The Future of Medical Video: DITM Reports From NAB 2008

I had the distinct pleasure of attending the 2008 National Association of Broadcasters (NAB) meeting last week in Las Vegas. As the foremost event for the TV, broadcast, and media industries this is the venue to see and explore the future of all things video and media.

The Floor of the Meeting and a Sea of Humanity- Why I Went

the floor of the nab 2008 meetingBeing probably the only physician in a sea of 105,000 TV and media folks raises the inevitable question- why did I go?

Endoscopic surgery (laparoscopy hysteroscopy arthroscopy etc) all share the common use of video equipment. Since the late 70′s these procedures are performed as remote surgery looking through a thin telescope inserted into a body cavity and observed on a TV monitor.

The progress we make in medical video surgery is a direct trickle down of innovations from the broadcast arena. From the first CCD camera hooked to a laparoscope and suspended from the ceiling via a jerry-rigged boom to the first use of HDTV in the OR – broadcast and TV technology drives innovation in surgical video.

I thrive on researching new technology and then extrapolating new solutions to medical problems using these developments. This meeting provides the raw material for my creative process.

I was honored to accept invitations from several major broadcast, video, computer, and even surgical companies to attend the meeting, walk the floor with them, brainstorm new ways of helping patients with new devices and predict future needs and uses for technology in medicine.

Everybody kept asking me: What was the most important development I saw at the show? What future technology do I predict is poised to transform medicine?

Beyond the entire rooms filled with the latest newschoppers and remote satellite trucks

I was most impressed with the following technologies which have the potential to transform both consumer entertainment and medical devices- I will be posting further about each of these and what I saw (including a series of interviews):

  1. Beyond HDTV- “ultra HD” 4k cameras and displays
  2. 3D video technology in SD and HD
  3. OLED display technology
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FDA Update: Ophthalmic Device Panel Meeting To Review LASIK Safety

eyeballLASIK Safety Review

On April 25, 2008, the committee will discuss general issues concerning the experience and quality of life of patients who have had LASIK.

How Serious is the Problem?  Are the Patients Going Blind?

Dr. Daniel Schultz, director of FDA’s Center for Devices and Radiological Health, said a number of concerns have been raised concerning patient satisfaction with LASIK.

Companies that could be affected by such a meeting include LASIK device makers such as Advanced Medical Optics Inc, as well as LASIK providers such as TLC Vision Corp and LCA-Vision Inc.

Obviously, it’s a technology that has caught on and is used very, very widely. And there have been questions raised in terms of … quality of life and what does it actually do for the patient as opposed to the technology itself,” Schultz told reporters.  Shultz said the meeting will focus on the quality of patients’ lives after surgery.

Known complications from the procedure can include dry eyes, glare, double vision, an increased risk of corneal inflammation or infection, and blindness.

Patients Call for Ban: In July 2007, the FDA responded to petitions from an individual asking for a halt to the procedures and a withdrawal of their approval. The agency said the devices were safe and effective but advisory panel discussions “could complement” its other safety monitoring.

The Boston Globes writes on the adverse effect of the current economic downturn on Lasik numbers and the potential adverse effect of this meeting on Lasik businesses.

But the declining U.S. economy continues to impact the number of laser vision correction surgeries, and Biegelsen cautioned investors that the outcome of the upcoming FDA Lasik advisory committee meeting on April 25 will likely be neutral at best.

“A best case scenario is little-to-no negative headlines in the media and the panel endorses the long safety of Lasik and encourages further use of femtosecond lasers,” he wrote in a note to clients. “On the downside, negative media coverage of unhappy Lasik patients and a panel recommendation to narrow the indications could drive volume down further. We think the most important variable is the media coverage which tends to be negative.”

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New FDA 510(k) Approvals for March 2008-(pt.1) New Video Monitor Screens

The FDA has published its 510(k) approval letters for March 2008. In terms of surgery, endoscopy, and imaging a few items caught my eye. The first is a pair of high resolution monitors from Eizo.

Eizo is upgrading both monchrome and color workstations to 5-megapixel units. This will be useful for radiologic workstations.

