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Objective The study objective was to investigate the impact of multiple arterial grafting on long-term all-cause mortality in women undergoing isolated coronary artery bypass grafting. Methods A comprehensive search was performed to identify observational studies reporting outcomes after coronary artery bypass grafting reported by sex and stratified into multiple arterial grafting versus single arterial grafting strategies. Articles were considered for inclusion if they were written in English and were propensity-matched observational studies. Included studies were then pooled in a meta-analysis performed using the generic inverse variance method. The primary outcome was long-term all-cause mortality. Secondary outcomes were operative mortality and spontaneous myocardial infarction. Meta-regression was used to explore the effects of preoperative and intraoperative variables on the primary outcome. Results A total of 6 studies with 32,793 women (25,714 single arterial grafting and 7079 multiple arterial grafting) were included. Women who received multiple arterial grafting had lower long-term mortality (incidence rate ratio, 0.86; 95% confidence interval, 0.76-0.96; P = .007) and spontaneous myocardial infarction (incidence rate ratio, 0.80; 95% confidence interval, 0.68-0.93; P = .003) compared with women who received single arterial grafting, but the difference in mortality disappeared when including only the 3 largest studies. There was no difference between groups in operative mortality (odds ratio, 0.99; 95% confidence interval, 0.84-1.17; P = .91). Meta-regression did not identify any associations with the incidence rate ratio for long-term mortality. Conclusions The use of multiple arterial grafting in women undergoing coronary artery bypass grafting is associated with lower long-term mortality, although the difference is mostly driven by small series. Further studies, including randomized trials, are needed to evaluate the efficacy of multiple arterial grafting in women undergoing coronary artery bypass grafting.

Poor glycemic control, regardless of patients' diabetic status, is associated with worse outcomes after coronary artery bypass grafting. As a result, in the perioperative and postoperative setting, the use of insulin is recommended to maintain glucose levels below 180 mg/dl (10.0 mmol/L). However, challenges exist and errors may occur that can prohibit adequate glucose management. In this commentary, we highlight a real-world example of an educational intervention to empower health workers in managing patients' glucose levels after coronary artery bypass grafting in order to improve postoperative outcomes. We discuss the current evidence and guidelines on peri- and postoperative glycemic control for patients undergoing cardiac surgery and present further quality improvement opportunities that may be introduced.

Currently, there is a worldwide shift toward competency-based medical education. This necessitates the use of automated skills assessment methods during self-guided interventions training. Making assessment methods that are transparent and configurable will allow assessment to be interpreted into instructional feedback. The purpose of this work is to develop and validate skills assessment methods in ultrasound-guided interventions that are transparent and configurable. We implemented a method based upon decision trees and a method based upon fuzzy inference systems for technical skills assessment. Subsequently, we validated these methods for their ability to predict scores of operators on a 25-point global rating scale in ultrasound-guided needle insertions and their ability to provide useful feedback for training. Decision tree and fuzzy rule-based assessment performed comparably to state-of-the-art assessment methods. They produced median errors (on a 25-point scale) of 1.7 and 1.8 for in-plane insertions and 1.5 and 3.0 for out-of-plane insertions, respectively. In addition, these methods provided feedback that was useful for trainee learning. Decision tree assessment produced feedback with median usefulness 7 out of 7; fuzzy rule-based assessment produced feedback with median usefulness 6 out of 7. Transparent and configurable assessment methods are comparable to the state of the art and, in addition, can provide useful feedback. This demonstrates their value in self-guided interventions training curricula.

PURPOSE: Partial nephrectomy is the preferred method for managing small renal masses. This procedure has significant advantages over radical nephrectomy. However, partial nephrectomy is under-used due to its difficulty. We propose a navigation system for laparoscopic partial nephrectomy. In this study, we evaluate the usability and accuracy of the navigation system. METHODS: An electromagnetically tracked navigation system for partial nephrectomy was developed. This system tracks the positions of the laparoscopic scissors, ultrasound probe, tumor, and calyces and vasculature. Phantom kidneys were created using mixtures of plastisol and cellulose. To test the system, the navigation display quality was measured through measurement of lag and frames per second displayed. The accuracy of the system was determined through fiducial registration. Finally, a study consisting of ten participants was conducted to assess the usability of the navigation system using the System Usability Survey. RESULTS: The mean System Usability Score of the navigation system was 82.5. The navigation display had an average lag of 243 milliseconds and showed 5 frames per second. The accuracy was measured with fiducial registration and found to have an RMS error of 2.84 mm. CONCLUSION: The results of this study suggest that the partial nephrectomy navigation system developed is both usable and accurate. Future work will include the conversion of the laparoscopic scissor tool tracking to optical. Further studies will be conducted to determine the effectiveness of this technology in tumor resection and avoidance of calyx and vasculature damage. We will additionally explore this system as a training tool.

