Multilevel stenting of malignant colonic obstructions from multilevel breast cancer colonic metastasis.

Video 1A video depicting the enclosed case, procedure, and discussion.

Acute Liver Failure in Hemophagocytic Lymphohistiocytosis Secondary to Metastatic Renal Cell Carcinoma: A Diagnostic Dilemma.

Hemophagocytic lymphohistiocytosis (HLH) is an aggressive hematologic disorder involving hyperstimulation of immune responses and severe inflammation. HLH has been well documented in lymphoid cancers and leukemias, but more rarely in solid tumors. The non-specific clinical characteristics of HLH can cause a diagnostic dilemma and delay in proper treatment, resulting in poor outcomes. We present a case of a patient with metastatic renal cell carcinoma who developed unexplained acute liver failure and was later found to have HLH. This case highlights the importance of including this syndrome on the differential diagnosis for acute liver failure of indeterminate cause and cytopenia in the setting of malignancy to facilitate proper timely treatment to improve outcomes and increase odds of survival.

Novel Iatrogenic Cause of Cholecystogastric Fistula.

Cholecystogastric fistula (CGF) is a rare, abnormal communication between the gallbladder and the stomach that can be identified on abdominal computed tomography (CT) and confirmed via endoscopy. CGFs are not usually problematic. However, they can cause fatal complications. We present a case of an adult patient with a history of percutaneous cholecystostomy (PC) presenting with non-specific gastrointestinal (GI) symptoms and found to have an iatrogenic CGF. The fistula is believed to be secondary to the PC tube. CGF from PC has not been described in the literature before.

New Model for Osteoporosis Risk Screening Using Emergency Department Visits.

Background Even though osteoporosis is the most common bone disease in the United States, it is frequently underscreened and underdiagnosed. In this study, we aimed to utilize the Emergency Department to conduct preemptive osteoporosis risk screening and assess the risk associated with gender and race based on a statistical analysis of survey responses. Methodology Patients >40 years of age presenting at two Emergency Departments were eligible. Consenting patients were asked questions from a modified One-Minute Osteoporosis Risk Test. Modifiable, fixed, and total (modifiable risks + fixed risks) risk sums were calculated. For the association test, chi-square and Wilcoxon rank-sum tests were used. Four total risk categories were created (0-1, 2-3, 4-5, 6+). Odds of being in a higher risk category were analyzed using univariate ordinal logistic regression. Results The prevalence of both a fixed and modifiable risk was 62.2%. Women were more likely than men to report a risk (81.2% vs. 67.5%; p = 0.0043) and to be in a higher risk category (odds ratio (OR) [95% confidence interval (CI)] = 1.63 [1.09-2.45]; p = 0.018). Evidence strongly indicated an unadjusted association of race and modifiable risk category (p < 0.001), with more than half of African Americans (53.0%) in the highest category compared to 26.0% of whites. The total risk was higher in African Americans than whites (OR [95% CI] = 1.75 [1.15-2.67]; p = 0.010). Conclusions Race and gender were associated with specific risk factors. The Emergency Department proved to be a feasible location for conducting health maintenance screenings and should be considered for patient-specific routine osteoporosis risk screenings.

A Rare Case of Gastric Intramural Hematoma in Recurrent Leukemia.

Gastric intramural hematoma (GIH) is a rare disorder that usually arises secondary to another condition or intervention, and less often occurs without an identifiable cause. Computed tomography (CT), as performed in this case, is the diagnostic modality of choice. The treatment comprises conservative measures, a minimally invasive approach, or surgical intervention. We present a case of recurrent acute lymphoblastic leukemia (ALL) as a new etiology for GIH that was managed conservatively to highlight the importance of including GIH in the differential for a patient with ALL, a drop in hemoglobin level, and vague gastrointestinal symptoms.

Clinical characteristics and symptom duration among outpatients with COVID-19.

