Introduction Sentinel lymph node (SLN) biopsy is recommended for all patients with intermediate thickness melanomas. We sought to identify such patients at low risk of SLN positivity. Methods All patients with intermediate thickness melanomas (1.01–4 mm) undergoing SLN biopsy at a single institution from 1995–2011 were included in this retrospective cohort study. Univariate and multivariate logistic regression determined factors associated with a low risk of SLN positivity. Classification and regression tree (CART) analysis was used to stratify groups based on risk of positivity. Results Of the 952 study patients, 157 (16.5%) had a positive SLN. In the multivariate analysis, thickness <1.5 mm (OR= 0.29), age ≥60 (OR=0.69), present tumor infiltrating lymphocytes (TIL) (OR=0.60), absent lymphovascular invasion (LVI) (OR=0.46), and absent satellitosis (OR=0.44) were significantly associated with a low risk of SLN positivity. CART analysis identified thickness of 1.5 mm as being the primary cut point for risk of SLN metastasis. Patients with a thickness of <1.5 mm represented 36% of the total cohort and had a SLN positivity rate of 6.6% (95% CI=3.8–9.4%). In patients with melanomas <1.5 mm in thickness, the presence of additional low risk factors identified 257 patients (75% of patients with <1.5 mm melanomas) in which the rate of SLN positivity was <5%. Discussion Despite a SLN positivity rate of 16.5% overall, substantial heterogeneity of risk exists among patients with intermediate thickness melanoma. Most patients with melanoma between 1.01–1.5 mm have a risk of SLN positivity similar to that in patients with thin melanomas.

: Among adult patients with hemophilia A and hemophilia B the emergent management of acute coronary syndromes (ACSs) is challenging, and exposure to antithrombotic agents and/or revascularization procedures may confer an enhanced risk of bleeding. We sought to identify clinical characteristics and in-hospital outcomes among ACS patients with hemophilia A/hemophilia B, compared with matched noncoagulopathic ACS controls. Case discharges from the Nationwide Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality (1998-2011) had International Classification of Diseases, 9th Revision codes for hemophilia A/hemophilia B and ACS. Control discharges were matched to cases by year of discharge and hospital. Discharges in both groups were assessed for cardiovascular risk factors, type of ACS, use of coronary artery bypass grafting, percutaneous coronary intervention (PCI), bare-metal stent and/or drug-eluting stent, bleeding, and death. In total, 237 cases and 148 848 matched controls were identified. Among cases, HIV/Hepatitis C positivity was more common and obesity/hyperlipidemia less common. ST-elevation myocardial infarction (STEMI) occurred less frequently among hemophilia A cases than controls. hemophilia A and hemophilia B cases were more likely to be managed medically. Cases treated with coronary stent placement were more likely to receive a bare-metal stent than controls. Among PCI, bleeding was more common among hemophilia A cases. The death rates were comparable between groups. ACS-hemophilia A/hemophilia B cases were more often treated noninvasively compared with controls, suggesting an avoidance of PCI/coronary artery bypass grafting in this population, and bleeding (among hemophilia A) was more common. These findings support further study of the management of ACS and in-hospital outcomes among individuals with hemophilia.

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There was a significantly higher percentage of women among the case discharges compared to the control discharges (59.5% and 39.4%, respectively; P < 0.001). The rate of medical therapy alone [i.e. avoidance of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)] was significantly higher among unstable angina cases than controls (55.0% vs. 46.4%; P = 0.01), and among cases undergoing PCI, bare-metal stents (BMS) were utilized in preference to drug-eluting stents (DES) (adjusted OR = 3.5); P < 0.001). No difference in in-hospital death was identified, but reported bleeding among discharges that underwent CABG was higher in cases compared to controls (12.9% vs. 5.2%; P = 0.047). Although medical and interventional management of ACS appears to be well tolerated in the majority of hospitalized patients with VWD, the gender ratio is reversed, interventions and DES are utilized less frequently and procedure-related bleeding may be increased, calling for further study.