Utility of high-frequency B-mode and contrast-enhanced ultrasound for the differential diagnosis of benign and malignant pleural diseases: a prospective study.

Background: Pleural disease is a prevalent condition. As precision therapy advances, noninvasive imaging modalities play even more important roles in the evaluation of pleural diseases. This study investigated the diagnostic capabilities of high-frequency B-mode ultrasound (US) and contrast-enhanced US (CEUS) in terms of differentiating between benign and malignant pleural diseases. Methods: Patients with unexplained thickened pleurae were prospectively analyzed via transthoracic US. High-frequency B-mode US was used to derive the pleural thickness, morphology, and echogenicity. We analyzed the high-frequency CEUS data including the enhancement mode and time intensity curve (TIC). The cause of pleural thickening was confirmed by pleural biopsy and follow-up after the biopsy. We analyzed the differences in various ultrasonic features between the malignant and benign groups. Moreover, we plotted receiver operator curves (ROCs) and obtained the area under the curves, sensitivities, and specificities of all significant continuous variables. Multivariate logistic regression was used to assess the combined usefulness of multiple US indicators in terms of predicting malignant pleurae. Results: Thirty malignant and twenty benign thickened pleurae were finally diagnosed via pleural biopsy and at least six months of follow-up. The pleural morphology and enhancement modes significantly differed between the two groups (all P<0.05). The thickness derived from B-mode US and CEUS were significantly thicker in the malignant group (both P<0.05). Arrival time (AT) and the time to peak (TTP) of TIC were significantly shorter in the malignant group, whereas peak intensity and the area under the TIC were significantly higher in the malignant group (all P<0.05). The area under the ROC for pleural thickness derived from B-mode US was 0.819; pleural thickness derived from CEUS was 0.848; AT was 0.804; TTP was 0.750; peak intensity was 0.745; the area under the TIC was 0.743; and the combined various B-mode and CEUS parameter was 0.975. Conclusions: Pleural thickness, morphology, enhancement mode, and the TIC of high-frequency US aided the differentiation of benign from malignant pleural diseases. Combined analysis of US indicators further improved the diagnostic capability.

Increasing the Status of Hospital General Medicine Departments with Emphasis on Outpatient Care in Japan.

Demand is increasing for general medicine services in Japan, a super-aged society. The new medical specialty system introduced in 2019 obligates physicians to obtain a qualified specialty from among 19 basic specialty fields, including general medicine, before obtaining more advanced qualified subspecialties. The role of the department of general medicine in Japan varies in each hospital. Remuneration for medical services obtained by general medicine departments that mainly provide outpatient care is relatively low, making it difficult to fill positions in this department within a hospital. We conducted a narrative review and discussed ways to increase the status of hospital general medicine departments that mainly provide outpatient care. We consider the following four points to be important: improvement of diagnostic capabilities in the outpatient setting; playing a central role in education for medical students and residents; active involvement with patients who have diagnostic difficulties or social problems; and branding and promotion of the general medicine department. We envision that adopting an active approach to these points will increase the status of general medicine departments that mainly provide outpatient care within the hospital, allowing such newly established departments to start easily in Japanese hospitals in the future.

How Clinicians Perceive Artificial Intelligence-Assisted Technologies in Diagnostic Decision Making: Mixed Methods Approach.

BACKGROUND: With the rapid development of artificial intelligence (AI) and related technologies, AI algorithms are being embedded into various health information technologies that assist clinicians in clinical decision making. OBJECTIVE: This study aimed to explore how clinicians perceive AI assistance in diagnostic decision making and suggest the paths forward for AI-human teaming for clinical decision making in health care. METHODS: This study used a mixed methods approach, utilizing hierarchical linear modeling and sentiment analysis through natural language understanding techniques. RESULTS: A total of 114 clinicians participated in online simulation surveys in 2020 and 2021. These clinicians studied family medicine and used AI algorithms to aid in patient diagnosis. Their overall sentiment toward AI-assisted diagnosis was positive and comparable with diagnoses made without the assistance of AI. However, AI-guided decision making was not congruent with the way clinicians typically made decisions in diagnosing illnesses. In a quantitative survey, clinicians reported perceiving current AI assistance as not likely to enhance diagnostic capability and negatively influenced their overall performance (ß=-0.421, P=.02). Instead, clinicians' diagnostic capabilities tended to be associated with well-known parameters, such as education, age, and daily habit of technology use on social media platforms. CONCLUSIONS: This study elucidated clinicians' current perceptions and sentiments toward AI-enabled diagnosis. Although the sentiment was positive, the current form of AI assistance may not be linked with efficient decision making, as AI algorithms are not well aligned with subjective human reasoning in clinical diagnosis. Developers and policy makers in health could gather behavioral data from clinicians in various disciplines to help align AI algorithms with the unique subjective patterns of reasoning that humans employ in clinical diagnosis.

