Risks of hypertension and thromboembolism in patients receiving bevacizumab with chemotherapy for colorectal cancer: A systematic review and meta-analysis

BACKGROUND

Guidelines show that for metastatic colorectal cancer (mCRC), a combination of three-drug regimens, fluorouracil, leucovorin, and oxaliplatin and bevacizumab (BVZ), is one of the first-line standard therapies. BVZ is generally well tolerated; however, it is associated with infrequent, life-threatening side effects such as severe hypertension (HTN) (5%-18%), Grade ≥3 arterial thromboembolism (ATE) (2.6%), Grade ≥3 hemorrhagic events (1.2%-4.6%), and gastrointestinal perforation (0.3%-2.4%). This meta-analysis aims to evaluate the additive risk of BVZ-induced severe HTN and thromboembolism when BVZ is combined with a standard chemotherapy regime in patients with mCRC.

METHODS

Our search was conducted from January 29, 2022, to February 22, 2022, through databases of PubMed, clinicaltrial.gov, EMBASE, Web of Science, and Cochrane Library. Data analysis from randomized controlled trials (RCTs) and clinical trials was conducted using Review Manager V.5.4, comparing BVZ-chemotherapy to chemotherapy only, focusing on cardiovascular AE such as HTN and arterial and venous thromboembolism.

RESULTS

The analysis from 26 clinical trials and RCTs showed that the odds of HTN were about four times higher, and ATE subgroup analysis of 11 studies showed over two times higher odds of ATE in patients being treated with BVZ compared to the chemotherapy-only group.

CONCLUSION

BVZ, when added to the standard chemotherapy regimen for mCRC, was associated with higher odds of developing HTN and thromboembolism, specifically ATE, than the chemotherapy-only group. Our findings are significant as they provide vital information in analyzing the risk-benefit ratio of adding BVZ to the standard chemotherapy regime in patients with mCRC, especially in patients with vascular comorbidities.

Links between socio-demographic characteristics and body mass index to colorectal cancer in North Borneo, Malaysia: A case-control study

INTRODUCTION

The fourth leading cause of cancer-related mortality and morbidity worldwide is colorectal cancer (CRC). Numerous reasons have contributed to the massive rise in CRC cases, for which Asian nations differ significantly in terms of risk incidence rates. The objectives of this study were to, first, identify the socio-demographic characteristics of those of North Borneo ethnicity and body mass index (BMI) and, second, determine the association of these factors with CRC. This research will contribute to preventing this form of cancer.

MATERIALS AND METHODS

This study is an analysis of a matched case-control study with a ratio of 1:2. The case group contained 206 respondents, and the control group contained 412. All CRC cases were confirmed with the histological results. The control group was matched for links between age, sex and ethnicity with CRC. The Statistical Package for Social Sciences Statistics (SPSS) IBM version 28.0 was used to conduct descriptive analysis using chi-squared testing and simple logistic regression. The statistical significance was P < 0.05.

RESULT

Overall, 618 respondents took part in this survey, of which 256 (41.4%) were female and 362 (58.6%) were male. The maximum age was 76, with a mean age ± SD of 53.17 ± 11.4. Those of Bajau ethnicity comprised 24.6% (152) of the population, followed by Dusun with 22.8% (141), Kadazan with 17.6% (109%), other North Borneo ethnic groups with 15.5% (96), Bugis with 9.7% (60), Brunei with 4.4% (27) and other predominant races with 5.3% (33). Regression analyses revealed that the incidence of CRC in North Borneo, Malaysia, was substantially correlated with income, occupation, other linked diseases and BMI.

CONCLUSION

Various risk factors are linked to CRC, based on the findings related to socio-demographic characteristics and BMI. Therefore, to lower the nationwide prevalence of CRC, national public health campaigns should include collaboration with the regional authorities to highlight the incidence and risk factors of CRC based on ethnicity.

A meta-analysis of bevacizumab’s cardiovascular risks in patients treated for colorectal cancer

113

Background: Bevacizumab (BVZ), a recombinant humanized monoclonal IgG antibody, is commonly used as first- and second-line adjuvant therapy in metastatic colorectal cancer. Recent guidelines have shown that a combination of three cytotoxic drug regimens FOLFOX (fluorouracil, leucovorin and oxaliplatin) along with BVZ is regarded as one of the first-line options. As we see an upward trend in using BVZ; it is crucial to analyze the side effects and potential toxicities. A frequent adverse effect with BVZ is hypertension. The prevailing hypothesis for the mechanism of BVZ induced hypertension is an increase in vascular tone due to the inhibition of VEGF-mediated vasodilation. A persistent elevation of arterial blood pressure is generally asymptomatic, but unmanaged hypertension can lead to cardiovascular complications, encephalopathy, and subarachnoid hemorrhage. Therefore, this meta-analysis aims to evaluate and assess the risk of BVZ induced hypertension. Methods: Our search included articles from PubMed, EMBASE, Web of Science, and Cochrane Library from 1980 to March 2022. Randomized controlled trials and clinical trials with BVZ as an add-on therapy mentioning cardiovascular side effects were included. Full analysis control group included various guideline directed chemotherapies and the subgroup analysis control group focused on FOLFOX therapy. A random-effects model was used with Review Manager, and a P value < 0.05 was considered significant. Results: We included a total of 17,807 patients in our study with an average age of 65 years. Analysis pooled from 19 RCTs showed that the odds of hypertension (Grade 3 or more) in patients treated with BVZ were about four times higher than the control group (OR 3.82, 95% CI 3.35-4.36, p-value < 0.00001, I2 = 78%). In a subgroup analysis, BVZ was compared with FOLFOX group, with odds of hypertension (Grade 3 or more) in BVZ group being about five times higher than in FOLFOX group (OR 5.24, 95% CI 4.06-6.77, p-value < 0.00001, I2 = 58%). Conclusions: Our meta-analysis demonstrates a significant cardiovascular risk of Bevacizumab when added to the standard regime for advanced colorectal cancer treatment. When BVZ was used as an add-on therapy to FOLFOX regimens for colorectal cancer, it was associated with about five times higher odds of developing hypertension (Grade 3 or more) in the treatment group with BVZ. Previous RCTs have demonstrated that BVZ add-on therapy to the standard regime is safe and without significant risk of toxicity. Our findings are important as they give vital information in assessing the risk-benefit ratio of adding BVZ, especially in a population with vascular comorbidities. Now that we have established the statistical significance of hypertensive risk with BVZ, it will be interesting to see how these events can be prevented in patients treated for metastatic colorectal cancer. Dedicated RCTs are needed to confirm these findings.

