Adding a Physical Therapist to the Health Care Team in an HIV Clinic Increases Physical Therapy Referrals and Reduces Opioid Prescriptions Provided for Chronic Musculoskeletal Pain in Patients Living With HIV.

BACKGROUND: Musculoskeletal (MSK) pain is common in people living with HIV (PLWH). Health care providers sometimes prescribe opioids to control pain, which may lead to opioid misuse. An interdisciplinary approach that includes physical therapy has been successful in managing MSK pain in various health care settings. Therefore, we sought to find the impact of recruiting a physical therapist (PT) on the number of opioid prescriptions and physical therapy referrals made by physicians in training to manage MSK pain in PLWH. METHODS: We performed a retrospective chart review of patients seen by Internal Medicine physicians in training in an HIV clinic in Detroit before (2017) and after (2018) recruiting a PT to the health care team and collected demographic and clinical data. We also surveyed the trainees to assess how the PT addition influenced their learning. Institutional review board waiver was obtained. RESULTS: Results showed that of all PLWH seen at the clinic, 28/249 (11%) and 37/178 (21%) had chronic MSK pain in the 2017 and 2018 data sets, respectively. In 2017, all 28 patients with MSK pain were prescribed opioids. This decreased in 2018 after the PT addition (10/37 patients; P < .0001). The number of physical therapy referrals significantly increased after the PT addition (2017: 5/28 patients; 2018: 17/37 patients; P = .03). Trainees felt that the PT helped improve their examination skills and develop a treatment plan for patients. CONCLUSIONS: The addition of a PT encouraged physicians in training to utilize nonopioid management of MSK pain in PLWH and enhanced their learning experience, as perceived by the trainees.

Tension Pneumothorax: Is it Sarcoma or Pazopanib?

Synovial sarcomas are rare malignant tumors that originate from primitive pluripotent mesenchymal stem cells that look similar to the developing synovium, but are histologically unrelated to it. Sarcomas commonly metastasize to the lungs and surrounding pleura, with a documented incidence as high as 85% for pleural-based metastases. The incidence of spontaneous pneumothorax in patients with sarcomas is only 1.9%, with synovial sarcoma being the third most common type of sarcoma associated with pneumothorax. While surgical resection is usually the treatment for localized primary synovial cell sarcoma, metastatic disease requires systemic therapy, mainly chemotherapy. Failure of chemotherapy calls for the use of targeted therapeutic agents such as pazopanib. Pazopanib has been linked to the incidence of spontaneous pneumothorax in previous case studies. However, primary research fails to establish a statistically significant causal association. Research shows that pneumothorax can result from lung metastases independent of therapeutic side effects. We report a case of synovial sarcoma of trapezius origin with secondary lung metastases, and development of pneumothorax after pazopanib treatment. We discuss the incidence of pneumothorax as a medication side effect versus independent effect of natural disease progression, and how this plays role in deciding when to continue using a medication in the face of complications.

Nosocomial Achromobacter xylosoxidans Infection Presenting as a Cavitary Lung Lesion in a Lung Cancer Patient.

Achromobacter xylosoxidans is a Gram-negative bacillus that is known to cause nosocomial infections, primarily in patients with hematological malignancies. The most common primary manifestation is bacteremia. We report a novel case of primary A. xylosoxidans infection presenting as a cavitary lung lesion with associated pneumonia in a lung cancer patient who showed no evidence of malignant disease progression after radiation therapy. Our patient was initially admitted for acute hypoxic respiratory failure requiring mechanical ventilation. Initial computed tomography (CT) revealed a cavitary lesion in the right upper lobe of the lung. Diagnostic bronchoscopy with bronchoalveolar lavage (BAL) was performed and was negative for infectious etiologies including tuberculosis (TB) and fungal infections. Cytology was also negative for malignancy. However, the bacterial culture grew A. xylosoxidans. Antimicrobial therapy was initiated based on culture susceptibilities and the patient showed significant improvement in oxygen requirements. Due to poor functional status, the palliative care route was pursued and mechanical ventilation weaning was not performed. Cavitary pulmonary infections secondary to A. xylosoxidans are rarely reported in the medical literature. After conducting a thorough PubMed database search of the medical literature, we believe this is the first case of A. xylosoxidans infection manifesting as a cavitary lung lesion with associated pneumonia in a lung cancer patient.

The relationship between eye movements and subsequent recognition: Evidence from individual differences and amnesia.

There is consistent agreement regarding the positive relationship between cumulative eye movement sampling and subsequent recognition, but the role of the hippocampus in this sampling behavior is currently unknown. It is also unclear whether the eye movement repetition effect, i.e., fewer fixations to repeated, compared to novel, stimuli, depends on explicit recognition and/or an intact hippocampal system. We investigated the relationship between cumulative sampling, the eye movement repetition effect, subsequent memory, and the hippocampal system. Eye movements were monitored in a developmental amnesic case (H.C.), whose hippocampal system is compromised, and in a group of typically developing participants while they studied single faces across multiple blocks. The faces were studied from the same viewpoint or different viewpoints and were subsequently tested with the same or different viewpoint. Our previous work suggested that hippocampal representations support explicit recognition for information that changes viewpoint across repetitions (Olsen et al., 2015). Here, examination of eye movements during encoding indicated that greater cumulative sampling was associated with better memory among controls. Increased sampling, however, was not associated with better explicit memory in H.C., suggesting that increased sampling only improves memory when the hippocampal system is intact. The magnitude of the repetition effect was not correlated with cumulative sampling, nor was it related reliably to subsequent recognition. These findings indicate that eye movements collect information that can be used to strengthen memory representations that are later available for conscious remembering, whereas eye movement repetition effects reflect a processing change due to experience that does not necessarily reflect a memory representation that is available for conscious appraisal. Lastly, H.C. demonstrated a repetition effect for fixed viewpoint faces but not for variable viewpoint faces, which suggests that repetition effects are differentially supported by neocortical and hippocampal systems, depending upon the representational nature of the underlying memory trace.