Hyperspectral dark-field microscopy of human breast lumpectomy samples for tumor margin detection in breast-conserving surgery.

Significance: Hyperspectral dark-field microscopy (HSDFM) and data cube analysis algorithms demonstrate successful detection and classification of various tissue types, including carcinoma regions in human post-lumpectomy breast tissues excised during breast-conserving surgeries. Aim: We expand the application of HSDFM to the classification of tissue types and tumor subtypes in pre-histopathology human breast lumpectomy samples. Approach: Breast tissues excised during breast-conserving surgeries were imaged by the HSDFM and analyzed. The performance of the HSDFM is evaluated by comparing the backscattering intensity spectra of polystyrene microbead solutions with the Monte Carlo simulation of the experimental data. For classification algorithms, two analysis approaches, a supervised technique based on the spectral angle mapper (SAM) algorithm and an unsupervised technique based on the K-means algorithm are applied to classify various tissue types including carcinoma subtypes. In the supervised technique, the SAM algorithm with manually extracted endmembers guided by H&E annotations is used as reference spectra, allowing for segmentation maps with classified tissue types including carcinoma subtypes. Results: The manually extracted endmembers of known tissue types and their corresponding threshold spectral correlation angles for classification make a good reference library that validates endmembers computed by the unsupervised K-means algorithm. The unsupervised K-means algorithm, with no a priori information, produces abundance maps with dominant endmembers of various tissue types, including carcinoma subtypes of invasive ductal carcinoma and invasive mucinous carcinoma. The two carcinomas' unique endmembers produced by the two methods agree with each other within <2% residual error margin. Conclusions: Our report demonstrates a robust procedure for the validation of an unsupervised algorithm with the essential set of parameters based on the ground truth, histopathological information. We have demonstrated that a trained library of the histopathology-guided endmembers and associated threshold spectral correlation angles computed against well-defined reference data cubes serve such parameters. Two classification algorithms, supervised and unsupervised algorithms, are employed to identify regions with carcinoma subtypes of invasive ductal carcinoma and invasive mucinous carcinoma present in the tissues. The two carcinomas' unique endmembers used by the two methods agree to <2% residual error margin. This library of high quality and collected under an environment with no ambient background may be instrumental to develop or validate more advanced unsupervised data cube analysis algorithms, such as effective neural networks for efficient subtype classification.

Polydimethylsiloxane tissue-mimicking phantoms with tunable optical properties.

SIGNIFICANCE: The polymer, polydimethylsiloxane (PDMS), has been increasingly used to make tissue simulating phantoms due to its excellent processability, durability, flexibility, and limited tunability of optical, mechanical, and thermal properties. We report on a robust technique to fabricate PDMS-based tissue-mimicking phantoms where the broad range of scattering and absorption properties are independently adjustable in the visible- to near-infrared wavelength range from 500 to 850 nm. We also report on an analysis method to concisely quantify the phantoms' broadband characteristics with four parameters. AIM: We report on techniques to manufacture and characterize solid tissue-mimicking phantoms of PDMS polymers. Tunability of the absorption (µa ( λ ) ) and reduced scattering coefficient spectra (µs'(λ)) in the wavelength range of 500 to 850 nm is demonstrated by adjusting the concentrations of light absorbing carbon black powder (CBP) and light scattering titanium dioxide powder (TDP) added into the PDMS base material. APPROACH: The µa ( λ ) and µs'(λ) of the phantoms were obtained through measurements with a broadband integrating sphere system and by applying an inverse adding doubling algorithm. Analyses of µa ( λ ) and µs'(λ) of the phantoms, by fitting them to linear and power law functions, respectively, demonstrate that independent control of µa ( λ ) and µs'(λ) is possible by systematically varying the concentrations of CBP and TDP. RESULTS: Our technique quantifies the phantoms with four simple fitting parameters enabling a concise tabulation of their broadband optical properties as well as comparisons to the optical properties of biological tissues. We demonstrate that, to a limited extent, the scattering properties of our phantoms mimic those of human tissues of various types. A possible way to overcome this limitation is demonstrated with phantoms that incorporate polystyrene microbead scatterers. CONCLUSIONS: Our manufacturing and analysis techniques may further promote the application of PDMS-based tissue-mimicking phantoms and may enable robust quality control and quality checks of the phantoms.

