A prospective survey on trephine biopsy of bone and bone marrow: an experience with 274 Indian patients' biopsies.

Trephine bone marrow biopsy is an effective technique for diagnosing hematological malignancies in patients of different ages. During trephine biopsy, bone marrow cores are obtained for detailed morphological evaluation to look for any abnormality and arrive at a diagnosis. The primary goal of this work is to perform a survey on Indian patients of various ages for the trephine bone marrow biopsy process. In the present study, data related to 274 trephine biopsy samples from 300 patients were acquired at the Post Graduate Institute of Medical Education and Research (PGIMER) in Chandigarh, India. Pain was found to be the sole major procedure-related complication, and patients reported no/less pain in 41 BMB (14.96%) patients, moderate pain in 82 (29.92%) cases, and unbearable pain in 151 (55.1%) BMB cases. In addition, the patients were evaluated by the authors and hematologist as non-anxious for the procedure in 34 (12.4%), anxious in 92 (33.57%), and very/highly anxious in 148 (56%) cases. The bone texture of the patients significantly affected the needle bending, number of repetitions required, and size of the bone marrow sample. This demonstrates the need for improvement in the biopsy procedure. To this end, a survey was conducted to assess the numerous difficulties and diagnostic outcomes throughout the trephine biopsy process.

Honeybee stinger-based biopsy needle and influence of the barbs on needle forces during insertion/extraction into the iliac crest: A multilayer finite element approach.

Bone marrow biopsy (BMB) needles are frequently used in medical procedures, including extracting biological tissue to identify specific lesions or abnormalities discovered during a medical examination or a radiological scan. The forces applied by the needle during the cutting operation significantly impact the sample quality. Excessive needle insertion force and possible deflection might cause tissue damage, compromising the integrity of the biopsy specimen. The present study aims at proposing a revolutionary bioinspired needle design that will be utilized during the BMB procedure. A non-linear finite element method (FEM) has been used to analyze the insertion/extraction mechanisms of the honeybee-inspired biopsy needle with barbs into/from the human skin-bone domain (i.e., iliac crest model). It can be seen from the results of the FEM analysis that stresses are concentrated around the bioinspired biopsy needle tip and barbs during the needle insertion process. Also, these needles reduce the insertion force and reduce the tip deflection. The insertion force in the current study has been reduced by 8.6% for bone tissue and 22.66% for skin tissue layers. Similarly, the extraction force has been reduced by an average of 57.54%. Additionally, it has been observed that the needle-tip deflection got reduced from 10.44 mm for a plain bevel needle to 6.3 mm for a barbed biopsy bevel needle. According to the research findings, the proposed bioinspired barbed biopsy needle design could be utilized to create and produce novel biopsy needles for successful and minimally invasive piercing operations.

Techniques for the detection and management of freezing of gait in Parkinson's disease - A systematic review and future perspectives.

Freezing of Gait (FoG) is one of the most critical debilitating motor symptoms of advanced Parkinson's disease (PD) with a higher rate of occurrence in aged people. PD affects the cardinal motor functioning and leads to non-motor symptoms, including cognitive and neurobehavioral abnormalities, autonomic dysfunctions and sleep disorders. Since its pathogenesis is complex and unclear yet, this paper targets the studies done on the pathophysiology and epidemiology of FoG in PD. Gait disorder and cardinal features vary from festination (involuntary hurrying in walking) to freezing of gait (breakdown of repetitive movement of steps despite the intention to walk) in patients. Hence, it is difficult to assess the FoG in clinical trials. Therefore, the current research emphasizes wearable sensor-based systems over pharmacology and surgical methods.•This paper presents a technological review of various techniques used for the assessment of FoG with a comprehensive comparison.•Researchers are aiming at the development of wireless sensor-based assistive devices to (a) predict the FoG episode in a different environment, (b) acquire the long-term data for real-time analysis, and (c) cue the FoG patients.•We summarize the work done till now and future research directions needed for a suitable cueing mechanism to overcome FoG.

Finite element simulation of multilayer model to simulate fine needle insertion mechanism into iliac crest for bone marrow biopsy.

The main aim of this work is to use a finite element technique (FEM) to gain understanding about the bone marrow biopsy (BMB) needle insertion process and needle-tissue interactions in the human iliac crest. A multi-layer iliac crest model consists of stratum corneum, dermis, epidermis, hypodermis, cortical, and cancellous bone has been established. This paper proposes a FE model that examines all phases of tissue deformation, including puncture, cutting, needle-tissue interaction, and various stress-strain values for BMB needle during interaction. The results explain the needle-tissue interface and show the potential of this technique to estimate bone damage and tissue deformation for multiple needle dimensions, coefficient of friction, and penetration speeds. The insertion and extraction force of conical-shaped needles in the multi-layered iliac crest model decreased by 18.92% and 37.5%, respectively, as the needle diameter reduced from 11 G to 20 G. It has also been found that the significant insertion motion raises the deformation of the tissue due to the augmented frictional forces but reduces the strain perpendicular to the penetration direction closer to the needle tip. The simulation outcomes are helpful for the optimal design of fine biopsy needles used to perform the bone marrow biopsies.

