Kelsey-Seybold Clinic

Cushing’s syndrome is a rare disorder caused by prolonged exposure to glucocorticoids, either from endogenous overproduction or exogenous sources, with exogenous steroid use being the most common etiology. Clinical manifestations may include moon facies, abdominal striae, easy bruising, muscle weakness, and complications such as osteoporosis and fragility fractures. Many remedies and supplements marketed for inflammatory conditions are sold online or over the counter, and some may contain hidden or undisclosed steroids that can lead to hypercortisolism. We present a case of a 52-year-old man with osteoporosis who sustained fragility fractures and became wheelchair-bound due to progressive lower extremity weakness. Evaluation demonstrated suppression of the hypothalamic-pituitary-adrenal axis, with undetectable salivary and urinary cortisol levels. Further investigation revealed long-term use of Artri King, a supplement for musculoskeletal pain that contains undisclosed glucocorticoids. This case highlights the risk of unregulated supplements causing iatrogenic Cushing’s syndrome and its associated complications.

Abstract Multi‐dimensional detector arrays have been adopted in radiation therapy clinics by medical physicists for various types of measurements. Typical applications of such devices include plan quality assurance (QA) measurements, periodic QA measurements for constancy checks of beam flatness and symmetry, as well as dose and beam quality constancy checks for linear accelerators (linacs). The multi‐dimensional arrays vary in terms of their size, detector types, and usage. This report provides guidelines to the users on initial and ongoing performance assessments that should be performed to ensure proper functionality of ion chamber and diode multi‐detector arrays that are positioned on the linac couch or gantry mounts and used for patient‐specific quality assurance (PSQA) and machine QA. The characteristics of the most common detector arrays are provided in this report along with their intended use. After reading this report, the user should understand how to assess the detector array's performance and proceed with its use. The report describes the most relevant array parameters for testing and offers detailed test instructions and frequencies. Test results from the TG members and other clinical users are presented in a table. The tolerances for the parameters with some statistics are recommended based on those test results and other publications. This report is not intended to provide a comprehensive review of linac quality assurance procedures or patient‐specific Intensity Modulated Radiation Therapy (IMRT) QA.

The landscape for the screening of colorectal cancer (CRC) has witnessed multiple triumphs over the past decades from policy-level interventions. In the United States (US), the most prominent intervention of this nature is the Patient Protection and Affordable Care Act (ACA), enacted more than a decade ago. Since its enactment, the ACA has seen multiple legal challenges, and its impact on CRC screening has been relatively well studied. However, a consolidated, concise analysis of the data on this subject is lacking. Herein, we evaluate the impact of the ACA on CRC screening through the lens of a policy analysis, highlighting its strengths and shortcomings, and suggest policy-level interventions to address these shortcomings and improve CRC screening adoption.

IntroductionUreteral stricture disease (UTSD) poses significant challenges in reconstructive urology, with recent advances highlighting disparities in healthcare outcomes based on race and ethnicity. This study investigates the impact of race and ethnicity on clinical outcomes following ureteral reconstruction.MethodsWe conducted a single‐centre prospective analysis of 233 patients who underwent ureteral reconstruction for UTSD from 2014 to 2023. Patient demographics, clinical characteristics, surgical details and outcomes were collected. Patients were stratified by race (White vs. non‐White) and ethnicity (Hispanic vs. non‐Hispanic). Statistical analyses included Kruskal–Wallis, Mann–Whitney U tests, ANOVA, Kaplan–Meier analysis and multivariate logistic regression.ResultsOur cohort included 233 patients who underwent ureteroplasty with 108 (46.4%) non‐White patients, and 71 (30.5%) were Hispanic. No significant differences were found in recurrence rates, complications, or stricture‐free survival between racial and ethnic groups. Prior reconstructions were more prevalent among non‐White patients (26.9% vs. 16.0%; p = 0.043). Unadjusted and adjusted regressions showed significant associations between non‐White race (unadjusted β = 0.76, p = 0.008; adjusted β = 0.82, p = 0.008) and Hispanic ethnicity (unadjusted β = 0.70, p = 0.025; adjusted β = 0.79, p = 0.020) with increased stricture lengths.ConclusionThis study highlights that although recurrence and complication rates do not significantly differ by race or ethnicity, disparities exist in clinical presentations, with non‐White and Hispanic patients presenting with longer stricture lengths and higher body mass index. These findings underscore the need for targeted interventions to address underlying disparities in healthcare delivery and access.

