Adherence Rate of Pediatric Lipid Screening at a Rural, Independently Owned Primary Care and Multispecialty Clinic.

BACKGROUND: In 2011, the AAP endorsed the recommendation of National Heart Lung and Blood Institute (NHLBI) for universal lipid screening in children 9-11 and 17-21 years old given the increasing prevalence of pediatric obesity. In 2017, a study conducted by the AAP showed low adherence with universal pediatric lipid screening. The purpose of this retrospective chart review is to assess the adherence rate for pediatric lipid screening at a rural, independently owned primary care and multispecialty clinic. METHODS: Patient data were compiled from the electronic medical record. Inclusion criteria include patients 9-11 or 17-21 years of age between Jan. 1, 2014-Dec. 31, 2019, with an appointment indication of well-child examination or annual physical. RESULTS: A low percentage of patients underwent a fasting lipid panel in both the 9-11 (n = 663) and 17-21 (n = 118) years age group, 3.3 percent and 4.2 percent respectively. Of those who underwent a fasting lipid panel, 59.0 percent in the 9-11 age group and 80.0 percent in the 17-21 years age group had at least one abnormal lipid level. Of the population classified as overweight and obese, 6.3 percent (16 out of 255) of the 9-11 years age group and 6.1 percent (three out of 49) of the 17-21 years age group underwent a lipid panel screen. DISCUSSION: The data show low adherence with universal lipid screening for patients ages 9-11 and 17-21 years old. Poor adherence may be due to inconsistent endorsement by professional medical societies and incongruent recommendations in the EMR. Further studies are required to determine the national adherence rate with the NHLBI recommendation.

A Cannabinoid Type 2 (CB2) Receptor Agonist Augments NOS-Dependent Responses of Cerebral Arterioles During Type 1 Diabetes.

INTRODUCTION: While activation of cannabinoid (CB2) receptors has been shown to be neuroprotective, no studies have examined whether this neuroprotection is directed at cerebral arterioles and no studies have examined whether activation of CB2 receptors can rescue cerebrovascular dysfunction during a chronic disease state such as type 1 diabetes (T1D). The goal was to test the hypothesis that administration of a CB2 agonist (JWH-133) would improve impaired endothelial (eNOS)- and neuronal (nNOS)- dependent dilation of cerebral arterioles during T1D. METHODS: In vivo diameter of cerebral arterioles in nondiabetic and diabetic rats was measured in response to an eNOS-dependent agonist (adenosine 5'-diphosphate; ADP), an nNOS-dependent agonist (N-methyl-Daspartate; NMDA), and an NOS-independent agonist (nitroglycerin) before and 1 hour following JWH-133 (1 mg/kg IP). In a second series of experiments, to determine the role of CB2 receptors, rats were injected with AM-630 (3 mg/kg IP). AM-630 has been shown to be a specific antagonist to CB2 receptors. After 30 minutes, the nondiabetic and T1D rats were treated with JWH-133 (1 mg/kg IP). One hour after the injection of JWH-133, responses of arterioles to the agonists were again examined. In a third series of experiments, a potential time-dependency in reactivity of cerebral arterioles to the agonists was examined. Initially responses of arterioles to ADP, NMDA and nitroglycerin were examined. Then, one hour after injection of vehicle (ethanol) for JWH-133 and AM-630 responses of arterioles to the agonists were again examined. RESULTS: Baseline diameter of cerebral arterioles was similar in nondiabetic and T1D rats across all groups of rats. In addition, treatment of the rats with JWH-133, JWH-133 and AM-630 or vehicle (ethanol) did not produce a change in baseline diameter in either nondiabetic or T1D rats. Dilation of cerebral arterioles to ADP and NMDA was greater in nondiabetic than in diabetic rats. Treatment with JWH-133 increased responses of cerebral arterioles to ADP and NMDA in both nondiabetic and diabetic rats. Responses of cerebral arterioles to nitroglycerin were similar between nondiabetic and diabetic rats, and JWH-133 did not influence responses to nitroglycerin in either group. The restoration in responses to the agonists by JWH-133 could be inhibited by treatment with a specific inhibitor of CB2 receptors. CONCLUSIONS: This study showed that acute treatment with a specific activator of CB2 receptors could potentiate dilation of cerebral resistance arterioles to eNOS- and nNOS-dependent agonists in both nondiabetic and T1D rats. In addition, the influence of activation of CB2 receptors on cerebral vascular function could be attenuated by treatment with a specific antagonist of CB2 receptors (AM-630). Based on these findings, one could speculate that treatment with CB2 receptor agonists may have potential therapeutic benefits for the treatment of cerebral vascular disease that can contribute to the pathogenesis of stroke.

