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PubMed2002

Moore's Law, disruptive technologies, and the clinician.

The advancement of technical power described by Moore's Law offers great potential for enabling more cost-effective medical devices and systems. However, progress has been slow. Many factors for this failure have been cited, including the anti-rational economic structure of healthcare and the complexity and long time scale of medical development. Christensen et al. suggest that "disruptive technologies" may circumvent some of these difficulties. "Disruptive Technologies" are defined as those that are established in one market, but then penetrate and overwhelm another market. These incursions are accelerated by economic factors, and capitalize on functionality, reliability, and advancements supported by the original market. Christensen has cited many examples from industrial and service businesses, but few examples can be found yet in healthcare. We argue that positive technology impacts in medicine occur most readily when innovators augment the skills of and collaborate with caregivers, rather than seeking to displace them. In the short term, a new approach may improve efficiency or quality. In the longer term, such approaches may obviate human tasks at lower-skill levels, and even permit task automation. One successful example has been the introduction of flexible monitoring for physiologic information. Systems for computer-aided diagnosis, which have failed to impact complex decision making, have succeeded in simpler specialty areas such as the interpretation of EKG's and mammograms, and may do the same with analysis of some pathology images. The next frontier may the operating room, and the adoption of such systemic technologies by caregivers in emergency medicine and general care may then have an even wider "disruptive" effect. Responding to time and cost pressures, and the desire to move care to the patient, other workers, such as radiologists, will drive the trend away from isolated, complex, large-scale devices, and toward integrated, modular, and simpler networked technologies. In summary, technological "push" will continue in the demanding cutting-edge application areas as always, but the "disruption" will occur through wider application of lower-cost technologies, pulled by the users. The capabilities described by Moore's Law will allow the advancements necessary to facilitate this dissemination of capability and its ultimate benefit, so long sought.

Cost-Benefit Analysis↗
PubMed2000

Real-time opto-electronic verification of patient position in breast cancer radiotherapy.

OBJECTIVE: The clinical application of an opto-electronic system for real-time three-dimensional (3D) control of patient position in breast cancer radiotherapy is described. The specific features of the motion analysis technology (shape recognition of passive markers) are detailed, and the outcomes of its clinical use for quantitative position control and immobility verification of the thoracic irradiation field during breast cancer treatment are reported. MATERIALS AND METHODS: The position control system is based on the ELITEtrade mark opto-electronic motion analyzer, which provides in real time the 3D coordinates of a set of passive markers (plastic hemispheres 3 mm in diameter) previously placed on selected landmarks on the patient's skin. The system-dedicated hardware performs marker recognition by means of 2D correlation of shape with a predefined marker modeling mask. This feature ensures a high accuracy, even with small marker dimensions, and successful analysis in a noisy environment (due to room light, reflexes, etc.). The patient repositioning control was based on a comparison between the current positions of the markers and a corresponding reference configuration. The resulting marker displacements were graphically displayed in real time for immediate control. This information was not provided to the operator as a repositioning tool. Instead, the kinematic data was stored for subsequent off-line analysis aimed at quantifying the different factors contributing to patient mis-positioning (initial repositioning errors, patient's breathing, and random movements) when conventional means for patient alignment (laser centering) and immobilization (casting techniques) are used. RESULTS: Clinical application of the system revealed median 3D localization errors for the directly controlled anatomical landmarks of around 4.5 mm. This value is proposed to represent the intrinsic accuracy of conventional laser-centering techniques in breast cancer radiotherapy, including the effects of patient body deformations. When the positional inaccuracies introduced by patients' respiration were also considered, the extent of the resulting 3D mis-positioning of the control points increased to median values of up to 8 mm. CONCLUSIONS: The reported clinical trial confirms the significant role that real-time opto-electronic motion analysis based on passive markers can have in augmenting the accuracy of patient repositioning and immobility verification in the radiotherapy of a non-rigid body area while also accounting for physiological movements. Evaluation of the data collected during each irradiation session for five patients provided valuable information concerning the optimization of the efficacy of traditional methods for patient centering and immobilization.

