Coccidioidomycosis masquerading as thyroid nodule: a rare diagnostic challenge.

We present a compelling case of disseminated coccidioidomycosis involving the thyroid gland, a remarkably uncommon manifestation of this infection. The gravity of this sporadic disease is underscored by its high mortality rate, primarily because of challenges in timely diagnosis and treatment initiation. Accurate diagnosis hinges upon utilizing various techniques, including the culture of a fine-needle aspirate, biopsy and direct microscopy. However, the medical community is still grappling with the optimal treatment strategy, encompassing considerations such as duration and dosage of medications, which continue to be subjects of intense controversy and ongoing research. This article aims to report an older patient with the incidental diagnosis and management of Coccidioides in the thyroid.

Analysis of Pre-clerkship Medical Students' Perceptions and Performance During the COVID-19 Pandemic.

Purpose: Virtual instruction became the primary educational delivery method for pre-clerkship medical students during the COVID-19 pandemic. The aims of this study were to evaluate the effectiveness of a virtual and blended pre-clerkship curriculum and to assess its impact on students. Methods: We surveyed 223 1st- and 2nd-year medical students (MS1s and MS2s) enrolled at the Paul L Foster School of Medicine. We analyzed student satisfaction with their courses, along with summative exam scores, compared to previous academic years. Results: The survey was completed by 125 of 223 students (56%). Most students changed their study methods (78%), experienced technical issues (85%), and had difficulty communicating with faculty (62%). MS1s were significantly more likely than MS2s to report difficulty in adjusting to virtual instruction (p = 0.037) and a negative impact on their learning skills (p = 0.005) and academic performance (p = 0.003). Students reported the virtual environment negatively affected their social skills (77%), connectedness to peers (89%), and professional development (62%). MS1s were more likely than MS2s to perceive a negative effect on their sense of wellness (p = 0.002). The overall satisfaction with the courses was similar to previous academic years. Student performance in the summative examination of the first virtually delivered unit was lower (p = 0.007) than the previous year's cohorts. Conclusion: The difference in MS1s and MS2s perceptions of virtual and blended instruction highlights the importance of face-to-face learning during the first year. Benefits and drawbacks were identified which may help inform educators when designing future learning models. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01723-6.

Parathyroidectomy Versus Cinacalcet for the Treatment of Secondary Hyperparathyroidism in Hemodialysis Patients.

BACKGROUND: Secondary hyperparathyroidism in patients with end stage renal disease on dialysis is associated with bone pain and fractures in addition to cardiovascular morbidity. Cinacalcet is the most commonly used drug to treat such patients, but it has never been compared to surgery. The goal of this study is to compare the long-term outcomes and survival between cinacalcet and parathyroidectomy in the treatment of secondary hyperparathyroidism in hemodialysis patients. METHODS: Adult patients on hemodialysis who were treated with cinacalcet or parathyroidectomy in the United States Renal Data System were included. Patients treated with surgery (n = 2023) were compared using 1:1 propensity score matching ratio to a cohort of patients treated with cinacalcet. A Cox regression analysis was conducted to compare the overall mortality. RESULTS: The propensity score matching successfully created two groups with similar demographics. Patients in the surgery group had a higher mean peak PTH level prior to therapy (2066.8 vs 1425.4, P < 0.001). No difference was observed in the development of new-onset coronary artery disease (7.7% vs 7.9%, P = 0.8) or cerebrovascular disease (7% vs 6.7%, P = 0.8). Surgical patients had a higher rate of pathologic fractures (27.8% vs 24.9%, P = 0.04). Survival analysis showed that patients undergoing surgery had a better 5-year survival (65.6% vs 57.8%) and were less likely to die within the study period (HR 0.77, 95% CI 0.7-0.85, P < 0.0001). CONCLUSIONS: Patients on dialysis undergoing parathyroidectomy for the treatment of secondary hyperparathyroidism have a better overall survival than those treated with cinacalcet.

Preoperative vitamin D deficiency is associated with increased risk of postoperative hypocalcemia after total thyroidectomy.

