Detection of Moderate Hepatic Steatosis on Portal Venous Phase Contrast-Enhanced CT: Evaluation Using an Automated Artificial Intelligence Tool.

BACKGROUND. Precontrast CT is an established means of evaluating for hepatic steatosis; postcontrast CT has historically been limited for this purpose. OBJECTIVE. The purpose of this study was to evaluate the diagnostic performance of portal venous phase postcontrast CT in detecting at least moderate hepatic steatosis using liver and spleen attenuation measurements determined by an automated artificial intelligence (AI) tool. METHODS. This retrospective study included 2917 patients (1381 men, 1536 women; mean age, 56.8 years) who underwent a CT examination that included at least two series through the liver. Examinations were obtained from an AI vendor's data lake of data from 24 centers in one U.S. health care network and 29 centers in one Israeli health care network. An automated deep learning tool extracted liver and spleen attenuation measurements. The reference for at least moderate steatosis was precontrast liver attenuation of less than 40 HU (i.e., estimated liver fat > 15%). A radiologist manually reviewed examinations with outlier AI results to confirm portal venous timing and identify issues impacting attenuation measurements. RESULTS. After outlier review, analysis included 2777 patients with portal venous phase images. Prevalence of at least moderate steatosis was 13.9% (387/2777). Patients without and with at least moderate steatosis, respectively, had mean postcontrast liver attenuation of 104.5 ± 18.1 (SD) HU and 67.1 ± 18.6 HU (p < .001); a mean difference in postcontrast attenuation between the liver and the spleen (hereafter, postcontrast liver-spleen attenuation difference) of -7.6 ± 16.4 (SD) HU and -31.8 ± 20.3 HU (p < .001); and mean liver enhancement of 49.3 ± 15.9 (SD) HU versus 38.6 ± 13.6 HU (p < .001). Diagnostic performance for the detection of at least moderate steatosis was higher for postcontrast liver attenuation (AUC = 0.938) than for the postcontrast liver-spleen attenuation difference (AUC = 0.832) (p < .001). For detection of at least moderate steatosis, postcontrast liver attenuation had sensitivity and specificity of 77.8% and 93.2%, respectively, at less than 80 HU and 90.5% and 78.4%, respectively, at less than 90 HU; the postcontrast liver-spleen attenuation difference had sensitivity and specificity of 71.4% and 79.3%, respectively, at less than -20 HU and 87.0% and 62.1%, respectively, at less than -10 HU. CONCLUSION. Postcontrast liver attenuation outperformed the postcontrast liver-spleen attenuation difference for detecting at least moderate steatosis in a heterogeneous patient sample, as evaluated using an automated AI tool. Splenic attenuation likely is not needed to assess for at least moderate steatosis on postcontrast images. CLINICAL IMPACT. The technique could promote early detection of clinically significant nonalcoholic fatty liver disease through individualized or large-scale opportunistic evaluation.

'Witness in White' medical ethics learning tours on medicine during the Nazi era.

During the Nazi era, physicians provided expertise and a veneer of legitimacy enabling crimes against humanity. In a creative educational initiative to address current ethical dilemmas in clinical medicine, we conduct ethics learning missions bringing senior physicians to relevant Nazi era sites in either Germany or Poland. The tours share a core curriculum contextualising history and medical ethics, with variations in emphasis. Tours to Germany provide an understanding of the theoretical origins of the ethical violations and crimes of Nazi physicians. Tours to Poland address the magnitude of the Nazi physician's atrocities as well as displays of heroism by Jewish and righteous among the nations' physicians. Exemplary as well as shameful physician behaviour is analysed from an ethical perspective. A combination of unique educational methodologies maximises learning and personal growth, enabling participants to examine ethically complex clinical situations with extrapolation to modern-day medical practice. Learning is designed with relevance to contemporary medical ethics dilemmas such as beginning and end-of-life issues, providing tenets from which participants can develop as more ethical and informed physicians. Participant feedback confirms efficacy and worth of these growth-promoting ethics learning tours which should be expanded to other international groups and settings (see online film Witness in White Berlin 2019 available at https://www.youtube.com/watch?v=75VUZvo3Bec).

["WITNESS IN WHITE" SEMINAR TOURS ON MEDICINE AND PHYSICIANS IN THE HOLOCAUST].