Breast Neoplasms↗
PubMed2000

There is more to monitoring a nuclear power plant than meets the eye.

A fundamental challenge in studying cognitive systems in context is how to move from the specific work setting studied to a more general understanding of distributed cognitive work and how to support it. We present a series of cognitive field studies that illustrate one response to this challenge. Our focus was on how nuclear power plant (NPP) operators monitor plant state during normal operating conditions. We studied operators at two NPPs with different control room interfaces. We identified strong consistencies with respect to factors that made monitoring difficult and the strategies that operators have developed to facilitate monitoring. We found that what makes monitoring difficult is not the need to identify subtle abnormal indications against a quiescent background, but rather the need to identify and pursue relevant findings against a noisy background. Operators devised proactive strategies to make important information more salient or reduce meaningless change, create new information, and off-load some cognitive processing onto the interface. These findings emphasize the active problem-solving nature of monitoring, and highlight the use of strategies for knowledge-driven monitoring and the proactive adaptation of the interface to support monitoring. Potential applications of this research include control room design for process control and alarm systems and user interfaces for complex systems.

Cognitive Science↗
PubMed2003

The ZEUS robotic system: experimental and clinical applications.

Laparoscopic procedures provide shorter hospitalization, less pain, better cosmetic results, and faster returns to normal than traditional surgery. Surgeons performing them, however, are hampered by lack of tridimensional view and haptic sense, and by remoteness; but this physical gap also allows robotic and computer interfaces. The computer digitizes surgical movements and images and modifies this information to filter out nonfinalized movements such as tremor, increasing dexterity and precision. Digitized information can also be transmitted to remote locations, allowing surgical care in remote or underserved areas, and enhancing surgical education. There are several robotic surgical systems available; this article reviews the experimental and clinical use of the ZEUS robotic system and discusses its possible role in the future operating room.

Animals↗
PubMed1995

[Air pollution by sevoflurane in operating room and serum and urine inorganic fluoride of anesthetists].

Since lower blood-gas partition coefficient of sevoflurane provides rapid induction and emergence from anesthesia, sevoflurane has been used widely for inhalational anesthesia. However, because higher minimum alveolar concentration of sevoflurane requires a large dosage of anesthetic than other volatile anesthetics, air pollution with sevoflurane in the operating room might be of great concern. Anesthetists may keep inhaling the low concentration of anesthetics every day, even though scavenging system is equipped in the operating room. The purpose of this study is to evaluate the effects on anesthetists of the low concentration of anesthetics by measuring the inorganic fluoride concentration in the urine and serum of anesthetists and operating room nurses. Healthy 29 anesthesiologists and two operating room nurses were studied. Informed consent was obtained. Inorganic fluoride ions in the serum and urine were measured. Simultaneously sevoflurane concentration in operating room was measured in three operating rooms, at two places in the corridor and in the recovery room. Sevoflurane concentrations in three operating rooms were 1.22 ppm, 2.13 ppm and 6.05 ppm respectively. Concentration in the recovery room was 0.544 ppm. Serum and urine concentrations of inorganic fluoride were 1.1 +/- 0.1 mumol.l-1 and 36.2 +/- 17.1 mumol.l-1, respectively (mean +/- SD). Serum concentration of inorganic fluoride was within normal ranges. Although it is possible that fluoride concentration in urine is influenced by urine volume and a half of fluoride deposits in bone, no abnormal values in urine were found in this study. These results suggest that long term exposure to low concentration of sevoflurane and isoflurane causes no significant increase in their metabolites in operating room staffs.

Adult↗
PubMed2005

Data-fusion display system with volume rendering of intraoperatively scanned CT images.

