Follow up duration of phase III Multiple Myeloma Clinical Trials: A systematic review

Long-term follow-up of multiple myeloma (MM) clinical trials are needed to assess long-term outcomes. We aimed to investigate the length of follow-up of all phase III MM clinical trials. Median follow-up duration of clinical trials of newly diagnosed MM was longer when compared to relapsed/refractory MM clinical trials (42.7 vs. 20.5 months, respectively). The follow-up duration of phase III clinical trials in MM is relatively short when compared to the improved outcomes in the current era. Efforts should be made to facilitate long-term clinical trials follow-up and/or publication of results of updated results.

Effectiveness of immunotherapy versus BRAF/MEK inhibitors in treatment-naïve BRAF-mutant advanced melanoma: A single institution retrospective analysis

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Background: Skin cancer is the most common type of cancer in the US. Melanoma constitutes about 1% of all skin cancers, but it accounts for most of skin cancer related deaths. In 2017, 85,000 new cases of melanoma were reported while 8000 people died. BRAF is the gene encoding for B-Raf protein; a serine/threonine-protein kinase involved in cell growth and survival. Activating mutations in BRAF are present in approximately 50% of melanomas. Therapeutics in melanoma have been rapidly evolving. Currently, advanced melanoma with a mutation in the BRAF gene has two different modalities for first-line treatment; immunotherapy which mediates checkpoint inhibition versus targeted therapy with BRAF + MEK inhibitors. The aim of our study was to compare effectiveness of immunotherapy versus BRAF/MEK inhibitors as first line treatment for metastatic BRAF-mutant advanced melanoma. Methods: A retrospective study of all patients aged ≥ 18 years, diagnosed with metastatic melanoma at our center between 1/1/2011 and 05/30/2021 was carried out. Patients who had BRAF negative melanoma or other active malignancies were excluded. Our primary endpoint was difference in overall survival and progression-free survival between two treatment groups. Secondary endpoint was to compare baseline characteristics associated with treatment options. Results: A total of 308 patients were diagnosed with advanced melanoma during the study period. N = 106 (34%) were found to have BRAF mutation. Of these, 88 (83%) received single-agent or combination immunotherapy while 18 (17%) received BRAF/MEK inhibitors. In immunotherapy group, 13 (14.7%) patients received combination immunotherapy while 75 (85%) got single agent treatment. 60 (56.6%) were males. Median age was 61 (89-21) years. Mean BMI at presentation was 29.5 ± 6.8 kg while mean LDH was 407 U/L. Mean age in immunotherapy and BRAF/MEK inhibitor group was 59.5 and 54.4 years, respectively. Differences between immunotherapy and BRAF/MEK inhibitors groups were observed in duration (months) between initiation of treatment and progression of disease (10.3 vs 7.23), death at time of last follow-up (21% vs 63%), remission at time of last follow up (37% vs 16%), and progression at time of last follow up (38% vs 16%). At the time of analysis, the mean follow-up was 28 ± 23.7 months in the immunotherapy group and 24 ± 23.3 months in the BRAF/MEK inhibitor group. Overall, at a mean follow up of 27.3 ± 23.5 months, no significant difference was found between the two treatment groups in unadjusted models in terms of overall survival (p 0.67) and progression free survival (p 0.16). Conclusions: Patients receiving first-line immunotherapy showed no significant survival benefit versus those receiving BRAF/MEK inhibitor therapy. This contrasts with other studies showing survival benefits in patients receiving immunotherapy as first line agent.

Cutibacterium acnes Pneumonia in an Immunocompromised Patient: A Case Report and Review of the Literature

Cutibacterium acnes (C. acnes), known previously as Proprionebacterium acnes, is a common skin and mucous membrane colonizing bacteria. On rare occasions it has been associated with invasive infections in both immunocompetent and immunosuppressed patients. We describe the case of a 55-year-old female with a history of Sjogren's syndrome and psoriatic arthritis on TNF-alpha inhibitor therapy with etanercept. She presented with signs and symptoms of a thoracic infection with pulmonary nodules, hilar adenopathy, and bronchiectasis on thoracic computed tomography. She was diagnosed with C. acnes pneumonia based on culture growth from both endoscopic bronchial ultrasound transbronchial lymph node needle biopsy and navigational bronchoscopy transbronchial lung biopsy. Our patient noticed marked symptom relief and radiographic pulmonary parenchymal improvement with intravenous ceftriaxone provided for a six-week course. This case highlights the potential invasive disease caused by C. acnes, a common skin commensal.

