Aids to improve understanding of statistical risk in patients consenting for surgery and interventional procedures: A systematic review.

BACKGROUND: Informed consent is an essential process in clinical decision-making, through which healthcare providers educate patients about benefits, risks, and alternatives of a procedure. Statistical risk information is difficult to communicate and the effectiveness of aids aimed at supporting this type of communication is uncertain. This systematic review aims to study the impact of risk communication adjuncts on patients' understanding of statistical risk in surgery and interventional procedures. METHODS: A systematic search was performed across Medline, Embase, PsycINFO, Scopus, and Web of Science until July 2021 with a repeated search in September 2022. RCTs and observational studies examining risk communication tools (e.g., information leaflets and audio-video) in adult (age >16) patients undergoing a surgical or interventional procedure were included. Primary outcomes included the objective assessment of statistical risk recall. Secondary outcomes included patient attitudes with respect to statistical information. Due to the study heterogeneity, a narrative synthesis was performed. RESULTS: A total of 4348 articles were identified, and following abstract and full-text screening 14 articles, including 9 RCTs, were included. The total number of adult patients was 1513. The most common risk communication tool used was written information (n = 7). Most RCTs (7/9, 77.8%) showed statistically significant improvements in patient understanding of statistical risk in the intervention group. Quality assessment found some concerns with all RCTs. CONCLUSION: Risk communication tools appear to improve recall of statistical risk. Additional prospective trials comparing various aids simultaneously are warranted to determine the most effective method of improving understanding.

Which recipient pretransplant factors, such as MELD, renal function, sarcopenia, and recent sepsis influence suitability for and outcome after living donor liver transplantation? A systematic review of the literature and expert panel recommendations.

BACKGROUND: Varied access to deceased donors across the globe has resulted in differential living donor liver transplant (LDLT) practices and lack of consensus over the influence of models for end stage liver disease (MELD), renal function, sarcopenia, or recent infection on short-term outcomes. OBJECTIVES: Consider these risk factors in relation to patient selection and provide recommendations. DATA SOURCES: Ovid MEDLINE, Embase, Scopus, Google Scholar, Cochrane Central. METHODS: PRIMSA systematic review and GRADE. PROSPERO ID: RD42021260809 RESULTS: MELD >25-30 alone is not a contraindication to LDLT, and multiple studies found no increase in short term mortality in high MELD patients. Contributing factors such as muscle mass, acute physiologic assessment and chronic health evaluation score, donor age, graft weight/recipient weight ratio, and inclusion of the middle hepatic vein in a right lobe graft influence morbidity and mortality in high MELD patients. Higher mortality is observed with pretransplant renal dysfunction, but short-term mortality is rare. Sarcopenia and recent infection are not contraindications to LDLT. Morbidity and prolonged LOS are common, and more frequent in patients with renal dysfunction, nutritional deficiency or recent infection. CONCLUSIONS: When individual risk factors are studied mortality is low and graft loss is infrequent, but morbidity is common. MELD, especially with concomitant risk factors, had the greatest influence on short term outcome, and recent infection had the least. A multidisciplinary team of experts should carefully assess patients with multiple risk factors, and an optimal graft is recommended.

Does pre-operative counselling of the donor improve immediate and short-term outcomes after living liver donation? - A review of the literature and expert panel recommendations.

BACKGROUND: There is some evidence in the literature to suggest that pre-operative counselling improves pain scores postoperatively. However, it is unclear whether pre-operative counselling of the donor improves immediate and short-term outcomes after living liver donation. OBJECTIVES: This systematic review aimed to investigate the available quality of evidence (QOE) of pre-operative counselling for living donors on short term outcomes, provide expert opinion, grade recommendations and identify relevant components for Enhanced Recovery after Surgery (ERAS) protocols. DATA SOURCES: Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS: Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Endpoints were defined by the WHOQOL-BREF scale: physical health, psychological, social relationships, and environment. PROSPERO ID: CRD42021260677. RESULTS: Screening of 452 records and full texts led to 12 articles matching inclusion criteria, of which one was a randomized controlled trial (RCT), and 11 were observational retrospective cohort studies. A total of 933 individuals undergoing donor hepatectomy were included, of whom only 90 received dedicated perioperative ERAS protocols. Donors that received pre-operative counselling had fewer physical symptoms post donation, lower rates of fatigue, lower rates of pain, shorter recovery times and fewer unexpected medical problems, and less anxiety post donation. Female donors had higher affective and adverse effects scores, and 50% of donors reported adverse effects to analgesia that interfered with functional activity. Receiving information about analgesic options increased perception of care among donors. CONCLUSIONS: Providing comprehensive pre-operative counselling to living liver donors is associated with improved short-term outcomes after donation (QOE; moderate to low I Grade of Recommendation; Strong).

