Involvement of Kindlin-1 in cutaneous squamous cell carcinoma.

Kindler syndrome (KS) is a rare genodermatosis resulting from loss-of-function mutations in FERMT1, the gene that encodes Kindlin-1. KS patients have a high propensity to develop aggressive and metastatic cutaneous squamous cell carcinoma (cSCC). Here we show in non-KS-associated patients that elevation of FERMT1 expression is increased in actinic keratoses compared to normal skin, with a further increase in cSCC supporting a pro-tumorigenic role in this population. In contrast, we show that loss of Kindlin-1 leads to increased SCC tumor growth in vivo and in 3D spheroids, which was associated with the development of a hypoxic tumor environment and increased glycolysis. The metalloproteinase Mmp13 was upregulated in Kindlin-1-depleted tumors, and increased expression of MMP13 was responsible for driving increased invasion of the Kindlin-1-depleted SCC cells. These results provide evidence that Kindlin-1 loss in SCC can promote invasion through the upregulation of MMP13, and offer novel insights into how Kindlin-1 loss leads to the development of a hypoxic environment that is permissive for tumor growth.

Choroidalyzer: An Open-Source, End-to-End Pipeline for Choroidal Analysis in Optical Coherence Tomography.

Purpose: To develop Choroidalyzer, an open-source, end-to-end pipeline for segmenting the choroid region, vessels, and fovea, and deriving choroidal thickness, area, and vascular index. Methods: We used 5600 OCT B-scans (233 subjects, six systemic disease cohorts, three device types, two manufacturers). To generate region and vessel ground-truths, we used state-of-the-art automatic methods following manual correction of inaccurate segmentations, with foveal positions manually annotated. We trained a U-Net deep learning model to detect the region, vessels, and fovea to calculate choroid thickness, area, and vascular index in a fovea-centered region of interest. We analyzed segmentation agreement (AUC, Dice) and choroid metrics agreement (Pearson, Spearman, mean absolute error [MAE]) in internal and external test sets. We compared Choroidalyzer to two manual graders on a small subset of external test images and examined cases of high error. Results: Choroidalyzer took 0.299 seconds per image on a standard laptop and achieved excellent region (Dice: internal 0.9789, external 0.9749), very good vessel segmentation performance (Dice: internal 0.8817, external 0.8703), and excellent fovea location prediction (MAE: internal 3.9 pixels, external 3.4 pixels). For thickness, area, and vascular index, Pearson correlations were 0.9754, 0.9815, and 0.8285 (internal)/0.9831, 0.9779, 0.7948 (external), respectively (all P < 0.0001). Choroidalyzer's agreement with graders was comparable to the intergrader agreement across all metrics. Conclusions: Choroidalyzer is an open-source, end-to-end pipeline that accurately segments the choroid and reliably extracts thickness, area, and vascular index. Especially choroidal vessel segmentation is a difficult and subjective task, and fully automatic methods like Choroidalyzer could provide objectivity and standardization.

Applicability of Oculomics for Individual Risk Prediction: Repeatability and Robustness of Retinal Fractal Dimension Using DART and AutoMorph.

Purpose: To investigate whether fractal dimension (FD)-based oculomics could be used for individual risk prediction by evaluating repeatability and robustness. Methods: We used two datasets: "Caledonia," healthy adults imaged multiple times in quick succession for research (26 subjects, 39 eyes, 377 color fundus images), and GRAPE, glaucoma patients with baseline and follow-up visits (106 subjects, 196 eyes, 392 images). Mean follow-up time was 18.3 months in GRAPE; thus it provides a pessimistic lower bound because vasculature could change. FD was computed with DART and AutoMorph. Image quality was assessed with QuickQual, but no images were initially excluded. Pearson, Spearman, and intraclass correlation (ICC) were used for population-level repeatability. For individual-level repeatability, we introduce measurement noise parameter λ, which is within-eye standard deviation (SD) of FD measurements in units of between-eyes SD. Results: In Caledonia, ICC was 0.8153 for DART and 0.5779 for AutoMorph, Pearson/Spearman correlation (first and last image) 0.7857/0.7824 for DART, and 0.3933/0.6253 for AutoMorph. In GRAPE, Pearson/Spearman correlation (first and next visit) was 0.7479/0.7474 for DART, and 0.7109/0.7208 for AutoMorph (all P < 0.0001). Median λ in Caledonia without exclusions was 3.55% for DART and 12.65% for AutoMorph and improved to up to 1.67% and 6.64% with quality-based exclusions, respectively. Quality exclusions primarily mitigated large outliers. Worst quality in an eye correlated strongly with λ (Pearson 0.5350-0.7550, depending on dataset and method, all P < 0.0001). Conclusions: Repeatability was sufficient for individual-level predictions in heterogeneous populations. DART performed better on all metrics and might be able to detect small, longitudinal changes, highlighting the potential of robust methods.

