Conceptual framework for the design, implementation and validation of psychomotor skills’ assessment systems in minimally invasive surgery

Las técnicas de cirugía de mínima invasión (CMI) se están consolidando hoy en día como alternativa a la cirugía tradicional, debido a sus numerosos beneficios para los pacientes. Este cambio de paradigma implica que los cirujanos deben aprender una serie de habilidades distintas de aquellas requeridas en cirugía abierta. El entrenamiento y evaluación de estas habilidades se ha convertido en una de las mayores preocupaciones en los programas de formación de cirujanos, debido en gran parte a la presión de una sociedad que exige cirujanos bien preparados y una reducción en el número de errores médicos. Por tanto, se está prestando especial atención a la definición de nuevos programas que permitan el entrenamiento y la evaluación de las habilidades psicomotoras en entornos seguros antes de que los nuevos cirujanos puedan operar sobre pacientes reales. Para tal fin, hospitales y centros de formación están gradualmente incorporando instalaciones de entrenamiento donde los residentes puedan practicar y aprender sin riesgos. Es cada vez más común que estos laboratorios dispongan de simuladores virtuales o simuladores físicos capaces de registrar los movimientos del instrumental de cada residente. Estos simuladores ofrecen una gran variedad de tareas de entrenamiento y evaluación, así como la posibilidad de obtener información objetiva de los ejercicios. Los diferentes estudios de validación llevados a cabo dan muestra de su utilidad; pese a todo, los niveles de evidencia presentados son en muchas ocasiones insuficientes. Lo que es más importante, no existe un consenso claro a la hora de definir qué métricas son más útiles para caracterizar la pericia quirúrgica. El objetivo de esta tesis doctoral es diseñar y validar un marco de trabajo conceptual para la definición y validación de entornos para la evaluación de habilidades en CMI, en base a un modelo en tres fases: pedagógica (tareas y métricas a emplear), tecnológica (tecnologías de adquisición de métricas) y analítica (interpretación de la competencia en base a las métricas). Para tal fin, se describe la implementación práctica de un entorno basado en (1) un sistema de seguimiento de instrumental fundamentado en el análisis del vídeo laparoscópico; y (2) la determinación de la pericia en base a métricas de movimiento del instrumental. Para la fase pedagógica se diseñó e implementó un conjunto de tareas para la evaluación de habilidades psicomotoras básicas, así como una serie de métricas de movimiento. La validación de construcción llevada a cabo sobre ellas mostró buenos resultados para tiempo, camino recorrido, profundidad, velocidad media, aceleración media, economía de área y economía de volumen. Adicionalmente, los resultados obtenidos en la validación de apariencia fueron en general positivos en todos los grupos considerados (noveles, residentes, expertos). Para la fase tecnológica, se introdujo el EVA Tracking System, una solución para el seguimiento del instrumental quirúrgico basado en el análisis del vídeo endoscópico. La precisión del sistema se evaluó a 16,33ppRMS para el seguimiento 2D de la herramienta en la imagen; y a 13mmRMS para el seguimiento espacial de la misma. La validación de construcción con una de las tareas de evaluación mostró buenos resultados para tiempo, camino recorrido, profundidad, velocidad media, aceleración media, economía de área y economía de volumen. La validación concurrente con el TrEndo® Tracking System por su parte presentó valores altos de correlación para 8 de las 9 métricas analizadas. Finalmente, para la fase analítica se comparó el comportamiento de tres clasificadores supervisados a la hora de determinar automáticamente la pericia quirúrgica en base a la información de movimiento del instrumental, basados en aproximaciones lineales (análisis lineal discriminante, LDA), no lineales (máquinas de soporte vectorial, SVM) y difusas (sistemas adaptativos de inferencia neurodifusa, ANFIS). Los resultados muestran que en media SVM presenta un comportamiento ligeramente superior: 78,2% frente a los 71% y 71,7% obtenidos por ANFIS y LDA respectivamente. Sin embargo las diferencias estadísticas medidas entre los tres no fueron demostradas significativas. En general, esta tesis doctoral corrobora las hipótesis de investigación postuladas relativas a la definición de sistemas de evaluación de habilidades para cirugía de mínima invasión, a la utilidad del análisis de vídeo como fuente de información y a la importancia de la información de movimiento de instrumental a la hora de caracterizar la pericia quirúrgica. Basándose en estos cimientos, se han de abrir nuevos campos de investigación que contribuyan a la definición de programas de formación estructurados y objetivos, que puedan garantizar la acreditación