Validity and effectiveness of augmented reality in surgical education: A systematic review

The synergy of embodied cognition and cognitive load theory for optimized learning

The integration of embodied cognition and cognitive load theory offers a promising framework for advancing educational practices. Cognitive load theory emphasizes the constraints of working memory and the importance of managing cognitive load through effective instructional design. Embodied cognition highlights the role of physical actions, such as gestures, object manipulation and whole-body activities, in enhancing cognitive processes. This Review highlights the importance of bridging these frameworks by exploring their theoretical foundations and synthesizing empirical evidence on the benefits of physical actions in learning. Here we present the introduction of the relevance-integration taxonomy as a transformative advancement in embodied cognition research, offering new perspectives for educational interventions. Additionally, we identify current gaps in cognitive load theory applications and propose future research directions to unify these approaches, aiming to optimize learning outcomes across diverse educational settings. This work has broad implications for advancing evidence-based instructional design.

Identifying Research Priorities in Digital Education for Health Care: Umbrella Review and Modified Delphi Method Study

BACKGROUND

In recent years, the use of digital technology in the education of health care professionals has surged, partly driven by the COVID-19 pandemic. However, there is still a need for focused research to establish evidence of its effectiveness.

OBJECTIVE

This study aimed to define the gaps in the evidence for the efficacy of digital education and to identify priority areas where future research has the potential to contribute to our understanding and use of digital education.

METHODS

We used a 2-stage approach to identify research priorities. First, an umbrella review of the recent literature (published between 2020 and 2023) was performed to identify and build on existing work. Second, expert consensus on the priority research questions was obtained using a modified Delphi method.

RESULTS

A total of 8857 potentially relevant papers were identified. Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology, we included 217 papers for full review. All papers were either systematic reviews or meta-analyses. A total of 151 research recommendations were extracted from the 217 papers. These were analyzed, recategorized, and consolidated to create a final list of 63 questions. From these, a modified Delphi process with 42 experts was used to produce the top-five rated research priorities: (1) How do we measure the learning transfer from digital education into the clinical setting? (2) How can we optimize the use of artificial intelligence, machine learning, and deep learning to facilitate education and training? (3) What are the methodological requirements for high-quality rigorous studies assessing the outcomes of digital health education? (4) How does the design of digital education interventions (eg, format and modality) in health professionals' education and training curriculum affect learning outcomes? and (5) How should learning outcomes in the field of health professions' digital education be defined and standardized?

CONCLUSIONS

This review provides a prioritized list of research gaps in digital education in health care, which will be of use to researchers, educators, education providers, and funding agencies. Additional proposals are discussed regarding the next steps needed to advance this agenda, aiming to promote meaningful and practical research on the use of digital technologies and drive excellence in health care education.

Machine Learning vs Traditional Approaches to Predict All-Cause Mortality for Acute Coronary Syndrome: A Systematic Review and Meta-analysis

BACKGROUND

Acute coronary syndrome (ACS) remains one of the leading causes of death globally. Accurate and reliable mortality risk prediction of ACS patients is essential for developing targeted treatment strategies and improve prognostication. Traditional models for risk stratification such as the GRACE and TIMI risk scores offer moderate discriminative value, and do not incorporate contemporary predictors of ACS prognosis. Machine learning (ML) models have emerged as an alternate method that may offer improved risk assessment. This review compares ML models with traditional risk scores for predicting all-cause mortality in patients with ACS.

METHODS

PubMed, Embase, Web of Science, Cochrane, CINAHL, Scopus, and IEEE XPlore databases were searched through October 30, 2024, as well as Google Scholar and manual screening of reference lists from included studies and the grey literature for studies comparing ML models with traditional statistical methods for event prediction of ACS patients. The primary outcome was comparative discrimination measured by C-statistics with 95% confidence intervals (CIs) in estimating risk of all-cause mortality.

