The prevalence of genital injuries in post-pubertal females presenting for forensic examination after reported sexual violence: a systematic review

BACKGROUND

Sexual violence is a prevalent issue in contemporary society requiring a robust forensic healthcare response. It is critically important that forensic examiners put clinical examination findings into an appropriate evidence-based context. The presence of genital injuries has been shown to increase the likelihood of successful criminal prosecution and report the crime. However, the reported rates of genital injury vary widely in published studies.

AIMS AND OBJECTIVES

We aim to critically evaluate and synthesize existing literature on the prevalence of genital injuries in post-pubertal females, examined following sexual violence, with a view to describing the prevalence and characteristics of genital injuries as well as the range of forensic practices employed.

METHODS

Three online databases (PubMed, Embase, and Scopus) were systematically searched with key terms.

RESULTS

Of the 1224 studies screened, 141 full-text publications met the inclusion criteria. Reported injury prevalence rates varied widely. Details pertaining to forensic examinations included in each study, such as grade of the examiner, type of examination, location of examination, and time interval from assault to examination also varied widely. Injury prevalence was highest in studies where enhanced visualization techniques were utilized.

CONCLUSIONS

This systematic review demonstrates that there is no universally agreed standard for documenting genital injuries in cases of sexual violence and highlights the need for standardized approaches and guidelines for assessing, documenting, and reporting these injuries. The review provides robust evidence to support a call for establishing consistent context, terminology, classification systems, and data collection methods to improve the comparability and reliability of future research findings.

Resilience in adolescence during the COVID-19 crisis in Canada

BACKGROUND

The COVID-19 pandemic constitutes a social crisis that will have long-term health consequences for much of the global population, especially for adolescents. Adolescents are triply affected as they: 1) are experiencing its immediate, direct effects, 2) will carry forward health habits they develop now into adulthood, and 3) as future parents, will shape the early life health of the next generation. It is therefore imperative to assess how the pandemic is influencing adolescent wellbeing, identify sources of resilience, and outline strategies for attenuating its negative impacts.

METHODS

We report the results of longitudinal analyses of qualitative data from 28 focus group discussions (FGDs) with 39 Canadian adolescents and of cross-sectional analyses of survey data from 482 Canadian adolescents gathered between September 2020 and August 2021. FGD participants and survey respondents reported on their: socio-demographic characteristics; mental health and wellbeing before and during the pandemic; pre- and during-pandemic health behaviours; experiences living through a crisis; current perceptions of their school, work, social, media, and governmental environments; and ideas about pandemic coping and mutual aid. We plotted themes emerging from FGDs along a pandemic timeline, noting socio-demographic variations. Following assessment for internal reliability and dimension reduction, quantitative health/wellbeing indicators were analyzed as functions of composite socio-demographic, health-behavioural, and health-environmental indicators.

RESULTS

Our mixed methods analyses indicate that adolescents faced considerable mental and physical health challenges due to the pandemic, and were generally in poorer health than expected in non-crisis times. Nevertheless, some participants showed significantly better outcomes than others, specifically those who: got more exercise; slept better; were food secure; had clearer routines; spent more time in nature, deep in-person social relationships, and leisure; and spent less time on social media.

CONCLUSIONS

Support for youth during times of crisis is essential to future population health because adolescence is a period in the life course which shapes the health behaviours, socio-economic capacities, and neurophysiology of these future parents/carers and leaders. Efforts to promote resilience in adolescents should leverage the factors identified above: helping them find structure and senses of purpose through strong social connections, well-supported work and leisure environments, and opportunities to engage with nature.

Influence of lactation stage on heat production and macronutrient oxidation in dairy cows during a 24-hour fasting period

Understanding nutrient utilization and partitioning is essential for advancing the efficiency of dairy cattle. Our objective was to determine if dairy cows exposed to a 24-h fasting period differ in heat production (HP) and macronutrient oxidation at different stages of lactation. Twelve primiparous, lactating German Holstein dairy cows were used in a longitudinal study design spanning from 2013 to 2014. Dairy cows were housed in respiration chambers during 3 stages of the lactation cycle: early (mean ± SD; 28.8 ± 6.42 d), mid- (89.4 ± 4.52 d), and late (293 ± 7.76 d) lactation. Individual CO₂, O₂, and CH₄ gas exchanges were measured every 6 min for two 24-h periods, an ad libitum period and fasting period (RES). Blood was sampled at the start and end of the RES period. Gas measurements were used to calculate HP, net carbohydrate oxidation (COX), and net fat oxidation (FOX). Measurements were corrected with metabolic BW (kg of BW^0.75; cBW). The RES period for each stage of lactation was further subdivided into the start (RES_start) and end (RES_end) by averaging the first and last 2 h of the RES period. The net change was calculated as RES_end - RES_start. All energy variables differed among lactation stage within the RES period except for HP/cBW. As expected, COX, COX/cBW, COX/HP, HP, and HP/cBW, were greater at the RES_start compared with RES_end, whereas FOX, FOX/cBW, and FOX/HP were greater at the RES_end except for FOX and FOX/cBW during mid lactation, which was only a tendency for a difference. The net change for COX, COX/cBW, HP, HP/cBW, and FOX/cBW did not differ among stages of lactation. Despite detecting a tendency for a difference among stage of lactation for FOX, pairwise analysis revealed no differences. Plasma triglyceride, urea, and nonesterified fatty acid concentrations were greater at RES_end than RES_start. The net change for plasma glucose, urea, β-hydroxybutyrate, and nonesterified fatty acid concentrations were greater in early than late lactation. Our results demonstrate that despite differences in absolute measurements of energy variables and plasma metabolites, the change in whole-body macronutrient oxidation and HP as cows' transition from a fed-like state to a starvation-like state during a 24-h fasting period is consistent throughout lactation.

