Edge Artificial Intelligence (AI) for real-time automatic quantification of filariasis in mobile microscopy.

Filariasis, a neglected tropical disease caused by roundworms, is a significant public health concern in many tropical countries. Microscopic examination of blood samples can detect and differentiate parasite species, but it is time consuming and requires expert microscopists, a resource that is not always available. In this context, artificial intelligence (AI) can assist in the diagnosis of this disease by automatically detecting and differentiating microfilariae. In line with the target product profile for lymphatic filariasis as defined by the World Health Organization, we developed an edge AI system running on a smartphone whose camera is aligned with the ocular of an optical microscope that detects and differentiates filarias species in real time without the internet connection. Our object detection algorithm that uses the Single-Shot Detection (SSD) MobileNet V2 detection model was developed with 115 cases, 85 cases with 1903 fields of view and 3342 labels for model training, and 30 cases with 484 fields of view and 873 labels for model validation before clinical validation, is able to detect microfilariae at 10x magnification and distinguishes four species of them at 40x magnification: Loa loa, Mansonella perstans, Wuchereria bancrofti, and Brugia malayi. We validated our augmented microscopy system in the clinical environment by replicating the diagnostic workflow encompassed examinations at 10x and 40x with the assistance of the AI models analyzing 18 samples with the AI running on a middle range smartphone. It achieved an overall precision of 94.14%, recall of 91.90% and F1 score of 93.01% for the screening algorithm and 95.46%, 97.81% and 96.62% for the species differentiation algorithm respectively. This innovative solution has the potential to support filariasis diagnosis and monitoring, particularly in resource-limited settings where access to expert technicians and laboratory equipment is scarce.

Digital Microscopy Augmented by Artificial Intelligence to Interpret Bone Marrow Samples for Hematological Diseases.

Analysis of bone marrow aspirates (BMAs) is an essential step in the diagnosis of hematological disorders. This analysis is usually performed based on a visual examination of samples under a conventional optical microscope, which involves a labor-intensive process, limited by clinical experience and subject to high observer variability. In this work, we present a comprehensive digital microscopy system that enables BMA analysis for cell type counting and differentiation in an efficient and objective manner. This system not only provides an accessible and simple method to digitize, store, and analyze BMA samples remotely but is also supported by an Artificial Intelligence (AI) pipeline that accelerates the differential cell counting process and reduces interobserver variability. It has been designed to integrate AI algorithms with the daily clinical routine and can be used in any regular hospital workflow.

Evaluation of the Performance of a 3D-Printed Smartphone-Based Retinal Imaging Device as a Screening Tool for Retinal Pathology in Mozambique.

Low-income countries carry approximately 90% of the global burden of visual impairment, and up to 80% of this could be prevented or cured. However, there are only a few studies on the prevalence of retinal disease in these countries. Easier access to retinal information would allow differential diagnosis and promote strategies to improve eye health, which are currently scarce. This pilot study aims to evaluate the functionality and usability of a tele-retinography system for the detection of retinal pathology, based on a low-cost portable retinal scanner, manufactured with 3D printing and controlled by a mobile phone with an application designed ad hoc. The study was conducted at the Manhiça Rural Hospital in Mozambique. General practitioners, with no specific knowledge of ophthalmology or previous use of retinography, performed digital retinographies on 104 hospitalized patients. The retinographies were acquired in video format, uploaded to a web platform, and reviewed centrally by two ophthalmologists, analyzing the image quality and the presence of retinal lesions. In our sample there was a high proportion of exudates and hemorrhages-8% and 4%, respectively. In addition, the presence of lesions was studied in patients with known underlying risk factors for retinal disease, such as HIV, diabetes, and/or hypertension. Our tele-retinography system based on a smartphone coupled with a simple and low-cost 3D printed device is easy to use by healthcare personnel without specialized ophthalmological knowledge and could be applied for the screening and initial diagnosis of retinal pathology.

