Improving Radiographic Fracture Recognition Performance and Efficiency Using Artificial Intelligence

Background Missed fractures are a common cause of diagnostic discrepancy between initial radiographic interpretation and the final read by board-certified radiologists. Purpose To assess the effect of assistance by artificial intelligence (AI) on diagnostic performances of physicians for fractures on radiographs. Materials and Methods This retrospective diagnostic study used the multi-reader, multi-case methodology based on an external multicenter data set of 480 examinations with at least 60 examinations per body region (foot and ankle, knee and leg, hip and pelvis, hand and wrist, elbow and arm, shoulder and clavicle, rib cage, and thoracolumbar spine) between July 2020 and January 2021. Fracture prevalence was set at 50%. The ground truth was determined by two musculoskeletal radiologists, with discrepancies solved by a third. Twenty-four readers (radiologists, orthopedists, emergency physicians, physician assistants, rheumatologists, family physicians) were presented the whole validation data set (n = 480), with and without AI assistance, with a 1-month minimum washout period. The primary analysis had to demonstrate superiority of sensitivity per patient and the noninferiority of specificity per patient at -3% margin with AI aid. Stand-alone AI performance was also assessed using receiver operating characteristic curves. Results A total of 480 patients were included (mean age, 59 years ± 16 [standard deviation]; 327 women). The sensitivity per patient was 10.4% higher (95% CI: 6.9, 13.9; P < .001 for superiority) with AI aid (4331 of 5760 readings, 75.2%) than without AI (3732 of 5760 readings, 64.8%). The specificity per patient with AI aid (5504 of 5760 readings, 95.6%) was noninferior to that without AI aid (5217 of 5760 readings, 90.6%), with a difference of +5.0% (95% CI: +2.0, +8.0; P = .001 for noninferiority). AI shortened the average reading time by 6.3 seconds per examination (95% CI: -12.5, -0.1; P = .046). The sensitivity by patient gain was significant in all regions (+8.0% to +16.2%; P < .05) but shoulder and clavicle and spine (+4.2% and +2.6%; P = .12 and .52). Conclusion AI assistance improved the sensitivity and may even improve the specificity of fracture detection by radiologists and nonradiologists, without lengthening reading time. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Link and Pedoia in this issue.

Effect of hydroxychloroquine on COVID-19 prevention in cancer patients undergoing treatment: study protocol for a randomized controlled trial

OBJECTIVES

In this study, we will investigate the effect of hydroxychloroquine on the prevention of novel coronavirus disease (COVID-19) in cancer patients being treated.

TRIAL DESIGN

This is a two-arm, parallel-group, triple-blind, phase 2-3 randomized controlled trial.

PARTICIPANTS

All patients over the age of 15 years from 5 types of cancer will be included in the study. Patients with acute lymphoid and myeloid leukemias in the first line treated with curative intent, patients with high-grade non-Hodgkin's lymphoma treated with leukemia regimens, and patients with non-metastatic breast and colon cancer in the first line of treatment will enter the study.

INTERVENTION AND COMPARATOR

Patients are randomly assigned to two groups: one being given hydroxychloroquine and the other is given placebo. During 2 months of treatment, the two groups will be treated with hydroxychloroquine every other day with a single 200-mg tablet (Amin® Pharmaceutical Company, Isfahan, Iran) or placebo (identical in terms of shape, color, and smell). Patients will be monitored for COVID-19 symptoms during follow-up period. If any COVID-19-related signs or symptoms occur, they will be examined, thoroughly, investigated with a high resolution computerize tomography (CT) scan of the lungs and nasopharyngeal swab assessed by RT-PCR for SARS-CoV-2 virus. This study will be performed in five centers affiliated to Mashhad University of Medical Sciences, Mashhad, Iran.

MAIN OUTCOMES

The primary end point of this study is to investigate the incidence of COVID-19 in patients being treated for their cancer and receiving prophylactic Hydroxychloroquine.

RANDOMIZATION

Randomization will be performed using random permuted blocks. By using online website ( www.randomization.com ), the randomization sequence will be produced by quadruple blocks. The allocation ratio in intervention and control groups is 1:1.

