Esophageal cancer with liver metastasis is rare and when diagnosed is usually advanced and surgical management is contraindicated. The most common sites of distant hematogenous metastases in esophageal cancer cases are the liver, lungs, and bones. Here, we present a rare case of esophageal carcinoma presenting with cystic metastases to the liver.

Background and Objectives: An magnetic resonance imaging (MRI)-guided focused ultrasound (MRgFUS) positioning device was developed with 3 identical Cartesian stages. The robotic system can be utilized to move a focused ultrasound transducer for performing various MR-guided applications. Materials and Methods: A single element spherically focused transducer of 4 cm diameter, focusing at 10 cm, and operating at 1.14 MHz was used during the evaluation of the robotic system. The propagation of ultrasound was either lateral or superior to inferior. MRI thermometry algorithms were developed to assess the thermal effects of MRgFUS. The proposed robotic system was developed using a three-dimensional printer. Results: The system was tested successfully in a gel phantom for various tasks (robot motion, functionality, and MR compatibility). Controlled thermal lesions were created in the gel phantom. The lesion creation was monitored successfully using MRI thermometry. Conclusions: The system was tested successfully for its functionality and its MR compatibility. This system has the potential to be used for focused ultrasound applications in the brain, breast, abdominal, and thyroid.

Background and Objectives: This study examined the learning effect of surface models made from the sectioned images of a male cadaver. Materials and Methods: The first author guided 46 medical students to study with a portable document format (PDF) file containing hundreds of surface models of a whole body. Their level of anatomy knowledge gained was evaluated by a digital examination on the tablet computers using the captured movies of PDF file. Results: The medical students' grades on the surface models were positively correlated with those on the remainder of the anatomy quiz. More than half of the students reported that the PDF file was helpful in anatomy learning and cadaver dissection. Conclusions: Digital anatomy learning is under continuous development in many ways. This report shows that surface models of the human body can be effective for self-learning and in the evaluation of anatomy knowledge.

Background and Objectives: This study describes a software application for controlling a focused ultrasound system that was guided by magnetic resonance imaging (MRI). Materials and Methods: The software's functionalities were tested using a custom-made electronic system, MRI compatible robotic systems, and a high-intensity focused ultrasound (HIFU) system. The experiments were conducted in gel phantoms to test the motion accuracy and functionality of the system. Results: The software includes the following functionalities: (a) patient database (patient identification number, age, weight, gender, etc.); (b) acquisition of MRI images; (c) transducer movement; (d) transducer coordinates; (e) ultrasound control; (f) MRI thermometry; (h) temperature measurement with thermocouple; (i) command history (command name, starting time, and remaining time); and (j) MRI compatible camera. Evaluation experiments were conducted to test the software for accuracy, functionality, and communication with MRI. Conclusions: User-friendly software was developed to control an MRI-guided HIFU system. The software was evaluated in phantom experiments and it was found to accomplish all the intended functions.

The three-dimensional (3D) visualization technology in hepatolithiasis could offer decision-making support to preoperative diagnosis, individualized surgical planning, and choosing operative approach. To standardize the application of 3D visualization and 3D printing technology in the precise diagnosis and treatment of hepatolithiasis, Chinese experts in relevant fields were organized by the Chinese Society of Digital Medicine and Chinese Research Hospital Association of Digital Surgery Committee to formulate this expert consensus.

Three-dimensional (3D) visualization technology is a tool used to display, describe, and explain the 3D anatomical and morphological features of tissues and organs, which has been widely used in liver surgery. Indocyanine green (ICG) molecular fluorescence imaging technique has been widely used as an auxiliary tool at cell function level in the diagnosis and surgical navigation of liver tumors. Computer-assisted ICG molecular fluorescence imaging technique can guide the diagnosis and surgical navigation of liver tumors from the perspective of 3D morphological anatomy and cell function of liver tissues, which has been proved by the clinical application to possess unique and accurate diagnosis and treatment value. This consensus provides recommendations for the hot issues of the application of the technique in liver tumors, hoping to provide certain guidance and reference value for surgeons engaging in, or aspiring to engage in the diagnosis and treatment model.

