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Value of a cognitive simulation in medicine: towards optimizing decision making performance of healthcare personnel.

Medical errors can be reduced or avoided by training in both factual knowledge and in optimal information processing. The latter is of special importance when task settings are complex, when information about a patient's condition is ambiguous and uncertain, and when rapid changes can occur. Simulations can contribute to effective training in these areas of functioning without putting patients at risk. The strategic management simulation (SMS) has been used worldwide with many high level professionals. Its application to assessing and training medical decision makers is discussed.

Cognition↗

Does reduction of blood prolactin levels reveal the activation of central dopaminergic pathways conveying reward in top athletes?

Prolactin blood levels are modulated directly by CNS via the known tubero-infundibular dopaminergic neurons which exert an inhibitory action on lactotrope cells in the hypophysis. Prolactin is devoid of peripheral negative feedback and via lesser known central pathways (e.g., mesolimbic and mesocortical) might be further tuned by means of appropriate stimuli (e.g., addictive drugs, gambling, exercise and so forth). Therefore, a prolactin test can be utilised to obtain an objective index to assess the compliance to exercise in men. This index may be used to identify the most suitable athlete for a given sport and mainly to survey exercise as rewarding behaviour in trained people. Prolactin was assessed in male top world windsurfers (WS) and in a control group of non-windsurfer trained subjects (CS) during an exercise simulating marine windsurfing. The result was that prolactin levels decreased significantly in WS with respect to CS when compared with pre-test levels (WS: -22.7%; P<0.05).

Dopamine↗

Birth simulator: reliability of transvaginal assessment of fetal head station as defined by the American College of Obstetricians and Gynecologists classification.

OBJECTIVE: This study was undertaken to investigate the reliability of transvaginal assessment of fetal head station by using a newly designed birth simulator. STUDY DESIGN: This prospective study involved 32 residents and 25 attending physicians. Each operator was given all 11 possible fetal stations in random order. A fetal head mannequin was placed in 1 of the 11 American College of Obstetricians and Gynecologists (ACOG) stations (-5 to +5) in a birth simulator equipped with real-time miniaturized sensor. The operator then determined head position clinically using the ACOG classification. Head position was described as: (1) "engaged" or "nonengaged" (engagement code); (2) "high," "mid," "low," or "outlet" (group code); and (3) according to the 11 ACOG ischial spine stations (numerical code). Errors were defined as differences between the stations given by the sensor and by the operator. We determined the error rates for the 3 codes. RESULTS: "Numerical" errors occurred in 50% to 88% of cases for residents and in 36% to 80% of cases for attending physicians, depending on the position. The mean "group" error was 30% (95% CI 25%-35%) for residents and 34% (95% CI 27%-41%) for attending physicians. In most cases (87.5% for residents and 66.8% for attending physicians) of misdiagnosis of "high" station, the "mid" station was retained. Residents and attending physicians made an average of 12% of "engagement" errors, equally distributed between false diagnosis of engagement and nonengagement. CONCLUSION: Our results show that transvaginal assessment of fetal head station is poorly reliable, meaning clinical training should be promoted. The choice not to perform vaginal delivery when the fetus is in the "mid" position strongly decreases the risk of applying instruments on an undiagnosed "high" station. Conversely, obstetricians who perform only "low" operative vaginal deliveries also deliver unrecognized "mid" station fetuses. Therefore, residency programs should offer training in "mid" pelvic operative vaginal deliveries. Birth simulators could be used in training programs.

Delivery, Obstetric↗

The realization of a haptic (force feedback) interface device for the purpose of angioplasty surgery simulation.

