Topotecan-induced Sweet's syndrome: A case report.

► A case of Sweet's syndrome caused by topotecan chemotherapy is reviewed. ► Major and minor criteria of drug-induced Sweet's syndrome are outlined in comparison to our case. ► Patient responded well to treatment with steroids.

Effect of ovarian tumor characteristics on venous thromboembolic risk.

OBJECTIVE: Deep venous thrombosis and pulmonary embolism are common in patients with epithelial ovarian cancer, resulting in high costs associated with diagnosis and treatment. I aimed to identify subtypes of epithelial ovarian cancer that pose greater and lesser venous thromboembolism (VTE) risk. METHODS: I assessed the outcomes of 641 patients with epithelial ovarian, fallopian tube, and primary peritoneal cancer over a ten-year period. All inpatient, outpatient, and pathology records were reviewed. The rates at which people were evaluated for and diagnosed with venous thromboembolism were assessed. RESULTS: Of the 641 cases, 30.0% underwent an imaging test to evaluate for deep venous thrombosis (DVT) and 21.7% underwent testing for pulmonary embolism (PE). A 10.8% of all subjects were diagnosed with DVT and 7.2% were diagnosed with PE. Borderline tumors and mucinous showed a strikingly low rate of both DVT and PE. Clear cell and high-grade undifferentiated adenocarcinomas were the most likely to result in VTE. In a multivariate model, pathologic subtype was not only a significant predictor of VTE, but was the single best predictor of VTE. CONCLUSION: Clear cell and undifferentiated pathology in epithelial ovarian carcinomas is associated with a higher VTE risk. The underlying reason for this may related to differences in tumor biology. By identifying low and high risk groups, I may both better conserve medical resources and design more effective thromboprophylaxis for my patients.

A case of small cell carcinoma of the ovary hypercalcemic variant in a teenager.

► Young women with hypercalcemic type small cell ovarian cancer face a poor prognosis. ► Tumors respond to multi-agent chemotherapy, although rapid recurrence is typical. ► Using updated immunohistochemical staining patterns, this tumor can be identified.

The impact of diabetes on survival in women with ovarian cancer.

OBJECTIVE: Diabetes is increasingly common among cancer patients and plausible biologic mechanisms exist by which diabetes may influence cancer prognosis. We aimed to investigate the impact of diabetes on ovarian cancer outcomes. METHODS: We assessed the outcomes of 570 non-diabetic and 72 diabetic patients with epithelial ovarian, fallopian tube, and primary peritoneal cancer over a ten-year period. All inpatient and outpatient records were reviewed. The primary end points were overall and disease-free survival. RESULTS: Of the 642 cases, 11.2% had type II diabetes. Diabetics were more likely to be older, had a higher BMI (33.4 vs. 27.8), and had more comorbid conditions. Diabetics were less likely to have been surgically staged as compared to non-diabetics (p=0.04) although stage, grade, and likelihood of optimal cytoreduction were similar between groups. Over a period of 10 years, with an average of 44 months of follow-up, the median overall survival for diabetics was 1503 days. The median overall survival for non-diabetics was 2464 days (log rank test, p=0.02). In a Cox proportional hazards multivariable model, diabetes remained a significant predictor of overall survival (HR=2.04, p<0.01). CONCLUSIONS: Diabetics with ovarian cancer demonstrate strikingly poorer survival. The underlying reason for this is yet unknown and deserves further attention. Differences in care, competing risks of death, and changes within the tumor biology are plausible mechanisms for the observed difference in survival.

A case of postpartum cerebral angiitis and review of the literature.

PURPOSE: To better characterize postpartum cerebral angiitis (PPCA). METHODS: We present a case of PPCA in which a 34-year-old G6P5104 underwent a normal vaginal delivery and developed PPCA. She had no signs or symptoms of gestational hypertension or preeclampsia. She had a history of migraines and received methylergonovine at delivery. She represented postpartum with headache and hypertension. The patient had characteristic findings of cerebral angiitis on imaging, and was diagnosed with PPCA. She was treated with nimodipine and steroids. She was monitored with transcranial Dopplers. RESULTS: In reviewing the literature, we found 23 cases of PPCA. We found that none had proteinuria, most were hypertensive, and all presented with headache. CONCLUSIONS: Use of sympathomimetic agents, particularly among those with migraines, may increase risk of PPCA.

