Incidental maternal findings on fetal MRI.

AIM: To evaluate the type and frequency of maternal findings incidentally identified during fetal magnetic resonance imaging (MRI). MATERIALS AND METHODS: A retrospective single-centre study was undertaken which included all consecutive fetal MRI studies performed between July 2017 and May 2021 at a tertiary institution. Two fellowship-trained radiologists reviewed the studies independently to determine the type and frequency of incidental maternal findings of both no clinical significance (requiring no further follow-up) and of clinical significance (requiring further follow-up, work-up, and/or management). Differences in acquisition were resolved by two-reader consensus. Non-diagnostic MRI examinations or abdominal MRI examinations indicated for maternal complications were excluded from review. RESULTS: A total of 455 consecutive fetal MRI examinations performed in 429 women were included. Mean age was 30 years (SD 5.5 years). At least one incidental maternal finding was identified in 58% (265/455) of studies. Umbilical hernias (35%), maternal hydronephrosis (19%), and maternal hydro-ureter (15%) were the most common. Only two studies (0.5%) showed clinically significant incidental maternal findings (pancreatic pseudocyst and ovarian cyst). CONCLUSIONS: Incidental maternal findings are common on fetal MRI but rarely require further follow-up, work-up, and/or management.

All or nothing? A second look at partial levator avulsion.

OBJECTIVE: To define associations between partial levator trauma and symptoms and signs of pelvic organ prolapse (POP). METHODS: This was a retrospective study of 3484 women attending a tertiary urogynecology unit for symptoms of pelvic floor dysfunction between January 2012 and February 2020. All women underwent a standardized interview, clinical pelvic organ prolapse quantification (POP-Q) examination and tomographic ultrasound imaging of the pelvic floor. Women with full levator avulsion were excluded from analysis. Partial levator avulsion was quantified using the tomographic trauma score (TTS), in which slices 3-8 are scored bilaterally for abnormal insertions. Binomial multiple logistic regression was analyzed independently for the outcome variables prolapse symptoms, symptom bother and objective prolapse on clinical examination and imaging, with age and body mass index as covariates. Two continuous outcome variables, prolapse bother score and hiatal area on Valsalva, were analyzed using multiple linear regression. RESULTS: Of the 3484 women, ultrasound data were missing or incomplete in 164 due to lack of equipment, clerical error and/or inadequate image quality. Full levator avulsion was diagnosed in 807 women, leaving 2513 for analysis. TTS ranged from 0-10, with a median of 0. Partial trauma (TTS > 0) was observed in 667/2513 (26.5%) women. All subjective and objective measures of POP were associated significantly with TTS, most strongly for cystocele. Associations were broadly linear and similar for all slice locations but disappeared after accounting for hiatal area on Valsalva. CONCLUSION: Partial avulsion is associated with POP and prolapse symptoms. This association was strongest for cystocele, both on POP-Q and ultrasound imaging. The effect of partial avulsion on POP and prolapse symptoms is explained fully by its effect on hiatal area. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Validation of new ultrasound algorithm for estimating prevalence of anal sphincter trauma in a urogynecological population.

OBJECTIVES: To estimate the prevalence of major perineal trauma in a urogynecological population, to test the predictive value of sonographic tear grading (Gillor algorithm) for anal incontinence (AI), AI bother score and St Mark's score, and to compare the predictive power of the Gillor algorithm with that of the residual-defect method. METHODS: This was a retrospective study of 721 women attending a tertiary urogynecology unit between February 2019 and May 2021. All women underwent a standardized interview, including determination of St Mark's score and visual analog scale (VAS) bother score for AI, as well as exoanal (translabial) ultrasound with later offline analysis. Results were reported as the presence of a residual defect of the external anal sphincter (EAS), i.e. a discontinuity of ≥ 30° in ≥ 4/6 tomographic slices, and according to the Gillor algorithm (normal, Grade 3a, Grade 3b or Grade 3c/4). RESULTS: Mean age at assessment was 57 (range, 19-93) years and mean body mass index was 30 (range, 17-57) kg/m2 . Six hundred and thirty-six (88.2%) women were vaginally parous and 161 (22.3%) had undergone at least one forceps delivery. AI was reported by 186/721 (25.8%) women, with a median St Mark's score of 10 (interquartile range (IQR), 6-14) and a median VAS score of 6.3 (IQR, 3.9-10). EAS defects were detected in 261 (36.2%) women, with a residual defect diagnosed in 88 (12.2%). On sonographic grading according to the Gillor algorithm, we identified 532 (73.8%) women with a normal sphincter, 66 (9.2%) with Grade-3a tear, 87 (12.1%) with Grade-3b tear and 36 (5.0%) with Grade-3c/4 tear. In total, the Gillor algorithm classified 189 (26.2%) women as having suffered a major perineal tear. The two grading systems were in moderate agreement (κ, 0.537 (95% CI, 0.49-0.56); P < 0.001). There were weak, albeit significant, associations between EAS defects and measures of AI (P = 0.009 to P = 0.047), both for residual defect as well as the Gillor algorithm. CONCLUSION: Neither the Gillor algorithm nor the residual-defect method of quantifying sphincter trauma on imaging is clearly superior in terms of predicting AI. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

