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PURPOSE: This study evaluates whether race, socioeconomic status, insurance type, oncological provider type, and prior cancer treatment are associated with the suggestion and acceptance of hormonal therapy in patients with estrogen receptor (ER)-positive Ductal carcinoma in situ (DCIS). This study also assesses whether disparities exist pertaining to prescription of such medications. METHODS: This single-center retrospective study included 111 patients diagnosed with DCIS between 2020 and 2021. Data collected included race, type of insurance, prescribing providers, and socioeconomic status. We used zip codes to identify the poverty levels in these areas as published in the United States Census Bureau and stratified the patients into quartiles accordingly. Chi-Square statistics were used to calculate significance levels. RESULTS: There was no significant correlation between the intake of hormonal therapy and race (p = 0.60), insurance (p = 0.50), socioeconomic (p = 0.58), or providers (p = 0.99). 79.3% of women were offered endocrine therapy. Of those who were offered endocrine therapy, 70.8% accepted. Of patients not on hormonal therapy, 45.8% were not recommended the medications by their provider, and 54.2% declined treatment when offered. CONCLUSION: In this study, patients' demographics and providers were not associated with adjuvant hormonal therapy initiation in DCIS. Our results show that abstaining from endocrine therapy in DCIS patients is both due to lack of provider recommendation and patient rejection of these medications. The wide variation in hormonal therapy treatment among ER-positive DCIS patients suggests a need for improved provider-patient communication regarding the risks and benefits of endocrine therapy in order to ensure a shared decision-making process.

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BACKGROUND: Renal cell carcinoma with sarcomatoid differentiation is a highly aggressive form of kidney cancer. OBJECTIVE: We aimed to analyze the outcomes of patients treated with cabozantinib for metastatic renal cell carcinoma with sarcomatoid features. METHODS: We retrospectively collected data from 16 worldwide centers. Overall survival and progression-free survival were analyzed using Kaplan-Meier curves. Cox proportional models were used for univariate and multivariate analyses. RESULTS: We collected data from 66 patients with metastatic sarcomatoid renal cell carcinoma receiving cabozantinib as second-line (51%) or third-line (49%) therapy. The median progression-free survival from the start of cabozantinib was 7.59 months (95% confidence interval [CI] 5.75-17.49) and was longer in male patients (8.81 vs 5.95 months, p = 0.042) and in patients without bone metastases (7.59 vs 5.11 months, p = 0.010); the median overall survival was 9.11 months (95% CI 7.13-23.80). At the multivariate analysis, female sex (hazard ratio = 1.81; 95% CI 1.02-3.37, p = 0.046), bone metastases (hazard ratio = 2.62; 95% CI 1.34-5.10, p = 0.005), and International Metastatic Renal Cell Carcinoma Database Consortium criteria (hazard ratio = 3.04; 95% CI 1.54-5.99, p = 0.001) were significant predictors of worse overall survival. CONCLUSIONS: Our data show that cabozantinib is active in pretreated patients with sarcomatoid renal cell carcinoma. Biomarkers are needed in this field to select patients for multi-kinase inhibitors or other options.

