Unplanned 30-Day Readmissions after Parathyroidectomy in Patients with Chronic Kidney Disease: A Nationwide Analysis

Objective To examine rates of readmission after parathyroidectomy in patients with chronic kidney disease and determine primary etiologies, timing, and risk factors for these unplanned readmissions. Study Design Retrospective cohort study. Setting Nationwide Readmissions Database. Subjects and Methods The Nationwide Readmissions Database was queried for parathyroidectomy procedures performed in patients with chronic kidney disease between January 2013 and November 2013. Patient-, admission-, and hospital-level characteristics were compared for patients with and without at least 1 unplanned 30-day readmission. Outcomes of interest included rates, etiology, and timing of readmission. Multivariate logistic regression was used to identify predictors of 30-day readmission. Results There were 2756 parathyroidectomies performed in patients with chronic kidney disease with an unplanned readmission rate of 17.2%. Hypocalcemia/hungry bone syndrome accounted for 40% of readmissions. Readmissions occurred uniformly throughout the 30 days after discharge, but readmissions for hypocalcemia/hungry bone syndrome peaked in the first 10 days and decreased over time. Weight loss/malnutrition at time of parathyroidectomy and length of stay of 5 to 6 days conferred increased risk of readmission with adjusted odds ratios (aOR) of 3.31 (95% confidence interval [CI], 1.55-7.05; P = .002) and 1.87 (95% CI, 1.10-3.19; P = .02), respectively. Relative to primary hyperparathyroidism, parathyroidectomies performed for secondary hyperparathyroidism (aOR, 2.53; 95% CI, 1.07-5.95; P = .03) were associated with higher risk of readmission. Conclusion Postparathyroidectomy readmission rates for patients with chronic kidney disease are nearly 5 times that of the general population. Careful consideration of postoperative care and electrolyte management is crucial to minimize preventable readmissions in this vulnerable population.

Intradialytic Central Venous Oxygen Saturation is Associated with Clinical Outcomes in Hemodialysis Patients

Central venous oxygen saturation (ScvO₂) in the superior vena cava is predominantly determined by cardiac output, arterial oxygen content, and oxygen consumption by the upper body. While abnormal ScvO₂ levels are associated with morbidity and mortality in non-uremic populations, ScvO₂ has received little attention in hemodialysis patients. From 1/2012 to 8/2015, 232 chronic hemodialysis patients with central venous catheters as vascular access had their ScvO₂ monitored during a 6-month baseline period and followed for up to 36 months. Patients were stratified into upper and lower two tertiles by a ScvO₂ of 61.1%. Survival analysis employed Kaplan-Meier curves and adjusted Cox proportional hazards models. Patients in the lower tertiles of ScvO₂ were older, had longer hemodialysis vintage, lower systolic blood pressure, lower ultrafiltration rates, higher leukocyte counts and neutrophil-to-lymphocyte ratios. Kaplan-Meier analysis indicated a shorter survival time in the lower tertiles of ScvO₂ (P = 0.005, log-rank test). In adjusted Cox analysis, a 1 percent point decrease in mean ScvO₂ was associated with a 4% increase in mortality (HR 1.04 [95% CI 1.01-1.08], P = 0.044), indicating that low ScvO₂ is associated with poor outcomes. Research on the relative contributions of cardiac output and other factors is warranted to further elucidate the pathophysiology underlying this novel finding.

Sensitivity of various body indices and visceral adiposity index in predicting metabolic syndrome among Chinese patients with adult growth hormone deficiency

AIM

Adult growth hormone deficiency (AGHD) refers to decreased secretion of growth hormones in the adults, which is associated with increased clustering of conventional cardiovascular risk factors such as central obesity, insulin resistance and dyslipidemia. Metabolic syndrome (MetS), a recognized risk factor of cardiovascluar diseases, shares some clinical features. Given that the prevalence of MetS is on the rise in patients with AGHD, and that cardiovascular disease (CVD) is an important cause of morbidity and mortality in that population, the alternative, simple, non-invasive methods of assessing MetS among this population are needed. This study aims to determine the sensitivity of five anthropometric indices [Body mass index (BMI), Waist circumference (WC), Waist-to-hip ratio (WHR), Waist-to-height ratio (WHtR) and Visceral adiposity index (VAI)] in predicting metabolic syndrome in Chinese population-based patients with adult growth hormone deficiency.

