Surgeons blinded by enhanced navigation: the effect of augmented reality on attention

Background

Advanced image-guidance systems allowing presentation of three-dimensional navigational data in real time are being developed enthusiastically for many medical procedures. Other industries, including aviation and the military, have noted that shifting attention toward such compelling assistance has detrimental effects. Using the detection rate of unexpected findings, we assess whether inattentional blindness is significant in a surgical context and evaluate the impact of on-screen navigational cuing with augmented reality.

Methods

Surgeons and trainees performed an endoscopic navigation exercise on a cadaveric specimen. The subjects were randomized to either a standard endoscopic view (control) or an AR view consisting of an endoscopic video fused with anatomic contours. Two unexpected findings were presented in close proximity to the target point: one critical complication and one foreign body (screw). Task completion time, accuracy, and recognition of findings were recorded.

Results

Detection of the complication was 0/15 in the AR group versus 7/17 in the control group (p = 0.008). Detection of the screw was 1/15 (AR) and 7/17 (control) (p = 0.041). Recognition of either finding was 12/17 for the control group and 1/15 for the AR group (p < 0.001). Accuracy was greater for the AR group than for the control group, with the median distance from the target point measuring respectively 2.10 mm (interquartile range [IQR], 1.29–2.37) and 4.13 (IQR, 3.11–7.39) (p < 0.001).

Conclusion

Inattentional blindness was evident in both groups. Although more accurate, the AR group was less likely to identify significant unexpected findings clearly within view. Advanced navigational displays may increase precision, but strategies to mitigate attentional costs need further investigation to allow safe implementation.     

Proton MR spectroscopy in the breast: Technical innovations and clinical applications

Proton magnetic resonance spectroscopy (MRS) is a promising noninvasive diagnostic technique for investigation of breast cancer metabolism. Spectroscopic imaging data may be obtained following contrast‐enhanced MRI by applying the point‐resolved spectroscopy sequence (PRESS) or the stimulated echo acquisition mode (STEAM) sequence from the MR voxel encompassing the breast lesion. Total choline signal (tCho) measured in vivo using either a qualitative or quantitative approach has been used as a diagnostic test in the workup of malignant breast lesions. In addition to tCho metabolites, other relevant metabolites, including multiple lipids, can be detected and monitored. MRS has been heavily investigated as an adjunct to morphologic and dynamic MRI to improve diagnostic accuracy in breast cancer, obviating unnecessary benign biopsies. Besides its use in the staging of breast cancer, other promising applications have been recently investigated, including the assessment of treatment response and therapy monitoring. This review provides guidance on spectroscopic acquisition and quantification methods and highlights current and evolving clinical applications of proton MRS. Level of Evidence 5 Technical Efficacy: Stage 5 J. Magn. Reson. Imaging 2019.     

Mycotic aneurysm of the left ventricle: echocardiographic diagnosis.

We report an unusual case of myocardial mycotic aneurysm of the left ventricle resulting from a healed myocardial abscess caused by an aortic regurgitant jet lesion. The diagnosis was made during intraoperative transesophageal echocardiography and confirmed by surgical inspection. The echocardiographic features are described.     

Barriers to early diagnosis of cancer in primary care: a needs assessment of GPs

This is the first needs assessment of general practitioners (GPs) in relation to early detection of cancer in the Republic of Ireland. Data was collected using focus groups with 47 GPs and a national survey of 929 GPs. Overall,74.6% of survey respondents had >10 years experience in general practice and 22.7% were single handed. Distance from the practice to the nearest hospital to which they could refer patients for assessment of suspected cancer was <5 miles for 53.3% of GPs. The principle barriers identified were not confined to early diagnosis but apply to the diagnosis of cancer at any stage. These included delayed patient presentation, lack of direct GP access to investigations, difficulty with hospital referral, lack of clear recommendations for screening, poor communication with hospital services, inequitable access to hospital services and a need for further education and clinical practice guidelines. The barriers identified have serious implications for early detection of cancer in primary care and are remedial.     