Background and Objectives: Three-dimensional (3D) printing has been increasingly used in medicine with applications in the diagnostic assessment of disease extent, medical education and training, preoperative planning, and surgical simulation. The use of 3D printing in brain tumors is very limited. In this study, we presented our preliminary experience of creating patient-specific 3D printed model of a brain tumor in a pediatric patient and demonstrated the feasibility of using 3D printing in delineating brain anatomy and tumor. Materials and Methods: A life-size 3D printed brain model of a 6-year-old girl, who was diagnosed with pilocytic astrocytoma, was generated. The model was created using high-resolution magnetic resonance images which were postprocessed and segmented to demonstrate normal anatomical structures and the tumor. The tumor was confirmed to be Grade I pilocytic astrocytoma after neurosurgery. Results: 3D printed model was found to provide realistic visualization of brain anatomical structures and tumor, and enhance understanding of pathology in relation to the surrounding structures. The mean difference in diameter measurements of the brain tumor was 0.53 mm (0.98%) between the 3D printed model and computerized model. Conclusions: This study shows it is feasible to generate a 3D printed model of brain tumor with encouraging results achieved to replicate brain anatomy and tumor. 3D printed model of brain tumor could serve as an excellent tool for preoperative planning and simulation of surgical procedures, which deserve to be investigated in further studies.

Background and Objectives: This paper evaluates the performance of a variational level set method for performing label fusion through the use of a penalty term, label fusion term, and length regularization term, which automatically labels objects of interest in biomedical images. This paper is an extension of our preliminary work in the conference paper. We mainly focus on the validation of the variational level set method. Subjects and Methods: Label fusion is achieved by combining the three terms: label fusion term, image data term, and regularization term. The curve evolution derived from the energy minimization is impacted by the three terms simultaneously to achieve optimal label fusion. Each label obtained from the nonlinear registration method is represented by a level set function whose zero level contour encloses the labeled region. In Lu et al.’s paper, they employ the level set formulation only for hippocampus segmentation. Results: Our method is compared with majority voting (MV), local weighted voting (LWV), and Simultaneous Truth and Performance Level Estimation (STAPLE). The method is evaluated on MICCAI 2012 Multi-Atlas Labeling challenge and MICCAI 2012 ventricle segmentation challenge. The mean Dice metric is computed using different atlases and produces results with 0.85 for the hippocampus, 0.77 for the amygdala, 0.87 for the caudate, 0.78 for the pallidum, 0.89 for the putamen, 0.91 for the thalamus, and 0.78 for cardiac left ventricles. Conclusions: Experimental results demonstrate that our method is robust to parameter setting and outperforms MV, LWV, and STAPLE. The image data term plays a key role in improving the segmentation accuracy. Our method can obtain satisfactory results with fewer atlases.

Background and Objectives: Cloud-based mHealth services have the potential to make quality healthcare available in remote locations in the world. A practical deployment will involve medicolegal issues involving physicians and patients in different within and across countries. However, the first step is to evaluate such a cloud-based mHealth (MyOnlineClinic). This study aimed to understand and find out the factors that influence the end-user intention to use this new technology in Australia. Materials and Methods: We surveyed 167 end-users in 2015 and performed a Structural Equation Model analysis using Smart PLS to identify the intention to use the system among the participants. Results: The study revealed that the Unified Theory of Acceptance and Use of Technology construct, particularly facilitating condition (FC) (β = 0.355, P = 0.002), has yielded a significant influence on the behavioral intention to use MyOnlineClinic. However, the relationships between performance expectancy and behavioral intention (β = 0.162, P = 0.141), effort expectancy and behavioral intention (β = −0.004, P = 0.971), and social influences and behavioral intention (β = 0.164, P = 0.100) were insignificant. Further, age showed moderating effect on these variables. The majority of the respondents agreed or strongly agreed that technological issues such as sound (92.2%), video qualities (88.6%), and interaction with doctor (89.8%) are good. Conclusion: The end-users’ intentions to use MyOnlineClinic system were particularly influenced by FCs such as hardware, software, and the information technology knowledge/familiarity of users. These factors may get further accentuated when these systems are deployed across countries with different languages, technological infrastructures, and medicolegal environments. Therefore, cloud-based mHealth would help in removing some barriers, such as differences in software versions and interoperability problems of systems at physician and patient ends.

