Diagnostics, Volume 14, Issue 7 (April-1 2024) – 114 articles

Objectives: To develop an opportunistic screening model based on a deep learning algorithm to detect recent vertebral fractures in abdominal or chest CTs. Materials and Methods: A total of 1309 coronal reformatted images (504 with a recent fracture from 119 patients, and 805 without fracture from 115 patients), from torso CTs, performed from September 2018 to April 2022, on patients who also had a spine MRI within two months, were included. Two readers participated in image selection and manually labeled the fractured segment on each selected image with Neuro-T (version 2.3.3; Neurocle Inc.) software. We split the images randomly into the training and internal test set (labeled: unlabeled = 480:700) and the secondary interval validation set (24:105). For the observer study, three radiologists reviewed the CT images in the external test set with and without deep learning assistance and scored the likelihood of an acute fracture in each image independently. Results: For the training and internal test sets, the AI achieved a 99.86% test accuracy, 91.22% precision, and 89.18% F1 score for detection of recent fracture. Then, in the secondary internal validation set, it achieved 99.90%, 74.93%, and 78.30%, respectively. In the observer study, with the assistance of the deep learning algorithm, a significant improvement was observed in the radiology resident’s accuracy, from 92.79% to 98.2% (p = 0.04). Conclusion: The model showed a high level of accuracy in the test set and also the internal validation set. If this algorithm is applied opportunistically to daily torso CT evaluation, it will be helpful for the early detection of fractures that require treatment. Full article

Tumid lupus erythematosus (TLE) has been the subject of heated debate regarding its correct nosographic classification. The definition of TLE has changed over time, varying according to the different studies performed. In this review, we address the initial definition of TLE, the changes that have taken place in the understanding of TLE, and its placement within the classification of cutaneous lupus erythematosus (CLE), with a focus on clinical, histopathological, immunophenotypical, and differential diagnosis aspects. Full article

Developmental dysplasia of the hip (DDH) presents varying degrees of femoral head dislocation, with severe cases leading to the formation of a new articular surface on the external side of the iliac bone—the neoacetabulum. Despite conventional understanding suggesting otherwise, a tissue resembling hyaline cartilage is found in the neoacetabulum and acetabulum of Crowe III and IV patients, indicating a potential for hyaline cartilage development without mechanical pressure. To test this theory, acetabular and femoral head cartilage obtained from patients with DDH was stained with hematoxylin–eosin and toluidine blue. The immunohistochemical analysis for collagen types II and VI and aggrecan was performed, as well as delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) analysis on a 7.0 T micro-MRI machine. The results obtained from DDH patients were compared to those of the control groups. Hyaline cartilage was found in the neoacetabulum and the acetabulum of patients with DDH. The nature of the tissue was confirmed with both the histological and the MRI analyses. The results of this study proved the presence of hyaline cartilage in patients with DDH at anatomical regions genetically predisposed to be bone tissue and at regions that are not subjected to mechanical stress. This is the first time that the neoacetabular cartilage of patients with advanced stages of DDH has been characterized in detail. Full article

Prior to the curative resection of colorectal carcinoma (CRC) or pancreatic ductal adenocarcinoma (PDAC), the exclusion of hepatic metastasis using cross-sectional imaging is mandatory. The Doppler perfusion index (DPI) of the liver is a promising method for detecting occult liver metastases, but the underlying visceral duplex sonography is critically viewed in terms of its reproducibility. The aim of this study was to investigate systematically the reproducibility of the measured variables, the calculated blood flow, and the DPI. Between February and September 2023, two examinations were performed on 80 subjects within a period of 0–30 days and at two previously defined quality levels, aligned to the German standards of the DEGUM. Correlation analyses were carried out using Pearson’s correlation coefficient (PCC) and the intraclass correlation coefficient (ICC). The diameters, blood flow, and DPI showed a high degree of agreement (PCC of 0.9 and ICC of 0.9 for AHP). Provided that a precise standard of procedure is adhered to, the Doppler examination of AHC, AHP, and PV yields very reproducible blood flows and DPI, which is a prerequisite for a comprehensive investigation of its prognostic value for the prediction of metachronous hepatic metastasis in the context of curatively treated CRC or PDAC. Full article

Soluble triggering receptor expressed on myeloid cells (sTREM-1) is a new biomarker that can be used for the diagnosis and monitoring of urinary system infections. This study aimed to evaluate the diagnostic performance of serum sTREM-1 in patients with a diagnosis of acute stone pyelonephritis (ASP). This prospective study included 46 patients with a diagnosis of ASP and a control group of 23 individuals without urinary system infection. Blood samples were taken from participants upon hospital admission, and basal serum sTREM-1 levels were analyzed using the ELISA method. Serum sTREM-1 concentrations were measured after treatment of ASP patients. Basal leukocyte counts, C-reactive protein (CRP) levels, procalcitonin (PCT), and sTREM-1 (98.6 vs. 68.4 pg/mL, p < 0.001) levels were higher in the ASP group compared to the control group. After treatment, the median leukocyte counts, PCT, and sTREM-1 levels decreased and were similar to those of the control group. The median CRP level also decreased after treatment, but it remained higher than that of the control group. In predicting patients with ASP, the baseline sTREM-1 exhibited a sensitivity of 74.6% and a specificity of 78.2%, while its diagnostic performance was lower than that of leukocyte counts, CRP, and PCT. Despite the findings that levels of sTREM-1 were higher upon hospital admission in patients with ASP and significantly decreased after treatment, the utility of sTREM-1 as a biomarker for predicting patients with ASP remains constrained when compared to established inflammatory markers. Full article

