LeRoy Heinrichs

Exploring virtual worlds for scenario-based repeated team training of cardiopulmonary resuscitation in medical students.

Background Contemporary learning technologies, such as massively multiplayer virtual worlds (MMVW), create new means for teaching and training. However, knowledge about the effectiveness of such training is incomplete, and there are no data regarding how students experience it. Cardiopulmonary resuscitation (CPR) is a field within medicine in high demand for new and effective training modalities. Objective In addition to finding a feasible way to implement CPR training, our aim was to investigate how a serious game setting in a virtual world using avatars would influence medical students’ subjective experiences as well as their retention of knowledge. Methods An MMVW was refined and used in a study to train 12 medical students in CPR in 3-person teams in a repeated fashion 6 months apart. An exit questionnaire solicited reflections over their experiences. As the subjects trained in 4 CPR scenarios, measurements of self-efficacy, concentration, and mental strain were made in addition to measuring knowledge. Engagement modes and coping strategies were also studied. Parametric and nonparametric statistical analyses were carried out according to distribution of the data. Results The majority of the subjects reported that they had enjoyed the training, had found it to be suitable, and had learned something new, although several asked for more difficult and complex scenarios as well as a richer virtual environment. The mean values for knowledge dropped during the 6 months from 8.0/10 to 6.25/10 (P = .002). Self-efficacy increased from before to after each of the two training sessions, from 5.9/7 to 6.5/7 (P = .01) after the first and from 6.0/7 to 6.7/7 (P = .03) after the second. The mean perceived concentration value increased from 54.2/100 to 66.6/100 (P = .006), and in general the mental strain was found to be low to moderate (mean = 2.6/10). Conclusions Using scenario-based virtual world team training with avatars to train medical students in multi-person CPR was feasible and showed promising results. Although we found no evidence of stimulated recall of CPR procedures in our test-retest study, the subjects were enthusiastic and reported increased concentration during the training. We also found that subjects’ self-efficacy had increased after the training. Despite the need for further studies, these findings imply several possible uses of MMVW technology for future emergency medical training.

Surgical simulator for hysteroscopy: a case study of visualization in surgical training

Computer-based surgical simulation promises to provide a broader scope of clinical training through the introduction of anatomic variation, simulation of untoward events, and collection of performance data. We present a haptically-enabled surgical simulator for the most common techniques in diagnostic and operative hysteroscopy-cervical dilation, endometrial resection and ablation, and lesion excision. Engineering tradeoffs in developing a real-time, haptic-rate simulator are discussed.

Nafarelin therapy in endometriosis: Long-term effects on bone mineral density

OBJECTIVE The study intent was to examine long-term effects on bone mass of 3 or 6 months of nafarelin therapy for endometriosis. STUDY DESIGN Women with established endometriosis (N = 173) were randomized to receive nafarelin (200 micrograms intranasally twice a day) for either 3 or 6 months in a double-blind fashion. Bone mineral density was measured by dual energy x-ray absorptiometry at lumbar spine and proximal femoral sites for 18 months. RESULTS Bone mineral density declined at spinal and femoral sites similarly in both 3- and 6-month treatment groups. There was a partial, but incomplete, return to baseline levels after 12 to 15 months of follow-up. The recovery of bone mass was more complete in subjects with higher dietary calcium intakes. CONCLUSION Nafarelin therapy for endometriosis results in a sustained loss of spinal and femoral bone density, particularly in women with lower calcium intakes.

Cardiopulmonary resuscitation training in High School using Avatars in Virtual Worlds : An International Feasibility Study

