Proliferating inverted follicular keratosis of genital skin: Case series of a challenging variant.

BACKGROUND: Inverted follicular keratosis (IFK) is a benign cutaneous epithelial tumor typically presenting as a small papule on the head and neck. We have encountered deep endophytic tumors on genital skin with some characteristics of IFK but also atypical features, raising concern for squamous cell carcinoma (SCC). METHODS: Four such tumors were identified in our database. Histopathologic analysis and ancillary studies were performed. RESULTS: All patients were young women who presented with a solitary 0.5-1.0 cm lesion on the vulva, perineum, or inner buttock. Each showed a squamous proliferation arising from the epidermis, with endophytic growth that was deep and bulbous but not infiltrative. The tumor lobules contained eosinophilic keratinocytes, forming numerous squamous eddies. Small irregular spaces and dyskeratotic cells were frequently found. Nuclear pleomorphism was minimal to absent. All demonstrated wild-type p53 expression and lack of p16 block positivity. In situ hybridizations for human papillomavirus were negative. None of the three cases with follow-up data showed evidence of recurrence. CONCLUSIONS: The absence of infiltrative growth or significant pleomorphism, the presence of numerous squamous eddies, the reassuring immunoprofile, and the lack of evidence of recurrence support a variant of IFK and speak against SCC. We propose the term "proliferating IFK" to highlight the florid squamous proliferation. Recognition of this unusual variant would avoid overdiagnosis of SCC.

Comparing the Quality of ChatGPT- and Physician-Generated Responses to Patients' Dermatologic Questions in the Electronic Medical Record.

BACKGROUND: Chat Generated Pre-trained Transformer ('ChatGPT,' Open AI, San Francisco, USA) is a free artificial intelligence (AI)-based natural language processing tool that generates complex responses to inputs from users. OBJECTIVE: To determine whether ChatGPT is able to generate high-quality responses to patient-submitted questions in the patient portal. METHODS: Patient-submitted questions and their corresponding responses from their dermatology physician were extracted from the electronic medical record for analysis. The questions were input into ChatGPT (version 3.5), and the outputs were extracted for analysis, with manual removal of verbiage pertaining to ChatGPT's inability to provide medical advice. Ten blinded reviewers (n=7 physicians, n=3 non-physicians) rated and selected their preference in terms of 'overall quality,' 'readability,' 'accuracy,' 'thoroughness,' and 'level of empathy,' of the physician- and ChatGPT-generated responses. RESULTS: Thirty-one messages and responses were analyzed. The physician-generated response was vastly preferred over the ChatGPT response by both physician and non-physician reviewers and received significantly higher ratings for 'readability' and 'level of empathy.' CONCLUSIONS: The results of this study suggest that physician-generated responses to patients' portal messages are still preferred over ChatGPT, but generative AI tools may still be helpful in generating first drafts of responses and education resources for patients.

Improving MR Image Quality in Patients with Metallic Implants.

The number of implanted devices such as orthopedic hardware and cardiac implantable devices continues to increase with an increase in the age of the patient population, as well as an increase in the number of indications for specific devices. Many patients with these devices have or will develop clinical conditions that are best depicted at MRI. However, implanted devices containing paramagnetic or ferromagnetic substances can cause significant artifact, which could limit the diagnostic capability of this modality. Performing imaging with MRI when an implant is present may be challenging, and there are numerous techniques the radiologist and technologist can use to help minimize artifacts related to implants. First, knowledge of the presence of an implant before patient arrival is critical to ensure safety of the patient when the device is subjected to a strong magnetic field. Once safety is ensured, the examination should be performed with the MRI system that is expected to provide the best image quality. The selection of the MRI system includes multiple considerations such as the effects of field strength and availability of specific sequences, which can reduce metal artifact. Appropriate patient positioning, attention to MRI parameters (including bandwidth, voxel size, and echo), and appropriate selection of sequences (those with less metal artifact and advanced metal reduction sequences) are critical to improve image quality. Patients with implants can be successfully imaged with MRI with appropriate planning and understanding of how to minimize artifacts. This improves image quality and the diagnostic confidence of the radiologist. ©RSNA, 2021.

Cardiac MRI for Patients With Cardiac Implantable Electronic Devices.

OBJECTIVE. Patients with cardiac implantable electronic devices (CIEDs) require cardiac MRI (CMRI) for a variety of reasons. The purpose of this study is to review and evaluate the value and safety of CMRI for patients with in situ CIEDs. CONCLUSION. Late gadolinium enhancement CMRI is the reference standard for assessing myocardial viability in patients with ventricular tachycardia before ablation of arrhythmogenic substrates. The use of late gadolinium enhancement CMRI for patients with CIEDs is safe as long as an imaging protocol is in place and precaution measures are taken.

Metal Artifact Reduction in Cardiovascular MRI for Accurate Myocardial Scar Assessment in Patients With Cardiac Implantable Electronic Devices.

