Probiotics, Prebiotics, Lactoferrin, and Combination Products for Prevention of Mortality and Morbidity in Preterm Infants: A Systematic Review and Network Meta-Analysis.

Importance: Modulation of intestinal microbiome by administering probiotics, prebiotics, or both may prevent morbidity and mortality in premature infants. Objective: To assess the comparative effectiveness of alternative prophylactic strategies through a network meta-analysis (NMA) of randomized clinical trials. Data Sources: MEDLINE, EMBASE, Science Citation Index Expanded, CINAHL, Scopus, Cochrane CENTRAL, and Google Scholar from inception until May 10, 2023. Study Selection: Eligible trials tested probiotics, prebiotics, lactoferrin, and combination products for prevention of morbidity or mortality in preterm infants. Data Extraction and Synthesis: A frequentist random-effects model was used for the NMA, and the certainty of evidence and inferences regarding relative effectiveness were assessed using the GRADE approach. Main Outcomes and Measures: All-cause mortality, severe necrotizing enterocolitis, culture-proven sepsis, feeding intolerance, time to reach full enteral feeding, and duration of hospitalization. Results: A total of 106 trials involving 25 840 preterm infants were included. Only multiple-strain probiotics were associated with reduced all-cause mortality compared with placebo (risk ratio [RR], 0.69; 95% CI, 0.56 to 0.86; risk difference [RD], -1.7%; 95% CI, -2.4% to -0.8%). Multiple-strain probiotics alone (vs placebo: RR, 0.38; 95% CI, 0.30 to 0.50; RD, -3.7%; 95% CI, -4.1% to -2.9%) or in combination with oligosaccharides (vs placebo: RR, 0.13; 95% CI, 0.05 to 0.37; RD, -5.1%; 95% CI, -5.6% to -3.7%) were among the most effective interventions reducing severe necrotizing enterocolitis. Single-strain probiotics in combination with lactoferrin (vs placebo RR, 0.33; 95% CI, 0.14 to 0.78; RD, -10.7%; 95% CI, -13.7% to -3.5%) were the most effective intervention for reducing sepsis. Multiple-strain probiotics alone (RR, 0.61; 95% CI, 0.46 to 0.80; RD, -10.0%; 95% CI, -13.9% to -5.1%) or in combination with oligosaccharides (RR, 0.45; 95% CI, 0.29 to 0.67; RD, -14.1%; 95% CI, -18.3% to -8.5%) and single-strain probiotics (RR, 0.61; 95% CI, 0.51 to 0.72; RD, -10.0%; 95% CI, -12.6% to -7.2%) proved of best effectiveness in reduction of feeding intolerance vs placebo. Single-strain probiotics (MD, -1.94 days; 95% CI, -2.96 to -0.92) and multistrain probiotics (MD, -2.03 days; 95% CI, -3.04 to -1.02) proved the most effective in reducing the time to reach full enteral feeding compared with placebo. Only single-strain and multistrain probiotics were associated with greater effectiveness compared with placebo in reducing duration of hospitalization (MD, -3.31 days; 95% CI, -5.05 to -1.58; and MD, -2.20 days; 95% CI, -4.08 to -0.31, respectively). Conclusions and Relevance: In this systematic review and NMA, moderate- to high-certainty evidence demonstrated an association between multistrain probiotics and reduction in all-cause mortality; these interventions were also associated with the best effectiveness for other key outcomes. Combination products, including single- and multiple-strain probiotics combined with prebiotics or lactoferrin, were associated with the largest reduction in morbidity and mortality.

Immersive Virtual Reality for Patient-Specific Preoperative Planning: A Systematic Review.

Background. Immersive virtual reality (iVR) facilitates surgical decision-making by enabling surgeons to interact with complex anatomic structures in realistic 3-dimensional environments. With emerging interest in its applications, its effects on patients and providers should be clarified. This systematic review examines the current literature on iVR for patient-specific preoperative planning. Materials and Methods. A literature search was performed on five databases for publications from January 1, 2000 through March 21, 2021. Primary studies on the use of iVR simulators by surgeons at any level of training for patient-specific preoperative planning were eligible. Two reviewers independently screened titles, abstracts, and full texts, extracted data, and assessed quality using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD). Results were qualitatively synthesized, and descriptive statistics were calculated. Results. The systematic search yielded 2,555 studies in total, with 24 full-texts subsequently included for qualitative synthesis, representing 264 medical personnel and 460 patients. Neurosurgery was the most frequently represented discipline (10/24; 42%). Preoperative iVR did not significantly improve patient-specific outcomes of operative time, blood loss, complications, and length of stay, but may decrease fluoroscopy time. In contrast, iVR improved surgeon-specific outcomes of surgical strategy, anatomy visualization, and confidence. Validity, reliability, and feasibility of patient-specific iVR models were assessed. The mean QATSDD score of included studies was 32.9%. Conclusions. Immersive VR improves surgeon experiences of preoperative planning, with minimal evidence for impact on short-term patient outcomes. Future work should focus on high-quality studies investigating long-term patient outcomes, and utility of preoperative iVR for trainees.

Immersive Virtual Reality for Surgical Training: A Systematic Review.

