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Item Artificial Intelligence-Augmented Pediatric Lung POCUS: A Pilot Study of Novice Learners(Wiley, 2022) Nti, Benjamin; Lehmann, Amalia S.; Haddad, Aida; Kennedy, Sarah K.; Russell, Frances M.; Pediatrics, School of MedicineObjective: Respiratory symptoms are among the most common chief complaints of pediatric patients in the emergency department (ED). Point-of-care ultrasound (POCUS) outperforms conventional chest X-ray and is user-dependent, which can be challenging to novice ultrasound (US) users. We introduce a novel concept using artificial intelligence (AI)-enhanced pleural sweep to generate complete panoramic views of the lungs, and then assess its accuracy among novice learners (NLs) to identify pneumonia. Methods: Previously healthy 0- to 17-year-old patients presenting to a pediatric ED with cardiopulmonary chief complaint were recruited. NLs received a 1-hour training on traditional lung POCUS and the AI-assisted software. Two POCUS-trained experts interpreted the images, which served as the criterion standard. Both expert and learner groups were blinded to each other's interpretation, patient data, and outcomes. Kappa was used to determine agreement between POCUS expert interpretations. Results: Seven NLs, with limited to no prior POCUS experience, completed examinations on 32 patients. The average patient age was 5.53 years (±1.07). The median scan time of 7 minutes (minimum-maximum 3-43; interquartile 8). Three (8.8%) patients were diagnosed with pneumonia by criterion standard. Sensitivity, specificity, and accuracy for NLs AI-augmented interpretation were 66.7% (confidence interval [CI] 9.4-99.1%), 96.5% (CI 82.2-99.9%), and 93.7% (CI 79.1-99.2%). The average image quality rating was 2.94 (±0.16) out of 5 across all lung fields. Interrater reliability between expert sonographers was high with a kappa coefficient of 0.8. Conclusion: This study shows that AI-augmented lung US for diagnosing pneumonia has the potential to increase accuracy and efficiency.Item The Association Between Nonalcoholic Fatty Liver Disease and Metabolic Abnormalities in The United States Population(Wolters Kluwer, 2017-02) Jinjuvadia, Raxitkumar; Antaki, Fadi; Lohia, Prateek; Liangpunsakul, Suthat; Medicine, School of MedicineBACKGROUND: Prevalence of nonalcoholic fatty liver disease (NAFLD) and rate of advanced fibrosis among individuals with metabolic syndrome (MetS) and its individual metabolic abnormalities needs better understanding in the United States population. We aim to study these by using a large United States population database, the Third National Health and Nutrition Examination Survey (NHANES III). METHODS: A total of 11,674 individuals were included in our study cohort. NAFLD was defined as presence of moderate to severe hepatic steatosis on liver ultrasound in absence of viral hepatitis, significant alcohol use, elevated transferrin level, and medication use leading to hepatic steatosis. Advanced fibrosis among those with NAFLD was determined using noninvasive method, the NAFLD fibrosis score. MetS was defined based on the National Cholesterol Education Program Adult Treatment Panel III definition. RESULTS: The prevalence of NAFLD among included study cohort was 18.2% (95% confidence interval, 16.5-19.9). Individuals with metabolic abnormalities demonstrated higher prevalence (MetS, 43.2%; increased waist circumference, 31.2%; impaired fasting glucose/diabetes, 41.2%; high triglyceride level, 34.7%; low high-density lipoprotein, 27.8%; high blood pressure, 29.2%). The individuals with MetS had significantly higher NAFLD prevalence compared with controls (adjusted odds ratio, 11.5; 95% confidence interval, 8.9-14.7). The severity of hepatic steatosis was also noted to increase with higher number of metabolic abnormalities. Among individual metabolic abnormalities, increased waist circumference, impaired fasting glucose/diabetes, high triglyceride, and low high-density lipoprotein levels were found to be independently associated with NAFLD. Individuals with impaired fasting glucose/diabetes and those with 5 metabolic abnormalities had higher rate of advanced fibrosis (18.6% and 30.3%, respectively). Prevalence