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Article: Next-generation Virtual and Augmented Reality in Surgical Education: A Narrative Review.

Sheik-Ali, Sharaf / Edgcombe, Hilary / Paton, Chris

2019 Volume 35, Page(s) 27–35

Abstract: Background: Virtual and Augmented Reality (VR/AR) has been used in surgery for several decades. Over the past 5-10 years, however, new technological advances, including high-resolution screens, mobile graphical processing units (mGPUs) and position- ... ...

Abstract	Background: Virtual and Augmented Reality (VR/AR) has been used in surgery for several decades. Over the past 5-10 years, however, new technological advances, including high-resolution screens, mobile graphical processing units (mGPUs) and position-sensing technologies, have been incorporated into relatively low-cost VR and AR devices. This review focuses on the current impact of the application of these "Phase 2" VR/AR technology in surgical training. Methods: A narrative literature review was undertaken using PubMed and Web of Science to identify comparative studies related to the impact of Phase 2 VR or AR tools on surgical training, defined in terms of the acquisition of technical surgical skills. Eleven studies on the effectiveness of VR/AR in surgical education were identified for full review. Further, the grey literature was searched for articles describing the current state of VR/AR in surgical education. A quality analysis using the Newcastle Ottawa scale showed a median score of 7 (out of a maximum achievable score of 9). Results: All studies showed a positive association between the use of VR/AR in surgical training and skill acquisition in terms of improving the speed of acquisition of surgical skills, the surgeon's ability to multitask, the ability to perform a procedure accurately, hand-eye coordination and bimanual operation. The grey literature presented a common, positive theme of the benefits of VR/AR in surgical training. Conclusions: Based on the limited evidence available, VR/AR appears to have positive training benefits in improving the speed of acquisition of surgical skills. However, the significant heterogeneity in study methodology and the relative recency of wider VR/AR adoption in surgical training mean that only tentative conclusions can be drawn at this stage. Further research, ideally with large sample sizes, robust outcome measures and longer follow-up periods, is recommended.
MeSH term(s)	General Surgery/education ; User-Computer Interface ; Virtual Reality
Language	English
Publishing date	2019-09-20
Publishing country	United States
Document type	Journal Article ; Review
ZDB-ID	1225512-9
ISSN	1090-3941
ISSN	1090-3941
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Article ; Online: Lessons from the design, development and implementation of a three-dimensional (3D) neonatal resuscitation training smartphone application: Life-saving Instruction for Emergencies (LIFE app).

Wanyama, Conrad / Nagraj, Shobhana / Muinga, Naomi / Tuti, Timothy / Edgcombe, Hilary / Geniets, Anne / Winters, Niall / English, Mike / Rossner, Jakob / Paton, Chris

Advances in simulation (London, England)

2022 Volume 7, Issue 1, Page(s) 2

Abstract: Neonatal mortality remains disproportionately high in sub-Saharan Africa partly due to insufficient numbers of adequately trained and skilled front-line health workers. Opportunities for improving neonatal care may result from upskilling frontline health ...

Abstract	Neonatal mortality remains disproportionately high in sub-Saharan Africa partly due to insufficient numbers of adequately trained and skilled front-line health workers. Opportunities for improving neonatal care may result from upskilling frontline health workers using innovative technological approaches. This practice paper describes the key steps involved in the design, development and implementation of an innovative smartphone-based training application using an agile, human-centred design approach. The Life-saving Instruction for Emergencies (LIFE) app is a three-dimension (3D) scenario-based mobile app for smartphones and is free to download. Two clinical modules are currently included with further scenarios planned. Whilst the focus of the practice paper is on the lessons learned during the design and development process, we also share key learning related to project management and sustainability plans, which we hope will help researchers working on similar projects.
Language	English
Publishing date	2022-01-10
Publishing country	England
Document type	Journal Article
ISSN	2059-0628
ISSN (online)	2059-0628
DOI	10.1186/s41077-021-00197-7
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Article ; Online: Evaluation of Adaptive Feedback in a Smartphone-Based Game on Health Care Providers' Learning Gain: Randomized Controlled Trial.

