Racial and regional disparities in deaths in breast cancer.

Breast cancer is the second most diagnosed malignancy in American women with a lifetime occurrence of 1 in 8 women in the United States. There has been a dearth of research focusing on regional differences in breast cancer mortality with respect to race in the US. It is crucial to identify regions that are lagging to uplift the outreach of breast cancer care to certain races. Data for this study were obtained from the 2016-2018 Nationwide Inpatient Sample. In-hospital mortality, race and hospital regions for the patients with the primary diagnosis of Malignant Neoplasms of Breast were studied. Baseline characteristics of participants were summarized using descriptive statistics. The patient population was stratified as per race, hospital region, gender, therapy received and family history. Logistic regression was performed to derive the odds ratio while adjusting for different variables. 99, 543 patients with metastatic breast cancer were identified. African Americans (AAs) were found to have the highest reported deaths at 5.54%, followed by Asians and Pacific Islanders at 4.80% and Caucasians 4.09% (p < 0.0001). The odds of dying were significantly higher in the AA population when compared to Caucasian population (OR 1.391 (1.286-1.504)), and the odds were consistently higher across all regions of the US. In terms of regional disparities with respect to race, AA's had highest mortality in the south whereas all other races had the highest mortality in the west. It was seen that races identifying as "others" had significantly higher odds of dying in the Northeast. It is crucial to identify racial differences in the various regions across the US in order to implement appropriate outreach strategies to tackle these disparities.

Ocular complications of plasma cell dyscrasias.

Plasma cell dyscrasias are a wide range of severe monoclonal gammopathies caused by pre-malignant or malignant plasma cells that over-secrete an abnormal monoclonal antibody. These disorders are associated with various systemic findings, including ophthalmological disorders. A search of PubMed, EMBASE, Scopus and Cochrane databases was performed in March 2021 to examine evidence pertaining to ocular complications in patients diagnosed with plasma cell dyscrasias. This review outlines the ocular complications associated with smoldering multiple myeloma and monoclonal gammopathy of undetermined significance, plasmacytomas, multiple myeloma, Waldenström's macroglobulinemia, systemic amyloidosis, Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal gammopathy and Skin changes (POEMS) syndrome, and cryoglobulinemia. Although, the pathological mechanisms are not completely elucidated yet, wide-ranging ocular presentations have been identified over the years, evolving both the anterior and posterior segments of the eye. Moreover, the presenting symptoms also help in early diagnosis in asymptomatic patients. Therefore, it is imperative for the treating ophthalmologist and oncologist to maintain a high clinical suspicion for identifying the ophthalmological signs and diagnosing the underlying disease, preventing its progression through efficacious treatment strategies.

Allogeneic Hematopoietic Stem Cell Transplantation in the Outpatient Setting: The Mayo Clinic Experience.

Hematopoietic stem cell transplantations (HSCT) are intensive and potentially curative modalities available for a variety of hematological diseases. Although alloHSCTs are typically performed in an inpatient setting, there has been increasing interest in moving them to the outpatient setting. AlloHSCTs are associated with a median length of hospital stay of 30 days. AlloHSCTs in the inpatient setting may increase patient exposure to nosocomial infections, drug-resistant organisms, rapid deconditioning with time spent in hospital beds, and loss of muscle mass. In this study, we aim to share outcomes of 856 consecutive alloHSCTs done in our institute over the past 2 decades. This is a single-center retrospective chart review encompassing 856 patients who underwent outpatient alloHSCTs between 2000 and 2017. Reduced-intensity conditioning, stem cell infusion, and much of the immediate follow-up in the early alloHSCT period was performed on an outpatient basis with daily evaluation, laboratory assessment, and intervention as needed. Rate of non-routine hospital admission was our primary outcome of interest. We also looked at various secondary outcomes, including causes of admission, median length of stay, and in-hospital mortality rate. Data analysis was performed using STATA statistical software Version 15. Descriptive statistics were used to summarize baseline demographic data and outcomes. Logistic regression modeling was used to identify predictors of hospital admission. We observed that about one third of our cohort never required admission to the hospital throughout the first 100 days after HSCT. Among those admitted, 6.6% experienced a direct admission to the intensive care unit, and the overall in hospital mortality was low at 5%. Furthermore, the median length of stay was noted to be decreased at 6 days compared to a median reported 30 days in existing literature. Overall, we observed favorable safety profile and outcomes with outpatient management of HSCTs.

Impact of the COVID-19 Pandemic on the Overall Health of Patients With Pre-diabetes and Diabetes.

