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TECHNICAL ABSTRACT Background: Musculoskeletal symptoms (MSS) are prevalent among veterinary surgeons. Recent research has proposed exoskeletons as potential solutions in reducing the risk of musculoskeletal disorders among surgeons, but no studies have addressed the neck forward postures (opposite of overhead work), a unique ergonomic neck risk, commonly required during live, open surgery. Purpose: We explored the effectiveness of a passive neck-support exoskeleton during live veterinary surgical procedures with experienced surgeons. Methods: We employed a within-subject crossover design involving surgeons who participated in procedures across specialties including soft tissue and orthopedics. Participants performed entire surgeries with and without a front head posture support prototype exoskeleton, and they completed pre- and post-surgical surveys to assess MSS and perceived effort. The Wilcoxon Signed Rank Test was used to compare median values of MSS and the perceived effort of each participant when they operated with and without the exoskeleton. Results: We collected data during 28 procedures involving eight surgeons, with each subject performing at least one surgery with (intervention) and at least one surgery without (control) the exoskeleton (randomized order). The number of control and intervention cases for each participant was balanced. We found that the difference in neck stiffness before and after surgery was greater in the control surgeries compared to when using the exoskeleton intervention. Increases in neck pain and neck stiffness were only observed in control cases, whereas no participant reported increased neck pain or neck stiffness when the exoskeleton was used. Conclusion: Our results indicate that a passive forward head posture support exoskeleton is a promising intervention for reducing the risk of MSS in live surgical procedures.

Image-based deformation estimation is an important tool used in a variety of engineering problems, including crack propagation, fracture, and fatigue failure. These tools have been important in biomechanics research where measuring in vitro and in vivo tissue deformations are important for evaluating tissue health and disease progression. However, accurately measuring tissue deformation in vivo is particularly challenging due to limited image signal-to-noise ratio. Therefore, we created a novel deep-learning approach for measuring deformation from a sequence of images collected in vivo called StrainNet. Utilizing a training dataset that incorporates image artifacts, StrainNet was designed to maximize performance in challenging, in vivo settings. Artificially generated image sequences of human flexor tendons undergoing known deformations were used to compare benchmark StrainNet against two conventional image-based strain measurement techniques. StrainNet outperformed the traditional techniques by nearly 90%. High-frequency ultrasound imaging was then used to acquire images of the flexor tendons engaged during contraction. Only StrainNet was able to track tissue deformations under the in vivo test conditions. Findings revealed strong correlations between tendon deformation and applied forces, highlighting the potential for StrainNet to be a valuable tool for assessing rehabilitation strategies or disease progression. Additionally, by using real-world data to train our model, StrainNet was able to generalize and reveal important relationships between the effort exerted by the participant and tendon mechanics. Overall, StrainNet demonstrated the effectiveness of using deep learning for image-based strain analysis in vivo., (© 2024. The Author(s).)

Worker and work-related musculoskeletal symptoms are prevalent among surgeons operating on human patients. Despite incidence rates for accidents among veterinarians and their staff being 2.9 times higher than that of general practitioners of human medicine, little is known about musculoskeletal symptoms among veterinary surgeons. In this study, 212 board-certified members of the American College of Veterinary Surgeons responded to a survey regarding various work-related activities and their experience with musculoskeletal symptoms in 10 different body regions. Across all body regions, reported pain increased from before to after a typical day of surgery ( p <.01). Gender, weight, age, and years performing surgery were worker factors that were related to pain ( p <.05), while number of procedures, practice focus, and proportion of minimally invasive surgery were work factors related to pain ( p <.05). Our findings suggest that musculoskeletal symptoms are prevalent among veterinary surgeons and may help provide evidence for guidelines for minimising musculoskeletal injuries in veterinary surgery. Practitioner summary : Little is known about the risk factors for musculoskeletal symptoms (MSS) among veterinary surgeons. This cross-sectional survey of veterinary surgeons investigates worker and work factors related to MSS. We show that MSS are prevalent and identify key factors providing evidence that MSS are a concern in veterinary surgery.

Objective: This study developed a fixation-related electroencephalography band power (FRBP) approach for situation awareness (SA) assessment in automated driving., Background: Maintaining good SA in Level 3 automated vehicles is crucial to drivers' takeover performance when the automated system fails. A multimodal fusion approach that enables the analysis of the visual behavioral and cognitive processes of SA can facilitate real-time assessment of SA in future driver state monitoring systems., Method: Thirty participants performed three simulated automated driving tasks. After each task, the Situation Awareness Global Assessment Technique (SAGAT) was deployed to capture their SA about key elements that could affect their takeover task performance. Participants eye movements and brain activities were recorded. Data on their brain activity after each eye fixation on the key elements were extracted and labeled according to the correctness of the SAGAT. Mixed-effects models were used to identify brain regions that were indicative of SA, and machine learning models for SA assessment were developed based on the identified brain regions., Results: Participants' alpha and theta oscillation at frontal and temporal areas are indicative of SA. In addition, the FRBP technique can be used to predict drivers' SA with an accuracy of 88% using a neural network model., Conclusion: The FRBP technique, which incorporates eye movements and brain activities, can provide more comprehensive evaluation of SA. Findings highlight the potential of utilizing FRBP to monitor drivers' SA in real-time., Application: The proposed framework can be expanded and applied to driver state monitoring systems to measure human SA in real-world driving.

