The impact of the affordable care act on breast cancer care in the USA: A multi-institutional analysis.

There are less data available on the effect of the ACA on breast cancer care beyond the screening level. A retrospective review at participating iCaRe2/BCCR institutions was completed before and after ACA. Post-ACA, patients were older, more urban, and more likely to be insured through Medicaid. Increased imaging use was noted post-ACA. These patients were less likely to be diagnosed with late-stage cancers, received fewer mastectomies, and were more likely to have radiation.

Reversal of warfarin-induced excessive anticoagulation with recombinant human factor VIIa concentrate.

BACKGROUND: Bleeding associated with warfarin anticoagulation correlates directly to duration and degree of international normalized ratio (INR) elevation above the therapeutic range. Safe and rapid reversal of excessive anticoagulation is occasionally needed to treat or avoid hemorrhagic complications. OBJECTIVE: To evaluate the efficacy and safety of human recombinant factor VIIa (rFVIIa) concentrate in persons requiring rapid reversal of the effects of warfarin. DESIGN: Uncontrolled case series. SETTING: Academic medical center. PATIENTS: 13 patients with critically increased INRs requiring immediate reversal of warfarin-induced anticoagulation. MEASUREMENTS: Prothrombin time and INR were measured before and after administration of varying doses of rFVIIa. RESULTS: Critically prolonged INR and bleeding complications were treated successively and rapidly in all patients, regardless of rFVIIa dose (range, 15 to 90 microg/kg of body weight). Indications for use of rFVIIa included an INR greater than 10 in high-risk persons (n = 5), clinical hemorrhage (n = 4), and diagnostic or therapeutic procedures (n = 4). CONCLUSION: Safe, rapid, and effective administration of rFVIIa corrects critically prolonged INRs and can avert or reverse bleeding associated with warfarin anticoagulation.

Reversal of low-molecular-weight heparin-induced bleeding in patients with pre-existing hypercoagulable states with human recombinant activated factor VII concentrate.

Low-molecular-weight heparins are widely employed in prophylactic and therapeutic antithrombotic regimens for venous thromboembolic events. Excessive anticoagulation with low-molecular-weight heparins rarely can precipitate catastrophic bleeding complications. Currently, there is no specific or reliable antidote that can reverse the anticoagulant effects of low-molecular-weight heparins efficiently and safely. This report describes three individuals with underlying hypercoagulable states, who developed clinically significant bleeding complications while receiving therapeutic anticoagulation with enoxaparin. All of the hemorrhagic events subsequently were safely and effectively reversed with a single intravenous bolus infusion of recombinant activated factor VIIa (RFVIIa) concentrate. Hemoglobins, prothrombin times, and clinical overt bleeding were monitored before and after the administration of RFVIIa. In all three cases, bleeding was controlled without an increase in thrombotic events. Our findings demonstrate that RFVIIa can rapidly and safely reverse the hemorrhagic adverse effects associated with excessive levels of low-molecular-weight heparin in patients with pre-existing hypercoagulable conditions and/or acute venous thromboembolism.