An upcoming drug for onychomycosis: Tavaborole

Fungal infection of the nail as well as nail bed is termed as 'onychomycosis'. It is caused by dermatophytes, non-dermatophytic fungal species and yeasts like Candida albicans. It is traditionally treated by topical antifungals, systemic agents like ketoconazole, griseofulvin, itraconazole, fluconazole, etc. Chemical avulsion or surgical removal of nail can also be tried to treat this disease. In spite of all these treatment options available, podiatrists were always in search of an ideal drug molecule with lesser side effects and which may improve the patient compliance. This exhaustive search led to the discovery of a better antifungal agent, known as "Tavaborole." A systematic literature search was carried out using databases such as PubMed, Cochrane Reviews, Google Scholar, etc. Detailed information about onychomycosis and tavaborole was gathered. Tavaborole is the first oxaborole antifungal agent approved by FDA in July 2014. It is marketed under the trade name "Kerydin." It acts by inhibiting protein synthesis in the fungus. It inhibits an enzyme known as cytosolic leucyl-transfer RNA synthetase, or LeuRS, which plays a key role in fungal essential protein synthesis. Dermatitis at the site of topical application, erythema, exfoliation and ingrowing toe nail has been reported in 1% of subjects. Tavaborole may offer a promising role in the treatment of onychomycosis and may compell podiatrists to offer its use in onychomycosis. The present study describes about chemical nature, mechanism of action and two completed phase 3 clinical trial findings of Tavaborole.

C4 article: Implications of COVID-19 in transplantation

A novel coronavirus has had global impact on individual health and health care delivery. In this C4 article, contributors discuss various aspects of transplantation including donor and recipient screening, management of infected patients, and prevention of coronavirus disease (COVID). Donor screening with SARS-CoV-2 nucleic acid testing (NAT) close to the time of procurement is recommended. Many programs are also screening all potential recipients at the time of admission. The management of COVID has evolved with remdesivir emerging as a new potential option for transplant recipients. Dexamethasone has also shown promise and convalescent plasma is under study. Prevention strategies for transplant candidates and recipients are paramount. Pediatric-specific issues are also discussed. Strategies for the psychological well-being of patients and providers are also imperative, in addition to future research priorities for transplantation.

Review of investigational drugs for coronavirus disease 2019

In December 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) became evident in Wuhan, China, and then spread rapidly worldwide. Numerous drugs and vaccines are under clinical trial pipeline for investigation against coronavirus disease 2019 (COVID-19) infection. The aim of this systematic review was to discuss about investigational new as well as repurposed drugs currently under trial for COVID-19 infection. An exhaustive search was carried out for this review article including scientific databases of PubMed, Embase, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, Web of Science, ScienceDirect, ProQuest, Google Scholar, and Scopus search engines using keywords of "Coronavirus," "COVID-19," "MERS-CoV," "MERS," "SARS-CoV-2," and "SARS-CoV-1" and "Solidarity trial" and their Persian-equivalent keywords from inception until May 2020. After screening the 296 articles searched from different databases (PubMed = 97 and other search engines = 199), 52 articles were included in the final systematic review. It was found that the World Health Organization introduced a Solidarity international clinical trial to discover an effectual treatment of COVID-19. Based on established in vitro and in vivo activity against different strains of coronaviruses, four repurposed drugs - remdesivir, lopinavir/ ritonavir combination, lopinavir/ritonavir with beta-1a, chloroquine, and hydroxychloroquine - were considered for clinical trial against COVID-19. A number of other drugs and vaccines are under clinical trial pipeline for investigation against COVID-19 infection. Despite multitude of treatment options available, treatment of choice is still not well established. Moreover, optimum supportive care and monitoring of seriously ill patients is the need of the hour.

Transplantation for chemotherapy-induced cardiomyopathy-case series and review of current practice

Multimodality therapies have improved the survival after tumors like Ewing's sarcoma and breast cancer. However, cardiotoxicity following chemotherapy remains an important concern. We report a case series of four patients who presented to our heart team with severe dilated cardiomyopathy along with biventricular involvement. Two of the patients were females and had breast cancer for which they were treated with trastuzumab and had developed chemotherapy induced cardiomyopathy (CCMP). The other two patients were males who had Ewing's sarcoma who developed CCMP following treatment with doxorubicin.

