Baptist Medical Center Research Articles

Clinical Characteristics of Patients With Renal Cell Carcinoma and Metastasis to the Thyroid Gland.

Introduction:Renal cell carcinoma (RCC) is the most common malignancy to metastasize to the thyroid gland. The aims of this study are as follows: (1) to analyze the clinical characteristics of patients with thyroid involvement of RCC and (2) in patients with RCC thyroid metastasis, to determine whether RCC metastasis to glandular organs only portends a better prognosis compared with other patterns of RCC metastasis.Methods:Patients from Wake Forest Baptist Medical Center (WFBMC) diagnosed with thyroid metastasis from RCC were identified and medical records retrospectively examined. A systematic review of the literature for cases of RCC involving the thyroid gland was also performed. The clinical characteristics of the institutional cohort and the cases from the literature review were compared. Descriptive statistical analysis was performed, and overall survival (OS) was summarized using Kaplan-Meier methods.Results:The median OS for the WFBMC cohort was 56.4 months. In the literature review cohort, OS of patients with RCC thyroid metastasis was 213.6 months, and there was no statistically significant survival difference based on the site of metastasis. Median survival after thyroid metastasis from RCC for the WFBMC and literature cohort was 21.6 and 45.6 months, respectively.Conclusions:Metastatic RCC should be included in the differential of a new thyroid mass. Treatment directed at the thyroid metastasis results in prolonged survival in some cases. Further analysis into the genomic differences and mechanisms of thyroid metastasis is warranted.

Donor Intervention Research.

Donor Intervention Research.

Relational Network for Knowledge Discovery through Heterogeneous Biomedical and Clinical Features.

Biomedical big data, as a whole, covers numerous features, while each dataset specifically delineates part of them. “Full feature spectrum” knowledge discovery across heterogeneous data sources remains a major challenge. We developed a method called bootstrapping for unified feature association measurement (BUFAM) for pairwise association analysis, and relational dependency network (RDN) modeling for global module detection on features across breast cancer cohorts. Discovered knowledge was cross-validated using data from Wake Forest Baptist Medical Center’s electronic medical records and annotated with BioCarta signaling signatures. The clinical potential of the discovered modules was exhibited by stratifying patients for drug responses. A series of discovered associations provided new insights into breast cancer, such as the effects of patient’s cultural background on preferences for surgical procedure. We also discovered two groups of highly associated features, the HER2 and the ER modules, each of which described how phenotypes were associated with molecular signatures, diagnostic features, and clinical decisions. The discovered “ER module”, which was dominated by cancer immunity, was used as an example for patient stratification and prediction of drug responses to tamoxifen and chemotherapy. BUFAM-derived RDN modeling demonstrated unique ability to discover clinically meaningful and actionable knowledge across highly heterogeneous biomedical big data sets.

Standardized Rehabilitation and Hospital Length of Stay Among Patients With Acute Respiratory Failure

Physical rehabilitation in the intensive care unit (ICU) may improve the outcomes of patients with acute respiratory failure. To compare standardized rehabilitation therapy (SRT) to usual ICU care in acute respiratory failure. Single-center, randomized clinical trial at Wake Forest Baptist Medical Center, North Carolina. Adult patients (mean age, 58 years; women, 55%) admitted to the ICU with acute respiratory failure requiring mechanical ventilation were randomized to SRT (n=150) or usual care (n=150) from October 2009 through May 2014 with 6-month follow-up. Patients in the SRT group received daily therapy until hospital discharge, consisting of passive range of motion, physical therapy, and progressive resistance exercise. The usual care group received weekday physical therapy when ordered by the clinical team. For the SRT group, the median (interquartile range [IQR]) days of delivery of therapy were 8.0 (5.0-14.0) for passive range of motion, 5.0 (3.0-8.0) for physical therapy, and 3.0 (1.0-5.0) for progressive resistance exercise. The median days of delivery of physical therapy for the usual care group was 1.0 (IQR, 0.0-8.0). Both groups underwent assessor-blinded testing at ICU and hospital discharge and at 2, 4, and 6 months. The primary outcome was hospital length of stay (LOS). Secondary outcomes were ventilator days, ICU days, Short Physical Performance Battery (SPPB) score, 36-item Short-Form Health Surveys (SF-36) for physical and mental health and physical function scale score, Functional Performance Inventory (FPI) score, Mini-Mental State Examination (MMSE) score, and handgrip and handheld dynamometer strength. Among 300 randomized patients, the median hospital LOS was 10 days (IQR, 6 to 17) for the SRT group and 10 days (IQR, 7 to 16) for the usual care group (median difference, 0 [95% CI, -1.5 to 3], P = .41). There was no difference in duration of ventilation or ICU care. There was no effect at 6 months for handgrip (difference, 2.0 kg [95% CI, -1.3 to 5.4], P = .23) and handheld dynamometer strength (difference, 0.4 lb [95% CI, -2.9 to 3.7], P = .82), SF-36 physical health score (difference, 3.4 [95% CI, -0.02 to 7.0], P = .05), SF-36 mental health score (difference, 2.4 [95% CI, -1.2 to 6.0], P = .19), or MMSE score (difference, 0.6 [95% CI, -0.2 to 1.4], P = .17). There were higher scores at 6 months in the SRT group for the SPPB score (difference, 1.1 [95% CI, 0.04 to 2.1, P = .04), SF-36 physical function scale score (difference, 12.2 [95% CI, 3.8 to 20.7], P = .001), and the FPI score (difference, 0.2 [95% CI, 0.04 to 0.4], P = .02). Among patients hospitalized with acute respiratory failure, SRT compared with usual care did not decrease hospital LOS. clinicaltrials.gov Identifier: NCT00976833.

