Variability in Liver Size Measurements Using Different View Angles in Ultrasound Imaging.

PURPOSE: The aim of this study was to compare liver size measurements in different conventional B-mode ultrasound image (US) field views using magnetic resonance imaging (MRI) measurement as a reference. METHODS: After receiving Institutional Review Board approval and informed consent, three operators measured the largest sagittal and transverse dimensions of adult livers on three US image field views (90°, 120°, and 140°) with a single curvilinear transducer. We analyzed the differences in liver size across three image field views using one-way analysis of variance (ANOVA) and examined the correlations between MRI and ultrasound measurements using Spearman regression. We used 95% Bland-Altman limits of agreement (95% LOA) to analyze the confidence interval for liver size measurements between MRI and US. Intra-observer and inter-observer reliability in measuring liver size were assessed using intraclass correlation coefficient (ICC). RESULTS: Based on sagittal liver length, 28 adult participants (7 men and 21 women, mean age 43 years) were divided into Group 1 (<17 cm, n = 10) or Group 2 (≥17 cm, n = 18). There was a significant difference in the liver size measurements across the three image field views (P < .001) in both groups. The highest correlation in liver size measurements between MRI and US was with ultra-wide-view (R2 = .87 in sagittal; R2 = .79 in transverse). Bland-Altman LOA also indicated good agreement between MRI and ultra-wide-view measurements. Intra-observer and inter-observer reliability in measuring liver size were good (ICC = 0.82-0.98). CONCLUSION: The study suggests that ultrasound ultra-wide-view provides the most accurate liver size measurement and good intra- and inter-operator reliability.

Young widowhood: A qualitative study of sexuality after partner loss.

Partner loss deprives young widows of physical contact, emotional intimacy, and the fulfillment of sexual desire. Although disenfranchised and oppressed, sexuality is a core piece of women's identity, and sexual bereavement may compel widows to reconstruct their sexual identities. This existential phenomenological study seeks to illuminate the sexual loss and coping of young widows aged 45 and under. Qualitative findings from 21 women indicated three findings: a) young widows felt profound loss regarding their sexual relationships, leading to deep physical loneliness and an initial disinterest in sex; b) some subsequently experienced widows' fire, an involuntary and often distressing intense sexual desire marked by cravings, obsessive thoughts, and a longing for connection; c) widows' fire complicated their struggle to understand their post-loss identities as sexual beings. These findings highlight the neglected and significant repercussions of sexual loss for young widows and point to a need for heightened support, psychoeducation, and research.

Does the clopidogrel CYP2C19 genotype assay predict postprocedure stenosis in cerebral aneurysms treated with a flow diverter?

OBJECTIVE: Flow diverters have emerged as a popular modality for treating cerebral aneurysms but require dual antiplatelet therapy (DAPT) after placement. Clopidogrel is a common choice but is a prodrug that some patients may not convert into an active metabolite. The CYP2C19 genotype assay is used to predict activation speed; however, limited data exist showcasing whether this genotype accurately predicts postprocedure complications after flow diversion treatment of cerebral aneurysms. Therefore, the authors sought to characterize whether CYP2C19 genotype correlated with the development of postprocedure intimal hyperplasia (stenosis) after flow diverter placement. METHODS: Medical records were reviewed for patients who underwent flow diverter treatment of cerebral aneurysm at a single academic institution between January 1, 2012, and May 31, 2020. Patient demographics and comorbidities were reviewed alongside CYP2C19 genotype assay, DAPT regimen, and postprocedure angiogram data. Stenosis was defined based on review of angiogram data by two independent physicians. RESULTS: In this review of 120 unique cerebral aneurysms, 102 received DAPT with clopidogrel and 18 received DAPT with an alternative agent. Stenosis was present on 3-month follow-up angiogram for 35/102 (34.3%) aneurysms receiving DAPT with clopidogrel and in 11/18 (61.1%) aneurysms receiving an alternative DAPT regimen (p = 0.031). The CYP2C19 genotype did not correlate with postprocedure stenosis (p = 0.35). CONCLUSIONS: Clopidogrel was a significantly more effective DAPT agent for preventing stenosis when compared to nonclopidogrel DAPT regimens. The clopidogrel CYP2C19 genotype did not predict postprocedure stenosis in this cohort of 120 cerebral aneurysms treated with a flow diverter.