BACKGROUND: Approximately 80% of people with COVID-19 do not require hospitalization. Studies examining the outpatient experience have not tracked symptoms to resolution leading to unknown expected symptom duration. Our objectives were to (1) determine symptom duration among patients with COVID-19 who do not require hospitalization and (2) identify potential risk factors associated with prolonged symptom duration. DESIGN: This is a retrospective cohort study conducted across an academic healthcare system including adult patients with laboratory-confirmed SARS-CoV-2 infection between March 18th and April 28th, 2020 who were not hospitalized. Symptom duration encompassed time from patient-reported symptom onset as documented in the chart until documented symptom resolution. We calculated the median symptom duration and tested if demographics, comorbidities, or reported symptoms were associated with symptom duration. KEY RESULTS: Of 294 patients meeting inclusion criteria, 178 (60.5%) had documented symptom resolution. The median [interquartile range (IQR)] symptom duration for included patients was 15 (8-24) days. No associations were found between comorbidities and symptom duration. Factors associated with prolonged symptom duration were presence vs lack of lower respiratory symptoms [median (IQR) 16.5 (10.75-33.5) vs 14.5 (7-21.75) days respectively, P < .001] and neurologic symptoms [median (IQR) 17 (9-28) vs 9.5 (4-17) days, P < .001] at disease onset. CONCLUSIONS: The median symptom duration in outpatients is 15 days and over 25% of patients have symptoms longer than 21 days.

Elucidating the Causes of Improved Survival in Clinical Trials of Randomized Adjuvant Pancreatic Ductal Adenocarcinoma (PDAC).

BACKGROUND: Overall survival (OS) has increased in recent adjuvant clinical trials of pancreatic ductal adenocarcinoma (PDAC). Although oncologists have taken notice, the root causes have not been fully examined. METHODS: All phase 3 adjuvant PDAC clinical trials were screened (n = 13), and eight trials (2007-2019) that met a study requirement of having a gemcitabine monotherapy arm to serve as a uniform comparative anchor across trials were identified. Patient enrollment eligibility criteria were compared across trials and categorized as tumor- or patient-related factors. Disease-free survival (DFS) and OS in the gemcitabine-only and non-gemcitabine arms were plotted and compared over time using linear regression. RESULTS: In the non-gemcitabine arms, OS increased over time, but the slope did not achieve statistical significance (p = 0.0815). Interestingly, OS improved for patients receiving only gemcitabine (slope, 1.99 months; p = 0.0018), whereas DFS remained constant (p = 0.897). Carbohydrate antigen (CA) 19-9 values and pathologic profiles of tumors were only marginally different across all cohorts. Recent adjuvant trials had stricter inclusion criteria (i.e., more patients were excluded for medical reasons; linear regression, p = 0.010). CONCLUSION: Survival for patients with resected PDAC has roughly doubled in phase 3 adjuvant trials during the past decade. Improved outcomes likely are attributable to improved adjuvant therapeutic regimens, but also reflect healthier patients enrolled in the more recent trials.

MRI does not predict pathologic complete response after neoadjuvant chemotherapy for breast cancer.

BACKGROUND: This study assessed whether magnetic resonance imaging (MRI) could accurately predict pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) for patients receiving standardized treatment, pre- and post-NAC MRI on the same instrumentation using a consistent imaging protocol, interpreted by a single breast fellowship-trained radiologist. METHODS: A single-institution retrospective analysis was performed including clinical, radiographic, and pathologic parameters for all patients with breast cancer treated with NAC from 2015 to 2018. Radiographic complete response (rCR) was defined as absence of suspicious MRI findings in the ipsilateral breast or lymph nodes. pCR was defined as the absence of invasive cancer or ductal carcinoma in-situ in breast or lymph nodes after operation (ypT0N0M0). RESULTS: Data for 102 consecutive patients demonstrated that 44 (43.1%) had rCR and 41 (40.1%) had pCR. pCR occurred in 12 (25.0%) of 48 estrogen receptor positive (ER+) patients, 29 (53.7%) of 54 ER- patients, and 25 (52.1%) of 48 human epidermal growth factor receptor 2 positive patients. The positive predictive value for MRI after NAC was 84.5% and the negative predictive value was 72.7%. The accuracy rate for MRI was 78.6%. Of the 44 patients with rCR, 12 (27.3%) had residual cancer on the pathologic specimen after surgical excision. CONCLUSION: rCR is not accurate enough to serve as a surrogate marker for pCR on MRI after NAC.