A cost analysis of robotic vs. video-assisted thoracic surgery: The impact of the learning curve and the COVID-19 pandemic.

Introduction: Robot-assisted thoracoscopic surgery (RATS) is an alternative to video-assessed thoracoscopic surgery (VATS) for the treatment of lung cancer but concern exists regarding the high associated costs. The COVID-19 pandemic added further financial pressure to healthcare systems. This study investigated the impact of the learning curve on the cost-effectiveness of RATS lung resection and the financial impact of the COVID-19 pandemic on a RATS program. Methods: Patients undergoing RATS lung resection between January 2017 and December 2020 were prospectively followed. A matched cohort of VATS cases were analyzed in parallel. The first 100 and most recent 100 RATS cases performed at our institution were compared to assess the learning curve. Cases performed before and after March 2020 were compared to assess the impact of the COVID-19 pandemic. A comprehensive cost analysis of multiple theatre and postoperative data points was performed using Stata statistics package (v14.2). Results: 365 RATS cases were included. Median cost per procedure was £7,167 and theatre cost accounted for 70%. Major contributing factors to overall cost were operative time and postoperative length of stay. Cost per case was £640 less after passing the learning curve (p < 0.001) largely due to reduced operative time. Comparison of a post-learning curve RATS subgroup matched to 101 VATS cases revealed no significant difference in theatre costs between the two techniques. Overall cost of RATS lung resections performed before and during the COVID-19 pandemic were not significantly different. However, theatre costs were significantly cheaper (£620/case; p < 0.001) and postoperative costs were significantly more expensive (£1,221/case; p = 0.018) during the pandemic. Discussion: Passing the learning curve is associated with a significant reduction in the theatre costs associated with RATS lung resection and is comparable with the cost of VATS. This study may underestimate the true cost benefit of passing the learning curve due to the effect of the COVID-19 pandemic on theatre costs. The COVID-19 pandemic made RATS lung resection more expensive due to prolonged hospital stay and increased readmission rate. The present study offers some evidence that the initial increased costs associated with RATS lung resection may be gradually offset as a program progresses.

Right heart catherisation - a virtual reality

Introduction: Right heart catheterisation (RHC) is the gold standard for assessing patients with pulmonary hypertension. Doctors require training in this procedure in a safe and friendly environment with minimal risk to patients. Due to the Covid pandemic, formal RHC teaching workshops were cancelled in our country, so we sought to develop a Virtual Reality Right Heart Catheterisation (VRRHC) training program to fulfil this area of need without the need for face to face contact. The aim was to improve training, competency and confidence in this technique with improved diagnostic skills and reduction of procedural errors. Method(s): We approached a health technology company to design a VRRHC training module based on our current RHC simulation workshops. Phase 1 required virtual insertion of RHC via the right internal jugular vein using micro-puncture, double Seldinger technique under ultrasound guidance, followed by insertion of the RHC to the right atrium, right ventricle and pulmonary artery with pulmonary artery occlusion using real time pressure tracings and fluoroscopy. Thermodilution cardiac outputs and chamber saturations were also performed. The proprietary platform technology was delivered via a laptop and VR headset. Clinicians perform the VRRHC with imaging, monitoring and haptic feedback with the collection of real time performance tracking allowing user data (e.g. failed steps and proficiency scores) to be captured and subsequently visualised in the learning management system. We collected analytics and data on user engagement, experience and retention, targeted learning outcomes and learning curve, reduction in operating costs, reduction in procedure times due to higher proficiency, early diagnosis of pulmonary hypertension, reduced complications, improved interpretation and diagnosis. Result(s): The program was launched in October 2021. Preliminary data shows a learning curve is associated with both using VR (10-15 minutes) and the RHC procedure itself. Initial time to completion of the RHC was 30-40 mins, reducing to 20-30 minutes with experience and 15 minutes in experts. Completion rates increase with experience from 40-50% to 100% and error rates reduce with frequency of completion. Conclusion(s): A Virtual Reality Right Heart Catheter training program is safe, feasible and non-invasive. Increased experience results in increased completion rates, reduced procedure time and reduced errors. Using this program will potentially have beneficial effects on doctor training, outcomes, patient safety and health economics with no risk to a real patient. VRRHC images VRRHC hardware and utilisation.

