Stratifying risk of urinary tract malignant tumors in patients with asymptomatic microscopic hematuria.

2013 ◽  
Vol 31 (31_suppl) ◽  
pp. 223-223
Author(s):  
Ronald Loo ◽  
Violeta Rabrenovich ◽  
Ann Michelle Aspera ◽  
Steven Jacobsen ◽  
Howard Landa ◽  
...  
Keyword(s):  
Improve Patient Safety ◽  
Risk Index ◽  
Microscopic Hematuria ◽  
Smoking History ◽  
Considerable Proportion ◽  
Prior History ◽  
Evidence Based ◽  
Gross Hematuria ◽  
Asymptomatic Patients ◽  
History Of

223 Background: AMH in the general population is common, occurring in up to 9-18%. Even low degrees of AMH have been considered a risk factor for UTMT. Although the prevalence of UTMT is low (.01-3%), many asymptomatic patients undergo unnecessary and hazardous evaluations. In 2007, the Kaiser Permanente (KP) Urologists started a multi-year QI effort to research and develop a risk stratified evidence-based approach in the evaluation of AMH. Methods: The group first conducted a retrospective analysis to determine the incidence of urinary cancer, and stratify risk according to age, gender, smoking history, and degree of hematuria. A multi-regional prospective, observational study was then conducted over a two year period. We used a data collection tool embedded within an EMR to determine patients with AMH who are at greatest risk for UTMT, and patients who might benefit from urologic evaluation or safely avoid unnecessary workup and radiation exposure. Results: 4,414 patients had full urologic work up. Overall, 100 bladder cancers were diagnosed among 4,414 patients (2.3%), and only 11 renal cancers (0.2%) were pathologically confirmed. Multivariable logistic regression was conducted for 5 common parameters: age, gender, smoking history, degree of microscopic hematuria, and history of gross hematuria within the past 6 months. The two most important risk factors were age > 50, and prior history of gross hematuria. A hematuria risk index (HRI) was developed, which significantly improved predictability (AUC = .809-HRI vs .532-AUA guideline). Overall, 32% of the population was identified as low risk with only 0.2% cancer detected; 14% of the population was identified as high risk, of whom 11.1% had a cancer diagnosed. Conclusions: These results suggest that a considerable proportion of patients may safely avoid hazardous evaluation using multivariate risk stratification. An evidence-based algorithm was developed for the management of asymptomatic microscopic hematuria and implemented within KP. We expect to significantly improve patient safety and improve reliability of patient evaluation.

scholarly journals Primary Lymphoma Presenting in an Ascending Aortic Aneurysm: A Case Report

Aorta ◽  
2020 ◽  
Vol 08 (02) ◽  
pp. 038-040
Author(s):  
Alexander M. Schurman ◽  
David Mendoza ◽  
Chris K. Rokkas
Keyword(s):  
Management Strategies ◽  
Ascending Aorta ◽  
Aortic Aneurysms ◽  
Prior History ◽  
Primary Lymphoma ◽  
Surgical Specimen ◽  
Hematological Disorders ◽  
Thoracic Aortic Aneurysms ◽  
Asymptomatic Patients ◽  
History Of

AbstractSmall lymphocytic lymphoma (SLL) is rarely associated with thoracic aortic aneurysms. Aneurysm of the ascending aorta associated with SLL has never been reported before. We describe the case of an asymptomatic 68-year-old woman who presented with a 5.5-cm aneurysm of the ascending aorta and no prior history of hematological disorders. Following excision and repair, the surgical specimen showed infiltration of the aortic wall by lymphocytes, expressing markers consistent with SLL. While symptomatic SLL carries a poor prognosis, risk stratification tools are applied to guide management strategies in asymptomatic patients.

scholarly journals Finding of pathological thrombomodulin gene variant in a patient with idiopathic nodular glomerulosclerosis and chronic thrombotic microangiopathy-like changes