Simulation is becoming an increasingly accepted method for training personnel for complex or high risk tasks. With the advent of modern Virtual Reality (VR) technology, such simulations are becoming more and more immersive. One significant limitation to the advance of this science is the challenges associated with simulating the touch or feel of various tasks in conjunction with VR simulations. This work has focused on creating and assessing the feasibility of haptic technology for high fidelity surgery simulation. It has culminated in a prototypical interface device to provide tactile feedback during the simulation of complex interventional radiology procedures such as Angioplasty. This device extends state of the art motion control, distributed computing processes, high resolution sensors for real-time feedback, and modular design techniques to accomplish these goals. The realization of the device, its capabilities, interfacing requirements, its limitations, and future extensions will be presented here.

Angioplasty, Balloon↗

Assessing a virtual reality surgical skills simulator.

The Institute for Defense Analyses (IDA) was contracted to perform a military standard task analysis of laparoscopic cholecystectomy, and to study the effectiveness of a virtual reality surgical skills simulator as a tool for surgical training and as a method for recording psychomotor behavior. This report describes the purpose of the study, its design, initial results, and implications for the field of medical education.

Cholecystectomy, Laparoscopic↗

[Anesthesia simulators: benefits and limits of experience gained at several European university hospitals].

Simulation has become essential in all situations where reality was too risky, too expensive, difficult to manage or inaccessible. In anaesthesia, the low rate of accidents and incidents, as well as the necessity to assure patient's safety, limit education and training in crisis management. The progress in data processing allowed the development of realistic anaesthesia simulators, associating the usual environment of an operating room, and made possible the simulation of a wide range of events. Most clinical incidents, mishaps, or manipulation errors can be simulated. A video recording allows the focus of attention on human factors. We assessed simulators in three European University hospitals. In Brussels as in Leiden, simulation was mainly used for training in crisis management. In Basel, the complete operating room staff participated in sessions, including also surgical simulation and improvement of communication within the team was one of the main goals. Simulation is valuable for residents' training, as well as continuing medical education, in crisis management and a better understanding of human factors. It remains without risk for the patient, with video possibilities improving the repetition of selected cases. However, its use for evaluation seems to be premature, due to the absence of studies demonstrating the validity and reproducibility of the results gained with simulation. Beyond technical limits which are amended continuously, the development of simulation is hindered by the very high cost of equipment and instructors.

Anesthesia↗

Intraosseous infusion: success of a standardized regional training program for prehospital advanced life support providers.

STUDY OBJECTIVE: To evaluate a standardized training program in intraosseous (IO) infusion for prehospital providers. DESIGN: Prospective multicenter 24-month study. SETTING: IO infusions were performed by prehospital providers from eight advanced life support units serving 14 hospitals within nine counties. PARTICIPANTS: Field advanced life support providers (paramedics and registered nurses). INTERVENTIONS: All providers participated in a one-hour standardized training session and supervised hands-on simulation. Providers completed a data sheet on all IO infusions performed. Data sheets were collected and summarized. RESULTS: One hundred thirty-four prehospital providers completed the training session and were approved to perform the procedure. Fifteen patients requiring IO infusion were encountered during the study period. Thirteen (87%) had IO infusion completed successfully. Clinical indications included 11 patients in cardiac arrest, two trauma resuscitations, one seizure, and one toxic ingestion. Patient ages ranged from 1 to 24 months. Seven patients were initially resuscitated. Four survived to hospital discharge. Procedural complications included one incidence of local fluid extravasation and one IO line that became dislodged en route. There were no complications at time of discharge in the four survivors. All procedures were performed in less than two minutes. CONCLUSION: A one-hour standardized training session was successfully used to train prehospital providers in the procedure of IO infusion. IO infusion then was implemented into their clinical practice with a satisfactory success rate and few complications.

Child, Preschool↗

[Various analogues of the second-signal behavior in monkeys during their symbolic "description" of properties of planimetric figures].

An attempt was made of experimental simulation of some components of the "second-signal" (verbal) behavior in rhesus monkeys (Macaca mulatta) under conditions of their "dialog" with a computer. Three monkeys were trained to perform manipulative actions on keyboard simulator to "describe" the properties of planimetric figures. For the period of research, the monkeys have learned to reproduce combinations of two symbols ("bigrams") that were used by them for a "description" up to 12 geometrical figures of various sizes. The data obtained indicate that rhesus monkeys are able not only to generalize the properties of a certain class of visual images at the perceptual level but also to use symbols for the description of these generalized properties.

