Real-world outcomes of autologous and allogeneic hematopoietic stem cell transplantation for relapsed/refractory Hodgkin lymphoma in the era of novel therapies: a Canadian perspective

BACKGROUND

Despite high cure rates with frontline therapy for Hodgkin lymphoma (HL), about 30% of patients will relapse or have primary refractory disease (R/r). Autologous hematopoietic stem cell transplantation (AHSCT) is the standard of care for R/r disease and alloHSCT is a curative option for patients in second relapse. Novel agents are being incorporated for the treatment of R/r HL, such that the optimal timing of transplant is currently being challenged. Additionally, because access to these new agents varies amongst transplant centers, we sought to offer a Canadian perspective to the treatment of R/r HL and demonstrate the utility and effectiveness of both AHSCT and alloHSCT for the treatment of R/r HL.

METHODS

This single-center retrospective study examined outcomes in 89 consecutive patients with R/r HL treated with AHSCT between January 2007 and December 2019. A total of 17 patients underwent alloHSCT either as a tandem auto-allo approach or as salvage therapy.

RESULTS

With a median follow-up of 5.0 years, the estimated 5-year PFS and OS for patients undergoing AHSCT were 57.5% (95% CI 45.2-68.0) and 81.3% (95% CI 70.0-88.8), respectively. Corresponding figures for patients who underwent alloHSCT were 76.5% (95% CI 48.8-90.4) and 82.4% (95% CI 54.7-93.9). NRM at 100 days and 5 years was 0% and 9.4% post AHSCT and 0% and 5.9% post alloHSCT. Cumulative incidence (CI) of acute GVHD at day +100 was 35.3% (95% CI 17.7 - 62.3) and CI of chronic GVHD at 1 year was 23.5% (95% CI 6.9 - 45.8).

CONCLUSIONS

AHSCT and alloHSCT can both provide robust and prolonged disease control and new agents should be used as a bridge to improve the curative potential of these definitive cellular therapies.

A new approach to solve fully intuitionistic fuzzy linear programming problem with unrestricted decision variables

In many real-world problems, one may encounter uncertainty in the input data. The fuzzy set theory fits well to handle such situations. However, it is not always possible to determine with full satisfaction the membership and non-membership degrees associated with an element of the fuzzy set. The intuitionistic fuzzy sets play a key role in dealing with the hesitation factor along-with the uncertainty involved in the problem and hence, provides more flexibility in the decision-making process. In this article, we introduce a new ordering on the set of intuitionistic fuzzy numbers and propose a simple approach for solving the fully intuitionistic fuzzy linear programming problems with mixed constraints and unrestricted variables where the parameters and decision variables of the problem are represented by intuitionistic fuzzy numbers. The proposed method converts the problem into a crisp non-linear programming problem and further finds the intuitionistic fuzzy optimal solution to the problem. Some of the key significance of the proposed study are also pointed out along-with the limitations of the existing studies. The approach is illustrated step-by-step with the help of a numerical example and further, a production planning problem is also demonstrated to show the applicability of the study in practical situations. Finally, the efficiency of the proposed algorithm is analyzed with the existing studies based on various computational parameters.

Outcomes in newly diagnosed young or high-risk myeloma patients receiving tandem autologous/allogeneic transplant followed by bortezomib maintenance: a phase II study

