Limited Evidence of Shared Decision Making for Prostate Cancer Screening in Audio-Recorded Primary Care Visits Among Black Men and their Healthcare Providers.

Prostate-specific antigen (PSA)-based prostate cancer screening is a preference-sensitive decision for which experts recommend a shared decision making (SDM) approach. This study aimed to examine PSA screening SDM in primary care. Methods included qualitative analysis of audio-recorded patient-provider interactions supplemented by quantitative description. Participants included 5 clinic providers and 13 patients who were: (1) 40-69 years old, (2) Black, (3) male, and (4) attending clinic for routine primary care. Main measures were SDM element themes and "observing patient involvement in decision making" (OPTION) scoring. Some discussions addressed advantages, disadvantages, and/or scientific uncertainty of screening, however, few patients received all SDM elements. Nearly all providers recommended screening, however, only 3 patients were directly asked about screening preferences. Few patients were asked about prostate cancer knowledge (2), urological symptoms (3), or family history (6). Most providers discussed disadvantages (80%) and advantages (80%) of PSA screening. Average OPTION score was 25/100 (range 0-67) per provider. Our study found limited SDM during PSA screening consultations. The counseling that did take place utilized components of SDM but inconsistently and incompletely. We must improve SDM for PSA screening for diverse patient populations to promote health equity. This study highlights the need to improve SDM for PSA screening.

Comparison of diabetic retinopathy severity grading on ETDRS 7-field versus ultrawide-field assessment.

OBJECTIVES: To compare the diabetic retinopathy (DR) severity level determined when considering only the ETDRS 7-field region versus the entire ultrawidefield (UWF) image. METHODS: In this retrospective, cross-sectional study, UWF pseudocolor images were graded on the Eyenuk image viewing, grading, and annotation platform for the severity of DR considering only the regions within the ETDRS 7-fields as well as the entire UWF image using two different protocols: 1) the simple International Classification of Diabetic Retinopathy (ICDR) scale and 2) the more complex DRCR.net Protocol AA grading scale. RESULTS: A total of 250 eyes from 157 patients were included in this analysis. Six eyes (2.4%) demonstrated a discrepancy in severity level between the ETDRS 7-field region and the entire UWF image when using the ICDR classification system. The discrepancies were due to the presence of lesions [intraretinal haemorrhage (n = 2), neovascular disease (n = 4)] in the peripheral fields which were not identified in the ETDRS 7-fields. Fourteen eyes (5.6%) had a discrepancy in severity level between the ETDRS 7-field region and the entire UWF image when using the ETDRS DRSS Protocol AA grading scale. The discrepancies were due to the presence of a higher level of disease [intraretinal haemorrhage (n = 4), neovascularization (n = 4), preretinal haemorrhage (n = 2), scatter laser scars (n = 4)] in the peripheral fields. CONCLUSION: Although considering regions outside of the ETDRS 7-fields altered the DR severity level assessment in <5% of cases in this cohort, significant and potentially vision-threatening lesions including neovascularization and preretinal haemorrhage were identified in these peripheral regions. This highlights the importance of evaluating the entire UWF region when assessing patients with diabetic retinopathy.

Clinical Trial Protocol for a Randomized Trial of Community Health Worker-led Decision Coaching to Promote Shared Decision-making on Prostate Cancer Screening Among Black Male Patients and Their Providers.

We propose a randomized controlled trial to evaluate the effectiveness of a community health worker-led decision-coaching program to facilitate shared decision-making for prostate cancer screening decisions by Black men at a primary care federally qualified health center.

Comparison of automated and expert human grading of diabetic retinopathy using smartphone-based retinal photography.

PURPOSE: The aim of this study is to investigate the efficacy of a mobile platform that combines smartphone-based retinal imaging with automated grading for determining the presence of referral-warranted diabetic retinopathy (RWDR). METHODS: A smartphone-based camera (RetinaScope) was used by non-ophthalmic personnel to image the retina of patients with diabetes. Images were analyzed with the Eyenuk EyeArt® system, which generated referral recommendations based on presence of diabetic retinopathy (DR) and/or markers for clinically significant macular oedema. Images were independently evaluated by two masked readers and categorized as refer/no refer. The accuracies of the graders and automated interpretation were determined by comparing results to gold standard clinical diagnoses. RESULTS: A total of 119 eyes from 69 patients were included. RWDR was present in 88 eyes (73.9%) and in 54 patients (78.3%). At the patient-level, automated interpretation had a sensitivity of 87.0% and specificity of 78.6%; grader 1 had a sensitivity of 96.3% and specificity of 42.9%; grader 2 had a sensitivity of 92.5% and specificity of 50.0%. At the eye-level, automated interpretation had a sensitivity of 77.8% and specificity of 71.5%; grader 1 had a sensitivity of 94.0% and specificity of 52.2%; grader 2 had a sensitivity of 89.5% and specificity of 66.9%. DISCUSSION: Retinal photography with RetinaScope combined with automated interpretation by EyeArt achieved a lower sensitivity but higher specificity than trained expert graders. Feasibility testing was performed using non-ophthalmic personnel in a retina clinic with high disease burden. Additional studies are needed to assess efficacy of screening diabetic patients from general population.

