Utility of Repeat Head Computed Tomography in Detecting Delayed Intracranial Hemorrhage in Falls on Direct Oral Anticoagulants.

INTRODUCTION: Ground level falls in the elderly often lead to complications due to use of anticoagulants (ACs). Intracranial hemorrhage (ICH), immediate or delayed, is a feared consequence of such falls. The rate of delayed ICH (dICH) in patients taking anticoagulants or antiplatelet (AP) agents ranges from .6% to 6%. Patients on warfarin have a persistent rate of dICH, leading to implementation of routine repeat head CTs at our institution. This policy was extended to direct oral anticoagulants (DOACs). This study aims to determine institutional incidence of DOAC-associated dICH. METHODS: With IRB waiver approval, we conducted a retrospective review of trauma evaluations for falls on DOACs from 2016 to 2018. We reviewed records for neurologic status, DOAC use, and results of initial and delayed head CTs. Exclusion criteria included initial GCS ≤14, new neurologic deficits, traumatic findings on initial CT, concurrent use of additional AC/AP, or absence of repeat head CT. RESULTS: Among 632 patients evaluated for falls on AC/AP therapy, 159 (25%) of patients were included in the review. The age range was 19-98 years old, with 99 females and 60 males. Half of the patients were on apixaban, with the rest on dabigatran or rivaroxaban. Ten patients presented with GCS of 14. No delayed hemorrhages were detected in this population. CONCLUSION: The necessity of a repeat head CT in patients taking DOACs is debated in the literature. Our analysis failed to demonstrate any delayed hemorrhage in neurologically intact patients after head strike on DOAC, suggesting no indication for follow-up imaging in this group.

Removing non-resonant background from broadband CARS using a physics-informed neural network.

Broadband coherent anti-Stokes Raman scattering (BCARS) is capable of producing high-quality Raman spectra spanning broad bandwidths, 400-4000 cm-1, with millisecond acquisition times. Raw BCARS spectra, however, are a coherent combination of vibrationally resonant (Raman) and non-resonant (electronic) components that may challenge or degrade chemical analyses. Recently, we demonstrated a deep convolutional autoencoder network, trained on pairs of simulated BCARS-Raman datasets, which could retrieve the Raman signal with high quality under ideal conditions. In this work, we present a new computational system that incorporates experimental measurements of the laser system spectral and temporal properties, combined with simulated susceptibilities. Thus, the neural network learns the mapping between the susceptibility and the measured response for a specific BCARS system. The network is tested on simulated and measured experimental results taken with our BCARS system.

Preliminary Approach to Implementing a COVID-19 Thoracic Radiation Therapy Program.

The value of low-dose whole thoracic radiation therapy (LD-WTRT) for SARS-CoV-2 (COVID-19) pneumonia is unknown. Should ongoing clinical trials demonstrate that LD-WTRT proves effective for COVID-19 pneumonia recovery, widespread rapid implementation will be helpful globally. Our aim was to outline a pragmatic process for safe and efficient administration of LD-WTRT to patients with COVID-19 pneumonia that could be implemented successfully in a community hospital setting based on participation in the PreVent clinical trial of LD-WTRT.

Automated Raman Micro-Spectroscopy of Epithelial Cell Nuclei for High-Throughput Classification.

Raman micro-spectroscopy is a powerful technique for the identification and classification of cancer cells and tissues. In recent years, the application of Raman spectroscopy to detect bladder, cervical, and oral cytological samples has been reported to have an accuracy greater than that of standard pathology. However, despite being entirely non-invasive and relatively inexpensive, the slow recording time, and lack of reproducibility have prevented the clinical adoption of the technology. Here, we present an automated Raman cytology system that can facilitate high-throughput screening and improve reproducibility. The proposed system is designed to be integrated directly into the standard pathology clinic, taking into account their methodologies and consumables. The system employs image processing algorithms and integrated hardware/software architectures in order to achieve automation and is tested using the ThinPrep standard, including the use of glass slides, and a number of bladder cancer cell lines. The entire automation process is implemented, using the open source Micro-Manager platform and is made freely available. We believe that this code can be readily integrated into existing commercial Raman micro-spectrometers.

B-Doped δ-Layers and Nanowires from Area-Selective Deposition of BCl3 on Si(100).

