Dual-Probe Transcranial Full-Waveform Inversion: A Brain Phantom Feasibility Study.

OBJECTIVE: Despite being a low-cost, portable and safe medical imaging technique, transcranial ultrasound imaging is not used widely in adults because of the severe degradation and distortion of signals caused by the skull. Full-waveform inversion (FWI) has recently been found to have potential as an effective method for transcranial ultrasound tomography to obtain high-quality, subwavelength-resolution acoustic models of the brain using low-frequency ultrasound data. In this study is the first demonstration of this method in recovering a high-resolution 2-D reconstruction of a brain and skull ultrasound imaging phantom using experimentally acquired data. METHODS: A 2:5 scale brain phantom encased within a 3-D-printed skull-mimicking layer was created to simulate a clinical transcranial imaging target. To obtain tomographic ultrasound data on the brain and skull phantom, a tomographic ultrasound acquisition system was designed and implemented using commercially available low-frequency cardiac probes. FWI reconstructions of the brain and skull phantom were performed using the acquired tomographic data and were compared with corresponding synthetic reconstructions. This comparison was used to evaluate the feasibility of the proposed imaging system when employing different transducer array configurations. RESULTS: We demonstrate the successful FWI reconstruction of the brain phantom within the skull mimic from experimentally acquired tomographic ultrasound data. To mitigate the effects of the skull-mimicking material, a reflection-matching algorithm was applied to model the morphology of the skull layer prior to performing the inversion. CONCLUSION: The findings of this study provide a promising step toward the clinical use of FWI for transcranial ultrasound imaging in adults.

The Role of Dental Occlusion Ties to Achieve Stable Maxillomandibular Fixation During Temporomandibular Joint Replacement.

Dental occlusion ties (Minne Ties®) are a new example of the concept of an oral zip tie used to establish maxillomandibular fixation (MMF). Each tie uses a blunt introducer that is easily passed between embrasures and fed through a self-locking, unidirectional clasp. Five to six ties are used to establish MMF. They are fast, easy to use, and relatively safe because there are no sharps or wires associated with their use. The authors report their experience using this MMF method for temporomandibular joint replacement surgery, where over the last 2 years, over 65 collective cases have been completed using this method.

Cost analysis of a watch-and-wait approach in patients with a complete clinical response to chemoradiotherapy for rectal cancer.

BACKGROUND: There is increasing interest in the watch-and-wait approach for patients with rectal cancer who have had a complete clinical response following neoadjuvant long course chemoradiotherapy. This study is a cost analysis of expenditure on patients in the watch-and-wait program versus patients who underwent standard rectal resection followed by routine surveillance. METHODS: Data were prospectively collated and retrospectively analysed in all patients who presented with rectal cancer from January 2016 to January 2018 at Sir Charles Gairdner Hospital, Perth, Western Australia. Software developed by the North Metropolitan Health Service was used to capture comprehensive data to calculate the in-hospital expenditure for an individual patient throughout their treatment journey. RESULTS: For a patient enrolled in the watch-and-wait pathway, the total cost of surveillance over a 5-year period was $45 246. This was compared with the cost of an ultra-low anterior resection/loop ileostomy/closure of loop and routine postoperative surveillance which came to a total of $87 473. While a patient who had an abdominoperineal resection followed by routine 5-year surveillance had an expenditure of $82 290. CONCLUSION: There is growing evidence that the watch-and-wait strategy is a valid management option. In the cost-conscious environment of the current health care system, the watch-and-wait pathway is a cost-effective and economically advantage treatment.

Early results from implementation of a 'watch and wait' protocol for complete clinical response following chemoradiotherapy for rectal cancer.

