Artifact reduction in photoacoustic images by generating virtual dense array sensor from hemispheric sparse array sensor using deep learning.

PURPOSE: Vascular distribution is important information for diagnosing diseases and supporting surgery. Photoacoustic imaging is a technology that can image blood vessels noninvasively and with high resolution. In photoacoustic imaging, a hemispherical array sensor is especially suitable for measuring blood vessels running in various directions. However, as a hemispherical array sensor, a sparse array sensor is often used due to technical and cost issues, which causes artifacts in photoacoustic images. Therefore, in this study, we reduce these artifacts using deep learning technology to generate signals of virtual dense array sensors. METHODS: Generating 2D virtual array sensor signals using a 3D convolutional neural network (CNN) requires huge computational costs and is impractical. Therefore, we installed virtual sensors between the real sensors along the spiral pattern in three different directions and used a 2D CNN to generate signals of the virtual sensors in each direction. Then we reconstructed a photoacoustic image using the signals from both the real sensors and the virtual sensors. RESULTS: We evaluated the proposed method using simulation data and human palm measurement data. We found that these artifacts were significantly reduced in the images reconstructed using the proposed method, while the artifacts were strong in the images obtained only from the real sensor signals. CONCLUSION: Using the proposed method, we were able to significantly reduce artifacts, and as a result, it became possible to recognize deep blood vessels. In addition, the processing time of the proposed method was sufficiently applicable to clinical measurement.

A study on the optimal condition of ground truth area for liver tumor detection in ultrasound images using deep learning.

PURPOSE: In recent years, efforts to apply artificial intelligence (AI) to the medical field have been growing. In general, a vast amount of high-quality training data is necessary to make great AI. For tumor detection AI, annotation quality is important. In diagnosis and detection of tumors using ultrasound images, humans use not only the tumor area but also the surrounding information, such as the back echo of the tumor. Therefore, we investigated changes in detection accuracy when changing the size of the region of interest (ROI, ground truth area) relative to liver tumors in the training data for the detection AI. METHODS: We defined D/L as the ratio of the maximum diameter (D) of the liver tumor to the ROI size (L). We created training data by changing the D/L value, and performed learning and testing with YOLOv3. RESULTS: Our results showed that the detection accuracy was highest when the training data were created with a D/L ratio between 0.8 and 1.0. In other words, it was found that the detection accuracy was improved by setting the ground true bounding box for detection AI training to be in contact with the tumor or slightly larger. We also found that when the D/L ratio was distributed in the training data, the wider the distribution, the lower the detection accuracy. CONCLUSIONS: Therefore, we recommend that the detector be trained with the D/L value close to a certain value between 0.8 and 1.0 for liver tumor detection from ultrasound images.

Severe hypotension during junctional rhythm in a patient with multiple cerebral infarcts.

An 82-year-old woman with parkinsonism and Lewy body dementia was re-admitted to our hospital due to convulsions and the recurrence of cerebral infarction. Parasternal transthoracic echocardiography showed normal left ventricular wall thickness and wall motion. To treat marked bradycardia and hypotension, she underwent temporary pacing. However, she lost her consciousness, when her blood pressure could not be measured. Simultaneous electrocardiogram and blood pressure monitoring showed that systolic blood pressure decreased by almost 30 mmHg from sinus rhythm to junctional rhythm. In the present case of acute cerebral infarction, severe hypotension occurred during junctional rhythm possibly contributed by parkinsonism and Lewy body dementia. Learning objective: As patients with junctional rhythm usually have no or mild symptoms, there are no specific guidelines for its evaluation and treatment. However, severe symptoms such as hypotension, cerebral infarction, loss of consciousness, or breathlessness may occur in some cases. Holter electrocardiogram with 24-hour noninvasive blood pressure monitoring may be helpful in such severe cases.

A novel murine model of autoimmune dysautonomia by α3 nicotinic acetylcholine receptor immunization.