of NAFLD among individuals without any metabolic abnormality was 6.1%. CONCLUSION: Prevalence of NAFLD and rate of advanced fibrosis are significantly high among individuals with metabolic abnormalities.Item Effect of Carbon Dioxide on the Twinkling Artifact in Ultrasound Imaging of Kidney Stones: A Pilot Study(Elsevier, 2017-05) Simon, Julianna C.; Wang, Yak-Nam; Cunitz, Bryan W.; Thiel, Jeffrey; Starr, Frank; Liu, Ziyue; Bailey, Michael R.; Biostatistics, School of Public HealthBone demineralization, dehydration and stasis put astronauts at increased risk of forming kidney stones in space. The color-Doppler ultrasound "twinkling artifact," which highlights kidney stones with color, can make stones readily detectable with ultrasound; however, our previous results suggest twinkling is caused by microbubbles on the stone surface which could be affected by the elevated levels of carbon dioxide found on space vehicles. Four pigs were implanted with kidney stones and imaged with ultrasound while the anesthetic carrier gas oscillated between oxygen and air containing 0.8% carbon dioxide. On exposure of the pigs to 0.8% carbon dioxide, twinkling was significantly reduced after 9-25 min and recovered when the carrier gas returned to oxygen. These trends repeated when pigs were again exposed to 0.8% carbon dioxide followed by oxygen. The reduction of twinkling caused by exposure to elevated carbon dioxide may make kidney stone detection with twinkling difficult in current space vehicles.Item First In-Human Burst Wave Lithotripsy for Kidney Stone Comminution: Initial Two Case Studies(Mary Ann Liebert, Inc., 2021) Harper, Jonathan D.; Metzler, Ian; Hall, Michael Kennedy; Chen, Tony T.; Maxwell, Adam D.; Cunitz, Bryan W.; Dunmire, Barbrina; Thiel, Jeff; Williams, James C., Jr.; Bailey, Michael R.; Sorensen, Mathew D.; Anatomy, Cell Biology and Physiology, School of MedicinePurpose: To test the effectiveness (Participant A) and tolerability (Participant B) of urinary stone comminution in the first-in-human trial of a new technology, burst-wave lithotripsy (BWL). Materials and Methods: An investigational BWL and ultrasonic propulsion system was used to target a 7-mm kidney stone in the operating room before ureteroscopy (Participant A). The same system was used to target a 7.5 mm ureterovesical junction stone in clinic without anesthesia (Participant B). Results: For Participant A, a ureteroscope inserted after 9 minutes of BWL observed fragmentation of the stone to <2 mm fragments. Participant B tolerated the procedure without pain from BWL, required no anesthesia, and passed the stone on day 15. Conclusions: The first-in-human tests of BWL pulses were successful in that a renal stone was comminuted in <10 minutes, and BWL was also tolerated by an awake subject for a distal ureteral stone.Item First Series Using Ultrasonic Propulsion and Burst Wave Lithotripsy to Treat Ureteral Stones(American Urological Association Education and Research, Inc., 2022) Hall, M. Kennedy; Thiel, Jeff; Dunmire, Barbrina; Samson, Patrick C.; Kessler, Ross; Sunaryo, Peter; Sweet, Robert M.; Metzler, Ian S.; Chang, Helena C.; Gunn, Martin; Dighe, Manjiri; Anderson, Layla; Popchoi, Christina; Managuli, Ravi; Cunitz, Bryan W.; Burke, Barbara H.; Ding, Lisa; Gutierrez, Brianna; Liu, Ziyue; Sorensen, Mathew D.; Wessells, Hunter; Bailey, Michael R.; Harper, Jonathan D.; Biostatistics and Health Data Science, School of MedicinePurpose: Our goal was to test transcutaneous focused ultrasound in the form of ultrasonic propulsion and burst wave lithotripsy to reposition ureteral stones and facilitate passage in awake subjects. Materials and methods: Adult subjects with a diagnosed proximal or distal ureteral stone were prospectively recruited. Ultrasonic propulsion alone or with burst wave lithotripsy was administered by a handheld transducer to awake, unanesthetized subjects. Efficacy outcomes included stone motion, stone passage, and pain relief. Safety outcome was the reporting of associated anticipated or adverse events. Results: Twenty-nine subjects received either ultrasonic propulsion alone (n = 16) or with burst wave lithotripsy bursts (n = 13), and stone motion was observed in 19 (66%). The stone passed in 18 (86%) of the 21 distal ureteral stone cases with at least 2 weeks follow-up in an average of 3.9±4.9 days post-procedure. Fragmentation was observed in 7 of the burst wave lithotripsy cases. All subjects tolerated the procedure with average pain scores (0-10) dropping from 2.1±2.3 to 1.6±2.0 (P = .03). Anticipated events were limited to hematuria on initial urination post-procedure and mild pain. In total, 7 subjects had associated discomfort with only 2.2% (18 of 820) propulsion bursts. Conclusions: This study supports the efficacy and safety of using ultrasonic propulsion and burst wave lithotripsy in awake subjects to reposition and break ureteral stones to relieve pain and facilitate passage.Item First-in-human clinical trial of ultrasonic propulsion of kidney stones(First in Human Clinical Trial of Ultrasonic Propulsion of Kidney Stones, 2016-04) Harper, Jonathan D.; Cunitz, Bryan W.; Dunmire, Barbrina; Lee, Franklin C.; Sorensen, Mathew D.; Hsi, Ryan S.; Thiel, Jeff; Wessells, Hunter; Lingeman, James E.; Bailey, Michael R.; Urology, School of MedicinePURPOSE: Ultrasonic propulsion is a new technology using focused ultrasound energy applied transcutaneously to reposition kidney stones. We report what are to our knowledge the findings from the first human investigational trial of ultrasonic propulsion toward the applications of expelling small stones and dislodging large obstructing stones. MATERIALS AND METHODS: Subjects underwent ultrasonic propulsion while awake without sedation in clinic, or during ureteroscopy while anesthetized. Ultrasound and a pain questionnaire were completed before, during and after propulsion. The primary outcome was to reposition stones in the collecting system. Secondary outcomes included safety, controllable movement of stones and movement of stones less than 5 mm and 5 mm or greater. Adverse events were assessed weekly for 3 weeks. RESULTS: Kidney stones were repositioned in 14 of 15 subjects. Of the 43 targets 28 (65%) showed some level of movement while 13 (30%) were displaced greater than 3 mm to a new location. Discomfort during the procedure was rare, mild, brief and self-limited. Stones were moved in a controlled direction with more than 30 fragments passed by 4 of the 6 subjects who had previously undergone a lithotripsy procedure. The largest stone moved was 10 mm. One patient experienced pain relief during treatment of a large stone at the ureteropelvic junction. In 4 subjects a seemingly large stone was determined to be a cluster of small passable stones after they were moved. CONCLUSIONS: Ultrasonic propulsion was able to successfully reposition stones and facilitate the passage of fragments in humans. No adverse events were associated with the investigational procedure.Item Iatrogenic Spinal Deformity Following Spinal Intradural Arachnoid Cyst Fenestration Despite Minimal Access With Laminoplasty and Endoscopy in a Pediatric Patient(Cureus, 2022-02-09) Ordaz, Josue D.; Huh, Andrew; Desai, Virendra; Raskin, Jeffrey S.; Neurological Surgery, School of MedicineSpinal intradural arachnoid cysts (SAC) are non-neoplastic lesions that can cause spinal cord compression and present with myelopathy, radiculopathy, and/or back pain. Because these cysts typically span multiple levels, endoscopy could be a useful tool to avoid wide exposure. We present an 8-year-old patient with a history of gait imbalance and urinary incontinence who was found to have a SAC spanning C7 to T6 causing spinal cord compression. An osteoplastic laminoplasty was performed from T4 to T7 followed by ultrasonic verification of intracystic septations, dural opening, and cyst fenestration. A flexible endoscope was then introduced into the cystic cavity to guide complete rostral and caudal decompression of the arachnoid cyst. At six months follow-up, the patient was able to ambulate independently, but his urinary incontinence remained unchanged. Despite the combination of ultrasound and neuroendoscopy to minimize exposure, our patient suffered from worsening kyphosis from 36 degrees preoperative to 55 degrees postoperative and worsening scoliosis from 17 to 39 degrees which required treatment with a thoracolumbar sacral