Clinical outcome and survival in 30 pulmonary hypertension patients with high severity indices and advanced functional class

BACKGROUND

Pulmonary hypertension (PH) is an idiopathic or secondary disorder associated with many systemic illnesses. Long-term survival in PH depends on the severity and functional class. Several new drugs are now available to treat PH, but their impact on clinical outcome and survival are not well established.

OBJECTIVES

Evaluate severity parameters and the impact of current recommended therapy on survival in PH.

DESIGN

Cross-sectional.

SETTINGS

Tertiary care center.

PATIENTS AND METHODS

The study included adult patients who had undergone right heart catheterization since 2012 and were diagnosed with pulmonary hypertension. Survival was recorded after 6 years, at the end of the study. Nine severity variables for PH were assessed including right ventricular size by echocardiogram and pulmonary artery diameter (PA diameter) and the ratio of pulmonary artery diameter to ascending aorta diameter (PA/Ao ratio) by CT.

MAIN OUTCOME MEASURES

Evaluation of severity parameters.

SAMPLE SIZE

30 patients.

RESULTS

Twenty-five patients were positive for 8/9 severity parameters. Eight of 30 (26.6%) patients died. In nonsurvivors, right ventricular size was increased by 25% ( P=.427), pulmonary vascular resistance increased by 29.4% in nonsurvivors ( P=.302), the 6-minute walk distance decreased by 21% ( P=.875), median brain natriuretic peptide increased by 96% ( P=.890), median GGT and alkaline phosphatase were 3 times higher in nonsurvivors ( P=.893 and P=.047, respectively) and PA/Ao was nonsignificantly decreased in nonsurvivors ( P=.373), Survival was decreased by a median of 2.3 years in nonsurvivors.

CONCLUSION

Our study identified a subgroup of PH patients with NYHA functional class III and above with worsening severity indicators who were labeled as a high-risk group. These patients showed continuous deterioration in their clinical status despite escalation of therapy with current guidelines. We recommend these high-risk group patients be referred for early lung transplantation.

LIMITATIONS

Low sample size and only a single center. Needs confirmation with a larger multicenter trial.

CONFLICT OF INTEREST

None.

Efficacy of second-line chemotherapy after a first-line triplet in patients with metastatic colorectal cancer

BACKGROUND

Exposing patients with metastatic colorectal cancer (mcrc) to all three active chemotherapeutic agents (oxaliplatin, irinotecan, fluorouracil) has improved survival. The benefit of second-line chemotherapy after a first-line triplet is not clearly defined. We evaluated the efficacy of second-line chemotherapy in patients who had received first-line triplet therapy.

METHODS

The medical records of patients treated on a prospective trial of first-line triplet therapy were reviewed for second-line treatment. Univariate and multivariate analyses were performed to establish factors of prognostic significance.

RESULTS

Of the 53 patients who received first-line triplet therapy, 28 (53%) received second-line chemotherapy [13 men; 8 with a colon primary; mutant KRAS in 10, wild-type in 15, and unknown status in 3; Eastern Cooperative Oncology Group performance status (ps) of 1 in 16 patients, ps 2 in 3, ps 3 in 2, and unknown in 7; involved organs: liver in 17 patients, lung in 16, and peritoneum in 8]. Second-line chemotherapy consisted of xelox or folfox in 13 patients, xeliri or folfiri in 12, and single-agent irinotecan in 3. Concurrent bevacizumab was given in 16 patients (57%), and cetuximab, in 2 (7%). Median survival was 28.0 months [95% confidence interval (ci): 22.8 months to 33.2 months] for patients receiving second-line therapy and 23.0 months (95% ci: 13.2 months to 32.8 months) for those not receiving it. Best response was partial in 6 patients (21%), stable disease in 11 (39%), and progressive disease in 11 (39%). Median progression-free survival was 4.8 months (95% ci: 2.4 months to 9.6 months), and overall survival was 15 months (95% ci: 9.6 months to 20.4 months).

CONCLUSIONS

Second-line chemotherapy after first-line triplet therapy in mcrc is feasible and suggests efficacy comparable to that reported for second-line therapy after a doublet, regardless of the agent used.

Unrelated cord blood transplantation in pediatric patients: a report from Saudi Arabia

In unrelated cord blood (UCB) transplantation, survival has been shown to correlate with the degree of HLA matching. Thus, to extend transplant access to different ethnic backgrounds, many western UCB transplantation banks now encourage donation from non-Caucasians. Until recently, Saudi Arabia did not have a national UCB bank. In this study we report our experience in UCB transplantation in children using units procured from western cord blood banks. A total of 97 children underwent unrelated UCB transplantation at King Faisal Specialist Hospital and Research Center (KFSHRC), of which 95 were of Arab ethnicity. A total of 30 patients had malignant disorders, 25 patients had non-malignant hematological disorders and 42 patients had inborn errors. Conditioning was according to disease, with six patients receiving reduced-intensity regimens. In all, 46 patients received one-Ag-mismatched units and 51 received two-Ag-mismatched units. Engraftment occurred in 93% of patients, the 100-TRM was 15%, acute GVHD developed in 20% of patients and chronic GVHD occurred in 9% of patients. The 5-year OS and EFS estimates were 52 and 43%, respectively. The search for UCB transplantation units for Saudi patients in western banks yielded reasonably compatible units for our patients; the results are consistent with published data. Our data are encouraging for UCB transplant programs in countries in which there are no national UCB transplantation banks.

Inflammatory, hemostatic, and clinical changes in a baboon experimental model for heatstroke

The mortality and neurological morbidity in heatstroke have been attributed to the host's inflammatory and hemostatic responses to heat stress, suggesting that immunomodulation may improve outcome. We postulated that an experimental baboon model of heatstroke will reproduce human responses and clinical outcome to allow testing of new therapeutic strategies. Eight anesthetized juvenile baboons (Papio hamadryas) were subjected to heat stress in an incubator maintained at 44-47 degrees C until rectal temperature attained 42.5 degrees C (moderate heatstroke; n = 4) or systolic arterial pressure fell to <90 mmHg (severe heatstroke; n = 4) and were allowed to recover at room temperature. Four sham-heated animals served as a control group. Rectal temperature at the end of heat stress was 42.5 +/- 0.0 and 43.3 +/- 0.1 degrees C, respectively. All heat-stressed animals had systemic inflammation and activated coagulation, indicated by increased plasma IL-6, prothrombin time, activated partial thromboplastin time, and D-dimer levels, and decreased platelet count. Biochemical markers and/or histology evidenced cellular injury/dysfunction: plasma levels of thrombomodulin, creatinine, creatine kinase, lactic dehydrogenase, and alanine aminotransferase were increased, and varying degrees of tissue damage were present in liver, brain, and gut. No baboon with severe heatstroke survived. Neurological morbidity but no mortality was observed in baboons with moderate heatstroke. Nonsurvivors displayed significantly greater coagulopathy, inflammatory activity, and tissue injury than survivors. Sham-heated animals had an uneventful course. Heat stress elicited distinct patterns of inflammatory and hemostatic responses associated with outcome. The baboon model of heatstroke appears suitable for testing whether immunomodulation of the host's responses can improve outcome.