Ambiguous Cases Research Articles

Intrahepatic Cholangiocarcinoma Presenting as an Incidentaloma on F-18 PYL PSMA PET/CT

AbstractCholangiocarcinoma is an aggressive malignancy arising from the biliary tract epithelium with rising incidence and mortality. Imaging commonly used for diagnostic workup includes computed tomography (CT) scan and magnetic resonance imaging (MRI). Fluorine-18 fluorodeoxyglucose positron emission tomography (FDG PET) scans can be used for investigating equivocal findings on radiographic imaging. Prostate-specific membrane antigen (PSMA) is known to be highly expressed in prostate adenocarcinoma, allowing it to be leveraged as a target for both imaging and radioligand therapy in prostate cancer. However, PSMA is also commonly expressed in other malignancies such as breast cancer, thyroid carcinomas, and head and neck malignancies, which increase the chances of their incidental diagnosis on PSMA PET scans. Biliary tract cancers, including cholangiocarcinoma, are not commonly expected to be incidentally diagnosed on PSMA PET imaging. Here, we describe the case of a patient with known prostate adenocarcinoma who was later incidentally diagnosed with advanced intrahepatic cholangiocarcinoma on PSMA PET/computed tomography (CT). This case highlights the unexpected finding of cholangiocarcinoma on PSMA PET/CT and suggests further investigation into the role of PSMA PET in diagnosing ambiguous cases of cholangiocarcinoma and its potential theranostic applications.

Ultrasound and computed tomography in differentiating between simple and complicated appendicitis in pediatric patients.

This study aims to measure the diagnostic accuracy and reliability of US and CT in diagnosing complicated appendicitis among pediatric patients and to find the performance of the imaging modalities in detecting complication signs. a systematic review and meta-analysis were done on 15 eligible studies from the Medline Database concerning pediatric appendicitis and its complications. Studies either provided an overall estimate of sensitivity and specificity of the imaging modality or addressed signs of complicated appendicitis The reference standard employed was either surgical findings or histopathology reports. The review included assessments of 4,497 pediatric patients, with 285 undergoing CT and 4,212 undergoing US imaging. CT demonstrated sensitivities of 62% and 68.4%, and specificities of 81% and 92.4%. US showed sensitivities of 33.9% to 51.5% and specificities ranging from 68.8% to 95%. The ultrasound's ability to detect appendiceal wall diameter > 5mm showed the highest sensitivity (99.4%), while the conglomerate sign indicated the highest specificity (99.9%). The findings suggest that both US and CT exhibit higher specificity than sensitivity in diagnosing complicated appendicitis in pediatric patients. Given its favorable specificity, non-invasiveness, and lack of radiation exposure, US should be the first-line imaging modality in suspected cases of pediatric appendicitis. CT, offering robust specificity, should be reserved for ambiguous cases where US results are inconclusive. These insights underscore the critical role of precise imaging modalities in enhancing diagnostic accuracy, reducing unnecessary surgeries, and improving clinical outcomes in pediatric appendicitis management.

Contrastive Learning for Morphological Disambiguation Using Large Language Models in Low-Resource Settings

In this paper, a contrastive learning approach for morphological disambiguation (MD) using large language models (LLMs) is presented. A contrastive loss function is introduced for training the approach, which reduces the distance between the correct analysis and contextual embeddings while maintaining a margin between correct and incorrect embeddings. One of the aims of the paper is to analyze the effects of fine-tuning an LLM on MD in morphologically complex languages (MCLs) with special reference to low-resource languages such as Kazakh, as well as Turkish. Another goal of the paper is to consider various distance measures for this contrastive loss function, aiming to achieve better results when performing disambiguation by computing the distance between the context and the analysis embeddings. The existing approaches for morphological disambiguation, such as HMM-based and feature-engineering approaches, have limitations in modeling long-term dependencies and in the case of large, sparse tagsets. These challenges are mitigated in the proposed approach by leveraging LLMs, thus achieving better accuracy in handling the cases of ambiguity and OOV tokens without the need to rely on other features. Experiments were conducted on three datasets for two MCLs, Kazakh and Turkish—the former is a typical low-resource language. The results revealed that the proposed approach with contrastive loss improves MD performance when integrated with knowledge from large language models.

