Mohamed Khadra

Advantages of polytetrafluoroethylene arteriovenous loops in the thigh for hemodialysis access

BACKGROUND The upper thigh is an alternative but infrequently used site to the forearm for placement of subcutaneous polytetrafluoroethylene (PTFE) arteriovenous conduits in patients requiring hemodialysis for end stage renal failure. This site has the great advantage of easier accessibility for self-cannulation. METHODS The outcome was reviewed for 74 PTFE loops placed in 61 patients between 1985 and 1991. RESULTS Mean loop survival time was 99.8 weeks (SD 78.0) when patients with early failure (<1 week), and those patients whose loops functioned adequately until transplantation or death were excluded. Infection occurred in 12 of 74 loops. CONCLUSIONS Thigh PTFE loops provide satisfactory medium- to long-term vascular access for hemodialysis although, like all other forms of access currently available, they fall short of the ideal for prolonged dialysis.

Prostate cancer incidence in Australia correlates inversely with solar radiation.

Whats known on the subject? and What does the study add?

A systematic review on incentive-driven mobile health technology: As used in diabetes management

Introduction Mobile health (mHealth) technologies have been shown to improve self-management of chronic diseases, such as diabetes. However, mHealth tools, e.g. apps, often have low rates of retention, eroding their potential benefits. Using incentives is a common mechanism for engaging, empowering and retaining patients that is applied by mHealth tools. We conducted a systematic review aiming to categorize the different types of incentive mechanisms employed in mHealth tools for diabetes management, which we defined as incentive-driven technologies (IDTs). As an auxiliary aim, we also analyzed barriers to adoption of IDTs. Methods Literature published in English between January 2008–August 2014 was identified through searching leading publishers and indexing databases: IEEE, Springer, Science Direct, NCBI, ACM, Wiley and Google Scholar. Results A total of 42 articles were selected. Of these, 34 presented mHealth tools with IDT mechanisms; Education was the most common mechanism (n = 21), followed by Reminder (n = 11), Feedback (n = 10), Social (n = 8), Alert (n = 5), Gamification (n = 3), and Financial (n = 2). Many of these contained more than one IDT (n = 19). The remaining eight articles, from which we defined barriers for adoption, were review papers and a qualitative study of focus groups and interviews. Discussion While mHealth technologies have advanced over the last five years, the core IDT mechanisms have remained consistent. Instead, IDT mechanisms have evolved with the advances in technology, such as moving from manual to automatic content delivery and personalization of content. Conclusion We defined the concept of IDT to be core features designed to act as motivating mechanisms for retaining and empowering users. We then identified seven core IDT mechanisms that are used by mHealth tools for diabetes management and classified 34 articles into these categories.

Second Life for Medical Education

Research suggests that virtual learning could considerably augment, if not eventually revolutionize medical education. In this study, medical students were provided with an opportunity to engage in an online, simulated Second Life environment in order to interactively address problem-based presentations of surgical disease within a safe, confidential, realistic and engaging medical educational platform.

Enhancing home area networks to facilitate telehealth services: Test-bed scenario with video-consultation-calls (VCC)

Recent years have witnessed rapid development of Telehealth applications and the integration of portable devices to facilitate services such as Voice-over-IP (VoIP), Video-over-IP and distribution of other data types e.g., medical images and health sensor data. In line with Telehelath, Home Area Network (HAN) has also seen broad deployments and has expanded conventional households to support latest electronic devices that are equipped with network connectivity. Telehealth applications are starting to be designed to take advantages of the HAN environment and are providing healthcare at the patients home, i.e., facilitates hospital at home via video-consultation-call (VCC). However, some of these Telehealth applications are highly delay sensitive and require higher bandwidth priority and a network load-balancing system in order to produce best quality of service (QoS). We observed that typical HAN is established without bandwidth priority and network-load-balancing systems. This lack of management causes HAN to produce unacceptable QoS for Telehealth applications. In this scenario, we propose a scheme to enhance HAN while providing better quality of VCC to support Telehealth services. Our scheme controls the Internet traffic within the HAN network infrastructure environment. In our experimental setting, we implemented a real network test-bed based on HAN where two-way Skype VCC was established and the quality of packet-loss was measured. Skype was chosen for its wide availability and support on all types of computing devices (PC, mobile, laptop etc.). Our results indicate that packet-loss fluctuates between ~5-16% when user datagram protocol (UDP) traffic is utilised concurrently by other devices in HAN. It also demonstrated that our scheme could enhance HAN performance for VCC as it reduced packet-loss down to ~0.3 %.

