An automatic glaucoma grading method based on attention mechanism and EfficientNet-B3 network.

Glaucoma infection is rapidly spreading globally and the number of glaucoma patients is expected to exceed 110 million by 2040. Early identification and detection of glaucoma is particularly important as it can easily lead to irreversible vision damage or even blindness if not treated with intervention in the early stages. Deep learning has attracted much attention in the field of computer vision and has been widely studied especially in the recognition and diagnosis of ophthalmic diseases. It is challenging to efficiently extract effective features for accurate grading of glaucoma in a limited dataset. Currently, in glaucoma recognition algorithms, 2D fundus images are mainly used to automatically identify the disease or not, but do not distinguish between early or late stages; however, in clinical practice, the treatment of early and late glaucoma is not the same, so it is more important to proceed to achieve accurate grading of glaucoma. This study uses a private dataset containing modal data, 2D fundus images, and 3D-OCT scanner images, to extract the effective features therein to achieve an accurate triple classification (normal, early, and moderately advanced) for optimal performance on various measures. In view of this, this paper proposes an automatic glaucoma classification method based on the attention mechanism and EfficientNetB3 network. The EfficientNetB3 network and ResNet34 network are built to extract and fuse 2D fundus images and 3D-OCT scanner images, respectively, to achieve accurate classification. The proposed auto-classification method minimizes feature redundancy while improving classification accuracy, and incorporates an attention mechanism in the two-branch model, which enables the convolutional neural network to focus its attention on the main features of the eye and discard the meaningless black background region in the image to improve the performance of the model. The auto-classification method combined with the cross-entropy function achieves the highest accuracy up to 97.83%. Since the proposed automatic grading method is effective and ensures reliable decision-making for glaucoma screening, it can be used as a second opinion tool by doctors, which can greatly reduce missed diagnosis and misdiagnosis by doctors, and buy more time for patient's treatment.

Circ_0000317/microRNA-520g/HOXD10 axis affects the biological characteristics of colorectal cancer.

Circular RNAs (circRNAs) are a class of noncoding RNAs that are widely expressed in cancer tissues and play a pro- or anticancer role in modulating cancer progression. This work is aimed to probe the biological role of circ_0000317 in colorectal cancer (CRC) and its underlying mechanism. Circ_0000317 was selected from the circRNA microarray datasets (GSE121895). Quantitative real-time polymerase chain reaction was utilized to examine circ_0000317, microRNA (miR)-520g, and homeobox D10 (HOXD10) mRNA expression in CRC. Cell Counting Kit-8 and Transwell experiments were conducted to examine the effects of circ_0000317 on proliferation, migration, and invasion of CRC cells. Bioinformatic analysis and dual-luciferase reporter gene experiments were implemented to predict and validate the targeting relationship between circ_0000317 and miR-520g, miR-520g, and HOXD10. Western blot was employed to examine HOXD10 expression at protein level in CRC cells. Circ_0000317 and HOXD10 mRNA expression were unveiled to be down-modulated and miR-520g expression was up-modulated in CRC. Functionally, circ_0000317 overexpression repressed CRC cell proliferation, migration, and invasion. Mechanistically, miR-520g was a direct target of circ_0000317 and miR-520g specifically modulated HOXD10 expression. Furthermore, miR-520g mimics partially counteracted the suppressing effect of circ_0000317 on malignant phenotype of CRC cells. Circ_0000317 represses CRC progression by targeting miR-520g and modulating HOXD10 expression. Hence, circ_0000317 may be a promising diagnostic biomarker and a therapeutic target for CRC.

Long non-coding RNA NBR2 suppresses the progress of colorectal cancer in vitro and in vivo by regulating the polarization of TAM.

