Impact of improving infection control and antibiotic stewardship practices on nosocomial infections and antimicrobial resistance in an oncology centre from India

BACKGROUND

Improving basic infection control (IC) practices, diagnostics and anti-microbial stewardship (AMS) are key tools to handle antimicrobial resistance (AMR).

MATERIALS AND METHODS

This is a retrospective study done over 6 years (2016-2021) in an oncology centre in North India with many on-going interventions to improve IC practices, diagnostics and AMS. This study looked into AMR patterns from clinical isolates, rates of hospital acquired infections (HAI) and clinical outcomes.

RESULTS

Over all, 98,915 samples were sent for culture from 158,191 admitted patients. Most commonly isolated organism was E. coli (n ​= ​6951; 30.1%) followed by Klebsiella pneumoniae (n ​= ​5801; 25.1%) and Pseudomonas aeroginosa (n ​= ​3041; 13.1%). VRE (Vancomycin resistant Enterococcus) rates fell down from 43.5% in Jan-June 2016 to 12.2% in July-Dec 2021, same was seen in CR (carbapenem resistant) Pseudomonas (23.0%-20.6%, CR Acinetobacter (66.6%-17.02%) and CR E. coli (21.6%-19.4%) over the same study period. Rate of isolation of Candida spp. from non-sterile sites also showed reduction (1.68 per 100 patients to 0.65 per 100 patients). Incidence of health care associated infections also fell from 2.3 to 1.19 per 1000 line days for CLABSI, 2.28 to 1.88 per 1000 catheter days for CAUTI. There was no change in overall mortality rates across the study period.

CONCLUSION

This study emphasizes the point that improving compliance to standard IC recommendations and improving diagnostics can help in reducing the burden of antimicrobial resistance.

Ancistrocladinium A Induces Apoptosis in Proteasome Inhibitor-Resistant Multiple Myeloma Cells: A Promising Therapeutic Agent Candidate

The N,C-coupled naphthylisoquinoline alkaloid ancistrocladinium A belongs to a novel class of natural products with potent antiprotozoal activity. Its effects on tumor cells, however, have not yet been explored. We demonstrate the antitumor activity of ancistrocladinium A in multiple myeloma (MM), a yet incurable blood cancer that represents a model disease for adaptation to proteotoxic stress. Viability assays showed a potent apoptosis-inducing effect of ancistrocladinium A in MM cell lines, including those with proteasome inhibitor (PI) resistance, and in primary MM cells, but not in non-malignant blood cells. Concomitant treatment with the PI carfilzomib or the histone deacetylase inhibitor panobinostat strongly enhanced the ancistrocladinium A-induced apoptosis. Mass spectrometry with biotinylated ancistrocladinium A revealed significant enrichment of RNA-splicing-associated proteins. Affected RNA-splicing-associated pathways included genes involved in proteotoxic stress response, such as PSMB5-associated genes and the heat shock proteins HSP90 and HSP70. Furthermore, we found strong induction of ATF4 and the ATM/H2AX pathway, both of which are critically involved in the integrated cellular response following proteotoxic and oxidative stress. Taken together, our data indicate that ancistrocladinium A targets cellular stress regulation in MM and improves the therapeutic response to PIs or overcomes PI resistance, and thus may represent a promising potential therapeutic agent.

Study of Efficacy and Toxicity of Capecitabine Maintenance After Response to Docetaxel, Cisplatin, and 5-Fluracil-Based Chemotherapy in Advanced Carcinoma Stomach

BACKGROUND

Advanced gastric cancer is associated with poor survival despite chemotherapy. Maintenance chemotherapy has been successfully tried in lung cancer and colorectal cancers however there is scarce literature on maintenance therapy in advanced gastric cancer. We report a prospective non-randomized single-arm trial of capecitabine maintenance after response to docetaxel, cisplatin, and 5-Flurouracil-based chemotherapy.

METHODS

50 patients with advanced gastric cancer, who had achieved response or had stable disease after 6 cycles of Docetaxel, Cisplatin, and 5-Flurouracil (D 75 mg/m2, C 75 mg/m2, FU 750 mg/m2/d d1-d5, q3 weeks) chemotherapy were prospectively selected to receive maintenance chemotherapy with capecitabine (1000mg/ m2 bid d1-d14 q21 days) until progression.

RESULTS

During the median follow-up period of 18 months all patients had progressed, however, there was no treatment-related death, the median time to tumor progression was 10.3 months, with grade 3 and 4 toxicities in 10-15% of patients, and treatment delays in 75% of patients.

CONCLUSIONS

Our study has shown that maintenance chemotherapy with capecitabine post-first-line docetaxel, cisplatin, and 5-FU-based chemotherapy is effective and delays tumor progression. However, toxicity was a concern in our study which led to treatment-related delays but without any treatment-related death. Most patients continued therapy till progression.

