Transplant versus no transplant in myelodysplastic syndrome and acute myeloid leukemia with TP53 mutation; a referral center experience

A remarkably high rate of post-transplant relapse in patients with TP53-mutated myelodysplastic syndrome/acute myeloid leukemia (MDS/AML) calls to question the utility of allogeneic stem cell transplant (HSCT). We, therefore, performed a retrospective analysis to compare the outcomes between HSCT (N = 38) versus non-HSCT (N = 45) approaches. Patients in the HSCT cohort were younger (median age 63 vs. 72) while patients in the non-HSCT cohort more commonly had complex karyotype with chromosome 17 aberrancy and 5q deletion (p < .01). A total of 69 TP53 variants including 64 pathogenic variants, and 5 variants of undetermined significance were detected. Nine patients (4 in HSCT and 5 in non-HSCT) had multi-hit TP53 variants. After induction: 57.9% versus 56.6% in the HSCT versus non-HSCT cohort achieved morphologic complete remission. Median time to HSCT was 6 months and median follow-up was 15.1 months for HSCT and 5.7 months for non-HSCT. Median disease-free survival (DFS) and overall survival (OS) were 11.7 and 15.9 months for HSCT, and 4.1 and 5.7 months for non-HSCT cohorts, respectively. Non-relapse mortality at 12 months was 22% versus 44% for HSCT versus non-HSCT. In the HSCT cohort, the rate of grade II-IV acute and chronic graft-versus-host disease (GVHD) was 55% and 18%, respectively. None of the patients from the non-HSCT cohort were alive while four patients from the HSCT cohort were alive, in remission, and without GVHD (GRFS) at the time of abstraction. Better treatment strategies for patients with TP53-mutated MDS/AML remain an area of unmet clinical need.

Tick magnets: The occupational risk of tick‐borne disease exposure in forestry workers in New York

Background

Outdoor workers, such as forestry workers, are at an increased risk for contracting tick‐borne diseases due to their prolonged time spent in tick habitats. Although well studied in Europe, no studies have been conducted with forestry workers in the Northeastern United States since 1990s.

Methods

Full‐time forestry workers and two comparison groups (volunteer firefighter/first responders and indoor/healthcare workers) within New York State Department of Environmental Conservation Regions 3, 4, 5, 6, and 7 were recruited for this cross‐sectional seroprevalence study. Blood draws were conducted to test for antibodies to Lyme, anaplasmosis, babesiosis, and ehrlichiosis. Surveys were administered to determine personal risk factors and protective behaviors.

Results

Between November 2020 and May 2021, 256 (105 forestry, 101 firefighter/first responder, and 50 indoor/healthcare) workers participated in this study. Forestry workers had a probability of testing positive nearly twice as high for any tick‐borne disease (14%) compared to firefighter/first responders (8%) and to indoor workers (6%); however, this difference was not statistically significant (P = .140). Forestry workers were more likely to find embedded ticks on themselves (f = 33.26, P < .0001 vs both comparison groups) and to have been previously diagnosed with a tick‐borne disease (P = .001 vs firefighter/first responders, P = .090 vs indoor/healthcare workers).

Conclusions

This pilot study suggests a higher proportion of tick‐borne disease risk among forestry workers compared to firefighters/first responders and indoor/healthcare workers with lesser exposure. A larger study to confirm or refute this pilot data could help optimize mitigation/prevention strategies.

Gender-Related Differences in Hypertrophic Cardiomyopathy: A Systematic Review and Meta-Analysis

Background

Gender-related differences in phenotypic expression and outcomes have been established in many cardiac conditions; however, the impact of gender in hypertrophic cardiomyopathy (HCM) remains unclear. We conducted a systematic review and meta-analysis to assess the differences in clinical outcomes between female and male HCM patients.

Methods

We searched MEDLINE and EMBASE from inception to October 2020. Included were cohort studies that compared outcomes of interest including all-cause mortality, HCM-related mortality, and worsening heart failure (HF) or HF hospitalization between male and female. Data from each study were combined using the random effects model to calculate pooled odds ratio (OR) with 95% confidence interval (CI).

Results

Eleven retrospective cohort studies with a total of 9,427 patients (3,719 females) were included. Female gender was significantly associated with an increased risk of all-cause mortality (pooled OR = 1.63, 95% CI: 1.26-2.10, p ≤ 0.001), HCM-related mortality (pooled OR = 1.47, 95% CI: 1.08-2.01, p = 0.015), and worsening HF or HF hospitalization (pooled OR = 2.05, 95% CI: 1.76-2.39, p ≤ 0.001).

Conclusions

Female gender was associated with a worse prognosis in HCM. These findings suggest the need for improved care in women including early identification of disease and more possible aggressive management. Moreover, gender-based strategy may benefit in HCM patients.

Same-day discharge after implantation of cardiac implantable electronic devices: A systematic review and meta-analysis

BACKGROUND

Due to an increasing need for cardiac implantable electronic device (CIED) placement, the cost of healthcare has been rising including the cost of hospital stay after the procedure. We conducted this systematic review and meta-analysis to assess the safety and feasibility of same-day discharge (SDD) after cardiac device implantations.

