Alabama College of Osteopathic Medicine

Birt-Hogg-Dubé syndrome (BHD) is a rare autosomal dominant disorder caused by germline mutations in the FLCN gene, characterized by cutaneous fibrofolliculomas, pulmonary cysts, and an increased risk of renal neoplasms. Parotid oncocytoma is an infrequently reported extracutaneous manifestation of the syndrome. A 30-year-old man with a prior history of testicular embryonal cell carcinoma presented with a right-sided neck mass. Workup of the parotid lesion ultimately led to a new diagnosis of BHD, confirmed by FLCN germline mutation testing. The patient underwent right parotidectomy, which was technically complex due to parapharyngeal extension and adherence to the facial nerve. Final pathology confirmed oncocytoma with clear cell features; all three lymph nodes were negative for metastatic carcinoma. The patient has remained without evidence of disease at over two years of postoperative follow-up. This case illustrates the diagnostic challenges posed by BHD-associated parotid oncocytoma, particularly when clear cell morphology raises concern for metastatic renal cell carcinoma or recurrent germ cell tumor. Clinicians should consider BHD in younger patients presenting with oncocytic parotid tumors, as recognition carries important implications for long-term renal and pulmonary surveillance.

Dermatologic surgery primarily involves clean procedures with low baseline infection rates. This 2-part continuing medical education article synthesizes current evidence to guide perioperative antibiotic decision-making for excisional dermatologic surgery, including standard excisions, Mohs micrographic surgery, and associated reconstructive techniques. Part I reviews indications for systemic prophylaxis, emphasizing a risk-stratified approach that incorporates procedural, anatomic, and patient-specific factors. Special attention is given to high-risk populations, including immunocompromised and transplant recipients, as well as the roles of topical and intra-incisional antibiotic alternatives.After completing this learning activity, participants should be able to:•Identify dermatologic surgery scenarios in which systemic antibiotic prophylaxis is indicated or not indicated, including considerations for patients with prosthetic joints, high-risk cardiac conditions, and immunosuppression.•Apply current, evidence-based guidelines to select appropriate antibiotic regimens and timing.•Evaluate the role of topical and intra-incisional antibiotics and implement strategies to minimize unnecessary use while maintaining optimal infection prevention.Patient-Facing Summary•Most skin surgeries are clean procedures with a low risk of infection.•Antibiotics are usually not needed for routine dermatologic procedures.•Certain patients, such as those with heart valve replacements, prosthetic joints, or weakened immune systems, may require antibiotics before surgery.•Using antibiotics only when necessary helps prevent side effects and antibiotic resistance.•Topical antibiotics are generally not required for clean wounds; simple ointments like petrolatum are safe and effective.•In higher-risk cases, localized intra-incisional antibiotics may be considered as an alternative to oral antibiotics.

BACKGROUND:Phenobarbital is an emerging treatment for alcohol withdrawal syndrome, however scant data exist comparing phenobarbital to benzodiazepines in the emergency department (ED). OBJECTIVES:To compare phenobarbital to benzodiazepines for treatment of severe alcohol withdrawal syndrome in the ED. METHODS:This was a retrospective study of severe alcohol withdrawal syndrome in the ED. The primary outcome measure was the number of drug administrations. Secondary outcomes included ICU admission and respiratory depression. RESULTS:490 patients met final inclusion criteria; 432 received phenobarbital, 58 received only benzodiazepines. Patients receiving phenobarbital received more diazepam equivalents in the first 6 hours after ED arrival (243 mg vs. 120 mg, difference -109 mg [95% CI: -123 mg to -95 mg]). The number of drug administrations in the first 6 hours after ED arrival was 4 (IQR 3-6) for those who received phenobarbital and 9 (IQR 8-11) for those who received only benzodiazepines (propensity-matched adjusted difference 4, 95% CI 4 to 5). There was no difference in respiratory depression between groups (phenobarbital, 31%; benzodiazepines only, 38% [difference 11.5%, 95% CI: -5.2% to 28.2%]), nor rates of tracheal intubation (13% vs. 14%). Intensive care unit admission was more common in the benzodiazepines-only group (66% vs. 29%; median difference 33% [95% CI: 18.7% to 47.4%]). CONCLUSIONS:For patients with severe alcohol withdrawal syndrome in the ED, phenobarbital administration was associated with fewer drug administrations and ICU admissions compared to a benzodiazepine-only strategy. There was no observed difference in rates of respiratory depression or tracheal intubation.

OBJECTIVES:To determine the incidence and severity of thyroid dysfunction following iodinated contrast media (ICM) exposure in our pediatric heart center, assess adherence to FDA guidelines and evaluate the utility of routine thyroid function testing. METHODS:This retrospective study reviewed charts of 186 patients under four years old who underwent cardiac catheterization between June 2022 and June 2024 at our pediatric heart center. Data collected included age, sex, gestational age, ethnicity, ICM use, and post-procedure thyroid-stimulating hormone (TSH) levels. Additional risk factors were assessed for patients with abnormal thyroid studies. RESULTS:Of the 186 cardiac catheterization procedures, 155 involved administration of ICM. Follow-up thyroid studies were conducted after 113 of these; three lab draws were excluded due to new diagnoses of hypothyroidism made during the study period. Among the remaining 110 cases with indicated TSH testing, only two patients (1.8 %) demonstrated persistently elevated TSH levels - both of whom had pre-existing risk factors for thyroid dysfunction. Among the 113 cases that completed follow-up TSH studies, 69 (61.1 %) occurred within the FDA's recommended 3-week period. Post-procedure thyroid studies were not completed in 42 cases (27.1 %), although four patients had passed away and four were transferred to another hospital system. CONCLUSIONS:No clinically significant relationship was found between ICM exposure and thyroid dysfunction in patients under four years old, suggesting routine post-catheterization thyroid screening may be unnecessary.

Background : Pre-exposure prophylaxis (PrEP) is a highly effective strategy for HIV prevention, yet its uptake remains limited in part due to gaps in provider preparedness. Medical school represents a critical opportunity to prepare future physicians to deliver HIV preventive care; however, variability in curricular exposure and clinical training may result in uneven preparedness among graduating students. Methods : An anonymous, cross-sectional survey was administered to osteopathic medical students (years 1–4) at two U.S. medical schools. The survey assessed exposure to HIV/PrEP education, perceived clinical preparedness, and professional attitudes toward HIV and PrEP. Preparedness and attitudes were compared by institution, training stage (preclinical vs. clinical), and educational exposure using Fisher’s exact test. Results : A total of 122 students completed the survey (response rate 8.7%). 70% percent reported receiving preclinical HIV/PrEP education, yet only 16.8% reported any hands-on experience in HIV prevention or care. Students at one institution reported significantly greater preparedness across multiple domains, including overall HIV preventive care (65% vs. 26%, p < 0.0001), handling PrEP care, and taking a comprehensive sexual history. Clinical students reported greater preparedness for sexual history taking, whereas preclinical students reported greater preparedness to integrate PrEP discussions into routine visits. Receipt of HIV/PrEP education was associated with greater overall preparedness and stronger belief in PrEP effectiveness, but not with consistent preparedness across PrEP-specific clinical tasks. Conclusions : Medical students demonstrate strong awareness of HIV prevention but limited experiential training and variable preparedness for PrEP-specific care. Early curricular exposure improves perceived preparedness and confidence; however, inconsistent longitudinal reinforcement and lack of hands-on training highlight the need for standardized, competency-based, and experiential HIV/PrEP education across medical curricula to better prepare future physicians.