Education as a protective factor for mental health risks among youth living in highly dangerous regions in Afghanistan

BACKGROUND

Children in Afghanistan live in dangerous areas, and have been exposed to traumatic events and chaotic education. Progress has been made on access to education for girls who were the most affected by traditional attitudes against engagement in education.

OBJECTIVES

The objectives were to evaluate the mental health of Afghan children living in regions of conflict and the association of mental health with school attendance for girls and boys.

METHOD

The study included 2707 school aged children in eight regions of Afghanistan (16 provinces) residing in households recruited through a multi-stage stratified cluster sampling strategy in 2017. The level of terrorist threat was evaluated by the intensity of terrorist attacks recorded that year in each province. Child mental health was assessed with the parental report Strengths and Difficulties Questionnaire (SDQ) along with information on school attendance, sociodemographic characteristics and geographic location.

RESULTS

A total of 52.75% of children had scores above threshold for the SDQ total difficulties score, 39.19% for emotional difficulties, 51.98% for conduct challenges, and 15.37% for hyperactivity/inattention. Peer relationship problems were high (82.86%) and 12.38% reported that these problems impacted daily life. The level of terrorist threat was associated with SDQ total difficulties (Adjusted Odds Ratio [AOR] = 4.08, P < 0.0001), with youth in regions with high levels of terrorist threat more likely to have problems than youth in regions with low or medium levels of danger, independent of region and ethnicity. School attendance was negatively associated with emotional symptoms (AOR = 0.65, P < 0.0001) and mental health difficulties with impairment (AOR = 0.67, P = 0.007), but positively associated with peer relationships difficulties (AOR = 1.96, P > 0.0001). Conduct (AOR = 1.66, P < .0001) and SDQ total difficulties (AOR = 1.22, P = 0.019) were higher among boys. Overall, gender did not modify the relationship between school attendance and child mental health.

CONCLUSION

Attending school is essential for children's mental health, across gender, and should be supported as a priority in Afghanistan despite the return of the Taliban.

Impact of colchicine on mortality and morbidity in COVID-19: a systematic review

INTRODUCTION

Colchicine, because of its anti-inflammatory and possible anti-viral properties, has been proposed as potential therapeutic option for COVID-19. The role of colchicine to mitigate "cytokine storm" and to decrease the severity and mortality associated with COVID-19 has been evaluated in many studies.

OBJECTIVE

To evaluate the role of colchicine on morbidity and mortality in COVID-19 patients.

METHODS

This systematic review was conducted in accordance with the PRISMA recommendations. The literature search was conducted in 6 medical databases from inception to February 17, 2021 to identify studies evaluating colchicine as a therapeutic agent in COVID-19. All included studies were evaluated for risk of bias (ROB) using the Revised Cochrane ROB tool for randomised controlled trials (RCTs) and Newcastle-Ottawa Scale (NOS) for case-control and cohort studies.

RESULTS

Four RCTs and four observational studies were included in the final analysis. One study evaluated colchicine in outpatients, while all others evaluated inpatient use of colchicine. There was significant variability in treatment protocols for colchicine and standard of care in all studies. A statistically significant decrease in all-cause mortality was observed in three observational studies. The risk of mechanical ventilation was significantly reduced only in one observational study. Length of hospitalisation was significantly reduced in two RCTs. Risk for hospitalisation was not significantly decreased in the study evaluating colchicine in outpatients. Very few studies had low risk of bias.

CONCLUSION

Based on the available data, colchicine shall not be recommended to treat COVID-19. Further high-quality and multi-center RCTs are required to assess the meaningful impact of this drug in COVID-19.KEY MESSAGESColchicine, an anti-inflammatory agent has demonstrated anti-viral properties in in-vitro studies by degrading the microtubules, as well as by inhibiting the production of pro-inflammatory cytokines.Colchicine has been studied as a potential therapeutic option for COVID-19, with variable results.Until further research can establish the efficacy of colchicine in COVID-19, the use of colchicine in COVID-19 shall be restricted to clinical trials.

A Rare Case of Metastatic Extragonadal Yolk Sac Tumor – A Challenging Diagnosis on Cytomorphology

Introduction/Objective

Yolk sac tumors are characterized by variable histologic patterns and broad cytologic spectrum; thereby making the distinction from a poorly differentiated adenocarcinoma in a metastatic site extremely challenging. We present cytology and histology of a metastatic extragonadal germ cell tumor with predominant solid yolk sac component.