BACKGROUND: Neoadjuvant long course chemoradiotherapy (NLCRT) for rectal cancer can result in complete pathological response (pCR). In 2017, we started offering patients who had a complete clinical response (cCR), a choice between total mesorectal excision (TME) and an intensive surveillance or 'watch and wait' (W&W) program. We report the early outcomes of this prospective study. METHODS: All patients undergoing NLCRT from 2017 to 2019 were included. All patients were restaged at 8 weeks, and those who had a cCR were offered TME or W&W. RESULTS: Of 59 patients who underwent NLCRT, 55 had restaging. Eleven of these patients had a cCR (20%). Three chose to have TME and all had a pCR. Eight were enrolled in W&W. Two patients were diagnosed with local regrowth and underwent TME at 7 and 17 months after NLCRT. A further nine patients, who were surgically unfit or refused TME, and had an excellent response to NLCRT, but one that did not reach criteria for a cCR, were also managed with W&W. Of these, two patients developed regrowth with distant metastases. From 2017 to 2019, of the 17 patients who were managed with a W&W approach, 13 patients have remained regrowth free after a median of 28 (13-58) months of W&W. CONCLUSION: Preliminary findings suggest management with W&W, following cCR, may be a safe alternative to TME. There have so far been no instances of distant failure, and those with cCR that had regrowth, were identified early and successfully managed with salvage TME.

Functional outcomes and local control are acceptable following hand-sewn colo-anal anastomoses for rectal cancer: Results of long-term follow-up.

BACKGROUND: Rectal cancer that grows so close to the anal canal that an adequate distal margin cannot be achieved with a double-stapled anastomosis (DSA) has been managed with abdominoperineal resection. Inter-sphincteric dissection and hand-sewn colo-anal anastomoses (HSCAA) allows anastomosis in some cases where DSA is impossible. There are concerns that HSCAA may lead to complications, local recurrence and poor continence. Our aim was to assess our experience with HSCAA in terms of recurrence, complications, continence and quality of life. METHODS: Consecutive patients at two metropolitan hospitals who underwent an ultra-low anterior resection with hand-sewn colo-anal anastomoses for low rectal cancer during a 10-year period were asked to complete a questionnaire which allowed continence and quality-of-life scores to be calculated. Recurrence and complication rates were obtained from a retrospective medical record review. RESULTS: A total of 26 patients underwent HSCAA. Six patients were not sent a questionnaire (3 deaths, 1 with ileostomy, 1 with ileostomy reversal within 3 months and one who had transferred care to another hospital). Fifteen patients returned questionnaires. Local recurrence occurred in zero cases. Two developed systemic recurrence. Four patients developed anastomotic stricture and three had anastomotic leak. Median Faecal Incontinence Severity Index score was 28 and median FIQoL scores were 3.00, 2.78, 3.86 and 3.00. One patient wished that they had had a permanent stoma rather than anastomosis. CONCLUSION: HSCAA delivered good local control of rectal cancer and high avoidance of permanent stoma. Faecal continence is impaired; however, the results are acceptable to the majority of patients.

Use of Messaging Principles to Design a Facebook Ad Promoting Public Engagement in Serious Illness Care for National Healthcare Decisions Day.

Public hesitation to engage in advance care planning, consultation with palliative care, and admission to hospice is a significant barrier to improving patient outcomes. In previous study, we derived five empirically supported messaging principles, and in this project we used these messaging principles to design, place, and analyze a 60-second video for the Oregon Coalition for Living Well with Serious Illness. The video was scripted to emphasize a single message that had emerged from the empirical research: that "you should have a say in your care." We deliberately did not use the term "advance care planning" because our prior focus groups showed that most consumers did not use this term. The marketing plan for the resulting video on Facebook included a paid sponsorship of the full-length video through a Facebook boosted post, and three 10-second ads featuring key lines from the video that tested different elaborations of the central message. Facebook Analytics indicated that the 60-second video was viewed 67,650 times in the week it was promoted. The three 10-second ads, which showed selected moments from the full-length video, were viewed a total of 253,087 times. Of the three 10-second ads, the one emphasizing "What matters to me is being near my family" (65% of clicks) strongly outperformed "I don't want to go out on a machine" and "I've heard so many medical horror stories" (35% for both messages combined) as messages that persuaded viewers to click through the ad to the website. Use of the messaging principles to guide the design and marketing of this Facebook ad shows that (1) the public is interested in serious illness care, (2) that targeted social media can be used to reach a defined public audience, and that (3) this public messaging strategy can be implemented at relatively low cost.