Background Approximately 300,000 people suffer sudden cardiac arrest (SCA) annually in the United States. Less than 30% of out-of-hospital victims receive cardiopulmonary resuscitation (CPR) despite the American Heart Association training over 12 million laypersons annually to conduct CPR. New engaging learning methods are needed for CPR education, especially in schools. Massively multiplayer virtual worlds (MMVW) offer platforms for serious games that are promising learning methods that take advantage of the computer capabilities of today’s youth (ie, the digital native generation). Objective Our main aim was to assess the feasibility of cardiopulmonary resuscitation training in high school students by using avatars in MMVM. We also analyzed experiences, self-efficacy, and concentration in response to training. Methods In this prospective international collaborative study, an e-learning method was used with high school students in Sweden and the United States. A software game platform was modified for use as a serious game to train in emergency medical situations. Using MMVW technology, participants in teams of 3 were engaged in virtual-world scenarios to learn how to treat victims suffering cardiac arrest. Short debriefings were carried out after each scenario. A total of 36 high school students (Sweden, n=12; United States, n=24) participated. Their self-efficacy and concentration (task motivation) were assessed. An exit questionnaire was used to solicit experiences and attitudes toward this type of training. Among the Swedish students, a follow-up was carried out after 6 months. Depending on the distributions, t tests or Mann-Whitney tests were used. Correlation between variables was assessed by using Spearman rank correlation. Regression analyses were used for time-dependent variables. Results The participants enjoyed the training and reported a self-perceived benefit as a consequence of training. The mean rating for self-efficacy increased from 5.8/7 (SD 0.72) to 6.5/7 (SD 0.57, P<.001). In the Swedish follow-up, it subsequently increased from 5.7/7 (SD 0.56) to 6.3/7 (SD 0.38, P=.006). In the Swedish group, the mean concentration value increased from 52.4/100 (SD 9.8) to 62.7/100 (SD 8.9, P=.05); in the US group, the concentration value increased from 70.8/100 (SD 7.9) to 82.5/100 (SD 4.7, P<.001). We found a significant positive correlation (P<.001) between self-efficacy and concentration scores. Overall, the participants were moderately or highly immersed and the software was easy to use. Conclusions By using online MMVWs, team training in CPR is feasible and reliable for this international group of high school students (Sweden and United States). A high level of appreciation was reported among these adolescents and their self-efficacy increased significantly. The described training is a novel and interesting way to learn CPR teamwork, and in the future could be combined with psychomotor skills training.

Retreatment with nafarelin for recurrent endometriosis symptoms: efficacy, safety, and bone mineral density☆

OBJECTIVE To assess the efficacy, safety, and effect on bone mineral density of a 3-month course of retreatment with intranasal nafarelin acetate for recurrent symptoms of endometriosis. DESIGN Multicenter, open-label, nonrandomized clinical trial. SETTING Eleven hospital-based and private practices. PATIENT(S) Thirty-six women with endometriosis symptoms recurring after 3 or 6 months of treatment with nafarelin. INTERVENTION(S) Nasal nafarelin 200 micrograms twice daily for 3 months. MAIN OUTCOME MEASURE(S) Assessments for dysmenorrhea, dyspareunia, pelvic pain, tenderness, and induration. Measurement of bone mineral density of the lumbar spine. RESULT(S) Improvements from admission to the end of retreatment were significant for dysmenorrhea, pelvic pain, tenderness, induration, and dyspareunia. Three months after retreatment ended, mean symptom scores for dysmenorrhea and pelvic tenderness, although worse than at the end of retreatment, were still significantly better than scores at admission. Mean bone mineral density 3 months after retreatment was 0.56% lower than before retreatment and 1.94% lower than before initial treatment. CONCLUSION(S) Three-month nafarelin retreatment for recurrent endometriosis symptoms was effective and safe.

Effects of a gonadotropin-releasing hormone agonist on the calcium-parathyroid axis and bone turnover in women with endometriosis.

OBJECTIVE Our purpose was to investigate the effects of nafarelin on bone turnover and mass (bone mineral density, in grams per square centimeter) in women with endometriosis. STUDY DESIGN We monitored 22 young women with endometriosis during and 6 months after 6 months of nafarelin treatment. We compared the bone mineral density status of these women with that of healthy controls undergoing sequential bone mineral density measurement. RESULTS Subjects had a 2.2% loss in L2-4 bone mineral density by 6 months, increasing 3 months later to 3% and returning toward baseline by 6 months after treatment. Radius bone mineral density did not change in the treatment group. Bone mineral density did not change in controls. Serum and urinary calcium levels rose during treatment. Hydroxyproline excretion increased and remained elevated 6 months after treatment. A rise in serum osteocalcin persisted 3 months after therapy but normalized by 6 months. CONCLUSIONS Bone mineral density deficits with nafarelin are reversible. Increased bone turnover persists 6 months beyond treatment, demonstrating the need for careful monitoring of women receiving prolonged or repeated treatment.

Surgical simulator for diagnostic and operative hysteroscopy

Abstract Computer-based surgical simulation promises to provide a broader scope of clinical training through the introduction of anatomic variation, simulation of untoward events, and collection of performance data. We present a haptically enabled surgical simulator for the most common techniques in diagnostic and operative hysteroscopy–cervical dilation, endometrial resection and ablation, and lesion excision. Engineering tradeoffs in developing a real-time, haptic-rate simulator are discussed.

