SUMMARY Review date: 1969 to 2003, 34 years. Background and context: Simulations are now in widespread use in medical education and medical personnel evaluation. Outcomes research on the use and effectiveness of simulation technology in medical education is scattered, inconsistent and varies widely in methodological rigor and substantive focus. Objectives: Review and synthesize existing evidence in educational science that addresses the question, ‘What are the features and uses of high-fidelity medical simulations that lead to most effective learning?’. Search strategy: The search covered five literature databases (ERIC, MEDLINE, PsycINFO, Web of Science and Timelit) and employed 91 single search terms and concepts and their Boolean combinations. Hand searching, Internet searches and attention to the ‘grey literature’ were also used. The aim was to perform the most thorough literature search possible of peer-reviewed publications and reports in the unpublished literature that have been judged for academic quality. Inclusion and exclusion criteria: Four screening criteria were used to reduce the initial pool of 670 journal articles to a focused set of 109 studies: (a) elimination of review articles in favor of empirical studies; (b) use of a simulator as an educational assessment or intervention with learner outcomes measured quantitatively; (c) comparative research, either experimental or quasi-experimental; and (d) research that involves simulation as an educational intervention. Data extraction: Data were extracted systematically from the 109 eligible journal articles by independent coders. Each coder used a standardized data extraction protocol. Data synthesis: Qualitative data synthesis and tabular presentation of research methods and outcomes were used. Heterogeneity of research designs, educational interventions, outcome measures and timeframe precluded data synthesis using meta-analysis. Headline results: Coding accuracy for features of the journal articles is high. The extant quality of the published research is generally weak. The weight of the best available evidence suggests that high-fidelity medical simulations facilitate learning under the right conditions. These include the following:

/pdf/features-and-uses-of-high-fidelity-medical-simulations-that-51wb8k5opy.pdf

Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review

In the United States, chronic wounds affect 6.5 million patients. An estimated excess of US$25 billion is spent annually on treatment of chronic wounds and the burden is rapidly growing due to increasing health care costs, an aging population and a sharp rise in the incidence of diabetes and obesity worldwide. The annual wound care products market is projected to reach $15.3 billion by 2010. Chronic wounds are rarely seen in individuals who are otherwise healthy. In fact, chronic wound patients frequently suffer from "highly branded" diseases such as diabetes and obesity. This seems to have overshadowed the significance of wounds per se as a major health problem. For example, NIH's Research Portfolio Online Reporting Tool (RePORT; http://report.nih.gov/), directed at providing access to estimates of funding for various disease conditions does list several rare diseases but does not list wounds. Forty million inpatient surgical procedures were performed in the United States in 2000, followed closely by 31.5 million outpatient surgeries. The need for post-surgical wound care is sharply on the rise. Emergency wound care in an acute setting has major significance not only in a war setting but also in homeland preparedness against natural disasters as well as against terrorism attacks. An additional burden of wound healing is the problem of skin scarring, a $12 billion annual market. The immense economic and social impact of wounds in our society calls for allocation of a higher level of attention and resources to understand biological mechanisms underlying cutaneous wound complications.

Human skin wounds: a major and snowballing threat to public health and the economy.

t. This paper surveys some of the work our group has done in electrical impedance tomography.

Electrical Impedance Tomography

▪ Abstract Paralyzed or paretic muscles can be made to contract by applying electrical currents to the intact peripheral motor nerves innervating them. When electrically elicited muscle contractions are coordinated in a manner that provides function, the technique is termed functional electrical stimulation (FES). In more than 40 years of FES research, principles for safe stimulation of neuromuscular tissue have been established, and methods for modulating the strength of electrically induced muscle contractions have been discovered. FES systems have been developed for restoring function in the upper extremity, lower extremity, bladder and bowel, and respiratory system. Some of these neuroprostheses have become commercialized products, and others are available in clinical research settings. Technological developments are expected to produce new systems that have no external components, are expandable to multiple applications, are upgradable to new advances, and are controlled by a combination of signals, ...

https://www.annualreviews.org/doi/pdf/10.1146/annurev.bioeng.6.040803.140103

Functional electrical stimulation for neuromuscular applications

Changes in the levels of the second messenger Ca2+ can result in the activation of broadly proliferative or cytotoxic responses. As reviewed here, to tip the balance in their favour, cancer cells often remodel the expression or activity of their Ca2+ signalling apparatus.

