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.

Kidney Transplantation in United States Native Americans: Breaking Barriers.

Advances in the field of solid-organ transplantation (SOT), namely evolution of surgical techniques, developments in immunosuppressive therapies and efforts to maximize utilization of donor allografts (deceased and living), have resulted in growing numbers of SOT performed annually in the United States (U.S.) (36,529 total organs and 21,167 kidneys transplanted in 2018). However, the Native American/American Indian (NA/AI) people of the U.S. experience enormous socioeconomic barriers such as poverty, lack of adequate healthcare, poor health literacy and geographic isolation which limit access to SOT resulting in low rates of organ donation and transplantation, poor quality of life and shorter life expectancy. The NA/AI population is at increased risk for end-stage renal disease secondary to the high prevalence of diabetes mellitus. We review existing challenges to kidney transplantation in NA/AI patients and discuss potential solutions which could improve equitable delivery of specialized healthcare to this underprivileged population.

Mammary-type Myofibroblastoma of the Pre-sacral Space: A Rare Neoplasm.

INTRODUCTION: Mammary-type myofibroblastoma is a very rare, benign, mesenchymal neoplasm that is histologically identical to a myofibroblastoma of the breast but located in an extra-mammary location. To our knowledge, there have been about 160 cases of extra-mammary myofibroblastoma reported to date. Our report describes a mammary-type myofibroblastoma located retro-rectally in the pre-sacral space. CASE REPORT: Our patient is a 55-year-old male that presented via referral for evaluation of a pelvic mass. He noted having a few loose stools since the mass had become apparent but did not report any other associated symptoms. An MRI of the pelvis revealed a 9 cm, fat containing, solid, retro-rectal mass within the pre-sacral space, which did not appear to be contiguous with the rectum, ureters, or pelvic sidewall. He elected to have the mass surgical removed. The mass was removed as a single specimen that measured 9.5 x 7.5 x 7.0 cm. By immunohistochemistry, the neoplastic cells show co-expression of desmin, CD34, estrogen receptor, and loss of RB1 expression, which is consistent with the diagnosis of mammary-type myofibroblastoma. DISCUSSION: Mammary-type myofibroblastoma is a very rare, benign, soft tissue neoplasm. These neoplasms most often present as a painless slow growing mass in a middle-aged male. Although exceedingly rare, mammary-type myofibroblastoma should be on the differential diagnosis of patients presenting with a mass that was found incidentally or one that is producing mass-effect symptoms. When found, these tumors should be investigated to rule out other more serious pathologies and removed due to their high curability with surgical resection.

Kidney Transplantation in Native Americans: Time to Explore, Expel Disparity.

Native Americans/American Indians (NA/AI) are perhaps the most disadvantaged population in the United States due to poverty, geographic isolation, and poor health care. The prevalence of diabetes mellitus and end-stage renal disease in NA/AI is higher compared with other racial/ethnic groups. Thus, a higher rate of kidney transplantation (KT) candidacy evaluation, wait-listing, and actual transplantation would be expected among NA/AI. However, KT is an underutilized life-saving therapy in this population. Half of the 20 poorest counties in the U.S. are within NA/AI reservations. Native Americans/American Indians residing on reservations are often isolated hundreds of miles from the nearest transplant center. Additionally, factors such as poor health literacy, distrust, and substance abuse contribute to low KT rates. However, collaboration between transplant centers and Indian Health Services, use of telemedicine, constructing socioculturally-competent educational strategies, and maintaining confidence-building measures to bridge the gap, create trust, and maintain patient autonomy could improve outcomes in this population.

Student Initiative Improves HIV Screening Rate in Student-Run Free Clinic.

Background The Center for Disease Control provides recommendations for preventative services and screenings including recommendations for a one-time HIV screening of all adult patients between the ages of 13-64. But not all clinics are fully compliant with these recommendations. We identified a need for increased screening at two clinics in a rural setting. As a healthcare quality improvement initiative, we developed educational informatics to increase screening compliance. Methods This project assessed HIV screening rates before and after educational interventions at two clinics, the Coyote Clinic and the Avera Downtown Clinic. Three changes were implemented to increase the HIV screening rate and ultimately provide more effective high-quality health care. The three initiatives focused on patients, physicians, and student volunteers in order to provide a strong foundation of knowledge to all parties involved in a patient's care. Results Prior to any interventions, the baseline screening rate (screenings/100 persons) at the Avera Downtown Clinic was 0.84 while the screening rate at the Coyote Clinic was 0.00. After the proposed interventions, the screening rate of the Downtown Clinic improved to 3.97 and the screening rate at the Coyote Clinic improved to 29.4. Using a Fisher's Exact test, we found a statistically significant post-intervention increase in HIV screening at the Coyote Clinic after the intervention (p = 0.0002) but not at the Downtown Clinic (p = 0.0940.) Conclusion HIV screening rates improved after the implementation of interventional education initiatives tailored for patients, medical students, and physicians. Implementation of low-cost quality improvement measures such as the ones detailed herein may significantly improve long-term patient management, particularly in the context of screening tests.

High-dose hydroxocobalamin in end-stage liver disease and liver transplantation.

Distributive shock is a serious complication in patients with chronic or end-stage liver disease, and can be exacerbated by vasoplegia in this patient population. Vasoplegic syndrome (VS) is a state of shock refractory to catecholamines and vasopressin that is often multifactorial in liver failure patients, and can occur in any phase of liver transplantation (LT) [i.e., pre-transplantation, intraoperative, and post-transplantation]. Methylene blue (MB) has been a well-established pharmacologic therapy for VS. However, it has been known to cause dose-related toxicity. Hydroxocobalamin (HXC) is not currently FDA approved for the management of VS, but studies have demonstrated its ability to cause an increase in systolic blood pressure by hypothesized mechanisms with only minimal side effects. To date, only three other reports have demonstrated the use of HXC in LT patients, which highlighted its use both intraoperatively and post-transplantation. Our report illustrates the utility of HXC in four LT patients with VS. Two of these cases illustrate the usefulness of HXC in the pre-transplantation period, which has never been previously reported. HXC is a useful pharmaceutical agent in the management of VS, especially if contraindications to MB exist or in cases of MB-resistant vasoplegia. Further studies with large sample sizes are necessary to ascertain the optimal dosage of HXC in LT patients.