Discordant Findings Research Articles

PET-Based TheraP Eligibility and Outcomes of VISION-Eligible Patients with Metastatic Castration-Resistant Prostate Cancer Who Received 177Lu-PSMA-617: Importance of 18F-FDG-Avid Discordant Findings.

The VISION and TheraP trials introduced different PET-based criteria for patient selection for treatment with 177Lu-PSMA-617 (LuPSMA). TheraP used a higher prostate-specific membrane antigen (PSMA) uptake threshold than VISION and required 18F-FDG PET to exclude patients with discordant findings. Although the screen-failed patients had shorter overall survival (OS) than those treated with LuPSMA, it remains unclear whether their outcomes might have been modified if they had been exposed to LuPSMA. In this study, we evaluated associations between the TheraP eligibility criteria and subgroups and the treatment outcomes of patients who were deemed suitable and treated on the basis of VISION criteria. Methods: Consecutive patients who were treated with LuPSMA and who underwent pretreatment PSMA and 18F-FDG PET were classified as TheraP-eligible (TheraP-E) and TheraP-ineligible (TheraP-I), the latter of which were subclassified as low PSMA or discordant. Odds ratios for an at least 50% decline in prostate-specific antigen (PSA50) were computed using logistic regression, and hazard ratios (HRs) for PSA progression-free survival (PSA-PFS) and OS were computed using Cox regressions. Multivariable analyses were adjusted for baseline imaging and clinical parameters. Results: Of 75 patients, 31 (41%) were deemed TheraP-I; of those, 24 were subclassified as having discordant disease. TheraP-I patients had a lower PSA50 rate than that of TheraP-E patients (28% vs. 67%; odds ratio, 0.19; 95% CI, 0.06-0.52; P = 0.002) and a higher risk of PSA progression (HR, 2.0; 95% CI, 1.2-3.3; P = 0.007). OS in the TheraP-I group was numerically shorter than in the TheraP-E group, but the comparison was only marginally significant (10.4 mo vs. not reached; HR, 1.9; 95% CI, 1.0-3.7; P = 0.054). TheraP-I patients with low PSMA had no significantly different risk of death (P = 0.9) from that of TheraP-E patients, but those with discordant findings had higher risk of death (HR, 2.3; 95% CI, 1.1-4.6; P = 0.02). Discordant disease remained prognostic for OS after adjusting for baseline imaging and clinical parameters (HR, 3.0; 95% CI, 1.3-6.8; P = 0.01). Conclusion: In VISION-eligible patients who were treated with LuPSMA, TheraP-I patients with discordant findings had lower PSA50, PSA-PFS, and OS. Our study suggests that the shorter OS of TheraP-I patients is mainly driven by the presence of discordant disease.

Abstract 4138517: Role of Coronary Computed Tomographic Angiography in Patients with Discordant Findings on Exercise Stress Echocardiography

Background: Exercise stress echocardiography is routinely used for risk stratification and diagnosis of myocardial ischemia in low-to-intermediate risk patients with suspected coronary artery disease (CAD). Discrepancies between exercise electrocardiography (EKG) and echocardiography (ECHO) are common in clinical practice. Prior literature suggests that patients with discordant stress test results generally have worse outcomes, though the extent of epicardial atherosclerotic disease remains unclear. Coronary computed tomographic angiography (CTA) has gained a class I recommendation for the assessment of atherosclerotic burden per ACC/AHA chest pain guidelines. Using non-invasive fractional flow reserve (CT-FFR), the functional significance of lesions can also be assessed. This study investigates the incidence and burden of CAD in patients with discordant exercise echocardiography findings. Methods: Patients aged 18 or older who had exercise echocardiography followed by CTA from January 1, 2013, to January 31, 2023, were retrospectively enrolled in this study and categorized into two discordant result groups: EKG+/ECHO- or EKG-/ECHO+. Those who failed to achieve the target heart rate or had a paced rhythm/left bundle branch block on baseline EKG were excluded. CTA findings were classified as no CAD, non-obstructive CAD (<50% stenosis), obstructive CAD (≥50% stenosis), and obstructive CAD with FFR+ (<0.75). Results: The study included 198 patients, the majority female (56.0%), with a mean age of 61 ±10 years. Among them, 159 (80.3%) were EKG+/ECHO- and 39 (19.7%) were EKG-/ECHO+ (Table 1). In the EKG+/ECHO- group, 55 (34.6%) had no CAD, 48 (30.2%) had non-obstructive CAD, and 56 (35.2%) had obstructive CAD, out of which 19 (33.9%) were FFR+. In the EKG-/ECHO+ group, 13 (33.3%) had no CAD, 17 (43.6%) had non-obstructive CAD, and 9 (23.2%) had obstructive CAD of which 3 (33.3%) was FFR+. There was no statistically significant difference in the degree of CAD between the two cohorts. Conclusions: The majority of patients with discordant results on exercise echocardiography were found to have CAD. There was no significant difference in the degree of disease between the EKG+/ECHO- or EKG-/ECHO+ groups. Overall, discordant results on exercise echocardiography should not be discounted and warrant further evaluation. CTA provides important information that can impact the diagnosis and further medical management of patients with chest pain and suspected CAD.

