Detecting pediatric wrist fractures using deep-learning-based object detection.

BACKGROUND: Missed fractures are the leading cause of diagnostic error in the emergency department, and fractures of pediatric bones, particularly subtle wrist fractures, can be misidentified because of their varying characteristics and responses to injury. OBJECTIVE: This study evaluated the utility of an object detection deep learning framework for classifying pediatric wrist fractures as positive or negative for fracture, including subtle buckle fractures of the distal radius, and evaluated the performance of this algorithm as augmentation to trainee radiograph interpretation. MATERIALS AND METHODS: We obtained 395 posteroanterior wrist radiographs from unique pediatric patients (65% positive for fracture, 30% positive for distal radial buckle fracture) and divided them into train (n = 229), tune (n = 41) and test (n = 125) sets. We trained a Faster R-CNN (region-based convolutional neural network) deep learning object-detection model. Two pediatric and two radiology residents evaluated radiographs initially without the artificial intelligence (AI) assistance, and then subsequently with access to the bounding box generated by the Faster R-CNN model. RESULTS: The Faster R-CNN model demonstrated an area under the curve (AUC) of 0.92 (95% confidence interval [CI] 0.87-0.97), accuracy of 88% (n = 110/125; 95% CI 81-93%), sensitivity of 88% (n = 70/80; 95% CI 78-94%) and specificity of 89% (n = 40/45, 95% CI 76-96%) in identifying any fracture and identified 90% of buckle fractures (n = 35/39, 95% CI 76-97%). Access to Faster R-CNN model predictions significantly improved average resident accuracy from 80 to 93% in detecting any fracture (P < 0.001) and from 69 to 92% in detecting buckle fracture (P < 0.001). After accessing AI predictions, residents significantly outperformed AI in cases of disagreement (73% resident correct vs. 27% AI, P = 0.002). CONCLUSION: An object-detection-based deep learning approach trained with only a few hundred examples identified radiographs containing pediatric wrist fractures with high accuracy. Access to model predictions significantly improved resident accuracy in diagnosing these fractures.

Inferring pediatric knee skeletal maturity from MRI using deep learning.

PURPOSE: Many children who undergo MR of the knee to evaluate traumatic injury may not undergo a separate dedicated evaluation of their skeletal maturity, and we wished to investigate how accurately skeletal maturity could be automatically inferred from knee MRI using deep learning to offer this additional information to clinicians. MATERIALS AND METHODS: Retrospective data from 894 studies from 783 patients were obtained (mean age 13.1 years, 47% female). Coronal and sagittal sequences that were T1/PD-weighted were included and resized to 224 × 224 pixels. Data were divided into train (n = 673), tune (n = 48), and test (n = 173) sets, and children were separated across sets. The chronologic age was predicted using deep learning approaches based on a long short-term memory (LSTM) model, which took as input DenseNet-121-extracted features from all T1/PD coronal and sagittal slices. Each test case was manually assigned a bone age by two radiology residents using a reference atlas provided by Pennock and Bomar. The patient's age served as ground truth. RESULTS: The error of the model's predictions for chronological age was not significantly different from that of radiology residents (model M.S.E. 1.30 vs. resident 0.99, paired t-test = 1.47, p = 0.14). Pearson correlation between model and resident prediction of chronologic age was 0.96 (p < 0.001). CONCLUSION: A deep learning-based approach demonstrated ability to infer skeletal maturity from knee MR sequences that was not significantly different from resident performance and did so in less than 2% of the time required by a human expert. This may offer a method for automatically evaluating lower extremity skeletal maturity automatically as part of every MR examination.

The role of atherectomy in the treatment of lower extremity peripheral artery disease.

