Swarm learning with weak supervision enables automatic breast cancer detection in magnetic resonance imaging

Background: Over the next 5 years, new breast cancer screening guidelines recommending magnetic resonance imaging (MRI) for certain patients will significantly increase the volume of imaging data to be analyzed. While this increase poses challenges for radiologists, artificial intelligence (AI) offers potential solutions to manage this workload. However, the development of AI models is often hindered by manual annotation requirements and strict data-sharing regulations between institutions. Methods: In this study, we present an integrated pipeline combining weakly supervised learning—reducing the need for detailed annotations—with local AI model training via swarm learning (SL), which circumvents centralized data sharing. We utilized three datasets comprising 1372 female bilateral breast MRI exams from institutions in three countries: the United States (US), Switzerland, and the United Kingdom (UK) to train models. These models were then validated on two external datasets consisting of 649 bilateral breast MRI exams from Germany and Greece. Results: Upon systematically benchmarking various weakly supervised two-dimensional (2D) and three-dimensional (3D) deep learning (DL) methods, we find that the 3D-ResNet-101 demonstrates superior performance. By implementing a real-world SL setup across three international centers, we observe that these collaboratively trained models outperform those trained locally. Even with a smaller dataset, we demonstrate the practical feasibility of deploying SL internationally with on-site data processing, addressing challenges such as data privacy and annotation variability. Conclusions: Combining weakly supervised learning with SL enhances inter-institutional collaboration, improving the utility of distributed datasets for medical AI training without requiring detailed annotations or centralized data sharing

Streptococcus pyogenes emm Type 3.93 Emergence, the Netherlands and England

A global increase in the incidence of invasive group A Streptococcus (iGAS) infections was observed after lifting of COVID-19 related restrictions in 2022, and type M1UK dominated in many countries. After seasonal declines in iGAS incidence during the summer of 2023, simultaneous, rapid expansion of a previously rare emm type 3.93 was seen beginning in November, increasing to 20% of all cases in England and 60% of all cases in the Netherlands within 4 months. emm3.93 was associated with iGAS in children 6–17 years of age and with increased risk for pneumonia or pleural empyema and meningitis in both countries. No excess risk of death was identified for emm3.93 compared with other types. Genomic analysis of historic and contemporary emm3.93 isolates revealed the emergence of 3 new clades with a potentially advantageous genomic configuration. Our findings demonstrate the value of molecular surveillance, including long-read sequencing, in identifying clinical and public health threats

Feasibility and efficacy of therapeutic drug monitoring of abiraterone in metastatic castration resistant prostate cancer patients: Clinical Studies

Background: Previous studies demonstrated better outcomes for mCRPC (metastatic castration resistant prostate cancer) patients with higher abiraterone exposure (minimal plasma concentration (Cmin) > 8.4 ng/mL), but around 40% of patients experience exposure below this target. Pharmacokinetic (PK)-guided interventions following Therapeutic Drug Monitoring (TDM) could optimise exposure and outcomes. We aimed to evaluate the feasibility and effect on treatment outcomes of abiraterone TDM. Methods: Patients with low exposure levels (Low-group, Cmin < 8.4 ng/mL) got a PK-guided intervention. We compared exposure, adverse event (AE) incidence, time on treatment (ToT) and Prostate-Specific Antigen response rate (PSArr) between the Low-group and Adequate-group. Results: We included 167 mCRPC patients, with 56 in the Adequate-group and 111 in the Low-group. Interventions were successful 86% of the time. Exposure between groups became corresponding (Low-group: 7.95 to 20.5 ng/mL, Adequate-group: 20.8 ng/mL, p = 0.72) with comparable AE incidence (17% vs. 23%, p = 0.4). Median ToT and PSArr were similar (351 vs. 379 days, p = 0.35; 61.3% vs. 67.9%, p = 0.51). Conclusions: PK-guided interventions improved above target exposure from 33.5% to 81.4% of patients without additional AEs. While historically, low exposure patients had significantly shorter survival, PK-guided interventions eliminated this disparity. As interventions are effective, low-cost and safe, TDM for abiraterone should be considered to enhance treatment outcomes

Cost-effectiveness of cranial implants compared with autologous bone grafts

Introduction: Autografts are considered more cost-effective than cranial implants due to the use of the patient's own bone. However, autografts are associated with a higher revision surgery rate because of their intrinsic risk of resorption. As revision surgeries imply additional hospital stays and therefore higher costs, autografts may be less cost-effective than cranial implants. Research question: To analyze the cost-effectiveness of cranial implants compared with autografts. Material and methods: We performed a retrospective cohort study of patients who underwent cranioplasty between 2014 and 2020. We collected data on the costs of cranioplasty using each patient's diagnosis and treatment combination (DBC) code. We used the incremental cost-effectiveness ratio (ICER) to assess cost-effectiveness, which was calculated as the ratio of incremental cost and incremental effect of using a cranial implant instead of an autograft. Results: A total of 168 patients were included (mean age 43.0 ± 20.0 years). The median cost of the first cranioplasty procedure was €6249.37 (IQR €5250.64 – €8551.36) for cranial implants and €6261.36 (IQR €5189.14 – €7792.10) for autografts (p = 0.094). The median total cost of all health care related to the cranioplasty procedure was €6460.64 (IQR €6039.68 – €9533.03) for cranial implants and €12,075.01 (IQR €6409.63 – €16,420.71) for autografts (p < 0.001). The ICER of cranial implants compared with autografts was –€7663.22 per revision surgery avoided. Discussion and conclusion: This study found that the use of cranial implants is at a lower cost and more clinically effective than the use of autologous bone grafts