Arrest Matters: The Pragmatics of Vulnerability in Phone Calls to the Stasi

Using Conversation Analysis (CA), this article focuses on the ways in which participants invoke vulnerability in phone calls to the former East German State Security Service, better known as the Stasi. The calls were made in the late 1970s and the 1980s and pertained in one way or the other to political arrests. The main aim is to understand the linkage between vulnerability as an attribute of an institutional setting and vulnerability as the mutual achievement of a social interaction with an organization. The data represent different ways of addressing experiences of vulnerabilisation and different complications, each with a specific interactional character (failed request for help, self-protection or expression of indignation about one’s own treatment). Starting with an ambiguous case and focusing on how participants work to describe experiences of arrest in other cases documented and available in the Stasi tape archive, the article describes the sequential unfolding of vulnerability in different formats, depending on how the recipient designs them and the communicative tasks that participants tackle in their interactions.

Differentiating Brazilian and European Portuguese Multiword Adverbs

The identification of Portuguese multiword adverbs in texts such as de fininho ‘sneakily’ or em plena luz do dia ‘in broad daylight’ is an essential part of determining the meaning units forming a text. This paper explores the boundaries of adverbial multiword expressions in European and Brazilian Portuguese varieties. The primary purpose is to determine the frequency and distribution of the expressions in the pt TenTen18 corpusfrom Sketch Engine. Furthermore, we aim to analyze lexical and grammatical differences, as well as some cases of ambiguity and faux-amis(false-friends) between the two varieties. Finally, we seek to establish the boundaries of the variety-specific lexicon (European and Brazilian), which is part of our ongoing investigation on identifying, collecting, and providing a syntactic-semantic description of multiword adverbs in (Brazilian) Portuguese based on similar studies for European Portuguese, French, and Spanish. We adopt and adapt the classification proposed by Molinier and Levrier (2000), based on the Lexicon-Grammar theoretical-methodological framework.

Dysbiotic signatures and diagnostic potential of gut microbial markers for inflammatory bowel disease in Korean population

Fecal samples were collected from 640 individuals in Korea, including 523 patients with IBD (223 with Crohn’s disease [CD] and 300 with ulcerative colitis [UC]) and 117 healthy controls. The samples were subjected to cross-sectional gut metagenomic analysis using 16 S rRNA sequencing and bioinformatics analysis. Patients with IBD, particularly those with CD, exhibited significantly lower alpha diversities than the healthy subjects. Differential abundance analysis revealed dysbiotic signatures, characterized by an expansion of the genus Escherichia-Shigella in patients with CD. Functional annotations showed that functional pathways related to bacterial pathogenesis and production of hydrogen sulfide (H2S) were strongly upregulated in patients with CD. A dysbiosis score, calculated based on functional characteristics, highly correlated with disease severity. Markers distinguishing between healthy subjects and patients with IBD showed accurate classification based on a small number of microbial taxa, which may be used to diagnose ambiguous cases. These findings confirm the taxonomic and functional dysbiosis of the gut microbiota in patients with IBD, especially those with CD. Taxa indicative of dysbiosis may have significant implications for future clinical research on the management and diagnosis of IBD.