Hematic Antegrade Repriming Reduces Emboli on Cardiopulmonary Bypass: A Randomized Controlled Trial.

Particulate and gaseous microemboli (GME) are side effects of cardiac surgery that interfere with postoperative recovery by causing endothelial dysfunction and vascular blockages. GME sources during surgery are multiple, and cardiopulmonary bypass (CPB) is contributory to this embolic load. Hematic antegrade repriming (HAR) is a novel procedure that combines the benefits of repriming techniques with additional measures, by following a standardized procedure to provide a reproducible hemodilution of 300 ml. To clarify the safety of HAR in terms of embolic load delivery, a prospective and controlled study was conducted, by applying Doppler probes to the extracorporeal circuit, to determine the number and volume of GME released during CPB. A sample of 115 patients (n = 115) was considered for assessment. Both groups were managed under strict normothermia, and similar clinical conditions and protocols, receiving the same open and minimized circuit. Significant differences in GME volume delivery (control group [CG] = 0.28 ml vs. HAR = 0.08 ml; p = 0.004) and high embolic volume exposure (>1 ml) were found between the groups (CG = 30.36% vs. HAR = 4.26%; p = 0.001). The application of HAR did not represent an additional embolic risk and provided a four-fold reduction in the embolic volume delivered to the patient (coefficient, 0.24; 95% CI, 0.08-0.72; p = 0.01), which appears to enhance GME clearance of the oxygenator before CPB initiation.

A Smartphone-Based Platform Assisted by Artificial Intelligence for Reading and Reporting Rapid Diagnostic Tests: Evaluation Study in SARS-CoV-2 Lateral Flow Immunoassays.

BACKGROUND: Rapid diagnostic tests (RDTs) are being widely used to manage COVID-19 pandemic. However, many results remain unreported or unconfirmed, altering a correct epidemiological surveillance. OBJECTIVE: Our aim was to evaluate an artificial intelligence-based smartphone app, connected to a cloud web platform, to automatically and objectively read RDT results and assess its impact on COVID-19 pandemic management. METHODS: Overall, 252 human sera were used to inoculate a total of 1165 RDTs for training and validation purposes. We then conducted two field studies to assess the performance on real-world scenarios by testing 172 antibody RDTs at two nursing homes and 96 antigen RDTs at one hospital emergency department. RESULTS: Field studies demonstrated high levels of sensitivity (100%) and specificity (94.4%, CI 92.8%-96.1%) for reading IgG band of COVID-19 antibody RDTs compared to visual readings from health workers. Sensitivity of detecting IgM test bands was 100%, and specificity was 95.8% (CI 94.3%-97.3%). All COVID-19 antigen RDTs were correctly read by the app. CONCLUSIONS: The proposed reading system is automatic, reducing variability and uncertainty associated with RDTs interpretation and can be used to read different RDT brands. The web platform serves as a real-time epidemiological tracking tool and facilitates reporting of positive RDTs to relevant health authorities.

Remote analysis of sputum smears for mycobacterium tuberculosis quantification using digital crowdsourcing.

Worldwide, TB is one of the top 10 causes of death and the leading cause from a single infectious agent. Although the development and roll out of Xpert MTB/RIF has recently become a major breakthrough in the field of TB diagnosis, smear microscopy remains the most widely used method for TB diagnosis, especially in low- and middle-income countries. This research tests the feasibility of a crowdsourced approach to tuberculosis image analysis. In particular, we investigated whether anonymous volunteers with no prior experience would be able to count acid-fast bacilli in digitized images of sputum smears by playing an online game. Following this approach 1790 people identified the acid-fast bacilli present in 60 digitized images, the best overall performance was obtained with a specific number of combined analysis from different players and the performance was evaluated with the F1 score, sensitivity and positive predictive value, reaching values of 0.933, 0.968 and 0.91, respectively.

Combining collective and artificial intelligence for global health diseases diagnosis using crowdsourced annotated medical images.

