Presbyterian Kaseman Hospital

This report reviews the clinical and pathologic features of 423 examples of sinus histiocytosis with massive lymphadenopathy (SHML) entered in a case registry, with special emphasis on extranodal manifestations of the disease. The most common sites of extranodal involvement in this population are skin, upper respiratory tract, and bone. However, SHML also can occur in a variety of other sites, including the genitourinary system, lower respiratory tract, oral cavity, and soft tissues. Involvement of kidney, lower respiratory tract, or liver was found to be a poor prognostic sign, and patients with associated immunologic disease often fared poorly. In general, prognosis has been found to correlate both with the number of nodal groups and with the number of extranodal systems involved by SHML. A complete bibliography of publications describing patients with SHML is included, and illustrations of the clinical, histopathologic, and radiographic features of the disease are provided.

The effects of changes in depression-relevant cognition were examined in relation to subsequent change in depressive symptoms for outpatients with major depressive disorder randomly assigned to cognitive therapy (CT; n = 32) versus those assigned to pharmacotherapy only (NoCT; n = 32). Depression severity scores were obtained at the beginning, middle, and end of the 12-week treatment period, as were scores on 4 measures of cognition: Attributional Styles Questionnaire (ASQ), Automatic Thoughts Questionnaire (ATQ), Dysfunctional Attitudes Scale (DAS), and the Hopelessness Scale (HS). Change from pretreatment to midtreatment on the ASQ, DAS, and HS predicted change in depression from midtreatment to posttreatment in the CT group, but not in the NoCT group. It is concluded that cognitive phenomena play mediational roles in cognitive therapy. However, data do not support their status as sufficient mediators.

Clozapine is an atypical antipsychotic drug with reduced risk of unwanted neurological effects in comparison with other drugs. In this multicenter study, 151 hospitalized schizophrenic patients were randomly assigned to treatment under double-blind conditions to assess the antipsychotic efficacy and safety of clozapine versus chlorpromazine. All patients exhibited tardive dyskinesia or other extrapyramidal side effects associated with at least two prior neuroleptics. Eleven patients were dropped from treatment due to extrapyramidal symptoms while being treated with chlorpromazine; only one clozapine patient's treatment was terminated for this reason. Clozapine patients exhibited clinical improvement superior to that of chlorpromazine patients as assessed by the Brief Psychiatric Rating and Clinical Global Impression scales. These results suggest that clozapine is well tolerated and may be therapeutically superior to chlorpromazine in treating psychotic behavior. Agranulocytosis potential can be minimized by frequent white blood cell counts and removing nonresponding patients from treatment prior to the peak risk period (months 2 through 6).

