Efficacy and safety of catheter ablation for atrial fibrillation in patients with history of cancer

BACKGROUND

Though the incidence of atrial fibrillation (AF) is increased in patients with cancer, the effectiveness of catheter ablation (CA) for AF in patients with cancer is not well studied.

METHODS

We conducted a retrospective cohort study of patients who underwent CA for AF. Patients with a history of cancer within 5-years prior to, or those with an exposure to anthracyclines and/or thoracic radiation at any time prior to the index ablation were compared to patients without a history of cancer who underwent AF ablation. The primary outcome was freedom from AF [with or without anti-arrhythmic drugs (AADs), or need for repeat CA at 12-months post-ablation]. Secondary endpoints included freedom from AF at 12 months post-ablation with AADs and without AADs. Safety endpoints included bleeding, pulmonary vein stenosis, stroke, and cardiac tamponade. Multivariable regression analysis was performed to identify independent risk predictors of the primary outcome.

RESULTS

Among 502 patients included in the study, 251 (50%) had a history of cancer. Freedom from AF at 12 months did not differ between patients with and without cancer (83.3% vs 72.5%, p 0.28). The need for repeat ablation was also similar between groups (20.7% vs 27.5%, p 0.29). Multivariable regression analysis did not identify a history of cancer or cancer-related therapy as independent predictors of recurrent AF after ablation. There was no difference in safety endpoints between groups.

CONCLUSION

CA is a safe and effective treatment for AF in patients with a history of cancer and those with exposure to potentially cardiotoxic therapy.

Recent Trends in Hypoparathyroidism-Related Inpatient and Emergency Department Admissions and Costs in the United States

Hypoparathyroidism (HypoPT) is a rare disease associated with high morbidity. Its economic impact is not well understood. This retrospective, cross-sectional study used data from the United States-based National Inpatient Sample and the Nationwide Emergency Department Sample from 2010 to 2018 to quantify overall trends in number, cost, charges, and length of stay (LOS) for inpatient hospitalizations and number and charges for emergency department (ED) visits for HypoPT-related and for non-HypoPT-related causes. Additionally, the study estimated the marginal effect of HypoPT on total inpatient hospitalization costs and LOS as well as ED visit charges. Over the observed period, a mean of 56.8-66.6 HypoPT-related hospitalizations and 14.6-19.5 HypoPT-related ED visits were recorded per 100 000 visits per year. Over this period, the rate of HypoPT-related inpatient hospitalizations and ED visits increased by 13.5% and 33.6%, respectively. The mean LOS for HypoPT-related hospitalizations was consistently higher than for non-HypoPT-related causes. Total annual HypoPT-related inpatient hospitalization costs increased by 33.6%, and ED visit charges increased by 96.3%. During the same period, the annual costs for non-HypoPT-related hospitalizations and charges for ED visits increased by 5.2% and 80.3%, respectively. In all years, HypoPT-related hospital encounters resulted in higher charges and costs per individual visit than non-HypoPT-related encounters. The marginal effect of HypoPT on inpatient hospitalization costs and LOS, and on ED charges, increased over the period of observation. This study demonstrated that HypoPT was associated with substantial and increasing healthcare utilization in the United States between 2010 and 2018.

Safety and efficacy of transcatheter edge-to-edge repair (TEER) in patients with history of cancer

Background

Surgical therapy has been a long-standing option for valvular heart disease, in patients with history of cancer, it carries an increased risk of complications.

Objectives

Transcatheter edge-to-edge repair (TEER) for mitral regurgitation, represents a less invasive option. However, patients with history of cancer have generally been excluded from trials.

Methods

A retrospective cohort analysis was performed on de-identified, aggregate patient data from the TriNetX research network. Patients 18 ≥ years of age, who had undergone TEER between January 1, 2013 and May 19, 2021, were identified using the CPT codes and divided into two cohorts based on a history of cancer. Subgroup analysis was performed based on history of systemic antineoplastic therapy. Odds ratio and log-rank test were used to compare the outcomes over 1 and 12-months.

Results

In matched cohorts (503 patients in each, mean age 77.7 years, men 55 vs 58 %, white 84 vs 87 % in non-cancer and cancer cohorts respectively), the risk of heart failure exacerbation, all-cause mortality and all-cause hospitalizations were similar at 1 and 12 months among patients undergoing TEER. Risk of major complications (ischemic stroke, blood product transfusion and cardiac tamponade) were also similar. In the cancer cohort, hematologic/lymphoid malignancies were the most common (28.0 %) and 12.5 % patients had a history of metastatic cancer. There was no significant difference in heart failure exacerbation or all-cause mortality based on history of systemic antineoplastic therapy.

Conclusions

Overall outcomes following TEER are similar in patients with a history of cancer and should be considered in selected patients in this population.

Racial disparities in ventricular tachycardia in young adults: analysis of national trends

BACKGROUND

In the last two decades, risk factors, prevalence, and mortality due to coronary artery disease in young adults are on the rise. We sought to assess the prevalence, trends, and economic burden of ventricular tachycardia (VT) hospitalizations in young adults (< 45 years), further stratified by race and gender.

METHODS

The Nationwide Inpatient Sample was explored for hospitalizations with VT in patients (< 45 years) between 2005 and 2018 and divided among 3 groups of the quadrennial period using validated International Classification of Diseases (ICD) 9^th and 10^th revision Clinical Modification (CM) codes. The Pearson chi-square test and Wilcoxon rank-sum were used for categorical and continuous variables, respectively. We assessed the temporal trends of mortality in VT hospitalizations and trends of VT hospitalization stratified by age, sex, and race by using Joinpoint regression analysis. The primary outcome was in-hospital mortality trends. Secondary outcomes were trends of hospital stay in days, cost of care in US dollars, cardiac arrest, and discharge disposition.

RESULTS

Out of 5,156,326 patients admitted with VT between 2005 and 2018, 309,636 were young adults. Among them, 102,433 were admitted between 2005 and 2009 (mean age 36.1 ± 6.99; 61% male, 58.5% White), 109,591 between 2010 and 2014 (mean age 35.5 ± 7.16; 59% male, 54.2% White), and 97,495 between 2015 and 2018 (mean age 35.4 ± 7.00; 60% male, 52.3% White) (p < 0.07). In the young adults with VT, all-cause mortality was 7.37% from 2005 to 2009, 7.85% from 2010 to 2014 (6.5% relative increase from 2005 to 2009), and 8.98% from 2015 to 2018 (relative increase of 14.4% from 2010 to 2014) (p < 0.0001). Similarly, risk of cardiac arrest was on the rise (6.15% from 2005 to 2009 to 7.77% in 2010-2014 and 9.97% in 2015-2018). Inflation-adjusted cost increased over the years [$12,177 in 2005-2009; $13,249 in 2010-2014; $15,807 in 2015-2018; p < 0.0001)].

