Zieglerknight2060

INTRODUCTION Current methods of training microsurgical interventions have various limitations, including limited transferability to the human model, economic demands, and ethical concerns. In this article, we show how surgery simulations can overcome these issues and how, combined with the application of an intelligent tutoring system (ITS), they can be used to train tasks in ophthalmic surgery more efficiently. METHODS We investigated physician trainee efficiency of learning microsurgical skills using our purpose-built microsurgery simulator that tracks a micromanipulator and displays a three-dimensional representation of the interior of a human eye in an augmented reality (AR) headset. The expertise of ophthalmic surgeons helped define five subtasks corresponding to the steps of internal limiting membrane peeling. Using our AR surgery simulation, 50 participants underwent two training sessions, one using the ITS that dynamically adapts the task sequence to the participant's progress and one using a fixed task sequence. RESULTS We found significant improvement in micromanipulation performance in the first training session with both the ITS and classic training. In the second session, however, only the participants training with the ITS had further improvements in performance. CONCLUSIONS Results of this study demonstrate the usability of AR simulation in training micromanipulation skills and support the claim that simulators can be used in ophthalmic surgery training. This study also extends the existing literature by demonstrating an application of ITS for surgical training. The potential of this method is further analyzed in ongoing studies and discussions with experts in ophthalmic surgery.INTRODUCTION Serious Games can be used effectively for clinical reasoning training in medical education. Case specificity of learning outcome elicited by Serious Games has not been studied in detail. This study investigated whether learning outcome elicited by repeated exposure to virtual patient cases is transferable to other cases addressing similar problems. METHODS In this monocentric, prospective, randomized trial, 69 fifth-year medical students participated in ten 90-minute sessions of using a computer-based emergency ward simulation game. Students were randomized to 3 groups (A, B, AB) and subsequently exposed to up to 46 different virtual patients. Group A was presented with 2 specific cases that were not shown in group B and vice versa. Group AB was exposed to all 4 specific cases. After 6 weeks of using the game as a learning resource, students were presented with 4 cases addressing similar problems. For each case, an aggregate score reflecting clinical reasoning was calculated, and performance was compared across groups. RESULTS In the final session, there were no significant between-group differences regarding the sum score reflecting aggregated performance in all 4 cases (A 66.5 ± 7.2% vs. B 61.9 ± 12.4% vs. AB 64.8 ± 11.1%, P = 0.399). An item-by-item analysis revealed that there were no between-group differences regarding correct therapeutic interventions. CONCLUSIONS Previous exposure had limited impact on subsequent performance in similar cases. This study suggests that case specificity of learning outcome elicited by the serious game is low and that acquired higher-order cognitive functions may transfer to similar virtual patients.Tranexamic acid (TXA) is an antifibrinolytic agent used to prevent traumatic exsanguination. It was first introduced to clinical practice for the management of patients with bleeding disorders, especially adapted to reduce bleeding in hemophiliacs undergoing oral surgical interventions. TXA exerts its action on the coagulation process by competitively inhibiting plasminogen activation, thereby reducing conversion of plasminogen into plasmin. This ultimately prevents fibrinolysis and reduces hemorrhage. Thus, TXA may be well suited for the management of traumatic hemorrhage in the prehospital setting.Despite multiplicity of studies on the use of TXA in clinical practice, there is no consensus regarding the use of TXA for the management of hemorrhage in trauma patients in the prehospital environment. Thus, a review on this topic was warranted. An extensive literature search yielded 14 full journal articles which met the inclusion criteria. These articles were thoroughly analyzed and the following themes were identified "dose of TXA administration," "route of TXA administration," "optimal window of TXA administration," "safety of TXA use," "clinical effectiveness of TXA application," and the "feasibility of TXA use in the prehospital setting."Overall, to achieve the best possible outcomes, the literature supports the use of a loading dose of 1 g of TXA, followed by 1 g infusion over 8 h, given by intravenous administration within a 3-h window period of traumatic injury. TXA is very effective and safe to use in the prehospital setting, and its use is clinically and economically feasible.In an effort to improve students' comfort level and confidence with spiritual care, nursing faculty initiated a classroom activity to encourage students to think about and reflect on 10 questions. Students responded by answering whether they had ever thought about the question being asked, then writing a short narrative response. Topics included issues about life, death, afterlife, spiritual well-being, truth, and God. Although 88.8% of participants (n = 107) considered themselves to be religious or spiritual, results revealed many had never thought about the questions being asked. Based on these findings, nurse educators should consider including a similar classroom reflection exercise to better prepare students for providing spiritual care prior to beginning clinical rotations.OBJECTIVE The Victorian Institute of Sport Assessment-Patella (VISA-P) is a questionnaire to assess the severity of patellar tendinopathies. Its use requires good reliability indicators internal consistency, test-retest and parallel forms. Several studies have been published