Solitary psoas muscle metastasis of gastroesphageal junction adenocarcinoma

Metastasis of gastroesphageal junction (GEJ) adenocarcinoma in skeletal muscle is rare and primary sites for skeletal muscle metastases are usually lung, renal and colorectal cancer. We have encountered with the first case report of solitary psoas muscle metastasis of GEJ adenocarcinoma. Here we describe a 65 years old man was diagnosed with GEJ adenocarcinoma in Gastroenterology Department, Imam Hussein Hospital, Tehran, Iran in February 2014. We were not able to use PET techniques due to lack of access. Staging CT scans demonstrated a small mass lateral to right psoas muscle. A CT-guided core needle biopsy of right psoas muscle was performed that supported a diagnosis of adenocarcinoma consistent with primary adenocarcinoma of the GEJ. Distant metastasis to skeletal muscle rarely occurs in patients with GEJ adenocarcinoma, but heightened awareness to these soft tissue lesions is warranted. CT or MR imaging could show findings suggestive of metastatic disease, although PET is preferable modality. © 2016, Iran J Pathol. All rights reserved

Rivaroxaban as an Alternative Agent for Heparin-Induced Thrombocytopenia

Heparin-induced thrombocytopenia (HIT) is a high-risk adverse drug reaction because of its associated risk of life- and limb-threatening thrombosis. Rivaroxaban may be considered as an ideal nonheparin anticoagulant alternative for the management of HIT. In this preliminary retrospective study, the efficacy and safety of rivaroxaban to control the clinically suspected HIT (4Ts score 4 points or greater) were evaluated. Patients with chronic kidney disease, hepatic impairment, mechanical heart valves, and active bleeding were excluded. Forty-two eligible patients who received rivaroxaban for clinically suspected HIT were evaluated by medical records review, with 12-month follow-up after the first dose of rivaroxaban. End points included confirmed thrombosis (primary end point), mortality, and adverse treatment-related events. HIT-associated thrombosis was found in 17/42 (40.5) patients before receiving rivaroxaban. After rivaroxaban therapy, platelet counts normalized in all patients, with only 1/42 (2.3) patients developing new thrombosis. No hemorrhagic event was recorded in the patients. Twelve patients (28.6) died, but the cause of death was not related to the thrombosis, hemorrhage, or adverse effects of rivaroxaban. Our findings are consistent with the available emerging data, suggesting that rivaroxaban is a safe and effective drug for the management of clinically suspected HIT. Rivaroxaban is a particularly valuable treatment option in developing countries, where there are issues of cost and availability of approved alternative agents. © 2020, The American College of Clinical Pharmacolog

Management of Abnormal Placenta Implantation with Methotrexate: A Review of Published Data

Abnormally invasive placenta is characterized by direct attachment of chorionic villi to the uterine wall. This adherent placenta traditionally has been managed by peripartum hysterectomy. Nowadays, there is a lot of interest toward gradual shift from traditional management of invasive placentation to conservative ones leaving the placenta in situ to avoid the surgical morbidity of hysterectomy and loss of future fertility. Administration of methotrexate (MTX), as an adjunctive antimetabolite drug, resulted in conflicting data during conservative management of abnormal placentation. This review assessed all published data on efficacy and safety of MTX therapy as conservative management of invasive placentation. Fifty-three articles including one prospective cohort study, 2 retrospective cohort studies, 10 case series and 40 case reports were identified. Conservative management has beneficial effects on the avoidance of major surgery with the consequent morbidity and the preservation of future fertility. Infection and vaginal bleeding were main complications of MTX therapy. Although MTX therapy may result in accelerated involution or expulsion of placenta and has some beneficial effects on hemorrhagic events, but there is not enough evidence on its efficacy and safety to recommend its routine uses in all cases of invasive placenta. © 2016 S. Karger AG, Basel

Dabigatran as a Treatment Option for Heparin-Induced Thrombocytopenia

Heparin-induced thrombocytopenia (HIT) is a potentially serious adverse drug reaction that can result in lethal vascular thrombosis. Dabigatran is a direct thrombin inhibitor that might be useful in the management of HIT. This study evaluated the efficacy and safety of dabigatran in patients with HIT. We included 43 patients in the study who received dabigatran for the management of suspected HIT, based on 4Ts (thrombocytopenia, timing of platelet count drop, thrombosis or other sequelae, and other causes of thrombocytopenia) scores. Three patients were excluded because they had received dabigatran with a creatinine clearance 120 kg) were excluded from the study. Arterial thrombosis was not observed in any of our patients. The platelet counts normalized in all patients except for 2, which was attributed to the underlying comorbidities. We did not observe any hemorrhagic events or significant thrombosis during the follow-up period. Eight patients died from nonthrombotic causes, which were unrelated to adverse effects of dabigatran. Based on our findings, dabigatran could be considered a safe and effective agent in the management of HIT, particularly in the developing countries, where there could be issues with the cost and availability of other agents recommended for this condition. Further studies are needed to validate our findings. © 2018, The American College of Clinical Pharmacolog

