Supporting a Learning System in Pediatric Emergency Pathways: Using Organizational Comparisons, Serious Incidents, and Near-Miss Events to Improve the Diagnosis and Treatment of Testicular Torsion.

BACKGROUND: Scrotal pain is a common presentation to the emergency department requiring prompt investigation and management to identify testicular torsion and increase the opportunity for testicular salvage. Using national data obtained from the NHS Improvement, we aim to identify key suboptimal areas in the acute diagnosis and management of testicular torsion with a view to learning from these and improving outcomes. METHODS: A freedom of information request was made to all 134 hospital groups in England and Wales that manage testicular torsion. Serious incidents experienced by these hospitals were analyzed to see whether those with pediatric emergency departments fared better than those without. In addition, a qualitative thematic analysis of the NHS Improvement National Reporting and Learning System database over a 12-year period (2007-2019) was undertaken, to identify common themes associated with orchidectomies and "near-miss" events in the pediatric population. RESULTS: Three hundred four patient safety incidents were returned and divided into 62 orchidectomies and 242 near-miss events. The most common factor in the orchidectomy group was individual factors (83.9%). Misdiagnosis of symptomatic testicle was not significant when comparing ED to specialist surgeons (odds ratio = 1.46, P = 0.3842). Atypical presentation resulting in orchidectomy was significant when comparing ED with specialists (odds ratio = 6, P = 0.0355). Near-miss events, not leading to orchidectomy, are often due to a wider variety of factors. A Mann-Whitney U test showed that there was no statistical significance in incidents when comparing general ED units caring for all ages with pediatric EDs in terms of incidents ( U = 807.5, z = -1.124, P = 0.261). CONCLUSIONS: There is a need for education in ED about atypical presentation of testicular torsion and examination of scrotum in cases of lower abdominal pain. It is also vital that specialist teams are cognizant of the standard operating procedures relevant to scrotal pain and testicular within the organization and the wider clinical network. Finally, there should be a drive for annual collation of data in urology and ED units with regards to testicular torsion as patient safety incidents may be underreported.

The cancer multidisciplinary team meeting: in need of change? History, challenges and future perspectives.

Two decades since their inception, multidisciplinary teams (MDTs) are widely regarded as the 'gold standard' of cancer care delivery. Benefits of MDT working include improved patient outcomes, adherence to guidelines, and even economic benefits. Benefits to MDT members have also been demonstrated. An increasing body of evidence supports the use of MDTs and provides guidance on best practise. The system of MDTs in cancer care has come under increasing pressure of late, due to the increasing incidence of cancer, the popularity of MDT working, and financial pressures. This pressure has resulted in recommendations by national bodies to implement streamlining to reduce workload and improve efficiency. In the present review we examine the historical evidence for MDT working, and the scientific developments that dictate best practise. We also explore how streamlining can be safely and effectively undertaken. Finally, we discuss the future of MDT working including the integration of artificial intelligence and decision support systems and propose a new model for improving patient centredness.

Impact of Toupet Versus Nissen Fundoplication on Dysphagia in Patients With Gastroesophageal Reflux Disease and Associated Preoperative Esophageal Dysmotility: A Systematic Review and Meta-Analysis.

BACKGROUND: Controversy exists regarding the best surgical approach for the management of gastroesophageal reflux disease (GORD) and associated preoperative esophageal dysmotility. Our aim was to conduct a systematic review and meta-analysis to compare the outcomes of Toupet fundoplication (TF) and Nissen fundoplication (NF) in patients with GORD and coexistent preoperative esophageal dysmotility. METHODS: We conducted a systematic search of electronic information sources, including MEDLINE, EMBASE, CINAHL, CENTRAL, ClinicalTrials.gov , and bibliographic reference lists. We applied a combination of free text search and controlled vocabulary search adapted to thesaurus headings, search operators, and limits in each of the above-mentioned databases. Postoperative dysphagia and improvement in dysphagia were primary outcome parameters. RESULTS: We identified 3 randomized controlled trials and 1 observational study reporting a total of 220 patients, of whom 126 underwent TF and the remaining 94 patients had NF. Despite the existence of significantly higher preoperative dysphagia in the TF group (29.3% vs 4.2%, P = .05), TF was associated with significantly lower postoperative dysphagia (odds ratio [OR] = 0.31, P = .002) with low between-study heterogeneity ( I2 = 11%, P = .34), and significantly higher improved dysphagia (OR = 10.32, P < .0001) with moderate between-study heterogeneity ( I2 = 31%, P = .23) compared with NF. CONCLUSION: TF may be associated with significantly lower postoperative dysphagia than NF in patients with GORD and associated preoperative esophageal dysmotility. However, no definite conclusions can be drawn as the best available evidence comes mainly from a limited number of heterogeneous randomized controlled trials. Future studies are encouraged to include patients with similar preoperative dysphagia status and report the outcomes with respect to recurrence of acid reflux symptoms.