Enhanced Surgical Safety through Protective Penetrating Keratoplasty: A Retrospective Analysis of 22 Cases.

Aim: To assess the surgical safety, postoperative outcomes, and the impact of PPK on corneal endothelial cell density through a retrospective analysis of 22 cases. Settings and Design. A retrospective cross-sectional observational study was executed at Hermanos Ameijeiras Hospital from February 2018 to December 2021, involving 22 patients (22 eyes) who were unresponsive to other medical treatments and had a corrected distance visual acuity of ≤0.1. Methods and Materials: Patients underwent PPK, with surgical procedures and postoperative care documented. Statistical analysis was performed on qualitative and quantitative variables to evaluate the surgical outcomes and the corneal endothelial cell density changes postoperation. Results: All surgeries demonstrated a significant improvement in postoperative visual acuity (p ≤ 0.001) and recorded a 9.2% decrease in the corneal endothelial cell density at 12 months. Noteworthy complications included one case of intraoperatively discovered haptic dislocation and one postoperative bacterial keratitis. Conclusions: PPK could potentially mitigate perioperative complications, ensure graft clarity, and reduce corneal endothelial cell loss, presenting itself as a viable alternative to traditional PK. Although the results are encouraging, larger-scale studies are essential to validate the benefits and applicability of PPK in broader clinical settings.

Retinal Changes From Hyperopia to Myopia: Not All Diopters Are Created Equal.

Purpose: To quantitatively characterize retinal changes across different quantiles of refractive error in 34,414 normal eyes of 23,064 healthy adults in the UK Biobank. Methods: Twelve optic disc (OD), foveal and vascular parameters were derived from color fundus photographs, correcting for ocular magnification as appropriate. Quantile regression was used to test the independent associations between these parameters and spherical equivalent refraction (SER) across 34 refractive quantiles (high hyperopia to high myopia)-controlling for age, sex and corneal radius. Results: More negative SER was nonlinearly associated with greater Euclidian (largely horizontal) OD-fovea distance, larger OD, less circular OD, more obliquely orientated OD (superior pole tilted towards the fovea), brighter fovea, lower vascular complexity, less tortuous vessels, more concave (straightened out towards the fovea) papillomacular arterial/venous arcade and wider central retinal arterioles/venules. In myopia, these parameters varied more strongly with SER as myopia increased. For example, while every standard deviation (SD) decrease in vascular complexity was associated with 0.63 D (right eye: 95% confidence interval [CI], 0.58-0.68) to 0.68 D (left eye: 95% CI, 0.63-0.73) higher myopia in the quantile corresponding to -0.60 D, it was associated with 1.61 D (right eye: 95% CI, 1.40-1.82) to 1.70 D (left eye: 95% CI, 1.56-1.84) higher myopia in the most myopic quantile. OD-fovea angle (degree of vertical separation between OD and fovea) was found to vary linearly with SER, but the magnitude was of little practical importance (less than 0.10 D variation per SD change in angle in almost all refractive quantiles) compared with the changes in OD-fovea distance. Conclusions: Several interrelated retinal changes indicative of an increasing (nonconstant) rate of mechanical stretching are evident at the posterior pole as myopia increases. These changes also suggest that the posterior pole stretches predominantly in the temporal horizontal direction.

Factors associated with pathologic myopia onset and progression: A systematic review and meta-analysis.