Utility of Environmental Complexity as a Predictor of Alzheimer's Disease Diagnosis: A Big-Data Machine Learning Approach

BACKGROUND

Rural-urban differences and spatial navigation deficits have received much attention in Alzheimer's Disease research. While individual environmental and neighborhood factors have been independently investigated, their integrative, multifactorial effects on Alzheimer's diagnosis have not. Here we explore this "environmental complexity" for predictive power in classifying Alzheimer's from cognitively-normal status.

METHODS

We utilized data from the National Alzheimer's Coordinating Center (NACC) uniform data set containing annual visits since 2005 and selected individuals with multiple visits and who remained in their zipcode (N = 22,553). We georeferenced each subject with 3-digit zipcodes of their residences since entering the program. We calculated environmental complexity measures using geospatial tools from street networks and landmarks for spatial navigation in subjects' zipcode zones. Zipcode zones were grouped into two cognitive classes (Cognitively-Normal and Alzheimer's-inclined) based on the ratios of AD and dementia subjects to all subjects in an individual zipcode zone. We randomly selected 80% of the data to train a neural network classifier model on environmental complexity measures to predict the cognitive class for each zone, controlling for salient demographic variables. The remaining 20% served as the test set for performance evaluation.

RESULTS

Our proposed model reached excellent classification ability on the testing data: 83.87% accuracy, 95.23% precision, 83.33% recall, and 0.8889 F1-score (F1-score=1 for perfect prediction). The most salient features of "Alzheimer's-inclined" zipcode zones included longer street-length average, higher circuity, and slightly fewer points of interest. Most "cognitively-normal" zipcode zones appeared in or near urban areas with high environmental complexity measures.

CONCLUSION

Environmental complexity, reflected in frequency and density of street networks and landmarks features, predicted with high precision the cognitive status of 3-digit zipcode zones based on the etiologic diagnoses and observed cognitive impairment of NACC subjects residing in these zones. The zipcode zones vary widely in size (1.6 km2 to 35,241 km2), and large zipcode zones suffer high spatial heterogeneity. Other proven AD risk factors, such as PM2.5, disperse across zones, and so do individual's activities, leading to spatial uncertainty. Nevertheless, the model classifies diagnosis well, establishing the need for prospective experiments to quantify effects of environmental complexity on Alzheimer's development.

Tissue engineered autologous cartilage-bone grafts for temporomandibular joint regeneration

Joint disorders can be detrimental to quality of life. There is an unmet need for precise functional reconstruction of native-like cartilage and bone tissues in the craniofacial space and particularly for the temporomandibular joint (TMJ). Current surgical methods suffer from lack of precision and comorbidities and frequently involve multiple operations. Studies have sought to improve craniofacial bone grafts without addressing the cartilage, which is essential to TMJ function. For the human-sized TMJ in the Yucatan minipig model, we engineered autologous, biologically, and anatomically matched cartilage-bone grafts for repairing the ramus-condyle unit (RCU), a geometrically intricate structure subjected to complex loading forces. Using image-guided micromilling, anatomically precise scaffolds were created from decellularized bone matrix and infused with autologous adipose-derived chondrogenic and osteogenic progenitor cells. The resulting constructs were cultured in a dual perfusion bioreactor for 5 weeks before implantation. Six months after implantation, the bioengineered RCUs maintained their predefined anatomical structure and regenerated full-thickness, stratified, and mechanically robust cartilage over the underlying bone, to a greater extent than either autologous bone-only engineered grafts or acellular scaffolds. Tracking of implanted cells and parallel bioreactor studies enabled additional insights into the progression of cartilage and bone regeneration. This study demonstrates the feasibility of TMJ regeneration using anatomically precise, autologous, living cartilage-bone grafts for functional, personalized total joint replacement. Inclusion of the adjacent tissues such as soft connective tissues and the TMJ disc could further extend the functional integration of engineered RCUs with the host.

Differences in net fat oxidation, heat production, and liver mitochondrial DNA copy numbers between high and low feed-efficient dairy cows

Improving feed utilization efficiency in dairy cattle could have positive economic and environmental effects that would support the sustainability of the dairy industry. Identifying key differences in metabolism between high and low feed-efficient animals is vital to enhancing feed conversion efficiency. Therefore, our objectives were (1) to determine whether cows grouped by either high or low feed efficiency have measurable differences in net fat and carbohydrate metabolism that account for differences in heat production (HP), and if so, whether these differences also exists under conditions of feed withdrawal when the effect of feeding on HP is minimized, and (2) to determine whether the abundance of mitochondria in the liver can be related to the high or low feed-efficient groups. Ten dairy cows from a herd of 15 (parity = 2) were retrospectively grouped into either a high (H) or a low (L) feed-efficient group (n = 5 per group) based on weekly energy-corrected milk (ECM) divided by dry mater intake (DMI) from wk 4 through 30 of lactation. Livers were biopsied at wk -4, 2, and 12, and blood was sampled weekly from wk -3 to 12 relative to parturition. Blood was subset to be analyzed for the transition period (wk -3 to 3) and from wk 4 to 12. In wk 5.70 ± 0.82 (mean ± SD) postpartum (PP), cows spent 2 d in respiration chambers (RC), in which CO₂, O₂, and CH₄ gases were measured every 6 min for 24 h. Fatty acid oxidation (FOX), carbohydrate oxidation (COX), metabolic respiratory quotient (RQ), and HP were calculated from gas measurements for 23 h. Cows were fed ad libitum (AD-LIB) on d 1 and had feed withdrawn (RES, restricted diet) on d 2. Additional blood samples were taken at the end of the AD-LIB and RES feeding periods in the RC. During wk 4 to 30 PP, H had greater DMI/kg of metabolic body weight (BW^0.75), ECM per kilogram of BW^0.75 yield, and ECM/DMI ratio, compared with L, but a lower body condition score between wk 4 and 12 PP. In the RC period, we detected no differences in BW, DMI, or milk yield between groups. We also detected no significant group or group by feeding period interactions for plasma metabolites except for Revised Quantitative Insulin Sensitivity Check Index, which tended to have a group by feeding period interaction. The H group had lower HP and HP per kilogram of BW^0.75 compared with L. Additionally, H had lower FOX and FOX per kilogram of BW^0.75 compared with L during the AD-LIB period. Methane, CH₄ per kilogram of BW^0.75, and CH₄ per kilogram of milk yield were lower in H compared with L, but, when adjusted for DMI, CH₄/DMI did not differ between groups, nor did HP/DMI. Relative mitochondrial DNA copy numbers in the liver were lower in the L than in the H group. These results suggest that lower feed efficiency in dairy cows may result from fewer mitochondria per liver cell as well as a greater whole-body HP, which likely partially results from higher net fat oxidation.

