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Case 1 A 31-year-old pregnant woman (38 wk + 2 d) presented to the obstetrics and gynecology team with a 5-day history of cough, low-grade fever (maximum temperature 37.8[degrees]C) and [...]

Purpose: Targeting accuracy determines outcomes for percutaneous needle interventions. Augmented reality (AR) in IR may improve procedural guidance and facilitate access to complex locations. This study aimed to evaluate percutaneous needle placement accuracy using a goggle-based AR system compared to an ultrasound (US)-based fusion navigation system. Methods: Six interventional radiologists performed 24 independent needle placements in an anthropomorphic phantom (CIRS 057A) in four needle guidance cohorts (n= 6 each): (1) US-based fusion, (2) goggle-based AR with stereoscopically projected anatomy (AR-overlay), (3) goggle AR without the projection (AR-plain), and (4) CT-guided freehand. US-based fusion included US/CT registration with electromagnetic (EM) needle, transducer, and patient tracking. For AR-overlay, US, EM-tracked needle, stereoscopic anatomical structures and targets were superimposed over the phantom. Needle placement accuracy (distance from needle tip to target center), placement time (from skin puncture to final position), and procedure time (time to completion) were measured. Results: Mean needle placement accuracy using US-based fusion, AR-overlay, AR-plain, and freehand was 4.5 ± 1.7 mm, 7.0 ± 4.7 mm, 4.7 ± 1.7 mm, and 9.2 ± 5.8 mm, respectively. AR-plain demonstrated comparable accuracy to US-based fusion (p= 0.7) and AR-overlay (p= 0.06). Excluding two outliers, AR-overlay accuracy became 5.9 ± 2.6 mm. US-based fusion had the highest mean placement time (44.3 ± 27.7 s) compared to all navigation cohorts (p< 0.001). Longest procedure times were recorded with AR-overlay (34 ± 10.2 min) compared to AR-plain (22.7 ± 8.6 min, p= 0.09), US-based fusion (19.5 ± 5.6 min, p= 0.02), and freehand (14.8 ± 1.6 min, p= 0.002). Conclusion: Goggle-based AR showed no difference in needle placement accuracy compared to the commercially available US-based fusion navigation platform. Differences in accuracy and procedure times were apparent with different display modes (with/without stereoscopic projections). The AR-based projection of the US and needle trajectory over the body may be a helpful tool to enhance visuospatial orientation. Thus, this study refines the potential role of AR for needle placements, which may serve as a catalyst for informed implementation of AR techniques in IR.

Fusing intraoperative 2-D ultrasound (US) frames with preoperative 3-D magnetic resonance (MR) images for guiding interventions has become the clinical gold standard in image-guided prostate cancer biopsy. However, developing an automatic image registration system for this application is challenging because of the modality gap between US/MR and the dimensionality gap between 2-D/3-D data. To overcome these challenges, we propose a novel US frame-to-volume registration (FVReg) pipeline to bridge the dimensionality gap between 2-D US frames and 3-D US volume. The developed pipeline is implemented using deep neural networks, which are fully automatic without requiring external tracking devices. The framework consists of three major components, including one) a frame-to-frame registration network (Frame2Frame) that estimates the current frame’s 3-D spatial position based on previous video context, two) a frame-to-slice correction network (Frame2Slice) adjusting the estimated frame position using the 3-D US volumetric information, and three) a similarity filtering (SF) mechanism selecting the frame with the highest image similarity with the query frame. We validated our method on a clinical dataset with 618 subjects and tested its potential on real-time 2-D-US to 3-D-MR fusion navigation tasks. The proposed FVReg achieved an average target navigation error of 1.93 mm at 5–14 fps. Our source code is publicly available at https://github.com/DIAL-RPI/Frame-to-Volume-Registration.

