Bi-parametric prostate MRI with a recall system for contrast enhanced imaging: Improving accessibility while maintaining quality.

PURPOSE: To review the efficacy of a recall system for bi-parametric non-contrast prostate MRI (bp-MRI). METHODS: A bi-parametric protocol was instituted in July 2020 for all patients who had a prostate MRI requested, excluding those after treatment of prostate cancer, patients with hip prosthesis or pacemaker, and those who lived out-of-town. The protocol consisted of tri-planar T2-weighted and diffusion weighted images (DWI) (b = 50, 800 s/mm2 for ADC map; b = 1,500 s/mm2 acquired separately) in accordance with the Prostate Imaging Reporting & Data system (PI-RADS) v2.1 guidelines. After interpretation of bp-MRI exams, patients with equivocal (PI-RADS 3) lesions in peripheral zone (PZ) or any technical limitations were recalled for contrast administration. RESULTS: Out of 909 bp-MRI scans performed from July 2020 to April 2021, only 52 (5.7 %) were recalled, of which 46 (88.5 %) attended. Amongst these, 41/52 (78.8 %) were recalled for PZ PI-RADS 3 lesions, while the rest of 11 (21.2 %) cases were recalled for technical reasons. Mean time to subsequent recall scan was 11.6 days. On assessment of post-contrast imaging, 29/46 (63 %) cases were upgraded to PI-RADS 4 while 17/46 (37 %) remained PI-RADS 3. This system avoided contrast-agent use in 857 patients, with contrast cost savings of €64,620 (US$68,560) and 214 hours 15 minutes of scanner time was saved. This allowed 255 additional bp-MRI scans to be performed, reducing the waitlist from 1 year to 2-3 weeks. CONCLUSION: A bi-parametric prostate MRI protocol with a robust recall system for contrast administration not only saved time eliminating the marked backlog but was also more cost efficient without compromising the quality of patient care.

Nontargeted Native Renal Biopsy Adequacy: Preintervention Data From a Province-Wide, Multicentre, and Interdepartmental Audit.

Background: Nontargeted renal biopsy is essential to diagnosis, classification, and prognostication of medical renal disease. Inadequate biopsies delay diagnosis, expose the patient to repeated biopsy, and increase costs. Objective: The purpose of this project is to characterize nontargeted renal biopsy specimen adequacy and identify areas for improvement. Design: This project was designed as a clinical audit of specimen adequacy rates of nontargeted renal biopsies from 13 hospitals, as well as a questionnaire of radiology and pathology department staff regarding current practices surrounding renal biopsies. Setting: Retrospective analysis of 2188 adult native renal biopsies was performed from January 1, 2018, to September 9, 2021, across 13 hospitals. Patients: Adult patients with medical renal disease undergoing a nontargeted renal biopsy were included. Methods: Retrospective analysis of 2188 adult native renal biopsies was performed from January 1, 2018, to September 9, 2021, across 13 hospitals. Adequacy was divided into 4 categories based on number of glomeruli received: ideally adequate (≥25 glomeruli), minimally adequate (15-24), suboptimal (<15 and diagnosis rendered), and inadequate (<15 and no diagnosis rendered). Two targets were chosen; target 1, to achieve a combined suboptimal and inadequate rate ≤ 10%, and target 2, to attain an ideally adequate rate ≥80%. Radiology department heads in the province were surveyed on biopsy equipment, technique, technologist support, and feasibility of possible interventions to enhance biopsy adequacy. Pathology department staff were surveyed on their education and experience. Results: Adequacy was as follows: ideally adequate 64.7%, minimally adequate 26.0%, suboptimal 7.9%, and inadequate 1.4%. The province (and 8/13 hospitals) met target 1 for native biopsies (9.3%). Two hospitals achieved target 2 for native biopsies. A key finding was that the 2 hospitals with the lowest target 1 scores did not have a technologist present at biopsy. Limitations: Survey data was used to assess biopsy technique at each hospital, and specific technique for each biopsy was not recorded. As such, a multivariate statistical analysis of specimen adequacy rates was not feasible. Data on complications was not collected. Conclusions: Preintervention the province was at target for limiting inadequate and suboptimal native biopsies. There was a substantial shortfall in the ideally adequate rate from the proposed target. Using insight from survey data, interventions with the greatest expected impact were identified and those that are feasible given limited resources will be implemented to improve sample adequacy. Trial Registration: Not registered.