Quantum cognition in management research: A novel methodological framework with an application to causal ambiguity

AbstractWe propose a novel methodological framework based on the emerging field of quantum cognition and illustrate its application to a central problem in management and strategy research: causal ambiguity. The current literature often assumes that causal ambiguity—the difficulty of managers to understand the causal link between resources and outcomes at the basis of a firm's performance—can be reduced through learning. This literature overlooks the fact that causal ambiguity reduction is impossible when causal systems exhibit so‐called complementary properties. Building upon quantum cognition—specifically the idea of complementarity as an alternative to causality—we illustrate that causal ambiguity is only a special case of ambiguity and we offer a novel methodological framework to model what we label as ‘acausal ambiguity’, which refers to the insurmountable limit of managers to achieve causal ambiguity reduction. Managers can, of course, cognize some causal links. However, this comes at the price of being agnostic about complementary ones. The implications of this novel methodological framework applied to causal ambiguity are twofold: while complementarity opacifies the attentional faculties of managers, it also accounts for the cognitive origins of novelty.

The utility of disc space and vertebral body specimens cell count differential for the diagnosis of native vertebral osteomyelitis: a prospective cohort study.

Diagnostic methods for native vertebral osteomyelitis (NVO) often yield inconclusive results. Image-guided spine biopsies for culture are specific but diagnose NVO in only 50% of cases. Pre-exposure to antimicrobials further reduces diagnostic yield. Our study assesses the value of neutrophil percentage in disc space fluid and vertebral body (DS/VB) samples for diagnosing NVO. Adults referred for spine biopsy at Mayo Clinic from August 2022 to September 2023 were consented and enrolled at the time of biopsy. Following routine specimen collection, the biopsy needle was rinsed in saline into an EDTA tube for cell analysis. NVO diagnosis required organism identification in spine tissue or blood and/or positive histopathology, and consistent symptoms and imaging. Sixty-eight patients were prospectively enrolled, comprising 14 with NVO and 54 with alternative diagnoses. The median biopsy sample polymorphonuclear (PMN) percentage for NVO patients was 80.5% (IQR 72.5-85.2), compared to 64.5% (IQR 54.0-69.0) for those without NVO (p < 0.001). Nine (64.3%) NVO patients received antibiotics within 10 days prior to spine biopsy. As a continuous measure, PMN differential showed a moderately strong ability in classifying NVO status with an area under ROC curve of 0.795; an optimal point on the curve of 71.5% corresponded to a sensitivity of 78.6%, specificity of 79.6%, negative predictive value of 93.5% and positive predictive value of 50.0%. PMN differential in DS/VB biopsies may serve as an effective diagnostic tool in the evaluation of patients with NVO particularly in ambiguous cases with an initially negative spine biopsy. Future efforts will aim to implement these findings within routine clinical practice.

Optical Coherence Tomography in Myocardial Infarction Management: Enhancing Precision in Percutaneous Coronary Intervention

In acute myocardial infarction (AMI), the urgency of coronary revascularization through percutaneous coronary intervention (PCI) is paramount, offering notable advantages over pharmacologic treatment. However, the persistent risk of adverse events, including recurrent AMI and heart failure post-revascularization, underscores the necessity for enhanced strategies in managing coronary artery disease. Traditional angiography, while widely employed, presents significant limitations by providing only two-dimensional representations of complex three-dimensional vascular structures, hampering the accurate assessment of plaque characteristics and stenosis severity. Intravascular imaging, specifically optical coherence tomography (OCT), significantly addresses these limitations with superior spatial resolution compared to intravascular ultrasound (IVUS). Within the context of AMI, OCT serves dual purposes: as a diagnostic tool to accurately identify culprit lesions in ambiguous cases and as a guide for optimizing PCI procedures. Its capacity to differentiate between various mechanisms of acute coronary syndrome, such as plaque rupture and spontaneous coronary dissection, enhances its diagnostic potential. Furthermore, OCT facilitates precise lesion preparation, optimal stent sizing, and confirms stent deployment efficacy. Recent meta-analyses indicate that OCT-guided PCI markedly improves safety and efficacy in revascularization, subsequently decreasing the risks of mortality and complications. This review emphasizes the critical role of OCT in refining patient-specific therapeutic approaches, aligning with the principles of precision medicine to enhance clinical outcomes for individuals experiencing AMI.

