Posterior pituitary tumors and other rare entities involving the pituitary gland.

Non-neuroendocrine tumors account for around 10% of all primary neoplasms of the sella. If meningiomas, craniopharyngiomas, and germ cell tumors are excluded, the remaining lesions include a broad spectrum of uncommon, benign, and aggressive, often diagnostically challenging lesions. This review aims to summarize the essential clinicopathological features of tumors of the posterior pituitary gland, infundibulum spectrum expressing thyroid transcription factor 1, and primary sellar atypical rhabdoid teratoid tumor, and provide the criteria for their diagnosis and management.

Evaluation of Antipsychotic-Induced Neuroleptic Malignant Syndrome Using a Self-Organizing Map.

Introduction In neuropsychiatric pharmacotherapy, neuroleptic malignant syndrome (NMS) is a potentially serious side effect of antipsychotics characterized primarily by fever, disorientation, extrapyramidal disorders, and autonomic nervous system imbalance, which can lead to death if left untreated. We visualized the NMS profile of antipsychotics using a self-organizing map (SOM). We combined it with decision tree analysis to discriminate between 31 antipsychotics in more detail than typical antipsychotic (TAP) and atypical antipsychotic (AAP) classifications. Method A total of 20 TAPs and 11 AAPs were analyzed. We analyzed NMS reports extracted from the Japanese Adverse Drug Event Report (JADER) database based on standardized Medical Dictionary for Regulatory Activities (MedDRA) queries (Standardized MedDRA Queries (SMQ) code: 20000044, including 68 preferred terms). The SOM was applied using the SOM package in R version 4.1.2 (R Foundation for Statistical Computing, Vienna, Austria). Results The Japanese Adverse Drug Event Report (JADER) database contained 887,704 reports published between April 2004 and March 2024. The numbers of cases of NMS (SMQ code: 20000044) reported for risperidone, aripiprazole, haloperidol, olanzapine, and quetiapine were 1691, 1294, 1132, 1056, and 986, respectively. After the antipsychotics were classified into six units using SOM, they were adapted for decision tree analysis. First, 31 antipsychotics branched off into groups with loss of consciousness, with one group (10 TAPs) consisting entirely of TAPs, and the other consisting of antipsychotics that were further separated into two groups with coma induced by TAPs and AAPs. Conclusion The results of this study provide a reference for healthcare providers when predicting the NMS characteristics induced by each drug in patients, thereby facilitating the effective treatment of schizophrenia.

The longitudinal patterns of depression subtypes and stressors in depression severity in the Canadian longitudinal study on aging (CLSA).

AIM: The current study aims to characterize the longitudinal patterns of depression subtypes and investigate the associations among the stability of depression subtypes, COVID-19-related stressors, and depression severity. METHODS: The study utilized data from the Canadian Longitudinal Study on Aging, which is a national, long-term study of Canadian adults aged 45 and older (n = 12,957). Latent profile analysis was used to identify latent depression subtypes. Latent transition analysis was then applied to assess the stability of these subtypes over time. Hierarchical multivariate linear regression was used to explore the relationships among these identified depression subtypes, COVID-19-related stressors, and depression severity among males and females, respectively. RESULTS: Distinct depression subtypes were identified. Except for atypical depression, other depression subtypes showed greater stability over time. We also found that melancholic depression (B = 9.432) and typical depression (B = 6.677) were strongly associated with depression severity during the pandemic. Health-related stressors (B = 0.840), conflict (B = 3.639), difficulties accessing resources (B = 0.927), separation from family (B = 0.840), and caregiving experience (B = 0.764), were significantly associated with increased depression severity. Sex-specific analyses also revealed differences in the associations between stressors and depression severity between males and females. CONCLUSIONS: This study contributes valuable insights into the latent clustering of depression subtypes and their stability. Stressors were associated with increased depression severity, with distinct associations observed among males and females. These findings have implications for targeted early interventions and integrated clinical management strategies by providing the evidence base for tailored mental health care during and after the pandemic.