PURPOSE: To synthesise evidence across studies on factors associated with pathologic myopia (PM) onset and progression based on the META-analysis for Pathologic Myopia (META-PM) classification framework. METHODS: Findings from six longitudinal studies (5-18 years) were narratively synthesised and meta-analysed, using odds ratio (OR) as the common measure of association. All studies adjusted for baseline myopia, age and sex at a minimum. The quality of evidence was rated using the Grades of Recommendation, Assessment, Development and Evaluation framework. RESULTS: Five out of six studies were conducted in Asia. There was inconclusive evidence of an independent effect (or lack thereof) of ethnicity and sex on PM onset/progression. The odds of PM onset increased with greater axial length (pooled OR: 2.03; 95% CI: 1.71-2.40; p < 0.001), older age (pooled OR: 1.07; 1.05-1.09; p < 0.001) and more negative spherical equivalent refraction, SER (OR: 0.77; 0.68-0.87; p < 0.001), all of which were supported by an acceptable level of evidence. Fundus tessellation was found to independently increase the odds of PM onset in a population-based study (OR: 3.02; 2.58-3.53; p < 0.001), although this was only supported by weak evidence. There was acceptable evidence that greater axial length (pooled OR: 1.23; 1.09-1.39; p < 0.001), more negative SER (pooled OR: 0.87; 0.83-0.92; p < 0.001) and higher education level (pooled OR: 3.17; 1.36-7.35; p < 0.01) increased the odds of PM progression. Other baseline factors found to be associated with PM progression but currently supported by weak evidence included age (pooled OR: 1.01), severity of myopic maculopathy (OR: 3.61), intraocular pressure (OR: 1.62) and hypertension (OR: 0.21). CONCLUSIONS: Most PM risk/prognostic factors are not supported by an adequate evidence base at present (an indication that PM remains understudied). Current factors for which an acceptable level of evidence exists (limited in number) are unmodifiable in adults and lack personalised information. More longitudinal studies focusing on uncovering modifiable factors and imaging biomarkers are warranted.

Corneal biomechanics are not exclusively compromised in high myopia.

INTRODUCTION: Research assuming linearity has concluded that corneal biomechanics are compromised in high myopia. We investigated whether this assumption was appropriate and re-examined these associations across different levels of myopia. METHODS: Myopic (spherical equivalent refraction, SER ≤ -0.50 D) eyes of 10,488 adults aged 40-69 years without any history of systemic and ocular conditions were identified in the UK Biobank. Ordinary least squares (OLS) regression was employed to test the linear association between corneal hysteresis (CH) or corneal resistance factor (CRF), separately, and SER while controlling for age, sex, corneal radius and intraocular pressure. Quantile regression (QR) was used to test the same set of associations across 49 equally spaced conditional quantiles of SER. RESULTS: In OLS regression, each standard deviation (SD) decrease in CH and CRF was associated with 0.08 D (95% CI: 0.04-0.12; p < 0.001) and 0.10 D (95% CI: 0.04-0.15; p < 0.001) higher myopia, respectively. However, residual analysis indicated that the linearity assumption was violated. QR revealed no evidence of a significant association between CH/CRF and SER in low myopia, but a significant (p < 0.05) positive association became evident from -2.78 D (0.06 and 0.08 D higher myopia per SD decrease in CH and CRF). The magnitude of association increased exponentially with increasing myopia: in the -5.03 D quantile, every SD decrease in CH and CRF was associated with 0.17 D (95% CI: 0.08-0.25; p < 0.001) and 0.21 D (95% CI: 0.10-0.31; p < 0.001) higher myopia. In the -8.63 D quantile, this further increased to 0.54 D (95% CI: 0.33-0.76; p < 0.001) and 0.67 D (95% CI: 0.41-0.93; p < 0.001) higher myopia per SD decrease in CH and CRF. CONCLUSIONS: Corneal biomechanics appeared compromised from around -3.00 D. These changes were observed to be exponential with increasing myopia.

Retinal Fractal Dimension Is a Potential Biomarker for Systemic Health-Evidence From a Mixed-Age, Primary-Care Population.

