Clinicians' Guide to Artificial Intelligence in Colon Capsule Endoscopy-Technology Made Simple.

Artificial intelligence (AI) applications have become widely popular across the healthcare ecosystem. Colon capsule endoscopy (CCE) was adopted in the NHS England pilot project following the recent COVID pandemic's impact. It demonstrated its capability to relieve the national backlog in endoscopy. As a result, AI-assisted colon capsule video analysis has become gastroenterology's most active research area. However, with rapid AI advances, mastering these complex machine learning concepts remains challenging for healthcare professionals. This forms a barrier for clinicians to take on this new technology and embrace the new era of big data. This paper aims to bridge the knowledge gap between the current CCE system and the future, fully integrated AI system. The primary focus is on simplifying the technical terms and concepts in machine learning. This will hopefully address the general "fear of the unknown in AI" by helping healthcare professionals understand the basic principle of machine learning in capsule endoscopy and apply this knowledge in their future interactions and adaptation to AI technology. It also summarises the evidence of AI in CCE and its impact on diagnostic pathways. Finally, it discusses the unintended consequences of using AI, ethical challenges, potential flaws, and bias within clinical settings.

Missed Opportunity Encounters for Early Diagnosis of HIV Infection in Adolescents.

BACKGROUND: Early diagnosis of HIV infection improves patient outcomes and reduces transmission. Adolescents make up one-fifth of new HIV diagnoses in the United States. We sought to quantify the number of missed opportunity encounters (MOEs) before HIV diagnosis for adolescents at a pediatric hospital (PediHosp) and a proximate adult hospital which employs universal HIV screening in its emergency department (ED) (CountyHosp). METHODS: An observational study at 2 academic tertiary care hospitals in the United States that included all adolescents 13-20 years old with a new diagnosis of behaviorally-acquired HIV infection from 2006 to 2017. MOE were defined as any encounter at PediHosp or CountyHosp after the latter of the individual's 13th birthday or the date 3 months after the individual's most recent negative HIV screen, and before the encounter of HIV diagnosis. Comparisons were made by site of diagnosis and location of MOE. RESULTS: Two-hundred five subjects met inclusion criteria: 68% male, 76% Black and 81% men who have sex with men. There were 264 MOE, the proportion of adolescent ED encounters that were MOE at the PediHosp ED was 8.3 MOE per 10,000 encounters and the proportion at the CountyHosp ED was 1.2 (relative risk = 6.7; 95% CI: 4.1-11.0; P < 0.001). CONCLUSIONS: MOE for HIV diagnosis in adolescents occur frequently and are greater in number at a PediHosp as compared with a similar adult setting with universal screening. Universal HIV screening protocols at PediHosp may identify HIV-positive adolescents earlier.

C-reactive protein and albumin association with mortality of hospitalised SARS-CoV-2 patients: A tertiary hospital experience.

OBJECTIVE: The objective was to study hospitalised COVID-19 patients' mortality and intensive care unit (ICU) admission with covariates of interest (age, gender, ethnicity, clinical presentation, comorbidities and admission laboratory findings). METHODS: Logistic regression analyses were performed for patients admitted to University Hospital, University Hospitals Coventry and Warwickshire NHS Trust, between 24 January 2020 - 13 April 2020. RESULTS: There were 321 patients hospitalised. Median age was 73 years and 189 (59%) were male. Ethnicity was divided between Caucasian (77%), and black, Asian, and minority ethnic (BAME) groups (23%). Commonest symptoms were dyspnoea (62.9%), fever (59.1%) and cough (56%). Gastrointestinal symptoms amounted to 11.8%.Forty-four patients (13.7%) received ICU care. ICU male to female ratio was 3:1 (p=0.027; odds ratio (OR) 2.3; 95% confidence interval (CI) 1.1-4.9), BAME (p=0.008; OR 2.5; 95% CI 1.3-4.9), age >65 years (p=0.026; OR 0.28; 95% CI 0.09-0.93), heart disease (p=0.009; OR 0.2; 95% CI 0.1-0.6) and elevated C-reactive protein (CRP; p<0.001; OR 1.004; 95% CI 1.002-1.008) were associated with ICU admission.One-hundred and four patients (32.4%) died. Age >65 years (p=0.011; OR 5; 95% CI 1.6-21.9), neutrophils (p=0.047), neutrophil:lymphocyte ratio (NLR; p=0.028), CRP (p<0.001) and albumin (p=0.002) were associated with mortality. When analysis adjusted for age, CRP (p<0.001; OR 1.006; 95% CI 1.004-1.008) and albumin (p=0.005; OR 0.94; 95% CI 0.90-0.98) remained associated with mortality. CONCLUSIONS: COVID-19 has high mortality. BAME and male patients were associated with ICU admission. High CRP and low albumin (after correcting for age) were associated with mortality.

