Phosphaturic mesenchymal tumor: two cases highlighting differences in clinical and radiologic presentation.

Phosphaturic mesenchymal tumors are rare, usually benign neoplasms that occur in the soft tissue or bone and are the cause of nearly all cases of tumor-induced osteomalacia. Tumor-induced osteomalacia due to phosphaturic mesenchymal tumor is a challenging diagnosis to make-patients present with variable clinical and radiologic findings and the culprit neoplasm is often small and can occur anywhere head to toe. We present two cases of phosphaturic mesenchymal tumor in the scapular body and plantar foot. In both cases, the patient endured years of debilitating symptoms before a tissue diagnosis was eventually reached. Descriptions of clinical presentation, laboratory workup, surgical resection, and imaging characteristics, with a focus on CT, MRI, and functional imaging, are provided to assist with the diagnosis and management of this rare entity. A brief review of current literature and discussion of the differential diagnoses of phosphaturic mesenchymal tumor is also provided.

Prevalence and predictors of shared decision-making in goals-of-care clinician-family meetings for critically ill neurologic patients: a multi-center mixed-methods study.

BACKGROUND: Shared decision-making is a joint process where patients, or their surrogates, and clinicians make health choices based on evidence and preferences. We aimed to determine the extent and predictors of shared decision-making for goals-of-care discussions for critically ill neurological patients, which is crucial for patient-goal-concordant care but currently unknown. METHODS: We analyzed 72 audio-recorded routine clinician-family meetings during which goals-of-care were discussed from seven US hospitals. These occurred for 67 patients with 72 surrogates and 29 clinicians; one hospital provided 49/72 (68%) of the recordings. Using a previously validated 10-element shared decision-making instrument, we quantified the extent of shared decision-making in each meeting. We measured clinicians' and surrogates' characteristics and prognostic estimates for the patient's hospital survival and 6-month independent function using post-meeting questionnaires. We calculated clinician-family prognostic discordance, defined as ≥ 20% absolute difference between the clinician's and surrogate's estimates. We applied mixed-effects regression to identify independent associations with greater shared decision-making. RESULTS: The median shared decision-making score was 7 (IQR 5-8). Only 6% of meetings contained all 10 shared decision-making elements. The most common elements were "discussing uncertainty"(89%) and "assessing family understanding"(86%); least frequent elements were "assessing the need for input from others"(36%) and "eliciting the context of the decision"(33%). Clinician-family prognostic discordance was present in 60% for hospital survival and 45% for 6-month independent function. Univariate analyses indicated associations between greater shared decision-making and younger clinician age, fewer years in practice, specialty (medical-surgical critical care > internal medicine > neurocritical care > other > trauma surgery), and higher clinician-family prognostic discordance for hospital survival. After adjustment, only higher clinician-family prognostic discordance for hospital survival remained independently associated with greater shared decision-making (p = 0.029). CONCLUSION: Fewer than 1 in 10 goals-of-care clinician-family meetings for critically ill neurological patients contained all shared decision-making elements. Our findings highlight gaps in shared decision-making. Interventions promoting shared decision-making for high-stakes decisions in these patients may increase patient-value congruent care; future studies should also examine whether they will affect decision quality and surrogates' health outcomes.

Exploring Deep Learning Applications using Ultrasound Single View Cines in Acute Gallbladder Pathologies: Preliminary results.

RATIONALE AND OBJECTIVES: In this preliminary study, we aimed to develop a deep learning model using ultrasound single view cines that distinguishes between imaging of normal gallbladder, non-urgent cholelithiasis, and acute calculous cholecystitis requiring urgent intervention. METHODS: Adult patients presenting to the emergency department between 2017-2022 with right-upper-quadrant pain were screened, and ultrasound single view cines of normal imaging, non-urgent cholelithiasis, and acute cholecystitis were included based on final clinical diagnosis. Longitudinal-view cines were de-identified and gallbladder pathology was annotated for model training. Cines were randomly sorted into training (70%), validation (10%), and testing (20%) sets and divided into 12-frame segments. The deep learning model classified cines as normal (all segments normal), cholelithiasis (normal and non-urgent cholelithiasis segments), and acute cholecystitis (any cholecystitis segment present). RESULTS: A total of 186 patients with 266 cines were identified: Normal imaging (52 patients; 104 cines), non-urgent cholelithiasis (73;88), and acute cholecystitis (61;74). The model achieved a 91% accuracy for Normal vs. Abnormal imaging and an 82% accuracy for Urgent (acute cholecystitis) vs. Non-urgent (cholelithiasis or normal imaging). Furthermore, the model identified abnormal from normal imaging with 100% specificity, with no false positive results. CONCLUSION: Our deep learning model, using only readily obtained single-view cines, exhibited a high degree of accuracy and specificity in discriminating between non-urgent imaging and acute cholecystitis requiring urgent intervention.

