SF-TMN: SlowFast temporal modeling network for surgical phase recognition.

PURPOSE: Automatic surgical phase recognition is crucial for video-based assessment systems in surgical education. Utilizing temporal information is crucial for surgical phase recognition; hence, various recent approaches extract frame-level features to conduct full video temporal modeling. METHODS: For better temporal modeling, we propose SlowFast temporal modeling network (SF-TMN) for offline surgical phase recognition that can achieve not only frame-level full video temporal modeling but also segment-level full video temporal modeling. We employ a feature extraction network, pretrained on the target dataset, to extract features from video frames as the training data for SF-TMN. The Slow Path in SF-TMN utilizes all frame features for frame temporal modeling. The Fast Path in SF-TMN utilizes segment-level features summarized from frame features for segment temporal modeling. The proposed paradigm is flexible regarding the choice of temporal modeling networks. RESULTS: We explore MS-TCN and ASFormer as temporal modeling networks and experiment with multiple combination strategies for Slow and Fast Paths. We evaluate SF-TMN on Cholec80 and Cataract-101 surgical phase recognition tasks and demonstrate that SF-TMN can achieve state-of-the-art results on all considered metrics. SF-TMN with ASFormer backbone outperforms the state-of-the-art Swin BiGRU by approximately 1% in accuracy and 1.5% in recall on Cholec80. We also evaluate SF-TMN on action segmentation datasets including 50salads, GTEA, and Breakfast, and achieve state-of-the-art results. CONCLUSION: The improvement in the results shows that combining temporal information from both frame level and segment level by refining outputs with temporal refinement stages is beneficial for the temporal modeling of surgical phases.

Autosomal recessive ALOX12B gene and consecutive collodion baby.

Autosomal recessive congenital ichthyosis is a type of inherited ichthyosis which is a rare cluster of genetic disorders leading to defective keratinisation. The combined prevalence for lamellar ichthyosis and congenital ichthyosiform erythroderma is almost 1 per 200 000-300 000 people. Among all the mutations in this gene, missense and frameshift mutations are most common which account for 80% of the cases. Our patient had a mutation in R-type arachidonate 12-lipoxygenase gene (ALOX12B, OMIM*603741).

Comparative Analysis of Conventional Cytology and Liquid-Based Cytology in the Detection of Carcinoma Cervix and its Precursor Lesions.

Context: The conventional smears (CS) and Liquid based cytology (LBC) are important tools to detect carcinoma cervix and its precursor lesions. Aims: The present study was done to compare the cytomorphological features of cervical lesions using both techniques and compare with the histopathological diagnosis. Settings and Design: This was a prospective observational study over a period of 1.5 years at a tertiary care hospital. Methods and Material: A total of 969 women in the age group of 21-65 years presenting with either routine screening or complaints of vaginal bleeding, discharge, or pelvic pain were enrolled for the study. Both the CS and LBC smears were analyzed and compared with the corresponding histopathology diagnosis. The data was analyzed using Statistical Package for the Social Sciences (SPSS) software and P values <0.05 were considered significant. Results: There were 8.57% unsatisfactory smears in CS as compared to 0.5% in LBC smears. Liquid-based cytology was superior to conventional preparations in terms of smear adequacy, lesser hemorrhagic and inflammatory background, and presence of more endocervical cells. Liquid-based cytology showed a better yield in detecting all the types of epithelial cell lesions with a concordance rate of 73.9% between the two techniques. On histopathology correlation of these lesions, LBC had a higher sensitivity (96.67%) and diagnostic accuracy (99.08%) as compared to CS (73.33% and 92.66%, respectively). Conclusions: Liquid-based cytology is superior to conventional cytology for the detection of epithelial cell lesions. Reduction in the unsatisfactory smears, a cleaner background, and better representation of the sample are more significantly appreciated on LBC in contrast to CS.

An artificial intelligence model that automatically labels roux-en-Y gastric bypasses, a comparison to trained surgeon annotators.