Esophageal Hemangioma: A Rare Cause of Chronic Gastrointestinal Blood Loss.

Esophageal hemangioma (EH) is a rare, benign tumor that is most often asymptomatic but may present insidiously with dysphagia and blood loss anemia. We report a case of a 70-year-old male with symptomatic anemia who underwent a full gastrointestinal evaluation and was found to have an EH. We review the classification of benign esophageal neoplasms and discuss the characteristics, imaging, interventions, and surveillance specific to EH.

Approach to Solitary Thyroid Nodules in Adults.

Thyroid nodules are exceedingly common in the general population and their increasing incidence appears to be secondary to incidental finding on imaging. Nonetheless, due to the potential for malignancy and thyroid dysfunction, most thyroid nodules require further investigation. Although there are no current guidelines for thyroid cancer screening in asymptomatic patients, a thorough history and physical which focuses on risk factors can serve as a good starting point during the evaluation of a thyroid nodule. This is followed by diagnostic analysis with thyroidstimulating hormone; as well as thyroid scintigraphy, T4, and T3 when indicated. Ultrasound is the gold standard diagnostic imaging modality for suspicious thyroid nodules and can provide further information on malignancy potential and the need for fine need aspiration (FNA). Thyroid nodules can then be further classified on a spectrum ranging from benign to malignant based on a combination of ultrasound and FNA findings. Patients with thyroid nodules that are malignant, suspicious for malignancy, or intermediate lesions should be referred on to a surgeon for potential operative intervention. It is important for primary care providers to be well versed in the work-up and initial evaluation of thyroid nodules as they are often the first provider a patient will present to. This review article serves to refresh and guide the primary care provider through the initial evaluation and management of thyroid nodules.

A cannabinoid type 2 (CB2) receptor agonist augments NOS-dependent responses of cerebral arterioles during type 1 diabetes.

While activation of cannabinoid (CB2) receptors has been shown to be neuroprotective, no studies have examined whether this neuroprotection is directed at cerebral arterioles and no studies have examined whether activation of CB2 receptors can rescue cerebrovascular dysfunction during a chronic disease state such as type 1 diabetes (T1D). Our goal was to test the hypothesis that administration of a CB2 agonist (JWH-133) would improve impaired endothelial (eNOS)- and neuronal (nNOS)-dependent dilation of cerebral arterioles during T1D. In vivo diameter of cerebral arterioles in nondiabetic and T1D rats was measured in response to an eNOS-dependent agonist (adenosine 5'-diphosphate; ADP), an nNOS-dependent agonist (N-methyl-d-aspartate; NMDA), and an NOS-independent agonist (nitroglycerin) before and 1 h following JWH-133 (1 mg/kg IP). Dilation of cerebral arterioles to ADP and NMDA was greater in nondiabetic than in T1D rats. Treatment with JWH-133 increased responses of cerebral arterioles to ADP and NMDA in both nondiabetic and T1D rats. Responses of cerebral arterioles to nitroglycerin were similar between nondiabetic and T1D rats, and JWH-133 did not influence responses to nitroglycerin in either group. The restoration in responses to the agonists by JWH-133 could be inhibited by treatment with a specific inhibitor of CB2 receptors (AM-630; 3 mg/kg IP). Thus, activation of CB2 receptors can potentiate reactivity of cerebral arterioles during physiologic and pathophysiologic states. We speculate that treatment with CB2 receptor agonists may have potential therapeutic benefits for the treatment of cerebral vascular diseases via a mechanism that can increase cerebral blood flow.