Notes

Cross-Depicted Historical Design Classification and also Collection with Serious Studying.
This editorial is a call to action for medical communities across the country to address the uninsured crisis in their communities. Thirty million Americans without insurance need access to affordable, high-quality care. An insurance solution may be years away, so we must start today.INTRODUCTION Primary neuroendocrine tumors (NETs) of the appendix are uncommon, but when present are usually not hyperfunctioning. This case represents an extraordinarily rare primary hyperfunctioning NET of the appendix with a clinical presentation of symptomatic hypoglycemia in an otherwise healthy man. CASE PRESENTATION A previously healthy 34-year-old man was found to be symptomatically hypoglycemic in early 2018. After the workup, the apparent explanation was a tumor in his midappendix, for which he was referred to our surgical oncology service for resection. The patient's clinical course is described in detail, including imaging, as well as surgical and pathologic descriptions of the appendiceal NET. DISCUSSION A literature review demonstrates no other case series or reports of a primary hyperfunctioning NET of the appendix presenting with hypoglycemic crisis. The symptoms of tumor-induced hypoglycemia more typically arise with islet cell tumors, such as pancreatic NETs or insulinomas. We believe this case represents a nonislet cell tumor-induced hypoglycemia. This patient's elevated serum proinsulin level preoperatively implies secretion of proinsulin by the tumor. However, tumor-induced hypoglycemia caused by proinsulin has been described previously only in pancreatic tumors. This unique case adds knowledge to the possible glycemic endocrine effects of nonpancreatic NETs, specifically those that arise primarily in the appendix.INTRODUCTION The evidence for outpatient management of hemodynamically stable, low-risk patients with acute symptomatic pulmonary embolism (PE) is mounting. Guidance in identifying patients who are eligible for outpatient (ambulatory) care is available in the literature and society guidelines. Less is known about who can identify patients eligible for outpatient management and in what clinical practice settings. OBJECTIVE To answer the question, "Can primary care do this?" (provide comprehensive outpatient management of low-risk PE). METHODS We undertook a narrative review of the literature on the outpatient management of acute PE focusing on site of care. TASIN-30 inhibitor We searched the English-language literature in PubMed and Embase from January 1, 1950, through July 15, 2019. RESULTS We identified 26 eligible studies. We found no studies that evaluated comprehensive PE management in a primary care clinic or general practice setting. In 19 studies, the site-of-care decision making occurred in the Emergency Department (or after a short period of supplemental observation) and in 7 studies the decision occurred in a specialty clinic. We discuss the components of care involved in the diagnosis, outpatient eligibility assessment, treatment, and follow-up of ambulatory patients with acute PE. DISCUSSION We see no formal reason why a trained primary care physician could not provide comprehensive care for select patients with low-risk PE. Leading obstacles include lack of ready access to advanced pulmonary imaging and the time constraints of a busy outpatient clinic. CONCLUSION Until studies establish safe parameters of such a practice, the question "Can primary care do this?" must remain open.INTRODUCTION Opioid dependency is a major epidemiologic problem with profound morbidity and mortality. Despite the availability of effective treatments, there are often overwhelming barriers to those treatments. CASE PRESENTATIONS We present a case series involving a novel approach to the induction phase of buprenorphine or buprenorphine-naloxone therapy using transdermal buprenorphine. This approach has been demonstrated in inpatient settings but has not been widely explored in the outpatient setting. We demonstrated that a range of patients, from the highly medically complex to relatively straightforward cases, benefited from this approach. DISCUSSION We believe that this approach can be used in a wide range of patients to transition from opioid use to buprenorphine therapy without the patient having to experience withdrawal or wait to start treatment. This should reduce the risk of lack of return for follow-up as well as decrease the dropout rate caused by patients being unable to tolerate withdrawal symptoms.INTRODUCTION Primary renal carcinoid tumors are a rare subset of neuroendocrine tumors arising in the kidneys. Although carcinoid syndrome has occasionally been described, most patients are asymptomatic at presentation. CASE PRESENTATIONS We present 2 cases of primary renal carcinoid tumor and describe the workup, immunohistochemical analysis, treatment, and surveillance of each female patient. The first patient was found to have a renal mass on imaging during a workup of chronic abdominal pain and subsequently underwent a robotic radical nephrectomy. The second patient was found to have an incidental renal mass on imaging and subsequently underwent renal biopsy, followed by robot-assisted laparoscopic partial nephrectomy. In both cases, a gallium dotatate Ga 68-enhanced positron emission tomography/computed tomography scan was used to further assess disease burden. DISCUSSION This report describes 2 cases of primary renal carcinoid tumor with unique presentations and management in our regional health care system. Because primary renal carcinoid tumors are quite uncommon, there are no clear established guidelines on preoperative imaging or posttreatment surveillance in patients with these tumors. There remains a large amount of variability in the diagnosis, workup, immunohistochemical analysis, treatment, and surveillance of patients with primary renal carcinoid tumors. As we learn more about this disease, we hope to optimize patient outcomes and standardize pretreatment workup and posttreatment surveillance.INTRODUCTION Providing high-quality health care to poor and uninsured individuals has been a challenge to the US health care system for decades. Often, patients do not seek care until they are in a crisis, or they seek care at a health care system while not addressing their primary care needs. OBJECTIVE To report on a community that has sought to change this dynamic with the development of an all-volunteer practitioner-run clinic model. METHODS Perspective on a successful volunteer-run safety-net clinic. RESULTS Volunteers in Medicine on Hilton Head Island, SC, provides free health care, with more than 28,000 eligible patient visits annually, for the underserved population. This clinic is self-funded through donations and charity events and accepts no federal money. The patients are not asked to pay a fee for service. Most medical specialties are represented at the clinic, and many partnerships are in place for referrals for more advanced procedures such as surgery. All health care clinicians are volunteers, including physicians, nurses, dentists, and mental health professionals.
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