Coronavirus disease 2019 (COVID-19) impacted those with chronic diseases worldwide, especially those with diabetes. Very few studies have explored the effect of COVID-19 on diabetic patients' health markers. The present retrospective study compared various health markers of diabetic patients before and during the COVID-19 pandemic. Patients (N = 511) displayed a significant increase in systolic blood pressure, hemoglobin A1c (HbA1c), diabetic medications, and dose of insulin (p < 0.05) as well as a decrease in low density lipoprotein (LDL) levels (p = 0.04). When patients were stratified by body mass index (BMI), those in higher BMI categories were more negatively impacted during the pandemic than those in lower categories. Results display the impact that COVID-19 had on the general well-being of diabetic patients, and should encourage providers to increase telehealth visits when in-person visits are not possible.

The Impact of Winter Months on Venous Thromboembolism (VTE) Patients: A Retrospective Analysis of Hospital Outcomes in the United States.

OBJECTIVE: We aimed to analyze the Health Care Utilization Project's (HCUP) Nationwide Inpatient Sample (NIS) and compare mortality rates in hospitals by month to determine if there is seasonal variability in outcomes associated with venous thromboembolism (VTE). METHODS: The Nationwide Inpatient Sample database was queried from 1998 to 2011. Inclusion criteria were a diagnosis of deep vein thrombosis (DVT) (ICD-9 {International Classification of Diseases, Ninth Revision, Clinical Modification} 453.4, 453.8) and/or VTE (ICD-9 415.1) in patients aged 18 years or more. Admission data was then analyzed to compare mortality rates in teaching and non-teaching hospitals over that time and by month. Demographics, Charlson Comorbidity Index, length of stay (LOS), hospital region, and admission types (emergent/urgent versus elective admissions) were assessed. Linear and logistic models were generated for complex survey design to analyze predictors of mortality and LOS. RESULTS: A total of 1,449,113 DVT/VTE cases were identified in the Nationwide Inpatient Sample (weighted n= 7,150,613), 54.7% female, 56.38% white, 49% in teaching hospitals. Higher mortality was found in the months of November 6.52%, December 6.9%, January 6.94%, and February 6.93% versus overall mortality of 6.4% over 12 months. Higher mortality was noted in these winter months in all regions, along with a significantly increased LOS. Mortality in the total cohort was found to be higher in January, with odds ratio (OR) 1.11 (1.08-1.15), p<0.0001; February, OR 1.11 (1.07-1.15), p<0.0001; and December, OR 1.10 (1.06-1.14), p<0.0001 compared to June. Mortality was significantly lower in the Midwest or North Central regions (OR 0.78 {0.72-0.83}, p<0.0001) and West (OR 0.80 {0.73-0.87}, p<0.0001) compared to the Northeast. Mortality was also significantly higher in teaching hospitals than in non-teaching hospitals (OR 1.16 {1.10-1.22}, p<0.0001), with mortality trending higher in teaching hospitals each month. Emergent/urgent admission, larger hospital size, female sex, age, and urban location were also significantly associated with increased mortality. CONCLUSIONS: This national study identified an increased risk of mortality associated with hospitalizations for DVT/VTE in the winter months, independent of hospital teaching status or region.

Feasibility of Global Assessment of Bone Metastases in Prostate Cancer with 18F-Sodium Fluoride-PET/Computed Tomography.

18F-sodium fluoride (NaF) PET/computed tomography (CT) allows detection of bone metastases in patients with prostate cancer (PCa). The aim of this study was to test the feasibility of assessing global metastatic bone disease in patients with PCa by using a threshold-based PET segmentation technique. This retrospective analysis was performed in 32 patients with PCa with known bone metastases who underwent NaF-PET/CT imaging. An adaptive contrast-oriented thresholding technique was used to segment NaF avid lesions. The mean metabolic volumetric product (MVPmean), partial volume-corrected MVPmean (cMVPmean), and metabolically active volume (MAV) were calculated. Lesional values were summed within each patient to obtain the global PET disease burden. Pearson correlation analysis was used to assess the associations between global NaF-PET/CT metrics and clinical biomarkers of metastatic disease activity. Global MVPmean, cMVPmean, and MAV were significantly correlated with alkaline phosphatase (ALP) levels (p < 0.05). No correlation was observed between global NaF-PET/CT measures and prostate-specific antigen (PSA) levels. Global assessment is a feasible method to quantify metastatic bone disease activity in patients with PCa. Convergent validity was supported by demonstrating a significant correlation between NaF-PET/CT parameters and blood ALP levels.

Widening spectrum of neuroleptic malignant syndrome: Case series.

