Real-time algorithm for Poissonian noise reduction in low-dose fluoroscopy: performance evaluation.

BACKGROUND: Quantum noise intrinsically limits the quality of fluoroscopic images. The lower is the X-ray dose the higher is the noise. Fluoroscopy video processing can enhance image quality and allows further patient's dose lowering. This study aims to assess the performances achieved by a Noise Variance Conditioned Average (NVCA) spatio-temporal filter for real-time denoising of fluoroscopic sequences. The filter is specifically designed for quantum noise suppression and edge preservation. It is an average filter that excludes neighborhood pixel values exceeding noise statistic limits, by means of a threshold which depends on the local noise standard deviation, to preserve the image spatial resolution. The performances were evaluated in terms of contrast-to-noise-ratio (CNR) increment, image blurring (full width of the half maximum of the line spread function) and computational time. The NVCA filter performances were compared to those achieved by simple moving average filters and the state-of-the-art video denoising block matching-4D (VBM4D) algorithm. The influence of the NVCA filter size and threshold on the final image quality was evaluated too. RESULTS: For NVCA filter mask size of 5 × 5 × 5 pixels (the third dimension represents the temporal extent of the filter) and a threshold level equal to 2 times the local noise standard deviation, the NVCA filter achieved a 10% increase of the CNR with respect to the unfiltered sequence, while the VBM4D achieved a 14% increase. In the case of NVCA, the edge blurring did not depend on the speed of the moving objects; on the other hand, the spatial resolution worsened of about 2.2 times by doubling the objects speed with VBM4D. The NVCA mask size and the local noise-threshold level are critical for final image quality. The computational time of the NVCA filter was found to be just few percentages of that required for the VBM4D filter. CONCLUSIONS: The NVCA filter obtained a better image quality compared to simple moving average filters, and a lower but comparable quality when compared with the VBM4D filter. The NVCA filter showed to preserve edge sharpness, in particular in the case of moving objects (performing even better than VBM4D). The simplicity of the NVCA filter and its low computational burden make this filter suitable for real-time video processing and its hardware implementation is ready to be included in future fluoroscopy devices, offering further lowering of patient's X-ray dose.

Agreement between Opal and G-Walk Wearable Inertial Systems in Gait Analysis on Normal and Pathological Subjects.

Despite the growing use of different wearable inertial systems, increasingly diffused in clinical practice, there is still a lack of knowledge about the agreement between systems based also on different sensor configuration. Aim of the study has been the investigation of the agreement between Opal and G-Walk wearable inertial systems in gait analysis on normal and post stroke subjects. Although both systems are able to describe significant gait differences in the two populations, study results suggest that gait analysis evaluations carried out by different inertial systems does not give completely overlapping estimation about the different parameters and that this must be taken in correct account especially comparing results of clinical trials obtained by different systems and sensor's placements.

Development of a Prototype E-Textile Sock.

The aim of this work is to design and develop a sensorized sock in Electronic Textile (ET), SWEET-Sock. The device has been realized by three textile sensor placed in a specific points of plantar arch and an accelerometer unit, both embedded and connected by conductive thread. The sensors allows the acquisition of plantar pressure and acceleration signals deriving from the motion of the lower limbs. The detected biosignals have been condictionated by a voltage divider and then were acquired through a LilyPad Arduino microcontroller and transmitted using the Simblee BLE technology to a custom made mobile app. Data were afterwards uploaded through a smartphone on a dropbox cloud where a custom made MATLAB GUI platform has been developed for further digital signal processing of main biomechanical parameters of clinical interest in postural and gait analysis.

Towards a patient-specific estimation of intra-operative femoral fracture risk.

Total Hip Arthroplasty requires pre-surgical evaluation between un-cemented and cemented prostheses. A Patient with intra-operative periprosthetic fracture and another with a successful outcome were recruited, and their finite element models were constructed by processing CT data, assuming elastic-plastic behavior of the bone as function of the local density. To resemble the insertion of the prosthesis into the femur, a fictitious thermal dilatation is applied to the broach volume. Strain-based fracture risk factor is estimated, depicting results in terms of the total mechanical strain expressed using a simple "traffic lights" color code to provide immediate, concise, and intelligible pre-operative information to surgeons.