Despite novel drugs and autologous HCT, MM remains incurable, with short survival in patients with poor biological characteristics. Allo HCT may be curative in some patients but is hampered by high rates of toxicity and relapse. We hypothesized that bortezomib (BTZ), with its anti-myeloma and immunologic properties, could improve PFS and cGVHD after allo HCT in newly diagnosed MM patients. In this prospective phase II study, we included 39 young (≤50 years) and high-risk patients who received a tandem auto-allo HCT followed by BTZ. Patients had prospective minimal residual disease (MRD) evaluations using Next-Generation Flow cytometry prior to allo HCT, prior BTZ and every 3 months for 2 years. With a median follow-up of 48 months, we report PFS and OS at 5 years of 41% and 80%, with a non-relapse mortality of 12%. Incidences of grade II-IV aGVHD at 12 months and moderate/severe cGVHD at 2 years were 26% and 57%. In a multivariate analysis model including cytogenetics, ISS and MRD status, MRD positivity prior to allo HCT (HR 3.75, p = 0.037), prior BTZ (HR 11.3, p = 0.018) and 3 months post-BTZ initiation (HR 9.7, p = 0.001) was highly predictive of progression. Peritransplant MRD assessment thus strongly predicts disease progression.

Micromorphological evaluation of Daphne mucronata Royle and Myrtus communis L. using scanning electron microscopic techniques

The present study was undertaken to establish micromorphological standards of Daphne mucronata Royle and Myrtus communis (L.). Daphne mucronata Royle is a xerophytic perennial shrub while, Myrtus communis is an evergreen shrub or small tree. Micromorphological investigation is one of the cheapest methods. It will be helpful in the accurate identification of these plants from other species. Results of macroscopic evaluation showed various organoleptic features. Anatomy of the selected plant parts was carried out. It showed a typical dicot structure as it revealed the presence of epidermal cells, crystals, trichomes, cuticle, mesophyll tissues, xylem, phloem, paracytic, and dicytic stomata. Anatomical study facilitates the detection of adulteration with inferior commercial varieties, exhausted drugs, cheaper natural substances, and chemicals. Stomatal number, types, and size of stomata, and palisade ratio of Myrtus communis were observed. These observations will be helpful in the preparation of taxonomic key for the identification of selected species. Powder drug study [scanning electron microscopy (SEM)] showed characteristics histological differentiation. The methods cited here can be measured as characteristics to identify and validate these drugs.

Prospective Analysis of Etiologies of Nose Defects in a Tertiary Care Referral Centre

The purpose of the study was to analyze the various causes of nasal defects seen in practice by plastic surgeons in the Department of Plastic Surgery, in a tertiary care North Indian Hospital. The study included all patients of any age and sex presenting to the outpatient department or emergency department with nose defects. The patients were enquired about the cause and history of their nasal defects. The most common etiologies of nasal defects seen were skin tumors of the nose, the most common one being the basal cell carcinoma (BCC) followed by squamous cell carcinoma (SCC), and congenital naevus. Both the malignancies BCC and SCC were seen in older age. While BCC was significantly more common in males, a specific gender preference could not be concluded in SCC. Trauma was the next most common cause and included road traffic accidents, assaults, and animal bites. These were more commonly seen in the youth and less commonly in geriatric or pediatric populations. Other less common causes of nasal defects included postburn lesions.

A STUDY ON COMPARATIVE YIELDS OF STANDARD SHORT TERM ELECTROENCEPHALOGRAM AND LONG TERM ELECTROENCEPHALOGRAM RECORDING IN SUSPECTED EPILEPSY PATIENTS

Objective: To compare the yield of interictal epileptiform discharges on prolonged (1-2 hours) electroencephalogram (EEG) as compared to standard routine (30 minutes) electroencephalogram (EEG). Study Design: Comparative observational study. Place and Duration of Study: Pak Emirates Military Hospital, Rawalpindi from Oct 2019 to Sep 2020. Methodology: A total of 364 outdoor patients with suspected epilepsy were recruited for the study. Out of these 55 electroencephalograms were excluded after applying exclusion criteria and 309 were included for final analysis. Electro-encephalograms were recorded using a 10-20 international system of electrode placement. The duration of each standard electroencephalogram was 30 minutes. It was followed by recording for an extended period of 60 minutes at least. The time to the appearance of the first abnormal interictal epileptiform discharge was noted. For analytical purposes, epileptiform discharges were classified as “early” if they appeared within the first 30 minutes and as “late” if appeared afterward. All electro-encephalograms were evaluated independently by two neurologists. Results: A total of 309 electroencephalograms were included for final analysis. Interictal epileptiform discharges were seen in 48 (15.6%) recordings. The mean time to appearance of first interictal epileptiform discharge was 14.6 ± 19.09 minutes. In 36 (11.7%) cases, discharges appeared early (within the first 30 minutes) whereas in the remaining 12 (3.9%) cases, discharges appeared late. This translates into a 33% increase in the diagnostic yield of electroencephalogram with an extended period of recording. Conclusion: Extending the electroencephalogram recording time results in a significantly better diagnostic yield of outdoor electroencephalogram.

