Diagnostic performance of [68Ga]DOTATATE PET/CT, [18F]FDG PET/CT, MRI of the spine, and whole-body diagnostic CT and MRI in the detection of spinal bone metastases associated with pheochromocytoma and paraganglioma.

OBJECTIVE: To compare the diagnostic performance of [68Ga]DOTATATE PET/CT, [18F]FDG PET/CT, MRI of the spine, and whole-body CT and MRI for the detection of pheochromocytoma/paraganglioma (PPGL)-related spinal bone metastases. MATERIALS AND METHODS: Between 2014 and 2020, PPGL participants with spinal bone metastases prospectively underwent [68Ga]DOTATATE PET/CT, [18F]FDG PET/CT, MRI of the cervical-thoracolumbar spine (MRIspine), contrast-enhanced MRI of the neck and thoraco-abdominopelvic regions (MRIWB), and contrast-enhanced CT of the neck and thoraco-abdominopelvic regions (CTWB). Per-patient and per-lesion detection rates were calculated. Counting of spinal bone metastases was limited to a maximum of one lesion per vertebrae. A composite of all functional and anatomic imaging served as an imaging comparator. The McNemar test compared detection rates between the scans. Two-sided p values were reported. RESULTS: Forty-three consecutive participants (mean age, 41.7 ± 15.7 years; females, 22) with MRIspine were included who also underwent [68Ga]DOTATATE PET/CT (n = 43), [18F]FDG PET/CT (n = 43), MRIWB (n = 24), and CTWB (n = 33). Forty-one of 43 participants were positive for spinal bone metastases, with 382 lesions on the imaging comparator. [68Ga]DOTATATE PET/CT demonstrated a per-lesion detection rate of 377/382 (98.7%) which was superior compared to [18F]FDG (72.0%, 275/382, p < 0.001), MRIspine (80.6%, 308/382, p < 0.001), MRIWB (55.3%, 136/246, p < 0.001), and CTWB (44.8%, 132/295, p < 0.001). The per-patient detection rate of [68Ga]DOTATATE PET/CT was 41/41 (100%) which was higher compared to [18F]FDG PET/CT (90.2%, 37/41, p = 0.13), MRIspine (97.6%, 40/41, p = 1.00), MRIWB (95.7%, 22/23, p = 1.00), and CTWB (81.8%, 27/33, p = 0.03). CONCLUSIONS: [68Ga]DOTATATE PET/CT should be the modality of choice in PPGL-related spinal bone metastases due to its superior detection rate. CLINICAL RELEVANCE STATEMENT: In a prospective study of 43 pheochromocytoma/paraganglioma participants with spinal bone metastases, [68Ga]DOTATATE PET/CT had a superior per-lesion detection rate of 98.7% (377/382), compared to [18F]FDG PET/CT (p < 0.001), MRI of the spine (p < 0.001), whole-body CT (p < 0.001), and whole-body MRI (p < 0.001). KEY POINTS: • Data regarding head-to-head comparison between functional and anatomic imaging modalities to detect spinal bone metastases in pheochromocytoma/paraganglioma are limited. • [68Ga]DOTATATE PET/CT had a superior per-lesion detection rate of 98.7% in the detection of spinal bone metastases associated with pheochromocytoma/paraganglioma compared to other imaging modalities: [18]F-FDG PET/CT, MRI of the spine, whole-body CT, and whole-body MRI. • [68Ga]DOTATATE PET/CT should be the modality of choice in the evaluation of spinal bone metastases associated with pheochromocytoma/paraganglioma.

Association between oral clefts and periodontal clinical measures: A meta-analysis.

