Piloting a Patient Tool to Aid Palliative Care Referrals during Advanced Lung Cancer Treatment.

CONTEXT: Patient misperceptions are a strong barrier to early palliative care discussions and referrals during advanced lung cancer treatment. OBJECTIVES: We developed and tested the acceptability of a web-based patient-facing palliative care education and screening tool intended for use in a planned multilevel intervention (i.e., patient, clinician, system-level targets). METHODS: We elicited feedback from advanced lung cancer patients (n = 6), oncology and palliative care clinicians (n = 4), and a clinic administrator (n = 1) on the perceived relevance of the intervention. We then tested the prototype of a patient-facing tool for patient acceptability and preliminary effects on patient palliative care knowledge and motivation. RESULTS: Partners agreed that the intervention-clinician palliative care education and an electronic health record-integrated patient tool-is relevant and their feedback informed development of the patient prototype. Advanced stage lung cancer patients (n = 20; age 60 ± 9.8; 40% male; 70% with a technical degree or less) reviewed and rated the prototype on a five-point scale for acceptability (4.48 ± 0.55), appropriateness (4.37 ± 0.62), and feasibility (4.43 ± 0.59). After using the prototype, 75% were interested in using palliative care and 80% were more motivated to talk to their oncologist about it. Of patients who had or were at risk of having misperceptions about palliative care (e.g., conflating it with hospice), 100% no longer held the misperceptions after using the prototype. CONCLUSION: The palliative care education and screening tool is acceptable to patients and may address misperceptions and motivate palliative care discussions during treatment.

First Documented Case of Percutaneous Endoscopic Gastrostomy (PEG) Tube-Associated Bacterial Peritonitis due to Achromobacter Species with Literature Review.

Introduction. Achromobacter species (spp.) peritonitis has seldom been identified in medical literature. Scarce cases of Achromobacter peritonitis described previously have been correlated with peritoneal dialysis and more sparingly with spontaneous bacterial peritonitis. Achromobacter exhibits intrinsic and acquired resistance, especially in chronic infections, to most antibiotics. This article conducts a literature review of all previously reported Achromobacter spp. peritonitis and describes the first reported case of Achromobacter peritonitis as a complication of percutaneous endoscopic gastrostomy (PEG) tube placement. Discussion. Achromobacter peritonitis as a complication of PEG-tube placement has not been previously reported. In our patients' case, the recently placed PEG-tube with ascitic fluid leakage was identified as the most plausible infection source. Although a rare bacterial peritonitis pathogen, Achromobacter may be associated with wide antimicrobial resistance and unfavorable outcomes. Conclusion. No current guidelines provide significant guidance on treatment of PEG-tube peritonitis regardless of microbial etiology. Infectious Disease Society of America identifies various broad-spectrum antibiotics targeting nosocomial intra-abdominal coverage; some of these antimicrobial selections (such as cefepime and metronidazole combination) may yet be inadequate for widely resistant Achromobacter spp. Recognizably, the common antibiotics utilized for spontaneous bacterial peritonitis, i.e., third generation cephalosporins and fluoroquinolones, to which Achromobacter is resistant and variably susceptible, respectively, would be extensively insufficient. Piperacillin/tazobactam (P/T) and carbapenem were identified to provide the most reliable coverage in vitro; clinically, 5 out of the 8 patients who received either P/T or a carbapenem, or both, eventually experienced clinical improvement.

Austrian Triad Complicated by Septic Arthritis and Aortic Root Abscess.

Austrian syndrome is a very rare manifestation of invasive Streptococcus pneumoniae infection comprising a triad of pneumonia, meningitis, and endocarditis, also known as Osler's triad. We herein report a rare case of Austrian syndrome further complicated by septic arthritis.

A Sweet Diagnosis for a Non-Resolving Rash.