BLINDING (MASKING)

Participants and caregivers do not know whether the patient is in the intervention or the control group. Those assessing the outcomes and data analyzer are also blinded to group assignment.

SAMPLE SIZE

The calculated total sample size is 60 patients, with 30 patients in each group.

No longer a historical ailment: two cases of childhood scurvy with recommendations for bone health providers

PURPOSE

Scurvy, due to vitamin C deficiency, is commonly referenced as a "forgotten" or "historical" disease. A growing number of case reports challenge this notion. Bone health providers are often consulted early in the presentation of scurvy to evaluate musculoskeletal complaints resulting from impaired collagen production and disrupted endochondral bone formation. In this report, we describe two cases of childhood scurvy. Our objective is to summarize the key features of scurvy for bone health providers, with the goal of raising awareness and facilitating diagnosis in future cases.

CASE DESCRIPTIONS

Case one occurred in a 12-year-old non-verbal, non-ambulatory female on a ketogenic diet for refractory epilepsy. Clinical findings included hemarthrosis, transfusion dependent anemia, elevated inflammatory markers, and epiphysiolysis. Magnetic resonance imaging (MRI) revealed multi-focal bone marrow signal abnormalities and physeal irregularities. Case two occurred in a typically developing 5-year-old male presenting with limp and knee pain. Symptoms progressed despite casting and immobilization. Mild anemia, elevated inflammatory markers, and multi-focal marrow and physeal MRI abnormalities were identified. Subsequent dietary history revealed total absence of fruit or vegetable consumption. The diagnosis of scurvy was confirmed in both cases by undetectable plasma vitamin C concentrations. Treatment with vitamin C led to rapid clinical improvement.

CONCLUSION

Scurvy can no longer be considered a historical diagnosis and should not be forgotten when evaluating children with musculoskeletal ailments. Early recognition of the signs, symptoms, and imaging findings of scurvy can reduce the clinical burden of this disease with the timely initiation of vitamin C therapy.

Anisakis pegreffii impacts differentiation and function of human dendritic cells

Human dendritic cells (DCs) show remarkable phenotypic changes when matured in the presence of helminth-derived products. These modifications frequently elicited a polarization towards Th2 cells and regulatory T cells thus contributing to immunological tolerance against these pathogens. In this study, the interaction between DCs and larvae of the zoonotic anisakid nematode Anisakis pegreffii was investigated. A. pegreffii larvae were collected from fish hosts, and monocyte-derived DCs were cocultured in the presence of the live larvae (L) or its crude extracts (CE). In both experimental conditions, A. pegreffii impacted DC viability, hampered DC maturation by reducing the expression of molecules involved in antigen presentation and migration (ie HLA-DR, CD86, CD83 and CCR7), increased the phagosomal radical oxygen species (ROS) levels and modulated the phosphorylation of ERK1,2 pathway. These biological changes were accompanied by the impairment of DCs to activate a T-cell-mediated IFNγ. Interestingly, live larvae appeared to differently modulate DC secretion of cytokines and chemokines as compared to CE. These results demonstrate, for the first time, the immunomodulatory role of A. pegreffii on DCs biology and functions. In addition, they suggest a dynamic contribution of DCs to the induction and maintenance of the inflammatory response against A. pegreffii.

Successful embolization of a enterocutaneous fistula tract with Onyx 34 following low anterior resection for rectal cancer

Enterocutaneous fistulas (ECFs) can be one of the complications found after surgical intervention for rectal cancer. Interventional modalities consisting of surgical, endoscopic, and radiological methods are often implemented to treat postoperative symptomatic complications. We present the case of 61-year-old Caucasian man who presented to us with a recent diagnosis of rectal cancer that had invaded the levators as well as anteriorly into the prostate, and who underwent low anterior resection with a diverting loop ileostomy. The patient was found to have a persistent presacral abscess due to an ECF tract. This case highlights the off-label use of ethylene-vinyl alcohol copolymer dissolved in dimethyl sulfoxide (Onyx 34) to seal an ECF.

