An Adaptive Seismocardiography (SCG)-ECG Multimodal Framework for Cardiac Gating Using Artificial Neural Networks.

To more accurately trigger data acquisition and reduce radiation exposure of coronary computed tomography angiography (CCTA), a multimodal framework utilizing both electrocardiography (ECG) and seismocardiography (SCG) for CCTA prospective gating is presented. Relying upon a three-layer artificial neural network that adaptively fuses individual ECG- and SCG-based quiescence predictions on a beat-by-beat basis, this framework yields a personalized quiescence prediction for each cardiac cycle. This framework was tested on seven healthy subjects (age: 22-48; m/f: 4/3) and eleven cardiac patients (age: 31-78; m/f: 6/5). Seventeen out of 18 benefited from the fusion-based prediction as compared to the ECG-only-based prediction, the traditional prospective gating method. Only one patient whose SCG was compromised by noise was more suitable for ECG-only-based prediction. On average, our fused ECG-SCG-based method improves cardiac quiescence prediction by 47% over ECG-only-based method; with both compared against the gold standard, B-mode echocardiography. Fusion-based prediction is also more resistant to heart rate variability than ECG-only- or SCG-only-based prediction. To assess the clinical value, the diagnostic quality of the CCTA reconstructed volumes from the quiescence derived from ECG-, SCG- and fusion-based predictions were graded by a board-certified radiologist using a Likert response format. Grading results indicated the fusion-based prediction improved diagnostic quality. ECG may be a sub-optimal modality for quiescence prediction and can be enhanced by the multimodal framework. The combination of ECG and SCG signals for quiescence prediction bears promise for a more personalized and reliable approach than ECG-only-based method to predict cardiac quiescence for prospective CCTA gating.

Evaluation of the Normal Cochlear Second Interscalar Ridge Angle and Depth on 3D T2-Weighted Images: A Tool for the Diagnosis of Scala Communis and Incomplete Partition Type II.

BACKGROUND AND PURPOSE: Cochlear malformations may be be subtle on imaging studies. The purpose of this study was to evaluate the angle and depth of the lateral second interscalar ridge or notch in ears without sensorineural hearing loss (normal ears) and compare them with ears that have a documented incomplete type II partition malformation. MATERIALS AND METHODS: The second interscalar ridge notch angle and depth were measured on MR imaging in normal ears by a single experienced neuroradiologist. The images of normal and incomplete partition II malformation ears were then randomly mixed for 2 novice evaluators to measure both the second interscalar ridge notch angle and depth in a blinded manner. For the mixed group, interobserver agreement was calculated, normal and abnormal ear measurements were compared, and receiver operating characteristic curves were generated. RESULTS: The 94 normal ears had a mean second interscalar ridge angle of 80.86° ± 11.4° and depth of 0.54 ± 0.14 mm with the 98th percentile for an angle of 101° and a depth of 0.3 mm. In the mixed group, agreement between the 2 readers was excellent, with significant differences for angle and depth found between normal and incomplete partition type II ears for angle and depth on average (P < .001). Receiver operating characteristic cutoffs for delineating normal from abnormal ears were similar for both readers (depth, 0.31/0.34 mm; angle, 114°/104°). CONCLUSIONS: A measured angle of >114° and a depth of the second interscalar ridge notch of ≤0.31 mm suggest the diagnosis of incomplete partition type II malformation and scala communis. These measurements can be accurately made by novice readers.

Echocardiography as an indication of continuous-time cardiac quiescence.

Cardiac computed tomography (CT) angiography using prospective gating requires that data be acquired during intervals of minimal cardiac motion to obtain diagnostic images of the coronary vessels free of motion artifacts. This work is intended to assess B-mode echocardiography as a continuous-time indication of these quiescent periods to determine if echocardiography can be used as a cost-efficient, non-ionizing modality to develop new prospective gating techniques for cardiac CT. These new prospective gating approaches will not be based on echocardiography itself but on CT-compatible modalities derived from the mechanics of the heart (e.g. seismocardiography and impedance cardiography), unlike the current standard electrocardiogram. To this end, echocardiography and retrospectively-gated CT data were obtained from ten patients with varied cardiac conditions. CT reconstructions were made throughout the cardiac cycle. Motion of the interventricular septum (IVS) was calculated from both echocardiography and CT reconstructions using correlation-based, deviation techniques. The IVS was chosen because it (1) is visible in echocardiography images, whereas the coronary vessels generally are not, and (2) has been shown to be a suitable indicator of cardiac quiescence. Quiescent phases were calculated as the minima of IVS motion and CT volumes were reconstructed for these phases. The diagnostic quality of the CT reconstructions from phases calculated from echocardiography and CT data was graded on a four-point Likert scale by a board-certified radiologist fellowship-trained in cardiothoracic radiology. Using a Wilcoxon signed-rank test, no significant difference in the diagnostic quality of the coronary vessels was found between CT volumes reconstructed from echocardiography- and CT-selected phases. Additionally, there was a correlation of 0.956 between the echocardiography- and CT-selected phases. This initial work suggests that B-mode echocardiography can be used as a tool to develop CT-compatible gating techniques based on modalities derived from cardiac mechanics rather than relying on the ECG alone.

