The Development of a Team-Based, Hybrid Inter-university Graduate Certificate Program Focused on Maternal Child Health Professionals

Introduction

Pregnancy, childbirth, and child well-being are identified by Healthy People 2030 as priority topics for improving the health of all Americans. New Mexico is the fifth largest state geographically with most of the state’s 33 counties considered rural or frontier. Accessing health care services is challenging in this resource-poor environment. The need to provide maternal and child health (MCH) education in the state was the impetus for developing a graduate certificate in maternal and child public health.

Methods

The hybrid MCH graduate certificate engaged professionals in formal training that included a public health approach to addressing MCH issues in the state’s diverse communities. Grant funds paid for the tuition, books and travel for students providing an opportunity to individuals who otherwise could not have pursued graduate education and professional development.

Results

Over a 4-year period, two cohorts were recruited, educated, and evaluated. The evaluations reflected an increase in competency knowledge scores for all students.

Discussion

This model of MCH education was successful at delivering public health graduate education to MCH practitioners and increasing their knowledge and skills. Listening to students and communities as to what their MCH public health needs are and responding with a flexible educational model provided individuals with information and tools that could be used to improve maternal and child health and reduce health disparities in rural, tribal, and underserved communities.

417 Vibrational Spectroscopy: A Rapid Tool for Soft Tissue Sarcoma Assessment

Aim

Soft tissue sarcomas (STS) are a comparatively unusual cluster of tumours; they arise from mesenchymal tissues. Surgery remains the primary and the only potentially curative treatment for most STS subtypes.

Existing intraoperative margin assessment techniques are inadequate and the current gold standard for resection margin assessment of STS is post-operative histopathology, but this takes weeks to finalize. Consequently, an augmented surgical technique established by real-time non-destructive recognition of clear margins is essential to diminish the risk of local relapse, decrease the resection area, and enhance the effectiveness of surgical resection of STS.

Vibrational spectroscopy (VS) is a non-destructive evaluation of the atomic oscillation within a molecule. Every molecule has a unique set of vibrational modes called molecular fingerprint. We aim to use Raman spectroscopy to analyse biomolecular spectra of sarcoma and develop a potential tool for intra operative margin assessment

Method

Human sarcoma was tissue obtained from the biobank at QEHB. The samples were identified as Lipoma and Liposarcoma. The samples underwent spectral measurement with the Raman microscope and the tissue samples were then sent for histopathological analysis.

Results

The spectral evaluation clearly demonstrates the biomolecular difference between the two groups and has a potential to become an intraoperative tool.

Conclusions

A positive resection margin is the ultimate prognosticator of local relapse. There is a need for a rapid and reliable tool that can offer surgeons with instant feedback during primary procedure.

A two-dimensional finite element model of cyclic adenosine monophosphate (cAMP) intracellular signaling

In this work, we present a two-dimensional finite element analysis (FEA) model that describes fundamental intracellular signals of cyclic adenosine monophosphate (cAMP) in a general fashion. The model was subsequently solved numerically and the results were displayed in forms of time-course plots of cAMP concentration at a cellular location or color-filled contour maps of cAMP signal distribution within the cell at specific time points. Basic intracellular cAMP signaling was described in this model so it can be numerically validated by verifying its numerical results against available analytical solutions and against results obtained from other numerical techniques reported in the literature. This is the first important step before the model can be expanded in future work. Model simulations demonstrate that under certain conditions, sustained cAMP concentrations can be formed within endothelial cells (ECs), similar to those observed in rat pulmonary microvascular ECs. Spatial and temporal cAMP dynamic simulations indicated that the proposed FEA model is an effective tool for the study of the kinetics and spatial spread of second messenger signaling and can be expanded to simulate second messenger signals in the pulmonary vasculature.

Abstract P6-01-03: Exploring the relationship between an in vitro model of breast cancer cell mineralisation and the cancer grade specific composition of ex vivo microcalcifications

Background: Microcalcifications resulting from calcium deposition in the mammary gland play a central role in the early detection of breast cancer [1]. However, the relationship between their occurrence in the breast and cancer progression remains poorly understood. Our approach is to use vibrational spectroscopy and imaging, which is non-invasive, non-destructive, label-free and chemically specific, to assess the composition and distribution of the deposits in an in vitro cancer cell model of mineralisation [2]. In parallel we will utilise the same methods to measure the biochemical composition of microcalcifications found in breast biopsies from different grades of cancer. The ultimate aim of the study is to link the changes identified during the in vitro mineralisation process with the different stages of breast cancer. Vibrational spectroscopic methods can provide incredibly detailed biomolecular fingerprints enabling us to elucidate both the compositional changes with advancing pathology and the spatial distribution of those changes within the calcification and the surrounding tissue.

