Discrimination between ventricular tachycardia and wide-QRS preexcited tachycardia.

BACKGROUND: To develop a new algorithm to differentiate ventricular tachycardia (VT) from preexcited tachycardia (pre-ET) according to left bundle branch block (LBBB) and right bundle branch block (RBBB) patterns. METHODS: This study included 67 electrocardiograms (ECGs) with VT and 63 ECGs with pre-ET, collected from our hospital and through PubMed. Of those, 64 were allocated to the derivation cohort and the rest to the validation cohort. The diagnoses of the ECGs were confirmed using an electrophysiological study. Parameters and classifiers from prior algorithms along with the propagation speeds in the early portion of the QRS complex (initial deflection index) in leads V1, V6, aVR, II, and III were manually measured. The performance of the new algorithm was compared with that of prior algorithms. RESULTS: The initial deflection index in lead III was the strongest predictor of pre-ET in LBBB-pattern wide-QRS tachycardia (p = 0.003, AUC 0.805). The initial deflection index in lead V1 was the most powerful predictor of pre-ET in RBBB-pattern wide-QRS tachycardia (p = 0.001, AUC 0.848). Compared to earlier algorithms, those using the initial deflection indexes: lead III in LBBB patterns (cutoff value >0.3) and lead V1 in RBBB patterns (cutoff value ≤0.48), demonstrated superior performance in screening VT, with AUC values of 0.828. The initial deflection indexes proved effective as discriminators between VT and pre-ET in the validation cohort. CONCLUSIONS: In LBBB-pattern wide-QRS tachycardia, the early propagation speed of pre-ET was faster than that in VT. Conversely, in RBBB-pattern wide-QRS tachycardia, it was slower.

Differentiation of autoimmune pancreatitis from pancreatic adenocarcinoma using CT characteristics: a systematic review and meta-analysis.

OBJECTIVES: To determine informational CT findings for distinguishing autoimmune pancreatitis (AIP) from pancreatic ductal adenocarcinoma (PDAC) and to review their diagnostic accuracy. METHODS: A systematic and detailed literature review was performed through PubMed, EMBASE, and the Cochrane library. Similar descriptors to embody the identical image finding were labeled as a single CT characteristic. We calculated the pooled diagnostic odds ratios (DORs) of each CT characteristic using a bivariate random-effects model. RESULTS: A total of 145 various descriptors from 15 studies (including 562 AIP and 869 PDAC patients) were categorized into 16 CT characteristics. According to the pooled DOR, 16 CT characteristics were classified into three groups (suggesting AIP, suggesting PDAC, and not informational). Seven characteristics suggesting AIP were diffuse pancreatic enlargement (DOR, 48), delayed homogeneous enhancement (DOR, 46), capsule-like rim (DOR, 34), multiple pancreatic masses (DOR, 16), renal involvement (DOR, 15), retroperitoneal fibrosis (DOR, 13), and bile duct involvement (DOR, 8). Delayed homogeneous enhancement showed a pooled sensitivity of 83% and specificity of 85%. The other six characteristics showed relatively low sensitivity (12-63%) but high specificity (93-99%). Four characteristics suggesting PDAC were discrete pancreatic mass (DOR, 23), pancreatic duct cutoff (DOR, 16), upstream main pancreatic duct dilatation (DOR, 8), and upstream parenchymal atrophy (DOR, 7). CONCLUSION: Eleven CT characteristics were informational to distinguish AIP from PDAC. Diffuse pancreatic enlargement, delayed homogeneous enhancement, and capsule-like rim suggested AIP with the highest DORs, whereas discrete pancreatic mass suggested PDAC. However, pooled sensitivities of informational CT characteristics were moderate. CLINICAL RELEVANCE STATEMENT: This meta-analysis underscores eleven distinctive CT characteristics that aid in differentiating autoimmune pancreatitis from pancreatic adenocarcinoma, potentially preventing misdiagnoses in patients presenting with focal/diffuse pancreatic enlargement. KEY POINTS: • Diffuse pancreatic enlargement (pooled diagnostic odds ratio [DOR], 48), delayed homogeneous enhancement (46), and capsule-like rim (34) were CT characteristics suggesting autoimmune pancreatitis. • The CT characteristics suggesting autoimmune pancreatitis, except delayed homogeneous enhancement, had a general tendency to show relatively low sensitivity (12-63%) but high specificity (93-99%). • Discrete pancreatic mass (pooled diagnostic odds ratio, 23) was the CT characteristic suggesting pancreatic ductal adenocarcinoma with the highest pooled DORs.

Value of T2-weighted-based radiomics model in distinguishing Warthin tumor from pleomorphic adenoma of the parotid.

