Approach to Lymphoma-Associated Cardiomyopathy

Cardiomyopathy is a disease of the myocardium that affects the heart structure and function, eventually resulting in heart failure, valvular regurgitation, arrhythmia, or even sudden cardiac death. Occurring following treatment of lymphoma, both Hodgkin's and Non-Hodgkin's, cardiomyopathy is a feared complication in these cancer survivors due to its significant association with morbidity and mortality. A review of the literature was conducted using a combination of keywords including "Cardiomyopathy," "Anthracycline," "Radiation," "Pathogenesis," and "Management." Anthracyclines and radiation are prominent entities explored in the discussion of lymphoma-associated cardiomyopathy, whereby the formation of reactive oxygen species following treatment with both has been seen in the pathogenesis. The current standard of care thus far for anthracycline-induced cardiomyopathy includes heart failure medications such as beta-blockers, angiotensin-converting enzyme inhibitors, aldosterone receptor antagonists, and loop-diuretics. On the other hand, radiation-induced cardiomyopathy management has not been well-established yet in literature, with agents such as antioxidants and anti-inflammatory drugs still being studied in rat models. The treatment approach to cardiotoxicity in a lymphoma patient should consist of a collaboration between the oncologist and cardiologist prior to lymphoma treatment initiation, to stratify the risk of development of cardiomyopathy in the patient, and decide the best chemotherapy or radiotherapy agent, dosing, and surveillance technique.

Survey of rectal cancer MRI technique and reporting tumour descriptors in the UK: a multi-centre British Society of Gastrointestinal and Abdominal Radiology (BSGAR) audit

AIM

To evaluate variation in magnetic resonance imaging (MRI) technique and reporting of rectal cancer staging examinations across the UK.

MATERIALS AND METHODS

A retrospective, multi-centre audit was undertaken of imaging protocols and information documented within consecutive MRI rectal cancer reports between March 2020 and August 2021, which were compared against American and European guidelines. Inclusion criteria included histologically proven rectal adenocarcinoma and baseline staging MRI rectum only.

RESULTS

Fully anonymised data from 924 MRI reports by 78 radiologists at 24 centres were evaluated. Thirty-two per cent of radiologists used template reporting, but these reports offered superior documentation of 13 out of 18 key tumour features compared to free-text reports including T-stage, relation to peritoneal reflection and mesorectal fascia (MRF), nodal status, and presence of extramural venous invasion (EMVI; p<0.027 in each). There was no significant differences in the remaining five features. Across all tumour locations, the tumour relationship to the MRF, the presence of EMVI, and the presence of tumour deposits were reported in 79.5%, 85.6%, and 44% of cases, respectively, and tumour, nodal, and distant metastatic stage documented in 94.4%, 97.7%, and 78.3%. In low rectal tumours, the relationship to the anal sphincter complex was reported in only 54.6%.

CONCLUSION

Considerable variation exists in rectal cancer MRI acquisition and reporting in this sample of UK centres. Inclusion of key radiological features in reports must be improved for risk stratification and treatment decisions. Template reporting is superior to free-text reporting. Routine adoption of standardised radiology practices should now be considered to improve standards to facilitate personalised precision treatment for patients to improve outcomes.

A Young Man With a Neck Mass and Hypereosinophilia

A 31-year-old man presented with left cervical and left inguinal masses and intermittent itching and night sweats for 2 years. What is your diagnosis?

The role of diffusion-weighted MRI in the accurate diagnosis of vertebral compression fractures: A comparative study

INTRODUCTION

Accurately distinguishing between benign and malignant vertebral compression fractures is crucial for clinical management. This study evaluated the predictive accuracy of diffusion-weighted imaging (DWI) in differentiating the cause of vertebral fractures using MRI.

METHODS

A longitudinal cross-over study was conducted at Jinnah Postgraduate Medical Centre (JPMC) Karachi from July 2018 to January 2021. Patients with vertebral compression fractures underwent T1-weighted, T2-weighted, and DWI imaging with ADC mapping on a 1.5 T MRI scanner. Imaging findings were compared with histopathologic results and clinical follow-up. Sensitivity, specificity, and ROC curve analyses were performed.

RESULTS

The study enrolled 303 patients with a mean age of 43.6 ± 10.9 years, of whom 118 were male. DWI demonstrated high accuracy in predicting the cause of vertebral compression fractures, with a sensitivity of 96.2 %, a specificity of 76.2 %, and an area under the ROC curve of 0.857. The optimal ADC cut-off value was 0.82 × 10˄-3 mm˄2/s, which yielded a positive predictive value of 79.7 % and a negative predictive value of 95.4 %.

CONCLUSIONS

DWI is a safe and non-invasive imaging modality with excellent predictive accuracy in differentiating between benign and malignant vertebral compression fractures. Iso- or hypointensity of collapsed vertebral bodies on DWI suggests a benign lesion, while T2-weighted hyperintensity is highly indicative of malignancy. Low signal on ADC is also highly indicative of malignant vertebral fractures. Incorporating DWI improves accuracy in assessing vertebral lesions, especially when standard sequences are inconclusive.

IMPLICATIONS FOR PRACTICE

DWI revolutionizes vertebral compression fracture diagnosis, distinguishing between benign and malignant cases. This precision guides treatment decisions, minimizing the necessity for invasive procedures like biopsy. As a safe and reliable imaging method, DWI elevates patient care, ensuring accurate diagnostics and improved outcomes.

