Introduction to the cognitive hospital.

The third industrial revolution has radically impacted the transformation of hospitals. Through the adoption of key digital technologies, hospitals have become more accessible, flexible, organised, responsive and able to deliver more personalised care. The digitalisation of patient health records, one of the most remarkable achievements to date in healthcare management, has enabled new opportunities, including the idea of hospitals evolving to become artificially intelligent. In parallel, the adoption of electronic and mobile internet technologies in hospitals has introduced new structural concepts, seeing a variety of terms blossom such as 'smart', 'intelligent', 'green' and 'liquid'. Now in the early fourth industrial revolution, driven by AI and internet-of-things technologies, this article unveils a new concept adapted to the upcoming era.

Telemedicine: improving clinical care and medical education in paediatrics.

The COVID-19 pandemic has led to a rapid increase in the use of telemedicine. This is likely to continue when the social distancing restrictions have been eased. There have been a number of technological advances that have contributed to the roll-out and improved quality of telemedicine consultations. Telemedicine has a number of benefits including facilitating home working for clinicians, reduce travel time for families and allows multidisciplinary team working across different sites. In addition to these clinical benefits there are also the environmental benefits of reduced travel to and from the hospital setting. There are limitations to this change in practice including the need for repeat appointments if a telemedicine facilitated contact is not adequate and the perpetuation of inequality for vulnerable families, the so called "digital divide". Due to the increase in the use of telemedicine it is important that clinicians develop effective consultation practices including appropriate selection of patients, technical setup and consultation tools. In order to ensure trainees are developing appropriate skills in telemedicine, educational opportunities should be developed including structured assessment tools to allow the demonstration of competence in this area.

Surgical management and outcomes of paediatric ovarian tumours-a 25-year UK single centre experience.

BACKGROUND: Ovarian neoplasms in children are rare heterogeneous lesions with variable biological behaviour and outcome. We herein report a 25-year experience from a UK specialist centre managing paediatric ovarian tumours. METHODS: All female patients requiring operation for ovarian tumours were identified during the study period 1990-2018. Patient demographics, clinical presentation, and management are highlighted. RESULTS: Eighty-eight females with 101 ovarian tumours including cases with synchronous and metachronous neoplasms were documented. Mean age at diagnosis was 11.8 years. Tumours were equally distributed in left and right ovary(s). Bilateral disease occurred in 11 (10.8%) patients. Eighty-six (85%) neoplasms were benign and 15 (15%) malignant requiring in addition to surgery chemotherapy and/or radiation. There were no significant difference(s) observed in maximum tumour diameter in benign vs malignant lesions. Only half of malignant tumours had positive tumour markers. Fifteen patients (15%) had ovarian lesions that were metastatic at primary presentation including a rare case of disseminated peritoneal gliomatosis. Surgical management included salpingo-oopherectomy n = 21 (21%), ovary excision n = 33 (33%), 'ovary sparing' tumourectomy n = 34 (34%), and cyto-reductive extirpation in 2 cases (2%). Lymphadenectomy was performed in 9 patients (9%) together with peritoneal fluid cytology in 18 cases (18%) who had abdominal ascites. Omentectomy was required in 14 patients (14%), multiple peritoneal biopsy(s)-in 11 cases (11%) and biopsy of other suspicious involved organs notably bowel, gut mesentery and contralateral ovary in 7 (7%) further patients. Recurrent and metachronous lesions occurred in 10 (10%) cases in those with teratoma (n = 9) and adenocarcinoma(s) (n = 1). Overall patient survival was 97% with only 3 deaths-mucinous cystadenocarcinoma (n = 1), desmoplastic small round cell tumour of ovarian origin (n = 1), and a small cell carcinoma of ovary with hypercalcaemia (n = 1). CONCLUSIONS: Findings from this study show an excellent survival (97%) for paediatric ovarian neoplasms. Rare malignant neoplasms though do carry a poor prognosis. In the modern era of care, all efforts should be made to preserve future hormonal health and fertility with 'ovarian sparing' operation(s) where appropriate.

Bleeding after suction rectal biopsy with Rbi2: identification of the root cause through a multi-staged approach.