Multiplex Determination of Glycan Profiles on Urinary Prostate-Specific Antigen by Quartz-Crystal Microbalance Combined with Surface-Enhanced Raman Scattering.

Prostate cancer remains a major health concern, with prostate-specific antigen (PSA) being a key biomarker for its detection and monitoring. However, PSA levels often fall into a "gray zone", where PSA levels are not clearly indicative of cancer, thus complicating early diagnosis and treatment decisions. Glycosylation profiles, which often differ between healthy and diseased cells, have emerged as potential biomarkers to enhance the specificity and sensitivity of cancer diagnosis in these ambiguous cases. We propose the integration of two complementary techniques, namely quartz-crystal microbalance with dissipation (QCM-D) and surface-enhanced Raman scattering (SERS) to study PSA glycan profiles. QCM-D offers real-time operation, PSA mass quantification, and label-free detection with high sensitivity, as well as enhanced specificity and reduced cross-reactivity when using nucleic acid aptamers as capture ligands. Complementary SERS sensing enables the determination of the glycosylation pattern on PSA, at low concentrations and without the drawbacks of photobleaching, thereby facilitating multiplexed glycosylation pattern analysis. This integrated setup could retrieve a data set comprising analyte concentrations and associated glycan profiles in relevant biological samples, which may eventually improve early disease detection and monitoring. Prostate-specific antigen (PSA), a glycoprotein secreted by prostate epithelial cells, serves as our proof-of-concept analyte. Our platform allows multiplex targeting of PSA multiplex glycosylation profiles of PSA at "gray zone" concentrations for prostate cancer diagnosis. We additionally show the use of SERS for glycan analysis in PSA secreted from prostate cancer cell lines after androgen-based treatment. Differences in PSA glycan profiles from resistant cell lines after androgen-based treatment may eventually improve cancer treatment.

Distinguishing injury patterns in fatal falls from heights versus pedestrian impacts: an autopsy study for differential diagnosis in ambiguous cases.

This study investigated the injury patterns associated with fatal falls from heights compared to individuals struck by cars, aiming to enhance the differential diagnosis in ambiguous cases, where it is unclear whether the body fell from nearby building or was left on the street following a road traffic incident. A retrospective review of comprehensive forensic reports from the Institute of Legal Medicine of the University of Rome "Tor Vergata" between 2012 and 2023 was conducted. The analysis included 232 cases, gathering data on internal organ injuries, skeletal fractures, external skin injuries, as well as pleural, peritoneal, and pericardial effusions. Bilateral lung injuries were significantly more common in falls from height (33.3%) compared to pedestrians (13.6%, p < 0.001). Liver injuries also occurred more frequently in fall victims (49.6%) than in pedestrians (28.2%, p < 0.001). Skull fractures were more frequent in falls from height (68.2%) versus individuals struck by cars (55.3%, p = 0.044), while unilateral leg fractures were more common in pedestrians (28.2%) compared to fall victims (16.3%, p = 0.029). External injuries, notably to the head and legs, were more frequent in pedestrians. The "Total Injured Skin Area" analysis revealed a significant discriminative power with an optimal cut-off of 84.2cm², suggesting that injuries exceeding this threshold may be indicative of a pedestrian road fatality.

МИКРОСПОРИДИИ ИЛИ КЛЕТКИ ПАНЕТА? ОСОБЕННОСТИ ДИАГНОСТИКИ МИКРОСПОРИДИОЗА ЧЕЛОВЕКА ПО ГИСТОСРЕЗАМ КИШЕЧНИКА

The Clinical Diagnostic Laboratory of Martsinovsky Institute of Medical Parasitology, Tropical and Vector Borne Diseases, I.M. Sechenov First Moscow State Medical University continues to share its experience in diagnosing rare, unusual and/or ambiguous cases of parasitosis in publications. The article describes two cases of suspected intestinal microsporidiosis. The difficulties and the probability of error of the microscopic method in the identification of intracellular protozoa on histosections are discussed.

