The emergence of tumor-initiating cells in an advanced hypopharyngeal tumor model exhibits enhanced angiogenesis and nuclear factor erythroid 2-related factor 2 associated antioxidant effects.

Hypopharyngeal cancer (HPC) is associated with the worst prognosis of all head and neck cancers and is typically identified in an advanced stage at the time of diagnosis. While oxidative stress might contribute to the onset of HPC in patients using tobacco or alcohol, the extent of this influence and the characteristics of HPC cells in advanced stage remain to be investigated. In this study, we explored whether HPC cells survived from necrotic xenograft tumors at late stage would display increased tumor resistance along with altered tolerance to oxidative stress. The remnant living HPC cells isolated from a late-stage xenograft tumor, named FaDu Ex-vivo cells showed stronger chemo- and radio-resistance, tumorigenesis, and invasiveness compared to parental FaDu cells. FaDu Ex-vivo cells also displayed increased angiogenic ability after re-transplantation to mice visualized by in vivo near infrared-II (NIR-II) fluorescence imaging modality. Moreover, FaDu Ex-vivo cells exhibited significant tumor-initiating cells (TICs) related properties accompanied by a reduction of the level of reactive oxygen species (ROS), which was associated with up-regulation of transcription factor nuclear factor erythroid 2-related factor 2 (Nrf2). Interestingly, inhibition of Nrf2 by the RNA interference and the chemical inhibitor could reduce TICs related properties of FaDu Ex-vivo cells. Oxidative stress potentially initiates HPC, but elevation of Nrf2-associated antioxidant mechanisms would be essential to mitigate this effect for promoting and sustaining the stemness of HPC at the advanced stage. Current data suggest that the antioxidant potency of advanced HPC would be a therapeutic target for the design of adjuvant treatm.

Ultrabright Dibenzofluoran-Based Polymer Dots with NIR-IIa Emission Maxima and Unusual Large Stokes Shifts for 3D Rotational Stereo Imaging.

Emerging organic molecules with emissions in the second near-infrared (NIR-II) region are garnering significant attention. Unfortunately, achieving accountable organic emission intensity over the NIR-IIa (1300 nm) region faces challenges due to the intrinsic energy gap law. Up to the current stage, all reported organic NIR-IIa emitters belong to polymethine-based dyes with small Stokes shifts (<50 nm) and low quantum yield (QY; ≤0.015%). However, such polymethines have proved to cause self-absorption with constrained emission brightness, limiting advanced development in deep-tissue imaging. Here a new NIR-IIa scaffold based on rigid and highly conjugated dibenzofluoran core terminated by amino-containing moieties that reveal emission peaks of 1230-1305 nm is designed. The QY is at least 10 times higher than all synthesized or reported NIR-IIa polymethines with extraordinarily large Stokes shifts of 370-446 nm. DBF-BJ is further prepared as a polymer dot to demonstrate its in vivo 3D stereo imaging of mouse vasculature with a 1400 nm long-pass filter.

Development of an integrated dual-modality 3D bioluminescence tomography and ultrasound imaging system for small animal tumor imaging.

Ultrasound (US) is a valuable tool for imaging soft tissue and visualizing tumor contours. Taking the benefits of US, we presented an integrated dual-modality imaging system in this paper that achieves three-dimensional (3D) bioluminescence tomography (BLT) with multi-view bioluminescence images and 3D US imaging. The purpose of this system is to perform non-invasive, long-term monitoring of tumor growth in 3D images. US images can enhance the accuracy of the 3D BLT reconstruction and the bioluminescence dose within an object. Furthermore, an integrated co-registered scanning geometry was used to capture the fused BLT and US images. We validated the system with an in vivo experiment involving tumor-bearing mice. The results demonstrated the feasibility of reconstructing 3D BLT images in the tumor region using 3D US images. We used the dice coefficient and locational error to evaluate the similarity between the reconstructed source region and the actual source region. The dice coefficient was 88.5%, and the locational error was 0.4 mm when comparing the BLT and 3D US images. The hybrid BLT/US system could provide significant benefits for reconstructing the source of tumor location and conducting quantitative analysis of tumor size.

