Thrombotic thrombocytopenic purpura (TTP) following coronary artery bypass: case series and review of the literature.

We reviewed 10 cases of thrombotic thrombocytopenic purpura (TTP) following cardiac surgery since November 1998. The object of the study was to define the natural history of post-CABG-TTP and to assess response to therapy. All patients underwent CABG; four also underwent aortic valve replacement and six mitral valve replacement. Eight patients had mental status changes and/or unexplained fever. All patients received plasmapheresis ranging from 5 to 24 days and nine required hemodialysis or continuous renal replacement therapy. All had significant improvement in their platelet count, LDH, renal function, and mental status changes at discharge. None of the five surviving patients has relapsed at follow-up ranging from 8 months to 6 years. Early recognition of this syndrome and early institution of plasmapheresis are important for a favorable outcome.

Cancer incidence in elderly West Virginians.

West Virginia has one of the oldest populations in the nation. Cancer is a common disease among the elderly. With the projected growth of the elderly population (defined as 65 years and older), cancer will become a major public health burden. This article provides a summary of cancer incidence in elderly West Virginians. Incidence data were obtained from the West Virginia Cancer Registry. Approximately 6,262 elderly persons are diagnosed with some form of reportable cancer in West Virginia each year. Among those aged 65 and older, the four leading primary cancer sites in the order of their relative frequency were lung and bronchus cancer (21.8%), prostate cancer (14.6%), colorectal cancer (12.7%), and female breast cancer (9.6%). In general, the burden of cancer was greater in elderly men than in elderly women. Knowledge of the epidemiology of cancer in the elderly can potentially help guide statewide cancer prevention and control efforts and be used for anticipating future health care needs in the state.

The benefit of the neutropenic diet: fact or fiction?

There really should not be a debate about the use of neutropenic diet for cancer patients. Its usefulness has never been scientifically proven. However, neutropenic diets remain in place in many institutions even though their usefulness is controversial. Neutropenic diets were once thought to be important in protecting patients from having to succumb to infection from neutropenia while undergoing chemotherapy. Although food may contain harmful organisms and research has shown that bacterial translocation is possible, recent studies have been unable to obtain significant differences between placebo and intervention groups. The dietetic challenges neutropenic patients struggle with include decreased quality of life, malnutrition, gastrointestinal side effects, food aversion, and impaired cell-mediated immunity from vitamin deficiency. Unanswered questions in regard to the neutropenic diet include the following: (a) which food should be included; (b) which food preparation techniques improve patient compliance; (c) which patient populations benefit most; and (d) when should such a diet be initiated. Without scientific evidence, the best advice for neutropenic patients is to follow food safety guidelines as indicated by government entities.

Coronary artery bypass grafting (CABG) in patients with immune thrombocytopenia (ITP): a community hospital experience and review of the literature.

We reviewed the records of 51 patients with Immune Thrombocytopenia (ITP) who underwent Coronary Artery Bypass Grafting (CABG) at Charleston Area Medical Center between June 1992 and September 2005. There were 41 males and 10 females with a median age of 68 years (range 49-87). Four patients had a previous splenectomy, one of whom had it performed concomitantly with the CABG. Three patients were on chronic corticosteroids on admission. The median pump time was 114 minutes (range: 42-244 minutes). The median cross-clamp time was 62 minutes (range 22-192 minutes). The median total chest tube drainage postoperatively was 1,346 cc (range: 265-9875cc). The mean preoperative and 24 hour postoperative platelet count was 126,000 (range 58,000-323,000) and 99,000/mm3 (range: 27,000-194,000), respectively. Twenty-one (40%) patients received platelet transfusions. Platelets were given intraoperatively or postoperatively in all but two of those patients. The median number of units of platelets given was 10 (range: 6-52). Twenty-seven (53%) received packed red cells intraoperatively or postoperatively. The median number of red cells given was 2 (range: 1-34). Other hemostatic agents given intraoperatively/ postoperatively included aprotinin (8 patients), aminocaproic acid (10 patients), DDAVP (5 patients), and intravenous gammaglobulin (IgG) in 3 patients. Thirteen patients were given corticosteroids preoperatively with little improvement in platelet count. CABG may be successfully performed in ITP patients with moderate thrombocytopenia (> or = 50,000/mm3) using conventional therapies (e.g., transfusions, IV IgG, hematinics) without the need for preoperative splenectomy or prolongation of hospital stay. However, a prospective study on the ideal management of ITP patients undergoing CABG would be beneficial.