A Case Report of a Rare 46,XX/47,XXY Mosaicism With Ovotesticular Disorder of Sex Development and a Literature Review.

Klinefelter syndrome (KS) is a common chromosomal abnormality in males, usually presenting as a 47,XXY karyotype and often underdiagnosed. Rarely, KS occurs as mosaic 46,XX/47,XXY. At the same time, ovotesticular disorder of sex development (OT-DSD) is also a rare condition in which both ovarian and testicular structures are present in the same individual, often associated with a 46,XX karyotype. The combination of mosaic 46,XX/47,XXY with OT-DSD is scarce. Herein, we report a new case of a six-month-old infant with unilateral OT-DSD and a 46,XX/47,XXY mosaic karyotype who presented with atypical genitalia at birth. On examination, the external genitalia showed asymmetry of the labioscrotal folds, an empty right fold, a 2.5 cm phallic structure, and a perineal urethral meatus. Imaging studies revealed a uterus and a vaginal cavity, as well as an ovotestis on the left side and an ovarian remnant on the right side. An unexpected increase in testosterone level was observed. Cytogenetics analysis confirmed a mosaic karyotype with 54% of 46,XX and 46% 47,XXY cells. Molecular genetic analysis revealed no mutations in the genes involved in gonadal development. These findings are discussed and the clinical characteristics of the reported cases of 46,XX/47,XXY with OT-DSD are summarized. In conclusion, atypical genitalia leads to the early diagnosis of the rare 46,XX/47,XXY mosaicism with OT-DSD. Mosaicism should be considered in all cryptorchidism cases. Persistent Müllerian structures were common, and the nearly male phenotype of the external genitalia led parents to prefer the male sex of rearing.

Transformative Outcomes With Paliperidone Long-Acting Injection in Severe Treatment-Resistant Schizophrenia: A Case Report and Literature Review.

Treatment-resistant schizophrenia (TRS) presents considerable challenges in contemporary psychiatric practice due to inadequate response to conventional antipsychotic treatments. Paliperidone, the primary active metabolite of risperidone, particularly in its long-acting injectable (LAI) form, has emerged as a promising option for TRS due to its consistent medication delivery, reducing symptom exacerbation and relapse associated with oral dosing fluctuations. This case report presents the clinical journey of a 42-year-old female diagnosed with schizophrenia at age 15. Despite numerous hospital admissions and trials of various oral and injectable antipsychotics, including clozapine and electroconvulsive therapy (ECT), her symptoms persisted. During her last admission, her condition showed minimal improvement despite extensive pharmacological interventions. Introducing paliperidone LAI while tapering off other antipsychotics led to significant improvements within four weeks. The patient exhibited reduced hallucinatory behaviour, delusions, and disorganized behaviour. Follow-up assessments confirmed sustained progress, with the patient showing increased engagement in daily activities and reduced irritability and suspiciousness. This case underscores the potential efficacy of paliperidone LAI in managing TRS. The patient's notable improvement highlights the importance of personalized treatment plans and continuous monitoring in complex psychiatric conditions. Its favourable safety and tolerability profile further supports its use as a long-term treatment option for TRS, potentially leading to enhanced patient compliance and overall quality of life. The significant symptomatic relief and functional improvement observed advocate for the consideration of paliperidone LAI as a promising therapeutic option for TRS, with the potential to be considered in the future among the first-line treatments for TRS.

An Atypical Pathogen at an Atypical Location: A Rare Case of Salmonella-Associated Submandibular Abscess.

Salmonella infections commonly cause gastroenteritis and enteric fever but can also result in extraintestinal infections, especially in immunocompromised individuals. Although rare, Salmonella infection in the head and neck region was found to be more common in diabetics and patients with malignancy. We present a unique case of a 52-year-old immunocompromised man with uncontrolled diabetes who developed a submandibular abscess due to Salmonella Paratyphi B. The patient initially presented with pain, swelling, and difficulty swallowing, which worsened over a week. Diagnostic imaging revealed a well-defined abscess with lymphadenopathy. Management included incision and drainage, followed by identification of Salmonella Paratyphi B and targeted antibiotic therapy based on culture and sensitivity analysis. This case highlights the importance of early recognition, appropriate diagnostic imaging, and targeted antimicrobial therapy in managing uncommon manifestations of Salmonella infection in the head and neck. Continued vigilance and multidisciplinary management are essential for favorable patient outcomes in such cases.