INTRODUCTION: Artificial intelligence (AI) can automate certain tasks to improve data collection. Models have been created to annotate the steps of Roux-en-Y Gastric Bypass (RYGB). However, model performance has not been compared with individual surgeon annotator performance. We developed a model that automatically labels RYGB steps and compares its performance to surgeons. METHODS AND PROCEDURES: 545 videos (17 surgeons) of laparoscopic RYGB procedures were collected. An annotation guide (12 steps, 52 tasks) was developed. Steps were annotated by 11 surgeons. Each video was annotated by two surgeons and a third reconciled the differences. A convolutional AI model was trained to identify steps and compared with manual annotation. For modeling, we used 390 videos for training, 95 for validation, and 60 for testing. The performance comparison between AI model versus manual annotation was performed using ANOVA (Analysis of Variance) in a subset of 60 testing videos. We assessed the performance of the model at each step and poor performance was defined (F1-score < 80%). RESULTS: The convolutional model identified 12 steps in the RYGB architecture. Model performance varied at each step [F1 > 90% for 7, and > 80% for 2]. The reconciled manual annotation data (F1 > 80% for > 5 steps) performed better than trainee's (F1 > 80% for 2-5 steps for 4 annotators, and < 2 steps for 4 annotators). In testing subset, certain steps had low performance, indicating potential ambiguities in surgical landmarks. Additionally, some videos were easier to annotate than others, suggesting variability. After controlling for variability, the AI algorithm was comparable to the manual (p < 0.0001). CONCLUSION: AI can be used to identify surgical landmarks in RYGB comparable to the manual process. AI was more accurate to recognize some landmarks more accurately than surgeons. This technology has the potential to improve surgical training by assessing the learning curves of surgeons at scale.

Surgical workflow recognition with temporal convolution and transformer for action segmentation.

PURPOSE: Automatic surgical workflow recognition enabled by computer vision algorithms plays a key role in enhancing the learning experience of surgeons. It also supports building context-aware systems that allow better surgical planning and decision making which may in turn improve outcomes. Utilizing temporal information is crucial for recognizing context; hence, various recent approaches use recurrent neural networks or transformers to recognize actions. METHODS: We design and implement a two-stage method for surgical workflow recognition. We utilize R(2+1)D for video clip modeling in the first stage. We propose Action Segmentation Temporal Convolutional Transformer (ASTCFormer) network for full video modeling in the second stage. ASTCFormer utilizes action segmentation transformers (ASFormers) and temporal convolutional networks (TCNs) to build a temporally aware surgical workflow recognition system. RESULTS: We compare the proposed ASTCFormer with recurrent neural networks, multi-stage TCN, and ASFormer approaches. The comparison is done on a dataset comprised of 207 robotic and laparoscopic cholecystectomy surgical videos annotated for 7 surgical phases. The proposed method outperforms the compared methods achieving a [Formula: see text] relative improvement in the average segmental F1-score over the state-of-the-art ASFormer method. Moreover, our proposed method achieves state-of-the-art results on the publicly available Cholec80 dataset. CONCLUSION: The improvement in the results when using the proposed method suggests that temporal context could be better captured when adding information from TCN to the ASFormer paradigm. This addition leads to better surgical workflow recognition.

Looking Beyond VIA to Improve Cervical Cancer Screening in Low Resource Settings.

Background: The two prongs for cervical cancer prevention are vaccination for primary prevention and effective screening for preinvasive and early invasive disease. Until human papilloma virus DNA testing can be provided in low resource settings, screening with VIA is the most feasible option. Various innovative methods have been used to improve the diagnostic accuracy of visual inspection with acetic acid (VIA). This study explores one such option. Method: We modified VIA (VIA-Md) by using a magnifying lens mounted with battery operated light emitting devices (LEDs) to study the acetowhite areas on the cervix. The peak wavelength of the light from the LEDs was in the bluish white range. The results of VIA and VIA-Md were compared using colposcopy directed biopsy as the reference standard. Result: The study was conducted in 273 eligible women. The sensitivity of VIA and VIA-Md for detecting CIN2 + lesions were 57.1% and 100% respectively. The specificity of VIA and VIA-Md were 99.2% and 89.5%; and p values using the colposcopy directed biopsy as the reference standard were 0.000 and 0.018 respectively. However, VIA-Md was also effective in identifying 21 out of the total 32 cases of chronic cervicitis identified by colposcopy directed biopsy. Conclusion: VIA-Md appears to be a highly sensitive test for detection of CIN2 + lesions. However, because of concerns regarding lower specificity, VIA-Md can be used simultaneously with VIA as an effective tool for triaging women who need to be kept under close surveillance or who might benefit from local ablative therapy.