Contexte: La biopsie rénale non ciblée est essentielle au diagnostic, à la classification et au pronostic d'une néphropathie. Les biopsies inadéquates retardent le diagnostic, exposent le patient à des biopsies répétées et coûtent plus cher au système de santé. Objectif: L'objectif de cette étude était de caractériser l'adéquation des échantillons des biopsies rénales non ciblées et de dégager les domaines d'amélioration. Conception: Cet essai a été conçu comme un audit clinique du taux d'adéquation des échantillons de biopsies rénales non ciblées provenant de 13 hôpitaux. Il comporte également un questionnaire destiné au personnel des services de radiologie et de pathologie portant sur les pratiques actuelles entourant les biopsies rénales. Cadre: Analyze rétrospective de 2 188 biopsies rénales natives réalisées chez des patients adultes dans 13 hôpitaux entre le 1er janvier 2018 et le 9 septembre 2021. Sujets: Ont été inclus les adultes atteints d'une pathologie rénale médicale ayant subi une biopsie rénale non ciblée. Méthodologie: Nous avons procédé à une analyze rétrospective de 2 188 biopsies rénales natives réalisées chez des patients adultes dans 13 hôpitaux entre le 1er janvier 2018 et le 9 septembre 2021. L'adéquation a été classée en 4 catégories en fonction du nombre de glomérules reçus: parfaitement adéquate (25 glomérules et plus), minimalement adéquate (15 à 24 glomérules), sous-optimale (moins de 15 glomérules + diagnostic rendu), inadéquate (moins de 15 glomérules sans diagnostic rendu). Deux objectifs ont été établis: obtenir un taux d'adéquation combiné « sous-optimale + inadéquate ¼ de 10 % ou moins (objectif 1) et obtenir au moins 80 % d'adéquation « parfaite ¼ (objectif 2). Les chefs des services de radiologie de la province ont été interrogés sur l'équipement de biopsie, la technique, le soutien des technologues et la faisabilité des interventions possibles visant à améliorer l'adéquation des biopsies. Le personnel des services de pathologie a été interrogé sur sa formation et son expérience. Résultats: Les taux d'adéquation étaient les suivants: parfaitement adéquate = 64,7 %; minimalement adéquate = 26,0 %; sous-optimale = 7,9 %; inadéquate = 1,4 %. Pour les biopsies natives, avec un taux de 9,3 %, la province (et 8 des 13 hôpitaux) a atteint l'objectif 1. Deux hôpitaux ont atteint l'objectif 2. Une des principales observations a été qu'il n'y avait aucun technologue présent lors de la biopsie dans les deux hôpitaux qui avaient obtenu les moins bons résultats pour l'objectif 1. Limites: Les données de l'enquête ont été utilisées pour évaluer la technique de biopsie dans chaque hôpital; la technique précise utilisée pour chaque biopsie n'a pas été consignée. Par conséquent, il n'était pas possible de réaliser une analyze statistique multivariée des taux d'adéquation des échantillons. Les données sur les complications n'ont pas été recueillies. Conclusion: Avant l'intervention la province atteignait déjà l'objectif de limiter des biopsies natives inadéquates et sous-optimales. Le taux d'adéquation jugé « parfaitement adéquat ¼ était nettement inférieur à l'objectif proposé. Les données de l'enquête ont permis d'identifier les interventions dont l'impact escompté est le plus important; celles qui sont réalisables compte tenu des ressources limitées seront mises en œuvre afin d'améliorer l'adéquation des échantillons.

Diastereoselective Synthesis of Cyclopropanes from Carbon Pronucleophiles and Alkenes.

Cyclopropanes are desirable structural motifs with valuable applications in drug discovery and beyond. Established alkene cyclopropanation methods give rise to cyclopropanes with a limited array of substituents, are difficult to scale, or both. Herein, we disclose a new cyclopropane synthesis through the formal coupling of abundant carbon pronucleophiles and unactivated alkenes. This strategy exploits dicationic adducts derived from electrolysis of thianthrene in the presence of alkene substrates. We find that these dielectrophiles undergo cyclopropanation with methylene pronucleophiles via alkenyl thianthrenium intermediates. This protocol is scalable, proceeds with high diastereoselectivity, and tolerates diverse functional groups on both the alkene and pronucleophile coupling partners. To validate the utility of this new procedure, we prepared an array of substituted analogs of an established cyclopropane that is en route to multiple pharmaceuticals.

What's new in the hot gallbladder: the evolving radiologic diagnosis and management of acute cholecystitis.

