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### Editorial

ASME J of Medical Diagnostics. 2017;1(1):010201-010201-2. doi:10.1115/1.4037771.
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Commentary by Dr. Valentin Fuster

### Review Article

ASME J of Medical Diagnostics. 2017;1(1):010801-010801-6. doi:10.1115/1.4038360.
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Novel imaging technologies continued to be introduced into the operative setting. In particular, novel image-enhanced laparoscopic techniques are being explored for use in gynecologic operations. This systematic review describes these technologies in four relevant areas of gynecologic surgery. The PubMed database was searched for human, English-language studies, and the reference lists of retrieved articles were reviewed. An analysis of pooled data from 34 studies that met inclusion criteria was performed. The results suggest that image-enhanced technology may be useful in several common gynecologic procedures. Auto- and drug-enhanced fluorescence laparoscopy allow for increased detection of nonpigmented endometriotic lesions. Using these technologies for peritoneal staging of ovarian malignancy is of uncertain benefit. Drug-enhanced fluorescence laparoscopy for sentinel lymph node (SLN) detection in patients with uterine or cervical malignancy is feasible, showing a high rate of SLN detection, but a low sensitivity of identifying metastases. Finally, their use in intra-operative visualization of the ureter is promising. The majority of available data was from feasibility studies with limited sample sizes. Nevertheless, the results described in this systematic review support the expectation that these upcoming image-enhanced laparoscopy techniques will play a more important role in the future care of gynecologic patients.

Commentary by Dr. Valentin Fuster

### Research Papers

ASME J of Medical Diagnostics. 2017;1(1):011001-011001-6. doi:10.1115/1.4038129.
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The aim of the study was to design a novel radiofrequency (RF) electrode for larger and rounder ablation volumes and its ability to achieve the complete ablation of liver tumors larger than 3 cm in diameter using finite element method. A new RF expandable electrode comprising three parts (i.e., insulated shaft, changing shaft, and hooks) was designed. Two modes of this new electrode, such as monopolar expandable electrode (MEE) and hybrid expandable electrode (HEE), and a commercial expandable electrode (CEE) were investigated using liver tissue with (scenario I) and without (scenario II) a liver tumor. A temperature-controlled radiofrequency ablation (RFA) protocol with a target temperature of 95 $°C$ and an ablation time of 15 min was used in the study. Both the volume and shape of the ablation zone were examined for all RF electrodes in scenario I. Then, the RF electrode with the best performance in scenario I and CEE were used to ablate a large liver tumor with the diameter of 3.5 cm (scenario II) to evaluate the effectiveness of complete tumor ablation of the designed RF electrode. In scenario I, the ablation volumes of CEE, HEE, and MEE were 12.11 cm3, 33.29 cm3, and 48.75 cm3, respectively. The values of sphericity index (SI) of CEE, HEE, and MEE were 0.457, 0.957, and 0.976, respectively. The best performance was achieved by using MEE. In scenario II, the ablation volumes of MEE and CEE were 71.59 cm3 and 19.53 cm3, respectively. Also, a rounder ablation volume was achieved by using MEE compared to CEE (SI: 0.978 versus 0.596). The study concluded that: (1) compared with CEE, both MEE and HEE get larger and rounder ablation volumes due to the larger electrode–tissue interface and rounder shape of hook deployment; (2) MEE has the best performance in getting a larger and rounder ablation volume; and (3) computer simulation result shows that MEE is also able to ablate a large liver tumor (i.e., 3.5 cm in diameter) completely, which has at least 0.785 cm safety margin.

Commentary by Dr. Valentin Fuster
ASME J of Medical Diagnostics. 2017;1(1):011002-011002-10. doi:10.1115/1.4038237.
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Radiofrequency ablation (RFA) has emerged as an alternative treatment modality for treating various tumors with minimum intervention. The application of RFA in treating breast tumor is still in its infancy stage. Nevertheless, promising results have been obtained while treating early stage localized breast cancer with RFA procedure. The outcome of RFA is tremendously dependent on the precise insertion of the electrode into the geometric center of the tumor. However, there remains plausible chances of inaccuracies in the electrode placement that can result in slight displacement of the electrode tip from the actual desired location during temperature-controlled RFA application. The present numerical study aims at capturing the influence of inaccuracies in electrode placement on the input energy, treatment time and damage to the surrounding healthy tissue during RFA of breast tumor. A thermo-electric analysis has been performed on three-dimensional heterogeneous model of multilayer breast with an embedded early stage spherical tumor of 1.5 cm. The temperature distribution during the RFA has been obtained by solving the coupled electric field equation and Pennes bioheat transfer equation, while the ablation volume has been computed using the Arrhenius cell death model. It has been found that significant variation in the energy consumption, time required for complete tumor necrosis, and the shape of ablation volume among different positions of the electrode considered in this study are prevalent.