Commentary on Ultrasound Instruction in Undergraduate Medical Education: Perspective from Two Students.

Background: Ultrasound integration in undergraduate medical education (UME) has been a focused endeavor in recent years. According to the American Institute of Ultrasound in Medicine, more than a third of all US medical schools have adopted a focused ultrasound training program for medical students. Medical student perspectives on best practices in ultrasound education are lacking in the literature. Curricula Experiences: Two students' reflections are presented regarding two different didactic approaches, flipped classroom and self-study learning models, to teaching ultrasound in the pre-clinical medical education curriculum. Students present reflections on these didactic approaches to facilitate further improvement in ultrasound education curricula. Discussion: The self-directed learning model enabled students to learn foundational ultrasound exam techniques efficiently in a low-stress environment and subsequently optimized the efficiency of later faculty-led learning events. However, we noted that in both the flipped classroom and self-study learning models of education, the training on basic physical properties of ultrasound, tissue characteristics, and probe manipulation was limited. Conclusion: A self-study learning model ultrasound curricula improves perceived learning efficiency and student confidence, especially when followed by faculty-guided didactics and scanning opportunities. We suggest a framework for ultrasound education curricula that includes components of both formats of ultrasound education alongside faculty-led sessions as an ideal model of ultrasound education. Further, we propose the added benefit of inanimate object scanning to optimize students' knowledge of waveform physics (image acquisition and physical properties of materials) early in the ultrasound education process.

Gender Disparities in Aortoiliac Revascularization in Patients with Aortoiliac Occlusive Disease.

BACKGROUND: Gender disparities have been previously reported in aortic aneurysm and critical limb ischemia outcomes; however, limited info is known about disparities in aortoiliac occlusive disease. We sought to characterize potential disparities in this specific population. MATERIAL AND METHODS: Patients who underwent aortobifemoral bypass and aortic thromboendarterectomy (Current Procedural Terminology codes 35646 and 35331) between 2012 and 2019 were identified in the National Surgical Quality Improvement Program database. A binomial regression model was used to estimate gender differences in 30-day morbidity and mortality. Inverse probability weighting was used to standardize demographic and surgical characteristics. RESULTS: We identified 1,869 patients, of which 39.8% were female and the median age was 61 years. Age, body composition, and other baseline characteristics were overall similar between genders; however, racial data were missing for 26.1% of patients. Females had a higher prevalence of preexisting chronic obstructive pulmonary disease (20.9% vs. 14.7%, prevalence difference 6.1%, P < 0.01), diabetes mellitus (25.4% vs. 19.4%, prevalence difference 6.0%, P < 0.01), and high-risk anatomical features (39.4% vs. 33.7%, prevalence difference 5.8%, P = 0.01). Preprocedural medications included a statin in only 68.2% of patients and antiplatelet agent in 76.7% of patients. Females also had a higher incidence of bleeding events when compared to males (25.2% vs. 17.5%, standardized risk difference 7.2%, P < 0.01), but were less likely to have a prolonged hospitalization greater than 10 days (18.2% vs. 20.9%, standardized risk difference -5.0%, P = 0.01). The 30-day mortality rate was not significantly different between genders (4.7% vs. 3.6%, standardized risk difference 1.2%, P = 0.25). CONCLUSIONS: Female patients treated with aortobifemoral bypass or aortic thromboendarterectomy are more likely to have preexisting chronic obstructive pulmonary disease, diabetes mellitus, and high-risk anatomical features. Regardless of a patient's gender, there is poor adherence to preoperative medical optimization with both statins and antiplatelet agents. Female patients are more likely to have postoperative bleeding complications while males are more likely to have a prolonged hospital stay greater than 10 days. Future work could attempt to further delineate disparities using databases with longer follow-up data and seek to create protocols for reducing these observed disparities.

Dynamic body acceleration as a proxy to predict the cost of locomotion in bottlenose dolphins.