Methods/Case Report

36-year-old male presented with bilateral supraclavicular masses (right: 6 x 7 cm, left: 3 x 4 cm). CT chest and abdomen revealed large mediastinal and hilar nodal mass (11.6 cm), right hilar mass (8.5 cm), bilateral heterogeneous adrenal masses (right: 11.4 cm, left: 3.1 cm), and an enhancing retroperitoneal implant. Differential diagnoses of lymphoma, adrenocortical carcinoma, small cell lung carcinoma, and metastatic germ cell tumor were considered. Testicular ultrasound revealed no masses. Fine needle aspiration of supraclavicular lymph nodes showed highly cellular smears comprised of tumor cells, dispersed singly and in clusters, with irregular nuclear contours, increased nuclear to cytoplasmic ratio, coarse chromatin, occasional prominent nucleoli, and vacuolated cytoplasm. Tumor cells were positive for KRT7 and TTF-1, and negative for p40 and PAX8. A diagnosis of metastatic poorly differentiated carcinoma was rendered. Subsequent excisional biopsy of the lymph node showed a metastatic tumor with tumor cells similar to those seen in cytology, appearing in solid sheets with focal papillary architecture, replacing the entire lymph node. Additional immunohistochemistry showed expression of SALL4, Glypican 3, with lack of expression for OCT3/4, AFP, hCG, and CD30, supporting the diagnosis of metastatic yolk sac tumor, solid pattern.

Results (if a Case Study enter NA)

NA.

Conclusion

Aggressive clinical presentation, broad clinical differential diagnoses, rarity of a primary mediastinal yolk sac tumor, non-diagnostic cytomorphology along with expression of divergent differentiation markers (TTF-1 in our case) makes a definitive diagnosis of metastatic extragonadal yolk sac tumor extremely challenging. High index of clinical suspicion is required for a definitive diagnosis on cytomorphology.

Metastatic Common Bile Duct Melanoma Presenting as Obstructive Jaundice: A Case Report and Review

Introduction/Objective

Malignant melanomas (MM) account for 4-7% of all new cancer cases. The most common primary site is the skin, however, in 1.3% of cases, these tumors originate from the mucous membranes of the respiratory, genitourinary, and gastrointestinal tracts. The metastatic spread to the biliary system is extremely infrequent, with rare reports in the literature. Herein, we report a case of history of cutaneous MM with metastasis to the biliary tract.

Methods/Case Report

A 35-year-old Caucasian female presented with pruritis, dark urine, and jaundice. Laboratory results favored the cholestatic process (total bilirubin – 10 mg/dL, alkaline phosphatase – 500 U/L, AST- 400 U/L, ALT – 1000 U/L). She had a remote diagnosis of MM of the left chest with metastases to bilateral axillary and periclavicular lymph nodes 8 years ago. She underwent wide local excision of the skin lesion and lymph node dissection then. ERCP with direct cholangioscopy revealed a 3 x 2 cm obstructive mass in the common bile duct which was biopsied to reveal cohesive, pleomorphic, epithelioid cells containing black-brown pigment with enlarged, irregular, and hyperchromatic nuclei. These atypical cells stained strongly with SOX10 and Mart-1 immunohistochemical stains, confirming the diagnosis of metastatic malignant melanoma.

Results (if a Case Study enter NA)

NA.

Conclusion

MM is cancer that originates from melanocytes, derived from the neural crest during embryogenesis. The pathogenesis of metastatic spread to the biliary system is still unknown due to the paucity of literature describing this. Diagnosis is often difficult, with many patients completely asymptomatic or occasionally presenting with biliary symptoms. There should be a detailed history, and extensive clinical workup along with extensive histological and immunoprofile, esp. in cases with a history of cutaneous melanoma for early detection of a potential metastasis leading to adequate management.

Malignant Dural Solitary Fibrous Tumor; An Exceedingly Rare Entity

Introduction/Objective

A solitary fibrous tumor (SFT) is an extremely rare mesenchymal neoplasm, accounting for &lt;1% of all primary CNS tumors. Most SFT is dural-based and occurs predominantly in the fourth to sixth decade of life. Here, we present a case of a dural solitary fibrous tumor.

Methods/Case Report

A 28-year-old male presented with intermittent throbbing headache, nausea, and vomiting. Imaging revealed a large, well-circumscribed left parafalcine, dural-based multilobulated, solid, and cystic mass. The patient underwent craniotomy with mass resection. Preliminary intraoperative findings were of a spindle cell neoplasm. Histopathologic examination showed hypercellular neoplasm composed of the spindle to ovoid cells with a high nuclear to cytoplasmic ratio and limited intervening stroma arranged in a haphazard pattern with prominent branching staghorn vasculature. Focal areas of necrosis and mitotic counts of 8/10 high power field were also seen. The lesional cells showed focal cytoplasmic CD34 expression and strong STAT6 nuclear expression. Finally, a diagnosis of SFT, haemangiopericytoma phenotype classified as grade 3, was made.

Results (if a Case Study enter NA)

NA

Conclusion

Most SFTs are considered clinically benign (grade 1 tumors) with favorable outcomes after complete resection. However, haemangiopericytoma phenotype with hypercellularity, necrosis, and elevated mitotic count (&gt; 4/10 HPF) is known to have an increased risk of local recurrence and rare metastasis, requiring patients to receive adjuvant radiotherapy after resection for longer progression-free survival. Therefore, it is vital to be aware of this entity for optimal management and more active systemic surveillance in patients with high-grade SFT tumors. Our patient is currently doing well post-adjuvant radiotherapy and is under active annual surveillance.

over-activated p21 protein activated kinase-3 (pak3) leads to myocardial lipotoxicity and cardiac dysfunction in diet-induced metabolic stress

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation

Background

In clinics, metabolic stress-induced cardiomyopathy is featured as diastolic/systolic dysfunction, at least partially resulting from impairment of metabolic flexibility in the myocardium, which leads to lipotoxicity and oxidative stress accompanied with cardiomyocytes death. P21-activated kinases (Paks) are a family of serine/threonine kinases, involved in cell survival, proliferation and cytoskeleton remodelling. In spite of the cardioprotective functions of Pak1 and Pak2 in the myocardium, the role of cardiac Pak3 is unexplored.

