Tag Archives: interventional pulmonology

Deep learning in Radiology and Pathology affects Bronchoscopists

Photo by Andrew Neel, on Unsplash

This is a second post relating to the promising role of artificial intelligence in interventional pulmonology.  My point is that lung specialists will spend less time learning facts and figures that are easily replaced by computer-generated analyses of complex algorithms. Much of this is because of Deep learning

This subset of machine learning (programs that adjust themselves as they are exposed to more data, but without human input) uses artificial neural networks (algorithms built on unstructured data). The word deep is a technical term referring to the number of layers in the neural network. Artificial Neural networks being a set of algorithms modeled after the human brain and used to recognize patterns.  Image recognition is one example, and its principles are responsible for much of the work done today in radiology and pathology. 

For example, using deep learning and pattern recognition, AI reveals CT abnormalities and interprets findings (Google’s AI team recently outperformed traditional radiologists looking at 45,800 screening CTs for lung cancer https://www.fiercebiotech.com/medtech/google-s-cancer-spotting-ai-outperforms-radiologists-reading-lung-ct-scans), and chest radiographs are accurately interpreted using fuzzy logic interpretations of spatial relationships (https://www.ijcaonline.org/specialissues/dia/number1/4156-spe320t).

Pathology is another area where practice patterns will undoubtedly change. In many regions, expert cytologic interpretation of lung and mediastinal nodal specimens is lacking. Digital pathology (image-based information generated from a digital slide) allows real-time interpretation by computers at sites that are distant from wherever the procedure takes place. Humans already do this despite the cost and logistic difficulties.  I believe that artificial intelligence will soon facilitate and universalize the process (https://www.healthimaging.com/topics/artificial-intelligence/ai-lung-cancer-slides-accuracy-pathologists). 

In today’s post, my goal was to introduce the concept of deep learning and provide a few examples of how this mode of artificial intelligence will affect procedural practice by changing how chest radiology and pathology are practiced. Rather than devote study time to learning X-ray and cytology interpretation, future bronchoscopists will improve their abilities to incorporate findings into appropriate management plans, as well as communicate results to patients, caregivers, and health-care teams.

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Challenges in East Africa: Abuse, AIDS, and Accidents

Photo from: Violence Against Children Survey (Uganda) 2015. UNICEF

There is something magical about traveling through East Africa. Perhaps it is because the region is the cradle of Homo Sapiens (the oldest remains of which were discovered in Omo National Park in Ethiopia, and Olduvai Gorge in Tanzania). Perhaps it  is because of the wildlife roaming throughout the Great Rift Valley, or scaling the fabulous mountains that include Kilimanjaro, Mount Kenya, and the Rwenzori range, or experience the awe of never-ending scenic landscapes. Perhaps it’s the smiling, friendly, and generous people of the region.

Whatever it may be, I fell in love with this part of the world many years ago. At that time I lived and worked in the region, almost settling into life journey that would have been very different from the one I eventually embarked upon, and that brought me to the United States and an eventual career in academia and medicine.

This year, I am experiencing again the magical aura of Tanzania, Kenya, and Uganda (not to forget the other 16 countries that comprise the East Africa region). The challenges these countries face in the realm of health care are stupendous, but not unsurmountable. In this piece I will focus on three areas; Abuse, AIDS, and Accidents. In particular, I want to suggest that our global community of bronchologists can assist colleagues in these countries build technical platforms that ultimately save lives and reduce patient suffering.

The first area I want to address should be of interest to bronchologists, but also to a growing number of pediatric pulmonologists. Using only Uganda as an example, a nation with a population of 44 million in a country about the size of Germany violence against children is a social nightmare. According to the recent UNICEF survey, one in four girls (25%), and one in ten boys (11%) between the ages of 13 and 17 reported sexual violence in the past year. These numbers are even higher when teenagers and young adults between the ages of 17 and 24 are asked about a personal history of sexual abuse. Physical violence, emotional violence, and sexual abuse occur at home, in school, while children walk often long distances to and from schools in the evening, and on the roads. There is a tight relationship between a history of violence and emotional disorders, sexually transmitted diseases, and HIV/AIDS.

The second area of focus in this piece is that of HIV/AIDS. According to the educational website avert.org, HIV/AIDS in East and Southern Africa has 6.2% of the world’s population, but over half of the number of people living with HIV/AIDS worldwide (in 2017, it is estimated art about 40 million people are living with HIV in the world). On a positive note, specialists report that new HIV infections have decreased by one third in the region in the last six years, and that access to antiretroviral therapy has increased significantly. Still, girls and young women are disproportionately affected by the disease, and the number of orphans due to AIDs continues to increase.

