The disparity between malignancy risks within the Bethesda "atypical" category suggests that cytologic (nuclear) atypia is significantly more predictive of malignancy than architectural atypia. This supports the substratification of patients according to risk and a corresponding management approach within this category. A sonographic finding of irregular margins is also predictive for malignancy. Cancer Cytopathol 2017;125:245-256. © 2016 American Cancer Society.

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Background: Despite advances in the medical management of peptic ulcer disease, duodenal ulcer (DU) perforation remains a common surgical emergency. Most DU perforations are small and can be managed with omental patch repair. However, occasionally the surgeon may encounter a giant perforation not amenable to this. Giant DU perforations are defined as > 2cm. They are associated with high leak rates and mortality. Prognosis in elderly patients are particularly poor because of advanced age and comorbidities. Furthermore, there are no specific recommendations for their management despite a variety of repair techniques being described. Here, we aim to describe a novel technique used to treat such patients, especially those of advanced age, in our institution and to review the current literature. Case presentation: Four patients with giant DU perforation underwent emergency laparotomy and repair with our duodenojejunostomy technique at our hospital. Post-operatively, patients were monitored clinically and radiologically and discharged when well and tolerating diet. The mean age of the patients was 67 years with an equal gender distribution. The average Charlson Comorbidity Index (CCI) score was 3 (moderately severe). All presented with peritonitis and two had concomitant bleeding. There were two anterior and two posterior ulcers. One was a revision repair after a leak post laparoscopic omental patch repair for the initial perforation. In all cases, the duodenojejunostomy repair technique was used. Post-operative recovery was uneventful for all except one who developed pneumonia. In particular; there were no anastomotic leaks, intra-abdominal collections, gastric outlet obstructions or mortalities. Conclusion: Giant DU perforation remains a challenge to the general surgeon, particularly so in elderly patients with multiple comorbids. A review of the current literature suggests a myriad of surgical techniques but no perfect solution. Some suggested techniques include omental patch with pyloric exclusion, controlled tube duodenostomy, jejunal pedicled graft or serosal patch, gastric disconnection and partial gastrectomy. Here, we propose that isolated duodenojejunostomy can be a quick, safe and novel solution that ensures definitive repair of giant ulcer perforation in a single setting in the high-risk patient.

Tacrolimus is the cornerstone of immunosuppressive therapy after pediatric liver transplantation. However, reliance on the physician's experience for dose titration, coupled with tacrolimus's narrow therapeutic window and inter and intra-patient variability, often results in frequent under or over-dosing with detrimental patient outcomes. Existing predictive dose personalization models are not readily feasible for clinical implementation, as they require multiple measurements each day while the standard frequency is once daily. We developed CURATE.AI, a small-data artificial intelligence-derived platform, as a clinical decision support system to personalize doses using the patient's own data obtained once a day. Retrospective dose personalization with CURATE.AI on 16 patients' data demonstrated potential to enable patients to stay in the therapeutic range longer and reach the therapeutic range significantly earlier. Our findings support the testing of CURATE.AI in a prospective controlled trial as an aid for the physician's decision on tacrolimus dose personalization after pediatric liver transplantation.

A 48-year-old woman with a 6-month history of worsening constipation but no other red flags or family history of malignancy underwent an elective colonoscopy, which showed a rectosigmoid mass with central ulceration involving one third of the circumference ( Figure A). Narrow-band imaging (NBI) showed a type 2 lesion based on the NBI International Colorectal Endoscopic classification ( Figure B), with a vessel and surface pattern suggestive of an adenoma. The histology was an adenomatous lesion with predominant low-grade dysplasia ( Figure C). The patient underwent a laparoscopic anterior resection with primary anastomosis. Final histopathology, however, showed endometriosis. Intestinal endometriosis is known to be a great masquerader of colonic pathologies. The endometriosis lesion in this case was concealed by an overlying adenoma. Despite the use of advanced imaging techniques such as NBI, a preoperative diagnosis of colonic endometriosis remains technically challenging as shown in this case. A high index of clinical suspicion thus is needed in females of reproductive age with no red flags presenting with atypical colonic lesions.