Colorectal cancer (CRC) threatens the health of patients with high mortality, which lacks sensitive biomarkers for diagnosis to improve total survival. The lncRNA NBR2 is reported to be downregulated in CRC and suppresses the proliferation of CRC cells. However, the underlying mechanisms remain unclear. The present study aimed to explore the regulatory function of the lncRNA NBR2 on tumor-associated macrophage (TAM) polarization and its consequent anti-tumor effect. Two CRC cell lines were used in this study. We found that the lncRNA NBR2, TNF-α, and HLA-DR were downregulated, and Arg-1, CD163, CD206, and IL-4 were upregulated in CRC tumors. M1 polarization was activated and M2 polarization was suppressed in NBR2-overexpressed macrophages, accompanied by increased production of inflammatory factors, decreased proliferation, and inhibited migration ability in the co-culture system of HCT-116 cells (SW480 cells) and NBR2-overexpressed macrophages. The promoted proliferation and migration were observed in the co-culture system of HCT-116 cells (SW480 cells) and NBR2-knockdown macrophages. The tumor growth of both HCT-116 cells and SW480 cells in the xenograft model was suppressed by co-planting NBR2-overexpressed macrophages and was facilitated by the co-planting of NBR2-knockdown macrophages. The release of inflammatory factors was induced, M1 polarization was facilitated, and M2 polarization was suppressed in tumor tissues in the NBR2-overexpressed group, which were all reversed in the NBR2-knockdown group. Therefore, the lncRNA NBR2 suppressed the progression of colorectal cancer in vitro and in vivo by regulating TAM polarization.

Robotic telepresence for medical training and education.

"See one, do one, teach one" has long been the paradigm for medical education. The challenge is that it is not always easy to be exposed to the entire spectrum of cases that is possible. One way to standardize the experiential training is to "open up" the OR or Angio Suite to more than the immediate team at the patient site. The Remote Presence system has been used to enable trainees and mentors to remotely observe cases and to be "virtually present" for a procedure taking place across the country or even around the world. This new paradigm for timely clinical expertise delivery and dissemination will have a palpable impact on clinical training and the availability of quality patient care across geographical barriers.

Robotic telepresence for collaborative clinical outreach.

The increasing complexity of healthcare and shortage of clinical specialists needs to be addressed through communication, collaboration and coordination of resources to ensure timely delivery of clinical expertise. Remote Presence is a next generation telemedicine technology platform which combines the power of robotics, wireless, and the internet to enable hospitals and physicians to bring the right care to the right patient at the right time. For example, Remote Presence has been successfully implemented in a hub and spoke model allowing stroke neurologists at a stroke center of excellence to provide the spoke hospital staff with patient consultation and training services. The results are improved geographical reach of stroke specialist care throughout the region with significant impact on patient outcomes as well as improved alignment with established care standards and best practices.

Pyoderma gangrenosum around an ileostoma: A case report.

RATIONALE: Pyoderma gangrenosum (PG) is a rare postoperative complication of enterostomy, mostly developing from dermatitis, which may have serious consequence. PATIENT CONCERNS: A patient with lower rectal cancer receiving low anterior resection (LAR) and protective ileostomy was initially diagnosed with dermatitis, which very quickly developed to PG, though no medical or familial history was found. DIAGNOSIS: We diagnosed the patient with peristoaml dermatitis starting from a tiny skin ulceration, but corrected the diagnosis to PG because of the rapid development and severe consequences. INTERVENTIONS: Routine stoma care did not improve the condition, so we performed 2 terms of debridement, the closure of the stoma and autologous skin transplantation before finally solving the problem. OUTCOMES: The patient was discharged 60 days after the first surgery and 5 days after the last one. After 18 months of follow-up, the patient kept in a stable condition. LESSONS: Medical staff should not neglect peristoaml dermatitis because of its common occurrence. Once the situation develops beyond the doctors' expectation, more efforts should be made to treat it, even expand debridement if possible.

Human factors engineering for designing the next in medicine.

Good design of emerging medical technology in an increasingly complex clinical and technological environment requires an understanding of the context of use, workload, and environment as well as appreciation for ease of use, fit into clinical workflow, and the need for user feedback in the design process. This is where human factors engineering can come into play for good design. Human factors engineering involves the application of principles about human behaviors, abilities, and limitations to the design of tools, devices, environments, and training in order to optimize human performance and safety. The human factors engineering process should be an integral part of the emerging technology development process and needs to be included upfront. This can help ensure that the new product is safe, functional, natural to use, seamlessly integrated into existing clinical workflow, and embraced by users to be incorporated into practice for maximum benefit to patient safety and healthcare quality.

Evaluation of a simulation-based program for medic cognitive skills training.