When rotational atherectomy is not enough.

Extreme coronary calcification may require rotational atherectomy to create a navigable intravascular lumen followed by intravascular lithotripsy to fracture areas of deep calcification to allow for successful percutaneous coronary intervention.

Reducing Delay to Treatment of ST-Elevation Myocardial Infarction With Software Electrocardiographic Interpretation and Transmission (SCINET).

BACKGROUND: Prehospital diagnosis of ST-elevation myocardial infarction (STEMI) has resulted in improved outcomes. However, many patients still walk in to the emergency department (ED) with STEMI, experiencing delays and worse outcomes. Software electrocardiogram (ECG) diagnosis of STEMI and electronic transmission to a cardiologist may result in improved door-to-device (D2D) times. METHODS: We retrospectively identified all patients presenting with STEMI from January 2015 to September 2016. Components of delay in D2D, ED variables, and the patients' ECGs were extracted from our regional database. All ECGs performed for suspected myocardial infarction in the region were extracted over the study period. We assessed the accuracy of the software 12SL in diagnosing STEMI, ED contributors to delays in D2D, and the potential reduction in D2D if software diagnosis of STEMI resulted in activation of the cardiac catheterization laboratory. RESULTS: A total of 379 patients presented to an ED in our region and received primary percutaneous coronary intervention over the study period. In the 143,574 ECGs performed over the study period for suspected STEMI, the overall sensitivity and specificity of 12SL were 90.5% and 99.98%, respectively. We estimated a potential 17-minute reduction in D2D in the 90.5% of patients correctly identified as having STEMI, with a false activation rate of 4%. Female patients and older patients experienced an even larger potential benefit, with 24- and 25-minute reductions in D2D, respectively. CONCLUSIONS: Patients who walk in to an ED with STEMI experience significant system-related delays in recognition and treatment. Automated software diagnosis of STEMI is accurate and could result in significant improvements in D2D times.

CONTEXTE: Le diagnostic préhospitalier de l'infarctus du myocarde avec élévation du segment ST (STEMI) contribue à améliorer les résultats pour les patients. Toutefois, de nombreux patients subissant un STEMI se présentent encore d'eux-mêmes au service des urgences, ce qui retarde leur traitement et entraîne des conséquences plus graves. Le diagnostic de STEMI au moyen d'un logiciel de prise d'électrocardiogramme (ECG) qui est ensuite transmis à un cardiologue par voie électronique pourrait réduire le délai entre l'arrivée à l'hôpital et la pose d'un dispositif (délai avant l'intervention). MÉTHODOLOGIE: Nous avons rétrospectivement recensé tous les patients ayant subi un STEMI entre janvier 2015 et septembre 2016. Les facteurs entraînant l'augmentation du délai avant l'intervention, les variables relatives au service des urgences et les ECG des patients ont été extraits d'une base de données régionale. Tous les ECG réalisés dans les cas d'infarctus du myocarde suspectés dans la région pendant la période visée ont été extraits. Nous avons évalué l'exactitude des diagnostics de STEMI obtenus à l'aide du logiciel 12SL, les facteurs contribuant au délai avant l'intervention et la réduction potentielle de ce délai lorsque le diagnostic de STEMI obtenu par logiciel a permis au laboratoire de cathétérisme cardiaque de se préparer avant l'arrivée du patient. RÉSULTATS: Au total, 379 patients se sont présentés au service des urgences d'un hôpital de la région et ont subi une intervention coronarienne percutanée primaire durant la période visée par l'étude. Sur les 143 574 ECG réalisés dans les cas de STEMI suspectés durant la période étudiée, la sensibilité et la spécificité globales du logiciel 12SL s'établissaient respectivement à 90,5 % et à 99,98 %. Nous avons estimé que le délai avant l'intervention avait été potentiellement réduit de 17 minutes chez les patients ayant reçu un diagnostic de STEMI correct (90,5 %), le taux d'activation inutile du laboratoire de cathétérisme s'établissant à 4 %. Les femmes et les patients plus âgés sont ceux qui semblent avoir bénéficié le plus de cette stratégie, la réduction potentielle du délai avant l'intervention s'établissant dans leurs cas à 24 et à 25 minutes, respectivement. CONCLUSIONS: Les patients subissant un STEMI qui se présentent eux-mêmes au service des urgences doivent passer par toutes les étapes du processus d'admission avant que leur état soit reconnu et traité. Les outils de diagnostic automatisé du STEMI donnent des résultats justes, et leur utilisation pourrait réduire considérablement le délai entre l'arrivée à l'hôpital et l'intervention.