Visual inspection of microscopic samples is still the gold standard diagnostic methodology for many global health diseases. Soil-transmitted helminth infection affects 1.5 billion people worldwide, and is the most prevalent disease among the Neglected Tropical Diseases. It is diagnosed by manual examination of stool samples by microscopy, which is a time-consuming task and requires trained personnel and high specialization. Artificial intelligence could automate this task making the diagnosis more accessible. Still, it needs a large amount of annotated training data coming from experts.In this work, we proposed the use of crowdsourced annotated medical images to train AI models (neural networks) for the detection of soil-transmitted helminthiasis in microscopy images from stool samples leveraging non-expert knowledge collected through playing a video game. We collected annotations made by both school-age children and adults, and we showed that, although the quality of crowdsourced annotations made by school-age children are sightly inferior than the ones made by adults, AI models trained on these crowdsourced annotations perform similarly (AUC of 0.928 and 0.939 respectively), and reach similar performance to the AI model trained on expert annotations (AUC of 0.932). We also showed the impact of the training sample size and continuous training on the performance of the AI models.In conclusion, the workflow proposed in this work combined collective and artificial intelligence for detecting soil-transmitted helminthiasis. Embedded within a digital health platform can be applied to any other medical image analysis task and contribute to reduce the burden of disease.

Mobile microscopy and telemedicine platform assisted by deep learning for the quantification of Trichuris trichiura infection.

Soil-transmitted helminths (STH) are the most prevalent pathogens among the group of neglected tropical diseases (NTDs). The Kato-Katz technique is the diagnosis method recommended by the World Health Organization (WHO) although it often presents a decreased sensitivity in low transmission settings and it is labour intensive. Visual reading of Kato-Katz preparations requires the samples to be analyzed in a short period of time since its preparation. Digitizing the samples could provide a solution which allows to store the samples in a digital database and perform remote analysis. Artificial intelligence (AI) methods based on digitized samples can support diagnosis by performing an objective and automatic quantification of disease infection. In this work, we propose an end-to-end pipeline for microscopy image digitization and automatic analysis of digitized images of STH. Our solution includes (a) a digitization system based on a mobile app that digitizes microscope samples using a 3D printed microscope adapter, (b) a telemedicine platform for remote analysis and labelling, and (c) novel deep learning algorithms for automatic assessment and quantification of parasitological infections by STH. The deep learning algorithm has been trained and tested on 51 slides of stool samples containing 949 Trichuris spp. eggs from 6 different subjects. The algorithm evaluation was performed using a cross-validation strategy, obtaining a mean precision of 98.44% and a mean recall of 80.94%. The results also proved the potential of generalization capability of the method at identifying different types of helminth eggs. Additionally, the AI-assisted quantification of STH based on digitized samples has been compared to the one performed using conventional microscopy, showing a good agreement between measurements. In conclusion, this work has presented a comprehensive pipeline using smartphone-assisted microscopy. It is integrated with a telemedicine platform for automatic image analysis and quantification of STH infection using AI models.

First study of the Polycladida (Rhabditophora, Platyhelminthes) from the Pacific Coast of Costa Rica.

In the present work was carried out in the intertidal zone of Las Baulas de Guanacaste National Marine Park (PNMB) located on the Pacific coast of Costa Rica.                The main objective was to contribute to knowledge about the invertebrate diversity of the park, one of the richest bioregions on the planet, about which little is known. This study assesses the Order Polycladida Lang, 1884, a cornerstone of this ecosystem and one of the most cosmopolitan and plastic invertebrate taxa in the animal kingdom.                In total, 57 individuals were collected in the rocky intertidal zone of Carbón and Langosta beaches. Nine different species were identified, of which four are new for Costa Rica: Semonia bauliensis n. sp.; Cryptostylochus sesei n. sp.; Paraplanocera angeli n. sp., Prostheceraeus fitae n. sp.; and five new records: Paraplanocera oligoglena (Schmarda, 1859); Marcusia ernesti Hyman, 1953; Enchiridium magec Cuadrado, Moro Noreña, 2017; Pseudobiceros bajae (Hyman, 1953); and the genus Boninia spp.