The Importance of Simulation in Vascular Training: A Literature Review

Funding: None. Synopsis: Once a subspecialty of general surgery, vascular surgery has transitioned to an entity with its own training paradigms and board certification. Part of this transition is due to many advances in technology, devices, and techniques. The management of vascular pathology that was at one time relegated to open procedures has now shifted to a field where endovascular options can be performed. These advances come with the concern of training competent vascular surgeons who are already under stringent duty hours restrictions, deal with heightened scrutiny associated with patient safety, and recently have had their operative volumes decreased due to COVID-19-related cancellations and shut downs. Simulation has been offered as a possible means to mitigate these limitations and shift the learning curve to competency. Despite this, little is known regarding the efficacy and best practices of incorporating simulation into vascular training. Method(s): A literature review was performed of English language articles on the EBSCO database without publication date restrictions on vascular surgery simulation. Search terms included vascular surgery simulation, endovascular surgery simulation and vascular education simulation. Additional studies were found by searching reference lists of relevant articles. All study designs were included if they pertained to simulation for open vascular or endovascular procedures. Simulator fidelity, educational efficacy, validity of the simulator, transfer of skill, and cost and time effectiveness were assessed. With endovascular simulation we assessed the amount of handling error, procedure time, fluoroscopy time, and the amount of contrast used. Result(s): Using these methods, twenty-two articles were identified. In regards to simulation used for open procedures in vascular surgery, the analysis showed that the most important factors in determining efficacy were the involvement of expert level (attending) proctors and the use of high fidelity (cadaver) simulators. Other important determinants were the use of trainee-specific models and the employment of specific learning objectives. The use of virtual endovascular simulators in enhancing trainee competence is supported by better quality data in the literature. Specifically measured and proven outcomes are a decrease in catheter handling errors, a reduction in both procedure and fluoroscopy time, and a diminished volume of contrast used. Endovascular simulators also allowed for reliable and consistent assessment of operator performance and showed a good transfer of skill to actual cases. Conclusion(s): Simulation is an important tool for both the assessment and training of vascular residents. The use of expert proctors, appropriate simulators, and well-designed curricula are the keys to success. Further studies connecting simulation training to patient-centered outcomes are still needed to define the true potential of these tools and methods. Institution: Lousiana State University HSC, New Orleans, LACopyright © 2022

Robotic surgery implementation in an isolated overseas territory - The case of Reunion Island.

INTRODUCTION: In February 2020, robotic surgery was introduced in University Hospital of St Pierre in Reunion Island. The aim of this study was to evaluate the implementation of robotic assisted surgery in the hospital and its impact on operating times and patient outcomes. METHODS: Data was prospectively collected on patients undergoing laparoscopic robotic assisted surgery between February 2020 and February 2022. Information included patient demographics, type of surgery, operating times and length of stay. RESULTS: Over the two-year study period, 137 patients underwent laparoscopic robotic assisted surgery performed by 6 different surgeons. 89 of the surgeries were in gynecology, including 58 hysterectomies, 37 were in digestive surgery, and 11 in urology. The installation and docking times decreased across all specialties and were found to be significantly reduced when comparing the first and last 15 hysterectomies: mean installation time decreased from 18.7 to 14.5 minutes (p=0.048), mean docking time decreased from 11.3 to 7.1 minutes (p = 0.009). CONCLUSIONS: The implementation of robotic assisted surgery in an isolated territory such as Reunion Island was slow due to a lack of trained surgeons, supply difficulties and Covid crisis. Despite these challenges, the use of robotic surgery allowed for technically more challenging surgeries and demonstrated similar learning curves to other centers.

In bed hybrid tracheostomy procedure in COVID-19 patients. Technique and results

Background: COVID-19 pandemic, results in a great number of critically ill patients requiring long-lasting periods of invasive mechanical ventilatory support;tracheostomy is considered during their hospital stay, to free patients from ventilatory support and optimize the resources, we developed a safe in bed hybrid tracheostomy procedure to avoid the operating room and minimize SARS-CoV2 transmission due to aerosols exposure. Method(s): We developed this protocol using PDCA (Plan, Do, Check, Act) in order to perform a safe in bed hybrid tracheostomy: percutaneous tracheostomy + flexible bronchoscopy. We used the Ciaglia Blue Rhino technique and flexible bronchoscopy. We analyzed: Gender, age, body mass index, intubation days, ventilatory parameters, procedure time, apnea time, oxygen saturation, complications and patient clinical evolution. Statistical evaluation: Fisher test, U Mann-Whitney, T test, logistic regression and Kaplan-Meier curves. Result(s): From march 2020 to February 2021, 292 patients underwent hybrid tracheostomy;Tracheostomy was successfully completed in all patients: 211 men (72.2%);81 women (27.8%), age 58.5 years old, intubation days before tracheostomy 23 days (19 to 28 days), 133 patients (45.5%) deaths due to COVID19 complications. Procedure time 6 to 14 minutes (mean 9 minutes), apnea time 147 to 360 seconds (mean 240 seconds), O2 saturation 66%-96% (mean 87%), PaO2/fiO2 106-194 (mean 142), SOFA 4-6 (mean 5). No complications due to the trachesotomy. Conclusion(s): In bed hybrid tracheostomy procedure implementation with the PDCA cycles is safe, with good results, zero procedure complications and a good and rapid learning curve.

