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Objectives To develop and test the performance of computerized ultrasound image analysis using deep neural networks (DNNs) in discriminating between benign and malignant ovarian tumors and to compare its diagnostic accuracy with that of subjective assessment (SA) by an ultrasound expert. Methods We included 3077 (grayscale, n = 1927; power Doppler, n = 1150) ultrasound images from 758 women with ovarian tumors, who were classified prospectively by expert ultrasound examiners according to IOTA (International Ovarian Tumor Analysis) terms and definitions. Histological outcome from surgery (n = 634) or long‐term (≥ 3 years) follow‐up (n = 124) served as the gold standard. The dataset was split into a training set (n = 508; 314 benign and 194 malignant), a validation set (n = 100; 60 benign and 40 malignant) and a test set (n = 150; 75 benign and 75 malignant). We used transfer learning on three pre‐trained DNNs: VGG16, ResNet50 and MobileNet. Each model was trained, and the outputs calibrated, using temperature scaling. An ensemble of the three models was then used to estimate the probability of malignancy based on all images from a given case. The DNN ensemble classified the tumors as benign or malignant (Ovry‐Dx1 model); or as benign, inconclusive or malignant (Ovry‐Dx2 model). The diagnostic performance of the DNN models, in terms of sensitivity and specificity, was compared to that of SA for classifying ovarian tumors in the test set. Results At a sensitivity of 96.0%, Ovry‐Dx1 had a specificity similar to that of SA (86.7% vs 88.0%; P = 1.0). Ovry‐Dx2 had a sensitivity of 97.1% and a specificity of 93.7%, when designating 12.7% of the lesions as inconclusive. By complimenting Ovry‐Dx2 with SA in inconclusive cases, the overall sensitivity (96.0%) and specificity (89.3%) were not significantly different from using SA in all cases (P = 1.0). Conclusion Ultrasound image analysis using DNNs can predict ovarian malignancy with a diagnostic accuracy comparable to that of human expert examiners, indicating that these models may have a role in the triage of women with an ovarian tumor. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology., This article's abstract has been translated into Spanish and Chinese. Follow the links from the abstract to view the translations.

Ketoprofen is a nonsteroidal anti-inflammatory and analgesic agent that nonselectively inhibits cyclooxygenase, with both COX-1 and COX-2 inhibition. Recent studies on COX receptor expression in reptiles suggest that nonselective COX inhibitors may be more appropriate than more selective inhibitors in some reptiles, but few pharmacokinetic studies are available. The goal of this study was to determine single- and multidose (three consecutive days) pharmacokinetics of racemic ketoprofen administered intravenously and intramuscularly at 2 mg/kg in healthy juvenile loggerhead turtles (Caretta caretta). The S-isomer is the predominant isomer in loggerhead sea turtles, similar to most mammals, despite administration of a 50:50 racemic mixture. Multidose ketoprofen administration demonstrated no bioaccumulation; therefore, once-daily dosing will not require dose adjustment over time. S-isomer pharmacokinetic parameters determined in this study were Cmax of 10.1 μg/ml by IM injection, C0 of 13.4 μg/ml by IV injection, AUC of 44.7 or 69.4 μg*hr/ml by IM or IV injection, respectively, and T½ of 2.8 or 3.6 hr by IM or IV injection, respectively. Total ketoprofen plasma concentrations were maintained for at least 12 hr above concentrations determined to be effective for rats and humans. A dose of 2 mg/kg either IM or IV every 24 hr is likely appropriate for loggerhead turtles.

Four captive raptors, an American kestrel ( Falco sparverius ), peregrine falcon ( Falco peregrinus ), golden eagle ( Aquila chrysaetos ), and barn owl ( Tyto alba ), were diagnosed with ventricular and/or proventricular foreign material impactions consisting of artificial turf substrate, paper and plastic substrate, grass, and newspaper. Partial or total anorexia was reported in all birds and decreased casting in 2 birds. Survey radiographs confirmed presence of gastric enlargement in all 4 birds. The kestrel and eagle were treated unsuccessfully with gastroscopy and gastric lavage, respectively, followed by surgical intervention to remove the ventricular impactions. Both birds died of undetermined causes after surgery. The peregrine falcon died before medical or surgical intervention was started, and the owl was managed successfully with oral mineral oil and liquid diet to facilitate egestion of the foreign material as a pellet. Lead poisoning was suspected as the predisposing cause for foreign body ingestion in the eagle, but underlying causes for pica in the other birds were not determined. Radiographs can provide useful diagnostic information in sick raptors that exhibit vomiting or changes in appetite or casting frequency, and may help guide treatment decisions of impacted birds. Careful consideration of substrate, enrichment items, and access to potential foreign material that could be ingested may be the best pre-emptive management strategy in captive raptors.

