Infrared thermal imaging analysis in screening for toddler’s fracture: A proof-of-concept study

This study explored and developed high-resolution infrared thermal (HRIT) imaging for screening toddler’s fractures. A toddler’s fracture is a common tibial fracture in children younger than six years old. The study included 39 participants admitted to an emergency department with a suspected toddler’s fracture. X-ray confirmed eight participants with a toddler’s fracture (20.5%). Infrared images of participants were recorded on their index visit, focusing on region-of-interests on the injured and the contralateral (uninjured) legs. The uninjured leg acted as a thermal reference. Six statistical measures obtained from the images were analyzed. These were maximum, mean, standard deviation, median, interquartile range, and skewness. The Shapiro–Wilk test indicated that the measures were from a normal distribution. A two-sample t-test indicated that the majority of the six measures had significantly different means (p < 0.05) when comparing the participants with and without a fracture. Similarly, the first principal component (PC1), obtained through principal component analysis of the six measures, was significantly different (p < 0.05) comparing participants with and without a fracture. Visualization of the statistical measures and their PC1 demonstrated distinct clustering. This study demonstrated that HRIT imaging is valuable for screening for toddler’s fractures, but a larger follow-on study will be required to confirm the findings

Infrared Thermal Imaging to Detect Inflammatory Intra-Abdominal Pathology in Infants

A thermal imaging method to detect inflammatory intra-abdominal pathology in infants is proposed and evaluated through a clinical trial. Nine surgical infants, mean chronological age 58 days old (range: 21-83 days), mean weight 2.65 kg (range: 2.45-3.15 kg) with abdominal pathologies were included in the analysis. Infrared thermal image processing consisted of selecting the surgical region of interest where the area of abdominal inflammation was most likely to be, and an abdominal reference region on the same infant, with the aid of clustering segmentation. Skewness was found to be the most sensitive variable to significantly differentiate between the surgical region and reference region (p = 0.022). Multilinear regression analysis indicated that the relationship between the temperature difference signified by skewness and the patients' demographic information (age at time of imaging, gestational age at birth, weight at the time of imaging, birthweight, last stool prior to imaging and last oral intake prior to imaging) was not significant. The study indicated that inflammatory regions, such as those found in infants following surgery, would have a significantly different temperature distribution than the surrounding skin. The method differentiated between an inflammatory and non-inflammatory region on the abdomen

Infrared thermal imaging and artificial neural networks to screen for wrist fractures in pediatrics

Paediatric wrist fractures are commonly seen injuries at emergency departments. Around 50% of the X-rays taken to identify these injuries indicate no fracture. The aim of this study was to develop a model using infrared thermal imaging (IRTI) data and multilayer perceptron (MLP) neural networks as a screening tool to assist clinicians in deciding which patients require X-ray imaging to diagnose a fracture. Forty participants with wrist injury (19 with a fracture, 21 without, X-ray confirmed), mean age 10.50 years, were included. IRTI of both wrists was performed with the contralateral as reference. The injured wrist region of interest (ROI) was segmented and represented by the means of cells of 10 × 10 pixels. The fifty largest means were selected, the mean temperature of the contralateral ROI was subtracted, and they were expressed by their standard deviation, kurtosis, and interquartile range for MLP processing. Training and test files were created, consisting of randomly split 2/3 and 1/3 of the participants, respectively. To avoid bias of participant inclusion in the two files, the experiments were repeated 100 times, and the MLP outputs were averaged. The model’s sensitivity and specificity were 84.2% and 71.4%, respectively. Further work involves a larger sample size, adults, and other bone fractures

Convolutional Neural Network to Classify Infrared Thermal Images of Fractured Wrists in Pediatrics

Convolutional neural network (CNN) models were devised and evaluated to classify infrared thermal (IRT) images of pediatric wrist fractures. The images were recorded from 19 participants with a wrist fracture and 21 without a fracture (sprain). The injury diagnosis was by X-ray radiography. For each participant, 299 IRT images of their wrists were recorded. These generated 11,960 images (40 participants × 299 images). For each image, the wrist region of interest (ROI) was selected and fast Fourier transformed (FFT) to obtain a magnitude frequency spectrum. The spectrum was resized to 100 × 100 pixels from its center as this region represented the main frequency components. Image augmentations of rotation, translation and shearing were applied to the 11,960 magnitude frequency spectra to assist with the CNN generalization during training. The CNN had 34 layers associated with convolution, batch normalization, rectified linear unit, maximum pooling and SoftMax and classification. The ratio of images for the training and test was 70:30, respectively. The effects of augmentation and dropout on CNN performance were explored. Wrist fracture identification sensitivity and accuracy of 88% and 76%, respectively, were achieved. The CNN model was able to identify wrist fractures; however, a larger sample size would improve accuracy

