Trends in outcomes, complications and readmission rates in patients undergoing transcatheter aortic valve implantation: a nationwide analysis from 2012 to 2019

Background

Transcatheter aortic valve implantation (TAVI) has evolved over the years from a procedure requiring surgical vascular access and general anesthesia, to one that can be completed entirely percutaneously with conscious sedation. Advancement in procedural techniques and operator experience has resulted in better outcomes for patients undergoing TAVI.

Purpose

The purpose of our study was to analyze the trends over the years in outcomes, complications and unplanned readmission rate in patients undergoing TAVI.

Methods

The United States Nationwide Readmission Database for the years 2012 to 2019 was queried to identify all adult patients who underwent elective TAVI. The primary outcome of the study was inpatient mortality during TAVI hospitalization. Secondary outcomes included periprocedural complications (like acute kidney injury, bleeding requiring transfusion, need for permanent pacemaker implantation, stroke), length of stay, hospitalization cost, and unplanned 30-day readmission rate. Appropriate International Classification of Diseases (ICD-9 and ICD-10) codes were used to identify comorbidities and complications.

Results

A total of 283,409 patients who underwent TAVI were included in the study. The baseline characteristics of these patients are shown in picture 1. The inpatient mortality during TAVI admission declined steadily and significantly from 5.3% in the year 2012 to 0.0% in the year 2019 (p value for trend <0.001). There was a significant reduction in peri-TAVI occurrence of acute kidney injury (from 18.1% in 2012 to 8.7% in 2019), bleeding requiring transfusion (from 28.0% in 2012 to 4.3% in 2019), and stroke (from 1.8% in 2012 to 0.1% in 2019) (p value for trend <0.001 for all). Periprocedural conduction abnormalities requiring permanent pacemaker implantation increased from 7.4% in 2012 to 12.1% in 2015, before coming down to 8.9% in 2019 (p value for trend <0.001). The mean length of hospital stay and inflation-adjusted costs during admission for TAVI decreased from 9.6 days and $64,695 in the year 2012, to 3.6 days and $49,710 in the year 2019, respectively (p value for both <0.001). The unplanned 30-day all-cause readmission rate after TAVI also reduced steadily and significantly from 18.2% in 2012 to 11.5% in 2019 (p value <0.001).

Conclusion

Over the years, there has been a significant reduction in inpatient mortality, periprocedural complications (such as acute kidney injury, need for blood transfusion, stroke), length of hospital stay, and inflation-adjusted hospital costs in patients undergoing transcatheter aortic valve implantation. Furthermore, there has been a significant decline in the 30-day unplanned readmission rate after transcatheter aortic valve implantation.

Funding Acknowledgement

Type of funding sources: None.

Practical consensus recommendations regarding the management of HER2 neu positive metastatic breast cancer

Metastatic breast cancer (MBC) is cancer that has spread from the breast to another part of the body or has come back in another distant location. Treatment options for MBC depend on several factors, including where the cancer has spread, the patient's overall health, and the levels of hormone receptors and HER2 in the tumour. Over-expression of HER2 is generally considered to be a negative prognostic feature because it accompanies an increase in breast cancer mortality. However, the development of agents that specifically target HER2 has improved the management of patients with these tumours.^{[7],[8],[9],[10]} This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations in regards with the use of these agents and the management of HER2 positive MBC for the benefit of community oncologists.

Practical consensus recommendations on ovarian suppression in early breast cancer (adjuvant)

Substantial survival benefits exist for patients with early-stage breast cancer who undergo treatment with single-modality ovarian suppression, but its value is uncertain. Expert oncologist discussed to determine whether additional benefits exist with ovarian suppression plus multiple adjuvant therapy which provides a new treatment option that reduces the risk of recurrence in early breast cancer. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Comparison of outcomes of infants with giant omphaloceles over two decades

BACKGROUND

The purpose of this study was to compare the outcomes of infants with giant omphalocele (GO) born in two different epochs over two decades at a single institution. Specifically, it examined whether the utilization of selective pulmonary vasodilators and extracorporeal membrane oxygenator (ECMO) in the management of pulmonary hypertension in the second epoch were associated with improved outcomes.

