Tumor-to-tumor spread: a case report and literature review of renal cell carcinoma metastasis into thyroid cancer.

Tumor-to-tumor metastasis is a rare, yet important entity. Patients with a history of renal cell carcinoma (RCC) may have tumor deposits to the thyroid gland preceding or following their initial cancer diagnosis for many years. The diagnosis can be challenging, and clinicians must remain suspicious of a newly found thyroid nodule in a patient with a history of RCC. In this review, we report a case of a patient with RCC who was incidentally found to have a thyroid nodule on surveillance imaging found to be consistent with tumor-to-tumor metastasis from RCC into papillary thyroid carcinoma. It is imperative to consider this diagnosis as the thyroid is the most common site of spread, and treatment with partial or total thyroidectomy has led to improved survival.

Validation of Plantar Pressure and Reaction Force Measured by Moticon Pressure Sensor Insoles on a Concept2 Rowing Ergometer.

The purpose of this study was to determine the reliability and validity of plantar pressure and reaction force measured using the Moticon and Pedar-x sensor insoles while rowing on a Concept2 ergometer. Nineteen participants performed four 500 m trials of ergometer rowing at 22-24 strokes/min; two trials wearing Moticon insoles and two wearing Pedar-x insoles in a randomised order. Moticon and Pedar-x insoles both showed moderate to strong test-retest reliability (ICC = 0.57-0.92) for mean and peak plantar pressure and reaction force. Paired t-test demonstrated a significant difference (p < 0.001) between Moticon and Pedar-x insoles, effect size showed a large bias (ES > 1.13), and Pearson's correlation (r < 0.37) showed poor agreement for all plantar pressure and reaction force variables. Compared to Pedar-x, the Moticon insoles demonstrated poor validity, however, the Moticon insoles had strong reliability. Due to poor validity, caution should be used when considering Moticon insoles to assess changes in pressure and force reliably over time, across multiple trials or sessions. Moticon's wireless and user-friendly application would be beneficial for assessing and monitoring biomechanical parameters in rowing if validity between measures of interest and Moticon's results can be established.

A case of COVID-19 Reinfection and Systematic Review of Patterns of Reinfection.

We present a case of a middle age Hispanic patient with COVID-19 reinfection. We conducted a systematic review of the literature of reinfection cases and found that women represent the majority of the cases and that reinfection usually presents with more severe disease, particularly among healthcare workers.

MR Imaging-Guided Transurethral Ultrasound Ablation of Localized Prostate Cancer: Preliminary Experience from a Single Center in a Prospective, Multi-Center, Single-Arm Clinical Trial.

This report details a single-center experience of using magnetic resonance imaging-guided transurethral ultrasound ablation (TULSA) for whole-gland prostate treatment. Nine men with organ-confined low-to-intermediate-risk prostate cancer underwent the TULSA procedure. The primary endpoint of reduction of more than 75% was achieved in 8 of 9 patients, and all patients demonstrated a histologic benefit at 12-month biopsy. No major urinary or gastrointestinal side effects were observed, and there were no postprocedural changes in erectile firmness. These findings suggest that TULSA is potentially safe and efficacious for patients with low-to-intermediate-risk disease.

PLAG1 immunohistochemistry is a sensitive marker for pleomorphic adenoma: a comparative study with PLAG1 genetic abnormalities.

AIMS: Pleomorphic adenoma gene 1 (PLAG1) gene rearrangement is the most common genetic abnormality in pleomorphic adenoma (PA), resulting in overexpression of PLAG1 protein. PA and carcinoma ex pleomorphic adenoma (CA ex-PA) can mimic various benign and malignant salivary gland tumours. The aims of this study are to evaluate the sensitivity and specificity of PLAG1 immunohistochemistry (IHC) in the differential diagnosis of PA and CA ex-PA and to compare the PLAG1 immunohistochemical results to PLAG1 gene abnormalities as detected by fluorescence in-situ hybridisation (FISH). METHODS AND RESULTS: PLAG1 immunostaining was performed on 83 salivary gland tumours, including 23 PA, 15 CA ex-PA and 45 other salivary gland tumours. In addition, PLAG1 FISH was performed in 44 cases for the presence of gene rearrangements/amplifications. The results showed high sensitivity of PLAG1 IHC in 96% of PA; however, discordant results between PLAG1 FISH abnormalities and IHC were noted in 15 of 44 cases (34%). Seven PA, four de-novo myoepithelial carcinomas and one basal cell adenocarcinoma had negative FISH results, but were positive for IHC; while three salivary duct carcinomas (SDC) ex-PA were positive for FISH but negative for IHC. PLAG1 IHC can differentiate CA ex-PA from de-novo SDC (P = 0.02), but not from de-novo myoepithelial carcinoma. PLAG1 IHC is a sensitive marker for PA. This could be due to PLAG1 gene abnormalities beyond FISH resolution. CONCLUSIONS: A negative PLAG1 IHC might be helpful in excluding a PA diagnosis. Interestingly, in the context of CA ex-PA, FISH is more sensitive than IHC in detecting PLAG1 abnormalities.