Presentation Number 29 - Preventing Healthcare Associated Blood Stream Infections Among Patients Suspected of Line Manipulation

Robyn Kay, MPH, CIC, Clinical Epidemiologist, Baptist Medical Center Jacksonville; Michelle Cox, RN, BSN, Clinical Nurse Manager, Baptist Medical Center; Blanca I. McKean, MSN, RN, NE-BC, Director of Adult Tower, Critical Care, Bariatrics, Orthopedics, Baptist Medical Center Jacksonville; Jacqueline Gunning, RN, MSN, Clinical Nurse Manager of Behavioral Health Inpatient, Baptist Medical Center; Nan Hucker, LMHC, Manager of IOP/PHP, Baptist Medical Center; Kenneth Meyer, MD, Infectious Disease Hospital Epidemiologist, Baptist Medical Center; Mary Elizabeth Briand, Pharm. D., BCPSAQ ID, CNSC, Clinical Pharmacist, Bapstist Medical Center

Risk of early mortality after placement of a temporary-permanent pacemaker

BackgroundTemporary-permanent pacemakers [TPPM] are externally placed permanent generators attached to active fixation transvenous leads. TPPM can be used as an alternative to standard temporary pacing leads when placement of a permanent pacemaker is contraindicated. We sought to determine the incidence and risk factors for early (within 6months) mortality after placement of a TPPM. MethodsElectronic medical records were used to extract baseline characteristics for 152 patients from Wake Forest Baptist Medical Center who had a TPPM placed between the years 2007 and 2012. Multivariable adjusted Cox proportional hazard models were used to estimate hazard ratios [HR] and 95% confidence intervals [C]) for baseline characteristics [age, sex, race, hypertension, diabetes, heart failure, coronary artery disease, smoking, dyslipidemia, chronic kidney disease [CKD], and indication for pacemaker] on early mortality. ResultsOf the 152 patients [mean age 68.9years; 57.2% female; 86.8% white], 45 [29.6%] died within the first 6months after TPPM placement. No deaths occurred as a direct result of TPPM placement, and only 1 patient experienced documented non-fatal complications. Maximum time to PPM from the date of insertion of TPPM was 336days. Using a backward multivariable adjusted hazard regression model, independent risk factors for early mortality were pre-existing CKD [HR (95% CI): 2.240 (1.002–5.010) for eGFR 30–59 and 7.645 (3.594–16.263) for eGFR <30 compared to eGFR >60] and history of smoking [HR (95% CI): 2.015 (1.099–3.696)]. Surprisingly, dyslipidemia was protective of early mortality [HR (95%CI): 0.470 (0.240–0.924)]. ConclusionTPPM placement is a safe procedure with rare direct complications. CKD and smoking are predictive of increased risk for early mortality in patients undergoing TPPM placement.

