PoopMD, a Mobile Health Application, Accurately Identifies Infant Acholic Stools.

Amy Franciscovich,Marcus Rice,Tanya Mahr,Joe Doyle,Douglas B Mogul,Montserrat Capdevila,Leslie Hancock,Dhananjay Vaidya,Josh Bolinger,Julio Vera

doi:10.1371/journal.pone.0132270

Amy Franciscovich, Marcus Rice + Show 8 more

Open Access

https://doi.org/10.1371/journal.pone.0132270

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Abstract

Biliary atresia (BA) is the leading cause of pediatric end-stage liver disease in the United States. Education of parents in the perinatal period with stool cards depicting acholic and normal stools has been associated with improved time-to-diagnosis and survival in BA. PoopMD is a mobile application that utilizes a smartphone’s camera and color recognition software to analyze an infant’s stool and determine if additional follow-up is indicated. PoopMD was developed using custom HTML5/CSS3 and wrapped to work on iOS and Android platforms. In order to define the gold standard regarding stool color, seven pediatricians were asked to review 45 photographs of infant stool and rate them as acholic, normal, or indeterminate. Samples for which 6+ pediatricians demonstrated agreement defined the gold standard, and only these samples were included in the analysis. Accuracy of PoopMD was assessed using an iPhone 5s with incandescent lighting. Variability in analysis of stool photographs as acholic versus normal with intermediate rating weighted as 50% agreement (kappa) was compared between three laypeople and one expert user. Variability in output was also assessed between an iPhone 5s and a Samsung Galaxy S4, as well as between incandescent lighting and compact fluorescent lighting. Six-plus pediatricians agreed on 27 normal and 7 acholic photographs; no photographs were defined as indeterminate. The sensitivity was 7/7 (100%). The specificity was 24/27 (89%) with 3/27 labeled as indeterminate; no photos of normal stool were labeled as acholic. The Laplace-smoothed positive likelihood ratio was 6.44 (95% CI 2.52 to 16.48) and the negative likelihood ratio was 0.13 (95% CI 0.02 to 0.83). kappauser was 0.68, kappaphone was 0.88, and kappalight was 0.81. Therefore, in this pilot study, PoopMD accurately differentiates acholic from normal color with substantial agreement across users, and almost perfect agreement across two popular smartphones and ambient light settings. PoopMD may be a valuable tool to help parents identify acholic stools in the perinatal period, and provide guidance as to whether additional evaluation with their pediatrician is indicated. PoopMD may improve outcomes for children with BA.

Highlights

Biliary atresia (BA) is a perinatal disease of hepatobiliary destruction that causes cirrhosis and is universally fatal without intervention
Among the initial 45 photographs, there was agreement between 6+ pediatricians on 34 samples including 27 photographs that were defined as true normal stools and 7 photographs that were defined as true acholic stools; there was no consensus among pediatricians that any photographs represented an indeterminate stool
All raw data has been provided (S1 Table). This pilot study demonstrates that PoopMD, a free mobile app available in the Apple and Google stores, can accurately identify images of acholic stool

Summary

Introduction

Biliary atresia (BA) is a perinatal disease of hepatobiliary destruction that causes cirrhosis and is universally fatal without intervention. BA is the most common cause of neonatal cholestasis and accounts for nearly half of all pediatric liver transplants in the United States [1]. Earlier time-to-diagnosis and subsequent surgical intervention with a hepatoportoenterostomy (HPE or “Kasai” procedure) is associated with better outcomes, including an increase in overall survival and decrease in rates of transplantation. Because physiologic jaundice of the newborn is extremely common and mimics the most common sign of BA, icterus, recognizing that an infant has BA proves challenging for health care providers. Adding to the difficulty of diagnosis is limited awareness for BA on the part of both parents and health care providers since it is a rare disease with an estimated incidence of 1 in 13,000 in the United States, or approximately 400 new cases per year [7]

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