Investigation of Ensemble Learning Method in Predicting Early Xerostomia Using Radiomics Features from CT and MRI

PURPOSE/OBJECTIVE(S)

There are different side effects in radiotherapy of head and neck cancer including xerostomia. Xerostomia is due to irradiation of salivary glands during treatment. In the present study, the main aim is evaluation and validation of individual and ensemble classifiers for prediction of early xerostomia in radiotherapy of head and neck cancer.

MATERIALS/METHODS

Totally 62 patients diagnosed with head and neck cancer were evaluated prospectively. For this purpose, patients' demographic information, dosimetric data, and the extracted features from CT and T1 and T2 MR images before radiotherapy treatments were used as input for the predictive model. There were two main steps in this study: 1- Comparison of the features from T1 and T2 MR images for prediction of xerostomia, and 2- Evaluation of the performance of the radiomics models using individual classifiers and combination of the classifiers using ensemble learning. Feature extraction was performed using 3D Slicer software and for both parotids, 642 features were extracted from both CT, and MRI and Pearson statistical test was used for feature selection. For model development, four models were used consist of Random Tree (RT), Neural Network (NN), Linear Support Vector Machine (LSVM) and Bayesian Network (BS) classifiers. Different algorithms combined by using the ensemble learning method. For evaluation of the performance of the constructed models, sensitivity, specificity, area under curve (AUC), and receiver operating characteristic (ROC) curve were utilized.

RESULTS

The results of the present study show that the extracted features from T1 weighted images have superior prediction ability compared to the T2 weighted ones. The RT and LSVM models which were based on T1 weighted images have better performance than those with T2 weighted images. The AUC in the test group for these models are 0.95 and 0.76, respectively, while for the T2 weighted images the corresponding values are 0.75 and 0.63. The AUC for the test group for the RT-BN, RT-LSVM-BN and RT-NN-LSVM-BN models amount to 0.96, 0.91, and 0.88, respectively.

CONCLUSION

The results show that the radiomics features from images before radiotherapy can be used as personalized and unique biomarkers for prediction of xerostomia. Ensemble classifiers can be more efficient than individual classifiers in prediction of early xerostomia.

The Role of Radiomics Model to Predict Early Xerostomia in Head and Neck Cancer after Radiotherapy

PURPOSE/OBJECTIVE(S)

Based on the patients' characteristics, the most treated patients suffering from early xerostomia during radiation therapy treatment and in the early months after treatment in head and neck cancer. The aim of this study is to provide an image-based model to predict early xerostomia in these patients before radiotherapy. The dosimetric and clinical factors (age, sex, history of disease) and computed tomography (CT) features are also combined with the image data in resolving xerostomia detection.

MATERIALS/METHODS

Clinical factors and CT features were considered for 62 patients with head and neck cancer, and the complication of parotid and salivary glands was evaluated. For feature extraction from CT images, 3D Slicer software was used to extract 107 features. The features type included shape, gray level dependence matrix, gray level co-occurrence matrix, first order gray level run length matrix, gray level size zone matrix, and neighborhood gray-tone difference matrix. Four different datasets; demographic + sum dose volume histogram (DVH), demographic + ipsilateral and contralateral DVH, demographic + CT features + sum DVH, and demographic + CT features + ipsilateral and contralateral DVH; were used as model inputs. Four algorithms: Random Tree (RT), Linear Support Vector Machine (LSVM), Neural Network (NN), and Bayesian Network (BN), were applied to analyze the datasets to predict xerostomia.

RESULTS

The metrics of the models used sensitivity, specificity, accuracy, and area-under-the-curve (AUC) to assess the performance. The AUC has its highest value for the RT model among the aforementioned models and its value for the first and second data sets were 0.84 and 0.64, respectively. In general, model performance was improved when the sum of the parotids DVH data was used. Furthermore, the RT model showed the best performance when using radiomics features in the third and fourth data sets with the AUC of 0.86 and 0.89, respectively.

CONCLUSION

Among the RT, LSVM, NN, and BN models, RT has the highest performance in predicting radiation-induced early xerostomia in patients who underwent head and neck radiotherapy. Model performance was improved when the sum of the parotids DVH data was used in addition to the dose data and CT features. This study showed that combining the dosimetric data with radiomics features may improve the model performance for predicting early xerostomia.

Conformality Indices and Brain Dose Objective for Multi-Lesion Brain Single Isocenter Linac-Based Stereotactic Radiosurgery

PURPOSE/OBJECTIVE(S)

The lack of recommendation on Linac-based stereotactic radiosurgery (SRS) and radiotherapy (SRT) plan quality for multi-lesion brain metastasis results in planning heterogeneity. The use of MLCs in the delivery is expected to add extra leakage when multi-lesions are treated simultaneously, and no recommendations availability in literature. We aimed to identify conformality indices and plan objectives that would guide multi-brain metastasis SRS & SRT MATERIALS/METHODS: We performed a retrospective analysis of clinically accepted brain metastasis radiotherapy plans treated using SRS and SRT at our department. Each plan was assessed for four metrics: Two conformality indices, including R50% referring to the ratio of the 50% dose cloud to the PTV, and %D1cm referring to the percentage of dose at 1cm away from PTV in any direction. One dose objective, V12 Gy referring to the brain volume receiving 12 Gy, and one delivery efficiency parameter, the modulation factor, defined as the ratio of the total MU to the prescribed dose. Each parameter was evaluated as a function of total PTV volume and number of lesions.

RESULTS

A total of 107 plans were analyzed. The analyzed plans included pre- and post-operative treated brain metastasis with 86% with ≤ 4 lesions (median is 2, IQR is 3), 80% of the plans received single fraction and 43% of plans have a total PTV volumes of ≤ 1cc (median is 2.2cc and IQR is 7.5cc). We used a two tail T-test to check for correlation. The 50% relative dose gradient, R50%, was found to be dependent on PTV volume (P < 0.001), and a power law was used to fit the data. The brain volume, V12 Gy, was also found to be dependent on total PTV volume (P < 0.0001) and a linear curve was used to fit V12 Gy vs PTV. We did not find correlation between the number of lesions and R50% and or V12 Gy (p-value = 0.154 and 0.736, respectively). The dose gradient at 1cm away in any direction from PTV, %D1cm, has a median, average and a S.D. of 32%, 33% and 9%, respectively. 85% of all plans have %D1cm<42% which falls within 1 S.D. In addition, we found %D1cm to be dependent on both PTV volume and number of lesions (P < 0.001 for both). The modulation factor (MF) has a median, average and a S.D. of 2.9, 3.0 and 1.5, respectively. We found that 81% of all plans has MF < 4.5, which is within the 1 S.D. It has a positive correlation of 0.628 with the number of lesions.

