Hafdahl, Luke

Abstract Introduction: Abemaciclib is a cyclin-dependant kinase 4/6 inhibitor used to treat HR+/HER2- advanced or metastatic breast cancer with disease progression following endocrine or chemotherapy. In 2023, the FDA expanded its indication alongside endocrine therapy for early HR+/HER2- breast cancer with high risk of recurrence. We present a case of Abemaciclib induced pneumonitis to raise awareness of this rare complication in a relatively new treatment with growing use. Case Presentation: An 85 year old female with HFpEF, atrial fibrillation on Rivaroxaban and metastatic breast adenocarcinoma on Letrozole/Abemaciclib for three years, was admitted with non-productive cough, dyspnea and low-grade fever. On initial evaluation she was hypoxemic requiring 4L/min of oxygen, and in atrial fibrillation at 140bpm. Chest x-ray showed bilateral airspace and interstitial opacities with vascular congestion. Respiratory viral panel was negative, and labs showed lymphopenia, elevated BNP (5768pg/mL), elevated CRP (245mg/L) and ESR (135mm/h). Ceftriaxone and Azithromycin was started, and Letrozole/Abemaciclib held. After 72h, despite antibiotics, rate control and diuresis, her hypoxemia persisted. On reviewing prior PET-CT scans from her oncological monitoring, early mosaic attenuation in both lungs was noted. Chest CT was obtained and revealed diffuse ground-glass and reticular opacities with basilar apical gradient. Due to fragile respiratory status, bronchoscopy was deferred and induced-sputum obtained. Extensive testing was negative including autoimmune studies, serum beta-D-glucan and galactomannan, Histoplasma/Blastomyces, Pneumocystis jirovecii, AFB stain, sputum and blood cultures. With a negative workup and chest CT suggesting non-infectious pneumonitis, she was treated with Methylprednisolone for a Grade 4 Drug-Induced Interstitial Lung Disease (DIILD). Treatment resulted in rapid improvements, and she was eventually weaned off oxygen. She was discharged with prednisone taper and outpatient Pulmonology follow up with repeat CT in 6-8 weeks. Discussion: Abemaciclib is associated with severe, potentially fatal DIILD. In clinical trials MONARCH 1-3, 3.4% of patients had pneumonitis of any grade, 0.6% had Grade 3-4, and in 0.4% it was fatal. Many agencies including the FDA and MHRA (United Kingdom) released post-marketing surveillance warnings to raise awareness of this toxicity. Our case highlights an important differential when autoimmune or microbiological workup is negative, and the patient is not improving despite diuresis and antibiotics. PET-CT imaging is frequently done in these patients for oncological monitoring, and re-review of these prior scans during acute admissions can evaluate for early evidence of non-infectious pneumonitis. Prompt recognition, discontinuation of Abemaciclib and early steroid therapy can prevent progression to severe respiratory failure or death.

Abstract Shoulder pain is a common occurrence after spinal cord injury (SCI) and can have significant negative effects on health and function as many individuals with SCI are reliant on their upper extremities for mobility and self-care activities. Shoulder pain after SCI can be caused by acute injury or chronic pathology, but it is most often related to overuse injuries of the rotator cuff. Both acute strain and chronic overuse shoulder injuries in persons with SCI typically result from increased weight bearing on the upper extremities during transfers, weight-relief raises, and wheelchair propulsion, which are often performed in poor postural alignment owing to strength deficits. This article discusses management of patients with SCI who present with shoulder pain from the perspective of primary care physicians including evaluation and diagnostic procedures, interventions appropriate for both acute and chronic shoulder pain, and strategies for prevention.

INTRODUCTION: Necrotizing pancreatitis is a serious complication of acute pancreatitis with high morbidity and mortality. We present a case of a 58 year old male diagnosed with necrotizing pancreatitis after cardiopulmonary bypass surgery and exposure to sulfamethoxazole-trimethoprim (TMP/SMX). CASE DESCRIPTION/METHODS: A 58 year old man presented with one week of jaundice and dyspnea. His history is significant for a recent cardiac surgery with coronary artery bypass grafts (CABG) and aortic valve repair (AVR) with a prolonged cardiopulmonary bypass time (CPBT) aortic cross-clamp time (ACCT). After the surgery, he was prescribed a course of TMP/SMX for an unknown indication. On assessment, he denied any other symptoms and had no history of alcohol use. He was hemodynamically stable with physical examination notable only for generalized jaundice. Lab findings were significant for hemoglobin 6.2 g/dL, WBC 19 × 10(9)/L, K 5.8 mmol/L, BUN 82 mg/dL, Cr 2.82 mg/dL, total calcium 6.7 mg/dL, serum glucose 110 mg/dL, total/direct bilirubin 8.7/6.8 mg/dL, alkaline phosphate 503 U/L, ALT 343 U/L, AST 640 U/L, lipase 540 U/L, and triglycerides 212 mg/dL. CT of the abdomen showed acute necrotizing pancreatitis. He was treated with fluid resuscitation and antibiotics. ERCP was deferred as his cholestasis was thought to be due to extrinsic compression. His course was complicated by hemorrhagic conversion, acute renal failure, shock liver and gastric ischemia. Ultimately, he expired on hospital day 20. DISCUSSION: Drug-induced pancreatitis accounts for 0.1-2% of cases of acute pancreatitis. Although TMP/SMX is classified as a potential cause of pancreatitis, the data is sparse with limited reported cases and a broad latency period ranging from 3 days to 20 years. Acute pancreatitis has also been described as a complication of cardiac surgery with an incidence of 0.4% per prior report. Notably, many of these patients are often asymptomatic, which makes early diagnosis of utmost priority. Factors that increase the risk of developing pancreatitis include prolonged CPBT/ACCT and combined CABG and valve repair, possibly related to splanchnic ischemia. Given that our patient with a recent cardiac surgery received a culprit antibiotic within several weeks of presentation, it is unclear whether TMP/SMX, cardiac surgery, or a combination caused our patient's episode of acute pancreatitis. Although rare, each of these factors should be considered when determining the cause of pancreatitis.

Purpose The flipped classroom (FC), in which instructional content is delivered before class with class time devoted to knowledge application, has the potential to engage residents. A Mayo Clinic Internal Medicine Residency Program study was conducted to validate an FC perception instrument (FCPI); determine whether participation improved FC perceptions; and determine associations between resident characteristics, change in quality improvement (QI) knowledge, and FC perception scores. Method All 143 internal medicine residents at Mayo Clinic, Rochester participated from 2014 to 2015; some experienced a flipped QI curriculum and others completed the traditional nonflipped course. The FCPI was developed, and factor analysis revealed an intuitive two-factor structure: preclass activity and in-class application. Residents were surveyed before and after the monthlong curriculum to measure changes in perception, and the QI Knowledge Assessment Tool was employed to measure knowledge improvement. Results Postcourse FCPI scores significantly increased for three of the eight items. QI knowledge increased significantly among residents who experienced the FC compared with residents who completed the non-FC curriculum. Those without prior FC exposure demonstrated a significant increase in QI knowledge compared with those with previous FC experience. The FCPI had compelling validity evidence with improved scores after curriculum exposure and associations with greater engagement in online modules. Conclusions Residents who participated in the FC demonstrated improved QI knowledge compared with the control group. Residents valued the in-class application sessions more than the online component. These findings have important implications for graduate medical education as residency training programs increasingly use FC models.