Post-diagnostic statin use and its association with cancer recurrence and mortality in breast cancer patients: a systematic review and meta-analysis

BACKGROUND

Statins are widely acknowledged for their application in patients with hypercholesterolemia to reduce cardiovascular morbidity and mortality. More recently, their potential to exert pleiotropic effects, particularly in impeding the proliferation of neoplastic cells, has attracted considerable attention. Prior studies have demonstrated that statins may mitigate cancer progression and micrometastasis. However, the benefits of statins in breast cancer have been inconclusive.

OBJECTIVE

The aim of this meta-analysis was to evaluate the impact of statin use following a breast cancer diagnosis on breast cancer recurrence and mortality.

METHODS

We performed a systematic literature search using PubMed, Embase, and Scopus for relevant articles from inception until 30th May 2023. Hazard ratios (HR) were pooled using a random-effect model. The primary outcome of interest was the risk of breast cancer recurrence. The secondary outcomes included breast cancer-specific mortality and all-cause mortality.

RESULTS

A total of 15 studies with 156 448 patients were included in the final analysis. The mean age of patients between statin users and non-users was 64.59 and 59.15 years, respectively. Statin use was associated with a reduction in the recurrence of breast cancer [HR 0.76, 95% confidence interval (CI): 0.67-0.87] compared with non-statin users. This trend was similar among lipophilic statin users (HR 0.73, 95% CI: 0.63-0.85) but not for hydrophilic statin users (HR 1.17, 95% CI: 0.82-1.68). Furthermore, statin users exhibited a lower risk of breast cancer mortality (HR 0.80, 95% CI: 0.66-0.96) but all-cause mortality (HR 0.82, 95% CI: 0.66-1.02) was comparable among both groups of patients. Conversely, lipophilic statins demonstrated a reduction in both all-cause mortality (HR 0.84, 95% CI: 0.75-0.93) and breast cancer mortality (HR 0.85, 95% CI: 0.74-0.99) compared to non-statin users.

CONCLUSION

Among patients with breast cancer, statin use post-diagnosis decreases the risk of breast cancer recurrence and breast cancer mortality. Furthermore, lipophilic statins exhibit an additional advantage of reduction in all-cause mortality.PROSPERO registration: CRD42022362011.

Narrative Review of Probiotic Use on the Recovery of Postoperative Patients with Esophageal Cancer

PURPOSE OF REVIEW

This narrative review discusses the significance of probiotic therapy in the postoperative care of patients with esophageal cancer and its role as an adjunct therapy to other treatment modalities for esophageal cancer.

RECENT FINDINGS

As such, there is an emerging need to address any malnutrition and gastrointestinal problems occurring in these patients which tend to have a strong negative impact on their prognosis. Probiotic effects on esophageal cancer biomarkers suggest that there is a positive correlation between these two factors. However, the beneficial effects remain controversial and warrant further investigation. Probiotics, now being widely utilized as postoperative therapy in some carcinomas of the gastrointestinal tract such as gastric cancer and colorectal cancer, have been shown in some clinical studies to positively impact the nutritional status of patients with esophageal cancer. Postoperative care among patients suffering from esophageal cancer is a very crucial aspect in the survival of these patients.

Efficacy of lenvatinib versus sorafenib in the primary treatment of advanced hepatocellular carcinoma: A meta-analysis

Background and Aim

Molecular-targeted agents such as lenvatinib and sorafenib have been approved to treat hepatocellular carcinoma (HCC). However, the choice between these two agents in the primary treatment for advanced HCC is still under debate with conflicting results. We sought to evaluate the efficacy of lenvatinib and sorafenib in patients with HCC.

Methods

We performed a systematic literature search using PubMed, Embase, and Scopus for relevant articles from inception until February 10, 2023. The primary outcome of this meta-analysis was overall survival (OS). The secondary outcomes were progression-free survival (PFS), time to progression, objective response rate (ORR), and disease control rate (DCR).

Results

A total of 13 studies with 3705 patients (1635 on lenvatinib and 2070 on sorafenib) were included in our analysis. The mean age of the patients in both groups was comparable (66.81 vs 65.9 years). Pooled analysis of primary outcomes showed that, compared with sorafenib, lenvatinib was associated with significantly better OS in patients treated with these drugs (HR 0.82, 95% CI: 0.69-0.97, P = 0.02). Pooled analysis also showed that PFS (HR 0.67, 95% CI: 0.57-0.78, P < 0.00001) and time to progression (HR 0.49, 95% CI: 0.31-0.79; P = 0.004) were significantly better in the lenvatinib group compared to the sorafenib group. It also showed that the lenvatinib group had significantly better ORR (odds ratio [OR] 5.43, 95% CI: 3.71-7.97; P < 0.00001) and DCR (OR 2.35, 95% CI: 1.75-3.16; P < 00001) than the sorafenib group.

Conclusion

Our study shows that lenvatinib is superior to sorafenib regarding OS and PFS in patients with advanced HCC.

Cardiac amyloidosis and aortic stenosis: a state-of-the-art review

Cardiac amyloidosis is caused by the extracellular deposition of amyloid fibrils in the heart, involving not only the myocardium but also any cardiovascular structure. Indeed, this progressive infiltrative disease also involves the cardiac valves and, specifically, shows a high prevalence with aortic stenosis. Misfolded protein infiltration in the aortic valve leads to tissue damage resulting in the onset or worsening of valve stenosis. Transthyretin cardiac amyloidosis and aortic stenosis coexist in patients > 65 years in about 4-16% of cases, especially in those undergoing transcatheter aortic valve replacement. Diagnostic workup for cardiac amyloidosis in patients with aortic stenosis is based on a multi-parametric approach considering clinical assessment, electrocardiogram, haematologic tests, basic and advanced echocardiography, cardiac magnetic resonance, and technetium labelled cardiac scintigraphy like technetium-99 m (99mTc)-pyrophosphate, 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid, and 99mTc-hydroxymethylene diphosphonate. However, a biopsy is the traditional gold standard for diagnosis. The prognosis of patients with coexisting cardiac amyloidosis and aortic stenosis is still under evaluation. The combination of these two pathologies worsens the prognosis. Regarding treatment, mortality is reduced in patients with cardiac amyloidosis and severe aortic stenosis after undergoing transcatheter aortic valve replacement. Further studies are needed to confirm these findings and to understand whether the diagnosis of cardiac amyloidosis could affect therapeutic strategies. The aim of this review is to critically expose the current state-of-art regarding the association of cardiac amyloidosis with aortic stenosis, from pathophysiology to treatment.