Simultaneous spatial frequency modulation imaging and micromachining with a femtosecond laser.

A Ti:Al2O3 chirped-pulse amplification system is used to simultaneously image and machine. By combining simultaneous spatial and temporal focusing (SSTF) with spatial frequency modulation for imaging (SPIFI), we are able to decouple the imaging and cutting beams to attain a resolution and a field-of-view that is independent of the cutting beam, while maintaining single-element detection. This setup allows for real-time feedback with the potential for simultaneous nonlinear imaging and imaging through scattering media. The novel SSTF machining platform uses refractive optics that, in general, are prohibitive for energetic, amplified pulses that might otherwise compromise the integrity of the focus as a result of nonlinear effects.

Submillisecond second harmonic holographic imaging of biological specimens in three dimensions.

Optical microscopy has played a critical role for discovery in biomedical sciences since Hooke's introduction of the compound microscope. Recent years have witnessed explosive growth in optical microscopy tools and techniques. Information in microscopy is garnered through contrast mechanisms, usually absorption, scattering, or phase shifts introduced by spatial structure in the sample. The emergence of nonlinear optical contrast mechanisms reveals new information from biological specimens. However, the intensity dependence of nonlinear interactions leads to weak signals, preventing the observation of high-speed dynamics in the 3D context of biological samples. Here, we show that for second harmonic generation imaging, we can increase the 3D volume imaging speed from sub-Hertz speeds to rates in excess of 1,500 volumes imaged per second. This transformational capability is possible by exploiting coherent scattering of second harmonic light from an entire specimen volume, enabling new observational capabilities in biological systems.

Two-dimensional single-pixel imaging by cascaded orthogonal line spatial modulation.

Two-dimensional (2D) images are taken using a single-pixel detector by temporally multiplexing spatial frequency projections from orthogonal, time varying spatial line modulation gratings. Unique temporal frequencies are applied to each point in 2D space, applying a continuous spread of frequencies to one dimension, and an offset frequency applied to each line in the orthogonal dimension. The object contrast information can then be recovered from the electronic spectrum of the single pixel, and through simple processing be reformed into a spatial image.

Plane wave analysis of coherent holographic image reconstruction by phase transfer (CHIRPT).

Fluorescent imaging plays a critical role in a myriad of scientific endeavors, particularly in the biological sciences. Three-dimensional imaging of fluorescent intensity often requires serial data acquisition, that is, voxel-by-voxel collection of fluorescent light emitted throughout the specimen with a nonimaging single-element detector. While nonimaging fluorescence detection offers some measure of scattering robustness, the rate at which dynamic specimens can be imaged is severely limited. Other fluorescent imaging techniques utilize imaging detection to enhance collection rates. A notable example is light-sheet fluorescence microscopy, also known as selective-plane illumination microscopy, which illuminates a large region within the specimen and collects emitted fluorescent light at an angle either perpendicular or oblique to the illumination light sheet. Unfortunately, scattering of the emitted fluorescent light can cause blurring of the collected images in highly turbid biological media. We recently introduced an imaging technique called coherent holographic image reconstruction by phase transfer (CHIRPT) that combines light-sheet-like illumination with nonimaging fluorescent light detection. By combining the speed of light-sheet illumination with the scattering robustness of nonimaging detection, CHIRPT is poised to have a dramatic impact on biological imaging, particularly for in vivo preparations. Here we present the mathematical formalism for CHIRPT imaging under spatially coherent illumination and present experimental data that verifies the theoretical model.