Atypical Multidrug-Resistant Salmonella paratyphi B Infection in a Patient with Uncontrolled Diabetes Mellitus: A Case Report.

Atypical Salmonella infection usually presents with unusual symptoms in addition to gastroenteritis. Such atypical presentations can pose a challenge for diagnosis and treatment as they may be misdiagnosed, leading to delayed care and potential complications. Here we report an unusual case of Salmonella spp. isolated from a wound swab. A 57-year-old male patient with a history of uncontrolled type 2 diabetes presented to the general surgery department with a 25-day history of swelling, ulceration, and purulent discharge on his right foot. A wound swab was collected for culture and sensitivity. Gram staining showed occasional pus cells and a few gram-negative bacilli. Culture was done, and the organism was identified as Salmonella Paratyphi B with the help of other biochemicals. The isolate showed susceptibility to chloramphenicol and cotrimoxazole and resistance to other panels of antibiotics. Routine blood and urine analysis of the patient showed normal findings. Wound dressing was done on an alternative day, followed by administration of antibiotics. The patient was advised to follow up after two weeks. The clinical outcome in the above patient was satisfactory with appropriate antibiotics. We present a case of atypical typhoidal Salmonella as a rare cause of wound infection and not a major threat if diagnosed and treated accordingly.

Aortic Dissection Masquerading as Pneumonia: A Case Report of an Atypical Presentation.

Aortic dissection is a critical and life-threatening condition that can present with atypical symptoms, often leading to misdiagnosis and delayed treatment. The report presents a case of a 65-year-old male who initially exhibited fever, right-sided chest pain, and a productive cough, resulting in an initial diagnosis of pneumonia. Despite empirical antibiotic therapy, his symptoms persisted, prompting further investigation. A computed tomography (CT) scan ultimately revealed a Type B aortic dissection. The patient was then transferred to a specialized tertiary care facility for successful endovascular intervention. This case underscores the importance of considering aortic dissection in patients presenting with persistent, atypical symptoms that do not respond to standard treatments, such as unexplained fever and chest pain. It highlights the crucial role of advanced imaging techniques, such as CT scans, in achieving an accurate and timely diagnosis. Clinicians must maintain a high index of suspicion and ensure prompt referral to specialized centers to improve patient outcomes in this potentially fatal condition.

Unusual Presentation of Aggressive Atypical Hemolytic Uremic Syndrome With Brugada Syndrome.

Hemolytic uremic syndrome (HUS) is part of a spectrum of disorders known as thrombotic microangiopathies. These disorders are characterized by giving rise to platelet microthrombi, which subsequently develop hemolytic anemia and thrombocytopenia. In HUS, the kidneys are destroyed, mainly due to damage to the renal blood vessels. HUS can be typical or atypical, depending on the cause, and can lead to significant mortality rates. We herein report an unusual case of atypical HUS in a 15-year-old female who presented with fatigue, abdominal pain with nausea and vomiting, loss of appetite, and urine discoloration. Further tests showed low platelets with significant anemia. She was diagnosed with atypical HUS after discovering that she had no previous bloody diarrhea episode with a negative E. coli strain, O157:H7, alongside valid ADAMTS13 activity. The diagnosis was confirmed by genetic testing, and a variant of uncertain significance was found in the CFH gene. The patient, therefore, was started on eculizumab, and a follow-up was done once or twice a month through blood testing. She showed significant improvement. Due to non-compliance with the eculizumab treatment, the patient showed deterioration numerous times. A kidney biopsy was subsequently done, showing signs of acute to chronic thrombotic microangiopathy with moderate tubular atrophy and interstitial fibrosis. After many hemodialysis and plasma exchange sessions and being put on several treatments, such as prednisolone and rituximab, the patient faced death after one year.