BACKGROUND: The incidence of lower extremity peripheral artery disease (LE-PAD) continues to increase and associated morbidity remains high. Despite the significant development of percutaneous revascularization strategies, over the past decade, LE-PAD still represents a unique challenge for interventional cardiologists and vascular surgeons. METHOD: Typical features of atherosclerosis that affects peripheral vascular bed (diffuse nature, poor distal runoff, critical limb ischemia, chronic total occlusion) contribute to the disappointing results of traditional percutaneous transluminal angioplasty (PTA). New technologies have been developed in attempt to improve the safety and effectiveness of percutaneous revascularization. Among these, atherectomy, debulking and removing atherosclerotic plaque, offers the potential advantage of eliminating stretch on arterial walls and reducing rates of restenosis. CONCLUSIONS: This review summarizes the features and the current applications of new debulking devices.

Cardiovascular effects of treadmill exercise in physiological and pathological preclinical settings.

Exercise adaptations result from a coordinated response of multiple organ systems, including cardiovascular, pulmonary, endocrine-metabolic, immunologic, and skeletal muscle. Among these, the cardiovascular system is the most directly affected by exercise, and it is responsible for many of the important acute changes occurring during physical training. In recent years, the development of animal models of pathological or physiological cardiac overload has allowed researchers to precisely analyze the complex cardiovascular responses to stress in genetically altered murine models of human cardiovascular disease. The intensity-controlled treadmill exercise represents a well-characterized model of physiological cardiac hypertrophy because of its ability to mimic the typical responses to exercise in humans. In this review, we describe cardiovascular adaptations to treadmill exercise in mice and the most important parameters that can be used to quantify such modifications. Moreover, we discuss how treadmill exercise can be used to perform physiological testing in mouse models of disease and to enlighten the role of specific signaling pathways on cardiac function.

Total occlusion of the abdominal aorta in a patient with renal failure and refractory hypertension: a case report.

Total occlusion of the abdominal aorta is unusual, and potentially catastrophic. It occurs in patients with advanced atherosclerotic occlusive disease, and can cause severe ischemic manifestations, depending on the site of obstruction. Prompt and appropriate diagnostic and therapeutic approaches are important whenever this condition is suspected, in order to avoid a fatal outcome. The development of a complex network of collaterals may prevent the manifestation of acute ischemic phenomena, and cause a delay in diagnosis and treatment. Here we report the clinical case of a 59-year-old man who was referred to our Department for evaluation of renal failure and refractory hypertension. Ultrasonography and 99mTc-DTPA scintigraphy showed a shrunken, non-functioning left kidney, while CT angiography and aortography showed the complete occlusion of the aorta from below the right renal artery down to the bifurcation of both common iliac arteries, with a critical stenosis of the origin of the right renal artery, an occlusion of the left renal artery as well as of the origin of the inferior mesenteric artery. The patient was referred to the surgery department for aorto-bifemoral bypass surgery and re-implantation of the right renal artery.

Endovascular treatment of carotid artery stenosis: evidences from randomized controlled trials and actual indications.

Atherosclerotic stenosis of common and internal carotid arteries is a well-recognized risk factor for ischemic stroke, and revascularization has been proven to be the main tool of prevention, particularly for patients with stenosis-related symptoms. While for many years surgical carotid endarterectomy (CEA) has been considered the gold-standard strategy to restore vascular patency, recently the endovascular treatment through percutaneous angioplasty and stent implantation (CAS) has become a valid alternative. In the last years, interesting data about the comparison of these strategies have emerged. CAS seems to cause more peri-procedural strokes, but may also avoid many adverse events related to surgery and general anaesthesia, including peri-procedural myocardial infarction. For these reasons, it was initially considered a second-choice strategy to be adopted in patients for whom surgery was contraindicated. However, more recent trials have shown that CAS might be considered an effective alternative to CEA. Moreover, the rapid evolution of CAS technique and materials suggests its potential to improve outcome and possible superiority compared to CEA in the next future. Purpose of this review is to discuss the most recent clinical evidences concerning the treatment of carotid artery stenosis, with a special focus on the endovascular treatment.

Identifying Factors Important to Patients for Resuming Elective Imaging During the COVID-19 Pandemic.