Purpose

The study is to investigate the function of cardiac Pak3 on myocardial steatosis in response to diet-induced metabolic stress, which will provide proof-of-concept evidence for the therapeutic potential for alleviating cardiac dysfunction by targeting lipotoxicity in the myocardium.

Methods

Pak3 overexpression in the myocardium was achieved by tail vein injection of adeno associated virus (AAV9) delivery of troponin T promoter-driven Pak3 on C57BL/6J mice. The mice were fed with high fat high sucrose diet, the metabolic profiles and cardiac function were measured at 4-week intervals. In addition, cardiac morphological and cellular changes were assessed, including cell size, fibrosis formation, cell death, lipid accumulation and lipid peroxidation. In addition, the transcript levels of the genes either participating lipid metabolism or regulating oxidative stress were also assessed by qPCR.

Results

First, we detected that Pak3 expression and activation was increased in the myocardium from human with obese or diabetes. Consistently, the augmented Pak3 was also detected in the failing heart from C57BL/6J mice, ob/ob and db/db mice. Next, in a time-course study, the mice with AAV9-delivery cardiac Pak3 overexpression were vulnerable to cardiac dysfunction upon diet-induced metabolic stress. Pak3 overexpression did not alter cardiomyocyte size; however, more fibrosis and cell death in the myocardium were detected due to Pak3 enhancement. More importantly, myocardial lipid accumulation and profound lipid peroxidation were determined by immunefluorescent staining of Perilipin 5 (PLIN5) and 4-Hydroxynonenal (4-NHE), respectively. Finally, the abnormal expression of the genes involved in lipid synthesis and fatty acid oxidation was detected in Pak3-overexpressed myocardium under metabolic stress, whereas the levels of anti-oxidative stress genes were decreased.

Conclusion

Altogether, the study has demonstrated that Pak3 over-activation makes the heart more susceptible to myocardial lipotoxicity, which accelerates cardiac steatosis and dysfunction in the fact of metabolic stress.

Paracrine signal emanating from stressed cardiomyocytes aggravates inflammatory microenvironment in diabetic cardiomyopathy

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation

Background

Cardiovascular issues associated with diabetes, such as diabetic cardiomyopathy (DCM), can lead to heart failure. DCM is etiologically related to myocardial inflammation and can stem from a complex interplay of different cell types. Cardiomyocyte as an active mediator of the inflammatory response is an emerging concept with limited mechanistic understanding.

Purpose

We aimed to address the knowledge gap of cardiomyocyte endoplasmic reticulum (ER) dysfunction-mediated macrophage response and provide functional evidence for the therapeutic feasibility of managing inflammatory paracrine signals in response to diet-induced metabolic stress.

Methods

In vivo mouse model of high fat high sucrose diet-induced diabetes, cardiomyocyte-specific p21-activated kinase 2 (PAK2) knockout model, echocardiography, histology, 3D imaging, qPCR, co-culture of H9c2 culturing medium and bone-marrow derived macrophages, immunoblotting, macrophage isolation from myocardium, flow cytometry and AAV9-gene therapy.

Results

In a time-course study, diet-induced diabetic mice demonstrated an association between cardiac ER stress and sustained myocardial inflammation, with a maladaptive shift in myocardial ER stress response over time. Furthermore, as a cardiac ER dysfunction model, mice with cardiac-specific PAK2 deletion exhibited heightened myocardial inflammatory response in diabetes. Using human and mice diabetic heart samples, we show that ER stress-induced CCAAT/enhancer-binding protein homologous protein (CHOP) is a novel transcriptional regulator of high mobility group box-1 (HMGB1). Cardiac stress-induced active release of HMGB1 facilitated M1 macrophage polarization, and aggravated myocardial inflammatory signatures. Therapeutically, sequestering the extracellular HMGB1 using Glycyrrhizin conferred cardioprotection through its anti-inflammatory action. Also, as functional evidence, we showed that un-mitigated cardiac ER response due to PAK2 loss under diabetes may account as a barrier for leveraging the anti-inflammatory potential of Vildagliptin.

Conclusion

Collectively, we introduce an ER stress-mediated cardiomyocyte-macrophage link, altering the macrophage response in the myocardium, thereby providing insight into therapeutic prospects for diabetes-associated cardiac dysfunction.

Fracture toughness and fractal analysis of ceramic benchmark materials

Previous studies have reported various methods of measuring the fracture toughness of brittle ceramics. The purpose of the present research was to use a new method of fractal dimension measurement on benchmark materials (silica glass, Viosil SX, Shin-Etsu, n = 13, and silicon nitride standard reference material, SRM2100, NIST, n = 10), to compare the fracture toughness calculated using different methods, and to study the effect of noise filtering on the fractal dimension and fracture surface roughness. Fracture toughness was determined using surface crack in flexure method according to ASTM C1421 and fractal analysis method. Fractal dimension was determined using the Minkowski Cover algorithm on atomic force microscope scans of epoxy replicas of fracture surfaces. The mean ± standard deviation of fracture toughness using surface crack in flexure method and fractals method were 0.97 ± 0.18 MPa·m1/2 and 1.03 ± 0.07 MPa·m1/2 for silica glass and 4.62 ± 0.14 MPa·m1/2 and 2.54 ± 0.07 MPa·m1/2 for silicon nitride, respectively. The mean ± standard deviation of fractal dimension was 2.17 ± 0.03 for silica glass and 2.13 ± 0.01 for silicon nitride. The mean ten-point roughness (Rz) before and after noise filtering was 89 ± 102 nm and 87 ± 101 nm for silica glass and 355 ± 132 nm and 357 ± 134 nm for silicon nitride, respectively. Noise filtering had no significance on the fracture surface roughness of the two materials. The newly developed fractal analysis method can be used to predict the baseline fracture toughness of specimens with unknown failure stress.