Discrepancy in the Diagnosis of Heart Failure With Preserved Ejection Fraction Between Supine Versus Upright Exercise Hemodynamic Testing.

Invasive exercise right heart catheterization is a gold standard in diagnosing heart failure with preserved ejection fraction (HFpEF). Body positions during the test influence hemodynamics. However, the discrepancy in HFpEF diagnosis between exercise testing in supine versus upright position is unknown. We conducted a 2-center prospective study enrolling patients referred for exercise right heart catheterization for HFpEF. We performed a Supright protocol integrating submaximal supine bicycle ergometry (20 W) followed by maximal upright bicycle ergometry with a breath-by-breath oxygen analyzer. HFpEF hemodynamic criteria specific to testing positions were applied. Patients were considered to have concordant HFpEF if they met criteria in both positions or discordant HFpEF if they met criteria only in the supine position. Of 36 patients who met HFpEF criteria in supine position, 18 (50%) did not meet criteria in upright position (discordant HFpEF). Discordant HFpEF had less atrial fibrillation (0% versus 55%; P<0.001), lower left atrial volume (60±14 versus 77±21 mL; P=0.010), and lower H2FPEF score (2.1±1.3 versus 5.1±2.3; P<0.001). In supine position, pulmonary arterial wedge pressure was lower in discordant HFpEF at rest (15±4 versus 19±7 mm Hg; P=0.040). In upright position, pulmonary arterial wedge pressure was lower in discordant HFpEF both at rest (8±4 versus 14±6 mm Hg; P=0.002) and at peak exercise (14±4 versus 27±7 mm Hg; P<0.001). Pulmonary arterial wedge pressure/cardiac output slope was lower in discordant HFpEF (1.6±1.7 versus 3.6±2.9; P<0.001). Maximal workload (46±18 versus 49±24 W; P=0.59) or peak oxygen consumption (11.4±2.8 versus 12.9±3.4 mL/[kg·min]; P=0.15) was similar between groups. Half of patients who met HFpEF criteria in the supine position did not meet the criteria in the upright position. Patients with a discordant HFpEF phenotype had less structural and hemodynamic abnormalities compared with those with concordant HFpEF. A Supright exercise right heart catheterization approach is feasible and merits further investigation to determine the clinical implications of discordant exercise hemodynamic findings in supine and upright positions.

The diagnostic accuracy of aortic valve calcium score in patients with low gradient and high gradient aortic stenosis

Abstract Introduction The standard imaging modality for diagnosing aortic stenosis (AS) is echocardiography (echo), by which the definition of severe AS is based on the transvalvular mean gradient (AMG) (&amp;gt;40 mmHg) and aortic valve area (AVA) (&amp;lt;1 cm2). However, in around one quarter of the cases, echo provides discordant findings (AVA&amp;lt;1 cm2, despite of an AMG &amp;lt;40 mmHg), complicating clinical decision making. Computed tomography aortic valve calcium scoring (CT- AVCS) offers an alternative diagnostic method. In cases with discordant echo measurements current guidelines recommend the use CT-AVCS to decide on severity. Purpose Our aim was to validate the sensitivity of the recommended AVCS thresholds within our patient population, as well as to identify any factors associated with below cut-off AVCS values despite confirmed severe AS (low AVCS). Methods Our retrospective study included 332 consecutive patients with severe AS (AVA ≤1 cm2), who underwent CT angiography (CTA) for transcatheter aortic valve implantation (TAVI) planning. Based on the AMG the patients were classified into high gradient (HG: AMG ≥ 40 mmHg) and low gradient (LG: AMG &amp;lt;40 mmHg) groups. In the LG group AS severity was assessed by a multiparametric algorithm. To specify the predictors of low AVCS among patients with HG-AS, logistic regression analysis was used. The patients were followed for 50 months. Cox proportional hazard model was used to assess the risk of death from any cause. Results The HG-AS group consisted of 244 and the LG-AS cohort of 88 patients. In the HG-AS population the sensitivity of AVCS to diagnose severe AS was 89%. Within the HG severe AS group, logistic regression analysis revealed an association between low AVCS and the AMG (OR 0.89, CI 0.83 – 0.95, p &amp;lt;0,001), whereas none of the other tested factors (age, sex, hypertension, diabetes, left ventricle function, renal function) showed any association. In the LG-AS group, contrary to the HG- AS patients, the sensitivity of AVCS to define severe LG AS was limited (53% in males and 67% in females). Over a median follow-up of 50 months, the prognosis of HG AS patients with low AVCS was more favourable than that of the high AVCS patient population (HR 0.41; CI 017 – 097; p=0.04), however, in the LG AS group, the prognosis was not different when stratifying the patients according to high or low AVCS (p=0.21). Conclusions Our results confirmed that among patients with HG AS, the recommended AVCS thresholds provide a good diagnostic sensitivity for severe AS. Nonetheless, the number of severe AS patients with low AVCS is not negligible, especially within the LG-AS population, where the diagnosis is the most challenging. Our findings underline that in patients with discordant echocardiographic findings, a personalized, multiparametric diagnostic approach is needed, instead basing the final diagnosis exclusively on AVCS.

