Metaverse Health

Archive for the ‘Medical’ Category

In the past week I received a note from Kerri McCusker (SL: Kerri Macchi) about a project completed for the Serious Games and Virtual Worlds Team, University of Ulster in Northern Ireland. Second Lives sets out to demonstrate a more recent approach to dealing with Crohn’s disease: autologous stem cell transplant.

You can view the Second Life aspect for yourself, or the video below explains the project in its entirety. I’ve also appended a section of the in-world notecard explaining the stem cell transplant history in some detail.

It’s yet another example of simulation as a useful adjunct for wider learning experiences. The level of complexity of this simulation is more at the patient education level rather than as a health professional training mechanism, but with further evolution it could obviously achieve both aims. I certainly learned a lot more about newer treatment options for Crohn’s disease. Anyone who’s been involved in the care of an individual with the disease knows that anything that improves health outcomes is a highly desirable thing.

Appendix: Sample of information provided by Second Lives Clinic

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Welcome to Second Lives Medical Clinic.
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This virtual clinic is a showcase of the process of the autologous stem cell transplant in Crohn’s disease.

Cellular therapy with stem cells is revolutionizing the focus of treatment of many serious diseases. Replacing the cells of damaged tissue with other new cells from the same patient is already a reality. This is the basis of cellular therapy and regenerative medicine, the latest great advance in biomedicine. In this line, Hospital Clínic, Barcelona is leading the world in the application of an innovative cellular therapy that uses stem cells to treat Crohn’s disease, a chronic genetic disease that affects 1% of the population in Spain and which has considerable impact on the quality of life of the patients. The procedure is based on an autologous bone-marrow transplant (when patients receive a transplant of their own stem cells) and now constitutes a treatment option to cure an intestinal disease that sometimes does not successfully respond to drugs and requires highly complex surgery that does not provide a cure.

Hospital Clínic, Barcelona is one of the few hospitals in the world to apply this new therapeutic option for patients with Crohn’s disease, and it does so with the guarantee of success experienced in the US and Italy, where the technique has been tested with excellent results: in an average follow-up period of 6 years, 80% of transplant patients are in a phase of total remission of the disease and the remaining 20% have shown considerable improvement following the transplant, and are now responding favorably to drugs. Dr. Julián Panés and Dr. Elena Ricart over the Gastroenterology Department of Hospital Clínic, Barcelona are the driving force behind this therapy in Spain and began to implement regenerative cellular therapy in patients with Crohn’s disease in August 2008. To date, a total of 6 patients are benefiting from this new treatment. The transplant requires several weeks of admission to hospital before patients receive their own cells. The procedure is the same as that carried out in bone-morrow transplants to cure leukemia or myeloma.

Autologous Stem-Cell Transplant: Phases of the Procedure

When the case is detected (that does not respond to drugs or surgery), the patient undergoes an autologous stem-cell transplant, which is a bone-morrow transplant in which the immune system is reset to prevent it from attacking the intestinal flora. The process lasts approximately 2 months and consists of 6 phases:
1. Initial Chemotherapy (Cyclophosphamide + G-CSF). In this initial phase, the reduction of the number of leukocytes (immune-system cells) in the blood is induced in the patient.

2. Migration of Stem-Cells to the Blood. Following the previous immunosuppression, the organism reacts by releasing stem cells from the bone marrow into the blood; these are the cells which will later be used for the transplant.

3. Collection of Stem Cells by means of Apheresis. Apheresis is a technique that separates components of the blood. Here, the stem cells that previously migrated from the bone marrow are separated.

4. Cryopreservation of Stem Cells. When the stem cells have been collected by apheresis, they are frozen and preserved until ready for transplant.

5. Second Chemotherapy. In this phase, total leukopenia is induced; that is, the immune system is left devoid of leukocytes, ready to be reset with the stem-cell transplant.

6. Autologous Stem-Cell Transplant. The patient receives the transplant by means of transfusion with his or her own stem cells. The immune system is reset, leading to remission or reduction of the abnormal inflammatory process of Crohn’s disease.

The Journal of Medical Internet Research has published a study on the outcomes of a a pilot postgraduate medical education program at the Boston University School of Medicine presence in Second Life.

You can read the full paper here, but the synopsis of the study is:

1. Fourteen physicians participated in the pilot, with twelve providing feedback.

2. The learning exercise was related to Type 2 diabetes, with participants surveyed on any change in confidence and performance, as well as attitudes toward the virtual learning environment itself.

3. Confidence increased after the Second Life event, in respect to selecting insulin for patients with type 2 diabetes, initiating insulin and adjusting insulin dosing.

4. There was an increase to 90% (from 60%) of participants initiating correct insulin dosages.

5. The percentage of participants who provided correct initiation of mealtime insulin increased from 40% to 80%.

6. All twelve participants surveyed agreed that their experience in Second Life was an effective method of medical education.

7. All twelve also agreed that “the virtual world approach to CME was superior to other methods of online CME, that they would enroll in another such event in SL, and that they would recommend that their colleagues participate in an SL CME course.”