In this study we have designed and created a data-fusion display that has enabled volumetric MIP image navigation using intraoperative C-arm CT data in the operating room. The 3D volumetric data reflecting a patient's inner structure is directly displayed on the monitor through video images of the surgical field using a 3D optical tracking system, a ceiling-mounted articulating monitor, and a small size video camera mounted at the back of the monitor. The system performance was validated in an experiment carried out in the operating room.

Computer Graphics↗
PubMed1999

The role of image-guidance systems for head and neck surgery.

BACKGROUND: Although image-guidance systems have gained widespread acceptance for neurosurgical procedures, their role for extracranial surgery of the head and neck is yet to be defined. OBJECTIVES: To describe the authors' experience with image-guidance systems and to measure the effects of image-guided technology on the performance of minimally invasive otolaryngological procedures. DESIGN: Prospective cohort study. METHODS: Optical- and electromagnetic-based image-guidance systems were used during the performance of endoscopic surgery on patients with disease of the paranasal sinuses, orbit, skull base, and temporal bone (n = 79). Results were compared with those in control patients who underwent similar surgery without image guidance during the same period (n = 42). RESULTS: Intraoperative anatomical localization was accurate to within 2 mm at the start of surgery in all cases. Accuracy degraded by 0.89 +/- 0.20 mm (mean +/- SE) during the operative procedure. The use of an image-guidance system increased operating room time by a mean of 17.4 minutes per case (image-guidance group, 137.3 +/- 6.0 minutes [mean +/- SE]; control group, 119.9 +/- 5.7 minutes; P=.006) and increased hospital charges by approximately $496 per case. Intraoperative blood loss (image-guidance group, 178.4 +/- 18.0 mL [mean +/- SE]; control group, 149.4 +/- 20.1 mL) and complication rates (image-guidance group, 2.7%; control group, 4.7%) did not differ significantly between groups. CONCLUSIONS: Image-guidance systems can provide the head and neck surgeon with accurate information regarding anatomical localization in cases with poor surgical landmarks caused by extensive disease or prior surgery; however, the use of such systems is associated with increased operative time and expense.

Adolescent↗
PubMed2003

Intraoperative imaging in a comprehensive neuronavigation environment for minimally invasive brain tumour surgery.

BACKGROUND: Development of an image-guided operation theatre offering multimodal information for mini-invasive neurosurgical brain tumour operations. METHODS: A multi-purpose resistive low-field MR scanner with on-off capability, was installed in a radio frequency-shielded operating room with in-room control panel and display. Intraoperative ultrasound imaging with Doppler mode as needed is used to provide check-up image data between intraoperative MR-imaging sessions. Cortical stimulation and registration are performed during awake craniotomies. The neuronavigation systems are customised arm-based and passive optical. The navigation systems show the positions of the ultrasound probe, cortical stimulation electrode, biopsy needles, endoscope and other instruments on the intraoperative MR-images. FINDINGS: Since 1999, 70 patients (mean age 47, range 3-88 years) have been operated with intraoperative MR-guidance (including 10 tumour biopsies, 56 resections). Twenty-one patients (mean age 46, range 16-67 years) underwent awake craniotomy and tumour resection secured with cortical stimulation and usually preoperative fMR-imaging. The present operating environment offered useful multimodal information for surgery of brain tumours in critical locations. Surgical mortality was 0%, morbidity included 3 (4.3%) infections and 2 (2.9%) permanent hemiparesis. Further removal of tumour was continued in 17 cases (57%) out of the 30 cases where intraoperative MR imaging was used for controlling completeness of the resection.

Adolescent↗
PubMed2003

Labor costs incurred by anesthesiology groups because of operating rooms not being allocated and cases not being scheduled to maximize operating room efficiency.

