bluuebunny/crossref_metadata_2025_split huggingface dataset:
Analysis of Low Estrogen Receptor (ER+) Breast Carcinomas in a Large Community Breast Cancer Center in Northern California
Authors: Bulusu G , Duncan K , Wheeler A 
Published: October 2021

Abstract

Introduction/Objective
Estrogen Receptor (ER) expression in breast cancers is a crucial factor for endocrine therapy in patients with tumors expressing ER in ≥1% of tumor cells. The 2019 guidelines published by ASCO/CAP states that breast cancers that have a 1% to 10% of cells staining Estrogen Receptor (ER) positive should be reported as ER Low Positive cases. This study aims to address this subset of low-positive ER tumors and compare the clinical features to other known breast cancer subtypes.

Methods/Case Report
We conducted a retrospective review of a prospectively maintained breast cancer registry from 2013 to 2021 at Mills-Peninsula Medical Center, a Sutter Health Affiliate. The study reviewed patient charts with respect to the pathology report, operative report, chemotherapy regimen, and clinical outcomes. Statistical analyses were conducted using R Project for Statistical Coding, with The Student’s T-test used to compare continuous variables. Two-sided P values less than 0.05 indicate statistical significance.

Results (if a Case Study enter NA)
Our study identified 1316 cases of invasive breast carcinomas, of which 29 (2.16%) demonstrated ER Low-Positive expression. We aimed to evaluate the clinical and pathological features, such as histological grade, ER, PR, HER-2, Ki-67%, and patient age for these tumors. We found that ER Low-Positive tumors demonstrated higher mean histological grade morphology (2.5 out of 3, p&lt;0.001) that was similar to that of Triple Negative Breast Cancers (TNBC) (3 of 3, p&lt;0.001) than to High ER-Positive (1.6 of 3, p&lt;0.001) cancers. Further observations, through examining proliferation rates by utilizing the Ki-67 index, indicate comparative trends between the ER Low-Positive cohort and the TNBC cohort.

Conclusion
The results suggest that the ER Low-Positive carcinomas, despite reported as ER-positive cases, present with similar clinicopathological features to those of ER-negative tumors. Through this study and future research, we would like to emphasize a stricter set of guidelines that can be adopted to reduce variability for reporting biomarkers. This standardization will allow oncologists to provide more appropriate treatment options and improve the quality of patient care.
High take-off of coronary arteries contributing to lethal myocardial ischemia: report of two cases
Authors: Conte J T , Prisneac I , Amin M 
Published: October 2021

Abstract

Introduction/Objective
High take-off coronary arteries (HTO) are defined by coronary ostia arising above the sinotubular junction (STJ). Although asymptomatic in most individuals, there is increasing evidence that HTO is a risk factor for sudden cardiac death. Here we present two patients where HTO contributed to death.

Methods/Case Report
Patient A was a 52 year old morbidly obese male with atypical chest pain, new inferior ST elevations and troponinemia. Multiple coronary angiographies did not reveal any stenosis, but 3 stents were placed in the RCA due to concern for vasospasm. 3 days later the patient died. Autopsy revealed cardiac tamponade and non- atherosclerotic ischemic heart disease with remote apical LV scar and diffuse patchy interstitial fibrosis in the myocardium, which could be attributed to HTO of the RCA 0.5 cm above the STJ and early intramuscular courses of both coronaries. Multiple angiographies likely caused iatrogenic coronary injury and subsequent tamponade. Patient B was a healthy 33 year old female at 34 weeks gestation, who developed anaphylaxis during IV iron infusion for severe iron deficiency anemia. She was transferred to the OR for emergent C-section. Minutes after delivery she died. Autopsy revealed HTO, with coronary ostia being 0.4 cm and 0.7 cm above the STJ, respectively and acute angle take-off of LCA. No atherosclerosis was noted. The inability to increase myocardial perfusion through the coronary arteries during a high stress situation due to pregnancy, iron deficiency anemia and anaphylaxis likely contributed to lethal myocardial ischemia.