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BACKGROUND: Dementia is a spectrum of neurological diseases characterized by memory impairment and cognitive decline with the pathogenesis and effective management remaining elusive. Several studies have identified a correlation between anemia and Alzheimer's disease and related dementias (ADRD); however, anemia subtypes and association with ADRD have yet to be studied conclusively. OBJECTIVE: To study an association between ADRD and anemia of chronic inflammation. METHODS: We conducted a retrospective case-control study of the patients, diagnosed with ADRD at Brookdale Hospital. Pair-wise comparisons between means of controls and cases in terms of iron studies and laboratory results were performed using a Mann-Whitney U test. Pair-wise comparisons between anemia subgroups (moderate and severe) were performed using a Two Sample proportion Z-Test, where for each couple of normally distributed population. RESULTS: There was a total of 4,517 (1,274 ADRD group; 3,243 Control group) patients. There was significant difference in hemoglobin 10.15 versus 11.04 [p-value <0.001]. Iron studies showed a significant difference in ferritin 395±488.18 versus 263±1023.4 [p < 0.001], total iron binding capacity 225±84.08 versus 266±82.30 [p < 0.001] and serum iron level 64±39.34 versus 53±41.83 [p < 0.001]. Folic acid and vitamin B12 levels were normal in both groups. Severe and moderate anemia in the ADRD group were respectively 6.2% [95% CI: 4.2-8.4] and 13% [95% CI: 9.8-16.2] higher. Overall, incidence of moderate-to-severe anemia was found to be 19% higher in ADRD group [95% CI: 15.8-22.1]. CONCLUSION: We demonstrated an association between ADRD and anemia of chronic inflammation independent of age, renal function, and HgbA1C levels.

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We present a rare case of primary hepatic lymphoma. An 82-year-old female patient presented with altered mental status, and fever. Her labs were significant for abnormal liver functions with markedly elevated lactate dehydrogenase. All infectious and auto-immune workup was negative. Imaging studies were only significant for hepatosplenomegaly, and no liver masses were detected. A liver biopsy was diagnostic of CD5+ CD20+ diffuse large b-cell lymphoma of the liver. Chemotherapy was planned with rituximab combined with cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). Unfortunately, the patient died before initiation of therapy. This case would highlight the importance of early liver biopsy in patients with abnormal liver functions and with no clear explanation, even if there were no discrete masses on computed tomography (CT) or magnetic resonance imaging (MRI). Lymphomas and other infiltrative processes should be considered in the differential diagnosis in such cases.

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The aim of this prospective study was to evaluate the results of combined lateral sagittal resection osteotomy with subtalar distraction fusion in heels with painful malunion of the os calcis. This case series included 22 patients (23 feet). The mean age of the patients was 37.52 years. Sixteen (69.6%) patients were initially treated conservatively, 5 (21.7%) patients were treated surgically, and 2 (8.7%) patients were missed. The mean time lapsed before surgery was 11.43 months. A wedge of bone was resected to reduce the width of the malunited os calcis and was used as a local graft for subtalar joint fusion and to increase the height of the os calcis. The mean follow-up period was 56.83 ± 6.09 months. According to the scoring system, satisfactory results were found in 18 (82.6%) patients, and 4 (17.4%) patients had unsatisfactory results. Postoperative radiographic assessment revealed an average increase in the heel height of 7.70 ± 1.22 mm and an average decrease in heel width of 8.39 ± 1.47 mm. The average correction in the coronal axis was approximately 8.04° ± 1.26°. Complications included infection and nonunion in 3 (13%) heels. Two heels still had residual varus postoperatively, and 1 patient had injury to the sural nerve. The restoration of heel height, the reduction in heel width, and the primary fracture pattern had a significant relation with the final score. This method is a successful method for the management of subtalar arthritis caused by malunited calcaneal fractures with broadening leading to lateral abutment.

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We report a case of a 47-year-old male from West Africa who presented with sepsis and was found to have acute monoblastic leukemia associated with tetrasomy 8 detected on bone marrow samples. This was the only chromosomal abnormality found. Tetrasomy 8 is a rare genetic finding that has been reported in acute myeloid leukemia (AML), predominantly the monocytic lineage. It carries a poor prognosis with a high mortality rate.