AIM: To conduct a systematic review and to evaluate the clinical parameters for periodontal diseases in individuals with cleft lip and/or palate (CL/P). DESIGN: The authors searched six indexed databases without any linguistic limitation through July 2021. The eligibility criteria were observational studies that compared the periodontal clinical measures of individuals with CL/P to those without CL/P. A meta-analysis was conducted using random-effects models with inverse variance weighting. RESULTS: The literature search generated 1277 records, and 40 full-text articles were reviewed. Twenty-three studies comprising 3235 individuals from four continents fulfilled our selection criteria. The meta-analysis revealed a significant difference in mean plaque index scores (MD = 0.31, 95% CI = 0.22, 0.41), gingival index scores (MD = 0.50, 95% CI = 0.24, 0.77), and periodontal pocket depth (MD = 0.64, 95% CI = 0.12, 1.16) between individuals with and without CL/P. A slight increase in clinical attachment loss was detected among individuals with CL/P; however, such an increase may have little clinical significance. CONCLUSIONS: As age is positively related to periodontal disease progression, and individuals with CL/P are more likely to present with more plaque accumulation and gingival inflammation, clinicians should reinforce preventive dental care from an early age.

Incision-Site Descemet Membrane Detachment During and After Phacoemulsification: Risk Factors and Management.

OBJECTIVE: To evaluate the occurrence of localized incision-site Descemet membrane detachment (DMD) during and after phacoemulsification and to study its relationship with phacoemulsification parameters. METHODS: Forty-three, consecutive uneventful cases of phacoemulsification through 2.8-mm clear corneal incision were included in this prospective study. Preoperatively, the grade of cataract was assessed. The phacoemulsification parameters noted were phacoemulsification time, aspiration time, cumulative dissipated energy (CDE), ultrasound time, and total fluid volume. Anterior segment optical coherence tomography (AS-OCT) was performed on postoperative days 1 and 7 to study the course of the incision-site DMD. RESULTS: Fourteen of 43 cases (32%) showed localized incision-site DMD either intraoperatively or on AS-OCT on the first postoperative day. Of these, nine cases were detected intraoperatively, and six cases were detected on AS-OCT on the first postoperative day. All cases were of planar type and resolved spontaneously. A single case showed a concurrent DMD involving central cornea, which resolved without any surgical intervention. The occurrence of DMD was significantly higher in those with the total ultrasound time greater than 60 sec (P=0.038) (odds ratio: 7.639). The CDE was higher in cases with DMD; however, the result was not statistically significant (P=0.062). Torsional equivalent in level-3, total torsional time, equivalent torsional time, aspiration time, and the total fluid volume were comparable (P>0.05) between cases with and without incision-site DMD. CONCLUSION: Postphacoemulsification incision-site DMD may occur in up to one third of cases and is associated with increase in the total ultrasound time.

Fusiform "True" Posterior Communicating Artery Aneurysm with Basilar Artery Occlusion: A Case Report.

Isolated posterior communicating artery (PCoA) aneurysms are rare, predominantly fusiform in morphology, and rarely present with subarachnoid hemorrhage. Endovascular management of this pathology is technically challenging due to extreme tortuosity, the artery course in the subarachnoid space, sharp angulations at PCoA junctions with the parent artery, and, at times, associations with either internal carotid artery or basilar artery occlusions. We present a case of a ruptured fusiform PCoA at the junction of middle and distal third with concomitant proximal basilar artery occlusion. The PCoA reforms the posterior circulation, making it a vital artery. Stent-assisted coiling was performed with extreme difficulty in achieving distal positioning of the stents in the basilar artery/posterior cerebral artery/distal PCoA due to artery tortuosity. There was technical difficulty in the stent deployment. After changing strategies to a larger diameter laser-cut stent, endovascular treatment could be performed. There were good angiographic and clinical outcomes with stable occlusion at 6-month-follow-up.

Coxsackievirus-Induced Myocarditis With Acute Onset of Heart Failure With Pleural Effusion.

This is a case of a 45-year-old Caucasian female with coxsackievirus-induced myocarditis. Myocarditis is an inflammation of the heart muscles, which can be difficult to diagnose at times because its symptoms overlap with other cardiovascular diseases. At times, when the patient presents, the full impact of the etiology would have either improved or resolved. In this case, the patient presented with symptoms closely resembling that of acute coronary syndrome but did not fit the typical age category. After lab and imaging workup, the coxsackievirus panel was positive, complicated with a new diagnosis of systolic heart failure with an ejection fraction of 30%-35% along with pericardial effusion.

Gold nanorods mediated controlled release of doxorubicin: nano-needles for efficient drug delivery.