After decades of conflict overseas, military service members are returning home as survivors of tragic injuries from war due to incredible advances in battlefield medicine and combat casualty care. Meanwhile, veterans from past wars and conflicts are also experiencing service-related health issues along with the natural effects of aging. Regardless of whether they served in the Vietnam War or the Iraq War, many veterans increasingly need long-term medical care and support. Oftentimes, family members nobly and selflessly take on these caregiving responsibilities. There are millions of these "hidden heroes" across the country, including the spouses, parents, and other family members who care for the nation's wounded, ill, or injured veterans. One of the foremost challenges that these family members face is balancing caregiving responsibilities at home with professional work outside the home. Likewise, employers face challenges when accommodating employees who are family military caregivers. This Article examines the critical employment law protections for family military caregivers. First, this Article explores the modern challenges that these caregivers face and the associated public policy concerns, including military recruitment and retention concerns. Next, this Article examines the specific employment law protections available for military family caregivers. The Article then shifts to examine best practices for employers so they can recruit and retain military caregiver employees. Finally, this Article argues that current protections are woefully inadequate and outlines and advances several solutions to help ameliorate the status quo, including legislative and regulatory measures. [ABSTRACT FROM AUTHOR]

Purpose: Thermal ablation of large tumors may benefit from simultaneous placement of multiple needles, but accurate placement becomes challenging as the number of needles increases. The aim of this work was to evaluate use of personalized needle guidance grid templates based on intraprocedural CT and fabricated at the point of care to implement ablation treatment plans with multiple needles in vivo. Methods: A plastic frame was designed to hold two parallel plastic guide plates in a rigid relationship, fixed over the abdomen by a mounting arm. Steel ball targets (1.5 mm) were implanted under ultrasound in the livers of two domestic swine under general anesthesia. Following breath-hold CT of the subject and frame, the targets and frame were identified using customized 3D Slicer-based planning software. Multiple needle trajectories targeting the balls were planned, including complex off-plane trajectories. A machining program for drilling the hole pattern corresponding to the planned needle trajectories was generated. The pattern was drilled in the two plates with a numerical-controlled milling machine in the suite. The plates were attached to the frame and needles passed through the paired holes to the calculated depth. Placement accuracy was defined as needle tip-to-target distance on post-placement CT. Results: The planning process and manufacturing required approximately 6 and 15 min, respectively. Needles were rapidly inserted (n= 11) to the target points without complications or traversing nontarget anatomy. The mean needle tip-to-target distance error was 3.4 ± 2.2, range 0–7 mm. Conclusion: Rapid and accurate needle placement was feasible using a subject-specific, custom-drilled, needle guidance grid template fabricated intraprocedurally. Targeting accuracy and performance were similar to more complex and expensive tracking systems which may enable accurate intraprocedural implementation of treatment plans in the liver or other organs. This may be of value in complex ablation cases or in areas where more advanced guidance systems are not available.

Transrectal ultrasound is commonly used for guiding prostate cancer biopsy, where 3D ultrasound volume reconstruction is often desired. Current methods for 3D reconstruction from freehand ultrasound scans require external tracking devices to provide spatial information of an ultrasound transducer. This paper presents a novel deep learning approach for sensorless ultrasound volume reconstruction, which efficiently exploits content correspondence between ultrasound frames to reconstruct 3D volumes without external tracking. The underlying deep learning model, deep contextual-contrastive network (DC$^{2}$-Net), utilizes self-attention to focus on the speckle-rich areas to estimate spatial movement and then minimizes a margin ranking loss for contrastive feature learning. A case-wise correlation loss over the entire input video helps further smooth the estimated trajectory. We train and validate DC$^{2}$-Net on two independent datasets, one containing 619 transrectal scans and the other having 100 transperineal scans. Our proposed approach attained superior performance compared with other methods, with a drift rate of 9.64$\mathbf{\%}$ and a prostate Dice of 0.89. The promising results demonstrate the capability of deep neural networks for universal ultrasound volume reconstruction from freehand 2D ultrasound scans without tracking information.

A little known federal statute may soon become a significant factor in settlements and judgments in liability cases. The Medicare Secondary Payer Act sets forth the statutory framework for what [...]

