United States

Background: The purpose of this quality improvement study is to gain a deeper understanding of the metrics that influence patient satisfaction and identify which metrics correlate with decreased patient satisfaction scores at a family medicine outpatient residency clinic. Resident physicians work under the guidance of experienced attending physicians to refine their physician skills as they progress through their training. Patient satisfaction ratings can help physicians assess how their patients feel after their appointments and identify areas where patients would like to see improvement. Our goal is to develop initiatives that enhance patient interactions, improve our quality of care, and help train our residents to become effective family physicians.

Methods: An optional, anonymous, post-visit survey was offered to eligible adult patients for three weeks. The survey questions directly assessed five patient satisfaction metrics: continuity of care, trust, communication, confidence in managing healthcare needs at home, and access to resources. These metrics correlate with physician skills that our clinic values in effective family doctors.

Results: The average patient satisfaction rating for the clinic was 9.81 out of 10. 90.5% of patients reported they could not be more satisfied with the care they received. 60.3% of patients who saw attending physicians reported perceived continuity of care, while only 37.5% of patients who saw resident physicians reported the same. While a similar percentage of patients denied confidence in managing healthcare at home and access to resources, patients who denied access to resources were five times as likely to report lower satisfaction ratings. There was a strong correlation between the number of patient satisfaction metrics denied and lower patient satisfaction ratings for third-year residents and attendings; however, this correlation was weaker for second-year residents and inverted for first-year residents.

Conclusion: There was no significant difference in average patient satisfaction ratings between residents and attending physicians; however, the percentage of patients who could not be more satisfied with their care increased from PGY-1 to PGY-3, with third-year residents exceeding attending physicians in this regard. Patients trusted their physicians at all levels of training. Attending physicians had better perceived continuity of care with their patients. Although continuity of care was the most frequently denied patient satisfaction metric at our clinic, it did
not correlate with lower patient satisfaction ratings. The patient satisfaction metric that most significantly correlated with lower patient satisfaction ratings was access to resources.

AMA Research Challenge 2025 

Analysis of patient satisfaction metrics between family medicine residents and attending physicians

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CASE REPORT – INVASIVE DUCTAL CARCINOMA FOLLOWING REMOVAL OF BENIGN BREAST TUMOR IN 93-YEAR-OLD MALE
Gavin Crist, OMS-II1, Jeffrey D. Goodwin, OMS-II1, Joseph Davenport, OMS-II1, Ben Brooks, PhD, MBA2 
1. College of Osteopathic Medicine, Rocky Vista University, Ivins, UT USA 
2. Department of Clinical Education, Rocky Vista University, Ivins, UT USA 