8. Two of the twelve disagreed with the statement that Second Life provided a superior to face-to-face option for continuing medical education.

The take-home message? Nothing new really: virtual environments can be very useful for education. The small sample size is obviously worth noting. Additionally, I remain amazed at the positive feedback garnered for education sessions held in Second Life given the rudimentary aspects of the platform itself i.e. the need to type responses in chat and viewing what’s essentially a Powerpoint presentation (as shown in the picture above). That’s not to take away from the work the University of Boston have done, it’s just one key aspect for future studies: how much of the positive feedback on virtual environments is the ‘wow’ factor experienced by newer users versus the well-established data on immersion and its benefits?

Another key point for me was this:

Our search of English language peer-reviewed publication databases did not identify any formal evaluation of the educational effectiveness of health professional training in SL or other virtual worlds.

Studies like this one are helping to address that gap, but there’s plenty more to be done. What’s fairly certain is that work is underway and within 12-18 months there’s likely to be a significant body of work pointing out the opportunities and challenges virtual worlds present for health-related training and education.

The past couple of weeks have seen some interesting articles in the mainstream media on virtual environments and health.

The first is in the Jerusalem Post, showing the benefits for the vision impaired. You can view the full article here.

The second appears in Information Week and covers the use of Second Life by Chicago Children’s Memorial Hospital for disaster preparedness and the work done on Virtual Ability island.

I’m noticing a slow but steady trickle of mainstream news reporting on the opportunities of virtual environments and health. The challenge is to ensure there’s really solid evidence to back those claims when they receive more widespread scrutiny.

(Originally published earlier this week over at The Metaverse Journal)

Over the past few days a product announcement and some interesting research have come together for me in illustrating some of the downsides of heavy regular use of virtual environments. I’m talking specifically about the physical impacts here: we’ve covered the psychological positives and negatives repeatedly (e.g. here and here). In regard to the psychological side, I’ve always believed the benefits and opportunities well outweigh the downsides, which is being recognised by professionals working in the area.

The research that caught my eye comes from the American Journal of Preventative Medicine, as reported by MSNBC. The researchers tested the hypothesis that gamers tended to be more overweight and had poorer mental health than non-players. The results, after surveying 552 people in the Seattle area of the US, showed that the hypothesis was essentially correct. Looking at the overweight issue, most people may say “well gee there’s no surprise there”. The gamer stereotype is certainly one of the overweight male staying up at all hours whilst eating endless bags of potato chips. Like any stereotype there can be distorted echoes of reality and this research is doing just that. I doubt there’s anyone claiming that heavy gaming or virtual environment use is good for one’s physical health in respect to exercise and nutrition. Sure, consoles like the Wii are increasing the level of physical activity but the jury is well and truly out on whether it equates to other forms of desirable physical activity. This research was conducted in 2006 but only published now, with an admission it’s just a taste for further research needing to be done – its findings however do point to the challenges for gaming, and by association, virtual environments.

The product announcement that I saw not long after the research above was for an MMO-gaming mouse produced by Razer, called the Naga. Here’s Razer’s PR pitch for it:

It’s not unique in that there’s no shortage of multi-button gaming mouses. What struck me though was the twelve buttons on the left-hand side that are designed purely for thumb use. Knowing the pace of MMO gaming at times, it seems astounding to me that you’d put one thumb through the trauma of operating twelve buttons continuously. In the five minutes-plus of sales pitch above, you’ll hear the word ‘comfort’ a few times, but that’s it. You’ll also hear a couple of mentions of statements like “playing all day” as qualifications for the level of effort that went into producing the design.

Am I alone in thinking that no matter how good the device’s ergonomics are, relying on one digit to control twelve buttons is a recipe for disaster? Sure, the heavy use of a keyboard for the same activity isn’t ideal either, but usually the repetition is spread around a few more digits if keyboard shortcuts are being used. Of course, gaming is different to broader virtual world use, but in proportion the same issues remain.

My point overall? Virtual environments are really no different to the real world in respects of the need to engage in physical activity. The ever improving development of new interface options may assist, but the reality in the short to medium term is that plenty of real world concentration on nutrition and exercise is needed. The three people I know best who are involved in virtual environments 8-16 hours a day all own pets and tend to have an exercise schedule. Do you?

(This story also appears over on The Metaverse Journal)

British firm Daden have been releasing virtual worlds products for a while now – we covered their in-world web browser last July. Their latest launch is an “open-source learning system or virtual worlds, the web and iPhone”. Its moniker is PIVOTE and it’s the result of a project called PREVIEW funded by the UK Government’s Joint Information Systems Committee (JISC). The project’s focus was problem-based learning in virtual worlds, and PIVOTE is the end-result. Paramedic training for St George’s, University of London was the initial focus that’s led to final product.

Essentially, Pivote is a web-based learning management system where detailed exercises can be formulated as fairly standard, text-driven scenarios with decision pathways, or as avatar driven exercises in Second Life or OpenSim (Daden states its platform can easily be adapted to other virtual worlds). The text-based options can also be utilised in-world via what is presumably Daden’s in-world browser. St George’s have a sim in Second Life (click here to see for yourself) that is publicly accessible.

