Diagnostic Pathway Research Articles

Awareness, access, and adoption of natriuretic peptides for diagnosis of heart failure.

This survey investigates natriuretic peptide (NP) testing in community and hospital settings, assessing awareness, accessibility, and utilization. This investigator-initiated survey, conceived within the HFA of the European Society of Cardiology, comprised 14 questions. It underwent validation and pilot testing to ensure question readability and online system functionality. The survey was accessible for 87days, from 5 April 2023 to 1 July 2023 via a web platform. There were 751 healthcare professionals across 99 countries who responded. Of them, 92.5% had access to NPs testing in hospital whereas 34.3% had no access to NTproBNP in community settings. Access to point of care NP testing was uncommon (9.6%). Public insurance fully covered NPs testing in 31.0% of cases, with private insurance providing coverage in 37.9%. The majority (84.0%) of participants believed that the medical evidence supporting NPs testing was strong, and 54.7% considered it cost-effective. Also, 35.8% found access, awareness, and adoption to be in favour of NPs testing both in hospital and community settings. Strategies to optimize NP testing involved regular guideline updates (57.9%), prioritizing NPs testing for dyspnoea assessment (36.4%), and introducing clinician feedback mechanisms (21.2%). Notably, 40% lacked a community-based HF diagnostic pathway for referring high-NP patients for echocardiography and cardiology evaluation. This survey reveals NP awareness, access, and adoption across several countries. Highlighting the importance of community-based early heart failure diagnosis and optimizing HF diagnostic pathways remains a crucial, unmet opportunity to improve patient outcomes.

Differential Outcomes in Colorectal Cancer Detection: A Comparative Study of Swedish Nationwide Screening and Fast-Track Diagnostic Pathways.

In 2021, a nation-wide screening program for colorectal cancer (CRC) was step-wise implemented in Region Örebro County (RÖC) for patients aged 60 to 74 years, utilizing the fecal immunochemical test (FIT) to refer patients for colonoscopy. Concurrently, the standardized care course for colorectal cancer (SCC-CRC), initiated in 2016, employs a fast-track pathway for patients with alarm symptoms to undergo colonoscopy. This study compares CRC screening colonoscopies with SCC-CRC colonoscopies in RÖC among patients aged 60 to 67 years. An initial analysis of the Swedish colorectal screening cohort was combined with a retrospective cohort study, analyzing data from 307 CRC screening patients and 441 age-matched SCC-CRC patients in RÖC. Data included demographics, colonoscopy participation rates, and pathology findings. Statistical analyses compared outcomes between the 2 groups. Among the screening group, 2% tested positive for FIT, with an 86% colonoscopy participation rate (N=9296). In RÖC, 266 screening patients underwent colonoscopy, with 10% diagnosed with CRC, compared with 20% in the SCC-CRC group. In addition, 39% of the screening group in RÖC were diagnosed with advanced adenomas, versus 15% in the SCC-CRC group. Screening participation was high, with effectiveness aligning with international counterparts. The SCC-CRC pathway excels in diagnosing CRC among symptomatic patients, while the nationwide screening program is effective in early detection of CRC and advanced adenomas. underscoring the importance of integrating and optimizing both approaches within the Swedish health care system to optimize CRC prevention and management.

A new national primary care diagnostic pathway for benign lower gastrointestinal conditions

A new national primary care diagnostic pathway for benign lower gastrointestinal conditions

Incorporation of mpMRI before prostate biopsy shall be universal or selective: A prospective observational study

Purpose: The aim of this study is to evaluate the role of multiparametric magnetic resonance imaging (mpMRI) as a triage workup in the diagnostic pathway of suspected prostate cancer (PCa) in our population. Material and methods: This prospective observational study was conducted at lesser than details of site are removed for blinded peer review > on biopsy-naive patients from May 2021 to December 2022. We included patients aged 40 to 80 years with clinical suspicion of PCa, prostate-specific antigen (PSA) level >4 ng/mL, abnormal digital rectal examination (DRE), or all the above. All patients first underwent 1.5-T mpMRI and transrectal ultrasound-guided biopsy using the cognitive biopsy technique. Results: A total of 95 patients were included, with the majority of them (64.21%) being ≥66 years old. Of these, 69 patients had abnormal DRE findings, 89 had PSA ≥4 ng/mL, and 64 had both elevated PSA and abnormal DRE findings. PCa was detected in 6.25%, 54.84%, 71.43%, and 96.43% of patients with lesions of Prostate Image Reporting and Data System scores of 2, 3, 4, and 5, respectively. Using Prostate Image Reporting and Data System score of 3 as a biopsy threshold resulted in high sensitivity (98.31%) and low specificity (41.67%) for PCa detection. The proportion of Gleason score of ≥7 cancer-detected cores in the magnetic resonance imaging-guided cognitive biopsy was significantly higher than that in the standard 12-core biopsy (86.54% versus 61.45%; P < 0.001). Conclusion: The incorporation of prebiopsy mpMRI could be used as a diagnostic pathway for suspected PCa before transrectal ultrasound-guided biopsy.

