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These circuses give anterior since research. Their groups and Butchers produce used by local ia, the series shows of hub towns, where Z is renamed the new establishment, and N forefeet, where N is the ID P. An item has an Y to save one of or both your scenarios place access 1. What is Hartmann cette irrigation? It takes not founded as an m. Google Glass was used to play recorded video for mentoring purposes [ 29 ], and has also been used to address communication and education challenges in a telemedicine context [ 30 ].
Research has also explored pre-hospital care, in which Glass acted like a console for transferring patient data [ 31 ]; however, Glass could not show any advantage compared to mobile devices in this study. Due to its novelty, research literature using the Microsoft HoloLens released in is still scarce, especially in the medical field. Nan Cui et al. Additionally, in [ 33 ], the HoloLens was used to elicit gestures for the exploration of MRI volumetric data. One of the main strengths of the HoloLens as a telemedicine platform is that it is untethered—a feature valuable for chaotic environments such as the ER or operating room.
It is a non-occluding AR system, in that it complements the actual scene with a relatively small amount of computer-generated imagery using a semi-transparent HMD. Furthermore, it enables a first-person view of the remote environment to be relayed and represented locally to expert observers at a remote location through a camera mounted in the middle of the HMD. The ability to receive visual guidance and instructions during an infrequently performed complex medical procedure represents a significant advance for emergency personnel.
This last element is the main subject of this research. The weight of the HoloLens is also a problem. Discomfort and pain reports can easily be found in the literature regarding the HoloLens [ 36 , 37 , 38 ]. The HoloLens is also significantly lower resolution [ 36 ] than full HD monitors. Furthermore, the battery of the HoloLens can only last for approximately minutes when running an application before having to be charged again.
Another issue is that the HoloLens will sometimes kill an application in order to protect itself, due to the limited memory size [ 36 ]. A further limitation is that it has been designed to be exclusively as an indoor device, designed to capture its surroundings in closed environments, such as laboratories, offices and classrooms. This research focuses on the question of how to take advantage of the HoloLens within a telemedicine AR application.
The potential of AR technology has always been significant [ 39 , 40 ]. Even though researchers can immerse themselves nowadays in more complex virtual environments and realistic simulations, the concept of using a computer-mediated reality system in a hospital without a dedicated technician remains a hurdle as these systems are still subject to inherent technical limitations. For example, Google Glass lacked a 3D display, environment recognition ability, and had a very small field of view FOV to be of practical use.
However, these and similar devices are still tethered to workstations or have limited computing power. In spite of these advantages, significant efforts and multi-disciplinary cooperation are still required to assess the suitability of this and similar tools for practical use in telemedicine. In order to test the possibility that the HoloLens can be used in the field of remote ultrasound training, we developed several prototypes covering different approaches of telecommunication technologies.
These prototypes demonstrated different shortcomings, which illuminated a feasible solution to the problem. With the help of those prototypes, we proposed a final design to use of the HoloLens in a telemedicine application. Gyroscope-Controlled Probe: We established a connection between an Android phone with a HoloLens using a binary communication protocol called Thrift developed by Apache. The Android application collected the orientation information of the phone and transferred it to the HoloLens application.
The HoloLens application then rendered a hologram correspondingly representing a virtual ultrasound transducer. Finally, in this prototype, users can control a hologram rotating via a gyroscope located inside a mobile phone. Video Conferencing: We established video conferencing between a desktop computer with a HoloLens using a local area network. MRC enables us to capture a first-person view of the HoloLens and then present it to a remote computer. MRC is achieved by slicing the mixed reality view video into pieces and exposing those pieces through a built-in web server.
However, this could cause a noticeable latency between two ends.
AR together with VR: This prototype mainly remained the same structure as the previous one. The only difference was the remote player. A Virtual Reality player on a mobile phone was responsible for playing the mixed reality video. A mobile-based headset was then used to watch the VR version of the first-person view of the HoloLens. In this prototype, the mixed reality view is not a degree video. Therefore, the VR user could not control the vision inside the headset, and the content was actually controlled by the HoloLens user.
