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Melodic Minor Quartal Boxes
A while ago I posted some general information about harmonizing chords in fourths. In this post I want to follow up on that, focusing on melodic minor modes in fourths as a way to create surprising voicings and give your chords some harmonic motion.
The idea here is to associate a particular melodic minor mode to each common chord type: major dominant, minor and m7b5. This will give us vocabulary for every chord type, meaning we can play through any standard tune using nothing but melodic minor quartal stacks if we want to, and that's a great way to get fluent with these.
In fact if we consider two different versions of dominant chords -- functioning and non-functioning -- and two minor chords -- depending on whether we hear it as the tonic or the ii -- then we have six chord qualities to consider. There are only seven modes of Melodic Minor; the "other" one is Mixolydian b6, so I thought I may as well include that one too.
In each case I look at three positions corresponding to C, E and A in the CAGED system, and for each position I give three quartal voicings on the top strings. Together these voicings cover almost the whole fretboard, so we don't really need to bother about the other two CAGED positions.
The colours aren't especially significant except that all the notes of the same colour in a particular box give one quartal chord, and I've used matching colours at the tops and bottoms of boxes to indicate overlaps.
Before learning these applications you should know the Melodic Minor scale, at least in the five CAGED positions, and be able to play the quartal voicings up the neck in any key. Of course, you should also be familiar with some more ordinary ways to play chords on jazz tunes; these are advanced sounds.
I recommend picking one application (i.e. one subheading below) and learning just the green form as a substitute; once this is internalized, add the forms above and below it to start joining the shapes together.
Major 7
There's no straightforward major 7 sound in the melodic minor scale; the closest is Lydian Augmented. The resulting chord -- 1 3 #5 7 -- can work as a sub for Maj7#11 or for a tonic major with a b13 on top, which is a very hip Harmonic Major kind of sound.
Dominant 7 (Altered Option)
Typically, when a dominant chord is functioning as the V -- whether it actually resolves or not -- it can take the altered scale (a.k.a. Super Locrian). These chords express the altered scale directly:
Dominant 7 (Lydian Option)
When a dominant chord is not functioning as a V, we usually think of it as a 7#11 or "Lydian Dominant" chord. Here we express this with the quartal voicings from the Lydian Dominant scale:
Dominant 7 (Mixolydian Option)
This is the third option Melodic Minor gives us on a dominant chord: Mixolydian b6. I like it as an alternative to the Lydian Dominant idea; essentially we're just using a b13 instead of a #11 while the 5 and 9 stay unaltered as usual. Be warned, this will cause consternation if you just throw it in unannounced when comping for another soloist:
Minor 7 (Tonic Option)
Here's Melodic Minor itself; these are beautiful chords to resolve to in bluesy minor-key tunes such as the A section of "Body and Soul":
Minor 7 (Dorian Option)
If you try the previous voicings on m7 chords that are functioning as the ii in a ii-V motion, you'll probably find they don't sound quite right. This is the sound I prefer on the ii. The b9 is a little hard on the ear at first but it's quite a cool sound -- it's the same pitch as the #5 of the V7 chord, which is a nice way to pivot into that.
Minor 7b5
Finally, here's the quartal version of Locrian Natural 6, a popular modern scale choice on m7b5 chords:


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If you visit Molyvos you simply must visit Molyvos Castle. It sits proudly on the hill overlooking the harbour and protecting the town. It's only €2 to get in and children are free. It has simply the most amazing views of Molyvos, the surrounding area and over the Aegean to Turkey.
You also have a choice. You can drive up or take a taxi to the castle or (better still) you can walk up through the wisteria-covered atmospheric streets of Molyvos. When you get to the top there is a cafe where you can take some refreshment before commencing your assault on the ancient fortress. Once inside you will find an interesting (and cool) visitor centre. Take care as you walk around the battlements, the views are as distracting as they are beautiful and the cobbled surface can be uneven.
I don't expect you to take my word for it, read the reviews on TripAdvisor here.
It can also be fun to play 'spot the lizard'. Our 5-year-old grand-daughter spotted 5 on our last visit.
The Historical and Technical bit
The castle was built around 1373, during the Byzantine period, on the site of the acropolis of the ancient city, after the island of Lesvos was granted to Francesco I Gattilusio by John V Palaiologos. A few remains of the Byzantine structure are preserved in the north-west part. In addition to the extensive reconstruction by the Genoese, significant repairs and modifications were undertaken during the period of Ottoman rule (1462-1912), to which almost all the buildings preserved inside the castle belong.
The castle, with an area of 2.9 hectares, is the second largest on the island. It has a polygonal ground plan, with a total of 10 towers both at the angles and on the sides of the polygon. For most of its length, the wall is a single one, apart from the south-west section which was reinforced by two further defensive zones. At this point a series of gates were created, one in each zone, set at right angles to the one immediately preceding and following it. The series of repairs and reconstructions have produced a variety of form of different parts. The towers in particular were adapted to the technique of warfare at the corresponding period so vertical fortification walls and quadrilateral towers with a uniform design throughout their height are to be found next to semicircular towers with a scarpa (a wall with a base larger then its upper part), cordone (an ornamental projecting band or continuous moulding along a wall) and parapets, while battlements dating from the medieval period are juxtaposed with rifle slits from the age of gunpowder.
The main body of the fort appears to belong to the period of Genoese rule. The towers of the west fortification wall, the circular bastions of the south-west part, the outer and middle gates along with the contiguous passageway, and the outworks pierced by them were added probably after 1462 while the upper parts of the complex of the entire curtain wall and the majority of the towers were repaired. The broad fortified main tower at the north-east edge of the castle and the outworks on the north and east were also added or reconstructed on the sites of earlier ones. The building material used in the Genoese period consisted of large dressed stone blocks of uniform size. The second phase also consisted of blocks of local stone, though laid in a more irregular system, while in the final phase (from 1462 to 1912) use was made of small roughly dressed blocks and bricks bound together with mortar, which was used copiously in places. Inside the castle are preserved a large cistern probably of Byzantine date, buildings for the accommodation of the garrison, and probably also to store weapons and munitions, and possibly ancillary buildings of the Ottoman period.
Molyvos Castle Location
By Robin on 22 September 2013.

redpajama_set_name: RedPajamaCommonCrawl


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I came across the LPO Adviser website by accident!
A friend & I got sick of working our butts off for other people. We decided to look at a business of our own that we could run together. She happened to mention to me that she had heard that the local post office was for sale and thought that we should check it out. I was under the impression that post office's were a government owned & run business. I had no idea that you could purchase one.
As I was not sure how to go about this type of purchase, I started to research on the internet & came across the website known as "The LPO Adviser". After reading all the material on the website it got me thinking that perhaps there was a post office out there for us. I emailed the website and got a very prompt reply form a person who was ever so helpful and offered advice on LPO's.
After taking to my husband about a post office he suggested buying our very own post office. "We can do it, we are both hard workers & friendly go lucky type of couple" was my husband's exact words. Anyway that was the start. From then we contacted a business broker to enquiry about LPO's in our area. We managed to get information on a couple that we liked. We then arranged a meeting with the broker so that we could get the ball rolling.
I got back in contact with the LPO Adviser. A gentleman by the name of Juen called me back on and spoke with me at great lengths about the proposed purchase. Juen was more than helful, in fact he was a person that is rare to find these days, well mannered, professional and ever so helpful. His advice and recommendations assisted us with our proposal to purchase the LPO.
Juen worked on our case over a number of nights and was always available to talk to us. I found Juen to be genuinely interested in trying to do what was best for us in making sure that we got the best price for the business. I hope that we are successful in purchasing a LPO in the not too distant future. We will definitely be engaging the services of Juen as our accountant if all goes to plan.
I would thoroughly recommend Juen to anyone who is looking to purchase a LPO, just make sure you speak to him before you sign on that dotted line.


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Q: How to compare values in a pandas pivot table? I'm currently analyzing a dataset with Olympic games medalists, df.head() is on the image below:

I am trying to figure out how many athletes received strictly more Gold medals than Silver and strictly more Silver medals than Bronze?
I started with creating a pivot table but don't see how to proceed and compare the number of medals against each other for each athlete. This is my code so far:
newdf_athletes = df.pivot_table(index = "Athlete", values = "Sport", columns = "Medal", aggfunc = "count")

Does it make sense to use a pivot table here at all?

A: pivot_table might be a way of making it work. Personally I would incline towards groupby() via the following code:
medals = df.groupby(['Athlete','Medal'])['Event'].count())

Pivotting could also work, you can then filter with slicing so that you only keep the athletes which fulfilled the condition:
athletes = newdf_athletes[(newdf_athletes['Gold'] > newdf_athletes['Silver']) & (newdf_athletes['Silver'] > newdf_athletes['Bronze'])