All-Serotype Dengue Virus Detection through Multilayered Origami-Based Paper/Polymer Microfluidics

The dengue virus (DENV) infection commonly triggers threatening seasonal outbreaks all around the globe (estimated yearly infections are in the order of 100 million, combining all the viral serotypes), testifying the need for early detection to facilitate disease management and patient recovery. The laboratory-based testing procedures for detecting DENV infection early enough are challenged by the need of resourced settings that result in inevitable cost penalty and unwarranted delay in obtaining the test results due to distance-related factors with respect to the patient's location. Recognizing that the introduction of alternative extreme point-of-care technologies for early detection may potentially mitigate this challenge largely, we develop here a multiplex paper/polymer-based detection strip that interfaces with an all-in-one simple portable device, synchronizing the pipeline of nucleic acid isolation, isothermal amplification, and colorimetric analytics as well as readout for detecting all the four serotypes of dengue viruses in around 30 min from about 50 μL of human blood serum with high specificity and sensitivity. Aligned with the mandatory guidelines of the World Health Organization, the ultralow-cost test is ideal for dissemination at different community centers via a user-friendly device interface, not only as a critical surveillance measure in recognizing the potential cocirculation of the infection across regions that are hyperendemic for all four DENV serotypes but also for facilitating effective monitoring of patients infected by any one of the particular viral serotypes as well as timely administration of life-saving measures on need.

Treatment conundrums in osteosarcoma of the breast: Case report of two cases from a tertiary care cancer center in India

Extraosseous sarcoma of the breast is an infrequent entity and a harbinger of poor prognosis. Histogenesis of this tumor is uncertain, and it can arise both in denovo and metastatic settings. Morphologically, it is indistinguishable from its skeletal counterpart and clinically, it presents like any other subtype of breast cancer. Tumor recurrence with a propensity for hematogenous rather than lymphatic spread plagues with this malicious disease. Treatment guidelines are mainly extrapolations from those of treatment of other extra-skeletal sarcomas as literature is limited in this context. In this study, it was aimed to present two clinical cases with similar clinical profiles and different treatment outcomes. The intent of this case report is to contribute to the limited database available for management of this rare disease.

Breast Cancer in Transgenders: Narrative Review

The molecular pathogenesis of breast cancer (BC), the second most common cancer, varies significantly between sexes, with minimal data in the transgender population. The overall prevalence of BC in transgenders is estimated to be 0.02%. Besides experiencing social disparities, transgenders have to face a lot of discrimination in the healthcare system. Adversities faced, along with the urge to identify with physical attributes to the gender felt by them, forces transgenders to use non-prescribed hormones. Gender affirming hormone therapy (GAHT) is a key feature of transition-related care, rehabbing mental health, and the quality of life of transgenders, but at the expense of their health. Studies have reported that GAHT is associated with severe health conditions such as cancer in transgenders. Estrogens and testosterone are associated with a moderate risk of developing BC. The types of BC diagnosed in transgenders after cross-sex hormone therapy include invasive ductal and neuroendocrine carcinoma, in addition to tubular adenocarcinoma. Although diagnosed at an age earlier compared with ciswomen, BC screening recommendations for transgenders are the same as for ciswomen. This review studies in detail the types of transgenders, their characteristics, different types of breast cancers associated, issues faced while treatment, and their best possible solutions. We also hope to have well-designed research in the future, which will fill the existing gaps in knowledge and provide scientific insight into the transgender population and issues related to their health. There are no international guidelines on screening and management of transgender patients but it appears that breast screening before cosmetic mastectomy, exposure to hormonal therapy for more than 5 years, and as per natal women screening guidelines should be offered to the patient with detailed discussion on the harms and benefits of the same.

Candida Empyema in Febrile Neutropenia - Augmented value of direct inoculation into BacT/Alert blood culture vials

Candida empyema is an uncommon complication of febrile neutropenia. We present 4 such cases which highlight the importance of direct inoculation of body fluids in automated blood culture bottle leading to increased yield. Our cases and review of literature also highlight that echinocandins have poor penetration into pleural fluid; azoles (especially voriconazole) should be preferred as drug of choice.

Immobilization of catalase on functionalized magnetic nanoparticles: a statistical approach

Magnetic nanoparticles (MNPs) Fe₃O₄, by virtue of easily modifiable surface, high surface-to-mass ratio and super-paramagnetic properties, are one of suitable candidates for the enzyme immobilization. Optimization of five important variables viz. concentration of 3-aminopropyl-tri-ethoxy-silane (APTES), glutaraldehyde (GA) and enzyme, time and temperature of loading was carried out using central composite type of experimental design without blocks giving 50 experiments including eight replicates at the central point. Characterization, stability and reusability studies were also carried out with optimized preparation. Results established the correlation between observed and response surface method (RSM) equation envisaged value (R ² 0.99, 0.97 and 0.98 for enzyme's activity, its loading over MNPs and corresponding specific activity, respectively. The predicted values suggested by RSM equation were 64.00 mM of APTES, 10.97 µL of GA, 14.50 mg mL^-1 of enzyme for 67 min at 22.6 °C, resulted in activity 32.1 U mg^-1 MNPs, while specific activity was 97.7 U mg^-1. Transmission electron microscopy (TEM) showed the sizes of MNPs (10.5 ± 1.7 nm), APTES-MNPs (10.23 ± 1.74 nm), GA-APTES-MNPs (11.84 ± 1.49 nm) and Catalase-GA-APTES-MNPs (13.32 ± 2.74 nm) were statistically similar. The enzyme MNPs preparation retained 81.65% activity after 144 h at 4 °C (free enzyme retained 7.87%) and 64.34% activity after 20 reuse cycles. Statistical optimized MNPs-based catalase preparation with high activity and magnetic strength was stable and can be used for further studies related to its application as analytical recyclable enzyme or magnetically oriented delivery in the body.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13205-022-03173-8.

