Sinus Histiocytosis: An Uncommon Presentation of an Uncommon Condition

Introduction Rosai–Dorfman Disease (RDD), also known as Sinus Histiocytosis with Massive Lymphadenopathy (SHML), is a rare, benign, proliferative disorder of macrophages and monocytes that was first described by Rosai and Dorfman in 1969. The vast majority of patients present with painless bilateral cervical lymphadenopathy during childhood or young adulthood. The condition is self-limited and rarely requires medical treatment. Involvement of extranodal sites such as eyelids, eye sockets, skin and subcutaneous tissue, gastrointestinal tract, upper airways and central nervous system have been infrequently described. Mediastinal involvement is extremely rare, and there are few cases reported in the literature. Here, we present a case of a 61-year-old female with a history of mediastinal sinus histiocytosis with massive lymphadenopathy

Retrospective Review of Fluoroscopic Swallowing Studies and Outcomes at an Academic Health Center

Introduction: Aspiration is often associated with underlying medical conditions and can cause pneumonia or death. Aspiration risk can be assessed via video fluoroscopic swallowing study (VFSS) or barium swallow (BaSw). We aimed to assess the diagnoses and clinical course of patients who were evaluated for potential aspiration through VFSS or BaSw to determine if there is a degree of aspiration that increases the risk of developing pneumonia and/or death. Methods: We conducted a retrospective chart review of 374 patients in TJUH who were evaluated via VFSS or BaSw from January 1 to June 30, 2017. We recorded the degree and contents of aspiration, the underlying diagnoses, and evidence of subsequent pneumonia. We then collected data for any future admissions concerning for pneumonia. Results: Of the 374 patients, 165 had swallowing studies positive for laryngeal penetration or aspiration. Of the 165 patients, 78 patients (47.2%) had evidence of clinical and radiological pneumonia, and 18 of those 78 patients (23.1%) died. We found that 61 of 165 exhibited laryngeal penetration. Of those 61, 23 patients (37.7%) showed clinical and radiological signs of pneumonia, and 7 of the 23 (30.4%) died of aspiration pneumonia. Discussion: The incidence of pneumonia was considerable in persons with an abnormal swallow and the mortality rate was substantial. Minimally abnormal swallows with laryngeal penetration, but no true aspiration, still had serious consequences. While the incidence of pneumonia was lower (37.7%), there was a substanitial mortality rate (30.4%)

Improvements on the Inhaler

Background: Inhalers are a commonplace in American health care and deliver crucial drugs to patients with COPD and asthma. Inhaler use has been shown to be unsatisfactory among patients resulting in ineffective medication delivery. The goal of this project was to improve the inhaler design for increased effectiveness and ease of use. Methods: Our team first interviewed a Pulmonologist regarding patient inhaler use. Dr. Harry Kane demonstrated the proper use of an inhaler as well and described errors in inhaler use are due to patient technique. A variety of inhalers currently available were examined and were compared for ease of use. Results: Interview with attending physician revealed numerous patient errors that impede effectiveness of inhaled medication. Two common mistakes were identified: patients inhaling too rapidly and patients dispensing the medication too late. Inhaling too rapidly decreases the fraction of drug that reaches the lungs, decreasing effectiveness. Dispensing the medication after a patient reaches total lung capacity (TLC) prevents the drug from reaching their lungs, decreasing effectiveness. Conclusions: We conclude that inhalers could be used more effectively by addressing patient education and feedback mechanisms. Possible solutions discuss audible feedback to help coordinate patient breath with optimal dispersal timing. Future work includes prototyping a design and eliciting patient feedback