Prior single-institution studies suggest that preoperative vitamin D deficiency (VDD) is associated with postoperative hypocalcemia and a prolonged length of hospital stay following total thyroidectomy. In this study, we employ a multi-institutional, de-identified electronic health records database to address this issue. We hypothesize that total thyroidectomy patients with preoperative VDD will be at an increased associated risk of postoperative hypocalcemia and hospitalization. Using Cerner Health Facts, we identified 2447 patients who underwent total or subtotal thyroidectomy between 2008 and 2016 and who had a documented 25-hydroxyvitamin D concentration obtained within 12 months of the surgery date using International Classification of Diseases 9/10, Current Procedural Terminology and Healthcare Common Procedure Coding System codes. Data from 984 patients who underwent total thyroidectomy were analyzed. Analysis of variance models estimated the effect of VDD on postoperative numerical variables. Multiple logistic regression estimated the risk of postoperative hypocalcemia and hospital stay, adjusting for any imbalanced demographic variables and operative characteristics. On average, postoperative total calcium concentrations in the VDD group were lower by 0.3 mg/dL compared with that of the non-VDD group (p<0.01). The risk of postoperative hypocalcemia was 2.2 times higher in the VDD group compared with the non-VDD group (p<0.01). Although the length of hospital stay after thyroidectomy was longer in the VDD group compared with the non-VDD group (p=0.03), VDD is not an independent risk factor for prolonged hospitalization following thyroidectomy (p=0.13). VDD is associated with a higher risk of hypocalcemia following total thyroidectomy. Prethyroidectomy operative screening for VDD should be considered.

Analyzing the ATA statement on outpatient thyroidectomy using the NSQIP database.

INTRODUCTION: The aim of this study is to examine the outcomes of outpatient thyroidectomy per the American Thyroid Association (ATA) statement on this procedure using the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database. METHODS: A retrospective study using NSQIP database (2016 2017) comparing outpatient (OP) and inpatient (IP) thyroidectomies based on the ATA statement. RESULTS: There were 382 inpatient and 628 outpatient thyroidectomies. A vessel sealing device and intraoperative nerve monitoring were more commonly used in OP group. Drain use was less common in OP group. There was no difference in the rate of recurrent laryngeal nerve injury, neck hematoma, or postoperative hypocalcemia within 30 days after surgery. IP group had a higher rate of readmissions (3.4% vs 1.8%, p = 0.004). Logistic regression showed OP surgery was associated with a lower risk of readmission OR 0.38 (CI 0.15-0.97; p = 0.04). CONCLUSION: The ATA criteria can be used to identify good candidates for outpatient thyroidectomy.

Post Graduate Education: Is Genomics Included on Board Certification Exams?

Integrating clinical genetic education in physician training is an important strategic approach in the era of genomic medicine. To understand how much the board examinations of the American Board of Medical Specialties contain genomics-related content, a descriptive analysis of 21 exam blueprints was performed. Topics in genomics were not included in 43% of specialty blueprints which shows underrepresentation of clinical genetics in graduate medical education curricula.

Pancreatic Adenocarcinoma in New Mexico Native Americans: Disparities in Treatment and Survival.

In this study, we examined the treatment and outcomes of pancreatic adenocarcinoma in New Mexico Native Americans (NA). METHODS: A retrospective review of patients treated for pancreatic adenocarcinoma at a university cancer center from 2002-2016 comparing demographic characteristics, disease presentation, treatment, and outcomes among three main ethnic groups in New Mexico. RESULTS: We identified 457 patients: 240 (52.5%) non-Hispanic Whites, 186 (40.7%) Hispanics, and 31 (6.8%) NA. Non-Hispanic Whites (OR 2.41; p=.026) and Hispanics (OR 2.37; p=.032) were more likely to receive or be offered chemotherapy than NA. More NA than non-Hispanic Whites died within one month of diagnosis (25.8% and 7.5%, respectively; p=.004). The NAs demonstrated a 26.2% one-year survival (CI 11.7-43.3), compared with 48.3% in non-Hispanic Whites (CI 40.9-55.2; p=.015). CONCLUSION: Significant disparities exist in the treatment and outcomes of pancreatic adenocarcinoma in New Mexico NA populations.

Racial disparities in treatment and survival of hepatocellular carcinoma in native Americans and Hispanics.

BACKGROUND: We investigated if there were any differences in disease presentation and survival between the 3 major ethnicities in New Mexico; non-Hispanic whites (NHW), native Americans (NA), and Hispanics (H). METHODS: A retrospective analysis of patients with hepatocellular carcinoma treated at our institution between 2000 and 2014 was performed. Overall survival was analyzed using the Kaplan-Meier and Cox regression models. RESULTS: We identified 326 patients; 106 (32.5%) NHW, 183 (56.1%) H, and 37 (11.4%) NA. No difference in disease stage, resectability, rate of offering surgery, or chemotherapy was found. Advanced cirrhosis was more common in H and NA than NHW (P = .01). NA had a higher incidence of nonviral hepatocellular carcinoma (P = .0009). NHW were more likely to receive transarterial chemoembolization/radiofrequency than NA or H (P = .04). Median survivals for NA, NHW, H were 24, 14, and 11 months, respectively, (P = .01). CONCLUSIONS: Although there was no difference in disease stage or resectability, NA and H had more advanced cirrhosis and were less likely to undergo transarterial chemoembolization and/or radiofrequency than NHW. NA had the best survival, whereas H had the worst survival.