Neuroleptic malignant syndrome (NMS) is a rare and rapidly progressive syndrome with mortality rate of 5.6%. The spectrum of onset, progression and outcome is heterogeneous and is associated with number of risk factors. In our case series, we entail the triggers, hospital course and outcome of five interesting in-patient cases that were admitted to our service in a tertiary care hospital in Northern India. This case series is to highlight the first ever reported case of NMS triggered by levosulpiride administration, along with one of the few first cases of NMS after programming of DBS, hypothyroid disorders, levodopa readjustment and selective basal ganglia and cerebellar injury following the hyperthermic syndrome. This is also to bring to attention of clinicians worldwide the atypical risk factors of NMS, and stress the importance of staying vigilant for the same by frequent follow-ups and high degree of clinical suspicion. We also aim to generate epidemiological data about these atypical triggers.

Isolated Pyridoxine Deficiency Presenting as Peripheral Neuropathy Post-chemotherapy.

Pyridoxine deficiency is a rare but identifiable cause of sideroblastic anemia, depression, and peripheral neuropathy. Platinum-based chemotherapeutic drugs display structural similarity to pyridoxine, which interferes with the absorption and hence the efficacy of the drug. If left untreated, it can lead to irreversible axonal loss and permanent deficits, leading to falls. Our case is a highly unusual scenario of isolated pyridoxine deficiency presenting as peripheral neuropathy and depression as a delayed side effect of chemotherapeutic drugs.

Atezolizumab-induced autoimmune diabetes mellitus presenting as diabetic ketoacidosis and Takotsubo cardiomyopathy.

Atezolizumab is a humanised monoclonal IgG1 antibody that is used in treating many solid malignancies. Endocrinopathies are known but a rare adverse event of these immunotherapeutic drugs. Autoimmune diabetes induced by atezolizumab has been rarely reported in the literature. We report the case of a woman in her eighth decade with no known history of diabetes who developed new-onset autoimmune diabetes and Takotsubo cardiomyopathy due to the adverse effects of atezolizumab therapy for hepatocellular carcinoma. We also review the characteristics and outcomes of cases previously reported in the literature.

Evaluating the Correlation of Bariatric Surgery and the Prevalence of Cancers in Obese Patients: A Study of the National Inpatient Sample (NIS) Database.

Purpose Obesity is a global pandemic that exerts a significant burden on healthcare worldwide. Multiple cancers, as well as deaths from the same, are more prevalent in obese patients. Bariatric surgery has been shown to be the most effective way of treating obesity once other measures have been exhausted. There is no concordant data available to support that bariatric surgery can reduce the prevalence of cancer. Using one of the largest data samples, we evaluate the correlation of bariatric surgery in morbidly obese patients with the prevalence of obesity-related cancers (breast, endometrial, esophageal, colorectal, prostate, and renal) in morbidly obese patients. Patients and methods A sample of 7,672,508 morbidly obese patients was identified from the 1994 to 2004 records of the National Inpatient Sample (NIS) database, divided into those who did and did not undergo bariatric surgery, and studied for the prevalence of obesity-associated cancers. Results Obesity was predominantly seen in the Caucasian population (68.22%). The mean age of cases who underwent bariatric surgery was younger when compared to those who did not undergo the procedure (43.89±25.16 vs. 54.90±36.40, p-value <0.0001). The highest bariatric surgery rate was seen in the Northeast (5.57%), followed by the West (4.15%), South (3.02%), and Midwest (2.96%) (p-value <0.0001). Overall, the odds of morbidly obese patients who underwent bariatric surgery and developed cancer are: esophageal cancer 0.19 (0.1218-0.3078, p <0.0001), colorectal cancer 0.0368 (0.0275- 0.0493, p <0.0001), endometrial cancer 0.0155 (0.0099-0.0244, p <0.0001), breast cancer 0.0712 (0.0582-0.0871, p <0.0001), prostate cancer 0.0285 (0.0199-0.0408, p <0.0001) and renal cancer 0.0182 (0.0106-0.0314, p <0.0001). The odds of cancer post-bariatric surgery remained significantly lower even after matching certain confounding factors. Conclusions The odds of developing breast, esophageal, prostate, renal, and colorectal cancers are significantly lower in morbidly obese patients who undergo bariatric surgery.

Cerebral Toxoplasmosis As the Initial Presentation of HIV: A Case Series.