CONCLUSIONS

VT hospitalizations and related all-cause mortality, and healthcare utilization costs in young adults are on the rise in the study period. Hospitalization burden related to VT and poor outcomes were more notable for Black adults. Further studies are required for targeted screening and preventative measures in young adults.

An update on national recommendations for the use of the adjuvanted recombinant zoster vaccine

Background

The adjuvanted recombinant zoster vaccine (RZV), first approved in 2017, has high, long-lasting efficacy against herpes zoster (HZ) and a clinically acceptable safety profile. In addition to the prevention of HZ in adults aged ≥50 years, the non-live RZV can be used from age 18 years in individuals with immunocompromised (IC) conditions. We reviewed the evolving landscape of national recommendations for RZV use.

Methods

National health authority and vaccination committee websites of countries where RZV is approved were searched in March 2022.

Results

Of 41 countries where RZV is licensed, 14 (Australia, Austria, Canada, Czech Republic, Germany, Ireland, Italy, Netherlands, New Zealand, Saudi Arabia, Spain, Switzerland, UK, US) provide national recommendations related to RZV; the majority are preferential to RZV or only recommend RZV. Overall, seven and seven countries recommend immunisation from age 50 years or 60/65 years, respectively. Of the seven countries that recommend immunisation from age 60/65 years, five recommend immunisation in individuals from age 50 years with comorbidities/IC conditions. Five countries recommend immunisation from age 18/19 years in individuals at increased risk of HZ due to immunosuppressive disease/treatment. In addition, six national recommendations refer to RZV safety and nine address prior HZ vaccination and/or infection. All recommendations outlined the RZV administration schedule.

Conclusions

Although national recommendations can inform decision making in clinical practice, RZV recommendations are not available in all licensed countries. The recommendations highlight a trend in favour of the use of RZV for the prevention of HZ in older individuals and those with IC conditions.

Main messages: An increasing number of countries are providing recommendations for the use of RZV for the prevention of HZ in older individuals and those with IC conditions.

Key messages

• An increasing number of countries are providing recommendations for the use of RZV for the prevention of HZ in older individuals.

• An increasing number of countries are providing recommendations for the use of RZV for the prevention of HZ in IC conditions.

The impact of the COVID-19 pandemic on the incidence of herpes zoster

Background

There have been several case reports of herpes zoster (HZ) following COVID-19 disease and vaccination. We conducted a non-systematic literature search to elucidate the global effects of the COVID-19 pandemic on the incidence of HZ.

Methods

The literature search was performed in October 2021 using PubMed and Embase. The search string was herpes zoster AND COVID-19. Publications were manually reviewed; case reports were removed.

Results

Three retrospective studies reported the risk of HZ following COVID-19 disease. One study (Bhavsar, 2021) used two US databases and found higher risk of HZ following COVID-19 disease (relative risk [RR]=1.15) and COVID-19 hospitalisation (RR = 1.21), respectively. A strong association between HZ and COVID-19 disease (RR = 5.27) was also reported in a study of the University of Florida patient registry (Katz, 2021). The third study (Barda, 2021) reported no association between COVID-19 disease and risk of HZ (RR = 0.82). In two of the three observational studies in Israel (Furer, 2021 and Barda, 2021), the incidence of HZ was increased following COVID-19 vaccination. The third study (Shasha, 2021) found no association (RR = 1.07). Other studies included a report in Brazil (Maia, 2021) that demonstrated a 35% increase in HZ diagnoses during the pandemic versus pre-pandemic and a published model (La, 2021) that estimated the declining uptake of recombinant zoster vaccine in the US may result in 63,117 avoidable HZ cases in those who remain unvaccinated in 2021.

Conclusions

Emerging data suggest that the COVID-19 pandemic may have increased the risk of HZ and negatively impacted HZ vaccine uptake. Therefore, there is an important need to increase awareness of HZ and HZ vaccination during the pandemic.

Key messages

• There is a need to increase awareness of HZ and HZ vaccination during the COVID-19 era.

• Further studies are needed to fully understand the impact of COVID-19 on the risk of HZ.

Pulmonary Hypertension in patients with Interstitial Lung Disease: a tool for early detection

Pulmonary hypertension (PH) complicates the treatment of interstitial lung disease (ILD) patients resulting in poor functional status and worse outcomes. Early recognition of PH in ILD is important for initiating therapy and considering lung transplantation. However, no standard exists regarding which patients to screen for PH‐ILD or the optimal method to do so. The aim of this study was to create a risk assessment tool that could reliably predict PH in ILD patients. We developed a PH‐ILD Detection tool that incorporated history, exam, 6‐min walk distance, diffusion capacity for carbon monoxide, chest imaging, and cardiac biomarkers to create an eight‐component score. This tool was analyzed retrospectively in 154 ILD patients where each patient was given a score ranging from 0 to 12. The sensitivity (SN) and specificity (SP) of the PH‐ILD Detection tool and an area‐under‐the‐curve (AUC) were calculated. In this cohort, 74 patients (48.1%) had PH‐ILD. A score of ≥6 on the PH‐ILD Detection tool was associated with a diagnosis of PH‐ILD (SN: 86.5%; SP: 86.3%; area‐under‐the‐curve: 0.920, p < 0.001). The PH‐ILD Detection tool provides high SN and SP for detecting PH in ILD patients. With confirmation in larger cohorts, this tool could improve the diagnosis of PH in ILD and may suggest further testing with right heart catheterization and earlier intervention with inhaled treprostinil and/or lung transplant evaluation.

tRForest: a novel random forest-based algorithm for tRNA-derived fragment target prediction

tRNA fragments (tRFs) are small RNAs comparable to the size and function of miRNAs. tRFs are generally Dicer independent, are found associated with Ago, and can repress expression of genes post-transcriptionally. Given that this expands the repertoire of small RNAs capable of post-transcriptional gene expression, it is important to predict tRF targets with confidence. Some attempts have been made to predict tRF targets, but are limited in the scope of tRF classes used in prediction or limited in feature selection. We hypothesized that established miRNA target prediction features applied to tRFs through a random forest machine learning algorithm will immensely improve tRF target prediction. Using this approach, we show significant improvements in tRF target prediction for all classes of tRFs and validate our predictions in two independent cell lines. Finally, Gene Ontology analysis suggests that among the tRFs conserved between mice and humans, the predicted targets are enriched significantly in neuronal function, and we show this specifically for tRF-3009a. These improvements to tRF target prediction further our understanding of tRF function broadly across species and provide avenues for testing novel roles for tRFs in biology. We have created a publicly available website for the targets of tRFs predicted by tRForest.