The three-dimensional (3D) visualization technology in liver tumor could offer decision-making support to preoperative diagnosis, individualized surgical planning, and choosing an operative approach. In addition, the hepatic 3D printing helps to realize the leapfrog development from 3D images to 3D physical models and provides better guidance of the precise surgery of complicated liver tumors. To standardize the application of 3D visualization and 3D printing technology in the precise diagnosis and treatment of complicated liver tumors, Chinese experts in relevant fields were organized by Chinese Society of Digital Medicine and Chinese Research Hospital Association of Digital Surgery Committee to formulate this expert consensus.

The three-dimensional (3D) visualization technology in hilar cholangiocarcinoma could offer decision-making support to preoperative diagnosis, individualized surgical planning and then proffer operative approach. In addition,the 3D printing technology helps to realize the leapfrog development from 3D image to 3D physical models and proffers better guidance of the precise surgery for patients with hilar cholangiocarcinoma. To standardize the application of 3D visualization and 3D printing technology in the precise diagnosis and treatment of hilar cholangiocarcinoma ,Chinese Society of Digital Medicine and Chinese Research Hospital Association of Digital Surgery Committee organized experts in related fields to formulate this consensus.

Senior Scientific Researcher at National Center for Scientific Research “Demokritos” and Co-Founder of the Spin Of company Syndesis Ltd, AgiaParaskevi, Athens, GREECE. Dr. Homer Papadopoulos holds a Physics degree and a Pre PhD on Telecommunications from the University of Athens and a Bio-design Graduate Certificate from Stanford University US. He has an MBA at Warwick University and he holds a PhD from IS/IT Department of Bath University UK. Dr. Papadopoulos is working for NCSR “Demokritos” www.demokritos.gr, in the Division of Applied Technologies and in the Institute of Informatics and Telecommunications, for almost two decades managing various European funded Research programs within the fields of e-services, mobile services and technologies and broadband telecommunication networks. Dr. Papadopoulos' research interests concern the domains of medical informatics, human computer interfaces for the ageing population, Internet of Things platforms and ontologies, wearable technologies, web services, machine learning and Big data platforms, ehealth and unobtrusive monitoring services. A web based integrated platform (www.iwelli.com) which enables ehealth, mhealth and IoT services in parallel with intelligent algorithms to provide Decision Support Services to Professionals has been developed and is under pilot validation within real settings. Dr. Papadopoulos has a track record of success in income generation from EU and National funded projects, while he acting as the principal investigator and coordinator in EU R&D funded projects like the www.usefil.eu project. He has published several papers in journals and international conferences. He is coordinating the European Innovation Partnership on Active Healthy Ageing, (supported by the European Union) Synergy group and A1 group for ICT technologies in Adherence in polypharmacy and medical plans. He is Co-founder of the NCSR “Demokritos” spin off company Syndesis LTD. Syndesis (www.sydnesis.eu) intends to apply the research results and develops ehealth/assistive living state of the art technologies and applications. Dr. Papadopoulos is also an expert at the World Health Organization (WHO) Public Health Emergency Operations Centre Network (EOC-NET).

Reconstructive surgery in the facial and oral sites requires high levels of precision. Intraoperative guidance can enhance surgical precision with three-dimensional (3D) image model. Here, case report was our endeavor of creating a 3D digital image model to guide plastic procedure is performed on the soft tissue of a patient's cheek. 3D facial structure was taken preoperatively by scanning the contours of the patient's head. The defect on patient's left cheek due to an aneurysm was identified and virtually corrected by mirroring image from the healthy right side of the cheek. Once the 3D virtual model was created, we displayed the 3D model onto the surgical site during the operation to guide surgical procedure. Digital technology is developing rapidly and is unavoidable to merge with surgical care. Clinical judgment and intraoperative performance will be improved by our efforts of integrating digital technology into the operating room.

Schwannoma, also called neurilemmoma, is a benign peripheral nerve sheath tumor. Most common locations are flexor surfaces of the extremities, neck, mediastinum, retroperitoneum, posterior spinal roots, and cerebellopontine angle. Pleural schwannomas are extremely rare neoplasms of the thoracic cavity. To the best of our knowledge, till date, <20 cases have been reported. Herein, we report a case of primary benign pleural schwannoma in an elderly 60-year-old female in whom the pleural mass was discovered incidentally on computed tomography chest. The patient was subjected to left posterolateral thoracotomy; pleural mass was resected which showed histopathological and immunohistochemical features of schwannoma.