Home area network for optimizing telehealth services--empirical simulation analysis.

Telehealth applications such as Video-over-IP and remote sensor monitoring are rapidly growing in utilisation and it has now expanded to the patients homes. These Telehealth applications are, however highly delay sensitive and require high quality (and bandwidth priority) in order to provide satisfactory performances. However, at the patients home area network (HAN) environment, typically there is no Internet traffic management system which highly affects the quality of these applications. As HAN expands its capacity by adding new devices in its network, the need for a network management system become urgent and necessary. In this study, we propose an infrastructure based method to improve Telehealth application quality by managing the quality and distribution of the Internet traffic among the connected devices in a HAN environment. We setup a HAN environment using existing devices readily available at home and tested the setting with typical Telehealth application needs that includes Video-over-IP, VoIP, data and other multimedia traffic. Our simulation results showed that our method is capable of providing better services. Our method indicated that it can provide ~11% lesser packet-loss under 12Mbps background traffic, while increasing 10% of the CPU load for Traffic management.

Guest Editorial: Telehealth Systems and Applications

In the 21st century, the convergence of healthcare and information and communications technologies (ICT) offers an opportunity to give patients greater liberty from their health problems. Telehealth systems and applications, supported by advances in ICT, are fostering a diversity of cost-effective and efficient healthcare solutions. These solutions are becoming embedded in all aspects of clinical care and are enhancing the quality, equality, and accessibility of care, while playing a pivotal role in decreasing the rising costs from the growth in aging population. The emergence of affordable health sensors and accessible mobile computing devices, such as smartphones, wearables and tablets, offers opportunities to revolutionize healthcare solutions.

Automatic prostate segmentation on MR images with deep network and graph model

Automated prostate diagnoses and treatments have gained much attention due to the high mortality rate of prostate cancer. In particular, unsupervised (automatic) prostate segmentation is an active and challenging research. Most conventional works usually utilize handcrafted (low-level) features for prostate segmentation; however they often fail to extract the intrinsic structure of the prostate, especially on images with blurred boundaries. In this paper, we propose a novel automated prostate segmentation model with learned features from deep network. Specifically, we first generate a set of prostate proposals in transverse plane via recognizing the position and coarse estimate of the shape of the prostate on the global prostate image and using the deep network to extract highly effective features for the boundary refinement in a finer scale. With consideration of the correlations among different sequential images, we then construct a graph to select the best prostate proposals from proposal set for its use in 3D prostate segmentation. Experimental evaluation demonstrates that our proposed deep network and graph based method is superior to state-of-the-art couterparts, in terms of both dice similarity coefficient and Hausdorff distance, on public dataset.

Do Electronic Medical Records Improve Advance Directive Documentation? A Systematic Review

Background: Documentation rates of advance directives (ADs) remain low. Using electronic medical records (EMRs) could help, but a synthesis of evidence is currently lacking. Objectives: To evaluate the evidence for using EMRs in documenting ADs and its implications for overcoming challenges associated with their use. Design: Systematic review of articles in English, published from inception of databases to December 2017. Data Sources: PubMed, PsycINFO, EMBASE, and CINAHL. Methods/Measurements: Four databases were searched from inception to December 2017. Randomized and nonrandomized quantitative studies examining the effects of EMRs on creation, storage, or use of ADs were included. All featured an advance care planning process. Evidence was evaluated using the Cochrane Collaboration’s risk assessment tool. Results: Fifteen studies were included: 1 randomized controlled trial, 1 randomized pilot, 4 pre–post studies, 4 cross-sectional studies, 1 retrospective cohort study, 1 historical control study, 1 retrospective observational study, 1 retrospective review, and 1 evaluation of an EMR feature. Seven studies showed that EMR-based reminders, AD templates, and decision aids can improve AD documentation rates. Three demonstrated that EMR search functions, decision aids, and automatic identification software can help identify patients who have or need ADs according to certain criteria. Five showed EMRs can create documentation challenges, including locating ADs, and making some patients more likely than others to have an AD. Most studies had an unclear or high risk of bias. Conclusions: Limited evidence suggests EMRs could be used to help address AD documentation challenges but may also create additional problems. Stronger evidence is needed to more conclusively determine how EMR may assist in population approaches to improving AD documentation.