General Alfred M. Gray Jr., the 29th Commandant of the Marine Corps, passed away at the age of 95. He had a diverse and varied career, serving in various roles including artillery officer, infantry officer, communications officer, aerial observer, and intelligence officer. Gen Gray's leadership had a lasting impact on the Marine Corps, including the development of tactical doctrine and warfighting philosophy. Marine Aviation, which has a long history of delivering speed, agility, and lethality, is currently focused on modernization through Project EAGLE, which aims to maintain the Marine Corps' competitive advantage in all warfighting functions. [Extracted from the article]

Supplemental digital content is available in the text.

Purpose: Adrenocortical carcinoma (ACC) is a rare malignancy of the adrenal cortex. Despite the rarity of ACC, highly aggressive nature of this malignancy highlights the importance of early diagnosis and timely initiation of treatment. Accurate pre-surgical diagnosis and staging are critical to distinguish ACC from benign adrenal adenomas and to evaluate distant metastatic disease. Imaging methods with high sensitivity and specificity are indispensable in this endeavor. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) plays an important complementary role to anatomical imaging in the initial diagnosis of ACC, staging, and response assessment to treatment. In this manuscript, we comprehensively review the literature on the role of 18F-FDG PET/CT and the complementary role it plays with regards to structural imaging modalities in various phases of management of ACC. Methods: We searched the literature for related terms to “adrenal lesions”, “adrenocortical carcinoma”, and “18F-FDG PET/CT” by mapping their Medical Subject Heading (MeSH) tree structure using the Public Library of Medicine’s (PubMed) Automatic Term Mapping (ATM). Then, we used all categories to search the PubMed database and Web of Science (Clarivate Analytics) Core Collection from 1950 to February 2021. Results: After excluding studies in languages other than English, our initial search resulted in 506 publications. Twenty-one articles discussing adrenal involvements with non-neoplastic nature such as tuberculosis and histoplasmosis were excluded resulting in a total of 485 studies, including 320 original research manuscripts, 82 review articles, 54 editorial materials, and 29 meeting abstracts. The selected number of manuscripts that are cited in this article reflect an in-depth review of the publications focused on the role of 18F-FDG PET/CT in management of ACC as established in the literature. Our results showed that 18F-FDG PET/CT could play an important role in primary diagnosis of adrenal lesions including ACC tumors. This imaging modality demonstrated higher sensitivity in identification of malignant tumors compared to non-enhanced CT. Moreover, this modality demonstrated added complementary value to anatomical imaging in identification of distant metastases and staging, assessment of local disease recurrence, and finally evaluation of locoregional response to systemic therapy in ACC patients. Conclusion: 18F-FDG PET/CT could play an important complementary role to structural imaging in evaluation of ACC tumors. Prospective studies assessing the value of 18F-FDG PET/CT are encouraged to definitively assess the incremental benefit of functional imaging compared to structural imaging.

Historically, investment committees have relied on risk/return asset-only strategies when making investment decisions for balance sheet asset pools. However, recent research confirms that these allocation strategies can have a significant [...]

