Evaluating use of IOTA two-step strategy to classify adnexal masses identified in pregnancy: pilot study.

OBJECTIVES: The primary aim was the validation of benign descriptors (BDs), followed by Assessment of Different NEoplasia's of the adneXa (ADNEX) (when BDs cannot be applied), in a two-step strategy to classify adnexal masses in pregnancy. The secondary aim was to describe the natural history of adnexal masses in pregnancy. METHODS: Retrospective analysis of prospectively collected data of women with an adnexal mass on ultrasonography identified during pregnancy between 2017 and 2022. The study was conducted at Queen Charlotte's and Chelsea Hospital, UK. Relevant clinical and ultrasound data were extracted from the medical records and ultrasound software astraia. Adnexal masses were classified and managed according to expert subjective assessment (SA). Ultrasound features were recorded prospectively at the time of ultrasound examination. Borderline ovarian tumours (BOT) were classified as malignant. Benign Descriptors (BDs) were applied to classify adnexal masses, in cases where BDs were not applicable, the ADNEX model (using a risk of malignancy of >10%) was used, in a two-step strategy. The two-step strategy was applied retrospectively. The reference standard used was histology (where available) or expert SA at the postnatal ultrasound scan. RESULTS: 291 women with a median age of 33 (IQR 29-36) years presented with an adnexal mass in pregnancy, at a median gestation of 12 (IQR 8-17) weeks. 267 (267/291, 91.8%) women were followed up to the postnatal period, as 24 women (24/291, 8.2%) were lost to follow up. Based on the reference standard, 4.1% of adnexal masses (11/267) were classified as malignant (all BOTs) and 95.9% (256/267) as benign (41 on histology and 215 based on expert SA at postnatal ultrasound). BDs could be applied to 68.9% of adnexal masses (184/267); of these only one mass (BOT) was misclassified as benign (1/184, 0.5%). ADNEX was used to classify the residual masses (83/267) and misclassified three BOTs as benign (3/10, 30.0%) and 25 benign masses (based on reference standard) as malignant (25/73, 34.2%), 13 (13/25, 52.0%) of these were classified as decidualised endometriomas on expert SA, with confirmed resolution of decidualisation in the postnatal period. The two-step strategy had a specificity of 90.2%, sensitivity of 63.6%, negative predictive value of 98.3% and positive predictive value of 21.9%. 56 (56/267, 21.0%) women had surgical intervention, four as an emergency during pregnancy (4/267, 1.5%,) and four (4/267, 1.5%) electively during caesarean section. 48 (48/267, 18.0%) women had surgical intervention in the post-natal period, 11 (11/267, 4.1%) in the first 12 weeks postnatal and 37 >12 weeks (37/267, 13.9%) postnatal. 64 (64/267, 24.0%) adnexal masses resolved spontaneously during follow up. Cyst-related complications occurred in four women (4/267, 1.5%) during pregnancy (ovarian torsion n=2, cyst rupture n=2) and six (6/267, 2.2%) in the postnatal period (all ovarian torsion). 196 (196/267, 73.4%) had a persistent adnexal mass, including one of the women who had an ovarian torsion and underwent de-torsion and had a persistent adnexal mass at postnatal ultrasound. Presumed decidualisation occurred in 31.1% (19/61) of endometriomas and had resolved in 89.5% (17/19) by the first postnatal ultrasound scan. CONCLUSION: We found Benign Descriptors apply to most masses in pregnancy, however the small number of malignant tumours in the cohort (4.1%) restricted the evaluation of the ADNEX model, so expert subjective assessment should be used to classify adnexal masses in pregnancy, when BDs do not apply. A larger multicentre prospective study is required to evaluate the use of the ADNEX model to classify adnexal masses in pregnancy. Our data suggests that most adnexal masses can be managed expectantly during pregnancy given a large proportion of masses spontaneously resolved and the low risk of complications. This article is protected by copyright. All rights reserved.

Vertebral heart size and vertebral left atrial size reference ranges in healthy Miniature Schnauzers.