142. The Reach, Implementation, and Effectiveness of Virtual Sex Education for Youth in Foster Care

Purpose: Youth in foster care have high rates of adverse sexual health outcomes and are important targets for evidence-based sex education. With the COVID-19 pandemic, sexual health programming was moved to a virtual format. However, few data existed to guide this transition. While it lowers expenses and can potentially broaden geographic reach, it is unclear if virtual programming meets the needs of youth in foster care or other vulnerable populations. We conducted a mixed-methods analysis comparing the reach, implementation, and effectiveness of virtual vs in-person sex education for youth in foster care before and during the COVID-19 pandemic. Methods: Indiana Proud and Connected Teens (IN-PACT) provides evidenced-based sex education programs to system-involved youth. The data used in this study focused exclusively on foster-care programming and includes attendance records, facilitator session reviews (n=64) from 2020-2021 virtual programs, and youth surveys from 2018-2020 in-person (n=965) and virtual (n=50) programs. Reach was measured using youth baseline survey demographics and sexual behaviors;implementation by free responses from facilitators on challenges and adaptation for virtual teaching;and effectiveness by attendance records and youth behavior intention on follow-up surveys. Results: Reach: Youth demographic diversity was maintained for virtual programming in ethnicity, race, sex, and sexual orientation. However, youth in virtual programs had lower rates of self-reported risk behaviors including lower rates of involvement with juvenile justice (35.0% vs 59.4%, p<0.01) to have ever had sex (44.4% vs 78.8%, p<0.001) or contributed to a pregnancy (4.4% vs 23.4%, p<0.05). And though not statistically significant, virtual youth reported higher rates of condom use (44.4% vs 30.4%, p=0.371) and lower rates of substance use before sex in the past 3 months (15.6% vs 28.5%, p=0.114) as compared to in-person youth. Implementation: Technical challenges included connection difficulties and learning curves to using Zoom. Virtual facilitators incorporated more technology than they did in-person by playing videos on complicated topics such as conception and STIs. In terms of curriculum, hands-on condom demonstrations were changed to facilitator-run experiments such as having youth use socks at home to simulate condoms on their arms. Breakout rooms were utilized to maintain small group work but were cumbersome. Relational challenges included awkward silences, disengagement, and a decrease in group trust due to cameras being turned off during sensitive topics and less connection between youth and facilitators. Effectiveness: Attendance records show that fewer virtual youth completed 100% of programming, as compared to in-person youth (23% vs 54%). More virtual youth answered yes to the question "As a result of this program, will you abstain from sex for the next three months?” as compared to in-person youth (55% vs 45%, p=0.462). However, virtual youth were significantly less likely to have baseline sexual experience. Conclusions: In-person sexual health programming had a wider reach, experienced fewer implementation challenges, and was potentially more effective than virtual programming for youth in foster care. If virtual programming becomes necessary again, sex educators and researchers can use these data to redesign virtual programming that maximizes reach, implementation, and effectiveness. Sources of Support: HHS 90AK0041-02-00 to Health Care Education and Training Inc.

Perception Of Post-Graduate Students On Online Classes During Covid-19 Pandemic Situation

Purpose: Online classes are one of the new innovative study methods that have been popularized in recent times. In the last few years there has been a great shift in the training methods. Online classes play a vital role during the pandemic, but its consequences cannot be ignored. Now-a-days online studies or learning turns out to be more and more practiced. It has become a trend especially during the period of COVID-19 lockdown in 2020 and 2021. It's very convenient as both, student and teacher, as they interact from their own places. Sampling Design: Here the researcher has used the purposive sampling method;data were collected on a sample unit of 100 students pursuing post-graduation from Chennai city. A researcher has used Google Forms for online questionnaire purposes with the intention to study the perception of Postgraduate students in an online class during pandemic situations. Understanding the student's perception using descriptive statistics with Chi-square analysis. The researcher has also used the telephone to collect the real data from the respondents. Finding(s): The researcher was observed significant differences between the fear of lack of knowledge and online offline environment among Male and female post-graduate students. A lot of students have started changing their mindset for work in the unorganized sector they earned money to help their family. Few students only they think differently and concentrate on creative and innovative ideas and also they have joined new courses like NPTEL Swayam. The majority of the students have faced stress and depression in the pandemic situation. Recommendations: This research helped stakeholders of the learning curve like Professors, Parents, Research Scholars, and students. Professors should understand the student's mindset in the pandemic situation. Whenever the teachers scheduled the class they should motivate, encourage and give safety measures. Apart from the syllabus, they are requested to share the real life inspirations. Conclusion(s): Postgraduate students all over the world facing stress and depression because of coronavirus, pandemic situations, lockdown and online classes. The researcher discovered that parents, management of the institution, and professors should take care of the future of all the students. We should always encourage, motivate, and proper guidance whenever they feel very sad and we try to reduce negative thoughts from the students' mind. Management of the Institution should insist that nothing is permanent in this world. Everything will change. Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.

