Improving the Quality and Completeness of Discharge Summaries at a Tertiary Care Hospital in Pakistan: A Quality Improvement Project.

Introduction Discharge summaries (DS) allow continued patient care after being discharged from the hospital. Only a few quality improvement projects (QIPs) focused on assessing and improving the quality and completeness of DS at tertiary care hospitals have been undertaken in Pakistan. This QIP aimed to evaluate and enhance the quality and completeness of DS at a tertiary care hospital in Pakistan to facilitate seamless healthcare transitions. Methods A QIP was conducted in the medical unit of a tertiary care hospital in Rawalpindi, Pakistan. The DS were assessed using the e-discharge summary self-assessment checklist devised by the Royal College of Physicians (RCP). This QIP was done by the plan, do, study, act (PDSA) cycle. The PDSA cycle comprised two audit cycles and an intervention in between them. The first audit cycle (AC) was conducted on 150 DS. Its duration was from March 2023 to June 2023. An educational workshop was conducted before the re-audit cycle (RAC) to address deficiencies and reinforce the implementation of the guidelines provided by the RCP. The RAC was conducted from June 2023 to August 2023. 100 DS were studied and analyzed to assess for improvement in the completeness of DS. Frequencies and percentages were calculated in each audit cycle. The Chi-squared test was applied to compare the statistical difference between the results of both audit cycles. Results A total of 150 DS were analyzed in the first AC and 100 DS in the RAC. The results of the first AC show that the details of any allergies were recorded only in 3% of the DS; this percentage significantly improved to 51% after the RAC (p-value <0.05). Relevant past medical history was included in 52% and 88% of the DS during the first AC and RAC, respectively (p-value <0.05). Secondary diagnoses were written in 54% and 71% of the DS during the first AC and RAC, respectively (p-value <0.05). Details of relevant investigations were included in 60% and 88% of the DS during the first AC and RAC, respectively (p-value <0.05). The post-discharge management plan was written in 90% and 98% of the DS during the first AC and RAC, respectively (p-value <0.05). The follow-up plan was written clearly in 65% and 93% of the DS during the first AC and RAC, respectively (p-value <0.05).  Conclusion The DS was found to be incomplete after analyzing the results of the first AC. The details related to allergies, medications, operations, and procedures were found to be missing in the majority of the cases. No mention of the patient's concerns or expectations was made in the DS. The results of the RAC showed improvement in the level of completeness of DS. The majority of the weak points observed after the first AC seemed to have improved after the RAC, which shows that intervention proved to be quite effective in improving the completeness and quality of DS. The RAC showed significant improvement in the completeness of the details relating to investigations, allergies, past medical history, secondary diagnoses, and the post-discharge follow-up plan. QIP must be routinely carried out to assess and improve the completeness and quality of DS at hospitals.

Enhanced detection of oral dysplasia by structured illumination fluorescence lifetime imaging microscopy.

We demonstrate that structured illumination microscopy has the potential to enhance fluorescence lifetime imaging microscopy (FLIM) as an early detection method for oral squamous cell carcinoma. FLIM can be used to monitor or detect changes in the fluorescence lifetime of metabolic cofactors (e.g. NADH and FAD) associated with the onset of carcinogenesis. However, out of focus fluorescence often interferes with this lifetime measurement. Structured illumination fluorescence lifetime imaging (SI-FLIM) addresses this by providing depth-resolved lifetime measurements, and applied to oral mucosa, can localize the collected signal to the epithelium. In this study, the hamster model of oral carcinogenesis was used to evaluate SI-FLIM in premalignant and malignant oral mucosa. Cheek pouches were imaged in vivo and correlated to histopathological diagnoses. The potential of NADH fluorescence signal and lifetime, as measured by widefield FLIM and SI-FLIM, to differentiate dysplasia (pre-malignancy) from normal tissue was evaluated. ROC analysis was carried out with the task of discriminating between normal tissue and mild dysplasia, when changes in fluorescence characteristics are localized to the epithelium only. The results demonstrate that SI-FLIM (AUC = 0.83) is a significantly better (p-value = 0.031) marker for mild dysplasia when compared to widefield FLIM (AUC = 0.63).

Quantitative Assessment of Breast Density: Transmission Ultrasound is Comparable to Mammography with Tomosynthesis.