Optical palpation for tumor margin assessment in breast-conserving surgery

Intraoperative margin assessment is needed to reduce the re-excision rate of breast-conserving surgery. One possibility is optical palpation, a tactile imaging technique that maps stress (force applied across the tissue surface) as an indicator of tissue stiffness. Images (optical palpograms) are generated by compressing a transparent silicone layer on the tissue and measuring the layer deformation using optical coherence tomography (OCT). This paper reports, for the first time, the diagnostic accuracy of optical palpation in identifying tumor within 1 mm of the excised specimen boundary using an automated classifier. Optical palpograms from 154 regions of interest (ROIs) from 71 excised tumor specimens were obtained. An automated classifier was constructed to predict the ROI margin status by first choosing a circle diameter, then searching for a location within the ROI where the circle was ≥ 75% filled with high stress (indicating a positive margin). A range of circle diameters and stress thresholds, as well as the impact of filtering out non-dense tissue regions, were tested. Sensitivity and specificity were calculated by comparing the automated classifier results with the true margin status, determined from co-registered histology. 83.3% sensitivity and 86.2% specificity were achieved, compared to 69.0% sensitivity and 79.0% specificity obtained with OCT alone on the same dataset using human readers. Representative optical palpograms show that positive margins containing a range of cancer types tend to exhibit higher stress compared to negative margins. These results demonstrate the potential of optical palpation for margin assessment.

Diagnostic Accuracy of Quantitative Micro-Elastography for Margin Assessment in Breast-Conserving Surgery

Inadequate margins in breast-conserving surgery (BCS) are associated with an increased likelihood of local recurrence of breast cancer. Currently, approximately 20% of BCS patients require repeat surgery due to inadequate margins at the initial operation. Implementation of an accurate, intraoperative margin assessment tool may reduce this re-excision rate. This study determined, for the first time, the diagnostic accuracy of quantitative micro-elastography (QME), an optical coherence tomography (OCT)-based elastography technique that produces images of tissue microscale elasticity, for detecting tumor within 1 mm of the margins of BCS specimens. Simultaneous OCT and QME were performed on the margins of intact, freshly excised specimens from 83 patients undergoing BCS and on dissected specimens from 7 patients undergoing mastectomy. The resulting three-dimensional images (45 × 45 × 1 mm) were coregistered with postoperative histology to determine tissue types present in each scan. Data from 12 BCS patients and the 7 mastectomy patients served to build a set of images for reader training. One hundred and fifty-four subimages (10 × 10 × 1 mm) from the remaining 71 BCS patients were included in a blinded reader study, which resulted in 69.0% sensitivity and 79.0% specificity using OCT images, versus 92.9% sensitivity and 96.4% specificity using elasticity images. The quantitative nature of QME also facilitated development of an automated reader, which resulted in 100.0% sensitivity and 97.7% specificity. These results demonstrate high accuracy of QME for detecting tumor within 1 mm of the margin and the potential for this technique to improve outcomes in BCS. SIGNIFICANCE: An optical imaging technology probes breast tissue elasticity to provide accurate assessment of tumor margin involvement in breast-conserving surgery.

Immune-mediated ECM depletion improves tumour perfusion and payload delivery

High extracellular matrix (ECM) content in solid cancers impairs tumour perfusion and thus access of imaging and therapeutic agents. We have devised a new approach to degrade tumour ECM, which improves uptake of circulating compounds. We target the immune‐modulating cytokine, tumour necrosis factor alpha (TNFα), to tumours using a newly discovered peptide ligand referred to as CSG. This peptide binds to laminin–nidogen complexes in the ECM of mouse and human carcinomas with little or no peptide detected in normal tissues, and it selectively delivers a recombinant TNFα‐CSG fusion protein to tumour ECM in tumour‐bearing mice. Intravenously injected TNFα‐CSG triggered robust immune cell infiltration in mouse tumours, particularly in the ECM‐rich zones. The immune cell influx was accompanied by extensive ECM degradation, reduction in tumour stiffness, dilation of tumour blood vessels, improved perfusion and greater intratumoral uptake of the contrast agents gadoteridol and iron oxide nanoparticles. Suppressed tumour growth and prolonged survival of tumour‐bearing mice were observed. These effects were attainable without the usually severe toxic side effects of TNFα.

Cochlear compound action potentials from high-level tone bursts originate from wide cochlear regions that are offset toward the most sensitive cochlear region