METHODS

The medical records of all patients diagnosed with GO at a large children's hospital from January 1, 1996 to December 31, 2016 were reviewed and divided into two epochs. Patients were classified as having an isolated GO or GO with minor or major associated anomalies. GO was defined as a defect more than or equal to 5 cm in size and/or liver in the sac.

RESULTS

During the study period, 59 infants with GO were identified. The duration of invasive mechanical ventilation was significantly shorter among the survivors from the second epoch (p = 0.03), with none greater than seven days. There were no significant differences in the outcomes of survival to NICU discharge and length of stay (LOS) between infants in the two epochs.

CONCLUSIONS

Infants with GO who required invasive mechanical ventilation for more than seven days did not survive in the second epoch. Survival did not improve with uses of selective pulmonary vasodilators and ECMO. This information could be shared with families during prenatal and postnatal counselling to facilitate informed decision making regarding goals of care.

Indian clinical practice consensus guidelines for the management of squamous cell carcinoma of head and neck

Head and neck cancers (HNCs) are malignant tumors of the upper aerodigestive tract and are the sixth most common cancer worldwide. In India, around 30-40% of all cancers are HNCs. Even though there are global guidelines or recommendations for the management of HNCs, these may not be appropriate for Indian scenarios. In an effort to discuss current practices, latest developments and to come to a consensus to recommend management strategies for different anatomical subsites of HNCs for Indian patients, a group of experts (medical, surgical and radiation oncologists and dentists) was formed. A review of literature from medical databases was conducted to provide the best possible evidence base, which was reviewed by experts during a consensus group meeting (January, 2019) to provide recommendations.

Haemorrhage control beyond Advanced Trauma Life Support (ATLS) protocol in life threatening maxillofacial trauma - experience from a level Ⅰ trauma centre

Maxillofacial injuries are usually not life-threatening and do not get priority over other associated injuries. However, some maxillofacial injuries with active oral or nasal bleeding need immediate management due to threatened airway and blood loss. In the case of major active vascular bleeding, measures such as local pressure, anterior nasal packing, posterior nasal packing, and balloon tamponade are ineffective. In these cases, angiography and transcatheter arterial embolisation (TAE) are used to treat life-threatening haemorrhage caused by maxillofacial trauma. We analysed the medical records of 39 patients with severe maxillofacial trauma and life-threatening haemorrhage that was a result of intractable oral or nasal bleeding. These patients were considered for TAE from January 2010 to December 2019. A total of 1668 patients was admitted, out of which 39 (2.3%) had severe maxillofacial injuries with life-threatening oral or nasal bleeding and underwent TAE. Out of a total of 39 patients, 38 were male and one female. Ages ranged from 16 to 65 years. Road traffic injury was the most common cause of injury (79.5%), Lefort I and II were the most common facial fractures, and traumatic brain injury was the most common associated injury. Embolisation and bleeding control were done successfully in all 39 patients with no procedure-related complications. A total of 17 deaths during the study period were due to severe traumatic brain injuries or haemorrhagic shock.

Genetic Counseling, Testing, and Management of HBOC in India: An Expert Consensus Document from Indian Society of Medical and Pediatric Oncology

PURPOSE

Hereditary breast and ovarian cancer (HBOC) syndrome is primarily characterized by mutations in the BRCA1/2 genes. There are several barriers to the implementation of genetic testing and counseling in India that may affect clinical decisions. These consensus recommendations were therefore convened as a collaborative effort to improve testing and management of HBOC in India.

DESIGN

Recommendations were developed by a multidisciplinary group of experts from the Indian Society of Medical and Pediatric Oncology and some invited experts on the basis of graded evidence from the literature and using a formal Delphi process to help reach consensus. PubMed and Google Scholar databases were searched to source relevant articles.

RESULTS

This consensus statement provides practical insight into identifying patients who should undergo genetic counseling and testing on the basis of assessments of family and ancestry and personal history of HBOC. It discusses the need and significance of genetic counselors and medical professionals who have the necessary expertise in genetic counseling and testing. Recommendations elucidate requirements of pretest counseling, including discussions on genetic variants of uncertain significance and risk reduction options. The group of experts recommended single-site mutation testing in families with a known mutation and next-generation sequencing coupled with multiplex ligation probe amplification for the detection of large genomic rearrangements for unknown mutations. Recommendations for surgical and lifestyle-related risk reduction approaches and management using poly (ADP-ribose) polymerase inhibitors are also detailed.

