Effectiveness of Virtual Reality in Reducing Perceived Pain and Anxiety Among Patients Within a Hospital System: Protocol for a Mixed Methods Study

BACKGROUND

Within hospital systems, diverse subsets of patients are subject to minimally invasive procedures that provide therapeutic relief and necessary health data that are often perceived as anxiogenic or painful. These feelings are particularly relevant to patients experiencing procedures where they are conscious and not sedated or placed under general anesthesia that renders them incapacitated. Pharmacologic pain management and topical anesthetic creams are used to manage these feelings; however, distraction-based methods can provide nonpharmacologic means to modify the painful experience and discomfort often associated with these procedures. Recent studies support distraction as a useful method for reducing anxiety and pain and as a result, improving patient experience. Virtual reality (VR) is an emerging technology that provides an immersive user experience and can operate through a distraction-based method to reduce the negative or painful experience often related to procedures where the patient is conscious. Given the possible short-term and long-term outcomes of poorly managed pain and enduring among patients, health care professionals are challenged to improve patient well-being during medically essential procedures.

OBJECTIVE

The purpose of this pilot project is to assess the efficacy of using VR as a distraction-based intervention for anxiety or pain management compared to other nonpharmacologic interventions in a variety of hospital settings, specifically in patients undergoing lumbar puncture procedures and bone marrow biopsies at the oncology ward, patients receiving nerve block for a broken bone at an anesthesia or surgical center, patients undergoing a cleaning at a dental clinic, patients conscious during an ablation procedure at a cardiology clinic, and patients awake during a kidney biopsy at a nephrology clinic. This will provide the framework for additional studies in other health care settings.

METHODS

In a single visit, patients eligible for the study will complete brief preprocedural and postprocedural questionnaires about their perceived fear, anxiety, and pain levels. During the procedure, research assistants will place a VR headset on the patient and the patient will undergo a VR experience to distract from any pain felt from the procedure. Participants' vitals, including blood pressure, heart rate, and rate of respiration, will also be recorded before, during, and after the procedure.

RESULTS

The study is already underway, and results support a decrease in perceived pain by 1.00 and a decrease in perceived anxiety by 0.3 compared to the control group (on a 10-point Likert scale). Among the VR intervention group, the average rating for comfort was 4.35 out of 5.

CONCLUSIONS

This study will provide greater insight into how patients' perception of anxiety and pain could potentially be altered. Furthermore, metrics related to the operational efficiency of providing a VR intervention compared to a control will provide insight into the feasibility and integration of such technologies in routine practice.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52649.

Sorption Isotherms and Thermodynamic Characteristics of Gelatin Powder Extracted from Whitefish Skin: Mathematical Modeling Approach

Moisture adsorption and desorption isotherms of gelatin extracted from whitefish skin powder (FSGP) at different temperatures across a wide range of water activity were determined along with their thermodynamic properties. Nine mathematical models were utilized for fitting the experimental data and simulating the adsorption and desorption behavior. The thermodynamic properties were determined and fitted to the experimental data. The results showed that Peleg and GAB models were the best fit for FSGP. The energies involved in the adsorption and desorption process of FSGP indicated a stronger dependence on equilibrium moisture content (Xe). When Xe decreased, there was a consistent trend of increasing thermodynamic properties. Both the moisture adsorption and desorption behaviors of FSGP were, therefore, non-spontaneous processes. Linear correlations between the changes in enthalpy and entropy for adsorption and desorption were observed, indicating the presence of enthalpy-entropy compensation for FSGP. For preserving FSGP quality, it should be stored with Xw ≤ 8 (gw/gdm, d.b.) at temperatures below 53 °C and an RH of 50% to avoid it becoming rubbery. These findings are crucial for providing insight into the optimal drying and storage conditions.

Impact of Prior Pulsed Electric Field and Chitooligosaccharide Treatment on Trypsin Activity and Quality Changes in Whole and Beheaded Harpiosquillid Mantis Shrimp during Storage in Iced Water

Harpiosquillid mantis shrimp (Harpiosquilla raphidea) (HMS) without and with beheading pretreated with pulsed electric field (PEF) (15 kV/cm, 800 pulses, 5 min) were soaked in chitooligosaccharide (COS) solution at varying concentrations (0, 1 and 2%, w/v) for 20 min and stored for 3 days in iced water. Changes in the trypsin activity, color, texture, protein pattern, TCA soluble peptide content, histological images, protein secondary structure and microbial load were monitored during the storage. The beheaded HMS pretreated with PEF and soaked in 2% COS solution showed the maximum efficacy in inhibiting trypsin activity and proteolysis, thus retaining muscle proteins, especially myosin heavy chain, actin and troponin T as well as shear force up to day 3. Pronounced muscle destruction in the whole HMS was displayed by a decreased mean grey index and fiber gapping. Such changes were lowered by the beheading and PEF/2% COS treatment (2% COS-BH). Nevertheless, no marked change in the secondary structure including α-helix, β-sheets, β-turns and random coil were observed among any of the samples. The microbiological analysis revealed that the total viable count (TVC) was below 6 log CFU/g till day 2 in all samples. Nonetheless, the 2% COS-BH sample had the lowest psychrophilic bacterial count and Enterobacteriaceae count at day 3, compared to the others. Thus, the combination of the prior PEF and 2% COS treatment of beheaded HMS could effectively inhibit proteases, retard the microbial growth and maintain the quality of HMS stored in iced water.

