Does Patient Blood Management Affect Outcomes in Metastatic Spine Tumour Surgery? A Review of Current Concepts.

STUDY DESIGN: Narrative review. OBJECTIVE: The spine is the most common site of metastases, associated with decreased quality of life. Increase in metastatic spine tumour surgery (MSTS) has caused us to focus on the management of blood, as blood loss is a significant morbidity in these patients. However, blood transfusion is also not without its own risks, and hence this led to blood conservation strategies and implementation of a concept of patient blood management (PBM) in clinical practise focusing on these patients. METHODS: A narrative review was conducted and all studies that were related to blood management in metastatic spine disease as well as PBM surrounding this condition were included. RESULTS: A total of 64 studies were included in this review. We discussed a new concept of patient blood management in patients undergoing MSTS, with stratification to pre-operative and intra-operative factors, as well as anaesthesia and surgical considerations. The studies show that PBM and reduction in blood transfusion allows for reduced readmission rates, lower risks associated with blood transfusion, and lower morbidity for patients undergoing MSTS. CONCLUSION: Through this review, we highlight various pre-operative and intra-operative methods in the surgical and anaesthesia domains that can help with PBM. It is an important concept with the significant amount of blood loss expected from MSTS. LEVEL OF EVIDENCE: Not applicable.

Research priorities in regional anaesthesia: an international Delphi study.

BACKGROUND: Regional anaesthesia use is growing worldwide, and there is an increasing emphasis on research in regional anaesthesia to improve patient outcomes. However, priorities for future study remain unclear. We therefore conducted an international research prioritisation exercise, setting the agenda for future investigators and funding bodies. METHODS: We invited members of specialist regional anaesthesia societies from six continents to propose research questions that they felt were unanswered. These were consolidated into representative indicative questions, and a literature review was undertaken to determine if any indicative questions were already answered by published work. Unanswered indicative questions entered a three-round modified Delphi process, whereby 29 experts in regional anaesthesia (representing all participating specialist societies) rated each indicative question for inclusion on a final high priority shortlist. If ≥75% of participants rated an indicative question as 'definitely' include in any round, it was accepted. Indicative questions rated as 'definitely' or 'probably' by <50% of participants in any round were excluded. Retained indicative questions were further ranked based on the rating score in the final Delphi round. The final research priorities were ratified by the Delphi expert group. RESULTS: There were 1318 responses from 516 people in the initial survey, from which 71 indicative questions were formed, of which 68 entered the modified Delphi process. Eleven 'highest priority' research questions were short listed, covering themes of pain management; training and assessment; clinical practice and efficacy; technology and equipment. CONCLUSIONS: We prioritised unanswered research questions in regional anaesthesia. These will inform a coordinated global research strategy for regional anaesthesia and direct investigators to address high-priority areas.

Telesimulation in healthcare education: A scoping review.

OBJECTIVES: To provide a comprehensive overview on the utilization and effectiveness of telesimulation in healthcare education. DESIGN: A scoping review. DATA SOURCES: A search of five databases including PubMed, Web of Science, Cochrane, EMBASE and ProQuest was conducted between 2000 and 2022. REVIEW METHODS: Arksey and O' Malley's scoping review framework was utilised. Data were narratively synthesised. RESULTS: 29 articles were included. More than half of the publications on telesimulation were borne out of need during the COVID-19 pandemic. Innovation reports were the most prevalent publications followed by descriptive studies. Telesimulation was applied for the delivery of diverse learning content including patient care management, procedural skills and team training. A variety of videoconferencing software and simulation modalities have been used for telesimulation. Telesimulation was generally well-received, despite its technical challenges. Learning effectiveness of telesimulation was evident in quasi-experimental studies. CONCLUSION: Telesimulation has been gaining acceptance as a distance-based simulation education modality. It will continue to evolve and potentially blend with in-person simulation. More rigorous research is warranted to evaluate learning outcomes and establish best practices in telesimulation.

Twelve tips for developing a systematic acute care curriculum for medical students.

