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Synoptic operative reporting has been used as a solution to the poor quality of narrative reports. The aim of this study was to develop operative report quality indicators for the laparoscopic sleeve gastrectomy and to generate parameters by which these reports can be evaluated and improved. A Delphi protocol was used to determine quality indicators for LSG. Bariatric surgeons across Canada were recruited along with key physician stakeholders to participate via a secure web-based platform. Transferrable consensus items for LSG from previously developed Roux-en-Y gastric bypass operative indictors were put forward for consideration. Participants also initially submitted potential QIs. These were grouped by theme. Items were rated on 5-point Likert scales in subsequent rounds. Scores of 70% or higher were used for inclusion and 30% or less denoted exclusion. Elements scoring 30% to 70% agreement were recirculated by runoff in subsequent rounds to generate the final list of quality indicators. Seven bariatric surgeons, representing all regions preforming LSG in Canada, were invited to participate in the Delphi group. Multidisciplinary invitees included one academic minimally invasive/acute care surgeon, one tertiary abdominal radiologist, and one academic gastroenterologist with bariatric expertise. Two rounds were required to achieve consensus. Both rounds achieved a 100% response (10/10). In round 1, forty items reached consensus. In Round 2, an additional 28 items reached consensus, with three items excluded, bringing the total number of quality indicators to 65. This study establishes consensus-derived multidisciplinary quality indicators for LSG operative reports. Application of these findings aims to advance the quality and completeness of operative reporting in LSG in order to improve communication of important surgical details and quality measures to the multidisciplinary team involved in bariatric surgery care.

Background Meckel's diverticulum is an embryologic remnant of the vitelline duct, occurring in approximately 2% of the adult population. A hernia containing a Meckel's diverticulum is called a Littre's hernia and is rarely reported in the medical literature. Clinically, a Littre's hernia is indistinguishable from a hernia containing small bowel and is often discovered incidentally during a repair. Case Presentation Herein, we report a rare case of strangulated Littre's hernia in a patient's right groin. The sac contained a long segment of small bowel in addition to a large Meckel's diverticulum. The bowel was irreducible through the groin incision, and a lower midline laparotomy was made. Necrotic bowel including the Meckel's diverticulum was resected. Given the presence of necrotic bowel and potential for infection, the hernia was repaired with a Bassini herniorrhaphy, reinforced with absorbable mesh. The patient recovered uneventfully. Conclusion Littre's hernia is a rare clinical entity. Treatment is similar to any bowel-containing hernia. Repair of the hernia defect with permanent mesh should be weighed against the risk of implant infection.

Laparoscopic adjustable gastric banding (LAGB) has declined in popularity due to poor weight loss and high revision rates. The study aim was to evaluate complication rates following LAGB removals, including conversions to other bariatric procedures. This was a retrospective cohort study of patients who underwent LAGB removal, identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database from the Toronto Western Hospital site. Patients were filtered using principal procedure and concurrent procedural terminology (CPT) codes. Patients converted to other bariatric procedures were also included. Outcomes were evaluated for 30-day morbidity, mortality, readmissions, and costs. From 2012 to 2018, 93 patients met inclusion. 96.77% had elective surgery, and 3.23% were emergent. Thirty-day postoperative complication rate was 11.83%, with 4.30% readmissions and no deaths. Surgical site infections accounted for 81.82% of complications (54.55% superficial, 27.27% deep). Thirty-day complication rate for LAGB removal alone was 17.50% and 33.33% following emergent explantation. 56.99% LAGBs were converted to other bariatric procedures: 48.39% laparoscopic Roux-en-Y gastric bypass (LRYGB) and 8.6% sleeve gastrectomy (LSG). Conversion to LSG had a significantly higher 30-day complication rate (all Clavien–Dindo class I–II) compared to conversion to LRYGB (37.50% versus 2.22%, p

Repeat preoperative endoscopy is common for patients with colorectal neoplasms. This can result in treatment delays, patient discomfort, and risks of colonoscopy-related complications. Repeat preoperative endoscopy has been attributed to poor communication between endoscopists and surgeons. In January 2019, mandatory electronic synoptic reporting for endoscopy was implemented to include elements consistent with quality indicators proposed in national guidelines. The aim of the present study is to assess whether the repeat preoperative endoscopy rate for colorectal lesions changed following synoptic report implementation. A retrospective review was performed of 1690 consecutive patients who underwent elective surgical resection for colorectal neoplasms from January 2007 to June 2020 at a tertiary hospital in Canada. Patients who had an index endoscopy documented via synoptic report were compared to those reported via narrative report. Primary outcomes were rates of repeat preoperative endoscopy and inclusion of colonoscopy quality indicators: photo-documentation, tattoo placement, and bowel preparation score. In total, 1429 patients who underwent elective colorectal resection for colorectal cancers or polyps between January 2007 and June 2020 were included. 115 had index endoscopies recorded via synoptic report and 1314 by narrative report. The repeat preoperative endoscopy rate after endoscopies documented by narrative report was 29.07% (95% CI 26.63–31.61) and 25.22% (95% CI 17.58–34.17%) for synoptic report. Patients whose index endoscopies where performed by a practitioner other than their operating surgeon had a re-endoscopy rate of 36.03% (95% CI 32.82–39.33%) after narrative report and 38.81% (95% CI 27.14–51.50%) for synoptic report. Rates of tattoo placement, photo-documentation, and reporting of bowel preparation quality were all significantly increased with synoptic reports (p ≤ 0.003). Endoscopy synoptic reports based on current guidelines were not associated with a decrease in rates of repeat pre-operative endoscopy at a high-volume colorectal cancer centre. Future study should examine guideline deficiencies for this purpose and make necessary modifications.