Casting light on 25-hydroxyvitamin D deficiency in ovarian cancer: a study from the NHANES.

OBJECTIVES: Ecological studies have long described a higher incidence of ovarian cancer in more extreme latitudes, where sun exposure, and presumably vitamin D exposure, is lower. Basic science studies have also noted polymorphisms of the vitamin D receptor in ovarian cancers. The aim of this study is to examine the relationship of serum vitamin D to ovarian cancer. METHODS: A case-control study of 7273 subjects from the National Health and Nutrition Examination Surveys (NHANES) was performed. Serum 25-hydroxyvitamin D (25[OH]D) levels were examined in both ovarian cancer patients and a control population. Logistic regression examined the odds of ovarian cancer for those with vitamin D levels below the median of the U.S. population. RESULTS: Ovarian cancer cases were more than three times more likely to have low 25[OH]D levels (OR 3.68, 95% CI 1.03-13.21, p=0.04). In the weighted multivariate model, the relationship persisted after adjusting for potential confounders, including age, body mass index, and diet. Adjusting for significant covariates, which included age and dietary calcium intake, ovarian cancer cases were nearly four times more likely to have low 25[OH]D levels (OR 3.92, 95% CI 1.11-13.85, p=0.03). CONCLUSIONS: Prevalent ovarian cancer cases have lower serum 25-hydroxyvitamin D (25[OH]D) than the general population. Deficiency in vitamin D may provide an etiologic link between the long-known ecologic findings regarding latitude and the basic science noting polymorphisms in the vitamin D receptor.

Postexposure prophylaxis for victims of sexual assault: treatments and attitudes of emergency department physicians.

BACKGROUND: Emergency departments (EDs) are the primary source of care for victims of sexual assault (SA). Provision of emergency contraception (EC) to these women has previously been noted to be sporadic. Completeness of care for victims of SA and the barriers to complete care are further investigated in this study. STUDY DESIGN: All ED attending physicians in Maryland, Virginia and the District of Columbia were identified and contacted for participation; 35% completed the survey. Practice patterns were analyzed for the 67% of physicians who do not refer SA victims to other hospitals. RESULTS: We found that 83% of physicians "always" or "usually" offer EC, but only half prescribe EC more than 48 h postassault. While most (89%) typically offer prophylaxis for STDs other than HIV, only 45% offer or counsel on HIV prophylaxis. Physician attitudes and hospital protocols were significant modifiers. CONCLUSION: Sexual assault victims are often not offered comprehensive care including prophylaxis against pregnancy and all STDs including HIV. Additional research is warranted to determine why physicians do not routinely offer HIV prophylaxis after SA.

Performance of contraceptive patch compared with oral contraceptive pill in a high-risk population.

OBJECTIVE: To evaluate the potential benefit of the transdermal contraceptive patch compared with the oral contraceptive pill for its acceptability and compliance in a population at high risk for future unintended pregnancies and abortions. METHODS: Assessment of the contraceptive patch and pill was prospective. We gathered information on women undergoing contraceptive counseling at three Planned Parenthood clinics. Discontinuation, adverse effects, and pregnancy outcomes were catalogued. The primary outcome was time to discontinuation of the patch or pill. Survival analyses with life tables and Cox proportional hazards were used to assess acceptability and compliance. Pearl indices were calculated for both the pill and patch. RESULTS: A total of 1,230 contraceptive-naïve women were identified. Subjects were a racially diverse group of primarily single women. Eighty-nine percent of the study population met our definition of being at high risk for a future unintended pregnancy or pregnancy termination. Loss to follow-up was higher among patch users (45.2% versus 29.5%, P<.001). Verified continued use beyond the first three cycles was lower with a patch (67% versus 89%, P<.001). Skin irritation and site reactions were the treatment-limiting factor for 3.3% of patch users. The 3,206 cycles captured in this study resulted in a Pearl index of 3.62 for the pill and 14.84 for the patch. Differences in the baseline demographic and contraceptive practices may account for this discrepancy although, in multivariate analysis, patch users continued to do worse. CONCLUSION: In this high-risk population, we found the contraceptive patch to have lower continuation and effectiveness rates. Further research should investigate factors contributing to poorer real-world performance by the patch.

