US Markers and Necroinflammation, Steatosis, and Fibrosis in Metabolic Dysfunction-associated Steatotic Liver Disease: The iLEAD Study.

Background Attenuation coefficient (AC) and shear-wave speed (SWS) are established US markers for assessing patients with metabolic dysfunction-associated steatotic liver disease (MASLD), while shear-wave dispersion slope (DS) is not. Purpose To assess the relationship between the multiparametric US imaging markers DS, AC, and SWS and liver histopathologic necroinflammation in patients with MASLD. Materials and Methods This international multicenter prospective study enrolled consecutive patients with biopsy-proven MASLD between June 2019 and March 2023. Before biopsy, all participants underwent multiparametric US, and measurements of DS, AC, and SWS were obtained. Multivariable linear regression analyses were performed to assess the association of clinical variables and imaging markers with pathologic findings. The diagnostic performance of imaging markers for determining inflammation grade, steatosis grade, and fibrosis stage was assessed using the area under the receiver operating characteristic curve (AUC). Results A total of 124 participants (mean age, 53 years ± 15 [SD]; 62 males) were evaluated. In multivariable regression, lobular inflammation was associated with DS (regression coefficient, 0.06; P = .02), alanine aminotransferase level (regression coefficient, 0.002; P = .002), and Hispanic or Latino ethnicity (regression coefficient, -0.68; P = .047), while steatosis was associated with AC (regression coefficient, 3.66; P < .001) and fibrosis was associated with SWS (regression coefficient, 2.02; P < .001) and body mass index (regression coefficient, 0.05; P = .02). DS achieved an AUC of 0.72 (95% CI: 0.63, 0.82) for identifying participants with inflammation grade A2 or higher (moderate to severe inflammation). AC showed excellent performance for identifying participants with grade S1 (mild) or higher steatosis (AUC, 0.92 [95% CI: 0.87, 0.97]), while SWS showed excellent performance for identifying participants with fibrosis stage F2 or higher (clinically significant fibrosis) (AUC, 0.91 [95% CI: 0.86, 0.96]). Of the three US markers, SWS showed the highest AUC (0.81 [95% CI: 0.74, 0.89]) for the diagnosis of metabolic dysfunction-associated steatohepatitis. Conclusion Of the three US imaging markers (DS, AC, and SWS), DS was most associated with lobular inflammation grade at histologic examination and demonstrated fair diagnostic performance in distinguishing moderate to severe lobular inflammation. ClinicalTrials.gov Identifier: NCT04012242 Published under a CC BY 4.0 license. Supplemental material is available for this article. See also the editorial by Yin in this issue.

Microplastic Particles Contain Ice Nucleation Sites That Can Be Inhibited by Atmospheric Aging.

Recent research has shown that microplastics are widespread in the atmosphere. However, we know little about their ability to nucleate ice and their impact on ice formation in clouds. Ice nucleation by microplastics could also limit their long-range transport and global distribution. The present study explores the heterogeneous ice-nucleating ability of seven microplastic samples in immersion freezing mode. Two polypropylene samples and one polyethylene terephthalate sample froze heterogeneously with median freezing temperatures of -20.9, -23.2, and -21.9 °C, respectively. The number of ice nucleation sites per surface area, ns(T), ranged from 10-1 to 104 cm-2 in a temperature interval of -15 to -25 °C, which is comparable to that of volcanic ash and fungal spores. After exposure to ozone or a combination of UV light and ozone, simulating atmospheric aging, the ice nucleation activity decreased in some cases and remained unchanged in others. Our freezing data suggest that microplastics may promote ice formation in cloud droplets. In addition, based on a comparison of our freezing results and previous simulations using a global transport model, ice nucleation by microplastics will impact their long-range transport to faraway locations and global distribution.

Professionalization of Clinical Ethics Consultants: A Need for Liability Protection?