Atomically precise, δ-doped structures forming electronic devices in Si have been routinely fabricated in recent years by using depassivation lithography in a scanning tunneling microscope (STM). While H-based precursor/monatomic resist chemistries for incorporation of donor atoms have dominated these efforts, the use of halogen-based chemistries offers a promising path toward atomic-scale manufacturing of acceptor-based devices. Here, B-doped δ-layers were fabricated in Si(100) by using BCl3 as an acceptor dopant precursor in ultrahigh vacuum. Additionally, we demonstrate compatibility of BCl3 with both H and Cl monatomic resists to achieve area-selective deposition on Si. In comparison to bare Si, BCl3 adsorption selectivity ratios for H- and Cl-passivated Si were determined by secondary ion mass spectrometry depth profiling (SIMS) to be 310(10):1 and 1529(5):1, respectively. STM imaging revealed that BCl3 adsorbed readily on bare Si at room temperature, with SIMS measurements indicating a peak B concentration greater than 1.2(1) × 1021 cm-3 with a total areal dose of 1.85(1) × 1014 cm-2 resulting from a 30 langmuir BCl3 dose at 150 °C. In addition, SIMS showed a δ-layer thickness of ∼0.5 nm. Hall bar measurements of a similar sample were performed at 3.0 K, revealing a sheet resistance of ρ□ = 1.9099(4) kΩ â–¡-1, a hole carrier concentration of p = 1.90(2) × 1014 cm-2, and a hole mobility of µ = 38.0(4) cm2 V-1 s-1 without performing an incorporation anneal. Finally, 15 nm wide B δ-doped nanowires were fabricated from BCl3 and were found to exhibit ohmic conduction. This validates the use of BCl3 as a dopant precursor for atomic-precision fabrication of acceptor-doped devices in Si and enables development of simultaneous n- and p-type doped bipolar devices.

Convolution Network with Custom Loss Function for the Denoising of Low SNR Raman Spectra.

Raman spectroscopy is a powerful diagnostic tool in biomedical science, whereby different disease groups can be classified based on subtle differences in the cell or tissue spectra. A key component in the classification of Raman spectra is the application of multi-variate statistical models. However, Raman scattering is a weak process, resulting in a trade-off between acquisition times and signal-to-noise ratios, which has limited its more widespread adoption as a clinical tool. Typically denoising is applied to the Raman spectrum from a biological sample to improve the signal-to-noise ratio before application of statistical modeling. A popular method for performing this is Savitsky-Golay filtering. Such an algorithm is difficult to tailor so that it can strike a balance between denoising and excessive smoothing of spectral peaks, the characteristics of which are critically important for classification purposes. In this paper, we demonstrate how Convolutional Neural Networks may be enhanced with a non-standard loss function in order to improve the overall signal-to-noise ratio of spectra while limiting corruption of the spectral peaks. Simulated Raman spectra and experimental data are used to train and evaluate the performance of the algorithm in terms of the signal to noise ratio and peak fidelity. The proposed method is demonstrated to effectively smooth noise while preserving spectral features in low intensity spectra which is advantageous when compared with Savitzky-Golay filtering. For low intensity spectra the proposed algorithm was shown to improve the signal to noise ratios by up to 100% in terms of both local and overall signal to noise ratios, indicating that this method would be most suitable for low light or high throughput applications.

Quantitative Polarization-Resolved Second-Harmonic-Generation Microscopy of Glycine Microneedles.

Second-harmonic generation (SHG) is a nonlinear optical process that can provide disease diagnosis through characterization of biological building blocks such as amino acids, peptides, and proteins. The second-order nonlinear susceptibility tensor χ(2) of a material characterizes its tendency to cause SHG. Here, a method for finding the χ(2) elements from polarization-resolved SHG microscopy in transmission mode is presented. The quantitative framework and analytical approach that corrects for micrometer-scale morphology and birefringence enable the determination and comparison of the SHG susceptibility tensors of ß- and γ-phase glycine microneedles. The maximum nonlinear susceptibility coefficients are d33  = 15 pm V-1 for the ß and d33  = 5.9 pm V-1 for the γ phase. The results demonstrate glycine as a useful biocompatible nonlinear material. This combination of the analytical model and polarization-resolved SHG transmission microscopy is broadly applicable for quantitative SHG material characterization and diagnostic imaging.

Reaction of Hydrazine with Solution- and Vacuum-Prepared Selectively Terminated Si(100) Surfaces: Pathways to the Formation of Direct Si-N Bonds.

