35 Background: Medical comorbidities pose challenges to the delivery of quality cancer care. Underserved cancer patients have the highest burden of chronic comorbidities, with increased risk for worse outcomes. Their health outcomes and care transitions might be improved by enhancing collaboration between oncologists and primary care providers (PCPs). Methods: This is a cross-sectional study of oncologists and PCPs in a large public safety-net hospital system in Houston, TX. Providers completed electronic surveys assessing demographics, attitudes, and satisfaction regarding the shared care of cancer patients with chronic comorbidities. Results: Eighteen oncologists (39% minority, 72% female) and 25 PCPs (23% minority, 77% female) completed the surveys. Independent samples t-tests revealed both oncologists and PCPs reported moderate levels of interprofessional collaboration, felt that existing processes to facilitate coordination of care were inadequate, and expressed moderate levels of dissatisfaction with the management of cancer patients with comorbidities within HHS (all p-values = n.s.). However, their attitudes toward care coordination differed significantly depending on the nature and timing of the care being provided. With regard to side effect management during cancer-directed therapy, 81% of PCPs preferred to co-manage side effects with oncologists, but 100% of oncologists preferred to be responsible for this activity (χ 2 = 23.08, p <.001). With regard to management of late-effects of cancer treatment, 40% of oncologists were either interested in co-managing late effects with PCPs or having PCPs be solely responsible for this activity. Conversely, 86% of PCPs preferred to co-manage late effects with oncologists (χ 2 = 26.74, p <.001). For cancer surveillance, oncologists and PCPs expressed interest in sharing responsibility depending on the patient’s risk for recurrence (χ 2 = 1.62, p =.30). Conclusions: Oncologists and PCPs were similarly dissatisfied with comorbidity management in cancer patients, but differed in their attitudes towards care coordination. Oncologists were more resistant to sharing responsibilities of toxicities during and after treatment. They were more accepting of PCPs assuming follow-up care for lower-risk patients. Further investigation is needed to determine specific areas of care coordination, barriers to provider collaboration, and knowledge and processes for effective shared care.

Background: Ambulatory training is an integral component of internal medicine residency programs, yet details regarding operational processes in resident continuity clinics remain limited. Methods: We surveyed a convenience sample of medical directors of residency practices between 2015 and 2019 (n = 222) to describe and share operational and scheduling processes in internal medicine resident continuity clinics in the US. Results: Among residency practices, support for the medical director role ranged substantially, but was most commonly reported at 11%-20% full-time-equivalent support. By the end of the survey period, the majority of programs (65.1%) reported obtaining patient-centered medical home (PCMH) certification (level 1-3). For new patient appointments, 34.9% of programs reported a 1-7 day wait and 25.8% reported an 8-14 day wait. Wait times for new appointments were generally shorter for PCMH certified practices (P = 0.029). No-show rates were most commonly 26%-50% for new patients and 11%-25% for established patients. Most programs reported that interns see 3-4 patients per(1/2)-day and senior residents see 5-6 patients per (1/2)-day. Most interns and residents maintain a panel size of 51-120 patients. Discussion: Creating high-performing residency clinics requires a focus on core building blocks and operational processes. Based on the survey results and consensus opinion, we provide five summary recommendations related to (1) support for the medical director leadership role, (2) patient-centered and coordinated models of care, (3) support for patient scheduling, (4) recommended visit lengths, and (5) ancillary support, such as social work.

Autoimmune myelofibrosis (AIMF) is a rare complication of systemic lupus erythematosus (SLE) characterized by deposition of collagen and reticulin fibers in the bone marrow mediated by an aberrant production of fibrogenic cytokines and autoantibodies. Cytopenias in SLE/AIMF result from simultaneous underproduction secondary to myelofibrosis and peripheral destruction of blood cells. A 43-year-old woman was admitted for symptomatic pancytopenia associated with chest pain, dizziness, and headaches. Initial studies showed pancytopenia with diffuse osteolytic lesions particularly prominent on the skull, suggesting a possible malignancy. Additional diagnostic workup revealed a new diagnosis of SLE (+ANA, +dsDNA, low C3/C4), myelofibrosis secondary to SLE (JAK2 and CALR negative; bone marrow biopsy showing diffuse grade 4 reticulin and collagen fibrosis), and concurrent immune thrombocytopenic purpura (ITP). She experienced severe thrombocytopenia with minimal response to frequent platelet transfusions and multiple first-line therapies including high-dose prednisone, hydroxychloroquine, and intravenous immunoglobulin. Ultimately, she was treated with rituximab and romiplostim that resulted in stabilization of her platelet count and resolution of osteolytic lesions at 1-year follow-up. The concomitant occurrence of AIMF and ITP in SLE is particularly rare and carries considerable prognostic significance. This presentation of SLE was further complicated by osteolytic lesions in the absence of malignancy, resistance to first-line therapies, and high mortality risk with severe unremitting thrombocytopenia dependent on platelet transfusions. As this constellation of symptoms and pathology posed significant challenges in diagnosis and management, representing the first documented case, we review the literature and discuss our approach and successful treatment.

