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Background Adenomyosis is a common gynecologic pathology that relies on diagnostic imaging to guide treatment. Accuracy of both pelvic ultrasound and magnetic resonance imaging (MRI) when specifically evaluating for the presence of adenomyosis is high. However, the accuracy of reported rates in clinical practice is less well understood. Purpose To demonstrate the accuracy in reporting of adenomyosis on pelvic ultrasound and MRI compared to histopathology in common clinical practice. Basic procedures An institutional database was searched for women with a pelvic ultrasound and a pelvic MRI with a subsequent hysterectomy. Findings were extracted from radiology and pathology reports, and the documented presence or absence of adenomyosis was recorded for each modality. Blinded radiologists viewed each imaging pair to directly evaluate for adenomyosis. Main findings Compared to prior published data, imaging had lower accuracy in clinical practice when adenomyosis was not specifically evaluated for. For the finding of adenomyosis, pelvic ultrasound had a sensitivity of 10.9%, a specificity of 98.3%, positive predictive value (PPV) of 77.8%, negative predictive value (NPV) of 66.7%, an accuracy of 67.2%, and a diagnostic odds ratio (DOR) of 7. Pelvic MRI had a sensitivity of 29.7%, specificity of 85.3%, PPV of 52.8%, NPV of 68.8%, an accuracy of 65.6%, and DOR of 2.5. Overall accuracy of MRI improved when adenomyosis was directly evaluated for (82.4% vs 65.6%). Principle conclusions Without direct communication to evaluate for adenomyosis, pelvic ultrasound and MRI may underestimate or misreport adenomyosis. Providers should be aware of these discrepancies when relying on radiology reports to guide treatment and potential interventions when diagnosing and managing adenomyosis.

Purpose The purpose of this study was to develop a novel swine model of recurrent gastrointestinal bleeding that could potentially be utilized for the study of provocative mesenteric angiography. Methods Animal experiments were approved by the Institutional Animal Care and Use Committee. The superior mesenteric artery was catheterized via percutaneous transfemoral access. Via laparotomy, multiple small incisions were created in the small bowel wall of four swine. After hemostasis was achieved, varying amounts of thrombolytics were infused into the superior mesenteric artery via a 5 french catheter. The number of incisions with observable rebleeding and interval until rebleeding were ascertained. Results In a test animal, active extravasation was confirmed to be detectable on digital subtraction angiography at a small bowel incision site. After tissue plasminogen activator (tPA) administration into the superior mesenteric artery, rebleeding from the incisions was visually observed in 11 of 30 small bowel incisions (37%). Provoked bleeding occurred at a median of 6 minutes (mean: 5 minutes and 52 seconds) after completion of tPA injection with a range of approximately 1 to 10 minutes. Conclusion This pilot study proposes a feasible model for provocative mesenteric angiography in swine.

To update normative data on fluoroscopy dose indices in the United States for the first time since the RAD-IR study in the late 1990s.The DIR-Fluoro pilot collected data from March 2018 through December 2019, with 50 fluoroscopes from 10 sites submitting data. Primary radiation dose indices including fluoroscopy time (FT), cumulative air kerma (KDose indices were collected for 70,377 FGI, with 50,501 ultimately eligible for analysis. Distribution parameters are reported for 100 ACR Common IDs. FT in minutes, KThe ACR DIR-Fluoro pilot has provided state of the practice statistics for radiation dose indices from IR FGI procedures. These data can be used to prioritize procedures for radiation optimization, as demonstrated in this work.

To compare radiation dose index distributions for fluoroscopically guided interventions in interventional radiology from the American College of Radiology (ACR) Fluoroscopy Dose Index Registry (DIR-Fluoro) pilot to those from the Radiation Doses in Interventional Radiology (RAD-IR) study.Individual and grouped ACR Common identification numbers (procedure types) from the DIR-Fluoro pilot were matched to procedure types in the RAD-IR study. Fifteen comparisons were made. Distribution parameters, including the 10th, 25th, 50th, 75th, and 95th percentiles, were compared for fluoroscopy time (FT), cumulative air kerma (KThe median FT was equally likely to be higher or lower in the DIR-Fluoro pilot as it was in the RAD-IR study, whereas the maximum FT was almost twice as likely to be higher in the DIR-Fluoro pilot than it was in the RAD-IR study. The median KThe median dose indices have decreased since the RAD-IR study. The typical K

Internalists and externalists disagree over how intimately normative judgment and motivation are linked. Proponents on both sides typically try to settle the issue by descriptively interpreting our...