Development of a Direct Non-Puncture Device for Measuring Portal Venous Pressure during Liver Transplantation-A Swine Model.

Portal hypertension-related complications pose a significant risk for liver failure post-transplantation. Thus, accurate monitoring of intraoperative portal venous pressure (PVP) is crucial. However, current PVP monitoring techniques requiring direct percutaneous puncture carry the risk of graft damage. In this study, we present an innovative non-puncture PVP monitoring device (PVPMD) using a 3D-printed prototype. PVPMD design is inspired by the sphygmomanometer principle, and strategically encompasses the portal vein and enables precise PVP measurement through blood flow ultrasonography after temporary occlusion. By a series of mini-pig experiments, the prototype PVPMD demonstrated a strong correlation with invasive catheter measurements in the main trunk of the portal vein (rs = 0.923, p = 0.000). There was a significant repeatability and reproducibility between the prototype PVPMD- and invasive catheter-measured PVP. This indicates that the PVPMD holds immense potential for direct application in liver transplantation and surgery. Moreover, it has the potential to replace catheter-based central venous pressure (CVP) measurements, thereby mitigating catheter-related complications during many surgeries. In conclusion, our innovative device represents a significant advancement in PVP monitoring during liver transplantation, with comprehensive validation from principle exploration to successful animal experiments. We anticipate that this groundbreaking PVPMD will attract the attention of researchers and clinicians, propelling the noninvasive measurement of PVP or other venous/arterial pressures into a new era of clinical practice.

Diagnosis of Salivary Gland Tumors Using Transfer Learning with Fine-Tuning and Gradual Unfreezing.

Ultrasound is the primary tool for evaluating salivary gland tumors (SGTs); however, tumor diagnosis currently relies on subjective features. This study aimed to establish an objective ultrasound diagnostic method using deep learning. We collected 446 benign and 223 malignant SGT ultrasound images in the training/validation set and 119 benign and 44 malignant SGT ultrasound images in the testing set. We trained convolutional neural network (CNN) models from scratch and employed transfer learning (TL) with fine-tuning and gradual unfreezing to classify malignant and benign SGTs. The diagnostic performances of these models were compared. By utilizing the pretrained ResNet50V2 with fine-tuning and gradual unfreezing, we achieved a 5-fold average validation accuracy of 0.920. The diagnostic performance on the testing set demonstrated an accuracy of 89.0%, a sensitivity of 81.8%, a specificity of 91.6%, a positive predictive value of 78.3%, and a negative predictive value of 93.2%. This performance surpasses that of other models in our study. The corresponding Grad-CAM visualizations were also presented to provide explanations for the diagnosis. This study presents an effective and objective ultrasound method for distinguishing between malignant and benign SGTs, which could assist in preoperative evaluation.

The online interactive visual learning improves learning effectiveness and satisfaction of physicians with postgraduate year during the COVID-19 pandemic in Taiwan.

BACKGROUNDS: Medical education has shifted from passive forms of teaching to more active learning strategies, particularly in response to the COVID-19 pandemic. Research has discussed the challenges and disadvantages associated with online education, but there is limited documentation on physicians' perceptions of this sudden and unexpected transformation in medical education. This study aimed to determine the effect of online interactive visual learning on physicians' perceptions of the effectiveness and their satisfaction with this online learning experience. METHODS: We routinely recruited 64 unclassified physicians in the hospital's postgraduate year (PGY) program between September 2021 and April 2022. PGY physicians received an online interactive visual learning course. Online (Google Form) testing and questionnaires before and after this course evaluated learning performance, learning attitude and satisfaction of these physicians. RESULTS: The interactive online learning tools facilitated the physicians' active learning processes by reducing their learning burden (burden vs. no burden: 4.69% vs. 68.75%) and increasing their learning interest (interest vs. no interest: 84.38% vs. 3.12%) in the online format. Post-test scores were significantly improved compared with pretest scores (post-test vs. pre-test: 5 vs. 4; p < 0.05) and their imaging recognition was markedly improved from baseline (post-test vs. pre-test: 85.19% vs. 61.11%). Levels of satisfaction correlated positively with the physicians' learning burden (rs = 0.541), learning interest (rs = 0.562), and perceived benefits of imaging recognition (post-course: rs = 0.508; future: rs = 0.563) (all p < 0.05). CONCLUSIONS: Our online course with interactive visual learning facilitated PGY physicians' learning performance, levels of satisfaction, interest, and perceived benefits of online learning. Hospitals and policymakers need to be aware that this learning approach can markedly enhance physicians' academic outcomes and levels of clinical practice.

