A Spatiotemporal Deep Learning Framework for Scalp EEG-Based Automated Pain Assessment in Children.

OBJECTIVE: Common pain assessment approaches such as self-evaluation and observation scales are inappropriate for children as they require patients to have reasonable communication ability. Subjective, inconsistent, and discontinuous pain assessment in children may reduce therapeutic effectiveness and thus affect their later life. METHODS: To address the need for suitable assessment measures, this paper proposes a spatiotemporal deep learning framework for scalp electroencephalogram (EEG)-based automated pain assessment in children. The dataset comprises scalp EEG data recorded from 33 pediatric patients with an arterial puncture as a pain stimulus. Two electrode reduction plans in line with clinical findings are proposed. Combining three-dimensional hand-crafted features and preprocessed raw signals, the proposed transformer-based pain assessment network (STPA-Net) integrates both spatial and temporal information. RESULTS: STPA-Net achieves superior performance with a subject-independent accuracy of 87.83% for pain recognition, and outperforms other state-of-the-art approaches. The effectiveness of electrode combinations is explored to analyze pain-related cortical activities and correspondingly reduce cost. The two proposed electrode reduction plans both demonstrate competitive pain assessment performance qualitatively and quantitatively. CONCLUSION AND SIGNIFICANCE: This study is the first to develop a scalp EEG-based automated pain assessment for children adopting a method that is objective, standardized, and consistent. The findings provide a potential reference for future clinical research.

Video-Based Neonatal Pain Assessment in Uncontrolled Conditions.

OBJECTIVE: Neonatal pain can have long-term adverse effects on newborns' cognitive and neurological development. Video-based Neonatal Pain Assessment (NPA) method has gained increasing attention due to its performance and practicality. However, existing methods focus on assessment under controlled environments while ignoring real-life disturbances present in uncontrolled conditions. METHODS: We propose a video-based NPA method, which is robust to four real-life disturbances and adaptively highlights keyframes. Our method involves a region-channel-attention module for extracting facial features under the disturbances of facial occlusion and pose variation; a body language analysis module robust to disturbances from body occlusion and movement interference, which utilizes skeleton sequences to represent the neonate's body; and a keyframes-aware convolution to get rid of information located at non-contributing moments. For evaluation, we built an NPA video dataset of 1091 neonates with disturbance annotations. RESULTS: The results show that our method consistently outperforms state-of-the-art methods on the full dataset and nine subsets, where it achieves an accuracy of 91.04% on the full dataset with an accuracy increment of 6.27%. Contributions: We present the problem of video-based NPA under uncontrolled conditions, propose a method robust to four disturbances, and construct a video NPA dataset, thus facilitating the practical applications of NPA.

Pose-invariant and occlusion-robust neonatal facial pain assessment.

Neonatal Facial Pain Assessment (NFPA) is essential to improve neonatal pain management. Pose variation and occlusion, which can significantly alter the facial appearance, are two major and still unstudied barriers to NFPA. We bridge this gap in terms of method and dataset. Techniques to tackle both challenges in other tasks either expect pose/occlusion-invariant deep learning methods or first generate a normal version of the input image before feature extraction, combining these we argue that it is more effective to jointly perform adversarial learning and end-to-end classification for their mutual benefit. To this end, we propose a Pose-invariant Occlusion-robust Pain Assessment (POPA) framework, with two novelties. We incorporate adversarial learning-based disturbance mitigation for end-to-end pain-level classification and propose a novel composite loss function for facial representation learning; compared to the vanilla discriminator that implicitly determines occlusion and pose conditions, we propose a multi-scale discriminator that determines explicitly, while incorporating local discriminators to enhance the discrimination of key regions. For a comprehensive evaluation, we built the first neonatal pain dataset with disturbance annotation involving 1091 neonates and also applied the proposed POPA to the facial expression recognition task. Extensive qualitative and quantitative experiments prove the superiority of the POPA.

A Wearable Multi-Segment Upper Limb Tremor Assessment System for Differential Diagnosis of Parkinson's Disease Versus Essential Tremor.

Upper limb tremor is a prominent symptom of both Parkinson's disease and essential tremor. Its kinematic parameters overlap substantially for these two pathological conditions, thus leading to high rate of misdiagnosis, especially for community doctors. Several groups have proposed various methods for improving differential diagnosis. These prior studies have attempted to identify better kinematic parameters, however they have mainly focused on single limb features including tremor intensity, tremor frequency, and tremor variability. In this paper, we propose a wearable system for multi-segment assessment of upper limb tremor and differential diagnosis of Parkinson's disease versus essential tremor. The proposed system collected tremor data from both wrist and fingers simultaneously. From this data, we extracted multi-segment features in the form of phase relationships between limb segments. Using support vector machine classifiers, we then performed differential diagnosis from the extracted features. We evaluated the performance of the proposed system on 19 Parkinson's disease patients and 12 essential tremor patients. Moreover, we also assessed the performance cost associated with reducing task load and sensor array size. The proposed system reached perfect accuracy in leave-one-out cross validation. Task reduction and sensor array reduction were associated with penalties of 2% and 9-10% respectively. The results demonstrated that the proposed system could be simplified for clinical applications, and successfully applied to the differential diagnosis of Parkinson's disease versus essential tremor in real-world setting.