The reactivity of liquid hydrazine (N2H4) with respect to H-, Cl-, and Br-terminated Si(100) surfaces was investigated to uncover the principles of nitrogen incorporation into the interface. This process has important implications in a wide variety of applications, including semiconductor surface passivation and functionalization, nitride growth, and many others. The use of hydrazine as a precursor allows for reactions that exclude carbon and oxygen, the primary sources of contamination in processing. In this work, the reactivity of N2H4 with H- and Cl-terminated surfaces prepared by traditional solvent-based methods and with a Br-terminated Si(100) prepared in ultrahigh vacuum was compared. The reactions were studied with X-ray photoelectron spectroscopy, atomic force microscopy, and scanning tunneling microscopy, and the observations were supported by computational investigations. The H-terminated surface led to the highest level of nitrogen incorporation; however, the process proceeds with increasing surface roughness, suggesting possible etching or replacement reactions. In the case of Cl-terminated (predominantly dichloride) and Br-terminated (monobromide) surfaces, the amount of nitrogen incorporation on both surfaces after the reaction with hydrazine was very similar despite the differences in preparation, initial structure, and chemical composition. Density functional theory was used to propose the possible surface structures and to analyze surface reactivity.

Label-free color staining of quantitative phase images of biological cells by simulated Rheinberg illumination.

Modern microscopes are designed with functionalities that are tailored to enhance image contrast. Dark-field imaging, phase contrast, differential interference contrast, and other optical techniques enable biological cells and other phase-only objects to be visualized. Quantitative phase imaging refers to an emerging set of techniques that allow for the complex transmission function of the sample to be measured. With this quantitative phase image available, any optical technique can then be simulated; it is trivial to generate a phase contrast image or a differential interference contrast image. Rheinberg illumination, proposed almost a century ago, is an optical technique that applies color contrast to images of phase-only objects by introducing a type of optical staining via an amplitude filter placed in the illumination path that consists of two or more colors. In this paper, the complete theory of Rheinberg illumination is derived, from which an algorithm is proposed that can digitally simulate the technique. Results are shown for a number of quantitative phase images of diatom cells obtained via digital holographic microscopy. The results clearly demonstrate the potential of the technique for label-free color staining of subcellular features.

Next-Generation Sequencing vs Culture-Based Methods for Diagnosing Periprosthetic Joint Infection After Total Knee Arthroplasty: A Cost-Effectiveness Analysis.

BACKGROUND: Periprosthetic joint infection (PJI) after total knee arthroplasty is challenging to diagnose. Compared with culture-based techniques, next-generation sequencing (NGS) is more sensitive for identifying organisms but is also less specific and more expensive. To date, there has been no study comparing the cost-effectiveness of these two methods to diagnose PJI after total knee arthroplasty. METHODS: A Markov, state-transition model projecting lifetime costs and quality-adjusted life years (QALYs) was constructed to determine the cost-effectiveness from a societal perspective. The primary outcome was incremental cost-effectiveness ratio, with a willingness-to-pay threshold of $100,000/QALY. Sensitivity analyses were performed to evaluate parameter assumptions. RESULTS: At our base case values, culture was not determined to be cost-effective compared to NGS, with an incremental cost-effectiveness ratio of $422,784 per QALY. One-way sensitivity analyses found NGS to be the cost-effective choice above a pretest probability of 45.5% for PJI. In addition, NGS was cost-effective if its sensitivity was greater than 70.0% and its specificity greater than 94.1%. Two-way sensitivity analyses revealed that the pretest probability and test performance parameters (sensitivity and specificity) were the largest factors for identifying whether a particular strategy was cost-effective. CONCLUSION: The results of our model suggest that the cost-effectiveness of NGS to diagnose PJI depends primarily on the pretest probability of PJI and the performance characteristics of the NGS technology. Our results are consistent with the idea that NGS should be reserved for clinical contexts with a high pretest probability of PJI. Further study is required to determine the indications and subgroups for which NGS offers clinical benefit.

Spatial-domain filter enhanced subtraction microscopy and application to mid-IR imaging.

We have experimentally investigated the enhancement in spatial resolution by image subtraction in mid-infrared central solid-immersion lens (c-SIL) microscopy. The subtraction exploits a first image measured with the c-SIL point-spread function (PSF) realized with a Gaussian beam and a second image measured with the beam optically patterned by a silicon π-step phase plate, to realize a centrally hollow PSF. The intense sides lobes in both PSFs that are intrinsic to the SIL make the conventional weighted subtraction methods inadequate. A spatial-domain filter with a kernel optimized to match both experimental PSFs in their periphery was thus developed to modify the first image prior to subtraction, and this resulted in greatly improved performance, with polystyrene beads 1.4 ± 0.1 µm apart optically resolved with a mid-IR wavelength of 3.4 µm in water. Spatial-domain filtering is applicable to other PSF pairs, and simulations show that it also outperforms conventional subtraction methods for the Gaussian and doughnut beams widely used in visible and near-IR microscopy.