METHODS

We searched MEDLINE, and Embase databases from inception to March 2021 to identify studies that compared clinical outcomes between SDD group and hospital overnight stay (HO) group after cardiac device implantations. Outcomes included complications after the procedure, mortality, and re-hospitalization. Data from each study were combined using the random-effects model to calculate pooled odds ratio (OR) with 95% confidence interval (CI).

RESULTS

Eight studies (one randomized control trial, three prospective cohort and four retrospective cohort studies) with a total of 61,602 patients (4153 in SDD group and 57,449 in HO group) were included. SDD was not associated with more procedure-related complications. The rates of wound problems (0.94% vs 1.84%, pooled OR = 0.86, 95%CI: 0.2-3.68, p = .834), pneumothorax (1.15% vs 0.73%, pooled OR = 1.36, 95%CI: 0.26-7.12, p = .718), hematoma (0.59% vs 2.32%, pooled OR = 0.35, 95%CI:0.01-9.85, p = .534), lead/device dislodgement (4% vs 2.48%, pooled OR = 1.71, 95%CI: 0.64-4.54, p = .281), readmission rate (17.6% vs 17.5%, pooled OR = 0.95, 95%CI: 0.74-1.21, p = .667), and mortality rate (1.66% vs 1.44%, pooled OR = 0.77, 95%CI: 0.58-1.01, p = .059) were similar between in SDD and HO groups respectively.

CONCLUSIONS

Our meta-analysis suggested that SDD after cardiac device implantations might be a safe and feasible alternative to HO without differences in procedure-related complications, readmission rates, or mortality rates.

Direct oral anticoagulants vs. vitamin K antagonists for left ventricular thrombus: a systematic review and meta-analysis

BACKGROUND

Current guidelines recommend vitamin K antagonists (VKAs) to reduce the risk of systemic thromboembolic (STE) events in patients with left ventricular (LV) thrombus. Direct oral anticoagulants (DOACs) are an emerging alternative to VKAs; however, data supporting DOAC use in LV thrombus are still lacking. We conducted this systematic review and meta-analysis to compare the efficacy and safety between DOACs and VKAs in this population.

METHODS

We searched MEDLINE, Embase, and the Cochrane Library databases from inception to October 2020 to identify studies that compared clinical outcomes of interest, including stroke or any STE, LV thrombus resolution, and bleeding, between patients who used DOACs and VKAs for LV thrombus. Data from each study were combined using the random-effects model.

RESULTS

Eight cohort studies with a total of 1771 patients (426 in DOAC group, 1345 in VKA group) were included. There were no statistically significant differences between VKA group and DOAC group on rates of STE events (pooled RR = 1.12, 95% confidence interval [CI]: 0.91-1.39, p = .286), LV thrombus resolution (pooled RR = 1.09, 95% CI: 0.94-1.27, p = .242), or bleeding events (pooled RR = 0.94, 95% CI: 0.59-1.51, p = .808).

CONCLUSIONS

Our meta-analysis found no significant differences in rates of STE events, LV thrombus resolution, or bleeding events between the use of DOACs and VKAs in LV thrombus. Further randomised controlled trials are needed to confirm our findingsHighlightsThere is limited evidence comparing the use of direct oral anticoagulants (DOACs) to vitamin K antagonists (VKAs) in left ventricular (LV) thrombus.Our systematic review and meta-analysis showed that DOACs are not inferior to VKAs in the incidence of systemic thromboembolism (STE), the rate of LV thrombus resolution, and the risk of bleeding.Current evidence is based on observational studies only. Further randomised controlled trials are needed to confirm the findings.

Efficacy and safety of direct oral anticoagulant in morbidly obese patients with atrial fibrillation: systematic review and meta-analysis

AIMS

We conducted a systematic review and meta-analysis on 3 outcomes. We assessed the efficacy and safety of direct oral anticoagulants (DOAC) compared to vitamin K antagonists (VKA) in morbidly obese patients with atrial fibrillation (AF). We compared the efficacy and safety of DOAC in obese patients and non-obese patients with AF. Finally, we updated the current knowledge of outcomes of AF patients with obesity compared to normal-weight patients regardless of anticoagulation type.

METHODS AND RESULTS

Using PubMed and Embase, we searched for literature published from inception to August 2020 for studies conducted in morbidly obese patients with AF who used DOACs and/or VKA for stroke or systemic embolism (stroke/SE) prevention that report efficacy and/or safety data. GRADE assessment was performed to determine the quality of the meta-analysis results. DOAC was not statistically different from VKA in reducing stroke/SE with RR of 0.85 (95%CI: 0.56 to 1.29; very low certainty evidence). Major bleeding risk was lower in the DOAC groups with RR of 0.62 (95%CI: 0.48 to 0.80; low certainty evidence). Obese patients with AF who used DOACs had lower risk of stroke/SE and similar major bleeding risk compared to nonobese patients with RR of 0.77 (95%CI: 0.70 to 0.84; low certainty evidence) and 1.02 (95%CI: 0.94 to 1.09; low certainty evidence), respectively. Obese patients with AF who used any type of anticoagulant had lower risk of stroke/SE compared to normal-weight patients with RR of 0.62 (95%CI: 0.57 to 0.69; low certainty evidence).

CONCLUSIONS

The use of DOACs in morbidly obese patients maybe reasonable if needed, but more dedicated studies are needed to make a more robust recommendation.