Background: The Pulmonary Embolism Severity Index (PESI) is an extensively validated prognostic score, but impact analyses of the PESI on management strategies, outcomes and health care costs are lacking. Our aim was to assess whether the adoption of the PESI for patients admitted to an internal medicine ward has the potential to safely reduce the length of hospital stay (LOS). Methods: We carried out a multicenter randomized controlled trial, enrolling consecutive adult outpatients diagnosed with acute PE and admitted to an internal medicine ward. Within 48 h after diagnosis, the treating physicians were randomized, for every patient, to calculate and report the PESI in the clinical record form on top of the standard of care (experimental arm) or to continue routine clinical practice (standard of care). The ClinicalTrials.gov identifier is NCT03002467. Results: This study was prematurely stopped due to slow recruitment. A total of 118 patients were enrolled at six internal medicine units from 2016 to 2019. The treating physicians were randomized to the use of the PESI for 59 patients or to the standard of care for 59 patients. No difference in the median LOS was found between the experimental arm (8, IQR 6–12) and the standard-of-care arm (8, IQR 6–12) (p = 0.63). A pre-specified secondary analysis showed that the LOS was significantly shorter among the patients who were treated with DOACs (median of 8 days, IQR 5–11) compared to VKAs or heparin (median of 9 days, IQR 7–12) (p = 0.04). Conclusions: The formal calculation of the PESI in the patients already admitted to internal medicine units did not impact the length of hospital stay. Full article

Advancing medical technology revolutionizes our ability to diagnose various disease processes. Conventional Single-Energy Computed Tomography (SECT) has multiple inherent limitations for providing definite diagnoses in certain clinical contexts. Dual-Energy Computed Tomography (DECT) has been in use since 2006 and has constantly evolved providing various applications to assist radiologists in reaching certain diagnoses SECT is rather unable to identify. DECT may also complement the role of SECT by supporting radiologists to confidently make diagnoses in certain clinically challenging scenarios. In this review article, we briefly describe the principles of X-ray attenuation. We detail principles for DECT and describe multiple systems associated with this technology. We describe various DECT techniques and algorithms including virtual monoenergetic imaging (VMI), virtual non-contrast (VNC) imaging, Iodine quantification techniques including Iodine overlay map (IOM), and two- and three-material decomposition algorithms that can be utilized to demonstrate a multitude of pathologies. Lastly, we provide our readers commentary on examples pertaining to the practical implementation of DECT’s diverse techniques in the Gastrointestinal, Genitourinary, Biliary, Musculoskeletal, and Neuroradiology systems. Full article

Background: Each year, millions of Americans develop truncal pressure ulcers (PUs) which can persist for months, years, or until the end of life. Despite the negative impact on quality of life and escalating costs associated with PUs, there is sparse evidence supporting validated and efficacious treatment options. As a result, treatment is based on opinion and extrapolation from other wound etiologies. The ideal reconstructive plan maximizes the patient’s nutritional status, incorporates the basic tenets of wound bed preparation (debridement, offloading, proper moisture balance, reduction of bacterial burden), and employs diagnostics to guide therapeutic intervention. The use of combination therapies can potentially overcome several of the barriers to wound healing. Negative pressure wound therapy (NPWT), a commonly used modality in the management of PUs, facilitates healing by stimulating the formation of granulation tissue and promoting wound contraction; however, NPWT alone is not always effective. Clinical studies examining microbial bioburden in PUs determined that most ulcers contain bacteria at levels that impede wound healing (>10⁴ CFU/g). Objective: Thus, we hypothesized that adding an anti-microbial agent to decrease both planktonic and biofilm bacteria in the wound would increase the efficacy of NPWT. Method: In this prospective study, twenty patients with recalcitrant PUs that previously failed NPWT were treated with a biofilm-disrupting agent (Blast-X, Next Science, Jacksonville, FL, USA) in combination with NPWT. Fluorescence imaging was used to follow bacterial burden and guide therapy. Results: In total, 45% of the PUs reduced in size over the course of the four-week study, with a resolution of bacterial fluorescence in the NPWT dressing and wound bed seen in an average of three weeks. Conclusion: The combination of an antibiofilm agent and NPWT reduced bacterial levels and improved wound healing in recalcitrant PUs. Full article

