Metastatic Phyllodes Tumor in a Patient With Beckwith-Wiedemann Syndrome.

Beckwith-Wiedemann syndrome (BWS) is an epigenetic disorder of imprinting on the chromosome 11p15 region that presents with clinical features, such as macroglossia, abdominal wall defects, neonatal hypoglycemia, hemihypertrophy, and embryonal tumors. Phyllodes tumors (PTs) are rare fibroepithelial tumors that account for 0.3% to 1% of breast tumors and present in women aged 35 to 55 years. Here we describe a rare case of metastatic malignant phyllodes tumor in a 27-year-old woman with BWS and uniparental disomy (UPD) of chromosome 11p15.5. To our knowledge, this is the first case report in literature to describe metastatic malignant phyllodes tumor in a woman with BWS.

Effects of cocaine and/or heroin use on resting cardiovascular function.

BACKGROUND: Regular cocaine and/or heroin use is associated with major health risks, especially cardiovascular disease, but confounded by other factors. We examined effects of chronic (years regular use) and recent (past-month) cocaine and heroin use, controlling for other factors, on resting cardiovascular function. METHODS: In a sample of 292 cocaine and/or heroin users, we assessed demographics, body mass index (BMI), substance use history, electrocardiogram, heart rate (HR) and blood pressure (BP). Three-block (1: demographics, BMI; 2: tobacco, alcohol, cannabis; 3: cocaine, heroin) regression analyses were conducted to predict cardiovascular measures. RESULTS: Higher BMI predicted increased systolic and diastolic BP (as did older age), increased supine HR, and longer QRS duration, QTc interval, PR interval, and P-wave duration. Past-month cannabis-use days predicted higher systolic BP, lower supine HR, and greater likelihood of early repolarization and ST elevation; average daily cannabis use predicted shorter QTc interval. Average daily alcohol use predicted higher diastolic BP, higher supine HR and lower likelihood of sinus bradycardia (HR < 60 bpm). Past-month tobacco-use days predicted shorter QTc interval and lower lower likelihood of profound bradycardia (HR < 50 bpm). Past-month heroin-use days predicted lower seated HR, greater likelihood of sinus bradycardia and lower likelihood of left ventricular hypertrophy. More years of regular cocaine use and past-month cocaine-use days predicted longer QTc interval. CONCLUSIONS: Cocaine and heroin use incrementally predicted modest variance in resting bradycardia and QTc interval. Clinicians should first consider demographics and recent use of tobacco, alcohol and cannabis before assuming cocaine and heroin affect these measures.

Gemella morbillorum isolated from a pelvic abscess in an HIV-positive patient with squamous cell carcinoma of the perianal region.

Gemella morbillorumis a known commensal organism of the human oropharynx, gastrointestinal tract and genitourinary tract which is a rare cause of infections and even more rarely implicated in skin and soft tissue infections. We present a case of a young, HIV-positive patient with squamous cell carcinoma of the perianal region who presented with difficulty initiating urination for 1 week as well as increasing left leg swelling. His CD4 count was found to be 186, predisposing him to infection, and he had also received chemotherapy in the past year for his malignancy. He was febrile and tachycardic on presentation and admitted for further care. CT scan of the pelvis at time of admission demonstrated a pelvic abscess. Aspiration cultures ultimately grew G. morbillorum. Despite initial improvement with drainage and targeted antimicrobial therapy, the patient's abscess recurred, and he ultimately elected transition to hospice due to worsening prognosis of malignancy.

Effective Chronic Pain Management and Responsible Opioid Prescribing: Aligning a Resident Workshop to a Protocol for Improved Outcomes.

Introduction: Effective chronic pain management is a core competency of internal medicine. Opioid use in the United States, both therapeutic and nonmedical in origin, has dramatically increased, as has the number of deaths due to opioid overdose. Despite this, formal training in pain management and responsible opioid prescribing is lacking for internal medicine residents. Methods: Our educational workshop for PGY 1-PGY 3 internal medicine residents was designed to provide a functional knowledge base and improve motivation to change behaviors in chronic pain management and responsible opioid prescribing. A secondary aim was to align our intervention with our new clinic opioid-prescribing protocol with the goal of increasing the adoption of opioid risk-reduction strategies in our resident clinic, specifically, use of urine drug screening (UDS). We collected data using pre- and postsession knowledge and motivation to change questionnaires as well as pre- and postintervention data regarding UDS in our ambulatory clinic. Results: Sixty-three residents participated in a workshop session. Based on pre- to posttest results, medical knowledge of principles of responsible opioid prescribing increased overall (p = .01). Most residents reported high motivation to change behaviors around management of chronic pain and opioid prescribing. There was also a significant postintervention ordering of UDS in patients on long-term opioid therapy. Discussion: Our workshop resulted in a short-term improvement in knowledge of principles of responsible opioid prescribing, a significant motivation to change behaviors, and increased adoption of opioid risk-reduction strategies in our resident clinic.

Variant of Lemierre's Syndrome Secondary to Trauma.

Classic Lemierre's syndrome is a septic internal jugular venous (IJV) thrombophlebitis secondary to oropharyngeal anaerobic infection in adolescent and young adult. Though upper respiratory tract infection is the most common antecedent, it has also been described following skin, soft tissues, genitourinary and gastrointestinal infections. Fusobacteria necrophorum is the commonest pathogen isolated from blood and tissue cultures but other bacteria like Eikenella correndens, Bacteroides melaninogenicus and Non Group A Streptococcal species have also been reported. The overall incidence of Lemierre's and Lemierre's like syndromes has declined since the first case report in 1936. There is however, a resurgence of cases in recent years due to more judicious use of antibiotics for treatment of upper respiratory tract infection among medical practitioners. The main stay of treatment of complete Lemierre's syndrome is prolonged antibiotic coverage and surgical drainage of nonresolving abscesses. Currently, there is no consensus opinion on the use of anticoagulation in patient with complete Lemierre's syndrome complicated by septic internal jugular thrombosis and embolism. High index of suspicion is required for early diagnosis of Lemierre's and Lemierre's like syndromes. Early and effective antibiotics therapy may prevent the development full spectrum of the syndrome and its associated complication.