PURPOSE: Spatially tracked ultrasound-guided needle insertions may require electromagnetic sensors to be clipped on the needle and ultrasound probe if not already embedded in the tools. It is assumed that switching the electromagnetic sensor clip does not impact the accuracy of the computed calibration. We propose an experimental process to determine whether or not devices should be calibrated on a more frequent basis. METHODS: We performed 250 calibrations. Of these, 125 were performed on the needle and 125 on the ultrasound. Every five calibrations, the tracking clip was removed and reattached. Every 25 calibrations, the tracking clip was exchanged for an identical 3D-printed model. From the resulting transform matrices, coordinate transformations were computed. Data reproducibility was analyzed through looking at the difference between mean and grand mean, standard deviation and the Shapiro-Wilks normality constant. Data was graphically displayed to visualize differences in calibrations in different directions. RESULTS: For the needle calibrations, transformations parallel to the tracking clip and perpendicular to the needle demonstrated the greatest deviation. For the ultrasound calibrations, transformations perpendicular to the sound propagation demonstrated the greatest deviation. CONCLUSION: Needle and ultrasound calibrations are reproducible when changing the tracking clip. These devices do not need to be calibrated on a more frequent basis. Caution should be taken to minimize confounding variables such as bending the needle or ultrasound beam width at the time of calibration. KEY WORDS: Calibration, tracking, reproducibility, electromagnetic, spatial, ultrasound-guided needle navigation, transformation, standard deviation.

Suturing is a fundamental skill in undergraduate medical education. It can be taught by faculty-led, peer tutor-led, and holography-augmented methods; however, the most educationally effective and cost-efficient method for proficiency-based teaching of suturing is yet to be determined. We conducted a randomized controlled trial comparing faculty-led, peer tutor-led, and holography-augmented proficiency-based suturing training in pre-clerkship medical students. Holography-augmented training provided holographic, voice-controlled instructional material. Technical skill was assessed using hand motion analysis every ten sutures and used to construct learning curves. Proficiency was defined by one standard deviation within average faculty surgeon performance. Intervention arms were compared using one-way ANOVA of the number of sutures placed, full-length sutures used, time to proficiency, and incremental costs incurred. Surveys were used to evaluate participant preferences. Forty-four students were randomized to the faculty-led (n = 16), peer tutor-led (n = 14), and holography-augmented (n = 14) intervention arms. At proficiency, there were no differences between groups in the number of sutures placed, full-length sutures used, and time to achieve proficiency. The incremental costs of the holography-augmented method were greater than faculty-led and peer tutor-led instruction ($247.00 ± $12.05, p

PURPOSE: A training module for basic suturing training called Suture Tutor was developed by combining video instruction and voice commands with the Microsoft HoloLens software. We put forth two hypotheses: Trainees find the HoloLens helpful and 2.) HoloLens helps the trainees to achieve a better score in objective skill assessment tests. METHODS: Software module was developed to show instructional video in the HoloLens under voice command. Thirtytwo participants were split into the control group or the HoloLens group. The control group used videos displayed on a computer during training while the HoloLens group practiced with Suture Tutor. Each group was given seven minutes to train with their assigned training method before testing. Testing involved replication of a running locking suturing pattern with a time limit of five minutes and was video recorded. The videos were expert reviewed. Participants in the HoloLens group filled out a usability survey. RESULTS: The trainees found the Hololens to be usable and realistic, and the HoloLens group used the instructional videos more than the control group did (p = 0.0175). There was no difference in the skill assessment test scores between the HoloLens and the control group and their rates of completion in the allotted time was similar. CONCLUSION: Participants found the Suture Tutor to be a user friendly and helpful adjunct. The study was unable to determine if the Suture Tutor helps trainees in achieving a better score in skill assessment testing.

PURPOSE: Under ultrasound guidance, procedures that have been traditionally performed using landmark approaches have become safer and more efficient. However, inexperienced trainees struggle with coordinating probe handling and needle insertion. We aimed to establish learning curves to identify the rate of acquisition of in-plane and out-of-plane vascular access skill in novice medical trainees. METHODS: Thirty-eight novice participants were randomly assigned to perform either in-plane or out-of-plane insertions. Participants underwent baseline testing, four practice insertions (with 3D visualization assistance), and final testing; performance metrics were computed for all procedures. Five expert participants performed insertions in both approaches to establish expert performance metric benchmarks. RESULTS: In-plane novices (n=19) demonstrated significant final reductions in needle path inefficiency (45.8 vs. 127.1, p