Left ventricular flow dynamics and energetics derived from 4D flow CMR in patients with low gradient severe aortic stenosis

Abstract Background Up to 40% of patients with severe aortic stenosis (SAS) determined by current guidelines present with discordant Doppler echocardiography findings and demonstrate divergent prognosis. Differentiation of true SAS who generally benefits from aortic valve intervention among this subset of patients is important albeit challenging for clinical management. Purpose Left ventricular (LV) 3-dimentional flow characterization was analyzed to illustrate altered intracardiac hemodynamics in different types of low gradient SAS and to investigate its application for the identification of true SAS in comparison with LV stroke volume index (LVSVI) and transaortic flow rate. Methods Four-dimensional flow cardiovascular magnetic resonance (4D flow CMR) was performed in 126 patients with low gradient SAS and 30 age- and gender-matched controls. All patients were categorized into 3 groups according to left ventricular ejection fraction (LVEF) and LVSVI as follows: classical low-flow low-gradient (CLFLG, n=37), paradoxical low-flow low-gradient (PLFLG, n=41), and normal-flow low-gradient (NFLG, n=48). Left ventricular flow was partitioned into 4 components: direct flow, retained inflow, delayed ejection flow, and residual volume. Average kinetic energetic parameters indexed to end-diastolic volume (KEiEDV) throughout the systolic phase were analyzed. Results Patients with CLFLG and PLFLG SAS had reduced LV direct flow proportion (CLFLG vs. control: 10±5% vs. 35±5%, P&amp;lt;0.001; PLFLG vs. control: 29±6% vs. 35±5%, P&amp;lt;0.001, Figure 1) and systolic ejection-flow KEiEDV (CLFLG vs. control: median, 5.3μJ/ml vs 8.7μJ/ml, P&amp;lt;0.001; PLFLG vs. control: median, 6.0μJ/ml vs. 8.7μJ/ml) compared with controls. Reduced systolic ejection-flow KEiEDV correlated with decreased LVSVI (R=0.47, P&amp;lt;0.001) and transaortic flow rate (R=0.72, P&amp;lt;0.001). Among 126 patients in the study cohort, 74 (59%) were determined as true SAS according to standardized criteria based on flow-independent parameters and demonstrated elevated systolic ejection-flow KEiEDV than patients with pseudo-SAS (median, 6.5μJ/ml vs 5.6μJ/ml, P&amp;lt;0.001). Systolic ejection-flow KEiEDV≥6.1μJ/ml demonstrated an optimal positive predictive value of 90% for distinguishing true SAS from pseudo-SAS among patients with low gradient SAS (Figure 2). Conclusion Alterations in LV flow components and kinetic energy were associated with the presence and type of low gradient SAS. LV systolic outflow energetic markers responsible for aortic valve opening could aid the evaluation of AS severity with Doppler-based parameters.Comparison of LV flow componentsROC analysis for discriminating true SAS

Concordance Between Platelet Expression Assay (PEA) and Serotonin Release Assay (SRA) in Heparin-Induced Thrombocytopenia: Implications for Diagnostic Accuracy and Laboratory Test Utilization

Abstract Introduction The Serotonin Release Assay (SRA) serves as the gold standard functional assay for heparin-induced thrombocytopenia (HIT) diagnosis at our institution. The present turnaround time (TAT) for SRA results ranges from 4-5 days, occasionally extending beyond 8 days, given outsourcing to a reference laboratory. Recently, an alternative functional assay, the Platelet Expression Assay (PEA), has been introduced. The PEA detects platelet activation through p-selectin expression by flow cytometry, with a reported sensitivity of 100% and specificity of 95% for HIT. The PEA is also a send-out test, and thus has similar TAT and cost profiles as the SRA, but with potential to transition into an in-house assay in the future. Herein, we sought to determine the concordance of the PEA and SRA for the detection and diagnosis of HIT within our patient population. Methods A retrospective review was conducted on all cases in which a HIT ELISA (screening immunoassay) was performed by the Special Coagulation Laboratory during a one-year period. A 4Ts score was calculated if not already documented by chart review. In a subset analysis, specimens with a positive screening ELISA were concurrently tested by both SRA and PEA to compare performance. Results Of the 1341 cases, a 4Ts score was calculated and found to be less than 4 for 30-50% of cases. A total of 490 cases were sent out for SRA, of which 49 (10%) returned positive results. In a subset analysis of 20 samples from 14 patients, all with positive ELISAs, results revealed concordance between the SRA and PEA for all but one sample (19/20, 95%). Specifically, three successive samples from one patient had [negative, negative, positive] results for SRA, and [negative, positive, positive] results for PEA, respectively. This discordant result suggests a potential difference in sensitivity between the two assays. Further subset analysis focused on an additional 13 samples from 10 patients, all with SRA-positive results. Only 8 samples were concordant (8/13, 62%). One case showed a negative PEA and presumed false positive SRA, given the clinical history, while 4 samples showed likely true positive SRA results, given strength of ELISA results and 4Ts score, but were negative by PEA. Conclusions The lack of adherence to the 4Ts score algorithm to drive laboratory test utilization resulted in unnecessary ELISA and functional assay testing, potentially resulting in increased costs and false positive results. This result underscores the need for vigilance in assessing and refining diagnostic strategies. Additionally, our discordant findings in the subset analysis underscore the importance of evaluating the concordance and discordance between SRA and PEA results, providing insights into the diagnostic accuracy and potential limitations of each assay in identifying HIT.