Animals↗

Construct and face validity of MIST-VR, Endotower, and CELTS: are we ready for skills assessment using simulators?

BACKGROUND: Video trainers may best offer visually realistic laparoscopic simulation, whereas virtual reality (VR) modules may best provide multidimensional objective measures of performance. This study compares the construct and face validity of three different laparoscopic simulators. METHODS: Subjects were voluntarily enrolled at the Learning Center during the 2004 SAGES annual meeting. Each subject completed two repetitions of a single task on each of three simulators, MIST-VR, Endotower, and CELTS; performance scores were automatically generated and recorded. Scores of individuals with various levels of experience were compared to determine construct validity for each simulator. Experience was defined according to four parameters: (a) PGY level, (b) fellowship training, (c) basic laparoscopic cases, and (d) advanced laparoscopic cases. Subjects rated each simulator regarding six face validity (realism of simulation) parameters using a 10-point Likert scale (10 = best rating) and participant scores were compared to previously established expert scores (proficiency goals for training). RESULTS: Ninety-one attendees completed the study. Construct validity was demonstrated for all three simulators; significant differences in scores were detected according to one parameter for MIST-VR, two parameters for Endotower, and all four parameters for CELTS. Face validity was rated as good to excellent for all three simulators (7.0 +/- 0.3 for MIST-VR, 7.9 +/- 0.3 for Endotower [p < 0.001 vs MIST-VR], and 8.7 +/- 0.1 for CELTS [p = 0.001 vs MIST-VR, p = 0.01 vs Endotower]); 6%, 0%, and 36% of "expert" participants obtained expert scores on MIST-VR, Endotower, and CELTS, respectively. CONCLUSIONS: All three simulators demonstrated significant construct and reasonable face validity. Although virtual reality holds great promise to expand the scope of laparoscopic simulation, current interfaces may limit their utility for assessment. Computer-enhanced video trainers may offer an improved interface while incorporating useful multidimensional metrics. Further work is needed to establish standards for appropriate skills assessment methods and performance levels using simulators.

Adult↗

Force-feedback in Web-based surgical simulators.

There is a growing requirement in the field of surgical training to allow trainees to practice procedures in a way that does not place patients in any risk. Computer based simulators allow students to gain experience and develop three-dimensional awareness in a safe and controlled environment. Typically systems that have been developed to perform this task are, due to their specialist nature, expensive to buy. With the increasing availability of Force-Feedback devices for the gaming market, is there now a cost-effective alternative for surgical simulations? In this paper we investigate the possibility of using such a device as a haptic input tool for surgical simulations.

Computer Simulation↗

Cellular telephones and driving performance: the effects of attentional demands on motor vehicle crash risk.

This study examines the effects of conversation mode and split-attention communication training on driving performance. The study is based on an experiment where drivers with and without communication training (pilots vs. nonpilots) completed a simulated driving course while involved in one of three conversation modes: no conversation, conversation with passenger, or conversation on a hands-free cellular telephone. Results indicate that cellular telephone conversations consume more attention and interfere more with driving than passenger conversations. Cell phone conversations lack the nonverbal cues available during close-contact conversations and conversation participants expend significant cognitive resources to compensate for the lack of such cues. The results also demonstrate that communication training may reduce the hazardous effects of cell phone conversations on driving performance.

Journal Article↗

Perceptual adaptation by normally hearing listeners to a simulated "hole" in hearing.