Study of human knowledge and attitude toward urban birds in Faisalabad city, Pakistan

Birds are very valuable indicators of species richness and endemic patterns in a specified ecosystem, which eventually help the scientist to measure the environmental degradation. The aim of present study was to know human knowledge and attitude toward urban birds in Faisalabad city, Pakistan. The study conducted in four consecutive months: November 2019 to February 2020. Population of birds was noted from eight residential towns of Faisalabad city, data were collected through questionnaire. Faisalabad has a reasonably large population of birds and present data show that, there is a significant difference between favorite bird of residential areas and institutions. The pigeon received the most likeness in bird population among residential area residents, while the myna received the least. The most popular bird in Faisalabad institutions was the sparrow, while the least popular bird was the common myna. Bird adaptation percentage of residential areas and institutional areas of Faisalabad was the highest for parrot and sparrow respectively. People in residential areas and institutions, on the other hand, adapted least to common myna. It is concluded that people of the study area like birds and offered food and high population of birds are present in study area.

Effect of microwave plasma treatment on magnetic and photocatalytic response of manganese ferrite nanoparticles for wastewater treatment

The conventionally synthesized nano-ferrite materials do not possess bulk properties, generally required for their use in mainstream industry. To make ferrite nanoparticles clinically applicable materials, it is important to have good control over morphology and optical properties of these materials. In this study, low-pressure microwave plasma was used to tailor the structural properties and surface chemistry of manganese ferrite nanoparticles. A facile sol-gel method was used to prepare cubic spinal structures of manganese ferrite nanoparticles. These nanoparticles were exposed to oxygen plasma sustained with a microwave source for improving their magnetic and photocatalytic activities. The techniques like XRD, SEM, PL, UV-Vis DRS, transient photocurrent response and EIS were used to characterize the samples. The plasma treated nanoparticles were used to degraded methyl blue (MB) dye in the solution. The photocatalytic activity showed 85% degradation of MB after 100 min of exposure of visible light. The second part of the paper studied the magnetic properties of the nanoparticles. The saturation magnetization decreased from 0.78 emu/g to 0.68 emu/g after plasma treatment of nanoparticles.

Gastric metastasis before diagnosis of primary invasive lobular breast carcinoma: a rare case presentation from Pakistan

Metastatic spread of invasive lobular breast carcinoma to stomach is rare especially before diagnosis of primary breast cancer. Incorrect diagnosis might result in delay of appropriate treatment for breast cancer. Recognition of this possibility enables better clinical management. A 62-year-old female presented with upper gastrointestinal symptoms and weight loss and was referred to a gastroenterologist for investigation. At the time of initial diagnosis of stomach cancer, patient was asymptomatic for breast cancer. Multiple gastric biopsies taken showed features suspicious of metastatic breast cancer. Consequently, the initial provisional diagnosis of stomach cancer changed into metastatic invasive lobular breast carcinoma. These findings were corroborated radiologically. The patient was treated with letrozole and zoledronic acid as first-line therapy for one year. Residual metastatic breast cancer was present in the gastric mucosa. The patient was treated with endocrine therapy containing ribociclib and treatment was ineffective confirmed by PET-CT scan. But her symptoms have resolved completely despite her presentation with stage IV. We present rare case of initial presentation of gastric metastasis before diagnosis of a primary invasive lobular breast carcinoma. Correct diagnosis and appropriate treatment were accomplished through initial clinical suspicion, accurate histological examination, and endoscopy together with analysis of disease-specific biomarkers.

