Utility of artificial intelligence in a binary classification of soft tissue tumors

Soft tissue tumors (STTs) pose diagnostic and therapeutic challenges due to their rarity, complexity, and morphological overlap. Accurate differentiation between benign and malignant STTs is important to set treatment directions, however, this task can be difficult. The integration of machine learning and artificial intelligence (AI) models can potentially be helpful in classifying these tumors. The aim of this study was to investigate AI and machine learning tools in the classification of STT into benign and malignant categories. This study consisted of three components: (1) Evaluation of whole-slide images (WSIs) to classify STT into benign and malignant entities. Five specialized soft tissue pathologists from different medical centers independently reviewed 100 WSIs, representing 100 different cases, with limited clinical information and no additional workup. The results showed an overall concordance rate of 70.4% compared to the reference diagnosis. (2) Identification of cell-specific parameters that can distinguish benign and malignant STT. Using an image analysis software (QuPath) and a cohort of 95 cases, several cell-specific parameters were found to be statistically significant, most notably cell count, nucleus/cell area ratio, nucleus hematoxylin density mean, and cell max caliper. (3) Evaluation of machine learning library (Scikit-learn) in differentiating benign and malignant STTs. A total of 195 STT cases (156 cases in the training group and 39 cases in the validation group) achieved approximately 70% sensitivity and specificity, and an AUC of 0.68. Our limited study suggests that the use of WSI and AI in soft tissue pathology has the potential to enhance diagnostic accuracy and identify parameters that can differentiate between benign and malignant STTs. We envision the integration of AI as a supportive tool to augment the pathologists' diagnostic capabilities.

Ki-67 Testing in Breast Cancer: Assessing Variability With Scoring Methods and Specimen Types and the Potential Subsequent Impact on Therapy Eligibility

Abemaciclib was originally FDA approved for patients with ER-positive/HER2-negative breast cancer with Ki-67 expression ≥20%. However, there were no guidelines provided on which specimen to test or which scoring method to use. We performed a comprehensive study evaluating the variation in Ki-67 expression in breast specimens from 50 consecutive patients who could have been eligible for abemaciclib therapy. Three pathologists with breast expertise each performed a blinded review with 3 different manual scoring methods [estimated (EST), unweighted (UNW), and weighted (WT) (WT recommended by the International Ki-67 in Breast Cancer Working Group)]. Quantitative image analysis (QIA) using the HALO platform was also performed. Three different specimen types [core needle biopsy (CNB) (n=63), resection (RES) (n=52), and axillary lymph node metastasis (ALN) (n=50)] were evaluated for each patient. The average Ki-67 for all specimens was 14.68% for EST, 14.46% for UNW, 14.15% for WT, and 11.15% for QIA. For the manual methods, the range between the lowest and highest Ki-67 for each specimen between the 3 pathologists was 8.44 for EST, 5.94 for WT, and 5.93 for UNW. The WT method limited interobserver variability with ICC1=0.959 (EST ICC1=0.922 and UNW=0.949). Using the aforementioned cutoff of Ki-67 ≥20% versus <20% to determine treatment eligibility, the averaged EST method yields 20 of 50 patients (40%) who would have been treatment-eligible, versus 15 (30%) for the UNW, 17 (34%) for the WT, and 12 (24%) for the QIA. There was no statistically significant difference in Ki-67 among the 3 specimen types. The average Ki-67 difference was 4.36 for CNB vs RES, 6.95 for CNB versus ALN, and RES versus ALN (P=0.93, 0.99, and 0.94, respectively). Our study concludes that further refinement in Ki-67 scoring is advisable to reduce clinically significant variation.

Automated Curation and AI Workflow Management System for Digital Pathology

Digital pathology applications present several challenges, including the processing, storage, and distribution of gigapixel images across distributed computational resources and viewing stations. Individual slides must be available for interactive review, and large repositories must be programmatically accessible for dataset and model building. We present a platform to manage and process multi-modal pathology data (images and case information) across multiple locations. Using an agent-based system coupled with open-source automated machine learning and review tools allows not only dynamic load-balancing and cross-network operation but also the development of research and clinical AI models using the data managed by the platform. The platform presented covers end-to-end AI workflow from data acquisition and curation through model training and evaluation allowing for sharing and review. We conclude with a case study of colon and prostate cancer model development utilizing the presented system.