Use of ivabradine for treatment of junctional ectopic tachycardia in post congenital heart surgery

Cardiac surgeries especially involving crux of the heart as performed in tetralogy of Fallot (TOF) and pulmonary stenosis are mainly responsible for junctional ectopic tachycardia (JET). Diversified antiarrhythmic agents have been used in an impressive way to treat JET but showed suboptimal efficacy and varied associated adverse effects. But, ivabradine has proved as final crusader for its treatment. We report our initial experience of 4 cases in last 6 months with ivabradine in the management of postoperative JET. Encouraged by various reports and our increasing experience with ivabradine in heart failure population, we have moved to ivabradine as the first drug of choice for postoperative JET. Bradycardia was the only significant adverse effect in our series. The availability of atrial and ventricular pacing wires or at least transvenous temporary pacing should be ensured before starting ivabradine.

A potential drug in the armamentarium of post-cardiac transplantation immunosuppression: belatacept

Undeterred by all the advancement in the field of cardiac transplantation, heart transplant rejection remained its mammoth quandary. Management of heart transplant recipients has drastically improved with current regimens of immunosuppressive drugs. The adverse effects of calcineurin inhibitors are lacking with the use of belatacept, which is a costimulation inhibitor that interferes with the interaction between CD28 on T cells and the B7 ligands on antigen-presenting cells. It was originally approved for use in renal transplant recipients but it has shown promising results in heart transplant recipients.

Scaling skin and failing heart: the cardio-cutaneous connection

Ichthyosis refers to a comparatively rare group of skin disorders which may present with associated cardiomyopathy. We report a case of an 11-year-old female child who presented with ichthyosis and associated dilated cardiomyopathy. Genetic testing revealed mutation in the RBCK1 gene. She was successfully managed with heart transplantation. The purpose of the case report is to embark on the association between the skin and heart, the role of desmosomes, and the cutaneous manifestations of life-threatening cardiac disease. Cutaneous manifestations should not be escaped, as some of which could be a marker for sudden cardiac death and appropriate corrective actions can potentially save life.

Cell-free DNA in the surveillance of heart transplant rejection

BACKGROUND

Circulating cell-free deoxyribonucleic acid (cfDNA) is promptly materializing as a highly useful tool for the surveillance of solid-organ transplant rejection. Donor-specific fraction (DF) cfDNA is a potential marker of selective donor organ injury. It is emerging as a promising analytical target in the near future. The aim of this systematic review is to throw light on the importance of cfDNA and future perspective in detecting acute rejection in heart transplantation.

METHODS

An exhaustive search was carried out for this review article on the basis of literature available including scientific databases of PubMed, Embase, and ClinicalTrials.gov. The search engines were systematically explored using the search terms "cell free DNA," "Heart transplant," and "Rejection" from inception until August 2020, and narrative analysis was accomplished. Majority of the studies described endomyocardial biopsy-proven acute rejection as reference standard.

RESULTS

After initial screening of 331 articles, 11 studies were included and discussed in detail in the present review article. Majority of the studies showed prospective designs. A firm correlation was noted between acute rejection (identified on endomyocardial biopsy) and cfDNA levels by most of the studies.

CONCLUSIONS

cfDNA is a promising tool to replace repeated biopsies to detect rejection. The development in the area of digital droplet polymerase chain reaction and massive parallel sequencing, along with the overall reduction in cost of sequencing with its automation, has helped establish its role in the transplant population.

A Remarkable Journey of Porcine to Human Xenotransplantation

Xenotransplantation of pig hearts offers a potential solution to the scarcity of available human organs for transplantation. This abstract explores the challenges and risks associated with xenotransplantation, as well as the ongoing research and development efforts aimed at overcoming these obstacles. The primary hurdle in pig-to-human heart transplantation is immunological compatibility, as the human immune system perceives pig organs as foreign and mounts a rejection response. Genetic engineering techniques are being investigated to modify pig organs and enhance compatibility with the human immune system. In addition, the risk of cross-species disease transmission, known as xenozoonosis, poses another concern. Researchers are actively working to identify and address these risks to ensure the safety of xenotransplantation. Although xenotransplantation of pig hearts is still in the experimental stage and not widely performed in clinical settings, numerous preclinical studies and clinical trials are underway to evaluate the safety and efficacy of the procedure. This abstract emphasizes the importance of ongoing research and development in the field, highlighting the potential of xenotransplantation as a viable solution for the organ shortage crisis. Ultimately, further advancements are necessary before xenotransplantation of pig hearts can be established as a routine clinical procedure.

DelNido cardioplegia versus St Thomas cardioplegia solution in double valve replacement: a single centre experience

INTRODUCTION

The role of cardioplegia cannot be underrated in cardiac surgery. St Thomas solution is the most widely used cardioplegic, but needs repeated dosing. Del Nido solution provides long duration of asystole with adequate protection; but has been used mainly in paediatric patients. This study was aimed to compare Del Nido cardioplegia with St Thomas cardioplegia in adult cardiac surgeries, requiring double valve replacement and compare the outcomes.

