Automated Detection of Anatomical Landmarks During Colonoscopy Using a Deep Learning Model.

Background and aims: Identification and photo-documentation of the ileocecal valve (ICV) and appendiceal orifice (AO) confirm completeness of colonoscopy examinations. We aimed to develop and test a deep convolutional neural network (DCNN) model that can automatically identify ICV and AO, and differentiate these landmarks from normal mucosa and colorectal polyps. Methods: We prospectively collected annotated full-length colonoscopy videos of 318 patients undergoing outpatient colonoscopies. We created three nonoverlapping training, validation, and test data sets with 25,444 unaltered frames extracted from the colonoscopy videos showing four landmarks/image classes (AO, ICV, normal mucosa, and polyps). A DCNN classification model was developed, validated, and tested in separate data sets of images containing the four different landmarks. Results: After training and validation, the DCNN model could identify both AO and ICV in 18 out of 21 patients (85.7%). The accuracy of the model for differentiating AO from normal mucosa, and ICV from normal mucosa were 86.4% (95% CI 84.1% to 88.5%), and 86.4% (95% CI 84.1% to 88.6%), respectively. Furthermore, the accuracy of the model for differentiating polyps from normal mucosa was 88.6% (95% CI 86.6% to 90.3%). Conclusion: This model offers a novel tool to assist endoscopists with automated identification of AO and ICV during colonoscopy. The model can reliably distinguish these anatomical landmarks from normal mucosa and colorectal polyps. It can be implemented into automated colonoscopy report generation, photo-documentation, and quality auditing solutions to improve colonoscopy reporting quality.

Postoperative Assessment of Pedicle Screws and Management of Breaches: A Survey among Canadian Spine Surgeons and a New Scoring System.

STUDY DESIGN: This study was designed as a survey amongst Canadian spine surgeon to determine a scoring system to standardize pedicle screw placement assessment. PURPOSE: This study aimed to obtain and analyze the opinions of spine surgeons regarding the assessment of pedicle screw accuracy, with the goal of establishing clinical guidelines for interventions for malpositioned pedicle screws. OVERVIEW OF LITERATURE: Accurate placement of pedicle screws is challenging, and misalignment can lead to various complications. To date, there is no recognized gold standard for assessing pedicle screw placement accuracy. The literature is lacking studies attempting to standardize pedicle screw placement accuracy assessment. METHODS: A survey of the clinical methods and imaging criteria that are used for assessing pedicle screw placement accuracy was designed and sent to orthopedic and neurosurgery spine surgeons from the Canadian Spine Society for their anonymous participation. RESULTS: Thirty-five surgeons completed the questionnaire. The most commonly used modalities for assessing pedicle screw position postoperatively were plain X-rays (97%) and computed tomography (CT, 97%). In both symptomatic and asymptomatic patients, the most and least worrisome breaches were medial and anterior breaches, respectively. The majority of surgeons tended not to re-operate on asymptomatic breaches. More than 60% of surgeons would re-operate on patients with new-onset pain and a ≤4-mm medial or inferior breach in both thoracic and lumbar regions. If a patient experienced sensory loss and a breach on CT, in either the thoracic or lumbar levels, 90% and 70% of the surgeons would re-operate for a medial breach and an inferior breach, respectively. CONCLUSIONS: Postoperative clinical presentation and imaging findings are crucial for interpreting aberrant pedicle screw placement. This study presents a preliminary scoring system for standardizing the classification of pedicle screws.

Assessment of the effect of systemic delivery of sclerostin antibodies on Wnt signaling in distraction osteogenesis.

Sclerostin is a known inhibitor of the Wnt signaling pathway which is involved in osteogenesis and, when inactivated, stimulates bone formation. To our knowledge, this effect has not been studied in the context of distraction osteogenesis (DO). Tibial DO was conducted on a total of 24 wild-type mice, which were then divided into 2 groups-a saline injection group (control) and an anti-sclerostin (Scl-Ab) injection group (treatment). The mice in the treatment group received 100 mg/kg intravenous injections of the antibody weekly until killing. The 12 mice in each group were subdivided into four time points according to post-osteotomy time of killing-11 days (mid-distraction), 17 days (late distraction), 34 days (mid-consolidation) and 51 days (late consolidation), with 3 mice per subgroup. After killing, the tibia specimens were collected for immunohistochemical analysis. Our results show that the group injected with anti-sclerostin had an earlier peak (day 11) in the distraction phase of the osteogenic molecules involved in the Wnt signaling pathway in comparison to the placebo group. In addition, downregulation of the inhibitors of this pathway was noted in the treatment group when compared with the placebo group. Furthermore, LRP-5 showed a significant increase in expression in the treatment group. Sclerostin inhibition has a significant effect on the DO process through its effect on the Wnt pathway. This effect was evident through the decreased effect of sclerostin on LRP-5 and earlier upregulation of the osteogenic molecules involved in this pathway.