Mycobacterium avium-intracellulare and the unpredictable course of hypercalcemia in an AIDS patient

Abstract A 37-year-old man with AIDS presented with altered mental status four weeks after stopping his medications for Mycobacterium avium-intracellulare (MAI). He had low CD4 cell count and severe hypercalcemia. Bone marrow biopsy revealed bone marrow infiltration by granulomas positive for acid-fast bacilli and cultures grew MAI. His hypercalcemia continued to worsen with the initiation of MAI therapy but we were able to treat it successfully with pamidronate and calcitonin.

Viral hepatitis status does not affect survival in patients with hepatocellular carcinoma.

BACKGROUND: There have been few studies on the impact of viral etiology on the prognosis in patients with hepatocellular carcinoma (HCC). The aim of this study was to evaluate the clinical characteristics and survival of patients with viral hepatitis-associated HCC (V-HCC), compared to patients with HCC of non-hepatitis B, non-hepatitis C (NBNC-HCC) etiology. METHODS: We performed a retrospective analysis of all patients with HCC treated at our comprehensive cancer center from 2000 through 2014. Patients were divided into two groups according to their viral hepatitis status. Presentation patterns, treatments, and survival data were analyzed. RESULTS: We evaluated 366 patients: 233 patients (63.7%) had V-HCC while 133 (36.3%) patients had NBNC-HCC. V-HCC patients were younger (P<0.0001) and more likely to be male (P=0.001). Decompensated cirrhosis was more prevalent in V-HCC patients (P=0.01). There was no difference in the resectability rate or disease stage. In patients with resectable disease, those with V-HCC were less likely to undergo hepatectomy (23.7% vs. 38%; P=0.04) for more advanced liver disease. The estimated median survival for V-HCC was 13 months compared to 16 months in NBNC-HCC patients (P=0.57). On multivariate analysis, disease stage (P<0.0001) and Child-Pugh class (P<0.0001) were independent factors affecting survival, but viral status was not (P=0.75). CONCLUSION: Despite presenting with more advanced cirrhosis and being less likely to undergo surgery, V-HCC patients had similar survival to patients with NBNC-HCC.

Mycobacterium avium-intracellulare and the unpredictable course of hypercalcemia in an AIDS patient.

A 37-year-old man with AIDS presented with altered mental status four weeks after stopping his medications for Mycobacterium avium-intracellulare (MAI). He had low CD4 cell count and severe hypercalcemia. Bone marrow biopsy revealed bone marrow infiltration by granulomas positive for acid-fast bacilli and cultures grew MAI. His hypercalcemia continued to worsen with the initiation of MAI therapy but we were able to treat it successfully with pamidronate and calcitonin.

DOES PRE-OPERATIVE VITAMIN D DEFICIENCY PREDICT POSTOPERATIVE HYPOCALCEMIA AFTER THYROIDECTOMY?

OBJECTIVE: Postoperative hypocalcemia is frequent after total thyroidectomy. The role of pre-operative vitamin D levels in the pathogenesis of this condition has not been studied under the most current guidelines for evaluation of the role of vitamin D in calcium homeostasis. We hypothesized that patients who are vitamin D deficient (VDD) pre-operatively are more likely to suffer from postoperative hypocalcemia, thereby requiring prolonged hospitalization. METHODS: A retrospective chart review of patients undergoing total thyroidectomy at the University of New Mexico Hospital between 2005 and 2014 was performed. Patients who underwent intentional parathyroidectomy were excluded. The study included 30 patients who had a 25-hydroxyvitamin D levels obtained within 12 months before surgery. RESULTS: Twelve patients who were VDD (25-hydroxyvitamin D ≤20 ng/mL) were compared to 18 patients who did not have VDD (non-VDD; 25-hydroxyvitamin D >20 ng/mL). The mean nadir postoperative ionized calcium concentration was lower in the VDD group (0.99 ± 0.10 vs. 1.06 ± 0.06 mmol/L, P = .04) (reference range = 1.15-1.27 mmol/L), as was the postoperative concentration of phosphorus (3.48 ± 0.60 vs. 4.17 ± 0.84 mg/dL, P = .03). VDD patients had a longer length of stay (4.3 ± 4.4 vs. 1.7 ± 1.5 days, P = .03). Three patients in the VDD group required intravenous calcium for treatment of symptomatic hypocalcemia, but none of the non-VDD patients required this intervention (P = .054). CONCLUSION: Pre-operative vitamin D deficiency is associated with an increased risk of postoperative hypocalcemia and a prolonged length of stay in patients undergoing total thyroidectomy. Vitamin D replacement before thyroidectomy may improve postsurgical outcomes in VDD patients. ABBREVIATIONS: BMI = body mass index non-VDD = non-vitamin D deficient PTH = parathyroid hormone VDD = vitamin D deficient.

