Clinical Utility of Genomic Recurrence Risk Stratification in Early, Hormone-Receptor-Positive, Human Epidermal Growth Factor Receptor 2-Negative Breast Cancer: Real-World Experience.

BACKGROUND: RNA-based genomic risk assessment estimates chemotherapy benefit in patients with hormone-receptor positive (HR+)/Human Epidermal Growth Factor 2-negative (ERBB2-) breast cancer (BC). It is virtually used in all patients with early HR+/ERBB2- BC regardless of clinical recurrence risk. PATIENTS AND METHODS: We conducted a retrospective chart review of adult patients with early-stage (T1-3; N0; M0) HR+/ERBB2- BC who underwent genomic testing using the Oncotype DX (Exact Sciences) 21-genes assay. Clinicopathologic features were collected to assess the clinical recurrence risk, in terms of clinical risk score (CRS) and using a composite risk score of distant recurrence Regan Risk Score (RRS). CRS and RRS were compared to the genomic risk of recurrence (GRS). RESULTS: Between January 2015 and December 2020, 517 patients with early-stage disease underwent genomic testing, and clinical data was available for 501 of them. There was statistically significant concordance between the 3 prognostication methods (P < 0.01). Within patients with low CRS (n = 349), 9.17% had a high GRS, compared to 8.93% in patients with low RRS (n = 280). In patients with grade 1 histology (n = 130), 3.85% had a high GRS and 68.46% had tumors > 1 cm, of whom only 4.49% had a high GRS. Tumor size > 1cm did not associate with a high GRS. CONCLUSION: Genomic testing for patients with grade 1 tumors may be safely omitted, irrespective of size. Our finds call for a better understanding of the need for routine genomic testing in patients with low grade/low clinical risk of recurrence.

In-hospital Outcomes of Patients with Septic Shock and Underlying Chronic Atrial Fibrillation: A Propensity Matched Analysis from A National Dataset.

INTRODUCTION: Atrial fibrillation (AF) is one of the most common arrhythmias among hospitalized patients. Among patients admitted with septic shock (SS), the new occurrence of atrial fibrillation has been associated with an increase in intensive care unit (ICU) length of stay and in-hospital mortality. This is partially related to further reduction in cardiac output and thus worsening organ perfusion due to atrial fibrillation. However, there is a paucity of research on the outcomes of patients who have underlying chronic AF (UCAF) and then develop SS. This study aimed to identify the clinical characteristics and outcomes of patients with UCAF admitted with SS compared to patients with SS without UCAF. METHODS: This study was a retrospective analysis of the 2016 and 2017 Nationwide Readmission Database. ICD-10 codes were used to identify patients with SS, and these patients were stratified into those with and without UCAF. Propensity matching analyses were performed to compare clinical outcomes and in-hospital mortality between the two groups. RESULTS: A total of 353,422 patients with hospitalization for SS were identified, 5.8% (n = 20,772) of whom had UCAF. After 2:1 propensity matching, 20,719 patients were identified as having SS with UCAF, and 41,438 patients were identified as having SS without UCAF. Patients with SS and UCAF had a higher incidence of ischemic stroke [2.5% versus 2.2%, p = 0.012], length of stay [11.5 days versus 10.9 days, p < 0.001], mean total charges [$154,094 versus $144,037, p < 0.001] compared to those with SS without UCAF. In-hospital mortality was high in both groups, but was slightly higher among those with SS and UCAF than those with SS and no UCAF [34.4% versus 34.1%, p = 0.049]. CONCLUSIONS: This study identified UCAF as an adverse prognosticator for clinical outcomes. Patients with SS and UCAF need to be identified as a higher risk category of SS who will require more intensive management.

A Qualitative Study of Traditional Bone Setters in South India: A Case Series.