Rwandan primary healthcare providers' perception of their capability in the diagnostic practice.

BACKGROUND: Skill-mix imbalance is a global concern for primary healthcare in low-income countries. In Rwanda, primary healthcare facilities (health centres, HCs) are predominantly led by nurses. They have to diagnose a multitude of health complaints. Whether they feel capable of undertaking this responsibility has yet to be explored. AIM: This study explored how healthcare providers (HPs) at Rwandan HCs perceived their capability in the diagnostic practice. SETTING: Rural and urban HCs in Muhanga district, Rwanda. METHOD: Qualitative, semi-structured interviews with nurses and clinical officers, and observations of consultations were made. Findings were analysed thematically. RESULTS: Rwandan HPs were confident in their competences to perform diagnostic procedures although nurses felt that the responsibilities lay beyond their professional training. Clinical officers believed that their professional training prepared them to function competently and autonomously in the diagnostic practice, although all HPs experienced a high dependency on medical history taking, physical examination and laboratory tests for reaching a diagnosis. Resource constraints (time, rooms and laboratory tests) were seen as a barrier to perform diagnostic tasks optimally, and HPs experienced in-service training and supervision as insufficient. They increased their diagnostic competences through work experience, self-learning and supportive peer collaboration. CONCLUSION: Clinical officers perceived themselves as capable in the diagnostic practice. Nurses may compensate for insufficient school training through in-service learning opportunities and feel capable in the diagnostic practice. Formative mentorship schemes and tailored education may prove valuable, but further research on how to improve HPs' diagnostic capability in Rwanda's primary healthcare sector is needed.

Immune reconstitution inflammatory syndrome in the central nervous system: Limitations for diagnosis in resource limited settings.

INTRODUCTION: The diagnosis of IRIS is based on evidence of clinical worsening and immune reconstitution in the setting of combined antiretroviral therapy (cART) initiation. While central nervous system IRIS (CNS IRIS) is thought to be prevalent in resource limited settings (RLS), its identification is constrained by limited data on pre-treatment HIV disease and diagnostic testing. A diagnosis can be improved with neuroimaging and cerebrospinal fluid (CSF) studies, which are not universally available in RLS. This study evaluated whether diagnoses of CNS IRIS could be achieved in a resource limited setting based on established criteria. METHODS: A retrospective chart review of HIV+ individuals, on ARVs at the time of presentation in two cohort studies of suspected CNS opportunistic infection or tuberculous (TB) meningitis who were admitted to a tertiary care facility in Lusaka, Zambia. RESULTS: Using currently validated criteria, none of the 254 participants evaluated could be diagnosed with CNS IRIS, as there was no information on post-treatment trajectory of HIV viral loads or CD4 counts. Only one participant had a definitive, non-IRIS infectious diagnosis based on comprehensive testing. Of the remaining 253 patients, 68 (27%) had an identified potential CNS pathogen, 92 (36%) had inflammatory CSF in the absence of a pathogen, and 94 (37%) had normal CSF despite presenting with CNS symptoms. CONCLUSION: The absence of HIV disease trajectory data, and lack of comprehensive diagnostic testing, compounded by a high prevalence of infectious pathogens, substantially limits the ability to diagnose CNS IRIS in RLS.

[Epidemic situation of imported malaria and diagnostic capabilities of medical institutions in Wuhan City from 2008 to 2017].