Subcutaneous Sweet's syndrome (SSS) is a rare variant of Sweet's syndrome (SS), clinically characterized by erythematous plaques or nodules with a histologic pattern demonstrating a neutrophilic panniculitis (NP). We report a case of a 74-year-old woman with myelodysplastic syndrome (MDS) who presented with persistent fever, malaise, and non-resolving generalized erythematous nodules and was found to have an MDS-related SSS. SSS should be entertained and other causes of NP should be excluded prior to treating a patient with systemic corticosteroids. Early diagnosis of SSS in a patient not responding to broad-spectrum antibiotics is crucial as it helps to minimize unnecessary prolonged antibiotics exposure in this era of antimicrobial resistance. In patients with frequent relapses, a slow corticosteroid taper could be beneficial.

Tracheomediastinal Fistula: Rare Complication of Treatment with Bevacizumab.

Tracheomediastinal fistula is a rare condition caused by multiple etiologies. We present a case of a patient of lung carcinoma receiving chemotherapy. A 63-year-old woman presented to the emergency room with a two-month history of worsening cough and shortness of breath. She was being treated with pemetrexed and bevacizumab for Stage IV non-small cell lung carcinoma. Chest X-ray showed a mass in the lung with mediastinal adenopathy. Computed tomography (CT) scan showed a perforation, confirmed with bronchoscopy. She had a secondary infection and she was started on intravenous antibiotics. The patient decided to continue care in a hospice. We present a rare complication of bevacizumab which has been only reported once in literature. Bevacizumab is known to cause tracheal fistulas when coupled with like invasive procedures. In our case, the patient developed a fistula without any invasive interventions. We advise that physicians using bevacizumab should be aware of the possibility of having such fistulas.

Upper Gastrointestinal Bleeding as a Manifestation of Metastasis from Laryngeal Cancer.

Upper gastrointestinal (GI) bleeding can be a rare manifestation of primary or metastatic tumor in the stomach. Tumors that commonly metastasize to stomach include breast, lung, and malignant melanoma. Laryngeal cancer usually metastasizes to the lung and cervical spine. We report the first case of upper GI bleed as a manifestation of laryngeal cancer in the stomach.

Idiopathic bilateral adrenal hemorrhage in a 63-year-old male: a case report and review of the literature.

Adrenal hemorrhage is a largely uncommon condition typically caused by a number of factors including infection, MI, CHF, anticoagulants, trauma, surgery, and antiphospholipid syndrome. Yet, idiopathic bilateral hemorrhage is rare. The authors present a case of a 63-year-old male who presented with abdominal pain that was eventually diagnosed as bilateral adrenal hemorrhages due to an unknown origin. Abdominal CT revealed normal adrenal glands without enlargement, but an MRI displayed enlargement due to hemorrhage in both adrenals. There was no known cause; the patient had not suffered from an acute infection and was not on anticoagulants, and the patient's history did not reveal any of the other known causative factors. The case underscores the importance of keeping bilateral adrenal hemorrhages on the list of differentials even when a cause is not immediately clear. It also raises the question of whether CT is the most sensitive test in the diagnosis of adrenal hemorrhage and whether the diagnostic approach should place greater weight on MRI. The case highlights the need for prompt therapy with steroids once bilateral hemorrhage is suspected to avert the development or progression of adrenal insufficiency.

Wire in the heart: fracture and fragment embolization of retrievable inferior vena cava filter into the right ventricle.

We report a case of a 58-year-old female who was found to have a fractured limb of her IVC filter in her right ventricle during a cardiac catheterization. A 25 mm radioopaque thin linear structure was seen in the proximal portion of the right ventricle. It was fixed and did not migrate or change position during investigations. On fluoroscopy, the IVC filter was observed in an appropriate location in the midabdomen. Yet, fractures of at least two of the metal filamentous legs of the IVC device were noticed. The patient was made aware of the many risks associated with filter removal. Due to the high risks of the procedure, she refused surgery and the filter fragment was not removed. We present this case to underscore the potential complications of IVC filters.