We aimed to establish a novel murine model of autoimmune autonomic ganglionopathy (AAG), which represents autoimmune dysautonomia, associated with MHC class II to understand its pathomechanism and the pathogenicity of nicotinic acetylcholine receptor (nAChR) antibodies. The amino acid sequence of the mouse nAChRα3 protein was analyzed using an epitope prediction tool to predict the possible MHC class II binding mouse nAChRα3 peptides. We focused on two nAChRα3 peptides in the extracellular region, and experimental AAG (EAAG) was induced by immunization of C57BL/6 mice with these two different peptides. EAAG mice were examined both physiologically and histologically. Mice with EAAG generated nAChRα3 antibodies and exhibited autonomic dysfunction, including reduced heart rate, excessive fluctuations in systolic blood pressure, and intestinal transit slowing. Additionally, we observed skin lesions, such as alopecia and skin ulcers, in immunized mice. Neuronal cell density in the sympathetic cervical ganglia in immunized mice was significantly lower than that in control mice at the light microscopic level. We interpreted that active immunization of mice with nAChRα3 peptides causes autonomic dysfunction similar to human AAG induced by an antibody-mediated mechanism. We suggested a mechanism by which different HLA class II molecules might preferentially affect the nAChR-specific immune response, thus controlling diversification of the autoantibody response. Our novel murine model mimics AAG in humans and provides a useful tool to investigate its pathomechanism.

Effectiveness of treatment for 31 patients with seropositive autoimmune autonomic ganglionopathy in Japan.

Background: Autoimmune autonomic ganglionopathy (AAG) is characterized by serum autoantibodies against the ganglionic acetylcholine receptor (gAChR). Immunomodulatory treatments may alleviate AAG symptoms, but the most appropriate treatment strategy is unclear. Objective: This study aimed to confirm the effectiveness of treatments, particularly immunotherapy, in patients with seropositive AAG in Japan, as well as to determine the most effective treatment and the best assessment method for clinical response to treatment. Methods: We collected data from a previous cohort study of patients with seropositive AAG. The clinical autonomic and extra-autonomic symptoms were objectively counted and subjectively assessed using the modified Composite Autonomic Symptom Score. Post-treatment changes in the gAChR antibody level were evaluated. Results: Thirty-one patients received immunotherapy. Among them, 19 patients received intravenous methylprednisolone; 27, intravenous immunoglobulin; 3, plasma exchange; 18, oral steroids; 2, tacrolimus; 1, cyclosporine; and 1, mycophenolate mofetil. Patients who received immunotherapy showed improvements in the total number of symptoms (from 6.2 ± 2.0 to 5.1 ± 2.0) and modified Composite Autonomic Symptom Score (from 37.4 ± 15.3 to 26.6 ± 12.8). Orthostatic intolerance, sicca, and gastrointestinal symptoms were ameliorated by immunotherapy. Immunotherapy decreased the antibody levels (gAChRα3 antibodies, from 2.2 ± 0.4 to 1.9 ± 0.4, p = 0.08; gAChRß4 antibodies, from 1.6 ± 0.1 to 1.0 ± 0.2, p = 0.002), but antibody levels increased in 10 patients despite immunotherapy. The rate of improvement in the total number of symptoms was higher in patients with combined therapy than in patients with non-combined therapy (70.7% vs 28.6%). Conclusions: The scores in many items on the rating scale decreased after immunotherapy in patients with seropositive AAG, particularly in the combined immunotherapy group. However, more accurate assessment scales for clinical symptoms and multicenter randomized, placebo-controlled prospective studies are warranted to establish future treatment strategies.

Miller Fisher Syndrome Following Vaccination against SARS-CoV-2.

After BNT162b2 messenger ribonucleic acid (mRNA) coronavirus disease 2019 (COVID-19) vaccination, a 30-year-old man developed bilateral lateral gaze palsy, diplopia, absent tendon reflexes, and ataxic gait. Serum anti-GQ1b and anti-GT1a immunoglobulin G (IgG) antibodies were strongly positive. Based on those findings, he was diagnosed with Miller Fisher syndrome (MFS). Intravenous immunoglobulin therapy was administered, and his symptoms fully recovered within approximately 3 months. To the best of our knowledge, this is the first report to describe the development of MFS after COVID-19 mRNA vaccination.

Artificial intelligence (AI) models for the ultrasonographic diagnosis of liver tumors and comparison of diagnostic accuracies between AI and human experts.

