Resource Oriented Decision Making for Treatment of Metastatic Colorectal Cancer (mCRC) in a Lower-Middle Income Country: Egyptian Foundation of Medical Sciences (EFMS) Consensus Recommendations 2020

Purpose

Colorectal cancer (CRC) is the third most commonly diagnosed cancer worldwide and the second cause of cancer related mortality. Treatment options for patients with metastatic CRC (mCRC) expanded during the last two decades, with introduction of new chemotherapeutic and targeted agents. Egypt is a lower middle-income country; Egyptian health care system is fragmented with wide diversity in drug availability and reimbursement policies across different health care providing facilities. We report the results of consensus recommendations for treatment of patients with metastatic colorectal cancer developed by Egyptian Foundation of Medical Sciences (EFMS), aiming to harmonize clinical practice through structured expert consensus-based recommendations consistent with the national status. EFMS recommendations could be utilized in other countries with similar economic status.

Methods

EFMS recommendations were developed using a modified Delphi process, with three rounds of voting till the final recommendations were approved. A non-systematic review of literature was conducted before generating the provisional statements. Content experts were asked to vote on some recommendations in two different resource groups (restricted resources and non-restricted resources). External review board of experts from a low income and lower-middle countries voted on the applicability of EFMS recommendations in their countries.

Results

The current recommendations highlighted the discrepancy in health care between restricted and non-restricted resources with expected survival loss and quality of life deterioration. Access to targeted agents in first line is very limited in governmental institutions, and no access to agents approved for third line in patients who failed oxaliplatin and irinotecan containing regimens for patients treated in restricted resource settings.

Conclusion

Management of mCRC in developing countries is a challenge. The currently available resource-stratified guidelines developed by international cancer societies represent a valuable decision-making tool, adaptation to national status in each country based on healthcare system status is required.

Cognitive dysfunction among patients referred for transcatheter aortic valve implantation: results of the Montreal Cognitive Assessment and clinical impact at 6 months

Background

Detection of Cognitive Dysfunction (CD) is not routinely performed among patients undergoing Transcatheter Aortic Valve Implantation (TAVI). We sought to determine whether CD has an impact on the clinical course of these patients, during hospitalization at the time of TAVI and up to 6 months afterwards.

Methods

The MoCA was performed before TAVI by an experienced operator in an unselected population of patients referred for TAVI. CD was defined according to the MoCA score: No CD if score ≥26, mild CD if score 18–25, moderate if 10–17 and severe if <10. Multivariate Cox logistic regression analysis was used to determine the impact of CD on procedural success of TAVI, length of stay, 6 month survival, re-admission, and change in clinical status (changes in NYHA class and/or functional status).

Results

MoCA was performed in 83 consecutive patients. TAVI was performed using femoral access and local anesthesia in all patients. There were no procedural deaths, and 2 deaths at 6 months. The median age was 85 years, and median Euroscore I was 11.62. The median MOCA score was 22, CD was excluded in 17 (20%), mild in 50 (60%), moderate in 15 (18%) and severe in one patient. No difference was observed in rate of procedural success, 6 month mortality, re-admission, degree of dyspnea by NYHA between the different cognitive groups. Length of stay after the TAVI procedure was lower in patients without CD, compared to those with CD at any level: 3±1 days versus 4.3±1 days, p=0.045, and p=0.02 by multivariate analysis (figure).

Conclusion

Among patients referred for TAVI, mild or moderate CD was observed in 80% of patients. Patients without CD had a shorter length of stay at the time of TAVI, but CD was not associated with worse prognosis or clinical status at 6 months.

Funding Acknowledgement

Type of funding sources: None.

Assessment of cognitive dysfunction using the Montreal Cognitive Assessment test: rate, severity and comparison with the Clock test alone in a population of patients referred for TAVI

Background

Although not recommended in routine practice, the detection and quantification of Cognitive Dysfunction (CD) in older patients might have an impact on clinical decisions. We assessed the rate and severity of CD in an unselected population of patients referred for Transcatheter Aortic Valve Implantation (TAVI) using the Montreal Cognitive Assessment (MoCA) and using the Clock Drawing Test (ClockT) alone.

