Ophthalmoplegia in a Her2+ and ß-hCG+ Patient With Leptomeningeal Carcinomatosis Secondary to Gastric Adenocarcinoma.

Leptomeningeal carcinomatosis (LMC) is an uncommon and devastating late complication of metastatic malignancy that carries a poor prognosis, typically faring worse when secondary to solid tumors. Diagnosis of LMC can be challenging, especially if the underlying cancer is undiagnosed, as presenting symptoms can be nonspecific or involve focal deficits such as cranial nerve palsies. Typically, LMC can be recognized due to new central neurological findings with concomitant peripheral nerve involvement, but there has not been a case of LMC with isolated peripheral nerve findings to our knowledge. In this report, we present a case of LMC secondary to metastatic gastric adenocarcinoma in a patient whose only manifestation was cranial nerve palsies, and whose cancer was also found to be Her2+ and ß-hCG positive, two markers not widely recognized in gastric cancer.

Better clinical outcomes in hospitalized COVID-19 minority patients with accompanying gastrointestinal symptoms.

BACKGROUND AND AIMS: The novel coronavirus (SARS-CoV-2) is highly contagious pathogen that primarily causes respiratory illnesses. Howerver, multiple gastrointestinal (GI) symptoms have been reported in Coronavirus Disease of 2019 (COVID-19). We conducted a retrospective cohort study of inpatients with COVID-19 at the George Washington University Hospital (GWUH) to assess the prevalence of GI symptoms and their association with clinical outcomes. METHODS: We reviewed the charts of 401 adults admitted to GWUH with positive SARS-CoV-2 tests from February 24 to May 21, 2020, ultimately including 382 inpatients. RESULTS: 87% of our cohort was African American or Latinx. 59% of patients reported at least one GI symptom, with diarrhea being the most common (29%). Patients with GI symptoms were slightly younger (58 +/- 15.8 vs. 65 +/- 16.9, p = 0.0005), have higher body mass index (31.5 +/- Standard Deviation of 8.7 vs. 28 +/- 8.2, p = 0.0001), and more likely to be Latinx (34 vs. 27, p = 0.01). Patients who presented with abdominal pain, nausea, vomiting, or diarrhea had significantly lower rates of death during hospitalization compared to those who did not present those symptoms (Odds Ratio 0.48, 95% Confidence Interval 0.28-0.8, p = 0.004). CONCLUSIONS: Our study suggests that GI symptoms portend a less-severe clinical course of COVID-19 which may reflect a different disease phenotype and lower overall immune response. Additional research should focus on more robust symptom reporting and longer follow-up.

Peripherally Inserted Central Catheter-associated Deep Vein Thrombosis: A Narrative Review.

BACKGROUND: Although common, little is known about factors associated with peripherally inserted central catheter-related deep vein thrombosis (PICC-DVT). To better guide clinicians, we performed a comprehensive literature review to summarize best practices for this condition. METHODS: A systematic search of the literature for studies reporting epidemiology, diagnosis, treatment, and prevention of PICC-DVT was conducted. Algorithms for diagnosis and management were compiled using available evidence. RESULTS: The incidence of PICC-DVT varied between 2% and 75% according to study population, testing modality and threshold for diagnosis. Studies evaluating the diagnostic utility of clinical symptoms suggested that these were neither sensitive nor specific for PICC-DVT; conversely, ultrasonography had excellent sensitivity and specificity and is recommended as the initial diagnostic test. Although more specific, contrast venography should be reserved for cases with high clinical probability and negative ultrasound findings. Centrally positioned, otherwise functional and clinically necessary PICCs need not be removed despite concomitant DVT. Anticoagulation with low-molecular-weight heparin or warfarin for at least 3 months represents the mainstay of treatment. The role of pharmacologic prophylaxis and screening for PICC-DVT in the absence of clinical symptoms is unclear at this time. CONCLUSIONS: PICC-DVT is common, costly and morbid. Available evidence provides guidance for diagnosis, treatment and prevention of this condition.