Authoring, deploying, and managing dynamic Virtual Patients in Virtual Clinical Environments

Abstract Following their introduction at the beginning of the 21st century, interactive or dynamic Virtual Patients are beginning to be used more widely in clinical education. They can be seen as being at the end of a continuum of simulation technical complexity, having been earlier developed on a wide range of “media”: human actors, paper, video, physical mannequins, etc. This paper focuses on the current emergent more complex Virtual Patients in three-dimensional (3D) immersive clinical environments. In these environments, in silico 3D patient avatars interact directly in response to virtual clinical interventions undertaken by avatars, each of which is controlled by one or more users. The paper explores the issues of authoring, deploying, and managing these real-time, dynamic Virtual Patients using as an example the immersive clinical environment CliniSpace. As clinician-accessible Virtual Patient authoring is now becoming available in immersive clinical environments, so these wider clinical and managerial non-technical issues are coming rapidly to the fore.

Designing case-based learning for virtual worlds.

SUMMIT hosted the 6th in its series of Simulation and Game-based Learning workshops entitled “Designing Case-Based Learning for Virtual Worlds” on August 24 and 25, 2006, at Wallenberg Hall on the Stanford University campus. Sponsored by TATRC, DARPA, and Stanford’s Center for Immersive and Simulation-based Learning (CISL), the program provided academic clinicians, education specialists, and technical experts an interactive forum for discussions about the creation and use of massively multiplayer online role playing games/simulations or “virtual world” learning environments, for training healthcare professionals. A 3D “virtual world” makes it possible for multiple trainees, who may be geographically dispersed, to interact in real time by taking the role of a character/avatar in the online learning environment. For healthcare training, trainees take on the role of healthcare team members who perform diagnostic and therapeutic actions on virtual patients. Trainees log into the world by clicking on the appropriate hyperlink on a standard HTML webpage, and once in the world, they navigate their avatar by using the mouse or keyboard directional keys. They talk with team members by using a headset with microphone, and initiate avatar actions, such as using a stethoscope or performing a venipuncture, by selecting from a controls menu. The goals of the workshop were to enable participants (G1) to design virtual worlds for learning using common gaming platforms, (G2) conduct a virtual worlds teaching/ learning session, (G3) assess learning in virtual worlds learning environments, and (G4) evaluate the virtual world learning experience. The 2-day program used an interactive workshop format. Talks were followed by extensive question and answer periods. Lectures and demonstrations were interspersed with small group sessions in which participants explored ways of using games for learning in their field or subspecialty (for details, see Table 1). Highlights of the program included the 2 keynote addresses. The presentation by Professor Jeremy Bailenson from the Department of Communications at Stanford, “Learning and Teaching among Virtual Humans: The Unique Affordances of Digital Transformations,” stimulated our thinking about the impact of persona and appearance changes of the digital human for improving real world interactions among healthcare professionals. Dr. Lou Halamek, Director of the CAPE Simulation Center at Stanford, presented “The Art of Debriefing,” a rich introduction to the many teaching opportunities and pitfalls in debriefing after an intense and emotionally charged scenario experience. Evening social events provided an opportunity for continued discussions and informal networking. Demonstrations included a sampling of current commercial games and of Virtual Worlds created with different game engines/platforms—Half-Life 2 (Valve Corporation), Second Life (Linden Laboratory), and OLIVE (Forterra Systems, Inc.). The debriefing talk was followed by a hands-on session in which participants practiced interacting in 2 Virtual Worlds created on 2 different platforms— one for training Emergency Department physicians and nurses to work effectively as a team in a medical emergency, and the other for training hospital personnel to respond appropriately to a mass casualty (CBRNE) incident in the community. In the final session, participants contributed to a large group “brainstorming session” to capture their ideas of how Virtual Worlds could be used for learning specific knowledge, skills, and behaviors in medicine and health. Evaluations indicated that the most valuable aspects were the presentations by Professor Bailenson and Dr. Halamek, and the opportunity for networking, for group interaction and brainstorming, and for the hands-on experience with a variety of engines/platforms (for details, see http://simworkshops.stanford. edu/06_0626/evaluation.html). From the SUMMIT (Stanford University Medical Media and Information Technologies), Stanford University School of Medicine, Stanford, CA. Reprints: Pat Youngblood, PhD, SUMMIT (Stanford University Medical Media and Information Technologies), Stanford University School of Medicine, Stanford, CA. (e-mail: pat@summit.stanford.edu).

Stanford university medical media and information technologies hosts open source surgical simulation workshop.

Stanford University Medical Media and Information Technologies’s technical workshop “Prototyping of Surgical Simulators using Open Source Simulation Software” was held in August 2006 at Stanford University. The objectives, program, and topics covered are presented in this short report.