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Supposing that Christ is impeccable – that, necessarily, Christ does not sin – what explains that impeccability? While there have been multiple theories of how the operations of Christ's human will could be fully free while Christ's sinlessness is nevertheless guaranteed, such accounts cannot be exploited to provide the requisite explanation. And not all of the divine purposes sufficient for becoming incarnate would also be sufficient to explain why Christ must be sinless. We should instead explain Christ's impeccability normatively, in terms of the reasons that God has to respond appropriately to God's own perfection by refraining from taking on a human nature with a will that ever opposes the divine will. Such reasons are reasons of divine holiness.

A 55-year-old man with a history of sarcoidosis was admitted 7 months after kidney transplantation for nephrocalcinosis because of fatigue, weight loss, and new pulmonary nodules. A diagnostic test was performed.

Despite being emphatically ascribed to God in Scripture, holiness is little examined in the current literature on the divine attributes. This article defends a normative theory of holiness, taking as its point of departure Rudolf Otto’s classic account of the phenomenology of the experience of holiness as that of a mysterium tremendum et fascinans. To be holy is to merit this dual response, that is, to merit both the overwhelming attraction and distinctive sort of repulsion that is characteristic of the experience of holiness. It is plausibly an implication of this account that a supremely holy being – one who is holy, holy, holy – must be the most perfect possible being.

Background Pulmonary embolism (PE) is a leading cause of pregnancy-related mortality. CT pulmonary angiogram (CTPA) is the first-line advanced imaging modality for suspected PE in pregnancy at institutes offering low-dose techniques; however, a protocol balancing safety with low dose remains undefined. The wide range of CTPA doses reported in pregnancy suggests a lack of confidence in implementing low-dose techniques in this group. Purpose To define and validate the safety, radiation dose and image quality of a low-dose CTPA protocol optimised for pregnancy. Materials and methods The OPTICA study is a prospective observational study. Pregnant study participants with suspected PE underwent the same CTPA protocol between May 2018 and February 2022. The primary outcome, CTPA safety, was judged by the reference standard; the 3-month incidence of venous thromboembolism (VTE) in study participants with a negative index CTPA. Secondary outcomes defined radiation dose and image quality. Absorbed breast, maternal effective and fetal doses were estimated by Monte-Carlo simulation on gestation-matched phantoms. Image quality was assessed by signal-to-noise and contrast-to-noise ratios and a Likert score for pulmonary arterial enhancement. Results A total of 116 CTPAs were performed in 113 pregnant women of which 16 CTPAs were excluded. PE was diagnosed on 1 CTPA and out-ruled in 99. The incidence of recurrent symptomatic VTE was 0.0% (one-sided 95% CI, 2.66%) at follow-up. The mean absorbed breast dose was 2.9 ± 2.1mGy, uterine/fetal dose was 0.1 ± 0.2mGy and maternal effective dose was 1.4 ± 0.9mSv. Signal-to-noise ratio (SNR) was 11.9 ± 3.7. Contrast-to-noise ratio (CNR) was 10.4 ± 3.5. Conclusion The OPTICA CTPA protocol safely excluded PE in pregnant women across all trimesters, with low fetal and maternal radiation. Clinical relevance OPTICA (Optimised CT Pulmonary Angiography in Pregnancy) is the first prospective study to define the achievable radiation dose, image-quality and safety of a low-dose CT pulmonary angiogram protocol optimised for pregnancy (NCT04179487). It provides the current benchmark for safe and achievable CT pulmonary angiogram doses in the pregnant population. Key Points • Despite the increased use of CT pulmonary angiogram in pregnancy, an optimised low-dose protocol has not been defined and reported doses in pregnancy continue to vary widely. • The OPTICA ( Opti mised C T Pulmonary A ngiography in Pregnancy) study prospectively defines the achievable dose, image quality and safety of a low-dose CT pulmonary angiogram protocol using widely available technology. • OPTICA provides a benchmark for safe and achievable CT pulmonary angiogram doses in the pregnant population.