There are inadequacies in the practice-readiness of junior doctors for providing acute care in areas of clinical deterioration. In addition, the existing undergraduate curricula are fragmented in how acute care is taught in medical schools. We propose twelve tips for developing a systematic acute care curriculum, including what to teach, how to teach it and, how to assess. Furthermore, we propose and incorporate an acute care learning dashboard as an assessment tool which collates and demonstrates the occurrence of learning, faculty feedback, and students' reflection. We also summarise the existing online resources available for acute care training. We hope to address the existing issues and improve acute care training to prepare the graduates to become practice-ready professionals.

Desktop Virtual Reality Versus Face-to-Face Simulation for Team-Training on Stress Levels and Performance in Clinical Deterioration: a Randomised Controlled Trial.

BACKGROUND: Simulation-based education can equip healthcare providers with the ability to respond to and manage stressors associated with rapidly deteriorating patient situations. However, little is known about the benefits of using virtual reality (VR) for this purpose. OBJECTIVE: To compare between desktop VR and face-to-face simulation in stress responses and performance outcomes of a team-based simulation training in managing clinical deterioration. DESIGN: A randomised controlled study METHOD: The study was conducted on 120 medical and nursing students working in interprofessional teams. The teams were randomly assigned to participate in a 2-h simulation using either the desktop VR or face-to-face simulation with simulated patient (SP). Biophysiological stress response, psychological stress, and confidence levels were measured before and after the simulation. Performance outcomes were evaluated after the simulation using a deteriorating patient scenario. RESULTS: The systolic blood pressure and psychological stress response were significantly increased among participants in VR and SP groups; however, no significant differences were found between the groups. There was also no significant difference in confidence and performance outcomes between participants in the VR and SP groups for both medical and  nursing students. Although the psychological stress response was negatively correlated (r = -0.43; p < 0.01) with confidence levels, there was no association between stress response and performance score. CONCLUSION: Despite being less immersive, the desktop VR was capable of inducing psychological and physiological stress responses by placing emotional, social, and cognitive demands on learners. Additionally, by ensuring close alignment between the simulation tasks and the clinical tasks (i.e. functional fidelity), the desktop VR may provide similar performance outcomes as conventional simulation training. This evidence is timely given the rise in the use of virtual learning platforms to facilitate training during the COVID-19 pandemic where face-to-face training may not be feasible. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov NCT04330924.

Mobile learning in clinical settings: unveiling the paradox / 한국의학교육

Purpose@#The use of mobile devices among medical students and residents to access online material in real-time has become more prevalent. Most literature focused on the technical/functional aspects of mobile use. This study, on the other hands, explored students, doctors and patients’ preferences and reasons towards the use of mobile devices in clinical settings underpinned by the Technology Acceptance Model 2 (TAM 2). @*Methods@#This research employs an exploratory research design using survey and semi-structured interviews. An online survey was administered to clinical year medical students, followed by semi-structured interviews with the doctors and patients. Questions for the online survey and semi-structured interviews were derived from previous literature and was then reviewed by authors and an expert panel. A convenience sampling was used to invite voluntary participants. @*Results@#Survey findings showed that most medical students used their devices to find drug information and practice guidelines. The majority of the students accessed UpToDate followed by Google to access medical resources. Key barriers that students often encountered during the use of mobile devices were internet connectivity in the clinical settings, reliability of the information, and technical issues. Thematic analysis of the interviews revealed four themes: general usage by students, receptivity of the use of mobile devices by students, features in selecting resources for mobile learning, and limitation in the current use of mobile devices for learning. @*Conclusion@#The findings from this study assist in recommending suitable material using mobile devices to enhance learning in the clinical environment and expand the TAM 2.

In the Extraordinary Times of Coronavirus Disease 2019: Clinical Strategies for Performing Spinal Surgery.