Diagnostic Performance of ASL-MRI and FDG-PET in Frontotemporal Dementia: A Systematic Review and Meta-Analysis.

While the diagnosis of frontotemporal dementia (FTD) is based mostly on clinical features, [18F]-FDG PET has been investigated as a potential imaging golden standard in ambiguous cases, with arterial spin labeling (ASL) MRI gaining recent interest. The purpose of this study is to conduct a systematic review and meta-analysis on the diagnostic performance of ASL MRI in FTD patients and compare it to that of [18F]-FDG PET. A systematic search of PubMed, Scopus and EMBASE was conducted until March 13, 2024. Inclusion criteria were: original articles, patients with FTD and/or its variants, use of ASL MR perfusion imaging with or without [18F]-FDG PET, presence of sufficient diagnostic performance data. Exclusion criteria were: meeting abstracts, comments, summaries, protocols, letters and guidelines, longitudinal studies, overlapping cohorts. The quality of eligible studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2. Pooled sensitivity, specificity, and diagnostic odds ratio (DOR) for [18F]-FDG PET and ASL MRI were calculated, and a summary receiver operating characteristic curve was plotted. Seven eligible studies were identified, which included a total of 102 FTD patients. Aside from some of the studies showing at worst an unclear risk of bias in patient selection, index test, flow and timing, all studies showed low risk of bias and applicability concerns in all categories. Data from 4 studies was included in our meta-analysis for ASL MRI and 3 studies for [18F]-FDG PET. Pooled sensitivity, specificity and DOR were 0.70 (95% CI: 0.59-0.79), 0.81 (95% CI: 0.71-0.88) and 8.00 (95% CI: 3.74-17.13) for ASL MRI, and 0.88 (95% CI: 0.71-0.96), 0.89 (95% CI: 0.43-0.99) and 47.18 (95% CI: 10.77-206.75) for [18F]-FDG PET. The number of studies was relatively small, with a small sample size. The studies used different scanning protocols as well as a mix of diagnostic metrics, all of which might have introduced heterogeneity in the data. While ASL MRI performed worse than [18F]-FDG PET in the diagnosis of FTD, it exhibited a decent diagnostic performance to justify its further investigation as a quicker and more convenient alternative. 3DPCASL, 3D pseudocontinuous ASL; AD, Alzheimer's disease; ASL, arterial spin labeling; AUC, area under the curve; CI, confidence interval; DOR, diagnostic odds ratio; FN, false negative; FP, false positive; FTD, frontotemporal dementia; LE, limbic encephalitis; NLR, negative likelihood ratio; PASL, pulsed ASL; PLD, post-label delay; PLR, positive likelihood ratio; PRISMA, PSP, progressive supranuclear palsy; Preferred Reporting Items for Systematic Reviews and Meta-Analysis; SROC, summary receiver operative characteristic; TN, true negative; TP, true positive; QUADAS-2, Quality Assessment of Diagnostic Accuracy Studies-2.

Assessment of Risk Factors for the Development of PROM in a Tertiary Care Hospital

