Simultaneous ST-elevation myocardial infarction in monozygotic twins: a case report of entangled twins

Background

The development of coronary artery disease (CAD) is strongly influenced by genetic and environmental factors. Monozygotic twins represent a unique population that provides insights into the interaction of genetic, environmental, and social factors and their effects on the development of CAD.

Case summary

Two 54-year-old identical twins presented to an outside hospital with acute chest pain. Twin B developed chest pain after witnessing Twin A in distress from an acute chest pain episode. Electrocardiogram performed on each of them was diagnostic of ST-elevation myocardial infarction. Upon arrival at the angioplasty centre, Twin A was taken for emergency coronary angiography yet his pain subsided on the way to the catheterization lab hence, Twin B was taken for angiography instead. Twin B angiography demonstrated acute occlusion of the proximal left anterior descending coronary artery and was treated with percutaneous coronary intervention. Twin A coronary angiogram demonstrated 60% ostial first diagonal branch stenosis with a normal distal flow. He was diagnosed with possible coronary vasospasm.

Conclusion

This is the first report of a simultaneous presentation of monozygotic twins with ST-elevation acute coronary syndrome. While genetic and environmental contributions to the development of CAD have been described, this case highlights the strong social bond that exists between monozygotic twins. Once CAD is diagnosed in one twin, aggressive risk factor modification and screening should be implemented in the other.

Evaluation of cardiovascular risk scores after implementation of digital therapeutic intervention in patients with uncontrolled primary hypertension

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Terrals Technologies Private Limited

Background

Cardiovascular risk scores serve as a useful tool to reinforce the importance of lifestyle modifications and treatment compliance. Yet, there remains a gap between advice by the physician and its implementation by the patient. Digital therapeutics (DTx) as a technology based approach can help bridge this gap. In this context, knowing the quantum of change in disease outcomes and long term cardiovascular risk after DTx implementation can be helpful in persuading the patients for lifestyle interventions.

Purpose

To evaluate the change in cardiovascular risk scores in hypertensive patients after a digital therapeutic intervention.

Method

We conducted a prospective, single arm, 12-week intervention trial at two primary care sites in India. A total of 125 subjects within the age group of 30-65 years with primary hypertension (≥ 140/90 mmHg) were enrolled. They were provided DTx intervention which consisted of modification in diet, physical activities, self-monitoring and health education superimposed on behavior science theories. Atherosclerotic Cardiovascular Disease (ASCVD) risk scores from Pooled Cohort Equation were calculated for all subjects before & after the DTx intervention and the change in score was assessed.

Results

We received the data of 116 patients having a mean age of 47.66 ± 9.47 years and mean BMI of 27.20 ± 4.77 Kg/m². After DTx intervention, the change in mean systolic blood pressure, among other ASCVD equation parameters, was -26.38 mmHg (154.77 vs 128.39 mmHg, P<0.001). The corresponding post-intervention 10-year mean ASCVD risk score for the sample population decreased by 4.74% (11.86% vs 7.12%, P<0.001). The 10-year mean relative risk of ASCVD decreased by 39.95 %. Similarly ASCVD lifetime risk score decreased by 3.04% (49.54% vs 46.50%, P<0.001), amounting to mean relative risk reduction of 6%. Female subjects (n=60) showed higher 10-year mean ASCVD risk reduction of 5.70% (11.70% vs 6.00%, P<0.001), compared to male subjects (n=56) who showed 10-year mean ASCVD risk reduction of 3.76% (12.06% vs 8.30%, P<0.001). This amounted to a relative risk reduction of 48.69% and 30.71% for female & male subjects, respectively. Patients with stage 1 hypertension (n=82) showed a reduction in 10-year mean ASCVD risk of 2.86% (9.90% vs 7.04%, P<0.001). Patients with stage 2 (n=30) & stage 3 hypertension (n=4) achieved higher 10-year mean ASCVD risk reduction of 8.67% (16.07% vs 7.40%, P<0.001) & 13.6% (20.88% vs 7.20%, P=.006).

