Diminished distal dorsal finger wrinkling in patients with sporadic inclusion body myositis

Sporadic Inclusion Body Myositis (IBM) is the most common acquired myopathy after the age of 45. Often there is a delay in diagnosis as the disease may be mistaken for other inflammatory myopathies and other neuromuscular disorders such as motor neuron disease. One of the hallmarks of the disease is distal finger flexor weakness but non-neurologists who see IBM may not have the expertise to make this assessment. Other clinical signs that require less expertise may be of value in identifying this disorder. We present three cases of patients with IBM who had loss of wrinkling of the dorsal distal interphalangeal joints of the fingers that was not seen in any control patients who had no finger flexor weakness. The loss of wrinkling of the dorsal distal interphalangeal joints of the fingers is an additional physical exam finding that could distinguish IBM from other neuromuscular disorders.

Anisocoria, An Unusual Physical Exam Finding Leading to a Concurrent Diagnosis of Cerebral Toxoplasmosis and HIV/AIDS

Cerebral toxoplasmosis is the most common opportunistic central nervous system (CNS) infection, affecting patients with advanced/untreated acquired immunodeficiency syndrome (AIDS). Cerebral toxoplasmosis is caused by the parasite Toxoplasma gondii typically and it usually occurs in immunecompromised patients with a CD4 count below 100cell/microL [1,2]. Left untreated, symptomatic patients can progress to coma within days to weeks, significantly increasing rates of this population’s morbidity and mortality. Cerebral toxoplasmosis is rarely encountered before the diagnosis of HIV infection is established, which is why seemingly benign neurological complaints can be easily overlooked.

Aortic Aneurysm: Clinical Findings, Diagnostic and Treatment

The aorta is the largest artery in the body and can have aneurysms, which are focal expansions of the vessel wall that can occur anywhere throughout the artery. These can be classified as thoracic, abdominal or thoracoabdominal aneurysms and can be caused by several etiologies, including degenerative, infectious, and genetic causes. Most aortic aneurysms are asymptomatic and are detected incidentally while looking for other primary diseases with a physical exam finding of a pulsatile mass, or with imaging such as ultrasound, computed tomography, x-rays, or magnetic resonance imaging. When symptoms are present, they are often nonspecific and occur due to inflammation, rapid expansion, compression/erosion of the aneurysm into surrounding structures, or rupture. Uncontrolled aortic aneurysms can lead to fatal outcomes, thus making proper management essential. Management can range from medical treatment to surgical repair based on location, size, rate of expansion, and presence of symptoms.

The Feasibility of Virtual Toxicity Assessments in Lymphoma Patients Receiving Immunochemotherapy

Background: In recent years, there has been a growing interest in telemedicine initiatives that maximize outcomes, reduce healthcare costs, and improve quality. The COVID-19 pandemic reduced healthcare access for many patients, including those undergoing chemotherapy, and thus accelerated these initiatives. We sought to evaluate the potential utility of telemedicine initiatives for lymphoma patients undergoing immunochemotherapy. Methods: To address this question, we conducted a retrospective review of adult lymphoma patients receiving R-CHOP +/- R, R-ICE, R-GEMOX, and R-DHAP at our institution in the last three years (2017-2019), and identified those for which dose modifications were required. Dose modifications were defined as a change in prescribed dose from the preceding cycle, or a change in the administered dose by 10% or greater. Laboratory results, patient history, and/or physical exam findings that informed dose modifications were retrospectively identified. Results: Of the 1,290 total treatment cycles identified in 301 unique patients, 1,102 cycles (85.4%) were R-CHOP +/- R, 105 (8.1%) were R-ICE, 71 (5.5%) were R-GEMOX, and 12 (0.9%) were R-DHAP. We found that 144 cycles (11.2%) were subject to dosing adjustments. The cohort of patients that received dose adjustments was comprised of 104 unique patients, of which 87 (60.4%) were male and 57 (39.6%) were female. Average age at diagnosis was 64 years old (Range: 22-91). Our cohort represented greater than 10 different lymphoma subtypes, most commonly Diffuse Large B-cell lymphoma (66.3%), Follicular lymphoma (14.5%), and Peripheral T-cell lymphomas (7.7%). We examined the basis for each dose adjustment by reviewing the clinical records from visits immediately preceding the dose adjusted cycle. Of the 144 dose adjustments, 11% of cycles contained dose increases due to a well-tolerated previous dose noted in the clinical assessment based on a combination of laboratory findings, interim history, and physical exam. The remaining 89% of adjustments (n=128) were dose reductions. The decision to dose reduce was most commonly informed by the clinical history (n=104, 81%). The clinical history was dichotomized into newly reported patient symptoms (69/104) or interim complications (35/104), usually infectious (n=26). Clinical assessments utilized laboratory findings as a rationale for dose reductions in 33/128 (26%) of cycles, most of which were secondary to myelosuppression (28/33 cycles). In contrast, only 7/128 dose reductions were based on physical exam findings alone, all of which were due to a change in patient body weight. As patients are routinely weighed immediately prior to chemotherapy administration, effectively no dose modifications (0/144) were exclusively based on abnormal physical exam finding during a pre-infusion assessment. Conclusions: The inability to perform a complete physical exam is a notable limitation of telemedicine initiatives. However, in an unselected group of lymphoma patients treated with immunochemotherapy, who subsequently had dose reductions to their regimens, we have found that all of the dose modifications were based on laboratory findings or the patient history, both of which are amenable to virtual visits. In stark contrast, no dose modifications were prompted by an abnormal physical exam finding alone. While further studies are needed, the data reviewed supports the implementation of telemedicine initiatives in lymphoma patients undergoing immunochemotherapy during the pandemic and potentially long term. Disclosures Phillips: Karyopharm: Consultancy; AstraZeneca: Consultancy; Beigene: Consultancy; Abbvie: Consultancy, Research Funding; Pharmacyclics: Consultancy; Bayer: Consultancy, Research Funding; BMS: Consultancy; Incyte: Consultancy, Other: travel expenses; Seattle Genetics: Consultancy; Cardinal Health: Consultancy.