BackgroundClinical practice guidelines (CPGs) are a helpful tool for the evidence-based management of Type 2 Diabetes Mellitus (T2D). The aim of this systematic review was to synthesize and appraise the scope and quality of South Asian T2D CPGs. MethodsThis PROPSERO registered (CRD42023425150) systematic review adhered to the 2020 PRISMA guidelines. We searched the PubMed, Embase, Cochrane, and Google Scholar databases for relevant guidelines. Data synthesis was performed using a qualitative approach and methodological quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. ResultsWe identified eleven unique CPGs (three each from Pakistan and Sri Lanka, two from India, and one each from Bangladesh, Nepal, and Bhutan) which were published or updated between 2017 and 2023. The CPGs included recommendations regarding screening, diagnosis, prevention, and management of T2D and its acute and chronic complications, comorbidities, and fasting with T2D. The AGREE II mean domain scores ranged from 37 % to 80 %; three CPGs were ‘recommended for clinical use,’ seven were ‘recommended for use with modifications’ and one was deemed unfit for implementation. ConclusionThe present review summarized and appraised broadly CPGs from South Asia for T2D and can help direct improvements to future iterations.

Carotid body tumor or paraganglioma, is located periadventitially in relation to the carotid bifurcation. Generally, the blood supply of carotid tumors is abundant, it comes mainly from the branches of the external carotid arteries, although cases have been reported where the irrigation comes from the internal carotid artery, vertebral artery, ascending pharyngeal artery and superior thyroid. Although its etiology is unknown, different factors have been associated that contribute to its incidence, such as genetic factors and states of chronic hypoxia. Histologically, they are well vascularized tumors. Between the capillaries there are groups of tumor cells known as Zellballen's pseudoalveolar pattern. These are cells with eosinophilic granular cytoplasm and small round or oval nuclei. The tumor is mobile, but with limitation to mobilization in the cephalocaudal direction. The mass can transmit the carotid pulse due to its proximity to the carotid, and it may also be accompanied by a murmur or thrill. Usually the carotid glomus is identified by clinical examination, so consideration of multiple differential diagnoses. The treatment of choice is surgical excision. The need for preoperative embolization is controversial. Embolization before surgery is recommended to improve surgical success with reduced blood loss as well as reduce the risk of cranial nerve injury. The decision to perform presurgical embolization or not depends on the surgeon.