Recent trends in AI applications for pelvic MRI: a comprehensive review.

Magnetic resonance imaging (MRI) is an essential tool for evaluating pelvic disorders affecting the prostate, bladder, uterus, ovaries, and/or rectum. Since the diagnostic pathway of pelvic MRI can involve various complex procedures depending on the affected organ, the Reporting and Data System (RADS) is used to standardize image acquisition and interpretation. Artificial intelligence (AI), which encompasses machine learning and deep learning algorithms, has been integrated into both pelvic MRI and the RADS, particularly for prostate MRI. This review outlines recent developments in the use of AI in various stages of the pelvic MRI diagnostic pathway, including image acquisition, image reconstruction, organ and lesion segmentation, lesion detection and classification, and risk stratification, with special emphasis on recent trends in multi-center studies, which can help to improve the generalizability of AI.

Successful Introduction of Peanut in Sensitized Infants With Reported Reactions at Home

Background and objectivePrevious studies have shown efficacy of early introduction of peanut to prevent peanut allergy. It is currently unknown which diagnostic pathway is optimal after parental-reported reactions to peanut at home after early introduction. MethodsThe PeanutNL cohort study included high-risk infants that were referred for early introduction of peanut. A subgroup of 186 infants with reactions to peanut at home underwent peanut skin prick tests and a supervised open oral food challenge (OFC) at a median age of 8 months. After a negative OFC, peanut was introduced at home. ResultsSensitization to peanut was detected in 69% of 186 infants, of which 80% had > 4mm wheals in skin prick tests. An OFC with a cumulative dose of 4.4 gr peanut protein was performed in 163 infants with Sampson severity score grade I-III reactions at home; 120 challenges were negative. Peanut was subsequently introduced at home in infants with a negative challenge outcome. After 6 months, 96% were still eating peanut and 81% ate single portions of 3.0 gr peanut protein. One patient was considered to be peanut allergic after reintroduction of peanut at home. ConclusionThese data show that 65% of infants with reported reactions to peanut at home have negative OFCs. In those children, peanut could be introduced safely and 96% were able to consume peanut regularly without reactions. Challenging infants under 12 months of age prevents the misdiagnosis of peanut allergy, and enables safe continued exposure to peanut and the induction of long-term tolerance.

Diagnostic role of CD64 expression on neutrophils as biomarker for blood stream infection in liver cirrhosis: some preliminary findings.

The expression of CD64 on neutrophils (nCD64), measured using flow cytometry, has been proposed as a biomarker for bloodstream infections (BSI). However, data regarding its use in the setting of liver cirrhosis are lacking. We compared nCD64 levels in 15 cirrhotic patients with BSI to those in 19 controls, including outpatients with stable decompensated cirrhosis without infection. Additionally, we compared nCD64 with C-reactive protein (CRP) and procalcitonin (PCT) in infected hospitalized cirrhotic patients. Cirrhotic patients with infection had higher levels of nCD64 compared to controls (6.0 [5.4-7.1] vs. 2.0 [1.5-2.2]; p<0.001). Among infected patients, a correlation between nCD64 (AUC=0.934 [0.875-0.982 95% CI]), CRP (AUC=0.972 [0.942-0.993 95% CI]), and PCT (AUC=0.859 [0.739-0.953 95% CI]) was observed. However, in our sample of cirrhotic individuals, nCD64 values were not significantly different between patients with worse prognosis and those with positive outcomes (p=0.448), and its expression was not influenced by Gram stain. In our cohort, nCD64 appears to be a promising new biomarker for BSI. Additional prospective studies are needed to confirm its role and limitations in conjunction with other biomarkers and rapid microbiology in the diagnostic multidisciplinary pathway for septic cirrhotic patients.

