Telephone-based anticoagulation management in the homebound setting: a retrospective observational study.

BACKGROUND: Anticoagulation management is currently performed through anticoagulation clinics or self-managed with or without the help of medical services. Homebound patients are a unique population that cannot utilize anticoagulation clinics or self-testing. Telephone-based anticoagulation management could be an alternative to the traditional methods of monitoring warfarin in this subgroup. The objective of this retrospective, observational study is to investigate the feasibility of warfarin management in homebound patients. METHODS: This study was performed through the use of telephone-based adjustments of warfarin dose based on an international normalized ratio (INR) result. Four hundred forty-eight homebound patients referred to the anticoagulation clinic at Staten Island University Hospital were visited at home by a phlebotomist; a blood sample was drawn for initial laboratory testing. A nurse practitioner then called the patient or designated person to relay the INR result and to direct dosage adjustment. INR results and dosage changes were entered into an electronic medical record and analyzed statistically. RESULTS: The mean percentage of INR values in range was 58.39%. The mean time when the INR was in the therapeutic range was 62.75%. The percent of patients who were therapeutically controlled decreased as the number of medications increased. The complication rate was 4% per patient year, with an equal distribution between bleeding and clotting. These values compared favorably to other studies in which monitoring was performed through anticoagulation clinics or self-monitoring. The cost per visit at our anticoagulation clinic was found to be approximately $300 compared with $82 when utilizing our homebound service. CONCLUSION: Telephone-based management of warfarin therapy in the homebound setting is feasible. It can lower the cost of health care expenditures compared to other modalities of anticoagulation management.

Value of the pretreatment albumin to globulin ratio in predicting long-term mortality in breast cancer patients.

BACKGROUND: Prior studies have demonstrated the prognostic value of pretreatment serum albumin in different types of cancer. The aim of this study was to assess the predictive value of the albumin to globulin ratio (AGR) on survival in breast cancer patients. METHODS: This retrospective study used an unselected cohort of 354 breast cancer patients who had documented total protein and albumin levels prior to chemotherapy. Survival status was obtained from our cancer registry. Survival analysis, stratified by AGR tertiles, was used to evaluate the prognostic value of AGR. RESULTS: Patients in the highest AGR tertiles (AGR > 1.45) had a lower 5-year mortality rate compared with those in the middle (AGR 1.21 to 1.45) and the lowest (AGR < 1.21) tertiles (6% vs. 18% and 32%, P < .001). After adjusting for confounding variables, AGR remained a significant predictor of mortality (P < .002). Moreover, after excluding the patients with albumin levels less than 3.6, the AGR remained a significant predictor of survival (P .0018). CONCLUSIONS: Pretreatment AGR is an independent, significant predictor of long-term mortality in breast cancer patients, even in patients with normal albumin levels.

Gastroduodenal artery aneurysm, diagnosis, clinical presentation and management: a concise review.

Gastroduodenal artery (GDA) aneurysms are rare but a potentially fatal condition if rupture occurs. They represent about 1.5% of all visceral artery (VAA) aneurysms and are divided into true and pseudoaneurysms depending on the etiologic factors underlying their development. Atherosclerosis and pancreatitis are the two most common risk factors. Making the diagnosis can be complex and often requires the use of Computed Tomography and angiography. The later adds the advantage of being a therapeutic option to prevent or stop bleeding. If this fails, surgery is still regarded as the standard for accomplishing a definite treatment.

Small cell lung cancer doubling time and its effect on clinical presentation: a concise review.

Small cell lung cancer (SCLC) is one of many types rapidly growing malignant diseases, such as Burkitt's lymphoma and testicular germ cell cancers. At present, there is no reliable way to screen for SCLC, and imaging modalities tend to be delayed in detecting this type of cancer. The clinical presentation of acutely and rapidly growing SCLC can mimic those of pulmonary inflammatory or infectious disorders, and in some instances, this delays appropriate management and negatively affects patient outcome.

Primary neuroendocrine breast cancer, how much do we know so far?

Primary neuroendocrine cancer of the breast (NECB) is an extremely rare tumor. In 2003, the World Health Organization (WHO) recognized this category with three well-described subtypes: small cell, large cell, and carcinoid-like carcinoma; very few peer-review publications based on the WHO definition were encountered in the literature, and we conducted a literature search to investigate the reported incidence, diagnosis, prognosis, hormone receptor status, and treatment options for this rare tumor. Confirming the breast as an origin of neuroendocrine tumor represents a challenge. The diagnosis is mainly dependent on the exclusion of other extra-mammary organs based on clinical, radiological, and pathological data. Except for the very rare type small cell carcinoma, estrogen and progesterone receptors were reported to be expressed in 90 and 83% of NECB, respectively. It is hypothesized that primary breast neuroendocrine carcinoma differentiates from the epithelial cells during the carcinogenesis process; the prognosis of non-small cell primary NECB seems to improve as the amount of mucinous component increases in the tumor specimen. Management similar to interventions utilized to manage the usual ductal-type carcinoma has been attempted in the past, such as chemotherapy and hormonal therapy; however, due to the rarity of the tumor, none of the published studies are randomized nor do they have a large number of patients. Additionally, none of reports analyzed NECB based on its distinct subtypes. These limitations make recommendations largely based on anecdotal and small observatory studies and call for the need for further research in this extremely rare tumor.

