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"Levine, Rhoda"
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Harrison loved his umbrella
A little boy refuses to close his umbrella and soon all his friends follow suit.
Book
Deceased airway complications after introduction of an airway curriculum in an academic setting
Discussion The implementation of an airway curriculum included not only year-specific educational goals and techniques (eg, anatomy, physiology, direct laryngoscopy, and supraglottic devices for CAY-1; skills using fiberoptic and other intubation aids for CAY-2; and jet ventilation and apneic oxygenation techniques for CAY-3), but also the development of a faculty interested in acquiring and transmitting these skills.
Journal Article
Arthur
When Arthur misses the chance to migrate with the other birds, he experiences, for the first time, winter in New York City.
Book
He was there from the day we moved in
When a family moves into a new house they find a sheep dog in the backyard that seems to want something, but four-year-old Ogden, his older brother, and their parents are unable to discover what it is.
Book
The Strep Threat
I am glad to see that leading newspapers and magazines are publishing articles about rheumatic fever which include the recommendation of the American Heart Association for children to receive a throat culture at the first sign of a red throat. I have seen what public education can do to aid in prevention of Reye's Syndrome by teaching people to use acetaminophen instead of aspirin for childhood viral infections.
Newspaper Article
SUN-506 Geography or Genomics? - A Case of Extra Adrenal Epinephrine Secreting Recurrent Pheochromocytoma
Abstract
Disclosure: E. Jalal: None. R.H. Cobin: None. A.C. Levine: None. K.C. Cheesman: None.
Background: Glucocorticoids upregulate the enzyme phenylethanolamine N-methyltransferase (PNMT), converting norepinephrine to epinephrine, explaining the exclusive location of epinephrine secreting pheochromocytomas in the adrenal medulla adjacent to the high glucocorticoid concentration of the cortex. This assumption is challenged by the finding of extra-adrenal pheochromocytomas and paragangliomas (PGL) secreting epinephrine. We report a case of an extra-adrenal mass secreting epinephrine many years after surgical removal of the adrenal glands. Case Presentation: A 54-year-old female with MEN2A presented with new headaches, palpitations, and diaphoresis. Bilateral adrenalectomy for pheochromocytoma occurred 29 years prior. Total thyroidectomy for medullary thyroid cancer was done at age 10. Primary hyperparathyroidism is managed conservatively. Serum metanephrines were 310 pg/mL (0-88 pg/mL) compared to 116 pg/mL seven months prior; normetanephrines increased from 144 pg/mL to 236.5 pg/mL (0-244 pg/mL). Fractionated plasma catecholamines were as follows: epinephrine 132 pg/mL (<82 pg/mL), norepinephrine 395 pg/mL (149-564 pg/mL), and normal dopamine and total catecholamine levels. PET/CT dotatate scan showed a 3.2 x 2.4 x 3.7 cm tracer avid soft tissue mass medial to the inferior vena cava. MRI abdomen/pelvis showed a 4.1 cm heterogeneous, diffusion-restricting retrocaval mass. She underwent mass resection with pathology showing a 6 cm pheochromocytoma. A small amount of normal adrenal tissue was seen. Discussion: Our patient developed extra-adrenal recurrence with predominant epinephrine secretion despite her history of bilateral adrenalectomy suggesting that high cortisol concentrations may not be necessary for PMNT upregulation. Typically, PGLs activate hypoxia signaling pathways including HIF2a gene expression, which block glucocorticoid mediated induction of PNMT. In one retrospective study, HRAS and FGFR1 gene mutations were seen in 80% of 29 epinephrine-secreting extra-adrenal PGLs (Jiang et al, 2020). Intra-adrenal HRAS mutated tumors upregulate PNMT expression by phosphorylation of SP1 via the MAPK pathway, do not induce HIF2a, and thus are able to produce PNMT (Li et al, 2023). Therefore, the production of epinephrine in extra-adrenal chromaffin tumors may be explained by their genomic signatures rather than solely by proximity to high cortisol concentrations. Epinephrine secretion alone cannot reliably differential intra from extra-adrenal PPGL.
Presentation: Sunday, July 13, 2025
Journal Article
Active Surveillance for Papillary Thyroid Microcarcinoma: New Challenges and Opportunities for The Health Care System
The dramatic increase in papillary thyroid carcinoma (PTC) is primarily a result of early diagnosis of small cancers. Active surveillance is a promising management strategy for papillary thyroid microcarcinomas (PTMCs). However, as this management strategy gains traction in the U.S., it is imperative that patients and clinicians be properly educated, patients be followed for life, and appropriate tools be identified to implement the strategy.
We review previous active surveillance studies and the parameters used to identify patients who are good candidates for active surveillance. We also review some of the challenges to implementing active surveillance protocols in the U.S. and discuss how these might be addressed.
Trials of active surveillance support nonsurgical management as a viable and safe management strategy. However, numerous challenges exist, including the need for adherence to protocols, education of patients and physicians, and awareness of the impact of this strategy on patient psychology and quality of life. The Thyroid Cancer Care Collaborative (TCCC) is a portable record keeping system that can manage a mobile patient population undergoing active surveillance.
With proper patient selection, organization, and patient support, active surveillance has the potential to be a long-term management strategy for select patients with PTMC. In order to address the challenges and opportunities for this approach to be successfully implemented in the U.S., it will be necessary to consider psychological and quality of life, cultural differences, and the patient's clinical status.
Journal Article