Conclusion

Digital therapeutics enabled intervention has caused a significant decrease in 10-year & lifetime ASCVD risks which can eventually lead to a decrease in cardiovascular complications, morbidity and mortality. Therefore, such intervention programs should be further explored and studied.

Prospective evaluation of digital therapeutic intervention on blood pressure control in Indian patients with uncontrolled primary hypertension

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Terrals Technologies Private Limited

Background

Digital therapeutics (DTx) has emerged as a new approach in recent years making use of connected devices, smartphone software and electronic communication tools to help manage chronic cardiovascular diseases such as hypertension. Considering its nascent stage, many questions still remain with respect to its applicability, effectiveness and limitations.

Purpose

Assess the effectiveness of digital therapeutic intervention in controlling blood pressure in Indian patients with primary hypertension

Methods

We conducted a prospective, 12 week, single arm, interventional study, including 125 subjects at multiple sites in India. Subjects with uncontrolled primary hypertension (≥140 mmHg systolic and/or ≥90 mmHg diastolic) in the age group of 30-65 years who were under routine antihypertensive treatment were enrolled. They were provided supplementary DTx intervention comprising of smartphone application based personalized management of diet, exercise, self monitoring and health education by nutritionists and health coaches. Efficacy endpoints such as blood pressure (BP), body mass index (BMI), lipids, etc. were measured before and after the intervention.

Results

A total of 122 subjects who completed the trial had mean age of 47.44 ± 9.43 years, comprising 58 (48%) male and 64 (52%) female patients and mean BMI of 27.21 ±4.7 kg/m². Post-intervention change in mean systolic BP (SBP) was -25.61 mmHg (95% CI 22.55 - 28.66, 154.98 mmHg vs 129.37 mmHg, P<.001). The post-intervention change in mean diastolic BP (DBP) was -18.62 mmHg (95% CI 16.29 - 20.96, 100.04 mmHg vs 81.42 mmHg, P<.001). Patients with stage 1 hypertension (69.6%) achieved mean systolic reduction of 20.87 ± 13.9 mmHg, (148.54 mmHg vs 127.67 mmHg, P<.001). The patients with stage 2 (27.04%) and stage 3 (3.27%) hypertension achieved a higher mean SBP reduction of 34.67 ± 15.19 mmHg (167.24 mmHg vs 132.58 mmHg, P<.001) and 51.5 ± 40.45 mmHg (190.75 mmHg vs 139.25 mmHg, P=.084), respectively. Male and female patients showed almost similar reduction in systolic BP of 25.47 ± 14.72 and 25.73 ± 19.39 mmHg, respectively. Also, the subjects with other chronic comorbidities (23.9%) achieved a mean systolic BP reduction of 29.51 ± 15.25 mmHg.

A total of 79.51% (n=97) patients achieved the SBP <140 mmHg, while 59.84% (n=73) patients achieved SBP <130 mmHg. Combining both the systolic and diastolic targets together, 65.57% (n=80) patients achieved the target of <140/90 mmHg, while ESC/ESH 2018 recommended BP target of <130/80 mmHg was achieved by 31.15% (n=38) patients.

Conclusion

The implementation of Digital therapeutic application integrated with primary healthcare resulted in significant reduction in blood pressure in participants with uncontrolled hypertension. Greater improvement was observed in participants with higher baseline blood pressure.

A Delphi consensus on the nomenclature and diagnosis of lichen planus pigmentosus and related entities

BACKGROUND

Although well known in clinical practice, research in lichen planus pigmentosus and related dermal pigmentary diseases is restricted due to lack of consensus on nomenclature and disease definition.

AIMS AND OBJECTIVES

Delphi exercise to define and categorise acquired dermal pigmentary diseases.

METHODS

Core areas were identified including disease definition, etiopathogenesis, risk factors, clinical features, diagnostic methods, treatment modalities and outcome measures. The Delphi exercise was conducted in three rounds.