redpajama_set_name: RedPajamaStackExchange


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You can find the originating thread here.
0 points (DX only): Punch at DX for thrust-1; kick at DX-2 for thrust; armed enemies who parry your unarmed strikes attack your limb at full skill; parry unarmed attacks at DX/2 + 3, or DX/2 + 4 if retreating; parry weapons at DX/2, or DX/2 + 1 if retreating; cannot attempt Back Kick, Elbow Strike, Jump Kick, Knee Strike.
1 point (Karate at DX-2): Punch at DX for thrust-1; kick at DX-2 for thrust; armed enemies who parry your unarmed strikes attack your limb at skill-4; parry unarmed attacks at DX/2 + 3, or DX/2 + 5 if retreating; parry weapons at DX/2 + 2, or DX/2 + 5 if retreating; Back Kick at DX-6, Elbow Strike at DX-4, Jump Kick at DX-6, Knee Strike at DX-3.
2 points (Karate at DX-1): Punch at DX for thrust-1; kick at DX-2 for thrust; armed enemies who parry your unarmed strikes attack your limb at skill-4; parry unarmed attacks at DX/2 + 3, or DX/2 + 5.5 if retreating; parry weapons at DX/2 + 2.5, or DX/2 + 5.5 if retreating; Back Kick at DX-5, Elbow Strike at DX-3, Jump Kick at DX-5, Knee Strike at DX-2.
4 points (Karate at DX): Punch at DX for thrust; kick at DX-2 for thrust+1; armed enemies who parry your unarmed strikes attack your limb at skill-4; parry unarmed attacks at DX/2 + 3, or DX/2 + 6 if retreating; parry weapons at DX/2 + 3, or DX/2 + 6 if retreating; Back Kick at DX-4, Elbow Strike at DX-2, Jump Kick at DX-4, Knee Strike at DX-1.
8 points (Karate at DX+1): Punch at DX+1 for thrust+1; kick at DX-1 for thrust+2; armed enemies who parry your unarmed strikes attack your limb at skill-4; parry unarmed attacks at DX/2 + 3.5, or DX/2 + 6.5 if retreating; parry weapons at DX/2 + 3.5, or DX/2 + 6.5 if retreating; Back Kick at DX-3, Elbow Strike at DX-1, Jump Kick at DX-3, Knee Strike at DX.
Adding in the Martial Arts rules gives you a bunch more techniques (almost none of which default to untrained DX). You also get to parry with the legs or feet, and may parry grappling techniques with "counters" that don't require a free hand. And you can dive, sideslip, and slip as well as or better than an untrained person can retreat.
The benefits of Karate don't fully augment the default "go ahead and strike at DX" expected success levels until you spend 8 points in it. At that level, every single thing you can do can be done better with karate than with straight-up DEX.
At four points, you are equal or better in all the things. You attack at the same relative skill level (DX) with Karate, but do more damage. All of your parries, especially when retreating, are better.
At lower levels, the benefits are things you can't even try without the point in the skill (Back Kick, Elbow Strike, Jump Kick, Knee Strike) and vastly improved defenses vs. weapons and when you can retreat.
So what does a point in Karate get you? It gets you options. One of those options is "not getting dead," due to higher defenses right out of the gate.


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Home Technology And Energy Keysight Technologies Inc. (NYSE: KEYS) Drops -0.62% Over A Month, But Analysts...
Technology And Energy
Keysight Technologies Inc. (NYSE: KEYS) Drops -0.62% Over A Month, But Analysts Still See Upside Potential
Katie Ford
Keysight Technologies Inc. (NYSE:KEYS) currently has a daily average trading volume of 1.93M but it saw 1709651 shares traded on Thursday. With a market cap of 19.18B USD, the company's enterprise value now stands nearly at $18.68B. Stock's current market price of $95.61 came falling about -2.51 while comparing to the previous closing price of $98.07. In past 52 weeks, the stock remained buoying in the range of price level as high as $110.00 and as low as $77.93. In the recent trading on the day, stock has struck highest price mark of $99.12 while lowest mark touched by it was $95.42.
Taking a look at 20-day trading activity of Keysight Technologies Inc. (KEYS) gives us an average price of $99.86, while its current price level is -13.08% below from 52-week high level whereas it is 22.69% above from lowest level seen by the stock during that period. Simple moving average of 50 days or SMA-50 of the stock's closing price is $99.47 while that of 200 days or SMA-200 reads an average of $98.46. A closer look into the stock's movement over the week reveals that its volatility is standing at 4.51% during that period while stretching the period over a month that decreases to 2.67%. It is also necessary to take a look into other indicators of a stock too, to get a better idea about its price movement. And in doing so, we find stock's 14-day relative strength index (RSI) standing at 39.48 which implies that the stock is in neutral territory.
Keysight Technologies Inc. (KEYS)'s stock is currently under the radar of 12 analysts who are in consensus at a 12-month price target range of between $112.00 and $135.00 for company's shares. The average price target assigned by the average number of analysts to a stock is a way to gauge worth of any stock in next 52 weeks. And in assigning price target to a stock, some analysts adopt a bearish approach by advocating lower-than-average price target which in this case is $112.00 while some adopt bullish approach by assigning higher-than-average price target which reads the price to top $135.00. Average price target assigned by them is $124.00 which highlights an upside potential of 22.9% for the stock over that period. And to attain the median price target of $126.00 assigned by those analysts, stock has to add about 24.12% of value to its current levels.
Data by FactSet Research shows that 12 analysts have issued their ratings for the stock. 0 of them are in opinions that stock is a Sell, while 1 are advising it as an Overweight. 10 analysts suggested the investors to Buy the stock while 1 advised them to Hold. Recommendations by all of those brokerages imply a consensus rating of Buy for the stock and that issued by Wall Street to investors is Strong Buy.
The company's shares got several price updates from the analyst firms in past one month and most recent of them is from the Goldman which upgraded the stock as "Buy" in its note to investors issued on August 13, 2020, recommending a price target of $120 for it. JP Morgan also issued its recommendations for the stock as it upgraded the price target for the stock is $127.
Over the week, KEYS's stock price is moving -7.01% down while it is -0.62% when we observe its performance for the past one month. Year-to-date it is -6.84% down and over the past year, the stock is showing a downside performance of -0.50%.
The latest quarterly earnings report issued by the company was for quarter ended 7/30/2020, when its quarterly earnings per share (EPS) of $1.19 beat the consensus estimate of $0.83 for the same. The company is expected to be releasing its next quarterly report in 11/18/2020, for which analysts forecasted an EPS of $1.46 while estimate for next year EPS is $4.6. For KEYS, analysts are forecasting an EPS-growth rate of -2.50% for current year and estimate for EPS growth in next year is 15.70%. In next quarter, company is expected to be making quarterly sales of $1.11 billion as analysts are expecting the sales for current fiscal year at $4.16 billion and seeing the company making $4.57 billion in sales next year. Moreover, analysts are in estimates of $1.18 billion for current-quarter revenue.
Currently, Keysight Technologies Inc.'s total number of outstanding shares is 187.00M with 0.44% of that held by the insiders while 92.94% of its common stock has been owned by the institutions. Company's return on investment (ROI) stands at 12.90% and return on equity (ROE) at 22.10%. It has a price to earnings ratio (P/E ratio) of 31.02 while having a 18.13 of forward P/E ratio. Stock's beta reads 1.12. Stock has a price to book (P/B) ratio of 5.79 while price to sale or P/S ratio amounts to 4.57. Its return on asset (ROA) is 10.10% on average.
A filing at the U.S. Securities and Exchange Commission revealed that Vanguard Total Stock Market Index came shrinking its share ownership by -0.32% in the Keysight Technologies Inc. (KEYS) decreasing its stake to 2.84% with control over 17253.0 shares in the company. As per SEC documents, Vanguard Total Stock Market Index shunned 5,305,426 of company's common stock of worth $529.96 million as per recent closing price of the stock. Vanguard Total Stock Market Index is not the only institutional holder which restructured its stake in Keysight Technologies Inc., as Vanguard Mid Cap Index Fund dumped 4,574,874 shares of worth $456.98 million to bring its holdings to a total of 37769.0 shares. In the most recent quarter, T Rowe Price Mid Cap Growth Fund came rising its stake by 0.07% in the company and now holds 4.25 million or 2.27% of the company's stake having worth of about 424.53 million.
KEYS stock
Keysight Technologies Inc.
NYSE:KEYS
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Facility Agreement with the Africa Agriculture and Trade Investment Fund targeting the agricultural financing activity of the MyBucks subsidiaries in Mozambique and Uganda.
AATIF is an innovative public-private partnership dedicated to uplifting Africa's agricultural potential for the benefit of the poor. The Fund aims at improving food security and providing additional employment and income to farmers, entrepreneurs and labourers alike by investing patiently and responsibly in efficient local value chains.


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Everett Collection
'Downton Abbey' Exhibit Lets You Walk Through Mrs. Patmore's Kitchen and More
by Katherine LaGrave
It's not time to say goodbye to the Crawley family just yet.
Cue the top hats, white gloves, and upturned noses: After starting its worldwide tour last summer, the Downton Abbey exhibit is currently in New York City, where it will run through April 2. Downton Abbey: The Exhibition (no points for a clever title) is an "interactive glimpse" into the upstairs-downstairs drama of the Crawleys and their staff, according to The New York Times. The exhibit examines the PBS show's historical context from World War I and into the 1920s, and showcases some of the characters' detailed costumes, including hats and dresses worn by Maggie Smith's dowager countess, Michelle Dockery's Lady Mary, and Hugh Bonneville's Lord Crawley. Even cooler? Visitors to the exhibit get to walk through some of the series' most recognizable sets, including the servants' quarters and Mrs. Patmore's kitchen (where, presumably, Daisy is still making pastry boats).
"Downton Abbey is a global phenomenon and viewers all around the world continue to ask for more," said Michael Edelstein, president of NBCUniversal International Studios, in a statement when the exhibit opened. "Downton Abbey: The Exhibition allows this incredible legacy to live on by offering a multi-million dollar museum quality experience that will delight fans, ultimately extending the connection they have with Downton's compelling characters and storylines."
Adult tickets bought online cost $35 and are sold for a specific time and date, while VIP tickets ($49) allow you to visit at any time on a chosen date. If you want even more of an experience, there are also some special events in the books, including a three-hour cocktail party (also known as the Downton Abbey Soiree) on Friday, March 23—all you have to do is dress up in your finest and be prepared to part with $225.
The exhibit is hardly the only Downton Abbey–themed enterprise to take shape in recent years: Fans could check into Highclere Castle for Valentine's Day or tour the costumes at Asheville's Biltmore Estate. (Those reluctant to shell out can even take their own self-guided Downton tours of London.) Interested in seeing where Thomas and Daisy sleep? Stay tuned: Additional locations and ticket sales for the exhibit will be announced at a later date—though we have a feeling Carson would disapprove of this whole thing.
This article was originally published in 2017. It has been updated with new information.
17 Most Beautiful Small Towns in France