Clinical Ethics Consultation (CEC) has grown significantly in the last decade, and efforts are being made to professionalize the practice. The American Society for Bioethics and Humanities (ASBH) has been instrumental in this process, having published the Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants and founded and endorsed the creation of the Healthcare Ethics Consultant Certified (HCEC) Certification Commission. The ASBH also published "core competencies" for healthcare ethics consultants and has delineated a clear identity and role of such consultants distinct from that other healthcare professionals. In addition, more enter the field armed with advanced degrees (MA and PhD) or certification in clinical ethics consultation. While some have questioned the trend toward professionalization, the momentum is clearly in its favor. This paper explores three questions: Does the professionalization of healthcare ethics consultation expose those engaged in the field to the types of liability claims faced by professionals in other fields? What specific liabilities could affect a healthcare ethics consultant? And finally, what should healthcare ethics consultants do to protect themselves against liability claims? We conclude that while the risk of liability remains low, those engaged in the field should accept that risk just as part of their status as professionals and, like those in allied professions, seek appropriate protection in the form of liability insurance.

Catalyst Aggregation Matters for Immobilized Molecular CO2RR Electrocatalysts.

Here, we detail how the catalytic behavior of immobilized molecular electrocatalysts for the CO2 reduction reaction (CO2RR) can be impacted by catalyst aggregation. Operando Raman spectroscopy was used to study the CO2RR mediated by a layer of cobalt phthalocyanine (CoPc) immobilized on the cathode of an electrochemical flow reactor. We demonstrate that during electrolysis, the oxidation state of CoPc in the catalyst layer is dependent upon the degree of catalyst aggregation. Our data indicate that immobilized molecular catalysts must be dispersed on conductive supports to mitigate the formation of aggregates and produce meaningful performance data. We leveraged insights from this mechanistic study to engineer an improved CO-forming immobilized molecular catalyst─cobalt octaethoxyphthalocyanine (EtO8-CoPc)─that exhibited high selectivity (FECO ≥ 95%), high partial current density (JCO ≥ 300 mA/cm2), and high durability (ΔFECO < 0.1%/h at 150 mA/cm2) in a flow cell. This work demonstrates how to accurately identify CO2RR active species of molecular catalysts using operando Raman spectroscopy and how to use this information to implement improved molecular electrocatalysts into flow cells. This work also shows that the active site of CoPc during CO2RR catalysis in a flow cell is the metal center.

Machine Learning Analysis of Raman Spectra To Quantify the Organic Constituents in Complex Organic-Mineral Mixtures.

Important decisions in local agricultural policy and practice often hinge on the soil's chemical composition. Raman spectroscopy offers a rapid noninvasive means to quantify the constituents of complex organic systems. But the application of Raman spectroscopy to soils presents a multifaceted challenge due to organic/mineral compositional complexity and spectral interference arising from overwhelming fluorescence. The present work compares methodologies with the capacity to help overcome common obstacles that arise in the analysis of soils. We created conditions representative of these challenges by combining varying proportions of six amino acids commonly found in soils with fluorescent bentonite clay and coarse mineral components. Referring to an extensive data set of Raman spectra, we compare the performance of the convolutional neural network (CNN) and partial least-squares regression (PLSR) multivariate models for amino acid composition. Strategies employing volume-averaged spectral sampling and data preprocessing algorithms improve the predictive power of these models. Our average test R2 for PLSR models exceeds 0.89 and approaches 0.98, depending on the complexity of the matrix, whereas CNN yields an R2 range from 0.91 to 0.97, demonstrating that classic PLSR and CNN perform comparably, except in cases where the signal-to-noise ratio of the organic component is very low, whereupon CNN models outperform. Artificially isolating two of the most prevalent obstacles in evaluating the Raman spectra of soils, we have characterized the effect of each obstacle on the performance of machine learning models in the absence of other complexities. These results highlight important considerations and modeling strategies necessary to improve the Raman analysis of organic compounds in complex mixtures in the presence of mineral spectral components and significant fluorescence.

International Expert Consensus on US Lexicon for Thyroid Nodules.

Multiple US-based systems for risk stratification of thyroid nodules are in use worldwide. Unfortunately, the malignancy probability assigned to a nodule varies, and terms and definitions are not consistent, leading to confusion and making it challenging to compare study results and craft revisions. Consistent application of these systems is further hampered by interobserver variability in identifying the sonographic features on which they are founded. In 2018, an international multidisciplinary group of 19 physicians with expertise in thyroid sonography (termed the International Thyroid Nodule Ultrasound Working Group) was convened with the goal of developing an international system, tentatively called the International Thyroid Imaging Reporting and Data System, or I-TIRADS, in two phases: (phase I) creation of a lexicon and atlas of US descriptors of thyroid nodules and (phase II) development of a system that estimates the malignancy risk of a thyroid nodule. This article presents the methods and results of phase I. The purpose herein is to show what has been accomplished thus far, as well as generate interest in and support for this effort in the global thyroid community.