Introduction: There are approximately 60,000 Traditional Bone Setters (TBS) in India, who have no formal education or training in modern medicine but treat approximately 60% of bone related trauma. This study investigated the history of TBS, why they are so popular, and their methods. Methods: From a list of TBS from four states in South India, a purposive and convenience sampling method identified participants. One lead TBS from each state was interviewed. With recommendations from these TBS, a total of six participants were interviewed on Zoom® in their native dialect and these interviews were transcribed into English. The data were analyzed using a constant comparative method which included several iterations to refine common themes and determine counterfactual and specific focal points from each interview. Results: Six overarching themes emerged: (1) history of traditional bone setters, (2) occupations outside bone setting, (3) training, certification, education, accolades, (4) patient characteristics and success stories, (5) infrastructure and approach to diagnosis/treatment, and (6) limitations of practice, challenges, and social relevance. The history of traditional bone setting is thousands of years old and passed down within families generationally. Conclusions: In rural India, where a large part of the population lives in poverty and without access to modern medicine, traditional healers provide a much-needed service, often without charge, and consequently, the income is not sufficient without other occupations such as farming. They follow a similar approach to diagnosis and treatment of simple fractures and dislocations as modern medical practitioners. Most would like to share their knowledge and collaborate with ayurvedic and allopathic practitioners and simply want to be respected and supported.

Liquid Biopsy-based Precision Therapy in Patients with Advanced Solid Tumors: A Real-world Experience from a Community-based Oncology Practice.

BACKGROUND: Liquid biopsy testing offers a significant potential in selecting signal-matched therapies for advanced solid malignancies. The feasibility of liquid biopsy testing in a community-based oncology practice, and its actual impact on selecting signal-matched therapies, and subsequent survival effects have not previously been reported. PATIENTS AND METHODS: A retrospective chart review was conducted on adult patients with advanced solid cancer tested with a liquid-biopsy assay between December 2018 and 2019, in a community oncology practice. The impact of testing on treatment assignment and survival was assessed at 1-year follow-up. RESULTS: A total of 178 patients underwent testing. A positive test was reported in 140/178 patients (78.7%), of whom 75% had an actionable mutation. The actual overall signal-based matching rate was 17.8%. While 85.7% of patients with no actionable mutation had a signal-based clinical trial opportunity, only 10% were referred to a trial. Survival analysis of lung, breast, and colorectal cancer patients with actionable mutations who received any therapy (n = 66) revealed a survival advantage for target-matched (n = 22) compared to unmatched therapy (n = 44): patients who received matched therapy had significantly longer progression-free survival (PFS) (mPFS: 12 months; 95%CI, 10.6-13.4 vs. 5.0 months; 95%CI, 3.4-6.6; P = .029), with a tendency towards longer overall survival (OS) (mOS: 15 months; 95%CI, 13.5-16.5 vs. 13 months; 95%CI: 11.3-14.7; P = .087). CONCLUSIONS: Implementation of liquid biopsy testing is feasible in a US community practice and impacts therapeutic choices in patients with advanced malignancies. Receipt of liquid biopsy-generated signal-matched therapies conferred added survival benefits.

Gastrointestinal Stromal Tumor and Ki-67 as a Prognostic Indicator.

Gastrointestinal stromal tumors (GISTs) albeit rare, are the most common mesenchymal neoplasms of our gastrointestinal (GI) tract. GISTs present with nonspecific symptoms and are found incidentally on endoscopy or imaging. A significant portion of GIST diagnoses expresses KIT/CD117 and DOG-1 tissue markers which are pathognomonic for GIST. More recently, Ki-67 was found to be a significant prognostic marker for determining the risk of recurrence. We present a patient with a mesenchymal mass in the small intestine with pathognomonic features of GIST and expression of Ki-67, an important immunocytochemical marker of proliferation. The patient was a 71-year-old male with a history of hyperlipidemia and hypertension. He presented to the emergency department complaining of bloody diarrhea for two days, with associated nausea, vomiting, and abdominal cramping. Initial blood pressure on presentation was 77/52 mm Hg. Computed tomography (CT) of the abdomen and pelvis revealed a large solid mass with cystic components. The mass was not visualized with esophagogastroduodenoscopy or colonoscopy, and surgical intervention was warranted. A 14 cm x 11.5 cm x 10 cm tumor was found in the ileum. The tumor was excised with small bowel segmental resection and the specimen was sent for pathological evaluation. Immunohistochemical analysis confirmed the diagnosis of GIST with diffuse CD117/c-Kit protein expression. The tumor was high grade with a high mitotic rate at 30 mitoses/50 high-power fields (HPF) and had spindle cell morphology. Of note, 10% of the tumor cells were positive for Ki-67. GISTs have a high risk of recurrence and a more favorable prognosis with advancements in management. Prior to imatinib therapy in the early 2000s, GISTs prognosis was very poor, as they are resistant to most conventional chemotherapeutic agents and radiation. While the prognosis is fair, surgical resection and imatinib therapy have improved outcomes and risk of recurrence. Prognosis and risk of recurrence can be determined by assessing the mitotic rate, tumor size, and recently, expression of Ki-67. Ki-67 provides a reliable and reproducible approach to assess the prognosis of GIST.