INTRODUCTION: The Holocaust represents a seminal event in the annals of medicine. For the first time in history, doctors played a prominent role in the extreme abuse of medical rights, violation of medical obligation to patients, infringement of patient autonomy, forced and unnecessary invasive and damaging procedures for political purposes and the ultimate injustice of involuntary euthanasia. Physicians provided the legitimacy, know-how and momentum that allowed these processes to take place in a symbiotic relationship with the political establishment during the Nazi era. It is critical that modern day physicians be aware of what transpired during this period. For that purpose, we describe a multiyear program bringing Israeli physicians on a learning mission to relevant sites of medical involvement and complicity in Nazi era crimes. These guided educational tours, under the auspices of the Israel Medical Association, originally took place in Poland and more recently, alternately visit Germany and Poland. At all sites, background information on medical practice during the Nazi era is provided, as well as ethical discussions on the merits (positive) or demerits (negative) of physicians who played a role at those particular locations. In addition to site visits, background discussions and lectures are provided to achieve a more comprehensive, deeper and more profound understanding of the issues. Emphasis is placed on learning from examples with relevance to modern day medicine, thus providing the principles from which participants can grow to become more ethical, principled and sensitive physicians as well as individuals. The tour includes formal and emotional ceremonies when relevant at extermination sites where physicians were directly involved, as well as focus groups allowing and encouraging emotional expression and catharsis. The critical role of personal growth during the tour is emphasized with both pre-tour and post-tour meetings providing buffering on both ends. Participants and staff, as well as documented feedback over the years, attest to the utility and profound value of these learning and growth-oriented medical missions.

[IS IT APPROPRIATE TO CHANGE THE NAMES OF SURGICAL PROCEDURES AND EXAMINATIONS IN THE FIELD OF OBSTETRICS AND GYNECOLOGY WHICH GIVE EPONYMS DISTINCTION TO NAZI DOCTORS?]

INTRODUCTION: The majority of the German medical institutions and nearly half of the clinicians during the Nazi regime provided unwavering support to the distorted Nazi views on health and disability. Leading physicians were an integral part of the atrocities carried out during that era, with some of them having a vital role in executing the ideology of the "final solution". The names of Carl Clauberg and Walter Stoeckel, two notable doctors in the fields of obstetrics and gynecology, were also linked with the third Reich. Both of these physicians, collaborated, each in his own way, with the Nazi regime, which tainted their legacy indefinitely. The two received professional honor for their contribution to the fields of obstetrics and gynecology, which were unrelated to their Nazi past, after their names were linked in the form of eponyms to surgical procedures and examinations, which they developed. In recent years, as a consequence of their disturbing past, there are increasing arguments which call for erasing their eponyms from the medical lexicon. We, on the contrary, believe that the opposite is true and that maintaining these eponyms will actually enable teaching future generations and serve a dual educational role to both highlight professional and scientific achievements as well as serve as a mark of Cain and warning that professional achievements do not prevent ethical decline. Preserving the name will provide an educational opportunity to teach about the responsibilities that come with professional leadership, which these doctors abused carelessly, in order to prevent history from repeating itself.

A comprehensive approach to identifying repurposed drugs to treat SCN8A epilepsy.

OBJECTIVE: Many previous studies of drug repurposing have relied on literature review followed by evaluation of a limited number of candidate compounds. Here, we demonstrate the feasibility of a more comprehensive approach using high-throughput screening to identify inhibitors of a gain-of-function mutation in the SCN8A gene associated with severe pediatric epilepsy. METHODS: We developed cellular models expressing wild-type or an R1872Q mutation in the Nav 1.6 sodium channel encoded by SCN8A. Voltage clamp experiments in HEK-293 cells expressing the SCN8A R1872Q mutation demonstrated a leftward shift in sodium channel activation as well as delayed inactivation; both changes are consistent with a gain-of-function mutation. We next developed a fluorescence-based, sodium flux assay and used it to assess an extensive library of approved drugs, including a panel of antiepileptic drugs, for inhibitory activity in the mutated cell line. Lead candidates were evaluated in follow-on studies to generate concentration-response curves for inhibiting sodium influx. Select compounds of clinical interest were evaluated by electrophysiology to further characterize drug effects on wild-type and mutant sodium channel functions. RESULTS: The screen identified 90 drugs that significantly inhibited sodium influx in the R1872Q cell line. Four drugs of potential clinical interest-amitriptyline, carvedilol, nilvadipine, and carbamazepine-were further investigated and demonstrated concentration-dependent inhibition of sodium channel currents. SIGNIFICANCE: A comprehensive drug repurposing screen identified potential new candidates for the treatment of epilepsy caused by the R1872Q mutation in the SCN8A gene.