Arrestin-3-assisted activation of JNK3 mediates dopaminergic behavioral sensitization.

In rodents with unilateral ablation of neurons supplying dopamine to the striatum, chronic treatment with the dopamine precursor L-DOPA induces a progressive increase of behavioral responses, a process known as behavioral sensitization. This sensitization is blunted in arrestin-3 knockout mice. Using virus-mediated gene delivery to the dopamine-depleted striatum of these mice, we find that the restoration of arrestin-3 fully rescues behavioral sensitization, whereas its mutant defective in c-Jun N-terminal kinase (JNK) activation does not. A 25-residue arrestin-3-derived peptide that facilitates JNK3 activation in cells, expressed ubiquitously or selectively in direct pathway striatal neurons, also fully rescues sensitization, whereas an inactive homologous arrestin-2-derived peptide does not. Behavioral rescue is accompanied by the restoration of JNK3 activity, as reflected by JNK-dependent phosphorylation of the transcription factor c-Jun in the dopamine-depleted striatum. Thus, arrestin-3-assisted JNK3 activation in direct pathway neurons is a critical element of the molecular mechanism underlying sensitization upon dopamine depletion and chronic L-DOPA treatment.

Atypical Chondroid Syringoma of the Toe.

Although chondroid syringoma rarely occurs outside the head and neck, the majority of malignant chondroid syringomas are identified in the extremities. Here, we present a case of atypical chondroid syringoma in the fifth toe. Diagnosis of chondroid syringoma with atypical cells was made following initial excisional biopsy and histology, necessitating repeated surgery for positive margins. In this case report, we examine the radiopathologic correlation of this diagnosis, detail the imaging findings of benign and malignant chondroid syringomas, and highlight how magnetic resonance imaging can be used to guide surgical planning and treatment course of this potentially malignant tumor.

Peritoneal equilibration testing: Your questions answered.

The peritoneal equilibration test (PET), first described in 1987, is a semiquantitative assessment of peritoneal transfer characteristics in patients undergoing peritoneal dialysis. It is typically performed as a 4-h exchange using 2.27/2.5% dextrose dialysate with serial measurements of blood and dialysate creatinine, urea, and glucose concentrations. The percentage absorption of glucose and D/P creatinine ratio are used to determine peritoneal solute transfer rates. It is used to both help guide peritoneal dialysis prescriptions and to prognosticate. There are several derivative tests which have been described in the literature. In this review, we describe the original PET, the various iterations of the PET, the information gleaned, and the use in the setting of poor solute clearance and in the diagnosis of membrane dysfunction, and limitations of the PET.

Savi-Scout Radar Localization: Transitioning From the Traditional Wire Localization to Wireless Technology for Surgical Guidance at Lumpectomies.

Breast-conserving surgery or lumpectomy requires localization of the lesion prior to surgery, which is traditionally accomplished by imaging-guided wire localization. Over the last decade, alternatives to wire localization have emerged. This work reviews the literature on one such wireless technology, SaviScout radar (SSR) system, and shares our experience with using this technology for presurgical tumor localization. The SSR surgical guidance system is non-radioactive. The radiologist implants a reflector device in the breast under mammography or ultrasound guidance at any time prior to surgery. The placement of this reflector can be confirmed from the cadence of a handheld percutaneous probe of a handpiece and console system. Results from several studies show that the surgical outcomes from SSR and wire-localization are similar. SSR provides operational advantages as the scheduling for reflector placement by radiologists is decoupled from surgery, but at an increased cost compared to wire-localization.

Current and upcoming radionuclide therapies in the direction of precision oncology: A narrative review.

As new molecular tracers are identified to target specific receptors, tissue, and tumor types, opportunities arise for the development of both diagnostic tracers and their therapeutic counterparts, termed "theranostics." While diagnostic tracers utilize positron emitters or gamma-emitting radionuclides, their theranostic counterparts are typically bound to beta and alpha emitters, which can deliver specific and localized radiation to targets with minimal collateral damage to uninvolved surrounding structures. This is an exciting time in molecular imaging and therapy and a step towards personalized and precise medicine in which patients who were either without treatment options or not candidates for other therapies now have expanded options, with tangible data showing improved outcomes. This manuscript explores the current state of theranostics, providing background, treatment specifics, and toxicities, and discusses future potential trends.