Estimates of the energetic costs of locomotion (COL) at different activity levels are necessary to answer fundamental eco-physiological questions and to understand the impacts of anthropogenic disturbance to marine mammals. We combined estimates of energetic costs derived from breath-by-breath respirometry with measurements of overall dynamic body acceleration (ODBA) from biologging tags to validate ODBA as a proxy for COL in trained common bottlenose dolphins (Tursiops truncatus). We measured resting metabolic rate (RMR); mean individual RMR was 0.71-1.42 times that of a similarly sized terrestrial mammal and agreed with past measurements that used breath-by-breath and flow-through respirometry. We also measured energy expenditure during submerged swim trials, at primarily moderate exercise levels. We subtracted RMR to obtain COL, and normalized COL by body size to incorporate individual swimming efficiencies. We found both mass-specific energy expenditure and mass-specific COL were linearly related with ODBA. Measurements of activity level and cost of transport (the energy required to move a given distance) improve understanding of the COL in marine mammals. The strength of the correlation between ODBA and COL varied among individuals, but the overall relationship can be used at a broad scale to estimate the energetic costs of disturbance and daily locomotion costs to build energy budgets, and investigate the costs of diving in free-ranging animals where bio-logging data are available. We propose that a similar approach could be applied to other cetacean species.

Creating an Ultrasound Scholarly Concentration Program for Medical Students.

INTRODUCTION: Point of care ultrasound (POCUS) is increasingly prevalent and standardized in undergraduate medical education (UME); however, roughly 25% of United States medical schools lack an ultrasound curriculum. One of the commonly cited barriers to ultrasound training in UME is faculty time resources. Here, we describe an ultrasound scholarly concentration program (SCP) designed to provide medical students with ultrasound opportunities in clinical and scholarly domains, while reducing the need for extensive faculty resources. METHODS: SCPs at the University of North Carolina School of Medicine have 3 requirements: an elective course, a longitudinal portfolio, and a final scholarly project. Thus, the ultrasound SCP was designed to comprise an introductory clinical elective to ultrasound, development of a longitudinal scan portfolio, and a final scholarly project in ultrasound related research or educational innovation. A review of the literature and search of the top 50 US medical schools by US News & World Report was performed to assess the novelty of the ultrasound SCP. RESULTS: To the best of our knowledge, the ultrasound SCP is the first scholarly concentration, track or pathway offered to medical students in the United States. It is the first description of a student designed and student led curriculum focused on providing meaningful ultrasound opportunities to students without necessitating unavailable faculty resources and educational infrastructure. CONCLUSION: A novel ultrasound SCP is described which has clinical aims to expose students to clinical ultrasound as well as scholarly aims to facilitate ultrasound related research and educational innovation. It is designed to enable students to make ultrasound a defining characteristic of their medical school experience. The SCP relies on motivated student involvement and near-peer teaching in a way that is self-sustaining and self-improving.

Total energy expenditure of bottlenose dolphins (Tursiops truncatus) of different ages.

Marine mammals are thought to have an energetically expensive lifestyle because endothermy is costly in marine environments. However, measurements of total energy expenditure (TEE; kcal day-1) are available only for a limited number of marine mammals, because large body size and inaccessible habitats make TEE measurements expensive and difficult to obtain for many taxa. We measured TEE in 10 adult common bottlenose dolphins (Tursiops truncatus) living in natural seawater lagoons at two facilities (Dolphin Research Center and Dolphin Quest) using the doubly labeled water method. We assessed the relative effects of body mass, age and physical activity on TEE. We also examined whether TEE of bottlenose dolphins, and more generally of marine mammals, differs from that expected for their body mass compared with other eutherian mammals, using phylogenetic least squares (PGLS) regressions. There were no differences in body mass or TEE (unadjusted TEE and TEE adjusted for fat-free mass) between dolphins from the two facilities. Our results show that adjusted TEE decreased and fat mass increased with age. Different measures of activity were not related to age, body fat or adjusted TEE. Both PGLS and the non-phylogenetic linear regression indicate that marine mammals have an elevated TEE compared with that of terrestrial mammals. However, bottlenose dolphins expended 17.1% less energy than other marine mammals of similar body mass. The two oldest dolphins (>40 years) showed a lower TEE, similar to the decline in TEE seen in older humans. To our knowledge, this is the first study to show an age-related metabolic decline in a large non-human mammal.

An integrated comparative physiology and molecular approach pinpoints mediators of breath-hold capacity in dolphins.

