Tailored Immersion: Implementing Personalized Components Into Virtual Reality for Veterans With Post-Traumatic Stress Disorder

Introduction

With the application of virtual reality (VR), tailored interventions can be created that mirror the traumatic experiences of veterans with post-traumatic stress disorder (PTSD). Visual elements can be mimicked, and auditory and other senses stimulated. In doing so, the degree of immersion can be adjusted to optimize the therapeutic process. Objectively measuring the sensory immersion is key to keep subjects within their personal window of tolerance. Based on this information the therapist can decide manipulate the sensory stimulation embedded in the treatment.

Objectives

The objectives of this study are to explore the different immersive design aspects of VRET that can be modified to influence the experienced presence in veterans with PTSD, and to discuss possible methods of measuring the emotional response facilitated by immersive design aspects and experienced presence.

Methods

Four design aspects are discussed: system, sensory cues, narrative and challenge. We also report on a user experiment in three veterans that informed on quality and depth of immersion.

Results

Believability of the neutral virtual environment was important for maintaining the veterans’ presence within the VR experience. The immersive design aspects that were personalized and supportive in the narrative of the veteran such as music and self-selected images appeared to have a strong influence on recall and reliving of the traumatic events.

Conclusions

Finally, in order to increase the therapeutic effect in veterans with PTSD, the highlighted design aspects should be recognized and tailored to maximize immersion in virtual reality exposure therapy.

Disclosure

No significant relationships.

External validation of machine learning models for prediction of survival in undifferentiated pleomorphic sarcoma

e13551

Background: Machine learning (ML) algorithms to predict cancer survival have recently been reported for a number of sarcoma subtypes, but none have investigated undifferentiated pleomorphic sarcoma (UPS). ML is a powerful tool that has the potential to better prognosticate UPS. Methods: The Surveillance, Epidemiology, and End Results (SEER) database was queried from 2004 to 2015 for cases of histologically confirmed undifferentiated pleomorphic sarcoma (UPS) and malignant fibrous histiocytoma (MFH). Patient, tumor, and treatment characteristics were recorded, and various machine learning (ML) models were built to predict 1-, 3-, and 5-year survival. The best performing ML models were externally validated using an institutional cohort of UPS patients. Results: All ML models performed best at the 1-year time point and worst at the 5-year time point. On internal validation within the SEER cohort, the best models had c-statistics of 0.71 to 0.73 at the 5-year time point. Similarly, all ML models performed best at 1-year and worst at 5-year on external validation. The best performing models had c-statistics of 0.81 at the 5-year time point on external validation, demonstrating good performance in survival prediction. Conclusions: Machine learning models perform well for survival prediction in UPS, though this sarcoma subtype may be more difficult to prognosticate than other subtypes. Future studies are needed to further validate the machine learning approach for UPS prognostication. [Table: see text]

Tranexamic Acid Administration in Arthroscopic Surgery Is a Safe Adjunct to Decrease Postoperative Pain and Swelling: A Systematic Review and Meta-analysis

PURPOSE

To systematically screen the literature in an effort to critically examine the effect of tranexamic acid (TXA) in patients undergoing arthroscopic surgery, specifically pertaining to pain, blood loss, length of surgery, and both major and minor complications.

METHODS

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) guidelines, 3 databases (MEDLINE, EMBASE, and Cochrane) were searched April 2020 and screened in duplicate using inclusion and exclusion criteria for studies on the given subject. Study findings were reviewed, and meta-analysis was then performed on sufficiently congruent data using a random-effects model.