Methods

The MoCA was performed before TAVI by an experienced operator. The ClockT was scored out of 10 points according to the Rouleau rating scale. CD was defined according to the MoCA score: No CD if score ≥26, mild CD if score 18–25, moderate if 10–17 and severe if <10. Inter-observer reliability of scoring on the ClockT was estimated with the Bland-Altman method. Agreement between MoCA scores and the ClockT for ruling out and for detecting CD were measured with the Kappa coefficient.

Results

MoCA was performed in 83 consecutive patients referred for TAVI, median age 85 years. The mean time required for assessment was 11±2 min for the MoCA and 3±2 min for the ClockT. The mean MoCA score was 21±4.5: CD was excluded in 17 (20%) pts, mild CD was found in 50 (60%), moderate in 15 (18%) and severe in one (1%). The median ClockT score was 8 (interquartile 6; 9), with excellent inter-observer concordance (Kappa= 0.84). Overall, 51% of the variance of the MoCA score was explained by the ClockT alone according to multiple regression. A ClockT <7 detected a group with significantly lower MoCA score, compared to pts with higher ClockT scores (figure).

Conclusion

Among patients referred for TAVI, CD can be excluded using the MoCA test in 20%, while moderate or severe CD is observed in 18%. The ClockT alone is faster to implement, reliable to interpret and enabled detection of patients with moderate CD when Rouleau scoring was <7.

Funding Acknowledgement

Type of funding sources: None.

[Single-use versus reusable flexible ureteroscope: Technical and medico-economic aspects]

INTRODUCTION

Sate of the art on the indications, methods of implementation and medico-economic considerations of reusable flexible ureteroscopes (URSr) vs single use (URSuu)?

METHOD

Review of the literature (Pubmed) on reusable and single-use ureteroscopes, as well as on the expertise of our center. A PubMed search and narrative review of the data was performed in July 2021. Only articles in French or English were selected.

RESULTS

The URSr and URSuu have similar technical characteristics and are suitable for the exploration of the upper urinary excretory tract: treatment of stones of the kidney <2cm or of the ureter. The URSr is the most common type of ureteroscope. URSuu are newer and associated with many advantages: no sterilization procedure, immediate availability of equipment in the operating room, reduced waste production at the institutional level. A hybrid use of URSr and URSuu currently seems to be the best compromise from a medico-economic point of view for high volume centers. In the case of a smaller activity or a secondary site, URSuu are more advantageous and the reduction in purchasing costs should accentuate this benefit.

CONCLUSION

URSr and URSuu are technically similar and allow identical treatment of upper urinary tract pathologies. Their complementary use optimizes the care of urology patients. The barrier to the exclusive use of URSuu remains their cost.

Micro RNA-148a Targets Bcl-2 in Patients with Non-Small Cell Lung Cancer

OBJECTIVE

Lung cancer is one of the most prevalent cancers and the leading cause of cancer-related deaths worldwide. MicroRNAs regulate more than 60% of human genes, including tumor suppressor genes and oncogenes. Accordingly, they can affect cancer risk. This study aimed to evaluate the role of serum miR-148a as a non-invasive biomarker in non-small cell lung cancer (NSCLC) patients and to assess the correlation between miR-148a and Bcl-2, as one of its target proteins.

MATERIALS AND METHODS

A total of 50 newly diagnosed NSCLC cases and 30 apparently healthy controls were recruited in this study. MiR-148a level was measured by TaqMan- Real time RT-PCR assay and Bcl-2 level was measured by ELISA.

RESULTS

Significant lower expression of serum miR-148a and higher serum Bcl-2 levels were observed in NSCLC patients as compared to the control group (p.