UNLABELLED: Determination of operating room (OR) block allocation and case scheduling is often not based on maximizing OR efficiency, but rather on tradition and surgeon convenience. As a result, anesthesiology groups often incur additional labor costs. When negotiating financial support, heads of anesthesiology departments are often challenged to justify the subsidy necessary to offset these additional labor costs. In this study, we describe a method for calculating a statistically sound estimate of the excess labor costs incurred by an anesthesiology group because of inefficient OR allocation and case scheduling. OR information system and anesthesia staffing data for 1 yr were obtained from two university hospitals. Optimal OR allocation for each surgical service was determined by maximizing the efficiency of use of the OR staff. Hourly costs were converted to dollar amounts by using the nationwide median compensation for academic and private-practice anesthesia providers. Differences between actual costs and the optimal OR allocation were determined. For Hospital A, estimated annual excess labor costs were $1.6 million (95% confidence interval, $1.5-$1.7 million) and $2.0 million ($1.89-$2.05 million) when academic and private-practice compensation, respectively, was calculated. For Hospital B, excess labor costs were $1.0 million ($1.08-$1.17 million) and $1.4 million ($1.32-1.43 million) for academic and private-practice compensation, respectively. This study demonstrates a methodology for an anesthesiology group to estimate its excess labor costs. The group can then use these estimates when negotiating for subsidies with its hospital, medical school, or multispecialty medical group. IMPLICATIONS: We describe a new application for a previously reported statistical method to calculate operating room (OR) allocations to maximize OR efficiency. When optimal OR allocations and case scheduling are not implemented, the resulting increase in labor costs can be used in negotiations as a statistically sound estimate for the increased labor cost to the anesthesiology department.

Anesthesiology↗
PubMed2000

Room temperature magnetic quantum cellular automata

All computers process information electronically. A processing method based on magnetism is reported here, in which networks of interacting submicrometer magnetic dots are used to perform logic operations and propagate information at room temperature. The logic states are signaled by the magnetization direction of the single-domain magnetic dots; the dots couple to their nearest neighbors through magnetostatic interactions. Magnetic solitons carry information through the networks, and an applied oscillating magnetic field feeds energy into the system and serves as a clock. These networks offer a several thousandfold increase in integration density and a hundredfold reduction in power dissipation over current microelectronic technology.

Journal Article↗
PubMed2006

Gestalt operating room display design for perioperative team situation awareness.

The perioperative environment is a complex, high risk environment that requires real-time coordination by all perioperative team members and accurate, up-to-date information for situation assessment and decision-making. There is the need for a "Gestalt" holistic awareness of the perioperative environment to enable synthesis and contextualization of the salient information such as: patient information, case and procedure information, staff information, operative site view, physiological data, resource availability. One potential approach is to augment the medical toolkit with a large screen wall display that integrates and makes accessible information that currently resides in different data systems and care providers. The objectives are to promote safe workflows, team coordination and communication, and to enable diagnosis, anticipation of events, and information flow from upstream to downstream care providers. We used the human factors engineering design process to design and develop a display that provides a common operational picture for shared virtual perioperative team situation awareness to enhance patient safety.

Awareness↗
PubMed1986

Improving the operating room to increase revenues.

Hospitals often overlook the potential to increase revenues by improving operating rooms and attracting additional surgery. Administrators should respond to surgeons' dissatisfaction with services despite limitations and ambiguities imposed by the surgical suite's chain of command. Directors of surgery can overcome formal authority problems by establishing informal relationships with the chiefs of surgery and anesthesia. Monthly reports to administration on quality and performance standards can avoid difficulties and prompt timely solutions. Satisfied surgeons will increase admissions by directing elective surgery patients to the hospital. Administrators can conduct interviews with all surgical personnel or use questionnaires to identify problems, potential new surgeons, and suggestions for improvement. Other tasks are to analyze each surgical section's functions, accumulate data by specialty and surgeon to plan daily schedules, evaluate organization and staffing, and evaluate instrumentation and supplies. Block scheduling and surgical acuity systems help establish controls in these areas. Feedback systems ensure that personnel remain sensitive to surgeons' needs. A nurse should be assigned to each surgeon to communicate information about patients, and surgeons should be encouraged to complete forms after each surgery to identify deficiencies in procedures. Other incentives for surgeons include favorable OR scheduling arrangements, purchase of special equipment, and package pricing for certain procedures.