de cirujanos sobradamente preparados y promocionen la seguridad del paciente en el quirófano. Abstract Minimally invasive surgery (MIS) techniques have become a standard in many surgical sub-specialties, due to their many benefits for patients. However, this shift in paradigm implies that surgeons must acquire a complete different set of skills than those normally attributed to open surgery. Training and assessment of these skills has become a major concern in surgical learning programmes, especially considering the social demand for better-prepared professionals and for the decrease of medical errors. Therefore, much effort is being put in the definition of structured MIS learning programmes, where practice with real patients in the operating room (OR) can be delayed until the resident can attest for a minimum level of psychomotor competence. To this end, skills’ laboratory settings are being introduced in hospitals and training centres where residents may practice and be assessed on their psychomotor skills. Technological advances in the field of tracking technologies and virtual reality (VR) have enabled the creation of new learning systems such as VR simulators or enhanced box trainers. These systems offer a wide range of tasks, as well as the capability of registering objective data on the trainees’ performance. Validation studies give proof of their usefulness; however, levels of evidence reported are in many cases low. More importantly, there is still no clear consensus on topics such as the optimal metrics that must be used to assess competence, the validity of VR simulation, the portability of tracking technologies into real surgeries (for advanced assessment) or the degree to which the skills measured and obtained in laboratory environments transfer to the OR. The purpose of this PhD is to design and validate a conceptual framework for the definition and validation of MIS assessment environments based on a three-pillared model defining three main stages: pedagogical (tasks and metrics to employ), technological (metric acquisition technologies) and analytical (interpretation of competence based on metrics). To this end, a practical implementation of the framework is presented, focused on (1) a video-based tracking system and (2) the determination of surgical competence based on the laparoscopic instruments’ motionrelated data. The pedagogical stage’s results led to the design and implementation of a set of basic tasks for MIS psychomotor skills’ assessment, as well as the definition of motion analysis parameters (MAPs) to measure performance on said tasks. Validation yielded good construct results for parameters such as time, path length, depth, average speed, average acceleration, economy of area and economy of volume. Additionally, face validation results showed positive acceptance on behalf of the experts, residents and novices. For the technological stage the EVA Tracking System is introduced. EVA provides a solution for tracking laparoscopic instruments from the analysis of the monoscopic video image. Accuracy tests for the system are presented, which yielded an average RMSE of 16.33pp for 2D tracking of the instrument on the image and of 13mm for 3D spatial tracking. A validation experiment was conducted using one of the tasks and the most relevant MAPs. Construct validation showed significant differences for time, path length, depth, average speed, average acceleration, economy of area and economy of volume; especially between novices and residents/experts. More importantly, concurrent validation with the TrEndo® Tracking System presented high correlation values (>0.7) for 8 of the 9 MAPs proposed. Finally, the analytical stage allowed comparing the performance of three different supervised classification strategies in the determination of surgical competence based on motion-related information. The three classifiers were based on linear (linear discriminant analysis, LDA), non-linear (support vector machines, SVM) and fuzzy (adaptive neuro fuzzy inference systems, ANFIS) approaches. Results for SVM show slightly better performance than the other two classifiers: on average, accuracy for LDA, SVM and ANFIS was of 71.7%, 78.2% and 71% respectively. However, when confronted, no statistical significance was found between any of the three. Overall, this PhD corroborates the investigated research hypotheses regarding the definition of MIS assessment systems, the use of endoscopic video analysis as the main source of information and the relevance of motion analysis in the determination of surgical competence. New research fields in the training and assessment of MIS surgeons can be proposed based on these foundations, in order to contribute to the definition of structured and objective learning programmes that guarantee the accreditation of well-prepared professionals and the promotion of patient safety in the OR.

