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PubMed2004

Proving the value of simulation in laparoscopic surgery.

OBJECTIVE: To assess the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) physical laparoscopic simulator for construct and predictive validity and for its educational utility. SUMMARY BACKGROUND DATA: MISTELS is the physical simulator incorporated by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in their Fundamentals of Laparoscopic Surgery (FLS) program. MISTELS' metrics have been shown to have high interrater and test-retest reliability and to correlate with skill in animal surgery. METHODS: Over 200 surgeons and trainees from 5 countries were assessed using MISTELS in a series of experiments to assess the validity of the system and to evaluate whether practicing MISTELS basic skills (transferring) would result in skill acquisition transferable to complex laparoscopic tasks (suturing). RESULTS: Face validity was confirmed through questioning 44 experienced laparoscopic surgeons using global rating scales. MISTELS scores increased progressively with increasing laparoscopic experience (n = 215, P < 0.0001), and residents followed over time improved their scores (n = 24, P < 0.0001), evidence of construct validity. Results in the host institution did not differ from 5 beta sites (n = 215, external validity). MISTELS scores correlated with a highly reliable validated intraoperative rating of technical skill during laparoscopic cholecystectomy (n = 19, r = 0.81, P < 0.0004; concurrent validity). Novice laparoscopists were randomized to practice/no practice of the transfer drill for 4 weeks. Improvement in intracorporeal suturing skill was significantly related to practice but not to baseline ability, career goals, or gender (P < 0.001). CONCLUSION: MISTELS is a practical and inexpensive inanimate system developed to teach and measure technical skills in laparoscopy. This system is reliable, valid, and a useful educational tool.

Clinical Competence↗

PubMed2005

Virtual reality simulators in orthopedic surgery: what do the surgeons think?

BACKGROUND: There is increasing pressure to develop virtual reality surgical simulation that can be used in surgical training. However, little is known of the attitudes of the surgical community toward such simulation, and which aspects of simulation are most important. MATERIALS AND METHODS: A postal survey on attitudes to surgical simulation was sent to all New Zealand orthopedic surgeons and advanced trainees. This comprised of 44 questions in 10 sections, using either a visual analogue scale (0 to 10) or free text box replies. Results were analyzed for two sub-groups; surgeons qualified before 1990 and those qualified in or after 1990 or still in training. RESULTS: Of the 208 possible responses, 142 were received, a response rate of 68%. Only four respondents had tried a surgical based simulator. Earlier qualified surgeons were more likely to agree that simulation was an effective way to practice surgical procedures, median score 7.7 versus 5.6 (P = 0.03). Both groups thought the most important task for simulation was practicing angulation/spatial orientation (median score 8.4/10), while a realistic view of the operation was the most important requirement (median score 9/10). Both groups were unconvinced that simulation would impact on their practice in the next 5 years, with this statement being scored lower by later qualified surgeons, median score 2.4 versus 4.1 (P = 0.04). CONCLUSIONS: Orthopedic surgeons in New Zealand are supportive of surgical simulation but do not expect simulation to have an impact in the near future. Intriguingly, later qualified surgeons and trainees are more skeptical than their earlier qualified colleagues.

Adult↗

PubMed2005

Artificial neural network modeling of apoptosis in gamma irradiated human lymphocytes.

PURPOSE: To develop an artificial neural network (ANN) model of apoptotic response in gamma irradiated human lymphocytes. To assess the feasibility of training ANN radiobiological models using data collected with flow cytometry. MATERIALS AND METHODS: Irradiated isolated human lymphocytes were labelled with Annexin V-Fluorescein Isothiocyanate (FITC) and 7-Amino-Actinomycin D (7AAD) then analysed using flow cytometry. Twenty-four dose responses per donor from 14 donors were collected from a flow cytometer and used in model development as the training and cross-validation datasets. The general ANN model architecture was a multi-layer perceptron using the mean squared error of a cross validation dataset as the objective function. The ANN model was optimized by varying the number of hidden layers and the number of processing elements per layer. The optimized model constituted of three hidden layers with 80, 40, and 10 hidden layers in the first, second, and third layers respectively. RESULTS: The optimized model was used to simulate dose responses at the training doses of 0, 2, 4 and 8 Gray. A strong agreement between the model and measured dose responses was observed. The model was also used to simulate a dose response at 0.1 Gray and results were compared to the measured dose response from a donor not used in model development. Again, strong agreement between the model and the observed dose response was found. CONCLUSIONS: This study shows that artificial neural networks can be trained to provide high resolution, high accuracy models of multivariate radiobiological data collected by flow cytometry.