Purpose: To investigate whether fractal dimension (FD), a retinal trait relating to vascular complexity and a potential "oculomics" biomarker for systemic disease, is applicable to a mixed-age, primary-care population. Methods: We used cross-sectional data (96 individuals; 183 eyes; ages 18-81 years) from a university-based optometry clinic in Glasgow, Scotland, to study the association between FD and systemic health. We computed FD from color fundus images using Deep Approximation of Retinal Traits (DART), an artificial intelligence-based method designed to be more robust to poor image quality. Results: Despite DART being designed to be more robust, a significant association (P < 0.001) between image quality and FD remained. Consistent with previous literature, age was associated with lower FD (P < 0.001 univariate and when adjusting for image quality). However, FD variance was higher in older patients, and some patients over 60 had FD comparable to those of patients in their 20s. Prevalent systemic conditions were significantly (P = 0.037) associated with lower FD when adjusting for image quality and age. Conclusions: Our work suggests that FD as a biomarker for systemic health extends to mixed-age, primary-care populations. FD decreases with age but might not substantially decrease in everyone. This should be further investigated using longitudinal data. Finally, image quality was associated with FD, but it is unclear whether this finding is measurement error caused by image quality or confounded by age and health. Future work should investigate this to clarify whether adjusting for image quality is appropriate. Translational Relevance: FD could potentially be used in regular screening settings, but questions around image quality remain.

Using artificial intelligence to improve human performance: efficient retinal disease detection training with synthetic images.

BACKGROUND: Artificial intelligence (AI) in medical imaging diagnostics has huge potential, but human judgement is still indispensable. We propose an AI-aided teaching method that leverages generative AI to train students on many images while preserving patient privacy. METHODS: A web-based course was designed using 600 synthetic ultra-widefield (UWF) retinal images to teach students to detect disease in these images. The images were generated by stable diffusion, a large generative foundation model, which we fine-tuned with 6285 real UWF images from six categories: five retinal diseases (age-related macular degeneration, glaucoma, diabetic retinopathy, retinal detachment and retinal vein occlusion) and normal. 161 trainee orthoptists took the course. They were evaluated with two tests: one consisting of UWF images and another of standard field (SF) images, which the students had not encountered in the course. Both tests contained 120 real patient images, 20 per category. The students took both tests once before and after training, with a cool-off period in between. RESULTS: On average, students completed the course in 53 min, significantly improving their diagnostic accuracy. For UWF images, student accuracy increased from 43.6% to 74.1% (p<0.0001 by paired t-test), nearly matching the previously published state-of-the-art AI model's accuracy of 73.3%. For SF images, student accuracy rose from 42.7% to 68.7% (p<0.0001), surpassing the state-of-the-art AI model's 40%. CONCLUSION: Synthetic images can be used effectively in medical education. We also found that humans are more robust to novel situations than AI models, thus showcasing human judgement's essential role in medical diagnosis.

Acute Pyelonephritis and an Incidental Diagnosis.

Gastrointestinal stromal tumors (GISTs) arise from the gastrointestinal tract. In rare cases, extra-gastrointestinal stromal tumors (EGISTs) occur in the omentum, mesentery, et cetera. They are mostly asymptomatic or have unspecific symptoms. Risk stratification classification systems are based on tumor size, mitotic rate, location, and perforation. The gold standard for diagnosis is a computed tomography (CT) scan. Ultrasound/CT-guided percutaneous biopsy allows histopathology and immunochemistry results (most stain positive for CD117 (c-KIT), CD34, and/or DOG1). Mutational analysis (most are in proto-oncogene c-KIT and platelet-derived growth factor receptor A (PDGFRA)) determines appropriate therapy. Surgical resection is the gold standard of treatment, with adjuvant and neoadjuvant molecular-targeted therapies depending on recurrence risk and mutations. This report describes a rare case of GIST (omentum EGIST) with a rare presentation (acute pyelonephritis) in a 67-year-old woman. Abdominal examination showed tenderness and a positive Murphy sign on the left side. Blood analysis presented microcytic hypochromic anemia, aggravated renal function, leukocytosis, and increased C-reactive protein. Abdominal CT revealed a heterogeneous abdominal mass, and a CT-guided biopsy showed epithelioid cells positive for CD117 and DOG1, which is compatible with a GIST. The patient underwent surgery that determined the GIST's origin from the greater omentum. Histology revealed an epithelioid GIST with large dimensions and a high histologic grade. Genetic testing detected a variant in the PDGFRA gene. With a high risk of progression, the patient received a three-year course of imatinib.

Hot-Melt Extrusion: from Theory to Application in Pharmaceutical Formulation-Where Are We Now?

