Work-up Of Patients Research Articles

68Ga-DOTATATE PET/CT in the Initial Staging of Well-Differentiated Gastroenteropancreatic and Non-Gastroenteropancreatic Neuroendocrine Tumors: Results of a Prospective Registry

Background and Objectives: At diagnosis, the initial staging of well-differentiated neuroendocrine tumors (WD NETs) aids in treatment planning. The somatostatin receptor (SSTR)-PET has been recommended for staging of WD NETs although limited data are available on its impact on non-gastroeneteropancreatic (GEP) NETs. The main purpose of this study was to compare the stage migration after the addition of SSTR-PET to the workup of patients at the initial staging of GEP NETs to those with non-GEP NETs, and its potential impact on patient management. Methods: This prospective study included patients with WD NETs at initial staging. Demographic data, results of conventional and SSTR-PET staging, and SUVmax were recorded. Three panels of experts assessed the potential impact of SSTR-PET to management. Results: There were 482 patients, including 376 with gastroenteropancreatic (GEP) NETs and 106 non-GEP NETs with a median SUVmax of 34.7 [Q1, Q3: 22.8, 59.1]) and 19.0 [Q1, Q3: 7.9, 39.8]), respectively; p < 0.001. The discordant M-stage was recorded in 111/473 patients (23.5%). PET suggested a higher stage in 78/369 GEP NETs (21.1%), including the detection of extrahepatic metastatic disease in 42/114 (36.8%) patients with liver metastases only on CI. For non-GEP NETs, PET suggested a higher stage in 10/104 (9.6%) and CI suggested a higher stage in 15/104 (14.4%), with CI detecting liver metastases more frequently. The potential impact to management for patients with discordant M-stage was scored as moderate to high between 57/101 (56.4%) and 79/101 (78.2%) of patients. Conclusions: One in five patients are upstaged following SSTR-PET, more frequently with GEP NETs than others. SSTR-PET identifies extrahepatic metastatic disease in >1/3 of patients with presumed liver-only metastases on CI. Stage migration following SSTR-PET may result in frequent moderate or significant management change.

Diagnostic accuracy of point-of-care ultrasound of the posterior fatpad in elbow fractures

BackgroundPoint-of-care ultrasound (POCUS) can potentially be used in the triage of patients with elbow injuries. However, the diagnostic accuracy of POCUS performed by non-radiologists for the exclusion of elbow fractures...

Change in management for digital subtraction angiography-identified false-positive traumatic vertebral artery injury.

For patients with suspected traumatic vertebral artery injury (TVAI), CT angiography (CTA) is the first-line screening modality. Digital subtraction angiography (DSA) serves as the confirmatory diagnostic imaging, and is the gold standard for cerebrovascular injury assessment, due to its higher sensitivity and specificity. Among patients with TVAI based on CTA who have undergone follow-up DSA, this study aims to investigate how diagnostic information with additional imaging affects clinical management. A retrospective review was conducted over 7 years (2016-2023) at a level 1 trauma center for TVAI patients undergoing both CTA and DSA. Pre- and post-DSA approaches to TVAI management were compared and summarized using propensity-score matched analysis. Among the 69 patients studied, 24.6% were determined to have false-positive TVAI after DSA. The rate of change in management after DSA was significantly different across DSA+ and DSA- cohorts (p = 0.02). The likelihood of a change in management in patients with based on outcome of the DSA was significant (p = 0.03) in the propensity-matched cohort. On average, 3 (NNI = 3.2) patients would need to receive a DSA for one additional patient to undergo a change in management. This study demonstrates that, despite initial CTA imaging suggestive of TVAI, follow-up DSA imaging negative for TVAI has a significant impact on changing clinical management, including cessation of antithrombotic agents. Thus, for TVAI patients, DSA may be considered in the diagnostic workup for select patients with positive CTA. Larger cohort analyses are needed to refine imaging algorithms and optimize clinical outcomes for TVAI patients.

Factors Associated with Clinically Significant Extrinsic Compression on Gastroduodenal Endoscopy.