2020 ◽  
Vol 8 ◽  
pp. 2050313X2094051
Author(s):  
Ramy Hanna ◽  
Jonathan E Zuckerman ◽  
Antoney Ferrey ◽  
Everado Arias Torres ◽  
Sam Tonthat ◽  
...  
Keyword(s):  
Alternative Pathway ◽  
Pathological Finding ◽  
Smoking History ◽  
Prior History ◽  
Diabetic Patients ◽  
Glomerular Injury ◽  
Nodular Glomerulosclerosis ◽  
Smoking Exposure ◽  
History Of ◽  
Idiopathic Nodular Glomerulosclerosis

Idiopathic nodular glomerulosclerosis is an unusual histopathological finding that has commonly been observed in male smokers with hypertension. It has remained an enigmatic condition and is best described as a diabetic pattern of glomerular injury seen in non-diabetic patients. It is also one of the few nicotine (smoking)-associated/smoking-associated patterns of renal injury. We present an even more unusual manifestation of this pathological finding in a 59-year-old Hispanic female who presented with chronic kidney disease approaching need for renal replacement therapy. The patient had idiopathic nodular glomerulosclerosis on kidney biopsy, despite no prior history of diabetes, nor smoking history, including no secondhand smoking exposure. The patient did have hypertension. The renal biopsy also showed evidence of chronic thrombotic-microangiopathic changes within arteries and arterioles. Genetic testing of the alternative pathway revealed an unusual and likely pathological variant of thrombomodulin supporting complement dysfunction as having a role in the presentation.

As-Needed Antihypertensive Therapy in Surgical Patients, Why and How: Challenging a Paradigm

2012 ◽  
Vol 78 (2) ◽  
pp. 250-253 ◽  
Author(s):  
Christopher P. Miller ◽  
Aaron M. Cook ◽  
D. Pharm ◽  
Christopher D. Case ◽  
Andrew C. Bernard
Keyword(s):  
Antihypertensive Therapy ◽  
Medical Center ◽  
Evidence Base ◽  
Prior History ◽  
Emergency General Surgery ◽  
University Of Kentucky ◽  
Asymptomatic Patients ◽  
History Of ◽  
Level I ◽  
The Cost

Hypertension is common in hospitalized patients and there are many causes. Some patients have no prior history of hypertension, few symptoms, and no apparent morbidity related to acute rises in blood pressure. Though there is no established guideline for therapy in these cases, patients often receive therapy directed at the abnormal vital sign. It is hypothesized that this practice is common and the associated costs are significant. Using the inpatient pharmacy database at the University of Kentucky Chandler Medical Center, a verified Level I trauma center and quaternary referral center, patients on the emergency general surgery or orthopedic surgery services receiving intravenous hydralazine, metoprolol, or labetalol were identified. Subjects were analyzed for indications, parameters, associated history of hypertension, and direct costs. Over the 4-month study period, 114 subjects received 522 drug doses. More than half (55%) of subjects had a prior history of hypertension but only 75 per cent were started on their home medication. Of those without hypertension before admission, 18 per cent required therapy at discharge. Labetalol was the most frequently used agent and total pharmacy costs for this cohort of patients was over $1200. Pro re nata (PRN), short-acting antihypertensive therapy has little evidence base in asymptomatic patients, but its prevalence is high on surgical services. The cost is significant, especially when extrapolated to the larger hospital population at this single institution. Further research is warranted to determine the prevalence of this practice in other centers or national regions, as well as its cost and benefit.

scholarly journals Evidence of SARS-CoV-2 Transcriptional Activity in Cardiomyocytes of COVID-19 Patients without Clinical Signs of Cardiac Involvement

