Search Results (1,002)

Background: People who inject drugs (PWID) comprise the majority of patients with native tricuspid valve (TV) infective endocarditis (IE). Many patients require surgical repair or replacement of their TV, but some may be deemed ineligible for surgical management due to high operative risk or patient preference. Vacuum-assisted percutaneous mechanical aspiration (PMA) has emerged as a potential alternative to surgical management in this population. The objective of this study was to describe real-world patient characteristics and clinical outcomes in PWID who underwent PMA or surgical management of TV IE. Methods: We retrospectively reviewed PWID hospitalized with endocarditis at a single tertiary care center (2016–2025) who underwent an isolated PMA or surgical TV repair/replacement (TVR). Baseline demographic, clinical, microbiologic, and echocardiographic characteristics were described. Clinical outcomes were compared descriptively between groups, recognizing imbalances in treatment selection. Results: A total of 40 PWID met inclusion criteria; 17 underwent PMA and 23 underwent surgical TVR. There was substantial baseline clinical heterogeneity between the two groups. Procedural success was numerically higher with surgery than with PMA (95.7% vs. 88.2%). Clinical success, a composite of procedural success, treatment completion, and lack of need for reintervention, was numerically higher in the TVR group (73.9% vs. 52.9%). One-year mortality was similar between groups. Conclusions: In this single-center retrospective observational cohort of PWID with isolated TV IE, there was no statistical difference in composite clinical or procedural success between patients who underwent PMA or TVR. PMA may be a feasible source-control strategy for select patients not eligible for immediate surgery; however, larger prospective studies are needed to define optimal patient selection factors and comparative effectiveness. Full article

This paper extends the classical Merton structural credit risk model by incorporating dynamic refinancing risk into the measurement of bank default risk. The study addresses a key limitation of traditional structural models, which treat default as a function of asset values relative to liabilities but abstract from debt maturity structure and rollover conditions. The proposed framework integrates an issuance-based refinancing ladder, a market-consistent funding curve, and firm-level balance sheet data within a liquidity-adjusted structural model featuring an endogenous default barrier and a refinancing-adjusted distance-to-default measure. Using bank-level data (1564 daily observations, 2020–2026), the results show that, although the institution remains solvent under conventional structural measures, refinancing exposure materially compresses the effective solvency buffer. Short-term refinancing exposure averages R8.1 billion and reaches approximately R19.6 billion during stress periods; the liquidity-adjusted distance to default averages 1.47 (range 0.46–2.15) and the implied probability of default averages 9.5% (range 1.6–32.2%). A Newey–West heteroskedasticity- and autocorrelation-consistent regression that controls for asset volatility and the underlying solvency ratio confirms that the refinancing ratio has a negative and highly statistically significant partial effect on distance to default (coefficient −1.95, t = −7.41, p < 0.001, N = 1564), isolating the liquidity-adjustment channel from concurrent changes in volatility and balance sheet solvency. Stress testing further reveals nonlinear amplification of default risk when funding and refinancing shocks interact. The findings indicate that bank default risk is driven not only by leverage, but also by the interaction between asset values, liability structure, and funding conditions, with implications for credit risk modelling, stress testing, and prudential risk management. Full article

Atrial fibrillation (AF) and heart failure (HF) frequently coexist, but the clinical relevance of AF may differ according to whether it appears to be a potentially reversible contributor, an aggravating factor in established HF, or a marker of advanced substrate. The driver–modifier–marker lens used in this review is a provisional, nonvalidated aid to clinical reasoning and should not be interpreted as a treatment score. This narrative review was informed by dated searches of PubMed/MEDLINE, the Cochrane Library, and OpenAlex through 29 July 2026, followed by a targeted update on 30 July 2026. It considers HF with reduced, mildly reduced, and preserved ejection fraction together with AF timing, burden, ventricular-rate exposure, myocardial substrate, and reversibility. Early rhythm control may be particularly relevant when AF is recent or temporally associated with ventricular dysfunction, symptoms, decompensation, or inadequate cardiac resynchronization therapy delivery. Evidence supporting catheter ablation is most direct in suspected AF-mediated cardiomyopathy and selected HFrEF populations, whereas evidence in HFpEF more consistently supports symptom relief, improved exercise hemodynamics, and AF-burden reduction than mortality reduction. Pulmonary vein isolation remains the procedural foundation. Radiofrequency, cryoballoon, and pulsed-field ablation are effective in broad AF populations, but HF phenotype-specific prognostic superiority has not been established for any energy source. Clinical decisions should reflect the design and directness of the evidence together with expected benefit, rhythm durability, procedural risk, patient-reported outcomes, stroke prevention, guideline-directed HF therapy, risk-factor management, and patient preference. Full article