Although clinicians frequently encounter incidentally detected gastroduodenal extrinsic compressive lesions (GDECLs) on upper gastrointestinal endoscopy (UGE), theoptimal management approach for GDECLs has not been fully established. This study aimed to stratify and identify important factors associated with clinically significant GDECLs that require regular follow-up or further treatment. Between June 2007 and December 2015, a total of 73 patients with suspected GDECLs on UGE at Kyung Hee University Hospital at Gangdong were identified and studied retrospectively. After the final diagnosis, patients were divided into the following two groups: clinically significant GDECLs, which requires regular follow-up or further treatment, and clinically non-significant GDECLs. Among 73 GDECLs, 23 (31.5%) lesions were classified as clinically significant GDECLs and 50 (68.5%) as clinically non-significant GDECLs. In multivariate analysis, clinical and endoscopic parameters that were independently associated with clinically significant GDECLs included older age (≥ 60years), large size (≥ 4cm) of extrinsic compression, previous history of intra-abdominal malignancy, and symptoms of abdominal distension (all p < 0.05). Several clinical and endoscopic parameters showed significant association with the identification of clinically significant GDECLs on endoscopy. These predictive factors might be useful in determining whether to perform further diagnostic work-up in patients with GDECLs.

Patients with severe mental illness in the general emergency department: Clinical characteristics, quality of care and challenges.

Morbidity and mortality rates are notably higher among individuals with severe mental illnesses (SMI). People with SMI often have lower access to healthcare services, and the medical care they receive is known to be suboptimal. Consequently, treatment in an acute care setting rather than a community setting is more common. We aim to explore medical care in the emergency department (ED) for people with SMI compared to a control population. In this matched cohort study, data on all adult Clalit Health Services (CHS) members who were referred to the general ED during the years 2018-2021 were extracted. Patients with SMI (ICD-10 codes for schizophrenia, schizoaffective disorder, and bipolar disorder) were matched with a control group of ED patients without SMI in a 1:3 ratio. The two groups were compared regarding ED admission reasons, management, and outcomes. The total sample (n=92,848) included ED patients with SMI (n=23,212) and without (n=69,636). The most common ED admission reasons in both groups were pain, traumatic injury, and cardiac symptoms. Patients in the SMI group had higher rates of diagnosed diabetes mellitus and obstructive pulmonary disease. ED assessment, measured by resource allocation, was less comprehensive for patients with SMI who presented with subjective complaints such as pain and weakness, while it was comparable between patients with and without SMI for other main presenting complaints. Workup for patients with SMI lasted longer and necessitated hospitalization at higher rates for most admission reasons. Mortality during the study period was almost twice as high among the SMI group (5% vs. 2.3%, p<0.001). Our findings indicate higher rates of morbidity and treatment complexity among patients with SMI. As expected, the mortality rate was higher in this group. An alarming gap in resource allocation for ED assessment was observed when patients presented with subjective complaints. Enhanced awareness and integrated resources in primary care are required to improve the management and physical healthcare of patients with SMI.

Use of Magnetic Resonance Neurography for Sensory Nerve Injuries of the Head and Neck.

Identification of peripheral nerve injuries of the head and neck can be challenging due to a broad spectrum of symptoms from neuropathic pain to headaches and migraine. This article aimed to present the clinical features and diagnostic workup of patients with acute and chronic peripheral nerve injuries of the head and neck using magnetic resonance neurography (MRN), to demonstrate potential advantages compared with conventional magnetic resonance imaging (MRI). Patients who presented with suspected peripheral nerve injury were either referred for a conventional MRI or MRN. Patients who underwent nerve exploration for suspected nerve transection and/or neuroma formation on imaging were included in this study. Imaging findings were correlated with intraoperative observations. Four patients (3 women, 1 man, age range: 34-70 years) were included. Three subjects had a history of head and neck surgery and 1 experienced direct trauma to the medial eyebrow. Clinical symptoms included numbness, allodynia, positive Tinel sign, and pain relief following nerve blocks. Two patients underwent conventional MRI and 2 underwent MRN. MRI provided a vague indication of potential neuromas and failed to accurately depict their locations. MRN offered a comprehensive visualization of the entire nerve path, identifying nerve transection and neuromas, as well as precise location, dimensions, and relation to adjacent bones and muscles. High-resolution 3-dimensional MRN provides clear visualization of acute and chronic peripheral nerve injuries of the head and neck region, facilitating early diagnosis of nerve injuries in this region and improving diagnostic accuracy, as well as surgical planning and execution.

The role of 18F-FDG PET/CT in detecting synchronous regional and distant metastatic disease in patients with an in-breast tumour recurrence.