Association between heart failure and the incidence of cancer: a systematic review and meta-analysis

Aims

The association between heart failure (HF) patients and the incidence of cancer is not well understood, with conflicting results to date. The aim of this meta-analysis was to evaluate whether patients with HF have a higher risk of developing cancer.

Methods and results

We performed a systematic literature search using PubMed, Embase, and Scopus for relevant articles from inception until 10 December 2022. The primary clinical outcome was the incidence of cancer. Secondary endpoints were the incidence of breast cancer, lung cancer, haematological cancer, colorectal cancer, and prostate cancer. A total of 9 articles with 7 329 706 (515 041 HF vs. 6 814 665 non-HF) patients were involved in the analysis. The mean age of the patients in the HF and the non-HF groups was 69.06 and 66.76 years. The median follow-up duration was 6.7 years. The most common comorbidity among both groups includes diabetes mellitus (27.58 vs. 14.49%) and hypertension (81.46 vs. 57.38%). Patients with HF were associated with a significant increase in the incidence of cancer {hazard ratio [HR], 1.43 [95% confidence interval (CI): 1.21-1.68], P < 0.001}, breast cancer [HR, 1.28 (95% CI: 1.09-1.50), P < 0.001], lung cancer [HR, 1.89 (95% CI: 1.25-2.85), P < 0.001], haematological cancer [HR, 1.63 (95% CI: 1.15-2.33), P = 0.01], and colorectal cancer [HR, 1.32 (95% CI: 1.11-1.57), P < 0.001] compared with patients without HF. However, the incidence of prostate cancer was comparable between both groups [HR, 0.97 (95% CI: 0.66-1.43), P = 0.88].

Conclusion

This meta-analysis confirms that the state of HF is associated with a higher risk for incident cancer. These data may aid in raising awareness with physicians that cancer may develop in patients with prevalent heart failure and that early screening and evaluation may be useful in an early diagnosis of cancer.

Association between nonalcoholic fatty liver disease and atrial fibrillation and other clinical outcomes: a meta-analysis

The association between nonalcoholic fatty liver disease (NAFLD) with cardiovascular and cerebrovascular outcomes, as well as their clinical impact, has yet to be established in the literature. This meta-analysis aims to evaluate the association between the NAFLD patients and the risk of atrial fibrillation (AF), heart failure (HF), stroke, cardiovascular mortality (CVM), and revascularization incidence. We performed a systematic literature search using PubMed, Embase, Scopus, and Cochrane libraries for relevant articles from inception until August 2022. A total of 12 cohort studies with 18,055,072 patients (2,938,753 NAFLD vs 15,116,319 non-NAFLD) were included in our analysis. The mean age of the NAFLD patients group and the non-NAFLD group was comparable (55.68 vs 55.87). The most common comorbidities among the NAFLD patients group included hypertension (38% vs 24%) and diabetes mellitus (14% vs 8%). The mean follow-up duration was 6.26 years. The likelihood of AF (risk ratio (RR), 1.42 (95% CI 1.19, 1.68), p < 0.001), HF (RR, 1.43(95% CI 1.03, 2.00), p < 0.001), stroke (RR, 1.26(95% CI 1.16, 1.36), p < 0.001), revascularization (RR, 4.06(95% CI 1.44, 11.46), p = 0.01), and CVM (RR, 3.10(95% CI 1.43, 6.73), p < 0.001) was significantly higher in the NAFLD patients group compared to that of the non-NAFLD group. However, all-cause mortality was comparable between both the groups of patients (RR, 1.30 (95% CI 0.63, 2.67), p = 0.48). In conclusion, the patients with NAFLD are at increased risk of AF, HF, and CVM.

Imaging manifestations of IgG4-related disease

IgG4-related disease is a multisystem immune-mediated disorder associated with lesions manifesting an IgG4-rich plasma cell infiltrate and often raised serum IgG4 concentrations. The disease can mimic neoplastic, infective, and inflammatory processes due to features such as development of masses or organ enlargement. Prompt consideration of this diagnosis is essential to avoid unnecessary investigations and offer appropriate treatments, which can include steroids and other immunosuppressive agents. Although histology is typically diagnostic, imaging is critical to assess disease burden, determine biopsy targets, and evaluate response to treatment. Characteristic imaging features can also point towards the diagnosis in the absence of biopsy. This review highlights these features, as well as more atypical findings, grouped by organ or system. Differential diagnoses are emphasised. The full spectrum of imaging methods is discussed. Whole-body imaging with integrated 2-[18F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography (PET)/computed tomography (CT) has an evolving role in the detection of multi-organ involvement and subsequent follow-up.

A Challenging Diagnosis Of Rare Co-Existent Multiple Myeloma And Prostate Adenocarcinoma: A Systematic Review Of Case Reports

Objective

To review biochemical parameters, clinical characteristics, demographics, radiological and histopathological findings, treatment modalities and outcomes used to examine patients with coexisting multiple myeloma and prostate adencocarcinoma.