Incidental finding of ileal gastrointestinal stromal tumour during prostate cancer staging with prostate-specific membrane antigen scan.

Prostate-specific membrane antigen (PSMA) positron emission tomography (PET)/computed tomography (CT) is used in managing and staging prostate cancer, but can identify other non-prostate pathology. We present the first reported case where small bowel gastrointestinal stromal tumour (GIST) has been incidentally identified on PSMA-PET scan and highlight the need for awareness of other pathology being identified on PSMA-PET/CT.

Outcomes and Survivorship of Biomet Microfixation Total Joint Replacement System: Results From an FDA Postmarket Study.

PURPOSE: In February 2011, the Food and Drug Administration issued a postmarket surveillance order to all manufacturers of temporomandibular joint (TMJ) implants in the United States. The objective of the present study was to measure implant subsequent surgical intervention (SSI) among patients who had undergone TMJ reconstruction with the Biomet TMJ replacement system (Zimmer Biomet, Warsaw, IN). MATERIALS AND METHODS: A prospective observational study was conducted by sending a questionnaire to patients who had received a Biomet TMJ replacement system from 1995 to 2010 in the United States. The questionnaire was sent annually from 2012 to 2015. The primary endpoint was the SSIs. SSIs included both device removal and reoperations. Kaplan-Meier survival analysis was used to determine the survivorship, and Cox proportional hazard regression analysis was performed to evaluate the preoperative diagnosis and SSI. RESULTS: The mean age at implantation was 46.6 ± 12.5 years, with a gender distribution of 86.1% female. Data from 499 joints in 319 subjects were collected as a part of the survey. The mean follow-up time was 8.6 ± 3.9 years (range, 2-20 years). The first SSI frequency was 11.2% (4.2% removal rate and 7.0% reoperation rate). The survivorship rate (Kaplan-Meier) was 96% at 3 years, 94% at 5 years, and 86% at 10 years. The mean interval to failure using a survival function to determine the time to SSI (Greenwood's formula) was 13.5 ± 0.193 years. The most common causes of SSI included adhesion removal (2.6%; 13 of 498), heterotopic bone/ankylosis (2.0%; 10 of 498), and infection (1.6%; 8 of 498). CONCLUSIONS: The results from the present study are consistent with the reported survivorship rates for other orthopedic devices (5-year survival for total hip or knee arthroplasty, 95.9 and 97.2%, respectively). The etiology of SSIs in the Biomet TMJ replacement system was primarily secondary to biologic failure (ie, adhesions, heterotopic bone, and infection).

Full-waveform inversion imaging of the human brain.

Magnetic resonance imaging and X-ray computed tomography provide the two principal methods available for imaging the brain at high spatial resolution, but these methods are not easily portable and cannot be applied safely to all patients. Ultrasound imaging is portable and universally safe, but existing modalities cannot image usefully inside the adult human skull. We use in silico simulations to demonstrate that full-waveform inversion, a computational technique originally developed in geophysics, is able to generate accurate three-dimensional images of the brain with sub-millimetre resolution. This approach overcomes the familiar problems of conventional ultrasound neuroimaging by using the following: transcranial ultrasound that is not obscured by strong reflections from the skull, low frequencies that are readily transmitted with good signal-to-noise ratio, an accurate wave equation that properly accounts for the physics of wave propagation, and adaptive waveform inversion that is able to create an accurate model of the skull that then compensates properly for wavefront distortion. Laboratory ultrasound data, using ex vivo human skulls and in vivo transcranial signals, demonstrate that our computational experiments mimic the penetration and signal-to-noise ratios expected in clinical applications. This form of non-invasive neuroimaging has the potential for the rapid diagnosis of stroke and head trauma, and for the provision of routine monitoring of a wide range of neurological conditions.