Safety and Efficacy of Apixaban, Rivaroxaban, and Warfarin in End-Stage Renal Disease With Atrial Fibrillation: A Systematic Review and Meta-Analysis

BACKGROUND

The use of warfarin in patients with atrial fibrillation (AF) and end-stage renal disease (ESRD) has been implicated with efficacy and safety concerns. Evidence on the role of direct oral anticoagulants (DOACs) in this population is limited.

METHODS

Electronic databases were searched and articles comparing the safety and efficacy of warfarin with apixaban or rivaroxaban were identified. Pooled hazard ratios (HR) were computed using a random-effects model.

RESULTS

A total of eight articles consisting of 30,806 patients; (rivaroxaban 2196, apixaban 2745 and warfarin 25,865) were identified. The pooled HR for major bleeding events favored apixaban over warfarin (0.53, 95% confidence interval (CI) 0.33-0.84, p = 0.008). Apixaban was similar to warfarin in terms of clinically relevant non-major bleeding (HR 1.08, 95% CI 0.64-1.84, p = 0.77) and stroke events (HR 1.09, 95% CI 0.85, 1.39, p = 0.99). There was no significant difference in the risk of major bleeding events (HR 0.95, 95% CI 0.50-1.81, p = 0.88) and stroke between rivaroxaban (HR 1.39, 95% CI, 0.59-3.29, p = 0.09) and warfarin. The combined results of major bleeding in the apixaban group were not affected by the sensitivity analysis.

CONCLUSIONS

Apixaban may have a lower risk of major bleeding and comparable risk of stroke when compared with warfarin in AF patients with ESRD.

Safety and Efficacy of Hydroxychloroquine in COVID-19: A Systematic Review and Meta-Analysis

BACKGROUND

During the initial phases of the coronavirus disease 2019 (COVID-19) epidemic, there was an unfounded fervor surrounding the use of hydroxychloroquine (HCQ); however, recently, the Centers for Disease Control and Prevention (CDC) has recommended against routine use of HCQ outside of study protocols citing possible adverse outcomes.

METHODS

Multiple databases were searched to identify articles on COVID-19. An unadjusted odds ratio (OR) was used to calculate the safety and efficacy of HCQ on a random effect model.

RESULTS

Twelve studies comprising 3,912 patients (HCQ 2,512 and control 1400) were included. The odds of all-cause mortality (OR: 2.23, 95% confidence interval (CI): 1.58 - 3.13, P value < 0.00001) were significantly higher in patients on HCQ compared to patients on control agent. The response to therapy assessed by negative repeat polymerase chain reaction (PCR) (OR: 1.83, 95% CI: 0.50 - 6.75, P = 0.36), radiological resolution (OR: 1.98, 95% CI: 0.47 - 8.36, P value = 0.36) and the need for invasive mechanical ventilation (IMV) (OR: 1.21, 95% CI: 0.34 - 4.33, P value = 0.76) were identical between the two groups. Overall, four times higher odds of net adverse events (NAEs) were observed in the HCQ group (OR: 4.59, 95% CI 1.73 - 12.20, P value = 0.02). The measures for individual safety endpoints were also numerically lower in the control arm; however, none of these values reached the level of statistical significance.

CONCLUSIONS

HCQ might offer no benefits in terms of decreasing the viral load and radiological improvement in patients with COVID-19. HCQ appears to be associated with higher odds of all-cause mortality and NAEs.

Comparative accuracy of non-invasive imaging versus right heart catheterization for the diagnosis of pulmonary hypertension: A systematic review and meta-analysis

BACKGROUND

Right heart catheterization (RHC) is the gold-standard in the diagnosis of pulmonary hypertension (PH) but at the cost of procedure-related complications. We sought to determine the comparative accuracy of RHC versus non-invasive imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI), and transthoracic echocardiography (TTE).