Dermal scatter reduction in human skin: a method using controlled application of glycerol.

BACKGROUND AND OBJECTIVE: Previous studies in a hairless Guinea pig model showed that transdermal application of glycerol effected a temporary reduction in dermal scatter of light. This study focuses on the application of this protocol on human patients. STUDY DESIGN/MATERIALS AND METHODS: After stratum corneal removal, glycerol was applied to human subjects using a low pressure transdermal application device. Optical coherence tomography imaging showed increased intensity of radiation reaching deeper regions in the skin and photographs showed enhanced visualization of dermal structures. RESULTS/CONCLUSION: Topically applied glycerol increased light penetration of in vivo corneal-stripped skin. This minimally invasive approach to temporary dermal scatter reduction has the potential to improve the efficacy of light-based diagnostic or therapeutic devices.

The use of the hairless guinea pig in tattoo research.

The study and optimization of tattoo removal continues to be of importance in the dermatology community. Robust animal models whose skin is physiologically similar to humans and who are easily handled are desirable. To this end, we report on our experience with the hairless guinea pig as a model for tattoo research. This research was conducted as part of a larger study toward increased efficacy of laser tattoo removal. Here we report on procedures for both placement and aftercare of tattoos which result in superior tattoo quality and retention.

A framework for a diabetes mellitus disease management system in southern Israel.

Chronic diseases are a significant burden on western healthcare systems and national economies. It has been suggested that automated disease management for chronic disease, like diabetes mellitus (DM), improves the quality of care and reduces inappropriate utilization of diagnostic and therapeutic measures. We have designed a comprehensive DM Disease Management system for the Negev region in southern Israel. This system takes advantage of currently used clinical and administrative information systems. Algorithms for DM disease management have been created based on existing and accepted Israeli guidelines. All data fields and tables in the source information systems have been analyzed, and interfaces for periodic data loads from these systems have been specified. Based on this data, four subsets of decision support algorithms have been developed. The system generates alerts in these domains to multiple end users. We plan to use the products of this information system analysis and disease management specification in the actual development process of such a system shortly.

Voice recognition is here comma like it or not period.

Voice recognition (VR) technology needs improvement, but is as integral to the current practice of radiology as Radiology Information Systems and Picture Archival and Communication Systems. In the 1990s, the radiology community gave VR technology a rather lukewarm reception, but since then it has emerged as the predominant method of radiology reporting in the United States. In this article, we examine how VR technology works, outline the positive and negative aspects of VR technology on work flow, identify common VR transcription errors and review the discussion on VR adoption in the recent literature. We add to the discussion our personal experiences in an international teleradiology group.

Temporary dermal scatter reduction: quantitative assessment and implications for improved laser tattoo removal.

BACKGROUND AND OBJECTIVES: Temporary dermal clearing, i.e., reduction in the attenuation coefficient of the dermis and epidermis, may lead to improved laser tattoo removal by providing increased efficiency of laser delivery to embedded ink particles and enabling the use of shorter wavelength visible lasers more effective on certain inks. STUDY DESIGNS/MATERIALS AND METHODS: In a hairless guinea pig model of human tattoo, we tested both intradermal and transdermal application of glycerol, using visual inspection, spectral analysis, and optical coherence tomography techniques to assess effectiveness. In controlled experiments, we compared the outcomes of single laser treatment sessions for both cleared and uncleared tattoo sites using Q-switched 755 and 532 nm lasers on three different inks. RESULTS: Intradermal injection of clearing agents induced dermal clearing but resulted in necrosis and scar. Transdermal application of clearing agents resulted in moderate reversible clearing, which was localized to the superficial layers of the skin and did not result in complications. Statistically significant differences in laser treatment outcome were observed relative to a number of treatment parameters including the treatment of certain tattoos by short wavelength lasers. CONCLUSIONS: Temporary clearing of superficial skin layers may be performed in an apparently safe and reliable manner. Clearing should lead to increased penetration of laser light to tattoos and should, therefore, increase treatment efficiency. Further study is needed to determine the degree to which this change is of clinical value.