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Second opinion consultation for patients with suspicious findings on breast imaging and patients with known breast cancer is not uncommon. We sought to determine the frequency of second opinion breast and axillary ultrasound imaging review and the subsequent impact on clinical management.

An IRB-approved retrospective chart review was conducted on 400 consecutive patients with second opinion radiology interpretations performed by subspecialized breast radiologists at a designated cancer center, including mammogram and ultrasound review. The outside institution imaging reports were compared with second opinion reports to categorize ultrasound review discrepancies which were defined as any BI-RADS category change. The discrepancy frequency, relevant alterations in patient management, and added cancer detection were measured.

The second opinion imaging review resulted in discrepant findings in 108/400 patients (27%). Patients with heterogeneously or extremely dense breasts had higher discrepancy frequency ed management in 12% of patients (47/400). This included discovery of additional breast malignancies in 6 patients, metastatic lymph nodes in 4 patients, excisional biopsy for atypia in 1 patient, 4 patients proceeding to mastectomy, 10 patients who avoided biopsies, and 22 patients who avoided follow-up of benign findings.

In this study, subspecialized second opinion ultrasound review had an impact on preventing unnecessary procedures and follow-up exams in 8% of patients while detecting additional cancer in 2.5%.

In this study, subspecialized second opinion ultrasound review had an impact on preventing unnecessary procedures and follow-up exams in 8% of patients while detecting additional cancer in 2.5%.

Pulmonary rehabilitation (PR) has multiple benefits in COPD patients. There are multiple barriers to utilize PR including lack of knowledge about the benefits of PR by providers.

We are conducting a Quality Improvement project to improve the referral rate of patients hospitalized for acute exacerbation of COPD to PR.

All patients admitted with a primary diagnosis of acute exacerbation of COPD requiring systemic steroids to Rochester General Hospital in the period between 7/1/2019 and 7/31/2019 were reviewed retrospectively. Between 7/15/2020 and 11/15/2020, we started a PR stewardship program, where we daily review patients hospitalized with acute COPD exacerbation, and then a note will be placed in the chart for the primary team to consider referring patients to PR upon discharge, patients’ charts were reviewed after discharge. The rate of referral before and after the intervention was compared.

During the pre-intervention period, 16 patients (mean age 67.7) with confirmed COPD by spirometry were hospitalized for COPD exacerbation, among them only 2 were referred to PR upon discharge (12.5%). During the post intervention period, 16 patients (mean age 65.0) were admitted with acute COPD exacerbation, among them 10 were referred to PR upon discharge (62.5%) [50% difference (16.5%-71%, 95% CI), P value = 0.004].

In our QI improvement project, we conclude that having a PR stewardship program to review patients hospitalized with COPD exacerbation significantly improves the referral rate to PR, and might help to improve utilization of those programs by patients who need them.

In our QI improvement project, we conclude that having a PR stewardship program to review patients hospitalized with COPD exacerbation significantly improves the referral rate to PR, and might help to improve utilization of those programs by patients who need them.Lemierre’s syndrome (LS) is a rare disease entity, which can be catastrophic if organism-directed treatment is not initiated early. Lemierre’s syndrome is frequently caused by Fusobacterium infection which is frequently susceptible to clindamycin. Evidence suggests there is an increase in the incidence of cases of drug resistant Fusobacterium species. Through this case we present a unique case of a 45-year-old Caucasian female with Lemierre’s Syndrome due to polymicrobial organisms that were resistant to clindamycin thus developing recurrent infections despite being on antibiotics.

Sinus of Valsalva aneurysm (SOVA) is a rare anomaly of the aorta that can be congenital or acquired. It can be associated with syndromes such as Marfan syndrome and Ehlers-Danlos syndrome. However, to our knowledge, it has never been described in a patient with Apert syndrome. Although it often presents as an incidental finding on imaging, SOVA is associated with the risk of serious complications, including rupture. A possible connection between the conditions might be the FGFR2 gene mutation in Apert syndrome and the influence of a mutation in fibroblast growth factor 2 (FGF2) on heart development. Here we report a case of acute heart failure secondary to rupture of SOVA into the right atrium in a patient with Apert syndrome.

A 47-year-old Caucasian woman with a history of Apert syndrome and rheumatoid arthritis presented with shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and progressive bilateral lower extremity edema for 2 weeks. She was diagnosed with acute right heart failure due to ruptured SOVA. The patient underwent surgical repair of the ruptured SOVA. Unfortunately, her postoperative course was complicated by a stroke leading to brain death.

Ruptured SOVA is a quite rare but serious condition that can cause life-threatening complications. In this case, SOVA occurred in a patient with Apert syndrome. learn more The case may suggest that these two conditions may be related through the FGFR2 gene mutation associated with Apert syndrome and the related growth factor FGF2 involved in heart development.