Results (if a Case Study enter NA)
NA

Conclusion
HTO and other coronary artery anomalies (CAAs) should be considered in cases of cryptogenic acute and chronic myocardial ischemia. Hemodynamic characterization of HTO, including those &lt; 1 cm above the STJ in presence and absence of other CAAs may help better understand their pathophysiologic significance. Antemortem diagnosis requires high clinical suspicion and appropriate surgical intervention could be life-saving.
The sensitivity of temporal artery biopsy in the detection of giant cell arteritis is independent of tissue length
Authors: Hurley H J , Deb P Q 
Published: October 2021

Abstract

Introduction/Objective
Giant cell arteritis (GCA) is the most common vasculitis of the elderly, and the most common primary systemic vasculitis overall, with an annual incidence of 200/million. The long term sequelae, namely vision loss and stroke, are permanent and devastating. While GCA is often treated empirically based on clinical presentation, panarteritis on temporal artery biopsy is required for diagnosis. However, these biopsies have the tendency to be falsely negative due to skip lesions, a common feature of GCA. Therefore, we set out to determine whether longer biopsy specimens were more sensitive in the detection of GCA.

Methods/Case Report
A census of temporal artery biopsies performed with the indication of clinical symptoms of GCA was taken at our institution. The patient age, sex, biopsy laterality, biopsy length, and pathological diagnosis were recorded for each cataloged sample. Statistical significance of difference in biopsy length was tested using an unpaired t-test in R 4.1.0.

Results (if a Case Study enter NA)
A total of 114 temporal artery specimens were biopsied from 94 different patients with the indication of GCA and assigned a definitive positive or negative diagnosis. Of the 94 patients, 54 were female and 40 were male. Of the total pathological specimens, 11 were positive and 103 were negative. The overall average length of biopsy specimens was 2.13 cm with a standard deviation of 0.65 cm. The average positive biopsy was 2.26 cm long, and the average negative was 2.12 cm, an insignificant difference (0.14 cm, t = 0.7, p = 0.43). In 25 patients, biopsies were taken from both the left and right temporal arteries. Of those patients, 2 were positive for GCA and the remaining 23 were negative. Interestingly, the biopsy result in every case was identical between the left and right samples; we found no instances of pathological evidence of GCA in only one of the two samples from the same patient.

Conclusion
According to data taken at our institution, there is no indication to lengthen the biopsy requirements from the existing 1.5 cm. However, we have demonstrated evidence that it may be unnecessary to biopsy both temporal arteries in a single patient. Larger studies would be required to confirm our findings.
Can cholesterol be too low? A retrospective correlation of cholesterol lab values to other markers of cardiovascular disease risk
Authors: Petersen P , Chambliss A 
Published: October 2021

Abstract

Introduction/Objective
Most recommendations for lipid panel reference ranges are one-sided (desirable total cholesterol is &lt;200 mg/dL, optimal LDL cholesterol [LDL-C] is &lt;100 mg/dL). However, recent studies suggest risks for cardiovascular diseases or mortality at very low cholesterol values. In this retrospective study, we investigated the association between lipid panel results and surrogate markers of cardiovascular disease to test the hypothesis that very low cholesterol levels are associated with increases in cardiovascular risk.

Methods/Case Report
Patients with lipid panels reported from April 2020-March 2021 at LAC+USC Medical Center were included. Lipid panels (total cholesterol, LDL-C, HDL-C, triglycerides) and laboratory results representing risk factors for cardiovascular disease (troponin T (TnT), NT-pro brain natriuretic peptide (BNP), hemoglobin A1c (HbA1c), high sensitivity C-reactive protein (CRP)) were collated. Lipid panel values were compared against the percentage of patients with non-optimal laboratory results for the cardiovascular risk markers.

Results (if a Case Study enter NA)
Decreasing total cholesterol levels vs. the percentage of patients with high TnT or BNP showed a U-curve with a nadir at 200-240 mg/dL (elevated TnT: 15%, BNP: 49%) and further increased with lower cholesterol levels &lt;60 mg/dL (TnT: 56%, BNP: 92%); HbA1c (U-curve, nadir: 160-180 mg/dL); and CRP (90% at cholesterol &lt;60 mg/dL; 43% at 220-240 mg/dL). Decreasing HDL-C against all markers of cardiovascular disease demonstrated a continued downtrend below optimal HDL-C levels. Decreasing LDL-C vs. the percentage of high TnT showed a U-curve with a nadir at 120-140 mg/dL; BNP (uptrends in the optimal range of LDL-C); HbA1c (U-curve, nadir: 90-100 mg/dL); and CRP (uptrends with decreasing LDL-C). TnT and BNP decreased with increasing triglycerides, while HbA1c increased with increasing triglycerides. Data points (TnT: n &gt; 5,000; BNP: n &gt; 3,000; HbA1c: n &gt; 29,000; CRP: n &gt; 4,500).

