Artificial intelligence and machine learning in orthopedic surgery: a systematic review protocol

BACKGROUND

Artificial intelligence (AI) and machine learning (ML) are interwoven into our everyday lives and have grown enormously in some major fields in medicine including cardiology and radiology. While these specialties have quickly embraced AI and ML, orthopedic surgery has been slower to do so. Fortunately, there has been a recent surge in new research emphasizing the need for a systematic review. The primary objective of this systematic review will be to provide an update on the advances of AI and ML in the field of orthopedic surgery. The secondary objectives will be to evaluate the applications of AI and ML in providing a clinical diagnosis and predicting post-operative outcomes and complications in orthopedic surgery.

METHODS

A systematic search will be conducted in PubMed, ScienceDirect, and Google Scholar databases for articles written in English, Italian, French, Spanish, and Portuguese language articles published up to September 2020. References will be screened and assessed for eligibility by at least two independent reviewers as per PRISMA guidelines. Studies must apply to orthopedic interventions and acute and chronic orthopedic musculoskeletal injuries to be considered eligible. Studies will be excluded if they are animal studies and do not relate to orthopedic interventions or if no clinical data were produced. Gold standard processes and practices to obtain a clinical diagnosis and predict post-operative outcomes shall be compared with and without the use of ML algorithms. Any case reports and other primary studies assessing the prediction rate of post-operative outcomes or the ability to identify a diagnosis in orthopedic surgery will be included. Systematic reviews or literature reviews will be examined to identify further studies for inclusion, and the results of meta-analyses will not be included in the analysis.

DISCUSSION

Our findings will evaluate the advances of AI and ML in the field of orthopedic surgery. We expect to find a large quantity of uncontrolled studies and a smaller subset of articles describing actual applications and outcomes for clinical care. Cohort studies and large randomized control trial will likely be needed.

TRIAL REGISTRATION

The protocol will be registered on PROSPERO international prospective register of systematic reviews prior to commencement.

Umbilical cord: an allogenic tissue for potential treatment of COVID-19

The COVID-19 pandemic has placed an unprecedented burden on health care systems and economies around the globe. Clinical evidences demonstrate that SARS-CoV-2 infection produces detrimental levels of pro-inflammatory cytokines and chemokines that can lead to acute respiratory distress syndrome (ARDS) and significant systemic organ damage. Currently, there is no definitive therapy for COVID-19 or associated complications, and with the hope of a safe and effective vaccine in the distant future, the search for an answer is paramount. Mesenchymal stem cells (MSCs) provide a viable option due to their immunomodulatory effects and tissue repair and regeneration abilities. Studies have demonstrated that compassionate use of MSCs can reduce symptoms associated with SARS-CoV-2 infection, eliminate fluid buildup, and act as a regenerative technique for alveolar damage; all in a safe and effective way. With multiple autologous sources available for MSCs, each with their own respective limitations, allogenic umbilical cord (UC) and/or UC-derived Wharton’s jelly (WJ) seem to be best positioned source to harvest MSCs to treat COVID-19 and associated symptoms. As an allogenic source, UC is readily available, easily obtainable, and is rich in immunomodulatory and regenerative factors. In this manuscript, we reviewed the current evidences and explored the potential therapeutic use of allogenic UC and/or WJ-derived MSCs for the treatment of COVID-19. Although, preliminary preclinical and clinical studies indicate that their use is safe and potentially effective, more multi-center, randomized, controlled trials are needed to adequately assess the safety and efficacy of UC and/or WJ-derived MSCs for the treatment of COVID-19.

Detection of recent infection of Japanese encephalitis virus in swine population using IgM ELISA: A suitable sentinel to predict infection in humans