MATERIALS AND METHODS

A total of 96 Chinese patients with adult growth hormone deficiency were included in this study. They were compared with equal number of apparently healthy persons with similar characteristics (matched with age and gender) to the previous group. Anthropometric measurements including weight, height, serum lipids indices, blood pressure (BP), fasting plasma glucose (FPG), WC were measured. BMI, WHR, WHtR, and VAI were calculated.

RESULTS AND DISCUSSION

AGHD patients with MetS had higher WC (91.00 ± 8.28 vs 78.01 ± 7.12), BMI (24.95 ± 2.91 VS 23.30 ± 2.80), WHR (0.92 ± 0.06 VS 0.87 ± 0.07), WHtR (0.53 ± 0.06 VS 0.47 ± 0.05), VAI [(5.59 (4.02, 7.55) VS 1.69 (0.87, 3.05)] levels in comparison to those without MetS. Meantime WC, BMI, WHR, WHtR, VAI was positively correlated to MetS components. ROC curve for participants with AGHD showed that VAI had the highest SS of 92% (BMI 0.812; WHR 0.706; WHtR 0.902; VAI 0.920, respectively) for prediction of MetS in AGHD. The optimal cutoff values for different adiposity markers in predicting MetS were as follows: WC (79.65), BMI (23.46); WHR (0.89); WHtR (0.54); VAI (2.29).

CONCLUSION

In conclusion, our study showed all adiposity measures of interest present themselves as easy and practical tools for use in population studies and clinical practice for evaluating MetS in AGDH and VAI was identified as the best in Chinese AGHD patients among them.

Reasons for admission and predictors of national 30-day readmission rates in patients with end-stage renal disease on peritoneal dialysis

Background

The number of patients with end-stage renal disease (ESRD) on peritoneal dialysis (PD) has increased by over 30% between 2007 and 2014. The Centers for Medicare and Medicaid has identified readmissions in ESRD patients to be a quality measure; however, there is a paucity of studies examining readmissions in PD patients.

Methods

Utilizing the National Readmission Database for the year 2013, we aimed to determine reasons for admission, the associated rates of unplanned readmission and independent predictors of readmissions in PD patients.

Results

The top 10 reasons for initial hospitalization were implant/PD catheter complications (23.22%), hypertension (5.47%), septicemia (5.18%), diabetes mellitus (DM) (5.12%), complications of surgical procedures/medical care (3.50%), fluid and electrolyte disorders (4.29%), peritonitis (3.76%), congestive heart failure (3.25%), pneumonia (2.90%) and acute myocardial infarction (AMI) (2.01%). The overall 30-day readmission rate was 14.6%, with the highest rates for AMI (21.8%), complications of surgical procedure/medical care (19.6%) and DM (18.4%). Concordance among the top 10 reasons for index admission and readmission was 22.6% and varied by admission diagnosis. Independent predictors of readmissions included age 35–49 years compared with 18–34 years [adjusted odds ratio (aOR) 1.35; 95% confidence interval (CI) 1.09–1.68; P = 0.006], female gender (aOR 1.27; 95% CI 1.12–1.44; P < 0.001), and comorbidities including liver disease (aOR 1.39; 95% CI 1.07–1.81; P = 0.01), peripheral vascular disease (aOR 1.33; 95% CI 1.14–1.56; P < 0.001) and depression (aOR 1.22; 95% CI 1.00–1.48; P = 0.04).

Conclusions

This study demonstrates the most common reasons for admission and readmissions in PD patients and several comorbidities that are predictive of readmissions. Targeted interventions towards these patients may be of benefit in reducing readmission in this growing population.

The Effect of Depression in Chronic Hemodialysis Patients on Inpatient Hospitalization Outcomes

BACKGROUND/AIMS

Depression is common in patients with end-stage renal disease (ESRD) on hemodialysis (HD). Although, depression is associated with mortality, the effect of depression on in-hospital outcomes has not been studied as yet.

METHODS

We analyzed the National Inpatient Sample for trends and outcomes of hospitalizations with depression in patients with ESRD.