PURPOSE: To identify factors important to patients for their return to elective imaging during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: In all, 249 patients had elective MRIs postponed from March 23, 2020, to April 24, 2020, because of the COVID-19 pandemic. Of these patients, 99 completed a 22-question survey about living arrangement and health care follow-up, effect of imaging postponement, safety of imaging, and factors important for elective imaging. Mann-Whitney U, Fisher's exact, χ2 tests, and logistic regression analyses were performed. Statistical significance was set to P ≤ .05 with Bonferroni correction applied. RESULTS: Overall, 68% of patients felt imaging postponement had no impact or a small impact on health, 68% felt it was fairly or extremely safe to obtain imaging, and 53% thought there was no difference in safety between hospital-based and outpatient locations. Patients who already had imaging performed or rescheduled were more likely to feel it was safe to get an MRI (odds ratio [OR] 3.267, P = .028) and that the hospital setting was safe (OR 3.976, P = .004). Staff friendliness was the most important factor related to an imaging center visit (95% fairly or extremely important). Use of masks by staff was the top infection prevention measure (94% fairly or extremely important). Likelihood of rescheduling imaging decreased if a short waiting time was important (OR = 0.107, P = .030). CONCLUSION: As patients begin to feel that it is safe to obtain imaging examinations during the COVID-19 pandemic, many factors important to their imaging experience can be considered by radiology practices when developing new strategies to conduct elective imaging.

Pseudopathological vertebral changes in a young individual from Herculaneum (79 C.E.).

Post mortem abnormal modification of bone are known as pseudopathologies. The geochemical characteristic of the burial soil and/or the presence of biological agents may produce marked changes in bone preservation. This could be the case for a young individual, E74, from Herculaneum, which was a Roman town near Naples completely destroyed by the volcanic eruption of Mt. Vesuvius in 79 CE. E74 is an incomplete skeleton of a male individual of 7-8 years of age. Its second and third cervical vertebrae, the eighth thoracic vertebra and the first lumbar vertebra show a septum dividing the vertebral foramen. This condition could be diagnosed as diastematomyelia that consists of the splitting of the spinal cord or cauda equina. In particular Type I malformations consist of two hemicords separated into two dural tubes by a bone septum. The gross anatomy and histological aspects of the vertebrae and their septa were investigated through macroscopic, microscopic, radiographic and chemical analyses. The results demonstrate that the vertebral septum is constituted by three layers of inorganic substances deposited at different times on a thin, probably organic, substrate (original meninges?). The central layer contain framboidal pyrite, that is a sedimentary mineral rarely found in ancient human skeletons. The septum splitting the vertebral canal of individual E74 is consequent to a taphonomic event and is not due to a pathological condition. Distinguishing between ante and post mortem alterations can be a challenging exercise even for the experienced paleopathologists and, as this case indicates, paleopathological diagnoses should be supported by detailed examinations.

The utility of 3D medical imaging techniques for obtaining a reliable differential diagnosis of metastatic cancer in an Iron Age skull.

In this report we present a case of neoplastic disease affecting an Iron Age skull that provides some of the earliest evidence of metastatic cancer (MC) in Western Europe. The cranium comes from the indigenous site of Baucina (Palermo, Sicily) and was recovered in a multiple burial context dated to the 6th-5th centuries BCE. The skull was attributed to an adult female and was characterized by numerous perforating lytic lesions. CT and 3D imaging analyses were crucial for obtaining a diagnosis of MC. Based on the morphology of the lytic lesions and the biological profile of our specimen, we can tentatively suggest breast carcinoma as the primary origin of the clinical manifestations recorded on the skull. This work also highlights the importance of utilizing an analytical approach to paleopathology that incorporates up-to-date CT and 3D imaging techniques.

Correction: Akap1 Deficiency Promotes Mitochondrial Aberrations and Exacerbates Cardiac Injury Following Permanent Coronary Ligation via Enhanced Mitophagy and Apoptosis.

[This corrects the article DOI: 10.1371/journal.pone.0154076.].

Akap1 Deficiency Promotes Mitochondrial Aberrations and Exacerbates Cardiac Injury Following Permanent Coronary Ligation via Enhanced Mitophagy and Apoptosis.