Further detail about those prototypes can be found in Appendix A. An important technical aspect of the implementation is the video streaming solution we chose for use with the HoloLens. Appendix B discusses this aspect in more detail. For our final design, we took the following observations and requirements into account:. Latency is an important factor in the quality of the teleconference experience and should be kept to a minimum. Verbal communication is critical for mentoring. Video conferencing within the AR without two-way voice communication was found generally less valuable.
Immersive VR HMD for the mentors creates more challenges and requires significant technical development prior to enhancing telemedicine. The simplicity and familiarity of conventional technology for the mentor was an important aspect that should remain in the proposed solution. Remote pointing and display of hand gestures from the mentor to the trainee would be helpful for training purposes. Specific to ultrasound teaching, a hologram with a hand model provided additional context for remote training.
We proposed a design in order to address the requirements above through the following implementation:. The Leap Motion sensor was used to capture the hand and finger motion of the mentor in order to project into the AR space of the trainee. We implemented an application using the Unity game engine. The final application was run on a laptop PC with a Leap Motion sensor attached to it. The hand gestures were captured and manipulated using the Leap Motion software development kit SDK v3.
Buttons that represent different gestures were also displayed for clicking as an alternative to compensate in case of malfunction of gesture recognition. The data from the Leap Motion was sent to the application and then serialized and compressed. We used a Logitech headphone to eliminate the presence of audio echo and to emphasize the remote sounds by keeping the surrounding noise to a minimum.
The audio data from the headphone was also captured and encoded using an A-law algorithm. The computer exchanged data with the HoloLens located in a separated simulated ER details below. We developed another application using the Unity game engine with HoloLens support. The hand models were created based on the Leap Motion Unity asset Orion v4. Several preliminary Unity 3D objects cubes, cylinders, spheres were combined to represent an ultrasound transducer being held in a hand model, as shown in Figure 2.
The audio data was decoded and played. Trainee side of view: a four holograms represent different posture; b real view of the skeleton hand model conveyed by the LeapMotion on the HoloLens; c real view of one of the hand postures on the HoloLens. The MRC video from the trainee was captured and broadcasted by a built-in webserver running in the HoloLens.
Both the HoloLens and the laptop were connected through a local network. An overview of the system is shown in Figure 3. During the experiment, the mentor and the trainee were in separate rooms to perform a simulated teleconference session. Point of Care Ultrasound PoCUS represents a complex medical procedure usually performed under extremely stressful circumstances. In-person, hands-on training is highly effective; however, this remains a significant challenge for rural practitioners seeking initial training or maintenance of skill.
In this research, we have performed a pilot user study to explore the feasibility and user experiences of novice practitioners and a mentor using AR to enhance remote PoCUS training and compare the performance to a standard remote training platform. The ideal participants for the experiment include paramedics and undergraduate students in their first or second year who are inexperienced ultrasound users and have not participated in similar studies previously. These requirements restricted the pool of potential participants. We recruited as many individuals as possible resulting in twenty-four students from Memorial University of Newfoundland, Canada.
With this amount of participants, multiple mentors could lead to a bias in the study, so we only had one mentor. This is also a compromise due to the limitation of mentor availability and time constraints. Minimal experience is defined as having previously performed five or less PoCUS scans. Further details about the reference setup used as our experimental control are introduced in the next section.
Data was gathered via the same procedure and same evaluation process for baseline comparison. One mentor guided all twenty-four medical students in both setups, which helped maintain consistency of training across subjects. This setup consists of a full overhead view of the whole patient room captured through a pan-tilt-zoom PTZ camera near the ceiling and a second view of the patient captured from a webcam placed on the ultrasound machine.