Spinal cord compression (SCC) is a rare initial presentation and complication of acute lymphoblastic leukemia (ALL) with nearly all reported cases occurring in the pediatric population. We report a 38-year-old previously healthy man who presented with acute on chronic lower back pain, gait instability, urinary retention, and severe thrombocytopenia. Radiologic examination revealed two soft tissue masses of the thoracic spine associated with compression fractures causing spinal canal narrowing and cord compression. Bone marrow biopsy confirmed the diagnosis of ALL. Immediate initiation of high-dose corticosteroids and systemic chemotherapy resolved the patient’s symptoms without radiation therapy or surgical intervention. After two courses of chemotherapy, the patient achieved complete remission in the bone marrow. Rapid administration of chemotherapy alone in this case resulted in a complete resolution of SCC. Given the rarity of this complication in adults, no standardized treatment has been established. The success of this case recommends chemotherapy as the initial management of SCC in chemotherapy-naïve ALL.

We report a patient with a rheumatic overlap syndrome on hydroxychloroquine and prednisone who developed tuberculous pyomyositis shortly after receiving 9 months of treatment of miliary tuberculosis. Her only presenting symptom was swelling of the left lower extremity without any systemic manifestation, despite extensive radiographic evidence of disseminated abscess formation. Acid-fast bacilli stains and cultures of the purulent material were negative for Mycobacterium tuberculosis (MTB), but polymerase chain reaction confirmed the diagnosis. To our knowledge, this is the first case report of tuberculous pyomyositis that developed shortly after the patient completed a full course of antituberculous therapy. We believe that the concurrent therapy of her rheumatic overlap syndrome with hydroxychloroquine likely led to her treatment failure for MTB and will discuss the possible pathogenesis. Our case also illustrates that MTB can cause significant soft tissue disease without systemic manifestations and that polymerase chain reaction is a valuable diagnostic study.

from their immunoregulatory roles.Colorectal cancer (CRC) cells with mutant BRAF(V600E) or KRAS alleles show increased PD-L1 transcripts (TCGA data) and we found increased tumor cell expression of cell surface PD-L1 protein compared to those with wild-type copies.In human colon cancer cells, ectopic expression of BRAF V600E or mutant KRAS induced PD-L1 whose upregulation was attenuated by inhibition of RAS-RAF-MEK-ERK signaling.Combined knockdown of MEK/ERK effectors c-JUN and YAP were shown to markedly reduce PD-L1.We then explored the role of PD-L1 in colon cancer cell sensitivity to chemotherapy given that treatment resistance in this disease is a major obstacle to improving therapeutic outcomes.Knockout of PD-L1 in RKO cells resulted in a reduction in chemotherapy-induced DNA double strand breaks (pH2AX) and caspase-3 cleavage compared to parental cells.Consistent results were seen for diverse cytotoxic drugs (oxaliplatin, irinotecan, gemcitabine).Results: were confirmed in PD-L1 knockout MC38 murine CRC cells where re-expression of PD-L1 but not its deletion mutants, was shown to promote DNA double strand breaks and apoptosis.In cells with knockout of PD-L1, reductions in p-AKT and the BH3-only proteins BIM and BIK were observed that could be restored by re-expression of PD-L1.Treatment of cells with an anti-PD-L1 antibody reduced p-AKT, BIM and BIK and also attenuated chemotherapy-induced apoptosis.Re-expression of BIM in PD-L1 knockout cells restored apoptosis.Using a murine model where tumor xenografts were generated from cells with knockout of PD-L1, tumors displayed resistance to oxaliplatin-induced regression compared to tumors derived from parental cells.To establish clinical relevance, stage III and IV primary human CRCs from TCGA datasets were identified with high vs low PD-L1 mRNA levels that were shown to be significantly associated with better patient survival.In conclusion, we identified a non-immune function of tumor cell-intrinsic PD-L1 that was shown to regulate apoptosis induction by anti-cancer drugs due to upregulation of proapoptotic BH3-only BIM and BIK proteins.Further study of the potential of PD-L1 to serve as predictive biomarker appears warranted.

