Novel Biodistribution of PSMA Radiotracer in the Uvula of Patients Undergoing PSMA PET/CT.

ABSTRACT: Prostate-specific membrane antigen (PSMA) PET/CT is an imaging technique that detects primary and metastatic prostate cancer and evaluates treatment effectiveness. The radioligands for PSMA PET/CT are known to have physiological off-target uptake in various tissues. These include the well-known off-target major and minor salivary glands. We report that, in addition to this location, radioligand uptake can be seen in the uvula, which we suggest is from salivary tissue in this location. PSMA uptake in the uvula is not reported in the literature and is a rare, but normal location for tracer biodistribution in some patients.

Use of GlideScope in Patients Undergoing NIM Thyroidectomy.

OBJECTIVES: Thyroidectomy and parathyroidectomy using the nerve integrity monitor (NIM) require proper placement of the endotracheal tube with electrodes aligned correctly within the larynx. The purpose of this study is to determine the percentage of patients who require positional adjustments of the endotracheal tube prior to beginning surgery and to understand the value of using the GlideScope to assure proper NIM tube placement within the larynx. METHODS: This prospective study examines operative data from 297 patients who underwent NIM thyroidectomy and parathyroidectomy. After routine orotracheal intubation by an anesthesiologist and positioning of the patient for surgery, a GlideScope was used to check the position of the tube in 2 planes: depth of tube placement and rotation of the tube within the larynx assuring proper placement of the electromyogram electrodes within the glottis. RESULTS: Tube adjustment was required for 66.5% of patients. In 48.1% of cases, tube retraction or advancement to a proper depth was needed. Tube rotation was required for 30.1% of patients, and 11.8% of patients required both adjustment of tube depth and tube rotation to properly align electrodes. CONCLUSIONS: After the anesthesiologist places the NIM endotracheal tube, and the patient is positioned for surgery, additional tube adjustment is often needed prior to the start of surgery. The GlideScope is readily available in the operating suite, its use adds little time to the procedure, and assures proper NIM tube placement. The use of the GlideScope is recommended.

MRI of 3-hydroxyisobutyryl-CoA hydrolase (HIBCH) deficiency.

3-Hydroxyisobutyryl-CoA hydrolase (HIBCH) deficiency is a rare mitochondrial disorder of valine metabolism which may present with motor delay, hypotonia, ataxia, dystonia, seizures poor feeding, and organic aciduria. Neuroimaging findings include signal abnormalities of the deep gray matter, particularly the globus pallidi, and cerebral peduncles. We report a 15-month-old male patient with HIBCH deficiency who presented with paroxysmal tonic upgaze of infancy, motor delay, and hypotonia. MRI revealed characteristic bilateral, symmetric signal abnormalities in the basal ganglia and a mutation in HIBCH was confirmed with whole exome sequencing. HIBCH should be a consideration in patients with Leigh-like features, especially if neuroimaging changes primarily affect the globus pallidi. Recognition of this pattern may help guide targeted testing and expedite the diagnosis and treatment of this rare disease.

Unexpected cancellation on a catatonic patient's electroconvulsive therapy due to the coronavirus pandemic.

We report a case of a 39-year-old woman with a psychiatric history of schizoaffective disorder with catatonia, dependent personality disorder and substance use disorder whose symptoms have been very difficult to control. During her most recent inpatient admission, she was treated with electroconvulsive therapy (ECT) for catatonia. Our treatment team was hopeful that ECT was making a difference for this patient. However, she was only able to receive two sessions of treatment due to new hospital protocols related to the coronavirus pandemic. Although the patient was not suspected to have the coronavirus, she could no longer undergo ventilation with a bag and mask during the procedure. Bag-mask ventilation is known to aerosolise the coronavirus and other diseases and potentially put healthcare workers at risk. Although orotracheal intubation also aerosolises the coronavirus, this was the only means of airway management still allowed by anaesthesia providers at this time. Our psychiatry team estimated that the risks of intubation outweighed the benefits of treatment, and ECT was cancelled. Without additional ECT treatments, the patient again decompensated for several weeks before being stabilised on clozapine, haloperidol and lorazepam. Although she eventually had a positive treatment outcome, her hospital course was likely prolonged due to unforeseen events related to the novel coronavirus. We feel that the current medical climate is unprecedented and is interfering with necessary psychiatric treatment in an unanticipated way. Anaesthesiologists will need to be flexible while working with psychiatrists and identify safe ways to provide this necessary psychiatric treatment for patients.