Apoptosis↗

PubMed1991

Common set of proteins in Aplysia sensory neurons affected by an in vitro analogue of long-term sensitization training, 5-HT and cAMP.

An in vitro analogue of long-term behavioral training in Aplysia was developed to simulate the intensity and timing of shocks delivered to the body wall of animals during sensitization training. The in vitro training analogue consisted of electrical stimulation of peripheral nerves of isolated pleural-pedal ganglia. We found that the in vitro training analogue led to long-term (24 h) changes in the membrane currents of sensory neurons; these changes were similar to those produced by behavioral training. Using two dimensional polyacrylamide gel electrophoresis, we examined early effects on protein synthesis in pleural sensory neurons induced by the training analogue. Incorporation of amino acid into 5 proteins was affected at the end of training. Incorporation of amino acid into some of these proteins was also affected by serotonin (5-HT) and by an analogue of cyclic adenosine monophosphate (cAMP). These results suggest that the effects on protein synthesis that are produced by the in vitro training analogue are mediated, at least in part, by release of 5-HT and an increase in the level of cAMP in the sensory neurons.

Animals↗

PubMed2001

Bimanual haptic workstation for laparoscopic surgery simulation.

Realistic laparoscopic surgical simulators will require real-time graphic imaging and tactile feedback. Our research objective is to develop a cost-effective haptic workstation for the simulation of laparoscopic procedures for training and treatment planning. The physical station consists of a custom-built frame into which laparoscopic trocars and surgical tools may be attached/inserted and which are continuously adjustable to various positions and orientations to simulate multiple laparoscopic surgical approaches. Instruments inserted through the trocars are attached to end effectors of two haptic devices and interfaced to a high speed PC with fast graphics capability. The haptic device transduces 3D motion of the two manually operated surgical instruments into slave maneuvers in virtual space. The slave instrument tips probe the simulated organ. Simulations currently in progress include: 1) Surface-only renderings, deformation, and haptic interactions with elements in the gall gladder surgical field; 2) Voxel-based simulations of the bulk manipulation of tissue; 3) laparoscopic herniorrhaphy. This system provides force feed-forward from the grasped tools to the contact tissue in virtual space, with deformation of the tissue by the virtual probe, and force feedback from the deformed tissue to the operator's hands.

Computer Graphics↗

PubMed2005

Structural flexibility of laparoscopic instruments: implication for the design of virtual reality simulators.

In accordance with the Practice Specificity Theory, training on models that closely resemble real life scenarios is most beneficial to learning. Research in the virtual reality (VR) simulation, as a potential teaching and evaluation tool, concentrated on the design of trainers to resemble operating room (OR) conditions. The purpose of the present investigation was to determine the structural flexibility of laparoscopic instruments of different materials and diameters under a wide range of stresses. Incorporating the mechanical properties of these instruments into the algorithms can prove to further increase the fidelity of VR simulators. The amount of deviation from pre-stress position in the instruments' shaft was measured with infrared markers and used as the index of structural flexibility. All instruments deviated considerably with the largest deviations observed for the small disposable, and lowest for the large reusable instruments. There was a linear relation between the stress and deviation for all instruments, which varied as a function of diameter. Similar instrument deviations were observed during cholecystectomy performed on porcine liver. Our findings show that laparoscopic instruments are not rigid bodies and are prone to significant deviations during standard laparoscopic procedures. This suggests that the structural flexibility of laparoscopic instruments should be modeled in the design of VR simulators.

Canada↗

PubMed2004

Trials of teaching methods in basic life support (4): comparison of simulated CPR performance at unannounced home testing after conventional or staged training.

