A Case of Primary Insular Ovarian Carcinoid Tumor with Hyperandrogenism and Carcinoid Heart Disease.

BACKGROUND Carcinoid heart disease typically occurs in the presence of metastatic carcinoid tumor deposits in the liver, as vasoactive substances access the systemic circulation through the hepatic vein. Primary ovarian carcinoid tumors are rare neuroendocrine tumors, and can be associated with carcinoid syndrome and carcinoid heart disease. CASE REPORT We describe the case of a 40-year-old woman who presented with secondary amenorrhea, acne, hirsutism, and diarrhea. She was found to have a heart murmur on exam in the absence of severe symptoms of heart failure. Her investigations demonstrated elevated urinary 5-hydroxyindoleacetic acid (5-HIAA), chromogranin A, and free testosterone. Abdominal computed tomography enterography showed a large and hypervascular pelvic mass. Octreotide scintigraphy confirmed the diagnosis of primary ovarian carcinoid tumor in the setting of an intensely octreotide-avid mass with no evidence of distant metastases. Transesophageal echocardiography showed severe tricuspid regurgitation with severe dilation of the right heart chambers. She underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The pathology demonstrated a 14-cm carcinoid tumor of 'insular' type confined to the ovary, pT1apNX, grade 1, positive for chromogranin and synaptophysin (neuroendocrine markers) and positive mib-1 (Ki-67). Postoperatively, clinical and biochemical parameters improved significantly but her cardiac function regressed over time, resulting in a tricuspid valve replacement 6 years later. CONCLUSIONS Primary ovarian carcinoid tumors can result in carcinoid heart disease, even in the absence of liver metastases. Early diagnosis and treatment contribute to favorable outcomes.

Effect of anticoagulants on admission rates and length of hospital stay for acute venous thromboembolism: A systematic review of randomized control trials.

BACKGROUND: There is a paucity of data available on hospitalization and length of stay (LOS) for different anticoagulant therapies. We sought to compare and summarize admission rates and LOS, and describe the frequency of reporting these two outcomes in randomized control trials (RCTs) comparing different anticoagulant therapies for venous thromboembolism (VTE). METHODS: A literature search was conducted from inception to August 15, 2016 on RCTs of anticoagulant therapy for patients with VTE. Study selection, data extraction and risk of bias analysis were done by two reviewers independently. Meta-analyses were conducted for admission rates and LOS. RESULTS: A total of 4064 articles were identified. There were 74 articles of 70 studies included in the analysis. Hospitalization rates and LOS were reported in 13 (18.6%) and 12 (17.1%) of the 70 included studies, respectively. Low-molecular-weight heparin (LMWH)-treated patients were 33.0% less likely to be admitted to hospitals compared to unfractionated heparin (UFH) (RR = 0.67, 95% CI [0.58, 0.78]). The mean difference in LOS between LMWH and UFH was 2.54 days in favor of LMWH (95% CI [-4.94, -0.14]). Compared to parenteral therapy, using rivaroxaban was associated with a lower admission rate for a difference of 1.4-5.1% in VTE, 2.5% in DVT and 0.2% in PE. The LOS of patients receiving rivaroxaban was significant shorter than the LOS in parenteral therapy group for a difference of 1-5 days in VTE, 3 days in DVT and 1 day in PE. CONCLUSION: Admission rates were lower and LOS was shorter using LMWH compared to UFH and oral therapy compared to parenteral therapy for acute VTE treatment in RCTs, based on limited eligible RCTs. These crucial clinically relevant outcomes are underreported in the existing VTE clinical trials.

Trends in admission rates and in-hospital stay for venous thromboembolism.

BACKGROUND: Acute venous thromboembolism leads to significant morbidity and mortality. Advances in pharmacotherapy facilitate outpatient care in low-risk acute venous thromboembolism. The proportion of hospitalized acute venous thromboembolism cases and the average length of stay are not known. We sought to identify predictors of hospitalization, changes in hospitalization rates and length of stay of acute venous thromboembolism over a decade in Alberta, Canada. METHODS: Using linked administrative health databases, we identified adult patients diagnosed primarily with acute venous thromboembolism between April 2002 and March 2012. We measured trends using Poisson regression, adjusted length of stay using analysis of covariance. We identified predictors of hospitalization using multivariate logistic regression. RESULTS: 8198 out of 31,656 acute venous thromboembolism cases were hospitalized. The overall venous thromboembolism admission rates ranged between 23.7% and 27.8% with no evident temporal trend (P=0.10). The average admission rate was 51.9% for pulmonary embolism and 16.1% for deep vein thrombosis. The mean length of stay for deep vein thrombosis and pulmonary embolism remained unchanged with an adjusted mean for venous thromboembolism of 6.9±1.0days. Higher Charlson index, older age, male gender, pulmonary embolism at presentation and multiple comorbidities were associated with hospitalization. Hospitalization was associated with 30-day mortality (odds ratio:2.8, 95% CI: 2.2-3.5) whereas the length of stay was not (odds ratio:1.0, 95% CI: 0.99-1.0). CONCLUSION: Hospitalization rates and mean length of stay for acute venous thromboembolism did not change significantly between 2002 and 2012. Advances in pharmacotherapy have not yet reduced hospitalization rates or length of stay for venous thromboembolism.

Sex disparities in hospitalization and mortality rates for venous thromboembolism.

Venous thromboembolism (VTE) is a major health problem for both men and women. Whether sex disparities exist for outcomes after acute VTE is unknown. We sought to measure sex-specific rates of hospitalization for and mortality from acute VTE. We used a population-based administrative dataset from Alberta, Canada, covering the years 2002 to 2012. We used Poisson regression to measure the incidence rate ratio for hospitalization and Cox regression to test for sex disparities in short-term all-cause mortality after adjusting for potential confounders. Of those diagnosed with VTE, 55.9% were women. The proportion of hospitalized women for VTE was 24.4 versus 27.8% in men (p < 0.001). The risk adjusted incidence rate ratio for VTE hospitalization increased with age for both sex. While women younger than 80 years old were less likely to be hospitalized than men, sex disparities for the risk of hospitalization were not significant after age 80 (p = 0.93). The adjusted 90-day all-cause mortality rate for women was 4.0% compared to 4.9% in men (adjusted HR = 1.0, p = 0.49). Women with acute VTE were less likely than men to be hospitalized in most age groups, but sex disparities in short-term all-cause mortality were not found.