Elevated breast density is among the strongest independent predictors of breast cancer. Breast density scores are critical inputs in models used to calculate a patient's lifetime risk of developing breast cancer. Today, the only FDA-cleared technology for assessing breast density uses mammography. An alternative modality for breast density quantification is 3D transmission ultrasound (TU). In this retrospective study, we compared automated breast density calculations derived from TU using quantitative breast density (QBD) and mammography with tomosynthesis using VolparaDensity 3.1 for 225 breasts. Pearson correlation coefficients (r) and intraclass correlation coefficients were compared. Subset analyses of extremely dense breasts, premenopausal, and postmenopausal breasts were also performed. Comparative analysis between radiologist-derived density assessment and objective automated scores was performed. Calculations from TU and mammography with tomosynthesis for breast density, total breast volume (TBV), and fibroglandular volume (FGV) were strongly correlated (r = 0.91, 0.92, and 0.67, respectively). We observed moderate absolute agreement for FGV and breast density, and strong absolute agreement for TBV. A subset of 56 extremely dense breasts showed similar trends, however with lower breast density agreement in the subset than in the full study. No significant difference existed in density correlation between premenopausal and postmenopausal breasts across modalities. QBD calculations from TU were strongly correlated with breast density scores from VolparaDensity. TU systematically measured higher FGV and breast density compared with mammography, and the difference increased with breast density. IMPACT: TU of the breast can accurately quantify breast density comparable with mammography with tomosynthesis.

Breast Cyst Fluid Analysis Correlations with Speed of Sound Using Transmission Ultrasound.

RATIONALE AND OBJECTIVES: The purpose of this work is to determine if the speed of sound value of a breast cyst can aid in the clinical management of breast masses. Breast macrocysts are defined as fluid-filled tissue masses >1 cm in diameter and are thought to be aberrations of normal development and involution, often associated with apocrine metaplasia. The benign natural history of breast cysts is well known, and it is important to obtain high specificity in breast imaging to avoid unnecessary biopsies in women who have benign diseases, particularly those with dense breast tissue. Transmission ultrasound is a tomographic imaging modality that generates high-resolution, 3D speed of sound maps that could be used to identify breast tissue types and act as a biomarker to differentiate lesions. We performed this study to investigate the microanatomy of macrocysts observed using transmission ultrasound, as well as assess the relationship of speed of sound to the physical and biochemical parameters of cyst fluids. MATERIALS AND METHODS: Cyst fluid samples were obtained from 37 patients as part of a case-collection study for ultrasound imaging of the breast. The speed of sound of each sample was measured using a quantitative transmission ultrasound scanner in vivo. Electrolytes, protein, cholesterol, viscosity, and specific gravity were also measured (in the aspirated cyst fluid) to assess their relationship to the speed of sound values obtained during breast imaging. RESULTS: We found positive correlations between viscosity and cholesterol (r = 0.71) and viscosity and total protein × cholesterol (r = 0.78). Additionally, we performed direct cell counts on cyst fluids and confirmed a positive correlation of number of cells with speed of sound (r = 0.74). The speed of sound of breast macrocysts, as observed using transmission ultrasound, correlated with the cytological features of intracystic cell clumps. CONCLUSION: On the basis of our work with speed as a classifier, we propose a spectrum of breast macrocysts from fluid-filled to highly cellular. Our results suggest high-speed cysts are mature macrocysts with high cell counts and many cellular clumps that correlate with cyst microanatomy as seen by transmission ultrasound. Further studies are needed to confirm our findings and to assess the clinical value of speed of sound measurements in breast imaging using transmission ultrasound.

Optically sectioned wide-field fluorescence lifetime imaging microscopy enabled by structured illumination.

In this paper, we demonstrate the ability of structured illumination microscopy to enhance the ability of fluorescence lifetime imaging to resolve fluorescence lifetimes in relatively thick samples that possess distinct but spectrally overlapping fluorescent layers. Structured illumination fluorescent lifetime imaging microscopy (SI-FLIM) is shown to be able to accurately reconstruct lifetime values in homogenous fluorophore samples (POPOP, NADH, and FAD) as well as accurately measure fluorescent lifetime in two layer models that are layered with NADH/FAD over POPOP, where NADH/FAD and POPOP have spectral overlap. Finally, the ability of SI-FLIM was demonstrated in a hamster cheek pouch ex vivo to show that more accurate lifetimes could be measured for each layer of interest in the oral mucosa (epithelium and submucosa).

Objective Detection of Oral Carcinoma with Multispectral Fluorescence Lifetime Imaging In Vivo.