ACR Lung CT Screening Reporting and Data System, a Systematic Review and Meta-Analysis Before Change in US Preventative Services Taskforce Eligibility Criteria: 2014 to 2021.

OBJECTIVE: To review Lung CT Screening Reporting and Data System (Lung-RADS) scores from 2014 to 2021, before changes in eligibility criteria proposed by the US Preventative Services Taskforce. METHODS: A registered systematic review and meta-analysis was conducted in MEDLINE, Embase, CINAHL, and Web of Science in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines; eligible studies examined low-dose CT (LDCT) lung cancer screening at institutions in the United States and reported Lung-RADS from 2014 to 2021. Patient and study characteristics, including age, gender, smoking status, pack-years, screening timeline, number of individual patients, number of unique studies, Lung-RADS scores, and positive predictive value (PPV) were extracted. Meta-analysis estimates were derived from generalized linear mixed modeling. RESULTS: The meta-analysis included 24 studies yielding 36,211 LDCT examinations for 32,817 patient encounters. The meta-analysis Lung-RADS 1-2 scores were lower than anticipated by ACR guidelines, at 84.4 (95% confidence interval [CI] 83.3-85.6) versus 90% respectively (P < .001). Lung-RADS 3 and 4 scores were both higher than anticipated by the ACR, at 8.7% (95% CI 7.6-10.1) and 6.5% (95% CI 5.707.4), compared with 5% and 4%, respectively (P < .001). The ACR's minimum estimate of PPV for Lung-RADS 3 to 4 is 21% or higher; we observed a rate of 13.1% (95% CI 10.1-16.8). However, our estimated PPV rate for Lung-RADS 4 was 28.6% (95% CI 21.6-36.8). CONCLUSION: Lung-RADS scores and PPV rates in the literature are not aligned with the ACR's own estimates, suggesting that perhaps Lung-RADS categorization needs to be reexamined for better concordance with real-world screening populations. In addition to serving as a benchmark before screening guideline broadening, this study provides guidance for future reporting of lung cancer screening and Lung-RADS data.

Arrestin-3-assisted activation of JNK3 mediates dopaminergic behavioral and signaling plasticity in vivo.

In rodents with unilateral ablation of the substantia nigra neurons supplying dopamine to the striatum, chronic treatment with the dopamine precursor L-DOPA or dopamine agonists induces a progressive increase of behavioral responses, a process known as behavioral sensitization. The sensitization is blunted in arrestin-3 knockout mice. Using virus-mediated gene delivery to the dopamine-depleted striatum of arrestin-3 knockout mice, we found that the restoration of arrestin-3 fully rescued behavioral sensitization, whereas its mutant defective in JNK activation did not. A 25-residue arrestin-3-derived peptide that facilitates JNK3 activation in cells, expressed ubiquitously or selectively in the direct pathway striatal neurons, fully rescued sensitization, whereas an inactive homologous arrestin-2-derived peptide did not. Behavioral rescue was accompanied by the restoration of JNK3 activity and of JNK-dependent phosphorylation of the transcription factor c-Jun in the dopamine-depleted striatum. Thus, arrestin-3-dependent JNK3 activation in direct pathway neurons is a critical element of the molecular mechanism underlying sensitization.

Prognostic Language in Critical Neurologic Illness: A Multicenter Mixed-Methods Study.