Background: Premature Rupture of Membranes (PROM) is a significant obstetric issue associated with increased rates of perinatal morbidity and mortality. Understanding the risk factors for PROM is essential to develop appropriate preventive policies to improve pregnancy and neonatal outcomes. Objective: This study aimed to assess the risk factors for the development of PROM in a tertiary care hospital and to analyze the associated maternal and neonatal complications. Methods: This descriptive cross-sectional study was conducted at the Gynae Department, Hayatabad Medical Complex, Peshawar, from March 2022 to February 2023. The study included 190 pregnant women diagnosed with PROM. Participants were selected using a non-probability consecutive sampling method. Data were collected using a structured questionnaire and patient medical records. PROM was diagnosed based on clinical examination, positive nitrazine test, and ferning test. In ambiguous cases, additional diagnostics like ultrasound and biochemical markers (PAMG-1 and IGFBP-1) were used. Ethical approval was obtained, and data were analyzed using SPSS Version 25. Descriptive statistics summarized the demographic and clinical characteristics, and associations between risk factors and PROM were evaluated using Chi-square and t-tests, with a p-value &lt;0.05 considered statistically significant. Results: The mean age of participants was 28.5±5.3 years, with 55.3% aged 20-29 years and 58.4% being multiparous. Significant risk factors included lower socioeconomic status (43.7%), history of sexually transmitted infections (21.6%), and previous PROM (34.2%). Obstetric factors such as multiple gestations and polyhydramnios were present in 12.1% and 15.8% of cases, respectively. Complications associated with PROM included intra-amniotic infection (17.9%), preterm labor (42.6%), and neonatal sepsis (9.5%). Conclusion: The study identified significant risk factors for PROM, including lower socioeconomic status, history of sexually transmitted infections, and prior PROM. These findings highlight the need for targeted interventions and management strategies to mitigate complications such as intra-amniotic infection, preterm labor, and neonatal sepsis, thereby improving maternal and neonatal outcomes. productivity.

A Multiwavelength Machine-learning Approach to Classifying X-Ray Sources in the Fields of Unidentified 4FGL-DR4 Sources

A large fraction of Fermi-Large Area Telescope (LAT) sources in the fourth Fermi-LAT 14 yr catalog (4FGL) still remain unidentified (unIDed). We continued to improve our machine-learning pipeline and used it to classify 1206 X-ray sources with signal-to-noise ratios >3 located within the extent of 73 unIDed 4FGL sources with Chandra X-ray Observatory observations included in the Chandra Source Catalog 2.0. Recent improvements to our pipeline include astrometric corrections, probabilistic cross-matching to lower-frequency counterparts, and a more realistic oversampling method. X-ray sources are classified into eight broad predetermined astrophysical classes defined in the updated training data set, which we also release. We present details of the machine-learning classification, describe the pipeline improvements, and perform an additional spectral and variability analysis for brighter sources. The classifications give 103 plausible X-ray counterparts to 42 GeV sources. We identify 2 GeV sources as isolated neutron star candidates, 16 as active galactic nucleus candidates, seven as sources associated with star-forming regions, and eight as ambiguous cases. For the remaining 40 unIDed 4FGL sources, we could not identify any plausible counterpart in X-rays, or they are too close to the Galactic Center. Finally, we outline the observational strategies and further improvements in the pipeline that can lead to more accurate classifications.

Periodic variable A-F spectral type stars in the southern TESS continuous viewing zone

Aims. Our primary objective is to accurately identify and classify the variability of A-F stars in the southern continuous viewing zone of the TESS satellite. The brightness limit was set to 10 mag to ensure the utmost reliability of our results and allow for spectroscopic follow-up observations using small telescopes. We aim to compare our findings with existing catalogues of variable stars. Methods. The light curves from TESS and their Fourier transform were used to manually classify stars in our sample. Cross-matching with other catalogues was performed to identify contaminants and false positives. Results. We have identified 1171 variable stars (51% of the sample). Among these variable stars, 67% have clear classifications, which includes δ Sct and γ Dor pulsating stars and their hybrids, rotationally variables, and eclipsing binaries. We have provided examples of the typical representatives of variable stars and discussed the ambiguous cases. We found 20 pairs of stars with the same frequencies and identified the correct source of the variations. Additionally, we found that the variations in 12 other stars are caused by contamination from the light of faint nearby large-amplitude variable stars. To compare our sample with other variable star catalogues, we have defined two parameters reflecting the agreement in identification of variable stars and their classification. This comparison reveals intriguing disagreements in classification ranging from 52 to 100%. However, if we assume that stars without specific types are only marked as variable, then the agreement is relatively good, ranging from 57 to 85% (disagreement 15–43%). We have demonstrated that the TESS classification is superior to the classification based on other photometric surveys. Conclusions. The classification of stellar variability is complex and requires careful consideration. Caution should be exercised when using catalogue classifications.