Ca2+ signalling checkpoints in cancer: remodelling Ca2+ for cancer cell proliferation and survival.

We have developed a new computational modelling paradigm for predicting the emergent behaviour resulting from the interaction of cells in epithelial tissue. As proof-of-concept, an agent-based model, in which there is a one-to-one correspondence between biological cells and software agents, has been coupled to a simple physical model. Behaviour of the computational model is compared with the growth characteristics of epithelial cells in monolayer culture, using growth media with low and physiological calcium concentrations. Results show a qualitative fit between the growth characteristics produced by the simulation and the in vitro cell models.

http://staffwww.dcs.shef.ac.uk/people/D.Walker/research/agent4.pdf

The epitheliome: agent-based modelling of the social behaviour of cells.

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(99)09095-9.pdf

Relation between tissue structure and imposed electrical current flow in cervical neoplasia

Individual-based or agent-based models have proved useful in a variety of different biological contexts. This paper presents an agent-based model using a formal computational modelling approach to model a crucial biological system—the intracellular NF-κB signalling pathway. The pathway is vital to immune response regulation, and is fundamental to basic survival in a range of species. Alterations in pathway regulation underlie many diseases, including atherosclerosis and arthritis. Our modelling of individual molecules, receptors and genes provides a more comprehensive outline of regulatory network mechanisms than previously possible with equation-based approaches. The model has been validated with data obtained from single cell experimental analysis.

Formal agent-based modelling of intracellular chemical interactions

Computational modeling of biological systems, or in silico biology, is an emerging tool for understanding structure and order in biological tissues. Computational models of the behavior of epithelial cells in monolayer cell culture have been developed and used to predict the healing characteristics of scratch wounds made to urothelial cell cultures maintained in low- and physiological [Ca/sup 2+/] environments. Both computational models and in vitro experiments demonstrated that in low exogenous [Ca/sup 2+/], the closure of 500-/spl mu/m scratch wounds was achieved primarily by cell migration into the denuded area. The wound healing rate in low (0.09 mM) [Ca/sup 2+/] was approximately twice as rapid as in physiological (2 mM) [Ca/sup 2+/]. Computational modeling predicted that in cell cultures that are actively proliferating, no increase in the fraction of cells in the S-phase would be expected, and this conclusion was supported experimentally in vitro by bromodeoxyuridine incorporation assay. We have demonstrated that a simple rule-based model of cell behavior, incorporating rules relating to contact inhibition of proliferation and migration, is sufficient to qualitatively predict the calcium-dependent pattern of wound closure observed in vitro. Differences between the in vitro and in silico models suggest a role for wound-induced signaling events in urothelial cell cultures.

/pdf/agent-based-computational-modeling-of-wounded-epithelial-mgd99o3atb.pdf

Agent-based computational modeling of wounded epithelial cell monolayers

This paper describes the Sheffield Mk3.5 EIT/EIS system which measures both the real and imaginary part of impedance at 30 frequencies between 2 kHz and 1.6 MHz. The system uses eight electrodes with an adjacent drive/receive electrode data acquisition protocol. The system is modular, containing eight identical data acquisition boards, which contain DSPs to generate the drive frequencies and to perform the FFT used for demodulation. The current drive is in three sequentially applied packets, where each packet contains ten summed sine waves. The data acquisition system is interfaced to a host PC through an optically isolated high speed serial link (RS485) running at 2 Mbaud (2 Mbits s(-1)). Measurements on a saline filled tank show that the average signal to noise performance of the system is 40 dB measured across all frequencies and that this figure is independent of frequency of measurement. These results suggest that the current system is 10 dB better in absolute terms than the previous Sheffield (Mk3a) system.

/pdf/mk3-5-a-modular-multi-frequency-successor-to-the-mk3a-eis-20vrew5w3s.pdf

Rod Smallwood

Papers

The epitheliome: agent-based modelling of the social behaviour of cells.

Relation between tissue structure and imposed electrical current flow in cervical neoplasia

Formal agent-based modelling of intracellular chemical interactions

Agent-based computational modeling of wounded epithelial cell monolayers

Mk3.5: a modular, multi-frequency successor to the Mk3a EIS/EIT system.