RESULTS

The proportion of ESRD hospitalizations with depression doubled from 2005 to 2013 (5.01-11.78%). Hospitalized patients on HD with depression were younger (60.47 vs. 62.70 years, p < 0.0001), female (56.93 vs. 47.81%, p < 0.0001), white (44.92 vs. 34.01%, p < 0.0001), and had higher proportion of comorbidities. However, there was a statistically significant lower risk of mortality in HD patients within the top 5 reasons for admissions.

CONCLUSION

There were significant differences in demographics and comorbidities for hospitalized HD patients with depression. Depression was associated with an increased rate of adverse effects in discharged patients, and decreased in-hospital mortality.

National Trends and Impact of Acute Kidney Injury Requiring Hemodialysis in Hospitalizations With Atrial Fibrillation

BACKGROUND

Atrial fibrillation (AF) is a common cause for hospitalization, but there are limited data regarding acute kidney injury requiring dialysis (AKI-D) in AF hospitalizations. We aimed to assess temporal trends and outcomes in AF hospitalizations complicated by AKI-D utilizing a nationally representative database.

METHODS AND RESULTS

Utilizing the Nationwide Inpatient Sample, AF hospitalizations and AKI-D were identified using diagnostic and procedure codes. Trends were analyzed overall and within subgroups and utilized multivariable logistic regression to generate adjusted odds ratios (aOR) for predictors and outcomes including mortality and adverse discharge. Between 2003 and 2012, 3751 (0.11%) of 3 497 677 AF hospitalizations were complicated by AKI-D. The trend increased from 0.3/1000 hospitalizations in 2003 to 1.5/1000 hospitalizations in 2012, with higher increases in males and black patients. Temporal changes in demographics and comorbidities explained a substantial proportion but not the entire trend. Significant comorbidities associated with AKI-D included mechanical ventilation (aOR 13.12; 95% CI 9.88-17.43); sepsis (aOR 8.20; 95% CI 6.00-11.20); and liver failure (aOR 3.72; 95% CI 2.92-4.75). AKI-D was associated with higher risk of in-hospital mortality (aOR 3.54; 95% CI 2.81-4.47) and adverse discharge (aOR 4.01; 95% CI 3.12-5.17). Although percentage mortality within AKI-D decreased over the decade, attributable risk percentage mortality remained stable.

CONCLUSIONS

AF hospitalizations complicated by AKI-D have quintupled over the last decade with differential increase by demographic groups. AKI-D is associated with significant morbidity and mortality. Without effective AKI-D therapies, focus should be on early risk stratification and prevention to avoid this devastating complication.

Gene Expression in Biopsies of Acute Rejection and Interstitial Fibrosis/Tubular Atrophy Reveals Highly Shared Mechanisms That Correlate With Worse Long-Term Outcomes

Interstitial fibrosis and tubular atrophy (IFTA) is found in approximately 25% of 1-year biopsies posttransplant. It is known that IFTA correlates with decreased graft survival when histological evidence of inflammation is present. Identifying the mechanistic etiology of IFTA is important to understanding why long-term graft survival has not changed as expected despite improved immunosuppression and dramatically reduced rates of clinical acute rejection (AR) (Services UDoHaH. http://www.ustransplant.org/annual_reports/current/509a_ki.htm). Gene expression profiles of 234 graft biopsy samples were obtained with matching clinical and outcome data. Eighty-one IFTA biopsies were divided into subphenotypes by degree of histological inflammation: IFTA with AR, IFTA with inflammation, and IFTA without inflammation. Samples with AR (n = 54) and normally functioning transplants (TX; n = 99) were used in comparisons. A novel analysis using gene coexpression networks revealed that all IFTA phenotypes were strongly enriched for dysregulated gene pathways and these were shared with the biopsy profiles of AR, including IFTA samples without histological evidence of inflammation. Thus, by molecular profiling we demonstrate that most IFTA samples have ongoing immune-mediated injury or chronic rejection that is more sensitively detected by gene expression profiling. These molecular biopsy profiles correlated with future graft loss in IFTA samples without inflammation.

Lipid Accumulation Product: a Simple and Accurate Index for Predicting Metabolic Syndrome in Patients with Adult Growth Hormone Deficiency

PURPOSE

It has been demonstrated that metabolic risk factors were increased in adult growth hormone deficiency (AGHD) patients. Lipid accumulation product (LAP) is a novel biomarker of central lipid accumulation related to risk of metabolic syndrome (MS), diabetes and cardiovascular disease. The aim of this study was to investigate the ability of LAP to identify MS in AGHD Patients.