Open-source artificial intelligence models (OSAIM) find free applications in various industries, including information technology and medicine. Their clinical potential, especially in supporting diagnosis and therapy, is the subject of increasingly intensive research. Due to the growing interest in artificial intelligence (AI) for diagnostic purposes, we conducted a study evaluating the capabilities of AI models, including ChatGPT and Microsoft Bing, in the diagnosis of single-curve scoliosis based on posturographic radiological images. Two independent neurosurgeons assessed the degree of spinal deformation, selecting 23 cases of severe single-curve scoliosis. Each posturographic image was separately implemented onto each of the mentioned platforms using a set of formulated questions, starting from ‘What do you see in the image?’ and ending with a request to determine the Cobb angle. In the responses, we focused on how these AI models identify and interpret spinal deformations and how accurately they recognize the direction and type of scoliosis as well as vertebral rotation. The Intraclass Correlation Coefficient (ICC) with a ‘two-way’ model was used to assess the consistency of Cobb angle measurements, and its confidence intervals were determined using the F test. Differences in Cobb angle measurements between human assessments and the AI ChatGPT model were analyzed using metrics such as RMSEA, MSE, MPE, MAE, RMSLE, and MAPE, allowing for a comprehensive assessment of AI model performance from various statistical perspectives. The ChatGPT model achieved 100% effectiveness in detecting scoliosis in X-ray images, while the Bing model did not detect any scoliosis. However, ChatGPT had limited effectiveness (43.5%) in assessing Cobb angles, showing significant inaccuracy and discrepancy compared to human assessments. This model also had limited accuracy in determining the direction of spinal curvature, classifying the type of scoliosis, and detecting vertebral rotation. Overall, although ChatGPT demonstrated potential in detecting scoliosis, its abilities in assessing Cobb angles and other parameters were limited and inconsistent with expert assessments. These results underscore the need for comprehensive improvement of AI algorithms, including broader training with diverse X-ray images and advanced image processing techniques, before they can be considered as auxiliary in diagnosing scoliosis by specialists. Full article

Colorectal cancer is a leading cause of cancer-related death. Liver metastases will develop in over one-third of patients with colorectal cancer and are a major cause of morbidity and mortality. Even though surgical resection has been considered the mainstay of treatment, only approximately 20% of the patients are surgical candidates. Liver-directed locoregional therapies such as thermal ablation, Yttrium-90 transarterial radioembolization, and stereotactic body radiation therapy are pivotal in managing colorectal liver metastatic disease. Comprehensive pre- and post-intervention imaging, encompassing both anatomic and metabolic assessments, is invaluable for precise treatment planning, staging, treatment response assessment, and the prompt identification of local or distant tumor progression. This review outlines the value of imaging for colorectal liver metastatic disease and offers insights into imaging follow-up after locoregional liver-directed therapy. Full article

Background: Ambulatory risk stratification for worsening heart failure (HF) using diagnostics measured by insertable cardiac monitors (ICM) may depend on the left ventricular ejection fraction (LVEF). We evaluated risk stratification performance in patients with reduced versus preserved LVEF. Methods: ICM patients with a history of HF events (HFEs) were included from the Optum^® de-identified Electronic Health Record dataset merged with ICM device-collected data during 2007–2021. ICM measures nighttime heart rate (NHR), heart rate variability (HRV), atrial fibrillation (AF) burden, rate during AF, and activity duration (ACT) daily. Each diagnostic was categorized into high, medium, or low risk using previously defined features. HFEs were HF-related inpatient, observation unit, or emergency department stays with IV diuresis administration. Patients were divided into two cohorts: LVEF ≤ 40% and LVEF > 40%. A marginal Cox proportional hazards model compared HFEs for different risk groups. Results: A total of 1020 ICM patients with 18,383 follow-up months and 301 months with HFEs (1.6%) were included. Monthly evaluations with a high risk were 2.3, 4.2, 5.0, and 4.5 times (p < 0.001 for all) more likely to have HFEs in the next 30 days compared to those with a low risk for AF, ACT, NHR, and HRV, respectively. HFE rates were higher for patients with LVEF > 40% compared to LVEF ≤ 40% (2.0% vs. 1.3%), and the relative risk between high-risk and low-risk for each diagnostic parameter was higher for patients with LVEF ≤ 40%. Conclusions: Diagnostics measured by ICM identified patients at risk for impending HFEs. Patients with preserved LVEF showed a higher absolute risk, and the relative risk between risk groups was higher in patients with reduced LVEF. Full article