Video-Based versus On-Site Neonatal Pain Assessment in Neonatal Intensive Care Units: The Impact of Video-Based Neonatal Pain Assessment in Real-World Scenario on Pain Diagnosis and Its Artificial Intelligence Application.

BACKGROUND: Neonatal pain assessment (NPA) represents a huge global problem of essential importance, as a timely and accurate assessment of neonatal pain is indispensable for implementing pain management. PURPOSE: To investigate the consistency of pain scores derived through video-based NPA (VB-NPA) and on-site NPA (OS-NPA), providing the scientific foundation and feasibility of adopting VB-NPA results in a real-world scenario as the gold standard for neonatal pain in clinical studies and labels for artificial intelligence (AI)-based NPA (AI-NPA) applications. SETTING: A total of 598 neonates were recruited from a pediatric hospital in China. METHODS: This observational study recorded 598 neonates who underwent one of 10 painful procedures, including arterial blood sampling, heel blood sampling, fingertip blood sampling, intravenous injection, subcutaneous injection, peripheral intravenous cannulation, nasopharyngeal suctioning, retention enema, adhesive removal, and wound dressing. Two experienced nurses performed OS-NPA and VB-NPA at a 10-day interval through double-blind scoring using the Neonatal Infant Pain Scale to evaluate the pain level of the neonates. Intra-rater and inter-rater reliability were calculated and analyzed, and a paired samples t-test was used to explore the bias and consistency of the assessors' pain scores derived through OS-NPA and VB-NPA. The impact of different label sources was evaluated using three state-of-the-art AI methods trained with labels given by OS-NPA and VB-NPA, respectively. RESULTS: The intra-rater reliability of the same assessor was 0.976-0.983 across different times, as measured by the intraclass correlation coefficient. The inter-rater reliability was 0.983 for single measures and 0.992 for average measures. No significant differences were observed between the OS-NPA scores and the assessment of an independent VB-NPA assessor. The different label sources only caused a limited accuracy loss of 0.022-0.044 for the three AI methods. CONCLUSION: VB-NPA in a real-world scenario is an effective way to assess neonatal pain due to its high intra-rater and inter-rater reliability compared to OS-NPA and could be used for the labeling of large-scale NPA video databases for clinical studies and AI training.

Economic Burden of Cervical and Head and Neck Cancer in Taiwan from a Societal Perspective.

BACKGROUND: Head and neck cancers (HNC) are increasingly recognized as important human papillomavirus (HPV)-related malignancies in addition to cervical cancer (CC). However, data on the socioeconomic impact of HNC and CC in Taiwan are limited. METHODS: A retrospective cohort study was conducted to estimate the total direct medical cost and indirect productivity loss from CC and HNC between 2014 and 2015. Patient data from the Taiwan National Cancer Registry were analyzed, with matched non-cancer controls from the Taiwan National Healthcare Reimbursement Database. Indirect costs due to premature deaths were calculated using public data from Taiwanese government reports. RESULTS: In the direct cost analysis, 2083 patients with newly diagnosed CC and 11,078 with newly diagnosed HNC (10,036 males) were identified between 2014 and 2015 and followed up through the end of 2016 or until death. The total direct medical costs incurred in 2014 and 2015 due to HNC were 11.54 times higher in males than in females, and 4.55 times higher than CC. Indirect cost analysis showed the total annual productivity loss was New Taiwan Dollar (NTD) $12 billion in 2019, and 79.99% was attributed to male HNC. CONCLUSION: In Taiwan, the socioeconomic burden associated with male HNC is high and greater than that seen with CC. While not all HNCs are attributable to HPV infection, prevention of HNC through HPV vaccination should be considered for both sexes.

Artificial Intelligence Based Pain Assessment Technology in Clinical Application of Real-World Neonatal Blood Sampling.