Commentary by Dr. Valentin Fuster
ASME J of Medical Diagnostics. 2017;1(1):011003-011003-7. doi:10.1115/1.4038228.
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A couple of fused deposition modeling (FDM) three-dimensional (3D) printers using variable infill density patterns were employed to simulate human muscle, fat, and lung tissue as it is represented by Hounsfield units (HUs) in computer tomography (CT) scans. Eleven different commercial plastic filaments were assessed by measuring their mean HU on CT images of small cubes printed with different patterns. The HU values were proportional to the mean effective density of the cubes. Polylactic acid (PLA) filaments were chosen. They had good printing characteristics and acceptable HU. Such filaments obtained from two different vendors were then tested by printing two sets of cubes comprising 10 and 6 cubes with 100% to 20% and 100% to 50% infill densities, respectively. They were printed with different printing patterns named “Regular” and “Bricks,” respectively. It was found that the HU values measured on the CT images of the 3D-printed cubes were proportional to the infill density with slight differences between vendors and printers. The Regular pattern with infill densities of about 30%, 90%, and 100% were found to produce HUs equivalent to lung, fat, and muscle. This was confirmed with histograms of the respective region of interest (ROI). The assessment of popular 3D-printing materials resulted in the choice of PLA, which together with the proposed technique was found suitable for the adequate simulation of the muscle, fat, and lung HU in printed patient-specific phantoms.

Commentary by Dr. Valentin Fuster
ASME J of Medical Diagnostics. 2017;1(1):011004-011004-5. doi:10.1115/1.4038259.
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Overhead throwing athletes are at high risk of the elbow ulnar collateral ligament (UCL) injury, and there is a need for clinical tools to objectively diagnose severity of injury and monitor recovery. Mechanical properties of ligaments can potentially be used as biomarkers of UCL health. The objectives of this study are to evaluate the reliability of shear wave ultrasound elastography (SWE) for quantifying UCL shear modulus in 16 healthy nonthrowing individuals and use this technique to evaluate the difference in UCL shear modulus between the injured and uninjured elbows in a baseball pitcher with UCL tear. In the reliability test, the UCL shear modulus of both elbows of each participant was evaluated by SWE for five trials. The same procedures were repeated on two different days. The intra-day and day-to-day reliabilities were determined by the five measurements on the first day and two averages on the two days, respectively. In the case study, each elbow of the baseball pitcher with UCL tear was tested for five trials, and the average was calculated. The intra-day (intraclass correlation coefficient (ICC) = 0.715, Cronbach's alpha = 0.926) and day-to-day (ICC = 0.948, Cronbach's alpha = 0.955) reliabilities were found to be good. There was no difference between both sides. In the case study, the UCL shear modulus of the injured elbow (186.45 kPa) was much lower than that of the uninjured elbow (879.59 kPa). This study shows that SWE could be a reliable tool for quantifying the mechanical properties and health status of the UCL.

Commentary by Dr. Valentin Fuster
ASME J of Medical Diagnostics. 2017;1(1):011005-011005-10. doi:10.1115/1.4038260.
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The presence of obstructions such as tracheal stenosis has important effects on respiratory functions. Tracheal stenosis impacts the therapeutic efficacy of inhaled medications as a result of alterations in particle transport and deposition pattern. This study explores the effects of the presence and absence of stenosis/obstruction in the trachea on air flow characteristics and particle depositions. Computational fluid dynamics (CFD) simulations were performed on three-dimensional (3D) patient-specific models created from computed tomography (CT) images. The analyzed model was generated from a subject with tracheal stenosis and includes the airway tree up to eight generations. CT scans of expiratory and inspiratory phases were used for patient-specific boundary conditions. Pre- and post-intervention CFD simulations' comparison reveals the effect of the stenosis on the characteristics of air flow, transport, and depositions of particles with diameters of 1, 2.5, 4, 6, 8, and 10 μm. Results indicate that the existence of the stenosis inflicts a major pressure force on the flow of inhaled air, leading to an increased deposition of particles both above and below the stenosis. Comparisons of the decrease in pressure in each generation between pre- and post-tracheal stenosis intervention demonstrated a significant reduction in pressure following the stenosis, which was maintained in all downstream generations. Good agreements were found using experimental validation of CFD findings with a model of the control subject up to the third generation, constructed via additive layer manufacturing from CT images.