Concept, hardware development, and clinical trials of a Galinstan based Mercury free sphygmomanometer: Merkfree.

The aim of this work is to develop Merkfree-a mercury-free sphygmomanometer that looks, feels, and operates just like a traditional mercury sphygmomanometer (MS). For this we use Galinstan as a substitute for mercury, which is a non-toxic alloy of Gallium, Indium and Tin. Galinstan is nearly half as dense as mercury and sticks to class. To work with the lower density, we designed an enclosure and scale that is nearly double the length of MS. The issue of stickiness with glass was resolved by maintaining a small meniscus of a reducing agent in the measuring tube and tank of Merkfree. Clinical trials to validate the accuracy of Merkfree against MS and oscillometric sphygmomanometer (OS) were conducted over 252 patients. The results show a good correlation of the systolic and diastolic BP measurements from Merkfree with respect to MS and the OS. The mean absolute percentage error is less than 10% for both SBP and DBP. We also found that Merkfree has lower rounding-off errors compared to MS. Merkfree can be a viable alternative to mercury sphygmomanometer that can help achieve the goal of WHO in eliminating mercury from healthcare, while simultaneously making sure that gold standard technique of sphygmomanometry continues to be available to the clinicians.

Automatic Pasteurized Formula Milk Preparation Machine with Automatic Sterilized Containers.

Children are the future of our generation, so reducing child mortality is very critical in developing countries. There are lots of asserting factors of child mortality but malnutrition is one of the prominent factors. Medically, it has been proven that breastfeeding is one of the sources of nutrients and it is being always appreciated to have mothers' milk to a child in the early days. However, with the increasing participation of women in the workforce, the child care load on breastfeeding mothers is very high. This forces many of them to take long career breaks. Here, in this paper, we have an automatic formula milk dispensing unit that will be used in Neonatal Intensive Care Units (NICUs) and for breastfeeding mothers at home. The device has inbuilt sterilization and pasteurization units that would maintain the overall hygiene and sterilization of baby milk bottles. Currently, the device has a few buttons through which we can control the functionality of the device.

An Optimized Machine Learning Model Accurately Predicts In-Hospital Outcomes at Admission to a Cardiac Unit.

Risk stratification at the time of hospital admission is of paramount significance in triaging the patients and providing timely care. In the present study, we aim at predicting multiple clinical outcomes using the data recorded during admission to a cardiac care unit via an optimized machine learning method. This study involves a total of 11,498 patients admitted to a cardiac care unit over two years. Patient demographics, admission type (emergency or outpatient), patient history, lab tests, and comorbidities were used to predict various outcomes. We employed a fully connected neural network architecture and optimized the models for various subsets of input features. Using 10-fold cross-validation, our optimized machine learning model predicted mortality with a mean area under the receiver operating characteristic curve (AUC) of 0.967 (95% confidence interval (CI): 0.963-0.972), heart failure AUC of 0.838 (CI: 0.825-0.851), ST-segment elevation myocardial infarction AUC of 0.832 (CI: 0.821-0.842), pulmonary embolism AUC of 0.802 (CI: 0.764-0.84), and estimated the duration of stay (DOS) with a mean absolute error of 2.543 days (CI: 2.499-2.586) of data with a mean and median DOS of 6.35 and 5.0 days, respectively. Further, we objectively quantified the importance of each feature and its correlation with the clinical assessment of the corresponding outcome. The proposed method accurately predicts various cardiac outcomes and can be used as a clinical decision support system to provide timely care and optimize hospital resources.

A Machine Learning Pipeline for Measurement of Arterial Stiffness in A-Mode Ultrasound.

Arterial stiffness (AS) of the carotid artery is an early marker of stratifying cardiovascular disease risk. This article aims to improve the performance of ARTSENS, a noninvasive A-mode ultrasound-based device for measuring AS. The primary objective of ARTSENS is to enable the measurement of elastic modulus using A-Mode ultrasound and blood pressure. As this device is image-free, there is a need to automate: 1) carotid detection; 2) wall localization; and 3) inner lumen diameter measurement. This has been performed using conventional signal processing methods in some of the earlier works in this domain. In this article, deep neural network (DNN) models are employed to perform the above three tasks. The DNNs were trained over data acquired from 82 subjects at two different medical centers. Ground-truth labeling was performed by a trained operator using corresponding measurements from the state-of-the-art Aloka e-Tracking system. All three DNN models had significantly lower errors compared to earlier signal processing methods and could perform their measurements using a single A-Mode frame. Using the DNNs, two different machine learning pipelines have been proposed here to measure the elastic modulus; the best among them could achieve an error of 9.3% with the Pearson correlation coefficient of 0.94 ( ). The models were tested on Raspberry Pi and Jetson Nano single board computers to demonstrate real-time processing on low computational resources.

