Biomedical subjects

Pablo R Ros

Publications and source records attributed to Pablo R Ros.

At least 19 recordsLinked to original sources

PubMed2006

PET imaging for evaluation of metastatic colorectal cancer of the liver.

Colorectal cancer is a major cause of cancer death in Western Europe and United States; the liver is the most common site for colorectal metastases. PET has an important role in the management of patients with colorectal liver metastases. It is an effective tool to detect hepatic metastases and to monitor the response to systemic and local therapy. The major impact of PET-CT over PET alone is the improvement in the certainty of lesion location. PET-CT has the unique advantage to combine functional and anatomic imaging in an integrated scanner; it allows a thoroughly evaluation of patients with colorectal liver metastases.

Aged↗

PubMed2006

Key criteria for selection of radiology residents: results of a national survey.

RATIONALE AND OBJECTIVES: We sought to identify the criteria that academic radiology departments in the United States consider for selecting their residents. MATERIALS AND METHODS: In a cross-sectional study, a validated survey was sent to all the program directors of radiology residency programs. A total of 25 variables were studied. Descriptive statistics and correlations were calculated by the chi2 test. Nonparametric correlations were calculated with the Kruskal-Wallis rank test. Statistical significance was set at 5% alpha-error level (P<.05). RESULTS: We had a response rate of 53.1% (77 of 145). All responders participate in the National Resident Matching Program (NRMP), and 93.5% fill all their positions through NRMP. The preinterview selection criteria showed no significant difference by size, region, or affiliation with a medical school. An "interviewing body" carries out the interview process in 87.3% of the cases. Residents and fellows are part of the interviewing body in 76.5% of the programs, the body has the final word in accepting candidates in 62.9% of the programs, 55.4% of the programs use score sheets during interviews with candidates, and only 6.5% of the programs perform panel interviews. Programs associated with a medical school are significantly more likely to have more members in their interviewing body and to use score sheets when evaluating candidates, and panel interviews (more than one candidate or interviewer) are significantly more common among programs in the northeast region. CONCLUSION: All preinterview selection criteria and some interview structural characteristics are independent of the program's size, region, or affiliation with a medical school. More research regarding optimal preselection and interview processes is needed, and closer attention should be paid to the NRMP process if current practices are to be maintained.

Data Collection↗

PubMed2006

MRI of focal splenic lesions without and with dynamic gadolinium enhancement.

OBJECTIVE: Our purpose was to identify the MR features of focal splenic lesions with an emphasis on enhancement patterns. The addition of a contrast-enhanced dynamic sequence to unenhanced MR images improves the study of focal splenic lesions. The analysis of the MR features along with the clinical history permits either the characterization of the most common splenic lesions or improvement in the detection of malignant diseases. CONCLUSION: Dynamic contrast-enhanced MRI improves the detection and characterization of focal splenic lesions.

Adult↗

PubMed2006

CT features of hepatic venoocclusive disease and hepatic graft-versus-host disease in patients after hematopoietic stem cell transplantation.

OBJECTIVE: We conducted this study to evaluate whether CT scans could be used to differentiate hepatic venoocclusive disease from hepatic graft-versus-host disease in patients treated with hematopoietic stem cell transplantation. SUBJECTS AND METHODS: We retrospectively evaluated 18 patients (eight women, 10 men; mean age, 42.4 years) after hematopoietic stem cell transplantation with biopsy-proven hepatic venoocclusive disease (n = 5), hepatic graft-versus-host disease (n = 6), or both (n = 7). Two radiologists reviewed abdominal and pelvic CT scans for hepatomegaly (> 18 cm), splenomegaly (> 13 cm), size of main portal and right hepatic veins, presence of periportal edema, gallbladder wall edema, hydropic gallbladder, ascites, and small-bowel wall thickening. CT and histopathology findings were correlated using analysis of variance and Fisher-Free-man-Holton tests. RESULTS: Ascites and periportal edema were present in all five patients with venoocclusive disease, but of six patients with graft-versus-host disease, ascites was seen in two (p < 0.05) and periportal edema in only one (p < 0.05). Small-bowel wall thickening was encountered in five patients with graft-versus-host disease and in none with venoocclusive disease (p < 0.05). The right hepatic vein diameter in patients with venoocclusive disease (mean, 0.27 cm) was significantly smaller than the right hepatic vein diameter in patients with graft-versus-host disease (mean, 0.87 cm; p < 0.05). CONCLUSION: In patients treated with hematopoietic stem cell transplantation, CT findings of periportal edema, ascites, and a narrow right hepatic vein suggest venoocclusive disease rather than graft-versus-host disease. Small-bowel wall thickening suggests graft-versus-host disease.