Right ventricular epicardial arrhythmogenic substrate in long-QT syndrome patients at risk of sudden death.

AIMS: The long-QT syndrome (LQTS) represents a leading cause of sudden cardiac death (SCD). The aim of this study was to assess the presence of an underlying electroanatomical arrhythmogenic substrate in high-risk LQTS patients. METHODS AND RESULTS: The present study enrolled 11 consecutive LQTS patients who had experienced frequent implantable cardioverter-defibrillator (ICD discharges triggered by ventricular fibrillation (VF). We acquired electroanatomical biventricular maps of both endo and epicardial regions for all patients and analyzed electrograms sampled from several myocardial regions. Abnormal electrical activities were targeted and eliminated by the means of radiofrequency catheter ablation. VF episodes caused a median of four ICD discharges in eleven patients (6 male, 54.5%; mean age 44.0 ± 7.8 years, range 22-53) prior to our mapping and ablation procedures. The average QTc interval was 500.0 ± 30.2 ms. Endo-epicardial biventricular maps displayed abnormally fragmented, low-voltage (0.9 ± 0.2 mV) and prolonged electrograms (89.9 ± 24.1 ms) exclusively localized in the right ventricular epicardium. We found electrical abnormalities extending over a mean epicardial area of 15.7 ± 3.1 cm2. Catheter ablation of the abnormal epicardial area completely suppressed malignant arrhythmias over a mean 12 months of follow-up (median VF episodes before vs. after ablation, 4 vs. 0; P = 0.003). After the procedure, the QTc interval measured in a 12-lead ECG analysis shortened to a mean of 461.8 ± 23.6 ms (P = 0.004). CONCLUSION: This study reveals that, among high-risk LQTS patients, regions localized in the epicardium of the right ventricle harbour structural electrophysiological abnormalities. Elimination of these abnormal electrical activities successfully prevented malignant ventricular arrhythmia recurrences.

Improving the Efficacy of ACR TI-RADS Through Deep Learning-Based Descriptor Augmentation.

Thyroid nodules occur in up to 68% of people, 95% of which are benign. Of the 5% of malignant nodules, many would not result in symptoms or death, yet 600,000 FNAs are still performed annually, with a PPV of 5-7% (up to 30%). Artificial intelligence (AI) systems have the capacity to improve diagnostic accuracy and workflow efficiency when integrated into clinical decision pathways. Previous studies have evaluated AI systems against physicians, whereas we aim to compare the benefits of incorporating AI into their final diagnostic decision. This work analyzed the potential for artificial intelligence (AI)-based decision support systems to improve physician accuracy, variability, and efficiency. The decision support system (DSS) assessed was Koios DS, which provides automated sonographic nodule descriptor predictions and a direct cancer risk assessment aligned to ACR TI-RADS. The study was conducted retrospectively between (08/2020) and (10/2020). The set of cases used included 650 patients (21% male, 79% female) of age 53 ± 15. Fifteen physicians assessed each of the cases in the set, both unassisted and aided by the DSS. The order of the reading condition was randomized, and reading blocks were separated by a period of 4 weeks. The system's impact on reader accuracy was measured by comparing the area under the ROC curve (AUC), sensitivity, and specificity of readers with and without the DSS with FNA as ground truth. The impact on reader variability was evaluated using Pearson's correlation coefficient. The impact on efficiency was determined by comparing the average time per read. There was a statistically significant increase in average AUC of 0.083 [0.066, 0.099] and an increase in sensitivity and specificity of 8.4% [5.4%, 11.3%] and 14% [12.5%, 15.5%], respectively, when aided by Koios DS. The average time per case decreased by 23.6% (p = 0.00017), and the observed Pearson's correlation coefficient increased from r = 0.622 to r = 0.876 when aided by Koios DS. These results indicate that providing physicians with automated clinical decision support significantly improved diagnostic accuracy, as measured by AUC, sensitivity, and specificity, and reduced inter-reader variability and interpretation times.