Analysis of Patient Handoff Between Providers at a Tertiary Urban Medical Center.

INTRODUCTION: Few studies have quantified the total number of attending and consulting physicians involved in inpatients' care, and no other research quantifies the total number of all providers participating in inpatients' care. The purpose of this study was to calculate the number of attending hand-offs, the attending encounter time, and the total number of providers participating in inpatients' care for all admitted patients at a tertiary urban medical center. METHODS: The study design was an observational retrospective cohort. Subjects included pediatric and adult patients who were admitted to and discharged from Ascension Via Christi St. Francis (AVCSF) in Wichita, Kansas between November 1, 2019 and January 31, 2020. Data were abstracted from the Cerner Electronic Medical Record. Variables included: patient demographics, admitting diagnosis, diagnosis related group (DRG), admission service, and duration of inpatient stay. Provider variables abstracted included provider type and provider specialty. Categorical variables were presented as frequencies and percentages, while continuous variables were presented as means ± standard deviation. RESULTS: The sample included information from 200 patient charts. Patients' ages ranged from 5 to 94 years, with a mean of 61 years. Approximately 52% were female and 74.9% were admitted to a surgical service. The length of all inpatients' stays ranged from less than 1 day to 31 days, with a mean of 4 days. Seventy-six different DRGs were recorded. The most frequent attending specialties were hospital medicine, internal medicine, general surgery, and interventional cardiology. Consulting physicians had more patient encounters than any other healthcare provider. For all inpatients, an average of two attending physicians participated in care over the duration of their stay with a range of one to six attending physicians. There was an average of one hand-off between attending physicians. Patients had an average of five consulting physicians, two resident physicians, two physician assistants, and two nurse practitioners during a stay. There was an average of 10 total providers, with a range of one to 46 total providers participating in care. CONCLUSIONS: Understanding the provider data surrounding an inpatient stay is a foundational step in assessing the quality of the provider-inpatient encounter and potential areas for improvement. In this study, the average number of attending physicians and handoffs was reasonable; however, the total number of providers involved in care was relatively high. Assessment of staffing and scheduling requirements by hospital administration could identify areas of improvement to reduce the potential for medical error caused by multiple providers being involved in patient care.

From Radical to Partial Nephrectomy in the Setting of Solitary Functioning Kidney: Neoadjuvant Treatment of Renal Cell Carcinoma.

Immunotherapy has revolutionized the treatment of metastatic renal cell carcinoma (RCC). This case evaluates the use of neoadjuvant immunotherapy for localized RCC in a patient with solitary functioning kidney. A retrospective chart review was conducted between September 2019 and January 2020 on a single patient. Before treatment, the tumor was 7 cm × 8 cm × 8.5 cm. The patient trialed nivolumab + ipilimumab then cabozantinib. The tumor shrunk to 6.3 cm × 5.5 cm and was removed via partial nephrectomy. This case demonstrates the efficacy of immunotherapy in neoadjuvant treatment of RCC. Expansion of guidelines could allow for patients with RCC to undergo partial nephrectomy.

Cardiovascular Outcomes Associated With Adult Electronic Cigarette Use.