BACKGROUND: Ultrasonography (US) is widely used for the diagnosis of liver tumors. However, the accuracy of the diagnosis largely depends on the visual perception of humans. Hence, we aimed to construct artificial intelligence (AI) models for the diagnosis of liver tumors in US. METHODS: We constructed three AI models based on still B-mode images: model-1 using 24,675 images, model-2 using 57,145 images, and model-3 using 70,950 images. A convolutional neural network was used to train the US images. The four-class liver tumor discrimination by AI, namely, cysts, hemangiomas, hepatocellular carcinoma, and metastatic tumors, was examined. The accuracy of the AI diagnosis was evaluated using tenfold cross-validation. The diagnostic performances of the AI models and human experts were also compared using an independent test cohort of video images. RESULTS: The diagnostic accuracies of model-1, model-2, and model-3 in the four tumor types are 86.8%, 91.0%, and 91.1%, whereas those for malignant tumor are 91.3%, 94.3%, and 94.3%, respectively. In the independent comparison of the AIs and physicians, the percentages of correct diagnoses (accuracies) by the AIs are 80.0%, 81.8%, and 89.1% in model-1, model-2, and model-3, respectively. Meanwhile, the median percentages of correct diagnoses are 67.3% (range 63.6%-69.1%) and 47.3% (45.5%-47.3%) by human experts and non-experts, respectively. CONCLUSION: The performance of the AI models surpassed that of human experts in the four-class discrimination and benign and malignant discrimination of liver tumors. Thus, the AI models can help prevent human errors in US diagnosis.

Shear wave speed measurement bias in a viscoelastic phantom across six ultrasound elastography systems: a comparative study with transient elastography and magnetic resonance elastography.

PURPOSE: To quantify the bias of shear wave speed (SWS) measurements in a viscoelastic phantom across six different ultrasound (US) systems and to compare the SWS with those from transient elastography (TE) and magnetic resonance elastography (MRE). METHODS: A viscoelastic phantom of stiffness representing fibrotic liver or healthy thyroid was measured with nine (linear probe) and 10 (convex probe) modes of six different US-based shear wave elastography (SWE) systems using linear and convex probes. SWS measurements of three regions of interest were repeated thrice at two focal depths, coupling the probe to the phantom using a jig. An MRE system using three motion-encoding gradient frequencies of 60, 90, and 120 Hz and TE were also used to measure the stiffness of the phantom. RESULTS: The SWS from different SWE systems had mean coefficients of variation of 9.0-9.2% and 5.4-5.6% with linear and convex probes, respectively, in viscoelastic phantom measurement. The focal depth was a less significant source of SWS variability than the system. The total average SWS obtained with US-SWE systems was 19.9% higher than that obtained with MRE at 60 Hz, which is commonly used in clinical practice, and 31.5% higher than that obtained with TE using the M probe. CONCLUSIONS: Despite the measurement biases associated with the SWE systems, biases were not necessarily consistent, and they changed with the probes used and depth measured. The SWS of the viscoelastic phantom obtained using different modalities increased according to the shear wave frequency used.

A review of physical and engineering factors potentially affecting shear wave elastography.

It has been recognized that tissue stiffness provides useful diagnostic information, as with palpation as a screening for diseases such as cancer. In recent years, shear wave elastography (SWE), a technique for evaluating and imaging tissue elasticity quantitatively and objectively in diagnostic imaging, has been put into practical use, and the amount of clinical knowledge about SWE has increased. In addition, some guidelines and review papers regarding technology and clinical applications have been published, and the status as a diagnostic technology is in the process of being established. However, there are still unclear points about the interpretation of shear wave speed (SWS) and converted elastic modulus in SWE. To clarify these, it is important to investigate the factors that affect the SWS and elastic modulus. Therefore, physical and engineering factors that potentially affect the SWS and elastic modulus are discussed in this review paper, based on the principles of SWE and a literature review. The physical factors include the propagation properties of shear waves, mechanical properties (viscoelasticity, nonlinearity, and anisotropy), and size and shape of target tissues. The engineering factors include the region of interest depth and signal processing. The aim of this review paper is not to provide an answer to the interpretation of SWS. It is to provide information for readers to formulate and verify the hypothesis for the interpretation. Therefore, methods to verify the hypothesis for the interpretation are also reviewed. Finally, studies on the safety of SWE are discussed.

gAChR antibodies in children and adolescents with acquired autoimmune dysautonomia in Japan.