What are the non-technical skills required by junior doctors in the NHS to manage medical emergencies? A scoping review.

Many junior doctors have reported a lack of confidence in managing emergency conditions. However, there is insufficient literature summarising the current knowledge about the non-technical skills needed by junior doctors to tackle medical emergencies. This paper aims to identify the non-technical skills necessary for the management of medical emergencies by junior doctors. Three databases were systematically searched to identify relevant articles published between January 2000 and March 2020. In total, 8707 unique articles were identified and independently screened by at least two authors, using predetermined inclusion and exclusion criteria. A coding framework was applied to extract relevant data and for thematic analysis of the included studies. These methods have been performed following the PRISMA-ScR Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. There were a total of 13 articles included in the thematic analysis. The result of this review was the identification of several key non-technical skills: teamwork, communication, asking for help, challenging seniority, task prioritisation, decision-making, leadership and handling stress. In conclusion, lack of non-technical skills in junior doctors has a negative impact on patient care in a medical emergency. The training of junior doctors can be re-evaluated and designed to reflect the importance of these non-technical skills.

Improving risk communication: a proof-of-concept randomised control trial assessing the impact of visual aids for neurosurgical consent.

Introduction: Informed consent is a fundamental component in the work-up for surgical procedures. Statistical risk information pertaining to a procedure is by nature probabilistic and challenging to communicate, especially to those with poor numerical literacy. Visual aids and audio/video tools have previously been shown to improve patients' understanding of statistical information. In this study, we aimed to explore the impact of different methods of risk communication in healthy participants randomized to either undergo the consent process with visual aids or the standard consent process for lumbar puncture. Material and methods: Healthy individuals above 18 years old were eligible. The exclusion criteria were prior experience of the procedure or relevant medical knowledge, lack of capacity to consent, underlying cognitive impairment and hospitalised individuals. After randomisation, both groups received identical medical information about the procedure of a lumbar puncture in a hypothetical clinical scenario via different means of consent. The control group underwent the standard consent process in current clinical practice (Consent Form 1 without any illustrative examples), whereas the intervention group received additional anatomy diagrams, the Paling Palette and the Paling perspective scale. Anonymised questionnaires were received to evaluate their perception of the procedure and its associated risks. Results: Fifty-two individuals were eligible without statistically significant differences in age, sex, professional status and the familiarity of the procedure. Visual aids were noted to improve the confidence of participants to describe the risks by themselves (p = 0.009) and participants in the intervention group felt significantly less overwhelmed with medical information (p = 0.028). The enhanced consent process was found to be significantly more acceptable by participants (p = 0.03). There was a trend towards greater appropriateness (p = 0.06) and it appeared to have "good" usability (median SUS = 76.4), although this also did not reach statistical significance (p = 0.06). Conclusion: Visual aids could be an appropriate alternative method for medical consent without being inferior regarding the understanding of the procedure, its risks and its benefits. Future studies could possibly compare or incorporate multiple interventions to determine the most effective tools in a larger scale of population including patients as well as healthy individuals.

Empowering Early Career Neurosurgeons in the Critical Appraisal of Artificial Intelligence and Machine Learning: The Design and Evaluation of a Pilot Course.

BACKGROUND: Artificial intelligence (AI) is expected to play a greater role in neurosurgery. There is a need for neurosurgeons capable of critically appraising AI literature to evaluate its implementation or communicate information to patients. However, there are a lack of courses delivered at a level appropriate for individuals to develop such skills. We assessed the impact of a 2-day (non-credit bearing) online digital literacy course on the ability of individuals to critically appraise AI literature in neurosurgery. METHODS: We performed a prospective, quasi-experimental non-randomized, controlled study with an intervention arm comprising individuals enrolled in our 2-day digital health literacy course and a waiting-list control arm used for comparison. We assessed participants' pre- and post-course knowledge, confidence, and course acceptability using Qualtrics surveys designed for the purpose of this study. RESULTS: A total of 62 individuals (33 participants, 29 waitlist controls), including neurosurgical trainees and both undergraduate and post-graduate students, attended the course and completed the pre-course survey. The 2 groups did not vary significantly in terms of age or demographics. Following the course, participants significantly improved in their knowledge of AI (mean difference = 3.86, 95% CI = 2.97-4.75, P-value < 0.0001) and confidence in critically appraising literature using AI (P-value = 0.002). Similar differences in knowledge (mean difference = 3.15, 95% CI = 1.82-4.47, P-value < 0.0001) and confidence (P-value < 0.0001) were found when compared to the control group. CONCLUSIONS: Bespoke courses delivered at an appropriate level can improve clinicians' understanding of the application of AI in neurosurgery, without the need for in-depth technical knowledge or programming skills.