Enzymatic Synthesis of Disialyllacto-N-Tetraose (DSLNT) and Related Human Milk Oligosaccharides Reveals Broad Siglec Recognition to the Atypical Neu5Acα2-6GlcNAc Motif.

Sialic acids (Sias) are ubiquitously expressed on all types of glycans, typically as terminating residues. They usually link to galactose, N-acetylgalactosamine, or other Sia residues, forming ligands of many glycan-binding proteins. An atypical linkage to the C6 of N-acetylglucosamine (GlcNAc) has been identified in human milk oligosaccharides (HMOs, e.g., DSLNT) and tumor-associated glycoconjugates. Herein, we achieved the systematic synthesis of these HMOs in an enzymatic modular manner. The synthetic strategy relies on a novel activity of ST6GalNAc6 for efficient construction of the Neu5Acα2-6GlcNAc linkage, and another 12 specific enzyme modules for sequential HMO assembly. The structures enabled comprehensive exploration into their structure-function relationships using glycan microarray, revealing broad yet distinct recognitions by Siglecs to the atypical Neu5Acα2-6GlcNAc motif. The work provides tools and new insights for functional study and potential applications of Siglecs and HMOs.

What Amount of Weight Loss Can Entail Anorexia Nervosa or Atypical Anorexia Nervosa After Bariatric Surgery?

OBJECTIVE: Post-operative development of restrictive eating disorders can occur in patients after bariatric surgery. In children and adolescents with anorexia nervosa (AN) or atypical AN, premorbid body mass index (BMI) has recently been shown to predict total weight loss. We hypothesized that pre-operative BMI similarly predicts weight loss and the development of a restrictive eating disorder in adult bariatric patients. METHOD: A PubMed search identified case studies/series of 29 adult females who developed AN or atypical AN/eating disorder not otherwise specified following bariatric surgery. Non-parametric Spearman's correlation (rs) between pre-operative BMI and total weight loss was calculated; a scatterplot was used to illustrate the relationship between pre-operative/premorbid BMI and weight loss in kg for 29 bariatric patients and 460 children and adolescents with AN or atypical AN as published previously. RESULTS: The correlation between pre-operative BMI and weight loss among bariatric patients was rs = 0.65 (p = 0.0001). Scatterplot data of this relationship fit the previously identified pattern in children and adolescents with AN or atypical AN. DISCUSSION: The prediction of weight loss by pre-operative/premorbid BMI appears applicable across the weight spectrum, from underweight to severe obesity, thus strengthening our hypothesis of underlying regulatory mechanisms for the development of AN and atypical AN. Such data may guide the determination of critical weight loss thresholds that trigger eating disorder development in predisposed individuals.

Complement system activation: bridging physiology, pathophysiology, and therapy.

The complement system is a set of over 50 proteins that constitutes an essential part of the innate immune system. Complement system activation involves an organized proteolytic cascade. Overactivation of complement system activation is the main pathogenic mechanism of several diseases and contributes to the manifestations of many other conditions. This review describes the normal complement system and the role for complement dysregulation in critical illnesses, notably sepsis and acute respiratory distress syndrome. Complement activation is involved in the immune system response to pathogens but, when excessive, can contribute to tissue damage, runaway inflammation, and capillary leakage syndrome. Complement overactivation may play a key role in severe forms of coronavirus disease 2019 (COVID-19). Two diseases whose manifestations are mainly caused by complement overactivation, namely, atypical hemolytic and uremic syndrome (aHUS) and myasthenia gravis, are discussed. A diagnostic algorithm for aHUS is provided. Early complement-inhibiting therapy has been proven effective. When renal transplantation is required, complement-inhibiting drugs can be used prophylactically to prevent aHUS recurrence. Similarly, acetylcholine-receptor autoantibody-positive generalized myasthenia gravis involves complement system overactivation and responds to complement inhibition. The two main complement inhibitors used in to date routine are eculizumab and ravulizumab. The main adverse event is Neisseria infection, which is rare and preventable, but can be fatal. The complement system is crucial to health but, when overactivated, can cause or contribute to disease. Effective complement inhibitors are now available, although additional data are required to determine optimal regimens. Further research is also needed to better understand the complement system, develop advanced diagnostic tools, and identify markers that allow the personalization of treatment strategies.