[ldquo]Do you want to know what most free thinkers want? Some want the freedom not to think at all...others want the freedom to think badly...and others still want the freedom to despise all authority and tradition.[rdquo] Louis Pasteur3 [ldquo]The good physician treats the disease, but the great physician treats the patient.[rdquo] Sir William Osler23 [ldquo]The value of diversity[mdash]including its extreme form, eccentricity[mdash]lies in creativity, adaptability, and the bypassing of the limits of convention. Innovation springs from dissatisfied minds....[rdquo] Pathologist Carl Gray13 In surgical pathology, diagnostic differences of opinion usually arise as a function of[colon] (1) variation among the classifiers, (2) variation among the classified, and (3) problems with using the systems and methods at the interface between classifier and classified. In the Letters section of the current issue of the journal, Dr. Medline expresses the opinion that variation among the classifiers, [ldquo]individuality[rdquo] to use his term, should be increased to improve diagnosis. 17 Although individuality or personal practice style is unquestionably important both in approaching some cases and in advancing the field of surgical pathology, the letter does not address the point likely to be of most interest to pathologists, clinicians, and patients, that is, when and under what circumstances does diagnostic individuality of the classifier enhance the care of patients, and when is it just another name for quirky, eccentric, or objectively wrong approaches that result in different diagnostic interpretations for the same findings? Placing a high value on individuality is certainly not Dr. Medline's idiosyncratic opinion. Debates about the degree to which it is appropriate for authorities to constrain the individual's tendency to act as he or she sees fit have been the subject of political debate for over 300 years. Individualism (self-directed, comparatively unrestrained behavior) is classically contrasted with collectivism (individual rights are subordinate to constraints imposed by systems or organizations). In the political sphere, there has been a tendency in recent years for individuality to triumph over collectivism, and historians now view as failures the various attempts to use social policy to strictly standardize how people think and act. 11 Writer David Frum has noted that currently in the United States, there is an [ldquo]obsession with personal freedom[rdquo] that grew out of the cultural and social turmoil of the 1960s and 1970s, essentially replacing the comparatively conformist, obedient attitudes of the past. 21 A similar debate over the right of the individual practitioner to come to his or her own conclusions about patient care 16,24 spans essentially the entire history of modern medicine, and recently this debate has become quite heated. For example, are HMO guidelines an effort to impose evidence-based standards on a workforce prone to irrational variation, or (as recently stated by an Albuquerque physician) are these guidelines an attempt to make physicians [ldquo]paint by numbers[rdquo]? With regard to the practice of surgical pathology, I am not aware that we have any enumerated right to express individuality in our practices, and in fact there are several powerful constraints on our diagnostic individuality. One constraint is the legal system, which for at least 150 years has identified variation from [ldquo]standard[rdquo] as a reason to pursue legal action. 20 Another constraint on individuality is ethical. Unless the patient has given informed consent to a deviation from standard practice, the pathologist is on extremely shaky ethical grounds when providing anything but standard interpretations. 2,30 It is true that the concept of autonomy is central to ethical standards in medicine, but autonomy is generally viewed as a right of the patient (for example, to be free from coercion) rather than a right of the physician to be free of external rules and guidelines. 12,18 Pathologists find that the legal and ethical environment in which we practice imposes an obligation that we assign to each case the label that represents the best practice of the specialty at the point in time that the case is evaluated. Ideally, identical findings would receive identical labels from all pathologists in all practice settings, although when our role as patient care advocate conflicts with our role as taxonomist, the best practice diagnosis for the same set of pathology findings will sometimes differ. It is interesting that despite the powerful pressures for diagnostic conformity, surgical pathologists who are attempting to follow current practice standards generate substantial numbers of diagnostic disagreements. 7,15,25 Some disagreements appear to represent examples of cases with an objective [ldquo]right answer[rdquo] that certain pathologists do not recognize, suggesting that there is a gap between what the specialty knows and what individual practitioners do. Other disagreements reveal that there is a gap between what we know as a specialty and what we would like to know. Of importance, diagnostic disagreements are now occurring in a setting in which medical issues of all sorts are becoming increasingly politicized, and the topic of medical error is of intense interest to groups outside of medicine. The issue of diagnostic individuality raised by Dr. Medline is central to a discussion of error, because this individuality is a source of variation that theoretically can be modified, and in the mind of the public and of many healthcare leaders, variation is becoming increasingly equated with error. For example, variation in clinical care now tends to be labeled by the elite media with pejorative terms such as [ldquo]overuse,[rdquo] [ldquo]underuse,[rdquo] or [ldquo]misuse[rdquo] of proper therapy, 1 and medical specialty organizations are grappling with the failure of individual practitioners to adhere to what these organizations perceive to be compelling evidence-based practice standards. 4,23,29 One study projected up to a 14-year gap between release of trial results and incorporation of results into some physicians' practices. 19 Is nonconformity[colon] (1) simply ignorance or eccentricity, (2) a reflection of the inability of practitioners to apply standards in a consistent fashion, or (3) have practitioners with no opportunity for input on standards concluded that many guidelines are GOBSAT (good old boys sat around a table) that does not apply to their practice setting? 10 In the present political climate, it may be appropriate for surgical pathologists to take a closer look at how well we understand the pathogenesis of our diagnostic disagreements, and whether we are prepared to propose, evaluate, and implement [ldquo]treatment[rdquo] options. We certainly have an extensive experience with studies of how often diagnostic disagreements occur in various settings, but these latter studies do not treat or cure the problem of disagreement any more than documenting that 3000 cases of polio occurred in a certain region in 1952 created or administered a vaccine. Furthermore, pressure to fix the error problem may lead to [ldquo]do something[rdquo] approaches that waste resources or are counterproductive. Especially when the pressure for change is political, there is a danger that the response will also be political, with science added as a window dressing. Similar to any other medical problem, diagnostic disagreement should be approached as much as possible using a scientific framework. Questions that should be answered include[colon] (1) Is the current incidence of error/disagreement too high? (2) What is a realistic goal for the rate of error/disagreement? (3) What would be the benefits of a reduction? (Ideally, the resources allocated to achieving the goal should be proportional to the benefits of achieving the goal.) (4) What methods do we have or can we develop to meet this goal? (5) Will implementing these methods cause important negative consequences? (6) Will we know that the goal has been met, that is, will the problem be attacked with testable hypotheses accompanied by objective measures of success or failure? (7) Will the measures of success or failure be patient care outcomes or easier to measure surrogates for outcome such as number of cases referred for a second opinion? Unfortunately, in surgical pathology, it does not appear that we are currently even at step one of this process because there is no consensus within the specialty about what level of disagreement is a problem. A leading pathologist recently interviewed in the New York Times suggested that diagnostic disagreement affecting 1.4[percnt] of cases referred to his institution was sufficient to change the practice of pathology to incorporate routine second opinions. 