A Retrospective Study of Brain Metastases From Solid Malignancies: The Effect of Immune Checkpoint Inhibitors.

INTRODUCTION: Brain metastases (BM) are associated with dismal prognosis, and there is a dearth of effective systemic therapy. In this study, patients with BM from multiple solid tumors were identified from TriNetX databases, their clinicopathological features were evaluated, and the effects of immune checkpoint inhibitor (ICI) therapy were assessed. METHODS: Variables, including median overall survival (OS), Eastern Cooperative Oncology Group (ECOG) performance status, primary diagnosis, and date of diagnosis, were retrieved from TriNetX, a real-world database. Kaplan-Meier plots and log-rank tests were applied to assess significance of differences in survival. Hazard ratio (HR) and 95% confidence interval (CI) values were calculated. All patient data were deidentified. RESULTS: A total of 227,255 patients with BM were identified in the TriNetX database; median OS was 12.3 months from initial cancer diagnosis and 7.1 months from development of BM. OS of BM from nonsmall-cell lung cancer (NSCLC), triple-negative breast cancer (TNBC), melanoma, and renal cell carcinoma (RCC) were 8.7, 14.7, 17.8, and 15.6 months, respectively. After matching patient baseline characteristics, OS of cohorts with or without exposure to ICIs was evaluated. For all types of cancer, median OS durations for the ICI and no-ICI cohorts were 14.0 and 7.9 months, respectively (HR: 0.88; 95% CI: 0.85-0.91). More specifically, OS was remarkably prolonged in patients with NSCLC (14.4 vs. 8.2 months; HR: 0.86; 95% CI: 0.82-0.90), TNBC (23.9 vs. 11.6 months; HR: 0.87; 95% CI: 0.82-0.92), and melanoma (27.6 vs. 16.8 months; HR: 0.80; 95% CI: 0.73-0.88) if patients had exposure to ICIs. In contrast, there was no significant difference in OS of patients with RCC treated with and without ICIs (16.7 vs. 14.0 months; HR: 0.96; 95% CI: 0.86-1.10). CONCLUSIONS: Overall, BM indicates poor patient outcome. Treatment with ICIs improves survival of patients with NSCLC, TNBC, and melanoma and BM; however, no significant improvement was observed in RCC. Investigations to identify prognostic features, oncogenomic profiles, and predictive biomarkers are warranted.

Use of radiation after breast conserving surgery (BCS) for DCIS and early invasive breast cancer at Charleston Area Medical Center (CAMC). A study of compliance with National Comprehensive Cancer Network (NCCN) guidelines.

The National Comprehensive Cancer Network (NCCN) recommends that patients with ductal carcinoma in situ (DCIS) and stage I/II invasive breast cancer receive radiation therapy following breast conserving surgery (BCS). The purpose for our study was to determine 1) the percentage of patients with DCIS and stage I/II breast cancer who received radiation therapy following BCS and 2) the clinical factors associated with the use of radiation. We retrospectively studied 606 patients treated between 2000 and 2007 with BCS for DCIS (n=104) and stage I/II breast cancer (n=502). Overall 93 percent of patients in our study received radiation therapy. We found that almost 85 percent and 95 percent of patients with DCIS and stage I/II breast cancer respectively received radiation therapy. Patients with invasive breast cancer who were less than 70 years of age and who received adjuvant systemic therapy were significantly more likely to receive radiation. The data from our study indicate that the use of radiation following BCS is high at our institution. Periodic review of treatment practices at local hospitals is valuable in assessing compliance with national guidelines and in improving quality of care.

Does sex make a difference in survival of patients undergoing resection for early stage non-small cell lung cancer (NSCLC)?

OBJECTIVE: To determine if sex associated differences exist in presentation and survival of patients undergoing resection for early stage nonsmall cell lung cancer (NSCLC). PATIENTS AND METHODS: Retrospective review of 2207 patients with Surveillance, Epidemiology, and End Results (SEER) Summary Stage I, II or III (local or regional disease) patients eligible for surgery, nonsmall cell lung cancer diagnosed and treated in WV between 1993 and 2000, which underwent surgery as a first course of treatment. Data set obtained from the West Virginia Cancer Registry. RESULTS: 1332 male cases and 875 female cases were reviewed. No statistically significant difference was found with mean age of diagnosis (men 66.5 years; women 67.2 years). A greater proportion of women had adenocarcinoma (p < 0.0001), lower grade (p = 0.002), and lower SEER summary stage (p = 0.009). There was no difference in laterality of tumor, 30-day post surgery survival or surgical procedure between men and women. Regression analysis showed a higher hazard ratio was associated with a increasing stage, grade, and those > or =65 years of age while lower hazard ratio was associated with adenocarcinoma. CONCLUSIONS: This study found that stage, grade, age, and histology, but not sex was the significant prognostic indicators of death in five years.