Electronic State Population Dynamics upon Ultrafast Strong Field Ionization and Fragmentation of Molecular Nitrogen.

Air lasing from single ionized N_{2}^{+} molecules induced by laser filamentation in air has been intensively investigated and the mechanisms responsible for lasing are currently highly debated. We use ultrafast nitrogen K-edge spectroscopy to follow the strong field ionization and fragmentation dynamics of N_{2} upon interaction with an ultrashort 800 nm laser pulse. Using probe pulses generated by extreme high-order harmonic generation, we observe transitions indicative of the formation of the electronic ground X^{2}Σ_{g}^{+}, first excited A^{2}Π_{u}, and second excited B^{2}Σ_{u}^{+} states of N_{2}^{+} on femtosecond timescales, from which we can quantitatively determine the time-dependent electronic state population distribution dynamics of N_{2}^{+}. Our results show a remarkably low population of the A^{2}Π_{u} state, and nearly equal populations of the X^{2}Σ_{g}^{+} and B^{2}Σ_{u}^{+} states. In addition, we observe fragmentation of N_{2}^{+} into N and N^{+} on a timescale of several tens of picoseconds that we assign to significant collisional dynamics in the plasma, resulting in dissociative excitation of N_{2}^{+}.

Electrocatalysts Derived from Copper Complexes Transform CO into C2+ Products Effectively in a Flow Cell.

Electrochemical reactors that electrolytically convert CO2 into higher-value chemicals and fuels often pass a concentrated hydroxide electrolyte across the cathode. This strongly alkaline medium converts the majority of CO2 into unreactive HCO3 - and CO3 2- byproducts rather than into CO2 reduction reaction (CO2RR) products. The electrolysis of CO (instead of CO2 ) does not suffer from this undesirable reaction chemistry because CO does not react with OH- . Moreover, CO can be more readily reduced into products containing two or more carbon atoms (i. e., C2+ products) compared to CO2 . We demonstrate here that an electrocatalyst layer derived from copper phthalocyanine (CuPc) mediates this conversion effectively in a flow cell. This catalyst achieved a 25 % higher selectivity for acetate formation at 200 mA/cm2 than a known state-of-art oxide-derived Cu catalyst tested in the same flow cell. A gas diffusion electrode coated with CuPc electrolyzed CO into C2+ products at high rates of product formation (i. e., current densities ≥200 mA/cm2 ), and at high faradaic efficiencies for C2+ production (FEC2+ ; >70 % at 200 mA/cm2 ). While operando Raman spectroscopy did not reveal evidence of structural changes to the copper molecular complex, X-ray photoelectron spectroscopy suggests that the catalyst undergoes conversion to a metallic copper species during catalysis. Notwithstanding, the ligand environment about the metal still impacts catalysis, which we demonstrated through the study of a homologous CuPc bearing ethoxy substituents. These findings reveal new strategies for using metal complexes for the formation of carbon-neutral chemicals and fuels at industrially relevant conditions.

Identifying pre-conception and pre-natal periods in which ambient air pollution exposure affects fetal growth in the predominately Hispanic MADRES cohort.

BACKGROUND: It is well documented that persons of color experience disproportionate exposure to environmental contaminants, including air pollution, and have poorer pregnancy outcomes. This study assessed the critical windows of exposure to ambient air pollution on in utero fetal growth among structurally marginalized populations in urban Los Angeles. METHODS: Participants (N = 281) from the larger ongoing MADRES pregnancy cohort study were included in this analysis. Fetal growth outcomes were measured on average at 32 [Formula: see text] 2 weeks of gestation by a certified sonographer and included estimated fetal weight, abdominal circumference, head circumference, biparietal diameter and femur length. Daily ambient air pollutant concentrations were estimated for four pollutants (particulate matter less than 2.5 µm (PM2.5) and less than 10 µm (PM10) in aerodynamic diameter, nitrogen dioxide (NO2), and 8-h maximum ozone (O3)) at participant residences using inverse-distance squared spatial interpolation from ambient monitoring data. Weekly gestational averages were calculated from 12 weeks prior to conception to 32 weeks of gestation (44 total weeks), and their associations with growth outcomes were modeled using adjusted distributed lag models (DLMs). RESULTS: Participants were on average 29 years [Formula: see text] 6 old and predominately Hispanic (82%). We identified a significant sensitive window of PM2.5 exposure (per IQR increase of 6 [Formula: see text]3) between gestational weeks 4-16 for lower estimated fetal weight [Formula: see text] averaged4-16 = -8.7 g; 95% CI -16.7, -0.8). Exposure to PM2.5 during gestational weeks 1-23 was also significantly associated with smaller fetal abdominal circumference ([Formula: see text] averaged1-23 = -0.6 mm; 95% CI -1.1, -0.2). Additionally, prenatal exposure to PM10 (per IQR increase of 13 [Formula: see text]3) between weeks 6-15 of pregnancy was significantly associated with smaller fetal abdominal circumference ([Formula: see text] averaged6-15 = -0.4 mm; 95% CI -0.8, -0.1). DISCUSSION: These results suggest that exposure to particulate matter in early to mid-pregnancy, but not preconception or late pregnancy, may have critical implications on fetal growth.