Tuti, Timothy / Winters, Niall / Edgcombe, Hilary / Muinga, Naomi / Wanyama, Conrad / English, Mike / Paton, Chris

Journal of medical Internet research

2020 Volume 22, Issue 7, Page(s) e17100

Abstract: Background: Although smartphone-based emergency care training is more affordable than traditional avenues of training, it is still in its infancy, remains poorly implemented, and its current implementation modes tend to be invariant to the evolving ... ...

Abstract	Background: Although smartphone-based emergency care training is more affordable than traditional avenues of training, it is still in its infancy, remains poorly implemented, and its current implementation modes tend to be invariant to the evolving learning needs of the intended users. In resource-limited settings, the use of such platforms coupled with gamified approaches remains largely unexplored, despite the lack of traditional training opportunities, and high mortality rates in these settings. Objective: The primary aim of this randomized experiment is to determine the effectiveness of offering adaptive versus standard feedback, on the learning gains of clinicians, through the use of a smartphone-based game that assessed their management of a simulated medical emergency. A secondary aim is to examine the effects of learner characteristics and learning spacing with repeated use of the game on the secondary outcome of individualized normalized learning gain. Methods: The experiment is aimed at clinicians who provide bedside neonatal care in low-income settings. Data were captured through an Android app installed on the study participants' personal phones. The intervention, which was based on successful attempts at a learning task, included adaptive feedback provided within the app to the experimental arm, whereas the control arm received standardized feedback. The primary end point was completion of the second learning session. Of the 572 participants enrolled between February 2019 and July 2019, 247 (43.2%) reached the primary end point. The primary outcome was standardized relative change in learning gains between the study arms as measured by the Morris G effect size. The secondary outcomes were the participants individualized normalized learning gains. Results: The effect of adaptive feedback on care providers' learning gain was found to be g=0.09 (95% CI -0.31 to 0.46; P=.47). In exploratory analysis, using normalized learning gains, when subject-treatment interaction and differential time effect was controlled for, this effect increased significantly to 0.644 (95% CI 0.35 to 0.94; P<.001) with immediate repetition, which is a moderate learning effect, but reduced significantly by 0.28 after a week. The overall learning change from the app use in both arms was large and may have obscured a direct effect of feedback. Conclusions: There is a considerable learning gain between the first two rounds of learning with both forms of feedback and a small added benefit of adaptive feedback after controlling for learner differences. We suggest that linking the adaptive feedback provided to care providers to how they space their repeat learning session(s) may yield higher learning gains. Future work might explore in more depth the feedback content, in particular whether or not explanatory feedback (why answers were wrong) enhances learning more than reflective feedback (information about what the right answers are). Trial registration: Pan African Clinical Trial Registry (PACTR) 201901783811130; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=5836. International registered report identifier (irrid): RR2-10.2196/13034.
MeSH term(s)	Adult ; Double-Blind Method ; Feedback ; Female ; Health Personnel/trends ; Humans ; Learning Health System/trends ; Male ; Smartphone/instrumentation ; Smartphone/standards ; Video Games/psychology
Language	English
Publishing date	2020-07-06
Publishing country	Canada
Document type	Journal Article ; Randomized Controlled Trial ; Research Support, Non-U.S. Gov't
ZDB-ID	2028830-X
ISSN	1438-8871 ; 1439-4456
ISSN (online)	1438-8871
ISSN	1439-4456
DOI	10.2196/17100
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Article ; Online: Enhancing emergency care in low-income countries using mobile technology-based training tools.

Edgcombe, Hilary / Paton, Chris / English, Mike

Archives of disease in childhood

2016 Volume 101, Issue 12, Page(s) 1149–1152

Abstract: In this paper, we discuss the role of mobile technology in developing training tools for health workers, with particular reference to low-income countries (LICs). The global and technological context is outlined, followed by a summary of approaches to ... ...