AB1421 IMPACT OF HOSPITALIZATION ON CLINICAL OUTCOMES IN PATIENTS WITH CONNECTIVE TISSUE DISEASE ASSOCIATED INTERSTITIAL LUNG DISEASE (CTD-ILD) - A SINGLE CENTER OBSERVATIONAL STUDY

Background

Interstitial lung disease(ILD) is major cause of morbidity and mortality in patients with connective tissue disease (CTD). Hospitalization is being increasingly recognized as poor prognostic indicator in these patients.

Objectives

The objective of our study was to assess the impact of hospitalization on clinical outcomes in patients with CTD-ILD.

Methods

We conducted a retrospective chart review of patients with radiologically or biopsy proven ILD associated with rheumatologist diagnosed CTD who were seen at Montefiore Medical Center between January 2007 and December 2018. Patients with age>18 years who had either 2 CT scans of the chest and/or 2 sets of pulmonary function tests (PFT) atleast 6 months apart were included in the study. Clinical demographics, cause of hospitalization, length of stay, use of immunosuppression and mortality were identified. Patients were stratified into 2 cohorts; non-hospitalized and hospitalized patients. The latter cohort was further sub-stratified into patients with cardiopulmonary vs. non-cardiopulmonary hospitalization (Figure 1). Two-sample t-tests and Wilcoxon’s rank sum tests were used for comparing the continuous variables. Chi-square tests and Fisher’s exact tests were used for comparing the categorical variables as appropriate. Kaplan-Meier method was used for calculating the survival probabilities, and log-rank tests were used to compare differences between the groups.

Results

During the study period, we identified 213 patients with CTD-ILD using ICD 9/10 code. Of the 213 patients, 96 met our inclusion criteria and 73 (76%) had at least 1 hospitalization (Figure 1). Both groups were similar in baseline clinical characteristics but we identified significantly higher transplant referrals in the hospitalized group(23.9%) vs. non-hospitalized group(0%) (Table 1). Overall rheumatoid arthritis (29.2%) was the most common CTD associated ILD followed by inflammatory myositis (21.9%) and scleroderma (14.6%). Median time from diagnosis of ILD to first hospitalization was 1.42 years.

Table 1.

Baseline Characteristics of patients with CTD-ILD

CharacteristicEntire Cohort (n = 96)Patients with CTD-ILD and hospitalization (n = 73)Patients with CTD-ILD and no hospitalization (n = 23)p-valueAge(mean ± SD)54.15 ± 13.9754.82 ± 13.7752.00 ± 14.710.40Female, n (%)76 (79.2)56 (76.7)20 (87.0)0.39Race, % (n)0.10 Black38 (39.6)31 (42.5)7 (30.4) White4 (4.2)3 (4.1)1 (4.4) Others54 (56.2)39(53.4)15(65.3)Ethnicity, % (n) (Hispanic)44 (53.7)35 (53.0)9 (56.3)0.82Former or active smoker, % (n)41 (42.7)34 (46.6)7 (30.4)0.17Pulmonary hypertension, % (n)28 (31.1)24 (33.3)4 (22.2)0.36FVC, n (%)0.37Moderately severe(47.1-64.2)37 (44.6)26 (40.6)11 (57.9)Severe(24.3-47.0)7 (8.4)6 (9.4)1 (5.3)DLCO, n(%)0.30Moderate26(31.7)23(37.1)3(15.0)Severe25(30.5)17(27.4)8(40.0)Immunosuppression, n(%)78 (81.3)59 (80.8)19 (82.6)1.00Transplant referral, n(%)17 (18.3)17 (23.9)0 (0)0.01

The patients hospitalized for cardiopulmonary cause were significantly older(57.2 ±13.1 years) than those admitted with non-cardiopulmonary cause(49.2±14.8 years)(Mean±SD). Older age (HR 1.95, p=0.02) and length of stay greater than 7 days for cardiopulmonary cause(HR 4.82,p=0.01) was associated with higher risk of mortality.

Kaplan Meier curve analysis showed that hospitalization (p-value=0.02) was associated with statistically significant increased risk of death.

Conclusion

-Hospitalization in CTD-ILD patients especially length of stay more than 7 days due to cardiopulmonary causes was associated with statistically significant increased risk of death.

Male gender and older age was associated with a worse prognosis in patients who were hospitalized.

References

[1]Ratwani AP, Ahmad KI, Barnett SD, Nathan SD, Brown AW. Connective tissue disease-associated interstitial lung disease and outcomes after hospitalization: A cohort study. Respiratory Medicine. 2019;154:1-5. doi:10.1016/j.rmed.2019.05.020

Disclosure of Interests

None declared

"Novel Management of Depression Using Ketamine in the Intensive Care Unit"

BACKGROUND

Ketamine, a dissociative anesthetic, induces improvement in depressive symptoms by antagonizing glutaminergic NMDA receptors. Ketamine has been used previously in outpatient setting for treatment-resistant depression, but we showcase its utility in depression management at the Intensive Care Unit (ICU). Research Question: Can ketamine be used for depression treatment in ICU patients? Study Design and Methods: A retrospective chart review of ICU patients was done at a tertiary center from 2018 to 2021, to assess the ketamine usage. Among the patients reviewed, ketamine was used for depression in 12, and for analgesia & sedation in 2322 patients. Ketamine was administered in doses of 0.5mg/kg & 0.75mg/kg for depression. Each course consisted of 3 doses of ketamine administered over 3 days, and 7 in 12 patients received a single course of ketamine. The rest received 3-4 courses 1 week apart. Results: Ketamine was found to improve mood and affect in most of the patients with depression. 11 in 12 patients had a positive response with better sleep. It has a major advantage over conventional anti-depressants since it takes only a few hours to induce clinical improvement. Patients who were observably withdrawn from care team and family, were administered ketamine. Conclusion: A major drawback of ketamine is that the duration of clinical improvement is short, with the response lasting only up to seven days after a single dose. Hence, all the patients in our study were weaned off ketamine with a supporting antidepressant. Ketamine has been documented to cause cardio-neurotoxicity; however, only one patient had worsening lethargy in our study. To conclude, ketamine has a marked benefit in treating depression in the ICU. Although our study was associated with positive outcomes, there is a need for prospective studies with long-term follow-up assessments.