Background: Accurate neonatal pain assessment (NPA) is the key to neonatal pain management, yet it is a challenging task for medical staff. This study aimed to analyze the clinical practicability of the artificial intelligence based NPA (AI-NPA) tool for real-world blood sampling. Method: We performed a prospective study to analyze the consistency of the NPA results given by a self-developed automated NPA system and nurses' on-site NPAs (OS-NPAs) for 232 newborns during blood sampling in neonatal wards, where the neonatal infant pain scale (NIPS) was used for evaluation. Spearman correlation analysis and the degree of agreement of the pain score and pain grade derived by the NIPS were applied for statistical analysis. Results: Taking the OS-NPA results as the gold standard, the accuracies of the NIPS pain score and pain grade given by the automated NPA system were 88.79% and 95.25%, with kappa values of 0.92 and 0.90 (p < 0.001), respectively. Conclusion: The results of the automated NPA system for real-world neonatal blood sampling are highly consistent with the results of the OS-NPA. Considering the great advantages of automated NPA systems in repeatability, efficiency, and cost, it is worth popularizing the AI technique in NPA for precise and efficient neonatal pain management.

Assessment of the appearance, location and morphology of mandibular lingual foramina using cone beam computed tomography.

OBJECTIVES: To investigate the appearance, location and morphology of mandibular lingual foramina (MLF) in the Chinese Han population using cone beam computed tomography (CBCT). METHODS: CBCT images of the mandibular body in 200 patients (103 female patients and 97 male patients, age range 10-70 years) were retrospectively analysed to identify MLF. The canal number, location and direction were assessed. Additionally, the diameter of the lingual foramen, the distance between the alveolar crest and the lingual foramen, the distance between the tooth apex and the lingual foramen and the distance from the mandibular border to the lingual foramen were examined to describe the MLF characteristics. Gender and age differences with respect to foramina were also studied. RESULTS: CBCT can be utilized to visualise lingual foramina. In this study, 683 lingual foramina were detected in 200 CBCT scans, with 538 (78.77%) being ≤1 mm in diameter and 145 (21.23%) being >1 mm. In total, 85.07% of MLF are median lingual canals (MLC) and 14.93% are lateral lingual canals (LLC). Two typical types of lingual foramina were identified according to their relationship with the tooth apex. Most lingual foramina (74.08%) were found below the tooth apex, and those above the tooth apex were much smaller in diameter. Male patients had statistically larger lingual foramina. The distance between the lingual foramen and the tooth apex changed with increasing age. CONCLUSIONS: Determination of the presence, position and size of lingual foramina is important before performing a surgical procedure. Careful implant-prosthetic treatment planning is particularly important in male and/or elderly patients because of the structural characteristics of their lingual foramina.

Dioxin distribution characteristics and health risk assessment in different size particles of fly ash from MSWIs in China.

During the process of treating and recycling Municipal Solid Waste Incinerators (MSWIs) fly ash, polychlorinated dibenzo-p-dioxins (PCDD/Fs) and polychlorinated dibenzofurans (dl-PCBs) in fly ash may potentially mobilize in the atmosphere and be widely distributed in the environment because of the inevitable re-suspension. Thus, this work presents the distributions of PCDD/Fs and dl-PCBs in inhalable coarse particles (Dp10-2.5 (particle diameter in µm)), fine particles (Dp<2.5) of fly ash and original fly ash from four MSWI plants in China. The results show that PCDD/Fs and dl-PCBs preferentially concentrated in Dp10-2.5 and Dp<2.5. Their mass concentrations and TEQ were significantly higher than those in the original fly ash, but the distribution of PCDD/Fs congeners in Dp10-2.5 and Dp<2.5 was close to that in the original fly ash. The main TEQ contribution included 1,2,3,7,8-PeCDD, 2,3,7,8-TeCDD in PCDDs and 2,3,4,7,8-PeCDF in PCDFs for Dp10-2.5, Dp<2.5 fractions and the original fly ash. Furthermore, the mass and TEQ contribution of dl-PCBs was relatively low. In addition, compared with the fluidized bed, the samples from the grate-type furnaces had significantly lower dioxin concentrations. In terms of potential health risk, the non-carcinogenic risk of PCDD/Fs in Dp10-2.5 and Dp<2.5 were estimated at 9.87 × 10(-1) to 4.81 and 1.19-7.95. For the carcinogenic risk of PCDD/Fs, both accumulation of Hazard Quotients (HQ) in Dp10-2.5 and Dp<2.5 exceeded the threshold limit and should be considered as unacceptable risk for onsite workers. The above findings could provide data to support the risk management of MSWI fly ash during the process of recycle and disposal.

Risk assessment of manufacturing equipment surfaces contaminated with DDTs and dicofol.

