Application of deep learning image assessment software VeriSee™ for diabetic retinopathy screening.

PURPOSE: To develop a deep learning image assessment software VeriSee™ and to validate its accuracy in grading the severity of diabetic retinopathy (DR). METHODS: Diabetic patients who underwent single-field, nonmydriatic, 45-degree color retinal fundus photography at National Taiwan University Hospital between July 2007 and June 2017 were retrospectively recruited. A total of 7524 judgeable color fundus images were collected and were graded for the severity of DR by ophthalmologists. Among these pictures, 5649 along with another 31,612 color fundus images from the EyePACS dataset were used for model training of VeriSee™. The other 1875 images were used for validation and were graded for the severity of DR by VeriSee™, ophthalmologists, and internal physicians. Area under the receiver operating characteristic curve (AUC) for VeriSee™, and the sensitivities and specificities for VeriSee™, ophthalmologists, and internal physicians in diagnosing DR were calculated. RESULTS: The AUCs for VeriSee™ in diagnosing any DR, referable DR and proliferative diabetic retinopathy (PDR) were 0.955, 0.955 and 0.984, respectively. VeriSee™ had better sensitivities in diagnosing any DR and PDR (92.2% and 90.9%, respectively) than internal physicians (64.3% and 20.6%, respectively) (P < 0.001 for both). VeriSee™ also had better sensitivities in diagnosing any DR and referable DR (92.2% and 89.2%, respectively) than ophthalmologists (86.9% and 71.1%, respectively) (P < 0.001 for both), while ophthalmologists had better specificities. CONCLUSION: VeriSee™ had good sensitivity and specificity in grading the severity of DR from color fundus images. It may offer clinical assistance to non-ophthalmologists in DR screening with nonmydriatic retinal fundus photography.

Deficiency of the microRNA-31-microRNA-720 pathway in the plasma and endothelial progenitor cells from patients with coronary artery disease.

OBJECTIVE: Defects in angiogenesis/vasculogenesis or vessel repair are major complications of coronary artery disease (CAD). Endothelial progenitor cells (EPCs) play a fundamental role in postnatal vascular repair and CAD. The role of microRNAs in CAD pathogenesis and their potential as biomarkers remain to be elucidated. APPROACH AND RESULTS: MicroRNA-31 (miR-31) level in both the plasma and EPCs of patients with CAD is found lower. miR-31 regulates EPC activities by targeting FAT atypical cadherin 4 and thromboxane A2 receptor, which show increased expression in CAD EPCs. Overexpressing miR-31 in CAD EPCs rescued their angiogenic and vasculogenic abilities both in vitro and in vivo. When exploring approaches to restore endogenous miR-31, we found that far-infrared treatment enhanced the expression of not only miR-31, but also miR-720 in CAD EPCs. miR-720, which was also decreased in EPCs and the plasma of patients with CAD, stimulated EPC activity by targeting vasohibin 1. The miR720-vasohibin 1 pair was shown to be downstream of FAT atypical cadherin 4, but not of thromboxane A2 receptor. FAT atypical cadherin 4 inhibited miR-720 expression via repression of the planar cell polarity signaling gene four-jointed box 1 (FJX1), which was required for miR-720 expression through a hypoxia-inducible factor 1, α subunit-dependent mechanism. Restoring miR-720 level strengthened activity of CAD EPCs. The miR-31-miR-720 pathway is shown critical to EPC activation and that downregulation of this pathway contributes to CAD pathogenesis. Circulating levels of miR-31, miR-720, and vasohibin 1 have the potential to allow early diagnosis of CAD and to act as prognosis biomarkers for CAD and other EPC-related diseases. CONCLUSIONS: Manipulating the expression of the miR-31-miR-720 pathway in malfunction EPCs should help develop novel therapeutic modalities.

miRNome traits analysis on endothelial lineage cells discloses biomarker potential circulating microRNAs which affect progenitor activities.

