LayNet-A multi-layer architecture to handle imbalance in medical imaging data.

In an imbalanced dataset, a machine learning classifier using traditional imbalance handling methods may achieve good accuracy, but in highly imbalanced datasets, it may over-predict the majority class and ignore the minority class. In the medical domain, failing to correctly estimate the minority class might lead to a false negative, which is concerning in cases of life-threatening illnesses and infectious diseases like Covid-19. Currently, classification in deep learning has a single layered architecture where a neural network is employed. This paper proposes a multilayer design entitled LayNet to address this issue. LayNet aims to lessen the class imbalance by dividing the classes among layers and achieving a balanced class distribution at each layer. To ensure that all the classes are being classified, minor classes are combined to form a single new 'hybrid' class at higher layers. The final layer has no hybrid class and only singleton(distinct) classes. Each layer of the architecture includes a separate model that determines if an input belongs to one class or a hybrid class. If it fits into the hybrid class, it advances to the following layer, which is further categorized within the hybrid class. The method to divide the classes into various architectural levels is also introduced in this paper. The Ocular Disease Intelligent Recognition Dataset, Covid-19 Radiography Dataset, and Retinal OCT Dataset are used to evaluate this methodology. The LayNet architecture performs better on these datasets when the results of the traditional single-layer architecture and the proposed multilayered architecture are compared.

Discharge Navigator: Implementation and Cross-Sectional Evaluation of a Digital Decision Tool for Social Resources upon Emergency Department Discharge.

INTRODUCTION: Many patients have unaddressed social needs that significantly impact their health, yet navigating the landscape of available resources and eligibility requirements is complex for both patients and clinicians. METHODS: Using an iterative design-thinking approach, our multidisciplinary team built, tested, and deployed a digital decision tool called "Discharge Navigator" (edrive.ucsf.edu/dcnav) that helps emergency clinicians identify targeted social resources for patients upon discharge from the acute care setting. The tool uses each patient's clinical and demographic information to tailor recommended community resources, providing the clinician with action items, pandemic restrictions, and patient handouts for relevant resources in five languages. We implemented two modules at our urban, academic, Level I trauma center. RESULTS: Over the 10-week period following product launch, between 4-81 on-shift emergency clinicians used our tool each week. Anonymously surveyed clinicians (n = 53) reported a significant increase in awareness of homelessness resources (33% pre to 70% post, P<0.0001) and substance use resources (17% to 65%, P<0.0001); confidence in accessing resources (22% to 74%, P<0.0001); knowledge of eligibility criteria (13% to 75%, P<0.0001); and ability to refer patients always or most of the time (11% to 43%, P<0.0001). The average likelihood to recommend the tool was 7.8 of 10. CONCLUSION: Our design process and low-cost tool may be replicated at other institutions to improve knowledge and referrals to local community resources.

Effect of semaglutide on coronary atherosclerosis progression in patients with type II diabetes: rationale and design of the semaglutide treatment on coronary progression trial.

BACKGROUND: Cardiovascular morbidity and mortality are a major burden in patients with type 2 diabetic mellitus. In a landmark study, semaglutide (an injectable glucagon like peptide-1 receptor agonist) has been shown to significantly reduce cardiovascular events, however, the mechanism of benefit is still unknown. The primary hypothesis of our current study is to assess the effect of semaglutide to reduce progression of noncalcified coronary atherosclerotic plaque volume as measured by serial coronary CTA as compared to placebo in persons with diabetes over 1 year. METHODS: One hundred forty patients will be enrolled after signing informed consent and followed up for 12 months and with a phone call 30 days after medical discontinuation. All the participants will undergo coronary artery calcium scoring and coronary computed tomography angiography at our center at baseline and 12 months. Eligible participants will be randomly assigned to semaglutide 2 mg/1.5 ml (1.34 mg/ml) prefilled pen for subcutaneous (SC) injection or placebo 1.5 ml, pen-injector for SC injection in a 1:1 fashion as add-on to their standard of care. RESULTS: As of July 2019, the study was approximately 30% enrolled with an estimated enrollment completion by first quarter of 2020 and end of study by first quarter 2021. Thirty patients were enrolled as of 23 July 2019. Preliminary data of demographics and clinical characteristics were summarized. CONCLUSION: Our current study will provide important imaging-derived data that may add relevance to the clinically derived outcomes from liraglutide effect and action in diabetes: evaluation of cardiovascular outcome results and semaglutide and cardiovascular outcomes in patients with type 2 diabetic mellitus 6 trials.

