Dissecting the Business Case for Adoption and Implementation of Digital Pathology: A White Paper from the Digital Pathology Association.

We believe the switch to a digital pathology (DP) workflow is imminent and it is essential to understand the economic implications of conversion. Many aspects of the adoption of DP will be disruptive and have a direct financial impact, both in short term costs, such as investment in equipment and personnel, and long term revenue potential, such as improved productivity and novel tests. The focus of this whitepaper is to educate pathologists, laboratorians and other stakeholders about the business and monetary considerations of converting to a digital pathology workflow. The components of a DP business plan will be thoroughly summarized, and guidance will be provided on how to build a case for adoption and implementation as well as a roadmap for transitioning from an analog to a digital pathology workflow in various laboratory settings. It is important to clarify that this publication is not intended to list prices although some financials will be mentioned as examples. The authors encourage readers who are evaluating conversion to a DP workflow to use this paper as a foundational guide for conducting a thorough and complete assessment while incorporating in current market pricing. Contributors to this paper analyzed peer-reviewed literature and data collected from various institutions, some of which are mentioned. Digital pathology will change the way we practice through facilitating patient access to expert pathology services and enabling image analysis tools and assays to aid in diagnosis, prognosis, risk stratification and therapeutic selection. Together, they will result in the delivery of valuable information from which to make better decisions and improve the health of patients.

"Eczema coxsackium" and unusual cutaneous findings in an enterovirus outbreak.

OBJECTIVE: To characterize the atypical cutaneous presentations in the coxsackievirus A6 (CVA6)-associated North American enterovirus outbreak of 2011-2012. METHODS: We performed a retrospective case series of pediatric patients who presented with atypical cases of hand, foot, and mouth disease (HFMD) from July 2011 to June 2012 at 7 academic pediatric dermatology centers. Patients were included if they tested positive for CVA6 or if they met clinical criteria for atypical HFMD (an enanthem or exanthem characteristic of HFMD with unusual morphology or extent of cutaneous findings). We collected demographic, epidemiologic, and clinical data including history of skin conditions, morphology and extent of exanthem, systemic symptoms, and diagnostic test results. RESULTS: Eighty patients were included in this study (median age 1.5 years, range 4 months-16 years). Seventeen patients were CVA6-positive, and 63 met clinical inclusion criteria. Ninety-nine percent of patients exhibited a vesiculobullous and erosive eruption; 61% of patients had rash involving >10% body surface area. The exanthem had a perioral, extremity, and truncal distribution in addition to involving classic HFMD areas such as palms, soles, and buttocks. In 55% of patients, the eruption was accentuated in areas of eczematous dermatitis, termed "eczema coxsackium." Other morphologies included Gianotti-Crosti-like (37%), petechial/purpuric (17%) eruptions, and delayed onychomadesis and palm and sole desquamation. There were no patients with serious systemic complications. CONCLUSIONS: The CVA6-associated enterovirus outbreak was responsible for an exanthem potentially more widespread, severe, and varied than classic HFMD that could be confused with bullous impetigo, eczema herpeticum, vasculitis, and primary immunobullous disease.

Posterior pedicle lateral nasal wall flap: new reconstructive technique for large defects of the skull base.

BACKGROUND: Indications for expanded endoscopic approaches continue to grow, resulting in larger and more complex skull base defects. Reconstructive developments, however, have lagged our extirpative capabilities. As the complexity of clinical scenarios continues to escalate, challenging our current reconstructive strategies, we are compelled to develop alternative techniques to prevent cerebrospinal fluid leaks and protect neurovascular structures. In this article we show the anatomic basis for a new posterior pedicled flap from the lateral wall of the nose (Carrau-Hadad [C-H] flap) for the reconstruction of median skull base defects and present our early clinical experience. METHODS: Using a cadaveric model, we designed a posterior pedicle flap comprising the nasal inferolateral wall mucoperiosteum. We applied this information clinically, to reconstruct transmural skull base defects. RESULTS: In our cadaveric model, we harvested and transposed C-H flaps into various defects of the planum sphenoidale, sella turcica, clivus, and nasopharynx. Then, we used the C-H flap in four patients, successfully reconstructing their clival (n = 3) and sellar (n = 1) surgical defects. All patients healed uneventfully. CONCLUSION: Our anatomic study and early clinical experience support the use of the posterior pedicle lateral nasal wall flap to reconstruct large cranial base defects resulting from endoscopic skull base surgery in properly selected patients.