Macrophage-Hitchhiked Orally Administered ß-Glucans-Functionalized Nanoparticles as "Precision-Guided Stealth Missiles" for Targeted Pancreatic Cancer Therapy.

The prognosis in cases of pancreatic ductal adenocarcinoma (PDAC) with current treatment modalities is poor owing to the highly desmoplastic tumor microenvironment (TME). Herein, a ß-glucans-functionalized zinc-doxorubicin nanoparticle system (ßGlus-ZnD NPs) that can be orally administered, is developed for targeted PDAC therapy. Following oral administration in PDAC-bearing mice, ßGlus-ZnD NPs actively target/transpass microfold cells, overcome the intestinal epithelial barrier, and then undergo subsequent phagocytosis by endogenous macrophages (ßGlus-ZnD@Mϕ). As hitchhiking cellular vehicles, ßGlus-ZnD@Mϕ transits through the intestinal lymphatic system and enters systemic circulation, ultimately accumulating in the tumor tissue as a result of the tumor-homing and "stealth" properties that are conferred by endogenous Mϕ. Meanwhile, the Mϕ that hitchhikes ßGlus-ZnD NPs is activated to produce matrix metalloproteinases, destroying the desmoplastic stromal barrier, and differentiates toward the M1 -like phenotype, modulating the TME and recruiting effector T cells, ultimately inducing apoptosis of the tumor cells. The combination of ßGlus-ZnD@Mϕ and immune checkpoint blockade effectively inhibits the growth of the primary tumor and suppresses the development of metastasis. It thus represents an appealing approach to targeted PDAC therapy.

Realization of NIR-II 3D whole-body contour and tumor blood vessels imaging in small animals using rotational stereo vision technique.

Significance: Optical imaging in the second near-infrared (NIR-II, 1000 to 1700 nm) region is capable of deep tumor vascular imaging due to low light scattering and low autofluorescence. Non-invasive real-time NIR-II fluorescence imaging is instrumental in monitoring tumor status. Aim: Our aim is to develop an NIR-II fluorescence rotational stereo imaging system for 360-deg three-dimensional (3D) imaging of whole-body blood vessels, tumor vessels, and 3D contour of mice. Approach: Our study combined an NIR-II camera with a 360-deg rotational stereovision technique for tumor vascular imaging and 3D surface contour for mice. Moreover, self-made NIR-II fluorescent polymer dots were applied in high-contrast NIR-II vascular imaging, along with a 3D blood vessel enhancement algorithm for acquiring high-resolution 3D blood vessel images. The system was validated with a custom-made 3D printing phantom and in vivo experiments of 4T1 tumor-bearing mice. Results: The results showed that the NIR-II 3D 360-deg tumor blood vessels and mice contour could be reconstructed with 0.15 mm spatial resolution, 0.3 mm depth resolution, and 5 mm imaging depth in an ex vivo experiment. Conclusions: The pioneering development of an NIR-II 3D 360-deg rotational stereo imaging system was first applied in small animal tumor blood vessel imaging and 3D surface contour imaging, demonstrating its capability of reconstructing tumor blood vessels and mice contour. Therefore, the 3D imaging system can be instrumental in monitoring tumor therapy effects.