OBJECTIVES: The differentiation of Warthin tumor and pleomorphic adenoma before treatment is crucial for clinical strategies. The aim of this study was to develop and test a T2-weighted-based radiomics model for differentiating pleomorphic adenoma from Warthin tumor of the parotid gland. METHODS: A total of 117 patients, including 61 cases of Warthin tumor and 56 cases of pleomorphic adenoma, were retrospectively enrolled from two centers between January 2010 and June 2022. The training set included 82 cases, and the validation set included 35 cases. From T2-weighted images, 971 radiomics features were extracted. Seven radiomics features remained after a two-step selection process. We used the seven radiomics features and clinical factors through multivariable logistic regression to build radiomics and clinical models, respectively. A radiomics-clinical model was also built that combined the independent clinical predictors with the radiomics features. Through ROC curves, the three models were evaluated and compared. RESULTS: In the radiomics model, AUCs were 0.826 and 0.796 in training and validation sets, respectively. In the clinical model, the AUCs were 0.923 and 0.926 in the training and validation sets, respectively. Decision curve analysis revealed that the radiomics-clinical model had the best diagnostic performance for distinguishing Warthin tumor from pleomorphic adenoma of the parotid gland (AUC = 0.962 and 0.934 for the training and validation sets, respectively). CONCLUSION: The radiomics-clinical model performed well in differentiating pleomorphic adenoma from Warthin tumor of the parotid gland. KEY POINTS: • The clinical model outperformed the radiomics model in distinguishing pleomorphic adenoma from Warthin tumor of the parotid gland. • The radiomics features extracted from T2-weighted images could help differentiate pleomorphic adenoma from Warthin tumor of the parotid gland. • The radiomics-clinical model was superior to the radiomics and the clinical models for differentiating pleomorphic adenoma from Warthin tumor of the parotid gland.

A case with prolonged headache after COVID-19 vaccination and later developed Bell's palsy.

PURPOSE: During COVID-19 pandemic, the authorization of emergent usage of new vaccine has raised suspicions and doubts about potential adverse events related to vaccination. Among the reported adverse events related to ChAdOx1/nCoV-19 vaccine, facial paralysis did not have an incident rate higher than natural occurrence like mRNA vaccines. However, temporal association between vaccination and facial palsy have been documented in several studies. Here, we report a case of an otherwise healthy 23-year-old Taiwanese female who experienced prolonged headache since the second day postvaccination and developed facial palsy on the tenth day. CASE REPORT: A 23-year-old Taiwanese female who was previously healthy experienced intermittent right side throbbing headache, general malaise, myalgia and fever. Headache, transient ear pain and right scalp numbness developed in the next few days but quickly resolved. On day ten after vaccination, signs of facial palsy on the right side of her face was noticed. The results of brain Magnetic Resonance Imaging (MRI) with contrast displayed no abnormality. Facial stimulation and blink reflex tests were compatible with right facial neuropathy. CONCLUSION: Reactivation of latent herpes virus has been suggested as one of the possible mechanisms underlying the phenomenon, but the causal pathophysiology related to the symptom needs further validation. Moreover, in the event of facial palsy post-vaccination, alternative diagnoses such as Guillain-Barre syndrome (GBS), Ramsey-Hunt syndrome, Lyme disease, trauma, central nervous system infection (CNS) infection, or stroke should also be considered.

[Intratesticular varicocele: Progress in research].

Intratesticular varicocele (ITV) is a relatively rare condition. Currently, there is no domestic literature available on this topic. This paper presents an overview of the epidemiology, diagnosis, differential diagnosis, impact on male reproductive health, and treatment of ITV with a review of recent foreign literature, aiming to gain a deeper insight into this condition.

Clinical Diagnosis and Magnetic Resonance Imaging in Patients With Transient and Minor Neurological Symptoms: A Prospective Cohort Study.