Background Prophylactic cholecystectomy following endoscopic retrograde cholangiopancreatography with sphincterotomy (ERCP-S) remains the gold standard management of choledocholithiasis. Some clinicians propose ERCP-S alone as the definitive management in the elderly, given perioperative complication risks. This retrospective cohort study aimed to assess the long-term efficacy and safety of non-operative management of choledocholithiasis in adults aged ≥70. Methodology A total of 252 patients aged ≥70 underwent ERCP from 2004 to 2014 at a single institution. The rates of cholecystectomy, ERCP, complications, and mortality were gathered. Data were linked to a provincial health database to capture follow-up visits to alternate hospitals. Predictors of operation, recurrence, and mortality were analyzed using multivariable regression. Results Following ERCP, of the 252 patients, 33 (13.1%) underwent prophylactic cholecystectomy within three months, while 219 (86.9%) were initially managed conservatively. Of the 219 patients, 147 (67.1%) experienced no further choledocholithiasis after conservative management, while 23 (10.5%) patients underwent cholecystectomy. The mean follow-up was 2.9 years. Delayed operative patients were younger (mean age: 77.56 vs. 82.90; p < 0.001) and had lower Charlson Comorbidity Index (CCI) (1.04 vs. 1.84; p = 0.030). When adjusted for age, CCI score, and sex, cholecystectomy was associated with increased survival, with an odds ratio of 0.48 (95% confidence interval = 0.26-0.90; p = 0.021). Perioperative complications occurred in 7/56 (12.5%) patients. Conclusions Recurrent choledocholithiasis is common in elderly patients. Despite recurrent symptoms, these patients are unlikely to undergo cholecystectomy. Surgeons operate on patients with greater life expectancy and fewer comorbidities with high success despite advanced patient age. Future prospective studies should examine objective criteria for prophylactic cholecystectomy in this population, given purported safety and benefits.

Background:Sonographic measurement of optic nerve sheath diameter (ONSD) is becoming increasingly accepted as a diagnostic modality to detect elevations in intracranial pressure. As this technique becomes more widespread, methods to address the inherent operator-dependent nature of this modality will need to be developed. We propose a novel low-cost model to accurately simulate sonographic ONSD measurement for purposes of training and assessment.Methods:We designed models composed of medical tubing of various diameters readily available from typical hospital supplies and suspended them in gelatin. The models were evaluated by ultrasound by three expert point-of-care sonographers using a standard linear array probe and technique proposed in the literature.Results:This model generates faithful simulation of the ONS that closely approximates in vivo images and can be used to produce accurate, reproducible measurements. Materials are low cost and easy to acquire and assemble.Conclusions:Our model provides realistic simulated images of the ONS. Through comparison of sonographic measurements to the known tube diameters, this model serves as a promising inexpensive tool to teach the method of ultrasound assessment of ONSD or as a way to determine accuracy of this novel ultrasound technology.

Homozygous familial hypercholesterolemia (HoFH) is a rare inherited disorder that presents as abnormally elevated levels of low-density lipoprotein cholesterol and premature heart disease, requiring frequent intervention through lipid apheresis for management. The risk of perioperative cardiac events is higher in patients with HoFH because of its pathophysiological manifestations in the vascular system. Careful cardiac precautions and anesthetic assessments are necessary to ensure patient safety. In the following case report, we discuss the clinical course and anesthetic considerations for a 14-year-old girl with HoFH undergoing sedation for dental extractions and mandibular molar uprighting in an outpatient oral surgery clinic. Considerations included the use of heparin in the patient's weekly plasma lipid apheresis treatment. In order to reduce the risks of peri- and postoperative bleeding and perioperative cardiac events, the operation was scheduled for 4 days after apheresis. This allowed for adequate heparin clearance, while also reducing the likelihood of possible cardiac events. A literature review revealed no results for the outpatient management of patients with HoFH undergoing sedation for noncardiac procedures. Our reported case serves as a clinical example for physicians to be utilized in the future.

Objective To compare the Mobility Enhancement roBotic (MEBot) wheelchair’s capabilities with commercial electric-powered wheelchairs (EPWs) by performing a systematic usability evaluation. Design Usability in effectiveness, efficacy, and satisfaction was evaluated using quantitative measures. A semistructured interview was employed to gather feedback about the users’ interaction with MEBot. Setting Laboratory testing of EPW driving performance with 2 devices in a controlled setting simulating common EPW driving tasks. Participants A convenience sample of expert EPW users (N=12; 9 men, 3 women) with an average age of 54.7±10.9 years and 16.3± 8.1 years of EPW driving experience. Interventions Not applicable. Main Outcome Measures Powered mobility clinical driving assessment (PMCDA), Satisfaction Questionnaire, National Aeronautics and Space Administration’s Task Load Index. Results Participants were able to perform significantly higher number of tasks (P=.004), with significantly higher scores in both the adequacy-efficacy (P=.005) and the safety (P=.005) domains of the PMCDA while using MEBot over curbs and cross-slopes. However, participants reported significantly higher mental demand (P=.005) while using MEBot to navigate curbs and cross-slopes due to MEBot’s complexity to perform its mobility applications which increased user’s cognitive demands. Conclusions Overall, this usability evaluation demonstrated that MEBot is a promising EPW device to use indoors and outdoors with architectural barriers such as curbs and cross-slopes. Current design limitations were highlighted with recommendations for further improvement.