Electronic cigarettes (E-Cigs) have been advertised as a safer alternative to smoking. However, E-Cigs use, like smoking, delivers ultra-small aerosol particles, which may be associated with cardiovascular disease. This study aimed to look into the association between E-Cigs use and cardiovascular disease outcomes. The study involved self-reported data from 16,855 participants from the National Health Interview Survey data from years 2014, 2016, 2017, and 2018. Results from the logistic regression analysis report E-Cigs users had higher odds of having myocardial infarction (OR 4.09, 95% CI [1.29, 12.98], P<0.05) when compared to non-users. Dual users had higher odds of myocardial infarction (OR 5.44, 95% CI [2.90, 10.22], P<0.05), stroke (OR 2.32, 95% CI [1.44, 3.74], P<0.05), and coronary artery disease (OR 2.27, 95% CI [1.37, 2.44], P<0.05) when compared to non-users.

Medial Dislocation of the Long Head of the Biceps without Concomitant Subscapularis Tear: A Case Report.

INTRODUCTION: Medial dislocation of the long head of the biceps tendon (LHBT) is classically known as a pathognomonic finding for a subscapularis or at least a rotator cuff (RC) injury. However, this case report outlines a young active individual with symptomatic medial dislocation of the long head of the biceps with associated posterior instability, without a corresponding RC injury. CASE REPORT: An 18-year-old male complained of the left shoulder pain and crepitus after a shoulder injury while playing hockey a year prior. Magnetic resonance imaging demonstrated medial dislocation of the LHBT without subscapularis or supraspinatus tendon injury. The patient complained of instability in the shoulder and exam findings supported posterior instability of the glenohumeral joint. Arthroscopic debridement of the glenohumeral joint with arthroscopic posterior capsulorrhaphy and open biceps tenodesis was performed. The patient regained full and painless range of motion at 2-year follow-up. CONCLUSION: Medial dislocation of the LHBT can occur without injury to the subscapularis tendon. Furthermore, a capsulorrhaphy with open biceps tenodesis and closure of the rotator interval may provide a successful outcome for this rare injury pattern.

Enriching Medical Student Learning Experiences.

OBJECTIVE: Medical students should develop skills in assessing their own learning needs and developing strategies to meet those needs. Medical curricula should be designed to provide active and enriching ways to explore medicine beyond the classroom. The program should enrich the elements of motivation, discovery, innovation, social services, cultural exploration, and personal development. The University of Kansas School of Medicine instituted a new curriculum in 2017 called ACE (Active, Competency-based, and Excellence-driven). Eight 1-week courses of enrichment experiences are embedded within the first 2 years of the curriculum. METHODS: After each of 8 medical content blocks, students are required to participate in a 1-week, nongraded enrichment experience according to their own learning needs and interests. Students choose the type of enrichment activities including clinical experiences, professional development, leadership development, research and scholarly activity, and community engagement. Students select their top enrichment choices and a computer lottery makes the assignments from their designations. Students engaged in research and scholarly activity are guided to appropriate research mentors. RESULTS: A total of 196 enrichment activities at 3 campuses were developed for 211 students during the first 2 years of medical school. Most students selected clinical experiences with enrichments available in most medical specialties and subspecialties. Students also use enrichment weeks to conduct research/scholarly activity, particularly those students pursuing the Honors Track. A total of 2071 enrichment experiences were completed in the first 2 years. CONCLUSIONS: Most enrichments involved clinical experiences, although research/scholarly activity and professional development enrichments also were popular. Evaluations from students and antidotal data suggested enrichments are popular among students and a good change of pace from the usual rigorous activities of the curriculum. Because of the large number of experiences required to conduct the enrichment weeks, a continuous process of evaluation is required to maintain the program. Therefore, flexibility is required to administer the program.

Erratum: Author's Name Correction for "From Radical to Partial Nephrectomy in the Setting of Solitary Functioning Kidney: Neoadjuvant Treatment of Renal Cell Carcinoma".

[This corrects the article on p. 126 in vol. 22, PMID: 33239972.].

The Problematic Nature of Fibromyalgia Diagnosis in the Community.

