MRI of Benign Prostatic Hyperplasia: Important Pre- and Posttherapeutic Considerations.

New minimally invasive techniques that reduce morbidity while improving lower urinary tract symptoms (LUTS) due to benign prostatic hypertrophy (BPH) have become attractive alternatives for patients, in comparison to traditional techniques such as transurethral resection of the prostate (TURP) and simple prostatectomy. Pre- and postprocedural MRI is not routinely performed for LUTS due to BPH treatments. However, because of the combination of rapidly evolving treatments available for LUTS due to BPH and increasing demand for prebiopsy prostate MRI for detection of clinically significant prostate cancer (PCa), an understanding of procedural techniques and expected changes are important for accurate interpretation of prostate MRI performed after treatment of BPH. The authors discuss the imaging evaluation of LUTS due to BPH and emerging predictors of treatment success. The posttreatment appearance and underlying anatomic changes in the prostate after medical, surgical, and minimally invasive treatments including TURP, simple prostatectomy, laser enucleations and ablations, prostatic urethral lift, water vapor thermal therapy, and prostate artery embolization are detailed. Most procedures reduce prostate volume, notably in the periurethral prostatic tissue. Ablations create areas of necrosis and can distort the normal zonal anatomy between the transition zone and the peripheral zone, and prostate artery embolization creates infarcts in the transition zone. Mechanical prostatic urethral lift devices open the anterior channel at the bladder base but create susceptibility artifacts that can obscure and prevent detection of a lesion in the transition zone. Also discussed are the detection of clinically significant prostate cancer in the postprocedural prostate and imaging of BPH procedure complications such as urethral strictures, abscesses, and hematuria. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material. See the invited commentary by Purysko in this issue.

Anomalous Circumrenal Inferior Vena Cava Associated With Horseshoe Kidney.

A 69-year-old male presented with periumbilical pain radiating across his abdomen, with associated nausea and emesis. CT imaging of his abdomen and pelvis revealed calculi in the right and left ureterovesical junctions with hydroureteronephrosis bilaterally. Furthermore, the imaging revealed that the patient had a horseshoe kidney with an associated anomalous inferior vena cava (IVC) that split superiorly to the horseshoe kidney at the L1 level and rejoined inferior to the horseshoe kidney at the L5 level. The IVC took on a "circumrenal" course, as it traversed the right kidney with an anterior and posterior portion. Furthermore, the patient's right ureter was compressed between the anterior portion of the IVC and the right kidney. We hypothesize that the development of the horseshoe kidney around the 7 to 8th week of gestation created a path of resistance for the forming of IVC around the same time. While surgical correction is not warranted, recognition of this circumrenal IVC variant could have major implications for planning of procedures, such as IVC filter placement.

Reasons for Guideline Nonadherence at Heart Failure Discharge.

Background Cardiology has advanced guideline development and quality measurement. Recognizing the substantial benefits of guideline-directed medical therapy, this study aims to measure and explain apparent deviations in heart failure ( HF ) guideline adherence by clinicians at hospital discharge and describe any impact on readmission rates. Methods and Results The extent of decongestion and prescription of neurohormonal therapy were recorded prospectively for 226 HF discharges, including 132 (58%) from an academic hospital and 94 (42%) from a community hospital. Among all discharges, 25% were discharged with residual congestion (30% academic versus 18% community, P=0.070). Among discharges of patients with HF with reduced ejection fraction, 37% (45% academic versus 18% community, P<0.001) were discharged without ß-blocker therapy or with lower doses than at admission. Moreover, 46% of patients with HF with reduced ejection fraction (48% academic versus 39% community, P=0.390) were discharged without an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker or with lower doses than at admission. Renal dysfunction was the most common reason for discharge with congestion, and hypotension the most common reason for discharge with no or decreased neurohormonal therapy. There was a trend toward higher 90-day readmission rates after discharge with residual congestion. Conclusions Clinicians frequently deviate from guidelines in both academic and community hospitals; however, this deviation may not always indicate poor quality. Application of guidelines recommended for stable populations is increasingly limited for hospitalized patients by hypotension, renal dysfunction, and inotrope use. Patients with renal dysfunction, hypotension, and recent inotrope use merit further study to determine best practices and possibly to adjust quality metrics for HF severity.

Biomusic: An Auditory Interface for Detecting Physiological Indicators of Anxiety in Children.

For children with profound disabilities affecting communication, it can be extremely challenging to identify salient emotions such as anxiety. If left unmanaged, anxiety can lead to hypertension, cardiovascular disease, and other psychological diagnoses. Physiological signals of the autonomic nervous system are indicative of anxiety, but can be difficult to interpret for non-specialist caregivers. This paper evaluates an auditory interface for intuitive detection of anxiety from physiological signals. The interface, called "Biomusic," maps physiological signals to music (i.e., electrodermal activity to melody; skin temperature to musical key; heart rate to drum beat; respiration to a "whooshing" embellishment resembling the sound of an exhalation). The Biomusic interface was tested in two experiments. Biomusic samples were generated from physiological recordings of typically developing children (n = 10) and children with autism spectrum disorders (n = 5) during relaxing and anxiety-provoking conditions. Adult participants (n = 16) were then asked to identify "anxious" or "relaxed" states by listening to the samples. In a classification task with 30 Biomusic samples (1 relaxed state, 1 anxious state per child), classification accuracy, sensitivity, and specificity were 80.8% [standard error (SE) = 2.3], 84.9% (SE = 3.0), and 76.8% (SE = 3.9), respectively. Participants were able to form an early and accurate impression of the anxiety state within 12.1 (SE = 0.7) seconds of hearing the Biomusic with very little training (i.e., < 10 min) and no contextual information. Biomusic holds promise for monitoring, communication, and biofeedback systems for anxiety management.