The impact of impulsivity on weight loss after bariatric surgery: a systematic review.

BACKGROUND: Impulsivity has been shown to be associated with obesity through links to pathological eating behavior such as binge eating. The recent literature suggests that impulsivity is linked to poorer outcomes post-bariatric surgery. Impulsivity can be measured in various ways and comprises of three broad domains: impulsive choice, impulsive action, and impulsive personality traits. The aim of this systematic review is to synthesize the current evidence on the impact of impulsivity on post-bariatric surgery weight loss. METHODS: A literature review was performed in February 2020. Original studies investigating the relationship between impulsivity and weight loss post-bariatric surgery were evaluated. RESULTS: Ten studies with a total of 1246 patients were analyzed. There were four case-control, four prospective observational and two retrospective observational studies. The postoperative follow-up ranged from 0.5 to 12 years. Eight studies measuring trait impulsivity did not show any association with weight loss post-bariatric surgery, although two studies reported an indirect effect of impulsivity on weight loss mediated via pathological eating behavior. Assessment of impulsive action by two studies showed that post-bariatric surgery weight loss is affected by impulsive action. CONCLUSION: Impulsivity may adversely affect postoperative outcomes after bariatric surgery. However, this may be specific to state impulsivity or impulsive action rather than trait impulsivity. Patients with a higher state impulsivity may benefit from closer follow-up post-bariatric surgery, as well as cognitive behavioral therapies targeting cognitive control over food. LEVEL OF EVIDENCE: Level I, systematic review.

Urban landscape genomics identifies fine-scale gene flow patterns in an avian invasive.

Invasive species exert a serious impact on native fauna and flora and have been the target of many eradication and management efforts worldwide. However, a lack of data on population structure and history, exacerbated by the recency of many species introductions, limits the efficiency with which such species can be kept at bay. In this study we generated a novel genome of high assembly quality and genotyped 4735 genome-wide single nucleotide polymorphic (SNP) markers from 78 individuals of an invasive population of the Javan Myna Acridotheres javanicus across the island of Singapore. We inferred limited population subdivision at a micro-geographic level, a genetic patch size (~13-14 km) indicative of a pronounced dispersal ability, and barely an increase in effective population size since introduction despite an increase of four to five orders of magnitude in actual population size, suggesting that low population-genetic diversity following a bottleneck has not impeded establishment success. Landscape genomic analyses identified urban features, such as low-rise neighborhoods, that constitute pronounced barriers to gene flow. Based on our data, we consider an approach targeting the complete eradication of Javan Mynas across Singapore to be unfeasible. Instead, a mixed approach of localized mitigation measures taking into account urban geographic features and planning policy may be the most promising avenue to reducing the adverse impacts of this urban pest. Our study demonstrates how genomic methods can directly inform the management and control of invasive species, even in geographically limited datasets with high gene flow rates.

Uncommon liver lesions with multimodality imaging and pathology correlation.

Uncommon liver lesions pose a diagnostic challenge because of unfamiliar imaging findings. For simplification, these lesions can be divided into four broad categories based on the dominant imaging feature in each: hypervascular, hypovascular, fat-containing, or cystic lesions. In this review, we profile the radiological features of uncommon liver lesions on multimodality imaging including ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine.

Hepatocellular adenoma: imaging review of the various molecular subtypes.

This educational review focuses on the epidemiology and radiological evaluation of the various subtypes of hepatic adenomas (HCAs). It includes detailed discussion of the imaging appearances of each HCA subtype and the clinical relevance of the new classification system. Each HCA subtype has a unique biological behaviour. Imaging plays a central role in diagnosis, subtype characterisation, identification of complications, and follow-up assessment. Management of patients should vary according to the specific HCA subtype.