The Effects of Beef, Chicken, or Whey Protein After Workout on Body Composition and Muscle Performance.

Sharp, MH, Lowery, RP, Shields, KA, Lane, JR, Gray, JL, Partl, JM, Hayes, DW, Wilson, GJ, Hollmer, CA, Minivich, JR, and Wilson, JM. The effects of beef, chicken, or whey protein after workout on body composition and muscle performance. J Strength Cond Res 32(8): 2233-2242, 2018-The purpose of this study was to determine the effects of postworkout consumption of beef protein isolate (Beef), hydrolyzed chicken protein (Chx), or whey protein concentrate (WPC), compared with a control on body composition and muscle performance during 8 weeks of resistance training. Forty-one men and women were randomized into 4 groups: WPC (m = 5, f = 5; age [years] = 19 ± 2, height [cm] = 171 ± 10, mass [kg] = 74.60 ± 14.19), Beef (m = 5, f = 5; age [years] = 22 ± 4, height [cm] = 170 ± 7, mass [kg] = 70.13 ± 8.16), Chx (m = 5, f = 6; Age [years] = 21 ± 2, height [cm] = 169 ± 9, mass [kg] = 74.52 ± 13.83), and Maltodextrin (control) (m = 4, f = 6; age [years] = 21 ± 2, height [cm] = 170 ± 9, mass [kg] = 73.18 ± 10.96). Subjects partook in an 8-week periodized resistance training program. Forty-six grams of protein or a control were consumed immediately after training or at similar times on off-days. Dual-energy x-ray absorptiometry was used to determine changes in body composition. Maximum strength was assessed by 1 repetition maximum for bench press (upper body) and deadlift (lower body). Power output was measured using cycle ergometer. Whey protein concentrate (52.48 ± 11.15 to 54.96 ± 11.85 kg), Beef (51.68 ± 7.61 to 54.65 ± 8.67 kg), and Chx (52.97 ± 12.12 to 54.89 ± 13.43 kg) each led to a significant increase in lean body mass compared with baseline (p < 0.0001), whereas the control condition did not (53.14 ± 11.35 to 54.19 ± 10.74 kg). Fat loss was also significantly decreased at 8 weeks compared to baseline for all protein sources (p < 0.0001; WPC: 18.70 ± 7.38 to 17.16 ± 7.18 kg; Beef: 16.43 ± 5.71 to 14.65 ± 5.41 kg; Chx: 17.58 ± 5.57 to 15.87 ± 6.07 kg), but not the control condition (16.29 ± 7.14 to 14.95 ± 7.72 kg). One repetition maximum for both deadlift and bench press was significantly increased for all treatment groups when compared with baseline. No differences in strength were noted between conditions. Overall, the results of this study demonstrate that consuming quality sources of protein from meat or WPC lead to significant benefits in body composition compared with control.

The future of anesthesia for interventional radiology.

PURPOSE OF REVIEW: To review novel procedures in interventional radiology and describe anesthetic implications. RECENT FINDINGS: Noninvasive treatment options for patients who are nonsurgical candidates are on the rise. The complication rate for patients receiving anesthesia in the interventional radiology suite is higher than other nonoperating room anesthetizing locations. The investigative use of catheter-directed thrombolysis for acute submassive pulmonary embolism will likely lead to an increased demand for anesthesia assistance. Treatment of prostate cancer with high-intensity focused ultrasound with MRI guidance is an alternative to surgical treatment and has unique anesthetic implications. With advances in technology, interventional radiologists have expanded their treatment armamentarium for benign and malignant bony lesions and thus the need for anesthesia assistance. SUMMARY: As the complexity of procedures and patients increases, the demand for anesthesia support in interventional radiology rises. As novel techniques are being developed, anesthesiologists must be mindful of the increased complication rate in interventional radiology and work in a multidisciplinary approach to improve patient safety.

Dye leakage and modification of fast-setting mineral trioxide aggregate.

The objective of this investigation was to determine and decrease dye leakage of fast-setting mineral trioxide aggregate (FSMTA). Specimens using differing setting times or concentrations of calcium sulfate modified FSMTA were assessed for dye penetration. Based on the results, no statistical difference was found in the dye leakage of FSMTA compared with regular mineral trioxide aggregate (MTA). The addition of 10 percent calcium sulfate resulted in a statistical reduction in dye leakage compared to both unmodified FSMTA and regular MTA.