Comparison of prophylactic phenylephrine and norepinephrine infusion on umbilical arterial pH and maternal blood pressure during spinal anaesthesia for caesarean delivery.

Background and Aims: Spinal anaesthesia induced maternal hypotension in parturients undergoing caesarean delivery may lead to neonatal acidosis and fall in umbilical artery pH. The aim of this study was to compare low dose norepinephrine infusion with phenylephrine to see the effect on umbilical arterial pH and maternal blood pressure during spinal anaesthesia for caesarean delivery. Methods: In a randomised, double-blind study, 60 parturients belonging to American Society of Anesthesiologists grade II, age 18-35 years with singleton term pregnancy were divided into the phenylephrine group and norepinephrine group. Participants received prophylactic phenylephrine and norepinephrine infusion after spinal anaesthesia till the delivery of the baby at a fixed rate of 50 µg/min and 2.5 µg/min, respectively. The primary outcome was umbilical artery pH. Neonatal Apgar score, incidence of bradycardia and hypotension, number of boluses of vasopressor required and reactive hypertension were also compared. Results: The umbilical arterial pH was comparable between the groups (p = 0.38). Apgar scores were comparable (p = 0.17). Incidence of bradycardia was higher in phenylephrine group without reaching statistical significance (43.3% vs. 20%, P = 0.052). Incidence of hypotension was more but not significant in norepinephrine group compared to phenylephrine group (16.7% vs. 10%, P = 0.44). Number of vasopressor boluses and reactive hypertension episodes were comparable between both groups (p = 0.09). Conclusion: Low dose (2.5 µg/min) intravenous infusion of norepinephrine is a suitable alternative to phenylephrine in the maintenance of umbilical arterial pH and maternal blood pressure.

Reference Levels for TSH in Iodine-Sufficient Low-Risk Pregnant Women.

BACKGROUND: Recent evidence suggests that thyrotropin (TSH) levels are population specific because of differences in ethnicity. As a result, the 2017 ATA guidelines state that treatment may be tailored as per the laboratory-specific reference ranges of TSH for the local population instead of using a fixed upper limit of 2.5 mIU/L during pregnancy. METHODOLOGY: This was a cross-sectional study in which we collected detailed clinical data of 604 pregnant women along with their TSH and spot urinary iodine excretion levels. Reflex testing for thyroid peroxidase antibodies (TPOAb) was done in women with TSH levels > 2.5 mIU/L in 1st trimester and 3.0 mIU/L in 2nd and 3rd trimester. After excluding 295 women who had high risk factors as per ATA 2017 guidelines and those who were TPOAb positive, we calculated the reference range for TSH in an iodine-sufficient low-risk cohort of 309 women. RESULTS: With median urinary Iodine of 255 µg/l, our population had more than required iodine levels. The 5th and 95th percentiles of TSH in our study cohort of 604 women were 0.64 and 7.81 mIU/L, respectively, while the 5th and 95th percentiles of TSH for the low-risk cohort of 309 women were 0.59 and 4.48 mIU/L, respectively. CONCLUSION: An upper limit of 4.5 mIU/L for TSH level during pregnancy can be used to guide management decisions for low-risk North Indian women.

Oral acetaminophen as an adjunct to continuous epidural infusion and patient-controlled epidural analgesia in laboring parturients: a randomized controlled trial.