Simulations of cochlear implants have demonstrated that the deleterious effects of a frequency misalignment between analysis bands and characteristic frequencies at basally shifted simulated electrode locations are significantly reduced with training. However, a distortion of frequency-to-place mapping may also arise due to a region of dysfunctional neurons that creates a "hole" in the tonotopic representation. This study simulated a 10 mm hole in the mid-frequency region. Noise-band processors were created with six output bands (three apical and three basal to the hole). The spectral information that would have been represented in the hole was either dropped or reassigned to bands on either side. Such reassignment preserves information but warps the place code, which may in itself impair performance. Normally hearing subjects received three hours of training in two reassignment conditions. Speech recognition improved considerably with training. Scores were much lower in a baseline (untrained) condition where information from the hole region was dropped. A second group of subjects trained in this dropped condition did show some improvement; however, scores after training were significantly lower than in the reassignment conditions. These results are consistent with the view that speech processors should present the most informative frequency range irrespective of frequency misalignment.

Adaptation, Physiological↗

Geometric and physical representations for a simulator of hepatic surgery.

Despite the large interest in simulators of minimally invasive surgery, it is still unclear to what extent simulators can achieve the task of training medical students in surgical procedures. The answer to that question is certainly linked to the realism of displays and force-feedback systems and to the level of interaction provided by the computer system. In this paper, we describe the virtual environment for anatomical and surgical training on the liver, currently under construction at INRIA. We specifically address the problems of geometric representation and physical modeling and their impact on the two aforementioned problems: realism and real-time interaction.

Computer Simulation↗

insilicoSV: a flexible grammar-based framework for structural variant simulation and placement.

SUMMARY: Structural variants (SVs) are key drivers of genetic variation and disease in the genome. Their discovery remains challenging, however, in large part due to the scarcity of validated SV callsets and comprehensive benchmarks, which are essential for method development and evaluation. The growing number of data-driven learning-based approaches for SV discovery, in particular, requires large, diverse, and well-balanced training datasets to achieve reliable performance. To address this need, SV simulation has served as a key tool for assessing method performance and training SV models. However, existing SV simulators only support a fixed and limited set of SV classes and do not provide fine-grained control over the placement of SVs within specific contexts of the genome. Here we present insilicoSV, a versatile framework for SV simulation, which models SVs using a simple and flexible grammar, allowing users to easily define standard and custom arbitrary genome rearrangements, as well as encode genome placement constraints. This design allows insilicoSV to naturally support new and bespoke SV types, such as the complex rearrangements of cancer genomes. In addition to grammar-based modeling, insilicoSV provides built-in support for 26 predefined SV types, placement of user-provided SVs, small variant simulation, streamlined workflows for the simulation of genome evolution and genome mixtures, read simulation, alignment, and visualization. These features enable the creation of comprehensive genomic datasets for a variety of downstream applications, such as in-depth benchmarking of alignment and variant calling methods, as well as training of data-driven learning-based approaches for SV detection. AVAILABILITY AND IMPLEMENTATION: insilicoSV is available under the MIT license at https://github.com/PopicLab/insilicoSV and https://doi.org/10.5281/zenodo.17402009.

Software↗

Cardiac arrest in the OR: how are our ACLS skills?

PURPOSE: While advanced cardiac life support (ACLS) training is widely available, it is not mandatory for all anaesthetists. We hypothesised that adherence to ACLS guidelines during resuscitation of ventricular fibrillation (VFib) as assessed in a simulator environment would be poor by anaesthetists not trained in ACLS compared with those who had received training. METHODS: With approval by the ethics review board, 89 subjects participated in the study. The simulation system consisted of a computer controlled mannequin with lifelike qualities set in a mock operating room. Each subject was given a test scenario that contained several standard anaesthetic problems. A VFib cardiac arrest occurred after approximately one hour into the simulation. A perfect score (score = A) defined complete compliance with the ACLS guidelines, whereas minor deviations (score = B) included changes in energy levels, drug doses or treatment order. The failure to discontinue the anaesthetic, defibrillate or administer epinephrine were considered major deviations (score = C). RESULTS: Eight subjects followed the ACLS guidelines (9%, score = A), while 27 subjects showed minor (30%, score = B) and 54 subjects major deviations (61%, score = C). Sixty-two of the 89 participants (70%) had taken the ACLS course and achieved higher scores than did anaesthetists without such training (P < 0.05). Forty-two participants (47%) did not discontinue the anaesthetic, 10 (11%) never gave epinephrine and 5 (6%) never used the defibrillator. CONCLUSION: Adherence to ACLS guidelines was poor. A greater proportion of subjects without previous ACLS training had deviations from protocol than did subjects who had received training. We need to consider ways to ensure that anaesthetists obtain and retain resuscitation skills according to ACLS guidelines.