Ruptured SOVA is a quite rare but serious condition that can cause life-threatening complications. In this case, SOVA occurred in a patient with Apert syndrome. The case may suggest that these two conditions may be related through the FGFR2 gene mutation associated with Apert syndrome and the related growth factor FGF2 involved in heart development.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) places internet Gaming disorder (IGD) in its research appendix as a potential new behavioral addiction diagnosis that requires further investigation. As part of the media campaign #HealthyAtHome, recommendation to relieve stress and anxiety during COVID-19, the World Health Organization (WHO) advocated for the playing of video games. The encouragement and expansion of playing video games may have led to the unintentional consequence of increasing the prevalence of IGD as IGD has been postulated to be a maladaptive response to stress.

A 34 year old male presented to his primary care physician with decline in work function, increased depression, and anxiety. Before the COVID-19 pandemic he estimated that he spent 2 h a day playing games and socialized with friends weekly; however at the time of presentation, his social interactions were through online gaming only and he was playing games 14 h per day. The patient began paroxetine and bupropion, with good result, though declined concomitant psychotherapy.

Internet Gaming Disorder is a potential new behavioral addiction that is likely to increase in prevalence over the continuing course of the COVID-19 pandemic. While initial studies show promising effects of medication and psychosocial interventions, further study on standardized diagnostic criteria and effectiveness of treatment modalities is needed.

Internet Gaming Disorder is a potential new behavioral addiction that is likely to increase in prevalence over the continuing course of the COVID-19 pandemic. While initial studies show promising effects of medication and psychosocial interventions, further study on standardized diagnostic criteria and effectiveness of treatment modalities is needed.

Acute esophageal necrosis (AEN) is an uncommon but fatal cause of upper gastrointestinal bleeding. The complex pathophysiology of the disorder provides multiple points for intervention. Therefore, it is important to discuss the many multifaceted aspects of the disease.

A scoping review was performed using PubMed, Google Scholar, and ClinicalTrials.gov. We reviewed literature from 1990 to 2021. The keywords used were ‘acute esophageal necrosis’, ‘upper GI bleed’, ‘pathogenesis’, ‘EGD’, ‘prognosis’.

The review summarized findings of 46 studies. AEN usually targets older males who have underlying cardiovascular disease. The middle part of the esophagus is commonly involved. The pathogenesis of AEN depends on conditions that increase risk of mucosal damage such as ischemia, lack of mucosal protection and excessive gastric reflux. Some medications are also responsible for the disease. Esophagogastroduodenoscopy is usually the gold standard for diagnosis. Findings suggestive of AEN include darkened, sharply d the cornerstone of therapy. A high index of suspicion should be maintained in patients with chronic health problems presenting with signs and symptoms of upper gastrointestinal bleeding because AEN can carry an unfavorable prognosis in these patients.Pulmonary vein thrombosis (PVT) is a rare but life-threatening clinical condition, often found incidentally on imaging. In this report, we present an interesting case of PVT of the left inferior pulmonary vein with extension into the left atrium in a 78-year-old woman presenting with “jolts” in the chest. Initial imaging with plain chest film radiograph showed findings consistent with COPD and no acute intrathoracic process. A CT angiogram of the chest revealed a filling defect consistent with thrombus within the left inferior pulmonary vein extending into the left atrium. A transthoracic echocardiogram was remarkable for a severely enlarged right ventricular cavity with moderately reduced right ventricular systolic function and normal left ventricular size with preserved systolic function. She was not a candidate for any surgical interventions, and she was managed with systemic anticoagulation. Management of PVT mostly depends on the underlying cause as there are no well-defined treatment guidelines. The consensus recommends systemic anticoagulation until thrombus resolution. When anticoagulation is contraindicated, thrombectomy is indicated to restore blood flow. In patients with similar presentation and clinical history it is important to consider PVT, and to focus on prompt diagnosis and early initiation of appropriate treatment.A 75-year-old male presented with lower back pain, bilateral lower extremity weakness, decreased sensation to vibration and proprioception in lower extremities, anemia, and vitamin B12 deficiency. The MRI of the lumbar spine revealed extensive leptomeningeal carcinomatosis. Subsequently, the patient was diagnosed with multiple myeloma (MM) and B12 deficiency with negative intrinsic factor antibodies. MM can present as extramedullary hematopoiesis (EM) to involve the central nervous system (CNS). CNS involvement is rare and develops in only around 1% of MM patients. It carries a poor prognosis with less than 6 months survival. MM is thought to be associated with both B12 deficiency and pernicious anemia. Some studies have even suggested B12 deficiency as a possible marker for worsening disease and a prognostic factor. In our patient’s case, he had extensive CNS involvement at diagnosis of MM with very low B12 levels. The extent of his disease with extensive CNS involvement, which carries a poor prognosis, could possibly explain the very low levels of B12.