Homam Alkaied

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.

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.

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.

Ovarian vein thrombosis in the nonpregnant woman: an overlooked diagnosis

Ovarian vein thrombosis (OVT) is a rare condition occurring in 1/600 to 1/2000 pregnancies [Dunnihoo et al. 1991; Ortin et al. 2005] mainly in the postpartum setting. It is also known to be associated with other conditions such as malignancy, pelvic inflammatory disease, inflammatory bowel disease, sepsis and recent pelvic or abdominal surgery [Andre et al. 2004; Heavrin and Wrenn, 2008; Jacoby et al. 1990; Klima and Snyder, 2008; Marcovici and Goldberg, 2000; Salomon et al. 1999; Simons et al. 1993]. It is extremely rare to find OVT without identified etiology and, hence, idiopathic OVT is only described as case reports throughout the literature. Here, we report a unique case of idiopathic isolated OVT that presented with right flank pain and an abdominal mass. Although four similar cases of idiopathic isolated OVT have been reported in the literature [Heavrin and Wrenn, 2008; Murphy and Parsa, 2006; Stafford et al. 2010; Yildirim et al. 2005], none of these patients presented with an abdominal mass. The diagnosis of isolated OVT requires a high index of suspicion. If misdiagnosed, OVT can lead to potentially fatal complications such as sepsis and pulmonary embolism. [Benfayed et al. 2003; Kominiarek and Hibbard, 2006; Maldjian and Zurlow, 1997; Wysokinska et al. 2006]. A 53-year-old postmenopausal woman with a past medical history of hypertension presented to the medical clinic complaining of 1-week history of aching right flank pain that was not associated with fever, dysuria, hematuria, nausea, vomiting, diarrhea or vaginal discharge. The patient denied any other constitutional symptoms. She is a nonsmoker with no family history of hematologic disorders. On physical examination, she was afebrile, normotensive, without tachycardia. Pelvic exam revealed a nontender, normal size uterus and adnexa. However, a 3 cm tender mass was palpated in the right lower quadrant. Laboratory data revealed a white blood cell count of 4400-cells/mm3 and hemoglobin level 11.9 g/dl. Renal function and electrolytes were within normal limits. Computed tomography (CT) of the abdomen and pelvis with intravenous contrast showed right ovarian vein thrombus without extension to the inferior vena cava (IVC) (Figure 1). Figure 1. CT scan at presentation. Further work up for hypercoagulability was negative. Age- and sex-appropriate cancer screenings were all negative. Moreover, screening for ovarian pathology, with pelvic ultrasound and CA-125, was also normal. Shortly after the diagnosis of isolated OVT, the patient was placed on oral anticoagulation. It was elected not to administer antibiotics. Warfarin was continued for 5 months with the International Normalized Ratio (INR) maintained between 2 and 3. A follow-up CT scan of the abdomen and pelvis performed 5 months later showed persistence of the thrombus with no further extension beyond the ovarian vein (see Figure 2). Anticoagulation was discontinued at this point with close clinical follow up. Figure 2. CT scan after 5 months of anticoagulation therapy. Ovarian vein thrombosis was first described by Austin in 1956 [Austin, 1956]. It occurs in the right side in 70–90% of cases, and bilaterally in 11–14% [Baran and Frisch, 1987; Prieto-Nieto et al. 2004]. The most widely accepted hypothesis for the higher incidence on the right is that the right ovarian vein is longer than the left, and lacks competent valves. The typical presentation is the triad of pelvic pain, fever, and a right-sided abdominal mass [Dessole et al. 2003; Dunnihoo et al. 1991; Klima and Snyder, 2008; Prieto-Nieto et al. 2004]. Fever is present in 80% and right iliac fossa pain in 55% of the patients [Prieto-Nieto et al. 2004]. Given the nonspecific presenting symptoms, prompt diagnosis of OVT requires a high index of suspicion. The differential diagnosis includes most conditions that affect the abdominal lower quadrant such as acute appendicitis and inflammatory bowel diseases. Therefore, imaging studies are essential to establish the diagnosis of OVT. Magnetic resonance angiography (MRA) has