Decommissioning of manufacturing plant in the chemical industry includes inspection of the surfaces of production equipment for potential contamination and associated health risks. In the present study wipe-samples were taken from the surfaces of dicofol manufacturing equipment at a chemical factory in north China and analyzed for chemicals of concern (COCs). Occupational hygiene assessment was conducted to assess the risks to demolition workers and health risk assessment was performed to evaluate the risks to demolition and general industrial workers. The concentrations of COCs on the equipment surfaces were found to be 0.54-3.75 × 10(4)mg DDTs m(-2) and 0.15-4.38 × 10(3)mg dicofolm(-2). The average concentration of p,p'-DDT does not represent an unacceptable risk to the demolition workers using occupational hygiene assessment. Under the industrial scenario the carcinogenic risks of COCs ranged from 2.28 × 10(-7) to 1.79 × 10(-2) for p,p'-DDT, 6.18 × 10(-7) to 3.04 × 10(-3) for p,p'-DDD and 1.89 × 10(-6) to 0.16 for p,p'-DDE. The non-carcinogenic hazard indices ranged from 3.86 × 10(-3) to 3.03 × 10(2) for p,p'-DDT and 1.16 × 10(-3) to 33.94 for dicofol. Both carcinogenic risk and hazard index of COCs under the industrial scenario were higher than under the demolition scenario. Oral ingestion and dermal contact were the major pathways and accounted for >88% of the total exposure of COCs. Parameter sensitivity analysis shows that equipment surface concentration (Cs), frequency of contact with surface (EV), fraction of dust transferred from surface to skin (FTss) and exposure frequency (EF) were the most sensitive parameters and these should be acquired on a site-specific basis. The accuracy of the risk assessment was controlled largely by the variation in the sensitive parameters and the uncertainty of the exposure model for the inhalation pathway.

Chemical characteristics and risk assessment of typical municipal solid waste incineration (MSWI) fly ash in China.

The release of heavy metals in municipal solid waste incineration (MSWI) fly ash has become a worrying issue while fly ash is utilized or landfilled. This work investigated the potential mobility of heavy metals in the fly ashes from 15 typical MSWI plants in Chinese mainland by the characterization of distribution, chemical speciation and leaching behavior of heavy metals. The results showed that total content of heavy metals decreased in the order Zn>Pb>Cu>Cr>Ni>Cd in samples. The toxicity characteristics leaching procedure (TCLP) of fly ash indicated that the amount of leached Cd in 67% of samples exceeded the regulated limit. Also, the excess amount of leached Zn and Pb was observed in 40% and 53% of samples, respectively. The chemical speciation analysis revealed that this excess of heavy metal leached in TCLP was contributed to the high content of acid soluble fraction (F1) and reducible fraction (F2) of heavy metal. Moreover, the great positive relevance between leaching behavior of heavy metals and F1 fraction was supported by principal component analysis (PCA). Risk assessment code (RAC) results suggested that Cd and Pb showed a very high risk class to the environment.

64-Slice spiral CT perfusion combined with vascular imaging of acute ischemic stroke for assessment of infarct core and penumbra.

The aim of this study was to determine the value of computed tomography perfusion (CTP) parameters, including cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT) and time-to-peak (TP), in a clinical study of patients with stroke. Additionally, we determined which parameter or combination of parameters are reliable in detecting the presence of an infarct and penumbra. CTP was performed within 24 h of the onset of symptoms in 20 patients with possible stroke. Magnetic resonance imaging (MRI) was performed 3-7 days later and the threshold of the CTP was adjusted according to the results to provide CT images that correlated with the MRI; the MRI results were taken as the gold standard. CBV, CBF and TP contrast agent enhancement were calculated using the CT results. The CTP results were compared with the MRI findings. All CTP parameters were reliable in detecting the penumbra (P<0.001). In these parameters, changes of MTT were the most useful. CTP revealed various changes in CBF, CBV, MTT and TP in ischemic areas. CTP parameters were also reliable in detecting the infarct core (P<0.001). We determined that when detecting the penumbra, all CTP parameters are reliable, and when detecting cerebral ischemia, a combination of parameters should be used.

LoColms: an innovative approach of enhancing traditional classroom form of education by promoting web-based distance learning in the poorer countries.

There have been numerous attempts recently to promote technology based education (Shrestha, 1997) in the poorer third world countries, but so far all these have not provided a sustainable solution as they are either centered and controlled from abroad and relying solely on foreign donors for their sustenance or they are not web-based, which make distribution problematic, and some are not affordable by most of the local population in these places. In this paper we discuss an application, the Local College Learning Management System (LoColms), which we are developing, that is both sustainable and economical to suit the situation in these countries. The application is a web-based system, and aims at improving the traditional form of education by empowering the local universities. Its economy comes from the fact that it is supported by traditional communication technology, the public switching telephone network system, PSTN, which eliminates the need for packet switched or dedicated private virtual networks (PVN) usually required in similar situations. At a later stage, we shall incorporate ontology and paging tools to improve resource sharing and storage optimization in the Proxy Caches (ProCa) and LoColms servers. The system is based on the client/server paradigm and its infrastructure consists of the PSTN, ProCa, with the learning centers accessing the universities by means of point-to-point protocol (PPP).