Immersive distance simulation: Exploring the educational impact of stereoscopic extended reality (XR) video in remote learning environments.

What was the educational challenge?There is a growing need for healthcare simulation options when local expertise or resources are not available. To connect instructors with remote learners, current options for distance simulation are typically limited to videoconferencing on desktop computers or mobile devices, which may not fully capture the complexity of clinical scenarios.What was the solution?Extended reality (XR) technology may provide a more immersive and realistic distance healthcare simulation experience compared to traditional videoconferencing options. Unlike computer- or phone-based video calls, stereoscopic video in XR provides a sense of depth that may increase spatial understanding and engagement in distance simulation.How was the solution implemented?We investigated the impact of XR for synchronous distance simulation compared to traditional desktop-based videoconferencing in Emergency Medicine (EM) resident training for an obstetrical emergency. A randomized controlled experiment was conducted with half of the residents using XR and half using computers to participate in the simulation.What lessons were learned that are relevant to a wider global audience?There was an unanticipated interaction between postgraduate year and condition such that performance in the XR condition was superior for first year residents, while this was reversed for more experienced residents. This indicates that the benefits of XR might be dependent on participant characteristics, such as learner level.What are the next steps?We plan to extend this research to clarify characteristics of learners and tasks that are important determinants of differences in outcomes between stereoscopic XR versus traditional videoconference displays.

Comparing Capabilities of Simulation Modalities for Training Combat Casualty Care: Perspectives of Combat Medics.

INTRODUCTION: Combat casualty care requires learning a complex set of skills to treat patients in challenging situations, including resource scarce environments, multiple casualty incidents, and care under fire. To train the skills needed to respond efficiently and appropriately to these diverse conditions, instructors employ a wide array of simulation modalities. Simulation modalities for medical training include manikins, task trainers, standardized patient actors (i.e., role players), computer or extended reality simulations (e.g., virtual reality, augmented reality), cadavers, and live tissue training. Simulation modalities differ from one another in multiple attributes (e.g., realism, availability). The purpose of this study was to compare capabilities across simulation modalities for combat casualty care from the perspective of experienced military medics. MATERIALS AND METHODS: To provide a more complete understanding of the relative merits and limitations of modalities, military combat medics (N = 33) were surveyed on the capabilities of simulation modalities during a 5-day technical experimentation event where they observed medical simulations from industry developers. The survey asked them to rate each of eleven modalities on each of seven attributes. To elicit additional context for the strengths, limitations, and unique considerations of using each modality, we also collected open-ended comments to provide further insight on when and how to use specific simulation modalities. RESULTS: Results showed differences among the simulation modalities by attribute. Cadavers, role play, moulage, and live tissue all received high ratings on two or more attributes. However, there was no modality that was rated uniformly superior to the others. Instead, modalities appear to have unique strengths and limitations depending on the training context and objectives. For example, cadavers were seen as highly realistic, but not very reusable. CONCLUSIONS: The study furthers our understanding of simulation modalities for medical training by providing insight from combat medics on the benefits, limitations, and considerations for implementing different modalities depending on the training context. These results may be helpful to instructors in selecting modalities for their programs.

Advanced Trauma Life Support Course Delivery: Comparison of Outcomes From Modifications During Covid-19.