A Device to Reduce Vasovagal Syncope in Blood Donors.

Vasovagal Syncope (VVS), or the transient loss of consciousness is the most widely recognized reason for syncope. (VVS), is a typical dysfunction of the autonomic nervous system. There are various factors which can influence the syncope. The major classification of the syncope are reflex(neurally mediated) syncope, syncope due to orthostatic hypertension, Cardiac syncope(cardiovascular). The vasovagal syncope is the part of reflex (neurally mediated)syncope, there are various cause of vasovagal reactions but in blood donation it is mediated due to the pooling of blood at calf muscles. Such near syncope incidence while donating the blood or after donation hampers the future motivation for blood donation of the donors. In this paper, we developed an electronic massager for calf muscles that can reduce the risk of VVS. It has a programmable circuit which can control the vacuum pump so that it can inflate and deflate the cuffs synergistically. The massager can relax the blood donor thereby reducing apprehension prior to blood donation and thus diverting from the trigger of Phlebotomy and improve peripheral blood circulation thereby improving venous return to the heart. This is expected to reduce the risk of VVS.

A survey to gauge confidence of Indian clinicians on three primary devices for blood pressure measurement.

PURPOSE: As per its commitment at Minamata convention, and in line with other developed economies, the Indian government is set to ban the use of mercury sphygmomanometers by end of the year 2020. However, the Mercury sphygmomanometer is still widely used by clinicians in India. We conducted a survey to gauge the confidence of Indian clinicians on three primary devices of blood pressure (BP) measurement - mercury sphygmomanometer, aneroid sphygmomanometer and automatic digital BP monitor. MATERIALS AND METHODS: We conducted an anonymous online survey through various clinician forums asking questions related to accuracy, reliability and expectations from BP monitors. RESULTS: A total of 139 responses were received from clinicians across specialties. The results show that more than 80% of clinicians believe that mercury sphygmomanometers are the most accurate and nearly 50% find it most reliable. For most respondents, accuracy is the most important parameter and convenience of use and portability are secondary considerations. If a mercury-free sphygmomanometer is offered with the same accuracy and reliability, 88% of respondents said they are willing to buy it. CONCLUSIONS: Mercury sphygmomanometer is still perceived favorably over other non-mercury alternatives by most Indian clinicians. Validated oscillometric devices should be promoted to bring about change in the perspectives of clinicians towards adopting non-mercury alternatives of BP measurement in India.

An Imageless Ultrasound Device to Measure Local and Regional Arterial Stiffness.

Arterial stiffness (AS) has been shown to be an important marker for risk assessment of cardiovascular events. Local arterial stiffness (LAS) is conventionally measured by evaluating arterial distensibility at particular arterial sites through ultrasound imaging systems. Regional arterial stiffness (RAS) is generally obtained by evaluating carotid to femoral pulse wave velocity (cfPWV) through tonometric devices. RAS has a better prognostic value than LAS and cfPWV is considered as the gold standard of AS. Over the past few years our group has been developing ARTerial Stiffness Evaluation for Non-Invasive Screening (ARTSENS), an inexpensive and portable device to measure the LAS. It uses a single element ultrasound transducer to obtain A-Mode frames from the desired artery and is fully automated to enable a non-expert to perform measurements. In this work, we report an extension of ARTSENS to enable measurement of cfPWV that now makes it the only fully automatic device that can measure both LAS and RAS. In this paper, we provide a general review of the ARTSENS and compare it with other state-of-the-art AS measurement systems. cfPWV measurement using ARTSENS was cross-validated against SphygmoCor by successive measurements with both devices on 41 human subjects and excellent agreement between both devices was demonstrated (Coefficient of determination and, limits of agreement m/s). The inter-device correlation between ARTSENS and SphygmoCor was found to be better than other similar studies reported in the literature.

Carotid and Jugular Classification in ARTSENS.