examining this question, but to date the reliability of this questionnaire (meta-analysis) has not been generalized. The aim of this study was to perform a meta-analysis to generalize the reliability of the VISA-P. DATA SOURCES MEDLINE, EMBASE, and Scopus. STUDY SELECTION Studies included were those examining the reliability coefficients of the VISA-P Cronbach alpha, intraclass correlation coefficient (ICC), and parallel-forms (correlation coefficients compared with other scales). DATA EXTRACTION All coefficients were extracted and the mean reliability was obtained using fixed- or random-effects models. Sensitivity (leave-one-out analysis) was analyzed. Quality assessment was performed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. Daclatasvir chemical structure DATA SYNTHESIS Of 364 scientific articles, 12 fulfilled meta-analysis criteria. The summary statistic was 0.86 [95% confidence interval (CI) 0.78-0.92] for Cronbach alpha and 0.94 (95% CI 0.89-0.97) for the ICC. Parallel forms depended on the comparative test used, ranging from -0.83 to 0.68. The sensitivity analysis found an influential study for the parallel-forms reliability in the Blazina score. We were unable to analyze the asymmetry of funnel plots and meta-regression models because of the number of studies. CONCLUSIONS The reliability of VISA-P for assessing the severity of patellar tendinopathies requires greater evaluation with more scientific evidence before it can be implemented in clinical practice.OBJECTIVES The UNAIDS 90-90-90 and other cross-sectional metrics can lead to potentially counterintuitive conclusions when used to evaluate health systems' performance. This study demonstrates how time and population dynamics impact UNAIDS 90-90-90 metrics in comparison with a longitudinal analogue. DESIGN A simplified simulation representing a hypothetical population was used to estimate and compare inference from UNAIDS 90-90-90 metrics and a longitudinal metrics based on Kaplan-Meier-estimated 2-year probability of transition between stages. METHODS We simulated a large cohort over 15 years. Everyone started out at risk for HIV, and then transitioned through the HIV care continuum based on fixed daily probabilities of acquiring HIV, learning status, entering care, initiating ART, and becoming virally suppressed, or dying. Within simulations we only varied the probability of ART initiation. We repeated the simulation with an increased probability of death. RESULTS The cross-sectional probability of being on ART among persons who were diagnosed responded relatively slowly to changes in the rate of ART initiation. Increases in ART initiation rates caused apparent declines in the cross-sectional probability of being virally suppressed among persons who had initiated ART, despite no changes in the rate of viral suppression. In some cases, higher mortality resulted in the cross-sectional metrics implying improved healthcare system performance. The longitudinal continuum was robust to these issues. CONCLUSION The UNAIDS 90-90-90 care continuum may lead to incorrect inference when used to evaluate health systems performance. We recommend that evaluation of HIV care delivery include longitudinal care continuum metrics wherever possible.BACKGROUND CD4 T-cells that express the chemokine receptor, CCR5, are the most important target of HIV-1 infection, but their functions, phenotypes and anatomical locations are poorly understood. We aimed to use multiparameter flow cytometry to better define the full breadth of these cells. METHODS High-parameter fluorescence flow and mass cytometry were optimized to analyse subsets of CCR5+ memory CD4 T-cells, including CD25CD127 Tregs, CXCR3+CCR6- Th1, CCR6+CD161+CXCR3- Th17, integrins α4+ß7+ gut-homing, CCR4+ skin-homing, CD62L+ lymph node-homing, CD38+HLA-DR+ activated cells, and CD27-CD28- cytotoxic T lymphocytes (CTL), in a total of 22 samples of peripheral blood, ultrasound-guided fine needle biopsies of lymph nodes and excised tonsils. CCR5+ antigen-specific CD4 T-cells were studied using the OX40 flow-based assay. RESULTS 10-20% of CCR5+ memory CD4 T-cells were Tregs, 10-30% were gut-homing, 10-30% were skin-homing, 20-40% were lymph node-homing, 20-50% were Th1 and 20-40% were Th17 cells. Up to 30% were CTL in CMV-seropositive donors, including cells that were either CCR5Granzyme K+ or CCR5Granzyme B+. When all possible phenotypes were exhaustively analysed, > 150 different functional and trafficking subsets of CCR5+ CD4 T-cells were seen. Also, a small population of resident CD69+Granzyme K+CCR5+ CD4 T-cells was found in lymphoid tissues. CMV- and M tuberculosis-specific CD4 T-cells were predominantly CCR5+. CONCLUSIONS These results reveal for the first time the prodigious heterogeneity of function and trafficking of CCR5+ CD4 T-cells in blood and in lymphoid tissue, with significant implications for rational approaches to prophylaxis for HIV-1 infection and for purging of the HIV-1 reservoir in those subjects already infected.OBJECTIVE To evaluate HIV testing yield under several candidate strategies for outreach testing at venues (i.e., places where people socialize and meet new sex partners) in East Africa cross-border areas. DESIGN Population-based cross-sectional biobehavioral survey of people who had not been previously diagnosed with HIV found in venues. METHODS We identified participants who would have been tested for HIV under each of 10 hypothetical outreach testing strategies and calculated the proportion who would have newly tested positive for HIV under each strategy. Based on this proportion, we calculated the "number needed to test" (NNT) to identify 1 new case of HIV under each strategy. All estimates were obtained by applying survey sampling weights to account for the complex sampling design. RESULTS If testing were performed at a random sample of venues, 35 people would need to be tested to identify 1 new case of HIV, but higher yield could be found by limiting testing to venues with specific characteristics. Strategies focusing on women had higher testing yield.