Isolated Myeloid Sarcoma: A Diagnostic Dilemma.

Myeloid sarcoma (MS)/granulocytic sarcoma/myeloblastoma/chloroma is a rare extramedullary proliferation of blast cells of one or more myeloid lineages along with the destruction of the normal architecture of adjacent tissue. Isolated MS is a rare entity with an incidence of 0.7 out of 1 million children and 2 out of 1 million adults. Varied clinical presentation, the rarity of the diagnosis, inadequate immunophenotyping, and lack of available literature makes the disease difficult to manage. Here, we report a case of MS in a 44-year-old male with an initial presentation of testicular mass without bone marrow involvement, causing diagnostic challenges. In this case report, we discuss the pathogenesis, diagnostic challenges, and therapeutic options of MS.

Integrative medicine considerations for convalescence from mild-to-moderate COVID-19 disease.

The majority of individuals infected with SARS-CoV-2 have mild-to-moderate COVID-19 disease. Convalescence from mild-to-moderate (MtoM) COVID-19 disease may be supported by integrative medicine strategies. Integrative Medicine (IM) is defined as healing-oriented medicine that takes account of the whole person, including all aspects of lifestyle. Integrative medicine strategies that may support recovery from MtoM COVID-19 are proposed given their clinically studied effects in related conditions. Adoption of an anti-inflammatory diet, supplementation with vitamin D, glutathione, melatonin, Cordyceps, Astragalus and garlic have potential utility. Osteopathic manipulation, Qigong, breathing exercises and aerobic exercise may support pulmonary recovery. Stress reduction, environmental optimization, creative expression and aromatherapy can provide healing support and minimize enduring trauma. These modalities would benefit from clinical trials in people recovering from COVID-19 infection.

Real-World Evidence from the Integrative Medicine Primary Care Trial (IMPACT): Assessing Patient-Reported Outcomes at Baseline and 12-Month Follow-Up.

PURPOSE: The University of Arizona Integrative Health Center (UAIHC) was an innovative membership-supported integrative medicine (IM) adult primary care clinic in Phoenix, Arizona. UAIHC delivered healthcare using an integrative medicine model that combined conventional and complementary medical treatments, including nutrition, mind-body medicine, acupuncture, manual medicine, health coaching, educational classes, and groups. Results from pre-post evaluation of patient-reported outcomes on several standardized measures are presented here. METHODS: UAIHC patients completed surveys at baseline and after 12 months of continuous integrative primary care. Patients reported on perceived changes in health outcomes as measured by Short-Form Health Survey (SF-12 general, mental, and physical health), Perceived Stress Scale (PSS4), Work Productivity and Activity Impairment Questionnaire (WPAI), World Health Organization Well-Being Index (WHO-5), Pain Visual Analog Scale (VAS), Fatigue Severity Scale (VAS; FSS), Generalized Anxiety Disorder Scale (GAD2), Patient Health Questionnaire for depression (PHQ2), Pittsburgh Sleep Quality Index (PSQI) global rating of sleep quality, and the Behavioral Risk Factor Surveillance System (BRFSS; nutrition, exercise, and physical activity). Overall differences between time points were assessed for statistical significance. Patient demographics are also described. RESULTS: 177 patients completed baseline and follow-up outcome measures. Patients were predominantly white, female, college-educated, and employed. Baseline to one-year follow-up results indicate statistically significant improvements (p <.05) on all but perceived stress (PSS-4) and work absenteeism (WPAI). Clinical impact and/or practical effects are reported as percent change or standardized effect sizes whenever possible. Other demographic and descriptive information is summarized. CONCLUSIONS: Following one year of IM primary care at UAIHC, patient-reported outcomes indicated positive impacts in several areas of patients' lives: mental, physical, and overall health; work productivity; sleep quality; pain; fatigue; overall well-being; and physical activity.

Refractory Heparin-Induced Thrombocytopenia With Cerebral Venous Sinus Thrombosis Treated With IVIg, Steroids, and a Combination of Anticoagulants: A Case Report.

Heparin-induced thrombocytopenia (HIT) type II is caused by antibody production that bind complexes between heparin and platelet factor 4 leading to platelet consumption and thrombosis. In a small subset of cases referred to as autoimmune HIT, the antibodies activate platelets even in the absence of heparin. Refractory HIT is a type of autoimmune HIT in which thrombocytopenia persists for weeks after heparin discontinuation and carries increased risk for thrombosis and more severe thrombocytopenia. We present a case of refractory HIT with cerebral venous sinus thrombosis (CVST) that was successfully treated with a change in anticoagulant alongside steroids and a second trial of intravenous immunoglobulin (IVIg).

Integrative medicine primary care: assessing the practice model through patients' experiences.

BACKGROUND: The University of Arizona Integrative Health Center (UAIHC) was an innovative integrative medicine (IM) adult primary care clinic in Phoenix, Arizona. UAIHC used a hybrid payment model to deliver comprehensive healthcare that includes conventional and complementary medical treatments. METHODS: Fidelity measures were collected to evaluate how well the IM care delivery process matched ideals for IM. Patient experiences are presented here. Patients visiting UAIHC on 1 of 10 randomly selected days between September 2013 and February 2015 were surveyed. Patients were asked about their experience with: holistic care; promotion of health, self-care, and well-being; relationship and communication with practitioners; and overall satisfaction. RESULTS: Eighty-three patients completed surveys. Based on patient-reported experiences, UAIHC delivered IM care as defined by the practice model. CONCLUSIONS: Patients received holistic care, established positive caring relationships with providers who promoted their self-care and well-being, and reported high overall satisfaction with UAIHC.