Popular evapotranspiration (ET) partitioning methods make assumptions that might not be well‐suited to dryland ecosystems, such as high sensitivity of plant water‐use efficiency (WUE) to vapor pressure deficit (VPD). Our objectives were to (a) create an ET partitioning model that can produce fine‐scale estimates of transpiration (T) in drylands, and (b) use this approach to evaluate how climate controls T and WUE across ecosystem types and timescales along a dryland aridity gradient. We developed a novel, semi‐mechanistic ET partitioning method using a Bayesian approach that constrains abiotic evaporation using process‐based models, and loosely constrains time‐varying WUE within an autoregressive framework. We used this method to estimate daily T and weekly WUE across seven dryland ecosystem types and found that T dominates ET across the aridity gradient. Then, we applied cross‐wavelet coherence analysis to evaluate the temporal coherence between focal response variables (WUE and T/ET) and environmental variables. At yearly scales, we found that WUE at less arid, higher elevation sites was primarily limited by atmospheric moisture demand, and WUE at more arid, lower elevation sites was primarily limited by moisture supply. At sub‐yearly timescales, WUE and VPD were sporadically correlated. Hence, ecosystem‐scale dryland WUE is not always sensitive to changes in VPD at short timescales, despite this being a common assumption in many ET partitioning models. This new ET partitioning method can be used in dryland ecosystems to better understand how climate influences physically and biologically driven water fluxes. We developed a new model to better understand how plants use and lose water in drylands and applied it to seven dryland sites. Our model partitions evapotranspiration—the total water lost to the atmosphere from the Earth's surface— into its components. Evapotranspiration consists of both evaporation from wet surfaces, such as wet soil, and the water lost from plants when they photosynthesize. Currently, models assume a strong relationship between the efficiency with which plants use water (“water‐use efficiency”) and the dryness of the atmosphere, but this violates what we know about how plants function in drylands. For example, in drylands many plants are adapted to very dry conditions and their water use can be less sensitive to increasing atmospheric dryness compared to plants from wet environments. Using this new model, we found that plant water‐use efficiency is only correlated with atmospheric dryness some of the time and that evapotranspiration is primary controlled by water lost from plants. This model allows us to better understand the importance of timescale and ecosystem type in governing plant water‐use dynamics and more accurately assess the potential impact of changing climate conditions on dryland water fluxes and ecosystem processes. A new evapotranspiration partitioning model (DEPART) was developed using eddy covariance flux tower measurements in a Bayesian frameworkThis method produces daily estimates of transpiration and weekly estimates of plant water‐use efficiency at the ecosystem scaleThis method reveals water‐use efficiency is limited by moisture supply in more arid climates and moisture demand in less arid climates A new evapotranspiration partitioning model (DEPART) was developed using eddy covariance flux tower measurements in a Bayesian framework This method produces daily estimates of transpiration and weekly estimates of plant water‐use efficiency at the ecosystem scale This method reveals water‐use efficiency is limited by moisture supply in more arid climates and moisture demand in less arid climates

OBJECTIVE--The aim of this study was to describe the National Institutes of Health's experience initiating an islet isolation and transplantation center, including descriptions of our first six recipients, and lessons [...]

While magnetic resonance imaging (MRI)-targeted biopsy (TBx) results in better prostate cancer (PCa) detection relative to systematic biopsy (SBx), the combination of both methods increases clinically significant PCa detection relative to either Bx method alone. However, combined Bx subjects patients to higher number of Bx cores and greater detection of clinically insignificant PCa.

Objectives: To compare CT virtual bronchoscopy (VB) to CT alone and to conventional bronchoscopy for evaluation of central airway stenoses in patients with Wegener's granulomatosis. Design: Prospective observer study, in [...]

A testimonial to the late Judge Giles S. Rich of the U.S. Court of Appeals is given. Rich's devotion to thinking, clarity and logic in the business of judging are legendary, and fidelity in writing, judging, teaching and character was the cornerstone of his life. His many contributions as judge to patent law are summarized.

A panel of experts reached consensus on recommendations on when to assess oncologic outcomes per patient, per session, and per tumor; definitions of starting and ending times; definitions of survival time; and time-to-event end points.