Adherence to national paediatric bronchiolitis management guidelines and impact on emergency department resource utilization

Objective To evaluate the association between the use of nonrecommended pharmacology (salbutamol and corticosteroids) per national bronchiolitis guidelines, either during the index visit or at discharge, and system utilization measures (frequency of return visits [RTED] and on paediatric emergency department [PED] length of stay [LOS]). Study Design We conducted a retrospective case control study of 185 infants (≤12 months old) who presented to the PED between December 2014 and April 2017 and discharged home with a clinical diagnosis of bronchiolitis. Inclusion criteria included ≥ 1 viral prodromal symptom and ≥ 1 physical exam finding of respiratory distress. Cases were defined as infants who had ≥ 1 RTED within 7 days of their index visit and controls were matched for age and acuity but without RTED. Logistic regression analysis and multivariable linear regression were used to assess the odds of RTED and PED LOS associated with nonadherence to pharmaceutical recommendations per AAP and CPS bronchiolitis guidelines. Results Use of nonrecommended pharmacology per national bronchiolitis guidelines was documented among 39% of the 185 study participants. Adjusting for acuity of index visit, age, severe tachypnea, oxygen desaturation, and dehydration, use of nonrecommended pharmacology was not associated with RTED (odds ratio [OR]: 0.98, 95% confidence interval [CI]: 0.47 to 2.03). Use of salbutamol and corticosteroids, however, were each independently associated with increased PED LOS (58.3 minutes [P=0.01] and 116.7 minutes [P<0.001], respectively). Conclusion Nonadherence to the pharmaceutical recommendations of national bronchiolitis guidelines was not associated with RTED but salbutamol and corticosteroid use increased PED LOS.

Prostate Calculi Causing Crepitus on Physical Exam

Crepitus on digital rectal examination is a rare physical exam finding, but can be clinically concerning in a patient with infective symptoms and may prompt extensive workup for severe infection with a gas-forming organism. Historical urologic literature suggests that this finding typically relates to large prostatic calculi, however. Here we present a case of significant prostatic stone burden in a symptomatic patient causing crepitus in the prostate on physical exam.

Primary CNS Lymphoma

Central nervous system (CNS) lymphoma must be considered in the differential diagnosis of any immunocompromised patient with a solid brain lesion. In such patients, diagnosis can be made via a careful review of important signs, symptoms, and classic radiologic findings. While there is no single physical exam finding classic for lymphoma, the clinician must carefully evaluate patients for the presence or absence of findings that may suggest an alternative diagnosis. Such findings include the stigmata of endocarditis, symptoms suggestive of pneumonia, or additional non-CNS mass lesions. Additionally, several imaging modalities including magnetic resonance imaging, diffusion-weighted magnetic resonance imaging, susceptibility weighted imaging, and dynamic contrast-enhanced imaging can be useful in identifying this condition. While steroids can be helpful in reducing the disease burden and decreasing edema, they may also hinder diagnosis. Surgery may be indicated for either diagnostic or decompressive purposes; however, the mainstay of treatment is chemotherapeutic and immunotherapeutic agents with radiation reserved for refractory cases.

The impact of a multi-specialty team for high risk pulmonary embolism on resident and fellow education

The impact of the Pulmonary Embolism Response Team (PERT) model on trainee physician education and autonomy over the management of high risk pulmonary embolism (PE) is unknown. A resident and fellow questionnaire was administered 1 year after PERT implementation. A total of 122 physicians were surveyed, and 73 responded. Even after 12 months of interacting with the PERT consultative service, and having formal instruction in high risk PE management, 51% and 49% of respondents underestimated the true 3-month mortality for sub-massive and massive PE, respectively, and 44% were unaware of a common physical exam finding in patients with PE. Comparing before and after PERT implementation, physicians perceived enhanced confidence in identifying ( p<0.001), and managing ( p=0.003) sub-massive/massive PE, enhanced confidence in treating patients appropriately with systemic thrombolysis ( p=0.04), and increased knowledge of indications for systemic thrombolysis and surgical embolectomy ( p=0.043 and p<0.001, respectively). Respondents self-reported an increased fund of knowledge of high risk PE pathophysiology (77%), and the perception that a multi-disciplinary team improves the care of patients with high risk PE (89%). Seventy-one percent of respondents favored broad implementation of a PERT similar to an acute myocardial infarction team. Overall, trainee physicians at a large institution perceived an enhanced educational experience while managing PE following PERT implementation, believing the team concept is better for patient care.