Outcome after autogenous brachial-basilic upper arm transpositions in the post-National Kidney Foundation Dialysis Outcomes Quality Initiative era.

BACKGROUND: The Dialysis Outcomes Quality Initiative (DOQI)-inspired push to create autogenous fistulas has led to a resurgence of interest in basilic vein transposition as an autogenous access conduit. We reviewed our experience with autogenous brachial-basilic upper arm transpositions (BTX) to clarify current maturation and patency rates and provide realistic expectations for a tertiary referral vascular practice. METHODS: We follow an aggressive "all-autogenous" policy with regard to dialysis access and recommend BTX when all cephalic options are exhausted. Prosthetic grafts are not attempted unless all upper extremity veins are unusable. The records of all patients undergoing autogenous basilic and brachial vein upper arm transpositions for hemodialysis access between April 2001 and December 2004 were retrospectively evaluated. Mean follow-up was 10 months (range, 0 to 38 months). RESULTS: Eighty-seven patients underwent 100 basilic and 3 brachial vein transpositions. Most of the patients were already receiving hemodialysis (83%), with a mean of 1.1 (range, 0 to 4) previous access attempts. Perioperative complications included 1 death secondary to a myocardial infarction, 7 hematomas (4 requiring reoperation), and 6 infections (2 requiring reoperation). Steal syndrome developed in five patients. Maturation rate was 79%. Functional primary and secondary patency rates were 23% +/- 5% and 47% +/- 6% at 1 year and 11% +/- 5% and 40% +/- 10% at 2 years, respectively (mean +/- SE). The most common causes of failure for a matured fistula were stenosis within the body of the basilic vein (44%) followed by central venous outflow stenosis (20%). No preoperative variable, including gender, age, diabetes mellitus, presence of ipsilateral hemodialysis catheter, number of previous access attempts, maximal or minimal vein diameter, or obesity, had a significant impact on rate of maturation or long term patency. CONCLUSIONS: In our experience, autogenous brachial-basilic upper arm transposition fistulas have initial maturation rates that exceed DOQI guidelines, but disappointing short- to medium-term patency rates. Although these outcomes were obtained within the context of an aggressive all-autogenous policy, the poor durability of these transpositions should prompt further investigation of current access algorithms.

Smoking cessation and cardiovascular disease risk factors: results from the Third National Health and Nutrition Examination Survey.

BACKGROUND: Cigarette smoking is a major risk factor for the development and progression of cardiovascular disease. While smoking is associated with increased levels of inflammatory markers and accelerated atherosclerosis, few studies have examined the impact of smoking cessation on levels of inflammatory markers. The degree and rate at which inflammation subsides after smoking cessation are uncertain. It also remains unclear as to whether traditional risk factors can adequately explain the observed decline in cardiovascular risk following smoking cessation. METHODS AND FINDINGS: Using data from 15,489 individuals who participated in the Third National Health and Nutrition Examination Survey (NHANES III), we analyzed the association between smoking and smoking cessation on levels of inflammatory markers and traditional cardiovascular risk factors. In particular, we examined changes in C-reactive protein, white blood cell count, albumin, and fibrinogen. Inflammatory markers demonstrated a dose-dependent and temporal relationship to smoking and smoking cessation. Both inflammatory and traditional risk factors improved with decreased intensity of smoking. With increased time since smoking cessation, inflammatory markers resolved more slowly than traditional cardiovascular risk factors. CONCLUSION: Inflammatory markers may be more accurate indicators of atherosclerotic disease. Inflammatory markers returned to baseline levels 5 y after smoking cessation, consistent with the time frame associated with cardiovascular risk reduction observed in both the MONICA and Northwick Park Heart studies. Our results suggest that the inflammatory component of cardiovascular disease resulting from smoking is reversible with reduced tobacco exposure and smoking cessation.