RETROSPECTIVE ANALYSIS OF DISCORDANT RESULTS BETWEEN UROVYSION FISH AND URINE CYTOLOGY IN THE DETECTION OF HIGH-GRADE UROTHELIAL CARCINOMA (HGUC): A STUDY OF 118 PATIENTS

Abstract Introduction/Objective Accurate detection of high-grade urothelial carcinoma (HGUC) relies on multiple diagnostic modalities, including UroVysion FISH and urine cytology; however, discordant results between these diagnostic tools can present a challenge. We present this study, scrutinizing the discordant results between UroVysion FISH and urine cytology to explore the potential factors that could contribute to discrepancies. Methods/Case Report A cohort of 118 patients, who underwent both UroVysion FISH and urine cytology testing for evaluation of HGUC, was selected from our cytopathology archives. Results of both the modalities were compared, and a retrospective review of original slides was done by experienced cytopathologists. Results (if a Case Study enter NA) Among the 118 cases, Urovysion FISH yielded positive results in 14 cases and negative in 104. In contrast, urine cytology reported 1 case as positive, 102 as negative, 10 as atypical (8 atypical and 2 rare atypical), and 5 as suspicious. Discordant findings were observed in 20 cases, accounting for 17% of the cases. After retrospective review of original slides, few cases were reclassified. 2 cases as atypical (initially labeled as negative), 2 cases as negative (initially labeled as atypical), 3 cases as positive (initially labeled as atypical/suspicious), 3 cases as suspicious (initially labeled as negative/atypical). Conclusion This reclassification highlights complexity of cytological interpretation, including the challenges of distinguishing between benign cellular alterations, reactive changes, ambiguous findings, suspicious features and malignant cytological changes. Integrating molecular and morphological assessment is essential for evaluation of urothelial carcinoma. Discrepancy between the two is an area which is open to study and can be related to differences in sensitivity and specificity of the testing modalities, sampling methods, variation in interpretation, limitations of testing modality and varying tumor characteristics. Review of clinical history, imaging studies, cystoscopy, and repeat testing may be considered in such cases for diagnostic accuracy.

A study of long-term supraphysiologic-dose anabolic-androgenic steroid use on cognitive function in middle-aged men

ABSTRACT Background: Long-term use of supraphysiologic doses of anabolic-androgenic steroids (AAS) has been associated with impaired visuospatial memory in young men but little is known about its cognitive effects in middle-aged men. Objectives: We compared cognition in middle-aged men with histories of long-term AAS use and age-matched non-users. Methods: We administered cognitive tests from the CANTAB battery to 76 weightlifters aged 37–60 years (mean [SD] 48.5 [6.5] years), of whom 51 reported at least 2 years of cumulative AAS use and 25 reported no AAS exposure. Results: We found no significant AAS user versus non-user group differences on visuospatial, verbal memory, emotional recognition, or executive function tasks (corrected p’s ≥ .00089; effect sizes ≤ .5). Conclusions: Our null visuospatial task findings contrast with our prior younger cohort study (mean age 37.1 [7.1] years), in which we found impaired visuospatial task performance in people who use AAS, and with other reports of cognitive impairments in younger men use AAS. Men who use AAS may develop early visuospatial memory deficits that stabilize by middle age while middle-aged non-users’ performance may “catch up” due to normal age-related visuospatial declines. Similar effects could contribute to our null findings on other tasks. Between-study cohort substance use differences or environmental factor differences that modify cognition, such as study geographical location and time of year, also could contribute to our discordant findings. Since young adult male AAS users experience increased mortality from unnatural causes, improving our understanding of AAS cognitive effects in this age group is important.