OBJECTIVE: Patients with acquired autonomic dysfunction may have antibodies specific to the ganglionic nicotinic acetylcholine receptor (gAChR). However, the clinical features of children and adolescents with acquired autonomic dysfunction (AAD) remain unclear. This study aimed to determine the clinical features of pediatric patients with acquired autonomic dysfunction. METHODS: This study retrospectively examined a series of patients of AAD with serum gAChR antibodies who were referred to our laboratory for antibody testing between January 2012 and April 2019. The study included 200 patients (<20 years, 20 cases; ≥20 years, 175 cases) with clinical features of AAD. RESULTS: Upon comparing pediatric and adult patients, we found that antecedent infection and autonomic symptoms at onset with gastrointestinal symptoms occurred more frequently in children with AAD. We confirmed that four children (20.0%) met the diagnostic criteria for postural orthostatic tachycardia syndrome (POTS). A significantly higher number of children than adults had POTS (P = 0.002). In addition, upper GI dysfunction was more prevalent in children than in adults (P = 0.042). In particular, nausea and vomiting occurred in 60.0% of children with AAD and in 21.1% of adults (P < 0.001). The frequency of paralytic ileus was significantly higher in children with AAD (20.0%) relative to adults (6.3%) (P = 0.030). Regarding extra-autonomic manifestations, encephalopathy was more frequent in children (15.0%) than in adults (1.1%) (P < 0.001). INTERPRETATION: Pediatric AAD patients have their own clinical characteristics, and these features may be unique to children and adolescents.

New possibilities for egg white lysozyme: heat-denatured lysozyme partially inactivates select foot-and-mouth disease virus strains.

Foot-and-mouth disease (FMD) is one of the most contagious diseases of cloven-hoofed animals. Disinfectants are used to inactivate FMD virus (FMDV) in Japan. Reports that heat-denatured lysozyme inactivates bacteria as well as viruses, such as norovirus and hepatitis A virus, led us to determine its effects on FMDV. We show here that heat-denatured lysozyme partially inhibited the infectivity of FMDV O/JPN/2010-1/14C but of FMDVs A/TAI/46-1/2015 and Asia1/Shamir (ISR/3/89). Further, heat-denatured lysozyme variably reduced RNA loads of FMDVs O/JPN/2010-1/14C, O/MOG/2/Ca/BU/2017, O/Taiwan/1997, Asia1/Shamir (ISR/3/89), Asia1/TUR/49/2011, SAT1/KEN/117/2009, SAT2/SAU/6/2000 and SAT3/ZIM/3/83 but could not those of O/JPN/2000, A/TAI/46-1/2015, A22/IRQ/24/64, A15/TAI/1/60 and C/PHI/7/84. These findings indicate that heat-denatured lysozyme may serve as a new disinfectant against FMDV.

Experimental infection of pigs with different doses of the African swine fever virus Armenia 07 strain by intramuscular injection and direct contact.

We experimentally infected pigs with the African swine fever virus (ASFV) Armenia 07 strain (genotype II) to analyze the effect of different dose injections on clinical manifestations, virus-shedding patterns, histopathology, and transmission dynamics by direct contact. Each three pigs and four pigs were injected intramuscularly with 0.1 fifty percent hemadsorbing doses (HAD50)/ml, 101 HAD50/ml and 106 HAD50/ml of ASFV Armenia 07 strain, respectively. Each two of three pigs injected with 0.1 HAD50/ml and 101 HAD50/ml died by 10 days post inoculation. All pigs had a gross lesion of splenomegaly. Perigastric and renal lymph nodes were enlarged and resembled blood clots in nine of ten pigs. It was revealed that 0.1 HAD50/ml of this ASFV was sufficient to infect healthy pigs by intramuscular injection and caused sub-acute lethal disease. For the transmission study, two 8-week-old pigs were injected intramuscularly with 103 HAD50/ml of the same virus. Each of the experimentally inoculated pigs was co-housed with two 8-week-old naive pigs. All contact pigs exhibited clinical manifestations at 6 or 7 days after the experimentally inoculated pigs developed pyrexia. These findings suggest that this strain may spread slowly within a herd. Histologically, lymph nodes resembled blood clots were formed by severe blood absorption and followed hemorrhage result of disruption of the lymphoid sinus filling with absorbed red blood cells. The severity of the gross and histological lesions depended on duration after infection, regardless of the difference of injection doses in this study.