Clinical Profile and Outcomes of Treatment in Gastric Cancer in Young Patients in India

Introduction Gastric cancer poses an enormous burden across the globe and India in terms of cancer-related mortality. There is paucity of epidemiological and survival data among young gastric cancer patients in India. In this study, we retrospectively analyzed the general characteristics, clinical profile, and survival data of gastric cancer in young patients < 30 years at tertiary care institution at New Delhi, India.

Materials and Methods Young gastric cancer patients (≤30 years) who were registered over a period of 7 years (2010–2017) were analyzed at a tertiary care center. Total of 2,735 patients of gastric cancers were registered out of which 70 cases were younger than 30 years, of which 63 patients were available for final analysis and data was missing for the remaining 7 cases. All patients underwent standard diagnostic and staging investigation and were staged as per American Joint Committee on Cancer 7 staging system. Lymph node ratio was calculated as number of positive nodes by the number of lymph nodes removed and were categorized as ≤0.6 and >0.6. Minimum follow-up of 1 year was required for inclusion in the study. Twelve patients were lost to follow-up and were not included for survival analysis.

Results Younger patients (≤30 years) with gastric cancer were 2.5% of total gastric cancer patients. Mean age was 24.9 years with males being involved twice as commonly as females (2.15:1). Positive family history was present in 14.2% patients and smoking was present in 57.1% patients. Metastatic disease at presentation was present in 69.8% patients, while only 6.4% patients presented with stage I/II disease. Fourteen patients underwent surgery, out of which six patients underwent partial gastrectomy and remaining eight underwent total gastrectomy with D2 nodal dissection. Median overall survival was 10.8 months (8.8–12.8) and 2-year overall survival was 15.1%.

Conclusion Incidence of stomach cancer in young patients is more than expected and more than global average in India. Most of these young patients are presenting in advanced stage and survival is poor compared with typical aged patients

Inhibition and disintegration of Bacillus subtilis biofilm with small molecule inhibitors identified through virtual screening for targeting TasA(28-261), the major protein component of ECM

Microbial biofilms have been recognized for a vital role in antibiotic resistance and chronic microbial infections for 2-3 decades; still, there are no 'anti-biofilm drugs' available for human applications. There is an urgent need to develop novel 'anti-biofilms' therapeutics to manage biofilm-associated infectious diseases. Several reports have suggested that targeting molecules involved in quorum sensing or biofilm-specific transcription may inhibit biofilm formation. However, the possibility of targeting other vital components of microbial biofilms, especially the extracellular matrix (ECM) components, has remained largely unexplored. Here we report targeting TasA_(28-261), the major proteinaceous component of Bacillus subtilis ECM with two small molecule inhibitors (lovastatin and simvastatin) identified through virtual screening and drug repurposing, resulted in complete inhibition of biofilm. In molecular docking and dynamics simulation studies, lovastatin was observed to make stable interactions with TasA_(28-261), whereas the simvastatin - TasA_(28-261) interactions were relatively less stable. However, in subsequent in vitro studies, both lovastatin and simvastatin successfully inhibited B. subtilis biofilm formation at MIC values of < 10 µg/ml. Besides, these potential inhibitors also caused the disintegration of pre-formed biofilms. Results presented here provide 'proof of concept' for the hypothesis that targeting the extracellular matrix's vital component(s) could be one of the most efficient approaches for inhibiting microbial biofilms and disintegrating the pre-formed biofilms. We propose that a similar approach targeting ECM-associated proteins with FDA-approved drugs could be implemented to develop novel anti-biofilm therapeutic strategies against biofilm-forming chronic microbial pathogens.Communicated by Ramaswamy H. Sarma.

Real World Data of Response of Trastuzumab Based Chemotherapy in Locally Advanced HER2 Positive Breast Cancer from a Developing Country

Background: Data regarding pathologic response of Trastuzumab based chemotherapy in locally advanced HER2 positive breast cancer in neoadjuvant setting is scarce. Methods: A retrospective analysis was conducted from January 2014 to January 2019 at a tertiary cancer care centre in North India and 81 breast cancer patients who underwent neoadjuvant chemotherapy were included. The clinical and pathologic characteristics, response, toxicity and survival data was collected, collated and analyzed. Results: The most commonly observed tumor characteristics at baseline were clinical stage T4 (72.8%), nodal stage N2 (40.7%), invasive ductal carcinoma on histology (98.8%), grade 3 (66.7%) and hormone receptor negativity (54.3%). In terms of post treatment characteristics, a higher incidence of partial response (55.6%), post treatment tumor stage ypT0 (45.7%), nodal status ypN0 (54.3%), absence of extracapsular invasion (77.8%) and absence of pathologic complete response (pCR, 63%) were observed. pCR was attained in 30 patients and was most commonly associated with clinical tumor stage T4 (26/30), nodal stage N2-N3 (19/30), grade 3 (21/30) and hormone receptor negativity (20/30). Altogether, 19.75% had grade 3/4 adverse events. At 6 years, 86% v/s 61% patients were disease free (p=0.037) and 93% v/s 79% patients (p=0.181) were alive in the pCR and no pCR groups, respectively. Conclusion: Even in locally advanced breast cancer (LABC), Trastuzumab had good response in terms of pCR and survival outcomes. Thus, one can be encouraged to use this single HER2 blockade if dual blockade is not feasible in HER2 positive LABC in the neoadjuvant setting.