Background: Age-related macular degeneration (AMD) is a multifactorial disease encompassing a complex interaction between aging, environmental risk factors, and genetic susceptibility. The study aimed to determine whether there is a relationship between the polygenic risk score (PRS) in patients with AMD and the characteristics of the retinal vascular network visualized by optical coherence tomography angiography (OCTA). Methods: 235 patients with AMD and 97 healthy controls were included. We used data from a previous AMD PRS study with the same group. The vascular features from different retina layers were compared between the control group and the patients with AMD. The association between features and PRS was then analyzed using univariate and multivariate approaches. Results: Significant differences between the control group and AMD patients were found in the vessel diameter distribution (variance: p = 0.0193, skewness: p = 0.0457) and fractal dimension distribution (mean: p = 0.0024, variance: p = 0.0123). Both univariate and multivariate analyses showed no direct and significant association between the characteristics of the vascular network and AMD PRS. Conclusions: The vascular features of the retina do not constitute a biomarker of the risk of AMD. We have not identified a genotype–phenotype relationship, and the expression of AMD-related genes is perhaps not associated with the characteristics of the retinal vascular network. Full article

Turner Syndrome (TS) is a rare genetic disorder that affects females when one of the X chromosomes is partially or completely missing. Due to high genetic and phenotypic variability, TS diagnosis is challenging and is often delayed until adolescence, resulting in poor clinical management. Numerous oral, dental and craniofacial anomalies have been associated with TS, yet a comprehensive description is still lacking. This study addresses this gap through a detailed analysis of oral health and craniofacial characteristics in a cohort of 15 females with TS and their first-degree relatives. Subjects with TS ranged from 3 to 48 years old, none showed evidence of periodontal disease and only the youngest was in mixed dentition. Using the Multifunction System, we identified an aggregation of multiple signs and symptoms in each TS subject, including tooth anomalies (supernumerary molars, agenesis, microdontia, enamel defects, alterations in eruption patterns -advanced and delayed for chronological age-, crowding, rotations and transpositions), malocclusion (class II/1 and II/2) and Class II facial profile, while relatives exhibited fewer manifestations. The early detection of these signs and symptoms is crucial for appropriate referral and the optimal clinical management of TS, especially during the critical period of 9 to 10 years when congenital dental anomalies appear. The use of an established taxonomy to describe these phenotypic features is essential for early detection. Multidisciplinary teams are required to ensure holistic care management in rare diseases like TS. Full article

The Retinal Pigment Epithelium (RPE) plays a prominent role in diseases such as age-related macular degeneration, but imaging individual RPE cells is challenging due to their high absorption and low autofluorescence emission. The RPE lies beneath the highly reflective photoreceptor layer (PR) and contains absorptive pigments, preventing direct backscattered light detection when the PR layer is intact. Here, we used near-infrared autofluorescence adaptive optics scanning laser ophthalmoscopy (NIRAF AOSLO) and transscleral flood imaging (TFI) in the same healthy eyes to cross-validate these approaches. Both methods revealed a consistent RPE mosaic pattern and appeared to reflect a distribution of fluorophores consistent with findings from histological studies. Interestingly, even in apparently healthy RPE, we observed dynamic changes over months, suggesting ongoing cellular activity or alterations in fluorophore distribution. These findings emphasize the value of NIRAF AOSLO and TFI in understanding RPE morphology and dynamics. Full article

Introduction: Point-of-care ultrasound has become a universal practice, employed by physicians across various disciplines, contributing to diagnostic processes and decision-making. Aim: To assess the association of reduced (<50%) left-ventricular ejection fraction (LVEF) based on prospective point-of-care ultrasound operated by medical students using an artificial intelligence (AI) tool and 1-year primary composite outcome, including mortality and readmission for cardiovascular-related causes. Methods: Eight trained medical students used a hand-held ultrasound device (HUD) equipped with an AI-based tool for automatic evaluation of the LVEF of non-selected patients hospitalized in a cardiology department from March 2019 through March 2020. Results: The study included 82 patients (72 males aged 58.5 ± 16.8 years), of whom 34 (41.5%) were diagnosed with AI-based reduced LVEF. The rates of the composite outcome were higher among patients with reduced systolic function compared to those with preserved LVEF (41.2% vs. 16.7%, p = 0.014). Adjusting for pertinent variables, reduced LVEF independently predicted the composite outcome (HR 2.717, 95% CI 1.083–6.817, p = 0.033). As compared to those with LVEF ≥ 50%, patients with reduced LVEF had a longer length of stay and higher rates of the secondary composite outcome, including in-hospital death, advanced ventilatory support, shock, and acute decompensated heart failure. Conclusion: AI-based assessment of reduced systolic function in the hands of medical students, independently predicted 1-year mortality and cardiovascular-related readmission and was associated with unfavorable in-hospital outcomes. AI utilization by novice users may be an important tool for risk stratification for hospitalized patients. Full article