Background: Isolated sphenoid sinus disease (ISSD) in children is an uncommon but clinically significant condition that may present primarily with neurological or neuro-ophthalmological symptoms rather than typical sinonasal complaints. Owing to the anatomical proximity of the sphenoid sinus to the optic nerves, cavernous sinus, and multiple cranial nerves, even localized sphenoid pathology may produce symptoms that mimic primary neurological, neuro-ophthalmological, or headache disorders, contributing to diagnostic delay. Objective: To characterize the spectrum and frequency of neurological and neuro-ophthalmological manifestations, diagnostic pathways, treatment strategies, and reported clinical outcomes in pediatric ISSD, with particular emphasis on diagnostic delay and persistent neurological sequelae. Methods: A systematic review was conducted in accordance with the PRISMA 2020 guidelines. PubMed and Web of Science were searched from database inception to 3 January 2026. Observational studies reporting pediatric patients aged ≤18 years with radiologically confirmed ISSD were included. Single-patient case reports, reviews, and studies without extractable pediatric data were excluded. Owing to substantial clinical and methodological heterogeneity, findings were synthesized descriptively. Risk of bias was assessed using Joanna Briggs Institute (JBI) critical appraisal tools. Results: Eleven studies comprising 136 pediatric patients were included. Most cases were inflammatory lesions (n = 121, 89%), followed by mucoceles (n = 10, 7.3%) and tumors (n = 5, 3.7%). Headache was the most frequent neurological manifestation reported in 129 patients (94.9%). Ocular manifestations were present in 33/136 patients (24.2%), whereas otolaryngological symptoms were reported in 25/134 patients (18.7%). Cranial nerve involvement was documented in 10 out of 54 patients with available data (19%), most commonly affecting cranial nerves III, V, VI, and VII. Among 79 reported initial diagnoses, primary headache disorders were the most common (49.4%), whereas sphenoid sinusitis was correctly identified in only 20.3%. Diagnosis was established using CT and/or MRI in all included cases. Antibiotic therapy was the most common treatment for inflammatory lesions, while all patients with mucoceles and tumors underwent surgical management. Full recovery was reported in 81% of inflammatory cases and in all patients with mucoceles, although follow-up reporting was heterogeneous. Conclusions: Pediatric ISSD frequently presents with neurological and neuro-ophthalmological manifestations, whereas sinonasal symptoms may be absent or subtle. Persistent or atypical neurological symptoms, particularly headache accompanied by ocular symptoms or cranial nerve deficits, should prompt consideration of sphenoid sinus pathology and early cross-sectional imaging. Full article