CONCLUSION

We found a clear correlation between the total PTV volumes and R50% and V12 Gy, and a fit line was used to relate each parameter to the total PTV volume. As for %D1cm and MF, we found that the average value within 1 S.D. is adequate to include > 80% of the plan. We propose these four parameters to fill the gap for plan quality for Linac-based SRS and SRT. Further evaluation and validation of our results on larger cohort is needed to allow generalizability and applicability of the results and correlation with clinical outcomes to guide clinical decision making.

Synthesis of benzylidene-benzofuranone derivatives as probes for detection of amyloid fibrils in cells

Aggregated protein is the common cause of a wide variety of neurodegenerative diseases, such as Alzheimer's disease (AD), Parkinson's disease, etc. It is proven that protein aggregation like amyloid β (Aβ) is one of the critical factors causing AD and, its diagnosis in the early stages of the disease is important for the treatment or prevention of AD. To have a better understanding of protein aggregation and its pathologies, there is a huge need to design and develop new and more trustworthy probe molecules for in vitro amyloid quantification and in vivo amyloid imaging. In this study, 17 new biomarker compounds, have been synthesized from benzofuranone derivatives, to detect and identify amyloid in vitro (dye-binding assay) as well as in the cell by staining method. According to the results, some of these synthetic derivatives can be considered suitable identifiers and quantifiers to detect amyloid fibrils in vitro. Compared to thioflavin T, 4 probes out of 17 probes have shown good results in selectivity and detectability of Aβ depositions, and their binding properties were also confirmed with in silico analysis. The drug-likeness prediction results for selected compounds by the Swiss ADME server show a satisfactory percentage of blood-brain barrier (BBB) permeability and gastrointestinal (GI) absorption. Among all of them, compound 10 was able to show better binding properties than others, and in vivo study showed that this compound was capable of detecting intracellular amyloid.Communicated by Ramaswamy H. Sarma.

Effects of dietary aspirin supplementation on liver enzymes, immune response, cecum microflora and fatty acids profile in breast meat of broiler chickens

The present study was performed to investigate the effect of dietary aspirin (A) on broilers. A completely randomized design using 120 one-day-old male broiler chicks Ross 308, three levels of aspirin (0, 50, and 100 mg/kg) was used in 4 replicates, each including 10 chicks, during 42 days. The effects of different levels of aspirin, added to a basal diet, on blood plasma parameters, liver enzymes, immune system, cecal microflora, and fatty acids profile of breast muscle of chicks were investigated. Data analysis was performed by SAS statistical software and the comparison of the means with Duncan's test. The results showed that the effects of aspirin on blood parameters, liver enzymes of broilers (except for alkaline phosphatase which significantly reduced), the humoral immune system in response to antigen injection as sheep red blood cell (SRBC), antibody titer against Newcastle and influenza virus were not significant (P≥0.05). The highest percentage of neutrophils and eosinophils was related to this treatment. Also, aspirin treatments increased numerically the levels of unsaturated fatty acids and decreased saturated fatty acids. Moreover, aspirin led to a reduction in the population of Escherichia coli. So, based on the results of the present study, the use of 100 mg/kg aspirin in the diet of broilers is recommendable.

Valgus Impacted Femoral Neck Fractures: Surgery or Non-Operative Approach?

Background: Non-operative management of valgus impacted femoral neck fracture leads to prolonged bed rest which may lead to deep vein thrombosis. The preferred method is the internal fixation because of pain control, enhanced mobilization, and better fracture healing but fails in older patients and individuals with medical comorbidities. The present study aims to assess the functional outcomes after the internal fixation or the non-operative management. Methods: A retrospective cohort study was conducted at a Level I trauma center from January 2013 to December 2019 on all patients with valgus-impacted femoral neck fractures [Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association Classification (AO/OTA 31-B1)]. Overall, 81 patients were managed operatively with three partially threaded, cannulated screws in a parallel configuration and 21 patients were managed non operatively with instant mobilization, physical therapy, and partial weight-bearing protocol. Results: 6 (28.0%) patients in the non-operative group and 3 (4.0%) cases in the operative group experienced fracture displacement (P < 0.001). 48 (59.2%) patients of the operative treatment group returned to baseline ambulatory function at 3 months, while this figure was 43.0% in the non-operative treatment group, not significantly different (P = 0.100). There was no significant difference in the mortality rates at one month and three months between the two groups (2 patients in each group, P = 0.140).  Conclusion: The ideal treatment of valgus-impacted femoral neck fractures is still controversial. The main purpose in the treatment of hip fractures is to return the patient to functional level equal to the level he or she was before the fracture. Surgically treated patients had lower failure rates in comparison with the other group.  

Surgical Sponge Retained in Femoral Canal for 22 Years: A Case Report

Background: Retained surgical items (RSIs) are not very common in the orthopedic surgery. Here, we are reporting a case of a sponge pad left in the femoral canal for 22 years. We could not find any other reported case of retained surgical sponge in the femoral canal and that is what makes this case report unique. Case Report: The patient was a 42 year-old man who underwent surgery for the fixation of a fractured femur 22 years ago. On August 2020, this patient was seen complaining about pain at the surgical site. The assessments revealed a sponge pad retained in the femoral canal, which was removed by surgery. The union of fractured bone did not take place in the first surgery, so after 6 months a second surgery was performed and the dynamic compression plate (DCP) placed was successfully replaced with an intramedullary nail. Conclusion: The surgeon could not detect the pad 22 years ago and the patient had no significant symptom all this time. The most important take-away lesson of this paper is that retention of surgical pads could also occur with correct gauze counting, so detection and prevention protocols for RSIs must be taken seriously.