Effect of swine manure dilution on ammonia, hydrogen sulfide, carbon dioxide, and sulfur dioxide releases.

Animal manure is a significant source of environmental pollution and manure dilution in barn cleaning and slurry storage is a common practice in animal agriculture. The effect of swine manure dilution on releases of four pollutant gases was studied in a 30-day experiment using eight manure reactors divided into two groups. One group was treated with swine manure of 6.71% dry matter and another with manure diluted with water to 3.73% dry matter. Ammonia release from the diluted manure was 3.32 mg min(-1)m(-2) and was 71.0% of the 4.67 mg min(-1)m(-2) from the undiluted manure (P<0.01). Because the ammonia release reduction ratio was lower than the manure dilution ratio, dilution could increase the total ammonia emissions from swine manure, especially in lagoons with large liquid surface areas. Carbon dioxide release of 87.3 mg min(-1)m(-2) from the diluted manure was 56.4% of the 154.8 mg min(-1)m(-2) from the undiluted manure (P<0.01). Manure dry matter was an important factor for carbon dioxide release from manure. No differences were observed between the treatments (P>0.05) for both hydrogen sulfide and sulfur dioxide releases. Therefore, dilution could also significantly increase the total releases of hydrogen sulfide and sulfur dioxide to the environment because dilution adds to the total manure volume and usually also increases the total gas release surface area.

Development of a wearable motion capture suit and virtual reality biofeedback system for the instruction and analysis of sports rehabilitation exercises.

This paper describes the design and development of a computer game for instructing an athlete through a series of prescribed rehabilitation exercises. In an attempt to prevent or treat musculoskeletal type injuries along with trying to improve physical performance, athletes are prescribed exercise programmes by appropriately trained specialists. Typically athletes are shown how to perform each exercise in the clinic following examination but they often have no way of knowing if their technique is correct while they are performing their home exercise programme. We describe a system that allows an automatic audit of this activity. Our system utilises ten inertial motion tracking sensors incorporated in a wearable body suit which allows a bluetooth connection from a root hub to a laptop/computer. Using our specifically designed software programme, the athlete can be instructed and analysed as he/she performs the individually tailored exercise programme and a log is recorded of the time and performance level of each exercise completed. We describe a case study that illustrates how a clinician can at a later date review the athletes progress and subsequently alter the exercise programme as they see fit.

Proton pump inhibitor therapy for chronic laryngo-pharyngitis: a randomized placebo-control trial.

OBJECTIVE: To determine the efficacy of proton-pump inhibitor (PPI) therapy for chronic laryngo-pharyngitis treated with lifestyle modification. STUDY DESIGN AND METHODS: Double-blind, randomized trial comparing two-month Rabeprazole (20 mg b.i.d.) to placebo control. RESULTS: Compared to baseline, both PPI and control patients had significant improvement in total reflux symptoms (P = 0.002 and P = 0.03 respectively), with significant improvement in "laryngo-pharyngeal" but not "typical" reflux symptoms. No significant difference was noted for change in reflux symptoms between PPI-treated and control patients (P = 0.44). Significant global improvement was noted by 50% of control and 53% of PPI-treated patients (P = 1.0). No significant differences were noted within or between treatment groups for change in health status or videostrobolaryngoscopy grade. Lifestyle modification compliance correlated significantly with global improvement. CONCLUSION: Compared to baseline, lifestyle modification for 2 months significantly improved chronic laryngo-pharyngitis symptoms. When compared to control, treatment with a PPI failed to demonstrate significantly greater improvement in reflux symptoms, health status, or laryngeal appearance.

Appropriate stoma covering for tracheoesophageal puncture speakers.

Laryngeal cancer commonly causes loss of bodily functions, damage to the body image, and threat to life itself. Amputation of the voice as the result of laryngectomy alters the way patients, their families, and others perceive their bodily changes of function and often results in alterations in the activities and roles that they are able to carry out. Loss of body parts can have enormous physical and emotional impact on the patient. Likewise, the surgical creation of alternative openings and passages, which are readily seen during even the most casual contact, can have a profound effect on body image.