Automated Identification of Innocent Still's Murmur in Children.

OBJECTIVE: Still's murmur is the most common innocent heart murmur in children. It is also the most commonly misdiagnosed murmur, resulting in a high number of unnecessary referrals to pediatric cardiologist. The purpose of this study was to develop a computer algorithm for automated identification of Still's murmur that may help reduce unnecessary referrals. METHODS: We first developed an accurate segmentation algorithm to locate the first and the second heart sounds. Once these sounds were identified, we extracted signal features specific to Still's murmur. Subsequently, machine learning-based classifiers, artificial neural network and support vector machine, were used to identify Still's murmur. RESULTS: We evaluated our classifiers using the jackknife method using 87 Still's murmurs and 170 non-Still's murmurs. Our algorithm identified Still's murmur accurately with 84-93% sensitivity and 91-99% specificity. CONCLUSION: We have achieved accurate automated identification of Still's murmur while minimizing false positives. The performance of our algorithm is comparable to the rate of murmur identification by auscultation by pediatric cardiologists. SIGNIFICANCE: To our knowledge, our solution is the first murmur classifier that focuses singularly on Still's murmur. Following further refinement and testing, the presented algorithm could reduce the number of children with Still's murmur referred unnecessarily to pediatric cardiologists.

Laparoscopic stereoscopic augmented reality: toward a clinically viable electromagnetic tracking solution.

The purpose of this work was to develop a clinically viable laparoscopic augmented reality (AR) system employing stereoscopic (3-D) vision, laparoscopic ultrasound (LUS), and electromagnetic (EM) tracking to achieve image registration. We investigated clinically feasible solutions to mount the EM sensors on the 3-D laparoscope and the LUS probe. This led to a solution of integrating an externally attached EM sensor near the imaging tip of the LUS probe, only slightly increasing the overall diameter of the probe. Likewise, a solution for mounting an EM sensor on the handle of the 3-D laparoscope was proposed. The spatial image-to-video registration accuracy of the AR system was measured to be [Formula: see text] and [Formula: see text] for the left- and right-eye channels, respectively. The AR system contributed 58-ms latency to stereoscopic visualization. We further performed an animal experiment to demonstrate the use of the system as a visualization approach for laparoscopic procedures. In conclusion, we have developed an integrated, compact, and EM tracking-based stereoscopic AR visualization system, which has the potential for clinical use. The system has been demonstrated to achieve clinically acceptable accuracy and latency. This work is a critical step toward clinical translation of AR visualization for laparoscopic procedures.

On-demand calibration and evaluation for electromagnetically tracked laparoscope in augmented reality visualization.

PURPOSE: Common camera calibration methods employed in current laparoscopic augmented reality systems require the acquisition of multiple images of an entire checkerboard pattern from various poses. This lengthy procedure prevents performing laparoscope calibration in the operating room (OR). The purpose of this work was to develop a fast calibration method for electromagnetically (EM) tracked laparoscopes, such that the calibration can be performed in the OR on demand. METHODS: We designed a mechanical tracking mount to uniquely and snugly position an EM sensor to an appropriate location on a conventional laparoscope. A tool named fCalib was developed to calibrate intrinsic camera parameters, distortion coefficients, and extrinsic parameters (transformation between the scope lens coordinate system and the EM sensor coordinate system) using a single image that shows an arbitrary portion of a special target pattern. For quick evaluation of calibration results in the OR, we integrated a tube phantom with fCalib prototype and overlaid a virtual representation of the tube on the live video scene. RESULTS: We compared spatial target registration error between the common OpenCV method and the fCalib method in a laboratory setting. In addition, we compared the calibration re-projection error between the EM tracking-based fCalib and the optical tracking-based fCalib in a clinical setting. Our results suggest that the proposed method is comparable to the OpenCV method. However, changing the environment, e.g., inserting or removing surgical tools, might affect re-projection accuracy for the EM tracking-based approach. Computational time of the fCalib method averaged 14.0 s (range 3.5 s-22.7 s). CONCLUSIONS: We developed and validated a prototype for fast calibration and evaluation of EM tracked conventional (forward viewing) laparoscopes. The calibration method achieved acceptable accuracy and was relatively fast and easy to be performed in the OR on demand.

Visualization of the Supraglottis in Laryngomalacia With 3-Dimensional Pediatric Endoscopy.

IMPORTANCE: The use of 3-dimensional (3D) endoscopy has been described in the pediatric airway and has been shown to improve visualization of complex airway anatomy. Laryngomalacia is one of the most common airway disorders evaluated in pediatric otolaryngology offices. Whether 3D visualization is superior to standard endoscopy as a means for assessment and surgical management of complex airway anatomy is unclear. OBJECTIVE: To describe a pilot case series using 3D endoscopy to facilitate supraglottoplasty and to assess surgical outcomes. DESIGN, SETTING, AND PARTICIPANTS: A prospective case series was conducted of 11 children undergoing supraglottoplasty from July 1, 2010, to June 31, 2014, at a tertiary care pediatric hospital. Infants and children with symptomatic laryngomalacia were eligible for the study. Follow-up was completed on December 31, 2014, and data were assessed from February 1 to 15, 2015. INTERVENTIONS: Supraglottoplasty performed using 3D endoscopy. MAIN OUTCOMES AND MEASURES: The outcome data collected included length of hospital stay and frequency of complications (ie, aspiration, granuloma formation, supraglottic narrowing, revision surgery, tracheostomy, and gastrostomy). RESULTS: Eleven children were treated for laryngomalacia with supraglottoplasty (6 boys and 5 girls; mean [SD] age, 29 [85] months). Four of these children (36%) also had grade I subglottic stenosis. The 3D endoscope was judged by all participating senior surgeons to improve visualization of the supraglottic anatomy and to permit more precise tissue removal. No complications occurred after the surgery. Hospital stay was found to be an unreliable indicator owing to multiple comorbidities in many children. Worsening of aspiration occurred in 1 child (9%) who subsequently required gastrostomy tube placement. This child demonstrated progressive neurologic impairment and had severe hypotonia and developmental delay. Another child with subglottic stenosis and subglottic cysts required a tracheostomy owing to severe rhinovirus tracheitis. The remaining 9 children (82%) had good outcomes, with a mean follow-up of 14.7 (range, 12-24) months. CONCLUSIONS AND RELEVANCE: The anatomy of the supraglottis in laryngomalacia is better visualized using 3D techniques. Use of 3D endoscopy may allow for more precise tissue removal. The outcomes and complication rates are similar to those of standard 2D techniques. This study provides a platform to begin comparative analysis between 3D and standard 2D techniques.