Cardiotoxicity with immune system targeting drugs: a meta-analysis of anti-PD/PD-L1 immunotherapy randomized clinical trials

Background: With antiprogrammed death receptor-1 (anti-PD-L1) therapy, a recent meta-analysis reported higher incidence of cutaneous, endocrine and gastrointestinal complications especially with dual anti-PD-L1 immunotherapy (IMM). Methods: Our primary outcome was assessment of all cardiotoxicity grades in IMM compared with different treatments, thus a systemic review and a meta-analysis on randomized clinical trials (RCTs) were done. Results: We included 11 RCTs with 6574 patients (3234 patients in IMM arm vs 3340 patients in the other arm). Three non-small-cell lung cancer RCTs, seven melanoma RCTs and only one prostatic cancer RCT met the inclusion criteria. There were five RCTs that compared monoimmunotherapy to chemotherapy "(n = 2631 patients)". No difference exists in all cardiotoxicity grades or high-grade cardiotoxicity (p > 0.05). Lung cancer exhibited a higher response rate and lower mortality in IMM. Conclusion: There was no reported statistically significant cardiotoxicity associated with anti-PD/PD-L1 use. Lung cancer subgroups showed better response and survival rates.

Pneumonitis as a complication of immune system targeting drugs?-a meta-analysis of anti-PD/PD-L1 immunotherapy randomized clinical trials

Background

Anti-PD/PD-L1-targeted immunotherapy is associated with remarkably high rates of durable clinical responses in patients across a range of tumor types, although their high incidence of skin, gastrointestinal, and endocrine side effects with their use. The risk of pneumonitis associated with checkpoint inhibition therapy is not well described.

Methods

A systematic review of the literature was conducted on randomized clinical trials (RCTs) comparing anti-PD/PD-L1 mono-immunotherapy (IMM) to chemotherapy (CTH) protocols in cancer patients. The primary endpoint was the pneumonitis rate in IMM compared to CTH. Secondary endpoints were (I) high-grade pneumonitis rate in IMM compared to CTH and (II) tumor response rate, progression-free survival (PFS), and overall survival (OS) between IMM and CTH. Random model and leave-one-out-analysis were performed.

Results

Thirteen RCTs studying 7,246 patients were included; 3,704 (51.12%) patients in the IMM arm and 3,542 (48.88%) patients in the chemotherapy arm. Seven non-small cell lung cancer (NSCLC) RCTs were included with 4,164 patients; 2,101 in the IMM arm and 2,063 patients in the CTH arm. Three RCTs were on melanoma patients (n=1,390). Nine RCTs compared mono-immunotherapy to CTH [docetaxel in 5 studies (38.5%), platinum-based in 2 studies (15.4%), dacarbazine in 1 study (7.7%) and everolimus in 1 study]. Both high-grade and all-grade pneumonitis were higher among patients in the IMM arm when compared to the CTH arm (OR =4.39, 95% CI: 1.65-11.69, P=0.003 and OR =2.46, 95% CI: 1.29-4.6, P=0.007). Tumor response rate was significantly better in the immunotherapy arm (OR =2.31, 95% CI: 1.62-3.29, P<0.001). PFS and OS were longer in patients who received IMM compared to patients in the CTH arm (HR =0.75, 95% CI: 0.65-0.85, P<0.001, and HR =0.71, 95% CI: 0.66-0.77, P<0.001).

Conclusions

The incidence of high-grade and all-grade pneumonitis is higher in anti-PD-1 therapy but not in anti-PD-L1 therapy when compared to traditional CTH regimens for NSCLC and melanoma. High-grade adverse events were otherwise more common in the CTH arm. Tumor response rate, PFS, and OS are all substantially improved with IMM over CTH. These results can be used to guide therapy selection and set expectations for treatment effect in these patients.

Contributing factors to the outcome of primary malignant chest wall tumors

Background

Primary malignant chest-wall tumors (PMCWTs) are a heterogeneous group of tumors. They require a special experience in designing resection and reconstruction. They account for less than 1% of all primary malignant tumors. This study is designed to clarify different factors contributing to the outcome of patients with PMCWTs in our institution.