Background and Objectives: Owing to the scarcity of health-care financing and the pressure of aging with the associated increased incidence of chronic heart failure, new models of health-care delivery supported by technology solution require a social economic analysis. We aim to assess improvement of Kansas City Living with Cardiomyopathy Questionnaire (KCCQ) score with telehome monitoring in elderly patients affected with Chronic Heart Failure (CHF) and to estimate a probable cost saving for health-care provider and patient, by calculating a probability to reduce fatal events such as mortality and hospitalization associated with improved health status measured with the KCCQ questionnaire. Materials and Methods: An observational quasi-experimental trial was used. Eight patients affected with chronic heart failure aged 85-90 years of age who have been at least three times hospitalized within the last year were recruited for the study. These patients received an educational module to empower their self-management capacity and a medicine kit necessary for telehome monitoring. The KCCQ questionnaire was employed. The KCCQ questionnaire is an independent predictor of health-care resource utilization. The KCCQ score improvement is associated likely with rehospitalization and mortality reduction according to results from previous clinical trial, where KCCQ score has been demonstrated as a strong statistically independent predictor of mortality and rehospitalization after adjustment for other variables. Results: The KCCQ score improved for 15 points from baseline measurement, after 6 months of telehome monitoring. The improvement of KCCQ score of 15 points represents a reduction of probability of hospitalization and mortality for 18% and 16%, respectively. In addition, an individual's cost savings were calculated, using the individual's willingness to pay to avoid fatal event, individual's productivity gain by avoiding a travel to remote hospital facilities, and an improved probability of positive event with telehome monitoring. Conclusion: Analysis demonstrated a probability for an important economical saving with the use of telehome monitoring for the provider and patient. We can conclude that telehome monitoring represents an innovative service that provides clinical and economical value addition to the patient, health-care system, and society.

Background and Objectives: Realistically and efficiently simulating dynamic behavior of human organs under interactions is crucial for the immersive user experience of the surgical simulator. Conventional methods are time-consuming to simulate this phenomenon due to topological modifications. Materials and Methods: This paper proposes a robust and efficient point-based framework for surgical simulation, allowing realistically simulating mechanical response of human organs under interactions with visual and tactile feedback. Considering the inevitable topological modifications occurred in surgical simulation, we adopt sparse point cloud to model the mechanics of deformable bodies while employ surface mesh to represent morphological details of human organ, which can not only disconnect mechanical complexity from geometrical details, but also enable precise boundary conditions to be solved with surface mesh. Results: We validate our method on a variety of challenging surgical scenarios, and the results demonstrate that our method can realistically and efficiently provide the visuo-haptic feedback for surgical simulation. Conclusions: Our method can well tackle the inefficiency limitation of mesh-based methods related to topological modifications issue, and has great potential to be adopted in practical surgical simulators.

Wearable technologies designed to deliver benefits to health and well-being through the use of digital applications are becoming increasingly ubiquitous. This article focuses on the use of wearable technologies which track user lifestyle behaviors and seek to provide tools for better personal health management. It provides an evidence of general positive health outcomes from previous research and provides a detailed analysis of the functionalities and strategic approaches of three different wearable devices which have been used continuously and simultaneously by the lead author for over 18 months. Based on the experience of long-term use of these devices, the article draws some conclusions about their usage and future development strategies.

[INLINE:1] Uwe Spetzger, MD, is the Chairman of Department of Neurosurgery, Klinikum Karlsruhe, and Institute for Anthropomatics, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany. Uwe Spetzger received his medical degree in 1989 at the Medical Faculty, University of Heidelberg, Germany. He passed the US American medical exam (ECFMG) in 1990. He has started his neurosurgical training in 1990 at the Department of Neurosurgery, Technical University (RWTH) Aachen and got his board certification of neurosurgeon in 1996. The Grant of the Wilhelm-Tonnis-Foundation of the German Society of Neurosurgery (DGNC) enables his scientific internship in 1999 at Department of Neurosurgery, University of Illinois at Chicago (UIC). In June 1999, he passed the European Examination in Neurosurgery (EANS). From 1999 - 2002 he was vice-chairman of the Department of Neurosurgery at the University of Freiburg and the director of the interdisciplinary centre for skull base surgery at Freiburg University. Since 2002 he is Chairman of the Department of Neurosurgery, Klinikum Karlsruhe and in 2003 he became an active member of the Faculty of Computer Science, Humanoids and Intelligence Systems Lab - Institute for Anthropomatics at KIT. Prof. Spetzger became the president of the international Society of Medical Innovation and Technology iSMIT in 2013 and the congress president of the 66th Annual Meeting of German Society of Neurosurgery DGNC in 2015 and the Vice-President of the International Society of Digital Medicine in 2016. He is member of several national and international neurosurgical and medical technological societies. His main surgical and research interests are cerebrovascular surgery, skull base surgery, computer-assisted and robotic surgery, neuronavigation and spinal microsurgery.