28 Other leading pathologists have concluded that a study with a case disagreement rate of 33[percnt] at the benign malignant threshold immediately following a tutorial has been [ldquo]incorrectly cited as a study that documents diagnostic disagreement.[rdquo]22 It is true that even one diagnostic disagreement can be an extremely distressing, perhaps even humiliating experience for the pathologist. However, disagreement is not polio, and it is unlikely that with current technology, zero tolerance for diagnostic disagreement is a rational expectation. If zero tolerance cannot be achieved, it falls to spokesmen for the specialty to explain to the public why this is so. Likewise, denying that high rates of disagreement are really disagreement makes pathologists sound like tobacco executives denying that cigarette smoking causes cancer. Finally, while the legal principle of stare decisis (stand by things decided) is not appropriate for retrospective medical review, it is also not appropriate to exaggerate differences of opinion or to use hindsight bias to create the perception of error when none exists. Current dogma in the field of error reduction holds that too much emphasis has been placed on the individual's contribution to error, and that many errors are caused by system flaws that inevitably lead to error. In pathology, major system factors that could be contributing to error include flawed classification systems, weak (for example, personality-based) diagnostic gold standards, poorly functioning sources of clinical information, and improper specimen preparation and handling. However, if pathology error is more closely linked to variation in individual diagnostic behavior rather than to flawed systems, then efforts to decrease error by changing systems would be misguided. Attention would be better directed to other tasks, such as modification of the training, certifying, and monitoring of pathologists in an attempt to create a less variable workforce. The lesions that we classify are diverse, but we cannot lose sight of the fact that there is also substantial diversity of the classifiers. This pathologist diversity arises out of differences in such factors as intelligence, inquisitiveness, willingness to work hard, interest in the field, quality of residency training, commitment to education after formal education, and volume of cases. Another important difference between pathologists is where they practice on a receiver operator curve (ROC) (favor false-positive or false-negative). Pathologist variation is like flawed systems in that it can theoretically be modified to reduce diagnostic disagreement. However, experience in a practice setting suggests that despite attempts to homogenize the members of the specialty workforce through mechanisms such as residency training, board testing, CME, and standard textbooks, individuality remains a major contributor to diagnostic disagreement. For example, the spread between the best and the worst diagnosticians completing pathology training is substantial, and directing underachievers into nonpathology careers is a task that can vary from unpleasant to dangerous. 9,14 The Anatomic Pathology Boards reject a subgroup of pathologists who complete residency, but what is the rationale behind the pass/fail threshold and how is the threshold validated? Following initial specialty credentialing, control of performance is left to the tort system, to hospital committees, and to state agencies, and the specialty itself plays no formal role. For example, what steps are taken by academic pathologists when a case is referred labeled with a diagnosis that is not a differential consideration? For private pathologists, what do you do if a consultant makes an implausible diagnosis? How do pathology organizations respond to objectively wrong interpretations of survey cases? 8 Presumably, these responses differ from aviation's response when a United pilot steers his plane toward a mountain. 5 Board recertification is a plausible mechanism to improve and/or standardize the skills of pathologists practicing surgical pathology, but as currently structured, it is not apparent that recertification addresses either of these goals. An interesting system work-around for diagnostic individuality is increased case referral, and this plan has the distinct advantage of simply changing the frequency of a practice behavior that is already well-established. We would find that if all of the odd breast tumors in a geographic area are prospectively referred to one pathologist, then the individuality of many pathologists would be reduced to the individuality of one pathologist. CONCLUSION Like modern industry, clinical medicine finds itself under pressure to both conform and to innovate. In medicine, these twin goals are pursued though a division of cognitive labor, with some physicians largely responsible for the innovation that advances the field and other physicians doing their best to apply established rules to cases. Pathologists attempting to follow rules theoretically work within the status quo, whereas a smaller group of pathologists works to revise the status quo. However, the division of labor in medicine is not nearly so clear-cut as that found in industry. Routine practice presents the pathologist with cases for which there is either no evidence-based literature to directly guide diagnostic behavior or, alternatively, the literature comes to conflicting conclusions. The result is that attempts to export [ldquo]one size fits all[rdquo] standards into pathology laboratories are substantially more difficult than standardizing the manufacture of a product. Even within industry, extreme standardization is recognized to create a workforce that cannot respond to exceptions. At the same time that we face difficulties in standardization, we also face barriers to the generation, study, and acceptance of good new ideas and the retirement of bad ideas. The practicing pathologist who is not happy following rules is the ideal candidate to perform innovative studies structured according to standard scientific and ethical principles. 6 It is clear that there is no place for the pathologist who expresses individuality by subjecting unsuspecting patients to uncontrolled diagnostic self-expression. Meeting the public's expectations for innovation will require that the surgical pathology leadership remain open to contrary opinions, resisting the natural tendency of leaders to establish a tyranny of the status quo. Theories and classification systems are created to be replaced, but complaints about the resistance to new ideas go back at least as far as Virchow, who is credited with noting that good new ideas go through three phases. First, they are ignored, then they are attacked, and finally, after a prolonged struggle, they are met with we knew that all along. 27 What we knew all along about diagnostic disagreements is that they will continue to happen, that additional concrete steps should be taken to minimize them, and that it is time to move beyond documentation and denial into well-constructed studies of disagreement. If pathologists conclude that disagreement is like the weather, something to complain about but not fix, we will face externally devised fixes. A fundamental shift has occurred in public awareness and attitude toward error. Collecting incidence data is an important first step, but a leap from incidence to cure without a full understanding of the problem is unlikely to be successful. Likewise, we probably do not have time for the luxury of analysis paralysis. It remains possible that the cure for error and disagreement is as simple as sending large numbers of cases for a second opinion. However, this tactic may distract us from potentially more useful tasks such as developing a better understanding of the classification system failures and the pathologist individuality that contribute to disagreement and error.