Introduction The Advanced Trauma Life Support (ATLS) Course is a two-day long medical training course developed by the American College of Surgeons (ACS) to help train and prepare healthcare providers to care for severely injured patients. The coronavirus disease 2019 (COVID-19) pandemic has resulted in the modification or cancellation of many education programs across the world. At the University of South Florida's Center for Advanced Medical Learning and Simulation (CAMLS) two different models of ATLS were delivered in response to the COVID-19 pandemic with both models utilizing the ACS's online mobile ATLS (mATLS). In this study three different models of ATLS delivered by USF CAMLS between 2019 and 2020 were compared to determine if there were any impacts on the education and functionality of the ATLS course between the three different models of ATLS: a baseline ATLS course, an augmented ATLS course that used mATLS, and an ATLS course that used mATLS as a replacement for in-person lectures. Material and methods To compare the three models of ATLS delivery, a total of six ATLS courses were studied: a baseline face-to-face ATLS course from June 2019, two Mobile ATLS (mATLS) courses from September 2020, and three augmented ATLS courses that contained both face-to-face and mATLS delivery from October, November and December 2020. The only differences between the traditional ATLS courses from 2020 and the pre-COVID ATLS course from 2019 were that the courses from 2020 utilized mATLS and that the course days were longer due to cleaning time. These courses were selected to have a non-significant difference in the number of learners in each model of ATLS course. The data that were collected from these courses included: post-test results from learners, learner feedback surveys, and interviews with the ATLS Course Director, ATLS Course Coordinator, and the Educational Coordinator. Results The only courses with significant differences in the post-test mean scores were for the baseline ATLS course compared to the mATLS courses. The augmented courses showed similar post-test performance to the mATLS courses. Students viewed the courses favorably with the only major complaint between the 2019 and the 2020 courses being a high amount of downtime for the 2020 courses due to time required to disinfect skill stations and equipment. The main difficulties for the ATLS Course Director, ATLS Course Coordinator, and the Educational Coordinator with the ATLS courses in 2020 were concerned with challenges from COVID-19, like social distancing, and not with mATLS or the shortened instruction time with the hybrid model. Discussion This preliminary study analyzed three delivery models of ATLS. The mATLS may be able to replace in-person lectures of ATLS courses as courses using alternative delivery formats showed post-test scores as good or better than the baseline face-to-face course.

Capturing the underlying distribution in meta-analysis: Credibility and tolerance intervals.

Tolerance intervals provide a bracket intended to contain a percentage (e.g., 80%) of a population distribution given sample estimates of the mean and variance. In random-effects meta-analysis, tolerance intervals should contain researcher-specified proportions of underlying population effect sizes. Using Monte Carlo simulation, we investigated the coverage for five relevant tolerance interval estimators: the Schmidt-Hunter credibility intervals, a prediction interval, two content tolerance intervals adapted to meta-analysis, and a bootstrap tolerance interval. None of the intervals contained the desired percentage of coverage at the nominal rates in all conditions. However, the prediction worked well unless the number of primary studies was small (<30), and one of the content tolerance intervals approached nominal levels with small numbers (<20) of primary studies. The bootstrap tolerance interval achieved near nominal coverage if there were sufficient numbers of primary studies (30+) and large enough sample sizes (N ≅ 70) in the included primary studies, although it slightly exceeded nominal coverage with large numbers of large-sample primary studies. Next, we showed the results of applying the intervals to real data using a set of previously published analyses and provided suggestions for practice. Tolerance intervals incorporate error of estimation into the construction of proper brackets for fractions of population true effects. In many contexts, such intervals approach the desired nominal levels of coverage.

Quantifying uncertainty in the meta-analytic lower bound estimate.

In meta-analyses, it is customary to compute a confidence interval for the overall mean effect (ρ̄ or δ̄), but not for the underlying standard deviation (τ) or the lower bound of the credibility value (90%CV), even though the latter entities are often as important to the interpretation as is the overall mean. We introduce 2 methods of computing confidence intervals for the lower bound (Lawless and bootstrap). We compare both methods using 3 lower bound estimators (Schmidt-Hunter, Schmidt-Hunter with k correction, and Morris/Hedges, labeled HOVr/HOVd) in 2 Monte Carlo studies (1 for correlations and 1 for standardized mean differences) and illustrate their application to published meta-analyses. For correlations, we found that HOVr bootstrap confidence intervals yielded coverage greater than 90% across a wide variety of conditions provided that there were at least 25 studies. For the standardized mean difference, all 3 methods produced acceptable results using the bootstrap for the lower bound confidence interval provided that there were at least 20 studies with an average sample size of at least 50. When the number of studies was small (k = 8 or 10), coverage was less than 90% and confidence intervals were very wide. Even with larger numbers of studies, if there was indirect range restriction coupled with a small underlying between-studies variance, the between-studies variance was poorly estimated and coverage of the lower bound suffered. We provide software to allow meta-analysts to compute bootstrap confidence intervals for the estimators described in the article. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Direct Aspiration versus Stent Retriever Thrombectomy for Acute Stroke: A Systematic Review and Meta-Analysis in 9127 Patients.