Effects of e-cigarettes versus nicotine replacement therapy on short-term smoking abstinence when delivered at a community pharmacy.

E-cigarettes (EC) are now the most popular quit aid in England but their effectiveness for cessation if offered at a pharmacy has not been tested. Here we test the effectiveness of offering an e-cigarette with and without nicotine replacement therapy (NRT) on 4-6-week quit rates in adult smokers seeking support from a community pharmacy. A between subject, six-week, prospective, cohort design. 115 smokers (female = 74; M age = 46.37, SD = 13.56) chose either an EC, EC + NRT or NRT alone, alongside standard behavioural support. Smokers opting for an EC alone or an EC + NRT were more likely to report complete abstinence from smoking at 4-6 weeks (62.2% and 61.5% respectively) compared to NRT alone (34.8%). An EC intervention was significantly more effective for smoking cessation than NRT in this community pharmacy. The results for e-cigarettes appear positive but with the caveat that participants chose their own products which may have introduced bias.

Secured Lumen-Apposing Fully Covered Metallic Stents for Stenoses in Post-Bariatric Surgery Patients.

New approaches for refractory stenosis in post-bariatric surgical patients include fully covered lumen-apposing metallic stents (LAMS); however, stent migration continues to be a problem. Endoscopic suture placement to LAMS can reduce the migration. Aiming to assess the feasibility and safety of the procedure, we evaluated nine consecutive patients with inability to tolerate a solid diet due to a benign gastrointestinal stricture recalcitrant to previous attempts at endoscopic therapy. All patients were symptom-free starting from 1-week follow-up. Median stent dwell time was nearly 3 months. During the removal procedures, three incidental foreign bodies were found and removed. No stent migration was observed in any patients. Suturing LAMS is a feasible technique allowing for prolonged stent dwell times; however, it requires a high level of expertise plus additional procedure time.

A Real-World, Insurance-Based Algorithm Using the Two-Fold Running Suture Technique for Transoral Outlet Reduction for Weight Regain and Dumping Syndrome After Roux-En-Y Gastric Bypass.

BACKGROUND AND AIMS: Transoral outlet reduction (TORe) by devitalization and/or endoscopic suturing (ES) has been implemented in the management of weight regain post-RYGB. This study aims to assess the efficacy and safety of TORe following an insurance-based algorithm. METHODS: A prospectively maintained database of patients who underwent TORe between September 2015 and January 2018 at a single academic center was reviewed. An algorithm was followed whereby management was based on insurance coverage. As part of the algorithm, all patients presented for a repeat endoscopy at 8 weeks. Patients did not receive any diet, lifestyle intervention, or pharmacotherapy. RESULTS: In total, 55 patients were included (median age 48 years), out of which 50 were females (90.9%). Patients presented for evaluation at a mean of 8.7 years post-RYGB. The main presenting symptom was combined dumping syndrome (DS) and weight regain (49.1%), followed by weight regain alone (45.5%). Twenty-nine patients required treatment at their second procedure, and 11 required treatment at their third procedure. Average percent total body weight loss (%TBWL) after TORe observed at 3-, 6-, 9-, and 12-month follow-up was 8.2, 9.3, 8.4, and 5.5%, respectively. The mean DS Severity Score was significantly reduced from 23.3 ± 12.4 before TORe to 16.3 ± 6.51 after TORe (p < 0.01). The adverse event rate from TORe was 14.5%. CONCLUSION: TORe is effective in halting ongoing weight regain and achieving moderate short-term weight loss as well as improving DS in post-RYGB patients. Durability at 1 year remains questionable due to weight recidivism.

Predictors of coronary artery disease in patients with Behçet's disease.

BACKGROUND: Behçet's disease (BD) is a multisystem vasculitis of unknown etiology. We aimed to determine the prevalence and predictors of coronary artery disease (CAD) in patients with BD. METHODS: All adult patients diagnosed with BD from the National Inpatient Sample database using the International Classification of Diseases 9th revision (ICD-9 code 136.1) during 2009-2010 were included in the analysis. We analyzed the demographics, traditional risk factors, prevalence, and predictors of CAD in patients with BD using ICD-9 codes. RESULTS: The prevalence of BD among adults was 0.006% (n = 2,540) of all in-hospital admissions in the USA. The mean age was 43.9 years, with women (45 years) being older than men (40 years) (p < 0.001). Traditional risk factors prevalent in our study were hypertension (35%), hyperlipidemia (17.4%), diabetes mellitus (13.8%), smoking (13.1%), and obesity (7.2%). The prevalence of CAD was 12.1%. Hypertension (OR = 2.20, p = 0.03) and hyperlipidemia (OR = 2.34, p = 0.02) were found to be independent predictors of CAD in a multimodel regression analysis. CONCLUSION: In patients with BD, traditional risk factors associated with CAD were similar to what is expected in the overall population. However, the young age of patients with CAD in this population suggests an accelerated course of atherosclerosis in BD.