The utility of MRI radiological biomarkers in determining intracranial pressure.

Intracranial pressure (ICP) is a physiological parameter that conventionally requires invasive monitoring for accurate measurement. Utilising multivariate predictive models, we sought to evaluate the utility of non-invasive, widely accessible MRI biomarkers in predicting ICP and their reversibility following cerebrospinal fluid (CSF) diversion. The retrospective study included 325 adult patients with suspected CSF dynamic disorders who underwent brain MRI scans within three months of elective 24-h ICP monitoring. Five MRI biomarkers were assessed: Yuh sella grade, optic nerve vertical tortuosity (VT), optic nerve sheath distension, posterior globe flattening and optic disc protrusion (ODP). The association between individual biomarkers and 24-h ICP was examined and reversibility of each following CSF diversion was assessed. Multivariate models incorporating these radiological biomarkers were utilised to predict 24-h median intracranial pressure. All five biomarkers were significantly associated with median 24-h ICP (p < 0.0001). Using a pair-wise approach, the presence of each abnormal biomarker was significantly associated with higher median 24-h ICP (p < 0.0001). On multivariate analysis, ICP was significantly and positively associated with Yuh sella grade (p < 0.0001), VT (p < 0.0001) and ODP (p = 0.003), after accounting for age and suspected diagnosis. The Bayesian multiple linear regression model predicted 24-h median ICP with a mean absolute error of 2.71 mmHg. Following CSF diversion, we found pituitary sella grade to show significant pairwise reversibility (p < 0.001). ICP was predicted with clinically useful precision utilising a compact Bayesian model, offering an easily interpretable tool using non-invasive MRI data. Brain MRI biomarkers are anticipated to play a more significant role in the screening, triaging, and referral of patients with suspected CSF dynamic disorders.

Ultrasound Histotripsy on a Viable Perfused Whole Porcine Liver: Histological Aspects, Including 3D Reconstruction of the Histotripsy Site.

Non-invasive therapeutic-focused ultrasound (US) can be used for the mechanical dissociation of tissue and is described as histotripsy. We have performed US histotripsy in viable perfused ex vivo porcine livers as a step in the development of a novel approach to hepatocyte cell transplantation. The histotripsy nidus was created with a 2 MHz single-element focused US transducer, producing 50 pulses of 10 ms duration, with peak positive and negative pressure values of P+ = 77.7 MPa and P- = -13.7 MPaat focus, respectively, and a duty cycle of 1%. Here, we present the histological analysis, including 3D reconstruction of histotripsy sites. Five whole porcine livers were retrieved fresh from the abattoir using human transplant retrieval and cold static preservation techniques and were then perfused using an organ preservation circuit. Whilst under perfusion, histotripsy was performed to randomly selected sites on the live. Fifteen lesional sites were formalin-fixed and paraffin-embedded. Sections were stained with Haematoxylin and Eosin and picro-Sirius red, and they were also stained for reticulin. Additionally, two lesion sites were used for 3D reconstruction. The core of the typical lesion consisted of eosinophilic material associated with reticulin loss, collagen damage including loss of birefringence to fibrous septa, and perilesional portal tracts, including large portal vein branches, but intact peri-lesional hepatic plates. The 3D reconstruction of two histotripsy sites was successful and confirmed the feasibility of this approach to investigate the effects of histotripsy on tissue in detail.

Analyzing historical and future acute neurosurgical demand using an AI-enabled predictive dashboard.

Characterizing acute service demand is critical for neurosurgery and other emergency-dominant specialties in order to dynamically distribute resources and ensure timely access to treatment. This is especially important in the post-Covid 19 pandemic period, when healthcare centers are grappling with a record backlog of pending surgical procedures and rising acute referral numbers. Healthcare dashboards are well-placed to analyze this data, making key information about service and clinical outcomes available to staff in an easy-to-understand format. However, they typically provide insights based on inference rather than prediction, limiting their operational utility. We retrospectively analyzed and prospectively forecasted acute neurosurgical referrals, based on 10,033 referrals made to a large volume tertiary neurosciences center in London, U.K., from the start of the Covid-19 pandemic lockdown period until October 2021 through the use of a novel AI-enabled predictive dashboard. As anticipated, weekly referral volumes significantly increased during this period, largely owing to an increase in spinal referrals (p < 0.05). Applying validated time-series forecasting methods, we found that referrals were projected to increase beyond this time-point, with Prophet demonstrating the best test and computational performance. Using a mixed-methods approach, we determined that a dashboard approach was usable, feasible, and acceptable among key stakeholders.