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PubMed2006

Past accomplishments and future directions: risk prevention in anesthesia and surgery.

Anesthesiology has served as a model for patient safety in health care and was the first medical profession to treat patient safety as an independent problem. Anesthesiology has implemented widely accepted guidelines on basic monitoring, conducted long-term analyses of closed malpractice claims, developed patient simulators as meaningful training tools, and addressed problems of human error. The National Surgical Quality Improvement Program is the first national, validated, and peer-controlled program that uses risk-adjusted outcomes for the comparative assessment and improvement of the quality of surgical care. The program has reduced postoperative complications in the Veterans Administration, at both national and local levels. It is becoming more evident that processes and events during surgery can be important determinants of long-term outcomes after anesthesia and surgery.

Anesthesia↗

PubMed2006

Simbionix simulator.

The GI Mentor (Simbionix, Lod, Israel) is a computer-based simulator used for training in endoscopy. It contains modules for training in hand-eye coordination, upper and lower gastrointestinal endoscopy, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography. It provides experience in the steering and torque of the endoscope, suction, and inflation, a realistic view through the monitor, and a realistic force feedback when performing the procedure. Its advantages include its availability for training with no need for previous preparation and the constant interaction with the trainee. It is costly, however, and presently is suitable only for the initial steps of training.

Clinical Competence↗

PubMed1998

Synaptic changes in rat maculae in space and medical imaging: the link.

Two different space life sciences missions (SLS-1 and SLS-2) have demonstrated that the synapses of the hair cells of rat vestibular maculae increase significantly in microgravity. The results also indicate that macular synapses are sensitive to stress. These findings argue that vestibular maculae exhibit neuroplasticity to macroenvironmental and microenvironmental changes. This capability should be clinically relevant to rehabilitative training and/or pharmacological treatments for vestibular disease. The results of this ultrastructural research also demonstrated that type I and type II hair cells are integrated into the same neuronal circuitry. The findings were the basis for development of three-dimensional reconstruction software to learn details of macular wiring. This software, produced for scientific research, has now been adapted to reconstruct the face and skull directly from computerized tomography scans. In collaboration with craniofacial reconstructive surgeons at Stanford University Medical Center, an effort is under way to produce a virtual environment workbench for complex craniofacial surgery. When completed, the workbench will help surgeons train for and simulate surgery. The methods are patient specific. This research illustrates the value of basic research in leading to unanticipated medical applications.

Acoustic Maculae↗

PubMed1998

The study of the effectiveness of chest compressions using the CPR-plus.

Effective cardiopulmonary resuscitation (CPR) requires a high level of skill from both healthcare professionals and the lay public. Inadequate chest compressions are a common cause of ineffective CPR. The CPR-plus is a non-invasive, hand-held, simple to use CPR adjunct designed to assist the rescuer to monitor and modify the compression technique during CPR, hopefully resulting in improved rescuer performance and more effective CPR. Forty qualified nurses were evaluated while they performed chest compressions on a training manikin. During simulated two-rescuer CPR (compression/ventilation ratio 5:1) the participants performed 150 compressions at a rate of 80-100 min. Compressions were performed with and without the CPR-plus and the results compared. The use of the CPR-plus was randomised with regard to whether the adjunct or the standard method was used first. The average number of correctly applied compressions was significantly better when the CPR-plus was used: 138.35/150 versus 110.70/150 (p = 0.0001). Improvements in techniques associated with the use of the CPR-plus also included a reduction in excessive application of pressure and incorrect hand position. The device provided reassurance of satisfactory compressions and an indication of impending fatigue in the rescuer.

Cardiopulmonary Resuscitation↗

PubMed2001

Reverse spikeology: predicting single spikes.

Neural models that simulate single spike trains can help us understand the basic principles of neural coding in vision. Keat et al. (2001) develop a hybrid model that combines spatiotemporal filtering with nonlinear spike generation. The model does a good job of predicting the responses of single retinal ganglion cells and thalamic relay neurons.

Action Potentials↗

PubMed1993

Automated laparoscope positioner: preliminary experience.

A new automated laparoscope positioner was designed that is easy to use and provides the surgeon with an opportunity to perform most laparoscopically directed procedures efficiently and safely without the need for an assistant. Potential additional benefits are reduced cost of care, development of laparoscopic simulators suitable for training residents, and development of surgical procedures and devices.

Equipment Design↗

PubMedDate not supplied

A comparative analysis of the emergency medical services and rescue responses to eight airliner crashes in the United States, 1987-1991.