Reducing mortality in mucormycosis of the head and neck in diabetic patients: A CARE case series

INTRODUCTION

Rhinocerebral mucormycosis is extremely fatal, with mortality rates ranging from 85-93% despite the best treatment in immunocompromised patients. We emphasize the importance of early diagnosis, repeated debridement, and aggressive antifungal treatment to reduce mortality.

CASE SUMMARY

We report six cases (five male and one female), with a mean age of 51 years who were diagnosed to have mucormycosis from 2017 to 2019. All patients were diabetic. Intracranial involvement and orbital involvement were found in four cases. Facial nerve palsy was seen in two cases, one without any apparent otological involvement. Aggressive serial debridement and amphotericin B was started. Posaconazole was added subsequently to the treatment in two cases. One patient succumbed to the disease five months after discharge. The other five patients are on regular follow-up for a mean duration of 14 months at the end of which two had residual disease which was under control.

DISCUSSION

Repeated surgical debridement with an early aggressive and combination antifungal therapy can result in good outcomes even in advanced mucormycosis. Concurrent management of the underlying pathology, monitoring of liver and kidney functions, and therapeutic drug monitoring are useful to ensure smooth and effective treatment.

Hydroxychloroquine: A review of its safety and efficacy in COVID-19

SARS-CoV-2 is a novel virus that has infected millions of people across the world. Given the compelling need to develop a therapeutic strategy, hydroxychloroquine has been advocated as an effective drug for the infection. However, multiple clinical trials conducted using hydroxychloroquine have yielded contrasting results. An electronic search using the primary databases from WHO, PubMed and Google Scholar was performed that yielded 21 studies eligible for inclusion. Among a total of 1,350 patients who received hydroxychloroquine, 689 (51.04%) were females. The most commonly reported comorbidities include hypertension (15.18%), diabetes mellitus (8.44%) and pulmonary disease (8.96%). Of the hydroxychloroquine-treated patients, 70% were virologically cured compared to 12.5% of the control group (p = 0.001). A good clinical outcome with virological cure was reported in 973 patients (91%) within 10 days out of 1,061 hydroxychloroquine-treated patients. A total of 29 (65%) renal transplant recipients achieved complete recovery following hydroxychloroquine administration. A total of 37 (2.7%) patients reported QT prolongation. Hydroxychloroquine was found to reduce mortality in healthy, SARS-Cov-2 positive patients and improve clinical recovery in renal transplant recipients. However, a definitive conclusion regarding its effect on viral clearance can only be reached by conducting more clinical trials involving bigger and diverse samples.

COVID-19 Outcomes Amongst Patients With Pre-existing Cardiovascular Disease and Hypertension

INTRODUCTION

 Coronavirus disease 2019 (COVID-19) has multiorgan involvement and its severity varies with the presence of pre-existing risk factors like cardiovascular disease (CVD) and hypertension (HTN). Therefore, it is important to evaluate their effect on outcomes of COVID-19 patients. The objective of this meta-analysis and meta-regression is to evaluate outcomes of COVID-19 amongst patients with CVD and HTN.

METHODS

English full-text observational studies having data on epidemiological characteristics of patients with COVID-19 were identified searching PubMed from December 1, 2019, to July 31, 2020, following Meta-analysis Of Observational Studies in Epidemiology (MOOSE) protocol. Studies having pre-existing CVD and HTN data that described outcomes including mortality and invasive mechanical ventilation (IMV) utilization were selected. Using random-effects models, risk of composite poor outcomes (meta-analysis) and isolated mortality and IMV utilization (meta-regression) were evaluated. Pooled prevalence of CVD and HTN, correlation coefficient (r) and odds ratio (OR) were estimated. The forest plots and correlation plots were created using random-effects models.

RESULTS

Out of 29 studies (n=27,950) that met the criteria, 28 and 27 studies had data on CVD and HTN, respectively. Pooled prevalence of CVD was 18.2% and HTN was 32.7%. In meta-analysis, CVD (OR: 3.36; 95% CI: 2.29-4.94) and HTN (OR: 1.94; 95% CI: 1.57-2.40) were associated with composite poor outcome. In age-adjusted meta-regression, pre-existing CVD was having significantly higher correlation of IMV utilization (r: 0.28; OR: 1.3; 95% CI: 1.1-1.6) without having any association with mortality (r: -0.01; OR: 0.9; 95% CI: 0.9-1.1) among COVID-19 hospitalizations. HTN was neither correlated with higher IMV utilization (r: 0.01; OR: 1.0; 95% CI: 0.9-1.1) nor correlated with higher mortality (r: 0.001; OR: 1.0; 95% CI: 0.9-1.1).

CONCLUSION

In age-adjusted analysis, though we identified pre-existing CVD as a risk factor for higher utilization of mechanical ventilation, pre-existing CVD and HTN had no independent role in increasing mortality.