Percutaneous mitral heart valve repair--MitraClip.

Mitral regurgitation (MR) is the most common cardiac valvular disease in the United States. Approximately 4 million people have severe MR and roughly 250,000 new diagnoses of MR are made each year. Mitral valve surgery is the only treatment that prevents progression of heart failure and provides sustained symptomatic relief. Mitral valve repair is preferred over replacement for the treatment of MR because of freedom from anticoagulation, reduced long-term morbidity, reduced perioperative mortality, improved survival, and better preservation of left ventricular function compared with valve replacement. A large proportion of patients in need of valve repair or replacement do not undergo such procedures because of a perceived unacceptable perioperative risk. Percutaneous catheter-based methods for valvular pathology that parallel surgical principles for valve repair have been developed over the last few years and have been proposed as an alternate measure in high-risk patients. The MitraClip (Abbott Labs) device is one such therapy and is the subject of this review.

Predictors of mortality, rehospitalization for syncope, and cardiac syncope in 352 consecutive elderly patients with syncope.

OBJECTIVES: To investigate the etiologies of syncope and predictors of all-cause mortality, rehospitalization, and cardiac syncope in consecutive elderly patients presenting with syncope to our emergency department. PARTICIPANTS: Participants were 352 consecutive patients aged 65 years or older with syncope admitted to hospital from the emergency department. DESIGN: Observational retrospective study. MEASUREMENTS: Review of medical records for history, physical examination, medications, and tests to determine causes of syncope. Cox stepwise logistic regression analysis was performed to identify significant independent prognostic factors for rehospitalization with syncope, all-cause mortality, and cardiac syncope. RESULTS: Of 352 patients, mean age 78 years, the etiology of syncope was diagnosed in 243 patients (69%). Vasovagal syncope was diagnosed in 12%, volume depletion in 14%, orthostatic hypotension in 5%, cardiac syncope in 29%, carotid sinus hypersensitivity in 2%, and drug overdose/others in 7% of patients. During a mean follow-up of 24 months, 10 patients (3%) were readmitted to the hospital for syncope and 39 (11%) died. Stepwise logistic regression analysis identified history of congestive heart failure (OR 5.18; 95% CI 1.23-21.84, P = .0257) and acute coronary syndrome (OR 5.95; 95% CI 1.11-31.79, P = .037) as independent risk factors for rehospitalization. Significant independent prognostic factors for mortality were diabetes mellitus (OR 2.08; 95% CI 1.09-3.99, P = .0263), history of smoking (OR 2.23; 95% CI 1.10-4.49, P = .0255), and use of statins (OR 0.37; 95% CI 0.19-0.72, P = .0036). Independent risk factors for predicting a cardiac cause of syncope were an abnormal electrocardiogram (OR 2.58; 95% CI 1.46-4.57, P = .0012) and reduced ejection fraction (OR 2.92; 95% CI 1.70-5.02, P < .001). The San Francisco Syncope Rule and Osservatorio Epidemiologico sulla Sincope nel Lazio scores did not predict mortality or rehospitalization in our study population. CONCLUSIONS: Significant independent risk factors for rehospitalization for syncope were congestive heart failure and acute coronary syndrome. Significant independent risk factors for mortality were diabetes mellitus, history of smoking, and use of statins (inverse association).

A rare case of successfully treated cardiac metastasis from transitional cell bladder cancer.

Although it is common to find metastases of transitional cell carcinoma of the bladder to the lymph nodes, lung, bone, and liver, cardiac metastases have only been rarely reported. We report a case of symptomatic metastasis of transitional cell cancer to the right ventricle. A 59-year-old man with a history of transitional cell bladder cancer status post cystectomy and chemotherapy, with neobladder placement, presented with hematuria, shortness of breath, murmur, and evidence of right-sided heart failure. On imaging workup, including transthoracic echocardiography and cardiac computed tomography, we found a large right ventricular mass. A review of the literature showed that there are only 9 cases of cardiac metastasis from transitional cell cancer reported; however, our case is unique because it is the only reported case of symptomatic improvement due to effective treatment with chemotherapy.