Thrombotic microangiopathy (TMA) associated with pregnancy: role of the clinical laboratory in differential diagnosis.

Objectives: Thrombotic microangiopathy (TMA) is characterized by thrombocytopenia, microangiopathic hemolytic anemia and target organ damage. Pregnancy is associated with several forms of TMA, including preeclampsia (PE), HELLP syndrome, thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). When HUS is secondary to a deregulation of the alternative complement pathway, it is known as atypical HUS (aHUS). Differential diagnosis is challenging, as these forms share clinical characteristics. However, early diagnosis is crucial for a specific treatment to be established and improve prognosis. Case presentation: We present the case of a 43 year-old primiparous woman admitted to hospital for an urgent C-section at 33 gestational weeks due to a diagnosis of severe preeclampsia and fetal distress. In the immediate postpartum, the patient developed acute liver failure and anuric renal failure in the context of the HELLP syndrome, anemia, thrombocytopenia, arterial hypertension (HTN) and neurological deficit. TMA study and differential diagnosis confirmed pregnancy-associated aHUS. Treatment with eculizumab was initiated, with good response and progressive improvement of clinical and analytical parameters. Conclusions: aHUS is a rare multifactorial disease that used to be associated with high mortality rates before the advent of eculizumab. Due to challenging diagnosis, the clinical laboratory plays a major role in the differential diagnosis and management of the disease.

Corrigendum: Genetic investigation of Nordic patients with complement-mediated kidney diseases.

[This corrects the article DOI: 10.3389/fimmu.2023.1254759.].

Outcome after ablation of atypical atrial flutter: Is induction a feasible approach?

Background: Atypical atrial flutter (AAF) is an increasingly relevant clinical problem. Despite advancements in mapping and ablation techniques, the general management of these patients remain challenging especially when mapping cannot be performed during ongoing arrhythmia. There are no data whether induction of AAF is a feasible approach in these cases. Methods: We retrospectively analyzed patients who underwent catheter ablation of AAF and compared procedural results between patients with ongoing tachycardia when starting the procedure and patients with induced AAF. Results: We analyzed 97 ablation procedures performed in 76 patients with a mean follow-up of 13.2 ± 12.2 months. In 68 procedures (70.1 %) AAF was ongoing at the beginning of the procedure and in 29 cases (29.9 %) AAF had to be induced.There was no statistically significant difference regarding acute procedural success. The recurrence rate of any arrhythmia during follow-up was significantly higher after ablation of ongoing AAF compared to induced AAF (63.2 % vs. 42.9 %; p = 0.047) driven by a significant higher rate of AAF-recurrence (57.4 % vs. 34.5 %; p = 0.039). The number of ablated tachycardias per patient as well as the number of de-novo tachycardias found during re-ablation showed no significant difference between both groups. Conclusion: Starting a procedure with ongoing arrhythmia did not result in better short- or mid-term outcome in patients undergoing AAF ablation. Furthermore, based on our results inducing AAF seems a legitimate approach for AAF ablation in patients presenting in sinus rhythm.

Utility of Image Morphometry in the Atypical Urothelial Cells and High-Grade Urothelial Carcinoma Categories of the Paris System for Reporting Urinary Cytology.