Non-invasive imaging assessment in angina with non-obstructive coronary arteries (ANOCA)

Due to its significant prevalence and clinical implications, angina with non-obstructive coronary arteries (ANOCA) has become a major focus in modern cardiology. In fact, diagnosing ANOCA presents a significant challenge. The final diagnosis is often difficult, delayed, and frequently necessitates an invasive assessment through coronary angiography. However, recent improvements in non-invasive cardiac imaging allow a diagnosis of ANOCA using a combination of clinical evaluation, anatomical coronary imaging, and functional testing. This narrative review aims to critically assess various non-invasive diagnostic methods and propose a multimodal approach to diagnose ANOCA and tailor appropriate treatments

A novel dataset for nuclei and tissue segmentation in melanoma with baseline nuclei segmentation and tissue segmentation benchmarks

BACKGROUND: Melanoma is an aggressive form of skin cancer in which tumor-infiltrating lymphocytes (TILs) are a biomarker for recurrence and treatment response. Manual TIL assessment is prone to interobserver variability, and current deep learning models are not publicly accessible or have low performance. Deep learning models, however, have the potential of consistent spatial evaluation of TILs and other immune cell subsets with the potential of improved prognostic and predictive value. To make the development of these models possible, we created the Panoptic Segmentation of nUclei and tissue in advanced MelanomA (PUMA) dataset and assessed the performance of several state-of-the-art deep learning models. In addition, we show how to improve model performance further by using heuristic postprocessing in which nuclei classes are updated based on their tissue localization. RESULTS: The PUMA dataset includes 155 primary and 155 metastatic melanoma hematoxylin and eosin-stained regions of interest with nuclei and tissue annotations from a single melanoma referral institution. The Hover-NeXt model, trained on the PUMA dataset, demonstrated the best performance for lymphocyte detection, approaching human interobserver agreement. In addition, heuristic postprocessing of deep learning models improved the detection of noncommon classes, such as epithelial nuclei. CONCLUSION: The PUMA dataset is the first melanoma-specific dataset that can be used to develop melanoma-specific nuclei and tissue segmentation models. These models can, in turn, be used for prognostic and predictive biomarker development. Incorporating tissue and nuclei segmentation is a step toward improved deep learning nuclei segmentation performance. To support the development of these models, this dataset is used in the PUMA challenge

Fast Analgesic Effect in Response Test with Topical Phenytoin Cream Correlates with Prolonged Pain Relief After Extended Use in Painful Diabetic Neuropathy

Background: Treatment of painful diabetic neuropathy (PDN) poses several challenges due to the limited effectiveness, high incidence of side effects, and potential drug interactions of oral neuropathic pain medication. Lacking systemic side effects, topical phenytoin cream offers a promising innovative approach to addressing unmet needs in neuropathic pain treatment. In this retrospective study in patients with PDN, we evaluated the analgesic effect of topical phenytoin cream in response tests and after extended use. Methods: We collected data from PDN patients who, prior to prolonged use of phenytoin 10% or 20% cream, either had an open response test (ORET), a single-blind (SIBRET), or a double-blind (DOBRET) placebo-controlled response test with phenytoin cream between November 2016 and February 2023. A positive ORET was defined as pain reduction of at least two points on the 11-point numerical scale (NRS) within 30 min after phenytoin cream application. A positive SIBRET or DOBRET required an additional pain reduction of 1 NRS point in the phenytoin treated area compared to the placebo. In patients with a positive response test, we evaluated the sustained pain reduction and the proportion of patients experiencing minimum pain relief of at least 30% (MPR30: moderate pain relief) and 50% (MPR50: considerable pain relief) after the extended use of phenytoin cream. We also assessed the correlation between the response test analgesic effect and the sustained pain relief. Results: We identified 65 patients with PDN of whom 31 (47.7%) had a positive response test. The median pain reduction in response tests was 3.0 NRS points (IQR 2.0–4.0). Extended use (median 3.3 months, IQR 1.5–12.1]) resulted in a median pain reduction of 4.0 NRS points (IQR 3.0–5.0); 26/31 (83.9%) of patients achieved MPR30, and 21/31 (67.7%) MPR50 achieved pain relief. The response test analgesic effect correlated significantly with sustained pain relief after extended use (τ = 0.72, p < 0.0001). Conclusions: In PDN patients who had a positive phenytoin cream response test, extended use of phenytoin cream provided a significant sustained pain relief

Failure to reintroduce home medication in critically ill patients

Purpose: Home medication is often discontinued or adjusted during hospital admission. This study aims to investigate discrepancies between home medication before admission and at ICU discharge. Materials and methods: In this retrospective cohort study, electronic health records of 200 patients admitted to the ICU of a large teaching hospital in the Netherlands between August 1, 2021, and September 30, 2022, were analyzed for (dis) continuation of home medication. Inclusion criteria: first-time ICU admission during hospital stay, a length of stay ≥48 h, survival at ICU discharge, and use of home medication at hospital admission. Exclusion criteria: transfer from/to another hospital, discharge with palliative care, or chronic ventilation with an elective admission. Results: The mean patient age was 63.5 (±12.8) years, and 63.0 % were male. Most ICU admissions were non-surgical (76.0 %). Mean APACHE4 scores were 68.4 (±22.9). At ICU discharge, 46.7 % (535/1003) of home medications were not reintroduced, with 22.4 % incorrectly not reintroduced, while at hospital discharge, these rates were 12.1 % (106/876) and 14.2 %, respectively. Conclusions: Nearly half of home medications were discontinued at ICU discharge, with nearly a quarter not properly reintroduced on ward transfer, posing unnecessary risks. However, at hospital discharge, most home medications were correctly reintroduced or appropriately discontinued