R-Tapp as a Training Model in Robotic Surgery

Aim: Themain aimof the project will be evaluating the effectiveness of an experimental structured didactic program in robotic surgery in filling the training gap caused by the pandemic. We intend to evaluate how establishing a training pathway could improve young surgeons' robotic skills and implement their participation in robotic procedures during the COVID-19 pandemic. We will also evaluate the learning curve of robotic transabdominal preperitoneal inguinal hernia repair (TAPP) for young surgeons with limited experience as first operators at the dual console. Matherials and Methods:Wedesigned an experimental stepwise training program in robotic surgery that starts from a first step of theoretical and laboratory lessons, followed by a second phase of bedside assistance training, and finally the completion of low complexity procedures by the trainees proctored at the dual console by senior surgeons. Robotic TAPP was selected as training model. The performance of each trainee will be registered in an evaluation data sheet and Learning scores will be recorded by the tutor with the evaluation of 6 corner steps of the procedure. Result(s): Preliminary results showed improved technical skills and increased team spirit and wellbeing. Conclusion(s): TAPP is a good training model because involves technical steps useful for more complex procedures. The robotic dual console represent an extraordinary training tool and a structured training program positively impacts technical skills and could help filling the training gap caused by the pandemic.

Building the state of the art from the thoughts of our people -Implementing developed world experience in developing world

Introduction: At the beginning of the pandemic, I was working in University Hospital of Leicester (UHL), a leading hospital in UK as a speciality doctor as a part of post graduate training in anaesthesia of Sri Lanka. 5 months into the pandemic, I find my self returning to Sri Lanka after the training and only to be appointed as a consultant anaesthetist in a designated COVID treatment hospital. This is my story of converting a normal ICU space to a COVID -ICU. Main body: The pandemic came late to Sri Lanka. Even after 5 months of pandemic, the Intensive care unit in a designated COVID hospital was not ready to accept any patients. Leaving UK, at the peak of pandemic after a steep learning curve, I realised that we Sri Lankans are just living on borrowed time. Being a developed country, UK also experienced inadequacies with manpower and equipment. Looking at a low income country like Sri Lanka, the challenges of converting the space in to COVID ICU seemed to be impossible. Starting from the scratch, with the constant encouragement of the colleges and authorities, a COVID ICU was built at a Base Hospital - Teldeniya, which was situated 15 miles away from a city. UHL was able to increase its ICU capacity within days. Most hospitals in UK did this within days to weeks. The story was not the same for Sri Lanka. People took time to realise the need for the COVID ICU. This made me desperate and sad thinking about the support the ICU authorities had at UHL. Our ICU started with one bed, adding to the total of 14 designated ICU beds in Sri Lanka. This number was bearable, as the number of reported cases were low all over the country. With the beginning of the year 2021, the number of reported COVID-19 cases gradually increased, with more patients needing ICU admissions. The bed number at BH Teldeniya was also increased to 5, but with minimal resources. When the pandemic reached its peak in early 2021, the miracle happened. There was an island wide appeal to donate equipment for COVID ICUs in Sri Lanka. This made people to change their attitude about the disease and about the COVID - ICUs. Generous donors from all over Sri Lanka and from overseas got together for this good cause. With no time, my ICU was well equipped with all kinds of sophisticated equipment. My greatest winning was to obtain a liquid oxygen plant to the hospital, allowing me to use high flow nasal oxygen therapy in deserving patients. Today, BH Teldeniya serves it maximum to the critically ill COVID-19 patients. Now I can sleep well in the night thinking that, my patients will get the same treatment as a patient in UHL. The unit is well equipped, and I can even lend equipment to ward HDUs. All this was possible due to simple thoughts of Sri Lankans. Conclusion: In 20 years' time, I will look back at the time of pandemic and be proud of my journey from a developed country to a developing country to make the difference that would change the fate of critically ill Sri Lankans.

