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Bogar PZ, Virag M, Bene M, Hardi P, Matuz A, Schlegl AT, Toth L, Molnar F, Nagy B, Rendeki S, Berner-Juhos K, Ferencz A, Fischer K, Maroti P. Validation of a novel, low-fidelity virtual reality simulator and an artificial intelligence assessment approach for peg transfer laparoscopic training. Sci Rep 2024; 14:16702. [PMID: 39030307 PMCID: PMC11271545 DOI: 10.1038/s41598-024-67435-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 07/11/2024] [Indexed: 07/21/2024] Open
Abstract
Simulators are widely used in medical education, but objective and automatic assessment is not feasible with low-fidelity simulators, which can be solved with artificial intelligence (AI) and virtual reality (VR) solutions. The effectiveness of a custom-made VR simulator and an AI-based evaluator of a laparoscopic peg transfer exercise was investigated. Sixty medical students were involved in a single-blinded randomised controlled study to compare the VR simulator with the traditional box trainer. A total of 240 peg transfer exercises from the Fundamentals of Laparoscopic Surgery programme were analysed. The experts and AI-based software used the same criteria for evaluation. The algorithm detected pitfalls and measured exercise duration. Skill improvement showed no significant difference between the VR and control groups. The AI-based evaluator exhibited 95% agreement with the manual assessment. The average difference between the exercise durations measured by the two evaluation methods was 2.61 s. The duration of the algorithmic assessment was 59.47 s faster than the manual assessment. The VR simulator was an effective alternative practice compared with the training box simulator. The AI-based evaluation produced similar results compared with the manual assessment, and it could significantly reduce the evaluation time. AI and VR could improve the effectiveness of basic laparoscopic training.
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Affiliation(s)
- Peter Zoltan Bogar
- 3D Printing and Visualisation Centre, University of Pecs, Medical School, Boszorkany Str. 2, Pecs, 7624, Hungary
| | - Mark Virag
- 3D Printing and Visualisation Centre, University of Pecs, Medical School, Boszorkany Str. 2, Pecs, 7624, Hungary
- Department of Public Health Medicine, University of Pecs, Szigeti Str. 12, Pecs, 7624, Hungary
| | - Matyas Bene
- 3D Printing and Visualisation Centre, University of Pecs, Medical School, Boszorkany Str. 2, Pecs, 7624, Hungary
| | - Peter Hardi
- Medical Skills Education and Innovation Centre, Medical School, University of Pecs, Szigeti Str. 12, Pecs, 7624, Hungary
- Department of Surgery and Vascular Surgery, Tolna County Janos Balassa Hospital, Beri Balogh Adam str. 5-7, Szekszard, 7100, Hungary
| | - Andras Matuz
- Department of Behavioural Sciences, Medical School, University of Pecs, Szigeti Str. 12, Pecs, 7624, Hungary
- Szentágothai Research Centre, University of Pecs, Pecs, Ifjusag str. 20., 7624, Hungary
| | - Adam Tibor Schlegl
- Medical Skills Education and Innovation Centre, Medical School, University of Pecs, Szigeti Str. 12, Pecs, 7624, Hungary
- Department of Orthopaedics, Medical School, University of Pecs, Akac Str. 1, Pecs, 7632, Hungary
| | - Luca Toth
- 3D Printing and Visualisation Centre, University of Pecs, Medical School, Boszorkany Str. 2, Pecs, 7624, Hungary.
- Department of Neurosurgery, Medical School, University of Pecs, 2 Ret Street, Pecs, 7624, Hungary.
| | - Ferenc Molnar
- Medical Skills Education and Innovation Centre, Medical School, University of Pecs, Szigeti Str. 12, Pecs, 7624, Hungary
| | - Balint Nagy
- Medical Skills Education and Innovation Centre, Medical School, University of Pecs, Szigeti Str. 12, Pecs, 7624, Hungary
| | - Szilard Rendeki
- Medical Skills Education and Innovation Centre, Medical School, University of Pecs, Szigeti Str. 12, Pecs, 7624, Hungary
| | - Krisztina Berner-Juhos
- Department of Surgical Research and Techniques, Heart and Vascular Centre, Semmelweis University, Nagyvarad Square 4, Budapest, 1089, Hungary
| | - Andrea Ferencz
- Department of Surgical Research and Techniques, Heart and Vascular Centre, Semmelweis University, Nagyvarad Square 4, Budapest, 1089, Hungary
| | - Krisztina Fischer
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Peter Maroti
- 3D Printing and Visualisation Centre, University of Pecs, Medical School, Boszorkany Str. 2, Pecs, 7624, Hungary.