This study compares the retention of basic life support (BLS) skills after 6 and 12 months by lay persons trained either in a conventional manner, or using a staged approach. Three classes, each of 2h, were offered to volunteers over a period of 4 months. For the conventional group, the second and third classes consisted of review of skills. Those in the staged group were first taught chest compression alone; chest compression with ventilation in a ratio of 50:5 was introduced at the second class; full standard CPR was taught at the third class. A total of 495 volunteers entered the study, 262 being randomly allocated to conventional training, and 233 to staged training. More of those who received staged training attended a second (78 volunteers) and third class (41 volunteers), compared with those who received conventional training (36 and 17, respectively). The objective of this study, however, was to compare the strategies of the different training methods. A total of 291 volunteers (167 conventional and 124 staged training) were available for unannounced home testing of full conventional CPR 6 months after initial training, and 260 volunteers (135 conventional and 125 staged training) were tested at 12 months. At 6 months, those taught by the staged method were significantly better at time to first compression (P < 0.0001), compression rate (P = 0.024), and hand position (P = 0.0001). At 12 months, those taught by the staged method were significantly better at shouting for help (P = 0.005), time to first compression (P < 0.0001), and compression depth (P = 0.003). Those taught conventionally were significantly better at checking for a carotid pulse at both 6 and 12 months (P < 0.0001). These results suggest that training lay persons in basic life support skills using a staged approach leads to overall better skill retention at 6 and 12 months, and has other advantages including a greater willingness to re-attend follow-up classes.

Adult↗

PubMed2002

Anticipation skill in a real-world task: measurement, training, and transfer in tennis.

Anticipation skill in tennis was examined using realistic film simulations, movement-based response measures, and a portable eye movement recording system. Skilled players were faster than their less skilled counterparts in anticipating the direction of opponents' tennis strokes, with this superior performance being based, at least in part, on more effective visual search behaviors. The processes mediating superior performance were then modeled in groups of recreational tennis players using video simulation, instruction, and feedback. Players who received perceptual training improved their performance on laboratory- and field-based tests of anticipation when compared with matched placebo and control groups that did not receive any instruction regarding expert performance strategies. The approach used may have practical utility in a variety of performance contexts.

Adult↗

PubMed2004

[Patient safety and training in human factor--challenge for anaesthesia training].

Patient safety is a central issue for every hospital. Prerequisites are reliable routine processes, avoidance of accidents, and flexible management of incidents. In anaesthesia, ca. 80% of all incidents can be assigned to human factors (e.g. communication, management of workload, decision-making). Deficits in these non-technical skills affect directly or indirectly the patient safety. Therefore, training of anaesthesia personnel in human factors and development of non-technical skills contribute to enhancement of patient safety. The question is how non-technical skills can be taught and learned. In this paper, we discuss an integrated strategy for training in non-technical skills in medicine. In a first step (analysis of demand), data were acquired as to which non-technical skills required training. These data led to the development of a comprehensive training concept for physicians based on learning psychology-derived modules. The individual modules and their methodological implementation are briefly presented here. Besides the communication of knowledge about human factors, we discuss the employment of computer-simulated low-fidelity scenarios and full-scale patient simulators. In principle, this integrative training strategy can be easily adapted to other related medical branches.

Anesthesia↗

PubMed2001

Virtual reality simulators for dermatologic surgery: measuring their validity as a teaching tool.

Surgical simulation is increasingly being considered for training, testing, and possibly credentialing in medicine and surgery. At the University of Washington we have been developing a virtual reality (VR) suturing simulator. In the course of development it must be realized that expensive new technologies should bear the burden of proof of their effectiveness and reliability before they are put into training programs. The purpose of this article is to define the concept of surgical skill and to discuss how it can be measured in the context of validating VR surgical simulators. Specific measures of validity and reliability are reviewed and discussed.

Computer Simulation↗

PubMed2003

[Manual skills in anaesthesiology].