DISTANCED-LEARNING BASIC SKILLS IN ERCP COURSE: TRAINEE FEEDBACK AND EFFECTIVENESS AT DELIVERING THE JAG CURRICULUM

Introduction Distanced learning has become common place in recent years. This online basic skills in ERCP course was developed in line with the JAG training pathway and certification standards. Considering previous JAG approved courses have been hands-on, we assessed whether a distanced learning format is effective at meeting trainee expectations and curriculum learning outcomes. Methods The course was delivered to 8 delegates through an online platform. Four half-day sessions introduced the theory and practical aspects of ERCP training, covering: pre-procedure, intra-procedure and post-procedure topics. Although not a hands-on course, the format was based on recorded cases to highlight the different learning points. Feedback, in the form of Likert scales (strongly disagree (1), disagree (2), neutral (3), agree (4), strongly agree (5)) assessed the effectiveness of the course at delivering learning outcomes drawn from the JAG curriculum, and whether it was suited to a distanced learning format. Pre and post course questionnaires asked delegates their confidence in managing the different learning outcomes. Results Feedback for the course format was positive, with agreement that it was suitable for theory-based learning (median response 4.0). There were mixed views regarding the separation of theory and practical content, and whether this was detrimental to learning (3.0). Overall, there was agreement that this course is useful for training (5.0) and would be recommended to a colleague (5.0). Post-course responses were more positive than those precourse for all learning outcomes. Particularly notable was the shift from disagreeing (pre-course) to agreeing (post-course) about confidence in biliary cannulation techniques (2.0 to 4.0), methods for cannulation when selective cannulation fails (2.0-4.0), biliary stent choices (2.0-4.5), and on the spot decisions about managing jaundiced patients (2.5-4.0). Conclusion JAG certification in ERCP will soon require attendance on basic skills courses and e-learning has been proposed as a novel way to deliver such courses in the recovery of endoscopy training following Covid-19. Feedback for this distanced learning course suggests this format is suitable for the theory-based learning, improving participants confidence in managing specific aspects of ERCP theory and knowledge. Further courses are needed to assess the impact on a wider audience, and a longer follow would allow evaluation of the impact on the ERCP learning curve.

One Anastomosis Gastric Bypass (OAGB) as a bariatric procedure in a teaching tertiary hospital in Athens during COVID-19 pandemic

Emmanouil Onoufrios Sgouromallis ATHENS1, Konstantinos Livanos Chalandri1, Georgios Xenakis ATHENS1, Melissanthi Bechraki- Triantafyllou ATHENS1, Parmenion Patias Athens1, Ilias Margaris Athens1 2nd Surgical Dept, George Gennimatas General Hospital, Athens, Greece1 Background: OAGB is a bariatric procedure with excellent results while presumed to have a lower learning curve than classic RYGB. COVID-19 pandemic has severe ramifications in the global health system and this effect is amplified in obesity management due to both the fear of perioperative mortality of bariatric patients and the social stigma that often follows. Methods: We retrospectively analyzed the data of 67 consecutive OAGBs performed in our center from March 2020 to end of December 2021. Results: 47 patients were female, mean age was 41.64 while mean preoperative BMI was 50.45. Mean Hgb decrease was 1.43 postoperatively with mean hospital stay of 4.47 days. All procedures were performed by an attending surgeon as supervisor and two 5th year residents with bariatric surgery experience. There were 3 postoperative leaks, 2 of which resolved with conservative management. No patients were infected during their hospital stay while one patient was admitted to the COVID clinic due to a mild infection two months post operatively with an uneventful course. During the short follow-up period hypertension, diabetes and obstructive sleep apnea were significantly improved or disappeared while no patient reported symptoms of reflux esophagitis. Conclusion: OAGB is feasible as a procedure, with an acceptable learning curve in tertiary centers. COVID pandemic did not decrease bariatric procedures;however one patient who was the only death in our study was admitted in ICU with 24 hours delay due to the decreased availability of ICUs during the pandemic, a factor to be considered during this period.