Successful early detection and demarcation of oral carcinoma can greatly impact the associated morbidity and mortality rates. Current methods for detection of oral cancer include comprehensive visual examination of the oral cavity, typically followed by tissue biopsy. A noninvasive means to guide the clinician in making a more objective and informed decision toward tissue biopsy can potentially improve the diagnostic yield of this process. To this end, we investigate the potential of fluorescence lifetime imaging (FLIM) for objective detection of oral carcinoma in the hamster cheek pouch model of oral carcinogenesis in vivo. We report that systematically selected FLIM features can differentiate between low-risk (normal, benign and low-grade dysplasia) and high-risk (high-grade dysplasia and cancer) oral lesions with sensitivity and specificity of 87.26% and 93.96%, respectively. We also show the ability of FLIM to generate "disease" maps of the tissue which can be used to evaluate relative risk of neoplasia. The results demonstrate the potential of multispectral FLIM with objective image analysis as a noninvasive tool to guide comprehensive oral examination.

A novel multimodal optical imaging system for early detection of oral cancer.

OBJECTIVES: Several imaging techniques have been advocated as clinical adjuncts to improve identification of suspicious oral lesions. However, these have not yet shown superior sensitivity or specificity over conventional oral examination techniques. We developed a multimodal, multi-scale optical imaging system that combines macroscopic biochemical imaging of fluorescence lifetime imaging with subcellular morphologic imaging of reflectance confocal microscopy for early detection of oral cancer. We tested our system on excised human oral tissues. STUDY DESIGN: In total, 4 tissue specimens were imaged. These specimens were diagnosed as either clinically normal, oral lichen planus, gingival hyperplasia, or superficially invasive squamous cell carcinoma. The optical and fluorescence lifetime properties of each specimen were recorded. RESULTS: Both quantitative and qualitative differences among normal, benign, and squamous cell carcinoma lesions can be resolved with fluorescence lifetime imaging reflectance confocal microscopy. The results demonstrate that an integrated approach based on these two methods can potentially enable rapid screening and evaluation of large areas of oral epithelial tissue. CONCLUSIONS: Early results from ongoing studies of imaging human oral cavity illustrate the synergistic combination of the 2 modalities. An adjunct device based on such optical characterization of oral mucosa can potentially be used to detect oral carcinogenesis in early stages.

Volumetric structured illumination microscopy enabled by a tunable-focus lens.

We present a mechanical-scan-free method for volumetric imaging of biological tissue. The optical sectioning is provided by structured illumination, and the depth of the imaging plane is varied using an electrically tunable-focus lens. We characterize and evaluate the ability of this axial-scanning mechanism in structured illumination microscopy and demonstrate its ability to perform subcellular resolution imaging in oral mucosa ex vivo. The proposed mechanism can potentially convert any wide-field microscope to a 3D-imaging platform without the need for mechanical scanning of imaging optics and/or sample.

A pulse coupled neural network segmentation algorithm for reflectance confocal images of epithelial tissue.

Automatic segmentation of nuclei in reflectance confocal microscopy images is critical for visualization and rapid quantification of nuclear-to-cytoplasmic ratio, a useful indicator of epithelial precancer. Reflectance confocal microscopy can provide three-dimensional imaging of epithelial tissue in vivo with sub-cellular resolution. Changes in nuclear density or nuclear-to-cytoplasmic ratio as a function of depth obtained from confocal images can be used to determine the presence or stage of epithelial cancers. However, low nuclear to background contrast, low resolution at greater imaging depths, and significant variation in reflectance signal of nuclei complicate segmentation required for quantification of nuclear-to-cytoplasmic ratio. Here, we present an automated segmentation method to segment nuclei in reflectance confocal images using a pulse coupled neural network algorithm, specifically a spiking cortical model, and an artificial neural network classifier. The segmentation algorithm was applied to an image model of nuclei with varying nuclear to background contrast. Greater than 90% of simulated nuclei were detected for contrast of 2.0 or greater. Confocal images of porcine and human oral mucosa were used to evaluate application to epithelial tissue. Segmentation accuracy was assessed using manual segmentation of nuclei as the gold standard.

Reflectance confocal endomicroscope with optical axial scanning for in vivo imaging of the oral mucosa.

This paper presents the design and evaluation of a reflectance confocal laser endomicroscope using a miniature objective lens within a rigid probe in conjunction with an electrically tunable lens for axial scanning. The miniature lens was characterized alone as well as in the endoscope across a 200 µm axial scan range using the tunable lens. The ability of the confocal endoscope to probe the human oral cavity is demonstrated by imaging of the oral mucosa in vivo. The results indicate that reflectance confocal endomicroscopy has the potential to be used in a clinical setting and guide diagnostic evaluation of biological tissue.

Handheld multispectral fluorescence lifetime imaging system for in vivo applications.