Summary Trauma care delivery is a complex team-based task that requires deliberate practice. The COVID-19 pandemic has not diminished the importance of excellent trauma team dynamics. However, the pandemic hampers our ability to gather safely and train together. A mitigating solution is the provision of high-fidelity simulation training in a virtual setting. The Simulated Trauma and Resuscitation Team Training (S.T.A.R.T.T.) course has provided multidisciplinary trauma team members with skills in crisis resource management (CRM) for nearly 10 years. It has promoted collaborative learning from coast to coast, as the course typically runs at our national surgical and trauma meetings. In response to COVID-19 challenges, the course content has been modified to virtually connect 2 centres in different provinces simultaneously. High participant satisfaction suggests that the new virtual E-S.T.A.R.T.T course is able to continue to help providers develop important CRM skills in a multidisciplinary setting while remaining compliant with COVID-19 safety precautions.

In the Greco-Roman Mediterranean, gymnasiums and baths served complex social functions. More than simply places to cleanse the body or engage in exercise, these became venues for public spectacle, a purpose suggested by the design features and artistic decoration that went into the construction of these spaces. By the first and second centuries ce, in the Roman world spaces dedicated to exercise were fully integrated into multipurpose bathing venues. In their developed forms, the gymnasia and the baths were both places to view and display the body and to sustain ideological discourse focusing on youthful and dynamic physicality.

Background Procedural simulation enhances early endoscopy training. Multiple commercial simulators are available; however, their application is limited by cost and poor user compliance. First-person "shooter" (FPS) video games are popular. In this study, we aimed to show that a novel in-house designed colonoscope controller used to play an FPS video game shares similar constructs with real-life endoscopy. Methodology Participants completed the first three levels on an FPS video game, Portal (Valve Corporation, Bellevue, WA), first using a conventional controller and then the modified endoscope controller. A total of 12 expert endoscopists and 12 surgical residents with minimal endoscopy experience were evaluated based on completion time, button presses, and hand motion analyses. Results Experts outperformed novices for completion time (expert: 944 seconds; novice: 1,515 seconds; p = 0.006) and hand movements (expert: 1,263.1; novice: 2,052.6; p = 0.004) in using the novel colonoscope controller. There was no difference in button presses or total path length traveled. Furthermore, performance did not differ using conventional game controls. Conclusions Experts outperformed novices using the endoscope but not the conventional controller with respect to the economy of movement and completion time. This result confirms that our endoscope-controlled video game shares similar paradigms with real-life endoscopy and serves as a first step toward creating a more enjoyable and cheaper alternative to commercially available endoscopy simulators.

Tips and falls are the most prominent causes of wheelchair accidents that occur when driving on uneven terrains and less accessible environments. The Mobility Enhancement Robotic Wheelchair (MEBot) was designed to improve the stability of Electric Powered Wheelchairs (EPW) when driving over these environments. MEBot offers six independently height-adjustable wheels to control attitude of its seat over uneven and angled terrains. Its attitude control application uses an inertial measurement unit to detect seat angles changes to adjust each wheel-height accordingly. MEBot was compared to commercial EPWs in terms of EPW performance (seat angle changes and response time) and participant perception (satisfaction and task-load demand) towards each device. Ten participants drove their own EPW and MEBot for five trials each through driving tasks that replicated outdoor environments. Results showed less change in the pitch angle when driving up and down a 10° slope using MEBot (5.6 ± 1.6°, 6.6 ± 0.5°) compared to the participants’ own EPW (14.6 ± 2.6°, 12.1 ± 2.6°). However, MEBot required 7.8 ± 3.0 s to self-adjust to the minimum angle when driving over the tasks. Participants reported no difference in satisfaction and task load demand between EPWs due to similarities in comfort and ease-of-use. Improving the speed and efficiency of MEBot's attitude control application will be addressed in future work based upon participants’ feedback.

Summary Simulation has become a popular and ubiquitous medical education tool. In response to learner demands, and because of technological advancement, there is a trend toward increasing the realism of simulation. However, there is a paucity of evidence regarding what degree of fidelity is needed to deliver optimal simulation-based medical education. Feedback from the Simulated Trauma And Resuscitation Team Training (S.T.A.R.T.T.) course suggests that higherfidelity simulation is viewed as highly valuable to learners. Research is needed in order to guide the growing demand for higher-fidelity simulation in our medical training curricula and in order to justify or mitigate the associated costs and logistical challenges.

Point-of-care ultrasound (POCUS) has become an integral component of daily care in the surgical ICU. There have been many novel advancements in the past two decades, too numerous to count. Many are of critical importance to the intensive care physician, whereas others are still accumulating evidence. Without appropriate training, diligence, and incorporation of the ultrasound findings into the whole clinical picture, this technique can be gravely misused. This review examines POCUS use in the surgical ICU, as well as highlights potential hazards and common pitfalls.POCUS is essential for guidance of vascular access procedures, as well as in the characterization and treatment of respiratory failure, shock, and unstable blunt abdominal trauma. Ultrasound has growing evidence for rapidly evaluating many other diseases throughout the entire body, as well as guidance for procedures. Using advanced ultrasound techniques should only be done with corresponding levels of training and experience.Ultrasound in the critical care setting has become an essential component of the assessment of most ICU patients. As more evidence accumulates, along with ever-increasing availability of ultrasound technology, its use will continue to expand. It, thus, behoves clinicians to not only ensure they are adept at obtaining and interpreting POCUS images but also efficiently incorporate these skills into holistic bedside care without delaying lifesaving therapies.