A-kinase anchoring proteins (AKAPs) transmit signals cues from seven-transmembrane receptors to specific sub-cellular locations. Mitochondrial AKAPs encoded by the Akap1 gene have been shown to modulate mitochondrial function and reactive oxygen species (ROS) production in the heart. Under conditions of hypoxia, mitochondrial AKAP121 undergoes proteolytic degradation mediated, at least in part, by the E3 ubiquitin ligase Seven In-Absentia Homolog 2 (Siah2). In the present study we hypothesized that Akap1 might be crucial to preserve mitochondrial function and structure, and cardiac responses to myocardial ischemia. To test this, eight-week-old Akap1 knockout mice (Akap1-/-), Siah2 knockout mice (Siah2-/-) or their wild-type (wt) littermates underwent myocardial infarction (MI) by permanent left coronary artery ligation. Age and gender matched mice of either genotype underwent a left thoracotomy without coronary ligation and were used as controls (sham). Twenty-four hours after coronary ligation, Akap1-/- mice displayed larger infarct size compared to Siah2-/- or wt mice. One week after MI, cardiac function and survival were also significantly reduced in Akap1-/- mice, while cardiac fibrosis was significantly increased. Akap1 deletion was associated with remarkable mitochondrial structural abnormalities at electron microscopy, increased ROS production and reduced mitochondrial function after MI. These alterations were associated with enhanced cardiac mitophagy and apoptosis. Autophagy inhibition by 3-methyladenine significantly reduced apoptosis and ameliorated cardiac dysfunction following MI in Akap1-/- mice. These results demonstrate that Akap1 deficiency promotes cardiac mitochondrial aberrations and mitophagy, enhancing infarct size, pathological cardiac remodeling and mortality under ischemic conditions. Thus, mitochondrial AKAPs might represent important players in the development of post-ischemic cardiac remodeling and novel therapeutic targets.

Dermcidin: a skeletal muscle myokine modulating cardiomyocyte survival and infarct size after coronary artery ligation.

AIMS: Coronary artery disease is the leading cause of death in western countries, and its association with lower extremity peripheral artery disease (LE-PAD) represents an independent predictor of worse outcome. However, the molecular mechanisms underlying these effects are currently unknown. METHODS AND RESULTS: To investigate these processes, we used in vitro approaches and several mouse models: (i) unilateral limb ischaemia by left common femoral artery ligation [peripheral ischaemia (PI), n = 38]; (ii) myocardial infarction by permanent ligation of the left descending coronary artery (MI, n = 40); (iii) MI after 5 weeks of limb ischaemia (PI + MI, n = 44); (iv) sham operation (SHAM, n = 20). Compared with MI, PI + MI hearts were characterized by a significant increase in cardiomyocyte apoptosis, larger infarct areas, and decreased cardiac function. By using a proteomic approach, we identified a ≅ 8 kDa circulating peptide, Dermcidin (DCD), secreted by ischaemic skeletal muscles, enhancing cardiomyocytes apoptosis under hypoxic conditions and infarct size after permanent coronary artery ligation. siRNA interference experiments to reduce DCD circulating levels significantly reduced infarct size and ameliorated cardiac function after MI. CONCLUSION: Our data demonstrate that chronic limb ischaemia activates detrimental pathways in the ischaemic heart through humoral mechanisms of remote organ crosstalk. Thus, DCD may represent a novel important myokine modulating cardiomyocyte survival and function.

Cardiac side effects of chemotherapy: state of art and strategies for a correct management.

In recent years, the development of more effective drugs has provided a better prognosis and an increase in life expectancy for patients at all-stages of cancer. On the other hand, the price for the improving effectiveness of therapies against malignant tumors is the development of severe and potentially life-threatening drug reactions. Among these, cardiac toxic effects have recently gained particular attention. The term cardiotoxicity includes many possible pathological manifestations, but the most frequent is the reduction in cardiac function, potentially leading to heart failure and death. Importantly, the development of cardiac dysfunction may occur immediately after drug administration, or after years. The purpose of this review is to discuss the clinical features of cardiotoxicity, its molecular basis and novel possible strategies to reduce the likelihood of serious cardiac complications.