BACKGROUND: The two most common approaches to thrombectomy of emergent large vessel occlusion (direct aspiration and primary stent retriever thrombectomy) have been extensively studied; however, the detailed benefit and risk comparison is largely unknown. OBJECTIVE: To conduct a systematic review and meta-analysis to compare radiographic and clinical outcomes between the use of primary stent retrievers and direct aspiration in management of acute ischemic stroke. METHODS: PubMed database was searched for studies between September 1, 2012 and December 31, 2017 with acute ischemic stroke patients. RESULTS: We identified 64 studies with 6875 patients in the primary stent retriever group and 25 studies with 2252 patients in the aspiration group. Primary aspiration alone, without the need of rescue stent retriever devices within the aspiration cohort, was performed in 65% of 2252 patients. There was no difference in the distribution of emergent large vessel occlusion based on occlusion site, age, baseline National Institutes of Health Stroke Scale, or the use of intravenous tPA (P = .19, .051, .23, and .093, respectively). Successful recanalization rates, defined as thrombolysis in cerebral Infarction 2b/3, were significantly higher in the aspiration group than the primary stent retriever group (89% versus 80%, P < .0001). No significant difference in good clinical outcome, defined as modified Rankin scale 0-2 (aspiration 52% versus stent 48%, P = .13), symptomatic intracerebral hemorrhage (aspiration 5.6% versus stent 7.2%, P = .07), and mortality at 3 months (aspiration 15% versus stent 19%, P = .10). CONCLUSIONS: Both aspiration-first (including the subsequent use of stent retriever) and primary stent retriever thrombectomy approaches are equally effective in achieving good clinical outcomes. Our study suggests that direct aspiration with or without subsequent use of stent retriever is a safe and effective alternative to primary stent retriever in acute ischemic stroke.

Is social network site usage related to depression? A meta-analysis of Facebook-depression relations.

BACKGROUND: Facebook depression is defined as feeling depressed upon too much exposure to Social networking sites (SNS). Researchers have argued that upward social comparisons made on SNS are the key to the Facebook depression phenomenon. To examine the relations between SNS usage and depression, we conducted 4 separate meta-analyses relating depression to: (1) time spent on SNS, (2) SNS checking frequency, (3) general and (4) upward social comparisons on SNS. We compared the four mean effect sizes in terms of magnitude. METHODS: Our literature search yielded 33 articles with a sample of 15,881 for time spent on SNS, 12 articles with a sample of 8041 for SNS checking frequency, and 5 articles with a sample of 1715 and 2298 for the general and the upward social comparison analyses, respectively. RESULTS: In both SNS-usage analyses, greater time spent on SNS and frequency of checking SNS were associated with higher levels of depression with a small effect size. Further, higher levels of depression were associated with greater general social comparisons on SNS with a small to medium effect, and greater upward social comparisons on SNS with a medium effect. Both social comparisons on SNS were more strongly related to depression than was time spent on SNS. LIMITATIONS: Limitations include heterogeneity in effect sizes and a small number of samples for social comparison analyses. CONCLUSIONS: Our results are consistent with the notion of 'Facebook depression phenomenon' and with the theoretical importance of social comparisons as an explanation.

The value of psychometric analysis of the advanced trauma life support cognitive test: Outcome of an ACS-Accredited educational institute multisite study.

BACKGROUND: The Advanced Trauma Life Support® (ATLS®) course provides a standard approach to trauma. Participants must pass the ATLS® post-test. We deployed the test online to allow ongoing psychometric item analysis and potential objective refinement. METHODS: A two-phase study was undertaken with the ACS COT permission. In the first phase, ATLS® post-test #2 was computerized and deployed using Qualtrics©. Data were collected from fourteen courses conducted between 2014 and 2015 (n = 306) at one ACS AEI site. In the second phase, the same post-test was administered to 238 trainees in 10 courses via secured computers at four ACS AEI sites in 2016. RESULTS: Phase 1 item analyses showed two items with very low percentages correct, and one of these also showed a low discrimination index. Phase 2 item analyses suggested four items as candidates for review and possible revision. We also found differences by learner background and by instructional site. CONCLUSIONS: This study demonstrates computerized delivery of the ATLS post-test is feasible, promotes psychometric analysis, and could improve the quality of the test. Further collaboration between the ACS COT and ACS AEI would be beneficial.