Extravascular complications following abdominal organ transplantation.

A variety of transplants have been performed in the abdomen including liver, kidney, pancreas and islet, bowel, and multivisceral transplants. Imaging plays an important role in graft surveillance particularly to exclude post-transplant complications. When complications occur, therapeutic image-guided interventions are invaluable as these may be graft-saving and even life-saving. Vascular complications following transplantation have been extensively reported in recent reviews. The focus of this review is to discuss post-transplant complications that are primarily extravascular in location. This includes biliary, urological, intestinal, malignancy, infections, and miscellaneous complications. Familiarity with the imaging appearances of these complications is helpful for radiologists as accurate diagnosis and expedient treatment has an impact on graft and patient survival.

Negative regulation of signal transducer and activator of transcription-3 signalling cascade by lupeol inhibits growth and induces apoptosis in hepatocellular carcinoma cells.

BACKGROUND: Constitutive activation of signal transducer and activator of transcription signalling 3 (STAT3) has been linked with survival, proliferation and angiogenesis in a wide variety of malignancies including hepatocellular carcinoma (HCC). METHODS: We evaluated the effect of lupeol on STAT3 signalling cascade and its regulated functional responses in HCC cells. RESULTS: Lupeol suppressed constitutive activation of STAT3 phosphorylation at tyrosine 705 residue effectively in a dose- and time-dependent manner. The phosphorylation of Janus-activated kinases (JAKs) 1 and 2 and Src was also suppressed by lupeol. Pervanadate treatment reversed the downregulation of phospho-STAT3 induced by lupeol, thereby indicating the involvement of a phosphatase. Indeed, we observed that treatment with lupeol increased the protein and mRNA levels of SHP-2, and silencing of SHP-2 abolished the inhibitory effects of lupeol on STAT3 activation. Treatment with lupeol also downregulated the expression of diverse STAT3-regulated genes and decreased the binding of STAT3 to VEGF promoter. Moreover, the proliferation of various HCC cells was significantly suppressed by lupeol, being associated with substantial induction of apoptosis. Depletion of SHP-2 reversed the observed antiproliferative and pro-apoptotic effects of lupeol. CONCLUSIONS: Lupeol exhibited its potential anticancer effects in HCC through the downregulation of STAT3-induced pro-survival signalling cascade.

Adrenal neoplasms.

Adenoma, myelolipoma, phaeochromocytoma, metastases, adrenocortical carcinoma, neuroblastoma, and lymphoma account for the majority of adrenal neoplasms that are encountered in clinical practice. A variety of imaging methods are available for evaluating adrenal lesions including ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine techniques such as meta-iodobenzylguanidine (MIBG) scintigraphy and positron-emission tomography (PET). Lipid-sensitive imaging techniques such as unenhanced CT and chemical shift MRI enable detection and characterization of lipid-rich adenomas based on an unenhanced CT attenuation of ≤ 10 HU and signal loss on opposed-phase compared to in-phase T1-weighted images, respectively. In indeterminate cases, an adrenal CT washout study may differentiate adenomas (both lipid-rich and lipid-poor) from other adrenal neoplasms based on an absolute percentage washout of >60% and/or a relative percentage washout of >40%. This is based on the principle that adenomas show rapid contrast washout while most other adrenal neoplasms including malignant tumours show slow contrast washout instead. ¹8F-2-fluoro-2-deoxy-d-glucose-PET (¹8FDG-PET) imaging may differentiate benign from malignant adrenal neoplasms by demonstrating high tracer uptake in malignant neoplasms based on the increased glucose utilization and metabolic activity found in most of these malignancies. In this review, the multi-modality imaging appearances of adrenal neoplasms are discussed and illustrated. Key imaging findings that facilitate lesion characterization and differentiation are emphasized. Awareness of these imaging findings is essential for improving diagnostic confidence and for reducing misinterpretation errors.

Value of subtraction MRI in assessing treatment response following image-guided loco-regional therapies for hepatocellular carcinoma.