RESULTS

There were 7 eligible randomized controlled trials, with 724 total patients, undergoing anterior cruciate ligament reconstruction (4 studies, 537 patients), meniscectomy (1 study, 45 patients), femoroacetabular impingement (1 study, 70 patients), or rotator cuff repair (1 study, 72 patients). The mean age throughout the included studies was 33.9 years, with a mean of 27.7% female patients. There was a 1% drop out rate at 3 months postoperatively. There were significantly lower visual analog scale scores at 2 weeks postoperatively in the TXA groups (mean difference: -1.65, 95% confidence interval [CI] -3.41 to 0.10, P = .06, I² = 97%). Furthermore, there was a significant decrease in the number of patients requiring joint aspiration in the TXA groups (risk ratio 0.27, 95% CI 0.12-0.56, I² = 0%, P = .0006). The drainage output in TXA groups was also significantly decreased (mean difference: -61.14 mL, 95% CI -104.43 to -17.85, I² = 94%, P = .006). Furthermore, there was a statistically significant decrease in hemarthrosis grade (Coupens & Yates) at 2 weeks postoperatively (Mean difference: -0.76, 95% CI -0.97 to -0.54, I² = 0%, P < .0001). Finally, there was no significant difference in operating time, across all studies (Mean difference: 0.53, 95% CI -3.43 to 4.50, I² = 57%, P < .79). The use of TXA showed no increased incidence of deep vein thrombosis, infection, arthrofibrosis, or other major complications or adverse reactions between the TXA and control groups.

CONCLUSIONS

This systematic review and meta-analysis of randomized controlled trialss found that the use of TXA significantly improves pain scores up to 6 weeks postoperatively, decreases drainage output, decreases the need for joint aspirations, decreases incidence of hemarthrosis, increases visual clarity and technical ease, and has no increased incidence of other complications, at no loss to operative time. These findings indicate that TXA may be a useful adjunct in arthroscopic knee and shoulder surgery.

LEVEL OF EVIDENCE

II.

Successful same-day discharge for robot-assisted radical prostatectomy: A systematic review and meta-analysis

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Background: In the current era of enhanced recovery after surgery (ERAS), same day discharge (SDD) following robot-assisted radical prostatectomy (RARP) is emerging as the standard of care. In order to implement a safe and efficient SDD pathway, it is imperative to appropriately select candidates and have established discharge criteria. We conducted a systematic review and meta-analysis to summarize published pathways, as well as to evaluate the differences in peri-operative characteristics, complication/readmissions rates, and satisfaction/cost data, between in-patient (IP) RARP versus SDD-RARP. Methods: This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was prospectively registered with PROSPERO (CRD42021258848). A comprehensive search of PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, Google Scholar, and conference abstract publications was performed comparing outcomes between IP-RARP and SDD-RARP. A leave-one-out sensitivity analyses was performed to control for heterogeneity and risk of bias. Results: A total of 14 studies (eight prospective and six retrospective cohort studies) were included with a pooled population of 3795 patients, including 2348 (61.9%) IP-RARPs and 1447 (38.1%) SDD-RARPs. SDD pathways varied, though many commonalities were present in patient selection (minimal comorbidities and lived close to the hospital [≤ 50-150 km]), peri-operative recommendations (judicious intra-operative intravenous fluids and short-acting narcotics), and post-operative management (immediate ambulation and diet, and non-narcotic analgesia). When compared to IP-RARP, SDD-RARP had no differences in ≥ Grade 3 Clavien–Dindo complications (RR: 0.4, 95% CI 0.2, 1.1, p = 0.07), 90-day readmission rates (RR: 0.6, 95% CI 0.3, 1.1, p = 0.10), or unscheduled ED visits (RR: 1.0, 95% CI 0.3, 3.1, p = 0.97). Cost savings per patient ranged between $367-2109 (USD), and overall satisfaction was high between 87.5-100%. Conclusions: Same day discharge following RARP is both feasible and safe, with comparable complication and readmission rates to IP-RARP. Additionally, SDD offers healthcare cost-savings with high patient satisfaction rates. Data from this study will further inform the uptake and development of future SDD pathways in contemporary urological care such that it may be offered to a broader patient population.

Realizing topologically ordered states on a quantum processor

[Figure: see text].