Co-developing a tailored vaccination intervention with Congolese migrants: a participatory study

Background

Disparities in vaccination uptake among migrant populations are well documented. WHO and ECDC have sought renewed focus on participatory research that engages migrants in co-producing tailored initiatives to address vaccination inequities and increase coverage.

Methods

This community-based participatory research study aims to engage Congolese migrants in co-developing a tailored approach to increase vaccine uptake. Phase 1 used poster walls and in-depth interviews with Congolese migrants (n = 32) to explore COVID-19 vaccination beliefs, experiences, and preferred information sources and communication methods, analysed iteratively and thematically in NVivo.

Preliminary results

Institutional distrust has shaped this population’s interpretation of the pandemic response and enabled vaccine misinformation and conspiracy theories to take hold. We found complex information networks and preference for Francophone, African and social media. Limited English proficiency and preference for the oral tradition restricted engagement with official public health messaging. Suspicion of government motives, low knowledge, and culturally specific perceptions about vaccination contributed to belief that breakthrough infections and need for COVID-19 boosters imply the vaccine is not effective. The population felt coerced by vaccination reminders and mandates, and were resultantly more hesitant to accept COVID-19 vaccination.

Conclusions

The population’s specific characteristics suggest that existing and trusted interpersonal networks and oral communication in first languages should be harnessed to spread credible information and encourage vaccine uptake, and mandate policies are unlikely to be effective. Training local role models to facilitate vaccination dialogues and myth-bust may be effective at changing behaviour. The next phases will gather more information from key stakeholders and engage migrants in workshops to co-design insight-driven, tailored interventions.

Key messages

• Global policy-setting organisations have called urgently for participatory research that engages migrants in the co-production of tailored initiatives to address vaccination inequalities.

• Populations with strong interpersonal networks and low trust in public institutions may be receptive to tailored, community-centred dialogue approaches using local messengers and role models.

A community-based participatory approach to engaging Congolese migrants in intervention co-design

Issue

The World Health Organization has called for tailored, community-based interventions to address disparities in vaccination uptake affecting migrant and minoritised populations, however few exist. This study directly responds to global calls for community-centred and participatory approaches to engaging migrants in routine and COVID-19 vaccination.

Problem description

Black and African migrants are known to be at risk of under-immunisation and have lower COVID-19 vaccine uptake rates in high-income countries. This UK study will use community-based participatory approaches to engage Congolese migrants in co-developing a tailored intervention to increase vaccine uptake. A community-academic coalition will lead the study. Community members will be trained as peer researchers and financially compensated. The final output will be an intervention strategy tailored to and embedded within the Congolese migrant community.

Preliminary results

The coalition held 20 hours of planning meetings and peer researcher training in 2021 and co-developed a phased study involving 1) community days with poster walls and qualitative in-depth interviews with Congolese migrants, 2) interviews and workshops with local stakeholders, and 3) co-design workshops with Congolese migrants. Following outreach and pre-engagement, approximately 80 migrants attended the community days, with more than 50 interviews and 100% left positive feedback (including: felt valued, welcomed, Congolese language recognised).

Lessons

Community-academic partnerships are resource-intensive but can be an effective means to build and maintain trust required to deliver a community-based research study. Academic partners should support community partners in understanding the research process to help manage expectations and provide financial compensation for their time and effort. This study offers an innovative engagement model and study design that can be adapted to other underserved populations.

Key messages

• Global policy-setting organisations have called urgently for participatory research that engages migrants in the co-production of tailored initiatives to address vaccination inequalities.

• This study uses a novel, theory-driven, participatory approach to engage with and identify barriers to vaccination in Congolese migrants and co-design a tailored strategy to increase uptake.