Use of cysteamine hydrochloride (Cys-HCl) protected gold nanorods (GNRs) as efficient carrier of widely used anti-cancer drug doxorubicin using folic acid as navigational molecule is presented in this work. GNRs were found to have excellent drug loading capacity of >97 %. A detailed comprehension of in vitro drug release profile under ideal physiological condition was found to obey 1st order kinetics at pH 6.8, 5.3 and 7.2, an ideal milieu for drug delivery to solid tumours.

Myxolipoma of hand in a child: case report of a rare tumor.

Lipomatous tumors account for less than 10% of tumors in the pediatric population. Myxolipomas (a subset of lipoma characterised by mature adipose tissue and abundant mucoid substance) are found to be even rarer. There are a few case reports in different body parts like heart, kidney, oral cavity, epiglottis, cervical and mediastinal regions. However, there are no case reports on the involvement of the hands in any age group. High resolution ultrasound is the imaging modality of choice for the initial evaluation of superficial soft tissue tumors, their site, nature and extent. In conjunction with clinical findings and age of presentation, it helps in narrowing down the differential diagnosis and planning the management. Hyperechoic fatty tumors in the pediatric hand are mostly benign and includes lipomas, lipoblastomas and fibrous hamartomas of infancy as the main differentials. A definitive diagnosis is based on a histo-pathological and molecular cytogenetic examination. This article presents a never before reported case of a rare, large, myxolipoma of the hand in a 22-month-old boy.

A Retrospective Analysis of High Resolution Ultrasound Evaluation of the "Split Fat Sign" in Peripheral Nerve Sheath Tumors.

Peripheral nerve sheath tumors (PNST) comprise schwannomas and neurofibromas. The finding of increased adipose tissue around benign PNSTs has been described as the "split fat sign" on magnetic resonance imaging exams, which is suggestive of an intramuscular or intermuscular location of the tumor. However, few studies have described this sign as a salient ultrasound feature of PNSTs. The main purpose of this study was to retrospectively evaluate the presence of increased fatty tissue deposition around benign PNSTs diagnosed by high-resolution ultrasound. In addition, we aimed to corroborate the presence of vascularization around the affected area. A retrospective analysis of ten cases of PNSTs and two cases of post-traumatic neuromas diagnosed by high-resolution ultrasound was performed with a Logiq® P8 ultrasound with a 2-11 MHz multifrequency linear probe L3-12-D (central frequency: 10 MHz). Localized types of neurofibromas and schwannomas in any location were seen as predominantly hypoechoic tumors with an oval or fusiform shape. Exiting and entering nerves (tail sign) were observed in six cases, showing localized lesions both in intermuscular and subcutaneous locations. The presence of increased hyperechoic tissue (the split fat sign) was noted in cases of solitary intermuscular and intramuscular peripheral nerve sheath tumors, mainly the schwannomas. Though small tumors did not demonstrate the tail sign, the increase in adipose tissue and vascularity on US was well demonstrated. In conclusion, the nerve in continuity forms the basis of the ultrasonographic diagnosis of PNSTs. However, high-resolution US can convincingly demonstrate the increased presence of fat in the upper and lower poles as well as circumferentially in intermuscular or intramuscular benign PNSTs.

Pediatric Transplant Interventions.

The field of pediatric organ transplantation has grown significantly in recent decades, with interventional radiology (IR) playing an essential role in managing pre and post-transplant complications. Pediatric transplant patients face unique challenges compared to adults, including donor-recipient size mismatch, and complications of a growing child with changing physiology. Interventional radiologists play a major role in pediatric renal and liver transplant. IR interventions begin early in the child's pretransplant journey, with diagnostic procedures such as biopsies, angiograms, and cholangiograms. These procedures are essential for understanding the etiology of organ failure and identifying potential transplant candidates. Minimally invasive therapeutic procedures may serve as bridges to transplant and may include vascular access optimization for hemodialysis, transjugular intrahepatic portosystemic shunts (TIPS) creation, and tumor embolization or ablation. After transplant, image-guided biopsies for the surveillance of graft rejection and treatment of vascular or luminal stenoses, pseudoaneurysms, and anastomotic leaks can maintain the function and longevity of the transplant organ. Careful consideration must be given to patient size and evolving anatomy, radiation exposure, and the need for deeper sedation for pediatric patients. Despite these challenges, the integration of IR in pediatric transplant care has proven beneficial, offering minimally invasive alternatives to surgery, faster recovery times, and improved outcomes.