206 EXPLORING THE RELATIONSHIP BETWEEN LONELINESS, FRAILTY, AND HEALTHCARE UTILISATION IN IRELAND’S OLDER ADULTS DURING THE COVID-19 PANDEMIC

Background

The COVID-19 pandemic has disproportionately affected older adults, both in morbidity and mortality¹. The effects of the pandemic go beyond contracting the SARS-CoV-2 virus, leading to devastating consequences, particularly for individuals over the age of 60. In Ireland, isolation in older adults was exacerbated by cocooning measures and geographical limitations. The purpose of this study was to explore the relationship between loneliness, frailty, and the utilisation of health services in a sample of sexagenarians in Ireland.

Methods

Adults aged 60–70 attending COVID-19 vaccine appointments at a Level 3 Hospital in Ireland (n = 75) were invited to participate in a 36-item questionnaire. Participants reported demographic information and questions regarding physical well-being, healthcare utilisation, lifestyle and behaviours, and impact of vaccination. The survey also included three validated questionnaires: PRISMA-7 for frailty, SARC-F for sarcopenia, and the UCLA 3-Item Loneliness Scale (UCLA-3ILS).

Results

Of the 75 survey respondents, the mean age was 63.2. 72% (n = 54) identified as female. 28% (n = 21) reported that they had been cocooning during the past year. While 84% (n = 63) of respondents reported that they cancelled routine medical appointments during the pandemic, none reported avoiding attending hospital. Five respondents met the criteria for frailty and four were identified as probable sarcopenic. There was no significant difference (p = 0.64) in mean scores on the UCLA 3-ILS between frail and non-frail individuals. Persons identified as sarcopenic were more likely to have higher scores on the UCLA-3ILS (p = 0.0005).

Conclusion

This research highlights the multifaceted relationship between frailty, loneliness, and healthcare utilisation among Irish adults ages 60–70 during the COVID-19 pandemic. Future research in program, policy, and intervention development for at-risk older adults, particularly those who are frail, sarcopenic, and/or lonely, can work to reduce associated negative outcomes.

Reference

1. Kang S-J and Jung, SI. (2020). Age-Related Morbidity and Mortality among Patients with COVID-19. Infect Chemother., 52(2): 154–164.

Thoracic bone mineral density measured by quantitative computed tomography in patients undergoing spine surgery

BACKGROUND CONTEXT

The thoracic spine is a common location for vertebral fractures as well as instrumentation failure after long spinal fusion procedures. The association between those complications and bone mineral density (BMD) are well recognized. Due to the overlying sternum and ribs in the thoracic spine, projectional BMD assessment tools such as dual energy x-ray absorptiometry (DXA) are limited to the lumbar spine. Quantitative computed tomography circumvents several shortcomings of DXA and allows for level-specific BMD measurements. Studies comprehensively quantifying BMD of the entire thoracic spine in patients undergoing spine surgery are limited.

PURPOSE

The objective of this study was: (1) to assess the reliability of thoracic QCT measurements, (2) to determine possible level-specific BMD variation throughout the thoracic spine and (3) to assess the correlation between BMDs of the T1-T12 spinal levels.

STUDY DESIGN/SETTING

Cross-sectional observation study.

PATIENT SAMPLE

Patients undergoing spine surgery from 2016-2020 at a single, academic institution with available preoperative CT imaging of the thoracic spine were included in this study.

OUTCOME MEASURES

The outcome measure was BMD measured by QCT.

METHODS

Patients undergoing spine surgery from 2016-2020 at a single, academic institution with available preoperative CT imaging of the thoracic spine were included in this study. Subjects with previous instrumentation at any thoracic level, concurrent vertebral fractures, a Cobb angle of more than 20 degrees, or incomplete thoracic spine CT imaging were excluded. Asynchronous quantitative computed tomography (QCT) measurements of T1-T12 were performed. To assess inter- and intra-observer reliability, a validation study was performed on 120 vertebrae in 10 randomly selected patients. The interclass correlation coefficient (ICC) was calculated. A pairwise comparison of BMD was conducted and correlations between each thoracic level were evaluated. The statistical significance level was set at p<.05.