METHODS

The systematic review comprised search on PubMed, Google Scholar, Science Direct and the Directory of Open Access Journal databases for case reports published till June 1, 2022. The search was done in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using appropriate key words. Case reports included were those dealing exclusively with human subjects, were published in the English language and had free, full-text, public access. Quality assessment was done using Joanna Briggs Institute's Critical Appraisal Checklist for Case Reports. Data was extracted and the case reports were evaluated for demographic, diagnostic and treatment parameters.

RESULTS

Of the 515 studies initially identified, 5(0.97%) were analysed; all males with mean age 68.6±10.78 years. The most common symptom reported at presentation was low back pain 3(60%), Osteolytic lesions were seen in 4(80%) patients on imaging with elevated prostate surface antigen levels. Anaemia was found in 3(60%) patients and 2(40%) had thrombocytopenia.

Conclusion

Multiple myeloma and prostate adenocarcinoma can coexist although it is rare. Awareness regarding the possible coexistence of the two prominent cancer types may further help clinicians during their practice in considering multiple myeloma as a differential diagnosis when encountered with patients having osteolytic bony lesions along with elevated levels of prostate-specific antigen.

PROSPERO Registration Number

CRD42022334906.

Waldenström macroglobulinemia: a review of pathogenesis, current treatment, and future prospects

Waldenström macroglobulinemia (WM) is a chronic B-cell lymphoproliferative disorder characterized by lymphoplasmacytic cell overgrowth in the bone marrow and increased secretion of IgM immunoglobulins into the serum. Patients with WM have a variety of clinical outcomes, including long-term survival but inevitable recurrence. Recent advances in disease knowledge, including molecular and genetic principles with the discovery of MYD88 and CXCR4 mutations, have rapidly increased patient-tolerable treatment options. WM patients may benefit from chemotherapy regimens that include rituximab-based regimens, alkylating drugs, proteasome inhibitors, monoclonal antibodies, and drugs targeting Bruton tyrosine kinase inhibitors. In light of these advancements, patients can now receive treatment customized to their specific clinical characteristics, focusing on enhancing the depth and durability of their response while limiting the adverse effects. Despite the rapidly developing therapeutic armament against WM, a lack of high-quality evidence from extensive phase 3 trials remains a significant challenge in the research. We believe clinical outcomes will keep improving when new medicines are introduced while preserving efficacy and minimizing toxicity.

Recent Advances in Association Between Vitamin D Levels and Cardiovascular Disorders

PURPOSE OF REVIEW

In this review, we discuss the evidence that vitamin D affects cardiovascular disease through interventional and observational studies and their corresponding association mechanisms. We also highlight the need for further research to definitively conclude clinical recommendations based on preliminary data and determine the extent to which vitamin D levels may impact the incidence and prognosis of major cardiovascular diseases in the future.

RECENT FINDINGS

Cardiovascular disease has long been recognized as the leading cause of morbidity and mortality worldwide, with many risk factors implicated in its pathogenesis. Vitamin D is a risk factor that, despite being known to be crucial for its role in maintaining bone health, also has several extra-skeletal effects due to vitamin D receptors in vascular smooth muscle and cardiomyocytes. Recent studies have documented a significant association between higher vitamin D levels and lower risk of each cardiovascular disease entity; 11 studies between serum vitamin D and heart failure, 7 studies between serum vitamin D and hypertension, 8 studies between serum vitamin D and coronary artery disease, and 5 studies between serum vitamin D and atrial fibrillation. More studies documenting a significant association between increased serum vitamin D and cardiovascular disease are in the context of heart failure compared to hypertension, coronary artery disease, and atrial fibrillation. Conversely, a significant association between increased serum vitamin D and a lower risk of atrial fibrillation is reported in fewer studies compared to the association of vitamin D with other cardiovascular disease entities. Although there is evidence documenting a clear significant association of vitamin D under each category, further research is still needed to definitively conclude the role of vitamin D in cardiovascular disease management.

Breast Cancer Diagnosis and Survival among Patients Diagnosed by a Structured Community Based Screening Program Compared to Opportunistic Diagnosis: A Case Control Study

INTRODUCTION

Breast cancer is ranked as the most common type of cancer effecting women worldwide. Early detection is associated with improved morbidity and mortality, along with decreased recurrence rates, due to regular breast cancer screening recommendations advised for women over the age of 40. Women in the Kingdom of Saudi Arabia (KSA) typically present with advanced symptoms at later stages due to lower-than-average rates of breast cancer awareness and screening.

METHODS

A case-control study was conducted utilizing data collected over 20 years in the primary care clinics linked to at a tertiary hospital to demonstrate the role of structured breast cancer screening programs within well-established primary care setting. Results were compared with outcomes of cancer cases diagnosed in the community through opportunistic diagnosis.

RESULTS

A total 292 patients included in the study had an overall mean survival time of 160 months, with a statistically significant higher survival time noted amongst the primary care group of 49 patients (p<0.01) by approximately 85 months. Clinical stages and clinical response rates between the two patient groups were found to be statistically significant (p<0.01), where 35 (73.3%) primary care patients were stage IIA and below, compared to 41 (30%) oncology patients. Patients who were diagnosed with breast cancer in the primary care group with well-established breast cancer screening programs were noted to present with breast cancer at earlier stages, have better prognosis and lower mortality as opposed to the oncology patient group.

CONCLUSION

Our study highlights the of structured breast cancer screening programs within well supported primary health services in Saudi Arabia and the region. Such programs were associated with improved survival outcomes and more favorable clinical responses. There is an urgent need to enable primary care services with the appropriate resources to significantly impact patient morbidity and mortality.