St George’s Senior Lecturer in Paramedic Science, Alan Rice said “This programme provides the students with a fun learning environment, where they can afford to make mistakes online, which they could not afford to make in the real world. When they make a mistake online, they are always keen not to make the same mistake again.” A paramedic student at St George’s, Fiona Cropp, was happy with the virtual training process – “It’s a really useful tool. It’s much better to be able to actually perform treatments rather than just talk about it. Everyone is online at the same time so you can bounce ideas off each other and make an informed decision. I had never used Second Life before, but I found it really easy to get on with.”

A useful overview of the paramedic training scenario can be viewed here:

Pivote isn’t the first integrated training solution using virtual worlds, but it’s certainly progressed things considerably. The challenge for any platform is convincing key management that scarce health dollars should be sunk into virtual worlds-based training. Health professionals and academics are perfectly positioned to demonstrate just that, and there’s no shortage of evidence of the cost benefits of effectively trained clinicians. Anything that increases the confidence of new practitioners in the breadth of the clinical decision-making in a cost-effective way, will surely gain some traction in what is usually a very conservative space.

Anyone wanting to install PIVOTE for themselves can do so for free by installing it on their own servers or paying Daden to host it for them. The full instructions can be found by browsing the ‘Getting Started’ section of the PIVOTE website.

Rather than assessing their students through a paper-based examination, or even by having real, live people come in to pretend to be patients, it is starting to become more common to hear of healthcare educators asking their students instead to use computer applications and tools featuring digitally-created patients.

There are a myriad decisions that need to be made surrounding patient care. Students need to be able to wield a large amount of technical data, be able to think well on the fly, and be able to make quick yet considered decisions as healthcare professionals. These digitally-created, or virtual, patients can assist in building these skills.

Though virtual patients look just like the avatars that represent actual people in virtual worlds, the virtual patients usually have either an artificial intelligence (AI) or a scripted backend behind them. As opposed to an AI, the scripted backend cannot make decisions itself – instead , it follows a decision tree that has already been set before the student engages with it.

Medicine

Source 1, Source 2

MyCaseSpace is a Web-based application which presents virtual patients to students at irregular intervals throughout the span of their course. Virtual patients may contact the student at any time of the day or night, through their computer, and request a clinical consult. The virtual patients use avatars to communicate visually with students; the speech of the virtual patients can be accessed in 13 different languages. These patients use a scripted backend for their interactions, the design of which was based on video-game decision trees.

The application can easily be updated and altered to include virtual family members of the virtual patient to make demands upon the students.

Critical thinking skills used to be tested by setting examination papers; some people believe that the current set of students, being more digitally aware, will respond better to a digital presentation. Others are of the opinion that modern students have an expectation that they will continue to receive paper exams, and may have trouble with digital resources.

Though it has not been proven that this method of assessment results in either better or poorer results for the students, the professors and tutors find the system to be most beneficial for them. The application collects, stores, and processes data generated by the students’ assessments, cutting down on time and tedium, and increasing accuracy, for the marking individual.

Nurses

Source

“Nurse Island” has been set up inside Second Life by the Glasgow Caledonian University. Apart from the virtual representation of the university, built so that prospective students can learn to find their way around campus, the Nursing Skills Laboratory has been recreated and populated with virtual patients. These patients can be controlled either by an AI or by a tutor, and use text to speech synthesis rather than recorded voices.

The conversations held between patients and students are recorded, so that students can be debriefed later by a tutor. This facility will open early next year.

Paramedics

Source 1, Source 2

This Second Life project represents a partnership between St George’s, University of London and Kingston University.

Paramedic students will work in teams of three or four, and will encounter emergency scenarios in Second Life in which they will need to treat a virtual patients or patients. They will need to perform such tasks as checking the patient’s pulse, dressing wounds and administering drugs. They may also need to be able to use equipment that would typically be found in an ambulance, such as oxygen masks and electrocardiograms (ECG). After assessing and treating the patient, they must load the patient into the ambulance and set a GPS device to take them to the hospital.

On reaching the hospital, students then handover a set of patient notes to their tutor via email.

Emily Conradi, e-Projects Manager, says: “Paramedic students spend a lot of time in work placements, which can be based anywhere in the country, so it can be hard for the students to meet face-to-face with each other and with their tutors.”

CPR and emergency first aid

Source

The Italian Resuscitation Council (IRC) headquarters in Second Life (to teleport there, click here) has been set up as a place that people can be trained and re-trained, whether they be instructors, medical professionals or laypeople.

The IRC training simulations for instructors and medical people would include simulations to improve and test teamwork, leadership and technical skills. The simulations would also impart knowledge concerning CPR and other emergency training procedures.

Some of the information directed at laypeople includes cardiac arrest prevention knowledge and basic life support information.

In conclusion

Effectiveness of learning is not the only reason to use a virtual world or virtual patients. If learning is not less effective than by using other methods, and there are other benefits to the virtual alternatives, they may still be well worthwhile.