Qualit?tsverbesserung von Koronardiagnostik und -intervention durch ?Virtual-Reality��-Simulation

Currently, more than 800,000 diagnostic procedures and 300,000 percutaneous coronary interventions are performed annually in 556 catheter laboratories in Germany. These numbers document the importance of training programs in interventional cardiology. However, this need is in sharp contrast to the time constraints for continuing medical education in Germany due to personnel and financial restrictions. A possible solution for this dilemma could be new training programs which partially supplement conventional clinical training by simulation-based medical education. Currently five virtual reality simulators for diagnostic procedures and percutaneous coronary interventions are available. These simulators provide a realistic hands-on training comparable to flight simulation in aviation.The simulator of choice for a defined training program depending on the underlying learning objectives could either be a simple mechanical model (for puncture training) or even a combination of virtual reality simulator and a full-scale mannequin (for team training and crisis resource management). For the selection of the adequate training program the basic skills of the trainee, the learning objectives and the underlying curriculum have to be taken into account. Absolutely mandatory for the success of simulation-based training is a dedicated teacher providing feedback and guidance. This teacher should be an experienced interventional cardiologist who knows both the simulator and the selected training cases which serve as a vehicle for transferring knowledge and skills.In this paper the potential of virtual reality simulation in cardiology will be discussed and the conditions which must be fulfilled to achieve quality improvement by simulation-based training will be defined.     

Virtual reality simulators for gastrointestinal endoscopy training

The use of simulators as educational tools for medical procedures is spreading rapidly and many efforts have been made for their implementation in gastrointestinal endoscopy training. Endoscopy simulation training has been suggested for ascertaining patient safety while positively influencing the trainees' learning curve. Virtual simulators are the most promising tool among all available types of simulators. These integrated modalities offer a human-like endoscopy experience by combining virtual images of the gastrointestinal tract and haptic realism with using a customized endoscope. From their first steps in the 1980s until today, research involving virtual endoscopic simulators can be divided in two categories: investigation of the impact of virtual simulator training in acquiring endoscopy skills and measuring competence. Emphasis should also be given to the financial impact of their implementation in endoscopy, including the cost of these state-of-theart simulators and the potential economic benefits from their usage. Advances in technology will contribute to the upgrade of existing models and the development of new ones; while further research should be carried out to discover new fields of application.     

Virtual reality simulators for gastrointestinal endoscopy training简

The use of simulators as educational tools for medical procedures is spreading rapidly and many efforts have been made for their implementation in gastrointestinal endoscopy training. Endoscopy simulation training has been suggested for ascertaining patient safety while positively influencing the trainees’ learning curve. Virtual simulators are the most promising tool among all available types of simulators. These integrated modalities offer a human-like endoscopy experience by combining virtual images of the gastrointestinal tract and haptic realism with using a customized endoscope. From their first steps in the 1980s until today, research involving virtual endoscopic simulators can be divided in two categories: investigation of the impact of virtual simulator training in acquiring endoscopy skills and measuring competence. Emphasis should also be given to the financial impact of their implementation in endoscopy, including the cost of these state-of-the-art simulators and the potential economic benefits from their usage. Advances in technology will contribute to the upgrade of existing models and the development of new ones; while further research should be carried out to discover new fields of application.     

What to consider when designing a laparoscopic colorectal training curriculum: a review of the literature

Multiple studies have demonstrated the benefits of laparoscopic colorectal surgery (LCS), but in several countries it has still not been widely adopted. LCS training is associated with several challenges, such as patient safety concerns and a steep learning curve. Current evidence may facilitate designing of efficient training curricula to overcome these challenges. Basic training with virtual reality simulators has witnessed meteoric advances and may be essential during the early parts of the learning curve. Cadaveric and animal model training still constitutes an indispensable training tool, due to a higher degree of difficulty and greater resemblance to real operative conditions. In addition, recent evidence favors the use of novel training paradigms, such as proficiency-based training, case selection and modular training. This review summarizes the recent advances in LCS training and provides the evidence for designing an efficient training curriculum to overcome the challenges of LCS training.     

