Marked Restriction Research Articles

Impressive weight loss induced by a very low-calorie ketogenic diet in a morbidly complex obese patient with a recent episode of acute kidney injury and advanced chronic kidney disease: a case report

The very low-calorie ketogenic diet (VLCKD), characterized by a marked energy restriction that induces rapid weight loss, has recently been proposed as a valid nutritional strategy for managing obesity. VLCKD is commonly considered dangerous for the kidneys due to the misconception that it is high in protein, beyond the risk of electrolyte imbalances and an increase in diuresis. We report a case of safe and effective weight loss induced by VLCKD in a 43-year-old Caucasian woman with a recent episode of acute kidney injury on advanced chronic kidney disease. Surprisingly, we observed that after the diet-induced weight loss, not only did renal function not worsen, but proteinuria also improved. The principal value of this case report is its singular demonstration of impressive weight loss induced by VLCKD in a complex obese patient that was apparently not accompanied by the development of serious adverse sequelae.

Inter-reader agreement for CT/MRI LI-RADS category M imaging features: a systematic review and meta-analysis.

To systematically evaluate inter-reader agreement in the assessment of individual liver imaging reporting and data system (LI-RADS) category M (LR-M) imaging features in computed tomography/magnetic resonance imaging (CT/MRI) LIRADS v2018, and to explore the causes of poor agreement in LR-M assignment. Original studies reporting inter-reader agreement for LR-M features on multiphasic CT or MRI were identified using the MEDLINE, EMBASE, and Cochrane databases. The pooled kappa coefficient (κ) was calculated using the DerSimonian-Laird random-effects model. Heterogeneity was assessed using Cochran's Q test and I2 statistics. Subgroup meta-regression analyses were conducted to explore the study heterogeneity. In total, 24 eligible studies with 5,163 hepatic observations were included. The pooled κ values were 0.72 (95% confidence interval [CI], 0.65-0.78) for rim arterial phase hyperenhancement, 0.52 (95% CI, 0.39-0.65) for peripheral washout, 0.60 (95% CI, 0.50-0.70) for delayed central enhancement, 0.68 (95% CI, 0.57-0.78) for targetoid restriction, 0.74 (95% CI, 0.65-0.83) for targetoid transitional phase/hepatobiliary phase appearance, 0.64 (95% CI, 0.49-0.78) for infiltrative appearance, 0.49 (95% CI, 0.30-0.68) for marked diffusion restriction, and 0.61 (95% CI, 0.48-0.73) for necrosis or severe ischemia. Substantial study heterogeneity was observed for all LR-M features (Cochran's Q test, P<0.01; I2≥89.2%). Studies with a mean observation size of <3 cm, those performed using 1.5-T MRI, and those with multiple image readers, were significantly associated with poor agreement of LR-M features. The agreement for peripheral washout and marked diffusion restriction was limited. The LI-RADS should focus on improving the agreement of LR-M features.

PI-RADS v2.1 evaluation of prostate "nodule in nodule" variants: clinical, imaging, and pathological features.

To analyze the correlation among the imaging features of prostate "nodule in nodule," clinical prostate indices, and pathology results. We retrospectively analyzed the prostate images from 47 male patients who underwent MRI scans and pathological biopsy from January 2022 to July 2023. Two radiologists (R1/R2) evaluated the morphology and signal intensity of the "nodule in nodule" in a double-blind manner and calculated the PI-RADS v2.1 score, which was compared with clinical prostate indices and pathological results. 34.04% (16/47) of patients were pathologically diagnosed with clinically significant prostate cancer (csPCa). Total prostate-specific antigen (tPSA), free/t PSA, PSA density (PSAD), and prostate gland volume (PGV) were significantly different between csPCa patients and benign prostatic hyperplasia (BPH) patients with prostate "nodule in nodule". R1/R2 detected 17/17 prostate "nodule in nodule" pathologically confirmed as csPCa on MRI; 10.60% (16/151) (R1) and 11.11% (17/153) (R2) had diffusion-weighted imaging (DWI) PI-RADS v2.1 score of 4, and 0.66% (1/151) (R1) had a score of 3. The percentages of encapsulated, circumscribed, and atypical nodules and obscured margins were 0.00% (0/151), 0.00% (0/151), 5.96% (9/151), and 5.30% (8/151), respectively, for R1, and 0.00% (0/153), 0.00% (0/153), 5.88% (9/153), and 4.58% (7/153) for R2. When the inner nodules of "nodule in nodule" lesions in PI-RADS v2.1 category 1 in the TZ show incomplete capsulation or obscured margins, they are considered atypical nodules and might be upgraded to PI-RADS v2.1 category 3 if they exhibit marked diffusion restriction. However, further validation is needed. This study first analyzed the relationship between clinical and pathological findings and the size, margin, and multimodal MRI manifestations of the prostate "nodule in nodule." These findings could improve the diagnostic accuracy of PI-RADS v2.1 for prostate lesions. • The margin of the prostate inner nodules affects the PI-RADS v2.1 score. • The morphology of prostate "nodule in nodule" is related to their pathology. • The PI-RADS v2.1 principle requires consideration of prostate "nodule in nodule" variants.