The coronavirus disease 2019 (COVID-19) pandemic has caused pronounced strain on global healthcare systems, forcing the streamlining of clinical activities and conservation of health resources. There is a pressing need for institutions to present discipline-specific strategies for the management of COVID-19 patients. We present the comprehensive considerations at the National University Hospital, Singapore from the surgeon's and anesthetist's perspectives in the performance of spinal surgery in COVID-19 patients. These are based on national guidelines and overarching principles of protection for the healthcare workers (HCWs) and efficiency in surgical planning. The workflow begins with the emergency department screening that has been adapted to the local epidemiology of COVID-19 in order to identify suspected/confirmed cases. If patient history cannot be obtained, demographic, clinical, and imaging data are used. Designated orthopedic "contaminated teams" are available 24/7 with an activation time of <30 minutes for review. In cases where sub-specialty spine surgeons were required, these professionals were inducted into the "contaminated team" and quarantined until cleared to return to work. Indications for emergency spine surgery were determined pre-emptively. Preoperative surgical considerations included the minimization of manpower, limited dissection, reduced operative time, and judicious use of equipment, leading to reduced aerosolization. Anesthesia considerations include preoperative screening for COVID-19-related concerns that influence surgery, operating room process planning and induction, intraoperative, reversal, recovery, and resuscitation considerations. Focused multi-disciplinary preoperative briefing facilitates familiarization. Surgical, anesthetic, and postoperative workflows were designed to reduce the risk of transmission and protect HCWs while effectively performing spinal surgery. The COVID-19 pandemic has necessitated paradigm shifts in healthcare planning, hospital workflows, and operative protocols. The viral burden does not discriminate between surgeons and physicians, and it is crucial that we, as medical professionals, adapt practices to be malleable and fluid to address the ever-changing developments.

Considerations for Continuing Simulation Training During Infectious Outbreaks.

STATEMENT: Healthcare simulation training can be significantly disrupted by infectious disease outbreaks, yet it is a key component in several important medical education activities, such as resuscitation refresher training and high-stakes prelicensure healthcare examinations. This article details the strategic and tactical considerations for continuing simulation training during infectious disease outbreaks. A framework of graded responses, titrated to outbreak severity, is provided from the perspective of an academic medical center managing simulation training during the early stage of the now global coronavirus disease 2019 outbreak.

A BEME systematic review of teaching interventions to equip medical students and residents in early recognition and prompt escalation of acute clinical deteriorations: BEME Guide No. 62.

Background: Current educational interventions and teaching for acute deteriorations seem to address acute care learning in discreet segments. Technology enhanced and team training methodologies are in vogue though well studied in the nursing profession, teaching avenues for junior 'doctors in training' seem to be a lacuna.Aims: The BEME systematic review was designed to (1) appraise the existing published evidence on educational interventions that are intended for 'doctors in training' to teach early recognition and prompt escalation in acute clinical deteriorations (2) to synthesise evidence & to evaluate educational effectiveness.Methodology: The method applied was a descriptive, justification & clarification review. Databases searched included PubMed, PsycINFO, Science Direct and Scopus for original research and grey literature with no restrictions to year or language. Abstract review, full text decisions and data extraction were completed by two primary coders with final consensus by a third reviewer.Results: 5592 titles and abstracts were chosen after removal of 905 duplications. After exclusion of 5555 studies, 37 full text articles were chosen for coding. 22 studies met final criteria of educational effectiveness, relevance to acute care. Educational platforms varied from didactics to blended learning approaches, small group teaching sessions, simulations, live & cadaveric tissue training, virtual environments and insitu team-based training. Translational outcomes with reduction in long term (up to 3-6 years) morbidity & mortality with financial savings were reported by 18% (4/22) studies. Interprofessional training were reported in 41% (9/22) of studies. Recent evidence demonstrated effectiveness of virtual environment and mobile game-based learning.Conclusions: There were significant improvements in teaching initiatives with focus on observable behaviours and translational real patient outcomes. Serious game-based learning and virtual multi-user collaborative environments might enhance individual learners' cognitive deliberate practice. Acute care learning continuum with programmatic acute care portfolios could be a promise of the future.

Continuing medical education during a pandemic: an academic institution's experience.