Learning curve for orotracheal intubation using Airtraq® videolaryngoscopy

Introduction: Orotracheal intubation is one of the medical skills that has gained the most importance for the management of the airway of hospitalized patients with severe COVID-19 symptoms. Objective: To determine the number of videolaryngoscopies that the operator must perform to master orotracheal intubation with videolaryngoscope. Methods: A longitudinal and prospective study was carried out, where the learning process of an anesthesiology specialist was evaluated to determine the reduction in the time they needed to perform an orotracheal intubation in COVID-19 positive patients with respiratory distress. Results: The anesthesiologist with no experience in the use of the Airtraq® videolaryngoscope achieved a learning rate of 86.98% within the first 10 interventions (p < 0.05), leading to a constant decrease in time in each procedure until reaching their mastery. Conclusions: The practice of orotracheal intubation facilitates that with a greater number of intubated patients, a significant decrease in the time required for this technique can be obtained, reducing the transient hypoxia of the patient in apnea due to COVID-19, being the number of repetitions of the procedure a more important factor than the difficulty of the cases. © 2022 Sociedad de Anestesiologia de Chile. All rights reserved.

Mathematics Performance Among Pre-Diploma Students with Online Learning Approach During Movement Control Order (MCO)

Various teaching and learning approaches have been applied among educators to the students during the Movement and Control Orders (MCO) employed due to COVID-19. Educators especially those who are teaching the mathematics subject require comprehensive and effective tools to help their students understand the concept and able to do exercises with less face-to-face guidance or a normal conventional teaching approach. Teaching the mathematics subject especially to the Pre-Diploma students is very challenging as they are quite weak in mathematics fundamentals and coincidentally, they have to face the obstacles of teaching approach with Online learning during MCO. Hence, a mathematics teaching model with an online learning approach was created to make the teaching delivery effective, thus increasing the learning curve or performance of mathematics among students. The ongoing and final assessment results of the students were analysed using an independent sample t-test to measure the difference between those experiencing and without experiencing the suggested model.

Virtual Reality Training in Right Heart Catheterisation

Introduction: Right heart catheterisation is the gold standard for assessing patients with pulmonary hypertension. Doctors require training in this procedure in a safe and friendly environment with minimal risk to patients. During the COVID-19 pandemic, we sought to develop a Virtual Reality Right Heart Catheterisation (VRRHC) training program to fulfil this area of need without face-to-face contact. The aim was to improve procedure competency, aid diagnosis and reduce medical error. Method: We approached a health technology company to design a VRRHC training module based on our current RHC simulation workshops. Phase 1 required virtual insertion of RHC via right internal jugular vein using a micro-puncture, double-Seldinger technique under ultrasound guidance, followed by insertion of the RHC to the right atrium, right ventricle, pulmonary artery, pulmonary artery occlusion position using real time pressure tracings and fluoroscopy. Thermodilution cardiac outputs were performed and measured. Using real-time performance tracking and haptic feedback, we collected analytics and data on user engagement, experience, retention, learning outcomes and curve, improved interpretation and diagnosis and reduction in operating costs, procedure times and complications. Results: The program was launched in October 2021. Preliminary data shows a short learning curve for VR itself (10-15 minutes) and RHC (initial 30-40 minutes reducing to 20-30minutes and <15 minutes in experts). Completion rates increase with experience from 40-50% to 100%. Error rate also reduces with frequency of completion. Conclusion: Virtual Reality Right Heart Catheter training is feasible with a short learning curve and results in improved competence and error rate with frequency of use.

The digital acquisition of practical skills in the medical curriculum using the example of the ENT mirror examination - blueprint, learning success measurement and evaluation

Background The COVID-19 pandemic has considerably catalyzed digitization processes in medical education. This opens up fields of innovative research, which must also show evidence in terms of student learning success. In particular, this applies to the acquisition of practical skills. Objective It was exmined to what extent students can acquire practical skills within a purely digitally implemented ENT mirror examination and how sustainable the learning success is when students return after one semester. By referring to the study 'Learning curve of the ENT mirror examination' by Polk et al. 2020, a comparison of online and face-to-face teaching can be drawn as well. Materials and methods Within a five-day ENT internship, 146 students were taught 6 ENT mirror examinations via a videoconferencing system. Student performance was assessed daily in a testing group (PG, n = 48) and also in a control group (KG, n = 98) on day 5 using a standardized checklist. After one semester, the examination was retaken for PG (n = 29) and KG (n = 17). Results Within the five days, PG showed a significant increase in performance on all partial examinations. For most partial examinations, PG's and KG's performance differed significantly, but these differences were largely undetectable after one semester. The results of online and face-to-face teaching showed great similarities. Conclusion Even during the COVID-19 pandemic, students were able to acquire practical skills in the ENT mirror examination at a level of performance comparable to that of face-to-face teaching. The PG's daily formative examinations seemed to ensure a better examination routine at the end of the internship, but the PG students' results became more similar to those of the KG over time.

