4D SPECT/CT: A Hybrid Approach to Primary Hyperparathyroidism.

Our rationale was to review the imaging options for patients with primary hyperparathyroidism and to advocate for judicious use of 4-dimensional (4D) SPECT/CT to visualize diseased parathyroid glands in patients with complex medical profiles or in whom other imaging modalities fail. We review the advantages and disadvantages of traditional imaging modalities used in preoperative assessment of patients with primary hyperparathyroidism: ultrasound, SPECT, and 4D CT. We describe a scheme for optimizing and individualizing preoperative imaging of patients with hyperfunctioning parathyroid glands using traditional modalities in tandem with 4D SPECT/CT. Using the input from radiologists, endocrinologists, and surgeons, we apply patient criteria such as large body habitus, concomitant multiglandular disease, multinodular thyroid disease, confusing previous imaging, and unsuccessful previous surgery to create an imaging paradigm that uses 4D SPECT/CT yet is cost-effective, accurate, and limits extraneous radiation exposure. 4D SPECT/CT capitalizes on the strengths of SPECT and 4D CT and addresses limitations that exist when these modalities are used in isolation. In select patients with complicated clinical parameters, preoperative imaging with 4D SPECT/CT can improve accuracy yet remain cost-effective.

Melanoma Detected Through Teledermatology Versus In-Person Visits.

Background: Early detection of melanoma improves survival; however, patients face long wait times to receive dermatology care. Teledermatology (TD) is a promising tool to optimize access to care and has shown promise for the identification of malignancies but has not been well studied for melanoma. We evaluated the utility of TD as a triage tool to allow high-risk lesions of concern to be seen more expeditiously. Methods: Patient sociodemographic factors and histological characteristics of 836 melanomas biopsied between March 2020 and November 2022 in the University of Pittsburgh Medical Center health system were retrospectively evaluated, stratified by initial appointment type of TD versus in-person visit. Results: Patients first seeking care through teledermatology had shorter wait times to initial evaluation (p < 0.001) and eventual biopsy (p < 0.001), and these melanomas had higher Breslow thickness (p < 0.001), were more ulcerated (p = 0.002), invasive (p = 0.001), and of a more aggressive subtype (p = 0.007) than those initially evaluated in-person. TD was also utilized by a higher proportion of younger (p = 0.001) and non-white (p = 0.03) patients who identified their own lesion (p < 0.001). Conclusions: TD may be a strategy to improve melanoma outcomes by providing an accessible avenue of expedited care for high-risk lesions associated with worse clinical prognosticators of disease.

Descriptive and Concordance Data for Asynchronous Teledermatology Consultations for Dermatitis: A Retrospective Study.

Background: Implementation of teledermatology for assessing dermatitis patients provides comparable diagnostic and management outcomes to in-person visits, but studies on consumer to physician asynchronous teledermatology (eDerm) consults submitted by patients in large dermatitis cohorts are limited. The objective of this study was to retrospectively assess associations of eDerm consults with diagnostic accuracy, management, and follow-up in a large cohort of dermatitis patients. Methods: One thousand forty-five eDerm encounters between April 1, 2020, and October 29, 2021, recorded in the University of Pittsburgh Medical Center Health System Epic electronic medical record were reviewed. Descriptive statistics and concordance were analyzed using chi-square. Results: Asynchronous teledermatology modified/changed treatment in 97.6% of cases and had the same diagnosis between teledermatology and in-person follow-up in 78.3% of cases. Patients following up in the time line requested were more likely to follow-up in person (61.2% vs. 43.8%) than those who did not. Patients with intertriginous dermatitis (p = 0.003), preexisting conditions (p = 0.002), who required follow-ups (<0.0001), and moderate-high severity scores of 4-7 (p = 0.019) were more likely to follow up in the time line requested. Limitations: Lack of similar in-person visit data did not allow us to compare descriptive and concordance data between eDerm and clinic visits. Conclusions: eDerm offers a quick accessible solution to provide comparable dermatologic care for patients with dermatitis.

Isolated pulmonary valve endocarditis in a patient without structural heart disease or a history of intravenous drug use.

We present a case of a febrile patient in his 70s who was found to have isolated native pulmonary valve vegetations on echocardiography, and Enterococcus faecalis on blood cultures. Of note, our patient had none of the typical risk factors associated with this rare form of endocarditis previously described in only a handful of case reports.

Impact of DTI tractography on surgical planning for resection of a pediatric pre-pontine neurenteric cyst: a case discussion and literature review.