Management of haematoma after thyroid surgery: systematic review and multidisciplinary consensus guidelines from the Difficult Airway Society, the British Association of Endocrine and Thyroid Surgeons and the British Association of Otorhinolaryngology, Head and Neck Surgery

Haematoma after thyroid surgery can lead to airway obstruction and death. We therefore developed guidelines to improve the safety of peri‐operative care of patients undergoing thyroid surgery. We conducted a systematic review to inform recommendations, with expert consensus used in the absence of high‐quality evidence, and a Delphi study was used to ratify recommendations. We highlight the importance of multidisciplinary team management and make recommendations in key areas including: monitoring; recognition; post‐thyroid surgery emergency box; management of suspected haematoma following thyroid surgery; cognitive aids; post‐haematoma evacuation care; day‐case thyroid surgery; training; consent and pre‐operative communication; postoperative communication; and institutional policies. The guidelines support a multidisciplinary approach to the management of suspected haematoma following thyroid surgery through oxygenation and evaluation; haematoma evacuation; and tracheal intubation. They have been produced with materials to support implementation. While these guidelines are specific to thyroid surgery, the principles may apply to other forms of neck surgery. These guidelines and recommendations provided are the first in this area and it is hoped they will support multidisciplinary team working, improving care and outcomes for patients having thyroid surgery.

Prospects of cryosphere-fed Kuhl irrigation system nurturing high mountain agriculture under changing climate in the Upper Indus Basin

Changing cryosphere and growing population have raised the importance of extending agriculture and improving the livelihoods of local communities in the Upper Indus Basin (UIB). In the present study, prospects of cryosphere-fed irrigation were investigated through adopting topographic suitability and water availability indexing approach to broaden the base of agriculture and socio-economic activities in the UIB of Pakistan. Topographic suitability for crop farming was found high (<15° slope below 3000 m) over 47.8% area of the Swat, 23.6% of the Indus, 16.6% of the Jhelum basin and overall 14.6% of the UIB region. This land can be developed through kuhl systems subject to availability of sufficient water resources. The glacier-melt was found >8.0 liters/sec/hectare in the Karakoram basins, i.e., Hunza, Shigar and Shyok, and within 4.0-8.0 lps/ha in the Chitral and Astore river basins. The scarcity of land and water was found (one at a time or both at once) at certain locations which may impact agricultural productivity in the region. In places with limited land for farming opportunities, the basis of livelihoods can be broaden through diversifying income sources, e.g. availing off-farm and nonlocal income opportunities. However, while framing adaptation process, the socio-political complexity of the area should be taken into account, as optimum integration of natural and socioeconomic aspects would ensure sustainable development in this high altitude region in future.

Time, cost and carbon-efficiency: a silver lining of COVID era virtual urology clinics?

INTRODUCTION

The COVID-19 pandemic has demanded radical changes in service delivery. Our centre adopted the use of outpatient telemedicine to reduce close-contact interactions between patients and staff. We hypothesised that incidental gains may be associated with this. We evaluated financial, practical and environmental implications of substituting virtual clinics (VCs) for in-person urology outpatient appointments.

METHODS

VCs were studied over a 3-month period. Based on patient-reported 'usual mode of transport' to the hospital, travel distance, time, petrol and parking costs, and the carbon emissions avoided by virtue of remote consultations were calculated. The underlying symptom/diagnosis and the 'effectiveness' of the VC were evaluated.

