Developing a Robotic Surgery Curriculum: Selection of Virtual Reality Drills for Content Alignment.

INTRODUCTION: Despite the importance of simulation-based training for robotic surgery, there is no consensus about its training curricula. Recently, a virtual reality (VR) platform (SimNow, Intuitive, Inc) was introduced with 33 VR drills but without evidence of their validity. As part of our creating a new robotic VR curriculum, we assessed the drills' validity through content mapping and the alignment between learning goals and drill content. METHODS: Three robotically trained surgeons content-mapped all 33 drills for how well the drills incorporated 15 surgery skills and also rated the drills' difficulty, usefulness, relevance, and uniqueness. Drills were added to the new curriculum based on consensus about ratings and historic learner data. The drills were grouped according to similar skill sets and arranged in order of complexity. RESULTS: The 33 drills were judged to have 12/15 surgery skills as primary goals and 13/15 as secondary goals. Twenty of the 33 drills were selected for inclusion in the new curriculum; these had 11/15 skills as primary goals and 11/15 as secondary goals. However, skills regarding energy sources, atraumatic handling, blunt dissection, fine dissection, and running suturing were poorly represented in the drills. Three previously validated inanimate drills were added to the curriculum to address lacking skill domains. CONCLUSIONS: We identified 20 of the 33 SimNow drills as a foundation for a robotic surgery curriculum based on content-oriented evidence. We added 3 other drills to address identified gaps in drill content.

Defining the Price Tag of Complications Following Pancreatic Surgery: A US National Perspective.

INTRODUCTION: Pancreatic surgery tends to have a high rate of postoperative complications due to its complex nature, significantly increasing hospital costs. Our aim was to describe the true association between complications and hospital costs in a national cohort of US patients. METHODS: The National Inpatient Sample was used to conduct a retrospective analysis of elective pancreatic resections performed between 2004 and 2017, categorizing them based on whether patients experienced major complications (MaC), minor complications (MiC), or no complications (NC). Multivariable quantile regression was used to analyze how costs varied at different percentiles of the cost curve. RESULTS: Of 37,893 patients, 45.3%, 28.6%, and 26.1% experienced NC, MiC, and MaC, respectively. Factors associated with MaC were a Charlson Comorbidity Index of ≥4, prolonged length of stay, proximal pancreatectomy, older age, male sex, and surgery performed at hospitals with a small number of beds or at urban nonteaching hospitals (all P < 0.01). Multivariable quantile regression revealed significant variation in MiC and MaC across the cost curve. At the 50th percentile, MiC increased the cost by $3352 compared to NC while MaC almost doubled the cost of the surgery, increasing it by $20,215 (both P < 0.01). The association between complications and cost was even greater at the 95th percentile, increasing the cost by $10,162 and $108,793 for MiC and MaC, respectively (P < 0.01). CONCLUSIONS: MiC and MaC were significantly associated with increased hospital costs. Furthermore, the relationship between MaC and costs was especially apparent at higher percentiles of the cost curve.

Defining benchmarks for fellowship training in foregut surgery: a 10-year review of fellowship council index cases.

INTRODUCTION: Surgical treatment of foregut disease is a complex field that demands advanced expertise to ensure favorable outcomes for patients. To address the growing need for foregut surgeons, leaders within several national societies have become interested in developing a foregut fellowship. The aim of this study was to develop data-driven benchmarks that will aid in defining appropriate accreditation criteria for these fellowships. METHODS: We obtained case log data for Fellowship Council fellows trained from 2009-2019. We identified 78 complex foregut (non-bariatric) case codes and divided them into 5 index case categories including (1) hiatal/paraoesophageal hernia repair, (2) fundoplication, (3) esophageal myotomy, (4) major organ resection, and (5) minor organ resection. Median volumes in each index category were compared over time using Kruskall-Wallis tests. The share of cases done using open, laparoscopic, or robotic approaches were analyzed using linear regression analysis. RESULTS: For the 10 years analyzed, 1362 fellows logged 82,889 operations and 111,799 endoscopies. Median foregut cases per fellow grew significantly from 42 (IQR = 24-74) cases in 2010 to 69 (IQR = 33-106) cases in 2019. Median endoscopy volumes also grew significantly from 42 (IQR = 7-88) in 2010 to 69 (IQR 32-123) in 2019.The volume of hiatal/paraoesophageal hernia repairs increased significantly over time while volumes in the remaining 4 index categories remained stable. The share of robotic cases exhibited near perfect linear growth from 2.2% of all foregut cases in 2010 to 14.4% in 2019 (R = 0.99, p < 0.0001). Open cases exhibited linear decay from 7.2% of cases in 2010 to 4.7% of cases in 2019 (R = 0.92, p = 0.0001). Laparoscopic/thoracoscopic cases also exhibited linear decay from 90.6% of cases in 2010 to 80.9% of cases in 2019 (R = 0.98, p < 0.00001). CONCLUSIONS: FC fellows are exposed to robust volumes of foregut cases. This rich data set provides an evidence-based guide for establishing criteria for potential foregut fellowships.