Two-dimensional spatial-frequency-modulated imaging through parallel acquisition of line images.

This Letter demonstrates a two-dimensional imaging technique that uses a line scan camera to resolve one spatial dimension and temporal modulation to resolve the perpendicular dimension. A temporal intensity modulation, which increases linearly in frequency along one direction is applied to an illumination beam. The modulated light distribution is imaged onto an object then onto a line scan camera oriented perpendicularly to the direction of the modulation sweep. A line diffuser is placed shortly before the line scan camera and diffuses light along the direction of modulation so that each pixel collects all modulation frequencies.

Developing and centralising a nurse-led local anaesthetic transperineal biopsy service during COVID.

Introduction: Transperineal (TP) biopsy has recently replaced the transrectal ultrasound (TRUS) approach as the ideal method of biopsy in the United Kingdom with growing trends to adopt. To minimise transmission of COVID-19 during the first wave of the pandemic, the British Association of Urological Surgeons Section of Oncology issued guidelines reducing general anaesthesia (GA) procedures and initiate COVID-secure 'green' site diagnostics. As a result of these guidelines and reduction in clinical diagnostics trust-wide, we ceased all TRUS diagnostics and implemented a centralised, nurse-led LA TP biopsy service. Materials and methods: A waiting list was developed for those awaiting prostate cancer diagnostics across the network. A COVID-secure 'green' site was quickly identified with TP biopsies starting soon after. Quality improvement methodology was utilised and a run chart was used to show if changes were sustainable. Results: Successful implementation and centralisation of a TP biopsy service occurred with TRUS guided biopsies ceasing across all sites on 12 May 2020. The procedures were carried out by urology advanced nurse practitioners under local anaesthesia with a select few occurring under GA. Centralising the service in a COVID-secure manner freed up dedicated theatre sessions and personal leading to increased efficiency elsewhere. The service was robust and was maintained upon lifting of COVID restrictions. Conclusions: A centralised, nurse led LA TP biopsy service in a procedural unit was implemented successfully. The service has remained resilient upon lifting of restrictions and return to business as usual. This led to improved performance across trust by freeing up valuable resources and staff to undertake more duties. The service remains highly valued trust-wide.

Evaluation of changes to work patterns in multidisciplinary cancer team meetings due to the COVID-19 pandemic: A national mixed-method survey study.

BACKGROUND: It is not well understood the overall changes that multidisciplinary teams (MDTs) have had to make in response to the COVID-19 pandemic, nor the impact that such changes, in addition to the other challenges faced by MDTs, have had on decision-making, communication, or participation in the context of MDT meetings specifically. METHODS: This was a mixed method, prospective cross-sectional survey study taking place in the United Kingdom between September 2020 and August 2021. RESULTS: The participants were 423 MDT members. Qualitative findings revealed hybrid working and possibility of virtual attendance as the change introduced because of COVID-19 that MDTs would like to maintain. However, IT-related issues, slower meetings, longer lists and delays were identified as common with improving of the IT infrastructure necessary going forward. In contrast, virtual meetings and increased attendance/availability of clinicians were highlighted as the positive outcomes resulting from the change. Quantitative findings showed significant improvement from before COVID-19 for MDT meeting organisation and logistics (M = 45, SD = 20) compared to the access (M = 50, SD = 12, t(390) = 5.028, p = 0.001), case discussions (M = 50, SD = 14, t(373) = -5.104, p = 0.001), and patient representation (M = 50, SD = 12, t(382) = -4.537, p = 0.001) at MDT meetings. DISCUSSION: Our study explored the perception of change since COVID-19 among cancer MDTs using mixed methods. While hybrid working was preferred, challenges exist. Significant improvements in the meeting organisation and logistics were reported. Although we found no significant perceived worsening across the four domains investigated, there was an indication in this direction for the case discussions warranting further 'live' assessments of MDT meetings.