In line with the trend towards minimally invasive, patient-tailored treatment, a selected group of patients with an in-breast tumour recurrence (IBTR) is treated by repeat breast-conserving treatment (BCT). To select eligible patients for repeat BCT, a reliable pre-operative work-up is essential. This study reports on the role of 18F-FDG PET/CT in detecting synchronous regional and distant metastases in patients with IBTR. A nation-wide data query was sent out to all Dutch hospitals offering breast cancer treatment. Breast cancer surgeons from 34 hospitals participated, filling electronic case report forms (eCRFs) on 549 patients treated for IBTR from 2016 to 2017. Of the 549 included patients, 297 were screened using 18F-FDG PET/CT for the presence of distant metastases. Forty of them (13.5%) presented with synchronous distant metastatic disease. In 168 clinically node-negative patients who underwent 18F-FDG PET/CT, a suspect regional lymph node was found in 18 (10.7%). Final pathology of these lymph nodes yielded a positive lymph node in 12 patients (7.1%). Positive predictive value (PPV) of 18F-FDG PET/CT in clinically node-negative patients was 66.7% and negative predictive value (NPV) was 85.3%. The clinically relevant percentage of synchronous distant metastatic disease justifies the use of 18F-FDG PET/CT in the workup of patients with an IBTR. Furthermore, 18F-FDG PET/CT can assist in detecting regional axillary lymph node metastases, but requires histopathological confirmation given the moderate PPV, before clinical decisions can be made.

Imaging of common coronary artery anomalies and imaging features important for clinical decision-making.

Anomalous coronary arteries are associated with sudden cardiac death, although only in a relatively small percentage. Although this has been a field of study for years and there are many ongoing studies of larger patient cohorts and longer term follow-up, important questions remain at present in clinical decision-making, particularly whether or not to have surgery. Advanced imaging techniques including coronary computed tomography (CT) and cardiac magnetic resonance (MR) play an important role in the workup of patients with known or suspected anomalies including delineating origin and course as well as defining presence of high-risk imaging features. Multidisciplinary decision-making is important when considering whether patients might need to undergo surgery. This review will describe types of anomalies, imaging techniques, and features as well as types of surgeries and postoperative imaging with highlights of imaging and surgical literature and several case examples.

Whole slide imaging of tumour microenvironment in classical Hodgkin’s lymphoma: development of a clinical prediction model based on programmed death-ligand 1 and tumorous Reed-Sternberg cells

AimsThe prognostic impact of programmed death-ligand 1 (PD-L1) cells in classic Hodgkin lymphoma (cHL) tumour microenvironment remains undefined.MethodsModel development via Transparent Reporting of a multivariable prediction model for Individual Prognosis...

The history of an effective, specific and sensitive diagnostic test: the GHRH test in clinical practice.

Growth hormone (GH) secretion is pulsatile, entropic, and nycthemeral and is mainly controlled by the hypothalamus through two neurohormones, the stimulating growth hormone releasing hormone (GHRH) and the inhibiting somatostatin. Shortly after its discovery and synthesis, GHRH was intensely investigated diagnostically to define GH secretion. The nascent enthusiasm for using GHRH as a single diagnostic tool to investigate GH deficiency (GHD) dropped down quickly due to a flawed reproducibility. The subsequent combinatory use of molecules implicated in GH secretion through inhibition of the somatostatinergic tone, such as arginine (ARG), or the synthesis of receptor-orphan pharmaceutical compounds capable of stimulating pituitary somatotrophs to release GH, such as the GH secretagogues (GHSs), improved the reproducibility of GH response to GHRH alone, thus gaining access into the clinical practice by means of different diagnostic approaches. This review will focus on the history of the GHRH test, with main emphasis on GHRH plus ARG as a dynamic testing for the diagnosis of GHD. Our attention will extend crosswise from studies aimed at validating GHRH-based tests for the clinical practice, to address main pitfall conditions capable of affecting per se GH secretion, such as obesity, hypothalamic damage, and ageing. The history of GHRH test has been progressively dismantled due to the cease of its production for business reasons, opening a gap in the diagnostic workup of patients with GHD. In the urgency to seek further robust, safe, and validated diagnostic tests or tools, we hope to stimulate attention on a so important peptide for the health of our patients suffering from pituitary diseases.

Elevated Vitamin D leading to an Incidental Diagnosis of Multiple Myeloma.