Background: Musculoskeletal symptoms and injuries adversely impact the health of surgical team members and their performance in the operating room (OR). Though ergonomic risks in surgery are well-recognized, mitigating these risks is especially difficult. In this study, we aimed to assess the impacts of an exoskeleton when used by OR team members during live surgeries., Methods: A commercial passive arm-support exoskeleton was used. One surgical nurse, one attending surgeon, and five surgical trainees participated. Twenty-seven surgeries were completed, 12 with and 15 without the exoskeleton. Upper-body postures and muscle activation levels were measured during the surgeries using inertial measurement units and electromyography sensors, respectively. Postures, muscle activation levels, and self-report metrics were compared between the baseline and exoskeleton conditions using non-parametric tests., Results: Using the exoskeleton significantly decreased the percentage of time in demanding postures (>45° shoulder elevation) for the right shoulder by 7% and decreased peak muscle activation of the left trapezius, right deltoid, and right lumbar erector spinae muscles, by 7%, 8%, and 12%, respectively. No differences were found in perceived effort, and overall scores on usability ranged from "OK" to "excellent.", Conclusions: Arm-support exoskeletons have the potential to assist OR team members in reducing musculoskeletal pain and fatigue indicators. To further increase usability in the OR, however, better methods are needed to identify the surgical tasks for which an exoskeleton is effective., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 National Safety Council and Elsevier Ltd. All rights reserved.)

Objective: This study developed and evaluated a mental workload-based adaptive automation (MWL-AA) that monitors surgeon cognitive load and assist during cognitively demanding tasks and assists surgeons in robotic-assisted surgery (RAS)., Background: The introduction of RAS makes operators overwhelmed. The need for precise, continuous assessment of human mental workload (MWL) states is important to identify when the interventions should be delivered to moderate operators' MWL., Method: The MWL-AA presented in this study was a semi-autonomous suction tool. The first experiment recruited ten participants to perform surgical tasks under different MWL levels. The physiological responses were captured and used to develop a real-time multi-sensing model for MWL detection. The second experiment evaluated the effectiveness of the MWL-AA, where nine brand-new surgical trainees performed the surgical task with and without the MWL-AA. Mixed effect models were used to compare task performance, objective- and subjective-measured MWL., Results: The proposed system predicted high MWL hemorrhage conditions with an accuracy of 77.9%. For the MWL-AA evaluation, the surgeons' gaze behaviors and brain activities suggested lower perceived MWL with MWL-AA than without. This was further supported by lower self-reported MWL and better task performance in the task condition with MWL-AA., Conclusion: A MWL-AA systems can reduce surgeons' workload and improve performance in a high-stress hemorrhaging scenario. Findings highlight the potential of utilizing MWL-AA to enhance the collaboration between the autonomous system and surgeons. Developing a robust and personalized MWL-AA is the first step that can be used do develop additional use cases in future studies., Application: The proposed framework can be expanded and applied to more complex environments to improve human-robot collaboration.

Objective: (1) To assess mental workloads of intensive care unit (ICU) nurses in 12-hour working shifts (days and nights) using eye movement data; (2) to explore the impact of stress on the ocular metrics of nurses performing patient care in the ICU., Background: Prior studies have employed workload scoring systems or accelerometer data to assess ICU nurses' workload. This is the first naturalistic attempt to explore nurses' mental workload using eye movement data., Methods: Tobii Pro Glasses 2 eye-tracking and Empatica E4 devices were used to collect eye movement and physiological data from 15 nurses during 12-hour shifts (252 observation hours). We used mixed-effect models and an ordinal regression model with a random effect to analyze the changes in eye movement metrics during high stress episodes., Results: While the cadence and characteristics of nurse workload can vary between day shift and night shift, no significant difference in eye movement values was detected. However, eye movement metrics showed that the initial handoff period of nursing shifts has a higher mental workload compared with other times. Analysis of ocular metrics showed that stress is positively associated with an increase in number of eye fixations and gaze entropy, but negatively correlated with the duration of saccades and pupil diameter., Conclusion: Eye-tracking technology can be used to assess the temporal variation of stress and associated changes with mental workload in the ICU environment. A real-time system could be developed for monitoring stress and workload for intervention development.

Objective: The purpose of this study was to identify objective measures that predict surgeon nontechnical skills (NTS) during surgery., Background: NTS are cognitive and social skills that impact operative performance and patient outcomes. Current methods for NTS assessment in surgery rely on observation-based tools to rate intraoperative behavior. These tools are resource intensive (e.g., time for observation or manual labeling) to perform; therefore, more efficient approaches are needed., Method: Thirty-four robotic-assisted surgeries were observed. Proximity sensors were placed on the surgical team and voice recorders were placed on the surgeon. Surgeon NTS was assessed by trained observers using the NonTechnical Skills for Surgeons (NOTSS) tool. NTS behavior metrics from the sensors included communication, speech, and proximity features. The metrics were used to develop mixed effect models to predict NOTSS score and in machine learning classifiers to distinguish between exemplar NTS scores (highest NOTSS score) and non-exemplar scores., Results: NTS metrics were collected from 16 nurses, 12 assistants, 11 anesthesiologists, and four surgeons. Nineteen behavior features and overall NOTSS score were significantly correlated (12 communication features, two speech features, five proximity features). The random forest classifier achieved the highest accuracy of 70% (80% F1 score) to predict exemplar NTS score., Conclusion: Sensor-based measures of communication, speech, and proximity can potentially predict NOTSS scores of surgeons during robotic-assisted surgery. These sensing-based approaches can be utilized for further reducing resource costs of NTS and team performance assessment in surgical environments., Application: Sensor-based assessment of operative teams' behaviors can lead to objective, real-time NTS measurement.