Neural mechanosensitivity findings in patients with adhesive capsulitis

BACKGOURND: The pathophysiology of adhesive capsulitis may be associated with increased neural mechanosensitivity in upper limb neurodynamic test. OBJECTIVE: To investigate the findings of neurodynamic assessment in patients with more than four month history of adhesive capsulitis. METHODS: Thirty-five patients with more than four month history of adhesive capsulitis were participated in this study. A physiotherapist performed the Upper Limb Neurodynamic test 1 procedure on the participant’s upper limb. Elbow extension range of motion at the end of the Upper Limb Neurodynamic test 1 was compared with the participant’s elbow extension at the end of Upper Limb Neurodynamic test 1 performed on the opposite upper limb and to elbow extension on the symptomatic side performed with the arm by the side. RESULTS: The intensity of pain in Upper Limb Neurodynamic test 1 increased with lateral flexion of the neck to the unaffected side and eased with lateral flexion to the affected side in all participants. A marked restriction of the elbow passive extension range of motion in Upper Limb Neurodynamic test 1 on the affected side (–54.6±17.8°) compared to the unaffected side was found (–7.3±10.7°) (p &lt; 0.001). CONCLUSIONS: Restriction of elbow passive extension range of motion at the end of the Upper Limb Neurodynamic 1 test reproduced patients’ familiar adhesive capsulitis associated pain and the pain changed with structural differentiation using cervical lateral flexion. Neurodynamic assessment may need to be considered to assess neural mechanosensitivity in patients with adhesive capsulitis.

Primary Hinged External Fixator for Complex Fracture Dislocations of the Elbow (Systematic Review/Meta-Analysis)

Background High-energy and fracture dislocations with compromise of the medial and lateral ligamentous complex, the joint capsule, and potentially the tertiary stabilizers (i.e., the flexor pronator, extensor supinator masses, and brachialis) often demonstrate residual instability after osseous and ligamentous stabilization. The optimal management of a complex elbow injury should results in restoring joint stability and its full range of motion. However, this is often difficult to achieve by surgical means and a marked restriction of movement remains a frequent con- sequence of severe elbow injury. Aim of the Study The aim of this study is to discuss the results of using a lateral hinged external fixator as an adjunct stabilizer in the treatment of a variety of acute destabilizing elbow injuries as a primary method of fixation not only in chronic or complicated cases. Patients and Methods Types of studies: Randomized controlled trials, including cluster RCTs, controlled (non-randomized) clinical trials or cluster trials, prospective and retrospective comparative cohort studies, and case-control or nested case-control studies. Types of participants: Only studies on human subjects with acute complex elbow fracture dislocation treated by hinged elbow external fixator. Types of interventions: Surgical treatment of acute complex elbow fracture dislocation with hinged external fixation of elbow. Types of outcome measures: Operative details, intra and postoperative complications and final clinical outcome. Literature searches will be conducted using the following databases:” PubMed, Ovid, Web of Science, ScienceDirect, Scopus, Cochrane Library, Google Scholar, Medline” using the following Keywords: acute complex elbow fracture dislocation, hinged external fixator, unstable elbow, terrible triad and long term for published studies from 2010-2021. Results Regarding studies done on the use of a lateral hinged external fixator on the elbow for complex fracture dislocation which are numerous in the last 11 years, we have reviewed the most applicable studies in our review. Regarding the mean flexion-extension arc and pronation-supination arc, the results were 121.5 º and 81 º respectively. Regarding the complications, wound infection was found in 10 patients out of 69 cases (14.4%) including pin tract infection and ORIF wound infection. Secondary humeral and ulnar shaft fractures were found in 3 patients out of 69 cases (4.3%) as a recognized complication of the shanz screws application in both humerus and ulna. Another complication founded was elbow joint incongruity in 5 patients among 69 cases (7.2%) which leads to series consequences like arthritis, progressive pain and instability. Instability as a postoperative complication was found in 1 patient out of 69 cases (1.4%) which shows the huge effect of adding a hinged external fixator to the ORIF construct. In fact, this was the only reason to add a hinged external fixator in the past where it was used in cases of recurrent and chronic instability. Non union was found in 2 patients out of 69 patients (2.8%) while heterotrophic calcification was found in 8 patients out of 69 cases (11.5%). Iordens et al in 2015 was the only paper to calculate the quick-dash score where among 27 patients the score were 30 at 6 weeks and 7 at 1 year. Regarding the mayo elbow performance score (MEPS), among the 69 patients 21 patients (30.4%) were not affiliated while the score was poor in 1 patient (1.4%), fair in 7 patients (10.1%), good in 18 patients (26%) and excellent in 22 patients (31.8%) which shows that above 50% of cases where good to excellent showing the effect of early protected range of motion gained by the addition of a hinged external fixator. Conclusion The best management for complex elbow fracture dislocations is still controversy but the additional use of a hinged external fixator to the ORIF repair shows better outcomes as described.

