Digital Microscopy Augmented by Artificial Intelligence to Interpret Bone Marrow Samples for Hematological Diseases.

Analysis of bone marrow aspirates (BMAs) is an essential step in the diagnosis of hematological disorders. This analysis is usually performed based on a visual examination of samples under a conventional optical microscope, which involves a labor-intensive process, limited by clinical experience and subject to high observer variability. In this work, we present a comprehensive digital microscopy system that enables BMA analysis for cell type counting and differentiation in an efficient and objective manner. This system not only provides an accessible and simple method to digitize, store, and analyze BMA samples remotely but is also supported by an Artificial Intelligence (AI) pipeline that accelerates the differential cell counting process and reduces interobserver variability. It has been designed to integrate AI algorithms with the daily clinical routine and can be used in any regular hospital workflow.

Evaluation of the Performance of a 3D-Printed Smartphone-Based Retinal Imaging Device as a Screening Tool for Retinal Pathology in Mozambique.

Low-income countries carry approximately 90% of the global burden of visual impairment, and up to 80% of this could be prevented or cured. However, there are only a few studies on the prevalence of retinal disease in these countries. Easier access to retinal information would allow differential diagnosis and promote strategies to improve eye health, which are currently scarce. This pilot study aims to evaluate the functionality and usability of a tele-retinography system for the detection of retinal pathology, based on a low-cost portable retinal scanner, manufactured with 3D printing and controlled by a mobile phone with an application designed ad hoc. The study was conducted at the Manhiça Rural Hospital in Mozambique. General practitioners, with no specific knowledge of ophthalmology or previous use of retinography, performed digital retinographies on 104 hospitalized patients. The retinographies were acquired in video format, uploaded to a web platform, and reviewed centrally by two ophthalmologists, analyzing the image quality and the presence of retinal lesions. In our sample there was a high proportion of exudates and hemorrhages-8% and 4%, respectively. In addition, the presence of lesions was studied in patients with known underlying risk factors for retinal disease, such as HIV, diabetes, and/or hypertension. Our tele-retinography system based on a smartphone coupled with a simple and low-cost 3D printed device is easy to use by healthcare personnel without specialized ophthalmological knowledge and could be applied for the screening and initial diagnosis of retinal pathology.

Hematic Antegrade Repriming Reduces Emboli on Cardiopulmonary Bypass: A Randomized Controlled Trial.

Particulate and gaseous microemboli (GME) are side effects of cardiac surgery that interfere with postoperative recovery by causing endothelial dysfunction and vascular blockages. GME sources during surgery are multiple, and cardiopulmonary bypass (CPB) is contributory to this embolic load. Hematic antegrade repriming (HAR) is a novel procedure that combines the benefits of repriming techniques with additional measures, by following a standardized procedure to provide a reproducible hemodilution of 300 ml. To clarify the safety of HAR in terms of embolic load delivery, a prospective and controlled study was conducted, by applying Doppler probes to the extracorporeal circuit, to determine the number and volume of GME released during CPB. A sample of 115 patients (n = 115) was considered for assessment. Both groups were managed under strict normothermia, and similar clinical conditions and protocols, receiving the same open and minimized circuit. Significant differences in GME volume delivery (control group [CG] = 0.28 ml vs. HAR = 0.08 ml; p = 0.004) and high embolic volume exposure (>1 ml) were found between the groups (CG = 30.36% vs. HAR = 4.26%; p = 0.001). The application of HAR did not represent an additional embolic risk and provided a four-fold reduction in the embolic volume delivered to the patient (coefficient, 0.24; 95% CI, 0.08-0.72; p = 0.01), which appears to enhance GME clearance of the oxygenator before CPB initiation.

Remote analysis of sputum smears for mycobacterium tuberculosis quantification using digital crowdsourcing.

Worldwide, TB is one of the top 10 causes of death and the leading cause from a single infectious agent. Although the development and roll out of Xpert MTB/RIF has recently become a major breakthrough in the field of TB diagnosis, smear microscopy remains the most widely used method for TB diagnosis, especially in low- and middle-income countries. This research tests the feasibility of a crowdsourced approach to tuberculosis image analysis. In particular, we investigated whether anonymous volunteers with no prior experience would be able to count acid-fast bacilli in digitized images of sputum smears by playing an online game. Following this approach 1790 people identified the acid-fast bacilli present in 60 digitized images, the best overall performance was obtained with a specific number of combined analysis from different players and the performance was evaluated with the F1 score, sensitivity and positive predictive value, reaching values of 0.933, 0.968 and 0.91, respectively.

Lifesaving interventions in blackout conditions using night vision technology: Come to the dark side.