Contaminated fungi in dried salted fishes: Isolation, identification, and their inhibition by chitooligosaccharide-gallic acid conjugate

Contaminated fungi on dried salted fish of three species including Talang queenfish (TQF, Scomberroides commersonianus), Hamilton's thryssa fish (HTF, Thryssa hamiltonii), and Cobia fish (CF, Rachycentron canadum) were isolated and identified. One hundred and sixty-nine isolates were obtained from TQF and HTF, respectively, while no fungi were detected in CF. The dominant genera were Aspergillus spp. (n = 79), Penicillium spp. (n = 60), and non-sporulating fungi (n = 30). The representative groups of Aspergillus spp. (n = 6) and Penicillium spp. (n = 3) based on different morphological characteristics were selected for species identification by molecular methods involving ITS1-5.8s-ITS2 region and Matrix-Assisted Laser Desorption/Ionization Time-of Flight Mass Spectrometer (MALDI-TOF MS) analysis. The nine isolates were identified to be Aspergillus versicolor (n = 2), Aspergillus montevidensis (n = 3), Penicillium citrinum (n = 3), and Aspergillus sp. (n = 1). The antifungal activity of chitooligosaccharide-gallic acid (COS-GAL) conjugate against A. versicolor F1/10M9, A. montevidensis F1/30M20, and P. citrinum F1/23M14 was examined. The minimum inhibitory concentration (MIC) and minimum fungicidal concentration (MFC) values were in the range of 0.625-2.5 mg/mL and 1.25-10 mg/mL, respectively. COS-GAL conjugate at the concentration of 5 mg/mL completely inhibited the spore germination of A. versicolor F1/10M9 and P. citrinum F1/23M14 after 72 h of treatment. COS-GAL conjugate at 4 × MIC mainly affected the mycelium of A. versicolor F1/10M9 and P. citrinum F1/23M14 after treatment with COS-GAL conjugate for 3 days by coating mycelium surface and reducing the size of mycelium. Therefore, COS-GAL conjugate could be used as a food additive to inhibit or prevent the growth of fungi contaminated in dried salted fish or other relevant products. PRACTICAL APPLICATION: During processing, dried salted fish can be contaminated with fungi, which may cause food poisoning and food spoilage. The contaminated fungi are capable of producing mycotoxin that is harmful to consumers. Synthetic food preservatives have long been used to inhibit fungal growth, but the side effects to consumers are of concern. Chitooligosaccharide is a nontoxic chitosan derivative produced from shrimp shell and its conjugate namely chitooligosaccharide-gallic acid conjugate showed high efficacy in inhibiting the growth of fungi including Aspergillus spp. and Penicillium spp. Therefore, it can serve as a natural alternative preservative for the prevention of fungal growth in dried salted fish.

Chitooligosaccharide and Its Derivatives: Potential Candidates as Food Additives and Bioactive Components

Chitooligosaccharide (CHOS), a depolymerized chitosan, can be prepared via physical, chemical, and enzymatic hydrolysis, or a combination of these techniques. The superior properties of CHOS have attracted attention as alternative additives or bioactive compounds for various food and biomedical applications. To increase the bioactivities of a CHOS, its derivatives have been prepared via different methods and were characterized using various analytical methods including FTIR and NMR spectroscopy. CHOS derivatives such as carboxylated CHOS, quaternized CHOS, and others showed their potential as potent anti-inflammatory, anti-obesity, neuroprotective, and anti-cancer agents, which could further be used for human health benefits. Moreover, enhanced antibacterial and antioxidant bioactivities, especially for a CHOS-polyphenol conjugate, could play a profound role in shelf-life extension and the safety assurance of perishable foods via the inhibition of spoilage microorganisms and pathogens and lipid oxidation. Also, the effectiveness of CHOS derivatives for shelf-life extension can be augmented when used in combination with other preservative technologies. Therefore, this review provides an overview of the production of a CHOS and its derivatives, as well as their potential applications in food as either additives or nutraceuticals. Furthermore, it revisits recent advancements in translational research and in vivo studies on CHOS and its derivatives in the medical-related field.

A Systematic Review of Digital Ophthalmoscopes in Medicine

Purpose

Recent advances in telemedicine have led to increased use of digital ophthalmoscopes (DO) in clinical settings. This review aims to assess commercially available DOs, including smartphone (SP), desktop, and handheld ophthalmoscopes, and evaluate their applications.