Mental workload (MWL) is a crucial area of study due to its significant influence on task performance and potential for significant operator error. However, measuring MWL presents challenges, as it is a multi-dimensional construct. Previous research on MWL models has focused on differentiating between two to three levels. Nonetheless, tasks can vary widely in their complexity, and little is known about how subtle variations in task difficulty influence workload indicators. To address this, we conducted an experiment inducing MWL in up to 5 levels, hypothesizing that our multi-modal metrics would be able to distinguish between each MWL stage. We measured the induced workload using task performance, subjective assessment, and physiological metrics. Our simulated task was designed to induce diverse MWL degrees, including five different math and three different verbal tiers. Our findings indicate that all investigated metrics successfully differentiated between various MWL levels induced by different tiers of math problems. Notably, performance metrics emerged as the most effective assessment, being the only metric capable of distinguishing all the levels. Some limitations were observed in the granularity of subjective and physiological metrics. Specifically, the subjective overall mental workload couldn't distinguish lower levels of workload, while all physiological metrics could detect a shift from lower to higher levels, but did not distinguish between workload tiers at the higher or lower ends of the scale (e.g., between the easy and the easy-medium tiers). Despite these limitations, each pair of levels was effectively differentiated by one or more metrics. This suggests a promising avenue for future research, exploring the integration or combination of multiple metrics. The findings suggest that subtle differences in workload levels may be distinguishable using combinations of subjective and physiological metrics., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (At least a portion of this work is authored by Christopher Stevens and Winston Bennett on behalf of the U.S. Government and as regards Dr. Stevens, Dr. Bennett, and the U.S. Government, is not subject to copyright protection in the United States. Foreign and other copyrights may apply.)

Background: Non-technical skills (NTS) are essential for safe surgical patient management. However, assessing NTS involves observer-based ratings, which can introduce bias. Eye tracking (ET) has been proposed as an effective method to capture NTS. The purpose of the current study was to determine if ET metrics are associated with NTS performance., Methods: Participants wore a mobile ET system and participated in two patient care simulations, where they managed a deteriorating patient. The scenarios featured several challenges to leadership, which were evaluated using a 4-point Likert scale. NTS were evaluated by trained raters using the Non-Technical Skills for Surgeons (NOTSS) scale. ET metrics included percentage of fixations and visits on areas of interest., Results: Ten medical students participated. Average visit duration on the patient was negatively correlated with participants' communication and leadership. Average visit duration on the patient's intravenous access was negatively correlated with participants' decision making and situation awareness., Conclusions: Our preliminary data suggests that visual attention on the patient was negatively associated with NTS and may indicate poor comprehension of the patient's status due to heightened cognitive load. In future work, researchers and educators should consider using ET to objectively evaluate and provide feedback on their NTS., Competing Interests: Conflict of Interest The authors have no financial conflicts of interest to disclose.

Introduction: Increased complexity in robotic-assisted surgical system interfaces introduces problems with human-robot collaboration that result in excessive mental workload (MWL), adversely impacting a surgeon's task performance and increasing error probability. Real-time monitoring of the operator's MWL will aid in identifying when and how interventions can be best provided to moderate MWL. In this study, an MWL-based adaptive automation system is constructed and evaluated for its effectiveness during robotic-assisted surgery., Materials and Methods: This study recruited 10 participants first to perform surgical tasks under different cognitive workload levels. Physiological signals were obtained and employed to build a real-time system for cognitive workload monitoring. To evaluate the effectiveness of the proposed system, 15 participants were recruited to perform the surgical task with and without the proposed system. The participants' task performance and perceived workload were collected and compared., Results: The proposed neural network model achieved an accuracy of 77.9% in cognitive workload classification. In addition, better task performance and lower perceived workload were observed when participants completed the experimental task under the task condition supplemented with adaptive aiding using the proposed system., Conclusions: The proposed MWL monitoring system successfully diminished the perceived workload of participants and increased their task performance under high-stress conditions via interventions by a semi-autonomous suction tool. The preliminary results from the comparative study show the potential impact of automated adaptive aiding systems in enhancing surgical task performance via cognitive workload-triggered interventions in robotic-assisted surgery., (© The Association of Military Surgeons of the United States 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Due to their large sizes and impediments to personnel workflows, integrating robotic technologies into the existing operating rooms (OR) is a challenge. In this study, we developed an ultra-wideband sensor-based human-machine-environment framework for layout and workflow assessments within the OR. In addition to providing best practices for use of the framework, we also demonstrated its effectiveness in understanding layout and workflow inefficiencies in 12 robotic-assisted surgeries (RAS) across 4 different surgical specialties. We found avoidable movements as the circulating nurse covers at least twice the distance of any other OR personnel before the patient cart (robot) is docked. OR areas of congestion and undesirable personnel-pair proximities across RAS phases that impose extra non-technical skill challenges were determined. Our findings highlight several implications for the added complexity of integrating robotic technologies into the OR, which can serve as drivers for objective evidence-based recommendations to combat RAS OR layout and workflow inefficiencies., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objective: The goal of this systematic literature review is to investigate the relationship between indirect physiological measurements and direct measures of situation awareness (SA)., Background: Across different environments and tasks, assessments of SA are often performed using techniques designed specifically to directly measure SA, such as SAGAT, SPAM, and/or SART. However, research suggests that indirect physiological sensing methods may also be capable of predicting SA. Currently, it is unclear which particular physiological approaches are sensitive to changes in SA., Method: Seven databases were searched using the PRISMA reporting guidelines. Eligibility criteria included human-subject experiments that used at least one direct SA assessment technique, as well as at least one physiological measurement. Information extracted from each article was the physiological metric(s), the direct SA measurement(s), the correlation between these two metrics, and the experimental task(s). All studies underwent a quality assessment., Results: Twenty-five articles were included in this review. Eye tracking techniques were the most commonly used physiological measures, and correlations between conscious aspects of eye movement measures and direct SA scores were observed. Evidence for cardiovascular predictors of SA were mixed. EEG studies were too few to form strong conclusions, but were consistently positive., Conclusion: Further investigation is needed to methodically collect more relevant data and comprehensively model the relationships between a wider range of physiological measurements and direct assessments of SA., Application: This review will guide researchers and practitioners in methods to indirectly assess SA with sensors and highlight opportunities for future research on wearables and SA.