OBJECTIVE: To understand the epidemiological characteristics of imported malaria and the control and diagnostic capacities of the medical institutions in Wuhan City, so as to offer the evidence for formulating the surveillance and control strategies. METHODS: From 2008 to 2017, the epidemiological data of imported malaria were collected. The information including gender, age, distribution, vocational background, positive rate of fever patients, and time of final diagnosis was analyzed with the descriptive statistic method. The Plasmodium species composition and infection source were analyzed by chi square test. The initial and confirmed diagnosis abilities of medical institutions were analyzed by rank sum test. RESULTS: Totally, 424 imported malaria cases were reported, including 301 falciparum malaria cases (70.99%). The male population aged 20 to 49 years was the main morbidity group, and the incidence was not related to seasons. For the parasite species, there was a significant difference between African countries and Southeast Asian countries (χ2 = 205.83, P < 0.01). Plasmodium ovale and P. malariae were all imported from sub-Saharan Africa. For diagnostic capacities of the medical institutions at different levels, the initial diagnosis (Z = -3.89, P < 0.01) and confirmed diagnosis (χ2 = 53.88, P < 0.01) were significantly different, respectively. The ability of malaria diagnosis was improved rapidly in the clinical laboratory after 2008 and achieved to 100% in 2010. The detection rate within 24 hours increased to at least 90% and the detection rate within 6 days decreased to 0 in 2016. CONCLUSIONS: Although the medical institutions in Wuhan City have strong ability to treat imported malaria, they are still faced with a serious situation for malaria control and elimination. The capacity building should be strengthened constantly.

A Systems Approach to Agricultural Biosecurity.

This article highlights the importance of systems approaches in addressing agricultural biosecurity threats. On the basis of documentary analysis and stakeholder interaction, a brief survey of agricultural biosecurity threats and vulnerabilities from global and Indian perspectives is provided, followed by an exploration of technological and institutional capabilities. Finally, a perspective on the agricultural disease diagnostic networks is provided, drawing instances from global developments. Technical barriers to agroterrorism are lower than those to human-targeted bioterrorism, and the sector is unique as even a very small disease outbreak could prompt international export restrictions. Key vulnerabilities in the agriculture sector stem from, among others, the structure of agricultural production; insufficient monitoring, surveillance, and controls systems at the borders and in the food chain; inefficient systems for reporting unusual occurrences and outbreaks of disease; and lack of sufficiently trained human resources capable of recognizing or treating transboundary pathogens and diseases. An assessment of technology and institutions pertaining to crop and animal protection management suggests certain gaps. Investment in developing new technologies for civilian application in agriculture, as well as for legitimate actions pertaining to defense, detection, protection, and prophylaxis, and in upgrading laboratory facilities can increase the agricultural sector's level of preparedness for outbreaks. To address potential threats and vulnerabilities of agroterrorism effectively requires the development of a comprehensive strategy and a combined, interagency approach, ideally on an international level. It is proposed that a systems-oriented approach for developing knowledge and innovation networks and strengthening skills and capacities would enable a more resilient agricultural biosecurity system.

Epidemic situation of imported malaria and diagnostic capabilities of medi-cal institutions in Wuhan City from 2008 to 2017 / 中国血吸虫病防治杂志

Objective To understand the epidemiological characteristics of imported malaria and the control and diagnostic capacities of the medical institutions in Wuhan City,so as to offer the evidence for formulating the surveillance and control strat-egies.Methods From 2008 to 2017,the epidemiological data of imported malaria were collected.The information including gender,age,distribution,vocational background,positive rate of fever patients,and time of final diagnosis was analyzed with the descriptive statistic method.The Plasmodium species composition and infection source were analyzed by chi square test.The initial and confirmed diagnosis abilities of medical institutions were analyzed by rank sum test.Results Totally,424 imported malaria cases were reported,including 301 falciparum malaria cases(70.99％).The male population aged 20 to 49 years was the main morbidity group,and the incidence was not related to seasons.For the parasite species,there was a significant differ-ence between African countries and Southeast Asian countries(Χ 2=205.83,P<0.01).Plasmodium ovale and P.malariae were all imported from sub-Saharan Africa.For diagnostic capacities of the medical institutions at different levels,the initial diag-nosis(Z=-3.89,P<0.01)and confirmed diagnosis(Χ2=53.88,P<0.01)were significantly different,respectively.The abili-ty of malaria diagnosis was improved rapidly in the clinical laboratory after 2008 and achieved to 100％in 2010.The detection rate within 24 hours increased to at least 90％and the detection rate within 6 days decreased to 0 in 2016.Conclusions Al-though the medical institutions in Wuhan City have strong ability to treat imported malaria,they are still faced with a serious sit-uation for malaria control and elimination.The capacity building should be strengthened constantly.

