Emergency Presentations Predict Worse Outcomes Among Patients with Pancreatic Cancer.

BACKGROUND: Emergency presentation (EP) of cancer, a new cancer diagnosis made following an emergency department (ED) visit, is associated with worse patient outcomes and greater organizational stress on healthcare systems. Pancreatic cancer has the highest rate of EPs among European studies but remains understudied in the U.S. AIMS: To evaluate the association between pancreatic cancer EPs and cancer stage, treatment, and survival. METHODS: We conducted a retrospective cohort study among patients with pancreatic adenocarcinoma diagnosed from 2007 to 2019 at a tertiary-care Veterans Affairs medical center. Electronic health records were reviewed to identify EP cases, defined as a new pancreatic cancer diagnosis made within 30 days of an ED visit where cancer was suspected. We used multivariate logistic regression models and Cox proportional hazards models to examine the associations between EPs and cancer stage, treatment, and survival. RESULTS: Of 243 pancreatic cancer patients, 66.7% had EPs. There was no difference in stage by EP status. However, patients diagnosed through EPs were 72% less likely to receive cancer treatment compared to non-emergency presenters (adjusted OR 0.28; 95% CI 0.13-0.57). Patients with EPs also had a 73% higher mortality risk (adjusted HR 1.73; 95% CI 1.29-2.34). This difference in mortality remained statistically significant after adjusting for cancer stage and receipt of cancer treatment (adjusted HR 1.47; 95% CI 1.09-1.99). CONCLUSIONS: Pancreatic cancer EPs are common and independently associated with lower treatment rates and survival. Enhanced understanding of process breakdowns that lead to EPs can help identify care gaps and inform future quality improvement efforts.

Effectiveness of Intra-Articular Injection of Ceftazidime/Vancomycin Combination during Total Knee Replacement: Prevention of Periprosthetic Joint Infection.

Background:The occurrence of prosthetic joint infection (PJI) subsequent to total knee arthroplasty (TKA), also known as total knee replacement, is a highly detrimental complication. Some studies have concluded that intra-articular antibiotic injection was an effective approach to prevention of PJI, while others have reached the opposite conclusion. However, there is no study performed in one center, by one surgeon, one surgical team, or one type of prosthetic device. Methods:This was a historical cohort study on patients who underwent primary TKA with vancomycin and ceftazidime (652 cases from September 2019 to the end of December 2020) and were compared with a cohort of patients also treated with TKA but without using antibiotic injection (620 controls from March 2018 to the end of August 2019). The incidence of PJI was followed for two years in each group by chart review. Results:Study groups were matched for age (P-value 0.193), gender (P-value 0.913), body mass index (BMI) (P-value 0.136), and radiologic features of their knees (P-value > 0.05). Prosthetic joint infection was developed by only three patients: one (0.18%) in the case group and the remaining two (0.32%) in the control group (P-value 0.615); all three patients had a positive response to the treatment which included debridement, antibiotics, implant retention (DAIR) surgery and a course of antibiotics. Conclusion:To our knowledge, this is the most precisely matched cohort of TKA subjects in this era. Intra-articular injection of vancomycin and ceftazidime during TKA showed no significant difference in reducing the risk of PJI in the case group. However, although PJI is a rare event in joint replacement surgery, it should be prospectively investigated in a study with even larger sample sizes.

Malignant Insulinoma Arising From Nonfunctioning Pancreatic Neuroendocrine Tumor.

Pancreatic neuroendocrine tumors are rare neoplasms characterized into nonfunctioning (NF-PNET) and functioning (F-PNET) subtypes. F-PNETs typically involve overt symptoms related to excessive hormone secretion but may rarely present first as NF-PNETs with delayed transformation. We present a patient with known NF-PNET with liver metastases who developed hypoglycemia 2 years after initial diagnosis due to malignant insulinoma. Hypoglycemia was refractory to continuous dextrose but improved temporarily after diazoxide and hepatic artery embolization. Malignant insulinomas are usually metastatic at presentation and portend poor prognosis. Hypoglycemia may be medically managed with steroids, somatostatin analogues, and diazoxide, along with therapies to reduce tumor burden.

Left Ventricular Assist Device Pump Thrombosis in a Patient Treated with Apixaban.