The future of simulation technologies for complex cardiovascular procedures

Changing work practices and the evolution of more complex interventions in cardiovascular medicine are forcing a paradigm shift in the way doctors are trained. Implantable cardioverter defibrillator (ICD), trasncatheter aortic valve implantation (TAVI), carotid artery stenting (CAS), and acute stroke intervention procedures are forcing these changes at a faster pace than in other disciplines. As a consequence, cardiovascular medicine has had to develop a sophisticated understanding of precisely what is meant by 'training' and 'skill'. An evolving conclusion is that procedure training on a virtual reality (VR) simulator presents a viable current solution. These simulations should characterize the important performance characteristics of procedural skill that have metrics derived and defined from, and then benchmarked to experienced operators (i.e. level of proficiency). Simulation training is optimal with metric-based feedback, particularly formative trainee error assessments, proximate to their performance. In prospective, randomized studies, learners who trained to a benchmarked proficiency level on the simulator performed significantly better than learners who were traditionally trained. In addition, cardiovascular medicine now has available the most sophisticated virtual reality simulators in medicine and these have been used for the roll-out of interventions such as CAS in the USA and globally with cardiovascular society and industry partnered training programmes. The Food and Drug Administration has advocated the use of VR simulation as part of the approval of new devices and the American Board of Internal Medicine has adopted simulation as part of its maintenance of certification. Simulation is rapidly becoming a mainstay of cardiovascular education, training, certification, and the safe adoption of new technology. If cardiovascular medicine is to continue to lead in the adoption and integration of simulation, then, it must take a proactive position in the development of metric-based simulation curriculum, adoption of proficiency benchmarking definitions, and then resolve to commit resources so as to continue to lead this revolution in physician training.     

Achieving competency in bronchoscopy: Challenges and opportunities

Bronchoscopy education is undergoing significant changes in step with other medical and surgical specialties that seek to incorporate simulation‐based training and objective measurement of procedural skills into training programmes. Low‐ and high‐fidelity simulators are now available and allow learners to gain fundamental bronchoscopy skills in a zero‐risk environment. Testing trainees on simulators is currently possible by using validated assessment tools for both essential bronchoscopy and endobronchial ultrasound skills, and more tools are under development for other bronchoscopic techniques. Educational concepts including the ‘flipped classroom’ model and problem‐based learning exercises are increasingly used in bronchoscopy training programmes. These learner‐centric teaching modalities require well‐trained educators, which is possible thorough the expansion of existing faculty development programmes.     

Evolution of surgical skills training

Surgical training is changing: one hundred years of tradition is being challenged by legal and ethical concerns for patient safety, work hours restrictions, the cost of operating room time, and complications. Surgical simulation and skills training offers an opportunity to teach and practice advanced skills outside of the operating room environment before attempting them on living patients. Simulation training can be as straight forward as using real instruments and video equipment to manipulate simulated "tissue" in a box trainer. More advanced, virtual reality simulators are now available and ready for widespread use. Early systems have demonstrated their effectiveness and discriminative ability. Newer systems enable the development of comprehensive curricula and full procedural simulations. The Accreditation Council of Graduate Medical Education's (ACGME) has mandated the development of novel methods of training and evaluation. Surgical organizations are calling for methods to ensure the maintenance of skills, advance surgical training, and to credential surgeons as technically competent. Simulators in their current form have been demonstrated to improve the operating room performance of surgical residents. Development of standardized training curricula remains an urgent and important agenda, particularly for minimal invasive surgery. An innovative and progressive approach, borrowing experiences from the field of aviation, can provide the foundation for the next century of surgical training, ensuring the quality of the product. As the technology develops, the way we practice will continue to evolve, to the benefit of physicians and patients.     

Role of simulation in training the next generation of endoscopists

The use of simulation based training in endoscopy hasbeen increasingly described,simulation has the potential reduce the harm caused to patients by novicesperforming procedures,increase efficiency by reducingthe time needed to train in the clinical environment andincrease the opportunity to repeatedly practice rareprocedures as well as allowing the assessment of performance.Simulators can consist of mechanical devices,employ cadaveric animal tissue or use virtual realitytechnology.Simulators have been used to teach upperand lower gastrointestinal endoscopy as well as interventional procedures.This review reviews the currentlyavailable endoscopic simulators,and the evidence fortheir efficacy,demonstrating that the ability of simulators to differentiate between novice and expert endoscopists is well established.There is limited evidencefor improved patient outcome as a result of simulationtraining.We also consider how the environment withinwhich a simulation is placed can be manipulated toalter the learning achieved,broadening the scope ofsimulation to develop communication as well as technical skills.Finally the implications for future practice areconsidered; technology is likely improve the fidelity of simulators,increasing the potential for simulation to improve patient outcomes.The impact of the simulation environment,and the correct place of simulation within the training curriculum are both issues which need addressing.     