Conclusion
Very low concentrations of total cholesterol and LDL-cholesterol are associated with elevated markers of cardiovascular risk. Laboratories may wish to consider incorporating low ends to total cholesterol and LDL-cholesterol reference ranges.
Impact of Removing Race Adjustment When Estimating GFR on Chronic Kidney Disease Staging
Authors: Cai C , Sahor F , Wilson B , Veeramachaneni T , Hashim I 
Published: October 2021

Abstract

Introduction/Objective
Determination of glomerular filtration rate (GFR) is essential in assessment of kidney function, particularly in patients with chronic kidney disease (CKD). Formulas were developed to calculate estimated GFR (eGFR), as direct measurement is cumbersome and not amenable to routine monitoring. CKD-EPI is the most widely used formula for eGFR, using parameters of serum creatinine, gender, race, and age. A race adjustment was added from an unfounded assumption that Black patients have more muscle mass, increasing their eGFR by about 16%. There is concern on the impact of “correcting” for Black race on patient management, utility of eGFR, and its possible contribution to healthcare disparities. This study examined the impact of eliminating race adjustment from the CKD- EPI formula on CKD staging in patients at a large safety-net hospital in an academic medical center.

Methods/Case Report
80090 serum creatinine values from 56676 adult patients (31.4% Black, 67.5% female, median age 51 yrs) were collected from the electronic medical record (Epic, Verona, WI) over a 16-month timeframe. Values were excluded if they lacked age, gender, self-identified race, or serum creatinine. eGFR was calculated using the CKD-EPI equation with and without race modifier, and CKD staging was performed using 2012 Kidney Disease: Improving Global Outcomes guidelines.

Results (if a Case Study enter NA)
In our cohort, only 50.8% of Black patients are in CKD1, indicative of no CKD, compared to 67.9% of non-Black patients. Given that these two cohorts are demographically similar, this shows a discrepancy in kidney function even before removing the race adjustment. After removal of the race modifier, 28.1% of Black patients were reclassified into a more severe CKD stage. The most restaging occurred from CKD3A to 3B (39%).

Conclusion
Many Black patients in our study were reclassified to a more severe CKD stage, with the highest percentage of patients restaged to CKD3B, which would have attracted clinical attention for nephrology referral. We recommend removal of the race adjustment in eGFR, given its basis in the incorrect belief in biological differences between races. It perpetuates systemic racism and discrimination in healthcare, and its removal will provide more equitable care and reduce healthcare disparities. Future studies should examine the increase in resources required to provide adequate medical care to patients who will be placed into a more severe CKD stage.
POC Programs: A Brief Survey on Critical Value Thresholds, Instrumentation, Repeat Testing, and Training Documentation
Authors: Castle B , Vonlinsowe E , Cook B , Hayward J , Sharma G 
Published: October 2021

Abstract

Introduction/Objective
Across the United States, Point of Care (POC) programs oversee glucometer testing and are often expected to enforce thresholds for critical values, as well as provide guidance on repeat testing. Additionally, POC must track training and ongoing competency assessments of glucometer operators. Our aim was to survey POC across North America to capture the current state of variation in these POC functions, and identify opportunities for standardization.

Methods/Case Report
In July of 2021, an online survey was created on www.surveymonkey.com and distributed via the POC listserv of the American Association for Clinical Chemistry (AACC). The survey listed nine questions regarding instrumentation, threshold levels for critical-high and critical-low, policies on repeat testing, and practices around documentation and record retention.

Results (if a Case Study enter NA)
Of the 63 responses received, almost all (95.2%, n=60) indicated that their institution defines glucometer critical value thresholds. Of these, the most common threshold for critical-high was 400 mg/dL (44.4%, n=28) and for critical-low was 50 mg/dL (39.7%, n=25). A majority (55.5%, n=35) of programs require repeat testing of results that exceeded critical limits. The most popular POC result management software (50.8%, n=32) was RALS (Abbott Diagnostics, Chicago, IL) and the most popular glucometer (56%, n=23) was Roche Accu- Chek Inform II (Roche Diagnostics, Basel, Switzerland). Regarding institutions that disclosed training and competency documentation practices (93.7%, n=59), a majority (57.6%, n=34) used online-only storage, followed by hybrid online- paper storage (32.2%, n=19), and paper-only storage (10.2%, n=6).