There is an increasing interest in the application of fluorescence lifetime imaging (FLIM) for medical diagnosis. Central to the clinical translation of FLIM technology is the development of compact and high-speed clinically compatible systems. We present a handheld probe design consisting of a small maneuverable box fitted with a rigid endoscope, capable of continuous lifetime imaging at multiple emission bands simultaneously. The system was characterized using standard fluorescent dyes. The performance was then further demonstrated by imaging a hamster cheek pouch in vivo, and oral mucosa tissue both ex vivo and in vivo, all using safe and permissible exposure levels. Such a design can greatly facilitate the evaluation of FLIM for oral cancer imaging in vivo.

Optical axial scanning in confocal microscopy using an electrically tunable lens.

This paper presents the use and characterization of an electrically focus tunable lens to perform axial scanning in a confocal microscope. Lateral and axial resolution are characterized over a >250 µm axial scan range. Confocal microscopy using optical axial scanning is demonstrated in epithelial tissue and compared to traditional stage scanning. By enabling rapid axial scanning, minimizing motion artifacts, and reducing mechanical complexity, this technique has potential to enhance in vivo three-dimensional imaging in confocal endomicroscopy.

Reflectance confocal microscopy of oral epithelial tissue using an electrically tunable lens.

We present the use of a commercially available electrically tunable lens to achieve axial scanning in a reflectance confocal microscope. Over a 255 µm axial scan range, the lateral and axial resolutions varied from 1-2 µm and 4-14 µm, respectively, dependent on the variable focal length of the tunable lens. Confocal imaging was performed on normal human biopsies from the oral cavity ex vivo. Sub-cellular morphologic features were seen throughout the depth of the epithelium while axially scanning using the focus tunable lens.

Fluorescence lifetime imaging and reflectance confocal microscopy for multiscale imaging of oral precancer.

Optical imaging techniques using a variety of contrast mechanisms are under evaluation for early detection of epithelial precancer; however, tradeoffs in field of view (FOV) and resolution may limit their application. Therefore, we present a multiscale multimodal optical imaging system combining macroscopic biochemical imaging of fluorescence lifetime imaging (FLIM) with subcellular morphologic imaging of reflectance confocal microscopy (RCM). The FLIM module images a 16×16 mm² tissue area with 62.5 µm lateral and 320 ps temporal resolution to guide cellular imaging of suspicious regions. Subsequently, coregistered RCM images are acquired at 7 Hz with 400 µm diameter FOV, <1 µm lateral and 3.5 µm axial resolution. FLIM-RCM imaging was performed on a tissue phantom, normal porcine buccal mucosa, and a hamster cheek pouch model of oral carcinogenesis. While FLIM is sensitive to biochemical and macroscopic architectural changes in tissue, RCM provides images of cell nuclear morphology, all key indicators of precancer progression.

Design and characterization of a ferromagnetic, air gapped magneto-optic Faraday rotator.

A method has been developed to modulate the plane of polarized light through the use of a high permeability ferrite core design. A proof-of-principal, optical Faraday effect device has been constructed and tested. Magnetic fields were generated to provide up to 1 deg of rotation at frequencies of direct current up to 10 kHz using a terbium gallium garnet crystal rod.

Dual-wavelength polarimetric glucose sensing in the presence of birefringence and motion artifact using anterior chamber of the eye phantoms.

Noninvasive glucose monitoring is being investigated as a tool for effectively managing diabetes mellitus. Optical polarimetry has emerged as one such method, which can potentially be used to ascertain blood glucose levels by measuring the aqueous humor glucose levels in the anterior chamber of the eye. The key limitation for realizing this technique is the presence of sample noise due to corneal birefringence, which in the presence of motion artifact can confound the glucose signature in the aqueous humor of the eye. We present the development and characterization of a real-time, closed-loop, dual-wavelength polarimetric system for glucose monitoring using both a custom-built plastic eye phantom (in vitro) and isolated rabbit corneas (ex vivo) mounted in an artificial anterior chamber. The results show that the system can account for these noise sources and can monitor physiologic glucose levels accurately for a limited range of motion-induced birefringence. Using the dual-wavelength system in vitro and ex vivo, standard errors were 14.5 mg/dL and 22.4 mg/dL, respectively, in the presence of birefringence with motion. The results indicate that although dual-wavelength polarimetry has a limited range of compensation for motion-induced birefringence, when aligned correctly, it can minimize the effect of time-varying corneal birefringence for a range of motion larger than what has been reported in vivo.

In vivo glucose monitoring using dual-wavelength polarimetry to overcome corneal birefringence in the presence of motion.