Utility of Contrast-Enhanced Ultrasound and 4-Dimensional Computed Tomography for Preoperative Detection and Localization of Parathyroid Adenomas Compared With Surgical Results.

OBJECTIVES: To investigate the accuracy, sensitivity, and specificity of contrast-enhanced ultrasound (CEUS) for detection of parathyroid adenomas and compare it to those of 4-dimensional computed tomography (4DCT), which has been established as a reliable, effective tool for preoperative localization of parathyroid adenomas. METHODS: About 27 patients with suspected parathyroid pathology underwent imaging evaluations with 4DCT and CEUS and 22 patients subsequently underwent surgical resection of parathyroid lesions. 4DCT and CEUS were performed and interpreted by consensus of two expert radiologists with extensive experience in each modality. Assessment for the side, z-axis (craniocaudal axis), and quadrant of the pathologically proven lesion was performed based on the surgical report. RESULTS: For single-gland disease, the accuracy for CEUS localization to the correct quadrant and side were 81.0 and 90.1% respectively. For single-gland disease, the accuracy for 4DCT localization to the correct quadrant and side were 81.0 and 90.5% respectively. 4DCT localization sensitivity and specificity were comparable to those for CEUS. 4DCT allowed for accurate diagnosis in multigland disease in contradistinction to CEUS. CONCLUSIONS: CEUS is a noninvasive, real-time imaging technique that has relatively high diagnostic confidence and accuracy of localization which are comparable to the accuracy of 4DCT for preoperative parathyroid adenoma detection, characterization, and localization. This technique should be considered for primary preoperative diagnosis, especially in younger patients.

A quantum molecular movie: polyad predissociation dynamics in the VUV excited 3pσ2Σu state of NO2.

The optical formation of coherent superposition states, a wavepacket, can allow the study of zeroth-order states, the evolution of which exhibit structural and electronic changes as a function of time: this leads to the notion of a molecular movie. Intramolecular vibrational energy redistribution, due to anharmonic coupling between modes, is the molecular movie considered here. There is no guarantee, however, that the formed superposition will behave semi-classically (e.g. Gaussian wavepacket dynamics) or even as an intuitively useful zeroth-order state. Here we present time-resolved photoelectron spectroscopy (TRPES) studies of an electronically excited triatomic molecule wherein the vibrational dynamics must be treated quantum mechanically and the simple picture of population flow between coupled normal modes fails. Specifically, we report on vibronic wavepacket dynamics in the zeroth-order 3pσ2Σu Rydberg state of NO2. This wavepacket exemplifies two general features of excited state dynamics in polyatomic molecules: anharmonic multimodal vibrational coupling (forming polyads); nonadiabatic coupling between nuclear and electronic coordinates, leading to predissociation. The latter suggests that the polyad vibrational states in the zeroth-order 3p Rydberg manifold are quasi-bound and best understood to be scattering resonances. We observed a rapid dephasing of an initially prepared 'bright' valence state into the relatively long-lived 3p Rydberg state whose multimodal vibrational dynamics and decay we monitor as a function of time. Our quantum simulations, based on an effective spectroscopic Hamiltonian, describe the essential features of the multimodal Fermi resonance-driven vibrational dynamics in the 3p state. We also present evidence of polyad-specificity in the state-dependent predissociation rates, leading to free atomic and molecular fragments. We emphasize that a quantum molecular movie is required to visualize wavepacket dynamics in the 3pσ2Σu Rydberg state of NO2.