BACKGROUND: Intravenous acetaminophen is safe and effective as an adjunct to labor analgesia with combined spinal-epidural (CSE) analgesia and patient-controlled epidural analgesia (PCEA). Oral acetaminophen is a much cheaper and safe option but has not been studied as an adjunct to labor analgesia till date. The aim of the present study is to evaluate the effect of oral acetaminophen as an adjunct in patients receiving local anesthetic-opioid combination using CSE analgesia. METHOD: In this ethically approved randomized double-blind placebo-controlled trial, 60 consenting parturients were randomly allocated to two groups of 30 each: acetaminophen (who received oral acetaminophen 1 g) or placebo, 45 min before the procedure. CSE was administered as per hospital protocol. All the patients received continuous epidural infusion (CEI) of levobupivacaine 0.1% and fentanyl 2 mcg/mL at 5 ml/h and PCEA boluses of 5 mL of the same drug with a lockout interval of 15 min if needed. The primary outcome was hourly mean consumption of levobupivacaine and fentanyl mixture (mL/h). Secondary outcomes included pain score, sensory and motor block, hemodynamic parameters of mother, duration of the second stage of labor, mode of delivery, maternal satisfaction, Apgar scores, fetal heart rate, and adverse effects. RESULTS: The mean drug consumption per hour was significantly less in the acetaminophen group than in the placebo group (7.66 mL/h, SD 2.01 vs. 9.01 mL/h, SD 2.83; p = 0.04). The requirement for bolus was also significantly less in the acetaminophen group than in the placebo group (median 2.5, IQR 3 vs. median 3.5, IQR 2; p = 0.04). CONCLUSION: The use of 1 g of oral acetaminophen could be a cheap, safe, and effective adjunct to CEI plus PCEA in labor analgesia.

Xanthogranulomatous Endometritis: A Benign Uncommon Masquerader of Malignancy.

Xanthogranulomatous endometritis is an uncommon benign lesion characterized by the destruction of endometrium and replacement by the sheets of foamy histiocytes, lymphocytes, plasma cells, multinucleated giant cells, fibrosis, calcification, and accompanying polymorphonuclear leukocytes. It is commonly mistaken for malignancy clinicoradiologically, and therefore, histopathological examination is of utmost importance. We report the case of a 61-year-old postmenopausal female who presented with pyometra, bulky uterus, and cervical stenosis, and histopathology revealed XGE.

An Uncommon Cause of Postmenopausal Bleeding.

A 65-year-old multiparous female was evaluated for postmenopausal bleeding. Imaging was strongly suggestive of malignancy. However, hysteroscopic-guided endometrial biopsy revealed tuberculous endometritis. The patient responded to antitubercular therapy and recovered completely. Genital tuberculosis is typically considered a disease of young women presenting with infertility. However, tuberculous endometritis should be considered in a patient of postmenopausal bleeding, particularly in developing countries. It is a rare, but curable cause of postmenopausal bleeding.

Vulvar myiasis following suction and evacuation for incomplete abortion.

Myiasis is caused by fly larva capable of penetrating healthy or necrotic tissue, usually in tropical and subtropical countries. The involvement of an exposed area is common; however it may very rarely involve the genital region. We present a rare case of vulvar myiasis which occurred after suction and evacuation performed for incomplete abortion.

Perforated duodenal ulcer -a rare cause of acute abdomen in pregnancy.

Acute abdomen during pregnancy is a medico-surgical emergency demanding concerted, synchronized specialties approach of obstetrician, surgeon and gastroenterologist. Duodenal perforation is one of the rarer causes of acute abdomen in pregnancy. Here, we report a case of duodenal perforation with peritonitis in third trimester of pregnancy requiring surgical management. Our aim of reporting this case is to stress the physicians to keep the differential of duodenal perforation also in mind while dealing with cases of acute abdomen in pregnancy and to proceed with multidisciplinary approach for better feto-maternal outcome.

A rare case of ovarian and pelvic filariasis.

Lymphatic filariasis is an important tropic disease associated with significant morbidity. The patients in endemic areas mostly experience problems related to lymphatic obstruction. Physicians practicing in non- endemic areas rarely consider filariasis, especially if it is an uncommon presentation. We present a young woman who posed a significant problem in the diagnosis of ovarian filariasis.