Acute cholecystitis (AC) is a common condition and its incidence is rising. New technologies have advanced the imaging diagnosis of AC, providing more structural and functional information as well as allowing the radiologist to distinguish AC from mimics and identify complications from both the disease and its management. Dual energy CT aids in detecting gallstones and gallbladder wall enhancement, which helps to diagnose AC and identify its complications. Similarly, contrast-enhanced and non-contrast perfusion ultrasound techniques improve detection of abnormal gallbladder wall enhancement. Advances in MR imaging including hepatobiliary contrast agents aid in characterizing post-cholecystectomy complications such as bile leaks. Newer interventional techniques have also expanded the suite of options for minimally invasive management. Lumen apposing metal stents provide more options for conservative treatment in non-surgical candidates and are compared to a standard percutaneous cholecystostomy. Radiologists should be familiar with these advanced imaging methods and intervention techniques and the value they can bring to the diagnosis and management of AC.

Specialist care of children with complex needs: Insights from comparison of child development and child mental health clinics.

AIM: Paediatricians and child psychiatrists review children with complex comorbidity, noting similarities between tertiary Child Development Service (CDS) and Child and Youth Mental Health Service (CYMHS) cohorts. Mental health comorbidity is common in developmental services. Developmental comorbidity in mental health cohorts is uncharacterised. The study aimed to describe CDS and CYMHS cohorts using measures of child development, mental health, physical health and psychosocial risk. METHODS: A questionnaire was completed by parents of CDS and CYMHS new clients aged 4-11. It included measures of mental health symptoms, child development, physical health, stressful life events, family functioning, parent mental health and socio-economic variables. Sample rates were compared to population norms. CDS and CYMHS cohorts were compared. RESULTS: The study population had elevated rates of psychosocial risk, family dysfunction, physical illness, developmental risk and mental health symptoms. CDS had higher levels of developmental risk and family dysfunction. Most CDS clients (81%) had mental health difficulties. CYMHS clients were older, and had more mental health symptoms, stressful life events and child safety contact; 81% of CYMHS clients demonstrated developmental risk. CDS and CYMHS had similar socio-demographic profiles and parent mental health difficulties, and similarly high rates of physical health problems. CONCLUSIONS: Consideration should be given to mental health screening and support in CDS, and to developmental screening in CYMHS. Both services support at-risk children with complex developmental, mental health and physical co-morbidity necessitating shared approaches to clinical and population health, including care integration, and collaborative cross-disciplinary models of service provision and training, and advocacy.

Species-specific reservoir effect estimates: A case study of archaeological marine samples from the Bering Strait.

Due to the marine reservoir effect, radiocarbon dates of marine samples require a correction. Marine reservoir effects, however, may vary among different marine species within a given body of water. Factors such as diet, feeding depth and migratory behaviour all affect the 14C date of a marine organism. Moreover, there is often significant variation within single marine species. Whilst the careful consideration of the ΔR values of a single marine species in a given location is important, so too is the full range of ΔR values within an ecosystem. This paper illustrates this point, using a sample pairing method to estimate the reservoir effects in 17 marine samples, of eight different species, from the archaeological site of Ekven (Eastern Chukotka, Siberia). An OxCal model is used to assess the strength of these estimates. The marine reservoir effects of samples passing the model range from ΔR (Marine20) = 136 ± 41-ΔR = 460 ± 40. Marine reservoir effect estimates of these samples and other published samples are used to explore variability in the wider Bering Strait region. The archaeological implications of this variability are also discussed. The calibrating of 14C dates from human bone collagen, for example, could be improved by applying a dietary relevant marine reservoir effect correction. For humans from the site of Ekven, a ΔR (Marine20) correction of 289 ± 124 years or reservoir age correction of 842 ± 123 years is suggested.

Peak frequency of the sensorimotor mu rhythm varies with autism-spectrum traits.