METHODS

Pulmonary hypertension was defined as a mean pulmonary artery pressure (mPAP) of>20 mmHg. Multiple databases were queried for relevant articles. Raw data were pooled using a bivariate model to calculate the measures of diagnostic accuracy and to estimate Hierarchical Summary Receiver Operating Characteristic (HSROC) on Stata 13.

RESULTS

A total of 51 studies with a total patient population of 3947 were selected. The pooled sensitivity and specificity of MRI for diagnosing PH was 0.92(95% confidence interval (CI) 0.88-0.96) and 0.86 (95% CI, 0.77-0.95), respectively. The net sensitivities for CT scan and TTE were 0.79 (95% CI 0.72-0.89) and 0.85 (95% CI 0.83-0.91), respectively. The overall specificity was 0.82 (0.76-0.92) for the CT scan and 0.71 (95% CI 0.61-0.84) for TTE. The diagnostic odds ratio (DOR) for MRI was 124 (95% CI 36-433) compared to 30 (95% CI 11-78) and 24 (95% 11-38) for CT scan and TTE, respectively. Chi-squared (x2) test showed moderate heterogeneity on the test for equality of sensitivities and specificities.

CONCLUSIONS

MRI has the highest sensitivity and specificity compared to CT and TTE. MRI can potentially serve as a surrogate technique to RHC for the diagnosis of PH.

Outcomes of open mitral valve replacement versus Transcatheter mitral valve repair; insight from the National Inpatient Sample Database

BACKGROUND

Transcatheter mitral valve repair and replacement (TMVR) is a minimally invasive alternative to conventional open-heart mitral valve replacement (OMVR). The present study aims to compare the burden, demographics, cost, and complications of TMVR and OMVR.

METHODS

The United States National Inpatient Sample (US-NIS) for the year 2017 was queried to identify all cases of TMVR and OMVR. Categorical and continuous data were analyzed using Pearson chi-square and independent t-test analysis, respectively. An adjusted odds ratio (aOR) based on the ordinal logistic regression (OLR) model was calculated to determine the association between outcome variables.

RESULTS

Of 19,580 patients, 18,460 (94%) underwent OMVR and 1120 (6%) TMVR. Mean ages of patients were 63 ± 14 years (OMVR) and 67 ± 13 years (TMVR). Both cohorts were predominantly Caucasian (73% OMVR vs. 74.0% TMVR). The patients who underwent TMVR were more likely to belong to a household with an income in the highest quartile (26.1% vs. 22.0% for OMVR) versus the lowest quartile (22.1% vs. 27.8%). The average number of days from admission to TMVR was less compared to OMVR (2.63 days vs. 3.02 days, p = 0.015). In-hospital length of stay (LOS) was significantly lower for TMVR compared to OMVR (11.56 vs. 14.01 days, p=<0.0001). Adjusted in-hospital mortality taking into account comorbidities showed no significant difference between the two groups (OR 1.2, 0.93-1.68, p = 0.15).

CONCLUSION

Patients undergoing TMVR were older and more financially affluent. TMVR was more costly but was associated with a shorter hospital stay and similar mortality to OMVR.

Diagnostic Accuracy of Cardiac Magnetic Resonance Versus Fractional Flow Reserve: A Systematic Review and Meta-Analysis

Background

Fractional flow reserve (FFR) is considered the gold standard for diagnosis of coronary artery disease (CAD). Stress Cardiac magnetic resonance (SCMR) has been recently gaining traction as a non-invasive alternative to FFR.

Methods

Studies comparing the diagnostic accuracy of SCMR versus FFR were identified and analyzed using Review Manager (RevMan) 5.3 and Stata software.