Japanese encephalitis (JE) is a mosquito-borne flaviviral zoonotic disease and is one of the major causes of encephalitis in children. Swine, being an amplifier host of Japanese encephalitis virus (JEV), play an important role in its epidemiology. Therefore, early detection of either JEV or antibodies against JEV in swine is a feasible alternative for initiating necessary measures to prevent the spread of infection to humans. Since IgM antibodies appear early in swine sera, recombinant NS1 protein based indirect IgM ELISA was developed in the present study with the objective to know the recent infection of swine population with JEV. The relative diagnostic sensitivity and specificity of the developed ELISA was 95.34% and 98.6%, respectively. The developed ELISA was found to have excellent reproducibility on inter-laboratory and inter-institutional validation studies. A total of 3,027 field swine sera samples were screened using the developed ELISA and 488 samples were found positive for IgM against JEV with an overall sero-positivity of 16.12% in swine population of India. The highest sero-positivity was observed in swine population of Eastern zone of India which coincided with the maximum number of human JE cases reported from this zone during the same period. Further, antibody kinetics study revealed that the IgM antibodies against NS1 protein of JEV started appearing in swine sera at day 5 and disappeared completely by day 40. The IgG antibodies started appearing at day 7, and remained for more than 365 days indicating the suitability of IgM ELISA to know the recent infection of JEV. The developed IgM ELISA can be readily incorporated into surveillance programs for detection of JEV activity in swine population so that outbreaks in humans can be prevented by taking suitable preventive measures.

Who manages health workforce in the States of India: Profile, knowledge and perceptions of the team

Problem

Human resources in the public health sector is of prime importance in a limited resource setting country, who at times work in a high-pressure, limited resource environment and where skilled staff continue to remain in short supply. The role of Human Resource for Health (HRH) team responsible for managing this health workforce is crucial. They play an important role in improving the human resource practices and creating an enabling organizational culture for optimal resource utilization. The paper explores the profile of the HRH teams of the states of India, their knowledge levels, and perceptions of their role.

Methods

The participants were HR Managers from 29 states of India who look after HRH in National Health Mission and State Health Departments. Cross-sectional survey tool was used for data collection. Quantitative data analysis included univariate and bivariate analysis. One Way ANOVA test of significance and post-hoc tests using Tukey's method was used to ascertain the groups with significant difference.

Results

Most of the HRH team members are postgraduates or have management background. Their experience varies from <1year to > 25 years. Mostly of them perceive their role to be limited to implementing bare essential HRM practices, mostly administrative. The educational qualification of the members did not have any significant bearing on their technical knowledge related to HRM practices; but their experience in public health sector showed a significant association.

Lessons

This study lends evidence to the principle that professionals who have been in the system for long, know about HRH and the associated policies better, and hence may be better equipped to handle HRH and establish good HR Management (HRM) systems. Better role clarity among the HRH teams, expansion of their current scope of work to include advanced practices of HRM and continuous capacity building mechanisms are needed to help strengthen the development and management of HRH.

Key messages

This study, a first of its kind in the country, lend evidence related to the principle for deciding the profile of team who should be entrusted with managing and development of HRH. The Study gives evidence to focus on the role clarity of HRH to zero down their knowledge and skills gaps and enhance their competencies through better capacity building.

Child drowning mortality in the Sundarbans, India: Applying the Community Knowledge Approach

Background

The Sundarbans in India is a rural, forested region where children are exposed to a high risk of drowning due to its waterlogged geography. Current data collection systems capture few drowning deaths in this region due to its remoteness and poor coverage of health and police systems. Household methodology was found to be resource and time intensive, and so a Community Knowledge Approach was used and applied to calculate injury mortality for the first time.

Methods

A community-based survey was conducted in the Sundarbans to determine the drowning mortality rate for 1-4 and 5-9 year old children. A Community Knowledge Approach was applied. Meetings were held with law community residents and key informants to identify drowning deaths in the population. Identified deaths were verified by the child's household through a structured survey, inquiring on the circumstances around the drowning death.

Results

The drowning mortality rate for children aged 1-4 years old was 243.8 per 100,000 children and 38.8 per 100,000 children for 5-9-year olds. 58.0% of deaths were of 1-2-year-old children. Most children drowned in ponds within 50 metres of their homes. Children were usually unaccompanied with their primary caretaker engaged in household work. Only one third of deaths were reported to hospitals or civil registration systems. Of deaths listed by community members, 63.0% were identified by both residents and by at least one key informant, 25.6% by key informants only, and 11.4% (n = 79) by community residents only.

Conclusions

Drowning is a major cause of death among children in the Sundarbans, particularly those aged 1-4 years old. The results illustrate how routine data collection systems grossly underestimate drowning deaths, emphasising the importance of community-based in rural low-and middle-income country contexts.