Introduction: Flexible ureteroscopy (fURS) is the most common procedure for treatment of urolithiasis. We previously utilized kinematic evaluations of simulated fURS to demonstrate that certain body movements are associated with efficient ureteroscopic manipulation for complex tasks. In this study, we incorporated computer vision to create an efficiency score using the ureteroscope travel distance (DIST), task time (TIME), spectral arc length (SPARC), and percentage of purposeful wall collisions (COLL). The goal is a simulation-based system that can abstract these automated performance metrics (APMs) to differentiate between novice and expert ureteroscope handling. Methods: A ureteroscopic simulation box was used. Body kinematics, task time, and ureteroscopic movements were analyzed using a motion capture system and video camera. Optical flow computer vision was used to track the ureteroscope. DIST, TIME, and SPARC were automatically calculated. Wall collisions were automatically captured and independently judged by two authors; an algorithm was developed to automatically determine the COLL variable. A mixed-effects model was used to aggregate these variables and distinguish between surgeons' first and final task attempts. Normalized values of these metrics were added to create a composite ureteroscopic efficiency score (CUES). Results: Twelve urologists completed the simulated tasks. The COLL assessment algorithm determined beneficial wall collisions with an accuracy of 77%. Normalized values of TIME, DIST, SPARC, and COLL were combined to create a composite ureteroscopic efficiency score (CUES). Compared with the first attempt, both the second and third attempts showed statistically significant improvements in CUES. The ROC-AUC score reached 0.86, suggesting excellent discrimination between attempts. There was also a statistically significant difference in CUES when comparing resident and attending performance. Conclusions: APMs can be abstracted using computer vision and artificial intelligence; an aggregate composite score (CUES) may be a promising method for evaluation of ureteroscopic efficiency.

Objectives:  The aim of this study was to determine the prevalence of work-related musculoskeletal symptoms (MSS) in veterinary surgeons using an online survey., Study Design:  An online survey was distributed to 1,031 diplomates of American College of Veterinary Surgeons. Responses were collected with data regarding surgical activities, experience with various types of MSS in 10 different body sites and attempts to reduce MSS., Results:  Two hundred and twelve respondents (21% response rate) completed the distributed survey in 2021. Ninety-three per cent of respondents had experienced MSS associated with surgery in at least one body part, with the neck, lower back and upper back frequently affected. Musculoskeletal discomfort and pain worsened with prolonged surgical hours. Forty-two per cent of them suffered from chronic pain persisting longer than 24 hours after surgeries. Musculoskeletal discomfort was common regardless of practice emphasis and procedure types. Forty-nine per cent of respondents with musculoskeletal pain had taken medication, 34% sought physical therapy for MSS and 38% ignored the symptoms. Over 85% of respondents showed more than some concern regarding career longevity due to musculoskeletal pain., Clinical Significance:  Work-related MSS are common in veterinary surgeons, and the results of this study warrant longitudinal clinical studies to determine risk factors and attention to workplace ergonomics in veterinary surgery., Competing Interests: None declared., (Thieme. All rights reserved.)