E35 Achondroplasia: delayed diagnosis of a severe, complicated form

Abstract Introduction Achondroplasia is the most common form of chondrodysplasia. It manifests by marked rhizomelia, hyperlordosis, brachydactyly and macrocephaly with large, prominent forehead and mid-face hypoplasia. Objective To describe a case of achondroplasia with delayed diagnosis and severe extra-skeletal complications. Result An eight-year-old girl, diagnosed with a bilateral pulmonary ecchinococcosis, was referred for thoracic surgery and a pediatric opinion was required. Physical examination revealed a severe juvenile form of achondroplasia with marked restriction of opening of the mouth and sleep apnea. Pulmonary function tests showed a mild restrictive lung disease. Her skeletal radiological survey showed the classic signs of achondroplasia and a bilateral coxa vara. Thoracic surgery was successfully scheduled with a multidisciplinary team encompassing pediatric surgeons, pediatricians, anesthesiologists and specialized nurses. A dedicated ENT and pulmonology team managed her sleep apnea and respiratory disorder respectively, while pediatric orthopedic team managed the hips. Discussion Achondroplasia is caused by mutations in the fibroblast growth factor receptor 3 (FGFR3) gene encoding a transmembrane receptor important among other things in the regulation of linear growth of long bones. Diagnosis is mainly based on the presence of specific clinical and radiological features. Strict adherence to recommendations for perioperative and surgical care are essential. Conclusion The management of achondroplasia is multidisciplinary, and supportive measures are more than crucial; especially in particular situations, such as anesthesia and surgery, that require additional precautions with prudent perioperative management and prolonged postoperative care. Evidently, long term follow-up of the respiratory and musculoskeletal systems is essential. The life expectancy of such patients is close to that of the general population, but patient’s and family’s quality of life is highly impacted. Ethics Parental consent taken before case reporting.

Prospective Evaluation of PI-RADS Version 2.1 for Prostate Cancer Detection and Investigation of Multiparametric MRI-derived Markers.

Background Data regarding the prospective performance of Prostate Imaging Reporting and Data System (PI-RADS) version 2.1 alone and in combination with quantitative MRI features for prostate cancer detection is limited. Purpose To assess lesion-based clinically significant prostate cancer (csPCa) rates in different PI-RADS version 2.1 categories and to identify MRI features that could improve csPCa detection. Materials and Methods This single-center prospective study included men with suspected or known prostate cancer who underwent multiparametric MRI and MRI/US-guided biopsy from April 2019 to December 2021. MRI scans were prospectively evaluated using PI-RADS version 2.1. Atypical transition zone (TZ) nodules were upgraded to category 3 if marked diffusion restriction was present. Lesions with an International Society of Urological Pathology (ISUP) grade of 2 or higher (range, 1-5) were considered csPCa. MRI features, including three-dimensional diameter, relative lesion volume (lesion volume divided by prostate volume), sphericity, and surface to volume ratio (SVR), were obtained from lesion contours delineated by the radiologist. Univariable and multivariable analyses were conducted at the lesion and participant levels to determine features associated with csPCa. Results In total, 454 men (median age, 67 years [IQR, 62-73 years]) with 838 lesions were included. The csPCa rates for lesions categorized as PI-RADS 1 (n = 3), 2 (n = 170), 3 (n = 197), 4 (n = 319), and 5 (n = 149) were 0%, 9%, 14%, 37%, and 77%, respectively. csPCa rates of PI-RADS 4 lesions were lower than PI-RADS 5 lesions (P < .001) but higher than PI-RADS 3 lesions (P < .001). Upgraded PI-RADS 3 TZ lesions were less likely to harbor csPCa compared with their nonupgraded counterparts (4% [one of 26] vs 20% [20 of 99], P = .02). Predictors of csPCa included relative lesion volume (odds ratio [OR], 1.6; P < .001), SVR (OR, 6.2; P = .02), and extraprostatic extension (EPE) scores of 2 (OR, 9.3; P < .001) and 3 (OR, 4.1; P = .02). Conclusion The rates of csPCa differed between consecutive PI-RADS categories of 3 and higher. MRI features, including lesion volume, shape, and EPE scores of 2 and 3, predicted csPCa. Upgrading of PI-RADS category 3 TZ lesions may result in unnecessary biopsies. ClinicalTrials.gov registration no. NCT03354416 © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Goh in this issue.

