Computer Assisted Learning in Obstetric Ultrasound

Ultrasound is a dynamic, real-time imaging modality that is widely used in clinical obstetrics. Simulation has been proposed as a training method, but how learners performance translates from the simulator to the clinic is poorly understood. Widely accepted, validated and objective measures of ultrasound competency have not been established for clinical practice. These are important because previous works have noted that some individuals do not achieve expert-like performance despite daily usage of obstetric ultrasound. Underlying foundation training in ultrasound was thought to be sub-optimal in these cases. Given the widespread use of ultrasound and the importance of accurately estimating the fetal weight for the management of high-risk pregnancies and the potential morbidity associated with iatrogenic prematurity or unrecognised growth restriction, reproducible skill minimising variability is of great importance. In this thesis, I will investigate two methods with the aim of improving training in obstetric ultrasound. The initial work will focus on quantifying operational performance. I collect data in the simulated and clinical environment to compare operator performance between novice and expert performance. In the later work I developed a mixed reality trainer to enhance trainee’s visualisation of how the ultrasound beam interacts with the anatomy being scanned. Mixed reality devices offer potential for trainees because they combine real-world items with items in the virtual world. In the training environment this allows for instructions, 3-dimensional visualisations or workflow instructions to be overlaid on physical models. The work is important because the techniques developed for the qualification of operator skill could be combined in future work with a training programme designed around educational theory to give trainee sonographers consistent feedback and instruction throughout their training

Augmented reality (AR) for surgical robotic and autonomous systems: State of the art, challenges, and solutions

Despite the substantial progress achieved in the development and integration of augmented reality (AR) in surgical robotic and autonomous systems (RAS), the center of focus in most devices remains on improving end-effector dexterity and precision, as well as improved access to minimally invasive surgeries. This paper aims to provide a systematic review of different types of state-of-the-art surgical robotic platforms while identifying areas for technological improvement. We associate specific control features, such as haptic feedback, sensory stimuli, and human-robot collaboration, with AR technology to perform complex surgical interventions for increased user perception of the augmented world. Current researchers in the field have, for long, faced innumerable issues with low accuracy in tool placement around complex trajectories, pose estimation, and difficulty in depth perception during two-dimensional medical imaging. A number of robots described in this review, such as Novarad and SpineAssist, are analyzed in terms of their hardware features, computer vision systems (such as deep learning algorithms), and the clinical relevance of the literature. We attempt to outline the shortcomings in current optimization algorithms for surgical robots (such as YOLO and LTSM) whilst providing mitigating solutions to internal tool-to-organ collision detection and image reconstruction. The accuracy of results in robot end-effector collisions and reduced occlusion remain promising within the scope of our research, validating the propositions made for the surgical clearance of ever-expanding AR technology in the future

Augmented Reality (AR) for Surgical Robotic and Autonomous Systems: State of the Art, Challenges, and Solutions

Despite the substantial progress achieved in the development and integration of augmented reality (AR) in surgical robotic and autonomous systems (RAS), the center of focus in most devices remains on improving end-effector dexterity and precision, as well as improved access to minimally invasive surgeries. This paper aims to provide a systematic review of different types of state-of-the-art surgical robotic platforms while identifying areas for technological improvement. We associate specific control features, such as haptic feedback, sensory stimuli, and human–robot collaboration, with AR technology to perform complex surgical interventions for increased user perception of the augmented world. Current researchers in the field have, for long, faced innumerable issues with low accuracy in tool placement around complex trajectories, pose estimation, and difficulty in depth perception during two-dimensional medical imaging. A number of robots described in this review, such as Novarad and SpineAssist, are analyzed in terms of their hardware features, computer vision systems (such as deep learning algorithms), and the clinical relevance of the literature. We attempt to outline the shortcomings in current optimization algorithms for surgical robots (such as YOLO and LTSM) whilst providing mitigating solutions to internal tool-to-organ collision detection and image reconstruction. The accuracy of results in robot end-effector collisions and reduced occlusion remain promising within the scope of our research, validating the propositions made for the surgical clearance of ever-expanding AR technology in the future