Virtual monoenergetic imaging in photon-counting CT of the head and neck.

PURPOSE: Advantages of virtual monoenergetic images (VMI) have been reported for dual energy CT of the head and neck, and more recently VMIs derived from photon-counting (PCCT) angiography of the head and neck. We report image quality metrics of VMI in a PCCT angiography dataset, expanding the anatomical regions evaluated and extending observer-based qualitative methods further than previously reported. METHODS: In a prospective study, asymptomatic subjects underwent contrast enhanced PCCT of the head and neck using an investigational scanner. Image sets of low, high, and full spectrum (Threshold-1) energies; linear mix of low and high energies (Mix); and 23 VMIs (40-150 keV, 5 keV increments) were generated. In 8 anatomical locations, SNR and radiologists' preferences for VMI energy levels were measured using a forced-choice rank method (4 observers) and ratings of image quality using visual grading characteristic (VGC) analysis (2 observers) comparing VMI to Mix and Threshold-1 images. RESULTS: Fifteen subjects were included (7 men, 8 women, mean 57 years, range 46-75). Among all VMIs, SNRs varied by anatomic location. The highest SNRs were observed in VMIs. Radiologists preferred 50-60 keV VMIs for vascular structures and 75-85 keV for all other structures. Cumulative ratings of image quality averaged across all locations were higher for VMIs with areas under the curve of VMI vs Mix and VMI vs Threshold-1 of 0.67 and 0.68 for the first reader and 0.72 and 0.76 for the second, respectively. CONCLUSION: Preferred keV level and quality ratings of VMI compared to mixed and Threshold-1 images varied by anatomical location.

Heterogeneous clinicopathological findings and patient-reported outcomes in adults with MN1-altered CNS tumors: A case report and systematic literature review.

The uncommon MN1-altered primary central nervous system (CNS) tumors were recently added to the World Health Organization 2021 classification under the name Astroblastoma, MN1-altered. Another term used to describe them, "High-grade neuroepithelial tumor with MN1 alteration" (HGNET-MN1), makes reference to their distinct epigenetic profile but is currently not a recommended name. Thought to occur most commonly in children and predominantly in females, MN1-altered CNS tumors are associated with typical but not pathognomonic histological patterns and are characterized by a distinct DNA methylation profile and recurrent fusions implicating the MN1 (meningioma 1) gene. Diagnosis based on histological features alone is challenging: most cases with morphological features of astroblastoma (but not all) show these molecular features, whereas not all tumors with MN1 fusions show astroblastoma morphology. There is large variability in reported outcomes and detailed clinical and therapeutic information is frequently missing. Some patients experience multiple recurrences despite multimodality treatment, whereas others experience no recurrence after surgical resection alone, suggesting large clinical and biological heterogeneity despite unifying epigenetic features and recurrent fusions. In this report, we present the demographics, tumor characteristics, treatment, and outcome (including patient-reported outcomes) of three adults with MN1-altered primary CNS tumors diagnosed via genome-wide DNA methylation and RNA sequencing. All three patients were females and two of them were diagnosed as young adults. By reporting our neuropathological and clinical findings and comparing them with previously published cases we provide insight into the clinical heterogeneity of this tumor. Additionally, we propose a model for prospective, comprehensive, and systematic collection of clinical data in addition to neuropathological data, including standardized patient-reported outcomes.

Phase I Study and Cell-Free DNA Analysis of T-DM1 and Metronomic Temozolomide for Secondary Prevention of HER2-Positive Breast Cancer Brain Metastases.