Simulation-based training is a promising instructional approach for training military and civilian first responders. In addition to training in relevant taskwork skills, there is increasing need for first responder training in cognitively-based skills such as situation assessment and decision making. The First Responder Simulation Training (FIRST) program trains cognitive skills using complex and degraded situations. The program is comprised of five detailed scenarios, evaluation instruments, debriefing guidelines for each scenario, a multimedia tutorial that explains how to use the evaluation and debriefing instruments, and a detailed scenario guide for administering the scenarios. We conducted an evaluation of the FIRST program to assess its training utility and usability. The program was well-received by both instructors and participants. Instructors noted the importance of training cognitive skills and found the instructor materials valuable for teaching them how to administer a simulation-based training program. Participants found the scenarios realistic and challenging, and noted that such simulation-based training would be a valuable supplement to medic curricula.

A web-based teamwork skills training program for emergency medical teams.

T-TRANE is a scenario-based teamwork skills training program for emergency medical teams that uses web-enabled collaborative technologies. The program assumes students are skilled in clinical techniques but have minimal formal knowledge of teamwork. By providing training that focuses on teamwork skills in emergency medical settings, the program is designed to rapidly increase team proficiency. The program is comprised of information about and examples of teamwork skills, and scenario-based training exercises that provide practice in strategies to promote teamwork such as conducting pre-planning and debriefing sessions. T-TRANE is comprised of four modules, with both live (synchronous) interactive sessions and self-paced (asynchronous) sessions that students can complete at their convenience within scheduled intervals. The program includes an Instructor's Guide that provides the designated instructor the necessary support to conduct the training. The approach used in this program can be adapted to any domain in which distributed teams will benefit from pre-deployment training.

Integrating surgical robots into the next medical toolkit.

Surgical robots hold much promise for revolutionizing the field of surgery and improving surgical care. However, despite the potential advantages they offer, there are multiple barriers to adoption and integration into practice that may prevent these systems from realizing their full potential benefit. This study elucidated some of the most salient considerations that need to be addressed for integration of new technologies such as robotic systems into the operating room of the future as it evolves into a complex system of systems. We conducted in-depth interviews with operating room team members and other stakeholders to identify potential barriers in areas of workflow, teamwork, training, clinical acceptance, and human-system interaction. The findings of this study will inform an approach for the design and integration of robotics and related computer-assisted technologies into the next medical toolkit for "computer-enhanced surgery" to improve patient safety and healthcare quality.

Gestalt operating room display design for perioperative team situation awareness.

The perioperative environment is a complex, high risk environment that requires real-time coordination by all perioperative team members and accurate, up-to-date information for situation assessment and decision-making. There is the need for a "Gestalt" holistic awareness of the perioperative environment to enable synthesis and contextualization of the salient information such as: patient information, case and procedure information, staff information, operative site view, physiological data, resource availability. One potential approach is to augment the medical toolkit with a large screen wall display that integrates and makes accessible information that currently resides in different data systems and care providers. The objectives are to promote safe workflows, team coordination and communication, and to enable diagnosis, anticipation of events, and information flow from upstream to downstream care providers. We used the human factors engineering design process to design and develop a display that provides a common operational picture for shared virtual perioperative team situation awareness to enhance patient safety.

Developing a simulation-based training program for medical first responders.

A major stumbling block for widespread incorporation of simulators into EMT training includes the limited availability of curricula infrastructure linking the key components of skills, scenarios, and measures as well as the expertise required to run such programs. To meet these needs we are developing a training program for first responders that uses mannequin-based simulator technology effectively to fill the identified training need for valid meaningful scenarios that can be integrated into the curriculum and are applicable for a variety of EMT skill levels. The program will provide detailed scenarios, instructions for administering the program, and measures for performance feedback. Each scenario will exercise a combination of task work and cognitive skills and the set of scenarios will span all of the higher-level skills that have been identified as benefiting from targeted training.

Involvement of endoplasmic reticulum stress in capsaicin-induced apoptosis of human pancreatic cancer cells.

