Three cases highlighting possible discrepancies in the interpretation of transgender DXA scores.

For diagnosis of osteoporosis, a T-score of ≤-2.5 is recommended for all transgender and gender-diverse patients aged 50 years or older, regardless of hormonal status. This case series presents 3 transgender individuals younger than 50 years undergoing gender-affirming hormone therapy (GAHT) who had DXA scores suggestive of osteoporosis. We highlight possible discrepancies in DXA scan interpretations, especially in forearm bone mineral density measurements. We present the baseline (prior to beginning GAHT), 6-month, and 1-year follow-up DXA data along with pertinent labs to include 25-OH vitamin D, calcium, and alkaline phosphatase, for 2 transgender males (assigned female at birth) and 1 transgender female (assigned male at birth) undergoing GAHT who had low Z-scores and T-scores suggestive of osteoporosis. Multiple studies have analyzed the BMD data of individuals taking GAHT over time, which identify possible causes for low baseline Z-scores for transgender females, but less so for transgender males. Other than positional statements, guidelines remain unclear regarding diagnostic approaches to osteoporosis and low Z-scores in transgender individuals who are premenopausal or under 50 years of age. This case series addresses discrepancies in interpretation that may be encountered by clinicians with baseline and follow-up DXAs, especially involving the forearm, during the course of GAHT. This highlights the importance of establishing clearer guidelines for the diagnosis and treatment of osteoporosis and low BMD for chronological age in the transgender population.

Robust, self-adhesive and anti-bacterial silk-based LIG electrodes for electrophysiological monitoring.

Flexible wearable electrodes have been extensively used for obtaining electrophysiological signals towards smart health monitoring and disease diagnosis. Here, low-cost, and non-conductive silk fabric (SF) have been processed into highly conductive laser induced graphene (LIG) electrodes while maintaining the original structure of SF. A CO2-pulsed laser was utilized to produce LIG-SF with controlled sheet resistance and mechanical properties. Laser processing of SFs under optimized conditions yielded LIG-SF electrodes with a high degree of homogeneity on both, top and bottom layers. Silk fibroin/Ca2+ adhesive layers effectively promoted the adhesive, anti-bacterial properties and provided a conformal contact of LIG-SF electrodes with human skin. Compared with conventional Ag/AgCl electrodes, LIG-SF electrodes possesses a much lower contact impedance in contact with human skin enabling highly stable electrophysiological signals recording. The applicability of adhesive LIG-SF electrodes to acquire electrocardiogram (ECG) signals was investigated. ECG signals recordings of adhesive LIG-SF electrodes showed excellent performance compared to conventional Ag/AgCl electrodes at intense body movements while running at different speeds for up to 9 km over a duration of 24 h. Therefore, our proposed adhesive LIG-SF electrodes can be applied for long-term personalized healthcare monitoring and sports management applications.

Simultaneous diagnosis of papillary thyroid cancer and systemic mastocytosis.

Key Clinical Message: When managing patients with differentiated thyroid cancers (DTC) and lytic bone lesions, physicians should consider etiologies other than DTC bony metastases when there is no biochemical and functional radiographic evidence of extensive DTC burden. Abstract: Systemic mastocytosis (SM) is a clonal expansion of mast cells associated with an increased risk of solid malignancies. There is no known association between systemic mastocytosis and thyroid cancer. We report a young woman who presented with cervical lymphadenopathy, palpable thyroid nodule, and lytic bone lesions who was diagnosed with papillary thyroid cancer (PTC). The patient's post-surgical thyroglobulin was lower than expected for metastatic thyroid cancer, and the lytic bone lesions did not demonstrate uptake of I123. Upon further evaluation, the patient was found to have SM. We report a case of co-occurrence of PTC and SM.

64-year-old woman • hot flashes, facial flushing, excessive sweating, and palpitations • daily headaches • history of hypertension • Dx?

► hot flashes, facial flushing, excessive sweating, and palpitations ► daily headaches ► history of hypertension.

Dental loss, stress fractures, and musculoskeletal pain in a 48-year-old woman.