Forewarning of poliovirus outbreaks in the Horn of Africa: an assessment of acute flaccid paralysis surveillance and routine immunization systems in Kenya.

BACKGROUND: Although the Horn of Africa region has successfully eliminated endemic poliovirus circulation, it remains at risk for reintroduction. International partners assisted Kenya in identifying gaps in the polio surveillance and routine immunization programs, and provided recommendations for improved surveillance and routine immunization during the health system decentralization process. METHODS: Structured questionnaires collected information about acute flaccid paralysis (AFP) surveillance resources, training, data monitoring, and supervision at provincial, district, and health facility levels. The routine immunization program information collected included questions about vaccine and resource availability, cold chain, logistics, health-care services and access, outreach coverage data, microplanning, and management and monitoring of AFP surveillance. RESULTS: Although AFP surveillance met national performance standards, widespread deficiencies and limited resources were observed and reported at all levels. Deficiencies were related to provider knowledge, funding, training, and supervision, and were particularly evident at the health facility level. CONCLUSIONS: Gap analysis assists in maximizing resources and capacity building in countries where surveillance and routine immunization lag behind other health priorities. Limited resources for surveillance and routine immunization systems in the region indicate a risk for additional outbreaks of wild poliovirus and other vaccine-preventable illnesses. Monitoring and evaluation of program strengthening activities are needed.

Global Health Professions Student Survey--Turkey: second-hand smoke exposure and opinions of medical students on anti-tobacco law.

AIM: This study, as a part of "the Global Health Professions Student Survey" (GHPSS), aimed to assess medical students' tobacco use, exposure to second-hand tobacco smoke (SHS), and opinions as well as smoking policies at medical faculties in Turkey. METHODS: The study was conducted in 2010 as a school-based survey of third-year students in 12 medical schools. GHPSS uses a standardised methodology for selecting schools (probability proportional to student enrolment size) and data processing. In total, data from 1,217 of third year medical students were analysed. RESULTS: Prevalence of current tobacco use among participating students was 28.5%. Exposure to SHS in the last seven days was 46.9% at home, and 42.2% in other places. Among smokers, over 7 in 10 students reported smoking on medical school premises during the past 30 days and the past year. CONCLUSION: Medical students' exposure to SHS is common and smoking on medical school premises/buildings constitutes a problem. Turkey passed an anti-tobacco law in 2008, yet enforcement of the law must be stronger. In addition, medical schools must evaluate, and likely revise their education curricula to better prepare medical students to advocate tobacco control.

Determination of three-dimensional muscle architectures: validation of the DTI-based fiber tractography method by manual digitization.

In the last decade, diffusion tensor imaging (DTI) has been used increasingly to investigate three-dimensional (3D) muscle architectures. So far there is no study that has proved the validity of this method to determine fascicle lengths and pennation angles within a whole muscle. To verify the DTI method, fascicle lengths of m. soleus as well as their pennation angles have been measured using two different methods. First, the 3D muscle architecture was analyzed in vivo applying the DTI method with subsequent deterministic fiber tractography. In a second step, the muscle architecture of the same muscle was analyzed using a standard manual digitization system (MicroScribe MLX). Comparing both methods, we found differences for the median pennation angles (P < 0.001) but not for the median fascicle lengths (P = 0.216). Despite the statistical results, we conclude that the DTI method is appropriate to determine the global fiber orientation. The difference in median pennation angles determined with both methods is only about 1.2° (median pennation angle of MicroScribe: 9.7°; DTI: 8.5°) and probably has no practical relevance for muscle simulation studies. Determining fascicle lengths requires additional restriction and further development of the DTI method.