Background The Southern Stingray (Dasyatis americana) is a batoid elasmobranch frequently exhibited in zoological institutions. Blood is commonly collected from the caudal hemal arch at the tail base in stingrays for the purpose of health assessment and clinical pathology tests. An alternative site that allows a dorsal or ventral approach without necessitating puncture of a cartilaginous structure has been identified between the cartilaginous pectoral fin rays (ceratotrichia). Objectives The purpose of the study was to compare CBC, plasma biochemistry analytes, and blood gas variables between blood samples collected from the caudal and pectoral fin vasculature sites of the Southern Stingray. Methods Fifteen captive Southern Stingrays (10 females, 5 males) from 4 zoo and aquarium facilities were sampled. Lithium heparinized blood samples were collected from the caudal and pectoral venipuncture sites of each animal. Values from estimated total and differential leukocyte counts, plasma biochemistry analytes, and blood gas variables were compared. Results There were no statistically significant differences between venipuncture sites for the measured analytes except for CK activity, which was statistically significantly higher in the pectoral site samples. Levels of agreement between sites were good or moderate for 22 analytes and poor for ALT, AST, CK, pO2, lactate, monocytes, and eosinophils. Conclusions The good agreement between sampling sites for the majority of the measured analytes and the lack of differences that would alter clinical interpretation support the use of the pectoral site as an alternative to the traditional caudal fin venipuncture site in Southern Stingrays.

Intravascular access in batoid species is commonly achieved using the ventral coccygeal or radial wing vessels. However, these approaches can be difficult because of the presence of cartilage, lack of specific landmarks, species variation, and small vessel size in many species. This study used postmortem contrast radiography and gross dissection to develop landmarks for a new, dependable vascular access in three Myliobatiform species commonly maintained in captivity: Atlantic stingray (Hypanus sabinus), cownose ray (Rhinoptera bonasus), and smooth butterfly ray (Gymnura micrura). The mesopterygial vein provides quick vascular access and is suitable for administration of large fluid volumes and intravascular drugs. It is located immediately ventrolateral to the metapterygium cartilage, which sits adjacent to the coelomic cavity and supports the caudal half of the pectoral fin. Using the pectoral girdle and cranial third of the metapterygium cartilage as landmarks, vascular access can be achieved by directing a needle medially at approximately a 30° (adult cownose rays) or 45° angle (Atlantic stingrays, juvenile cownose rays, smooth butterfly rays) toward the metapterygium cartilage. Differences in the degree of needle direction are due to species and age-specific shapes of the metapterygium cartilage. The mesopterygial vein is an alternate site of quick and reliable venous access in batoid species.

A 12 –yr-old female Goeldi's monkey (Callimico goeldii) in British Columbia, Canada was diagnosed with alveolar echinococcosis (AE) on postmortem examination. Echinococcus multilocularis has been identified in several species of nonhuman primates, most frequently Old World primates, in zoos and research facilities in Europe and Asia. The strain affecting this monkey was identified as a European haplotype, indistinguishable from E. multilocularis recently identified in several canids in British Columbia. The animal is suspected to have been exposed while living in a zoological institution in Alberta, where E. multilocularis has also been reported in urban coyotes. Alveolar echinococcosis is a zoonotic disease of increasing concern in the United States and Canada, and this disease should be considered on the differential list of any nonhuman primate exhibiting signs of abdominal pain or distension, along with diagnostic imaging consistent with cystic structures of the liver or other organs.

Leatherback sea turtles are globally distributed and endangered throughout their range. There are limited data available on disease in this species. Initial observations of solitary large intestinal diverticulitis in multiple leatherbacks led to a multi-institutional review of cases. Of 31 subadult and adult turtles for which complete records were available, all had a single exudate-filled diverticulum, as large as 9.0 cm in diameter, arising from the large intestine immediately distal to the ileocecal junction. All lesions were chronic and characterized by ongoing inflammation, numerous intralesional bacteria, marked attenuation of the muscularis, ulceration, and secondary mucosal changes. In three cases, Morganella morganii was isolated from lesions. Diverticulitis was unrelated to the cause of death in all cases, although risk of perforation and other complications are possible.

