Eric Maslowski

Virtual Reality Triage Training Provides a Viable Solution for Disaster-preparedness

OBJECTIVES The objective of this study was to compare the relative impact of two simulation-based methods for training emergency medicine (EM) residents in disaster triage using the Simple Triage and Rapid Treatment (START) algorithm, full-immersion virtual reality (VR), and standardized patient (SP) drill. Specifically, are there differences between the triage performances and posttest results of the two groups, and do both methods differentiate between learners of variable experience levels? METHODS Fifteen Postgraduate Year 1 (PGY1) to PGY4 EM residents were randomly assigned to two groups: VR or SP. In the VR group, the learners were effectively surrounded by a virtual mass disaster environment projected on four walls, ceiling, and floor and performed triage by interacting with virtual patients in avatar form. The second group performed likewise in a live disaster drill using SP victims. Setting and patient presentations were identical between the two modalities. Resident performance of triage during the drills and knowledge of the START triage algorithm pre/post drill completion were assessed. Analyses included descriptive statistics and measures of association (effect size). RESULTS The mean pretest scores were similar between the SP and VR groups. There were no significant differences between the triage performances of the VR and SP groups, but the data showed an effect in favor of the SP group performance on the posttest. CONCLUSIONS Virtual reality can provide a feasible alternative for training EM personnel in mass disaster triage, comparing favorably to SP drills. Virtual reality provides flexible, consistent, on-demand training options, using a stable, repeatable platform essential for the development of assessment protocols and performance standards.

Reduced basal ganglia μ-opioid receptor availability in trigeminal neuropathic pain: A pilot study

BackgroundAlthough neuroimaging techniques have provided insights into the function of brain regions involved in Trigeminal Neuropathic Pain (TNP) in humans, there is little understanding of the molecular mechanisms affected during the course of this disorder. Understanding these processes is crucial to determine the systems involved in the development and persistence of TNP.FindingsIn this study, we examined the regional μ-opioid receptor (μOR) availability in vivo (non-displaceable binding potential BPND) of TNP patients with positron emission tomography (PET) using the μOR selective radioligand [11C]carfentanil. Four TNP patients and eight gender and age-matched healthy controls were examined with PET. Patients with TNP showed reduced μOR BPND in the left nucleus accumbens (NAc), an area known to be involved in pain modulation and reward/aversive behaviors. In addition, the μOR BPND in the NAc was negatively correlated with the McGill sensory and total pain ratings in the TNP patients.ConclusionsOur findings give preliminary evidence that the clinical pain in TNP patients can be related to alterations in the endogenous μ-opioid system, rather than only to the peripheral pathology. The decreased availability of μORs found in TNP patients, and its inverse relationship to clinical pain levels, provide insights into the central mechanisms related to this condition. The results also expand our understanding about the impact of chronic pain on the limbic system.

Development of a Language-Independent Functional Evaluation

UNLABELLED Haig AJ, Jayarajan S, Maslowski E, Yamakawa KS, Tinney M, Beier KP, Juang D, Chan L, Boggess T, Loar J, Owusu-Ansah B, Kalpakjian C. Development of a language-independent functional evaluation. OBJECTIVE To design, validate, and critique a tool for self-report of physical functioning that is independent of language and literacy. DESIGN Software design and 2 prospective trials followed by redesign. SETTING United States and African university hospitals. PARTICIPANTS Outpatient and inpatient competent adults with diverse physical impairments. INTERVENTIONS (1) Software design process leading to a Preliminary Language-Independent Functional Evaluation (Pre-L.I.F.E.); (2) patient surveys using a printed Pre-L.I.F.E. and a computer-animated Pre-L.I.F.E. tested in random order, followed by a questionnaire version of the standard Barthel Index; and (3) software redesign based on objective and qualitative experiences with Pre-L.I.F.E. MAIN OUTCOME MEASURES Validation of the general concept that written and spoken language can be eliminated in assessment of function. Development of a refined Language-Independent Functional Evaluation (L.I.F.E.). RESULTS A viable Pre-L.I.F.E. software was built based on design parameters of the clinical team. Fifty Americans and 51 Africans demonstrated excellent (Cronbach alpha>0.8 Americans) and good (alpha>.425 Africans) reliability. In general, the relations between Pre-L.I.F.E. and Barthel scores were excellent in the United States (interclass correlation coefficient for stair climbing, .959) but somewhat less good in Africa, with elimination functions very poorly related. The computer-animated Pre-L.I.F.E. was faster and trended to be more reliable than the printed Pre-L.I.F.E. in both the United States and Africa. Redesign meetings corrected statistical and qualitative challenges, resulting in a new tool, the L.I.F.E. CONCLUSIONS Literacy and language translation can be eliminated from some aspects of functional assessment. The new L.I.F.E., based on solid empirical evidence and design principles, may be a practical solution to assessment of function in the global culture.