Study for quantitative evaluation of photoaging with photoacoustic microscopy.

Skin aging caused by ultraviolet light exposure is one of the serious problems from the viewpoint of beauty and healthcare. This is because ultraviolet light can cause age spot, wrinkles, at the worst case, skin cancer and so on. To evaluate skin aging, various modalities are being used, such as histopathological diagnosis, optical coherence tomography, ultrasound examination (B-mode imaging). However, they have disadvantages in terms of invasiveness, penetration depth and tissue specificity, respectively. To overcome these defects, photoacoustic imaging (PAI), a novel modality was used in this work. This modality can sense differences of tissue characteristics non-invasively. In this experiment, human skin tissues in various generations (i.e. various degrees of photoaging) were measured by using acoustic resolution photoacoustic microscopy (AR-PAM). To verify the feasibility of quantitative skin aging evaluation with PA technique, signals from sectioned human skin (cheek and buttock; female from 28 to 95 years old) were measured with PA microscopy. The effects of photoaging progress on the signal intensity were investigated. The results demonstrated that the PA signal from the dermis significantly increases with aging progress (p < 0.05). These analyses demonstrate the feasibility of quantitative skin aging evaluation with a PAI system.

Antibodies to the α3 subunit of the ganglionic-type nicotinic acetylcholine receptors in patients with autoimmune encephalitis.

Since autonomic dysfunction is closely associated with autoimmune encephalitis (AE), the objective of this study was to determine the autonomic symptoms and the prevalence of anti-α3 subunit of the ganglionic-type nicotinic acetylcholine receptor (gAChRα3) antibodies in the patients with AE. We reviewed the clinical features of 19 AE patients, and specifically analyzed sera for anti-gAChRα3 antibodies using the luciferase immunoprecipitation system (LIPS) assay. Cardiovascular autonomic symptoms were found to be common in patients with AE, and hypersalivation was seen only in patients with NMDAR encephalitis. LIPS detected anti-gAChRα3 antibodies in the sera from patients with AE (5/29, 26%). This study is the first to demonstrate that clinical characteristics including autonomic symptoms of AE patients with seropositivity for gAChR autoantibodies. It will be important to verify the role of gAChR antibodies in autonomic dysfunction and brain symptoms to clarify the pathogenesis of AE.

Evolution of antigenic and genetic characteristics of foot-and-mouth disease virus serotype A circulating in Thailand, 2007-2019.

Foot-and-mouth disease (FMD) is a persistent, major economic concern for livestock productivity, which is highly exacerbated by outbreaks in Thailand. FMD virus (FMDV) serotype A is more highly antigenic and genetically diverse than other serotypes, which has important implications for vaccine development as well as selection. Therefore, it is essential to continuously monitor antigenic and genetic changes of field isolates of FMDV serotype A. Here we used antisera against three vaccine strains (A/118/87, A/Sakolnakorn/97, and A/Lopburi/2012) to analyze the antigenicity of 133 field isolates of FMDV serotypes A in Thailand from 2007 to 2019. The majority of the isolates from 2007 to 2008 reacted only with the antiserum against strain A/118/87. In contrast, antigenic analysis revealed broad cross-reactivity and antigenic variations of the isolates from 2009 through 2019 against strains A/Sakolnakorn/97 and A/Lopburi/2012. These results indicate periodic changes in the antigenicity of field isolates of FMDV serotype A. Phylogenetic analysis of the VP1 region revealed that all isolates were of the Sea-97 lineage within the ASIA topotype. Analysis of the L-fragment genome sequences of 30 FMDV isolates collected throughout Thailand revealed highly variable amino acid sequences of VP1 and 3A, with the lowest average identity (94.56 %) and invariant (78.43 %) rates, respectively. The present findings indicate the importance of an active routine surveillance system incorporating antigenic and genetic analysis designated to continually update information about field isolates of FMDV serotype A. Such a system is essential for establishing and improving measures to control FMDV infections in Thailand and in neighboring Asian countries.