Abstract P2-09-08: Impact of race on clinical outcomes among patients with advanced triple negative breast cancer (TNBC) and Germline BRCA1/2 mutation(s) (gBRCA1/2mut): Results from a US real-world study

Background: Racial disparities among patients with breast cancer in the United States are well documented, with Black patients having a 40% higher mortality than White patients. Socioeconomic status, tumor biology differences, and treatment access are known contributing factors. Additionally, despite having a higher incidence of TNBC, Black patients are substantially less likely to receive gBRCA1/2mut testing than White patients. TNBC is an aggressive subtype, accounting for 15% of all breast cancers diagnosed in the United States. TNBC disproportionately affects BRCA mutation carriers and Black women. With the advent of poly ADP-ribose polymerases inhibitors (PARPi), gBRCA1/2mut are considered actionable biomarkers. Limited data are available on the impact of race on clinical outcomes among patients with gBRCA1/2-mutated advanced TNBC in the United States. Methods: US oncologists retrospectively reviewed patient charts (July 2019-June 2020) of a quasirandom selection of patients aged ≥18 years with gBRCA1/2-mutated advanced TNBC who received ≥1 cytotoxic chemotherapy (CT) regimen for advanced TNBC between Jan 2013-April 2018. Patients were categorized into 2 mutually exclusive cohorts of White and Black (based on self-identification). Descriptive analysis was performed for treatment patterns for the first 2 lines of therapy (LOT). Clinical outcomes (progression-free survival [PFS] by LOT and survival rates) were estimated with the Kaplan-Meier method. A log-rank test was used to assess differences in PFS and survival rates between White and Black patients. Results: Among 182 patients with gBRCA1/2-mutated advanced TNBC, 99.5% were women and 76.4% were White. The median age was 57.2 years (range, 48.7-64.7 years), and 30.2% had no known family history of BRCA-related cancer. Treatments for White patients with advanced TNBC included first-line (n=139) nonplatinum-based CT (61.9%) and platinum-based CT (38.1%) and second-line (n=90) PARPi (40.0%), nonplatinum-based CT (43.3%), platinum-based CT (11.1%), and other (5.6%). Treatments for Black patients with advanced TNBC included first-line (n=43) nonplatinum-based CT (60.5%) and platinum-based CT (39.5%) and second-line (n=19) PARPi (47.4%), nonplatinum-based CT (31.6%), platinum-based CT (10.5%), and other (10.5%). Across treatment types, no significant difference in 2-year survival rates was observed between White and Black patients (73.8% vs 73.2%, P=0.89). Median PFS rates by LOT were not statistically different across White and Black patients (Table 1). Conclusion: In this real-world study, no significant differences in clinical outcomes were observed between White and Black patients with gBRCA1/2-mutated advanced TNBC. This observation may be because this sample reflects a select patient population with a known genetic test result of a gBRCA1/2mut who were treated by oncologists that understood the value of genetic testing, and provided appropriate treatment options. The findings suggest that when all patients are provided with equitable care (inclusive of genetic testing), racial disparities in breast cancer may be minimized. Further trials are needed to validate these findings. Funding: Pfizer Inc

Table 1.PFS (Months) by LOT and Race Among Patients With gBRCA1/2-Mutated Advanced TNBCWhite PatientsBlack PatientsP ValueFirst-line, n 13642PFS, median (95% CI)10.7 (9.3−12.6)15.6 (9.7−NE)0.078Second-line, n 5310PFS, median (95% CI)7.2 (5.9−11.4)9.2 (2.8−NE)0.406NE=not estimatable.

Citation Format: Kristen Whitaker, Rohan Parikh, Elizabeth Esterberg, Bhakti Arondekar, Abigail Hitchens, Lillian Shahied Arruda, Alexander Niyazov, Elias Obeid. Impact of race on clinical outcomes among patients with advanced triple negative breast cancer (TNBC) and Germline BRCA1/2 mutation(s) (gBRCA1/2mut): Results from a US real-world study [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-09-08.

Diagnostic characteristics, treatment patterns, and clinical outcomes for patients with advanced/metastatic medullary thyroid cancer

Background

Medullary thyroid cancer (MTC) accounts for approximately 1.6% of new cases of thyroid cancer. The objective of this study was to describe patient characteristics, biomarker testing, treatment patterns, and clinical outcomes among patients with advanced/metastatic MTC in a real-world setting in the United States and to identify potential gaps in the care of these patients.

Methods

Selected oncologists retrospectively reviewed medical records of patients aged ≥ 12 years diagnosed with advanced MTC. Patients must have initiated ≥ 1 line of systemic treatment for advanced/metastatic MTC between January 2013–December 2018 to be eligible. Patient characteristics, biomarker testing, and treatment patterns were summarized descriptively; progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan–Meier method.

Results

The 203 patients included in this study had a mean (SD) age of 52.2 (10.4) years; mean (SD) duration of follow-up from start of first-line treatment was 24.5 (16.0) months. Most patients (82.8%) were initially diagnosed with stage IVA, IVB, or IVC disease. Among all patients, 121 (59.6%) had testing for RET mutations, of whom 37.2% had RET-mutant MTC. The RET-mutation type was reported for 28 patients; the most common mutations reported were M918T (64.3%) and C634R (32.1%). Of the 203 patients, 75.9% received only one line of systemic treatment for advanced disease, and 36% were still undergoing first-line therapy at the time of data extraction. Cabozantinib (30.0%), vandetanib (30.0%), sorafenib (17.2%), and lenvatinib (4.9%) were the most common first-line treatments. Among 49 patients who received second-line treatment, most received cabozantinib (22.4%), vandetanib (20.4%), lenvatinib (12.2%), or sunitinib (12.2%). Median PFS (95% confidence interval [CI]) from start of first- and second-line treatments was 26.6 months (20.8–60.8) and 15.3 months (6.6-not estimable [NE]), respectively. Median OS from initiation of first- and second-line treatment was 63.8 months (46.3-NE) and 22.4 months (12.4-NE), respectively.

Conclusions

For the treatment of advanced/metastatic MTC, no specific preference of sequencing systemic agents was observed in the first- and second-line settings. Considering the recent approval of selective RET inhibitors for patients with RET-mutant MTC, future research should investigate how treatment patterns evolve for these patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13044-021-00119-9.

