Cape Fear Valley Health System

The popularity of escape rooms as a teaching tool in medical education has grown in recent years due to their ability to increase knowledge, self-confidence, and promote team-based skills. To increase efficacy in learning head and neck anatomy, a virtual escape room was built and employed as a review with a Health Professions Anatomy course. The concept was that students were trapped within the brain and had to determine the correct cranial nerve exit. One hundred thirty-nine students participated in a pre-post single-arm pilot. There was a significant difference (p < 0.01) in the overall pretest score (55.08%) compared with the posttest (70.17%). On the post-activity survey, 82.1% of students agreed/strongly agreed that the activity was a productive use of time; 90.5% thought it was an effective team-building activity; 96.8% thought it encouraged the use of communication and collaborative skills; 66.32% felt more confident about the material after the activity; 92.6% said it helped expose gaps in knowledge; and 75.8% planned to play the escape room again as a review for their exam. Overall, the use of a virtual escape room was an effective mechanism to increase students' knowledge and confidence related to anatomy and is an active learning strategy that encourages teamwork and communication skills.

Vitamin C deficiency, or scurvy, is an often-overlooked nutritional disorder in modern clinical practice, particularly in high-income countries, such as the United States. It is most commonly associated with food insecurity, poverty, and generalized malnutrition. However, this case underscores an equally important yet less recognized risk factor: autism spectrum disorder (ASD). Individuals with ASD are at high risk given their sensory sensitivities and food selectivity, and frequently exhibit restricted dietary patterns that limit their nutritional intake.We present the case of a 24-year-old male with a known diagnosis of ASD who was admitted with symptomatic anemia, hematuria, spontaneous bruising, and mucosal bleeding. Initial workup revealed severe normocytic anemia with poor reticulocyte response and evidence of renal dysfunction, necessitating multiple transfusions. Physical examination findings, which included perifollicular hemorrhage and corkscrew hairs, and a detailed dietary history revealed a highly restricted intake. His serum vitamin C level was subsequently found to be undetectable. After several days of vitamin C supplementation and multiple transfusions, the patient showed significant clinical improvement, with resolution of hematuria and normalization of hemoglobin levels on follow-up.This case illustrates the diagnostic challenges posed by micronutrient deficiencies presenting with nonspecific and severe clinical manifestations, such as anemia, hematuria, and renal dysfunction. It also reinforces the importance of considering atypical etiologies in patients with developmental disorders, particularly those with restrictive eating behaviors. Early dietary assessment and nutritional screening should be integral components of care for patients with ASD, especially when clinical presentations are unexplained or involve bleeding, bruising, or fatigue.

The authors declare no conflict of interest.

Chronic Foley catheter use significantly increases the risk of scrotal abscesses, particularly in patients with comorbidities that impair immune function, such as diabetes and chronic kidney disease (CKD). We report a case of a 56-year-old male with type II diabetes, CKD, and a chronic indwelling Foley catheterwho presented with progressive scrotal swelling and pain. Cultures identified Escherichia coli and Serratia marcescens from both urine and abscess fluid, confirming a possible urinary tract infection (UTI) as the source of scrotal abscess. The patient was found to have an abscessapproximately 5 cm in size with significant drainage of abscess fluid overlying necrotic tissue of the right hemiscrotum. The management involved surgical debridement and excision of all necrotic scrotal tissue down to viable tissue, along with abscess washout to reduce the risk of further infections, and culture-directed antibiotic therapy. Outpatient and inpatient physicians, as well as advanced care providers, should prioritize proactive measures that include regular catheter care protocols to reduce the likelihood of complications arising in this vulnerable population.

Pelvic masses in women can originate from both gynecological and non-gynecological sources, necessitating careful evaluation to ensure appropriate treatment. Gynecological masses can range from functional ovarian cysts and tubo-ovarian abscesses to malignant and benign tumors. This case report presents a mucinous borderline ovarian tumor (BOT), a rare type of ovarian neoplasm. This case highlights a 48-year-old G6P6006 White female with a history of asthma, presenting to the emergency department with a 10-day history of constipation and a month-long history of abdominal distention, which caused shortness of breath when supine. The patient had no recent primary care or gynecological follow-up. Physical examination revealed abdominal distension with absent bowel sounds and multiple hemangiomas, but no peritoneal signs. Initial laboratory studies were within normal limits, except for an elevated cancer antigen 19.9 (CA 19.9) level of 736.5. Imaging studies, including ultrasound and CT, identified a large complex adnexal mass measuring 28 x 21.5 x 15.4 cm. Given the suspicion of a gynecologic malignancy, the patient underwent a total abdominal hysterectomy with bilateral oophorosalpingectomy and an appendectomy. The mass, which was completely excised, was identified as a mucinous BOT measuring 32 cm at its largest diameter. Intraoperative pathology and peritoneal washings were negative for malignancy. Postoperatively, the patient met all recovery milestones and was discharged on day three, with a successful follow-up for staple removal. This case emphasizes the importance of timely access to healthcare in managing large ovarian tumors and potentially preventing malignant transformation. Improved access to healthcare services, particularly through insurance coverage, can enhance early detection and allow for comprehensive cancer care, thus improving survival outcomes. The case also highlights the lack of routine screening for many gynecological tumors, underscoring the need for improved healthcare access and awareness, which could facilitate earlier intervention and better patient outcomes. Early diagnosis and management of mucinous BOTs can significantly improve prognosis. Addressing healthcare access barriers remains crucial in reducing the risk of late-stage presentations and ensuring effective treatment for women with gynecological malignancies.