Autism spectrum disorder (ASD) is a neurodevelopmental syndrome characterized by impairments in social perception and communication. Growing evidence suggests that the relationship between deficits in social perception and ASD may extend into the neurotypical population. In electroencephalography (EEG), high autism-spectrum traits in both ASD and neurotypical samples are associated with changes to the mu rhythm, an alpha-band (8-12 Hz) oscillation measured over sensorimotor cortex which typically shows reductions in spectral power during both one's own movements and observation of others' actions. This mu suppression is thought to reflect integration of perceptual and motor representations for understanding of others' mental states, which may be disrupted in individuals with autism-spectrum traits. However, because spectral power is usually quantified at the group level, it has limited usefulness for characterizing individual variation in the mu rhythm, particularly with respect to autism-spectrum traits. Instead, individual peak frequency may provide a better measure of mu rhythm variability across participants. Previous developmental studies have linked ASD to slowing of individual peak frequency in the alpha band, or peak alpha frequency (PAF), predominantly associated with selective attention. Yet individual variability in the peak mu frequency (PMF) remains largely unexplored, particularly with respect to autism-spectrum traits. Here we quantified peak frequency of occipitoparietal alpha and sensorimotor mu rhythms across neurotypical individuals as a function of autism-spectrum traits. High-density 128-channel EEG data were collected from 60 participants while they completed two tasks previously reported to reliably index the sensorimotor mu rhythm: motor execution (bimanual finger tapping) and action observation (viewing of whole-body human movements). We found that individual measurement in the peak oscillatory frequency of the mu rhythm was highly reliable within participants, was not driven by resting vs. task states, and showed good correlation across action execution and observation tasks. Within our neurotypical sample, higher autism-spectrum traits were associated with slowing of the PMF, as predicted. This effect was not likely explained by volume conduction of the occipitoparietal PAF associated with attention. Together, these data support individual peak oscillatory alpha-band frequency as a correlate of autism-spectrum traits, warranting further research with larger samples and clinical populations.

Treatment with IgM-enriched intravenous immunoglobulins enhances clearance of stroke-associated bacterial lung infection.

Post-stroke infection is a common complication of stroke that is associated with poor outcome. We previously reported that stroke induces an ablation of multiple sub-populations of B cells and reduces levels of immunoglobulin M (IgM) antibody, which coincides with the development of spontaneous bacterial pneumonia. The loss of IgM after stroke could be an important determinant of infection susceptibility and highlights this pathway as a target for intervention. We treated mice with a replacement dose of IgM-enriched intravenous immunoglobulin (IgM-IVIg) prior to and 24 h after middle cerebral artery occlusion (MCAO) and allowed them to recover for 2- or 5-day post-surgery. Treatment with IgM-IVIg enhanced bacterial clearance from the lung after MCAO and improved lung pathology but did not impact brain infarct volume. IgM-IVIg treatment induced immunomodulatory effects systemically, including rescue of splenic plasma B cell numbers and endogenous mouse IgM and IgA circulating immunoglobulin concentrations that were reduced by MCAO. Treatment attenuated MCAO-induced elevation of selected pro-inflammatory cytokines in the lung. IgM-IVIg treatment did not increase the number of lung mononuclear phagocytes or directly modulate macrophage phagocytic capacity but enhanced phagocytosis of Staphylococcus aureus bioparticles in vitro. Low-dose IgM-IVIg contributes to increased clearance of spontaneous lung bacteria after MCAO likely via increasing availability of antibody in the lung to enhance opsonophagocytic activity. Immunomodulatory effects of IgM-IVIg treatment may also contribute to reduced levels of damage in the lung after MCAO. IgM-IVIg shows promise as an antibacterial and immunomodulatory agent to use in the treatment of post-stroke infection.

An unusual cause of pericardial effusion: A case report of a hepatic abscess following foreign body migration and duodenal perforation.

INTRODUCTION AND IMPORTANCE: Although foreign bodies are a rare cause of gastrointestinal tract perforation, they may serve as a nidus for hepatic abscess. Abdominal pain is the most common presenting symptom. We present a case of an ingested pen causing duodenal perforation and hepatic abscess several months after initially presenting with a pericardial effusion. CASE PRESENTATION: A 59-year-old female living in an intensive tertiary mental health facility was noted to have an incidental pericardial effusion during work-up for hyponatremia. Seven months later, she developed a new fever and was noted to have interval increase in the pericardial effusion size. This prompted further investigation which finally revealed that an ingested pen had perforated through the first part of the duodenum and caused an abscess in the left lobe of the liver. The pericardial effusion was presumed secondary to local inflammation. Upon discovery of the abscess, the patient underwent successful operative management including abscess drainage, foreign body extraction, and duodenal repair. CLINICAL DISCUSSION: Reports of hepatic abscess from foreign body causing duodenal perforation are rare, with bone fragments and toothpicks the most common foreign bodies implicated. There is one other previously reported case of an ingested pen. Abdominal pain is present in up to 85% of cases, but fever may be the only presenting symptom. CONCLUSION: Foreign body migration causing a hepatic abscess may present non-specifically with unexplained fever or even pericardial effusion. Psychiatric comorbidities may contribute to delays in diagnosis due to difficulties recalling the episode of ingestion.