A case involving the incidental diagnosis of multiple myeloma (MM) due to interference in the 25-hydroxy-vitamin D (25(OH) vitamin D) immunoassay is presented. The patient, under the care of rheumatology and receiving treatment with alendronic acid and vitamin D supplements, was referred to endocrinology for investigation of acromegaly. Acromegaly was subsequently ruled out; however, during the investigations, consistently elevated levels of 25(OH) vitamin D were noted, raising suspicion of vitamin D resistance syndrome. The laboratory and endocrinology teams engaged in discussions, and following the cessation of medication, repeated analyses for 25(OH) vitamin D and a single analysis of 1,25-dihydroxy-vitamin D levels were requested, yielding high and normal results, respectively. The laboratory conducted a three-step interference investigation, ultimately identifying a high molecular weight molecule responsible for the initially elevated 25(OH) vitamin D levels. Due to the clinical presentation of back pain, a proteinogram was requested, revealing a monoclonal band of 36g/L. Subsequent free light chain analysis indicated an elevated ratio. With three risk factors identified, this was classified as an established MM and urgently referred to haematology for correct management. Laboratory assay interferences have the potential to disrupt the accurate diagnostic workup of patients. Collaborative discussions between laboratory and clinical teams regarding such cases aid in directing the diagnostic pathway appropriately, facilitating prompt and proper diagnosis and management.

Surgical Options for Retained Gallstones After Cholecystectomy.

Retained gallstones are the most common cause of postcholecystectomy pain. They may be in a long remnant cystic duct (CD), the common bile duct (CBD), or within a remnant gallbladder (GB) post subtotal cholecystectomy. Although endoscopic management is often attempted, occasionally surgical clearance is required. Rates of preoperative surgery to remove stones in a remnant GB are rising due to the increased practice of subtotal cholecystectomy during a problematic laparoscopic cholecystectomy. This study aims to review the surgical management of symptomatic retained stones at a tertiary hepatobiliary referral center in Sydney, Australia. This retrospective analysis of prospectively collected data was performed on patients who underwent an operation for retained stones after a previous cholecystectomy over 18 years (2004-2022). All of the patients with residual CBD stones had failed endoscopic retrograde cholangiopancreatogram (ERCP) attempts or could not have an ERCP because of prior foregut surgery. All patients underwent a systematic preoperative workup confirming the biliary anatomy and pathology. Fourteen patients had surgical intervention for retained stones. All cases were attempted laparoscopically and were successful in 11/14 patients (78%). Retained stones were found within a remnant GB (29%, n=4), a remnant CD (36%, n=5), or the CBD (36%, n=5). Conversion to an open procedure in 3 patients was for dense fibrosis associated with a long low-insertion of the CD, necessitating a hepatico-jejunostomy, failure to delineate the biliary anatomy, and inability to clear CBD stones, respectively. One patient developed a minor postoperative complication (superficial wound infection), and all patients were free of symptoms at a median follow-up of 33.5 months. This study demonstrates favorable outcomes in patients undergoing laparoscopic intervention for retained gallstones. A systematic approach to the workup and surgical management of patients with retained stones is essential.

A process mining approach to assessing diagnostic pathways in a memory clinic

AbstractBackgroundSeveral clinical guidelines and recommendations have been developed to improve the diagnostic process of patients with dementia, with the aim of optimising patient care and fostering a cost‐effective use of resources. However, patient characteristics and organizational factors in clinical practice can lead physicians to deviate from recommendations. In this context, process mining (PM) is a powerful technique for evaluating the compliance of actual to ideal diagnostic pathways, but has never been used in the cognitive field. This study aims to pilot the use of PM to study the diagnostic workup of patients with cognitive complains in an academic memory clinic.MethodWe retrospectively reviewed medical charts of 539 consecutive new patients referred to the University Hospitals of Geneva (Switzerland) between July 2021 and December 2022. The collected information includes socio‐demographic data, number and dates of clinical visits and biomarker exams (e.g., FDG‐, amyloid‐, tau‐PET, cerebrospinal fluid ‐ CSF). The pMineR package, a R library for PM, was used for data inspection and process discovery (e.g., First Order Markov Model ‐ FOMM, Careflow Miner ‐ CFM) to extract features of most frequent diagnostic pathway according to clinical stage.ResultPatients were 96 subjective cognitive decline (SCD; MMSE: 28.5±1.6), 308 Mild Cognitive Impairment (MCI; MMSE: 26.5±2.7), and 135 Mild Dementia (DEM; MMSE: 22.7±3.2). FOMM showed that all SCD patients received a syndromic diagnosis based on a detailed neuropsychological evaluation and a morphological imaging. CSF was the first‐line biomarker to ascertain the aetiology of cognitive impairment, used in 90 MCI (30%) and 32 DEM (24%). A second‐line biomarker (e.g., amyloid‐, FDG‐, Tau‐PET) was required in 23% of MCI and 16% of DEM. Differential PM with CFM revealed that DEM was more commonly referred to the first clinical assessment with morphological imaging than MCI (DEM:68/135vs.MCI:123/308, ratio:1.8; p = 0.047).ConclusionThese preliminary results demonstrate that the PM approach is appropriate for describing the diagnostic workup in memory clinics. Using the same approach and study design, a further project will evaluate the diagnostic pathways in 6 European academic memory clinics and contrast them to recommendations recently issued from a large European consensus effort (Frisoni, LancetNeurol 2024).