Medical errors: Disclosure styles, interpersonal forgiveness, and outcomes

RationaleThis study investigates the intrapersonal and interpersonal factors and processes that are associated with patient forgiveness of a provider in the aftermath of a harmful medical error. ObjectiveThis study aims to examine what antecedents are most predictive of patient forgiveness and non-forgiveness, and the extent to which social-cognitive factors (i.e., fault attributions, empathy, rumination) influence the forgiveness process. Furthermore, the study evaluates the role of different disclosure styles in two different forgiveness models, and measures their respective causal outcomes. MethodsIn January 2011, 318 outpatients at Wake Forest Baptist Medical Center in the United States were randomly assigned to three hypothetical error disclosure vignettes that operationalized verbally effective disclosures with different nonverbal disclosure styles (i.e., high nonverbal involvement, low nonverbal involvement, written disclosure vignette without nonverbal information). All patients responded to the same forgiveness-related self-report measures after having been exposed to one of the vignettes. ResultsThe results favored the proximity model of interpersonal forgiveness, which implies that factors more proximal in time to the act of forgiving (i.e., patient rumination and empathy for the offender) are more predictive of forgiveness and non-forgiveness than less proximal factors (e.g., relationship variables and offense-related factors such as the presence or absence of an apology). Patients' fault attributions had no effect on their forgiveness across conditions. The results evidenced sizeable effects of physician nonverbal involvement-patients in the low nonverbal involvement condition perceived the error as more severe, experienced the physician's apology as less sincere, were more likely to blame the physician, felt less empathy, ruminated more about the error, were less likely to forgive and more likely to avoid the physician, reported less closeness, trust, and satisfaction but higher distress, were more likely to change doctors, less compliant, and more likely to seek legal advice. ConclusionThe findings of this study imply that physician nonverbal involvement during error disclosures stimulates a healing mechanism for patients and the physician-patient relationship. Physicians who disclose a medical error in a nonverbally uninvolved way, on the other hand, carry a higher malpractice risk and are less likely to promote healthy, reconciliatory outcomes.

Abstract TP398: Telestroke: Expanding the Utilization of Endovascular Treatment

Background: The Comprehensive Stroke Center at Wake Forest Baptist Medical Center in Winston-Salem, N.C. implemented a telestroke network system in January of 2010 to provide 24/7 access to one of their board certified vascular neurologists. There are presently fourteen hospitals in the network with over 1900 consults and a tPA administration rate of 42%. In early 2015, positive results from four stroke interventional trials showed that recanalization rates were much higher after stent retrieval compared with tPA alone. It was shown that these devices can safely and effectively remove a blood clot that is causing a stroke, with improved clinical outcomes over IV tPA alone. Wake Forest Baptist has made the commitment to expand the use of intraarterial therapy to give every telestroke patient with a large vessel occlusion an opportunity to experience the outstanding clinical outcomes that have been seen in stroke patients treated at their medical center. The following guidelines were developed to assist the network physician in determining when to consider interventional treatment: - The time from onset is less than 6 hrs. (up to 12 hrs. in a suspected basilar artery stroke) - A NIHSS score equal to or greater than 10 (indicating large vessel occlusion) Method: Education was provided regarding the new interventional treatment guidelines and for quick reference, the protocol was placed on the screen of the telestroke robot/cart in each of the network hospitals and a cell phone number was provided that gave 24/7 access to communicate with the neurointerventionalist on call. A retrospective study was performed to determine if there had been an increase in patient transfers for an interventional procedure. Results: In FY'14, 14 of 139 patients (10%) transferred received an IR procedure and in FY'15, 26 of 146 (17%) patients received an IR procedure. An increase of 7% was identified in telestroke patients that were transferred and underwent an interventional treatment. A combination of providing guidelines regarding when to consider interventional treatment as well as 24/7 access to a neurointerventionalist has significantly increased number of telestroke patients receiving interventional treatment.

Abstract B32: Serum calcium and serum albumin can discriminate malignant from benign pelvic masses.