The Value of Automated Diabetic Retinopathy Screening with the EyeArt System: A Study of More Than 100,000 Consecutive Encounters from People with Diabetes.

Background: Current manual diabetic retinopathy (DR) screening using eye care experts cannot scale to screen the growing population of diabetes patients who are at risk for vision loss. EyeArt system is an automated, cloud-based artificial intelligence (AI) eye screening technology designed to easily detect referral-warranted DR immediately through automated analysis of patient's retinal images. Methods: This retrospective study assessed the diagnostic efficacy of the EyeArt system v2.0 analyzing 850,908 fundus images from 101,710 consecutive patient visits, collected from 404 primary care clinics. Presence or absence of referral-warranted DR (more than mild nonproliferative DR [NPDR]) was automatically detected by the EyeArt system for each patient encounter, and its performance was compared against a clinical reference standard of quality-assured grading by rigorously trained certified ophthalmologists and optometrists. Results: Of the 101,710 visits, 75.7% were nonreferable, 19.3% were referable to an eye care specialist, and in 5.0%, the DR level was unknown as per the clinical reference standard. EyeArt screening had 91.3% (95% confidence interval [CI]: 90.9-91.7) sensitivity and 91.1% (95% CI: 90.9-91.3) specificity. For 5446 encounters with potentially treatable DR (more than moderate NPDR and/or diabetic macular edema), the system provided a positive "refer" output to 5363 encounters achieving sensitivity of 98.5%. Conclusions: This study captures variations in real-world clinical practice and shows that an AI DR screening system can be safe and effective in the real world. This study demonstrates the value of this easy-to-use, automated tool for endocrinologists, diabetologists, and general practitioners to address the growing need for DR screening and monitoring.

Automated detection of diabetic retinopathy lesions on ultrawidefield pseudocolour images.

PURPOSE: We examined the sensitivity and specificity of an automated algorithm for detecting referral-warranted diabetic retinopathy (DR) on Optos ultrawidefield (UWF) pseudocolour images. METHODS: Patients with diabetes were recruited for UWF imaging. A total of 383 subjects (754 eyes) were enrolled. Nonproliferative DR graded to be moderate or higher on the 5-level International Clinical Diabetic Retinopathy (ICDR) severity scale was considered as grounds for referral. The software automatically detected DR lesions using the previously trained classifiers and classified each image in the test set as referral-warranted or not warranted. Sensitivity, specificity and the area under the receiver operating curve (AUROC) of the algorithm were computed. RESULTS: The automated algorithm achieved a 91.7%/90.3% sensitivity (95% CI 90.1-93.9/80.4-89.4) with a 50.0%/53.6% specificity (95% CI 31.7-72.8/36.5-71.4) for detecting referral-warranted retinopathy at the patient/eye levels, respectively; the AUROC was 0.873/0.851 (95% CI 0.819-0.922/0.804-0.894). CONCLUSION: Diabetic retinopathy (DR) lesions were detected from Optos pseudocolour UWF images using an automated algorithm. Images were classified as referral-warranted DR with a high degree of sensitivity and moderate specificity. Automated analysis of UWF images could be of value in DR screening programmes and could allow for more complete and accurate disease staging.

Automated Diabetic Retinopathy Screening and Monitoring Using Retinal Fundus Image Analysis.

BACKGROUND: Diabetic retinopathy (DR)-a common complication of diabetes-is the leading cause of vision loss among the working-age population in the western world. DR is largely asymptomatic, but if detected at early stages the progression to vision loss can be significantly slowed. With the increasing diabetic population there is an urgent need for automated DR screening and monitoring. To address this growing need, in this article we discuss an automated DR screening tool and extend it for automated estimation of microaneurysm (MA) turnover, a potential biomarker for DR risk. METHODS: The DR screening tool automatically analyzes color retinal fundus images from a patient encounter for the various DR pathologies and collates the information from all the images belonging to a patient encounter to generate a patient-level screening recommendation. The MA turnover estimation tool aligns retinal images from multiple encounters of a patient, localizes MAs, and performs MA dynamics analysis to evaluate new, persistent, and disappeared lesion maps and estimate MA turnover rates. RESULTS: The DR screening tool achieves 90% sensitivity at 63.2% specificity on a data set of 40 542 images from 5084 patient encounters obtained from the EyePACS telescreening system. On a subset of 7 longitudinal pairs the MA turnover estimation tool identifies new and disappeared MAs with 100% sensitivity and average false positives of 0.43 and 1.6 respectively. CONCLUSIONS: The presented automated tools have the potential to address the growing need for DR screening and monitoring, thereby saving vision of millions of diabetic patients worldwide.