Feasibility, effectiveness and transferability of a novel mastery-based virtual reality robotic training platform for general surgery residents.

BACKGROUND: The annual number of robotic surgical procedures is on the rise. Robotic surgery requires unique skills compared to other surgical approaches. Simulation allows basic robot skill acquisition and enhances patient safety. The purpose of this study was to evaluate the feasibility, effectiveness, and transferability of a mastery-based curriculum using a new virtual reality (VR) robotic simulator for surgery resident training. METHODS: Nineteen PGY2s and 22 PGY4s were enrolled. Residents completed a pretest and posttest consisting of five VR and three previously validated inanimate tasks. Training included practicing 33 VR tasks until a total score ≥ 90% ("mastery") was achieved using automated metrics (time, economy of motion). Inanimate performance was evaluated by two trained, blinded raters using video review metrics (time, errors, and modified OSATS). Outcomes were defined as: curriculum feasibility (completion rate, training time, repetitions), training effectiveness (pre/post training skill improvement), and skill transferability (skill transfer to validated inanimate drills). Wilcoxon signed-rank and Mann-Whitney U tests were used; median (IQR) reported. RESULTS: Thirty-four of 41 residents (83%) achieved mastery on all 33 VR tasks; median training time was 7 h (IQR: 5'26″-8'52″). Pretest vs. post-test performance improved (all p < 0.001) according to all VR and Inanimate metrics for both PGY2 and PGY4 residents. Significant pretest performance differences were observed between PGY2 and PGY4 residents for VR but not inanimate tasks; no PGY2 vs. PGY4 posttest performance differences were observed for both VR and inanimate tasks. CONCLUSION: This mastery-based VR curriculum was associated with a high completion rate and excellent feasibility. Significant performance improvements were noted for both the VR and inanimate tasks, supporting training effectiveness and skill transferability. Additional studies examining validity evidence may help further refine this curriculum.

Characterization of retardance spatial variations over the aperture of liquid-crystal variable retarders.

We present a comparison of two experimental methods to measure retardance as a function of applied voltage and as a function of position over the aperture of liquid-crystal variable retarders. These measurements are required for many applications, particularly in polarimetry. One method involves the scan of an unexpanded laser beam over the aperture, and the other uses an expanded beam from a LED and a CCD camera to measure the full aperture with a single measurement. The first method is time consuming, is limited in the measured spatial resolution, and requires more expensive equipment to perform the scan, whereas the second method is low cost, with the spatial resolution of the CCD, and fast, but in principle has variations of the incident beam over the aperture that affect the measured retardance values. The results obtained show good agreement for the average values of retardance for the two methods, but the expanded-beam method shows more noise, particularly close to the voltage values at which the variable-retarder retardance versus voltage curves are unwrapped. These retardance variations can be reduced by smoothing the retardance image, which makes the expanded-beam method an attractive method for polarimetry applications since it gives the complete information in the full aperture of the device with the additional advantages of low cost, simplicity, and being less time consuming.

RGS14414 treatment induces memory enhancement and rescues episodic memory deficits.