Teaching NeuroImage: Glioblastoma Multiforme Presenting as Optic Neuropathy.

A 63-year-old man presented with sudden vision loss in the right eye. Funduscopic examination revealed right severe disc edema with peripapillary hemorrhages with no abnormality on the left (Figure 1, A and B). Orbit and brain MRI's showed an extensive enhancing lesion with restricted diffusion involving the right optic nerve (Figure 1, C–F) and FLAIR hyperintense lesions in the right hippocampus (Figure 2A) and parietal lobe (Figure 2, C and D). The patient received oral corticosteroids followed by plasma exchange. Owing to lack of clinical improvement, a new brain MRI was obtained, showing an enlargement of the lesions (Figure 2, E–H). The biopsy of the parietal lesion confirmed the diagnosis of glioblastoma multiforme (GBM). Visual deficit as initial presentation of GBM is rare (13%).1 A neoplastic origin of an optic neuropathy should be considered in enlarged optic nerve with persistent enhancement and marked MRI diffusion restriction.2

Impact of virtual reality excergaming and conventional physiotherapy in stage 2 frozen shoulder patient: A case report

ABSTRACT Introduction- Frozen Shoulder which is also called as Periarthritis of shoulder joint. It is commonly seen in 40-60 years of age group. When the tendon gets inflamed from a long period of time it leads to Frozen Shoulder due to involvement of Subscapularis, Supraspinatus, Infraspinatus and Teres minor muscles and marked restriction in the movements which cannot be performed by the patient itself or by the help of therapist. Moreover, injury leads to inflammation of joint capsule which lead to pain and joint stiffness. Aim and objective of this case study is to check the effect of Virtual Reality and Conventional Physiotherapy in the patient having Frozen Shoulder. Outcome Measure were Pain and functional disability measured by Shoulder disability and disability index scale (SPADI), Range of Motion (ROM) measured by Universal Goniometer, Kinesiophobia was measured through Tampa Scale of Kinesiophobia (TAMPA) and Sleeping routine was checked through Pittsburgh Sleep Quality Index (PSQI). Conclusions- Four weeks of intervention, thrice a day in a week showed marked improvement in pain, Rom, fear of avoidance, sleep quality through Virtual Reality exergaming and Conventional Physiotherapy in Frozen shoulder patient. Keywords: Virtual reality exergaming, Frozen shoulder, Pain, Function, Sleep, Tens.

Preoperative prediction of glypican-3 positive expression in solitary hepatocellular carcinoma on gadoxetate-disodium enhanced magnetic resonance imaging.

PurposeAs a coreceptor in Wnt and HGF signaling, glypican-3 (GPC-3) promotes the progression of tumor and is associated with a poor prognosis in hepatocellular carcinoma (HCC). GPC-3 has evolved as a target molecule in various immunotherapies, including chimeric antigen receptor T cell. However, its evaluation still relies on invasive histopathologic examination. Therefore, we aimed to develop an easy-to-use and noninvasive risk score integrating preoperative gadoxetic acid–enhanced magnetic resonance imaging (EOB-MRI) and clinical indicators to predict positive GPC-3 expression in HCC.Methods and materialsConsecutive patients with surgically-confirmed solitary HCC who underwent preoperative EOB-MRI between January 2016 and November 2021 were retrospectively included. EOB-MRI features were independently evaluated by two masked abdominal radiologists and the expression of GPC-3 was determined by two liver pathologists. On the training dataset, a predictive scoring system for GPC-3 was developed against pathology via logistical regression analysis. Model performances were characterized by computing areas under the receiver operating characteristic curve (AUCs).ResultsA total of 278 patients (training set, n=156; internal validation set, n=39; external validation set, n=83) with solitary HCC (208 [75%] with positive GPC-3 expression) were included. Serum alpha-fetoprotein >10 ng/ml (AFP, odds ratio [OR]=2.3, four points) and five EOB-MR imaging features, including tumor size >3.0cm (OR=0.5, -3 points), nonperipheral “washout” (OR=3.0, five points), infiltrative appearance (OR=9.3, 10 points), marked diffusion restriction (OR=3.3, five points), and iron sparing in solid mass (OR=0.2, -7 points) were significantly associated with positive GPC-3 expression. The optimal threshold of scoring system for predicting GPC-3 positive expression was 5.5 points, with AUC 0.726 and 0.681 on the internal and external validation sets, respectively.ConclusionBased on serum AFP and five EOB-MRI features, we developed an easy-to-use and noninvasive risk score which could accurately predict positive GPC-3 HCC, which may help identify potential responders for GPC-3-targeted immunotherapy.