BACKGROUND: The utility of magnetic resonance imaging (MRI) brain in patients with transient or minor neurological symptoms is uncertain. We sought to determine the proportion of participants with transient or minor neurological symptoms who had MRI evidence of acute ischemia at different clinical probabilities of transient ischemic attack (TIA) or minor stroke. METHODS: Cohort of participants with transient or minor neurological symptoms from emergency and outpatient settings. Clinicians at different levels of training gave each participant a diagnostic probability (probable when TIA/stroke was the most likely differential diagnosis; possible when TIA/stroke was not the most likely differential diagnosis; or uncertain when diagnostic probability could not be given) before 1.5 or 3T brain MRI ≤5 days from onset. Post hoc, each clinical syndrome was defined blind to MRI findings as National Institute of Neurological Disorders and Stroke criteria TIA/stroke; International Headache Society criteria migraine aura; non-TIA focal symptoms; or nonfocal symptoms. MRI evidence of acute ischemia was defined by 2 reads of MRI. Stroke was ascertained for at least 90 days and up to 18 months after recruitment. RESULTS: Two hundred seventy-two participated (47% female, mean age 60, SD 14), 58% with MRI ≤2 days of onset. Most (92%) reported focal symptoms. MR evidence of acute ischemia was found, for stroke/TIA clinical probabilities of probable 23 out of 75 (31% [95% CI, 21%-42%]); possible 26 out of 151 (17% [12%-24%]); and uncertain 9 out of 43, (20% [10%-36%]). MRI evidence of acute ischemia was found in National Institute of Neurological Disorders and Stroke criteria TIA/stroke 40 out of 95 (42% [32%-53%]); migraine aura 4 out of 38 (11% [3%-25%]); non-TIA focal symptoms 16 out of 99 (16% [10%-25%]); and no focal features 1 out of 29 (3% [0%-18%]). After MRI, a further 14 (5% [95% CI, 3-8]) would be treated with an antiplatelet drug compared with treatment plan before MRI. By 18 months, a new ischemic stroke occurred in 9 out of 61 (18%) patients with MRI evidence of acute ischemia and 2 out of 211 (1%) without (age-adjusted hazard ratio, 13 [95% CI, 3-62]; P<0.0001). CONCLUSIONS: MRI evidence of acute brain ischemia was found in about 1 in 6 transient or minor neurological symptoms patients with a nonstroke/TIA initial diagnosis or uncertain diagnosis. Methods to determine the clinical and cost-effectiveness of MRI are needed in this population.

The role of reflectance confocal microscopy in the diagnosis of eccrine poroma: A retrospective case-control study.

Eccrine poroma (EP) is a rare benign adnexal tumor that may mimic benign or malignant tumors and differential diagnosis may be difficult under clinical and dermoscopic examination. Reflectance confocal microscopy (RCM) examination may add important information to diagnosis and subsequent management of solitary lesions for which dermoscopy can be challenging. The aim of the present study was to investigate features of EP at RCM in order to detect the characteristics that might aid in the differential diagnosis of EP versus other solitary lesions (benign or malignant). Secondary objective was to correlate the resulting features with histopathological findings. This monocentric retrospective observational case-control study included all EPs registered with RCM between January 2007 and May 2018. Control cases were benign or malignant lesions similar in clinical appearance, morphology, and dermoscopic features to EPs. RCM evaluators were blinded to clinical-dermoscopic images and to final histopathological diagnoses. Finally, RCM-histopathological correlation was performed. A total of 11 EPs and 33 controls were included in the present study. Among RCM parameters, "cords without palisading," "dark holes," "prominent vascularization" and "abundant stroma" resulted positively associated with EP in univariate analysis. RCM features correspond to the histopathological diagnosis of EP in 97% of cases, as illustrated by the cluster analysis. An excellent correlation between diagnostic features of conventional histopathology and RCM was observed. RCM assists in the differential diagnosis of solitary lesions, allowing to reach a correct diagnosis of EP through the identification of its four characteristics.

Perfusion measurement in brain gliomas using velocity-selective arterial spin labeling: comparison with pseudo-continuous arterial spin labeling and dynamic susceptibility contrast MRI.

OBJECTIVES: To evaluate the performance of velocity-selective (VS) ASL among patients with untreated gliomas by comparing with both pseudo-continuous (PC) ASL and dynamic susceptibility contrast-enhanced perfusion-weighted imaging (DSC-PWI). METHODS: Forty-four consecutive patients with newly diagnosed glioma who underwent preoperative perfusion MRI including VSASL, PCASL, and DSC-PWI between 2017 and 2019 were retrospectively evaluated. Visual inspection was performed to evaluate the tumor signal intensity relative to gray matter based on 1-5 score criteria and weighted kappa was used to evaluate the pair-wise concordance between VSASL or PCASL and DSC-PWI. The relative tumor blood flow (rTBF) was measured from sampling intra-tumoral areas of hot-spot on the blood flow map and normalized against the contralateral normal gray matter blood flow. Linear regression and Bland-Altman analyses were performed to evaluate the correlation and agreement of rTBF measurements between ASL methods and DSC-PWI. The ROC analysis was constructed to determine the diagnostic performance of three perfusion methods for grading gliomas. RESULTS: TBF maps derived from VSASL were more comparable with DSC-PWI than PCASL on visual inspection (weighted kappa of 0.90 vs 0.68). In quantitative analysis, VSASL-rTBF yielded higher correlation with the values from DSC-PWI than PCASL-rTBF (R2 = 80% vs 47%, p < 0.001 for both). Both ASL and DSC-derived rTBF showed good distinction between low-grade and high-grade gliomas (p < 0.001). Compared to PCASL, VSASL yielded superior diagnostic sensitivity, specificity, and accuracy in glioma grading. CONCLUSIONS: VSASL showed great promise for accurate quantification of TBF and could potentially improve the diagnostic performance of ASL in preoperative grading of gliomas. KEY POINTS: • VSASL demonstrated a greater agreement with DSC-PWI than with PCASL on visual inspection and perfusion quantification. • VSASL showed a higher diagnostic sensitivity, negative predictive value, and accuracy than PCASL for glioma grading. • With the advantages of insensitivity to transit delay and no need of prescribing a labeling plane, VSASL could potentially improve the diagnostic performance of ASL for a more accurate, noninvasive quantification of TBF in patients with glioma.

