Ebook: Medicine Meets Virtual Reality 20

During the past twenty years, computers have evolved from relatively cumbersome machines, used primarily at work to create documents and do accounting, into sleek, intuitive, and nearly omnipresent extensions of our fingers, eyes, and brains. Ready access to the information they provide has transformed our lives. It is telling that one hears health warnings against sleeping next to a mobile phone (the most common variety of computer) because twenty years ago, no one worried about computers being taken to bed. It's not just an issue of devices' growing “sexiness.” In 1992, there wasn't much on a PC that one would desire in the middle of the night.

Healthcare also has been transformed by the expanded role of our data-purveying gizmos. Physicians and scientists have unprecedented access to the knowledge of peers around the world, enabling better decision-making. For investigators, data mining can amplify the number of subjects in a study; crowd sourcing enlists a wider perspective. Medical schools educate students more effectively with tools that offer greater realism, useful repetition, and continual assessment. Even the general public can explore medical articles online to learn more about the therapies their doctors prescribe. Also at home, devices monitor patients, report back to their caregivers, and automatically remind them to take their medicine.

There are shortcomings, of course. Physicians can feel like clerks instead of healers, and patients often resent the effect that typing has on bedside manner. Electronic health records can be spoiled when clinicians cut and paste data to save time, while haphazard standardization and interoperability limit records' utility. Crowd sourcing may generate poorly vetted noise instead of useful guidance. Hackers compromise network integrity, and insurers and industry sift through information with eyes perhaps too focused on profits. The relentless disruption of technological change creates additional stress for caregivers and administrators. And for sick patients not in the mood for a learning curve, weighing too many therapeutic options is confusing and frustrating.

Yet there is no feasible alternative to increased reliance upon our devices and their data. Wealthier countries have high expectations about maintaining the health of their rapidly aging Boomer populations, despite shrinking budgets. The developing world, with its growing middle class, wants greater investment in wellness with measurable outcomes as the result. The technological efficiency—meaning affordability—described by Moore's Law is the only way the medical community can address both demographic challenges successfully.

Back in 1992, my colleagues founded “Medicine Meets Virtual Reality” with the aim of using computers to advance clinical care and medical education. They recognized how exponential upgrades in software and hardware would make healthcare more efficient, precise, and personal. Over the years, many visionary ideas have become viable tools: it is not uncommon to read in the general media about a medical breakthrough whose basis was shared at this conference in previous years. And although “virtual reality” faded as a buzzword years ago and “NextMed” more accurately describes this conference now, the creative energy that turns information technology into better medicine remains vibrant.

Many thanks to the Organizing Committee for its steadfast support over two decades, and to all of you who are participating in this year's conference—the twentieth since 1992 and a noteworthy anniversary.

James D. Westwood

Aligned Management Associates, Inc.

This paper presents the pattern cutting and ligating loop simulation in the Virtual Basic Laparoscopic Skill Trainer (VBLaST^©). In the simulation, the gauze, tubular foam, and ligating loop thread are modeled by the mass-spring method and constraint projection for the inextensible characteristics. Discrete simulation states defined based on the tool-object interaction types are utilized to efficiently and accurately manages the physics simulation, collision processing, and haptic feedback in real-time. An automated scoring system provides quantitative measurement for evaluation of trainees' skills. The simulation results show advanced visual realism and real-time performances.

Although the placebo effect is known to have a strong impact on the outcomes of clinical trials, methods for measuring it are limited to physiological observations. We propose a method of localizing, identifying and measuring placebo and treatment-induced networks in the brain using functional neuroimaging. Measuring the relative activation of these “placebo” brain networks serves as a proxy for the placebo effect contained within the variable of interest (depression rating, blood pressure, etc). Analogous to the difference between a paired and unpaired t-test, this allows for a sharp gain in power and reduction in the sample sizes needed in clinical trials, potentially leading to a drastically smaller sample sizes for establishing efficacy, a shorter time-to-market for a drug, and a drastic reduction in the cost of bringing new drugs into the market.

This pilot study tests the effects on individual performance of dyadic versus individual practice in a 3D virtual world (VW) home safety assessment. Sixty medical students in three conditions (dyadic spatially separated with paired avatars DPA; individual with avatar IND; and dyadic spatially together with single avatar DSA) participated in a geriatric home safety simulation. The participants, via avatars, conducted an assessment of physical hazards. Participants then worked individually in a separate 3D VW home assessment. Dyadic practice, spatially together with a single avatar (DSA), improved individual performance in the subsequent 3D VW home assessment.

VCath is a neurosurgery training tool for the catheterization of the lateral ventricle that has been designed for use on tablet devices. We believe this is the first use of a tablet (iPad) for this purpose and demonstrates future utility for this approach, particularly for Objective Structured Clinical Exams (OSCEs). This paper outlines the implementation and use of VCath.

Peg transfer is one of the five tasks in the Fundamentals of Laparoscopic Surgery (FLS), which is now established as a standard for training minimally invasive surgery. In this paper we report development and preliminary validation of Virtual Basic Laparoscopic Skill Trainer-peg transfer (VBLaST-PT^©) simulator. Face validation of the VBLaST-PT^© with 34 subjects revealed high scores for all aspects of simulation. A two-tailed Mann-Whitney performed on the total scores on VBLaST-PT^© showed significant (p=0.001) difference between the skill groups.