Objective Manual lifting can be burdensome for people who care for power wheelchair users. Although technologies used for dependent transfers are helpful, they have shortcomings of their own. This study compares the usability and task load demand of a novel robot-assisted transfer device to a clinical standard when performing dependent transfers. Design A cross-sectional study was conducted to assess caregivers (N = 21) transferring a 56-kg mannequin with the Strong Arm and Hoyer Advance at three transfer locations. Feedback was gathered through qualitative surveys. Results Usability was significant in multiple areas important for transfers. Caregiver fatigue and discomfort intensity were reduced, and the Strong Arm was preferred at the three transfer locations. Device ease and efficiency favored Strong Arm at two stations as was discomfort frequency. In addition, physical demand, frustration, and effort were significantly lower using Strong Arm compared with the Hoyer Advance. Conclusions Compared with the Hoyer, participants favored Strong Arm for transfer usability and task load demand. However, further Strong Arm developments are needed.

In this paper we describe results from the first year of field study examining U.S. Air Force (USAF) F-16 pilots’ trust of the Automatic Ground Collision Avoidance System (Auto-GCAS). Using semistructured interviews focusing on opinion development and evolution, system transparency and understanding, the pilot–vehicle interface, stories and reputation, usability, and the impact on behavior, we identified factors positively and negatively influencing trust with data analysis methods based in grounded theory. Overall, Auto-GCAS is an effective life-/aircraft-saving technology and is generally well received and trusted appropriately, with trust evolving based on factors including having a healthy skepticism of the system, attributing system faults to hardware problems, and having trust informed by reliable performance (e.g., lives saved). Unanticipated findings included pilots reporting reputation to not be negatively affected by system activations and an interface anticipation cue having the potential to change operational flight behavior. We discuss emergent research avenues in areas of transparency and culture, and values of conducting trust research with operators of real-world systems having high levels of autonomy.

Background: The task of performing transfers, such as from a wheelchair to a bed, has a high risk of injury to both the caregiver and the person being transferred. Although mechanical transfer devices can reduce these risks, these devices are not meant for use in the community and they still place strain on the caregiver when used. Purpose: The aim of this study is to describe feedback gathered from focus groups of potential users of the Robotic-Assisted Transfer Device (RATD) and describe design changes aimed at preparing the device for the next step in the development process. Method: The RATD was transferred to a newer electric-powered wheelchair (EPW), key components were redesigned, and the control program was updated to increase the safety of the device. Two focus groups, one consisting of people with disabilities and the other consisting of clinicians and caregivers, were conducted to gather feedback from potential users. Results: Error checking, safety zones, a motor brake, and a new track helped increase the safety of the device. Sixty-three percent of the people with disabilities and 83% of caregivers surveyed said they would use the device. Conclusions: The results from the focus groups were positive and the design changes were successful, but more development is needed before the RATD can be marketed.

Created more than 30 years ago, 3-dimensional printing (3DP) has recently seen a meteoric rise in interest within medicine, and the field of Physical Medicine and Rehabilitation is no exception. Also called additive manufacturing (AM), the recent increase in the use of 3DP is likely due to lower-cost printers as well as breakthroughs in techniques and processing. This thematic narrative review serves to introduce the rehabilitation professional to 3DP technology and how it is being applied to orthoses, prostheses, and assistive technology (AT). The basics of the technology, as well as the benefits and challenges of using it within the rehabilitation framework, are described. Proponents of the technology suggest that 3DP offers not only a better way to make devices, but a better way to make improved devices. However, the strength of this claim has not been properly tested by the current literature. This narrative review evaluates the evidence and provides a discussion of possible implications for the rehabilitation professional.

A sensorized air cell-based seat cushion system was developed to address the issues of loading magnitude and duration at a sitting interface to aid in reducing risk of sitting acquired pressure ulcers. This system is capable of pressure mapping, redistribution, and offloading which were verified using an anthropomorphic model and a human subject. The system is comprised of an air cell array cushion, a pneumatic control unit, and a graphical user interface. ISO load deflection testing confirmed that the cushion's loading response is comparable to commercial air cell-based seat cushions. Testing demonstrated that the internal pressure of the air cells are indicative of interface pressure and can be used as input to pressure modulating algorithms. Uniform pressure distribution was achieved through automated pressure redistribution algorithm implementation where the immersion of a subject into the seat cushion increased and interface pressure decreased. High pressure point identification and automatic offloading were performed in which newly created high pressure points were addressed using subsequent redistribution. Pressure mapping enabled offloading and redistribution can objectively manage the effects of loading magnitude and duration at the sitting interface.

Electric powered wheelchairs (EPWs) are essential devices for people with disabilities as aids for mobility and quality of life improvement. However, the design of currently available common EPWs is still limited and makes it challenging for the users to drive in both indoor and outdoor environments such as uneven surfaces, steep hills, or cross slopes, making EPWs susceptible to loss of stability and at risk for falls. An alternative wheel-legged robotic wheelchair, "MEBot", was designed to improve the safety and mobility of EPW users in both indoor and outdoor environments. MEBot is able to elevate its six wheels using pneumatic actuators, as well to detect changes in the seat angle using a gyroscope and accelerometer. This capability enables MEBot to provide sensing for a dynamic self-leveling seat application that can maintain the center of mass within the boundaries of the wheelchair, thereby, improving EPW safety. To verify the effectiveness of the application, MEBot was tested on a motion platform with six degrees of freedom to simulate different slopes that could be experienced by the EPW in outdoor environments. The results demonstrate the robustness of the application to maintain the wheelchair seat in a horizontal reference against changes in the ground angle.