Abstract Background: Biomarkers that aid in the differential diagnosis of malignant pelvic masses from benign ones prior to surgery are needed in order to triage women with malignant masses to appropriate specialist care. Because high albumin-adjusted serum calcium predicted ovarian cancer among women without evidence of disease, we hypothesized that it might predict cancer among women with pelvic masses that were evident radiographically. Methods: We studied a cohort of 514 women with pelvic masses who underwent resection at Wake Forest University Baptist Medical Center from July 2009 through June 2013. We divided patients into a “training” set, to identify associations in the data, and a “testing” set, to confirm them. Data were obtained from medical records. A best fit model was selected using the Akaike Information Criterion. Results: Albumin-adjusted serum calcium was significantly higher in women with malignant vs. benign masses (P= 0.0004). High normocalcemia, i.e., an albumin-adjusted serum calcium ≥ 10 mg/dL, occurred in 53% of women with malignant tumors vs. 12% of benign tumors. High normocalcemia was associated with a ~14-fold increased risk of malignancy. The best fit model (Overall) included albumin, calcium, and non-linear terms. Overall achieved an AUC of 0.83 with a sensitivity of 72% and specificity of 83%, a PPV of 71% and a NPV of 85%. Conclusions: A model using serum calcium and serum albumin to predict malignancy in women with pelvic masses has high sensitivity and is economical. Impact: Our model can help triage women with ovarian cancer to appropriate surgical care. Citation Format: Gary G. Schwartz, Michael G. Kelly, Stuart S. Winkler, Samuel S. Lentz, Steve H. Berliner, Melissa F. Swain, Halcyon G. Skinner. Serum calcium and serum albumin can discriminate malignant from benign pelvic masses. [abstract]. In: Proceedings of the AACR Special Conference on Advances in Ovarian Cancer Research: Exploiting Vulnerabilities; Oct 17-20, 2015; Orlando, FL. Philadelphia (PA): AACR; Clin Cancer Res 2016;22(2 Suppl):Abstract nr B32.

Serum Calcium and Serum Albumin Are Biomarkers That Can Discriminate Malignant from Benign Pelvic Masses

Biomarkers that aid in the differential diagnosis of malignant pelvic masses from benign ones prior to surgery are needed in order to triage women with malignant masses to appropriate specialist care. Because high albumin-adjusted serum calcium predicted ovarian cancer among women without evidence of disease, we hypothesized that it might predict cancer among women with pelvic masses that were evident radiographically. We studied a cohort of 514 women with pelvic masses who underwent resection at Wake Forest University Baptist Medical Center from July 2009 through June 2013. We divided patients into a "training" set, to identify associations in the data, and a "testing" set, to confirm them. Data were obtained from medical records. A best fit model was selected using the Akaike Information Criterion. Albumin-adjusted serum calcium was significantly higher in women with malignant versus benign masses (P = 0.0004). High normocalcemia, i.e., an albumin-adjusted serum calcium ≥ 10 mg/dL, occurred in 53% of women with malignant tumors versus 12% of benign tumors. High normocalcemia was associated with an approximately 14-fold increased risk of malignancy. The best fit model (Overa) included albumin, calcium, and nonlinear terms. Overa achieved an area under the curve of 0.83 with a sensitivity of 72% and specificity of 83%, a positive predictive value of 71% and a negative predictive value of 85%. A model using serum calcium and serum albumin to predict malignancy in women with pelvic masses has high sensitivity and is economical. Our model can help triage women with ovarian cancer to appropriate surgical care.

Abstract A84: Rural residence and late staging at breast cancer diagnosis

Abstract Rural residing residents in the United States are medically under-served which may contribute to the late stage presentation of breast cancer, a major determinant of prognosis in breast cancer. We sought to determine if women from more rural residing communities presented to an academic medical center with later stage cancers than those women who live in more urbanized areas. We also determined if the cancers from the two communities were biologically similar by comparing the distribution of estrogen receptors (ER + vs. ER-). From the cancer registry at Wake Forest Baptist Medical Center we identified newly diagnosed female breast cancer cases between 1999-2013 (N = 3,372) who lived in the Piedmont and Appalachian Mountain regions of North Carolina and Virginia. These cases were characterized by urban-rural status at diagnosis to the level of ZIP code. Using both a linear model and a Cochran-Armitage trend test , women from rural areas presented with a more advanced clinical stage (stage 3 incidence 17.8% vs 15.6%, p 0.051). This trend remained roughly significant when we controlled for age at diagnosis (p 0.04), ER status (0.05), insurance status (0.06), and healthcare access (p 0.06). However, the difference became insignificant when we controlled for local poverty (p 0.12) and unemployment (p 0.13) levels within the individual ZIP-defined communities. Overall, we did not find large differences in the stage of presentation between urban and rural residing women. However, the trend that was found could be largely accounted for by measures of local poverty and unemployment, suggesting that communities may be identified for tailored educational or outreach efforts. Citation Format: Thomas W. Lycan, Jr., Scott Isom, Julia Lawrence. Rural residence and late staging at breast cancer diagnosis. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr A84.