Mucinous tubular and spindle cell carcinomas of the kidney (MTSCC-Ks): CT and MR imaging characteristics

To strengthen the recognition of mucinous tubular and spindle cell carcinomas of the kidney (MTSCC-Ks) by analyzing CT and MR imaging findings of MTSCC-Ks. This study retrospectively enrolled ten patients with pathologically confirmed MTSCC-Ks from 2007 to 2020. The main observed imaging characteristics included growth pattern, signal characteristics on T2-weighted imaging (T2WI) and diffusion-weighted imaging (DWI), hemorrhage, necrosis, cystic degeneration, lipid component, pseudocapsule and the enhancement pattern. Apparent diffusion coefficient (ADC) value of MTSCC-Ks and normal renal cortex were measured, respectively. All imaging features were evaluated in consensus by two genitourinary radiologists. All patients (53.1 ± 6.5years, male to female, 3:7) presented with a solitary renal tumor with the mean diameter of 3.5 ± 0.4cm. All lesions showed iso- or slight hypoattenuation on non-contrast CT with no hemorrhage but cystic degeneration (10%) and necrosis (10%). On T2WI, all lesions showed predominantly slight hypointensity with focal hyperintensity. The ADC value of MTSCC-Ks was 0.845 ± 0.017 × 10-3 mm2/s, and ADCtumor-to-ADCrenal cortex value was 0.376 ± 0.084. Pseudocapsules existed in all MTSCC-Ks on MRI. There were seven lesions showed heterogeneous enhancement, while three lesions showed homogeneous enhancement. Among them, six MTSCC-Ks showed slight multiple patchy enhancement (60%) in the corticomedullary phase, while the remaining MTSCC-Ks showed homogeneously slight enhancement (30%) or slightly stratified enhancement (10%). All MTSCC-Ks exhibited slow and progressive enhancement in the late phases. Iso- or slight hypoattenuation on CT, slight hypointensity with focal hyperintensity on T2WI, marked diffusion restriction on DWI and ADC map, slight multiple patchy enhancement in the corticomedullary phase, and slow and progressive enhancement in the late phases are the imaging features of MTSCC-Ks, which may facilitate the diagnosis of MTSCC-Ks.

Perinatal Obesity Induces Hepatic Growth Restriction with Increased DNA Damage Response, Senescence, and Dysregulated Igf-1-Akt-Foxo1 Signaling in Male Offspring of Obese Mice.

Maternal obesity predisposes for hepato-metabolic disorders early in life. However, the underlying mechanisms causing early onset dysfunction of the liver and metabolism remain elusive. Since obesity is associated with subacute chronic inflammation and accelerated aging, we test the hypothesis whether maternal obesity induces aging processes in the developing liver and determines thereby hepatic growth. To this end, maternal obesity was induced with high-fat diet (HFD) in C57BL/6N mice and male offspring were studied at the end of the lactation [postnatal day 21 (P21)]. Maternal obesity induced an obese body composition with metabolic inflammation and a marked hepatic growth restriction in the male offspring at P21. Proteomic and molecular analyses revealed three interrelated mechanisms that might account for the impaired hepatic growth pattern, indicating prematurely induced aging processes: (1) Increased DNA damage response (γH2AX), (2) significant upregulation of hepatocellular senescence markers (Cdnk1a, Cdkn2a); and (3) inhibition of hepatic insulin/insulin-like growth factor (IGF)-1-AKT-p38-FoxO1 signaling with an insufficient proliferative growth response. In conclusion, our murine data demonstrate that perinatal obesity induces an obese body composition in male offspring with hepatic growth restriction through a possible premature hepatic aging that is indicated by a pathologic sequence of inflammation, DNA damage, senescence, and signs of a possibly insufficient regenerative capacity.

Predicting microvascular invasion in hepatocellular carcinoma: A dual-institution study on gadoxetate disodium-enhanced MRI.