Background: Population aging is driving a convergent rise in three disorders historically managed in isolation: cardiovascular disease, neurocognitive decline, and osteoporotic bone loss. Mechanistic data indicate that these systems are coupled through shared regulators of calcium trafficking, inflammation resolution, vascular integrity, and inflammaging. On this basis, a “Heart–Brain–Bone” axis has been proposed; it should be understood as an integrative conceptual framework that organizes evidence drawn from three separate studies, not as a validated physiological entity with agreed diagnostic criteria or demonstrated modifiability. Three lipid-soluble nutrients—long-chain omega-3 polyunsaturated fatty acids (EPA/DHA), vitamin D3 (cholecalciferol), and vitamin K2 (menaquinone-7 [MK-7])—act on overlapping nodes of this network. Methods: We performed a structured narrative review. PubMed/MEDLINE, Embase, the Cochrane Library, and Web of Science were searched from database inception to 25 June 2026 using predefined term blocks for each nutrient, each organ domain, and each candidate mechanism, and the search was updated on 7 August 2026. Records were screened against prespecified inclusion and exclusion criteria by two authors independently, with disagreements resolved by a third. The strength of evidence for each nutrient–organ relationship was graded with an explicitly defined four-level scheme ((−) to (+++)) applied separately to preclinical, observational, randomized and meta-analytic evidence. Results: Vitamin K2-dependent gamma-carboxylation of matrix Gla protein (MGP) and osteocalcin has been proposed to influence whether calcium is incorporated into the bone matrix or deposited in the arterial wall, offering a candidate mechanistic account of the “calcium paradox” associated with isolated vitamin D3 supplementation; EPA/DHA-derived specialized pro-resolving mediators may support resolution of endothelial and neuronal inflammation; and bone-, vascular- and brain-derived signals (osteocalcin, FGF23, the neurovascular unit) interconnect the three organs. These mechanisms are biologically plausible but remain insufficiently confirmed in humans. The clinical evidence is heterogeneous, formulation- and population-dependent, and comprises positive, neutral and null results: cardiovascular omega-3 trials are discordant (REDUCE-IT, which used icosapent ethyl [an EPA ethyl ester], positive; VITAL/STRENGTH/ASCEND null, predominantly in lower-risk or replete cohorts); cognitive trials are largely null or subgroup-dependent (MAPT, DO-HEALTH, VITAL); and MK-7 improves surrogate bone and calcification biomarkers and slowed coronary artery calcification in one recent randomized imaging trial (VitaK-CAC), whereas combined MK-7 plus vitamin D3 did not slow aortic valve or coronary calcification in AVADEC and MK-7 did not reduce bone loss in early menopausal women. Recognized safety signals include a dose-dependent increase in atrial fibrillation with high-dose omega-3, adverse skeletal effects of high-dose or bolus vitamin D, and clinically relevant interference of even low-dose MK-7 with vitamin K antagonist therapy. Conclusions: No adequately powered randomized trial has demonstrated that the combination of long-chain omega-3, vitamin D3 and MK-7 is superior to its individual components or to placebo for any clinical endpoint. The combined regimen is therefore mechanistically rational and hypothesis-generating rather than clinically established; benefit appears most plausible in individuals with elevated risk or demonstrable nutritional insufficiency, and least in replete, low-risk populations. Findings should be interpreted within a broader healthy-aging context that includes lifestyle and psychosocial factors. Adequately powered factorial randomized controlled trials stratified by baseline Omega-3 index, 25(OH)D and vitamin K status, with prespecified mechanistic biomarkers and hard endpoints, are required. Full article

Brazil presents a distinctive convergence of continental-scale climatic diversity, extensive urbanization, large-scale biomass burning, rapid land-use change, persistent air-quality monitoring gaps, and deep social inequalities, producing highly heterogeneous and compound environmental health risks. In this context, treating air pollution and climate change as parallel environmental crises obscures their structural interconnections through shared emission sources, mutually reinforcing exposure pathways, and overlapping health and social consequences. In this narrative review, we critically synthesize scientific and institutional lines of evidence and argue that air pollution and climate risks can be more effectively addressed in Brazil through a single strategic agenda for science, public health, and governance. We first discuss why these challenges cannot be managed in isolation, emphasizing the effects of heat, drought, stagnation events, biomass burning, and extreme weather on pollutant formation, dispersion, and health burden. We then examine Brazil as a critical case where recent regulatory advances coexist with structural limitations in monitoring, data integration, and territorial coverage. Based on this diagnosis, we propose an integrated national agenda organized around five mutually reinforcing priorities: monitoring through hybrid networks; predictive science through climate-informed modeling and early warning; public health through the convergence of epidemiology, toxicology, and mechanistic research; equity-oriented research and action through the explicit incorporation of vulnerability, inequality, and climate justice; and policy appraisal through the assessment of disease burden, economic costs, mitigation co-benefits, and trade-offs. We further discuss the governance mechanisms needed to connect these priorities and translate evidence into coordinated action and adaptive public policies. We also argue that the Amazon should be approached not as an isolated ecological exception but as a central component of a broader Brazilian and Global South discussion on environmental health, land-use change, and climate justice. In this scenario, Brazil has the scientific capacity and regulatory momentum to become a reference in the integrated management of air pollution and climate risks, but this will depend on replacing fragmented approaches with a coordinated framework capable of linking exposure, mechanism, burden, inequality, and action. Full article