Adult↗

PubMed2006

Survey of the use of quality indicators in academic radiology departments.

OBJECTIVE: Our purpose was to determine whether quality in academic radiology departments in the United States is systematically measured through indicators and evaluated by preset standards. MATERIALS AND METHODS: We performed a cross-sectional study using a validated survey sent to Society of Chairmen of Academic Radiology Departments (SCARD) members and studied type, frequency of monitoring, and use of preset standards for evaluation of quality indicators. Statistical methods were descriptive summary statistics, chi-square test, analysis of variance, and Spearman's rank correlation test. RESULTS: The response rate was 42% (55/132). Most responding hospitals were from the Northeast (20/55, 36.4%) and Midwest (18/55, 32.7%). About 58% (32/55) of the responding hospitals had more than 500 beds in operation; 50.9% (28/55) of the radiology departments performed 200,000-400,000 examinations per year. Among the 80% of departments (44/55) that monitored patient satisfaction, only 49.1% and 45.5% assessed referring physician and employee satisfaction, respectively. The most frequently monitored customer satisfaction indicator, patient satisfaction, was monitored quarterly or less frequently by 70.5% (31/44) of departments; about 45.5% (20/44) had preset standards for this indicator. MRI and CT were monitored for patient appointment access by 80% (44/55) and 72.7% (40/55) of departments, respectively; 59.1% (26/44) and 62.5% (25/40) of departments applied preset standards to these indicators, respectively. The reporting-time indicator monitored most frequently was report turnaround time (45/55, 81.8%). None of the differences in mean numbers and monitoring frequencies of the indicators and the use of preset standards to evaluate them by region and size of departments were significant (p >0.05). CONCLUSION: Use of quality management indicators, particularly customer satisfaction indicators, is not a fully standardized and established process for academic radiology departments in the United States.

Academic Medical Centers↗

PubMed2005

Use of productivity and financial indicators for monitoring performance in academic radiology departments: U.S. nationwide survey.

PURPOSE: To determine how productivity- and finance-related indicators are used by radiology departments to evaluate departmental performance. MATERIALS AND METHODS: The study met the criteria to be exempt from institutional review board approval. All subjects were informed of the purpose of the study and that their questionnaire responses would be kept confidential. For the study, a survey was sent to 132 members of the Society of Chairmen of Academic Radiology Departments (SCARD) nationwide. The survey was designed to (a) assess organizational information about hospital and radiology departments, (b) determine the types and mean numbers of productivity and financial indicators used by radiology departments, (c) determine how these indicators are used to influence departmental productivity, and (d) assess the reference-standard goals with which each indicator value was compared. A total of 77 variables were studied. Summary statistics, Spearman rank correlation coefficient, and chi2 analyses were performed. RESULTS: The response rate was 42% (55 of 132 surveyed SCARD members). The mean number of productivity indicators used by radiology departments was 4.55 +/- 2.56 (standard deviation), while the mean number of financial indicators used was 2.89 +/- 1.99. Twenty-two (40%) of the 55 responding departments used productivity indicators to monitor and provide feedback to radiologists, hospital leaders, and technical staff members for improved productivity, but only 11 (20%) departments used these indicators to compare personnel performances against specific productivity standards. The most frequent goal (of seven [13%] responding departments) of using the indicators was to increase the examination volume from the previous year by 5%-10%. CONCLUSION: Academic radiology departments across the United States do not use a standardized set of productivity and financial indicators to measure departmental performance. Examination volume is the most frequently used productivity indicator, whereas general expenses are commonly used as indicators of financial status.

Chi-Square Distribution↗

PubMed2005

Multidetector row CT of the small bowel.

Multidetector row CT (MDCT) has become an imaging technique of choice to study routinely the small bowel. Thin collimation and fast scanning allow coverage of the entire abdomen within a single suspended respiration phase allowing the use of multiple enhancement phases after intravenous contrast administration. MDCT of the small bowel can identify and stage most of the common diseases of the small bowel. MDCT is changing the paradigm for diagnosing small bowel disease by becoming the first diagnostic line for almost all small bowel diseases. MDCT has the needed sensitivity and specificity, the availability, and the safety for a front-line diagnostic method.

