Medical Decision-Making System of Ultrasound Carotid Artery Intima–Media Thickness Using Neural Networks

The objective of this work is to develop and implement a medical decision-making system for an automated diagnosis and classification of ultrasound carotid artery images. The proposed method categorizes the subjects into normal, cerebrovascular, and cardiovascular diseases. Two contours are extracted for each and every preprocessed ultrasound carotid artery image. Two types of contour extraction techniques and multilayer back propagation network (MBPN) system have been developed for classifying carotid artery categories. The results obtained show that MBPN system provides higher classification efficiency, with minimum training and testing time. The outputs of decision support system are validated with medical expert to measure the actual efficiency. MBPN system with contour extraction algorithms and preprocessing scheme helps in developing medical decision-making system for ultrasound carotid artery images. It can be used as secondary observer in clinical decision making.     

Prevalence of Asymptomatic Critical Carotid Artery Stenosis in Korean Patients with Chronic Atherosclerotic Lower Extremity Ischemia: Is a Screening Carotid Duplex Ultrasonography Worthwhile?

This study aimed to investigate prevalence of asymptomatic carotid artery stenosis (ACAS) in Korean patients with peripheral arterial disease (PAD) and identify predictive factors of ACAS in patients with PAD. Between 1994 and 2008, 546 patients who underwent bypass surgery due to PAD were identified in a single tertiary teaching hospital. Of those, 409 patients underwent preoperative screening carotid duplex ultrasonography (CDUS). Patients who had an episode of cerebrovascular event or previous carotid artery intervention were excluded and then a retrospective analysis was made of 340 patients. The degree of internal carotid artery (ICA) stenosis was determined by the criteria of Society of Radiologists in Ultrasound Consensus Conference. To determine the risk factors of ACAS, demographic, coexisting medical condition and lesion characteristics were tested with binary logistic regression model. The prevalence of ≥70% ICA stenosis was 14%. ICA occlusion was detected in 7.1%. Multivariate analysis revealed age >65 yr (OR: 2.610, 95% CI: 1.197-5.691) and coronary artery disease (CAD, OR: 2.333, 95% CI: 1.169-4.657) are predictive factors of ≥70% stenosis. A PAD patient who needs revascularization, particularly, >65 yr or has a concomitant CAD, can be a good candidate of screening CDUS.     

Evaluation of the potential of Trichoderma viride in the control of fungal pathogens of Roselle (Hibiscus sabdariffa L.) in vitro

The potential of Trichoderma viride as a bio-control agent was evaluated in vitro against Roselle pathogens i.e. Phoma exigua, Fusarium nygamai and Rhizoctonia solani [1] using the dual culture technique. Volatile and non-volatile inhibitors of Trichoderma were also evaluated for this purpose. T. viride [2] was shown to have a marked inhibitory effect on the tested pathogens in vitro. Maximum inhibition occurred against P. exigua, with 71.76% reduction in mycelial radial growth. The three pathogens, P. exigua, F. nygamai and R. solani were also found to be susceptible to the volatile inhibitors produced by T. viride, giving rise to growth inhibition of about 68% in each case. When T. viride non-volatile metabolites were tested against the pathogens, maximum inhibition occurred against R. solani (73.95% mycelial growth inhibition), followed by P. exigua (37.17% inhibition). The inhibitory effect of the non-volatile metabolites on F. nygamai was, however, minimal.     

Association of Online Health Information–Seeking Behavior and Self-Care Activities Among Type 2 Diabetic Patients in Saudi Arabia

Background

Health information obtained from the Internet has an impact on patient health care outcomes. There is a growing concern over the quality of online health information sources used by diabetic patients because little is known about their health information–seeking behavior and the impact this behavior has on their diabetes-related self-care, in particular in the Middle East setting.

Objective

The aim of this study was to determine the online health-related information–seeking behavior among adult type 2 diabetic patients in the Middle East and the impact of their online health-related information–seeking behavior on their self-care activities.