Methods

A literature review was performed by searching PubMed (pubmed.ncbi.nlm.nih.gov), Web of Science (webofknowledge.com), and Science Direct (sciencedirect.com). All English-language papers that resulted from the search terms "digital ophthalmoscope", "screening tool", "glaucoma screening", "diabetic retinopathy screening", "cataract screening", and "papilledema screening" were reviewed. Studies that contained randomized clinical trials with human participants between January 2010 and December 2020 were included. The Risk of Bias in Systematic Reviews (ROBIS) tool was used to assess the methodological quality of each included paper.

Results

Of the 1307 studies identified, 35 met inclusion and exclusion criteria. The ROBIS tool determined that 29/35 studies (82.8%) had a low risk of bias, 3/35 (8.5%) had a moderate risk of bias, and 3/35 (8.5%) had a high risk of bias.

Conclusion

The continued adoption of DOs remains uncertain because of concerns about the image quality for non-mydriatic eyes and the confidence in data captured from the device. Likewise, there is a lack of guidelines for the use of DOs, which makes it difficult for providers to determine the best device for their practice and to ensure appropriate use. Even so, DOs continue to gain acceptance as technology and practice integration improve, especially in underserved areas with limited access to ophthalmologists.

Gelation characteristics of partially purified myofibrillar proteins extracted from commercially harvested Indian mackerel and threadfin bream

Gelling behaviors of partially purified myofibrillar proteins (PPMP) extracted from Indian mackerel (IM) and threadfin bream (TB) as a function of heating temperatures (20-75°C) were comparatively studied. PPMP obtained from IM (IM-MP) showed lower turbidity and surface hydrophobicity as compared to those extracted from TB (TB-MP). Moreover, lower disulfide bond content was noticed in IM-MP (7.7-9.46 mol/106  g protein) as compared to TB-MP (10.99-13.95 mol/106  g protein) during the heating process. There was no major difference in the amino acid profile noticed between PPMP from both the species, except lysine and glutamine contents, which were higher in TB-MP. Structural analysis, FTIR spectra, amide I band, and fluorescence intensity substantiated those changes. The protein pattern also revealed autolysis of IM-MP. The transmission analysis also showed lower aggregation and crosslinking ability of IM-MP than TB-MP. Therefore, poorer gelling behavior of IM-MP reconfirmed the inferior gel property of surimi gel from IM to gel from TB. Potential development is still required for the improvement of the gel properties of dark-fleshed fish surimi such as IM. PRACTICAL APPLICATION: Indian mackerel (IM) is an abundant and widely captured fish species. Due to overexploitation of lean fish, pelagic fish could be explored as a potential raw material for surimi production. However, poor gelling properties of IM limit its use in the surimi industry. This study provides an insight into the gelling behavior of myofibrillar proteins from IM during the gelation process in comparison with the lean fish (threadfin bream). Overall, structural and rheological changes of myofibrillar proteins play a role in gelation, thus affecting gel properties between two species. Further improvement of the gel of IM is still required.

Correlation of Transient Elastography with Liver Iron Concentration and Serum Ferritin Levels in Patients with Transfusion-Dependent Thalassemia Major from Oman

Aims

In a longitudinal study, we aimed to assess the correlation between ultrasound transient elastography (TE), serum ferritin (SF), liver iron content (LIC) by magnetic resonance imaging (MRI) T2* along with the fibrosis-4 (FIB-4) score as a screening tool to detect significant liver fibrosis among chronically transfusion-dependent beta-thalassemia (TDT) patients.

Methods

The study was conducted at a tertiary health center treating TDT patients. Transient elastography was performed within 3 months of Liver MRI T2* examinations at the radiology department over a median of one-year duration. T-test for independent data or Mann-Whitney U test was used to analyze group differences. Spearman correlation with linear regression analysis was used to evaluate the correlation between TE liver stiffness measurements, Liver MRI T2* values, and SF levels.

Results

In this study on 91 patients, the median age (IQR) of the subjects was 33 (9) years, and the median (IQR) body mass index was 23.8 (6.1) kg/m2. Median (IQR) TE by fibroscan, MRI T2*(3T), Liver iron concentration (LIC) by MRI Liver T2*, and SF levels were 6.38 (2.6) kPa, 32.4 (18) milliseconds, 7(9) g/dry wt., and 1881 (2969) ng/mL, respectively. TE measurements correlated with LIC g/dry wt. (rS =0.39, p=0.0001) and with SF level (rS =0.43, P=0.001) but not with MRI T2* values (rS =-0.24; P=0.98).

Conclusion

In TDT patients, liver stiffness measured as TE decreased significantly with improved iron overload measured as LIC by MRI and SF levels. However, there was no correlation of TE with the fibrosis-4 (FIB-4) score.

Chitooligosaccharide-catechin conjugate loaded liposome using different stabilising agents: characteristics, stability, and bioactivities

AIM

To determine the optimum condition for preparing chitooligosaccharide-catechin conjugate (COS-CAT) liposomes using different stabilising agents.

METHODS

COS-CAT liposomes (0.1-1%, w/v) were prepared using soy phosphatidylcholine (SPC) (50-200 mM) and glycerol or cholesterol (25-100 mg). Encapsulation efficiency (EE), loading capacity (LC), physicochemical characteristics, FTIR spectra, thermal stability, and structure of COS-CAT liposomes were assessed.