Introduction: Suction rectal biopsy (SRB) is a key diagnostic tool in Hirschsprung's disease. The original Noblett device has been superseded by modern alternatives including the Rbi2 rectal biopsy gun. We describe a comparison of biopsy results from the Noblett device and the Rbi2 gun and an investigation into significant post-biopsy bleeding episodes with the latter. Methods: A retrospective review of SRB episodes between 2006 and 2014 was undertaken to audit biopsy success rates. Significant post-procedure bleeding after SRB with the Rbi2 gun prompted further investigations. Results: Biopsies taken with the Noblett gun were more likely to be inadequate (Noblett 82/197 (40%) vs Rbi2 77/438 (18%)). After biopsy with the Rbi2 gun, 2 infants suffered from significant bleeding requiring resuscitation, blood product support and multiple theater episodes. As there were no reported cases of bleeding with the Rbi2 gun, a report was made to the Medicines & Healthcare products Regulatory Agency who identified incorrect biopsy technique as a potential contributing factor. A questionnaire of trainees and consultants found unexpected individual variation in SRB technique, with some users applying excessive suction. Conclusions: Significant bleeding occurred after SRB with the Rbi2 gun, excessive suction was thought to be the cause.

Does a 3D Image Improve Laparoscopic Motor Skills?

AIM: To quantitatively determine whether a three-dimensional (3D) image improves laparoscopic performance compared with a two-dimensional (2D) image. METHOD: This is a prospective study with two groups of participants: novices (5) and experts (5). Individuals within each group undertook a validated laparoscopic task on a box simulator, alternating between 2D and a 3D laparoscopic image until they had repeated the task five times with each imaging modality. A dedicated motion capture camera was used to determine the time taken to complete the task (seconds) and instrument distance traveled (meters). RESULTS: Among the experts, the mean time taken to perform the task on the 3D image was significantly quicker than on the 2D image, 40.2 seconds versus 51.2 seconds, P < .0001. Among the novices, the mean task time again was significantly quicker on the 3D image, 56.4 seconds versus 82.7 seconds, P < .0001. There was no significant difference in the mean time it took a novice to perform the task using a 3D camera compared with an expert on a 2D camera, 56.4 seconds versus 51.3 seconds, P = .3341. CONCLUSION: The use of a 3D image confers a significant performance advantage over a 2D camera in quantitatively measured laparoscopic skills for both experts and novices. The use of a 3D image appears to improve a novice's performance to the extent that it is not statistically different from an expert using a 2D image.

The LEAP™ Gesture Interface Device and Take-Home Laparoscopic Simulators: A Study of Construct and Concurrent Validity.

AIM: To assess the potential of the LEAP™ infrared motion tracking device to map laparoscopic instrument movement in a simulated environment. Simulator training is optimized when augmented by objective performance feedback. We explore the potential LEAP has to provide this in a way compatible with affordable take-home simulators. METHOD: LEAP and the previously validated InsTrac visual tracking tool mapped expert and novice performances of a standardized simulated laparoscopic task. Ability to distinguish between the 2 groups (construct validity) and correlation between techniques (concurrent validity) were the primary outcome measures. RESULTS: Forty-three expert and 38 novice performances demonstrated significant differences in LEAP-derived metrics for instrument path distance (P < .001), speed (P = .002), acceleration (P < .001), motion smoothness (P < .001), and distance between the instruments (P = .019). Only instrument path distance demonstrated a correlation between LEAP and InsTrac tracking methods (novices: r = .663, P < .001; experts: r = .536, P < .001). Consistency of LEAP tracking was poor (average % time hands not tracked: 31.9%). CONCLUSION: The LEAP motion device is able to track the movement of hands using instruments in a laparoscopic box simulator. Construct validity is demonstrated by its ability to distinguish novice from expert performances. Only time and instrument path distance demonstrated concurrent validity with an existing tracking method however. A number of limitations to the tracking method used by LEAP have been identified. These need to be addressed before it can be considered an alternative to visual tracking for the delivery of objective performance metrics in take-home laparoscopic simulators.

Early cholecystectomy in children with gallstone pancreatitis reduces readmissions.