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Vol. 5,
•https://doi.org/10.1364/BOE.5.000197
Tethered confocal endomicroscopy capsule for diagnosis and monitoring of eosinophilic esophagitis
Nima Tabatabaei, DongKyun Kang, Tao Wu, Minkyu Kim, Robert W. Carruth, John Leung, Jenny S Sauk, Wayne Shreffler, Qian Yuan, Aubrey Katz, Norman S Nishioka, and Guillermo J. Tearney
Nima Tabatabaei,1 DongKyun Kang,1 Tao Wu,1 Minkyu Kim,1,2 Robert W. Carruth,1 John Leung,3 Jenny S Sauk,4 Wayne Shreffler,3 Qian Yuan,5 Aubrey Katz,5 Norman S Nishioka,4 and Guillermo J. Tearney1,6,7,*
1Harvard Medical School and Wellman Center for Photomedicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
2School of Engineering, The University of Tokyo, Yayoi 2-11-16 Bunkyo, Tokyo 113-8656, Japan
3Food Allergy Center and Pediatric Allergy & Immunology, Harvard Medical School/Massachusetts General Hospital, Boston, MA 02114, USA
4Department of Gastroenterology, Massachusetts General Hospital, Boston, MA 02114, USA
5Department of Pediatrics, Harvard Medical School/Massachusetts General Hospital, Boston, MA 02114, USA
6Harvard-MIT Division of Health Sciences and Technology, 77 Massachusetts Avenue, Cambridge, MA 02139, USA
7Department of Pathology, Harvard Medical School/Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
*Corresponding author: gtearney@partners.org
N Tabatabaei
D Kang
T Wu
M Kim
R Carruth
J Leung
J Sauk
W Shreffler
Q Yuan
A Katz
N Nishioka
G Tearney
Nima Tabatabaei, DongKyun Kang, Tao Wu, Minkyu Kim, Robert W. Carruth, John Leung, Jenny S Sauk, Wayne Shreffler, Qian Yuan, Aubrey Katz, Norman S Nishioka, and Guillermo J. Tearney, "Tethered confocal endomicroscopy capsule for diagnosis and monitoring of eosinophilic esophagitis," Biomed. Opt. Express 5, 197-207 (2014)
Characterization of eosinophilic esophagitis murine models using optical coherence tomography
Aneesh Alex, et al.
Biomed. Opt. Express 5(2) 609-620 (2014)
Automated segmentation and characterization of esophageal wall in vivo by tethered capsule optical...
Giovanni J. Ughi, et al.
Spectrally encoded confocal microscopy of esophageal tissues at 100 kHz line rate
Simon C. Schlachter, et al.
Biomed. Opt. Express 4(9) 1636-1645 (2013)
Endoscopes, Catheters and Micro-Optics
Confocal microscopy
Diffraction gratings
Imaging systems
Wavefront aberrations
Confocal microscopy (170.1790)
Gastrointestinal (170.2680)
Optical pathology (170.4730)
Original Manuscript: October 7, 2013
Revised Manuscript: November 13, 2013
Manuscript Accepted: November 18, 2013
Eosinophilic esophagitis (EoE) is an allergic condition that is characterized by eosinophils infiltrating the esophageal wall. The treatment of the disease may require multiple follow up sedated endoscopies and biopsies to confirm elimination of eosinophils. These procedures are expensive, time consuming, and may be difficult for patients to tolerate. Here we report on the development of a confocal microscopy capsule for diagnosis and monitoring of EoE. The swallowable capsule implements a high-speed fiber-based reflectance confocal microscopy technique termed Spectrally Encoded Confocal Microscopy (SECM). SECM scans the sample in one dimension without moving parts by using wavelength swept source illumination and a diffraction grating at the back plane of the objective lens. As the wavelength of the source is tuned, the SECM optics within the 7 x 30 mm capsule are rotated using a driveshaft enclosed in a 0.8 mm flexible tether. A single rotation of the optics covered a field of view of 22 mm x 223 µm. The lateral and axial resolutions of the device were measured to be 2.1 and 14 µm, respectively. Images of Acetic Acid stained swine esophagus obtained with the capsule ex vivo and in vivo clearly showed squamous epithelial nuclei, which are smaller and less reflective than eosinophils. Imaging of esophageal biopsies from EoE patients ex vivo demonstrated the capability of this technology to visualize individual eosinophils. Based on the results of this study, we believe that this capsule will be a simpler and more effective device for diagnosing EoE and monitoring the therapeutic response of this disease.
Eosinophilic esophagitis (EoE) is a prevalent food allergy disorder that manifests by eosinophilic infiltration within the esophageal wall. The cytokines released by eosinophils inflame the surrounding esophageal tissue and result in symptoms such as dysphagia, food impaction, nausea, vomiting, and heart burn [1]. The keys to treating of the disease are identification of the triggering food allergen and attenuation of local inflammation. Therefore, the treatments include an iterative process of eliminating potential allergenic foods from a person's diet and/or corticosteroids. Both treatment methods require that patients be followed up by sedated endoscopies with biopsy to confirm that the eosinophils have been eliminated. These endoscopic procedures are expensive, time consuming, and frequently difficult for patients, many of whom are children, to tolerate. Moreover, large numbers of biopsies are required to achieve acceptable diagnostic yield due to the patchy nature of the disease [2]. By providing a less invasive and potentially less expensive method for evaluating the esophagus on the microscopic level, swallowable capsule endomicroscopy devices capable of resolving eosinophils have the potential to improve the standard of care in EoE.
Confocal microscopy is a popular optical imaging technique in the life sciences that can provide high contrast depth-resolved cellular information from tissue. Recently, confocal microscopy has been introduced in the gastrointestinal endoscopy field, termed confocal laser endomicroscopy (CLE). There are two main configurations for CLE, eCLE integrates a miniature confocal microscope into the tip of an endoscope (Pentax, Japan), while pCLE is a stand-alone fiber-bundle probe delivered through the accessory channel of endoscopes (Mauna Kea Technologies, France) [3]. Both configurations use fluorescent dyes, applied either systemically or topically, to visualize cellular features. Investigators have used CLE to study several gastrointestinal tract disorders such as esophageal dysplasia and carcinoma in Barrett's esophagus [4], colon aberrant crypt foci [5], colorectal polyps [6], and colonic mucosa in patients with ulcerative colitis [7]. Recently [8,9], pCLE has been used to identify eosinophils in patients with EoE disease. Neumann et al. have indicated that pCLE can identify eosinophils as small pale gray cells within the intercellular spaces after injection of 5 ml of 10% fluorescein sodium intravenously [8,9]. Another method for identifying eosinophils is two-photon microscopy. It is well known that eosinophils are highly fluorescent [10]. A recent study conducted by Safdarian et al. [11] has shown that two-photon autofluorescence microscopy can identify eosinophils in biopsy samples. This technology could become useful when multiphoton microscopy probes are available for clinical use.
Alternatively, we have shown in prior work [12] that eosinophils are highly scattering relative to surrounding esophageal tissue and therefore are easily seen with high contrast using Spectrally Encoded Confocal Microscopy (SECM), a fiber-based reflectance confocal microscopy technique [13]. High-speed form of SECM was introduced by Boudoux et al. [14] where a rapid wavelength-swept source is utilized in conjunction with a single-element photodetector for imaging, as opposed to the previous implementation of broadband illumination and spectrometric detection. With SECM, light from a rapid wavelength swept laser is coupled into an optical fiber. At its distal end, light is collimated on to a diffraction grating; once diffracted, the light is focused into the tissue using an objective lens. As the laser wavelength is swept, the focused beam is scanned across the sample. Light reflected from the tissue at each point is transmitted back through the system into the fiber, which serves as a spatial filter that rejects multiply scattered and out of focus light (i.e., confocal microscopy). This configuration enables one to rapidly acquire one line of a confocal microscopy image without high speed moving parts and therefore facilitates miniaturization of confocal microscopy into a small probe. In recent years, SECM has been successfully incorporated into bench top imaging systems [14,15] and probes [16–19] to image cellular features of a variety of disorders.
Here we describe the development of a tethered SECM capsule for the diagnosis and monitoring of EoE. The SECM capsule is designed to be swallowed without sedation and, because eosinophils scatter light much more strongly than surrounding esophageal tissue, does not require the use of exogenous contrast agents. The SECM system and capsule design are detailed and then the capsule's optical and mechanical performance tests are reported. Ex vivo images of swine esophageal tissue and biopsies from EoE patients and swine in vivo images are presented to demonstrate that the SECM capsule endomicroscopy device has the potential to evaluate the eosinophil load for this prevalent disease.
2.1 SECM system
Figure 1(a) shows an overview of the developed SECM clinical system. The light source is a 100-kHz wavelength-swept source [20] developed based on an approach previously used for high-speed optical coherence tomography swept sources [21]. The initial swept source spectrum is generated using a polygon mirror tunable filter and a fiber-based laser ring cavity with a sweep rate of 25 kHz and a duty cycle of 25%. Then, a "cut and paste" scheme [21] using four fiber-optic delay lines is incorporated to achieve a wavelength swept source with a tuning rate of 100 kHz and a duty cycle of 100%. The average output power is 80 mW and the FWHM of the spectrum is 91 nm centered at 1296.5 nm.
Fig. 1 (a) Schematic view of the SECM clinical system and SECM tethered capsule. (b) ZEMAX optical design integrated to the mechanical design of the capsule. (c) Close up view of the tilted focal line based on the ZEMAX simulation.
The detection unit consists of InGaAs avalanche photo diode (Princeton Lightwave, USA) and a custom-designed post amplifier with bandwidth of 100 MHz. A high-speed DAQ unit, with a bit depth of 16 bit/pixel and sampling rate of 120 MSamples/sec, digitizes the photodiode signal and stores it on a hard drive array in a RAID 0 configuration. Based on this acquisition rate, each A-line (one SECM line) is Nyquist sampled with 256 points. Given the diameter of the capsule of 7 mm, an entire circumferential image is 22 mm. A total of 16,500 A-lines form a single circumferential image, corresponding to a spatial sampling of 1.3 µm in the angular direction, and a frame rate of 6 Hz.
The opto-mechanical connection between the SECM clinical system and the capsule system is achieved by an optical rotary junction made in-house [22]. The swept source and back-reflected light from tissue are coupled at the interface between the stationary and rotary parts of the rotary junction using custom-made fiber collimators. The rotational torque is provided by a DC motor (Micro Motion Solutions, USA), rotating the capsule's optics at a speed of 6 revolutions/s.
2.2 Capsule mechanical design
The SECM capsule device is composed of tether and capsule sections. The innermost component of the tether is a single-mode fiber threaded inside three-layer stainless steel driveshaft (Asahi Intecc, Japan; 0.54mm OD/0.26mm ID). This assembly is covered by medical grade braided tube (Microlumen, USA). At the proximal end, the driveshaft assembly is locked to the rotary junction by E2000 diamond fiber connector and the braided tube is held stationary by a fixture. At the distal end, the drive shaft is epoxied to the optics assembly and the braided tube is epoxied to the capsule body with a brass ring. This configuration allows for the rotary motion of the fiber/driveshaft/optics assembly while the braided tube/capsule body assembly is stationary and in contact with the luminal organ. The optics assembly is carefully aligned and fixed by epoxy inside the stainless steel housing and the distal end of the housing is sealed, Fig. 1(b).
The capsule body is comprised of three parts. Proximal and distal caps are machined out of medical grade Polymethyl Methacrylate (PMMA) to give mechanical integrity to the capsule and the optical window is made out of medical grade Fluorinated ethylene propylene (FEP) tubing. The inner surface of the FEP tube is chemically etched (Acton Technologies, USA) at both ends to achieve optimal epoxy bonding to the PMMA caps. The capsule is filled with sterile water and sealed at the most distal end by stainless steel set screw. The SECM capsule is 7 mm in diameter and 30 mm in length.
The optics of this SECM probe share similarities to that previously reported [19] with some important differences that reduce the size of the device for easy swallowing. Figure 1(b) shows the ZEMAX design of the SECM capsule optics integrated into the mechanical drawing. Light from the swept-source laser is delivered to the optics by the lensed single-mode fiber (OZ Optics, Canada). The NA(1/e2) of the lensed single-mode fiber is 0.18 which is twice that of the conventional SMF28 fiber. Use of the high NA fiber allowed us to reduce the length of collimation optics from 23.5 mm to 14.5 mm, which ultimately results in a smaller SECM capsule size. Index-matching epoxies as well as angle-polished surfaces are used to minimize the amount of back-reflected light. The light beam is expanded within the glass spacer (GRIN Tech, Germany) and then collimated by the GRIN lens (GRIN Tech, Germany), filling the full aperture of the 1.8 mm optics. Using a second glass spacer (GRIN Tech, Germany) a high-density polarization independent diffraction grating (Ibsen technologies, Denmark; groove density = 1144 line/mm) is mounted at 60° with respect to the optical axis. This configuration results in optimal diffraction efficiency and a 12.5° propagation angle of the first order diffracted beam relative to the normal axis of the tissue surface. Finally, the swept-source light is focused by a custom-designed water-immersion aspheric singlet objective lens (Japan; NA = 0.5) to an oblique focal line inside the tissue. Using water as the objective immersion medium further minimizes the spherical aberration and diminishes the specular reflection from the tissue surface.
