A Case Presentation of Pericarditis Associated with Haemophilus Influenzae Bacteremia

Acute pericarditis, or inflammation of the pericardial sac, is a clinical condition which can often be attributed to a variety of underlying etiologies, including infection, autoimmune disease, trauma, and malignancy. While viral infections are commonly implicated in the etiology of pericarditis, bacteria known to be associated with pericarditis include staphylococcus species, streptococcal species, tuberculosis, and in children, Haemophilus influenzae.1 Here we present a rare case of pericarditis in an adult male patient which occurred in association with Haemophilus influenzae bacteremia

Improved Accuracy of Surgical Pathology Accessioning, Coding, and Billing Practices after Self-Evaluation

INTRODUCTION Accurate accessioning, coding, and billing of specimens are vital, but often disregarded, aspects of a surgical pathologist’s job. This study had two aims related to those aspects. First, to evaluate the quality of our systems based practices in order to identify areas for improvement. Second, to assess if changes made based on our self-evaluation improved accuracy

Homeopathy: A New Scientific Perspective

Overall Goals and Objectives: 1. Identify recent advances in integrative medical care and discuss their application to clinical practice. 2. Describe the latest data on complementary and alternative medical therapies that could improve patient outcomes. 3. Discuss core integrative medicine topics that patients frequently ask physicians about. Presentation: 53 minute

Review of Triple Negative Breast Cancer Cases Treated at Lehigh Valley Health Network in 2013-14

