Occult Breast Cancer Metastasis Presenting as Acute Liver Failure

CASE: A 45 year-old-female with history of clinically stage IA ER/PR/Her-2 Negative moderately differentiated ductal carcinoma of right breast presented with abdominal pain, abdominal distension, jaundice, and scleral icterus three weeks after laparoscopic cholecystectomy due to acute cholecystitis. Intraoperatively her liver was noted to be cirrhotic and an intraoperative biopsy was done. Upon discharge after surgery her total bilirubin remained elevated. On presentation she showed signs of acute liver failure and coagulopathy with a bilirubin of 10.5, INR was elevated to 2.8, and AST/ALT downtrending. Clinically she continued to have increased abdominal pain and distension, jaundice, and scleral icterus. Intraoperative biopsy pathology showed fragments of benign liver cyst with granulomatous inflammation. During her hospital course she continued to display worsening liver function with elevated AST/ALT, total bilirubin, alkaline phosphatase, and INR. Post-surgical complications including bile leak, viral, autoimmune, and granulomatous causes of acute liver failure were excluded. Further evaluation with transjugular hepatic biopsy was done due to limited diagnostic value of previous biopsy, and revealed cirrhosis. Immunohistochemical staining was positive for GATA-3 immunostain and CK-7 stain, revealing adenocarcinoma most consistent with primary breast carcinoma. DISCUSSION: Acute Liver Failure (ALF) is defined as sudden liver dysfunction manifesting as coagulopathy and any degree of encephalopathy in a patient without preexisting cirrhosis with illness lasting less than 26 weeks\u27 duration. As much as 20-40% of ALF is due to unclear causes. Hepatic metastases have been identified in up to 40% of adults with malignant tumors. In the case of breast cancer metastases,the liver is considered to among the common sites of metastasis, along with lungs and bone. However, most metastases present in the form of a discrete mass, and patients do not usually present with liver disease. Isolated liver metastases from breast cancer is rare and only seen in 5-12% of breast cancer patients. Prior studies have shown that isolated liver involvement prognosis improves if patients have hormone positive cancer, normal liver function, good performance status, and have had a long Disease Free Interval (DFI). Resection of liver metastasis is indicated of helical CT or MRI demonstrates well-circumscribed mass that can be excised without further damaging liver function. Diffuse liver metastasis is very rare and difficult to diagnose as they are not identifiable on routine radiologic diagnostic studies. There are multiple case reports of occult metastatic breast cancer in the liver presenting with acute liver failure, in patients with a history of known and treated breast cancer. The majority of these cases are only identified as metastasis from breast cancer primary upon autopsy, as the prognosis for such a presentation of metastatic breast cancer is appalling. In few reported cases, early diagnosis and treatment resulted in some improvement beyond the 18-24 months expected prognosis in metastatic breast cancer. CONCLUSION: Our patient presents a challenging case in which liver function and performance status was poor prior to diagnosis of metastasis. Helical CT also demonstrated a unique presentation of cirrhotic liver with vastly diffuse metastatic lesions, with no circumscribed mass seen. The findings of this case emphasize the unique presentations of metastatic breast cancer in patients who are in remission, necessitating a broader differential diagnosis at time of presentation.https://scholarlycommons.henryford.com/merf2019caserpt/1123/thumbnail.jp

Using a Frontline Staff Intervention to Improve Cervical Cancer Screening in a Large Academic Internal Medicine Clinic

BACKGROUND: Cervical cancer is the third most common malignancy affecting women. Screening with Papanicolaou (Pap) tests effectively identifies precancerous lesions and early-stage cervical cancer. While the nationwide rate of cervical cancer screening (CCS) is 84%, our urban general internal medicine (GIM) clinic population had a CCS rate of 70% in 2016. OBJECTIVE: To improve our clinic\u27s CCS rate to match or exceed the national average within 18 months by identifying barriers and testing solutions. DESIGN: A quality improvement project led by a multidisciplinary group of healthcare providers. PARTICIPANTS: Our GIM clinic includes 16 attending physicians, 116 resident physicians, and 20 medical assistants (MAs) with an insured and underserved patient population. INTERVENTION: Phase 1 lasted 9 months and implemented CCS patient outreach, patient financial incentives, and clinic staff education. Phase 2 lasted 9 months and involved a workflow change in which MAs identified candidates for CCS during patient check-in. Feedback spanned the entire study period. MAIN MEASURES: Our primary outcome was the number of Pap tests completed per month during the 2 study phases. Our secondary outcome was the clinic population\u27s CCS rate for all eligible clinic patients. KEY RESULTS: After interventions, the average number of monthly Pap tests increased from 35 to 56 in phase 1 and to 75 in phase 2. Of 385 patients contacted in phase 1, 283 scheduled a Pap test and 115 (41%) completed it. Compared to baseline, both interventions improved cervical cancer screening (phase 1 relative risk, 1.86; 95% CI, 1.64-2.10; P \u3c 0.001; phase 2 relative risk, 2.70; 95% CI, 2.40-3.02; P \u3c 0.001). Our clinic\u27s CCS rate improved from 70% to 75% after the 18-month intervention. CONCLUSIONS: The rate of CCS increased by 5% after a systematic 2-phase organizational intervention that empowered MAs to remind, identify, and prepare candidates during check-in for CCS