102 Peer Teaching in Hip Fracture: Responding to the Medical Needs of Surgical Patients and Educational Needs of Junior Doctors

Introduction

Fractured Neck of Femur (FNOF) patients are complex. A mortality project identified topics for a peer-led teaching programme.

Method

Eight bite-sized case-based sessions were devised, to provide a framework to approach the following topics: Anaemia, delirium/dementia, ECG abnormalities, metastatic cancer, osteoporosis, renal disease, respiratory disease, and vascular complications. Attendees were asked to complete pre- and post- teaching programme questionnaires using a Likert Scale to indicate agreement with statements relating to the topic areas chosen (1=strongly disagree and 5=strongly agree).

Result

Pre-programme questionnaire: respondents were neutral (average 3.04) when asked whether topic areas were currently “well managed”. Attendees lacked confidence, indicating preparedness as neutral (average 3.35). Trainees agreed that they would benefit from teaching (average 4.56).

Post-programme questionnaire: increased confidence was reported when considering preparedness (average 4.3). Attendees felt the teaching programme was “accessible” and the “topics well-chosen”. 100% of attendees regarded the teaching as ‘excellent’ or ‘very-good’.

Conclusions

Matching patient needs to an educational programme is important.

The “bite-sized” nature of the programme paired with case-based learning increased confidence. A peer-led teaching programme is a positive response to themes emerging from morbidity and mortality reviews.

Cardiotoxicity of Immune Checkpoint Inhibitors

Purpose of Review

Immune checkpoint inhibitors (ICIs) have improved the survival of several cancers. However, they may cause a wide range of immune-related adverse events (irAEs). While most irAEs are manageable with temporary cessation of ICI and immunosuppression, cardiovascular toxicity can be associated with high rates of morbidity and mortality. As ICIs evolve to include high-risk patients with preexisting cardiovascular risk factors and disease, the risk and relevance of ICI-associated cardiotoxicity may be even higher.

Recent Findings

Several cardiovascular toxicities such as myocarditis, stress cardiomyopathy, and pericardial disease have been reported in association with ICIs. Recent findings also suggest an increased risk of atherosclerosis with ICI use. ICI-associated myocarditis usually occurs early after initiation and can be fulminant. A high index of suspicion is required for timely diagnosis. Prompt treatment with high-dose corticosteroids is shown to improve outcomes.

Summary

Although the overall incidence is rare, ICI cardiotoxicity, particularly myocarditis, is associated with significant morbidity and mortality, making it a major therapy-limiting adverse event. Early recognition and prompt treatment with the cessation of ICI therapy and initiation of high-dose corticosteroids are crucial to improve outcomes. Cardio-oncologists will need to play an important role not just in the management of acute cardiotoxicity but also to reduce the risk of long-term sequelae.

Outcomes of COVID-19 in Patients With a History of Cancer and Comorbid Cardiovascular Disease

BACKGROUND

Cancer and cardiovascular disease (CVD) are independently associated with adverse outcomes in patients with COVID-19. However, outcomes in patients with COVID-19 with both cancer and comorbid CVD are unknown.

METHODS

This retrospective study included 2,476 patients who tested positive for SARS-CoV-2 at 4 Massachusetts hospitals between March 11 and May 21, 2020. Patients were stratified by a history of either cancer (n=195) or CVD (n=414) and subsequently by the presence of both cancer and CVD (n=82). We compared outcomes between patients with and without cancer and patients with both cancer and CVD compared with patients with either condition alone. The primary endpoint was COVID-19-associated severe disease, defined as a composite of the need for mechanical ventilation, shock, or death. Secondary endpoints included death, shock, need for mechanical ventilation, need for supplemental oxygen, arrhythmia, venous thromboembolism, encephalopathy, abnormal troponin level, and length of stay.

RESULTS

Multivariable analysis identified cancer as an independent predictor of COVID-19-associated severe disease among all infected patients. Patients with cancer were more likely to develop COVID-19-associated severe disease than were those without cancer (hazard ratio [HR], 2.02; 95% CI, 1.53-2.68; P<.001). Furthermore, patients with both cancer and CVD had a higher likelihood of COVID-19-associated severe disease compared with those with either cancer (HR, 1.86; 95% CI, 1.11-3.10; P=.02) or CVD (HR, 1.79; 95% CI, 1.21-2.66; P=.004) alone. Patients died more frequently if they had both cancer and CVD compared with either cancer (35% vs 17%; P=.004) or CVD (35% vs 21%; P=.009) alone. Arrhythmias and encephalopathy were also more frequent in patients with both cancer and CVD compared with those with cancer alone.

CONCLUSIONS

Patients with a history of both cancer and CVD are at significantly higher risk of experiencing COVID-19-associated adverse outcomes. Aggressive public health measures are needed to mitigate the risks of COVID-19 infection in this vulnerable patient population.

The effect of COVID-19 on general anaesthesia rates for caesarean section. A cross-sectional analysis of six hospitals in the north-west of England

At the onset of the global pandemic of COVID-19 (SARS-CoV-2), guidelines recommended using regional anaesthesia for caesarean section in preference to general anaesthesia. National figures from the UK suggest that 8.75% of over 170,000 caesarean sections are performed under general anaesthetic. We explored whether general anaesthesia rates for caesarean section changed during the peak of the pandemic across six maternity units in the north-west of England. We analysed anaesthetic information for 2480 caesarean sections across six maternity units from 1 April to 1 July 2020 (during the pandemic) and compared this information with data from 2555 caesarean sections performed at the same hospitals over a similar period in 2019. Primary outcome was change in general anaesthesia rate for caesarean section. Secondary outcomes included overall caesarean section rates, obstetric indications for caesarean section and regional to general anaesthesia conversion rates. A significant reduction (7.7 to 3.7%, p < 0.0001) in general anaesthetic rates, risk ratio (95%CI) 0.50 (0.39-0.93), was noted across hospitals during the pandemic. Regional to general anaesthesia conversion rates reduced (1.7 to 0.8%, p = 0.012), risk ratio (95%CI) 0.50 (0.29-0.86). Obstetric indications for caesarean sections did not change (p = 0.17) while the overall caesarean section rate increased (28.3 to 29.7%), risk ratio (95%CI) 1.02 (1.00-1.04), p = 0.052. Our analysis shows that general anaesthesia rates for caesarean section declined during the peak of the pandemic. Anaesthetic decision-making, recommendations from anaesthetic guidelines and presence of an on-site anaesthetic consultant in the delivery suite seem to be the key factors that influenced this decline.

