An atypical presentation of Liposarcoma: Primary involvement of the liver with secondary metastatic seeding

A 61-year old male with PMH significant for gastric bypass, anxiety/depression, and previous alcohol abuse, presented to the ED with 10-day history of SOB and abdominal distention. He endorsed difficulty taking deep breaths, urinating, and bowel movements. He denied any unexplained weight loss, night sweats, or history of ascites. Physical exam revealed abdominal distension and tenderness. Hepatitis screen, AFP, CEA, and CA19-9 were negative. AST, ALT, total bilirubin, and alkaline phosphatase were all WNL. CT imaging demonstrated pleural effusion with atelectasis, large amounts of ascites with mesenteric stranding, and a 7cm mass of unknown etiology adjacent/medial to the liver. CT-guided biopsy of the perihepatic mass was consistent with well-differentiated liposarcoma. IR-guided biopsy of the omental mass demonstrated de-differentiated liposarcoma, FNCLCC grade 2. Colonoscopy to assess second primary tumor found three polyps demonstrating tubular adenoma. The patient was diagnosed metastatic primary liposarcoma of the liver. Soft tissue sarcomas comprise ~1% of all malignancies in adults. The majority of these arise from primary soft tissue, with bone as the next closest site of involvement. Liposarcomas are a subclass of soft-tissue sarcomas, arising from precursor adipocytes. Their primary focus is in the retroperitoneum and extremities. A liposarcoma with primary involvement of the liver is very rare. If the liver is involved it is usually from distant metastasis rather than a primary focus, though that is also rare. With only about a dozen cases of primary liver liposarcoma reported in the literature, the knowledge of the clinical course, management, and prognosis are limited.https://scholarlycommons.henryford.com/merf2020caserpt/1055/thumbnail.jp

Unusual Etiology of Chronic Cough and Syncope as Chiari Malformation Type 1

Chronic cough is a common chief complaint in ambulatory clinics. Unlike most cases that are caused by upper airway cough syndrome, gastroesophageal reflux disease, asthma, and non-asthmatic eosinophilic bronchitis, chronic cough can also be the presenting feature of a Chiari malformation. Our case is that of a 39-year-old female who had a chronic cough associated with shortness of breath, and when severe, associated with loss of consciousness. Her cough was refractory to conventional management. Further workup including pulmonary functions tests (PFT), laryngoscopy, high-resolution CT of the chest, an upper GI series, and esophageal pH manometry study were all normal. An MRI of her brain was obtained due to her syncopal episodes and revealed findings concerning a type 1 Chiari malformation. She subsequently underwent a Chiari decompression with patchy duraplasty and tonsilloplasty with cervical vertebrae 1 and 2 (C1-C2) laminectomy with a resolution of her symptoms. Chiari malformations are sometimes inherited but are often sporadic in nature, and, thus, appropriate diagnosis is key. Our patient is unique in that she presented at an older age, suggesting that atypical etiologies of a chronic cough refractory to conventional treatments must be considered

Inappropriate statin therapy according to ASCVD risk: Can we do better?

Background: Statin therapy targeted at reducing 10-year risk of ASCVD has become a cornerstone of preventative health in the outpatient setting. Appropriate statin prescription can lead to improved morbidity and mortality as outlined by current American College of Cardiology/American Heart Association (ACC/AHA) guidelines. Methods: In this empiric observational study performed in August 2018, we calculated the 10-year ASCVD risk for patients visiting the Henry Ford Hospital Academic Internal Medicine Clinic between January and December 2017, and compared the ACC/AHA guideline recommended statin intensity with the one currently prescribed. Our aim was to assess appropriateness of statin therapy based on ASCVD risk calculation and ACC/AHA guidelines. Results: Of the 2994 patients assessed, approximately 1548 patients were prescribed an inappropriate intensity of statin based on 10-year ASCVD risk calculation (p \u3c 0.001). For female patients, the odds of appropriate statin dose prescription increased by approximately 81.9% (odds ratio 1-1.819) when compared to male patients (95% CI 1.559-2.124). For black patients, the odds of appropriate statin prescription decreased by 32.2% (odds ratio 1-0.678) when compared to white patients (95% CI 0.532-0.864). Approximately 1245 patients currently taking high-intensity statin did not qualify for one as compared to 484 patients (p \u3c 0.001). Conclusion: Calculation of 10-year ASCVD risk is an integral part of guiding statin prescription and preventative health therapy in the outpatient setting, However, an increasing percentage of patients are not managed adequately according to ACC/AHA guidelines. Race, gender, and income disparities appear to be major factors influencing appropriateness of statin prescription. This demonstrates a major opportunity for potential intervention to improve statin prescription and patient health outcomes.https://scholarlycommons.henryford.com/merf2019hcd/1000/thumbnail.jp