Figure 1(c) is the close up view of the tilted focal line based on the ZEMAX design. The focal line is 200 µm wide and centered 100 µm below the tissue surface, imaging a tilted area of 0.491 mm2 (0.223mm x 22mm) in a single optics rotation. The oblique focal line design allows inspection of several depths within one sweep of the laser source. This is particularly beneficial in detecting heterogeneously scattered epithelial eosinophils in EoE patients [2]. While the consensus diagnostic recommendations for EoE require histopathologic detection of at least 15 eosinophils per high-power field (approximately 0.16mm2), no specific orientation (e.g. iso-depth) is suggested for the inspection. As a result, the SECM capsule is designed to acquire isolated circumferential microscopic image strips from the entire esophagus rather than to perform volumetric imaging through stitching of adjacent image strips. In this scenario, 3 high-power fields worth of microscopic information (0.491 mm2 / 0.16 mm2) is acquired in each optics rotation (i.e., image strip). Therefore, a manual pull back of the capsule in 30 seconds provides hundreds of high-power fields microscopic information along the whole esophagus, which covers significantly more tissue than the current 2 to 6 biopsy specimens taken from the proximal, mid, and distal esophagus [1].
2.3 Performance tests
Non-uniform rotational distortion (NURD) is a documented problem with helical scanning systems such as intravascular ultrasound and OCT catheters [23]. NURD is caused by non-uniform transmission of torque from the external motor to the distal end of the driveshaft and results in distortion of the acquired lumen structure. To estimate NURD in the SECM capsule, the distal PMMA cap was removed and a thin radial mark was placed at the distal end of the stainless steel housing. The tether was placed under a mild curvature of 90° and high-resolution optical photography was carried out with a CMOS camera (iDS, Germany) at 100 fps while spinning the optics at 7.25 rev/s. The angular displacement of the radial mark was then quantified in Matlab® platform by fitting a circle along the contour of the housing and identifying the location of the mark at each frame. The absolute value of the angle difference between the measured and expected values was calculated and termed the "angle error". The average angle error over a course of 3 seconds was used as a measure of NURD.
In order to evaluate the optical performance of the capsule several standard tests were carried out. The lateral resolution was quantified by imaging a high-resolution 1951 US Air Force (USAF) resolution target as well as by measuring the full width at half maximum (FWHM) of the line spread function. The field of view was also quantified using this target. The axial resolution was measured as the FWHM of the intensity profile acquired while scanning a mirror through the focus.
To ensure safety of the capsule in clinical practice, the capsule was tested for mechanical integrity, leakage, and dissociation under repeated cycles of acid exposure, mechanical load, and high-level disinfection (Cidex-Opa). It was found that each SECM capsule can be reliably sterilized and reused for at least 5 imaging procedures.
2.4 Tissue imaging studies
In vivo and ex vivo experiments were designed to evaluate the performance of the SECM capsule in imaging tissue. All the imaging studies carried out on swine were performed in accordance with a protocol (Protocol# 2013N000143) approved by the Massachusetts General Hospital's subcommittee on research animal care. For ex vivo imaging, excised swine esophagus tissues were collected and treated with 6% acetic acid (AA) prior to imaging to enhance the nuclear contrast. The thinking behind using an exogenous contrast agent to stain epithelial cells was to create features in swine esophageal mucosa that are smaller and less reflective than the target features in EoE patients (i.e. eosinophils). This design of experiment allowed us to indirectly evaluate the imaging capability of the capsule for imaging structures that approximately have the size of eosinophils in vivo. The capability of the capsule for directly visualizing eosinophils was studied using human biopsy samples. That is, de-identified pinch biopsies from EoE patients were obtained in collaboration with researchers in food and allergy department at Massachusetts General Hospital (MGH) and in accordance with an IRB-approved protocol (Protocol# 201P001159). AA treatment was not carried out on human biopsy samples. Tissues were placed in imaging chambers and were covered with a 250µm thick FEP sheet prior to imaging. In order to perform the imaging, capsule optics assembly was fixed on a 3D raster scanning system and was aligned to place the imaging focal line parallel to the tissue surface. For ex vivo studies, raster scanning was preferred over the helical scanning scheme because it allowed for well-controlled positioning of the focal line within the tissue. Water was added between the objective lens and the FEP cover sheet to simulate the SECM capsule in vivo conditions. The 3D data was collected and stitched together to form the large-area SECM image stack.
For testing the device in vivo, Yorkshire swine (35-42 kgs) were anesthetized, intubated, and ventilated using standard methods. To facilitate the delivery and removal of the SECM capsule to the esophagus, an endoscopy over tube (US Endoscopy, USA) was placed in the proximal esophagus using an endoscope (Pentax Corp, Japan). Then, the esophagus was sprayed with 20ml of 6% AA with a spray catheter and the endoscope was removed. There was no attempt to wash away the excess acetic acid. The SECM capsule was gently pushed to the mid esophagus by a semi-rigid tube placed over the tether. Once positioned in the desired location, the rigid tube was removed and the imaging commenced with the capsule stationary in esophagus. Upon completion of the study, the capsule was withdrawn and the animal was immediately sacrificed.
2.5 Histology
For histology, tissues were fixed in formalin for 48 hours and were subsequently embedded in paraffin. Sections with 5µm thickness were cut en face to the SECM imaging plane. Hematoxylin and eosin (H&E) histopathology was conducted per the standard of care at the MGH Gastrointestinal Pathology Service. Slides were digitized by using a full-slide scanner (Aperio Technologies Inc, USA).
Figure 2 presents the NURD study performed on the SECM capsule. Panels (a) – (c) show the image processing carried out on three representative frames. The image processing program first identifies the center and the boundary of the housing at each frame and then places a radial line at the center of the radial mark. Panel (d) is the plot of the radial mark angular position as a function of time over a course of 10 revolutions. The solid line is the expected trend based on the set rotational speed (7.25 rev/s) and open circles denote the measured angular positions. The plot shows that the measured position closely follow the expected values. Interestingly, it can be seen that the angular errors do not accumulate over time. The average absolute angle error over a course of 3 seconds was found to be 1.86 ± 1.3°. This value is significantly smaller than those reported for certain intravascular ultrasound and OCT devices (3.2 ± 1° and 6.9 ± 2.1°, respectively [23]).
Fig. 2 (a-c) Representative frames captured from the optics housing while rotating, showing the principles of the NURD assessment image processing. (b) Plot of the radial mark's angular position as a function of time over a course of 10 revolutions.
Figure 3 shows the SECM capsule images of the USAF resolution target. The magnified views, panels (b) and (c), indicate that the element 6 of group 8 with a line width of 1.10 µm is the finest pattern that can be visually recognized. This line width corresponds to spatial frequency of 456.0 lp/mm. The lateral resolution measured from the FWHM of the line spread function was found to be 2.1 µm, which is consistent with that of the USAF resolution target images. Based on the known dimensions of the target patterns, the field of view was estimated to be 200 µm. Figure 3(d) is a plot of the axial response obtained by scanning a mirror through the focus of the SECM optics. The FWHM of the main lobe (i.e., axial resolution) was measured to be 14 µm.
Fig. 3 (a) SECM image of a USAF resolution target constructed by raster scanning the capsule optics over the target. Panels (b) and (c) are the magnified view of regions of interest delineated in panels (a) and (b), respectively. (d) Intensity axial plot obtained by scanning a mirror through the focus. The FWHM is 14 µm.
3.2 Ex vivo imaging
Figure 4 shows the SECM images acquired by raster scanning the capsule optics over the swine esophageal tissue. Images were taken at depth of 180 µm from tissue surface.
Fig. 4 (a) Large area SECM image of swine esophageal tissue ex vivo stained with 6% AA. The image was formed by raster scanning the capsule optics over the tissue. (b) Magnified view of the region of interest delineated in (a) demonstrates brightly scattering structures consistent with epithelial nuclei (arrows).
Panel (a) is a large area view constructed by stitching 11 longitudinal scans together. This image clearly shows enhancement of nuclear contrast due to the 6% AA staining. It has been hypothesized that AA induces spatial fluctuations in the nuclear index of refraction, possibly arising from the coagulation of nuclear proteins. This increases backscattering from the nuclear region and results in clearer delineation of nuclear structure [24]. To compensate for the structural differences between the swine and human tissues, however, the concentration of AA used in this study (6%) was higher than that commonly used in the clinical practice (1.5-3%) [25]. The dense population of nuclei in Fig. 4 suggests the presence of imaging plane at the basal zone.
Figure 4(b) shows a magnified view of the area highlighted in panel (a). The stained cell nuclei appear as highly reflective round features. Similar findings have been reported elsewhere [14,15]. The dark round feature in Fig. 4 is possibly squamous papilla which is expected to be observed in the basal layer. Although key structural features of the esophageal tissue are observed in Fig. 4, high level of speckle noise is evident. However, speckle noise is not expected to jeopardize the performance of the SECM capsule in detecting eosinophils because our prior bench top study [12] indicates that the average intensity of the back reflected light from eosinophils is 4 times higher than those of the surrounding tissue. Eosinophils are of the similar size as epithelial cells; therefore, this study indirectly verifies the performance of the capsule optics for visualizing eosinophils.
Figure 5(a) shows the SECM image of a de-identified biopsy sample from an EoE patient. The biopsy was taken from proximal esophagus for research purpose only. The large-area image of panel (a) show several highly reflective features, magnified in panel (b). Panel (c) is a z-stack of the area highlighted in panel (b). The confocal image stack shows the highly reflective features over a depth range of 20 µm. The image taken at the relative depth zero, same depth as panels (a) and (b), shows a bi-lobed structure, which is the characteristic shape of eosinophil nucleus. The significant intensity difference between the feature and the background is also suggestive of eosinophils based on our previous findings [12]. Furthermore, images of panel (c) indicate that speckle noise is not a limiting factor for SECM capsule when visualizing eosinophils. Panel (d) depicts the histology images of the biopsy sample. The high magnification image confirms the presence of eosinophils in the sample. The bi-lobed structure of the nucleus is also evident for some of the eosinophils. The comparison of the features in Fig. 5 with those previously reported in our bench top study [12] suggests that the capsule optics do not have as high optical performance (e.g. contrast, speckle noise, etc.) as our SECM bench top system. However, it should be noted that a single-mode illumination and multimode detection imaging configuration was used in the bench top system to reduce laser speckle noise and improve the signal-to-noise ratio. Moreover, the bench top system incorporated chromatic and wave front aberration corrected microscope objective lens with an effective NA of 0.7 in water to produce images with axial resolution of 10µm. While miniaturization of the bench top system into a swallowable tethered capsule comes at the price of compromises in optical performance, it does not change the physics of the light interaction with eosinophils that provides intrinsic contrast. The ex vivo studies of Figs. 4 and 5 suggest that the SECM capsule optics provides images with sufficient resolution and contrast to image the native eosinophils in humans in vivo.
Fig. 5 (a) Large area SECM image of a de-identified biopsy sample obtained from an EoE patient. The SECM image was formed by acquiring frames as the capsule optics were raster scanned over the tissue. The spongy feature enclosing the tissue is water condensation. (b) Magnified view of a region of interest, showing brightly reflecting cells (arrows) with size and distribution that are consistent with the eosinophils seen in corresponding histology (e, arrows). (c) Z-stack of a magnified portion of (b). (d) Histology of biopsy sample (H&E, magnification 3x). (e) Magnified view of a region within (d). Red rectangles show the regions of interest in (a), (b), and (d) that are shown magnified in (b), (c), and (e), respectively.
3.3 In vivo imaging
Figure 6(a) is a photograph of the SECM capsule next to a penny. The SECM capsule was delivered to swine esophagus to study the overall performance of the system in vivo. AA staining was performed prior to imaging and then the capsule was placed stationary in mid-esophagus. The image in panel (b) was constructed by stitching images from 188 revolutions of the optics, at the same location, below each other. A close look at this image reveals that the amount of NURD is reasonably low and structural features are of the same size at different revolutions. The black vertical strip is probably a fold in tissue where the focal line was outside the tissue. The puckered nature of swine esophageal mucosa makes esophagus distensible to permit the swallowing of a fairly large bolus of food. The relatively uniform width of this fold along the image is also suggestive of low NURD of the optics. Moreover, it can be seen that the contact between the capsule and tissue was not uniform during optics revolution. For instance, the focal line was placed deeper in the epithelial layer in areas toward the edges of the image, yielding lower average intensity from deep unstained regions. The partial dropouts highlighted by arrows in Fig. 6(b) are probably caused by secondary peristaltic waves placing the focal line out of the tissue. We do not anticipate that these problems will jeopardize the capability of the SECM tethered capsule in diagnosis and screening of EoE in humans; because, our recent in vivo studies with OCT tethered capsules [26] had revealed that loss of contact is minimal in unsedated humans due to the contraction of esophageal muscles that grab to capsule during the peristaltic wave.
