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.

Supervised classification of minimally invasive surgery psychomotor competence based on instruments motion analysis

Background Objective assessment of psychomotor skills has become an important challenge in the training of minimally invasive surgical (MIS) techniques. Currently, no gold standard defining surgical competence exists for classifying residents according to their surgical skills. Supervised classification has been proposed as a means for objectively establishing competence thresholds in psychomotor skills evaluation. This report presents a study comparing three classification methods for establishing their validity in a set of tasks for basic skills’ assessment. Methods Linear discriminant analysis (LDA), support vector machines (SVM), and adaptive neuro-fuzzy inference systems (ANFIS) were used. A total of 42 participants, divided into an experienced group (4 expert surgeons and 14 residents with >10 laparoscopic surgeries performed) and a nonexperienced group (16 students and 8 residents with <10 laparoscopic surgeries performed), performed three box trainer tasks validated for assessment of MIS psychomotor skills. Instrument movements were captured using the TrEndo tracking system, and nine motion analysis parameters (MAPs) were analyzed. The performance of the classifiers was measured by leave-one-out cross-validation using the scores obtained by the participants. Results The mean accuracy performances of the classifiers were 71 % (LDA), 78.2 % (SVM), and 71.7 % (ANFIS). No statistically significant differences in the performance were identified between the classifiers. Conclusions The three proposed classifiers showed good performance in the discrimination of skills, especially when information from all MAPs and tasks combined were considered. A correlation between the surgeons’ previous experience and their execution of the tasks could be ascertained from results. However, misclassifications across all the classifiers could imply the existence of other factors influencing psychomotor competence.

Feasibility of controlling nitrification in predenitrification plants using DO, pH and ORP sensors

Experimental studies were carried out on a bench-scale nitrogen removal system with a predenitrification configuration to gain insights into the spatial and temporal variations of DO, pH and ORP in such systems. It is demonstrated that these signals correlate strongly with the operational states of the system, and could therefore be used as system performance indicators. The DO concentration in the first aerobic zone, when receiving constant aeration, and the net pH change between the last and first aerobic zones display strong correlations with the influent ammonia concentration for the domestic wastewater used in this study. The pH profile along the aerobic zones gives good indication on the extent of nitrification. The experimental results also showed a good correlation between ORP values in the last aerobic zone and effluent ammonia and nitrate concentrations, provided that DO in this zone is controlled at a constant level. These results suggest that the DO, pH and ORP sensors could potentially be used as alternatives to the on-line nutrient sensors for the control of continuous systems. An idea of using a fuzzy inference system to make an integrated use of these signals for on-line aeration control is presented and demonstrated on the bench-scale system with promising results. The use of these sensors has to date only been demonstrated in intermittent systems, such as sequencing batch reactor systems.

A computational model of prosody for Yorùbá text-to-speech synthesis

This work examines prosody modelling for the Standard Yorùbá (SY) language in the context of computer text-to-speech synthesis applications. The thesis of this research is that it is possible to develop a practical prosody model by using appropriate computational tools and techniques which combines acoustic data with an encoding of the phonological and phonetic knowledge provided by experts. Our prosody model is conceptualised around a modular holistic framework. The framework is implemented using the Relational Tree (R-Tree) techniques (Ehrich and Foith, 1976). R-Tree is a sophisticated data structure that provides a multi-dimensional description of a waveform. A Skeletal Tree (S-Tree) is first generated using algorithms based on the tone phonological rules of SY. Subsequent steps update the S-Tree by computing the numerical values of the prosody dimensions. To implement the intonation dimension, fuzzy control rules where developed based on data from native speakers of Yorùbá. The Classification And Regression Tree (CART) and the Fuzzy Decision Tree (FDT) techniques were tested in modelling the duration dimension. The FDT was selected based on its better performance. An important feature of our R-Tree framework is its flexibility in that it facilitates the independent implementation of the different dimensions of prosody, i.e. duration and intonation, using different techniques and their subsequent integration. Our approach provides us with a flexible and extendible model that can also be used to implement, study and explain the theory behind aspects of the phenomena observed in speech prosody.