Pharmacological thromboembolic prophylaxis for medical patients in a tertiary care, teaching community hospital: room for improvement.

Venous Thrombembolism (VTE) is a potentially lethal complication in hospitalized patients. Studies indicate that pharmacological prophylaxis may reduce the incidence of VTE. However, the use of VTE prophylaxis remains unclear. We aimed to retrospectively assess whether medically ill hospitalized patients with established risk factors receive pharmacological VTE prophylaxis in our 912-bed community-based tertiary care teaching hospital between 1997 and 2003. We randomly selected a sample of 350 medically ill (non surgical) hospitalized patients with risk factors for VTE. A total of 164 of 321 patients (51.1%) received pharmacological VTE prophylaxis. Patients with a platelet count of greater than or equal to 278 K/cu mm, a weight of 146 to 184 lbs, or a weight > or = 185 lbs were found more likely to receive prophylaxis. Patients with cancer as well as other diagnoses (compared to MI patients) were less likely to receive prophylaxis. We conclude that there continues to be a significant underutilization of VTE prophylaxis in this patient population. Strategies for identifying patients at risk for VTE and implementing appropriate protocols to ensure that these patients receive prophylaxis are necessary.

Gefitinib (IRESSA, ZD 1839) as a salvage treatment for patients with advanced non-small cell lung cancer.

This study assessed the anti-tumor activity and tolerability of gefitinib (IRESSA, ZD 1839) in a series of patients with previously treated advanced non-small cell lung cancer (NSCLC) seen at Charleston Area Medical Center in Charleston, W.Va. All patients were required to have proven advanced or metastatic NSCLC, along with meeting other study criteria. In 41 patients, the partial response rate was 7%, and 10% of patients achieved stable disease. Symptom improvement (dyspnea, anorexia) was reported in 44%. Mean survival for the entire group was 6.7 months (10.3 months for females, 3.7 months for males), with a 6-month survival rate of 33%. Adverse events were generally mild (grade I or II) and reversible and consisted mostly of diarrhea, rash, and anorexia. Although the major response rate was low, gefitinib (IRESSA, ZD 1839) demonstrated clinically meaningful anti-tumor activity with significant improvement in symptoms in this heavily pretreated group of patients with advanced NSCLC.

The prevalence of viral hepatitis and HIV infections in patients with congenital bleeding disorders.

Patients with clotting disorders, including hemophilias A and B, and von Willebrand Disease generally receive pooled human blood products, and are at high risk for HIV-1 and hepatitis A, B and C viral infection. This retrospective study describes patients receiving treatment at a federally funded Hemophilia Treatment Center (HTC) from 1998 - 2002 and assesses the prevalence of viral infection. In addition, current rates of viral infection are compared to 1984-1996 rates.

Prognostic indicators for stage II (Dukes' stage B) adenocarcinoma of the colon.

To determine the prognostic indicators that are associated with lower disease free survival (DFS) and overall survival (OS) in stage II colon cancer patients, the tumor registry records were reviewed for all patients diagnosed with stage II and III adenocarcinoma of the colon at Charleston Area Medical Center from 1986 to 1994. The prognostic indicators of 174 stage II patients who had not undergone treatment were assessed for DFS and OS. The results demonstrated that the 5-year OS was reduced for those patients with the following prognostic indicators: male, obstruction at time of presentation, need for blood transfusion, and those who had < 7 LNR (lymph nodes removed). In addition, DFS and OS curves for stage II patients with < 7 LNR were not significantly different from survival curves for stage III patients. Treatment decisions are made based primarily on stage, and stage II patients are not routinely offered adjuvant therapy. Placing patients on a randomized clinical trial, until a standardized treatment is agreed upon, is one alternative. If patients are ineligible for, or refuse a clinical trial, then patients with poor prognostic indicators should be considered for adjuvant treatment.

The role of the bone marrow examination in the diagnosis of immune thrombocytopenic purpura: case series and literature review.

