Theoretical Perspectives Underpinning Research on the Physician-Patient Relationship in a Digital Health Practice: Scoping Review.

BACKGROUND: The advent of digital health technologies has transformed the landscape of health care, influencing the dynamics of the physician-patient relationship. Although these technologies offer potential benefits, they also introduce challenges and complexities that require ethical consideration. OBJECTIVE: This scoping review aims to investigate the effects of digital health technologies, such as digital messaging, telemedicine, and electronic health records, on the physician-patient relationship. To understand the complex consequences of these tools within health care, it contrasts the findings of studies that use various theoretical frameworks and concepts with studies grounded in relational ethics. METHODS: Using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines, we conducted a scoping review. Data were retrieved through keyword searches on MEDLINE/PubMed, Embase, IEEE Xplore, and Cochrane. We screened 427 original peer-reviewed research papers published in English-language journals between 2010 and 2021. A total of 73 papers were assessed for eligibility, and 10 of these were included in the review. The data were summarized through a narrative synthesis of the findings. RESULTS: Digital health technologies enhance communication, improve health care delivery efficiency, and empower patients, leading to shifts in power dynamics in the physician-patient relationship. They also potentially reinforce inequities in health care access due to variations in technology literacy among patients and lead to decreases in patient satisfaction due to the impersonal nature of digital interactions. Studies applying a relational ethics framework have revealed the nuanced impacts of digital health technologies on the physician-patient relationship, highlighting shifts toward more collaborative and reciprocal care. These studies have also explored transitions from traditional hierarchical relationships to mutual engagement, capturing the complexities of power dynamics and vulnerabilities. Other theoretical frameworks, such as patient-centered care, and concepts, such as patient empowerment, were also valuable for understanding these interactions in the context of digital health. CONCLUSIONS: The shift from hierarchical to collaborative models in the physician-patient relationship not only underscores the empowering potential of digital tools but also presents new challenges and reinforces existing ones. Along with applications for various theoretical frameworks and concepts, this review highlights the unique comprehensiveness of a relational ethics perspective, which could provide a more nuanced understanding of trust, empathy, and power dynamics in the context of digital health. The adoption of relational ethics in empirical research may offer richer insights into the real-life complexities of the physician-patient relationship, as mediated by digital technologies.

Algorithms for early detection of silent liver fibrosis in the primary care setting - a scoping review.

INTRODUCTION: Fatty liver disease affects almost 30% of the adult population worldwide. Most patients are asymptomatic, and there is not a linear relationship between exposure to risk factors and the risk of developing fibrosis. The combination of a very large, asymptomatic risk population where only a few percent will develop life-threatening liver disease is a growing diagnostic challenge for the health services. Accurate fibrosis assessment in primary care is limited by poor correlation with liver blood tests and low availability of elastography. Non-invasive tests are promising tools, but little is known about their diagnostic accuracy in low-risk populations. AREAS COVERED: A scoping review was conducted to identify articles that focused on the current use of biomarkers and algorithms in primary care for the detection of patients with fatty liver disease in need of referral for further work-up. EXPERT OPINION: Currently available algorithms for targeted screening for liver fibrosis perform better than the individual routine liver blood tests or liver ultrasonography. However, primary care physicians urgently need algorithms with even higher diagnostic accuracies than what is available today. The main limitation of the existing widely accessible algorithms, such as the FIB-4, is the large number of false-positive tests, resulting in overdiagnosis and futile referrals to secondary care.

Vortex Whistle and Smart Phone Application for Peak Flow Recordings in Asthmatic Children: A Feasibility Study.

Introduction: Variable airflow obstruction that can be confirmed by diurnal variability of peak expiratory flow (PEF) >13% is an important characteristic of asthma. Home monitoring of PEF may be helpful to diagnose and monitor asthma. In this feasibility study, we aimed to study if asthmatic children can measure PEF at home twice daily during a 4-week period using a device designed as a "whistle" and a smart phone software application.Materials and Methods: Twice daily during 4 weeks, children aged 5-12 years with current asthma rated their asthma condition electronically on the smart phone application Blowfish before inhaling deeply then exhaling into the device to produce a high-pitched sound recorded by the application. Through mathematical algorithms, the sound was transferred to PEF, which was uploaded to a server. At inclusion, the Pediatric Asthma Quality of Life Questionnaire and the Childhood Asthma Control Test were answered. At the end, the parents graded the device and application.Results: One child did not manage to upload PEF. For the remaining 21 children, the median (quartiles) days with at least one measurement during the period were 27 (21-29.5), and on median 18 (9-24) days PEF was recorded twice daily. The median parental score (potential score 0-20) of the application was 18 (15-20).Discussion/Conclusion: The study shows promising results for home monitoring of PEF by an electronic device with automatic teletransmission. The high rate of successful recordings and parental satisfaction suggests that the clinical utility of the solution should be further studied.

