Left main bronchus compression due to main pulmonary artery dilatation in pulmonary hypertension: two case reports

Abstract. Pulmonary arterial dilatation associated with pulmonary hypertension may result in significant compression of local structures. Left main coronary artery and left recurrent laryngeal nerve compression have been described. Tracheobronchial compression from pulmonary arterial dilatation is rare in adults, and there are no reports in the literature of its occurrence in idiopathic pulmonary arterial hypertension. Compression in infants with congenital heart disease has been well described. We report 2 cases of tracheobronchial compression: first, an adult patient with idiopathic pulmonary arterial hypertension who presents with symptomatic left main bronchus compression, and second, an adult patient with Eisenmenger ventricular septal defect and right-sided aortic arch, with progressive intermedius and right middle lobe bronchi compression in association with enlarged pulmonary arteries

Discrepancies in autologous bone marrow stem cell trials and enhancement of ejection fraction (DAMASCENE): weighted regression and meta-analysis

Objective To investigate whether discrepancies in trials of use of bone marrow stem cells in patients with heart disease account for the variation in reported effect size in improvement of left ventricular function. Design Identification and counting of factual discrepancies in trial reports, and sample size weighted regression against therapeutic effect size. Meta-analysis of trials that provided sufficient information. Data sources PubMed and Embase from inception to April 2013. Eligibility for selecting studies Randomised controlled trials evaluating the effect of autologous bone marrow stem cells for heart disease on mean left ventricular ejection fraction. Results There were over 600 discrepancies in 133 reports from 49 trials. There was a significant association between the number of discrepancies and the reported increment in EF with bone marrow stem cell therapy (Spearman’s r=0.4, P=0.005). Trials with no discrepancies were a small minority (five trials) and showed a mean EF effect size of −0.4%. The 24 trials with 1-10 discrepancies showed a mean effect size of 2.1%. The 12 with 11-20 discrepancies showed a mean effect of size 3.0%. The three with 21-30 discrepancies showed a mean effect size of 5.7%. The high discrepancy group, comprising five trials with over 30 discrepancies each, showed a mean effect size of 7.7%. Conclusions Avoiding discrepancies is difficult but is important because discrepancy count is related to effect size. The mechanism is unknown but should be explored in the design of future trials because in the five trials without discrepancies the effect of bone marrow stem cell therapy on ejection fraction is zero

Exercise cardiac MRI unmasks right ventricular dysfunction in acute hypoxia and chronic pulmonary arterial hypertension

Background - Coupling of right ventricular (RV) contractility to afterload is maintained at rest in the early stages of pulmonary arterial hypertension (PAH), but exercise may unmask depleted contractile reserves. We assessed whether elevated afterload reduces RV contractile reserve despite compensated resting function using non-invasive exercise imaging. Methods and Results - Fourteen patients with PAH (mean age 39.1 years, 10 females) and 34 healthy control subjects (mean age 35.6 years, 17 females) completed real-time cardiac magnetic resonance imaging during sub-maximal exercise breathing room-air. Controls were then also exercised during acute normobaric hypoxia (FiO2 12%). RV contractile reserve was assessed by the effect of exercise on ejection fraction (RVEF). In control subjects the increase in RVEF on exercise was less during hypoxia (P=0.017), but the response of left ventricular ejection fraction to exercise did not change. Patients with PAH had impaired RV reserve with half demonstrating a fall in RVEF on exercise despite comparable resting function to controls (PAH: rest 53.6{plus minus}4.3% vs exercise 51.4{plus minus}10.7%; controls: rest 57.1{plus minus}5.2% vs exercise 69.6{plus minus}6.1%, P<0.0001). In control subjects the increase in stroke volume index (SVi) on exercise was driven by reduced RV end-systolic volume, whereas PAH patients did not augment SVi, with increases in both end-diastolic and end-systolic volumes. From baseline hemodynamic and exercise capacity variables only VE/VCO2 was an independent predictor of RV functional reserve (P=0.021). Conclusions - Non-invasive cardiac imaging during exercise unmasks depleted RV contractile reserves in healthy adults under hypoxic conditions and PAH patients under normoxic conditions despite preserved ejection fraction