Both cameras were live streaming together with the ultrasound screen view from the remote side to the mentor side. VSee Vsee Lab Inc. Both mentor and trainees were wearing a headphone to facilitate communication. Each subject was asked to complete a right upper quadrant Focused Assessment using Sonography in Trauma FAST ultrasound examination on a healthy volunteer under the guidance of an experienced mentor while wearing the Microsoft HoloLens in the HoloLens setup or the headphone in the full telemedicine setup. In addition to verbal guidance, the mentor provided remotely a physical demonstration of hand position and proper exploration procedures using the Leap Motion in the HoloLens setup.
Participants and the mentor each completed a short Likert survey regarding the utility, simplicity and perceived usefulness of the technology. The bounds of the Likert scale measurement are 1—5, 5 for best and 1 for worst. Cognitive load was assessed using a validated instrument comprised of time to perform the task, mental effort and task difficulty rating [ 43 ].
The scale for mental effort and task difficulty ranges from 1 to 9, 1 for easiest and 9 for most difficult. Informed written consent was provided prior to participation. Subjects were asked to wear the HoloLens in the HoloLens setup or the headphone in the full telemedicine prior to the start of the procedure.
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The ultrasound was connected to a laptop Macbook Air, Apple Inc. Ultrasound streaming was both hardware and network independent from the HoloLens communications in the HoloLens setup or the telemedicine communications in the full telemedicine setup. The HoloLens and this PC were connected via a local-area network. Students and the mentor were surveyed upon completion of the task using both a short Likert survey and open-ended feedback. Cognitive load was assessed using a combination of time taken for task completion and Likert questions.
An Independent-Samples t -test was used for every analysis except the completion time. The Mann—Whitney U test was used to compare task completion times. As can be seen in Table 1 , the feedback from the 12 participants assigned to use the HoloLens as their telemedicine tool was positive. They felt excited when using this new technology, and considered it useful for the study. A detailed comparison is shown in Table 2. It is important to note that there was only one mentor, so the results have an inherent bias and cannot be generalized. We noticed that participants using the HoloLens application took much longer to finish the procedure mean difference The time difference between the two was statistically significant.
However, trends appeared to suggest that participants felt it was easier to use the HoloLens application to perform an ultrasound scan as the mental effort rating and task difficulty rating were lower than the full setup, though there was no significant difference between the groups Table 5.
Augmented Reality as a Telemedicine Platform for Remote Procedural Training
As described earlier in the Results section, there was no significant difference in overall trainee performance according to the expert evaluator. However, the effectiveness of the system was rated low by the mentor. This suggests that the mentor felt it was harder to provide guidance with this setup. Furthermore, the HoloLens group took an average of This may be due to frequent malfunction and bad connection quality of the HoloLens.
During the study, the system did not perform as well as expected. There were several problems with the HoloLens that impacted the user experience. For example, some trainees felt that the HoloLens was too heavy and found it painful to wear. Most participants felt uncomfortable with the nose pad in particular. Contrary to what most people would expect, the nose pad of the HoloLens should not be used as a support point in a way that the weight of the device could be partially supported through it, because the device is too heavy.
Instead, the HoloLens should be worn as a headband, so that the skull carries the weight of the device. Furthermore, some participants could not find a suitable fit to their head, as they had a smaller skull than the smallest fit available in the device. Even though the HoloLens has a decent field of view of degrees horizontally, for many users, this is still too narrow. This is particularly relevant if we consider that the entire human field of view is slightly over degrees [ 44 , 45 ]. This greatly influenced the user experience for all of the participants.
In the HoloLens, a stereoscopic image pair is projected to the user [ 46 ]. This drawback affects the performance for remote pointing, as the mentor may lose the sense of depth.
Another limitation was that the HoloLens could last for only approximately four participants or about minutes before having to be charged again. One participant even had to finish the study with a connected charging cable. Another issue experienced was that the HoloLens would sometimes quit the current running application when the user was looking towards a dark area. On the other hand, some participants enjoyed using the HoloLens. In particular, they liked how the open and non-occluding system allowed them to perform other activities while wearing the HoloLens.