orthosis. Preoperative imaging demonstrated a reverse S-shaped scoliosis with the apex at T6 and T7 which were the levels included in the laminoplasty. This illustrates the need for careful preoperative risk stratification to avoid this postoperative complication.Item In Vitro Evaluation of Urinary Stone Comminution with a Clinical Burst Wave Lithotripsy System(Mary Ann Liebert, Inc., 2020-11) Ramesh, Shivani; Chen, Tony T.; Maxwell, Adam D.; Cunitz, Bryan W.; Dunmire, Barbrina; Thiel, Jeff; Williams, James C., Jr.; Gardner, Anthony; Liu, Ziyue; Metzler, Ian; Harper, Jonathan D.; Sorensen, Mathew D.; Bailey, Michael R.; Anatomy, Cell Biology and Physiology, School of MedicineObjective: Our goals were to validate stone comminution with an investigational burst wave lithotripsy (BWL) system in patient-relevant conditions and to evaluate the use of ultrasonic propulsion to move a stone or fragments to aid in observing the treatment endpoint. Materials and Methods: The Propulse-1 system, used in clinical trials of ultrasonic propulsion and upgraded for BWL trials, was used to fragment 46 human stones (5-7 mm) in either a 15-mm or 4-mm diameter calix phantom in water at either 50% or 75% dissolved oxygen level. Stones were paired by size and composition, and exposed to 20-cycle, 390-kHz bursts at 6-MPa peak negative pressure (PNP) and 13-Hz pulse repetition frequency (PRF) or 7-MPa PNP and 6.5-Hz PRF. Stones were exposed in 5-minute increments and sieved, with fragments >2 mm weighed and returned for additional treatment. Effectiveness for pairs of conditions was compared statistically within a framework of survival data analysis for interval censored data. Three reviewers blinded to the experimental conditions scored ultrasound imaging videos for degree of fragmentation based on stone response to ultrasonic propulsion. Results: Overall, 89% (41/46) and 70% (32/46) of human stones were fully comminuted within 30 and 10 minutes, respectively. Fragments remained after 30 minutes in 4% (1/28) of calcium oxalate monohydrate stones and 40% (4/10) of brushite stones. There were no statistically significant differences in comminution time between the two output settings (p = 0.44), the two dissolved oxygen levels (p = 0.65), or the two calyx diameters (p = 0.58). Inter-rater correlation on endpoint detection was substantial (Fleiss' kappa = 0.638, p < 0.0001), with individual reviewer sensitivities of 95%, 86%, and 100%. Conclusions: Eighty-nine percent of human stones were comminuted with a clinical BWL system within 30 minutes under conditions intended to reflect conditions in vivo. The results demonstrate the advantage of using ultrasonic propulsion to disperse fragments when making a visual determination of breakage endpoint from the real-time ultrasound image.Item Integration of ultrasound simulation to improve medical student knowledge and satisfaction on the obstetrics and gynecology clerkship(Elsevier, 2023-06-12) Shanks, Anthony L.; Darwish, Adrianna; Cook, Myanna; Asencio, Ivana; Rouse, Carrie; Obstetrics and Gynecology, School of MedicineBackground: There has been increased use of ultrasound in contemporary medical education. Students tend to report a higher sense of satisfaction when ultrasound is incorporated into medical education, but little is known about whether its use leads to an improvement in medical knowledge acquisition independent of the ultrasound skill. In addition, there is no consensus among obstetrics and gynecology clerkships on the most effective way to incorporate ultrasound into the clerkship curriculum. Objective: This project described a method to integrate ultrasound simulation into an obstetrics and gynecology clerkship curriculum. Our hypothesis was that the incorporation of ultrasound simulation in the obstetrics and gynecology clerkship curriculum will lead to an increase in standardized assessments of obstetrics and gynecology knowledge. Study design: A prepost study at a single institution with multiple methods design was employed. Of note, 10 high-yield pathology topics commonly tested on the Association of Professors of Gynecology and Obstetrics quizzes and National Board of Medical Examiners examinations were summarized into study