This study presents the results of a completed nationwide, five-year official surveillance programme (2016–2020) conducted in Poland to assess microbiological hazards in retail food products. The programme combined official food control and national monitoring activities targeting major foodborne pathogens and hygiene indicators of public health relevance. Compliance with both EU microbiological criteria and national guidelines was assessed for Salmonella spp., Listeria monocytogenes, Escherichia coli (including Shiga toxin-producing E. coli), Campylobacter spp., and coagulase-positive staphylococci. The programme covered all 16 administrative regions of Poland and included 380,314 retail food samples representing major food categories. Analyses were performed in accredited laboratories using ISO standard methods. Isolates obtained from positive samples were confirmed by the National Reference Laboratory (NIPH NIH-NRI), ensuring high data reliability and consistency. The findings provide a comprehensive and nationally representative assessment of microbiological compliance in retail food over a complete five-year surveillance cycle. The dataset represents one of the largest officially generated microbiological surveillance collections of retail food in Europe, providing robust evidence for risk-based food safety management and regulatory decision-making. Food categories requiring targeted control measures were identified. Full article

Electric Vehicle Charging Systems (EVCSs) have become a critical component of the global transition toward sustainable and intelligent transportation. However, their tight integration with heterogeneous cyber–physical, vehicular, and cloud-based infrastructures exposes them to an expanding attack surface, including data poisoning, malware injection, denial-of-service, and man-in-the-middle (MITM) attacks. Existing security solutions largely rely on isolated detection mechanisms and lack a unified semantic representation of EVCS assets, attack propagation paths, and mitigation dependencies, limiting their effectiveness in complex and evolving threat scenarios. To address these challenges, this paper proposes EVCS-SecOnt, an ontology-driven cybersecurity framework for modeling, reasoning, and mitigating security threats in EVCS infrastructures. The proposed ontology formalizes relationships across four core modules, namely Attack Surface, Attack Classification, Protection Mechanisms, and Risk and Mitigation, enabling holistic threat representation and TARA-based risk assessment. EVCS-SecOnt incorporates standard semantic namespaces (em:, seas:, uiote:, sch:, and time:) to ensure interoperability and is instantiated using the CICEVSE2024 dataset to support observation-level security reasoning. A unified SPARQL-based analytical workflow is employed to perform global ontology validation, attack–risk–severity correlation, mitigation prioritization, and observation-level inference using statistical feature vectors. Experimental results demonstrate that the ontology captures multiple attack classes, risk levels, severity categories, and mitigation strategies, enabling automated identification of critical attack scenarios and context-aware defense recommendations. The validation demonstrates logical consistency, semantic traceability, and query-based coverage of the ontology across attack classes, risk levels, severity categories, and mitigation strategies. EVCS-SecOnt enhances the interpretability, reusability, and explainability of EVCS cybersecurity management by bridging operational data with semantic intelligence. The proposed framework supports adaptive protection, risk-aware decision-making, and ontology-driven security analytics, providing a semantic foundation for next-generation e-mobility and smart charging infrastructures. Full article