BACKGROUND: Endothelial progenitor cells (EPCs) play a fundamental role in not only blood vessel development but also post-natal vascular repair. Currently EPCs are defined as early and late EPCs based on their biological properties and their time of appearance during in vitro culture. Both EPC types assist angiogenesis and have been linked to ischemia-related disorders, including coronary artery disease (CAD). RESULTS: We found late EPCs are more mobile than early EPCs and matured endothelial cells (ECs). To pinpoint the mechanism, microRNA profiles of early EPCs late EPCs, and ECs were deciphered by small RNA sequencing. Obtained signatures made up of both novel and known microRNAs, in which anti-angiogenic microRNAs such as miR-221 and miR-222 are more abundant in matured ECs than in late EPCs. Overexpression of miR-221 and miR-222 resulted in the reduction of genes involved in hypoxia response, metabolism, TGF-beta signalling, and cell motion. Not only hamper late EPC activities in vitro, both microRNAs (especially miR-222) also hindered in vivo vasculogenesis in a zebrafish model. Reporter assays showed that miR-222, but not miR-221, targets the angiogenic factor ETS1. In contrast, PIK3R1 is the target of miR-221, but not miR-222 in late EPCs. Clinically, both miR-221-PIK3R1 and miR-222-ETS1 pairs are deregulated in late EPCs of CAD patients. CONCLUSIONS: Our results illustrate EPCs and ECs exploit unique miRNA modalities to regulate angiogenic features, and explain why late EPC levels and activities are reduced in CAD patients. These data will further help to develop new plasma biomarkers and therapeutic approaches for ischemia-related diseases or tumor angiogenesis.

A novel reference chart and growth standard of fetal biometry in the Taiwanese population.

OBJECTIVE: The purpose of this study was to establish a new reference chart and growth standards for fetal biometry in Taiwan. MATERIALS AND METHODS: 2047 singleton pregnancies were enrolled in this study with 15,813 fetal scans between 18 and 40 gestational weeks. A reference chart and normal range for fetal biparietal diameter (BPD), abdominal circumference (AC) and femur length (FL) was established by longitudinal quantile regression model. 330 women with comorbidities including gestational hypertension, preeclampsia and gestational diabetes were excluded and 1717 pregnant women were enrolled for the growth standard. RESULTS: The new reference values were significantly larger across all gestational ages compared with the prior National Taiwan University reference chart in 1983. Compared with Intergrowth-21st, the BPD was larger at 18-23 weeks, the AC was larger at 18-24 weeks and the FL was larger at 18-36 weeks whereas they were all smaller at 29-40 weeks for the BPD, at 32-40 weeks for the AC and at 38-40 weeks for the FL. A quantile regression equation of biometry was established. BPD, AC, and FL had weekly growth of 2.5, 9.87 and 2.15 mm. Prepregnancy body weight, height, age, and gestational diabetes increased fetal size. Both gestational and chronic hypertension decreased fetal size. CONCLUSION: To promote maternal-fetal safety, a new reference chart and growth standard for fetal biometry is necessary to measure fetal growth.

Cross-Camera External Validation for Artificial Intelligence Software in Diagnosis of Diabetic Retinopathy.

Aims: To investigate the applicability of deep learning image assessment software VeriSee DR to different color fundus cameras for the screening of diabetic retinopathy (DR). Methods: Color fundus images of diabetes patients taken with three different nonmydriatic fundus cameras, including 477 Topcon TRC-NW400, 459 Topcon TRC-NW8 series, and 471 Kowa nonmyd 8 series that were judged as "gradable" by one ophthalmologist were enrolled for validation. VeriSee DR was then used for the diagnosis of referable DR according to the International Clinical Diabetic Retinopathy Disease Severity Scale. Gradability, sensitivity, and specificity were calculated for each camera model. Results: All images (100%) from the three camera models were gradable for VeriSee DR. The sensitivity for diagnosing referable DR in the TRC-NW400, TRC-NW8, and non-myd 8 series was 89.3%, 94.6%, and 95.7%, respectively, while the specificity was 94.2%, 90.4%, and 89.3%, respectively. Neither the sensitivity nor the specificity differed significantly between these camera models and the original camera model used for VeriSee DR development (p = 0.40, p = 0.065, respectively). Conclusions: VeriSee DR was applicable to a variety of color fundus cameras with 100% agreement with ophthalmologists in terms of gradability and good sensitivity and specificity for the diagnosis of referable DR.

A survey of career-decision factors for obstetrics and gynecology residents in Taiwan.