Introduction: Nurse decision making (DM) is critical for patient safety. Eye-tracking methods can effectively assess nurse DM. The purpose of this pilot study was to use eye-tracking methods to assess nurse DM during a clinical simulation., Materials and Methods: Experienced nurses managed a simulated patient manikin who suffered from a stroke mid-simulation. We assessed nurses' gaze patterns prior to and after the stroke. DM in general was assessed by nursing faculty using a clinical judgement rubric, and dichotomously based on recognition of the stroke or not., Results: Data from eight experienced nurses was examined. For the nurses who recognized the stroke, visual attention was focused on the vital sign monitor and patient's head, which suggest those locations were consistently examined for correct decision-makers., Conclusions: Dwell time on general AOIs was associated with poorer DM, which may reflect poorer pattern recognition. Eye-tracking metrics may be effective to objectively assess nurse DM., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Lifting tasks remain one of the leading causes of musculoskeletal disorders (MSDs), primarily in the low back region. Lifting analysis tools are, therefore, designed for assessing the risk of low back pain. Shoulder musculoskeletal problems have emerged as common MSDs associated with manual handling tasks. It is hypothesized that gripping force is related to lifting conditions and may be used as a supplementary risk metric for MSDs in the shoulder and low back regions, because it measures additional hand exertions for coupling the lifted object during lifting. We assessed the capability tactile gloves for measuring the gripping force during lifting as a means for assessing different task conditions (lifting weight, lifting height, lifting direction, body rotation, and handle). Thirty participants wore the tactile gloves and performed simulated lifting tasks. Regression models were used to analyze the effects of the task variables on estimating the measured gripping force. Results demonstrated that 58% and 70% of the lifting weight variance were explained by the measured gripping force without and with considering the individual difference, respectively. In addition to the lifting risk measures commonly used by practitioners, this study suggests a potential for using gripping force as a supplementary or additional risk metric for MSDs., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Introduction: Work related injuries in minimally invasive surgery (MIS) are common because of the strains placed on the surgeon's or assistant's body. The objective of this study was to compare specific ergonomic risks among surgeons and surgical trainees performing robotic and laparoscopic procedures., Materials and Methods: Ergonomic data and discomfort questionnaires were recorded from surgeons and trainees (fellows/residents) for both robotic and laparoscopic procedures. Perceived discomfort questionnaires were recorded pre/postoperatively. Intraoperatively, biomechanical loads were captured using motion tracking sensors and electromyography (EMG) sensors. Perceived discomfort, body position and muscle activity were compared between robotic and laparoscopic procedures using a linear regression model., Results: Twenty surgeons and surgical trainees performed 29 robotic and 48 laparoscopic procedures. Postoperatively, increases in right finger numbness and right shoulder stiffness and surgeon irritability were noted after laparoscopy and increased back stiffness after robotic surgery. Further, the laparoscopic group saw increases in right hand/shoulder pain (OR 0.8; p = 0.032) and left hand/shoulder pain (0.22; p < 0.001) compared to robotic. Right deltoid and trapezius excessive muscle activity were significantly higher in laparoscopic operations compared to robotic. Demanding and static positioning was similar between the two groups except there was significantly more static neck position required for robotic operations., Conclusion: Robotic assisted surgeries led to lower postoperative discomfort and muscle strain in both upper extremities, particularly dominant side of the surgeon, but increased static neck positioning with subjective back stiffness compared with laparoscopy. These recognized ergonomic differences between the two platforms can be used to raise surgeon awareness of their intraoperative posture and to develop targeted physical and occupational therapy interventions to decrease surgeon WMSDs and increase surgeon longevity., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Adoption of robotic-assisted surgery has steadily increased as it improves the surgeon's dexterity and visualization. Despite these advantages, the success of a robotic procedure is highly dependent on the availability of a proficient surgical assistant that can collaborate with the surgeon. With the introduction of novel medical devices, the surgeon has taken over some of the surgical assistant's tasks to increase their independence. This, however, has also resulted in surgeons experiencing higher levels of cognitive demands that can lead to reduced performance. In this work, we proposed a neurotechnology-based semi-autonomous assistant to release the main surgeon of the additional cognitive demands of a critical support task: blood suction. To create a more synergistic collaboration between the surgeon and the robotic assistant, a real-time cognitive workload assessment system based on EEG signals and eye-tracking was introduced. A computational experiment demonstrates that cognitive workload can be effectively detected with an 80% accuracy. Then, we show how the surgical performance can be improved by using the neurotechnological autonomous assistant as a close feedback loop to prevent states of high cognitive demands. Our findings highlight the potential of utilizing real-time cognitive workload assessments to improve the collaboration between an autonomous algorithm and the surgeon., (© 2022. The Author(s).)