Treatment of Atrophic Ridges with Titanium Mesh: A Retrospective Study Using 100% Mineralized Allograft and Comparing Dental Stone Versus 3D-Printed Models.

This multicenter study retrospectively evaluated implant survival and bone growth in atrophic ridges that were augmented with titanium mesh and 100% mineralized solvent-dehydrated bone allografts (MSDBA). A secondary objective of this study was to evaluate differences in outcomes by diagnostic model type. Titanium mesh was shaped on a diagnostic wax-up of the patient's jaw: Twenty-three patients (Group 1) had wax-ups on dental stone models, and 16 patients (Group 2) had wax-ups on models fabricated with three-dimensional (3D) printing technology. Clinical and histologic data were analyzed. The average bone gain ranged from 5.94 to 6.91 mm horizontally and 5.76 to 6.99 mm vertically and was not significantly different between the two model groups (P > .05). Implant survival was 100% after 18 to 48 months. Although model type had no significant influence on outcomes, 3D-printed models allowed for faster surgery and served as visual aids for patient education.

Convergent eusocial evolution is based on a shared reproductive groundplan plus lineage-specific plastic genes.

Eusociality has convergently evolved multiple times, but the genomic basis of caste-based division of labor and degree to which independent origins of eusociality have utilized common genes remain largely unknown. Here we characterize caste-specific transcriptomic profiles across development and adult body segments from pharaoh ants (Monomorium pharaonis) and honey bees (Apis mellifera), representing two independent origins of eusociality. We identify a substantial shared core of genes upregulated in the abdomens of queen ants and honey bees that also tends to be upregulated in mated female flies, suggesting that these genes are part of a conserved insect reproductive groundplan. Outside of this shared groundplan, few genes are differentially expressed in common. Instead, the majority of the thousands of caste-associated genes are plastically expressed, rapidly evolving, and relatively evolutionarily young. These results emphasize that the recruitment of both highly conserved and lineage-specific genes underlie the convergent evolution of novel traits such as eusociality.

Transcriptomic basis and evolution of the ant nurse-larval social interactome.

Development is often strongly regulated by interactions among close relatives, but the underlying molecular mechanisms are largely unknown. In eusocial insects, interactions between caregiving worker nurses and larvae regulate larval development and resultant adult phenotypes. Here, we begin to characterize the social interactome regulating ant larval development by collecting and sequencing the transcriptomes of interacting nurses and larvae across time. We find that the majority of nurse and larval transcriptomes exhibit parallel expression dynamics across larval development. We leverage this widespread nurse-larva gene co-expression to infer putative social gene regulatory networks acting between nurses and larvae. Genes with the strongest inferred social effects tend to be peripheral elements of within-tissue regulatory networks and are often known to encode secreted proteins. This includes interesting candidates such as the nurse-expressed giant-lens, which may influence larval epidermal growth factor signaling, a pathway known to influence various aspects of insect development. Finally, we find that genes with the strongest signatures of social regulation tend to experience relaxed selective constraint and are evolutionarily young. Overall, our study provides a first glimpse into the molecular and evolutionary features of the social mechanisms that regulate all aspects of social life.

Genomic Signature of Kin Selection in an Ant with Obligately Sterile Workers.