Methods: The breast cancer cell line MDA-MB-231 has the ability to produce mineralisation. This mineralisation was assessed over a 14-day period in the presence of different osteogenic cocktails: one composed of ascorbic acid, β-glycerophosphate (βG) and dexamethasone (Dex), and another one composed of inorganic phosphate (Pi). Fixed cells were analysed using Raman spectroscopy and micro-FTIR imaging at different time points (3, 7, 11 and 14 days). Tissue sections from patients with microcalcifications identified in histopathology will be sectioned to 3 mm and imaged with infrared (Agilent 670 FTIRinterferometer and Focal Plane Array imaging microscope) and Raman (Renishaw inVia) microspectrometers.

Results: We observed distinct and specific phosphate peak (PO43-) at 960 and 1020 cm-1 in Raman and FTIR spectra, respectively, corresponding to hydroxyapatite crystal and indicating the presence of microcalcification formation. Treatment with Pi induced a faster mineralisation (day 3) compared to cells treated with βG (day 11) and different spectral profiles during this development phase. In addition, there are changes in both the relative DNA and protein concentrations in the cells following 11 days exposure to the osteogenic agents.

It has been shown that the level of carbonate substitution in the calcium hydroxyapatite crystal correlates directly with the pathology of the tissue surrounding the microcalcification. Here we compare the mineral composition found ex vivo versus the in vitro model.

Conclusion: It could be possible to link the progressive biophysical changes associated with mineralisation to distinct stages of breast cancer pathology based on protein, lipid and carbonated apatite contents of the mineralised cells.

Support:This work was conducted as part of the Marie Curie Innovative Training Network Mid-TECH [H2020-MSCA-ITN-2014-642661]

References:

[1] R. Baker, KD. Rogers, N. Shepherd and N. Stone. British Journal of Cancer. 103, 1034-1039 (2010)

[2] RF. Cox, A. Hernandez-Santana, S. Ramdass, G. McMahon, JH. Harmey and MP. Morgan. British Journal of Cancer. 106, 525–537 (2012)

Citation Format: Bouzy P, O'Grady S, Palombo F, Morgan MP, Stone N. Exploring the relationship between an in vitro model of breast cancer cell mineralisation and the cancer grade specific composition of ex vivo microcalcifications [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-01-03.

Rapid infrared mapping for highly accurate automated histology in Barrett's oesophagus

Barrett's oesophagus (BE) is a premalignant condition that can progress to oesophageal adenocarcinoma. Endoscopic surveillance aims to identify potential progression at an early, treatable stage, but generates large numbers of tissue biopsies. Fourier transform infrared (FTIR) mapping was used to develop an automated histology tool for detection of BE and Barrett's neoplasia in tissue biopsies. 22 oesophageal tissue samples were collected from 19 patients. Contiguous frozen tissue sections were taken for pathology review and FTIR imaging. 45 mid-IR images were measured on an Agilent 620 FTIR microscope with an Agilent 670 spectrometer. Each image covering a 140 μm × 140 μm region was measured in 5 minutes, using a 1.1 μm² pixel size and 64 scans per pixel. Principal component fed linear discriminant analysis was used to build classification models based on spectral differences, which were then tested using leave-one-sample-out cross validation. Key biochemical differences were identified by their spectral signatures: high glycogen content was seen in normal squamous (NSQ) tissue, high glycoprotein content was observed in glandular BE tissue, and high DNA content in dysplasia/adenocarcinoma samples. Classification of normal squamous samples versus 'abnormal' samples (any stage of Barrett's) was performed with 100% sensitivity and specificity. Neoplastic Barrett's (dysplasia or adenocarcinoma) was identified with 95.6% sensitivity and 86.4% specificity. Highly accurate pathology classification can be achieved with FTIR measurement of frozen tissue sections in a clinically applicable timeframe.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Prolonged and large outbreak of invasive group A Streptococcus disease within a nursing home: repeated intrafacility transmission of a single strain

OBJECTIVES

Multiple invasive group A Streptococcus (GAS) infections were reported to public health by a skilled nursing facility (facility A) in Illinois between May 2014 and August 2016. Cases continued despite interventions including antibiotic prophylaxis for all residents and staff. Two other geographically close facilities reported contemporaneous outbreaks of GAS. We investigated potential reasons for ongoing transmission.