Lifesaving interventions in blackout conditions using night vision technology: Come to the dark side.

BACKGROUND: During military combat operations and civilian night-time aeromedical transport, medical providers are frequently required to perform lifesaving interventions (LSIs) in low-light environments. Because definitive surgical care is often delayed until a white light environment is permissible, we sought to determine if night optical device (NOD) technology could enable surgical capabilities in blackout conditions. METHODS: Using a crossover design, six surgeons performed 11 different procedures on six swine, three in normal light conditions (LC) and 3 in blackout conditions (BC) using two-chamber NODs after familiarization with the procedures in both conditions on manikins. Successful completion and procedural times were compared between groups. RESULTS: Blackout conditions were confirmed with ambient light reading of 0.2 lux during BC versus 3962.9 lux for LC (p < 0.001). There were no significant differences in success rates for any procedure. There were no differences in operative times between BC and LC for extremity tourniquet placement, femoral artery cut-down and clamping, resuscitative thoracotomy, or percutaneous resuscitative endovascular balloon occlusion of the aorta placement. The following procedures took significantly longer in BC vs. LC: Focused Assessment with Sonography for Trauma examination (98 seconds vs. 62 seconds), peripheral IV placement (140 seconds vs. 35 seconds), intraosseous access (51 seconds vs. 26 seconds), jugular vein cut-down and access (237 seconds vs. 104 seconds), laparotomy and packing (71 seconds vs. 51 seconds), stapled splenectomy (137 seconds vs. 74 seconds), resuscitative endovascular balloon occlusion of the aorta placement via cutdown (1,008 seconds vs. 338 seconds), and cricothyroidotomy (177 seconds vs. 109 seconds) (all p < 0.05). CONCLUSION: Lifesaving interventions can be safely and effectively performed in blackout conditions using NODs, although increased difficulty with select procedure types was identified. Focused training and technological improvements to currently available devices are needed. LEVEL OF EVIDENCE: Basic science.

Collaborative intelligence and gamification for on-line malaria species differentiation.

BACKGROUND: Current World Health Organization recommendations for the management of malaria include the need for a parasitological confirmation prior to triggering appropriate treatment. The use of rapid diagnostic tests (RDTs) for malaria has contributed to a better infection recognition and a more targeted treatment. Nevertheless, low-density infections and parasites that fail to produce HRP2 can cause false-negative RDT results. Microscopy has traditionally been the methodology most commonly used to quantify malaria and characterize the infecting species, but the wider use of this technique remains challenging, as it requires trained personnel and processing capacity. OBJECTIVE: In this study, the feasibility of an on-line system for remote malaria species identification and differentiation has been investigated by crowdsourcing the analysis of digitalized infected thin blood smears by non-expert observers using a mobile app. METHODS: An on-line videogame in which players learned how to differentiate the young trophozoite stage of the five Plasmodium species has been designed. Images were digitalized with a smartphone camera adapted to the ocular of a conventional light microscope. Images from infected red blood cells were cropped and puzzled into an on-line game. During the game, players had to decide the malaria species (Plasmodium falciparum, Plasmodium malariae, Plasmodium vivax, Plasmodium ovale, Plasmodium knowlesi) of the infected cells that were shown in the screen. After 2 months, each player's decisions were analysed individually and collectively. RESULTS: On-line volunteers playing the game made more than 500,000 assessments for species differentiation. Statistically, when the choice of several players was combined (n > 25), they were able to significantly discriminate Plasmodium species, reaching a level of accuracy of 99% for all species combinations, except for P. knowlesi (80%). Non-expert decisions on which Plasmodium species was shown in the screen were made in less than 3 s. CONCLUSION: These findings show that it is possible to train malaria-naïve non-experts to identify and differentiate malaria species in digitalized thin blood samples. Although the accuracy of a single player is not perfect, the combination of the responses of multiple casual gamers can achieve an accuracy that is within the range of the diagnostic accuracy made by a trained microscopist.