Contrast Media↗

PubMed2005

Universal use of nonionic iodinated contrast medium for CT: evaluation of safety in a large urban teaching hospital.

OBJECTIVE: We evaluated the safety of the universal use of the nonionic iodinated contrast agent iopromide in patients undergoing CT in a large urban teaching hospital. SUBJECTS AND METHODS: For 2 years, we prospectively recorded all adverse events temporally associated with the administration of iopromide in 29,508 consecutive patients undergoing contrast-enhanced CT at our institution. The types, intensities, treatments, and outcomes of adverse events were recorded along with relevant patient history, including risk factors. Descriptive analyses of the variables, comparisons of means, and proportions using Student's t and chi-square tests, and logistic regressions were conducted. RESULTS: Adverse events were observed in 211 patients (0.7%) and were categorized as follows: urticaria (n = 161), facial or laryngeal edema (n = 13), bronchospasm (n = 8), severe nausea or vomiting (n = 10), or other (n = 19). One hundred eighty-eight adverse events (89%) were rated mild, 19 moderate (9%), and four severe (2%), including one fatality. Adverse events required treatment in 89 patients (42%). A history of allergy was present in 92 patients (44%), and 29 (14%) had a prior contrast reaction. Other relevant risk factors were identified in 63 patients (30%). No relationship existed between the occurrence of adverse events and any of the following: patient age, dose of iodine administered, or time of study (i.e., month, season, and year). Women (p < 0.001) and outpatients (p < 0.001) had a statistically significant higher incidence of adverse events. CONCLUSION: The universal use of iopromide as an IV CT contrast agent has a favorable safety profile.

Adult↗

PubMed2005

CT and MRI features of pure acinar cell carcinoma of the pancreas in adults.

OBJECTIVE: We sought to describe the CT and MRI features of pure acinar cell carcinoma of the pancreas in adults. MATERIALS AND METHODS: Eleven patients (six women and five men; mean age, 64 years) with acinar cell carcinoma, documented by pathologic examination of resected specimens, underwent CT (n=9) or MRI (n=2) examinations. Two radiologists evaluated imaging studies and determined, by consensus, the following data for each tumor: size, location, margination, internal density or signal intensity, and contrast enhancement pattern. In addition, they assessed the presence of calcification, pancreatic or bile duct dilation, and metastases. Imaging features were correlated with gross and microscopic pathologic features of the tumors. RESULTS: Masses were distributed throughout the pancreas (head, n=5; body, n=2; and tail, n=4). The mean largest dimensions were 6.0 x 5.3 cm (range, from 2 x 1.7 to 15 x 11 cm). Tumors were oval (n=5), round (n=4), or lobular (n=2). Ten (91%) masses were well marginated; nine (82%) were exophytic. Five (45%) masses enhanced homogeneously; the remaining tumors contained cystic areas. All masses enhanced less than the surrounding pancreas. Three (27%) masses contained calcifications. Four (80%) masses invaded the duodenum. Common bile and pancreatic duct dilatation was present in two and three patients, respectively. One patient had metastatic liver disease at presentation. CONCLUSION: Pure acinar cell carcinoma of the pancreas is usually an exophytic, oval or round, well-marginated, and hypovascular mass on CT and MRI. It typically is completely solid when small and contains cystic areas due to necrosis when large.

Adult↗

PubMed2004

Peripancreatic vascular abnormalities complicating acute pancreatitis: contrast-enhanced helical CT findings.