A Rare Presentation of Minimally Invasive Mesothelioma as a Large Tension Pneumothorax.

Development of mesothelioma is associated with asbestos exposure. Common presentations are with pleural-based plaques invading the chest wall and/or pleural effusion on chest imaging. The intent of this case report is to describe a rare presentation of mesothelioma, which presented atypically as a large tension pneumothorax. A 93-year-old male presented with a history of dyspnea that started after a coughing episode. On physical examination he was hemodynamically stable, but was hypoxic requiring 2L of supplemental oxygen. Computed tomography of the chest revealed a large right tension pneumothorax. A chest tube was placed and connected to suction (-20cmH20), but he continued to have an unresolving air leak over the following 2-week period. Upon video-assisted thoracotomy there were no blebs or adhesions seen. Right apical wedge resection and talc pleurodesis were performed. Pathologic examination revealed an atypical mesothelial cell proliferation with minimal, focal invasion into the pulmonary parenchyma. Tumor spread along the visceral pleura was thought to be the underlying cause of the pneumothorax. The surgical margins were uninvolved by the tumor, and the patient was later discharged home in stable condition. This was a rare presentation of what could best be described as minimally invasive mesothelioma arising in a background of probable mesothelioma in situ, which presented atypically as a large tension pneumothorax. This case highlighted the importance of establishing a pathologic diagnosis from pleural effusion cytology and/or pleural biopsy in persons presenting with spontaneous pneumothorax, and the difficulty in confirming a pathologic diagnosis of early mesothelial neoplasia.

Tricuspid Papillary Fibroelastoma: A Rare Tumor in an Uncommon Location.

Papillary fibroelastomas (PFEs) are rare benign cardiac tumors typically arising from the valvular endocardium, often affecting the aortic and mitral valves. They can range from asymptomatic to causing severe thromboembolic complications like stroke. This article presents a case of a tricuspid valve PFE in an 81-year-old patient with severe multi-vessel coronary artery disease. Transthoracic echocardiography revealed a mass on the tricuspid valve, confirmed by cardiac MRI. The patient underwent surgical excision, and histopathology confirmed the PFE diagnosis. The case highlights the importance of multimodal imaging in diagnosis and individualized treatment strategies for valvular heart tumors.

SMARCA4-Deficient Undifferentiated Esophageal Carcinoma: A Clinical Case Series and Literature Review.

PURPOSE: Undifferentiated carcinoma of the esophagus (UEC) is a rare malignancy. Deficiency in SMARCA genes, critical for chromatin regulation, has been observed in cases of UEC. Research in UEC is sparse, however, and we present a case series along with a comprehensive review of the literature. CASE SERIES: Case 1 is a 49-year-old female with abdominal pain and dysphagia and esophagogastroduodenoscopy (EGD) showing a friable mass at the gastroesophageal (GE) junction. Biopsies showed a poorly differentiated neoplasm and immunohistochemistry showed loss for SMARCA4. With metastatic disease, she agreed to undergo palliative chemotherapy and radiation, passing away at 4 months. Case 2 is an 88-year-old male with dysphagia, nausea, vomiting, and distal esophageal mass with biopsy showing a malignancy with loss of SMARCA4 expression. Due to extensive metastases, he was counseled on hospice care. Case 3 is a 53-year-old male with extensive alcohol and smoking history presenting with hematemesis, passing away shortly. Posthumous histopathology consistent with undifferentiated SMARCA4-deficient carcinoma of the esophagus. Results of the literature review indicate a predilection towards males (75.0%) and a variable age range (39-88 years). Majority (76.2%) reported with a distal esophagus location. Metastatic disease was common at initial presentation. Median survival was 2.60 months. Some were managed with chemotherapy and radiation. CONCLUSIONS: Research in SMARCA-deficient UEC is very limited. It is more common in men, age is variable, and associated with Barret's esophagus. Further research is necessary to better understand it and to establish treatment guidelines; however, it is clear that SMARCA4-deficient UEC carries a significantly poor prognosis.

Improving needle visualization by novice residents during an in-plane ultrasound nerve block simulation using an in-plane multiangle needle guide.