Automated driving systems are becoming increasingly prevalent throughout society. In conditionally automated vehicles, drivers may engage in non-driving-related tasks (NDRTs), which can negatively affect their situation awareness (SA) and preparedness to resume control of the vehicle, when necessary. Previous work has investigated engagement in NDRTs, but questions remain unanswered regarding its effect on drivers' SA during a takeover event. The objective of the current study is to use eye-tracking to aid in understanding how visual engagement in NDRTs affects changes in SA of the driving environment after a takeover request (TOR) has been issued. Thirty participants rode in a simulated SAE Level 3 automated driving environment and engaged in three separate pre-TOR tasks (Surrogate Reference Task, Monitoring Task, and Peripheral Detection Task) until presented with a TOR. Situation Awareness Global Assessment Technique (SAGAT) scores and gaze behavior were recorded during the post-TOR segment. Overall, longer times spent viewing the driving scene, and more dispersed visual attention allocation, were observed to be associated with better overall SA. Also, location-based eye tracking metrics show most promise in differentiating between task conditions with significantly different SAGAT scores. Findings from this work can inform the development of real-time SA assessment techniques using eye movements and ultimately contribute to improved operator roadway awareness for next-generation automated transportation., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Work-related musculoskeletal injuries have been increasingly recognized to affect surgeons. It is unknown whether such injuries also affect surgical trainees. The purpose of this study was to assess the ergonomic risk of surgical trainees as compared with that of experienced surgeons., Methods: Ergonomic data were recorded from 9 surgeons and 11 trainees. Biomechanical loads during surgery were assessed using motion tracking sensors and electromyography sensors. Demanding and static positions of the trunk, neck, right/left shoulder, as well as activity from the deltoid and trapezius muscles bilaterally were recorded. In addition, participants reported their perceived discomfort on validated questionnaires., Results: A total of 87 laparoscopic general surgery cases (48 attendings and 39 trainees) were observed. Both trainees and attendings spent a similarly high percentage of each case in static (>60%) and demanding positions (>5%). Even though residents reported overall more discomfort, all participants shared similar ergonomic risk with the exception of trainees' trunk being more static (odds ratio: -11.42, P = .006)., Conclusion: Surgeons are prone to ergonomic risk. Trainees are exposed to similar postural ergonomic risk as surgeons but report more discomfort and, given that musculoskeletal injuries are cumulative over time, the focus should be on interventions to reduce ergonomic risk in the operating room., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Training of surgeons is essential for safe and effective use of robotic surgery, yet current assessment tools for learning progression are limited. The objective of this study was to measure changes in trainees' cognitive and behavioral states as they progressed in a robotic surgeon training curriculum at a medical institution. Seven surgical trainees in urology who had no formal robotic training experience participated in the simulation curriculum. They performed 12 robotic skills exercises with varying levels of difficulty repetitively in separate sessions. EEG (electroencephalogram) activity and eye movements were measured throughout to calculate three metrics: engagement index (indicator of task engagement), pupil diameter (indicator of mental workload) and gaze entropy (indicator of randomness in gaze pattern). Performance scores (completion of task goals) and mental workload ratings (NASA-Task Load Index) were collected after each exercise. Changes in performance scores between training sessions were calculated. Analysis of variance, repeated measures correlation, and machine learning classification were used to diagnose how cognitive and behavioral states associate with performance increases or decreases between sessions. The changes in performance were correlated with changes in engagement index (r rm =-.25,p<.001) and gaze entropy (r rm =-.37,p<.001). Changes in cognitive and behavioral states were able to predict training outcomes with 72.5% accuracy. Findings suggest that cognitive and behavioral metrics correlate with changes in performance between sessions. These measures can complement current feedback tools used by medical educators and learners for skills assessment in robotic surgery training., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objective: Effective teamwork and communication are critical to patient outcomes, and subjective assessment tools have been studied in predicting team performances. However, inherent biases remain while using subjective assessment tools. This study hypothesizes that objective communication features can assess and predict clinical performance., Design: Forty 3rd-year medical students participated in the Acute Care Trauma Simulation as the role of doctor, teaming up with a nurse confederate and a simulated patient. Participants conducted postoperative patient management, patient care diagnoses, and treatment. Audio from all team members were recorded, speech variables (e.g., speech duration, number of conversations, etc.) were extracted, and statistical analyses were performed to associate communication with clinical performance., Setting: This study was performed at the simulation center located at Fairbanks Hall, Indiana University School of Medicine., Participants: Data from forty 3rd-year medical students were collected and analyzed., Results: Majority (67%) of the communications were initiated by student. Speech ratio, intensity, and frequency of communications differed when students communicate with nurse than with patient (e.g., student communication to patient had higher intensity than nurse). Increasing frequency of check-backs between student and nurse (p < 0.05) and speech duration from student to patient (p = 0.001) positively associated with student's clinical performance score., Conclusion: Objective communication features can predict medical trainee's clinical performance and provide an objective approach for simulation-based trauma care training., (Copyright © 2019 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Determining networks of healthcare providers quantitatively can identify impactful care processes that improve health outcomes for a high-risk populations such as elderly people with multiple chronic conditions. By applying social network analysis to health claim data of a large university in the Midwest, we measured healthcare provider networks of patients with diabetes for two consecutive years. Networks were built based on the assumption that having common patients may indicate potential working relationships between providers. Measures of the social network analysis including degree and betweenness centrality were utilized to identify healthcare providers with an important role in the care process. Both degree and betweenness centrality measures identified a supply center and three laboratories as the central providers of the network for both years. This study can positively impact informed decision-making of policymakers and insurance companies to better design their insurance coverage plans based on the collaboration patterns of the healthcare providers.

Objective: To evaluate the validity of a novel inverted peg transfer (iPT) task for assessing laparoscopic skills of novices and experts and compare iPT to the regular PT (rPT) task to ensure surgical trainee acquisition of an adequate advanced laparoscopic skills level for safe laparoscopic practice in the operating room., Design: Prospective crossover study., Setting: Multidisciplinary simulation center and motion analysis laboratory, Mayo Clinic., Participants: Novices were medical students and surgical interns without laparoscopic experience. Experts were surgeons with at least 3 years of experience in laparoscopic surgery., Methods: This was the first exposure to iPT for both groups. Completion time and performance metrics were recorded. A scoring rubric was used to calculate a normalized performance score between 0 and 100. Wilcoxon rank sum and Mann-Whitney tests were performed with α = 0.05. Receiver-operating characteristic curves were graphed for the 2 task scores to assess the tasks' sensitivity and specificity in differentiating laparoscopic experience level., Main Outcome Measures: Performance measures of completion time, transferred triangles, dropped triangles (errors), and the overall performance score on both tasks between- and within-subjects (i.e., novices and experts)., Results: Thirty-six novices and eight experts participated. Both experts and novices had longer completion time and lower scores during iPT than rPT (p < 0.05). Within iPT, novice completion times were 144 seconds longer (p = 0.04), and performance score was 35 points lower than experts (p < 0.01). No differences between novices and experts were observed for completion time or performance scores (p > 0.05) for rPT. The iPT scores had a higher sensitivity and specificity than the rPT (area under the receiver-operating characteristic curve: iPT = 0.91; rPT = 0.69)., Conclusions: iPT is a valid assessment of advanced laparoscopic skills for surgical trainees with higher specificity and sensitivity than rPT. As advanced minimally invasive surgery becomes more common, it is important that tasks such as iPT be included in surgical simulation curricula and training assessment., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To assess impact of an onsite clinic on healthcare utilization of preventive services for employees of a public university and their dependents., Method: Descriptive statistics, logistic regression and classification tree techniques were used to assess health claim data to identify changes in patterns of healthcare utilization and factors impacting usage of onsite clinic., Result: Utilization of preventive services significantly increased for women and men employees by 9% and 14% one year after implementation of the onsite clinic. Hourly-paid employees, employees without diabetes, employees with spouse opt out or no coverage were more likely to go to the onsite clinic., Conclusion: Adapted framework for assessing performance of onsite clinics based on usage of health informatics would help to identify health utilization patterns and interaction between onsite clinic and offsite health providers.