Byline: Bradford J Wood, Stuart E Mirvis, Kathirkamuganathan Shanmuganathan Abstract: We present the first reported case of vision loss due to tension orbital emphysema associated with tension pneumocephalus resulting from blunt trauma. In the setting of trauma, intraorbital air indicates paranasal sinus-orbital communication. Tension orbital emphysema may cause vision loss through optic nerve compression, ischemia, or contusion; or central retinal artery occlusion. Vision impairment after craniofacial injury should prompt urgent computed tomography. Tension orbital emphysema with associated vision impairment requires treatment including direct decompression and, in some cases, high-dose steroids to preserve vision. Increases in sinus pressure from coughing, nose-blowing, or vomiting should be avoided until definitive treatment can be instituted. [Wood BJ, Mirvis SE, Shanmuganathan K: Tension pneumocephalus and tension orbital emphysema following blunt trauma. Ann Emerg Med October 1996;28:446-449.] Article History: Received 28 February 1996; Revised 5 June 1996; Accepted 10 June 1996 Article Note: (footnote) [star] From the Department of Radiology*, and Shock Trauma Centera , University of Maryland Medical Center, Baltimore, Maryland; and the Department of Radiology, Georgetown University Medical Center, Washington DCAs.., [star][star] Address for reprints: Stuart Mirvis, MD, Department of Radiology, University of Maryland Medical Center, 22 Greene Street, Baltimore, Maryland 21201, 410-328-8845, Fax 410-328-0641, a Reprint no. 47/1/76437

Federated learning (FL) is a method used for training artificial intelligence models with data from multiple sources while maintaining data anonymity, thus removing many barriers to data sharing. Here we used data from 20 institutes across the globe to train a FL model, called EXAM (electronic medical record (EMR) chest X-ray AI model), that predicts the future oxygen requirements of symptomatic patients with COVID-19 using inputs of vital signs, laboratory data and chest X-rays. EXAM achieved an average area under the curve (AUC) >0.92 for predicting outcomes at 24 and 72 h from the time of initial presentation to the emergency room, and it provided 16% improvement in average AUC measured across all participating sites and an average increase in generalizability of 38% when compared with models trained at a single site using that site’s data. For prediction of mechanical ventilation treatment or death at 24 h at the largest independent test site, EXAM achieved a sensitivity of 0.950 and specificity of 0.882. In this study, FL facilitated rapid data science collaboration without data exchange and generated a model that generalized across heterogeneous, unharmonized datasets for prediction of clinical outcomes in patients with COVID-19, setting the stage for the broader use of FL in healthcare.

The term "inherently" appears in a variety of patent law contexts and is often applied as a standard of proof for certain defenses to patent actions. The most common usage relates to anticipation claims in which it is argued that the invention in question was based on material inherently disclosed in prior art. The term also arises in unobviousness claims, interference actions and disclosure and description requirements. Extrinsic evidence may be used to show inherency. Inherency claims are most successful on latency issues.

We analyzed the records of 132 patients hospitalized between July 1986 and February 1989 for management of traumatic hyphema. The incidence of secondary hemorrhage was compared between patients treated with or without systemic administration of aminocaproic acid in addition to an otherwise identical protocol. Results among patients who were examined within one day of injury disclosed a 4.8% secondary hemorrhage rate in aminocaproic acid-treated patients (three of 63 patients) compared with a 5.4% rate in the patients not treated with aminocaproic acid (three of 56 patients, P = .31). All six patients sustaining secondary hemorrhage recovered visual acuities of 20/40 or better, with five of six patients achieving 20/20 visual acuities. A separate group of 13 patients who were examined more than one day after injury were found to have a secondary hemorrhage rate of 38.5% (five of 13 patients). Macular injury, not secondary hemorrhage, was most often responsible among those patients suffering permanent visual loss. In this study of a predominantly white population, patients had a relatively low incidence of secondary hemorrhage and did not demonstrate detectable benefit from aminocaproic acid administration. Because of the recognized side effects and cost of treatment, further analysis to determine which patients will benefit from treatment with aminocaproic acid is indicated., There is lack of agreement concerning the best method for treatment of traumatic hyphema (hemorrhage into the anterior chamber of the eye, between the cornea and the lens). The goal of treatment is to identify the site of injury, control the increased intraocular pressure and prevent subsequent bleeding. Secondary hemorrhage is usually more severe than the initial hemorrhage and may result in vision-threatening complications. The reported incidence of secondary hemorrhage varies by population group from 3.5 percent to 38 percent. Blacks may have a higher incidence than whites; however, there are conflicting reports on this difference. The only treatment shown to reduce the risk of secondary hemorrhage is treatment with corticosteroids. One study reported a low incidence (7.1 percent) of secondary hemorrhage in patients treated with systemic aminocaproic acid; other studies have found no beneficial effect from treatment with aminocaproic acid. A report is presented of 132 patients treated for traumatic hyphema between July 1986 and February 1989. Patients were predominantly white. There were 119 patients examined within a day of injury and 13 examined later than 24 hours after injury. Comparison was made between patients treated with and those treated without systemic aminocaproic acid. Patients examined within a day of injury who had been treated with aminocaproic acid had a 4.8 percent incidence of secondary hemorrhage, compared with 5.4 percent for those not treated with aminocaproic acid; this difference was not significant. All six patients with secondary hemorrhage regained vision of 20/40 or better. A separate group of 13 patients was examined more than one day after injury; this group had a 38.5 percent incidence of secondary hemorrhage. It is concluded that use of aminocaproic acid did not appear to benefit this study group. Further study is needed to determine if patients examined more than one day after injury may benefit from this expensive treatment, with recognized side effects. (Consumer Summary produced by Reliance Medical Information, Inc.)