BACKGROUND: Multiple guidelines exist in adult practice regarding the timing of cholecystectomy for gallstone pancreatitis. Current evidence to support their application to pediatric practice is minimal. This study sought to determine the effect of timing of cholecystectomy for gallstone pancreatitis in children on the risk of readmission. METHOD: All patients younger than 19years of age presenting to an acute NHS trust in England with a diagnosis of gallstone pancreatitis between 1 January 1999 and 31st December 2009 were included. Patient level data were extracted from the English Hospital Episode Statistic Database. ICD10, OPCS4.6 and hospital administrative data were used to determine: diagnosis, age, associated comorbidities and subsequent procedures performed. RESULTS: 670 cases of gallstone related pancreatitis were recorded in younger than 19 years old between 1999 and 2009 resulting in 3 deaths during this period. The majority (534/670) underwent a cholecystectomy which was performed less than two weeks from primary admission in 33% (174/534) of cases. Cholecystectomy within two weeks provides an actual risk reduction (ARR) of readmission of 57.5% (95% CI 50.1 to 64.4%, p<0.0001, NNT 2). No significant difference was identified in operative complications or mortality following early cholecystectomy in this group (p>0.05). CONCLUSIONS: Readmissions can be significantly reduced in this population by performing a cholecystectomy within two weeks with no apparent rise in surgical complications.

Virtual reality versus box laparoscopic simulators in trainee selection and aptitude testing.

BACKGROUND: The purpose of this study was to compare the validity of high-fidelity and low-fidelity simulators in a selection center environment, using measures of construct and concurrent validity. METHODS: A total of 46 novice and expert participants were tested on both the low-fidelity Fundamentals of Laparoscopic Surgery (FLS) box trainer and the high fidelity, Lapsim, virtual reality laparoscopic simulator. Outcome scores and performance metrics where recorded. RESULTS: Experts performed better than novices on the FLS (median 71% vs. 51%; P<0.0001) but not the Lapsim (59.1% vs. 57.1%; P = 0.41). No correlation was found between overall Lapsim metrics and FLS outcome scores (correlation = -0.024; P = 0.874). Although most novice participants performed within a narrow window on the FLS simulator, a few high-performing and low-performing outliers where identified. CONCLUSIONS: In a selection center scenario, testing with low-fidelity platforms appears to demonstrate greater validity. Outliers can be identified using low-fidelity simulators.

Accessible laparoscopic instrument tracking ("InsTrac"): construct validity in a take-home box simulator.

INTRODUCTION: Objective performance feedback has potential to maximize the training benefit of laparoscopic simulators. Instrument movement metrics are, however, currently the preserve of complex and expensive systems. We aimed to develop and validate affordable, user-ready software that provides objective feedback by tracking instrument movement in a "take-home" laparoscopic simulator. MATERIALS AND METHODS: Computer-vision processing tracks the movement of colored bands placed around the distal instrument shafts. The position of each instrument is logged from the simulator camera feed and movement metrics calculated in real time. Ten novices (junior doctors) and 13 general surgery trainees (StR) (training years 3-7) performed a standardized task (threading string through hoops) on the eoSim (eoSurgical™ Ltd., Edinburgh, Scotland, United Kingdom) take-home laparoscopic simulator. Statistical analysis was performed using unpaired t tests with Welch's correction. RESULTS: The software was able to track the instrument tips reliably and effectively. Significant differences between the two groups were observed in time to complete task (StR versus novice, 2 minutes 33 seconds versus 9 minutes 53 seconds; P=.01), total distance traveled by instruments (3.29 m versus 11.38 m, respectively; P=.01), average instrument motion smoothness (0.15 mm/second(3) versus 0.06 mm/second(3), respectively; P<.01), and handedness (mean difference between dominant and nondominant hand) (0.55 m versus 2.43 m, respectively; P=.03). There was no significant difference seen in the distance between instrument tips, acceleration, speed of instruments, or time off-screen. CONCLUSIONS: We have developed software that brings objective performance feedback to the portable laparoscopic box simulator. Construct validity has been demonstrated. Removing the need for additional motion-tracking hardware makes it affordable and accessible. It is user-ready and has the potential to enhance the training benefit of portable simulators both in the workplace and at home.

Utility of sonographic assessment of the position of the third part of the duodenum using water instillation in intestinal malrotation: a single-center retrospective audit.