Background: Electric-powered wheelchairs (EPWs) are essential devices for people with disabilities for mobility and quality of life. However, the design of common EPWs makes it challenging for users to overcome architectural barriers, such as curbs and steep ramps. Current EPWs lack stability, which may lead to tipping the EPW causing injury to the user. An alternative Mobility Enhancement Robotic Wheelchair (MEBot), designed at the Human Engineering Research Laboratories (HERL), was designed to improve the mobility of, and accessibility for, EPW users in a wide variety of indoor and outdoor environments. Seat height and seat inclination can be adjusted using pneumatic actuators connected to MEBot's 6 wheels. Method: This article discusses the design and development of MEBot, including its kinematics, stability margin, and calculation of the center of mass location when performing its mobility applications of curb climbing/descending and attitude control. Motion capture cameras recorded the seat angle and joint motion of the 6 wheel arms during the curb climbing/descending process. The center of mass location was recorded over a force plate for different footprint configurations. Results: Results showed that the area of the footprint changed with the location of the wheels during the curb climbing/descending and attitude control applications. The location of the center of mass moved ±30 mm when the user leaned sideways, and the seat roll and pitch angle were 0° and ±4.0°, respectively, during curb climbing and descending. Conclusion: Despite the user movement and seat angle change, MEBot maintained its stability as the center of mass remained over the wheelchair footprint when performing its mobility applications.

Background. New sonographic quality criteria to optimize optic nerve sheath diameter (ONSD) measurements were suggested. The latter were correlated to elevated intracranial pressure (ICP) in traumatic brain injury (TBI). Aim. We investigated whether ONSD measurements were correlated to simultaneous ICP measurements in severe TBI. Methods. Forty patients with severe TBI (Marshall Scale ≥II and GCS ≤8) participated in the study. All patients had an intraparenchymal ICP catheter inserted, while ONSD was measured bilaterally, upon admission and over the next 48 hours, based on the new sonographic criteria. A total of 400 ONSD measurements were performed, while mean ONSD values of both eyes were used in the analysis. Results. ONSD measurements were strongly correlated to ICP values (r=0.74, p<0.0001). Receiver operator curve (ROC) analysis revealed that the ONSD cutoff value for predicting elevated ICP was 6.4 mm when using the mean of both eyes (AUC = 0.88, 95% CI = 0.80 to 0.95; sensitivity = 85.3%, specificity = 82.6%). Linear regression analysis nested models revealed that sex (p=0.006) and height (p=0.04) were significant predictors of ONSD values. Conclusion. When applying the new sonographic quality criteria, ONSD is strongly correlated to ICP in severe TBI. Whether to use such criteria to monitor ONSD as a proxy for ICP trend in TBI remains to be further explored.

The true value of a human-machine team (HMT) consisting of a capable human and an automated or autonomous system will depend, in part, on the richness and dynamic nature of the interactions and degree of shared awareness between the human and the technology. Contemporary views of HMTs emphasize the notion of bidirectional transparency, one type of which is Robot-of-Human (RoH) transparency. Technologies that are capable of RoH transparency may have awareness of human physiological and cognitive states, and adapt their behavior based on these states thus providing augmentation to operators. Yet despite the burgeoning presence of health monitoring devices, little is known about how humans feel about an automated system using sensing capabilities to augment them in a work environment. The current study provides some preliminary data on user acceptance of sensing capabilities on automated systems. The present research examines an emerging predictor of trust in automation, Perfect Automation Schema, as a predictor of trust in the sensing capabilities. Additionally, the current study examines trust of a human wingman as an analogy for looking at trust within the context of a HMT. The findings suggest that Perfect Automation Schema is related to some facets of sensing technology acceptance. Further, trust of a human wingman is contingent on familiarity and experience.

The design of the mobility enhancement robotic wheelchair (MEBot) was based on input from electric powered wheelchair (EPW) users regarding the conditions they encounter when driving in both indoor and outdoor environments that may affect their safety and result in them becoming immobilized, tipping over, or falling out of their wheelchair. Phase I involved conducting a participatory design study to understand the conditions and barriers EPW users found to be difficult to drive in/over. Phase II consisted of creating a computer-aided design (CAD) prototype EPW to provide indoor and outdoor mobility that addressed these conditions with advanced applications. Phase III involved demonstrating the advanced applications and gathering feedback from end users about the likelihood they would use the advanced applications. The CAD prototype incorporated advanced applications, including self-leveling, curb climbing, and traction control, that addressed the challenging conditions and barriers discussed with EPW users (n = 31) during the participatory design study. Feedback of the CAD design and applications in phase III from end users (n = 12) showed a majority would use self-leveling (83%), traction control (83%), and curb climbing (75%). The overall design of MEBot received positive feedback from EPW users. However, these opinions will need to be reevaluated through user trials as the design advances.

Within human factors there is burgeoning interest in the “human-autonomy teaming” (HAT) concept as a way to address the challenges of interacting with complex, increasingly autonomous systems. The HAT concept comes out of an aspiration to interact with increasingly autonomous systems as a team member, rather than simply use automation as a tool. The authors, and others, have proposed core tenets for HAT that include bi-directional communication, automation and system transparency, and advanced coordination between human and automated teammates via predefined, dynamic task sequences known as “plays.” It is believed that, with proper implementation, HAT should foster appropriate teamwork, thus increasing trust and reliance on the system, which in turn will reduce workload, increase situation awareness, and improve performance. To this end, HAT has been demonstrated and/or studied in multiple applications including search and rescue operations, healthcare and medicine, autonomous vehicles, photography, and aviation. The current paper presents one such effort to apply HAT. It details the design of a HAT agent, developed by Human Automation Teaming Solutions, Inc., to facilitate teamwork between the automation and the human operator of an advanced ground dispatch station. This dispatch station was developed to support a NASA project investigating a concept called Reduced Crew Operations (RCO); consequently, we have named the agent R-HATS. Part of the RCO concept involves a ground operator providing enhanced support to a large number of aircraft with a single pilot on the flight deck. When assisted by R-HATS, operators can monitor and support or manage a large number of aircraft and use plays to respond in real-time to complicated, workload-intensive events (e.g., an airport closure). A play is a plan that encapsulates goals, tasks, and a task allocation strategy appropriate for a particular situation. In the current implementation, when a play is initiated by a user, R-HATS determines what tasks need to be completed and has the ability to autonomously execute them (e.g., determining diversion options and uplinking new routes to aircraft) when it is safe and appropriate. R-HATS has been designed to both support end users and researchers in RCO and HAT. Additionally, R-HATS and its underlying architecture were developed with generaliz ability in mind as a modular software applicable outside of RCO/aviation domains. This paper will also discuss future further development and testing of R-HATS.