Little is known about the spatial origins of auditory nerve (AN) compound action potentials (CAPs) evoked by moderate to intense sounds. We studied the spatial origins of AN CAPs evoked by 2- to 16-kHz tone bursts at several sound levels by slowly injecting kainic acid solution into the cochlear apex of anesthetized guinea pigs. As the solution flowed from apex to base, it sequentially reduced CAP responses from low- to high-frequency cochlear regions. The times at which CAPs were reduced, combined with the cochlear location traversed by the solution at that time, showed the cochlear origin of the removed CAP component. For low-level tone bursts, the CAP origin along the cochlea was centered at the characteristic frequency (CF). As sound level increased, the CAP center shifted basally for low-frequency tone bursts but apically for high-frequency tone bursts. The apical shift was surprising because it is opposite the shift expected from AN tuning curve and basilar membrane motion asymmetries. For almost all high-level tone bursts, CAP spatial origins extended over 2 octaves along the cochlea. Surprisingly, CAPs evoked by high-level low-frequency (including 2 kHz) tone bursts showed little CAP contribution from CF regions ≤ 2 kHz. Our results can be mostly explained by spectral splatter from the tone-burst rise times, excitation in AN tuning-curve "tails," and asynchronous AN responses to high-level energy ≤ 2 kHz. This is the first time CAP origins have been identified by a spatially specific technique. Our results show the need for revising the interpretation of the cochlear origins of high-level CAPs-ABR wave 1. NEW & NOTEWORTHY Cochlear compound action potentials (CAPs) and auditory brain stem responses (ABRs) are routinely used in laboratories and clinics. They are typically interpreted as arising from the cochlear region tuned to the stimulus frequency. However, as sound level is increased, the cochlear origins of CAPs from tone bursts of all frequencies become very wide and their centers shift toward the most sensitive cochlear region. The standard interpretation of CAPs and ABRs from moderate to intense stimuli needs revision.

Clinical feasibility of optical coherence micro-elastography for imaging tumor margins in breast-conserving surgery

It has been demonstrated that optical coherence micro-elastography (OCME) provides additional contrast of tumor compared to optical coherence tomography (OCT) alone. Previous studies, however, have predominantly been performed on mastectomy specimens. Such specimens typically differ substantially in composition and geometry from the more clinically relevant wide-local excision (WLE) specimens excised during breast-conserving surgery. As a result, it remains unclear if the mechanical contrast observed is maintained in WLE specimens. In this manuscript, we begin to address this issue by performing a feasibility study of OCME on 17 freshly excised, intact WLE specimens. In addition, we present two developments required to sustain the progression of OCME towards intraoperative deployment. First, to enable the rapid visualization of en face images required for intraoperative assessment, we describe an automated segmentation algorithm to fuse en face micro-elastograms with OCT images to provide dual contrast images. Secondly, to validate contrast in micro-elastograms, we present a method that enables co-registration of en face images with histology of WLE specimens, sectioned in the orthogonal plane, without any modification to the standard clinical workflow. We present a summary of the observations across the 17 specimens imaged in addition to representative micro-elastograms and OCT images demonstrating contrast in a number of tumor margins, including those involved by invasive ductal carcinoma, mucinous carcinoma, and solid-papillary carcinoma. The results presented here demonstrate the potential of OCME for imaging tumor margins.

Wide-field quantitative micro-elastography of human breast tissue

Currently, 20-30% of patients undergoing breast-conserving surgery require a second surgery due to insufficient surgical margins in the initial procedure. We have developed a wide-field quantitative micro-elastography system for the assessment of tumor margins. In this technique, we map tissue elasticity over a field-of-view of ~46 × 46 mm. We performed wide-field quantitative micro-elastography on thirteen specimens of freshly excised tissue acquired from patients undergoing a mastectomy. We present wide-field optical coherence tomography (OCT) images, qualitative (strain) micro-elastograms and quantitative (elasticity) micro-elastograms, acquired in 10 minutes. We demonstrate that wide-field quantitative micro-elastography can extend the range of tumors visible using OCT-based elastography by providing contrast not present in either OCT or qualitative micro-elastography and, in addition, can reduce imaging artifacts caused by a lack of contact between tissue and the imaging window. Also, we describe how the combined evaluation of OCT, qualitative micro-elastograms and quantitative micro-elastograms can improve the visualization of tumor.

In vivo volumetric quantitative micro-elastography of human skin

In this paper, we demonstrate in vivo volumetric quantitative micro-elastography of human skin. Elasticity is estimated at each point in the captured volume by combining local axial strain measured in the skin with local axial stress estimated at the skin surface. This is achieved by utilizing phase-sensitive detection to measure axial displacements resulting from compressive loading of the skin and an overlying, compliant, transparent layer with known stress/strain behavior. We use an imaging probe head that provides optical coherence tomography imaging and compression from the same direction. We demonstrate our technique on a tissue phantom containing a rigid inclusion, and present in vivo elastograms acquired from locations on the hand, wrist, forearm and leg of human volunteers.

Cell-matrix mechanical interaction in electrospun polymeric scaffolds for tissue engineering: Implications for scaffold design and performance

Engineered scaffolds produced by electrospinning of biodegradable polymers offer a 3D, nanofibrous environment with controllable structural, chemical, and mechanical properties that mimic the extracellular matrix of native tissues and have shown promise for a number of tissue engineering applications. The microscale mechanical interactions between cells and electrospun matrices drive cell behaviors including migration and differentiation that are critical to promote tissue regeneration. Recent developments in understanding these mechanical interactions in electrospun environments are reviewed, with emphasis on how fiber geometry and polymer structure impact on the local mechanical properties of scaffolds, how altering the micromechanics cues cell behaviors, and how, in turn, cellular and extrinsic forces exerted on the matrix mechanically remodel an electrospun scaffold throughout tissue development. Techniques used to measure and visualize these mechanical interactions are described. We provide a critical outlook on technological gaps that must be overcome to advance the ability to design, assess, and manipulate the mechanical environment in electrospun scaffolds toward constructs that may be successfully applied in tissue engineering and regenerative medicine.

STATEMENT OF SIGNIFICANCE

Tissue engineering requires design of scaffolds that interact with cells to promote tissue development. Electrospinning is a promising technique for fabricating fibrous, biomimetic scaffolds. Effects of electrospun matrix microstructure and biochemical properties on cell behavior have been extensively reviewed previously; here, we consider cell-matrix interaction from a mechanical perspective. Micromechanical properties as a driver of cell behavior has been well established in planar substrates, but more recently, many studies have provided new insights into mechanical interaction in fibrillar, electrospun environments. This review provides readers with an overview of how electrospun scaffold mechanics and cell behavior work in a dynamic feedback loop to drive tissue development, and discusses opportunities for improved design of mechanical environments that are conducive to tissue development.