Doubling the far-field resolution in mid-infrared microscopy.

The spatial resolution in far-field mid-infrared (λ>2.5 µm) microscopy and micro-spectroscopy remains limited with the full-width at half maximum of the point-spread function ca. λ/1.3; a value that is very poor in comparison to that commonly accessible with visible and near-infrared optics. Hereafter, it is demonstrated however that polymer beads that are centre-to-centre spaced by λ/2.6 can be resolved in the mid-infrared. The more than 2-fold improvement in resolution in the far-field is achieved by exploiting a newly constructed scanning microscope built around a mid-infrared optical parametric oscillator and a central solid-immersion lens, and by enforcing the linear polarization unidirectional resolution enhancement with a novel and robust specimen error minimization based on a particle swarm optimization. The method is demonstrated with specimens immersed in air and in water, and its robustness shown by the analysis of dense and complex self-assembled bead islands.

Severe neurologic manifestations of fat embolism syndrome in a polytrauma patient.

Fat embolism syndrome (FES) is most commonly diagnosed when the classic triad of respiratory difficulty, neurologic abnormalities, and petechial rash are present in the appropriate clinical setting. Neurologic manifestations can range from headache, confusion, and agitation to stupor and, less commonly, coma. This article describes a case of FES with severe neurologic sequelae without typical pulmonary involvement in a polytrauma patient with proximal humerus and L1 compression fractures. The case highlights the importance of considering FES in the patient with deteriorating mental status in the setting of multiple fractures, particularly in the absence of other characteristic clinical findings. Early recognition allows for the anticipation of other complications, such as respiratory distress and the potential need for mechanical ventilation.

Blunt cerebrovascular injury practice management guidelines: the Eastern Association for the Surgery of Trauma.

BACKGROUND: Blunt injury to the carotid or vertebral vessels (blunt cerebrovascular injury [BCVI]) is diagnosed in approximately 1 of 1,000 (0.1%) patients hospitalized for trauma in the United States with the majority of these injuries diagnosed after the development of symptoms secondary to central nervous system ischemia, with a resultant neurologic morbidity of up to 80% and associated mortality of up to 40%. With screening, the incidence rises to 1% of all blunt trauma patients and as high as 2.7% in patients with an Injury Severity Score of >or=16. The Eastern Association for the Surgery of Trauma organization Practice Management Guidelines committee set out to develop an EBM guideline for the screening, diagnosis, and treatment of BCVI. METHODS: A computerized search of the National Library of Medicine/National Institute of Health, Medline database was performed using citations from 1965 to 2005 inclusive. Titles and abstracts were reviewed to determine relevance, and isolated case reports, small case series, editorials, letters to the editor, and review articles were eliminated. The bibliographies of the resulting full-text articles were searched for other relevant citations, and these were obtained as needed. These papers were reviewed based on the following questions: 1. What patients are of high enough risk, so that diagnostic evaluation should be pursued for the screening and diagnosis of BCVI? 2. What is the appropriate modality for the screening and diagnosis of BCVI? 3. How should BCVI be treated? 4. If indicated, for how long should antithrombotic therapy be administered? 5. How should one monitor the response to therapy? RESULTS: One hundred seventy-nine articles were selected for review, and of these, 68 met inclusion criteria and are excerpted in the attached evidentiary table and used to make recommendations. CONCLUSIONS: The East Practice Management Guidelines Committee suggests guidelines that should be safe and efficacious for the screening, diagnosis, and treatment of BCVI. Risk factors for screening are identified (see ), screening modalities are reviewed indicating that although angiography remains the gold standard, multi-planar (>or==8 slice) CT angiography may be equivalent, and treatment algorithms are evaluated. It is noted that change in the diagnosis and management of this injury constellation is rapid due to technological advancement and the difficulties inherent in performing randomized prospective trials in this patient population.

Radiographic assessment of biomechanical parameters following hip resurfacing and cemented total hip arthroplasty.