Abstract	In this paper, we discuss the role of mobile technology in developing training tools for health workers, with particular reference to low-income countries (LICs). The global and technological context is outlined, followed by a summary of approaches to using and evaluating mobile technology for learning in healthcare. Finally, recommendations are made for those developing and using such tools, based on current literature and the authors' involvement in the field.
MeSH term(s)	Cell Phone ; Developing Countries ; Education, Medical/methods ; Emergency Medical Services/standards ; Emergency Medicine/education ; Emergency Treatment/standards ; Health Personnel/education ; Humans ; Income ; International Cooperation ; Program Evaluation
Language	English
Publishing date	2016-09-22
Publishing country	England
Document type	Journal Article
ZDB-ID	524-1
ISSN	1468-2044 ; 0003-9888 ; 1359-2998
ISSN (online)	1468-2044
ISSN	0003-9888 ; 1359-2998
DOI	10.1136/archdischild-2016-310875
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Article ; Online: Training non-physician anaesthetists in sub-Saharan Africa: a qualitative investigation of providers' perspectives.

Edgcombe, Hilary / Baxter, Linden S / Kudsk-Iversen, Soren / Thwaites, Victoria / Bulamba, Fred

BMJ open

2019 Volume 9, Issue 3, Page(s) e026218

Abstract: Objectives: To explore the views of non-physician anaesthesia providers (NPAPs) and their colleagues regarding the effectiveness of NPAP training programmes in three contrasting sub-Saharan African countries.: Design: This was a qualitative ... ...

Abstract	Objectives: To explore the views of non-physician anaesthesia providers (NPAPs) and their colleagues regarding the effectiveness of NPAP training programmes in three contrasting sub-Saharan African countries. Design: This was a qualitative exploratory descriptive study. Semistructured interviews were conducted online, recorded, transcribed and analysed thematically using NVivo. Setting: Participants' homes or workplaces in Sierra Leone, Somaliland and Uganda. Participants: 15 NPAPs, physician anaesthetists and surgeons working in the countries concerned. Results: Three major themes were identified: (1) discrepancy between urban training and rural practice, (2) prominent development of attitudes outside the curricular set during training, including approaches to learning and clinical responsibility and (3) the importance of interprofessional relationships developed during training for later practice. Conclusions: Anaesthesia providers in different cadres and very different country contexts in sub-Saharan Africa describe common themes in training which appear to be significant for their later practice. Not all these issues are explicitly planned for in current training programmes, although they are important in the view of providers. Subsequent programme development should consider these themes with a view to enhancing the safety and quality of anaesthesia practice in this context.
MeSH term(s)	Adult ; Anesthesiology/education ; Anesthetists/education ; Attitude of Health Personnel ; Clinical Competence/standards ; Female ; Health Personnel/education ; Humans ; Male ; Middle Aged ; Qualitative Research ; Sierra Leone
Language	English
Publishing date	2019-03-07
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	2747269-3
ISSN	2044-6055 ; 2044-6055 ; 2053-3624
ISSN (online)	2044-6055
ISSN	2044-6055 ; 2053-3624
DOI	10.1136/bmjopen-2018-026218
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Article ; Online: Sonographic identification of needle tip by specialists and novices: a blinded comparison of 5 regional block needles in fresh human cadavers.

Edgcombe, Hilary / Hocking, Graham

Regional anesthesia and pain medicine

2010 Volume 35, Issue 2, Page(s) 207–211

Abstract: Background and objectives: Needle visibility using ultrasound remains problematic at steep insertion angles. Despite modified techniques, steep approaches are still needed, particularly in the obese, neuraxial anesthesia or pain blocks around the spine. ...