Mobile Augmented Reality: User Interfaces, Frameworks, and Intelligence

Mobile Augmented Reality (MAR) integrates computer-generated virtual objects with physical environments for mobile devices. MAR systems enable users to interact with MAR devices, such as smartphones and head-worn wearables, and perform seamless transitions from the physical world to a mixed world with digital entities. These MAR systems support user experiences using MAR devices to provide universal access to digital content. Over the past 20 years, several MAR systems have been developed, however, the studies and design of MAR frameworks have not yet been systematically reviewed from the perspective of user-centric design. This article presents the first effort of surveying existing MAR frameworks (count: 37) and further discuss the latest studies on MAR through a top-down approach: (1) MAR applications; (2) MAR visualisation techniques adaptive to user mobility and contexts; (3) systematic evaluation of MAR frameworks, including supported platforms and corresponding features such as tracking, feature extraction, and sensing capabilities; and (4) underlying machine learning approaches supporting intelligent operations within MAR systems. Finally, we summarise the development of emerging research fields and the current state-of-the-art, and discuss the important open challenges and possible theoretical and technical directions. This survey aims to benefit both researchers and MAR system developers alike.Peer reviewe

Evaluation of the Diagnostic Performance of Lung Ultrasound Compared to Chest X-rays for Diagnosis of Pneumonia in Children

Pneumonia remains a global health priority in children. It is the leading cause of death in children outside the neonatal period, over 90% of which occur in low-resource settings, and a major cause of morbidity, accounting for over 100 million episodes globally each year. Early, correct diagnosis is a modifiable factor which can potentially improve pneumonia outcomes. Current guidelines recommend the use of clinical signs and symptoms alone to make a diagnosis of pneumonia in low risk, ambulatory cases with clinically mild disease. However, clinical diagnosis lacks specificity and may lead to antibiotic overuse and drive antibiotic resistance. Addition of chest X-ray (CXR) to diagnostic algorithms improves specificity, but CXR use is limited by radiation exposure and relatively high costs, limiting access in low-resource settings. Current guidelines therefore reserve CXR for moderate to severe disease and hospitalised cases, even in well-resourced settings. Lung ultrasound (LUS) is a promising imaging modality which uses no radiation, is less costly than CXR and can improve the time to results when used as a point-of-care tool by clinicians outside the radiology department. These characteristics make LUS, at least theoretically, a potential option either as add-on screening test aimed at decreasing unnecessary antibiotic prescription or as a lower risk, lower cost definitive diagnostic test capable of replacing CXR, or both. The objective of this study was to understand the role of LUS as a diagnostic test for pneumonia in children by performing a structured literature review and metaanalysis summarizing the current evidence comparing diagnostic performance of LUS and CXR, and by reporting previously unpublished data from the Drakenstein Child Health Study comparing diagnostic performance of LUS and CXR for pneumonia in children in a resource-constrained, African setting

Is Stratification of "Low-Risk" Women with Gestational Diabetes Mellitus to Usual Antenatal Care Safe?