Development of Single-Channel Dual-Element Custom-Made Ultrasound Scanner with Miniature Optical Position Tracker for Freehand Imaging.

Handheld ultrasound has great potential in resource-limited areas, and can improve healthcare for rural populations. Single-channel ultrasound has been widely used in many clinical ultrasound applications, and optical tracking is considered accurate and reliable. In this study, we developed a 10 MHz lead magnesium niobate-lead titanate (PMN-PT) dual-element ultrasound transducer combined with a miniature optical position tracker, and then measured the rectus femoris of the thigh, upper arm, and cheek muscles. Compared to single-element transducers, dual-element transducers improve the contrast of near-field signals, effectively reduce noise, and are suitable for measuring curved surfaces. The purpose of position tracking is to calculate the location of the ultrasound transducer during the measurement process. By utilizing positioning information, 2D ultrasound imaging can be achieved while maintaining structural integrity. The dual-element ultrasound scanner presented in this study can enable continuous scanning over a large area without a scanning width limitation. The custom-made dual-element ultrasound scanner has the advantage of being a portable, reliable, and low-cost ultrasound device, and is helpful in popularizing medical care for remote villages.

Rational Design of Asymmetric Polymethines to Attain NIR(II) Bioimaging at >1100 nm.

Organic molecules having emission in the NIR(II) region are emergent and receiving enormous attention. Unfortunately, attaining accountable organic emission intensity around the NIR(II) region is hampered by the dominant internal conversion operated by the energy gap law, where the emission energy gap and the associated internal reorganization energy λint play key roles. Up to the current stage, the majority of the reported organic NIR(II) emitters belong to those polymethines terminated by two symmetric chromophores. Such a design has proved to have a small λint that greatly suppresses the internal conversion. However, the imposition of symmetric chromophores is stringent, limiting further development of organic NIR(II) dyes in diversity and versatility. Here, we propose a new concept where as far as the emissive state of the any asymmetric polymethines contains more or less equally transition density between two terminated chromophores, λint can be as small as that of the symmetric polymethines. To prove the concept, we synthesize a series of new polymethines terminated by xanthen-9-yl-benzoic acid and 2,4-diphenylthiopyrylium derivatives, yielding AJBF1112 and AEBF1119 that reveal emission peak wavelength at 1112 and 1119 nm, respectively. The quantum yield is higher than all synthesized symmetric polymethines of 2,4-diphenylthiopyrylium derivatives (SC1162, 1182, 1185, and 1230) in this study. λint were calculated to be as small as 6.2 and 7.3 kcal/mol for AJBF1112 and AEBF1119, respectively, proving the concept. AEBF1119 was further prepared as a polymer dot to demonstrate its in vitro specific cellular imaging and in vivo tumor/bone targeting in the NIR(II) region.

TADF-based NIR-II semiconducting polymer dots for in vivo 3D bone imaging.

Intraoperative fluorescence imaging in the second near-infrared (NIR-II) region heralds a new era in image-guided surgery since the success in the first-in-human liver-tumor surgery guided by NIR-II fluorescence. Limited by the conventional small organic NIR dyes such as FDA-approved indocyanine green with suboptimal NIR-II fluorescence and non-targeting ability, the resulting shallow penetration depth and high false positive diagnostic values have been challenging. Described here is the design of NIR-II emissive semiconducting polymer dots (Pdots) incorporated with thermally activated delayed fluorescence (TADF) moieties to exhibit emission maxima of 1064-1100 nm and fluorescence quantum yields of 0.40-1.58% in aqueous solutions. To further understand how the TADF units affect the molecular packing and the resulting optical properties of Pdots, in-depth and thorough density-functional theory calculations were carried out to better understand the underlying mechanisms. We then applied these Pdots for in vivo 3D bone imaging in mice. This work provides a direction for future designs of NIR-II Pdots and holds promising applications for bone-related diseases.

Observation and identification of autofluorescent urine crystals may be linked to a sign of urolithiasis.