Additional Benefits of Facial Nerve Monitoring during Otologic Surgery.

OBJECTIVE: This study assesses the role of facial nerve monitoring (FNM) for intraoperative decision making during otologic surgery and possible benefits beyond protecting facial nerve integrity. STUDY DESIGN: This prospective study examines intraoperative FNM data and structured interviews collected during 52 otologic procedures. SETTING: Tertiary referral center. SUBJECTS AND METHODS: Subjects include adults and children undergoing middle ear or mastoid surgery. Data include intraoperative neuromonitoring activity and structured interviews conducted with the operating surgeon immediately following surgery. RESULTS: Facial nerve stimulation was used to confirm the position of the nerve in 42 of 52 surgical procedures. In 26.9% of cases, the patient became "light" and moved under anesthesia, which was predicted by neuromonitoring 71.4% of the time. Through structured interviews, the operating surgeons reported the following. (1) The facial nerve took an unexpected anatomic course in 7.8% of patients and was difficult to identify in 39.2%. (2) The nerve was at increased risk of injury in 66.7% of cases due to chronic disease or previous surgery. (3) Among these high-risk cases, the monitor helped reduce the risk of nerve damage 100% of the time. (4) Neuromonitoring allowed the surgeon to operate faster 86.5% of the time, and (5) FNM allowed the resident to perform more of the operation 68.9% of the time. No patients experienced postoperative facial weakness. CONCLUSIONS: Beyond potentially protecting facial nerve integrity, this study identified additional benefits of FNM, including warning of patient movement during anesthesia, confirming facial nerve anatomic location, reducing operative time, and enhancing resident surgical experience.

Gorlin-like phenotype in a patient with a PTCH2 variant of uncertain significance.

Gorlin syndrome, also known as Nevoid Basal-Cell Carcinoma Syndrome (NBCCS), is an autosomal dominant tumor predisposition syndrome that presents early in life with characteristic congenital malformations and tumors. This syndrome most commonly results from germline mutations of the PTCH1 tumor suppressor gene, which shows high penetrance and great intra and interfamilial phenotypic variability, as well as the SUFU tumor suppressor gene. Recently, the PTCH2 gene has also been implicated as a cause of Gorlin syndrome. Notably, these patients displayed milder phenotypes of Gorlin syndrome when considered against PTCH1 and SUFU-related disease. We report a patient with a novel PTCH2 mutation inherited from his father. The proband displays several minor diagnostic features of Gorlin syndrome, supporting the pathogenic role of this gene. Features in the proband include macrocephaly, a wide face, prominent forehead, hypertelorism/telecanthus, large eyes, cleft lip and palate, thin vertical palmar creases, penoscrotal inversion, and a hyperpigmented spot on his penis. His father displays macrocephaly, several nevi on his back and shoulders, and a single palmar pit on his left hand, raising suspicion for Gorlin syndrome. Whole exome sequence (trio) found that the proband and father are heterozygous for NM_003738.4:c.3347C>T;p.(Pro1116Leu) in exon 21 of PTCH2, found also in his mildly affected brother. This semi-conservative amino acid substitution has been reported in the literature, but its significance is unclear. Notably, the proband, brother, and father do not meet clinical criteria for Gorlin syndrome. However, the clinical findings described in this family support the association between PTCH2 mutations and Gorlin-like phenotypes.

Photobleaching studies reveal that a single amino acid polymorphism is responsible for the differential binding affinities of linker histone subtypes H1.1 and H1.5.

Mammals express six major somatic linker histone subtypes, all of which display dynamic binding to chromatin, characterized by transient binding at a given location followed by rapid translocation to a new site. Using photobleaching techniques, we systematically measured the exchange rate of all six mouse H1 subtypes to determine their relative chromatin-binding affinity. Two subtypes, H1.1 and H1.2, display binding affinities that are significantly lower than all other subtypes. Using in vitro mutagenesis, the differences in chromatin-binding affinities between H1.1 (lower binding affinity) and H1.5 (higher binding affinity) were mapped to a single amino acid polymorphism near the junction of the globular and C-terminal domains. Overexpression of H1.5 in density arrested fibroblasts did not affect cell cycle progression after release. By contrast, overexpression of H1.1 resulted in a more rapid progression through G1/S relative to control cells. These results provide structural insights into the proposed functional significance of linker histone heterogeneity.