CONCLUSION

With rapid strides being made in the field of genetic testing/counseling in India, more oncologists are expected to include genetic testing/counseling as part of their clinical practice. These consensus recommendations are anticipated to help homogenize genetic testing and management of HBOC in India for improved patient care.

THU0299 MYOCARDIAL INVOLVEMENT IN TAKAYASU ARTERITIS PATIENTS ASSESSED BY MAGNETIC RESONANCE IMAGING AND ITS RELATION WITH DISEASE ACTIVITY

Background:

Cardiac involvement in Takayasu arteritis(TA) is the major cause of morbidity and mortality. [1] Cardiovascular magnetic resonance (CMR) is an excellent modality for the assessment of myocardial involvement. Studies have shown subclinical myocardial scarring in 25-27% of patients.[2,3] There is no such study from India.

Objectives:

To evaluate the prevalence of myocardial involvement in TA, as detected by CMR and its correlation with disease activity score (ITAS 2010 and ITAS-A).

Methods:

Patients classified as Takayasu arteritis according to Sharma et al. criteria [4] were included after an informed consent. Demographic, clinical, laboratory data were documented in the predesigned proforma. CMR was done on a dedicated CMR machine. Disease activity was recorded by ITAS2010 and ITAS-A.[5] Ethical clearance has been obtained from the ethics committee of the institute (INT/IEC/2018/001538).

Results:

In the present study, 37 TA patients were included. Mean(±SD) age was 29 ±11 years. Female to male ratio was 3:1. The most frequent presenting symptom was upper limb claudication (49%), and vessel involved was left subclavian and descending thoracic aorta(75% each). Of the total cohort, 65% had hypertension, 35% had dyslipidemia and 19% had valvular involvement. Five patients (14%) had myocardial involvement as detected by CMR. Three (8%) patients had late gadolinium enhancement(LGE) on CMR suggestive of myocardial fibrosis. In the current study, both the CMR and echocardiography performed equally in detecting various valvular heart disease, whereas only CMR had detected subclinical myocardial fibrosis in two patients. Details of different risk factors and relation with disease activity provided in table 1.

Conclusion:

To the best of our knowledge, this is the largest cohort on CMR in TA. Prevalence of subclinical myocardial involvement in Indian patients was much less(8% vs 25-27%) compared to the previous studies. The higher percentage of LGE detected by the earlier studies may be a reflection of cumulative damage with increasing age, prolonged hypertension, and disease duration. Myocardial involvement trend towards early age of onset, less disease duration, lack of classical risk factors, and more with disease activity. Judicious use of CMR may help in detecting subclinical myocardial involvement.

Table 1.

Relation of different risk factors with myocardial heart disease.

ParametersMHD - (n=32)MHD + (n=5)pDisease duration>5 yr13(41)2(40)0.98Age at onset<18 yr7(22)3(60)0.07BMI>23kg/m219(59)1(20)0.1Hb<12gm/dl16(50)2(40)0.68Platelets>450x 109/L4(13)0(0)0.40ESR>20 mm in 1sthour28(88)4(80)0.65CRP>10 mg/dl16(50)4(80)0.21Cholesterol>200 mg/dl10(31)1(20)0.61LDL>130 mg/dl9(28)0(0)0.17BNP>125 pg/ml11(34)3(60)0.27ITAS2010-Active17(53)3(60)0.77ITAS-A-Active11(34)3(60)0.27

[MHD: myocardial heart disease]

References:

[1]Cong XL, Dai SM, Feng X et al. Takayasu’s arteritis: clinical features and out- comes of 125 patients in China. Clin Rheumatol 2010;29:973–81.

[2]Keenan NG, Mason JC, Maceira A et al. Integrated cardiac and vascular assessment in Takayasu arteritis by cardiovascular magnetic resonance. Arthritis Rheum. 2009;60:3501-9.

[3]Comarmond C, Cluzel P, Toledano D et. al. Findings of cardiac magnetic resonance imaging in asymptomatic myocardial ischemic disease in Takayasu arteritis. Am J Cardiol. 2014;113:881-7.

[4]Sharma BK, Jain S, Suri S et al. Diagnostic criteria for Takayasu Arteritis. Int J Cardiol 1996;54: S141-7.

