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.

Illinois tax incentives : a report on Illinois tax incentives /

In January 2007, the Commission took a look at the State's business tax incentives and how Illinois' business climate compared to other states in its report entitled "State Tax Incentives for Illinois Businesses." This report is an update and expansion of that effort and includes : a detailed description of Illinois' current tax incentives, and economic growth programs; an examination of the business tax, climate based on different methodologies; and, a discussion of the importance of tax incentives in business site selection.

Being, Belonging, and Connecting: Filipino Youths' Narratives of Place(s) and Wellbeing in Hawai'i

Thesis (Ph. D.)--University of Washington, 2016-04

The Localization Procedures of the Vector of Weighting Coefficients on the Set of Teaching Experts in the Tasks of Consuming

In terms of binary relations the author analyses the task of an individual consumers’ choice on the teaching excerpts set. It is suggested to analyse the function of consumer’s value as additive reduction. For localization of the vector of weighting coefficients of additive reduction the procedures based on metrics of object distance towards the ideal point are suggested.

Automated Assessment of Image Quality and Dose Attributes in Clinical CT Images

Computed tomography (CT) is a valuable technology to the healthcare enterprise as evidenced by the more than 70 million CT exams performed every year. As a result, CT has become the largest contributor to population doses amongst all medical imaging modalities that utilize man-made ionizing radiation. Acknowledging the fact that ionizing radiation poses a health risk, there exists the need to strike a balance between diagnostic benefit and radiation dose. Thus, to ensure that CT scanners are optimally used in the clinic, an understanding and characterization of image quality and radiation dose are essential.

The state-of-the-art in both image quality characterization and radiation dose estimation in CT are dependent on phantom based measurements reflective of systems and protocols. For image quality characterization, measurements are performed on inserts imbedded in static phantoms and the results are ascribed to clinical CT images. However, the key objective for image quality assessment should be its quantification in clinical images; that is the only characterization of image quality that clinically matters as it is most directly related to the actual quality of clinical images. Moreover, for dose estimation, phantom based dose metrics, such as CT dose index (CTDI) and size specific dose estimates (SSDE), are measured by the scanner and referenced as an indicator for radiation exposure. However, CTDI and SSDE are surrogates for dose, rather than dose per-se.

Currently there are several software packages that track the CTDI and SSDE associated with individual CT examinations. This is primarily the result of two causes. The first is due to bureaucracies and governments pressuring clinics and hospitals to monitor the radiation exposure to individuals in our society. The second is due to the personal concerns of patients who are curious about the health risks associated with the ionizing radiation exposure they receive as a result of their diagnostic procedures.

An idea that resonates with clinical imaging physicists is that patients come to the clinic to acquire quality images so they can receive a proper diagnosis, not to be exposed to ionizing radiation. Thus, while it is important to monitor the dose to patients undergoing CT examinations, it is equally, if not more important to monitor the image quality of the clinical images generated by the CT scanners throughout the hospital.

The purposes of the work presented in this thesis are threefold: (1) to develop and validate a fully automated technique to measure spatial resolution in clinical CT images, (2) to develop and validate a fully automated technique to measure image contrast in clinical CT images, and (3) to develop a fully automated technique to estimate radiation dose (not surrogates for dose) from a variety of clinical CT protocols.

Cultura e clima organizacionais: um estudo multicasos em indústrias de laticínios do estado do Rio Grande do Norte

The objective of this study is to investigate if exist relationship between organizational culture and the organizational climate, having as research s locus three dairy industries in the Rio Grande do Norte State. As such, an exploratory-descriptive and conclusive-causal study, with a sample composed of 211 employees of all firms hierarchical levels was undertaken. By way the data collection, the employees personal characteristics, the predominant organizational culture profile and the predominant organizational climate in the industries researched were identified. In order to analyse the organizational culture, the Competing Value Model (CAMERON; QUINN, 2006), with adaptations by Santos (1998, 2000), was used. In order to analyse the organizational climate, the Organizational Climate Measurement Scale, proposed by Martins (et al., 2004, 2008), with modifications, was used. The data were submitted to quantitative statistical analyses, firstly to the set of firms and afterwards to the firms alone, that permitted arrival to the following conclusions: the cultural profiles was met in a balanced way in the researched organizations, with emphasis to clan culture and market culture profiles; the researched organizations have a good organizational climate, based in the Martins (2008) classification, with emphasis to boss and organization s support and physical comfort , being these factors coherent whit the clan culture profile; the personal variables are correlated with the cultural profiles and with the organizational climate factors, however, each organization show its singular form of relation; and the cultural profiles showed influence on organizational climate factors. Thus, the results permitted to conclude that there are relations between the cultural profiles and the organizational climate factors in the researched organizations