Assessment of breast lesions by the Kaiser score for differential diagnosis on MRI: the added value of ADC and machine learning modeling.

OBJECTIVES: To evaluate the diagnostic performance of Kaiser score (KS) adjusted with the apparent diffusion coefficient (ADC) (KS+) and machine learning (ML) modeling. METHODS: A dataset of 402 malignant and 257 benign lesions was identified. Two radiologists assigned the KS. If a lesion with KS > 4 had ADC > 1.4 × 10-3 mm2/s, the KS was reduced by 4 to become KS+. In order to consider the full spectrum of ADC as a continuous variable, the KS and ADC values were used to train diagnostic models using 5 ML algorithms. The performance was evaluated using the ROC analysis, compared by the DeLong test. The sensitivity, specificity, and accuracy achieved using the threshold of KS > 4, KS+ > 4, and ADC ≤ 1.4 × 10-3 mm2/s were obtained and compared by the McNemar test. RESULTS: The ROC curves of KS, KS+, and all ML models had comparable AUC in the range of 0.883-0.921, significantly higher than that of ADC (0.837, p < 0.0001). The KS had sensitivity = 97.3% and specificity = 59.1%; and the KS+ had sensitivity = 95.5% with significantly improved specificity to 68.5% (p < 0.0001). However, when setting at the same sensitivity of 97.3%, KS+ could not improve specificity. In ML analysis, the logistic regression model had the best performance. At sensitivity = 97.3% and specificity = 65.3%, i.e., compared to KS, 16 false-positives may be avoided without affecting true cancer diagnosis (p = 0.0015). CONCLUSION: Using dichotomized ADC to modify KS to KS+ can improve specificity, but at the price of lowered sensitivity. Machine learning algorithms may be applied to consider the ADC as a continuous variable to build more accurate diagnostic models. KEY POINTS: • When using ADC to modify the Kaiser score to KS+, the diagnostic specificity according to the results of two independent readers was improved by 9.4-9.7%, at the price of slightly degraded sensitivity by 1.5-1.8%, and overall had improved accuracy by 2.6-2.9%. • When the KS and the continuous ADC values were combined to train models by machine learning algorithms, the diagnostic specificity achieved by the logistic regression model could be significantly improved from 59.1 to 65.3% (p = 0.0015), while maintaining at the high sensitivity of KS = 97.3%, and thus, the results demonstrated the potential of ML modeling to further evaluate the contribution of ADC. • When setting the sensitivity at the same levels, the modified KS+ and the original KS have comparable specificity; therefore, KS+ with consideration of ADC may not offer much practical help, and the original KS without ADC remains as an excellent robust diagnostic method.

Small lesion classification on abbreviated breast MRI: training can improve diagnostic performance and inter-reader agreement.

OBJECTIVE: To determine whether the diagnostic performance and inter-reader agreement for small lesion classification on abbreviated breast MRI (AB-MRI) can be improved by training, and can achieve the level of full diagnostic protocol MRI (FDP-MRI). METHODS: This retrospective study enrolled 1165 breast lesions (≤ 2 cm; 409 malignant and 756 benign) from 1165 MRI examinations for reading test. Twelve radiologists were assigned into a trained group and a non-trained group. They interpreted each AB-MRI twice, which was extracted from FDP-MRI. After the first read, the trained group received a structured training for AB-MRI interpretation while the non-trained group did not. FDP-MRIs were interpreted by the trained group after the second read. BI-RADS category for each lesion was compared to the standard of reference (histopathological examination or follow-up) to calculate diagnostic accuracy. Inter-reader agreement was assessed using multirater k analysis. Diagnostic accuracy and inter-reader agreement were compared between the trained and non-trained groups, between the first and second reads, and between AB-MRI and FDP-MRI. RESULTS: After training, the diagnostic accuracy of AB-MRI increased from 77.6 to 84.4%, and inter-reader agreement improved from 0.410 to 0.579 (both p < 0.001), which were higher than those of the non-trained group (accuracy, 84.4% vs 78.0%; weighted k, 0.579 vs 0.461; both p < 0.001). The post-training accuracy and inter-reader agreement of AB-MRI were lower than those of FDP-MRI (accuracy, 84.4% vs 92.8%; weighted k, 0.579 vs 0.602; both p < 0.001). CONCLUSIONS: Training can improve the diagnostic performance and inter-reader agreement for small lesion classification on AB-MRI; however, it remains inferior to those of FDP-MRI. KEY POINTS: • Training can improve the diagnostic performance for small breast lesions on AB-MRI. • Training can reduce inter-observer variation for breast lesion classification on AB-MRI, especially among junior radiologists. • The post-training diagnostic performance and inter-reader agreement of AB-MRI remained inferior to those of FDP-MRI.