Differences in antimicrobial susceptibility testing complicating management of IMP carbapenemase-producing Enterobacterales infection

OBJECTIVES

IMP-type carbapenemases are rarely detected in Europe and limited information is available to guide the treatment of infections caused by carbapenemase-producing Enterobacterales (CPE) producing these carbapenemases. Accurate antimicrobial susceptibility testing (AST) results are essential for optimal antibiotic management. Here we report discrepancies in AST of IMP-producing Enterobacterales (IMP-CPE) complicating the management of severe sepsis.

METHODS

Antimicrobial susceptibilities were analysed by in-house VITEK® 2, Etest and broth microdilution (BMD). Carbapenemase-encoding genes were detected by PCR. Whole-genome sequencing (WGS) was performed using an Illumina MiSeq platform.

RESULTS

Minimum inhibitory concentrations (MICs) determined by VITEK® 2 for Enterobacter hormaechei and Klebsiella oxytoca blood culture isolates were ≥16 mg/L for meropenem and ≤0.5 mg/L for ertapenem. In contrast, Etest analysis and BMD returned MICs of 2 mg/L and 1 mg/L, respectively. Both isolates tested positive for IMP carbapenemase-encoding genes by PCR. WGS revealed that both isolates carried the same bla_IMP-4 gene. Based on VITEK® 2 susceptibilities, initial treatment was with tigecycline and amikacin. After subsequent deterioration, the patient was successfully treated with ertapenem and amikacin.

CONCLUSION

This case highlights that automated AST by VITEK® 2 can over-report meropenem resistance for IMP carbapenemase-producers compared with Etest and BMD. Clinicians need to be cautious deciding against carbapenem treatment based on VITEK® 2 susceptibility testing results for IMP-positive Enterobacterales. Tigecycline was inferior to carbapenem treatment for pyelonephritis caused by isolates expressing IMP carbapenemases, however specific evidence guiding the treatment of these infections is lacking.

Half-integer quantized anomalous thermal Hall effect in the Kitaev material candidate α-RuCl3

Half-integer thermal quantum Hall conductance has recently been reported for the two-dimensional honeycomb material α-RuCl₃ We found that the half-integer thermal Hall plateau appears even for a magnetic field with no out-of-plane components. The measured field-angular variation of the quantized thermal Hall conductance has the same sign structure as the topological Chern number of the pure Kitaev spin liquid. This observation suggests that the non-Abelian topological order associated with fractionalization of the local magnetic moments persists even in the presence of non-Kitaev interactions in α-RuCl₃.

In vitro prediction of clinical signs of respiratory toxicity in rats following inhalation exposure

To date there are no OECD validated alternative approaches to study toxicity following inhalation exposure to airborne chemicals. The available OECD test guidelines for acute inhalation toxicity aim to estimate a value of the lethal air concentration of the test chemical leading to the death of 50% of the exposed animals (LC50), to satisfy hazard classification and labelling requirements. This paper explores the view that alternative approaches must compare to outcomes of existing guideline methods to become accepted and implemented in a regulatory context. This case study describes the initiatives taken to validate the lung surfactant bioassay, an in vitro cell-free method, and discusses the challenges faced. While the lung surfactant bioassay could not predict the GHS classification for acute inhalation toxicity of 26 chemicals, the assay successfully predicted the clinical signs of respiratory toxicity observed during or shortly after exposure in vivo as reported in registration dossiers. The lung surfactant bioassay is a promising alternative approach to assess the potential of chemicals to cause changes to respiration remaining after exposure (indicating decreased lung function), and can be combined with other test methods in an integrated approach to testing and assessment of inhaled substances.

Hepatitis E Virus (HEV) Infection in Ireland

Hepatitis E virus (HEV) is a single stranded RNA virus causing infection worldwide. In developing countries HEV genotypes 1 and 2 spread faeco-orally via water. Recently, infections with HEV have been detected in Europe and North America in patients with no travel history. These are food-borne HEV genotypes 3 and 4, a pig-associated zoonosis. Most infections are asymptomatic but morbidity and chronic infection may occur with prior liver disease or immunosuppression. International seroprevalence rates vary and with improved diagnostics have increased. To determine the current prevalence in this region we studied anonymised serum samples submitted in 2015 for routine testing. We detected anti-HEV IgG in 16/198 (8%) individuals, highest rate in 40-59 year olds (43.8%). This is higher than reported for the same region in 1995 (0.4%) using a previous generation assay. This study provides evidence of HEV circulation in Ireland and reinforces the need for ongoing surveillance.

