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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.

Objective To document ocular lesions present in cold-stunned sea turtles and determine the impact of these lesions on their release. Animals All sea turtles (Caretta caretta, Chelonia mydas, and Lepidochelys kempii) presenting to rehabilitation centers in North Carolina over two cold stun seasons. Procedures Complete ophthalmic examination using slit-lamp biomicroscopy, fluorescein stain, rebound tonometry, and occasionally binocular indirect funduscopy was performed within 1 week of presenting to the rehabilitation centers. A second examination was performed 2 weeks after the first examination in animals with ocular lesions and still present at the center. Results One hundred and sixty-four turtles (121 Chelonia mydas, 26 Lepidochelys kempii, 17 Caretta caretta) were evaluated over two cold stun seasons (2016-2017 and 2017-2018). Ocular or periocular lesions were identified in 78 of 164 (47.5%) turtles examined with 37 of 164 (22.5%) having bilateral disease. The most common ocular lesion was superficial corneal ulceration, accounting for 21.3% of all lesions. Adnexal lesions were also common, while intraocular abnormalities were overall rare. Most resolved uneventfully. Though some blinding lesions were noted, these were not present bilaterally in any one turtle, and thus, ocular findings did not affect release. Conclusion Ocular lesions in cold-stunned sea turtles are common. Some of these lesions are potentially blinding or require appropriate care, so evaluation of cold-stunned turtles should include a complete ophthalmic examination.

Sea turtles are frequently presented for rehabilitation with injuries for which analgesic treatment is warranted. Ketoprofen is a nonsteroidal anti-inflammatory drug (NSAID) widely used in clinical veterinary medicine for musculoskeletal pain relief. Pharmacokinetics of 2 mg/kg IM have been studied in loggerhead sea turtles (Caretta caretta) as a single and a repeated dose q24hr for 3 days. Safety of longer term administration has not been performed, however, and NSAID use carries a risk of potential complications, including gastrointestinal ulceration, kidney damage, and bleeding. The objective of the current study was to determine the effects of a 5-day course of ketoprofen on thromboelastography (TEG) and hematological (including thrombocytes) and plasma biochemical analytes in loggerheads. A secondary objective was to determine 24-hr trough concentrations of ketoprofen after 5 days of treatment. Eight loggerheads were treated with ketoprofen 2 mg/kg IM q24hr for 5 days, and TEG, hematology, and plasma biochemistry panels were performed before and at the conclusion of treatment. Eight controls were treated with an equivalent volume of saline intramuscularly. Virtually no changes were detected before and after treatment or between treatment and control groups in any of the 24 endpoints evaluated, and marginal differences were not considered clinically relevant. Plasma ketoprofen concentrations after 5 days of treatment indicated no accumulation over that duration. Ketoprofen at 2 mg/kg IM q24hr for up to 5 days in loggerheads appears safe with respect to blood clotting and blood data, although other potential effects were not evaluated.

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.

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.

Measuring plasma protein electrophoresis fractions and plasma concentrations of acute phase proteins (APPs) is commonly used to monitor inflammation and illness in mammalian species, but its use is not widespread in fish species, despite the presence of similar proteins. This study aims to determine plasma protein electrophoresis values for koi carp ( Cyprinus carpio ) and to assess the use of plasma protein electrophoresis and commercially available assays for 3 primary APPs (C-reactive protein, serum amyloid A, and haptoglobin) as markers of inflammation in 13 koi following invasive surgery. Median packed cell volume decreased by nearly 50% but recovered to baseline by 14 days postsurgery. Plasma protein electrophoresis fractions were consistent across the experimental period and did not demonstrate an inflammatory pattern, but electrophoretograms exhibited variation between individual fish. No clinically meaningful changes were observed in the APPs of the test subjects 28 days following surgery. Despite grossly evident inflammation of the incision line, either this surgical procedure did not stimulate a marked systemic inflammatory response, or the available assays are not effective in detecting the acute phase inflammatory response in this fish species.

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.

For many acute care nursing units, such as the Burn Progressive Care Unit (BPCU) at the U.S. Army Burn center, staff stress and burnout is always a concern for leaders. Job stress not only contributes to nursing turnover, but can have a negative impact on patient care. The purpose of this project was to develop a training platform for nursing staff education and teambuilding with the intent of improving nurse satisfaction, increasing resiliency, building unit cohesion, enhancing morale, and increasing staff awareness of unit performance. All nursing staff were given an 8-hour training day, half of which was focused on education and the other half on teambuilding and resiliency. At the end of the staff development day (SDD), participants were encouraged to complete an evaluation; all activities were scored on a 10-point scale, with 10 representing the most informative. In total, 46 of 48 staff (96%) participated in the first two SDDs. During the first iteration (Spring 2015), participants scored all activities very high, with a total average score of 9.15 ± 0.26 (n = 246). In the Fall of 2015, the SDD program was again rated well, with an average score of 9.36 ± 0.13 (n = 276). The SDD program has been successful in supporting teamwork and resiliency among BPCU staff. Staff feedback supported success in meeting the objectives of building unit cohesion and increasing satisfaction and morale.