Background: The introduction of robotic technology has revolutionized radical prostatectomy surgery. However, the potential benefits of robotic techniques may have trade-offs in increased mental demand for the surgeon and the physical demand for the assisting surgeon. This study employed an innovative motion tracking tool along with validated workload questionnaire to assess the ergonomics and workload for both assisting and console surgeons intraoperatively., Methods: Fifteen RARP cases were collected in this study. Cases were performed by 10 different participants, six primarily performed console tasks and four primarily performed assisting tasks. Participants had a median 12 (min-3, max-25) years of surgical experience. Both console and assisting surgeons performed robotic prostatectomy cases while wearing inertial measurement units (IMUs) that continuously track neck, shoulder, and torso motion without interfering with the sterile environment. Postoperatively, participants completed a workload questionnaire (SURG-TLX) and a body part discomfort questionnaire., Results: Twenty-six questionnaires were completed from 13 assisting and 13 console surgeons over the 15 cases. Postoperative pain was reported highest for the right shoulder and neck. Mental demands were 41 % higher for surgeons at the console than assisting (p < 0.05), while physical demands were not significantly different. Assisting surgeons worked in demanding neck postures for 58 % of the procedure compared to 24 % for the console surgeon (p < 0.01). Surgeons at the console were primarily static and showed 2-5 times fewer movements than assisting surgeons (p < 0.01)., Conclusions: Postures were more ergonomic during console tasks than when assisting by the bedside; however, the console may constrain postures leading to static loads that have been associated with musculoskeletal symptoms for the neck, torso, and shoulders. The IMU sensors were effective at quantifying ergonomics in robotic prostatectomies, and these methods and findings have broad applications to other robotic procedures.

Background: Reliable prediction of operative duration is essential for improving patient and care team satisfaction, optimizing resource utilization and reducing cost. Current operative scheduling systems are unreliable and contribute to costly over- and underestimation of operative time. We hypothesized that the inclusion of patient-specific factors would improve the accuracy in predicting operative duration., Methods: We reviewed all elective laparoscopic cholecystectomies performed at a single institution between 01/2007 and 06/2013. Concurrent procedures were excluded. Univariate analysis evaluated the effect of age, gender, BMI, ASA, laboratory values, smoking, and comorbidities on operative duration. Multivariable linear regression models were constructed using the significant factors (p < 0.05). The patient factors model was compared to the traditional surgical scheduling system estimates, which uses historical surgeon-specific and procedure-specific operative duration. External validation was done using the ACS-NSQIP database (n = 11,842)., Results: A total of 1801 laparoscopic cholecystectomy patients met inclusion criteria. Female sex was associated with reduced operative duration (-7.5 min, p < 0.001 vs. male sex) while increasing BMI (+5.1 min BMI 25-29.9, +6.9 min BMI 30-34.9, +10.4 min BMI 35-39.9, +17.0 min BMI 40 + , all p < 0.05 vs. normal BMI), increasing ASA (+7.4 min ASA III, +38.3 min ASA IV, all p < 0.01 vs. ASA I), and elevated liver function tests (+7.9 min, p < 0.01 vs. normal) were predictive of increased operative duration on univariate analysis. A model was then constructed using these predictive factors. The traditional surgical scheduling system was poorly predictive of actual operative duration (R 2  = 0.001) compared to the patient factors model (R 2  = 0.08). The model remained predictive on external validation (R 2  = 0.14).The addition of surgeon as a variable in the institutional model further improved predictive ability of the model (R 2  = 0.18)., Conclusion: The use of routinely available pre-operative patient factors improves the prediction of operative duration during cholecystectomy.

Background: Laparoscopic tool handles causing wrist flexion and extension more than 15° from neutral are considered "at risk" for musculoskeletal strain. Therefore, this study measured the impact of laparoscopic tool handle angles on wrist postures and task performance., Methods: Eight surgeons performed standard and modified Fundamentals of Laparoscopic Surgery (FLS) tasks with laparoscopic tools. Tool A had three adjustable handle angle configurations, i.e., in-line 0° (A0), 30° (A30), and pistol-grip 70° (A70). Tool B was a fixed pistol-grip grasper. Participants performed FLS peg transfer, inverted peg transfer, and inverted circle cut with each tool and handle angle. Inverted tasks were adapted from standard FLS tasks to simulate advanced tasks observed during abdominal wall surgeries, e.g., ventral hernia. Motion tracking, video analysis, and modified NASA-TLX workload questionnaires were used to measure postures, performance (e.g., completion time and errors), and workload., Results: Task performance did not differ between tools. For FLS peg transfer, self-reported physical workload was lower for B than for A70, and mean wrist postures showed significantly higher flexion for in-line than for pistol-grip tools (B and A70). For inverted peg transfer, workload was higher for all configurations. However, less time was spent in at-risk wrist postures for in-line (47 %) than for pistol-grip (93-94 %), and most participants preferred Tool A. For inverted circle cut, workload did not vary across configurations, mean wrist posture was 10° closer to neutral for A0 than B, and median time in at-risk wrist postures was significantly less for A0 (43 %) than for B (87 %)., Conclusion: The best ergonomic wrist positions for FLS (floor) tasks are provided by pistol-grip tools and for tasks on the abdominal wall (ventral surface) by in-line handles. Adjustable handle angle laparoscopic tools can reduce ergonomic risks of musculoskeletal strain and allow versatility for tasks alternating between the floor and ceiling positions in a surgical trainer without impacting performance.