Fig. 6 (a) Photograph of the SECM tethered capsule. (b) SECM image of swine esophagus mucosa, obtained in vivo. The image was captured while the capsule was stationary within the esophagus. SECM scans obtained from a total of 188 revolutions are seen from top to bottom. Arrows indicate partial drop outs of focal line due to peristaltic waves. (c) Magnified image of the area highlighted in panel (b) showing structures consistent with nuclei of epithelial cells (arrows).
Figure 6(c) is a magnified view of the area highlighted in panel (b). Nuclei of epithelial cells are clearly visualized by the SECM capsule in vivo. Careful examination of Figs. 6(b) and 6(c) indicates presence of a variation in background signal level along the width of each image strip (i.e. spectrally encoded line). The variation is larger towards the edges of each image strip, producing a periodic pattern that can be seen when the strips are stitched together. This variation is due to the larger attenuation of light at the deeper edge of the focal line as well as the spectral variation of source intensity. Source spectrum compensation has already been applied to all the images in this paper but a more optimized processing algorithm can eliminate this artifact more effectively. Nevertheless, as mentioned in the mechanical design section, the SECM tethered capsule is designed to acquire isolated circumferential microscopic images and therefore the image strips do not need to be stitched together for diagnosis of EoE in patients.
We have miniaturized the SECM technology into a 7x30 mm tethered capsule. The capsule is designed to perform near infrared reflectance confocal microscopy of luminal organs, especially for the diagnosis and monitoring eosinophilic esophagitis disease in unsedated patients. Optical performance tests demonstrate that this capsule has lateral and axial resolutions of 2.1 and 14 µm, which is sufficient for identifying individual eosinophils [12]. NURD was evaluated and the average angular error was found to be 1.86 ± 1.3°, significantly lower than those previously reported for certain intravascular ultrasound and OCT catheters [17]. Low NURD is essential for good optical performance of high resolution helical scanning endomicroscopy devices such as the SECM capsule. Ex vivo imaging of excised swine esophageal tissue enabled the visualization of epithelial cell nuclei after staining with AA. Ex vivo imaging of de-identified biopsy sample from EoE patients suggests that this device enables identification of individual eosinophils. Performance of the SECM capsule was verified in vivo in swine, showing the capability of the device to clearly image individual epithelial cell nuclei with no significant NURD generated artifacts. Our research continues towards optimizing the performance of the SECM capsule and performing in vivo imaging in patients with EoE disease.
Dr. Tearney consults for and receives sponsored research from Ninepoint Medical. Massachusetts General Hospital has a licensing relationship with Ninepoint Medical. Drs. Kang, Tearney, and Nishioka have rights to receive royalties from this licensing relationship.
This research was supported by National Institute of Diabetes and Digestive and Kidney Diseases grant (5R01DK091923-02, PI: G. Tearney). N.T. is thankful to the Natural Sciences and Engineering Research Council of Canada (NSERC) for a post-doctoral fellowship award.
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18. C. Boudoux, S. C. Leuin, W. Y. Oh, M. J. Suter, A. E. Desjardins, B. J. Vakoc, B. E. Bouma, C. J. Hartnick, and G. J. Tearney, "Optical microscopy of the pediatric vocal fold," Arch. Otolaryngol. Head Neck Surg. 135(1), 53–64 (2009). [CrossRef] [PubMed]
19. D. Kang, R. W. Carruth, M. Kim, S. C. Schlachter, M. Shishkov, K. Woods, N. Tabatabaei, T. Wu, and G. J. Tearney, "Endoscopic probe optics for spectrally encoded confocal microscopy," Biomed. Opt. Express 4(10), 1925–1936 (2013). [CrossRef] [PubMed]
20. S. C. Schlachter, D. Kang, M. J. Gora, P. Vacas-Jacques, T. Wu, R. W. Carruth, E. J. Wilsterman, B. E. Bouma, K. Woods, and G. J. Tearney, "Spectrally encoded confocal microscopy of esophageal tissues at 100 kHz line rate," Biomed. Opt. Express 4(9), 1636–1645 (2013). [CrossRef] [PubMed]
21. W. Y. Oh, B. J. Vakoc, M. Shishkov, G. J. Tearney, and B. E. Bouma, ">400 kHz repetition rate wavelength-swept laser and application to high-speed optical frequency domain imaging," Opt. Lett. 35(17), 2919–2921 (2010). [CrossRef] [PubMed]
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23. Y. Kawase, Y. Suzuki, F. Ikeno, R. Yoneyama, K. Hoshino, H. Q. Ly, G. T. Lau, M. Hayase, A. C. Yeung, R. J. Hajjar, and I. K. Jang, "Comparison of nonuniform rotational distortion between mechanical IVUS and OCT using a phantom model," Ultrasound Med. Biol. 33(1), 67–73 (2007). [CrossRef] [PubMed]
24. R. A. Drezek, T. Collier, C. K. Brookner, A. Malpica, R. Lotan, R. R. Richards-Kortum, and M. Follen, "Laser scanning confocal microscopy of cervical tissue before and after application of acetic acid," Am. J. Obstet. Gynecol. 182(5), 1135–1139 (2000). [CrossRef] [PubMed]
25. L. M. Wong Kee Song, D. G. Adler, B. Chand, J. D. Conway, J. M. B. Croffie, J. A. Disario, D. S. Mishkin, R. J. Shah, L. Somogyi, W. M. Tierney, B. T. Petersen, and ASGE Technology Committee, "Chromoendoscopy," Gastrointest. Endosc. 66(4), 639–649 (2007). [CrossRef] [PubMed]
26. M. J. Gora, J. S. Sauk, R. W. Carruth, K. A. Gallagher, M. J. Suter, N. S. Nishioka, L. E. Kava, M. Rosenberg, B. E. Bouma, and G. J. Tearney, "Tethered capsule endomicroscopy enables less invasive imaging of gastrointestinal tract microstructure," Nat. Med. 19(2), 238–240 (2013). [CrossRef] [PubMed]
C. A. Liacouras, G. T. Furuta, I. Hirano, D. Atkins, S. E. Attwood, P. A. Bonis, A. W. Burks, M. Chehade, M. H. Collins, E. S. Dellon, R. Dohil, G. W. Falk, N. Gonsalves, S. K. Gupta, D. A. Katzka, A. J. Lucendo, J. E. Markowitz, R. J. Noel, R. D. Odze, P. E. Putnam, J. E. Richter, Y. Romero, E. Ruchelli, H. A. Sampson, A. Schoepfer, N. J. Shaheen, S. H. Sicherer, S. Spechler, J. M. Spergel, A. Straumann, B. K. Wershil, M. E. Rothenberg, and S. S. Aceves, "Eosinophilic esophagitis: Updated consensus recommendations for children and adults," J. Allergy Clin. Immunol. 128(1), 3–20 (2011).
N. Gonsalves, M. Policarpio-Nicolas, Q. Zhang, M. S. Rao, and I. Hirano, "Histopathologic variability and endoscopic correlates in adults with eosinophilic esophagitis," Gastrointest. Endosc. 64(3), 313–319 (2006).
P. E. Paull, B. J. Hyatt, W. Wassef, and A. H. Fischer, "Confocal Laser Endomicroscopy: A Primer for Pathologists," Arch. Pathol. Lab. Med. 135(10), 1343–1348 (2011).
H. Bertani, F. Pigò, E. Dabizzi, M. Frazzoni, V. G. Mirante, M. Manno, R. Manta, and R. Conigliaro, "Advances in Endoscopic Visualization of Barrett's Esophagus: The Role of Confocal Laser Endomicroscopy," Gastroenterol. Res. Pract. 2012, 493961 (2012).
M. Mascolo, S. Staibano, G. Ilardi, M. Siano, M. L. Vecchione, D. Esposito, G. De Rosa, and G. D. De Palma, "Probe-Based Confocal Laser Endomicroscopy Evaluation of Colon Preneoplastic Lesions, with Particular Attention to the Aberrant Crypt Foci, and Comparative Assessment with Histological Features Obtained by Conventional Endoscopy," Gastroenterol. Res. Pract. 2012, 645173 (2012).
V. M. Ussui and M. B. Wallace, "Confocal Endomicroscopy of Colorectal Polyps," Gastroenterol. Res. Pract. 2012, 545679 (2012).
F. Salvatori, S. Siciliano, F. Maione, D. Esposito, S. Masone, M. Persico, and G. D. De Palma, "Confocal Laser Endomicroscopy in the Study of Colonic Mucosa in IBD Patients: A Review," Gastroenterol. Res. Pract. 2012, 525098 (2012).
H. Neumann, M. Vieth, R. Atreya, J. Mudter, and M. F. Neurath, "First description of eosinophilic esophagitis using confocal laser endomicroscopy (with video)," Endoscopy 43(S 02Suppl 2 UCTN), E66 (2011).
H. Neumann and K. Monkemuller, "Endoscopic characterization of eosinophilic esophagitis," Video J. Encyclopedia GI Endosc. 1(1), 23–24 (2013).
D. E. Fuerst and J. R. Jannach, "Autofluorescence of eosinophils: a bone marrow study," Nature 205(4978), 1333–1334 (1965).
N. Safdarian, Z. Liu, X. Zhou, H. Appelman, T. T. Nostrant, T. D. Wang, and E. T. Wang, "Quantifying Human Eosinophils using Three-Dimensional Volumetric Images Collected with Multiphoton Fluorescence Microscopy," Gastroenterology 142(1), 15–20 (2012).
H. Yoo, D. Kang, A. J. Katz, G. Y. Lauwers, N. S. Nishioka, Y. Yagi, P. Tanpowpong, J. Namati, B. E. Bouma, and G. J. Tearney, "Reflectance confocal microscopy for the diagnosis of eosinophilic esophagitis: a pilot study conducted on biopsy specimens," Gastrointest. Endosc. 74(5), 992–1000 (2011).
G. J. Tearney, R. H. Webb, and B. E. Bouma, "Spectrally encoded confocal microscopy," Opt. Lett. 23(15), 1152–1154 (1998).
C. Boudoux, S. Yun, W. Oh, W. White, N. Iftimia, M. Shishkov, B. Bouma, and G. Tearney, "Rapid wavelength-swept spectrally encoded confocal microscopy," Opt. Express 13(20), 8214–8221 (2005).
D. Kang, M. J. Suter, C. Boudoux, H. Yoo, P. S. Yachimski, W. P. Puricelli, N. S. Nishioka, M. Mino-Kenudson, G. Y. Lauwers, B. E. Bouma, and G. J. Tearney, "Comprehensive imaging of gastroesophageal biopsy samples by spectrally encoded confocal microscopy," Gastrointest. Endosc. 71(1), 35–43 (2010).
C. Pitris, B. Bouma, M. Shiskov, and G. Tearney, "A GRISM-based probe for spectrally encoded confocal microscopy," Opt. Express 11(2), 120–124 (2003).
D. Kang, H. Yoo, P. Jillella, B. E. Bouma, and G. J. Tearney, "Comprehensive volumetric confocal microscopy with adaptive focusing," Biomed. Opt. Express 2(6), 1412–1422 (2011).
C. Boudoux, S. C. Leuin, W. Y. Oh, M. J. Suter, A. E. Desjardins, B. J. Vakoc, B. E. Bouma, C. J. Hartnick, and G. J. Tearney, "Optical microscopy of the pediatric vocal fold," Arch. Otolaryngol. Head Neck Surg. 135(1), 53–64 (2009).
D. Kang, R. W. Carruth, M. Kim, S. C. Schlachter, M. Shishkov, K. Woods, N. Tabatabaei, T. Wu, and G. J. Tearney, "Endoscopic probe optics for spectrally encoded confocal microscopy," Biomed. Opt. Express 4(10), 1925–1936 (2013).
S. C. Schlachter, D. Kang, M. J. Gora, P. Vacas-Jacques, T. Wu, R. W. Carruth, E. J. Wilsterman, B. E. Bouma, K. Woods, and G. J. Tearney, "Spectrally encoded confocal microscopy of esophageal tissues at 100 kHz line rate," Biomed. Opt. Express 4(9), 1636–1645 (2013).
W. Y. Oh, B. J. Vakoc, M. Shishkov, G. J. Tearney, and B. E. Bouma, ">400 kHz repetition rate wavelength-swept laser and application to high-speed optical frequency domain imaging," Opt. Lett. 35(17), 2919–2921 (2010).
B. E. Bouma, M. Shishkov, and G. J. Tearney, "Fiber-optic rotational device, optical system and method for imaging a sample," PCT Patent WO2006050453 A1, issued May 11, 2006.
Y. Kawase, Y. Suzuki, F. Ikeno, R. Yoneyama, K. Hoshino, H. Q. Ly, G. T. Lau, M. Hayase, A. C. Yeung, R. J. Hajjar, and I. K. Jang, "Comparison of nonuniform rotational distortion between mechanical IVUS and OCT using a phantom model," Ultrasound Med. Biol. 33(1), 67–73 (2007).
R. A. Drezek, T. Collier, C. K. Brookner, A. Malpica, R. Lotan, R. R. Richards-Kortum, and M. Follen, "Laser scanning confocal microscopy of cervical tissue before and after application of acetic acid," Am. J. Obstet. Gynecol. 182(5), 1135–1139 (2000).
L. M. Wong Kee Song, D. G. Adler, B. Chand, J. D. Conway, J. M. B. Croffie, J. A. Disario, D. S. Mishkin, R. J. Shah, L. Somogyi, W. M. Tierney, B. T. Petersen, and ASGE Technology Committee, "Chromoendoscopy," Gastrointest. Endosc. 66(4), 639–649 (2007).
M. J. Gora, J. S. Sauk, R. W. Carruth, K. A. Gallagher, M. J. Suter, N. S. Nishioka, L. E. Kava, M. Rosenberg, B. E. Bouma, and G. J. Tearney, "Tethered capsule endomicroscopy enables less invasive imaging of gastrointestinal tract microstructure," Nat. Med. 19(2), 238–240 (2013).
Aceves, S. S.
Adler, D. G.
Appelman, H.
Atkins, D.
Atreya, R.
Attwood, S. E.
Bertani, H.
Bonis, P. A.
Boudoux, C.
Bouma, B.
Brookner, C. K.
Burks, A. W.
Carruth, R. W.
Chand, B.
Chehade, M.
Collier, T.
Collins, M. H.
Conigliaro, R.
Conway, J. D.
Croffie, J. M. B.
Dabizzi, E.
De Palma, G. D.
De Rosa, G.
Dellon, E. S.
Disario, J. A.
Dohil, R.
Drezek, R. A.
Esposito, D.
Falk, G. W.
Fischer, A. H.
Follen, M.
Frazzoni, M.
Fuerst, D. E.
Furuta, G. T.
Gallagher, K. A.
Gonsalves, N.
Gora, M. J.
Gupta, S. K.
Hajjar, R. J.
Hartnick, C. J.
Hayase, M.
Hirano, I.
Hoshino, K.
Hyatt, B. J.
Ikeno, F.
Ilardi, G.
Jannach, J. R.
Jillella, P.
Kang, D.
Katz, A. J.
Katzka, D. A.
Kava, L. E.
Kawase, Y.
Kim, M.
Lau, G. T.
Lauwers, G. Y.
Leuin, S. C.
Liacouras, C. A.
Liu, Z.
Lotan, R.
Lucendo, A. J.
Ly, H. Q.
Maione, F.
Malpica, A.
Manno, M.
Manta, R.
Markowitz, J. E.
Mascolo, M.
Masone, S.
Mino-Kenudson, M.
Mirante, V. G.
Mishkin, D. S.
Monkemuller, K.
Mudter, J.
Namati, J.
Neumann, H.
Neurath, M. F.
Noel, R. J.
Nostrant, T. T.
Odze, R. D.
Oh, W.
Paull, P. E.
Persico, M.
Petersen, B. T.
Pigò, F.
Policarpio-Nicolas, M.
Puricelli, W. P.
Putnam, P. E.
Rao, M. S.
Richards-Kortum, R. R.
Richter, J. E.
Romero, Y.
Rosenberg, M.
Rothenberg, M. E.
Ruchelli, E.
Safdarian, N.
Salvatori, F.
Sampson, H. A.
Sauk, J. S.
Schlachter, S. C.
Schoepfer, A.
Shah, R. J.
Shaheen, N. J.
Shiskov, M.
Siano, M.
Sicherer, S. H.
Siciliano, S.
Somogyi, L.
Spechler, S.
Spergel, J. M.
Staibano, S.
Straumann, A.
Suzuki, Y.
Tabatabaei, N.
Tanpowpong, P.
Tearney, G.
Tierney, W. M.
Ussui, V. M.
Vacas-Jacques, P.
Vecchione, M. L.
Vieth, M.
Wallace, M. B.
Wang, E. T.
Wang, T. D.
Wassef, W.
Webb, R. H.
Wershil, B. K.
White, W.
Wilsterman, E. J.
Wong Kee Song, L. M.
Woods, K.
Wu, T.
Yachimski, P. S.
Yagi, Y.
Yeung, A. C.
Yoneyama, R.
Yoo, H.
Yun, S.
Zhang, Q.
Zhou, X.
Am. J. Obstet. Gynecol. (1)
Arch. Otolaryngol. Head Neck Surg. (1)
Arch. Pathol. Lab. Med. (1)
Biomed. Opt. Express (3)
Gastroenterol. Res. Pract. (4)
J. Allergy Clin. Immunol. (1)
Ultrasound Med. Biol. (1)
Video J. Encyclopedia GI Endosc. (1)
Ruikang (Ricky) Wang, Editor-in-Chief