Anesthesia Department, Hospital↗
PubMed1996

Enhanced optical imaging of human gliomas and tumor margins.

One of the potential variables affecting the overall survival and quality of life of patients with intracranial gliomas is the extent of tumor resection that results in the smallest volume of residual disease. A technique involving enhanced optical imaging of human gliomas has the potential to localize tumors, identify tumor remaining at the resection margins, and determine the grade of the tumor. In a preliminary study involving nine patients undergoing surgery for the removal of intrinsic brain tumors, enhanced optical imaging was performed using indocyanine green as an intravenous contrast-enhancement agent. Optical images were obtained before and after injection of the indocyanine green. The studies in the nine patients showed differences in the dynamic optical signals among normal brain, low-grade astrocytomas, and malignant astrocytomas. Optical imaging of the resection margins in malignant tumors showed differences between adjacent normal tissue and remaining tumor tissue. Enhanced optical imaging of human gliomas using a contrast-enhancing dye, indocyanine green, provides a potential means to differentiate between normal brain and tumor tissue at the cortical surface and the depths of the resection margins. Having the ability to obtain real-time information and feedback in the operating room may allow neurosurgeons to maximize the extent of tumor resection while sparing normal brain and increasing the diagnostic accuracy of intraoperative biopsies. Enhanced optical imaging potentially could facilitate the accuracy and safety of surgery when tumors are removed at sites even outside the central nervous system.

Adult↗
PubMed1980

Systems theory and the anaesthetist.

The application of the various aspects of systems theory has increased steadily over the last 10 years and has proved useful in such diverse fields as surgical services (Spratt et al. 1974), public health (Haas 1974), education (Harrington 1966), nephrology (Bigelow et al. 1973), medical information (Davis 1973), behavior (Shooster 1974), internal medicine (Guyton et al. 1972), metaphysics (Gayer 1972), and sociology (Attinger & Millendorfer 1968). More recently, system analysis has been applied to anaesthetic systems in the engineering literature (Smith & Schwede 1972) and has begun to appear in the anaesthesia literature (Brown 1973). The anaesthetist in the operating room is part of a complex system. In its simplest form the latter involves the anaesthetist, the anaesthesia delivery system, the patient and the surgeon. This discussion is intended to introduce the anaesthetist to some of the terminology and techniques common to the systems analysis approach. Examples have been drawn from biological systems in man which have proved useful to describe in feedback control terms. Where possible, the examples used are those most relevant to anaesthesiology.

Anesthesia↗
PubMed1981

A physical assessment of the imaging performance of panel-type X-ray image intensifier.

The performance of a commercial panel-type X-ray image intensifier has been investigated by physical methods, both objective and subjective. The objective measurements show that the manufacturer's claims are justified, except perhaps in regard to contrast loss. The subjective measurements reveal that the conversion factor ("gain") of the device is such that dark-adaptation is not necessary, though best results are obtained in a nearly dark room. Hence the device confers a significant advantage, both in information and in dose to the patient, over traditional fluoroscopy. However, the conversion factor is nearly three orders of magnitude smaller than that of a conventional X-ray image-intensifier television system. Therefore, at modern fluoroscopic exposure rates, the eye is operating at light levels at which its own deficiencies set a limit to the perceptible information. To equal the performance of modern fluoroscopy the exposure rate to the intensifier must be increased to about 20 times the value customary in modern fluoroscopy. This can be done only by increasing the X-ray factors (kV and mA), resulting in a corresponding increase in dose to the patient of about one order of magnitude. Such an increase is in many circumstance unacceptable.

Evaluation Studies as Topic↗
PubMed1988

Computerized Anesthesia Personnel System.

