Cardiac Arrhythmia Classification Using Advanced Deep Learning Techniques on Digitized ECG Datasets.

ECG classification or heartbeat classification is an extremely valuable tool in cardiology. Deep learning-based techniques for the analysis of ECG signals assist human experts in the timely diagnosis of cardiac diseases and help save precious lives. This research aims at digitizing a dataset of images of ECG records into time series signals and then applying deep learning (DL) techniques on the digitized dataset. State-of-the-art DL techniques are proposed for the classification of the ECG signals into different cardiac classes. Multiple DL models, including a convolutional neural network (CNN), a long short-term memory (LSTM) network, and a self-supervised learning (SSL)-based model using autoencoders are explored and compared in this study. The models are trained on the dataset generated from ECG plots of patients from various healthcare institutes in Pakistan. First, the ECG images are digitized, segmenting the lead II heartbeats, and then the digitized signals are passed to the proposed deep learning models for classification. Among the different DL models used in this study, the proposed CNN model achieves the highest accuracy of ∼92%. The proposed model is highly accurate and provides fast inference for real-time and direct monitoring of ECG signals that are captured from the electrodes (sensors) placed on different parts of the body. Using the digitized form of ECG signals instead of images for the classification of cardiac arrhythmia allows cardiologists to utilize DL models directly on ECG signals from an ECG machine for the real-time and accurate monitoring of ECGs.

Migration of the anal distal end due to ventriculoperitoneal shunt placement: an atypical case report of a 9-month-old infant with tuberculous meningitis and review of the literature.

BACKGROUND: Ventriculoperitoneal shunt (VPS) represents one of the most classic and widely used treatments for hydrocephalus in pediatric patients. Migration and externalization of the distal end of the catheter through the rectum are extremely rare complications of intestinal perforation with devastating consequences such as meningitis or peritonitis due to enteric bacteria that are significantly life-threatening. Besides, one of the biggest topics with that is that it can happen without producing symptoms, like the patient we present in this case report, which further masks the condition and puts the patient's life more at risk. CASE PRESENTATION: We present a case of a 9-month-old infant patient, with a history of prematurity, tuberculous meningitis (TBM), and hydrocephalus, who came to ED with a functional VPS and the distal end of the catheter protruding outside the rectum for 7 days, without presenting neurological or intestinal symptoms accompanying. One of the parameters that guided the diagnosis and made us suspicious of asymptomatic intestinal perforation (IP) was the background of TMB. The patient was immediately transferred to the OR where both ends of the shunt were removed: in the first instance, the shunt tube was disconnected through the abdomen, thus withdrawing through the anus, and subsequently, the proximal end of the catheter was exteriorized. In turn, the intestinal fistula was successfully repaired laparoscopically, and prophylactic antibiotic treatment was early administered. On the 6th postop day, a shunt was internalized, and a child was discharged on postop day 15 without complications with alarm guidelines. CONCLUSIONS: The authors of this article strongly suggest that (1) anal extrusion of catheters is an uncommon complication but real: for this reason, its development should be considered in all patients with VPS, especially in infants. (2) The patients are often asymptomatic since false tracts can form around the catheter protecting it from spillage, and thus can be removed without complications. (3) Special care should be taken in patients with conditions that increase the risk of developing IP, such as TMB.

Supraorbital keyhole approaches in the first 3 years of practice: outcomes and lessons learned. Patient series.

BACKGROUND: Supraorbital keyhole approaches (SKAs) have garnered criticism for a limited surgical exposure, restrictive surgical freedom, blind spots, and the learning curve. This retrospective study of patients who underwent SKA aims to explore the outcomes, technical nuances, and the learning curve reflected in a single surgeon's experience in the initial 3 years of practice. OBSERVATIONS: A total of 20 SKA operations were performed in 19 patients. Gross- or near-total resection was achieved in 14 of 17 tumor cases. The mean blood loss was 80.5 mL, the mean duration of surgery was 5 hours, and the median stay was 3 days. Endoscopic augmentation was used in 11 cases in which additional tumor removal occurred in 8 of the 11 cases. There were no cases of cerebrospinal fluid leakage or wound infection. A 30-day readmission and typical narcotics after discharge were seen in one patient each. When comparing two halves of a neurosurgery practice over 3 years, the duration of surgery was significantly longer in the later year, which is likely due to operating on a larger tumor size as the years progressed. No cases required static retractors or conversion to larger craniotomies. LESSONS: Careful case selection and respecting the learning curve allows the safe incorporation of SKA in the early stages of neurosurgical practice.