OBJECTIVE: The recruitment of obstetrics and gynecology residents has been challenging in Taiwan since 2000. There are a lots factors influencing applying, including career interest and prospects, lifestyle, salary, litigation, stress level, time demands of specialty work and gender consideration. The purpose of this study was to evaluate the factors influencing the career choice of current OB/GYN residents and identify the important factors influencing recruitment. MATERIALS AND METHODS: A cross-sectional questionnaire of career-decision factors was sent to all 280 residents during December, 2019. Total 16 factors were rated on a 5-point Likert and were ranking by their average score on the scale. Gender of residents was analyzed for their association with the scores by a two-sample test and two-tailed t test. RESULTS: 91 (32.5%) residents responded and 61 were female and 30 were male. The top influencing factor was being interested in clinical expertise with an average score of 4.32. The second factor was having a great sense of accomplishment in saving people with an average score of 3.82, followed by it being easier to become a medical practitioner at 3.77. The lowest scoring factor was fewer hours of work, with an average score of 1.77 and a safer working environment with a score of 2.33 was the second lowest factor. Female residents agreed that it was easier to get specialist certification with a score of 3.0. This score was significantly higher than male doctors at 2.63 with p value of 0.017. CONCLUSION: Career interest and prospects were key influencing factors for applying OB/GYN residents. Minimizing the influence of detracting factors like heavy workload and medical litigation was also effective. Enrolling new residents is key to maintaining adequate staffing in specialties in healthcare. Establishing a safer work environment and determining the optimal workload will be the next reforms in the future.

Effect of music interventions on anxiety during labor: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Anxiety is commonly experienced during the delivery process and has shown to have adverse effects on maternal and infant health outcomes. Music interventions tend to reduce the effects of anxiety in diverse populations, are low cost, are easily accessible, and have high acceptability. The aim of this review and meta-analysis was to assess the effectiveness of music interventions in reducing anxiety levels among women during labor. METHODS: Seven databases from inception to the end of December, 2018, without any language or time restriction including Embase, PubMed, the Cochrane Library, the Cumulative Index to Nursing and Allied Health, PsycINFO, Airiti Library, and PerioPath: Index to Taiwan Periodical Literature were searched using key terms related to pregnancy, anxiety, and music. Randomized controlled trials that assessed the effect of music during labor and measured anxiety levels as an outcome were included. Meta-analyses were conducted to assess anxiety reduction following a music intervention compared to that after placebo treatment. RESULTS: A total of 14 studies that investigated a total of 1,310 participants were included in this review. The meta-analyses indicated that those in the intervention group had a significant decrease in anxiety scores (standardized mean difference = -2.40, 95% confidence interval (CI) [-3.29 to -1.52], p < 0.001; I 2 = 97.66%), heart rate (HR) (difference in means = -3.04 beats/min, 95% CI [-4.79 to -1.29] beats/min, p = 0.001; I 2 = 0.00%), systolic blood pressure (SBP) (difference in means = -3.71 mmHg, 95% CI [-7.07 to -0.35] mmHg, p = 0.031; I 2 = 58.47%), and diastolic blood pressure (DBP) (difference in means = -3.54 mmHg, 95% CI [-5.27 to -1.81] mmHg, p < 0.001; I 2 = 0.00%) as compared to the women in the control group. CONCLUSIONS: Music interventions may decrease anxiety scores and physiological indexes related to anxiety (HR, SBP, and DBP). Music interventions may be a good non-pharmacological approach for decreasing anxiety levels during labor.

Human placental multipotent mesenchymal stromal cells modulate placenta angiogenesis through Slit2-Robo signaling.