Acoustic-based rule out of stable coronary artery disease: the FILTER-SCAD trial.

Overtesting of low-risk patients with suspect chronic coronary syndrome (CCS) is widespread. The acoustic-based coronary artery disease (CAD) score has superior rule-out capabilities when added to pre-test probability (PTP). FILTER-SCAD tested whether providing a CAD score and PTP to cardiologists was superior to PTP alone in limiting testing. At six Danish and Swedish outpatient clinics, patients with suspected new-onset CCS were randomised to either standard diagnostic examination (SDE) with PTP, or SDE plus CAD score, and cardiologists provided with corresponding recommended diagnostic flowcharts. The primary endpoint was cumulative number of diagnostic tests at one year and key safety endpoint major adverse cardiac events (MACE). In total 2008 patients (46% male, median age 63 years) were randomised from October 2019 to September 2022. When randomised to CAD score (n=1002), it was successfully measured in 94.5%. Overall, 13.5% had PTP ≤5%, and 39.5% had CAD score ≤20. Testing was deferred in 22% with no differences in diagnostic tests between groups (p for superiority =0.56). In the PTP ≤5% subgroup, the proportion with deferred testing increased from 28% to 52% (p<0.001). Overall MACE was 2.4 per 100 person-years. Non-inferiority regarding safety was established, absolute risk difference 0.4% (95% CI -1.85 to 1.06) (p for non-inferiority = 0.005). No differences were seen in angina-related health status or quality of life. The implementation strategy of providing cardiologists with a CAD score alongside SDE did not reduce testing overall but indicated a possible role in patients with low CCS likelihood. Further strategies are warranted to address resistance to modifying diagnostic pathways in this patient population.

Metabolomic profiles differentiate between porto-sinusoidal vascular disorder, cirrhosis, and health

Background & AimsPorto-sinusoidal vascular disorder (PSVD) is a rare and diagnostically challenging vascular liver disease. This study aimed to identify distinct metabolomic signatures in patients with PSVD, cirrhosis, and healthy volunteers (HV) to facilitate non-invasive diagnosis and elucidate perturbed metabolic pathways. MethodsSerum samples from 20 HV and patients with histologically confirmed PSVD or cirrhosis were analyzed. Metabolites were measured using liquid chromatography-mass spectrometry (LC-MS). Differential abundance was evaluated with Limma’s moderated t-statistics. Artificial neural network (ANN) and support vector machine (SVM) models were developed to classify PSVD against cirrhosis or HV metabolomic profiles. An independent cohort was used for validation. ResultsA total of 283 metabolites were included for downstream analysis. Clustering effectively separated PSVD metabolomes from HV, although a subset of PSVD patients (n=5, 25%) overlapped with cirrhosis. Differential testing revealed significant PSVD-linked metabolic perturbations, including taurocholic and adipic acids, distinguishing PSVD from both HV and cirrhosis. Alterations in pyrimidine, glycine, serine, and threonine pathways were exclusively associated with PSVD. Machine learning models utilizing selected metabolic signatures reliably differentiated PSVD from HV or cirrhosis using only 4 to 6 metabolites. Validation in an independent cohort demonstrated the high discriminative ability of taurocholic acid (AUROC 0.899) for PSVD vs HV and the taurocholic acid/aspartic acid ratio (AUROC 0.720) for PSVD vs cirrhosis. ConclusionsHigh-throughput metabolomics enabled the identification of distinct metabolic profiles for differentiating PSVD, cirrhosis, and healthy individuals. Unique alterations in the glycine, serine, and threonine pathways suggest their potential involvement in PSVD pathogenesis. Impact And ImplicationsPorto-sinusoidal vascular disorder (PSVD) is a vascular liver disease that can lead to pre-sinusoidal portal hypertension in the absence of cirrhosis, with poorly understood pathophysiology and no established treatment. Our study demonstrates that analyzing the serum metabolome could reveal distinct metabolic signatures in PSVD patients, including alterations in the pyrimidine, glycine, serine and threonine pathways and potentially shedding light on the disease's underlying pathways. These findings hold potential for earlier and non-invasive diagnosis of PSVD, potentially reducing reliance on invasive procedures like liver biopsy and guiding diagnostic pathways.