RESULTS

Twelve studies were included (250,510 patients). The summary C-statistic of best-performing ML models across all end points was 0.88 (95% CI 0.86-0.91), compared with 0.82 (95% CI 0.80-0.85) for traditional methods. The difference in C-statistic between ML models and traditional methods was 0.06 (P < 0.0007). Five studies undertook external validation. The PROBAST tool demonstrated high risk of bias for all studies. Common sources of bias included reporting bias and selection bias. Best-performing ML models demonstrated superior discrimination of all-cause mortality for ACS patients compared with traditional risk scores.

CONCLUSIONS

Despite outperforming well established prognostic tools such as the GRACE and TIMI scores, current clinical applications of ML approaches remain uncertain, particularly in view of the need for greater model validation.

How to teach the anatomy of the inguinal canal? A multimodal approach

Introduction

Learning the anatomy of the inguinal canal is challenging for medical students and residents. Current teaching via didactic lectures may not suffice for optimal learning, and visualization of the complicated 3D-structure of the inguinal canal. Hence, we investigated the efficacy of a low-fidelity model creation to improve the teaching.

Materials and methods

30 pre-clinical students were split into three groups and assigned different teaching interventions: 1) Lecture (Group L), 2) Lecture with individual model creation (Group M1), and 3) Lecture with group model creation (Group M2). Gain in knowledge were assessed through a pre- and post-intervention multiple-choice quizzes (MCQs), while perceptions of confidence/engagement/model efficacy were measured using post-intervention questionnaires.

Results

For knowledge acquisition, average MCQ scores improved most for Group L (23 ± 1%), followed by M1 (19 ± 1%) and M2 (13 ± 1%). In learning the inguinal canal, perceived confidence was enhanced by modelling compared to lecture only (p < 0.05). There was no difference between group M1 and M2 respectively. Perceived engagement had also been enhanced by modelling compared to lecture only (p < 0.05). Interestingly, there was statistical difference between M1 and M2 (p < 0.05). However, perceived usefulness of the model compared to lecture only was insignificant (p > 0.05). There was also no difference between M1 and M2 (p > 0.05).

Conclusion

As a supplement to didactic teaching of the inguinal canal, model creation was well-received, and provided opportunities for experiential learning. However, the usefulness of modelling in learning the anatomy and pathologies of inguinal canal was insignificant. Our research design was inadequate in showing long term gain. Additionally, results from group model creation could be affected by the dynamics amongst members. Future work should aim to address these issues.

Acceptance and use of extended reality in surgical training: an umbrella review

BACKGROUND

Extended reality (XR) technologies which include virtual, augmented, and mixed reality have significant potential in surgical training, because they can help to eliminate the limitations of traditional methods. This umbrella review aimed to investigate factors that influence the acceptance and use of XR in surgical training using the unified theory of acceptance and use of technology (UTAUT) model.

METHODS

An umbrella review was conducted in 2024 by searching various databases until the end of 2023. Studies were selected based on the predefined eligibility criteria and analyzed using the components of the UTAUT model. The quality and risk of bias of the selected studies were assessed, and the findings were reported descriptively.

RESULTS

A total of 44 articles were included in this study. In most studies, XR technologies were used for surgical training of orthopedics, neurology, and laparoscopy. Based on the UTAUT model, the findings indicated that XR technologies improved surgical skills and procedural accuracy while simultaneously reducing risks and operating room time (performance expectancy). In terms of effort expectancy, user-friendly systems were accessible for the trainees with various levels of expertise. From a social influence standpoint, XR technologies enhanced learning by providing positive feedback from experienced surgeons during surgical training. In addition, facilitating conditions emphasized the importance of resource availability and addressing technical and financial limitations to maximize the effectiveness of XR technologies in surgical training.

CONCLUSIONS

XR technologies significantly improve surgical training by increasing skills and procedural accuracy. Although adoption is facilitated by designing user-friendly interfaces and positive social influences, financial and resource challenges must be overcome, too. The successful integration of XR into surgical training necessitates careful curriculum design and resource allocation. Future research should focus on overcoming these barriers, so that XR can fully realize its potential in surgical training.

