Surgical resection of vulvar metastases of endometrial cancer: a presentation of two cases

OBJECTIVE: Endometrial cancer generally carries a good prognosis. However, 10% to 15% of patients will manifest recurrent disease. One half of these recurrences are confined to the vagina. Whereas pelvic recurrence is most common in patients who do not receive postoperative adjuvant radiation therapy, distant metastases predominate among patients who received postoperative radiation therapy. Surgical resection of disease may be possible, therapeutic and even curative, in select patients with isolated cancer recurrence. CASE 1: A 63-year-old patient presented 7 years after treatment of endometrial cancer with a vulvar lesion and groin mass. The lesions were successfully resected and confirmed to be recurrent endometrial cancer. Adjuvant radiation and chemotherapy were prescribed leading to a complete clinical response. This patient survived without evidence of disease for 1 year. However, she eventually died 8 months later because of a disease recurrence. CASE 2: An 83-year-old patient with a history of a hysterectomy for endometrial cancer and radiation therapy for a vaginal vault recurrence presented with an exophytic labial mass. After radical wide excision of her vulvar mass and bilateral groin dissection, final pathology revealed that the mass was consistent with recurrent endometrial cancer. This patient remains without evidence of disease 18 months after treatment of disease recurrence. CONCLUSIONS: Uncommon sites of recurrence of endometrial cancer may include the vulva. These rare metastases may be amenable to surgical resection with adjuvant therapy as indicated.     

Nontuberculous mycobacterial peritonitis in peritoneal dialysis patients

While nontuberculous mycobacterial peritonitis is uncommon among peritoneal dialysis (PD) patients, these infections have serious consequences. They present a significant diagnostic and therapeutic challenge for clinicians. Diagnosis can be delayed due to the slow growth rate of some mycobacterial species. These organisms can also be overlooked when adequate culture media are not used in the microbiological evaluation process. The choice of antimicrobial therapy depends upon isolation and speciation of the infecting Mycobacterium species, and prompt catheter removal is essential. Because serious intra-abdominal complications may follow infection, identifying patient risk factors for nontuberculous mycobacterial peritonitis and initiating prompt diagnosis and treatment are essential. We report three cases of peritonitis associated with Mycobacterium chelonae and Mycobacterium gordonae, each with a unique presentation, and discuss the appropriate diagnosis and treatment strategies for the management of PD-associated mycobacterial infections.     

Recruitment of minority and underserved populations in the United States: the Centers for Population Health and Health Disparities experience

ObjectiveThe recruitment of minority and underserved individuals to research studies is often problematic. The purpose of this study was to describe the recruitment experiences of projects that actively recruited minority and underserved populations as part of The Centers for Population Health and Health Disparities (CPHHD) initiative.MethodsPrincipal investigators and research staff from 17 research projects at eight institutions across the United States were surveyed about their recruitment experiences. Investigators reported the study purpose and design, recruitment methods employed, recruitment progress, problems or challenges to recruitment, strategies used to address these problems, and difficulties resulting from Institutional Review Board (IRB) or Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements. Additionally, information was collected about participant burden and compensation. Burden was classified on a three-level scale. Recruitment results were reported as of March 31, 2007.ResultsRecruitment attainment ranged from 52% to 184% of the participant recruitment goals. Commonly reported recruitment problems included administrative issues, and difficulties with establishing community partnerships and contacting potential participants. Long study questionnaires, extended follow-up, and narrow eligibility criteria were also problematic. The majority of projects reported difficulties with IRB approvals, though few reported issues related to HIPAA requirements. Attempted solutions to recruitment problems varied across Centers and included using multiple recruitment sites and sources and culturally appropriate invitations to participate. Participant burden and compensation varied widely across the projects, however, accrual appeared to be inversely associated with the amount of participant burden for each project.ConclusionRecruitment of minority and underserved populations to clinical trials is necessary to increase study generalizbility and reduce health disparities. Our results demonstrate the importance of flexible study designs which allow adaptation to recruitment challenges. These experiences also highlight the importance of involving community members and reducing participant burden to achieve success in recruiting individuals from minority and underserved populations.     

Adolescent impulsivity phenotypes characterized by distinct brain networks

The impulsive behavior that is often characteristic of adolescence may reflect underlying neurodevelopmental processes. Moreover, impulsivity is a multi-dimensional construct, and it is plausible that distinct brain networks contribute to its different cognitive, clinical and behavioral aspects. As these networks have not yet been described, we identified distinct cortical and subcortical networks underlying successful inhibitions and inhibition failures in a large sample (n = 1,896) of 14-year-old adolescents. Different networks were associated with drug use (n = 1,593) and attention-deficit hyperactivity disorder symptoms (n = 342). Hypofunctioning of a specific orbitofrontal cortical network was associated with likelihood of initiating drug use in early adolescence. Right inferior frontal activity was related to the speed of the inhibition process (n = 826) and use of illegal substances and associated with genetic variation in a norepinephrine transporter gene (n = 819). Our results indicate that both neural endophenotypes and genetic variation give rise to the various manifestations of impulsive behavior.     

Testing for lupus anticoagulants - fresh or frozen?

Abstract Background: There are no previous studies reporting the effect of using frozen-thawed plasma on lupus anticoagulant ratios in kits with the combined screen and confirm assay. Methods: In the following study we chose patients with elevated dilute Russel's viper venom test (dRVVT) normalized ratios and compared the test results of fresh to frozen-thawed plasma. Platelet counts ranged from 2 to 7×103/μL (109/L) after a second centrifugation before freezing. Results: There were 13 out of 14 dRVVT test normalized ratios that decreased after freezing (p<0.001), leading to the misclassification of six of 14 patients with high values that decreased into the reference interval. Conclusion: The major finding of this study is that testing frozen-thawed plasma with platelet counts <10,000/μL (109/L) results in a significant decrease in dRVVT ratios. Although there was a consistent decrease in SCT normalized ratios as well, it did not lead to misclassifications.