Impact of node mobility in user-centric routing

Recent paradigms in wireless communication architectures describe environments where nodes present a highly dynamic behavior (e.g., User Centric Networks). In such environments, routing is still performed based on the regular packet-switched behavior of store-and-forward. Albeit sufficient to compute at least an adequate path between a source and a destination, such routing behavior cannot adequately sustain the highly nomadic lifestyle that Internet users are today experiencing. This thesis aims to analyse the impact of the nodes’ mobility on routing scenarios. It also aims at the development of forwarding concepts that help in message forwarding across graphs where nodes exhibit human mobility patterns, as is the case of most of the user-centric wireless networks today. The first part of the work involved the analysis of the mobility impact on routing, and we found that node mobility significance can affect routing performance, and it depends on the link length, distance, and mobility patterns of nodes. The study of current mobility parameters showed that they capture mobility partially. The routing protocol robustness to node mobility depends on the routing metric sensitivity to node mobility. As such, mobility-aware routing metrics were devised to increase routing robustness to node mobility. Two categories of routing metrics proposed are the time-based and spatial correlation-based. For the validation of the metrics, several mobility models were used, which include the ones that mimic human mobility patterns. The metrics were implemented using the Network Simulator tool using two widely used multi-hop routing protocols of Optimized Link State Routing (OLSR) and Ad hoc On Demand Distance Vector (AODV). Using the proposed metrics, we reduced the path re-computation frequency compared to the benchmark metric. This means that more stable nodes were used to route data. The time-based routing metrics generally performed well across the different node mobility scenarios used. We also noted a variation on the performance of the metrics, including the benchmark metric, under different mobility models, due to the differences in the node mobility governing rules of the models.

Qualificação de edifícios residenciais verticais em Natal/RN à luz do regulamento técnico da qualidade para o nível de eficiência energética de edificações residenciais (RTQ-R)

The goal of the research was to investigate the energy performance of residential vertical buildings envelope in the hot and humid climate of Natal, capital of Rio Grande do Norte, based in the Technical Regulation of Quality for Energy Efficiency Level in Residential Buildings (RTQ -R), launched in 2010. The study pretends to contribute to the development of design strategies appropriate to the specific local climate and the increasing of energy efficiency level of the envelope. The methodological procedures included the survey in 22 (twenty two) residential buildings, the formulation of representative prototypes based on typological and constructives characters researched and the classification of the level of energy efficiency in the envelopment of these prototypes, using as a tool the prescriptive method of the RTQ-R and the parametric analyzes from assigning different values of the following variables: shape of the pavement type; distribution of housing compartments; orientation of the building; area and shading of openings; thermal transmittance, and solar absorptance of opaque materials of the frontage in order to evaluate the influence of these on the envelopment performance. The main results accomplished with this work includes the qualification of vertical residential buildings in Natal/RN; the verification of the adequacy of these buildings to local climate based from the diagnosis of the thermal energy of the envelopment performance, the identification of variables with more significant influence on the prescriptive methodology of RTQ-R and design solutions more favorable to obtain higher levels energy efficiency by this method. Finally, it was verified, that some of these solutions proved contradictory in relation to the recommendations contained in the theoretical approaches regarding environmental comfort in hot and humid weather, which indicates the need for improvement of the prescriptive method RTQ-R and further research on efficient design solutions

Cultura e clima organizacionais: um estudo multicasos em indústrias de laticínios do estado do Rio Grande do Norte