- Medical Skills Education and Innovation Centre, Medical School, University of Pecs, Szigeti Str. 12, Pecs, 7624, Hungary.
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Truckenmueller P, Krantchev K, Rubarth K, Früh A, Mertens R, Bruening D, Stein C, Vajkoczy P, Picht T, Acker G. Augmented 360° Three-Dimensional Virtual Reality for Enhanced Student Training and Education in Neurosurgery. World Neurosurg 2024; 186:e35-e47. [PMID: 38272307 DOI: 10.1016/j.wneu.2024.01.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 01/27/2024]
Abstract
OBJECTIVE This prospective study assesses the acceptance and usefulness of augmented 360° virtual reality (VR) videos for early student education and preparation in the field of neurosurgery. METHODS Thirty-five third-year medical students participated. Augmented 360° VR videos depicting three neurosurgical procedures (lumbar discectomy, brain metastasis resection, clipping of an aneurysm) were presented during elective seminars. Multiple questionnaires were employed to evaluate conceptual and technical aspects of the videos. The analysis utilized ordinal logistic regression to identify crucial factors contributing to the learning experience of the videos. RESULTS The videos were consistently rated as good to very good in quality, providing detailed demonstrations of intraoperative anatomy and surgical workflow. Students found the videos highly useful for their learning and preparation for surgical placements, and they strongly supported the establishment of a VR lounge for additional self-directed learning. Notably, 81% reported an increased interest in neurosurgery, and 47% acknowledged the potential influence of the videos on their future choice of specialization. Factors associated with a positive impact on students' interest and learning experience included high technical quality and comprehensive explanations of the surgical steps. CONCLUSIONS This study demonstrated the high acceptance of augmented 360° VR videos as a valuable tool for early student education in neurosurgery. While hands-on training remains indispensable, these videos promote conceptual knowledge, ignite interest in neurosurgery, and provide a much-needed orientation within the operating room. The incorporation of detailed explanations throughout the surgeries with augmentation using superimposed elements, offers distinct advantages over simply observing live surgeries.
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Affiliation(s)
- Peter Truckenmueller
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurosurgery, Charitéplatz 1, 10117 Berlin, Germany
| | - Kiril Krantchev
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurosurgery, Charitéplatz 1, 10117 Berlin, Germany
| | - Kerstin Rubarth
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Informatics, Invalidenstrasse 90, 10115 Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Charitéplatz 1, 10117 Berlin, Germany
| | - Anton Früh
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurosurgery, Charitéplatz 1, 10117 Berlin, Germany; Berlin Institue of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Junior Digital Clinician Scientist Program, Charitéplatz 1, 10117 Berlin, Germany
| | - Robert Mertens
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurosurgery, Charitéplatz 1, 10117 Berlin, Germany; Berlin Institute of Health at Charité - Univsersitätsmedizin Berlin, BIH Academy, Junior Clinician Scientist Program, Charitéplatz 1, 10117 Berlin, Germany
| | - Daniel Bruening
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurosurgery, Charitéplatz 1, 10117 Berlin, Germany
| | - Christian Stein
- Humboldt-Universität zu Berlin, Cluster of Excellence: "Matters of Activity. Image Space Material", Unter den Linden 6, 10099 Berlin, Germany; Humboldt-Universität zu Berlin, gamelab.berlin, Cluster of Excellence: "Matters of Activity. Image Space Material", Unter den Linden 6, 10099 Berlin, Germany
| | - Peter Vajkoczy
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurosurgery, Charitéplatz 1, 10117 Berlin, Germany
| | - Thomas Picht
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurosurgery, Charitéplatz 1, 10117 Berlin, Germany; Humboldt-Universität zu Berlin, Cluster of Excellence: "Matters of Activity. Image Space Material", Unter den Linden 6, 10099 Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin Simulation and Training Center (BeST), Charitéplatz 1, 10117 Berlin, Germany
| | - Gueliz Acker
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurosurgery, Charitéplatz 1, 10117 Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Academy, Clinician Scientist Program, Charitéplatz 1, 10117 Berlin, Germany.