Adult↗

Predictive validity of driving-simulator assessments following traumatic brain injury: a preliminary study.

OBJECTIVE: To evaluate whether driving simulator and road test evaluations can predict long-term driving performance, we conducted a prospective study on 11 patients with moderate to severe traumatic brain injury. Sixteen healthy subjects were also tested to provide normative values on the simulator at baseline. METHOD: At their initial evaluation (time-1), subjects' driving skills were measured during a 30-minute simulator trial using an automated 12-measure Simulator Performance Index (SPI), while a trained observer also rated their performance using a Driving Performance Inventory (DPI). In addition, patients were evaluated on the road by a certified driving evaluator. Ten months later (time-2), family members observed patients driving for at least 3 hours over 4 weeks and rated their driving performance using the DPI. RESULTS: At time-1, patients were significantly impaired on automated SPI measures of driving skill, including: speed and steering control, accidents, and vigilance to a divided-attention task. These simulator indices significantly predicted the following aspects of observed driving performance at time-2: handling of automobile controls, regulation of vehicle speed and direction, higher-order judgment and self-control, as well as a trend-level association with car accidents. Automated measures of simulator skill (SPI) were more sensitive and accurate than observational measures of simulator skill (DPI) in predicting actual driving performance. To our surprise, the road test results at time-1 showed no significant relation to driving performance at time-2. CONCLUSION: Simulator-based assessment of patients with brain injuries can provide ecologically valid measures that, in some cases, may be more sensitive than a traditional road test as predictors of long-term driving performance in the community.

Adolescent↗

Lead hopping using SVM and 3D pharmacophore fingerprints.

The combination of 3D pharmacophore fingerprints and the support vector machine classification algorithm has been used to generate robust models that are able to classify compounds as active or inactive in a number of G-protein-coupled receptor assays. The models have been tested against progressively more challenging validation sets where steps are taken to ensure that compounds in the validation set are chemically and structurally distinct from the training set. In the most challenging example, we simulate a lead-hopping experiment by excluding an entire class of compounds (defined by a core substructure) from the training set. The left-out active compounds comprised approximately 40% of the actives. The model trained on the remaining compounds is able to recall 75% of the actives from the "new" lead series while correctly classifying >99% of the 5000 inactives included in the validation set.

Computer Simulation↗

Validity of fixed-interval observations for postural assessment in construction work.

While observing six simulated construction tasks in the field, trained analysts recorded arm, trunk and leg postures categorically with two fixed-interval observational protocols. Observations were compared to measurements obtained with an electronic postural assessment system coupled with video analysis. The electronic postural assessment system consisted of electronic inclinometers to measure upper arm posture, knee flexion and trunk flexion, coveralls to house the inclinometer wiring, and an eletrogoniometric system to measure trunk lateral bending and twisting. Video analysis included frozen-frame analysis that corresponded to the moment of observation and simulated real-time analysis. Measurements were made on five male participants who each performed three tasks representative of construction laborers' work. Agreement among the observational and reference methods was generally high, although significant differences in measured frequency of exposure existed for knee flexion, trunk lateral bending and trunk twisting. The results suggest that, under appropriate conditions, discrete observations can be used to obtain reasonably accurate estimates of exposure frequency for broad categories of certain body postures.

Humans↗