Multigrid algorithms are gaining popularity in virtual reality simulations as they have a theoretically optimal performance that scales linearly with the number of degrees of freedom of the simulation system. We propose a multilevel approach that combines the efficiency of the multigrid algorithms with the ability to resolve multi-body constraints during interactive simulations. First, we develop a single level modified block Gauss-Seidel (MBGS) smoother that can incorporate constraints. This is subsequently incorporated in a standard multigrid V-cycle with corrections for constraints to form the modified multigrid V-cycle (MMgV). Numerical results show that the solver can resolve constraints while achieving the theoretical performance of multigrid schemes.

In this paper a framework is presented for monitoring shape changes on the human body with applications to obesity control. This framework uses a low-cost infrared depth camera in order to capture the 3D shape of the human body and approximate it as a set of spherical functions.

There are currently few Virtual Reality simulators for orthopedic trauma surgery. The current simulators provide only a basic recreation of the manual skills involved, focusing instead on the procedural and anatomical knowledge required. One factor limiting simulation of the manual skills is the complexity of adding realistic haptic feedback, particularly torques. This paper investigates the requirements, in terms of forces and workspace (linear and rotational), of a haptic interface to simulate placement of a lag screw in the femoral head, such as for fixation of a fracture in the neck of the femur. To measure these requirements, a study has been conducted involving 5 subjects with experience performing this particular procedure. The results gathered are being used to inform the design of a new haptic simulator for orthopedic trauma surgery.

We describe a system which provides high-fidelity haptic feedback in the same physical location as a 3D graphical display, in order to enable realistic physical interaction with virtual anatomical tissue during modelled procedures such as needle driving, palpation, and other interventions performed using handheld instruments. The haptic feedback is produced by the interaction between an array of coils located behind a thin flat LCD screen, and permanent magnets embedded in the instrument held by the user. The coil and magnet configuration permits arbitrary forces and torques to be generated on the instrument in real time according to the dynamics of the simulated tissue by activating the coils in combination. A rigid-body motion tracker provides position and orientation feedback of the handheld instrument to the computer simulation, and the 3D display is produced using LCD shutter glasses and a head-tracking system for the user.

Airway management skills are essential for healthcare providers within military and civilian settings. To maintain competency in these skills, it is crucial for the provider to have opportunities for review and retraining. Virtual airway training or telementoring can be an effective means to fulfilling these requirements for healthcare providers located in remote sites. The projection of high quality imagery to far forward locations is essential for health care practitioners in the provision of telemedicine and distance training. The Storz C-CAM was developed to interface with existing endoscopy equipment to facilitate implementation of telemetric devices in remote locations. This work describes the use of the Storz C-CAM in providing medical device training to deployed medical personnel at a far forward location.

This work describes the use of a new intubation device, the intubating laryngeal tube (iLTA) as developed by Boedeker. Emergency Department residents and staff from the University of Nebraska Medical Center performed intubations using the Laerdal Difficult Airway Trainer Manikin^TM. The participants' perceived value of the intubating laryngeal tube as well as its efficacy in intubation performance were measured and found to be highly favorable.

Interactive Storytelling technologies have attracted significant interest in the field of simulation and serious gaming for their potential to provide a principled approach to improve user engagement in training scenarios. In this paper, we explore the use of Interactive Storytelling to support Narrative Medicine as a reflective practice. We describe a workflow for the generation of virtual narratives from high-level descriptions of patients' experiences as perceived by physicians, which can help to objectivize such perceptions and support various forms of analysis.

In recent years, surgical simulation has emerged at the forefront of new technologies for improving the education and training of surgical residents. To objectively evaluate the surgical skills of the trainees and reduce the training cost, an automated method for rating the performance of the operator is critical. However, automated evaluation of surgical skills in a video-based system, e.g., the FLS trainer box, is still a challenging task, both due to the lack of reliable visual features and the lack of analysis tools that bridge the semantic gap between the low-level visual features and the high-level surgical skills. This study attempts to find a latent space for the visual features for supporting more meaningful analysis of surgical skills. The approach employs multi-modality fusion and Canonical Correlation Analysis as the key techniques. Experiments were designed to evaluate the proposed approach. The results suggest that this is a promising direction.

Both simulation-based education and training (SBET) and Web-based Learning (WBL) are increasingly used in medical education. We developed a Web-based learning course on “Observational Practice and Educational Networking” (OPEN), to augment SBET for central venous catheterization (CVC), a complex clinical skill, for novice learners. This pilot study aimed to firstly, understand the perspectives of novice learners on using WBL in preparation for SBET for a psychomotor skill and secondly, to observe how learners use the OPEN courseware to learn more about how to perform this skill.