Background & AimsMicrovascular invasion (MVI) is an important risk factor in hepatocellular carcinoma (HCC), but its diagnosis mandates postoperative histopathologic analysis. We aimed to develop and externally validate a predictive scoring system for MVI.MethodsFrom July 2015 to November 2020, consecutive patients underwent surgery for HCC with preoperative gadoxetate disodium (EOB)‐enhanced MRI was retrospectively enrolled. All MR images were reviewed independently by two radiologists who were blinded to the outcomes. In the training centre, a radio‐clinical MVI score was developed via logistic regression analysis against pathology. In the testing centre, areas under the receiver operating curve (AUCs) of the MVI score and other previous MVI schemes were compared. Overall survival (OS) and recurrence‐free survival (RFS) were analysed by the Kaplan–Meier method with the log‐rank test.ResultsA total of 417 patients were included, 195 (47%) with pathologically‐confirmed MVI. The MVI score included: non‐smooth tumour margin (odds ratio [OR] = 4.4), marked diffusion restriction (OR = 3.0), internal artery (OR = 3.0), hepatobiliary phase peritumoral hypointensity (OR = 2.5), tumour multifocality (OR = 1.6), and serum alpha‐fetoprotein >400 ng/mL (OR = 2.5). AUCs for the MVI score were 0.879 (training) and 0.800 (testing), significantly higher than those for other MVI schemes (testing AUCs: 0.648–0.684). Patients with model‐predicted MVI had significantly shorter OS (median 61.0 months vs not reached, P < .001) and RFS (median 13.0 months vs. 42.0 months, P < .001) than those without.ConclusionsA preoperative MVI score integrating five EOB‐MRI features and serum alpha‐fetoprotein level could accurately predict MVI and postoperative survival in HCC. Therefore, this score may aid in individualized treatment decision making.

Differential effects of walking across visual cortical processing stages

Perceptual processes are almost exclusively investigated and understood under marked movement restriction, while natural behaviour includes pronounced movements. Recent human studies have indicated a profound influence of body movement on early visual responses (e.g., evoked components around 100 msec in EEG, electroencephalogram). However, very little is known about the influence of free walking on later visual responses (e.g., responses related to visual selective attention in a later time window than the stimulus evoked N1 component). In the current study, we measured neural signals (EEG) and behavioural performance in a visual selective attention task while participants were standing or freely walking. The results showed that walking was associated with an amplification of early sensory-evoked potential as indicated by the N1 component. Interestingly, neural indexes of the succeeding processing stages of stimulus discrimination and identification, namely the N2pc component and alpha oscillations, and the eventual behavioural measures were comparable between standing and walking. Additionally, in both standing and walking conditions, an overall advantage in target processing for the right visual field was observed. Our work provides evidence that the early sensory processing is enhanced during locomotion while the succeeding processing steps in a later time window are not modulated by locomotion. We conclude that walking has differential effects across visual cortical processing stages.

A perspective on animal welfare of grazing ruminants and its relationship with sustainability

Sustainability is a complex theorem driven through the optimisation of interconnected economic, social and environmental parameters. Balancing trade-offs between these three parameters is used to define a sustainable system, and while economic and, to a degree, environmental parameters can be numericised, making optimisation more defined, social parameters are often more complex. In livestock systems, animal welfare is held as a central pillar of sustainability, but due to its complex nature, indicators of welfare are in practice often restricted to negative nutritional/environmental/health domains (e.g. poor food quality, injuries/diseases) rather than the wider more complex ‘behavioural’ or ‘mental state’ domain indicators (e.g. expression of rewarding behaviours). This perspective discusses the potential synergies and trade-offs between animal welfare and economic, societal and environmental pillars of sustainability for grazing ruminant systems. Grazing is often considered more animal welfare-friendly than housed or feedlot type systems, especially in relation to the behavioural and mental state domains (BMSD) within a more ‘natural’ environment, as it may provide a positive experience to the animal. However, the welfare status of grazing ruminants can differ with factors such as management practices and environmental conditions greatly influencing nutritional/environmental/health domains of welfare, where a more ‘controlled environment’ can be efficacious. Animals that are not maintained at a good level of welfare will not express their productive potential, although improving welfare standards may lead to higher costs of production and therefore an economic break, as a critical component of sustainability, is often applied to what can be achieved on farm. Increasing animal performance is seen as an effective approach to reducing emissions intensity, which has been borne out by the lower methane intensity of high-yielding dairy housed herds, although there are important ethical concerns regarding BMSD of animal welfare and the marked restriction in environmental choices and in foraging behaviour (negative effect on behavioural interactions). However, consumers need to understand that implementing more ‘natural’ production systems with higher animal welfare standards can incur extra costs for producers, leading to higher output prices and also higher emissions per unit of product, which will require a reduction in consumption to reduce overall emissions.

