For the first time ever Hollywood’s digital vanguard has teamed up with a surgeon to use tomorrow’s cinematic tools to revolutionize visualization in the operating room. We successfully filmed produced and played a 4k digital cinema movie of a live human surgery.  This was an amazing collaboration between a fertility surgeon, the AAGL endoscopy society, Sony Medical & Broadcast divisions, Red Digital Cinema Camera Company, FotoKem, Vincent Pace films, USC professor Richard Weinberg, and the NBA just to name a few!  We also showed the largest medical 3d displays ever.

The AAGL reported on this groundbreaking session today .   Further details are here and here.

Dual Sony SXRD 4k projectors in 3D scaffold

New cinematic technologies are transforming the film business today.  The two major revolutionary developments are 1) ultrahigh definition “4k” technology - which brings resolution to 4 times that of HD and 2) realistic immersive high definition 3D. I set out to introduce these technologies to the medical world and to see if we could for the first time apply them to surgical practice- setting the goal to once again use technological innovation to improve our patient outcomes.

Virtually all of my surgery is endoscopic- performed through tiny telescopes and viewed on a TV monitor. In 2001 I performed the world’s firs HDTV surgery and demonstrated how increased resolution improved the surgeon’s visualization and performance of procedures.  For those interested in the history of HDTV surgery and the details of its development further details of my work are here from the New York Times and here from Science Daily and here from MIT Technology Review.   Over the past two years I refined this work with even better performing camera systems and this work was featured on 20/20 and on the National Geographic Channel’s first ever HD medical show - Inside the Living Body.

Hollywood is embracing its digital future by adopting (with $1 billion in financing and a follow-up deal by Sony) planned conversion of 20,000 theaters to ultrahigh definition 4k (4096x 2048) video.  The revolutionary Red One camera is one of the few that can natively record this type of file.   Having heard about it I went to vegas for NAB in April and saw with my own eyes the amazing realistic movies  being made with it.  While there I met with Ted Schilowitz, Red’s “Leader of the Rebellion” and was ecstatic with his desire to help with with a proof of concept- to film surgery with a 4k camera. I also partnered with Sony’s Medical and Broadcast Divisions who eagerly helped me set up a 4k and 3dHD digital cinema in an international medical conference hall in the Las Vegas Paris Hotel.  The theme of my Keynote lecture was “Film and Medicine: From the Past to the Future- Through the 4th Wall.”  In this, I traced how cinematic film  technology has transformed the teaching and performance of surgery- and how the future will again have revolutionary changes in physician visualization.  Our Hollywood partners allowed me to first show jaw-dropping pro-sports and theatrical demos of the technology.

Sony’s digital cinemas allow the next generation of film to be projected at these previously impossible resolutions.  We used dual SXRD 4k projectors with linear polarizing filters for 3D HD then went to a single projector for the 4k.  4k footage has to be played off a dedicated media block digital server  and we used an LMT-100 like a movie theater would and FotoKem converted the 4k files into a DCP digital cinema package that can be played.  For 3d footage we played off an HD SR tape dual stream deck.  I’ll post a follow-up explaination of each of these technologies in detail.

By increasing resolution to this level we allow the surgeon to be actually immersed in images that surpass the live surgical experience. The progress from regular surgical film technology is like comparing sitting in an HD home theater to watching a video on a cell phone.

Ultra high resolution digital cameras are transforming the art of cinema. Leading Hollywood directors such as Peter Jackson and Stephen Soderbergh today have just started filming the next generation of cinema blockbusters using cameras with “4K” resolution, four times the resolution of High Definition (HD) with 4096 lines of resolution to give audiences unprecedented realism. The Red One digital cinema camera is the at the forefront of the revolution.  Director Soderberg previously described this technology as “This is the camera I’ve been waiting for my whole career: Red is going to change everything….Shooting with Red is like hearing The Beatles for the first time. Red sees the way I see.” 