Background: Recreational marijuana use is rising, especially among young adults. The cardiovascular (CVD) effect of marijuana remains mostly unknown.Methods: This is a retrospective study of 14,490 patients admitted to our hospital between 2012 and 2014 who had urine toxicology done for various reasons. Patients with a primary diagnosis of acute coronary syndrome (ACS) were queried in both the marijuana-positive group (n = 59) and the marijuana-negative group (n = 195). The risks of having ACS were compared in both groups.Results: There was no difference in the risk of having ACS between the two groups in the population < 54 years of age (OR: 0.90, 95% CI: 0.67-1.20, p = 0.48). However, there was a significant difference in the risk of having ACS in the 18-36 age group (OR: 2.84, 95% CI: 1.14-7.07, p = 0.01). Multivariate analysis performed to adjust for the potential confounding effects of smoking and cocaine use showed that marijuana use (OR: 0.93, 95% CI: 0.68-1.25, p = 0.65) did not increase the likelihood of ACS for patients ≤ 54 years or for those in the 37-54 age group (OR: 1.11, 95% CI: 0.79-1.53, p = 0.50). However, among the 18-36 age bracket, marijuana use was independently associated with a higher risk of ACS (OR: 5.24, 95% CI: 1.84-16.93, p = 0.002).Conclusion: In younger patients (age 18-36 years), marijuana use is independently associated with a five-fold higher risk of ACS.

IntroductionChest pain is a common reason for ambulance transport. Acute coronary syndrome (ACS) and pulmonary embolism (PE) risk assessments, such as history, electrocardiogram, age, risk factors (HEAR); Emergency Department Assessment of Chest Pain Score (EDACS); Pulmonary Embolism Rule-out Criteria (PERC); and revised Geneva score, are well validated for emergency department (ED) use but have not been translated to the prehospital setting. The objectives of this study were to evaluate the 1) prehospital completion rate and 2) inter-rater reliability of chest pain risk assessments.MethodsWe conducted a prospective observational cohort study in two emergency medical services (EMS) agencies (April 18, 2018 – January 2, 2019). Adults with acute, non-traumatic chest pain without ST-elevation myocardial infarction or unstable vital signs were accrued. Paramedics were trained to use the HEAR, EDACS, PERC, and revised Geneva score assessments. A subset of patients (a priori goal of N = 250) also had the four risk assessments completed by their treating clinicians in the ED, who were blinded to the EMS risk assessments. Outcomes were 1) risk assessments completion rate and 2) inter-rater reliability between EMS and ED assessments. An a priori goal for completion rate was set as >75%. We computed kappa with corresponding 95% confidence intervals (CI) for each risk assessment as a measure of inter-rater reliability. Acceptable agreement was defined a priori as kappa ≥ 0.60.ResultsDuring the study period, 837 patients with acute chest pain were accrued. The median age was 54 years, interquartile range 43–66, with 53% female and 51% Black. Completion rates for each risk assessment were above goal: the HEAR score was completed on 95.1% (796/837), EDACS on 92.0% (770/837), PERC on 89.4% (748/837), and revised Geneva score on 90.7% (759/837) of patients. We assessed agreement in a subgroup of 260 patients. The HEAR score had a kappa of 0.51 (95% CI, 0.41–0.61); EDACS was 0.60 (95% CI, 0.49–0.72); PERC was 0.71 (95% CI, 0.61–0.81); and revised Geneva score was 0.51 (95% CI, 0.39–0.62).ConclusionThe completion rate of risk assessments for ACS and PE was high for prehospital field personnel. The PERC and EDACS both demonstrated acceptable agreement between paramedics and clinicians in the ED, although assessments with better agreement are likely needed.

