Virtual-reality simulation to assess performance in hip fracture surgery

Background and purpose

Internal fixation of hip fractures is a common and important procedure that orthopedic surgeons must master early in their career. Virtual-reality training could improve initial skills, and a simulation-based test would make it possible to ensure basic competency of junior surgeons before they proceed to supervised practice on patients. The aim of this study was to develop a reliable and valid test with credible pass/fail standards.

Methods

20 physicians (10 untrained novices and 10 experienced orthopedic surgeons) each performed 3 internal fixation procedures of an undisplaced femoral neck fracture: 2 hook-pins, 2 screws, and a sliding hip screw. All procedures were preformed on a trauma simulator. Performance scores for each procedure were obtained from the predefined metrics of the simulator. The inter-case reliability of the simulator metrics was explored by calculation of intra-class correlation coefficient. Validity was explored by comparison between novices’ and experts’ scores using independent-samples t-test. A pass/fail standard was set by the contrasting-groups method and the consequences were explored.

Results

The percentage of maximum combined score (PM score) showed an inter-case reliability of 0.83 (95% CI: 0.65–0.93) between the 3 procedures. The mean PM score was 30% (CI: 7–53) for the novices and 76% (CI: 68–83) for the experienced surgeons. The pass/fail standard was set at 58%, resulting in none of the novices passing the test and a single experienced surgeon failing the test.

Interpretation

The simulation-based test was reliable and valid in our setting, and the pass/fail standard could discriminate between novices and experienced surgeons. Potentially, training and testing of future junior surgeons on a virtual-reality simulator could ensure basic competency before proceeding to supervised practice on patients.Worldwide, hip fractures account for substantial healthcare costs and high mortality, morbidity, and reoperation rates. Fractures are often treated with different types of internal fixation, which is a great contributor to training of surgical skills through the principle of the master-apprentice model. This model is not without risk, though. Inexperienced trainees contribute to a higher rate of re-admissions and reoperations (Palm et al. 2007, Leblanc et al. 2013).A review of 609 studies found that virtual-reality simulation training improved operative skills (Cook et al. 2011), and simulation-based training in orthopedic surgery is starting to emerge. Most of the development is in arthroscopy, but simulation-based training in fracture fixation is also being developed (Blyth et al. 2007, 2008, Mabrey et al. 2010, Atesok et al. 2012, Rambani et al. 2013). Current papers describe the simulators and explore construct validity of the simulator metrics (Tillander et al. 2004, Froelich et al. 2011). Reliable and valid tests with credible pass/fail standards are necessary to ensure basic competency of trainees before allowing them to proceed to supervised practice on patients (Stefanidis et al. 2012a, Konge et al. 2013).The objective of this study was to develop a test, to explore the reliability of this test, and to gather validity evidence. Furthermore, we wanted to establish a credible pass/fail standard and explore the consequences of this standard. The research questions were: (1) Which simulator metrics were able to discriminate between novices and experienced orthopedic surgeons?; (2) How many procedures on the simulator must be performed to ensure sufficient reliability?; and (3) What was a credible pass/fail standard in the test?     

Metazoan parasites from herring (Clupea harengus L.) as biological indicators in the Baltic Sea

Zoographical distribution of metazoan fish parasites in herring, Clupea harengus, from the Baltic Sea was analysed in order to use them as potential biological indicators. A total of 210 herring from six different sampling sites were investigated, harbouring 12 different parasite species [five digeneans (D), one cestode (C), three nematodes (N) and three acanthocephalans (A)]. The distribution of the parasite species differed according to region, with a distinct gradient of decreasing species richness towards the east of the Baltic Sea. The western localities at Kiel Bay, Rügen and Poland had the highest parasite diversity, including the marine parasite species Anisakis simplex (s.s.) (N), Brachyphallus crenatus and Hemiurus luehei (both D). The eastern localities had low parasite species richness, predominated by the freshwater digenean Diplostomum spathaceum. We could identify three different Baltic herring stocks, the spring-spawning herring of the western Baltic reaching from the Kattegat to the German and Polish coast, the stock of the central Baltic proper and the northern stock of C. harengus var. membras of the Gulf of Finland. The limited distribution of the herring parasites within the Baltic Sea enables their use as biological indicators for migration patterns and stock separation. The acanthocephalan Pomphorhynchus laevis that has already been used as an accumulation bioindicator for heavy metals was only recorded for the western herring stocks. However, the presence of mainly generalistic parasites and their uneven distribution patterns make their use as indicators for regional environmental and global change more difficult.     