Amazingly, the surgeons in the conference were able to visualize the surgery they were watching better than if they had been in the operating room live. If it can transform the immersive experience of the movies with unprecedented realism wouldn’t you want that degree of vision in your surgeon’s hands? By combining unprecedented resolution and magnification the surgical images were beyond what a surgeon would have standing live in the operating room. Those in the audience predicted this technology would further revolutionize minimally invasive surgery as it becomes incorporated into the OR of the future.

We then projected the largest high definition (HD) 3d surgical images ever. Wearing glasses reminiscent of today’s 3d Hollywood blockbusters U23D and Journey to the Center of the Earth a standing-room only crowd of 1600 surgeons felt as if they could “reach out and join the operation”. These images were enabled by converting Sony’s ultrahigh definition and 3d theatrical systems to show medical footage in what the AAGL called the “Theater of Tomorrow.”  A Vince Pace 3D demo reel showed where Hollywood is going as well with Gwen Stefani concert footage, underwater vistas, and movie clips.

Since laparoscopic surgery is performed by a surgeon watching on a video monitor making the images “better than live” may facilitate teaching and procedures in the future.

The 4K system, manufactured by RED Digital Cinema Camera Company, was used to film Jumper, Crossing the Line, and The Argentine. This recording represents its first use for medicine and biology in the world.  In addition to a surgery we showed the first ever 4k microscopy images of single cell organisms ever recorded (from USC).

Stay tuned a for a series of posts coming up this week that will review the session, how we managed the collaborations, the difficulty in executing each of the technologies, and where I predict this is going in surgical visualization.

After a year of prep I just gave a Keynote lecture at the International Congress of Endoscopy where I showedthe first ever surgery recorded in 4k ultrahigh definition.  Stay tuned for posts with all the details and pictures but here’s the press release for now.  The AAGL society also issued a report. 

Steven F. Palter, MD

In this post I want to review the most exciting new display technology I saw on multiple fronts at the meeting- and share with you my predictions of how it will be used in medicine in the future. This technology is OLED

OLED represents the next step in the future of video display technology. I have previously written about what the technology is and how it works here. The technology was introduced commercially by Sony at the 2007 CES meeting also in Vegas (the home of all new media conventions). Currently flat panel technology is dominated by LCD’s and plasma displays - the limitations of which have been extensively reviewed elsewhere,

The Importance of Display Technology and its Market:

The display used to watch video is the final link that determines ultimate picture quality. The size of the current consumer flat panel TV market is estimated at $80-$100 Billion. I don’t have to say that number twice to convince you why consumer electronics giants will push the limit of display technologies creating the raw materials for medical displays in the process. This happened with CRT’s, LCD’s , and plasmas in the OR.

Let me be the first to predict- OLED will 100% dominate OR surgical displays as the technology matures. Not to mention the potential for their use in head mounted displays (HMD’s) and alternate display technologies.

I was enormously impressed by several features of the first OLED displays I laid my hands on. - my favorites are highlighted below

1. Fantastic brightness and contrast ratio. This 11″ model i looked at had a contrast ration greater than 1,000,000:1 (not a typo).
2. Excellent grayscale
3. Full-motion video without ghosting
   
4. Wide viewing angles from all directions
5. A wide range of pixel sizes
6. Low power consumption
7. Low operating voltages
8. Wide operating temperature range
9. Long operating lifetime
10. A thin and lightweight form factor
11. Cost-effective manufacturability

Here is an an example of the unbelievable wide viewing angle of OLED displays. When you look at standard LCD displays the brightness and ultimately entire image falls off as you start to look from the side angle. This has been a big problem for me with LCD displays in the OR for endoscopic surgery. When we operate as a team often the assistant or nurse need their own separate monitors since they are unable to get a bright clear image viewing my image from a tangential angle.

The OLED looked even better than this since there is a bit of a glare reflection from my camera’s flash.

Here is a view of just how thin these displays are. The screens themselves can be made 0.3 mm thick in current implementations.

This was Sony’s implementation of OLED for the broadcast pros demo’d at NAB 2008. The HDVF-EL100 is an OLED viewfinder for pro video TV cameras. The same wide viewing angle, incredibly thin dimensions and low heat that will benefit it in the OR went into choosing it for this use as well.

As Engadget HD said- you can see these OLED displays from a mile away.