Introduction: Urinary cytology (UrCy) is highly sensitive to diagnosing high-grade urothelial carcinoma (HGUC) but cannot predict muscularis propria invasion. Further, the atypical urothelial cell category (AUC) may have variable outcomes. Image morphometry (IM) may be a valuable adjunct technique in this setting. Hence, we evaluated IM in the AUC and HGUC categories to improve the diagnostic performance. Materials and Methods: The following six nuclear parameters were evaluated by IM on 3150 cells: nucleo-cytoplasmic (N:C) ratio, nuclear area, diameter, perimeter, standard deviation of the nuclear area (SDNA; pleomorphism) and integrated density (ID; nuclear chromasia), using the ImageJ software, in three cohorts based on the histopathology outcome: 20 cases of AUC - benign non-neoplastic outcome (AUC-B); 22 cases of HGUC Muscle invasive (HGUC-MI) and 21 cases of HGUC non-muscle invasive (HGUC-MF). Results: A retrospective analysis of urine cytology. The patient's ages ranged from 36 to 85 years, with a mean age of 60.6. The male-to-female ratio was 5.4:1. A total of 20 cases of AUC-B and 43 cases of HGUC were selected for IM analysis. HGUC cases had higher nuclear parameters than AUC-B, and HGUC-MI had higher SDNA, ID, diameter, and area than HGUC-MF. SDNA and ID predict muscularis propria invasion in HGUC. Conclusions: Image morphometry successfully differentiates HGUC cases from benign non-neoplastic ones and might help to identify muscularis propria invasion in HGUC using a combination of nuclear parameters.

Atypical placental site nodules: Clinicopathologic features, management and patient outcomes in an institutional series.

OBJECTIVE: To report the New England Trophoblastic Disease Center (NETDC) experience with atypical placental site nodules (APSN). METHODS: The NETDC registry was reviewed from 2005 to 2022 and clinical data abstracted. Expert pathologists in GTD reviewed available slides with concurrent immunohistochemical analysis. Targeted deep sequencing was performed for four cases. RESULTS: Among 35 cases of APSN identified, 29 had clinical and demographic data available. Abnormal uterine bleeding (59.3%) was the most common presenting symptom. Most women (79.3%) had an antecedent live birth. Two cases were incidentally diagnosed after hysterectomy for other indications, and one case lost to follow-up. Among the remaining 26 cases, 11 (42.3%) opted for hysterectomy and 15 for re-sampling (57.7%), among whom 3 later underwent hysterectomy for persistent APSN. Subsequent obstetrical outcomes included 3 spontaneous abortions, 1 therapeutic abortion, 1 ectopic pregnancy, 2 cesarean sections, 1 cesarean hysterectomy, and 1 spontaneous vaginal delivery. Subsequent pathology was available for 26 cases: 4 epithelioid trophoblastic tumors (15.4%), 9 APSN (34.6%), 3 PSN (11.5%), and 10 without abnormalities (38.4%). Histopathologic characteristics of APSN included moderate to severe cytologic atypia, median Ki-67 proliferation index of 8%, and typical immunohistochemical profiles (diffuse or multifocal positivity for p63 and GATA-3 and absent or focal CD146). No histopathologic feature predicted ETT. Among 4 sequenced cases, no recurrent genomic features were identified. CONCLUSIONS: APSN is a rare form of gestational trophoblastic proliferation with uncertain malignant potential. While normal obstetric outcomes are possible, the persistence rate is high, and definitive management remains hysterectomy.

Cervical cytology in endometrial cancer patients with Lynch syndrome: opportunities for early detection and limitations.