The HIV epidemic afflicts millions across the globe, and Sub-Saharan countries bear a disproportionately high burden. Cerebral toxoplasmosis is commonly seen as the disease progresses but is rarely ever reported as the initial manifestation of HIV. The clinical presentation, co-existing risk factors, and outcomes remain underreported. The objective of this article is to report cerebral toxoplasmosis as the initial manifestation of HIV. This is a consecutive series of three patients that presented to a community hospital in Pennsylvania, United States, with a variety of neuropsychiatric symptoms and were found to have cerebral toxoplasmosis. The findings are compared with existing literature on cerebral toxoplasmosis as the initial manifestation of HIV. Cerebral toxoplasmosis as the initial manifestation of HIV is a rarely reported phenomenon. Hyponatremia may be linked with this disease-complex, although further studies are warranted to establish a causal relationship. Co-infection with hepatitis viruses is also a common finding in these patients.

Aggressive Vertebral Hemangioma: The Mystery of Spastic Legs Unveiled by a Purple Shoulder.

Vertebral hemangiomas (VHs) are benign vascular tumors that develop from the endoderm of blood vessels, although their exact pathogenesis is poorly understood. Most hemangiomas are small, about a third are multiple in number, and a very small number of these hemangiomas cause symptoms. Even more rare are aggressive VHs, which comprise a small number of all VHs, and are associated with expansion and extraosseous extension into the paraspinal and epidural spaces. Management of aggressive VHs involve pre-op embolization, spinal surgery, and reconstruction. Pain management, physical rehabilitation, and close neurological follow-up are imperative to near-total recovery. Aggressive VHs are most commonly seen in the thoracic region but may rarely involve a large number of vertebrae. Cutaneous hemangiomas, when seen along with VHs, are often metameric.  We present a rare and challenging case of compressive myelopathy and a large cutaneous hemangioma or a "purple shoulder", found during an exam in a young male. He was found to have an extensive VH extending through 13 vertebral levels (C7 to D12), non-metameric to the cutaneous lesion. A thorough physical examination and evaluation along with prompt surgical treatment were the cornerstone of treatment and prevention of permanent neurological deficits.

Grade 3 Neuroendocrine Tumor (G3NET): An Unusual Tumor With A Histochemical Surprise.

Given the rare occurrence and the indolent course of Neuroendocrine tumors (NETs), few epidemiological studies exist on these cancers. A small but interesting subset of these tumors are G3- Neuroendocrine Tumors. Grade 3 Neuroendocrine tumors (or G3-NETs) are unique in their intermediate prognosis. These grade discordant tumors lie in between high-grade poorly differentiated neuroendocrine carcinomas and grade 2 well-differentiated NETs, which have a worse and better prognosis than this rare entity, respectively. In this case report, we present a case of Grade 3 NET with an unusually high Ki67 index, diagnosed upon biopsy of metastasis visualized on imaging. Additionally, we review existing literature for characteristics, immunohistochemical markers, prognosis, and treatment modalities for the same.

PSMA: a game changer in the diagnosis and treatment of advanced prostate cancer.

Although management of advanced prostate cancer is evolving, a lot of work remains to be done for patients who have exhausted all options. Molecular targeting of prostate specific membrane antigen (PSMA) is valuable not only for diagnostic but also for therapeutic reasons. PSMA is thus considered to be useful in a theranostic approach. PSMA scans are upcoming diagnostic modalities which detect metastatic lesions that are missed by conventional imaging modalities. PSMA ligand therapy is also an upcoming treatment modality that has been proven to be beneficial with minimal toxicity in patients with advanced prostate cancer that have progressed on prior therapy. In this review article, we summarize the current knowledge regarding PSMA diagnostics and PSMA ligand therapies and discuss their implication in the treatment of advanced prostate cancer.

HIV-Associated Anal Cancer.

Anal cancer, despite being a rare malignancy, is increasing in incidence, accounting for 0.5% of all new cancer cases in the United States, with rate of new cases being 1.9 per 100,000 men and women. It is common in immunocompromised individuals, especially those with malignancy, human immunodeficiency virus (HIV) and human papillomavirus (HPV) infection. Despite similar treatment of anal cancer in both HIV-positive and negative patients, guidelines for prevention and treatment of therapy-related side effects are rarely studied. While these patients have a better prognosis on HAART, limited guidelines exist regarding appropriate therapy. There is a common link between HPV and HIV and the transmission of one is associated with increased risk of transmission of the other. HPV vaccine which is known to prevent high-grade cervical intraepithelial neoplasia is thought to also decrease the incidence of anal intraepithelial neoplasia. The association of HPV vaccine in the prevention of anal cancer in high-risk groups with HIV is a scarcely studied subject that requires further research.