Understanding river channel evolution is essential for effective management, as lateral erosion shapes riverbeds, floodplains, and riparian habitats. Despite advancements in remote sensing, translating these technologies into operational tools for institutional monitoring remains a challenge. This study introduces a semi-automated framework designed to bridge this gap by quantifying lateral mobility and bank retreat rates in high-energy, gravel-bed rivers. The methodology utilizes a Random Forest classifier applied to Copernicus Sentinel-2 time series (2016–2024) across five rivers in Piedmont (Italy). By detecting pixel-level class shifts between water, vegetation, and sediment, the procedure provides a proxy for lateral mobility. Validated against 120 km of manual delineations, the model achieved high spatial accuracy for both bank retreat rates and eroded bank lengths measurements (Mean Absolute Deviation of 2.64 m/yr and 4.34%, respectively). Integrating discharge data and the hydraulic infrastructure cadaster of the Sesia River, the proposed framework effectively detects reaches prone to significant geomorphic changes, isolates their underlying drivers, simulates 10-year evolutionary trajectories, and demonstrates strong predictive capabilities regarding future channel–infrastructure interactions. This study marks a shift from sporadic, labor-intensive assessments to a dynamic, systematic monitoring framework. Leveraging free satellite data, it provides competent authorities with an objective, cost-effective tool to prioritize interventions, supporting flood risk reduction and river restoration. Full article

Cross-chain bridges represent one of the most damaging attack surfaces in decentralized finance, with major exploits (e.g., Ronin, Wormhole, Nomad, Multichain) arising not from broken signature schemes but from failures in proof verification, replay protection, and signer-set management, gaps that conventional threshold-signature multisignature wallets do not address. This study presents an incident-aware multisignature architecture combining three on-chain predicates—block-height freshness windows, epoch-bound signer sets, and Merkle inclusion-proof verification—with a non-authoritative off-chain LightGBM classifier that generates SHAP-attributed risk explanations to support governance actions such as pausing, vetoing, or rotating signers, without directly blocking or approving execution. The framework was evaluated on a simulated benchmark of 78,600 Ethereum testnet transactions containing six injected anomaly classes (gas spikes, nonce jitter, malformed call data, stale intents, proof-delivery delays, and epoch-rotation replays). The LightGBM advisor achieved ROC-AUC 0.92 (95% CI [0.906, 0.926]) and F1 0.73 ([0.712, 0.749]), outperforming five baselines—logistic regression, Random Forest, XGBoost, isolation forest, and a rule-based detector—with the highest F1 (0.731) and PR-AUC (0.799), while the rule-based detector, which by construction covers only the anomaly classes addressed by the deterministic predicates, attained F1 0.282. Differences were statistically significant except for the LightGBM–XGBoost PR-AUC comparison. The deterministic layer itself is verified through 28 property-level contract tests covering all seven modeled attack objectives, with measured per-function gas costs (execute_Intent: 118,756 gas, of which 28,432 gas is Merkle-proof verification). Within this controlled setting, the results indicate that a machine learning advisor can extend anomaly-prioritization coverage beyond the scope of the deterministic predicates while leaving execution control fully deterministic. This work is presented as a controlled proof of concept: the reported metrics quantify recovery of scripted injection patterns, and validation against real-world exploit traces remains future work. Full article