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text:
iOS 16 Accessibility: How to Use Live Captions and Accessibility Shortcuts
Image Description: Pointilism-style image of an iPhone with Live Captions
I finally got a sign it was time to upgrade from an iPhone 7 Plus. Of course, I like to use the latest technologies. But I also like to stretch my dollars. So, I drive cars (2008) and use technologies for as long as possible.
What was the sign? Two words: Live Captions (beta). The catch? Live Captions would only be available for iPhone 11 and later. No way was I going to miss out on Live Captions.
Here are the models that support Live Captions:
iPhone 11 and later
iPad mini: 5th generation and later
iPad: 8th generation and later
iPad Air: 3rd generation and later
iPad Pro 11-inch: all generations
iPad Pro 12.9-inch: 3rd generation and later
As of this time, Live Captions are only available in the U.S. and Canada.
What are Live Captions? They're automatic captions that use your iPhone's microphone to add captions for any speech it hears in the world around the iPhone or inside the apps.
Playing with the Live Caption Button
As soon as the lightly purple iPhone 14 Pro arrived, the first thing I did was turn on the Live Captions (beta). Yes, it shows "beta" in the name. Apple took a progress-over-perfection approach with the Live Captions.
They could've waited a long time until the captions worked well before releasing it. Instead, they released it sooner with a note that it's in beta. Letting people know it's in beta makes them more forgiving of its bugs.
When you turn on Live Captions, it sits on your screen as a button. You can move the button around the screen. You can also control the transparency of the button. The following image shows a screenshot of the Live Captions settings with the button's opacity set to 30%.
The following image is the same screenshot except the button's opacity is set to 100%.
After playing with the shiny new phone for a while, the button started bugging me. No matter where I put it, the button got in the way of the content behind it. Decreasing the transparency didn't help as the appearance of the button remained distracting.
Then a proverbial light bulb went off above my head. Turn Live Captions into a shortcut.
Creating the Accessibility Shortcut
Even on the ancient iPhone 7 Plus, I used the Accessibility Shortcut for easy access to the Color Filters and Magnifier. I'd press the Home button three times for the Accessibility options to pop up and then select the one I wanted.
This also works on the iPhone 14. Instead of the Home button on the bottom of the screen, you press the right-side button. While I don't have hand dexterity issues, I could tell pressing the button three times felt like a strain. Pressing required a little more force than the old Home button.
Fortunately, there is a better way that requires less effort. Two ways, actually. One way may not be available for all phones. For example, tapping the back of the vintage iPhone 7 Plus did nothing. It didn't have this capability. The iPhone 14 does.
Here are two ways to open the Accessibility shortcuts. You can pull down the Control Center or tap the back of the phone twice or thrice (depending on the setting) to open the Accessibility shortcut options.
First, add Accessibility Shortcuts to the Control Center. Select the following:
+ next to Accessibility Shortcuts.
Next, add Live Captions to the Accessibility Shortcuts by selecting the following.
Accessibility Shortcut
And you're set. Now it's available as a shortcut whenever you open the Control Center as the following image shows. In the upper-right, swipe down to select Accessibility and Live Captions.
You can access the Accessibility Shortcut through Back Tap if it's available on your iPhone's model. Select the following to use Back Tap for Accessibility Shortcuts:
Double Tap or Triple Tap
Here's the option to add Back Tap to Accessibility Shortcuts.
Tap the back of the phone twice or thrice depending on the setting you chose for Step 5. The menu pops up from the bottom with Live Captions listed.
Taking the Live Captions (Beta) for a Test Ride
You can move the Live Captions button wherever you want. To use it, select the button. If you want to caption something playing on your phone, deselect the Microphone icon. If you want to caption the world around you, ensure the Microphone icon is selected.
Press the pause button to start the captions or to stop them. There is a button with two arrows pointing in the opposite direction. Tap that to expand the captions to full screen.
Here are the Appearance settings you can customize for Live Captions:
Bold (off / on)
Idle opacity % (controls visibility of Live Caption button when not in use)
The Live Captions settings are confusing. First, if you want them to work for all apps and around you, then make sure the in-app live captions are turned off for FaceTime and RTT. However, it wouldn't work with any of the videos playing on the phone.
After a bit of work, I figured out why. The iPhone connects to my cochlear implant. Because of this, the Live Captions aren't getting any sound. Therefore, it wasn't captioning anything. I could not change the microphone to point to the iPhone's speaker instead of my bionic ear.
I switched to an older bionic ear that doesn't connect to the phone. That worked.
There are two ways to fix it. One is to switch the playback sound from the ear to the iPhone's speaker. This is not intuitive. You have to go to the player options to switch the playback destination. For me, the Ear icon showed up instead of the triangle with three partial circles above it as shown in the following image.
The second way is to turn off Bluetooth. This disconnects the phone from my cochlear implant.
By the way, you can't record or take screenshots of the captions or the button. They're like a vampire — they don't show up in videos or pictures! This is most likely due to concerns of privacy for people on the other end of the conversation or copyrights when it comes to other audio. So, I had to record this video with another device.
The following video shows how to use the Accessibility Shortcuts and Live Captions.
Video description: Hand interacting with iPhone. Pulls down the menu to select Live Captions from Accessibility Shortcuts. Moving Live Captions window and unpausing microphone. Expanding Live Captions window to full screen. Moving the Live Captions window up and down. Changing the window back to a button and closing the button with the Accessibility Shortcut.
I tested it on my TEDx Talk through the YouTube app. Automatic captions aka autocraptions still don't like my accent. The captions were bad. YouTube's original automatic captions were noticeably more accurate than Live Captions. The captions on the talk now contain human captions as the next video shows. (The next video contains open captions. No caption file in this one.)
Video description: iPhone playing Meryl's TEDx Talk with Live Captions and YouTube captions showing. YouTube captions are accurate whereas Live Captions are not.
The verdict isn't out yet on the quality of the captions that don't come from me. Apple makes it clear that it's in beta. I appreciate they released it in beta as I'd rather get it sooner with bugs than wait a year until they're perfect.
Facetime Captions
You can use the Live Captions with Facetime. However, Facetime comes with its own built-in captions. If you opt to use Live Captions only with FaceTime, it will put the captions up top. You wouldn't need the Live Captions button.
I hadn't done a FaceTime call in more than a year. With Live Captions in iOS 16 and upgrading from an iPhone 7 to an iPhone 14, I gave FaceTime another try. My mom had fantastic timing. She asked if we could FaceTime because she had a lot of updates. It gave me the opportunity to test the captions.
It turned out my phone has two different captions turned on. One was FaceTime's in-app captions, which show on top. The other was the iOS Live Captions. FaceTime's in-app Live Captions worked a lot better than the iPhone's Live Captions. Why the quality of the captions between FaceTime in-app and iOS live captions are different, I don't know.
During the conversation with my mom, the FaceTime in-app captions stopped working within five minutes. Fortunately, my mom is one of the easiest people for me to lipread. I rebooted my phone and did another test of FaceTime in-app captions. They worked, but we talked for under 5 minutes. Yet another time I tried them, the FaceTime captions would not show up.
I wanted to get a photo of the captions for this post, so I used FaceTime to call my spouse. This time, FaceTime's in-app top captions didn't work on either end of the conversation. The following image shows the captions box on top with no captions.
Since Live Captions is beta, it's going to be buggy. Still, it's perplexing why the top captions didn't work at all. I can understand their stopping in the middle of the conversation. Many other live caption apps have done that.
I've submitted a request to Apple to please allow us to move FaceTime in-app captions. You can move the iOS captions, but not the FaceTime in-app captions. I can't read lips when the captions are on top. Or I can't see the captions because I'm reading lips. For now, I won't be using FaceTime for a call with anyone other than my mom.
It's about time Apple made Live Captions available. As expected, they're very buggy. That's why it helps to create a shortcut. I don't use them enough to have the button there at all times. I want to give a shout-out to Apple for releasing the beta of Live Captions rather than waiting until it's perfect. That's progress over perfection.
You might also be interested in these posts.
Captions: Humans vs Artificial Intelligence: Who Wins?
Augmented Reality Captioned Glasses
Why and How to Caption Videos Folks Love
Does Your Website or Technology Need to Be Audited for Accessibility or Get a VPAT?
Equal Entry has a rigorous process for identifying the most important issues your company needs to address. The process will help you address those quickly. We also help companies create their VPAT so they can sell to the government or provide it to potential clients who require it. Contact us about auditing and creating VPAT conformance reports.
Accessibility Virtual Reality: Augmented Reality Captioned Glasses
Marketing in Accessibility