Investigation of optical coherence micro-elastography as a method to visualize micro-architecture in human axillary lymph nodes

Background

Evaluation of lymph node involvement is an important factor in detecting metastasis and deciding whether to perform axillary lymph node dissection (ALND) in breast cancer surgery. As ALND is associated with potentially severe long term morbidity, the accuracy of lymph node assessment is imperative in avoiding unnecessary ALND. The mechanical properties of malignant lymph nodes are often distinct from those of normal nodes. A method to image the micro-scale mechanical properties of lymph nodes could, thus, provide diagnostic information to aid in the assessment of lymph node involvement in metastatic cancer. In this study, we scan axillary lymph nodes, freshly excised from breast cancer patients, with optical coherence micro-elastography (OCME), a method of imaging micro-scale mechanical strain, to assess its potential for the intraoperative assessment of lymph node involvement.

Methods

Twenty-six fresh, unstained lymph nodes were imaged from 15 patients undergoing mastectomy or breast-conserving surgery with axillary clearance. Lymph node specimens were bisected to allow imaging of the internal face of each node. Co-located OCME and optical coherence tomography (OCT) scans were taken of each sample, and the results compared to standard post-operative hematoxylin-and-eosin-stained histology.

Results

The optical backscattering signal provided by OCT alone may not provide reliable differentiation by inspection between benign and malignant lymphoid tissue. Alternatively, OCME highlights local changes in tissue strain that correspond to malignancy and are distinct from strain patterns in benign lymphoid tissue. The mechanical contrast provided by OCME complements the optical contrast provided by OCT and aids in the differentiation of malignant tumor from uninvolved lymphoid tissue.

Conclusion

The combination of OCME and OCT images represents a promising method for the identification of malignant lymphoid tissue. This method shows potential to provide intraoperative assessment of lymph node involvement, thus, preventing unnecessary removal of uninvolved tissues and improving patient outcomes.

Quantitative micro-elastography: imaging of tissue elasticity using compression optical coherence elastography

Probing the mechanical properties of tissue on the microscale could aid in the identification of diseased tissues that are inadequately detected using palpation or current clinical imaging modalities, with potential to guide medical procedures such as the excision of breast tumours. Compression optical coherence elastography (OCE) maps tissue strain with microscale spatial resolution and can delineate microstructural features within breast tissues. However, without a measure of the locally applied stress, strain provides only a qualitative indication of mechanical properties. To overcome this limitation, we present quantitative micro-elastography, which combines compression OCE with a compliant stress sensor to image tissue elasticity. The sensor consists of a layer of translucent silicone with well-characterized stress-strain behaviour. The measured strain in the sensor is used to estimate the two-dimensional stress distribution applied to the sample surface. Elasticity is determined by dividing the stress by the strain in the sample. We show that quantification of elasticity can improve the ability of compression OCE to distinguish between tissues, thereby extending the potential for inter-sample comparison and longitudinal studies of tissue elasticity. We validate the technique using tissue-mimicking phantoms and demonstrate the ability to map elasticity of freshly excised malignant and benign human breast tissues.

Investigation of Optical Coherence Microelastography as a Method to Visualize Cancers in Human Breast Tissue

An accurate intraoperative identification of malignant tissue is a challenge in the surgical management of breast cancer. Imaging techniques that help address this challenge could contribute to more complete and accurate tumor excision, and thereby help reduce the current high reexcision rates without resorting to the removal of excess healthy tissue. Optical coherence microelastography (OCME) is a three-dimensional, high-resolution imaging technique that is sensitive to microscale variations of the mechanical properties of tissue. As the tumor modifies the mechanical properties of breast tissue, OCME has the potential to identify, on the microscale, involved regions of fresh, unstained tissue. OCME is based on the use of optical coherence tomography (OCT) to measure tissue deformation in response to applied mechanical compression. In this feasibility study on 58 ex vivo samples from patients undergoing mastectomy or wide local excision, we demonstrate the performance of OCME as a means to visualize tissue microarchitecture in benign and malignant human breast tissues. Through a comparison with corresponding histology and OCT images, OCME is shown to enable ready visualization of features such as ducts, lobules, microcysts, blood vessels, and arterioles and to identify invasive tumor through distinctive patterns in OCME images, often with enhanced contrast compared with OCT. These results lay the foundation for future intraoperative studies. Cancer Res; 75(16); 3236-45. ©2015 AACR.

Optical palpation in vivo: imaging human skin lesions using mechanical contrast

We demonstrate the first application of the recently proposed method of optical palpation to in vivo imaging of human skin. Optical palpation is a tactile imaging technique that probes the spatial variation of a sample's mechanical properties by producing an en face map of stress measured at the sample surface. This map is determined from the thickness of a translucent, compliant stress sensor placed between a loading element and the sample and is measured using optical coherence tomography. We assess the performance of optical palpation using a handheld imaging probe on skin-mimicking phantoms, and demonstrate its use on human skin lesions. Our results demonstrate the capacity of optical palpation to delineate the boundaries of lesions and to map the mechanical contrast between lesions and the surrounding normal skin.

Three-dimensional optical coherence micro-elastography of skeletal muscle tissue

In many muscle pathologies, impairment of skeletal muscle function is closely linked to changes in the mechanical properties of the muscle constituents. Optical coherence micro-elastography (OCME) uses optical coherence tomography (OCT) imaging of tissue under a quasi-static, compressive mechanical load to map variations in tissue mechanical properties on the micro-scale. We present the first study of OCME on skeletal muscle tissue. We show that this technique can resolve features of muscle tissue including fibers, fascicles and tendon, and can also detect necrotic lesions in skeletal muscle from the mdx mouse model of Duchenne muscular dystrophy. In many instances, OCME provides better or additional contrast complementary to that provided by OCT. These results suggest that OCME could provide new understanding and opportunity for assessment of skeletal muscle pathologies.