Introduction: Gestational Diabetes Mellitus (GDM) patients are stratified into low-risk and high-risk groups in Canberra, Australia, according to whether their glycaemic control reaches the target levels with lifestyle measures only. High-risk patients, in whom glycaemic control is unsatisfactory, are referred to a multidisciplinary “diabetes in pregnancy” team, while low-risk patients continue regular antenatal care. The aims of this study were to test the accuracy of the current stratification system of GDM treatment in Canberra, and to access whether low-risk patients have satisfactory perinatal outcomes compared to the high-risk patients, considering their less intensive antenatal care. Methods: A retrospective clinical audit of GDM patients treated between 01/01/2010 and 30/06/2014 was conducted. Maternal demographic data and neonatal/maternal clinical outcomes data were analysed including, for key outcomes, comparison with outcomes for the background population in the ACT. Results: Low-risk (n=509) compared to high-risk (n=466) GDM mothers were younger (31.7±4.8 vs 32.6±5.3 years-old, p=0.009), leaner [body mass index (BMI) 26.3±6.7 vs 29.3±7.5 kg/m2, p<0.001], and less parous (0.73±1.0 vs 0.98±1.2 times, p<0.001), with less past GDM (13.2% vs 23.2%, p<0.001), less family history of diabetes (55.4% vs 67.0%, p=0.001), and a lower fasting glucose level in the oral glucose tolerance test (OGTT) (4.9±0.5 mmol/l vs 5.0±0.8 mmol/l, p<0.001). There were more South-East Asian women in the low-risk group (19.4% vs 11.9%, p=0.002). Low-risk mothers had lower rates of pregnancy-induced hypertension (PIH) (6.1% vs 11.8%, p=0.002; ACT 5.7%), induced labour (23.2% vs 50.6%, p<0.001) and elective Caesarean-section (CS) (14.1% vs 20.4%, p=0.010). Rates of emergency CS were similar in the low- and high-risk groups (16.7% vs 19.1%, p=0.328; ACT 14.9%). The rate of preterm delivery (delivery before 37 weeks gestation) was higher in the low-risk group, (9.8% vs 6.0%, p=0.014; ACT 8.3%), attributed to a higher rate of spontaneous preterm delivery (6.1% vs 2.6%, p=0.010). After adjusting for maternal age, BMI, parity, smoking status and alcohol consumption during pregnancy, premature delivery was still more likely in the low-risk group (odds ratio 1.897, 95% Confidence Interval 1.137-3.164). For neonatal outcomes, there were no differences in rates of babies with birth weight >4000g (5.5% vs 7.1%, p=0.309; ACT 11.8%), shoulder dystocia (1.6% vs 1.5%, p=0.930), hypoglycaemia (6.1% vs 7.1%, p=0.532), respiratory disorder (6.3% vs 6.0%, p=0.857), and hyperbilirubinaemia (8.8% vs 10.7%, p=0.320). There was a trend towards a lower rate of customized large for gestational age infants (cLGA) in the low-risk group, compared to the high-risk group (6.1% vs. 9.4%, p= 0.050). The rate of neonatal admission to the intensive care unit (NICU)/special care nursery (SCN) was higher in the low-risk group (16.7% vs 10.9%, p=0.010; ACT 14.7%). However, this difference might have been attributed to the different NICU/SCN admission criteria adopted by the two evaluated hospitals. Conclusion: The stratification system is efficient: low-risk compared to high risk patients were younger, leaner, and had less past GDM, less family history of diabetes and lower fasting glucose during the OGTT. Adverse pregnancy outcomes were either less (PIH, delivery interventions, cLGA) or similar (emergency CS and some neonatal complications) in the low compared to high risk group. One exception was a higher rate of preterm delivery among low-risk women. Some adverse neonatal outcomes for low-risk women were also higher than in the general ACT population. The treatment pathway of low-risk GDM patients has considerable merit, but requires further assessment and optimisation to ensure safety

Foretelling futures: dilemmas in neonatal neurology: a social science research project, 2002-2004

This end-of-project report has been written for the project funders, The Wellcome Trust, and for individuals who generously helped with the research. The report is also intended to be a background resource for readers who would like to know more details about the „foretelling futures‟ research, the context, aims and methods, and the neonatal units and families involved in the project. Most of the time on writing up the „foretelling futures‟ research has been devoted to writing papers for academic and professional journals, for several reasons: to publicise the research to a wide readership; to try to do justice to the wealth of data that has been gathered; to use the critical peer review process to enable us to write to higher standards; through publication, to join in long-standing international neonatal discussions; to show how social science observations and analyses can be relevant to current controversies, policy and practice. For these reasons, and perhaps unconventionally, the main part of this report, section 4, provides summaries of the journal papers that have been or are being written so far. The aim is to provide a guide to the range of findings that are emerging from the project, and to show how the papers relate together and fit into five themes: families in the NICU; babies‟ rights; sharing information, dilemmas and decisions; time; and knowledge. The brief summaries in this report are not given as alternatives to reading the papers, which explain issues in greater detail and with more examples that readers can interpret for themselves. Instead, the summaries are intended to encourage readers to refer to the journal articles. Section 2 shows that the protocol raised seven exploratory research questions. We received numerous varying, complicated, and sometimes contradictory responses to these questions from the practitioners and parents and the related multidisciplinary literature, and no simple answers. The journal papers go some way towards answering some of the questions. We have much more material from the observations and interviews that could provide further answers, if we had more time for analysis and writing of papers. Because each paper separately and at some length explores answers to one or more of the research questions, we have not tried to summarise the answers into a concluding section. Instead, section 5 gives a four-page summary about the whole project and some key findings