Carotid Artery Tortuosity and Internal Carotid Artery Plaque Composition.

BACKGROUND: Little is known about the association between carotid artery tortuosity and internal carotid artery atherosclerosis. This study sought to evaluate the associations between various types of arterial tortuosity and vulnerable plaque components on magnetic resonance angiography (MRA). MATERIAL AND METHODS: A retrospective review was completed of 102 patients who had undergone MRA neck imaging, with intraplaque hemorrhage (IPH) present in one or both cervical internal carotid arteries (ICA). Each ICA was assessed for two categories of tortuosity: variant arterial pathway(s) (retrojugular and/or retropharyngeal) and abnormal curvature (kinks, loops, and/or coils). All ICA plaques were assessed for the presence or absence of intraplaque hemorrhage (IPH), lipid-rich necrotic core (LRNC), ulceration, and enhancement, as well as the volume of IPH and degree of luminal stenosis. RESULTS: The mean age of included patients was 73.5 years (SD = 9.0 years) and 88 (86.3%) subjects were male. The left carotid plaque was significantly more likely to have IPH (68.6% vs. 47.1%; p = 0.02). The left ICA was more likely to have a retrojugular course (22% vs. 9.9%; p = 0.002) and any variant arterial course (26.5% versus 14.67%, p = 0.01). On the right there was an association between the presence of a LRNC and retropharyngeal and/or retrojugular arterial pathway (p = 0.03). On the left there was an association between the presence of any abnormal arterial curvature and IPH volume (p = 0.03). Neither association met the adjusted statistical threshold after Bonferroni correction, with alpha set at 0.0028. CONCLUSION: ICA tortuosity is not associated with carotid artery plaque composition, and likely does not play a role in the development of high-risk plaques.

Generalizable Natural Language Processing Framework for Migraine Reporting from Social Media.

Migraine is a highly prevalent and disabling neurological disorder. However, information about migraine management in real-world settings is limited to traditional health information sources. In this paper, we (i) verify that there is substantial migraine-related chatter available on social media (Twitter and Reddit), self-reported by those with migraine; (ii) develop a platform-independent text classification system for automatically detecting self-reported migraine-related posts, and (iii) conduct analyses of the self-reported posts to assess the utility of social media for studying this problem. We manually annotated 5750 Twitter posts and 302 Reddit posts, and used them for training and evaluating supervised machine learning methods. Our best system achieved an F1 score of 0.90 on Twitter and 0.93 on Reddit. Analysis of information posted by our 'migraine cohort' revealed the presence of a plethora of relevant information about migraine therapies and sentiments associated with them. Our study forms the foundation for conducting an in-depth analysis of migraine-related information using social media data.

Intraplaque hemorrhage on magnetic resonance angiography: How often do signal abnormalities persist on follow-up imaging?

BACKGROUND AND PURPOSE: Intraplaque hemorrhage (IPH) in carotid atherosclerosis demonstrates increased signal on magnetic resonance angiography images. Little remains known about how this signal changes on subsequent examinations. MATERIALS AND METHODS: A retrospective observational study was completed of patients that had IPH on a neck MRA between 1/1/2016 and 3/25/2021, defined as ≥ 200 % signal intensity of the sternocleidomastoid muscle on MPRAGE images. Examinations were excluded if the patients had undergone carotid endarterectomy between examinations or had poor quality imaging. IPH volumes were calculated by manually outlining IPH components. Up to 2 subsequent MRAs, if available, were assessed for both the presence and volume of IPH. RESULTS: 102 patients were included, of which 90 (86.5 %) were male. IPH was on the right in 48 patients (average volume = 174.0 mm3), and on the left in 70 patients (average volume 186.9 mm3). 22 had at least one follow-up (average 444.7 days between exams), and 6 had two follow-up MRAs (average 489.5 days between exams). On the first follow-up, 19 (86.4 %) plaques had persistent hyperintense signal in the region of IPH. The second follow-up showed persistent signal in 5/6 plaques (88.3 %). Combined volume of IPH from right and left carotid arteries did not significantly decrease on the first follow-up exam (p = 0.08). CONCLUSIONS: IPH usually retains hyperintense signal on follow-up MRAs, possibly representing recurrent hemorrhage or degraded blood products.