Key messages

Drowning is likely the largest killer of 1-9 year old children in the Sundarbans region, emphasising the need to better understanding drowning epidemiology in similar rural LMICs contexts. The Community Knowledge Approach provides a low-resource, valid method for capturing injury mortality data.

Opportunities for drowning interventions using existing government policy and programmes in India

Background

Children living in coastal, rural India face a particularly high risk of drowning due to rurality, presence of open water, lack of accessible health systems and poor infrastructure. No drowning interventions are currently implemented in India. Interventions that build on existing policy targets or government programs are more likely to be sustainable and scalable.

Methods

For the first time to our knowledge for an injury-related issue in India, detailed content review of policy was conducted to identify both policy principles and/or specific government programs that may be leveraged for drowning interventions. The reach, enablers and barriers of these programs were assessed through a systematic literature review. Identified policies and programs were also assessed on how they catered for underserved groups and took into consideration equity.

Results

Three programs may be leveraged for drowning interventions: The Integrated Child Development Scheme (ICDS), Self-Help Group (SHG) and Accredited Social Health Activist (ASHA) programs. All three had high coverage and considered underserved groups such as women and rural populations.

Conclusions

Programs targeting specific health outcomes should consider interventions outside of the health sector that address social determinants of health. This may enable the program to better align with relevant government agendas and increase sustainability.

Key messages

This is the first systematic analysis of both policy content and execution of government programs to provide comprehensive insights into possible implementation strategies for an injury intervention. This methodology may be applied by other researchers identifying sustainable intervention options supported by government policy and/or programs.

Mesenchymal stem cells and exosome therapy for COVID-19: current status and future perspective

Acute respiratory distress syndrome (ARDS) is the main cause for the COVID-19 infection-related morbidity and mortality. Recent clinical evidences suggest increased level of cytokines and chemokines targeting lung tissue as a prominent etiological factor. The immunomodulatory effect of mesenchymal stem cells (MSCs) as the alternative therapy for the treatment of inflammatory and autoimmune diseases is well known. Several studies have also revealed that similar therapeutic impacts of parent MSCs are also exhibited by MSCs-derived extracellular vesicles (EVs) including exosomes. In this review, we explored the therapeutic potential of both MSCs and exosomes in mitigating the COVID-19 induced cytokine storm as well as promoting the regeneration of alveolar tissue, attributed to the intrinsic cytokines and growth factor present in the secretome. The preliminary studies have demonstrated the safety and efficacy of MSCs and exosomes in mitigating symptoms associated with COVID-19. Thus, they can be used on compassionate basis, owing to their ability to endogenously repair and decrease the inflammatory reactions involved in the morbidity and mortality of COVID-19. However, more preclinical and clinical studies are warranted to understand their mechanism of action and further establish their safety and efficacy.

Evolution of structural and magnetic properties of FePtCu alloy films on annealing of FePt/Cu multilayers

Thin films of ternary (FePt)100-xCux alloys were obtained by annealing of FePt (100 Å)/Cu (d Å) multilayers with d = 50 and 100 Å deposited by sputtering at room temperature on Si substrates. The evolution of structural and magnetic properties of these multilayers induced by isochronal and isothermal annealing in a vacuum has been studied using depth dependent characterization techniques. Isochronal annealing for 0.5 h at different temperatures (300 to 600 °C) showed very low interdiffusion at the interfaces with no signature of alloy phase formation. However, isothermal annealing of multilayers at 600 °C for longer times (1.5-6.5 h) showed significantly large interdiffusion accompanied by the formation of polycrystalline ternary alloy and iron silicide phases. The iron silicide formed at the substrate-film interface assists the growth of the L10 ordered ternary alloy phase, which showed different stoichiometry for different multilayers. The L10 phase formed with higher Cu content showed drastically different magnetic properties with a reduction in saturation magnetization and an increase in coercivity (∼6 kOe) at room temperature. The iron silicide formed on high temperature annealing showed ferromagnetic nature with a magnetization of ∼140 emu cm-3 at room temperature.

