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Telemedicina e e-Saúde 2012/2013

Telemedicine and eHealth Technologies 1

Telemedicine and eHealthTechnologies

Telemedicina e e-Saúde

2012/13

Pedro Brandão

References

Sources are indicated by [RefSource] where the complete citation will be at the end

Insite citations will be From: CitationSource

TeleSaude 12/13 - Telemedicine and eHealth Technologies - pbrandao

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ROBOTICSTELE SURGERY

Technologies


Robot example NAO

From Aldebarran group

o NAO

Some medical goals [MSHB]s

o Elders companion/helpers

o Children education

• “in San Raffaele Hospital [...] NAOs are used to train diabetic children to take the insulin injections”


Vi

4

http://www.aldebaran-robotics.com/en/nao_robot_interactif

../media/NAO Playtime (SD).mp4



History – Telesurgery

Experimental Telesurgery 1990 by Satava, Green, and Bowersox [VTFE]

o Prototype experiment on bovine and swine

o Comparison to regular surgery

• 192 ± 24 sec conventional

• 483 ± 118 sec telepresence surgery

• Same precision results


From [ROBSUR]

5

History – Telesurgery

Clinical Demonstration in 2001 by Jacques Marescaux

o telerobotic cholecystectomy on a patient in Strasbourg

o Controlled from New York City

o Distance: 4000 km


From [ROBSUR]

From Marescaux etal’s Article

6

http://www.ncbi.nlm.nih.gov/pubmed/11923603?dopt=Abstract



History (cont) 1994 Computer Motion, Inc. produced Aesop 2000

o Automated Endoscopic System for Optimal Positioning

o surgical robot, laparoscopic camera

o Next was Zeus tele-operatedRobotic System


AESOPComputer Motion

ZeusComputer Motion

7

History (cont)

Davinci System from Intuitive Surgical*

o Instruments are swapped by nurses

o Head control

o 3D display

o Small incisions

o High precision


From Intuitive Surgical(1999)

*Merged with Computer Motion in 2000

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Davinci System


From Intuitive Surgical

9

History (cont)

2005 Penelope robotic scrub technician

o responsible for dispensing and retrieving surgical instruments.

o Voice commands

o By Robotic Surgical


From [ROBSUR]

Source: Columbia Surgery

10



Prototypes – SILS in robot

Single Incision Laparoscopic Surgery

One small tube one incision


Robotic prototype from Intuitive Surgical

SILS Port from CovidienFor “regular” laparoscopy

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History (cont)

“February 2003 Dr. Anvari performed the world’s first hospital-to-hospital teleroboticsurgery over a telecommunications network”o Done on a routine basis, but experimental

Marescaux was in 2001

Centre for Minimal Access Surgery (CMAS), from McMaster University, Canadao “telementoring and telerobotics for the provision

of training and clinical services within remote areas of Canada”


From CMAS

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http://www.cmas.ca/telehealth.aspx



CyberKnife System Non invasive x-radiation cancer treatment

Uses a linear accelerator

Automatic real time image-guidance

o No patient restrain

o Minimizes damageto healthy tissues


From [STRS]

13

More consultation

RP-7 robot


©Intouch Health

“enables the physician to be remotely present”

Direct connection to Class II medical devices (electronic stethoscopes, otoscopesand ultrasound)

FDA approved

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“When this robot needs a hand, it borrows yours” [IEESpectrum]“a French research team has demonstrated

how a robot can control both its own arm and a person’s arm to manipulate objects in a collaborative manner”

The work is from from Laboratoired’informatique de robotique et de microélectronique de Montpelier

oMovie


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More interesting is the other way aroundControlling a robot arm with thought

o Implants in the motor cortex

o 1st a cursor

o Then an arm

• 1st 2 chips (4mmx4mm) with 96 electrodes

• Double the nr of chips

Video

o 1st prototype


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../media/Robot HumanArm.wmv

http://www.technologyreview.com/news/508641/patient-shows-new-dexterity-with-a-mind-controlled-robot-arm/?utm_campaign=newsletters&utm_source=newsletter-weekly-biomedicine&utm_medium=email&utm_content=20121218

http://www.youtube.com/watch?v=ogBX18maUiM



Robot capabilities

Manipulation

Movement

Vision

Everything is information

o Can be assessed

o Can be commandeered


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Usages – Operations Cardiac surgery

o arterial anastomoses of Coronary Artery Bypass Grafting (CABG);

o mitral valve replacement ;o atrial septal defect;

Urologyo radical prostatectomyo laparoscopic nephrectomyo Pyeloplastyo laparascopic cholecystectomy

Gynaecologyo Hysterectomyo fallopian tube (re)anastomosis


From [ROBSUR,TEUS]