TOGA feature selection and the prediction of mechanical properties of paper from the Raman spectra of unrefined pulp.

Process-monitoring laboratories in the pulp and paper industry generally use a combination of wet chemical analyses and physical measurements to certify the fitness of a production pulp for a specific end-use. These laboratory tests require time and the effort of trained personnel, limiting their utility for real-time process control. Here we show that Raman probes of unrefined cellulosic pulps, well-suited to the online measurement of in-process materials, can predict the quality attributes of manufactured papers. The accuracy of prediction improves when the covariance is modelled in a reduced measurement space selected by a data-driven, feature-selection technique referred to as a Template Oriented Genetic Algorithm (TOGA). TOGA, combined with discrete wavelet transform (DWT), isolates functional-group features that correlate best with mechanical properties paper derived from refined pulp. Paper makers refine market pulps to build sheet strength using a beating process that decreases freeness as it increases fibre-fibre bonding. Methods demonstrated here predict manufactured sheet properties obtainable after any specified degree of refining from the Raman spectrum of an unrefined pulp. This analysis capacity will enable both vendors of market pulp and makers of sheet paper to specify in advance the amount of beating required to produce a desired product, thereby saving cost and conserving resources.

Contrast-Enhanced Ultrasound for the Evaluation of Renal Transplants.

Contrast-enhanced ultrasound has emerged as a useful imaging modality for the evaluation of the transplant kidney. Advantages over traditional imaging modalities such as computed tomography and magnetic resonance imaging include the ability to visualize a lesion's enhancement pattern in real time, the lack of nephrotoxicity, and relatively low cost. Potential uses of contrast-enhanced ultrasound include characterization of solid and cystic transplant renal masses, assessment for pyelonephritis and identification of its complications, and evaluation of transplant complications in immediate and delayed settings. Contrast-enhanced ultrasound will likely play an increasing role for evaluating the transplant kidney, as an accurate diagnosis based on imaging can direct treatment and prevent unnecessary interventions.

Usability and preference of epinephrine auto-injectors: Auvi-Q and EpiPen Jr.

BACKGROUND: Despite the importance of prompt epinephrine auto-injector (EAI) treatment during anaphylaxis, proper administration technique is often lacking among patients and caregivers. OBJECTIVE: To compare usability and participant preference of Auvi-Q and EpiPen Jr EAIs in a simulated life-threatening allergic emergency-use scenario. METHODS: In this randomized, crossover, human-factors usability study, untrained adults (18-65 years) were tasked with using 0.15 mg Auvi-Q and EpiPen Jr trainers to simulate epinephrine administration to a child-sized manikin. Only written instructions on the device label and/or device voice instructions were available to participants. Endpoints included completing injection tasks per device instructions (primary endpoint), completing key injection tasks, and participant preference/ratings of devices. Completion of injection tasks were evaluated using a McNemar test for paired dichotomous data. RESULTS: Ninety-six adults were included in study analyses. Significantly more participants completed all injection tasks per device instructions with Auvi-Q (85.4%) vs EpiPen Jr (19.8%; P < .001). Significant differences were also observed for completion of key injection tasks (Auvi -Q, 94.8%; EpiPen Jr, 72.9%; P < .001). No digital/hand injection errors were seen with Auvi-Q, whereas 14 participants (14.6%) would have accidentally received a digital/hand injection with EpiPen Jr (P < .001). Overall, significantly more participants preferred Auvi-Q over EpiPen Jr (91.7% vs 6.3%; P < .001 [2.1% no preference]). Median scores for 8 EAI characteristics were also higher for Auvi-Q vs EpiPen Jr. CONCLUSION: In this study, untrained adults preferred and were more likely to use Auvi-Q correctly vs EpiPen Jr, highlighting the importance of device design for successful epinephrine administration during a life-threatening allergic emergency.

Peripheral Thyroid Nodule Calcifications on Sonography: Evaluation of Malignant Potential.