OBJECTIVE. An important application of late gadolinium enhancement (LGE) cardiac MRI is accurate assessment of myocardial scar before ablation. However, this is often limited in patients with cardiac implantable electronic devices (CIEDs) because of metal device-induced artifacts. The purpose of this study was to determine whether a modified wideband inversion recovery (IR) LGE MRI technique decreases artifact volume to allow the assessment of myocardial scar. SUBJECTS AND METHODS. Fifty patients (17 women and 33 men; mean age ± SD, 61 ± 12 years; mean ejection fraction ± SD, 35.9% ± 13.3%) with CIEDs underwent cardiac MRI using conventional and modified wideband IR LGE techniques before ablation. The volume of device-induced artifact was quantified and stratified by tertiles on mild, moderate, and severe. Ordinal logistic regression analysis assessed the association between artifact volume on conventional and wideband images adjusted for patients' demographics. RESULTS. Conventional LGE MRI resulted in device-induced hyperintense artifacts that obscured ventricular segments in 32 of 50 (64%) cases. Wideband LGE MRI significantly reduced severe artifact volume (p < 0.0001) and completely resolved all mild and most moderate artifacts. Overall, wideband techniques resulted in a 56% reduction in total artifact volume for the cohort (p < 0.0001). The wideband LGE MRI sequence minimized artifacts in the most commonly obscured segments on the conventional LGE MRI sequence, with persistent artifacts in seven, eight, and four of 32 cases at the basal anterior, midventricular anterior, and midventricular anteroseptal segments, respectively. CONCLUSION. The modified wideband IR technique completely resolves mild and moderate device-induced hyperintense artifacts and significantly reduces the volume of severe artifact to allow accurate identification of myocardial scar in patients with CIEDs before ablation.

Optimized cardiac magnetic resonance imaging inversion recovery sequence for metal artifact reduction and accurate myocardial scar assessment in patients with cardiac implantable electronic devices.

Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) is the gold standard for imaging myocardial viability. An important application of LGE CMR is the assessment of the location and extent of the myocardial scar in patients with ventricular tachycardia (VT), which allows for more accurate identification of the ablation targets. However, a large percentage of patients with VT have cardiac implantable electronic devices (CIEDs), which is a relative contraindication for cardiac magnetic resonance imaging due to safety and image artifact concerns. Previous studies showed that these patients can be safely scanned on 1.5 T scanners provided that an adequate imaging protocol is adopted. Nevertheless, imaging patients with a CIED result in metal artifacts due to the strong frequency off-resonance effects near the device; therefore, the spins in the surrounding myocardium are not completely inverted, and thus give rise to hyperintensity artifacts. These artifacts obscure the myocardial scar tissue and limit the ability to study the correlation between the myocardial scar structure and the electro-anatomical map during catheter ablation. In this study, we developed a modified inversion recovery technique to alleviate the CIED-induced metal artifacts and improve the diagnostic image quality of LGE images in patients with CIEDs without increasing scan time or requiring additional hardware. The developed technique was tested in phantom experiments and in vivo scans, which showed its capability for suppressing the hyperintensity artifacts without compromising myocardium nulling in the resulting LGE images.

Pacemaker recycling: A notion whose time has come.

The purpose of this paper is to summarize the need, feasibility, safety, legality, and ethical perspectives of pacemaker reutilization in low- and middle-income countries (LMICs). It will also describe, in-depth, Project My Heart Your Heart (PMHYH) as a model for pacemaker reuse in LMICs. The primary source of the discussion points in this paper is a collection of 14 publications produced by the research team at the University of Michigan and its collaborative partners. The need for pacemaker reutilization in LMICs is evident. Numerous studies show that the concept of pacemaker reutilization in LMICs is feasible. Infection and device malfunction are the main concerns in regard to pacemaker reutilization, yet many studies have shown that pacemaker reuse is not associated with increased infection risk or higher mortality compared with new device implantation. Under the right circumstances, the ethical and legal bases for pacemaker reutilization are supported. PMHYH is a proof of concept pacemaker donation initiative that has allowed funeral home and crematory directors to send explanted devices to an academic center for evaluation and re-sterilization before donation to underserved patients in LMICs. The time is now to pursue large-scale studies and trials of pacemaker reuse for the betterment of society. PMHYH is leading the way in the effort and is poised to conduct a prospective randomized, non-inferiority, multicenter study to confirm the clinical efficacy and safety of pacemaker reuse, for clinical and legal support.

NADPH oxidases regulate CD44 and hyaluronic acid expression in thrombin-treated vascular smooth muscle cells and in atherosclerosis.

The intracellular signaling events by which NADPH oxidase-generated reactive oxygen species (ROS) modulate vascular smooth muscle cell (VSMC) function and atherogenesis are yet to be entirely elucidated. We previously demonstrated that NADPH oxidase deficiency decreased atherosclerosis in apoE(-/-) mice and identified adhesion protein CD44 as an important ROS-sensitive gene expressed in VSMC and atherosclerotic lesions. Here, we examined the molecular mechanisms by which NADPH oxidase-generated ROS regulate the expression of CD44 and its principal ligand, hyaluronan (HA), and how CD44-HA interaction affects VSMC proliferation and migration and inflammatory gene expression in apoE(-/-) mice aortas. Thrombin-induced CD44 expression is mediated by transcription factor AP-1 in a NADPH oxidase-dependent manner. NADPH oxidase-mediated ROS generation enhanced thrombin-induced HA synthesis, and hyaluronan synthase 2 expression in VSMC. Hyaluronidase, which generates low molecular weight HA (LMW-HA), is induced in VSMC in a NADPH oxidase-dependent manner and LMW-HA stimulated ROS generation and cell proliferation in wild-type but not p47(phox-/-) VSMC, effects that were enhanced by thrombin pretreatment. Haptotactic VSMC migration toward HA was increased by thrombin in a CD44-dependent manner. HA expression in atherosclerotic lesions and plasma-soluble CD44 and HA levels were higher in apoE(-/-) compared with apoE(-/-)/p47(phox-/-) mice. HA-regulated pro-inflammatory gene expression was higher in apoE(-/-) than apoE(-/-)/p47(phox-/-) mouse aortas. GKT136901, a specific inhibitor of Nox1- and Nox4-containing NADPH oxidase activity, attenuated ROS generation and atherosclerosis and decreased CD44 and HA expression in atherosclerotic lesions. Together, these data suggest that increased CD44 and HA expression and CD44-HA-dependent gene regulation may play a role in atherosclerosis stimulated by NADPH oxidase activation.