Multiparametric MRI provides prognostic information, and pairing information from MRI with molecular characterization from biopsy samples may assist prostate cancer risk stratification.

A deep learning–based algorithm automatically detected cancerous lesions on prostate biparametric MRI scans with reasonable performance and reliably predicted clinically significant prostate cancer at biopsy.

The ability of serial magnetic resonance imaging (MRI) to capture pathologic progression during active surveillance (AS) remains in question.

ABSTRACTIntroductionDrug-eluting embolic (DEE) microspheres, or drug-eluting beads (DEB), delivered by transarterial chemoembolization (TACE) serve as a therapeutic embolic to stop blood flow to tumors and a drug delivery vehicle. New combinations of drugs and DEE microspheres may exploit the potential synergy between mechanisms of drug activity and local tissue responses generated by TACE to enhance the efficacy of this mainstay therapy.Areas coveredThis review provides an overview of key drug delivery concepts related to DEE microspheres with a focus on recent technological developments and promising emerging clinical applications as well as speculation into the future.Expert opinionTACE has been performed for nearly four decades by injecting chemotherapy drugs into the arterial supply of tumors while simultaneously cutting off their blood supply, trying to starve and kill cancer cells, with varying degrees of success. The practice has evolved over the decades but has yet to fulfill the promise of truly personalized therapies envisioned through rational selection of drugs and real-time multi-parametric image guidance to target tumor clonality or heterogeneity. Recent technologic and pharmacologic developments have opened the door for potentially groundbreaking advances in how TACE with DEE microspheres is performed with the goal of achieving advancements that benefit patients.

Photon-counting CT (PCCT) detectors are the next step in advancing CT system development and will replace the current energy-integrating detectors (EIDs) in CT systems in the near future. In this context, the performance of PCCT was compared to EID CT for three clinically relevant tasks: 1) abdominal soft tissue imaging, where differentiating low contrast features is important; 2) vascular imaging, where iodine detectability is critical; and 3) high-resolution skeletal and lung imaging. A multitiered phantom was imaged on an investigational clinical PCCT system (Siemens Healthineers) across different doses using three imaging modes: macro and ultrahigh resolution (UHR) PCCT modes and EID CT. Images were reconstructed using filtered backprojection and soft tissue (B30f), vascular (B46f), or high-resolution (B70f; U70f for UHR) kernels. Noise power spectra, task transfer functions, and detectability index were evaluated. For a soft tissue task, PCCT modes showed comparable noise and resolution with improved contrast-to-noise ratio. For a vascular task, PCCT modes showed lower noise and improved iodine detectability. For a high resolution task, macro mode showed lower noise and comparable resolution while UHR mode showed higher noise but improved spatial resolution for both air and bone. PCCT offers competitive advantages to EID CT for clinical tasks.