Trends in Personal Belief Exemption Rates Among Alternative Private Schools: Waldorf, Montessori, and Holistic Kindergartens in California, 2000-2014.

OBJECTIVES: To evaluate trends in rates of personal belief exemptions (PBEs) to immunization requirements for private kindergartens in California that practice alternative educational methods. METHODS: We used California Department of Public Health data on kindergarten PBE rates from 2000 to 2014 to compare annual average increases in PBE rates between schools. RESULTS: Alternative schools had an average PBE rate of 8.7%, compared with 2.1% among public schools. Waldorf schools had the highest average PBE rate of 45.1%, which was 19 times higher than in public schools (incidence rate ratio = 19.1; 95% confidence interval = 16.4, 22.2). Montessori and holistic schools had the highest average annual increases in PBE rates, slightly higher than Waldorf schools (Montessori: 8.8%; holistic: 7.1%; Waldorf: 3.6%). CONCLUSIONS: Waldorf schools had exceptionally high average PBE rates, and Montessori and holistic schools had higher annual increases in PBE rates. Children in these schools may be at higher risk for spreading vaccine-preventable diseases if trends are not reversed.

Fetal death associated with asymptomatic intrauterine Candida albicans infection and a retained intrauterine contraceptive device.

We present a case of intrauterine fetal death at 18 weeks of gestation associated with a retained intrauterine contraceptive device and asymptomatic intraamniotic and fetal infection by Candida albicans. The infection was verified by histopathologic examination of the placenta and umbilical cord, growth of C. albicans in samples of amniotic fluid and the presence of high levels of IL-6 in the amniotic fluid.

Prenatal diagnosis of congenital hypophosphatasia in a consanguineous Bedouin couple. A case report.

BACKGROUND: Hypophosphatasia is a rare autosomal recessive metabolic disorder characterized by low serum and tissue alkaline phosphatase activity, increased urinary excretion of phosphoethanolamine and ricketslike changes in the bone. CASE: We present a case of prenatal diagnosis of congenital hypophosphatasia in a consanguineous Bedouin couple. The case was diagnosed at 24.5 weeks of gestation. Sonographic evaluation revealed a fetus with short and deformed bones and a hypoechogenic skull. Based on the sonographic findings and the obstetric history of the couple, hypophosphatasia was diagnosed. The parents opted for pregnancy termination. Feticide was accomplished uneventfully. Laboratory findings confirmed the diagnosis. CONCLUSION: This couple was prone to this metabolic disorder due to their consanguineous marriage and previous affected fetus. Early-first-trimester prenatal diagnosis by first-trimester chorionic villus sampling or second-trimester measuring of alkaline phosphatase activity in the amniotic fluid is required to exclude this lethal disease in subsequent pregnancies.

Prenatal diagnosis of a fetal abdominal cyst.

Hepatic liver cysts are rare and few cases have been described in the literature. Initially, these cysts are detected by a prenatal ultrasound as abdominal, and consequently, the final diagnosis of hepatic cysts is done during the postnatal period. We present a case of a giant hepatic cyst found incidently during a routine ultrasound examination. The diagnosis and management of a fetal intraabdominal cyst is discussed.

Maternal serum concentrations of CA-125 in second trimester pregnancy complicated by congenital fetal anomalies.

OBJECTIVE: The purpose of the study was to determine the value of maternal serum CA-125 concentrations in pregnancies complicated by fetal anomalies with or without hydramnios. STUDY DESIGN: The study population (n=40) consisted of the following four groups of patients: (1) 10 women with abnormal maternal serum alpha fetal protein (MSAFP) in whom no fetal anomalies were observed; (2) 10 women in whom fetal anomalies were diagnosed in addition to abnormal MSAFP; (3) 10 women with fetal anomalies accompanied by hydramnios and abnormal MSAF, and (4) 10 women had normal MSAFP and were diagnosed with hydramnios without fetal anomaly. The control group consisted of 10 patients who were matched for gestational age with normal MSAFP and normal ultrasonographic examination. In all 50 cases MSAFP and maternal serum CA-125 levels were assessed. CA-125 was measured using OC 125 monoclonal antibody (IMX CA-125, Abott Lab. IL) and a value of >20 U/ml was defined as abnormal. RESULTS: Maternal serum CA-125 levels were significantly higher in the study group than in the control group, 19.8+/-15.9 U/ml and 9.9+/-4.0 U/ml (P=0.015). The difference was even greater when patients with malformed fetuses and hydramnios were compared to those with fetal anomalies and normal amount of amniotic fluid, 32.4+/-12.7 U/ml and 7.2+/-2.1 U/ml, respectively (P=0.0005). The maternal serum CA-125 levels in patients with hydramnios but without fetal anomalies were significantly lower when compared with those of the malformed fetuses and hydramnios, 9.8+/-2.3 U/ml and 32.4+/-12.7 U/ml, respectively (P=0.002). CONCLUSION: Maternal serum CA-125 is lacking in value for screening fetal structural anomalies as a significant increase in maternal serum CA-125 levels was found only in patients with fetal anomalies accompanied by hydramnios.

Multiple pregnancies in women after renal transplantation. Case report that rises a management dilemma.

OBJECTIVES: To report the pregnancy outcome in women with multiple pregnancies after renal transplantation. MATERIALS AND METHODS: We report two cases of multiple pregnancies (triplets and twins) in renal allograft recipients and evaluate the pregnancy courses and maternal and fetal outcome of these patients. RESULTS: After fetal reduction from triplet to twin pregnancy the first patient delivered healthy twin babies at 36 weeks gestation. Six months after delivery the woman is well with no signs of renal function impairment. Although the second patient did not meet the optimal criteria for consideration of pregnancy in renal transplant recipients, she delivered normal twin babies at 33 weeks' gestation. Maternal complications during pregnancy included preeclampsia, mild deterioration of renal function tests, and secondary complications due to drug therapy that was resolved after delivery. No graft rejection episodes were noted in either case during pregnancy. CONCLUSIONS: Multifetal gestation in renal allograft recipients represents a high-risk pregnancy that should be managed at a tertiary care institution. The overall outcome in properly consulted patients can be considered favorable. Based on our limited experience with two cases, we suggest reduction of triplets to a twin pregnancy which is consistent with the current literature data.

Changing sonographic features of fetal ovarian cysts during pregnancy and the neonatal period.

We present a case in which serial sonographic examinations revealed changing pattern of cystic ovarian masses from hypoechogenic to echogenic appearance. These changes were attributed to suspected torsion of ovarian cyst. Nevertheless, a healthy baby girl was born without clinical and sonographic evidence of ovarian torsion.

The relationship between congenital cardiovascular malformations and spontaneous abortion in preceding pregnancy.

Previous studies have shown an increased frequency of spontaneous abortions in the pregnancy preceding a fetus or a newborn with neural tube defect (NTD) compared with a normal newborn. One explanation of this observation is the trophoblastic cell rest hypothesis put forward by Knox and Clarke, suggesting a teratogenic interaction between the developing embryo and pathological remnants of a previous pregnancy. The other explanation is that the previously lost fetus was also affected with neural tube defect. The aim of this study was to verify whether this observation is also valid for congenital cardiovascular malformations (CCVM). Demographic and obstetric data of 99 mothers (58 Jewish and 41 Bedouin) of newborns who died in the neonatal period from isolated CCVM were compared with those of 103 mothers (48 Jewish and 55 Bedouin) of newborns who died of congenital defects other than NTD and CCVM. Spontaneous abortions in the preceding pregnancy were found in 32% of the cases with CCVM compared with 14% of cases with other defects (ODs) (P=0.0012; odds ratio=3.1, 95% confidence interval 1.5-6.4). This significant difference was independent of maternal age and number of pregnancies or deliveries. No difference was found between Jews and Bedouins. As there is no indication in the literature that fetuses with isolated CCVM tend to be spontaneously aborted, our findings are more supportive of the trophoblastic cell rest theory.