Repeat Radiosurgery for Trigeminal Neuralgia.

Repeat Gamma Knife radiosurgery (GKRS) is an established option for patients whose pain has recurred after the initial procedure, with reported success rates varying from 68% to 95%. Predictive factors for response to the repeat GKRS are ill-defined. This cohort study aimed to report the outcomes and factors predictive of success for patients who have undergone repeated GKRS for trigeminal neuralgia at Wake Forest University Baptist Medical Center. Between 1999 and 2013, 152 patients underwent repeat GKRS at Wake Forest, 125 of whom were available for long-term follow-up. A retrospective chart review and telephone interviews were conducted to determine background medical history, dosimetric data, outcomes, and adverse effects of the procedure. Eighty-four percent of patients achieved at least Barrow Neurological Institute (BNI) IIIb pain relief, with 46% achieving BNI I. The 1-, 3-, and 5-year rates of BNI I pain relief were 63%, 50%, and 37%, respectively. The 1-, 3-, and 5-year rates of BNI IIIb or better pain relief were 74%, 59%, and 46%, respectively. One patient experienced bothersome numbness and 2 patients developed anesthesia dolorosa. The dominant predictive factors for pain relief were facial numbness after the first GKRS and a positive pain response to the first GKRS. Repeat GKRS is an effective method of treating recurrent trigeminal neuralgia. Patients who have facial numbness after the first treatment and a positive pain response to the first GKRS are significantly more likely to respond well to the second treatment.

Otopathogens Detected in Middle Ear Fluid Obtained during Tympanostomy Tube Insertion: Contrasting Purulent and Non-Purulent Effusions.

Otitis media is a prominent disease among children. Previous literature indicates that otitis media is a polymicrobial disease, with Haemophilus influenzae, Streptococcus pneumoniae, Alloiococcus otitidis and Moraxella catarrhalis being the most commonly associated bacterial pathogens. Recent literature suggests that introduction of pneumococcal conjugate vaccines has had an effect on the etiology of otitis media. Using a multiplex PCR procedure, we sought to investigate the presence of the aforementioned bacterial pathogens in middle ear fluid collected from children undergoing routine tympanostomy tube placement at Wake Forest Baptist Medical Center during the period between January 2011 and March 2014. In purulent effusions, one or more bacterial organisms were detected in ~90% of samples. Most often the presence of H. influenzae alone was detected in purulent effusions (32%; 10 of 31). In non-purulent effusions, the most prevalent organism detected was A. otitidis (26%; 63 of 245). Half of the non-purulent effusions had none of these otopathogens detected. In purulent and non-purulent effusions, the overall presence of S. pneumoniae was lower (19%; 6 of 31, and 4%; 9 of 245, respectively) than that of the other pathogens being identified. The ratio of the percentage of each otopathogen identified in purulent vs. non-purulent effusions was >1 for the classic otopathogens but not for A. otitidis.

Integration of lung cancer screening into practice is lacking.

Integration of lung cancer screening into practice is lacking.

Abstract T P339: Plan-Do-Study-Act Model Has Positive Impact on Dysphagia Screening in the Emergency Room

Background: Dysphagia is a serious complication of stroke, which can cause aspiration pneumonia leading to increased length of stay or death. Baptist Medical Center (BMC) is one of five Primary Stroke Center Certified hospitals in the Baptist Health System (BHS). In October 2013 it was noted that BMC dysphagia screen measure results had trended downward to be the lowest in the system. Purpose: The purpose of this abstract is to outline actions taken to address the documentation of the dysphagia screen in the emergency room (ER) at BMC. Methods: An analysis of BMC’s dysphagia screen fall outs revealed four contributing factors for this quality measure including: no screen completed (34%), oral intake prior to the screen (38%), a delay in stroke diagnosis 22%) or incomplete documentation (6%). Initially the dysphagia screen was completed on paper while the rest of the ER documentation was completed in the electronic medical record (EMR). In October a performance improvement effort was implemented using a Plan-Do-Study-Act Model (PDSA). Initial changes included placing dysphagia screening forms in each room for easier access, 1:1 teaching with staff for fall outs, and designating a nurse Stroke Champion. Inconsistent improvement was seen so dysphasia documentation was add to the EMR, a patient complaint list was developed and attached to each computer, and any patient with a Head CT order was automatically screened. In April, the directors started assigning a dysphagia screen education module to any staff member with 2 or more fallouts. The PDSA graph and action plan was posted in the ER and discussed during monthly staff meetings. Results: Dysphagia screen documentation in stroke patients in the ER at BMC improved from a low of 73.7% in October 2013 to 100% in May 2014. The drop in April 2014 to 88.5% was attributed to leadership changes and staff turnover. Conclusion: A focus on dysphagia improved the screening of stroke patients in the ER. The commitment to 1:1 teaching and further education emphasized the importance of screening. Dysphagia screening results will continue to be monitored, posted, and discussed monthly.