Sleep, Cognitive impairment, and Alzheimer's disease: A Systematic Review and Meta-Analysis.

Study Objectives: Mounting evidence implicates disturbed sleep or lack of sleep as one of the risk factors for Alzheimer's disease (AD), but the extent of the risk is uncertain. We conducted a broad systematic review and meta-analysis to quantify the effect of sleep problems/disorders on cognitive impairment and AD. Methods: Original published literature assessing any association of sleep problems or disorders with cognitive impairment or AD was identified by searching PubMed, Embase, Web of Science, and the Cochrane library. Effect estimates of individual studies were pooled and relative risks (RR) and 95% confidence intervals (CI) were calculated using random effects models. We also estimated the population attributable risk. Results: Twenty-seven observational studies (n = 69216 participants) that provided 52 RR estimates were included in the meta-analysis. Individuals with sleep problems had a 1.55 (95% CI: 1.25-1.93), 1.65 (95% CI: 1.45-1.86), and 3.78 (95% CI: 2.27-6.30) times higher risk of AD, cognitive impairment, and preclinical AD than individuals without sleep problems, respectively. The overall meta-analysis revealed that individuals with sleep problems had a 1.68 (95% CI: 1.51-1.87) times higher risk for the combined outcome of cognitive impairment and/or AD. Approximately 15% of AD in the population may be attributed to sleep problems. Conclusion: This meta-analysis confirmed the association between sleep and cognitive impairment or AD and, for the first time, consolidated the evidence to provide an "average" magnitude of effect. As sleep problems are of a growing concern in the population, these findings are of interest for potential prevention of AD.

Estimating the Reliability of Nontechnical Skills in Medical Teams.

OBJECTIVE: To assess the reliability of measurement of assessments of nontechnical skills in medical teams. BACKGROUND: There are several scales for assessing nontechnical skills in medical teams. In this critique, we describe the reliability of such assessments and discuss factors that may influence the obtained estimate of reliability for such scales. METHOD: A review of the literature yielded 28 reliability estimates, mostly intraclass correlations. We analyzed the methods of scale development and reliability estimation for factors that are likely to influence the resulting estimate, including aspects of the judges, the targets, what is observed, and the kind of reliability coefficient. RESULTS: Typical reliability was approximately 0.7, but estimates were quite varied in magnitude, from quite low (0.3) to quite high (0.9). Thus, highly reliable assessment is possible, but rarely achieved. Factors that are likely to influence the magnitude of reliability include the number of assessors, the participants' range in skill level, and the observational process. Most studies do not present enough information to make the estimates comparable from one study to the next. CONCLUSIONS: Although nontechnical skills can be measured reliably under some circumstances, it is not clear from the existing literature that one scale provides more reliable data than another. We recommend several practices that would help readers to make informed decisions about which scales are most useful for their purposes.

Cross-hairs: a scatterplot for meta-analysis in R.

We describe a meta-analytic scatterplot that indicates precision of points for two variables paired within studies; this is equivalent in form to a 'cross-hairs' plot used to portray specificity and sensitivity in diagnostic testing. At the user's discretion, the plot also displays boxplots for each of the X and Y variable distributions, means for each of the variables, and the correlation between the two. The cross-hairs may be suppressed for dense point clouds. The program is written in R, so it can be modified by the user and can serve as a companion to existing meta-analysis programs. Some of the program's novel uses are described and illustrated with (1) independent effect sizes, (2) dependent effect sizes, and (3) shrunken estimates. Copyright © 2016 John Wiley & Sons, Ltd.

Medical student quality-of-life in the clerkships: a scale validation study.

Many aspects of medical school are stressful for students. To empirically assess student reactions to clerkship programs, or to assess efforts to improve such programs, educators must measure the overall well-being of the students reliably and validly. The purpose of the study was to develop and validate a measure designed to achieve these goals. The authors developed a measure of quality of life for medical students by sampling (public domain) items tapping general happiness, fatigue, and anxiety. A quality-of-life scale was developed by factor analyzing responses to the items from students in two different clerkships from 2005 to 2008. Reliability was assessed using Cronbach's alpha. Validity was assessed by factor analysis, convergence with additional theoretically relevant scales, and sensitivity to change over time. The refined nine-item measure is a Likert scaled survey of quality-of-life items comprised of two domains: exhaustion and general happiness. The resulting scale demonstrated good reliability and factorial validity at two time points for each of the two samples. The quality-of-life measure also correlated with measures of depression and the amount of sleep reported during the clerkships. The quality-of-life measure appeared more sensitive to changes over time than did the depression measure. The measure is short and can be easily administered in a survey. The scale appears useful for program evaluation and more generally as an outcome variable in medical educational research.

