A Rare Case of Metachronous Quadruple Primary Malignancies in a Single Patient: A Case Report and Comprehensive Literature Review.

Multiple primary malignancies (MPMs) in the same patient are rare. Over the past decade, the incidence of MPMs is increasing. The prevalence in the general population is 0.7-11.7%, with a higher incidence in the elderly. This increase in incidence can be attributed to advanced lifespan, environmental factors, early chronic disease/cancer screening, and advanced treatment leading to more metaplasia. The chances are higher in cancer patients due to the carcinogenic effect of chemoradiotherapy. Here, we present a 79-year-old female with a 27 pack-year smoking history without any significant genetic predisposition, who developed four different primary malignancies including (1) chronic lymphocytic leukemia in 2017 (stage I modified Rai), positive for CD23 and CD5, which did not require treatment; (2) melanoma in situ on the left cheek in 2019 status post excision; (3) lung adenocarcinoma with negative molecular study (epidermal growth factor receptor (EGFR)/ROS proto-oncogene, receptor tyrosine kinase (ROS)/v-Raf murine sarcoma viral oncogene homolog B1 (BRAF)/anaplastic lymphoma kinase (ALK)) and negative programmed cell death ligand 1 (PDL-1) in 2020 for which she received treatment with carboplatin, pemetrexed, and pembrolizumab; and (4) left lower pole renal mass on surveillance CT scan, which was highly suspicious for primary malignancy as opposed to metastasis, for which she underwent radical nephrectomy and biopsy positive for clear cell renal cancer. Regarding these multiple primary cancers, the thought of germline mutation was considered. But as she did not have a family history of malignancy, genetic testing was not needed as per the genetic counselor. Patients are being diagnosed with MPMs as there is more advancement in tumor detection and treatment. With the advancement in the treatment, cancer survivorship is improving. Given that there are no large studies, we believe that treatment modality for MPMs should be on a case-to-case basis and needs a multidisciplinary approach to tackle therapeutic challenges and provide radical treatment.

A deadly cold.

This narrative describes how non-execution of screening at an urgent care visit may have delayed the diagnosis of cervical cancer in a young woman.

Influenza Vaccination During COVID-19 in a Rural Community: A Cross-sectional Survey.

Vaccination behavior is an informative metric for assessing flu seasons and is especially important to understand for the 2020-2021 flu season, which coincided with the COVID-19 pandemic. This study aimed to estimate flu vaccine behavior and assess vaccine perceptions during the pandemic season. Using a cross-sectional descriptive study design, we conducted an online survey to assess vaccination behavior and perceptions of both COVID-19 and the flu. Patients were identified as recently seen by providers in an academic internal medicine practice (n = 827) and surveys were distributed as messages in the Epic electronic medical record system. We found that 88.3% of respondents (188/206) had received their flu vaccination for the season at the time of their survey response in December 2020-February 2021. Of those that had not yet received the flu vaccine, only 13.6% indicated they planned on getting one. 12.5% of respondents said they had changed their flu vaccine plans due to the COVID-19 pandemic. Looking at differences from past season's behavior, more individuals switched to getting the flu vaccine than those that switched to not getting the vaccine this season. The most frequently cited reasons for not receiving the flu vaccination were concerns about side effects and not being in a priority group. Changes in flu vaccination behavior from previous seasons represent a net positive in the direction of vaccine acceptance. Barriers to vaccination were identified and results from this study provide more information on vaccine perceptions, beliefs, and behavior, which can benefit future vaccination programs.

Petechiae, as seen on TV.

This narrative describes how a patient facilitated a diagnosis of acute myeloid leukemia in a primary care visit because she recognized petechiae she had seen on television on her own skin.

Looking Back and Going Forward: Roles of Varenicline and Electronic Cigarettes in Smoking Cessation.