Optical coherence micro-elastography: mechanical-contrast imaging of tissue microstructure

We present optical coherence micro-elastography, an improved form of compression optical coherence elastography. We demonstrate the capacity of this technique to produce en face images, closely corresponding with histology, that reveal micro-scale mechanical contrast in human breast and lymph node tissues. We use phase-sensitive, three-dimensional optical coherence tomography (OCT) to probe the nanometer-to-micrometer-scale axial displacements in tissues induced by compressive loading. Optical coherence micro-elastography incorporates common-path interferometry, weighted averaging of the complex OCT signal and weighted least-squares regression. Using three-dimensional phase unwrapping, we have increased the maximum detectable strain eleven-fold over no unwrapping and the minimum detectable strain is 2.6 με. We demonstrate the potential of mechanical over optical contrast for visualizing micro-scale tissue structures in human breast cancer pathology and lymph node morphology.

Optical palpation: optical coherence tomography-based tactile imaging using a compliant sensor

We present optical palpation, a tactile imaging technique for mapping micrometer- to millimeter-scale mechanical variations in soft tissue. In optical palpation, a stress sensor consisting of translucent, compliant silicone with known stress-strain behavior is placed on the tissue surface and a compressive load is applied. Optical coherence tomography (OCT) is used to measure the local strain in the sensor, from which the local stress at the sample surface is calculated and mapped onto an image. We present results in tissue-mimicking phantoms, demonstrating the detection of a feature embedded 4.7 mm below the sample surface, well beyond the depth range of OCT. We demonstrate the use of optical palpation to delineate the boundary of a region of tumor in freshly excised human breast tissue, validated against histopathology.

Needle optical coherence elastography for the measurement of microscale mechanical contrast deep within human breast tissues

Optical coherence elastography (OCE) is an emerging imaging technique that probes microscale mechanical contrast in tissues with the potential to differentiate healthy and malignant tissues. However, conventional OCE techniques are limited to imaging the first 1 to 2 mm of tissue in depth. We demonstrate, for the first time, OCE measurements deep within human tissues using needle OCE, extending the potential of OCE as a surgical guidance tool. We use needle OCE to detect tissue interfaces based on mechanical contrast in both normal and malignant breast tissues in freshly excised human mastectomy samples, as validated against histopathology. Further, we demonstrate the feasibility of in situ measurements >4 cm from the tissue surface using ultrasound guidance of the OCE needle probe. With further refinement, our method may potentially aid in accurate detection of the boundary of the tumor to help ensure full removal of all malignant tissues, which is critical to the success of breast-conserving surgery.

Analysis of mechanical contrast in optical coherence elastography

Optical coherence elastography (OCE) maps the mechanical properties of tissue microstructure and has potential applications in both fundamental investigations of biomechanics and clinical medicine. We report the first analysis of contrast in OCE, including evaluation of the accuracy with which OCE images (elastograms) represent mechanical properties and the sensitivity of OCE to mechanical contrast within a sample. Using phase-sensitive compression OCE, we generate elastograms of tissue-mimicking phantoms with known mechanical properties and identify limitations on contrast imposed by sample mechanics and the imaging system, including signal-processing parameters. We also generate simulated elastograms using finite element models to perform mechanical analysis in the absence of imaging system noise. In both experiments and simulations, we illustrate artifacts that degrade elastogram accuracy, depending on sample geometry, elasticity contrast between features, and surface conditions. We experimentally demonstrate sensitivity to features with elasticity contrast as small as 1.1∶1 and calculate, based on our imaging system parameters, a theoretical maximum sensitivity to elasticity contrast of 1.002∶1. The results highlight the microstrain sensitivity of compression OCE, at a spatial resolution of tens of micrometers, suggesting its potential for the detection of minute changes in elasticity within heterogeneous tissue.

Improved measurement of vibration amplitude in dynamic optical coherence elastography

Optical coherence elastography employs optical coherence tomography (OCT) to measure the displacement of tissues under load and, thus, maps the resulting strain into an image, known as an elastogram. We present a new improved method to measure vibration amplitude in dynamic optical coherence elastography. The tissue vibration amplitude caused by sinusoidal loading is measured from the spread of the Doppler spectrum, which is extracted using joint spectral and time domain signal processing. At low OCT signal-to-noise ratio (SNR), the method provides more accurate vibration amplitude measurements than the currently used phase-sensitive method. For measurements performed on a mirror at OCT SNR = 5 dB, our method introduces <3% error, compared to >20% using the phase-sensitive method. We present elastograms of a tissue-mimicking phantom and excised porcine tissue that demonstrate improvements, including a 50% increase in the depth range of reliable vibration amplitude measurement.

Strain estimation in phase-sensitive optical coherence elastography

We present a theoretical framework for strain estimation in optical coherence elastography (OCE), based on a statistical analysis of displacement measurements obtained from a mechanically loaded sample. We define strain sensitivity, signal-to-noise ratio and dynamic range, and derive estimates of strain using three methods: finite difference, ordinary least squares and weighted least squares, the latter implemented for the first time in OCE. We compare theoretical predictions with experimental results and demonstrate a ~12 dB improvement in strain sensitivity using weighted least squares compared to finite difference strain estimation and a ~4 dB improvement over ordinary least squares strain estimation. We present strain images (i.e., elastograms) of tissue-mimicking phantoms and excised porcine airway, demonstrating in each case clear contrast based on the sample's elasticity.

Needle optical coherence elastography for tissue boundary detection

We incorporate, for the first time, optical coherence elastography (OCE) into a needle probe and demonstrate its ability to measure the microscopic deformation of soft tissues located well beyond the depth limit of reports to date. Needle OCE utilizes the force imparted by the needle tip as the loading mechanism and measures tissue deformation ahead of the needle during insertion. Measurements were performed in tissue-mimicking phantoms and ex vivo porcine trachea. Results demonstrate differentiation of tissues based on mechanical properties and highlight the potential of needle OCE for in vivo tissue boundary detection.