AIM: To compare contrast-enhanced subtraction magnetic resonance imaging (MRI) with contrast-enhanced standard MRI in assessing treatment response following loco-regional therapies for hepatocellular carcinoma (HCC). METHOD AND MATERIALS: Institutional review board approval was obtained and informed consent was waived for this retrospective study. All patients were analysed from our institution's liver tumour database that had loco-regional HCC therapy and the following: (1) a contrast-enhanced MRI ≤6 weeks post-treatment, (2) an unenhanced T1-weighted high-signal treatment zone (TZ) ≥1 cm, (3) follow-up contrast-enhanced MRI performed ≥6 months post-treatment. Randomized standard and subtraction TZ datasets were independently assessed by three blinded radiology readers for either complete treatment necrosis or residual disease. The standard of reference (SOR) comprised a consensus read by two radiologists with knowledge of the follow-up MRI and all available clinical data. Statistical analyses were performed using receiver operating characteristics (ROC), t-test, and kappa statistic. RESULTS: Twenty-six patients (19 male and seven female patients; mean age 60 years, standard deviation 10.9 years, range 46-88 years) had a total of 45 corresponding HCCs and TZs. For ROC, the area under the curve (AUC) was 0.93 (subtraction protocol) versus 0.90 (standard protocol; p = 0.49). For the t-test, the mean reader confidence level was 4.4, 3.6, and 4.4 (subtraction protocol) versus 3, 3, and 3.7 (standard protocol; p ≤ 0.011). The kappa statistic for reader-to-SOR agreement was 0.83, 0.63, and 0.71 (subtraction protocol) versus 0.51, 0.36, and 0.64 (standard protocol). CONCLUSION: Subtraction MRI significantly improves the reader confidence level in the assessment of treatment response following loco-regional therapies for HCC.

The role of imaging in the pre-operative staging and post-operative follow-up of rectal cancer.

Developments in rectal cancer imaging have revolutionised the management of this condition. It has become increasingly important for oncologists and surgeons to have a working insight into radiological assessment in order to make informed clinical decisions. In this context, we discuss the role that imaging plays in the pre-operative staging, post-operative follow-up and therapy of this disease including some novel advances in the field. Rectal cancer outcomes have improved due to modern surgical techniques, namely total mesorectal excision. Meticulous pre-operative assessment remains key. Conventional TNM staging now appears less crucial compared to assessing tumour distance from the potential plane of surgical resection (particularly the circumferential margin bounded by the mesorectal fascia), and this is reliant on high-quality imaging. Those with margin threatening disease can be offered downstaging chemoradiotherapy to facilitate successful resection. Endorectal ultrasound is useful for T staging and CT for detecting metastases. Malignant lymph node identification remains a problem and the use of size and morphological criteria may lead to misdiagnosis. In the post-operative setting, intensive follow-up is associated with improved outcomes but there are many variations in protocols. Most modalities struggle to differentiate tumour from reactive or fibrotic tissue and functional imaging is being investigated as the solution. PET scanning, particularly PET/CT, has been a major recent development. It has superior utility in detecting recurrent disease, including when conventional imaging is negative, detects occult metastases and may significantly enhance our ability to deliver accurate radiotherapy. Imaging has also opened up avenues for guided therapies aimed at ablating liver metastases. Radiofrequency ablation, in particular, is being used successfully and can improve survival of stage four patients.

Evaluation of biliary ductal anatomy in potential living liver donors: comparison between MRCP and Gd-EOB-DTPA-enhanced MRI.

PURPOSE: To compare magnetic resonance cholangiopancreatography (MRCP) and Gd-EOB-DTPA-enhanced MRI in the evaluation of the biliary anatomy in potential living liver donors (LLDs). METHODS: A retrospective study was conducted in a tertiary care liver transplant center after obtaining ethics and institutional approvals. A total of 42 potential LLD MRI examinations were performed between November 2013 and March 2016. All patients underwent a standard MRI protocol which included MRCP and Gd-EOB-DTPA-enhanced MRI sequences in a single session. Three abdominal MR radiologists independently reviewed the studies and completed a customized data collection sheet for each MR sequence. The readers subjectively scored the bile duct visualization on each MR sequence on a Likert scale and classified the biliary anatomic configuration. Statistical analysis was performed using intraclass correlation coefficient and the McNemar Chi-square (χ 2) test. RESULTS: The 42 potential LLDs included 22 males and 20 females with an age range of 18-60 years. There was 'good' or 'excellent' inter-reader agreement on either MRI examination for the visualization of the first- and second-order ducts and the majority of third-order ducts. 'Good' inter-reader agreement on Gd-EOB-DTPA-enhanced MRI and 'fair' inter-reader agreement on MRCP was noted for the left third-order medial duct. There was significantly better visualization of the cystic duct, left hepatic duct, and right second-order ducts on Gd-EOB-DTPA-enhanced MRI compared with MRCP. A 12.6% improvement in classifying the biliary branch pattern was also observed on Gd-EOB-DTPA-enhanced MRI compared with MRCP (P = 0.03). CONCLUSION: Gd-EOB-DTPA-enhanced MRI provides additional diagnostic confidence over MRCP in the evaluation of the biliary ductal anatomy in potential LLDs.