Colonic polyp-rare site of metastasis from primary lung carcinoma: Clinical presentations and outcome

Although majority of lung cancers have distant metastasis at the time of initial diagnosis, colonic metastases are extremely rare. This report presents a rare clinical case which presented with lower limb deep vein thrombosis and found to have colon polyp incidentally detected while evaluating for occult blood positive in stool. Histopathology of the polyp was suggestive of lung primary and on further evaluation PET scan was suggestive of left lung mass with widespread distant metastasis.

Chronic kidney disease recognition amongst physicians and advanced practice providers

Objective

Chronic kidney disease is a worldwide public health issue, with increasing prevalence resulting in high morbidity and mortality. As a result, recognizing and treating it early can lead to improved outcomes. We hypothesized that some providers might be more comfortable making this diagnosis than others.

Methods

Retrospective study of 380 patients with chronic kidney disease seen between 2012 and 2016 in an outpatient setting.

Results

Three hundred and sixteen patients were treated by physicians and sixty-four by advanced practice providers. Chronic kidney disease was identified by the primary care providers in 318 patients (83.6%). Patients recognized with chronic kidney disease were older, 76 ± 8.8 vs 72 ± 7.45 years, p = 0.001; had lower GFR, 37 [29, 46] vs 57 [37, 76] ml/min/1.73 m², p < 0.0001 and were more likely to be seen by a physician compared to an advanced practice provider: 272/316 (86%) vs 46/64 (71.8%), p = 0.008. In multivariate analyses, care by a physician, OR = 2.27 (1.13–4.58), p = 0.02 was associated with increased recognition of chronic kidney disease. On the other hand, higher GFR was associated with decreased diagnosis of chronic kidney disease, OR = 0.95 (0.93–0.96), p < 0.0001.

Conclusion

The odds of chronic kidney disease recognition were higher amongst physicians in comparison to non-physician providers.

STK35L1 regulates host cell cycle-related genes and is essential for Plasmodium infection during the liver stage of malaria

Protein kinases of both the parasite and the host are crucial in parasite invasion and survival and might act as drug targets against drug-resistant malaria. STK35L1 was among the top five hits in kinome-wide screening, suggesting its role in malaria's liver stage. However, the role of host STK35L1 in malaria remains elusive. In this study, we found that STK35L1 was highly upregulated during the infection of Plasmodium berghei (P. berghei) in HepG2 cells and mice liver, and knockdown of STK35L1 remarkably suppressed the sporozoites' infection in HepG2 cells. We showed that STAT3 is upregulated and phosphorylated during P. berghei sporozoites' infection, and STAT3 activation is required for both the upregulation of STK35L1 and STAT3. Furthermore, we found that ten cell cycle genes were upregulated in the sporozoite-infected hepatocytes. Knockdown of STK35L1 inhibited the basal expression of these genes except CDKN3 and GTSE1 in HepG2 cells. Thus, we identified STK35L1 as a host kinase that plays an obligatory role in malaria's liver stage and propose that it may serve as a potential drug target against drug-resistant malaria.

Sphingosine kinases negatively regulate the expression of matrix metalloproteases (MMP1 and MMP3) and their inhibitor TIMP3 genes via sphingosine 1-phosphate in extravillous trophoblasts

PURPOSE

Extracellular matrix remodeling is essential for extravillous trophoblast (EVT) cell migration and invasion during placental development and regulated by matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteases (TIMPs). Sphingosine kinases (SPHK1 and SPHK2) synthesize sphingosine-1-phosphate (S1P), which works either intracellularly or extracellularly via its receptors S1PR1-5 in an autocrine or paracrine manner. The role of SPHKs/S1P in regulating the expression of MMPs and TIMPs in EVT is mostly unknown and forms the primary objective of the study.

METHODS

HTR-8/SVneo cells were used as a model of EVT. To inhibit the expression of SPHKs, cells were treated with specific inhibitors, SK1-I and SKI-II, or gene-specific siRNAs. The expressions of MMPs and TIMPs were estimated by qPCR.

RESULTS

We demonstrated that SPHK1, MMP1-3, and TIMP1-3 were highly expressed in HTR-8/SVneo cells. We found that treatment of cells with SK1-I, SKI-II, and knockdown of SPHK1 or SPHK2 increased the expression of MMP1, MMP3, and TIMP3. The addition of extracellular S1P inhibits the upregulation of MMPs and TIMPs in treated cells.