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Falcone V, Catic A, Heinzl F, Steinbauer P, Wagner M, Mikula F, Dorittke T, Roessler B, Farr A. Impact of a virtual reality-based simulation training for shoulder dystocia on human and technical skills among caregivers: a randomized-controlled trial. Sci Rep 2024; 14:7898. [PMID: 38570525 PMCID: PMC10991516 DOI: 10.1038/s41598-024-57785-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 03/21/2024] [Indexed: 04/05/2024] Open
Abstract
This study analyzed the adherence to the modified Advanced Life Support in Obstetrics (ALSO) algorithm (HELP-RER) for handling shoulder dystocia (SD) using a virtual reality (VR) training modality. Secondary outcomes were improvements in the post-training diagnosis-to-delivery time, human skills factors (HuFSHI), and perceived task-load index (TLX). Prospective, case-control, single-blind, 1:1 randomized crossover study. Participants were shown a 360° VR video of SD management. The control group was briefed theoretically. Both groups underwent HuFSHI and HELP-RER score assessments at baseline and after the manikin-based training. The TLX questionnaire was then administered. After a washout phase of 12 weeks, we performed a crossover, and groups were switched. There were similar outcomes between groups during the first training session. However, after crossover, the control group yielded significantly higher HELP-RER scores [7 vs. 6.5; (p = 0.01)], with lower diagnosis-to-delivery-time [85.5 vs. 99 s; (p = 0.02)], and TLX scores [57 vs. 68; (p = 0.04)]. In the multivariable linear regression analysis, VR training was independently associated with improved HELP-RER scores (p = 0.003). The HuFSHI scores were comparable between groups. Our data demonstrated the feasibility of a VR simulation training of SD management for caregivers. Considering the drawbacks of common high-fidelity trainings, VR-based simulations offer new perspectives.
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Affiliation(s)
- Veronica Falcone
- Division of Obstetrics and Feto-Maternal Medicine, Department of Obstetrics and Gynecology, Comprehensive Center for Pediatrics, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Anja Catic
- Division of Obstetrics and Feto-Maternal Medicine, Department of Obstetrics and Gynecology, Comprehensive Center for Pediatrics, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Florian Heinzl
- Division of Obstetrics and Feto-Maternal Medicine, Department of Obstetrics and Gynecology, Comprehensive Center for Pediatrics, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Philipp Steinbauer
- Division of Neonatology, Pediatric Intensive Care Medicine and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Michael Wagner
- Division of Neonatology, Pediatric Intensive Care Medicine and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Fanny Mikula
- Division of Obstetrics and Feto-Maternal Medicine, Department of Obstetrics and Gynecology, Comprehensive Center for Pediatrics, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Tim Dorittke
- Division of Obstetrics and Feto-Maternal Medicine, Department of Obstetrics and Gynecology, Comprehensive Center for Pediatrics, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Bernhard Roessler
- Medical Simulation and Emergency Management Research Group, Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Alex Farr
- Division of Obstetrics and Feto-Maternal Medicine, Department of Obstetrics and Gynecology, Comprehensive Center for Pediatrics, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Tsukada K, Yasui Y, Miyata S, Fuyumuro J, Kikuchi T, Mizuno T, Nakayama S, Kawano H, Miyamoto W. Effectiveness of Virtual Reality Training in Teaching Personal Protective Equipment Skills: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2355358. [PMID: 38353953 PMCID: PMC10867681 DOI: 10.1001/jamanetworkopen.2023.55358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 12/12/2023] [Indexed: 02/16/2024] Open
Abstract
Importance Training on the proper use of personal protective equipment (PPE) is critical for infection prevention among health care workers. Traditional methods, such as face-to-face and video-based training, can strain resources and present challenges. Objective To determine the effectiveness of 360° virtual reality (VR) training for PPE donning and doffing compared with face-to-face and video training in enhancing the PPE use skills of prospective health care practitioners. Design, Setting, and Participants A blinded, prospective, and randomized noninferiority clinical trial was conducted from August to December 2021 at Teikyo University School of Medicine in Tokyo, Japan, with a mixed population of medical students. Participants were second- to fourth-year medicine, medical technology, or pharmacy students aged 20 years or older with no prior PPE training. Participants were randomized into 1 of 3 training groups (VR, face-to-face, or video) based on their enrollment order. An intention-to-treat analysis was conducted. Intervention A 30-minute lecture on PPE procedures was delivered to all participants before the training. After the lecture, the VR group trained with an immersive 360° VR tool, the face-to-face group trained with actual PPE, and the video group trained by watching video footage on a computer and a projector. After 3 days, a standardized practical skills test was administered. Main Outcomes and Measures The primary outcome was the mean score on a 20-point practical skills test, and the secondary outcome was the percentage of correct execution. Results A total of 91 participants were recruited and randomized into 3 groups: VR (n = 30), face-to-face (n = 30), and video (n = 31) training. After excluding 1 participant due to illness, 90 participants (mean [SD] age, 24.2 [3.15] years; 54 males [60.0%]) completed the assessment. The mean (SD) scores were 17.70 (2.10) points for the VR group, 17.57 (2.45) points for the face-to-face group, and 15.87 (2.90) points for the video group. The VR group demonstrated no significant difference in performance from the face-to-face group. However, the VR group had significantly higher effectiveness than the video group (17.70 vs 15.87 points; P = .02). Conclusions and Relevance Results of this trial indicate that VR training was as effective as face-to-face training in enhancing PPE donning and doffing skills and was superior to video training. The findings suggest that VR training is a viable resource-conserving training option. Trial Registration Japan Registry of Clinical Trials Identifier: jRCT103021029.