Elevated mercury concentrations in fish in lakes in the Mackenzie River Basin: the role of physical, chemical, and biological factors.

During the mid-1990s and through the early 2000s, researchers determined that elevated mercury concentrations were a common occurrence in predatory fish in many lakes in the Mackenzie River Basin (MRB), located in northern Canada. Here we present the results of studies investigating factors contributing to higher mercury concentrations in fish in many of these lakes. Twenty-two percent of lake trout, 33% of northern pike, and 50% of walleye populations had mean mercury concentrations >0.5 microg/g, the guideline for the commercial sale of fish. Higher mercury concentrations were strongly associated with the relatively old age of MRB predatory fish; mean age ranged from 7.6 to 24.9 years for the three species. In contrast, none of the lake trout sampled in eight lakes further south in northern Saskatchewan and Alberta had mean mercury concentrations >0.5 microg/g; fish also were younger (mean age 6 years for the 8 lakes). Mercury concentrations in MRB fish generally increased with fish length, age, and trophic feeding although the nature of these relationships varied with the lake. Mean length was a good predictor of mean mercury concentrations in walleye populations across the study lakes but not for whitefish, lake trout, and pike; age was a good predictor for lake trout and walleye. Mercury concentrations in water and invertebrates were similar to those observed in more southerly regions where fish do not have elevated mercury concentrations. Mercury concentrations tended to be higher in fish in smaller vs. larger lakes and as a probable consequence of higher summer epilimnion temperatures, which favour a higher net methylation rate, and higher mercury and methyl mercury concentrations in water which enter these lakes from the watershed. Increasing fishing pressures on MRB lakes may be a means of reducing mean fish age, improving growth rates, and decreasing mercury body burdens. Increased global warming may result in higher mercury concentrations in fish through increased water temperatures, a longer ice free season, and increased release of stored mercury from the watershed into these lakes.

A history of total mercury in edible muscle of fish from lakes in northern Canada.

Subsistence fishing has been an important source of food for Native People in northern Canada since prehistoric time. Measurements of the levels of mercury in edible muscle of northern fish have been undertaken for over three decades in efforts to evaluate the risks of consuming northern fish. This report summarizes the data obtained from 7974 fish of 25 species from sites distributed from the Yukon to Labrador. The most abundant species were lake trout, lake whitefish, arctic char, walleye, northern pike and burbot. The question being asked was essentially "Are the fish safe to eat?" The results were used to support decisions on fishing and consumption of fish. They were sorted in several ways, into concentration ranges corresponding to human consumption guidelines, into political jurisdictions and into types of bedrock geology. Overall walleye, northern pike and lake trout, usually exceeded the subsistence consumption guideline of 0.2 microg g-1 total mercury and often exceeded the higher guideline of 0.5 microg g-1 total mercury for commercial sales of fish. Mercury in burbot, another facultative predator, was often lower but several still exceeding a guideline. Arctic char collections were mostly from anadromous populations and these had very low levels of mercury, presumably reflecting marine food sources. Lake whitefish were among the cleanest fish examined with 69 of 81 collections falling in the lowest range. Most collections were from sites in sedimentary rock. However a few sites were in metamorphic, intrusive or volcanic rocks and these, taken together, tended to have a higher proportion of sites in the higher ranges of mercury. These results indicate a widespread problem with mercury in subsistence fisheries for predator species of fish with the problem being most problematic for Nunavut.

Hepatorenal syndrome: aetiology, diagnosis, and treatment.

Acute renal impairment is common in patients with chronic liver disease, occurring in approximately 19% of hospitalised patients with cirrhosis. A variety of types of renal impairment are recognised. The most important of these is the hepatorenal syndrome, a functional renal impairment due to circulatory and neurohormonal abnormalities that underpin cirrhosis. It is one of the most severe complications of cirrhosis with survival often measured in weeks to months. A variety of treatment options exist with early diagnosis and appropriate treatment providing the best hope for cure. This paper provides a comprehensive and up-to-date review of hepatorenal syndrome and lays out the topic according to the following sections: pathophysiology, historical developments, diagnostic criteria and limitations, epidemiology, precipitating factors, predictors, clinical and laboratory findings, prognosis, treatment options, prophylaxis, and conclusion.