Kin selection is thought to drive the evolution of cooperation and conflict, but the specific genes and genome-wide patterns shaped by kin selection are unknown. We identified thousands of genes associated with the sterile ant worker caste, the archetype of an altruistic phenotype shaped by kin selection, and then used population and comparative genomic approaches to study patterns of molecular evolution at these genes. Consistent with population genetic theoretical predictions, worker-upregulated genes experienced reduced selection compared with genes upregulated in reproductive castes. Worker-upregulated genes included more taxonomically restricted genes, indicating that the worker caste has recruited more novel genes, yet these genes also experienced reduced selection. Our study identifies a putative genomic signature of kin selection and helps to integrate emerging sociogenomic data with longstanding social evolution theory.

Use of Patient-Authored Prehistory to Improve Patient Experiences and Accommodate Federal Law.

CONTEXT: Although federal law grants patients the right to view and amend their medical records, few studies have proposed a process for patients to coauthor their subjective history in their medical record. Allowing patients to fully disclose and document their medical history is an important step to improve the diagnostic process. OBJECTIVE: To evaluate patients' office experience before and after they authored their subjective medical history for the electronic health record. METHODS: Patients were mailed a prehistory form and presurvey to be completed before their family medicine office visit. On arrival to the office, the prehistory form was scanned into the electronic health record while the content was transcribed by hospital staff into the appropriate fields in the history component of the encounter note. Postsurveys were given to patients to be completed after their visit. Pre- and postsurveys measured the patients' perception of office visit quality as well as completeness and accuracy of their electronic health record documentation before and after their appointment. Medical staff surveys were collected weekly to measure the staff's viewpoint of the federal law that allows patients to view and amend their medical records. RESULTS: Of 405 patients who were asked to participate, 263 patients aged 14 to 94 years completed a presurvey and a prehistory form. Of those 263 patients, 134 completed a postsurvey. The pre- and postsurveys showed improved patient satisfaction with the office visit and high scores for documentation accuracy and completeness. Before filling out the prehistory form, 116 of 249 patients (46.6%) agreed or strongly agreed that they felt more empowered in their health care by completing the prehistory form compared with 110 of 131 (84.0%) who agreed or strongly agreed after the visit (P<.001). Staff members agreed that patients should have the right to view and amend their medical records in accordance with federal law. CONCLUSION: Empowering patients to contribute subjective information to their electronic health record has the potential to improve the diagnostic process. When conducting a medical encounter, the authors recommend having patients complete a prehistory form beforehand to improve the patient experience while accommodating federal law.

Bleeding Small Intestine Pyogenic Granuloma on 18F-FDG PET/CT.

A 53-year-old man with metastatic melanoma, in remission, presented with an 8-week history of melena and anemia. Initial investigations including upper and lower gastrointestinal endoscopy, capsule endoscopy, and Tc-labeled red blood cell scan did not reveal a source of bleeding. Given the concern over melanoma recurrence, F-FDG PET/CT was performed that demonstrated a focus of intense uptake in the small bowel. Uncomplicated surgical resection of the segment of jejunum containing the lesion was performed, after which the patient reported no further gastrointestinal bleeding. Histopathological assessment of the lesion was consistent with pyogenic granuloma.

Substrate temperature and strain during sputter deposition of aluminum on cast borosilicate glass in a Gemini Observatory coating chamber.

Temperature and strain measurements obtained during coating of spin-cast borosilicate samples are presented here with an analysis of these results. These tests were performed for the Large Synoptic Survey Telescope (LSST) project to verify the possible use of sputtering deposition of optical coating on its large 8.4m diameter primary-tertiary mirror. Made of spin-cast borosilicate glass, the working stress of the mirror's nonpolished surfaces is 100 psi (0.69 MPa), resulting in a local temperature difference limit of 5 degrees C. To ensure representative environmental conditions, the tests were performed in the Gemini Observatory coating chamber located in Hawaii, whose design was utilized to develop the LSST coating chamber design. In particular, this coating chamber is equipped with linear magnetrons built with cooled heat shields directly facing the mirror surface. These measurements have demonstrated that it will be safe for the LSST to use a magnetron sputtering process for coating its borosilicate primary-tertiary mirror.