Initial Results from Mobile Low-Dose Computerized Tomographic Lung Cancer Screening Unit: Improved Outcomes for Underserved Populations.

INTRODUCTION: The National Lung Screening Trial (NLST) demonstrated that screening high-risk patients with low-dose computed tomography (CT) of the chest reduces lung cancer mortality compared with screening with chest x-ray. Uninsured and Medicaid patients usually lack access to this hospital-based screening test because of geographic and socioeconomic factors. We hypothesized that a mobile screening unit would improve access and confer the benefits demonstrated by the NLST to this underserved group, which is most at risk of lung cancer deaths. PATIENTS AND METHODS: We created a mobile unit by building a Samsung BodyTom portable 32-slice low-dose CT scanner into a 35-foot coach; it delivers high-quality images for both soft tissue and bone and includes a waiting area and high-speed wireless internet connection for fast image transfer. The unit was extensively tested to show robustness and stability of mobile equipment. This project was designed to screen uninsured and underinsured patients, otherwise with eligibility criteria identical to that of the National Lung Screening Trial, with the only difference being exclusion of patients eligible for Medicare (which provides financial coverage for CT-based lung cancer screening). RESULTS: We screened 550 patients (20% black, 3% Hispanic, 70% rural) with a male-to-female ratio of 1.1:1, median age 61 years (range, 55-64), and found 12 lung cancers at initial screen (2.2%), including 6 at stage I-II (58% of total lung cancers early stage) and 38 Lung-RADS 4 (highly suspicious) lesions that are being followed closely. Incidental findings included nonlung cancers and coronary artery disease. DISCUSSION: In this initial pilot study, using the first mobile low-dose whole body CT screening unit in the U.S., the initial cancer detection rate is comparable to that reported in the NLST, despite excluding patients over the age of 64 years who have Medicare coverage, but with marked improvement of screening rates specifically in underserved sociodemographic, racial, and ethnic groups and with better outcomes than conventionally found in the underserved and at lower cost per case. IMPLICATIONS FOR PRACTICE: This study shows clearly that a mobile low-dose CT scanning unit allows effective lung cancer screening for underserved populations, such as impoverished African Americans, Hispanics, Native Americans, or isolated rural groups, and has a pick-up rate of 1% for early stage disease. If confirmed in a planned randomized trial, this will be policy changing, as these groups usually present with advanced disease; this approach will produce better survival data at lower cost per case.

A validated low-cost training model for suprapubic catheter insertion.

OBJECTIVE: To describe an anatomically correct simulator for use in suprapubic catheter (SPC) insertion training. METHODS: A scale reproduction of an adult male pelvis with bony landmarks and a subcutaneous fluid-filled reservoir was created using platinum cured silicone rubber. This model was evaluated by 6 expert urologists for content validity with a 16-item 5-point rating scale used to evaluate domains relevant to the simulator­physical attributes, realism of experience, realism of materials, and global rating. The simulator was used by 25 general surgeons from rural practices participating in a 2-day comprehensive specialized surgical skills course. RESULTS: The domains were scored between 1 and 5; 1 being "not at all realistic" and 5 being "highly realistic, no changes needed." The average expert ratings of the domains were 3.9 (physical attributes), 4.3 (realism of experience), and 3.9 (realism of materials). The simulator was rated more valuable as a training tool (4.5) compared with a testing tool (3.8) with an average global rating of 4.1. CONCLUSION: Experts and trainees reported high satisfaction with their experience using this simulator. Preliminary evidence suggests this simulator is a useful tool that can be integrated into training programs to facilitate learning this necessary urologic skill.

Evaluation of Three Sources of Validity Evidence for a Synthetic Thoracoscopic Esophageal Atresia/Tracheoesophageal Fistula Repair Simulator.

PURPOSE: Thoracoscopic esophageal atresia (EA)/tracheoesophageal fistula (TEF) repair is technically challenging. We have previously reported our experiences with a high-fidelity hybrid model for simulation-based educational instruction in thoracoscopic EA/TEF, including the high cost of the tissue for these models. The purposes of this study were (1) to create a low-cost synthetic tissue EA/TEF repair simulation model and (2) to evaluate the content validity of the synthetic tissue simulator. MATERIALS AND METHODS: Review of the literature and computed tomography images were used to create computer-aided drawings (CAD) for a synthetic, size-appropriate EA/TEF tissue insert. The inverse of the CAD image was then printed in six different sections to create a mold that could be filled with platinum-cured silicone. The silicone EA/TEF insert was then placed in a previously described neonatal thorax and covered with synthetic skin. Following institutional review board-exempt determination, 47 participants performed some or all of a simulated thoracoscopic EA/TEF during two separate international meetings (International Pediatric Endosurgery Group [IPEG] and World Federation of Associations of Pediatric Surgeons [WOFAPS]). Participants were identified as "experts," having 6-50 self-reported thoracoscopic EA/TEF repairs, and "novice," having 0-5 self-reported thoracoscopic EA/TEF repairs. Participants completed a self-report, six-domain, 24-item instrument consisting of 23 5-point rating scales and one 4-point Global Rating Scale. Validity evidence relevant to test content and response processes was evaluated using the many-facet Rasch model, and evidence of internal structure (interitem consistency) was estimated using Cronbach's alpha. RESULTS: A review of the participants' ratings indicates there were no overall differences across sites (IPEG versus WOFAPS, P=.84) or experience (expert versus novice, P=.17). The highest observed averages were 4.4 (Value of Simulator as a Training Tool), 4.3 (Physical Attributes-chest circumference, chest depth, and intercostal space), and 4.3 (Realism of Experience-fistula location). The lowest observed averages were 3.5 (Ability to Perform-closure of fistula), 3.7 (Ability to Perform-acquisition target trocar sites), 3.8 (Physical Attributes-landmark visualization), 3.8 (Ability to Perform-anastomosis and dissection of upper pouch), and 3.9 (Realism of Materials-skin). The Global Rating Scale was 2.9, coinciding with a response of "this simulator can be considered for use in neonatal TEF repair training, but could be improved slightly." Material costs for the synthetic EA/TEF inserts were less than $2 U.S. per insert. CONCLUSIONS: We have successfully created a low-cost synthetic EA/TEF tissue insert for use in a neonatal thoracoscopic EA/TEF repair simulator. Analysis of the participants' ratings of the synthetic EA/TEF simulation model indicates that it has value and can be used to train pediatric surgeons, especially those early in their learning curve, to begin to perform a thoracoscopic EA/TEF repair. Areas for model improvement were identified, and these areas will be the focus for future modifications to the synthetic EA/TEF repair simulator.

Design and development of low-cost tissue replicas for simulation of rare neonatal congenital defects.

Studies have shown that simulation can be a valuable tool for training pediatric surgeons to perform thoracoscopic repair of rare congenital anomalies [1-3]. The previously evaluated models were high fidelity, hybrid models that required the use of fetal bovine or porcine tissue blocks within a simulated neonate chest cavity. Real tissue blocks can be expensive, and may not be readily available in some parts of the world. We have developed low-cost, portable simulators for esophageal atresia with tracheoesophageal fistula (EA/TEF) and duodenal atresia (DA) that recreate the 3-dimensional challenges for minimally invasive repair. These are fully simulated models of the thoracic and abdominal cavities containing synthetic tissue that replicates the required anatomy.