The modelling of energy efficient drying for DSM (BL)

This thesis investigates the modelling of drying processes for the promotion of market-led Demand Side Management (DSM) as applied to the UK Public Electricity Suppliers. A review of DSM in the electricity supply industry is provided, together with a discussion of the relevant drivers supporting market-led DSM and energy services (ES). The potential opportunities for ES in a fully deregulated energy market are outlined. It is suggested that targeted industrial sector energy efficiency schemes offer significant opportunity for long term customer and supplier benefit. On a process level, industrial drying is highlighted as offering significant scope for the application of energy services. Drying is an energy-intensive process used widely throughout industry. The results of an energy survey suggest that 17.7 per cent of total UK industrial energy use derives from drying processes. Comparison with published work indicates that energy use for drying shows an increasing trend against a background of reducing overall industrial energy use. Airless drying is highlighted as offering potential energy saving and production benefits to industry. To this end, a comprehensive review of the novel airless drying technology and its background theory is made. Advantages and disadvantages of airless operation are defined and the limited market penetration of airless drying is identified, as are the key opportunities for energy saving. Limited literature has been found which details the modelling of energy use for airless drying. A review of drying theory and previous modelling work is made in an attempt to model energy consumption for drying processes. The history of drying models is presented as well as a discussion of the different approaches taken and their relative merits. The viability of deriving energy use from empirical drying data is examined. Adaptive neuro fuzzy inference systems (ANFIS) are successfully applied to the modelling of drying rates for 3 drying technologies, namely convective air, heat pump and airless drying. The ANFIS systems are then integrated into a novel energy services model for the prediction of relative drying times, energy cost and atmospheric carbon dioxide emission levels. The author believes that this work constitutes the first to use fuzzy systems for the modelling of drying performance as an energy services approach to DSM. To gain an insight into the 'real world' use of energy for drying, this thesis presents a unique first-order energy audit of every ceramic sanitaryware manufacturing site in the UK. Previously unknown patterns of energy use are highlighted. Supplementary comments on the timing and use of drying systems are also made. The limitations of such large scope energy surveys are discussed.

The psychosocial impact of an activity holiday for young children with severe food allergy:a longitudinal study

Background Food allergy has been shown to severely affect quality of life (QoL) in children and their families. The Anaphylaxis Campaign UK supports families with allergic children and as part of that support ran an activity holiday for those with food allergy. This study investigated the effectiveness of this activity holiday for reducing anxiety and improving QoL and food allergy management for these children. Methods Measures were taken at baseline, at the start of the activity holiday, at the end of the holiday, at 3 and 6 months follow-up. Children (n = 24) completed a paediatric food allergy–specific QoL questionnaire (PFA-QL), a generic QoL questionnaire (PedsQL™), the Spence Children's Anxiety Scale (SCAS) and the Children's Health Locus of Control (CHLC) scale at all stages of the study. Results There were significant improvements in social QoL, food allergy–specific QoL, total CHLC and internal locus of control scores over time (p > 0.05). There were significant decreases in powerful others locus of control, total anxiety and obsessive compulsive disorder scores (p < 0.05). Greater anxiety significantly correlated with poorer QoL at all time points; no correlations with locus of control were significant at the 3- and 6-month follow-up. Conclusions The activity holiday was of significant benefit to the children who took part, providing support for the need for activity holidays such as this for children with severe food allergy. Ways in which adaptive locus of control and improved quality of life can be facilitated need to be further explored.

Anisotropic opinion dynamics

We consider the process of opinion formation in a society of interacting agents, where there is a set B of socially accepted rules. In this scenario, we observed that agents, represented by simple feed-forward, adaptive neural networks, may have a conservative attitude (mostly in agreement with B) or liberal attitude (mostly in agreement with neighboring agents) depending on how much their opinions are influenced by their peers. The topology of the network representing the interaction of the society's members is determined by a graph, where the agents' properties are defined over the vertexes and the interagent interactions are defined over the bonds. The adaptability of the agents allows us to model the formation of opinions as an online learning process, where agents learn continuously as new information becomes available to the whole society (online learning). Through the application of statistical mechanics techniques we deduced a set of differential equations describing the dynamics of the system. We observed that by slowly varying the average peer influence in such a way that the agents attitude changes from conservative to liberal and back, the average social opinion develops a hysteresis cycle. Such hysteretic behavior disappears when the variance of the social influence distribution is large enough. In all the cases studied, the change from conservative to liberal behavior is characterized by the emergence of conservative clusters, i.e., a closed knitted set of society members that follow a leader who agrees with the social status quo when the rule B is challenged.

PCA-ANFIS based prediction for water Injection effectiveness cycle in oil fields.

By proposing a numerical based method on PCA-ANFIS(Adaptive Neuro-Fuzzy Inference System), this paper is focusing on solving the problem of uncertain cycle of water injection in the oilfield. As the dimension of original data is reduced by PCA, ANFIS can be applied for training and testing the new data proposed by this paper. The correctness of PCA-ANFIS models are verified by the injection statistics data collected from 116 wells inside an oilfield, the average absolute error of testing is 1.80 months. With comparison by non-PCA based models which average error is 4.33 months largely ahead of PCA-ANFIS based models, it shows that the testing accuracy has been greatly enhanced by our approach. With the conclusion of the above testing, the PCA-ANFIS method is robust in predicting the effectiveness cycle of water injection which helps oilfield developers to design the water injection scheme.