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Usages - Education

Medical conferences:

o live video session of a robotic procedure

Save movements and use them as feedback for students;

Pre-operative testing

o Use a virtual patient to test/practice an operation procedure


From [ROBSUR]

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Advantages

Higher precision, dexterity

o Tremor reduction

Couple several instruments (camera included)

o Control

o (possibly) In a single incision

Small incisions (pencil diameter)

Smaller learning curve

Ergonomic position


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Others

NOTES: Natural Orifice TranslumenalEndoscopic Surgery

o Feasibility has been studied in animals

o Being evaluated in Humans

Cooperative Robots

oMore than one robot to help on the procedure


From [COOPROB]

Davinci and lighting/imaging robot(from [COOPROB])

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Nanorobots

Nano is 10-9

Targeted drug delivery

Target blood vessels

Cell/DNA repairs

Attack/Destroy specific cells

Diagnostics


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Nanorobot example

Chemical Sensors

Power supply

Actuators

Data transmission


From [NBA]

Image from [NBA]

Nanorobot for brain aneurismComputer simulation

Robot dimensions2 µm in length0.5 µm in diameter

6 µm diameter red blood cell1012 nanorobots in the 5l blood vol.

Total of 0.2g

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Nanorobots

Projects studying the magnetic controlled movement of these robots

o No medical studies yet


From [ArtBact1]

From [ArtBact2]

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ACQUISITIONTechnologies


Intel Health Guide PHS6000

Two way video calls

Specific devices connectivityo blood pressure monitors, glucose meters, pulse

oximeters, peak flow, weight scales

o Wired: 4 USB 2.0 ports;

o Wireless: Bluetooth* v2.0, Class 1

o RJ 45 connector (broadband access)

Multimedia content

History

Reminders


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Microscope for the Phone

Aydogan Ozcan aims for mobile microscope

o LUCAS (Lensless Ultra-wide-field Cell Monitoring Array platform based on Shadow imaging)


From Physorg

From MIT Tech Review

27

Phone Microscope

“A personalized food allergen testing platform on a cellphone”, RSC Lab on Chip

o “test and control tubes are inserted from the side and are vertically illuminated by two separate light-emitting-diodes”

o incubation time of ~20 min per test

o digitally processed within 1 s


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From RSC Lab on Chip

http://innovate.ee.ucla.edu/

http://www.physorg.com/news191170981.html

http://www.technologyreview.com/tr35/profile.aspx?trid=808

http://pubs.rsc.org/en/content/articlelanding/2012/LC/C2LC41152K

http://pubs.rsc.org/en/content/articlelanding/2012/LC/C2LC41152K



NETRA – Near Eye Tool Refractive Assessment


From Camera Culture, MIT Media Lab

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Cheap phones as stethocopeDeveloped by Oxford University and South

African researchersRecord and analyse their own heart sounds using

a mobile phone microphone. Send the recordings to medics


From Oxford news

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http://web.media.mit.edu/~pamplona/CATRA/

http://www.ox.ac.uk/media/science_blog/160911.html



Portable ultrasound – Vscan (GE)

PC software to act as a gateway between Vscan, customers’ PC tools and GE hotline service.


From GE Vscan brochure

From Vscan

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Vscan Specifications Clinical Applications

o Cardiaco Abdomeno Urinary bladdero Obstetrics and gynaecologyo Paediatrico Selected peripheral vascular applicationso Thoracic/pleural fluid and motion detection

Imagingo Black and white mode for displaying anatomy in real-timeo Colour-coded overlay for real-time blood flow imagingo Field-of-view for black and white imaging: up to 75 degrees with

maximum depth of 25 cmo The colour flow sector represents blood flow within an angle of 30

degrees


From GE Vscan datasheet

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https://www2.gehealthcare.com/doccart/public?guid=f4fcf2e0b7f46210VgnVCM10000024dd1403____

http://www.gehealthcare.com/vscan/

https://www2.gehealthcare.com/doccart/public?guid=06c95f7decf43210VgnVCM10000024dd1403____



Alive ECG

iPhone portable ECG

One lead ECG, for basic rhythm


Source: Alive ECG for iPhone, Android

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Lifebot Ambulances for telemed


Source: LifeBot telemedicine ambulances

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http://mobihealthnews.com/9955/interview-iphoneecg-ready-for-android-too/

http://mobihealthnews.com/10052/interview-roger-lee-heaths-lifebot-and-super-ambulances/



Super-Cheap Health Tests

From George Whitesides’ Lab

o Paper based tests with chemical reagents that colour differently according to enzyme concentration

o “stamp-size square of paper with wells that change colour when a drop of blood is applied”

o Testing liver function


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Source: TechReview, David Talbot, Images also from article

OTHERSTechnologies


http://www.technologyreview.com/demo/429609/super-cheap-health-tests/



ECG on the run

Blackberry application to receive ECG reports

Use/development of eUNO R 10 technology

oWith Maestros Mediline Systems


From HealthAge

37

Mobile Devices

Sending high definition images to mobile devices (Smartphones)

o Prototypes using Waaves compression program to send the images using GSM


From MSDN Blog by Octavian Purcarea. Images also.