Using Mixed Reality to Teach Medical Students Lumbar Punctures

BACKGROUND

Gaining familiarity with bedside procedures during medical school is essential for preparing medical students for intern year. However, this is often not a core component of undergraduate medical education, and students often feel unprepared to perform bedside procedures upon graduation from medical school. Extended reality technologies have rapidly developed in the past few years, become more accessible, and show great promise in education, most recently in healthcare. We aim to show the feasibility and usability of a mixed-reality lumbar puncture simulated experience.

METHODS

We created the mixed-reality simulation by filming a procedure conducted by an expert on a lumbar puncture simulator from the first-person view. We performed a study to assess the feasibility and usability of mixed-reality lumbar puncture training compared with traditional faculty-led high-fidelity mannikin-based simulation training. Fourth-year medical students were randomly selected to participate in the mixed-reality lumbar puncture training. Students watched the virtual first-person teaching via a virtual reality headset while mimicking hand movements on a lumbar puncture mannikin. Faculty taught students in the traditional high-fidelity group in small groups before practicing on the high-fidelity manikin. Students in both groups then performed the procedure entirely with performance assessed via a standardized checklist. Number of attempts to achieve a predetermined minimum passing score were recorded, and students were also surveyed regarding their experience with both simulations.

RESULTS

Fifty-nine percent of students felt comfortable using mixed reality as a training modality with less than 6% having any prior extended reality experience. More than 55% felt the mixed-reality experience was as effective as the traditional high-fidelity simulation training. Many students (72%) desired more mixed-reality opportunities. In terms of performance, 58.8% of students in the mixed-reality group vs 65.5% in the traditional group completed the checklist in 1 attempt (P = .79).

CONCLUSIONS

We demonstrate that mixed reality is an acceptable and effective modality to train health care professionals in lumbar punctures with opportunities to further enhance the immersive learning experience.

Video-Instrument Synergistic Network for Referring Video Instrument Segmentation in Robotic Surgery

Surgical instrument segmentation is fundamentally important for facilitating cognitive intelligence in robot-assisted surgery. Although existing methods have achieved accurate instrument segmentation results, they simultaneously generate segmentation masks of all instruments, which lack the capability to specify a target object and allow an interactive experience. This paper focuses on a novel and essential task in robotic surgery, i.e., Referring Surgical Video Instrument Segmentation (RSVIS), which aims to automatically identify and segment the target surgical instruments from each video frame, referred by a given language expression. This interactive feature offers enhanced user engagement and customized experiences, greatly benefiting the development of the next generation of surgical education systems. To achieve this, this paper constructs two surgery video datasets to promote the RSVIS research. Then, we devise a novel Video-Instrument Synergistic Network (VIS-Net) to learn both video-level and instrument-level knowledge to boost performance, while previous work only utilized video-level information. Meanwhile, we design a Graph-based Relation-aware Module (GRM) to model the correlation between multi-modal information (i.e., textual description and video frame) to facilitate the extraction of instrument-level information. Extensive experimental results on two RSVIS datasets exhibit that the VIS-Net can significantly outperform existing state-of-the-art referring segmentation methods. We will release our code and dataset for future research (https://github.com/whq-xxh/RSVIS).

Evaluating Mixed Reality as a Tool for Patient Education of Facial Fractures

Background: Patients may be educated about facial fractures using two-dimensional computed tomography (2DCT); however, three-dimensional mixed reality (3DMR) goggles may improve patient education by delivering content in an immersive environment. Objective: To compare the effectiveness of 2DCT and 3DMR formats used for patient education on facial fractures, as measured by surveys. Methods: In this prospective, randomized, crossover study, video tutorials intended for facial fracture informed consent were created in 2DCT and 3DMR formats from a single CT data set of a zygomaticomaxillary complex (ZMC) fracture. Subjects were randomly assigned into two groups. Group 1 (n = 25) viewed the 2DCT tutorial, answered self-assessment and information recall surveys, viewed the 3DMR tutorial, repeated the prior surveys as well as a comparison survey. Group 2 (n = 25) followed the same sequence but viewed the 3DMR tutorial and then the 2DCT tutorial. Results: Participants (n = 50) had no differences in age (group 1-51.9 years/standard deviation [SD] 20.9; group 2-44.7 years/SD 17.6 years; p = 0.223), gender (group 1-10 male/15 female; group 2-11 male/14 female; p = 0.999), college education level (group 1-25 yes; group 2-25 yes; p = 0.844), or prior 2DCT or 3DMR experience (group 1-9 yes/16 no; group 2-13 yes/12 no; p = 0.393). The 3DMR format was preferred over 2DCT (p < 0.05), and it was reported to enhance understanding as compared to 2DCT (p < 0.05). No differences for information recall were noted (p = 0.753). Conclusion: In this study, participants preferred 3DMR goggles over 2DCT for a simulated ZMC fracture-informed consent.