Malleability of weight-biased attitudes and beliefs: a meta-analysis of weight bias reduction interventions.

Weight bias exists across many important life domains, necessitating interventions designed to reduce weight-biased attitudes and beliefs. Though the effectiveness of weight bias interventions has been questioned, to our knowledge no meta-analysis of these interventions has been conducted. This meta-analysis evaluated the impact of weight bias interventions on weight-biased attitudes and beliefs and explored potential moderators. Interventions were eligible if they used an adult sample and a validated measure of weight-biased attitudes, which resulted in the inclusion of 30 studies represented in 29 articles. A random effects approach using inverse weights resulted in a mean effect size estimate of g=-0.33 (lower scores indicate less weight bias) for both attitudes and beliefs. Intervention type, publication type, and population type were not significant moderators but demonstrated noteworthy trends. Results reveal a small, positive effect of weight bias interventions on weight-biased attitudes and beliefs and provide useful information for future interventions.

FLS skill acquisition: a comparison of blocked vs interleaved practice.

INTRODUCTION: Fundamentals of Laparoscopic Surgery (FLS) certification is required for general surgery. The recommended practice for learning FLS is to practice tasks one at a time until proficient (blocked practice). Learning theory suggests that interleaved practice, a method in which tasks are rotated rather than learned one at a time, may result in superior learning. METHOD: Residents were randomized into 1 of 2 groups: blocked practice or interleaved practice. We compared the performance of residents across groups over 20 trials of each of 4 FLS tasks (peg transfer, pattern cut, extracorporeal suture, and intracorporeal suture). Four weeks later, participants returned to the laboratory and completed 2 additional trials of each of the 4 tasks. RESULTS: Performance on each of the tasks improved with increased practice. The interleaved group showed significantly better performance on the peg transfer task; trends favoring the interleaved group resulted for the other tasks. Standardized mean differences in favor of the interleaved group were substantial both at the end of practice and at follow-up (with the exception of the pattern cut). CONCLUSION: Interleaved practice appears to have advantages over blocked practice in developing and retaining FLS skills. We encourage others to experiment with the method to confirm our findings.

Bayesian meta-analysis of coefficient alpha.

The current paper describes and illustrates a Bayesian approach to the meta-analysis of coefficient alpha. Alpha is the most commonly used estimate of the reliability or consistency (freedom from measurement error) for educational and psychological measures. The conventional approach to meta-analysis uses inverse variance weights to combine information from independent studies to provide an overall estimate. The Bayesian approach provides similar estimates to the conventional approach if a diffuse prior is used. However, the Bayesian approach also provides 'shrunken' local estimates of reliability in each context. The amount of shrinkage depends upon both the variability in the underlying populations and the sampling variance of the local estimates. Advantages of the approach are the estimation of individual studies adjusted for sampling error and the application of meta-analytic results to new local studies in which the local study 'borrows strength' from the meta-analysis. The ability to borrow strength for the new local studies is particularly useful in applied work in which the estimate of the local parameter is of primary interest. The approach is illustrated by the analysis of studies of the reliability of the General Ethnicity Questionnaire - Abridged, a measure of identification with the culture of one's heritage and the culture of one's host country. Copyright © 2013 John Wiley & Sons, Ltd.

Surgical interest and surgical match for third-year students: results of a prospective multivariate longitudinal cohort study.