Promoting balance and strength in the middle-aged workforce.

The prevalence of sustaining fall-related injuries is high in the middle-aged workforce. Deficits in postural control/muscle strength represent important fall-risk factors. The objective of this study was to examine the impact of balance and strength training followed by detraining on postural control and muscle strength in the workforce. Thirty-two adults with sedentary office work participated in this study and were assigned to an intervention (age 56.0 ± 3.7 yrs) or a control group (age 55.5 ± 3.4 yrs). The intervention group participated in 8 weeks of balance and strength training conducted at the worksite, followed by 8 weeks of detraining. Tests included the measurement of (a) total centre of pressure (COP) displacements during one-legged standing, (b) gait velocity and stride-to-stride variability, (c) peak isometric/isokinetic torque and rate of torque development (RTD) of the plantar flexors, and (d) jumping height. After training, significant improvements in COP displacements, gait velocity, peak isometric/isokinetic torque, RTD, and jumping height were observed. During detraining, muscle strength deteriorated, whereas postural control improved. This fall-preventive training program conducted at the worksite proved to be feasible and effective. It is suggested that this training program should be permanently conducted to maintain/improve muscle strength.

High pressure effects on proteolytic and glycolytic enzymes involved in cheese manufacturing.

The activity of chymosin, plasmin, and Lactococcus lactis enzymes (cell envelope proteinase, intracellular peptidases, and glycolytic enzymes) were determined after 5-min exposures to pressures up to 800 MPa. Plasmin was unaffected by any pressure treatment. Chymosin activity was unaffected up to 400 MPa and decreased at 500 to 800 MPa. Fifty percent of control chymosin activity remained after the 800 MPa treatment. The lactococcal cell envelope proteinase (CEP) and intracellular peptidase activities were monitored in cell extracts of pressure-treated cells. A pressure of 100 MPa increased the CEP activity, whereas 200 MPa had no effect. At 300 MPa, CEP activity was reduced, and 400 to 800 MPa inactivated the enzyme. X-Prolyl-dipeptidyl aminopeptidase was insensitive to 5-min pressure treatments of 100 to 300 MPa, but was inactivated at 400 to 800 MPa. Aminopeptidase N was unaffected by 100 and 200 MPa. However, 300 MPa significantly reduced its activity, and 400 to 800 MPa inactivated it. Aminopeptidase C activity increased with increasing pressures up to 700 MPa. High pressure did not affect aminopeptidase A activity at any level. Hydrolysis of Lys-Ala-p-NA doubled after 300-MPa exposure, and was eliminated at 400 to 800 MPa. Glycolytic enzyme activities of pressure-treated cells were evaluated collectively by determining the titratable acidity as lactic acid produced by cell extracts in the presence of glucose. The titratable acidities produced by the 100 and 200 MPa samples were slightly increased compared to the control. At 300 to 800 MPa, no significant acid production was observed. These data demonstrate that high pressure causes no effect, activation, or inactivation of proteolytic and glycolytic enzymes depending on the pressure level and enzyme. Pressure treatment of cheese may alter enzymes involved in ripening, and pressure-treating L. lactis may provide a means to generate attenuated starters with altered enzyme profiles.

An enabling system for echocardiography providing adaptive support through behavioral analysis.

Echocardiography requires the integrated application of a broad spectrum of cognitive and practical skills, e.g. diagnostic knowledge (symbolic), image interpretation (visual perception) and handling of the ultrasound probe (sensorimotor). This complex expertise is acquired through extensive practical training guided by a skilled cardiologist that is often incompatible with clinical reality. Especially for beginners, the most critical point during an echocardiographic examination is the steering of the ultrasound probe to navigate between different cardiological standard planes (sensorimotor skill) without loosing orientation. These transitions or "standard trajectories" can roughly be described by specific movement patterns. We propose an enabling system based on an Augmented Reality simulator for two-dimensional echocardiography imitating this apprenticeship [1]-[3]. During a simulated ultrasound examination the system monitors the activities of the trainee and analyzes the motion pattern of the ultrasound probe. The simulator reacts by mapping the motion patterns onto cognitive orientation demands and providing adaptive feedback in the form of context sensitive help (animations). It partly takes the role of the critical teacher.

Molecular interactions and metal binding in the theophylline-binding core of an RNA aptamer.