Purpose The impact of a quality-assessment dashboard and individualized pharmacist performance feedback on the adherence of order verification was evaluated. Methods A before-and-after study was conducted at a 1,440-bed academic medical center. Adherence of order verification was defined as orders verified according to institution-derived, medication-related guidelines and policies. Formulas were developed to assess the adherence of verified orders to dosing guidelines using patient-specific height, weight, and serum creatinine clearance values from the electronic medical record at the time of pharmacist verification. A total of 5 medications were assessed by the formulas for adherence and displayed on the dashboard: ampicillin–sulbactam, ciprofloxacin, piperacillin–tazobactam, acyclovir, and enoxaparin. Adherence of order verification was assessed before (May 1–July 31, 2015) and after (November 1, 2015–January 31, 2016) individualized performance feedback was given based on trends identified by the quality-assessment dashboard. Results There was a significant increase in the overall adherence rate postintervention (90.1% versus 91.9%, p = 0.040). Among the 34 pharmacists who participated, the percentage of pharmacists with at least 90% overall adherence increased postintervention (52.9% versus 70.6%, p = 0.103). Time to verification was similar before and after the study intervention (median, 6.0 minutes; interquartile range, 3–13 minutes). The rate of documentation for nonadherent orders increased significantly postintervention (57.1% versus 68.5%, p = 0.019). Conclusion The implementation of the quality-assessment dashboard, educational sessions, and individualized performance feedback significantly improved pharmacist order-verification adherence to institution-derived, medication-related guidelines and policies and the documentation rate of nonadherent orders.

Autonomous systems dominate future Department of Defense (DoD) strategic perspectives, yet little is known regarding the trust barriers of these future systems as few exemplars exist from which to appropriately baseline reactions. Most extant DoD systems represent “automated” versus “autonomous” systems, which adds complexity to our understanding of user acceptance of autonomy. The trust literature posits several key trust antecedents to automated systems, with few field applications of these factors into the context of DoD systems. The current paper will: (1) review the trust literature as relevant to acceptance of future autonomy, (2) present the results of a qualitative analysis of trust barriers for two future DoD technologies (Automatic Air Collision Avoidance System [AACAS]; and Autonomous Wingman [AW]), and (3) discuss knowledge gaps for implementing future autonomous systems within the DoD. The study team interviewed over 160 fighter pilots from 4th Generation (e.g., F-16) and 5th Generation (e.g., F-22) fighter platforms to gauge their trust barriers to AACAS and AW. Results show that the trust barriers discussed by the pilots corresponded fairly well to the existing trust challenges identified in the literature, though some nuances were revealed that may be unique to DoD technologies/operations. Some of the key trust barriers included: concern about interference during operational requirements; the need for transparency of intent, function, status, and capabilities/limitations; concern regarding the flexibility and adaptability of the technology; cyber security/hacking potential; concern regarding the added workload associated with the technology; concern for the lack of human oversight/decision making capacity; and doubts regarding the systems’ operational effectiveness. Additionally, the pilots noted several positive aspects of the proposed technologies including: added protection during last ditch evasive maneuvers; positive views of existing fielded technologies such as the Automatic Ground Collision Avoidance System; the potential for added operational capabilities; the potential to transfer risk to the robotic asset and reduce risk to pilots; and the potential for AI to participate in the entire mission process (planning-execution-debriefing). This paper will discuss the results for each technology and will discuss suggestions for implementing future autonomy into the DoD.

The ability of people with disabilities to live in their homes and communities with maximal independence often hinges, at least in part, on their ability to transfer or be transferred by an assistant. Because of limited resources and the expense of personal care, robotic transfer assistance devices will likely be in great demand. An easy-to-use system for assisting with transfers, attachable to electrical powered wheelchairs (EPWs) and readily transportable, could have a significant positive effect on the quality of life of people with disabilities. We investigated the stability of our newly devel- oped Strong Arm, which is attached and integrated with an EPW to assist with transfers. The stability of the system was analyzed and verified by experiments applying different loads and using different system configurations. The model predicted the distributions of the system's center of mass very well com- pared with the experimental results. When real transfers were conducted with 50 and 75 kg loads and an 83.25 kg dummy, the current Strong Arm could transfer all weights safely with- out tip-over. Our modeling accurately predicts the stability of the system and is suitable for developing better control algo- rithms to enhance the safety of the device.

This paper describes the development of a mobile base for the Personal Mobility and Manipulation Appliance Generation II (PerMMA Gen II robotic wheelchair), an obstacle-climbing wheelchair able to move in structured and unstructured environments, and to climb over curbs as high as 8 inches. The mechanical, electrical, and software systems of the mobile base are presented in detail, and similar devices such as the iBOT mobility system, TopChair, and 6X6 Explorer are described.The mobile base of PerMMA Gen II has two operating modes: "advanced driving mode" on flat and uneven terrain, and "automatic climbing mode" during stair climbing. The different operating modes are triggered either by local and dynamic conditions or by external commands from users. A step-climbing sequence, up to 0.2 m, is under development and to be evaluated via simulation. The mathematical model of the mobile base is introduced. A feedback and a feed-forward controller have been developed to maintain the posture of the passenger when driving over uneven surfaces or slopes. The effectiveness of the controller has been evaluated by simulation using the open dynamics engine tool.Future work for PerMMA Gen II mobile base is implementation of the simulation and control on a real system and evaluation of the system via further experimental tests.