OBJECTIVE: Ultrasound-guided regional anesthesia with in-plane needle approaches can be challenging due to difficult needle visualization. We hypothesized that an in-plane, multiangle needle guide can help reduce the time it takes novice regional anesthesiologists to perform a simulated ultrasound-guided nerve-targeting procedure and enhance the visualization of the needle. DESIGN: Crossover simulation study. SETTING: Simulation environment at an academic institution. SUBJECTS: Volunteer trainees in their postgraduate years 1 and 2. METHODS: Sixteen subjects were randomized to repeat a single nerve targeting simulation task four times with and four times without a needle guide. End points were time to complete the nerve targeting, needle visualization, number of passes, and needle approximation to the target. RESULTS: The needle guide reduced median time to complete the task by 27% (95% confidence interval: 4-44%) and increased the odds of an acceptable needle visualization by 355% (95% confidence interval: 171-737%). A learning benefit for the time outcome was also noted, with multiple attempts regardless of whether the needle guide was used or not. CONCLUSIONS: A needle guide can help reduce the time needed to complete a simulated nerve targeting procedure and enhance needle visualization for the novice sonographer in a phantom gel simulation. There was no significant reduction in the number of needle passes or in improvement of target approximation noted.

A pilot study describing knowledge and practices in the health care of men who have sex with men by U.S. Air Force primary care providers.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) recommends annual sexually transmitted infection (STI) screening in men who have sex with men (MSM) that is unique to this patient population. The goal of this study is to establish whether U.S. Air Force (USAF) providers are familiar with these guidelines and determine if USAF providers offer these tests appropriately. METHODS: A survey designed to determine primary care provider knowledge and practices in MSM health care was disseminated via e-mail to 124 primary care providers at 3 separate USAF medical facilities in Northern California from September 15 to 30, 2011. FINDINGS: There was a 46% response rate. 15% of respondents correctly identified all CDC-recommended STI screens. 42% stated that they did not know the CDC screening guidelines. 51% did not screen male patients for MSM activity in the past year. 81% of respondents had not offered the full complement of MSM STI screening in the past year. CONCLUSION: The majority of USAF primary care providers surveyed were not familiar with CDC-recommended annual screening tests for STIs in MSM, and they did not screen for MSM activity or offer MSM STI screening tests regularly. Further studies across the Department of Defense are needed to corroborate the findings of this study.

Adult-type granulosa cell tumor of the testis: A case report and review of the literature.

Granulosa cell tumors (GCTs) of the testicle are a rare subtype of sex cord stromal tumors which usually present with painless testicular swelling. The histology of an adult testicular GCT often resembles normal granulosa cell tissue morphology, with similar immunohistochemical staining pattern such as positivity for steroidogenic factor 1 (SF1), calretinin, and inhibin A.4,5 We present a case of a 39-year-old male with an adult GCT of the testicle who underwent successful unilateral orchiectomy. This case adds to the body of literature and furthers our understanding of tumor histopathology, tumor behavior, clinical surveillance, and treatment strategies for this testicular neoplasm.

Urticarial Vasculitis Associated With Levothyroxine.

Urticarial vasculitis (UV) is a protean disorder that can be triggered by a myriad of causes although it is often idiopathic. Treatment is often successful with corticosteroids and/or immunosuppressive drugs. However, when a cause is found, specific treatment of the underlying problem or removal of an offending agent will resolve the symptoms. This report describes a patient with UV triggered by thyroid replacement, necessitated by Hashimoto's thyroiditis, which can itself cause UV. In this unusual presentation, rather than thyroiditis, thyroid replacement was the trigger for the vasculitis.

Access to Health Care Improves COVID-19 Vaccination and Mitigates Health Disparities Among Medicare Beneficiaries.

BACKGROUND: COVID-19 disproportionately impacts the elderly, particularly racial/ethnic minorities and those with low socioeconomic status (SES). These latter groups may also have higher vaccine hesitancy. We aim to evaluate if access to care improves COVID-19 vaccination rates and improves health disparities. METHODS: We conducted a retrospective cohort study of Medicare patients receiving care in a high-touch capitated network across ten states. We collected type and date of COVID-19 vaccine and demographic and clinical data from the inpatient and outpatient electronic health records and socioeconomic status from the US census. Our primary outcome was completing vaccination using logistic regression. RESULTS: Our cohort included 93,224 patients enrolled in the network during the study period. Sixty nine percent of all enrolled patients completed full vaccination. Those who completed vaccination did it with Pfizer (46%), Moderna (49%), and Jannsen (4.6%) vaccines. In adjusted models, we found that the following characteristics increased the odds of being vaccinated: being male, increasing age, BMI, and comorbidities, being Black or Hispanic, having had the flu vaccine in 2020, and increasing number of office primary care visits. Living in a neighborhood with higher social deprivation and having dual Medicaid/Medicare enrollment decreased the odds of completing full vaccination. CONCLUSIONS: Increasing office visit in a high-touch primary care model is associated with higher vaccination rates among elderly populations who belong to racial/ethnic minorities or have low socioeconomic status. However, lower SES and Medicaid populations continue to have difficulty in completing vaccination. KEY POINTS: • High COVID-19 vaccination rates of minorities enrolled in Medicare can be achieved. • Lower socioeconomic status is associated with completing vaccination. • Increasing office visits can lead to higher vaccination rates.