Imaging Features with Histopathologic Correlation of CNS High-Grade Neuroepithelial Tumors with a BCOR Internal Tandem Duplication.

A new brain tumor entity occurring in early childhood characterized by a somatic BCL6 corepressor gene internal tandem duplication was recently described. The aim of this study was to describe the radiologic pattern of these tumors and correlate this pattern with histopathologic findings. This retrospective, noninterventional study included 10 children diagnosed with a CNS tumor, either by ribonucleic acid-sequencing analysis or deoxyribonucleic acid methylation analysis. Clinical, radiologic, and histopathologic data were collected. A neuropathologist reviewed 9 tumor samples. Preoperative images were analyzed in consensus by 7 pediatric radiologists. All tumors were relatively large (range, 4.7-9.2 cm) intra-axial peripheral masses with well-defined borders and no peritumoral edema. All tumors showed mild and heterogeneous enhancement and marked restriction on DWI of the solid portions. Perfusion imaging showed a relatively lower CBF in the tumor than in the adjacent normal parenchyma. Nine of 10 tumors showed areas of necrosis, with the presence of hemorrhage in 8/10 and calcifications in 4/7. Large intratumoral macroscopic veins were observed in 9/10 patients. No intracranial or spinal leptomeningeal dissemination was noted at diagnosis. CNS tumors with a BCL6 corepressor gene internal tandem duplication present as large intra-axial peripheral masses with well-defined borders, no edema, restricted diffusion, weak contrast enhancement, frequent central necrosis, hemorrhage and calcifications, intratumoral veins, and no leptomeningeal dissemination at the time of diagnosis. Knowledge of these imaging characteristics may aid in histologic, genomic, and molecular profiling of brain tumors in young children.

The Impact of the COVID-19 Pandemic on Cancer Patient's Management-Lithuanian Cancer Center Experience.

The pandemic spread of the COVID-19 virus significantly affected daily life, but the highest pressure was piled on the health care system. Our aim was to evaluate an impact of COVID-19 pandemic management measures on cancer services at the National Cancer Institute (NCI) of Lithuania. We assessed the time period from 1 February 2020 to 31 December 2020 and compared it to the same period of 2019. Data for our analysis were extracted from the NCI Hospital Information System (HIS) and the National Health Insurance Fund (NHIF). Contingency table analysis and ANOVA were performed. The COVID-19 pandemic negatively affected the cancer services provided by NCI. Reductions in diagnostic radiology (−16%) and endoscopy (−29%) procedures were accompanied by a decreased number of patients with ongoing medical (−30%), radiation (−6%) or surgical (−10%) treatment. The changes in the number of newly diagnosed cancer patients were dependent on tumor type and disease stage, showing a rise in advanced disease at diagnosis already during the early period of the first lockdown. The extent of out-patient consultations (−14%) and disease follow-up visits (−16%) was also affected by the pandemic, and only referrals to psychological/psychiatric counselling were increased. Additionally, the COVID-19 pandemic had an impact on the structure of cancer services by fostering the application of modified systemic anticancer therapy or hypofractionated radiotherapy. The most dramatic drop occurred in the number of patients participating in cancer prevention programs; the loss was 25% for colon cancer and 62% for breast cancer screening. Marked restriction in access to preventive cancer screening and overall reduction of the whole spectrum of cancer services may negatively affect cancer survival measures in the nearest future.

Accuracy of central neuro-imaging review of DIPG compared with histopathology in the International DIPG Registry.

Diffuse intrinsic pontine glioma (DIPG) remains a clinico-radiologic diagnosis without routine tissue acquisition. Reliable imaging distinction between DIPG and other pontine tumors with potentially more favorable prognoses and treatment considerations is essential. Cases submitted to the International DIPG registry (IDIPGR) with histopathologic and/or radiologic data were analyzed. Central imaging review was performed on diagnostic brain MRIs (if available) by two neuro-radiologists. Imaging features suggestive of alternative diagnoses included nonpontine origin, <50% pontine involvement, focally exophytic morphology, sharply defined margins, and/or marked diffusion restriction throughout. Among 286 patients with pathology from biopsy and/or autopsy, 23 (8%) had histologic diagnoses inconsistent with DIPG, most commonly nondiffuse low-grade gliomas and embryonal tumors. Among 569 patients with centrally-reviewed diagnostic MRIs, 40 (7%) were classified as non-DIPG, alternative diagnosis suspected. The combined analysis included 151 patients with both histopathology and centrally-reviewed MRI. Of 77 patients with imaging classified as characteristic of DIPG, 76 (99%) had histopathologic diagnoses consistent with DIPG (infiltrating grade II-IV gliomas). Of 57 patients classified as likely DIPG with some unusual imaging features, 55 (96%) had histopathologic diagnoses consistent with DIPG. Of 17 patients with imaging features suggestive of an alternative diagnosis, eight (47%) had histopathologic diagnoses inconsistent with DIPG (remaining patients were excluded due to nonpontine tumor origin). Association between central neuro-imaging review impression and histopathology was significant (p < 0.001), and central neuro-imaging impression was prognostic of overall survival. The accuracy and important role of central neuro-imaging review in confirming the diagnosis of DIPG is demonstrated.