Biomedicines ◽  
2020 ◽  
Vol 8 (12) ◽  
pp. 626
Author(s):  
Gaetano Pietro Bulfamante ◽  
Gianluca Lorenzo Perrucci ◽  
Monica Falleni ◽  
Elena Sommariva ◽  
Delfina Tosi ◽  
...  
Keyword(s):  
Transcriptional Activity ◽  
Cardiac Involvement ◽  
Cardiac Injury ◽  
Clinical Signs ◽  
Digital Pcr ◽  
Considerable Proportion ◽  
Cardiac Phenotype ◽  
Asymptomatic Patients ◽  
Transmission Electron ◽  
History Of

Aims: A considerable proportion of patients affected by coronavirus respiratory disease (COVID-19) develop cardiac injury. The viral impact in cardiomyocytes deserves, however, further investigations, especially in asymptomatic patients. Methods: We investigated for SARS-CoV-2 presence and activity in heart tissues of six consecutive COVID-19 patients deceased from respiratory failure showing no signs of cardiac involvement and with no history of heart disease. Cardiac autopsy samples were collected within 2 h after death, and then analysed by digital PCR, Western blot, immunohistochemistry, immunofluorescence, RNAScope, and transmission electron microscopy assays. Results: The presence of SARS-CoV-2 into cardiomyocytes was invariably detected in all assays. A variable pattern of cardiomyocyte injury was observed, spanning from absence of cell death and subcellular alterations hallmarks, to intracellular oedema and sarcomere ruptures. In addition, we found active viral transcription in cardiomyocytes, by detecting both sense and antisense SARS-CoV-2 spike RNA. Conclusions: In this autopsy analysis of patients with no clinical signs of cardiac involvement, the presence of SARS-CoV-2 in cardiomyocytes has been detected, determining variable patterns of intracellular damage. These findings suggest the need for cardiologic surveillance in surviving COVID-19 patients not displaying a cardiac phenotype.

scholarly journals THU0438 INADEQUATE CARE FOR PATIENTS HOSPITALISED WITH GOUT: EVIDENCE THAT EULAR GUIDANCE IS NOT UTILISED

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 456.2-456
Author(s):  
M. Russell ◽  
B. Clarke ◽  
S. Rampes ◽  
K. Dokal ◽  
A. Mahto ◽  
...  
Keyword(s):  
At Risk ◽  
Hospital Admissions ◽  
Admission Diagnosis ◽  
Prior History ◽  
Evidence Based ◽  
Acute Gout ◽  
Discharge Plan ◽  
Icd 10 ◽  
History Of ◽  
Direct Contrast

Background:Hospitalisations due to gout have increased over the last decade, in direct contrast to declining admissions for other inflammatory arthritides including RA [1]. Gout is a treatable condition with recently published EULAR guidelines [2, 3]. Admissions could be avoided with effective use of urate-lowering therapies (ULT).Objectives:We hypothesised that the majority of patients attending hospital with acute gout attacks would not be on ULT. Furthermore, we hypothesised that the majority of patients would not be provided with a plan for ULT commencement and/or uptitration on discharge, leaving them at risk of further hospitalisations.Methods:We retrospectively analysed electronic health records for all patients presenting acutely with a primary admission diagnosis of gout (ICD-10 code: M10) at two hospitals in London, UK, from January – December 2017. Analyses of in-hospital gout management were performed for these patients, including to ascertain the number and proportion of patients who: i) had a known history of gout; ii) were receiving ULT at time of attendance; iii) were provided with a discharge plan for ULT commencement and/or uptitration.Results:Over a 12-month period, there were 234 emergency attendances for gout in 225 individuals. 80% were male, with a mean age of 58 years. 70/234 (30%) attendances resulted in admission to hospital (mean length of stay: 2 days; range: 0-31 days). 211 patients had routinely captured clinical data available for further analysis. 90/211 (43%) patients had prior diagnoses of gout, of whom 38% were on ULT at presentation (32 allopurinol, 2 febuxostat). 38% of patients were discharged with a plan for ULT commencement and/or uptitration. 20 patients re-presented to hospital with acute gout within 12 months (17/20 were not receiving ULT).Conclusion:Most patients hospitalised with gout were not receiving ULT, even those with a prior history of gout attacks. Few were provided with a ULT plan, leaving them at risk of re-admission to hospital. Hospital admissions are unpleasant for patients and incur a high economic burden for health services; if they are to be prevented, there must be a concerted effort to implement and follow gout management guidelines to ensure patients receive ULT at appropriate doses.References:[1]Russell M,et al. Return of the King: Rising Incidence of Acute Hospital Admissions due to Gout. J Rheum 2019 Sep 15.[2]Richette P, et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis 2017;76:29-42.[3]Richette P, et al. 2018 updated European League Against Rheumatism evidence-based recommendations for the diagnosis of gout. Ann Rheum Dis 2020;79:31-38.Disclosure of Interests: :None declared