BACKGROUND Direct oral anticoagulants (DOAC) are currently the preferred agents for long-term anticoagulation in the appropriate patient with venous thromboembolism, non-valvular atrial fibrillation, and left ventricular thrombi because of their ease of use, fixed dosing, lack of need for routine monitoring, and limited dietary and drug interactions. However, warfarin is still the agent of choice for preventing thromboembolic events in patients with left ventricular assist devices (LVAD). In this case report, we explore the outcome of using apixaban in a patient with an LVAD. CASE REPORT A 56-year-old woman with morbid obesity and stage D congestive heart failure status after HeartWare ventricular assist device (HVAD) placement 2 years prior, who was on long-term anticoagulation with apixaban after failure of warfarin therapy, presented to the Emergency Department with 2 months of worsening fatigue, dark urine, and 1 day of low-flow alarms from her HVAD. Laboratory and radiographic data were consistent with a diagnosis of pump thrombosis. She underwent pump exchange and was started on a heparin drip. Genetic testing for warfarin resistance was negative. Detailed history-taking revealed that the failure to maintain a therapeutic international normalized ratio (INR) was likely due to dietary factors. She was re-challenged with warfarin, and a therapeutic INR level was reached shortly after initiation. She was later discharged on a stable dose of warfarin and remained in a good clinical state without any major adverse events at the 1-year follow-up. CONCLUSIONS Apixaban can be associated with an increased risk of thrombosis in patients with HVADs and should be used with caution and only in select patients.

Plasmodium in the bone marrow: case series from a hospital in Pakistan, 2007-2015.

BACKGROUND: Malaria is a life-threatening, multisystem disease caused by the plasmodial parasite with a global incidence of approximately 229 million annually. The parasites are known to have unique and crucial interactions with various body tissues during its life cycle, notably the liver, spleen, and recent work has shown the bone marrow to be a reservoir of infection. METHODS: This study is a case series of patients in whom examination of bone marrow revealed malarial parasites. A retrospective record review of 35 parasite-positive bone marrow specimens examined at Aga Khan University Hospital (AKUH), Karachi, Pakistan, over the years 2007 to 2015 was conducted. Bone marrow aspirates were collected as per International Council for Standardization in Haematology (ICSH) guidelines. RESULTS: The median age of patients was 22 years (range 1-75), and 60 % (n = 21) were male. 22 patients had evidence of Plasmodium falciparum, 12 had evidence of Plasmodium vivax and 1 patient had a mixed infection. Gametocytes and trophozoites were the most common stages identified on both peripheral blood and bone marrow examinations. Indications for bone marrow examination included fever of unknown origin and the workup of cytopenias and malignancies. CONCLUSIONS: The incidental finding of Plasmodium in samples of bone marrow suggests the reticuloendothelial system may be regularly harbour these parasites, be the infection acute or chronic in character.

Feasibility of preoperative tattooing of percutaneously biopsied axillary lymph node: an experimental pilot study.

BACKGROUND: In the last three decades, axillary lymph node dissection (ALND) has been replaced by sentinel lymph node biopsy (SLNB) in all clinically node-negative patients. However, when SLNB alone is performed in clinically node-positive patients who are rendered node-negative by neoadjuvant chemotherapy, the procedure has a high false-negative rate and other complementary procedures have been described to improve its reliability. Preoperative tattooing of the suspicious lymph node with India ink at the time of biopsy, in addition to sentinel lymph node biopsy, is a reasonable alternative. The objective of our study is to determine, in clinically node-positive patients, the feasibility of tattooing suspicious axillary lymph node at the time of percutaneous needle biopsy and its retrieval at the time of surgery. METHODS: A prospective experimental study will be conducted divided into two phases-phases I and II. In phase I, 10 patients committed to undergo upfront surgery (without neoadjuvant chemotherapy) will have a suspicious lymph node tattooed by injecting India ink at the time of core needle biopsy. All patients will undergo a SLNB, during which the axilla will be inspected to determine if the tattooed lymph node can be visualized. Routine microscopic examination will follow, and concordance between the sentinel and tattooed node will also be established. In phase II, the process will be repeated for 30 patients who undergo surgery after neoadjuvant chemotherapy. The analysis will be performed in Stata version 12. DISCUSSION: There is a need to identify and test the techniques for the down-staged axilla in post-neoadjuvant chemotherapy patients, which are not only practical and limit the number of invasive procedures necessary but are representative of the new axillary status and help limit the extent of axillary surgery without negatively impacting outcomes. We propose that, for the patient undergoing neoadjuvant chemotherapy with a biopsy-proven disease in the axilla, this could be achieved by India ink which allows marking, identification, and retrieval of the biopsied lymph node. Retrieval of this previously biopsied lymph node along with sentinel nodes, if found to be representative of the status of the remainder of the axilla, could potentially eliminate the need for routine axillary lymph node dissection and thus limit morbidity. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03939598. Retrospectively registered on 7 May 2019.