INTRODUCTION: Timely detection of endometrial carcinoma in Lynch syndrome patients ensures prompt treatment and appropriate cancer screening for the patient and impacted family members. While cervical cytology is utilized primarily in cervical cancer screening, endometrial glandular abnormalities can be identified as part of routine cervical cancer screening or during work-up for abnormal uterine bleeding. MATERIALS AND METHODS: We retrospectively evaluated cervical cytology samples from Lynch syndrome patients with endometrial carcinoma to determine how often atypical/malignant glandular cells were identified on prior/concurrent cytology. RESULTS: We identified 14 Lynch syndrome patients with cervical cytology available within a year of endometrial carcinoma diagnosis. The average patient age was 55 years (36-73). Cervical cytology preceded diagnostic biopsy in 57% and was concurrent in 43%. A glandular abnormality was identified on original diagnosis in 43% and ranged from atypical glandular cells (AGC), not otherwise specified to adenocarcinoma consistent with endometrial primary. In 4 cases, abnormal cervical cytology triggered the subsequent biopsy. Evaluation of 8 cases with accessible cytology slides revealed 2 previously unrecognized glandular abnormalities, leading to an abnormal rate of 63% among cases reviewed retrospectively and a final glandular abnormality detection rate of 57% based on either original or review diagnosis. CONCLUSIONS: In summary, abnormal glandular cells were commonly identified in endometrial cancer patients with Lynch syndrome and led to endometrial cancer work-up and diagnosis in a subset. These results suggest that cervical cytology may have utility in endometrial cancer screening in this population and indicate that awareness of the patient's familial cancer risk is important for maximizing sensitivity of this test. They also caution against primary human papillomavirus screening in the Lynch syndrome population, as this may result in missed opportunities for early endometrial carcinoma detection among these high-risk individuals.

MRI changes observed in a case of atypical scrapie in a 7-year-old Herdwick ewe.

Atypical scrapie is a transmissible spongiform encephalopathy that is rarely diagnosed in living animals. In March 2022, a 7-y-old Herdwick ewe was referred to the Scottish Centre for Production Animal Health and Food Safety because of circling behavior and ill thrift. The ewe had a low body condition score, was obtunded, with a wide-based stance of the pelvic limbs, and was circling to the left. Hematologic, biochemical, and CSF analyses were unremarkable, but postmortem magnetic resonance imaging (MRI) findings were consistent with diffuse, bilateral, and symmetrical atrophy of the forebrain and ventriculomegaly. The clinical signs, the involvement of an individual older ewe, and the MRI results led to the clinical diagnosis of scrapie. Immunohistochemistry on the fixed brain, performed by the U.K. Animal and Plant Health Agency, revealed deposits of PrPSc, which is a specific disease marker of transmissible spongiform encephalopathies, mainly in the cerebellum and at lower concentrations in the cerebrum and obex, consistent with the diagnosis of atypical scrapie. MRI findings in a sheep with atypical scrapie have not been described previously, to our knowledge. Scrapie should be included in the list of clinical differential diagnoses when veterinarians are presented with sheep with progressive neurologic signs of several weeks' duration.

When is it necessary to perform biopsy in asymptomatic postmenopausal women with incidental finding of thickened endometrium?

OBJECTIVE: To determine the cutoff value for endometrial thickness (ET) that prompts a biopsy in asymptomatic postmenopausal women with an incidental finding of thickened endometrium, and to develop a risk prediction model. METHODS: This is a retrospective cohort analysis of the clinical records of the Hysteroscopic Center of Fu Xing Hospital, Capital Medical University, Beijing, China. We collected asymptomatic postmenopausal women who presented with an ET of ≥4 mm (double-layer) as an incidental finding. We stratified the participants into non-malignant and malignant groups based on pathology results and assessed differences between the two groups. A receiver operating characteristic curve (ROC) was used to identify the cutoff value of ET for predicting endometrial malignancy. Logistic regression models were also constructed to predict the risk of malignancy. RESULTS: A total of 581 consecutive eligible cases were included. The optimal cutoff value for ET was 8 mm, with a maximum area under the curve (AUC) of 0.755 (95 % CI: 0.645-0.865). In addition to ET, the regression model incorporated diabetes, blood flow signal, BMI, and hypertension to predict the risk of malignancy. A ROC curve constructed for the model yielded an AUC of 0.834 (95 % CI: 0.744-0.924). CONCLUSION: It is reasonable to offer hysteroscopy and visually-directed endometrial biopsy for asymptomatic postmenopausal women when ET is 8 mm or above. For those with an ET between 4 and 8 mm, further decision to perform biopsy should be determined on an individual basis, considering risk factors and blood flow signals of the endometrium.