METHODS

We obtained epidemiologic data from chart review of cases and review of facility and public health records from previous investigations into the outbreak. Infection control practices at facility A were observed and evaluated. Whole genome sequencing followed by phylogenetic analysis was performed on available isolates from the three facilities.

RESULTS

From 2014 to 2016, 19 invasive and 60 noninvasive GAS infections were identified at facility A occurring in three clusters. Infection control evaluations during clusters 2 and 3 identified hand hygiene compliance rates of 14% to 25%, appropriate personal protective equipment use in only 33% of observed instances, and deficient wound-care practices. GAS isolates from residents and staff of all three facilities were subtype emm89.0; on phylogenetic analysis, facility A isolates were monophyletic and distinct.

CONCLUSIONS

Inadequate infection control and improper wound-care practices likely led to this 28-month-long outbreak of severe infections in a skilled nursing facility. Whole genome sequencing and phylogenetic analysis suggested that intrafacility transmission of a single highly transmissible GAS strain was responsible for the outbreak in facility A. Integration of genomic epidemiology tools with traditional epidemiology and infection control assessments was helpful in investigation of a facility-wide outbreak.

Multi-centre Raman spectral mapping of oesophageal cancer tissues: a study to assess system transferability

The potential for Raman spectroscopy to provide early and improved diagnosis on a wide range of tissue and biopsy samples in situ is well documented. The standard histopathology diagnostic methods of reviewing H&E and/or immunohistochemical (IHC) stained tissue sections provides valuable clinical information, but requires both logistics (review, analysis and interpretation by an expert) and costly processing and reagents. Vibrational spectroscopy offers a complimentary diagnostic tool providing specific and multiplexed information relating to molecular structure and composition, but is not yet used to a significant extent in a clinical setting. One of the challenges for clinical implementation is that each Raman spectrometer system will have different characteristics and therefore spectra are not readily compatible between systems. This is essential for clinical implementation where classification models are used to compare measured biochemical or tissue spectra against a library training dataset. In this study, we demonstrate the development and validation of a classification model to discriminate between adenocarcinoma (AC) and non-cancerous intraepithelial metaplasia (IM) oesophageal tissue samples, measured on three different Raman instruments across three different locations. Spectra were corrected using system transfer spectral correction algorithms including wavenumber shift (offset) correction, instrument response correction and baseline removal. The results from this study indicate that the combined correction methods do minimize the instrument and sample quality variations within and between the instrument sites. However, more tissue samples of varying pathology states and greater tissue area coverage (per sample) are needed to properly assess the ability of Raman spectroscopy and system transferability algorithms over multiple instrument sites.

Towards new material biomarkers for fracture risk

Osteoporosis is a prevalent bone condition, characterised by low bone mass and increased fracture risk. Currently, the gold standard for identifying osteoporosis and increased fracture risk is through quantification of bone mineral density (BMD) using dual energy X-ray absorption (DEXA). However, the risk of osteoporotic fracture is determined collectively by bone mass, architecture and physicochemistry of the mineral composite building blocks. Thus DEXA scans alone inevitably fail to fully discriminate individuals who will suffer a fragility fracture. This study examines trabecular bone at both ultrastructure and microarchitectural levels to provide a detailed material view of bone, and therefore provides a more comprehensive explanation of osteoporotic fracture risk. Physicochemical characterisation obtained through X-ray diffraction and infrared analysis indicated significant differences in apatite crystal chemistry and nanostructure between fracture and non-fracture groups. Further, this study, through considering the potential correlations between the chemical biomarkers and microarchitectural properties of trabecular bone, has investigated the relationship between bone mechanical properties (e.g. fragility) and physicochemical material features.

Utilization of multiparametric prostate magnetic resonance imaging in clinical practice and focal therapy: report from a Delphi consensus project

Purpose

To codify the use of multiparametric magnetic resonance imaging (mpMRI) for the interrogation of prostate neoplasia (PCa) in clinical practice and focal therapy (FT).

Methods

An international collaborative consensus project was undertaken using the Delphi method among experts in the field of PCa. An online questionnaire was presented in three consecutive rounds and modified each round based on the comments provided by the experts. Subsequently, a face-to-face meeting was held to discuss and finalize the consensus results.

