Incidental Finding of Attenuated Familial Adenomatous Polyposis.

Attenuated familial adenomatous polyposis (AFAP) or attenuated adenomatous polyposis coli (AAPC) is defined as the milder polyposis phenotype of classic familial adenomatous polyposis (FAP). FAP syndromes are caused by germline mutations in the adenomatous polyposis coli (APC) gene. AFAP is an inherited autosomal dominant with predominant mutations at the far proximal (5') end of the APC gene. Unlike FAP, AFAP is characterized by the occurrence of fewer than 100 adenomas that are found mostly in the proximal part of the colon with a delayed progression to colorectal cancer (CRC). The lower risk of development of colorectal cancer and extra-intestinal neoplasms is likely attributable to under-diagnosis. However, 2-5% of all CRCs happen because of inherited syndromes which include both hereditary polyposis syndromes and hereditary nonpolyposis colorectal cancer syndrome (HNPCC) or otherwise known as Lynch syndrome (LS). Here, we present a case of a 64-year-old Polish-speaking female in whom an incidental finding of polyposis turned out to be a malignancy. Our patient had a positive family history of colon cancer. The delay in performing an annual colonoscopy with endoscopic polypectomy per AFAP surveillance guidelines was supposedly delayed due to lack of insurance and language barrier. There were no metastases and she was negative for the APC gene mutation. Pathology was significant for moderately differentiated adenocarcinoma with intact mismatch repair protein (MMRP) (expression of MLH1, PMS2, MSH2, and MSH6) genes immune-histochemical staining. The patient underwent a subtotal colectomy with ileostomy without any complications. This study aimed to emphasize that communication with the patient in their primary language is essential to gather all the data which can lead to an accurate diagnosis and to provide adequate care. Physicians are required to have a professional interpreter to acquire the appropriate medical history and be more vigilant in following up with the patient in order to provide comprehensive care.

For Residents, by Residents: Developing a Physician Handoff Tool at a University Affiliated Community Hospital.

The 80-hour per week work limit resulted in an increased number of patient handoffs. A satisfactory handoff system should optimize the exchange of vital patient information while concisely minimizing error. This project describes our experience and lessons learned in successfully developing and implementing an Electronic Health Record (EHR)-integrated handoff system based on the I-PASS model. The handoff system, termed Physician Handoff, was refined through end-user feedback. End-users were evaluated on the quality of handoff in the following categories: Illness Severity, Patient Summary, Action List, and Situational Awareness. Resulting survey showed high adoption and satisfaction rate with Physician Handoff. Success can be attributed to interdepartmental collaboration, credentialing the users, and recognizing the importance of end-user feedback.

Leukocytoclastic Vasculitis: Depiction of the Diagnostic Dilemma.

Vasculitis is classified based on the size of the blood vessels involved. Sub-group Leukocytoclastic vasculitis (LCV) refers to small blood vessel inflammation, which involves cutaneous capillaries and venules. To date, there have been myriad primary and secondary probable causes of LCV. Here, we present a case of an 86-year-old male who presented with non-blanchable purpura involving the ankles, knees, and palms. The patient had idiopathic pulmonary fibrosis (IPF), for which he had been on long-term oxygen therapy and chronic corticosteroids. He was recently started on Bactrim DS (trimethoprim-sulfamethoxazole double strength) for prophylaxis of pneumocystis pneumonia. After a meticulous workup, including a skin biopsy, the causative agent of the LCV was established to be Bactrim DS, and the event was likely triggered by superimposed acute stress of sepsis secondary to UTI and bacteremia. There were several diagnostic dilemmas due to the ongoing chronic medical conditions; however, the occurrence of LCV while being on chronic corticosteroids was concerning as it should have prevented such an untoward occurrence. Eventually, the presentation subsided past an increase in the dose of corticosteroids and discontinuation of Bactrim DS. This raises concern regarding either the dose-dependent immunosuppressive effects of corticosteroids or deficits in our current understanding of the mechanism of action. Additionally, it necessitates further exploration into the causes of LCV and a thorough understanding of its pathogenesis.

A Case of Tick Bite Induced Babesiosis With Lyme Disease.

The Ixodes tick may transmit multiple pathogens, Lyme disease being the most common. Early detection of tick bites and using prophylaxis measures is the key to prevent tick bite-associated diseases like babesiosis, anaplasmosis, and Lyme disease. It is recommended to follow preventive measures like using diethyltoluamide (DEET) on the skin, applying permethrin on clothes while visiting the tick-infested areas. Co-infection is an uncommon occurrence but still representative in endemic areas. If there is delayed initiation of therapy in these kinds of patients, there may be dire consequences that may require aggressive therapy. Clinicians should consider co-infection when suspecting tick-borne disease which can prove to be fatal if not addressed promptly. Here, we present the case of a 72-year-old female with atypical symptoms, who was found to have coinfection with Lyme disease and Babesiosis on serology testing and peripheral smear and was diagnosed and treated promptly.