Prevalence and Outcomes Associated with Vitamin D Deficiency among Indexed Hospitalizations with Cardiovascular Disease and Cerebrovascular Disorder-A Nationwide Study

Background: According to past studies, recovery and survival following severe vascular events such as acute myocardial infarction and stroke are negatively impacted by vitamin D deficiency. However, the national estimate on disability-related burden is unclear. We intend to evaluate the prevalence and outcomes of vitamin D deficiency (VDD) among patients with cardiovascular disease (CVD) and cerebrovascular disorder (CeVD). Methods: We performed a cross-sectional study on the Nationwide Inpatient Sample data (2016-2017) of adult (≥18 years) hospitalizations. We identified patients with a secondary diagnosis of VDD and a primary diagnosis of CVD and CeVD using the 9th revision of the International Classification of Diseases, clinical modification code (ICD-10-CM) codes. A univariate and mixed-effect multivariable survey logistic regression analysis was performed to evaluate the prevalence, disability, and discharge disposition of patients with CVD and CeVD in the presence of VDD. Results: Among 58,259,589 USA hospitalizations, 3.44%, 2.15%, 0.06%, 1.28%, 11.49%, 1.71%, 0.38%, 0.23%, and 0.08% had primary admission of IHD, acute MI, angina, AFib, CHF, AIS, TIA, ICeH, and SAH, respectively and 1.82% had VDD. The prevalence of hospitalizations due to CHF (14.66% vs. 11.43%), AIS (1.87% vs. 1.71%), and TIA (0.4% vs. 0.38%) was higher among VDD patients as compared with non-VDD patients (p < 0.0001). In a regression analysis, as compare with non-VDD patients, the VDD patients were associated with higher odds of discharge to non-home facilities with an admission diagnosis of CHF (aOR 1.08, 95% CI 1.07-1.09), IHD (aOR 1.24, 95% CI 1.21-1.28), acute MI (aOR 1.23, 95% CI 1.19-1.28), AFib (aOR 1.21, 95% CI 1.16-1.27), and TIA (aOR 1.19, 95% CI 1.11-1.28). VDD was associated with higher odds of severe or extreme disability among patients hospitalized with AIS (aOR 1.1, 95% CI 1.06-1.14), ICeH (aOR 1.22, 95% CI 1.08-1.38), TIA (aOR 1.36, 95% CI 1.25-1.47), IHD (aOR 1.37, 95% CI 1.33-1.41), acute MI (aOR 1.44, 95% CI 1.38-1.49), AFib (aOR 1.10, 95% CI 1.06-1.15), and CHF (aOR 1.03, 95% CI 1.02-1.05) as compared with non-VDD. Conclusions: CVD and CeVD in the presence of VDD increase the disability and discharge to non-home facilities among USA hospitalizations. Future studies should be planned to evaluate the effect of VDD replacement for improving outcomes.

Epidemiological and Clinical Characteristics of 6635 COVID-19 Patients: a Pooled Analysis

An unidentified pneumonia outbreak was first observed in Wuhan, the capital of Hubei Province, China, in December 2019. WHO officially named the disease, Coronavirus Disease 2019 (COVID-19), and declared it as pandemic on Mar 11, 2020. Globally, there are more than 3 million confirmed cases with nearly 200,000 deaths. Hence, we aimed to perform a systematic review and pooled analysis of the current published literature on COVID-19 to provide an insight on the epidemiological and clinical characteristics of COVID-19 patients. A systematic search of published peer-reviewed articles that reported cases with demographical and clinical features of real-time reverse transcriptase polymerase chain reaction (rRT-PCR)-confirmed SARS-CoV-2 infection using MOOSE guidelines was conducted from December 1, 2019, to April 27, 2020, and 50 eligible articles were included for the final analysis. Review articles, opinion articles, and letters not presenting original data as well as studies with incomplete information were excluded. We included a total of 6635 patients from 50 articles, with 54.5 % being male. The predominant symptoms were fever (80.3%), cough (64.2%), and fatigue/myalgia (36.5%) and other symptoms including dyspnea, chest pain, and sore throat. We also found patients with GI symptoms like diarrhea (9.2%) and nausea/vomiting (5.2%). Comorbidities were found in 3,435 (51.7%) patients with the most common being hypertension (22.67%) followed by diabetes mellitus (12.78%). COVID-19 pandemic is not only leading a huge burden on health care facilities but significant disruption in the world society. Patients with coexisting comorbidities are at higher risk and need more utilization of health care resources. As this virus is spreading globally, all countries have to join hands and prepare at all levels of human resources, infrastructure, and facilities to combat the COVID-19 disease.

Mechanical and release behaviour of theophylline from matrix tablets containing psyllium powder in combination with grewia polysaccharides

This study was aimed at investigating the effect of grewia polysaccharides on the mechanical and release properties of tablet matrices containing binary mixtures of the polysaccharide with psyllium. Two grades of grewia polysaccharides (GG and GDS) were extracted and binary mixtures of the polysaccharides with psyllium were formulated into tablet matrices containing theophylline as the model drug. The true, bulk and tapped densities, Carr's compressibility index of the powders and binary composites were determined before tablet compression. Tablet properties (hardness, porosity, and drug release from the matrices) were investigated. The dissolution test was carried out in 0.1 M HCl (pH 1.2) and phosphate buffer (pH 6.8). The results show that GG and GDS produced tablets with good mechanical strength (108.33 N and 95.70 N, respectively) while psyllium produced softer tablets (7.13 N). The combination of psyllium and grewia polysaccharides in the matrices resulted in a significant increase in the mechanical strength of the matrices when compared to matrices containing psyllium alone as the matrix former. The results also showed that GG and GDS reduced the dissolution rate and effectively eliminated the burst release of theophylline from the psyllium matrices at both pHs. The matrices of GG or GDS and the binary mixtures conform to non-Fickian anomalous diffusion with n > 0.45. When overcoming the burst release of drug from matrices such as psyllium, grewia polysaccharides may provide an effective reduction and a more sustained drug release from such matrices.

Socioecological differences in factors associated with inconsistent condom use with female sex workers and casual partners: an observational study of heterosexual men attending an anonymous HIV testing clinic in Singapore

Sexual practices among heterosexual men may differ between female sex workers (FSWs) and casual partners. We surveyed 203 heterosexual men and investigated the attributes associated with inconsistent condom use among them. Lower educational attainment was positively associated with inconsistent condom use with FSWs (adjusted prevalence ratio (aPR) 2.63; P = 0.018) and casual partners (aPR 1.55; P = 0.022), whereas early age of sexual debut (aPR 3.00; P = 0.012) and alcohol use during sex (aPR 7.95; P < 0.001) were positively associated with inconsistent condom use with FSWs. Socioecological factors may explain such differences.

