Barriers to genetic testing in newly diagnosed breast cancer patients: Do surgeons limit testing?

BACKGROUND: Genetic testing results influence treatment recommendations in newly diagnosed breast cancer patients. However, at-risk patients do not uniformly undergo genetic testing. The goal of this study was to identify barriers to genetic testing in newly diagnosed breast cancer patients. METHODS: A prospective database of newly diagnosed breast cancer patients meeting specific criteria over an 18-month period was created and retrospectively reviewed. RESULTS: A total of 532 patients were identified at risk for genetic mutation. Of these 313 (59%) patients completed a genetic counseling appointment and 292 (55%) underwent genetic testing. One hundred seven (24%) were never referred to genetic counselors and 89 (17%) were referred but did not complete an appointment. Patients referred to genetics were younger than the nonreferred patients (50.9 vs 60.6 years, P < .001). The 89 women referred to genetics who did not complete an appointment were surveyed and had varied reasons for not completing an appointment. CONCLUSIONS: The largest barrier to genetic testing was lack of physician referral; therefore, provider education must be improved. Appointments should be convenient and providers should proactively discuss the significant implications of testing results.

A Case of a Bilateral Inflammatory Breast Cancer: A Case Report.

Cases of bilateral inflammatory breast cancer (IBC) are extremely rare. Our search criteria only found one other record of metachronous bilateral IBC (1). We present the case of a patient who was treated for IBC with neoadjuvant chemotherapy, modified radical mastectomy (MRM), and whole breast radiation. Less than 1 year later, the patient had a recurrence of IBC on the left chest wall with in the radiated field, as well as a new IBC on the contralateral side. Bilateral IBC is extremely rare. This entity can present challenges for the standard treatment of IBC with neoadjuvant chemotherapy, MRM, and whole breast radiation (2). Our case study shows the importance of scheduled routine imaging, screening with physical examination after IBC management, and good patient compliance in this aggressive disease (3).

A 5-year review of management of lower extremity arterial injuries at an urban level I trauma center.

BACKGROUND: The purpose of this study was to review the management of lower extremity arterial injuries to determine incidence, assess the current management strategy, and evaluate hospital outcome. METHODS: This was a retrospective review, including trauma database query, and medical records review set in an urban level I trauma center. Sixty-five patients with 75 lower extremity arterial injuries were admitted between April 2005 and April 2010. The interventions were primary amputation, medical management, vascular surgical intervention, and subsequent amputation. The main outcome measures were age, gender, race, mechanism of injury, type of injury, associated lower extremity injuries, concomitant injuries, Injury Severity Score, Abbreviated Injury Scale, surgical procedures and interventions, limb salvage rate, mortality, length of stay, and discharge disposition. RESULTS: During a 5-year period, 65 patients with 75 lower extremity arterial injuries were admitted to the hospital, yielding an incidence of 0.39% among trauma admissions. The study population was comprised primarily of young men, with a mean Injury Severity Score of 15.2 and a mean Abbreviated Injury Scale of 2.7 (moderate to severe injuries). The majority of patients (78.4%) suffered concomitant lower extremity injuries, most frequently bony or venous injuries, whereas 35.4% experienced associated injuries to other body regions. The most common injury mechanism was a gunshot wound (46.7%). Arterial injuries were categorized into 42 penetrating (56.0%) and 33 blunt mechanisms (44.0%). Involved arterial distribution was as follows: 4 common femoral (5.3%), 4 profunda femoris (5.3%), 24 superficial femoral (32.0%), 16 popliteal (21.3%), and 27 tibial (36.0%) arteries. The types of arterial injuries were as follows: 28 occlusion (37.3%), 23 transection (30.7%), 16 laceration (21.3%), and 8 dissection (10.7%). Orthopedic surgeons performed amputations as primary procedures in 3 patients (4.6%). The majority (76.8%) of injuries receiving vascular management underwent surgical intervention, with procedure distribution as follows: 26 bypass (49.1%); 13 primary repair (24.5%); 7 ligation (13.2%); 4 endovascular (7.5%); and 3 isolated thrombectomy (5.7%) procedures. Concomitant venous repair and fasciotomy were performed in 22.4% and 38.2% of cases, respectively. Medication was the primary strategy for 16 arterial injuries (23.2%). Subsequent major amputation was required for 3 patients (4.8%) who initially received vascular management. Three patients (4.6%) died during hospitalization. CONCLUSION: The current multidisciplinary team management approach, including use of computed tomographic or conventional angiography and prompt surgical management, resulted in successful outcomes after lower extremity arterial injuries and will continue to be utilized.

Treatment of Iatrogenic Pseudoaneurysms Using Ultrasound-Guided Thrombin Injection over a 5-Year Period.

In this study we demonstrate that ultrasound (US)-guided injection of thrombin is a safe and effective way to treat iatrogenic pseudoaneurysms as a new treatment modality at a 650-bed urban community hospital. We included retrospective chart review of patients who were treated for iatrogenic pseudoaneurysms from January 2004 to June 2010 at a single institution. All patients' pseudoaneurysms were treated using US-guided thrombin injection. This study demonstrated an overall success rate of 97.1% in treating iatrogenic pseudoaneurysms in 33 of 34 patients. One patient underwent open surgical repair. No mortality or complications were noted. The study was successful in demonstrating that the US-guided injection of thrombin is an efficacious way to treat iatrogenic pseudoaneurysms and can be safely implemented as a new treatment modality by appropriately trained vascular surgeons. A review of different techniques is included. An algorithm for the treatment of iatrogenic pseudoaneurysms is proposed from this study.