Construction and Validation of a Benchtop Model for Testing of Mechanical Thrombectomy Devices for Pulmonary Embolism.

PURPOSE: This study aims to define the process of designing and manufacturing 3D printed and glass models of the pulmonary artery (PA) and utilizing them in a test bed for evaluation of devices for mechanical thrombectomy of pulmonary embolism (PE). MATERIALS AND METHODS: Patient derived computed tomography angiography (CTA) images of the PA were digitally converted into a hollowed-out structure and translated into clear 3D printed and glass models. A test bed was created using a peristaltic pump and silicone tubing connected to the models. Human clot analogs were then prepared and injected within the models. Thrombectomy testing was done using clinically used predicates and baseline characteristics of the models were evaluated by independent interventionalists. RESULTS: The mean sizes of the main pulmonary artery (MPA) for the 3D printed model and glass model were 30.4 mm and 29.2 mm, mimicking those of the patient's PA obtained on CTA. Heterogeneous human clot analogs were created with fibrin composition ranging from 60 to 30%. Mechanical thrombectomy was successfully attempted by independent interventionalists. Both the 3D printed, and glass model were appraised as very good for multiple attributes. CONCLUSION: A complete test bed using 3D printed and glass models of the PA with human clot analogs was created for testing of mechanical thrombectomy devices for PE.

Human "live cadaver" neurovascular model for proximal and distal mechanical thrombectomy in stroke.

BACKGROUND: Preclinical testing platforms that accurately replicate complex human cerebral vasculature are critical to advance neurointerventional knowledge, tools, and techniques. Here, we introduced and validated a human "live cadaveric" head-and-neck neurovascular model optimized for proximal and distal vascular occlusion and recanalization techniques. METHODS: Human cadaveric head-and-neck specimens were cannulated bilaterally in the jugular veins, carotid, and vertebral arteries. Specimens were then coupled with modular glass models of the aorta and extracranial carotid arteries, as well as radial and femoral access ports. Intracranial physiological flow was simulated using a flow-delivery system and blood-mimicking fluid. Baseline anatomy, histological, and mechanical properties of cerebral arteries were compared with those of fresh specimens. Radiopaque clot analogs were embolized to replicate proximal and distal arterial occlusions, followed by thrombectomy. Experienced interventionalists scored the model on different aspects. RESULTS: Compared with counterpart fresh human arteries, formalin-fixed arteries showed similar mechanical properties, including maximum stretch, increased tensile strength/stiffness, and friction coefficients were also not significantly different. On histology, minimal endothelial damage was noted in arteries after 3 months of light fixation, otherwise the arterial wall maintained the structural integrity. Contrast angiographies showed no micro- or macro-vasculature obstruction. Proximal and distal occlusions created within the middle cerebral arteries were consistently obtained and successfully recanalized. Additionally, interventionists scored the model highly realistic, indicating great similarity to patients' vasculature. CONCLUSIONS: The human "live cadaveric" neurovascular model accurately replicates the anatomy, mechanics, and hemodynamics of cerebral vasculature and allows the performance of neurointerventional procedures equivalent to those done in patients.

Evaluation of an in vivo preclinical model for human middle meningeal artery embolization using the posterior intercostal artery of the swine.

BACKGROUND: Embolization of the middle meningeal artery (MMA) is a promising minimally invasive technique that is gaining traction in the treatment of chronic subdural hematoma. Unfortunately, the human meninges and associated arteries are significantly larger than those of conventional laboratory animals, making the development of a clinically relevant animal model for testing of embolization agents elusive. OBJECTIVE: To introduce the posterior intercostal artery (PIA) model in swine and provide anatomical, angiographic, histological, and procedural data to validate its relevance in modeling the human MMA. METHODS: In human cadaveric specimens, 3D angiograms of the internal maxillary arteries (n=6) were obtained and the dura with MMA were harvested and histologically processed. Angiographic and histologic data of the human MMA were compared with the swine PIA (three animals). Then, embolization of the PIA (n=48 arteries) was conducted with liquid embolization agent (Onyx, Medtronic), and angiographic and histological results were assessed acutely (four animals) and after 30 days (two animals). RESULTS: The human MMA has equivalent diameter, length, branching pattern, 3D trajectory, and wall structure to those of swine PIAs. Each swine has 12 to 14 PIAs (6-7 per side) suitable for acute or chronic embolization, which can be performed with high fidelity using the same devices, agents, and techniques currently used to embolize the MMA. The arterial wall structure and the acute and chronic histological findings in PIAs after embolization are comparable to those of humans. CONCLUSIONS: This PIA model in swine could be used for research and development; objective benchmarking of agents, devices, and techniques; and in the training of neurointerventionalists.