OBJECTIVE: The inclusion of vertebral heart score (VHS) and, more recently, the inclusion of the vertebral left atrial size (VLAS) in radiographic evaluation have become important screening tools for identifying dogs with occult cardiac disease. Several recent papers have shown there are interbreed variations in the VHS reference range. Our hypothesis is that the Miniature Schnauzer would also have a higher reference range for its VHS. ANIMALS: The electronic medical records of IDEXX Telemedicine Consultants were searched for Miniature Schnauzers undergoing thoracic radiographs between March 1, 2022, and February 28, 2023. METHODS: Dogs were included if they had 3 view thoracic radiographs performed and no evidence of cardiopulmonary disease was detected. Dogs with incomplete radiographic studies or cardiac or extracardiac disease were excluded. The VHS and VLAS measurements were performed by 2 board-certified cardiologists independent of one another. RESULTS: A total of 1,000 radiographs were obtained of which 272 were included for the study. The overall range for the VHS in this cohort was 9.68 to 12.07 with a median of 10.9. For VLAS measurements, a range of 1.71 to 2.4 was documented with a median of 2.0. CLINICAL RELEVANCE: The VHS for Miniature Schnauzers without cardiac disease was confirmed to be higher than the canine reference range.

Successful return to work in anaesthesia after maternity leave: a qualitative study.

Returning to work after maternity leave poses significant challenges, with potential long-term implications including decreased engagement or attrition of clinicians. Many quantitative studies have identified challenges and supports for women during pregnancy, maternity leave and re-entry to clinical practice. This qualitative study explored the experiences of anaesthetists returning to clinical work after maternity leave, to identify influential factors with the aim of providing a framework to assist planning re-entry. We conducted semi-structured interviews with 15 anaesthetists. Attendees of a re-entry programme were invited to participate, with purposive sampling and snowball recruitment to provide diversity of location and training stage, until data saturation was reached at 13 interviews. Five themes were identified: leave duration; planning re-entry; workplace culture; career impact and emotional impact. Leave duration was influenced by concerns about deskilling, but shorter periods of leave had logistical challenges, including fatigue. Most participants started planning to return to work with few or no formal processes in the workplace. Workplace culture, including support for breastfeeding, was identified as valuable, but variable. Participants also experienced negative attitudes on re-entry, including difficulty accessing permanent work, with potential career impacts. Many participants identified changes to professional and personal identity influencing the experience with emotional sequelae. This research describes factors which may be considered to assist clinicians returning to work after maternity leave and identifies challenges, including negative attitudes, which may pose significant barriers to women practising in anaesthesia and may contribute to lack of female leadership in some workplaces.

Management of an Unexploded Intracorporeal Firework in a Low Resource Setting: Case Report and Tips.

Surgical removal of unexploded ordnance has been described in literature, usually in the context of the military. We describe a case of a 31-year-old gentleman who presented with a traumatic fireworks injury resulting in an unexploded three-inch aerial shell lodged in his left upper thigh. The sole regional Explosive Ordinance Disposal (EOD) expert was not available, so a local pyrotechnic engineer was contacted and he helped in identification of the firework. The firework was removed without the use of electrocautery, irrigation, or metal instrument contact after skin incision. The patient recovered well after prolonged wound healing. Creativity needs to be employed in low resource settings to identify all available resources that can impart knowledge when medical training is not enough. People with knowledge of explosives can be, as in our case, local pyrotechnics engineer or can be local cannon enthusiasts, veterans, or active military personnel at a nearby military base.

A multi-centre prospective evaluation of internet research habits among owners seeing a veterinary oncologist.

The purpose of this study is to evaluate the internet-use among pet owners seeing a veterinary oncologist. Over a two-month period, 137 questionnaires were collected at three specialty hospitals around a large urban city. Approximately 85% of respondents reported using the internet to research their pet's condition and/or treatment. A search engine was the most employed means however veterinary university websites were considered to provide the most accurate information. The odds of owners who researched their own health condition online researching their pet's condition was 4.3 (95% CI: 1.2-23.1, p < .021) times as high as owners who did not research their own health condition. The odds of owners who have been to their oncologist previously to research their pet's condition was 4.7 (95% CI: 26.9.3, p < .001) times as high than owners who have not been to an oncologist previously. Oncologists should be aware internet use among pet owners appears common and further research to assess the accuracy and readability of veterinary medical websites appears indicated.