Methods

A cross-sectional survey was conducted on 344 patients with type 2 diabetes attending inpatient and outpatient primary health care clinics at 2 teaching hospitals in Riyadh, Saudi Arabia. The main outcome measures included the ability of patients to access the Internet, their ability to use the Internet to search for health-related information, and their responses to Internet searches in relation to their self-care activities. Further analysis of differences based on age, gender, sociodemographic, and diabetes-related self-care activities among online health-related information seekers and nononline health-related information seekers was conducted.

Results

Among the 344 patients, 74.1% (255/344) were male with a mean age of 53.5 (SD 13.8) years. Only 39.0% (134/344) were Internet users; 71.6% (96/134) of them used the Internet for seeking health-related information. Most participants reported that their primary source of health-related information was their physician (216/344, 62.8%) followed by television (155/344, 45.1%), family (113/344, 32.8%), newspapers (100/344, 29.1%), and the Internet (96/344, 27.9%). Primary topics participants searched for were therapeutic diet for diabetes (55/96, 57%) and symptoms of diabetes (52/96, 54%) followed by diabetes treatment (50/96, 52%). Long history of diabetes, familial history of the disease, unemployment, and not seeking diabetes education were the most common barriers for online health-related information–seeking behavior. Younger age, female, marital status, higher education, higher income, and longer duration of Internet usage were associated with more online health-related information–seeking behaviors. Most (89/96, 93%) online health-related information seekers reported positive change in their behaviors after seeking online health information. Overall odds ratio (OR 1.56, 95% CI 0.63-3.28) for all self-care responses demonstrated that there was no statistically significant difference between those seeking health-related information online and non–health-related information seekers. However, health-related information seekers were better in testing their blood glucose regularly, taking proper action for hyperglycemia, and adopting nonpharmacological management.

Conclusions

Physicians and television are still the primary sources of health-related information for adult diabetic patients in Saudi Arabia whether they seek health-related information online or not. This study demonstrates that participants seeking online health-related information are more conscious about their diabetes self-care compared to non–health-related information seekers in some aspects more than the others.     

Regional Analysis of Spontaneous MEG Rhythms in Patients with Alzheimer’s Disease Using Spectral Entropies

Alzheimer’s disease (AD) is the most common form of dementia. Ageing is the greatest known risk factor for this disorder. Therefore, the prevalence of AD is expected to increase in western countries due to the rise in life expectancy. Nowadays, a low diagnosis accuracy is reached, but an early and accurate identification of AD should be attempted. In this sense, only a few studies have focused on the magnetoencephalographic (MEG) AD patterns. This work represents a new effort to explore the ability of three entropies from information theory to discriminate between spontaneous MEG rhythms from 20 AD patients and 21 controls. The Shannon (SSE), Tsallis (TSE), and Rényi (RSE) spectral entropies were calculated from the time-frequency distribution of the power spectral density (PSD). The entropies provided statistically significant lower values for AD patients than for controls in all brain regions (p < 0.0005). This fact suggests a significant loss of irregularity in AD patients’ MEG activity. Maximal accuracy of 87.8% was achieved by both the TSE and RSE (90.0%, sensitivity; 85.7%, specificity). The statistically significant results obtained by both the extensive (SSE and RSE) and non-extensive (TSE) spectral entropies suggest that AD could disturb long and short-range interactions causing an abnormal brain function.     

Evaluation of the Use of Peripherally Inserted Central Catheters in Orthopedic Patients at the Day Hospital of University of São Paulo

The use of peripherally inserted central catheters (PICCs) in hospitalized patients is already well established by studies and guidelines, and PICCs are widely used at our institution. However, few studies have been published examining patients using the device in day hospital systems; specifically, if the device brings about early dehospitalization, if it facilitates quick return to coexistence in society and to work, and how to plan medication administration through this system. Our general objective was to evaluate the advantages and disadvantages of the use of PICCs in patients undergoing prolonged intravenous treatment. We selected patients using PICCs in the day hospital at the Institute of Orthopedics and Traumatology at Clinics Hospital of the School of Medicine of the University of São Paulo, conducted a semistructured interview, and did an analysis of medical records. The most frequent diagnoses that led to use of a PICC were postoperative infection (53.84%) and osteomyelitis (23.07%). Teicoplanin was the most common drug prescribed, followed by vancomycin. Regarding the puncture site, the basilic vein prevailed with 69.23%. Most of the catheters (61.54%) remained in place from 60 to 150 days. The end of the drug therapy was the reason for removal in 66.4% of cases. Regarding pain assessment, 88.47% of patients declared they did not feel any pain or felt moderate pain during the PICC insertion procedure. Based on the data collected, it can be concluded that PICCs are reliable devices for a wide variety of intravenous infusions used in patients treated at our day hospital.     