PURPOSE: Preclinical data showed that prophylactic, low-dose temozolomide (TMZ) significantly prevented breast cancer brain metastasis. We present results of a phase I trial combining T-DM1 with TMZ for the prevention of additional brain metastases after previous occurrence and local treatment in patients with HER2+ breast cancer. PATIENTS AND METHODS: Eligible patients had HER2+ breast cancer with brain metastases and were within 12 weeks of whole brain radiation therapy (WBRT), stereotactic radiosurgery, and/or surgery. Standard doses of T-DM1 were administered intravenously every 21 days (3.6 mg/kg) and TMZ was given orally daily in a 3+3 phase I dose escalation design at 30, 40, or 50 mg/m2, continuously. DLT period was one 21-day cycle. Primary endpoint was safety and recommended phase II dose. Symptom questionnaires, brain MRI, and systemic CT scans were performed every 6 weeks. Cell-free DNA sequencing was performed on patients' plasma and CSF. RESULTS: Twelve women enrolled, nine (75%) with prior SRS therapy and three (25%) with prior WBRT. Grade 3 or 4 AEs included thrombocytopenia (1/12), neutropenia (1/12), lymphopenia (6/12), and decreased CD4 (6/12), requiring pentamidine for Pneumocystis jirovecii pneumonia prophylaxis. No DLT was observed. Four patients on the highest TMZ dose underwent dose reductions. At trial entry, 6 of 12 patients had tumor mutations in CSF, indicating ongoing metastatic colonization despite a clear MRI. Median follow-up on study was 9.6 m (2.8-33.9); only 2 patients developed new parenchymal brain metastases. Tumor mutations varied with patient outcome. CONCLUSIONS: Metronomic TMZ in combination with standard dose T-DM1 shows low-grade toxicity and potential activity in secondary prevention of HER2+ brain metastases.

Radiopaque jaw lesions: an approach to the differential diagnosis.

Radiopaque jaw lesions are frequently encountered at radiography and computed tomography, but they are usually underevaluated or underdescribed in radiology reports. A systematic approach to the evaluation of radiopaque jaw lesions is necessary to diagnose the lesion or at least provide a meaningful differential diagnosis. To evaluate a radiopaque jaw lesion, the first, most important step is to categorize the lesion according to its attenuation, its relationship to the teeth, and its location with respect to the tooth. These basic observations are essential to the evaluation of any type of jaw lesion. Once these observations have been made, it is easy to create a proper differential diagnosis. The presence of important characteristics, such as margination, a perilesional halo, bone expansion, and growth pattern, as well as whether the lesion is sclerotic, has ground-glass attenuation, or is mixed lytic and sclerotic, further narrows the differential diagnosis. It is important to note that some radiopaque jaw lesions may be entirely lucent early in their evolution. Awareness of the demographic distribution of these lesions and their associated clinical features, as well as the radiologic approach, is important to explore the "terra incognita" of radiopaque jaw lesions.

Radiation necrosis in the brain: imaging features and differentiation from tumor recurrence.

Radiation necrosis in the brain commonly occurs in three distinct clinical scenarios, namely, radiation therapy for head and neck malignancy or intracranial extraaxial tumor, stereotactic radiation therapy (including radiosurgery) for brain metastasis, and radiation therapy for primary brain tumors. Knowledge of the radiation treatment plan, amount of brain tissue included in the radiation port, type of radiation, location of the primary malignancy, and amount of time elapsed since radiation therapy is extremely important in determining whether the imaging abnormality represents radiation necrosis or recurrent tumor. Conventional magnetic resonance (MR) imaging findings of these two entities overlap considerably, and even at histopathologic analysis, tumor mixed with radiation necrosis is a common finding. Advanced imaging modalities such as diffusion tensor imaging and perfusion MR imaging (with calculation of certain specific parameters such as apparent diffusion coefficient ratios, relative peak height, and percentage of signal recovery), MR spectroscopy, and positron emission tomography can be useful in differentiating between recurrent tumor and radiation necrosis. In everyday practice, the visual assessment of diffusion-weighted and perfusion images may also be helpful by favoring one diagnosis over the other, with restricted diffusion and an elevated relative cerebral blood volume being seen much more frequently in recurrent tumor than in radiation necrosis.

Pediatric osmotic demyelination syndrome in a case of type 1 diabetes mellitus with diabetic ketoacidosis.