Results

mpMRI should be performed in patients with prior negative biopsies if clinical suspicion remains, but not instead of the PSA test, nor as a stand-alone diagnostic tool or mpMRI-targeted biopsies only. It is not recommended to use a 1.5 Tesla MRI scanner without an endorectal or pelvic phased-array coil. mpMRI should be performed following standard biopsy-based PCa diagnosis in both the planning and follow-up of FT. If a lesion is seen, MRI-TRUS fusion biopsies should be performed for FT planning. Systematic biopsies are still required for FT planning in biopsy-naïve patients and for patients with residual PCa after FT. Standard repeat biopsies should be taken during the follow-up of FT. The final decision to perform FT should be based on histopathology. However, these consensus statements may differ for expert centers versus non-expert centers.

Conclusions

The mpMRI is an important tool for characterizing and targeting PCa in clinical practice and FT. Standardization of acquisition and reading should be the main priority to guarantee consistent mpMRI quality throughout the urological community.

Electronic supplementary material

The online version of this article (doi:10.1007/s00345-016-1932-1) contains supplementary material, which is available to authorized users.

The micro-architecture of human cancellous bone from fracture neck of femur patients in relation to the structural integrity and fracture toughness of the tissue

Osteoporosis is clinically assessed from bone mineral density measurements using dual energy X-ray absorption (DXA). However, these measurements do not always provide an accurate fracture prediction, arguably because DXA does not grapple with ‘bone quality’, which is a combined result of microarchitecture, texture, bone tissue properties, past loading history, material chemistry and bone physiology in reaction to disease. Studies addressing bone quality are comparatively few if one considers the potential importance of this factor. They suffer due to low number of human osteoporotic specimens, use of animal proxies and/or the lack of differentiation between confounding parameters such as gender and state of diseased bone. The present study considers bone samples donated from patients (n = 37) who suffered a femoral neck fracture and in this very well defined cohort we have produced in previous work fracture toughness measurements (FT) which quantify its ability to resist crack growth which reflects directly the structural integrity of the cancellous bone tissue. We investigated correlations between BV/TV and other microarchitectural parameters; we examined effects that may suggest differences in bone remodelling between males and females and compared the relationships with the FT properties. The data crucially has shown that TbTh, TbSp, SMI and TbN may provide a proxy or surrogate for BV/TV. Correlations between FT critical stress intensity values and microarchitecture parameters (BV/TV, BS/TV, TbN, BS/BV and SMI) for osteoporotic cancellous tissue were observed and are for the first time reported in this study. Overall, this study has not only highlighted that the fracture model based upon BMD could potentially be improved with inclusion of other microarchitecture parameters, but has also given us clear clues as to which of them are more influential in this role.

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first time ever study to relate microarchitecture to the fracture toughness of cancellous bone from the femoral head of FNF victims

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reduction in bone mass relates to a reduction in the number of trabeculae and trabecular thickness and an increase in trabeculae spacing

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bone loss observed appears to be a consequence of thinning of the trabeculae in males and perforation of the trabeculae in females

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study hints that TbTh, TbSp, SMI and TbN may provide a proxy or surrogate for BV/TV

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fracture models can be improved by including microarchitecture, BMD and the bone mineral quality of osteoporotic cancellous bone

X-ray diffraction from bone employing annular and semi-annular beams

There is a compelling need for accurate, low cost diagnostics to identify osteo-tissues that are associated with a high risk of fracture within an individual. To satisfy this requirement the quantification of bone characteristics such as 'bone quality' need to exceed that provided currently by densitometry. Bone mineral chemistry and microstructure can be determined from coherent x-ray scatter signatures of bone specimens. Therefore, if these signatures can be measured, in vivo, to an appropriate accuracy it should be possible by extending terms within a fracture risk model to improve fracture risk prediction.In this preliminary study we present an examination of a new x-ray diffraction technique that employs hollow annular and semi-annular beams to measure aspects of 'bone quality'. We present diffractograms obtained with our approach from ex vivo bone specimens at Mo Kα and W Kα energies. Primary data is parameterized to provide estimates of bone characteristics and to indicate the precision with which these can be determined.

