Mindy L. Hartgers

Importance of device evaluation for point-of-care prothrombin time international normalized ratio testing programs

OBJECTIVE To determine the accuracy of 2 commercially available point-of-care devices relative to plasma international normalized ratio (INR) values. PATIENTS AND METHODS Point-of-care INR testing was performed with the CoaguChek and ProTime 3 devices in consecutive patients attending an anticoagulation clinic between June 18, 2003, and August 6, 2003. Results were compared with plasma INRs using a sensitive thromboplastin (International Sensitivity Index, 1.0). RESULTS Ninety-four patients agreed to participate in the study. Relative to the plasma INR, values were in agreement +/-0.4 INR unit 82% and 39% of the time for the CoaguChek and ProTime 3 devices, respectively. The mean +/- SD CoaguChek INRs were 0.2+/-0.31 unit lower, whereas ProTime 3 INRs were 0.8+/-0.68 unit higher than plasma INR values. Treatment decisions based on these data would have resulted in inappropriate dose adjustments 10% and 22% of the time for these 2 respective devices. Correlation with plasma was greater for the CoaguChek (r2=0.90) compared with the ProTime 3 device (r2=0.73). CONCLUSIONS Optimal warfarin treatment requires accurate measurement of the INR. The choice of a point-of-care device for INR management depends on the reliability of INR data generated by the device.

Capecitabine and Temozolomide: Design, Implementation, and Preliminary Outcomes From a Pilot Project to Ensure Safe Prescribing of Oral Chemotherapy

Without adequate safety measures, oral chemotherapy can lead to undetected dosing errors. The Mayo Clinic launched a project to ensure that all capecitabine and temozolomide prescriptions receive an independent double check.

E-mail and photographs: a case report of a patient-initiated diagnostic tool in the era of electronic communication.

This case report reviews some of the clinical aspects of epidermal growth factor receptor (EGFR) inhibitor-induced rash, and, more importantly, it describes a specific case in which the diagnosis of such a rash occurred by means of a patient-initiated photographic electronic communication. The fact that this electronic communication was patient-initiated suggests that health care providers will likely be asked to make clinical decisions based on this type of communication soon and that this type of seemingly low-cost approach will likely become an important aspect of cancer symptom control and palliative care in the future.

Malignant transformation of biliary adenofibroma: a rare biliary cystic tumor

Biliary adenofibromas (BAFs) are rare, benign biliary cystic tumors with potential for malignant transformation. Of the eleven prior cases of BAF reported in the literature, six showed evidence of malignant transformation. We describe the clinical, imaging and pathology features of two cases of malignant BAF and review the existing literature to raise awareness of this entity and provide additional tools for diagnosing this rare tumor Additionally, we identified a loss of function mutation in the cyclin-dependent kinase inhibitor 2A (CDKN2A) tumor suppressor gene in a malignant caudate lobe BAF, thereby providing potential insight into the molecular pathogenesis of BAF malignant transformation. Although additional cases and longer-term follow-up are needed, our cases suggest that recurrence or metastasis of malignant BAF is not common and that complete surgical resection can be curative.

Bolus 5-fluorouracil (5-FU) in combination with Oxaliplatin (FLOX) is safe and well tolerated in patients who experienced coronary vasospasm with infusional 5-FU or capecitabine

Introduction: Coronary vasospasm associated with fluoropyrimidine (FP)‐based chemotherapy is a potentially serious complication and reported to occur more often with infusional 5‐fluorouracil (5‐FU) or capecitabine than with bolus 5‐FU. Given the additional benefit of oxaliplatin over FP alone in the management of colorectal cancer, retaining oxaliplatin in the treatment regimen is desirable, but the safety of combining bolus 5‐FU with oxaliplatin in patients with FP‐induced vasospasm is not well established. We performed a retrospective review to explore the safety of substituting FLOX (bolus 5‐FU, oxaliplatin, leucovorin) for FOLFOX (infusional 5‐FU, oxaliplatin, leucovorin) and CAPOX (capecitabine, oxaliplatin) in patients who had FP‐induced coronary vasospasm. Patients and Methods: The pharmacy database of Mayo Clinic was queried to identify patients who developed coronary vasospasm associated with FOLFOX or CAPOX between January 2011 and January 2018 and were subsequently treated with FLOX. Detailed information was obtained on these patients by retrospective electronic chart review. Results: A total of 10 patients (median age, 56.5 years; range, 36‐77 years) were identified, 9 with FOLFOX and 1 with CAPOX. Among the patients treated with FOLFOX, 8 patients had chest pain as the presenting complaint that had started within 48 hours of beginning of the 5‐FU infusion. In 9 of 10 patients, coronary vasospasm occurred with the first cycle of therapy. All patients made full recovery after discontinuation of infusional 5‐FU or capecitabine. All patients subsequently received FLOX with 7 median bolus 5‐FU doses (range, 2‐22 doses) and 7 median oxaliplatin doses (range, 2‐12 doses) at 7 days to 18 months after the event, with 7 patients treated within 4 weeks of the event. FLOX did not cause any cardiovascular adverse events in any of the 10 patients. Conclusion: Bolus 5‐FU in combination with oxaliplatin is safe in patients who have experienced coronary vasospasm with infusional 5‐FU or capecitabine. Micro‐Abstract Coronary vasospasm with capecitabine or infusional 5‐fluorouracil (5‐FU) is a potentially serious complication. We performed a retrospective review to explore the safety of substituting FLOX (bolus 5‐FU, oxaliplatin, leucovorin) for capecitabine or infusional 5‐FU–based regimens in patients who had coronary vasospasm. FLOX is safe in patients who experienced coronary vasospasm with infusional 5‐FU or capecitabine.