Monoclonal Gammopathy of Undetermined Significance: A Comprehensive Review

Monoclonal Gammopathy of Undetermined Significance (MGUS) is an asymptomatic premalignant plasma cell dyscrasia with a predominate rise of the IgG immunoglobulin fraction without end-organ damage, often diagnosed incidentally. Despite its progression into various subsequent forms of hematological malignancies, MGUS remains underdiagnosed. A literature search was conducted using the Medline, Cochrane, Embase, and Google Scholar databases, including articles published until December 2022. Keywords used encompassed "Monoclonal Gammopathy of Undetermined Significance," "Plasma Cell dyscrasia," "Monoclonal gammopathy of renal significance," and "IgM Monoclonal gammopathy of Undetermined Significance," This study aimed to conduct a critical review to update knowledge regarding the pathophysiology, risk factors, clinical features, diagnostic protocols, complications, and current and novel treatments for MGUS. We recommend a multidisciplinary approach to manage MGUS due to the complexity of the illness's etiology, diagnosis, and therapy. This comprehensive review also highlights future prospects, such as developing screening protocols for at-risk populations, prevention of disease progression by early diagnosis through genome-wide association studies, and management using Daratumumab and NSAIDs.

Artificial intelligence in pancreatic cancer: diagnosis, limitations, and the future prospects-a narrative review

PURPOSE

This review aims to explore the role of AI in the application of pancreatic cancer management and make recommendations to minimize the impact of the limitations to provide further benefits from AI use in the future.

METHODS

A comprehensive review of the literature was conducted using a combination of MeSH keywords, including "Artificial intelligence", "Pancreatic cancer", "Diagnosis", and "Limitations".

RESULTS

The beneficial implications of AI in the detection of biomarkers, diagnosis, and prognosis of pancreatic cancer have been explored. In addition, current drawbacks of AI use have been divided into subcategories encompassing statistical, training, and knowledge limitations; data handling, ethical and medicolegal aspects; and clinical integration and implementation.

CONCLUSION

Artificial intelligence (AI) refers to computational machine systems that accomplish a set of given tasks by imitating human intelligence in an exponential learning pattern. AI in gastrointestinal oncology has continued to provide significant advancements in the clinical, molecular, and radiological diagnosis and intervention techniques required to improve the prognosis of many gastrointestinal cancer types, particularly pancreatic cancer.

COVID-19 Ramifications: A Scientific Approach to Bridge the Existing Gap between COVID Vaccines Hesitancy and Effectiveness

The 2019 coronavirus disease (COVID-19) has been a major dilemma all over the world since December 2019. Several types of COVID-19 vaccines were developed for public utilization to halt the widespread of the disease; however, vaccine hesitancy is one major factor that prevents a successful control of this pandemic. This study aimed to summarize the different kinds of available COVID-19 vaccines and their effectiveness, and to assess the associated factors regarding vaccine hesitancy of the general population to bridge the gap existing between the two factors.1 3

The racial disparity among post transcatheter aortic valve replacement outcomes: A meta-analysis

Background

Racial disparities have been well described in cardiovascular disease. However, the impact of race on the outcomes post - Transcatheter aortic valve replacement (TAVR) remains unknown.

Objective

We aim to evaluate the disparity among the race (black and white) post - TAVR.

Methods

We systematically searched all electronic databases from inception until September 26, 2022. The primary outcome was in-hospital all-cause mortality, and secondary outcomes was myocardial infarction (MI), acute kidney injury (AKI), permanent pacemaker implantation (PPI) or ICD, stroke, vascular complications, and major bleeding.

Results

A total of three studies with 1,02,009 patients were included in the final analysis. The mean age of patients with white and black patients was 82.65 and 80.45 years, respectively. The likelihood of in-hospital all-cause mortality (OR, 1.01(95 %CI: 0.86-1.19), P = 0.93), stroke (OR, 0.83(95 %CI:0.61-1.13), P = 0.23, I2 = 46.57 %], major bleeding [OR, 1.05(95 %CI:0.92-1.20), P = 0.46), and vascular complications [OR, 0.92(95 %CI:0.81-1.06), P = 0.26), was comparable between white and black patients. However, patients with white race have lower odds of MI (OR, 0.65(95 %CI:0.50-0.84), P < 0.001), and AKI (OR, 0.84(95 %CI:0.74-0.95), P = 0.01) and higher odds of PPI or ICD (OR, 1.16(95 %CI: 1.06-1.27), P < 0.001, I2 = 0 %) compared with black race patients.

Conclusion

Our findings suggest disparity post - TAVR outcomes existed, and black patients are at higher risk of MI and AKI than white patients.Key Clinical Message:•What is already known on this topic: Disparity has been witnessed among patients with cardiovascular disease. However, no studies have drawn a significant association among post-TAVR patients' outcomes•What this study adds: Among patients who underwent TAVR, there is a difference in the adverse outcomes between black and white race patients. White patients have a lower risk of post-procedure MI and AKI compared with Black patients.•How this study might affect research, practice, or policy: These disparities need to be addressed, and proper guidelines need to be made along with engaging patients with better medical infrastructure and treatment options..