We report a 48-year-old female patient with various stress fractures of extremities, musculoskeletal pain, and tooth loss. Hypophosphatasia was diagnosed based on clinical and laboratory findings and ALPL genetic results. This case highlights the importance of early diagnosis of hypophosphatasia in adults and appropriate treatment to prevent further complications.

Dilemmas in the diagnosis and management of osteoporosis in a patient with alkaptonuria: Successful treatment with teriparatide.

Management of osteoporosis in patients with alkaptonuria can be challenging. This is the first case report confirming the effectiveness of teriparatide following zoledronic acid therapy in treating osteoporosis and preventing fragility fractures in a patient with alkaptonuria.

Graves' disease complicated by concurrent thyroid eye disease and pretibial myxedema successfully treated with teprotumumab.

We report a 51-year-old woman with thyroid eye disease and biopsy-proven pretibial myxedema that was subsequently treated with teprotumumab with improvement.

Strategies for improved management of hypothyroidism.

Management is clear-cut-yet many patients don't reach treatment goals. To optimize quality of life, master the fine points of T4 replacement and address the impact of comorbidities.

Improvement of depression in a patient with hypothyroidism and deiodinase polymorphism with LT3 Therapy.

We report a 54-year-old man with treatment-resistant depression (TRD) and hypothyroidism who responded to LT3/LT4 combination, rather than LT4 alone. He was able to discontinue all antidepressant medications eventually. Interestingly, the patient has a DIO2 polymorphism.

Histomorphological, histochemical and scanning electron microscopic investigation of the proventriculus (Ventriculus glandularis) of the hooded crow (Corvus cornix).

The current investigation aimed to clarify the histomorphological features, scanning electron microscopy (SEM) and histochemistry of the proventriculus in the adult hooded crow (Corvus cornix). Twenty-two adult birds of both sexes were collected from El-Fayoum and Beni-Suef governorates, Egypt; ten were used for anatomical investigation, two were scanned using SEM, and ten were subjected to routine histological technique. The obtained anatomical results revealed a small-sized spindle-shaped proventriculus obliquely located in the left ventral part of the body cavity with an average body weight, length and diameter of 1.689 ± 0.231 gm, 1.54 ± 0.383cm and 3.51 ± 0.416cm, respectively. The histological examination revealed a typical tubular organ. The mucosa exhibited several plicae and sulci that were lined with simple columnar cells. The lamina propria was composed of collagenous connective tissue infiltrated by lymphocytes, lymphatic aggregations and tubular glands. The submucosa consisted of collagenic fibres and compound tubuloalveolar glandular lobules lined with oxynticopeptic cells and enteroendocrine cells. The oxynticopeptic cells reacted negatively with PAS and Alcian Blue stains, whereas the ductal cells reacted positively with PAS only. Enteroendocrine cells were seen singly in the lamina epithelialis mucosae and were abundant in submucosal glands. The tunica musclaris was arranged in two layers covered by serosa. The proventricular glands' openings were noticed by SEM as raised tubes with regular circular outlines surrounded by anastomosed microscopic folds. The obtained histomorphological structure of the hooded crow's proventriculus revealed some shared morphological features with most species of birds and some variations that might be attributed to their diet and feeding behaviour.

Coexistence of Cushing Disease With a Solitary Adrenocorticotrophic Hormone-Dependent Adrenal Adenoma.