Does hormonal therapy have a therapeutic role in metastatic primary small cell neuroendocrine breast carcinoma? Case report and literature review.

Primary neuroendocrine carcinoma of breast (NECB) is a very rare tumor; the World Health Organization(WHO) subcategorized these tumors into 3 major histologic subtypes: solid, small cell carcinoma (SMCC), and large cell NE carcinoma. The SMCC subtype is the least common and most aggressive and has been reported to be as aggressive as its pulmonary counterpart. SMCC is usually confirmed based on clinical, pathologic,and imaging studies. Local disease is usually managed in a fashion similar to that of the usual ductal breast cancer; in the metastatic SMCC setting, regimens that are implemented in small cell lung cancer are usually attempted, according to case reports and published small case series. Hormone receptors can be expressed in more than 90% of the solid tumor subtype; however its expression is manifested in about 50% of cases of SMCC. Although hormonal therapy can be used successfully to treat the usual metastatic ductal breast cancer,its utility in metastatic SMCC has not been reported. We report an impressive response to hormonal therapy in a patient with late relapse of breast carcinoma with a metastatic SMCC subtype that expressed hormone receptors. The response to hormonal therapy was sustained for about 12 months. The response to hormonal therapy is definitely an interesting finding that, to our knowledge, has not been described before in the setting of metastatic SMCC. We suggest considering adding hormonal therapy to the treatment pipeline for primary SMCC of the breast that express hormone receptors.

Cement pulmonary embolism after percutaneous vertebroplasty and kyphoplasty: an overview.

BACKGROUND: Because of the aging of the American population, osteoporotic vertebral fractures are becoming a common problem in the elderly. Minimally invasive percutaneous vertebral augmentation techniques have gained a great deal of importance in relieving the pain associated with these fractures, and are becoming the standard of care. METHODS: These procedures involve the injection of polymethylmethacrylate (PMMA) into the vertebral body. However, these techniques have their complications, and among these, pulmonary embolism is one of the most feared. It is attributable to the passage of cement into the pulmonary vasculature. After encountering a case of PMMA embolism in our practice, we decided to highlight this topic and discuss the incidence, clinical presentation, diagnosis, and treatment of cement pulmonary embolisms.

Does Kaposi's sarcoma predict multicentric Castleman disease in the presence of generalized lymphadenopathy?

Multisystemic Castleman disease (MCD) can be associated with HHV8 infection, which involves the mantle zone of follicles. This condition results in an increase number of HHV8-positive (HHV8+) plasmablasts that multiply and amalgamate to form plasmablastic B-cell lymphoma. All previously reported cases of HIV-positive patients with MCD were coinfected with HHV8. Twelve cases of HIV- MCD that are HHV8+ were encountered in the literature, three of them developed lymphoma, and none of those cases were reported to have Kaposi's sarcoma (KS). We report a unique case of HIV-negative elderly woman with preexisting KS that presented to the hospital with recurring nausea, vomiting, and fever, assessment revealed diffuse lymphadenopathy. Axillary lymph node biopsy showed HHV8+ MCD with foci of microlymphoma. Despite the treatment with high-dose steroids, she developed multisystem failure that lead to her death.

A complete resolution of sialadenitis induced by iodine containing contrast with intravenous dexamethasone infusion.

Salivary gland enlargement following the administration of iodine is an extremely rare event, and the pathophysiology of iodine-induced sialadenitis is not yet fully known. The onset of symptoms can start within a few minutes to five days after contrast administration. The course of iodine-induced sialadenitis is extremely benign, and rapid resolution of symptoms is expected without treatment. We report the case of a 59-year-old white female who noted mildly painful swelling involving the right side of her face within five days of receiving intravenous iodine-containing contrast. A diagnosis of iodine-related sialadenitis was made. She was given 20 mg of decadron intravenously, with prompt resolution of the swelling within a few hours.

Thymoma calcification: is it clinically meaningful?

Among anterior mediastinal lesions, thymoma is the most common. Thymomas are tumors of thymic epithelial cell origin that are distinguished by inconsistent histological and biologic behavior. Chest imaging studies typically show a round or lobulated tumor in the anterior mediastinum. Calcifications in thymomas are classically punctuate or amorphous, positioned within the lesion. Chest computed tomography (CT) features suggesting higher risk thymoma consist of tumor heterogeneity, vascular involvement, lobulation, pulmonary nodules, lymphadenopathy, and pleural manifestations. Imaging findings have an imperfect ability to predict stage and prognosis for thymoma patients. Our objective is to highlight the clinical implications of thymoma calcifications on the diagnosis, clinical manifestation and prognosis. A pubmed and google search was performed using the following words: thymoma calcification, calcified thymus, mediastinal calcification, anterior mediastinal calcification, and calcified thymoma. After reviewing 370 articles, 32 eligible articles describing thymoma calcifications were found and included in this review. Although the presence of thymus calcifications was more common in patients with invasive thymomas, they were present in significant portion of non-invasive thymomas. The presence of calcifications was not a significant factor in differentiating between benign and malignant thymoma. As a result, the type, location, size or other characteristics of thymus gland calcifications were not relevant features in clinical and radiologic diagnosis of thymoma. The histopathological diagnosis is still the only possible way to confirm the neoplastic nature of thymoma. All types of thymomas should be evaluated and managed independently of the presence of calcifications.