Abstract Background: POLARIS is an ongoing, prospective, real world, noninterventional study in patients (pts) with HR+/HER2– ABC receiving PAL. This interim report describes real-world PAL use in preMeno pts. Methods: POLARIS has a targeted enrollment of 1500 pts from ~110 sites in the United States and Canada. Using patient data collected from medical charts and physician surveys, baseline demographics, clinical characteristics, and treatment patterns were analyzed descriptively in self-reported preMeno pts with ABC. Results: At the data cutoff of May 20, 2020, 1208 pts were enrolled; 134 (11.1%) from 61 sites were preMeno, of whom 14.2% completed ≥6 months of PAL treatment. Among 134 preMeno pts (74.6%) who received first-line (1L) therapy, 69.0% received PAL+letrozole (LET) or anastrozole, 28.0% PAL+fulvestrant, and 3.0% PAL+exemestane. Median disease-free interval was 39.3 (range: 0 to 236) months; median treatment-free interval was 14.8 (-3 to 134) months. Of 34 pts (25.4%) who received PAL as second or later line (≥2L), 23.8% previously received hormonal therapy, 28.6% chemotherapy, and 14.3% both. The majority of pts (96.27%) initiated PAL at 125 mg regardless of line of therapy (Table). During the first PAL treatment cycle, 2.9% of all preMeno pts, 1% of 1L pts, and 8.8% of ≥2L pts had a dose reduction; 8.2%, 9%, and 5.9%, respectively, had an interruption. Dose reductions/interruptions peaked in cycle 2 (11.9%/15.7%); 56.67% of these modifications were due to adverse events. Conclusions: PAL is routinely prescribed in clinical practice for preMeno women with HR+/HER2- ABC. The majority of preMeno pts in this real-world dataset received PAL+LET as 1L ABC treatment; PAL was primarily initiated at the recommended dose (125 mg) and was well tolerated with few dose modifications required. Clinical trial identification: Pfizer (NCT03280303) Table.CharacteristicFirst-Line Pre/Perimenopausal Patients (n=100)Second or Later Line Pre/Perimenopausal Patients (n=34)Pre/Perimenopausal Patients (N=134)Age at study enrollment, yMedian (range)44 (22-61)42.5 (27-58)44 (22-61)Distribution, n (%)&amp;lt;4032 (32.0)12 (35.3)44 (32.8)40–5045 (45.0)17 (50.0)62 (46.3)51–6923 (23.0)5 (14.7)28 (20.9)Race, n (%)White73 (73.0)26 (76.5)99 (73.9)Black or African American16 (16.0)4 (11.8)20 (14.9)Asian1 (1.0)1 (2.9)2 (1.5)Native Hawaiian or other Pacific Islander2 (2.0)0 (0.0)2 (1.5)American Indian or Alaska Native1 (1.0)0 (0.0)1 (0.7)Other3 (3.0)2 (5.9)5 (3.7)Not reported because of confidentiality regulations4 (4.0)1 (2.9)5 (3.7)Hispanic/Latino ethnicity, n (%)10 (10.0)3 (8.8)13 (9.7)Disease status, n (%)Visceral35 (35.0)13 (38.2)48 (35.8)Nonvisceral61 (61.0)17 (50.0)78 (58.2)Not reported4 (4.0)4 (11.8)8 (6.0)Bone metastases at mBC diagnosis, among patients with metastatic (stage IV) disease at study enrollment, n (%)Bone only40 (40)8 (23.5)48 (35.8)Bone plus other metastases32 (32)13 (38.2)45 (33.6)Disposition of patient ABC/mBC diagnosis at study at study enrollment, n (%)Recurrent from earlier stage (Stage 0-III)72 (72.0)18 (52.9)90 (67.2)De novo (Newly diagnosed Stage IV at enrollment)26 (26.0)15 (44.1)41 (30.6)Not reported2 (2.0)1 (2.9)3 (2.2)ECOG performance status at study enrollment (N, %)041 (41)15 (44.1)56 (41.8)126 (26)7 (20.6)33 (24.6)28 (8)3 (8.8)11 (8.2)32 (2)0 (0)2 (1.5)Not reported23 (23)9 (26.5)32 (23.9)Starting dose, first cycle of PAL treatment n (%)125 mg96 (96.0)33 (97.1)129 (96.3)100 mg2 (2.0)1 (2.9)3 (2.2)75 mg2 (2.0)0 (0.0)2 (1.5)Reason for first cycle starting dose &amp;lt;125 mg, n (%)Patient preference0 (0.0)1 (100)1 (25.0)Other3 (100)0 (0.0)3 (75.0) Citation Format: Meghan S Karuturi, Adnan Garrett, Joanne L Blum, Jay Anderson, Erin Jepsen, Timothy Pluard, Thomas Stanton, Kenneth Manning, Joseph C Cappelleri, Faith Beery, Yao Wang, Debu Tripathy. Pre/perimenopausal (preMeno) women receiving palbociclib (PAL) for hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2–) advanced breast cancer (ABC) in a real-world setting: Treatment patterns from POLARIS [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 PS7-19.