Teratology Primer-2nd Edition (7/9/2010)

Foreword: What is Teratology? “What a piece of work is an embryo!” as Hamlet might have said. “In form and moving how express and admirable! In complexity how infinite!” It starts as a single cell, which by repeated divisions gives rise to many genetically identical cells. These cells receive signals from their surroundings and from one another as to where they are in this ball of cells —front or back, right or left, headwards or tailwards, and what they are destined to become. Each cell commits itself to being one of many types; the cells migrate, combine into tissues, or get out of the way by dying at predetermined times and places. The tissues signal one another to take their own pathways; they bend, twist, and form organs. An organism emerges. This wondrous transformation from single celled simplicity to myriad-celled complexity is programmed by genes that, in the greatest mystery of all, are turned on and off at specified times and places to coordinate the process. It is a wonder that this marvelously emergent operation, where there are so many opportunities for mistakes, ever produces a well-formed and functional organism. And sometimes it doesn’t. Mistakes occur. Defective genes may disturb development in ways that lead to death or to malformations. Extrinsic factors may do the same. “Teratogenic” refers to factors that cause malformations, whether they be genes or environmental agents. The word comes from the Greek “teras,” for “monster,” a term applied in ancient times to babies with severe malformations, which were considered portents or, in the Latin, “monstra.” Malformations can happen in many ways. For example, when the neural plate rolls up to form the neural tube, it may not close completely, resulting in a neural tube defect—anencephaly if the opening is in the head region, or spina bifida if it is lower down. The embryonic processes that form the face may fail to fuse, resulting in a cleft lip. Later, the shelves that will form the palate may fail to move from the vertical to the horizontal, where they should meet in the midline and fuse, resulting in a cleft palate. Or they may meet, but fail to fuse, with the same result. The forebrain may fail to induce the overlying tissue to form the eye, so there is no eye (anophthalmia). The tissues between the toes may fail to break down as they should, and the toes remain webbed. Experimental teratology flourished in the 19th century, and embryologists knew well that the development of bird and frog embryos could be deranged by environmental “insults,” such as lack of oxygen (hypoxia). But the mammalian uterus was thought to be an impregnable barrier that would protect the embryo from such threats. By exclusion, mammalian malformations must be genetic, it was thought. In the early 1940s, several events changed this view. In Australia an astute ophthalmologist, Norman Gregg, established a connection between maternal rubella (German measles) and the triad of cataracts, heart malformations, and deafness. In Cincinnati Josef Warkany, an Austrian pediatrician showed that depriving female rats of vitamin B (riboflavin) could cause malformations in their offspring— one of the early experimental demonstrations of a teratogen. Warkany was trying to produce congenital cretinism by putting the rats on an iodine deficient diet. The diet did indeed cause malformations, but not because of the iodine deficiency; depleting the diet of iodine had also depleted it of riboflavin! Several other teratogens were found in experimental animals, including nitrogen mustard (an anti cancer drug), trypan blue (a dye), and hypoxia (lack of oxygen). The pendulum was swinging back; it seemed that malformations were not genetically, but environmentally caused. In Montreal, in the early 1950s, Clarke Fraser’s group wanted to bring genetics back into the picture. They had found that treating pregnant mice with cortisone caused cleft palate in the offspring, and showed that the frequency was high in some strains and low in