The relationship between nurse counseling of hysterectomy patients and sexual adjustment following surgery was the focus of this descriptive study. Of 108 premenopausal women admitted to seven hospitals in California, New Mexico, and Utah who completed a series of questionnaires preoperatively, postoperatively, and eight weeks post-surgery, only 11 percent identified the nurse as the person who supplied the most valuable information. Self-reported sexual adjustment following surgery was significantly (p=.001) related to their presurgical pattern. Almost half the respondents wrote comments urging nurses to initiate discussion about the effect of hysterectomy on sexuality.

In diagnostic pathology, decision-making skills are used to match the facts of a particular case to a diagnostic category. Ideally the diagnosis is established with "beyond a reasonable doubt" certainty, but substantial uncertainty orfrank diagnostic error can afflict the diagnostic process for a variety of reasons. Many of these diagnostic problems are explained by failures of decision-making. Unfortunately, it appears that substantial components of decision-making are too poorly understood to study or improve. For example, "instant pattern recognition," use of implicit knowledge, and use of creativity represent areas where discussion may not be helpful. In contrast, rule-based problem-solving is sufficiently well understood that the members of an almost purely cognitive specialty might be prompted to ask, what do we know about what we do when we problem-solve? This article reviews some of the more intriguing aspects of decision-making in the hope of stimulating interest in the topic among pathologists.

Error in anatomic pathology is a topic that is currently making the difficult transition from a problem peculiar to a subset of poorly trained or otherwise inadequate pathologists to a problem shared by the specialty of pathology. This transition will involve a number of difficult steps, including sorting error from both inherent diagnostic uncertainty andfrom variations in practice patterns from which no evidence-based best practice has emerged. Identification of error will require scientifically valid diagnostic gold standards, and in those areas of diagnosis without such a standard, the identification of and response to error will continue to be heavily influenced by hindsight bias and subjective opinion. The pathologist, like other physicians, has limited options to "make things right" following a significant error The silver lining is that many errors have the potential to prompt changes that will prevent future patient harm. Unfortunately, a dysfunctional legal system that values punishment and transfer of assets over future improvements in health care has wrung much of the positive potential out of error, leaving only the damaged patient and damaged pathologist.

From the Department of Pathology, Presbyterian Hospital, Albuquerque, New Mexico, USA. Address correspondence and reprint requests to Dr. E. Foucar, Department of Pathology, Presbyterian Hospital, 1100 Central Southeast, Albuquerque, NM 87106, USA.

Importance: Adding fulvestrant to anastrozole (A+F) improved survival in postmenopausal women with advanced estrogen receptor (ER)-positive/ERBB2 (formerly HER2)-negative breast cancer. However, the combination has not been tested in early-stage disease. Objective: To determine whether neoadjuvant fulvestrant or A+F increases the rate of pathologic complete response or ypT1-2N0/N1mic/Ki67 2.7% or less residual disease (referred to as endocrine-sensitive disease) over anastrozole alone. Design, Setting, and Participants: A phase 3 randomized clinical trial assessing differences in clinical and correlative outcomes between each of the fulvestrant-containing arms and the anastrozole arm. Postmenopausal women with clinical stage II to III, ER-rich (Allred score 6-8 or >66%)/ERBB2-negative breast cancer were included. All analyses were based on data frozen on March 2, 2023. Interventions: Patients received anastrozole, fulvestrant, or a combination for 6 months preoperatively. Tumor Ki67 was assessed at week 4 and optionally at week 12, and if greater than 10% at either time point, the patient switched to neoadjuvant chemotherapy or immediate surgery. Main Outcomes and Measures: The primary outcome was the endocrine-sensitive disease rate (ESDR). A secondary outcome was the percentage change in Ki67 after 4 weeks of neoadjuvant endocrine therapy (NET) (week 4 Ki67 suppression). Results: Between February 2014 and November 2018, 1362 female patients (mean [SD] age, 65.0 [8.2] years) were enrolled. Among the 1298 evaluable patients, ESDRs were 18.7% (95% CI, 15.1%-22.7%), 22.8% (95% CI, 18.9%-27.1%), and 20.5% (95% CI, 16.8%-24.6%) with anastrozole, fulvestrant, and A+F, respectively. Compared to anastrozole, neither fulvestrant-containing regimen significantly improved ESDR or week 4 Ki67 suppression. The rate of week 4 or week 12 Ki67 greater than 10% was 25.1%, 24.2%, and 15.7% with anastrozole, fulvestrant, and A+F, respectively. Pathologic complete response/residual cancer burden class I occurred in 8 of 167 patients and 17 of 167 patients, respectively (15.0%; 95% CI, 9.9%-21.3%), after switching to neoadjuvant chemotherapy due to week 4 or week 12 Ki67 greater than 10%. PAM50 subtyping derived from RNA sequencing of baseline biopsies available for 753 patients (58%) identified 394 luminal A, 304 luminal B, and 55 nonluminal tumors. A+F led to a greater week 4 Ki67 suppression than anastrozole alone in luminal B tumors (median [IQR], -90.4% [-95.2 to -81.9%] vs -76.7% [-89.0 to -55.6%]; P < .001), but not luminal A tumors. Thirty-six nonluminal tumors (65.5%) had a week 4 or week 12 Ki67 greater than 10%. Conclusions and Relevance: In this randomized clinical trial, neither fulvestrant nor A+F significantly improved the 6-month ESDR over anastrozole in ER-rich/ERBB2-negative breast cancer. Aromatase inhibition remains the standard-of-care NET. Differential NET response by PAM50 subtype in exploratory analyses warrants further investigation. Trial Registration: ClinicalTrials.gov Identifier: NCT01953588.

Thirty-four children with presumptive acute osteomyelitis or septic arthritis underwent early gallium-67 citrate scintigraphy and have been retrospectively reviewed. Diagnostic accuracy using this technique was 91%. Gallium-67 citrate is a more reliable radiopharmaceutical agent for the detection of selected acute musculoskeletal infections than either technetium methylene diphosphonate or indium-111. However, the radiation dosage from gallium is higher than from other radiopharmaceutical agents, and the authors would recommend its use only in cases where the diagnosis cannot be made on the basis of clinical, laboratory, or plain roentgenographic criteria.

Classification is the activity that allows pathologists to arrange the bewildering morphologic manifestations of disease into comprehensible order Ideally, our precise diagnoses would each be based on some timeless biological law of nature, and these diagnoses would group together patients with identical clinical manifestations and responses to therapy. However, in spite of the amazing success of pathology classification, it is apparent to everyone that diagnostic disagreements are common, and that patients who exactly fit into a diagnostic category often have markedly different disease courses and responses to therapy. At this time, it is unclear how quickly the potential of genomic medicine will be translated into revolutionary changes in pathology classification. However, it is clear that the rules of classification are part of the foundation of diagnostic pathology and that there is a high likelihood that pathology classification will undergo substantial changes in the next few years. This article reviews the topic of classification for pathologists who will practice during these interesting times.