Decisions regarding pregnancy termination among Bedouin couples referred to third level ultrasound clinic.

OBJECTIVE: To identify predictors of parental decision whether to terminate a pregnancy after a diagnosis of a major congenital malformation in a traditional society. STUDY DESIGN: The Bedouin Arabs in southern Israel are a traditional society, with a high incidence of congenital disorders. Data were abstracted from medical records of 295 families who sought counseling in the third level ultrasound clinic between 1990 and 1996. Statistical analysis included univariate and multiple logistic regression. RESULTS: The diagnosis of a major malformation was confirmed in 64% of the cases. Pregnancy termination was a realistic option for 125 women (66.5%) as the rest were too advanced in their pregnancy. Such a delay was less common in cases of multiple malformations than in a single malformation (19.2% versus 39.0% respectively, P < 0.01). Forty-nine of the 125 women (39.2%) chose to terminate their pregnancy. The only significant predictors of termination decision were earlier gestational week at diagnosis and previous uncompleted pregnancies. CONCLUSIONS: These findings indicate the importance of promoting early genetic counseling and early prenatal diagnosis, for any population where abortions are not readily acceptable.

Abdominal wall pain in pregnant women caused by thoracic lateral cutaneous nerve entrapment.

Three pregnant women presented with disabling lower abdominal wall pain unresponsive to conventional therapies. The striking similarities among the clinical signs and symptoms prompted a review of the literature and led to the suspicion of thoracic lateral cutaneous nerve entrapment, a syndrome reported in other conditions, including after surgery, but not during pregnancy. Treatment by nerve block with local anesthetics was rapidly and completely successful in relieving the symptoms.

GnRH in pregnancy.

Human trophoblast produce GnRH and its precursor, immunologically and chemically identical to those of hypothalamic origin. Placental GnRH stimulates human chorionic gonadotropin secretion by the syncytiotrophoblast. It is known that GnRH analogue has negative effect on early rat pregnancy and may cause abortion through its action on the corpus luteum. A significant reduction of progesterone production was found in pregnant rats treated with GnRH agonist. GnRH caused a significant decrease in the maximal contraction intensity of non-pregnant and pregnant uterine muscle strip, following the action of oxytocin and acetylcholine. It was observed that treatment of pregnant rat with pharmacological doses of GnRH was able to delay parturition. Experimentally, GnRH significantly inhibited the release of placental prostaglandins E and F and thromboxane B 2 in a dose dependent fashion. Maternal circulating GnRH levels at 25-35 weeks of gestation were significantly higher in women who later had post-term pregnancies. In an other study maternal circulating GnRH concentration was found to be significantly lower in four patients who developed preterm labor and delivery. Low doses of GnRH in pregnant rats produced inhibition of postpartum lordosis behavior.

Spontaneous abortion--high risk factor for neural tube defects in subsequent pregnancy.

An increased spontaneous abortion rate has been observed in pregnancies preceding that of fetuses or newborn infants with neural tube defects (NTDs). There are 2 suggested explanations for this observation. One is that a trophoblastic cell rest, remaining from a previous aborted pregnancy, interferes with normal embryogenesis. The second is that the previous lost fetus was affected with NTD. We studied the obstetric history of mothers of newborn infants with NTDs compared to those with other birth defects, in low and high risk groups for NTD (Jew and Bedouins). A significantly higher spontaneous abortion rate (48%) in the preceding pregnancy was found in the NTD group compared to the group with other birth defects (20%). This was especially remarkable for spina bifida cases in the Jewish study population. A significantly higher rate of preceding spontaneous abortion was also found in congenital heart defects (CHD) when compared to other congenital malformations. A hypothesis based on the multifactorial threshold model is put forward to explain these findings. Based on the realization that spontaneous abortion constitutes a high risk factor for NTD and possibly also CHD, we recommend a delay of subsequent pregnancy and periconceptional treatment with folic acid following spontaneous abortion.