CONCLUSIONS

SPHKs negatively regulate the expression of MMP1, MMP3, and TIMP3. The level of intracellular S1P acts as a negative feedback switch for MMP1, MMP3, and TIMP3 expression in EVT cells.

Role of Maintenance Gemcitabine in Advanced Carcinoma Gallbladder

Objective  The aim of this study is to investigate the effects of gemcitabine maintenance on progression-free survival (PFS) in patients with metastatic gallbladder cancer (GBC).

Materials and Methods  Sixty patients with unresectable or metastatic GBC having ongoing response to treatment with initial six cycles of gemcitabine and a platinum-based doublet chemotherapy were prospectively randomized on day 21 of the 6th cycle in 1:1 fashion to receive either maintenance gemcitabine 1 g/m ² intravenously on day 1 and day 8 of three weekly cycle or observation. Survival analysis was performed using the Kaplan–Meier method and comparisons by the log-rank test. A p -value < 0.05 was considered as statistically significant.

Results  Of 60 patients, a total of 56 were available for final analysis. The median PFS was 4.7 months (3.1–6.3) in gemcitabine arm and 2.6 months (2.4–2.8) in observation arm, hazard ratio (HR) 0.196 (95% confidence interval [CI]: 0.1–0.39), p < 0.001. Median overall survival in gemcitabine arm was 12.4 months (9.15–15.6) as opposed to 9.9 months (8.29–11.5) in observation arm, HR 0.76 (95% CI: 0.43–1.35), p = 0.354. The grade 3 or 4 side effects in maintenance arm were transaminitis (17.9%), thrombocytopenia (17.8%), neutropenia (14.2%), and febrile neutropenia (7.1%).

Conclusions  Maintenance gemcitabine therapy in unresectable/metastatic GBC patients responding to first-line gemcitabine and platinum treatment contributes to increase PFS with minimal and manageable side effects.

Challenges and operative strategy in an unusual case of giant mastoid osteoma

A 19-year-old female patient presented to the outpatient department of ear, nose and throat with complaints of hard swelling behind her left ear for the past 5 years. It was a large bony swelling arising from the left temporal bone causing a cosmetic deformity that was surgically excised. The patient made a good recovery post procedure. Histopathology confirmed the lesion to be osteoma.

Thrombin impairs the angiogenic activity of extravillous trophoblast cells via monocyte chemotactic protein-1 (MCP-1): A possible link with preeclampsia

Cytokines' secretion from the decidua and trophoblast cells has been known to regulate trophoblast cell functions, such as Extravillous trophoblasts (EVTs) cell migration and invasion and remodeling of spiral arteries. Defective angiogenesis and spiral arteries transformation are mainly caused by proinflammatory cytokines and excessive thrombin generation during preeclampsia. Monocyte chemotactic protein-1 (MCP-1), a crucial cytokine, has a role in maintaining normal pregnancy. In this study, we explored whether thrombin regulates the secretion of MCP-1 in HTR-8/SVneo cells; if yes, what is its function? We used HTR-8/SVneo cells, developed from first trimester villous explants of early pregnancy, as the model of EVTs. MCP-1 gene silencing was performed using gene-specific siRNA. qPCR and ELISA were performed to estimate the expression and secretion of MCP-1. Here, we found that thrombin enhanced the secretion of MCP-1 in HTR-8/SVneo cells. Proteinase-activated receptor-1 (PAR-1) was found as the primary receptor, regulating MCP-1 secretion in these cells. Furthermore, MCP-1 secretion is modulated via protein kinase C (PKC) α, β, and Rho/Rho-kinase-dependent pathways. Thrombin negatively regulates HTR-8/SVneo cells' ability to mimic tube formation in an MCP-1 dependent manner. In conclusion, we propose that thrombin-controlled MCP-1 secretion may play an essential role in normal placental development and successful pregnancy maintenance. Improper thrombin production and MCP-1 secretion during pregnancy might cause inadequate vascular formation and transformation of spiral arteries, which may contribute to pregnancy disorders, such as preeclampsia.

Current Treatment Approaches for Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer in Adjuvant and Neoadjuvant Settings

Breast cancer (BC) is the second most common cancer and the second leading cause of mortality among women globally. Approximately 20 to 25% of BC patients have amplification of the human epidermal growth factor receptor 2 (HER2) genes, a marker of poor prognosis. However, the introduction of anti-HER2-therapies (trastuzumab, followed closely by lapatinib, pertuzumab, trastuzumab emtansine, and neratinib) has changed the natural history of HER2-positive BC and improved the outcome in HER2-positive BC patients. The preeminence of anti-HER2 combination therapy in achieving complete inhibition of the various HER receptor dimers has been demonstrated in clinical studies. However, despite these therapeutic advances, tumors expressing estrogen receptor have poorer responses to targeted therapy and are more likely to relapse. A better understanding of resistance to existing anti-HER2 agents, along with the role played by the microenvironment and of interconnected signaling pathways, can permit tailor-made therapeutic options for each patient. This review aimed to evaluate treatment approaches for BC patients with HER2-positive disease in the adjuvant and neoadjuvant settings, also exploring the possibilities of extended duration of anti-HER2 maintenance therapy.