Background: Surgical performance, provider health, and patient safety can be compromised when workload demands exceed individual capability on the surgical team. The purpose of this study is to quantify and compare intraoperative workload among surgical team members., Methods: Observations were conducted for an entire surgical day for 33 participating surgeons and their surgical team at one medical institution. Workload (mental, physical, case complexity, distractions, and case difficulty) was measured for each surgical team member using questions from validated questionnaires. Statistical analyses were performed with a mixed effects model., Results: A total of 192 surgical team members participated in 78 operative cases, and 344 questionnaires were collected. Procedures with high surgeon mental and physical workload included endovascular and gastric surgeries, respectively. Ratings did not differ significantly among surgeons and residents, but scrub nurses physical demand ratings were 14-22 (out of 100) points lower than the surgeons, residents, and surgical assistants. Residents reported the highest mental workload, averaging 19-24 points higher than surgical assistants, scrub nurses, and circulating nurses. Mental and physical demands exceeded 50 points 28-45 % of the time for surgeons and residents. Workload did not differ between minimally invasive and open techniques., Conclusion: The workload questionnaires are an effective tool for quantifying intraoperative workload across the surgical team to ensure mental and physical demands do not exceed thresholds where performance may decrease and injury risk increase. This tool has the potential to measure the safety of current procedures and drive design of workload interventions.

Physical work demands and posture constraint from operating microscopes may adversely affect microsurgeon health and performance. Alternative video displays were developed to reduce posture constraints. Their effects on postures, perceived efforts, and performance were compared with the microscope. Sixteen participants performed microsurgery skill tasks using both stereo and non-stereoscopic microscopes and video displays. Results showed that neck angles were 9-13° more neutral and shoulder flexion were 9-10° more elevated on the video display than the microscope. Time observed in neck extension was higher (30% vs. 17%) and neck movements were 3x more frequent on the video display than microscopes. Ratings of perceived efforts did not differ among displays, but usability ratings were better on the microscope than the video display. Performance times on the video displays were 66-110% slower than microscopes. Although postures improved, further research is needed to improve task performance on video displays., (Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.)

Sociometers are wearable sensors that continuously measure body movements, interactions, and speech. The purpose of this study is to test sociometers in a smart environment in a live clinical setting, to assess their reliability in capturing and quantifying data. The long-term goal of this work is to create an intelligent emergency department that captures real-time human interactions using sociometers to sense current system dynamics, predict future state, and continuously learn to enable the highest levels of emergency care delivery. Ten actors wore the devices during five simulated scenarios in the emergency care wards at a large non-profit medical institution. For each scenario, actors recited prewritten or structured dialogue while independent variables, e.g., distance, angle, obstructions, speech behavior, were independently controlled. Data streams from the sociometers were compared to gold standard video and audio data captured by two ward and hallway cameras. Sociometers distinguished body movement differences in mean angular velocity between individuals sitting, standing, walking intermittently, and walking continuously. Face-to-face (F2F) interactions were not detected when individuals were offset by 30°, 60°, and 180° angles. Under ideal F2F conditions, interactions were detected 50 % of the time (4/8 actor pairs). Proximity between individuals was detected for 13/15 actor pairs. Devices underestimated the mean duration of speech by 30-44 s, but were effective at distinguishing the dominant speaker. The results inform engineers to refine sociometers and provide health system researchers a tool for quantifying the dynamics and behaviors in complex and unpredictable healthcare environments such as emergency care.

Introduction: Single-incision laparoscopic cholecystectomy (SILC) may lead to higher patient satisfaction; however, SILC may expose the surgeon to increased workload. The goal of this study was to compare surgeon stress and workload between SILC and conventional laparoscopic cholecystectomy (CLC)., Methods: During a double-blind randomized controlled trial comparing patient outcomes for SILC versus CLC (NCT0148943), surgeon workload was assessed by four measures: surgery task load index questionnaire (Surg-TLX), maximum heart rate, salivary cortisol level, and instruments usability survey. The maximum heart rate and salivary cortisol levels were sampled from the surgeon before the random assignment of the surgical procedure, intraoperatively after the cystic duct was clipped, and at skin closure. After each procedure, the surgeon completed the Surg-TLX and an instrument usability survey. Student's t tests, Wilcoxon rank sum test, and Kruskal-Wallis nonparametric ANOVAs on the dependent variables by the technique (SILC vs. CLC) were performed with α = 0.05., Results: Twenty-three SILC and 25 CLC procedures were included in the intent-to-treat analysis. No significant differences were observed between SILC and CLC for patient demographics and procedure duration. SILC had significantly higher post-surgery surgeon maximum heart rates than CLC (p < 0.05). SILC also had significantly higher mean change in the maximum heart rate between during and post-procedure (p < 0.05) than CLC. Salivary cortisol level was significantly higher during SILC than CLC (p < 0.01). Awkward manipulation of the instruments and limited fine motions were reported significantly more frequently with SILC than CLC (p < 0.01). In the surgeon-reported Surg-TLX, subscale of physical demand was significantly more demanding for SILC than CLC (p < 0.05)., Conclusions: Surgeon heart rate, salivary cortisol level, instrument usability, and Surg-TLX ratings indicate that SILC is significantly more stressful and physically demanding than the CLC. Surgeon stress and workload may impact patients' outcomes; thus, ergonomic improvement on SILC is necessary.