Medicaid Status is Independently Predictive of Increased Complications, Readmission, and Mortality Following Primary Total Shoulder Arthroplasty

In recent years, several studies have evaluated the effect of Medicaid insurance status on total shoulder arthroplasty (TSA) outcomes and have presented discordant findings. The purpose of this study is to determine if Medicaid status is an independent predictor of all-cause complications, readmission, revision, and mortality following elective primary TSA using a large, national administrative claims database. The Nationwide Readmissions Database (NRD) was queried to identify patients who underwent elective primary TSA from 2016 to 2020. Patients were propensity score matched in a 1:1 proportion based on age, sex, and discharge weight, yielding 15,374 Medicaid cases and 15,448 control cases. Patient demographic and discharge information, preoperative comorbidities, and postoperative outcomes were compared with bivariate analysis. Binary logistic regression was performed to account for the influence of variables other than Medicaid status on postoperative outcomes. Medicaid patients had higher rates of preoperative comorbidities, higher Charlson-Deyo Comorbidity Index scores, and lower household incomes than matched controls. Compared to controls, Medicaid patients undergoing TSA had higher odds of adverse clinical outcomes, including all-cause complications, readmission, and mortality within 180 days, along with other specific medical and implant-related complications including broken hardware, dislocation, prosthetic loosening, and surgical site infection. Medicaid status was independently predictive of increased rates of all-cause complications within 180 days, readmission within 180 days, dislocation, pneumonia, sepsis, and decreased rates of prosthetic loosening. Medicaid patients had an increased mean cost of $1,396 and increased mean length of stay of 0.4 days. Medicaid status was independently predictive of readmission, complications, and mortality within 180 days of primary TSA, as well as other specific medical and surgical complications. Medicaid patients experience higher admission costs and longer hospital stays compared to those with other insurance types. Medicaid status is a risk factor for adverse clinical outcomes, and orthopedic surgeons need to consider the multitude of disparities that Medicaid patients experience when determining surgical options, treatment plans, and hospital disposition.

Magnetoencephalography Profile of Patients with Drug-Resistant Focal Epilepsy and Normal MRI.

Magnetoencephalography (MEG) could be a valuable tool in the presurgical evaluation of drug-resistant epilepsy (DRE), especially when the initial evaluation is inconclusive. In this retrospective study, we describe the profile of MEG in patients with DRE and normal magnetic resonance imaging (MRI). We included patients with focal epilepsy and normal MRI who underwent presurgical evaluation for DRE. MEG profiles of these patients, including the frequency of spikes, density of clusters, number of clusters, and concordance with video electroencephalography (VEEG), were analyzed. Of the 73 patients included, magnetic source imaging (MSI) provided localizing information in 51 (69.9%) patients. Among patients with localizing MEG findings, localizing information on VEEG too was noted in 42 (57.5% of the whole cohort). Thirty-one (42.5%) patients had concordant findings with region-specific localization, six (8.2%) patients had partial concordance, and five (6.8%) subjects showed discordant findings. There was a moderate agreement for the presumed epileptogenic zone in comparing findings derived from MEG and VEEG (kappa value of 0.451, P < 0.001). The agreement was lower when MEG localized to the frontal lobe (kappa value of 0.379, P = 0.001) than the temporal lobe (kappa value 0.442, P = 0.002). MEG can provide localizing information in most patients with a normal MRI. A moderate degree of agreement between localization by MEG and VEEG was noted. These findings highlight the usefulness of MSI in the presurgical evaluation of MRI-negative DRE.

Clinical value of MR defecography: What additional knowledge is provided by the radiologist to the surgeon?

PurposeTo evaluate the clinical value of MR defecography in supporting surgical decision-making and management strategies in a consecutive series of patients. Material and methodsA consecutive series of patients with clinical suspicion of pelvic disorders who underwent MR defecography at a single university hospital from January 2021 to June 2024 were included. MR defecography was performed at rest (axial/sagittal and coronal T2-weighted sequences), during squeezing, straining, and evacuation (dynamic sagittal T2-weighted sequences). An expert surgeon assessed his satisfaction about the diagnostic information given by the prospective radiological report as: 1: insufficient, 2: sufficient, 3: good, 4: excellent. For patients who underwent surgery, the same surgeon assessed the usefulness of the MR defecography, using a score from 1 to 4 (1: discordant findings, useless exam; 2: concordant findings without new information; 3: concordant findings, useful new information; 4: concordant findings, extremely useful new information). ResultsA total of 218 patients (age 27 − 79, mean 60 ± 11; 193 females and 25 males) entered the analysis. For 211 of them (97 %), the radiologist was able to evaluate the images and determine an MR defecography-based diagnosis; in 7 patients (3 %), a diagnosis was not provided due to exam interruption for low patient’s compliance. In 195/211 patients (92 %), the radiological diagnosis matched the clinical suspect that prompted the examination. The satisfaction about the diagnostic information given by the radiological report of the 211 exams was assessed by the surgeon as follows: excellent (n = 99, 47 %), good (n = 48, 23 %), sufficient (n = 35, 16 %), and insufficient (n = 29, 14 %). Out of 211 patients, 73 (34.6 %) underwent surgery. MR defecography provided concordant findings with relevant additional information in 63 (86.3 %), concordant findings with additional information in 3 (4.1 %), concordant findings without additional information in 4 (5.5 %), and discordant findings in 3 (4.1 %). ConclusionsThe diagnostic information prospectively provided by MR defecography resulted to be good or excellent in 70 % of the patients, adding clinical value in the preoperative surgical setting in 86 % of those patients who underwent surgery.