Factors Influencing International Collaboration on the Prevention of COVID-19

Objectives

Study design

Methods

Results

Conclusion

Recent advances in Lewy body dementia: A comprehensive review

Lewy Body Dementia is the second most frequent neurodegenerative illness proven to cause dementia, after Alzheimer's disease (AD). It is believed to be vastly underdiagnosed, as there is a significant disparity between the number of cases diagnosed clinically and those diagnosed via neuropathology at the time of postmortem autopsy. Strikingly, many of the pharmacologic treatments used to treat behavioral and cognitive symptoms in other forms of dementia exacerbate the symptoms of DLB. Therefore, it is critical to accurately diagnose DLB as these patients require a specific treatment approach. This article focuses on its pathophysiology, risk factors, differentials, and its diverse treatment modalities. In this study, an English language literature search was conducted on Medline, Cochrane, Embase, and Google Scholar till April 2022. The following search strings and Medical Subject Headings (MeSH) terms were used: "Lewy Body Dementia," "Dementia with Lewy bodies," and "Parkinson's Disease Dementia." We explored the literature on Lewy Body Dementia for its epidemiology, pathophysiology, the role of various genes and how they bring about the disease, biomarkers, its differential diagnoses and treatment options.

Cancer survivorship in gulf countries: A systematic review

e24046

Background: Cancer survivors have been increasing worldwide due to advancements in early cancer detection, chemo-hormonal therapy, and improved supportive care with an estimated four-to-five-fold increase in cancer burden in Gulf countries by the year 2040. Cancer survivorship deals with the host of challenges that cancer leaves in its wake. We seek to explore the experience of Gulf countries' cancer survivors and identify the gaps that need to be addressed. Methods: A systematic review of current evidence regarding cancer survivorship in the 6 Gulf countries (inclusive of Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates) was conducted according to the PRISMA 2020 checklist, without restricting to a starting date. We searched five major online databases: Embase, Cochrane, PubMed, SciELO, and Web of Science. Twenty-two articles were reviewed for the inclusion of predefined domains of cancer survivorship (Nekhlyudov et al, JNCI 2019). Results: Most of the studies included were published in Saudi Arabia (63.6%), followed by UAE (13.6%), Oman (9.1%), Bahrain (4.5%), Kuwait (4.5%), and Qatar (4.5%). Data within the included studies encompassed 9 domains of survivorship, of which clinical structure was reported most consistently (95.5%), followed by surveillance and management of physical and psychosocial effects (77.3% and 68.2% respectively). The most frequently reported domain, clinical structure, refers to the type of healthcare delivery environment offered, patient education, availability of necessary specialty care and subsequent healthcare professionals, access to care, the functionality of available healthcare information systems (e.g., electronic medical records and telehealth) and whether opportunities for research participation was offered to patients. Comparatively, the three domains health promotion (27%), patient experience (27%), and surveillance and management of chronic medical conditions (13%) were reported least frequently. Conclusions: Cancer survivorship in Gulf countries is currently in its infancy, evidenced by a paucity of literature on the topic. This systematic review assesses domains explored by available studies, finding a significant focus on clinical structure. Gaps in literature particularly within the surveillance and management of chronic medical conditions in cancer survivor patients need to be addressed in future research.[Table: see text]

Non-pharmacological integrative therapies for chronic cancer pain

Objective

Chronic pain is one of the most detrimental symptoms exhibited by cancer patients, being an indication for opioid therapy in up to half of the patients’ receiving chemotherapy and in 90% of advanced cases. Various successful non-pharmacological integrative therapy options have been explored and implemented to improve the quality of life in these patients. This review aims to highlight the mechanisms implicated; assessment tools used for cancer pain and summarize current evidence on non-pharmacological approaches in the treatment of chronic cancer pain.

Data sources

A review of the literature was conducted using a combination of MeSH keywords including “Chronic cancer pain,” “Assessment,” “Non-pharmacological management,” and “Integrative therapy.”

Data summary

Data on the approach and assessment of chronic cancer pain as well as non-pharmacological integrative options have been displayed with the help of figures and tables. Of note, non-pharmacological integrative management was divided into three subcategories; physical therapy (involving exercise, acupuncture, massage, and transcutaneous electric nerve stimulation), psychosocial therapy (e.g. mindful practices, supportive therapy), and herbal supplementation.

Conclusions

The use of non-pharmacological integrative therapy in the management of chronic cancer pain has been grossly underestimated and must be considered before or as an adjuvant of other treatment regimens to ensure appropriate care.

Insulin analogs in the treatment of type II diabetes and future perspectives

The discovery of insulin by Banting and Best marked 100 years in 2021, and it was a life-saving treatment modality for type II diabetes mellitus (T2DM). Insulin is a natural hormone that has been used extensively in T2DM patients since its discovery. Currently, insulin analogs are also available in different formulations for T2DM management, overcoming the limitations of human insulin with better safety and side effect profiles. The insulin analogs like the rapid-acting analogs (Aspart, lispro, glulisine), the long-acting basal analogs (Glargine, detemir), the ultra-long acting (Insulin degludec), and the premixed insulin analog formulations (75% Neutral protamine lispro, 25% lispro; 50% neutral protamine lispro, 50% lispro; 70% protamine aspart, 30% aspart) have been prepared through genetic engineering while preserving the basic insulin profile. A large number of studies have demonstrated their clinical effects on glycated hemoglobin test (HbA1c) in achieving glycemic control and thereby lowering the microvascular and macrovascular complications of T2DM with less traditional side effects of regular human insulin, mainly the risk of hypoglycemia, postprandial glycemic excursions, and weight gain. This review explores the currently available insulin analogs, their clinical implications, pharmacokinetics (PK), pharmacodynamics (PD), safety profile, and cost-effectiveness. We also discuss the future developments in the management of T2DM, especially the scientific advancements surrounding the novel insulin formulations, including the biosimilar insulin, and the innovative insulin delivery methods, such as oral and inhaled insulin.

A cross sectional survey on the effect of COVID-19 related restrictions on undergraduate and postgraduate medical education in Qatar

BACKGROUND

COVID-19 pandemic has affected all dimensions of day to day life across the world and medical education was no exception. With this study, we aimed to understand the effect of nationwide restrictions on medical education in Qatar, the models of education adopted during this period and perceptions of participants to the same.