Clinical Evaluation of a (1,3)-β-d-Glucan Assay for Presumptive Diagnosis of Pneumocystis jiroveci Pneumonia in Immunocompromised Patients

(1,3)-β-d-Glucan (BG) is a component of the Pneumocystis jiroveci cell wall. Thirty-one immunocompromised patients with pneumonia (16 with presumptive pneumocystis pneumonia [PCP] and 15 with non-PCP) were evaluated for serum BG levels. Serum from all 16 presumptive PCP patients and from 2/15 patients with non-PCP was positive for BG. Results indicate that BG is a reliable marker for diagnosing PCP.The diagnosis of pneumocystis pneumonia (PCP) due to Pneumocystis jiroveci is usually based on the microscopic detection of cysts in respiratory specimens, such as bronchoalveolar lavage specimens made by fiber-optic bronchoscopy, which has a good sensitivity although it is sometimes very difficult to perform due to the frequent severe respiratory failure of affected patients. In addition, when an appropriate specimen is obtained, the microscopic identification of P. jiroveci is strongly related to the observer''s skills and experience.Other diagnostic procedures, such as PCR, have been reported to be both sensitive and specific, although none of these procedures turned out to be a reliable method in the analysis of biological samples—sputum and pharyngeal swabs—taken using noninvasive techniques (12).(1,3)-β-d-Glucan (BG) is a component of the cell wall of many fungal organisms, and its presence in serum had been shown to be a reliable marker of invasive fungal infection in both clinical (7, 8, 10, 11) and autoptic (6) studies. Its clinical usefulness had been demonstrated with hematologic patients when used either alone (13) or in combination with serum galactomannan (9). BG is also a component of the P. jiroveci cell wall, but no method for detecting BG in serum has so far been validated for diagnostic purposes in PCP, despite some encouraging reports (3, 10, 14).The aim of this study was to evaluate the role of a serum BG test in the presumptive diagnosis of PCP in immunocompromised patients unable to undergo invasive diagnostic procedures.From May 2008 to January 2009, 31 serum samples from immunocompromised patients with pneumonia were collected and stored. All patients admitted to our clinical unit and for whom invasive diagnostic procedures were unfeasible had clear risk factors (see below) for PCP. Clinical presentations of patients were either consistent or not consistent with PCP. Each patient gave informed consent. In the same period of time, 11 control sera from healthy volunteers (the investigators involved in the study and laboratory personnel) were also collected.A case of presumptive PCP was based on the presence of a baseline clinical condition compatible with the risk of PCP (human immunodeficiency virus [HIV] disease with fewer than 200 CD4 cells/μl, administration of high-dose steroids for more than 8 weeks, or hematological malignancies treated with immunosuppressive therapy) plus, according to the modified 1993 definition of PCP as an AIDS-defining condition (1), all the following factors: (i) a history of dyspnea on exertion or nonproductive cough of recent onset (less than 3 months); (ii) arterial PO₂ of less than 70 mm Hg; (iii) chest X-ray finding of bilateral interstitial infiltrate; and (iv) no evidence of bacterial pneumonia.PCP therapy was administered according to the clinical judgment of attending physicians.After all data collection and before the final analysis, each case was evaluated by an independent expert, who was unaware of BG test results, and classified as presumptive PCP or non-PCP pneumonia (NPCP).Serum BG evaluation was performed according to the manufacturer''s instructions by using Fungitell (Associates of Cape Cod, Inc., Cape Cod, MA), one of the tests commercially available for the detection of BG and approved in 2003 by the U.S. Food and Drug Administration for the presumptive diagnosis of invasive fungal infection. BG values of ≥80 pg/ml were considered positive according to the manufacturer''s indications.Median BG concentrations in the subgroups of patients were calculated. Results for the subgroups were reciprocally compared by means of the Mann-Whitney U test. P values of <0.05 were considered significant.Of 31 pneumonia patients, 16 were judged as having likely PCP and 15 as having NPCP. Eight out of 16 PCP patients had HIV infection, six had hematologic malignancies, and two were being given corticosteroids due to autoimmune disorders. Four out of six patients with hematologic malignancies were also being given corticosteroids. Thirteen had a favorable clinical course with a full response to PCP therapy and discharge from our unit, while three patients died. Two of them (one of whom was HIV infected) showed a transitory clinical response (improvement of lactate dehydrogenase, PO₂, and fever) to pneumonia; however, their liver function deteriorated (they were both HCV infected), contributing to death. The other patient (HIV infected) had a severe wasting syndrome, rendering poorly evaluable the clinical response to pneumonia.All patients had a positive BG test result.Two of 15 patients with NPCP had a positive BG test result. Both of them were HIV positive with a CD4 cell count of less than 200/μl. One had lobar pneumonia with Streptococcus pneumoniae bacteremia, a possible cause of BG positivity (4), while the other had bilateral pneumonia treated successfully with ciprofloxacin.All 11 healthy volunteers had negative results for BG.The median BG levels for the three groups are reported in Table ​Table1.1. In a comparison of the BG concentrations for the two subgroups of patients by means of the Mann-Whitney U test, the difference was statistically significant (P < 0.0001). Box plots of BG values divided by subgroups are shown in Fig. ​Fig.11.Open in a separate windowFIG. 1.Distribution of serum BG values (pg/ml). Boxes show interquartile range; whiskers show 95% confidence intervals. Plus signs represent outliers.