Patterns, risk factors and treatment associated with PICC-DVT in hospitalized adults: A nested case-control study.

BACKGROUND: Peripherally inserted central catheters (PICCs) are associated with upper extremity-deep vein thrombosis (DVT). However, patterns, risk factors and treatment associated with this event remain poorly defined. OBJECTIVE: To determine patterns, risk factors and treatment related to PICC-DVT in hospitalized patients. DESIGN, SETTING & PATIENTS: Between 2012-2013, consecutive cases of ultrasound-confirmed, symptomatic PICC-DVT were identified. For each case, at least two contemporaneous controls were identified and matched by age and gender. Patient- and device-specific data were obtained through electronic-medical records. Using variables selected a priori, multivariable logistic regression models were fit to the outcome of PICC-DVT, comparing cases to controls. RESULTS: 909 adult hospitalized patients (268 cases, 641 controls) were included in the study. Indications for PICC placement included long-term intravenous antibiotic therapy (n=447; 49.1%), in-hospital venous access for blood draws or infusion of medications (n=342; 44.2%), and total parenteral nutrition (n=120; 6.7%). Patients with PICC-DVT were more likely to have a history of venous thromboembolism (OR 1.70, 95% CI=1.02-2.82) or have undergone surgery while the PICC was in situ (OR 2.17, 95%CI=1.17-4.01 for surgeries longer than two hours). Treatment for PICC-DVT varied and included heparin bridging, low molecular weight heparin only and device removal only; the average duration of treatment also varied across these groups. Compared to 4-Fr PICCs, 5- and 6-Fr PICCs were associated with greater risk of DVT (OR 2.74, 95%CI=0.75-10.09 and OR 7.40 95%CI=1.94-28.16, respectively). Patients who received both aspirin and statins were less likely to develop PICC-DVT than those that received neither treatment (OR 0.31, 95%CI=0.16-0.61). Receipt of pharmacological DVT prophylaxis during hospitalization showed a non-significant trend towards reduction in risk of PICC-DVT (OR=0.72, 95%CI=0.48-1.08). CONCLUSION: Several factors appear associated with PICC-DVT. While some of these characteristics may be non-modifiable, future studies that target potentially modifiable variables to prevent this adverse outcome would be welcomed.

Perioperative statin therapy: current knowledge and future directions.

Perioperative statin therapy has come to represent a cornerstone of risk reduction for millions of patients who undergo cardiac and noncardiac surgeries. While large-scale, robust, randomized controlled studies support the use of statins in cardiac surgery, their role in noncardiac surgery has become ambiguous following concerns regarding scientific misconduct in many pivotal studies. In this edition of the Expert Opinion on Pharmacotherapy, Irwin et al. comprehensively summarize the evidence for perioperative statin treatment. The authors add to this review by providing expert opinions regarding the state of the science and future paths for research and enquiry.

Statin withdrawal after major noncardiac surgery: risks, consequences, and preventative strategies.

BACKGROUND: A growing body of research suggests that statins improve perioperative cardiac outcomes by attenuating inflammation. Conversely, some studies suggest that withdrawal of statins after surgery results in an upsurge of inflammation and adverse cardiac outcomes. METHODS: We performed a literature search using multiple medical databases to examine the basic, clinical, and experimental evidence supporting the existence of a statin withdrawal state. Studies examining outcomes associated with statin withdrawal were narratively synthesized. RESULTS: Published evidence suggests that statin withdrawal is associated with worse cardiac outcomes in a variety of scenarios, including acute coronary syndrome, ischemic stroke, and surgery. Although certain reasons for postoperative statin cessation are difficult to avoid (eg, ileus after surgery), we posit that many perioperative clinicians may be unaware of the importance of statin resumption in a timely fashion. This lack of awareness translates into preventable harm and an opportunity for outcome improvement. We introduce innovative practices through which perioperative practitioners may prevent statin discontinuation. CONCLUSIONS: Ensuring the resumption of statins after surgery should become routine practice for perioperative providers. We highlight knowledge gaps and identify a research agenda aimed at better understanding this practice.