Cardiac Ultrasound for the Nephrologist: Know Thy Heart to Know Thy Kidneys

Kidney disease patients have a high prevalence of cardiovascular morbidity and mortality. It can be challenging to adequately assess their cardiovascular status based on physical examination alone. Cardiac ultrasound has proven to be a powerful tool to accomplish this objective and is increasingly being adopted by noncardiologists to augment their skills and expedite clinical decision-making. With the advent of inexpensive and portable ultrasound equipment, simplified protocols, and focused training, it is becoming easier to master basic cardiac ultrasound techniques. After a short course of training in focused cardiac ultrasound, nephrologists can quickly and reliably assess ventricular size and function, detect clinically relevant pericardial effusion and volume status in their patients. Additional training in Doppler ultrasound can extend their capability to measure cardiac output, right ventricular systolic pressure, and diastolic dysfunction. This information can be instrumental in effectively managing patients in inpatient, office, and dialysis unit settings. The purpose of this review is to highlight the importance and feasibility of incorporating cardiac ultrasound in nephrology practice, discuss the principles of basic and Doppler ultrasound modalities and their clinical utility from a nephrologist's perspective.

Super-rapid race for saving lives by developing COVID-19 vaccines

The pandemic of coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has affected millions of people and claimed thousands of lives. Starting in China, it is arguably the most precipitous global health calamity of modern times. The entire world has rocked back to fight against the disease and the COVID-19 vaccine is the prime weapon. Even though the conventional vaccine development pipeline usually takes more than a decade, the escalating daily death rates due to COVID-19 infections have resulted in the development of fast-track strategies to bring in the vaccine under a year’s time. Governments, companies, and universities have networked to pool resources and have come up with a number of vaccine candidates. Also, international consortia have emerged to address the distribution of successful candidates. Herein, we summarize these unprecedented developments in vaccine science and discuss the types of COVID-19 vaccines, their developmental strategies, and their roles as well as their limitations.

Predicting Hospitalization Due to COPD Exacerbations in Swedish Primary Care Patients Using Machine Learning - Based on the ARCTIC Study

Purpose

Chronic obstructive pulmonary disease (COPD) exacerbations can negatively impact disease severity, progression, mortality and lead to hospitalizations. We aimed to develop a model that predicts a patient's risk of hospitalization due to severe exacerbations (defined as COPD-related hospitalizations) of COPD, using Swedish patient level data.

Patients and Methods

Patient level data for 7823 Swedish patients with COPD was collected from electronic medical records (EMRs) and national registries covering healthcare contacts, diagnoses, prescriptions, lab tests, hospitalizations and socioeconomic factors between 2000 and 2013. Models were created using machine-learning methods to predict risk of imminent exacerbation causing patient hospitalization due to COPD within the next 10 days. Exacerbations occurring within this period were considered as one event. Model performance was assessed using the Area under the Precision-Recall Curve (AUPRC). To compare performance with previous similar studies, the Area Under Receiver Operating Curve (AUROC) was also reported. The model with the highest mean cross validation AUPRC was selected as the final model and was in a final step trained on the entire training dataset.

Results

The most important factors for predicting severe exacerbations were exacerbations in the previous six months and in whole history, number of COPD-related healthcare contacts and comorbidity burden. Validation on test data yielded an AUROC of 0.86 and AUPRC of 0.08, which was high in comparison to previously published attempts to predict COPD exacerbation.

Conclusion

Our work suggests that clinically available information on patient history collected via automated retrieval from EMRs and national registries or directly during patient consultation can form the basis for future clinical tools to predict risk of severe COPD exacerbations.

Clinical outcome study of crizotinib in immunohistochemistry-proven echinoderm microtubule-associated protein-like 4-anaplastic lymphoma kinase fusion gene among Indian patients with adenocarcinoma lung

Aims:

The anaplastic lymphoma kinase (ALK) Break Apart FISH Probe Kit and Ventana anti-ALK (D5F3) CDx immunohistochemistry (IHC) assay are the Food and Drug Administration-approved companion diagnostic for targeted therapy with the ALK inhibitor crizotinib in lung cancers. The aim of this study was to assess the efficacy and safety of twice daily crizotinib tablet (250 mg) in IHC-proven echinoderm microtubule-associated protein-like 4 (EML4)-ALK fusion gene among Indian patients with adenocarcinoma lung in the routine clinical practice.

Subjects and Methods:

Patients with nonsmall cell lung cancer (NSCLC), adenocarcinoma histology, whose tumors were found to be positive for EML4-ALK fusion gene using IHC, were considered for this study. IHC analysis was performed using a Ventana automated immunostainer (Benchmark XT). Detection was performed using Optiview DAB detection and amplification kit.