MATERIALS AND METHODS

In this cross-sectional study, 75 AGHD patients and 75 controls matched with age and gender were enrolled. The general anthropometries and blood biochemical indexes were measured. Body mass index(BMI), waist-hip ratio (WHR), LAP, HOMA-IR were calculated. Receiver operating characteristic (ROC) analysis was used to find out the cut-off points of LAP to predict MS.

RESULTS

Compared with control group, waist circumference (WC), WHR, Systolic blood pressure (SBP), Diastolic blood pressure (DBP), total cholesterol (TC), triglyceride (TG) and LAP were increased in AGHD group, while high density lipoprotein cholesterol (HDL-c) level was lower in AGHD group (P<0.05). The prevalence of MS was 41.3% in AGHD patients. AGHD patients with MS had significantly higher LAP levels compared to those without MS. LAP was highly correlated with components of MS. ROC analysis showed that LAP was a significant discriminator for MS in AGHD patients, and the optimal cutoff point of LAP to predict MS was 44.96 (96.8% sensitivity, 86.4% specificity).

CONCLUSIONS

LAP was associated with MS and had a strong and reliable diagnostic accuracy for MS in AGHD patients.

Comprehensive Geriatric Assessment (CGA) based risk factors for increased caregiver burden among elderly Asian patients with cancer

OBJECTIVE

This study aims to identify Comprehensive Geriatric Assessment (CGA) based risk factors to help predict caregiver burden among elderly patients with cancer.

MATERIALS AND METHOD

The study evaluated 249 patients newly diagnosed with cancer, aged 70years and above, who attended the geriatric oncology clinic at the National Cancer Centre Singapore between 2007 and 2010.

RESULTS

Out of 249 patients, 244 patients had information available on family caregiver burden and were analysed. On univariate analysis, ADL dependence, lower IADL scores, ECOG performance status of 3-4, higher fall risk, lower scores in dominant hand grip strength test and mini mental state examination, polypharmacy, higher nutritional risk, haemoglobin <12g/dL and presence of geriatric syndromes were significantly associated with mild to severe caregiver burden. On multivariate analysis, only ECOG performance status of 3-4 (odds ratio [OR], 4.47; 95% confidence interval [CI], 2.27-8.80) and haemoglobin <12g/dL (OR, 2.38; 95% CI, 1.14-4.99) were associated with an increased probability of mild to severe caregiver burden. The model achieved a good fit (Hosmer-Lemeshow's p=0.196) and discrimination (area under the curve [AUC]=0.742; bias-corrected AUC=0.737). Based on this, patients were stratified into 3 risk groups with different proportion of patients with increased caregiver burden (low risk: 3.9% vs intermediate risk: 18.8% vs high risk: 39.6%; p<0.001).

CONCLUSION

ECOG performance status and haemoglobin were associated with increased caregiver burden among elderly patients with cancer. Using these two factors in the clinic may help clinicians identify caregivers at risk and take preventive action to mitigate that.

Intradialytic Hypoxemia and Clinical Outcomes in Patients on Hemodialysis

BACKGROUND AND OBJECTIVES

Intradialytic hypoxemia has been recognized for decades, but its associations with outcomes have not yet been assessed in a large patient cohort.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Our retrospective cohort study was conducted between January of 2012 and January of 2015. We recorded blood oxygen saturation every minute during hemodialysis in patients with arteriovenous access. A 6-month baseline period with at least 10 treatments with oxygen saturation measurements preceded a 12-month follow-up. Patients were stratified by the presence or absence of prolonged intradialytic hypoxemia defined as oxygen saturation <90% for at least one third of the treatment time. Demographic, laboratory, and treatment data and hospitalization and mortality rates were compared between the groups. Multivariate Cox regression analysis was used to assess baseline predictors of all-cause mortality during follow-up.

RESULTS

In total, 100 (10%) of 983 patients had prolonged intradialytic hypoxemia. These patients were older (+3.6 years; 95% confidence interval, 0.8 to 6.3), had longer dialysis vintage (+1.2 years; 95% confidence interval, 0.3 to 2.1), and had higher prevalence of congestive heart failure (+10.8%; 95% confidence interval, 1.6 to 20.7) and chronic obstructive pulmonary disease (+13%; 95% confidence interval, 5 to 21.2). They also resembled an inflammatory phenotype, with lower serum albumin levels (-0.1 g/dl; 95% confidence interval, -0.2 to 0) and higher neutrophil-to-lymphocyte ratios (+1; 95% confidence interval, 0.5 to 1.6). They had lower hemoglobin levels (-0.2 g/dl; 95% confidence interval, -0.4 to 0) and required more erythropoietin (+1374 U per hemodialysis treatment; 95% confidence interval, 343 to 2405). During follow-up, all-cause hospitalization (1113 hospitalizations; univariate hazard ratio, 1.46; 95% confidence interval, 1.22 to 1.73) and mortality (89 deaths; adjusted hazard ratio, 1.98; 95% confidence interval, 1.14 to 3.43) were higher in patients with prolonged intradialytic hypoxemia.

CONCLUSIONS

Prolonged intradialytic hypoxemia was associated with laboratory indicators of inflammation, higher erythropoietin requirements, and higher all-cause hospitalization and mortality.

Intradialytic Hypoxemia in Chronic Hemodialysis Patients

When kidney failure occurs, patients are at risk for fluid overload states, which can cause pulmonary edema, pleural effusions, and upper airway obstruction. Kidney disease is also associated with impaired respiratory function, as in central sleep apnea or chronic obstructive pulmonary disease. Hence, respiratory and renal diseases are frequently coexisting. Hypoxemia is the terminal pathway of a multitude of respiratory pathologies. The measurement of oxygen saturation (SO2) is a basic and commonly used tool in clinical practice. Both arterial oxygen saturation (SaO2) and central venous oxygen saturation (ScvO2) can be easily obtained in hemodialysis (HD) patients, SaO2 from an arteriovenous access and ScvO2 from a central catheter. Here, we give a brief overview of the anatomy and physiology of the respiratory system, and the different technologies that are currently available to measure oxygen status in dialysis patients. We then focus on literature regarding intradialytic SaO2 and ScvO2. Lastly, we present clinical vignettes of intradialytic drops in SaO2 and ScvO2 in association with different symptoms and clinical scenarios with an emphasis on the pathophysiology of these cases. Given the fact that in the general population hypoxemia is associated with adverse outcomes, including increased mortality, cardiac arrhythmias and cardiovascular events, we posit that intradialytic SO2 may serve as a potential marker to identify HD patients at increased risk for morbidity and mortality.

Lentivirus-induced 'Smart' dendritic cells: Pharmacodynamics and GMP-compliant production for immunotherapy against TRP2-positive melanoma

Monocyte-derived conventional dendritic cells (ConvDCs) loaded with melanoma antigens showed modest responses in clinical trials. Efficacy studies were hampered by difficulties in ConvDC manufacturing and low potency. Overcoming these issues, we demonstrated higher potency of lentiviral vector (LV)-programmed DCs. Monocytes were directly induced to self-differentiate into DCs (SmartDC-TRP2) upon transduction with a tricistronic LV encoding for cytokines (granulocyte macrophage colony stimulating factor (GM-CSF) and interleukin-4 (IL-4)) and a melanoma antigen (tyrosinase-related protein 2 (TRP2)). Here, SmartDC-TRP2 generated with monocytes from five advanced melanoma patients were tested in autologous DC:T cell stimulation assays, validating the activation of functional TRP2-specific cytotoxic T lymphocytes (CTLs) for all patients. We described methods compliant to good manufacturing practices (GMP) to produce LV and SmartDC-TRP2. Feasibility of monocyte transduction in a bag system and cryopreservation following a 24-h standard operating procedure were achieved. After thawing, 50% of the initial monocyte input was recovered and SmartDC-TRP2 self-differentiated in vitro, showing uniform expression of DC markers, detectable LV copies and a polyclonal LV integration pattern not biased to oncogenic loci. GMP-grade SmartDC-TRP2 expanded TRP2-specific autologous CTLs in vitro. These results demonstrated a simpler GMP-compliant method of manufacturing an effective individualized DC vaccine. Such DC vaccine, when in combination with checkpoint inhibition therapies, might provide higher specificity against melanoma.