Clinicopathologic Features Predictive of Distant Metastasis in Patients Diagnosed With Invasive Breast Cancer.

PURPOSE: National Comprehensive Cancer Network and European Society for Medical Oncology guidelines suggest screening for distant metastasis (M1) in symptomatic patients or those with locally advanced breast cancer. These guidelines are based on studies that often used pathologic staging for analysis. Physician variability in screening for M1 has also resulted in overuse of diagnostic tests. We sought to identify clinicopathologic features at diagnosis that could guide testing for metastatic disease. METHODS: Patients diagnosed with invasive breast cancer between January 2014 and December 2015 were identified from our institutional database. Demographic and clinical variables were collected, including receptor profiles and clinical TNM staging. Rates of upstaging for each clinical stage and rates of concordance of pathologic and clinical staging were analyzed. Univariate analysis and multivariate regression analysis (P < .05) identified predictors of upstaging to stage IV disease. RESULTS: A total of 370 patients met the inclusion criteria. Seventy patients (18.9%) had metastatic disease at diagnosis. The rate of upstaging for stages I, IIA, IIB, and III were 0%, 5.6%, 18.8%, and 36.6%, respectively. Advancing clinical stage, tumor size, and nodal status resulted in a significantly higher rate (P < .001) of upstaging to M1 disease. Age and hormone receptor status were not associated with upstaging to stage IV disease. Clinical stages I-III were concordant with pathologic staging in 65(42.8%) of 152 patients (kappa's index, 0.197; P < .000). CONCLUSION: Advancing clinical stage, tumor size, and nodal status at diagnosis were predictive of upstaging to M1 disease in patients with breast cancer. Distant metastatic workup should be considered in patients with clinical stage IIB disease or higher.

Clinicopathological Features of Young Versus Older Patients With Breast Cancer at a Single Pakistani Institution and a Comparison With a National US Database.

PURPOSE: The age at which women present with breast cancer varies widely among nations, and breast cancer may behave differently in younger women. Differences in clinicopathological characteristics based on age have not been well characterized in Pakistani patients with breast cancer. METHODS: We conducted a retrospective review of patients with symptoms of breast cancer presenting to Aga Khan University Hospital (AKUH), a large tertiary care center in Pakistan, between 2001 and 2010; we compared young (≤ 40 years) versus older (> 40 years) patients in terms of their clinicopathological characteristics. We also compared this Pakistani cohort with the US population using data from the National Cancer Database (NCDB). RESULTS: A total of 1,334 patients with breast cancer presented to our center over the 10-year review period. The median age at diagnosis was 50 years, compared with 60 years for patients in the NCDB. In the AKUH cohort, younger patients were significantly more likely than their older counterparts to present with metastatic disease (13.1% v 10.8%; P < .01). They also were more likely to present with higher-grade tumors (grade 3: 40.1% v 28.3%; P < .001), have triple hormone receptor-negative phenotype (25.4% v 14.1%, P < .001), and have positive axillary lymph node involvement (70.9% v 57.5%; P < .001) compared with older women. Younger and older patients in the AKUH cohort tended to present with higher-stage disease ( P < .001) and were more likely to have triple hormone receptor-negative disease ( P < .001), compared with all patients in the NCDB and with those of Indo-Pakistani origin. CONCLUSION: Young Pakistani women, similar to their Western counterparts, present with more advanced disease and more aggressive tumor biology than their older counterparts.

Lack of correlation between non-labile iron parameters, total carbonyl and malondialdehyde in major thalassemia.

Thalassemia patients are at high risk of iron-induced toxicity and oxidative stress consequences. The present cross-sectional study is conducted to determine whether or not lipid peroxidation or protein oxidation is correlated with iron parameters in patients with thalassemia major. To prove this hypothesis, malondialdehyde and total carbonyl were correlated with the degree of excess iron concentration in the patients. A total of 118 Arabic Iraqi patients and 30 healthy children were participated in the present study. Results showed a significant increase (p<0.05) in serum total carbonyls, malondialdehyde and the iron indices of patients as compared with the control group. Total iron binding capacity and transferrin concentrations decreased significantly (p<0.05) in patients with thalassemia compared with the control group. The results also showed a lack of a significant correlation between each serum malondialdehyde and total carbonyl with each component of iron status. In conclusion, total carbonyls and malondialdehyde were increased in thalassemia patients indicating the vulnerability of these patients to tissue injury caused by oxidative stress. The formation of total carbonyl and malondialdehyde are independent of excess non-labile iron concentration, indicating that different mechanisms are involved in injury caused by the labile iron and in the formation of oxidation end products.