Application of Differential Subsampling with Cartesian Ordering in Evaluating Left Ovarian Venous Reflux for Pretreatment Planning for Pelvic Venous Disorders.

The diagnosis of a common cause of chronic pelvic pain can be made by visualizing reflux in the ovarian veins. Fluoroscopic venography is the gold standard for diagnosing ovarian vein reflux, but it is an invasive technique that exposes patients to ionizing radiation. MRI, with its lack of ionizing radiation and capability of high-temporal and spatial-resolution vascular imaging, has the potential to provide similar diagnostic information. This retrospective report describes and assesses the utility of a dynamic contrast-enhanced MRI technique based on Differential Subsampling with Cartesian Ordering (DISCO)-MRI in 30 patients with chronic pelvic pain. Among the 14 patients who underwent both DISCO-MRI and fluoroscopic venograms, 11 (78.6%) exhibited concordant results, while 3 patients (21.4%) had discordant findings. These results suggest the potential of multiphasic contrast-enhanced DISCO-MRI as a non-invasive diagnostic tool for evaluating chronic pelvic pain.

SISCOS in focal cortical dysplasia: localization and comparative analysis with MRI.

This study evaluates the efficacy of SISCOS (Subtraction ictal-interictal SPECT coregistered to SPECT) in localizing the epileptogenic zone (EZ) in focal cortical dysplasia (FCD), comparing its predictive performance with MRI and post-surgical outcomes based on ILAE classification. 84 patients with drug refractory epilepsy (DRE) who were operated and had histopathology consistent with FCD, were included in the study. All patients had undergone a complete work-up including SISCOS and MRI for EZ localization, followed by discussion in the multidisciplinary epilepsy surgery meeting prior to surgery. Ictal & interictal perfusion SPECT studies were performed with Tc-99m Ethylene Cysteinate Dimer (Tc-99m ECD) followed by SISCOS analysis using SPM2 and Bioimage Suite 2.6. Concordance for localization was determined by comparing with the surgical resection site and post-surgical outcomes were assessed using the ILAE classification. The concordance for EZ localization demonstrated by SISCOS was 73.8% and MRI was 82.1%. 52 patients (61.9%) had good surgical outcome and 31(59%) of these were FCD type 2. In patients with discordant MRI findings, SISCOS was able to provide localisation in 86% (13/15), with 69.2% showing good surgical outcomes. Sensitivity of SISCOS and MRI was 73% (95% CI = 59-84.8%) and 78% (95% CI = 67.5-90.3%) respectively with no significant difference between the two. In FCD type I, both SISCOS and MRI revealed a similar a sensitivity of 76.4% (95%CI = 50.1-93.2%). Concordant cases exhibited higher seizure-free odds ratios for both modalities. SISCOS is effective in localizing the EZ in FCD patients, comparable to MRI. Integrating SISCOS and MRI enhances lesion detection, especially in MRI discordant cases. A comprehensive diagnostic approach utilizing SISCOS and MRI can optimize the non-invasive pre-surgical assessment in DRE thereby guiding surgical decision-making in a resource-limited setting.

Determining what matters most to Marfan syndrome (MFS) patients: a convergent mixed method study of the health-related quality of life and psychosocial effects of MFS aortovascular manifestations

Abstract Background Marfan Syndrome (MFS) affects multiple organ systems but the aortovascular manifestations are the most serious and life-threatening. However, there is no available evidence on the effect of the aortovascular manifestations on health-related quality of life (HRQoL) and psychosocial wellbeing of MFS patients. Purpose This study aims to determine the HRQoL and the psychosocial effects of the aortovascular manifestation of MFS. Methods A convergent mixed-method design was used in this single site study. Specifically, the quantitative study (S1) is an observational exploratory study using seven validated questionnaires relating to HRQoL (SF36, EQ-5D-5L) and psychosocial health (depression [CESD], illness perception [IPQ], fatigue [FSS], self-esteem [RSES], stigma [PSQ]), previously used in MFS research. The qualitative study (S2) is an exploratory study using semi-structured interviews. Analysis consisted of descriptive and inferential statistics and Framework method1 for S1 and S2, respectively. Joint display was used for data integration. Results A total of 75 participants completed the questionnaires (S1) and 20 were interviewed (S2). The mean age was 43 years (S1) and 40 years (S2) and the majority (S1: 54 (72%); S2: 17 (85%)) were white British. S1 found the majority of MFS participants experienced depression, anxiety, pain and fatigue. These areas were confirmed in S2. A positive self-esteem was generally reported in S1, but this is not supported by S2, which highlighted patients experience a loss of self-esteem due to perceived body image disturbance. Finally, S2 generated new areas not identified in S1 including health anxiety, loss of personal efficacy, self-stigma and ‘invisible disability’ affecting work and socio-economic condition. Overall, the joint display generated three confirmed, seven expanded and one discordant finding. Conclusion MFS patients with aortovascular manifestations experienced several HRQoL and psychosocial issues related to their condition. Collaborative efforts are needed to develop multifaceted interventions and programs to address their needs and provide a holistic and comprehensive service for MFS patients. Finally, four new areas were identified in S2, which added important new evidence in this body of knowledge.