An RNA aptamer containing a 15-nt binding site shows high affinity and specificity for the bronchodilator theophylline. A variety of base modifications or 2' deoxyribose substitutions in binding-site residues were tested for theophyllinebinding affinity and the results were compared with the previously determined three-dimensional structure of the RNA-theophylline complex. The RNA-theophylline complex contains a U6-A28-U23 base triple, and disruption of this A28-U23 Hoogsteen-pair by a 7-deaza, 2'-deoxy A28 mutant reduces theophylline binding >45-fold at 25 degrees C. U24 is part of a U-turn in the core of the RNA, and disruption of this U-turn motif by a 2'-deoxy substitution of U24 also reduces theophylline binding by >90-fold. Several mutations outside the "conserved core" of the RNA aptamer showed reduced binding affinity, and these effects could be rationalized by comparison with the three-dimensional structure of the complex. Divalent ions are absolutely required for high-affinity theophylline binding. High-affinity binding was observed with 5 mM Mg2+, Mn2+, or Co2+ ions, whereas little or no significant binding was observed for other divalent or lanthanide ions. A metal-binding site in the core of the complex was revealed by paramagnetic Mn2+-induced broadening of specific RNA resonances in the NMR spectra. When caffeine is added to the aptamer in tenfold excess, the NMR spectra show no evidence for binding in the conserved core and instead the drug stacks on the terminal helix. The lack of interaction between caffeine and the theophylline-binding site emphasizes the extreme molecular discrimination of this RNA aptamer.

[Augmented reality in echocardiography. A new method of computer-assisted training and image processing using virtual and real three-dimensional data sets]. / Augmented Reality in der Echokardiographie--Eine neue Methode der computergestützten Ausbildung und Bildbearbeitung durch virtuelle und reale dreidimensionale Datensätze.

Augmented reality (AR) applications link real with virtual image data, in order to increase their information content. In medicine they are especially useful for education and for supporting the interpretation of three-dimensional (3D) image data. Simulators are used to train risky or expensive procedures. In the AR application EchoCom2 a 3D surface model of the human heart is linked with echocardiographic volume data sets. The 3D echocardiographic data sets are registered with the heart model to synchronize it's temporal and spatial orientation. The heart model together with an animated ultrasound sector represents a reference scenario, which displays the currently selected cutting plane within the echocardiographic volume data set. Modifications of the cutting plane within the echocardiographic data are transferred simultaneously and in real time to the reference scenario. The AR application is used as a simulator to train two-dimensional echocardiographic examinations and as an orientation and navigation aid for the exploration of 3D echocardiographic data sets. Beginners in echocardiography have only a rudimentary conception of the spatial relationship between the actual ultrasound image and the 3D anatomy of the heart. They are unable to translate multiple two-dimensional slices into a coherent 3D mental image of the heart. In EchoCom2 the trainee can interactively explore the 3D heart model and the registered 3D echocardiographic data sets by the animated ultrasound sector, whose position is controlled by an electromagnetic orientation and position system (EPOS). The data from the EPOS are used to calculate the echocardiographic images that are analogue to the position of the animated ultrasound sector. EchoCom2 is also used to support the interpretation of 3D echocardiographic data sets. The analysis of 3D echocardiographic data has to be done during a post processing. Defining the exact position of a cutting plane within the volume is difficult due to the lack of a standardized representation, the independence of the cutting plane of any transducer position and the possibility to calculate an indefinite number of views. The simultaneous representation of the current cutting plane both in the volume data, and in the heart model enables the examiner ad hoc to recognize it's position and the visualized structures.

Augmented reality simulator for training in two-dimensional echocardiography.

In two-dimensional echocardiography the sonographer must synthesize multiple tomographic slices into a mental three-dimensional (3D) model of the heart. Computer graphics and virtual reality environments are ideal to visualize complex 3D spatial relationships. In augmented reality (AR) applications, real and virtual image data are linked, to increase the information content. In the presented AR simulator a 3D surface model of the human heart is linked with echocardiographic volume data sets. The 3D echocardiographic data sets are registered with the heart model to establish spatial and temporal congruence. The heart model, together with an animated ultrasound sector represents a reference scenario, which displays the currently selected two-dimensional echocardiographic cutting plane calculated from the volume data set. Modifications of the cutting plane within the echocardiographic data are transferred and visualized simultaneously and in real time within the reference scenario. The trainee can interactively explore the 3D heart model and the registered 3D echocardiographic data sets by an animated ultrasound probe, whose position is controlled by an electromagnetic tracking system. The tracking system is attached to a dummy transducer and placed on a plastic puppet to give a realistic impression of a two-dimensional echocardiographic examination.