3D-Neuronavigation In Vivo Through a Patient's Brain During a Spontaneous Migraine Headache

A growing body of research, generated primarily from MRI-based studies, shows that migraine appears to occur, and possibly endure, due to the alteration of specific neural processes in the central nervous system. However, information is lacking on the molecular impact of these changes, especially on the endogenous opioid system during migraine headaches, and neuronavigation through these changes has never been done. This study aimed to investigate, using a novel 3D immersive and interactive neuronavigation (3D-IIN) approach, the endogenous µ-opioid transmission in the brain during a migraine headache attack in vivo. This is arguably one of the most central neuromechanisms associated with pain regulation, affecting multiple elements of the pain experience and analgesia. A 36 year-old female, who has been suffering with migraine for 10 years, was scanned in the typical headache (ictal) and nonheadache (interictal) migraine phases using Positron Emission Tomography (PET) with the selective radiotracer [11C]carfentanil, which allowed us to measure µ-opioid receptor availability in the brain (non-displaceable binding potential - µOR BPND). The short-life radiotracer was produced by a cyclotron and chemical synthesis apparatus on campus located in close proximity to the imaging facility. Both PET scans, interictal and ictal, were scheduled during separate mid-late follicular phases of the patients menstrual cycle. During the ictal PET session her spontaneous headache attack reached severe intensity levels; progressing to nausea and vomiting at the end of the scan session. There were reductions in µOR BPND in the pain-modulatory regions of the endogenous µ-opioid system during the ictal phase, including the cingulate cortex, nucleus accumbens (NAcc), thalamus (Thal), and periaqueductal gray matter (PAG); indicating that µORs were already occupied by endogenous opioids released in response to the ongoing pain. To our knowledge, this is the first time that changes in µOR BPND during a migraine headache attack have been neuronavigated using a novel 3D approach. This method allows for interactive research and educational exploration of a migraine attack in an actual patients neuroimaging dataset.

Electronic device use by individuals with traumatic spinal cord injury

Objective: To describe use of several electronic devices among individuals with traumatic spinal cord injury (SCI). Study Design: Cross-sectional survey. Setting: Community. Methods: Potential participants consisted of all individuals with traumatic SCI, ages 7 and older, who had received care through a large academic medical center in the Midwest between January 1, 2003, and January 2, 2013. All eligible individuals received the survey as part of a four-stage mailing that asked questions about electronic device use in addition to questions about demographic and injury-related characteristics. Results: Mailings were sent to 820 individuals; of those, 451 completed and returned the survey. Descriptive and nonparametric statistics were performed. Individuals with high-level tetraplegia were less likely to use tablet and handheld electronic devices than individuals at all other SCI levels. Individuals aged 65 years and older were less likely to own or use tablet computers and handheld devices than all other age groups. Conclusion: While electronic devices hold considerable potential as a treatment modality for individuals who have sustained SCI, there is diversity in the particular electronic devices that are used by such individuals due to injury-related characteristics and age.

Poster 152 BackQuack™: An On-Line Computer Game that Teaches Doctors and Patients to Mess Up

tion of the left shoulder and marked atrophy of the left supraspinatus and infraspinatus. Patient was referred for a course of physical therapy in addition to diagnostic work-up. MRI of the left shoulder was significant for unilateral fatty infiltration and atrophy of the supraspinatus muscle without rotator cuff pathology. MRI of the cervical spine showed multilevel spondylitic foraminal narrowing at C3-5 on the left, and C6-7 bilaterally. Multiple nerve conduction studies and EMGs were performed in order to assess course and severity. Findings were consistent with incomplete denervation of the suprascapular. Radiographs, CT arthrogram, MRI and ultrasound of left shoulder failed to show an anatomic lesion as a cause for mononeuropathy. Due to worsening symptoms and loss of function despite physical therapy, patient was taken to the operating room for left open suprascapular nerve decompression with epineurolysis and open release of the transverse ligament. Setting: Sports medicine clinic. Results or Clinical Course: On 4-week postoperative visit, patient’s pain had resolved, left shoulder strength had improved (4/5 on MMT). Discussion: The “bowstring effect” during repetitive overhead activities is a pathophysiologic mechanism proposed for isolated suprascapular nerve injury in the absence of compressive pathology (ie, mass, cyst) as previously described. Conclusions: Prompt surgical release may be a necessary intervention in preventing permanent disability and functional recovery despite lack of findings on imaging.

Virtual Reality as a Surrogate Sensory Environment

This chapter examines certain aspects of virtual reality systems that contribute to their utility as surrogate sensory environments. These systems aim to provide users with sensory stimuli that simulate other worlds. The fidelity of the simulation depends on the input data, the software, the display hardware, and the physical environment that houses it all. Robust highfidelity general-purpose simulation requires a collaborative effort of modelers, artists, programmers, and system administrators. Such collaboration depends on standards for modeling and data representation, but these standards lag behind the leading-edge capabilities of processors and algorithms. We illustrate this through a review of the evolution of a few of the leading standards and case studies of projects that adhered to them to a greater or lesser extent. Multi-modal simulation often requires multiple representations of elements to accommodate the various algorithms that apply to each mode – for example, alternative geometries for visualization, auralization, and collision detection. Tools and algorithms to assist in the extraction of these representations from common base data will expand the pool of high-quality multi-modal simulations. In the final analysis, the output stimuli depend on aspects of the display hardware and its physical setting that might not be adequately accounted for by idealistic algorithms. It is important to measure these actual stimuli in order to validate and fine-tune the simulation system.