RESULTS

Of 1,016 scheduled consultations, 736 (72.44%) were conducted by VCs over the study period. VCs resulted in an agreed treatment plan in 98.4% of a representative patient sample. The use of VCs was associated with an overall travel distance saving for patients of 31,038 miles (49,951km) over 3 months, with an average round-trip journey of 93.8 miles (151km) avoided for each rural-dwelling patient and an average financial saving of £25.91 (€28.70) per rural-dwelling car traveller. An estimated 1,257.8 hours of patient time were saved by avoidance of travel and clinic waiting times. Based on car-travelling patients alone, a 6.07-tonne reduction in carbon emissions was achieved with the use of VCs.

CONCLUSIONS

In appropriate clinical circumstances, VCs appear to provide efficiency across a number of domains. Future healthcare may involve offering outpatients the option of telemedicine as an alternative to physical attendance.

Endoxifen: A new, protein kinase C inhibitor to treat acute and mixed mania associated with bipolar I disorder

OBJECTIVES

Endoxifen is a protein kinase C inhibitor. The objective of the present phase III study was to demonstrate the safety and efficacy of endoxifen in treating bipolar I disorder (BPD I) patients.

METHODS

A multicenter, double-blind, active-controlled study was conducted using a daily dose of 8 mg endoxifen compared to 1000 mg divalproex, the current standard treatment, in patients with BPD I acute manic episodes with/without mixed features. The primary endpoint of our study was the mean change in total Young Mania Rating Scale (YMRS) score at day 21.

RESULTS

Endoxifen (n = 116) significantly (p < 0.0001) reduced total YMRS score (from 33.1 to 17.8. A significant (p < 0.001) improvement in Montgomery-Åsberg Depression Rating Scale (MADRS) score was observed for endoxifen (4.8 to 2.5). Early time to remission of the disease was observed with endoxifen compared to divalproex. None of the patients required rescue medication and there was no drug-associated withdrawals. Changes in Clinical Global Impressions-Bipolar Disorder and Clinical Global Impression-Severity of Illness scores showed that treatment with endoxifen was well-tolerated.

CONCLUSIONS

Endoxifen at a low daily dose of 8 mg was as efficacious and safe in patients with BPD I acute manic episodes with/without mixed features.

Clinical Efficacy of a Novel Lipid-based Thymoquinone Gel: A Two-arm, Single-blinded, and Randomized Study

Objective:

To evaluate the clinical efficacy of topical 0.1% lipid-based Thymoquinone (TQ) gel, as an antiplaque and antigingivitis agent.

Materials and Methods:

A randomized clinical trial was carried out in the Outpatient Department of Pediatric and Preventive Dentistry, Dr. Z.A. Dental College, India with a purposive sample of 60 healthy children of 12–18 years of age, having a gingival and plaque index ≥1; the children were divided into two groups by simple randomization. Group A (30 subjects) was advised to apply peanut amount of Chlorhexidine (CHX) gel, twice a day for 2min. Group B (30 subjects) was advised the same but with a peanut amount of 0.1% lipid-based TQ gel. The clinical parameters were the recording of plaque and gingival indices, prior to the treatment (baseline) and at the 14th and 28th day, respectively (post-treatment). The total duration of the study was 28 days with follow-up.

Results:

Data analysis was done by employing IBM Statistical Package for Social Sciences Windows software, version 20 (IBM Corp, Armonk, NY, USA). The 0.1% lipid-based TQ gel had a statistically significant reduction (P < 0.001) in plaque index as compared with CHX gel during the 0–14th day and 0–28th day, respectively. Similarly, 0.1% lipid-based TQ gel showed a statistically significant reduction in gingival index (P = 0.005) during the 0–14th day and a statistically significant reduction during the 0–28th day (P < 0.001), as compared with CHX gel.

Conclusions:

Statistically significant reduction in plaque (P < 0.001) and gingival index (P < 0.001) with the usage of 0.1% lipid-based TQ gel.

Impact of granulocyte-colony stimulating factor on docetaxel-induced febrile neutropenia in patients with breast cancer

BACKGROUND

Febrile neutropenia (FN) is a life-threatening complication of Docetaxel-based chemotherapy regimens (DBRs). Prophylactic granulocyte-colony stimulating factor (G-CSF) can reduce the risk of FN. This study investigated the effect of G-CSF on FN in patients receiving DBRs for breast cancer.