Ocular Manifestations of Neuronal Ceroid Lipofuscinoses.

Neuronal ceroid lipofuscinoses (NCLs) are a group of rare neurodegenerative storage disorders associated with devastating visual prognosis, with an incidence of 1/1,000,000 in the United States and comparatively higher incidence in European countries. The pathophysiological mechanisms causing NCLs occur due to enzymatic or transmembrane defects in various sub-cellular organelles including lysosomes, endoplasmic reticulum, and cytoplasmic vesicles. NCLs are categorized into different types depending upon the underlying cause i.e., soluble lysosomal enzyme deficiencies or non-enzymatic deficiencies (functions of identified proteins), which are sub-divided based on an axial classification system. In this review, we have evaluated the current evidence in the literature and reported the incidence rates, underlying mechanisms and currently available management protocols for these rare set of neuroophthalmological disorders. Additionally, we also highlighted the potential therapies under development that can expand the treatment of these rare disorders beyond symptomatic relief.

Metastatic squamous cell carcinoma of the colon: a conundrum in colorectal malignancies.

Small-cell carcinoma of the colon is an extremely rare tumour, with poorly understood pathogenesis and unestablished treatment guidelines. The first case was documented in 1919, and only about 100 cases of this condition have been reported to this date. In this case report, we present a case of sigmoid squamous cell carcinoma that eventually led to bowel perforation and was diagnosed on histopathology after emergent surgical intervention. Additionally, we also review the incidence, epidemiology, pathogenesis, immunohistological markers, neogenomics and therapeutic strategies for the same.

Current Perspectives on Management of Type 2 Diabetes in Youth.

The prevalence of type 2 diabetes mellitus (T2DM) in children and adolescents is on the rise, and the increase in prevalence of this disorder parallels the modern epidemic of childhood obesity worldwide. T2DM affects primarily post-pubertal adolescents from ethnic/racial minorities and those from socioeconomically disadvantaged backgrounds. Youth with T2DM often have additional cardiovascular risk factors at diagnosis. T2DM in youth is more progressive in comparison to adult onset T2DM and shows lower rates of response to pharmacotherapy and more rapid development of diabetes-related complications. Lifestyle modifications and metformin are recommended as the first-line treatment for youth with T2DM in the absence of significant hyperglycemia. Assessment of pancreatic autoimmunity is recommended in all youth who appear to have T2DM. Pharmacotherapeutic options for youth with T2DM are limited at this time. Liraglutide, a GLP-1 agonist, was recently approved for T2DM in adolescents 10 years of age and older. Several clinical trials are currently underway with youth with T2DM with medications that are approved for T2DM in adults. Bariatric surgery is associated with excellent rates of remission of T2DM in adolescents with severe obesity and should be considered in selected adolescents.

Clinical characteristics of epilepsy in resource-limited communities in Punjab, Northwest India.

OBJECTIVES: To describe clinical characteristics of a community-based epilepsy cohort from resource-limited communities in Punjab, Northwest India. METHODS: The cohort was gathered following a two-stage screening survey. We cross-sectionally examined and followed up the cohort for one year. A panel of neurologists assigned seizure types, syndromes, and putative etiologies and categorized drug responsiveness. RESULTS: The cohort of 240 included 161 (67.1%) men, 109 (45.4%) illiterates and 149 (62.1%) unemployed. Current age was >18 years in 155 (64.6%) but age at epilepsy onset was <18 years in 173 (72.1%). Epilepsies due to structural and metabolic causes were diagnosed in 99 (41.3%), but syndromic assignments were not possible in 97 (40.4%). After one year, drug-resistant epilepsy was established in 74 (30.8%). Perinatal events (n = 35; 14.6%) followed by CNS infections (n = 32; 13.3%) and traumatic brain injury (n = 12; 5.0%) were common risk factors. Most of those with CNS infections (n = 19; 63.3%), perinatal antecedents (n = 23; 76.7%), and other acquired risk factors (n = 27; 90.0%) presented with epilepsy due to structural and metabolic causes. Perinatal events were the putative etiology for nearly 40.7% of generalized epilepsies due to structural and metabolic causes and 28.2% of all epilepsies with onset <10 years. SIGNIFICANCE: Existing classifications schemes should be better suited to field conditions in resource-limited communities in low- and middle-income countries. The finding of drug-resistant epilepsy in nearly at least a third in a community-based sample underscores an unmet need for enhancing services for this segment within healthcare systems. Perinatal events, CNS infections, and head injury account for a third of all epilepsies and hence preventative interventions focusing on these epilepsy risk factors should be stepped up.