To compare outcomes after conversion of arteriovenous (AV) access to Hemodialysis Reliable Outflow (HeRO) graft vs stent deployment in patients with arm swelling owing to ipsilateral central vein stenosis.This single-center retrospective study comprised 48 patients (19 men, mean age 58 y) with arm swelling ipsilateral to AV access and central vein stenosis over a 13-year period who had clinical follow-up and without prior central stents. Twenty-one patients underwent placement of a HeRO graft with anastomosis of the HeRO graft to the existing graft or fistula, and 27 patients underwent central venous stent deployment. Symptomatic improvement in arm swelling and access patency rates after intervention were ascertained from medical records.Improvement in swelling within 1 month after HeRO conversion and stent deployment was found in 95% and 89%, respectively (P = .62). Swelling eventually recurred in 16 patients (59%) treated with stents compared with 1 patient (5%) who underwent HeRO conversion (P.001). Primary access patency was statistically significantly longer after HeRO conversions than stent deployments, with 6- and 12-month primary patency rates of 89% and 72% vs 47% and 11% (P.001). HeRO conversions also resulted in longer 6- and 12-month secondary access patency rates (95% and 95% vs 79% and 58%, P = .006). Mean number of interventions per 1,000 access days to maintain secondary patency was 2.7 for the HeRO group vs 6.3 for the stent group.Although stent deployment and HeRO graft conversion are effective for alleviating arm swelling in the short term in patients receiving hemodialysis with clinically significant arm swelling and functioning AV access, the HeRO graft has more durable results.

There has lately been substantial interest in scrutinizing our evaluative attitudes in light of our evolutionary history. However, these discussions have been hampered by an insufficiently expansive vantage. Our history did not begin ex nihilo a few million years ago with the appearance of hominins, or apes, or primates—those are very recent chapters of a much larger story that spans billions of years. This paper situates the mechanisms underlying normative thought within this broader context. I argue that this historical perspective creates difficulties for metaethical nonnaturalists. The expanded scope enables the story to be anchored in negative claims about value, making room for novel epistemological and metaphysical challenges that are more threatening than extant evolutionary debunking arguments.

Many environmentalists hold that the loss of a species is intrinsically bad, and many also think that we have moral obligations to species as such. In an attempt to capture these thoughts, some philosophers have suggested that species are bearers of intrinsic value. This approach works well in paradigmatic cases. However, it begins to break down in more difficult scenarios, such as when species boundaries are unclear or when resources are scarce. The case study of the Galápagos giant tortoises in this essay illustrates the limitations of traditional accounts of the non-instrumental value of species. Careful attention to this case indicates how species-centric accounts diverge from the evaluative attitudes of environmentalists, and suggests new directions for theoretical replacements.

Cornell realists maintain that irreducible moral properties have earned a place in our ontology in virtue of the indispensable role they play in a variety of explanations. These explanations can be divided into two groups: those that employ thin ethical concepts and those that employ thick ethical concepts. Recent work on thick concepts suggests that they are not inherently evaluative in their meaning. If correct, this creates problems for the moral explanations of Cornell realists, since the most persuasive moral explanations are those that employ thick concepts. If thick concepts are not inherently evaluative, then the most plausible explanations on offer cannot support Cornell realism. Moral explanations employing thin concepts, however, are too flimsy to support the view. Unless proponents can develop a compelling story about thick concepts or thin explanations, Cornell realism is in trouble.