Is hyperglycemia a prognostic factor in pancreatic cancer?

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 14078-14078 ◽  
Author(s):  
S. F. Mekan ◽  
M. M. Safa ◽  
R. S. Komrokji ◽  
Z. A. Nahleh ◽  
A. R. Jazieh
Keyword(s):  
Diabetes Mellitus ◽  
Pancreatic Cancer ◽  
Median Survival ◽  
Tumor Biology ◽  
Stage Iv ◽  
Smoking History ◽  
Prior History ◽  
P Value ◽  
History Of ◽  
The Impact

14078 Background: Pancreatic hyperglycemia is one of the manifestations of pancreatic cancer.The purpose of this study is to explore the prevalence and significance of hyperglycemia at the time of diagnosis of pancreatic cancer. Methods: We reviewed retrospectively cases presenting to our institution with diagnosis of pancreatic carcinoma between 1999–2003. Hyperglycemia was defined as a blood sugar of greater than 140mg/dL. Results: There were 155 cases diagnosed with pancreatic cancer. Out of these, 67 (43.2%) were males and 71(45.8%) were females. The mean age was 63 years. Staging was reported in 134 patients: 19 patients (14%) were stage I, 23 (17%) stage II, 40 (30%) stage III and 52 (39%) stage IV. Median survival time was 8 months. Thirty-four (22%) patients had prior history of diabetes mellitus and were excluded from subsequent analysis. Sixty-four patients out of 121 patients (53%) were found to be hyperglycemic. These patients had no prior history of diabetes mellitus or were diagnosed with diabetes within six months. There was no difference between hyperglycemic patients and normoglycemic patients regarding age, sex, race, tumor location, smoking history, history of pancreatitis and hypertension. Hyperglycemic patients were more likely to have history of alcohol use compared to normoglycemic patients (p value = 0.005, OR = 4.07). Hyperglycemic patients were less likely to present with stage IV disease as compared to normoglycemic patients (25% vs. 55%) (p-value 0.002). The median survival in hyperglycemic patients was significantly longer than in normoglycemic patients (12 vs. 6 months, p-value = 0.02).There was a trend towards better survival among stage IV hyperglycemic patients as compared to normoglycemic patients (13 months vs 3 months) (p-value 0.38). Conclusions: In this retrospective analysis, 53% of pancreatic cancer patients without diabetes had hyperglycemia at presentation. These patients presented at an earlier stage compared to normoglycemic patients and had significantly longer survival. The impact of hyperglycemia on survival could be related to earlier presentation or difference in the tumor biology. The clinical significance of hyperglycemia in pancreatic cancer should be further studied in prospective fashion. No significant financial relationships to disclose.

Randomized phase II study of nivolumab (N) alone versus with pegilodecakin (PEG) in combination with N in patients (pts) with post-platinum immunotherapy-naive stage IV non-small cell lung cancer (NSCLC) and no or low PD-L1 expression (CYPRESS 2).

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. e21744-e21744
Author(s):  
Robert M. Jotte ◽  
Jerome H. Goldschmidt ◽  
Jeffrey Gary Schneider ◽  
Merrill Kingman Shum ◽  
David Berz ◽  
...  
Keyword(s):  
Phase Ii ◽  
Phase Ii Trial ◽  
Stage Iv ◽  
Smoking History ◽  
Prior History ◽  
Open Label ◽  
Randomized Phase Ii ◽  
Open Label Phase ◽  
History Of ◽  
Secondary Endpoints

e21744 Background: Nivolumab (N) is an immune checkpoint inhibitor (CPI) approved to treat post-platinum NSCLC as monotherapy. PEG in combination with N has demonstrated promising efficacy in NSCLC pts in a phase I trial (IVY; NCT02009449; Naing et al., 2019 Lancet Oncol), providing rationale for this randomized phase II trial (CYPRESS 2). Methods: CYPRESS 2 was an open label phase II trial, for ECOG 0-1, PD-L1 negative or low (TPS 0-49%), Stage IV NSCLC pts, without known EGFR/ALK mutations. Pts were randomized 1:1 to arm N (240 mg every 14-days or 480 mg every 28-days as decided by investigator) v. arm PEG+N (received N as above + PEG daily of 0.8 mg if weight ≤80kg and 1.6mg if weight > 80 kg). Pts were stratified by tumor histology and smoking history and must have no prior history of cancer or CPI therapy. Primary endpoint was ORR (per RECIST v 1.1 per investigator). Secondary endpoints included PFS, OS, and safety. Exploratory endpoints included immune activation biomarkers (baseline and change from baseline), assessed by immunoassay. Results: As of Aug 28, 2019, 52 pts were randomized to PEG+N (n=27) or N (n=25). Median follow-up time was 11.6 months. The following results were found for PEG+N versus N: ORR 14.8% v. 12.0%, mPFS 1.9 v. 1.9 months with HR = 1.01 (95% CI [0.52, 1.95]), mOS 6.7 v. 10.7 months with HR = 1.87 (95% CI [0.77, 4.53]). Gr ≥3 treatment related adverse events (TRAEs) for PEG+N versus N were 70.4% vs. 16.7%. Gr 3 TRAEs of ≥10% incidence included anemia (40.7% v. 0%), fatigue (18.5% v. 0%), and thrombocytopenia (14.8% v. 0%). In PEG+N arm, increased circulating IL-18, Granzyme B, FasL, and IFNg levels and decreased TGFb levels were observed on treatment. Conclusions: Exploratory pharmacodynamic results were consistent with immunostimulatory signals of the IL-10R pathway. Despite evidence of biological effect, adding PEG to N did not lead to improvement in ORR, PFS, or OS in post-platinum advanced NSCLC with no or low PD-L1 expression. PEG+N arm demonstrated expected safety profile but overall higher toxicity compared to nivolumab alone. Clinical trial information: NCT03382912.

scholarly journals Actinomycosis of the urinary bladder

2013 ◽  
Vol 7 (7-8) ◽  
pp. 502 ◽  
Author(s):  
Chun Huang ◽  
Turki Al-Essawi
Keyword(s):  
Urinary Bladder ◽  
Bladder Wall ◽  
Smoking History ◽  
Gross Hematuria ◽  
Inflammatory Mass ◽  
Gram Positive Bacteria ◽  
Ultrasound Computed Tomography ◽  
Actinomyces Species ◽  
History Of ◽  
The Right

Actinomycosis of the urinary bladder is a rare anaerobic bacterial infection caused by Actinomyces isrealii. Initial diagnosis is often difficult and this disease is easily misdiagnosed as a urothelial or urachal tumour. The definitive diagnosis is usually made postoperatively via tissue pathology. We discuss a case of a 54-year-old male with a smoking history and a 2.5-week history of gross hematuria. Ultrasound, computed tomography and cystoscopy revealed a large inflammatory mass adherent to the right, anterior bladder wall, suggesting malignancy. Transurethral resection and histological pathology subsequently confirmed inflammatory urothelium and gram-positive bacteria consistent with actinomyces species.

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