Introduction: Periapical lesions of teeth are typically evaluated using periapical X-rays (PA) or cone-beam computer tomography (CBCT); however, ultrasound imaging (US) can also be used to detect bone defects. A comparative analysis is necessary to establish the diagnostic accuracy of US for the detection of periapical lesions in comparison with PA and CBCT. Objectives: This study aimed to evaluate and compare the measurement precision of US against PA and CBCT in detecting periapical lesions. Methods: This study included 43 maxillary and mandibular teeth with periapical lesions. All teeth were examined clinically, radiographically, and ultrasonographically. Observers evaluated and measured the periapical lesions on CBCT, PA, and US images. Results: The comparison of lesion size showed that it differs significantly between the different methods of examination. A statistically significant difference was found between CBCT and US (mean difference = 0.99 mm, 95% CI [0.43–1.55]), as well as between CBCT and PA (mean difference = 0.61 mm, 95% CI [0.17–1.05]). No difference was found between the US and PA methods (p = 0.193). Conclusion: US cannot replace PA radiography in detecting pathologies but it can accurately measure and characterize periapical lesions with minimal radiation exposure. CBCT is the most precise and radiation-intensive method so it should only be used for complex cases. Full article

Bone metastasis has been reported in up to 70% of patients with advanced breast cancer. A total of 55.76% of skeletal metastases in women were derived from breast cancer. However, patients with bone metastasis from an occult primary breast cancer are a rare subset of patients. Here, we present the case of a 38-year-old woman who had sternum pain for 4 months. A whole-body PET-CT scan revealed that the FDG uptake of both the sternum and internal mammary node was significantly increased. The final diagnosis of occult breast cancer was established by immunohistochemical (IHC) staining, which is of great significance for identifying the origin of a metastatic tumor despite no visualized lesions of mammary glands. Full article

The imagistic evaluation of non-neovascular age-related macular degeneration (AMD) is crucial for diagnosis, monitoring progression, and guiding management of the disease. Dry AMD, characterized primarily by the presence of drusen and retinal pigment epithelium atrophy, requires detailed visualization of the retinal structure to assess its severity and progression. Several imaging modalities are pivotal in the evaluation of non-neovascular AMD, including optical coherence tomography, fundus autofluorescence, or color fundus photography. In the context of emerging therapies for geographic atrophy, like pegcetacoplan, it is critical to establish the baseline status of the disease, monitor the development and expansion of geographic atrophy, and to evaluate the retina’s response to potential treatments in clinical trials. The present review, while initially providing a comprehensive description of the pathophysiology involved in AMD, aims to offer an overview of the imaging modalities employed in the evaluation of non-neovascular AMD. Special emphasis is placed on the assessment of progression biomarkers as discerned through optical coherence tomography. As the landscape of AMD treatment continues to evolve, advanced imaging techniques will remain at the forefront, enabling clinicians to offer the most effective and tailored treatments to their patients. Full article

Cystic fibrosis (CF) is a chronic and potentially life-threatening condition, wherein timely diagnosis assumes paramount significance for the prompt initiation of therapeutic interventions, thereby ameliorating pulmonary function, addressing nutritional deficits, averting complications, mitigating morbidity, and ultimately enhancing the quality of life and extending longevity. This review aims to amalgamate existing knowledge to provide a comprehensive appraisal of contemporary diagnostic modalities pertinent to CF in the 21st century. Deliberations encompass discrete delineations of each diagnostic modality and the elucidation of potential diagnostic quandaries encountered in select instances, as well as the delineation of genotype–phenotype correlations germane to genetic counseling endeavors. The synthesis underscores that, notwithstanding the availability and strides in diagnostic methodologies, including genetic assays, the sweat test (ST) retains its position as the preeminent diagnostic standard for CF, serving as a robust surrogate for CFTR functionality. Prospective clinical investigations in the realm of CF should be orchestrated with the objective of discerning novel diagnostic modalities endowed with heightened specificity and sensitivity. Full article

Background: The triglyceride–glucose index (TyG) and a combination of body mass index (BMI) and waist circumference (WC) have been proposed as predictive scores for liver steatosis (LS). The aim of this study was to determine the diagnostic accuracy of these indices compared with controlled attenuation parameters (CAPs) and other predictive scores of LS. Methods: A retrospective analysis of patients who attended a check-up unit in 2021 was performed. LS was determined by CAP. Anthropometric and biochemical parameters for calculating TyG, TyG-BMI, TyG-WC, fatty liver index, and hepatic steatosis index were obtained. ROC curve was used to establish the best cut-off point of each TyG index for LS detection. The accuracy was determined for all patients, as well as for overweight and diabetic patients. Results: Medical records of 855 patients with a median age of 48 [IQR, 44–54] years and a BMI of 25.7 [IQR 23.4–28.1] kg/m² were included. According to CAP, LS prevalence was 31.8% (n = 272). TyG-BMI and TyG-WC show better AUCs compared with CAP (0.82, 0.81), FLI (0.96, both), and HSI (0.93, 0.85). For diabetic patients, TyG-WC shows an AUC of 0.70. Meanwhile, TyG-BMI shows better accuracy (0.75) compared with CAP. Conclusions: TyG-BMI and TyG-WC showed a superior predictive accuracy for detecting LS compared with the TyG index. Full article