Aortic Valve Calcium Score: Applications in Clinical Practice and Scientific Research-A Narrative Review.

In this narrative review, we investigate the essential role played by the computed tomography Aortic Valve Calcium Score (AVCS) in the cardiovascular diagnostic landscape, with a special focus on its implications for clinical practice and scientific research. Calcific aortic valve stenosis is the most prevalent type of aortic stenosis (AS) in industrialized countries, and due to the aging population, its prevalence is increasing. While transthoracic echocardiography (TTE) remains the gold standard, AVCS stands out as an essential complementary tool in evaluating patients with AS. The advantage of AVCS is its independence from flow; this allows for a more precise evaluation of patients with discordant findings in TTE. Further clinical applications of AVCS include in the assessment of patients before transcatheter aortic valve replacement (TAVR), as it helps in predicting outcomes and provides prognostic information post-TAVR. Additionally, we describe different AVCS thresholds regarding gender and the anatomical variations of the aortic valve. Finally, we discuss various scientific studies where AVCS was applied. As AVCS has some limitations, due to the pathophysiologies of AS extending beyond calcification and gender differences, scientists strive to validate contrast-enhanced AVCS. Furthermore, research on developing radiation-free methods of measuring calcium content is ongoing.

Cerebrospinal Creatine Kinase BB Isoenzyme: A Biomarker for Predicting Outcome After Cardiac Arrest.

Cerebrospinal fluid creatine kinase BB isoenzyme (CSF CK-BB) after cardiac arrest (CA) has been shown to have a high positive predictive value for poor neurological outcome, but it has not been evaluated in the setting of targeted temperature management (TTM) and modern CA care. We aimed to evaluate CSF CK-BB as a prognostic biomarker after CA. We performed a retrospective cohort study of patients with CA admitted between 2010 and 2020 to a three-hospital health system who remained comatose and had CSF CK-BB assayed between 36 and 84h after CA. We examined the proportion of patients at hospital discharge who achieved favorable or intermediate neurological outcome, defined as Cerebral Performance Category score of 1-3, compared with those with poor outcome (Cerebral Performance Category score 4-5) for various CSF CK-BB thresholds. We also evaluated additive value of bilateral absence of somatosensory evoked potentials (SSEPs). Among 214 eligible patients, the mean age was 54.7 ± 4.8years, 72% of patients were male, 33% were nonwhite, 17% had shockable rhythm, 90% were out-of-hospital CA, and 83% received TTM. A total of 19 (9%) awakened. CSF CK-BB ≥ 230 U/L predicted a poor outcome at hospital discharge, with a specificity of 100% (95% confidence interval [CI] 82-100%) and sensitivity of 69% (95% CI 62-76%). When combined with bilaterally absent N20 response on SSEP, specificity remained 100% while sensitivity increased to 80% (95% CI 73-85%). Discordant CK-BB and SSEP findings were seen in 13 (9%) patients. Cerebrospinal fluid creatine kinase BB isoenzyme levels accurately predicted poor neurological outcome among CA survivors treated with TTM. The CSF CK-BB cutoff of 230 U/L optimizes sensitivity to 69% while maintaining a specificity of 100%. CSF CK-BB could be a useful addition to multimodal neurological prognostication after CA.

Poster 244: Magnetic Resonance Imaging versus Diagnostic Arthroscopy to Identify Intraarticular Pathology Associated with Patellar Instability: A High Rate of Discordant Findings Altering Surgical Treatment