A comprehensive analysis of the clinical characteristics and laboratory features in 179 patients with autoimmune autonomic ganglionopathy.

The clinical importance of autoantibodies against the ganglionic acetylcholine receptor (gAChR) remains to be fully elucidated. We aimed to identify the clinical characteristics of autoimmune autonomic ganglionopathy (AAG) in patients with gAChR autoantibodies. For this cohort investigation, serum samples were obtained from patients with AAG between 2012 and 2018 in Japan. We measured the levels of autoantibodies against gAChRα3 and gAChRß4 and evaluated clinical features, as well as assessing the laboratory investigation results among the included patients. A total of 179 patients tested positive for antibodies, including 116 gAChRα3-positive, 13 gAChRß4-positive, and 50 double antibody-positive patients. Seropositive AAG patients exhibited widespread autonomic dysfunction. Extra-autonomic manifestations including sensory disturbance, central nervous system involvement, endocrine disorders, autoimmune diseases, and tumours were present in 118 patients (83%). We observed significant differences in the frequencies of several autonomic and extra-autonomic symptoms among the three groups. Our 123I-metaiodobenzylguanidine myocardial scintigraphy analysis of the entire cohort revealed that the heart-to-mediastinum ratio had decreased by 80%. The present study is the first to demonstrate that patients with AAG who are seropositive for anti-gAChRß4 autoantibodies exhibit unique autonomic and extra-autonomic signs. Decreased cardiac uptake occurred in most cases, indicating that 123I- metaiodobenzylguanidine myocardial scintigraphy may be useful for monitoring AAG. Therefore, our findings indicate that gAChRα3 and gAChRß4 autoantibodies cause functional changes in postganglionic fibres in the autonomic nervous system and extra-autonomic manifestations in seropositive patients with AAG.

Horizontal transmission of foot-and-mouth disease virus O/JPN/2010 among different animal species by direct contact.

Foot-and-mouth disease (FMD) is highly contagious and easily transmitted among species of cloven-hoofed animals. To investigate the transmission of FMD virus (FMDV) among different animal species, experimental infections using the O/JPN/2010 strain were performed in cows, goats and pigs. One cow or two goats/pigs were housed with a different species of inoculated animals, and clinical observations, virus shedding and antibody responses were analysed daily. Whilst all cows and goats were infected horizontally by contact with inoculated pigs, transmission from cows to goats/pigs and from goats to cows/pigs was not observed in all in-contact animals. In particular, no pigs were infected horizontally by contact with inoculated goats. Comparison with our previous study on experimental infections among animals of the same species indicates that horizontal transmission occurred more easily between animals of the same species than between those of the different species. These findings will be useful for establishing and performing species-specific countermeasures in farms and regions where multiple species of animals coexist in potential future outbreaks.

Development and evaluation of silver amplification immunochromatography kit for foot-and-mouth disease virus antigen detection.

A silver amplification immunochromatography (SAI) kit for the detection of all seven serotypes of foot-and-mouth disease virus (FMDV)-FMDV-Ag SAI-was developed using the monoclonal antibody 1H5 recognizing the highly conserved N terminus region of VP2. The FMDV-Ag SAI can be used under conditions of high biosecurity containment as it does not require any apparatus. The FMDV-Ag SAI exhibited 10-100 times higher sensitivity against the five serotypes (O, A, Asia1, C, and SAT1) and similar sensitivity against SAT2 and SAT3, compared with the Svanodip® FMDV-Ag kit immunochromatography kit. The Svanodip kit showed inhibitory results with several saliva samples but not with the FMDV-Ag SAI kit. In a validation study using clinical samples (n = 132; vesicular epithelium = 92, vesicular lesion swabs = 20, saliva = 20) in Mongolia, the sensitivity of FMDV-Ag SAI in comparison with real-time reverse transcription-polymerase chain reaction revealed the following data: vesicular epithelium, 85.4% (76/89); vesicular lesion swab, 46.7% (7/17); and saliva, 36.8% (7/19). No cross-reactivity with the non-FMDV vesicular-forming viruses and taxonomically related viruses of the Picornaviridae family occurred. The FMDV-Ag SAI is a highly sensitive diagnostic tool that enables pen-side diagnosis without requiring the use of any equipment.