Identifying Demographic and Clinical Determinants of Ischemic Workup in Patients with Heart Failure.

Background/Objectives: Coronary artery disease (CAD) is a common and treatable cause of heart failure (HF), but ischemic evaluation is often overlooked when evaluating patients with new-onset HF. Here, we sought to discern demographic and clinical predictors of ischemic workup in patients with newly diagnosed HF. Methods: A retrospective study of 200 consecutive patients with new-onset HF admitted to our safety-net hospital between 2011 and 2015 was performed. We developed a multivariate logistic regression model to analyze determinants of undergoing ischemic evaluation. Results: A total of 99 patients (49.5%) underwent ischemic workup, while 101 patients (50.5%) did not. The mean age of the cohort was 73.9 ± 16, with 50% as male and 51% as White. In total, 41.5% of patients had HF with reduced ejection fraction, and 37% of patients had HF with preserved ejection fraction. Among the patients who underwent ischemic evaluation, 63.6% received nuclear stress testing, 24.2% received cardiac catheterization, 9.1% received stress echocardiography, and 3% received computed tomography angiography. Demographic and clinical factors such as sex, age, race, presence of hypertension, hyperlipidemia, chronic kidney disease, diabetes, or obesity had no significant association with receiving ischemic workup (p > 0.05). Patients with known CAD (OR 2.816, p = 0.015) and a higher social deprivation index (SDI) (OR 1.022, p = 0.003) were significantly more likely to receive an ischemic evaluation. Atrial fibrillation was significantly negatively associated with receiving ischemic workup (OR: 0.24; p = 0.001). Conclusions: In our single-center safety-net hospital analysis, known CAD and higher SDI were significant predictors of ischemic evaluation in patients with newly diagnosed HF. Multiple demographic features, including age, sex, race, and clinical features, including HF type, hypertension, hyperlipidemia, and diabetes, had no significant correlation with ischemic workup.

Atypical delayed ventriculoperitoneal shunt infection following hysteroscopic polypectomy: illustrative case.

A 36-year-old female with a history of congenital hydrocephalus, treated with ventriculoperitoneal (VP) shunt placement at 3 months of age and a shunt revision at 9 years of age, presented with erythema, induration, and drainage of an abdominal incision through which the distal catheter of her VP shunt had been implanted many years prior. She had no recent risk factors for infection apart from a minor transvaginal gynecological procedure that involved hysteroscopy with dilation and curettage for uterine polyps. Abdominal wound cultures grew Cutibacterium acnes, Corynebacterium species, and Mycobacterium chelonae. She was managed with initial externalization, followed by complete explantation of her shunt system following a successful clamp trial; in tandem, the atypical polymicrobial infection was treated with a prolonged regimen of intravenous antibiotics followed by oral antibiotics and close monitoring of the wound, which healed appropriately. Although the majority of shunt infections occur due to a characteristic set of organisms within an expected time frame, this case emphasizes the importance of a thorough workup and follow-up for shunt-treated patients with potential infections-even when they fall outside the usual window or have an atypical presentation-for the possibility of uncommon infecting organisms. https://thejns.org/doi/10.3171/CASE24472.

A Tumor Volume Segmentation Algorithm Based on Radiomics Features in FDG-PET in Lung Cancer Patients, Validated Using Surgical Specimens.

