Diverticular Bleeding of the Colon during Combination Chemotherapy with Bevacizumab and Paclitaxel for Recurrent Breast Cancer

Pre-existing Opioid Use Worsens Outcomes in Patients With Diverticulitis

Background and objective Diverticulitis occurs in 10-25% of patients with diverticulosis. Although opioids can decrease bowel motility, there is scarce data on the effect of chronic opioid use on the outcomes of diverticulitis. In this study, we aimed to explore the outcomes of diverticulitis in patients with pre-existing opioid use. Methods Data between 2008 and 2014 from the National Inpatient Sample (NIS) database was extracted using the International Classification of Diseases, 9th Revision (ICD-9) codes. Univariate and multivariate analyses were used to generate odds ratios (OR). Elixhauser Comorbidity Index (ECI) scores predicting mortality and readmission were calculated based on weighted scores from 29 different comorbidities. Scores were compared between the two groups using univariate analysis. Inclusion criteria included patients with a primary diagnosis of diverticulitis. Exclusion criteria included patients less than 18 years of age, and a diagnosis of opioid use disorder in remission. Studied outcomes included inpatient mortality, complications (including perforation, bleeding, sepsis event, ileus, abscess, obstruction, and fistula), length of hospital stay, and total costs.  Results A total of 151,708 patients with diverticulitis and no active opioid use and 2,980 patients with diverticulitis and active opioid use were hospitalized in the United States from 2008 to 2014. Opioid users had a higher OR for bleeding, sepsis, obstruction, and fistula formation. Opioid users had a lower risk of developing abscesses. They had longer lengths of stay, higher total hospital charges, and higher Elixhauser readmission scores. Conclusion Hospitalized diverticulitis patients with comorbid opioid use are at an elevated risk of in-hospital mortality and sepsis. This could be attributed to complications from injection drug use predisposing opioid users to these risk factors. Outpatient providers caring for patients with diverticulosis should consider screening their patients for opioid use and try offering them medication-assisted treatment to reduce their risk of poor outcomes.

Endobronchial Watanabe Spigot Placement for a Secondary Pneumothorax

Although bevacizumab has several adverse effects, pneumothorax is rare. This is the first case of initial treatment using an Endobronchial Watanabe Spigot (EWS) for pneumothorax after bevacizumab-containing chemotherapy. A 56-year-old woman with recurrent breast cancer was treated with bevacizumab. Pneumothorax occurred 6 days after the last administration of bevacizumab. The pneumothorax failed to resolve after the chest tube drainage. This was because the bronchopleural fistula formed at the site of the subpleural metastatic lesion. Patient was in need of a surgical repair of the bronchopleural fistula, which could not be carried out due to the recent bevacizumab administration. After the insertion of the EWS, the air leak stopped immediately. A lobectomy was successfully performed for the recurrent pneumothorax and for the resection of the metastatic lung lesion; at a most appropriate duration since the chemotherapy. EWS is useful as the initial palliation of pneumothorax after the treatment with medication causing delayed wound healing.

Use of bevacizumab in recurrent glioblastoma

Glioblastoma (GBM) is the most common adult primary brain neoplasm. Despite advances in treatment, GBM continues to be associated with considerable morbidity and mortality as compared with other malignancies. Standard treatment for GBM results in survival of 12.9 months (95% CI: 12.3-13.7 months) with a median progression-free survival of 7.2 months (95% CI: 6.4-8.2 months) in a modern GBM cohort. These aggressive tumors recur and treatment for recurrent GBM continues to have very poor outcomes. Prior to the use of bevacizumab, monoclonal antibody to VEGF, 6-month progression-free survival in clinical trials for recurrent GBM ranged from 9 to 15%. Trials utilizing bevacizumab and its subsequent US FDA approval have given more hope to recurrent GBM and this concise review discusses bevacizumab in recurrent GBM. This review focuses on time-to-event outcomes (overall survival, progression-free survival and 6-month progression-free survival) in clinical trials utilizing bevacizumab for the treatment of recurrent GBM. For this review, we have chosen to focus primarily on Phase II clinical trials that have been published and available in the literature (PubMed). While we focused primarily on time-to-event variables, toxicity and safety of bevacizumab is very important and this agent can be associated with serious life-threatening toxicities. We have included a general section of toxicities but for a more lengthy review please see the excellent study by Odia and colleagues.