Efficacy and safety of catheter ablation for atrial fibrillation in patients with cancer

Background

Atrial fibrillation (AF) is the most common arrhythmia in patients with cancer. Management of AF in patients with cancer poses unique challenges. Long-term use of antiarrhythmic drug (AAD) therapy lacks evidence of efficacy in this population and poses risk of drug interactions. Catheter ablation is a well-established treatment modality for AAD resistant symptomatic AF and in patients with heart failure. Nevertheless, the effectiveness and safety of catheter ablation in patients with cancer is not well established.

Method

We retrospectively analyzed consecutive patients who underwent catheter ablation for AF, with either history of cancer (other than non-melanoma skin cancer) within 5-years prior or exposure to systemic anthracycline and/or thoracic radiation therapy at any time.

Results

The study included 162 patients. The mean age was 65.5 (26–84 years) years and 50% were female. Overall 133 (82%) patients had freedom from AF at 12 months following ablation. Of these 74 (54%) required post-ablation AAD, 18 (13.5%) required another ablation within the first 12 months and 9 (6.7%) required both AAD and a second ablation to maintain sinus rhythm. There were 14 adverse events (8.6%); 5 access site and 4 non-access site bleeding, 2 strokes, 2 cardiac tamponade and 1 pulmonary vein stenosis with ≈1% serious complications.

Conclusion

The success of catheter ablation for AF and the incidence of procedure related complications in patients with a history of recent cancer or prior exposure to cardiotoxic therapies are similar to that reported in patients without a history of cancer and hence if needed, it should be considered in select patients.

Funding Acknowledgement

Type of funding source: Private hospital(s). Main funding source(s): Dr. S Ganatra is supported by Lahey Physician Research Stipend Program.

Cardiovascular effects of chimeric antigen receptor t-cell therapy for refractory or relapsed non-hodgkin lymphoma

Purpose

Cardiovascular complications of chimeric antigen receptor T-cell (CAR T-cell) therapy are poorly understood. We examined the incidence, predictors and impact of new or worsening cardiomyopathy in patients undergoing CAR T-cell therapy.

Methods

All patients with refractory or relapsed non-Hodgkin's lymphoma, undergoing CAR T-cell therapy at collaborative institutes underwent serial echocardiograms at baseline and within 7 days after developing high-grade cytokine release syndrome (CRS), and were followed for all-cause mortality. New or worsening cardiomyopathy was defined as a reduction in left ventricular ejection fraction (LVEF) &gt;10% from baseline to &lt;50% during the index hospitalization.

Results

Among 187 consecutive CAR T-cell therapy patients, 116 (50 Grade ≤1 CRS, 66 Grade ≥2 CRS) had &gt;1 echocardiogram performed and were included in this analysis. The median age was 63 (range 19–80) years, 42% were women, 91% were Caucasian. A total of 12 (10.3%) patients developed new or worsening cardiomyopathy with a decline in LVEF from 58±6% to 36±7% within a median of 12.5 (range 2–24) days of CAR T-cell infusion. In multivariable analyses, older age, prior stem cell transplantation, baseline angiotensin-converting enzyme inhibitor use and CRS grade ≥2 were associated with the development of cardiomyopathy. Patients who developed cardiomyopathy were more likely to require vasopressor support (p=0.004) and mechanical ventilation (p=0.014). LVEF improved in 9/12 (75%) patients. CAR T-cell associated cardiomyopathy did not impact overall mortality or cancer response to CAR-T cell therapy.

Conclusions

Patients undergoing CAR T-cell therapy are at risk of developing cardiomyopathy and hemodynamic instability. Pre-CAR T-cell therapy cardiovascular risk stratification and echocardiogram surveillance during therapy should be considered for prompt identification and mitigation of cardiac complications.

Predictors of Cardiomyopathy Development

Funding Acknowledgement

Type of funding source: Private hospital(s). Main funding source(s): Anju Nohria, MD is supported by the Gelb Master Clinician Award at Brigham and Women's Hospital.

Management of Cardiovascular Disease During Coronavirus Disease (COVID-19) Pandemic

Patients with pre-existing cardiovascular disease and risk factors are more likely to experience adverse outcomes associated with the novel coronavirus disease-2019 (COVID-19). Additionally, consistent reports of cardiac injury and de novo cardiac complications, including possible myocarditis, arrhythmia, and heart failure in patients without prior cardiovascular disease or significant risk factors, are emerging, possibly due to an accentuated host immune response and cytokine release syndrome. As the spread of the virus increases exponentially, many patients will require medical care either for COVID-19 related or traditional cardiovascular issues. While the COVID-19 pandemic is dominating the attention of the healthcare system, there is an unmet need for a standardized approach to deal with COVID-19 associated and other traditional cardiovascular issues during this period. We provide consensus guidance for the management of various cardiovascular conditions during the ongoing COVID-19 pandemic with the goal of providing the best care to all patients and minimizing the risk of exposure to frontline healthcare workers.

Treatment patterns and clinical outcomes among patients (pts) with HER2+ advanced breast cancer (ABC) and germline BRCA1/2 mutation(s) (gBRCA1/2mut): Results from a US real-world study

e13076

Background: g BRCA1/2mut ABC represents ~5% of all breast cancer (BC) including pts with HER2+ BC. While HER2-targeted therapy remains an effective tx for those pts, limited information is available on the use and effectiveness of PARP inhibitors (PARPi) for pts with HER2+ g BRCA1/2mut ABC. Recently, NCCN updated its guidelines (v1.2020) to support the use of PARPi in pts with g BRCA1/2mut metastatic BC regardless of subtype. In order to establish a baseline reference point, we assessed real-world tx patterns and clinical outcomes among pts with g BRCA1/2mut HER2+. Methods: Oncologists retrospectively reviewed charts (July-Oct 2019) of randomly selected pts ≥18 y, with g BRCA1/2mut HER2+ABC who received ≥1 cytotoxic chemotherapy (CT) regimen(s) for ABC between Jan 2013-April 2018. Descriptive analysis was performed for 1st line ABC tx patterns. Clinical outcomes (1st line ABC PFS rates) were estimated using the Kaplan-Meier method. PARPi clinical outcomes data was immature given its recent launch. Additional analyses evaluating outcomes in pts receiving PARPi are planned. Results: Of the 225 pts with g BRCA1/2mut ABC included in the study, 48 (21%) female pts had HER2+ disease. Of the g BRCA1/2mut HER2+ pts, 77% were white with a median age of 58 y. Clinical characteristics: 42% HR+/HER2+, 56% HR-/HER2+, 2% had unknown HR/HER2+ ABC. Txs in the 1st line setting for HR+/HER2+ ABC pts (n = 20) included: CT (75%), CT + HER2-targeted therapy (25%) (Table). First-line txs used for HR-/HER2+ ABC pts (n = 27) included: CT + HER2-targeted therapy (78%), CT (15%), other (7%) (Table). 12-month PFS for 1st line HR+/HER2+ pts was 73% and for HR-/HER2+ pts was 69% (Table). Later line tx patterns will be presented. Conclusions: In this analysis of pts with g BRCA1/2mut HR+/HER2+, unexpectedly low rates of HER2-targeted therapy were observed. As expected, high rates of HER2-targeted therapy with CT were observed among g BRCA1/2mut HR-/HER2+ pts. Clinical outcome findings demonstrate the need for more efficacious tx options. Studies assessing clinical outcomes among g BRCA1/2mut HER2+ ABC pts receiving PARPi +/- HER2-targeted tx are warranted. This is a limited sample size; additional data collection including median PFS is ongoing. [Table: see text]