Although the integration of positron emission tomography into radiation therapy treatment planning has become part of clinical routine, the best method for tumor delineation is still a matter of debate. In this study, therefore, we analyzed a novel, radiomics-feature-based algorithm in combination with histopathological workup for patients with non-small-cell lung cancer. A total of 20 patients with biopsy-proven lung cancer who underwent [18F]fluorodeoxyglucose positron emission/computed tomography (FDG-PET/CT) examination before tumor resection were included. Tumors were segmented in positron emission tomography (PET) data using previously reported algorithms based on three different radiomics features, as well as a threshold-based algorithm. To obtain gold-standard results, lesions were measured after resection. Pathological volumes and maximal diameters were then compared with the results of the segmentation algorithms. A total of 20 lesions were analyzed. For all algorithms, segmented volumes correlated well with pathological volumes. In general, the threshold-based volumes exhibited a tendency to be smaller than the radiomics-based volumes. For all lesions, conventional threshold-based segmentation produced coefficients of variation which corresponded best with pathologically based volumes; however, for lesions larger than 3 ccm, the algorithm based on Local Entropy performed best, with a significantly better coefficient of variation (p = 0.0002) than the threshold-based algorithm. We found that, for small lesions, results obtained using conventional threshold-based segmentation compared well with pathological volumes. For lesions larger than 3 ccm, the novel algorithm based on Local Entropy performed best. These findings confirm the results of our previous phantom studies. This algorithm is therefore worthy of inclusion in future studies for further confirmation and application.

MS O10 - BN Case Report: Aberrant Right Subclavian Artery As A Rare Differential For Dysphagia

Abstract Background Dysphagia lusoria (DL) is characterised by swallowing difficulty due to external oesophageal compression from congenital aortic arch malformations. It is clinically rare and affects less than 2.5% of the population. The most prevalent form of DL is the aberrant right subclavian artery (ARSA) where approximately 10% of patients experience dysphagia. Despite AL being congenital, dysphagia often manifests later in life, likely due to age-related atherosclerotic changes in the vasculature and decreased oesophageal flexibility. Method Presented is a case report of a female in her seventies where, despite repeat hiatal hernia repair and maximal medical management, her index symptoms of dyspepsia and retrosternal discomfort persisted when reviewed in specialist upper gastrointestinal clinic. She underwent extensive investigation; however, her symptoms were unremitting, manifesting in numerous emergency department presentations to exclude acute coronary syndrome. This case report details the anatomical differences via diagrams and documents the comprehensive investigation and multi-disciplinary approach to the management of dysphagia in ARSA. Results Prior to referral to our team, the patient had a laparoscopic hiatus hernia repair and Nissen fundoplication undertaken. Oesophageal manometry revealed weak oesophageal motility and 24-hour pH monitoring did not demonstrate pathological acid-reflux. Recurrence of hiatus hernia was observed on oral contrast swallow and gastroscopy. Subsequently, the patient underwent laparoscopic revision of hiatus hernia and conversion of Nissen to a Dor. Post-operatively her symptoms required complete fundoplication reversal. Following reversal, assessment demonstrated improved distal oesophageal emptying. Her CT emphasised an ARSA causing significant compression and deviation of the proximal oesophagus. The patient was referred onwards to vascular surgery. Conclusion Initial diagnostic workup for patients presenting with dysphagia in the upper gastrointestinal clinic seeks to encompass several common aetiologies including oesophageal motility disorders, malignant compression and benign strictures. Clinicians must consider less common causes of extrinsic compression, such as ARSA, particularly in patients with unrelenting and persistent symptoms despite appropriate implementation of both medical and surgical interventions. Treatment approaches for ARSA reflect symptom severity, with both conservative and surgical options considered.

Evolution in the diagnosis and treatment of carcinoma of unknown primary: a multicenter Canadian analysis.

Guidelines for the management of patients with cancer of unknown primary (CUP), who have metastatic disease without an identified primary tumor site, have evolved. We sought to describe the diagnostic work-up and outcomes of patients with CUP in Canada over the last decade. We also sought to identify factors associated with improved prognosis in CUP, including primary tumor site identification, identification of "favorable subtypes," and concordance with published guidelines. With ethics board approval, patients with histologically confirmed CUP between 2012 and 2021 in 3 Canadian cancer centers were reviewed and clinicopathological variables retrospectively collected. The primary endpoint was to describe significant trends in CUP diagnosis and management over the decade using linear regression models. Univariable (UVA) and multivariable (MVA) logistic regression analyses identified variables correlated with primary site identification and overall survival (OS). Kaplan-Meier curves with the log-rank test were used to compare OS outcomes. In total, 907 patients were included, with a median follow-up of 5.1 months. There was an increase in both 5-year survival and identification of primary tumors over the decade. Diagnostic tests including next-generation sequencing were independently associated with primary site identification on UVA. However, primary site identification was not found to be predictive of survival; instead, patients with "favorable subtypes" of CUP had significantly longer OS. Survival in patients with CUP in Canada has been increasing over the last decade. Identifying the primary site does not influence survival, and efforts should be focused on discovering novel "favorable subtypes" which have superior outcomes.