BACKGROUND: Numerous factors have been linked to surgical career choice, including the quality of third-year surgical clerkship. The vast majority of studies also selectively evaluate one or only a few variables that link to surgical career choice, so relative impact cannot be assessed. This study simultaneously evaluates the majority of variables linked to surgical career choice in previous research so that the relative contributions of each of these variables with respect to surgical career choice can be determined. STUDY DESIGN: Surveys before, during, and after the third-year surgical clerkship included student demographics, background, and values (eg, importance of money, controllable lifestyle), and student reactions to the third-year surgical clerkship. The dependent variables in this study included interest in surgery at the beginning and end of the clerkship and matching into a surgical residency. RESULTS: Both univariate and multivariate analyses generally supported findings in the literature, but the strengths of these associations reported previously might not have been accurate. In this study, the surgical resident match odds ratio for students starting the clerkship already knowing they wanted to be a surgeon was 22.46; the next highest associations were 4.65 and 3.37, which corresponded to earlier exposure to a surgical specialty and earlier exposure to general surgery, respectively. Differences in career choice for general surgeons and surgical specialists were also explored. CONCLUSIONS: Although the experience of the clerkship is related to career choice, the largest impact of the clerkship is for those already interested in a surgical career. Interest in a surgical career largely develops before the third-year clerkship. Implications of the results for recruiting greater numbers of students into surgical careers are discussed.

Teamwork in the trauma room evaluation of a multimodal team training program.

INTRODUCTION: Poor teamwork leads to preventable medical errors, and thus negatively impacts medical care. One way to improve teamwork is training. A multimodality team training program was designed to impact the attitudes and behavior of first-year residents who will encounter medical situations in the trauma room. The training program included low-fidelity role plays, lectures, and high-fidelity simulation with feedback. MATERIALS AND METHODS: The training program was a one-day workshop that was conducted twice, once for each of the two groups over two days at the beginning of the academic year in July. A total of 41 first-year interns (10 Emergency Medicine and 31 Surgery) were recruited for participation. Participants completed a Situational judgment test (SJT) on trauma teamwork before training. The training began with a low-fidelity simulation that served as an icebreaker to team concepts. Subsequently, a lecture with discussion provided key points regarding teamwork in the trauma room. A high-fidelity simulation then allowed participation in one of four trauma room scenarios with medical expert debriefing. The course concluded with a course summary and an assessment of participant attitudes regarding training along with a second administration of SJT. RESULTS: Participant reactions to the training were positive overall. Results of SJT showed a positive effect for team training in three of the four possible comparisons. CONCLUSION: The program was well received by the residents. Results suggest that a comprehensive training approach using role play, lecture, and simulation can positively affect behavioral choices for teamwork in the trauma room.

Publication bias in psychological science: prevalence, methods for identifying and controlling, and implications for the use of meta-analyses.

The issue of publication bias in psychological science is one that has remained difficult to address despite decades of discussion and debate. The current article examines a sample of 91 recent meta-analyses published in American Psychological Association and Association for Psychological Science journals and the methods used in these analyses to identify and control for publication bias. Of the 91 studies analyzed, 64 (70%) made some effort to analyze publication bias, and 26 (41%) reported finding evidence of bias. Approaches to controlling publication bias were heterogeneous among studies. Of these studies, 57 (63%) attempted to find unpublished studies to control for publication bias. Nonetheless, those studies that included unpublished studies were just as likely to find evidence for publication bias as those that did not. Furthermore, authors of meta-analyses themselves were overrepresented in unpublished studies acquired, as compared with published studies, suggesting that searches for unpublished studies may increase rather than decrease some sources of bias. A subset of 48 meta-analyses for which study sample sizes and effect sizes were available was further analyzed with a conservative and newly developed tandem procedure of assessing publication bias. Results indicated that publication bias was worrisome in about 25% of meta-analyses. Meta-analyses that included unpublished studies were more likely to show bias than those that did not, likely due to selection bias in unpublished literature searches. Sources of publication bias and implications for the use of meta-analysis are discussed.

Psychometrics of Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) scores.

A sample of 183 medical students completed the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT V2.0). Scores on the test were examined for evidence of reliability and factorial validity. Although Cronbach's alpha for the total scores was adequate (.79), many of the scales had low internal consistency (scale alphas ranged from .34 to .77; median = .48). Previous factor analyses of the MSCEIT are critiqued and the rationale for the current analysis is presented. Both confirmatory and exploratory factor analyses of the MSCEIT item parcels are reported. Pictures and faces items formed separate factors rather than loading on a Perception factor. Emotional Management appeared as a factor, but items from Blends and Facilitation failed to load consistently on any factor, rendering factors for Emotional Understanding and Emotional Facilitation problematic.