I had an opportunity to chat with the engineers about OLED and what is delaying its dominance of the market. They said that currently maufacturing becomes problematic as sizes increase leading also to cost escalations.  In addition they are produced in totally new types of production factories which are currently being built- such as the Samsung 8G LCD factory.  There is no doubt these issues will be overcome with current development.

Update:  for those interested in truely amazing future potential for OLED read here about a version that is on a flexible material that can simply be rolled up in testing now by the US Army.

Also - it appears mainstream OLEDs will hit the consumer markets in large number in 2009-2011.  Samsung predicts 2008/2009 while LG predicts a 32 inch version in 2011.  Details are here.

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

Being 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

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.”

The FDA Ophthalmic Devices Panel will meet Apr 24, 08 8:30 AM - 5:00 PM & Apr 25, 08 8:30 AM - 5:00 PM in the Gaithersburg Holiday Inn, Ballroom - 2 Montgomery Village Ave. Gaithersburg , MD

On April 24, 2008, the committee will discuss, make recommendations, and vote on a premarket approval application, sponsored by VisionCare Technologies, Inc., for an implantable miniature telescope (IMT™). The IMT™, a visual prosthetic device, is indicated for monocular implant in patients with stable, moderate to profound central vision impairment due to bilateral central scotomas associated with end-stage macular degeneration with geographic atrophy or disciform scar, foveal involvement and cataract.

Since these diseases lead to central dysfunction of the retina the implantable telescope spreads the visual image over a larger area of normal retina.

The prosthetic telescope, together with the cornea, acts as a telephoto system to enlarge images 3X or 2.2X, depending on the device model used. The telephoto effect allows images in the central visual field (’straight ahead vision’) to not be focused directly on the damaged macula, but over other healthy areas of the central and peripheral retina. This generally helps reduce the ‘blind spot’ impairing vision in patients with AMD

This is your brain on performance enhancing drugs

Perhaps the top science journal in the world - Nature - reported today on epidemic-like levels of cognitive performance enhancing drug abuse by top academic scientists.

why they began the survey

The survey was triggered by a Commentary by behavioural neuroscientists Barbara Sahakian and Sharon Morein-Zamir of the University of Cambridge, UK, who had surveyed their colleagues on the use of drugs that purportedly enhance focus and attention (Nature 450, 1157–1159 ; 2007). In the article, the two scientists asked readers whether they would consider “boosting their brain power” with drugs. Spurred by the tremendous response, Nature ran its own informal survey. 1,400 people from 60 countries responded to the online poll.

They looked at illegally obtained (no prescription) use of three drugs: methylphenidate (Ritalin), a stimulant normally used to treat attention-deficit hyperactivity disorder but well-known on college campuses as a ’study aid’; modafinil (Provigil), prescribed to treat sleep disorders but also used off-label to combat general fatigue or overcome jet lag; and beta blockers, drugs prescribed for cardiac arrhythmia that also have an anti-anxiety effect.”

One in five respondents said they had used drugs for non-medical reasons to stimulate their focus, concentration or memory. Use did not differ greatly across age-groups

Favorite drugs of the performance enhancing professor:

For those who choose to use, methylphenidate was the most popular: 62% of users reported taking it. 44% reported taking modafinil, and 15% said they had taken beta blockers such as propanolol, revealing an overlap between drugs. 80 respondents specified other drugs that they were taking. The most common of these was adderall, an amphetamine similar to methylphenidate. But there were also reports of centrophenoxine, piractem, dexedrine and various alternative medicines such as ginkgo and omega-3 fatty acids.

As I have srtten many times before. Prepare for the upcoming epidemic of performance enhancing drug abuse. I predict these drugs will be used at rates surpassing any other illegal drug in history. They have minimal side-effects and are becomming increasing viewed on college campuses as nothing more than a no-doze.

Read my previous posts on this topic here:

1. New Drugs Enhance Performance, Eliminate Need to Sleep
2. New Generation of Performance Enhancing Drugs
3. How far would you enhance your body for performance?