Hierarchical statistical techniques are necessary to draw reliable conclusions from analysis of isolated cardiomyocyte studies

Aims It is generally accepted that post-MI heart failure (HF) changes a variety of aspects of sarcoplasmic reticular Ca2+ fluxes but for some aspects there is disagreement over whether there is an increase or decrease. The commonest statistical approach is to treat data collected from each cell as independent, even though they are really clustered with multiple likely similar cells from each heart. In this study, we test whether this statistical assumption of independence can lead the investigator to draw conclusions that would be considered erroneous if the analysis handled clustering with specific statistical techniques (hierarchical tests). Methods and results Ca2+ transients were recorded in cells loaded with Fura-2AM and sparks were recorded in cells loaded with Fluo-4AM. Data were analysed twice, once with the common statistical approach (assumption of independence) and once with hierarchical statistical methodologies designed to allow for any clustering. The statistical tests found that there was significant hierarchical clustering. This caused the common statistical approach to underestimate the standard error and report artificially small P values. For example, this would have led to the erroneous conclusion that time to 50% peak transient amplitude was significantly prolonged in HF. Spark analysis showed clustering, both within each cell and also within each rat, for morphological variables. This means that a three-level hierarchical model is sometimes required for such measures. Standard statistical methodologies, if used instead, erroneously suggest that spark amplitude is significantly greater in HF and spark duration is reduced in HF. Conclusion Ca2+ fluxes in isolated cardiomyocytes show so much clustering that the common statistical approach that assumes independence of each data point will frequently give the false appearance of statistically significant changes. Hierarchical statistical methodologies need a little more effort, but are necessary for reliable conclusions. We present cost-free simple tools for performing these analyses

Efficient labelling for efficient deep learning: the benefit of a multiple-image-ranking method to generate high volume training data applied to ventricular slice level classification in cardiac MRI

BACKGROUND: Getting the most value from expert clinicians' limited labelling time is a major challenge for artificial intelligence (AI) development in clinical imaging. We present a novel method for ground-truth labelling of cardiac magnetic resonance imaging (CMR) image data by leveraging multiple clinician experts ranking multiple images on a single ordinal axis, rather than manual labelling of one image at a time. We apply this strategy to train a deep learning (DL) model to classify the anatomical position of CMR images. This allows the automated removal of slices that do not contain the left ventricular (LV) myocardium. METHODS: Anonymised LV short-axis slices from 300 random scans (3,552 individual images) were extracted. Each image's anatomical position relative to the LV was labelled using two different strategies performed for 5 hours each: (I) 'one-image-at-a-time': each image labelled according to its position: 'too basal', 'LV', or 'too apical' individually by one of three experts; and (II) 'multiple-image-ranking': three independent experts ordered slices according to their relative position from 'most-basal' to 'most apical' in batches of eight until each image had been viewed at least 3 times. Two convolutional neural networks were trained for a three-way classification task (each model using data from one labelling strategy). The models' performance was evaluated by accuracy, F1-score, and area under the receiver operating characteristics curve (ROC AUC). RESULTS: After excluding images with artefact, 3,323 images were labelled by both strategies. The model trained using labels from the 'multiple-image-ranking strategy' performed better than the model using the 'one-image-at-a-time' labelling strategy (accuracy 86% vs. 72%, P=0.02; F1-score 0.86 vs. 0.75; ROC AUC 0.95 vs. 0.86). For expert clinicians performing this task manually the intra-observer variability was low (Cohen's κ=0.90), but the inter-observer variability was higher (Cohen's κ=0.77). CONCLUSIONS: We present proof of concept that, given the same clinician labelling effort, comparing multiple images side-by-side using a 'multiple-image-ranking' strategy achieves ground truth labels for DL more accurately than by classifying images individually. We demonstrate a potential clinical application: the automatic removal of unrequired CMR images. This leads to increased efficiency by focussing human and machine attention on images which are needed to answer clinical questions

Si-doped zinc oxide transparent conducting oxides; Nanoparticle optimisation, scale-up and thin film deposition