Comparative Performance of Prediction Models for Contrast-Associated Acute Kidney Injury After Percutaneous Coronary Intervention.

BACKGROUND: Identifying patients at increased risk of contrast-associated acute kidney injury (CA-AKI) can help target risk mitigation strategies toward these individuals during percutaneous coronary intervention. Illuminating which risk models best stratify risk is an important foundation for such quality improvement efforts. METHODS AND RESULTS: Seven previously published risk prediction models for CA-AKI and 3 models for kidney injury requiring dialysis were validated using 2 definitions for CA-AKI (the Kidney Disease: Improving Global Outcomes definition of ≥0.3 mg/dL within 48 hours or ≥50% increase in serum creatinine from baseline within 7 days and the historical definition of ≥0.5 mg/dL or ≥25% increase in serum creatinine from baseline within 48 hours), and AKI requiring dialysis within 30 days of percutaneous coronary intervention. Model performance was compared based on discrimination, calibration, and categorical net reclassification index before and after model recalibration. Among 7888 patients who underwent percutaneous coronary intervention in Alberta Canada, CA-AKI occurred in 330 patients (4.2%) when CA-AKI was defined using the Kidney Disease: Improving Global Outcomes definition and 571 (7.3%) when using the historical definition. CA-AKI requiring dialysis occurred in 42 (0.6%) patients. When validated using the Kidney Disease: Improving Global Outcomes definition for CA-AKI, the 2 most recently published models for CA-AKI showed better discrimination (C statistics, 0.75-0.76) than older models (C statistics, 0.61-0.68). C statistics of models for kidney injury requiring dialysis ranged from 0.70 to 0.86. The calibration of all models for CA-AKI deviated from ideal, and the proportion of patients classified into different risk categories for CA-AKI differed substantially for the 2 most recent models. Recalibration significantly improved risk stratification of patients into clinical risk categories for some models. CONCLUSIONS: Recent prediction models for CA-AKI show better discrimination compared with older models; however, model recalibration should be examined in external cohorts to improve the accuracy of predictions, particularly if predicted risk strata are used to guide management approaches.

Clinical Decision Support to Reduce Contrast-Induced Kidney Injury During Cardiac Catheterization: Design of a Randomized Stepped-Wedge Trial.

BACKGROUND: Contrast-induced acute kidney injury (CI-AKI) is a common and serious complication of invasive cardiac procedures. Quality improvement programs have been associated with a lower incidence of CI-AKI over time, but there is a lack of high-quality evidence on clinical decision support for prevention of CI-AKI and its impact on processes of care and clinical outcomes. METHODS: The Contrast-Reducing Injury Sustained by Kidneys (Contrast RISK) study will implement an evidence-based multifaceted intervention designed to reduce the incidence of CI-AKI, encompassing automated identification of patients at increased risk for CI-AKI, point-of-care information on safe contrast volume targets, personalized recommendations for hemodynamic optimization of intravenous fluids, and follow-up information for patients at risk. Implementation will use cardiologist academic detailing, computerized clinical decision support, and audit and feedback. All 31 physicians practicing in all 3 of Alberta's cardiac catheterization laboratories will participate using a cluster-randomized stepped-wedge design. The order in which they are introduced to this intervention will be randomized within 8 clusters. The primary outcome is CI-AKI incidence, with secondary outcomes of CI-AKI avoidance strategies and downstream adverse major kidney and cardiovascular events. An economic evaluation will accompany the main trial. CONCLUSIONS: The Contrast RISK study leverages information technology systems to identify patient risk combined with evidence-based protocols, audit, and feedback to reduce CI-AKI in cardiac catheterization laboratories across Alberta. If effective, this intervention can be broadly scaled and sustained to improve the safety of cardiac catheterization.