The objective of this study was to investigate whether human placental multipotent mesenchymal stromal cell (hPMSC)-derived Slit2 and endothelial cell Roundabout (Robo) receptors are involved in placental angiogenesis. The hPMSC-conditioned medium and human umbilical vein endothelial cells were studied for Slit2 and Robo receptor expression by immunoassay and RT-PCR. The effect of the conditioned medium of hPMSCs with or without Slit2 depletion on endothelial cells was investigated by in vitro angiogenesis using growth factor-reduced Matrigel. hPMSCs express Slit2 and both Robo1 and Robo4 are present in human umbilical vein endothelial cells. Human umbilical vein endothelial cells do not express Robo2 and Robo3. The hPMSC-conditioned medium and Slit2 recombinant protein significantly inhibit the endothelial cell migration, but not by the hPMSC-conditioned medium with Slit2 depletion. The hPMSC-conditioned medium and Slit2 significantly enhance endothelial tube formation with increased cumulated tube length, polygonal network number and vessel branching point number compared to endothelial cells alone. The tube formation is inhibited by the depletion of Slit2 from the conditioned medium, or following the expression of Robo1, Robo4, and both receptor knockdown using small interfering RNA. Furthermore, co-immunoprecipitation reveals Slit2 binds to Robo1 and Robo4. Robo1 interacts and forms a heterodimeric complex with Robo4. These results suggest the implication of both Robo receptors with Slit2 signaling, which is involved in endothelial cell angiogenesis. Slit2 in the conditioned medium of hPMSCs has functional effect on endothelial cells and may play a role in placental angiogenesis.

Small RNA and RNA-IP Sequencing Identifies and Validates Novel MicroRNAs in Human Mesenchymal Stem Cells.

Organ regeneration therapies using multipotent mesenchymal stem cells (MSCs) are currently being investigated for a variety of common complex diseases. Understanding the molecular regulation of MSC biology will benefit regenerative medicine. MicroRNAs (miRNAs) act as regulators in MSC stemness. There are approximately 2500 currently known human miRNAs that have been recorded in the miRBase v21 database. In the present study, we identified novel microRNAs involved in MSC stemness and differentiation by obtaining the global microRNA expression profiles (miRNomes) of MSCs from two anatomical locations bone marrow (BM-MSCs) and umbilical cord Wharton's jelly (WJ-MSCs) and from osteogenically and adipogenically differentiated progenies of BM-MSCs. Small RNA sequencing (smRNA-seq) and bioinformatics analyses predicted that 49 uncharacterized miRNA candidates had high cellular expression values in MSCs. Another independent batch of Ago1/2-based RNA immunoprecipitation (RNA-IP) sequencing datasets validated the existence of 40 unreported miRNAs in cells and their associations with the RNA-induced silencing complex (RISC). Nine of these 40 new miRNAs were universally overexpressed in both MSC types; nine others were overexpressed in differentiated cells. A novel miRNA (UNI-118-3p) was specifically expressed in BM-MSCs, as verified using RT-qPCR. Taken together, this report offers comprehensive miRNome profiles for two MSC types, as well as cells differentiated from BM-MSCs. MSC transplantation has the potential to ameliorate degenerative disorders and repair damaged tissues. Interventions involving the above 40 new microRNA members in transplanted MSCs may potentially guide future clinical applications.

Integrated genomics has identified a new AT/RT-like yet INI1-positive brain tumor subtype among primary pediatric embryonal tumors.

BACKGROUND: Pediatric embryonal brain tumors (PEBTs), which encompass medulloblastoma (MB), primitive neuroectodermal tumor (PNET) and atypical teratoid/rhabdoid tumor (AT/RT), are the second most prevalent pediatric brain tumor type. AT/RT is highly malignant and is often misdiagnosed as MB or PNET. The distinction of AT/RT from PNET/MB is of clinical significance because the survival rate of patients with AT/RT is substantially lower. The diagnosis of AT/RT relies primarily on morphologic assessment and immunohistochemical (IHC) staining for a few known markers such as the lack of INI1 protein expression. However, in our clinical practice we have observed several AT/RT-like tumors, that fulfilled histopathological and all other biomarker criteria for a diagnosis of AT/RT, yet retained INI1 immunoreactivity. Recent studies have also reported preserved INI1 immunoreactivity among certain diagnosed AT/RTs. It is therefore necessary to re-evaluate INI1(+), AT/RT-like cases. METHOD: Sanger sequencing, array CGH and mRNA microarray analyses were performed on PEBT samples to investigate their genomic landscapes. RESULTS: Patients with AT/RT and those with INI(+) AT/RT-like tumors showed a similar survival rate, and global array CGH analysis and INI1 gene sequencing showed no differential chromosomal aberration markers between INI1(-) AT/RT and INI(+) AT/RT-like cases. We did not misdiagnose MBs or PNETs as AT/RT-like tumors because transcriptome profiling revealed that not only did AT/RT and INI(+) AT/RT-like cases express distinct mRNA and microRNA profiles, their gene expression patterns were different from those of MBs and PNETs. The most similar transcriptome profile to that of AT/RTs was the profile of embryonic stem cells. However; the transcriptome profile of INI1(+) AT/RT-like tumors was more similar to that of somatic neural stem cells, while the profile of MBs was closer to that of fetal brain tissue. Novel biomarkers were identified that can be used to distinguish INI1(-) AT/RTs, INI1(+) AT/RT-like cases and MBs. CONCLUSION: Our studies revealed a novel INI1(+) ATRT-like subtype among Taiwanese pediatric patients. New diagnostic biomarkers, as well as new therapeutic tactics, can be developed according to the transcriptome data that were unveiled in this work.