The objective of this study is to investigate if exist relationship between organizational culture and the organizational climate, having as research s locus three dairy industries in the Rio Grande do Norte State. As such, an exploratory-descriptive and conclusive-causal study, with a sample composed of 211 employees of all firms hierarchical levels was undertaken. By way the data collection, the employees personal characteristics, the predominant organizational culture profile and the predominant organizational climate in the industries researched were identified. In order to analyse the organizational culture, the Competing Value Model (CAMERON; QUINN, 2006), with adaptations by Santos (1998, 2000), was used. In order to analyse the organizational climate, the Organizational Climate Measurement Scale, proposed by Martins (et al., 2004, 2008), with modifications, was used. The data were submitted to quantitative statistical analyses, firstly to the set of firms and afterwards to the firms alone, that permitted arrival to the following conclusions: the cultural profiles was met in a balanced way in the researched organizations, with emphasis to clan culture and market culture profiles; the researched organizations have a good organizational climate, based in the Martins (2008) classification, with emphasis to boss and organization s support and physical comfort , being these factors coherent whit the clan culture profile; the personal variables are correlated with the cultural profiles and with the organizational climate factors, however, each organization show its singular form of relation; and the cultural profiles showed influence on organizational climate factors. Thus, the results permitted to conclude that there are relations between the cultural profiles and the organizational climate factors in the researched organizations

Qualificação de edifícios residenciais verticais em Natal/RN à luz do regulamento técnico da qualidade para o nível de eficiência energética de edificações residenciais (RTQ-R)

The goal of the research was to investigate the energy performance of residential vertical buildings envelope in the hot and humid climate of Natal, capital of Rio Grande do Norte, based in the Technical Regulation of Quality for Energy Efficiency Level in Residential Buildings (RTQ -R), launched in 2010. The study pretends to contribute to the development of design strategies appropriate to the specific local climate and the increasing of energy efficiency level of the envelope. The methodological procedures included the survey in 22 (twenty two) residential buildings, the formulation of representative prototypes based on typological and constructives characters researched and the classification of the level of energy efficiency in the envelopment of these prototypes, using as a tool the prescriptive method of the RTQ-R and the parametric analyzes from assigning different values of the following variables: shape of the pavement type; distribution of housing compartments; orientation of the building; area and shading of openings; thermal transmittance, and solar absorptance of opaque materials of the frontage in order to evaluate the influence of these on the envelopment performance. The main results accomplished with this work includes the qualification of vertical residential buildings in Natal/RN; the verification of the adequacy of these buildings to local climate based from the diagnosis of the thermal energy of the envelopment performance, the identification of variables with more significant influence on the prescriptive methodology of RTQ-R and design solutions more favorable to obtain higher levels energy efficiency by this method. Finally, it was verified, that some of these solutions proved contradictory in relation to the recommendations contained in the theoretical approaches regarding environmental comfort in hot and humid weather, which indicates the need for improvement of the prescriptive method RTQ-R and further research on efficient design solutions

How much information is lost by using global-mean climate metrics? an example using the transport sector

Metrics are often used to compare the climate impacts of emissions from various sources, sectors or nations. These are usually based on global-mean input, and so there is the potential that important information on smaller scales is lost. Assuming a non-linear dependence of the climate impact on local surface temperature change, we explore the loss of information about regional variability that results from using global-mean input in the specific case of heterogeneous changes in ozone, methane and aerosol concentrations resulting from emissions from road traffic, aviation and shipping. Results from equilibrium simulations with two general circulation models are used. An alternative metric for capturing the regional climate impacts is investigated. We find that the application of a metric that is first calculated locally and then averaged globally captures a more complete and informative signal of climate impact than one that uses global-mean input. The loss of information when heterogeneity is ignored is largest in the case of aviation. Further investigation of the spatial distribution of temperature change indicates that although the pattern of temperature response does not closely match the pattern of the forcing, the forcing pattern still influences the response pattern on a hemispheric scale. When the short-lived transport forcing is superimposed on present-day anthropogenic CO2 forcing, the heterogeneity in the temperature response to CO2 dominates. This suggests that the importance of including regional climate impacts in global metrics depends on whether small sectors are considered in isolation or as part of the overall climate change.