Infrared thermal imaging for bone fracture identification and monitoring of fracture healing: A review of the latest developments

Infrared thermography (IRT) is a non-destructive imaging technology which detects thermal energy emitted from objects and converts it into numeric and visual data. IRT has been receiving increasing interest by clinicians as a non-invasive and safe tool for medical diagnosis and monitoring. Studies have reported the potential of IRT for physiological measurements, medical diagnosis and monitoring. In this paper, developments in the applications of IRT for bone fracture identification and the monitoring of fracture healing are reviewed. A significant proportion of x-rays taken to diagnose bone fracture are negative, i.e. reveal that there is no underlying fracture. IRT may have potential as a screening tool to filter out these negative cases where the injury has not resulted in fracture. Exclusion of cases without an underlying fracture would reduce the cost and exposure to harmful radiation associated with unnecessary x-ray imaging. In infants and young children, who may not be able to accurately report the site of injury, IRT may assist in locating possible injury sites, thus facilitating more timely treatment. This feature could also be valuable in child abuse cases with possible bone fracture. Some fractures, such as toddlers fracture, may not be visible on an initial x-ray examination and repeat x-ray imaging is required around two weeks later to confirm diagnosis. IRT may be able to assist clinicians in the initial assessment of such fractures, enabling a more timely diagnosis

Infrared thermal imaging as a screening tool for paediatric wrist fractures

Wrist injuries are common in paediatric trauma, however only half of children evaluated with an x-ray for possible fractures will have one. Thermal imaging offers a possible non-ionising method of screening for fractures and thus reducing negative x-ray rates. 105 children attending the Emergency Department for wrist injuries were recruited. Two 30s thermal videos were recorded from injured and uninjured wrists – in flat and 45o elevated positions. A region of interest (ROI) was defined on each wrist. Cases in which the ROI was covered or had ice applied, were excluded, leaving 40 patients for analysis. Comparisons of ROI included (i) injured and uninjured wrists - flat and elevated positions; (ii) as in (i) with a reference region on the proximal forearm subtracted; (iii) injured wrist ROI - flat and elevated positions. Fractures and sprains increased the mean skin surface temperature by 1.519% (p=0.008) and 0.971% (p=0.055) respectively compared with the uninjured wrist. The mean temperature difference between flat and elevated positions for fractures was 0.268% and -0.1291% for sprains. This difference was statistically significant for fracture (p=0.004) but not sprain (p=0.500). The temperature differences recorded by thermal imaging between fractured and sprained wrists may assist in differentiation of these injuries

Primary care services co-located with Emergency Departments across a UK region: early views on their development

Background Co-location of primary care services with Emergency Departments (ED) is one initiative aiming to reduce the burden on EDs of patients attending with non-urgent problems. However, the extent to which these services are operating within or alongside EDs is not currently known. This study aimed to create a typology of co-located primary care services in operation across Yorkshire and Humber (Y&H) as well as identify early barriers and facilitators to their implementation and sustainability. Methods A self-report survey was sent to the lead consultant or other key contact at 17 EDs in the Y&H region to establish the extent and configuration of co-located primary care services. Semi-structured interviews were then conducted with urgent and unscheduled care stakeholders across five hospital sites to explore the barriers and facilitators to the formation and sustainability of these services. Results Thirteen EDs completed the survey and interviews were carried out with four ED consultants, one ED nurse and three general practitioners (GPs). Three distinct models were identified: ‘Primary Care Services Embedded within the ED’ (seven sites), ‘Co-located Urgent Care Centre’ (two sites) and ‘GP out-of-hours’ (nine sites). Qualitative data were analysed using framework analysis. Four interview themes emerged (justification for the service, level of integration, referral processes and sustainability) highlighting some of the challenges in implementing these co-located primary care services. Conclusion Creating a service within or alongside the ED in which GPs can use their distinct skills and therefore add value to the existing skill mix of ED staff is an important consideration when setting up these systems. Effective triage arrangements should also be established to ensure appropriate patients are referred to GPs. Further research is required to identify the full range of models nationally and to carry out a rigorous assessment of their impact