Evaluation of PCR-reverse line blot hybridization assay for simultaneous identification of medically important saprophytic fungi

BACKGROUND

In immunocompromised patients suffering from invasive fungal infections, rapid identification of fungal species is important since the appropriate treatment is usually related to the responsible species. We describe here, an assay based on combination of PCR and reverse line blot hybridization (PCR/RLB) for differentiation causative agent of fungal infections.

MATERIALS AND METHODS

We performed PCR/RLB assay on 10 reference strains, which include Aspergillus species (A. fumigatus, A. flavus, A. niger, A. terreus, and A. clavatus), Mucor circnelloides, Rhizopus oryzae, Alternaria alternata, Cladosporium herbarum, and Fusarium solani. Besides, twenty-two clinical specimens from patients with proven fungal infections were analyzed for the identification of species. The obtained results were then compared with the results of culture and sequence analysis.

RESULTS

The fungal species-specific oligonucleotide probes were able to distinguish between all species represented in this study with the exception of cross-reactivity between A. niger and A. fumigatus species. Two specimens, which were represented as mixed fungi in culture, were identified properly by this method. Results of the RLB assay were concordant with the culture and ITS sequencing results.

CONCLUSION

Our result demonstrate that the RLB assay potentially is suitable for rapid and simultaneous identification of variety fungal pathogens directly from culture as well as from clinical specimens.

A structural model of the anaphase promoting complex co-activator (Cdh1) and in silico design of inhibitory compounds

Anaphase promoting complex (APC) controls cell cycle and chromosome segregation. The APC activation occurs after binding of co-activators, cdh1 and cdc20. Cdh1 plays a role in cancer pathogenesis and is known as a potential drug target. The main aim of this study was prediction of 3D structure of cdh1 and designing the inhibitory compounds based on the structural model. First, 3D structure of cdh1 was predicted by means of homology modelling and molecular dynamics tools, MODELLER and Gromacs package, respectively. Then, inhibitory compounds were designed using virtual screening and molecular docking by means AutoDock package. The overall structure of cdh1 is propeller like and each DW40 repeat contains four anti-parallel beta-sheets. Moreover, binding pocket of the inhibitory compounds was determined. The results might be helpful in finding a suitable cdh1 inhibitor for the treatment of cancer.

Past, present and future strategies of immunotherapy in gynecological malignancies

Recently, the combining of different drugs has greatly improved response and survival rates in gynecological malignancies. Results are however far from being satisfactory. Treatments used in case of advanced or recurrent disease offer limited results in terms of long-term responses. The urgent need for new and more effective treatments has prompted researchers to investigate and propose new therapeutic strategies. One of the most interesting approaches that are being explored is constituted by immunotherapy. Currently, immunotherapeutic strategies include vaccination with peptide, viral vectors, carbohydrates and antiidiotypic antibodies. In addition, cell based immunotherapy has been adopted in vitro activated lymphocytes and dendritic cells. Most experience has been acquired in ovarian cancer and cervical cancer. Little has been investigated in endometrial and rare gynecologic neoplasms.The clinical experiences and results achieved with immunotherapy in this setting of patients have been reviewed and the future avenues that are currently being explored have also been discussed.

Aberrant regulation of the integrin very late antigen-4 in systemic lupus erythematosus

Integrin very late antigen-4 (VLA4) is induced during inflammation and can regulate monocyte migration. It has been implicated in atherogenesis, a significant concern in systemic lupus erythematosus (SLE). The aim of this study was to define VLA4 expression in SLE monocytes. Flow cytometry, reverse transcription polymerase chain reaction, Western blotting, and immunohistochemistry staining with confocal microscopy were used to evaluate VLA4 expression in SLE patients and controls. We found elevated expression of VLA4 in SLE patients with significantly increased VLA4 staining intracellularly compared to control. Exposure of control monocytes to SLE sera or immune complexes led to increased intracellular expression, and immune complexes were capable of driving redistribution of surface VLA4 to the cytoplasm. Therefore, VLA4 was found to be subject to complex regulation with SLE sera driving both RNA expression and redistribution of protein. Stimulation of SLE monocytes with a VLA4 ligand induced significant TNFα expression, confirming a functional effect. This behavior may contribute to increased atherosclerosis and monocyte infiltrates in end organs.