Exposure study on UV-induced degradation of PTFE and ceramic optical diffusers.

We report on a study of the ultraviolet (UV)-induced degradation on optical grade polytetrafluoroethylene (PTFE) and ceramic diffuser samples. Long-term UV exposure may significantly alter the reflectance and lead to an error in the calibration of optical instruments. A large integrating sphere was used to irradiate the samples for 334.7 days at an irradiance level of 194.9 W/m2. Samples were qualified and measured for reflectance factor, bidirectional reflectance distribution function, and fluorescence, before and after the exposure, and at 12-week intervals during the exposure. This study revealed significant differences between the aging behavior of ceramic and PTFE samples.

Atherectomy and Specialty Balloons in Percutaneous Coronary Intervention.

PURPOSE OF REVIEW: Interventional cardiologists are increasingly being called upon to perform complex revascularization in patients who are deemed not to be candidates for surgical revascularization and, until recently, many of these patients would have only been offered medical management. Further, changing demographics have resulted in an increasingly elderly and frail population with diabetes and chronic kidney disease being referred for revascularization. Owing to the increasing prevalence of coronary artery calcification and the importance of achieving complete revascularization, advanced tools and techniques are required to safely revascularize this patient population. RECENT FINDINGS: Coronary artery calcification is a marker for increased periprocedural complications and worse long-term outcomes in percutaneous intervention. Its presence may mandate advanced revascularization strategies to facilitate safe revascularization. Several studies have highlighted the importance of intracoronary imaging and there have been iterative changes and new devices that have been developed that can facilitate revascularization in the setting of significant coronary artery calcification. Successful coronary revascularization is increasingly dependent on the rational use of intraavascular imaging, specialized balloons and atherectomy to overcome complex coronary artery disease and calcification. A rational strategy for the safe use of advanced techniques and tools is presented here.

Fabrication of a multilayer tissue-mimicking phantom with tunable optical properties to simulate vascular oxygenation and perfusion for optical imaging technology.

Vast research has been carried out to fabricate tissue-mimicking phantoms, due to their convenient use and ease of storage, to assess and validate the performance of optical imaging devices. However, to the best of our knowledge, there has been little research on the use of multilayer tissue phantoms for optical imaging technology, although their structure is closer to that of real skin tissue. In this work, we design, fabricate, and characterize multilayer tissue-mimicking phantoms, with a morphological mouse ear blood vessel, that contain an epidermis, a dermis, and a hypodermis. Each tissue-mimicking phantom layer is characterized individually to match specific skin tissue layer characteristics. The thickness, optical properties (absorption coefficient and reduced scattering coefficient), oxygenation, and perfusion of skin are the most critical parameters for disease diagnosis and for some medical equipment. These phantoms can be used as calibration artifacts and help to evaluate optical imaging technologies.

Correction of an adding-doubling inversion algorithm for the measurement of the optical parameters of turbid media.

We present broadband measurements of the optical properties of tissue-mimicking solid phantoms using a single integrating sphere to measure the hemispherical reflectance and transmittance under a direct illumination at the normal incident angle. These measurements are traceable to reflectance and transmittance scales. An inversion routine using the output of the adding-doubling algorithm restricted to the reflectance and transmittance under a direct illumination was developed to produce the optical parameters of the sample along with an uncertainty budget at each wavelength. The results for two types of phantoms are compared to measurements by time-resolved approaches. The results between our method and these independent measurements agree within the estimated measurement uncertainties.

Risk Prediction Models for Contrast-Induced Acute Kidney Injury Accompanying Cardiac Catheterization: Systematic Review and Meta-analysis.