How paediatricians investigate early developmental impairment in the UK: a qualitative descriptive study.

BACKGROUND: Early developmental impairment (EDI) is common and has many aetiologies and, therefore, potential investigations. There are several published guidelines recommending aetiological investigations, and paediatricians' views of them varies. Little is known on the thought processes underlying clinical decisions in investigating EDI. This study aimed to describe the thought processes affecting clinical decisions on the investigation of EDI within a nationalised health care system. METHODS: A qualitative descriptive study using semi-structured qualitative interviews performed in person or via video link with paediatricians who see children with EDI in England. As part of the interview, a case study of a fictional disease, Cavorite deficiency, modelled on biotinidase deficiency, was given to participants with the cost of testing, incidence and likelihood it would respond to treatment. This allowed exploration of cost without encumbrance from predisposing views and training on the condition. Thematic analysis was performed by iterative approach. Where participants stated they wanted to redirect money from investigations to treatment, were that even possible, we asked which services they would like to be better funded in their area. RESULTS: Interviews were conducted with 14 consultant paediatricians: 9 Community / Neurodisability, 2 General paediatricians, and 3 Paediatric Neurologists. Two themes were identified: the value of an aetiological diagnosis to families and managing risk and probability when investigating EDI. The latter contained 4 subthemes: 'circumspection' involved blanket investigations chosen irrespective of phenotype and high regard for guidelines; 'accepting appropriate risk' involved participants choosing investigations based on clinical phenotype, recognising some aetiologies would be missed; consultants found they 'transitioned between practices' during their career; and 'improved practice' was thought possible with better evidence on how to stratify investigations based on phenotype. Services that were most frequently reported to need additional funding were therapy services, early community developmental services, management of behaviour, sleep and mental health, and educational support. CONCLUSIONS: There are many factors that influence paediatricians' choice of aetiological investigation in EDI, but clinical factors are the most important. Paediatricians want better evidence to allow them to select the right investigations for each child without a significant risk of missing an important diagnosis.

Attitudes towards the neurological examination in an unwell neonate: a mixed methods approach.

BACKGROUND: The neurological examination of an unwell neonate can aid management, such as deciding if hypothermia treatment is warranted in hypoxic ischaemic encephalopathy or directing investigations in hypotonic neonates. Current standardised examinations are not designed for unwell or ventilated neonates, and it is unclear how confident paediatricians feel about the examination or what aspects they perform.  AIM: This study aimed to review the confidence of UK paediatricians on the neurological examination in unwell neonates, describe their attitudes towards it, and determine what could improve practice. METHODS: An explanatory sequential mixed methods approach (QUAN → QUAL) with equal weighting between stages. A survey on attitudes to the neonatal neurological examination was sent to all UK neonatal units and members of the British Paediatric Neurology Association. Volunteers were sought for semi-structured interviews. Thematic analysis was used to interpret qualitative data, which was triangulated with quantitative questionnaire data. RESULTS: One hundred ninety-three surveys were returned, 31.0% from neonatologists, 9.3% paediatric neurologist. The median range for confidence was 4 (IQR3-5). Twenty-three interviews occurred. Thematic analysis revealed three themes: "Current culture on neonatal units", " Practicalities of the neurological examination in unwell neonates", and "Changing the culture". Most interviewees did not feel confident performing or interpreting the neurological examination in unwell neonates. Many units had a culture of seeing it as low priority, did not see its relevance in the acute management of unwell neonates. A few interviewees worked in units with a positive culture towards the neurological examination who used adapted standardised examinations and provided training. 72% of questionnaire responders wanted a new standardised neurological examination designed for the unwell neonate, which should be short, utilise pictures like the Hammersmith Neonatal Neurological Examination, contain an assessment of consciousness, be developmentally appropriate and achievable in unwell, ventilated neonates, be accompanied by a schematic to aid interpretation, and for greater training and assessments of competence. CONCLUSIONS: There are barriers preventing paediatricians being able to perform a neurological examination in unwell neonates, and a culture of neurophobia is common. A new standardised examination is needed, alongside aids to interpretation, training, and assessment.