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Affiliation(s)
- Keisuke Tsukada
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Kaga Itabashi-ku, Tokyo, Japan
| | - Youichi Yasui
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Kaga Itabashi-ku, Tokyo, Japan
| | - Satoshi Miyata
- Teikyo University Graduate School of Public Health, Kaga Itabashi-ku, Tokyo, Japan
| | - Junko Fuyumuro
- Department of Infection Control, Teikyo University Hospital, Kaga Itabashi-ku, Tokyo, Japan
| | - Tomomi Kikuchi
- Department of Infection Control, Teikyo University Hospital, Kaga Itabashi-ku, Tokyo, Japan
| | | | - Satoshi Nakayama
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Kaga Itabashi-ku, Tokyo, Japan
| | - Hirotaka Kawano
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Kaga Itabashi-ku, Tokyo, Japan
| | - Wataru Miyamoto
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Kaga Itabashi-ku, Tokyo, Japan
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Virtual Reality in Health Science Education: Professors’ Perceptions. MULTIMODAL TECHNOLOGIES AND INTERACTION 2022. [DOI: 10.3390/mti6120110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Virtual reality (VR) is a simulated experience in a three-dimensional (3D) computer-simulated world. Recent advances in technology position VR as a multipurpose technology in the healthcare sector and as a critical component in achieving Health 4.0. In this article, descriptive and correlationally quantitative research is carried out on the assessments made by Latin American health sciences university professors on the didactic use of virtual reality technologies. The main objective was to analyze the differences in the perceptions expressed by the public or private tenure of the universities where the professors teach. In addition, gender and age gaps were identified in the assessments obtained from each of the types of universities. The results reveal that Latin American health science professors at private universities have a higher selfconcept of their digital skills for the use of virtual reality in the lectures. This greater selfconcept also leads to a reduction in the gender and age gaps in the participating private universities with respect to the public counterparts. It is advisable to increase both faculty training in the didactic use of virtual reality and funding for its use, mainly in public universities.
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Hsin LJ, Chao YP, Chuang HH, Kuo TBJ, Yang CCH, Huang CG, Kang CJ, Lin WN, Fang TJ, Li HY, Lee LA. Mild simulator sickness can alter heart rate variability, mental workload, and learning outcomes in a 360° virtual reality application for medical education: a post hoc analysis of a randomized controlled trial. VIRTUAL REALITY 2022; 27:1-17. [PMID: 36118174 PMCID: PMC9470506 DOI: 10.1007/s10055-022-00688-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 04/28/2022] [Indexed: 06/02/2023]
Abstract
Virtual reality (VR) applications could be beneficial for education, training, and treatment. However, VR may induce symptoms of simulator sickness (SS) such as difficulty focusing, difficulty concentrating, or dizziness that could impair autonomic nervous system function, affect mental workload, and worsen interventional outcomes. In the original randomized controlled trial, which explored the effectiveness of using a 360° VR video versus a two-dimensional VR video to learn history taking and physical examination skills, only the former group participants had SS. Therefore, 28 undergraduate medical students who participated in a 360° VR learning module were included in this post hoc study using a repeated measures design. Data of the Simulator Sickness Questionnaire (SSQ), heart rate variability (HRV) analysis, Task Load Index, and Mini-Clinical Evaluation Exercise were retrospectively reviewed and statistically analyzed. Ten (36%) participants had mild SS (total score > 0 and ≤ 20), and 18 (64%) had no SS symptom. Total SSQ score was positively related to the very low frequency (VLF) band power, physical demand subscale, and frustration subscale, and inversely related to physical examination score. Using multilevel modeling, the VLF power mediated the relationship between total SSQ score and physical examination score. Furthermore, frustration subscale moderated the mediating effects of the VLF power. Our results highlight the importance of documenting SS to evaluate a 360° VR training program. Furthermore, the combination of HRV analysis with mental workload measurement and outcome assessments provided the important clinical value in evaluating the effects of SS in VR applications in medical education.