Spry1 and spry2 are essential for development of the temporomandibular joint

The temporomandibular joint (TMJ) is a specialized synovial joint essential for the function of the mammalian jaw. The main components of the TMJ are the mandibular condyle, the glenoid fossa of the temporal bone, and a fibrocartilagenous disc interposed between them. The genetic program for the development of the TMJ remains poorly understood. Here we show the crucial role of sprouty (Spry) genes in TMJ development. Sprouty genes encode intracellular inhibitors of receptor tyrosine kinase (RTK) signaling pathways, including those triggered by fibroblast growth factors (Fgfs). Using in situ hybridization, we show that Spry1 and Spry2 are highly expressed in muscles attached to the TMJ, including the lateral pterygoid and temporalis muscles. The combined inactivation of Spry1 and Spry2 results in overgrowth of these muscles, which disrupts normal development of the glenoid fossa. Remarkably, condyle and disc formation are not affected in these mutants, demonstrating that the glenoid fossa is not required for development of these structures. Our findings demonstrate the importance of regulated RTK signaling during TMJ development and suggest multiple skeletal origins for the fossa. Notably, our work provides the evidence that the TMJ condyle and disc develop independently of the mandibular fossa.

Lipoid Proteinosis in two Iranian Sisters: A Case Report and Review of Literature

Lipoid proteinosis is a rare autosomal recessive disorder which may be seen within a family very occasionally. Herein, we report lipoid proteinosis in two sisters characterized by verrucous lesions and hoarseness of voice, dysphagia and multiple beaded papules along the margins of their eyelids, fissured lips and thick ferenulum.

Performance of antigen B isolated from different hosts and cyst locations in diagnosis of cystic echinococcosis

BACKGROUND

The aim of this study was to assess the performance of Antigen B (AgB) isolated from different Echinococcusgranulosus intermediate hosts and from different cyst locations for immunodiagnosis of human cystic echinococcosis (CE).

METHODS

Hydatid cyst fluids were collected from lung and liver cysts of sheep, liver cysts of goats, lung cysts of camels and cattle, and liver cysts of human. AgB was purified from each of these hydatid cysts fluids. Serum samples obtained from 47 pathologically confirmed cases of CE along with 30 sera samples from non-CE patients and 40 sera from healthy individuals were tested by ELISA using AgB prepared from different hosts or cyst locations.

RESULTS

The highest sensitivity (97.8%) for diagnosis of CE was seen with AgB prepared from human liver cysts. This maximal sensitivity was followed by AgB isolated from those of sheep liver and lung cysts. The least sensitivity was found with AgB prepared from bovine lung cysts. The highest specificities (97.1%) were observed with AgB isolated from human liver cysts followed by those of sheep and goat liver cysts while the lowest specificity was seen with AgB isolated from bovine lung cysts. In view of the specificities and sensitivities of the different AgB, the best validity was found for AgB prepared from human liver cysts while the least validity was found with AgB prepared from bovine lung cysts.

CONCLUSION

For any AgB-based tests, obtaining of the antigen from one of these sources will significantly increase the diagnostic sensitivity and specificity of the assay.

Habitat characterization and mapping of Anopheles maculatus (Theobald) mosquito larvae in malaria endemic areas in Kuala Lipis, Pahang, Malaysia

In Peninsular Malaysia, a large proportion of malaria cases occur in the central mountainous and forested parts of the country. As part of a study to assess remote sensing data as a tool for vector mapping, we conducted entomological surveys to determine the type of mosquitoes, their characteristics and the abundance of habitats of the vector Anopheles maculatus in malaria endemic areas in Pos Senderot. An. maculatus mosquitoes were collected from 49 breeding sites in Pos Senderot. An. maculatus preferred to breed in water pockets formed on the bank of rivers and waterfalls. The most common larval habitats were shallow pools 5.0-15.0 cm deep with clear water, mud substrate and plants or floatage. The mosquito also preferred open or partially shaded habitats. Breeding habitats were generally located at 100-400 m from the nearest human settlement. Changes in breeding characteristics were also observed. Instead of breeding in slow flowing streams, most larvae bred in small water pockets along the river margin.