Diagnostic capability of peripapillary retinal nerve fiber layer parameters in time-domain versus spectral-domain optical coherence tomography for assessing glaucoma in high myopia.

AIM: To evaluate and compare the diagnostic capabilities of peripapillary retinal nerve fiber layer (p-RNFL) parameters of Spectralis optical coherence tomography (OCT) versus Stratus OCT to detect glaucoma in patients with high myopia. METHODS: This is a retrospective, cross-sectional study. Sixty highly myopic eyes of 60 patients were enrolled, with 30 eyes in the glaucoma group and 30 eyes in the control group. All eyes received peripapillary imaging of the optic disc using Stratus and Spectralis OCT. Areas under the receiver operating characteristic curve (AUROC) and the sensitivity at specificity of >80% and >95% for p-RNFL parameters obtained using the two devices to diagnose glaucoma were analysed and compared. RESULTS: In Spectralis OCT, p-RNFL thickness parameters with the largest AUROC were the temporal-inferior sector (0.974) and the inferior quadrant (0.951), whereas in Stratus OCT, the best parameters were the 7-o'clock sector (0.918) and the inferior quadrant (0.918). Compared to the Stratus OCT parameters, the Spectralis OCT parameters demonstrated generally higher AUROC; however, the difference was not statistically significant. CONCLUSION: The best p-RNFL parameters for diagnosing glaucoma in patients with high myopia were the temporal-inferior sector on Spectralis OCT and the 7-o'clock sector on Stratus OCT. There were no significant differences between the AUROCs for Spectralis OCT and Stratus OCT, which suggest that the glaucoma diagnostic capabilities of these two devices in patients with high myopia are similar.

Diagnostic capability of retinal thickness measures in diabetic peripheral neuropathy.

PURPOSE: To examine the diagnostic capability of the full retinal and inner retinal thickness measures in differentiating individuals with diabetic peripheral neuropathy (DPN) from those without neuropathy and non-diabetic controls. METHODS: Individuals with (n=44) and without (n=107) diabetic neuropathy and non-diabetic control (n=42) participants underwent spectral domain optical coherence tomography (SDOCT). Retinal thickness in the central 1mm zone (including the fovea), parafovea and perifovea was assessed in addition to ganglion cell complex (GCC) global loss volume (GCC GLV) and focal loss volume (GCC FLV), and retinal nerve fiber layer (RNFL) thickness. Diabetic neuropathy was defined using a modified neuropathy disability score (NDS) recorded on a 0-10 scale, wherein, NDS ≥3 indicated neuropathy and NDS indicated <3 no neuropathy. Diagnostic performance was assessed by areas under the receiver operating characteristic curves (AUCs), 95 per cent confidence intervals (CI), sensitivities at fixed specificities, positive likelihood ratio (+LR), negative likelihood ratio (-LR) and the cut-off points for the best AUCs obtained. RESULTS: The AUC for GCC FLV was 0.732 (95% CI: 0.624-0.840, p<0.001) with a sensitivity of 53% and specificity of 80% for differentiating DPN from controls. Evaluation of the LRs showed that GCC FLV was associated with only small effects on the post-test probability of the disease. The cut-off point calculated using the Youden index was 0.48% (67% sensitivity and 73% specificity) for GCC FLV. For distinguishing those with neuropathy from those without neuropathy, the AUCs of retinal parameters ranged from 0.508 for the central zone to 0.690 for the inferior RNFL thickness. For distinguishing those with moderate or advanced neuropathy from those with mild or no neuropathy, the inferior RNFL thickness demonstrated the highest AUC of 0.820, (95% CI: 0.731-0.909, p<0.001) with a sensitivity of 69% and 80% specificity. The cut-off-point for the inferior RNFL thickness was 97µm, with 81% sensitivity and 72% specificity. CONCLUSIONS: The GCC FLV can differentiate individuals with diabetic neuropathy from healthy controls, while the inferior RNFL thickness is able to differentiate those with greater degrees of neuropathy from those with mild or no neuropathy, both with an acceptable level of accuracy. Optical coherence tomography represents a non-invasive technology that aids in detection of retinal structural changes in patients with established diabetic neuropathy. Further refinement of the technique and the analytical approaches may be required to identify patients with minimal neuropathy.