Association of corrected QT interval with long-term mortality in patients with syncope.

INTRODUCTION: The electrocardiographic parameters QRS duration, QRS-T angle and QTc can predict mortality in patients with cardiovascular disease. The prgnostic value of these parameters in hospitalized patients with syncope needs investigation. MATERIAL AND METHODS: We retrospectively studied 590 consecutive patients hospitalized with syncope. After excluding patients with baseline abnormal rhythm, QT- prolonging medications, and missing data, 459 patients were analyzed. Baseline demographic characteristics, co-morbidities, medication use, San Francisco Syncope Rule (SFSR) and Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) score and data on mortality were collected. The categorical variables and continuous variables of the 2 groups of patients with prolonged QTc and normal QTc interval were analyzed by Fischer's exact test and Mann-Whitney Test. A stepwise Cox regression model was used for time to death analysis. RESULTS: Of 459 patients, prolonged QTc interval was observed in 122 (27%). Mean follow-up was 41 months. Patients with prolonged QTc interval had higher prevalence of cardiovascular disease, OESIL score, high risk SFSR, hypertension, dyslipidemia, coronary artery disease, congestive heart failure, and increased mortality. Stepwise Cox regression analysis showed that significant independent prognostic factors for time to death were prolonged QTc interval (p = 0.005), age (p = 0.001), diabetes mellitus (p = 0.001) and history of malignancy (p = 0.006). QRS duration and QRS-T angle were not independent predictors of mortality. CONCLUSIONS: A prolonged QTc interval is an independent predictor of long-term mortality in hospitalized patients with syncope.

Dual-source versus single-source cardiac CT angiography: comparison of diagnostic image quality.

OBJECTIVE: Dual-source CT improves temporal resolution, and theoretically improves the diagnostic image quality of coronary artery examinations without requiring preexamination beta-blockade. The purpose of our study was to show the improved diagnostic image quality of dual-source CT compared with single-source CT despite the absence of preexamination beta-blockade in the dual-source CT group. MATERIALS AND METHODS: We performed a retrospective analysis of consecutive patients who underwent coronary artery evaluation with either single-source CT or dual-source CT at our institution between February 2005 and October 2006. Examination reports were analyzed for the presence of image artifacts, and image quality was graded on a 3-point scale (no, mild, or severe artifact). Type of artifact (motion, calcium, quantum mottle) was also noted. RESULTS: Examinations (339 single-source CT and 126 dual-source CT) of 465 patients were analyzed. Artifact was reported in 39.8% of examinations using single-source CT and in 29.4% of examinations using dual-source CT (p < 0.05). The number of examinations with motion artifact was significantly higher with single-source CT than with dual-source CT (15.9% vs 4.8%; p < 0.001) despite significantly higher heart rates in the dual-source CT group (59.4 +/- 8.4 vs 68.6 +/- 14.6 beats per minute; p < 0.001). No patients in the dual-source CT group received preexamination beta-blockade compared with 81% of patients in the single-source CT group. The presence of severe (nondiagnostic) calcium artifact was also significantly reduced in the dual-source CT group (13.0% vs 3.2%; p < 0.001). CONCLUSION: Dual-source CT provides significantly better diagnostic image quality than single-source CT despite higher heart rates in the dual-source CT group. These findings support the use of dual-source CT for coronary artery imaging without the need for preexamination beta-blockade.

Enhancing the utility of prostascint SPECT scans for patient management.

This project investigated reducing the artifact content of In-ill ProstaScint SPECT scans for use in treatment planning and management. Forty-one patients who had undergone CT or MRI scans and simultaneous Tc-99m RBC/In-111 ProstaScint SPECT scans were included. SPECT volume sets, reconstructed using Ordered Set-Expectation Maximum (OS-EM) were compared against those reconstructed with standard Filtered Back projection (FBP). Bladder activity in Tc-99m scans was suppressed within an ellipsoidal volume. Tc-99m voxel values were subtracted from the corresponding In-111 after scaling based on peak activity within the descending aorta. The SPECT volume data sets were merged with the CT or MRI scans before and after processing. Volume merging, based both on visual assessment and statistical evaluation, was not affected. Thus iterative reconstruction together with bladder suppression and blood pool subtraction may improve the interpretation and utility of ProstaScint SPECT scans for patient management.