Memory deficits affect a large proportion of the human population and are associated with aging and many neurologic, neurodegenerative, and psychiatric diseases. Treatment of this mental disorder has been disappointing because all potential candidates studied thus far have failed to produce consistent effects across various types of memory and have shown limited to no effects on memory deficits. Here, we show that the promotion of neuronal arborization through the expression of the regulator of G-protein signaling 14 of 414 amino acids (RGS14414) not only induced robust enhancement of multiple types of memory but was also sufficient for the recovery of recognition, spatial, and temporal memory, which are kinds of episodic memory that are primarily affected in patients or individuals with memory dysfunction. We observed that a surge in neuronal arborization was mediated by up-regulation of brain-derived neurotrophic factor (BDNF) signaling and that the deletion of BDNF abrogated both neuronal arborization activation and memory enhancement. The activation of BDNF-dependent neuronal arborization generated almost 2-fold increases in synapse numbers in dendrites of pyramidal neurons and in neurites of nonpyramidal neurons. This increase in synaptic connections might have evoked reorganization within neuronal circuits and eventually supported an increase in the activity of such circuits. Thus, in addition to showing the potential of RGS14414 for rescuing memory deficits, our results suggest that a boost in circuit activity could facilitate memory enhancement and the reversal of memory deficits.-Masmudi-Martín, M., Navarro-Lobato, I., López-Aranda, M. F., Delgado, G., Martín-Montañez, E., Quiros-Ortega, M. E., Carretero-Rey, M., Narváez, L., Garcia-Garrido, M. F., Posadas, S., López-Téllez, J. F., Blanco, E., Jiménez-Recuerda, I., Granados-Durán, P., Paez-Rueda, J., López, J. C., Khan, Z. U. RGS14414 treatment induces memory enhancement and rescues episodic memory deficits.

Broadband extended source imaging Mueller-matrix polarimeter.

An imaging Mueller matrix polarimeter, named the red-green-blue (RGB)950, takes images of medium-sized (tens of centimeters) objects by using a very bright source, large polarization state generator, and high-quality camera. Its broadband extended light source switches between red, green, blue, and near-infrared light to allow taking polarimetric images for comparison with RGB camera images. The large diffuse source makes shadow transitions gradual and spreads out the specular reflected spot into a larger less conspicuous area.

Permitted experimental errors for optimized variable-retarder Mueller-matrix polarimeters.

An optimized Mueller-matrix polarimeter is simulated. The polarimeter is optimized by finding the configurations of the polarization state generator and polarization state analyzer that give the minimum condition number. Noise is included in the measurement of the polarimeter intensities, and the eigenvalue calibration procedure is used to reduce the errors in the final Mueller matrix. Controlled errors are introduced to the polarimeter configuration, and the error in the final measured Mueller matrix is calculated as a function of these configuration errors. It is found that the alignment of the retarder axes in the polarimeter is much more important than the use of the ideal, optimized retardance values. In particular, the misalignment of the retarders farthest from the sample is the error source with the highest impact in the precision of the polarimeter.

Experimental limits for eigenvalue calibration in liquid-crystal Mueller-matrix polarimeters.

A numerical study is carried out to find the experimental conditions necessary for the eigenvalue calibration procedure to work correctly in a liquid-crystal variable-retarder-based Mueller-matrix polarimeter. Using the error between the simulated experimental Mueller matrix in a polarimeter with errors and the expected ideal Mueller matrices for four calibration samples, the maximum experimental errors are estimated for a successful eigenvalue calibration. It is found that the retarder axes' orientations have smaller permitted errors than the retardation values.

Enabling choice, recovery and participation: evidence-based early intervention support for psychosocial disability in the National Disability Insurance Scheme.

OBJECTIVES:: The aim of this study was to identify the most effective interventions for early intervention in psychosocial disability in the National Disability Insurance Scheme (NDIS) through an evidence review. METHODS:: A series of rapid reviews were undertaken to establish possible interventions for psychosocial disability, to develop our understanding of early intervention criteria for the NDIS and to determine which interventions would meet these criteria. RESULTS:: Three interventions (social skills training, supported employment and supported housing) have a strong evidence base for effectiveness in early intervention in people with psychosocial disability, with the potential for adoption by the NDIS. They support personal choice and recovery outcomes. Illness self-management, cognitive remediation and cognitive behavioural therapy for psychosis demonstrate outcomes to mitigate impairment. The evidence for family psycho-education is also very strong. CONCLUSIONS:: This review identified evidence-based, recovery-oriented approaches to early intervention in psychosocial disability. They meet the criteria for early intervention in the NDIS, are relevant to participants and consider their preferences. Early intervention has the potential to save costs by reducing participant reliance on the scheme.