Molecular Detection of Spotted Fever Group Rickettsia (Rickettsiales: Rickettsiaceae) in Ticks of Iran

Ticks are reservoir hosts of pathogenic Rickettsia in humans and domestic animals. Most pathogenic Rickettsia species belong to the spotted fever group (SFG). The present study aimed to determine the tick species infected with Rickettsia based on the genus-specific 23S ribosomal ribonucleic acid (rRNA), 16S rRNA, and citrate synthase (gltA) gene fragments. A total of 61 tick specimens were selected for molecular assay and 12 samples for sequencing. Phylogenetic analysis was conducted using neighbor-joining and Bayesian inference methods. Argas persicus, Haemaphysalis sulcata, Ha. inermis, and Hyalomma asiaticum were infected by spotted fever Rickettsia. The SFG is the main group of Rickettsia that can be detected in the three genera of ticks from Iran.

Management of the Multiply Injured Child

The article's abstract is no available.

Persian Orthopedic Trauma Association: History and Activities

This article is an Editorial and does not include an Abstract.

Prevalence of allergic bronchopulmonary aspergillosis in cystic fibrosis patients using two different diagnostic criteria

Summary

Objective.There are different diagnostic criteria for the diagnosis of Allergic bronchopulmonary aspergillosis (ABPA) in CF patients. In this present study we evaluated the prevalence of ABPA in Iranian CF patients by two more usual diagnostic criteria as ISHAM working criteria (A) and CF Foundation Consensus Conference criteria (B). Methods.Eighty-six CF patients were included in the study. All CF patients underwent for Aspergillus skin prick test (AST), Aspergillus-specific IgE (sIgEAf) and Aspergillus-specific IgG (sIgGAf), total IgE. The ABPA prevalence was estimated by two diagnostic criteria, (A) and (B) and compared. Results. The frequency of positive AST, total IgE, sIgEAf and sIgGAf were 47 (54.6%), 9 (10.5%), 42 (48.8%) and 67 (77.9%), respectively. The obtained rate of ABPA prevalence (10.5%) was identical in two diagnostic criteria A and B (kappa value of 1.000). Conclusions.The applied diagnostic criteria had no significant effect on the reported rate of ABPA prevalence.

Molecular Detection of Anaplasma marginale and Anaplasma ovis (Rickettsiales: Anaplasmataceae) in Ixodid Tick Species in Iran

The present study was conducted as the first molecular detection of Anaplasma species in tick samples based on the sequencing of major surface proteins 4 (msp4) gene fragments in different parts of Iran. A total of 130 tick specimens were collected from Hormozgan, Lorestan, and Guilan, Iran, within 2015 to 2017. Hyalomma asiaticum, Hyalomma dromedarii, Rhipicephalus sanguineus, and Rhipicephalus (Boophilus) species were identified in different geographical regions. An amplicon of 464-bp msp4 of Anaplasma was amplified using polymerase chain reaction in various tick species. Three sequences, including one Anaplasma marginale from R. (Boophilus) species and two Anaplasma ovis from Rhipicephalus sanguineus, were obtained after sequencing. It is concluded that bovine and ovine anaplasmosis agents are present in tick samples in Iran. The use of the gene families of six major surface proteins for the detection of various Anaplasma species is recommended.

An electrochemical study of acrylate bone adhesive permeability and selectivity change during in vitro ageing: A model approach to the study of biomaterials and membrane barriers

This study assessed the solute permeability of a family of UV and moisture cured acrylates-based adhesives during in vitro ageing in pH 7.4 buffer. Acrylates have a potential role in bone fracture fixation, but their inability to allow microsolute exchange between the fractured bone surfaces may contribute to ineffective healing. Cyclic voltammetry and chronoamperometry were used to determine the diffusion coefficients for various electrochemically active probe molecules (O_2, H₂O₂, acetaminophen, catechol, uric acid and ascorbic acid) at proprietary acrylic, urethane – acrylate and cyanoacrylate adhesives. All adhesives proved to be impermeable for up to 9 days ageing, following which a near-exponential increase in permeability resulted for all solutes. At 18 days, the diffusion coefficients were in the range of 10⁻⁵ cm²s⁻¹ for O₂ and H₂O₂ and 10⁻⁶ cm²s⁻¹ for the organic solutes; no transport selectivity was seen between the latter. Adhesive joint strength showed a direct, inverse, correlation with permeability, with the more hydrophilic cyanoacrylates showing the greatest loss of strength. Adhesive permeabilisation does not appear to be compatible with the retention of bonding strength, but it serves as a new non-destructive predictor of adhesion strength change during ageing and practical use.

Intraoperative factors associated with stranded source placement accuracy in low-dose-rate prostate brachytherapy

PURPOSE

The quality of a low-dose rate prostate brachytherapy implant depends on the accurate placement of sources in their planned locations. This study investigates intraoperative factors that potentially contribute to stranded source placement inaccuracy in prostate brachytherapy.

METHODS AND MATERIALS

Intraoperative video images of the brachytherapist's hand motions and needle insertions during the implant procedure were acquired for analysis. Using video analysis software, maximum and average needle insertion velocities were determined. The number of needle insertion attempts and the use of the brachytherapist's other hand to manipulate the needle direction were also recorded. Sources misplacements were analyzed using an ultrasound-based method described elsewhere.

RESULTS

Fifteen patients agreed to undergo this study; 1619 ¹²⁵I seeds were inserted using 357 needles; 1197 seeds were confidently identified using ultrasound images and included in the analysis. The mean overall misplacement was 0.49 cm (0-2 cm, 95% CI = 0.47-0.51); 614 seeds were delivered with a single pass and 583 seeds with >1 passes (range 2-6). The mean maximum needle velocity was 12.34 cm s^-1 (range 4-28 cm s^-1) and mean average velocity was 4.76 cm s^-1 (range 0.4-17.4 cm s^-1); 747 seeds were delivered with manipulation of the needle. The generalized linear model test was used to analyze factors contributing to seed misplacement, and it was found that a maximum speed <12 cm s^-1 was associated with a decrease in seed misplacement by 0.049 cm vs. a maximum speed >12 cm s^-1, p = 0.0121). Other evaluated factors were found to have no statistically significant correlation with seed misplacement: average speed (p = 0.4947), manual manipulation of needle (p = 0.9264), and number of needle passes (p = 0.8907).