INTRODUCTION: Crashes involving commercial airliners stress emergency medical services (EMS) and rescue operations to performance far in excess of everyday activities, and special adaptations of everyday responses need to be implemented. Fortunately, these events are infrequent and usually do not occur more than once in any location. The responses that occur must be highly coordinated and efficient. Little is known about the responses to such events. This study examines the EMS and rescue responses associated with eight recent crashes involving commercial airliners in the United States. OBJECTIVE: To identify common factors for which alterations in responses may enhance the survival and decrease the morbidity to victims involved in commercial aviation crashes. STUDY POPULATION: Eight commercial airliner crashes in the United States from 1987 through 1991. METHODS: Case review using: 1) press and media accounts; 2) U.S. National Transportation and Safety Board testimony and reports; and 3) structured interviews with airport, fire, EMS, and hospital personnel. Data were collated and common factors identified for the cases. Findings are classified into: 1) conditions at the crash sites; 2) initial responses; 3) scene management; 4) scene status; 5) patient transport; 6) hospital responses; and 7) preplanning exercises. RESULTS: Common factors that impaired responses for which some remediation is possible include: 1) new methods for training including computerized simulations; 2) improvements in rescue-extrication equipment and supplies; 3) stored caches of EMS equipment and supplies at airports; 4) ambulance transport capabilities; and 5) augmentation of patient transport capabilities. CONCLUSIONS: Many lessons can be learned through structured studies of commercial aircraft crashes. These findings suggest that simple and relatively inexpensive modifications may enhance all levels of emergency responses to such events.

Accidents, Aviation↗

PubMed2002

High-throughput SELEX SAGE method for quantitative modeling of transcription-factor binding sites.

The ability to determine the location and relative strength of all transcription-factor binding sites in a genome is important both for a comprehensive understanding of gene regulation and for effective promoter engineering in biotechnological applications. Here we present a bioinformatically driven experimental method to accurately define the DNA-binding sequence specificity of transcription factors. A generalized profile was used as a predictive quantitative model for binding sites, and its parameters were estimated from in vitro-selected ligands using standard hidden Markov model training algorithms. Computer simulations showed that several thousand low- to medium-affinity sequences are required to generate a profile of desired accuracy. To produce data on this scale, we applied high-throughput genomics methods to the biochemical problem addressed here. A method combining systematic evolution of ligands by exponential enrichment (SELEX) and serial analysis of gene expression (SAGE) protocols was coupled to an automated quality-controlled sequence extraction procedure based on Phred quality scores. This allowed the sequencing of a database of more than 10,000 potential DNA ligands for the CTF/NFI transcription factor. The resulting binding-site model defines the sequence specificity of this protein with a high degree of accuracy not achieved earlier and thereby makes it possible to identify previously unknown regulatory sequences in genomic DNA. A covariance analysis of the selected sites revealed non-independent base preferences at different nucleotide positions, providing insight into the binding mechanism.

Base Sequence↗

PubMed2000

Acute effects of moderate exercise on serum lipids, lipoproteins and apolipoproteins in sedentary young women.

1. The aim of the present study was to examine the effects of moderate exercise on serum lipids, lipoproteins and apolipoproteins in seven sedentary young women under controlled conditions. 2. The subjects exercised on separate days for 30 or 60 min at an intensity of 60% of maximal oxygen uptake on a cycle ergometer. Total cholesterol, triglycerides, high-density lipoprotein-cholesterol (HDL-C), HDL2-C, HDL3-C, low-density lipoprotein-cholesterol, apolipoproteins A-I, A-II and B were measured in the serum at the end of the 60 min rest period before each exercise, immediately after the performance of each exercise and at 30 min and 1, 2 and 24 h after each exercise. 3. The results showed that there were no significant differences between the pre- and postexercise samples for any of the parameters tested. 4. The results of the present study suggest that a single bout of exercise designed to simulate a typical training workout has no noticeable effect on serum lipids, lipoproteins and apolipoproteins in normal sedentary young women who have normal lipid profiles, are in the follicular phase of their menstrual cycle and who consume a relatively low-fat diet.

Adult↗

PubMed2005

Web-integration PROAFTN methodology for acute leukemia diagnosis.

OBJECTIVE: To develop and test a web-based Clinical Decision Support System (CDSS) tool, which integrated a new fuzzy multiple criteria classification methodology named PROAFTN in acute leukemia (AL) diagnosis. METHODS: We have integrated a PROAFTN method and developed a web-based clinical decision support system using standard JSP, servlets, and XML technologies. All website data are database-driven; and the database system can handle data store, update, and retrieval instantly. Since the system was moved to a web server, we have started our experimental testing on 191 AL cases. RESULTS: The percentage of correct classification in this experimental testing was consistent with the proposed prototype. 96.4% of AL cases were correctly classified, proving that web-integration can be a promising tool for dissemination of CDSS tools. We found our system to be robust and capable of deployment for referring physicians. CONCLUSIONS: Our experimental results suggest that the Internet has promise as a means for distribution of CDSS tools. This system will help to: 1) make a "virtual" diagnosis and to compare its performances with given clinical diagnosis; 2) exchange health information between physicians and hematologists at the location and time of need; 3) assist online learning and simulate cases for training practitioners; 4) implement a strict security and access control for transmission of electronic health data through the Internet. The method will not replace specialists, but was developed to assist biologist-hematologists and general practitioners remotely in making decisions on medical diagnosis.