Measuring Oxygen Saturation With Smartphone Cameras Using Convolutional Neural Networks.

Arterial oxygen saturation ([Formula: see text]) is an indicator of how much oxygen is carried by hemoglobin in the blood. Having enough oxygen is vital for the functioning of cells in the human body. Measurement of [Formula: see text] is typically estimated with a pulse oximeter, but recent works have investigated how smartphone cameras can be used to infer [Formula: see text]. In this paper, we propose methods for the measurement of [Formula: see text] with a smartphone using convolutional neural networks and preprocessing steps to better guard against motion artifacts. To evaluate this methodology, we conducted a breath-holding study involving 39 participants. We compare the results using two different mobile phones. We compare our model with the ratio-of-ratios model that is widely used in pulse oximeter applications, showing that our system has significantly lower mean absolute error (2.02%) than a medical pulse oximeter.

VEGF-A mRNA measurement in meningiomas using a new simplified approach: branched DNA and chemiluminescence.

For decades, the preferred and almost sole method for measurement of gene expression has been RT-qPCR. The method is robust, inexpensive, and well-studied; however, PCR is also quite laborious and vulnerable to contamination. As part of an investigation of VEGF-A gene expression in meningiomas, an alternative and less laborious method for gene expression analysis based on branched DNA hybridization and chemiluminescence (Lumistar) was tested. Albeit the two methods differ, in principle, cellular mRNA-concentration is measured with both. Because they both determine gene expression via the measurement of mRNA-concentration, they were expected to be comparable. The aim of the present study was to compare Lumistar to the traditional RT-qPCR approach in a routine laboratory setting, where there is emphasis on rapid analysis response. Meningioma (n = 10) and control brain tissue (n = 5) samples were collected and VEGF-A and GAPDH mRNA were quantified using both RT-qPCR and Lumistar. Furthermore, two dilution series of two of the meningioma samples were prepared in order to make quantitative analyses. Both Lumistar and RT-qPCR-results were found to follow concentration dependent linear paths when diluted (p < 0.0001 and p < 0.01). Finally, Lumistar and RT-qPCR analyses were performed with the inclusion of a reference gene (GAPDH), where similar results were obtained with the two methods (R2 = 0.48; p = 0.01). It is intriguing that in spite of the vast difference in handling and assay principles, gene expression results are similar. The preferred method depends on the variability of the samples, budget, and time. Lumistar was less time consuming, while RT-qPCR was less expensive and best suited for data sets with large sample variability.

Intracranial meningiomas, the VEGF-A pathway, and peritumoral brain oedema.