Tracking epithelial cell junctions in C. elegans embryogenesis with active contours guided by SIFT flow.

Quantitative analysis of cell shape in live samples is an important goal in developmental biology. Automated or semi-automated segmentation and tracking of cell nuclei has been successfully implemented in several biological systems. Segmentation and tracking of cell surfaces has been more challenging. Here, we present a new approach to tracking cell junctions in the developing epidermis of C. elegans embryos. Epithelial junctions as visualized with DLG-1::GFP form lines at the subapical circumference of differentiated epidermal cells and delineate changes in epidermal cell shape and position. We develop and compare two approaches for junction segmentation. For the first method (projection approach), 3-D cell boundaries are projected into 2D for segmentation using active contours with a nonintersecting force, and subsequently tracked using scale-invariant feature transform (SIFT) flow. The resulting 2-D tracked boundaries are then back-projected into 3-D space. The second method (volumetric approach) uses a 3-D extended version of active contours guided by SIFT flow in 3-D space. In both methods, cell junctions are manually located at the first time point and tracked in a fully automated way for the remainder of the video. Using these methods, we have generated the first quantitative description of ventral epidermal cell movements and shape changes during epidermal enclosure.

Application of single-image camera calibration for ultrasound augmented laparoscopic visualization.

Accurate calibration of laparoscopic cameras is essential for enabling many surgical visualization and navigation technologies such as the ultrasound-augmented visualization system that we have developed for laparoscopic surgery. In addition to accuracy and robustness, there is a practical need for a fast and easy camera calibration method that can be performed on demand in the operating room (OR). Conventional camera calibration methods are not suitable for the OR use because they are lengthy and tedious. They require acquisition of multiple images of a target pattern in its entirety to produce satisfactory result. In this work, we evaluated the performance of a single-image camera calibration tool (rdCalib; Percieve3D, Coimbra, Portugal) featuring automatic detection of corner points in the image, whether partial or complete, of a custom target pattern. Intrinsic camera parameters of a 5-mm and a 10-mm standard Stryker® laparoscopes obtained using rdCalib and the well-accepted OpenCV camera calibration method were compared. Target registration error (TRE) as a measure of camera calibration accuracy for our optical tracking-based AR system was also compared between the two calibration methods. Based on our experiments, the single-image camera calibration yields consistent and accurate results (mean TRE = 1.18 ± 0.35 mm for the 5-mm scope and mean TRE = 1.13 ± 0.32 mm for the 10-mm scope), which are comparable to the results obtained using the OpenCV method with 30 images. The new single-image camera calibration method is promising to be applied to our augmented reality visualization system for laparoscopic surgery.

Syndecan defines precise spindle orientation by modulating Wnt signaling in C. elegans.

Wnt signals orient mitotic spindles in development, but it remains unclear how Wnt signaling is spatially controlled to achieve precise spindle orientation. Here, we show that C. elegans syndecan (SDN-1) is required for precise orientation of a mitotic spindle in response to a Wnt cue. We find that SDN-1 is the predominant heparan sulfate (HS) proteoglycan in the early C. elegans embryo, and that loss of HS biosynthesis or of the SDN-1 core protein results in misorientation of the spindle of the ABar blastomere. The ABar and EMS spindles both reorient in response to Wnt signals, but only ABar spindle reorientation is dependent on a new cell contact and on HS and SDN-1. SDN-1 transiently accumulates on the ABar surface as it contacts C, and is required for local concentration of Dishevelled (MIG-5) in the ABar cortex adjacent to C. These findings establish a new role for syndecan in Wnt-dependent spindle orientation.

Quantitative semi-automated analysis of morphogenesis with single-cell resolution in complex embryos.

A quantitative understanding of tissue morphogenesis requires description of the movements of individual cells in space and over time. In transparent embryos, such as C. elegans, fluorescently labeled nuclei can be imaged in three-dimensional time-lapse (4D) movies and automatically tracked through early cleavage divisions up to ~350 nuclei. A similar analysis of later stages of C. elegans development has been challenging owing to the increased error rates of automated tracking of large numbers of densely packed nuclei. We present Nucleitracker4D, a freely available software solution for tracking nuclei in complex embryos that integrates automated tracking of nuclei in local searches with manual curation. Using these methods, we have been able to track >99% of all nuclei generated in the C. elegans embryo. Our analysis reveals that ventral enclosure of the epidermis is accompanied by complex coordinated migration of the neuronal substrate. We can efficiently track large numbers of migrating nuclei in 4D movies of zebrafish cardiac morphogenesis, suggesting that this approach is generally useful in situations in which the number, packing or dynamics of nuclei present challenges for automated tracking.