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Pyeloduodenal Fistula: A Rare Complication

Objectives: Diagnose pyeloduodenal fistulaManage pyeloduodenal fistulaCase: 85-year-old male with a history of bladder cancer status post tumor resection and left ureteral stent placement presented with right flank pain, hematuria, and CVA tenderness on physical exam. UA was consistent with urinary tract infection, CT abdomen pelvis showed gas and fluid in the dilated right renal pelvis and collecting system. Cystoscopy with bilateral retrograde pyelogram was performed, but urologists were unable to place right stent due to stricture and unable to remove left stent. Bilateral nephrostomy tubes were placed, but a fistulous connection was noted between the right collecting system and the duodenum. Upper GI and small bowel follow-through showed opacification of the right intrarenal collecting system, consistent with a fistula between the duodenum and the right renal collecting system. EGD showed an ulcer in the duodenum with a small central fistula, correlating with the known pyeloduodenal fistula. This was treated with argon plasma coagulation and closed using the Tulip Bundle method of placing hemoclips around the margin and closure with an endoloop around the clips. Discussion: A pyeloduodenal fistula is a rare but serious condition, generally associated with chronic inflammatory renal diseases or trauma.The posterior aspect of the second portion of the duodenum lies in proximity to the medial portion of the kidney and renal pelvis. When perirenal inflammation takes place, this portion of the duodenum is more easily involved. Pyeloenteric fistulas may be classified as traumatic or spontaneous, which constitute the majority of cases. Malignant etiologies include urothelial carcinoma, renal transitional cell carcinoma and nephrolithiasis-related squamous cell carcinoma and adenocarcinoma. Diagnosis of pyeloduodenal fistula requires imaging studies of the urinary system. Retrograde pyelography is the method of choice which demonstrates the fistula in 64% of cases. Intravenous urography can be used only in functioning kidneys, and CT often shows fistula. Other imaging modalities include antegrade pyelography, EGD and upper GI studies.Nephrectomy and primary closure of the duodenum are traditional treatment methods. Small sized fistula and accessible location by EGD may be favorable features for nonsurgical treatment. Nonsurgical management includes intravenous antibiotics, relieving obstruction by employing nephrostomy, or internal ureteric stents. A new method of treatment is endoscopic ligation, as was seen in this case. Conclusion: Retrograde pyelography is the study of choice for diagnosing pyeloduodenal fistula in a functioning kidney. EGD can be used both for diagnosis and intervention. Conservative management with antibiotics and stent placement may be possible with small fistulas. Endoscopic intervention by an advanced GI team can be done to avoid extensive surgical intervention.https://scholarlycommons.henryford.com/merf2019caserpt/1047/thumbnail.jp

Idiopathic Chylothorax: Is It a Benign or Malignant Diagnosis?

Learning Objective #1: Diagnose idiopathic chylothorax Learning Objective #2: Manage chylothorax CASE: A 29-year-old healthy male presented with acute onset of dyspnea and right-sided pleuritic chest pain. CT scan of the chest showed large right-sided pleural effusion. Thoracentesis was performed, draining 2 liters of turbid white pleural fluid and a chest tube was placed. Fluid analysis revealed exudative effusion with lymphocytic predominance and triglyceride (TG) of 1,100 mg/dl consistent with chylothorax. Pleural fluid cytology and cultures were negative for malignancy and infection. Patient was made nil per os, total parenteral nutrition (TPN) and IV octreotide were started. High-volume chyle leakage was persistent. Patient underwent lymphangiogram, which showed chyle leak from the thoracic duct (TD) at the level of T7-T8. He underwent embolization, however, output did not improve. Patient underwent video-assisted thoracoscopy (VATs) and TD ligation by thoracic surgery. Pleural biopsy was negative for malignancy. Serum LDH, alpha-fetoprotein, beta-human chorionic gonadotropin, HIV, acid-fast bacilli, fungal, and anaerobic cultures were all negative. Peripheral blood smear was negative for dysplasia and blasts. Full body CT did not show any evidence of malignancy. Output trended down, and chest tube was removed when chest X-ray showed resolution of pleural effusion. Diet was advanced to low-fat, medium chain triglyceride (MCT) diet. There was no leak recurrence at 1-month follow-up. IMPACT/DISCUSSION: Chylothorax is the presence of chyle in the pleural space with a TG level \u3e 110 mg/dl or evidence of chylomi-crons in the pleural fluid. Non-traumatic chylothorax is a rare condition and can be due to many disease processes. A thorough evaluation of the most common causes of non-traumatic chylothorax includes malignancy (lymphomas, lung and mediastinal cancers), infections (tuberculosis, fungal infections), and congenital disorders of the lymphatic system, which were negative in our case. Conservative management includes either nothing by mouth or a low-fat diet with MCTs, which are absorbed directly into the portal system, bypassing the TD to reduce chyle flow and promote healing. TPN is used to replace proteins, electrolytes, and deliver lipids directly into the bloodstream, thereby bypassing the lymphatic system and decreasing chyle flow. Octreotide is an adjunct to help reduce chyle absorption from the intestines. When conservative measures fail, there are many interventional modalities to consider, including TD embolization, TD ligation, or pleurodesis. For our patient, a combination of conservative and operative interventions was performed given high-output of chyle and absence of a clear etiology, resulting in leakage resolution. Conclusion: It is crucial to perform a comprehensive assessment in non-traumatic chylothorax to exclude occult underlying etiology. Initial conservative management includes dietary modifications. If there is no improvement, interventions are available to repair TD and reduce chyle output