others. The only difference was in the genes. So began “teratogenetics,” the study of how genes influence the embryo’s susceptibility to teratogens. The McGill group went on to develop the idea that an embryo’s genetically determined, normal, pattern of development could influence its susceptibility to a teratogen— the multifactorial threshold concept. For instance, an embryo must move its palate shelves from vertical to horizontal before a certain critical point or they will not meet and fuse. A teratogen that causes cleft palate by delaying shelf movement beyond this point is more likely to do so in an embryo whose genes normally move its shelves late. As studies of the basis for abnormal development progressed, patterns began to appear, and the principles of teratology were developed. These stated, in summary, that the probability of a malformation being produced by a teratogen depends on the dose of the agent, the stage at which the embryo is exposed, and the genotype of the embryo and mother. The number of mammalian teratogens grew, and those who worked with them began to meet from time to time, to talk about what they were finding, leading, in 1960, to the formation of the Teratology Society. There were, of course, concerns about whether these experimental teratogens would be a threat to human embryos, but it was thought, by me at least, that they were all “sledgehammer blows,” that would be teratogenic in people only at doses far above those to which human embryos would be exposed. So not to worry, or so we thought. Then came thalidomide, a totally unexpected catastrophe. The discovery that ordinary doses of this supposedly “harmless” sleeping pill and anti-nauseant could cause severe malformations in human babies galvanized this new field of teratology. Scientists who had been quietly working in their laboratories suddenly found themselves spending much of their time in conferences and workshops, sitting on advisory committees, acting as consultants for pharmaceutical companies, regulatory agencies, and lawyers, as well as redesigning their research plans. The field of teratology and developmental toxicology expanded rapidly. The following pages will show how far we have come, and how many important questions still remain to be answered. A lot of effort has gone into developing ways to predict how much of a hazard a particular experimental teratogen would be to the human embryo (chapters 9–19). It was recognized that animal studies might not prove a drug was “safe” for the human embryo (in spite of great pressure from legislators and the public to do so), since species can vary in their responses to teratogenic exposures. A number of human teratogens have been identified, and some, suspected of teratogenicity, have been exonerated—at least of a detectable risk (chapters 21–32). Regulations for testing drugs before market release have greatly improved (chapter 14). Other chapters deal with how much such things as population studies (chapter 11), post-marketing surveillance (chapter 13), and systems biology (chapter 16) add to our understanding. And, in a major advance, the maternal role of folate in preventing neural tube defects and other birth defects is being exploited (chapter 32). Encouraging women to take folic acid supplements and adding folate to flour have produced dramatic falls in the frequency of neural tube defects in many parts of the world. Progress has been made not only in the use of animal studies to predict human risks, but also to illumine how, and under what circumstances, teratogens act to produce malformations (chapters 2–8). These studies have contributed greatly to our knowledge of abnormal and also normal development. Now we are beginning to see exactly when and where the genes turn on and off in the embryo, to appreciate how they guide development and to gain exciting new insights into how genes and teratogens interact. The prospects for progress in the war on birth defects were never brighter. F. Clarke Fraser McGill University (Emeritus) Montreal, Quebec, Canad