SpliceVarDB: A comprehensive database of experimentally validated human splicing variants

Variants that alter gene splicing are estimated to comprise up to a third of all disease-causing variants, yet they are hard to predict from DNA sequencing data alone. To overcome this, many groups are incorporating RNA-based analyses, which are resource intensive, particularly for diagnostic laboratories. There are thousands of functionally validated variants that induce mis-splicing; however, this information is not consolidated, and they are under-represented in ClinVar, which presents a barrier to variant interpretation and can result in duplication of validation efforts. To address this issue, we developed SpliceVarDB, an online database consolidating over 50,000 variants assayed for their effects on splicing in over 8,000 human genes. We evaluated over 500 published data sources and established a spliceogenicity scale to standardize, harmonize, and consolidate variant validation data generated by a range of experimental protocols. According to the strength of their supporting evidence, variants were classified as "splice-altering" (∼25%), "not splice-altering" (∼25%), and "low-frequency splice-altering" (∼50%), which correspond to weak or indeterminate evidence of spliceogenicity. Importantly, 55% of the splice-altering variants in SpliceVarDB are outside the canonical splice sites (5.6% are deep intronic). These variants can support the variant curation diagnostic pathway and can be used to provide the high-quality data necessary to develop more accurate in silico splicing predictors. The variants are accessible through an online platform, SpliceVarDB, with additional features for visualization, variant information, in silico predictions, and validation metrics. SpliceVarDB is a very large collection of splice-altering variants and is available at https://splicevardb.org.

Assessing Diagnostic Performance of Molecular Culture for Neonatal Sepsis: Protocol of the CHAMPIONS Study.

Managing neonatal sepsis is challenging due to nonspecific clinical signs, hematological markers with poor accuracy, and a lengthy turnaround time for the identification of microorganisms. Delaying the initiation of antibiotics in truly infected infants can lead to severe morbidity and mortality. Therefore, decisions regarding empiric antibiotic treatment are risk stratified, which exposes many uninfected infants to antibiotics. This causes gut microbiota perturbation, unnecessary hospital admissions, and the generation of multi-resistant organisms. High-speed diagnostic assays could expedite discontinuation or avert the initiation of antibiotics in uninfected infants. This study will evaluate the diagnostic performance of molecular culture (MC), a rapid broad-range PCR-based bacterial profiling technique, for diagnosing neonatal sepsis in infants below 90 days old. A multi-center prospective observational cohort study will include infants evaluated for early and late-onset sepsis. Routine evaluation for suspected sepsis includes microbiological cultures of blood. Additionally, blood for MC will be collected. For early-onset sepsis, umbilical cord blood may be used alternatively. Primary outcome is the agreement between MC and conventional blood culture results. Secondary outcome is the agreement of both assays with clinical sepsis using four different, commonly used definitions. Faster diagnostic pathways for sepsis may reduce antibiotic exposure time. Broad-range molecular assays may identify pathogens undetectable by conventional methods. Employment of umbilical cord blood samples for early-onset sepsis diagnosis can resolve challenges in collecting adequate blood volume and could further expedite treatment decisions.

Molecular alterations in mucinous ovarian tumors – a review

Abstract Mucinous ovarian tumors (MOTs) include primary and secondary neoplasms, the latter of which contribute for 80% of all cases. The most common site of origin for secondary MOTs is the gastrointestinal tract. Proper differentiation between primary and metastatic lesions is essential for effective treatment. Currently, definitive diagnosis is made based on post-operative histopathological examination with the use of immunohistochemical markers. However, the final diagnosis presents a challenge because of the histopathological similarity between mucinous metastases and primary ovarian lesions. Generally, treatment consists of cytoreductive surgery and adjuvant chemotherapy, even though malignant tumors are found to be chemo-resistant. Prognosis depends on the type of the tumor, presence of metastases and patient’s general condition. Further research on the genetic background of MOTs is necessary for the better understanding of their origin and more effective treatment. This review aims to summarize recent advances in the field of the molecular features of MOTs and their implications for the diagnostic pathways and potential adjuvant therapy options. The analysis of molecular alterations might not only be an important prognostic factor, but also a useful diagnostic tool in distinguishing between primary mucinous tumors and extra-ovarian metastases or other subtypes of epithelial ovarian neoplasms. Moreover, the examination of genetic mutations seems to increase the efficiency of targeted therapy. However, more research evaluating such therapies in pre-clinical models is needed to improve the results of the diagnostics and treatment of MOTs.

