Outcomes of delays in time to treatment in triple negative breast cancer.

BACKGROUND: Compared with other breast cancer subtypes, triple negative breast cancers (TNBC) are associated with higher recurrence rates and worse survival. Because of the aggressive nature of TNBC, outcomes may be more sensitive to delays in time to treatment. This study evaluates whether delays from diagnosis to initial treatment in TNBC impacts survival or locoregional recurrence (LRR). METHODS: Retrospective review of TNBC patients treated between January 2004 and January 2011 at an academic center was performed. Data collected included demographics, pathology, treatment, recurrence, and survival. Interval to treatment was defined as days from pathologic diagnosis to first local or systemic treatment. The t test, Cox regression, and Kaplan-Meier analyses were used to evaluate impact of time to treatment on overall survival and LRR. RESULTS: Median follow-up was 40 months for 301 TNBC patients. Mean interval to treatment was 46 ± 2 days. Higher initial stage yielded worse survival (p < .0001). Interval to treatment did not impact overall survival (p = .24), although there was a trend toward worse survival with delays of >90 days (p = .06). LRR was seen in 20 patients (7 %). Median time to recurrence was 15 months. Time to treatment was 38 ± 6 days for patients with LRR versus 44 ± 2 days without a recurrence (p = .37). Short delay in time to treatment did not impact LRR (p = .54). CONCLUSIONS: In TNBC, a short delay from pathologic diagnosis to initial treatment does not appear to adversely affect survival or LRR. Appropriate time to perform evaluations such as genetic testing, imaging, or additional consultation can be taken to guide optimal treatment options.

Cessation of clopidogrel before major abdominal procedures.

OBJECTIVE: To determine whether timing of clopidogrel bisulfate cessation influences outcome after abdominal operations. METHODS: A review was performed of 104 patients receiving clopidogrel who underwent abdominal operations between March 2003 and March 2009. Patients were grouped by last clopidogrel use: group A (<7 days) and group B (≥7 days). RESULTS: Of 104 patients, 43 were in group A and 61 were in group B. Overall, 6 deaths occurred (group A, 5 patients [12%] vs group B, 1 [2%]; P = .03) and 27 patients required intensive care unit admission (group A, 16 patients [37%] vs group B, 11 [18%]; P = .03). Twenty-one patients developed a postoperative bleeding complication; 19 complications were managed by blood transfusion and 2 required reoperation. Group A vs group B had significantly increased rates of postoperative bleeding requiring blood transfusion (13 patients [30%] vs 8 [13%]; P = .03). No significant difference in postoperative bleeding resulting in reoperation or mortality was demonstrated. Timing of clopidogrel cessation within 7 days did not affect postoperative bleeding risk. Eighty-nine patients (86%) underwent elective operations (group A, 30 patients [70%] vs group B, 59 [97%]; P < .001). While elective patients in group A vs those in group B demonstrated a trend toward increased risk of postoperative bleeding requiring transfusion (7 patients [23%] vs 8 [14%]; P = .25), no significant difference in intensive care unit admission (group A, 6 patients [20%] vs group B, 9 [15%]; P = .31) or mortality (1 [3%] vs 1 [2%]; P = .62) was demonstrated. CONCLUSIONS: While clopidogrel use within 7 days of an operation significantly increased the risk of postoperative bleeding, most bleeding episodes were successfully managed by transfusion without an increase in bleeding-related mortality or necessity for reoperation. After controlling for operative urgency, no significant difference in mortality or intensive care unit admission was demonstrated in patients undergoing elective procedures. High-risk patients undergoing elective operations may not require preoperative clopidogrel cessation. When clopidogrel cessation is warranted, 7 days before the procedure is recommended. Perioperative risk does not vary by timing of cessation within 7 days of an operation.

Ischemic colitis after endovascular aortoiliac aneurysm repair: a 10-year retrospective study.