BACKGROUND: Intestinal malrotation and particularly volvulus are potentially devastating conditions. Upper gastrointestinal (UGI) contrast studies have been considered the gold standard for diagnosis. However the use of ultrasonography (US) has been increasingly described. We describe a method for delineating the duodenal anatomy with US as a means to exclude malrotation. OBJECTIVE: To report our experience using US to assess intestinal rotation. MATERIALS AND METHODS: We conducted a retrospective audit of US scans performed at a tertiary referral centre to exclude malrotation for paediatric surgery between 2008 and 2011. RESULTS: One hundred thirty-nine infants were included, of whom 114 had a normal US scan. Of the 114, nine had subsequent upper gastrointestinal contrast studies that confirmed the initial results; there were no false-negatives. There were abnormal US scans in four infants associated with midgut volvulus and malrotation; there were no false-positives. The other 21 US scans were equivocal, and 11 of these had a confirmatory UGI contrast study; only one required surgery to correct malrotation. CONCLUSION: US has been a safe and effective tool in the assessment of intestinal rotation at our institution. The main advantages of US imaging are its lack of ionising radiation and its rapid and accurate diagnosis of volvulus.

Validating the use of smartphone-based accelerometers for performance assessment in a simulated neurosurgical task.

BACKGROUND: Reductions in working hours affect training opportunities for surgeons. Surgical simulation is increasingly proposed to help bridge the resultant training gap. For simulation training to translate effectively into the operating theater, acquisition of technical proficiency must be objectively assessed. Evaluating "economy of movement" is one way to achieve this. OBJECTIVE: We sought to validate a practical and economical method of assessing economy of movement during a simulated task. We hypothesized that accelerometers, found in smartphones, provide quantitative, objective feedback when attached to a neurosurgeon's wrists. METHODS: Subjects (n = 25) included consultants, senior registrars, junior registrars, junior doctors, and medical students. Total resultant acceleration (TRA), average resultant acceleration, and movements with acceleration >0.6g (suprathreshold acceleration events) were recorded while subjects performed a simulated dural closure task. RESULTS: Students recorded an average TRA 97.0 ± 31.2 ms higher than senior registrars (P = .03) and 103 ± 31.2 ms higher than consultants (P = .02). Similarly, junior doctors accrued an average TRA 181 ± 31.2 ms higher than senior registrars (P < .001) and 187 ± 31.2 ms higher than consultants (P < .001). Significant correlations were observed between surgical outcome (as measured by quality of dural closure) and both TRA (r = .44, P < .001) and number of suprathreshold acceleration events (r = .33, P < .001). TRA (219 ± 66.6 ms; P = .01) and number of suprathreshold acceleration events (127 ± 42.5; P = .02) dropped between the first and fourth trials for junior doctors, suggesting procedural learning. TRA was 45.4 ± 17.1 ms higher in the dominant hand for students (P = .04) and 57.2 ± 17.1 ms for junior doctors (P = .005), contrasting with even TRA distribution between hands (acquired ambidexterity) in senior groups. CONCLUSION: Data from smartphone-based accelerometers show construct validity as an adjunct for assessing technical performance during simulation training.

Construct, concurrent, and content validity of the eoSim laparoscopic simulator.

BACKGROUND: The purpose of this study was to validate the eoSim box laparoscopic simulator using measures of construct, concurrent, and content validity. SUBJECTS AND METHODS: Forty-seven novice and expert participants were tested on both the Fundamentals of Laparoscopic Surgery (FLS™; Society of American Gastrointestinal and Endoscopic Surgeons, Los Angles, CA) and eoSim (eoSurgical™, Edinburgh, Scotland, United Kingdom) laparoscopic simulators, using established scoring mechanisms. Three skill areas were examined: object transfer, precision cutting, and intracorporeal suturing. A questionnaire was also completed. RESULTS: Experts performed significantly better on the eoSim than novices, with a median score of 51.1% versus 14.8% (P<.0001), showing construct validity. There was a high correlation between performance on the validated FLS simulator and the eoSim (0.78; P<.0001), demonstrating concurrent validity. Feedback from participants indicated an agreement that the eoSim was a useful training tool providing content validity. CONCLUSIONS: The eoSim demonstrates validity as a model for laparoscopic simulation. It is hoped that its decreased cost relative to other simulators will encourage increased uptake by trainees and institutions.