BACKGROUND: During military combat operations and civilian night-time aeromedical transport, medical providers are frequently required to perform lifesaving interventions (LSIs) in low-light environments. Because definitive surgical care is often delayed until a white light environment is permissible, we sought to determine if night optical device (NOD) technology could enable surgical capabilities in blackout conditions. METHODS: Using a crossover design, six surgeons performed 11 different procedures on six swine, three in normal light conditions (LC) and 3 in blackout conditions (BC) using two-chamber NODs after familiarization with the procedures in both conditions on manikins. Successful completion and procedural times were compared between groups. RESULTS: Blackout conditions were confirmed with ambient light reading of 0.2 lux during BC versus 3962.9 lux for LC (p < 0.001). There were no significant differences in success rates for any procedure. There were no differences in operative times between BC and LC for extremity tourniquet placement, femoral artery cut-down and clamping, resuscitative thoracotomy, or percutaneous resuscitative endovascular balloon occlusion of the aorta placement. The following procedures took significantly longer in BC vs. LC: Focused Assessment with Sonography for Trauma examination (98 seconds vs. 62 seconds), peripheral IV placement (140 seconds vs. 35 seconds), intraosseous access (51 seconds vs. 26 seconds), jugular vein cut-down and access (237 seconds vs. 104 seconds), laparotomy and packing (71 seconds vs. 51 seconds), stapled splenectomy (137 seconds vs. 74 seconds), resuscitative endovascular balloon occlusion of the aorta placement via cutdown (1,008 seconds vs. 338 seconds), and cricothyroidotomy (177 seconds vs. 109 seconds) (all p < 0.05). CONCLUSION: Lifesaving interventions can be safely and effectively performed in blackout conditions using NODs, although increased difficulty with select procedure types was identified. Focused training and technological improvements to currently available devices are needed. LEVEL OF EVIDENCE: Basic science.

Minimally invasive surgery for valvular heart disease.

OPINION STATEMENT: Valvular heart disease imposes varying degrees of stress on the myocardium, which, untreated, leads to eventual ventricular dysfunction. The pathophysiologic mechanisms by which these lesions act depend not only on the affected valve, but also the degree to which they causes stenosis, regurgitation, or both. The goal of patient treatment is to identify and correct the defect before irreversible ventricular changes have occurred. Historically, the conventional surgical approach for valvular disease was via median sternotomy. Minimally invasive valve surgery (MIVS) refers to alternative surgical techniques, which avoid the trans-sternal approach. The objective is to (1) minimize surgical trauma, (2) reduce blood utilization, and (3) hasten postoperative convalesce. These goals are accomplished through the use of partial sternal, para-sternal, or thoracotomy incisions and can be adapted to robotic technologies. As with all evolving surgical techniques, the therapeutic aim of valve repair or replacement must be performed at or above the same standard of conventional surgery. Outcomes must not be sacrificed for the sake of better cosmesis. In addition, percutaneous catheter-based valvular interventions have seen rapid advances. These emerging technologies have dramatically broadened the therapeutic options, especially for an ever-increasing group of high-risk patients. As expected with all minimally invasive techniques, the major differences in the hard outcomes of mortality and major morbidity are seen in these highest risk groups. However, intermediate and low risk patients receive a tremendous benefit with regard to shortened hospital stay and quicker functional recovery. With the myriad of interventional options now available, the clinical challenge now is how best to individualize the treatment approach to a given patient providing the most durable result in order to alleviate symptoms and preserve myocardial function.

The changing face of the general surgeon: national and local trends in resident operative experience.

BACKGROUND: The authors hypothesized that the increasing use of nonoperative management, percutaneous and endoscopic intervention, minimally invasive surgery, and endovascular surgery has radically altered case mix and resident training. METHODS: A review was performed of the Nationwide Inpatient Sample and Accreditation Council for Graduate Medical Education reports from 1993 to 2007 and of local resident operative logs for 2002 to 2008. RESULTS: For all nationwide procedures, there have been major increases in percutaneous interventions, angiographic embolizations, and endovascular surgery, with corresponding sharp declines in major open biliary, aortic, colon, and trauma cases. In training programs, there have been small decreases in total case numbers but major changes in the operative case mix at the expense of traditional open surgery. A profound decline in open vascular surgery is noted. At the authors' institution, similar radical changes in the operative case mix were demonstrated. CONCLUSIONS: Nationwide trends toward the increased use of nonoperative, minimally invasive, endoscopic, and endovascular techniques are altering the operative experience of surgeons and residents in training. This may radically change the abilities and expectations for the field of general surgery and what it means to be a "general surgeon."