Results:

A total of 25 NSCLC adenocarcinoma patients were included in the study. There were 14 (56%) women and 10 (44%) men with a median age of 53 years. All patients had Stage IV disease at the time of initiation of crizotinib therapy. One patient achieved complete response and 20 achieved response rate (PR) for an overall PR of 84%. The median progression-free survival (PFS) was 11.8 months and median overall survival (OS) was 20.6 months. Two (8%) patients experienced severe hepatotoxicity requiring permanent discontinuation of crizotinib therapy.

Conclusions:

A very high PR, PFS, and OS achieved in our study population indicates that IHC can accurately identify EML4 ALK fusion gene mutations in lung adenocarcinoma patients who are responsive to ALK inhibitors such as crizotinib. IHC should be considered as a cost-effective alternative to FISH, especially in low-resource countries.

Olfactory and taste dysfunction in coronavirus disease 2019 patients: its prevalence and outcomes

OBJECTIVES

To evaluate the occurrence, clinical course and outcomes of olfactory and gustatory dysfunction in patients with laboratory confirmed coronavirus disease 2019 infection.

METHODS

This is a prospective cross-sectional study of patients diagnosed with coronavirus disease 2019 infection by reverse transcription polymerase chain reaction over two months. The epidemiological and clinical outcomes studied were: age, sex, general symptoms, and olfactory and taste dysfunction.

RESULTS

A total of 410 coronavirus disease 2019 infected patients were included in the study, with 262 males (63.9 per cent) and 148 females (36.1 per cent). Ninety-nine patients (24.1 per cent) reported chemosensory dysfunction, of which 85 patients (20.7 per cent) reported both olfactory and taste dysfunction. Olfactory and taste dysfunction were proportionally more common in females. The mean duration of olfactory and taste dysfunction was 4.9 days, with a range of 2-15 days.

CONCLUSION

Olfactory and taste dysfunction are prevalent symptoms in coronavirus disease 2019 patients. In this study, they were more common in females than males. The occurrence of such dysfunctions is lower in the Indian population than in the European population.

Beta-blockers are associated with incident heart failure: a secondary analysis of the systolic blood pressure intervention (SPRINT) trial

Background

The Systolic Blood Pressure Intervention Trial (SPRINT) evaluated whether a blood pressure (BP) goal of less than 120mmHg versus less than 140mmHg would reduce cardiovascular outcomes in subjects with at least one cardiovascular risk factor and without heart failure. Participating investigators were encouraged to use any antihypertensive medication class with a strong evidence base. The SPRINT trial was halted early due to a lower rate of the composite primary outcome in the 120mmHg group, which was mainly driven by a reduction in heart failure (HF).

Objective

As there is a concern that beta-blocker use may be associated with an excess risk for incident HF in subjects with a normal left ventricular systolic function, we evaluated the association between beta-blocker use and HF. Beta-blockers were compared with other major classes of antihypertensive medications. We also studied the association of antihypertensive class with loop-diuretic initiation.

Methods and results

In the 9,012 subjects, without HF at baseline, the association of beta-blocker exposure and incident HF was examined using time-variant competing risk analysis. Beta-blocker exposure was associated with an increased HF risk (HR 1.18; CI 1.07–1.30; p&lt;0.001) and more frequent and earlier loop diuretic-use compared to other antihypertensive agents (both p&lt;0.01). Sensitivity analyses of propensity-score matched cohorts confirmed a strong association of beta-blocker use and HF. Other major antihypertensive medication classes did not show this association.

Conclusions

Beta-blocker exposure was associated with a higher incidence of HF in hypertensive subjects without HF at baseline.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Institutes of Health

Brain Imaging of Patients with COVID-19: Findings at an Academic Institution during the Height of the Outbreak in New York City

BACKGROUND AND PURPOSE

A large spectrum of neurologic disease has been reported in patients with coronavirus disease 2019 (COVID-19) infection. Our aim was to investigate the yield of neuroimaging in patients with COVID-19 undergoing CT or MR imaging of the brain and to describe associated imaging findings.

MATERIALS AND METHODS

We performed a retrospective cohort study involving 2054 patients with laboratory-confirmed COVID-19 presenting to 2 hospitals in New York City between March 4 and May 9, 2020, of whom 278 (14%) underwent either CT or MR imaging of the brain. All images initially received a formal interpretation from a neuroradiologist within the institution and were subsequently reviewed by 2 neuroradiologists in consensus, with disputes resolved by a third neuroradiologist.

RESULTS

The median age of these patients was 64 years (interquartile range, 50-75 years), and 43% were women. Among imaged patients, 58 (21%) demonstrated acute or subacute neuroimaging findings, the most common including cerebral infarctions (11%), parenchymal hematomas (3.6%), and posterior reversible encephalopathy syndrome (1.1%). Among the 51 patients with MR imaging examinations, 26 (51%) demonstrated acute or subacute findings; notable findings included 6 cases of cranial nerve abnormalities (including 4 patients with olfactory bulb abnormalities) and 3 patients with a microhemorrhage pattern compatible with critical illness-associated microbleeds.

CONCLUSIONS

Our experience confirms the wide range of neurologic imaging findings in patients with COVID-19 and suggests the need for further studies to optimize management for these patients.