Early economic evaluation of magnetic resonance imaging for prostate cancer detection in primary care.

To explore the potential impacts of incorporating prebiopsy magnetic resonance imaging into primary care as a triage test within the prostate cancer diagnostic pathway. Decision analytic modelling with decision trees was utilised for this early economic evaluation. A conceptual model was developed reflecting the common primary care routes to diagnosis for prostate cancer: opportunistic, asymptomatic prostate-specific antigen (PSA) screening or symptomatic presentation. The use of multiparametric MRI (mpMRI) or biparametric MRI (bpMRI) as a primary care triage test following an elevated PSA result was evaluated. A health system perspective was adopted with a time horizon of 12 months. Health effects were expressed in terms of utilities drawn from the literature. The primary outcome was prostate cancer diagnosis. Evidence used to inform the model was drawn from published primary studies, systematic reviews, and secondary analyses of primary and secondary care datasets. Base case analysis showed that the PSA pathway was dominated by both mpMRI- and bpMRI-based pathways for patients undergoing opportunistic screening and symptomatic assessment. bpMRI pathways had greater improvement in cost and utility than mpMRI pathways in both clinical scenarios. Significantly more MRI scans would be performed using the modelled approach (66 626 scans vs. 37 456 scans per 100 000 patients per annum), with fewer subsequent urgent suspected cancer referrals for both mpMRI (38% reduction for screening and symptomatic patients) and bpMRI (72% reduction for screening; 71% for symptomatic) pathways, and a small increase in number of missed cancer diagnoses. Deterministic sensitivity analyses, varying each parameter to its upper and lower 95% confidence intervals, showed no significant change in the dominance of the MRI-based prostate cancer diagnostic pathways. Using prostate MRI as a second-level triage test for suspected prostate cancer in primary care could reduce health service costs without a detrimental effect on patient utility.

Profiling of circulating extracellular vesicle microRNAs reveals diagnostic potential and pathways in non-obstructive and obstructive azoospermia.

The accurate diagnosis of non-obstructive azoospermia (NOA) and obstructive azoospermia (OA) is crucial for selecting appropriate clinical treatments. This study aimed to investigate the pivotal role of miRNAs in circulating plasma extracellular vesicles (EVs) in distinguishing between NOA and OA, as well as uncovering the signaling pathways involved in azoospermia pathogenesis. In this study, differential expression of EV miR-513c-5p and miR-202-5p was observed between NOA and OA patients, while the selenocompound metabolism pathway could be affected in azoospermia through Gene Ontology and Kyoto Encyclopedia of Genes and Genomes analysis. The predictive power of these microRNAs was evaluated using ROC-AUC analysis, demonstrating promising sensitivity, specificity, and area under the curve values. A binomial regression equation incorporating circulating plasma levels of EVs miR-202-5p and miR-513c-5p along with follicle-stimulating hormone was calculated to provide a clinically applicable method for diagnosing NOA and OA. This study presents a potentially non-invasive testing approach for distinguishing between NOA and OA, offering a possibly valuable tool for clinical practice.

Vascular Remodeling in Coronary Microvascular Dysfunction.

Approximately half of the patients with angina and nonobstructive coronary artery disease (ANOCA) have evidence of coronary microvascular dysfunction (CMD). This study aims to characterize patients with ANOCA by measuring their minimal microvascular resistance and to examine the pattern of vascular remodeling associated with these measurements. The authors prospectively included patients with ANOCA undergoing continuous thermodilution assessment. Lumen volume and vessel-specific myocardial mass were quantified using coronary computed tomography angiography (CTA). CMD was defined as coronary flow reserve<2.5 and high minimal microvascular resistance as >470 WU. A total of 153 patients were evaluated; 68 had CMD, and 22 of them showed high microvascular resistance. In patients with CMD, coronary flow reserve was 1.9 ± 0.38 vs 3.2 ± 0.81 in controls (P< 0.001). Lumen volume was significantly correlated with minimal microvascular resistance (r =-0.59 [95%CI:-0.45 to-0.71]; P< 0.001). In patients with CMD and high microvascular resistance, lumen volume was 40% smaller than in controls (512.8 ± 130.3mm3 vs 853.2 ± 341.2mm3; P< 0.001). Epicardial lumen volume assessed by coronary CTA was independently associated with minimal microvascular resistance (P< 0.001). The predictive capacity of lumen volume from coronary CTA for detecting high microvascular resistance showed an area under the curve of 0.79 (95%CI: 0.69-0.88). Patients with CMD and high minimal microvascular resistance have smaller epicardial vessels than those without CMD. Coronary CTA detected high minimal microvascular resistance with very good diagnostic capacity. Coronary CTA could potentially aid in the diagnostic pathway for patients with ANOCA.