METHODOLOGY

This retrospective, observational, descriptive study was conducted over a time period spanning from January 2016 to December 2019. A total of 209 patients were included and were separated in two groups DC group (n = 114) and BC group (n = 95) on the basis of cardioplegic solution used. Del Nido solution was administered as single dose. Parameters noted were CPB time, cross clamp time, wean off bypass time, DC shocks given, inotropic support required, ventilation duration, duration of ICU and hospital stay.

RESULTS

There was significantly shorter aortic cross clamp time (72.6 ± 10.2 vs. 98.2 ± 9.2), CPB time (92.1 ± 12.3 vs.129.5 ± 11) and wean off bypass time (19.4 ± 5.9 vs. 31.3 ± 7.6) and less requirement of DC shocks (21.2% vs. 65.9%) in DC group. Inotropic requirement in immediate post-operative period was significantly less in DC group both on day of surgery (5.35 ± 1.44 vs. 7.52 ± 3.8) and 24 hours later (3.4 ± 2.12 vs. 2.18 ± 0.72). There was no significant difference in duration of ventilation, ICU and hospital stay.

CONCLUSION

Del Nido can be used safely in long duration adult cardiac surgeries and in a single dose with better intra operative and immediate post-operative outcomes as compared to St Thomas solution.

Cardiac transplantation for cardiomyopathy with constrictive pericarditis

Constrictive pericarditis is a great mimic and has posed a diagnostic dilemma since its first description 300 years ago as "Concretio Cordis." It can mimic restrictive cardiomyopathy, endomyocardial fibrosis, and chronic liver and renal disease. This would perhaps be the first clinical report of constriction in patients undergoing cardiac transplantation. We report two distinct cases with cardiomyopathy requiring cardiac transplantation and the clinical implications of concomitant pericardial constriction. While the first case mimics a natural "cardiac support device," which addresses ventricular remodeling in heart failure by reducing the wall stress, the second case is a case in point against the use of "biological pericardial membrane-like the bovine pericardium," as a pericardial substitute.

A Rare Case of Multiple Myeloma Presenting As Lytic Lesion of the Rib

Multiple Myeloma (MM) is a disease which results from malignant proliferation of plasma cells. It is commonly encountered in elderly patients. Diffuse bony lesions are the most frequent thoracic involvement with MM. We report a case of 42-year-old male patient who came with pain and full swelling in the right chest wall since two years. On CT scan of thorax, heterogenously enhancing soft tissue density lesion with lytic sclerotic destruction of right 4(th) rib seen. En-bloc resection of third and fourth rib was done and plasmacytoma was confirmed on biopsy.

Use of ivabradine in postoperative junctional ectopic tachycardia

Purpose:

When tachyarrhythmias originates from atrioventricular (AV) node, AV junction or bundle of His complex, they are termed “junctional ectopic tachycardia” (JET). Cardiac surgeries especially involving crux of the heart are mainly responsible for JET. Amiodarone and other pharmaco-therapeutic agents are tried as antiarrhythmics for the treatment of postoperative JET. Aim of this review was to discuss about role of ivabradine in the treatment of postoperative JET.

Materials and Methods:

A search was carried out for this review article on the basis of literature available including scientific databases of PubMed, Embase, Scopus, Google Scholar, using keywords “Ivabradine,” “Postoperative junctional ectopic tachycardia,” “Arrhythmias,” “Funny currents,” from October 2011 to October 2020.

Results:

After initial screening of 377 articles, 9 studies were included and discussed in detail in the present review article.

Conclusion:

Treatment of choice of postoperative JET is still not well established. Although there are very few case reports and case series that have been reported on the use of ivabradine in JET, yet it seems to offer a promising use.

Heart transplantation for patients with single ventricle physiology

BACKGROUND

There is a growing population of palliated and unpalliated single ventricle physiology patients for whom heart transplantation is the only treatment option available. There is a paucity of reports of heart transplantation in this challenging and growing subset of patients from our part of the world. The purpose of the article is to briefly review our experience in the subgroup and compare it with the available literature.

METHODS

This was a single-institution retrospective observational study of 16 patients with single ventricle physiology who were transplanted between 2016 and 2019 and their outcomes. The study groups were divided into those with ventricular dysfunction (group 1), who fare substantially better than those with normal ventricular function (group 2) whose short-term outcomes were poorer. Worsening cyanosis, poor candidature for completion Fontan procedure due to severe atrioventricular valve regurgitation or pulmonary artery anatomy, protein-losing enteropathy, plastic bronchitis, and worsening systemic venous congestion are indications in those with normal ventricular function.