A modern baseline for the paired isotopic analysis of skin and bone in terrestrial mammals.

We present the isotopic discrimination between paired skin and bone collagen from animals of known life history, providing a modern baseline for the interpretation of archaeological isotopic data. At present, the interpretation of inter-tissue variation (Δ(skin-bone)) in mummified remains is based on comparisons with other archaeological material, which have attributed divergence to their contrasting turnover rates, with rapidly remodelling skin collagen incorporating alterations in environmental, cultural and physiological conditions in the months prior to death. While plausible, the lack of baseline data from individuals with known life histories has hindered evaluation of the explanations presented. Our analysis of a range of animals raised under a variety of management practices showed a population-wide trend for skin collagen to be depleted in 13C by -0.7‰ and enriched in 15N by +1.0‰ relative to bone collagen, even in stillborn animals. These results are intriguing and difficult to explain using current knowledge; however, on the basis of the findings reported here, we caution any results which interpret simply on differing turnover rates. We hypothesize that there may be a consistent difference in the routing of dietary protein and lipids between skin and bone, with potentially on-site synthesis of non-essential amino acids using carbon and nitrogen that have been sourced via different biochemical pathways.

Second-opinion reads in prostate MRI: added value of subspecialty interpretation and review at multidisciplinary rounds.

PURPOSE: This study evaluates the impact of second-opinion review of multiparametric prostate MRI for cancer detection by a multidisciplinary review board at a tertiary care center when compared with the initial community radiologist interpretation. METHODS: Cases were collected retrospectively from multidisciplinary prostate MRI rounds from 2017 to 2020 at a single tertiary care center. Patients with suspected prostate cancer or on active surveillance were referred for consideration of TRUS/MRI-fusion biopsy based on community-read prostate MRIs. All MRIs were re-read by subspecialized abdominal radiologists and a PI-RADS score assigned. Targeted fusion and 8-12 core systematic biopsy was performed in patients with PIRADS ≥ 3 lesions. Cohen kappa values were used to quantify interobserver agreement. Positive predictive value (PPV) was used to determine accuracy of PI-RADS score for detection of clinically significant prostate cancer (csPCa) (ISUP Grade Group ≥ 2). RESULTS: Three hundred and thirty-two lesions in 303 patients were reviewed and 252 lesions in 198 patients biopsied. The PI-RADS score was concordant in 60.5% of lesions, downgraded in 17.8%, and upgraded in 7.8%. Agreement between community and tertiary center interpretation was fair (κ = 0.354), with greater agreement for PI-RADS ≥ 4 (κ = 0.523) than PI-RADS ≥ 3 (κ = 0.456), and peripheral zone (κ = 0.419) than transition zone lesions (κ = 0.251). Prevalence of csPCa in biopsied lesions was 40.9%. CONCLUSION: There is variability in community and tertiary care center interpretation of prostate MRI in cancer detection, with higher concordance rates for higher grade and peripheral zone lesions. These differences demonstrate the added value of multidisciplinary round review and highlight the need for ongoing education and feedback.

Temporal dynamics of decision making: A synthesis of computational and neurophysiological approaches.

As interest in the temporal dynamics of decision-making has grown, researchers have increasingly turned to computational approaches such as the drift diffusion model (DDM) to identify how cognitive processes unfold during choice. At the same time, technological advances in noninvasive neurophysiological methods such as electroencephalography and magnetoencephalography now allow researchers to map the neural time course of decision making with millisecond precision. Combining these approaches can potentially yield important new insights into how choices emerge over time. Here we review recent research on the computational and neurophysiological correlates of perceptual and value-based decision making, from DDM parameters to scalp potentials and oscillatory neural activity. Starting with motor response preparation, the most well-understood aspect of the decision process, we discuss evidence that urgency signals and shifts in baseline activation, rather than shifts in the physiological value of the choice-triggering response threshold, are responsible for adjusting response times under speeded choice scenarios. Research on the neural correlates of starting point bias suggests that prestimulus activity can predict biases in motor choice behavior. Finally, studies examining the time dynamics of evidence construction and evidence accumulation have identified signals at frontocentral and centroparietal electrodes associated respectively with these processes, emerging 300-500 ms after stimulus onset. These findings can inform psychological theories of decision-making, providing empirical support for attribute weighting in value-based choice while suggesting theoretical alternatives to dual-process accounts. Further research combining computational and neurophysiological approaches holds promise for providing greater insight into the moment-by-moment evolution of the decision process. This article is categorized under: Psychology > Reasoning and Decision Making Neuroscience > Cognition Economics > Individual Decision-Making.