38

http://www.thehealthage.com/doctors-can-read-ecg-report-on-blackberry-phone/0608/

http://www.waaves.com/

http://blogs.msdn.com/b/ms_emea_health_blog/archive/2009/12/22/the-future-is-mobile.aspx



Imaging – Mobile MIM

FDA cleared for viewing and making diagnoses on:

o Computed Tomography

oMRI

o PET


Source: MobileHealthNewsMobile MIM for iPhone, iPad

Proteus/Raisin

Ingestible technology

o Pills with micro sensors that “tell” when it was taken

Implantable technology

o Enabling longer life for electronics inside the body


Source: Novartis Proteus Biomedical

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http://mobihealthnews.com/10173/fda-clears-first-diagnostic-radiology-app-mobile-mim/

http://mobihealthnews.com/10173/fda-clears-first-diagnostic-radiology-app-mobile-mim/

http://proteusdigitalhealth.com/technology/



APPLICATIONSTechnologies


Dr. SMS

Kerala region in India

User sends a text with:

o Needed facilities

o Pin-code identifying the centre (location) where the facility should be situated

User receives:

o details of nearest centres with the requirement


From Dr SMS

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http://www.drsms.kerala.gov.in/



Tele Psychiatry

Dept of Mental Health in South Carolina (USA)o “develop a telepsychiatry network for all South

Carolina (SC) hospitals operating emergency departments (ED)”

o “The objective of the grant is to make psychiatric consultation available in all SC EDs at all times.”

Portugal = 92 090 Km2

South Carolina = 80 780 Km2

Development Map


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Telerehabilitation for speech Patients with

o Aphasia, dysarthria, apraxia of speech, cognitive-linguistic disorders.

Resulting from:o stroke, traumatic brain injury, Parkinson’s disease,

multiple sclerosis

Consultations are based in audio-visual interactionso Use of video-conference or telephone

Swallowing treatmento Assessed (experimental) using real time video-

fluoroscopy


From [REHAB]

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http://www.state.sc.us/dmh/telepsychiatry/index.htm

http://www.state.sc.us/dmh/telepsychiatry/available_psychiatry.pdf



Telerehabilitation – PhysicalPatients with

o muscular-skeletal problems, stroke-induced paralysis, cognitive deficits.

Consultations use Virtual Reality environmentso “teaching by example”, “video-game like”, “exposure

therapy”

Advantages o Ability to multiplex treatmento “more fun” patient motivationo Access to detailed patient “performance” datao Easy reuse of software and hardware


From [REHABVR]

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VR Rehab examples


The VR-based orthopedic rehabilitation using a haptic glove during a pegboard exercise. © IEEE 2000

Virtual scene used in desensitizingVietnam veterans © Virtually Better 2000

Teaching by example, © Lawrence Erlbaum 2002

Refs from [REHABVR]

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Uses of video-conference

Tele-psychiatry

Tele-paediatrics

Tele-dermatology

Acute care

Remote consultation of stroke patients

Telemergency (UMississipi)

Family-Link (UCDavis)

Etc...TeleSaude 12/13 - Telemedicine and eHealth

Technologies - pbrandao

From UCDavis

©Technical Innovation

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Neuro feedback/monitoring Enables Electro Encephalogram reading Software for training/feedback, managed

remotely by doctor Skin potential/impedance, temperaturePhotic, vibratory and auditory feedback


From BrainMaster Discovery Brochure

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http://telemergency.umc.edu/telemergency.html

http://www.ucdmc.ucdavis.edu/children/clinical_services/pediatric_telemedicine/

http://www.ucdmc.ucdavis.edu/children/clinical_services/pediatric_telemedicine/

http://www.brainmaster.com/

http://www.brainmaster.com/Discovery Brochure.pdf



Emotiv EEG neuro headset

Raw EEG

Channel names based on the International 10-20 locations are: AF3, F7, F3, FC5, T7, P7, O1, O2, P8, T8, FC6, F4, F8, AF4


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Triage – example Aid-Network

Objective: replace the paper based triage systems

Uses

o Bio-sensors

oMesh networks

To enhance the normal disaster 1st responder architecture


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Aid-N – Components miTag

o heart-rate and pulse oximetero Led with triage level/priorityo LCD with HR, O2 sat

PDAo Real time info of patients

Central control (miView)o Real time view of every patient triaged


From Aid-N

51

Aid-N – Architecture


From [AIDN]

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http://www.aid-n.org/



Aid-N (cont)

Forms a Mesh Network

o Uses 802.15.4

o Can have repeaters

Long term wear carrier

o Use in hospitals


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Vital Responder

Monitoring fire-fighters in action

Assess stress/exhaustion levels

o Vital Jacket sensory shirt (1 or 5 lead Holtersystem + accelerometer)

Positioning

o GPS to be embedded in Vital Jacket


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http://www.vitalresponder.pt/



Remember? Dermatology consult

Use of special cameras for acquisition

Triage, diagnosis

Wounds, skin cancer.