Brown trout redd superimposition in relation to spawning habitat availability

The relationship between redd superimposition and spawning habitat availability was investigated in the brown trout (Salmo trutta L.) population inhabiting the river Castril (Granada, Spain). Redd surveys were conducted in 24 river sections to estimate the rate of redd superimposition. Used and available microhabitat was evaluated to compute the suitable spawning habitat (SSH) for brown trout. After analysing the microhabitat characteristics positively selected by females, SSH was defined as an area that met all the following five requirements: water depth between 10 and 50 cm, mean water velocity between 30 and 60 cm s)1, bottom water velocity between 15 and 60 cm s)1, substrate size between 4 and 30 mm and no embeddedness. Simple regression analyses showed that redd superimposition was not correlated with redd numbers, SSH or redd density. A simulation-based analysis was performed to estimate the superimposition rate if redds were randomly placed inside the SSH. This analysis revealed that the observed superimposition rate was higher than expected in 23 of 24 instances, this difference being significant (P menor que 0.05) in eight instances and right at the limit of statistical significance (P = 0.05) in another eight instances. Redd superimposition was high in sections with high redd density. High superimposition however was not exclusive to sections with high redd density and was found in moderate- and low-redd-density sections. This suggests that factors other than habitat availability are also responsible for redd superimposition. We argue that female preference for spawning over previously excavated redds may be the most likely explanation for high superimposition at lower densities.

Organ-focused mutual information for nonrigid multimodal registration of liver CT and Gd–EOB–DTPA-enhanced MRI

Accurate detection of liver lesions is of great importance in hepatic surgery planning. Recent studies have shown that the detection rate of liver lesions is significantly higher in gadoxetic acid-enhanced magnetic resonance imaging (Gd–EOB–DTPA-enhanced MRI) than in contrast-enhanced portal-phase computed tomography (CT); however, the latter remains essential because of its high specificity, good performance in estimating liver volumes and better vessel visibility. To characterize liver lesions using both the above image modalities, we propose a multimodal nonrigid registration framework using organ-focused mutual information (OF-MI). This proposal tries to improve mutual information (MI) based registration by adding spatial information, benefiting from the availability of expert liver segmentation in clinical protocols. The incorporation of an additional information channel containing liver segmentation information was studied. A dataset of real clinical images and simulated images was used in the validation process. A Gd–EOB–DTPA-enhanced MRI simulation framework is presented. To evaluate results, warping index errors were calculated for the simulated data, and landmark-based and surface-based errors were calculated for the real data. An improvement of the registration accuracy for OF-MI as compared with MI was found for both simulated and real datasets. Statistical significance of the difference was tested and confirmed in the simulated dataset (p < 0.01).

Estimate of the total ice volume of Svalbard glaciers and their potential contribution to sea-level rise = Estimación del volumen de hielo de Svalbard y su contribución potencial a la subida del nivel del mar