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BACKGROUND Autoimmune heparin-induced thrombocytopenia (aHIT) refers to a condition, in which antiplatelet factor-4 (PF4) antibodies activate platelets even in the absence of heparin (heparin independent platelet activation). This is a severe hypercoagulable state triggering massive thrombin storm needing additional therapies and aggressive anticoagulation apart from stopping heparin. Thrombocytopenia in these cases seems to be very severe and prolonged compared to classic HIT and poses additional clinical challenges in terms of anticoagulation management. Recently, direct oral anticoagulants (DOACs) seem to be an attractive option in the management of HIT as an alternative to vitamin K antagonists (VKA). CASE REPORT We describe a case of a 55-year African American male who presented with pleuritic chest pain and was found to have worsening kidney disease. Clinical and electrocardiogram findings suggested uremic pericarditis, and dialysis was warranted. After 5 days of exposure to heparin flushes during dialysis, the patient developed thrombocytopenia, and subsequently HIT was diagnosed. Argatroban was started initially, however, his platelets count continued to drop, and he developed acute deep venous thrombosis of the right lower leg. IVIG (intravenous immunoglobulin) was started and his platelet count started to improve after several days. The patient was discharged on Eliquis and his platelet count returned to normal levels after 3 months. CONCLUSIONS This case emphasizes the challenge managing HIT, a condition that has a high rate of complications. Several studies have reported platelet recovery with IV immunoglobulin when standard therapies fail. Recent evidence also supports the safety and efficacy of DOACs in offering a simplified way of managing these patients, especially in outpatient settings.

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OBJECTIVE: The diagnostic capacity of ultrasonography (US) for differentiating between malignant and benign thyroid nodules is crucial in preventing unnecessary invasive procedures. This is the first study to evaluate whether thyroid nodule location on US has predictive value for malignancy. METHODS: We retrospectively reviewed data from 219 patients with thyroid nodules who underwent fine-needle aspiration biopsy in 1 year. Patients' demographics as well as nodule's laterality, polarity, morphology, and multinodularity were analyzed. All malignant lesions were confirmed by surgical pathology. RESULTS: The majority of the patients were female (86.2%). Nodules were evenly distributed between the right lobe (46.3%) and left lobe (49.5%). Eight nodules (4.2%) were located in the isthmus. Most nodules (79.3%) were located in the lower pole, while 9.6% were located in the upper pole and 6.9% in the middle pole. Seventy-five patients (39.9%) had multiple nodules. Fourteen nodules were malignant, representing a prevalence of 7.4%. A significantly higher frequency of malignancy was observed in upper pole (22.2%) compared to lower pole (4.7%) and middle pole (15.4%). A multiple logistic regression model confirmed such association after adjusting for age, body mass index, multinodularity, and laterality. The odds of malignancy in the upper pole were 4 times higher than other locations (odds ratio, 4.6; P = .03). CONCLUSION: Our study is the first showing that thyroid nodules located in the upper pole can be considered as having higher risk for malignancy. It may enhance the predictive value of malignancy if it is included in thyroid nodule ultrasound classification guidelines. ABBREVIATIONS: AACE = American Association of Clinical Endocrinologists; ATA = American Thyroid Association; BMI = body mass index; FNA = fine-needle aspiration; TMS = total malignancy score; TTW = taller than wide; US = ultrasonography.

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OBJECTIVE: To determine the association of hemoglobin (Hb) and plasma nitrite (PN) concentrations on admission to the delivery ward with the occurrence of atonic postpartum hemorrhage (PPH). METHODS: Of 319 women admitted to the Department of Obstetrics and Gynecology, Dayrout General Hospital, Assiut, Egypt, for delivery in July 2010, 200, who were not considered to be at risk of atonic PPH, were eligible for inclusion. Plasma levels of Hb and nitrite were measured on admission. The third stage of labor was actively managed. RESULTS: A total of 22 participants had significantly raised PN levels (P<0.001), 12 of whom developed PPH-with Hb levels of 9 g/dL or less and nitric oxide (NO) levels of 180 µM/L or greater. The other 10 women underwent over 6 hours of stressful labor prior to hospital admission. CONCLUSION: Even moderate anemia can raise levels of NO and enhance its biologic effects, which in turn can result in uterine muscle relaxation and atonic PPH. Preventing or treating anemia during pregnancy could avoid these complications.

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