Introduction – Invasive ductal carcinoma (IDC) is the most common breast cancer in men but represents less than 1% percent of breast carcinomas diagnosed in the US annually. To date, there is only one identifiable male case reporting carcinoma in the same breast following surgical resection of a benign neoplasm. This case report aims to document an incredibly rare occurrence of IDC in the same location as a previously removed benign neoplasm in a 93-year-old man. 
Case description – A 93-year-old male presented to the surgical oncologist with newly diagnosed left breast cancer, determined to be IDC by a diagnostic mammogram, ultrasound, and biopsy. He had a long history of lumps on the left side including gynecomastia at age 20, which was treated without surgery, and a lump that was excised in his late 50s, a (patient-reported) teratoma. A left mastectomy and sentinel node biopsy was performed. The tumor was confirmed IDC, grade 2, 2.5 cm, margins >10 mm, negative lymph nodes (0/6), ER positive (strong, 90%), PR positive (strong, 85%), HER2 negative, Ki-67 15%, Magee score 14, stage IIA (pT2N0). The patient reported no postoperative complications with well controlled pain. 
Discussion – The development of IDC in the same location as a previously resected benign tumor is unusual but highlights the importance of long-term surveillance in patients with a history of breast lesions. The presence of benign precursor lesions, such as atypical ductal hyperplasia (ADH) or ductal carcinoma in situ (DCIS), can increase the risk of subsequent invasive cancer. In this case, the long interval between the benign tumor and the IDC suggests a de novo malignancy rather than a recurrence with transformation. A retrospective cohort study done by Visscher, et al. showed a correlation between benign breast disease (BBD) and breast cancer in women, with 9.4% of BBD becoming breast cancer.1 Although no published studies have identified recurrence rates of benign tumors in men, the recurrence rate in women is between three and six percent.2,3 An estimation of the likelihood of benign recurrence with subsequent transformation would be approximately 0.28-0.56%. Although there is no data available to estimate the probability of breast cancer occurring in the same location as a benign tumor over 30 years post-surgery, there is one other documented occurrence where a benign, resected tumor preceded IDC in a male.4 
Conclusion – The scarcity of cases, low likelihood of recurrence with transformation, and long interval between tumors demonstrate the need for consistent vigilance and follow-up care in men with a history of benign breast tumors.
References:
1. Visscher DW, Frost MH, Hartmann LC, et al. Clinicopathologic features of breast cancers that develop in women with previous benign breast disease. Cancer. 2016;122(3):378-385. doi:10.1002/cncr.29766
2. Benign and Low-Grade Fibroepithelial Neoplasms of the Breast Have Low Recurrence Rate After Positive Surgical Margins. Cowan ML, Argani P, Cimino-Mathews A. Modern Pathology : An Official Journal of the United States and Canadian Academy of Pathology, Inc. 2016;29(3):259-65. doi:10.1038/modpathol.2015.157.
3. Risk of Local Recurrence of Benign and Borderline Phyllodes Tumors: A Danish Population-Based Retrospective Study. Borhani-Khomani K, Talman ML, Kroman N, Tvedskov TF. Annals of Surgical Oncology. 2016;23(5):1543-8. doi:10.1245/s10434-015-5041-y.
4. Nicosia L, Lissidini G, Sargenti M, et al. Ductal carcinoma in situ of the male breast: clinical radiological features and management in a cancer referral center. Breast Cancer Res Treat. 2022;196(2):371-377. doi:10.1007/s10549-022-06689-y


Case Report - Invasive Ductal Carcinoma Following Removal of Benign Breast Tumor in 93-Year-Old Male

Background
Allergic transfusion reactions (ATRs) represent a common adverse event, particularly with plasma rich blood components like platelets. While most are mild, severe (anaphylactic) reactions can occur, posing significant risks. The underlying pathophysiology is thought to involve complex interactions between donor factors and recipient susceptibility, often mediated by IgE but potentially involving other mechanisms like passive transfer of inflammatory mediators. Our study details two cases of anaphylactic reaction caused by platelet products from the same donor to explore potential underlying factors. 

Methods 

A retrospective investigation was initiated following the two reactions. To investigate potential mechanisms, we applied the Milliplex 48-plex human cytokine panel to compare levels of plasma cytokines in residual donor product, post-transfusion plasma from both affected recipients, and plasma from three random platelet units. All tests were performed in triplicate.

Results
Both reactions were reported as anaphylactic and resolved with epinephrine. Neither recipient had a prior history of allergy or ATRs. Hemovigilance investigation showed that both reactions linked to apheresis platelet units originating from the same donor who is previously a long-time and frequent donor, had donated a separate product two months earlier that also resulted in an anaphylactic reaction. Consequently, the donor was indefinitely deferred from the donor pool.

Cytokine analysis demonstrated that several pro-inflammatory cytokines were elevated in the remaining donor product, including notable increases in TNFa, IL-9, and IL-13, along with chemokines including CCL22 and CCL11. These cytokines are implicated in mast cell function, eosinophil recruitment, Th2 immunity, and IgE class-switching, all potentially contributing to or amplifying an allergic/anaphylactic state. Recipient post-transfusion plasma contained elevated levels of CCL2, IL-10, and IL-6, all inflammatory mediators known to be pre-stored in basophil granules and suggestive of an anaphylactic response.


Conclusion
These cases highlight the complex mechanisms of ATRs and suggest that anaphylactic transfusion reactions may be related to passively transfused biologically active mediators or other factors within the donor component, as evidenced by a single donor causing multiple anaphylactic reactions in different recipients across different donations. The findings underscore the importance of donor history review (identifying potentially problematic donors) and potential of personalized transfusion approaches to enhance patient safety and efficacy in transfusion medicine, setting the stage for further investigations for pathophysiology of ATRs. 