Non-invasively identifying candidates of active surveillance for prostate cancer using magnetic resonance imaging radiomics

Active surveillance (AS) is the primary strategy for managing patients with low or favorable-intermediate risk prostate cancer (PCa). Identifying patients who may benefit from AS relies on unpleasant prostate biopsies, which entail the risk of bleeding and infection. In the current study, we aimed to develop a radiomics model based on prostate magnetic resonance images to identify AS candidates non-invasively. A total of 956 PCa patients with complete biopsy reports from six hospitals were included in the current multicenter retrospective study. The National Comprehensive Cancer Network (NCCN) guidelines were used as reference standards to determine the AS candidacy. To discriminate between AS and non-AS candidates, five radiomics models (i.e., eXtreme Gradient Boosting (XGBoost) AS classifier (XGB-AS), logistic regression (LR) AS classifier, random forest (RF) AS classifier, adaptive boosting (AdaBoost) AS classifier, and decision tree (DT) AS classifier) were developed and externally validated using a three-fold cross-center validation based on five classifiers: XGBoost, LR, RF, AdaBoost, and DT. Area under the receiver operating characteristic curve (AUC), accuracy (ACC), sensitivity (SEN), and specificity (SPE) were calculated to evaluate the performance of these models. XGB-AS exhibited an average of AUC of 0.803, ACC of 0.693, SEN of 0.668, and SPE of 0.841, showing a better comprehensive performance than those of the other included radiomic models. Additionally, the XGB-AS model also presented a promising performance for identifying AS candidates from the intermediate-risk cases and the ambiguous cases with diagnostic discordance between the NCCN guidelines and the Prostate Imaging-Reporting and Data System assessment. These results suggest that the XGB-AS model has the potential to help identify patients who are suitable for AS and allow non-invasive monitoring of patients on AS, thereby reducing the number of annual biopsies and the associated risks of bleeding and infection.

Challenges in Diagnosis of Non-A Non-B Acute Aortic Dissection

ObjectiveNon-A non-B (NANB) aortic dissections are uncommon and frequently unrecognized diseases.However, their proper identification is crucial given the unpredictable behaviour of the dissected aorta with potential mortality and increased morbidity. We investigate the accuracy of radiological computed angio-tomography (CTA) reports in the diagnosis of acute NANB and the risk related to delayed recognition or misdiagnosis. MethodsThe pre-treatment contrast CTA of all consecutive patients admitted with acute aortic dissection (AAD) in a University Hospital in London (UK) between January 2017 and May 2023 were reviewed to retrospectively verify the accuracy of CTA reports in the diagnosis of NANB AAD (B1-2D The risk related to the delayed diagnosis (morbidity, mortality, and hospital re-admissions) were evaluated as secondary outcomes. The study was conducted according to the STROBE guidelines. ResultsOverall, 588 aortic CTAs were reviewed for a total of n=393 (66.8%) type A AADs, n=171 (29%) type B AADs and n=25(4.3%) NANB AADs (n=16, 64% men, mean age 60.56, DS+/- 14.6 years). While no case of misdiagnosis was identified in Type A or B AAD groups, in NANBs only about a third of cases (n=9, 36%) were immediately indicated as “NANB” (n=2, 8%) or “B with retrograde extension into the arch” (n=7, 28%), n=8 cases (32%) were described generically as “arch dissections” (n=6, 24%) or “type A and B” AAD (n=2, 8%). The remaining 32% of patients received a diagnosis that did not include mention of the arch, as n=6(24%) cases were reported to be “type A” and n=2(8%) to be “type B” AADs. Despite the heterogeneity of terms used to describe NANB AAD, no case of cardiac tamponade, new onset malperfusion nor neurological complications were reported, and no sudden death nor home-discharge and readmission while waiting for the proper diagnosis. ConclusionThe heterogeneity of terms used to describe NANB aortic dissection highlights the need for increased awareness, adoption of in guideline based classification systems, and further education to better understand and correctly address this challenging entity, minimizing misdiagnosis in ambiguous or difficult cases.