Distinct Patterns of P1 and C2 VEP Potentiation and Attenuation in Visual Snow: A Case Report.

Visual snow syndrome, characterized by persistent flickering dots throughout the visual field, has been hypothesized to arise from abnormal neuronal responsiveness in visual processing regions. Previous research has reported a lack of typical VEP habituation to repeated stimulus presentation in patients with visual snow. Yet these studies generally used pattern-reversal paradigms, which are suboptimal for measuring cortical responses to the onset of foveal stimulation. Instead, these responses are better indexed by the C2, a pattern-onset VEP peaking 100-120 ms after stimulus onset. In this case study, we analyzed the C2 and its adaptation profile in data previously collected from a single patient with visual snow using a "double-pulse" presentation paradigm. In controls, shorter intervals between stimulus pairs were associated with greater attenuation of the C2 VEP, with recovery from adaptation at longer stimulus onset asynchronies (SOAs). However, the visual snow patient showed the opposite pattern, with reduced C2 amplitude at longer SOAs despite distinct C2 peaks at the shortest SOAs. These results stand in contrast not only to the pattern of C2 VEP attenuation in controls, but also to a lack of adaptation previously reported for the pattern-onset P1 VEP in this patient. Exploratory source localization using equivalent current dipole fitting further suggested that P1 and C2 VEPs in the visual snow patient arose from distinct sources in extrastriate visual cortex. While preliminary, these results support differential patterns of VEP attenuation and potentiation within the same individual, potentially pointing toward multiple mechanisms of abnormal neuronal responsiveness in visual snow syndrome.

High-resolution dietary reconstruction of victims of the 79 CE Vesuvius eruption at Herculaneum by compound-specific isotope analysis.

The remains of those who perished at Herculaneum in 79 CE offer a unique opportunity to examine lifeways across an ancient community who lived and died together. Historical sources often allude to differential access to foodstuffs across Roman society but provide no direct or quantitative information. By determining the stable isotope values of amino acids from bone collagen and deploying Bayesian models that incorporate knowledge of protein synthesis, we were able to reconstruct the diets of 17 adults from Herculaneum with unprecedented resolution. Significant differences in the proportions of marine and terrestrial foods consumed were observed between males and females, implying that access to food was differentiated according to gender. The approach also provided dietary data of sufficient precision for comparison with assessments of food supply to modern populations, opening up the possibility of benchmarking ancient diets against contemporary settings where the consequences for health are better understood.

SBRT for HCC: Overview of technique and treatment response assessment.

Stereotactic body radiation therapy (SBRT) is an emerging locoregional treatment (LRT) modality used in the management of patients with hepatocellular carcinoma (HCC). The decision to treat HCC with LRT is evaluated in a multidisciplinary setting, and the specific LRT chosen depends on the treatment intent, such as bridge-to-transplant, down-staging to transplant, definitive/curative treatment, and/or palliation, as well as underlying patient clinical factors. Accurate assessment of treatment response is necessary in order to guide clinical management in these patients. Patients who undergo LRT need continuous imaging evaluation to assess treatment response and to evaluate for recurrence. Thus, an accurate understanding of expected post-SBRT imaging findings is critical to avoid misinterpreting normal post-treatment changes as local progression or viable tumor. SBRT-treated HCC demonstrates unique imaging findings that differ from HCC treated with other forms of LRT. In particular, SBRT-treated HCC can demonstrate persistent APHE and washout on short-term follow-up imaging. This brief review summarizes current evidence for the use of SBRT for HCC, including patient population, SBRT technique and procedure, tumor response assessment on contrast-enhanced cross-sectional imaging with expected findings, and pitfalls in treatment response evaluation.

Weighting on waiting: Willpower and attribute weighting models of decision making.

Willpower is often conceptualized as incorporating effortful and momentary suppression of immediate but ultimately inferior rewards. Yet, growing evidence instead supports a process of attribute weighting, whereby normatively optimal choices arise from separable evaluation of different attributes (e.g., time and money). Strategic allocation of attention settles conflicts between competing choice-relevant attributes, which could be expanded to include self-referential predictions ("resolve").