BACKGROUND AND OBJECTIVES: Ischemic events, such as ischemic heart disease and stroke, are the number one cause of death globally. Ischemia prevents blood, carrying essential nutrients and oxygen, from reaching tissues, leading to cell and tissue death, and eventual organ failure. While humans are relatively intolerant to ischemic events, other species, such as marine mammals, have evolved a unique tolerance to chronic ischemia/reperfusion during apneic diving. To identify possible molecular features of an increased tolerance for apnea, we examined changes in gene expression in breath-holding dolphins. METHODOLOGY: Here, we capitalized on the adaptations possesed by bottlenose dolphins (Tursiops truncatus) for diving as a comparative model of ischemic stress and hypoxia tolerance to identify molecular features associated with breath holding. Given that signals in the blood may influence physiological changes during diving, we used RNA-Seq and enzyme assays to examine time-dependent changes in gene expression in the blood of breath-holding dolphins. RESULTS: We observed time-dependent upregulation of the arachidonate 5-lipoxygenase (ALOX5) gene and increased lipoxygenase activity during breath holding. ALOX5 has been shown to be activated during hypoxia in rodent models, and its metabolites, leukotrienes, induce vasoconstriction. CONCLUSIONS AND IMPLICATIONS: The upregulation of ALOX5 mRNA occurred within the calculated aerobic dive limit of the species, suggesting that ALOX5 may play a role in the dolphin's physiological response to diving, particularly in a pro-inflammatory response to ischemia and in promoting vasoconstriction. These observations pinpoint a potential molecular mechanism by which dolphins, and perhaps other marine mammals, respond to the prolonged breath holds associated with diving.

Respiratory sinus arrhythmia and submersion bradycardia in bottlenose dolphins (Tursiops truncatus).

Among the many factors that influence the cardiovascular adjustments of marine mammals is the act of respiration at the surface, which facilitates rapid gas exchange and tissue re-perfusion between dives. We measured heart rate (fH) in six adult male bottlenose dolphins (Tursiops truncatus) spontaneously breathing at the surface to quantify the relationship between respiration and fH, and compared this with fH during submerged breath-holds. We found that dolphins exhibit a pronounced respiratory sinus arrhythmia (RSA) during surface breathing, resulting in a rapid increase in fH after a breath followed by a gradual decrease over the following 15-20 s to a steady fH that is maintained until the following breath. RSA resulted in a maximum instantaneous fH (ifH) of 87.4±13.6 beats min-1 and a minimum ifH of 56.8±14.8 beats min-1, and the degree of RSA was positively correlated with the inter-breath interval (IBI). The minimum ifH during 2 min submerged breath-holds where dolphins exhibited submersion bradycardia (36.4±9.0 beats min-1) was lower than the minimum ifH observed during an average IBI; however, during IBIs longer than 30 s, the minimum ifH (38.7±10.6 beats min-1) was not significantly different from that during 2 min breath-holds. These results demonstrate that the fH patterns observed during submerged breath-holds are similar to those resulting from RSA during an extended IBI. Here, we highlight the importance of RSA in influencing fH variability and emphasize the need to understand its relationship to submersion bradycardia.

Spindle Cell Sarcoma of the Paraspinal Musculature with Late Pulmonary Metastases.

BACKGROUND Sarcomas account for less than 1% of all cancers. Spindle cell sarcomas are a rare form of soft tissue sarcomas classified as undifferentiated/unclassified based on their histomorphology. These tumors have a propensity for local recurrence and distant metastases are frequently found in the lungs. The risk for metastases increases with higher-grade malignancy and the size of the primary tumor. The often-painless nature of these tumors results in a delay in diagnosis, and physicians frequently overlook sarcomas in their differentials due to their rarity, complicating the disease process. CASE REPORT This article reports a case of a spindle cell sarcoma in the left paraspinal musculature in a 58-year-old Caucasian male; the tumor was excised in large pieces. There was an initial benign course, during which time the patient was undergoing regular imaging studies to evaluate for recurrence. Eight years later, the tumor metastasized to the lungs with an initial presentation of shortness of breath and pleural effusion on imaging. CONCLUSIONS Sarcomas are very rare soft tissue neoplasms, but they should not be overlooked in a physician's differentials, especially when evaluating an enlarging mass. Recommended treatment of choice is complete surgical excision with adequate resection margins of at least 1 cm or greater to a fascial barrier. Recurrence and late pulmonary metastases are common and metastatectomy is the recommended treatment choice if metastases are present.