Fatal cranial injury in an individual from Messina (Sicily) during the times of the Roman Empire.

Forensic and archaeological examinations of human skeletons can provide us with evidence of violence. In this paper, we present the patterns of two cranial lesions found on an adult male (T173) buried in a grave in the necropolis 'Isolato 96', Messina, Sicily, dating back to the Roman Empire (1st century BC - 1st century AD). The skull reveals two perimortem traumatic lesions, one produced by a sharp object on the right parietal bone and the other one on the left parietal bone, presumably the result of a fall. The interpretation of fracture patterns found in this cranium are an illustration of how forensic approaches can be applied with great benefit to archaeological specimens.

Genetic deletion of uncoupling protein 3 exaggerates apoptotic cell death in the ischemic heart leading to heart failure.

BACKGROUND: Uncoupling protein 3 (ucp3) is a member of the mitochondrial anion carrier superfamily of proteins uncoupling mitochondrial respiration. In this study, we investigated the effects of ucp3 genetic deletion on mitochondrial function and cell survival under low oxygen conditions in vitro and in vivo. METHODS AND RESULTS: To test the effects of ucp3 deletion in vitro, murine embryonic fibroblasts and adult cardiomyocytes were isolated from wild-type (WT, n=67) and ucp3 knockout mice (ucp3(-/-), n=70). To test the effects of ucp3 genetic deletion in vivo, myocardial infarction (MI) was induced by permanent coronary artery ligation in WT and ucp3(-/-) mice. Compared with WT, ucp3(-/-) murine embryonic fibroblasts and cardiomyocytes exhibited mitochondrial dysfunction and increased mitochondrial reactive oxygen species generation and apoptotic cell death under hypoxic conditions in vitro (terminal deoxynucleotidyl transferase-dUTP nick end labeling-positive nuclei: WT hypoxia, 70.3 ± 1.2%; ucp3(-/-) hypoxia, 85.3 ± 0.9%; P<0.05). After MI, despite similar areas at risk in the 2 groups, ucp3(-/-) hearts demonstrated a significantly larger infarct size compared with WT (infarct area/area at risk: WT, 48.2 ± 3.7%; ucp3(-/-), 65.0 ± 2.9%; P<0.05). Eight weeks after MI, cardiac function was significantly decreased in ucp3(-/-) mice compared with WT (fractional shortening: WT MI, 42.7 ± 3.1%; ucp3(-/-) MI, 24.4 ± 2.9; P<0.05), and this was associated with heightened apoptotic cell death (terminal deoxynucleotidyl transferase-dUTP nick end labeling-positive nuclei: WT MI, 0.7 ± 0.04%; ucp3(-/-) MI, 1.1 ± 0.09%, P<0.05). CONCLUSIONS: Our data indicate that ucp3 levels regulate reactive oxygen species levels and cell survival during hypoxia, modulating infarct size in the ischemic heart.

Physical activity after total joint arthroplasty.

CONTEXT: Total joint arthroplasty (TJA) is a common surgical option to treat painful degenerative joint disease. However, there is currently no consensus on the appropriate intensity of physical activity after TJA or how physical activity level affects the rate of revision surgery. MATERIALS AND METHODS: A systematic review of the literature regarding physical or athletic activity after TJA was performed to determine current clinical opinion and recommendations regarding appropriate activity levels after TJA, as well as variables affecting successful surgery and improved outcomes. RESULTS: Many studies in the literature regarding athletic activity after TJA focus on total hip arthroplasty and total knee arthroplasty. The literature reports contradictory results regarding rates of physical activity after TJA as well as the relationship between physical activity and rates of revision surgery. The current trend in expert opinion shows more liberal recommendations for patients to engage in athletic activity after TJA. CONCLUSIONS: Individual characteristics, lifestyle, and patient preferences must be taken into account when one considers appropriate recommendations for athletic activity after TJA. Current trends in clinical opinion favor a higher level of athletic activity after TJA, but clinicians should caution patients not to participate in contact sports or sports that create high joint loads in the replaced joint.