We report a case of a four-year-old male who presented with symptoms of brainstem compression and lower cranial nerve neuropathies. MRI revealed a large, pre-pontine mass causing brainstem compression with an uncertain intra-axial component. Using diffusion tensor imaging (DTI) tractography and other imaging modalities, we were able to confirm that the lesion was extra-axial and did not involve the corticospinal tracts. In addition, DTI tractography illustrated that corticospinal tracts were displaced to the right obligating a left-sided approach. Upon resection, the mass was identified as a pre-pontine, extra-axial neurenteric cyst (NEC), which represents a rare finding in the pediatric population. The patient ultimately did well following the drainage and resection of the cyst wall and had excellent recovery. In this paper, we discuss the pathophysiology of and treatment options for NECs and explain how DTI tractography in our case assisted in planning the surgical approach.

Myxopapillary ependymoma in children: a study of 11 cases and a comparison with the adult experience.

BACKGROUND: Myxopapillary ependymomas (MEPN) are uncommon tumors of the central nervous system, mainly occurring within the conus medullaris-filum terminale. MEPNs can also present in the skin and underlying soft tissues of the sacrococcygeal region. The incidence of extramedullary MEPNs in children is unclear. PROCEDURE: We retrospectively reviewed our institutional files for MEPN cases between the years 1990-2012. A total of 11 pediatric and 38 adult cases were identified and compared to determine differences between these two distinct age groups. RESULTS: There were 40 (82%) tumors arising in the spine and nine (18%) in extramedullary sites. Pathologic examination revealed that extramedullary and spinal MEPNs were indistinguishable morphologically and immunophenotypically. Among the 11 children with MEPNs, seven had tumors presenting in extramedullary sites whereas only two adults (5%) had extramedullary tumors; this difference was highly significant (P < 0.0001). The lumbosacral portion of the spinal cord was the primary site for the remaining 40 MEPNs, four (10%) of which presented in children. One extramedullary MEPN (9%) recurred in a 45-year-old woman, and five (11%) of 40 spinal tumors recurred and/or metastasized; two of four children with spinal MEPNs developed recurrences and a manifestation to the aggressive nature of the latter tumor in the spinal cord of children. CONCLUSIONS: Based upon our experience, MEPN in children is more likely to present in the extramedullary soft tissues of the sacrococcygeal region where its behavior is more indolent than those tumors arising in the spinal cord in children.

Myelodysplastic syndrome with pulmonary tumor thrombotic microangiopathy in an 11-year-old male patient.

Myelodysplastic syndrome (MDS) and pulmonary tumor thrombotic microangiopathy (PTTM) are independently rare in the pediatric population. This report describes an 11-year-old male patient who initially presented with respiratory distress and cardiovascular collapse. A large left main pulmonary artery embolus and multiple, smaller pulmonary thromboemboli were widely dispersed throughout both lungs. Despite aggressive supportive care, he died within seven hours of admission. A complete postmortem examination was performed, leading to the diagnoses of primary MDS and microthrombi in the lungs, including the characteristic fibroproliferative lesions seen in PTTM. Individually, both conditions are extremely uncommon, and therefore the coincidence of these 2 conditions in a child is singularly unique.

Knocking down nucleolin expression in gliomas inhibits tumor growth and induces cell cycle arrest.

Nucleolin is a multifunctional protein whose expression often correlates with increased cellular proliferation. While the expression of nucleolin is often elevated in numerous cancers, its expression in normal human brain and in astrocytomas has not been previously reported. Using paraffin-embedded sections from normal adult autopsy specimens and glioma resection specimens, we demonstrate that nucleolin expression is limited in the normal human brain specifically to mature neurons, ependymal cells, and granular cells of the dentate gyrus. While astrocytes in the normal human brain do not express nucleolin at significant levels, glioblastoma cell lines and primary human astrocytoma cells exhibit considerable nucleolin expression. Reduction of nucleolin expression through siRNA-mediated knockdown in the U87MG glioblastoma cell line caused a dramatic decrease in cell proliferation and induced cell cycle arrest in vitro. Moreover, conditional siRNA knockdown of nucleolin expression in U87MG intracranial xenografts in nude mice caused dramatic reduction in tumor size. Taken together, these results implicate nucleolin in the regulation of human astrocytoma proliferation in vitro and tumorigenicity in vivo and suggest that nucleolin may represent a potential novel therapeutic target for astrocytomas.