Hot-melt extrusion (HME) is a globally recognized, robust, effective technology that enhances the bioavailability of poorly soluble active pharmaceutical ingredients and offers an efficient continuous manufacturing process. The twin-screw extruder (TSE) offers an extremely resourceful customizable mixer that is used for continuous compounding and granulation by using different combinations of conveying elements, kneading elements (forward and reverse configuration), and distributive mixing elements. TSE is thus efficiently utilized for dry, wet, or melt granulation not only to manufacture dosage forms such as tablets, capsules, or granule-filled sachets, but also for designing novel formulations such as dry powder inhalers, drying units for granules, nanoextrusion, 3D printing, complexation, and amorphous solid dispersions. Over the past decades, combined academic and pharmaceutical industry collaborations have driven novel innovations for HME technology, which has resulted in a substantial increase in published articles and patents. This article summarizes the challenges and models for executing HME scale-up. Additionally, it covers the benefits of continuous manufacturing, process analytical technology (PAT) considerations, and regulatory requirements. In summary, this well-designed review builds upon our earlier publication, probing deeper into the potential of twin-screw extruders (TSE) for various new applications.

Transitioning from MODIS to VIIRS Global Water Reservoir Product.

Reservoirs play a crucial role in regulating water availability and enhancing water security. Here, we develop NASA's Visible Infrared Imaging Radiometer Suite (VIIRS) based Global Water Reservoir (GWR) product, consisting of measurements of reservoir area, elevation, storage, evaporation rate, and evaporation loss for 164 large global reservoirs. The dataset is available at 8-day and monthly temporal resolutions. Since the Moderate Resolution Imaging Spectroradiometer (MODIS) is close to the end of its life, we further evaluated the consistency between MODIS and VIIRS-based GWR to ensure continuity to the 20+ year MODIS GWR product. Independent assessment of VIIRS reservoir storage (8-day) retrievals against in-situ measurements shows an average of R2 = 0.84, RMSE = 0.47 km3, and NRMSE = 16.45%. The evaporation rate has an average of R2 = 0.56, RMSE = 1.32 mm/day, and NRMSE = 28.14%. Furthermore, results show good consistency (R2 ≥ 0.90) between the VIIRS and MODIS-based product components, confirming that long-term data continuity can be achieved. This dataset can provide valuable insights for long-term trend analysis, hydrological modeling, and understanding hydroclimatic extremes in the context of reservoirs.

An in vitro agent-based modelling approach to optimization of culture medium for generating muscle cells.

Methodologies for culturing muscle tissue are currently lacking in terms of quality and quantity of mature cells produced. We analyse images from in vitro experiments to quantify the effects of culture media composition on mouse-derived myoblast behaviour and myotube quality. Metrics of early indicators of cell quality were defined. Images of muscle cell differentiation reveal that altering culture media significantly affects quality indicators and myoblast migratory behaviours. To study the effects of early-stage cell behaviours on mature cell quality, metrics drawn from experimental images or inferred by approximate Bayesian computation (ABC) were applied as inputs to an agent-based model (ABM) of skeletal muscle cell differentiation with quality indicator metrics as outputs. Computational modelling was used to inform further in vitro experiments to predict the optimum media composition for culturing muscle cells. Our results suggest that myonuclei production in myotubes is inversely related to early-stage nuclei fusion index and that myonuclei density and spatial distribution are correlated with residence time of fusing myoblasts, the age at which myotube-myotube fusion ends and the repulsion force between myonuclei. Culture media with 5% serum was found to produce the optimum cell quality and to make muscle cells cultured in a neuron differentiation medium viable.

Inhaled JAK Inhibitor GDC-0214 Nanoaggregate Powder Exhibits Improved Pharmacokinetic Profile in Rats Compared to the Micronized Form: Benefits of Thin Film Freezing.

Asthma is a common chronic disease affecting the airways in the lungs. The receptors of allergic cytokines, including interleukin (IL)-4, IL-5, and IL-13, trigger the Janus kinase (JAK)/signal transducer and activator of transcription (STAT) pathway, which involves the pathogenesis of asthma. GDC-0214 is a JAK inhibitor that was developed as a potent and selective target for the treatment of asthma, specifically targeting the lungs. While inhaled GDC-0214 is a promising novel treatment option against asthma, improvement is still needed to achieve increased potency of the powder formulation and a reduced number of capsules containing powder to be inhaled. In this study, high-potency amorphous powder formulations containing GDC-0214 nanoaggregates for dry powder inhalation were developed using particle engineering technology, thin film freezing (TFF). A high dose per capsule was successfully achieved by enhancing the solubility of GDC-0214 and powder conditioning. Lactose and/or leucine as excipients exhibited optimum stability and aerosolization of GDC-0214 nanoaggregates, and aerosolization of the dose was independent of air flow through the device between 2 and 6 kPa pressure drops. In the rat PK study, formulation F20, which contains 80% GDC-0214 and 20% lactose, resulted in the highest AUC0-24h in the lungs with the lowest AUC0-24h in the plasma that corresponds to a 4.8-fold higher ratio of the lung-to-plasma exposures compared to micronized crystalline GDC-0214 powder administered by dry powder inhalation. Therefore, GDC-0214 nanoaggregates produced by TFF provided an improved dry powder for inhalation that can lead to enhanced therapeutic efficacy with a lower risk of systemic toxicity.