sheets and associated with a representative ultrasound simulation module. All students were provided access to the summary sheets. Students with instruction in ultrasound simulation consisted of the postintervention group and were compared with students that did not have ultrasound simulation (preintervention group). Quiz and examination scores were compared between the groups. In addition, students who accessed the ultrasound simulator were given a survey at the end of their rotation to obtain qualitative information regarding satisfaction and the incorporation of ultrasound into the clerkship curriculum. Results: There was no significant difference in quiz or examination scores between students who had access to the ultrasound simulation and those who did not. Most students found the integration of ultrasound simulation into the obstetrics and gynecology clerkship to be beneficial, to enhance their learning, to boost their confidence in ultrasound skills, and to be a potential substitute for clinical ultrasounds during the rotation. Conclusion: Integration of ultrasound simulation into obstetrics and gynecology clerkships and medical school education is understudied but can be a valuable educational tool. The incorporation of ultrasound into the medical education system is a topic of current studies. This study found that integration was viewed favorably by students, although integration was not associated with an improvement in medical knowledge measured via quiz and examination performance. Our research provided students with a standardized ultrasound education experience, which improved student satisfaction with the obstetrics and gynecology clerkship but did not correlate to increased demonstrated medical knowledge and understanding of examinations. Moving forward, student participants provided various suggestions on how we can continue to enrich medical students' education with the implementation of ultrasound.Item Long-term follow-up and liver outcomes in children with cystic fibrosis and nodular liver on ultrasound in a multi-center study(Elsevier, 2023) Leung, Daniel H.; Ye, Wen; Schwarzenberg, Sarah J.; Freeman, A. Jay; Palermo, Joseph J.; Weymann, Alexander; Alonso, Estella M.; Karnsakul, Wikrom W.; Murray, Karen F.; Stoll, Janis M.; Huang, Suiyuan; Karmazyn, Boaz; Masand, Prakash; Magee, John C.; Alazraki, Adina L.; Towbin, Alexander J.; Nicholas, Jennifer L.; Green, Nicole; Otto, Randolph K.; Siegel, Marilyn J.; Ling, Simon C.; Navarro, Oscar M.; Harned, Roger K.; Narkewicz, Michael R.; Molleston, Jean P.; CFLD Research Network; Pediatrics, School of MedicineBackground: Nodular liver (NOD) in cystic fibrosis (CF) suggests advanced CF liver disease (aCFLD); little is known about progression of liver disease (LD) after detection of sonographic NOD. Methods: Clinical, laboratory, and ultrasound (US) data from Prediction by Ultrasound of the Risk of Hepatic Cirrhosis in CFLD Study participants with NOD at screening or follow-up were compared with normal (NL). Linear mixed effects models were used for risk factors for LD progression and Kaplan-Meier estimator for time-to-event. Results: 54 children with NOD (22 screening, 32 follow-up) and 112 NL were evaluated. Baseline (BL) and trajectory of forced expiratory volume, forced vital capacity, height/BMI z-scores were similar in NOD vs NL. Platelets were lower in NOD at BL (250 vs 331×103/microL; p < 0.001) and decreased by 8600/year vs 2500 in NL. Mean AST to Platelet Ratio Index (1.1 vs 0.4; p < 0.001), Fibrosis-4 Index (0.4 vs 0.2, p < 0.001), and spleen size z-score (SSZ) [1.5 vs 0.02; p < 0.001] were higher in NOD at BL; SSZ increased by 0.5 unit/year in NOD vs 0.1 unit/year in NL. Median liver stiffness (LSM) by transient elastography was higher in NOD (8.2 kPa, IQR 6-11.8) vs NL (5.3, 4.2-7, p < 0.0001). Over 6.3 years follow-up (1.3-10.3), 6 NOD had esophageal varices (cumulative incidence in 10 years: 20%; 95% CI: 0.0%, 40.0%), 2 had variceal bleeding, and 2 underwent liver transplantation; none had ascites or hepatic encephalopathy. No NL experienced liver-related events. Conclusions: NOD developed clinically evident portal hypertension faster than NL without worse growth or lung disease.