Conclusion
Our brief survey has uncovered variations and insights that should raise queries on the feasibility of standardized critical value thresholds, as well as uniform recommendations for retesting critical values. We observed widespread adoption of middleware, as well as online record-keeping. We hope that our findings will trigger further discussions and follow-up studies by other researchers in the POC field.
Vitamin D deficiency Crisis in Egypt
Authors: Abdelmonem M , Elhusseny A , Wasim H , Shedid M , Boraik A S 
Published: October 2021

Abstract

Introduction/Objective
Vitamin D deficiency is a worldwide health problem. Even with the latest medical technology worldwide, vitamin D deficiency is still an ignored epidemic. More than a billion people globally are vitamin D deficient or insufficient. Vitamin D is essential for strong bones as it is responsible for the absorption of calcium, magnesium, and phosphate in the human body. It is essential for building the human immune system and legalizing cell growth. Vitamin D deficiency can result in muscle vulnerability, pain, tiredness, and depression. Severe Vitamin D deficiency can cause Rickets disease.

Objectives
This study aims to predict the percentage of vitamin D deficiency in Egypt.

Methods/Case Report
A total of 498 subjects were enrolled in this study from the Cairo region in Egypt; 203 (41%) were male, 260 (52%) were female, and 35 (7%) were children with a median age of 36.2 years, 36.7 years and 5.3 years respectively. A fully automated chemiluminescence immunoassay analyzer (CLIA) was used to measure Vitamin D in all subjects’ specimens.

Results (if a Case Study enter NA)
The overall prevalence of Vitamin D deficiency was 90.09%. Among the 498 patients, 453 patients (90.09%) were Vitamin D deficient (less than 30 ng/ml), while 45 patients (9.03%) of the patients were within the normal Vitamin D range. It was observed that 192 patients (94.54%) of males,237 patients (91.15%) of females, and 11patients (31.42%) of children were Vitamin D deficient. Furthermore, 11 patients (5.41%) of males, 23 patients (8.84%) of females, and 23 patients 65.71% of children are within the normal Vitamin D range.

Conclusion
Our findings reveal a significant frequency of vitamin D deficiency in Egypt. Inadequate sun exposure, Insufficient dietary calcium, gastrointestinal disorders, renal diseases, and liver diseases contribute to vitamin D deficiency. We recommend that the Egyptian Health ministry launch an awareness campaign for the severe Vitamin D deficiency in Egypt.
Pancreatic Metastasis from Breast Cancer: A Clinicopathological Study of Four Cases by Fine Needle Aspiration
Authors: Chen M Y , Xu Y 
Published: October 2021

Abstract

Introduction/Objective
Pancreatic metastases are rare, and the most common neoplasms are carcinomas from the kidney, lung, and breast.

Methods/Case Report
We present four cases of breast ductal carcinoma in patients with metastases to the pancreas diagnosed by endoscopic ultrasound guided fine needle aspiration (EUS-FNA). The four female patients ranged from 37 to 64 years in age. Three patients had breast cancer histories, ranging from 1 to 21 years. The patient without cancer history was found to have breast mass also. Two patients had triple negative breast ductal carcinoma. The breast cancer biomarkers on the other two patients showed ER+, PR-, Her2 3+, and ER-, PR-, Her2 3+, respectively. Two patients had histories of metastatic breast cancer involving bone, liver and brain. All patients presented with symptoms associated with pancreatic mass. By imaging, solitary pancreatic head masses were found in three patients, ranging from 2.4 to 3.7 cm. One patient had two pancreatic masses (head, 2.6 cm; body, 2.9 cm). EUS-FNAs targeting the pancreatic head masses were performed on the four patients. Cell blocks were available for all except one (due to limited cells), which had subsequent histology diagnosis.

Results (if a Case Study enter NA)
FNAs demonstrated loosely cohesive tumor cells with enlarged, hyperchromatic nuclei, occasional prominent nucleoli, and occasional intracytoplasmic vacuoles, morphologically and immunohistochemically (CK7 +, GCDFP-15 focally +, CA19.9 -, biomarkers similar to primary tumors) consistent with breast primary. Follow-up revealed three patients expired one month, 2.5 years, and 5 years post-diagnosis, respectively. One patient without prior cancer history has been stable for 7 years.