Opportunities for gender transformative approaches in a community-based drowning reduction program in Bangladesh

Background

Community-based programs in rural low-and middle-income country settings are well-placed to conduct gender transformative activities that aid program sustainability and catalyse wider social change, such as reducing gender inequities that in turn improve health outcomes. The Anchal program is a drowning prevention intervention for children aged 1–5 years old in rural Bangladesh. It provides community crèche-based supervision delivered by local trained paid-female volunteers. We aimed to identify the influence of the Anchal program on gender norms and behaviours in the community context, and the effects these had on program delivery and men and women’s outcomes.

Methods

Qualitative in-depth interviews, focus group discussions and observations were conducted with program beneficiaries and providers. Gender outcomes were analysed using FHI 360’s Gender Integration Framework.

Results

The Anchal program was found to be a gender accommodating program as it catered for communities’ gender-based roles and constraints but did not actively seek to change underlying beliefs, perceptions and norms that led to these. The program in some cases enhanced the independence and status of female community staff. This changed perceptions of communities towards acceptable levels of physical mobility and community involvement for women. Conversely, gender affected program delivery by reducing the ability of female supervisory staff to engage with male community leaders. The double burden of wage and household labour carried by local female staff also limited performance and progression. Gender-based constraints on staff performance, attrition and community engagement affected efficiency of program delivery and sustainability.

Conclusions

The Anchal program both adapted to and shaped community gender norms and roles. The program has well-established relationships in the community and can be leveraged to implement gender transformative activities to improve gender-based equity. Health programs can broaden their impacts and target social determinants of health like gender equity to increase program sustainability and promote equitable health outcomes.

AB1030 IgG4-RELATED DISEASE: A RETROSPECTIVE CLINICAL CASE SERIES FROM A TERTIARY CARE CENTRE IN INDIA

Background:

IgG4-related disease (IgG4-RD) is an often unrecognized, rare fibro-inflammatory condition that can involve various organ systems.

Objectives:

The aim of this study was to identify the different clinical patterns of this disease in a single centre in North India.

Methods:

70 patients were diagnosed on the basis of published diagnostic criteria for IgG4-RD. Patients’ presenting complaints, epidemiological profiles, laboratory, radiological and histological findings along with the treatment and outcomes were collated and analyzed from 2011 – 2019.

Results:

In a total of 70 patients who were diagnosed with the disease, the ratio of female to male ratio was 1:1. The mean age of patients was 41.4 years. Involvement of orbits and peri-orbital tissues was highest (52.9%) due to large number of referrals from ophthalmology services. 13% of patients had multiple organ involvement. Patients with involvement of retroperitoneal tissues and lymph nodes were 8.5% and 5.7%, respectively. Increased serum IgG4 levels were found in 74.3% of the patients. Histopathological examinations of the affected organs were performed in 44 (62.85%) patients and a diagnosis of possible (38.57), probable (32.85%) and definite (28.57%) IgG4-RD was made. Majority of the patients (94.3%) required immunosuppressive medications along with corticosteroids. Azathioprine was the most commonly used (72.8%) immunosuppressive medication. Rituximab was used in17.1% of the patients, of whom one had multisystem involvement.

Conclusion:

This study depicts the most common patterns of organ involvement along with the epidemiological, laboratory, histological, radiological data and response to treatment, in IgG4-RD, with a definite ophthalmology referral bias, in a tertiary care centre in North India.

References:

[1]Stone JH, Zen Y, Deshpande V. IgG4-related disease. N Engl J Med 2012; 366(6):539-51.

[2]Khosroshahi A, CarruthersMN, Deshpande V, Unizony S, Bloch DB, Stone JH. Rituximab for the treatment of IgG4-related disease: lessons from 10 consecutive patients. Medicine 2012; 91(1):57-66.

Table 1.

Clinical and laboratory characteristics

CharacteristicsNumber of patients (N=70)Age (years)41.4Age group in years, n (%) >5024 (34.28) <5046 (65.71)Sex, n (%) Male36 (51.42) Female34 (47.22) ESR (mm/hr)24.37 CRP (mg/dL)12.31 Serum IgG (mg/dL)1214.2 Serum IgE (IU/L)587.2Type of IgG4 related disease, n (%) Definite20 (28.57) Probable23 (32.85) Possible27 (38.57)

Data represented as mean, unless otherwise specified.

CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; Ig, immunoglobulin.

Table 2.

Distribution of patients according to organ involvement.

Organ involvementNumber (%)Orbital and periorbital37(52.9)Retroperitoneum6 (8.5)Laryngotracheal tissue4 (5.7)Aorta and branches4 (5.7)Lymph nodes3(4.2)Paranasal sinus2 (2.8)Paravertebral tissue2 (2.8)Pancreas2 (2.8)Lung and bronchus2 (2.8)Eye (Scleritis)1 (1.4)Prevesical Mass1 (1.4)Ear polyp1 (1.4)Small Bowel1 (1.4)Primary sclerosing cholangitis1 (1.4)Musculoskeletal1(1.4)Submandibular gland1(1.4)Central nervous system1 (1.4)Multisystem involvement9 (12.86%)Figure 1.

Right eye proptosis

Figure 2.

CT abdomen showing hydronephrosis due to retroperitoneal fibrosis

Disclosure of Interests:

None declared

Opportunities for the development of drowning interventions in West Bengal, India: a review of policy and government programs

BACKGROUND

Four million people living in the Indian Sundarbans region in the state of West Bengal face a particularly high risk of drowning due to rurality, presence of open water, lack of accessible health systems and poor infrastructure. Although the World Health Organization has identified several interventions that may prevent drowning in rural low-and middle-income country contexts, none are currently implemented in this region. This study aims to conduct contextual policy analysis for the development of a drowning program. Implementation of a drowning program should consider leveraging existing structures and resources, as interventions that build on policy targets or government programs are more likely to be sustainable and scalable.

METHODS

A detailed content review of national and state policy (West Bengal) was conducted to identify policy principles and/or specific government programs that may be leveraged for drowning interventions. The enablers and barriers of these programs as well as their implementation reach were assessed through a systematic literature review. Identified policies and programs were also assessed to understand how they catered for underserved groups and their implications for equity.

RESULTS

Three programs were identified that may be leveraged for the implementation of drowning interventions such as supervised childcare, provision of home-based barriers, swim and rescue skills training and community first responder training: the Integrated Child Development Scheme (ICDS), Self-Help Group (SHG) and Accredited Social Health Activist (ASHA) programs. All three had high coverage in West Bengal and considered underserved groups such as women and rural populations. Possible barriers to using these programs were poor government monitoring, inadequate resource provision and overburdening of community-based workers.

CONCLUSIONS

This is the first systematic analysis of both policy content and execution of government programs to provide comprehensive insights into possible implementation strategies for a health intervention, in this case drowning. Programs targeting specific health outcomes should consider interventions outside of the health sector that address social determinants of health. This may enable the program to better align with relevant government agendas and increase sustainability.

Recommendations from the CSO-HNS taskforce on performance of tracheotomy during the COVID-19 pandemic

INTRODUCTION

The performance of tracheotomy is a common procedural request by critical care departments to the surgical services of general surgery, thoracic surgery and otolaryngology - head & neck surgery. A Canadian Society of Otolaryngology - Head & Neck Surgery (CSO-HNS) task force was convened with multi-specialty involvement from otolaryngology-head & neck surgery, general surgery, critical care and anesthesiology to develop a set of recommendations for the performance of tracheotomies during the COVID-19 pandemic.

MAIN BODY

The tracheotomy procedure is highly aerosol generating and directly exposes the entire surgical team to the viral aerosol plume and secretions, thereby increasing the risk of transmission to healthcare providers. As such, we believe extended endotracheal intubation should be the standard of care for the entire duration of ventilation in the vast majority of patients. Pre-operative COVID-19 testing is highly recommended for any non-emergent procedure.

CONCLUSION

The set of recommendations in this document highlight the importance of avoiding tracheotomy procedures in patients who are COVID-19 positive if at all possible. Recommendations for appropriate PPE and environment are made for COVID-19 positive, negative and unknown patients requiring consideration of tracheotomy. The safety of healthcare professionals who care for ill patients and who keep critical infrastructure operating is paramount.

