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Background More accurate diagnosis of mucinous cysts will reduce the risk of unnecessary pancreatic surgery. Carcinoembryonic antigen (CEA) and glucose in pancreatic cyst fluid (PCF) can differentiate mucinous from non-mucinous pancreatic cystic neoplasms (PCN). The current study assessed the value of combined CEA and glucose testing in PCF. Methods Cross-sectional validation study including prospectively collected PCF from patients undergoing endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) and pancreatic surgery. We performed laboratory measurements for CEA and glucose and measured glucose levels by a hand glucometer. Primary outcome was diagnostic accuracy evaluated by receiver operator curves (ROC), sensitivity, specificity, positive, and negative predictive value (PPV, NPV). Results Overall, PCF was collected from 63 patients, including 33 (52%) with mucinous and 30 (48%) with non-mucinous PCN. Histopathology (n = 36; 57%), cytopathology (n = 2; 3%), or clinical and/or radiological diagnosis (n = 25; 40%) was used as reference standard. Combined CEA (cut-off ≥ 192 ng/ml) and laboratory glucose testing (cut-off ≤ 50 mg/dL) reached 92% specificity and 48% sensitivity, whereas either positive CEA (cut-off ≥ 20 ng/ml) or glucose testing (cut-off ≤ 50 mg/dL) showed 97% sensitivity and 50% specificity. Sensitivity and specificity were 80% and 68% for CEA ≥ 20 ng/mL versus 50% and 93% for CEA ≥ 192 ng/mL (the conventional cut-off level). Laboratory and glucometer glucose both reached 100% sensitivity and 60% and 45% specificity, respectively. None of the biomarkers and cut-offs reached a PPV exceeding 90%, whereas both glucose measurements had a NPV of 100% (i.e., high glucose excludes a mucinous cyst). Conclusion Combined CEA and glucose testing in PCF reached high specificity and sensitivity for differentiating mucinous from non-mucinous PCN. Glucose testing, whether alone or combined with the new CEA cut-off (≥ 20 ng/mL), reached > 95% sensitivity for mucinous cysts, whereas only glucose reached a NPV > 95%. Graphical abstract

Pancreatobiliary diseases compromise a heterogeneous group of lesions, ranging from benign to malignant entities. The aim of this thesis is to improve diagnosis and management in these patients, with a specific focus on pancreatic cystic neoplasms (PCN). This thesis therefore describes the results of an international study on the outcomes of spleen-preserving distal pancreatectomy (SPDP) in patients with intraductal papillary mucinous neoplasm (IPMN). Although current guidelines recommend DP including splenectomy in these patients, this study found that SPDP appears to be oncologically safe in patients without preoperative suspicion of malignancy, and improved short-term outcomes after surgery. This thesis also includes the results of a nationwide registry-based study investigating overall survival after resection in patients with PCN-associated pancreatic cancer compared to patients with pancreatic cancer without this association. This study found that patients with PCN-associated pancreatic cancer had better estimated median overall survival when compared to patients with pancreatic cancer not associated with PCN. This thesis also describes the results of the randomised controlled BRIX-trial, which investigates the sensitivity of brush cytology during endoscopic retrograde cholangiopancreatography (ERCP) in patients with suspected malignant pancreatobiliary strictures. Brush cytology is commonly performed during ERCP, yet its sensitivity to diagnose malignancy remains poor. This study therefore compared the sensitivity of a dense brush cytology device to a conventional brush device. The dense brush did not yield higher sensitivity when compared to the conventional brush in diagnosing suspected malignant pancreatobiliary strictures. As a consequence, the study was ended prematurely because of futility.

Pancreatic cystic neoplasms are increasingly detected in the general population. Although most of these lesions are benign, some are (pre)malignant and require follow-up or even surgical intervention. Three cases are presented and used to discuss the clinical implications of the renewed European Guideline on pancreatic cystic neoplasms in which relative and absolute indications for resection are proposed. In the first case, a pancreatic cystic lesion was found on abdominal ultrasound in a 77-year old female patient. After endoscopic ultrasound was performed, a serous cystic neoplasm was diagnosed without need for surveillance. In a 57-year old male, an abdominal MRI was performed to further assess an incidentally found pancreatic cystic lesion. Based on the MRI, a side-branch intraductal papillary mucinous neoplasm (SB-IPMN) was diagnosed and yearly surveillance was initiated. A 61-year old male underwent a laparoscopic distal pancreatectomy because of a mixed-type IPMN (MT-IPMN). The pathological results showed an IPMN with high-grade dysplasia.