Here is the text from the FDA

DEVICE: 5 MEGAPIXEL MONOCHROME LCD MONITOR, MODEL RADIFORCE GS520 EIZO NANAO CORPORATION 510(k) NO: K080422(SPECIAL)
ATTN: HIROAKI HASHIMOTO PHONE NO : 81 76 2742468 153 SHIMOKASHIWANO-CHO SE DECISION MADE: 10-MAR-08 HAKUSAN, ISHIKAWA-KEN, JAPAN 924-8510(k)

DEVICE: COLOR LCD MONITOR, MODEL RADIFORCE RX211 EIZO NANAO CORPORATION 510(k) NO: K080457(SPECIAL)
ATTN: HIROAKI HASHIMOTO PHONE NO : 817 627 42468 153 SHIMOKASHIWANO-CHO SE DECISION MADE: 20-MAR-08 HAKUSAN, ISHIKAWA-KEN, JAPAN 924-8510(k)

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New Technique Sees Inside Blood Vessels in a Microsecond

Technology Review is reporting on a new technology to look inside the tiniest spaces such as blood vessels in a microsecond. Up until now endoscopic surgery has been limited as engineers tried to shrink telescopes to ever smaller diameters shifting from glass lenses to fiberoptic scopes to newer technologies. You can read my brief history and overview of microendoscopy here.

The new scope is based on optical coherence tomography but now uses new mathematical image analysis. Read the full article if you are interested in the heavy technical foundations of the system.

Suffice it to say, the system is a sort of “ultrahigh resolution optical ultrasound” and the new modification allows it to process the signal so fast that it could be used inside blood vessels without needing to interrupt blood flow and flush out the blood. The players in this development are two compnaies – LightLab and CardioSpectra of Austin, TX. The latter company was recently purchased by Volcano, one of the leading manufacturers of IVUS products for $25M.

Example of an OCT image of a fingertip (standard old OCT system)

Basic Explanation of How the Foundation Technology of OCT Works from wiki

“OCT is a technique for obtaining sub-surface images of materials at a resolution equivalent to a low-power microscope. It is effectively ‘optical ultrasound’, imaging reflections from within tissue to provide cross-sectional images. It is attracting a great deal of interest in the medical community, because of its potential to provide images at a far higher resolution (better than 10 µm) than is possible with other imaging modalities such as MRI or ultrasound.”

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Bizarre Russian Interactive Art is Surgery Control Concept!

I have written many times on the concept of what I call “gesture control”. This is the idea of waving your arm or hand in a movement that is picked up by sensors (optical or other tracking) and which is then translated into the movement of a robotic surgical device, OR room or equipment control, or energy delivery system. You can see all these posts by clicking gesture control on the category drop down on the sidebar. Some faves are here here and here.

Lily Chaos has reviewed a bizzare interactive Russian art display that employs gesture control concepts.

She writes

A new video art installation by Russian media artist Sergey Kotsun invites the viewer to become the author and main character of an interactive audio-visual performance.

The viewer’s image is captured via a webcam and thrown up onto a projection screen. On the screen, two lines of transparent square boxes are also displayed, with the lines approaching each other at the top and veering away at the bottom, almost forming two sides of a triangle. Inside the boxes are different geometrical shapes.

As the viewer waves or makes other motions that can be picked up by the webcam, a computer program analyzes those movements. Any time a movement is perceived to intersect with one of the transparent squares, the corresponding geometrical shape displays onscreen and the sound of a musical instrument is played.

The viewer, in effect, becomes the artist as well as an integral part of the performance, creating movements that translate into sounds and abstract compositions of circles, squares, lines and half-moons. Kind of like playing an air banjo from inside a colorful kaleidoscope.

Here is a video of it in play- too Yoko Ono for my musical taste but pay attention to how the participant’s gestures are picked up by the camera and converted into actions- the same principle I advocate in the OR.

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If you have a webcam you can try a home demo!

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Glimpse the Future of Medicine at a Cell-Phone Convention: What is 4G?