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Andrea Leadsom has recommended Conservative MPs to not be "purist" concerning the adjustments Theresa Might hopes to safe for the Irish backstop association, as she stated the Area of Commons will have to give the high minister extra time for negotiations.
The feedback are more likely to spark fear amongst Tory Eurosceptics who've insisted the withdrawal settlement will have to be reopened and legally binding adjustments made to the backstop, even though MPs range over whether or not they would adore it got rid of completely and changed or simply given a point in time.
Might will give a remark to the Commons on Tuesday the place she's going to hope to persuade MPs to present her any other fortnight's grace to stay pushing for adjustments to the backstop – regardless of the insistence of the EU leader negotiator, Michel Barnier, in a single day that it's Britain that will have to compromise.
Leadsom, the chief of the Commons, stated MPs will have to "dangle their nerve" and provides Might time to hunt the adjustments they required, a coded caution to a couple MPs who will have been searching for to amend the high minister's movement later this week to power a brand new timetable for a recent vote at the Brexit deal.
Might had prior to now vowed to Eurosceptics after a vote handed in parliament mandating her to seek out "choice preparations" to the backstop that she understood that supposed reopening the withdrawal settlement textual content – one thing the EU has insisted can't be carried out.
Leadsom sounded cooler about that prospect on Tuesday, talking on BBC Radio four's Nowadays programme, and hinted codicil is also another.
"The purpose is to be sure that the United Kingdom can't be held in a backstop completely. The way it's completed isn't one thing to be purist about," she stated.
Leadsom would now not decide to a brand new vote at the Brexit deal being held through the tip of February, and even ahead of the following EU summit on 21 March, 8 days ahead of the United Kingdom is because of go away the EU.
She stated the significant vote could be introduced again most effective when Might had "met the phrases of parliament's directions two weeks in the past that the backstop had to be time-limited".
Might is anticipated to deliver ahead any other amendable movement, very similar to the movement tabled this week, on 27 February so MPs can have any other alternative for debate if no deal has been reached through then.
"Her message nowadays goes to be that parliamentarians will have to dangle their nerve," Leadsom stated.
Yvette Cooper and Nick Boles, two senior backbenchers whose modification towards no deal failed to realize majority give a boost to remaining month, have now not but made a last resolution about whether or not to desk a remodeled model or wait till 27 February, the Father or mother understands.
However they've been running on a revised model in their invoice to increase article 50, which might then need to be tabled through mid-March to have a possibility of being handed ahead of go out day.
Their modification would set a last mid-March time limit for Might to win a majority for her deal, obliging the federal government to find time for the invoice if she has now not secured parliament's give a boost to ahead of then.
Labour will desk its personal modification this week searching for to place what the shadow Brexit secretary, Keir Starmer, calls a "onerous forestall", at the executive's negotiating time through imposing a time limit during which Might will have to deliver a deal again to the Commons.
At a dinner with the Brexit secretary, Stephen Barclay, on Monday night time, Barnier stated he would pay attention to the United Kingdom's plans for choice to the backstop however insisted there was once no probability of reopening the settlement.
Responding to his feedback, Leadsom stated it was once transparent the compromise had to be from Brussels.
"It will be an bizarre end result if the article the backstop is looking for to keep away from – a troublesome border in Northern Eire – if the EU had been so made up our minds to be totally intransigent about it that they in fact incur the very factor they're searching for to keep away from through pushing the United Kingdom right into a scenario the place we go away with no deal on the finish of March," she stated.