CONCLUSIONS

This study identified that needles inserted with lower maximum velocity were associated with less seed misplacement. Manual manipulation of the needle, number of passes, and average speed did not show statistically significant correlation with seed misplacement.

Molecular detection of virulence genes and multi-drug resistance patterns in Escherichia coli (STEC) in clinical bovine mastitis: Alborz province, Iran

The aim of this study was to identify virulence genes and antimicrobial resistance of Escherichia coli isolated from bovine clinical mastitis in dairy herds in Iran. Sampling was done from 86 inflamed quarters of dairy cows in 8 commercial farms of Alborz province, Iran in summer 2015. Shiga toxin-producing E. coli (STEC) virulence genes were detected by multiplex PCR and multi-drug resistance profiles were confirmed using disk diffusion method. Among 60 E. coli isolated from examined samples, 13 (21.6%) of them were STEC. The results of PCR assay showed that eaeA gene was carried by 4 (30.8%) of STEC isolates. Although stx1 in combination with eaeA gene was detected from 7 (53.8%) of STEC isolates, stx1 and stx2 genes were detected from only 1 (7.7%) of the examined samples. The result of the disk diffusion method showed that all E. coli isolates were resistant to penicillin, tylosin, oxytetracycline, erythromycin, ampicillin, streptomycin and neomycin. However all isolates were susceptible to enrofloxacin. Therefore, according to the results establishing a regular monitoring system for identification of cases with clinical mastitis and conducting antibiotic sensitivity tests are recommended.

Paired vehicle occupant analysis indicates age and crash severity moderate likelihood of higher severity injury in second row seated adults in frontal crashes

The majority of advances in occupant protection systems for motor vehicle occupants have focused on occupants seated in the front row of the vehicle. Recent studies suggest that these systems have resulted in lower injury risk for front row occupants as compared to those in the second row. However, these findings are not universal. In addition, some of these findings result from analyses that compare groups of front and second row occupants exposed to dissimilar crash conditions, raising questions regarding whether they might reflect differences in the crash rather than the front and second row restraint systems. The current study examines factors associated with injury risk for pairs of right front seat and second row occupants in frontal crashes in the United States using paired data analysis techniques. These data indicate that the occupant seated in the front row frequently experiences the more severe injury in the pair, however there were no significant differences in the rate of occurrence of these events and events where the more severe injury occurs in the second row occupant of the pair. A logistic regression indicated that the likelihood of the more severe injury occurring in the second row seated occupant of the pair increased as crash severity increased, consistent with data from anatomic test dummy (ATD) tests. It also indicated that the second row occupant was more likely to have the more severe injury in the pair if that occupant was the older occupant of the pair. These findings suggest that occupant protection systems which focus on providing protection specifically for injuries experienced by older occupants in the second row in higher severity crash conditions might provide the greatest benefit.

The diagnostic accuracy of Neuropad for assessing large and small fibre diabetic neuropathy

AIMS

Neuropad is a simple visual indicator test, with moderate diagnostic performance for diabetic peripheral neuropathy. As it assesses sweating, which is a measure of cholinergic small nerve fibre function, we compared its diagnostic performance against established measures of both large and, more specifically, small fibre damage in patients with diabetes.

METHODS

One hundred and twenty-seven participants (89 without diabetic peripheral neuropathy and 38 with) aged 57 ± 9.7 years underwent assessment with Neuropad, large nerve fibre assessments: Neuropathy Disability Score, vibration perception threshold, peroneal motor nerve conduction velocity; small nerve fibre assessments: neuropathy symptoms (Diabetic Neuropathy Symptoms score) corneal nerve fibre length and warm perception threshold.

RESULTS

Neuropad has a high sensitivity but moderate specificity against large fibre neuropathy assessments: Neuropathy Disability Score (> 2) 70% and 50%, vibration perception threshold (> 14 V) 83% and 53%, and peroneal motor nerve conduction velocity (< 42 m/s) 81% and 54%, respectively. However, the diagnostic accuracy of Neuropad was significantly improved against corneal nerve fibre length (< 14 mm/mm2) with a sensitivity and specificity of 83% and 80%, respectively. Furthermore, the area under the curve for corneal nerve fibre length (85%) was significantly greater than with the Neuropathy Disability Score (66%, P = 0.01) and peroneal motor nerve conduction velocity (70%, P = 0.03). For neuropathic symptoms, sensitivity was 78% and specificity was 60%.

CONCLUSIONS

The data show the improved diagnostic performance of Neuropad against corneal nerve fibre length. This study underlines the importance of Neuropad as a practical diagnostic test for small fibre neuropathy in patients with diabetes.

Macroscopic and microscopic examination of pulmonary Crenosoma striatum in hedgehog

The aim of study was to necropsy and histopathology evaluation of lung Crenosoma striatum in hedgehog. In July 2012, 10 porcupines were collected from Urmia city and transferred to parasitology lab of the veterinary faculty where they were euthanized by ketamine (over 40-90 mg/kg) intraperitoneally. In this study the lungs were assessed through naked eyes regarding parasite presence upon washing. The lung tissue was examined under loop microscope in order to finding small worms in lung parenchyma. The worms were removed by Anse forceps and kept in AFA solution, and collected for diagnosis. In order to carrying out pathological tests, some samples prepared and placed in formalin 10 % for fixation. The counted worms frequency in high severe and moderate lungs were as 86 (50 females and 36 males) and 19 (13 females and 16 males) worms respectively. But no worms were observed in healthy lungs. The infestation severity was as; low infestation (1-7 worms), moderate infestation (8-20), severe infestation (21-50) and very severe infestation (more than 50 worms). The lung examinations of non-infested lungs indicated that the lung tissues had no parasite. In addition, no inflammation reactions as inflammatory cells presence were observed, and the air spaces with alveoles' wall in some regions were observable. On histopathological examination, the observed alteration was primarily inflammatory changes, and in some cases the proliferation was also observable. Hyperemia and inflammatory cell infiltration, somehow the alveolar space was filled, representing bronchopneumonia reaction. The bronchioles had various changes as hypertrophy and hyperplastic in different parts of respiratory system. Hyperemia and hemorrhage were very severe in some cases caused hemosiderosis in the lung. In severe inflammations the pneumonia along with increasing of bronchial cells in the lumen rose as well, leading to severe verminous infestation of the lung. In regard to the obtained results, the verminous infestation of the porcupines' lung with C. striatum indicated inflammatory and proliferative alteration which was as inflammatory changes in mild cases, and inflammatory and proliferative stances in severe cases.