RESULTS

Patients with ventricular dysfunction as the main indication had excellent early survival with no early mortality compared to 40% mortality in patients with normal ventricular function. Patients who survived to leave the hospital had however similar long-term outcomes. Two patients with protein-losing enteropathy resolved completely by one month. Normal ventricular function, pulmonary artery stenting, early Fontan failure (6 months), ascites, and need for desensitization were risk factors for early mortality. After the early acute phase of increased risk, the mortality risk plateaued off.

CONCLUSION

Transplantation in patients with single ventricle and ventricular dysfunction can be offered with a good early and late outcome. There is a need to have multi-institutional and multi-disciplinary collaboration along with work in basic sciences to better understand the effects of failed Fontan physiology with normal ventricular function.

Surgery for foreign body retrieval from airway after failed bronchoscopy intervention-a decade-long experience

BACKGROUND

Foreign body aspiration is a critical surgical emergency among pediatric patients, carrying a substantial risk of mortality and contributing significantly to respiratory distress in children. Timely intervention by experts is crucial to mitigating cumulative morbidity. This study aims to evaluate the efficacy of bronchotomy as a secure alternative following unsuccessful attempts at bronchoscopic foreign body retrieval.

METHODS

A retrospective review of 21 instances involving bronchotomies and resections carried out following unsuccessful bronchoscopic foreign body extraction was conducted between June 2013 and March 2022. The posterolateral thoracotomy approach was employed for surgical interventions.

RESULTS

A total of 21 cases underwent bronchotomy and resectional procedures, with a retrospective follow-up spanning 10 years. Patient ages ranged from 1 to 12 years, predominantly affecting the left lung. Bronchotomy was chosen as the intervention in 85% (18 cases) of instances. The incision was extended towards the foreign body in 8 cases involving the right bronchus and in 13 cases for the left bronchus. Late presenters commonly exhibit hemoptysis. Objects retrieved ranged from pen caps and whistles to metal balls. All enrolled cases underwent preoperative bronchoscopy.

CONCLUSION

This study underscores the significance of rigid bronchoscopy as the diagnostic and primary intervention for foreign body aspirations in pediatric cases. Bronchotomy emerges as a secure and effective alternative. Retained foreign bodies causing endobronchial obstruction with stasis necessitate resection, while bronchotomy is a safe procedure for non-retrievable foreign bodies without structural changes.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s12055-024-01845-z.

Curbing Proteastasis to Combat Antibody-Mediated Rejection Post Lung Transplant

Lung transplantation (LTx) has emerged as the treatment of choice for patients suffering from end-stage lung disease all over the past 35 years. Despite ameliorated early survival with a median survival of 6.5 years, its long-term outcomes are dissatisfactory. Although antibody-mediated rejection (AMR) remained “the Achilles heel of LTx,” yet we have not attained consensus on the optimal therapeutic approach. The aim of this review article is to address the upcoming role of proteasome inhibitor drugs in managing AMR post-LTx.

Insight into Noninvasive Radiological Modalities to Detect Heart Transplant Rejection

Purpose  Patients with end-stage heart failure who remain symptomatic even with exemplary medical and device therapy are treated with heart transplantation. Multitudes of endeavor have been contrived during the last decennium in the field of noninvasive tests to rule out heart transplant rejection (HTR). In spite of having supportive literature, noninvasive imaging techniques lack acceptable documentation of clinical robustness, and endomyocardial biopsy (EMB) still remains the gold standard. The aim of this review is to shed light on the existing noninvasive radiological modalities to detect rejection among heart transplant recipients. Methods  A comprehensive search was conducted for this review article on the basis of literature available including scientific databases of PubMed, Embase, and Google Scholar, using keywords of "Heart transplantation," "Acute allograft rejection," "Arrhythmias," "Echocardiography," "Speckle tracking echocardiography," and "Cardiac magnetic resonance imaging" from inception until September 2020. Results  After preliminary screening of the databases, details regarding existent noninvasive radiological modalities to detect HTR were gathered and compiled in this review article. Currently, deformation imaging using speckle tracking and T2 time using cardiac magnetic resonance imaging can serve as screening tools based on which further invasive investigations can be planned. Standardization of blood-based and imaging modalities as screening and possible diagnostic tools for rejection would have obvious clinical and financial benefits in the care of growing number of post heart transplant recipients in our country. Conclusion  Diagnosis of allograft rejection in heart transplant recipients through noninvasive techniques is demanding. To unravel the potential of noninvasive radiological modalities that can serve as a standard-of-care test, a prospective multicentric study randomizing noninvasive modality as first strategy versus current EMB-based gold standard of care is the need of the hour.