OBJECTIVE: To examine the incidence, cause, and outcomes of ischemic colitis after endovascular stent graft repair of aortoiliac aneurysms (EVAR). DESIGN: Medical record review. SETTING: University teaching hospital. PATIENTS: Eight hundred nine patients treated during 10 years were included in the study. Preoperative data regarding the size of the aneurysm, hypogastric coil embolization, and inferior mesenteric artery patency were evaluated by means of computed tomographic scans and aortograms. Ischemic colitis was diagnosed by lower endoscopy or pathology reports. MAIN OUTCOME MEASURES: Ischemic colitis after EVAR. RESULTS: Eleven patients (1.4%) developed ischemic colitis. Seven patients' episode occurred less than 30 days from repair (early), whereas 4 occurred 30 days or more from repair (late). Ten of 11 patients had preoperative inferior mesenteric artery occlusion. Microembolization was seen histologically in 2 patients in the early group, both of whom died. A significant increase in ischemic colitis was seen in patients undergoing preoperative unilateral hypogastric coil embolization (P = .02). Three of the patients with late ischemic colitis had comorbidities other than the EVAR to explain the ischemia. CONCLUSIONS: The incidence of ischemic colitis is decreased in patients undergoing EVAR vs open repair. The cause of the ischemia is multifactorial and seems to differ between patients in the early and late groups. Microembolization tends to produce severe ischemic colitis and is usually fatal. There should be a low threshold for performing endoscopy in any patient thought to have ischemic colitis after EVAR.

Clopidogrel and bleeding after general surgery procedures.

Although many studies in the cardiothoracic literature exist about the relationship between clopidogrel and postoperative bleeding, there is scarce data in the general surgery literature. We assessed whether there are increased bleeding complications, morbidity, mortality, and resource utilization in patients who are on clopidogrel (Plavix) within 1 week before undergoing a general surgery procedure. Fifty consecutive patient charts were retrospectively reviewed after identifying patients who had pharmacy orders for clopidogrel and who underwent a general surgery procedure between 2003 and 2007. Patients who took clopidogrel within 6 days before surgery (group I, n = 28) were compared with patients who stopped clopidogrel for 7 days or more (group II, n = 22). A larger percentage of patients who took their last dose of clopidogrel within 1 week of surgery (21.4% vs 9.5%) had significant bleeding after surgery requiring blood transfusion. However, there were no significant differences between the groups in operative or postoperative blood transfusions (P = 0.12, 0.53), decreases in hematocrit (P = 0.21), hospital stay (P = 0.09), intensive care unit stay (P = 0.41), late complications (P = 0.45), or mortality (P = 0.42). Although our cohort is limited in size, these results suggest that in the case of a nonelective general surgery procedure where outcomes depend on timely surgery, clopidogrel taken within 6 days before surgery should not be a reason to delay surgery. However, careful attention must be paid to meticulous hemostasis, and platelets must be readily available for transfusion in the operating room.

Conductive keratoplasty and the coupling phenomenon.

PURPOSE: To determine whether changes in corneal astigmatism with astigmatic conductive keratoplasty (CK) treatment obey Gaussian coupling (i.e., the steepening of the flat axis associated with the flattening of the steep axis) and to measure the coupling ratio and the coupling constant to determine the effect of astigmatic CK treatment on spherical equivalent. METHODS: Retrospective review of 33 eyes in 24 patients who had undergone CK for hyperopia and who were treated intraoperatively for induced astigmatism. Induced astigmatism was determined by comparison of keratometric readings before and after CK. RESULTS: The coupling ratio was calculated according to two equations: clinical coupling ratio (1.61 +/- 0.81 diopters) and coupling ratio of the surgically induced refractive change (1.57 +/- 1.16 diopters). Values of the coupling ratio between 0.72 and 1.88 indicate coupling. CONCLUSIONS: The cornea does not behave according to Gauss's law of elastic domes. The targeted flat axis and steep axis 90 degrees away are affected by CK in opposite but not equal amounts. Therefore, when correcting surgically induced astigmatism with CK, the overall spherical equivalent of the patient will change because the coupling ratio is not equal to 1.