The objective of this study was to characterize the behavioral effects and changes in heart rate of four doses of alfaxalone delivered by intravascular injection to blue crabs (Callinectes sapidus). Thirty (male, n = 27; female, n = 3) blue crabs were randomly assigned to one of four treatment groups of alfaxalone: eight animals were assigned to each of the 5-, 10-, and 15-mg/kg treatment groups, and the remaining six animals were assigned to the 100-mg/kg group. Times for anesthetic induction and recovery periods were recorded. Righting reflex, defensive posturing, and heart rate were evaluated before, during, and after the anesthetic trial. Anesthesia was induced in all 14 animals consolidated into the high-dosage group (15 mg/kg [n = 8] and 100 mg/kg [n = 6]), which was significantly greater than 8 of 16 animals in the low-dosage group (5 mg/kg [n = 2] and 10 mg/kg [n = 6]). Median anesthesia induction time for all crabs was 0.4 min, with no significant difference in induction time between groups observed. Median recovery time was 9.4 min (n = 2), 6.1 min (n = 5), 11.3 min (n = 8), and 66.1 min (n = 5) for the 5-, 10-, 15-, and 100-mg/kg groups, respectively. Recovery times were significantly longer for crabs exposed to an induction dose of 100 mg/kg compared with the 10- and 15-mg/kg induction doses. A significant decrease in the median heart rate was observed between the baseline value and that observed at both induction and 5 min postinjection in the 100-mg/kg dose trial. Two mortalities were observed during the anesthesia trials (n = 1, 10 mg/kg; n = 1, 100 mg/kg), both associated with the autotomization of limbs. In summary, the intravascular administration of alfaxalone at 15 mg/kg provided rapid and reliable sedation, whereas alfaxalone administered at 100 mg/kg produced rapid and long lasting anesthesia.

A woman with tetra-X is presented together with a survey of the physical signs and the mental retardation in the 26 cases previously published.

The population is aging. We examined changes in the proportion of elderly (≥ 80 years) intensive care unit (ICU) patients during 2005-2011 and the association between age and mortality controlling for preexisting morbidity.Through the Danish National Patient Registry, we identified a cohort of 49,938 ICU admissions (47,596 patients) in Northern Denmark from 2005 to 2011. Patients were subdivided in age groups (15-49, 50-64, 65-79 and ≥ 80 years) and calendar year. We estimated 30-day and 31-365-day mortality and mortality rate ratios (MRRs), stratified by admission type (medical and elective/acute surgical patients). Mortality was compared between age groups adjusting for sex and preexisting morbidity using 50-64-year-olds as reference.The proportion of elderly patients increased from 11.7% of all ICU patients in 2005 to 13.8% in 2011. Among the elderly, the 30-day mortality was 43.7% in medical, 39.6% in acute surgical, and 11.6% in elective surgical ICU patients. The corresponding adjusted 30-day MRRs compared with the 50-64-year-olds were 2.7 [95% confidence interval (CI) 2.5-3.0] in medical, 2.7 (95% CI 2.4-3.0) in acute surgical, and 5.2 (95% CI 4.1-6.6) in elective surgical ICU patients. The 31-365-day mortality among elderly patients was 25.4% in medical, 26.9% in acute, and 11.9% in elective surgical ICU patients, corresponding to adjusted MRRs of 2.5 (95% CI 2.1-2.9), 2.2 (95% CI 1.9-2.5), and 1.9 (95% CI 1.6-2.3), respectively.During 2005-2011, there was an 18% increase in the proportion of elderly ICU patients. Advancing age is associated with increased mortality even after controlling for preexisting morbidity.

For diagnosis of pulmonary embolism (PE), ventilation/perfusion lung scintigraphy is routinely used; approximately one-third of the patients will have the diagnosis “intermediate probability of PE” (inconclusive). In this group only about 33% are found to have pulmonary emboli if examined with pulmonary angiography. To evaluate the diagnostic, therapeutic, and economic consequences of ultrasound of the legs as a complementary diagnostic investigation to “intermediate probability”, 72 consecutive patients were investigated with bilateral ultrasound of the proximal deep veins of the legs and pulmonary angiography in a prospective study. Ten patients had PE, of whom 7 had deep venous thrombosis, and 62 had no PE, of whom 2 had deep venous thrombosis. The negative predictive value of ultrasound was 0.95. In view of the importance of adequate treatment and rational use of public health care expenditure, complementary diagnostics should be performed, and ultrasound is an adequate complementary investigation.