The need for a bone marrow examination was assessed in patients with clinical and laboratory features consistent with ITP; the literature was reviewed. The records of all patients undergoing a bone marrow examination between January 1988 to January 1998 were retrospectively reviewed to determine which were motivated by the suspicion of ITP. Data were collected from hospital and outpatient medical and pathology records. Eighty-six patients with isolated thrombocytopenia (i.e., normal white blood cell count, hemoglobin, peripheral smear and clotting studies) were studied. The bone marrow was consistent with ITP in 82 patients, (i.e., normal or increased megakaryocytes and other hemopoietic lineages normal.) Four patients had decreased megakaryocytes, but all patients responded to corticosteroids. All 86 patients were followed up for a median of 22 months after bone marrow aspiration (range, 2-76 months.) During that time, none of the patients developed features to suggest an alternative diagnosis to ITP. The initial clinical and laboratory findings of 99 patients with acute leukemia were also reviewed; all had features atypical of ITP. These data suggest that routine performance of a bone marrow examination for the diagnosis of ITP is not necessary, provided that a thorough history and physical examination are performed and that the complete blood cell count, peripheral blood smear, and routine clotting studies show no abnormalities apart from thrombocytopenia. The findings of seven prior retrospective studies, two in adults and five in children are consistent with the previous findings. However, the value of marrow investigation in ITP remains unresolved and data from a large prospective study would be helpful.

Thrombotic thrombocytopenic purpura following cardiovascular surgery: a case report.

Thrombotic thrombocytopenic purpura, a rare clinical syndrome characterized by thrombocytopenia and microangiopathic hemolytic anemia, was almost uniformly fatal until the introduction of plasma exchange in 1970. The thrombotic thrombocytopenic purpura following cardiovascular surgeries is relatively a new entity with high mortality if untreated. Plasma exchange is the most important therapy in this disease with good clinical outcomes. With the addition of this report, there are now 13 cases of thrombotic thrombocytopenic purpura in association with coronary artery bypass graft reported in the literature.

Incidence of colorectal cancer in West Virginia from 1993-1999: an update by gender, age, subsite and stage.

The sensitivities of different screening methods for pre-cancerous adenomas may affect the apparent anatomical distribution of colorectal cancers. Our objective was to describe changes in the distribution of left and right-sided colon cancers by time while adjusting for age, gender, stage and year of diagnosis. We studied the 7,895 cases of colorectal cancer reported to the West Virginia Cancer Registry between 1993 and 1999 and termed cancers proximal to, but not including the sigmoid colon as "right-sided," and the remaining tumors as "left-sided." Multivariate analyses were used to differentiate the effects of age and gender on changes in tumor location over time. The impact of screening was shown by the increase in the percentage of localized disease from 30.5% among cancers in the proximal colon to 37.6% in the distal colorectum. In contrast, the percentage of regional disease decreased from 50% among cancers in the proximal colon to the distal colorectum. The male to female ratios also increased from the proximal colon to the distal colorectum. Incidence rates, regardless of time, increased with advancing age for cancers located in all anatomical subsite groups, but more substantially for proximal colon cancer than for descending and distal colorectal cancers. For males ages > 85 and for females who are > 75 years of age, the cancer rates arising in the proximal colon exceeded observed in groups but more substantially for proximal colon cancer than for descending and distal colorectal cancers. For males age > 85 and females > 75, the cancer rates arising in the proximal colon exceeded those arising in the distal colorectum. This shift occurred at a younger age among females than males. The apparent shift of colorectal cancers to more proximal locations with advancing age has important implications for screening strategies. A further decrease in the relative incidence of left-sided colon cancers may require modifying current practices to include more frequent use of screening colonoscopy, particularly in women ages 75 years or older.

Primary cutaneous follicle center lymphoma of the arm with a novel chromosomal translocation t(12;21)(q13;q22): a case report.

We report a reciprocal translocation between the long arms of chromosomes 12 and 21, t(12;21)(q13;q22), in a patient with primary cutaneous follicle center lymphoma. Follicle center lymphoma of the skin and follicle center cell lymphoma of the lymph node are morphologically and immunophenotypically very similar. However, the clinical behavior and prognosis of these tumors are different due to the molecular basis of these malignancies. Follicle center cell lymphoma of the lymph node is determined by the presence of a unique translocation between chromosomes 14 and 18, t(14;18)(q32;q21), BCL-2-JH gene rearrangement, that is not present in primary cutaneous follicle center lymphomas. Chromosomal translocations in the primary skin lymphomas have not been previously reported. We hope that our discovery of a new translocation t(12:21)(q13q22) will encourage further investigation into the molecular basis of this translocation and other cytogenetic abnormalities in primary cutaneous B-cell lymphomas.