[5]Misra R, Danda D, Rajappa SM, et al. Development and initial validation of the Indian Takayasu Clinical Activity Score (ITAS2010). Rheumatology 2013;52:1795-801.

Disclosure of Interests:

None declared

The future of lung cancer therapy: Striding beyond conventional EGFR and ALK treatments

Lung cancer, one of the most frequently diagnosed cancers worldwide has long relied on testing for the molecular biomarkers EGFR/ALK. However, achieving superior clinical outcomes for patients with lung cancer requires developing comprehensive techniques beyond contemporary EGFR/ALK testing. Current technologies are on par with molecular testing for EGFR/ALK in terms of efficacy, most of them failing to offer improvements perhaps primarily due to skepticism among clinicians, despite being recommended in the NCCN guidelines. The present study endeavored to minimize chemotherapy-dependence in EGFR/ALK-negative patient cohorts, and use evidence-based methods to identify ways to improve clinical outcomes. In total, 137 lung cancer cases obtained from 'PositiveSelect NGS data', comprising 91 males and 46 females, were investigated. EGFR- and ALK-positivity was used for data dichotomization to understand the therapeutic utility of rare gene alterations beyond just EGFR/ALK. Statistics obtained from PositiveSelect were collated with data from international studies to construct a meta-analysis intended to achieve better clinical outcomes. Upon dichotomization, 23% of cases harbored EGFR variants indicating that treating with EGFR TKIs would be beneficial; the remaining 77% exhibited no EGFR variants that would indicate favorable results using specific currently available chemotherapy practices. Similarly, 28% of cases had EGFR+ALK variants favoring EGFR/ALK-based targeted therapeutics; the remaining 72% harbored no EGFR/ALK variants with known beneficial chemotherapy routes. The present study aimed to overcome current inadequacies of targeted therapies in patients with a conventional EGFR/ALK-positive diagnosis and those in EGFR+ALK-negative cohorts. Upon analysis of the negative cohorts, significant and clinically relevant single nucleotide variants were identified in KRAS, ERBB2, MET and RET, with frequencies of 7, 1, 2 and 3% in patients who were EGFR-negative and 6, 1, 1, and 3% in patients who were EGFR and ALK-negative, respectively, enabling the use of targeted therapeutics aside from EGFR/ALK TKIs. From the results of the current study only 35% of the two negative arms (EGFR negative and EGFR+ALK negative) would be recommended NCCN or off-label chemotherapy; prior to the current study, the entire cohorts would have been recommended this treatment. The present study emphasizes the potential of comprehensive genomics in identifying hallmarks of lung cancer beyond EGFR/ALK, using broad-spectrum genetic testing and data-sharing among medical professionals to circumvent ineffective chemotherapy.

Meeting report, “First Indian national conference on cervical cancer management - expert recommendations and identification of barriers to implementation”

Objective

In India, cervical cancer accounts for almost 14% of all female cancer cases. Although poverty continues to cast a wide net over the Indian subcontinent, the preceding three decades have borne witness to improvements in nutrition and sanitation for many citizens. However, due to an absence of a national immunization program to cover human papillomavirus (HPV) vaccination and lack of accessible cervical cancer screening, the disease is characterized by late detection, lack of access to affordable and quality health care, and high mortality rates. Treatment of cervical cancer is stage-specific and depends on the patient’s age, desire to preserve fertility, overall health, the clinician’s expertise, and accessibility to resources. There is a paucity of uniform treatment protocols for various stages of cervical cancer in India. Considering all these parameters, a need to optimize treatment paradigms for the Indian population emerged.

Methods/materials

Three expert panel meetings were held in different regions of India from 2016 to 2017. They were comprised of 15 experts from across the country, and included surgical oncologists, radiation oncologists, and medical oncologists. The panel members reviewed the literature from both national and global sources, discussed their clinical experience and local practices and evaluated current therapeutic options and management gaps for women diagnosed with cervical cancer.

Results

This article summarizes the expert opinion from these meetings. It discusses the available resources and highlights the current therapeutic options available for different cervical cancer stages: early stage disease, locally advanced tumors, recurrent/persistent/metastatic cancer. An Indian consensus governing treatment options emerged, including guidelines for use of the only approved targeted therapy in this disease, the anti-angiogenesis drug, bevacizumab.