Successful treatment of disseminated mucormycosis in a neutropenic patient with T-cell acute lymphoblastic leukaemia.

Mucormycosis is a rare angioinvasive fungal infection, more commonly seen in immunosuppressed patients, with reported mortality rates of 95% in disseminated disease. We present a case report of a patient with T-cell acute lymphoblastic leukaemia who developed disseminated infection with mucormycosis (involving the pancreas, left occipital lobe, right lower lobe of lung, appendix and right kidney) after having completed induction and consolidation chemotherapy. Growth of Lichtheimia corymbifera was initially isolated following a right pleural tap with fungal elements identified repeatedly on subsequent pathology specimens. Following radical surgical debridement and concurrent treatment with combination antifungal therapy, the patient survived. This case demonstrates that aggressive multisite surgical de-bulking of disseminated fungal foci, in conjunction with combination antifungal therapy and reversal of immunosuppression, can result in survival despite the grave prognosis associated with disseminated mucormycosis.

Thymectomy for inducing remission in juvenile myasthenia gravis.

PURPOSE: The aim of this study was to determine the efficacy of thymectomy to induce remission in juvenile myasthenia gravis. METHODS: A retrospective review of all patients undergoing a thymectomy for the treatment of juvenile myasthenia gravis was performed at a single tertiary referral centre between 1997 and 2009 (N = 8). All cases were moderate to severe cases (Osserman stage ≥ 2a). All operations were open. Median follow-up was 18 months (range 1-77). Postoperative progress was assessed using the De Filippi classification of remission. MAIN RESULTS: Only two minor complications were reported. Mean operative time was 120 min (range 80-290 min). Mean postoperative stay was 17 days (range 3-52 days). Remission was observed in 5 of 8 patients (62%) at last known follow up. CONCLUSIONS: Spontaneous remission rates for myasthenia gravis are quoted to be between 20 and 29% while remission rates following thymectomy are 29-68% at 3 years. Although not all of our patients have had 3 years of follow up-the remission rate of 62% demonstrated by this study is encouraging. If reproducible over a larger series this provides evidence of the efficacy of thymectomy for treating juvenile myasthenia gravis in selected patients.

Central venous line dressings: can you stick it?

AIM: The objective of this study is to investigate which central venous catheter dressing is most secure. BACKGROUND: Central venous catheter insertion is a common procedure. A secure dressing is essential to prevent early line displacement. Many different dressings are used, but there is no consensus in choosing an optimal dressing. METHODS: A sandwich, loop-line, or bridge technique was used to apply each of the dressings. Two mechanisms of displacement were tested: dressing adherence to skin and dressing adherence to line. Dressing to skin adherence was tested on a relatively hairless part of the upper arm. Weights were added sequentially until the dressing peeled off. Dressing to line adherence was tested by applying the dressing to a 7F Dual Lumen Bard Hickman line passing through a piece of foam (measuring 13 x 12 cm). Weights were attached to the line until the cuff was pulled through the foam. RESULTS: Dressing to skin adherence was poorest for the clear dressings, followed by Mefix and Sleek, and greatest for a combination of Tegaderm and Mefix. Dressing to line adherence was improved using a sandwich technique instead of a loop-line technique and most secure when a bridge technique was used to the thicker shaft of the line. CONCLUSIONS: The dressings used for securing Hickman lines are not all equally secure. The least effective is the IV 3000 loop-line dressing. Tegaderm-Mefix bridge and Tegaderm-Mefix-Sleek combination dressings are the most secure and cost effective.

Pancreatic tissue in congenital segmental dilatation of intestine: case presentation and recommendation for treatment.

Segmental dilatation of intestine (SDI) is a very uncommon condition affecting children. The case that we present suggests that SDI may have may histologic findings in common with vitellointestinal remnants. A limited resection or other minimal procedure to preserve bowel length is usually undertaken for SDI. However, this case illustrates that the dilated segments of small bowel should be completely excised, in the same fashion as for vitellointestinal duct remnants, because of the possible presence of ectopic gastric mucosa and exocrine pancreatic tissue.