Methods

A retrospective study included 98 patients with pathology proven PMCWTs, treated at the National Cancer Institute (NCI), Cairo University, Egypt, during the past 10 years. Used variables were: age, sex, forced expiratory volume in the 1^st second (FEV1), site, size, multiplicity, pathologic subtype, tumor grade, safety margin (SM), excised ribs, complications, estimated blood loss (EBL), neo-adjuvant and adjuvant treatments, Overall and disease free survival (DFS) were obtained using Kaplan-Meier method and compared using Log rank test. Cox regression was used to identify DFS predictors.

Results

PMCWTs represented 10.5% of all thoracic malignancies in our institution. There were 51 females (52%). The median age was 39 years [interquartile range (IQR) =25-52.3)] years. Chondrosarcoma was the commonest tumor histology (20.4%). The median tumor size was 8 cm (IQR =5-14). Tumor multiplicity was found in 18.4% of patients. Bone resection was performed in 76 patients (78.3%), ribs resection was performed in 59 patients and the median number of resected ribs per patient was 3 (IQR =1-3) ribs. Sternal resection was done in 7 (7.1%) cases. R0 resection was achieved in 62.2% of patients. There was one operative related mortality (1.02%) and 17.3% patients suffered procedure related complications. Local recurrence developed in 35 (35.7%) patients. The overall survival (OS) at 1, 3 and 5 years was 73.9%, 45.6% and 34.6% respectively and the median OS was 33 months (95% CI, 21.8-44.2), while median DFS was 24 months (95% CI, 19.6-28.4). Predictors of better DFS were -ve SM (P<0.001), tumors <5 cm (P=0.039), low grade (P=0.033), lower EBL (P=0.003) and absence of adjuvant therapy (P=0.007); however, on multivariate analysis, only -ve SM was the only predictor (HR =0.54; 95% CI, 0.29-0.97, P=0.041).

Conclusions

In primary malignant CWTs (PMCWTs) achievement of wide resection margins is of great importance to minimize the local tumor recurrence that will have an adverse impact on long-term survival.

Translation in Arabic, adaptation and validation of the SF-36 Health Survey for use in Tunisia

OBJECTIVE

To translate into Arabic and validate the SF-36 quality of life index in a Tunisian Arabic population.

BACKGROUND

No validated Arabic quality of life index is published.

DESIGN

Arabic translation of the SF-36 scale was obtained by the "forward/backward translation" method. Adaptations were made after a pilot study involving 22 subjects from general population. Inter-rater reliability was assessed by use of intraclass correlation coefficient (ICC) and Bland and Altman method. Construct validity was assessed by Spearman rank correlation coefficient (convergent and divergent validity), and factor analysis with Varimax rotation. Internal consistency was assessed by Cronbach alpha coefficient.

RESULTS

We note that 130 Tunisian subjects were included in the validation study. No items were excluded. Inter-rater reliability was excellent (ICC=0.98). Cronbach alpha coefficient was 0.94 conferring to translated index a good internal consistency. Expected divergent and convergent validity results suggested good construct validity. Two main factors were extracted by factor analysis and explained 62.3% of the cumulative variance: the first factor represented mental component, the second physical component. The Cronbach alpha coefficient was 0.88 and 0.91 respectively for factor 1 and factor 2.

CONCLUSION

We translated into Arabic language and adapted the SF-36 scale for use in Tunisian population. The Arabic version is reliable and valid. Although the scale was validated in a Tunisian population, we expect that it is suitable for other Arab populations, especially North Africans. Further studies are needed to confirm such a hypothesis.

Tête tombante fixée : efficacité d'une rééducation intensive

OBJECTIVES

To point out the diagnostic and etiologic context of neck extensor weakness and to consider orthopedic and rehabilitation treatment of dropped head syndrome.

METHODS

We report a case of a 68-year-old hospitalized woman with atypical and serious idiopathic neck extensor weakness who was treated by orthopedic measurements and intensive rehabilitation.