This case report presents a unique instance of small bowel perforation caused by solitary metastasis from renal cell carcinoma (RCC), a rare and complex clinical scenario. The patient, a 59-year-old male with a history of RCC treated with nephrectomy four years prior, presented with acute abdomen symptoms. Emergency diagnostic procedures identified a significant lesion in the small intestine. Surgical intervention revealed a perforated jejunal segment due to metastatic RCC. Postoperatively, the patient developed complications, including pneumonia and multi-organ failure, leading to death 10 days after surgery. Histopathological analysis confirmed the metastatic nature of the lesion. This case underscores the unpredictable nature of RCC metastasis and highlights the need for vigilance in post-nephrectomy patients. The rarity of small bowel involvement by RCC metastasis, particularly presenting as perforation, makes this case a significant contribution to medical literature, emphasizing the challenges in the diagnosis and management of such atypical presentations. Full article

In forensic medicine, myocarditis is a complicated topic in the context of sudden death and medical malpractice. A good knowledge of the etiopathology, histopathology, and available literature are both indispensable and essential for the correct management and evaluation of the causal link. Some agents, which are rarely lethal for humans, are not necessarily related to death from myocarditis, even if an infection in other organs such as the gastrointestinal tract is documented. The diagnosis of the causes of death is often difficult and confusing. In some cases, the hypothetical diagnosis of myocarditis as the cause of death is formulated by deduction, causing error and misleading the correct temporal evaluation of pathological events. We reviewed the literature realizing that histomorphological data are scarce and often poorly documented. Only after COVID-19 have the histomorphological aspects of myocarditis been better documented. This is due to poor autopsy practice and poor accuracy in identifying the specific histotype of myocarditis with identification of the responsible agent. We believe that four points are essential for a better understanding and complete diagnosis of the disease: (1) clinical classification of myocarditis; (2) etiological classification of myocarditis; (3) pathophysiology of viral and bacterial infections with host response; and (4) histopathological diagnosis with precise identification of the histotype and pathogen. In the review we provide histological images from authoritative scientific references with the aim of providing useful information and food for thought to readers. Full article

Intestinal ultrasound is a non-invasive, safe, and cost-effective technique to study the small and large intestines. In addition to conventional B-mode and color doppler imaging, new US tools have been developed in more recent years that provide auxiliary data on many GI conditions, improving the diagnosis and assessment of relevant outcomes. We have reviewed the more recent literature (from 2010 onwards) on auxiliary tools in bowel ultrasound such as elastography techniques, CEUS, SICUS, and the potential contribution by artificial intelligence (AI) to overcome current intestinal ultrasound limitations. For this scoping review, we performed an extensive literature search on PubMed and EMBASE to identify studies published until December 2023 and investigating the application of elastography techniques, CEUS, SICUS, and AI in the ultrasonographic assessment of the small and large intestines. Multiparametric intestinal ultrasound shows promising capabilities in Crohn’s disease, while less is known about the role in ulcerative colitis. Despite some evidence, the CEUS role as a point-of-care examination tool for rare conditions such as intestinal GvHD and ischemic small bowel disease seems promising, possibly avoiding the need to perform further cross-sectional imaging. The use of AI in intestinal ultrasound is still anecdotical and limited to acute appendicitis. Full article

(1) Background: Transsphenoidal pituitary surgery can be conducted via microscopic or endoscopic approaches, and there has been a growing preference for the latter in recent years. However, the occurrence of rare complications such as postoperative sinusitis remains inadequately documented in the existing literature. (2) Methods: To address this gap, we conducted a comprehensive retrospective analysis of medical records spanning from 2018 to 2023, focusing on patients who underwent transsphenoidal surgery for pituitary neuroendocrine tumors (formerly called pituitary adenoma). Our study encompassed detailed evaluations of pituitary function and MRI imaging pre- and postsurgery, supplemented by transnasal endoscopic follow-up assessments at the otolaryngology outpatient department. Risk factors for sinusitis were compared using univariate and multivariate logistic regression analyses. (3) Results: Out of the 203 patients included in our analysis, a subset of 17 individuals developed isolated sphenoid sinusitis within three months postoperation. Further scrutiny of the data revealed significant associations between certain factors and the occurrence of postoperative sphenoid sinusitis. Specifically, the classification of the primary tumor emerged as a notable risk factor, with patients exhibiting nonfunctioning pituitary neuroendocrine tumors with 3.71 times the odds of developing sinusitis compared to other tumor types. Additionally, postoperative cortisol levels demonstrated a significant inverse relationship, with lower cortisol levels correlating with an increased risk of sphenoid sinusitis postsurgery. (4) Conclusions: In conclusion, our findings underscore the importance of considering tumor classification and postoperative cortisol levels as potential predictors of postoperative sinusitis in patients undergoing transsphenoidal endoscopic pituitary surgery. These insights offer valuable guidance for clinicians in identifying at-risk individuals and implementing tailored preventive and management strategies to mitigate the occurrence and impact of sinusitis complications in this patient population. Full article