Diagnostic Accuracies of Bruch Membrane Opening-minimum Rim Width and Retinal Nerve Fiber Layer Thickness in Glaucoma

PURPOSE: To compare the diagnostic capability of Bruch membrane opening-minimum rim width (BMO-MRW) and peripapillary retinal nerve fiber layer (RNFL) thickness for the detection of primary open angle glaucoma. METHODS: Spectral-domain optical coherence tomography (SD-OCT) with 24 radial and 1 peripapillary B-scans centered on the Bruch membrane opening (BMO) was performed. Two SD-OCT parameters were computed globally and sectorally: (1) BMO-MRW, the minimum distance between BMO and internal limiting membrane; and (2) peripapillary retinal nerve fiber layer (RNFL) thickness. The diagnostic performance of BMO-MRW and RNFL thickness were compared with receiver operating characteristic (ROC) analysis globally and sectorally. Areas under the ROC (AUC) were calculated and compared. RESULTS: One hundred fourteen eyes (52 healthy, 62 glaucomatous) of 114 participants were included. In global analyses, the performance of BMO-MRW was similar to that of RNFL thickness (AUC 0.95 [95% confidence interval {CI}, 0.91-0.99], and 0.95 [95% CI, 0.91-0.99], respectively, p=0.93). In sectoral analyses, the pair-wise comparison among the ROC curves showed no statistical difference for all sectors except for the superotemporal, superonasal, and nasal sectors, which had significantly larger AUCs in BMO-MRW compared to RNFL thickness (p=0.03, p<0.001, and p=0.03, respectively). The parameter with the largest AUC was the inferotemporal sector for both BMO-MRW and RNFL thickness (AUC 0.98 [95% CI, 0.96-1.00], and 0.98 [95% CI, 0.96-1.00], respectively, p=0.99). CONCLUSIONS: Global BMO-MRW performed as well as global RNFL thickness for detection of glaucoma. In superotemporal, superonasal and nasal sectors, regional BMO-MRW performed better than regional RNFL thickness.

Retinal Nerve Fiber Layer Thickness Measurement Comparison Using Spectral Domain and Swept Source Optical Coherence Tomography.

PURPOSE: To investigate the retinal nerve fiber layer (RNFL) thickness concordance when measured by spectral domain (SD) and swept source (SS) optical coherence tomography (OCT), and to compare glaucoma-discriminating capability. METHODS: RNFL thicknesses were measured with the scan circle, centered on the optic nerve head, in 55 healthy, 41 glaucoma suspected, and 87 glaucomatous eyes. The RNFL thickness measured by the SD-OCT (sdRNFL thickness) and SS-OCT (ssRNFL thickness) were compared using the t-test. Bland-Altman analysis was performed to examine their agreement. We compared areas under the receiver operating characteristics curve and examined sdRNFL and ssRNFL thickness for discriminating glaucomatous eyes from healthy eyes, and from glaucoma suspect eyes. RESULTS: The average ssRNFL thickness was significantly greater than sdRNFL thickness in healthy (110.0 ± 7.9 vs. 100.1 ± 6.8 µm, p < 0.001), glaucoma suspect (96.8 ± 9.3 vs. 89.6 ± 7.9 µm, p < 0.001), and glaucomatous eyes (74.3 ± 14.2 vs. 69.1 ± 12.4 µm, p = 0.011). Bland-Altman analysis showed that there was a tendency for the difference between ssRNFL and sdRNFL to increase in eyes with thicker RNFL. The area under the curves of the average sdRNFL and ssRNFL thickness for discriminating glaucomatous eyes from healthy eyes (0.984 vs. 0.986, p = 0.491) and glaucoma suspect eyes (0.936 vs. 0.918, p = 0.132) were comparable. CONCLUSIONS: There was a tendency for ssRNFL thickness to increase, compared with sdRNFL thickness, in eyes with thicker RNFL. The ssRNFL thickness had comparable diagnostic capability compared with sdRNFL thickness for discriminating glaucomatous eyes from healthy eyes and glaucoma suspect eyes.