Concurrent Incidental Presentation of Primary Retroperitoneal Follicular Lymphoma With Acute Pancreatitis.

BACKGROUND: Follicular lymphomas are a common type of non-Hodgkin's lymphomas (NHL). Presentation varies widely from being asymptomatic to painless peripheral lymphadenopathy to classic B symptoms. We present an unusual case of follicular lymphoma where the patient initially presented with signs and symptoms of acute pancreatitis. The aim of this study is to recognize the challenges faced while diagnosing retroperitoneal NHL and the need for timely management of this disease. CASE REPORT: A 66-year-old Hispanic female with a medical history of treatment compliant asthma and hypertension presented to the ER with complaints of abdominal pain in the right upper quadrant with serum lipase >3000 U/L and elevated liver function tests (LFTs), aspartate aminotransferase (AST) 139 U/L, alanine aminotransferase (ALT) 65 U/L, alkaline phosphatase (ALP) 122 U/L. Abdominal ultrasound identified gall bladder wall thickening and dilation of biliary ducts. CT scan showed soft tissue mass in the retroperitoneum, measuring 9.3x4.8cm which wrapped around the aorta and pushed it off the spine. After two days of conservative management, her pain resolved and lipase levels normalized, she was discharged and scheduled for outpatient endoscopic ultrasound (EUS) with biopsy of the retroperitoneal mass. The next day, the patient presented to the ER with similar pain, and labs again showed elevated lipase, EUS, and fine needle biopsy of mass showed CD-10 positive B-cell lymphoma. The patient was discharged after the resolution of pain. A positron emission tomography (PET) scan four weeks after the initial CT scan showed an increase in tumor size without any metastatic lesions. While awaiting core biopsy, the patient presented to the ER for the third time with worsening abdominal pain, lipase >3000 IU/L, and ultrasound showing cholelithiasis with cholecystitis. The patient underwent laparoscopic cholecystectomy. Core needle biopsy of paraspinal lymph nodes showed grade 1-2 follicular lymphoma. Finally, the patient underwent six cycles of chemotherapy with Bendamustine and Rituximab and after the fourth cycle, a repeat CT scan showed resolution of adenopathy with minimal residual soft tissue attenuation in retroperitoneum. DISCUSSION: NHL rarely occurs in retroperitoneum and its diagnosis is challenging. Our patient presented with the primary and unique occurrence of follicular lymphoma in the retroperitoneum. She presented with symptoms of an acute abdomen with elevated lipase and LFTs. She underwent multiple hospitalization and cholecystectomy before the correct diagnosis was made and until she was treated for follicular lymphoma. CONCLUSION: This study emphasizes the importance of being vigilant when a patient presents with unusual presentations of a disease in order to diagnose and treat the condition early to decrease the risk of complications and to mitigate the risk of poor outcomes.

Oxidized HDL, Adipokines, and Endothelial Dysfunction: A Potential Biomarker Profile for Cardiovascular Risk in Women with Obesity.

OBJECTIVE: High BMI predicts adverse cardiovascular outcomes and positively correlates with increased levels of adipokines. The relationship among BMI, IL-6, TNFα, adiponectin, and oxidized high-density lipoprotein (Ox-HDL) with circulating endothelial cells (CECs) and endothelial progenitor cells (EPCs) has not been well studied. Elevated CEC levels have been described in both humans and mice with obesity and diabetes. Ox-HDL has been shown to be a potent driver of adipogenesis in vivo and in vitro. In this study, elevated BMI was examined in 2 groups of women studied in Brooklyn, New York, and Huntington, West Virginia, respectively. METHODS: Twenty-six females with obesity and five lean controls without overt cardiovascular disease were enrolled, 13 from Huntington and 13 from Brooklyn. Cytokine levels, EPCs, and CECs were determined. RESULTS: Females with obesity had elevated levels of leptin, IL-6, and Ox-HDL, increased CEC levels, and decreased EPC and adiponectin levels (all P < 0.01). The Ox-HDL levels were higher in women from Brooklyn versus Huntington (P < 0.01), possibly from higher TNFα levels in Brooklyn or higher adiponectin levels in Huntington. Seventy-five percent of the variance in Ox-HDL levels could be predicted in this population (P < 0.01). CONCLUSIONS: This study reveals a unique inflammatory biomarker profile in females with obesity.