Cautious treatment of hyponatremia in diabetic ketoacidosis is necessary in order to avoid the development of osmotic demyelination syndrome which is a demyelinating disorder. Individualized supportive therapy would be fruitful for the management of such cases but there is a need for larger studies to guide the management.

Evaluation of a poverty-focused educational program and simulation for pharmacists.

BACKGROUND AND PURPOSE: Limited literature explores the impact that poverty-focused educational simulations can have on practicing clinicians. This study used a poverty simulation, specifically created to resemble the lives of Medicare patients, to sensitize practicing pharmacists to the situations faced by people living in poverty. The study evaluated how a poverty-focused educational program impacted practicing pharmacists' actual knowledge gain, intention to assist patients with limited income, and satisfaction with the educational program. EDUCATIONAL ACTIVITY AND SETTING: A quasi-experimental one-group pre-/posttest design of practicing pharmacists was utilized. The intervention was a live continuing educational (CE) program at a pharmacy alumni event and a pharmacy convention. The CE program was delivered in person and included a Medicare poverty simulation and a 75-min didactic lecture. Pre- and posttests were used to assess outcomes. The primary outcome was change in knowledge as measured by test scores. Secondary outcomes included intention to assist future low-income patients and participant satisfaction with the educational program. FINDINGS: Eighty-nine pharmacists participated in the educational program. Participants' mean knowledge increased from 2.76 (SD = 0.97) to 3.61 (SD = 1.21) (P < .001) out of 5. The majority (88.3%) agreed they were interested in assisting patients with limited income in the future. Most participants strongly agreed that the program was satisfactory and contributed to their learning. SUMMARY: This is the first identifiable study that incorporated a poverty simulation into an educational program for practicing pharmacists. The study may help inform the development of future educational programs for practicing pharmacists.

Challenges of imaging interpretation to predict oligodendroglioma grade: a report from the Neuro-Oncology Branch.

Background: To illustrate challenges of imaging interpretation in patients with oligodendroglioma seen at a referral center and evaluate interrater reliability. Methods: Two neuro-oncologists reviewed diagnostic preradiation MRIs of oligodendroglioma patients; interrater reliability was calculated with the kappa coefficient (k). A neuroradiologist measured presurgical apparent diffusion coefficient (ADC), if available. Results: Extensive enhancement was noted in four of 58 patients, k = 0.7; necrosis in seven of 58, k = 0.61; calcification in seven of 17, k = 1.0; diffusion restriction in two of 39 patients, k = 1.0 (all only in grade 3). ADC values with receiver operator characteristic analysis for area under the curve were 0.473, not significantly different from the null hypothesis (p = 0.14). Conclusions: Extensive enhancement, necrosis and calcification correlated with grade 3 oligodendroglioma in our sample. However, interrater variability is an important limitation when assessing radiographic features, supporting the need for standardization of imaging protocols and their interpretation.

Imaging of petrous apex lesions: self-assessment module.

The educational objectives for this self-assessment module are for the participant to exercise, self-assess, and improve his or her understanding of the role of imaging in the evaluation of petrous apex lesions.

Hexachlorobenzene, a pollutant in hypothyroidism and reproductive aberrations: a perceptive transgenerational study.

Hexachlorobenzene (HCB), a widespread environmental pollutant, contributes to endocrine disruption resulting in hypothyroidism. We investigated the effect of chronic exposure of HCB to explore the functional interconnection between hypothyroidism and infertility. All observations were made through the F1 and F2 generations. Thyroidectomy was also performed to evaluate the contribution of the thyroid gland in affecting ovarian dysfunction and reproductive aberrations. We confirmed that the preconception exposure of HCB leads to hypothyroidism which was reflected by an increase in the body weight, alteration in the thyroid hormones, and alteration of the lipid profile. Hypothyroid female rats exhibited a poor reproductive profile with altered steroidogenic pathways, altered estrus cyclicity, reduced litter size, and stunted growth. The external supplementation of thyroxine in thyroidectomized animals rescues the reproductive aberrations confirming the protective role of the thyroid gland in reproductive biology. All results highlight the jeopardizing functional connection of the thyroid and ovary due to HCB, leading to serious consequences on upcoming generations.