Recurrence score distributions in stage II colon cancers of African American (AA) and Caucasian (CA) patients.

613 Background: The 12-gene colon cancer assay (Oncotype DX) can identify groups of stage II colon cancer patients with lower or higher recurrence risk, but distribution of scores based on race/ethnicity has not been assessed. This study compared the distribution of Recurrence Score results and gene expression profiles between African American (AA) and Caucasian (CA) stage II colon cancer patients. Methods: Stage II colon cancer patients were identified from tumor registry data from four institutions: University of Arkansas for Medical Sciences, Little Rock; Veterans Administration Medical Center, Little Rock; Baptist Medical Center, Memphis, and University of Alabama at Birmingham. The 12-gene assay and mismatch repair (MMR) status were performed on formalin-fixed paraffin-embedded tissues by Genomic Health (Redwood City, CA). T-test and Wilcoxon test were used to compare data from the two groups (SAS Enterprise Guide 5.1). Results: Of the 244 subjects, there were 118 women (63 AA, 55 CA) and 126 men (59 AA, 67 CA). Median ages (years) were 66 for AAs and 68 for CAs. Age, gender, surgery year, pathologic T-Stage, tumor location, number of nodes examined, lympho-vascular invasion, and MMR status were not significantly different between groups (p&gt;0.05). Recurrence Score results between AAs (mean 27.9; SD 12.8) and CAs (mean 28.1; SD 11.8) were not statistically different (p&gt;0.05). The proportion of patients with high Recurrence Score values (≥41) was similar between the groups (17/122 AA; 15/122 CA). None of the gene expression variables, either single genes or gene groups, (cell cycle group, stromal group, BGN1, FAP, INHBA1, Ki67, MYBL2, cMYC3 and GADD45B) was significantly different between the racial groups (p&gt;0.05). After controlling for clinical and pathologic covariates, means and distributions of Recurrence Score and gene expression profiles still showed no statistical significance between racial groups (p&gt;0.05). Conclusions: In a cohort of AA and CA stage II colon cancer patients with similar clinical characteristics, the distribution of Recurrence Score results and gene expression data were similar between AA and CA patients.

Abstract 18942: Is Bilirubin Protective Against Anthracycline-induced Cardiomyopathy?

Introduction: Reductions in left ventricular ejection fraction (LVEF) may occur after the administration of anthracycline-based chemotherapeutic regimens. Oxidative stress at the myocellular level has been implicated in these reductions, and as a consequence, we hypothesized that bilirubin, an effective endogenous anti-oxidant, would ameliorate some of the reductions in LVEF associated with anthracyline administration. Methods: From 1/1/2002 to 12/31/2012, we identified 751 consecutive individuals who were treated with anthracyclines at Wake Forest Baptist Medical Center, received serial LVEF measures, and exhibited basal serum bilirubin levels &lt; 2mg/dl prior to their treatment for cancer. The correlation between pre-chemotherapy bilirubin levels and serial pre- to post-chemotherapy changes in LVEF was analyzed using linear regression models. For dose response analysis, the participants were divided into 3 groups based on their bilirubin levels. ANOVA was used to test for the difference in the mean LVEF change across groups. Tukey’s Studentized Range test was used in pairwise comparisons. Chi-square test was used for categorical variables. Results: There were 65 (35%), 86 (30%) and 68 (24%) participants whose LVEF decreased by more than 15% in Group 1 (bilirubin ≤0.5mg/dl), Group2 (bilirubin 0.6 - 0.8mg/dl) and Group 3 (bilirubin 0.9 - 1.9mg/dl) respectively (Table 1). On pairwise comparison, there was a significant decrease in LVEF between Group 1 and Group 3 (2.9, 95% CI: 0.15 - 5.7). After adjusting for age, BMI, race, CAD/MI, diabetes, hematocrit and medications; increased bilirubin and reduced BMI were associated with LVEF preservation (p = 0.028 and 0.033 respectively). Conclusions: In patients treated with anthracyclines, bilirubin level was negatively correlated with reduction in LVEF. These results have potential therapeutic implications for preserving left ventricular function in patients treated with anthracyclines.