Case study of SARS-CoV-2 transmission risk assessment in indoor environments using cloud computing resources

Complex flow simulations are conventionally performed on HPC clusters. However, the limited availability of HPC resources and steep learning curve of executing on traditional supercomputer infrastructure has drawn attention towards deploying flow simulation software on the cloud. We showcase how a complex computational framework-that can evaluate COVID-19 transmission risk in various indoor classroom scenarios-can be ed and deployed on cloud services. The availability of such cloud-based personalized planning tools can enable educational institutions, medical institutions, public sector workers (courthouses, police stations, airports, etc.), and other entities to comprehensively evaluate various in-person interaction scenarios for transmission risk. We deploy the simulation framework on the Azure cloud framework, utilizing the Dendro-ktmesh generation tool and PETSc solvers. The cloud ion is provided by RocketML cloud infrastructure. We compare the performance of the cloud machines with state-of-the-art HPC machine TACC Frontera. Our results suggest that cloud-based HPC resources are a viable strategy for a diverse array of end-users to rapidly and efficiently deploy simulation software. © 2021 IEEE.

Evaluation of the use of personal protective equipment (PPE) in health personnel of a University Hospital using the CUSUM curves

Introduction: Health personnel who care for patients with COVID-19 are at great risk of contagion, unless they learn and properly implement the procedure for donning and doffing personal protective equipment (PPE). Objectives: To evaluate the use of PPE (donning and doffing) using the CUSUM method in health personnel who care for hospitalized patients with a presumptive or confirmed diagnosis of COVID-19. Use the CUSUM curves as an appropriate method for the meaningful learning and psychomotor skills of these professionals. Materials and Methods: Cross-sectional study carried out in 10 health professionals from the National University Hospital. Measurements were made for one hour per participant from July 13 to 29, 2020, and in each one checklists were used to evaluate compliance with the protocol. In the formative evaluation using the CUSUM, an acceptable failure rate of 20% (Po) was considered and an unacceptable one of 40% (P1), with an error parameter α and β of 10%. Results: 40% reached H0, the goal;20% approached the target and 40% and 20% were distanced from the target with regard to donning and doffing the PPE. Conclusions: Proper use of PPE is a strategy for the prevention of contagion of COVID-19 in health personnel;The study found that less than half demonstrated adequate use, so training these professionals in the placement and removal of PPE according to an institutional protocol based on constant feedback and strict monitoring is essential to achieve the acquisition of skills, which will considerably reduce your risk of infection in clinical practice. © 2022 Sociedad de Anestesiologia de Chile. All rights reserved.

One-year results of treatment of incompetent truncal veins and incompetent perforators using high intensity focused ultrasound (HIFU)