Simulating nitrogen balance in Canadian agricultural soils from 1981 to 2016.

Agriculture produces food, fiber and biofuels for the world's growing population, however, agriculture can be a major contributor of nitrogen (N) losses including emissions of ammonia (NH3), nitrous oxide (N2O) and nitrate (NO3-) leaching and runoff. A Canadian Agricultural Nitrogen Budget for Reactive N (CANBNr) model was developed to estimate the soil N balance in 3487 soil landscape of Canada polygons from 1981 to 2016. The CANBNr model integrates NH3 emission from fertilizers, manure from housing, storage and field, as well as direct/indirect N2O emissions from fertilizers, manures, crop residues and soil organic matter. The NO3- leaching is estimated based on the residual soil N (RSN) at harvest and drainage derived with the DeNitrification-DeComposition (DNDC) model. From 1981 to 2016, the N input from fertilizer and N fixation increased at a greater rate than N removal in harvested crops in all provinces of Canada, resulting in an increase in the RSN and N losses. In 2016, the Prairie provinces had lower N losses (11.7 kg N ha-1) from N2O, NH3 and NO3- compared with 43.2 kg N ha-1 in central Canada, and 76.5 kg N ha-1 in Atlantic Canada. However, the Prairie provinces had 84.3% of the total Canadian farmland (74.3% of the total Canadian N input), while central Canada had 12.9% of Canadian farmland (21.7% of the total Canadian N input). In the Prairie provinces, the total N2O loss from fertilizer N ranged 4.4-8.6 Gg N whereas NH3 loss ranged from 17.1 to 44.6 Gg N and these values were influenced by both emission intensity and total land area. Total N2O losses from manure were highest in Alberta, Ontario and Quebec resulting in 4.8, 4.4, and 3.4 Gg N and NH3 losses from manure were also highest in these 3 provinces at 61.1, 45.2 and 40.4 Gg N, respectively. Nitrate leaching was impacted by drainage volumes, soil type and N inputs. In the non-growing season, NO3- leaching losses (36-yr average) were 63.3 Gg in Ontario and 57.5 Gg N in Quebec compared with 20.8 Gg N for Ontario and 35.5 Gg N for Quebec in the growing season. In contrast, the Prairie provinces showed higher NO3- leaching in the growing season (23.1-37.4 Gg N) than in the non-growing season (10.4-13.7 Gg N). In summary, total fertilizer N increased the most over the 36 years in the Prairies which resulted in increased RSN and N leaching losses that will require further intervention.

Iron status influences mitochondrial disease progression in Complex I-deficient mice.

Mitochondrial dysfunction caused by aberrant Complex I assembly and reduced activity of the electron transport chain is pathogenic in many genetic and age-related diseases. Mice missing the Complex I subunit NADH dehydrogenase [ubiquinone] iron-sulfur protein 4 (NDUFS4) are a leading mammalian model of severe mitochondrial disease that exhibit many characteristic symptoms of Leigh Syndrome including oxidative stress, neuroinflammation, brain lesions, and premature death. NDUFS4 knockout mice have decreased expression of nearly every Complex I subunit. As Complex I normally contains at least 8 iron-sulfur clusters and more than 25 iron atoms, we asked whether a deficiency of Complex I may lead to iron perturbations, thereby accelerating disease progression. Consistent with this, iron supplementation accelerates symptoms of brain degeneration in these mice, while iron restriction delays the onset of these symptoms, reduces neuroinflammation, and increases survival. NDUFS4 knockout mice display signs of iron overload in the liver including increased expression of hepcidin and show changes in iron-responsive element-regulated proteins consistent with increased cellular iron that were prevented by iron restriction. These results suggest that perturbed iron homeostasis may contribute to pathology in Leigh Syndrome and possibly other mitochondrial disorders.