METHODS

Patients treated between 2015 and 2017 were identified from the hospital's pharmacy database and their medical records were examined retrospectively. Data from patients' first four cycles of DBR were collected. FN rate, FN associated length of hospital stay (FN-LOS), and chemotherapy dose modification/delay due to FN were compared between patients who did (G-CSF group) or did not (non-GCSF group) receive prophylactic G-CSF.

RESULTS

Of the 276 included patients, 83.3% received a DBR as adjuvant or neoadjuvant therapy, and 50% received docetaxel as combination therapy. Prophylactic G-CSF was administered with the first cycle of a DBR in 69.9% of patients who were significantly less likely to experience FN compared to the non-G-CSF group (6.2% vs. 15.7%; odds ratio: 0.36 [95% CI: 0.16-0.82]; p = 0.020). Collectively and after the 4 DBR treatment cycles, FN rate (4.8 vs. 8.5; odds ratio: 0.54 [95% CI: 0.30-0.97]; p = 0.043) and the mean FN-LOS (3.55 vs. 5.28 days; t = -2.22; p = 0.037) were reduced in the G-CSF group. There was no difference in DBR dose delay/reduction between both groups in cycles 2-4.

CONCLUSION

In patients receiving DBRs for breast cancer, prophylactic G-CSF significantly reduced both the rate of FN and duration of hospitalization for FN.

"Osteomyelitis of mandible"-a rare presentation of osteopetrosis

Osteopetrosis is a rare metabolic disease. Dental abnormalities may be attributed to the pathological changes in osteopetrosis. Patients with disease seem to be especially susceptible to osteomyelitis of mandible. A 9 yrs old girl presented with complaints of jaw swelling on left side with multiple discharging sinuses since last seven months. The radiograph of left mandible (oblique lateral view) showed periodontal involvement of associated molars with loss of lamina dura with small sequestrum with irregularity and erosions of the mandibular cortical margins. The patient was diagnosed as a case of osteopetrosis with superadded mandibular osteomyelitis.

Influence of respiratory protective equipment on simulated advanced airway skills by specialist tracheal intubation teams during the COVID-19 pandemic

Background

The COVID-19 pandemic has highlighted the importance of respiratory protective equipment for clinicians performing airway management.

Aim

To evaluate the impact of powered air-purifying respirators, full-face air-purifying respirators and filtering facepieces on specially trained anaesthesiologists performing difficult airway procedures.

Methods

All our COVID-19 intubation team members carried out various difficult intubation drills: unprotected, wearing a full-face respirator, a filtering facepiece or a powered respirator. Airway management times and wearer comfort were evaluated and analysed.

Results

Total mean (SD) intubation times did not show significant differences between the control, the powered, the full-face respirator and the filtering facepiece groups: Airtraq 6.1 (4.4) vs. 5.4 (3.1) vs. 6.1 (5.6) vs. 7.7 (7.6) s; videolaryngoscopy 11.4 (9.0) vs. 7.7 (4.3) vs. 9.8 (8.4) vs. 12.7 (9.8) s; fibreoptic intubation 16.6 (7.8) vs.13.8 (6.7) vs. 13.6 (8.1) vs. 16.9 (9.2) s; and standard endotracheal intubation by direct laryngoscopy 8.1 (3.5) vs. 6.5 (5.6) vs. 6.2 (4.2) vs. 8.0 (4.4) s, respectively. Use of the Airtraq achieved the shortest intubation times. Anaesthesiologists rated temperature and vision significantly better in the powered respirator group.

Conclusions

Advanced airway management remains unaffected by the respiratory protective equipment used if performed by a specially trained, designated team. We conclude that when advanced airway skills are performed by a designated, specially trained team, airway management times remain unaffected by the respiratory protective equipment used.