Restructuring Ambulatory Curriculum

Needs and Objectives: During the 2017-2018 academic year, the curriculum for ambulatory medicine consisted mainly of discussion of clinical trials from scholarly journals. Results of both the mid-year and end of the year survey administered to residents showed dissatisfaction with the educational session, due to emphasis on clinical trials and lack of discussion regarding medical management of common outpatient pathology. This prompted restructuring of the curriculum with the goal of improving resident satisfaction, providing more management guidelines, and better preparing residents for board exams. Setting and Participants: Ambulatory education in our institution takes place prior to our residents\u27 traditional half-day continuity clinic. Small groups of up to 10 residents and 4 faculty participate in a flipped classroom format. Description: In the 2018-2019 academic year, our ambulatory curriculum underwent several key changes. First, educational sessions were shifted to focus more on guidelines and medical management of outpatient conditions. Second, each month a subspecialty topic was assigned that paralleled our inpatient educational noon conference. In this format, the outpatient curriculum built on concepts and topics addressed in our inpatient curriculum. Third, we utilized our in-training Results to help optimize topic selection to help residents focus on areas where scores tend to be lower. At the end of each month we had a resident-lead board review session to review key points and answer questions as a group. Evaluation: Mid-year surveys identical to the previous academic year were used to assess the resident and preceptor response to changes in the curriculum. 77% of residents rated the curriculum as good or excellent, a 30% increase from the year prior. 23% of residents rated it as fair/poor, a 30% decrease from the year prior. When asked about board review content, 56% of residents felt there were enough board review questions, a 38% increase from the year prior. Preceptors also felt their residents were more engaged during the sessions then they had been previously. D I r e C t r e s I d e n t feedback has been positive, including comments that they appreciate the synchrony of the inpatient and outpatient curriculum Discussion/Reflection/Lessons Learned: Resident satisfaction with the ambulatory curriculum has improved with the recent curriculum changes, leading to increased engagement in our educational sessions. Residents prefer broad discussions about clinic management rather than discussing clinical trials. By organizing these discussions to supplement the inpatient curriculum, residents felt they had a more structured educational experience. Board review questions help to reinforce the monthly topic while simultaneously preparing the residents for the ABIM. Choosing topics that are relevant and enjoyable to the targeted learners help enrich the ambulatory educational experience through increased participation and learning opportunities

Inappropriate Statin Therapy According to Atherosclerotic Cardiovascular Disease (ASCVD) Risk: Can We Do Better?