Jaw pain as a first presentation in the diagnosis of breast cancer

The oral cavity is uncommon site for metastatic disease usually discovered secondary to malignancy. We encountered with a rare case in which metastasis to mandibular bone was the first clinical sign in the diagnosis of breast cancer without any radiographic findings. A 49-yr-old premenopausal woman, was referred to the Department of Medical Oncology of Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran in 2014, presented with pain and tenderness in the left mandibular and temporal bone and paresthesia of the lower left lip and chin. CT scan of mandible showed no significant finding. Four months later, she was referred with complaints left breast pain for 4 wk and worsening swelling, pain and paresthesia. Breast examination revealed a 2 cm firm nodule on the left breast. Based on her medical history and histopathological study, metastatic carcinoma of the breast was suspected. She has received chemoradiotherapy that led to complete relief of her symptoms and remission of the disease. In the presence of an ambiguous sign in oral cavity such as jaw pain or paresthesia, diagnostic examination of malignancy is recommended. © 2017, IRANIAN JOURNAL OF PATHOLOGY

Aripiprazole for prevention of delirium in the neurosurgical intensive care unit: a double-blind, randomized, placebo-controlled study

Purpose: Delirium is reported in over 50 of critically ill ICU patients, and is associated with increased mortality and long-term cognitive consequences. Prevention and early management of delirium are essential components of ICU care. However, pharmacological interventions have not been effective in delirium prevention. This study investigated the effect of aripiprazole in the prevention of delirium in a neurosurgical intensive care unit. Methods: In this prospective, randomized placebo-controlled small clinical trial, 53 patients, 18 to 80 years old, were randomized to receive enteric aripiprazole (15 mg) or placebo for up to 7 days. Delirium, detected by the Confusion Assessment Method-ICU, ICU events, laboratory studies, aripiprazole safety, time to delirium onset, delirium-free days, delirium prevalence during follow-up and ICU length of stay were recorded. Results: Forty patients with similar baseline characteristics, including age, sex, neurosurgery types and APACHE II scores, completed the study. Delirium incidence and the mean days to its onset were 20 vs. 55 (p = 0.022) and 2.17 ± 0.41 vs. 2.09 ± 0.30 (p = 0.076) in the aripiprazole and placebo groups, respectively. The mean number of delirium-free days were: 5.6 (95CI, 4.6-6.5) and 4.3 (95CI, 3.2-5.4), in aripiprazole and placebo groups, respectively (p = 0.111). The prevalence of delirium during the follow-up was significantly lower in the aripiprazole group (p = 0.018). Serious aripiprazole adverse reactions were not observed. Conclusions: Aripiprazole can reduce the incidence of delirium in the neurosurgical ICU. Studies with larger sample size in diverse ICU settings and longer follow-up are needed to confirm our findings. © 2020, Springer-Verlag GmbH Germany, part of Springer Nature

Methotrexate infusion followed by uterine artery embolisation for the management of placental adhesive disorders: a case series

AIM: To evaluate the efficacy and safety of the uterine artery embolisation (UAE) in combination with methotrexate (MTX) for conservative management of placental adhesive disorders. MATERIAL AND METHODS: Patients with placental adhesive disorders (including accreta, increta, and percreta lesions) that were treated with UAE in combination with MTX were identified and were followed prospectively for outcomes including uterine preservation and complications. RESULTS: Twenty-six patients were identified who had the diagnosis of abnormal placenta implantation during this study. Fourteen patients were excluded because they were treated by a caesarean hysterectomy. Among remaining 12 patients, the successful uterine preservation observed in seven (58) cases. Menstruation cycles returned in all successfully treated patients, although they did not have desire to get pregnant. Five (42) patients underwent primary or delayed hysterectomy due to severe post-partum haemorrhage in three cases, and intestinal adhesion/peritonitis and secondary post-partum haemorrhage/sepsis in two patients, respectively. CONCLUSION: Although this interventional method is relatively successful in uterine preservation, the possibility of treatment failure cannot be ignored. Given that there are too few data regarding its efficacy and safety, this method should be reserved to patients who have a strong desire to maintain the uterus and their fertility, or if it is technically difficult to perform hysterectomy due to the extent of the invasion. © 2019 The Royal College of Radiologist