METHODS

We conducted a cross-sectional study utilizing an online questionnaire distributed via convenience sampling between April-October 2020. Study participants were faculty and trainees in governmental undergraduate and postgraduate medical education institutes. Two sets of questionnaires were designed for each group. They were asked a series of questions to assess pre- and post-COVID pandemic educational practices, their preferred teaching methods, and their familiarity with electronic teaching platforms. Faculty respondents were asked about their perceived barriers to delivery of medical education during the pandemic and their agreement on a 5-point Likert scale on specific elements. Trainees were asked a series of multiple-choice questions to characterize their pre- and post-COVID pandemic educational experiences. Both groups were asked open-ended questions to provide qualitative insights into their answers. Data were analysed using STATA software version 12.0.

RESULTS

Majority of trainees (58.5%) responded that the pandemic has adversely affected medical education at both the undergraduate and postgraduate levels. Trainees (58.5%) and faculty (35.7%) reported an increased reliance on e-learning. Trainees preferred face-to-face education, while faculty preferred a combination of models of education delivery (33.5% versus 37.1%, p = 0.38). Although 52.5% of the faculty had no previous experience of delivering education through e-learning modalities, 58.9% however felt confident in using e-learning software.

CONCLUSIONS

Faculty and trainees agree that the COVID-19 pandemic has had a significant impact on the provision of medical education and training in Qatar, with an increased dependence on e-learning. As trainee's prefer face-to-face models of education, we may have to consider restructuring of medical curricula in order to ensure that optimum learning is achieved via e-learning, while at the same time enhancing our use, knowledge and understanding of the e -learning methods. Further research is warranted to assess if these changes have influenced objective educational outcomes like graduation rates or board scores.

Performance of cell-free tumor DNA testing for 101 clinical laboratories on College of American Pathologists proficiency tests

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Background: Cell-free tumor DNA or circulating tumor DNA tests are increasingly used in clinical care to detect somatic mutations from solid tumors. However, data on laboratory performance characteristics using standardized samples is limited. Methods: Well-characterized reference materials were used for the College of American Pathologists (CAP) cell-free tumor DNA proficiency testing surveys, which consisted of stabilized DNA fragmented to simulate cell-free DNA in a synthetic plasma matrix. For the 2018A, 2018B, 2019A and 2019B surveys, laboratories tested for hotspot mutations (single and dinucleotide sequence changes) in EGFR, BRAF, KRAS, NRAS, and IDH1 at variant allele fractions ranging from 0.1% - 1.0%. As per CAP proficiency testing standards, results were scored according to the known mutation(s) engineered at designated variant allele fractions in each PT sample. Nine laboratories were excluded from analysis because they provided incomplete results. Statistical significance was calculated using a multivariate logistic regression model. Results: In 2018 and 2019, 101 laboratories submitted survey results for at least one proficiency testing mailing. There were 5088 total proficiency testing responses for EGFR, BRAF, KRAS, NRAS, and IDH1 mutations across 12 different samples. For the 3585 responses submitted for BRAF, KRAS, NRAS, and IDH1, sensitivity ranged from 94.6 – 100%, while specificity exceeded 99%. There were no significant differences in performance between analytical methodologies for BRAF, KRAS, NRAS, and IDH1 mutations. Performance characteristics for EGFR mutations among the 1503 responses showed a combined sensitivity of 87.1% and specificity of 98.7%. For laboratories detecting mutations in EGFR, next-generation sequencing methods exhibited a sensitivity (true positivity) of 95.7% while the sensitivity of non-NGS methods was lower at 81.7% ( P= 0.02). Conclusions: These findings demonstrate high sensitivity and specificity for clinical laboratories performing cell-free tumor DNA tests. For EGFR mutations, NGS outperformed non-NGS methods. These data suggest excellent overall agreement among laboratories performing clinical cell-free tumor DNA tests. Further investigation across variant allele fractions and additional variant types is warranted.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Role of water chemistry and stabilizers on the Vero-cells-based infectivity of Newcastle disease virus live vaccine

Newcastle disease virus (NDV) live vaccines are supplied in lyophilized form and usually administered through conventional routes (drinking water, spray, or eye drop) following reconstitution in a diluent. Virus inactivation due to physico-chemical properties of the diluent at the time of administration may lead to vaccine failure. The present study aimed to evaluate the survival of NDV live vaccine strain immersed in 5 pH-amended water samples (pH 5.00, pH 6.00, pH 7.00, pH 8.00, and pH 9.00) by sequential determination of virus infectivity on Vero cells for 3 hours. Minimum reduction in virus infectivity was recorded in the water with neutral or slightly alkaline pH, while the virus was relatively less stable at extreme pH conditions. Maximum reduction of infectivity was observed in the water with pH 9.00 in which the virus was completely inactivated within 3 hours. Addition of stabilizers (Cevamune^® or skimmed milk) slightly altered the pH and total dissolved solids (TDS) values of the virus-charged water samples. In the stabilizer-added water samples, minimum reduction in infectivity was observed in the water with neutral pH, followed by the ones with a pH of 8.00, 6.00, 5.00, and 9.00. In all types of water samples, T-90 values (time required for 90% reduction in virus infectivity) were highest (485 minutes) at neutral pH (pH 7.00) and lowest (102 to 134 min) at an extreme alkaline condition (pH 9.00). Results of the present study indicate that water with a pH range of 7.00 to 8.00 is suitable for administration of NDV live vaccines. However, the addition of Cevamune^® or skimmed milk may have beneficial effects on preserving the infectivity of the virus, even at extreme pH conditions.