Novel linkage approach to join community-acquired and national data.

BACKGROUND: Community optometrists in Scotland have performed regular free-at-point-of-care eye examinations for all, for over 15 years. Eye examinations include retinal imaging but image storage is fragmented and they are not used for research. The Scottish Collaborative Optometry-Ophthalmology Network e-research project aimed to collect these images and create a repository linked to routinely collected healthcare data, supporting the development of pre-symptomatic diagnostic tools. METHODS: As the image record was usually separate from the patient record and contained minimal patient information, we developed an efficient matching algorithm using a combination of deterministic and probabilistic steps which minimised the risk of false positives, to facilitate national health record linkage. We visited two practices and assessed the data contained in their image device and Practice Management Systems. Practice activities were explored to understand the context of data collection processes. Iteratively, we tested a series of matching rules which captured a high proportion of true positive records compared to manual matches. The approach was validated by testing manual matching against automated steps in three further practices. RESULTS: A sequence of deterministic rules successfully matched 95% of records in the three test practices compared to manual matching. Adding two probabilistic rules to the algorithm successfully matched 99% of records. CONCLUSIONS: The potential value of community-acquired retinal images can be harnessed only if they are linked to centrally-held healthcare care data. Despite the lack of interoperability between systems within optometry practices and inconsistent use of unique identifiers, data linkage is possible using robust, almost entirely automated processes.

Higher intraocular pressure is associated with slower axial growth in children with non-pathological high myopia.

OBJECTIVES: To investigate the association between intraocular pressure (IOP) and axial elongation rate in highly myopic children from the ZOC-BHVI High Myopia Cohort Study. METHODS: 162 eyes of 81 healthy children (baseline spherical equivalent: -6.25 D to -15.50 D) aged 7-12 years with non-pathological high myopia were studied over five biennial visits. The mean (SD) follow-up duration was 5.2 (3.3) years. A linear mixed-effects model (LMM) was used to assess the association between IOP (at time point t-1) and axial elongation rate (annual rate of change in AL from t-1 to t), controlling for a pre-defined set of covariates including sex, age, central corneal thickness, anterior chamber depth and lens thickness (at t-1). LMM was also used to assess the contemporaneous association between IOP and axial length (AL) at t, controlling for the same set of covariates (at t) as before. RESULTS: Higher IOP was associated with slower axial growth (ß = -0.01, 95% CI -0.02 to -0.005, p = 0.001). There was a positive contemporaneous association between IOP and AL (ß = 0.03, 95% CI 0.01-0.05, p = 0.004), but this association became progressively less positive with increasing age, as indicated by a negative interaction effect between IOP and age on AL (ß = -0.01, 95% CI -0.01 to -0.003, p = 0.001). CONCLUSIONS: Higher IOP is associated with slower rather than faster axial growth in children with non-pathological high myopia, an association plausibly confounded by the increased influence of ocular compliance on IOP.

Immune Checkpoint Inhibitor-Induced Pure Red Cell Aplasia: A Review of 2 Cases in Metastatic Melanoma.