Silica diatom shells tailored with Au nanoparticles enable sensitive analysis of molecules for biological, safety and environment applications.

Diatom shells are a natural, theoretically unlimited material composed of silicon dioxide, with regular patterns of pores penetrating through their surface. For their characteristics, diatom shells show promise to be used as low cost, highly efficient drug carriers, sensor devices or other micro-devices. Here, we demonstrate diatom shells functionalized with gold nanoparticles for the harvesting and detection of biological analytes (bovine serum albumin-BSA) and chemical pollutants (mineral oil) in low abundance ranges, for applications in bioengineering, medicine, safety, and pollution monitoring.

Nano-topography Enhances Communication in Neural Cells Networks.

Neural cells are the smallest building blocks of the central and peripheral nervous systems. Information in neural networks and cell-substrate interactions have been heretofore studied separately. Understanding whether surface nano-topography can direct nerve cells assembly into computational efficient networks may provide new tools and criteria for tissue engineering and regenerative medicine. In this work, we used information theory approaches and functional multi calcium imaging (fMCI) techniques to examine how information flows in neural networks cultured on surfaces with controlled topography. We found that substrate roughness S a affects networks topology. In the low nano-meter range, S a = 0-30 nm, information increases with S a . Moreover, we found that energy density of a network of cells correlates to the topology of that network. This reinforces the view that information, energy and surface nano-topography are tightly inter-connected and should not be neglected when studying cell-cell interaction in neural tissue repair and regeneration.

Microvascular Blood Flow Improvement in Hyperglycemic Obese Adult Patients by Hypocaloric Diet.

The present study was aimed to assess the changes in skin microvascular blood flow (SBF) in newly diagnosed hyperglycemic obese subjects, administered with hypocaloric diet. Adult patients were recruited and divided in three groups: NW group (n=54), NG (n=54) and HG (n=54) groups were constituted by normal weight, normoglycemic and hyperglycemic obese subjects, respectively. SBF was measured by laser Doppler perfusion monitoring technique and oscillations in blood flow were analyzed by spectral methods under baseline conditions, at 3 and 6 months of dietary treatment. Under resting conditions, SBF was lower in HG group than in NG and NW ones. Moreover, all subjects showed blood flow oscillations with several frequency components. In particular, hyperglycemic obese patients revealed lower spectral density in myogenic-related component than normoglycemic obese and normal weight ones. Moreover, post-occlusive reactive hyperemia (PORH) was impaired in hyperglycemic obese compared to normoglycemic and normal weigh subjects. After hypocaloric diet, in hyperglycemic obese patients there was an improvement in SBF accompanied by recovery in myogenic-related oscillations and arteriolar responses during PORH. In conclusion, hyperglycemia markedly affected peripheral microvascular function; hypocaloric diet ameliorated tissue blood flow.

Software for computerised analysis of cardiotocographic traces.

Despite the widespread use of cardiotocography in foetal monitoring, the evaluation of foetal status suffers from a considerable inter and intra-observer variability. In order to overcome the main limitations of visual cardiotocographic assessment, computerised methods to analyse cardiotocographic recordings have been recently developed. In this study, a new software for automated analysis of foetal heart rate is presented. It allows an automatic procedure for measuring the most relevant parameters derivable from cardiotocographic traces. Simulated and real cardiotocographic traces were analysed to test software reliability. In artificial traces, we simulated a set number of events (accelerations, decelerations and contractions) to be recognised. In the case of real signals, instead, results of the computerised analysis were compared with the visual assessment performed by 18 expert clinicians and three performance indexes were computed to gain information about performances of the proposed software. The software showed preliminary performance we judged satisfactory in that the results matched completely the requirements, as proved by tests on artificial signals in which all simulated events were detected from the software. Performance indexes computed in comparison with obstetricians' evaluations are, on the contrary, not so satisfactory; in fact they led to obtain the following values of the statistical parameters: sensitivity equal to 93%, positive predictive value equal to 82% and accuracy equal to 77%. Very probably this arises from the high variability of trace annotation carried out by clinicians.