Angelman syndrome in adulthood

We studied the clinical and EEG-findings in 28 adult patients (aged 20–53 years) with Angelman syndrome (AS). Twenty-three showed a maternal chromosome 15q11–13 deletion; in 5, the diagnosis was based on a combination of typical clinical findings. Compared to the clinical manifestations present in childhood, “coarsening” of facial traits (100%), thoracic scoliosis (71%), and being wheelchair-bound (39%) were found more frequently. Paroxysms of laughter were still observed in adulthood (79%), but less frequently than in childhood. Most adult patients could feed themselves, but needed help with many daily activities. The majority (82%) had epileptic seizures. Abnormal EEG-activity consisting of 2–3/s rhythmic triphasic waves of high amplitude with a maximum over the frontal regions, which has been identified in many AS children, was found in 67% of these adult patients. © 1996 Wiley-Liss, Inc.     

Novel water-soluble block copolymers of dimethylaminoethyl methacrylate and dihydroxypropyl methacrylate

In this publication we describe the synthesis and properties of a novel type of block copolymer. The anionically synthesised block copolymer consists of a neutral, watersoluble block (2,3-dihydroxypropyl methacrylate, HMA) and a pH-dependently charged one (2-dimethylaminoethyl methacrylate, AMA). The adsorption on silica and its effect on the colloidal stability were evaluated. The adsorbed amount is mainly determined by the electrostatics, which leads to a maximum adsorbed amount at low AMA content. The block copolymers tend to destabilise colloidal silica, due to a charge neutralisation upon adsorption, which is not compensated by the formation of a steric layer.     

Three learning phases for radial-basis-function networks.

In this paper, learning algorithms for radial basis function (RBF) networks are discussed. Whereas multilayer perceptrons (MLP) are typically trained with backpropagation algorithms, starting the training procedure with a random initialization of the MLP's parameters, an RBF network may be trained in many different ways. We categorize these RBF training methods into one-, two-, and three-phase learning schemes. Two-phase RBF learning is a very common learning scheme. The two layers of an RBF network are learnt separately; first the RBF layer is trained, including the adaptation of centers and scaling parameters, and then the weights of the output layer are adapted. RBF centers may be trained by clustering, vector quantization and classification tree algorithms, and the output layer by supervised learning (through gradient descent or pseudo inverse solution). Results from numerical experiments of RBF classifiers trained by two-phase learning are presented in three completely different pattern recognition applications: (a) the classification of 3D visual objects; (b) the recognition hand-written digits (2D objects); and (c) the categorization of high-resolution electrocardiograms given as a time series (ID objects) and as a set of features extracted from these time series. In these applications, it can be observed that the performance of RBF classifiers trained with two-phase learning can be improved through a third backpropagation-like training phase of the RBF network, adapting the whole set of parameters (RBF centers, scaling parameters, and output layer weights) simultaneously. This, we call three-phase learning in RBF networks. A practical advantage of two- and three-phase learning in RBF networks is the possibility to use unlabeled training data for the first training phase. Support vector (SV) learning in RBF networks is a different learning approach. SV learning can be considered, in this context of learning, as a special type of one-phase learning, where only the output layer weights of the RBF network are calculated, and the RBF centers are restricted to be a subset of the training data. Numerical experiments with several classifier schemes including k-nearest-neighbor, learning vector quantization and RBF classifiers trained through two-phase, three-phase and support vector learning are given. The performance of the RBF classifiers trained through SV learning and three-phase learning are superior to the results of two-phase learning, but SV learning often leads to complex network structures, since the number of support vectors is not a small fraction of the total number of data points.     

Recurrence of blackwater fever: triggering of relapses by different antimalarials

Five cases of blackwater fever (BWF) are described, all of whom had a history of recent quinine therapy. In two cases a second haemolytic crisis was induced by halofantrine, in one case also a third. Increasing frequency of this syndrome with its dramatic clinical presentation is to be expected as imported P. falciparum infection, parasite resistance to chloroquine and the use of quinine and other related antimalarials become more frequent.