Association of pain and itch with depth of invasion and inflammatory cell constitution in skin cancer: results of a large clinicopathologic study.

This study highlights a simple bedside evaluation of itch and pain for suspicious skin lesions. To examine the correlation of pain and itch with histologic features of skin cancers. This large, prospective, clinicopathologic study enrolled patients who filled out questionnaires that assessed itch and pain intensity of their skin tumors at the time of excision. Study participants were from the patient population presenting to the Department of Dermatology surgical unit at Wake Forest University Baptist Medical Center from July 1, 2010, through March 31, 2011. Study participants included 268 patients, representing 339 histopathologically confirmed cutaneous neoplasms. The following skin cancer subtypes were represented in this analysis: 166 basal cell carcinomas, 146 squamous cell carcinomas, and 27 melanomas. Itch and pain associated with skin cancer at the time of excision ranked on an 11-point (score range, 0-10) numerical visual analog scale and histopathologic analysis for each neoplasm (assessment of the amount and type of inflammation, ulceration, perineural invasion, and depth of invasion). The prevalence of itch and pain across all skin cancers was 36.9% and 28.2%, respectively. However, these symptoms were mostly absent in melanomas. Pain intensity was significantly associated with the degree of inflammation (mild or none vs moderate or marked; P < .001), presence of neutrophils in the inflammatory infiltrate (predominantly mononuclear vs mixed or neutrophilic; P = .003), presence of eosinophils (present vs absent; P = .007), ulceration (yes vs no; P = .003), perineural invasion (yes vs no; P < .001), depth of invasion (P = .001), and largest diameter length of skin lesion (P < .003). Itch intensity was significantly associated with the degree of inflammation (mild or none vs moderate or marked; P = .001) and the presence of eosinophils (present vs absent; P = .02). These findings support the theory that itch emanates from the upper layers of the skin, whereas pain is associated with deeper processes. This study also reports that a simple bedside assessment for the presence and intensity of pain or itch is an easily implementable tool for physicians evaluating suspicious skin lesions.

Abstract CT302: A phase II clinical trial of weekly paclitaxel and carboplatin in combination with panitumumab in metastatic or recurrent breast cancer patients with triple negative disease

Abstract Purpose: Metastatic triple negative breast cancer is an unmet need in oncology. A targeted therapy for triple negative breast cancer has not been found so metastases are treated with chemotherapy as a single agent or in combination. The epidermal growth factor receptor (EGFR) is frequently over-expressed in triple negative breast cancer. This EGFR receptor can be targeted with agents such as cetuximab or panitumumab. We designed a single-arm clinical trial to investigate the activity of panitumumab in combination with carboplatin and paclitaxel in women with triple negative breast cancer. Patients and Methods: Patients with metastatic disease and who had received no greater than one prior chemotherapy regimen were eligible for the study. Patients received paclitaxel 80mg/m^2 and carboplatin with AUC 2 on days 1, 8, and 15. In addition they received panitumumab 6mg/kg on days 1 and 15. The primary endpoint was overall response rate. We evaluated patients for toxicity prior to each cycle. We also subtyped the breast tumor specimens using microarray into basal-like, Her-2 enriched, luminal A, luminal B, and normal-like to assess for differential response to therapy among these subtypes. Results: We enrolled 14 patients into the study at two sites (Wake Forest University Baptist Medical Center and Ochsner Medical Center). The average age of enrolled patients was 54.1 years. Nine out of the 14 women were African American and 5 patients were Caucasian. The median number of cycles received by the cohort was 3.5 (1-9) with median time to progression of 98 days. Common grade 3 and 4 adverse events included lymphopenia in 5 patients and neutropenia in 9 patients. Seven participants experienced grade 1/2 mucositis and two participants had grade 3 mucositis. Seven patients experienced grade 1/2 acneiform rash. Response to therapy based on tumor subtype (basal-like, Her-2 enriched, luminal A, luminal B, or normal-like) will also be presented, data in progress. Conclusion: Adding the EGFR inhibitor panitumumab to carboplatin/paclitaxel was a well-tolerated and effective therapy for metastatic triple negative breast cancer. This combination could be most appropriate for certain subtypes of triple negative disease. Citation Format: Stacy Cowherd, Susan Melin, Steven Akman, John Cole, Julia Lawrence. A phase II clinical trial of weekly paclitaxel and carboplatin in combination with panitumumab in metastatic or recurrent breast cancer patients with triple negative disease. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr CT302. doi:10.1158/1538-7445.AM2014-CT302