Towards true unipolar ECG recording without the Wilson central terminal (preliminary results).

We present an innovative bio-potential front-end capable of recording true unipolar ECG leads for the first time without making use of the Wilson central terminal. In addition to the convenience in applications such as continuous monitoring and rapid diagnosis, the information in unipolar recordings may yield unique diagnostic information as it avoids the need to essentially subtract data or make use of the averaging effect imposed from the Wilson central terminal. The system also allows direct, real-time software calculation of signals corresponding to standard ECG leads which achieve correlations in excess of 92% with a gold standard ECG during a parallel in vivo recording. In addition, the implemented circuit is wideband (0.05-1000 Hz), compatible with standard (Ag/AgCl) bio-potential electrodes, and dry (paste-less) textile electrodes. The circuit is also low power, requiring less than 50 mW (when powered at 12 V) per standard ECG lead (two channels required). It is therefore well suited for wearable, long-term applications.

X-ray fluoroscopy noise modeling for filter design.

PURPOSE: Fluoroscopy is an invaluable tool in various medical practices such as catheterization or image-guided surgery. Patient's screen for prolonged time requires substantial reduction in X-ray exposure: The limited number of photons generates relevant quantum noise. Denoising is essential to enhance fluoroscopic image quality and can be considerably improved by considering the peculiar noise characteristics. This study presents analytical models of fluoroscopic noise to express the variance of noise as a function of gray level, a practical method to estimate the parameters of the models and a possible application to improve the performance of noise filtering. METHODS: Quantum noise is modeled as a Poisson distribution and results strongly signal-dependent. However, fluoroscopic devices generally apply gray-level transformations (i.e., logarithmic-mapping, gamma-correction) for image enhancement. The resulting statistical transformations of the noise were analytically derived. In addition, a characterization of the statistics of noise for fluoroscopic image differences was offered by resorting to Skellam distribution. Real fluoroscopic sequences of a simple step-phantom were acquired by a conventional fluoroscopic device and were utilized as actual noise measurements to compare with. An adaptive spatio-temporal filter based on the local conditional average of similar pixels has been proposed. The gray-level differences between the local pixel and the neighboring pixels have been assumed as measure of similarity. Filter performance was evaluated by using real fluoroscopic images of a step phantom and acquired during a pacemaker implantation. RESULTS: The comparison between experimental data and the analytical derivation of the relationship between noise variance and mean pixel intensity (noise-parameter models) were presented relatively to raw-images, after applying logarithmic-mapping or gamma-correction and for difference images. Results have confirmed a great agreement (adjusted R-squared values >  0.8). Clipping effects of real sensors were also addressed. A fine image restoration has been obtained by using a conditioned spatio-temporal average filter based on the noise statistics previously estimated. DISCUSSION: Fluoroscopic noise modeling is useful to design effective procedures for noise estimation and image filtering. In particular, filter performance analysis has showed that the knowledge of the noise model and the accurate estimate of noise characteristics can significantly improve the image restoration, especially for edge preserving. Fluoroscopic image enhancement can support further X-ray exposure reduction, medical image analysis and automated object identification (i.e., surgery tools, anatomical structures).

Simulation of foetal phonocardiographic recordings for testing of FHR extraction algorithms.