The efficacy of passiflora incarnata linnaeus in reducing dental anxiety in patients undergoing periodontal treatment

STATEMENT OF PROBLEM

Oral premedication used to reduce the anxiety in patients undergoing dental treatment. Passion flower has been used as a sedative that can control the dental anxiety.

PURPOSE

This study determines the efficacy of Passion flower, in reducing anxiety during the dental procedures.

MATERIAL AND METHODS

In this randomized- one sided blind clinical trial, 63 patients, with moderate, high and severe anxiety(according to VAS score) in need of periodontal treatment were randomly divided into 3 groups of 21.The first group was given the drop Passion flower drop and the second group were given the drop of placebo and the third group; neither drug nor placebo were given (negative control group). RESULTS were analyzed by Chi Square, Variance Analysis, Tucky and Paired-T using SPSS software.

RESULTS

Mean anxiety level prior to the drug administration was 12.09±2.42 for the Passion flower group, 12.00±2.66 for the placebo group and 11.66±2.39 for the negative control group. After premedication, these values were: 8.47±2.58 for the Passion flower group, 10.52±2.11 for the placebo group and 11.23±2.34 for the negative control group. These results demonstrated a significant difference (p< 0.0001) in the anxiety levels before and after the Passion flower administration in the Passion flower group and also between the Passion flower group and the other two groups.

CONCLUSION

RESULTS indicated that administration of Passion flower, as a premedication, is significantly effective in reducing the anxiety. Since this study is a pioneer on the subject, further trials with greater number of subjects are required to confirm our results.

Corneal confocal microscopy detects improvement in corneal nerve morphology with an improvement in risk factors for diabetic neuropathy

AIM

We have assessed whether corneal confocal microscopy can be used to detect alterations in nerve morphology following an improvement in risk factors associated with diabetic neuropathy.

METHODS

Twenty-five patients with diabetes with mild to moderate neuropathy and 18 control subjects underwent corneal confocal microscopy to quantify corneal nerve fibre (density, branch density, length and tortuosity) at baseline and after 24 months from first visit. This was not planned as an intervention trial and was simply an observational follow-up.

RESULTS

At baseline, nerve fibre density (18.8 ± 2.1 vs. 46.0 ± 3.8 number/mm(2), P = 0.001), nerve branch density (6.9 ± 1.5 vs. 35.6 ± 6.7 number/mm(2), P < 0.0001), nerve fibre length (8.3 ± 0.9 vs. 13.5 ± 0.8 mm/mm(2), P < 0.0001) and nerve fibre tortuosity (19.8 ± 1.6 vs. 22.7 ± 2.2, P < 0.05) were significantly lower in patients with diabetes than in control subjects. At follow-up, glycaemic control (HbA(1c) 64 ± 3 to 58 ± 2 mmol/mol, P = 0.08), total cholesterol (4.9 ± 0.2 to 4.2 ± 0.2 mmol/l, P = 0.01), systolic blood pressure (145.8 ± 4.9 to 135.9 ± 3.7 mmHg, P = 0.09) and diastolic blood pressure (77.8 ± 2.7 to 70.8 ± 2.5, P = 0.03) improved. Nerve fibre density (24.1 ± 2.0, P = 0.05), nerve branch density (11.1 ± 1.3, P < 0.01) and nerve fibre tortuosity (22.6 ± 1.5, P = 0.05) increased significantly, with no change in nerve fibre length (8.4 ± 0.5). Improvement in nerve fibre density correlated significantly with the improvement in HbA(1c) (r = -0.51, P = 0.008). Via four multifactorial regressions, this confirms the negative association between HbA(1c) and nerve fibre density (P = 0.02).

CONCLUSIONS

This study shows that corneal confocal microscopy may be employed in longitudinal studies to assess progression of human diabetic neuropathy and also supports the hypothesis that improvements in risk factors for diabetic neuropathy, in particular HbA(1c) , may lead to morphological repair of nerve fibres.

Increased Langerhan cell density and corneal nerve damage in diabetic patients: role of immune mechanisms in human diabetic neuropathy

AIM/HYPOTHESIS

Immune mechanisms have been proposed to play a role in the development of diabetic neuropathy. We employed in vivo corneal confocal microscopy (CCM) to quantify the presence and density of Langerhans cells (LCs) in relation to the extent of corneal nerve damage in Bowman's layer of the cornea in diabetic patients.

METHODS

128 diabetic patients aged 58 ± 1 yrs with a differing severity of neuropathy based on Neuropathy Deficit Score (NDS-4.7 ± 0.28) and 26 control subjects aged 53 ± 3 yrs were examined. Subjects underwent a full neurological evaluation, evaluation of corneal sensation with non-contact corneal aesthesiometry (NCCA) and corneal nerve morphology using corneal confocal microscopy (CCM).

RESULTS

The proportion of individuals with LCs was significantly increased in diabetic patients (73.8%) compared to control subjects (46.1%), P = 0.001. Furthermore, LC density (no/mm(2)) was significantly increased in diabetic patients (17.73 ± 1.45) compared to control subjects (6.94 ± 1.58), P = 0.001 and there was a significant correlation with age (r = 0.162, P = 0.047) and severity of neuropathy (r = -0.202, P = 0.02). There was a progressive decrease in corneal sensation with increasing severity of neuropathy assessed using NDS in the diabetic patients (r = 0.414, P = 0.000). Corneal nerve fibre density (P < 0.001), branch density (P < 0.001) and length (P < 0.001) were significantly decreased whilst tortuosity (P < 0.01) was increased in diabetic patients with increasing severity of diabetic neuropathy.