The compact Erlangen Active Simulator for Interventional Endoscopy: a prospective comparison in structured team‐training courses on ‘endoscopic hemostasis’ for doctors and nurses to the ‘Endo‐Trainer’ model

Background: In 1997 Hochberger and Neumann presented the ‘Erlangen Biosimulation Model’ (commercialized as the ‘Erlangen Endo‐Trainer’) at various national and international meetings. The new compactEASIE® is a simplified version of the original ‘Biosimulation Model’ (Endo‐Trainer) and is specially designed for easy handling. CompactEASIE is reduced in its features, focusing exclusively on fexible endoscopy training. The acceptance of training in endoscopic hemostasis is accepted by workshop participants, as evaluated by a questionnaire on both models. Methods: Eleven structured courses on endoscopic hemostasis for doctors and nurses organized by the same endoscopists from 3/1998 to 5/1999 were evaluated using one of both models. The questionnaires were filled in by 207/291 trainees (71%). The Endo‐Trainer was used in 4 (n?=?103) and the compactEASIE in 7 courses (n?=?104). Both simulators were equipped with identical types of specially prepared pig‐organ packages consisting of esophagus, stomach and duodenum, including artificial sewn‐in vessels, polyps and varices. Blood perfusion was done with a roller pump connected to the sewn‐in vessels and blood surrogate. All workshops were identical concerning the course structure: a 30‐min theoretical introduction on ulcer bleeding was followed by 2?h of practical training in injection techniques and hemoclip application. The second part of variceal therapy consisted of a 30‐min theoretical introduction prior to 2?h of practical training on sclerotherapy, band ligation and cyanoacrylate application. Finally, a questionnaire on the trainees' pre‐experience and their rating of the different workshop sections was handed out to each participant. Results: Previous endoscopic experience was comparable in both groups. The training in both simulators was highly accepted by the trainees (compactEASIE 95% excellent and good versus EASIE (Endo‐Trainer) 97%) and did not show any significant difference (P?=?0.493). Even in the assessment of the single techniques, no statistical difference was observed. Furthermore, the assessments of the closeness to reality and the endoscopic environment in both simulators were identical. Conclusions: Both simulators (Endo‐Trainer, compactEASIE) are excellent educational tools for interventional endoscopy with a high level of acceptance. The easy‐to‐handle, ‘lightweight’ compactEASIE is a significant, progress tool for the future.     

Auditorium of the future: e learning platform

Principles of surgical training have not changed, but methods of training are evolving very fast. Online tools are being adopted in both knowledge and skills training for surgical residents. As a result, to evaluate the outcome of these tools, online assessment is also developing. Knowledge resources are very diverse ranging from lectures, webinars, surgical videos to three-dimensional planning and printing. Skills resources include virtual reality simulators, remote skills training and interdisciplinary teamwork. Assessment of E-learning tools can be performed using online questions, task-based simulations, branching scenarios and online interviews/discussions. In thoracic surgery, video assisted thoracic surgery (VATS) lobectomy simulator has been developed and it appears to be an important tool for minimally invasive thoracic surgery education. Training programs incorporate e-Learning in their curriculum and online training and assessment will become an important part of thoracic surgical training as well.     

Multicenter, randomized, controlled trial of virtual-reality simulator training in acquisition of competency in colonoscopy