Review of tissue simulating phantoms with controllable optical, mechanical and structural properties for use in optical coherence tomography

We review the development of phantoms for optical coherence tomography (OCT) designed to replicate the optical, mechanical and structural properties of a range of tissues. Such phantoms are a key requirement for the continued development of OCT techniques and applications. We focus on phantoms based on silicone, fibrin and poly(vinyl alcohol) cryogels (PVA-C), as we believe these materials hold the most promise for durable and accurate replication of tissue properties.

β-Amyloid burden in healthy aging: regional distribution and cognitive consequences

OBJECTIVE

Several lines of evidence suggest that pathologic changes underlying Alzheimer disease (AD) begin years prior to the clinical expression of the disease, underscoring the need for studies of cognitively healthy adults to capture these early changes. The overall goal of the current study was to map the cortical distribution of β-amyloid (Aβ) in a healthy adult lifespan sample (aged 30-89), and to assess the relationship between elevated amyloid and cognitive performance across multiple domains.

METHODS

A total of 137 well-screened and cognitively normal adults underwent Aβ PET imaging with radiotracer (18)F-florbetapir. Aβ load was estimated from 8 cortical regions. Participants were genotyped for APOE and tested for processing speed, working memory, fluid reasoning, episodic memory, and verbal ability.

RESULTS

Aβ deposition is distributed differentially across the cortex and progresses at varying rates with age across cortical brain regions. A subset of cognitively normal adults aged 60 and over show markedly elevated deposition, and also had a higher rate of APOE ε4 (38%) than nonelevated adults (19%). Aβ burden was linked to poorer cognitive performance on measures of processing speed, working memory, and reasoning.

CONCLUSIONS

Even in a highly selected lifespan sample of adults, Aβ deposition is apparent in some adults and is influenced by APOE status. Greater amyloid burden was related to deleterious effects on cognition, suggesting that subtle cognitive changes accrue as amyloid progresses.

Differential aging of the medial temporal lobe: A study of a five-year change

OBJECTIVE

To test the hypothesis that entorhinal cortex (EC) volume decreases at a slower rate than the hippocampal (HC) volume in healthy adults, and to examine whether the rate of shrinkage increases with age.

METHODS

Volumes of the HC and EC were measured twice on MRI scans of 54 healthy adults (aged 26 to 82 years), with an average interval of 5 years.

RESULTS

Markedly different age trends were noted in the examined regions. The EC showed no age-related differences on both occasions and only minimal age-related change (0.33%/y). By contrast, the HC exhibited significant age-related differences at baseline and at follow-up evaluation and decreased at a faster pace of 0.86%/y. Older participants (aged > or = 50 years) showed increased annual shrinkage of the HC (1.18%) and EC shrinkage (0.53%/y). The rate of HC volume loss significantly exceeded that of the EC. No EC shrinkage and modest HC volume reduction were observed in people aged <50 years.

CONCLUSIONS

Age-related shrinkage occurs in the medial temporal lobes of healthy adults, with significant hippocampal decline and minimal entorhinal changes. In both regions, the rate of decline accelerates with age, although the role of pathologic factors in age-related increase of volume loss merits further investigation.

Synaptic vesicle recruitment for release explored by Monte Carlo simulation at the crayfish neuromuscular junction

Neurotransmission at chemically transmitting synapses requires calcium-mediated fusion of synaptic vesicles with the presynaptic membrane. Utilizing ultrastructural information available for the crustacean excitatory neuromuscular junction, we developed a model that employs the Monte Carlo simulation technique to follow the entry and movement of Ca2+ ions at a presynaptic active zone, where synaptic vesicles are preferentially docked for release. The model includes interaction of Ca2+ with an intracellular buffer, and variable separation between calcium channels and vesicle-associated Ca2+-binding targets that react with Ca2+ to trigger vesicle fusion. The end point for vesicle recruitment for release was binding of four Ca2+ ions to the target controlling release. The results of the modeling experiments showed that intracellular structures that interfere with Ca2+ diffusion (in particular synaptic vesicles) influence recruitment or priming of vesicles for release. Vesicular recruitment is strongly influenced by the separation distance between an opened calcium channel and the target controlling release, and by the concentration and binding properties of the intracellular buffers, as in previous models. When a single opened calcium channel is very close to the target, a single synaptic vesicle can be recruited. However, many of the single-channel openings actuated by a nerve impulse are likely to be ineffective for release, although they contribute to the buildup of total intracellular Ca2+. Thus, the overall effectiveness of single calcium channels in causing vesicles to undergo exocytosis is likely quite low.Key words: synapse, Monte Carlo simulation, synaptic vesicle, active zone, vesicle recruitment, crayfish, calcium, calcium buffer.

Lessons learned from three physician-equity models

To improve the profitability of group practice ownership, some healthcare organizations have structured arrangements to include a form of physician equity. An equity incentive is designed to encourage physician behavior that supports business operations by tying financial reward to overall organizational performance. Three physician-equity models--third-party integration, joint venture management services organization (MSO), and physician-owned practice management company--have used the physician equity incentive with varying degrees of success. The experiences of three healthcare systems that implemented these models demonstrates that strategies often cannot be executed as planned, growth should not be assumed, and the changing healthcare marketplace is unpredictable.

