Utility of 99mTc-Sestamibi Single-Photon Emission Computed Tomography (SPECT)/CT Single Imaging Strategy in the Preoperative Localization of Parathyroid Adenoma.

Background Primary hyperparathyroidism is an endocrinopathy associated with dysregulated calcium homeostasis. The most common etiology is a parathyroid adenoma most definitely managed via a parathyroidectomy. The two main surgical approaches include a minimally invasive parathyroidectomy (MIP) and open four-gland exploration (4-GE). MIP is the preferred operative strategy since it is associated with less postoperative complications. Accurate preoperative imaging is essential in informing the optimal approach to surgery. MIP is only considered if adenoma is able to be localized precisely. The most commonly used imaging modality includes ultrasound and sestamibi single-photon emission computed tomography (SPECT)/CT, either as a single or combination strategy. Other options include MRI, PET, and 4D CT. There is no universally accepted preoperative imaging strategy. The literature is discordant and recommendations proposed by existing guidelines are incongruous. Objectives This study aimed to evaluate currently utilized preoperative parathyroid imaging modalities at our institution and correlate them with surgical and histological findings to determine the most efficient imaging strategy to detect adenomas for our patient cohort. This will ultimately guide the best surgical approach for patients receiving parathyroidectomies. Methods This is a retrospective observational study of all patients undergoing first-time surgery for biochemically proven primary hyperparathyroidism at our institution over the past five years. Multiple data points were collected including modality of preoperative disease localization, operation type, final histopathology, biochemical investigations, and cure rate. Patients were categorized into one of three groups based on the method of disease localization. Results A total of 244 patients had parathyroidectomies performed at our institution in the past five years from January 2018 to December 2022. Ninety-six percent (n=235) of all patients received dual imaging preoperatively with SPECT/CT and ultrasound performed on the same day and therefore included in this study. A total of 64.3% (n=151) underwent MIP. Eighty percent (n=188) of all histopathology revealed adenomas and 26.8% (n=63) of patients had adenoma localized on SPECT/CT only (sensitivity: 58.1%, specificity: 71%, and positive predictive value {PPV}: 85.7%). A total of 9.8% (n=23) had adenoma localized on ultrasound only (sensitivity: 15.6%, specificity: 73.3%, and PPV: 65.2%). A total of 45.1% (n=106) were dual localized on both SPECT/CT and ultrasound (sensitivity: 75.6%, specificity: 46.6%, and PPV: 84.9%). The cure rate was 91.5% in the dual-localized group, 86% in the dual-unlocalized group, and 96.5% when localized with SPECT/CT alone. Conclusion A dual-imaging modality with SPECT/CT and ultrasound should remain the first-line imaging strategy. This approach has higher sensitivity rates and poses no inherent patient or surgical-related risks. Patients with disease unlocalized on SPECT/CT alone had a positive predictive value, specificity, and likelihood ratio for adenoma detection comparable to dual-localized patients. Therefore, SPECT/CT alone is sufficient for directing MIP in the presence of a negative ultrasound.

Informed Written Consent for Emergency and Elective General Surgery at a Model 4 Hospital: A Closed-Loop Audit.

Introduction The objective of this investigation was to conduct an audit of the consent form standards signed by patients before elective or emergency general surgery at our institution. The investigation involved a comparison of these standards with those outlined in the "HSE National Consent Policy 2022" established by the Health Service Executive (HSE) and the Royal College of Surgeons in Ireland (RCSI). In the event of discrepancies, we intended to complete the audit loop by educating general surgeons on the essential standards for obtaining written consent in both elective and emergency general surgical procedures. Methods To assess the quality of patient consent, a pre-interventional phase was conducted over one week. Information was gathered exclusively through electronic medical record systems. Subsequent to the data analysis, an in-person educational session was conducted to enlighten non-consultant hospital doctors (NCHDs) in surgery about the significance of informed written consent and the criteria for lawful consent according to local guidelines established by the HSE and the RCSI. Three months following the intervention, a follow-up cycle was carried out to evaluate whether there were any improvements in the standards of consent. Results In the initial phase, prior to intervention, a total of 95 consent forms were collected. The patient's name, date of birth (DOB), and hospital board number (BN) were accurately recorded in all consent forms. However, only 66% (n=63) were accurately documented without the use of abbreviations or acronyms. Following the intervention, 145 consent forms were gathered. All appropriately indicated the patient's name, DOB, and BN. However, 84% (n=122) of consent forms were correctly labeled without the use of abbreviations or acronyms (p=0.0017). Conclusion This closed-loop review illustrates that the quality of consent can be notably enhanced through a straightforward educational intervention led by NCHDs in general surgery. Such interventions can be instructive, leading to improved consent form documentation. This, in turn, enhances patient safety and helps prevent potential medico-legal repercussions for both healthcare providers and institutions.

Radiomics to Differentiate Malignant and Benign Breast Lesions: A Systematic Review and Diagnostic Test Accuracy Meta-Analysis.