Tobacco use is the single largest preventable cause of death in the United States (US). The national goal of reducing the prevalence of adult cigarette smoking to 12% was retained for 20 years due to non-attainment. Meanwhile, varenicline and electronic cigarettes (ECs) became available in the US in 2006 and 2007, respectively, and have been used by many smokers wanting to quit. The purpose of this review is to compare varenicline and ECs in terms of efficacy for smoking cessation after over a decade of widespread use in the US. Data collection for systematic review and qualitative synthesis by a PubMed search using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelinesand the Oxford Quality Scale, respectively, was performed in June 2018 and updated in June 2020. Articles were eligible if published in English as original research in the form of a randomized clinical trial (RCT), a systematic review and meta-analysis, a systematic review, or a cross-sectional study. Eighteen studies were included: nine RCTs, four cross-sectional studies, two meta-analyses, one systematic review, one systematic review and meta-analysis, and one cohort study. No head-to-head RCT compared varenicline to ECs. In four RCTs, varenicline was more effective than placebo for smoking cessation. In two RCTs, ECs were more effective than placebo but a meta-analysis of 20 studies reported a statistically significant decrease in the odds of quitting smoking using ECs as compared to placebo. To conclude, varenicline and ECs have data suggesting efficacy for smoking cessation; however, unlike varenicline, ECs were not effective in all studies.

Celiac disease unmasked by acute severe iron deficiency anemia.

The prevalence of celiac disease (CD) appears to be increasing in the United States. However, the proportion of new CD cases with atypical presentations is also rising. We present the case of a 49-year-old woman who was diagnosed with CD in the setting of new, severe iron-deficiency anemia, 13 years into treatment of diarrhea-predominant irritable bowel syndrome associated with chronic mildly elevated liver function tests. While CD and iron deficiency anemia are common, this is a rare presentation of CD.

Documentation of quality improvement exposure by internal medicine residency applicants.

BACKGROUND: Quality improvement (QI) has become an essential component of medical care in the United States. In residency programs, QI is a focus area of the Clinical Learning Environment Review visits conducted by the Accreditation Council for Graduate Medical Education. The readiness of applicants to internal medicine residency to engage in QI on day one is unknown. PURPOSE: To document the reporting of QI training or experience in residency applications. METHODS: Electronic Residency Application Service applications to a single internal medicine program were reviewed individually looking for reported QI involvement or actual projects in the curriculum vitae (CVs), personal statements (PSs), and letters of recommendation (LORs). CVs were also reviewed for evidence of education in QI such as completion of Institute for Healthcare Improvement (IHI) modules. RESULTS: Of 204 candidates shortlisted for interview, seven had QI items on their CVs, including one basic IHI certificate. Three discussed their QI work in their PSs, and four had recommendation letters describing their involvement in QI. One applicant had both CV and LOR evidence, so that 13 (6%) documented QI engagement. CONCLUSION: Practice of or instruction in QI is rarely mentioned in application documents of prospective internal medicine interns.

Topiramate as a rare cause of reversible Fanconi syndrome and acute kidney injury: a case report and literature review.

Topiramate (TPM) is a sulfa-derivative monosaccharide that has been used for multiple indications in the last several years. We describe a 53-year-old woman with known chronic kidney disease stage 2 and baseline creatinine of 1 mg/dL who developed acute kidney injury and proximal renal tubular dysfunction while on TPM for depression. The Naranjo Adverse Drug Reaction Probability Scale indicated a probable relationship (score of 6) between TPM and acute kidney injury as well as proximal tubular dysfunction; these renal conditions resolved on withdrawal of TPM. To our knowledge, this is the first report of such a scenario. Patients receiving TPM therapy should be closely monitored for evidence of kidney dysfunction and electrolyte abnormalities.

Partially reversible bortezomib-induced cardiotoxicity: an unusual cause of acute cardiomyopathy.

Chemotherapy-associated cardiotoxicity can present as a spectrum from arrhythmia to acute congestive heart failure. Unlike anthracyclines, proteasome inhibitors - for example, bortezomib - are not notorious for causing cardiotoxicity in absence of pre-existing cardiac dysfunction or without concomitant use of other cardiotoxic agents. We describe a 66-year-old woman with end-stage renal disease who developed acute dyspnea hours after a third treatment with bortezomib for IgG kappa myeloma. The Naranjo adverse drug reaction probability scale indicated a probable relationship (score of 5) between bortezomib and acute left ventricular dysfunction. Patients receiving proteasome inhibitors should be closely monitored for evidence of cardiac dysfunction during treatment.