Soft-tissue detectability in cone-beam CT: evaluation by 2AFC tests in relation to physical performance metrics

Soft-tissue detectability in cone-beam computed tomography (CBCT) was evaluated via two-alternative forced-choice (2AFC) tests. Investigations included the dependence of detectability on radiation dose, the influence of the asymmetric three-dimensional (3D) noise-power spectrum (NPS) in axial and sagittal or coronal planes, and the effect of prior knowledge on detectability. Custom-built phantoms (approximately 15 cm diameter cylinders) containing soft-tissue-simulating spheres of variable contrast and diameter were imaged on an experimental CBCT bench. The proportion of correct responses (Pcorr) in 2AFC tests was analyzed as a figure of merit, ideally equal to the area under the receiver operating characteristic curve. Pcorr was evaluated as a function of the sphere diameter (1.6-12.7 mm), contrast (20-165 HU), dose (1-7 mGy), plane of visualization (axial/sagittal), apodization filter (Hanning and Ram-Lak), and prior knowledge provided to the observer [ranging from stimulus known exactly (SKE) to stimulus unknown (SUK)]. Detectability limits were characterized in terms of the dose required to achieve a given level of Pcorr (e.g., 70%). For example, a 20 HU stimulus of diameter down to approximately 6 mm was detected with Pcorr 70% at dose > or =2 mGy. Detectability tended to be greater in axial than in sagittal planes, an effect amplified by sharper apodization filters in a manner consistent with 3D NPS asymmetry. Prior knowledge had a marked influence on detectability--e.g., Pcorr for a approximately 6 mm (20 HU) sphere was approximately 55%-65% under SUK conditions, compared to approximately 70%-85% for SKE conditions. Human observer tests suggest practical implications for implementation of CBCT: (i) Detectability limits help to define minimum-dose imaging techniques for specific imaging tasks; (ii) detectability of a given structure can vary between axial and sagittal/coronal planes, owing to the spatial-frequency content of the 3D NPS in relation to the imaging task; and (iii) performance under SKE conditions (e.g., image guidance tasks in which lesion characteristics are known) is maintained at a lower dose than in SUK conditions (e.g., diagnostic tasks in which lesion characteristics are unknown).     

Ascertainment Through Family History of Disease Often Decreases the Power of Family-based Association Studies

Selection of cases with additional affected relatives has been shown to increase the power of the case-control association design. We investigated whether this strategy can also improve the power of family-based association studies that use the transmission disequilibrium test (TDT), while accounting for the effects of residual polygenic and environmental factors on disease liability. Ascertainment of parent-offspring trios conditional on the proband having affected first-degree relatives almost always reduced the power of the TDT. For many disease models, this reduction was quite considerable. In contrast, for the same sample size, designs that analyzed more than one affected offspring per family often improved power when compared to the standard parent-offspring trio design. Together, our results suggest that (1) residual polygenic and environmental influences should be considered when estimating the power of the TDT for studies that ascertain families with multiple affected relatives; (2) if trios are selected conditional on having additional affected offspring, then it is important to genotype and include in the analysis the additional siblings; (3) the ascertainment strategy should be considered when interpreting results from TDT analyses. Our analytic approach to estimate the asymptotic power of the TDT is implemented online at http://pngu.mgh.harvard.edu/∼purcell/gpc/. Edited by David Allison     

Junior staffing changes and the temporal ecology of adverse incidents in acute psychiatric wards

AIM: This paper reports an examination of the relationship between adverse incident rates, the arrival of new junior staff on wards, and days of the week on acute psychiatric wards. BACKGROUND: Incidents of violence, absconding and self-harm in acute inpatient services pose risks to patients and staff. Previous research suggests that the arrival of inexperienced new staff may trigger more adverse incidents. Findings on the relationship between incidents and the weekly routine are inconsistent. METHOD: A retrospective analysis was conducted of formally reported incident rates, records of nursing student allocations and junior doctor rotation patterns, using Poisson Regression. Variance between days of the week was explored using contingency table analysis. The data covered 30 months on 17 psychiatric wards, and were collected in 2002-2004. FINDINGS: The arrival of new and inexperienced staff on the wards was not associated with increases in adverse incident rates. Most types of incidents were less frequent at weekends and midweek. Incident rates were unchanged on ward-round days, but increased rates were found on the days before and after ward rounds. CONCLUSION: Increased patient tension is associated with raised incident rates. It may be possible to reduce incident rates by moderating stimulation in the environment and by mobilizing support for patients during critical periods.