Prenatal diagnosis and molecular cytogenetic characterization of mosaic ring chromosome 13.

We present prenatal diagnosis and molecular cytogenetic characterization of de novo mosaic r(13). A 32-year-old woman underwent amniocentesis at 18 weeks of gestation because of maternal anxiety. Amniocentesis revealed a karyotype of 46,XY,r(13)[33]/45,XY,-13[19]. aCGH on uncultured amniocytes at repeated amniocentesis detected a 4.22-Mb deletion at 13q34. Interphase FISH on 100 uncultured amniocytes showed the ratio of r(13):-13:idic r(13) as 85%:13%:2%. The cord blood had a karyotype of 46,XY,r(13)[91]/46,XY,idic r(13)[6]/45,XY,-13[3]. The placenta had a karyotype of 46,XY,mar(13)[31]/45,XY,-13[3]. Metaphase FISH confirmed that the marker chromosomes in placenta were derived from chromosome 13. aCGH on cultured placental cells detected a 77.81-Mb deletion at 13q13.3-q34. The fetus postnatally manifested facial dysmorphism. Prenatal diagnosis of r(13) should alert mosaicism for deletion/duplication of r(13) and distal 13q deletion. Fetoplacental chromosomal discrepancy of r(13) may exist in case of mosaic r(13) detected by amniocentesis.

Characteristics of early-onset neonatal sepsis caused by Escherichia coli.

OBJECTIVE: This study was conducted to document the perinatal risk factors associated with early-onset neonatal Escherichia coli sepsis and adverse neonatal outcomes. MATERIALS AND METHODS: A case-control study of early-onset E coli sepsis compared with that of non-E coli sepsis was conducted by a retrospective data review of all infants with a diagnosis of sepsis during the first 7 days of life from the pediatric unit of Mackay Memorial Hospital from January 2004 to October 2008. After adjustment for gestational age, each patient with E coli early-onset sepsis was further compared with two gestational age-matched uninfected controls. RESULTS: Compared with infants with non-E coli sepsis (n = 27), infants with E coli sepsis (n = 19) were more likely to have preterm birth, especially at less than 30 weeks of gestation (47% vs. 4%, p < 0.01), very low birth weights (<1500 g; 47% vs. 4%, p < 0.01), intrapartum fever (26% vs. 4%, p = 0.036), preterm premature rupture of membranes (PPROM; 74% vs. 11%, p < 0.01), prolonged rupture of membranes (>24 hours; 47% vs. 0%, p < 0.01), antibiotic use (63% vs. 15%, p < 0.01), and sepsis onset on the first day of life (63% vs. 15%, p < 0.01). After adjusting for gestational age, intrapartum fever (26% vs. 5%, p = 0.035) and PPROM (74% vs. 39%, p = 0.015) were more common in infants with E coli sepsis. Fifteen of the 19 E coli isolates (79%) were ampicillin-resistant, and three (16%) were gentamicin-resistant. Antepartum and intrapartum antibiotic exposure was associated with ampicillin-resistant E coli sepsis (100% vs. 43%, p < 0.01). CONCLUSION: Early-onset E coli sepsis is more common in premature and very low birth weight infants and is more likely associated with intrapartum fever, PPROM, and sepsis onset on the first day of life than non-E coli sepsis. Broad-spectrum, multiple antibiotics or longer duration of antibiotic exposure may be associated with antibiotic-resistant pathogen infection.