Introduction, Objectives, and/or Purpose: Incompetent truncal and perforating veins of the legs contribute to a variety of conditions collectively called chronic venous insufficiency (CVI). Symptoms and signs of CVI adversely affect patient's quality-of-life. These can range from tired and heavy legs, through varicose veins, swollen ankles, fasciocutaneous damage all the way to leg ulceration. International guidelines recommend the treatment of venous reflux using endovenous thermal ablation as a first-line, and foam sclerotherapy as a second-line treatment. Both of these ablate the incompetent vein. There has been a push towards less invasive techniques, but most of these still involve endovenous cannulation. High-Intensity Focused Ultrasound (HIFU) is a completely non-invasive ablative technique. The HIFU technique uses to ultrasound systems within one machine. The first, a greyscale ultrasound with a colour flow capability, is used to identify the target vein and to target the focused ultrasound. The second is a conical focused ultrasound beam, that focuses on a point approximately 5 mm high by 3.6 mm circumference. In this focus area, temperatures can rise to 70-90°C. This is sufficient to ablate biological tissue. Objectives: (1) To assess the success of using HIFU for the treatment of incompetent truncal veins (GSV, SSV, AASV). (2) To assess the success of using HIFU for the treatment of incompetent perforator veins. (3) To determine the success of adjuvant foam sclerotherapy with of after HIFU, as a treatment protocol. Methods: A retrospective audit of 55 patients treated with HIFU using the Sonovein device (Theraclion, Paris, France) between May 2019 and September 2020 was performed. Due to the COVID-19 pandemic, and consequent travel restrictions and lockdowns, not all patients could return for follow-up DUS at the planned time intervals (1-2 weeks, 6- 8 weeks, 6 months, 1-year post-treatment). DUS outcome of the treated vein was graded: 1. complete success (complete atrophy of the target vein) 2. partial success (≥ 1 patent section;none giving rise to recurrent varicose veins / subclinical reflux not requiring treatment) 3. partial failure (≥ 1 patent section giving rise to significant recurrent varicose veins) 4. complete failure. Initially, we performed HIFU of incompetent veins and then completed the procedure with ultrasound-guided foam sclerotherapy. Later, the foamsclerotherapy was delayed and only used if required.We analysed the success rate of HIFU alone in those patients who had only HIFU treatment. In those who had additional foam sclerotherapy, we analysed the success rate of HIFU and foam sclerotherapy starting from the date of the foam sclerotherapy, regardless of whether it was performed on the same day as HIFU or subsequently. Results: Fifty patients (female:male 39:11) returned for at least one follow-up scan giving a 90.9% response rate for at least 1 scan. Due to the COVID-19 pandemic, and consequent travel restrictions and lockdowns, not all patients could return for follow-up DUS at planned time intervals (1-2 weeks, 6-8 weeks, 6 months, 1-year post-treatment). There were 78 legs treated, and 41 truncal veins and 146 incompetent perforator veins. Truncal veins: Twenty-nine patients (41 truncal veins in 35 legs) had at least one follow-up scan. Ten patients (15 truncal veins) had concurrent foam sclerotherapy, and nineteen patients (26 truncal veins) did not. Of these nineteen patients, seven patients (10 truncal veins) received foam sclerotherapy within one year of having HIFU treatment. Twelve patients (16 truncal veins) did not receive foam sclerotherapy at all. Those patients having HIFU only showed an 83.3% (15 out of 18) closure at 6- 8 weeks (Figure 1). The results for HIFU and foam sclerotherapy are shown in Figure 2. Despite difficulties in getting patients back for scans, closure rates of 83.3% and 100% were found between 9 and 12 months and over 12 months, respectively. Perforator veins: Forty-three patients (146 perforator veins in 68 legs) attended at least once. Suc essful ablation was seen in 88% at 6 months and 70% at one year in those not having foam sclerotherapy, and 83.3% and 100% in those having HIFU and foam sclerotherapy. Conclusions: High Intensity Focused Ultrasound (HIFU) is a new technique that can treat incompetent truncal and incompetent perforator veins extracorporeally. We have reported the one-year results of patients having either HIFU alone, or HIFU combined with ultrasound guided foam sclerotherapy. Allowances need to be made for the sporadic follow-up due to the COVID-19 pandemic, and also the fact that we changed our protocols of treatment as we got more experienced. Hence, even although we are reporting what is in effect the learning curve for this technique, the outcomes are not dissimilar from the early outcomes from endovenous thermal ablation. Increased speed of treatment with a corresponding reduction in the need of any local anaesthetic is being introduced, and further audits will be performed in the future to ensure the success rates are maintained or improved.

Changing practice in the management of non-palpable breast lesion during pandemic;Early experience using Magseed markers

Background: The Covid Pandemic has influenced how cancer surgeries are performed and their pre-operative management to allow appropriate social distancing and self-isolation prior to Surgery. With the requirement of wire localisation of non-palpable breast cancers/ lesions on the day of surgery and non-availability of mammogram and ultrasound machine in an isolated zone, we embarked on localisation of non-palpable breast lesions using MagseedR markers and SentimagR localisation system. We describe our initial experience in the management of these cancers and diagnostic excision biopsies using Magseed. Materials and Methods: Forty consecutive female patients, median age 61 (range 36-84) years underwent Magseed insertion for diagnostic excision biopsy (n=4) and breast conservation surgery (WLE;n= 36). Check mammograms were performed following Magseed insertion to confirm appropriate localisation. During the initial audit of 16 patients, one Magseed guided WLE and sentinel node biopsy was abandoned due to erratic signal strength on the day of surgery and underwent surgery with wire localisation on a later date. Subsequently all cases had Magseed signals confirmed following insertion in the radiology department along with check mammograms. Results: Thirty-nine patients underwent successful breast surgery (Magseed in intra-operative specimen X-ray) with standard axillary procedures (29 sentinel node biopsy, 2 axillary node clearance). The median time from magseed insertion to surgery was 13 (range 3-38) days. The lesions were invasive neoplasm +/- insitu (DCIS) disease (n= 32), DCIS (n=5), and papilloma (n=3). The median overall tumour size was 20 (range 3-38) mm and on postop histology was 17 (2-50) mm. Six patients required further re-excision for margin positivity with DCIS;margins were clear after single cavity shave(n=4) and two patients underwent mastectomy subsequently. Conclusions: Magseed localisation have given us significant flexibility in the management of non-palpable breast cancer and indeterminate lesions requiring diagnostic biopsy during the Covid pandemic. Initial audit suggests usefulness of confirming adequate Magseed signal in the radiology department along with check mammogram during the early learning curve.