Per-pass analysis of recanalization and good neurological outcome in thrombectomy for stroke: Systematic review and meta-analysis.

BACKGROUND AND AIM: First pass effect (FPE) is defined as achieving a complete recanalization with a single thrombectomy device pass. Although clinically desired, FPE is reached in less than 30% of thrombectomy procedures. Multiple device passes are often necessary to achieve successful or complete recanalization. We performed a systematic review and meta-analysis to determine the recanalization rate after each pass of mechanical thrombectomy and its association with good neurological outcome. METHODS: A literature search was performed for studies reporting the number of device passes required for either successful (mTICI 2b or higher) or complete (mTICI 2c or higher) recanalization. Using random-effect meta-analysis, we evaluated the likelihood of recanalization and good neurological outcome (measured with the modified Rankin Score <2 at 90 days) after each device pass. RESULTS: Thirteen studies comprising 4197 patients were included. Among cases with failed first pass, 24% of them achieved final complete recanalization and 45% of them achieved final successful recanalization. Independently to the total number of previously failed attempts, the likelihood of achieving successful recanalization was 30% per pass, and the likelihood to achieve complete recanalization was about 20% per pass. The likelihood of good neurological outcome in patients with final successful recanalization decreased after each device pass: 55% after the first pass, 48% after the second pass, 42% after the third pass, 36% after the fourth pass, and 26% for 5 passes or more. CONCLUSION: Each pass is associated with a stable likelihood of recanalization but a decreased likelihood of good neurological outcome.

Evaluation and treatment of headache associated with moyamoya disease - a narrative review.

BACKGROUND: Headache in patients with moyamoya disease is an under-addressed topic in the medical literature. Delay in the diagnosis of moyamoya disease or inappropriate treatment of headache could lead to devastating cerebrovascular outcome. With the evolving understanding of moyamoya disease, migraine pathophysiology, and various migraine-specific medications that have become available, it is crucial to provide an updated overview on this topic. METHODS: We searched PubMed for keywords including moyamoya disease, moyamoya syndrome, headache in moyamoya, surgical revascularization, surgical bypass, migraine and moyamoya, and calcitonin gene-related peptide (CGRP). We summarized the literature and provide a comprehensive review of the headache presentation, possible mechanisms, the impact of various surgical revascularizations on headache in patients with moyamoya disease, and the medical management of headache incorporating novel migraine-specific treatments.Results and conclusion: The most common headache phenotype is migraine; tension-type headache, hemiplegic migraine, and cluster headache have also been reported. Most patients experience improvement of headache after surgical revascularization, though some patients report worsening, or new-onset headache after surgery. Given the complexity of moyamoya disease, careful consideration of different types of medical therapy for headache is necessary to improve the quality of life while not increasing the risk of adverse cerebrovascular events. More prospective studies are warranted to better understand and manage headache in patients with moyamoya disease.

Quantification of clot spatial heterogeneity and its impact on thrombectomy.