Breast cancer is a prevalent global health concern, necessitating accurate diagnostic tools for effective management. Diagnostic imaging plays a pivotal role in breast cancer diagnosis, staging, treatment planning, and outcome evaluation. Radiomics is an emerging field of study in medical imaging that contains a broad set of computational methods to extract quantitative features from radiographic images. This can be utilized to guide diagnosis, treatment response, and prognosis in clinical settings.  A systematic review was performed in concordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy. Quality was assessed using the radiomics quality score. Diagnostic sensitivity and specificity of radiomics analysis, with 95% confidence intervals (CIs), were included for meta-analysis. The area under the curve analysis was recorded. An extensive statistical analysis was performed following the Cochrane guidelines. Statistical significance was determined if p-values were less than 0.05. Statistical analyses were conducted using Review Manager (RevMan), Version 5.4.1. A total of 31 manuscripts involving 8,773 patients were included, with 17 contributing to the meta-analysis. The cohort comprised 56.2% malignant breast cancers and 43.8% benign breast lesions. MRI demonstrated a sensitivity of 0.91 (95% CI: 0.89-0.92) and a specificity of 0.84 (95% CI: 0.82-0.86) in differentiating between benign and malignant breast cancers. Mammography-based radiomic features predicted breast cancer subtype with a sensitivity of 0.79 (95% CI: 0.76-0.82) and a specificity of 0.81 (95% CI: 0.79-0.84). Ultrasound-based analysis yielded a sensitivity of 0.92 (95% CI: 0.90-0.94) and a specificity of 0.85 (95% CI: 0.83-0.88). Only one study reported the results of radiomic evaluation from CT, which had a sensitivity of 0.95 (95% CI: 0.88-0.99) and a specificity of 0.56 (95% CI: 0.45-0.67).  Across different imaging modalities, radiomics exhibited robust diagnostic accuracy in differentiating benign and malignant breast lesions. The results underscore the potential of radiomic assessment as a minimally invasive alternative or adjunctive diagnostic tool for breast cancer. This is pioneering data that reports on a novel diagnostic approach that is understudied and underreported. However, due to study limitations, the complexity of this technology, and the need for future development, biopsy still remains the current gold standard method of determining breast cancer type.

An Atypical Presentation of Creutzfeldt-Jakob Disease as a Stroke Mimic: Experience From an Irish Tertiary Center.

Sporadic Creutzfeldt-Jakob Disease (sCJD) is a rare neurodegenerative prion disease that presents with symptoms of rapid neuropsychiatric decline including dementia, behavioural abnormalities, and loss of higher cortical function. Patients commonly present with rapidly progressive neuromotor symptoms such as ataxia and myoclonus. Very few cases of CJD have been reported in which the patient initially presents with stroke symptoms such as hemiparesis as their primary presenting symptom. We present a case of a 56-year-old male who initially presented to the stroke unit with waxing and waning left-sided weakness and a non-corresponding ipsilateral left-sided acute parietal infarct on diffusion-weighted MRI. Over four weeks, his condition progressively worsened with declining cognitive function, motor dysfunction, sphincter dysfunction, and eventual death.

Rare Cutaneous Manifestations of Erdheim Chester Disease: A Case Report and Literature Review.

Erdheim Chester disease (ECD) is a rare and complex non-Langerhans histiocytic systemic disease that affects multiple organ systems, including the bones, heart, lungs, and central nervous system. Fewer than 1,000 cases have been reported in the medical literature and dermatological manifestations of the disease are rare but can provide valuable diagnostic clues for this challenging disease. The cutaneous manifestations of ECD can take many forms, including nodules, plaques, papules, and xanthomas. These lesions can occur on any part of the body and may be solitary or multiple. Cutaneous manifestations of ECD have been reported to occur in up to 20% of cases, but the true prevalence may be higher, as many cases may go undiagnosed. We present the case of a 62-year-old gentleman with a history of ECD currently on vemurafenib who presented with multiple painless subcutaneous nodules on his back after an excision biopsy under local anesthetic revealed histological features of ECD. The objective of this case report is to raise awareness of ECD and its dermatological manifestations. Further research is warranted to better understand the pathogenesis and morphology of cutaneous involvement in ECD.

A Surgical Presentation of Churg-Strauss Syndrome.

Eosinophilic granulomatosis with polyangiitis (EGPA) or Churg-Strauss syndrome (CSS) is a rare, autoimmune vasculitis usually affecting small and medium-sized blood vessels in its later phases. It is a diffuse, systemic, multisystem disease that is reported to present with gastrointestinal manifestations but very rarely as an acute abdomen secondary to eosinophilic peritonitis. A 28-year-old relatively healthy male with a pre-existing diagnosis of inactive pulmonary sarcoidosis presented to the emergency department with an acute abdomen. After an exploratory laparotomy, multi-specialty involvement, and extensive investigations to exclude other differentials, a diagnosis of EGPA was made. The patient was treated with systemic glucocorticoids initially, followed by a tapering course of steroids and anti-interleukin 5 monoclonal antibodies as maintenance upon remission. EGPA can manifest in a myriad of ways including an acute abdomen, and medical treatment is useful in managing this presentation. Surgeons should be aware of the atypical causes of acute abdomen and should routinely broaden their differential diagnosis to include medical pathologies.