Natural orifice translumenal endoscopic surgery is an emerging procedure. High fidelity virtual reality-based simulators allow development of new surgical procedures and tools and train medical personnel without risk to human patients. As part of a project funded by the National Institutes of Health, we are developing a Virtual Transluminal Endoscopic Surgery Trainer (VTEST^TM) for this purpose. In this work, objective performance measures derived from motion tracking sensors attached to an endoscope was tested for the transgastric NOTES appendectomy procedure performed with ex-vivo pig organs using the EASIE-R^TM trainer box. Results from our study shows that both completion time and economy of motion parameters were able to differentiate between expert and novice NOTES surgeons with p value of 0.039 and 0.02 respectively. Jerk computed on sensor 2 data also showed significant results (p = 0.02). We plan to incorporate these objective performance measures in VTEST^TM.

Template-guided intraoral surgery is attracting interest due to its accuracy and convenience. Usually, fiducial markers are used for registration of the different model coordinates for patients or plaster and fabrication coordinates in template-guided dental surgery. The accuracy of markers is important because it is directly related to the accuracy of the template-guide, which ultimately affects the success of surgical results. In this paper, we present the methods of determining optimal marker parameters such as size, shape, and material. We have defined parameters that could potentially influence the accuracy of markers and tested them with various values for each parameter. Experiments were performed to measure repeatability, and we tested accuracy and minimized potential error by comparing the actual and calculated dimensions. As a result, the following optimal marker parameters were identified: 3-mm diameter, positively tapered cylindrical shape, and titanium composition.

In prior studies, mannequin-based simulation training has been used to help decrease student anxiety toward intimate clinical examinations. Using time away as an independent variable, the aim of this study was to assess decay of clinical confidence for four procedural tasks that vary in procedural complexity. Clinical confidence with intimate examinations, after a standardized mannequin-based simulation curriculum, decays over time. This decay is noted after two months of time away. Longer periods of time away did not show increased differences.

This RCT study aimed to investigate if VIS-Ed (Visualization through Imaging and Simulation - Education) had the potential to improve medical student education and specialist training in clinical diagnosis and treatment of trauma patients. The participants' general opinion was reported as high in both groups (lecture vs. virtual patient (VP)). Face validity of the VIS-Ed for cervical spine trauma was demonstrated and the VP group reported higher stimulation and engagement compared to the lecture group. No significant difference in the knowledge test between both groups could be observed, confirming our null hypothesis that VIS-Ed was on par with a lecture.

Natural orifice translumenal endoscopic surgery (NOTES) is a minimally invasive procedure, known for its scar-less nature and short post operative recovery periods. A critical skill necessary for a NOTES procedure is the surgeon's ability to navigate and gain visualization of the target organ, which is done by moving the endoscope tip using the dials on the handle. We have developed an accurate and high resolution optical encoder based system to measure that dial manipulations, as part of a larger project to develop a VR-NOTES surgical simulator.

Natural orifice translumenal endoscopic surgery (NOTES) is an experimental surgical technique with benefits including reduced pain, post operative recovery period and better cosmesis compared to traditional laparoscopic procedures. In a pure NOTES procedure, a flexible endoscope is used for performing the surgery and visualization. The Virtual Translumenal Endoscopic Surgical Trainer (VTEST^TM) is being developed as a platform to train for NOTES procedures and innovate NOTES tools and techniques. In this work we report the design specification for the hardware interface to be used for VTEST^TM.

Virtual surgical skills trainers are proving to be very useful for the medical training community. With efforts to increase patient safety and surgeon expertise, the need for surgical skills trainers that provide training in an operating room (OR) like condition is now more pressing. To allow for virtual surgery simulators to be instructed in an OR-like setting we have created a large display based immersive surgical simulation environment. Using the Microsoft Kinect we have created a real-time simulation environment that tracks the test user and appropriately adjust the perspective of the virtual OR for an immersive virtual experience.

Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula (EA/TEF) is a technically challenging surgical procedure. This congenital anomaly is rare; therefore, training opportunities for surgical trainees are limited. There are currently no validated simulation tools available to help train pediatric surgery trainees. The simulator that was developed is a low-cost, reusable model. It simulates the right side of a term neonate chest and contains a tissue block that has been surgically modified to replicate the anatomy of EA/TEF.

No-scar surgery, which aims at performing surgical operations without visible scars, is the vanguard in the field of Minimally Invasive Surgery. No-scar surgery can be performed with flexible instruments, carried by a guide under the vision of an endoscopic camera. This technique brings many benefits for the patient, but also introduces several difficulties for the surgeon. We aim at developing a teleoperated robotic system for assisting surgeons in this kind of operations. In this paper, we present a virtual simulator of the system that allows to assess different control strategies for our robot and to study possible mechanical issues.

This study determined the muscle effort and fatigue of the upper extremity while performing fundamental surgical skills training tasks. Ten novices performed three tasks (precision cutting, needle passing, and peg transfer) using either a virtual simulator or a laparoscopic box-trainer. Their electromyography (EMG) activities in both proximal and distal parts of upper extremity were measured. Significantly more muscle effort were required to complete tasks with the box-trainer, whereas similar muscle fatigue levels between tasks were found in both training environments. These EMG results demonstrated how the virtual trainer could provide meaningful physiological value to the surgeon training in laparoscopic surgery.