AIDS-Related Kaposi Sarcoma Associated with Steroid-Unresponsive Periorbital Lymphedema that Responded to Chemotherapy.

BACKGROUND As an AIDS-defining illness, the neoplasm Kaposi sarcoma (KS) classically presents as cutaneous lesions that are often associated with periorbital edema. This association with KS is important because it frequently leads to the misuse of steroids in HIV-infected patients. This report presents 2 cases of AIDS-related Kaposi sarcoma (AIDS-KS) associated with severe steroid-unresponsive periorbital lymphedema that responded to chemotherapy. CASE REPORT Case 1: A 30-year-old African-American man with KS-related periorbital edema suffered progression after receiving multiple corticosteroids for a presumed hypersensitivity reaction. After multiple hospitalizations, the patient's KS had disseminated, and he eventually opted for hospice. Case 2: A 29-year-old White male with recurrent facial edema had been repeatedly treated with corticosteroids for impending anaphylaxis reactions. He had multiple admissions with similar presentations, and it was found that his KS had progressed. After receiving chemotherapy, his facial edema has not recurred. CONCLUSIONS The failure to recognize periorbital edema as tumor-associated edema has direct consequences for the management of AIDS-KS. In addition to a delay in administering chemotherapy, the mischaracterization of periorbital edema as a hypersensitivity/allergic reaction often prompts the use of corticosteroids, potentially exacerbating the underlying AIDS-KS. Despite the current evidence, clinicians continue to order steroids in advanced AIDS-KS patients presenting with periorbital edema. Although that management is started with the best intentions and done with concerns for airway compromise, this anchoring bias could lead to devastating consequences and a rather poor prognosis.

Antineutrophil Cytoplasmic Autoantibody (ANCA)-Associated Vasculitis With Mucosal Involvement Following COVID-19 Pneumonia.

Antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitides (AAV) are a group of inflammatory disorders in which autoantibodies damage small arteries throughout the body, including in the upper and lower respiratory system, kidneys, as well as the skin. AAV may be precipitated by a variety of causes, including infections. In this report, we examine the case of a patient who developed AAV that was suspected primarily based on mucocutaneous hemorrhagic bullae, elevated ANCA levels, and subsequently confirmed by kidney biopsy, while recovering from coronavirus disease 2019 (COVID-19) infection. AAV and COVID-19 infections may present with similar symptoms, rendering an accurate diagnosis challenging. Additionally, only a few other cases describing a similar onset of AAV post-COVID-19 infection have been described in the literature. Initial presenting features of AAV in such cases have varied considerably, which makes the diagnosis even more challenging. We also engage in a review of such cases to assess key similarities, different treatment options, and outcomes. Lastly, the fact that several mechanisms have been proposed for AAV highlights the need for continued research to help clarify the pathophysiology while also identifying the optimal therapy.

Malignant Priapism as a Result of Metastatic Thyroid Cancer: A Hard Reality.

Metastasis to the penis is an extremely rare entity. Malignant priapism is defined as a persistent, nonsexual erection that is refractory to pharmacologic treatment, corporal aspiration, and surgical shunts. Furthermore, it is typically a hallmark of an advanced cancer that has metastasized, most commonly from regional organs like the prostate or bladder. We report an unusual case of malignant priapism in the setting of metastatic follicular thyroid carcinoma. To date, this is the second reported case of penile metastasis due to thyroid carcinoma and the first incidence of priapism secondary to follicular thyroid carcinoma metastasis.

Hemophagocytic Lymphohistiocytosis Complicated by Acute Respiratory Distress Syndrome and Multiorgan Failure.

Hemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening condition that is characterized by an overactive response of the immune system with excessive production of proinflammatory cytokines. Initial presentation of this condition often mimics and overlaps with many diseases including infections, sepsis, and multiorgan failure syndrome, which makes diagnosis the diagnosis of HLH challenging. Herein is described a case of a patient who developed acute respiratory distress syndrome and multiple organ failure related to HLH in a setting of probable viral pneumonia. The diagnosis was established based on laboratory and bone marrow biopsy findings. This patient was treated with the standard chemotherapy regimen of intravenous dexamethasone, etoposide in addition to intrathecal methotrexate for central nervous system involvement.