BACKGROUND AND OBJECTIVES: There are no evidence-based guidelines for discussing prognosis in critical neurologic illness, but in general, experts recommend that clinicians communicate prognosis using estimates, such as numerical or qualitative expressions of risk. Little is known about how real-world clinicians communicate prognosis in critical neurologic illness. Our primary objective was to characterize prognostic language clinicians used in critical neurologic illness. We additionally explored whether prognostic language differed between prognostic domains (e.g., survival, cognition). METHODS: We conducted a multicenter cross-sectional mixed-methods study analyzing deidentified transcripts of audio-recorded clinician-family meetings for patients with neurologic illness requiring intensive care (e.g., intracerebral hemorrhage, traumatic brain injury, severe stroke) from 7 US centers. Two coders assigned codes for prognostic language type and domain of prognosis to each clinician prognostic statement. Prognostic language was coded as probabilistic (estimating the likelihood of an outcome occurring, e.g., "80% survival"; "She'll probably survive") or nonprobabilistic (characterizing outcomes without offering likelihood; e.g., "She may not survive"). We applied univariate and multivariate binomial logistic regression to examine independent associations between prognostic language and domain of prognosis. RESULTS: We analyzed 43 clinician-family meetings for 39 patients with 78 surrogates and 27 clinicians. Clinicians made 512 statements about survival (median 0/meeting [interquartile range (IQR) 0-2]), physical function (median 2 [IQR 0-7]), cognition (median 2 [IQR 0-6]), and overall recovery (median 2 [IQR 1-4]). Most statements were nonprobabilistic (316/512 [62%]); 10 of 512 prognostic statements (2%) offered numeric estimates; and 21% (9/43) of family meetings only contained nonprobabilistic language. Compared with statements about cognition, statements about survival (odds ratio [OR] 2.50, 95% CI 1.01-6.18, p = 0.048) and physical function (OR 3.22, 95% 1.77-5.86, p < 0.001) were more frequently probabilistic. Statements about physical function were less likely to be uncertainty-based than statements about cognition (OR 0.34, 95% CI 0.17-0.66, p = 0.002). DISCUSSION: Clinicians preferred not to use estimates (either numeric or qualitative) when discussing critical neurologic illness prognosis, especially when they discussed cognitive outcomes. These findings may inform interventions to improve prognostic communication in critical neurologic illness.

Rothia Mucilaginosa Peritonitis Complicating Peritoneal Dialysis.

For the 11% of dialysis patients worldwide who receive peritoneal dialysis (PD) to treat their end-stage kidney disease (ESKD), recent PD-associated peritonitis is estimated to contribute to 5-30% of reported mortality.1,2 These infections are most commonly caused by coagulase-negative Staphylococcus (32%), followed by culture-negative peritonitis (16%), and the timely identification and targeted treatment of peritonitis is critical to avoid complications such as PD catheter removal.3 Here, we present a case of atypical Rothia mucilaginosis peritonitis in a PD patient.

Variability of Prognostic Communication in Critically Ill Neurologic Patients: A Pilot Multicenter Mixed-Methods Study.

IMPORTANCE: Withdrawal-of-life-sustaining treatments (WOLST) rates vary widely among critically ill neurologic patients (CINPs) and cannot be solely attributed to patient and family characteristics. Research in general critical care has shown that clinicians prognosticate to families with high variability. Little is known about how clinicians disclose prognosis to families of CINPs, and whether any associations exist with WOLST. OBJECTIVES: Primary: to demonstrate feasibility of audio-recording clinician-family meetings for CINPs at multiple centers and characterize how clinicians communicate prognosis during these meetings. Secondary: to explore associations of 1) clinician, family, or patient characteristics with clinicians' prognostication approaches and 2) prognostication approach and WOLST. DESIGN SETTING AND PARTICIPANTS: Forty-three audio-recorded clinician-family meetings during which prognosis was discussed from seven U.S. centers for 39 CINPs with 88 family members and 27 clinicians. MAIN OUTCOMES AND MEASURES: Two investigators qualitatively coded transcripts using inductive methods (inter-rater reliability > 80%) to characterize how clinicians prognosticate. We then applied univariate and multivariable multinomial and binomial logistic regression. RESULTS: Clinicians used four distinct prognostication approaches: Authoritative (21%; recommending treatments without discussing values and preferences); Informational (23%; disclosing just the prognosis without further discussions); advisory (42%; disclosing prognosis followed by discussion of values and preferences); and responsive (14%; eliciting values and preferences, then disclosing prognosis). Before adjustment, prognostication approach was associated with center (p < 0.001), clinician specialty (neurointensivists vs non-neurointensivists; p = 0.001), patient age (p = 0.08), diagnosis (p = 0.059), and meeting length (p = 0.03). After adjustment, only clinician specialty independently predicted prognostication approach (p = 0.027). WOLST decisions occurred in 41% of patients and were most common under the advisory approach (56%). WOLST was more likely in older patients (p = 0.059) and with more experienced clinicians (p = 0.07). Prognostication approach was not independently associated with WOLST (p = 0.198). CONCLUSIONS AND RELEVANCE: It is feasible to audio-record sensitive clinician-family meetings about CINPs in multiple ICUs. We found that clinicians prognosticate with high variability. Our data suggest that larger studies are warranted in CINPs to examine the role of clinicians' variable prognostication in WOLST decisions.