The annual cell-phone (I should say wireless) convention of the year just wound up over at CTIA in Vegas. Usually these meeting spark some idea in me due to a new device or new wireless technology such as a universal wireless device charger, or an image recognition and analysis system that can lead to a future medical device. No such individual device or software at this meeting- but much bigger I am amazed at the awesome potential of the next generation wireless system in general: 4G wireless. This always on technology promises a wireless future where multiple devices that are always on will pull and deliver all sorts of data from your patients or surgical devices. A 4G system will be able to provide a comprehensive solution where voice, data and streamed multimedia can be given to users on an “Anytime, Anywhere” basis, and at higher data rates.

My analysis of the awards given out at CTIA was struck by the focus on developing 4G technologies.

First some background definitions – What is 4G: The History of Wireless Cell-phone Technologies: Briefly the first generation systems were analog based (1G). 2G second generation systems were the first that were all digital. Reported advantages of digital 2G systems are voice data can be compressed more effectively than allowing more calls to be packed into the same amount of radio bandwidth and they required less radio power.

3G systems promised: (such as Verizon’s EV-DO)

  1. Enhanced multimedia (voice, data, video, and remote control).

  2. Usability on all popular modes (cellular telephone, e-mail, paging, fax, videoconferencing, and Web browsing).

  3. Broad bandwidth and high speed (upwards of 2 Mbps).

  4. Roaming capability throughout Europe, Japan, and North America

Why 4G Will Transform Medicine & Surgery: Let me be the first to ring the bell for the promise of 4G in medicine. It has been written that it is expected that end-to-end intenet lanuage (IP) based system and high-quality streaming video will be among 4G’s distinguishing features. Fourth generation networks are likely to use a combination of WiMAX and WiFi- like your high speed wireless internet at home. The explosive potential is:

When fully implemented, 4G is expected to enable pervasive computing, in which simultaneous connections to multiple high-speed networks provide seamless handoffs throughout a geographical area. Network operators may employ technologies such as cognitive radio and wireless mesh networks to ensure connectivity and efficiently distribute both network traffic and spectrum.

4G networks, when coupled with cellular phones equipped with higher quality digital cameras and even HD capabilities, will enable vlogs to go mobile, as has already occurred with text-based moblogs. New models for collaborative citizen journalism are likely to emerge as well in areas with 4G connectivity.

In medicine this means you can have surgical devices, electronic medicial records, imaging devices, and your cell-phone like handheld all communicating and sharing info at broadband speeds in HD.

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Can Vision Testing Improve Surgical & Athletic Performance?

visual testing Gizmodo is reporting today about how White Sox catcher A.J. Pierzynski said he improved his performance though the daily use of a Nintendo video game. This reminded me of research I did while at Yale on similar visual testing on surgeons. We found back then that for both athletes, and surgeons (especially endoscopic surgeons) visual acuity correlated with performance and both could be improved with exercises.

First the report on the catcher and the video game. Gizmodo writes:

We were just about to stuff Nintendo’s Flash Focus vision game into the snake oil file when White Sox catcher A.J. Pierzynski revealed he actually improved his hitting through daily use of the software. Like many of the White Sox batters last year, Pierzynski stunk, and to come around he played Flash Focus in the off season. Now, one week into the 2008 schedule, the hapless catcher has two home runs, a .529 average and a team-leading seven RBIs.

What is Flash Focus?: Flash Focus is a video game for the Nintendo DS. Basically it is a series of hand eye coordination exercises designed to improve overall visual acuity through vision “exercises”. A review of the game and screen shots are here.

The Concept of Optomeric Testing for Athletes and Surgeons: The idea behind optomic testing is two fold. First, there are innate differences in visual performance between people second, elite athletes perform significantly better on objective tests of visual performance and hand-eye coordination, and third, specific testing and exercises can identify areas of optical performance weakness and improve them- and performance.