Soil nitrous oxide emissions in long-term cover crops-based rotations under subtropical climate

It has been shown that cover crops can enhance soil nitrous oxide (N(2)O) emissions, but the magnitude of increase depends on the quantity and quality of the crop residues. Therefore, this study aimed to evaluate the effect of long-term (19 and 21 years) no-till maize crop rotations including grass [black oat (Avena strigosa Schreb)] and legume cover crops [vetch (Vigna sativa L), cowpea (Vigna unguiculata L. Walp), pigeon pea (Cajanus cajan L. Millsp.) and lablab (Dolichos lablab)] on annual soil N(2)O emissions in a subtropical Acrisol in Southern Brazil. Greater soil N(2)O emissions were observed in the first 45 days after the cover crop residue management in all crop rotations, varying from -20.2 +/- 1.9 to 163.9 +/- 24.3 mu g N m(-2) h(-1). Legume-based crop rotations had the largest cumulative emissions in this period, which were directly related to the quantity of N (r(2) = 0.60, p = 0.13)and inversely related to the lignin:N ratio(r(2) = 0.89,p = 0.01) of the cover crop residues. After this period, the mean fluxes were smaller and were closely related to the total soil N stocks (r(2) = 0.96, p = 0.002). The annual soil N(2)O emission represented 0.39-0.75% of the total N added by the legume cover crops. Management-control led soil variables such as mineral N (NO(3)(-) and NH(4)(+)) and dissolved organic C influenced more the N(2)O fluxes than environmental-related variables as water-filled pore space and air and soil temperature. Consequently, the synchronization between N mineralization and N uptake by plants seems to be the main challenge to reduce N(2)O emissions while maintaining the environmental and agronomic services provided by legume cover crops in agricultural systems. (C) 2009 Elsevier B.V. All rights reserved.

Spatial and temporal variation in distribution of mangroves in Moreton Bay, subtropical Australia: a comparison of pattern metrics and change detection analyses based on aerial photographs

An assessment of the changes in the distribution and extent of mangroves within Moreton Bay, southeast Queensland, Australia, was carried out. Two assessment methods were evaluated: spatial and temporal pattern metrics analysis, and change detection analysis. Currently, about 15,000 ha of mangroves are present in Moreton Bay. These mangroves are important ecosystems, but are subject to disturbance from a number of sources. Over the past 25 years, there has been a loss of more than 3800 ha, as a result of natural losses and mangrove clearing (e.g. for urban and industrial development, agriculture and aquaculture). However, areas of new mangroves have become established over the same time period, offsetting these losses to create a net loss of about 200 ha. These new mangroves have mainly appeared in the southern bay region and the bay islands, particularly on the landward edge of existing mangroves. In addition, spatial patterns and species composition of mangrove patches have changed. The pattern metrics analysis provided an overview of mangrove distribution and change in the form of single metric values, while the change detection analysis gave a more detailed and spatially explicit description of change. An analysis of the effects of spatial scales on the pattern metrics indicated that they were relatively insensitive to scale at spatial resolutions less than 50 m, but that most metrics became sensitive at coarser resolutions, a finding which has implications for mapping of mangroves based on remotely sensed data. (C) 2003 Elsevier Science B.V. All rights reserved.

SPAnDX: a process-based population dynamics model to explore management and climate change impacts on an invasive alien plant, Acacia nilotica

This paper describes a process-based metapopulation dynamics and phenology model of prickly acacia, Acacia nilotica, an invasive alien species in Australia. The model, SPAnDX, describes the interactions between riparian and upland sub-populations of A. nilotica within livestock paddocks, including the effects of extrinsic factors such as temperature, soil moisture availability and atmospheric concentrations of carbon dioxide. The model includes the effects of management events such as changing the livestock species or stocking rate, applying fire, and herbicide application. The predicted population behaviour of A. nilotica was sensitive to climate. Using 35 years daily weather datasets for five representative sites spanning the range of conditions that A. nilotica is found in Australia, the model predicted biomass levels that closely accord with expected values at each site. SPAnDX can be used as a decision-support tool in integrated weed management, and to explore the sensitivity of cultural management practices to climate change throughout the range of A. nilotica. The cohort-based DYMEX modelling package used to build and run SPAnDX provided several advantages over more traditional population modelling approaches (e.g. an appropriate specific formalism (discrete time, cohort-based, process-oriented), user-friendly graphical environment, extensible library of reusable components, and useful and flexible input/output support framework). (C) 2003 Published by Elsevier Science B.V.