Commentary by Dr. Valentin Fuster
ASME J of Medical Diagnostics. 2017;1(1):011006-011006-8. doi:10.1115/1.4038261.
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As the strongest of the meningeal tissues, the spinal dura mater plays an important role in the overall behavior of the spinal cord-meningeal complex (SCM). It follows that the accumulation of damage affects the dura mater's ability to protect the cord from excessive mechanical loads. Unfortunately, current computational investigations of spinal cord injury (SCI) etiology typically do not include postyield behavior. Therefore, a more detailed description of the material behavior of the spinal dura mater, including characterization of damage accumulation, is required to comprehensively study SCI. Continuum mechanics-based viscoelastic damage theories have been previously applied to other biological tissues; however, the current work is the first to report damage accumulation modeling in a tissue of the SCM complex. Longitudinal (i.e., cranial-to-caudal long-axis) samples of ovine cervical dura mater were tensioned-to-failure at one of three strain rates (quasi-static, 0.05/s, and 0.3/s). The resulting stress–strain data were fit to a hyperelastic continuum damage model to characterize the strain-rate-dependent subfailure and failure behavior. The results show that the damage behavior of the fibrous and matrix components of the dura mater are strain-rate dependent, with distinct behaviors when exposed to strain rates above that experienced during normal voluntary neck motion suggesting the possible existence of a protective mechanism.

Commentary by Dr. Valentin Fuster
ASME J of Medical Diagnostics. 2017;1(1):011007-011007-7. doi:10.1115/1.4038408.
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Changes in left ventricle (LV) shape are observed in patients with pulmonary hypertension (PH). Quantification of ventricular shape could serve as a tool to noninvasively monitor pediatric patients with PH. Decomposing the shape of a ventricle into a series of components and magnitudes will facilitate differentiation of healthy and PH subjects. Parasternal short-axis echo images acquired from 53 pediatric subjects with PH and 53 age and sex-matched normal control subjects underwent speckle tracking using Velocity Vector Imaging (Siemens) to produce a series of x,y coordinates tracing the LV endocardium in each frame. Coordinates were converted to polar format after which the Fourier transform was used to derive shape component magnitudes in each frame. Magnitudes of the first 11 components were normalized to heart size (magnitude/LV length as measured on apical view) and analyzed across a single cardiac cycle. Logistic regression was used to test predictive power of the method. Fourier decomposition produced a series of shape components from short-axis echo views of the LV. Mean values for all 11 components analyzed were significantly different between groups (p < 0.05). The accuracy index of the receiver operator curve was 0.85. Quantification of LV shape can differentiate normal pediatric subjects from those with PH. Shape analysis is a promising method to precisely describe shape changes observed in PH. Differences between groups speak to intraventricular coupling that occurs in right ventricular (RV) overload. Further analysis investigating the correlation of shape to clinical parameters is underway.

Topics: Shapes , Pediatrics
Commentary by Dr. Valentin Fuster

### Technical Brief

ASME J of Medical Diagnostics. 2017;1(1):014501-014501-6. doi:10.1115/1.4038238.
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The purpose of this study was to investigate the feasibility of generating larger ablation volumes using the pulse delivery method in irreversible electroporation (IRE) using a potato model. Ten types of pulse timing schemes and two pulse repetition rates (1 pulse per 200 ms and 1 pulse per 550 ms) were proposed in the study. Twenty in vitro experiments with five samples each were performed to check the effects on the ablation volumes for the ten pulse timing schemes and two pulse repetition rates. At the two pulse repetition rates (1 pulse per 200 ms and 1 pulse per 550 ms), the largest ablation volumes achieved were 1634.1 $mm3±$ 122.6 and 1828.4 $mm3±$160.9, respectively. Compared with the baseline approach (no pulse delays), the ablation volume was increased approximately by 62.8% and 22.6% at the repetition rates of 1 pulse per 200 ms and 1 pulse per 550 ms, respectively, using the pulse timing approach (with pulse delays). With the pulse timing approach, the ablation volumes generated at the lower pulse repetition rate were significantly larger than those generated at the higher pulse repetition rate (P < 0.001). For the experiments with one pulse train (baseline approach), the current was 5.2 $A±$0.4. For the experiments with two pulse trains, the currents were 6.4 $A±$0.9 and 6.8 $A±$0.9, respectively (P = 0.191). For the experiments with three pulse trains, the currents were 6.6 $A±$0.6, 6.9 $A±$0.6, and 6.5 $A±$0.6, respectively (P = 0.216). For the experiments with five pulse trains, the currents were 6.6 $A±$0.9, 6.9 $A±$0.9, 6.5 $A±$1.0, 6.5 $A±$1.0, and 5.7 $A±$1.2, respectively (P = 0.09). This study concluded that: (1) compared with the baseline approach used clinically, the pulse timing approach is able to increase the volume of ablation; but, the pulse timing scheme with the best performance might be various with the tissue type; (2) the pulse timing approach is still effective in achieving larger ablation volumes when the pulse repetition rate changes; but, the best pulse timing scheme might be different with the pulse repletion rate; (3) the current in the base line approach was significantly smaller than that in the pulse timing approach.

Commentary by Dr. Valentin Fuster