Health-related quality of life in healthy children and adolescents of HIV-infected parents in Alexandria, Egypt

BACKGROUND

Egypt as part of the Eastern Mediterranean region is facing a growing HIV epidemic. Developments in the National HIV Program are associated with an increase in survival of HIV-positive persons. This study aimed to assess health-related quality of life (HRQOL) of healthy children/adolescents of HIV-positive parents compared with healthy children/adolescents of healthy HIV-negative parents.

MATERIALS AND METHODS

A cross-sectional comparative study was conducted. Healthy children aged 3-17 years old of all HIV-positive parents registered in the national HIV treatment center in Alexandria Fever Hospital during the year 2016 were enrolled (n=33) and compared with a comparable group of children of healthy parents (n=33). The HRQOL of studied groups was assessed by interviewing parents using Kinder Lebensqualität Fragebogen questionnaire revised parents' version.

RESULTS

Among the HIV-positive persons, 54.5% of their children had poor to fair HRQOL compared with only 9.1% of children of healthy parent group. They had significantly lower HRQOL scores in the physical, mental, family, and friends domains (P<0.05). Adolescents of HIV-positive parents had significantly lower HRQOL score compared with children (P=0.028). Parents' education was the only independent predictor of daughter/son's HRQOL (b=13.073, P=0.014).

CONCLUSION

HIV-positive status of parents negatively affects the HRQOL of their children. Development of organized social and mental support services to families with HIV-affected member/s within the Egyptian National HIV program is highly recommended with specific focus on adolescents and children, especially those having lower educated parents.

A phase Ib/II study of imatinab and everolimus in patients with PDGFRA+ synovial sarcoma

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Background: Our group previously reported that PDGFRA is the most highly overexpressed kinase gene in synovial sarcoma. Our preclinical studies also demonstrated synergistic anti-tumor activity by inhibiting both PDGFRA and mTOR signaling with imatinib and rapamycin respectively in PDGFRA + synovial sarcoma cell lines. Based on these data, a phase Ib/II study to evaluate the toxicity and efficacy of imatinib and everolimus was undertaken. Methods: The primary endpoint of the phase 1b portion of the study was to determine the maximum tolerated dose (MTD) of everolimus administered with imatinib. Starting dose of everolimus and imatinib was 5 mg/day and 400 mg/day respectively. Response rate (RR) by RECIST was the primary end-point of the Phase II study. The phase II study used a Simon two stage design. 9 patients (pts) were to be accrued initially. If there were no responses, further accrual would be stopped and treatment declared ineffective. If there was at least 1 response, an additional 15 pts would be accrued for a total of 24. Key eligibility: metastatic disease, any number of priors. Pre and post treatment tumor biopsies were mandated. Results: 12 pts were treated.5 M and 7 F, median age 44 (range: 22-71), median priors 4 (range: 0 - 6). Two DLTs were observed at dose level 2 (10 mg everolimus /400 mg imatinib) with grade 3 transaminases and hypophosphatemia. Everolimus 5 mg/ imatinib 400 mg was the MTD in the phase II study. 10 pts evaluable for response, included 4 pts treated at the MTD in the Phase 1b study. There were no RECIST responses. Stable disease was observed in 3 pts (7, 7, 19 mos.). Western blot and IHC analysis of matched pair tumor biopsies indicate inhibition of p-AKT, p-S6 and decreases in Ki 67. Conclusions: Imatinib and everolimus failed to achieve its primary response endpoint. However, prolonged stable disease in 3 pts in association with inhibition of PDGFRA and mTOR suggest clinical benefit and biological effect for this drug combination. Clinical trial information: CTEP 8603.

Pancreatic injuries after blunt abdominal trauma: an analysis of 110 patients treated at a level 1 trauma centre

BACKGROUND AND OBJECTIVE

Injuries to the pancreas are uncommon, but may result in considerable morbidity and mortality. This study evaluated the management of blunt pancreatic injuries using a previously defined protocol to determine which factors predicted morbidity and mortality.

METHODS

The study design was a retrospective chart review of all adult patients with blunt pancreatic injuries treated at a level 1 trauma centre between March 1981 and June 2009.

RESULTS

One hundred and ten patients (92 men, 18 women; mean age 30 years, range 13-68 years) were treated during the study period. Forty-six patients had American Association for the Surgery of Trauma (AAST) grade 1 or 2 pancreatic injuries and 64 had AAST grade 3, 4 or 5 pancreatic injuries. Injuries involved the head (N=21), neck (N=15), body (N=48) and tail (N=26) of the pancreas. The mean number of organs injured was 2.7 per patient (range 1-4). One hundred and one patients underwent a total of 123 operations, including drainage of the pancreatic injury (N=73), distal pancreatectomy (N=39) and Whipple resection (N=5). The overall complication rate was 74.5% and the mortality rate 16.4%. Only 2 of the 18 deaths were attributable to the pancreatic injury. Shock on presentation was highly predictive of death; 17 of 39 patients with shock died, compared with 1 of 71 patients who were not shocked (p < 0.0001). Fourteen of 46 patients with grade 1 and 2 pancreatic injuries died compared with 4 of 64 patients with grades 3, 4 and 5 injuries (p < 0.001). Mortality increased exponentially as the number of associated injuries increased. Two of 57 patients with injury to the pancreas only or one associated injury died, compared with 16 of 53 with two or more associated injuries (p < 0.0013).

CONCLUSIONS

This study demonstrated a significant correlation between the AAST grade of injury and pancreas-specific morbidity and between shock on admission, the number of associated injuries and death, in patients with blunt pancreatic injuries. Although morbidity and mortality rates after blunt pancreatic trauma are high, death was usually the result of major associated injuries and not related to the pancreatic injury.