Urolithiasis is a common disease of the urinary system. Its recurrence rate is high and may increase medical expenses. Urine stones are composed of urine crystals and other impurities. We discovered the existence of autofluorescence in some of the urine crystals, especially in urolithiasis patients. The fluorescent molecule existed in urine crystals was verified and identified. We have applied micro-Raman and fluorescence microscopy to classify the urine crystals, used confocal laser scanning microscopy (CLSM) to examine the 3D images and spectra of autofluorescence in crystals, used Fourier-transform infrared spectroscopy (FTIR) and mass spectrometry (MS) to identify the type of fluorophore in the autofluorescent urine crystals in urine. Riboflavin was identified as one of the major fluorophores in these autofluorescent urine crystals. The prevalence rates of the autofluorescent crystals in urolithiasis patients and subjects without the history of urolithiasis were to gather statistics. We observed that 80% of urolithiasis patients had autofluorescent crystals. Contrastingly, such crystals existed in only 7% of subjects without the history of urolithiasis. The presence of autofluorescent urine crystals may be linked to a sign of urolithiasis.

Development of Stereo NIR-II Fluorescence Imaging System for 3D Tumor Vasculature in Small Animals.

Near-infrared-II (NIR-II, 1000-1700 nm) fluorescence imaging boasts high spatial resolution and deep tissue penetration due to low light scattering, reduced photon absorption, and low tissue autofluorescence. NIR-II biological imaging is applied mainly in the noninvasive visualization of blood vessels and tumors in deep tissue. In the study, a stereo NIR-II fluorescence imaging system was developed for acquiring three-dimension (3D) images on tumor vasculature in real-time, on top of the development of fluorescent semiconducting polymer dots (IR-TPE Pdots) with ultra-bright NIR-II fluorescence (1000-1400 nm) and high stability to perform long-term fluorescence imaging. The NIR-II imaging system only consists of one InGaAs camera and a moving stage to simulate left-eye view and right-eye view for the construction of 3D in-depth blood vessel images. The system was validated with blood vessel phantom of tumor-bearing mice and was applied successfully in obtaining 3D blood vessel images with 0.6 mm- and 5 mm-depth resolution and 0.15 mm spatial resolution. The NIR-II stereo vision provides precise 3D information on the tumor microenvironment and blood vessel path.

Ultrasound Measurement of Rectus Femoris Muscle Parameters for Discriminating Sarcopenia in Community-Dwelling Adults.

OBJECTIVES: Sarcopenia patients require more medical attention and caretaking. As such, early detection of sarcopenia and appropriate interventions are crucial for decreasing medical costs and meeting the challenges of aging populations. The aim of the present study was to develop a reliable and accurate model to estimate muscle mass using ultrasound-derived parameters from the rectus femoris (RF), referenced by dual-energy X-ray absorptiometry. METHODS: Cross-sectional study was performed. The study patients were recruited by Taipei Veterans General Hospital (No. 2016-07-013C) between 2016 and 2019. A total of 91 community-dwelling adults (35 men and 56 women) were enrolled in this study. Ultrasound measurements of RF muscle thickness (MT), cross-sectional area (CSA), and muscle volume (MV) were performed in B-mode. Muscle strength and physical performance were also examined. Multivariate linear regression was used to build models for the prediction of appendicular skeletal muscle index (ASMI) based on MT, CSA, and MV values. The accuracy of ultrasound RF measurements for predicting sarcopenia was evaluated by using receiver operating characteristic (ROC) curve analysis. RESULTS: The regression equations used for ASMI prediction (adjusted body mass index, sex, and leg length) had high precision and low error. Moreover, the MV model results were close to those of the CSA model and higher than those of the MT model. The ROC analysis showed that both MV and CSA had excellent discrimination when assessing sarcopenia (AUC = 0.83 and 0.81, respectively), whereas MT showed acceptable discrimination (AUC = 0.73). CONCLUSIONS: Ultrasound-derived RF MV was accurate when predicting ASMI and diagnosing sarcopenia in community-dwelling adults.