RESULTS

60 patients (men, 51.7%) met inclusion criteria. The study population was 90% Caucasian with a mean age of 62.2 years and a mean BMI of 30.2 kg/m². The inter- and intra-observer reliability of the thoracic QCT measurements was excellent (ICC of 0.97 and 0.97, respectively). The trabecular BMD was highest in the upper thoracic spine and decreased in the caudal direction (T1 = 182.3 mg/cm³, T2 = 168.1 mg/cm³, T3 = 163.5 mg/cm³, T4 = 164.7 mg/cm³, T5 = 161.4 mg/cm³, T6 = 152.5 mg/cm³, T7 = 143.5 mg/cm³, T8 = 141.3 mg/cm³, T9 = 143.5 mg/cm³, T10 = 145.1 mg/cm³, T11 = 145.3 mg/cm³, T12 = 133.6 mg/cm³). The BMD of all thoracic levels cranial to T6 was statistically higher than the BMD of all levels caudal to T6 (p < .001). Nonetheless, significant correlations in BMD among all measured thoracic levels were observed, with a Pearson's correlation coefficient ranging from 0.74 to 0.97.

CONCLUSIONS

There is significant regional BMD variation in the thoracic spine depending on spinal level. This BMD variation might contribute to several clinically relevant phenomena. First, vertebral fractures occur most commonly at the thoracolumbar junction including T12. In addition to mechanical reasons, these fractures might be partially attributed to thoracic BMD that is lowest at T12. Second, the optimal upper instrumented vertebra (UIV) for stopping long fusions to the sacrum and pelvis is controversial. The BMD of surgically relevant upper thoracic stopping points (T2-T4) was significantly higher than the BMD of lower thoracic stopping points (T10-T12). Besides stress concentration at the relatively mobile lower thoracic segments, the low BMD at these levels might contribute to previously suggested higher rates of junctional failures with short fusions.

1174 The Reporting of Centre and Surgeon Experience in Studies of Robot Assisted Cholecystectomy: A Systematic Review

Introduction

Over 90% of cholecystectomies are performed using minimally invasive techniques. Robotic cholecystectomy (RC) has been developed to overcome technical limitations of laparoscopy, including improved range of movement and visualisation. Despite becoming increasingly widespread, the safety and efficacy of RC remain unestablished. This review aims to analyse the quality assurance reporting through centre and surgeon expertise in RC.

Method

A systematic search was conducted to identify all published studies reporting RC. Data on quality assurance measures were collected, including: centres involved, surgeons’ experience and training.

Results

Of the 1425 abstracts screened, 90 full-text papers were included. Sixty-four studies (71%) were single institutions. Of the thirty studies (33%) reporting centre type, 28 were conducted in specialist/regional/tertiary centres. Only four stated their caseload of RC. No studies described pre-specified criteria or minimum experience required for a surgeon to participate. Fifty-two (58%) reported the number of surgeons operating and 13 (14%) stated surgeons’ training grade. Two quantified previous RC experience, 7 stated prior laparoscopic experience. Only 21 (23%) described training prior to the surgeons’ first in-human procedure; animal based (n = 12), simulation (n = 12), observation (n = 4), lab-based (n = 3). Specific mentorship was reported in 8 studies, and 13 described dual operating.

Conclusions

Little information was provided about the experience and training of operating surgeons, making it difficult to ascertain whether replicable techniques were utilised which would allow development of a learning curve. This highlights the need for better transparency when reporting surgical innovation, to ensure the safe, evidence-based adoption of new technologies into clinical practice.