BACKGROUND: Identification of patients at risk of contrast-induced acute kidney injury (CI-AKI) is valuable for targeted prevention strategies accompanying cardiac catheterization. METHODS: We searched MedLine and EMBASE for articles that developed or validated a clinical prediction model for CI-AKI or dialysis after angiography or percutaneous coronary intervention. Random effects meta-analysis was used to pool c-statistics of models. Heterogeneity was explored using stratified analyses and meta-regression. RESULTS: We identified 75 articles describing 74 models predicting CI-AKI, 10 predicting CI-AKI and dialysis, and 1 predicting dialysis. Sixty-three developed a new risk model whereas 20 articles reported external validation of previously developed models. Thirty models included sufficient information to obtain individual patient risk estimates; 9 using only preprocedure variables whereas 21 included preprocedural and postprocedure variables. There was heterogeneity in the discrimination of CI-AKI prediction models (median [total range] in c-statistic 0.78 [0.57-0.95]; I2 = 95.8%, Cochran Q-statistic P < 0.001). However, there was no difference in the discrimination of models using only preprocedure variables compared with models that included postprocedural variables (P = 0.868). Models predicting dialysis had good discrimination without heterogeneity (median [total range] c-statistic: 0.88 [0.87-0.89]; I2 = 0.0%, Cochran Q-statistic P = 0.981). Seven prediction models were externally validated; however, 2 of these models showed heterogeneous discriminative performance and 2 others lacked information on calibration in external cohorts. CONCLUSIONS: Three published models were identified that produced generalizable risk estimates for predicting CI-AKI. Further research is needed to evaluate the effect of their implementation in clinical care.

Antigen retrieval prior to on-tissue digestion of formalin-fixed paraffin-embedded tumour tissue sections yields oxidation of proline residues.

MALDI-mass spectrometry imaging (MALDI-MSI) has been shown to allow the study of protein distribution and identification directly within formalin-fixed paraffin-embedded (FFPE) tissue sections. However, direct protein identification from tissue sections remains challenging due to signal interferences and/or existing post-translational or other chemical modifications. The use of antigen retrieval (AR) has been demonstrated for unlocking proteins prior to in situ enzymatic digestion and MALDI-MSI analysis of FFPE tissue sections. In the work reported here, the identification of proline oxidation, which may occur when performing the AR protocol, is described. This facilitated and considerably increased the number of identified peptides when adding proline oxidation as a variable modification to the MASCOT search criteria. This article is part of a Special Issue entitled: MALDI Imaging, edited by Dr. Corinna Henkel and Prof. Peter Hoffmann.

Biological and structural studies of phosphonium 'masked thiolate' compounds.

The ability of phosphonium cations to act as intracellular transport vectors is well-established. Phosphonioalkylthiosulfate zwitterions, and ω-thioacetylalkylphosphonium salts, which act as 'masked thiolate' ligands, are useful precursors for the formation of phosphonium-functionalised gold nanoparticles, enabling the nanoparticles to be transported into cells for diagnostic and therapeutic purposes. In this study we have completed cytotoxicity studies of ω-thioacetylpropylphosphonium salts derived from triphenylphosphine and tri(4-fluorophenyl)phosphine, which show that the compounds are only toxic towards PC3 prostate cancer cells at high concentrations and at prolonged incubation periods and display IC50 values of 67 µM and 252 µM respectively, significantly higher than those of other phosphonium salts. MALDI-TOF-MS has been used to investigate the uptake of the compounds by PC3 cells and to quantify detectable levels of the compounds inside the cells. The structures of ω-thioacetylpropyl(tri-4-fluorophenyl) phosphonium bromide and the corresponding tri(4-fluorophenyl)phosphoniopropylthiosulfate zwitterion have been investigated by single crystal X-ray crystallography. The results show that molecules of the zwitterion are held together through an extensive array of electrostatic and non-covalent interactions. The unit cell of ω-thioacetylpropyl(tri-4-fluorophenyl)phosphonium bromide contains eight cations together with eight bromide anions and two waters of crystallisation, all held together through a complex network of hydrogen bonds. The differences in the molecular packing of the two compounds may account for the lower solubility of the zwitterion in aqueous solutions, compared with that of the phosphonium salt.

National Institute of Standards and Technology measurement service of the optical properties of biomedical phantoms: Current status.