RESULTS

COS-CAT loaded liposome stabilised by cholesterol (COS-CAT-CHO) showed higher stability as shown by the highest EE (76.81%) and LC (4.57%) and the lowest zeta potential (ZP) (-76.51 mV), polydispersity index (PDI) (0.2674) and releasing efficiency (RE) (53.54%) (p < 0.05). COS-CAT-CHO showed the highest retention and relative remaining bioactivities of COS-CAT under various conditions (p < 0.05). FTIR spectra revealed the interaction between the choline group of SPC and -OH groups of COS-CAT. Phase transition temperature of COS-CAT-CHO was shifted to 184 °C, which was higher than others (p < 0.05).

CONCLUSION

SPC and cholesterol-based liposome could be used as a promising vesicle for maintaining bioactivities of COS-CAT.

Inhibition Mechanism of Chitooligosaccharide-Polyphenol Conjugates toward Polyphenoloxidase from Shrimp Cephalothorax

Crustaceans are perishable with a short shelf-life. They are prone to deterioration after capture, particularly during handling, processing, and storage due to melanosis caused by polyphenoloxidase (PPO). Therefore, inhibitory effects of chitooligosaccharide (CHOS) in comparison with CHOS-catechin (CHOS-CAT), CHOS-epigallocatechin gallate (CHOS-EGCG), and CHOS-gallic acid (CHOS-GAL) conjugates on Pacific white shrimp cephalothorax PPO were studied. IC₅₀ of CHOS-CAT (0.32 mg/mL) toward PPO was less than those of all conjugates tested (p < 0.05). CHOS-CAT exhibited the mixed-type inhibition. K_ic (0.58 mg/mL) and K_iu (0.02 mg/mL) of CHOS-CAT were lower than those of other conjugates (p < 0.05). CHOS-CAT showed static fluorescence-quenching, suggesting a change in micro-environment around the active site of PPO. Moreover, CHOS-CAT was linked with various amino acid residues, including Tyr208 or Tyr209 of proPPO via van der Waals, hydrophobic interaction, and hydrogen bonding as elucidated by the molecular docking of proPPO. Although CHOS-CAT had the highest PPO inhibitory activity, it showed a lower binding energy (-8.5 kcal/mol) than other samples, except for CHOS-EGCG (-10.2 kcal/mol). Therefore, CHOS-CAT could act as an anti-melanosis agent in shrimp and other crustaceans to prevent undesirable discoloration associated with quality losses.

Proteome Analysis of the Antiproliferative Activity of the Novel Chitooligosaccharide-Gallic Acid Conjugate against the SW620 Colon Cancer Cell Line

Chitooligosaccharide (COS) and gallic acid (GA) are natural compounds with anti-cancer properties, and their conjugate (COS-GA) has several biological activities. Herein, the anti-cancer activity of COS-GA in SW620 colon cancer cells was investigated. MTT assay was used to evaluate cell viability after treatment with 62.5, 122, and 250 µg/mL of COS, GA, and COS-GA for 24 and 48 h. The number of apoptotic cells was determined using flow cytometry. Proteomic analysis was used to explore the mechanisms of action of different compounds. COS-GA and GA showed a stronger anti-cancer effect than COS by reducing SW620 cell proliferation at 125 and 250 µg/mL within 24 h. Flow cytometry revealed 20% apoptosis after COS-GA treatment for 24 h. Thus, GA majorly contributed to the enhanced anti-cancer activity of COS via conjugation. Proteomic analysis revealed alterations in protein translation and DNA duplication in the COS group and the structural constituents of the cytoskeleton, intermediate filament organization, the mitochondrial nucleoid, and glycolytic processes in the COS-GA group. Anti-cancer-activity-related proteins were altered, including CLTA, HSPA9, HIST2H2BF, KRT18, HINT1, DSP, and VIM. Overall, the COS-GA conjugate can serve as a potential anti-cancer agent for the safe and effective treatment of colon cancer.

An Automated Segmentation of Leukocytes Using Modified Watershed Algorithm on Peripheral Blood Smear Images

Leukemia can be detected by an abnormal rise in the number of immature lymphocytes and by a decrease in the number of other blood cells. To diagnose leukemia, image processing techniques are utilized to examine microscopic peripheral blood smear (PBS) images automatically and swiftly. To the best of our knowledge, the initial step in subsequent processing is a robust segmentation technique for identifying leukocytes from their surroundings. The paper presents the segmentation of leukocytes in which three color spaces are considered in this study for image enhancement. The proposed algorithm uses a marker-based watershed algorithm and peak local maxima. The algorithm was used on three different datasets with various color tones, image resolutions, and magnifications. The average precision for all three-color spaces was the same, i.e. 94% but the Structural Similarity Index Metric (SSIM) and recall of HSV were better than other two. The results of this study will aid experts in narrowing down their options for segmenting leukemia. Based on the comparison, it was concluded that when the colour space correction technique is used, the accuracy of the proposed methodology improves.