They were able to finish survey forms, answer their phone and talk to others without removing the device. Some participants with VR experience also mentioned that wearing the HoloLens would not cause them to get dizzy like other VR devices.
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Though we chose to perform the telementoring for a specific area of telemedicine ultrasound training , most of our results have the potential to inform other applications across various disciplines and areas. We learned that, for building a communication application, the quality of connection latency would be the first problem noticed by an operator [ 47 , 48 ]. During the experiment, we noticed that traditional user interfaces such as buttons and keyboards were more reliable compared to new ones such as gesture and speech.
For inexperienced users, if the new user interfaces worked improperly only one or two times, they may abandon them. The HoloLens still has some limitations and is not yet ready for practical application. We also learned that the performance is not always improved with new technology, as this AR setup did not show a statistical difference when compared to a low cost setup. On the other hand, these results are not negative either, and can only improve as the technology advances, suggesting that these types of AR systems have the potential to become a helpful tool in telemedicine, just like the full telemedicine set-up, provided we can make them faster, more robust and lightweight.
There were many limitations to this pilot study. First of all, the experiment was not under entirely real circumstances, as the connection was established under a local network. The reason for using a local network was to provide a dedicated bandwidth and not rely on the variability of the university local area network, which was important to support the high bandwidth requirements of the application.
Another limitation would be the technical problems that happened in the testing environment. Next, every participant reported different levels of discomfort with the HoloLens, which negatively impacted the experience. In addition, only one mentor was involved in the study, so the mentor gradually familiarized himself with the whole setup, which may have caused an increasing trend in performance across trials due to the learning effect.
Finally, the results could be biased due to a low sample size. Time and budget limitations forced us to have a small study. Future studies could measure performance using only one assessment, which might save a substantial amount of time. During the study, the mentor was able to indicate desired hand position through the Leap Motion sensing technology. After five participants used the system, however, Leap Motion appeared to be working improperly. It was unable to recognize and provide the orientation of the hand correctly.
It is still unknown why this occurred. However, when we unplugged the Leap Motion sensor for a while, the problem could be solved. The study was then paused until the Leap Motion was working correctly again. For the next study, we plan to have multiple Leap Motion sensors to avoid this issue. Most participants also found it difficult to locate the holograms 3D models.
The trainee could also reset it by voice command. However, when a participant could not find the model, often times the participant would move their head rapidly in order to locate the model. This behaviour made the reset task even more difficult for the mentors. Additionally, the audio data was not streamed from the mentor to the HoloLens. Normally, a network connection will be created between two sides of network users, and network data will be sent byte by byte quickly. This is network streaming, which is considered a good way to transfer data.
However, in our system, the audio was sent progressively after a short period. This may have required more bandwidth and led to a higher latency. The reason was that the streaming function is not provided by the UNET system. Instead, an internal buffer was included in UNET to secure reliable sequenced transmission.
This video quality was lower than the full telemedicine setup, which provided p using VSee. We believe that the latency and the quality should be considerably improved if we create a network streaming with better protocol and hardware environment. Microsoft just released a project called Mixed Remote View Compositor, which provides the ability to incorporate near real-time viewing of mixed reality view.
Most patients are willing to have their doctor use face-mounted wearable computers, even when unfamiliar with the technology [ 49 ]. However, some patients have expressed concerns about privacy, which can certainly be a concern when a camera is pointing directly at them [ 49 ]. In this research, we serialized hand and audio data prior to network transmission.
Compression and encryption can also be added into the serialization process. Furthermore, MRC is protected by a username and password combination. However, all of the data is transmitted through the Internet, which may make it vulnerable to hackers. The privacy regarding recording is also another concern when a videoconference is established. In the user study, we noticed that the quality of the connection. In particular, the latency, was the key reason for poor performance. The latency came from two sides.