Efficacy and tolerability of nimotuzumab in combination with chemotherapy in recurrent and metastatic squamous cell carcinoma of head and neck at a cancer center in Northern India

Introduction

Squamous cell carcinoma of head and neck (SCCHN) account for approximately 30-33% of all cancer and the median survival for recurrent and metastatic(R/M) SCCHN remains less than 1 year despite modern advances in therapy. Chemotherapy, usually single agent remains the backbone of therapy in these patients. EGFR antibodies are being used in (R/M) SCCHN. Nimotuzumab is one such agent that has anti-EGFR action similar to other agents without similar skin toxicity.

Methods

Prospective, interventional, non-randomized study done at Rajiv Gandhi Cancer Institute and Research Centre. A total 124 patients were enrolled and divided into Arm A (Chemotherapy + Nimotuzumab) and Arm B (Chemotherapy) in a ratio of 1:1 i.e., 62 in each arm. They were evaluated and treated as per protocol after a written informed consent. Statistical analysis was done using the SPSS software. Quantitative variables were compared using Unpaired t-test/Mann-Whitney Test. Qualitative variables were compared using Chi-Square test /Fisher's exact test. Kaplan-Meier analysis was used to assess the PFS, with log rank test for comparison between the groups. A p value of < 0.05 was considered statistically significant.

Results

The most frequent primary location of tumor was oral cavity (n=38, 69%) and (n=33, 56.9%) in both arms. The overall response rate in Arm A was 38.2% and 19% in Arm B (p= 0.023). The disease control rate in Arm A was 74.5% and 43.1% Arm B (p= 0.0007). The median PFS in Arm A was 5.2 months whereas it was 3.2 months in Arm B (p= 0.009).

Conclusion

In this study, the combination of Nimotuzumab plus platinum/taxane based chemotherapy was active and well tolerated in Indian patients in R/M SCCHN. Addition of Nimotuzumab to chemotherapy had a response rate of 38.2% and median PFS of 5.2 months are strong arguments for clinically testing this combination.

Computational investigation for modeling the protein-protein interaction of TasA(28-261)-TapA(33-253): a decisive process in biofilm formation by Bacillus subtilis

Biofilms have a significant role in microbial persistence, antibiotic resistance, and chronic infections; consequently, there is a pressing need for development of novel "anti-biofilm strategies." One of the fundamental mechanisms involved in biofilm formation is protein-protein interactions of "amyloid-like proteins" (ALPs) in the extracellular matrix. Such interactions could be potential targets for development of novel anti-biofilm strategies; therefore, assessing the structural features of these interactions could be of great scientific value. Characterization of structural features the of protein-protein interaction with conventional structure biology tools including X-ray diffraction and nuclear magnetic resonance is technically challenging, expensive, and time-consuming. In contrast, modeling such interactions is time-efficient and economical, and might provide deeper understanding of structural basis of interactions. Although it is often acknowledged that molecular modeling methods have varying accuracy, their careful implementation with supplementary verification methods can provide valuable insight and directions for future studies. With this reasoning, during the present study, the protein-protein interaction of TasA_(28-261)-TapA_(33-253) (which is a decisive process for biofilm formation by Bacillus subtilis) was modeled using in silico approaches, viz., molecular modeling, protein-protein docking, and molecular dynamics simulations. Results obtained here identified amino acid residues present within intrinsically disordered regions of both proteins to be critical for interaction. These results were further supported with principal component analyses (PCA) and free energy landscape (FEL) analyses. Results presented here represent novel finding, and we hypothesize that amino acid residues identified during the present study could be targeted for inhibition of biofilm formation by B. subtilis.

Role of 18F-Flurodeoxyglucose Positron-Emission Tomography/Computed Tomography in the Evaluation of Early Response to Neoadjuvant Chemotherapy in Patients with Locally Advanced Triple-Negative Breast Cancer

Background:

Response evaluation in locally advanced breast cancer is done through different methods ranging from clinical examination to magnetic resonance imaging, however evaluation with positron-emission tomography/computed tomography (PET/CT) in now being incorporated for the response evaluation. The aim of the present study is to correlate response to neoadjuvant chemotherapy (NACT) with PET/CT scan.

Materials and Methods:

The present study is a retrospective analysis of 30 locally advanced, triple-negative breast cancer patients. PET/CT scan was done pretreatment and post three and six cycles of NACT and was correlated with pathologic complete response (pCR). Responding disease was considered when there was at least a 50% reduction in the longest diameter.

Results:

The median pretreatment size of the breast lesion in CT scan was 3.9 ± 2.3 cm (2–12 cm) and maximum standardized uptake value (SUVmax) on PET/CT was 8.5 ± 5.5 (2.9–24). Among the responders, the median decrease in size of lesion was 3.2 ± 1.3 cm and median reduction in SUV of the tumor among was −8.1 ± 5.4 and was statistically significant when compared with nonresponders (P < 0.001). CT scan has 66% accuracy and PET has 82% accuracy at post three cycles NACT in predicting the pathological response. PET/CT had higher sensitivity and specificity when compared with CT findings alone in response evaluation.

Conclusion:

PET/CT scan can be considered as a sensitive tool for predicting pCRs and further larger trials are required to establish these findings.