Resurfacing hip arthroplasty and total hip replacement both aim to restore anatomical parameters.Leg length and offset discrepancy can result in altered joint reaction forces, and are associated with increased wear, dislocation, and decreased patient satisfaction. This study assesses the accuracy of leg length and offset restoration after either a Birmingham Hip Resurfacing (BHR) or a cemented total hip replacement (THR).Standardised antero-posterior radiography was performed on two groups of 30 patients with unilateral primary osteoarthritis undergoing either a cemented total hip or resurfacing. The normal contra-lateral hip was used as the control. Leg length and offset were measured pre-operatively with no significant difference between the two groups.Cup offset, femoral offset, total offset and leg length of the prosthesis and normal side were measured by two observers and mean measurements were analysed by a paired t test.Leg lengths in each group did not differ significantly from the normal side, THR 0.53 mm (95% CI -2.4 to 3.4 mm) but BHR implantation did result in mean leg shortening of -1.9 mm (95% CI -4.5 mm to 0.6mm). Cup offset differed significantly from normal anatomy in both groups, as did femoral and total offset for the total hip replacement group. However, femoral offset was restored in the Birmingham resurfacing group. When the THR group was compared against the BHR group we found no difference between restoration of leg lengths (p = 0.21) and cup offset (p = 0.30) but femoral (p = 0.0063) and total offset (p = 0.03) were restored more accurately with a BHR.

Use of Intralipid for kinetic analysis of HDL apoC-III: evidence for a homogeneous kinetic pool of apoC-III in plasma.

Apolipoprotein C-III (apoC-III) is an important regulator of lipoprotein metabolism. Radioisotope and stable isotope kinetic studies show differing results in relation to the kinetics of apoC-III in HDL. Kinetic analysis of HDL apoC-III may be difficult because of its low concentration, as well as the presence of other apoproteins at higher concentration, in the HDL fraction. We used Intralipid(R) (IL), known to preferentially extract apoC proteins from plasma, as a means of extracting apoC-III from HDL before apoprotein separation by isoelectric focusing gel electrophoresis for the measurement of tracer enrichment. Protein purity was assessed by an isoleucine-to-leucine (Ile/Leu) ratio, as apoC-III contains no isoleucine. We compared apoC-III kinetics in 14 men using a bolus infusion of deuterated leucine. The Ile/Leu ratio for IL-extracted HDL (IL-HDL) apoC-III (3.0 +/- 0.7%) was not different from that of VLDL apoC-III (2.6 +/- 0.6%) but was significantly lower than that of untreated HDL apoC-III (9.0 +/- 2.9%) (P < 0.001). The isotopic enrichment curves and fractional catabolic rates (FCRs) for IL-HDL apoC-III were not different from those of VLDL apoC-III. In contrast, HDL apoC-III had significantly lower isotopic enrichments and FCRs than IL-HDL apoC-III (P < 0.001). In conclusion, this simple IL method can be used to isolate apoC-III from HDL with minimal interference from other HDL apoproteins, and it demonstrates that the kinetics of apoC-III in VLDL and HDL are similar, supporting the concept of a single kinetically homogeneous pool of apoC-III in plasma.

Oxazolinone derivative of leucine for GC-MS: a sensitive and robust method for stable isotope kinetic studies of lipoproteins.

Stable isotope labeled amino acids are commonly used as endogenous tracers to study the metabolism of lipoproteins. The determination of isotopic enrichment of particular amino acids in apolipoproteins is carried out by gas chromatography mass spectrometry (GC-MS). This report describes a robust and sensitive derivative for analysis of d3-leucine by GC-MS and its utility in studying the metabolism of human lipoproteins. The trifluoromethyloxazolinone (oxazolinone) derivative of leucine was formed in a rapid single step procedure using a mixture of trifluoroacetic anhydride (TFAA) and trifluoroacetic acid (TFA). Analysis of the oxazolinone by negative ion chemical ionization GC-MS gave excellent sensitivity and precision, which enabled accurate determination of low levels of isotopic enrichment from small amounts of protein. For example, enrichments between 0.05% and 100% in 100 pg leucine can be measured with a coefficient of variation of <3%. To demonstrate the utility of this procedure, we measured d3-leucine enrichment in apolipoprotein B (apoB) isolated from VLDL and LDL as well as apoA-I isolated from HDL by gel electrophoresis and western blotting. The derivatization procedure gave excellent enrichment data from a single intravenous bolus dose of 5 mg/kg, from which the fractional catabolic rate and production rate of the lipoproteins were calculated. In conclusion, the oxazolinone derivative provides a robust and simple procedure for the sensitive analysis of isotopic enrichment for metabolic studies of human lipoproteins.