The role of virtual reality in the changing landscape of surgical training.

BACKGROUND: The current coronavirus disease 2019 pandemic has caused unprecedented challenges to surgical training across the world. With the widespread cancellations of clinical and academic activities, educators are looking to technological advancements to help 'bridge the gap' and continue medical education. SOLUTIONS: Simulation-based training as the 'gold standard' for medical education has limitations that prevent widespread adoption outside suitably resourced centres. Virtual reality has the potential to surmount these barriers, whilst fulfilling the fundamental aim of simulation-based training to provide a safe, effective and realistic learning environment. CURRENT LIMITATIONS AND INSIGHTS FOR FUTURE: The main limitations of virtual reality technology include comfort and the restrictive power of mobile processors. There exists a clear developmental path to address these restrictions. Continued developments of the hardware and software set to deepen immersion and widen the possibilities within surgical education. CONCLUSION: In the post coronavirus disease 2019 educational landscape, virtual, augmented and mixed reality technology may prove invaluable in the training of the next generation of surgeons.

Respiratory complications of metabolic disease in the paediatric population: A review of presentation, diagnosis and therapeutic options.

Inborn errors of metabolism (IEMs) whilst individually rare, as a group constitute a field which is increasingly demands on pulmonologists. With the advent of new therapies such as enzyme replacement and gene therapy, early diagnosis and treatment of these conditions can impact on long term outcome, making their timely recognition and appropriate investigation increasingly important. Conversely, with improved treatment, survival of these patients is increasing, with the emergence of previously unknown respiratory phenotypes. It is thus important that pulmonologists are aware of and appropriately monitor and manage these complications. This review aims to highlight the respiratory manifestations which can occur. It isdivided into conditions resulting primarily in obstructive airway and lung disease, restrictive lung disease such as interstitial lung disease or pulmonary alveolar proteinosis and pulmonary hypertension, whilst acknowledging that some diseases have the potential to cause all three. The review focuses on general phenotypes of IEMs, their known respiratory complications and the basic metabolic investigations which should be performed where an IEM is suspected.

Gastrointestinal microcirculation and cardiopulmonary function during experimentally increased intra-abdominal pressure.

OBJECTIVES: The aim of this study was to assess gastric, intestinal, and renal cortex microcirculation parallel with central hemodynamics and respiratory function during stepwise increase of intra-abdominal pressure (IAP). DESIGN: Prospective, controlled animal study. SETTING: Research laboratory, University Hospital. SUBJECTS: Twenty-six anesthetized and mechanically ventilated pigs. INTERVENTIONS: Following baseline registrations, CO2 peritoneum was inflated (n = 20) and IAP increased stepwise by 10 mm Hg at 10 mins intervals up to 50 mm Hg and subsequently exsufflated. Control animals (n = 6) were not insufflated with CO2. MEASUREMENTS AND MAIN RESULTS: The microcirculation of gastric mucosa, small bowel mucosa, small bowel seromuscular layer, colon mucosa, colon seromuscular layer, and renal cortex were selectively studied at all pressure levels and after exsufflation using a four-channel laser Doppler flowmeter (Periflex 5000, Perimed). Central hemodynamic and respiratory function data were registered at each level and after exsufflation. Cardiac output decreased significantly at IAP levels above 10 mm Hg. The microcirculation of gastric mucosa, renal cortex and the seromuscular layer of small bowel and colon was significantly reduced with each increase of IAP. The microcirculation of the small bowel mucosa and colon mucosa was significantly less affected compared with the serosa (p < 0.01). CONCLUSIONS: Our animal model of low and high IAP by intraperitoneal CO2-insufflation worked well for studies of microcirculation, hemodynamics, and pulmonary function. During stepwise increases of pressure there were marked effects on global hemodynamics, respiratory function, and microcirculation. The results indicate that intestinal mucosal flow, especially small bowel mucosal flow, although reduced, seems better preserved in response to intra-abdominal hypertension caused by CO2-insufflation than other intra-abdominal microvascular beds.