U.S. POINTER is a Phase 3, multicenter, randomized 2-year clinical trial of two multidomain lifestyle interventions in 2111 older adults who are at increased risk of cognitive decline and dementia due sedentary lifestyle, poor diet, and other factors such as family history of memory impairment and suboptimum cardiovascular health. Enrollment took place at five geographically diverse sites, beginning in 2019 and completing in early 2023. Participants are randomly assigned to one of two lifestyle intervention groups that differ in format, intensity, and accountability. Those randomized to the Self-Guided Lifestyle Intervention receive annual medical monitoring and health education information, tools, and support to encourage increased physical and cognitive activity and a healthier diet through 2-3 annual group meetings. Those randomized to the Structured Lifestyle Intervention receive frequent medical monitoring of cardiovascular health and a structured program of exercise (primarily aerobic), nutritional counseling, cognitive training and social engagement initially through weekly and then monthly group meetings. U.S. POINTER includes partnerships with local chapters of the Alzheimer's Association and lifestyle specialists to assist with intervention delivery. The primary outcome is 2-year change in cognitive function measured with a global cognition composite score that permits harmonization with FINGER and other trials. Secondary and tertiary outcomes include measures of executive function and episodic memory, physical activity, diet, cognitive and physical activity, cardiometabolic disease risks, mood, quality of life, health care costs, and health care utilization. U.S. POINTER is generating a richly phenotyped cohort that will provide a rigorous comparison of two lifestyle interventions designed to preserve cognitive function. It has nurtured 4 ancillary studies to assess intervention effects on outcomes related to sleep quality, brain structure and pathology, peripheral and neurovascular function, and the microbiome. It also partners with clinical trials within the World-Wide FINGERS international network. The study is generating an archive of biospecimens and de-identified public use data. Plans for a post-intervention observational study of the U.S. POINTER cohort are underway. U.S. POINTER provides an important national resource to advance the field in understanding the role of nonpharmacological interventions in reducing risk for cognitive decline and Alzheimer's disease and related dementia.

The unstructured region of Ara h 2, referred to as epitope 3, contains a repeated motif, DYPSh (h = hydroxyproline) that is important for IgE binding. IgE binding assays to 20mer and shorter peptides of epitope 3, defines a 16mer core sequence containing one copy of the DPYSh motif, DEDSYERDPYShSQDP. Thisstudy performs alanine scanning of this and a related 12mer mimotope, LLDPYAhRAWTK. IgE binding, using a pool of 10 sera and with individual sera, is greatly reduced when alanine is substituted for aspartate at position 8 (D8; p < 0.01), tyrosine at position 10 (Y10; p < 0.01), and hydroxyproline at position 12 (h12; p < 0.001). IgE binding to alanine-substituted peptides of a mimotope containing the DPY_h motif confirm the critical importance of Y (p < 0.01) and h (p < 0.01), but not D. Molecular modeling of the core and mimotope suggests an h-dependent conformational basis for the recognition of these sequences by polyclonal IgE. IgE from pooled sera and individual sera differentially bound amino acids throughout the sequences of Epitope 3 and its mimotope, with Y10 and h12 being most important for all sera. These results are highly significant for designing hypoallergenic forms of Ara h 2.

The intestinal microbiome plays a primary role in the pathogenesis of neurodegenerative disorders and may provide an opportunity for disease modification. We performed a pilot clinical study looking at the safety of fecal microbiota transplantation (FMT), its effect on the microbiome, and improvement of symptoms in Parkinson's disease. This was a randomized, double-blind placebo-controlled pilot study, wherein orally administered lyophilized FMT product or matching placebo was given to 12 subjects with mild to moderate Parkinson's disease with constipation twice weekly for 12 weeks. Subjects were followed for safety and clinical improvement for 9 additional months (total study duration 12 months). Fecal microbiota transplantation caused non-severe transient upper gastrointestinal symptoms. One subject receiving FMT was diagnosed with unrelated metastatic cancer and was removed from the trial. Beta diversity (taxa) of the microbiome, was similar comparing placebo and FMT groups at baseline, however, for subjects randomized to FMT, it increased significantly at 6 weeks (p = 0.008) and 13 weeks (p = 0.0008). After treatment with FMT, proportions of selective families within the phylum Firmicutes increased significantly, while proportion of microbiota belonging to Proteobacteria were significantly reduced. Objective motor findings showed only temporary improvement while subjective symptom improvements were reported compared to baseline in the group receiving FMT. Constipation, gut transient times (NS), and gut motility index (p = 0.0374) were improved in the FMT group. Subjects with Parkinson's disease tolerated multi-dose-FMT, and experienced increased diversity of the intestinal microbiome that was associated with reduction in constipation and improved gut transit and intestinal motility. Fecal microbiota transplantation administration improved subjective motor and non-motor symptoms. ClinicalTrial.gov, identifier: NCT03671785.