[Sudden-onset dyspnea, cough and hemoptysis in a previously healthy 46-year-old female swimmer]. / Akut einsetzende Dyspnoe, Husten und Hämoptysen bei einer 46-jährigen bisher gesunden Schwimmerin.

This case report describes the case of a patient that developed suddenly dyspnea, cough and hemoptysis while swimming. Under the clinical presentation of pulmonary edema she required short-term invasive ventilation. Initially, echocardiography showed globally highly reduced systolic left ventricular function, which rapidly normalized. After exclusion of other pulmonary or cardiac causes swimming-induced pulmonary edema was diagnosed. This should be considered in cases of pulmonary edema, particularly in patients practicing sports with contact to water.

The splenial angle: a novel radiological index for idiopathic normal pressure hydrocephalus.

OBJECTIVES: To evaluate the utility of the splenial angle (SA), an axial angular index of lateral ventriculomegaly measured on diffusion tensor MRI color fractional anisotropy maps, in differentiating NPH from Alzheimer's disease (AD), Parkinson's disease (PD), and healthy controls (HC), and post-shunt changes in NPH, compared to Evans' index and callosal angle. METHODS: Evans' index, callosal angle, and SA were measured on brain MRI of 76 subjects comprising equal numbers of age- and sex-matched subjects from each cohort of NPH, AD, PD, and HC by two raters. Receiver operating characteristics (ROC) and multivariable analysis were used to assess the screening performance of each measure in differentiating and predicting NPH from non-NPH groups respectively. Temporal changes in the measures on 1-year follow-up MRI in 11 NPH patients (with or without ventriculoperitoneal shunting) were also assessed. RESULTS: Inter-rater and intra-rater reliability were excellent for all measurements (intraclass correlation coefficients > 0.9). Pairwise comparison showed that SA was statistically different between NPH and AD/PD/HC subjects (p < 0.0001). SA performed the best in predicting NPH, with an area under the ROC curve of > 0.98, and was the only measure left in the final model of the multivariable analysis. Significant (p < 0.01) change in SA was seen at follow-up MRI of NPH patients who were shunted compared to those who were not. CONCLUSIONS: The SA is readily measured on axial DTI color FA maps compared to the callosal angle and shows superior performance differentiating NPH from neurodegenerative disorders and sensitivity to ventricular changes in NPH after surgical intervention. KEY POINTS: • The splenial angle is a novel simple angular radiological index proposed for idiopathic normal pressure hydrocephalus, measured in the ubiquitous axial plane on DTI color fractional anisotropy maps. • The splenial angle quantitates the compression and stretching of the posterior callosal commissural fibers alongside the distended lateral ventricles in idiopathic normal pressure hydrocephalus (NPH) using tools readily accessible in clinical practice and shows excellent test-retest reliability. • Splenial angle outperforms Evans' index and callosal angle in predicting NPH from healthy, Parkinson's disease, and Alzheimer's disease subjects on ROC analysis with an area under the curve of > 0.98 and is sensitive to morphological ventricular changes in NPH patients after ventricular shunting.

Differential diagnosis of benign and malignant vertebral fracture on CT using deep learning.

OBJECTIVES: To evaluate the performance of deep learning using ResNet50 in differentiation of benign and malignant vertebral fracture on CT. METHODS: A dataset of 433 patients confirmed with 296 malignant and 137 benign fractures was retrospectively selected from our spinal CT image database. A senior radiologist performed visual reading to evaluate six imaging features, and three junior radiologists gave diagnostic prediction. A ROI was placed on the most abnormal vertebrae, and the smallest square bounding box was generated. The input channel into ResNet50 network was 3, including the slice with its two neighboring slices. The diagnostic performance was evaluated using 10-fold cross-validation. After obtaining the malignancy probability from all slices in a patient, the highest probability was assigned to that patient to give the final diagnosis, using the threshold of 0.5. RESULTS: Visual features such as soft tissue mass and bone destruction were highly suggestive of malignancy; the presence of a transverse fracture line was highly suggestive of a benign fracture. The reading by three radiologists with 5, 3, and 1 year of experience achieved an accuracy of 99%, 95.2%, and 92.8%, respectively. In ResNet50 analysis, the per-slice diagnostic sensitivity, specificity, and accuracy were 0.90, 0.79, and 85%. When the slices were combined to ve per-patient diagnosis, the sensitivity, specificity, and accuracy were 0.95, 0.80, and 88%. CONCLUSION: Deep learning has become an important tool for the detection of fractures on CT. In this study, ResNet50 achieved good accuracy, which can be further improved with more cases and optimized methods for future clinical implementation. KEY POINTS: • Deep learning using ResNet50 can yield a high accuracy for differential diagnosis of benign and malignant vertebral fracture on CT. • The per-slice diagnostic sensitivity, specificity, and accuracy were 0.90, 0.79, and 85% in deep learning using ResNet50 analysis. • The slices combined with per-patient diagnostic sensitivity, specificity, and accuracy were 0.95, 0.80, and 88% in deep learning using ResNet50 analysis.