OBJECTIVE: We report a 49-year-old woman who had minimal features of Cushing syndrome and an incidentally discovered adrenal adenoma. She was subsequently diagnosed with pituitary-dependent Cushing syndrome. METHODS: Laboratory and imaging studies including serum cortisol, plasma adrenocorticotrophic hormone (ACTH), high dose dexamethasone test, corticotropin-releasing hormone test, computed tomography (CT) scan, and magnetic resonance imaging were performed. RESULTS: A 49-year-old woman was admitted for urosepsis. An abdominal CT scan performed during the urosepsis workup showed a 2.7-cm right adrenal adenoma. She denied any abdominal striae or other symptoms. Physical examination showed normal vital signs, minimal facial fullness without central obesity, and striae. Laboratory results were as follows: 24-hour-urine cortisol 294 µg (reference 4.0-50.0), midnight serum cortisol 23.0 µg/dL (reference < 7.5), and plasma ACTH level 39 pg/mL (reference 5-27). A corticotropin-releasing hormone stimulation test showed >20% rise in serum cortisol and >35% rise in ACTH levels. A pituitary magnetic resonance image showed a 5 mm pituitary lesion. The patient underwent transsphenoidal pituitary surgery, which confirmed an ACTH-secreting lesion. Postoperatively, she required hydrocortisone replacement for the next 10 months. A follow-up adrenal CT performed 6 months later showed a decrease in the size of the adrenal adenoma (1.8 cm). CONCLUSION: This case highlights the importance of recognizing the coexistence of ACTH-dependent Cushing disease with an adrenal adenoma and partial ACTH dependency of the adrenal adenoma.

A Rare Case of Familial Neurogenic Diabetes Insipidus in a 22-Year-Old Man.

OBJECTIVE: Diabetes insipidus (DI) can be classified into 2 types: central/neurogenic DI and nephrogenic DI. Most cases of central DI occur after brain surgery, trauma, tumor, or infection. Here we report a rare case of familial central DI due to a heterozygous AVP gene mutation. METHODS: A case of familial neurogenic DI has been described with thorough clinical, laboratory, and genetic workup. PubMed and Google scholar databases were used for literature discussion. RESULTS: A 22-year-old man presented with polyuria and polydipsia. He drank about 4 gallons of water everyday and urinated large volumes very frequently. His physical examination was unremarkable. After 2 hours of water-deprivation, his serum sodium level was 147 mmol/L, serum osmolality was 302 mOsm/kg with concurrent urine osmolality of 78 mOsm/kg, vasopressin level was <0.8 pg/mL, and copeptin level was <2.8 pmol/L, suggesting neurogenic DI. His brain magnetic resonance imaging revealed the absence of the posterior pituitary bright spot but a normal anterior pituitary gland. Genetic analysis revealed a nonfunctional heterozygous mutation in the AVP gene. Further questioning revealed that his mother also had the disease and that he had been treated with desmopressin as a child; however, it was later self-stopped. The patient was reinitiated on desmopressin, which improved his symptoms. CONCLUSION: Genetic mutations in the AVP gene represent a very rare etiology of DI, and patients with DI respond well to desmopressin treatment.

Severe Symptomatic Hypocalcemia, complicating cardiac arrhythmia following Cinacalcet (SensiparTM) administration: A Case Report.

Clinicians should closely monitor patients on calcimimetics for hypocalcemic symptoms and arrhythmia, even though asymptomatic hypocalcemia typically resolves without intervention.

Morphological characteristics of the forebrain in the donkey (Equus asinus): A compared atlas of magnetic resonance imaging and cross-sectional anatomy.

The brain is the most essential part of the central nervous system which regulates and coordinates all body activities. Based on its phylogenetic development from the neural tube, the brain is divided into rhombencephalon (hindbrain), mesencephalon (midbrain) and prosencephalon (forebrain). The present study is achieved to describe the morphological characteristics of the normal forebrain in the donkey using the matched magnetic resonance imaging (MRI) and cross-sectional anatomy. Ten cadaveric heads of healthy adult donkeys of both sexes were used. Two heads were examined using a 1.5 Tesla MRI scanner, and the brains of the other heads were gently extracted; six brains were sectioned into transverse, dorsal and sagittal slices, and two brains were grossly inspected. MR images were selected in correlation to their closely corresponding gross sections. Both cross-sectional anatomy and MRI scans showed extensive gyration of the neocortex. The forebrain structures appeared with variable intensities on three sequences, Flair, T1-weighted and T2-weighted MRI, enabling comprehensive evaluation of the relevant neuroanatomical structures. The present study provided a precise neuroanatomical atlas of the forebrain in the donkey which could help in the quick and efficient interpretation of clinical diseases of the forebrain, localization of the forebrain functions and evolutionary neurobiology.