Textiloma Mimicking a Recurrent High-Grade Astrocytoma: A Case Report

Introduction  Textiloma (Txm) is a nonmedical term that has been given to foreign body-related inflammatory pseudotumor arising from retained nonabsorbable cotton matrix that is either inadvertently or deliberately left behind during surgery, which may trigger an inflammatory reaction. This report describes a case of Txm mimicking a recurrent high-grade astrocytoma. Case Report  We, here, present the case of a 69-year-old female with a 6-month history of progressive left-sided weakness. Neuroimaging studies revealed a large nonenhancing mass in the right frontoparietal lobe. Pathology reported a World Health Organization tumor classification grade II, diffuse astrocytoma. After surgical intervention, external beam radiation was given to the remaining areas of residual tumor. Routine magnetic resonance imaging (MRI) revealed a nodular area of contrast enhancement in the dorsal and inferior margin of the biopsy tract, growing between interval scans, and perfusion-weighted imaging parameters were elevated being clinically asymptomatic. She underwent a complete resection of this area of interest and pathology returned as a Txm with Surgicel fibers. Conclusion  After treatment of a neoplasm, if unexpected clinical or imaging evidence of recurrence is present, a foreign body reaction to hemostatic material used during the initial surgery should be included in the differential diagnosis.

A129 THE VALUE OF REPEAT MANOMETRIC TESTING

Background

While motility disorders may evolve over time, there is scant guidance around the role of repeat high-resolution esophageal manometry (HRM). Given the invasive nature of HRM and the implications on financial cost and patient discomfort, it is obvious that the emphasis should be on minimizing unnecessary repeat examinations. However, there are no recommendations around indications or timing of repeat HRM.

Aims

We aimed to determine the outcomes in patients who underwent repeat manometry and look for predictors of progression to achalasia or major motility disorder.

Methods

Consecutive reports from HRM studies performed between Aug 2013 – May 2017 were retrospectively analyzed. All patients with ≥ 2 HRM studies were included. Studies without a Chicago classification diagnosis were excluded. Chi-squared analysis was performed to determine if initial HRM diagnosis was associated with change in diagnosis on follow-up HRM. Initial and follow-up manometric parameters were compared with paired T-tests. Binary logistic regression analysis was performed to look for predictors of progression to achalasia or major motility disorder.

Results

134 patients underwent ≥ 2 HRM studies. Initial diagnoses were IEM (45 patients [33.6%], EGJOO (34 [25.4%], absent peristalsis (18 [13.4%], achalasia (11 [8.2%], DES (4 [3.0%]), and JH (3 [2.2%]; 29 (14.2%) of patients had a normal HRM. 109 (81.3%) patients underwent 2 HRM, 18 (13.4%) 3 HRM, 4 (3%) 4 HRM, and 3 (2.2%) 5 HRM.

The final follow-up HRM occurred after a median 496 [80 – 1823] days. 72 (53.7%) of patients had no change from their initial diagnosis. Patients with an initial diagnosis of DES were significantly more likely to have a change in diagnosis on the final follow-up (3 normal:1 IEM) (p = .043). No other classes reached significance. Patients with IEM had a significantly higher mean DCI (395.1 [0 - 3248] vs 790.8 [0 – 10715.0], p = .006) and IRP (4.5 [-10.4 – 14.2] vs [6.6 [-6.2 – 21.0], p = .017) on their follow-up HRM.

4 patients without achalasia (3 EGJOO:1 IEM) on their index HRM had a diagnosis of achalasia on their final HRM. The median IRP in non-achalasia patients with a diagnosis of achalasia on final HRM (22.3 [8.4 – 30.7] was significantly higher than those without a diagnosis of achalasia on final HRM (6.6 [-10.4 – 39.8]) (p = .013); however no manometric criteria or initial HRM diagnoses predicted progression to achalasia or major motility disorder on binary logistic regression analysis.

Conclusions

In most patients, repeat manometry did not change the manometric diagnosis. Patients with DES were significantly likely to have their diagnosis change with repeat HRM, and most of these patients had normalization of their HRM. Manometric parameters in IEM appear to improve over time. This finding could reflect interval therapy, or shed some light on the natural history of this disease.

Funding Agencies

None