Iron is a mineral that contributes to many vital body functions. But as people age, it accumulates in many organs, including the liver and the brain. Excess iron accumulation is linked to age-related diseases like Parkinson's disease. Too much iron may contribute to harmful chemical reactions in the body. Usually, the body has systems in place to mitigate this harm, but these mechanisms may fail as people age. Uncontrolled iron accumulation may damage essential proteins, DNA and fats in the brain. These changes may kill brain cells causing neurodegenerative diseases like Parkinson's disease. Mitochondria, the cell's energy-producing factories, use and collect iron inside cells. As people age, mitochondria fail, which is also linked with age-related diseases. It has been unclear if mitochondrial failure may also contribute to iron accumulation and associated diseases like Parkinson's. Kelly et al. show that mitochondrial dysfunction causes iron accumulation and contributes to neurodegeneration in mice. In the experiments, Kelly et al. used mice with a mutation in a key-iron processing protein in mitochondria. These mice develop neurodegenerative symptoms and die early in life. Feeding the mice a high-iron diet accelerated the animals' symptoms. But providing them with an iron-restricted diet slowed their symptoms and extended their lives. Low-iron diets also slowed iron accumulation in the animal's liver and reduced brain inflammation. The experiments suggest that mitochondrial dysfunction contributes to both iron overload and brain degeneration. The next step for scientists is understanding the processes leading to mitochondrial dysfunction and iron accumulation. Then, scientists can determine if they can develop treatments targeting these processes. This research might lead to new treatments for Parkinson's disease or other age-related conditions caused by iron overload.

Pathology in Practice.

In collaboration with the American College of Veterinary Pathologists.

Development of a multi-task learning V-Net for pulmonary lobar segmentation on CT and application to diseased lungs.

AIM: To develop a multi-task learning (MTL) V-Net for pulmonary lobar segmentation on computed tomography (CT) and application to diseased lungs. MATERIALS AND METHODS: The described methodology utilises tracheobronchial tree information to enhance segmentation accuracy through the algorithm's spatial familiarity to define lobar extent more accurately. The method undertakes parallel segmentation of lobes and auxiliary tissues simultaneously by employing MTL in conjunction with V-Net-attention, a popular convolutional neural network in the imaging realm. Its performance was validated by an external dataset of patients with four distinct lung conditions: severe lung cancer, COVID-19 pneumonitis, collapsed lungs, and chronic obstructive pulmonary disease (COPD), even though the training data included none of these cases. RESULTS: The following Dice scores were achieved on a per-segment basis: normal lungs 0.97, COPD 0.94, lung cancer 0.94, COVID-19 pneumonitis 0.94, and collapsed lung 0.92, all at p<0.05. CONCLUSION: Despite severe abnormalities, the model provided good performance at segmenting lobes, demonstrating the benefit of tissue learning. The proposed model is poised for adoption in the clinical setting as a robust tool for radiologists and researchers to define the lobar distribution of lung diseases and aid in disease treatment planning.

A multimodality intervention to improve musculoskeletal health, function, metabolism, and well-being in spinal cord injury: study protocol for the FIT-SCI randomized controlled trial.