The COVID-19 pandemic has affected healthcare systems worldwide. The disruption to hospital routines has affected continuing medical education (CME) for specialty trainees (STs). We share our academic institution's experience in mitigating the disruption on the CME programme amidst the pandemic. Most specialty training programmes had switched to videoconferencing to maintain teaching. Some programmes also utilized small group teachings with precautions and e-learning modules. Surgical residencies were disproportionately affected due to reductions in elective procedures but some ways to provide continued surgical exposure include going through archived surgical videos with technical pointers from experienced faculty and usage of surgical simulators . We should adapt CME sessions to keep trainees up to date with core clinical competencies as they will continue to manage both COVID-19 and non-COVID-19 cases and this pandemic may last until year's end.

Coordinated responses of academic medical centres to pandemics: Sustaining medical education during COVID-19.

Background: The Corona Virus Disease-19 (COVID-19) has been declared a pandemic by the World Health Organization (WHO). We state the consolidated and systematic approach for academic medical centres in response to the evolving pandemic outbreaks for sustaining medical education.Discussion: Academic medical centres need to establish a 'COVID-19 response team' in order to make time-sensitive decisions while managing pandemic threats. Major themes of medical education management include leveraging on remote or decentralised modes of medical education delivery, maintaining the integrity of formative and summative assessments while restructuring patient-contact components, and developing action plans for maintenance of essential activities based on pandemic risk alert levels. These core principles must be applied seamlessly across the various fraternities of academic centres: undergraduate education, residency training, continuous professional development and research. Key decisions from the pandemic response teams that help to minimise major disruptions in medical education and to control disease transmissions include: minimising inter-cluster cross contaminations and plans for segregation within and among cohorts; reshuffling academic calendars; postponing or restructuring assessments.Conclusions: While minimising the transmission of the pandemic outbreak within the healthcare establishments is paramount, medical education and research activities cannot come to a standstill each time there is a threat of one.

Reconfiguring the scope and practice of regional anesthesia in a pandemic: the COVID-19 perspective.

The COVID-19 outbreak is on the world. While many countries have imposed general lockdown, emergency services are continuing. Healthcare professionals have been infected with the virulent severe acute respiratory syndrome coronavirus-2 (SARS), which spreads by close contact and aerosols. The anesthesiologist is particularly vulnerable to aerosols while performing intubation and other airway related procedures. Regional anesthesia (RA) minimizes the need for airway manipulation and the risks of cross infection to other patients, and the healthcare personnel. In this context, for prioritizing RA over general anesthesia, wherever possible, a structured algorithmic approach is outlined. The role of percentage saturation of hemoglobin with oxygen (oxygen saturation), blood pressure and early use of point-of-care ultrasound in differential diagnosis and specific management is detailed. The perioperative anesthetic implications of multisystem manifestations of COVID-19, anesthetic management options, the scope of RA and considerations for its safe conduct in operating rooms is described. An outline for safe and rapid training of healthcare personnel, with an Entrustable Professional Activity framework for ascertaining the practice readiness among trained residents for RA in COVID-19, is suggested. These are the authors' experiences gained from the current pandemic and similar SARS, Middle East Respiratory Syndrome and influenza outbreaks in recent past faced by our authors in Singapore, India, Hong Kong and Canada.

Care of the pregnant woman with coronavirus disease 2019 in labor and delivery: anesthesia, emergency cesarean delivery, differential diagnosis in the acutely ill parturient, care of the newborn, and protection of the healthcare personnel.