Peripheral vestibulopathy (PV) is a common disorder that causes dizziness and balance impairment, substantially affecting patients’ quality of life. When symptoms persist, they frequently lead to anxiety, depression, and an increased risk of social isolation. Although central vestibular compensation (CVC) often promotes functional recovery, current pharmacological options remain limited and are primarily aimed at symptom control. Consequently, they should be considered adjuncts rather than alternatives to rehabilitation-based strategies. Vestibular rehabilitation (VR) remains the cornerstone of treatment for promoting functional recovery in patients with PV. Based on the complementary mechanisms of adaptation, substitution, and habituation, VR enhances the central nervous system’s ability to compensate for vestibular deficits by optimizing the integration of visual, proprioceptive, and residual vestibular inputs. Robust evidence from both clinical and preclinical studies has demonstrated its efficacy in improving postural stability, dynamic balance, gaze stabilization, and overall functional performance. Experimental studies using animal models have further highlighted the critical role of active sensorimotor training in ecologically relevant environments for enhancing vestibular compensation. Pharmacological interventions may further facilitate these adaptive processes by modulating the neurobiological mechanisms underlying vestibular compensation, thereby improving responsiveness to rehabilitation. Likewise, emerging neuromodulation approaches, including galvanic vestibular stimulation, have shown promising potential to enhance neural plasticity and augment the effects of rehabilitation. Consequently, combining VR with targeted pharmacological therapies and/or vestibular stimulation techniques may provide synergistic benefits and maximize functional recovery. In conclusion, vestibular rehabilitation should remain the foundation of PV management and be integrated with pharmacological and neuromodulatory approaches within a multidisciplinary therapeutic framework. Further research is needed to optimize rehabilitation protocols, identify the biological determinants of successful vestibular compensation, and develop personalized therapeutic strategies aimed at maximizing functional recovery and improving patients’ quality of life. Full article

Beef is an excellent source of protein in the human diet; however, high production levels in the livestock industry expose meat products to a greater risk of contamination by bacteria such as Escherichia coli, a pathogen of great significance in public health due to its widespread distribution and multidrug-resistance (MDR). Therefore, the objective of this study was to analyze the phenotypic and genotypic antimicrobial resistance (AMR) in E. coli isolated from raw beef through a systematic review and meta-analysis. A total of 24 articles were selected for this study; in the phenotypic evaluation, 9356 observations were reported with a pooled prevalence ratio for AMR of 0.49. Additionally, 44 antibiotics were reported, with ampicillin (0.60), tetracycline (0.59), and sulfamethoxazole/trimethoprim (0.51) having the highest frequency of use in the evaluation of the resistance profile of E. coli. Resistant genes showed a pooled prevalence ratio of 0.42; the bla (0.33), tet (0.42) and sul (0.48) genes were particularly notable for their association with AMR in the strains. The analyzed data on MDR provides valuable information for monitoring E. coli to help in the health management of this pathogen that affects human and animal health worldwide. Full article

Traditional traffic safety analysis has long suffered from a reliance on retroactive, sparse crash logs, which mathematically struggle to capture the highly stochastic and non-linear dynamics of real-time traffic streams, rendering proactive safety prevention difficult. To bridge this gap, this study introduces an innovative, data-driven Traffic Operational Risk (TOR) assessment framework that integrates unsupervised deep learning with extreme-value statistics to achieve continuous, proactive risk monitoring. By mapping macroscopic traffic flow parameters and microscopic aggressive driving behaviors (ADBs) onto a unified spatiotemporal grid, we deploy a Variational Autoencoder (VAE) to learn the continuous latent “safe traffic manifold”. On this basis, Extreme Value Theory (EVT) is introduced to mathematically calibrate a dynamic, robust safety frontier on a unified scale (0–100), effectively suppressing sensor noise. The evaluation results demonstrate that the VAE-EVT framework robustly quantifies dynamic operational risks, effectively overcoming the linear limitations of traditional surrogate models. Furthermore, spatial frequency mapping reveals that elevated operational risks inherently cluster at geometric bottlenecks, such as merge/diverge zones and sharp curves. This spatial aggregation elucidates a typical “High Risk, Low Crash” phenomenon primarily driven by driver compensatory behaviors. Crucially, the integration of a novel multidimensional risk decoupling mechanism successfully isolates micro-behavioral volatility from macro-flow degradation. By tracing this causal progression, the framework captures the mechanistic evolution of traffic breakdowns, securing a critical 10 to 15 min proactive pre-warning window before systemic crashes or congestion materialize. Ultimately, this methodology liberates risk assessment from retroactive crash logs, providing a mathematically rigorous paradigm for precision-guided highway safety management. Full article