RESULTS

Sixteen researchers representing 12 different universities across India and Australia agreed to be part of this Delphi exercise. At the end of three rounds, a consensus of >80% was reached on usage of the umbrella term 'acquired dermal macular hyperpigmentation'. It was agreed that there were minimal differences, if any, among the disorders previously defined as ashy dermatosis, erythema dyschromicum perstans, Riehl's melanosis and pigmented contact dermatitis. It was also agreed that lichen planus pigmentosus, erythema dyschromicum perstans and ashy dermatosis did not differ significantly apart from the sites of involvement, as historically described in the literature. Exposure to hair colours, sunlight and cosmetics was associated with these disorders in a significant proportion of patients. Participants agreed that both histopathology and dermatoscopy could diagnose dermal pigmentation characteristic of acquired dermal macular hyperpigmentation but could not differentiate the individual entities of ashy dermatosis, erythema dyschromicum perstans, Riehl's melanosis, lichen planus pigmentosus and pigmented contact dermatitis.

LIMITATIONS

A wider consensus involving representatives from East Asian, European and Latin American countries is required.

CONCLUSION

Acquired dermal macular hyperpigmentation could be an appropriate conglomerate terminology for acquired dermatoses characterised by idiopathic or multifactorial non-inflammatory macular dermal hyperpigmentation.

Mental health outcome in hospitalized COVID-19 patients: An observational analysis from North Indian tertiary care hospital

Aim

The study investigate the severity of perceived stress and wide domains of psychiatric symptoms reported on initial screening in hospitalized patients of COVID-19 with a second aim to determine the role of sociodemographic factors and coping styles in the hospitalized patients of COVID-19.

Method

Total 224 patients of COVID-19 infection, hospitalized in various isolation facilities were assessed via web-based self-reported questionnaires on perceived stress scale, brief cope inventory, and DSM-5 crosscutting level-1 questionnaire.

Results

Majority of the patients reported moderate level of stress followed by mild and severe. Depression and Anxiety symptoms were most common psychopathologies though the patients have reported greater severity in various domains of psychiatric symptoms. Coping styles explains most of variance (64.8%) of the perceived stress. Similarly total PSS scores, coping styles, COVID-19 status and sociodemographic factors contributed significantly to the variance of all psychiatric symptoms.

Conclusion

Factors like female gender, being married, belonging to nuclear families, service class and urban domicile are the significant factors determining higher risk of stress and developing more psychopathologies. Furthermore, coping styles used by the patients have a greater moderating effect on mental health symptoms and their perceived stress which can be a major area for interventions to reduce the mental health morbidities.

Cutaneous Adnexal Tumours: A Study of 395 Cases from a Tertiary Care Hospital

Background

Cutaneous adnexal tumours (CATs) are one of the commonest clinical presentations in dermatology outpatients. They constitute a subset of skin tumours with a common clinical presentation and variable histological findings. Almost all of them clinically present as a subcutaneous nodule. Depending upon the site and distribution, the clinician can suspect the diagnosis. However, histopathological examination is the gold standard for the definitive diagnosis and proper subtyping of CATs.

Aims

The present study is conducted to see the overall spectrum, incidence and distribution of CATs in a large cohort at the tertiary care centre with their clinical profile.

Methods

This was a retrospective study in which all the CATs diagnosed over a period of 5 years (2015 to 2019) in a tertiary care hospital were studied. Clinical data were recorded from the histopathology requisition forms.

Results

Three hundred and ninety-five cases of CATs were retrieved. Approximately 90% of cases were benign and 10% were malignant. The age of presentation ranged from 8 months to 81 years with male preponderance in all the histological subtypes. The most common site was the head and neck followed by the extremities. Morphologically, the maximum cases showed a differentiation towards sweat glands (44%), followed by sebaceous (29%), follicular (26.5%) and apocrine differentiation (5.3%). Malignant tumours were common in the elderly age group with sebaceous carcinoma being the commonest.