Conclusion
Our study demonstrates the clinicopathological features of four cases of breast ductal carcinoma metastasized to the pancreas. We emphasize the important role of EUS-FNA for diagnoses of pancreas metastases. The finding of two of four cases with triple negative biomarkers may raise the importance of close follow-up in these patients for pancreatic metastasis.
Cytomorphologic Features of Extramammary Paget’s Disease of The Vulva in a patient with history of Squamous Cell Carcinoma of The Cervix, Status Post Chemoradiation and Neoadjuvant Therapy. The Importance of Basic Principles
Authors: Duhoki D , Gonzalez M F 
Published: October 2021

Abstract

Introduction/Objective
Extramammary Paget disease (EMPD) is a rare neoplasm commonly affects postmenopausal women. It usually presents in the anogenital area where apocrine sweat glands are abundant, most commonly in the vulva. The disease is characterized by slow grow and high local recurrence rates. Clinically, EMPD present as well demarcated erythematous lesion or plaques that may ulcerated. Microscopically, it shows a group of atypical cells with abundant clear cytoplasm and nuclear pleomorphism.

Methods/Case Report
Here in we present a 58-year-old female with history of vulvar intraepithelial neoplasia III (VIN III) status post wide local excision, and poorly differentiated squamous cell carcinoma status post radical hysterectomy and bilateral salpingo-oopherectomy and chemoradiation who presented for perineal pain, itching and discomfort. She also noticed skin changes on her left labia without bleeding or discharge. Punch biopsies of the vulva and periurethral areas revealed acanthosis of the epidermis with intraepidermal scattering of single or clusters of large cells with round/ovoid nuclei and abundant clear cytoplasm. The cells are positive for p16, CK19, CK7, PAX8 supporting the diagnosis of EMPD without evidence of dysplasia. The concurrent PAP smear shows hypercellular specimen composed of hyperchromatic fragments of tissue with high nuclear-to-cytoplasmic rations, and apoptotic bodies. The presence of intracytoplasmic mucin and the tridimensionality of the fragments supported the diagnosis of adenocarcinoma. The HPV testing was positive for HPV-16.

Results (if a Case Study enter NA)
N/A

Conclusion
This study compares the histological and cytomorphological features of EMPD with high-grade squamous intraepithelial lesion (HSIL), since the molecular pathways, precursor lesions, etiologic associations, staging, clinical treatment, and prognosis differ substantially and may have a significant clinical impact for the patient’s treatment.
Cytology Detects Endobronchial Metastasis from Appendiceal Signet-Ring Cell Carcinoma in the Absence of Radiographic Lung Masses: A Case Report
Authors: Taylor B W , Hummel K , Xu Y 
Published: October 2021

Abstract

Introduction/Objective
Endobronchial metastasis (EBM) is uncommon, with a reported prevalence of 2% in cases of non-lung primary malignancies. The most frequently observed carcinomas in EBM are from breast, colon, and renal origins. We present a rare case of endobronchial metastasis from a primary tumor of the appendix without lung masses by computed tomography (CT).

Methods/Case Report
An 83-year-old woman with signet-ring cell carcinoma of the appendix underwent right hemicolectomy and chemotherapy. Two years later, she returned with intractable nausea and vomiting, and respiratory distress. CT of the chest demonstrated diffuse bilateral pulmonary opacities without lung masses. CT of the abdomen showed peritoneal carcinomatosis. Cytology of ascitic fluid displayed metastasis of the patient’s known appendiceal tumor. Bronchoscopy found significant friable debris appearing to be tumor tissue and occluding multiple bronchioles in the right lung. A bronchoalveolar lavage (BAL) specimen from the right lung was sent for liquid-based cytology, which revealed a few atypical cells with eccentric nuclei and intracytoplasmic vacuoles, abundant macrophages, degenerated mixed inflammatory cells, and scattered bronchial epithelial cells. Cell block demonstrated signet-ring cells mimicking macrophages and infiltrating into small fragments of bronchiolar wall. The signet-ring cells were morphologically similar to those found in the ascitic fluid and the patient’s primary tumor, and were highlighted by mucicarmine stain and immunohistochemical stains for CDX-2 and CK20, but not CK7.

Results (if a Case Study enter NA)
N/A

Conclusion
Collectively, the findings supported the diagnosis of endobronchial metastasis of signet-ring cell carcinoma from the lower gastrointestinal tract, i.e. the patient’s known appendiceal primary. Our case demonstrates a rare endobronchial metastasis of a primary neoplasm of the appendix, an important diagnostic consideration when evaluating respiratory distress in patients with such cancer histories. We have described the significant role of BAL cytology to uncover endobronchial metastases without lung masses by CT, and illustrated the finding of signet-ring cells mimicking macrophages in a BAL cytology specimen.