Disseminating a Clinically Effective Physical Activity Program to Preserve Mobility in a Community Setting for Older Adults

BACKGROUND

As the population of older adults continues to increase, the dissemination of strategies to maintain independence of older persons is of critical public health importance. Recent large-scale clinical trial evidence has definitively shown intervention of moderate-intensity physical activity (PA) reduces major mobility disability in at-risk older adults. However, it remains unknown whether structured PA interventions, with demonstrated efficacy in controlled, clinical environments, can be successfully disseminated into community settings to benefit wider populations of older adults.

OBJECTIVE

To assess the dissemination of an evidence-based PA program for older adults by evaluating program participation and its impact on mobility, strength and quality of life.

SETTING

An urban senior center.

PARTICIPANTS

Fifty older adults (71.2 ± 8 years aged; BMI: 30.1 ± 7 kg/m2).

INTERVENTION

Average of 8.0 ± 1.8 months of participation in the Fit-4-Life Program, a community-based PA and nutrition counseling intervention.

MEASUREMENTS

Mobility (Short Physical Performance Battery (SPPB)), self-reported physical activity (CHAMPS questionnaire), leg strength, grip strength, and quality of life (Quality of Well-Being Self-Administered (QWB-SA) scale) were assessed at baseline and follow-up.

RESULTS

Mean attendance was 55.8%. Fourteen participants were lost to follow-up. Those who dropped-out engaged in less PA at baseline (78 ± 108 mins/wk) compared to those who completed follow-up (203 ± 177 mins/wk, P=0.01). Participants exhibited sustained increases of PA (65 ± 153 mins/wk, P= 0.08), and there were meaningful improvements in SPPB (0.5 ± 0.2, P< 0.01), knee extensor strength (2.6 ± 4.4 kg, P< 0.01) and QWB-SA (0.04 ± 0.09, P= 0.05).

CONCLUSION

The dissemination of a clinically efficacious PA intervention into a community-based setting can improve mobility, strength and quality of life for older adults. This knowledge may be helpful for the design and implementation of larger-scale PA intervention studies designed to preserve mobility in older adults within community-based settings.

Evidence for expression of a single distinct form of mammalian cysteine dioxygenase

Cysteine dioxygenase (CDO) plays a critical role in the regulation of cellular cysteine concentration. Because multiple forms of CDO ( approximately 23 kDa, approximately 25 kDa, and approximately 68 kDa) have been claimed based upon separation and detection using SDS-PAGE/western blotting (with antibodies demonstrated to immunoprecipitate CDO), we further investigated the possibility of more than one CDO isoform. Using either rabbit antibody raised against purified rat liver CDO or against purified recombinant his(6)-tagged CDO (r-his(6)-CDO) and using 15% (wt/vol) polyacrylamide for the SDS-PAGE, we consistently detected the approximately 25 kDa band, but never detected a approximately 68 kDa band, in rat liver, kidney, lung and brain. Nondenatured gel electrophoresis of r-his(6)-CDO yielded a molecular mass estimate of 25.7 kDa and no evidence of dimerization. Mass spectrometry of r-his(6)-CDO yielded two peaks with molecular masses of 24.1 kDa and 24.3 kDa. Anion-exchange FPLC of r-his(6)-CDO also gave two peaks, with the first containing CDO that was 7.5-times as active as the more anionic form that eluted second. When the two peaks recovered from FPLC were run on SDS/PAGE, the first (more active) CDO fraction yielded two bands (perhaps as an artifact of SDS/PAGE), whereas the second (less active) CDO fraction yielded only the approximately 23 kDa band. We conclude that the physiologically active form of CDO is the approximately 25 kDa (i.e., 23.5 kDa based on mass spectrometry) monomer and that this active form is probably derived by post-translational modification of the 23 kDa gene product.