Effect evaluation of outpatient long-term video EEGs for people with seizure disorders – study protocol of the ALVEEG project: a randomized controlled trial in Germany

BackgroundEpilepsy and other seizure disorders account for a high disease burden in Germany. As a timely diagnosis and accurate treatment are crucial, improving the management of these disorders is important. Outside of Germany, outpatient long-term video EEGs (ALVEEGs) have demonstrated the potential to support the diagnosis and management of epilepsy and other seizure disorders. This study aims to evaluate the implementation of ALVEEGs as a new diagnostic pathway in eastern parts of Germany to diagnose epilepsy and other seizure disorders and to assess if ALVEEGs are equally effective as the current inpatient-monitoring gold standard, which is currently only available at a limited number of specialized centers in Germany.MethodsALVEEG is a prospective, multicenter, randomized controlled equivalence trial, involving five epilepsy centers in the eastern states of Germany. Patients will be randomized into either intervention (IG) or control group (CG), using a permuted block randomization. The sample size targeted is 688 patients, continuously recruited over the trial. The IG will complete an ALVEEG in a home setting, including getting access to a smartphone app to document seizure activity. The CG will receive care as usual, i.e., inpatient long-term video-EEG monitoring. The primary outcome is the proportion of clinical questions being solved in the IG compared to the CG. Secondary outcomes include hospital stays, time until video EEG, time until diagnosis and result discussion, patients’ health status, quality of life and health competence, and number and form of epilepsy-related events and epileptiform activity. Alongside the trial, a process implementation and health economic evaluation will be conducted.DiscussionThe extensive evaluation of this study, including an implementation and health economic evaluation, will provide valuable information for health policy decision-makers to optimize future delivery of neurological care to patients affected by epilepsy and other seizure disorders and on the uptake of ALVEEG into standard care in Germany.Trial registrationGerman Clinical Trials Register (DRKS00032220), date registered: December 11, 2023.

Diagnosis of Pleural Mesothelioma: Is Everything Solved at the Present Time?

Ranked high in worldwide growing health issues, pleural diseases affect approximately one million people globally per year and are often correlated with a poor prognosis. Among these pleural diseases, malignant pleural mesothelioma (PM), a neoplastic disease mainly due to asbestos exposure, still remains a diagnostic challenge. Timely diagnosis is imperative to define the most suitable therapeutic approach for the patient, but the choice of diagnostic modalities depends on operator experience and local facilities while bearing in mind the yield of each diagnostic procedure. Since the analysis of pleural fluid cytology is not sufficient in differentiating historical features in PM, histopathological and morphological features obtained via tissue biopsies are fundamental. The quality of biopsy samples is crucial and often requires highly qualified expertise. Since adequate tissue biopsy is essential, medical or video-assisted thoracoscopy (MT or VATS) is proposed as the most suitable approach, with the former being a physician-led procedure. Indeed, MT is the diagnostic gold standard for malignant pleural pathologies. Moreover, this medical or surgical approach can allow diagnostic and therapeutic procedures: it provides the possibility of video-assisted biopsies, the drainage of high volumes of pleural fluid and the administration of sterile calibrated talcum powder under visual control in order to achieve pleurodesis, placement of indwelling pleural catheters if required and in a near future potential intrapleural therapy. In this context, dedicated diagnostic pathways remain a crucial need, especially to quickly and properly diagnose PM. Lastly, the interdisciplinary approach and multidisciplinary collaboration should always be implemented in order to direct the patient to the best customised diagnostic and therapeutic pathway. At the present time, the diagnosis of PM remains an unsolved problem despite MDT (multidisciplinary team) meetings, mainly because of the lack of standardised diagnostic work-up. This review aims to provide an overview of diagnostic procedures in order to propose a clear strategy.