Conclusions

The panel concluded that given the availability of state-of-the-art imaging modalities, surgical devices, radiotherapeutics, and novel agents in several population-dense urban centers, a uniform, multi-disciplinary treatment approach across patient care centers is ideal but not realistic due to cost and a paucity of third party payors for most Indian citizens. Preventative strategies including visual inspection with acetic acid to screen for precursor lesions (i.e., cervical intraepithelial neoplasia) with immediate referral for cervical cryotherapy and possible large-scale roll-out of the HPV vaccine in the near future can be expected to reduce mortality rates significantly in this country.

Efficacy and Safety of Ibrutinib in Indian Patients with Relapsed or Refractory Chronic Lymphocytic Leukemia and Mantle Cell Lymphoma: Cases from a Named Patient Program

Context:

This named patient program evaluated the safety and efficacy of ibrutinib, a selective inhibitor of Bruton's tyrosine kinase in Indian patients with relapsed/refractory chronic lymphocytic leukemia (CLL, with/without chromosome 17 deletion [del17p]) and mantle cell lymphoma (MCL).

Subjects and Methods:

The eight enrolled patients (relapsed/refractory CLL: n = 6 [4/6 patients with del17p] and relapsed/refractory MCL: n = 2) had median age of 55 years (range, 52–60) and had received a median of 3 (CLL patients) and 4 (MCL patients) prior therapies. Patients received once-daily dose of ibrutinib (420 mg: CLL, 560 mg: MCL).

Results:

In CLL patients, the median time to response was 3 months (range, 0.5–7) and five of six patients had partial response (PR) whereas one achieved complete response (CR). Median time on treatment was 11.5 months (range, 8–14); five patients continued treatment and one was recommended stem cell transplantation (SCT). Of the two MCL patients, one achieved PR and one showed CR and advanced to SCT. In CLL patients, the median (range) hemoglobin level improved from 9.8 g/dL (7.2–11) at baseline to 12.0 g/dL (9.5–13.2) and median (range) platelet count improved from 150,000 cells/μL (21,000–195,000) at baseline to 190,350 cells/μL (130,000–394,000) at the time of analysis (July 2016). Most adverse events (AEs) reported were infections (n = 2). No Grade 3-4 or serious AEs, dose reductions, or treatment discontinuation due to AEs were reported.

Conclusions:

In this first real-world experience in Indian patients, ibrutinib demonstrated therapeutic efficacy in relapsed/refractory CLL (with/without del17p) and MCL. Safety results were consistent with the current known profile of ibrutinib.

Pilot feasibility study to detect mesenchymal stem cell biomarkers of bronchopulmonary dysplasia in the tracheal aspirate fluid of preterm infants

OBJECTIVE

This study aimed to detect novel mesenchymal stem cell peptides/biomarkers of bronchopulmonary dysplasia (BPD) in the tracheal aspirate fluid (TAF) of preterm infants.

STUDY DESIGN

Participants included infants less than 32 weeks' gestational age or birth weight under 1500 grams who required endotracheal intubation and mechanical ventilation within first 24 hours of life. TAF sample collection was performed at the time of the first clinically indicated routine suctioning. Standardization curves for human levels of osteopontin (Opn), macrophage colony stimulating factor 1 (Csf1), transforming growth factor beta 1 (TGF-β1), and secretory immunoglobulin A (sIgA) were generated for 15 enrolled participants.

RESULTS

We demonstrated that stem cell biomarkers are secreted into the TAF of preterm infants and their concentrations can be easily measured during the first week of life.

CONCLUSIONS

Further studies are warranted to determine a causal relationship between these biomarkers and BPD development and severity.

Human papillomavirus in head and neck cancer in India: Current status and consensus recommendations

Human papillomavirus (HPV) associated head and neck squamous cell cancers (HNSCC) have become increasingly common in the West, but the same cannot be said about India. These cancers have a different biology and confer a better prognosis, however, its current role in the management of patients in India is not clearly defined. At the 35th Indian Cooperative Oncology Network conference held in September 2016, a panel of radiation, surgical and medical oncologists, pathologists, and basic scientists from across the country having experience in clinical research with respect to HPV in HNSCC reviewed the available literature from India. All the ideas and facts were thereafter collated in this report. Various topics of controversy in dealing with the diagnosis and management of HPV-associated HNSCC have been highlighted in this report in context to the Indian scenario. Furthermore, the prevalence of the same and its association with tobacco and high-risk sexual behavior has been touched on. Conclusively, a set of recommendations has been proposed by the panel to guide the practicing oncologists of the country while dealing with HPV-associated HNSCC.