692 A Machine Learning Approach to Predict the Postoperative Length of Stay After Coronary Artery Bypass Grafting Using Preoperative Characteristics

Aim

Lengthy hospital length of stay (LOS) has a direct impact on healthcare costs. We aimed to design predictive models of prolonged LOS after coronary artery bypass grafting (CABG) with only preoperative characteristics and machine learning (ML) strategies.

Method

In a single centre retrospective analysis, 2,082 consecutive patients underwent first-time elective/urgent CABG: 1,262 has a short postoperative LOS (≤ 6 days) while the remaining 820 had a long LOS (&gt; 6 days). 70/30 training/testing ratio and resampling methods were used, and cross-validation was conducted.

Results

The two groups differ significantly in terms of pre-operative variables: short LOS patients were younger (p &lt; 0.01), more frequently male (p &lt; 0.01) with lower BMI (p &lt; 0.01) and better angina class (p &lt; 0.01) and NYHA class (p &lt; 0.01). Moreover, they had lower incidence of hypertension (p = 0.04), COPD (p &lt; 0.01) and PVD (p &lt; 0.01). The Logistic Euroscore was also better in this group (median 0.02 vs 0.03, p &lt; 0.01). The predictive abilities of the ML models were as follows: logistic regression: Area under the Curve (AUC) = 0.71, accuracy = 0.69; Generalized additive model: AUC= 0.7, Accuracy = 0.68; Random Decision Forest: AUC = 0.7, Accuracy = 0.68; Naïve Bayes AUC = 0.63, Accuracy 0.58.

Conclusions

Developing a reliable predictive model with only pre-operative variables proved to be difficult, but several preoperative characteristics have a significant impact on the probability of prolonged LOS after CABG. Larger studies are needed to investigate the possibility of developing a reliable predictive model that would help to improve surgical planning.

1024 The Use of the Pedicled Anterolateral Thigh (ALT) Flap for the Reconstruction of Abdominal Wall Defects in High-Risk Patients: A Case Series and Systematic Review

Introduction

The pedicled anterolateral thigh (ALT) flap is considered as a suitable option in complex abdominal wall reconstruction. Its use as a reconstructive option is infrequent in the literature, and to date, there has been no systematic review evaluating its long-term outcomes. We report our experience with the pedicled anterolateral thigh flap for abdominal wall reconstruction in high-risk patients.

Method

A prospective database was created for patients with abdominal wall defects treated with pedicled ALT with extended fascia lata flaps between 2014 and 2017. Patient demographics, aetiology, size, location of defect and post-operative results were reviewed. Abdominal defects were classified into the following zones: 1A, upper midline; 1B, lower midline; 2, upper quadrant; 3, lower quadrant. A systematic review of the literature was conducted using PUBMED and EMBASE.

Results

4 patients (mean age 59.5 years, range 50-65 years) underwent reconstruction with pedicled ALT flaps. 3 flaps developed partial necrosis secondary to infection; 1 flap required surgical debridement, and 2 were managed conservatively. There was one flap failure, due to avulsion of the pedicle during inset. At mean follow up of 2.75 years (range 1 to 4 years) 3 patients have clinical bulging or herniation.

Conclusions

Review of the literature demonstrated 52 patients from 17 case series or reports. The overall infection and partial flap loss rates were both 6%. There were no reported flap failures. Our study demonstrates that the pedicled anterolateral thigh flap is an effective flap option for the repair of large defects of the abdominal wall in high-risk patients.

1158 Summarising the Reporting of Study Outcomes in Robotic Oesophagectomy: A Systematic Review

Introduction

There is an increasing adoption of robotic oesophagectomy in place of standard techniques for oesophageal cancer resection. This is potentially due to its perceived technical benefits and improved short-term outcomes. Consistency in outcome selection, definition and reporting between studies is required for effective evidence synthesis and prevention of research waste. The aim of this review is to perform an in-depth analysis of outcome reporting in robotic oesophagectomy.