A controlled trial of fluoxetine in nondepressed patients with Huntington's disease

To examine the antidepressant specificity of fluoxetine in Huntington's disease (HD), we carried out a randomized, double-blind, placebo-controlled trial of this medication in nondepressed HD patients. Thirty patients with early HD who were depressed (Hamilton Depression Inventory < 16) were randomized to placebo (N = 13) or fluoxetine 20 mg/day (N = 17) and were followed up for 4 months. Outcome measures included changes in total functional capacity (TFC) and in standardized neurological, cognitive, and behavioral ratings. After adjustment for the higher education level found in the placebo group at baseline, no differences between the treatment groups were found in TFC, neurological, or cognitive ratings. Fluoxetine-treated patients did show a slight reduction in agitation and in the need for routine. Although fluoxetine may be a useful antidepressant in depressed HD patients, it failed to exert substantial clinical benefits in nondepressed HD patients.

A controlled trial of remacemide hydrochloride in Huntington's disease

We conducted a randomized, double-blind, placebo-controlled tolerability study of a N-methyl-D-aspartate (NMDA) glutamate receptor ion-channel blocker, remacemide hydrochloride, in 31 independently ambulatory patients (18 men, 13 women) with Huntington's disease (HD). Subjects were randomized to receive either placebo or active remacemide at dosages of 200 mg/day or 600 mg/day. The primary outcome measure was the proportion of subjects able to complete the study with the assigned treatment. Remacemide was generally well tolerated, and no significant differences between the treatment arms were found in the primary outcome measure. A trend toward improvement in chorea was observed among subjects administered remacemide 200 mg/day. Based on the tolerability and safety demonstrated during this short-term trial, remacemide warrants more extended controlled investigation in patients with HD.

Assessment of coenzyme Q10 tolerability in Huntington's disease

We performed a 6-month open-label trial to evaluate the tolerability and efficacy of coenzyme Q10 (CoQ) in 10 patients with Huntington's disease (HD). Subjects were evaluated at baseline, 3 months, and 6 months using the HD Rating Scale (HDRS), the HD Functional Capacity Scale (HDFCS), and standardized neuropsychological measures. Adverse events (AEs) were assessed by telephone interview every month. CoQ doses ranged from 600 to 1,200 mg per day. All subjects completed the study, although four subjects reported mild AEs, including headache, heartburn, fatigue, and increased involuntary movements. There was no significant effect of the treatment on the clinical ratings. The good tolerability of CoQ suggests that it is a good candidate for evaluation in long-term clinical trials designed to slow the progression of HD.

Cognitive performance and regional brain volume in human immunodeficiency virus type 1 infection

BACKGROUND

Brain atrophy has been reported to occur in advancing human immunodeficiency virus (HIV) infection, particularly in patients with HIV-related dementia. Atrophy of the caudate region, as assessed by magnetic resonance imaging measures, has been reported to correlate with cognitive impairment in patients with HIV infection; however, differences in the severity of HIV-induced immunosuppression may have contributed to these findings.

OBJECTIVE

To determine the relationship between regional brain volumes and cognitive performance in individuals with HIV infection.

PATIENTS AND METHODS

We evaluated 11 patients with advanced HIV disease by using neuropsychologic tests and quantitative magnetic resonance imaging volume analysis.

SETTING

University hospital, involving patients from a clinical trial.

RESULTS

Caudate volume, expressed as a ratio of total intracranial volume, correlated with performance on the Trails A and Grooved Pegboard tests, but not with other tests of memory, motor speed, or mood (adjusted for age and education). Hippocampal volume did not correlate with any of the neuropsychologic tests.

CONCLUSIONS

Caudate volume in patients with advanced HIV disease is associated with poor performance on neuropsychologic tests of complex motor and sequencing skills. Hippocampal volume does not appear to be related to impairment on neuropsychologic tests. These findings are independent of the degree of immunosuppression and the overall extent of brain atrophy; however, these results must be interpreted with some caution, given the limited sample size.