Background: Statin therapy targeted at reducing 10-year risk of stroke and heart attack has become a cornerstone for preventative health in the outpatient setting. Appropriate statin intensity prescription based on 10-year ASCVD risk calculation can lead to improved morbidity and mortality as outlined by current American College of Cardiology/American Heart Association (ACC/AHA) guidelines. Methods: We conducted an empiric observational study in August 2018 based on lab Results of patients visiting the Henry Ford Hospital Academic Internal Medicine Clinic between January 2017 and December 2017. We calculated the 10-year ASCVD risk for the patients based on this data, and compared the ACC/AHA guideline recommended statin therapy with the one currently prescribed. The primary outcome was appropriateness of statin therapy based on ASVCD risk calculation. Our aim was to assess whether patients in the clinic setting are being adequately managed for ASCVD risk according to ACC/AHA guidelines. Results: Of the 2994 patients assessed, approximately 1548 patients were prescribed an inappropriate intensity of statin based on 10-year ASCVD risk calculation (p \u3c 0.001). For female patients, the odds of appropriate statin dose prescription increased by approximately 81.9% (odds ratio 1-1.819) when compared to male patients (95% CI 1.559-2.124). For black patients, the odds of appropriate statin dose prescription decreased by 32.2% (odds ratio 1-0.678) when compared to white patients (95% CI 0.532-0.864). Asian patients were more likely to be on an appropriate statin dose as compared to non-Asians (p = 0.022), and Hispanic patients were more likely to be on an appropriate statin dose as compared to non-Hispanics (p = 0.005). Approximately 1245 patients currently taking high-intensity statin did not qualify for one based on 10-year ASCVD risk calculation as compared to 484 patients (p \u3c 0.001). Conclusions: There is marked discrepancy in the guideline recommended statin therapy (based on 10-year ASCVD risk calculation) and currently prescribed statin, with gender and race serving as major variables. This data demonstrates a major opportunity for intervention on the part of primary care internists to improve patient outcomes in the outpatient setting

Fresh prescription: Improving nutrition education and access to fresh produce in detroit

STATEMENT OF PROBLEM OR QUESTION (ONE SENTENCE): Lack of basic knowledge of nutrition and limited access to fresh produce contribute to difficulty in controlling chronic diseases like obesity, diabetes, and cardiovascular disease among underserved adults in Detroit. OBJECTIVES OF PROGRAM/INTERVENTION (NO MORE THAN THREE OBJECTIVES): To improve patient\u27s knowledge of nutrition and confidence in their ability to eat healthy. To improve access to fresh produce by 1) providing financial support, 2) introducing patients to new local Detroit farmer\u27s markets. DESCRIPTION OF PROGRAM/INTERVENTION, INCLUDING ORGANIZATIONAL CONTEXT (E.G. INPATIENT VS. OUTPATIENT, PRACTICE OR COMMUNITY CHARACTERISTICS): Fresh Prescription is a program that serves patients at several different sites in the Detroit area. We implemented Fresh Prescription at our tertiary-care academic institution in the outpatient Internal Medicine clinic. Eligible participants with body mass index \u3e25 and motivation to learn healthy eating habits were enrolled by their primary care physician from July- September 2016. Participants were given a $10 reward on a rechargeable debit card for completing a nutrition educational counseling session, which could include tele-counseling, cooking demonstrations, and other events. They were able to redeem their reward at local farmer\u27s markets or with boxed food deliveries to receive a maximum total of$40 in fresh produce. Patients underwent a total of 4 counseling sessions over 6 weeks and received an additional $20 boxed food delivery for returning for a 12 week follow up. MEASURES OF SUCCESS (DISCUSS QUALITATIVE AND/OR QUANTITATIVE METRICS WHICH WILL BE USED TO EVALUATE PROGRAM/INTERVENTION): Success was measured through comparison of pre- and post-survey responses. FINDINGS TODATE (IT IS NOT SUFFICIENT TOSTATE FINDINGS WILL BEDISCUSSED):Atotal of 149 patients were referred to the program by their primary care physician. 39 of these patients were enrolled, and 28 patients completed the program (72% completion rate). Post-survey responses are available for 27 of the 39 patients enrolled in the program. 96% of participants reported they were better able to manage their health and their chronic conditions. 78% of participants reported an increase in their daily intake for fresh fruits and vegetables, with an average increase of 2 cups/day. 48% of participants reported a decrease in their intake of unhealthy food items, with an average decrease of 1 item/day. There was an increase in measures of knowledge base, which included ability to select, prepare, and store fresh produce. 85% of participants reported better knowledge of where to buy fresh produce. Price, access, and transportation were still noted to be barriers for many participants. Of the 39 patients who completed the program, 16 returned for follow up on biometrics, including weight and blood pressure. 5 of 16 participants had weight loss, and 5 of 16 had improvement in blood pressure. KEYLESSONS FORDISSEMINATION(WHATCAN OTHERS TAKE AWAY FOR IMPLEMENTATION TO THEIR PRACTICE OR COMMUNITY?): Increasing general nutrition knowledge base among participants led to an increase in the amount of fresh produce consumed, a decrease in unhealthy food items consumed, and increase in ability to manage chronic health conditions. Providing financial resources and improving access to fresh produce are important in supporting patients in an underserved population while encouraging healthy eating habits

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit