A Case Of Multifactorial Orthostatic Hypotension Complicated By Chemotherapy Associated Autonomic Toxicity

A Case Of Multifactorial Orthostatic Hypotension Complicated By Chemotherapy Associated Autonomic Toxicity Christopher Bender, MD Providence Portland Medical Center – Portland, OR Additional Authors: Amy Dechet, MD Introduction: Autonomic neuropathy is known to occur as a side effect of some chemotherapy drugs, including cisplatin. This reports presents a patient with new onset of autonomic instability and orthostatic hypotension after receiving multiple rounds of cisplatin and gemcitabine chemotherapy. Case Presentation: An 81-year-old man with history of stage III lung cancer presented after a fall at home that occurred while getting out of bed in the middle of the night in the setting of recent malaise and poor oral fluid intake. His cancer was treated with surgical lobectomy and thoracic lymphadenectomy five months prior to his admission, and three rounds of chemotherapy with cisplatin and gemcitiabine. He had been admitted to the same hospital three days prior for weakness and back pain and was empirically started on tamsulosin for urinary retention and was discharged with a foley catheter in place. On presentation he was noted to have marked orthostatic hypotension, and during the first night of admission he had high blood pressures while sleeping, with systolic blood pressure greater than two hundred mmHg. Postural hypotension did not improve over the first twenty-four hours after multiple intravenous fluid boluses. He was managed by discontinuing exacerbating medications including tamsulosin and benadryl, as well as treatment with physical therapy, an abdominal binder, and minimizing the amount of time spent supine. He was discharged on the fifth day of hospitalization after clearance by physical therapy. Discussion: Although this case initially appeared to be a straightforward case of orthostatic hypotension related to hypovolemia, it became more complicated when the patient continued to display orthostatic hypotension after initial fluid resuscitation and discontinuation of associated medications. Further suggesting autonomic dysfunction was an inconsistent response of heart rate in relation to hypotension, as well as markedly elevated systolic blood pressure readings at night while the patient was supine. While not a common side effect, there are prior documented cases of autonomic neuropathy in association with cisplatin, which was determined to be the most likely etiology in this case, given the timeline of presentation. An additional factor complicating this case was the issue of addressing orthostatic hypotension in a patient with autonomic instability causing intermittent severe hypertension such that the use of midodrine was not an option. This required creative problem solving including the use of an abdominal binder and compression stockings in order to get the patient stable for discharge from the hospital.https://digitalcommons.psjhealth.org/ppmc_internal/1000/thumbnail.jp

The contemporary role of renal mass biopsy in the management of small renal tumors

The selective use of percutaneous biopsy for diagnosis in renal masses is a relatively uncommon approach when compared to the management of other solid neoplasms. With recent advancements in imaging techniques and their widespread use, the incidental discovery of asymptomatic, small renal masses (SRM) is on the rise and a substantial percentage of these SRM are benign. Recent advances in diagnostics have significantly improved accuracy rates of renal mass biopsy (RMB), making it a potentially powerful tool in the management of SRM. In this review, we will discuss the current management of SRM, problems with the traditional view of RMB, improvements in the diagnostic power of RMB, cost-effectiveness of RMB, and risks associated with RMB. RMB may offer important information enabling treating clinicians to better risk-stratify patients and ultimately provide a more personalized treatment approach for SRM

Comparison of complications from radical cystectomy between old-old versus oldest-old patients