Abstract	Background and objectives: Needle visibility using ultrasound remains problematic at steep insertion angles. Despite modified techniques, steep approaches are still needed, particularly in the obese, neuraxial anesthesia or pain blocks around the spine. We describe a novel technique for objective assessment of needle-tip identification and present data on a new needle. Methods: Five needles were compared for accuracy of tip position identification. Pajunk facet-tipped, Tuohy-tipped, Polymedic Ultrasound, Hakko EchoStim, and a new intermittently textured needle (T). Static ultrasound images were obtained of the needles in first-thaw, unembalmed cadavers at shallow, moderate and steep angles. Actual tip position was defined. Images were presented in blinded, random order to 10 experienced and 10 novice anesthetists who estimated tip position. Distance between true tip position and estimated position was measured ("tip error"). Secondary objectives included subjective measures of visibility and differences between needles at shallower insertion angles and between novice and expert observers. Results: At steep angles, study needles varied significantly with regard to tip error (P < 0.0001). Needle T scored highest for confidence and subjective visibility at moderate and steep angles. There was no significant difference between novice and experienced anesthetists for tip error or visibility. Experts were more confident in their estimates. Conclusions: Needle T demonstrated good properties even at steep insertion angles. Tip location was accurate, and observers rated it highly visible. Ability to identify needle-tip position can be objectively assessed.
MeSH term(s)	Anesthesiology/standards ; Cadaver ; Equipment Design ; Humans ; Needles ; Nerve Block/instrumentation ; Nerve Block/methods ; Pattern Recognition, Visual ; Ultrasonography, Interventional
Language	English
Publishing date	2010-02-04
Publishing country	England
Document type	Comparative Study ; Journal Article
ZDB-ID	1425299-5
ISSN	1532-8651 ; 1098-7339 ; 0146-521X
ISSN (online)	1532-8651
ISSN	1098-7339 ; 0146-521X
DOI	10.1097/aap.0b013e3181d273da
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Article ; Online: Evaluation of Adaptive Feedback in a Smartphone-Based Game on Health Care Providers’ Learning Gain

Tuti, Timothy / Winters, Niall / Edgcombe, Hilary / Muinga, Naomi / Wanyama, Conrad / English, Mike / Paton, Chris

Journal of Medical Internet Research, Vol 22, Iss 7, p e

Randomized Controlled Trial

2020 Volume 17100

Abstract: BackgroundAlthough smartphone-based emergency care training is more affordable than traditional avenues of training, it is still in its infancy, remains poorly implemented, and its current implementation modes tend to be invariant to the evolving ... ...

Abstract	BackgroundAlthough smartphone-based emergency care training is more affordable than traditional avenues of training, it is still in its infancy, remains poorly implemented, and its current implementation modes tend to be invariant to the evolving learning needs of the intended users. In resource-limited settings, the use of such platforms coupled with gamified approaches remains largely unexplored, despite the lack of traditional training opportunities, and high mortality rates in these settings. ObjectiveThe primary aim of this randomized experiment is to determine the effectiveness of offering adaptive versus standard feedback, on the learning gains of clinicians, through the use of a smartphone-based game that assessed their management of a simulated medical emergency. A secondary aim is to examine the effects of learner characteristics and learning spacing with repeated use of the game on the secondary outcome of individualized normalized learning gain. MethodsThe experiment is aimed at clinicians who provide bedside neonatal care in low-income settings. Data were captured through an Android app installed on the study participants’ personal phones. The intervention, which was based on successful attempts at a learning task, included adaptive feedback provided within the app to the experimental arm, whereas the control arm received standardized feedback. The primary end point was completion of the second learning session. Of the 572 participants enrolled between February 2019 and July 2019, 247 (43.2%) reached the primary end point. The primary outcome was standardized relative change in learning gains between the study arms as measured by the Morris G effect size. The secondary outcomes were the participants individualized normalized learning gains. ResultsThe effect of adaptive feedback on care providers’ learning gain was found to be g=0.09 (95% CI −0.31 to 0.46; P=.47). In exploratory analysis, using normalized learning gains, when subject-treatment interaction and differential time effect was controlled ...
Keywords	Computer applications to medicine. Medical informatics ; R858-859.7 ; Public aspects of medicine ; RA1-1270
Subject code	150
Language	English
Publishing date	2020-07-01T00:00:00Z
Publisher	JMIR Publications
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article: Anesthetic implications for the parturient with hereditary hemorrhagic telangiectasia.