Assessment in anaesthesia traditionally takes the form of written papers and oral examinations. These are important for assessing trainee's knowledge and judgement, but do not test for competency in practical skills, which is essential for successful clinical practice. The presence of learning curves for practical skills in anaesthesia is now well recognized and they are useful tools to monitor a learning process. From these, estimates of the number of procedures that must be performed by trainees in order to reach an acceptable success rate can be produced. It is clear that these figures give some help for the rational design of training programs, however, numbers alone do not provide a sufficient basis to declare a trainee competent for a given procedure. Not only technical skills need to be taught, but also decision-making and even more important behavioral skills. In clinical practice there are often problems in providing all the necessary training on patients and by this reorganization of residency programs may be necessary. However, the role of medical simulation in the assessment of anesthetists in training is still unclear, and the introduction of simulator-based tests may be premature.

Anesthesia, Conduction↗

PubMed2006

Ankle force and rate of force production increase following high intensity strength training in frail older adults.

BACKGROUND AND AIMS: The most common cause of accidental injury and death in people over age 65 results from impacts associated with falling. Balance impaired older adults have poorer balance control than healthy young adults or healthy older adults. Lack of sufficient lower extremity strength and inability to rapidly produce muscle force may contribute to diminished balance control in the elderly. This study evaluated the effect of a 10-week high intensity strength-training program targeting key lower extremity muscles for the purpose of improving postural control in frail older adults. METHODS: Thirteen experimental and fourteen control subjects, all balance impaired older adults were evaluated in response to unexpected platform perturbations that simulated slips. RESULTS: Following strength training the experimental group was significantly stronger than the control group. Mean ankle moments improved in the experimental group following strength training during forward sway (Right: p=0.067, Left: p=0.009) and backward sway (Right: p=0.031, Left: p=0.058). For the backward sway condition the ankle rate of torque production increased significantly in the experimental group (Right: p=0.016, Left: p=0.031). CONCLUSIONS: Enhancement of lower extremity strength contributed to improvements in balance stability demonstrated by greater ankle force production, in response to balance threats.

Accidental Falls↗

PubMed2005

From the lexicon to expectations about kinds: a role for associative learning.

In the novel noun generalization task, 2 1/2-year-old children display generalized expectations about how solid and nonsolid things are named, extending names for never-before-encountered solids by shape and for never-before-encountered nonsolids by material. This distinction between solids and nonsolids has been interpreted in terms of an ontological distinction between objects and substances. Nine simulations and behavioral experiments tested the hypothesis that these expectations arise from the correlations characterizing early learned noun categories. In the simulation studies, connectionist networks were trained on noun vocabularies modeled after those of children. These networks formed generalized expectations about solids and nonsolids that match children's performances in the novel noun generalization task in the very different languages of English and Japanese. The simulations also generate new predictions supported by new experiments with children. Implications are discussed in terms of children's development of distinctions between kinds of categories and in terms of the nature of this knowledge.

Association Learning↗

PubMed2003

Development of race profiles for the performance of a simulated 2000-m rowing race.

The purpose of this study was to determine the race profile for a 2000-m simulated rowing race as well as the effect of training and gender on the race profile. Nineteen men and 19 women undertook a 2000-m simulated rowing race before and after 10 weeks of a typical off-season training program for rowing. Velocity was calculated every 200 m and the deviation in velocities from the mean race velocity (MRV) was plotted every 200 m to produce race profiles for each gender before and after training. The three fastest male rowers varied approximately 0.02 m.s from the MRV after training and displayed a constant-pace model. The fastest female rowers displayed an all-out strategy after training, producing large deviations from MRV. Average squared deviations from the mean (SDM) determined that all groups except the fastest females had a reduction in MRV deviation after training. These results suggest that the optimal race profile for a simulated 2000-m rowing race may be different between genders. Training reduces SDM and influences both male and female pacing patterns such that both exhibit a pacing strategy that is more similar to that of elite athletes in other events of similar and shorter duration.

Adult↗

PubMed2005

[A primary study on simulation of fracture strength based on BP neural networks].

