Randomized study of remote telehealth genetic services versus usual care in oncology practices without genetic counselors.

PURPOSE: To examine the benefit of telehealth over current delivery options in oncology practices without genetic counselors. METHODS: Participants meeting cancer genetic testing guidelines were recruited to this multi-center, randomized trial comparing uptake of genetic services with remote services (telephone or videoconference) to usual care in six predominantly community practices without genetic counselors. The primary outcome was the composite uptake of genetic counseling or testing. Secondary outcomes compare telephone versus videoconference services. RESULTS: 147 participants enrolled and 119 were randomized. Eighty percent of participants in the telehealth arm had genetic services as compared to 16% in the usual care arm (OR 30.52, p < 0.001). Five genetic mutation carriers (6.7%) were identified in the telehealth arm, compared to none in the usual care arm. In secondary analyses, factors associated with uptake were lower anxiety (6.77 vs. 8.07, p = 0.04) and lower depression (3.38 vs. 5.06, p = 0.04) among those who had genetic services. There were no significant differences in change in cognitive or affective outcomes immediately post-counseling and at 6 and 12 months between telephone and videoconference arms. CONCLUSION: Telehealth increases uptake of genetic counseling and testing at oncology practices without genetic counselors and could significantly improve identification of genetic carriers and cancer prevention outcomes.

Abciximab and fatal pulmonary hemorrhage.

Abciximab, a platelet glycoprotein IIb/IIIa receptor blocker, is a well-known agent in percutaneous coronary intervention because of its antiplatelet, antithrombotic effects, which allow for good outcome. Major bleeding is a well-recognized complication of abciximab therapy, and pulmonary hemorrhage, although infrequent, is a serious, under-recognized, and often fatal complication. We describe a case of fatal pulmonary hemorrhage in a young woman who presented with acute myocardial infarction and cardiogenic shock and was treated with abciximab in conjunction with percutaneous coronary intervention. The possibility of diffuse pulmonary hemorrhage should be strongly suspected in the presence of hypoxemia, infiltrates on chest radiography, and a decrease in hemoglobin. Awareness about this complication of abciximab therapy on the part of physicians and health care professionals is strongly warranted. Therapy that may be used if diagnosis is promptly made includes bronchoscopic-guided balloon tamponade or iced saline lavage. These therapeutic interventions are still in the developmental stage, and to date there are no trials to document their efficacy and survival benefit.

Romidepsin: a new therapy for cutaneous T-cell lymphoma and a potential therapy for solid tumors.

Romidepsin is a histone deacetylase inhibitor (HDI), approved by the US FDA for the treatment of cutaneous T-cell lymphoma (CTCL). Although various mechanisms have been proposed for the activity of HDIs, including induction of genes controlling cell cycle, acetylation of cytoplasmic proteins and direct induction of apoptosis, the mechanism underlying activity of romidepsin and other HDIs in CTCL is not known. Romidepsin induces long-lasting responses. The side-effect profile is similar to that of other HDIs, causing fatigue, nausea and thrombocytopenia. Management of the CTCL population requires vigilence to prevent infection with skin contaminants, and monitoring of potassium and magnesium, electrolytes found to be low in a large proportion of patients. Electrocardiographic (ECG) changes are common but are not associated with myocardial damage. When molecular end points were evaluated in 61 patients enrolled on a Phase II trial with romidepsin, response was associated with persistence of acetylated histone H3, suggesting that drug exposure is important in effective therapy with romidepsin. Future studies will endeavor to identify combination strategies to increase the efficacy both in resistant CTCL and in solid tumors and to identify biomarkers of response that will allow selection of patients most likely to benefit from the therapy.

Ezetimibe-induced acute pancreatitis.

Ezetimibe is a lipid-lowering agent that inhibits the intestinal absorption of cholesterol and other related phytosterols. It is used alone or in combination with other lipid-lowering agents in the treatment of various forms of hypercholesterolemia. Since its FDA approval in 2002, there are no known citations of ezetimibe-induced pancreatitis.

New pulmonary infiltrates in a 19 year-old with sickle cell crisis.

OBJECTIVE: Sickle cell anemia (SCA) is the most common inherited blood disorder. Sickle cell crisis is characterized by episodes of pain, chronic hemolytic anemia and severe infections, usually beginning in early childhood. Sickle cell disease primarily affects those of African descent and Hispanics of Caribbean ancestry, but the trait has also been found in those with Middle Eastern, Indian, Latin American, Native American, and Mediterranean heritage. Recent studies indicate that more than 12,500 people in England have sickle cell disorders. The acute chest syndrome is the leading cause of death and the second most common cause of hospitalization among patients with sickle cell disease. The acute chest syndrome (ACS) is characterized by chest pain with dyspnea and recent radiological abnormalities. Since its cause is largely unknown, rapid recognition and early institution of therapy is paramount as with timely and appropriate intervention majority of these patients survive. The treatment of ACS rests on controlled hydration, antibiotic therapy, oxygen therapy, controlled analgesic therapy, blood transfusion and exchange transfusion. A better understanding of the disease and a close collaborative approach between a primary care physician and a specialist may be the key to improve the quality of care rendered. METHODS: Research studies, review articles, and published scientific meeting abstracts were reviewed.