Given the rising global interest in Environmental, Social, and Governance (ESG), this paper investigates whether a company’s ESG news affects equity investors’ sentiment, addressing a gap in the relevant research. Interest in ESG investing has grown rapidly, yet existing research measures investor sentiment only indirectly—through market-wide proxies such as the CBOE Volatility Index, low-frequency investor surveys, or realized stock returns—measures that conflate sentiment with risk aversion and fundamentals and cannot isolate firm-specific reactions to ESG news. This study measures investor sentiment directly from investors’ own expressions: we pair firm-day ESG news-sentiment scores for all S&P 500 constituents with investor sentiment extracted from stock-related tweets using a finance-tuned RoBERTa model. Using Bayesian Ridge Regression (BRR), the study finds that ESG news significantly impacts equity investors’ sentiment. This study contributes to both academic and managerial practice by establishing the association and sensitivity of ESG news and investor sentiment in academic literature and proposing a framework for firms to practice effective sustainability management. Full article

Background: Sclerosing adenosis (SA) is a benign, proliferative breast lesion that frequently mimics malignancy on multimodality imaging. The appropriate clinical management of SA diagnosed via core needle biopsy (CNB) remains a highly debated topic in breast oncology. This study aimed to evaluate the clinical, imaging, and histopathological characteristics of CNB-diagnosed SA-spectrum lesions and to determine the rate of, and factors associated with, pathological upgrade at the time of surgical excision in a symptomatic cohort. Methods: This retrospective, single-center study evaluated 34 symptomatic female patients who received a CNB diagnosis of SA. Patients were assessed using targeted ultrasound (US, n = 34), digital mammography (n = 19), and/or dynamic contrast-enhanced breast MRI (n = 17). Based on CNB findings, lesions were classified as isolated SA, complex/accompanied SA, or atypical SA. Patients subsequently underwent either definitive surgical excision or long-term imaging surveillance. Upgrades were defined as the presence of a high-risk B3 lesion not identified on CNB (Level 1) or overt malignancy, such as ductal carcinoma in situ or invasive carcinoma (Level 2), at final surgical pathology. Results: Twenty-one patients (61.8%) underwent surgical excision, while thirteen (38.2%) were managed with radiological follow-up (median surveillance 16 months, range 7–84). Within the surgical cohort, 9 of 21 patients (42.9%; 95% CI: 24.5–63.5%) demonstrated an upgrade: 6 (28.6%; 95% CI: 13.8–50.0%) to a B3-level lesion and 3 (14.3%; 95% CI: 5.0–34.6%) to malignancy. Notably, two of the three malignant upgrades originated from lesions initially classified as isolated SA without atypia on CNB. Due to the limited sample size, no single clinical or imaging variable (BI-RADS category, lesion size, or age) reached statistical significance as an independent predictor of upgrade (all p > 0.10). All patients managed with imaging surveillance remained radiologically stable. Conclusions: In stark contrast to the 1–2% upgrade rates traditionally reported in asymptomatic screening populations, symptomatic SA-spectrum lesions selected for surgical excision following CNB exhibited a substantially higher overall upgrade rate (42.9%) and malignant upgrade rate (14.3%) in our cohort, albeit with wide confidence intervals reflecting the modest surgical subgroup size. The occurrence of malignant upgrades from presumed isolated SA underscores the limitations of CNB sampling and highlights the necessity of multimodality imaging–pathology concordance. Because this estimate derives exclusively from patients already selected for surgery on the basis of clinical and imaging suspicion, it reflects the upgrade risk of this pre-selected, imaging-discordant subgroup and should not be extrapolated to the baseline risk of all CNB-diagnosed SA. Accordingly, these findings caution against extending non-operative management without further scrutiny to symptomatic SA cases showing a similar degree of imaging–pathology discordance: in such cohorts, surgical excision or large-volume vacuum-assisted excision may still merit consideration despite the absence of atypia on CNB, although this observation is drawn from a small, non-randomly selected surgical subgroup and should be interpreted with corresponding caution. Full article