Deep gluteal syndrome (DGS) is caused by sciatic nerve entrapment. Because fascial entrapment neuropathies may occur in multiple locations, ultrasound-guided nerve hydrodissection is a key component of DGS treatment. In this study, we examined the clinical outcomes of patients with DGS undergoing ultrasound-guided sciatic nerve hydrodissection. A 10 mL mixture consisting of 5% dextrose, 0.2% lidocaine (Xylocaine), and 4 mg betamethasone (Rinderon) was used for nerve hydrodissection. Clinical outcomes were evaluated using Numeric Rating Scale (NRS) scores of pain, the proportion of patients with favorable outcomes (reduction of ≥50% in pain), the duration for which patients exhibited favorable outcomes (percentage of follow-up duration), and the occurrence of major complications and minor side effects. A total of 53 patients were consecutively included and followed up for 3 to 19 months. After the initial injection, the NRS scores significantly improved at 1 week, 1 month, 3 months, and the final follow-up. Specifically, 73.6%, 71.7%, 64.2%, and 62.3% of the patients exhibited favorable outcomes at 1 week, 1 month, 3 months, and the final follow-up, respectively. The median duration for which the patients exhibited favorable outcomes was 84.7% of the follow-up period. Three patients (5.7%) experienced transient dizziness and vomiting, which resolved without further treatment. No vessel or nerve puncture was observed. Overall, ultrasound-guided sciatic nerve hydrodissection is a safe procedure that mitigates the pain associated with DGS. To achieve favorable outcomes, three consecutive injections 3 weeks apart are required. Full article

Introduction: To evaluate the clinical usefulness of demographic data, fetal imaging findings and urinary analytes were used for predicting poor postnatal renal function in children with congenital megacystis. Materials and methods: A systematic review was conducted in MEDLINE’s electronic database from inception to December 2023 using various combinations of keywords such as “luto” [All Fields] OR “lower urinary tract obstruction” [All Fields] OR “urethral valves” [All Fields] OR “megacystis” [All Fields] OR “urethral atresia” [All Fields] OR “megalourethra” [All Fields] AND “prenatal ultrasound” [All Fields] OR “maternal ultrasound” [All Fields] OR “ob-stetric ultrasound” [All Fields] OR “anhydramnios” [All Fields] OR “oligohydramnios” [All Fields] OR “renal echogenicity” [All Fields] OR “biomarkers” [All Fields] OR “fetal urine” [All Fields] OR “amniotic fluid” [All Fields] OR “beta2 microglobulin” [All Fields] OR “osmolarity” [All Fields] OR “proteome” [All Fields] AND “outcomes” [All Fields] OR “prognosis” [All Fields] OR “staging” [All Fields] OR “prognostic factors” [All Fields] OR “predictors” [All Fields] OR “renal function” [All Fields] OR “kidney function” [All Fields] OR “renal failure” [All Fields]. Two reviewers independently selected the articles in which the accuracy of prenatal imaging findings and fetal urinary analytes were evaluated to predict postnatal renal function. Results: Out of the 727 articles analyzed, 20 met the selection criteria, including 1049 fetuses. Regarding fetal imaging findings, the predictive value of the amniotic fluid was investigated by 15 articles, the renal appearance by 11, bladder findings by 4, and ureteral dilatation by 2. The postnatal renal function showed a statistically significant relationship with the occurrence of oligo- or anhydramnion in four studies, with an abnormal echogenic/cystic renal cortical appearance in three studies. Single articles proved the statistical prognostic value of the amniotic fluid index, the renal parenchymal area, the apparent diffusion coefficient (ADC) measured on fetal diffusion-weighted MRI, and the lower urinary tract obstruction (LUTO) stage (based on bladder volume at referral and gestational age at the appearance of oligo- or anhydramnios). Regarding the predictive value of fetal urinary analytes, sodium and β2-microglobulin were the two most common urinary analytes investigated (n = 10 articles), followed by calcium (n = 6), chloride (n = 5), urinary osmolarity (n = 4), and total protein (n = 3). Phosphorus, glucose, creatinine, and urea were analyzed by two articles, and ammonium, potassium, N-Acetyl-l3-D-glucosaminidase, and microalbumin were investigated by one article. The majority of the studies (n = 8) failed to prove the prognostic value of fetal urinary analytes. However, two studies showed that a favorable urinary biochemistry profile (made up of sodium < 100 mg/dL; calcium < 8 mg/dL; osmolality < 200 mOsm/L; β2-microglobulin < 4 mg/L; total protein < 20 mg/dL) could predict good postnatal renal outcomes with statistical significance and urinary levels of β2-microglobulin were significantly higher in fetuses that developed an impaired renal function in childhood (10.9 ± 5.0 mg/L vs. 1.3 ± 0.2 mg/L, p-value < 0.05). Conclusions: Several demographic data, fetal imaging parameters, and urinary analytes have been shown to play a role in reliably triaging fetuses with megacystis for the risk of adverse postnatal renal outcomes. We believe that this systematic review can help clinicians for counseling parents on the prognoses of their infants and identifying the selected cases eligible for antenatal intervention. Full article