Risk factor profiling and study of atherosclerotic coronary plaque burden and morphology with coronary computed tomography angiography in coronary artery disease among young Indians

BACKGROUND

With a decade earlier manifestation of coronary artery disease (CAD) and paucity of data characterizing coronary plaque with coronary computed tomography angiography (CTA) among CAD patients in India, the study aimed to analyze patient characteristics and coronary plaque burden and morphology in young Indian patients with CAD.

METHODS

Serial coronary CTA was performed in 96 CAD patients. Among 60 patients ≤40years, risk factor and coronary plaque analysis done using a 256- slice CT in 33 patients with acute coronary syndrome (ACS) was compared with 27 patients with chronic stable angina (CSA). Univariate and multivariate analysis was performed, for factors predicting ACS as an outcome among young CAD patients. In addition, quantitative and morphologic plaque characteristics were compared among those ≤40years and >40years.

RESULTS

Among 60 subjects ≤40years of age, 77% had dyslipidemia, 70% high lipoprotein(a), 53.33% elevated hs-CRP and 73.33% raised homocysteine. hs-CRP (9.33 vs. 3.33, p value=0.01) and serum triglycerides (178.67 vs. 141.42, p value=0.03) were markedly raised in patients with ACS. Statistically significant number of patients in the ACS group had positive remodelling (ACS, 69.7% vs. CSA, 14.8%; p value<0.001), low attenuation plaque (ACS, 63.6% vs. CSA, 11.1%; p value<0.001), spotty calcification (ACS, 36.4% vs. CSA, 3.7%; p=0.002) and non-calcified plaque (ACS, 69.7% vs. CSA, 11.1%; p<0.001). On multivariate analysis, only lipoprotein (a) >30mg/dL and composite vulnerability score maintained a predictive value for ACS in patients ≤40years. Statistically significant number of patients in the younger age group had higher mean total plaque volume (66.17±41.31mm³ vs. 44.94±49.07mm³; p=0.03), remodelling index (1.5±0.27 vs. 1.08±0.38; p=0.0001). Comparing culprit lesion characteristics of ACS patients in the two age groups, positive remodelling (95.8% vs. 70.5%, p=0.02), spotty calcification (50% vs. 11.7%, p=0.01) and non-calcified plaque (95.8% vs. 70.5%, p=0.02) were significantly more frequent in patients ≤40years.

CONCLUSION

ACS in young Indians is characterized by a higher prevalence of both conventional and newer risk factors. In addition, culprit lesions in young ACS patients are more frequently characterized by coronary plaques with high risk morphological features. This may have implications in terms of preventive strategies to identify this high-risk group.

Association of pharmacokinetic and metabolic parameters derived using simultaneous PET/MRI: Initial findings and impact on response evaluation in breast cancer

PURPOSE

To study relationships among pharmacokinetic and ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) PET parameters obtained through simultaneous PET/MRI in breast cancer patients and evaluate their combined potential for response evaluation.

METHODS

The study included 41 breast cancer patients for correlation study and 9 patients (pre and post therapy) for response evaluation. All patients underwent simultaneous PET/MRI with dedicated breast imaging. Pharmacokinetic parameters and PET parameters for tumor were derived using an in- house developed and vendor provided softwares respectively. Relationships between SUV and pharmacokinetic parameters and clinical as well as histopathologic parameters were evaluated using Spearman correlation analysis. Response to chemotherapy was derived as percentage reduction in size and in parameters post therapy.

RESULTS

Significant correlations were observed between SUVmean, max, peak, TLG with K^trans (ρ=0.446, 0.417, 0.491, 0.430; p≤0.01); with Kep(ρ=0.303, ρ=0.315, ρ=0.319; p≤0.05); and with iAUC(ρ=0.401, ρ=0.410, ρ=0.379; p≤0.05, p≤0.01). The ratio of ve/iAUC showed significant negative correlation to SUVmean, max, peak and TLG (ρ=0.420, 0.446, 0.443, 0.426; p≤0.01). Ability of SUV as well as pharmacokinetic parameters to predict response to therapy matched the RECIST criteria in 9 out of 11 lesions in 9 patients. Maximum post therapy quantitative reduction was observed in SUVpeak, TLG and K^trans.