A valuable alternative to traditional diagnostic tools, such as ultrasonographic cardiotocography, to monitor general foetal well-being by means of foetal heart rate analysis is foetal phonocardiography, a passive and low cost recording of foetal heart sounds. In this paper, it is presented a simulator software of foetal phonocardiographic signals relative to different foetal states and recording conditions (for example different kinds and levels of noise). Before developing the software, a data collection pilot study was conducted with the purpose of specifically identifying the characteristics of the waveforms of the foetal and maternal heart sounds, since the available literature is not rigorous in this area. The developed software, due to the possibility to simulate different physiological and pathological foetal conditions and recording situations simply modifying some system parameters, can be useful as a teaching tool for demonstration to medical students and others and also for testing and assessment of foetal heart rate extraction algorithms from foetal phonocardiographic (fPCG) recordings. On this purpose, the simulator software was used to test an algorithm developed by the authors for foetal heart rate extraction considering different foetal heart rate parameters and signal to noise ratio values. Our tests demonstrated that simulated fPCG signals are very close to real fPCG recordings.

Advanced template matching method for estimation of intervertebral kinematics of lumbar spine.

Diagnosis of low back pain and other degenerative spinal pathologies can be extremely difficult and, so far, there are not accepted standards. In general, such pathologies are associated with alteration of mechanical properties of spine and, in particular, with the instability of spinal motion. Intervertebral kinematics can be a valuable, objective method to assess the functionality of spinal segments. Fluoroscopic imaging system can provide continuous screening of lumbar tracts during patient's motion, with an acceptable low X-ray dose. Estimation of intervertebral kinematics relies on accurate recognition of vertebrae positions throughout the fluoroscopic sequence: specific vertebrae features are identified and tracked either by manual selection or by automated methods. This study presents a new method of vertebra tracking, based on image template matching of the contour of the vertebral body for an accurate intervertebral kinematics analysis. An image gradient operator was utilized to obtain the vertebral contours; it operates after an edge-preserving smoothing filter designed to reduce low dose X-ray image noise. Once a template is defined for each vertebra, this is used to determine the best vertebral location in each image throughout the fluoroscopic sequence. Accuracy of the proposed method was tested using images of a calibration model. Average error achieved for the intervertebral angle is of the order of 0.4° and approximately 2mm for the intervertebral centre of rotation. Five fluoroscopic lumbar sequences of healthy volunteers undergoing passive flexion-extension motion were processed. The intervertebral kinematics was compared with other methods (automated and manual) by an estimation of measurement error. Results showed that the current method provides a better representation of the evolution over time of kinematic parameters. In particular, root mean square differences between the current method and a manual selection procedure performed by an experienced and trained clinician resulted 1.3° for the intervertebral angles and 0.9 mm for the intervertebral trajectory. The proposed method provides an effective, automated and objective technique for estimation of intervertebral kinematics of lumbar spine.

Comparison of short term variability indexes in cardiotocographic foetal monitoring.

Concise indexes related to variability of foetal heart rate (FHR) are usually utilised for foetal monitoring; they enrich information provided by cardiotocography (CTG). Most attention is paid to the short term variability (STV), which relates to activity and reaction of autonomic nervous control of foetal heart. There is not a unique method to compute short term variability of the FHR but different formulas have been proposed and are employed in clinical and scientific environments: this leads to different evaluations and makes difficult comparative studies. Nine short term variability indexes: Arduini, Dalton, Organ, Sonicaid 8000, Van Geijn, Yeh, Zugaib a modified version of Arduini index and Standard Deviation were considered and compared to test their robustness in CTG applications. A large set of synthetic foetal heart rate series with known features were used to compare indexes performances. Different amounts of variability, mean foetal heart rate, storage rates, baseline variations were considered. The different indexes were in particular tested for their capability to recognise short term heart rate variability variation, their dependence on heart rate signal storage rate (as those provided by commercial cardiotocographic devices), on mean value of the foetal heart rate and on modifications of the floatingline, such in case of accelerations or decelerations. Concise statistical parameters relative to indexes scores were presented in comparative tables. Results indicate that although the indexes are able to recognise STV variation, they show substantial differences in magnitude and some in sensibility. Results depend on the frequency used to acquire and store FHR data (depending on devices); in general, the lower is data rate the more degraded are the results. Furthermore, results differently depend on FHR mean, some for their intrinsic definition; differences arise also in correspondences of accelerations and decelerations. Our results demonstrate that only indexes which refer directly to differences in FHR values, such as Organ and SD indexes, not show dependence on FHR mean. The use of the Standard Deviation index may provide efficient information while showing independence from the considered variables. Indexes performance in case of real cardiotocographic signals were also presented as examples.