Clinical emergency care research in low-income and middle-income countries: Opportunities and challenges

Disease processes that frequently require emergency care constitute approximately 50% of the total disease burden in low-income and middle-income countries (LMICs). Many LMICs continue to deal with emergencies caused by communicable disease states such as pneumonia, diarrhoea, malaria and meningitis, while also experiencing a marked increase in non-communicable diseases, such as cardiovascular diseases, diabetes mellitus and trauma. For many of these states, emergency care interventions have been developed through research in high-income countries (HICs) and advances in care have been achieved. However, in LMICs, clinical research, especially interventional trials, in emergency care are rare. Furthermore, there exists minimal research on the emergency management of diseases, which are rarely encountered in HICs but impact the majority of LMIC populations. This paper explores challenges in conducting clinical research in patients with emergency conditions in LMICs, identifies examples of successful clinical research and highlights the system, individual and study design characteristics that made such research possible in LMICs. Derived from the available literature, a focused list of high impact research considerations are put forth

Clinical emergency care research in low-income and middle-income countries: opportunities and challenges

Disease processes that frequently require emergency care constitute approximately 50% of the total disease burden in low-income and middle-income countries (LMICs). Many LMICs continue to deal with emergencies caused by communicable disease states such as pneumonia, diarrhoea, malaria and meningitis, while also experiencing a marked increase in non-communicable diseases, such as cardiovascular diseases, diabetes mellitus and trauma. For many of these states, emergency care interventions have been developed through research in high-income countries (HICs) and advances in care have been achieved. However, in LMICs, clinical research, especially interventional trials, in emergency care are rare. Furthermore, there exists minimal research on the emergency management of diseases, which are rarely encountered in HICs but impact the majority of LMIC populations. This paper explores challenges in conducting clinical research in patients with emergency conditions in LMICs, identifies examples of successful clinical research and highlights the system, individual and study design characteristics that made such research possible in LMICs. Derived from the available literature, a focused list of high impact research considerations are put forth

Levetiracetam versus phenytoin for second-line treatment of paediatric convulsive status epilepticus (EcLiPSE): a multicentre, open-label, randomised trial

Background Phenytoin is the recommended second-line intravenous anticonvulsant for treatment of paediatric convulsive status epilepticus in the UK; however, some evidence suggests that levetiracetam could be an effective and safer alternative. This trial compared the efficacy and safety of phenytoin and levetiracetam for second-line management of paediatric convulsive status epilepticus.Methods This open-label, randomised clinical trial was undertaken at 30 UK emergency departments at secondary and tertiary care centres. Participants aged 6 months to under 18 years, with convulsive status epilepticus requiring second-line treatment, were randomly assigned (1:1) using a computer-generated randomisation schedule to receive levetiracetam (40 mg/kg over 5 min) or phenytoin (20 mg/kg over at least 20 min), stratified by centre. The primary outcome was time from randomisation to cessation of convulsive status epilepticus, analysed in the modified intention-to-treat population (excluding those who did not require second-line treatment after randomisation and those who did not provide consent). This trial is registered with ISRCTN, number ISRCTN22567894.Findings Between July 17, 2015, and April 7, 2018, 1432 patients were assessed for eligibility. After exclusion of ineligible patients, 404 patients were randomly assigned. After exclusion of those who did not require second-line treatment and those who did not consent, 286 randomised participants were treated and had available data: 152 allocated to levetiracetam, and 134 to phenytoin. Convulsive status epilepticus was terminated in 106 (70%) children in the levetiracetam group and in 86 (64%) in the phenytoin group. Median time from randomisation to cessation of convulsive status epilepticus was 35 min (IQR 20 to not assessable) in the levetiracetam group and 45 min (24 to not assessable) in the phenytoin group (hazard ratio 1·20, 95% CI 0·91–1·60; p=0·20). One participant who received levetiracetam followed by phenytoin died as a result of catastrophic cerebral oedema unrelated to either treatment. One participant who received phenytoin had serious adverse reactions related to study treatment (hypotension considered to be immediately life-threatening [a serious adverse reaction] and increased focal seizures and decreased consciousness considered to be medically significant [a suspected unexpected serious adverse reaction]). Interpretation Although levetiracetam was not significantly superior to phenytoin, the results, together with previously reported safety profiles and comparative ease of administration of levetiracetam, suggest it could be an appropriate alternative to phenytoin as the first-choice, second-line anticonvulsant in the treatment of paediatric convulsive status epilepticus