An Innovative Approach to Improve Communication and Reduce Physician Stress and Burnout in a University Affiliated Residency Program.

Ineffective communication between nursing staff and residents leads to numerous educational and patient-care interruptions, increasing resident stress and overall workload. We developed an innovative and simple, secure electronic health record (EHR) base text paging system to communicate with internal medicine residents. The goal is to avoid unnecessary interruption during patient care or educational activities and reduce stress. Traditional paging system can send a phone number to call back. We developed and implemented a HIPPA-compliant, EHR-integrated text paging at a busy 591-bed urban hospital. Access was granted to unit clerks, nursing staff, case managers, and physicians. Senders could either send a traditional telephone number page or a text page through our EHR. The recipient could then either acknowledge receipt of the page or take appropriate actions. Afterward, Internal medicine residents were polled on overall satisfaction difference between basic phone based numeric paging and the enhanced EHR text paging system. Educational interruptions (averaging over 7 pages) decreased from 64% to 16%. Patient care interruptions fell from 68% to 12%. 88% of residents felt that 50% or less of the pages were non-emergent and did not require an immediate action. 92% of 25 surveyed internal medicine residents preferred text paging over numeric paging and responded through the EHR 60% of the time by placing direct orders. Time savings using the new system over a 3-month span amounted to 72.5 h in transmission time alone. Text paging among medical caregivers and internal medicine residents through EHR-associated communication reduced patient care and educational interruptions. It saved time spent sending pages, answering unnecessary pages and it improved resident's subjective stress and satisfaction levels.

Use of Electronic Clinical Decision Support and Hard Stops to Decrease Unnecessary Thyroid Function Testing.

NewYork-Presbyterian Brooklyn Methodist Hospital embarked on a Zero Unnecessary Study (ZEUS) initiative, whereby all aspects of clinical care were evaluated and strategies were implemented to mitigate waste. An opportunity was found in regards to thyroid function testing. It has been shown that certain TFTs are ordered far more often than clinically indicated. Free T3 (fT3) and Free T4 (fT4) are only indicated when the TSH is abnormal in the inpatient setting, with rare exceptions. Thus, a clinical algorithm for Clinical Decision Support (CDS) and Hard Stops (HS) were incorporated into the Electronic Medical Record (EMR) to prevent fT3 or fT4 to be ordered without an abnormal TSH, with certain predefined exceptions. In addition, a reflex rule was built which automatically orders (reflex) fT3 and fT4 if the TSH is abnormal. The pre and post-intervention ratios of fT3 and fT4 orders per total TSH orders were analyzed. Pre-intervention data revealed that fT4 was the most frequently ordered TFT laboratory test on admission, after TSH. Post-Intervention, there was a decrease in the ratio of fT4 to TSH orders (fT4/TSH) of 35.2%, from 44.6% to 28.9%. The percentage of fT4 ordered due to abnormal TSH increased by 126.1%, from 36.8% to 83.2%. The fT3 to TSH ordering ratio similarly decreased by 55.2%, from 6.2% to 2.9%. The decreases in both fT3/TSH and fT4/TSH ratios were statistically significant. Any unnecessary orders are a burden on healthcare. It is now possible to achieve goals that were not previously thought to be possible because of advancement in medicine and technology. By making small changes and saving costs, we can target our energy and resources toward effectively treating patients.

Antenatal Diagnosis of Jeune Syndrome (Asphyxiating Thoracic Dysplasia) with Micromelia and Facial Dysmorphism on Second-Trimester Ultrasound.

BACKGROUND: Jeune syndrome is a rare congenital malformation with a reported incidence of 1 in 100,000-130,000 live births. Thoracic hypoplasia is the most striking abnormality of this disorder. Here we report a case of Jeune syndrome with marked thoracic hypoplasia, micromelia and facial dysmorphism, which was diagnosed on a second-trimester antenatal real-time three-dimensional ultrasound. CASE REPORT: A 24-year-old primigravida came for routine anomaly scan at 19 weeks of gestation. Transabdominal grey scale and real time 3D ultrasound (US) was done with GE Logiq P5 with curvilinear array transducers (4C and 4D3C-L). US findings were consistent with the diagnosis of Jeune syndrome (Asphyxiating thoracic dysplasia). CONCLUSIONS: Jeune syndrome is an extremely rare congenital disorder with a spectrum of abnormalities of which thoracic hypoplasia is the most striking. It can be diagnosed on early antenatal US by its characteristic skeletal and morphological features which can guide further management of pregnancy in form of termination or preparation for surgical correction of the deformity.