Plasmodium species differentiation by non-expert on-line volunteers for remote malaria field diagnosis.

BACKGROUND: Routine field diagnosis of malaria is a considerable challenge in rural and low resources endemic areas mainly due to lack of personnel, training and sample processing capacity. In addition, differential diagnosis of Plasmodium species has a high level of misdiagnosis. Real time remote microscopical diagnosis through on-line crowdsourcing platforms could be converted into an agile network to support diagnosis-based treatment and malaria control in low resources areas. This study explores whether accurate Plasmodium species identification-a critical step during the diagnosis protocol in order to choose the appropriate medication-is possible through the information provided by non-trained on-line volunteers. METHODS: 88 volunteers have performed a series of questionnaires over 110 images to differentiate species (Plasmodium falciparum, Plasmodium ovale, Plasmodium vivax, Plasmodium malariae, Plasmodium knowlesi) and parasite staging from thin blood smear images digitalized with a smartphone camera adapted to the ocular of a conventional light microscope. Visual cues evaluated in the surveys include texture and colour, parasite shape and red blood size. RESULTS: On-line volunteers are able to discriminate Plasmodium species (P. falciparum, P. malariae, P. vivax, P. ovale, P. knowlesi) and stages in thin-blood smears according to visual cues observed on digitalized images of parasitized red blood cells. Friendly textual descriptions of the visual cues and specialized malaria terminology is key for volunteers learning and efficiency. CONCLUSIONS: On-line volunteers with short-training are able to differentiate malaria parasite species and parasite stages from digitalized thin smears based on simple visual cues (shape, size, texture and colour). While the accuracy of a single on-line expert is far from perfect, a single parasite classification obtained by combining the opinions of multiple on-line volunteers over the same smear, could improve accuracy and reliability of Plasmodium species identification in remote malaria diagnosis.

Minimally invasive surgery for valvular heart disease.

OPINION STATEMENT: Valvular heart disease imposes varying degrees of stress on the myocardium, which, untreated, leads to eventual ventricular dysfunction. The pathophysiologic mechanisms by which these lesions act depend not only on the affected valve, but also the degree to which they causes stenosis, regurgitation, or both. The goal of patient treatment is to identify and correct the defect before irreversible ventricular changes have occurred. Historically, the conventional surgical approach for valvular disease was via median sternotomy. Minimally invasive valve surgery (MIVS) refers to alternative surgical techniques, which avoid the trans-sternal approach. The objective is to (1) minimize surgical trauma, (2) reduce blood utilization, and (3) hasten postoperative convalesce. These goals are accomplished through the use of partial sternal, para-sternal, or thoracotomy incisions and can be adapted to robotic technologies. As with all evolving surgical techniques, the therapeutic aim of valve repair or replacement must be performed at or above the same standard of conventional surgery. Outcomes must not be sacrificed for the sake of better cosmesis. In addition, percutaneous catheter-based valvular interventions have seen rapid advances. These emerging technologies have dramatically broadened the therapeutic options, especially for an ever-increasing group of high-risk patients. As expected with all minimally invasive techniques, the major differences in the hard outcomes of mortality and major morbidity are seen in these highest risk groups. However, intermediate and low risk patients receive a tremendous benefit with regard to shortened hospital stay and quicker functional recovery. With the myriad of interventional options now available, the clinical challenge now is how best to individualize the treatment approach to a given patient providing the most durable result in order to alleviate symptoms and preserve myocardial function.

The changing face of the general surgeon: national and local trends in resident operative experience.