Normal subchondral high T2 signal on MRI mimicking sacroiliitis in children: frequency, age distribution, and relationship to skeletal maturity.

OBJECTIVES: To determine patterns of variation of subchondral T2 signal changes in pediatric sacroiliac joints (SIJ) by location, age, sex, and sacral apophyseal closure. METHODS: MRI of 502 SIJ in 251 children (132 girls), mean age 12.4 years (range 6.1-18.0), was obtained with parental informed consent. One hundred twenty-seven out of 251 had asymptomatic joints and were imaged for non-rheumatologic reasons, and 124 had low back pain but no sign of sacroiliitis on initial clinical MRI review. After calibration, three subspecialist radiologists independently scored subchondral signal changes on fat-suppressed fluid-sensitive sequences from 0 to 3 in 4 locations, and graded the degree of closure of sacral segmental apophyses. Associations between patient age, sex, signal changes, and apophyseal closure were analyzed. RESULTS: Rim-like subchondral increased T2 signal or "flaring" was much more common at sacral than iliac SIJ margins (72% vs 16%, p < 0.001) and was symmetrical in > 90% of children. Iliac flaring scores were always lower than sacral, except for 1 child. Signal changes decreased as sacral apophyses closed, and were seen in < 20% of subjects with fully closed apophyses. Signal changes were more frequent in boys, and peaked in intensity later than for girls (ages 8-12 vs. 7-10). Subchondral signal in iliac crests was high throughout childhood and did not correlate with other locations. CONCLUSIONS: Subchondral T2 "flaring" is common at SIJ of prepubertal children and is generally sacral-predominant and symmetrical. Flaring that is asymmetrical, greater in ilium than sacrum, or intense in a teenager with closed apophyses, is unusual for normal children and raises concern for pathologic bone marrow edema. KEY POINTS: • A rim of subchondral high T2 signal is commonly observed on MRI at pediatric sacroiliac joints, primarily on the sacral side before segmental apophyseal closure, and should not be confused with pathology. • Unlike subchondral signal changes elsewhere, high T2 signal underlying the iliac crest apophyses is a near-universal normal finding in children that usually persists throughout adolescence. • The following patterns are unusual in normal children and are suspicious for pathology: definite iliac flaring, iliac flaring more intense than sacral flaring, left-right difference in flaring, definite flaring of any pattern in teenagers after sacral apophyseal closure.

[Clinical characteristics of central nervous system involvement in IgG4 related diseases].

OBJECTIVE: To improve the understanding of the clinical characteristics of immunoglobulin G4-related disease (IgG4-RD) with central nervous system (CNS) involvement, so as to contribute to the early diagnosis and treatment. METHODS: In this study, 10 patients with IgG4-RD with CNS involvement were selected. Clinical data including demographic features, clinical manifestations, organ involvement, laboratory findings, radiological results, pathology, treatments and outcomes were collected retrospectively. RESULTS: Among the 10 IgG4-RD patients complicated with CNS involvement, 6 cases manifested as pituitary involvement and 4 cases manifested as dural involvement. Only 2 patients had nervous system involvement alone, while the left patients were complicated with other organ involvement besides nervous system. Half of the patients presented nervous system involvement as the initial manifestation, and the main symptoms of nervous system included polydipsia, polyuria, headache, decreased vision and so on. In the laboratory examination, the serum IgG4 level was increased in 9 cases (90.0%), and the total serum IgE was increased in 7 cases (87.5%). At the same time, their IgG, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were increased, while complement (C) 3 and C4 were decreased in some patients. Eight patients underwent tissue biopsies in different parts, the pathological examination showed a large number of lymphocyte and plasma cell infiltration, accompanied by fibrous tissue proliferation in part. All the patients were treated with glucocorticoids, and 8 cases (80%) were given immunosuppressants at the same time, and 3 cases were treated with rituximab when they expe-rienced disease relapse. As a result, 2 cases (20%) achieved complete remission (CR), and 8 cases (80%) achieved partial remission (PR). The median follow-up time was 13.5 months, and 4 cases relapsed. CONCLUSION: Pituitary and dura are common affected organs of IgG4-RD with CNS involvement. Most IgG4-RD patients with CNS involvement are combined with other organ involvement, but half of them presented nervous system involvement as the initial manifestation, and the symptoms are not typical. In order to make an early diagnosis, laboratory, imaging examination and tissue biopsy should be taken into consideration in combination if necessary.

[Primary extraskeletal osteosarcoma: a clinicopathological study of ten cases].