Anaphylactic Transfusion Reactions Linked to a Single Donor: Pathophysiological
Insights

Background: Wildfire ashes from the wildland-urban interface (WUI) can contain high levels of toxic metals, such as chromium (Cr), copper (Cu), arsenic (As), and incidental nanomaterials. We hypothesized that the viability of mouse atrioventricular cushion mesenchymal (AVM) cells has a negative dose dependent relationship with WUI wildfire ash.

Methods: Mouse AVM cells were seeded into wells at 5x105 cells/mL. After 24 hours the wells were treated with 42 fire ash supernatants at 0.1, 1, 2, 5, and 7.5 mg/mL. After incubation, a 5 mg/mL MTT (3- (4, 5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) solution was added. The solution was then aspirated and dimethyl sulfoxide was added. The absorbance of each well was then taken at 570 nm. The viability of the treated cells was estimated by comparison to controls on each plate. The desired toxic effect was less than or equal to 50% viability (LD50) after treatment. An unpaired t-test was used to compare the LD50 value to the control.

Results: Of the 42 samples tested, 23 showed a decrease in cell viability, 7 showed a decrease of 50% or more, and 6 showed an increase in cell viability. Over two thirds of the samples that achieved a 50% decrease in viability were structural or vehicular burns, such as those found in the WUI. Sample A-013, collected from a trailer, achieved LD50 at 5 mg/mL (p=0.0034). Sample A-031, collected from burned vegetation, had 46% viability at 7.5 mg/mL (p=0.0011). Sample A-081, collected from a burned oak, had 44% viability at 7.5 mg/mL (p=0.0006). Sample A-092, collected from burned artificial wood, showed 32% viability at 7.5 mg/mL (p=0.0019). Sample A-095, collected from a garage, had 44% viability at 5 mg/mL (p=0.0011). Sample A-096, collected from treated wood and burnt electronics, also had 44% viability at 5 mg/mL (p=0.0035). Sample NCWZ 4-B, collected from a burnt car, had a viability of 45% at 7.5 mg/mL (p=0.0161).

Conclusion: Tested WUI fire ashes showed significant toxicity. Samples with treated wood or trace metals were particularly toxic. These fire ash samples are highly prevalent in the WUI. Regardless, the tested fire ashes supported the hypothesis that the viability of AVM cells has a negative dose dependent relationship with WUI fire ash exposure. These results indicate that WUI fire ashes may cause significant cardiotoxicity in vivo. Further studies on the effects of fire ashes on developmental processes, such as epithelial to mesenchymal transition, will also aid in understanding how exposure may influence heart development.

Wildfire Heartburn: Wildfire Ash Induced Cardiotoxicity and Congenital Heart Defects

Trigeminal trophic syndrome (TTS) is a cause of facial ulceration that occurs secondary to trigeminal nerve injury. This condition mimics other causes of facial ulceration, often leading to misdiagnosis. This case series presents the clinical features, diagnostic approaches, and treatment outcomes of five patients with TTS to help improve understanding of this rare condition and diagnostic accuracy. Review of these cases demonstrates the most common area of ulceration was the nose, a female predominance, and an age of presentation of middle-aged to older adults. Four patients had biopsy results revealing an absence of malignant or infectious cause of facial ulceration. Ulceration typically develops years after nerve injury and may persist for months to years. Treatment typically involved topical antibiotics, neurology consultation, and four of the five patients underwent surgical repair for the treatment of TTS. Early recognition and an individualized multidisciplinary therapeutic approach are vital in improving patient outcomes and quality of life, as well as preventing recurrence in patients with TTS.

