CI: 0.006-0.022) while pooled LMRs in untreated and treated coeliac were 0.133 (95% CI: 0.089-0.178) and 0.037 (95% CI: 0.019-0.055). In active and inactive Crohn's disease, pooled LMRs were 0.093 (95% CI: 0.031-0.156) and 0.028 (95% CI: 0.015-0.041). Significant differences were observed in LMR between: (1) healthy controls and treated coeliacs (SMD = 0.409 95% CI 0.034 to 0.783, p = 0.032), (2) healthy controls and untreated coeliacs (SMD = 1.362 95% CI: 0.740 to 1.984, p < 0.001), (3) treated coeliacs and untreated coeliacs (SMD = 0.722 95% CI: 0.286 to 1.157, p = 0.001), (4) healthy controls and inactive Crohn's (SMD = 1.265 95% CI: 0.845 to 1.686, p < 0.001), (5) healthy controls and active Crohn's (SMD = 2.868 95% CI: 2.112 to 3.623, p < 0.001), and (6) active Crohn's and inactive Crohn's (SMD = 1.429 (95% CI: 0.580 to 2.278, p = 0.001). High heterogeneity was observed, which was attributed to variability in protocols used across different studies. CONCLUSION: The use of gut permeability measurements in screening and monitoring of coeliac and Crohn's disease is promising. LMR is useful in performing this function with significant limitations. More robust alternative tests with higher degrees of clinical evidence are needed if measurements of gut permeability are to find widespread clinical use.