OBJECTIVE: To model the relationship between stimulating stress and fracture strength using BP neural networks, and to provide a theoretical basis for accurate prediction of the rate of fracture healing. METHODS: The bilateral tibiae in New Zealand rabbits were osteotomized and fixed by stress-relaxation plate(SRP) and rigid plate(RP), respectively. The stress shielding rate and bending strength of the healing fractures were measured at 2 to 48 weeks postoperatively. A BP neural network was constructed and trained using the experimental data of the stress-relaxation group. Then the trained network was used for simulation to predict fracture strength of the two groups from the stress at the fracture site. RESULTS: With the input of the data that has been used to train the network, fracture strength similar to those measured in experiment was calculated from the BP neural network. However, poor results were obtained with the input of new data. CONCLUSION: BP neural network can be used to investigate the influence of various factors on fracture healing quantitatively, and to predict the rate of healing. However, the model still needs to be perfected. More experimental or clinical data are needed to train the network

Animals↗

PubMed2000

EMS roadshow.

Explore the source record for details and available documents.

Canada↗

PubMed2001

Simulation of acute spinal cord injury: effects on respiration.

The respiratory effects of acute spinal injury and paralysis are difficult to study. Urgent medical needs of human spinal cord injury victims usually preclude study, while induction of spinal cord lesions in awake animals is not feasible ethically. We utilized controlled, segmental infusion of epidural anesthetic in awake, highly trained, implanted canines to reversibly simulate the effects of thoracic and cervical (paraplegic and quadriplegic) spinal cord injury. We studied six animals, an average of 29 days after implantation with electromyogram and sonomicrometry transducers in transversus abdominis, external intercostal, parasternal intercostal and costal diaphragm muscles. Anesthetic was infused through an epidural catheter inserted percutaneously, under fluoroscopic guidance. Asymmetrical motor blockade was prevented using repositioning during epidural infusions. By sequential infusion we were able to induce three distinct, functional levels of spinal paralysis showing cumulative paralysis of abdominal, external intercostal, and parasternal intercostal muscles. Paralysis of the abdomen and chest wall, sparing only the diaphragm, showed unexpected bradypnea and failure to maintain minute ventilation.

Acute Disease↗

PubMed2005

A novel 3-year longitudinal pilot study of medical students' acquisition and retention of screening eye examination skills.

OBJECTIVE: To assess the acquisition and retention of screening ophthalmic clinical skills over 3 years of medical school. DESIGN: Observational, longitudinal, multiple skills measures. PARTICIPANTS: All 96 students enrolled in a single graduating class at a public medical school in California. METHODS: Immediately after the second-year ophthalmic clinical skills course, all students were evaluated by their preceptors and self-rated for competence in defined skills. Follow-up assessments were done during 2 required third-year clerkships without additional formal ophthalmic clinical exposure. Three complete history and physical examination chart notes routinely submitted for course grading in third-year clerkships were selected randomly for each student by clerkship directors in family medicine and internal medicine, masked for identity, and then scored for appropriateness. Funduscopic skills were assessed objectively with a simulator in the third-year Clinical Performance Examination. During a fourth-year 4-day ophthalmology clerkship, students were trained and reassessed with the same simulator. Just before graduation, a self-assessment questionnaire was administered to the entire class. MAIN OUTCOMES MEASURES: Twelve skills were assessed: ability to evaluate visual acuity (VA); pupils; extraocular muscles; confrontation fields; lids; cornea; conjunctiva/sclera; anterior chamber depth; and, funduscopically, the disc, macula, vessels, and retina. RESULTS: Faculty rated 88% to 90% of students as able to assess acuity, pupils, ductions, and fields, and 72% to 82% as able to visualize various parts of the fundus. Seventy-six percent of students felt comfortable after funduscopic training. In 364 analyzed chart notes, one VA was measured, and pupils were examined in 66% of notes, ductions in 54%, and fields in 3%. Only 11% of notes documented attempted funduscopy; <2% suggested actual visualization. In the Clinical Performance Examination, 32% of students accurately described some aspect of the disc, with an improvement to 84% of 38 students retested after brief ophthalmology training in year 4. Of 54 (56%) respondents to the exit questionnaire, 59% felt comfortable visualizing some aspect of the fundus. CONCLUSIONS: There is worrisome erosion of students' acquired screening skills across the third-year clerkships. Skill reinforcement in the fourth year yielded improved performance. Attention must be directed to reinforcing basic ophthalmology skills training within medical school curricula to assure competence of graduates.

California↗