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A 67-year-old male with history of well controlled type 2 diabetes mellitus and hypertension developed acute interstitial nephritis (AIN) with nephrotic-range proteinuria during treatment with cefazolin for methicillin-sensitive Staphylococcus aureus and Group B Streptococcus (GBS) bacteremia. The patient received intravenous cefazolin 2 g every 8 h for 4 weeks prior to presentation to the emergency department with abdominal distension, nausea, and vomiting. Investigations revealed a serum ascites albumin gradient of 1.0 with total protein of 1.8 g/dL suggestive of nephrotic syndrome, which was confirmed with a spot urine protein/creatinine ratio that estimated 7.95 g of protein per day. Serum creatinine was elevated compared with baseline. Urine studies showed sterile pyuria with 3+ protein and eosinophiluria. The patient was diagnosed with AIN with nephrotic-range proteinuria associated with cefazolin use. Cefazolin was discontinued and, within a couple of days, the patient’s creatinine stabilized. He was discharged with prednisone 60 mg once a day for 10 days with a taper over 2 weeks for his AIN. The patient’s creatinine and proteinuria slowly decreased over the next couple of weeks, however, did not recover to baseline. A Naranjo assessment score of 6 was obtained, indicating a probable relationship between the patient’s AIN with nephrotic-range proteinuria and his use of cefazolin.

Finishing the progress note on my last patient, I realized it was already 11:45 a.m. My medical student had not come out of the exam room yet. I waited for another 5 minutes and then knocked on the door. The student opened it and signaled to me that she would be out in 5 minutes. She finally came out of the room, looking exhausted. She started to present the history of our patient, Ms. H. This is a 50-year-old female with a history of substance abuse with intravenous 'speed,' endocarditis, and left hip septic joint status post removal of left femoral head, here for pain medication refill. She was recently discharged from the hospital from the orthopedic service. Her left hip pain is severe. While in the hospital, she had been very demanding and had refused physical therapy unless she received more pain medication. Social history was significant for her occupation as an exotic dancer and a 'madam' and drug abuse. The medical student proceeded with the review of systems and physical examination. How should I approach this patient? I had to stand firm given her high-risk behavior. In front of me sat an anxious woman in a wheelchair. I started to introduce myself but was interrupted with, Doc, I need my pain medication. I explained to the patient my concern about her history and risks for opioid dependence. She cried and begged me to give her some pain relief so she could pursue outpatient physical therapy. She wanted to be able to walk again. I glanced at the clock. An hour had passed. I attempted to negotiate a plan that would not involve opioids. I reviewed the X-rays. She had a missing left femoral head. Her left knee range of motion was fixed at 90 degrees. She could not stand up. This patient objectively should not have been prescribed an opioid, but my heart told me differently. Should I give her a chance to help her get better with short-term use of an opioid? The clock was ticking. I informed the patient that I would need to check her urine drug screen and would then decide. The next morning, my nurse told me that Ms. H had already called and wanted to know the results of her drug screen and whether I would give her some pain medication. She was negative for all illegal drugs, including opioids. I decided to give her a short course of an opioid and made a close follow-up appointment. I also gave her a physical therapy appointment. I continued to worry whether I had made the right choice. Ms. H came back for the follow-up visit. This time, she was calmer. She had started physical therapy and felt stronger but still needed her opioid refill. During this visit, I learned more about her. Her mother had died in a car wreck. Her father was an alcoholic who was later imprisoned for money laundering. Ms. H and her four brothers, ranging in age from 10 to 15 years, were put in foster homes and were often moved from home to home. At 16, she ran away looking for love and subsequently became an exotic dancer and a call girl. Because she was beautiful, she quickly climbed up the ladder, became the madam, and was paid well. With her high income, she purchased fancy clothes and bought love from her partners by giving them expensive gifts. In this career path, she inevitably joined a group of drug users and became addicted to intravenous speed. After 20 years of this high-risk lifestyle, she hit rock bottom when she fell while dancing. She was admitted for endocarditis and left septic hip requiring resection, which left her handicapped and unable to dance again. After 2 months of being hospitalized for antibiotic treatment and hip surgery, she realized that her lifestyle was no longer right for her and decided to quit using illegal drugs. All she wanted was to be able to walk again. As I listened, tears flowed down my cheeks. She had endured a harsh life. This time, I saw not just her sincerity but also her determination. I rechecked her urine, which was negative for all illegal substances except the opioid I had prescribed. At the subsequent visit, we established a pain agreement. She came monthly for her prescription and continued to improve with physical therapy. She met an elderly couple from her church group who let her stay with them and showed her the real love she had never had. A whole new world opened to her. For the first time in her life, she was able to say I love you and actually mean it. After 6 months, she was able to stand. Her knee flexion deformity had resolved. She was elated to walk in the swimming pool and to swim again. She is presently waiting for orthotic shoes with a sole and heel lift to allow her to walk. I cannot wait for the day when she walks into my office instead of using a scooter. Her goal has become to work with runaway girls. With all the opioid abuse and overdose, more restrictions are being placed on physicians to prescribe these agents responsibly. Our first instinct is to say no to all patients with pain who have identifiable risks for addiction and do not have cancer. But a new dimension was opened up to me. Ms. H showed me my bias toward patients with history of illegal drug abuse. More important, she showed me the trust that can exist between a physician and her patient. Audio. Virginia L. Hood, MD, Annals Associate Editor, reads "To Walk in Another's Shoes," by L. Lu.