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.

Deletion of short arm 9 was found in a 61-year-old, mentally retarded male with few of the previously described signs typical of deletion of short arm 9 in children. A survey is given of the nine previously described cases of deletion of short arm 9.

Purpose: The PIOPED criteria in their original and revised forms are today's standards in the interpretation of ventilation-perfusion scintigraphy. When the PIOPED criteria are used by experienced raters with training in consensus interpretation, the agreement rates have been demonstrated to be excellent. Our purpose was to investigate the rates of agreement between 2 experienced raters from different hospitals who had no training in consensus interpretation. Material and Methods: The 2 raters investigated a population of 195 patients. This group included 72 patients from a previous study who had an intermediate probability of pulmonary embolism and who had also been examined by pulmonary angiography. Results: The results demonstrated moderate agreement rates with a kappa value of 0.54 (0.45–0.63 in a 95% confidence interval), which is similar to the kappa value of the PIOPED study but significantly lower than the kappa values of agreement rates among consensus-trained raters. There was a low consistency in the intermediate probability category, with a proportional agreement rate of 0.39 between the experienced raters. Conclusion: The moderate agreement rates between raters from different hospitals make it difficult to compare study populations of a certain scintigraphic category in different hospitals. Further investigations are mandatory for accurate diagnosis when the scintigrams are in the category of intermediate probability of pulmonary embolism.

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.

Purpose: Using the PIOPED criteria in the interpretation of lung scintigraphy, perfect agreement between experienced raters with training in consensus interpretation has been demonstrated. In a previous paper we found a kappa value of 0.54 (0.45–0.63) between experienced raters with no experience of interpretation in consensus; this is significantly lower than the perfect agreement described between consensus-trained raters. The purpose of this study was to reinvestigate the same study population with the same raters, but this time after they had undergone consensus training. Material and Methods: Lung scintigrams of 192 patients were reviewed and categorized according to the PIOPED criteria by 2 raters after consensus training. The 2 raters reviewed a training material of 59 cases, which was not part of the study population, in order to reach a full consensus interpretation. Results: After consensus training the kappa value was 0.57 (0.48–0.66). Three cases had a discrepancy of 2 categories (1.6%), and the remaining discrepancies were of one category. Conclusion: Consensus training did not significantly improve the agreement rate between experienced raters from different hospitals. A substantial improvement in agreement rates between hospitals may make heavy demands on resources.

Purpose: Reporting a lung scintigraphy diagnosis as a PIOPED categorical probability of pulmonary embolism offers the clinician a wide range of interpretation. Therefore the purpose of this study was to analyze the impact on lung scintigraphy reporting of adding a visual linear scale (VLS) probability assessment to the ordinary PIOPED categorical probability. Material and Methods: the study material was a re-evaluation of lung scintigrams from a prospective study of 170 patients. All patients had been examined by lung scintigraphy and pulmonary angiography. the scintigrams were re-evaluated by 3 raters, and the probability of pulmonary embolism was estimated by the PIOPED categorization and by a VLS probability. the test was repeated after 6 months. Results: There was no significant difference (p>0.05) in the area under the ROC curve between the PIOPED categorization and the VLS for any of the 3 raters. Analysis of agreement among raters and for repeatability demonstrated low agreement in the mid-range of probabilities. Conclusion: A VLS probability estimate did not significantly improve the overall accuracy of the diagnosis compared to the categorical PIOPED probability assessment alone. from the data of our present study we cannot recommend the addition of a VLS score to the PIOPED categorization.

Gonadectomy of pet lizards may be necessary to treat various medical conditions, and prophylactic surgery may prevent life-threatening reproductive-associated conditions. This study provides information relevant to the pre-surgical evaluation of bearded dragons (Pogona vitticeps). Blood samples collected from seven male and seven female inland bearded dragons prior to elective gonadectomy surgery, and again 12 days following surgery, were analyzed using a point-of-care blood gas analyzer (iStat) and a semiportable chemistry analyzer (Abaxis VetScan) to obtain plasma biochemistry and electrolyte concentrations. Statistically significant differences were seen for packed cell volume and protein, calcium, and potassium concentrations when pre-surgical values were compared with post-surgical values. Four female lizards in the cohort died in the immediate post-operative period, and three of these animals had large, well-developed ovarian follicles. The ovaries of all surviving female lizards were chara...

This article discusses the importance of team building between occupational therapists and occupational therapy assistants and the relationship of teamwork to the effectiveness of service delivery within the profession of occupational therapy. If team members’ needs are not satisfied, dysfunctional intraprofessional teams result. Team building is based on the satisfaction of three areas of individual need: (a) ministration, which leads to mutual respect; (b) mastery or effective performance; and (c) maturation or personal growth and professional socialization. A better understanding and appreciation of the roles of therapist and assistant and their relationships can resolve the team deficits. A developmental team chart that uses a systems theory model as an organizing framework is presented as an action plan for team building. Suggestions are made to academic and fieldwork educators and professional and technical clinicians to strengthen intraprofessional relationships in occupational therapy.