Valley fever is endemic to the southwestern United States. Humans contract this fungal disease by inhaling spores of Coccidioides spp. Changes in the environment can influence the abundance and dispersal of Coccidioides spp., causing fluctuations in valley fever incidence. We combined county‐level case records from state health agencies to create a regional valley fever database for the southwestern United States, including Arizona, California, Nevada, New Mexico, and Utah. We used this data set to explore how environmental factors influenced the spatial pattern and temporal dynamics of valley fever incidence during 2000–2015. We compiled climate and environmental geospatial data sets from multiple sources to compare with valley fever incidence. These variables included air temperature, precipitation, soil moisture, surface dust concentration, normalized difference vegetation index, and cropland area. We found that valley fever incidence was greater in areas with warmer air temperatures and drier soils. The mean annual cycle of incidence varied throughout the southwestern United States and peaked following periods of low precipitation and soil moisture. From year‐to‐year, however, autumn incidence was higher following cooler, wetter, and productive springs in the San Joaquin Valley of California. In southcentral Arizona, incidence increased significantly through time. By 2015, incidence in this region was more than double the rate in the San Joaquin Valley. Our analysis provides a framework for interpreting the influence of climate change on valley fever incidence dynamics. Our results may allow the U.S. Centers for Disease Control and Prevention to improve their estimates of the spatial pattern and intensity of valley fever endemicity., Key Points We created a valley fever database for the southwestern United States and explored the climate factors influencing the dynamics of disease incidenceIncidence was higher in areas with warmer air temperatures and drier soils and seasonal peaks followed periods of low environmental moistureOur results may improve estimates of valley fever endemicity and aid future analysis of global change and valley fever incidence dynamics

[EN]This paper contains the conclusion of a mycological survey of western Catalonia. The first part of the results was published in Acta. Bot. Barc. 45 (Homenatge a Oriol de Bolòs): 57-89. The present part covers the last two groups of Basidiomycota: the agarics (326 species) and the gasteromycetes (44 species). The data regarding the surveyed area, collection localities, abreviations used in the information on ecology, collectors and identifiers are found in the mentioned first part, which contains records of 37 species of Myxomycota, 5 of Zygomycota, 101 of mitosporic fungi, 8 of Teliomycetes, 1 of Ustomycetes, 16 of Phragmobasidiomycetes and 92 of Aphyllophorales. Together with the first part, the results of our survey are a useful contribution to an improved understanding of the fungal component of plant communities of the dry, warm lowlands of the western Mediterranean region, and highlight the remarkable reproductive activity of the fungi observed during late Autumn and Winter, in the studied area., [CAT] Aquesta continuació del treball del mateix títol, publicat de forma parcial a Acta. Bot. Barc. 45 (Homenatge a Oriol de Bolós): 57-89, conté les dades sobre 326 agàrics i 44 gasteromicets, que no capigueren a la primera part, a la qual cal referir-se per trobar el llistat i els mapes de les localitats prospectades i les abreviatures indispensables per a interpretar les dades sobre ecologia, recol.lectors i determinadors. Les dues parts juntes formen una unitat que ens permet adquirir una idea més precisa del component fúngic de moltes comunitats vegetals de les terres baixes seques i càlides de la regió Mediterrània occidental i de la seva activitat reproductora durant bona part de l´hivern.

[EN] This work intends to collect the mycological data gathered during the last four years as a result of the project "Fungal biodiversity of Catalonia", in the western and southern, mainly lowland areas of this country. The climate is mainly dry (400-600 mm/year) and warm. The survey, that covers 160 localities, has enabled the identification of 37 species of Myxomycota, 5 of Zygomycota, 159 of Ascomycota, 101 mitosporic fungi, 8 Teliomycetes, 1 Ustomycetes, 16 Phragmobasidiomycetes and 92 Aphyllophorates, that are included in this paper. Because of space limitations, the remaining 326 agarics and 44 Gasteromycetes will be published in the next number of this journal. This work is a contribution to a best understanding of the fungal flora, chorology, ecology and phenology of the West-Mediterranean dry lowlands., [CAT]Aquest estudi reuneix les dades micològiques obtingudes, durant els quatre anys de durada del programa "Biodiversitar dels fongs de Catalunya", a la part occidental i meridional de Catalunya, sobretot en comarques baixes i poc plujoses, de clima predominantment sec (400-600 mm/any) i suau. L´exploració de 160 localitats ha fet possible la identificació de 37 espècies de mixomicets, 5 de zigomicets, 159 ascomicets, 101 deuteromicets, 8 teliomicets, 1 ustomicet, 16 fragmobasidiomicets i 92 afil.loforats, que s´esmenten en aquesta primera part. Per limitacions d´spai, els fongs restants, 326 agàrics i 44 gasteromicets, seran publicats en el número següent d´aquesta revista. Aquest treball vol contribuir a una més bona comprensió de la flora, la corologia, l´ecologia i la fenologia dels fongs de les terres baixes i poc plujoses de la mediterrània occidental.