OBJECTIVE: To determine the prevalence and morphologic helical computed tomography (CT) features of peripancreatic vascular abnormalities in patients with acute pancreatic inflammatory disease in correlation with the severity of the pancreatitis. MATERIALS AND METHODS: One hundred and fifty-nine contrast-enhanced helical CT scans of 100 consecutive patients with acute pancreatitis were retrospectively and independently reviewed by three observers. CT scans were scored using the CT severity index (CTSI): pancreatitis was graded as mild (0-2 points), moderate (3-6 points), and severe (7-10 points). Interobserver agreement for both the CT severity index and the presence of peripancreatic vascular abnormalities was calculated (K-statistic). Correlation between the prevalence of complications and the degree of pancreatitis was estimated using Fisher's exact test. RESULTS: The severity of pancreatitis was graded as mild (n = 59 scans), moderate (n = 82 scans), and severe (n = 18 scans). Venous abnormalities detected included splenic vein (SV) thrombosis (31 scans, 19 patients), superior mesenteric vein (SMV) thrombosis (20 scans, 14 patients), and portal vein (PV) thrombosis (17 scans, 13 patients). Arterial hemorrhage occurred in five patients (6 scans). In our series, no cases of arterial pseudoaneurysm formation were detected. The interobserver agreement range for scoring the degree of pancreatitis and the overall presence of major vascular abnormalities was 75.5-79.2 and 86.2-98.8%, respectively. The presence of the vascular abnormalities in correlation with the severity of pancreatitis was variable. CONCLUSION: Vascular abnormalities are relatively common CT findings in association with acute pancreatitis. The CT severity index is insufficiently accurate in predicting some of these complications since no statistically significant correlation between their prevalence and the severity of pancreatitis could be established.

Acute Disease↗

PubMed2004

Practice management performance indicators in academic radiology departments.

PURPOSE: To determine the management performance indicators most frequently utilized in academic radiology departments in the United States. MATERIALS AND METHODS: This investigation met the criteria for an exemption from institutional review board approval. A cross-sectional study in which a validated national survey was sent to members of the Society of Chairmen of Academic Radiology Departments (SCARD) was conducted. The survey was designed to examine the following six categories of 28 performance indicators: (a) general organization, (b) volume and productivity, (c) radiology reporting, (d) access to examinations, (e) customer satisfaction, and (f) finance. A total of 158 variables were included in the analysis. Summary statistics, the chi(2) test, rank correlation, multiple regression analysis, and analysis of variance were used. RESULTS: A response rate of 42% (55 of 132 SCARD members) was achieved. The mean number of performance indicators used by radiology departments was 16 +/- 6.35 (standard deviation). The most frequently utilized performance indicators were as follows: (a) productivity, in terms of examination volume (78% [43 departments]) and examination volume per modality (78% [43 departments]); (b) reporting, in terms of report turnaround (82% [45 departments]) and transcription time (71% [39 departments]); (c) access, in terms of appointment access to magnetic resonance imaging (80% [44 departments]); (d) satisfaction, in terms of number of patient complaints (84% [46 departments]); and (e) finance, in terms of expenses (67% [37 departments]). Regression analysis revealed that the numbers of performance indicators in each category were statistically significant in predicting the total number of performance indicators used (P < .001 for all). Numbers of productivity and financial indicators were moderately correlated (r = 0.51). However, there were no statistically significant correlations between the numbers of performance indicators used and hospital location, hospital size, or department size (P > .4 for all). CONCLUSION: Assessing departmental performance with a wide range of management indicators is not yet an established and standardized practice in academic radiology departments in the United States. Among all indicators, productivity indicators are the most frequently used.

Academic Medical Centers↗

PubMed2004

A modified CT severity index for evaluating acute pancreatitis: improved correlation with patient outcome.

OBJECTIVE: This study was conducted to assess the correlation with patient outcome and interobserver variability of a modified CT severity index in the evaluation of patients with acute pancreatitis compared with the currently accepted CT severity index. MATERIALS AND METHODS: Of 266 consecutive patients diagnosed with acute pancreatitis during a 1-year period, 66 underwent contrast-enhanced MDCT within 1 week of the onset of symptoms. Three radiologists who were blinded to patient outcome independently scored the severity of the pancreatitis using both the currently accepted and modified CT severity indexes. The modified index included a simplified assessment of pancreatic inflammation and necrosis as well as an assessment of extrapancreatic complications. Outcome parameters included the length of hospital stay; the need for surgery or percutaneous intervention; and the occurrences of infection, organ failure, and death. For both the current and modified indexes, correlation between the severity of the pancreatitis and patient outcome was estimated using the Wilcoxon's rank sum test and Fisher's exact test. Interobserver agreement for both indexes was calculated using the kappa statistic. RESULTS: When applying the modified index, the severity of pancreatitis and the following parameters correlated more closely than when the currently accepted index was applied: the length of the hospital stay (0-34 days) (modified index [p = 0.0054-0.0714] vs current index [p = 0.0052-0.3008]); the need for surgical or percutaneous procedures (10/66 patients) (modified index [p = 0.0112] vs current index [p = 0.0324]); and the occurrence of infection (21/66 patients) (modified index [p < 1e(-10)] vs current index [p < 1e(-04)]). Significant correlation between the severity of pancreatitis and the development of organ failure (9/66 patients) was seen only using the modified index (p = 0.0024), not the current index (p = 0.0513). The interobserver agreement was similar with the modified (kappa range, 0.71-0.85) and the current (kappa range, 0.63-0.86) indexes. CONCLUSION: The modified CT severity index correlates more closely with patient outcome measures than the currently accepted CT severity index, with similar interobserver variability.