Meningiomas are the second-most common intracranial tumours in adults. They are derived from the arachnoid cells, and although approximately 90% of meningiomas are benign, more than half of all meningiomas develop peritumoral brain oedema (PTBE), which increases morbidity. The PTBE can be treated with steroid therapy, but this treatment is not specific, is not always effective, and involves long-term side-effects. Meningiomas are treated with radiation therapy, stereotactic radio-surgery or surgical resection. At the moment surgical resection is the only definite treatment, and the removal of the tumour also removes the PTBE. Based on the localization of the meningioma, surgery can be complicated. Although PTBE around meningiomas is frequent, the mechanisms behind its development are not clearly understood. It is believed that due to tumour growth and local tissue hypoxia, angiogenesis is increased and leads to the formation of PTBE. The angiogenic protein vascular endothelial growth factor A (VEGF-A) is believed to be involved in the formation of PTBE around meningiomas, as several studies have found that it is increased in meningiomas with PTBE. VEGF-A is also known as vascular permeability factor due to its ability to increase the permeability of capillaries. Paper I examines the VEGF-A protein and mRNA levels in 101 intracranial meningiomas. The PTBE is quantified on MRI, and capillary length and tumour water content are measured and compared to control brain tissue. Possible co-factors to PTBE like meningioma localization and subtypes are also examined. Forty-three of the patients have primary, solitary, supratentorial meningiomas with PTBE. The correlation between PTBE or edema index with the VEGF-A protein and mRNA, capillary length, and tumour water content is investigated in these patients. A novel method is used for mRNA quantification. It involves direct amplification of the mRNA with probes and branched DNA in order to produce a chemiluminescence signal that can be measured using a luminometer. The paper shows that the oedema index is correlated to the VEGF-A protein and mRNA, and that capillary length is correlated to the PTBE. It also finds that VEGF-A protein and mRNA, capillary length and water content is increased in meningiomas compared to control tissue, suggesting that VEGF-A is produced in, and possibly secreted from the meningiomas. In addition, supratentorial meningiomas are shown to have larger PTBE compared to infratentorial meningiomas, suggesting that infratentorial meningiomas are diagnosed and removed earlier, due to earlier symptom development based on the anatomical features of the fossa posterior. Finally, a gender-specific difference in tumour water content and VEGF-A protein is revealed (higher and lower in females, respectively). Paper II is a method-comparison study pitting the chemiluminescence assay against the often used quantitative real-time reverse transcription polymerase chain reaction (RT-qPCR) assay. In RT-qPCR, RNA is isolated, measured, reverse transcribed, purified, amplified via real-time PCR, and analyzed. The method is robust and reliable, albeit laborious to some extent. The chemiluminescence assay detects RNA directly without the need for RNA purification, complement DNA synthesis or cyclic amplification. By comparing the output of the two protocols to a dilution series ranging from 1 to 128 times of the homogenized samples, the precision of the protocols is measured. Furthermore, VEGF-A/GAPDH ratios are quantified for 15 tissue samples and the results compared between the two protocols, showing significant correlation. The study finds that the chemiluminescence assay is competitive to RT-qPCR, and reflects a similar pattern in gene expression measurement with a similar precision. Whether one method or the other should be used depends on the variability of the samples, budget, and time. RT-qPCR has a much wider dynamic range, and is preferable in case of significant sample inter-variability. It is also less expensive, and gives the user more flexibility as homemade reagents can be used. On the other hand, the chemiluminescence assay is straight forward, requires less hands-on-time, and can be used on formalin-fixed and paraffin-embedded (FFPE) tissue. Paper III continues the investigations in paper I. The sample size is increased so that 22 angiomatous and secretory meningiomas are compared to 40 non-angiomatous meningiomas and 10 control brain tissue samples. Angiomatous and secretory meningiomas are chosen because they are known to have larger PTBE compared to other meningiomas. In addition to VEGF-A, capillary length, and PTBE, the VEGF-A tyrosine kinase receptor VEGFR-2 mRNA and protein levels are also examined. VEGFR-2 is a transmembrane receptor found on endothelial cells. It binds VEGF-A and thereby increases angiogenesis. VEGFR-2's co-receptor neuropilin-1 is also examined. Neuropilin-1 is an agonist of angiogenesis through complex-binding of VEGF-A, but it can also work as an inhibitor through competitive binding of semaphorin-3A. The complex binding of semaphorin-3A to neuropilin-1 can also induce endothelial cell apoptosis, thus working as an antagonist of angiogenesis. The study finds that VEGF-A mRNA, VEGF-A protein, and neuropilin-1 mRNA are higher in angiomatous and non-angiomatous meningiomas compared to controls. VEGFR-2 protein is higher, and neuropilin-1 protein lower in angiomatous meningiomas compared to controls. The mean capillary length is 3614 mm/mm3 in angiomatous, 605 mm/mm3 in non-angiomatous meningiomas, and 229 mm/mm3 in the controls. Non-angiomatous and angiomatous meningioma patients have equally sized tumours. The mean PTBE around the angiomatous meningiomas is 695 cm3, i.e. 477 cm3 larger than the non-angiomatous meningiomas (p = 0.0045), and the mean oedema index is twice the size compared to the non-angiomatous meningiomas. Further comparison between the two meningioma groups shows that mean VEGF-A mRNA, VEGFR-2 protein, and neuropilin-1 mRNA is significantly higher and neuropilin-1 protein is lower in the angiomatous meningiomas. We believe that the VEGF-A pathway participates in the formation of PTBE in meningiomas by inducing formation of "leaky" capillaries, resulting in secretion of VEGF-A and plasma to the peritumoural brain tissue. It may therefore be worth pursuing therapies targeted directly against VEGF-A and its receptors through drugs like bevacizumab, sorafenib, sunitifib, and cediranib.

Peritumoral brain edema in angiomatous supratentorial meningiomas: an investigation of the vascular endothelial growth factor A pathway.

The aim of this work was to study the vascular endothelial growth factor A (VEGF-A) pathway and peritumoral brain edema (PTBE) through comparison of non-angiomatous and angiomatous meningiomas. Meningiomas are common intracranial tumors, which often have PTBE. VEGF-A is an integral part of PTBE formation and angiogenesis, and the capillary-rich angiomatous meningiomas are known for their PTBE. The VEGF-A receptor VEGFR-2 is responsible for the angiogenic effect of VEGF-A on endothelial cells, which is enhanced by the co-receptor neuropilin-1. Forty non-angiomatous, 22 angiomatous meningiomas, and 10 control tissue samples were collected for the study. Magnetic resonance images were available for 40 non-angiomatous and 10 angiomatous meningiomas. Tissue sections were immunostained for CD34, MIB-1, estrogen- and progesterone receptors. ELISA, chemiluminescence, and RT-qPCR were used for VEGF-A, VEGFR-2, and neuropilin-1 protein and mRNA quantification. Angiomatous meningiomas had larger PTBE (695 vs 218 cm(3) , p = 0.0045) and longer capillary length (3614 vs 605 mm/mm(3) , p < 0.0001). VEGF-A mRNA, neuropilin-1 mRNA, and VEGFR-2 protein levels were higher in angiomatous meningiomas independently of the capillary length (p < 0.05). Neuropilin-1 protein levels were lower in angiomatous meningiomas (p < 0.0001). The VEGF-A pathway and tumor capillary length may be essential for PTBE-formation in meningiomas. Further investigations of this pathway could lead to earlier therapy and targeted pharmacological treatment options.

Vascular endothelial growth factor A protein level and gene expression in intracranial meningiomas with brain edema.

Meningiomas are the second most common primary intracranial tumors in adults. Although meningiomas are mostly benign, more than 50% of patients with meningioma develop peritumoral brain edema (PTBE), which may be fatal because of increased intracranial pressure. Vascular endothelial growth factor (VEGF) is an endothelial cell-specific mitogen and angiogen. VEGF-A protein, which is identical to vascular permeability factor, is a regulator of angiogenesis. In this study, 101 patients with meningiomas, and possible co-factors to PTBE, such as meningioma subtypes and tumor location, were examined. Forty-three patients had primary, solitary, supratentorial meningiomas with PTBE. In these, correlations in PTBE, edema index, VEGF-A protein, VEGF gene expression, capillary length, and tumor water content were investigated. DNA-branched hybridization was used for measuring VEGF gene expression in tissue homogenates prepared from frozen tissue samples. The method for VEGF-A analysis resembled an ELISA assay, but was based on chemiluminescence. The edema index was positively correlated to VEGF-A protein (p = 0.014) and VEGF gene expression (p < 0.05). The capillary length in the meningiomas was positively correlated to the PTBE (p = 0.038). If VEGF is responsible for the formation of PTBE, the edema may be treated with the anti-VEGF drug Bevacizumab (Avastin), which has been shown to reduce PTBE in patients with glioblastoma multiforme.

[Primary psoas abscess in a young healthy male]. / Primaer psoasabsces hos en ung rask mand.

A young male saw his general practitioner because of lower back pain, limpness, nightly sweating, subfebrilia, and weight loss. Further diagnostics showed that he had a primary psoas abscess. Psoas abscesses are categorized as primary and secondary. Primary psoas abscess is a rare disease in Europe and North America. It is primarily seen in young men, and the classical symptom-triad is: fever, back pain, and limpness. The golden standard diagnostic tool is computed tomography, and treatment involves appropriate antibiotics, which can be combined with percutaneous drainage.