Trigeminal trophic syndrome: case series and review of surgical treatment strategies

Temporomandibular joint (TMJ) ankylosis causes severe restriction in mouth opening, affecting speech, nutrition, appearance, and oral hygiene. While a variety of techniques for the treatment of TMJ ankylosis have been reported, the exact relationship between different surgical treatment options and patient outcomes is poorly defined. This systematic review aims to assess the current literature on the surgical treatment of TMJ ankylosis to develop a predictive relationship between surgical intervention and patient outcomes. PubMed, Embase, and Web of Science were searched and 52 studies met inclusion criteria. Data extracted included demographics, surgery type, maximal incisal opening (MIO), physiotherapy, complications, and follow-up. Outcomes assessed were re-ankylosis, facial nerve injury, infection, and MIO change. In children, greatest MIO improvement occurred with gap arthroplasty with costochondral and interposition grafts (6.14mm to 32.72mm); smallest with interposition grafts (6.26mm to 31.38mm). Complication rate was 16.7%; re-ankylosis was 10.6%. In adults, greatest MIO improvement was with gap arthroplasty with costochondral and interposition grafts (8.18mm to 37.3mm); smallest in TMJ replacement (9.08mm to 24.62mm). Complication rate was 7.7%; re-ankylosis was 0.89%. Noncompliance to physiotherapy (PT) was a key factor in re-ankylosis and reduced MIO. Treating patients with TMJ ankylosis is challenging due to limited data available to guide treatment. After surgical treatment, an average of 32mm of postoperative MIO can be expected. Postoperative physiotherapy should be emphasized to increase postoperative MIO to prevent re-ankylosis and improve outcomes.

Surgical and Clinical Outcomes of Temporomandibular Joint Ankylosis: A Systematic Review

Background
Acromial fractures (AcFx) are a complication of reverse total shoulder arthroplasty (RTSA), associated with pain, impaired shoulder function, and prothesis failure. Predictors of AcFx risk are poorly defined. Morphologic features and prothesis position may influence mechanics of the scapular spine and acromion, thereby increasing susceptibility to AcFx. This study sought to identify imaging-based patient and prothesis characteristics that predict AcFx risk post-RTSA.

Methods
A retrospective case-control study was done on patients who underwent RTSA at a single large tertiary institution between January 2020 and July 2024, with >10 months of follow-up. Exclusion criteria included revision arthroplasty, pre-existing bone lesions, AcFx before RTSA or from postoperative trauma, insufficient imaging, and displaced humeral fractures. Non-displaced fractures were included if surgical approach was not altered. AcFx were classified using the Levy classification. Subjects were matched 1:2 (case:control) by age and sex. Covariates included BMI, bone demineralization, inflammatory arthropathy, diabetic and smoking status, as well as acromial morphometrics (length and thickness) and preoperative global offset. Descriptive analyses and multivariable logistic regression were performed.

Results
After screening 718 RTSAs, 36 (6.8%) AcFx cases were identified among 526 procedures. Mean time to fracture was 4.64 months, with 78% occurring within six months. Using the Levy classification, 61% were Type 1 fractures, 33% Type 2, and 6% Type 3. The AcFx group and matched controls (n=72) were 80% female, with a mean age of 709 years. AcFx patients had a higher prevalence of bone demineralization (47% vs. 26%, p=0.03), shorter acromial length (34.7 vs. 37.5 mm, p=0.053), and less humeral lateralization (15.6 vs. 18 mm, p=0.038). Multivariable logistic regression_ adjusting for age, sex, BMI, acromion measurements, and humeral lateralization_ trended toward significance for bone demineralization (OR 2.56, p=0.059), shorter acromial length (OR 0.93, p=0.083), and reduced humeral lateralization (OR0.92, p=0.075).

Conclusion
Shorter acromial length and reduced humeral lateralization are associated with increased risk of AcFx after RTSA. These features could be predictive of postoperative AcFx, alerting radiologists to higher-risk patients and prompting closer postoperative surveillance.

Imaging Predictors of Acromial Fractures Following Reverse Total 
Shoulder Arthroplasty