Community treatment orders: towards a new research agenda.

OBJECTIVES: The aim of this study was to report on a half-day multi-stakeholder symposium on community treatment orders (CTOs) hosted by the Melbourne Social Equity Institute (MSEI), which identified research gaps and opportunities, and produced an agreed agenda for future CTO research. METHODS: The MSEI convened a symposium for 22 experts in CTO research to discuss research priorities in this field in Australasia. An independent moderator elicited views and recommendations and produced a report detailing possible research projects. RESULTS: Research on CTOs is contentious and there is a need to gather and examine information regarding both their use and utility. Due to the complexities involved, it was agreed that research should be undertaken in partnership with persons with had lived experience of mental health problems, clinicians, policymakers and other interdisciplinary stakeholders. Five key areas for future investigation were identified. CONCLUSIONS: The issues and recommendations arising from the symposium should shape the scope, nature and conduct of future research directions in the field.

The atheroma plaque secretome stimulates the mobilization of endothelial progenitor cells ex vivo.

Endothelial progenitor cells (EPCs) constitute a promising alternative in cardiovascular regenerative medicine due to their assigned role in angiogenesis and vascular repair. In response to injury, EPCs promote vascular remodeling by replacement of damaged endothelial cells and/or by secreting angiogenic factors over the damaged tissue. Nevertheless, such mechanisms need to be further characterized. In the current approach we have evaluated the initial response of early EPCs (eEPCs) from healthy individuals after direct contact with the factors released by carotid arteries complicated with atherosclerotic plaques (AP), in order to understand the mechanisms underlying the neovascularization and remodeling properties assigned to these cells. Herein, we found that the AP secretome stimulated eEPCs proliferation and mobilization ex vivo, and such increase was accompanied by augmented permeability, cell contraction and also an increase of cell-cell adhesion in association with raised vinculin levels. Furthermore, a comparative mass spectrometry analysis of control versus stimulated eEPCs revealed a differential expression of proteins in the AP treated cells, mostly involved in cell migration, proliferation and vascular remodeling. Some of these protein changes were also detected in the eEPCs isolated from atherosclerotic patients compared to eEPCs from healthy donors. We have shown, for the first time, that the AP released factors activate eEPCs ex vivo by inducing their mobilization together with the expression of vasculogenic related markers. The present approach could be taken as a ex vivo model to study the initial activation of vascular cells in atherosclerosis and also to evaluate strategies looking to potentiate the mobilization of EPCs prior to clinical applications.

Calibration and data extraction in nonoptimized Mueller matrix polarimeters.

We present a method for calibration and data extraction for a nonoptimized Mueller matrix polarimeter. The advantage of this type of method is a reduction in measurement time for multiwavelength systems or in systems with slow response times. The calibration process requires the measurement of four known polarization devices. Here we use free-space transmission, a horizontal and a vertical linear polarizer, and a quarter-wave retarder with its fast axis at 30° to the horizontal. Experimental measurements of rotating quarter-wave and half-wave retarders show that accurate results can be obtained with the proposed method.

Characterization of optical polarization properties for liquid crystal-based retarders.

We present the analysis and implementation of a set of experimental procedures to characterize optical polarization properties as a function of the applied voltage for liquid-crystal variable retarders (LCVRs) in the transmission mode. The studied properties are those involved in the operation of the LCVRs and, generally, are the most significant for optical applications: retardance, diattenuation, optical axes position, and output depolarization effects. The correct characterization of these polarization properties can be useful to improve results or estimate errors in applications using these devices. The results obtained show good accuracy and good agreement with the expected results.

Current Challenges for the Regulation of Chemical Restraint in Health Care Settings.

Various forms of restraint may be used in a variety of health care settings to control behaviour. Laws and policies regulate the use of physical and mechanical restraint across health care settings, but there is a gap in relation to the regulation of chemical restraint. This may partly be because of problems in defining the term and partly because of a lack of information as to the extent of the use of drugs aimed at controlling behaviour rather than ameliorating a medical condition. This column provides an overview of current definitions and argues that there is a need for national guidance as to what constitutes chemical restraint in order to reduce its use.