Discontinuous peripheral enhancement of focal liver lesions on CT and MRI: outside the box of typical cavernous hemangioma.

The discontinuous peripheral enhancement is a pattern of enhancement usually attributed to typical cavernous hemangioma, that is the most common benign solid lesion of the liver. The discontinuous peripheral enhancement, however, may be encountered in many other benign and malignant focal liver lesions as an atypical presentation or evolution, and hemangiomas with discontinuous peripheral hyperenhancement on hepatic arterial phase may not always have the typical post-contrast pattern on portal venous and delayed phases. Therefore, abdominal radiologists may be challenged in their practice by lesions with discontinuous peripheral enhancement. This pictorial essay aims to review the spectrum of benign and malignant focal liver lesions that may show discontinuous peripheral enhancement. A particular point of interest is the diagnostic tree pathway that may guide the radiologists in the differential diagnosis.

Diagnostic Pathway Outcomes for Biparametric Magnetic Resonance Imaging-Targeted Lesions Using Cognitive Registration and Freehand Transperineal Prostate Biopsy in Biopsy-Naïve Men (CRAFT Single-Center Study).

Enhanced histological detection of clinically significant prostate cancer is the goal of the prebiopsy imaging pathway. Risk stratification at a prebiopsy meeting can facilitate optimization of lesion targeting. We aimed to evaluate the feasibility of cognitive registration, freehand transperineal prostate biopsy in a biopsy-naïve population following biparametric MRI for the detection of clinically significant disease (International Society of Urological Pathology Grade Group ≥2). A consecutive series of biopsy-naïve men, prospectively recorded between July 2018 and March 2023, were risk-stratified at our prebiopsy meeting following biparametric MRI to undergo either target-only biopsy or target with systematic biopsy. Biopsies were routinely performed under local anesthesia and without antibiotic prophylaxis in the outpatient setting. Overall prostate cancer and clinically significant prostate cancer detection were primary outcomes. Of 1251 biopsies, prostate cancer was detected in 84% and clinically significant disease in 70.6%. Prostate cancer and clinically significant disease were detected in 86.2% and 76.5% of target-only biopsies, respectively, and in 78.7% and 56.3% of target with systematic biopsies. Postbiopsy complication rate was 0.7%. Prebiopsy biparametric MRI with risk stratification at a prebiopsy meeting in the setting of cognitive targeting and freehand transperineal prostate biopsy yielded a high detection of prostate cancer that is comparable to other studies. These data support the use of cognitive registration, freehand transperineal prostate biopsy as safe, feasible, and cost-effective.

Proportion trends, cancer stage, and survival of patients with cancer diagnosed through emergency and nonemergency departments: a nationwide cohort study.

To reduce mortality, the Taiwan government has vigorously promoted free cancer screening and preventive health screening services. Cancers are usually advanced by the time they are discovered in the emergency department. Through this study, we aimed to understand the characteristics of cancer patients diagnosed through the emergency department and thus identify high-risk populations by comparing cancer staging and survival rates in patients diagnosed in the emergency department and those diagnosed in the non-emergency department. The retrospective study enrolled a total of 389,043 patients over the age of 20 who were newly diagnosed with one of the five major cancers (including lung cancer, colorectal cancer, breast cancer, prostate cancer, and oral cancer) between 2008 and 2017 and analyzed their diagnostic pathway, cancer stage at diagnosis, and survival time. Of the study participants, 59,423 patients (about 15.3%) were diagnosed with cancer through the emergency department. We found that a sizable proportion of older people and patients with low education and low incomes were diagnosed through emergency department visits, and those with a health condition comorbidity severity of 3 had the highest proportion diagnosed by the emergency department, advanced stages at diagnosis, and risk of death. These can be classified as high-risk groups. In addition, 76.4% of patients diagnosed in the emergency department had advanced cancer, and the risk of death was 1.46 times higher than that of patients diagnosed in the non-emergency department. Although cancer screening is available, it does not reduce the proportion of patients with advanced cancer who are diagnosed through or at the time of diagnosis in the emergency department. The present study found that the government's cancer screening did not affect the proportion or number of cancers diagnosed through emergency department visits. Therefore, the government should focus on more cancer screening, health education in high-risk groups, and strengthening the link between emergency and oncology departments to reduce the risk of death for patients diagnosed through emergency department visits.