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Affiliation(s)
- Li-Jen Hsin
- Department of Otorhinolaryngology-Head and Neck Surgery, Sleep Center, Linkou Medical Center, Linkou Chang Gung Memorial Hospital, No. 5, Fu-Hsing Street, Gueishan District, Taoyuan City, 33305 Taiwan, Republic of China
- Faculty of Medicine, Graduate Institute of Clinical Medicine Sciences, Chang Gung University, Taoyuan, 33302 Taiwan
| | - Yi-Ping Chao
- Department of Computer Science and Information Engineering, Graduate Institute of Biomedical Engineering, Chang Gung University, Taoyuan, 33302 Taiwan
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, 33305 Taiwan
| | - Hai-Hua Chuang
- Faculty of Medicine, Graduate Institute of Clinical Medicine Sciences, Chang Gung University, Taoyuan, 33302 Taiwan
- Department of Family Medicine, Taipei Branch and Linkou Main Branch, Linkou Medical Center, Chang Gung Memorial Hospital, No. 5, Fu-Hsing Street, Gueishan District, Taoyuan, 33305 Taiwan, Republic of China
- Department of Industrial Engineering and Management, National Taipei University of Technology, Taipei, 10608 Taiwan
- School of Medicine, National Tsing Hua University, Hsinchu, 300044 Taiwan
| | - Terry B. J. Kuo
- Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, 11221 Taiwan
| | - Cheryl C. H. Yang
- Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, 11221 Taiwan
| | - Chung-Guei Huang
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, 33305 Taiwan
- Department of Medical Biotechnology and Laboratory Science, Graduate Institute of Biomedical Sciences, Chang Gung University, Taoyuan, 33302 Taiwan
| | - Chung-Jan Kang
- Department of Otorhinolaryngology-Head and Neck Surgery, Sleep Center, Linkou Medical Center, Linkou Chang Gung Memorial Hospital, No. 5, Fu-Hsing Street, Gueishan District, Taoyuan City, 33305 Taiwan, Republic of China
- Faculty of Medicine, Graduate Institute of Clinical Medicine Sciences, Chang Gung University, Taoyuan, 33302 Taiwan
| | - Wan-Ni Lin
- Department of Otorhinolaryngology-Head and Neck Surgery, Sleep Center, Linkou Medical Center, Linkou Chang Gung Memorial Hospital, No. 5, Fu-Hsing Street, Gueishan District, Taoyuan City, 33305 Taiwan, Republic of China
- Faculty of Medicine, Graduate Institute of Clinical Medicine Sciences, Chang Gung University, Taoyuan, 33302 Taiwan
| | - Tuan-Jen Fang
- Department of Otorhinolaryngology-Head and Neck Surgery, Sleep Center, Linkou Medical Center, Linkou Chang Gung Memorial Hospital, No. 5, Fu-Hsing Street, Gueishan District, Taoyuan City, 33305 Taiwan, Republic of China
- Faculty of Medicine, Graduate Institute of Clinical Medicine Sciences, Chang Gung University, Taoyuan, 33302 Taiwan
| | - Hsueh-Yu Li
- Department of Otorhinolaryngology-Head and Neck Surgery, Sleep Center, Linkou Medical Center, Linkou Chang Gung Memorial Hospital, No. 5, Fu-Hsing Street, Gueishan District, Taoyuan City, 33305 Taiwan, Republic of China
- Faculty of Medicine, Graduate Institute of Clinical Medicine Sciences, Chang Gung University, Taoyuan, 33302 Taiwan
| | - Li-Ang Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Sleep Center, Linkou Medical Center, Linkou Chang Gung Memorial Hospital, No. 5, Fu-Hsing Street, Gueishan District, Taoyuan City, 33305 Taiwan, Republic of China
- Faculty of Medicine, Graduate Institute of Clinical Medicine Sciences, Chang Gung University, Taoyuan, 33302 Taiwan
- Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, 11221 Taiwan
- School of Medicine, National Tsing Hua University, Hsinchu, 300044 Taiwan
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