Would you use it? My history of working to the limit. I was in an accelerated 6-year combined college and medical school program. Balancing the advantage of being accepted to medical school while still in high school was taking full years of college courses ever summer to catch up on the skipped time. At one point I had medical school 8-5 followed by college classes from 6-10. All was manageable until med school finals hit the same week as college midterms. I remember giving up sleep and filling 2-liter soda bottles with iced coffee to get through the day. We moved onto iced coffee in Captain Crunch next. I stopped at this point (actually at two of these bottles a day= 3000 mg caffeine). I knew others who went the route of amphetamines no-doze and pizza. While an intern my worst shift ever in the hospital was 7AM Friday until 4PM monday= 81 hours. By sunday night I was unwell to say the least. Will drugs help this? I have a good friend who is a leading academic physician. He is a brilliant physician, professor and inventor. He could not believe I had not taken modenifil and raved about how well it worked for him.

Apparently other experts agree with me:

“Neuroscientist Anjan Chatterjee of the University of Pennsylvania in Philadelphia predicts a rise in the use of these drugs and other neuroenhancing products and procedures as they become available (A. Chatterjee Cam. Q. Healthc. Ethics 16, 129–137; 2007). Like the rise in cosmetic surgery, use of cognitive enhancers is likely to increase as bioethical and psychological concerns are overcome and as the products gain cultural acceptance. One difference, Chatterjee says, is that use of cognitive enhancers doesn’t rely on training of medical specialists such as surgeons. Internet availability will also greatly accelerate use, he says.”

A new development is a chip containing networked pill that reports back on medication taking and the dissolution of the pill as reported by MIT technology review.

The company behind the technology, Proteus Biomedical, of Redwood City, CA, calls its technology the Raisin system.

In the Raisin system, each pill contains an “ingestible event marker” (IEM). The IEM consists of a sand-grain-size microchip with a thin-film battery that is activated on ingestion, as it is exposed to water. The battery, Proteus says, is nontoxic because it is made from materials similar to those in a vitamin pill. Once swallowed, the IEM sends through the body’s tissues a high-frequency electrical current that’s modulated in such a way that it provides a unique marker of the pill. It’s not an RFID technology: it uses the conductive tissues of the body to conduct the signal, rather than a radio, and the signal is confined within the body.

I previously wrote about about the development of swallowable RFID chips- a technology I like better.

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.

Part 1 looked at a new monitor.  Here is a device from Ethicon that allows accessory instruments to be placed along with endoscopes- primarily for flexible scopes primarily used for the lung or GI tract.

These concepts of placing multiple instruments through new and unique entry devices is a huge area of research and development in surgery including Natural Orifice Surgery and SIngle Port Surgery.

First the announcement from FDA:

DEVICE: ETHICON ENDO SURGERY SHEATH AND ARTICULATING ACCESSORY CHANNEL - ETHICON ENDO-SURGERY, INC. 510(k) NO: K073484(TRADITIONAL)
ATTN: RENEE L ROWE PHONE NO : 513-337-8243 4545 CREEK RD. SE DECISION MADE: 10-MAR-08 CINCINNATI, OH 45242-2839

Text from Ethicon’s application on how it works.

The flexible Sheath is installed over the insertion tube of the endoscope. The Sheath
contains a track (C-Channel) along which the Articulating External Accessory Channel can
be can be introduced and removed without removing and re-introducing the endoscope,
allowing for multiple intubations and/or specimen retrieval independent of the endoscope.
The Articulating External Accessory Channel enables the use of two accessory devices
simultaneously - one in the Articulating External Accessory Channel and the other in the
endoscope working channel. The Articulating External Accessory Channel provides off
axis articulation to off the shelf accessory devices, thereby allowing the user to more
effectively direct devices to the targeted tissue.
Improvements

The external accessory channel of the new device is not fixed to the scope and can be
introduced and removed without a need to remove or re-introduce the endoscope. The
LSI Solutions Endoscopic External Accessory Channel predicate device is fixed to the
endoscope and must be must be removed and re-introduced with the endoscope.
* The new device enables articulation of compatible commercially available endoscopic
accessory devices for improved ability to reach the target tissue.

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)