Chronic diseases are common among intensive care unit (ICU) patients and may worsen their prognosis. We examined the prevalence and impact of pre-admission/index morbidity among ICU patients compared with a general population cohort.Our study encompassed all 28,172 adult patients admitted to ICUs in northern Denmark in 2005-2007 and 281,671 age- and sex-matched individuals from the general population. We used a nationwide hospital registry to obtain a 5-year history of 19 chronic diseases and computed Charlson Comorbidity Index (CCI) for each study participant and grouped them into low (CCI=0), moderate (CCI=1-2), and high (CCI=3+) morbidity levels. We computed mortality and mortality rate ratios (MRRs) adjusted for confounders, and compared the mortality between ICU patients and the general population cohort.Low, moderate, and high pre-admission morbidity levels were present in 51.5%, 34.1%, and 14.4% of ICU patients, respectively. In these groups, 30-day mortality was 10.8%, 18.4%, and 26.7%, respectively. Three-year mortality was 21.3%, 43.1%, and 63.2%, respectively. The adjusted 30-day MRR was 1.30 [95% confidence intervals (CI): 1.21-1.39] and 1.86 (95% CI: 1.71-2.01) for ICU patients with moderate and high morbidity levels, both compared with a low morbidity level. The general population had a lower morbidity level and mortality at all morbidity levels throughout the study period. Interaction between ICU admission and high morbidity level added 5.1% to the mortality during the second and third year of follow-up.A high pre-admission morbidity level was frequent among ICU patients and associated with a worsened prognosis. Morbidity had more impact on mortality among ICU patients compared with a general population cohort.

The common strategy of combining clinical information, lung scintigraphy and pulmonary angiography in the diagnosis of acute pulmonary embolism (PE), has many limitations in clinical use. The major causes are that pulmonary angiography and lung scintigraphy are not universally available, and that pulmonary angiography is very expensive. The purpose of this thesis was to analyse different aspects of validity in regard to lung scintigraphy, pulmonary angiography, spiral CT, and ultrasound of the legs, with the subsequent intention of discussing new diagnostic strategies. Observer variations in lung scintigraphy interpretation when applying the PIOPED criteria were tested in 2 studies with 2 and 3 observers respectively and expressed as kappa values. The ability to improve agreement in lung scintigraphy interpretation was tested by training 2 observers from different hospitals. The impact of 3 observers' variations in lung scintigraphy interpretation when compared to pulmonary angiography, was tested by comparing the ROC areas of the observers. The value of combining subjectively derived numerical probabilities and the PIOPED categorical probabilities in lung scintigraphy reporting was compared to using the PIOPED categorization only, and this was tested by comparing ROC areas. The sensitivity and specificity of detecting an embolic source in the deep veins of the legs by ultrasound as a sign of PE when lung scintigraphy is inconclusive, was tested by comparison with pulmonary angiography. The sensitivity and specificity of spiral CT, compared to pulmonary angiography, was tested by comparison to pulmonary angiography. The inter- and intra-observer kappa values were in the range of moderate and fair. It was not possible to achieve better kappa values after training. Although observer variations were substantial, the accuracy did not differ significantly between the 3 observers. Incoorporating subjectively derived probabilities into lung scan reporting could not reduce the number of inconclusive investigations. Sensitivity and specificity of ultrasound in detecting PE was 0.70 and 0.97, respectively. However, 2 patients (of 9) had deep venous thrombosis and no pulmonary emboli at angiography. The sensitivity and specificity of spiral CT was 0.90 and 0.96, respectively. The observer variations at lung scintigraphy are substantial and may be difficult to improve between hospitals, even though the accuracy of observers in general is good. Although subjectively derived interpretation criteria did not show to be useful when added to categorical interpretation criteria, they may be useful when substituting established criteria. Despite recent progress in refining interpretation criteria, a substantial fraction of the patients still need pulmonary angiography to be performed. However, in many patients pulmonary angiography is not performed as prescribed. Spiral CT and ultrasound of the legs is a new favourable diagnostic strategy with a high validity in detecting venous thromboembolic disease, and a good availability and cost-effectiveness.

A case of interstitial deletion 13q is presented and compared with the previously presented nine cases of different terminal as well as interstitial deletion 13q.