Dual optical recordings for action potentials and calcium handling in induced pluripotent stem cell models of cardiac arrhythmias using genetically encoded fluorescent indicators.

Reprogramming of human somatic cells to pluripotency has been used to investigate disease mechanisms and to identify potential therapeutics. However, the methods used for reprogramming, in vitro differentiation, and phenotyping are still complicated, expensive, and time-consuming. To address the limitations, we first optimized a protocol for reprogramming of human fibroblasts and keratinocytes into pluripotency using single lipofection and the episomal vectors in a 24-well plate format. This method allowed us to generate multiple lines of integration-free and feeder-free induced pluripotent stem cells (iPSCs) from seven patients with cardiac diseases and three controls. Second, we differentiated human iPSCs derived from patients with Timothy syndrome into cardiomyocytes using a monolayer differentiation method. We found that Timothy syndrome cardiomyocytes showed slower, irregular contractions and abnormal calcium handling compared with the controls. The results are consistent with previous reports using a retroviral method for reprogramming and an embryoid body-based method for cardiac differentiation. Third, we developed an efficient approach for recording the action potentials and calcium transients simultaneously in control and patient cardiomyocytes using genetically encoded fluorescent indicators, ArcLight and R-GECO1. The dual optical recordings enabled us to observe prolonged action potentials and abnormal calcium handling in Timothy syndrome cardiomyocytes. We confirmed that roscovitine rescued the phenotypes in Timothy syndrome cardiomyocytes and that these findings were consistent with previous studies using conventional electrophysiological recordings and calcium imaging with dyes. The approaches using our optimized methods and dual optical recordings will improve iPSC applicability for disease modeling to investigate mechanisms underlying cardiac arrhythmias and to test potential therapeutics.

The role of the sphingosine-1-phosphate signaling pathway in osteocyte mechanotransduction.

Osteocytes are proposed to be the mechanosensory cells that translate mechanical loading into biochemical signals during the process of bone adaptation. The lipid mediator sphingosine-1-phosphate (S1P) has been reported to play a role in the mechanotransduction process of blood vessels and also in the dynamic control of bone mineral homeostasis. Nevertheless, the potential role of S1P in bone mechanotransduction has yet to be elucidated. In this study, we hypothesized that a S1P cascade is involved in the activation of osteocytes in response to loading-induced oscillatory fluid flow (OFF) in bone. MLO-Y4 osteocyte-like cells express the necessary components of a functional S1P cascade. To examine the involvement of S1P signaling in osteocyte mechanotransduction, we applied OFF (1 Pa, 1 Hz) to osteocyte-like MLO-Y4 cells under conditions where the S1P signaling pathway was modulated. We found that decreased endogenous S1P levels significantly suppressed the OFF-induced intracellular calcium response. Addition of extracellular S1P to MLO-Y4 cells enhanced the synthesis and release of prostaglandin E2 (PGE2) under static cells and amplified OFF-induced PGE2 release. The stimulatory effect of OFF on the gene expression levels of osteoprotegerin (OPG) and receptor activator for nuclear factor κB ligand (RANKL) was S1P dependent. Furthermore, the S1P2 receptor subtype was shown to be involved in OFF-induced PGE2 synthesis and release, as well as down-regulation of RANKL/OPG gene expression ratio. In summary, our data suggest that S1P cascade is involved in OFF-induced mechanotransduction in MLO-Y4 cells and that extracellular S1P exerts its effect partly through S1P2 receptors.

Development of Standardized Clinical Assessment and Management Plans (SCAMPs) in Plastic and Reconstructive Surgery.

BACKGROUND: With rising cost of healthcare, there is an urgent need for developing effective and economical streamlined care. In clinical situations with limited data or conflicting evidence-based data, there is significant institutional and individual practice variation. Quality improvement with the use of Standardized Clinical Assessment and Management Plans (SCAMPs) might be beneficial in such scenarios. The SCAMPs method has never before been reported to be utilized in plastic surgery. METHODS: The topic of immediate breast reconstruction was identified as a possible SCAMPs project. The initial stages of SCAMPs development, including planning and implementation, were entered. The SCAMP Champion, along with the SCAMPs support team, developed targeted data statements. The SCAMP was then written and a decision-tree algorithm was built. Buy-in was obtained from the Division of Plastic Surgery and a SCAMPs data form was generated to collect data. RESULTS: Decisions pertaining to "immediate implant-based breast reconstruction" were approved as an acceptable topic for SCAMPs development. Nine targeted data statements were made based on the clinical decision points within the SCAMP. The SCAMP algorithm, and the SDF, required multiple revisions. Ultimately, the SCAMP was effectively implemented with multiple iterations in data collection. CONCLUSIONS: Full execution of the SCAMP may allow better-defined selection criteria for this complex patient population. Deviations from the SCAMP may allow for improvement of the SCAMP and facilitate consensus within the Division. Iterative and adaptive quality improvement utilizing SCAMPs creates an opportunity to reduce cost by improving knowledge about best practice.