CONCLUSION

Utilising in vivo corneal confocal microscopy we have demonstrated increased LCs in diabetic patients particularly in the earlier phases of corneal nerve damage suggestive of an immune mediated contribution to corneal nerve damage in diabetes.

An ultra-low-power pulse oximeter implemented with an energy-efficient transimpedance amplifier

Pulse oximeters are ubiquitous in modern medicine to noninvasively measure the percentage of oxygenated hemoglobin in a patient's blood by comparing the transmission characteristics of red and infrared light-emitting diode light through the patient's finger with a photoreceptor. We present an analog single-chip pulse oximeter with 4.8-mW total power dissipation, which is an order of magnitude below our measurements on commercial implementations. The majority of this power reduction is due to the use of a novel logarithmic transimpedance amplifier with inherent contrast sensitivity, distributed amplification, unilateralization, and automatic loop gain control. The transimpedance amplifier, together with a photodiode current source, form a high-performance photoreceptor with characteristics similar to those found in nature, which allows LED power to be reduced. Therefore, our oximeter is well suited for portable medical applications, such as continuous home-care monitoring for elderly or chronic patients, emergency patient transport, remote soldier monitoring, and wireless medical sensing. Furthermore, our design obviates the need for an A-to-D and digital signal processor and leads to a small single-chip solution. We outline how extensions of our work could lead to submilliwatt oximeters.

Comparison of Enterocystoplasty and Ureterocystoplasty before Kidney Transplantation

BACKGROUND

Augmentation cystoplasty before or after renal transplantation is an option for patients with end-stage renal disease who are candidates for renal transplantation and have low capacity and poorly compliant bladders.

OBJECTIVE

To compare two surgical methods of bladder augmentation-enterocystoplasty (EC) and ureterocystoplasty (UC)-before kidney transplantation, and their outcome with that in kidney recipients who had normal bladder function.

METHODS

During a 20-year period (1988-2008), 1406 renal transplantation were performed in our center by our team. In 16 patients having a mean age of 18.8 years, EC (group A) and in 8 with mean age of 11.5 years, UC (group B) were performed before renal transplantation. These two groups were compared with a control group of 30 recipients with normal bladder (group C) with mean age of 15.6 years, for kidney function, graft and patient survival, and the frequency of urinary tract infection (UTI).

RESULTS

There was normal graft function in 11 of group A, 7 of group B, and 24 of group C patients, during a mean follow-up of 73.1 months. The mean±SD serum creatinine in follow-up was 1.72±0.31, 1.37±0.13 and 1.33±0.59 mg/dL in groups A, B and C, respectively. No statistically significant differences were observed among the 3 studied groups in terms of 1-, 5- and 10-year graft and patient survivals. Number of episodes of febrile UTI requiring hospitalization was 23, 6 and 2 in groups A, B and C, respectively. UTI and urosepsis were significantly more frequent in group A than groups B (p=0.025) and C (p=0.001); no significant difference was observed in the frequency between groups B and C (p=0.310).

CONCLUSION

Both EC and UC are equally recommended before renal transplantation for reconstruction of the lower urinary tract; use of each method should be individualized depending on specific conditions of recipient.

Upregulation of the ERG11 gene in Candida krusei by azoles

BACKGROUND AND THE PURPOSE OF THE STUDY

Candida species are the agents of local and systemic opportunistic infections and have become a major cause of morbidity and mortality in the last few decades. Azole resistance in Candida krusei (C. krusei) species appears to be the result of gene alterations in relation to the ergosterol biosynthesis pathway, as well as efflux pumps. The main objective of this study was to examine the RNA expression of ERG11 in C. krusei which had been identified to be resistance to azoles.

METHODS

The ERG11 mRNA expression was investigated in four Iranian clinical isolates of C. krusei, which were resistant to fluconazole and itraconazole by a semiquantitative RT-PCR.

RESULTS

The mRNA expression levels were observed in all four isolates by this technique. Furthermore, it was found that ERG11 expression levels vary among four representative isolates of C. krusei. Although DNA sequencing revealed no significant genetic alteration in the ERG11 gene, one heterozygous polymorphism was observed in two isolates, but not in others. This polymorphism was found in the third base of codon 313 for Thr (ACT>ACC).

MAJOR CONCLUSION

Even though such a polymorphism creates a new Ear1 restriction site, no significant effect was found on the resistance of C. krusei to azoles. RESULTS of this investigation are consistent with previous studies and may provide further evidence for the genetic heterogeneity and complexity of the ergosterol biosynthetic pathway or efflux pumps.

Dual-model automatic detection of nerve-fibres in corneal confocal microscopy images

Corneal Confocal Microscopy (CCM) imaging is a non-invasive surrogate of detecting, quantifying and monitoring diabetic peripheral neuropathy. This paper presents an automated method for detecting nerve-fibres from CCM images using a dual-model detection algorithm and compares the performance to well-established texture and feature detection methods. The algorithm comprises two separate models, one for the background and another for the foreground (nerve-fibres), which work interactively. Our evaluation shows significant improvement (p approximately 0) in both error rate and signal-to-noise ratio of this model over the competitor methods. The automatic method is also evaluated in comparison with manual ground truth analysis in assessing diabetic neuropathy on the basis of nerve-fibre length, and shows a strong correlation (r = 0.92). Both analyses significantly separate diabetic patients from control subjects (p approximately 0).

Haptic Effects of Surgical Teleoperator Flexibility

Minimally invasive surgery systems typically involve thin and cable-driven surgical instruments. This introduces link and joint flexibility in the slave robot of a master—slave teleoperation system, reducing the effective stiffness of the slave and the transparency of teleoperation. In this paper, we analyze transparency under slave link and joint flexibility (tool flexibility). We also evaluate the added benefits of using extra sensors at the tip of the flexible robot. It is shown that tip velocity (or position) feedback improves free-space position tracking performance in the presence of robot flexibility. Also, when the interaction forces with an environment are measured by a force sensor and fed back to the user’s hand, tip velocity feedback improves hard-contact force tracking performance. During a hard contact task, tip velocity feedback can also eliminate the transmission of robot flexibility to the user’s hand.