Functional decline in Huntington's disease

We prospectively evaluated 129 patients with manifest Huntington's disease (HD) to determine the rate of illness progression and the clinical features that correlate with functional decline. A single examiner evaluated each patient using the HD Functional Capacity Scale. Standardized motor performance was also assessed in 94 of the patients (73%) using the HD Rating Scale. Total Functional Capacity declined at a rate of 0.63 +/- 0.75 U per year. As functional capacity worsened, chorea lessened, and dystonia intensified. There was no correlation between rate of functional decline and age at onset of HD, body weight, gender of affected parent, or history of neuroleptic use.

Intraoperative somatosensory evoked potential monitoring predicts peripheral nerve injury during cardiac surgery

BACKGROUND

Brachial plexus injury may occur without obvious cause in patients undergoing cardiac surgery. To determine whether such peripheral nerve injury can be predicted intraoperatively, we monitored somatosensory evoked potentials (SEPs) from bilateral median and ulnar nerves in 30 patients undergoing coronary artery bypass surgery.

METHODS

SEPs were analyzed for changes during central venous cannulation and during use of the Favoloro and Canadian self-retaining sternal retractors, events hereto implicated in brachial plexus injury. Brachial plexus injury was evaluated during physical examination in the postoperative period by an individual blinded to results of SEP monitoring.

RESULTS

Central venous cannulation was associated with transient changes in SEPs in four patients (13%). These changes occurred intermittently during insertion of the cannula but completely resolved within 5 min. Postoperative neurologic deficits did not occur in these cases. Use of the Canadian and Favoloro retractors was associated with significant changes in 21 patients (70%). In 16 of these, waveforms reverted toward baseline levels intraoperatively and were not associated with postoperative neurologic deficits. Five patients demonstrated a neurologic deficit postoperatively. In each of these, SEP change associated with use of surgical retractors persisted to the end of surgery compared to the immediate pre-bypass period.

CONCLUSION

Intraoperative upper extremity SEPs may be used to predict peripheral nerve injury occurring during cardiac surgery.

Early nutrition intervention services for children with special health care needs

Dietitians must be responsive to the changing needs of their clients and employers, to societal concerns, and to legal mandates. A recently passed amendment (PL 99-457) to the Federal Education for the Handicapped Act gives nutrition professionals the opportunity to have a voice in establishing nutrition policy and standards of care for young handicapped and high-risk children. The new law extends preventive services to children as young as 3 years of age, and Part H of the law provides financial incentives for states to provide services to children with special health care needs from birth to 2 years of age. This article reviews relevant provisions of the new law and describes two projects undertaken by nutritionists from Alabama, Mississippi, and Texas. It also summarizes challenges to nutritionists that will result from the law's implementation.

Ulex europeus type I agglutinin detects carcinoembryonic antigen in extracts of human colorectal carcinoma

Recent interest has focused on fucosylated epitopes expressed on human neoplasms. The plant lectin Ulex europus agglutinin, Type I (UEA) binds fucosylated oligosaccharides, while UEA-reactive substances have a tissue distribution similar to carcinoembryonic antigen (CEA). We sought to determine if UEA reacted with CEA in extracts of fresh primary and metastatic colorectal carcinomas and paired normal tissues. The extracts were electrophoretically transferred to nitrocellulose membranes after the proteins were separated by SDS-PAGE in 10% polyacrylamide gels. The transfer membranes were then stained with peroxidase-conjugated UEA (UEA-P) or antibody to CEA (CEA-P). UEA-P reacted with a 170-190-kDa band in extracts of 22 of 30 primary tumors, 10 of 12 metastases, but only 1 of 5 villous adenomas. UEA-P generally did not react with normal colon or liver extracts. UEA-P also did not bind to 170-190-kDa molecules in Western transfers of a breast carcinoma metastatic to bowel and a focal nodular hyperplasia of liver. CEA-P displayed similar reactivity and detected CEA in a tumor extract negative for UEA. Fucose blocked binding of UEA-P to Western transfers of tumor extracts. CEA-P reacted with a 170-190-kDa substance in tumor extracts eluted with fucose from a column of immobilized UEA. Thus, UEA reacts with fucosylated oligosaccharides on most, but not all, species of CEA and may be a useful adjunct to anti-CEA immunohistochemistry.