Acute Disease↗

PubMed2003

Rectal inflammation as first manifestation of graft-vs-host disease: radiologic-pathologic findings.

Graft-vs-host disease (GVHD) is a common, life-threatening complication of bone marrow transplantation that frequently involves the gastrointestinal tract. Since symptoms are typically nonspecific, radiologic examination is often performed to reach a diagnosis. To the best of our knowledge, this is the first reported radiologic description of a case of rectal involvement as the first manifestation of GVHD. The differential diagnosis of segmental rectal wall thickening in a patient following bone marrow transplantation should include GVHD.

Abdominal Pain↗

PubMed2003

CT of acute bowel ischemia.

Bowel ischemia may be caused by many conditions and manifest with typical or atypical and specific or nonspecific clinical, laboratory, and radiologic findings. It may mimic various intestinal diseases and be confused with certain nonischemic conditions clinically and at computed tomography (CT). Bowel ischemia severity ranges from mild (generally transient superficial changes of intestinal mucosa) to more dangerous and potentially life-threatening transmural bowel wall necrosis. Causes of critically reduced blood flow to the bowel are diverse, ranging from occlusions of mesenteric arteries or veins to complicated bowel obstruction and overdistention. CT can demonstrate changes in ischemic bowel segments accurately, is often helpful in determining the primary cause of ischemia, and can demonstrate important coexistent findings or complications. Unfortunately, common CT findings in bowel ischemia are not specific, and specific findings are rather uncommon. Therefore, it often is a combination of nonspecific clinical, laboratory, and radiologic findings-especially detailed knowledge about the pathogenesis of acute bowel ischemia in different conditions-that helps most in correct interpretation of CT findings. To improve understanding of this complex heterogeneous entity, this article provides an overview of the anatomy and physiology of mesenteric perfusion and discussions of causes and pathogenesis of acute bowel ischemia, CT findings in various types of acute bowel ischemia, and potential pitfalls of CT.

Acute Disease↗

PubMed2003

Spontaneous intraperitoneal hemorrhage: imaging features.

Spontaneous intraperitoneal bleeding can result from a vast array of etiologies. Fortunately, most are uncommon and currently available imaging modalities can be used to differentiate them in almost all cases. Meticulous imaging technique and careful observation of key imaging features are important for accurate characterization of the organ of origin of the spontaneous bleeding. CT is the single most important imaging technique in the detection and characterization of spontaneous intraperitoneal bleeding. Further development in multidetector technology, such as the introduction of new machines with 8 or 16 detectors, should improve the effectiveness of CT further. Sonography and MR imaging are complimentary to CT, especially in patients with pelvic abnormalities or equivocal CT findings.

Contrast Media↗

PubMed2003

Acute small bowel ischemia: CT imaging findings.

Small bowel ischemia is a disorder related to a variety of conditions resulting in interruption or reduction of the blood supply of the small intestine. It may present with various clinical and radiologic manifestations, and ranges pathologically from localized transient ischemia to catastrophic necrosis of the intestinal tract. The primary causes of insufficient blood flow to the small intestine are various and include thromboembolism (50% of cases), nonocclusive causes, bowel obstruction, neoplasms, vasculitis, abdominal inflammatory conditions, trauma, chemotherapy, radiation, and corrosive injury. Computed tomography (CT) can demonstrate changes because of ischemic bowel accurately, may be helpful in determining the primary cause of ischemia, and can demonstrate important coexistent findings or complications. However, common CT findings in acute small bowel ischemia are not specific and, therefore, it is often a combination of clinical, laboratory and radiologic signs that may lead to a correct diagnosis. Understanding the pathogenesis of various conditions leading to mesenteric ischemia and being familiar with the spectrum of diagnostic CT signs may help the radiologist recognize ischemic small bowel disease and avoid delayed diagnosis. The aim of this article is to provide a review of the pathogenesis and various causes of acute small bowel ischemia and to demonstrate the contribution of CT in the diagnosis of this complex disease.