Neurofibromatosis Clinic: A Report on Patient Demographics and Evaluation of the Clinic.

BACKGROUND: Neurofibromatosis type 1 (NF1) is a common single-gene disorder. A multidisciplinary approach to the management of NF1 patients is necessitated by the heterogeneity of clinical manifestations. Although multidisciplinary paediatric clinics have been well established, there is a dearth of such resources for adults with NF1. Herein we report our one-year institutional experience with a multidisciplinary adult NF1 clinic. METHODS: A multidisciplinary team was assembled, and an NF Patient Registry Initiative questionnaire was adapted to collect patient-reported data during clinics. Multiple databases were searched to identify publications pertaining to the experience of other multidisciplinary NF1 clinics focusing on adult patients. Data on patient epidemiology and clinical staff were compared to our data. RESULTS: A total of 77 patients were scheduled, and 68 attended the clinic, of whom 66 completed the intake questionnaire. The demographic and clinical data from this Canadian population are mostly consistent with previous reports, with some exceptions. Clinical data related to immune system involvement such as asthma, airway/breathing-related difficulties or allergies were striking in our NF1 population. Six relevant published reports of other NF1 clinics were identified. Reports from these studies pertained to periods ranging from 10 to 38 months, and the number of adults assessed ranged from 19 to 177 patients. CONCLUSIONS: The structure of our clinic and the patient volume are comparable to those of other established centres found in the literature. Our data offer valuable cross-sectional prevalence statistics in the Canadian population. The patient-reported data concerning involvement of the immune system contribute to an emerging recognized medical concern within the NF1 population and warrant further clinical and basic investigation.

ß-Catenin modulation in neurofibromatosis type 1 bone repair: therapeutic implications.

Tibial pseudarthrosis causes substantial morbidity in patients with neurofibromatosis type 1 (NF1). We studied tibial pseudarthrosis tissue from patients with NF1 and found elevated levels of ß-catenin compared to unaffected bone. To elucidate the role of ß-catenin in fracture healing, we used a surgically induced tibial fracture model in conditional knockout (KO) Nfl (Nf1(flox/flox)) mice. When treated with a Cre-expressing adenovirus (Ad-Cre), there was a localized knockdown of Nf1 in the healing fracture and a subsequent development of a fibrous pseudarthrosis. Consistent with human data, elevated ß-catenin levels were found in the murine fracture sites. The increased fibrous tissue at the fracture site was rescued by local treatment with a Wingless-type MMTV integration site (Wnt) antagonist, Dickkopf-1 (Dkk1). The murine pseudarthrosis phenotype was also rescued by conditional ß-catenin gene inactivation. The number of colony-forming unit osteoblasts (CFU-Os), a surrogate marker of undifferentiated mesenchymal cells able to differentiate to osteoblasts, correlated with the capacity to form bone at the fracture site. Our findings indicate that the protein level of ß-catenin must be precisely regulated for normal osteoblast differentiation. An up-regulation of ß-catenin in NF1 causes a shift away from osteoblastic differentiation resulting in a pseudarthrosis in vivo These results support the notion that pharmacological modulation of ß-catenin can be used to treat pseudarthrosis in patients with NF1.-Ghadakzadeh, S., Kannu, P., Whetstone, H., Howard A., Alman, B. A. ß-catenin modulation in neurofibromatosis type 1 bone repair: therapeutic implications.

Small Players Ruling the Hard Game: siRNA in Bone Regeneration.

Silencing gene expression through a sequence-specific manner can be achieved by small interfering RNAs (siRNAs). The discovery of this process has opened the doors to the development of siRNA therapeutics. Although several preclinical and clinical studies have shown great promise in the treatment of neurological disorders, cancers, dominant disorders, and viral infections with siRNA, siRNA therapy is still gaining ground in musculoskeletal tissue repair and bone regeneration. Here we present a comprehensive review of the literature to summarize different siRNA delivery strategies utilized to enhance bone regeneration. With advancement in understanding the targetable biological pathways involved in bone regeneration and also the rapid progress in siRNA technologies, application of siRNA for bone regeneration has great therapeutic potential. High rates of musculoskeletal injuries and diseases, and their inevitable consequences, impose a huge financial burden on individuals and healthcare systems worldwide.