Advances in electric motors, electronics, and control systems have enhanced the capability and drivability of electric power mobility devices over the last 60 years. Yet, battery technologies used in powered mobility devices (PMDs) have not kept pace. Recent advances in pneumatic technology, primarily the high torque, low speed design of rotary piston air motors, directly align with the needs of PMD. Pneumatic technology has advantages over battery-powered technology, including lighter weight, lower operating costs, decreased environmental impact, better reliability, and increased safety. Two prototypes were created that incorporated rotary piston air motors, high-pressure air tanks, and air-pressure regulators. Prototype 1 was created by modifying an existing electric PMD. Range tests were performed to determine the feasibility of pneumatic technology and the optimal combination of components to allow the longest range possible at acceptable speeds over ideal conditions. Using a 1.44 L air tank for feasibility testing, prototype 1 was capable of traveling 800 m, which confirmed the feasibility of pneumatic technology usage in PMDs. Prototype 2 was designed based on the testing results from prototype 1. After further optimization of prototype 2, the average maximum range was 3,150 m. Prototype 2 is up to 28.3% lighter than an equivalent size electric PMD and can be fully recharged in approximately 2 minutes. It decreases the cost of PMDs by approximately $1,500, because batteries do not need to be replaced over the lifetime of the device. The results provide justification for the use of pneumatic technology in PMDs.

Background Ultrasound measurement of optic nerve sheath diameter (ONSD) appears to be a promising, rapid, non-invasive bedside tool for identification of elevated intra-cranial pressure. With improvements in ultrasound technology, machines are becoming smaller; however, it is unclear if these ultra-portable handheld units have the resolution to make these measurements precisely. In this study, we estimate the accuracy of ONSD measurement in a pocket-sized ultrasound unit. Methods Utilizing a locally developed, previously validated model of the eye, ONSD was measured by two expert observers, three times with two machines and on five models with different optic nerve sheath sizes. A pocket ultrasound (Vscan, GE Healthcare) and a standard portable ultrasound (M-Turbo, SonoSite) were used to measure the models. Data was analyzed by Bland–Altman plot and intra-class correlation coefficient (ICC). Results The ICC between raters for the SonoSite was 0.878, and for the Vscan was 0.826. The between-machine agreement ICC was 0.752. Bland–Altman agreement analysis between the two ultrasound methods showed an even spread across the range of sheath sizes, and that the Vscan tended to read on average 0.33 mm higher than the SonoSite for each measurement, with a standard deviation of 0.65 mm. Conclusions Accurate ONSD measurement may be possible utilizing pocket-sized, handheld ultrasound devices despite their small screen size, lower resolution, and lower probe frequencies. Further study in human subjects is warranted for all newer handheld ultrasound models as they become available on the market.

We performed a human-in-the-loop study to explore the role of transparency in engendering trust and reliance within highly automated systems. Specifically, we examined how transparency impacts trust in and reliance upon the Autonomous Constrained Flight Planner (ACFP), a critical automated system being developed as part of NASA's Reduced Crew Operations (RCO) Concept. The ACFP is designed to provide an enhanced ground operator, termed a super dispatcher, with recommended diversions for aircraft when their primary destinations are unavailable. In the current study, 12 commercial transport rated pilots who played the role of super dispatchers were given six time-pressured “all land” scenarios where they needed to use the ACFP to determine diversions for multiple aircraft. Two factors were manipulated. The primary factor was level of transparency. In low transparency scenarios the pilots were given a recommended airport and runway, plus basic information about the weather conditions, the aircraft types, and the airport and runway characteristics at that and other airports. In moderate transparency scenarios the pilots were also given a risk evaluation for the recommended airport, and for the other airports if they requested it. In the high transparency scenario additional information including the reasoning for the risk evaluations was made available to the pilots. The secondary factor was level of risk, either high or low. For high-risk aircraft, all potential diversions were rated as highly risky, with the ACFP giving the best option for a bad situation. For low-risk aircraft the ACFP found only low-risk options for the pilot. Both subjective and objective measures were collected, including rated trust, whether the pilots checked the validity of the automation recommendation, and whether the pilots eventually flew to the recommended diversion airport. Key results show that: 1) Pilots' trust increased with higher levels of transparency, 2) Pilots were more likely to verify ACFP's recommendations with low levels of transparency and when risk was high, 3) Pilots were more likely to explore other options from the ACFP in low transparency conditions and when risk was high, and 4) Pilots' decision to accept or reject ACFP's recommendations increased as a function of the transparency in the explanation. The finding that higher levels of transparency was coupled with higher levels of trust, a lower need to verify other options, and higher levels of agreement with ACFP recommendations, confirms the importance of transparency in aiding reliance on automated recommendations. Additional analyses of qualitative data gathered from subjects through surveys and during debriefing interviews also provided the basis for new design recommendations for the ACFP.

The use of explosive armaments during Operation Iraqi Freedom, Operation Enduring Freedom, and Operation New Dawn has resulted in a significant number of injured U.S. service members. These weapons often generate substantial extremity trauma requiring multiple surgical procedures to preserve life, limb, and restore function. For those individuals who require multiple surgeries, the use of patient-controlled analgesia (PCA) devices can be an effective way to achieve adequate pain management and promote successful rehabilitation and recovery during inpatient treatment. A subpopulation of patients are unable to independently control a PCA device because of severe multiple limb dysfunction and/or loss. In response to the needs of these patients, our team designed and developed a custom adaptor to assist service members who would otherwise not be able to use a PCA. Patient feedback of the device indicated a positive response, improved independence, and overall satisfaction during inpatient hospitalization.