Effects of a 3-Week In-Hospital Multidisciplinary Body Weight Reduction Program in Obese Females: Is Measured Resting Energy Expenditure Essential for Tailoring Adequately the Amount of Energy Intake?

In the obese population, the prescription of a proper diet plan is essential to ensure an appropriate and gradual weight loss, reduce the risk of weight cycling and favor an overall improvement of health conditions. Energy needs are commonly estimated using predictive equations, even if their accuracy is still debated, especially in severely obese subjects. In the present study, 850 severely obese females admitted to our hospital for a multidisciplinary body weight reduction program (BWRP) were divided into three subgroups, “hypo-,” “normo-,” and “hyper-metabolic,” based on the comparison between estimated resting energy expenditure (eREE, using the Mifflin equation) and measured REE (mREE, using indirect calorimetry). The majority of this study population was considered normo-metabolic (59.4%, mREE between 90 and 110% of eREE), 32.6% was hyper-metabolic (mREE > 110% of eREE) and only 8% was hypo-metabolic (mREE < 90% of eREE). The three subgroups were evaluated before and after a 3-week BWRP, entailing energy restricted diet, adapted physical activity, psychological counseling and nutritional education. Since the diet plan during the BWRP consisted of a 30% reduction of total energy expenditure (obtained by multiplying mREE by the physical activity level), each subgroup responded positively to the BWRP independently from the difference between mREE and eREE, the extent of BMI reduction and clinical, metabolic and physical amelioration being comparable among the three subgroups. By contrast, the restriction of the energy intake based on eREE during the BWRP would have determined a slighter caloric restriction in the hypo-metabolic subgroup, thus determining a smaller body weight reduction, and, by contrast, a more marked caloric restriction in the hyper-metabolic subgroup, probably difficult to be tolerated and maintained for prolonged period. In conclusion, the percentage of subjects with “slow metabolism” in a Caucasian female obese population seeking hospitalization for a BWRP is actually lower than expected, finding controverting the common notion that obesity is mostly due to reduced REE. The high percentage (40%) of inadequate eREE in these female obese populations further underlines the absolute need to include the measurement of REE in the clinical practice for the correct prescription of energy intake in severely obese populations.

Diffusion‐ and perfusion‐weighted imaging characteristics of an intracranial abscess in a cat

The images are of a 15-year-old male neutered domestic short-haired cat with a two-day progressive history of inappetence and lethargy. Neurological examination localised a right forebrain lesion with evidence of raised intracranial pressure (hypertension and bradycardia). Magnetic Resonance Imaging was performed with a 1.5 T MRI unit (Philips Ingenia CX, Philips Healthcare, Best, Netherlands,), with details described in Supplementary Data 1. MRI showed a large intra-axial sharply marginated spherical cyst-like mass within the right parietal lobe (Supplementary Fig 1). DWI represented a predominantely restrictive diffusive pattern and PWI significant hypoperfusion of the centre of the mass (Fig 1). The patient underwent a rostrotentorial craniectomy which confirmed imaging findings of an intracranial bacterial abscess, supported by a positive culture and intracellular bacteria in cytological evaluation. Distinguishing between intracranial abscessation, on conventional MRI, from other cystic or necrotic masses can be a challenging process. This feline case is a good example of the typical diffusion and perfusion characteristics that have only been described in human reports. The cavity of a “mature” abscess typically has a highly cellular and viscous composition due to inflammatory cells and bacteria. These features result in a marked restriction of microscopic diffusion of water molecules, resulting in low ADC values. Perfusion-weighted imaging has identified significant hypoperfusion (low relative cerebral blood volume, low relative cerebral blood flow and prolonged mean transit time). This finding can be explained by the reported large amounts of collagen and very low amounts of neovascularisation in intracranial abscesses, leading to a low density of capillary networks within the abscess. The appearance of intracranial bacterial infection in conventional imaging can vary from initial cerebritis developing into the capsular stages. The combination of diffusion- and perfusion-weighted imaging, in addition to conventional MRI, was useful in this case in the diagnosis of an intracranial abscess. Supporting Information Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.