Toxic Ingestion: Anion Gap Metabolic Acidosis Caused by Acute Salicylate Ingestion

OPEN ACCESSSeptember 26, 2014Toxic Ingestion: Anion Gap Metabolic Acidosis Caused by Acute Salicylate Ingestion Jennifer Mitzman, MD, Mary Wittler, MD Jennifer Mitzman, MD Wake Forest School of Medicine of Wake Forest Baptist Medical Center Google Scholar More articles by this author , Mary Wittler, MD Wake Forest School of Medicine of Wake Forest Baptist Medical Center Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.9893 SectionsAbout ToolsDownload Citations ShareFacebookTwitterEmail Abstract Introduction: This educational resource provides information and materials for a simulation case suitable for resident physicians in emergency medicine. The scenario has been used at our institution for the past year. Participants have included medical students, emergency medicine and general pediatrics residents in years 1-3 of postgraduate education, and pediatric emergency medicine fellows in years 4-6 of postgraduate education. Methods: This simulation involves a patient presenting to an emergency department with an anion gap metabolic acidosis secondary to acute salicylate ingestion. Evaluation in the emergency department reveals a tachycardic, tachypneic patient who requires aggressive fluid resuscitation. The patient also requires alkalinization with bicarbonate to halt the progression of the acidosis. Ultimately, levels obtained should prompt learners to admit the patient to the intensive care unit for dialysis. The case has been used with small groups of two to four learners in each session. Debriefing materials are provided to illustrate key concepts in recognition of anion gap metabolic acidosis and to stimulate discussion of the important treatment steps in acute salicylate ingestion. Typical timing for the case is approximately 20 minutes for the simulation and 20 minutes for debriefing. Results: Testing of this scenario has been accomplished via repetition with various learners. While this educational case has been used for simulation sessions as part of the didactic component of our residency and fellowship, it has not been validated as a formal assessments tool for evaluation of clinical competency. Discussion: Implementation of this case requires significant resources: a high-fidelity patient simulator, appropriate environment, medical equipment, and personnel to provide the educational experience for learners. The case requires one faculty or staff member capable of running the simulator and one faculty member with the required clinical expertise to facilitate the case and conduct the debriefing and educational session. We have used this case primarily for resident physician education in pediatrics and emergency medicine, as well as for fellows in pediatric emergency medicine. Medical students have participated at times in supporting provider roles but not as team leaders given the degree of difficulty of this case. Educational Objectives By the end of this simulation, learners will be able to: Demonstrate recognition of acute salicylate toxicity.Identify the need for fluid resuscitation.Interpret arterial blood gas and recognize acid-base disturbance.Understand the need to begin alkalinization and initiate bicarbonate. Sign up for the latest publications from MedEdPORTAL Add your email below FILES INCLUDEDReferencesRelatedDetails FILES INCLUDED Included in this publication: Instructor's Guide Aspirin Case.docx Simulation Template Acute Salicylate Ingestion.docx Appendix A Aspirin Case Labs and Imaging.ppt Appendix B Aspirin Debriefing Tool.pptx Appendix C Aspirin Case Evaluation Form.doc To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Download editor’s noteThis publication may contain technology or a display format that is no longer in use. CitationMitzman J, Wittler M. Toxic Ingestion: Anion Gap Metabolic Acidosis Caused by Acute Salicylate Ingestion. MedEdPORTAL. 2014;10:9893. https://doi.org/10.15766/mep_2374-8265.9893 Copyright & Permissions© 2014 Mitzman and Wittler. This is an open-access publication distributed under the terms of the Creative Commons Attribution-NonCommercial-Share Alike license.KeywordsEatingAcute PoisoningEditor's ChoiceSalicylatesIngestion Disclosures None to report. Funding/Support None to report. Loading ...