Immunogenicity of allo-vesicle carrying ERBB2 tumor antigen for dendritic cell-based anti-tumor immunotherapy

Dendritic cells (DCs) are able to orchestrate innate and acquired immunity and can activate and sustain a long-lasting anti-tumor immune response in vivo when used as anti-tumor cell therapy. The selection of the antigen and the choice of its formulation are key points in designing anti-cancer DC-based vaccines. Cell released vesicles/exosomes have been shown to transfer antigens, HLAI/peptide complexes and co-stimulatory molecules to recipient cells. In this study we describe the generation of an allogenic microvesicle cell factory in which the expression of a specific tumor antigen was combined to the expression of co-stimulatory and allogeneic molecules. The DG75 lymphoblastoid cell line was selected as microvesicle producer and transfected with ErbB2, as tumor antigen prototype. The shed microvesicles transferred antigenic components to recipient DCs, increasing their immunogenicity. DC pulsing resulted in cross-presentation of ErbB2 both in HLAI and HLAII compartments, and ErbB2-specific CD8+ T cells from cancer patients were activated by DCs pulsed with vesicle-bound ErbB2. The microvesicle cell factory proposed may represent a source of cell free immunogen to be used for DC-based cancer therapy.

Dietary betaine affect duodenal histology of broilers challenged with a mixed coccidial infection

The purpose of this research was to investigate effect of dietary betaine on intestinal morphology after an experimental coccidiosis. Hence a total of 189 male and female broiler chicks were randomly assigned to 9 floor cages. Chicks were fed a basal diet supplemented with 0, 0.6 or 1.2 g kg(-1) betaine. All birds were inoculated orally with Eimeria oocysts on day 28. Duodenal morphology parameters and lesions were scored by microscopic observation on intestine samples which were taken at day 42 of age. Adding 1.2 g kg(-1) betaine to diet diminished intestinal lesions (p < 0.05). Dietary supplementation with 0.6 or 1.2 g kg(-1) betaine significantly (p < 0.01) increased intraepithelial lymphocytes as well. Level of additive betaine had no effect on the ratio of villus height/crypt depth or villus surface area. Lamina propria of duodenum became thicker in the intestine of chickens which received more supplemental betaine via their diet. In conclusion, since the number of intraepithelial lymphocytes and thickness of lamina propria represent the condition of gut immune response, it seems that dietary betaine may immunomodulate the gastrointestinal tract of broilers. In addition, betaine effect on villus morphology measured later in life differed from what had been measured already earlier in life of the chicks.

Boosting effect of bisphosphonates on osteoconductive materials: a histologic in vivo evaluation

BACKGROUND AND OBJECTIVE

The effect on bone regeneration, of adding pamidronate disodium to bovine-derived hydroxyapatite, was histologically evaluated, using the sheep bone model.

MATERIAL AND METHODS

Twenty-four intrabony defects were prepared in the lower jaw of eight sheep using trephine 6 mm burs. One cavity was left unfilled and the other two were filled with bovine-derived hydroxyapatite (BioOss) alone (control group) or with bovine-derived hydroxyapatite mixed with pamidronate disodium (Aredia) (case group), respectively. After 6 wk, the animals were killed and the coded samples observed using an optical microscope. The percentage of regenerated bone, number of osteoclasts and amount of inflammation was recorded. Statistical analysis was carried out using chi-square and Mann-Whitney U-tests.

RESULTS

The results manifested a significant difference in the amount of bone formation, with the most being observed in the case group and the least in the negative-control group (p<0.001). Significantly fewer osteoclasts were observed in the case group than in the other groups (p<0.001). The amount of inflammation did not seem to differ within the case and control groups (p>0.05).

CONCLUSION

Adding pamidronate disodium to bovine-derived hydroxyapatite improves its osteoconductive and regenerative specifications. Further study should determine the systemic effects of a single local administration of these drugs, and their appropriate dose and type, with minimal risk.

[An unusual cause of hemoptysis: a leech]

We report an exceptional case of hemoptysis observed in a 38-year-old woman with an uneventful past history. Bronchial fibroscopy demonstrated the presence of a leech attached to the laryngeal orifice. This condition is common in endemic areas but is underdiagnosed. The association of hemoptysis, voice alterations, and difficult respiration are suggestive signs. Extraction should be achieved rapidly to avoid death due to acute respiratory failure.