Hilbert reconstruction of phase-shifted second-harmonic holographic images.

New techniques are presented that make phase-shifting holography viable for second-harmonic generation (SHG) holography with weak object fields. We developed an intrinsic phase shift calibration of SHG holograms, an algorithm that extracts the reference and object intensity directly from a set of phase-shifted holographic data, and a more robust phase-shifting holography reconstruction algorithm based on π-shifted hologram pairs that permits self-calibration of the phase shift and recovery of the complex field through a Hilbert transform.

Theory of diffraction effects in spatial frequency-modulated imaging.

An analytic theory describing the effects of diffraction and aberrations on single-pixel imaging performed by temporally modulating illumination light is presented. This method encodes spatial information using sinusoidal temporal modulations that are chirped in frequency across the extent of an illumination line focus. With some approximations, a point spread function relationship as a function of defocus or other aberrations is found for both spatially coherent and incoherent cases. The theory is validated through experiments and simulations, including measurement of the transverse and longitudinal optical transfer function, and confirmation of insensitivity to aberrations and significant optical scattering after encoding of spatial information through temporal modulation.

Computable Guidelines and Clinical Decision Support for Cervical Cancer Screening and Management to Improve Outcomes and Health Equity.

Cervical cancer is highly preventable when precancerous lesions are detected early and appropriately managed. However, the complexity of and frequent updates to existing evidence-based clinical guidelines make it challenging for clinicians to stay abreast of the latest recommendations. In addition, limited availability and accessibility to information technology (IT) decision supports make it difficult for groups who are medically underserved to receive screening or receive the appropriate follow-up care. The Centers for Disease Control and Prevention (CDC), Division of Cancer Prevention and Control (DCPC), is leading a multiyear initiative to develop computer-interpretable ("computable") version of already existing evidence-based guidelines to support clinician awareness and adoption of the most up-to-date cervical cancer screening and management guidelines. DCPC is collaborating with the MITRE Corporation, leading scientists from the National Cancer Institute, and other CDC subject matter experts to translate existing narrative guidelines into computable format and develop clinical decision support tools for integration into health IT systems such as electronic health records with the ultimate goal of improving patient outcomes and decreasing disparities in cervical cancer outcomes among populations that are medically underserved. This initiative meets the challenges and opportunities highlighted by the President's Cancer Panel and the President's Cancer Moonshot 2.0 to nearly eliminate cervical cancer.

Spatially-chirped modulation imaging of absorbtion and fluorescent objects on single-element optical detector.

Line imaging of fluorescent and absorptive objects with a single-pixel imaging technique that acquires one-dimensional cross-sections through a sample by imposing a spatially-varying amplitude modulation on the probing beam is demonstrated. The fluorophore concentration or absorber distribution of the sample is directly mapped to modulation frequency components of the spatially-integrated temporal signal. Time-domain signals are obtained from a single photodiode, with object spatial frequency correlation encoded in time-domain bursts in the electronic signal from the photodiode.

Subpicosecond fiber-based soliton-tuned mid-infrared source in the 9.7-14.9 microm wavelength region.

We present a fiber-based mid-IR source of ultrafast laser pulses tunable in the 9.7-14.9 microm spectral region based on difference-frequency mixing between an Er:fiber laser and a first-order frequency-shifted soliton pulse. We have measured subpicosecond pulses at a repetition rate of 37 MHz, with a maximum power of 1.5 microW.

A Sparsity Regularization Approach to the Electromagnetic Inverse Scattering Problem.