Pulse propagation by a capacitive mechanism drives embryonic blood flow.

Pulsatile flow is a universal feature of the blood circulatory system in vertebrates and can lead to diseases when abnormal. In the embryo, blood flow forces stimulate vessel remodeling and stem cell proliferation. At these early stages, when vessels lack muscle cells, the heart is valveless and the Reynolds number (Re) is low, few details are available regarding the mechanisms controlling pulses propagation in the developing vascular network. Making use of the recent advances in optical-tweezing flow probing approaches, fast imaging and elastic-network viscous flow modeling, we investigated the blood-flow mechanics in the zebrafish main artery and show how it modifies the heart pumping input to the network. The movement of blood cells in the embryonic artery suggests that elasticity of the network is an essential factor mediating the flow. Based on these observations, we propose a model for embryonic blood flow where arteries act like a capacitor in a way that reduces heart effort. These results demonstrate that biomechanics is key in controlling early flow propagation and argue that intravascular elasticity has a role in determining embryonic vascular function.

4D reconstruction of the beating embryonic heart from two orthogonal sets of parallel optical coherence tomography slice-sequences.

Current methods to build dynamic optical coherence tomography (OCT) volumes of the beating embryonic heart involve synchronization of 2D+time slice-sequences acquired over separate heartbeats. Temporal registration of these sequences is performed either through gating or postprocessing. While synchronization algorithms that exclusively rely on image- intrinsic signals allow forgoing external gating hardware, they are prone to error accumulation, require operator-supervised correction, or lead to nonisotropic resolution. Here, we propose an image-based, retrospective reconstruction technique that uses two sets of parallel 2D+T slice-sequences, acquired perpendicularly to each other, to yield accurate and automatic reconstructions with isotropic resolution. The method utilizes the similarity of the data at the slice intersections to spatio-temporally register the two sets of slice sequences and fuse them into a high-resolution 4D volume. We characterize our method by using 1) simulated heart phantom datasets and 2) OCT datasets acquired from the beating heart of live cultured E9.5 mouse and E10.5 rat embryos. We demonstrate that while our method requires greater acquisition and reconstruction time compared to methods that use slices from a single direction, it produces more accurate and self-validating reconstructions since each set of reconstructed slices acts as a reference for the slices in the perpendicular set.

Motion-based structure separation for label-free, high-speed, 3D cardiac microscopy.

Capturing the dynamics of individual structures in the embryonic heart is an essential step for studying its function and development. Label-free brightfield (BF) microscopy allows for higher acquisition frame-rates than techniques requiring molecular labeling, without interfering with embryo viability or needing complex equipment. However, since different structures contribute similarly to image contrast, label-free microscopy lacks specificity. Here we mitigate this problem by separating a single-channel image series into multiple channels specific to different cardio-vascular structures, based only on their motion patterns. The technique combines images from multiple cardiac cycles and z-sections after non-uniform temporal registration to produce 3D+time image volumes of one full cardiac cycle with separate channels for static, transient and periodically moving structures. The resulting data is well-suited for velocity analysis and 3D-visualization. We characterize the separating capabilities of our technique on a synthetic cardiac dataset and demonstrate its practical applicability, by reconstructing three-channel views of the beating embryonic zebrafish heart with an effective frame rate of 1000 volumes (256×256×20 voxels each) per second. This technique enables quantitative characterization of dynamic heart function during cardiogenesis.

Pancreaticojejunostomy in proximal pancreatic transection: A viable option.

Complete pancreatic transection following blunt abdominal trauma is not a common injury. Distal pancreatectomy with or without splenectomy is routinely performed if the transection is to the left of the superior mesenteric vessels. We performed pancreaticojejunostomy on a six-year-old female patient who presented with complete transection at the pancreatic neck following blunt abdominal trauma. The aim was to preserve the pancreatic parenchyma and the spleen and assess the feasibility of the procedure. The patient has been followed for more than one year and is doing well. We conclude that the procedure should be considered in proximal pancreatic transection, particularly in the pediatric age group.

A coaxial thermocouple for shock tunnel applications.

A chromel-constantan coaxial surface junction thermocouple has been designed, fabricated, calibrated, and tested to measure the temperature-time history on the surface of a body in a hypersonic freestream of Mach 8 in a shock tunnel. The coaxial thermocouple with a diameter of 3.25 mm was flush mounted in the surface of a hemisphere of 25 mm diameter. The hypersonic freestream was of a very low temperature and density, and had a flow time of about a millisecond. Preliminary test results indicate that the thermocouple is quite sensitive to low temperature-rarefied freestreams, and also has a response time of a few microseconds (≈5 µs) to meet the requirements of short duration transient measurements. The sensor developed is accurate, robust, reproducible, and is highly inexpensive.

