Artificial intelligence and echocardiography

Echocardiography plays a crucial role in the diagnosis and management of cardiovascular disease. However, interpretation remains largely reliant on the subjective expertise of the operator. As a result inter-operator variability and experience can lead to incorrect diagnoses. Artificial intelligence (AI) technologies provide new possibilities for echocardiography to generate accurate, consistent and automated interpretation of echocardiograms, thus potentially reducing the risk of human error. In this review, we discuss a subfield of AI relevant to image interpretation, called machine learning, and its potential to enhance the diagnostic performance of echocardiography. We discuss recent applications of these methods and future directions for AI-assisted interpretation of echocardiograms. The research suggests it is feasible to apply machine learning models to provide rapid, highly accurate and consistent assessment of echocardiograms, comparable to clinicians. These algorithms are capable of accurately quantifying a wide range of features, such as the severity of valvular heart disease or the ischaemic burden in patients with coronary artery disease. However, the applications and their use are still in their infancy within the field of echocardiography. Research to refine methods and validate their use for automation, quantification and diagnosis are in progress. Widespread adoption of robust AI tools in clinical echocardiography practice should follow and have the potential to deliver significant benefits for patient outcome

Healthcare finance in the Kingdom of Saudi Arabia:a qualitative study of householders’ attitudes

Background: The public sector healthcare system in Saudi Arabia, essentially financed by oil revenues and ‘free at the point of delivery’, is coming under increasing strain due to escalating expenditure and an increasingly volatile oil market and is likely to be unsustainable in the medium to long term. Objectives: This study examines how satisfied the Saudi people are with their public sector healthcare services and assesses their willingness to contribute to financing the system through a national health insurance scheme. The study also examines public preferences and expectations of a future national health insurance system. Methods: A total of 36 heads of households participated in face-to-face audio-recorded semi-structured interviews. The participants were purposefully selected based on different socio-economic and socio-demographic factors from urban and rural areas to represent the geographical diversity that would presumably influence individual views, expectations, preferences and healthcare experiences. Results: The evidence showed some dissatisfaction with the provision and quality of current public sector healthcare services, including the availability of appointments, waiting times and the availability of drugs. The households indicated a willingness to contribute to a national insurance scheme, conditional upon improvements in the quality of public sector healthcare services. The results also revealed a variety of preferences and expectations regarding the proposed national health insurance scheme. Conclusions: Quality improvement is a key factor that could motivate the Saudi people to contribute to financing the healthcare system. A new authority, consisting of a partnership between the public and private sectors under government supervision, could represent an acceptable option for addressing the variation in public preferences

Investigating the Willingness to Pay for a Contributory National Health Insurance Scheme in Saudi Arabia:A Cross-sectional Stated Preference Approach

Background: The Saudi Healthcare System is universal, financed entirely from government revenue principally derived from oil, and is ‘free at the point of delivery’ (non-contributory). However, this system is unlikely to be sustainable in the medium to long term. This study investigates the feasibility and acceptability of healthcare financing reform by examining households’ willingness to pay (WTP) for a contributory national health insurance scheme. Methods: Using the contingent valuation method, a pre-tested interviewer-administered questionnaire was used to collect data from 1187 heads of household in Jeddah province over a 5-month period. Multi-stage sampling was employed to select the study sample. Using a double-bounded dichotomous choice with the follow-up elicitation method, respondents were asked to state their WTP for a hypothetical contributory national health insurance scheme. Tobit regression analysis was used to examine the factors associated with WTP and assess the construct validity of elicited WTP. Results: Over two-thirds (69.6%) indicated that they were willing to participate in and pay for a contributory national health insurance scheme. The mean WTP was 50 Saudi Riyal (US$13.33) per household member per month. Tobit regression analysis showed that household size, satisfaction with the quality of public healthcare services, perceptions about financing healthcare, education and income were the main determinants of WTP. Conclusions: This study demonstrates a theoretically valid WTP for a contributory national health insurance scheme by Saudi people. The research shows that willingness to participate in and pay for a contributory national health insurance scheme depends on participant characteristics. Identifying and understanding the main influencing factors associated with WTP are important to help facilitate establishing and implementing the national health insurance scheme. The results could assist policy-makers to develop and set insurance premiums, thus providing an additional source of healthcare financing