We investigate solving the electromagnetic inverse scattering problem using the distorted Born iterative method (DBIM) in conjunction with a variable-selection approach known as the elastic net. The elastic net applies both ℓ1 and ℓ2 penalties to regularize the system of linear equations that result at each iteration of the DBIM. The elastic net thus incorporates both the stabilizing effect of the ℓ2 penalty with the sparsity encouraging effect of the ℓ1 penalty. The DBIM with the elastic net outperforms the commonly used ℓ2 regularizer when the unknown distribution of dielectric properties is sparse in a known set of basis functions. We consider two very different 3-D examples to demonstrate the efficacy and applicability of our approach. For both examples, we use a scalar approximation in the inverse solution. In the first example the actual distribution of dielectric properties is exactly sparse in a set of 3-D wavelets. The performances of the elastic net and ℓ2 approaches are compared to the ideal case where it is known a priori which wavelets are involved in the true solution. The second example comes from the area of microwave imaging for breast cancer detection. For a given set of 3-D Gaussian basis functions, we show that the elastic net approach can produce a more accurate estimate of the distribution of dielectric properties (in particular, the effective conductivity) within an anatomically realistic 3-D numerical breast phantom. In contrast, the DBIM with an ℓ2 penalty produces an estimate which suffers from multiple artifacts.

Remote clinics: a panacea during the pandemic or a promoter of health inequality?

Remote clinics have shown many benefits including patient safety, but if we look closer, does this move exclude certain groups of patients from accessing healthcare and promote health inequality?

The effect of material defects on resonant spin wave modes in a nanomagnet.

We have theoretically studied how resonant spin wave modes in an elliptical nanomagnet are affected by fabrication defects, such as small local thickness variations. Our results indicate that defects of this nature, which can easily result from the fabrication process, or are sometimes deliberately introduced during the fabrication process, will significantly alter the frequencies, magnetic field dependence of the frequencies, and the power and phase profiles of the resonant spin wave modes. They can also spawn new resonant modes and quench existing ones. All this has important ramifications for multi-device circuits based on spin waves, such as phase locked oscillators for neuromorphic computing, where the device-to-device variability caused by defects can be inhibitory.

Estimating the breast surface using UWB microwave monostatic backscatter measurements.

This paper presents an algorithm for estimating the location of the breast surface from scattered ultrawideband (UWB) microwave signals recorded across an antenna array. Knowing the location of the breast surface can improve imaging performance if incorporated as a priori information into recently proposed microwave imaging algorithms. These techniques transmit low-power microwaves into the breast using an antenna array, which in turn measures the scattered microwave signals for the purpose of detecting anomalies or changes in the dielectric properties of breast tissue. Our proposed surface identification algorithm consists of three procedures, the first of which estimates M points on the breast surface given M channels of measured microwave backscatter data. The second procedure applies interpolation and extrapolation to these M points to generate N > M points that are approximately uniformly distributed over the breast surface, while the third procedure uses these N points to generate a 3-D estimated breast surface. Numerical as well as experimental tests indicate that the maximum absolute error in the estimated surface generated by the algorithm is on the order of several millimeters. An error analysis conducted for a basic microwave radar imaging algorithm (least-squares narrowband beamforming) indicates that this level of error is acceptable. A key advantage of the algorithm is that it uses the same measured signals that are used for UWB microwave imaging, thereby minimizing patient scan time and avoiding the need for additional hardware.

Effect of electron-donating and electron-withdrawing groups on peptide/single-walled carbon nanotube interactions.

Nano-1, a designed peptide, has been demonstrated to efficiently disperse individual single-walled carbon nanotubes (SWNTs) by folding into an amphiphilic alpha-helix wherein the phenylalanine (Phe) residues on the hydrophobic face of the helix interact via pi-stacking with the aromatic surface of the SWNT. In this study, the ability of electron-donating (hydroxyl) and electron-withdrawing (nitro) groups on the phenyl ring of Phe to affect the interactions between the peptide and SWNTs is examined by substituting the Phe residues in the nano-1 sequence with tyrosine and p-nitro-phenylalanine, respectively. Atomic force microscopy measurements and optical absorption spectroscopy revealed that the ability to disperse individual SWNTs increases with increasing electron density of the aromatic residue on the hydrophobic face of the amphiphilic helical peptides. Scanning tunneling spectroscopy (STS) and Raman analyses were used to examine the effect of noncovalent protein functionalization on the electronic properties of SWNTs. Small shifts in the Raman G band peak for the peptide/SWNT composites, as well as weak features that appear near the Fermi energy (Ef) in the STS dI/dV spectra of the peptide-coated SWNTs, are suggestive of a weak charge-transfer interaction between the peptides and the SWNTs.