A semiconserved residue inhibits complex formation by stabilizing interactions in the free state of a theophylline-binding RNA.

The theophylline-binding RNA aptamer contains a 15 nucleotide motif that is required for high-affinity ligand binding. One residue within this RNA motif is only semiconserved and can be an A or C. This residue, C27, was disordered in the previously determined three-dimensional structure of the complex, suggesting that it is dynamic in solution. 13C Relaxation measurements are reported here, demonstrating that C27 is highly dynamic in the otherwise well-ordered RNA-theophylline complex. A synthetic complex with an abasic residue at position 27 was found to exhibit wild-type binding affinity (Kd approximately 0.2 microM), indicating that the base of residue 27 is not directly involved with theophylline binding. Surprisingly, the U27 and G27 RNAs were found to bind theophylline with low affinity (Kd values > 4 microM). NMR spectroscopy on the U27 RNA revealed the presence of an A7-U27 base pair in the free RNA that prevents formation of a critical base-platform structural motif and therefore blocks theophylline binding. Similarly, a protonated A7H+-C27 base pair forms in the absence of theophylline at low pH, which explains the unusual pH dependence of theophylline binding of the C27 RNA aptamer. Thus the weak binding for various nucleotides at position 27 arises not from unfavorable interactions in the RNA-theophylline complex but instead from stable interactions in the free state of the RNA that inhibit theophylline binding.

Interlocking structural motifs mediate molecular discrimination by a theophylline-binding RNA.

To visualize the interplay of RNA structural interactions in a ligand binding site, we have determined the solution structure of a high affinity RNA-theophylline complex using NMR spectroscopy. The structure provides insight into the ability of this in vitro selected RNA to discriminate theophylline from the structurally similar molecule caffeine. Numerous RNA structural motifs combine to form a well-ordered binding pocket where an intricate network of hydrogen bonds and stacking interactions lock the theophylline into the complex. Two internal loops interact to form the binding site which consists of a sandwich of three base triples. The complex also contains novel base-zipper and 1-3-2 stacking motifs, in addition to an adenosine platform and a reversed sugar. An important feature of the RNA is that many of the conserved core residues participate in multiple overlapping tertiary interactions. This complex illustrates how interlocking structural motifs can be assembled into a highly specific ligand-binding site that possesses high levels of affinity and molecular discrimination.

Modeling and simulation of illumination effects for evaluation of microvessels of the conjunctiva.

We present the development of a comprehensive model that was undertaken to determine the relationships between the components of an image and the light intensity values present in the image of the microvessels of translucent tissues such as the bulbar conjunctiva. Experiments were conducted during the modeling process by use of a cylindrical microvessel embedded in a diffuse medium (phantom) on a reflecting background to affirm model components and simulations. The three-dimensional model was reduced to a single illumination plane with four regions of interest and modeled as Lambertian radiators and surfaces. The modeling showed that the top of the cylinder and its immediate vicinity are diffuse reflectors of light from the source plus light reflected from the background. The limbus of the cylinder is a diffuse reflector of the source and background illumination and a specular reflector of background reflections that achieve a high grazing angle with the cylinder. The immediate vicinity of the cylinder receives direct illumination from the source, but the light is partially obscured by the cylinder. The region beyond the shadow of the cylinder is a diffuse reflector of the overhead light. The diffuse medium additionally reflects the source and also attenuates the illumination reaching the other compo- rents of the scene. The direct and reflected illumination at each region of the model was calculated by use of specific geometric relationships. To verify those calculations, we analyzed a video simulation for the effects of different illumination conditions and their contributing elements. Intensity values were calculated from the relative reflectivity data determined from the video signals. The illumination values at the points along the line at the meridian of the cylinder were due to its reflectivity and also that of the medium. Similarly, the values of points distant from the shadow of the cylinder were due to the reflectivity of the background and the medium. The excellent agreement between the model and the phantom provides a foundation for the detection and precise measurement of microvessel dimensions within a diffuse medium. The additional ability to compute relative depth, from a single view, also permits discrimination between neighboring microvessels in complex images.