Survivourship Issues As Determinants of Quality of Life After Breast Cancer Treatment: Report From a Limited Resource Setting

Background: Cancer survivorship is an unremitting struggle for breast cancer patients, as the consequence of complex treatment processes and its multitude of residual and late emerging side effects, have a significant impact on their quality of life (QOL). Unique issues of survivorship include those related to physical, psychological, social, and spiritual well-being of women. Amid a growing population of breast cancer survivors (BCs) worldwide, supportive care research is assuming greater importance in breast cancer care. Focus of survivorship research is to identify issues impacting QOL of the cancer survivors so that supportive care services can be tailored to their specific needs. Role of individual survivor's issues have been widely reported but a comprehensive picture is lacking. Aim: This study was conducted with the aim to identify important survivorship issues adversely affecting QOL of women after breast cancer treatment. Main objectives were to (1) estimate prevalence of various survivorship issues (2) assess QOL of survivors by using FACT-B and SF-36 questionnaires (3) study impact of time elapsed since treatment on survivorship issues and QOL scores (4) identify most important issues from the perspective of impact on QOL. Methods: This descriptive, hospital based, cross sectional study was conducted in 230 breast cancer survivors and a group of 112 healthy age-matched-controls, in an academic healthcare setting in northern India. A checklist of 14 commonly reported survivorship issues, and questionnaires for QOL assessment were administered to participants. Main outcome measures were (1) frequencies of survivorship issues and QOL scores among three groups divided on the basis of time elapsed since treatment (< 2 year follow-up, 2-5 year follow-up and > 5 year follow-up) (2) association of survivorship issues with QOL scores (3) stepwise regression analysis to identify issues with most significant impact on QOL of survivors. Results: Breast cancer survivors showed an improvement in their QOL over time which was sustained in long term survivors. However their quality of life remains poorer, compared with healthy women, irrespective of the duration of follow-up. The most prevalent survivorship issues were fatigue (60%), restriction of shoulder movement (59.6%), body and joint pain (63.5%), chemotherapy induced cessation of menstruation (73.3%) and loss of sexual desire (60%). However the issues which had maximum adverse effect on QOL scores were emotional distress, fatigue, postmastectomy chronic pain, cessation of menstruation, body and joint pain, vaginal dryness and sleep disturbances. Conclusion: Thus in this study, emotional distress and cancer related fatigue were found to be the chief determinants of poor QOL. Further premature menopause, with its attendant systemic symptoms, vulvo-vaginal atrophy and sexual dysfunction emerged as a key contributor to poor QOL in BCs.

Organochlorine Pesticides Exposure as a Risk Factor for Breast Cancer in Young Women: A Case Control Study

Background: Young women (< 40 years) constitutes about 10%–25% of total breast cancer cases in south-Asian women and an increase in incidence rates have been noted in the recent past. It is higher compared with their western counterparts, where rates of 5%–10% are reported. Younger women usually present with more aggressive tumor and poorer prognosis, suggesting that breast cancer in young women represents a distinct entity. Exposure to environmental estrogens such as organochlorine compounds in pesticides and industrial chemical has been proposed to be a risk factor for breast cancer. There is rampant use of pesticides in farming in south-Asian countries. However the associations between organochlorine compounds and breast cancer risk, reported in different studies has been inconsistent. Hence this study was planned with the objectives to assess the serum levels of organochlorine compound and the presence of other risk factors in north Indian population of young women diagnosed with breast cancer. Aim: To assess the serum level of organochlorine compounds and the other risk factors in north-Indian population of young women diagnosed with breast cancer. Methods: This case control study was conducted at UCMS & GTB Hospital, Delhi, India in 42 patients of breast cancer ≤ 40 years age and 42 age-matched-controls. The study subjects were evaluated for various known risk factors such as family history of breast or ovarian cancer, age of menarche, number of pregnancies and abortions, duration of breast feeding, oral contraceptive intake, obesity, benign breast disease & biopsy, etc. Study subjects were also evaluated for exposure to environmental pollutants by performing of assays of twelve different organochloride pesticides in their blood samples. Genetic analysis also done to look for polymorphisms of genes: BRCA1 at Q365R, BRCA2 at 6174delT and p53 at 216 location. Results: Significant association was seen between serum level of β- HCH, heptachlor, dieldrin, p,p'-DDE and risk of breast cancer in young women in our patient population. Significant association was also found between early age of menarche, obesity, BRCA 2 and p53 gene polymorphism as risk factors for breast cancer. Conclusion: Exposure to organochlorine pesticides could be an important modifiable risk factor, responsible for an increase in the rates of breast cancer in younger women. Polymorphism of p53 at 216 location & BRCA2 at 6174delT could be independent susceptibility marker in younger women with breast cancer. Larger studies are required to validate these results.

Examples of dynamic chirality in nuclei

In many cases the chirality was almost observed but the transition probabilities are different. This fact is clearly seen in the cases of 134Pr and 102Rh. In the case of chirality, the yrast and the side bands should be nearly degenerate. In the angular momentum region where chirality sets, the B(E2) values of the electromagnetic transitions deexciting analog states of the chiral twin bands should be almost equal. Correspondingly the B(M1) values should exhibit staggering. Our lifetime measurements in the cases of 134Pr and 102Rh and the theoretical analysis do not support static chirality. Chirality has mainly a dynamical character in both nuclei. In the present paper, we compare our results with the results for other chiral candidate nuclei, which fulfill static chirality conditions.