Consumers' and their supporters' perspectives on barriers and strategies to reducing seclusion and restraint in mental health settings.

Objective This paper examines the perspectives of consumers and their supporters regarding the use of seclusion and restraint in mental health settings. Methods Five focus groups for consumers and five focus groups for supporters were conducted in four Australian cities and in one rural location. The 66 participants were asked about strategies to reduce or eliminate the use of seclusion and restraint in mental health settings. Results All participants supported the reduction of the use of seclusion and restraint. Barriers to reducing these practices related to the environment, the effects of drug and alcohol issues, lack of a human rights focus and poor recognition of trauma, stigma and discrimination. Strategies for reducing or eliminating seclusion and restraint included workforce development, environmental and cultural changes. Conclusions Participants clearly identified that the status quo needs to change and conveyed urgency for action. Participants suggested that the involvement of supporters and a range of consumer roles are integral to reducing the use of seclusion and restraint. The findings support the current policy emphasis of working towards the elimination of these practices. What is known about the topic? Mental health policies across many jurisdictions support the reduction and elimination of restraint and seclusion. Evidence suggests those subjected to restraint and seclusion largely experience a range of harmful consequences. No studies focus on the views of supporters of consumers regarding the reduction and elimination of seclusion and restraint, whereas the views of consumers appear in a minority of international studies. What does this paper add? The research enabled an opportunity to hear from people who have been personally affected by and/or have lived experience of these coercive practices. Participants identified local reforms that can uphold the human rights of consumers. They suggested practices to increase accountability, peer support and family involvement, areas that have not been analysed in depth in any of the seclusion and restraint literature. What are the implications for practitioners? This paper will give healthcare services a deeper insight into how to reduce or eliminate restraint or seclusion from the perspective of those with lived experience.

Safety and Feasibility of Single-Port Robotic-Assisted Nipple-Sparing Mastectomy.

Importance: Robotic-assisted nipple-sparing mastectomies with multiport robots have been described in the US since 2015; however, significant hurdles to multiport robotic surgery exist in breast surgery. Objective: To demonstrate that the single-port da Vinci SP (Intuitive Surgical) robotic system is feasible in patients undergoing robotic nipple-sparing mastectomy (rNSM). Design, Setting, and Participants: An initial case series of 20 patients at a large university hospital underwent bilateral single-port robotic nipple-sparing mastectomies (SPrNSM) with tissue expander reconstruction from February 1, 2020, through January 4, 2023. Participants included women who met surgical criteria for nipple-sparing mastectomies, per standard of care. Intervention: Surgery using a single-port robot and the surgical technique of the authors. Main Outcomes and Measures: Age, indication, body mass index, breast size, operative time, conversion to open surgery, systemic complications, postoperative skin necrosis, and reported skin and nipple areolar complex (NAC) sensation. Results: Twenty women aged 29 to 63 years (median, 40 years) underwent bilateral SPrNSM. Eleven patients completed prophylactic surgery due to a high risk for breast cancer (more than 20% lifetime risk) and 9 patients had breast cancer. Breast size ranged from A through D cup with median B cup and a body mass index range of 19.7 through 27.8 (median 24.4). The total duration of the procedure from incision to skin closure for both sides ranged from 205 minutes to 351 minutes (median, 277). The median robotic time for bilateral SPrNSM was 116 minutes and varied by cup size (A cup, 95 minutes; B cup, 140 minutes; C cup, 118 minutes; D cup, 114 minutes) with no inflection point in learning curve. No cases were converted to open and no immediate complications, such as hematoma, positive margins, or recurrence, were seen. In the first 10 patients prior to routine sensation testing, 20 resected breasts had measurable NAC sensation at a range from 4 to 36 months post-index resection (65%). In the second 10 patients of the cohort, measurable NAC was preserved in 13 of 20 resected breasts 2 weeks following the index operation (65%). Conclusion and Relevance: In this case series, SPrNSM with immediate reconstruction was feasible and performed safely by an experienced breast surgeon with limited previous robotic training. Further studies confirming the preliminary data demonstrating improved NAC and skin sensation following SPrNSM are warranted. Trial Registration: ClinicalTrials.gov Identifier: NCT05245812.