An algorithm for the recovery of fetal heart rate series from CTG data.

Cardiotocography (simultaneous recording of fetal heart rate (FHR) and uterine contractions) is one of the most used diagnostic techniques to evaluate fetal well-being and to investigate the functional state of the fetal autonomic nervous system. Recently, great interest has been paid to the variability of the FHR, and its frequency analysis, as a base for a more objective analysis of the cardiotocographic (CTG) tracings. FHR signals are unevenly sampled series. To obtain evenly sampled series, cardiotocographs often use zero-order interpolation. Such process is simple and fast but results unsuitable for frequency analyses because it introduces alterations in the FHR power spectrum. An algorithm for the recovery of the true FHR series out of the zero-order interpolated CTG data was developed and evaluated.

Foetal heart rate power spectrum response to uterine contraction.

Cardiotocography is the most diffused prenatal diagnostic technique in clinical routine. The simultaneous recording of foetal heart rate (FHR) and uterine contractions (UC) provides useful information about foetal well-being during pregnancy and labour. However, foetal electronic monitoring interpretation still lacks reproducibility and objectivity. New methods of interpretation and new parameters can further support physicians' decisions. Besides common time-domain analysis, study of the variability of FHR can potentially reveal autonomic nervous system activity of the foetus. In particular, it is clinically relevant to investigate foetal reactions to UC to diagnose foetal distress early. Uterine contraction being a strong stimulus for the foetus and its autonomic nervous system, it is worth exploring the FHR variability response. This study aims to analyse modifications of the power spectrum of FHR variability corresponding to UC. Cardiotocographic signal tracts corresponding to 127 UC relative to 30 healthy foetuses were analysed. Results mainly show a general, statistically significant (t test, p<0.01) power increase of the FHR variability in the LF 0.03-0.2 Hz and HF 0.2-1 in correspondence of the contraction with respect to a reference tract set before contraction onset. Time evolution of the power within these bands was computed by means of time-varying spectral estimation to concisely show the FHR response along a uterine contraction. A synchronised grand average of these responses was also computed to verify repeatability, using the contraction apex as time reference. Such modifications of the foetal HRV that follow a contraction can be a sign of ANS reaction and, therefore, additional, objective information about foetal reactivity during labour.

Automatic recognition of vertebral landmarks in fluoroscopic sequences for analysis of intervertebral kinematics.

Intervertebral kinematics closely relates to the functionality of the spinal segments. Direct measurement of the intervertebral kinematics in vivo is very problematic. The use of a fluoroscopic device can provide continuous screening of the lumbar tract during patient spontaneous motion, with an acceptable, low X-ray dose. The kinematic analysis is intended to be limited to planar motion. Kinematic parameters are computed from vertebral landmarks on each frame of the image sequence. Landmarks are normally selected manually in spite of the fact that this is subjective, tedious to perform and regarded as one of the major contributors to errors in the computed kinematic parameters. The aim of this work is to present an innovative method for the automatic recognition of vertebral landmarks throughout a fluoroscopic image sequence to provide an objective and more precise quantification of intervertebral kinematics. The recognition procedure is based upon comparing vertebral features in two adjacent frames by means of a cross-correlation index, which is also robust despite the low signal-to-noise ratio of the lumbar fluoroscopic images. To provide a quantitative assessment of this method a calibration model was used which consisted of two lumbar vertebrae linked by a universal joint. The reliability and accuracy of the kinematic measurements have been investigated. The errors are of the order of a millimetre for the localisation of the intervertebral centre of rotation and tenths of a degree for the intervertebral angle. Error analysis suggests that this method improves the accuracy of the intervertebral kinematic calculations and has the potential to automate the selection of anatomical landmarks.