Modelos de simulação clínica virtual : revisão de escopo

Orientador: Prof. Dr. Jorge Vinícius Cestari FelixCoorientador: Profª Drª Shirley BollerDissertação (mestrado) - Universidade Federal do Paraná, Setor de Ciências da Saúde, Programa de Pós-Graduação em Enfermagem. Defesa : Curitiba, 25/03/2022Inclui referências: p. 90-100Área de concentração: Prática Profissional de EnfermagemResumo: O objetivo deste presente estudo foi identificar quais modelos de simulação clínica virtual descritos na literatura científica são utilizados como estratégia de ensino em estudantes e profissionais de enfermagem. A simulação clínica, é uma técnica que substitui as experiências reais por experiências guiadas replicáveis permitindo aos estudantes e profissionais de enfermagem vivenciarem a representação de um acontecimento real. Uma vez que a simulação clínica virtual utiliza um computador de alto nível, fazendo com que essa técnica viabilize condições de maior segurança e autoconfiança do estudante durante sua formação teórica e prática, consolidando seus conhecimentos, habilidades e competências. Método: Revisão sistematizada do tipo Scoping Review, que consiste nas cinco etapas: (1) formulação da questão de pesquisa (2) identificação dos estudos relevantes; (3) seleção de estudos; (4) mapeamento de evidências científicas; (5) apresentação e interpretação dos resultados. As bibliotecas digitais e bases de dados escolhidas para este estudo foram: PubMed, Medline, Scielo, Scopus, BvS, Web of Science, Lilacs, Embase, Ebsco. Os descritores utilizados foram: Simulação/ Simulação clínica/ Simulação clínica virtual/ Realidade virtual /Treinamento por Simulação/ Treinamento com Simulação de Alta Fidelidade/ Simulação por Computador/ Estudante de Enfermagem/ Estratégias de ensino/ Educação. A coleta de dados ocorreu no período de 1° de maio até 1° de novembro do ano de 2020. Foram descritos os seguintes critérios de seleção: trabalhos de qualquer natureza que retratam estudos sob simulação clínica virtual em estudantes de enfermagem da graduação e pós-graduação; artigos publicados na literatura nacional e internacional nos idiomas português, inglês e espanhol dos últimos 20 anos, desde janeiro 2000 até agosto 2020, todos estes disponíveis online nas bases de dados consultados e aqueles que respondem ao problema ou questão de revisão. Os dados extraídos foram analisados e sintetizados narrativamente. Resultados: Dos 711 artigos recuperadas na busca, foram salvas para revisão e conteúdo, onde apenas 52 artigos duplicados e excluídas por não contribuírem com elementos para a análise temática desta revisão, 507 estudos foram excluídos com base no título e resumo, dos quais 152 foram selecionados, assim 99 estudos foram excluídos com base no conteúdo. Apenas 53 estudos atenderam os critérios de seleção para o estudo. Destes, 16 foram selecionados no Scopus, 17 no Medline/PubMed, 1 no Embase, 11 no Ebesco, 1 no BvS, 7 no Web Of Science e 5 no PubMed Central. Conclusão: Esta revisão de escopo fornece uma avaliação abrangente do uso de diferentes modelos de simulação clínica virtual no ensino de enfermagem, esses modelos podem melhorar o conhecimento de estudantes e profissionais de enfermagem. Em geral, o uso da simulação de realidade virtual deve ser considerado para aprimorar o conhecimento e como complemento a outras estratégias de simulação para melhorar a qualidade e a segurança da prática clínica. No entanto, a heterogeneidade e o risco de viés entre os estudos incluídos devem ser levados em consideração. Estudos de grande escala rigorosamente desenhados são necessários para confirmar ainda mais os resultados desta revisão.Abstract: The objective of this present study was to identify which virtual clinical simulation models described in the scientific literature are used as a teaching strategy for nursing students and professionals. Clinical simulation is a technique that replaces real experiences with replicable guided experiences, allowing nursing students and professionals to experience the representation of a real event. Since the virtual clinical simulation uses a high-level computer, making this technique possible conditions of greater security and self-confidence of the student during their theoretical and practical training, consolidating their knowledge, skills and competences. Method: Systematized review of the Scoping Review type, which consists of five steps: (1) formulation of the research question (2) identification of relevant studies; (3) selection of studies; (4) mapping of scientific evidence; (5) presentation and interpretation of results. The digital libraries and databases chosen for this study were: PubMed, Medline, Scielo, Scopus, BvS, Web of Science, Lilacs, Embase, Ebesco. The descriptors used were: Simulation / Clinical Simulation / Virtual Clinical Simulation / Virtual Reality / Training by Simulation / Training with High Fidelity Simulation / Computer Simulation / Nursing Student / Teaching Strategies / Education. Data collection took place from May 1st to November 1st, 2020. The following selection criteria were described: works of any nature that portray studies under virtual clinical simulation in undergraduate and graduate nursing students graduation; articles published in national and international literature in Portuguese, English and Spanish for the last 20 years, from January 2000 to August 2020, all of which are available online in the consulted databases and those that respond to the problem or review question. The extracted data were analyzed and synthesized narratively. Results: Of the 711 articles retrieved in the search, they were saved for review and content, where only 52 articles were duplicated and excluded for not contributing elements to the thematic analysis of this review, 507 studies were excluded based on title and abstract, of which 152 were selected, thus 99 studies were excluded based on content. Only 53 studies met the selection criteria for the study. Of these, 16 were selected from Scopus, 17 from Medline/PubMed, 1 from Embase, 11 from Ebesco, 1 from BvS, 7 from Web Of Science and 5 from PubMed Central. Conclusion: This scoping review provides a comprehensive assessment of the use of different virtual clinical simulation models in nursing education, these models can improve the knowledge of nursing students and professionals. In general, the use of virtual reality simulation should be considered to enhance knowledge and as a complement to other simulation strategies to improve the quality and safety of clinical practice. However, heterogeneity and risk of bias among included studies must be taken into account. Large-scale rigorously designed studies are needed to further confirm the results of this review