Repeat cytoreductive surgery with or without intraperitoneal chemotherapy for recurrent epithelial appendiceal neoplasms

Background

With recurrence rates after primary cytoreductive surgery (CRS) in excess of 50 per cent, repeat CRS is being performed increasingly, but survival outcomes have not been reported widely. This study examined the outcomes following repeat CRS for appendiceal cancer with peritoneal surface malignancy (PSM), and evaluated its feasibility and safety.

Methods

A retrospective cohort of patients who had surgery between 1996 and 2018 were analysed. Patients who underwent a single CRS procedure with or without heated intraperitoneal chemotherapy (HIPEC) were compared with those who had multiple procedures with or without HIPEC. Perioperative morbidity and survival outcomes were analysed.

Results

Some 462 patients were reviewed, 102 of whom had repeat procedures. For high‐grade tumours, patients who had a single CRS procedure had significantly reduced overall survival (OS) compared with those who had repeat CRS (55·6 versus 90·7 months respectively; P = 0·016). For low‐grade tumours, there was no difference in OS (P = 0·153). When patients who had a single procedure were compared with those who had multiple procedures, there was no significant difference in major morbidity (P = 0·441) or in‐hospital mortality (P = 0·080). For multiple procedures, no differences were found in major morbidity (P = 0·262) or in‐hospital mortality (P = 0·502) when the first procedure was compared with the second. For low‐grade cancers, the peritoneal carcinomatosis index was a significant prognostic factor for OS (hazard ratio (HR) 1·11, 95 per cent c.i. 1·05 to 1·17; P < 0·001), whereas for high‐grade cancers repeat CRS (HR 0·57, 0·33 to 0·95; P = 0·033), complete cytoreduction score (HR 1·55, 1·01 to 2·40; P = 0·046) and presence of signet ring cells (HR 2·77, 1·78 to 4·30; P < 0·001) were all significant indicators of long‐term survival.

Conclusion

In selected patients presenting with PSM from epithelial appendiceal neoplasms, repeat CRS performed in high‐volume centres could provide survival benefits.

Cardiotoxicity of Immune Therapy

The advent of immunotherapy, particularly immune checkpoint inhibitors and chimeric antigen receptor T-cell therapy, has ushered in a promising new era of treatment of patients with a variety of malignancies who historically had a poor prognosis. However, these therapies are associated with potentially life-threatening cardiovascular adverse effects. As immunotherapy evolves to include a wider variety of malignancies, risk stratification, prompt recognition, and treatment of cardiotoxicity will become increasingly important and hence cardiologists will need to play a fundamental role in the comprehensive care of these patients. This article reviews cardiotoxicity associated with contemporary immunotherapy and discusses potential management strategies.

Priorities and preferences for school-based mental health services in India: a multi-stakeholder study with adolescents, parents, school staff, and mental health providers

BACKGROUND

Schools are important settings for increasing reach and uptake of adolescent mental health interventions. There is limited consensus on the focus and content of school-based mental health services (SBMHSs), particularly in low-resource settings. This study elicited the views of diverse stakeholders in two urban settings in India about their priorities and preferences for SBMHSs.

METHODS

We completed semi-structured interviews and focus group discussions with adolescents (n  =  191), parents (n  =  9), teachers (n  =  78), school counsellors (n  =  15), clinical psychologists/psychiatrists (n  =  7) in two urban sites in India (Delhi and Goa). Qualitative data were obtained on prioritized outcomes, preferred content and delivery methods, and indicated barriers.

RESULTS

All stakeholders indicated the need for and acceptability of SBMHSs. Adolescents prioritized resolution of life problems and exhibited a preference for practical guidance. Parents and teachers emphasized functional outcomes and preferred to be involved in interventions. In contrast, adolescents' favored limited involvement from parents and teachers, was related to widespread concerns about confidentiality. Face-to-face counselling was deemed to be the most acceptable delivery format; self-help was less frequently endorsed but was relatively more acceptable if blended with guidance or delivered using digital technology. Structured sensitization was recommended to promote adolescent's engagement. Providers endorsed a stepped care approach to address different levels of mental health need among adolescents.

CONCLUSION

SBMHSs are desired by adolescents and adult stakeholders in this setting where few such services exist. Sensitization activities are required to support implementation. School counsellors have an important role in identifying and treating adolescents with different levels of mental health needs, and a suite of interventions is needed to target these needs effectively and efficiently.

Medical record review of transition to lanreotide following octreotide for neuroendocrine tumors

BACKGROUND

Octreotide has been used for decades in the United States (US) and Europe to treat patients with advanced neuroendocrine tumors (NETs). Lanreotide was approved in 2014 to improve progression-free survival (PFS) in patients with unresectable, well- or moderately-differentiated, locally advanced or metastatic gastroenteropancreatic NETs. Therefore, clinicians and patients may consider sequencing therapy from octreotide to lanreotide. However, current real-world outcomes data on patients who have made this transition is limited.

METHODS

We conducted a multicenter, noninterventional, retrospective medical record review of patients with locally advanced or metastatic gastroenteropancreatic NETs (NCT03112694). Included patients had been treated with long-acting octreotide monotherapy for ≥90 days before transitioning to lanreotide monotherapy and continued on lanreotide for ≥90 days. Abstractors entered patient demographic and clinical data into a customized, web-based case report form. We assessed clinically defined PFS and other tumor-related outcomes while patients were treated with lanreotide. Outcomes were analyzed according to level of response at the time of transition from octreotide to lanreotide: progressive disease, nonprogressive disease, or unknown. Statistical analyses were descriptive. Clinically defined PFS and duration of treatment with lanreotide were estimated using the Kaplan-Meier method.