CAPS, (Computerized Anesthesia Personnel System), is a personnel management system for a large anesthesia department. It is written in BASIC for the IBM PC or IBM-compatible computer using 2 or more 5 1/4 inch disk drives or a hard disk. CAPS is designed to facilitate assignment of up to 30 attending anesthesiologists, 40 residents, 15 CRNAs, 5 interns, 5 anesthesia assistants, and up to 15 medical students to the operating room schedule. The system supports part-time personnel, regular laboratory/office/reading days, and resident rotations inside the operating suite, outside the operating suite, and to secondary hospitals. CAPS generates an availability list each day, listing all persons available for the operating room and the rotations and call days assigned. It then lists all persons not available that day and the reason for the absence. CAPS also tracts vacation, meeting, administrative and compensatory time for all members of the department, and maintains an absence record for each person listing sick times and all other absences. CAPS generates a weekly staffing list showing days each person is available to the operating room and the total number of attendings, residents, CRNAs, and assistants available each day. This article discusses why the program was developed, how it was designed, and how well it has met the objectives of the designers.

Anesthesia Department, Hospital↗
PubMed2005

Augmented virtuality based on stereoscopic reconstruction in multimodal image-guided neurosurgery: methods and performance evaluation.

Displaying anatomical and physiological information derived from preoperative medical images in the operating room is critical in image-guided neurosurgery. This paper presents a new approach referred to as augmented virtuality (AV) for displaying intraoperative views of the operative field over three-dimensional (3-D) multimodal preoperative images onto an external screen during surgery. A calibrated stereovision system was set up between the surgical microscope and the binocular tubes. Three-dimensional surface meshes of the operative field were then generated using stereopsis. These reconstructed 3-D surface meshes were directly displayed without any additional geometrical transform over preoperative images of the patient in the physical space. Performance evaluation was achieved using a physical skull phantom. Accuracy of the reconstruction method itself was shown to be within 1 mm (median: 0.76 mm +/- 0.27), whereas accuracy of the overall approach was shown to be within 3 mm (median: 2.29 mm +/- 0.59), including the image-to-physical space registration error. We report the results of six surgical cases where AV was used in conjunction with augmented reality. AV not only enabled vision beyond the cortical surface but also gave an overview of the surgical area. This approach facilitated understanding of the spatial relationship between the operative field and the preoperative multimodal 3-D images of the patient.

Algorithms↗
PubMed2000

Virtual university applied to telesurgery: from teleeducation to telemanipulation.

UNLABELLED: PROBLEM/BACKGROUND: In order to improve patient care by minimal invasive surgery (MIS), we perfected a Virtual TeleSurgical University that allows for teleeducation, teleconcertation, surgical planning and telemanipulation, through new Virtual Reality and multimedia systems. TOOLS AND METHODS: The organization of this innovative school was federated around three major research programs. First, the TESUS program focused on the teletransmission of medical information, allowing for videoconferencing around the world and telementoring. Next, the WeBS-Surg program is a multimedia continuous surgical education system on internet, that allows for teleeducation and teleconcertation between world experts in MIS. Then, the MASTER program (Minimal Access Surgery by Telecommunications and Robotics) allowed the development of the third millenium Operating room. It included Virtual Reality systems that delineate automatically anatomical and pathological structures of a patients from him CT-scan, and that allow for an interactive surgical planning and force-feed-back simulation. It also included a telesurgical robot named Zeus controlled by surgeons through telemanipulation system. RESULTS: Tests and validation shows that all these systems improved all steps of the surgical procedure: preoperatively due to a better continuous education and a computer assisted surgical planning, and peroperatively due to teleconcertation, telementoring and telemanipulation systems. CONCLUSION: Revolutionary tools for minimal invasive surgery learning, planning and performing are all ready available. These tools represents the first prototype of the computer assisted tele-robotical surgery that will be the future of surgery.

Computer Simulation↗