Retinal Nerve Fiber Layer Thickness Measurement Comparison Using Spectral Domain and Swept Source Optical Coherence Tomography

PURPOSE: To investigate the retinal nerve fiber layer (RNFL) thickness concordance when measured by spectral domain (SD) and swept source (SS) optical coherence tomography (OCT), and to compare glaucoma-discriminating capability. METHODS: RNFL thicknesses were measured with the scan circle, centered on the optic nerve head, in 55 healthy, 41 glaucoma suspected, and 87 glaucomatous eyes. The RNFL thickness measured by the SD-OCT (sdRNFL thickness) and SS-OCT (ssRNFL thickness) were compared using the t-test. Bland-Altman analysis was performed to examine their agreement. We compared areas under the receiver operating characteristics curve and examined sdRNFL and ssRNFL thickness for discriminating glaucomatous eyes from healthy eyes, and from glaucoma suspect eyes. RESULTS: The average ssRNFL thickness was significantly greater than sdRNFL thickness in healthy (110.0 ± 7.9 vs. 100.1 ± 6.8 µm, p < 0.001), glaucoma suspect (96.8 ± 9.3 vs. 89.6 ± 7.9 µm, p < 0.001), and glaucomatous eyes (74.3 ± 14.2 vs. 69.1 ± 12.4 µm, p = 0.011). Bland-Altman analysis showed that there was a tendency for the difference between ssRNFL and sdRNFL to increase in eyes with thicker RNFL. The area under the curves of the average sdRNFL and ssRNFL thickness for discriminating glaucomatous eyes from healthy eyes (0.984 vs. 0.986, p = 0.491) and glaucoma suspect eyes (0.936 vs. 0.918, p = 0.132) were comparable. CONCLUSIONS: There was a tendency for ssRNFL thickness to increase, compared with sdRNFL thickness, in eyes with thicker RNFL. The ssRNFL thickness had comparable diagnostic capability compared with sdRNFL thickness for discriminating glaucomatous eyes from healthy eyes and glaucoma suspect eyes.

Diagnostic Accuracy of the Transvaginal Ultrasonography in Asymptomatic Ectopic Pregnancy / 대한주산의학회잡지

OBJECTIVE: To assess diagnostic accuracy of the transvaginal ultrasonography and confirm the clinical safety as a final diagnosis in the asymptomatic ectopic pregnancy. METHODS: Total 58 women which were suspected with ectopic pregnancy were recruited during 1 year period. Women without sonographic evidence of the intrauterine gestational sac with serum beta-hCG level beyond 1,500 mIU/ml or gestational periods beyond 37 days were included (n=44), and women with acute symptom were excluded (n=14). We performed the laparoscopy and compared them with the ultrasonographic findings. We regarded the cases with accordance between two findings as an accurate diagnosis, and calculated diagnostic accuracy. All surgical specimens were confirmed by the pathological examination. RESULTS: Of 44 subjects, we suspected ectopic pregnancy by ultrasonography in 42 patients and classified as right fallopian tube (20 cases), left fallopian tube (15 cases), right interstitial (3 cases), left interstitial (4 cases), normal finding (2 cases). Of 42 cases, 41 cases were confirmed as an ectopic pregnancy by laparoscopical and pathological examination. There were two cases of inaccurate diagnosis, in one case, suspected site was not concordant, in another case, ectopic pregnancy focus was not identified in laparoscopy. In 2 cases with normal ultrasonographic findings, any other findings suspicious of ectopic pregnancy were not identified in laparoscopy. By 2X2 contingency table analysis, sensitivity, specificity, positive predictive value, negative predictive value of the transvaginal ultrasonography for diagnosis of the ectopic pregnancy were 100%, 50%, 98%, 100%, respectively. CONCLUSION: Diagnostic capability of the transvaginal ultrasonography in the ectopic pregnancy was very powerful and reliable, and sonographical diagnosis may replace the diagnostic laparoscopy if medical treatment is intended.