BACKGROUND: Immersive virtual reality (iVR) simulators provide accessible, low cost, realistic training adjuncts in time and financially constrained systems. With increasing evidence and utilization of this technology by training programs, clarity on the effect of global skill training should be provided. This systematic review examines the current literature on the effectiveness of iVR for surgical skills acquisition in medical students, residents, and staff surgeons. METHODS: A literature search was performed on MEDLINE, EMBASE, CENTRAL, Web of Science and PsycInfo for primary studies published between January 1, 2000 and January 26, 2021. Two reviewers independently screened titles, abstracts, and full texts, extracted data, and assessed quality and strength of evidence using the Medical Education Research Quality Instrument (MERSQI) and Cochrane methodology. Results were qualitatively synthesized, and descriptive statistics were calculated. RESULTS: The literature search yielded 9650 citations, with 17 articles included for qualitative synthesis. The mean (SD) MERSQI score was 11.7 (1.9) out of 18. In total, 307 participants completed training in four disciplines. Immersive VR-trained groups performed 18% to 43% faster on procedural time to completion compared to control (pooled standardized mean difference = -0.90 [95% CI=-1.33 to -047, I2=1%, P < 0.0001]). Immersive VR trainees also demonstrated greater post-intervention scores on procedural checklists and greater implant placement accuracy compared to control. CONCLUSIONS: Immersive VR incorporation into surgical training programs is supported by high-quality, albeit heterogeneous, studies demonstrating improved procedural times, task completion, and accuracy, positive user ratings, and cost-effectiveness.

Identifying the gap in clinical skills: a pilot study investigating the use of clinical respiratory examination skills in practice.

There is a paucity of literature that explores whether students use clinical skills learned during medical school in practice. The study aimed to report on the most clinically relevant examination skills to focus on and increase student preparedness for clinical practice. We disseminated a 10-minute online anonymised survey to residents and physicians using an open recruitment strategy with convenience and snowball sampling. This survey sought to determine the practical use of respiratory exam skills. We conducted basic quantitative and descriptive content analysis to evaluate results.From a total of 161 respondents, 148 completed the entire survey. The majority of respondents found all 12 inspection skills to be useful in practice. Tracheal deviation was the only palpation skill found useful (68.63% useful). Auscultating for breath sounds was found to be unanimously useful, while all other percussion and auscultation skills were not found useful. In qualitative analysis, the major theme was that skills should be taught despite minimal use as they help teach disease pathophysiology, help in limited resource settings, and have usefulness in particular situations (e.g. traumas or different specialities).There is a discrepancy between the clinical skills taught to students and the ones actually used in practice. Despite this, there is still utility in teaching these skills to medical students. Rather than removing skills from the curriculum, a better avenue would be to emphasise manoeuvres that are clinically important to help guide preparation for clinical settings.

Stethopedia: an e-learning resource for medical students to supplement Canadian clinical skills education.

Online clinical skills videos can supplement teaching and allow for greater flexibility when learning physical examination skills. There are currently few open access clinical skills video resources available for Canadian medical students. Stethopedia is an easy-to-use, open-access library of clinical skills teaching videos based on the Canadian medical curriculum. We created Stethopedia to increase accessibility to clinical skills resources and improve the competency and confidence of medical students performing clinical skills on examinations and clerkship rotations. Medical students would benefit from similar resources based on their school's specific curriculum in order to improve clinical skill performance.

Les vidéos disponibles en ligne sur les habiletés cliniques peuvent améliorer l'apprentissage de nouvelles compétences cliniques. Cependant, il existe très peu de ressources canadiennes gratuites qui enseignent les compétences cliniques basées sur la vidéo. Stethopedia est une bibliothèque qui est facile à utiliser et à l'accès libre avec des vidéos d'enseignement des compétences cliniques basées sur le curriculum médical canadien. Nous avons créé Stethopedia pour accroître l'accessibilité aux ressources de compétences cliniques et améliorer la compétence et la confiance des étudiants en médecine qui exécutent des compétences cliniques pendant leurs examens et l'externat. Les étudiants en médecine bénéficieraient de ressources similaires basées sur le programme spécifique de leur école afin d'améliorer leurs compétences cliniques.

The gut microbiome in psychiatry: A primer for clinicians.

Research in the past decade has shown that variations in the gut microbiome may influence behavior, and vice versa. As such, interest in the role of the gut microbiome in psychiatric conditions has drawn immense interest. This is evidenced by the recent surge in published studies examining microbial dysbiosis in clinical psychiatric populations, particularly autism spectrum disorder and depression. However, critical examination of these studies reveals methodological flaws in design and execution, suggesting that they may not be held to the same standards as other bodies of clinical research. Given the complex nature of the gut microbiome, this narrative review attempts to clarify concepts critical to effectively examine its potential role in psychopathology to appropriately inform mental health researchers. More specifically, the numerous variables known to affect the gut microbiome are discussed, including inflammation, diet, weight, and medications. A comprehensive review of the extant microbiome literature in clinical psychiatric populations is also provided, in addition to clinical implications and suggestions for future directions of research. Although there is a clear need for additional studies to elucidate the gut microbiome's role in psychiatric disorders, there is an even greater need for well-designed, appropriately controlled studies to truly impact the field.