RESULTS

Data were abstracted for 91 patients with gastroenteropancreatic NETs who received long-acting octreotide followed by lanreotide at six US based sites. At initial diagnosis, 71.4% of patients had stage IV disease. Small intestine (63.7%) and pancreas (14.3%) were the most common primary tumor sites. Mean [standard deviation (SD)] duration of follow-up from diagnosis was 70.6 (41.3) months. Patients received long-acting octreotide for a mean (SD) of 38.4 (32.8) months. When patients transitioned to lanreotide, 57.1% had nonprogressive disease on octreotide, 30.8% had progressive disease, and the remainder had unknown disease status. The most common reasons for switching from octreotide to lanreotide were progressive disease (22.0%), formulary change (15.4%), and patient preference (9.9%). Patients received lanreotide for a median (95% CI) duration of 24.7 (16.7-59.9) months. At the end of follow-up, 74% of patients remained on lanreotide monotherapy. Progression occurred in 24.2% of patients during lanreotide treatment. Overall median (95% CI) clinician-defined PFS following the transition to lanreotide was estimated to be 23.7 months [20.2 months-NE (not estimable)]. Patients with nonprogressive disease when they transitioned to lanreotide experienced a median clinician-defined PFS of 24.7 (17.0-NE) months. Among patients reported to have progressive disease when they transitioned to lanreotide, median (95% CI) clinician-defined PFS was estimated to be 15.2 (11.4-NE) months. There were no material differences in adverse events recorded during the long-acting octreotide and lanreotide treatment periods.

CONCLUSIONS

Our study suggests that lanreotide monotherapy is well tolerated and may contribute to stabilization of disease in a subset of patients with locally advanced or metastatic gastroenteropancreatic NETs previously treated with long-acting octreotide.

Cesarean delivery to prevent anal incontinence: a systematic review and meta-analysis

BACKGROUND

Cesarean delivery (CD), is increasingly recommended as a mode of delivery that prevents the anal incontinence (AI) that arises in some women after vaginal delivery (VD). The assessment of the efficacy of CD in this regard was the subject of this systematic review.

METHODS

Searches were conducted in Medline, EMBASE and the Cochrane Library. Both randomized (RCTs) and non-randomized trials (NRTs) comparing the risk of sustained fecal and/or flatus incontinence after VD or CD were sought from 1966 to 1 January, 2019. Studies were eligible if they assessed AI more than 6 months after birth, and had statistical adjustment for at least one of the three major confounders for AI: age, maternal weight or parity. In addition, each study was required to contain more than 250 participants, more than 50 CDs and more than 25 cases of AI. Data after screening and selection were abstracted and entered into Revman for meta-analysis. Analyses were done for combined fecal and flatus incontinence (comAI), fecal incontinence (FI), gas incontinence (GI), CD before or during labor, time trend of incontinence after delivery, assessment of both statistical and clinical heterogeneity, parity and late incident AI.

RESULTS

Out of the 2526 titles and abstracts found, 24 eligible studies were analyzed, 23 NRTs and one RCT. These included women with 29,597 VDs and women with 6821 CDs. Among the primary outcomes, VD was found not to be a significant predictor of postpartum comAI compared to CD in 6 studies, incorporating 18,951 deliveries (OR = 0.74; 0.54-1.02). VD was also not a significant predictor of FI in 14 studies, incorporating 29,367 deliveries, (OR = 0.89; 0.76-1.05). VD was not a significant predictor of GI in six studies, incorporating 6724 deliveries (OR = 0.96; 0.79-1.18). The strength of the grading of recommendations, assessment, development and evaluations (GRADE) evidence for each of these was low for comAI and moderate for FI and GI (upgrade for lack of expected effect). Time trend FI showed incontinence at 3 months often resolved at 1 year. Other secondary analyses assessing parity, delayed incidence of FI, clinical and statistical heterogeneity, spontaneous VD only, late risk of incidence of AI, and CD in or prior to labor all had similar results as in the primary outcomes.

CONCLUSIONS

There are three components of pelvic floor dysfunction that are thought to be caused by VD and hopefully prevented by CD: AI, urinary incontinence and pelvic floor prolapse. Of these, AI was not found to be reliably prevented by CD in this review.

Abstract A45: Treatment patterns and outcomes among platinum-refractory/resistant ovarian cancer patients

Background: Real-world evidence on current treatment patterns and outcomes is limited for patients with platinum-refractory/resistant epithelial ovarian, fallopian tube, or primary peritoneal cancer (PRROC). This study aimed to describe the treatment patterns and outcomes of patients with PRROC in the United States (US), the United Kingdom (UK), and Canada (CA).

Methods: Physicians retrospectively reviewed medical records of females aged ≥18 years diagnosed with PRROC from January 2010 to June 2014. Follow-up data available through October 2016 were extracted. Patient characteristics, initial PRROC treatment regimens, and associated health care utilization were assessed descriptively; clinical outcomes were estimated using the Kaplan-Meier and Cox proportional-hazards methods.

Results: Data were obtained on 392 US, 296 UK, and 82 CA patients. At initial diagnosis of epithelial ovarian, fallopian tube, or peritoneal cancer, 65.8% (US), 93.3% (UK), and 82.9% (CA) of patients had stage III/IV disease and 43.6% (US), 73.7% (UK), and 56.1% (CA) had high-grade tumors. Most patients were diagnosed with PRROC in 2013 or 2014 (US: 64.8%, UK: 72.3%, CA: 64.6%) and mean age at PRROC diagnosis was 57 years in the US and CA and 59 years in the UK. The proportion of patients with ECOG performance status (PS) ≤1 at PRROC diagnosis was 57.7% in the US, 80.1% in the UK, and 36.6% in CA. Most patients received systemic treatment after PRROC diagnosis (US 71.4%; UK 83.1%; CA 81.7%). Most of the patients received only one treatment line at the time of extraction (US: 64.3%, UK: 75.6%, CA: 70.2%). Bevacizumab ± chemotherapy (US 41.4%; UK 12.6%; CA 35.8%) and pegylated liposomal doxorubicin (PLD) monotherapy (US 18.6%; UK 50.0%; CA 34.3%) were the most common initial therapies. Common subsequent treatments varied between the countries, including topotecan, gemcitabine, PLD, paclitaxel. During initial treatment for PRROC, 80.7%, 59.8%, and 44.8% of patients had at least one office visit and 18.9%, 7.3%, and 19.4% of patients had at least one emergency department visit in the US, UK, and CA, respectively.