A case of peritoneal mesothelioma masquerading as a urachal mass.

A 71-year-old man presented for urological assessment with a 4-month history suprapubic pain. The pain was described as dull and also had an element of renal colic. It was associated with microscopic haematuria and significant weight loss of 20 kg. Routine bloods, prostate-specific antigen and urine cytology were unremarkable. A computed tomography of the abdomen and pelvis revealed a large calcified mass adjacent to the bladder wall initially thought to be a large residual urarchal cyst. There was no invasion of the pelvic wall. However, because of the degree of calcification, the mass was deemed to be suspicious of urachal carcinoma (Fig. 1). Cystoscopy, however, showed a normal bladder with no evidence of dome involvement. Laparotomy was performed for excision of the mass. At laparotomy, a mass was revealed in the lower pelvis, adherent to the right pelvic and femoral vessels. Tumour debulking, with removal of a soft tissue mass 110 × 85 × 90 mm in size and partial cystectomy was performed. Histopathology revealed a high-grade, poorly differentiated mesothelioma with spindle cell morphology, showing malignant heterologous elements because of osteosarcomalike bone formation. The specimen stained positive for caltretin and pancytokeratin. There was involvement of the margin and lymphovascular and perineural infiltration. The patient recovered from his laparotomy and was referred to radio-oncology for palliative radiotherapy. Given the diagnosis, further history was obtained. There is a glancing history of asbestos exposure, in that the patient performed home renovations about 30 years ago. He was thus also referred to the Dust Diseases Board. Malignant mesothelioma is a primary tumour of the serous membranes. It is a rare tumour, affecting as few as two people per million. The most common site of origin is the pleura (65–70%), but it may also arise from the peritoneum (30%). More rarely, it may arise from the pericardium or tunica vaginalis of the testes. Malignant peritoneal mesothelioma (MPM) predominates in older men in their fifth and sixth decades. Patients may present with non-specific symptoms such as abdominal pain, ascites and marked weight loss. MPM is a disease that combines the tragedy of poor prognosis and difficult diagnosis. The rarity of occurrence, vague symptoms and spectrum of disease presentation makes the diagnosis of MPM difficult. It is often diagnosed in advanced stages because of the variety of radiological and clinical findings. The urachus is an embryological remnant connecting the apex of the bladder to the umbilicus. During development, the urachus eventually undergoes fibrosis to form a non-patent, fibromuscular strand. However, in rare cases, a defect in this process may occur, giving rise to an intraabdominal mass such as an urachal cyst (1/5000 births) or urachal carcinoma (<0.5% of all bladder cancers). The anatomical location of the urachus may mean that urachal masses remain largely asymptomatic. Treatment of urachal cysts found incidentally is generally conservative. However, they must be suspected when patients present with localized suprapubic pain associated with a micturition disorder. The degree of clinical silence in urachal carcinoma until late stages denotes the poor prognosis of this disease. There are currently no established guidelines on the treatment of MPM. This is due to multiple factors, including the fact that MPM remains a rare disease, making large-scale clinical trials difficult. Furthermore, MPM has several clinical and histopathological variants. Currently, many centres combine cytoreductive surgery for the removal of macroscopic disease and intraperitoneal chemotherapy with platinum-based agents, which have shown increased survival. Differential diagnoses for MPM include peritoneal metastases from adenocarcinoma, endometriosis and pseudomyxoma peritonei. It is important to differentiate MPM from welldifferentiated papillary mesotheliomas, which are benign. The literature is rich in cases detailing the multiple and highly variable presentations of MPM such as adrenal failure, ovarian cancer and inguinal hernia. The role of biopsy in the context of an uncertain peritoneal malignancy is not clearly characterized in the literature. Seeding of malignant cells is a potential concern. This is the first reported case of MPM presenting as an urachal mass. This is particularly significant given the management of urachal cysts is generally conservative. It is a powerful reminder of the spectrum of disease, the lack of specificity of disease presentation and the fact that disease may arise from any serosal surface. Fig. 1. Calcified mass found on computed tomography. IMAGES FOR SURGEONS