BACKGROUND: A spinal cord injury (SCI) is a devastating, life-changing event that has profoundly deleterious effects on an individual's health and well-being. Dysregulation of neuromuscular, cardiometabolic, and endocrine organ systems following an SCI contribute to excess morbidity, mortality and a poor quality of life. As no effective treatments currently exist for SCI, the development of novel strategies to improve the functional and health status of individuals living with SCI are much needed. To address this knowledge gap, the current study will determine whether a Home-Based Multimodality Functional Recovery and Metabolic Health Enhancement Program that consists of functional electrical stimulation of the lower extremity during leg cycling (FES-LC) plus arm ergometry (AE) administered using behavioral motivational strategies, and testosterone therapy, is more efficacious than FES-LC plus AE and placebo in improving aerobic capacity, musculoskeletal health, function, metabolism, and wellbeing in SCI. METHODS: This single-site, randomized, placebo-controlled, parallel group trial will enroll 88 community-dwelling men and women, 19 to 70 years of age, with cervical and thoracic level of SCI, ASIA Impairment Scale grade: A, B, C, or D, 6 months or later after an SCI. Participants randomized to the multimodality intervention will undergo 16 weeks of home-based FES-LC and AE training plus testosterone undecanoate. Testosterone undecanoate injections will be administered by study staff in clinic or by a visiting nurse in the participant's home. The control group will receive 16 weeks of home-based FES-LC and AE exercise plus placebo injections. The primary outcome of this trial is peak aerobic capacity, measured during an incremental exercise testing protocol. Secondary outcomes include whole body and regional lean and adipose tissue mass; muscle strength and power; insulin sensitivity, lipids, and inflammatory markers; SCI functional index and wellbeing (mood, anxiety, pain, life satisfaction and depressive symptoms); and safety. DISCUSSION: We anticipate that a multimodality intervention that simultaneously addresses multiple physiological impairments in SCI will result in increased aerobic capacity and greater improvements in other musculoskeletal, metabolic, functional and patient-reported outcomes compared to the control intervention. The findings of this study will have important implications for improving the care of people living with an SCI. TRIAL REGISTRATION: ClinicalTrials.gov :  ( NCT03576001 ). Prospectively registered: July 3, 2018.

An analysis of client complaints and their effects on veterinary support staff.

BACKGROUND: Veterinarians and support staff have been reporting the negative mental health effects from client complaints (CC). A previous study was performed evaluating these effects in veterinarians however no such study has been performed on veterinary support staff (VSS). OBJECTIV: The purpose of this study was to investigate the frequency and effects of CCs on VSS. METHODS: A cross sectional anonymous survey using a web-based questionnaire was created evaluating the frequency, type, and effects from CC. The survey was distributed to five different VSS Facebook groups and respondents provided demographic information and reported the frequency and effects of such complaints. RESULTS: A total of 681 questionnaires were collected during the study period but 130 were incomplete and were excluded from analysis. This resulted in 551 completed questionnaires available for review. One hundred and ninety (34.4%) VSS reported being subject to a CC in the previous 6 months with cost of care the most common reason (78.6%). Two hundred and sixty VSS (47.2%) reported feeling depressed because of CCs made against them, 295 VSS (53.5%) stated CCs negatively affected their enjoyment of their job, and 146 (26.5%) have considered changing their career because of CCs. CONCLUSIONS: CC have detrimental effects on VSS career satisfaction, mental health and hospital practices. Further studies are warranted to mitigate the detrimental effects of CCs.

Is the development of desalination compatible with sustainable development of the Arabian Gulf?

The development of desalination has been essential to the rapid economic development of the countries bordering the Arabian Gulf. The current production capacity of sea water desalination plants drawing water from Gulf is over 20 million m3 day-1, which may rise to 80 million m3 day-1 by 2050. Whilst supporting aspects of sustainable development related to water and sanitation, desalination impacts the marine environment through impingement and entrainment of organisms in intakes, and through thermal, brine and chemical discharges. This may compromise other objectives for sustainable development related to sustainable use of the oceans. Under business as usual scenarios, by 2050, the impact of individual desalination plants will combine causing a regional scale impact. Without mitigating actions to avoid the business as usual scenario, by 2050, desalination in combination with climate change, will elevate coastal water temperatures across more than 50% of the Gulf by at least 3 °C, and a volume of water equivalent to more than a third of the total volume of water between 0 and 10 m deep will pass through desalination plants each year. This will adversely impact the coastal ecosystem of the Gulf, with impacts on biodiversity, fisheries and coastal communities and may cause potential loss of species and habitats from the Gulf. Given the significant implications of these preliminary findings, and in light of the precautionary approach to management, it is recommended that mitigating options addressing behavioural, regulatory and technological change are rapidly evaluated and implemented to avoid the development of desalination in the region along a business as usual pathway, and multidisciplinary research studies should be conducted to reduce uncertainty in predictions of future impacts.