Since the IARC (International Agency for Research on Cancer) announcement in 2007 indicating the possibility of night-shift work carrying carcinogenesis risk, multiple studies on a global level have been conducted to investigate the correlation between night-shift work and cancer development. Circadian rhythm disruption and decreased melatonin production have been postulated as potential contributing factors. There is also growing evidence that night-shift workers tend to adopt unhealthier lifestyles which contribute to poorer health and increase the risk of developing diseases such as cancer. No experimental study has been specifically dedicated to testing specific methods that could decrease cancer risk in night-shift workers. While there are a few studies that investigate melatonin's concurrent use with chemotherapy in cancer patients, there is yet to be seen for studies that investigate melatonin specifically as a cancer prevention method. This narrative review aims to examine current evidence of healthcare night-shift work's risk in cancer incidence, potential pathogenesis, and its significance in clinical practice.

Paxlovid (nirmatrelvir/ritonavir) is a game changer in the fight against COVID-19 due to its ease of administration and significant benefits of reducing progression to severe COVID-19, hospitalization, and death. Cardiac adverse events such as bradycardia and syncope are not known with this medication. We report a case of a 71-year-old patient who developed symptomatic bradycardia, syncopal episodes, and sinus pause after taking Paxlovid. Discontinuing medication and intravenous atropine helped to reverse the bradycardia and symptoms promptly. She did not require a pacemaker. We would like to report this possible association between Paxlovid and bradycardia. Until further information or studies are available, it is advised to promptly discontinue Paxlovid after any evidence of bradycardia and closely monitor for at least 40 hours in a hospital setting. The reported half-life (t 1/2) of the medication is 6.05 ± 1.79 hours and using 8 hours as a reference for the upper limit of t 1/2, around 97 % of the medication should be cleared off in about 40 hours (five half-lives).

Liver cirrhosis remains a major public health issue. Liver fibrosis leading to cirrhosis is the terminal stage of various chronic liver diseases. Inflammatory cytokines are involved in the pathogenesis. Patients with cirrhosis often have hematological abnormalities, such as anemia and thrombocytopenia, which have multifactorial etiologies. Anemia in cirrhosis could be related to bleeding leading to iron deficiency anemia or other nutritional anemia such as vitamin B12 and folate deficiency. The pathophysiology of thrombocytopenia in liver cirrhosis has been postulated to range from splenic sequestration to bone marrow suppression from toxic agents, such as alcohol. It often complicates management due to the risk of bleeding with severely low platelets. This review aimed to highlight pathogenesis of liver cirrhosis, hematological abnormalities in liver cirrhosis, and their clinical significance.

Coronavirus disease 2019 (COVID-19) is a febrile respiratory illness caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It may develop into respiratory failure or pneumonia. Antimicrobials have facilitated medical progress for decades. However, antimicrobial resistance (AMR) limits our ability to treat diseases and undermines efforts to attain health-related sustainable development and universal health coverage objectives. Antimicrobial resistance is a major concern that must be addressed immediately. The principles of appropriate prescription, optimal use of antimicrobials, quality diagnosis and treatment, and infection reduction and prevention have led to antimicrobial stewardship initiatives. During the current COVID-19 epidemic, there are possible hazards to antimicrobial stewardship measures and drug resistance. Many people with mild illnesses but without pneumonia or moderate infections with pneumonia are administered antibiotics. Antimicrobial therapy has no documented benefit in COVID-19 patients without microbial co-infection. COVID-19 patients may have an increased risk of developing concomitant microbial infections, which would necessitate antibiotic treatment. This review evaluated the role of empiric antibiotics in COVID-19 patients.

Chronic factitious disorder with physical symptoms, or Munchausen syndrome, is a well-recognized but uncommonly diagnosed psychiatric condition characterized by the deliberate production of signs and symptoms of disease in order to receive medical attention. Clinical suspicion of this disease is rarely confirmed by autopsy, as the patients usually do not die as a consequence of feigning illness. Here we report the autopsy confirmation of a case of a suspected Munchausen syndrome patient who presented with a history of cystic fibrosis. Examination of the lungs demonstrated extensive severe interstitial fibrosis, and polariscopic examination revealed a large quantity of crystalline material throughout the tissue; X-ray diffraction identified the material as talc. Synopses of published cases of Munchausen syndrome presenting as cystic fibrosis, and cases of Munchausen syndrome with pulmonary talcosis are presented as part of the discussion.