Bactericidal Action of Shrimp Shell Chitooligosaccharide Conjugated with Epigallocatechin Gallate (COS-EGCG) against Listeria monocytogenes

The antibacterial effect of chitooligosaccharide conjugated with five different polyphenols, including catechin (COS-CAT), epigallocatechin gallate (COS-EGCG), gallic acid (COS-GAL), caffeic acid (COS-CAF), and ferulic acid (COS-FER), against Listeria monocytogenes was investigated. Among all the conjugates tested, COS-EGCG showed the highest inhibition toward Listeria monocytogenes, with a minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of 1024 and 1024 µg/mL, respectively. The COS-EGCG conjugate also had a bactericidal effect on the environmental and clinical strains of L. monocytogenes. The low concentration of COS-EGCG conjugate augmented the formation of biofilm and the growth of L. monocytogenes. Nevertheless, the inhibition of biofilm formation and bacterial growth was achieved when treated with the COS-EGCG conjugate at 2 × MIC for 48 h. In addition, the COS-EGCG conjugate at 2 × MIC had the potential to inactivate the pre-biofilm, and it reduced the production of the extracellular polysaccharides of L. monocytogenes. The COS-EGCG conjugate at the MIC/4 effectively impeded the motility (the swimming and swarming) of L. monocytogenes, with an 85.7-94.3% inhibition, while 100% inhibition was achieved with the MIC. Based on scanning electron microscopic (SEM) images, cell wall damage with numerous pores on the cell surface was observed. Such cell distortion resulted in protein leakage. As a result, COS-EGCG could penetrate into the cell and bind with the DNA backbone. Therefore, the COS-EGCG conjugate could be further developed as a natural antimicrobial agent for inhibiting or controlling L. monocytogenes.

Self-supervised Learning: A Succinct Review

Machine learning has made significant advances in the field of image processing. The foundation of this success is supervised learning, which necessitates annotated labels generated by humans and hence learns from labelled data, whereas unsupervised learning learns from unlabeled data. Self-supervised learning (SSL) is a type of un-supervised learning that helps in the performance of downstream computer vision tasks such as object detection, image comprehension, image segmentation, and so on. It can develop generic artificial intelligence systems at a low cost using unstructured and unlabeled data. The authors of this review article have presented detailed literature on self-supervised learning as well as its applications in different domains. The primary goal of this review article is to demonstrate how images learn from their visual features using self-supervised approaches. The authors have also discussed various terms used in self-supervised learning as well as different types of learning, such as contrastive learning, transfer learning, and so on. This review article describes in detail the pipeline of self-supervised learning, including its two main phases: pretext and downstream tasks. The authors have shed light on various challenges encountered while working on self-supervised learning at the end of the article.

Transfer learning for image classification using VGG19: Caltech-101 image data set

Image classification is getting more attention in the area of computer vision. During the past few years, a lot of research has been done on image classification using classical machine learning and deep learning techniques. Presently, deep learning-based techniques have given stupendous results. The performance of a classification system depends on the quality of features extracted from an image. The better is the quality of extracted features, the more the accuracy will be. Although, numerous deep learning-based methods have shown enormous performance in image classification, still due to various challenges deep learning methods are not able to extract all the important information from the image. This results in a reduction in overall classification accuracy. The goal of the present research is to improve the image classification performance by combining the deep features extracted using popular deep convolutional neural network, VGG19, and various handcrafted feature extraction methods, i.e., SIFT, SURF, ORB, and Shi-Tomasi corner detector algorithm. Further, the extracted features from these methods are classified using various machine learning classification methods, i.e., Gaussian Naïve Bayes, Decision Tree, Random Forest, and eXtreme Gradient Boosting (XGBClassifier) classifier. The experiment is carried out on a benchmark dataset Caltech-101. The experimental results indicate that Random Forest using the combined features give 93.73% accuracy and outperforms other classifiers and methods proposed by other authors. The paper concludes that a single feature extractor whether shallow or deep is not enough to achieve satisfactory results. So, a combined approach using deep learning features and traditional handcrafted features is better for image classification.

Management of Mandibular Angle Fractures Using Single Y-Shaped Titanium Miniplate at the Superior Border: A Prospective Clinical Study

Treatment of angle fractures remains controversial. The various techniques documented for the treatment are: wire osteosynthesis, one miniplate at superior border (2.0 mm), a single plate on inferior border (2.3 or 2.7 mm) along with tension band in the form of arch bar at the upper border, 2 miniplates (1 at superior border and 1 at inferior border), 3-D strut plates or lag screw. To evaluate the efficacy of single Y-shaped titanium miniplate at the superior border in the management of mandibular angle fractures. Total of 15 healthy adult patients reporting to the department of Oral and Maxillofacial Surgery for the treatment of mandibular angle fractures was randomly selected. All the cases were assessed clinically at 1st post-operative day, 1st, 3rd, 6th and 12th week post-operatively for pain, status of occlusion, neurosensory deficit and postoperative hard & soft tissue healing. Radiographic assessment was also done at 1st postoperative day, 6 weeks and 12 weeks. Postoperative pain, infection, wound dehiscence, neurosensory deficit were not evident during the follow- up periods. Radiographically, the fracture reduction was good and plate fracture was not seen in any case. Y- shaped titanium miniplate is an effective method in the management of the mandibular angle fractures and provided satisfactory results.