Acute Disease↗

PubMed2001

A case study of using artificial neural networks for classifying cause of death from verbal autopsy.

BACKGROUND: Artificial neural networks (ANN) are gaining prominence as a method of classification in a wide range of disciplines. In this study ANN is applied to data from a verbal autopsy study as a means of classifying cause of death. METHODS: A simulated ANN was trained on a subset of verbal autopsy data, and the performance was tested on the remaining data. The performance of the ANN models were compared to two other classification methods (physician review and logistic regression) which have been tested on the same verbal autopsy data. RESULTS: Artificial neural network models were as accurate as or better than the other techniques in estimating the cause-specific mortality fraction (CSMF). They estimated the CSMF within 10% of true value in 8 out of 16 causes of death. Their sensitivity and specificity compared favourably with that of data-derived algorithms based on logistic regression models. CONCLUSIONS: Cross-validation is crucial in preventing the over-fitting of the ANN models to the training data. Artificial neural network models are a potentially useful technique for classifying causes of death from verbal autopsies. Large training data sets are needed to improve the performance of data-derived algorithms, in particular ANN models.

Autopsy↗

PubMed1988

Antibiotic dispensing by drug store personnel in Bangkok, Thailand.

The current pattern of antibiotic use by drug store personnel in Bangkok was examined. Ten well-trained medical students (simulated patients) presented to 40 randomly selected drug stores with common complaints, namely urethral discharge, acute watery diarrhoea, fever with sore throat, coryza, skin infection and acute dysuria. Analysis of medications obtained revealed that 50-100% of drug stores dispensed antibiotics for each condition. Co-trimoxazole, ampicillin, chloramphenicol, penicillin V and tetracycline were commonly given. Most antibiotics were dispensed inappropriately with respect to choice of drug and duration of treatment. The cost per treatment varied from 20 cents to 6 $US. Strategies to promote rational use are proposed.

Adult↗

PubMed2005

The research we still are not doing: an agenda for the study of computer-based learning.

Media-comparative research-that is, the comparison of computer-based learning (CBL) to noncomputer instruction-is logically impossible because there are no valid comparison groups. Results from media-comparative studies are thus confounded and difficult to meaningfully interpret. In 1994, Friedman proposed that such research be supplanted by investigations into CBL designs, usage patterns, assessment methods, and integration. His proposal appears to have largely been ignored. In this article, the author updates the agenda for research in CBL (including Web-based learning). While media-comparative studies are confounded, CBL-CBL comparisons are often not. CBL instructional designs vary in configuration (e.g., discussion board or tutorial), instructional method (e.g., case-based learning, personalized feedback, or simulation), and presentation (e.g., screen layout, hyperlinks, or multimedia). Comparisons within one level (for example, comparing two instructional methods) facilitate evidence-based improvements, but comparisons between levels are confounded. Additional research questions within the CBL-CBL framework might include: Does adaptation of CBL in response to individual differences such as prior knowledge, computer experience, or learning style improve learning outcomes? Will integrating CBL with everyday clinical practice facilitate learning? How can simulations augment clinical training? And, how can CBL be integrated within and between institutions? In addressing these questions it is important to remember the most important outcome-effect on patients and practice-and outcomes specific to CBL including costs, cognitive structuring, and learning unique to the computer-based environment. CBL is not a panacea, but holds great promise. Realization of this potential requires that media-comparative studies be replaced by rigorous, theory-guided comparisons of CBL interventions.

Computer-Assisted Instruction↗

PubMed2003

Laser in situ keratomileusis flap stability during simulated aircraft ejection in a rabbit model.

PURPOSE: To determine the stability of the laser in situ keratomileusis (LASIK) flap in a rabbit model when subjected to vertical acceleration at nine times the force of gravity (+9 Gz) in an aircraft cockpit ejection simulator. METHODS: Thirty-six eyes from 25 New Zealand white rabbits underwent LASIK flap creation without laser photoablation. One month after surgery, the rabbits were sedated and harnessed in a cockpit ejection seat simulator used to train United States Air Force pilots. They then underwent a controlled rapid-sequence ejection at +9 Gz. Subsequently, the rabbits were euthanized and the corneas harvested for microscopic examination. Refractive measurements and corneal examination were made before LASIK flap creation and prior to and after the +9 Gz ejections. Determination of LASIK flap dislocation was based on clinical observation of flap slippage or a significant shift in pre-ejection to postejection cylinder axis. RESULTS: The average preoperative refraction of the rabbit eye was +1.83 D + 3.25 D x 086 degrees. The average change from pre-ejection to postejection was 0.04 D sphere, 0.02 D cylinder, 6.8 axis degrees, and 0.04 D spherical equivalent. The pre-ejection to postejection measurements were not statistically significantly different by a paired test. Laser in situ keratomileusis flap dislocation or ejection-induced corneal folds or striae were not clinically observed. Histologic examination revealed well-healed LASIK flaps but no reactive keratocytes at the central stromal-stromal interface. CONCLUSIONS: Healed LASIK flaps as created in this rabbit model without laser ablation are stable when subjected to a rapid vertical ejection at nine times the force of gravity.