TABLE 1.

Median and range of BG concentrations

In vivo Characterization of Brain Morphometric and Metabolic Endophenotypes in Three Inbred Strains of Mice Using Magnetic Resonance Techniques

C57BL/6J, FVB/N and 129/SvJ mice are commonly used as background strains to engineer genetic models of brain pathologies and psychiatric disorders. Magnetic resonance imaging (MRI) and spectroscopy provide alternative approaches to neuroanatomy, histology and neurohistochemistry for investigating the correlation between genes and brain neuroanatomy and neurometabolism in vivo. We used these techniques to non-invasively characterize the cerebral morphologic and metabolic endophenotypes of inbred mouse strains commonly used in neurological and behavioral research. We observed a great variability in the volume of ventricles and of structures involved in cognitive function (cerebellum and hippocampus) among these strains. In addition, distinct metabolic profiles were evidenced with variable levels of N-acetylaspartate, a neuronal marker, and of choline, a compound found in membranes and myelin. Besides, significant differences in high-energy phosphates and phospholipids were detected. Our findings demonstrate the great morphologic and metabolic heterogeneity among C57BL/6J, FVB/N and 129/SvJ mice. They emphasize the importance of selecting the appropriate genetic background for over-expressing or silencing a gene and provide some directions for modeling symptoms that characterize psychiatric disorders such as autism, schizophrenia and depression.The first two authors contributed equally to this work.     

Evaluation of a Commercial Microarray System for Detection of SHV-, TEM-, CTX-M-, and KPC-Type β-Lactamase Genes in Gram-Negative Isolates