Large Undifferentiated Pleomorphic Sarcoma of the Posterior Thigh.

BACKGROUND Sarcomas account for less than 1% of all cancers. Undifferentiated Pleomorphic Sarcoma, formerly called Malignant Fibrous Histiocytoma, is a rare subtype identified by a lack specific immunohistochemical markers for a specific lineage of differentiation. These soft tissue tumors are aggressive and rapidly enlarge. Risk for metastasis increases almost linearly as the tumor increases in size, emphasizing the importance of early detection, treatment, and post-resection monitoring. CASE REPORT This article reports a case of a large undifferentiated pleomorphic sarcoma of the posterior thigh in a 62-year-old female. Given the patient's history of thrombotic thrombocytopenic purpure, her initial mass was thought to be a hematoma following a hernia repair surgery. After diagnosis of undifferentiated pleomorphic sarcoma, she underwent radical excision revealing a 24×9.5×7cm lesion - one of the largest reported in the literature. CONCLUSIONS Sarcomas are very rare soft tissue neoplasms, but they should not be excluded in a physician's differentials when a patient presents with an enlarging soft tissue mass. Because sarcomas enlarge rapidly, delay in evaluation and management should be avoided and these patients should be quickly referred to a center specializing in sarcoma treatment. Magnetic Resonance Imaging (MRI) is the recommended initial imaging for all soft tissue masses of the extremities, trunk, and head and neck while Computed Tomography (CT) is the recommended imaging choice for retroperitoneal and visceral masses. After successful surgical excision with clean margins, patients should undergo serial monitoring by CT or MRI for surveillance of recurrence or late pulmonary metastases.

Resting Metabolic Rate and Lung Function in Wild Offshore Common Bottlenose Dolphins, Tursiops truncatus, Near Bermuda.

Diving mammals have evolved a suite of physiological adaptations to manage respiratory gases during extended breath-hold dives. To test the hypothesis that offshore bottlenose dolphins have evolved physiological adaptations to improve their ability for extended deep dives and as protection for lung barotrauma, we investigated the lung function and respiratory physiology of four wild common bottlenose dolphins (Tursiops truncatus) near the island of Bermuda. We measured blood hematocrit (Hct, %), resting metabolic rate (RMR, l O2 ⋅ min-1), tidal volume (VT, l), respiratory frequency (fR, breaths ⋅ min-1), respiratory flow (l ⋅ min-1), and dynamic lung compliance (CL, l ⋅ cmH2O-1) in air and in water, and compared measurements with published results from coastal, shallow-diving dolphins. We found that offshore dolphins had greater Hct (56 ± 2%) compared to shallow-diving bottlenose dolphins (range: 30-49%), thus resulting in a greater O2 storage capacity and longer aerobic diving duration. Contrary to our hypothesis, the specific CL (sCL, 0.30 ± 0.12 cmH2O-1) was not different between populations. Neither the mass-specific RMR (3.0 ± 1.7 ml O2 ⋅ min-1 ⋅ kg-1) nor VT (23.0 ± 3.7 ml ⋅ kg-1) were different from coastal ecotype bottlenose dolphins, both in the wild and under managed care, suggesting that deep-diving dolphins do not have metabolic or respiratory adaptations that differ from the shallow-diving ecotypes. The lack of respiratory adaptations for deep diving further support the recently developed hypothesis that gas management in cetaceans is not entirely passive but governed by alteration in the ventilation-perfusion matching, which allows for selective gas exchange to protect against diving related problems such as decompression sickness.

Chemoreception drives plastic consumption in a hard coral.

The drivers behind microplastic (up to 5mm in diameter) consumption by animals are uncertain and impacts on foundational species are poorly understood. We investigated consumption of weathered, unfouled, biofouled, pre-production and microbe-free National Institute of Standards plastic by a scleractinian coral that relies on chemosensory cues for feeding. Experiment one found that corals ingested many plastic types while mostly ignoring organic-free sand, suggesting that plastic contains phagostimulents. Experiment two found that corals ingested more plastic that wasn't covered in a microbial biofilm than plastics that were biofilmed. Additionally, corals retained ~8% of ingested plastic for 24h or more and retained particles appeared stuck in corals, with consequences for energetics, pollutant toxicity and trophic transfer. The potential for chemoreception to drive plastic consumption in marine taxa has implications for conservation.