CheXPrune: sparse chest X-ray report generation model using multi-attention and one-shot global pruning

Automatic radiological report generation (ARRG) smoothens the clinical workflow by speeding the report generation task. Recently, various deep neural networks (DNNs) have been used for report generation and have achieved promising results. Despite the impressive results, their deployment remains challenging because of their size and complexity. Researchers have proposed several pruning methods to reduce the size of DNNs. Inspired by the one-shot weight pruning methods, we present CheXPrune, a multi-attention based sparse radiology report generation method. It uses encoder-decoder based architecture equipped with a visual and semantic attention mechanism. The model is 70% pruned during the training to achieve 3.33× compression without sacrificing its accuracy. The empirical results evaluated on the OpenI dataset using BLEU, ROUGE, and CIDEr metrics confirm the accuracy of the sparse model viz-a ` -viz the dense model.

Defining the rate of nutritional and metabolic derangements after pancreatic resection

BACKGROUND AND AIMS

Pancreatic resection is associated with pancreatic exocrine insufficiency (PEI) leading to nutritional consequences. The Pancreatic Nutrition Clinic was established to diagnose and manage PEI through standardised nutritional assessment. In this prospective observational study, we aimed to define the rate of PEI, diabetes mellitus and nutritional abnormalities in patients who underwent pancreatic resection.

METHODS

All Pancreatic Nutrition Clinic patients were included for analysis. Clinical data were prospectively obtained at initial assessment. Biochemical data included micronutrient levels, faecal elastase-1 and haemoglobin A1c. Bone mineral density and nutritional assessment were undertaken.

RESULTS

Ninety-eight patients were included. Fifty-nine per cent (58/98) had undergone a pancreatoduodenectomy. Ninety-three patients had a faecal elastase-1 result, 65% (60/93) of which had a faecal elastase-1 less than 200 μg/g of faeces. Seventy-five patients (76%) of the total population required PERT, and thirty-nine (40%) were classified as malnourished using the patient-generated subjective global assessment tool. Seventy-two per cent (70/97) had a biochemical deficiency of one or more micronutrients. Thirty-eight people (39%) had diabetes mellitus. Of the seventy-eight patients with a bone mineral density scan available for analysis, 29% (23/78) had osteoporosis and 49% (38/78) osteopenia.

CONCLUSIONS

Pancreatic exocrine insufficiency, micronutrient deficiency, bone disease, diabetes mellitus and malnutrition are highly prevalent in patients who have undergone pancreatic resection.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Undesirable discoloration in edible fish muscle: Impact of indigenous pigments, chemical reactions, processing, and its prevention

Fish is rich in proteins and lipids, especially those containing polyunsaturated fatty acids, which made them vulnerable to chemical or microbial changes associated with quality loss. Meat color is one of vital criteria indicating the freshness, quality, and acceptability of the meat. Color of meat is governed by the presence of various pigments such as hemoglobin, myoglobin (Mb), and so on. Mb, particularly oxy-form, is responsible for the bright red color of fish muscle, especially tuna, and dark fleshed fish, while astaxanthin (AXT) directly determines the color of salmonids muscle. Microbial spoilage and chemical changes such as oxidation of lipid/proteins result in the autoxidation of Mb or fading of AXT, leading to undesirable color with lower acceptability. The discoloration has been affected by chemical composition, post-harvesting handling or storage, processing, cooking, and so on . To tackle discoloration of fish meat, vacuum or modified atmospheric packaging, low- or ultralow-temperature storage, uses of artificial and natural additives have been employed. This review article provides information regarding the factors affecting color and other quality aspects of fish muscle. Moreover, promising methodologies used to control discoloration are also focused.

Atrial fibrillation in unexplained syncope: observations from the Reveal LINQ registry

Background

Implantable loop recorders (ILRs) have come to play an important role in the workup of patients with recurrent syncope of uncertain origin. In addition to detecting bradyarrhythmias related to syncope, which is the main diagnostic focus in these patients, ILRs are also capable of uncovering subclinical atrial fibrillation (AF).

Purpose

We sought to determine the percentage of patients monitored with an ILR for unexplained syncope who have AF detected and to describe clinical actions taken in these patients.

Methods

Patients enrolled in the Reveal LINQ Registry who received an ILR for unexplained syncope and had at least one follow-up form were included. The device automatically detects AF episodes lasting ≥2 minutes. Patients were considered to have AF based on an AF diagnosis made by the treating physician during follow-up or if device-detected AF was adjudicated as true AF by an external reviewer. AF detection rates were calculated using Kaplan-Meier methods.