Diagnosis, Differential↗

PubMed2003

Comparing Levovist-enhanced pulse inversion harmonic imaging and ferumoxides-enhanced MR imaging of hepatic metastases.

OBJECTIVE: The aim of this study was to compare the sensitivity of pulse inversion harmonic digital sonography, unenhanced transabdominal sonography, and ferumoxides-enhanced MR imaging in the depiction of liver metastases. In addition, pulse inversion harmonic digital sonography was performed at different scanning times after Levovist injection to define the best phase for depiction. SUBJECTS AND METHODS: Twenty-six consecutive patients with findings of extrahepatic primary malignancies and liver metastases suspected on transabdominal sonography were examined with both pulse inversion harmonic imaging and ferumoxides-enhanced MR imaging within a 7-day period. Pulse inversion harmonic imaging was performed before and at 20, 100, and 180 sec after a bolus injection of Levovist. MR imaging was performed before and after ferumoxides administration, using breath-hold gradient-recalled echo T1-weighted and turbo spin-echo short tau inversion recovery T2-weighted sequences. Two radiologists independently evaluated image quality, and the number, location, and diameter of lesions scanned using both techniques. Intraoperative sonography or at least 8-month follow-up confirmed the lesions depicted. Analyses included Wilcoxon's signed rank test and Interclass correlation test. RESULTS: Levovist-enhanced pulse inversion harmonic imaging revealed 104 metastases on the first scan after contrast injection, 126 on the second scan, and 118 on the third, compared with 66 on the unenhanced scan. Pulse inversion harmonic digital sonography depicted 90% of lesions shown on ferumoxides-enhanced MR imaging (140 metastases) (p = 0.001). CONCLUSION: Levovist-enhanced pulse inversion harmonic digital sonography is a sensitive technique for depiction of liver metastases. Pulse inversion harmonic digital sonography may have a potential role in imaging patients with possible metastatic involvement of the liver. Further studies are needed to define its place in the workup of these patients. At present, ferumoxides-enhanced MR imaging, being more sensitive, must be performed in all patients in whom pulse inversion harmonic digital sonography is not conclusive or when after pulse inversion harmonic digital sonography, patients remain eligible for surgery.

Adult↗

PubMed2003

Macrocystic serous adenoma of the pancreas: radiologic-pathologic correlation.

OBJECTIVE: Macrocystic serous adenoma is a rare benign pancreatic neoplasm, recently described in the pathology literature. We describe the CT and MR imaging features in a series of five consecutive pathologically proven cases. MATERIALS AND METHODS: Of seven cases fulfilling the pathology criteria for macrocystic serous adenoma over an 11-year period, five patients underwent preoperative CT and MR imaging at our institution. In addition to the clinical presentation and pathologic features of the tumor, the following CT and MR imaging features were reviewed: size and location; wall thickness; internal septations; and presence of mural nodules, papillary projections, or calcifications. RESULTS: All patients but one were women (age range, 36-78 years; mean age, 48.6 years). The sizes of the tumors ranged from 1.5 to 5.0 cm (mean, 3.1 cm). Three (60%) of five tumors were located in the pancreatic head. The wall measured less than 2 mm in four lesions and 4 mm in one. No mural nodules, papillary projections, or calcifications were present. Lesions were unilocular (n = 3) or bilocular (n = 2). Excellent correlation of imaging features with gross pathology was observed. CONCLUSION: On CT and MR imaging, the macrocystic variant of serous adenoma typically appears as a small (< 5 cm), uni- or bilocular cyst with a thin (< 2 mm) wall that lacks mural nodules or calcifications. The imaging appearance of macrocystic serous adenoma is distinctly different from that of microcystic serous cystadenoma, but the imaging appearance of macrocystic serous adenoma is indistinguishable from mucinous cystadenoma and cystadenocarcinoma of the pancreas.

Cystadenoma, Serous↗