Relationship between visual acuity and eye position variability during foveations in congenital nystagmus.

Visual acuity in congenital nystagmus has proven to be primarily related to the duration of foveation periods, during which the image of a target falls onto the fovea and eye velocity slows down. It was found that the longer the foveation time the higher the visual acuity. However, the cycle-to-cycle variability of the eye position and velocity during foveation periods also contribute to visual acuity. A high variability of the eye position during the foveations hinders a stable placement of the target image on the centralmost fovea and consequently decreases visual acuity. To investigate the relationship between different nystagmus features and visual acuity, infrared- oculographic and electro-oculographic eye position recordings of 20 patients affected by congenital nystagmus were analysed in different gaze positions. In several patients' recordings, a high variability of the eye position during foveations (i.e. greater than 0.5 degrees) was detected. Correspondingly, low visual acuity was measured, in spite of sufficiently long foveation periods. The standard deviation of eye positions during foveation periods was used to measure this variability and it was found to be correlated to visual acuity, in conjunction with the mean duration of the foveation periods. On the basis of the data analysis, an exponential relationship is proposed to relate visual acuity and the standard deviation of the eye position during foveations.

Study of the control strategy of the quadriceps muscles in anterior knee pain.

Anterior knee pain (AKP) is a common pathological condition, particularly among young people and athletes, associated to an abnormal motion of the patella during the bending of the knee and possibly dependent on a muscular or structural imbalance. A lack of synergy in the quadriceps muscles results in a dynamic misalignment of the patella, which in turn produces pain. AKP rehabilitative therapy consists of conservative treatment whose main objective is to strengthen the Vastus Medialis. The aim of this article is to study the quadriceps muscle control strategy in AKP patients during an isokinetic exercise. Analysis of the muscle activation strategy is important for an objective measurement of the knee functionality in that it helps to diagnose and monitor the rehabilitative treatment. Surface electromyography (EMG) from the three superficial muscles of the femoral quadriceps during a concentric isokinetic exercise has been analyzed along with the signals of knee joint position and torque. A group of 12 AKP patients has been compared with a group of 30 normal subjects. Analysis of the grand ensemble average of the EMG linear envelopes in AKP patients reveals significant modifications in Vastus Medialis activity compared to the other quadriceps muscles. In order to study the synergy of the muscles, temporal identifiers have been associated to the EMG linear envelopes. To this end, EMG linear envelope decomposition in Gaussian pulses turned out to be effective and the results highlight an appreciable delay in the activation of the Vastus Medialis in AKP patients. This muscular unbalance can explain the abnormal motion of the patella.

Quadriceps muscles activation in anterior knee pain during isokinetic exercise.

The aim of this paper is to study the femoral quadriceps muscles activation in patients suffering from anterior knee pain (AKP) during an isokinetic exercise. AKP is a common pathological condition, associated to an abnormal motion of the patella. It possibly depends on a muscular or structural imbalance. A lack of synergy in the quadriceps muscles results in a dynamic misalignment of the patella, which in turn produces pain. A quantitative analysis of the muscle activation strategy is important for an objective measurement of the knee functionality in that it helps to diagnose and monitor the rehabilitative treatment. Surface electromyography (EMG) from the three superficial muscles of the femoral quadriceps during a concentric isokinetic exercise has been analysed. A group of AKP patients has been compared with a control group of healthy subjects. Ensemble average of the EMG linear envelopes reveals significant modifications in Vastus Medialis activity in AKP patients. In order to quantify the synergy of the muscles, different parameters have been associated to EMG linear envelopes significant features. A decomposition in gaussian pulses and an asymmetry coefficient have been utilised. The results relative to these concise parameters highlight an appreciable delay and a modification in the activation of the Vastus Medialis in AKP patients.