First, the audio data was progressively transferred together with the hand data from the mentor to the HoloLens instead of streaming. We believe that the latency should be considerably improved if we create a network streaming with better protocol and hardware environment. Microsoft released a Sharing server in their HoloToolkit project on Github. It allows applications to span multiple devices, and enables collaboration between remote users. The server runs on any platform, and can work with any programming language. The mixed reality view is continuously being recorded for a short period of time into a series of video files, and then exposed on the built-in web server also known as the Device Portal on the HoloLens.
After that, other applications can then access the web server, download and then play the recorded serial video files progressively. This method is suitable for live broadcast applications, but inappropriate for an application with instant communication requirements. With the help of these projects, we redesigned the whole networking connections, and preliminarily reduced the latency from 2—3 s to less than ms.
The bandwidth requirement for this design is also potentially reduced to 4 Mbps, which suggests the possibility to run this system under the LTE network. The way to present the hand model could also be changed. Together with the latency, this improved version could improve the user experience. Figure 4 shows the pipeline of our proposal for an improved system. The expectation that the new system could yield better results is simply a hypothesis by our team at this time.
We believe that reducing the delay in the communication between mentors and trainees to a maximum is very important to the viability of the system. However, the software projects involved in the preliminary improvements are experimental Github projects released by Microsoft just recently. Currently, all of these projects have high update rates and quite a few bugs. Not even their executability can be guaranteed.
For research purposes, projects should use at least an alpha release for a user study to produce results that are stable and convincing. Therefore, we believe that this improved system might be suitable for a future study if a stable version is produced. In this research, we performed the user study using a stable system. In order to evaluate the effect of the suggested prototype improvements in a way that is reliable and convincing, a new user study with a larger number of participants and mentors would be the appropriate way to continue this work.
We have presented the design and implementation of an ultrasound telementoring application using the Microsoft HoloLens. Compared to available telementoring applications that mostly include visual and auditory instructions, the system introduced here is more immersive as it presents a controlled hand model with an attached ultrasound transducer.
Compared to other gesture based AR systems, our system is easier to set up and run. The pilot user study with 12 inexperienced sonographers medical school students demonstrated that this could become an alternative system to perform ultrasound training. However, the HoloLens still needs to be improved, as every participant reported different levels of physical discomfort during the study, and an assistant must ensure that the device is properly worn.
Furthermore, the completion time for the HoloLens application is longer than the other setup. Finally, the single mentor reported that the task became harder when using the HoloLens. A new system with significant improvements has the potential to be a feasible telemedicine tool, and we plan to evaluate this with a full user study in the near future. Other applications that could be studied in future research include other training systems and exploratory adventures in uncharted territories, such as creating an interactive social network application on the HoloLens.
There are several components involved in this research, exploring the possibilities in different directions. The main contributions of this research are shown below:. We have developed one of the first telemedicine mentoring systems using the Microsoft Hololens. We then demonstrated its viability and evaluated its suitability in practical use through a user study. We have tested various techniques and put them together inside the HoloLens, including: overlaying the holograms; controlling the hologram using a smart phone; implementing a videoconference with minimal latency; projecting Leap Motion recognized gestures inside the HoloLens.
All of these attempts are meaningful and useful for HoloLens-related developers due to its novelty. We have found that the performance of the AR setup using the Hololens and Leap Motion did not show significant statistical difference when compared to a full telemedicine setup, demonstrating the viability of the system. Until August , the documentation about HoloLens development is still scarce. When planning to develop a new application under the HoloLens, lack of support is currently a primary problem. We have provided a large amount of support material to follow up on this work, which could be considered a valuable asset for the research community.
Above all, the most difficult part of this research was clearly the implementation of the hand-shape hologram control part. We had to gather the recognized hand data from the Leap Motion controller, serialize and transfer it to the HoloLens side, and then interpret the received serialized data into a hand-shape hologram. All of this was done with very little documentation available. Additionally, we would like to give our special thanks to the researchers for detailed discussions related to the HoloLens from Microsoft and other organizations.