BACKGROUND: Compositional and structural features of retrieved clots by thrombectomy can provide insight into improving the endovascular treatment of ischemic stroke. Currently, histological analysis is limited to quantification of compositions and qualitative description of the clot structure. We hypothesized that heterogeneous clots would be prone to poorer recanalization rates and performed a quantitative analysis to test this hypothesis. METHODS: We collected and did histology on clots retrieved by mechanical thrombectomy from 157 stroke cases (107 achieved first-pass effect (FPE) and 50 did not). Using an in-house algorithm, the scanned images were divided into grids (with sizes of 0.2, 0.3, 0.4, 0.5, and 0.6 mm) and the extent of non-uniformity of RBC distribution was computed using the proposed spatial heterogeneity index (SHI). Finally, we validated the clinical significance of clot heterogeneity using the Mann-Whitney test and an artificial neural network (ANN) model. RESULTS: For cases with FPE, SHI values were smaller (0.033 vs 0.039 for grid size of 0.4 mm, P=0.028) compared with those without. In comparison, the clot composition was not statistically different between those two groups. From the ANN model, clot heterogeneity was the most important factor, followed by fibrin content, thrombectomy techniques, red blood cell content, clot area, platelet content, etiology, and admission of intravenous tissue plasminogen activator (IV-tPA). No statistical difference of clot heterogeneity was found for different etiologies, thrombectomy techniques, and IV-tPA administration. CONCLUSIONS: Clot heterogeneity can affect the clot response to thrombectomy devices and is associated with lower FPE. SHI can be a useful metric to quantify clot heterogeneity.

The CODYSUN Approach: A Novel Distributed Paradigm for Dynamic Spectrum Sharing in Satellite Communications.

With a constant increase in the number of deployed satellites, it is expected that the current fixed spectrum allocation in satellite communications (SATCOM) will migrate towards more dynamic and flexible spectrum sharing rules. This migration is accelerated due to the introduction of new terrestrial services in bands used by satellite services. Therefore, it is important to design dynamic spectrum sharing (DSS) solutions that can maximize spectrum utilization and support coexistence between a high number of satellite and terrestrial networks operating in the same spectrum bands. Several DSS solutions for SATCOM exist, however, they are mainly centralized solutions and might lead to scalability issues with increasing satellite density. This paper describes two distributed DSS techniques for efficient spectrum sharing across multiple satellite systems (geostationary and non-geostationary satellites with earth stations in motion) and terrestrial networks, with a focus on increasing spectrum utilization and minimizing the impact of interference between satellite and terrestrial segments. Two relevant SATCOM use cases have been selected for dynamic spectrum sharing: the opportunistic sharing of satellite and terrestrial systems in (i) downlink Ka-band and (ii) uplink Ka-band. For the two selected use cases, the performance of proposed DSS techniques has been analyzed and compared to static spectrum allocation. Notable performance gains have been obtained.

Coexistence Scheme for Uncoordinated LTE and WiFi Networks Using Experience Replay Based Q-Learning.

Nowadays, broadband applications that use the licensed spectrum of the cellular network are growing fast. For this reason, Long-Term Evolution-Unlicensed (LTE-U) technology is expected to offload its traffic to the unlicensed spectrum. However, LTE-U transmissions have to coexist with the existing WiFi networks. Most existing coexistence schemes consider coordinated LTE-U and WiFi networks where there is a central coordinator that communicates traffic demand of the co-located networks. However, such a method of WiFi traffic estimation raises the complexity, traffic overhead, and reaction time of the coexistence schemes. In this article, we propose Experience Replay (ER) and Reward selective Experience Replay (RER) based Q-learning techniques as a solution for the coexistence of uncoordinated LTE-U and WiFi networks. In the proposed schemes, the LTE-U deploys a WiFi saturation sensing model to estimate the traffic demand of co-located WiFi networks. We also made a performance comparison between the proposed schemes and other rule-based and Q-learning based coexistence schemes implemented in non-coordinated LTE-U and WiFi networks. The simulation results show that the RER Q-learning scheme converges faster than the ER Q-learning scheme. The RER Q-learning scheme also gives 19.1% and 5.2% enhancement in aggregated throughput and 16.4% and 10.9% enhancement in fairness performance as compared to the rule-based and Q-learning coexistence schemes, respectively.

"Tocilizumab-an option for patients with COVID-19 associated cytokine release syndrome: A single center experience", a retrospective study-original article.