Energy-dispersive X-ray diffraction using an annular beam

We demonstrate material phase identification by measuring polychromatic diffraction spots from samples at least 20 mm in diameter and up to 10 mm thick with an energy resolving point detector. Within our method an annular X-ray beam in the form of a conical shell is incident with its symmetry axis normal to an extended polycrystalline sample. The detector is configured to receive diffracted flux transmitted through the sample and is positioned on the symmetry axis of the annular beam. We present the experiment data from a range of different materials and demonstrate the acquisition of useful data with sub-second collection times of 0.5 s; equating to 0.15 mAs. Our technique should be highly relevant in fields that demand rapid analytical methods such as medicine, security screening and non-destructive testing.

Evaluation of a confocal Raman probe for pathological diagnosis during colonoscopy

AIM

Raman spectroscopy of human tissue can provide a unique biochemical 'fingerprint' that alters with disease progression. Light incident on tissue is scattered and may be altered in wavelength, which can be represented as a Raman spectrum. A confocal fibreoptic Raman probe designed to fit down the accessory channel of a colonoscope has been constructed. This in-vitro study evaluated the accuracy of pathological diagnosis in the colon using probe-based Raman spectroscopy.

METHOD

Biopsy samples were collected at colonoscopy, snap frozen and stored at -80 °C. Raman spectra with 10-s and 1-s acquisition periods were measured with the probe tip in contact with the mucosal surface of thawed specimens. Mathematical modelling using principal component analysis followed by linear discriminant analysis was used to correlate Raman spectra with histopathological diagnoses.

RESULTS

Three-hundred and seventy-five Raman spectra were measured from a total of 356 colon biopsies (81 of normal colon mucosa, 79 of hyperplastic polyps, 92 of adenomatous polyps, 64 of adenocarcinoma and 40 of ulcerative colitis) from 177 patients. Spectral classification accuracies comparing pathology pairs ranged from 72.1 to 95.9% for 10-s acquisitions and from 61.5 to 95.1% for 1-s acquisitions. For a three-group model of normal, adenomatous and adenocarcinoma tissue, accuracies were 74.1% for 10-s acquisitions and 63.5% for 1-s acquisitions.

CONCLUSION

The confocal Raman probe system can distinguish between different colorectal pathologies. The probe has potential to establish Raman spectroscopy as a clinical tool for instant diagnosis at colonoscopy.

Mechanical mapping with chemical specificity by confocal Brillouin and Raman microscopy

We describe the first application of confocal Brillouin and Raman microscopy to ex vivo human epithelial tissue - Barrett's oesophagus. This non-invasive label-free approach provides high-resolution mechanical mapping with chemical specificity, opening the route to a new integrated method for multiple biomedical and bioengineering applications, and potentially in vivo real-time diagnostics.

Signal-to-noise contribution of principal component loads in reconstructed near-infrared Raman tissue spectra

The overall quality of Raman spectra in the near-infrared region, where biological samples are often studied, has benefited from various improvements to optical instrumentation over the past decade. However, obtaining ample spectral quality for analysis is still challenging due to device requirements and short integration times required for (in vivo) clinical applications of Raman spectroscopy. Multivariate analytical methods, such as principal component analysis (PCA) and linear discriminant analysis (LDA), are routinely applied to Raman spectral datasets to develop classification models. Data compression is necessary prior to discriminant analysis to prevent or decrease the degree of over-fitting. The logical threshold for the selection of principal components (PCs) to be used in discriminant analysis is likely to be at a point before the PCs begin to introduce equivalent signal and noise and, hence, include no additional value. Assessment of the signal-to-noise ratio (SNR) at a certain peak or over a specific spectral region will depend on the sample measured. Therefore, the mean SNR over the whole spectral region (SNR(msr)) is determined in the original spectrum as well as for spectra reconstructed from an increasing number of principal components. This paper introduces a method of assessing the influence of signal and noise from individual PC loads and indicates a method of selection of PCs for LDA. To evaluate this method, two data sets with different SNRs were used. The sets were obtained with the same Raman system and the same measurement parameters on bladder tissue collected during white light cystoscopy (set A) and fluorescence-guided cystoscopy (set B). This method shows that the mean SNR over the spectral range in the original Raman spectra of these two data sets is related to the signal and noise contribution of principal component loads. The difference in mean SNR over the spectral range can also be appreciated since fewer principal components can reliably be used in the low SNR data set (set B) compared to the high SNR data set (set A). Despite the fact that no definitive threshold could be found, this method may help to determine the cutoff for the number of principal components used in discriminant analysis. Future analysis of a selection of spectral databases using this technique will allow optimum thresholds to be selected for different applications and spectral data quality levels.