The long-term efficacy and safety of amlodipine (2.5 to 10 mg) once daily was compared with that of hydrochlorothiazide (HCTZ) (25 to 100 mg) daily in 139 patients with mild-to-moderate hypertension. The study was a randomized, open-label, parallel comparison of 50 weeks' duration. Patients were randomized in a 2:1 ratio (amlodipine n = 92: HCTZ n = 47). Atenolol was added at week 12 if monotherapy was inadequate. At week 12, the mean reductions for supine and standing systolic and diastolic blood pressure values with amlodipine were found to be -15.2/-12.3 mmHg and -14.0/-11.6 mmHg respectively, as compared to -15.5/-11.1 mmHg and -16.1/-10.1 mmHg after treatment with HCTZ. The percentage of patients responding to treatment at week 12 was 74% on amlodipine and 70% on HCTZ. The addition of atenolol in those patients not adequately controlled on monotherapy produced additional mean reductions in supine and standing systolic and diastolic pressures in both the amlodipine-atenolol group and in the HCTZ-atenolol group. The incidence of adverse effects was 47% with amlodipine and 26% with HCTZ at 12 weeks. Overall, six patients were discontinued because of side effects while receiving amlodipine monotherapy and one from the HCTZ monotherapy group; none were discontinued because of side effects on combination therapy. Laboratory test abnormalities were reported by 16% of amlodipine-treated patients compared with 63% of patients on HCTZ. The antihypertensive effects of amlodipine and hydrochlorothiazide appeared to be comparable and were maintained during long-term therapy.

Abstract Background: Ki67 values &amp;gt;10% 2-4 weeks (wks) after starting neoadjuvant ET (NET) indicates persistent cell proliferation, resistance to ET, and is associated with increased risk of recurrence. The ACOSOG Z1031 trial suggested that these tumors are also relatively chemotherapy (chemo) resistant with a low pathologic complete response (pCR) rate to NCT. The ALTERNATE trial (NCT01953588) is a randomized study of neoadjuvant anastrozole (ANA), fulvestrant (FUL), or ANA + FUL in postmenopausal patients (pt) with newly diagnosed clinical stage II or III ER+ (Allred score 6-8)/HER2- BC. Ki67 &amp;gt;10% at wk 4 or 12 after starting NET triggered triage to NCT of physician choice or weekly paclitaxel. Pts who refused protocol-directed therapy, were not candidates for NCT, or decided to undergo immediate surgery are being followed per protocol. Here we report the rates of pCR and residual cancer burden (RCB) following NCT for pts triaged to NCT due to Ki67 &amp;gt;10% at wk 4 or 12. Results: Of the 1,299 eligible pts randomized to receive ANA, FUL, or ANA + FUL, 286 (22%) had Ki67 &amp;gt;10% at wk 4 or 12. 168 of these 286 pts (58.7%) chose to switch to NCT, 32 went to surgery (11.2%), and 86 discontinued further protocol-directed therapy (30.1%). Among the 168 pts who underwent NCT, the presenting clinical T stages were cT2 (n=113; 67.26%), cT3 (n=47; 27.98%) and cT4 (n=8; 4.76%) and N stages were cN0 (n=82; 48.8%), cN1 (n=75; 44.6%), cN2/3 (n=9; 5.4%) and cNx (n=2; 1.2%). Central ER testing was performed on pre-treatment biopsies and confirmed ER Allred score 6-8 in 155 of 168 (92.2%) pts, with the rest being ER Allred score 4-5 (n=5; 3%), ER- (Allred score 0) (n=2; 1.2%), or not tested (n=6; 3.6%). Most (n=139; 82.7%) were ER+/PR+, while 17.3% (n=29) were ER+/PR-, and tumor grades were G1 (n=10; 6%), G2 (n=99; 58.9%), G3 (n=54; 32.1%), not reported (n=5; 3%). Baseline Ki67 levels prior to NET were &amp;gt;10% in 94% (n=158), ≤10% in 3% (n=5), and not done in 3% (n=5). NCT regimens administered included doxorubicin/cyclophosphamide (AC) followed by paclitaxel (T) (n=60; 35.71%); weekly paclitaxel (n=56; 33.33%), docetaxel/cyclophosphamide (TC) (n=33; 19.65%), other doxorubicin and/or taxane containing regimen (n=17; 10.12%), and cyclophosphamide/methotrexate/fluorouracil (CMF) (n=2; 1.19%). 35 (20.8%) pts did not complete planned course of NCT due to toxicity (n=27) or refusal (n=8). 154 NCT pts underwent surgery (mastectomy in 40.3%, and breast conserving surgery in 59.7%). The path ypT stages were Tis/0 (n=10; 6.5%), T1 (n=62; 40.3%), T2 (n=61; 39.6%), and T3/4 (n=21; 13.6%), and the ypN stages were N0 (n=66; 42.9%), N1 (n=57; 37%), N2/3 (n=30; 19.5%), and Nx (n=1; 0.6%). Among the 168 pts who started on NCT (intent to treat population), there were 8 pCRs (no invasive disease in the breast or lymph nodes) (4.8%; 95% CI: 2.1% to 9.2%). Residual Cancer Burden (RCB) categories include RCB 0 (n=8; 4.8%), RCB 1 (n=15; 8.9%), RCB 2 (n=82; 48.8%), RCB 3 (n=42; 25.0%), and not determined (n=21; 12.5%). Correlations of baseline pt and tumor characteristics with pathology response to NCT will also be presented. Conclusion: In pts with NET-resistant ER+/HER2- BC, salvage NCT is not likely to induce a complete or near complete response. More effective treatments are needed for this high-risk ER+/HER2- pt population. Support: U10CA180821, U10CA180882, U24CA196171, UG1CA189856, U10CA180868 (NRG); NCI BIQSFP, BCRF, Genentech, AstraZeneca. https://acknowledgments.alliancefound.org. Clinical Trials.gov Identifier: NCT01953588 Citation Format: Cynthia X Ma, Vera Suman, A. Marilyn Leitch, Souzan Sanati, Kiran Vij, Gary W Unzeitig, Jeremy Hoog, Mark Watson, Olwen Hahn, Joseph Guenther, Abigail Caudle, Erika Crouch, Horacio Maluf, Amy Tiersten, Monica Mita, Wajeeha Razaq, Tina J Hieken, Yang Wang, Travis Dockter, Jo Anne Zujewski, Anna Weiss, Kelly Hunt, Clifford Hudis, Eric P Winer, Matthew J Ellis, Lisa A Carey, Ann H Partridge. Neoadjuvant chemotherapy (NCT) response in postmenopausal women with clinical stage II or III estrogen receptor positive (ER+) and HER2 negative (HER2-) breast cancer (BC) resistant to endocrine therapy (ET) in the ALTERNATE trial (Alliance A011106) [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr GS4-05.