Data driven regularization models of non-linear ill-posed inverse problems in imaging

Imaging technologies are widely used in application fields such as natural sciences, engineering, medicine, and life sciences. A broad class of imaging problems reduces to solve ill-posed inverse problems (IPs). Traditional strategies to solve these ill-posed IPs rely on variational regularization methods, which are based on minimization of suitable energies, and make use of knowledge about the image formation model (forward operator) and prior knowledge on the solution, but lack in incorporating knowledge directly from data. On the other hand, the more recent learned approaches can easily learn the intricate statistics of images depending on a large set of data, but do not have a systematic method for incorporating prior knowledge about the image formation model. The main purpose of this thesis is to discuss data-driven image reconstruction methods which combine the benefits of these two different reconstruction strategies for the solution of highly nonlinear ill-posed inverse problems. Mathematical formulation and numerical approaches for image IPs, including linear as well as strongly nonlinear problems are described. More specifically we address the Electrical impedance Tomography (EIT) reconstruction problem by unrolling the regularized Gauss-Newton method and integrating the regularization learned by a data-adaptive neural network. Furthermore we investigate the solution of non-linear ill-posed IPs introducing a deep-PnP framework that integrates the graph convolutional denoiser into the proximal Gauss-Newton method with a practical application to the EIT, a recently introduced promising imaging technique. Efficient algorithms are then applied to the solution of the limited electrods problem in EIT, combining compressive sensing techniques and deep learning strategies. Finally, a transformer-based neural network architecture is adapted to restore the noisy solution of the Computed Tomography problem recovered using the filtered back-projection method.

Self-organising neural networks for adaptive control

Self-organizing neural networks have been implemented in a wide range of application areas such as speech processing, image processing, optimization and robotics. Recent variations to the basic model proposed by the authors enable it to order state space using a subset of the input vector and to apply a local adaptation procedure that does not rely on a predefined test duration limit. Both these variations have been incorporated into a new feature map architecture that forms an integral part of an Hybrid Learning System (HLS) based on a genetic-based classifier system. Problems are represented within HLS as objects characterized by environmental features. Objects controlled by the system have preset targets set against a subset of their features. The system's objective is to achieve these targets by evolving a behavioural repertoire that efficiently explores and exploits the problem environment. Feature maps encode two types of knowledge within HLS — long-term memory traces of useful regularities within the environment and the classifier performance data calibrated against an object's feature states and targets. Self-organization of these networks constitutes non-genetic-based (experience-driven) learning within HLS. This paper presents a description of the HLS architecture and an analysis of the modified feature map implementing associative memory. Initial results are presented that demonstrate the behaviour of the system on a simple control task.

PID autotuning using neural networks and model reference adaptive control

This paper describes the application of artificial neural networks for automatic tuning of PID controllers using the Model Reference Adaptive Control approach. The effectiveness of the proposed method is shown through a simulated application.

Transient stability analysis of electrical power systems using a neural network based on fuzzy ARTMAP

This work presents a methodology to analyze transient stability for electric energy systems using artificial neural networks based on fuzzy ARTMAP architecture. This architecture seeks exploring similarity with computational concepts on fuzzy set theory and ART (Adaptive Resonance Theory) neural network. The ART architectures show plasticity and stability characteristics, which are essential qualities to provide the training and to execute the analysis. Therefore, it is used a very fast training, when compared to the conventional backpropagation algorithm formulation. Consequently, the analysis becomes more competitive, compared to the principal methods found in the specialized literature. Results considering a system composed of 45 buses, 72 transmission lines and 10 synchronous machines are presented. © 2003 IEEE.

Adaptive fuzzy knowledge-based systems for control metabots' mobility on virtual environments

The confluence of three-dimensional (3D) virtual worlds with social networks imposes on software agents, in addition to conversational functions, the same behaviours as those common to human-driven avatars. In this paper, we explore the possibilities of the use of metabots (metaverse robots) with motion capabilities in complex virtual 3D worlds and we put forward a learning model based on the techniques used in evolutionary computation for optimizing the fuzzy controllers which will subsequently be used by metabots for moving around a virtual environment.

Experimental investigation on adaptive robust controller designs applied to a free-floating space manipulator

This paper aims to formulate and investigate the application of various nonlinear H(infinity) control methods to a fiee-floating space manipulator subject to parametric uncertainties and external disturbances. From a tutorial perspective, a model-based approach and adaptive procedures based on linear parametrization, neural networks and fuzzy systems are covered by this work. A comparative study is conducted based on experimental implementations performed with an actual underactuated fixed-base planar manipulator which is, following the DEM concept, dynamically equivalent to a free-floating space manipulator. (C) 2011 Elsevier Ltd. All rights reserved.