A counteranion triggered arylation strategy using diaryliodonium fluorides

A mild and transition metal-free counteranion triggered arylation strategy has been developed using diaryliodonium fluorides.

A mild and transition metal-free counteranion triggered arylation strategy has been developed using diaryliodonium fluorides. The fluoride counteranion within the hypervalent iodonium species displays unusual reactivity that activates a phenolic O–H bond leading to electrophilic O-arylation. A wide range of phenols and diaryliodonium salts are compatible with this transformation under remarkably mild conditions. Furthermore, we pre-empt the wider implications of this strategy by demonstrating the compatibility of the arylation tactic with latent carbon nucleophiles.

Adherence to oral bisphosphonates and the risk of subtrochanteric and femoral shaft fractures among female medicare beneficiaries

Previous studies have shown an association between duration of bisphosphonate use and atypical femur fractures. This cohort study showed an increasingly higher risk of subtrochanteric and femoral shaft fractures among those who were more adherent to oral bisphosphonates.

INTRODUCTION

Long-term use of oral bisphosphonates has been implicated in an increased risk of atypical femur fractures located in subtrochanteric and femoral shaft regions. Another measure of drug exposure, medication adherence, however, has not been investigated.

METHODS

Among all Medicare fee-for-service female beneficiaries from 2006-2010, we followed 522,287 new bisphosphonate users from their index prescription until being censored or having a primary diagnosis of closed subtrochanteric/femoral shaft or intertrochanteric/femoral neck fractures. Data about radiographs of fracture site and features were not available. Adherence was classified according to the medication possession ratio (MPR) as the following: MPR < 1/3 as less compliant, MPR ≥ 1/3- < 2/3 as compliant, and MPR ≥ 2/3 as highly compliant. Alternative cutoff points at 50 and 80% were also used. Survival analysis was used to determine the cumulative incidence and hazard of subtrochanteric/femoral shaft or intertrochanteric/femoral neck fractures.

RESULTS

There was a graded increase in incidence of subtrochanteric/femoral shaft fractures as the level of adherence increased (Gray's test, P < 0.001). The adjusted hazard ratio (HR) for the highly compliant vs. the less compliant was 1.23 (95% Confidence Interval [CI] 1.06-1.43) overall, became significant after 2 years of follow-up (HR = 1.51, 95% CI 1.06-2.15) and reached the highest risk in the fifth year (HR = 4.06, 95% CI 1.47-11.19). However, age-adjusted incidence rates of intertrochanteric/femoral neck fractures were significantly lower among highly compliant beneficiaries, compared to less compliant users (HR = 0.69, 95% CI 0.66-0.73). Similar results were obtained when the cutoff points for being compliant and highly compliant were set at 50 and 80 %, respectively.

CONCLUSIONS

Subtrochanteric/femoral shaft fractures, unlike intertrochanteric/femoral neck fractures, are positively associated with higher adherence to long-term (≥3 years) oral bisphosphonates in the elderly female Medicare population.

Myoclonus in renal failure: Two cases of gabapentin toxicity

Gabapentin, an AED approved for the adjunctive treatment of partial seizures with/without secondary generalization and for the treatment of postherpetic neuralgia, is frequently used off-label for the treatment of both psychiatric and pain disorders. Since gabapentin is cleared solely by renal excretion, dosing requires consideration of the patient's renal function. Myoclonic activity may occur as a complication of gabapentin toxicity, especially with acute kidney injury or end-stage renal disease. We report 2 cases of myoclonic activity associated with gabapentin toxicity in the setting of renal disease which resolved with discontinuation of gabapentin and treatment with hemodialysis and peritoneal dialysis. As gabapentin has multiple indications and off-label uses, an understanding of myoclonus, neurotoxicity, and renal dosing is important to clinicians in multiple specialties.

Abstract P5-16-04: Predictive biomarkers for invasion on final pathology in patients with preoperative diagnosis of ductal carcinoma in situ of the breast by needle biopsy

Background

Predictors of synchronous invasive breast cancer in patients diagnosed with only ductal carcinoma in situ (DCIS) in pre-operative needle biopsies have not been well-defined. Establishing such predictors of invasion has potential to significantly alter management by identifying those patients for whom surgery may be avoidable en lieu of conservative management. This study aims to identify clinicopathologic factors from pre-operative needle biopsies that are predictive of invasive cancer on subsequent surgical excision.

Methods

The study population consisted of 69 breasts from 67 patients initially diagnosed with only DCIS on needle biopsy (core needle or mammotome) at St. Luke's International Hospital, Japan from 2006 until 2008. Parameters analyzed included presenting clinical features, DCIS nuclear grade and morphologic pattern, and immunohistochemical expression of estrogen receptor (ER), progesterone receptor (PR), epidermal growth factor receptor-2 (HER2), Ki-67 antigen, p16, p53 and cyclooxygenase-2 (COX2) in biopsy specimens. These immunohistochemical markers were previously identified to foretell invasive carcinoma subsequent to DCIS (Kerlikowske, JNCI 2010). Associations between clinical, pathological, and immunohistochemical findings in initial biopsy specimens and the presence of invasive cancer on subsequent excision were analyzed for significance using univariate and multivariate analysis.

Results

Of 69 breasts with only DCIS on initial needle biopsy, subsequent surgical excision revealed pure DCIS in 46 (66.7%), microinvasive carcinoma in 4 (5.8%), and invasive carcinoma in 19 (27.5%) cases. Sentinel node biopsy was performed in 57 (82.6%) of 69 cases, and 53 (93.0%) of these showed no evidence of lymph node metastases. All 4 cases with lymph node metastases revealed invasive carcinoma in surgical excisions. By univariate analysis, pre-operative factors significantly associated with invasion on surgical excision included detection of a lump by palpation (p&lt;0.05), sampling by core needle biopsy rather than mammotome (p&lt;0.01), p53 positivity (p&lt;0.01), and lack of ER expression (p&lt;0.05) in needle biopsy samples. Combined absence of p16 and COX2 with low Ki-67 expression in needle biopsies was associated with pure DCIS (and absence of invasive cancer) in surgical excisions (p&lt;0.05). Multivariate analysis using all five significant univariate variables revealed two independent pre-operative predictors of invasive cancer on final pathology, namely sampling by core needle biopsy (odds ratio 7.0; 95% CI 1.2-41.7; p&lt;0.05) and p53 positivity (odds ratio 7.1; 95% CI 1.1-44.9; p&lt;0.05).

Conclusion

If confirmed in a larger sample, predictive clinical and biomarker parameters can help identify those patients diagnosed with only DCIS in needle biopsy who are at high risk of harboring unsampled invasive cancer on final pathology.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-16-04.

Sub-labial packing: a novel method of stopping epistaxis from Little's area

Epistaxis is frequently managed both by patients in the community and by health professionals. Many methods have been described in the literature about how to manage this condition. Epistaxis is usually due to anterior circulation bleeding at an area known as Kiesselbach's plexus (Little's area). Five vessels supply Little's area; one of these, the septal branch of the superior labial artery, can be compressed via an easy and novel technique, sub-labial packing. Sub-labial packing is a technique proposed as an adjunct to the standard 15 min ala nasi compression as a simple yet effective technique to stop epistaxis. We hereby report two cases of managing epistaxis from Little's area using sub-labial packing.

A randomised comparison of two intranasal dexmedetomidine doses for premedication in children

We compared sedation levels in children following administration of intranasal dexmedetomidine. One hundred and sixteen children aged between 1 and 8 years were enrolled in this prospective, randomised trial. Children were assigned to receive either intranasal dexmedetomidine 1 μg.kg(-1) (Group 1) or 2 μg.kg(-1) (Group 2). Thirty-one (53%) patients from Group 1 and 38 (66%) patients from Group 2 were satisfactorily sedated at the time of anaesthetic induction. Logistic regression showed a significant interaction effect (p=0.049), with the odds ratio between Group 2 over Group 1 estimated as 1.1 (95% CI 0.5-2.7) for the 1-4 year age group, and 10.5 (95% CI 1.4-80.2) for the 5-8 year age group. Both doses produced a similar level of satisfactory sedation in children aged 1-4 years, whereas 2 μg.kg(-1) resulted in a higher proportion of satisfactory sedation in children aged 5-8 years. There were no adverse haemodynamic effects. We conclude that intranasal dexmedetomidine in a premedication dose of 2 μg.kg(-1) resulted in excellent sedation in children.