El objetivo final de las investigaciones recogidas en esta tesis doctoral es la estimación del volumen de hielo total de los ms de 1600 glaciares de Svalbard, en el Ártico, y, con ello, su contribución potencial a la subida del nivel medio del mar en un escenario de calentamiento global. Los cálculos más exactos del volumen de un glaciar se efectúan a partir de medidas del espesor de hielo obtenidas con georradar. Sin embargo, estas medidas no son viables para conjuntos grandes de glaciares, debido al coste, dificultades logísticas y tiempo requerido por ellas, especialmente en las regiones polares o de montaña. Frente a ello, la determinación de áreas de glaciares a partir de imágenes de satélite sí es viable a escalas global y regional, por lo que las relaciones de escala volumen-área constituyen el mecanismo más adecuado para las estimaciones de volúmenes globales y regionales, como las realizadas para Svalbard en esta tesis. Como parte del trabajo de tesis, hemos elaborado un inventario de los glaciares de Svalbard en los que se han efectuado radioecosondeos, y hemos realizado los cálculos del volumen de hielo de más de 80 cuencas glaciares de Svalbard a partir de datos de georradar. Estos volúmenes han sido utilizados para calibrar las relaciones volumen-área desarrolladas en la tesis. Los datos de georradar han sido obtenidos en diversas campañas llevadas a cabo por grupos de investigación internacionales, gran parte de ellas lideradas por el Grupo de Simulación Numérica en Ciencias e Ingeniería de la Universidad Politécnica de Madrid, del que forman parte la doctoranda y los directores de tesis. Además, se ha desarrollado una metodología para la estimación del error en el cálculo de volumen, que aporta una novedosa técnica de cálculo del error de interpolación para conjuntos de datos del tipo de los obtenidos con perfiles de georradar, que presentan distribuciones espaciales con unos patrones muy característicos pero con una densidad de datos muy irregular. Hemos obtenido en este trabajo de tesis relaciones de escala específicas para los glaciares de Svalbard, explorando la sensibilidad de los parámetros a diferentes morfologías glaciares, e incorporando nuevas variables. En particular, hemos efectuado experimentos orientados a verificar si las relaciones de escala obtenidas caracterizando los glaciares individuales por su tamaño, pendiente o forma implican diferencias significativas en el volumen total estimado para los glaciares de Svalbard, y si esta partición implica algún patrón significativo en los parámetros de las relaciones de escala. Nuestros resultados indican que, para un valor constante del factor multiplicativo de la relacin de escala, el exponente que afecta al área en la relación volumen-área decrece según aumentan la pendiente y el factor de forma, mientras que las clasificaciones basadas en tamaño no muestran un patrón significativo. Esto significa que los glaciares con mayores pendientes y de tipo circo son menos sensibles a los cambios de área. Además, los volúmenes de la población total de los glaciares de Svalbard calculados con fraccionamiento en grupos por tamaño y pendiente son un 1-4% menores que los obtenidas usando la totalidad de glaciares sin fraccionamiento en grupos, mientras que los volúmenes calculados fraccionando por forma son un 3-5% mayores. También realizamos experimentos multivariable para obtener estimaciones óptimas del volumen total mediante una combinación de distintos predictores. Nuestros resultados muestran que un modelo potencial simple volumen-área explica el 98.6% de la varianza. Sólo el predictor longitud del glaciar proporciona significación estadística cuando se usa además del área del glaciar, aunque el coeficiente de determinación disminuye en comparación con el modelo más simple V-A. El predictor intervalo de altitud no proporciona información adicional cuando se usa además del área del glaciar. Nuestras estimaciones del volumen de la totalidad de glaciares de Svalbard usando las diferentes relaciones de escala obtenidas en esta tesis oscilan entre 6890 y 8106 km3, con errores relativos del orden de 6.6-8.1%. El valor medio de nuestras estimaciones, que puede ser considerado como nuestra mejor estimación del volumen, es de 7.504 km3. En términos de equivalente en nivel del mar (SLE), nuestras estimaciones corresponden a una subida potencial del nivel del mar de 17-20 mm SLE, promediando 19_2 mm SLE, donde el error corresponde al error en volumen antes indicado. En comparación, las estimaciones usando las relaciones V-A de otros autores son de 13-26 mm SLE, promediando 20 _ 2 mm SLE, donde el error representa la desviación estándar de las distintas estimaciones. ABSTRACT The final aim of the research involved in this doctoral thesis is the estimation of the total ice volume of the more than 1600 glaciers of Svalbard, in the Arctic region, and thus their potential contribution to sea-level rise under a global warming scenario. The most accurate calculations of glacier volumes are those based on ice-thicknesses measured by groundpenetrating radar (GPR). However, such measurements are not viable for very large sets of glaciers, due to their cost, logistic difficulties and time requirements, especially in polar or mountain regions. On the contrary, the calculation of glacier areas from satellite images is perfectly viable at global and regional scales, so the volume-area scaling relationships are the most useful tool to determine glacier volumes at global and regional scales, as done for Svalbard in this PhD thesis. As part of the PhD work, we have compiled an inventory of the radio-echo sounded glaciers in Svalbard, and we have performed the volume calculations for more than 80 glacier basins in Svalbard from GPR data. These volumes have been used to calibrate the volume-area relationships derived in this dissertation. Such GPR data have been obtained during fieldwork campaigns carried out by international teams, often lead by the Group of Numerical Simulation in Science and Engineering of the Technical University of Madrid, to which the PhD candidate and her supervisors belong. Furthermore, we have developed a methodology to estimate the error in the volume calculation, which includes a novel technique to calculate the interpolation error for data sets of the type produced by GPR profiling, which show very characteristic data distribution patterns but with very irregular data density. We have derived in this dissertation scaling relationships specific for Svalbard glaciers, exploring the sensitivity of the scaling parameters to different glacier morphologies and adding new variables. In particular, we did experiments aimed to verify whether scaling relationships obtained through characterization of individual glacier shape, slope and size imply significant differences in the estimated volume of the total population of Svalbard glaciers, and whether this partitioning implies any noticeable pattern in the scaling relationship parameters. Our results indicate that, for a fixed value of the factor in the scaling relationship, the exponent of the area in the volume-area relationship decreases as slope and shape increase, whereas size-based classifications do not reveal any clear trend. This means that steep slopes and cirque-type glaciers are less sensitive to changes in glacier area. Moreover, the volumes of the total population of Svalbard glaciers calculated according to partitioning in subgroups by size and slope are smaller (by 1-4%) than that obtained considering all glaciers without partitioning into subgroups, whereas the volumes calculated according to partitioning in subgroups by shape are 3-5% larger. We also did multivariate experiments attempting to optimally predict the volume of Svalbard glaciers from a combination of different predictors. Our results show that a simple power-type V-A model explains 98.6% of the variance. Only the predictor glacier length provides statistical significance when used in addition to the predictor glacier area, though the coefficient of determination decreases as compared with the simpler V-A model. The predictor elevation range did not provide any additional information when used in addition to glacier area. Our estimates of the volume of the entire population of Svalbard glaciers using the different scaling relationships that we have derived along this thesis range within 6890-8106 km3, with estimated relative errors in total volume of the order of 6.6-8.1% The average value of all of our estimates, which could be used as a best estimate for the volume, is 7,504 km3. In terms of sea-level equivalent (SLE), our volume estimates correspond to a potential contribution to sea-level rise within 17-20 mm SLE, averaging 19 _ 2 mm SLE, where the quoted error corresponds to our estimated relative error in volume. For comparison, the estimates using the V-A scaling relations found in the literature range within 13-26 mm SLE, averaging 20 _ 2 mm SLE, where the quoted error represents the standard deviation of the different estimates.