Objectives To compare the incidence of persistent air leak (PAL) following cryoablation vs MWA of lung tumors when the ablation zone includes the pleura. Methods This bi-institutional retrospective cohort study evaluated consecutive peripheral lung tumors treated with cryoablation or MWA from 2006 to 2021. PAL was defined as an air leak for more than 24 h after chest tube placement or an enlarging postprocedural pneumothorax requiring chest tube placement. The pleural area included by the ablation zone was quantified on CT using semi-automated segmentation. PAL incidence was compared between ablation modalities and a parsimonious multivariable model was developed to assess the odds of PAL using generalized estimating equations and purposeful selection of predefined covariates. Time-to-local tumor progression (LTP) was compared between ablation modalities using Fine-Gray models, with death as a competing risk. Results In total, 260 tumors (mean diameter, 13.1 mm ± 7.4; mean distance to pleura, 3.6 mm ± 5.2) in 116 patients (mean age, 61.1 years ± 15.3; 60 women) and 173 sessions (112 cryoablations, 61 MWA) were included. PAL occurred after 25/173 (15%) sessions. The incidence was significantly lower following cryoablation compared to MWA (10 [9%] vs 15 [25%]; p  = .006). The odds of PAL adjusted for the number of treated tumors per session were 67% lower following cryoablation (odds ratio = 0.33 [95% CI, 0.14–0.82]; p  = .02) vs MWA. There was no significant difference in time-to-LTP between ablation modalities ( p  = .36). Conclusions Cryoablation of peripheral lung tumors bears a lower risk of PAL compared to MWA when the ablation zone includes the pleura, without adversely affecting time-to-LTP. Key Points • The incidence of persistent air leaks after percutaneous ablation of peripheral lung tumors was lower following cryoablation compared to microwave ablation (9% vs 25%; p  =  .006). • The mean chest tube dwell time was 54% shorter following cryoablation compared to MWA (p  =  .04). • Local tumor progression did not differ between lung tumors treated with percutaneous cryoablation compared to microwave ablation (p  =  .36).

The Philosophy of Law is a broad-reaching text that guides readers through the basic analytical and normative issues in the field, highlighting key historical and contemporary thinkers and offering a unified treatment of the various issues in the philosophy of law. * * Enlivened with numerous, everyday examples to illustrate various concepts of law. * Employs the idea of three central commonplaces about law - that law is a social matter, that law is authoritative, and that law is for the common good - to organize seemingly disparate topics and to bring rival views into contention with each other. * The first volume in the Fundamentals of Philosophy series, in which leading philosophers explore the fundamental issues and core problems in the major sub-disciplines of philosophy.

A 49-year-old man was admitted with hypokalemia and paranoia. Small-cell lung cancer had been diagnosed 6 months earlier; he had declined medical therapy and pursued alternative treatment. A diagnostic test was performed.

Objectives Patients with TIA and minor stroke commonly undergo CT and CTA in the emergency department with subsequent MRI with MRA for further workup. The purpose of this study was to review outpatient MRIs for TIA/stroke patients to assess the additional benefit, if any, of the MRA sequence in the detection of intracranial atherosclerotic disease in patients for whom CTA had already been performed. Methods The radiology reports of outpatient MRIs of the brain for TIA/minor stroke patients were retrospectively reviewed via the hospital PACS system. Following this, the imaging report from the patient’s initial presentation to the emergency department was reviewed. This index imaging and subsequent MRI were compared to assess the incidence of new vascular findings detected on the MRA sequence in patients for whom CTA had already been performed. Where new lesions had been identified at follow-up, the imaging was retroactively reviewed to assess if they were present on the index imaging. Results Two hundred seven consecutive patients were reviewed. Significant (> 50%) intracranial atherosclerotic disease was present on MRA in 18 patients (8.7%). This was a new finding in 11 patients. Five had initial CTA where the atherosclerosis was not detected. All 5 of these cases were located in the posterior cerebral arteries. Incidental aneurysms were seen in 14 (6.7%); 12 were a new finding at time of MRI. Conclusion The MRA sequence provides additional value by increasing the detection of clinically important intracranial atherosclerotic disease which may inform management in patients with minor stroke and TIA.

In this symposium on God's Own Ethics, Erik Wielenberg, Kristen Irwin, and Paul Draper raise important criticisms of the arguments of that book. I respond to these criticisms.

In God's Own Ethics: Norms of Divine Agency and the Argument from Evil, I consider what norms of action we should take to regulate God's agency. I also consider what inferences we should draw about the success of the argument from evil when we consider how an all-powerful, all-knowing agent would be motivated, given the ascription of those norms of action to God. This article is a précis of the main arguments of that book.