Selective Serotonin Reuptake Inhibitor Use Is Associated with Right Ventricular Structure and Function: The MESA-Right Ventricle Study

PURPOSE:Serotonin and the serotonin transporter have been implicated in the development of pulmonary hypertension (PH). Selective serotonin reuptake inhibitors (SSRIs) may have a role in PH treatment, but the effects of SSRI use on right ventricular (RV) structure and function are unknown. We hypothesized that SSRI use would be associated with RV morphology in a large cohort without cardiovascular disease (N = 4114). METHODS:SSRI use was determined by medication inventory during the Multi-Ethnic Study of Atherosclerosis baseline examination. RV measures were assessed via cardiac magnetic resonance imaging. The cross-sectional relationship between SSRI use and each RV measure was assessed using multivariable linear regression; analyses for RV mass and end-diastolic volume (RVEDV) were stratified by sex. RESULTS:After adjustment for multiple covariates including depression and left ventricular measures, SSRI use was associated with larger RV stroke volume (RVSV) (2.75 mL, 95% confidence interval [CI] 0.48-5.02 mL, p = 0.02). Among men only, SSRI use was associated with greater RV mass (1.08 g, 95% CI 0.19-1.97 g, p = 0.02) and larger RVEDV (7.71 mL, 95% 3.02-12.40 mL, p = 0.001). SSRI use may have been associated with larger RVEDV among women and larger RV end-systolic volume in both sexes. CONCLUSIONS:SSRI use was associated with higher RVSV in cardiovascular disease-free individuals and, among men, greater RV mass and larger RVEDV. The effects of SSRI use in patients with (or at risk for) RV dysfunction and the role of sex in modifying this relationship warrant further study

Analysis of Visit Factors Associated with Colorectal Cancer Screening in an Academic Outpatient Care Center

Background: Colorectal cancer (CRC) is the third most commonly diagnosed malignancy and the second leading cause of cancer related death in the United States. CRC screening recommendations by all major organizations allow for either the use of stool-based tests such as fecal immunochem-ical test (FIT), fecal occult blood testing (FOBT) and multitargeted stool DNA (such as Cologuard) or visual tests such as Colonoscopy, CT Colonography, and flexible sigmoidoscopy. Prior literature has shown that screening services are inconsistently delivered across practice settings and continue to be underutilized. Most insurance cover preventative visits to accomplish screening goals and offer services in form of outreach, however, data is lacking on effectiveness of these visits. Likewise, interventions to increase CRC screening uptake have focused on modifying provider attitudes, although, studies have not addressed provider level and gender as a potential factor. Our primary objective was to assess the frequency and type of CRC screening offered by primary care doctors. Our secondary objective was to assess how type of visit and provider factors affect if screening was offered and the type of screening offered. Methods: A retrospective chart review of 2196 patients who were seen in an outpatient academic tertiary care center was performed. Patients between the ages 50-75 years old who had a primary care doctor and were seen in clinic between July 1, 2017 and July 31, 2018 were assessed. Screening offered was defined as either stool tests (FIT, FOBT and Cologuard) or visual tests (Colonoscopy and CT colonography). Results: A total of 2196 patients met our criteria. The mean age was 62.7 years; body mass index (BMI), 31.1kg/m2; females, 54.7%. Cohort was divided into Group A (62%), comprising of people who did not have CRC screening ordered and Group B (38%), who had one or more CRC screening tests ordered. In Group B, some patients had more than one test ordered: 83.1% had Colonoscopy ordered, 10.7% had Cologuard ordered, 13.5% had FIT/FOBT ordered. The rate of colonoscopy completion was 14.7%, and stool testing completion was 34-37.5%. Out of 739 visits during which CRC screening was implemented, 90% were office visits. Surprisingly, having a preventative visit was not associated with an increased likelihood of having CRC screening test ordered (p=0.91). Among patients who had either test ordered, 65.6% of Colonoscopies or 48.4% of Stool tests were ordered by residents (p\u3c 0.001). Conclusions: A significant amount of patients (62.3%) that were seen by their primary care doctor had no CRC screening ordered. Having a wellness visit was not associated with having CRC screening tests ordered. Although colonoscopy was the most commonly ordered screening test, compliance to stool testing was twice as that of colonoscopy. Residents as provider were more likely to order colonoscopy compared to senior staff

Fulfillment in food: A pilot study of a culinary curriculum\u27s impact on internal medicine resident burnout.