NETest in advanced high-grade gastroenteropancreatic neuroendocrine neoplasms.

Molecular blood biomarkers are lacking for high-grade (HG) gastroenteropancreatic (GEP) neuroendocrine neoplasms (NEN). To histologically distinguish between neuroendocrine carcinoma (NEC), neuroendocrine tumors G3 (NET G3), adenocarcinoma and MINEN is often challenging. The mRNA-based NETest has diagnostic, prognostic and predictive value in neuroendocrine tumors G1-2 but has not been studied in HG GEP-NEN. Patients with advanced HG GEP-NEN were prospectively included in an observational study. A blood sample was collected before the start of chemotherapy and pseudonymised before NETest was performed. NETest results are expressed as an activity index (NETest score) from 0 to 100. The normal score cut-off is 20. Histological sections were pseudonymised before centralized pathological re-evaluation. Samples from 60 patients were evaluable with the NETest. Main primary tumor sites were colon (14), rectum (12), pancreas (11) and esophagus (7). Re-classification: 30 NEC, 12 NET G3, 3 HG-NEN ambiguous morphology, 8 MiNEN, 3 adenocarcinomas with neuroendocrine differentiation (ADNE), 3 adenocarcinomas and 1 NET G2. Elevated NETest (>20) was seen in 38/45 (84%) HG GEP-NEN, all 17 large-cell NEC (100%), 11/13 (85%) small-cell NEC, all ambiguous cases and 7/12 (64%) NET G3. NETest was elevated in 5/8 (63%) MiNEN, 2/3 ADNE, however not in 3 adenocarcinomas. Median survival was 10.2 months (9.6-10.8 95%CI) for evaluable HG GEP-NEN treated with palliative chemotherapy (n = 39), and survival was significantly shorter in patients with NETest >60 with an OS of only 6.5 months. This is the first study to evaluate use of the NETest in advanced HG GEP-NEN. The NETest was almost always elevated in GEP-NEC and in all large-cell NEC. The NETest was also frequently elevated in NET G3 and MiNEN, however cases were limited. Baseline NETest was not predictive for benefit of chemotherapy, however a NETest >60 was prognostic with a shorter survival for patients receiving chemotherapy.

Endoscopic Ultrasound-Guided Fine Needle Biopsy of Focal Liver Lesions: An Effective Mini-Invasive Alternative to the Percutaneous Approach.

Despite the introduction of serological neoplastic biomarkers and typical radiological characteristics in clinical practice, liver biopsy (LB) is often still necessary to establish a histological diagnosis, especially in ambiguous cases. Nowadays, LB via the percutaneous approach (PC-LB), under computed tomography (CT) scan or ultrasonography (US) guidance, is the route of choice. However, certain focal liver lesions can be challenging to access percutaneously. In such cases, endoscopic ultrasound (EUS)-guided fine needle biopsy (FNB) may represent an attractive, minimally invasive alternative. This retrospective observational study aimed to evaluate the efficacy, diagnostic performance, and safety of EUS-FNB conducted on 58 focal liver lesions located in both liver lobes. The adequacy of FNB samples for focal liver lesions located in the left and right lobes was 100% and 81.2%, respectively, and the difference was statistically significant (p = 0.001). Technical success was 100% for both liver lobes. The overall sensitivity and specificity were 95% and 100%, respectively. EUS-FNB is effective in making an accurate diagnosis with an excellent safety profile for focal liver lesions located in both liver lobes.