BACKGROUND: The first case of Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was diagnosed in Wuhan, China in 2019. In the first half of 2020, this disease has already converted into a global pandemic. This study aimed to find that treatment of patients with COVID-19 pneumonia with Tocilizumab or steroids was associated with better outcomes. Objectives: To analyze the effectiveness of Tocilizumab in moderate to severe Covid-19 patients based on predefined assessment criteria . Study Settings: Single-center, Fatima Memorial Hospital, Lahore. STUDY DESIGN: Quasi-experimental. DURATION OF STUDY: From May 12, 2020 to June 12, 2020. PATIENTS & METHODS SAMPLE SIZE AND TECHNIQUE: Sample size was 93; 33 patients were kept in the experimental group, given Tocilizumab, 8 mg/kg intravenously or 162 mg subcutaneously, and the rest of the 60 patients were given corticosteroids, methylprednisolone 80 mg/day. Consecutive sampling. Failure of therapy was labeled when patients were intubated or died, and the endpoints were failure-free survival which was the primary endpoint, and overall survival secondary at the time of discharge. RESULTS: A total of 93 patients were enrolled, the Tocilizumab (TCZ) group (case) and Corticosteroid (CS) group (Control). The median age was 58 years (IQR-21), 37 (39.8%) patients with diabetes mellitus, 11 (11.8%) in the TCZ group, and 26 (28%) in the CS group. On the whole, the total median hospital stay in days was 7 with IQR (4), a total of 83 (89.2%) patients recovered successfully and discharged, 27 (29%) in the TCZ group and 56 (60.2%) in the CS group. Total 10 (10.8%) patients died, out of which 6 (6.5%) belonged to the TCZ group and 4 (4.3%) belonged to the CS group The median Oxygen requirement with IQR was 8 (9) in both the groups and in total as well, p-value (0.714). CONCLUSIONS: Tocilizumab is a quite effective treatment option for critically sick patients of Covid-19 by reducing their oxygen requirement drastically and so the ICU stay, median hospital stay and so the mortality as well. CLINICALS TRIALS REGISTRATION: UIN # NCT04730323.

The Bluetooth Mesh Standard: An Overview and Experimental Evaluation.

Mesh networks enable a many-to-many relation between nodes, which means that each node in the network can communicate with every other node using multi-hop communication and path diversity. As it enables the fast roll-out of sensor and actuator networks, it is an important aspect within the Internet of Things (IoT). Utilizing Bluetooth Low Energy (BLE) as an underlying technology to implement such mesh networks has gained a lot of interest in recent years. The result was a variety of BLE meshing solutions that were not interoperable because of the lack of a common standard. This has changed recently with the advent of the Bluetooth Mesh standard. However, a detailed overview of how this standard operates, performs and how it tackles other issues concerning BLE mesh networking is missing. Therefore, this paper investigates this new technology thoroughly and evaluates its performance by means of three approaches, namely an experimental evaluation, a statistical approach and a graph-based simulation model, which can be used as the basis for future research. Apart from showing that consistent results are achieved by means of all three approaches, we also identify possible drawbacks and open issues that need to be dealt with.

Cognitive Impairments After Clipping of Ruptured Anterior Circulation Aneurysms.

BACKGROUND: The cognitive impairments after treatment of ruptured aneurysms have often been underestimated. This study sought to assess their prevalence and analyze various associated factors. METHODS: Patients who were operated on for ruptured anterior circulation aneurysms and discharged with a Glasgow Outcome Scale score of 4-5 were studied at 3 months for various cognitive impairments. Continuous scales of memory (recent, remote, verbal, visual, and overall memory), verbal fluency (phonemic and category fluency), and others were studied in relation to various factors. Univariate and multivariate analyses were performed using SPSS version 21. RESULTS: A total of 87 patients were included in our study. Phonemic fluency was the most affected, noted in 66% of patients. Although 56% had some memory-related impairments, 13 (15%) and 6 (7%) had moderate and severe deficits in recent memory and 19 (22%) and 12 (14%) had moderate and severe deficits in remote memory, respectively. Patients operated on for anterior cerebral artery (ACA) aneurysms had significantly greater impairments in recent (34% vs. 8%) and remote memory (43% vs. 28%) compared with the rest, both in univariate (P = 0.01 and 0.002, respectively) and multivariate analyses (P = 0.01 and 0.03, respectively). ACA-related aneurysms also had significantly greater independent impairments in phonemic fluency (P = 0.04), compared with others. The clinical grade had a significant independent impact only on remote memory (P = 0.01). CONCLUSIONS: Cognitive impairments are frequent after treatment of ruptured anterior circulation aneurysms. Impairments in recent memory, remote memory, and phonemic fluency are significantly greater after treatment of ACA-related aneurysms, compared with others, independent of other factors.