Over past few years our group has been working on the development of a low-cost device, ARTSENS, for measurement of local arterial stiffness (AS) of the common carotid artery (CCA). This uses a single element ultrasound transducer to obtain A-mode frames from the CCA. It is designed to be fully automatic in its operation such that, a general medical practitioner can use the device without any prior knowledge of ultrasound modality. Placement of the probe over CCA and identification of echo positions corresponding to its two walls are critical steps in the process of measurement of AS. We had reported an algorithm to locate the CCA walls based on their characteristic motion. Unfortunately, in supine position, the internal jugular vein (IJV) expands in the carotid triangle and pulsates in a manner that confounds the existing algorithm and leads to wrong measurements of the AS. Jugular venous pulse (JVP), on its own right, is a very important physiological signal for diagnosis of morbidities of the right side of the heart and there is a lack of noninvasive methods for its accurate estimation. We integrated an ECG device to the existing hardware of ARTSENS and developed a method based on physiology of the vessels, which now enable us to segregate the CCA pulse (CCP) and the JVP. False identification rate is less than 4%. To retain the capabilities of ARTSENS to operate without ECG, we designed another method where the classification can be achieved without an ECG, albeit errors are a bit higher. These improvements enable ARTSENS to perform automatic measurement of AS even in the supine position and make it a unique and handy tool to perform JVP analysis.

Evaluation of the algorithm for automatic identification of the common carotid artery in ARTSENS.

Arterial compliance (AC) is an indicator of the risk of cardiovascular diseases (CVDs) and it is generally estimated by B-mode ultrasound investigation. The number of sonologists in low- and middle-income countries is very disproportionate to the extent of CVD. To bridge this gap we are developing an image-free CVD risk screening tool-arterial stiffness evaluation for non-invasive screening (ARTSENS™) which can be operated with minimal training. ARTSENS uses a single element ultrasound transducer to investigate the wall dynamics of the common carotid artery (CCA) and subsequently measure the AC. Identification of the proximal and distal walls of the CCA, in the ultrasound frames, is an important step in the process of the measurement of AC. The image-free nature of ARTSENS creates some unique issues which necessitate the development of a new algorithm that can automatically identify the CCA from a sequence of A-mode radio-frequency (RF) frames. We have earlier presented the concept and preliminary results for an algorithm that employed clues from the relative positions and temporal motion of CCA walls, for identifying the CCA and finding the approximate wall positions. In this paper, we present the detailed algorithm and its extensive evaluation based on simulation and clinical studies. The algorithm identified the wall position correctly in more than 90% of all simulated datasets where the signal-to-noise ratio was greater than 3 dB. The algorithm was then tested extensively on RF data obtained from the CCA of 30 human volunteers, where it successfully located the arterial walls in more than 70% of all measurements. The algorithm could successfully reject frames where the CCA was not present thus assisting the operator to place the probe correctly in the image-free system, ARTSENS. It was demonstrated that the algorithm can be used in real-time with few trade-offs which do not affect the accuracy of CCA identification. A new method for depth range selection that leads to significant performance improvements has also been demonstrated.

An improved method for detection of carotid walls in ARTSENS.

We have been developing a fully automated ultrasound based imageless system to facilitate mass screening of patients for future risk of cardiovascular diseases. The device shall enable a general medical practitioner to non-invasively measure the local arterial stiffness of common carotid artery (CCA) and has been acronymed ARTerial Stiffness Evaluation for Non-invasive Screening (ARTSENS™). Complete automation of the system requires providing assistance in placement of probe over the CCA location and automatic identification of approximate location of proximal wall (PW) and distal wall (DW) of the CCA. In this paper we propose a method based on temporal motion of PW and DW over successive A-Mode frames to locate the CCA. We evaluated the performance of the algorithm with data obtained from CCA of 30 subjects. It could correctly identify the CCA in more than 70 % of trials. We also propose a method for preprocessing the frames by using the transmitted pulse wavelet. This improved the detection rate significantly. False positives were always less than 6% of total detections.

Automatic measurement of lumen diameter of carotid artery in A-Mode ultrasound.

Accurate measurement of lumen diameter is essential for correct estimation of arterial compliance. We have been developing a new non-invasive arterial compliance measurement tool using a single element ultrasound transceiver. In this paper we propose a new method for measurement of lumen diameter from single line of Radio-Frequency Signal (RF) obtained from the common carotid artery (CCA). The method is free from fixed thresholds and uses shape fitting to get objective measurement. The accuracy of the algorithm was found to be better than 5 % for software simulated and phantom arteries and better than 10 % in case of data obtained from CCA of human volunteers.

Automated system for imageless evaluation of arterial compliance.

Evaluation of arterial compliance is very significant in early detection of coronary heart disease. Here we present an imageless portable system for automated estimation of local arterial compliance, designed to be operated by a general medical practitioner with no prior knowledge of ultrasonography. An algorithm for automatic detection and tracking of the arterial wall locations has been developed to minimize the operator expertise required for measurement. The performance of the automated algorithm was thoroughly characterized using a simulation platform developed for the purpose. Measurements performed on a few human volunteers by untrained personnel clearly illustrated the practical utility of the automatic algorithm during in-vivo tests. The proposed system could be used for developing an inexpensive cardiovascular screening device for large scale deployment in primary health care centers.