A comparison of open versus closed techniques using the Harmonic Scalpel in outpatient hemorrhoid surgery.

BACKGROUND: Surgical excision using the Harmonic Scalpel is a modern technique for symptomatic third- and fourth-degree hemorrhoids. The resulting mucosal defect is then left open or sutured closed depending on surgeon preference. PURPOSE: The purpose of this study was to compare the open vs. closed techniques of hemorrhoid excision using the Harmonic Scalpel in an outpatient setting. METHODS: From July 2000 through October 2001, 42 patients underwent surgical excision of complex grade III or grade IV hemorrhoids via the Harmonic Scalpel with closure of the overlying mucosa (closed), and without closure of the overlying mucosa (open). Quality of life was assessed using the Short Form-36 survey. RESULTS: Both groups were comparable in terms of patient demographics and type of anesthesia. There were no late complications. Mean follow-up was 16.9 (range, 12-27) months. CONCLUSION: Leaving the mucosal defect open following Harmonic Scalpel hemorrhoidectomy significantly reduces operative time, and thus operative costs, without diminishing quality of life. Although morbidity was equivalent, this requires further evaluation with a prospective study to ensure patient safety.

Post-bariatric panniculectomy: pre-panniculectomy body mass index impacts the complication profile.

BACKGROUND: Morbid obesity continues to increase in the United States, which accounts for the increase in bariatric procedures performed. After these patients experience massive weight loss, many are left with a redundant pannus that poses physical limitations and psychosocial disturbances. An increasing proportion of bariatric patients are returning for body-contouring procedures. METHODS: This is a retrospective cohort study set in a tertiary care center. We evaluated 126 post-bariatric panniculectomies performed over a 3-year period. Perioperative and postoperative data were collected through chart review. Descriptive and inferential analyses were performed using SPSS 11.0. RESULTS: Ninety-six percent of patients were female. Mean age of the population was 42 (+/-12). The average post-bariatric weight loss and pre-panniculectomy weight were 53 (+/-16) kg and 78 (+/-14) kg, respectively. Complication rates were as follows: seroma 17%, hematoma 13%, surgical site infection (SSI) 17%, transfusion 6%, skin breakdown/necrosis 11%, and re-exploration 11%. Forty percent of patients experienced a complication. Using multivariate logistic regression, we evaluated age, pre-panniculectomy body mass index (BMI), American Society of Anesthesiologists (ASA) class, specimen weight, and operative duration; only pre-panniculectomy BMI was an independent predictor for developing a postoperative complication (odds ratio 3.3, confidence interval 1.2 to 8.4, P < .01). CONCLUSIONS: Post-bariatric patients who have sustained significant weight loss report subjective improvement after panniculectomy. Even though this population has experienced significant weight loss, they are still at an increased risk for postoperative complications. Maximal reduction in BMI should be stressed to these patients in order to reduce their risk of complications following panniculectomy.

Trauma team activation: simplified criteria safely reduces overtriage.

BACKGROUND: Our current trauma triage system uses patient and scene variables within a 3-tiered trauma response system. Our purpose was to evaluate the accuracy of the current system and to identify the most reliable variables for trauma triage. METHODS: This was a retrospective review at a level II trauma center. Multivariate logistic regression was used to identify independent predictors of the need for any urgent emergency department procedure or operative intervention. The current triage system was analyzed and compared with a proposed simplified system. RESULTS: There were 1495 consecutive trauma admissions identified, the majority (88%) were blunt mechanism. Urgent emergency department interventions were required in 11%, and 4% required emergent surgery. Logistic regression demonstrated that prehospital Glasgow Coma Score <14 (odds ratio [OR] 9.7), hypotension (OR 3.3), altered respiratory effort (OR 4.6), and penetrating truncal injury (OR 10.8) independently predicted the need for urgent intervention (all P < .01). The current system undertriaged only 1% but overtriaged 51% of patients. A simplified triage system using these 4 variables significantly decreased overtriage and reliably identified patients with severe injury. CONCLUSIONS: A simplified triage system using only highly predictive variables can safely decrease the high rate of overtriage of trauma patients.

Renal artery stenting slows the rate of renal function decline.