BACKGROUND: The GI Mentor is a virtual reality simulator that uses force feedback technology to create a realistic training experience. OBJECTIVE: To define the benefit of training on the GI Mentor on competency acquisition in colonoscopy. DESIGN: Randomized, controlled, blinded, multicenter trial. SETTING: Academic medical centers with accredited gastroenterology training programs. PATIENTS: First-year GI fellows. INTERVENTIONS: Subjects were randomized to receive 10 hours of unsupervised training on the GI Mentor or no simulator experience during the first 8 weeks of fellowship. After this period, both groups began performing real colonoscopies. The first 200 colonoscopies performed by each fellow were graded by proctors to measure technical and cognitive success, and patient comfort level during the procedure. MAIN OUTCOME MEASUREMENTS: A mixed-effects model comparison between the 2 groups of objective and subjective competency scores and patient discomfort in the performance of real colonoscopies over time. RESULTS: Forty-five fellows were randomized from 16 hospitals over 2 years. Fellows in the simulator group had significantly higher objective competency rates during the first 100 cases. A mixed-effects model demonstrated a higher objective competence overall in the simulator group (P < .0001), with the difference between groups being significantly greater during the first 80 cases performed. The median number of cases needed to reach 90% competency was 160 in both groups. The patient comfort level was similar. CONCLUSIONS: Fellows who underwent GI Mentor training performed significantly better during the early phase of real colonoscopy training.     

Learning models for endoscopic ultrasonography in gastrointestinal endoscopy

Endoscopic ultrasonography(EUS) has become a useful diagnostic and therapeutic modality in gastrointestinal endoscopy.However,EUS requires additional training since it requires simultaneous endoscopic manipulation and ultrasonographic interpretation.Obtaining adequate EUS training can be challenging since EUS is highly operator-dependent and training on actual patients can be associated with an increased risk of complications including inaccurate diagnosis.Therefore,several models have been developed to help facilitate training of EUS.The models currently available for EUS training include computer-based simulators,phantoms,ex vivo models,and live animal models.Although each model has its own merits and limitations,the value of these different models is rather complementary than competitive.However,there is a lack of objective data regarding the efficacy of each model with recommendations on the use of various training models based on expert opinion only.Therefore,objective studies evaluating the efficacy of various EUS training models on technical and clinical outcomes are still needed.     

Prospective randomized study on the use of a computer-based endoscopic simulator for training in esophagogastroduodenoscopy

Background and Aim:  Computer-based endoscopic simulators have been developed in recent years, and their usefulness has been reported. However, there is no blinded prospective randomized controlled study on esophagogastroduodenoscopy (EGD) training using virtual reality simulators. The present study aimed to assess the effectiveness of a computer-based simulator for basic training in EGD.
Methods:  The GI-Mentor II simulator was used. The subjects were 20 hospital medical residents. After receiving an explanation regarding the fundamentals of endoscopy, 10 trainees were each randomized into a simulator group and a non-simulator group. The simulator group received 5 h of training with the GI-Mentor II plus bedside training, while the non-simulator group received bedside training. Subsequently, each subject performed endoscopy twice for assessment. Performance was evaluated according to a five-grade scale for a total of 11 items.
Results:  The score was significantly higher in the skills required for insertion into the esophagus, passing from the esophagogastric junction (EGJ) to the antrum, passing through the pylorus, and examination of the duodenal bulb and the fornix.
Conclusions:  The performance of endoscopy was improved by 5 h of simulator training. The simulator was more effective with regard to the items related to manipulation skills. Computer-based simulator training in EGD is useful for beginners.     

Training simulators in digestive endoscopy

Advanced techniques, optimal patient care, and quality management are currently important topics in clinical medicine. The increasing numbers of minimally invasive procedures being carried out in gastroenterology and surgery, and the effects of the learning curve on complication rates with various procedures, have given rise a recently debate on training standards. Public awareness and increasing legal pressure to show and document competence have further contributed to the importance of training in interventional medicine. Although evidence-based medicine is rapidly becoming the gold standard for treatment modalities, responsibility for education-including the theoretical background, as well as acquiring and refining manual skills in gastrointestinal endoscopy--is still a matter for the individual physician. Practical skills are routinely acquired by practicing on patients, initially under the supervision of a senior endoscopist. The development of new endoscopy simulators has brought out the debate whether training in basic manual skills is better obtained outside the patient. This paper presents an overview of the training simulators currently available and issues associated with them.     

Computer-based virtual reality colonoscopy simulation improves patient-based colonoscopy performance

BACKGROUND:

Colonoscopy simulators that enable one to perform computer-based virtual colonoscopy now exist. However, data regarding the effectiveness of this virtual training are limited.

OBJECTIVE:

To determine whether virtual reality simulator training translates into improved patient-based colonoscopy performance.