Coronavirus disease 2019, caused by the severe acute respiratory syndrome coronavirus 2, has been declared a pandemic by the World Health Organization. As the pandemic evolves rapidly, there are data emerging to suggest that pregnant women diagnosed as having coronavirus disease 2019 can have severe morbidities (up to 9%). This is in contrast to earlier data that showed good maternal and neonatal outcomes. Clinical manifestations of coronavirus disease 2019 include features of acute respiratory illnesses. Typical radiologic findings consists of patchy infiltrates on chest radiograph and ground glass opacities on computed tomography scan of the chest. Patients who are pregnant may present with atypical features such as the absence of fever as well as leukocytosis. Confirmation of coronavirus disease 2019 is by reverse transcriptase-polymerized chain reaction from upper airway swabs. When the reverse transcriptase-polymerized chain reaction test result is negative in suspect cases, chest imaging should be considered. A pregnant woman with coronavirus disease 2019 is at the greatest risk when she is in labor, especially if she is acutely ill. We present an algorithm of care for the acutely ill parturient and guidelines for the protection of the healthcare team who is caring for the patient. Key decisions are made based on the presence of maternal and/or fetal compromise, adequacy of maternal oxygenation (SpO2 >93%) and stability of maternal blood pressure. Although vertical transmission is unlikely, there must be measures in place to prevent neonatal infections. Routine birth processes such as delayed cord clamping and skin-to-skin bonding between mother and newborn need to be revised. Considerations can be made to allow the use of screened donated breast milk from mothers who are free of coronavirus disease 2019. We present management strategies derived from best available evidence to provide guidance in caring for the high-risk and acutely ill parturient. These include protection of the healthcare workers caring for the coronavirus disease 2019 gravida, establishing a diagnosis in symptomatic cases, deciding between reverse transcriptase-polymerized chain reaction and chest imaging, and management of the unwell parturient.

Ideal Sequence of Didactic Lectures and Simulation in Teaching Transesophageal Echocardiography Among Anesthesiologists.

OBJECTIVE: Performing a basic perioperative transesophageal echocardiography (TEE) requires 3-dimensional knowledge of cardiac anatomy, psychomotor skills, and image interpretation. Commonly, lectures followed by simulation sequence is used for teaching TEE. Differences may occur among learners when this sequencing of instructional components is altered. The authors investigated the ideal sequence of lectures and simulation in teaching basic perioperative TEE. DESIGN: Prospective randomized comparative study. SETTING: Simulation room in a large academy tertiary care center. PARTICIPANTS: Noncardiac anesthesiologists in Singapore with no prior knowledge of TEE. INTERVENTION: Comparison of acquisition and retention of knowledge and skills between the lecture followed by simulation group (LS) and the simulation followed by lecture (SL) group. MEASUREMENTS AND MAIN RESULTS: Knowledge was assessed using multiple-choice questions (MCQs) and skills using a skill test. The primary outcome measured was the MCQ scores (post-course and retest) and the skill test scores (post-course and retest). Of the 43 anesthesiologists who were recruited, 22 were randomized into the LS group and 21 to the SL group. All participants took pre-course and post-course MCQs and post-course skill tests. Post-tests were repeated 1 month after the course to assess retention. There was no significant difference in the post-course MCQ (85.87% v 81.82%) and skill test scores (85.78% v 81.55%) between the SL and LS groups, respectively. The SL group demonstrated significantly better retention of knowledge at 1 month (MCQ score 83.5% v 72.73%; p = 0.003) and skills (skill test score 85.32% v 1.90%; p = 0.016) than the other. CONCLUSION: This study showed that, for retention (at 1 month) of both knowledge and skills, it is preferable to teach practical skills followed by theoretical knowledge to anesthesiologists who are complete novices to TEE.

Echocardiography for Intraoperative Decision Making in Mitral Valve Surgery-A Pilot Simulation-Based Training Module.

Echocardiographic assessment of the repaired or replaced mitral valve intraoperatively involves making a high-impact joint decision with the surgeon, in a time-sensitive manner, in a dynamic clinical situation. These decisions have to take into account the degree of imperfection if any, the likelihood of obtaining a better result, the underlying condition of the patient, and the impact of a longer cardiopulmonary bypass period if the decision is made to reintervene. Traditional echocardiography teaching is limited in its ability to provide this training. The authors report the development and implementation of a training module simulating the dynamic clinical environment of a mitral valve surgery in progress and the critical echo-based intraoperative decision making involved in the assessment of the acceptability of the surgical result.