Aerospace Medicine↗

PubMed2006

Individual recognition using gait energy image.

In this paper, we propose a new spatio-temporal gait representation, called Gait Energy Image (GEI), to characterize human walking properties for individual recognition by gait. To address the problem of the lack of training templates, we also propose a novel approach for human recognition by combining statistical gait features from real and synthetic templates. We directly compute the real templates from training silhouette sequences, while we generate the synthetic templates from training sequences by simulating silhouette distortion. We use a statistical approach for learning effective features from real and synthetic templates. We compare the proposed GEI-based gait recognition approach with other gait recognition approaches on USF HumanID Database. Experimental results show that the proposed GEI is an effective and efficient gait representation for individual recognition, and the proposed approach achieves highly competitive performance with respect to the published gait recognition approaches.

Algorithms↗

PubMed1997

Anesthesia patient risk: a quantitative approach to organizational factors and risk management options.

The risk of death or brain damage to anesthesia patients is relatively low, particularly for healthy patients in modern hospitals. When an accident does occur, its cause is usually an error made by the anesthesiologist, either in triggering the accident sequence, or failing to take timely corrective measures. This paper presents a pilot study which explores the feasibility of extending probabilistic risk analysis (PRA) of anesthesia accidents to assess the effects of human and management components on the patient risk. We develop first a classic PRA model for the patient risk per operation. We then link the probabilities of the different accident types to their root causes using a probabilistic analysis of the performance shaping factors. These factors are described here as the "state of the anesthesiologist" characterized both in terms of alertness and competence. We then analyze the effects of different management factors that affect the state of the anesthesiologist and we compute the risk reduction benefits of several risk management policies. Our data sources include the published version of the Australian Incident Monitoring Study as well as expert opinions. We conclude that patient risk could be reduced substantially by closer supervision of residents, the use of anesthesia simulators both in training and for periodic recertification, and regular medical examinations for all anesthesiologists.

Accidents↗

PubMed2004

Enhancing temporal cues to voice pitch in continuous interleaved sampling cochlear implants.

The limited spectral resolution of cochlear implant systems means that voice pitch perception depends on weak temporal envelope cues. Enhancement of such cues was investigated in implant users and in acoustic simulations. Subjects labeled the pitch movement of processed synthetic diphthongal glides. In standard processing, noise carriers (simulations) or pulse trains (implant users) were modulated by 400 Hz low-pass envelopes. In modified processing, carriers were modulated by two components: (1) Slow-rate (<32 Hz) envelope modulations, conveying dynamic spectral shape changes crucial for speech; (2) a simplified waveform (e.g., a sawtooth) matching the periodicity of the input diphthong. In both normal listeners and implant users performance was better with modified processing, though temporal envelope cues were less effective with higher F0. Factors contributing to the advantage for modified processing may include increased modulation depth and use of a modulation waveform featuring a rapid onset in each period, resulting in a clearer representation of F0 in the neural firing pattern. Eliminating slow-rate spectral dynamics, so that within-channel amplitude changes solely reflected F0, showed that dynamic spectral variation obscured temporal pitch cues. Though significant, advantages for modified processing were small, suggesting that the potential for developing strategies delivering enhanced pitch perception is limited.

Acoustic Stimulation↗

PubMed1990

Range resolution and the possible use of spectral information in the echolocating bat, Eptesicus fuscus.

Individuals of the echolocating bat Eptesicus fuscus were trained to discriminate simulated two-wave-front targets with internal time delays of 0 to 100 microns between the wave fronts from a one-wave-front target. The ability of bats to discriminate between such targets can be referred to as range resolution. In Eptesicus fuscus, this ability is limited to distinct internal time delays (12, 32-40, and 52-100 microns) between the two wave fronts of a double-wave-front target. Analysis of the simulated two-wave-front echoes reveals periodic frequency minima in the spectrum. Position and separation of these spectral minima depend on the time delay between the two wave fronts. The occurrence of spectral minima within the frequency range of the first harmonic in the echo of the bats' echolocation call correlates to the bats' ability to discriminate a one-wave-front echo from two-wave-front echoes, suggesting that Eptesicus fuscus uses spectral differences within the first harmonic in echoes for range resolution.

Animals↗