Capsaicin, main pungent ingredient of hot chilli peppers, has been shown to have anticarcinogenic effect on various cancer cells through multiple mechanisms. In this study, we investigated the apoptotic effect of capsaicin on human pancreatic cancer cells in both in vitro and in vivo systems, as well as the possible mechanisms involved. In vitro, treatment of both the pancreatic cancer cells (PANC-1 and SW1990) with capsaicin resulted in cells growth inhibition, G0/G1 phase arrest, and apoptosis in a dose-dependent manner. Knockdown of growth arrest- and DNA damage-inducible gene 153 (GADD153), a marker of the endoplasmic-reticulum-stress- (ERS-) mediated apoptosis pathway, by specific siRNA attenuated capsaicin-induced apoptosis both in PANC-1 and SW1990 cells. Moreover, in vivo studies capsaicin effectively inhibited the growth and metabolism of pancreatic cancer and prolonged the survival time of pancreatic cancer xenograft tumor-induced mice. Furthermore, capsaicin increased the expression of some key ERS markers, including glucose-regulated protein 78 (GRP78), phosphoprotein kinase-like endoplasmic reticulum kinase (phosphoPERK), and phosphoeukaryotic initiation factor-2 α (phospho-eIF2 α ), activating transcription factor 4 (ATF4) and GADD153 in tumor tissues. In conclusion, we for the first time provide important evidence to support the involvement of ERS in the induction of apoptosis in pancreatic cancer cells by capsaicin.

Antiangiogenic effects of oxymatrine on pancreatic cancer by inhibition of the NF-κB-mediated VEGF signaling pathway.

Oxymatrine, the main alkaloid component in the traditional Chinese herbal medicine Sophora japonica (Sophora flavescens Ait), has been reported to have antitumor properties. However, the mechanisms of action in human pancreatic cancer are not well established to date. In the present study, we investigated the antiangiogenic effects of oxymatrine on human pancreatic cancer as well as the possible mechanisms involved. The results of the cell viability assay showed that treatment of PANC-1 pancreatic cancer cells with oxymatrine resulted in cell growth inhibition in a dose- and time-dependent manner. To investigate the possible mechanisms involved in these events, we performed western blotting and reverse transcription-polymerase chain reaction (RT-PCR) analysis. The results revealed that oxymatrine decreased the expression of angiogenesis-associated factors, including nuclear factor κB (NF-κB) and vascular endothelial growth factor (VEGF). Finally, the antiproliferative and antiangiogenic effects of oxymatrine on human pancreatic cancer were further confirmed in pancreatic cancer xenograft tumors in nude mice. In conclusion, our studies for the first time suggest that oxymatrine has potential antitumor effects on pancreatic cancer via suppression of angiogenesis, probably through regulation of the expression of the NF-κB-mediated VEGF signaling pathway.

Involvement of the phosphoinositide 3-kinase/Akt pathway in apoptosis induced by capsaicin in the human pancreatic cancer cell line PANC-1.

Capsaicin, one of the major pungent ingredients found in red peppers, has been recently demonstrated to induce apoptosis in various malignant cell lines through an unclear mechanism. In this study, the effect of capsaicin on proliferation and apoptosis in the human pancreatic cancer cell line PANC-1 and its possible mechanism(s) of action were investigated. The results of a Cell Counting Kit-8 (CCK-8) assay revealed that capsaicin significantly decreased the viability of PANC-1 cells in a dose-dependent manner. Capsaicin induced G0/G1 phase cell cycle arrest and apoptosis in PANC-1 cells as demonstrated by a flow cytometric assessment. Caspase-3 expression at both the protein and mRNA level was promoted following capsaicin treatment. Furthermore, we revealed that phospho-PI3 Kinase p85 (Tyr458) and phospho-Akt (Ser473) in PANC-1 cells were downregulated in response to capsaicin. Moreover, capsaicin gavage significantly inhibited the growth of pancreatic cancer PANC-1 cell xenografts in athymic nude mice. An increased number of TUNEL-positive cells and cleaved caspase-3 were observed in capsaicin-treated mice. In vivo, capsaicin downregulated the expression of phospho-PI3 Kinase p85 (Tyr458) and phospho-Akt (Ser473). In conclusion, we have demonstrated that capsaicin is an inhibitor of growth of PANC-1 cells, and downregulation of the phosphoinositide 3-kinase/Akt pathway may be involved in capsaicin-induced apoptosis in vitro and in vivo.

Emodin induces Panc-1 cell apoptosis via declining the mitochondrial membrane potential.