The evolution of integrative medical education: the influence of the University of Arizona Center for Integrative Medicine.

The University of Arizona Center for Integrative Medicine (AzCIM) was founded in 1994 with a primary focus of educating physicians in integrative medicine (IM). Twenty years later, IM has become an internationally recognized movement in medicine. With 40% of United States' medical schools having membership in the Academic Consortium for Integrative Medicine and Health it is foreseeable that all medical students and residents will soon receive training in the principles and practices of IM. The AzCIM has the broadest range and depth of IM educational programs and has had a major influence on integrative medical education in the United States. This review describes the fellowship, residency and medical student programs at AzCIM as well as other significant national drivers of IM education; it also points out the challenges faced in developing IM initiatives. The field of IM has matured with new national board certification in IM requiring fellowship training. Allied health professional IM educational courses, as well as integrative health coaching, assure that all members of the health care team can receive training. This review describes the evolution of IM education and will be helpful to academic centers, health care institutions, and countries seeking to introduce IM initiatives.

Pulmonary involvement by chronic lymphocytic leukemia/small lymphocytic lymphoma is a specific pathologic finding independent of inflammatory infiltration.

Pulmonary infiltrates in patients with chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) are usually secondary to infection, but a subset is due to pathologic infiltration of malignant lymphocytes into the lung parenchyma. In cases with both CLL/SLL and inflammatory infiltrates, it is unknown whether the CLL infiltrate represents a nonspecific "passenger effect" secondary to ongoing inflammation or pathologic leukemic pulmonary infiltration (LPI). We reviewed 49 lung biopsies taken from 38 patients with CLL/SLL. LPI was found in 2 of 21 cases (9.5%) with acute inflammation, 0 of 10 cases of chronic inflammation and in 7 of 18 cases (38.8%) without any pathologic findings of acute or chronic inflammation (p = 0.01). These results demonstrate that LPI identified in biopsies with concurrent inflammation is uncommon, and that most inflammatory infiltrates in patients with CLL do not cause "passenger effect" CLL infiltration. Therefore, LPI usually represents a specific pathologic process. We conclude that bronchoscopy with transbronchial biopsy is an effective tool for guiding treatment decisions for symptomatic patients with CLL with pulmonary infiltrates. Moreover, LPI by CLL is not a bystander effect secondary to acute inflammation, but instead represents a distinct pathologic process in a subset of patients.

Integrative medicine in residency education: developing competency through online curriculum training.

INTRODUCTION: The Integrative Medicine in Residency (IMR) program, a 200-hour Internet-based, collaborative educational initiative was implemented in 8 family medicine residency programs and has shown a potential to serve as a national model for incorporating training in integrative/complementary/alternative medicine in graduate medical education. INTERVENTION: The curriculum content was designed based on a needs assessment and a set of competencies for graduate medical education developed following the Accreditation Council for Graduate Medical Education outcome project guidelines. The content was delivered through distributed online learning and included onsite activities. A modular format allowed for a flexible implementation in different residency settings. EVALUATION: TO ASSESS THE FEASIBILITY OF IMPLEMENTING THE CURRICULUM, A MULTIMODAL EVALUATION WAS UTILIZED, INCLUDING: (1) residents' evaluation of the curriculum; (2) residents' competencies evaluation through medical knowledge testing, self-assessment, direct observations, and reflections; and (3) residents' wellness and well-being through behavioral assessments. RESULTS: The class of 2011 (n  =  61) had a high rate of curriculum completion in the first and second year (98.7% and 84.2%) and course evaluations on meeting objectives, clinical utility, and functioning of the technology were highly rated. There was a statistically significant improvement in medical knowledge test scores for questions aligned with content for both the PGY-1 and PGY-2 courses. CONCLUSIONS: The IMR program is an advance in the national effort to make training in integrative medicine available to physicians on a broad scale and is a success in terms of online education. Evaluation suggests that this program is feasible for implementation and acceptable to residents despite the many pressures of residency.

The integrative family medicine program: an innovation in residency education.

The Integrative Family Medicine (IFM) Program is a four-year combined family medicine residency program and integrative medicine fellowship. It was created in 2003 to address the needs of four constituencies: patients who desire care from well trained integrative physicians, physicians who seek such training, the health care system which lacks a conventional integrative medicine training route, and educational leaders in family medicine who are seeking new strategies to reverse the declining interest in family medicine amongst U.S. graduates. The program was designed jointly by the University of Arizona Program in Integrative Medicine (PIM) and family medicine residency programs at Beth Israel/Albert Einstein College of Medicine (AECOM), Maine Medical Center, Middlesex Hospital, Oregon Health & Science University, and the Universities of Arizona and Wisconsin. One or two residents from each of these institutions may apply, and when selected, commit to extending their training by a fourth year. They complete their family medicine residencies at their home sites, enroll in the distributed learning associate fellowship at PIM, and are mentored by local faculty members who have training in integrative medicine. To date three classes totaling twenty residents have entered the program. Evaluation is performed jointly: PIM evaluates the residents during residential weeks and through online modules and residency faculty members perform direct observation of care and review treatment plans. Preliminary data suggest that the program enhances interest amongst graduating medical students in family medicine training. The Accreditation Council of Graduate Medical Education Family Medicine residency review committee has awarded the pilot experimental status.