Background: Burnout among medical residents is increasing, with residency programs seeking ways toaddress this challenge. While leisure cooking has been associated with lower burnout among practicing physicians and a number of burnout interventions have been shown to be effective among residents, no research to date has investigated the efficacy of a cooking class in reducing resident burnout. We hypothesized that an engaging culinary skills class intervention would increase cooking proficiency, encourage health be-haviors, and decrease resident burnout. Methods: With all internal medicine residents at our health system eligible, 8 participants enrolled in a 2-hour class of culinary instruction and hands-on cooking in small groups. Assessment surveys were completed immediately prior to, immediately following, and 6 weeks after the intervention. The baseline and 6 weeks post-intervention surveys included the Abbreviated Maslach Burnout Inventory. Secondary outcomes included within-subject improvements and sustainability of culinary knowledge, skills, and healthy cooking frequency. Results: All 8 participants completeda survey for each of the 3 time-points. The results showed immediately post-intervention increases in cooking knowledge (standardized mean difference 1.87 [95% confidence interval 1.12, 2.63]), skills (0.85 [0.19, 1.50]), confidence (1.39 [0.64, 2.14]), and motivation (0.85 [0.16, 1.53]) compared to baseline. There were no statistically significant differences between the post-intervention and 6 weeks post-intervention surveys. At 6 weeks post-intervention, residents reported (on a scale of 0-10) they\u27d used their new knowledge and skills to positively impact their health (mean 8.1 [95% confidence interval 6.4, 9.8]), wellness (7.8 [6.3, 9.3]), and burnout (7.3 [5.8, 8.8]). However, self-reported number of home-cooked versus pre-prepared meals eaten per week remained stable over time. Baseline scores (on a scale of 0-18) on the Abbreviated Maslach Burnout Inventory were found to be 5.1, 7.9, and 14.8 for depersonalization, emotional exhaus-tion, and personal accomplishment, respectively. There were no statistically significant differences in these scores at 6 weeks post-intervention. Conclusions: This study demonstrates that a resident cooking class may improve culinary knowledge, skills, and confidence and that these improve-ments may be retained over time. It may also improve healthy behaviors. Burnout indices did not improve; however, baseline burnout levels were low. More studies with a greater number of participants and an increased frequency of intervention should be conducted

Does physician gender effect ordering practice.

BACKGROUND: Breast cancer cases represent 14.6% of all new cancer diagnosis in the United States. However, medical societies disagree when, and how often, we should be screening. The United States Preventative Service Task Force recommends starting at 50 years of age and screening biennially, while others recommend starting at 40 years of age, or screening annually. This has created an environment where physicians must decide which guideline is best for their patients. We sought to find out what factors influence this decision, specifically if the gender of the ordering physician was associated with different screening practices in women aged 40-49. METHODS: We examined every office visit for female patients age 40-49 with an internal medicine (IM), family medicine (FM) or gynecology (Gyn) provider in our health system between July 1, 2015 to May 30, 2016. Patients with a history of breast cancer or other malignant neoplasm were excluded. The association between physician gender and mammogram ordering rates was assessed via chi-squared testing. Other factors, such as comparison between specialties, were assessed via multivariable binary logistic regression. RESULTS: In female patients aged 40-49, female physicians are more likely to order mammograms than male physicians overall. This disparity between genders was largest in internal medicine. Gynecology physicians order mammograms at a higher rate than internal medicine or family medicine physicians. Women aged 45-49 were more likely to receive a mammogram order than women aged 40-44. Also, black patients were less likely to receive a mammogram order compared to white patients. CONCLUSIONS: Physician ordering practices do appear to vary by gender, however, this pattern is also influenced by specialty. The decision also seems to be effected by the age and/or race of the patient. The results of this study support the need for more research in factors contributing to preventive healthcare disparities

Depression and literacy are important factors for missed appointments

Multiple variables are related to missed clinic appointments. However, the prevalence of missed appointments is still high suggesting other factors may play a role. The purpose of this study was to investigate the relationship between missed appointments and multiple variables simultaneously across a health care system, including patient demographics, psychiatric symptoms, cognitive functioning and literacy status. Chart reviews were conducted on 147 consecutive patients who were seen by a primary care psychologist over a six month period and completed measures to determine levels of depression, anxiety, sleep, cognitive functioning and health literacy. Demographic information and rates of missed appointments were also collected from charts. The average rate of missed appointments was 15.38%. In univariate analyses, factors related to higher rates of missed appointments included younger age (p = .03), lower income (p = .05), probable depression (p = .05), sleep difficulty (p = .05) and limited reading ability (p = .003). There were trends for a higher rate of missed appointments for patients identifying as black (p = .06), government insurance (p = .06) and limited math ability (p = .06). In a multivariate model, probable depression (p = .02) and limited reading ability (p = .003) were the only independent predictors. Depression and literacy status may be the most important factors associated with missed appointments. Implications are discussed including regular screening for depression and literacy status as well as interventions that can be utilized to help improve the rate of missed appointments