Transforming Nursing Education: Developing Augmented Reality Procedural Training

The shortage of nursing faculty and the scarcity of clinical placements have compelled researchers to investigate innovative solutions for procedural development to bridge the gap between didactic teaching and clinical experiences. This feasibility study uses augmented reality (AR) with Microsoft HoloLens2 and Dynamics 365 Guides to train graduate nursing students on advanced nursing procedures, focusing on lumbar puncture. A convenience sample of 24 nurse practitioner students participated in the study. The System Usability Scale, Acceptability Scale, and Engagement Scale were used to assess participant's experiences and perceptions. The results are positive for the feasibility and acceptance of AR technology for procedural training. Participants found the HoloLens2 device easy to use and showed confidence in its functionality. The step-by-step instructions provided by Microsoft 365 Guides were understandable, useful, and satisfactory. The students reported high levels of engagement and found the AR experience to be helpful and motivating for learning. Faculty time was significantly reduced using the HoloLens2 for procedural training compared to traditional methods. This study demonstrates the potential for AR as an effective and efficient modality for nursing education. The findings support the integration of AR technology to enhance procedural development, address the challenges of limited clinical sites, and provide students with an immersive and self-paced learning experience. Additional studies will need to explore the impact of AR on clinical competency, patient outcomes, and cost-effectiveness. Overall, the use of AR technology may be useful and effective for nursing pedagogy.

Evolution of the meta-neurosurgeon: A systematic review of the current technical capabilities, limitations, and applications of augmented reality in neurosurgery

Background

Augmented reality (AR) applications in neurosurgery have expanded over the past decade with the introduction of headset-based platforms. Many studies have focused on either preoperative planning to tailor the approach to the patient's anatomy and pathology or intraoperative surgical navigation, primarily realized as AR navigation through microscope oculars. Additional efforts have been made to validate AR in trainee and patient education and to investigate novel surgical approaches. Our objective was to provide a systematic overview of AR in neurosurgery, provide current limitations of this technology, as well as highlight several applications of AR in neurosurgery.

Methods

We performed a literature search in PubMed/Medline to identify papers that addressed the use of AR in neurosurgery. The authors screened three hundred and seventy-five papers, and 57 papers were selected, analyzed, and included in this systematic review.

Results

AR has made significant inroads in neurosurgery, particularly in neuronavigation. In spinal neurosurgery, this primarily has been used for pedicle screw placement. AR-based neuronavigation also has significant applications in cranial neurosurgery, including neurovascular, neurosurgical oncology, and skull base neurosurgery. Other potential applications include operating room streamlining, trainee and patient education, and telecommunications.

Conclusion

AR has already made a significant impact in neurosurgery in the above domains and has the potential to be a paradigm-altering technology. Future development in AR should focus on both validating these applications and extending the role of AR.

The application of augmented reality for improving clinical skills: a scoping review

Augmented reality technology had developed rapidly in recent years and had been applied in many fields, including medical education. Augmented reality had potential to improve students' knowledge and skills in medical education. This scoping review primarily aims to further elaborate the current studies on the implementation of augmented reality in advancing clinical skills. This study was conducted by utilizing electronic databases such as PubMed, Embase, and Web of Science in June 2022 for articles focusing on the use of augmented reality for improving clinical skills. The Rayyan website was used to screen the articles that met the inclusion criteria, which was the application of augmented reality as a learning method in medical education. Total of 37 articles met the inclusion criteria. These publications suggested that using augmented reality could improve clinical skills. The most researched topics explored were laparoscopic surgery skills and ophthalmology were the most studied topic. The research methods applied in the articles fall into two main categories: randomized control trial (RCT) (29.3%) and non-RCT (70.3%). Augmented reality has the potential to be integrated in medical education, particularly to boost clinical studies. Due to limited databases, however, any further studies on the implementation of augmented reality as a method to enhance skills in medical education need to be conducted.

Evaluation of Mixed Reality Technologies for Remote Feedback and Guidance During Transrectal Ultrasound Biopsy Simulation: A Prospective, Randomized, Crossover Study

OBJECTIVE

To compare equivalency of remote to in-person training during simulated transrectal ultrasound-guided prostate biopsy, we combined three technologies (mixed reality [MR] software, smart glasses, and hydrogel simulation model). Taken together, telemonitoring harnesses data streaming to provide real-time supervision and technical assistance for surgical procedures from an expert at a remote geographical location.

METHODS

Nineteen students were randomized into two groups (MR-first and in-person-first) and proctored to measure prostate volume and perform 14-biopsies over seven sessions: pretest, two MR/in-person-guided training sessions, mid-test, crossover into two in-person/MR-guided training sessions, and post-test. MR sessions utilized Vuzix smart glasses with MR software (HelpLightning) to share the student's first-person perspective and Zoom to project the ultrasound screen to a remote instructor. Training and test sessions utilized single-color and seven-color prostate models, respectively. Accuracy of biopsy cores from test sessions were compared. Perception of instruction following each training session using 5-point Likert scales across five domains was assessed. Preference of instruction modality was assessed qualitatively.

RESULTS

Comparison of mid-test performance following two training sessions was similar across the two groups (MR-first 63.8% vs in-person-first 57.6%, P = .340). Following crossover, difference in post-test performance of the MR-first group and the in-person-first group approached significance (MR-first 80.2% vs in-person-first 70.8%, P = .050). Student evaluation of MR and in-person instruction following training sessions was similar across the five metrics.

CONCLUSION

MR-based remote learning is equally effective when compared to traditional in-person instruction.

Does Extended Reality Simulation Improve Surgical/Procedural Learning and Patient Outcomes When Compared With Standard Training Methods?: A Systematic Review

INTRODUCTION

The use of extended reality (XR) technologies, including virtual, augmented, and mixed reality, has increased within surgical and procedural training programs. Few studies have assessed experiential learning- and patient-based outcomes using XR compared with standard training methods.

METHODS

As a working group for the Society for Simulation in Healthcare, we used Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and a PICO strategy to perform a systematic review of 4238 articles to assess the effectiveness of XR technologies compared with standard training methods. Outcomes were grouped into knowledge, time-to-completion, technical proficiency, reactions, and patient outcomes. Because of study heterogeneity, a meta-analysis was not feasible.

RESULTS

Thirty-two studies met eligibility criteria: 18 randomized controlled trials, 7 comparative studies, and 7 systematic reviews. Outcomes of most studies included Kirkpatrick levels of evidence I-III (reactions, knowledge, and behavior), while few reported level IV outcomes (patient). The overall risk of bias was low. With few exceptions, included studies showed XR technology to be more effective than standard training methods in improving objective skills and performance, shortening procedure time, and receiving more positive learner ratings. However, XR use did not show significant differences in gained knowledge.

CONCLUSIONS

Surgical or procedural XR training may improve technical skill development among trainees and is generally favored over standard training methods. However, there should be an additional focus on how skill development translates to clinically relevant outcomes. We recommend longitudinal studies to examine retention and transfer of training to clinical settings, methods to improve timely, adaptive feedback for deliberate practice, and cost analyses.

Extended reality in surgical education: A systematic review

BACKGROUND

This review aims to evaluate the effectiveness of extended reality-based training in surgical education.

METHODS

This systematic review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

A total of 33 studies were included in the qualitative analysis. Nine studies evaluated the effectiveness of virtual reality-based training against no substitutional training. Seven studies looked at training for laparoscopic surgery, and the results were contradicting. Two studies focused on orthopedics training, and the outcomes were positive. Fourteen studies compared the outcomes of virtual reality-based training to conventional didactic teaching, all demonstrating superior outcomes for virtual reality-based training. Nine studies compared the outcomes of virtual reality simulation training to dry lab simulation training. The inferior outcomes of virtual reality simulation training were demonstrated by 5 studies for laparoscopic surgery, 1 study for arthroscopic procedures, 1 study for robotic surgery, and 1 study for dental procedures. One study found potential benefits of virtual reality simulation training on orthopedics surgeries. One study found virtual reality simulation training to be superior to cadaveric training, and 3 studies found augmented reality and virtual reality-based training to be comparable to supervised operative opportunities.

CONCLUSION

Extended reality-based training is a potentially useful modality to serve as an adjunct to the current physical surgical training.

Augmented Reality in Otology/Neurotology: A Scoping Review with Implications for Practice and Education

OBJECTIVE

To determine how augmented reality (AR) has been applied to the field of otology/neurotology, examine trends and gaps in research, and provide an assessment of the future potential of this technology within surgical practice and education.

DATA SOURCES

PubMed, EMBASE, and Cochrane Library were assessed from their inceptions through October 2022. A manual bibliography search was also conducted.

REVIEW METHODS

A scoping review was conducted and reported according to PRISMA-ScR guidelines. Data from studies describing the application of AR to the field of otology/neurotology were evaluated, according to a priori inclusion/exclusion criteria. Exclusion criteria included non-English language articles, abstracts, letters/commentaries, conference papers, and review articles.

RESULTS

Eighteen articles covering a diverse range of AR platforms were included. Publication dates spanned from 2007 to 2022 and the rate of publication increased over this time. Six of 18 studies were case series in human patients although the remaining were proof of concepts in cadaveric/artificial/animal models. The most common application of AR was for surgical navigation (14 of 18 studies). Computed tomography was the most common source of input data. Few studies noted potential applications to surgical training.

CONCLUSION

Interest in the application of AR to otology/neurotology is growing based on the number of recent publications that use a broad range of hardware, software, and AR platforms. Large gaps in research such as the need for submillimeter registration error must be addressed prior to adoption in the operating room and for educational purposes.

LEVEL OF EVIDENCE

N/A Laryngoscope, 133:1786-1795, 2023.

Mixed reality for the assessment of aortoiliac anatomy in patients with abdominal aortic aneurysm prior to open and endovascular repair: Feasibility and interobserver agreement

OBJECTIVES

The objective is to evaluate the feasibility and interobserver agreement of a Mixed Reality Viewer (MRV) in the assessment of aortoiliac vascular anatomy of abdominal aortic aneurysm (AAA) patients.

METHODS

Fifty preoperative computed tomography angiographies (CTAs) of AAA patients were included. CTAs were assessed in a mixed reality (MR) environment with respect to aortoiliac anatomy according to a standardized protocol by two experienced observers (Mixed Reality Viewer, MRV, Brainlab AG, Germany). Additionally, all CTAs were independently assessed applying the same protocol by the same observers using a conventional DICOM viewer on a two-dimensional screen with multi-planar reconstructions (Conventional viewer, CV, GE Centricity PACS RA1000 Workstation, GE, United States). The protocol included four sets of items: calcification, dilatation, patency, and tortuosity as well as the number of lumbar and renal arteries. Interobserver agreement (IA, Cohen's Kappa, κ) was calculated for every item set.

RESULTS

All CTAs could successfully be displayed in the MRV (100%). The MRV demonstrated equal or better IA in the assessment of anterior and posterior calcification (κMRV: 0.68 and 0.61, κCV: 0.33 and 0.45, respectively) as well as tortuosity (κMRV: 0.60, κCV: 0.48) and dilatation (κMRV: 0.68, κCV: 0.67). The CV demonstrated better IA in the assessment of patency (κMRV: 0.74, κCV: 0.93). The CV also identified significantly more lumbar arteries (CV: 379, MRV: 239, p < 0.01).

CONCLUSIONS

The MRV is a feasible imaging viewing technology in clinical routine. Future efforts should aim at improving hologram quality and enabling accurate registration of the hologram with the physical patient.

Surgeons' attitudes during laparoscopic appendectomy: do subjective intraoperative assessments affect the choice of peritoneal irrigation? A spin-off analysis from the REsiDENT-1 multicentre prospective observational trial

AIMS

Laparoscopic appendectomy (LA) for acute appendicitis (AA) is one of the most performed procedures. The effects of peritoneal lavage (PL) and the reasons to perform it have not been cleared and all meta-analyses didn't show a statistical advantage to prevent infectious complications. This study aims to investigate surgeons' perceptions during LA, comparing intraoperative findings with histological results, and exploring how surgeons' subjectivity influences the decision-making process on PL.

METHODS

Data were extracted from the two-year data lock from REsiDENT-1 registry, a prospective resident-led multicentre observational trial. This study investigates the relationships between PL and postoperative intraabdominal abscesses (pIAA) introducing a classification for AA to standardize the intraoperative grading. We included pre, intra, and postoperative variables. We applied our classification proposal, used a five-point Likert scale (Ls) to assess subjective LA difficulty and ran a concordance analysis between the assessment of AA and histology. Subsequently, a multivariate logistic regression model was built to find factors influencing PL.

RESULTS

561 patients were enrolled from twenty-one hospitals and 51 residents. 542 procedures were included in the logistic regression analysis and 441 in the concordance analysis, due to missing data. PL was used in 222 LA (39, 6%). We discovered a moderate positive monotonic relationship between surgical evaluation and histology, p < 0.001. Despite this, the reliability of the surgeon's assessment of appendicitis is progressively lower for gangrenous and perforated forms. The increasing grade of contamination, the increasing grade of subjective difficulty and the intraoperative finding of a gangrenous or perforated appendicitis were independent predictors of PL.

CONCLUSION

This study shows how surgeons' evaluation of AA severity overestimated more than half of gangrenous or perforated appendices with the perception of a challenging procedure. These perceptions influenced the choice of PL. We proved that the evaluation during LA could be affected by subjectivity with a non-negligible impact on the decision-making process.

Geographical distribution of authorship for leading cardiothoracic surgery journals

BACKGROUND

Evolution of surgical practice is influenced by publications in the leading journals of that field. If the authorship of a publication lacks geographical diversity, this could create bias and limit generalizability of the evidence. Accordingly, we conducted a geographical analysis of the leading Cardiothoracic Surgery journals worldwide.

METHODS

Using 2020 Impact Factor, we searched the leading Cardiothoracic Surgery journals over the past decade. Only original articles were included. Data regarding first, second and last authors were extracted from every article. From this, we analysed country of affiliation, highest academic degree obtained and author location by metropolitan or rural setting.

RESULTS

A total of 12,706 original articles were published in the top 5 ranked Cardiothoracic journals between 2011 and 2020. Authors originated from 69 countries, with the majority being from North America and Western Europe. The United States was the most common country of affiliation (42.8%) in all five journals, with New York City the most prominent city. A total of  63.7% of the authorship originated from large metropolitan areas (estimated as population greater than 500,000 residents), and the most common degrees obtained by authors were MD and PhD.

CONCLUSION

The prominent Cardiothoracic authorship is predominantly located in Western countries, most commonly large metropolitan centers in the United States. This raises questions as to whether the literature adequately reflects populations in other geographical areas such as the continents of South America and Africa and rural settings. Leading journals should consider policies which encourage publication by authors from geographical locations that are underrepresented globally.

A scoping review of deep learning in cancer nursing combined with augmented reality: The era of intelligent nursing is coming

Artificial intelligence has been developing greatly in the field of medicine. As a new research hotspot of artificial intelligence, deep learning (DL) has been widely applied in the fields of cancer risk assessment, symptom recognition, and cancer detection. Therefore, nursing care issues in terms of consuming time and energy, lower accuracy, and lower efficiency can be solved with applying DL in caring cancer patients. In addition, augmented reality (AR) has great navigation potential through combining computer-generated virtual elements with the real world. Thus, DL ​+ ​AR may facilitate patients with cancer to possess a brand-new model of nursing care that is more intelligent, mobile, and adapted to the information age, compared to traditional nursing. With the advent of the era of intelligent nursing, future nursing models can not only learn from the DL ​+ ​AR model to meet the needs of patients with cancer but also reduce nursing workload, save healthcare resources, and improve work efficiency, the quality of nursing care, as well as the quality of life for cancer patients.

The impact of COVID-19 pandemic on hand surgery: a FESSH perspective

COVID-19 has affected us all. The following collection of short essays highlights various aspects of the pandemic and how it has impacted hand surgery and lessons learned, from the perspective of the Federation of European Societies for Surgery of the Hand (FESSH) Executive Committee members. A range of topics were individually chosen by each of the five committee members and presented.

Emergency Neurosurgery Performed by General Surgeons: A Systematic Review

BACKGROUND

In under-resourced settings, general surgeons may be called upon to perform emergency operations within other specialties. Accordingly, we aimed to characterise patient outcomes after emergency neurosurgery performed by a general surgeon or general surgery trainee.

METHODS

PubMed, Embase and the Cochrane Library were searched to 30 May 2021 for observational studies reporting outcomes after emergency neurosurgery performed by a general surgeon. Study screening, data extraction, and risk of bias using the Downs and Black checklist were performed in duplicate. Data on setting, operation undertaken, mortality rates and complications were extracted. Meta-analysis was planned but not possible due to heterogeneity. This study is registered with PROSPERO, CRD42021258097.

RESULTS

From 632 records, 14 retrospective observational studies were included, covering a total sample of 1,988 operations. Four studies were from Australia, and the remaining 10 were, respectively, from 10 other countries. Most common operations performed were decompressive surgery with burr holes or craniectomy for head trauma and insertion of intracranial pressure monitors. Rural hospitals were the most common settings. Mortality rates for procedures performed by general surgeons at latest follow-up were heterogenous, ranging from 5% for evacuation of chronic subdural haematoma in Kenya to 81% in head injured patients in a Hong Kong study.

CONCLUSIONS

This is the first systematic review that synthesises the literature to characterise patient outcomes after neurosurgical operations performed by a general surgeon. Findings from this study may benefit global surgery performed in rural, remote, military or humanitarian settings.

An Augmented Reality Device for Remote Supervision of Ultrasound Examinations in International Exercise Science Projects: Usability Study

Background

Support for long-distance research and clinical collaborations is in high demand and has increased owing to COVID-19–related restrictions on travel and social contact. New digital approaches are required for remote scientific exchange.

Objective

This study aims to analyze the options of using an augmented reality device for remote supervision of exercise science examinations.

Methods

A mobile ultrasound examination of the diameter and intima-media thickness of the femoral and carotid arteries was remotely supervised using a head-mounted augmented reality device. All participants were provided with a link to a YouTube video of the technique in advance. In part 1, 8 international experts from the fields of engineering and sports science were remotely connected to the study setting. Internet connection speed was noted, and a structured interview was conducted. In part 2, 2 remote supervisors evaluated 8 physicians performing an examination on a healthy human subject. The results were recorded, and an evaluation was conducted using a 25-item questionnaire.

Results

In part 1, the remote experts were connected over a mean distance of 1587 km to the examination site. Overall transmission quality was good (mean upload speed: 28.7 Mbps, mean download speed: 97.3 Mbps, mean ping: 21.6 milliseconds). In the interview, participants indicated that the main potential benefits would be to the fields of education, movement analysis, and supervision. Challenges regarding internet connection stability and previous training with the devices used were reported. In part 2, physicians’ examinations showed good interrater correlation (interclass correlation coefficient: 0.84). Participants valued the experienced setting as highly positive.

Conclusions

The study showed the good feasibility of the chosen design and a highly positive attitude of all participants toward this digital approach. Head-mounted augmented reality devices are generally recommended for collaborative research projects with physical examination–based research questions.