BACKGROUND: Recently, some studies suggested that clinical diagnosis of fibromyalgia is inaccurate and does not reflect current definitions. However, this hypothesis has not been tested. We examined whether fibromyalgia was accurately diagnosed in the community. METHODS: We surveyed 3276 primary care patients to determine current fibromyalgia status by criteria (CritFM). We also determined whether the patients had a physician's diagnosis of fibromyalgia (MDFM) and the level of symptom severity as measured by the polysymptomatic distress scale (PSD). RESULTS: The prevalence of MDFM and CritFM was 6.1% (95% confidence interval [CI] 5.3%, 6.9%) and 5.5% (95% CI 4.8%, 6.3%), respectively. However, only 32.2% with MDFM met 2016 criteria (CritFM), and only 35.4% with CritFM also had MDFM. The kappa statistic for diagnostic agreement was 0.296 (minimal agreement). The mean PSD score was 12.4 and 18.4 in MDFM and CritFM, respectively. The odds ratio for being a woman compared with being a man was 3.2 for MDFM versus 1.9 for CritFM, P = 0.023. Of the patients with MDFM, 68.3% received specific fibromyalgia pharmacotherapy. CONCLUSIONS: There is little agreement between MDFM and CritFM. Only one-third of MDFM satisfy fibromyalgia criteria, and only one-third of patients who meet the criteria have a clinical diagnosis of fibromyalgia. Physician diagnosis is biased and more likely in women. Fibromyalgia treatment is common in MDFM (70.7%). Overall, MDFM appears subjective and unrelated to fibromyalgia criteria. There appears to be no common definition of fibromyalgia in the community.

Decreased Renal Function is Associated with Heart Failure Readmissions.

Introduction Heart failure (HF) is one of the most common causes of hospitalization and readmissions. Approximately six million Americans are living with HF. Among patients with HF, hospitalization rate in the United States is higher for those over age 65, making it one of the leading causes of hospitalization in this age group. Furthermore, about 15% of those who were hospitalized with HF were readmitted within 30 days and 30% within 60 days. HF and chronic kidney disease (CKD) share many risk factors; therefore, it is expected that CKD is more prevalent in HF. About 50% of patients with HF also have concomitant CKD. Those patients have been found to have an increased risk of mortality and morbidity. This risk increases as glomerular filtration rate (GFR) decreases. Strategies to reduce the hospitalization rate in patients with HF include optimizing evidence-based drug and device therapies, addressing the causes of HF, treating comorbidities, and improving management of care. In our study, we aim to find an association between HF and the patient's renal function as well as the GFR level. This study investigates the effect of renal function on HF morbidity and readmission rate. Methods We performed a retrospective study looking at 132 patients who were admitted to the hospital with HF and compared their measured GFR at three key time periods: admissions, discharges, and readmissions at 30 days. A Pearson product-moment correlation coefficient was calculated to determine the association between the GFR and readmission in HF admission cases. Results There is a statistically significant difference in the readmission rate based on the change in GFR between admission and discharge (Admit GFR - Discharge GFR; t = 2.28; p < 0.05). We found that patients who were readmitted in 30 days had an average decrease in GFR by 2.46 ml/min/1.73 m2, whereas patients with a lower readmission rate had an average increase in GFR by 1.92 ml/min/1.73 m2. Conclusion A decline in renal function due to hospitalization in patients with renal failure is associated with an increase in readmission for HF. Providers should be cognizant of the need to optimize renal function as well as cardiac function during hospitalization.

Reducing Over-Utilization of Cardiac Telemetry with Pop-Ups in an Electronic Medical Record System.