Fire safety study on high-flow nasal oxygen in shared-airway surgeries with diathermy and laser: simulation based on a physical model.

High-flow nasal oxygen (HFNO) has been used in "tubeless" shared-airway surgeries but whether HFNO increased the fire hazard is yet to be examined. We used a physical model for simulation to explore fire safety through a series of ignition trials. An HFNO device was attached to a 3D-printed nose with nostrils connected to a degutted raw chicken. The HFNO device was set at twenty combinations of different oxygen concentration and gas flow rate. An electrocautery and diode laser were applied separately to a fat cube in the cavity of the chicken. Ten 30 s trials of continuous energy source application were conducted. An additional trial of continuous energy application was conducted if no ignition was observed for all the ten trials. A total of eight short flashes were observed in one hundred electrocautery tests; however, no continuous fire was observed among them. There were thirty-six events of ignition in one hundred trials with laser, twelve of which turned into violent self-sustained fires. The factors found to be related to a significantly increased chance of ignition included laser application, lower gas flow, and higher FiO2. The native tissue and smoke can ignite and turn into violent self-sustained fires under HFNO and continuous laser strikes, even in the absence of combustible materials. The results suggest that airway surgeries must be performed safely with HFNO if only a short intermittent laser is used in low FiO2.

Molecular Design of Ultrabright Semiconducting Polymer Dots with High NIR-II Fluorescence for 3D Tumor Mapping.

Fluorescence probes emitting in the second near-infrared (NIR-II, 1000-1700 nm) window with the ability for deep-tissue imaging in mammals herald a new era in surgical methodology. However, the brightness of these NIR-II probes is still far from satisfactory due to their low fluorescence quantum yields (QYs), preventing the observation of high-resolution images such as whole-organ vascular networks in real time. Described here is the molecular engineering of a series of semiconducting polymer dots (Pdots) incorporated with aggregation-induced emission moieties to exhibit the QYs as high as 14% in the NIR-II window. Benefiting from the ultrahigh brightness, a 1400 nm long-pass filter is utilized to realize in vivo 3D tumor mapping in mice. To further understand how the geometrical and electron structures of the semiconducting polymers affect their optical properties, the in-depth and thorough density-functional theory calculations are performed to interpret the experimental results. This study lays the groundwork for further molecular design of highly bright NIR-II Pdots.

Intercostal Nerve Block Using an Innovative Intraneedle Ultrasound Transducer: A Proof-of-Concept study.

Intercostal nerve block is a widely used and effective approach to providing regional anesthesia in the thoracic region for pain relief. However, during ultrasound-guided intercostal nerve block, inaccurate identification of the anatomic structures or suboptimal positioning of the needle tip may result in complications and blockade failure. In this study, we designed an intraneedle ultrasound (INUS) system and validated its efficacy in identifying anatomic structures relevant to thoracic region anesthesia. The 20-MHz INUS transducer comprised a single lead magnesium niobate-lead titanate crystal, and gain was set to 20 dB. It fit into a regular 18G needle and emitted radiofrequency-mode ultrasound signals at 1 mm from the needle tip. One hundred intercostal punctures were performed in 10 piglets. Intercostal spaces were identified by surface ultrasound or palpation and located by inserting and advancing the INUS transducer needle until the appropriate anatomy was identified. Blockade success was defined by ideal saline and dye spreading and confirmed by dissection. The pleura had a distinctive ultrasound signal, and successful detection of the intercostal muscles, endothoracic fascia and double-layered parietal and visceral pleura was achieved in all 100 puncture attempts. INUS allows real-time identification of intercostal structures and facilitates successful intercostal nerve blocks.

Development of an Automated Optical Inspection System for Rapidly and Precisely Measuring Dimensions of Embedded Microchannel Structures in Transparent Bonded Chips.