Leiomyosarcoma of the Inferior Vena Cava: A Case Series and Review of the Literature.

BACKGROUND: Leiomyosarcoma of the inferior vena cava (IVC) is an exceedingly rare smooth muscle sarcoma. Approximately 300 cases have been described in the literature, and further research is needed to understand the disease and guide its management. Surgery remains the only potential curative measure. METHODS: A retrospective chart review of patients who underwent surgical resection of IVC leiomyosarcoma at our institution over the past 3 years was performed. The patients were identified using a prospectively maintained database. RESULTS: Three patients with leiomyosarcoma of the infrahepatic IVC underwent radical resection carried out by a team of surgical oncologists and vascular surgeons. There were 2 males (66.7%) and 1 female (33.3%). Mean age at diagnosis was 60.3 years (range 43-78). Mean tumor size was 12.2 cm (range 5.6-22). The mean operative time was 320 min (range 180-421), mean estimated blood loss was 1,300 mL (100-2,000) mL, and average length of stay 8.67 days (6-12). All patients achieved grossly negative margins (R1 or R0 resections) and are alive with a mean overall survival of 21 months (range 12-30). Patient 1 was a 60-year-old man who presented with metachronous skin leiomyosarcomas at 2 different sites. He underwent PET/CT scan that revealed an IVC mass. Resection of the middle segment of the IVC and right kidney was performed with reconstruction with polytetrafluorethylene (PTFE) graft. Patient 2 was a 78-year-old man with an incidentally found a 9-cm IVC tumor. Resection of the tumor was performed, and no reconstruction was needed since the tumor had a completely extraluminal growth pattern. Patient 3 was a 43-year-old woman who presented with abdominal pain. Her work-up showed a 15-cm IVC mass. She underwent resection of the middle segment of the IVC, right nephrectomy, and cholecystectomy with reconstruction of the IVC with PTFE graft. CONCLUSIONS: Surgical resection is the mainstay of treatment in patients with leiomyosarcoma of the IVC. A collaborative approach involving surgical oncologists and vascular surgeons ensures adequate resection with functional reconstruction to achieve the best patient outcomes.

Giant acrochordon of the axilla.

Acrochordons or fibroepithelial polyps, are very common skin lesions. However, giant acrochordons are extremely rare. We present a case of a morbidly obese diabetic man who was treated with primary excision of a giant 18 cm acrochordon of the left axilla.

The utility of neck ultrasound and sestamibi scans in patients with secondary and tertiary hyperparathyroidism.

INTRODUCTION: Secondary hyperparathyroidism (SHPT) and tertiary hyperparathyroidism (THPT) are disease entities in patients with chronic kidney disease that are caused by parathyroid hyperplasia. The role of preoperative localization studies in patients undergoing parathyroidectomy for these conditions remains poorly defined. AIM: To evaluate the utility of surgeon-performed neck ultrasound (US) as well as sestamibi scans in the localization of parathyroid glands in patients with SHPT/THPT. MATERIALS AND METHODS: A retrospective analysis of patients with SHPT/THPT who underwent parathyroidectomy at a single institution. Results of preoperative localization studies were compared to intraoperative findings. RESULTS: One hundred and three patients underwent parathyroidectomy for SHPT/THPT. All patients underwent surgeon-performed neck US, while 92 (89%) underwent sestamibi scans. US failed to localize any of the parathyroids in 4 patients (3.8%), while sestamibi was negative in 11 (12%). Forty-seven ectopic glands were identified in 38 patients in whom sestamibi was performed. In five patients (13%), ectopic glands were identified by both modalities, by US only in 6 (16%), by sestamibi only in 8 (21%), and by neither study in 19 patients (50%). US showed new thyroid nodules in 19 patients (18.4 %), leading to lobectomy or thyroidectomy at the time of parathyroidectomy in 16 patients (15.5%). Pathology showed malignancy in 7 patients (6.8%). CONCLUSION: US and MIBI offer little benefit in localizing ectopic glands and rarely change the conduct of a standard four-gland exploration. Although there was a benefit of US in the assessment of thyroid nodules, in only 8.7% of patients was sestamibi of benefit in identifying ectopic glands.