the highest sensitivity and specificity that approaches 100%. CT scan with intravenous contrast enhancement has a sensitivity of 77.8% and specificity of 62.5%. Color Doppler ultrasound has the lowest sensitivity of 55.6% and a specificity of 41.5% among other imaging modalities [Kubik-Huch et al. 1999]. A delay in the diagnosis and treatment of OVT can lead to potentially life-threatening complications, such as thrombus extension into the IVC or ileofemoral vessels and eventually the evolution of pulmonary arterial embolization. The incidence of pulmonary embolism is approximately 25% in patients with untreated OVT and the mortality in these patients can reach about 4% [Benfayed et al. 2003; Dunnihoo et al. 1991; Kominiarek and Hibbard, 2006]. Other serious complications include septic thrombophlebitis and, rarely, infectious emboli [Dessole et al. 2003; Heavrin and Wrenn, 2008]. Ovarian vein thrombosis can resolve spontaneously but considering the potential catastrophic consequences, anticoagulation is usually recommended [Wysokinska et al. 2006]. There is no definite guideline regarding the duration of anticoagulation therapy. Wysokinska and colleagues studied the incidence and the recurrence of OVT compared with lower extremity deep venous thrombosis (DVT) [Wysokinska et al. 2006]. None of the 35 patients in the OVT group was idiopathic and the recurrence rate was comparable to patients diagnosed with lower extremity DVT (3 per 100 patient years of follow up). The average treatment with warfarin was 5.3 and 6.9 months for OVT and lower extremity DVT, respectively. Based on these findings, the authors suggested the application of lower extremity guidelines for the treatment of OVT. Antibiotics can also be administered for approximately 7 days especially in cases of postpartum OVT [Brown and Munsick, 1971; Dessole et al. 2003; Maldjian and Zurlow, 1997; Wysokinska et al. 2006]. In patients with hypercoagulable disorders, anticoagulation may need to be lifelong therapy [Wysokinska et al. 2006]. In rare cases of persistent OVTs, an IVC filter or surgical intervention to ligate the ovarian vein can be considered [Carr and Tefera, 2006; Clarke and Harlin, 1999]. Our patient was diagnosed with an idiopathic OVT since none of the above predisposing factors for OVT were found. The patient’s abdominal pain subsided few days after starting anticoagulation and she did not develop any worrisome signs such as fever, dyspnea, or chest pain. Five years later, the patient remains asymptomatic while off anticoagulation, without any further thrombotic conditions. To date, four cases of idiopathic OVT were described [Heavrin and Wrenn, 2008; Murphy and Parsa, 2006; Stafford et al. 2010; Yildirim et al. 2005]. None of these cases had abdominal or pelvic palpable masses at presentation. Therefore, our report describes a unique case of idiopathic OVT presenting with one symptom and one sign of the typical triad. The palpable mass in the right iliac fossa was only described in cases of OVT that occur in the postpartum period as well as in other inflammatory and hypercoagulable conditions. OVT is a rare condition with potential life-threatening complications. In female patients presenting with lower quadrant pain, with or without fever or palpable abdominal or pelvic mass, OVT should be considered in the differential diagnosis after ruling out other common conditions. MRA and CT scan with intravenous contrast are the most useful imaging modalities to diagnose this condition. Overlooking this diagnosis can lead to life-threatening conditions, such as pulmonary embolism, sepsis, and even death. Hence, prompt diagnosis of OVT requires a high index of suspicion in order to prevent these outcomes.

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.

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

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

300 compared with

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

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.

A complete Resolution of sialadenitis Induced by Iodine containing contrast with Intravenous Dexamethasone Infusion

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.

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

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.