Exercise is Medicine™: A pilot study linking primary care with community physical activity support.

INTRODUCTION: Exercise is Medicine™ (EIM) is an approach to clinic-based physical activity (PA) promotion. Study aims were to 1) assess the acceptability of current EIM protocols among healthcare providers (providers) and health and fitness professionals (fitness professionals); and 2) pilot test the resultant modified EIM protocols comparing patients referred to community PA programming with patients exposed to the EIM protocols alone. METHODS: During 2012-2013 in Chattanooga, Tennessee, USA, 30/80 invited providers and 15/25 invited fitness professionals received training and provided feedback in the use of the EIM protocols. Following EIM use, feedback from providers and fitness professionals about acceptability of EIM protocols resulted in the adaptation of EIM protocols into the electronic health record. Subsequently, 50 providers and 8 fitness professionals participated in the intervention phase of the pilot study. Healthy and/or disease managed adults 18 years and older were enrolled with a sample of patients exposed to both the EIM protocols and community PA programming (EIM +) while another sample was exposed to the EIM protocols only (EIM). All patients were assessed for physical activity and Health-related Quality of Life. Measures were repeated ~ 3 months later for each patient. RESULTS: Eighteen EIM + and 18 EIM participants were studied. The EIM + participants had a greater net increase in total PA (∆[Formula: see text] = + 250 min/week) vs. EIM participants (∆[Formula: see text] = - 38.6 min/week) (p = 0.0002). CONCLUSIONS: EIM + participation significantly increased PA levels among participants, suggesting this approach significantly impacts the PA of inactive adults more than just EIM only.

A survey of primary care resident attitudes toward continuity clinic patient handover.

BACKGROUND: Transfer of clinic patients from graduating residents to interns or junior residents occurs every year, affecting large numbers of patients. Breaches in care continuity may occur, with potential for risk to patient safety. Several guidelines have been developed for implementing standardized inpatient sign-outs, but no specific guidelines exist for outpatient handover. METHODS: Residents in primary care programs - internal medicine, family medicine, and pediatrics - at a US academic medical center were invited to participate in an online survey. The invitation was extended approximately 2 years after electronic medical record (EMR) rollout began at the institution. RESULTS: Of 71 eligible residents, 22 (31%) responded to the survey. Of these, 18 felt that handover of ambulatory patients was at least moderately important - but only one affirmed the existence of a system for handover. IM residents perceived that they had the highest proportion of high-risk patients (p=0.042); transition-of-care letters were more important to IM residents than other respondents (p=0.041). CONCLUSION: There is room for improvement in resident acknowledgement of handover processes in continuity clinics. In this study, IM residents attached greater importance to a specific handover tool than other primary care residents. Thus, the different primary care specialties may need to have different handover tools available to them within a shared EMR system.

Feasibility of an innovative third-year chief resident system: an internal medicine residency leadership study.

INTRODUCTION: The role of the internal medicine chief resident includes various administrative, academic, social, and educational responsibilities, fulfillment of which prepares residents for further leadership tasks. However, the chief resident position has historically only been held by a few residents. As fourth-year chief residents are becoming less common, we considered a new model for rotating third-year residents as the chief resident. METHODS: Online surveys were given to all 29 internal medicine residents in a single university-based program after implementation of a leadership curriculum and specific job description for the third-year chief resident. Chief residents evaluated themselves on various aspects of leadership. Participation was voluntary. Descriptive statistics were generated using SPSS version 21. RESULTS: Thirteen junior (first- or second-year) resident responses reported that the chief residents elicited input from others (mean rating 6.8), were committed to the team (6.8), resolved conflict (6.7), ensured efficiency, organization and productivity of the team (6.7), participated actively (7.0), and managed resources (6.6). Responses from senior residents averaged 1 point higher for each item; this pattern repeated itself in teaching evaluations. Chief resident self-evaluators were more comfortable running a morning report (8.4) than with being chief resident (5.8). CONCLUSION: The feasibility of preparing internal medicine residents for leadership roles through a rotating PGY-3 (postgraduate year) chief residency curriculum was explored at a small internal medicine residency, and we suggest extending the study to include other programs.