CT data-based navigation for post-mortem biopsy-a feasibility study

INTRODUCTION: Recent advances in medical imaging have brought post-mortem minimally invasive computed tomography (CT) guided percutaneous biopsy to public attention. AIMS: The goal of the following study was to facilitate and automate post-mortem biopsy, to suppress radiation exposure to the investigator, as may occur when tissue sampling under computer tomographic guidance, and to minimize the number of needle insertion attempts for each target for a single puncture. METHODS AND MATERIALS: Clinically approved and post-mortem tested ACN-III biopsy core needles (14 gauge x 160 mm) with an automatic pistol device (Bard Magnum, Medical Device Technologies, Denmark) were used for probe sampling. The needles were navigated in gelatine/peas phantom, ex vivo porcine model and subsequently in two human bodies using a navigation system (MEM centre/ISTB Medical Application Framework, Marvin, Bern, Switzerland) with guidance frame and a CT (Emotion 6, Siemens, Germany). RESULTS: Biopsy of all peas could be performed within a single attempt. The average distance between the inserted needle tip and the pea centre was 1.4mm (n=10; SD 0.065 mm; range 0-2.3 mm). The targets in the porcine liver were also accurately punctured. The average of the distance between the needle tip and the target was 0.5 mm (range 0-1 mm). Biopsies of brain, heart, lung, liver, pancreas, spleen, and kidney were performed on human corpses. For each target the biopsy needle was only inserted once. The examination of one body with sampling of tissue probes at the above-mentioned locations took approximately 45 min. CONCLUSIONS: Post-mortem navigated biopsy can reliably provide tissue samples from different body locations. Since the continuous update of positional data of the body and the biopsy needle is performed using optical tracking, no control CT images verifying the positional data are necessary and no radiation exposure to the investigator need be taken into account. Furthermore, the number of needle insertions for each target can be minimized to a single one with the ex vivo proven adequate accuracy and, in contrast to conventional CT guided biopsy, the insertion angle may be oblique. Navigation for minimally invasive tissue sampling is a useful addition to post-mortem CT guided biopsy.

[Navigation and robotics of the lateral skull base]

Computer-aided microscopic surgery of the lateral skull base is a rare intervention in daily practice. It is often a delicate and difficult minimally invasive intervention, since orientation between the petrous bone and the petrous bone apex is often challenging. In the case of aural atresia or tumors the normal anatomical landmarks are often absent, making orientation more difficult. Navigation support, together with imaging techniques such as CT, MR and angiography, enable the surgeon in such cases to perform the operation more accurately and, in some cases, also in a shorter time. However, there are no internationally standardised indications for navigated surgery on the lateral skull base. Miniaturised robotic systems are still in the initial validation phase.

Exploiting Runtime Information in the IDE

Developers rely on the mechanisms provided by their IDE to browse and navigate a large software system. These mechanisms are usually based purely on a system's static source code. The static perspective, however, is not enough to understand an object-oriented program's behavior, in particular if implemented in a dynamic language. We propose to enhance IDEs with a program's runtime information (eg. message sends and type information) to support program comprehension through precise navigation and informative browsing. To precisely specify the type and amount of runtime data to gather about a system under development, dynamically and on demand, we adopt a technique known as partial behavioral reflection. We implemented navigation and browsing enhancements to an IDE that exploit this runtime information in a prototype called Hermion. We present preliminary validation of our experimental enhanced IDE by asking developers to assess its usefulness to understand an unfamiliar software system.

Augmenting Static Source Views in IDEs with Dynamic Metrics

Mainstream IDEs such as Eclipse support developers in managing software projects mainly by offering static views of the source code. Such a static perspective neglects any information about runtime behavior. However, object-oriented programs heavily rely on polymorphism and late-binding, which makes them difficult to understand just based on their static structure. Developers thus resort to debuggers or profilers to study the system's dynamics. However, the information provided by these tools is volatile and hence cannot be exploited to ease the navigation of the source space. In this paper we present an approach to augment the static source perspective with dynamic metrics such as precise runtime type information, or memory and object allocation statistics. Dynamic metrics can leverage the understanding for the behavior and structure of a system. We rely on dynamic data gathering based on aspects to analyze running Java systems. By solving concrete use cases we illustrate how dynamic metrics directly available in the IDE are useful. We also comprehensively report on the efficiency of our approach to gather dynamic metrics.

Tackling Software Navigation Issues of the Smalltalk IDE

The IDE used in most Smalltalk dialects such as Pharo, Squeak or Cincom Smalltalk did not evolve significantly over the last years, if not to say decades. For other languages, for instance Java, the available IDEs made tremendous progress as Eclipse or NetBeans illustrate. While the Smalltalk IDE served as an exemplar for many years, other IDEs caught up or even overtook the erstwhile leader in terms of feature-richness, usability, or code navigation facilities. In this paper we first analyze the difficulty of software navigation in the Smalltalk IDE and second illustrate with concrete examples the features we added to the Smalltalk IDE to fill the gap to modern IDEs and to provide novel, improved means to navigate source space. We show that thanks to the agility and dynamics of Smalltalk, we are able to extend and enhance with reasonable effort the Smalltalk IDE to better support software navigation, program comprehension, and software maintenance in general. One such support is the integration of dynamic information into the static source views we are familiar with. Other means include easing the access to static information (for instance by better arranging important packages) or helping developers re-locating artifacts of interest (for example with a categorization system such as smart groups).

Autumn Leaves: Curing the Window Plague in IDEs

Navigating large software systems is difficult as the various artifacts are distributed in a huge space, while the relationships between different artifacts often remain hidden and obscure. As a consequence, developers using a modern interactive development environment (IDE) are forced to open views on numerous source artifacts to reveal these hidden relationships, leading to a crowded workspace with many opened windows or tabs. Developers often lose the overview in such a cluttered workspace as IDEs provide little support to get rid of unused windows. AutumnLeaves automatically selects windows unlikely for future use to be closed or grayed out while important ones are displayed more prominently. This reduces the number of windows opened at a time and adds structure to the developer's workspace. We validate AutumnLeaves with a benchmark evaluation using recorded navigation data of various developers to determine the prediction quality of the employed algorithms.

[Second victim : Critical incident stress management in clinical medicine]

BACKGROUND Critical incidents in clinical medicine can have far-reaching consequences on patient health. In cases of severe medical errors they can seriously harm the patient or even lead to death. The involvement in such an event can result in a stress reaction, a so-called acute posttraumatic stress disorder in the healthcare provider, the so-called second victim of an adverse event. Psychological distress may not only have a long lasting impact on quality of life of the physician or caregiver involved but it may also affect the ability to provide safe patient care in the aftermath of adverse events. METHODS A literature review was performed to obtain information on care giver responses to medical errors and to determine possible supportive strategies to mitigate negative consequences of an adverse event on the second victim. An internet search and a search in Medline/Pubmed for scientific studies were conducted using the key words "second victim, "medical error", "critical incident stress management" (CISM) and "critical incident stress reporting system" (CIRS). Sources from academic medical societies and public institutions which offer crisis management programs where analyzed. The data were sorted by main categories and relevance for hospitals. Analysis was carried out using descriptive measures. RESULTS In disaster medicine and aviation navigation services the implementation of a CISM program is an efficient intervention to help staff to recover after a traumatic event and to return to normal functioning and behavior. Several other concepts for a clinical crisis management plan were identified. CONCLUSIONS The integration of CISM and CISM-related programs in a clinical setting may provide efficient support in an acute crisis and may help the caregiver to deal effectively with future error events and employee safety.