The Neuropad test: a visual indicator test for human diabetic neuropathy

AIMS/HYPOTHESIS

The commercially available Neuropad test was developed as a simple visual indicator test to evaluate diabetic neuropathy. It uses a colour change to define the integrity of skin sympathetic cholinergic innervation. We compared the results of Neuropad assessment in the foot with established measures of somatic and autonomic neuropathy.

METHODS

Fifty-seven diabetic patients underwent Neuropad assessment, quantitative sensory and autonomic function testing, and evaluation of intra-epidermal nerve fibre density in foot skin biopsies.

RESULTS

Neuropad responses correlated with the neuropathy disability score (r(s)=0.450, p<0.001), neuropathic symptom score (r(s)=0.288, p=0.03), cold detection threshold (r(s)=0.394, p = 0.003), heat-as-pain perception threshold visual analogue score 0.5 (r(s)=0.279, p=0.043) and deep-breathing heart rate variability (r(s)= -0.525, p<0.001). Intra-epidermal nerve fibre density (fibres/mm) compared with age- and sex-matched control subjects (11.06+/-0.82) was non-significantly reduced (7.37+/-0.93) in diabetic patients with a normal Neuropad response and significantly reduced in patients with a patchy (5.01+/-0.93) or absent (5.02+/-0.77) response (p=0.02). The sensitivity of an abnormal Neuropad response in detecting clinical neuropathy (neuropathy disability score >or=5) was 85% (negative predictive value 71%) and the specificity was 45% (positive predictive value 69%).

CONCLUSIONS/INTERPRETATION

The Neuropad test may be a simple indicator for screening patients with diabetic neuropathy.

Tool/tissue interaction feedback modalities in robot-assisted lump localization

Providing a surgeon with information regarding contacts made between tools and tissue during robot-assisted interventions can improve task efficiency and reliability. It is hypothesized that various modalities of contact feedback have the potential to enhance performance in a robot-assisted minimally invasive environment. In this paper, (kinesthetic) haptic feedback is compared with visual feedback of haptic information in terms of several performance metrics. Using a haptics-capable master-slave test-bed for endoscopic surgery, experiments involving a lump localization task are conducted and the performance of human subjects is compared for these two modalities of contact feedback. It is shown that the two feedback modalities result in comparable localization accuracies--an advantage of visual haptic feedback due to the lower system complexity required--while the task completion times are significantly shorter with haptic feedback.

Comparative susceptibility of cypermethrin in Ornithodoros lahorensis Neuman and Argas persicus Oken (Acari: Argasidae) field populations

The toxicity of cypermethrin was determined in five different soft tick strains of Argas persicus Oken and Ornithodoros lahorensis Neuman by topical application method. The O. lahorensis Bij, O. lahorensis west O1, O. lahorensis Mesh, A. persicus Lor, A. persicus West Ap strains were collected from Bijar, Kurdistan province, Takab, Western Azerbaijan province, Meshkinshar, Ardebil province, Khoramabad, Lorestan province, Takab, Western Azerbaijan province of different areas of Islamic Republic of Iran, respectively during 2004 and 2005. In the topical application bioassay, the average LD50 of O. lahorensis Bij, West O1, Mesh and A. reflexus Lor and West AP strains were 0.03, 0.04, 1.7, 0.7 and 1.7 microg tick(-1), respectively and the steep slopes of dose-response curves indicated that the field population of these soft tick strains were homogenous in response to cypermethrin. Comparison of the resistance ratio of collected strains with susceptible strain showed a resistance ratio of 56.7 and 2.4-folds for cypermethrin in O. lahorensis Mesh and A. reflexus West Ap strains, whereas the O. lahorensis West O1 completely susceptible to cypermethrin.

Fludarabine and busulfan as a myeloablative conditioning regimen for allogeneic stem cell transplantation in high- and standard-risk leukemic patients

Busulfan and cyclophosphamide (BuCy) are currently the most widely used myeloablative regimen to treat malignancies with allogeneic stem cell transplantation. Fludarabine has considerable efficacy in both immunosuppression and tumor cells killing with a minimal extramedullary toxicity. We evaluated the efficacy of 40 mg/m(2) fludarabine i.v. for 5 days and busulfan 4 mg/kg/day p.o. for 4 days as myeloablative conditioning regimen in 70 patients (median age 24 years) with acute leukemia or chronic phase of myelogenous leukemia. They all had human leukocyte antigen-matched sibling donors. The patients received 10 mug/kg granulocyte colony stimulating factor (GCSF), 24 h after stem cell infusion until engraftment occurred. Graft-versus-host disease (GVHD) prophylaxis included 3 mg/kg cyclosporine-A i.v. from day -2 to +6 followed by 12 mg/kg p.o. until day +60. The median time of neutrophil recovery (>0.5 x 109/l) and platelet recovery (>20 x 109/l) were 10 and 12 days, respectively. Mucositis (93%) and hepatic toxicity (16%) resolved with conservative therapy. The incidence of acute GVHD grade I-II and III-IV were 38.6 and 15.7% respectively. Overall survival and disease-free survival were 71 and 64% respectively with 17 months median follow-up for surviving patients. We conclude that FluBu may be used as a substitute for BuCy with almost the same efficacy and with a lower transplant adverse effect but to increase anti-leukemic effects, especially in acute lymphoblastic leukemia patients, it needs some modifications.

The use of power beams in surface modification

This review of surface modification technologies focuses on the use of power beams, that is, lasers and electron beams, to modify polymer surfaces. A novel electron-beam materials processing technique is also described that offers scope for generating new types of surface functionality on metals used to construct stents and implants.

The impact of anti-tumour necrosis factor therapy for rheumatoid arthritis on the use of other drugs and hospital resources in a pragmatic setting

BACKGROUND

Anti-tumour necrosis factor (anti-TNF) therapy has been an important development for the treatment of rheumatoid arthritis (RA) but the impact of its delivery on hospital resources in still emerging.

AIMS

We audited the effect of starting anti-TNF on the use of other anti-rheumatic therapies and hospital resources in a routine secondary care setting.

METHODS

A retrospective study of resource use before and after anti-TNF was conducted. Hospital records of 54 RA patients were studied and data taken from the time of commencing anti-TNF to 1 October 2004 and an equal time period prior to commencing anti-TNF. Identical data were collected for 54 controls not on anti-TNF. Relevant figures were extrapolated to per annum rates. Results were analysed using two-factor ANOVAs comparing the pre- versus post-anti-TNF period. Cases on intravenous (IV) versus subcutaneous (SC) anti-TNF were also compared in separate ANOVAs.