Results

In total, 498 patients (aged 61.8±20.0 years, 49.6% female, CHA2DS2VASc score 2.2±1.7) were included and followed for 22±12 months. A history of AF was present in 97 (20%) patients, while 401 patients had no history. By 18 months, the incidence of AF was 70.9% (95% CI, 60.8%, 80.3%) in patients with a history of AF and 21.4% (95% CI, 17.4%, 26.1%) in patients without (Figure). AF detection in those with (30.4%) and without (30.1%) syncope during follow-up was similar. By the end of follow-up, and among patients with newly detected AF, 29/86 (33.7%) were on oral anticoagulation, 7 (8.1%) underwent AF ablation, 6 (7.0%) underwent other type of ablation, and 2 (2.3%) received cardioversion. Other actions among the whole cohort included implant of an IPG, ICD, or CRT in 98/498 (19.7%).

Conclusion

Among patients monitored with ILRs to determine the cause of recurrent syncope episodes, approximately 1 in 5 patients had new AF detected. In addition to improving the management of patients with syncope, ILR data served to support AF-related clinical decisions.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Medtronic Inc Incidence of AF according to baseline AF

Preparation and characterisation of liposome loaded with chitosan-epigallocatechin gallate conjugate

Liposomes (LS) were prepared using chitosan-epigallocatechin gallate (CE) conjugate (0.1 and 0.5%, w/v) and soy phosphatidylcholine (SPC)/cholesterol as a lipid phase (LP) (30 and 60 µmol mL^-1). The encapsulation efficiency (EE), particle diameter, zeta potential, and polydispersity index of LS were observed. The highest EE (76.96%) was found when LS was prepared using 0.5% (w/v) of CE conjugate and 60 µmol mL^-1 of LP (CELP-60-0.5) (p < 0.05). FTIR analysis showed the interaction between choline present in SPC and OH-groups of CE conjugate. The phase transition temperature of CELP-60-0.5 was 134.67 °C, higher than other samples (p < 0.05). CELP-60-0.5 showed inhibitory action against Gram-positive and Gram-negative bacteria. Higher retention of antioxidant and antimicrobial activities of CELP-60-0.5 was observed than unencapsulated CE conjugate sample when stored for 28 days at 30 °C (p < 0.05). LS might be used as an efficient vesicle for maintaining bioactivities of CE conjugate, plausibly when used as a preservative in foods.

Transfer learning for image classification using VGG19: Caltech-101 image data set

Image classification is getting more attention in the area of computer vision. During the past few years, a lot of research has been done on image classification using classical machine learning and deep learning techniques. Presently, deep learning-based techniques have given stupendous results. The performance of a classification system depends on the quality of features extracted from an image. The better is the quality of extracted features, the more the accuracy will be. Although, numerous deep learning-based methods have shown enormous performance in image classification, still due to various challenges deep learning methods are not able to extract all the important information from the image. This results in a reduction in overall classification accuracy. The goal of the present research is to improve the image classification performance by combining the deep features extracted using popular deep convolutional neural network, VGG19, and various handcrafted feature extraction methods, i.e., SIFT, SURF, ORB, and Shi-Tomasi corner detector algorithm. Further, the extracted features from these methods are classified using various machine learning classification methods, i.e., Gaussian Naïve Bayes, Decision Tree, Random Forest, and eXtreme Gradient Boosting (XGBClassifier) classifier. The experiment is carried out on a benchmark dataset Caltech-101. The experimental results indicate that Random Forest using the combined features give 93.73% accuracy and outperforms other classifiers and methods proposed by other authors. The paper concludes that a single feature extractor whether shallow or deep is not enough to achieve satisfactory results. So, a combined approach using deep learning features and traditional handcrafted features is better for image classification.

Protein-polyphenol conjugates: Preparation, functional properties, bioactivities and applications in foods and nutraceuticals

Protein is a crucial nutritional ingredient in the daily human diet. Polyphenols (PPNs) are the abundant phytochemicals in plants, which are associated with health promotion as well as affect functionality in food systems. Both ingredients possess different types of functionalities (crosslinking, gelling, emulsifying, film-forming, etc.) and bioactivities (antioxidant, antimicrobial, anti-inflammatory, etc.). In the past decade, various methods have been implemented to enhance the functionalities and bioactivities of foods. Conjugation or grafting methods has been introduced widely. Conjugations of PPNs with proteins through various methods have been performed for the synthesis of the protein-polyphenol conjugate. Those potential grafting methods are alkaline associated, free-radical mediated, enzyme catalyzed, and chemical coupling methods. Several factors such as reaction conditions, type of proteins, and PPNs also influenced the conjugation efficiency. Various technologies, e.g., mass spectroscopy, fluorescence spectroscopy, UV spectroscopy, Fourier transform infrared spectroscopy, circular dichroism, and sodium dodecyl sulfate polyacrylamide gel electrophoresis have been used to elucidate conjugation and structural alternation of proteins and some properties of resulting conjugates. The prepared protein-PPN conjugates have been documented to enhance the bioactivities and functional properties of an initial protein. Moreover, conjugates have been employed in emulsions or as nanoparticles for nutraceutical delivery. Edible-films for food packaging and hydrogels for controlled drug release have been developed using protein-PPN conjugates. This chapter focuses on the methodologies and characteristics of protein-PPN conjugates and their applications in various food systems and nutraceutical field.