Silicon-doped zinc oxide, Zn 1-x Si x O y , transparent conducting oxide nanoparticles were prepared using a laboratory scale (production rate of 60 g h -1 ) continuous hydrothermal flow synthesis (CHFS) process in the dopant range 0.25 to 3.0 at% Si. The resistivity of the materials was assessed as pressed heat-treated pellets, revealing that the sample with the lowest resistivity (3.5 × 10 -2 Ω cm) was the 0.25 at% Si doped ZnO sample. The synthesis of this optimum composition was then scaled up to 350 g h -1 using a larger pilot plant CHFS process. Spin coating of a slurry of the resulting nanopowder made on the pilot plant, followed by an appropriate heat-treatment, produced a thin film with an optical transmission > 80% and a low resistivity of 2.4 × 10 -3 Ω cm, with a carrier concentration of 1.02 × 10 20 cm -3 and a mobility of 11 cm 2 V -1 s -1 . This is a factor of almost twenty times improvement in the resistivity versus the analogous pressed, heat-treated pellet

High-Throughput Continuous Hydrothermal Synthesis of Transparent Conducting Aluminum and Gallium Co-doped Zinc Oxides

High-throughput continuous hydrothermal flow synthesis was used to generate a library of aluminum and gallium-codoped zinc oxide nanoparticles of specific atomic ratios. Resistivities of the materials were determined by Hall Effect measurements on heat-treated pressed discs and the results collated into a conductivity-composition map. Optimal resistivities of ∼9 × 10–3 Ω cm were reproducibly achieved for several samples, for example, codoped ZnO with 2 at% Ga and 1 at% Al. The optimum sample on balance of performance and cost was deemed to be ZnO codoped with 3 at% Al and 1 at% Ga

Conducting Al and Ga-doped zinc oxides; rapid optimisation and scale-up

A high-throughput synthesis, screening and subsequent scale-up approach was utilised for the optimisation of conductive aluminium and gallium-doped zinc oxide (AZO and GZO, respectively) nanoparticles. AZO and GZO nanoparticles with up to 6 at% dopant (with respect to Zn) were directly synthesised using a laboratory scale continuous hydrothermal process at a rate of 60 g per hour. The resistivities were determined by Hall effect measurements on pressed, heat-treated discs. Both Al- and Ga-doping yielded resistivities of the order of 1 × 10−2 Ω cm for most samples; the lowest resistivity of AZO was 7.0 × 10−3 Ω cm (at 2.5 at% Al doping), and the lowest resistivity of GZO was 9.1 × 10−3 Ω cm (at 3.5 at% Ga doping), which are considered exceptionally conductive for pressed nanopowders. Synthesis of the optimised lab-scale compositions was scaled-up using a pilot-scale continuous hydrothermal process at a production rate of 8 kg per day (by dry mass); results obtained from these nanopowders generally retained resistivity trends observed for the lab-scale analogues

Simulation of the Response of the Inner Hair Cell Stereocilia Bundle to an Acoustical Stimulus

Mammalian hearing relies on a cochlear hydrodynamic sensor embodied in the inner hair cell stereocilia bundle. It is presumed that acoustical stimuli induce a fluid shear-driven motion between the tectorial membrane and the reticular lamina to deflect the bundle. It is hypothesized that ion channels are opened by molecular gates that sense tension in tip-links, which connect adjacent stepped rows of stereocilia. Yet almost nothing is known about how the fluid and bundle interact. Here we show using our microfluidics model how each row of stereocilia and their associated tip links and gates move in response to an acoustical input that induces an orbital motion of the reticular lamina. The model confirms the crucial role of the positioning of the tectorial membrane in hearing, and explains how this membrane amplifies and synchronizes the timing of peak tension in the tip links. Both stereocilia rotation and length change are needed for synchronization of peak tip link tension. Stereocilia length change occurs in response to accelerations perpendicular to the oscillatory fluid shear flow. Simulations indicate that nanovortices form between rows to facilitate diffusion of ions into channels, showing how nature has devised a way to solve the diffusive mixing problem that persists in engineered microfluidic devices