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Almost every day, we speak with people who have questions about their UNUM long-term disability claims. Unfortunately, that insurance company has a reputation for mishandling disability claims and unfounded benefits denials.
At Bryant Legal Group, we've handled countless UNUM disability claims and understand how the company operates. While nothing compares to a personalized assessment from one of our disability lawyers, here are four things you need to know about UNUM.
1. UNUM Is One of the Largest Disability Insurance Companies in the Country
UNUM is a giant in the disability insurance industry. Globally, the company's policies cover 36 million people and almost 194,000 businesses. A Fortune 500 business, UNUM reported more than $11.5 billion in revenue and paid out a little more than $8 billion in insurance benefits in 2018.
In addition to group and individual disability insurance, UNUM also sells life insurance and accidental death and dismemberment policies. Its subsidiaries include Provident Life and Accidental Insurance Company and The Paul Revere Life Insurance Company.
RELATED ARTICLE: Building a Comprehensive Application for Disability Benefits
2. Every State Insurance Commissioner in the U.S. Has Sued UNUM
UNUM has faced nationwide scrutiny for its unfair business practices and mishandling of claims. In 2003, every state insurance commissioner in the United States — along with the District of Columbia, American Samoa, and the U.S. Department of Labor — sued UNUM due to its systemic unfair claims processes.
UNUM settled with 48 states in 2004, paying $15 million in fines and agreeing to restructure its claims processing systems and reevaluate 200,000 disability claims. However, the State of California refused to accept the settlement, and its insurance commissioner alleged that UNUM was an "outlaw company." Eventually, California entered a separate agreement with the insurer that included another $8 million fine and changes to the company's statewide claims handling procedures.
3. UNUM Has Been Ranked One of the Worst Insurance Carriers in America.
In July 2008, the American Association for Justice (AAJ), an advocacy group for trial lawyers, ranked the United States' ten worst insurance companies. It based these rankings on the company's well-documented track record of improperly denied claims, fraudulent behaviors, and blatant disregard for claimants. The AAJ named UNUM the second worst insurer in the country.
While the insurance commissioners' lawsuits played a significant role in UNUM's ranking, the AAJ noted that even after UNUM settled its multiple lawsuits with the state insurance commissioners, it did not significantly improve its behaviors.
Three years after the settlements, UNUM had only reopened 10% of its eligible cases and was still denying valid claims. Today, experienced long-term disability lawyers are still winning cases against UNUM, convincing judges that its denials are arbitrary, capricious, and contrary to medical science.
RELATED ARTICLE: 5 Essential Questions You Should Ask a Disability Insurance Lawyer
4. You Need an Experienced Disability Lawyer When You're Fighting UNUM
When you're dealing with a company like UNUM, you don't want to go it alone; it's too easy to make mistakes and missteps. Instead, it's in your best interest to consult with an experienced disability insurance lawyer early on — even before you complete your application for long-term disability benefits. An attorney can clearly explain your legal rights and options while also building a practical strategy that focuses on both your immediate needs and long-term goals.
At Bryant Legal Group, we've handled thousands of disability claims — many of them against UNUM. Our lawyers implement immense skill and their decades of experience to fight for the benefits their clients deserve, using sophisticated and aggressive techniques.
Bryant Legal Group: Disability Lawyers Who Stand Up to UNUM
If you're struggling with a UNUM disability insurance claim, you need to speak with a lawyer who understands the company's tactics. Bryant Legal Group is one of Chicago's premier disability law firms, and we have successfully handled many UNUM claims.
To request a free consultation, contact our office by calling 312-561-3010 or completing this brief online form.
In the Matter of UNUM Life Insurance Company of America, Regulatory Settlement Agreement (2004, November). Retrieved from https://www.maine.gov/pfr/insurance/publications_reports/exam_rpts/2004/unum_multistate/unum_regulatory_settlement_agreement.pdf
The ten worst insurance companies in America: How they raise premiums, deny claims, and refuse insurance to those who need it most (2008, July). American Association for Justice. Retrieved from https://www.justice.org/sites/default/files/file-uploads/AAJ_Report_TenWorstInsuranceCompanies_FINAL.pdf
UNUM 2018 annual report (2018, December 31). UNUM. Retrieved from https://investors.unum.com/Cache/1001251175.PDF?O=PDF&T=&Y=&D=&FID=1001251175&iid=103324
UnumProvident reaches settlement with California Department of Insurance; 'Changing landscape' may impact cost, availability of disability insurance in state (2005, October 3). UNUM. Retrieved from https://investors.unum.com/File/Index?KeyFile=1939934
The content provided here is for informational purposes only and should not be construed as legal advice on any subject.


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