A diagnostic comparison study between maximal systolic acceleration and acceleration time to detect peripheral arterial disease

Detecting peripheral arterial disease (PAD) can be particularly challenging in patients with diabetes mellitus (DM) or chronic kidney disease (CKD) due to medial arterial calcification (MAC). Current bedside tests, such as the ankle-brachial index, are less accurate in these patient groups. The primary aim of this study is to evaluate the diagnostic accuracy of point-of-care duplex ultrasound parameters maximal systolic acceleration (ACCmax) and acceleration time (AT) to detect PAD, including a comparison of both metrics. Patients suspected of having PAD, who underwent point-of-care duplex ultrasound measurements (ACCmax and AT) of the posterior tibial artery (PTA) and/or anterior tibial artery (ATA) at ankle level along with computed tomography angiography were eligible for inclusion. PAD was defined as a stenosis >50% on computed tomography angiography. Diagnostic accuracy of AT was evaluated at calculated (Youden index) and prespecified cut-off values (121ms), using the sensitivity, specificity, positive likelihood ratio, negative likelihood ratios, and area under the curve. The McNemar test compared ACCmax with AT at prespecified and calculated cut-off values. Subgroup analyses of patients prone to MAC (i.e., those with DM and/or CKD) were also performed. This study included 184 patients (267 legs) with a high prevalence of DM (53%) and CKD (36%). The diagnostic accuracy of AT to identify PAD for PTA showed a sensitivity of 84%, specificity of 98%, positive likelihood ratio of 42.00, negative likelihood ratio of 0.16 and area under the curve of 0.96. Regarding the ATA, the results were 81%, 93%, 11.57, 0.20, and 0.92, respectively. Statistical comparisons favored ACCmax over AT in detecting PAD at prespecified and calculated cut-off values for both the PTA and ATA (P<0.001). Additionally, in patients prone to MAC, ACCmax also outperformed AT in detecting PAD (P values ranging from <0.001 to 0.039). For patients without PAD, no significant differences were observed in the ability to rule out the disease. ACCmax proved to be more accurate than AT in detecting PAD, also in patients prone to MAC. While no significant difference was found between ACCmax and AT in their diagnostic accuracy to exclude PAD, ACCmax should be favored in the diagnostic work-up in patients suspected of PAD due to its superior ability to detect an arterial stenosis.

Coronary Artery Vasculitis and Encasement: Multimodality Imaging Findings and Mimics.

Coronary artery vasculitis (CAV) and coronary artery encasement are rarely diagnosed conditions that are important diagnostic considerations, particularly in patients with acute coronary syndrome without traditional cardiovascular risk factors or systemic illness. Vasculitis refers to inflammation of the blood vessel walls, which can be primary or secondary. This process should be distinguished from neoplastic involvement of the coronary arteries, termed coronary artery encasement. Prospective diagnosis of these diseases is challenging, often requiring multidisciplinary workup with careful attention to clinical presentation and multiorgan findings. While CAV and coronary artery encasement can be indistinguishable at coronary CT angiography, certain imaging features help order the differential diagnosis. CAV should be considered when there is smooth wall thickening that is circumferential and/or continuous. A diagnosis of coronary artery encasement is favored when there is irregular or nodular wall thickening that is eccentric to the vessel lumen. Epicardial fat stranding may also appear more extensive compared with CAV. Potential mimics of CAV include atherosclerosis, acute plaque rupture, coronary artery aneurysm, and spontaneous coronary artery dissection. Detection and diagnosis of CAV may help avoid complications related to accelerated atherosclerosis and infarction. Radiologists should be familiar with the range of pathologic conditions that can affect the coronary arteries beyond atherosclerosis as they may be the first to raise such diagnostic possibilities, guiding next steps in patient workup and management. ©RSNA, 2024 Supplemental material is available for this article.