BACKGROUND: The authors hypothesized that the increasing use of nonoperative management, percutaneous and endoscopic intervention, minimally invasive surgery, and endovascular surgery has radically altered case mix and resident training. METHODS: A review was performed of the Nationwide Inpatient Sample and Accreditation Council for Graduate Medical Education reports from 1993 to 2007 and of local resident operative logs for 2002 to 2008. RESULTS: For all nationwide procedures, there have been major increases in percutaneous interventions, angiographic embolizations, and endovascular surgery, with corresponding sharp declines in major open biliary, aortic, colon, and trauma cases. In training programs, there have been small decreases in total case numbers but major changes in the operative case mix at the expense of traditional open surgery. A profound decline in open vascular surgery is noted. At the authors' institution, similar radical changes in the operative case mix were demonstrated. CONCLUSIONS: Nationwide trends toward the increased use of nonoperative, minimally invasive, endoscopic, and endovascular techniques are altering the operative experience of surgeons and residents in training. This may radically change the abilities and expectations for the field of general surgery and what it means to be a "general surgeon."

A comparison of open versus closed techniques using the Harmonic Scalpel in outpatient hemorrhoid surgery.

BACKGROUND: Surgical excision using the Harmonic Scalpel is a modern technique for symptomatic third- and fourth-degree hemorrhoids. The resulting mucosal defect is then left open or sutured closed depending on surgeon preference. PURPOSE: The purpose of this study was to compare the open vs. closed techniques of hemorrhoid excision using the Harmonic Scalpel in an outpatient setting. METHODS: From July 2000 through October 2001, 42 patients underwent surgical excision of complex grade III or grade IV hemorrhoids via the Harmonic Scalpel with closure of the overlying mucosa (closed), and without closure of the overlying mucosa (open). Quality of life was assessed using the Short Form-36 survey. RESULTS: Both groups were comparable in terms of patient demographics and type of anesthesia. There were no late complications. Mean follow-up was 16.9 (range, 12-27) months. CONCLUSION: Leaving the mucosal defect open following Harmonic Scalpel hemorrhoidectomy significantly reduces operative time, and thus operative costs, without diminishing quality of life. Although morbidity was equivalent, this requires further evaluation with a prospective study to ensure patient safety.

Renal artery stenting slows the rate of renal function decline.

OBJECTIVE: The primary objective of this study was to analyze renal artery interventions performed at a tertiary medical center and to evaluate improvements in hypertension and renal excretory function. METHODS: A retrospective analysis was performed of patients treated at a tertiary medical center from January 2001 to December 2005. All patients treated with renal artery stenting by the Interventional Radiology or Endovascular Services were included. Descriptive and inferential analyses were performed. RESULTS: Forty patients with renal artery stenosis were evaluated for renal artery stenting, of these 22 were followed up with medical management. Twenty-six renal artery stents were placed in 18 patients (mean age, 70 +/- 8 years), of whom 76% were treated for multidrug resistant hypertension, and 24% were treated for renal salvage. Mean follow-up was 15 months. Patients experienced a significant reduction in hypertension and in the number of antihypertensive agents, but this significance deteriorated at 6 months, when their blood pressure and number of medications returned to preprocedural values. Compared with a cohort that was followed up with medical management, the rate of renal function decline improved from -0.08 mg/dL per month to 0.00 mg/dL per month (P < .05) after intervention. Patients with baseline chronic renal insufficiency experienced the greatest benefit from renal artery stenting. CONCLUSIONS: Renal artery stenting initially improves hypertension control, but the durability is lost after 6 months. Renal artery stenting dramatically slows the rate of renal function decline and could potentially delay a patient's requirement for hemodialysis.

Post-bariatric panniculectomy: pre-panniculectomy body mass index impacts the complication profile.