Method

Systematic searches were conducted using key words for robotic surgery and oesophageal cancer, from inception to February 2020. Studies reporting any outcome for robotic oesophagectomy were included. Outcomes in each study were recorded verbatim and categorised into twelve domains. Outcomes were independently categorised by two reviewers. Where reported, the follow-up period was also recorded.

Results

Of 954 abstracts screened, 226 full texts were reviewed and 102 included. Only one study was a RCT. A total of 1422 outcomes were reported. Each study had a median of 14 reported outcomes (range 1-25). Outcomes related to complications (n = 578, 99 studies), technical/operative factors (n = 290, 90 studies), and pathology (e.g., resection margin) (n = 197, 83 studies) were reported most frequently. No single outcome, or outcome domain was reported in all studies. No studies used a core outcome set for reporting. Forty-five studies stated a follow-up period, ranging from &lt;1 month to 58 months.

Conclusions

There is significant heterogeneity in the selection and reporting of outcomes in robotic oesophagectomy. This calls for the use of a core outcome set to allow standardisation and transparency of outcome reporting.

Endplate volumetric bone mineral density is a predictor for cage subsidence following lateral lumbar interbody fusion: a risk factor analysis

BACKGROUND CONTEXT

It has been reported in previous studies that a decreased bone mineral density (BMD) as measured by dual X-ray absorptiometry (DXA) is associated with subsidence. However, there is limited research on the role of volumetric BMD (vBMD) as measured by quantitative computed tomography (QCT). Further, metabolic conditions such as obesity and type 2 diabetes have been associated with poor bone quality, but the impact of these metabolic conditions on on subsidence rates following lateral lumbar interbody fusion (LLIF) remains unclear. As such, risk factors for subsidence following LLIF is an area of ongoing research.

PURPOSE

The purpose of this study is to identify risk factors for subsidence following LLIF with a focus on metabolic conditions and vBMD as measured by QCT.

STUDY DESIGN/SETTING

Retrospective cohort study at a single academic institution.

PATIENT SAMPLE

Consecutive patients undergoing LLIF with or without posterior screws from 2014 to 2019 at a single academic institution who had a pre-operative CT and radiological imaging including radiographs or CT scans between 5 and 14 months post-operatively to assess for cage subsidence.

OUTCOME MEASURE

Subsidence prevalence following LLIF.

METHODS

We reviewed patients undergoing LLIF with or without posterior screws from 2014 to 2019 with a follow-up ≥5 months. Cage subsidence was assessed using the grading system by Marchi et al. Endplate volumetric BMD (EP-vBMD), vertebral bone volumetric BMD (VB-vBMD), BMI, and diabetes status were measured. Univariable analysis and multivariable logistic regression analyses with a generalized mixed model were conducted. Ad hoc analysis, including receiver operative characteristic curve analysis, was used for identifying the cut-off values in significant continuous variables for subsidence. Chi-Squared and ANOVA tests were used for categorical comparisons.

RESULTS

Five hundred sixty-seven levels in 347 patients were included in the final analysis. Mean age (± SD) was 61.7 ± 11.1yrs, 50.3% were male, and 89.6% were Caucasian. Subsidence was observed in 160 levels (28.2%). Multivariable analysis demonstrated an absence of posterior screws [OR = 2.854 (1.483 - 5.215), p=.001] and decreased EP-vBMD [0.996 (0.991 - 1.000), p=.032] were associated with an increased risk of subsidence. Increased BMI and diabetes status were not associated with increased rates of subsidence. Patients without posterior screws and low EP-vBMD experienced subsidence at 44.9% of levels.

CONCLUSIONS

Our results demonstrated that decreased EP-vBMD and standalone status were significantly associated with increased rates of subsidence following LLIF independent of BMI or diabetes status. Further analysis demonstrated that patients with a decreased EP-vBMD and without posterior screws experienced subsidence nearly 2.5 times higher than patients with no risk factors. In patients with a low EP-vBMD undergoing LLIF, posterior screws should be considered.