©Technical Innovation

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Dermatology: other

Web sites for discussion of diagnosis

o Upload of images

o Telederm.org

o Dermatlas (image database)

o Virtual Grand Grounds in Dermatology


Example of sharing knowledge to increase it

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https://www.telederm.org/

http://dermatlas.med.jhmi.edu/derm/

http://www.vgrd.org/



Remember: Tele Consultation

From Medical Centre Kansas University

Uses:o Digital stethoscope

o Otoscope Camera

o Dermascope

o Intra-oral camera


57

The art of medicine consists of keeping the patient amused, while nature heals the disease. ~ Voltaire


http://www2.kumc.edu/telemedicine/Technology.htm



END OFTELEMEDICINE TECH


Referências – Robots – I [ArtBact1] Zhang L, Abbott JJ, Dong L, Kratochvil BE, Bell D, Nelson

BJ: Artificial bacterial flagella: fabrication and magnetic control. Appl. Physics Lett.94(064107),1–3 (2009).

[ArtBact2] Ghosh A, Fischer P: Controlled propulsion of artificial magnetic nanostructured propellers. Nano Lett.9(6),2243–2245 (2009).

[COOPROB] Lehman A, Berg K, Dumpert J, et al. “Surgery with cooperative robots. Computer Aided Surgery” Official Journal Of The International Society For Computer Aided Surgery, March 2008;13(2).

[IEEESPECTRUM] Watch This Robot Control a Person's Arm Using Electrodes, Erico Guizzo, Nov 2011

[NBA] Adriano Cavalcanti, Bijan Shirinzadeh, Toshio Fukuda, Seiichi Ikeda, “Nanorobot for Brain Aneurysm”, IJRR International Journal of Robotics Research, Special Issue, Sage, Vol. 28, no. 4, pp. 558-570, April 2009.


60

http://spectrum.ieee.org/automaton/robotics/medical-robots/robot-controls-human-arm

http://www.nanorobotinvention.com/nanorobot-asic.pdf



Referências – Robots – II [ROBSUR] Richard M. Satava, “Robotics in Colorectal Surgery:

Telemonitoring and Telerobotics”, Surgery Clinic N Am 86 (2006) [RSB] Brown University, Robotic surgery, Student Project Report

on, 2005o Video of a surgery available

[STRS] Coste‐Manière È, Olender D, Kilby W, Schulz R. “Robotic whole body stereotactic radiosurgery: clinical advantages of the Cyberknife® integrated system”. International Journal of Medical Robotics and Computer Assisted Surgery, January 2005;1(2):28-39.

[TEUS] Pamela Whitten and Beverly Sypher, “Evolution of Telemedicine from an Applied Communication Perspective in the United States”, Telemedicine and e-Health Vol 12, N 5, 2006

[VTFE] Jon C. Bowersox, Ajit Shah, et al, “Vascular applications of telepresence surgery: Initial feasibility studies in swine”, Presented at the Forty-ninth Annual Meeting of the Society for Vascular Surgery 1996


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References – Applications [AIDN] Tia Gao, et al ““The Advanced Health and

Disaster Aid Network: A Light-Weight Wireless Medical System for Triage”, IEEE Transactions on Biomedical Circuits and Systems, September 2007

[REHAB] Deborah G Theodoros“Telerehabilitation for service delivery in speech-language pathology”, Journal of Telemedicine and Telecare 2008; 14

[REHABVR] G. C. Burdea, “Virtual Rehabilitation -Benefits and Challenges”, Methods of Information in Medicine 2003 (Vol. 42)


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http://biomed.brown.edu/Courses/BI108/BI108_2005_Groups/04/index.html

http://biomed.brown.edu/Courses/BI108/BI108_2005_Groups/04/video.html

http://www3.interscience.wiley.com/journal/112395643/abstract

http://www.jvascsurg.org/article/S0741-5214%2896%2970272-0/abstract



Acronyms

CABG – Coronary Artery Bypass Grafting

CT – Computed Tomography

FDA – Food and Drug Administration

MRI – Magnetic Resonance Imaging

PET – Positron Emission Tomography


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