Lomax, Suzi / Edgcombe, Hilary

Canadian journal of anaesthesia = Journal canadien d'anesthesie

2009 Volume 56, Issue 5, Page(s) 374–384

Abstract: Purpose: To review the effects of hereditary hemorrhagic telangiectasia (HHT) in the parturient and the anesthetic management of such patients during pregnancy and delivery.: Source: A literature search (1966-2008) was performed using Medline and ... ...

Abstract	Purpose: To review the effects of hereditary hemorrhagic telangiectasia (HHT) in the parturient and the anesthetic management of such patients during pregnancy and delivery. Source: A literature search (1966-2008) was performed using Medline and EMBASE databases. Bibliographies of retrieved articles were searched for additional sources. Principal findings: Hereditary hemorrhagic telangiectasia affects 1 in 5000-8000 people. It is a genetic condition in which vascular dysplasia affects many organs particularly the pulmonary, cerebral, gastrointestinal, and spinal vasculature. A large proportion of women with HHT have uneventful pregnancies. However, women can present in pregnancy with clinically silent but potentially life-threatening features of the disorder including fatal hemorrhage from ruptured arteriovenous malformations (AVMs), systemic emboli, and high output cardiac failure secondary to arteriovenous shunting. Literature on the anesthetic management of HHT in pregnancy is limited. Both general and regional anesthetic techniques have been successfully performed in these patients, but are reliant on identifying the presence of specific AVMs; avoidance of cardiovascular instability; and prophylaxis against systemic emboli secondary to pulmonary AVM shunting. The presence of spinal AVMs is considered a relative contraindication to regional techniques. As with other systemic AVMs, these can develop and increase in size during pregnancy with implications for the timing of screening and surveillance. Conclusions: An understanding of the presence and potential development of life-threatening AVMs during pregnancy is imperative for anesthesiologists caring for parturients with HHT. Even in the asymptomatic patient, a high index of suspicion should be maintained, screening performed where possible and anesthetic technique adapted accordingly.
MeSH term(s)	Analgesia, Obstetrical/methods ; Anesthesia, Obstetrical/methods ; Anesthesiology/methods ; Arteriovenous Malformations/complications ; Arteriovenous Malformations/diagnosis ; Arteriovenous Malformations/surgery ; Delivery, Obstetric/methods ; Female ; Humans ; Pregnancy ; Pregnancy Complications, Cardiovascular/diagnosis ; Pregnancy Complications, Cardiovascular/surgery ; Telangiectasia, Hereditary Hemorrhagic/complications ; Telangiectasia, Hereditary Hemorrhagic/diagnosis ; Telangiectasia, Hereditary Hemorrhagic/surgery
Language	English
Publishing date	2009-05
Publishing country	United States
Document type	Journal Article ; Review
ZDB-ID	91002-8
ISSN	1496-8975 ; 0832-610X
ISSN (online)	1496-8975
ISSN	0832-610X
DOI	10.1007/s12630-009-9076-z
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Article ; Online: Analysis of a capped carbon nanotube by linear-scaling density-functional theory.

Edgcombe, C J / Masur, S M / Linscott, E B / Whaley-Baldwin, J A J / Barnes, C H W

Ultramicroscopy

2018 Volume 198, Page(s) 26–32

Abstract: The apex region of a capped (5,5) carbon nanotube (CNT) has been modelled with the DFT package ONETEP, using boundary conditions provided by a classical calculation with a conducting surface in place of the CNT. Results from the DFT solution include the ... ...