Body Image Concern Inventory (BICI) for identifying patients with BDD seeking rhinoplasty: using a Persian (Farsi) version.

BACKGROUND: Dissatisfaction with appearance is most pronounced in rhinoplasty patients compared to candidates for other aesthetic procedures. We aimed to test and introduce the Body Image Concern Inventory (BICI) as a self-report screening tool for identifying body dysmorphic disorder (BDD) among patients seeking rhinoplasty. METHODS: The surgeon completed a two-point defect severity scale in which a score of 1 represented no defect or one defect and a score of 2 represented more than one defect. Each of the 117 subjects with a score of 1 answered a questionnaire that was designed to obtain demographic data and completed the Persian version of the BICI. The psychiatrist, considering the patient's demographic data and blind to the BICI score, interviewed him/her using a semistructured diagnostic tool for BDD based on DSM-IV. RESULTS: The validity of the Persian version of the BICI was calculated at 85%. The reliability of the Persian BICI items was tested and Cronbach's alpha was 0.90. The results of ROC analysis for the ideal cutoff point of the Persian BICI, based on the Youden index method and optimum sensitivity and specificity, revealed that the ideal cutoff point for positive or negative criterion of that questionnaire's result may be the total score of 42 (sensitivity, 93.5%; specificity, 80.8%) The diagnostic accuracy of the Persian BICI in comparison with the gold standard (psychiatric interview), according to the area under the ROC curve (AUC), was 91.4% (95% CI = 86-97%, P < 0.0001). The agreement of the results of the Persian BICI questionnaire with the psychiatric interview for diagnosis of BDD, according to kappa index, was 61.7% (P < 0.001), and the odds ratio (OR) of being diagnosed with BDD in a psychiatric interview for those with overall scores ≥42 for the Persian BICI was 47.7 (95% CI = 43-52). CONCLUSION: The results of the present study emphasize the high rate of BDD (12.2%) in subjects seeking rhinoplasty. The BICI appears to be an internally consistent and valid brief multiple-choice instrument for assessing dysmorphic concern. To our knowledge, this is the first time that this measure has ever been used for identifying BDD patients in a rhinoplasty setting; it is also the first time that ROC analysis has been used for calculating and analyzing the results of BICI. Our study suggests that rhinoplasty surgeons could rely on the scores of the BICI to identify subjects with probable BDD among their consultants with no or one slight defect.

Swyer syndrome in a woman with pure 46,XY gonadal dysgenesis and a hypoplastic uterus: a rare presentation.

OBJECTIVE: To report a rare presentation of Swyer syndrome in a woman with pure 46,XY gonadal dysgenesis. DESIGN: Case report. SETTING: Academic gynecology and obstetrics department. PATIENT(S): A 28-year-old woman with primary amenorrhea. INTERVENTION(S): Laparoscopic gonadectomy. MAIN OUTCOME MEASURE(S): Age at diagnosis, risk of gonadal malignancy, bone mineral density, uterus size, height. RESULT(S): The patient had pure 46,XY gonadal dysgenesis with hypoplastic uterus, which is a rare finding in Swyer syndrome. She had developed no gonadal malignancies and, despite receiving estrogen, had remained amenorrheic. CONCLUSION(S): Further studies should be done on this rare chromosomal condition to find the exact factors affecting the uterus size and to improve the ways of inducing puberty in such patients by considering the age of diagnosis in order to help them have a normal sex life and also the ability to carry a fetus in their immature uteruses.

The comparison between two different combinations of alar cartilage-modifying techniques: is lateral crural steal the choice?

To assess the effect of two different combinations of alar cartilage-modifying techniques on the degree of nasal tip projection and rotation, a prospective trial was performed using preoperative and postoperative photos. The patients were seen in private practice. Sixty patients who had underprojected with/without underrotated nasal tips, primarily due to alar cartilage malformities, were randomly divided into two equal groups (A, B). All patients were operated using an external rhinoplasty approach. The techniques of narrowing transdomal sutures and placing a collumellar strut were used in both groups; in addition, lateral crural steal (LCS) was used only in group B. The patients were reevaluated after a minimum period of 6 months. The nasofacial angle and the Goode ratio were measured to assess tip projection and the nasolabial angle was used to assess tip rotation. The patients of both groups showed significant increase in tip projection and rotation (P < 0.001). Additionally, the use of LCS in patients of group B resulted in significantly more increase in tip projection and rotation in comparison with group A (P < 0.05). The LCS along with placement of a columellar strut and a transdomal suture is more beneficial in patients suffering from underprojection with/without underrotated nasal tips.