OBJECTIVE: The primary objective of this study was to analyze renal artery interventions performed at a tertiary medical center and to evaluate improvements in hypertension and renal excretory function. METHODS: A retrospective analysis was performed of patients treated at a tertiary medical center from January 2001 to December 2005. All patients treated with renal artery stenting by the Interventional Radiology or Endovascular Services were included. Descriptive and inferential analyses were performed. RESULTS: Forty patients with renal artery stenosis were evaluated for renal artery stenting, of these 22 were followed up with medical management. Twenty-six renal artery stents were placed in 18 patients (mean age, 70 +/- 8 years), of whom 76% were treated for multidrug resistant hypertension, and 24% were treated for renal salvage. Mean follow-up was 15 months. Patients experienced a significant reduction in hypertension and in the number of antihypertensive agents, but this significance deteriorated at 6 months, when their blood pressure and number of medications returned to preprocedural values. Compared with a cohort that was followed up with medical management, the rate of renal function decline improved from -0.08 mg/dL per month to 0.00 mg/dL per month (P < .05) after intervention. Patients with baseline chronic renal insufficiency experienced the greatest benefit from renal artery stenting. CONCLUSIONS: Renal artery stenting initially improves hypertension control, but the durability is lost after 6 months. Renal artery stenting dramatically slows the rate of renal function decline and could potentially delay a patient's requirement for hemodialysis.

Intestinal fatty acid binding protein (I-FABP) for the detection of strangulated mechanical small bowel obstruction.

OBJECTIVE: Intestinal fatty acid binding protein (I-FABP), a protein released by necrotic enterocytes, is a useful marker for the detection of ischemia from mechanical small bowel obstruction. DESIGN: Validation cohort. SETTING: Academic medical center. PARTICIPANTS: Cohort of 21 patients admitted with a clinical diagnosis of mechanical small bowel obstruction. Plasma and urine samples were collected from patients upon hospital admission and again immediately before laparotomy if surgical intervention was delayed. RESULTS: Plasma and urine I-FABP levels (pg/ml by enzyme-linked immunosorbent assay) in patients found to have small bowel necrosis at the time of laparotomy were compared with those without significant ischemia upon laparotomy and those that did not require laparotomy and, by default, did not have small bowel ischemia. A positive test was defined as 1000-pg/ml I-FABP in urine and 100-pg/ml I-FABP in plasma. Small bowel necrosis was confirmed in 3 of 21 enrolled patients. Urine I-FABP levels were positive in 3 of 3 patients with necrosis and 3 of 18 patients without necrosis (sensitivity 100%, specificity 83%, PPV 50%, NPV 100%). Plasma I-FABP levels were positive in 3 of 3 patients with necrosis and 4 of 18 patients without necrosis (sensitivity 100%, specificity 78%, PPV 43%, NPV 100%). CONCLUSIONS: I-FABP is a sensitive marker for ischemia in mechanical small bowel obstruction. Additional work should be done to validate I-FABP in a variety of clinical settings and to develop a rapid I-FABP laboratory assay.

The impact of hypothermia on trauma care at the 31st combat support hospital.

BACKGROUND: The primary objective of this study was to review the incidence of hypothermia, and its effect on surgical management, resource utilization, and survival at the 31st Combat Support Hospital (CSH). METHODS: This study was a retrospective analysis of all combat trauma injuries treated at the 31st CSH over a 12-month period. All trauma admissions were included. Descriptive and inferential analysis were performed using SPSS 11.0 software package (SPSS Inc., Chicago, IL). RESULTS: A cohort of 2848 patients was identified; 18% were hypothermic (temperature < 36 degrees C). Hypothermia was significantly (P < .05) correlated with admission Glasgow Coma Scale (GCS), tachycardia, hypotension, lower hematocrit, and acidosis. Hypothermic patients had a significantly higher blood product and factor VIIa requirement. Hypothermia was an independent predictor of operative management of injuries, damage control laparotomy, factor VIIa use, and overall mortality (P < .05). CONCLUSION: Combat trauma patients have a high percentage of penetrating injuries with variable evacuation times. Hypothermia was a pre-hospital physiologic marker, and independent contributor to overall mortality. Prevention of hypothermia could reduce resource utilization and improve survival in the combat setting.

Focused high-risk population screening for carotid arterial stenosis after radiation therapy for head and neck cancer.