The facet joint injection is the most common procedure used to release lower back pain. In this paper, we proposed a deep learning method for detecting and segmenting facet joints in ultrasound images based on convolutional neural networks (CNNs) and enhanced data annotation. In the enhanced data annotation, a facet joint was considered as the first target and the ventral complex as the second target to improve the capability of CNNs in recognizing the facet joint. A total of 300 cases of patients undergoing pain treatment were included. The ultrasound images were captured and labeled by two professional anesthesiologists, and then augmented to train a deep learning model based on the Mask Region-based CNN (Mask R-CNN). The performance of the deep learning model was evaluated using the average precision (AP) on the testing sets. The data augmentation and data annotation methods were found to improve the AP. The AP50 for facet joint detection and segmentation was 90.4% and 85.0%, respectively, demonstrating the satisfying performance of the deep learning model. We presented a deep learning method for facet joint detection and segmentation in ultrasound images based on enhanced data annotation and the Mask R-CNN. The feasibility and potential of deep learning techniques in facet joint ultrasound image analysis have been demonstrated. Full article

To obtain a quantitative parameter for the measurement of choroidal vascular hyperpermeability (CVH) on ultra-widefield indocyanine green angiography (UWICGA) using an objective analysis method in macular choroidal neovascularization (CNV). A total of 113 UWICGA images from 113 subjects were obtained, including with 25 neovascular age-related macular degeneration (nAMD), 37 with polypoidal choroidal vasculopathy (PCV) (19 with thin-choroid and 18 with thick-choroid), 33 with pachychoroid neovasculopathy (PNV), and 18 age-matched controls. CVH was quantified on a gray image by the subtraction of 2 synchronized UWICGA images of early and late phases. The measured CVH parameter was compared with human graders and among CNV subtypes and correlated with choroidal vascular density (CVD) and subfoveal choroidal thickness (SFCT). The mean CVH values were 28.58 ± 4.97, 33.36 ± 8.40, 33.61 ± 11.50, 42.19 ± 13.25, and 43.59 ± 7.86 in controls and patients with nAMD, thin-choroid PCV, thick-choroid PCV, and PNV, respectively (p < 0.001). CVH was higher in thick-choroid PCV and PNV compared to the other groups (all p ≤ 0.006). The measured CVH value positively correlated with those reported by human graders (p < 0.001), CVD, and SFCT (p = 0.001 and p < 0.001, respectively). CVH can be measured objectively using quantitative UWICGA analysis. The CVH parameter differs among macular CNV subtypes and correlates with CVD and SFCT. Full article

A crucial challenge in critical settings like medical diagnosis is making deep learning models used in decision-making systems interpretable. Efforts in Explainable Artificial Intelligence (XAI) are underway to address this challenge. Yet, many XAI methods are evaluated on broad classifiers and fail to address complex, real-world issues, such as medical diagnosis. In our study, we focus on enhancing user trust and confidence in automated AI decision-making systems, particularly for diagnosing skin lesions, by tailoring an XAI method to explain an AI model’s ability to identify various skin lesion types. We generate explanations using synthetic images of skin lesions as examples and counterexamples, offering a method for practitioners to pinpoint the critical features influencing the classification outcome. A validation survey involving domain experts, novices, and laypersons has demonstrated that explanations increase trust and confidence in the automated decision system. Furthermore, our exploration of the model’s latent space reveals clear separations among the most common skin lesion classes, a distinction that likely arises from the unique characteristics of each class and could assist in correcting frequent misdiagnoses by human professionals. Full article

The advent of rapid molecular microbiology testing has revolutionized infectious disease diagnostics and is now impacting pneumonia diagnosis and management. Molecular platforms offer highly multiplexed assays for diverse viral and bacterial detection, alongside antimicrobial resistance markers, providing the potential to significantly shape patient care. Despite the superiority in sensitivity and speed, debates continue regarding the clinical role of multiplex molecular testing, notably in comparison to standard methods and distinguishing colonization from infection. Recent guidelines endorse molecular pneumonia panels for enhanced sensitivity and rapidity, but implementation requires addressing methodological differences and ensuring clinical relevance. Diagnostic stewardship should be leveraged to optimize pneumonia testing, emphasizing pre- and post-analytical strategies. Collaboration between clinical microbiologists and bedside providers is essential in developing implementation strategies to maximize the clinical utility of multiplex molecular diagnostics in pneumonia. This narrative review explores these multifaceted issues, examining the current evidence on the clinical performance of multiplex molecular assays in pneumonia, and reflects on lessons learned from previous microbiological advances. Additionally, given the complexity of pneumonia and the sensitivity of molecular diagnostics, diagnostic stewardship is discussed within the context of current literature, including implementation strategies that consider pre-analytical and post-analytical modifications to optimize the clinical utility of advanced technologies like multiplex PCR. Full article