RESULTS

Mean duration of anti-TNF therapy was 17.04 months (range 3.60-42.36). Mean pre- and 3-months post-anti-TNF Disease Activity Scores (DAS28) were 6.93 and 3.88, respectively. Cases were more likely than controls to be on oral prednisolone pre- and post-anti-TNF. Methylprednisolone requirement, number of disease-modifying anti-rheumatic drugs (DMARDs), telephone helpline contacts and duration as an inpatient reduced significantly post-anti-TNF. Day case admissions increased but outpatient appointments decreased only in cases on IV anti-TNF.

CONCLUSIONS

In a pragmatic setting, anti-TNF therapy led to reduced need for steroid injections and other DMARDs, as well as reductions in use of several hospital resources. Wider replication of these findings will be important for planning delivery.

Methods and mechanisms for contact feedback in a robot-assisted minimally invasive environment

Providing a surgeon with information regarding contacts made between instruments and tissue during robot-assisted interventions can improve task efficiency and reliability. In this report, different methods for feedback of such information to the surgeon are discussed. It is hypothesized that various methods of contact feedback have the potential to enhance performance in a robot-assisted minimally invasive environment. To verify the hypothesis, novel mechanisms needed for incorporating contact feedback were designed, including a surgeon-robot interface with full force feedback capabilities and a surgical end-effector with full force sensing capabilities, that are suitable for minimally invasive applications. These two mechanisms were used to form a robotic "master-slave" test bed for studying the effect of contact feedback on the system and user performance. Using the master-slave system, experiments for surgical tasks involving soft tissue palpation were conducted. The performance of the master-slave system was validated in terms of criteria that assess the accurate transmission of task-related information to the surgeon, which is critical in the context of soft tissue surgical applications. Moreover, using a set of experiments involving human subjects, the performance of several users in carrying out the task was compared among different methods of contact feedback.

A novel polymeric coating for enhanced ultrasound visibility of medical devices

A dynamic novel coating, consisting of a hydrophilic polymeric matrix and a bubbling agent, has been developed for precise entry and positioning of needles, and accurate collection of biopsy samples. These coated biopsy needles have been successfully used in in vitro trials. The results are discussed here. Potential application areas include vascular, cardiovascular and orthopaedics.

The relationship of medical, demographic and psychosocial factors to direct and indirect health utility instruments in rheumatoid arthritis

OBJECTIVES

Cost-effectiveness analysis (CEA) is essential for the comparison of treatments for rheumatoid arthritis (RA). CEA centres on accurate measurement of health utility (HU) preferences. Direct measures of HU in RA patients demonstrate weaker correlations with health status (functional disability and pain) than indirect measures. We examined whether demographic and psychosocial factors relate to HU in RA patients.

METHODS

HU was measured for 142 RA patients (76% women; mean age 58.75 yr) directly through standard gamble (SG) and time trade-off (TTO), and indirectly on the EuroQol (EQ-5D). Current pain (100 mm visual analogue scale) and recent functional disability (Health Assessment Questionnaire; HAQ) were assessed. A subsample of 48 provided demographic and psychosocial information (education, employment, marital/family status, knowledge about RA, medication beliefs, desirable responding, social support, optimism, and the Hospital Anxiety and Depression Scale; HADS).

RESULTS

Direct HU had higher means (SG = 0.88, TTO = 0.86) than indirect HU (EQ-5D = 0.52). HAQ functional disability correlated with SG (r = - 0.28), TTO (r = - 0.31) and EQ-5D (r = - 0.67). Current pain correlated with TTO (r = - 0.19) and EQ-5D (r = - 0.36). HADS depression correlated with TTO (r = - 0.35) and EQ-5D (r = - 0.64); HADS anxiety also correlated with EQ-5D (r = - 0.46).

CONCLUSIONS

Demographic and psychosocial factors cannot completely explain either the significant differences between direct and indirect HUs in RA patients or the moderate correlations of direct HUs with health status. Characteristics of the SG and TTO may make them inappropriate for HU assessment and CEA among RA patients.

Multi-sensory force/deformation cues for stiffness characterization in soft-tissue palpation

In the commercially available robot-assisted surgical systems, camera vision constitutes the only flow of data from the patient side to the surgeon side. This paper studies how various modalities for feedback of interaction between a surgical tool and soft tissue can improve the efficiency of a typical surgical task. Utilizing a haptics-enabled master-slave test-bed for minimally invasive surgery, user performance during a telemanipulated soft tissue stiffness discrimination task is compared under visual, haptic, graphical, and graphical plus haptic feedback modes in terms of task success rate and completion time and the amount of energy transfer and consequently trauma to tissue. While no significant difference is found in terms of the task completion times, graphical cueing and visual cueing are found to lead to the highest success rate and the highest risk of tissue damage (proportional to energy), respectively.

Innovation and the medical devices Farady partnership

Demand for development of new generation medical devices has led many governments to support medical-sector research. In the United Kingdom, the Medical Devices Faraday Partnership was created to establish a collaborative network that would enhance the transfer of good ideas into new products and processes. The services it offers medical device manufacturers are outlined here.

Haptic interaction in robot-assisted endoscopic surgery: a sensorized end-effector

Conventional endoscopic surgery has some drawbacks that can be addressed by using robots. The robotic systems used for surgery are still in their infancy. A major deficiency is the lack of haptic feedback to the surgeon. In this paper, the benefits of haptic feedback in robot-assisted surgery are discussed. A novel robotic end-effector is then described that meets the requirements of endoscopic surgery and is sensorized for force/ torque feedback. The endoscopic end-effector is capable of non-invasively measuring its interaction with tissue in all the degrees of freedom available during endoscopic manipulation. It is also capable of remotely actuating a tip and measuring its interaction with the environment without using any sensors on the jaws. The sensorized end-effector can be used as the last arm of a surgical robot to incorporate haptic feedback and/or to evaluate skills and learning curves of residents and surgeons in endoscopic surgery.