Abstract	The apex region of a capped (5,5) carbon nanotube (CNT) has been modelled with the DFT package ONETEP, using boundary conditions provided by a classical calculation with a conducting surface in place of the CNT. Results from the DFT solution include the Fermi level and the physical distribution and energies of individual orbitals for the CNT tip. Application of an external electric field changes the orbital number of the highest occupied molecular orbital (HOMO) and consequently changes its distribution on the CNT.
Language	English
Publishing date	2018-11-14
Publishing country	Netherlands
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	1479043-9
ISSN	1879-2723 ; 0304-3991
ISSN (online)	1879-2723
ISSN	0304-3991
DOI	10.1016/j.ultramic.2018.11.007
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Article ; Online: Anaesthesia care providers employed in humanitarian settings by Médecins Sans Frontières: a retrospective observational study of 173 084 surgical cases over 10 years.

Kudsk-Iversen, Søren / Trelles, Miguel / Ngowa Bakebaanitsa, Elie / Hagabimana, Longin / Momen, Abdul / Helmand, Rahmatullah / Saint Victor, Carline / Shah, Khalid / Masu, Adolphe / Kendell, Judith / Edgcombe, Hilary / English, Mike

BMJ open

2020 Volume 10, Issue 3, Page(s) e034891

Abstract: Objective: To describe the extent to which different categories of anaesthesia provider are used in humanitarian surgical projects and to explore the volume and nature of their surgical workload.: Design: Descriptive analysis using 10 years (2008- ... ...

Abstract	Objective: To describe the extent to which different categories of anaesthesia provider are used in humanitarian surgical projects and to explore the volume and nature of their surgical workload. Design: Descriptive analysis using 10 years (2008-2017) of routine case-level data linked with routine programme-level data from surgical projects run exclusively by Médecins Sans Frontières-Operational Centre Brussels (MSF-OCB). Setting: Projects were in contexts of natural disaster (ND, entire expatriate team deployed by MSF-OCB), active conflict (AC) and stable healthcare gaps (HG). In AC and HG settings, MSF-OCB support pre-existing local facilities. Hospital facilities ranged from basic health centres with surgical capabilities to tertiary referral centres. Participants: The full dataset included 178 814 surgical cases. These were categorised by most senior anaesthetic provider for the project, according to qualification: specialist physician anaesthesiologists, qualified nurse anaesthetists and uncertified anaesthesia providers. Primary outcome measure: Volume and nature of surgical workload of different anaesthesia providers. Results: Full routine data were available for 173 084 cases (96.8%): 2518 in ND, 42 225 in AC, 126 936 in HG. Anaesthesia was predominantly led by physician anaesthesiologists (100% in ND, 66% in AC and HG), then nurse anaesthetists (19% in AC and HG) or uncertified anaesthesia providers (15% in AC and HG). Across all settings and provider groups, patients were mostly healthy young adults (median age range 24-27 years), with predominantly females in HG contexts, and males in AC contexts. Overall intra-operative mortality was 0.2%. Conclusion: Our findings contribute to existing knowledge of the nature of anaesthetic provision in humanitarian settings, while demonstrating the value of high-quality, routine data collection at scale in this sector. Further evaluation of perioperative outcomes associated with different models of humanitarian anaesthetic provision is required.
MeSH term(s)	Adolescent ; Adult ; Anesthesiologists/statistics & numerical data ; Anesthesiology/organization & administration ; Developing Countries ; Global Health ; Humans ; International Agencies/statistics & numerical data ; Medical Missions ; Medically Underserved Area ; Nurse Anesthetists/statistics & numerical data ; Retrospective Studies ; Surgical Procedures, Operative/statistics & numerical data ; Young Adult
Language	English
Publishing date	2020-03-04
Publishing country	England
Document type	Journal Article ; Observational Study ; Research Support, Non-U.S. Gov't
ZDB-ID	2599832-8
ISSN	2044-6055 ; 2044-6055
ISSN (online)	2044-6055
ISSN	2044-6055
DOI	10.1136/bmjopen-2019-034891
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