BACKGROUND: Morbid obesity continues to increase in the United States, which accounts for the increase in bariatric procedures performed. After these patients experience massive weight loss, many are left with a redundant pannus that poses physical limitations and psychosocial disturbances. An increasing proportion of bariatric patients are returning for body-contouring procedures. METHODS: This is a retrospective cohort study set in a tertiary care center. We evaluated 126 post-bariatric panniculectomies performed over a 3-year period. Perioperative and postoperative data were collected through chart review. Descriptive and inferential analyses were performed using SPSS 11.0. RESULTS: Ninety-six percent of patients were female. Mean age of the population was 42 (+/-12). The average post-bariatric weight loss and pre-panniculectomy weight were 53 (+/-16) kg and 78 (+/-14) kg, respectively. Complication rates were as follows: seroma 17%, hematoma 13%, surgical site infection (SSI) 17%, transfusion 6%, skin breakdown/necrosis 11%, and re-exploration 11%. Forty percent of patients experienced a complication. Using multivariate logistic regression, we evaluated age, pre-panniculectomy body mass index (BMI), American Society of Anesthesiologists (ASA) class, specimen weight, and operative duration; only pre-panniculectomy BMI was an independent predictor for developing a postoperative complication (odds ratio 3.3, confidence interval 1.2 to 8.4, P < .01). CONCLUSIONS: Post-bariatric patients who have sustained significant weight loss report subjective improvement after panniculectomy. Even though this population has experienced significant weight loss, they are still at an increased risk for postoperative complications. Maximal reduction in BMI should be stressed to these patients in order to reduce their risk of complications following panniculectomy.

Trauma team activation: simplified criteria safely reduces overtriage.

BACKGROUND: Our current trauma triage system uses patient and scene variables within a 3-tiered trauma response system. Our purpose was to evaluate the accuracy of the current system and to identify the most reliable variables for trauma triage. METHODS: This was a retrospective review at a level II trauma center. Multivariate logistic regression was used to identify independent predictors of the need for any urgent emergency department procedure or operative intervention. The current triage system was analyzed and compared with a proposed simplified system. RESULTS: There were 1495 consecutive trauma admissions identified, the majority (88%) were blunt mechanism. Urgent emergency department interventions were required in 11%, and 4% required emergent surgery. Logistic regression demonstrated that prehospital Glasgow Coma Score <14 (odds ratio [OR] 9.7), hypotension (OR 3.3), altered respiratory effort (OR 4.6), and penetrating truncal injury (OR 10.8) independently predicted the need for urgent intervention (all P < .01). The current system undertriaged only 1% but overtriaged 51% of patients. A simplified triage system using these 4 variables significantly decreased overtriage and reliably identified patients with severe injury. CONCLUSIONS: A simplified triage system using only highly predictive variables can safely decrease the high rate of overtriage of trauma patients.

Intestinal fatty acid binding protein (I-FABP) for the detection of strangulated mechanical small bowel obstruction.

OBJECTIVE: Intestinal fatty acid binding protein (I-FABP), a protein released by necrotic enterocytes, is a useful marker for the detection of ischemia from mechanical small bowel obstruction. DESIGN: Validation cohort. SETTING: Academic medical center. PARTICIPANTS: Cohort of 21 patients admitted with a clinical diagnosis of mechanical small bowel obstruction. Plasma and urine samples were collected from patients upon hospital admission and again immediately before laparotomy if surgical intervention was delayed. RESULTS: Plasma and urine I-FABP levels (pg/ml by enzyme-linked immunosorbent assay) in patients found to have small bowel necrosis at the time of laparotomy were compared with those without significant ischemia upon laparotomy and those that did not require laparotomy and, by default, did not have small bowel ischemia. A positive test was defined as 1000-pg/ml I-FABP in urine and 100-pg/ml I-FABP in plasma. Small bowel necrosis was confirmed in 3 of 21 enrolled patients. Urine I-FABP levels were positive in 3 of 3 patients with necrosis and 3 of 18 patients without necrosis (sensitivity 100%, specificity 83%, PPV 50%, NPV 100%). Plasma I-FABP levels were positive in 3 of 3 patients with necrosis and 4 of 18 patients without necrosis (sensitivity 100%, specificity 78%, PPV 43%, NPV 100%). CONCLUSIONS: I-FABP is a sensitive marker for ischemia in mechanical small bowel obstruction. Additional work should be done to validate I-FABP in a variety of clinical settings and to develop a rapid I-FABP laboratory assay.