Non-invasive cardiac monitoring has well-established indications and protocols. Telemetry is often overused leading to a shortage of tele-beds and an increment of hospital expenses. In some cases, patients are kept on telemetry longer than the indicated length because providers are unaware of its ongoing use. We investigated the effect of reminder pop-ups, incorporated into an electronic medical record (EMR), on minimizing the use of telemetry. Three regional hospitals implemented an electronic pop-up reminder for discontinuing the use of telemetry when no longer indicated. A retrospective analysis of data for patients on telemetry, outside of the intensive care unit (ICU), was conducted and comparisons were drawn from pre- and post-implementation periods. A composite analysis of the number of days on telemetry was calculated using the Kruskal-Wallis test. With the implementation of the pop-up reminder, the median number of days on telemetry was significantly lower in 2016 than in 2015 (2.25 vs 3.61 days, p < 0.0001). Overutilization of telemetry is widely recognized, despite not being warranted in non-ICU hospitalizations. The implementation of a pop-up reminder built into the electronic medical record system reduced the overuse of telemetry by 37% between the two time periods studied.

Malignant Clear Cell Hidradenoma of the Breast.

A 58-year-old female had a mass in the right breast palpable beneath the areola. A mammogram revealed a 1.5-centimeter soft tissue density that was confirmed with a subsequent ultrasound. The patient underwent a core needle biopsy which was initially reported as a moderately differentiated invasive ductal carcinoma. Immunohistochemical analysis revealed negative staining for estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor (HER2), mammaglobin, and gross cystic disease fluid protein 15 (GCDFP-15). A wide local excision of the mass was performed. The pathology report stated the tumor had an infiltrative growth pattern with a desmoplastic stromal response with enhanced epithelial atypia consistent with malignant transformation of a nodular clear cell hidradenoma. Clear cell hidradenoma is a very rare tumor originating from the sweat gland and has a propensity for the face and extremities. The malignant variant of this tumor is extremely rare and has been reported to originate from the breast in few cases. This case represents the difficulty in diagnosing this tumor along with the radiographic and histologic features that can distinguish this malignancy from other entities.

Decreased Renal Function Is Associated with Elevated CHA2DS2VASC and R2CHADS2 Scores in Non-Valvular Atrial Fibrillation Patients Presenting with Stroke.

Introduction Atrial fibrillation (AF), the most common cardiac arrhythmia, affects approximately 2.3 million patients in the United States, costing around $26 billion. Atrial fibrillation is associated with a two- to seven-fold increased risk of stroke, one of the most serious complications. Chronic kidney disease affects approximately 13% of the US population and has been associated with higher rates of AF than the general population. In patients with chronic kidney disease (CKD), the risk of stroke increases as the glomerular filtration rate (GFR) decreases, especially in CKD stages three and four. Several risks stratification scores such as CHADS2 (congestive heart failure, hypertension, age, diabetes mellitus, stroke), CHA2DS2VASc (congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, age, sex), and R2CHADS2 (renal failure, congestive heart failure, age, diabetes, stroke) scores are used for stroke risk assessment in patients with non-valvular atrial fibrillation (NVAF). This study investigates the association between renal functions and risk stratification scoring systems in patients with non-valvular AF presenting with stroke. Methods Using the convenience sampling method, 171 subjects were selected from the eligible population (n = 386). A Pearson product-moment correlation coefficient was calculated to determine the association between the GFR and each of the CHA2DS2VASc and R2CHADS2 scores. In addition, a Pearson product-moment correlation coefficient was calculated to determine the association between the CHA2DS2VASc and R2CHADS2 scores. Results The selected population represented 44.3% of the eligible subjects. Of these, 88% were Caucasian, 60% were female, and the mean age was 78 years. The mean CHA2DS2VASc score was six (range 2-9). The mean eGFR was 69.77 (range 6-108). Both the mode and the median CHA2DS2VASc score was four (range 2-8). A weak, but significant, negative correlation was found between renal function (eGFR) and the CHA2DS2VASc score (r = -0.263; p = 0.0005). There was a stronger negative correlation between the eGFR and R2CHADS2score (r = -0.70; p < 0.00001). The CHA2DS2VASc and R2CHADS2scoring schemes were significantly and positively correlated (r = 0.627; p < 0.00001). Discussion In NVAF patients presenting with stroke, renal failure is associated with higher CHA2DS2VASc and R2CHADS2 scores. One must consider renal failure (end-stage or non-end stage renal failure) as an additional potential risk factor for stroke when recommending anticoagulation in non-valvular atrial fibrillation.