The current research discusses transparency as a means to enable trust of automated systems. Commercial pilots (N = 13) interacted with an automated aid for emergency landings. The automated aid provided decision support during a complex task where pilots were instructed to land several aircraft simultaneously. Three transparency conditions were used to examine the impact of transparency on pilot’s trust of the tool. The conditions were: baseline (i.e., the existing tool interface), value (where the tool provided a numeric value for the likely success of a particular airport for that aircraft), and logic (where the tool provided the rationale for the recommendation). Trust was highest in the logic condition, which is consistent with prior studies in this area. Implications for design are discussed in terms of promoting understanding of the rationale for automated recommendations.

Participation in exercise and sport, such as throwing events, can have a positive effect on both the physical and physiological health of people with disabilities. While the biomechanics of seated throwing athletics has been studied, there is paucity of literature that focuses on chairs for this sport. This work describes the design and evaluation of a highly adjustable chair for throwing athletics. A prototype was designed, fabricated, and evaluated by 19 participants at the 2010 National Veterans Wheelchair games. Participants conveyed their thoughts on the chair in an interview, which followed a throwing session. The participants indicated a positive response to the device citing improved range of motion as its best feature. Future work should focus on quantitative data collection and improvement in the designs portability.

The ability to perform activities of daily living and mobility-related activities of daily living are substantial indicators of one's ability to live at home and to participate in one's community. Technologies to assist with mobility and manipulation are among the most important tools that clinicians can provide to people with disabilities to promote independence and community participation. For people with severe disabilities involving both the upper and lower extremities, there are few systems that provide practical and coordinated assistance with mobility and manipulation tasks. The personal mobility and manipulation appliance (PerMMA) was created in response to goals set forth by a team of clinicians and people with disabilities.

The Director's Forum series is edited by Robert J. Weber and Scott M. Mark and is designed to guide pharmacy leaders in establishing patient-centered services in hospitals and health systems. This article focuses on meaningful use and the impact and opportunity for pharmacists to influence the way in which it will be embraced within a given hospital and the role that pharmacy will have in meeting key metrics.

For people with significant mobility impairments who also have both lower and upper limb disability, there are few technology solutions. The aim of this article is to describe the design and development of the Personal Mobility and Manipulation Appliance, a device that provides coordinated mobility and bimanual manipulation for people with both lower and upper limb impairment. The Personal Mobility and Manipulation Appliance is integrated from several commercial products and custom technologies, including two robotic arms mounted on a mobile robotic base. It has three primary operating modes: local user, remote user, and autonomous. It also has a cooperative control mode where two or more of the primary modes can be used simultaneously. The device was evaluated in a kitchen and was able to perform several complex tasks. Future work should focus on interface improvements and evaluations by end users.

The Director's Forum series is edited by Robert J. Weber and Scott M. Mark and is designed to guide pharmacy leaders in establishing patient-centered services in hospitals and health systems. This article focuses on an important program for expanding pharmacy practice models to uninsured and underinsured patients. The 340B program provides assistance to hospitals on drug pricing to allow organizations sufficient additional savings to channel to patients in need. The regulations surrounding eligibility, drug pricing, and pharmacy contracting are complex and can make participating in 340B seem intimidating and unattractive to potentially eligible organizations. By gaining further understanding of the intricacies of the 340B Drug Pricing Program, pharmacists and other health care providers can utilize the program to maximize the benefit for both their patients and their organization.

The purpose of this study was to evaluate the effects of three different control methods on driving speed variation and wheel-slip of an electric-powered wheelchair (EPW). A kinematic model as well as 3-D dynamic model was developed to control the velocity and traction of the wheelchair. A smart wheelchair platform was designed and built with a computerized controller and encoders to record wheel speeds and to detect the slip. A model based, a proportional-integral-derivative (PID) and an open-loop controller were applied with the EPW driving on four different surfaces at three specified speeds. The speed errors, variation, rise time, settling time and slip coefficient were calculated and compared for a speed step-response input. Experimental results showed that model based control performed best on all surfaces across the speeds.

Unmanned aerial systems, advanced cockpits, and air traffic management are all seeing dramatic increases in automation. However, while automation may take on some tasks previously performed by humans, humans will still be required to remain in the system for the foreseeable future. The collaboration between humans and these increasingly autonomous systems will begin to resemble cooperation between teammates, rather than simple task allocation. It is critical to understand this human-autonomy teaming (HAT) to optimize these systems in the future. One methodology to understand HAT is by identifying recurring patterns of HAT that have similar characteristics and solutions. This paper applies a methodology for identifying HAT patterns to an advanced cockpit project.

The purpose of this research was to study directional stability during reversing of rear-wheel drive, electric powered wheelchairs (EPW) under different initial front caster orientations. Specifically, the weight distribution differences caused by certain initial caster orientations were examined as a possible mechanism for causing directional instability that could lead to accidents. Directional stability was quantified by measuring the drive direction error of the EPW by a motion analysis system. The ground reaction forces were collected to determine the load on the front casters, as well as back-emf data to attain the speed of the motors. The drive direction error was found to be different for various initial caster orientations. Drive direction error was greatest when both casters were oriented 90 degrees to the left or right, and least when both casters were oriented forward. The results show that drive direction error corresponds to the loading difference on the casters. The data indicates that loading differences may cause asymmetric drag on the casters, which in turn causes unbalanced torque load on the motors. This leads to a difference in motor speed and drive direction error.