Beyond SF3B1: Clinical Response to Luspatercept in a Case of SF3B1-Negative Lower-Risk MDS 
Background 
Luspatercept is a recombinant fusion protein that binds transforming growth factor-beta (TGF-β) ligands, reducing SMAD2/SMAD3 signaling (named after Sma/Mad genes) and promoting erythroid maturation. It is a first-line treatment option for symptomatic anemia in very low- to intermediate-risk myelodysplastic syndrome (MDS) patients, who are erythropoiesis-stimulating agent (ESA)-naive and have serum erythropoietin levels below 500, particularly with the positive SF3B1 mutation. However, for other MDS cases, it serves as a secondary treatment choice, competing with ESA, imetelstat, hypomethylating agents (HMAs) and lenalidomide. 
We present a case of an MDS patient with 20q deletion, multiple mutations and no definitive FDA-approved therapy, who was treated with luspatercept. 
Case Presentation 
A 76-year-old Bangladeshi male with a history of anemia, thrombocytopenia, hypertension (status post aortocoronary bypass graft), hypothyroidism, peripheral vascular disease, and benign prostatic hyperplasia presented with weakness, fatigue, shortness of breath, and chest pain on exertion for the past few months. 
The initial workup revealed a decrease in hemoglobin from 11 to 8.6 within two months and thrombocytopenia, with platelets at 59. Iron deficiency was ruled out. A bone marrow biopsy revealed MDS with low blasts in a hypercellular marrow, positive for 20q deletion, DNMT3A, TET2, and PHF6 mutations, and negative for SF3B1 or ring sideroblasts. The age-adjusted Revised and Molecular International Prognostic Scoring System (IPSS-R/IPSS-M) scores were in the intermediate and moderate low-risk categories, respectively. 
Six cycles of intravenous azacitidine and oral allopurinol were administered, resulting in a temporary improvement of hemoglobin to normal levels. Azacitidine was switched to epoetin alfa due to declining kidney function and treatment resistance; however, hemoglobin levels continued declining. The patient then received one dose of luspatercept, which caused hemoglobin to rise from 7.7 to 11.5 within three weeks. 
Luspatercept dosage and frequency have been adjusted to hemoglobin levels, maintaining it at 11. 
Discussion 
Early investigation is crucial for effective treatment of anemia, the most common hematological disorder. While 20q deletion and TET2 mutation in MDS are biomarkers of a better response to azacitidine, a standard first-line therapy for higher-risk MDS with multiple mutations, treatment resistance and side effects including kidney damage pose a significant challenge. Proven by a very good response in our patient, luspatercept could be a competitive alternative treatment option. Although luspatercept is FDA-approved in lower-risk MDS with SF3B1 mutation and ring sideroblasts, more studies should be conducted to investigate the response of luspatercept in MDS with mutations other than SF3B1.

Beyond SF3B1: Clinical Response to Luspatercept in a Case of SF3B1-Negative‬ Lower-Risk MDS

Background: Emery-Dreifuss Muscular Dystrophy (EDMD) is a complex congenital multi-system disorder characterized by progressive generalized muscle weakness frequently leading to restrictive lung disease and cardiomyopathy resulting in heart failure with reduced ejection fraction (HFrEF). This poses a diagnostic dilemma as patients can present with acute-on-chronic hypercapnic respiratory failure (AChRF) with a severely decompensated arterial blood gas (ABG) profile that belies the less overt signs of respiratory distress stemming from respiratory muscle weakness. This case highlights the central role of Bilevel Positive Airway Pressure (BiPAP) in managing concurrent respiratory and cardiac pump failure and underscores the management challenges inherent in care transitions for patients with complex diseases.

Case Presentation: A 56-year-old woman with sleep disordered breathing and chronic hypercapnic respiratory failure secondary to EDMD, managed with nocturnal BiPAP, and HFrEF (ejection fraction [EF] 30-35%), managed with a cardiac resynchronization therapy (CRT) device, was admitted to the intensive care unit (ICU) with carbon dioxide (CO2) narcosis and acute decompensated heart failure. This admission occurred two days after discharge to a skilled nursing facility (SNF), where her BiPAP was not administered for 48 hours. Upon presentation, she was obtunded with an arterial oxygen saturation level (SpO₂) of 61%. Initial ABG revealed severe respiratory acidosis (pH 7.26, PaCO₂ 65 mmHg, HCO₃⁻ 35 mmol/L), with chest X-ray showing cardiomegaly and pulmonary congestion. She responded well to non-invasive ventilation (NIV) (BiPAP with Average Volume-Assured Pressure Support [AVAPS]) and intravenous diuretics leading to clinical improvement and acid-base stabilization. Following discharge back to the SNF, she was readmitted the next morning with an identical presentation after her BiPAP was again not administered for nine hours. Subsequent management additionally included a detailed, direct peer-to-peer telephonic sign-out with the SNF staff to ensure consistent BiPAP administration. This intervention proved successful, and the patient was discharged without further readmission.