Clustering techniques for patients suffering acquired brain injury inneuro personal trainer

The study of the effectiveness of the cognitive rehabilitation processes and the identification of cognitive profiles, in order to define comparable populations, is a controversial area, but concurrently it is strongly needed in order to improve therapies. There is limited evidence about cognitive rehabilitation efficacy. Many of the trials conclude that in spite of an apparent clinical good response, differences do not show statistical significance. The common feature in all these trials is heterogeneity among populations. In this situation, observational studies on very well controlled cohort of studies, together with innovative methods in knowledge extraction, could provide methodological insights for the design of more accurate comparative trials. Some correlation studies between neuropsychological tests and patients capacities have been carried out -1---2- and also correlation between tests and morphological changes in the brain -3-. The procedures efficacy depends on three main factors: the affectation profile, the scheduled tasks and the execution results. The relationship between them makes up the cognitive rehabilitation as a discipline, but its structure is not properly defined. In this work we present a clustering method used in Neuro Personal Trainer (NPT) to group patients into cognitive profiles using data mining techniques. The system uses these clusters to personalize treatments, using the patients assigned cluster to select which tasks are more suitable for its concrete needs, by comparing the results obtained in the past by patients with the same profile.

Morphological Functions with Parallel Sets for the Pore Space of X-ray CT Images of Soil Columns

During the last few decades, new imaging techniques like X-ray computed tomography have made available rich and detailed information of the spatial arrangement of soil constituents, usually referred to as soil structure. Mathematical morphology provides a plethora of mathematical techniques to analyze and parameterize the geometry of soil structure. They provide a guide to design the process from image analysis to the generation of synthetic models of soil structure in order to investigate key features of flow and transport phenomena in soil. In this work, we explore the ability of morphological functions built over Minkowski functionals with parallel sets of the pore space to characterize and quantify pore space geometry of columns of intact soil. These morphological functions seem to discriminate the effects on soil pore space geometry of contrasting management practices in a Mediterranean vineyard, and they provide the first step toward identifying the statistical significance of the observed differences.