While Richard Joyce’s moral skepticism might seem to be an extreme metaethical view, it is actually far more moderate than it might first appear. By articulating four challenges facing his approach to moral skepticism, I argue that Joyce’s moderation is, in fact, a theoretical liability. First, the fact that Joyce is not skeptical about normativity in general makes it possible to develop close approximations to morality, lending support to moderate moral revisionism over moral error theory. Second, Joyce relies on strong, contentious conceptual and empirical claims in support of his views. Third, Joyce’s evolutionary debunking argument threatens to backfire, generalizing to all normative judgments. Finally, Joyce fails to offer an adequate account of the normativity of desire. Each of these four challenges can be either sidestepped (the first and second) or embraced (the third and fourth) by radicalizing and defending a global form of normative skepticism. There are thus several ways in which global normative skepticism appears to be in a more robust dialectical position than Joyce’s moral skepticism. Furthermore, I argue, Joyce’s arguments against global normative skepticism are unconvincing. While this discussion is framed in terms of Joyce’s work, its arguments will apply to other moral skeptics who are not also global normative skeptics. The result is an invitation for Joyce and other moral skeptics to leave these problems behind and join the radical camp.

David Enoch has recently proposed that the deliberative indispensability of irreducibly normative facts suffices to support their inclusion in our ontology, even if they are not necessary for the explanation of any observable phenomena. He challenges dissenters to point to a relevant asymmetry between explanation and deliberation that shows why explanatory indispensability, but not deliberative indispensability, is a legitimate guide to ontology. In this paper, I aim to do just that. Given that an entity figures in the actual explanation of some phenomenon, it is not an open question whether that entity exists. Thus, if you can manage to find actual explanations, you can find answers to ontological questions. In contrast, even if some entity is indispensable to deliberation, it still might not exist. For example, even if some form of libertarian free will is deliberatively indispensable, we still might not have libertarian free will. So even if you manage to discover the indispensable commitments of deliberation, there is still more work to do to get to the bottom of things. That additional work is explanatory work, and so deliberative indispensability is not an independent guide to what there is.

A 66-year-old woman was admitted to an outside facility with leg swelling and dyspnea on exertion. Initial workup revealed severe aortic stenosis and congestive heart failure (CHF) thought to be the culprit; however, a CT performed in the emergency department revealed massive uterine mass resulting in significant inferior vena cava (IVC) compression. Her cardiac status precluded hysterectomy, due to concerns regarding intraoperative fluid shifts decreasing preload in the setting of preload dependence in severe aortic stenosis. Similarly, her degree of IVC compression was thought to make valve replacement unacceptably dangerous, so she was referred to interventional radiology for consideration of uterine artery embolisation (UAE) to relieve IVC compression. She underwent UAE without complication, and her leg swelling nearly completely resolved at follow-up.

To establish outcome rates for patients receiving intravenous thrombolysis based on vascular occlusion site.This is a retrospective analysis of 225 patients who had received intravenous-rt-PA for anterior circulation strokes. The occlusion-site was prospectively determined on the admission computed tomographic angiography (CTA) and divided into: large vessel occlusion (LVO) including patients with an internal carotid artery terminus or middle cerebral artery (M1/proximal M2) occlusions and no large vessel occlusion (No-LVO; distal M2/M3/ACA) including patients with either distal or no occlusions. The primary outcome was the modified Rankin score (mRS) at 90-days with a good outcome defined by mRS of 0-2.000.There were 114 (50.7%) patients in the LVO and 111 (49.3%) in the No-LVO group. A good outcome was seen in 28 (24.6%) patients in the LVO and 77 (69.4%) patients in the No-LVO group (OR .14; 95% CI: .08-.26; P.0001). Mortality was observed in 13 (11.7%) patients in the No-LVO group and 48 (42.1%) patients in the LVO group (OR .18; 95% CI: .09-.36; P.0001). Significant hemorrhage was seen in 14 (12.5%) patients in the LVO and 0 (0%) patients in the No-LVO group (P.0001). Older age (OR .96; 95% CI: .93-.98; P = .002) and presence of LVO (OR .29; 95% CI: .12-.68; P = .004) were significant independent predictors of poor outcome.CTA identification of proximal occlusions is associated with significantly poor outcomes in patients receiving intravenous stroke thrombolysis.