We evaluated the ability of a commercial microarray system (Check KPC/ESBL; Check-Points Health BV) to detect clinically important class A β-lactamase genes. A total of 106 Gram-negative strains were tested. The following sensitivity and specificity results were recorded, respectively: for bla_SHV, 98.8% and 100%; for bla_TEM, 100% and 96.4%; and for bla_CTX-M and bla_KPC, 100% and 100%.The spread of class A or group 2be extended-spectrum β-lactamases (ESBLs) represents an emerging public-health concern (1, 17). Among the organisms of the Enterobacteriaceae family (e.g., Klebsiella pneumoniae and Escherichia coli), the most frequently detected and clinically important ESBLs belong to the TEM, SHV, and CTX-M families (17). While TEM- and SHV-type ESBLs arise via substitutions in strategically positioned amino acids (e.g., Gly238 and Arg164) from the natural narrow-spectrum TEM-1, TEM-2, or SHV-1 β-lactamase genes, all currently identified CTX-M enzymes demonstrate an ESBL phenotype (7, 14).The ability to rapidly identify narrow-spectrum β-lactamases (e.g., SHV-11 and TEM-1) and ESBLs (e.g., SHV-5 and SHV-12 or TEM-10) has important clinical implications. Usually, Enterobacteriaceae species producing narrow-spectrum enzymes are resistant to penicillins and narrow-spectrum cephalosporins, whereas those producing ESBLs manifest resistance to extended-spectrum oxyimino-cephalosporins and aztreonam (14). Since resistance to quinolones and aminoglycosides is frequently observed among ESBL producers, carbapenems represent one of the therapeutic options of last resort for life-threatening infections due to these organisms (6, 14).In some geographic areas, the spread of carbapenemases belonging to class A (e.g., KPCs), class B (e.g., VIMs and IMPs), and class D (e.g., OXA-48) has significantly compromised the clinical use of carbapenems, consigning clinicians to the use of “last-line” antimicrobials such as colistin (2, 19). In particular, the KPC β-lactamases (primarily KPC-2 and KPC-3) are the serine carbapenemases that are most widespread in the United States, and strains producing these enzymes are responsible for numerous outbreaks with high mortality rates (3, 9, 13). Although nine KPC-type β-lactamases have been described, their susceptibility profiles are similar, rendering the differentiation of these variants less clinically relevant (13, 22).Prompt and appropriate antibiotic treatment for infections due to ESBLs- and/or KPC-producing Enterobacteriaceae may positively affect the final outcome for infected patients (6, 13). Unfortunately, standard and confirmatory phenotypic tests may fail to identify ESBL- and, more frequently, KPC-producing organisms. For the latter group, the use of the modified Hodge test delays the final report by an additional 24 h (11, 12, 21). Therefore, a rapid and reliable method is needed to perform a quick and accurate analysis of the most important bla genes possessed by clinical isolates.Microarray technologies are promising genotyping systems that possess a high multiplexing capacity and can be used for detecting different β-lactamase genes that are present in a single strain (8, 10, 23). This ability can assist clinicians in directing antimicrobial therapy. In the present work, we evaluated the ability of Check KPC/ESBL (Check-Points Health BV, Wageningen, Netherlands), the first rapid, commercially available, microarray-based diagnostic test system for detection and identification of bla genes belonging to the TEM, SHV, CTX-M, and KPC types. This system can detect single nucleotide polymorphisms found in the most important TEM- and SHV-type ESBLs (www.lahey.org/studies), including single mutations corresponding to amino acid positions Val84Ile, Glu104Lys, Arg164Ser/His/Cys, and Gly238Ser in TEMs and Gly238Ser/Ala and/or Glu240Lys in SHVs (7).A total of 102 Enterobacteriaceae and four Acinetobacter baumannii isolates possessing different bla genes were tested (Table ​(Table1;1; see also Table S1 in the supplemental material). The majority of strains (n = 61) had previously been characterized (3-5, 15), whereas the bla genes of the remaining isolates were characterized by PCR amplification, standard DNA sequencing, and analytical isoelectric focusing (aIEF) as previously described (4). In this collection, isolates possessed an average of three different bla genes (range, one to five; see Table S1 in the supplemental material). The collection also included K. pneumoniae ATCC 700603, which produces the SHV-18 ESBL (20), and six E. coli DH10B control strains in which single bla genes are carried in different plasmid vectors (see Table S1 in the supplemental material).

TABLE 1.