Spontaneous perforation of rectum with evisceration of small bowel simulating intussusception.

CONTEXT: Spontaneous perforation of rectum is a rare event; however evisceration of the small bowel through the perforated site without predisposing factors is extremely rare, complex and worth reporting. CASE REPORT: A 14 years old presented to us apparently as a case of intussception. The operative findings revealed it to be a case of spontaneous perforation of rectum with evisceration of the small bowel through the perforation. CONCLUSION: Sudden increase in the intra-abdominal pressure leads to the perforation in the chronically deranged rectal wall and pushes the small bowel loops into the pelvis and through the perforated rectum to appear transanally.

Multiple-cardiac-cycle noise reduction in dynamic optical coherence tomography of the embryonic heart and vasculature.

Recent progress in optical coherence tomography (OCT) allows imaging dynamic structures and fluid flow within scattering tissue, such as the beating heart and blood flow in mouse embryos. Accurate representation and analysis of these dynamic behaviors require reducing the noise of the acquired data. Although noise can be reduced by averaging multiple neighboring pixels in space or time, such operations reduce the effective spatial or temporal resolution that can be achieved. We have developed a computational postprocessing technique to restore image sequences of cyclically moving structures that preserves frame rate and spatial resolution. The signal-to-noise ratio (SNR) is improved by combining images from multiple cycles that have been synchronized with a temporally elastic registration procedure. Here we show how this technique can be applied to OCT images of the circulatory system in cultured mouse embryos. Our technique significantly improves the SNR while preserving temporal and spatial resolution.

Contrast-enhanced MRI of the liver with mangafodipir trisodium: imaging technique and results.

Magnetic resonance (MR) contrast agents are now routinely used for detecting and characterizing focal liver lesions. Liver specific, hepatobiliary, MRI contrast agent mangafodipir trisodium (Mn-DPDP) is taken up by the functioning hepatocytes and excreted by the biliary system. Contrast uptake leads to persistent elevation of T1-weighted signal of normal liver parenchyma within 10 minutes of injection. Most tumors of non-hepatocellular origin typically are hypointense relative to enhanced liver parenchyma on T1 weighted images and are more conspicuous than on unenhanced images. Whereas, tumors of hepatocellular origin such as focal nodular hyperplasia (FNH), adenoma, and well-differentiated hepatocellular carcinomas (HCC) have been shown to accumulate Mn-DPDP, providing characterization information to discriminate hepatocellular from non-hepatocellular tumors. The purpose of this pictorial essay is to illustrate the appearance of various liver tumors on mangafodipir enhanced liver MR imaging.

Multimodality diagnosis of liver tumors: feature analysis with CT, liver-specific and contrast-enhanced MR, and a computer model.

RATIONALE AND OBJECTIVES: The purpose of this study was to measure and to clarify the diagnostic contributions of image-based features in differentiating benign from malignant and hepatocyte-containing from non-hepatocyte-containing liver lesions. MATERIALS AND METHODS: Six experienced abdominal radiologists each read images from 146 cases (including a contrast material-enhanced computed tomographic [CT] scan and contrast-enhanced and unenhanced magnetic resonance [MR] images) following a checklist-questionnaire requiring them to rate quantitatively each of as many as 131 image features and then reported on each of the two differentiations. The diagnostic value of each feature was assessed, and linear discriminant analysis was used to develop statistical prediction rules (SPRs) for merging feature data into computerized "second opinions." For the two differentiations, accuracy (area under the receiver operating characteristic curve [Az]) was then determined for the radiologists' readings by themselves and for each of three SPRs. RESULTS: Thirty-seven candidate features had diagnostic value for each of the two differentiations (a slightly different feature set for each). Radiologists' performance at both differentiations was excellent (Az = 0.929 [benign vs malignant] and 0.926 [hepatocyte-containing vs non-hepatocyte-containing]). Performance of the SPR that operated on the features from all modalities together was better than that of radiologists (Az = 0.936 [benign vs malignant] and 0.951 [hepatocyte-containing vs non-hepatocyte-containing]), but this difference was of marginal statistical significance (P = .11). Contrast-enhanced MR imaging and contrast-enhanced CT each made significant adjunctive contributions to accuracy compared with unenhanced MR imaging alone. CONCLUSION: Many CT- and MR imaging-based features have diagnostic value in differentiating benign from malignant and hepatocyte-containing from non-hepatocyte-containing liver lesions. Radiologists could also benefit from the fully informed SPR's "second opinions."