This study aimed to develop an automated optical inspection (AOI) system that can rapidly and precisely measure the dimensions of microchannels embedded inside a transparent polymeric substrate, and can eventually be used on the production line of a factory. The AOI system is constructed based on Snell's law. The concept holds that, when light travels through two transparent media (air and the microfluidic chip transparent material), by capturing the parallel refracted light from a light source that went through the microchannel using a camera with a telecentric lens, the image can be analyzed using formulas derived from Snell's law to measure the dimensions of the microchannel cross-section. Through the NI LabVIEW 2018 SP1 programming interface, we programmed this system to automatically analyze the captured image and acquire all the needed data. The system then processes these data using custom-developed formulas to calculate the height and width measurements of the microchannel cross-sections and presents the results on the human-machine interface (HMI). In this study, a single and straight microchannel with a cross-sectional area of 300 µm × 300 µm and length of 44 mm was micromachined and sealed with another polymeric substrate by a solvent bonding method for experimentations. With this system, 45 cross-sectional areas along the straight microchannel were measured within 20 s, and experiment results showed that the average measured error was less than 2%.

Small-animal 360-deg fluorescence diffuse optical tomography using structural prior information from ultrasound imaging.

We demonstrate dual modality of free-space fluorescence diffuse optical tomography (FDOT) and handheld ultrasound (US) imaging to reveal both functional and structural information in small animals. FDOT is a noninvasive method for examining the fluorophore inside an object from the light distribution of the surface. In FDOT, a 660-nm continuous wave diode laser was used as an excitation source and an electron-multiplying charge-coupled device (EMCCD) was used for fluorescence data acquisition. Both the laser and EMCCD were mounted on a 360-deg rotation gantry for the transmission optical data collection. The structural information is obtained from a 6- to 17-MHz handheld US linear transducer by single-side access and conducts in the reconstruction as soft priors. The rotation ranges from 0 deg to 360 deg; different rotation degrees, object positions, and parameters were determined for comparison. Both phantom and tissue phantom results demonstrate that fluorophore distribution can be recovered accurately and quantitatively using this imaging system. Finally, an animal study confirms that the system can extract a dual-modality image, validating its feasibility for further in vivo experiments. In all experiments, the error and standard deviation decrease as the rotation degree is increased and the error was reduced to 10% when the rotation degree was increased over 135 deg.

High-Flow Nasal Cannula and Mandibular Advancement Bite Block Decrease Hypoxic Events during Sedative Esophagogastroduodenoscopy: A Randomized Clinical Trial.

During sedated endoscopic examinations, upper airway obstruction occurs. Nasal breathing often shifts to oral breathing during open mouth esophagogastroduodenoscopy (EGD). High-flow nasal cannula (HFNC) which delivers humidified 100% oxygen at 30 L min-1 may prevent hypoxemia. A mandibular advancement (MA) bite block with oxygen inlet directed to both mouth and nose may prevent airway obstruction during sedated EGD. The purpose of this study was to evaluate the efficacy of these airway devices versus standard management. One hundred and eighty-nine patients were assessed for eligibility. One hundred and fifty-three were enrolled. This study randomly assigned eligible patients to three arms: the standard bite block and standard nasal cannula, HFNC, and MA bite block groups. EGD was performed after anaesthetic induction. The primary endpoint was the oxygen desaturation area under curve at 90% (AUCDesat). The secondary endpoints were percentage of patients with hypoxic, upper airway obstruction, and apnoeic and rescue events. One hundred and fifty-three patients were enrolled. AUCdesat was significantly lower for HFNC and MA bite blocks versus the standard management (p= 0.019). The HFNC reduced hypoxic events by 18% despite similar airway obstruction and apnoeic events as standard group. The MA bite block reduced hypoxic events by 12% and airway obstructions by 32%. The HFNC and MA groups both showed a 16% and 14% reduction in the number of patients who received rescue intervention, respectively, compared to the standard group. The HFNC and MA bite block may both reduce degree and duration of hypoxemia. HFNC may decrease hypoxemic events while maintaining nasal patency is crucial during sedative EGD. The MA bite block may prevent airway obstruction and decrease the need for rescue intervention.