OBJECTIVE. The purpose of this study is to assess the association of thyroid cancer with sonographic features of peripheral calcifications. MATERIALS AND METHODS. We retrospectively reviewed patients who had a total of 97 thyroid nodules with peripheral calcifications who underwent ultrasound-guided fine-needle aspiration from 2008 to 2018. Three board-certified radiologists evaluated the nodules for features of peripheral calcifications: the percentage of the nodule involved by peripheral calcifications, whether the calcifications were continuous or discontinuous, the visibility of internal components of the nodule, and the presence of extrusion of soft tissue beyond the calcifications. The correlation of peripheral calcification parameters with the rate of thyroid nodule malignancy was evaluated. In addition, the interobserver agreement between readers was assessed with Cohen kappa coefficient. RESULTS. Of the 97 nodules with peripheral calcifications, 27% (n = 26) were found to be malignant on biopsy. The continuity of peripheral calcifications, visibility of internal components, and extrusion of soft tissue beyond the calcification rim showed no significant association with benign or malignant nodules. Readers had good agreement on peripheral calcification continuity (κ = 0.63; 95% CI, 0.53-0.73) and moderate agreement on internal component visibility (κ = 0.43; 95% CI, 0.35-0.51) and percentage of the nodule involved by rim calcifications (κ = 0.52; 95% CI, 0.44-0.59). There was fair agreement for extranodular soft-tissue extrusion (κ = 0.32, 95% CI, 0.24-0.39). CONCLUSION. Peripheral rim calcifications are highly associated with malignancy. However, specific peripheral rim calcification features do not aid in distinguishing benign from malignant nodules, which may in part be caused by high interobserver variability.

Assessment of Fibrosis in Liver Transplant Recipients: Diagnostic Performance of Shear Wave Elastography (SWE) and Correlation of SWE Findings With Biopsy Results.

OBJECTIVE. Liver transplant patients are monitored for rejection and hepatic fibrosis and often undergo liver biopsies. The purpose of the present study is to determine whether noninvasive shear wave elastography (SWE) can quantify fibrosis in liver transplant recipients, with the aim of decreasing and possibly eliminating unnecessary biopsies for patients with suspected or progressive hepatic fibrosis. MATERIALS AND METHODS. Between May 1, 2015, and December 31, 2017, our prospective study evaluated 111 adult liver transplant patients (age range, 23-79 years) who underwent 147 ultrasound (US) SWE examinations of the right hepatic lobe followed by biopsies. SWE values were compared with the histologic fibrosis (Metavir) scores of the biopsy samples. SWE threshold values were determined using classification and regression tree analysis by anchoring to the degree of fibrosis. The sensitivity, specificity, positive predictive value, and negative predictive value (with 95% CIs) were calculated on the basis of the threshold value. Overall prediction accuracy was estimated using the AUC value from the ROC curve. RESULTS. From the 147 US SWE examinations and liver biopsies, consistent threshold values were identified for patients with no or minimal fibrosis (Metavir scores of F0 and F1, respectively) compared with significant fibrosis (Metavir scores of F2, F3, or F4). A median SWE value of 1.76 m/s or less denoted no or minimal fibrosis, whereas a value greater than 1.76 m/s denoted significant fibrosis. The sensitivity of US SWE examinations in classifying fibrosis was 0.77 (95% CI, 0.5-0.93). The specificity, positive predictive value, and negative predictive value were 0.79 (95% CI, 0.71-0.86), 0.33 (95% CI, 0.19-0.49), and 0.96 (95% CI, 0.91-0.99), respectively. CONCLUSION. Liver transplant patients may avoid liver biopsy if US SWE examination shows a median shear wave velocity of 1.76 or less, which corresponds to a Metavir score of F0 or F1, denoting no or minimal fibrosis.

Delocalized excitons and interaction effects in extremely dilute thermal ensembles.

Long-range interparticle interactions are revealed in extremely dilute thermal atomic ensembles using highly sensitive nonlinear femtosecond spectroscopy. Delocalized excitons are detected in the atomic systems at particle densities where the mean interatomic distance (>10 µm) is much greater than the laser wavelength and multi-particle coherences should destructively interfere over the ensemble average. With a combined experimental and theoretical analysis, we identify an effective interaction mechanism, presumably of dipolar nature, as the origin of the excitonic signals. Our study implies that even in highly-dilute thermal atom ensembles, significant transition dipole-dipole interaction networks may form that require advanced modeling beyond the nearest neighbor approximation to quantitatively capture the details of their many-body properties.