Proficiency Levels and Validity Evidence for Scoring Metrics for a Virtual Reality and Inanimate Robotic Surgery Simulation Curriculum.

OBJECTIVE: Our institution recently implemented a virtual reality (VR) skills curriculum for general surgery residents using the SimNow simulator. Based on a content alignment study, we revised the curriculum to include only 20 of 33 VR tasks and we added 3 previously validated inanimate tasks. The purpose of this study was to establish expert-derived proficiency levels for all tasks and to evaluate the validity of the scoring for the VR tasks. DESIGN: Two expert robotic surgeons performed 5 repetitions of each VR and inanimate task. The trimmed mean (lowest scoring attempt and outliers [>2 standard deviations] were eliminated) was defined as the expert level for each task. For the VR tasks, expert levels were compared to resident performance to evaluate validity. SETTING: This study was conducted at the University of Texas Southwestern Medical Center (Dallas, TX), a tertiary care academic teaching hospital. PARTICIPANTS: Two expert robotic surgeons participated in this study. The data from 42 residents (PGY2-4) who completed the original curriculum was used to represent novice performance. RESULTS: Comparison of expert levels and resident performance was statistically significant for 15 VR tasks (supporting validity) and approached significance (p = 0.06, 0.09) for 2 VR tasks; expert levels were designated as proficiency levels for these 17 tasks. Group comparisons were clearly not significant (p = 0.2-0.8) for 3 VR tasks; 2 of these 3 tasks were retained as introductory exercises (with 3 repetitions required) and 1 was excluded. For the 3 inanimate tasks, expert levels minus 2 standard deviations were designated as proficiency levels. CONCLUSIONS: This analysis generated validity evidence for 15 VR tasks and established expert-derived proficiency levels for 17 VR tasks and 3 inanimate tasks. Our proposed curriculum now consists of 19 VR and 3 inanimate tasks using the selected proficiency levels. We anticipate that this design will maximize curriculum efficiency and effectiveness.

Brain areas interconnected to ventral pathway circuits are independently able to induce enhancement in object recognition memory and cause reversal in object recognition memory deficit.

AIMS: Ventral pathway circuits are constituted by the interconnected brain areas that are distributed throughout the brain. These brain circuits are primarily involved in processing of object related information in brain. However, their role in object recognition memory (ORM) enhancement remains unknown. Here, we have studied on the implication of these circuits in ORM enhancement and in reversal of ORM deficit in aging. METHODS: The brain areas interconnected to ventral pathway circuits in rat brain were activated by an expression of a protein called regulator of G-protein signaling 14 of 414 amino acids (RGS14414). RGS14414 is an ORM enhancer and therefore used here as a gain-in-function tool. ORM test and immunohistochemistry, lesions, neuronal arborization, and knockdown studies were performed to uncover the novel function of ventral pathway circuits. RESULTS: An activation of each of the brain areas interconnected to ventral pathway circuits individually induced enhancement in ORM; however, same treatment in brain areas not interconnected to ventral pathway circuits produced no effect. Further study in perirhinal cortex (PRh), area V2 of visual cortex and frontal cortex (FrC), which are brain areas that have been shown to be involved in ORM and are interconnected to ventral pathway circuits, revealed that ORM enhancement seen after the activation of any one of the three brain areas was unaffected by the lesions in other two brain areas either individually in each area or even concurrently in both areas. This ORM enhancement in all three brain areas was associated to increase in structural plasticity of pyramidal neurons where more than 2-fold higher dendritic spines were observed. Additionally, we found that an activation of either PRh, area V2, or FrC not only was adequate but also was sufficient for the reversal of ORM deficit in aging rats, and the blockade of RGS14414 activity led to loss in increase in dendritic spine density and failure in reversal of ORM deficit. CONCLUSIONS: These results suggest that brain areas interconnected to ventral pathway circuits facilitate ORM enhancement by an increase in synaptic connectivity between the local brain area circuits and the passing by ventral pathway circuits and an upregulation in activity of ventral pathway circuits. In addition, the finding of the reversal of ORM deficit through activation of an interconnected brain area might serve as a platform for developing not only therapy against memory deficits but also strategies for other brain diseases in which neuronal circuits are compromised.