Background and Objectives: Spinal cord injury (SCI) is a severe disease where the patients lost the body function below the level of lesion. Neurorehabilitative exercise leads to improvements in physical functions such as strength, range of motion, transfers, wheelchair mobility, and gait. The aim of this study is to evaluate the impact of overground gait training using an active powered exoskeleton. Materials and Methods: Patients affected of SCI admitted to our rehabilitation unit have been studied. We used an active powered exoskeleton (Ekso). Training occurred each day for 5 days a week for a total of 4 weeks. Patients were trained for at least twenty sessions, with a duration of 45–60 min each session. Patients were scored with the 6 min walking test (6MWT) before and after treatment to evaluate the movement and Ashwort scale was used to test spasticity. Psychological tests were also performed to focus on depression (Beck Depression Inventory) and on self-perception (Body Uneasiness Test-A). Results: Thirteen patients were studied (mean age 31 ± 10.4; ten males and three females), who were affected by SCI with motor complete/incomplete lesions (seven complete, six incomplete), according to the American Spinal Injury Association guidelines. All patients completed the overground gait training for all 4 weeks without collateral effects. The motor recovery evaluated with the 6MWT in incomplete motor patients described a statistical significant recovery in terms of meters and absence of rest, especially in thoracic and lumbar level lesions (48/114 m [improvement 137.5%]; 98/214 m [improvement 118.37%], P < 0.05). We did not find any difference in terms of spasticity using the Ashworth Scale. After the treatment, we found in all patients a great improvement in mood disorders and body perception. Conclusions: The overground training with the exoskeleton is a promising therapeutical approach for SCI patients, which can increase both motor and psychological aspects.

Background and Objectives: Aging society is a social health issue that digital gaming solutions can address by enabling both infrastructures as advanced environments for care and patients as active people in their aging. Cost-effective patient management may be emphasized thanks to the communication protocols that allow remote monitoring and intervention by medical professionals. Services for elderly depend on their behavior and lifestyle toward personal health management. Digital games could increase seniors' engagement and motivation. However, a few studies have looked at the acceptance of digital games by the elderly. The study here presented aims to evaluate the feasibility of a gaming rehabilitation platform. Materials and Methods: In Singapore, fifty elderly practiced 30-min sessions and evaluated their experience with a new tool based on game scenarios for rehabilitation. Results: Results are discussed in the light of Davis' Technology Acceptance Model, highlighting mainly a good perceived usefulness of the service. Conclusions: This preliminary study is encouraging the spread of digital medical games for old patients.

Background: The development of telemedicine has become a solution to provide healthcare service to the elderly while they remain in their homes. The unit of cost of healthcare service provided at home is lower than the unit of cost of Institutional Healthcare Service. The healthcare users' attitude and motivation are a fundamental factor for the acceptance of technology and behavior change. Still, motivation and attitude toward telemedicine, especially among elderly and their caregivers is not satisfactory. Objectives: The object of this study is to investigate the utilization of Telehomecare and its effect on user's attitude and motivation among caregivers of elderly population who are affected by chronic heart failure. Materials and Methods: Observational trial and quasi-experimental design with duration of 6 months were adopted. Intervention with the telemedicine platform that supports multispecialty teleconsultation and questionnaire for evaluating the effect of intervention “Use and attitude of current technology” were used. Results: The results after 6 months showed that expectations and attitude were improved, and the user's opinion about barriers was positive. Conclusion: We evaluated readiness and responsiveness of naïve user before and after 6 months during observational trial. The trial has demonstrated a unified user's opinion that the barriers to telemedicine's use are not so high that they cannot be overcome.