BACKGROUND: Cervical radiation for head and neck cancer has been associated with an increased incidence of carotid arterial stenosis. Modern radiation therapy delivers higher doses with increasing long-term survival. Accordingly, the prevalence of radiation-associated carotid stenosis may be higher than previously reported. Phase I of this prospective study was to establish the prevalence of carotid artery stenosis after high-dose cervical radiation. METHODS: From a prospectively maintained database, we identified patients who had received cervical high-dose radiotherapy (minimum 5,500 cGy). All patients were screened with bilateral carotid arterial duplex ultrasonography. We defined disease as "normal or mild" if the carotid stenosis was <50%, and "significant" if >50%. The relationship between standard demographic risk factors and screening outcomes was then analyzed. RESULTS: Screening was performed in 40 patients (mean age 68.2 years, range 26 to 87). Patients received a mean cumulative radiation dose of 6,420 cGy (range 5,500 to 7,680), with a mean duration of 10.2 years since their last radiation treatment. Sixteen patients (40%) had significant carotid artery stenosis. Patients with and without significant stenosis were comparable in terms of age, radiation dose, tobacco use, comorbidities, and postradiation interval (P = not significant). Six patients (15%) had unilateral complete carotid occlusion and 6 patients (15%) had significant bilateral carotid stenosis. Three patients (7.5%) had sustained a previous stroke after radiation therapy. CONCLUSIONS: The prevalence of carotid arterial disease in patients with prior cervical radiation therapy is clinically significant and warrants aggressive screening as part of routine preradiation and postradiation care. Focused screening of this high-risk population may be cost effective and medically beneficial in terms of risk factor modification and stroke prevention, and will be examined in phase II of this study.

Secondary operations are frequently required to complete the surgical phase of therapy in the era of breast conservation and sentinel lymph node biopsy.

BACKGROUND: Breast conservation therapy (BCT) is an oncologically equivalent and cosmetically preferable alternative to mastectomy for most early-stage breast cancers. The number of operations required to complete the surgical phase of therapy with BCT has not been widely reported. METHODS: From our institutional tumor registry, we reviewed the records of all patients receiving primary surgical therapy for breast cancer from January 1, 1998, to June 30, 2002. There were 204 patients with 210 breast cancers in the cohort. These cancers were initially managed with either BCT (n = 150) or mastectomy (modified radical mastectomy or total mastectomy with sentinel lymph node biopsy) (n = 60). We compared the percentages of patients in each group who required additional surgeries to obtain clear margins, manage axillary disease, or otherwise complete the surgical phase of therapy. Patients with secondary surgery related to long-term local recurrence were excluded. RESULTS: Fifty-one percent of patients initially managed with BCT required additional surgery compared with 12% in the mastectomy group (P <0.05). Factors independently associated with multiple surgeries among all patients included management with BCT (odds ratio [OR] 5.4, P = 0.01) and positive margins at initial excision (OR 4.7, P <0.01). Significant independent predictors of positive margins included BCT (OR 11.9, P <0.01); disease stage (OR 6.7, P <0.01); submission of supplemental margins in addition to the main specimen (OR 2.8, P = 0.03); and positive nodes (OR 1.1, P = 0.04). Breast conservation was ultimately successful in 95% of patients who underwent BCT. CONCLUSIONS: Patients undergoing BCT may require multiple surgeries to reconcile successful breast conservation with sound oncologic resection.

A case-match analysis of failed prior bariatric procedures converted to resectional gastric bypass.

BACKGROUND: Failure to lose weight or intractable symptoms after bariatric surgery presents a complex diagnostic and management challenge. The outcome of a standardized surgical approach to this problem has not been well described. Conversion of failed bariatric procedures to a resectional gastric bypass (RGB) can achieve symptomatic relief and acceptable weight loss. METHODS: We reviewed all patients in a prospectively maintained database who underwent reoperative bariatric surgery over a 4-year period. Reoperative patients (RO) were case-matched (by age, body mass index, and comorbidities) in a 1:2 ratio with control patients undergoing an initial bariatric procedure (IN). RESULTS: Twenty-seven reoperative patients and 54 case-matched control patients were identified. Mean body mass index was 42 in the RO group versus 45 in the IN group (P = not significant). Indications for conversion were weight gain (89%), dysphagia/emesis (30%), esophagitis (19%), and marginal ulcer (7%). All patients in both groups underwent RGB (subtotal gastrectomy with Roux-Y gastrojejunostomy). Compared with IN patients, the RO patients had significantly longer operative times (420 versus 268 minutes), greater blood loss (650 versus 315 cc), longer time to oral intake (3.1 versus 2.2 days), and longer hospital stays (6.5 versus 4.7 days), all P <0.01. There were no deaths or anastomotic leaks in either group. Excess body weight lost at 6 months was 46% for RO versus 54% for IN (P = 0.02). One-year excess weight lost was 71% for RO versus 77% for IN (P = not significant). All RO patients achieved symptomatic relief, and no patient required further bariatric revision. There was significant improvement in weight-related comorbidity in each group. CONCLUSIONS: Conversion of failed bariatric procedures to RGB, although technically demanding, resulted in relief of presenting symptoms, significant 6-month and 1-year weight loss, and improvement of major comorbidities. Conversion of failed bariatric procedures to resectional gastric bypass can achieve results comparable with those of patients undergoing an initial bariatric procedure.