A review of optometric testing in general for athletes can be read here:

The basic tests they mention are:

  1. Visual acuity – right and left eye separately without an occluder
  2. Stereopsis at distance – contour and random dot
  3. Ocular dominance – independent of handedness
  4. Letter contrast
  5. Contrast sensitivity – at spatial frequencies known to be related to sport performance
  6. Contrast sensitivity with glare
  7. Reaction time
  8. Reaction time with varying targets

Our experiments with surgeons- Some years ago whenI was at Yale My Partner David Olive and I conducted a lerge study of novice and expert endoscopic surgeons using the validated athletic optometric testing tools. We testing a very large group of trainees as well as experts at an international AAGL conference. We found similar patterns as with the athletes. Namely significant differerences existed between visual ability and eye hand coordination skills and these were related to measures of performance and skill. We also found that with exercise performance could improve.

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New Monitoring System Approved by FDA- Potential for Future Robotic Diagnostics

freestyle glucose sensor

The FDA has just approved the FreeStyle Navigator Glucose Monitoring System – a glucose sensor that reports glucose values continuously for up to 120 hours.  Here is a copy of the FDA PMA letter.  This device is interesting to me since it works with a sensor inserted in either the abdomen or the back of the upper arm.   The device then continuous provides glucose readings and updated glucose trend information for viewing and contains a built-in alarm that can be programmed to alert the user when results fall below pre-set values.  Other similar devices have been approved that monitor for 7 days

Potential for Future Robotic Diagnostics  I have written before that I predict a whole new field of chip based biologic disease screening and monitoring in the future.  This is another step to that result.  Here a sensor is placed under the skin that measure blood sugar.  In the future minitaturized chips could be placed in any body cavity or organ to sense any imaginable molecule.

Options for Future Diagnostics: 

  1. DNA based sensors screen for cancer metastasis or recurrances such as an intrabdomnal ovarian cancer detector.
  2. Sensore that measure drug levels in target tissues – chemotherapy of course comes to mind
  3. protein sensors that look for the earliest stages of disease development.

As personalized genetics becomes more widespread, we will identify individuals at particular risk for particular diseases before they occur.  Since the genetic basis of these diseases will be known markers will likely exist.  Implanted chip sensors could then be placed to sniff for these markers and wireless transmit the alarm- or even deliver a predetermined treatment agent- all before there is any external sign of the disease.  First generation implantable devices such as this for blood sugar monitoring are lisated here (none yet available):

Here are links to some of the technology that will be involved for these future diagnostics including tiny sensors that transmit with RFID, smartdust sensors the size of a speck of dust or less, smart pills that travel through the body transmitting data and the concept of personalized genetic information based diagnostics and personalized genetics in general.

All approved continuouis blood sugar monitoring devices are here and a comparison from a patient site here:  

As an aside – in terms of glucose monitoring the use of thse devices may come into question.  An ongoing diabetes study called ACCORD was cut short in one treatment arm when it was shown that ultra tight strict blood sugar control in diabetics with heart disease actually WORSENED outcomes!

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New Visual Search Engine Debut-Works with a cell phone photo! Medical Uses Next?

voda.jpg

I have been following the consumer device CeBIT show in Germany.  Pocket-lint UK reports:

At the CeBIT show in Germany, Vodafone is demonstrating a trial service called “Otello”, which is a search engine that uses images, rather than words.  Rather than use a word as a search term, Otello users can send images via MMS from their mobiles and the search service which then returns the results to the user’s phone as an “ordinary” search result.

A picture from a newspaper, billboard, book cover or place are all examples of what can be searched for.

Vodafone is running trials with a German newspaper that lets users find out more about stories by photographing the images that appear in the article and MMSing the images.

There’s no word on breaking this out of trial phase at this stage.

I just had a meeting with reps from a major medical device company where I discussed the potential for smart image tagging and identification in medical imaging.  Just think of the potential when this smart technology could be applied to image pattern recognition for skin lesions, radiologic images, and pathology slides.  Rural medicine will never be the same!  Cell photo snap an image and link to a search engine to get a diagnosis (we know who wants that to happen).  Right now the system is prepopulated with images then recognized.  In the future neural net and patern recognition technology will take this a step forward.  Similar systems already exist for pap smear screening of cytologic abnormalities including a commercially available system papnet (made by Neuromedical Systems, Inc. who filed for chapter 11 and sold their intellectual proprty to Autocyte Inc). 