A less talked about subject in this region, but one that warrants attention is that of road traffic accidents. According to a recent World Health Organization report, Uganda, for example, joins South Africa, Nigeria, Thailand, and the Dominican Republic in leading statistics for road-related accidents that cause death and significant morbidity. There are 28.9 deaths per 100,000 population in Uganda, much higher than the 18/100,000 global average. Road traffic incidents are, in fact, the leading cause of death in Uganda, alongside malaria, respiratory infections, meningitis, tuberculosis, and HIV/AIDS. Overcrowding on minibuses (called matatus), speeding, alcohol use, lack of safety precautions such as seatbelts and motorcycle helmets, as well as poor road conditions contribute to this problem. Increased urbanization and a paucity of effective public educational programs are also contributing factors.

Uganda’s challenges in the realm of Accidents, Abuse, and AIDS are not unique. In fact, successful intervention in these areas is also challenging in most developing countries, as well as in many developed nations. Successful implementation of educational programs and social services  in addition to access to expert health care is needed throughout the region (for more information see various publications in the African Social Sciences Review, UNICEF and WHO reports, and the Journal of Injury and Violence Research).

I have intentionally avoided to address the problems of poverty, hunger, tuberculosis, or malaria that also plague the region, although I suspect I will be writing about these in future Corners. Today, my goal is to simply raise awareness regarding Accidents, Abuse, and AIDS, and to hopefully prompt readers to ponder how these three areas are related, and how interventional pulmonologists and bronchologists might help address these issues.

Technical platforms, for example, are essential to providing competent care to victims of the Accidents, Abuse,  and AIDS triad. Chest physicians and critical care specialists, as well as pediatric pulmonologists are especially skilled (or should be) in communicating bad news, and are (or should be)  strong advocates for introducing technologies (such as bronchoscopic procedures) into clinical practice. These procedures are essential to caring for critically ill or physically traumatized individuals. Training remains an issue, as does equipment acquisition, resources, and economics. In addition to raising awareness about these issues, my goal is encourage bronchologists and pediatric pulmonologists to join our community of specialists so that one day, we might all work together to combat these ills of humanity.

Suggested reading:
– Violence against children: https://www.unicef.org/uganda/VACS_Report_lores.pdf
– Violence against children: https://bmjopen.bmj.com/content/6/5/e010443
– Road traffic incidents in Uganda: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5279989/
– HIV/AIDS in east Africa https://www.unicef.org/esaro/5482_HIV_AIDS.html

Is there a “culture” of bronchoscopy?

(Photo from The Mindful Art of Thich Nhat Hahn)

In the early 19th century German philosophers and social scientists sought to define the word “culture” in their studies of human behavior and history. Influenced by the Romanticist concept of Volksgeist (spirit of a people), they proposed that culture described the values, ideals, and higher qualities, i.e. intellectual, artistic, and moral, of a society. Anthropologists have since argued about narrowing or broadening this definition, yet most agree that culture, at the very least is defined by values, norms, and modes of thinking that are considered important and  passed down from generation to generation.

During the past forty years, I have been fortunate to practice medicine or teach in dozens of countries and in diverse medical environments. This experience prompts me to conclude there is indeed a “culture” of bronchoscopy and interventional pulmonology. 

This specialty differs from others because we are often with patients from their diagnoses to their deaths. In some countries, we may be asked to prolong life using palliative procedures, then later to take life by honoring a request for physician-assisted suicide. The instant gratification resulting from a treat and release form of patient encounters is rare, and better describes the professional satisfactions of an orthopedic surgeon or ophthalmologist. 

Bronchologists, on the other hand, spend their days delivering news of a terminal process or describing the spread of a potentially fatal disease. Minimally invasive procedures, while offered to reduce suffering and prolong life, are often performed without a chance for cure. 

We live in operating theaters, bronchoscopy suites, and intensive care units. We handle emergencies both night and day, and our expertise and scope of practice usually mean the difference between life and death for patients with few other options. We learn empathy, understanding, patience, and tolerance. Even when our ethics come into question; knowing, for example, that institutional biases favor surgical explorations of the mediastinum instead of EBUS-guided TBNA, our goals, for the most part, are to serve patients and to relieve suffering.

Furthermore, we believe in the effectiveness of palliative procedures to prolong and improve quality of life. We value honesty and warmth in our physician-patient relationships. We advocate for patients and speak truth to power in our demands for better equipment from medical institutions. We seek competency through education; hands-on training using models, observerships in centers of excellence, mentorship, and attendance at medical conferences. 

These core values, beliefs, and behaviors are being passed from the generation that created the specialty since the 1970s, to a younger group of enthusiastic doctors who continue their practice with this same spirit. 

The answer is a resounding yes. There IS a “culture” of bronchoscopy.