The National Institute of Standards and Technology (NIST) has maintained scales for reflectance and transmittance over several decades. The scales are primarily intended for regular transmittance, mirrors, and solid surface scattering diffusers. The rapidly growing area of optical medical imaging needs a scale for volume scattering of diffuse materials that are used to mimic the optical properties of tissue. Such materials are used as phantoms to evaluate and validate instruments under development intended for clinical use. To address this need, a double-integrating sphere based instrument has been installed to measure the optical properties of tissue-mimicking phantoms. The basic system and methods have been described in previous papers. An important attribute in establishing a viable calibration service is the estimation of measurement uncertainties. The use of custom models and comparisons with other established scales enabled uncertainty measurements. Here, we describe the continuation of those efforts to advance the understanding of the uncertainties through two independent measurements: the bidirectional reflectance distribution function and the bidirectional transmittance distribution function of a commercially available solid biomedical phantom. A Monte Carlo-based model is used and the resulting optical properties are compared to the values provided by the phantom manufacturer.

Double-integrating-sphere system at the National Institute of Standards and Technology in support of measurement standards for the determination of optical properties of tissue-mimicking phantoms.

There is a need for a common reference point that will allow for the comparison of the optical properties of tissue-mimicking phantoms. After a brief review of the methods that have been used to measure the phantoms for a contextual backdrop to our approach, this paper reports on the establishment of a standardized double-integrating-sphere platform to measure absorption and reduced scattering coefficients of tissue-mimicking biomedical phantoms. The platform implements a user-friendly graphical user interface in which variations of experimental configurations and model-based analysis are implemented to compute the coefficients based on a modified inverse adding-doubling algorithm allowing a complete uncertainty evaluation. Repeatability and validation of the measurement results of solid phantoms are demonstrated for three samples of different thicknesses, d = 5.08 mm, 7.09 mm, and 9.92 mm, with an absolute error estimate of 4.0% to 5.0% for the absorption coefficient and 11% to 12% for the reduced scattering coefficient (k = 2). The results are in accordance with those provided by the manufacturer. Measurements with different polarization angles of the incident light are also presented, and the resulting optical properties were determined to be equivalent within the estimated uncertainties.

Digital phantoms generated by spectral and spatial light modulators.

A hyperspectral image projector (HIP) based on liquid crystal on silicon spatial light modulators is explained and demonstrated to generate data cubes. The HIP-constructed data cubes are three-dimensional images of the spatial distribution of spectrally resolved abundances of intracellular light-absorbing oxyhemoglobin molecules in single erythrocytes. Spectrally and spatially resolved image data indistinguishable from the real scene may be used as standard data cubes, so-called digital phantoms, to calibrate image sensors and validate image analysis algorithms for their measurement quality, performance consistency, and interlaboratory comparisons for quantitative biomedical imaging applications.

Digital phantoms generated by spectral and spatial light modulators.

A hyperspectral image projector (HIP) based on liquid crystal on silicon spatial light modulators is explained and demonstrated to generate data cubes. The HIP-constructed data cubes are three-dimensional images of the spatial distribution of spectrally resolved abundances of intracellular light-absorbing oxyhemoglobin molecules in single erythrocytes. Spectrally and spatially resolved image data indistinguishable from the real scene may be used as standard data cubes, so-called digital phantoms, to calibrate image sensors and validate image analysis algorithms for their measurement quality, performance consistency, and interlaboratory comparisons for quantitative biomedical imaging applications.

Development of traceable measurement of the diffuse optical properties of solid reference standards for biomedical optics at National Institute of Standards and Technology.

The development of a national reference instrument dedicated to the measurement of the scattering and absorption properties of solid tissue-mimicking phantoms used as reference standards is presented. The optical properties of the phantoms are measured with a double-integrating sphere setup in the steady-state domain, coupled with an inversion routine of the adding-doubling procedure that allows for the computation of the uncertainty budget for the measurements. The results are compared to the phantom manufacturer's values obtained by a time-resolved approach. The results suggest that the agreement between these two independent methods is within the estimated uncertainties. This new reference instrument will provide optical biomedical research laboratories with reference values for absolute diffuse optical properties of phantom materials.