Dose-dense Paclitaxel and Carboplatin as Neoadjuvant Chemotherapy for Stage IIB/IIIA Non-small Cell Lung Cancer - A Phase II trial

AIMS

The approach to potentially resectable non-small cell lung cancer (NSCLC) remains controversial. There is a benefit of neoadjuvant chemotherapy (NACT), but the ideal regimen is unknown. We evaluated the efficacy and safety of dose-dense NACT in potentially resectable NSCLC in this phase II trial.

MATERIALS AND METHODS

Paclitaxel at 80 mg/m² on days 1, 8 and 15 with AUC-6 carboplatin on day 1, 3 weekly for four cycles was evaluated as NACT. Patients with Eastern Cooperative Oncology Group performance status 0-2, stage IIB and IIIA (with only non-bulky N2 nodes) were included. The primary end point was the objective response rate. Secondary end points included toxicity, progression-free survival, recurrence-free survival, complete resection rate and overall survival. The relative dose intensity (RDI) was calculated to define tolerability (CTRI/2016/05/006916).

RESULTS

In total, 37 patients were enrolled (median age 55 years). Most (78.8%) were smokers. Most patients had adenocarcinoma (57.6%) and stage IIIA disease (81.0%) according to the seventh American Joint Committee on Cancer staging system. Seventy-eight per cent of patients completed four cycles. The objective response rate was 75.6% with a complete response in 10.8%. The mean RDI of paclitaxel was 88.61%, with 68.0% of patients able to maintain an RDI ≥85.0%. In total, 187 toxicity events were recorded (120 grade 1, 64 grade 2 and three grade 3 events). Common toxicities were peripheral neuropathy (20.3%), myalgia (19.8%), nausea (15.7%) and neutropenia (10.2%). There were no treatment-related deaths. Seventeen patients underwent surgery (lobectomy 82.4%). After a median follow-up of 47 months (95% confidence interval 27-50.7 months), the median progression-free survival was 9.6 months (7.4-17.4) and overall survival was 29.2 months (16.0-37.2).

CONCLUSION

Dose-dense paclitaxel-carboplatin is feasible, safe and efficacious and should be evaluated further in potentially resectable NSCLC.

Management of peri-prosthetic joint infection and severe bone loss after total hip arthroplasty using a long-stemmed cemented custom-made articulating spacer (CUMARS)

Background

There is little evidence on techniques for management of peri-prosthetic infection (PJI) in the context of severe proximal femoral bone loss. Custom-made articulating spacers (CUMARS) utilising cemented femoral stems as spacers was described providing better bone support and longer survival compared to conventional articulating spacers. We retrospectively report our experience managing PJI by adaptation of this technique using long cemented femoral stems where bone loss precludes use of standard stems.

Methods

Patients undergoing 1st stage revision for infected primary and revision THA using a cemented long stem (> 205 mm) and standard all-polyethylene acetabulum between 2011 and 2018 were identified. After excluding other causes of revision (fractures or aseptic loosening), Twenty-one patients remained out of total 721 revisions. Medical records were assessed for demographics, initial microbiological and operative treatment, complications, eradication of infection and subsequent operations. 2nd stage revision was undertaken in the presence of pain or subsidence.

Results

Twenty-one patients underwent 1st stage revision with a cemented long femoral stem. Mean follow up was 3.9 years (range 1.7–7.2). Infection was eradicated in 15 (71.4%) patients. Two patients (9.5%) required repeat 1st stage and subsequently cleared their infection. Three patients (14.3%) had chronic infection and are on long term suppressive antibiotics. One patient (4.8%) was lost to follow up before 2 years. Complications occurred in seven patients (33%) during or after 1st stage revision. Where infection was cleared, 2nd stage revision was undertaken in 12 patients (76.5%) at average of 9 months post 1st stage. Five (23.8%) CUMARS constructs remained in-situ at an average of 3.8 years post-op (range 2.6–5.1).

Conclusions

Our technique can be used in the most taxing of reconstructive scenarios allowing mobility, local antibiotic delivery, maintenance of leg length and preserves bone and soft tissue, factors not afforded by alternative spacer options.

Extending Horizon of Robotic Surgery to Bladder-Preserving Approach for Vesical Paraganglioma: Rare Case with Unusual Presentation

Background: Vesical paraganglioma is rare and accounts for <0.1% of all urinary bladder tumors. They are mostly functional because of secretion of catecholamines and clinical presentation may mimic like a hyperfunctioning adrenal pheochromocytoma. They are easily misdiagnosed as urothelial malignancy and adequate perioperative attention is not provided. Case presentation: We hereby report a case of 55-year-old Indian lady with silent vesical paraganglioma at anatomically difficult location of bladder neck managed with robot-assisted excision of mass and bladder preservation. Conclusion: Surgery is the mainstay of the treatment that requires total excision of mass. However, minimally invasive bladder-preserving approach should be always kept as an option, if feasible. Robot assistance can help in bladder preservation even in difficult anatomic locations.