CONCLUSION

Simultaneous PET/MRI enables illustration of close interactions between glucose metabolism and pharmacokinetic parameters in breast cancer patients and potential of their simultaneity in response assessment to therapy.

P21-activated kinase 1 (Pak1) signaling influences therapeutic outcome in pancreatic cancer

BACKGROUND

Therapeutic resistance to gemcitabine in pancreatic ductal adenocarcinoma (PDAC) is attributed to various cellular mechanisms and signaling molecules that influence as a single factor or in combination.

DESIGN

In this study, utilizing in vitro p21-activated kinase 1 (Pak1) overexpression and knockdown cell line models along with in vivo athymic mouse tumor xenograft models and clinical samples, we demonstrate that Pak1 is a crucial signaling kinase in gemcitabine resistance.

RESULTS

Pak1 kindles resistance via modulation of epithelial-mesenchymal transition and activation of pancreatic stellate cells. Our results from gemcitabine-resistant and -sensitive cell line models showed that elevated Pak1 kinase activity is required to confer gemcitabine resistance. This was substantiated by elevated levels of phosphorylated Pak1 and ribonucleotide reductase M1 levels in the majority of human PDAC tumors when compared with normal. Delineation of the signaling pathway revealed that Pak1 confers resistance to gemcitabine by preventing DNA damage, inhibiting apoptosis and regulating survival signals via NF-κB. Furthermore, we found that Pak1 is an upstream interacting substrate of transforming growth factor β-activated kinase 1-a molecule implicated in gemcitabine resistance. Molecular mechanistic studies revealed that gemcitabine docks with the active site of Pak1; furthermore, gemcitabine treatment induces Pak1 kinase activity both in vivo and in cell-free system. Finally, results from athymic mouse tumor models illustrated that Pak1 inhibition by IPA-3 enhances the cytotoxicity of gemcitabine and brings about pancreatic tumor regression.

CONCLUSION

To our knowledge, this is the first study illustrating the mechanistic role of Pak1 in causing gemcitabine resistance via multiple signaling crosstalks, and hence Pak1-specific inhibitors will prove to be a better adjuvant with existing chemotherapy modality for PDAC.

Traumatic Diaphragmatic Injury: A Marker of Serious Injury Challenging Trauma Surgeons

The objectives of this study are (1) to evaluate prevalence of traumatic diaphragmatic injury (TDI), (2) identify the predictors of mortality, and (3) study the accuracy of investigations in survivors of TDI. Retrospective analysis of prospectively maintained database of TDI from January 2007 to December 2011. Emergency department (ED) records, operative details, and autopsy reports were reviewed to determine injury characteristics, treatment provided, and outcome. Statistical analyses were performed using the SPSS ver.15 software. TDI was identified in 75 individuals. Thirty-two of 75 (42.6 %) cases were brought dead to the hospital, and 43/75 (57.3 %) were survivors presented to emergency department, diagnosed to have TDI intraoperatively. Seven of 43 (16.3 %) died postoperatively. Mortality in TDI was significantly related to age (p = 0.001), injury severity (p < 0.001), site of TDI (p = 0.002), and associated injuries (p = 0.021, odds ratio of 9). Death increased with increase in the number of organ injured (p < 0.001, odds ratio of 12). Multi-detector computer tomography (MDCT) detected TDI in 23/26 (88.5 %) cases preoperatively. Laparotomy (p < 0.001, odds ratio of 22) and thoracotomy (p = 0.021, with odds ratio of 9) were associated with survival benefit when compared to minimal invasive surgery in injured cases. The prevalence of TDI was 2.67 %, TDI's mark severity of injury. Mortality increases with increasing number of organ injured. Right-sided or bilateral injury of diaphragm is associated with increased mortality.