In this study, we investigated the apoptotic effect of emodin on human pancreatic cancer cell line Panc-1 in vitro and in vivo as well as the possible mechanisms involved. In vitro, human pancreatic cancer cell line Panc-1 was exposed to varying concentrations of emodin (0, 10, 20, 40 or 80 µmol/l). Then the mitochondrial membrane potential (MMP) was analyzed by JC-1 staining, cell apoptosis was analyzed by flow cytometry (FCM) and cell proliferation was analyzed by MTT. In vivo, nude mice orthotopically implanted were randomly divided into five groups to receive treatments by different doses of emodin: control group (normal saline 0.2 ml), E10 group (emodin 10 mg/kg), E20 group (emodin 20 mg/kg), E40 group (emodin 40 mg/kg) and E80 group (emodin 80 mg/kg). Each mouse was treated 5 times by intraperitoneal injection of emodin every 3 days. During the treatment, the feeding stuff was recorded. One week after the last treatment, we recorded the body weight and the maximum diameter of tumor in each group before the mice were sacrificed. Then the cell apoptosis of the tumor was tested by TUNEL assay. The results in vitro showed that the MMP of the cells declined and the apoptosis rate increased with the emodin concentration increasing and the cell proliferation of each group was inhibited in a dose- and time-dependent manner by emodin. The feeding stuff curve did not decline significantly in E40 group and the apoptosis rate of the tumor cells in this group was higher than the lower-dose groups. Taken together, our results demonstrate that emodin may induce the pancreatic cancer cell apoptosis via declining the MMP and a moderate dose of emodin improved the living state of the model mice.

Stroke networks based on robotic telepresence.

In the USA, several telestroke networks have been successfully implemented in which a stroke centre of excellence provides expertise to community and rural hospitals via telemedicine. Stroke patients can thus receive round-the-clock access to stroke expertise. The Remote Presence (RP) system is used in several of these telestroke networks. The stroke expert uses a laptop and wireless Internet to connect to the RP robot in the peripheral emergency department. This improves the geographical reach of stroke specialist care, and improves patient outcomes as well as conforming with best practice. The stroke network concept combined with telemedicine is a powerful way of transforming stroke care.

Training teams for the perioperative environment: a research agenda.

A research agenda for investigating the impact of team-work training on patient safety in the perioperative environment is presented. The current status of teamwork training is reviewed briefly, and conclusions based on existing research are presented. We present a roadmap for future research on how teamwork training should be structured, delivered, and evaluated to optimize patient safety in the operating room. For teamwork skills to be assessed and have credibility, team performance measures must be grounded in team theory, account for individual and team-level performance, capture team process and outcomes, adhere to standards for reliability and validity, and address real or perceived barriers to measurement. The interdisciplinary nature of work in the perioperative environment and the necessity of cooperation among team members play an important role in enabling patient safety and avoiding errors. Teams make fewer mistakes than do individuals, especially when each team member knows his or her responsibilities, as well as those of other team members. However, simply installing a team structure without addressing the organizational context of care--the culture--does not automatically ensure it will operate effectively. Factors associated with the design of teamwork training, measures of training effectiveness, and the assessment process that should be explored in near-term work (1 to 2 years) are addressed. We also address the impact of the organizational environment, including the role of institutional support and culture, that need to be explored in longer term research (3 to 5 years).

The potential of training to increase acceptance and use of computerized decision support systems for medical diagnosis.

OBJECTIVE: The goals of this study were to understand the reasons underlying the limited use of medical decision-support tools and to explore the potential of a computer-based tutorial to mitigate barriers to use. BACKGROUND: Medical decision-support tools such the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI) have demonstrated statistical validity and clinical impact for patient safety but have seen limited adoption and use. METHODS: The study developed a brief Web-based "demystifying" ACI-TIPI tutorial employing case-based training and evaluated the effectiveness of that tutorial in changing self-reported attitudes and behaviors. RESULTS: Clinicians using the tutorial reported greater understanding of how to use the ACI-TIPI score appropriately and increased confidence in the score. Case studies in the tutorial that provided examples of how to use the score for actual cases were rated as especially helpful. CONCLUSION: This study suggests that a primary barrier to the use of statistical decision support tools for patient diagnosis is lack of training or experience in combining a population-based numerical risk score with other diagnostic information about the individual patient's case that is not considered in that score. The results of this study indicate that there is a potential for a relatively brief tutorial to increase acceptance and use of decision support tools for medical diagnosis. APPLICATION: These findings have the potential for the identification of methods to help clinicians learn how to use statistical and probabilistic information to better assess risk and to promote integration of decision support tools into medical decision making for improvement of patient safety.