Hospitalizations during initial treatment for PRROC were observed among 17.5% of patients in the US, 10.2% in the UK, and 14.9% in CA. Treatment toxicity was the most common reason for hospitalization (US 75.5%; UK 64.0%; CA 80.0%). Median progression-free survival (PFS; 95% confidence interval) was 6.4 (5.4-9.3), 8.0 (6.8-9.2), and 5.6 (4.9-6.2) months in the US, UK, and CA, respectively. The Cox proportional-hazards model showed that stage III/IV, high-grade tumors, and poorer PS were associated with shorter survival.

Conclusions: Even though bevacizumab ± chemotherapy and PLD were the most common initial PRROC treatments in the three countries, relatively higher utilization of bevacizumab ± chemotherapy was observed in the US and CA than the UK, plausibly due to lack of bevacizumab reimbursement in the UK for the treatment of PRROC. Limited PFS and a high prevalence of hospitalization due to treatment toxicity observed with initial treatments suggest a continued need for more effective and tolerable treatment strategies for PRROC.

Citation Format: Rohan Parikh, Samantha Kurosky, Margarita Udall, Jane Chang, Joseph C. Cappelleri, Jim P. Doherty, James A. Kaye. Treatment patterns and outcomes among platinum-refractory/resistant ovarian cancer patients. [abstract]. In: Proceedings of the AACR Conference: Addressing Critical Questions in Ovarian Cancer Research and Treatment; Oct 1-4, 2017; Pittsburgh, PA. Philadelphia (PA): AACR; Clin Cancer Res 2018;24(15_Suppl):Abstract nr A45.

Newborn Screening Guidelines for Congenital Hypothyroidism in India: Recommendations of the Indian Society for Pediatric and Adolescent Endocrinology (ISPAE) - Part I: Screening and Confirmation of Diagnosis

The Indian Society for Pediatric and Adolescent Endocrinology has formulated locally relevant Clinical Practice Guidelines for newborn screening, diagnosis and management of primary congenital hypothyroidism (CH).

RECOMMENDATIONS

Screening should be done for every newborn using cord blood, or postnatal blood, ideally at 48 to 72 h of age. On this screen sample, neonates with TSH > 20 mIU/L serum units (or >34 mIU/L for samples taken between 24 to 48 h of age) should be recalled for confirmation. For screen TSH > 40 mIU/L, immediate confirmatory venous T4/FT4 and TSH, and for milder elevation of screen TSH, a second screening TSH at 7 to 10 d of age, should be taken. Preterm and low birth weight infants should undergo screening at 48-72 h postnatal age. Sick babies should be screened at least by 7 d of age. Venous confirmatory TSH >20 mIU/L before age 2 wk and >10 mIU/L after age 2 wk, with low T4 (<10 μg/dL) or FT4 (<1.17 ng/dL) indicate primary CH and treatment initiation. Imaging is recommended by radionuclide scintigraphy and ultrasonography after CH is biochemically confirmed but treatment should not be delayed till scans are performed. Levothyroxine is commenced at 10 to 15 μg/kg in the neonatal period. Serum T4/FT4 is measured at 2 wk and TSH and T4/FT4 at 1 mo, then 2 monthly till 6 mo, 3 monthly from 6 mo-3 y and every 3-6 mo thereafter. Babies with the possibility of transient congenital hypothyroidism should be re-evaluated at age 3 y, to assess the need for lifelong therapy.

Outcomes of early carotid stenting and angioplasty in large-vessel anterior circulation strokes treated with mechanical thrombectomy and intravenous thrombolytics

Introduction Proximal cervical internal carotid artery stenosis greater than 50% merits revascularization to mitigate the risk of stroke recurrence among large-vessel anterior circulation strokes undergoing mechanical thrombectomy. Carotid artery stenting necessitates the use of antiplatelets, and there is a theoretical increased risk of hemorrhagic transformation given that such patients may already have received intravenous thrombolytics and have a significant infarct burden. We investigate the outcomes of large-vessel anterior circulation stroke patients treated with intravenous thrombolytics receiving same-day carotid stenting or selective angioplasty compared to no carotid intervention. Materials and methods The study cohort was obtained from the National (Nationwide) Inpatient Sample database between 2006 and 2014, using International Statistical Classification of Diseases, ninth revision discharge diagnosis and procedure codes. A total of 11,825 patients with large-vessel anterior circulation stroke treated with intravenous thrombolytic and mechanical thrombectomy on the same day were identified. The study population was subdivided into three subgroups: no carotid intervention, same-day carotid angioplasty without carotid stenting, and same-day carotid stenting. Outcomes were assessed with respect to mortality, significant disability at discharge, hemorrhagic transformation, and requirement of percutaneous endoscopic gastronomy tube placement, prolonged mechanical ventilation, or craniotomy. Results This study found no statistically significant difference in patient outcomes in those treated with concurrent carotid stenting compared to no carotid intervention in terms of morbidity or mortality. Conclusions If indicated, it is reasonable to consider concurrent carotid stenting and/or angioplasty for large-vessel anterior circulation stroke patients treated with mechanical thrombectomy who also receive intravenous thrombolytics.

Catheter Assisted Management of Massive Pulmonary Embolism

Pulmonary thromboembolism is common and missed by clinicians. We report a case of massive pulmonary embolism which was life threatening treated by the catheter assisted technique. Anticoagulation is the mainstay of therapy for most patients, with thrombolytic therapy reserved for some patients.1 Recent studies have suggested a role for systemic or catheter-directed thrombolytic therapy in selected patients.2 We present a case of a patient who presented with an PE, was successfully treated with catheter-directed thrombolysis.

Heart Failure and the Iron Deficiency

Iron deficiency anemia is a significant problem worldwide and more so in developing countries, like India. The prevention and treatment of iron deficiency is a major public health goal in India It is now well recognized that iron deficiency has detrimental effects in patients with coronary artery disease, heart failure, and pulmonary hypertension, and possibly in patients undergoing cardiac surgery. Around one-third of all patients with HF, and around one-half of patients with pulmonary hypertension, are affected by iron deficiency.1.

Asymptomatic Presentation of Large Cardiac Hydatid

Hydatid cyst is a tissue parasitic infection caused by tapeworm Echinococcus granulosus. Common location for hydatid cysts are the liver (65%) and the lungs (25%). Cardiac hydatid cyst is seen rarely, occurring in about 0.5-2% of all cases of hydatid disease. We present this case of 45 years female who presented with short duration of dry cough and atypical chest pain. Chest X ray showed cardiomegaly with round bulge at the right heart border and curvilinear calcification in left upper abdomen in the region of spleen. Transthoracic echocardiography (TTE) depicted cystic lesion in Right Ventricle free wall causing compression of right atrial and ventricular cavity. Cardiac CT confirmed this cyst as hydatid cyst. Patient underwent successful excision of right ventricular hydatid cyst.