Results

A total of 28 studies, comprising 2,387 patients, were included. The pooled sensitivity and specificity for SCMR were 86% and 86% at the patient level, and 82% and 88% at the vessel level, respectively. When the patient-level data were stratified based on the FFR thresholds, higher sensitivity and specificity (both 90%) were noted with the higher cutoff (0.75) and lower cutoff (0.8), respectively. At the vessel level, sensitivity and specificity at the lower FFR threshold were significantly higher at 88% and 89%, compared to the corresponding values for higher cutoff at 0.75. Similarly, meta-regression analysis of SCMR at higher (3T) resolution showed a higher sensitivity of 87% at the patient level and higher specificity of 90% at the vessel level. The highest sensitivity and specificity of SCMR (92% and 94%, respectively) were noted in studies with CAD prevalence greater than 60%.

Conclusions

SCMR has high diagnostic accuracy for CAD comparable to FFR at a spatial resolution of 3T and an FFR cut-off of 0.80. An increase in CAD prevalence further improved the specificity of SCMR.

Efficacy of antibacterial envelope in prevention of cardiovascular implantable electronic device infections in high-risk patients: A systematic review and meta-analysis

BACKGROUND

Limited evidence is available to determine the efficacy of an antibacterial enveloped (AE) cardiovascular implantable electronic device (CIED).

OBJECTIVE

To assess if the use of antibacterial enveloped devices in high-risk patients are associated with lower chances of major CIED infections and mortality compared to non-enveloped devices.

METHODS

A comprehensive literature search on multiple databases was performed. The relative odds ratio (OR) of major CIED infection and mortality was calculated using a random-effect model.

RESULTS

A total of six studies consisting of 11,897 patients, were included; 5844 with an AE-CIED and 6053 with conventional CIED. In the pooled cohort, patients with AE-CIED had a 66% lower odds of major CIED infection (OR 0.34, 0.13, 0.86, CI 95%, p = 0.02) compared to CIED. Propensity matched analysis showed a 71% lower odds of major infection in the AE-CIED group (OR 0.29, 95% CI 0.10-0.82, p = 0.02). Stratified analysis based on the type of study (retrospective vs. prospective) and duration of follow up (6 months vs. greater than six months) also showed numerically lower infection odds in the AE-CIED. Similarly, the relative odds of mortality were lower in patients with AE-CIED (OR 0.55, 95% CI 0.16-1.91, p = 0.34) compared to CIED patients; however, this difference was statistically non-significant.

CONCLUSION

In high-risk patients, AE-CIED might offer lower odds of CIED infections. It has numerically lower (45%) but statistically non-significant odds of mortality if used in conjunction with the standard infection prevention protocol. More large scale studies and long-term follow-ups are required to validate our findings.

Confined states in graphene quantum blisters

Bilayer graphene samples may exhibit regions where the two layers are locally delaminated forming a so-called quantum blister in the graphene sheet. Electron and hole states can be confined in this graphene quantum blisters (GQB) by applying a global electrostatic bias. We scrutinize the electronic properties of these confined states under the variation of interlayer bias, coupling, and blister's size. The spectra display strong anti-crossings due to the coupling of the confined states on upper and lower layers inside the blister. These spectra are layer localized where the respective confined states reside on either layer or equally distributed. For finite angular momentum, this layer localization can be at the edge of the blister and corresponds to degenerate modes of opposite momenta. Furthermore, the energy levels in GQB exhibit electron-hole symmetry that is sensitive to the electrostatic bias. Finally, we demonstrate that confinement in GQB persists even in the presence of a variation in the inter-layer coupling.

Quantum transport across van der Waals domain walls in bilayer graphene

Bilayer graphene can exhibit deformations such that the two graphene sheets are locally detached from each other resulting in a structure consisting of domains with different van der Waals inter-layer coupling. Here we investigate how the presence of these domains affects the transport properties of bilayer graphene. We derive analytical expressions for the transmission probability, and the corresponding conductance, across walls separating different inter-layer coupling domains. We find that the transmission can exhibit a valley-dependent layer asymmetry and that the domain walls have a considerable effect on the chiral tunnelling properties of the charge carriers. We show that transport measurements allow one to obtain the strength with which the two layers are coupled. We perform numerical calculations for systems with two domain walls and find that the availability of multiple transport channels in bilayer graphene significantly modifies the conductance dependence on inter-layer potential asymmetry.