METHODS:

The present study was a prospective controlled trial involving 18 residents between postgraduate years 2 and 4 with no previous colonoscopy experience. These residents were assigned to receive 16 h of virtual reality simulator training or no training. Both groups were evaluated on their first five patient-based colonoscopies. The primary outcome was the number of proctor ‘assists’ required per colonoscopy. Secondary outcomes included insertion time, depth of insertion, cecal intubation rate, proctor- and nurse-rated competence, and patient-rated pain.

RESULTS:

The simulator group required significantly fewer proctor assists than the control group (1.94 versus 3.43; P≤0.001), inserted the colonoscope further unassisted (43 cm versus 24 cm; P=0.003) and there was a trend to intubate the cecum more often (26% versus 10%; P=0.06). The simulator group received higher ratings of competence from both the proctors (2.28 versus 1.88 of 5; P=0.02) and the endoscopy nurses (2.56 versus 2.05 of 5; P=0.001). There were no significant differences in proctor-, nurse- or patient-rated pain, or attention to discomfort.

CONCLUSIONS:

Computer-based colonoscopy simulation in the initial stages of training improved novice trainees’ patient-based colonoscopy performance.     

Improving medical diagnoses by understanding how they are made

While a correct diagnosis is essential to appropriate patient management, scant attention is paid to the processes by which medical diagnoses are arrived at. While mismanagement may arise from a lack of relevant knowledge or the misuse of available data, this is probably uncommon. In many cases in which diagnistic errors occur, an initial faulty triggering of an inappropriate hypothesis is followed by a premature closure, excluding the search for further data that might be relevant to the diagnostic process. Often this is followed by anchoring, so that even when additional relevant data becomes available, the new information is ignored, and the original, faulty diagnosis is retained. Disturbingly, these errors may not be a reflection of lack of training or experience, and must be guarded against by even the most senior clinicians. Perhaps a systematic review of diagnostic accuracy should become a routine part of institutional quality assurance programmes.     

Using high-level models for modeling industrial machines in a virtual environment

The work presented in this paper deals with a platform independent model formalism for designing virtual reality applications. In our approach, we focused on industrial machine simulators design. The structure of an industrial machine model is composed by “Virtual Components” which corresponds to the physical industrial components of the machine and a control part which corresponds to the functional specification of the machine. Each virtual component is modeled by VRML model for geometry and by hybrid automata (HA) for behavior. The control part is modeled by Sequential Function Charts (SFC), as it is the case in the majority of industrial machines. Those SFC are translated to HA and composed with the virtual components HA. The whole HA model of the machine is then implemented in the generic virtual environment “OpenMASK” by specific software translation tools which was developed previously. This method makes virtual prototyping accessible by the specialists in the domain of industrial machine design domain In this paper, we describe the high level modeling method putting the accent on the coupling between the control part and the process and then we apply it in the case of an assembly machine.     

Telementoringineducationoflaparoscopicsurgeons:Anemergingtechnology

Laparoscopy, minimally invasive and minimal access surgery with more surgeons performing these ad-vanced procedures. We highlight in the review several key emerging technologies such as the telementor-ing and virtual reality simulators, that provide a solid ground for delivering surgical education to rural area and allow young surgeons a safety net and confidence while operating on a newly learned technique.     

To diet or not if you have inflammatory bowel disease

Liver surgery remains a difficult challenge in which preoperative data analysis and strategy definition may play a significant role in the success of the procedure. Medical image processing led to a major improvement of patient care by guiding the surgical gesture. From this initial data, new technologies of virtual reality and augmented reality can increase the potential of such images. The 3D modeling of the liver of patients from their CT scan or MRI thus allows an improved surgical planning. Simulation allows the procedure to be simulated preoperatively and offers the opportunity to train the surgical gesture before carrying it out. These three preoperative steps can be used intraoperatively thanks to the development of augmented reality, which consists of superimposing the preoperative 3D modeling of the patient onto the real intraoperative view of the patient and his/her organs. Augmented reality provides surgeons with a transparent view of the patient. This facilitated the intraoperative identification of the vascular anatomy and the control of the segmental arteries and veins in liver surgery, thus preventing intraoperative bleeding. It can also offer guidance due to the virtual improvement of their real surgical tools, which are tracked in real-time during the procedure. During the surgical procedure, augmented reality, therefore, offers surgeons a transparent view of their patient, which will lead to the automation of the most complex maneuvers. The new ways of processing and analyzing liver images have dramatically changed the approach to liver surgery.