Performance of the Check KPC/ESBL microarray assay in identification of β-lactamase genes^a

Determination of Cell Proliferation Using Mcm2 Antigen and Evaluation of Apoptosis and TGF-β1 Expression in GH-secreting or Clinically Nonfunctioning Pituitary Adenomas

Pituitary adenomas (PA) occasionally show aggressive behavior, with invasion of the surrounding tissues. The identification of markers able to recognize aggressive PA in early stages remains a challenge. We aimed to determine the expression of a new cell proliferation marker, Mcm2, and the presence of apoptosis in PA, and to evaluate the association of clinicopathological features with the apoptotic and proliferative indices. Additionally, the TGF-β1 expression, an inducer of apoptosis, was determined. The proliferative index was determined in GH-secreting or clinically nonfunctioning PA using immunohistochemical (IH) methods for Mcm2 and Ki-67 antigens. The apoptosis was assessed by the TUNEL method and the TGF-β1 expression by IH. A significant positive correlation was found between log Mcm2 index and log Ki-67 index (p < 0.001). Mcm2 and Ki-67 detected a similar number of proliferating cells. Mcm2 index showed a significant association with tumor extension (p = 0.02), but not with tumor invasion. Apoptosis was detected in 17% of the adenomas, with a maximum apoptotic index of 0.77%. Immunoreactivity to TGF-β1 was observed in 77% of the adenomas, showing an association with tumor extension. We concluded that, in this sample, Mcm2 was similar to Ki-67 in the identification of the proliferating cells and that apoptosis was rare.     

The Current State of Doctors’ Communication Skills in Mainland China from the Perspective of Doctors’ Self-evaluation and Patients’ Evaluation: A Cross-Sectional Study

ObjectiveTo assess doctors’ communication skills in mainland China using the SEGUE Framework.MethodsA survey on doctors’ communication skills with doctors (n = 1361) and patients (n = 1757) from 14 provinces in eastern, central and western China was conducted.ResultsThe doctors’ self-evaluation scores were higher than patients’ evaluations (p < .001). The scores of female doctors were higher than males (p = .022). Both doctors’ self-evaluations and patients’ evaluations indicated that the scores of doctors in tertiary hospitals were higher than those in primary hospitals.ConclusionDoctors’ communication skills don’t match patients’ needs. Female doctors are more empathetic and patient than male doctors and consequently have better communication skills. Doctors in tertiary hospitals have better communication skills because tertiary hospitals provide more training opportunities in communication skills and have better medical services and management.Practice implicationsThis study confirms the applicability of the SEGUE Framework to doctors and patients in mainland China. The effectiveness of cultivating doctors’ communication skills should be evaluated through feedback from the perspective of both doctors and patients. Medical institutes need to prioritize patients’ needs and provide training in doctors’ communication skills to address the discrepancy in the perceptions of doctors and patients.     

Detection and Magnetic Source Imaging of Fast Oscillations (40–160 Hz) Recorded with Magnetoencephalography in Focal Epilepsy Patients

We present a framework to detect fast oscillations (FOs) in magnetoencephalography (MEG) and to perform magnetic source imaging (MSI) to determine the location and extent of their generators in the cortex. FOs can be of physiologic origin associated to sensory processing and memory consolidation. In epilepsy, FOs are of pathologic origin and biomarkers of the epileptogenic zone. Seventeen patients with focal epilepsy previously confirmed with identified FOs in scalp electroencephalography (EEG) were evaluated. To handle data deriving from large number of sensors (275 axial gradiometers) we used an automatic detector with high sensitivity. False positives were discarded by two human experts. MSI of the FOs was performed with the wavelet based maximum entropy on the mean method. We found FOs in 11/17 patients, in only one patient the channel with highest FO rate was not concordant with the epileptogenic region and might correspond to physiologic oscillations. MEG FOs rates were very low: 0.02–4.55 per minute. Compared to scalp EEG, detection sensitivity was lower, but the specificity higher in MEG. MSI of FOs showed concordance or partial concordance with proven generators of seizures and epileptiform activity in 10/11 patients. We have validated the proposed framework for the non-invasive study of FOs with MEG. The excellent overall concordance with other clinical gold standard evaluation tools indicates that MEG FOs can provide relevant information to guide implantation for intracranial EEG pre-surgical evaluation and for surgical treatment, and demonstrates the important added value of choosing appropriate FOs detection and source localization methods.