Modulation of blood circulating immune cells by radiofrequency tumor ablation

Tumor ablation by radiofrequency (RFA) is an appealing therapeutical strategy for the treatment of liver tumors (hepatocarcinoma and metastatic lesions) to be used as valid alternative to the surgical resection that often is appropriate and feasible in only a minority of patients. RFA induces the localised and controlled disruption of the tumor by heating the tissue causing its coagulative necrosis. Such therapy results as a pathogenic "noxa" for the body, inducing a strong inflammatory response. We wanted to ascertain whether the inflammatory response induced by RFA was similar in patients with hepatocarcinoma and in patients with liver metastasis. We considered body temperature, leucocyte counts at different time points as inflammatory parameters. We observed that RFA treatment produced the inflammatory systemic effects as expected (fever, increase of neutrophils) only in the patients with liver metastasis, while no such effect could be seen in the HCC patients. On the other hand the circulating monocytes increased after RFA in both groups of patients. These preliminary results suggest that RFA tratment can exert different effects on the immune system depending the etiopathogenesis of the treated neoplastic liver lesions.

Transfected human dendritic cells to induce antitumor immunity

Dendritic cells are professional antigen-presenting cells able to prime naive T lymphocytes and regulate steadily the delicate balance between tolerance and activation during the immune response. In past years several reports have shown that genetically engineered dendritic cells (DCs) can be a powerful tool for inducing an antigen-specific immune response. The use of such modified antigen-presenting cells is a real working hypothesis in preclinical studies and in clinical vaccination approaches for cancer treatment. The definition of optimal transfection conditions for preserving DC survival and functionality is necessary to design a correct immunotherapeutic protocol. Different lipid-based transfection compounds were studied for their effects on DC survival, phenotype and functional properties. All the transfection procedures were able to select DCs with a higher expression of activation and costimulatory molecules (ie MHCII-DR, CD83, CD86, CD25) than the untreated DCs. However, only two compounds (LipofectAMINE PLUS and FuGENE 6), preserved or even increased the immunopotency of DCs as antigen-presenting cells. These protocols were applied to modify DCs in order to express an epithelial tumor-associated antigen, MUC1, and such cells were able to induce in vitro a specific immune response in healthy donors.

Human antibodies against the polymorphic epithelial mucin in ovarian cancer patients recognise a novel sequence in the tandem repeat region

The humoral immune response to the polymorphic epithelial mucin (PEM) was studied by characterising the reactivity of human antibodies generated by EBV-immortalised B-cells from tumour-draining lymph nodes of ovarian cancer patients. All the human antibodies, selected in ELISA for their reactivity to the protein tandem core repeat sequence, reacted with PEM-expressing tumour cells. Aberrant glycosylation of the peptide core of the PEM molecule in cancer cells leads to the exposure of peptide epitopes that can be considered tumour specific. The epitope mapping of six human antibodies revealed that only one of them contained the PDTR sequence, shown to be the immunodominant epitope in the mouse. Four of the six human antibodies recognised a novel common immunogenic sequence (APPAH) in the tandem repeats. The binding of these human antibodies did not appear to be modulated by the length of the carbohydrate side chains, as shown by O-glycosylation inhibition studies. These results indicate that distinct sequences within the tandem repeat of PEM are target for a humoral immune response in humans. The presence of antibodies directed against different epitopes within the same antigenic region may modulate the antigen presentation process and the ongoing immune response. This data may help in clarifying the mechanisms of the immune response to PEM in cancer patients for the development of PEM-based immunotherapy.

[Rare location of an epidermoid cyst in the forefoot region with nerve compression syndrome. Contribution to the differential diagnosis of Morton's metatarsalgia (author's transl)]

The case of a rare location of an epiderman cyst in the forefoor region is reported. Very intense pain on pressure or tension in the plantar region of the second and third metatarsals suggested a metatarsalgia and the existing diffuse swelling a synovitis. Surgical revision revealed an epidermoid cyst the size of a hazelnut which pressed the N. digitalis plantaris communis against the head of the third metartarsal.