OBJECTIVE: Over the past 35 years considerable research has been performed toward the investigation of noninvasive and minimally invasive glucose monitoring techniques. Optical polarimetry is one noninvasive technique that has shown promise as a means to ascertain blood glucose levels through measuring the glucose concentrations in the anterior chamber of the eye. However, one of the key limitations to the use of optical polarimetry as a means to noninvasively measure glucose levels is the presence of sample noise caused by motion-induced time-varying corneal birefringence. RESEARCH DESIGN AND METHODS: In this article our group presents, for the first time, results that show dual-wavelength polarimetry can be used to accurately detect glucose concentrations in the presence of motion-induced birefringence in vivo using New Zealand White rabbits. RESULTS: In total, nine animal studies (three New Zealand White rabbits across three separate days) were conducted. Using the dual-wavelength optical polarimetric approach, in vivo, an overall mean average relative difference of 4.49% (11.66 mg/dL) was achieved with 100% Zone A+B hits on a Clarke error grid, including 100% falling in Zone A. CONCLUSIONS: The results indicate that dual-wavelength polarimetry can effectively be used to significantly reduce the noise due to time-varying corneal birefringence in vivo, allowing the accurate measurement of glucose concentration in the aqueous humor of the eye and correlating that with blood glucose.

Modeling the corneal birefringence of the eye toward the development of a polarimetric glucose sensor.

Optical polarimetry for monitoring glucose concentration in the aqueous humor of the eye as a potential noninvasive means of assessing blood glucose has promise, but the realization of such an approach has been limited by noise from time-varying corneal birefringence due to motion artifact. Modeling the corneal birefringence of the eye is critically important toward understanding the overall effect of this noise source compared to other changes in the signal, and can aid in design of the polarimetric system. To this end, an eye model is introduced in this work that includes spatially varying birefringence properties of the cornea. The degree of birefringence and the fast axis orientation is calculated as a function of beam position on the anterior chamber. It is shown that the minimum change in polarization vector orientation occurs for beam position near the midpoint between the corneal apex and limbus. In addition, the relative wavelength independence of motion artifact is shown in the same region. The direct consequence of these findings are that a multiwavelength polarimetric system can potentially be utilized to eliminate the effect of time-varying corneal birefringence, and that eye coupling is optimal at the midpoint between the apex and limbus.

Real-time, closed-loop dual-wavelength optical polarimetry for glucose monitoring.

The development of a real-time, dual-wavelength optical polarimetric system to ultimately probe the aqueous humor glucose concentrations as a means of noninvasive diabetic glucose monitoring is the long-term goal of this research. The key impact of the work is the development of an approach for the reduction of the time-variant corneal birefringence due to motion artifact, which is still a limiting factor preventing the realization of such a device. Our dual-wavelength approach utilizes real-time, closed-loop feedback that employs a classical three-term feedback controller and efficiently reduces the effect of motion artifact that appears as a common noise source for both wavelengths. In vitro results are shown for the open-loop system, and although the dual-wavelength system helps to reduce the noise, it is shown that closed-loop control is necessary to bring the noise down to a sufficient level for physiological monitoring. Specifically, in vitro measurement results with the closed-loop dual-wavelength approach demonstrate a sensitivity of 12.8 mg/dl across the physiologic glucose range in the presence of time-variant test cell birefringence. Overall, it is shown that this polarimetric system has the potential to be used as a noninvasive measure of glucose for diabetes.

Characterizing dual wavelength polarimetry through the eye for monitoring glucose.

Diabetes is an insidious disease that afflicts millions of people worldwide and typically requires the person with the disease to monitor their blood sugar level via finger or forearm sticks multiple times daily. Therefore, the ability to noninvasively measure glucose would be a significant advancement for the diabetic community. The use of optically polarized light passed through the anterior chamber of the eye is one proposed noninvasive approach for glucose monitoring. However, the birefringence of the cornea and the difficulty in coupling the light across the eye have been major drawbacks toward realizing this approach. A dual wavelength optical polarimetric approach has been proposed as a means to potentially overcome the birefringence noise but has never been fully characterized. Therefore, in this paper an optical model has been developed along with experiments performed on New Zealand White rabbit eyes for characterizing the light path and corneal birefringence at two different wavelengths as they are passed through the anterior chamber of the eye. The results show that, without index matching, it is possible to couple the light in and out of the eye but only across a very limited range otherwise the light does not come back out of the eye. It was also shown that there is potential to use a dual wavelength approach to accommodate the birefringence noise of the cornea in the presence of eye motion. These results will be used to help guide the final design of the polarimetric system for use in noninvasive monitoring of glucose in vivo.