Improving the Inhaler

Background: Inhalers used to dispense various pharmacological agents play an important role in the care of patients with pulmonary disease. These pharmacological agents can be very effective, however, many patients that use inhalers often deliver these drugs incorrectly or in a sub-optimal manner. Our project aims to improve the design of the inhaler in order to increase the effectiveness of drug delivery and also ease of patient use. Methods: We interviewed a critical care pulmonologist regarding patient inhaler use and compliance. This physician offered information about proper inhaler use and described common errors that patients encounter when attempting to dispense drugs via inhalers. Both steroidal and albuterol inhalers that are currently being prescribed were allocated for our examination and use to help develop a more user friendly model. Results: The pulmonologist illustrated several errors that patients will commonly make which can degrade the efficacy of the inhaled drug delivery. One frequently encountered error was that drug is dispensed by the patient once they had already reached their total lung capacity, or inhaled fully. This sort of error leads to the drug being dispensed into the throat and failure to reach the intended target, the lungs. Additionally, the physician noted that patients often forget to administer their inhaled drugs because the inhaler does not fit comfortably into the patient’s pocket and so it is not optimally portable. Conclusion: Our research suggests that inhaler design could be improved in order to increase the effectiveness of drug delivery and patient compliance. We are considering incorporating audible actuation clues that will alert the patient when to dispense the drug, and also provide electronic feedback to the patient’s mobile device. This would help educate the patient on how to coordinate their breathing with actuation of the device to dispense the medication

Quality Improvement of Diabetic Care at a Resident Clinic

Our objective was to develop a quality improvement project on diabetes mellitus at our internal medicine residency clinic. Residents developed projects aimed at improving an aspect of diabetic care. Continuity of care, achievement of clinical targets, no-show rates, patient knowledge of diabetes, and preventive care were evaluated. Our data was obtained with a questionnaire and a retrospective review of medical records. A different provider was scheduled about every 1.78 visit. The no-show rate was 25.4%. About half of patients identified goal hgbA1c and BPs, and 35% and 60% achieved their hgbA1c and SBP goals respectively. Nearly all of the charts planned for screening exams. We concluded that our clinic needs to improve diabetes education, reaching clinical targets, continuity of care and no-shows. Incorporating a QI project into the clinic with one disease such as diabetes is an efficient way to include practice based learning into an internal medicine residency’s curriculum

Predictors and Characteristics of Rib Fracture Following SBRT for Lung Tumors

Background Stereotactic body radiation therapy (SBRT) is an increasingly utilized therapy for primary and metastatic lung tumors. Despite promising tumor control, SBRT is associated with increased risk of rib osteoradionecrosis leading to rib fracture. We aimed to 1) determine clinical, demographic, and procedural risk factors of osteonecrosis and 2) radiographically characterize rib osteonecrotic fractures. Methods We retrospectively identified 106 patients who underwent SBRT between 2015 and 2018 for a primary or metastatic lung neoplasm with a minimum of 12 months of follow up. Patients with incomplete records, prior ipsilateral thoracic radiotherapy, or relevant trauma were excluded. Computed tomography (CT) scans were reviewed to identify and characterize rib fractures. Multivariate logistic regression modeling was used to elucidate clinical, demographic, and procedural risk factors (e.g., age, sex, race, medical comorbidities, dosage, and tumor location). Results A total of 106 patients with 111 treated tumors satisfied the inclusion criteria, 35 (32%) of whom developed at least one fractured rib (60 total ribs). The maximum number of affected ribs per subject was five. Multivariate regression identified posterolateral location as an independent risk factor for rib fracture. Radiographically, fractures in 77% of affected subjects showed discontinuity between healing edges. Discussion Post-SBRT fractures demonstrated distinct discontinuity, a possible signal of osteoradionecrosis. Tumor location along the posterolateral chest wall was the only independent predictor of rib fracture. Given its increasing frequency of use, understanding the risk profile of SBRT is vital to maintain patient safety and appropriately inform patient expectations