Introduction: The purpose of this study was to evaluate and compare complications after radical cystectomy in patients aged ≥75 years. Materials and Methods: 251 patients aged 75-95 years (median 79) underwent radical cystectomy between 2000 and 2012 at four institutions. The patients were divided into two groups: ≥75-84 years of age (group 1) versus ≥85 years of age (group 2). Comorbidities, body mass index, and complications were obtained retrospectively, except at the Central Hospital of Bolzano and Weill Cornell Medical Center, which collected data prospectively. Cancer-specific survival, overall mortality, hospital stay, clinical outcome and complications were assessed. Complications were categorized using the Clavien-Dindo classification reporting system. The mean follow-up was 21 months. Results: The median hospital stay was 17 (2-91) days. Perioperative Clavien-Dindo grade ≥III complications were seen in 24.1% (48/199) of group 1 patients and 19.2% (10/52) of group 2 patients (p = 0.045). 30- and 90-day mortality was 4.5 and 13.5% in group 1 and 6.5 and 32.3% in group 2, respectively. Only the 90-day mortality rate was statistically significant (p < 0.05) between the two groups. The 3-year overall survival was 40% in group 1 and 34% in group 2. The 3-year cancer-specific survival was 52% in group 1 and 50% in group 2. Conclusions: We evaluated a large series of elderly (≥75 years) patients undergoing radical cystectomy at four institutions. Comparing patients aged ≥75-84 and ≥85 years revealed no significant difference in complications, 30-day mortality, overall and cancer-specific survival rates. Only 90-day mortality rates were significantly higher in the ≥85-year-old patients

Psychosocial impact of undergoing prostate cancer screening for men with BRCA1 or BRCA2 mutations.

OBJECTIVES: To report the baseline results of a longitudinal psychosocial study that forms part of the IMPACT study, a multi-national investigation of targeted prostate cancer (PCa) screening among men with a known pathogenic germline mutation in the BRCA1 or BRCA2 genes. PARTICPANTS AND METHODS: Men enrolled in the IMPACT study were invited to complete a questionnaire at collaborating sites prior to each annual screening visit. The questionnaire included sociodemographic characteristics and the following measures: the Hospital Anxiety and Depression Scale (HADS), Impact of Event Scale (IES), 36-item short-form health survey (SF-36), Memorial Anxiety Scale for Prostate Cancer, Cancer Worry Scale-Revised, risk perception and knowledge. The results of the baseline questionnaire are presented. RESULTS: A total of 432 men completed questionnaires: 98 and 160 had mutations in BRCA1 and BRCA2 genes, respectively, and 174 were controls (familial mutation negative). Participants' perception of PCa risk was influenced by genetic status. Knowledge levels were high and unrelated to genetic status. Mean scores for the HADS and SF-36 were within reported general population norms and mean IES scores were within normal range. IES mean intrusion and avoidance scores were significantly higher in BRCA1/BRCA2 carriers than in controls and were higher in men with increased PCa risk perception. At the multivariate level, risk perception contributed more significantly to variance in IES scores than genetic status. CONCLUSION: This is the first study to report the psychosocial profile of men with BRCA1/BRCA2 mutations undergoing PCa screening. No clinically concerning levels of general or cancer-specific distress or poor quality of life were detected in the cohort as a whole. A small subset of participants reported higher levels of distress, suggesting the need for healthcare professionals offering PCa screening to identify these risk factors and offer additional information and support to men seeking PCa screening

Robotic Surgery 3×3

Inability to perform more than 1-2 robotic surgery cases per day

Improving Utilization of Buprenorphine in a Residency Program

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Co-existing Sarcoidosis Confounds the Staging of Bilateral Renal Cell Carcinoma

We present a case in which the undiagnosed condition of sarcoidosis complicated the staging of bilateral, subtype-discordant renal cell carcinoma. Initially thought to have metastatic renal cell carcinoma based on computed tomography imaging and referred for immunotherapy, a positron emission tomography/computed tomography scan demonstrated different levels of radiotracer activity in the primary site and the presumed pulmonary metastatic sites. The patient underwent bilateral partial nephrectomies and was ultimately diagnosed with stage T1 bilateral renal cell carcinoma and sarcoidosis. This case highlights the need to consider concurrent medical conditions that can lead to false positive results when evaluating for metastatic disease with imaging studies as well as the importance of evaluating the levels of radiotracer activity between different sites