Association of Serum Ustekinumab Levels With Clinical Response in Psoriasis

Importance: High-cost biologic therapies have transformed the management of immune-mediated inflammatory diseases. To optimize outcomes and reduce costs, dose adjustment informed by measurement of circulating drug levels has been shown to be effective in various settings. However, limited evidence exists for this approach with the interleukin 12 and interleukin 23 inhibitor ustekinumab. Objective: To evaluate clinical utility of therapeutic drug monitoring for ustekinumab in patients with psoriasis. Design, Setting, and Participants: A prospective observational cohort of 491 adults with psoriasis was recruited to the multicenter Biomarkers of Systemic Treatment Outcomes in Psoriasis study within the British Association of Dermatologists Biologic and Immunomodulators Register from June 2009 to December 2017; samples from some patients were taken between 2009 and 2011 as part of a pilot study with the same inclusion criteria. Exposure: Serum ustekinumab level measured at any point during the dosing cycle using an enzyme-linked immunosorbent assay. Main Outcomes and Measures@ Disease activity measured using the Psoriasis Area and Severity Index (PASI) score. Treatment response outcomes were PASI75 (75% reduction in PASI score from baseline [primary outcome]), PASI90 (90% reduction of PASI score from baseline), and absolute PASI score of 1.5 or less. Results: A total of 491 patients (171 women and 320 men; mean [SD] age, 45.7 [12.8] years) had 1 or more serum samples (total, 853 samples obtained 0-56 weeks from start of treatment) and 1 or more PASI scores within the first year of treatment. Antidrug antibodies were detected in only 17 of 490 patients (3.5%). Early measured drug levels (1-12 weeks after starting treatment) were associated with PASI75 response 6 months after starting treatment (odds ratio, 1.38; 95% CI, 1.11-1.71) when adjusted for baseline PASI score, age, and ustekinumab dose. However, this finding was not consistent across the other PASI outcomes (PASI90 and PASI score of ≤1.5). Conclusions and Relevance: This real-world study provides evidence that measurement of early serum ustekinumab levels could be useful to direct the treatment strategy for psoriasis. Adequate drug exposure early in the treatment cycle may be particularly important in determining clinical outcome

Report from the Annual Conference of the British Society of Echocardiography, November 2017, Edinburgh International Conference Centre, Edinburgh

No abstract available

Identification of pre-clinical cardiovascular imaging phenotypes related to blood pressure in young adults

Hypertension prevalence in young adults is rising and is associated with an increased risk of stroke and cardiovascular disease in later life. However, hypertension management guidelines for patients below the age of 40 years remain conservative as their absolute risk of imminent vascular events is low. Additionally, due to the relatively short duration of exposure to hypertension, traditional measures of target organ damage such as left ventricular hypertrophy are often normal. In this thesis, I sought to identify pre-clinical cardiovascular phenotypes associated with blood pressure elevation in young adults, which might be of value for monitoring disease progression in young people. A cohort of young participants aged 18 to 40 years with a range of blood pressure measures were recruited through clinical studies conducted at the Cardiovascular Clinical Research Facility for multi-dimensional assessment of cardiovascular health. Detailed cardiac structure and function assessment was performed using a range of imaging modalities including resting and stress echocardiography imaging. First, I established that participants with suboptimal blood pressure (≥120/80 mmHg) have novel changes in cardiovascular remodelling identifiable with echocardiography. Specifically, I identified a reduction in left ventricular systolic function during physical exercise, which was associated with altered left atrial pump function at rest. Then, I studied whether it was possible to combine multiple echocardiographic measures using a contrastive trajectory inference machine learning model to describe the progression of cardiovascular remodelling in young adults with hypertension, and place participants on a pseudo-temporal trajectory of disease, with a corresponding score, from health (zero) to disease (one). I demonstrated feasibility of this approach and the practicality of summarising this disease progression as a single score. Finally, I demonstrated that longer duration of treatment was associated with higher score and was consistent with an established modifiable cardiovascular risk score and fitness levels. Therefore, I have demonstrated that there are progressive changes in cardiac structure and function, identifiable with echocardiography, in young adults with suboptimal blood pressure. Further work is now needed to determine whether these measures could be used clinically to better manage blood pressure in younger patients.</p