Escherichia coli community-acquired pneumonia (CAP) is an under-recognized condition associated with higher mortality compared to the other well-studied causes of pneumonia. E. coli pneumonia is frequently associated with bacteremia. Despite the absence of abdominal or urinary symptoms, the infection may originate from an occult gastrointestinal (GI) source since it is a common commensal bacteria of the GI tract. Conditions related to extraintestinal pathogenic E. coli (ExPEC) are gaining attention, and there has been a trend toward the rise of pneumonia secondary to gram-negative bacteria. This presents a diagnostic stewardship dilemma in a patient with sepsis, E. coli bacteremia, and apparent pneumonia - to assume and treat for E. coli CAP or to look for a GI/genitourinary source which may, in turn, lead to incidental findings and further studies. We report a case of E. coli CAP in a 62-year-old patient and our approach regarding the treatment and imaging course.

A lung abscess is a walled necrotizing infection involving the lung parenchyma, characterized by a cavitary lesion filled with fluid. It is usually caused by microbial infection with aspiration of oropharyngeal contents being the most common mechanism for primary lung abscesses. Secondary lung abscesses occur in the presence of predisposing lung conditions like bronchial obstruction, vascular or septic emboli or impaired host defenses. Lung abscesses caused by electronic cigarette use have gained relevance in the recent years since the outbreak of EVALI, that is, e-cigarette or vaping product use-associated lung injury, in 2019. First-line therapy involves prompt initiation of antibiotics given their success rate in the treatment of lung abscess in the current potent antibiotic era. Percutaneous aspiration and catheter drainage is considered a second line approach due to concerns for potential complications including catheter blockage necessitating repeat procedures, pneumothorax, hemothorax, hemoptysis, need for surgical intervention, infection of pleural space and bronchopleural fistula. We describe a case of a 21-year-old female with a history of electronic cigarette use presenting with a large left upper lobe lung abscess (14.5 x 8.5 x 13.3 cm) treated successfully with broad-spectrum antibiotics alone resulting in clinical and radiologic improvement.