Objectives: While uncommon, acute traumatic patellar dislocations can lead to recurrent symptoms of patellar instability in 15% to 45% of patients. Patellar stability is an interplay of bony and soft tissue restraints as well as anatomic factors, however, a mainstay of treatment remains reconstruction of the medial patellofemoral ligament (MPFL). Instability events can lead to intra-articular derangements of the knee, both in the acute and chronic patellar instability setting. These findings may not always be appropriately identified on magnetic resonance imaging (MRI). The incidence of these “surprise” injuries have not been previously reported. The purpose of this study is to determine the rates of coexisting intra-articular pathology in patients with patellar instability requiring MPFL reconstruction and elucidate any discordance between preoperative MRI findings and diagnostic arthroscopy findings. Methods: All patients undergoing MPFL reconstruction at a single institution between 2010 and 2023 were identified and preoperative MRI reports, defined as the most recent MRI report to the date of surgery with no interval traumatic events, were queried. Records without full MRI reports as read by a radiologist or cases in which a diagnostic arthroscopy was not conducted were excluded. MRI findings were discordant from arthroscopic findings if a lesion identified on diagnostic arthroscopy was not present in the full MRI report. Procedures that were undertaken because of these missed pathologies on MRI were recorded. Results: A total of 640 patients were identified during the study period, and 507 complete records were ultimately included. Preoperative MRI identified patellar osteochondral lesions or cartilage fissures in 333 patients (66%), loose bodies in 119 patients (24%), lateral femoral condyle osteochondral lesions or fissures in 97 patients (19%) and meniscus tears in 47 patients (9%). Among these patients, 172 (34%) had a diagnosis at the time of arthroscopy which was not identified on the preoperative MRI. These arthroscopic findings resulted in 75 loose body removals, 74 patellar shaving chondroplasties, 16 partial meniscectomies, 3 microfractures, 3 osteochondral lesion open reduction internal fixation, and 2 meniscal repairs which would have been missed without diagnostic arthroscopy due to discordant MRI findings. Conclusions: Over one-third of patients at a single institution who underwent diagnostic arthroscopy in the setting of patellar instability surgery had pathology identified which required surgical intervention that was not reported on a preoperative MRI. A comparison of MRI and diagnostic arthroscopy has been extensively reported on for other knee pathologies including ACL tear and lateral meniscal tear; however, there has been no similar investigation of the reliability of MRI for identification of concomitant pathology in the setting of patellar instability to date. The findings of this study highlight the importance of diagnostic arthroscopy in the treatment of patellar instability, the frequency with which this altered treatment, and the high preponderance of discordant MRI findings.

Strongyloides Stercoralis Infection Mimicking Relapse of ANCA Vasculitis

A 48-year-old female with anti-neutrophilic cytoplasmic antibody (ANCA)-associated vasculitis, initially responded well to standard therapy but later presented with diffuse alveolar hemorrhage (DAH), simulating disease relapse. Following renal remission with standard immunosuppressive therapy, the patient exhibited fever, hemoptysis, and declining renal function, suggestive of a relapse. Bronchoscopy revealed DAH, raising concern for vasculitis exacerbation. However, discordant laboratory findings prompted scrutiny, leading to the detection of Strongyloides larvae in bronchoalveolar lavage.

Transdiagnostic markers across the psychosis continuum: a systematic review and meta-analysis of resting state fMRI studies.

https://osf.io/, identifier (ycqpz).

Evaluation of concordance between blood-based and matched tissue molecular testing in a regional cancer center.

e15062 Background: Next-generation sequencing (NGS) to identify cancer-associated mutations together with an increasing array of targeted drugs with FDA approval allows for matching patients with more effective therapies. Tumor tissue molecular profiling is most often used to identify actionable biomarkers. Blood-based tests to sequence cell-free circulating tumor DNA (ctDNA) are a less invasive approach. Both methods have high specificity and sensitivity and provide insights into actionable biomarkers; however, little is known about how these NGS tests compare when used for the same patient. This study assessed the concordance of paired ctDNA and solid tumor profiling in patients treated in our regional cancer center. Methods: We retrospectively reviewed ctDNA and matching tumor sequencing data test results from CLIA/CAP laboratories between June 2018, and October 2023. The average testing turnaround time was 12.9 days for solid tumor sequencing and 7.7 days for ctDNA testing. We analyzed genomic variants, gene fusions, and microsatellite status in these patient results. The NGS tests for ctDNA included 83 relevant genes which reported single nucleotide variants, small insertions and deletions, splice variants, and limited copy number alterations and gene fusions. The NGS tests for tumor testing were performed on Formalin-Fixed Paraffin Embedded tissue samples using either a 592 relevant gene panel or whole exome sequencing, and either an RNA-based targeted capture panel of 52 genes or RNA whole transcriptome sequencing. Concordance is defined as both ctDNA and tumor testing reporting the same alterations, whereas discordant reports are defined as each reporting different alterations that didn’t overlap between ctDNA and tumor sequencing. Results: A total of 186 patients had both ctDNA and solid tumor sequencing tests done. Cancer types included pancreatic cancer (n = 42), breast cancer (n = 29), lung cancer (n = 28), colorectal cancer (n = 14), and others (n = 73). We observed concordance between tests in 76 (41%) patients in identifying the same genomic alterations. In 103 (55%) patients, we found discordant genomic findings (in the remaining 7 (4%) patients, there were no alterations detected (ND)). Among 103 patients for whom we found discordant findings between the tests, 41 (40%) showed genomic alterations only from the ctDNA test, 46 (45%) had results only from solid tumor profiling, and 16 (15%) had abnormal gene findings from both solid tumor and ctDNA testing but the results did not overlap. Conclusions: Our retrospective analysis comparing sequencing of ctDNA and tumor tissue demonstrated about 40% concordance in genomic findings. Our study indicates that these tests may be complementary. If one accepts a degree of discordance, then testing of ctDNA may be used to identify actionable genomic alterations in the setting of inaccessible or inadequate tumor samples for sequencing.