Review of Triple Negative Breast Cancer Cases Treated at Lehigh Valley Health Network in 2013-14 Elliott Goldberg and Savitri Skandan, MD July 2015 Abstract Triple-negative breast cancer (TNBC) is an aggressive subtype of breast cancer characterized by the lack of HER2, estrogen and progesterone receptors. Mutation to the BRCA1/2 gene increases susceptibility to several types of cancer, including breast and ovarian, and women with germline BRCA1 or BRCA2 mutations are estimated to have a lifetime risk of 50-85% of developing breast cancer.1 Frequency of BRCA mutation is observed to be higher in patients with TNBC (~20%) relative to all breast cancer subtypes (~5%).2 BRCA mutation is also correlated with a younger age at diagnosis and a higher risk of recurrence.3,7 By reviewing TNBC cases seen by Lehigh Valley Health Network (LVHN) in 2013-14, we show that all treatments offered by LVHN are in accordance with the national standard and that 16% of patients tested were positive for BRCA1 mutation. Introduction Female breast cancer is estimated to be the most common type of cancer diagnosed in 2015, representing 14% of all new cancer cases in the United States.4 Prognoses vary based on the expression of certain receptor proteins by the breast tumor: those expressing receptors to estrogen (ER) or progesterone (PR) can be treated with systemic endocrine chemotherapy in the form of tamoxifen or aromatase inhibitor, which are effective treatments with mild side effects.5 Breast cancers can also overexpress receptors to human epidermal growth factor (HER2)—these tumors exhibit rapid growth and sensitivity to treatment with a monoclonal antibody such as trastuzumab, which is also well tolerated.6 Breast cancers expressing neither endocrine receptors nor HER2 are called triple-negative and are associated with a poor prognosis due to their resistance to the targeted hormonal or HER2 therapies as well as their apparent aggressiveness relative to other types of breast cancer.7 Triple-negative breast cancer (TNBC) has been observed to develop more frequently in pre-menopausal or younger women and displays both higher mitotic grade and larger tumor size at diagnosis.7 It is estimated that 15-20% of all breast cancers diagnosed in the United States are triple-negative.3 Susceptibility to TNBC may arise from mutations to the genes BRCA1/2, which encode central proteins to many DNA repair and cell cycle regulatory macromolecular complexes.8 At least 13 different tumor suppressor proteins have been found to interact with BRCA1 and BRCA2 and function in homologous-recombination-mediated DNA repair, apoptosis and cell cycle regulation.8 Women with BRCA mutations are estimated to have a lifetime risk of developing breast cancer of 50-85%.1 BRCA mutations are more common in patients with TNBC (~20%) relative to all breast cancer subtypes (~5%).2 In TNBC patients, BRCA mutations have also been correlated with a younger age at diagnosis.3,7 It is recommended that all patients diagnosed with TNBC receive genetic screening for BRCA mutation.9 Breast cancer was the most common type of cancer treated at Lehigh Valley Health Network (LVHN) in 2013 and 2014. One goal of this study is to determine whether treatments offered to patients with TNBC at LVHN in 2013-14 were in agreement with the National Comprehensive Cancer Network (NCCN) Practice Guidelines in Oncology for Breast Cancer, Version 2.2015. We also determine the frequency of BRCA mutation in the population of TNBC patients seen by LVHN who were referred to genetic counseling and were tested for BRCA mutation. We show that the treatment offered to TNBC patients by LVHN in 2013 and 2014 was in accordance with the NCCN Guidelines and that 16% of patients who received genetic testing were positive for a BRCA mutation. Methods All charts of patients who were diagnosed and treated for TNBC at LVHN during 2013 and 2014 were reviewed. 69 total charts were examined: it was found that 5 of these cases were not triple-negative, 1 had no follow-up, and 1 transferred care. The remaining 62 charts were reviewed for information on the patient’s age, staging, and treatment, which was determined from all recorded transcriptions including pathology results. Genetic consultations and test results were also reviewed to determine the presence of BRCA mutation. All data analysis was performed using Microsoft Excel. Comparison to the NCCN Practice Guidelines in Oncology for Breast Cancer Version 2.2015 was made to determine whether the treatments offered by LVHN were in accordance with the national standard. Results Staging of Triple Negative Breast Cancer Patients at LVHN in 2013-14 Table 1. Organization of 62 cases of TNBC seen by Lehigh Valley Health Network from 2013-2014 by staging. Figure 1. Treatments received by TNBC patients at Lehigh Valley Health Network in 2013-14. Surgery includes either lumpectomy or mastectomy, with surgical axillary staging. Chemotherapy for Stage I patients was given in the adjuvant setting, while chemotherapy for Stage II and III patients was given in either the neoadjuvant or adjuvant setting depending on the tumor size and the timing of the surgery: treatments include combined Adriamycin and Cytoxan followed by Taxol, combined Taxol and Cytoxan, or weekly Taxol. Chemotherapy for Stage IV patients includes the above drugs as well as Doxil, Ixempra, combined carboplatin and gemcitabine, epirubicin, vinorelbine, Xeloda, or 5-fluorouracil given palliatively. Radiation (XRT) includes brachytherapy or beam radiation given in either the adjuvant or palliative setting to the whole breast, axilla, or chest wall. Patients with comorbid conditions were ineligible for chemotherapy and/or radiation. The first goal of our study is to determine whether treatments offered to TNBC patients at LVHN in 2013-14 were in accordance with the NCCN guidelines. In total, 62 cases of TNBC were reviewed [Table 1]. There were two patients with Stage 0 breast cancers: one was treated with lumpectomy and radiation, and the other was treated with mastectomy [Figure 1]. Both patients had regular follow up visits. These treatments are in accordance with the recommended NCCN guidelines for the treatment of ductal carcinoma in situ which state that either lumpectomy with adjuvant radiation or mastectomy followed by observation and yearly mammograms are appropriate treatments.10 There were 23 patients who presented with Stage I TNBC [Table 1]. All of these patients were also Stage IA meaning that their tumor was less than 2 cm in its greatest dimension without involvement of the lymph nodes.10 All 23 of the patients received surgery [Figure 1]. Of these, 16 received breast-conserving surgery, 15 received adjuvant radiation therapy and 1 declined radiation [Figure 1]. The remaining 7 received mastectomies, one of whom went on to receive adjuvant radiation due to her high risk of recurrence [Figure 1]. Of these 23 patients, 16 received adjuvant chemotherapy, 2 were offered chemotherapy but declined, 2 were ineligible for chemotherapy due to their comorbid conditions, and 3 were not recommended chemotherapy due to the size of their tumor [Figure 1]. All 23 patients attended regular follow up visits. These treatments offered are in accordance with the recommended NCCN guidelines for treatment of localized invasive TNBC which state that either lumpectomy with adjuvant radiation or mastectomy are appropriate treatments, and which recommend chemotherapy in triple-negative tumors greater than 1 cm in greatest dimension or consideration of chemotherapy in triple-negative tumors greater than 0.5 cm with no lymph node involvement.10 In addition, patients are recommended to attend follow up appointments regularly and receive yearly mammograms.10 There were 21 patients diagnosed with Stage II TNBC [Table 1]. Of these 21, 14 were Stage IIA, which is defined as any tumor between 2 and 5 cm in greatest dimension without metastasis to lymph nodes or any tumor less than 2 cm in greatest dimension with metastasis to movable ipsilateral axillary lymph nodes.10 The other 7 patients were diagnosed as Stage IIB, which is defined as any tumor greater than 5 cm in greatest dimension without lymph node metastasis or any tumor between 2 and 5 cm in greatest dimension with metastasis to movable ipsilateral axillary lymph nodes.10 All 21 of the Stage II patients received surgery: 13 patients received mastectomy and 8 received lumpectomy [Figure 1]. 15 of these patients received chemotherapy, either in the neoadjuvant or adjuvant setting, 2 declined chemotherapeutic treatment, and 3 were ineligible for chemotherapy due to comorbid conditions [Figure 1]. 13 patients received adjuvant radiation therapy, 5 declined radiation, and 2 were not recommended to receive radiation [Figure 1]. One patient had cerebral palsy and was recommended to receive neither chemotherapy nor radiation because she would not tolerate the treatments [Figure 1]. All 21 patients did attend follow up visits. All of the treatments offered by LVHN for Stage II TNBC are in accordance with the recommended NCCN guidelines for treatment of localized invasive TNBC depending on the tumor size: neoadjuvant chemotherapy followed by breast-conserving surgery and adjuvant radiation may be given if the cancer responds sufficiently to the neoadjuvant treatment, with the option of mastectomy if the disease progresses during the neoadjuvant treatment.10 Total mastectomy without neoadjuvant chemotherapy remains an option as well.10 Adjuvant radiation is recommended for consideration in mastectomy patients who have axillary lymph node metastases, a tumor greater than 5 cm in greatest dimension, positive surgical margins or negative margins less than 1 mm.10 In addition, patients are recommended to attend follow up appointments regularly and receive yearly mammograms.10 There were 13 patients diagnosed with Stage III TNBC [Table 1]. Of these, 6 were Stage IIIA, which is defined as any sized tumor with metastases in ipsilateral axillary lymph nodes that are fixed to one another, or in ipsilateral internal mammary lymph nodes in the absence of axillary lymph node metastases.10 Tumors metastatic to movable ipsilateral axillary lymph nodes which are larger than 5 cm in greatest dimension are also staged as IIIA.10 There was 1 patient with Stage IIIB cancer, defined as an inflammatory tumor or any tumor invasive of the chest wall.10 There were 6 patients with Stage IIIC cancers, defined as any tumor metastatic to ipsilateral infraclavicular lymph nodes, ipsilateral supraclavicular lymph nodes, or both internal mammary and axillary nodes.10 Of these 13 Stage III patients, all received surgery: there were 9 mastectomies and 4 lumpectomies [Figure 1]. All of the patients received chemotherapy in either the neoadjuvant or adjuvant setting, or both [Figure 1]. 12 of the 13 patients were offered radiation therapy, and one patient was not recommended to receive radiation therapy due to the extent of her disease [Figure 1]. The patients attended regular follow up appointments. All treatments offered by LVHN for these patients was in accordance with the NCCN guidelines for treatment of Stage III locally advanced breast cancer, which recommends neoadjuvant chemotherapy: if responsive, it recommends lumpectomy or mastectomy followed by radiation to the chest wall and infraclavicular and supraclavicular lymph nodes.10 If the cancer does not respond to the first line of chemotherapy, additional systemic therapy and preoperative radiation are recommended.10 In addition, patients are recommended to attend follow up appointments regularly and receive yearly mammograms.10 There were 3 patients diagnosed with Stage IV TNBC [Table 1]. Stage IV, or metastatic cancer, is characterized by detectable metastases histologically proven larger than 0.2 mm in distant organs.10 Metastatic breast cancer is not curable, but it can be treated. All three patients received palliative chemotherapy: 2 of the patients received three or more chemotherapy regimens [Figure 1]. One patient received mastectomy, and one patient received palliative radiation therapy [Figure 1]. These treatments are in accordance with the NCCN guidelines for treatment of Stage IV TNBC which recommend three sequential lines of chemotherapy, with or further chemotherapy if the disease responds or transition to palliative care.10 The second goal of our study is to determine the frequency of BRCA mutations among TNBC patients seen at LVHN in 2013-14. All 62 patients were eligible to receive genetic testing as a result of their triple-negative diagnosis: of these 62 referrals, 25 followed up with the genetic counselor and underwent genetic testing.9 4 patients tested positive for a mutation to the BRCA1 gene. None of the patients in our study tested positive for a BRCA2 mutation. These results indicate that 16% of TNBC patients seen by LVHN in 2013-14 who received genetic testing carried a mutant BRCA gene. This result is consistent with the literature findings which suggest 15-20% of patients diagnosed with TNBC have a mutation in BRCA1.2 Furthermore, the average age of TNBC patients diagnosed at LVHN in 2013-14 was determined as 61 years, while the average age at diagnosis for TNBC patients with BRCA mutation was significantly younger at 47 years. This result is also consistent with the literature suggesting that BRCA mutation is correlated with a younger age at TNBC diagnosis.3 Conclusions The goals of our study were to determine if the treatments offered to TNBC patients treated at LVHN in 2013-14 were in accordance with the NCCN Guidelines Version 2.2015 and to determine the frequency of BRCA mutation among the population of those patients who had received genetic testing. We have shown the treatments offered to TNBC patients in 2013-14 were in accordance with the national guidelines. We have also determined the incidence of BRCA1 mutation to be 16% in a population of 25 TNBC patients who received genetic testing. Our results show the average age of BRCA mutant TNBC patients (47) to be significantly younger than the average age of all TNBC patients in our study (61). However, we report that of the 62 patients in our study, only 25 received genetic testing (~40%). A further subject of interest may be methods to mainstream these genetic tests. We hope that BRCA screening will gain more popularity in the future as a prognostic factor. References Muendlein, A., Rohde, B. H., Gasser, K., et al. (2015). Evaluation of BRCA1/2 mutational status among German and Austrian women with triple-negative breast cancer. J Cancer Res Clin Oncol. doi:10.1007/s00432-015-1986-2 Anders, C. K., Zagar, T. M., & Carey, L. A. (2013). The management of early stage and metastatic triple negative breast cancer: A Review. Hematol Oncol Clin North Am, 27(4), 737-749. doi:10.1016/j.hoc.2013.05.003 Hartman, A., Kaldate, R. R., Sailer, L. M., et al. (2012). Prevalence of BRCA mutations in an unselected population of triple-negative breast cancer. Cancer, 118(11), 2787-95. doi:10.1002/cncr.26576 SEER Stat Fact Sheets: Breast Cancer. (2015). Retrieved from http://seer.cancer.gov/statfacts/html/breast.html. Rao, R. D., & Cobleigh, M. A. (2012). Adjuvant endocrine therapy for breast cancer. Oncology, 26(6), 541-7, 550, 552 passim. Retrieved from http://www.cancernetwork.com/oncology-journal/adjuvant-endocrine-therapy-breast-cancer. Wang, W., Lei, Y., Mei, J., & Wang, C. (2015). Recent progress in HER2 associated breast cancer. Asian Pac J Cancer Prev, 16(7), 2591-2600. doi:10.7314/APJCP.2015.16.7.2591 De Ruijter, T. C., Veeck, J., De Hoon, J. P., Van Engeland, M., & Tjan-Heijnen, V. C. (2011). Characteristics of triple-negative breast cancer. J Cancer Res Clin Oncol, 137(2), 183-92. doi:10.1007/s00432-010-0957-x Jiang, Q., & Roger, G. (2015). Deciphering the BRCA1 tumor suppressor network. J Biol Chem, 290(29), 17724-32. doi:10.1074/jbc.R115.667931 Daly M. B., Axilbund J. E., Buys S., et al. (2010) Genetic/familial highrisk assessment: breast and ovarian Version 1.2010. J Natl Compr Canc Netw. 2010;8:562-594. Gradishar W. J., Anderson B. O., Balassanian R., et al. (2015). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Breast Cancer Version 2.2015. J Natl Compr Canc Netw. 2015

Microcystic, Elongated, and Fragmented (MELF) Pattern Invasion in Ovarian Endometrioid Carcinoma: Immunohistochemical Profile and Prognostic Implications

BACKGROUND •Microcystic, Elongated and Fragmented (MELF) is a well-recognized pattern of uterine endometrioid carcinoma (UEC) associated with lymphovascular space invasion and occult lymph node metastasis •MELF in UEC may be seen with Lynch Syndrome •MELF in UEC is hypothesized to be histologic evidence of an epithelial mesenchymal transition •MELF pattern invasion in ovarian endometrioid carcinoma (OEC) was first described at USCAP 2015 • Current study evaluates MELF in OEC for •Prognostic implications •Immunohistochemical (IHC) profile related to •Lynch Syndrome •Epithelial mesenchymal transition DESIGN •42 consecutive cases of OEC without concurrent UEC (1996-2014) evaluated by 2 pathologists •MELF defined as at least three glands fulfilling histologic criteria •32 cases had blocks available for staining •MLH1, PMS2, MSH2 and MSH6 for mismatch repair (MMR) protein expression •Graded as “retained” or “lost” •β-catenin, e-cadherin, CK19 and cyclin D1 for evidence of epithelial mesenchymal transition •Graded as “rare” (75% cells stain) •Retrospective chart review of clinical and demographic features and overall survival •Data analyzed using Fisher exact test analysis •Survival analyzed using Kaplan-Meier metho

Identifying the Prevalence of underdiagnosed Obstructive Sleep Apnea (OSA) in the Primary Care Population via Targeted Screening Measures

Introduction: Obstructive sleep apnea (OSA) is a condition with detrimental health consequences, yet over 75% of OSA cases remain undiagnosed in the United States. This study aimed to determine the efficacy of using targeted screening measures to determine the prevalence of undiagnosed OSA in a primary care population. Methods: This prospective pilot study utilized a primary care population from Thomas Jefferson University’s family medicine department. Participants were selected using three risk criteria for OSA from STOP-BANG identifiable from their EMR records (BMI \u3e35, age over 50, and hypertension). After screening out patients previously diagnosed with OSA, patients were called and further screened with the entire STOP-BANG questionnaire; Patients who scored \u3e 6/8 were referred for sleep study testing. Results: Of the 112 patients meeting the three initial criteria, 5 were excluded for having previously undocumented OSA diagnoses, and 81 were unable to be contacted or not interested. Of the 31 remaining participants, 11 patients had a STOP-BANG score \u3e6 (35%); 3 of these patients (27%) were diagnosed with OSA after going in for a sleep study (100%). Discussion: The main obstacle in our pilot to date is low patient contact and participation. However, all of the patients who qualified for and completed sleep study testing using our screening algorithm were effectively diagnosed with OSA. We will continue to screen more patients in the upcoming months and test methodologies to increase patient participation

Primary Care Obstructive Sleep Apnea Screening (PCOSA)

Introduction: Obstructive sleep apnea (OSA) is a largely underdiagnosed disorder of upper airway collapse during sleep. Primary care providers do not routinely screen for OSA. This project aims to determine the yield of using the STOP-BANG questionnaire to identify previously undiagnosed OSA in a primary care population. Methods: This prospective quality improvement pilot project included 181 patients of the Jefferson Department of Family Medicine identified as high-risk for OSA based on 3 EMR-based search criteria taken from STOP-BANG: hypertension, age \u3e50 years, and BMI \u3e35 kg/m2. We attempted contact with patients by mail, followed by up to 3 weekly telephone calls to verbally screen patients with the full STOP-BANG questionnaire. A score of \u3e6 was considered high-risk for OSA. High risk patients were referred for sleep study testing. Results: From the initial 181 patients, 71 were excluded due to a prior OSA diagnosis; 3 were excluded for various other reasons; and 53 could not be reached. Of those reached, 28 patients refused participation, and 15 patients had a low-risk STOP-BANG score \u3c6. The remaining 11 patients had a high-risk STOP-BANG score \u3e6 and were referred for sleep study testing. While data collection is ongoing, all 3 patients (100%) who completed sleep studies have been newly diagnosed with OSA. Discussion: Preliminary results confirm utility of the STOP-BANG questionnaire to identify patients at high risk for OSA. The main limitation in our pilot project was difficulty contacting patients. We are adding alternate forms of communication (email, outreach at upcoming patient visits)

Patient Perceptions and Expectations About Postoperative Analgesia

Introduction Opioid overdose deaths have nearly quadrupled since 1999. Nearly 2 out of 3 persons being prescribed medications are prescribed an opioid. Physicians may be prescribing opioids for more than what is required for postoperative pain control, leading to increased risk for opioid abuse and addiction. Patient perceptions of perioperative pain medications are poorly understood. Objective This survey aims to understand patient expectations of perioperative analgesics. Methods Following IRB approval, patients 18 years of age or older, were given a 13-question survey prior to their surgery at Thomas Jefferson University Hospital, to evaluate the perception of pain medications, medication efficacy, and risk profile. For this analysis, 503 patients were surveyed and only 5 questions were used. Results Overall, 100% of patients believed they would receive analgesics after surgery, with 76% of patients expecting opioids. Additionally, 94% of patients expecting to receive postoperative opioid prescriptions believed opioids would be effective in controlling their pain. Furthermore, 67.5% of patients not expecting to receive opioids postoperatively still believed opioids would be superior to non-opioid medications. Conclusion Patients expected to experience pain after surgery and be prescribed analgesics. Patients anticipated receiving analgesics they perceived most effective, which was most often an opioid. The perception of superior efficacy of opioids is worthy of further study as this is inconsistent with the literature, and education may be needed to bridge this gap. As the opioid crisis continues, cultural attitudes toward pain and medications will play a central role in reducing the prevalence of opioids in healthcare and society

A Virtual Educational Intervention Addressing Weight Bias in Medical Students

Introduction: Individuals with higher body weight experience severe and pervasive discrimination in nearly every walk of life. Stigmatizing treatment from healthcare providers increases anxiety, depression, body dissatisfaction and risk of weight gain while decreasing the likelihood that patients will seek preventative or emergency care. This study assessed whether a virtual session exploring obesity, which included the personal testimony of a Physician Professor with obesity, positively influenced the explicit attitudes and implicit biases of medical students towards people with higher body weight. Methods: SKMC medical students completed an Implicit Associations Test (IAT), a Universal Measure of Bias (UMB) and a demographics questionnaire before and after a virtual session. IAT responses were scored as strong, moderate, slight, or no automatic preference for fat or thin people and UMB items were scored for strength of bias in accordance with the scale design. Mean change between pretest and posttest UMB scores and t-score were calculated. Results: 200 medical students from all class years participated. Participants’ explicit weight bias (UMB) improved after the intervention (mean change = -x; p-value = y). Participants’ implicit biases (IAT) did not change significantly (IAT category change: z/200). Discussion: This is the first weight bias intervention in medical students to utilize a virtual format and incorporate the personal experience of a respected mentor with obesity. These accessible tools could be a practical way to change biased attitudes. Further research is required to see if these improvements in attitudes persist and translate to better care and outcomes for patients with obesity