BACKGROUND Immunotherapy is a novel treatment offering an alternative to traditional chemotherapeutic agents for different malignancies. Hematologic adverse reactions (HARs) related to immune checkpoint inhibitors (ICIs) are uncommon. Pure red cell aplasia (PRCA) is a rare hematologic complication of ICI therapy in metastatic melanoma with significant mortality risk despite treatment with steroids or immunosuppressive therapy. For unexplained acute anemia after exclusion of other causes, performing bone marrow biopsy is imperative to diagnose PRCA and rule out involvement of bone marrow by primary tumor. HARs can occur during ICI therapy or even after ICI therapy is stopped. ICI rechallenge, even after the development of HARs, is considered in some patients with good response to treatment of HARs from ICIs. Recurrence of HARs with the same or different type of reaction is seen in some patients. CASE REPORT Two cases of ICI-induced PRCA were confirmed on bone marrow biopsy after dual ICI treatment with nivolumab and ipilimumab in metastatic melanoma. In case 2, PRCA was successfully treated with steroids and later rechallenged with single-agent nivolumab, causing mild ICI-induced immune thrombocytopenia, which did not require treatment with steroids. CONCLUSIONS It is crucial to increase clinician awareness of the possibility of PRCA development not only during treatment with ICI but also after finishing treatment with ICI; there is high mortality associated with missing an opportunity to diagnose and treat PRCA on time with favorable results. ICI rechallenge can be considered in patients who showed response to immunotherapy, especially those with limited alternative therapeutic options.

An Open-Source Deep Learning Algorithm for Efficient and Fully Automatic Analysis of the Choroid in Optical Coherence Tomography.

Purpose: To develop an open-source, fully automatic deep learning algorithm, DeepGPET, for choroid region segmentation in optical coherence tomography (OCT) data. Methods: We used a dataset of 715 OCT B-scans (82 subjects, 115 eyes) from three clinical studies related to systemic disease. Ground-truth segmentations were generated using a clinically validated, semiautomatic choroid segmentation method, Gaussian Process Edge Tracing (GPET). We finetuned a U-Net with the MobileNetV3 backbone pretrained on ImageNet. Standard segmentation agreement metrics, as well as derived measures of choroidal thickness and area, were used to evaluate DeepGPET, alongside qualitative evaluation from a clinical ophthalmologist. Results: DeepGPET achieved excellent agreement with GPET on data from three clinical studies (AUC = 0.9994, Dice = 0.9664; Pearson correlation = 0.8908 for choroidal thickness and 0.9082 for choroidal area), while reducing the mean processing time per image on a standard laptop CPU from 34.49 ± 15.09 seconds using GPET to 1.25 ± 0.10 seconds using DeepGPET. Both methods performed similarly according to a clinical ophthalmologist who qualitatively judged a subset of segmentations by GPET and DeepGPET, based on smoothness and accuracy of segmentations. Conclusions: DeepGPET, a fully automatic, open-source algorithm for choroidal segmentation, will enable researchers to efficiently extract choroidal measurements, even for large datasets. As no manual interventions are required, DeepGPET is less subjective than semiautomatic methods and could be deployed in clinical practice without requiring a trained operator. Translational Relevance: DeepGPET addresses the lack of open-source, fully automatic, and clinically relevant choroid segmentation algorithms, and its subsequent public release will facilitate future choroidal research in both ophthalmology and wider systemic health.

Early Experiences of Integrating an Artificial Intelligence-Based Diagnostic Decision Support System into Radiology Settings: A Qualitative Study.

BACKGROUND: Artificial Intelligence (AI) based clinical decision support systems to aid diagnosis are increasingly being developed and implemented but with limited understanding of how such systems integrate with existing clinical work and organizational practices. We explored the early experiences of stakeholders using an AI-based e-learning imaging software tool Veye Lung Nodules (VLN) aiding the detection, classification, and measurement of pulmonary nodules in computed tomography scans of the chest. We performed semi-structured interviews and observations across early adopter deployment sites with clinicians, strategic decision-makers, suppliers, patients with long-term chest conditions, and academics with expertise in the use of diagnostic AI in radiology settings. We coded the data using the Technology, People, Organizations and Macro-environmental factors framework (TPOM). We conducted 39 interviews. Clinicians reported VLN to be easy to use with little disruption to the workflow. There were differences in patterns of use between experts and novice users with experts critically evaluating system recommendations and actively compensating for system limitations to achieve more reliable performance. Patients also viewed the tool positively. There were contextual variations in tool performance and use between different hospital sites and different use cases. Implementation challenges included integration with existing information systems, data protection, and perceived issues surrounding wider and sustained adoption, including procurement costs. Tool performance was variable, affected by integration into workflows and divisions of labor and knowledge, as well as technical configuration and infrastructure. These under-researched factors require attention and further research.