Pertuzumab: Unprecedented benefit in human epidermal growth factor receptor 2-positive breast cancer

Human epidermal growth factor receptor 2 (HER2)-positive breast cancer is a more aggressive subtype of breast cancer and targeting the HER2 receptor has proven effective in improving the prognosis of these patients. Pertuzumab, a recombinant humanized monoclonal antibody and the first in a class of HER2 dimerization inhibitors approved for treating HER2+ breast cancer. It blocks ligand-dependent heterodimerization and ligand-independent homodimerization of HER2 with other HER members. When used in combination with trastuzumab and taxane, pertuzumab complements the action of trastuzumab and results in a comprehensive blockade of HER2 signaling pathway. This review article traces the development of pertuzumab from concept to its current use in HER2+ breast cancer treatment. A search of Medical Literature Published since 2007 was performed in PubMed using the keywords “pertuzumab,” “HER2+ breast cancer,” “HER2 targeted therapy,” “metastatic breast cancer,” and in search engines for ongoing trials with pertuzumab and incidence of cancer and breast cancer in India. A total of 35 publications and abstracts from the American Society of Clinical Oncology were selected for this review. Pertuzumab is approved in combination with trastuzumab and docetaxel for the treatment of patients with HER2+ metastatic BC, who have not received prior anti-HER2 therapy or chemotherapy for metastatic disease. The dual HER2 blockade of pertuzumab and trastuzumab is now accepted worldwide as a standard of care by various guidelines.

Percutaneous injection of acrylic glue into renal allograft pseudoaneurysm for control of intractable post-biopsy hematuria

We report a 44-year-old male, renal allograft recipient of 1-year duration who had two episodes of steroid responsive acute rejection. He presented with graft dysfunction for which a graft biopsy was performed and was suggestive of mixed rejection. At 2 weeks post-biopsy, patient developed severe pain over the graft site with anuria and graft hydronephrosis (HDN). The HDN and anuria intermittently settled with the passage of blood clots per-urethra. Contrast enhanced computerized tomography was suggestive of pseudoaneurysm in the graft kidney. The case was successfully managed with ultrasound guided percutaneous cyanoacrylate glue injection into the pseudoaneurysm.

Cytomorphologic significance of marginal vacuoles in diffuse thyroid enlargements

Background:

Fine needle aspiration cytology (FNAC) of the thyroid is an established first-line test for thyroid lesions. Marginal vacuoles (MVs) have been associated with hyperactivity of the thyroid, but some studies have pointed towards their nonspecific status.

Aims:

To assess the presence of MVs in diffuse thyroid enlargements and evaluate the strength of correlation between MVs, levels of thyroid hormone and cytological diagnosis.

Materials and Methods:

Ninety-seven cases of diffuse thyromegaly were studied. Cytomorphological features were examined with special attention to MVs. MVs were graded as scant, moderate and abundant. Hormonal status of the patients was recorded. The presence and grading of MVs was correlated with cytological diagnosis and hormonal status. The strength of association was studied by applying the Chi-square test and test of proportion; a P ≤ 0.05 was considered significant.

Results:

Abundant MVs were not associated with hypothyroidism in this study; 79% of these cases were hyperthyroid. The correlation between moderate/insignificant MVs and functional status of the thyroid gland was inconclusive. Further, abundant MVs in thyroid FNACs were seen in cases of primary hyperplasia and Hashimoto's thyroiditis. There was a significant correlation between the presence of abundant/moderate MVs and primary hyperplasia and their absence in colloid goiter (P = 0.01 and 0.004, respectively).

Conclusions:

A significant association was found between abundant MVs and a hyperthyroid state. Moderate/absent MVs in diffuse goiters were not found to correlate with thyroid function. Thus, all diffuse goiters with prominent MVs require hormonal evaluation to rule out hyperfunction of the thyroid.

Gelatin-thrombin hemostatic matrix injection to salvage refractory post-renal graft biopsy bleed

Post-renal biopsy bleeding refractory to angioembolization usually requires graft nephrectomy as a life-saving measure. Gelatin-thrombin hemostatic matrix injection in the needle tract is a novel attempt to control bleeding in such cases and to salvage the allograft. We hereby describe two cases of post-graft biopsy bleed. Both these patients continued to bleed even after angioembolization. They were shifted to the operating room upon developing hypotension, having received multiple blood transfusions with the intention of performing graft nephrectomy to save their lives. However, bleeding was successfully controlled by using Gelatin-thrombin hemostatic matrix injection in the biopsy needle tract. Patients improved hemodynamically after the procedure. Graft function returned to normal in both the cases. At an average follow-up of 10.4 months, both the patients have shown stable graft functions.