Synaptic vesicle recruitment for release explored by Monte Carlo stimulation at the crayfish neuromuscular junction

Neurotransmission at chemically transmitting synapses requires calcium-mediated fusion of synaptic vesicles with the presynaptic membrane. Utilizing ultrastructural information available for the crustacean excitatory neuromuscular junction, we developed a model that employs the Monte Carlo simulation technique to follow the entry and movement of Ca2+ ions at a presynaptic active zone, where synaptic vesicles are preferentially docked for release. The model includes interaction of Ca2+ with an intracellular buffer, and variable separation between calcium channels and vesicle-associated Ca(2+)-binding targets that react with Ca2+ to trigger vesicle fusion. The end point for vesicle recruitment for release was binding of four Ca2+ ions to the target controlling release. The results of the modeling experiments showed that intracellular structures that interfere with Ca2+ diffusion (in particular synaptic vesicles) influence recruitment or priming of vesicles for release. Vesicular recruitment is strongly influenced by the separation distance between an opened calcium channel and the target controlling release, and by the concentration and binding properties of the intracellular buffers, as in previous models. When a single opened calcium channel is very close to the target, a single synaptic vesicle can be recruited. However, many of the single-channel openings actuated by a nerve impulse are likely to be ineffective for release, although they contribute to the buildup of total intracellular Ca2+. Thus, the overall effectiveness of single calcium channels in causing vesicles to undergo exocytosis is likely quite low.

Alternatives to traditional capitation in managed care agreements

Risk arrangements typically fall into one of three categories: primary care capitation, professional services capitation, and global, or full-risk, capitation. Yet, in light of various disadvantages associated with these three methods, such as high administrative costs and inappropriate levels of risk assumed by providers, many healthcare payers and providers are experimenting with alternative payment plans. These alternatives include contact capitation arrangements, under which specialists receive a capitation payment on a per referral basis; open-access arrangements, under which patients do not need a gatekeeper referral to see specialists; and capitation arrangements with quality and hospital utilization bonuses, under which specialists and primary care physicians receive a capitation payment plus the potential for bonuses based on quality and utilization criteria.

Physician equity in health care delivery systems: three alternative models

The 1990s have seen many health care organizations attempting to merge, acquire, or affiliate with physician groups. Many have failed to provide physicians a stake in the success of the newly formed enterprise, frequently resulting in declining physician productivity, poor morale, and large operating losses. These problems warrant a reexamination of the traditional acquisition model of growth in favor of structures that retain a physician ownership component. This article examines three models of health care organization in which physicians share in the success of the enterprise and compares them in terms of ownership structure, governance, and funds flow.

Matching physician compensation plans to capitation levels

As managed care penetration increases, physician compensation plans need to reflect the current transition from fee-for-service to capitated payment. In choosing the compensation structure that will be most beneficial to the success of the group practice and secure physician buy-in, practices need to assess their mission, goals, and corporate culture. They also need to assess their percentage of capitation to total revenues and develop, when necessary, new compensation pools that reward physicians for a variety of behaviors, such as increased productivity and utilization control. Compensation plans should be fair, flexible, and simple to understand and administer.

Evaluating and negotiating a profitable capitation contract

Evaluating the financial terms of capitation contracts and negotiating their nonfinancial provisions are becoming increasingly important responsibilities for healthcare financial managers. To evaluate the financial terms of a contract, financial managers must understand both incremental and replacement pricing strategies. They also must understand when strategic positioning objectives make a capitated plan attractive despite limited financial rewards. Before a contract is accepted, financial managers can take steps to increase its potential profitability by negotiating the nonfinancial provisions that can help control contract expenses. These provisions are related to services to be provided, payment terms, withholds and risk pools, access to data, provision of eligibility data, utilization review and quality assurance procedures, filing of grievances, contract renewal terms, and contract termination.

A "high-tech," "soft-touch" immunization program for members of a Medicaid managed care organization

Immunization rates among the very poor are critically low. The solution to improving rates requires technological tracking of immunizations linked to extensive home visiting outreach services as well as physician and member support services to increase compliance with recommended immunization schedules. This paper describes the development and implementation of a comprehensive immunization program which incorporates these strategies for members of a Medicaid managed care organization. Analysis of preliminary data provides some indication of the value of the tracking system and the effectiveness of incentives and home visiting on member compliance with immunizations.

Corticotropin-releasing factor binding protein dimerizes after association with ligand

We have suggested recently that the fall in plasma CRF-binding protein (BP) during the last few weeks of pregnancy is a direct effect of association with its ligand because of the rapid decrease in plasma BP concentration seen in normal males reaching a nadir some 15 min after a bolus injection of synthetic CRF. In the present study, we have investigated the physicochemical properties of both natural and recombinant BP by gel filtration under physiological conditions and have shown that association of human CRF to this BP results in an increase in molecular weight consistent with the formation of a dimer form of the BP ligand complex. The dimer is more stable when the interaction occurs in the presence of serum or if a peptide with a higher affinity for the BP is substituted as ligand. Experimental evidence would also suggest that the dimer BP has a higher affinity for ligand than the monomeric form. We suggest that this dimerization occurs in vivo when CRF is released into the bloodstream and provides the trigger that causes the uptake of the complex at specific receptor sites.

Auditory brainstem response to tone bursts in quiet, notch noise, highpass noise, and broadband noise

This study investigated the effects of tone bursts (1000 Hz, 2000 Hz, and 4000 Hz) in quiet, notch noise, highpass noise, and broadband noise on the identifiability, latency, and amplitude of the auditory brainstem response (wave V). Normal listeners were presented with 40 dB and 80 dB nHL tone bursts having rise-plateau-fall times of 1 msec. Wave V was observed in all subjects at 40 dB and 80 dB nHL for the quiet and noise conditions. The latency findings suggest that responses elicited by the 80 dB nHL tone bursts in quiet were, in part, mediated by regions on the basilar membrane that did not correspond to the center frequency of the tone burst. To increase frequency-specificity, high-level tone bursts (e.g., 80 dB nHL) should be mixed with notch, highpass, or broadband noise. The use of noise conditions for low intensity levels (e.g., 40 dB nHL) does not appear necessary for isolating the response because both the notch and the highpass conditions yielded latencies similar to the quiet condition. Although similar wave V amplitudes were found at all frequencies, amplitudes were smaller for the broadband noise than for the quiet, notch, and highpass conditions. Thus, the latter conditions seem preferred.