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How Smartdust, Souveillance, Web 3.0, and Personalized Genetics Will Transform the Future of Medical Diagnostics

smartdust.gif

There has been a flurry of debate in the military, industrial, and privacy sectors on “smartdust” and the concept of “souveillance” – but no one has yet realized this technology is poised to springboard into medicine and transform medical diagnostics.  Here I wanted to give you an overview of what this idea is and why you should keep your eye on it. 

First the general concept background:

“Smartdust” refers to micro devices (called motes) which are detection microchips each potentially the size of a speck of dust.  These grains of sand however can automatically self-network.  So far people have conceived of these low-power distributed sensing networks as having functions for climate control systems, entertainment devices and especially for big brother type surveillance systems.  

Wikipedia wrote “the smartdust concept was introduced by Kristofer S. J. Pister (University of California) in 2001 , though similar ideas existed in science fiction before then. A recent review discusses various techniques to take smartdust in sensor networks beyond millimeter dimensions to the micrometre level.  A typical application scenario is scattering a hundred of these sensors around a building or around a hospital to monitor temperature or humidity, track patient movements, or inform of disasters, such as earthquakes. In the military, they can perform as a remote sensor chip to track enemy movements, detect poisonous gas or radioactivity. The ease and low cost of such applications have raised privacy concerns.”  Beyond web 2.0 vast networks of these real time sensors are once possible technology leap of the yet inknown web 3.0.

General concept – What is Souveillance?:  is a term from Steve Mann that refers to “bottom up” surveillance using smart dust as opposed to “top down” big brother networks looking at us little people.  Here instead activities are recorded from the “perspective of a participant in the activity, typically by way of small portable or wearable recording devices that often stream continuous live video to the Internet.”  Remember the impact of the Rodney King video and of all the user generated video content on the web.  Now fast forward to a world where a large segment or even a majority of the populice had real time streaming video devices on all the time (no we are not going to discuss the porn angle on this).   This has also been called “inverse surveillance”.

Privacy advocates have been debating the merits or horrors of this type of sensor technology.   I serve on the Scientific Advisory Board of the Lifeboat Foundation which is dedicated to protecting us from future technological threats through advocacy research and education.  They have been having a heated debate on the “paradox of smart dust: we may not live without the greater security provided by smart dust, but many think they could not live with smart dust impinging on our privacy.’  

Medical Implications:  I have a vision that once this type of low power networked microsensor technology exists it will logically lead to medical sensor technology.  Potential uses I see include:

  1. mass screening for infectious disease or bioterror agents.  Subjects walking into screening areas could be checked for signature molecules associated with infectious agents.  Just as we have metal detectors and now have molecular signature detectors (the litle wipe test for explosives at the airport) we will have such biological screening techology.
  2. The next step will be similar screening for disease states.  Metabolomics is one such technology. Metabolomics is the study of the small-molecule metabolite byproducts left behind from cellular processes.  In simple terms it’s like examining poop.  The concept is that by measuring the collection of all the byproducts of the cells metabolism you can get a snapshot of the physiology of a cell or organism that translates to health.  One such sensor is being developed as a breath sensor for disease.  This could lead to Star Trek like medical sensors. 
  3. Similarly, such technology will lead to individual genetic screening for disease risk using chips that interact with the tiny bits of DNA we shed every time we touch something. Companies commercializing this approach also already exist and have products
  4. Taking a clue from smart dust we will then inject such sensors into our bodies where thy could circulate in the bloodstream or sit in the abdminal cavity silently sensing for disease, infectious agents, or the DNA or signature molecules of a cancer cell.  Alternative chips could exist that sit and slowly release drugs when such cell reappear once a patient is diagnosed.

I will be writing more about the details of these concepts and devices being developed in future posts now that I have introducted the concepts.  Let me know what you think! 

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