Discussion: This case offers educational value by highlighting the crucial role of NIV, such as BiPAP, in patients with cardiorespiratory compromise. BiPAP offers a dual benefit - it supports respiratory function and improves cardiac output by reducing both preload and afterload, often averting the need for more invasive interventions. Additionally, this case emphasizes the importance of direct peer-to-peer communication, as reliance on electronic systems alone can omit subtle details, potentially compromising patient safety during care transitions. Personal interactions among healthcare providers, increasingly uncommon in the current era of electronic communication, often facilitate clearer understanding, convey urgency, and promote accountability, thereby enhancing patient safety and outcomes.


Dual Pump Failure and Communication Failure: Lessons from Recurrent Hospitalizations in Emery-Dreifuss Muscular Dystrophy - A Case Report

Background: Liver cancer is the sixth leading cause of cancer death in the United States (US), and is one of 13 different types of cancer related to obesity. Access to healthy food is a modifiable factor that reduces liver cancer morbidity and mortality risk, but residing in areas with no grocery store and greater access to unhealthy food options (i.e. food swamps) reduces healthy food access. Georgia ranks ninth in the US with low access to key food resources, with over 80% of Georgia counties having significantly high food swamp scores. The association between food swamps and liver cancer in Georgia is poorly elucidated, so we examined the county-level relationship between food swamps and liver cancer mortality in Georgia. 

Methods: We performed a cross-sectional (ecological) analysis using 2010 – 2020 data from the US Department of Agriculture Food Environment Atlas, US Census, and Centers for Disease and Control (CDC) Wonder database. A total of 86 rural Georgia counties were analyzed with complete information on food environment scores and liver cancer mortality. The ratio of fast food and convenience stores to grocery stores and farmer’s markets defined food swamps. Higher scores indicated greater access to unhealthy food resources. An age-adjusted, mixed-effects regression model was run for the association of food swamp scores with liver cancer mortality rates. 

Results: Rural Georgia counties with high liver cancer mortality rates had higher poverty rates (20.4 vs. 16.3), and food swamp scores (28.9 vs. 27.6) compared to counties with low mortality rates (p - value < 0.05). There were 50% increased odds of having high liver cancer mortality rates among Georgia counties with high food swamp scores vs. low food swamp scores (AOR = 1.50; 95% CI: 0.48 - 4.65) in fully adjusted models.  

Conclusions: We found a nonsignificant higher association between high food swamp scores and liver cancer mortality. Future steps include utilizing Georgia Cancer Center patient-level data to further elucidate the potential association between food swamps and liver cancer outcomes. New policy and governmental action should be prioritized regarding healthy food access for rural Georgia counties to combat obesity and cancer-related outcomes especially among disenfranchised populations.

The Association Between Food Swamps and Liver Cancer Mortality Among Rural Georgia

Concussions are a mild traumatic brain injury that affects brain function – typically caused by a head or body impact, which often impacts high school athletes. Post-injury accommodations vary by school, and teachers feel inadequately prepared for students' Return-to-Learning due to their perceived lack of knowledge. We looked at differences between teachers who do not coach and teachers who currently or previously coached a sport at James Campbell High School in ‘Ewa Beach, Hawai’i on their concussion detection and subsequent academic accommodations related knowledge and perceptions. An interview schedule was adapted using items from BAKPAC-TEACH. Teachers and teachers who were also coaches were invited to participate in focus group interviews via zoom. Interviews were recorded and transcribed. Transcripts were analyzed for themes using ChatGPT4.5 and the analysis was validated with manual content analysis. Both groups expressed dissatisfaction with their current training because it is ineffective as it is brief and provided alongside unrelated topics. There is a lack of guidelines on academic accommodations, and they wish for more accessible resources that outline accommodations and the Return-To-Learn criteria.

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Case Report - Invasive Ductal Carcinoma Following Removal of Benign Breast Tumor in 93-Year-Old Male

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