Objective: To investigate the clinicopathologic features, differential diagnosis, immunohistochemical profiles and molecular characteristics of primary extraskeletal osteosarcoma (ESOS). Methods: Ten cases of ESOS diagnosed and treated in Fujian Provincial Hospital, Fuzhou, China from January 2003 to January 2019 were collected and subjected to immunohistochemical staining and molecular analyses. The patients were followed up by telephone interview. Relative literature was also reviewed to assess the characteristics of this tumor. Results: The ten cases occurred in 3 women and 7 men, aged from 36 to 85 years (median, 60 years). The sizes of these tumors ranged from 5.5 to 17.5 cm (median, 11.0 cm). Histologically, at low magnification, the tumors were nodular, leafy and lobulated. They were composed of spindle cells, neoplastic osteoid cells, and cartilage tissues, with unequally-proportional mixture of these components. The three components intermingled with each other. Immunohistochemistry profiling showed that the tumor cells were positive for SATB2 (9/9), while α-SMA (4/10) and EMA (1/10) stains were focally positive. Ki-67 proliferation index was 10%‒50%. Desmin, CD68, S-100 protein, SOX10, HMB45, CD117, DOG1, CD34, CKpan, GATA3 and PAX8 stains were negative. MDM2/CDK4 gene amplification signals were not detected in the 6 cases (0/6), which were subjected to the FISH. The SSX18 break-apart signal and the C-KIT and PDGFR-α mutations were not detected (0/5 and 0/3, respectively). Conclusions: Primary ESOS is an extra-osseous osteogenic tumor. The diagnosis is mainly dependent on clinical, radiological and pathological characteristics. Immunohistochemistry and molecular profiling are helpful for making the correct diagnosis.

[ETV6-rearranged low-grade sinonasal non-intestinal-type adenocarcinoma: a clinicopathological analysis].

Objective: To investigate the clinicopathologic features, immunophenotype, molecular genetic changes of ETV6-rearranged low-grade sinonasal non-intestinal-type adenocarcinoma (ETV6-RLGSNAC). Methods: Primary sinonasal epithelial malignant tumors were collected from January 2015 to January 2020 in the Department of Pathology, Eye, Ear, Nose and Throat Hospital affiliated to Fudan University. Through morphological observation, immunohistochemical detection and fluorescence in situ hybridization (FISH), ETV6-RLGSNAC was screened out for clinicopathological feature analysis, and relevant literatures were reviewed. Results: There were 550 cases of primary sinonasal epithelial malignant tumors, among which 82 cases were adenocarcinoma. There were 29 cases of low-grade non-intestinal adenocarcinoma, only 3 cases of ETV6-RLGSNAC were screened out. Of the 3 patients, 2 cases were male and 1 case was female, with a mean age of 54 years (range 37-64 years). The main clinical manifestations were nasal stenosis, nasal obstruction and epistaxis. A neoplasm with smooth surfaces was observed under nasal endoscopy. Imaging showed an expansive mass in the sinonasal area. Gross examination showed gray-yellow cut surface with firm texture and a maximum diameter of 2-3 cm. Microscopically, tumors were non-encapsulated and well-circumscribed with expansive growth pattern. The tumor cells were small and mild, cylindrical and cuboidal, and arranged in regular glandular and trabecular patterns. The cytoplasm was eosinophilic and the nuclei were basally located with inconspicuous nucleoli. By immunohistochemistry (IHC), CK7, SOX-10, DOG1 and vimentin were positive and S-100 expressed in small clusters of cells in all cases. GCDFP-15, CD56, CK20, mammaglobin, TTF-1, NR4A3 were all negative. The Ki-67 value-added index of all cases was low (<5%). ETV6 gene rearrangement was confirmed in all the cases by FISH, and two cases had NTRK3 gene rearrangement. All three patients underwent radical resection after diagnosis, and one also had adjuvant radiotherapy. All three patients were available with a follow-up time of 12-25 months, and all were recurrence free. Conclusions: ETV6-RLGSNAC is a rare low-grade and newly named non-intestinal adenocarcinoma. The histomorphology is similar to other low-grade nasal sinonasal adenocarcinomas and some salivary gland tumors. IHC and FISH are useful for the diagnosis and differential diagnosis.

[Upper abdominal pain: a frequent and multifaceted leading symptom in primary care internal medicine]. / Oberbauchschmerz ­ ein häufiges und facettenreiches Leitsymptom in der internistisch-hausärztlichen Praxis.

Upper gastrointestinal symptoms are among the most common reasons for medical consultation and represent a challenge for general practitioners in the outpatient care setting. History taking, symptom evaluation and physical examination are the crucial steps toward establishing an initial working diagnosis. The subsequent abdominal ultrasound and laboratory analyses are essential tools for the differential diagnosis.