RESULTS

Our patient had progressive neck extensor weakness and total inflection of the cervico-cephalic axis over two years. Fixed and permanent contact of the chin and the sternum severely affected her ability to eat, and mandibular and sternal pressure ulcers developed. Cervical spine radiography revealed degenerative lesions. Other clinical and biological parameters were normal. Atypical idiopathic head drop was diagnosed because of painful and fixed head position. Rehabilitation consisted of cervical traction with a halo apparatus during eight weeks and an exercise programme based on cervical proprioception and muscular work. Orthopedic management consisted of cervical collar immobilization after cutaneous cicatrization. After ten weeks of treatment, the patient was able to raise her head and maintain it horizontally. Two years later, clinical results were stable.

DISCUSSION

Neck extensor weakness may be the presenting feature of several neuromuscular disorders. Generally, idiopathic dropped head syndrome appears to be the most likely diagnosis in patients with isolated neck extensor involvement. For our patient, clinical findings and cervical computed tomography showed important muscular weakness. However, painful passive extension and progressive stiffness of the neck do not represent the typical clinical course of idiopathic head drop. Neither degenerative lesions of the cervical spine nor other joint diseases can cause head drop. This case may result from the combined effects of idiopathic dropped head syndrome and cervical arthrosis. Orthopedic treatment and intensive rehabilitation had spectacular effects. Clinical management of head drop syndrome should always consist of orthopedic and rehabilitation treatment.

Traduction en arabe et étude des qualités métrologiques de l'indice de Lequesne sur une population de gonarthrosiques nord-africains

OBJECTIVE

To translate in Arabic and validate the Lequesne index for use in Tunisian.

BACKGROUND

No instrument wording in Arabic language and validated in an Arab population to measure lower limb functional disability caused by OA.

DESIGN

Arab translation was obtained using the "forward translation/backward translation" method. Adaptations were made after a pilot study. Patients with symptomatic knee osteoarthritis fulfilling the revised criteria of the American College of Rheumatology were included. Impairment outcome measures (VAS pain; knee mobility; Kellgren's radiological score); disability (the maximum distance walked; WOMAC index) and Beck depression scale were recorded. Inter rater reliability was assessed using the intra-class correlation coefficient (ICC) and the Bland and Altman method. Construct validity was investigated using the Spearman rank correlation coefficient (convergent and divergent validities) and a factor analysis was performed. Internal consistency of each factor was assessed by Crohnbach alpha coefficient.

RESULTS

One hundred and three patients were included. All questions were acceptable and retained. Inter rater reliability was excellent with ICC = 0.91. The Bland and Altman method showed distribution of differences homogenous and no systematic trend. Expected divergent validity and convergent validity were observed, suggested good construct validity. Two main factors were extracted by factor analysis of the Lequesne, and explained more than 55% of the cumulative variance, the first factor represents disability and the second represents pain and stiffness. Crohnbach alpha coefficient was, respectively, 0.68 for factor 1 and 0.54 for factor 2. In conclusion, we translated and adapted the Lequesne index into Arabic to suit Tunisian people. Translated questionnaire is reliable and valid. Although the scale was validated in a Tunisian population, we expect that it can suit other Arab populations especially North Africans. Further studies are needed to confirm such hypothesis.

Preliminary data on seasonally related alcohol dependence

BACKGROUND

The purpose of the study was to examine whether some individuals who report alcohol dependence consistently deteriorate during the fall and winter months. We also explored whether this deterioration could be attributed to seasonal affective disorder.

METHOD

Veterans Administration inpatients were administered a screening questionnaire concerning seasonal patterns in alcohol use and other variables. Those who suggested a fall-winter pattern were interviewed.

RESULTS

Six individuals were identified who met criteria for seasonal alcohol dependence (based on DSM-III-R criteria for seasonal depression). Two case summaries are provided.

CONCLUSION

Evaluation for seasonal affective disorder may be warranted in alcoholic patients. In such cases, light therapy may prove a useful adjunct to conventional treatment.

Guilt feelings and locus of control of concentration camp survivors

The present study compared concentration camp survivors and controls from the same ethnic and religious background on two variables: guilt feelings in everyday life and locus of control. No significant differences were found between survivors and controls. As for sex differences, it was found that women expressed significantly more guilt than men in "behaviors contrary to moral or ethical principles" and men were significantly more internal than women. The implications of these findings were discussed.