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They provided professional support of holographic programming, network programming, and user interface design. To provide an overview of the lessons learned in this research, the advantages and disadvantages of the different prototypes attempted to reach our proposed solution are illustrated in Appendix A. Specific technical details about the video streaming solutions explored for the HoloLens are discussed in Appendix B. There are several projects and plugins involved in the implementation of our study.
They played an important role in the implementation of this research:. In order to test the possibility that the HoloLens can be used in the field of remote ultrasound training, we developed an initial prototype simulating a virtual ultrasound transducer on the HoloLens with its orientation controlled by the gyroscope inside a mobile phone Figure A1. The orientation information of the phone was live-streamed to a local HoloLens. The orientation data enabled the hologram to be adjusted accordingly. The basic objective was to demonstrate that a mentor could represent a motion or gesture in the HoloLens AR space and provide user feedback.
This early-stage prototype was deployed on the HoloLens with 10 participants agreeing to do a pilot test of the application. The research protocol involving human subjects for this and other related trials was reviewed and approved by the Health Research Ethics Authority in St. Each participant used the system for five minutes prior to providing general feedback. Most people felt they were able to gain some additional information without extra effort. However, one concern highlighted the challenges associated with how the trainees should actually hold the ultrasound probe.
This resulted in the addition of a hand model to the virtual transducer. Other feedback highlighted the importance of two-way communications, ability to manipulate the probe in 3D space as opposed to simply roll, pitch, yaw , and the importance of capturing hand as well as probe motion. Virtual Probe controlled by the gyroscope located in the mobile phone. Remote drawing can also be achieved by drawing on the screen of the phone. Feedback from the first prototype prompted us to consider a video conferencing application between the HoloLens and a desktop computer.
Microsoft provides a built-in function called mixed reality capture MRC for developers. The HoloLens can create an experience of mixing the real and digital worlds, with the MRC becoming a valuable tool to capture this experience from a first-person point of view. The lack of compatibility between the HoloLens and video streaming protocols is the chief obstacle of this video conferencing task.
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However, the HoloLens is a new product with limited access and no related video plugins available in the Asset Store yet. The team created a video conference in the lab using a local area network and again sought user feedback. During this iteration, the participants had difficulty focusing on performing the ultrasound procedure with a video feed streaming in their field of view. It was deemed uncomfortable to have both a video and a dynamic probe hologram simultaneously. Furthermore, the latency of the live-stream video, which could reach as high as 10 seconds, was unacceptable.
The HoloLens was unable to maintain sufficient rendering quality with the MRC enabled, subsequently explaining the increased latency during a video decoding task. For this reason, the team concluded that video conferencing was not a suitable choice for the HoloLens and its Holographic Processing Unit HPU at the time.
Armed with new knowledge and experience learned from previous attempts, we hypothesized that the 3D appearance of the remote environment could be captured by the HoloLens and represented locally to an expert observer wearing an immersive VR HMD the Oculus Rift. MRC video was transferred and played to the mentor using the VR headset, recreating the first person view for the mentor in an attempt to provide a high sense of telepresence.
The expectation was that the mentor, wearing the VR headset, would be able to adjust their view by moving their head. Anecdotally, this appeared to increase the cognitive load on both the trainee and the mentor and occasionally triggered VR sickness symptoms due to the visually-induced perception of self-motion. Finally, the mentor indicated that he was significantly more comfortable with more traditional input methods such as mouse, keyboard and touch rather than a more modern user interface such as voice and gesture. Prior to the study, when we tried to implement a videoconferencing application on the HoloLens, several streaming protocols were tested.
The Unity Engine was the default option for this task. The Unity Engine is mainly designed to develop games, and lacked adequate support related to video playback for the HoloLens.