Tumor Doubling Time of Pulmonary Carcinoid Tumors Measured by CT

Introduction: Pulmonary carcinoid tumor (PCT) is a rare neuroendocrine lung cancer that is known clinically to be a slow-growing neoplasm. Few studies have established the true growth rate of these tumors when followed over time by radiography. Therefore, we sought to determine PCT tumor doubling time using longitudinal Computed Tomography (CT) scans. Nodule guidelines may misclassify early PCT nodules with a small diameter as benign if tumor growth is too slow to be appreciable on follow up radiographic scans completed between six months and two years after initial detection. Methods: We performed a retrospective analysis of available CT imaging of all PCTs treated at Thomas Jefferson University Hospital between 2006-2020 where radiographic follow up occurred prior to biopsy or resection. Nodule dimensions were measured manually using Phillips Intellispace PACS or retrieved from radiology reports. Tumor doubling time was calculated for all tumors demonstrating definitive growth (an increase in average diameter ≥ 2 mm) over a follow up interval of at least two years. Results: Fifteen patients had pathologically proven PCT with pre-resection observation times exceeding two years. 12/15 (80%) were typical carcinoids and 3/15 were atypical. 11/12 of the typical PCTs demonstrated definitive growth with a median doubling time of 140 weeks (mean = 161 ± 105 weeks). Discussion: The median doubling time of typical PCT was 141 weeks, or almost three years. It is conceivable that PCTs detected early with small diameter may be mistaken for benign non-growing lesions when followed for less than two years in low-risk patients

Standardized Direct Observation Assessment Tool: Using a Training Video.

BACKGROUND: We developed a DVD training tool to educate physicians evaluating emergency residents on accurate Standardized Direct Observation Assessment Tool (SDOT) application. OBJECTIVE: Our goal was to assess whether this training video improved attendings\u27 and senior residents\u27 SDOT use. METHODS: Participants voluntarily completed SDOT evaluations based on a scripted test video. A DVD with positive and negative scenarios of proper SDOT use was viewed. It included education on appropriate recording of 26 behaviors. The test scenario was viewed again and follow-up SDOTs submitted. Performances by attendings and residents on the pre- and post-test SDOTs were compared. RESULTS: Twenty-six attendings and 26 senior residents participated. Prior SDOT experience was noted for 8 attendings and 11 residents. For 20 anchors, participants recorded observed behaviors with statistically significant difference on one each of the pretest (no. 20; p = 0.034) and post-test (no. 14; p = 0.041) SDOTs. On global competency assessments, pretest medical knowledge (p = 0.016) differed significantly between groups. The training intervention changed one anchor (no. 5; p = 0.035) and one global assessment (systems-based practice; p = 0.031) more negatively for residents. Recording SDOTs with exact agreement occurred 48.73% for attendings pretest and 54.41% post-test; resident scores were 45.86% and 49.55%, respectively. DVD exposure slightly raised attending scores (p = 0.289) and significantly lowered resident scores (p = 0.046). CONCLUSIONS: Exposure to an independently developed SDOT training video tended to raise attending scores, though without significance, while at the same time lowered senior resident scores statistically significantly. Emergency attendings\u27 and senior residents\u27 SDOT scoring rarely differed with significance; about half of anchor behaviors were recorded with exact agreement. This suggests senior residents, with appropriate education, may participate in SDOT assessment

Black patients referred to a lung cancer screening program experience lower rates of screening and longer time to follow-up.

BACKGROUND: Racial disparities are well-documented in preventive cancer care, but they have not been fully explored in the context of lung cancer screening. We sought to explore racial differences in lung cancer screening outcomes within a lung cancer screening program (LCSP) at our urban academic medical center including differences in baseline low-dose computed tomography (LDCT) results, time to follow-up, adherence, as well as return to annual screening after additional imaging, loss to follow-up, and cancer diagnoses in patients with positive baseline scans. METHODS: A historical cohort study of patients referred to our LCSP was conducted to extract demographic and clinical characteristics, smoking history, and lung cancer screening outcomes. RESULTS: After referral to the LCSP, blacks had significantly lower odds of receiving LDCT compared to whites, even while controlling for individual lung cancer risk factors and neighborhood-level factors. Blacks also demonstrated a trend toward delayed follow-up, decreased adherence, and loss to follow-up across all Lung-RADS categories. CONCLUSIONS: Overall, lung cancer screening annual adherence rates were low, regardless of race, highlighting the need for increased patient education and outreach. Furthermore, the disparities in race we identified encourage further research with the purpose of creating culturally competent and inclusive LCSPs