A miniature confocal Raman probe for endoscopic use

Raman spectroscopy is a powerful tool for studying biochemical changes in the human body. We describe a miniature, confocal fibre optic probe intended to fit within the instrument channel of a standard medical endoscope. This probe has been optimized for the study of the carcinogenesis process of oesophageal malignancy. The optical design and fabrication of this probe is described including the anisotropic wet etching technique used to make silicon motherboards and jigs. Example spectra of PTFE reference samples are shown. Spectra with acquisition times as low as 2 s from resected oesophageal tissue are presented showing identifiable biochemical changes from various pathologies.

Optical coherence tomography: a potential tool for unsupervised prediction of treatment response for Port-Wine Stains

BACKGROUND

Treatment of Port-Wine Stains (PWS) suffers from the absence of a reliable real-time tool for monitoring a clinical endpoint. Response to treatment varies substantially according to blood vessel geometry. Even though optical coherence tomography (OCT) has been identified as a modality with potential to suit this need, it has not been introduced as a standard clinical monitoring tool. One reason could be that - although OCT acquires data in real-time - gigabyte data transfer, processing and communication to a clinician may impede the implementation as a clinical tool.

OBJECTIVES

We investigate whether an automated algorithm can address this problem.

METHODS

Based on our understanding of pulsed dye laser treatment, we present the implementation of an unsupervised, real-time classification algorithm which uses principal components data reduction and linear discriminant analysis. We evaluate the algorithm using 96 synthesized test images and 7 clinical images.

RESULTS

The synthesized images are classified correctly in 99.8%. The clinical images are classified correctly in 71.4%.

CONCLUSIONS

Principal components-fed linear discriminant analysis (PC-fed LDA) may be a valuable method to classify clinical images. Larger sampling numbers are required for a better training model. These results justify undertaking a study involving more patients and show that disease can be described as a function of available treatment options.

Cost-effectiveness of clinical interventions for AIDS wasting

Economic studies of HIV/AIDS interventions are important for providing cost-effective care. This paper presents a costeffectiveness study of a three-arm clinical trial conducted at Tufts University School of Medicine/New England Medical Center in Boston, Massachusetts that treated 50 patients with AIDS wasting from March 1998 through January 2001. This study compared the costs and impacts of a nutritional counseling intervention alone (NC arm), the nutrition intervention with oxandrolone (OX arm), and the nutrition intervention with progressive resistance training (PRTarm) for the treatment of AIDS wasting. The cost of each intervention was derived for both the three-month clinical trial and a six-month estimated community model (ECM), its projected adaptation to community-based medical care. The cost determination involved obtaining and multiplying unit economic costs and quantities expended of each resource within each study arm. The ECM average cost per client in the cost-effectiveness analysis incorporated both institutional and societal perspectives. The costeffectiveness analysis compared the cost of each intervention to its quality-adjusted life-year (QALY) gain (Zeckhauser and Shepard, 1976). From a societal perspective, for the NC arm, the cost per client totaled US dollars 983 for the actual and US dollars 596 under the ECM. For the OX arm, the cost per client totaled US dollars 3,772 for the actual study and US dollars 3,385 under the ECM. For the PRT arm, the cost per client totaled US dollars 3,189 for the actual study and US dollars 2,987 under the ECM. Under the societal perspective the cost per QALY was US dollars 55,000 (range: US dollars 51,000 to US dollars 83,000) for the NC arm, US dollars 151,000 (range: US dollars 149,000 to US dollars 171,000) for the OX arm, and US dollars 65,000 (range: US dollars 44,000 to US dollars 104,000) for the PRTarm. When using only an institutional perspective, the cost per QALY was US dollars 45,000 (range: US dollars 42,000-US dollars 64,000) for the NC arm, US dollars 147,000 (range: US dollars 147,000 to US dollars 163,000) for the OX arm, and US dollars 31,000 (US dollars 21,000 to US dollars 44,000) for the PRTarm. This paper shows that cost and cost-effectiveness analyses can be adapted to a community setting by combining information from community practice and costs with data from a randomized trial. Compared to other AIDS treatments, such as highly active antiretroviral therapies, all three interventions were affordable, but their cost-effectiveness was intermediate. Oxandrolone was the least cost effective of the interventions, even compared to nutrition alone, as it included similar or somewhat greater costs for less of an increase in quality of life. PRT was the most cost-effective treatment for AIDS wasting, particularly from an institutional perspective. Third party payers should consider coverage of PRT.