Conclusion

CATs comprise of a wide spectrum of tumours occurring in all age groups. Malignant CATs are rare and common in older age groups. Histopathological examination is the gold standard in distinguishing between the different subtypes.

Association of Pack-Years of Cigarette Smoking With Survival and Tumor Progression Among Patients Treated With Chemoradiation for Head and Neck Cancer

IMPORTANCE

After 10 pack-years of smoking was initially established as a threshold for risk stratification, subsequent clinical trials incorporated it to identify candidates for treatment deintensification. However, several recent studies were unable to validate this threshold externally, and the threshold for smoking exposure remains unclear.

OBJECTIVE

To estimate the threshold of pack-years of smoking associated with survival and tumor recurrence among patients with head and neck cancer.

DESIGN, SETTING, AND PARTICIPANTS

This single-institution, cohort study included patients with nonmetastatic head and neck cancer receiving chemoradiation from January 2005 to April 2021. Data were analyzed from January to April 2022.

EXPOSURES

Heavy vs light smoking using 22 pack-years as a threshold based on maximizing log-rank test statistic.

MAIN OUTCOMES AND MEASURES

Overall survival (OS), progression-free survival (PFS), locoregional failure (LRF), and distant failure (DF).

RESULTS

A total of 518 patients (427 male [82.4%]; median [IQR] age, 61 [55-66] years) were included. Median (IQR) follow-up was 44.1 (22.3-72.8) months. A nonlinear Cox regression model using restricted cubic splines showed continuous worsening of OS and PFS outcomes as pack-years of smoking increased. The threshold of pack-years to estimate OS and PFS was 22. Cox multivariable analysis (MVA) showed that more than 22 pack-years was associated with worse OS (adjusted hazard ratio [aHR] 1.57; 95% CI, 1.11-2.22; P = .01) and PFS (aHR, 1.38; 95% CI, 1.00-1.89; P = .048). On Fine-Gray MVA, heavy smokers were associated with DF (aHR, 1.71; 95% CI, 1.02-2.88; P = .04), but not LRF (aHR, 1.07; 95% CI, 0.61-1.87; P = .82). When 10 pack-years of smoking were used as a threshold, there was no association for OS (aHR, 1.23; 95% CI, 0.83-1.81; P = .30), PFS (aHR, 1.11; 95% CI, 0.78-1.57; P = .56), LRF (aHR, 1.19; 95% CI, 0.64-2.21; P = .58), and DF (aHR, 1.45; 95% CI, 0.82-2.56; P = .20). Current smoking was associated with worse OS and PFS only among human papillomavirus (HPV)-positive tumors (OS: aHR, 2.81; 95% CI, 1.26-6.29; P = .01; PFS: aHR, 2.51; 95% CI, 1.22-5.14; P = .01).

CONCLUSIONS AND RELEVANCE

In this cohort study of patients treated with definitive chemoradiation, 22 pack-years of smoking was associated with survival and distant metastasis outcomes. Current smoking status was associated with adverse outcomes only among patients with HPV-associated head and neck cancer.

Isolated primary hydatid cyst of the pancreas: Management challenges of a cystic masquerade

Abdominal hydatid cyst disease mostly involves the liver. Involvement of the pancreas as an isolated primary organ is rare accounting for < 2% of all systemic echinococcosis cases. It mostly involves the head of the pancreas. Symptoms depend on the location, size, and associated complications; therefore, it can have varied presentations including acute pancreatitis. On imaging, it can mimic other common pancreatic cystic lesions like pseudocyst or cystic neoplasm. Accurate preoperative diagnosis is usually difficult and requires a very high index of suspicion even in endemic areas. Herein, a case of primary isolated hydatid cyst of the pancreas that was initially diagnosed and managed as acute pancreatic pseudocyst is reported.

Formic acid, an organic acid food preservative, induces viable-but-non-culturable state, and triggers new Antimicrobial Resistance traits in Acinetobacter baumannii and Klebsiella pneumoniae

Numerous human pathogens, especially Gram-negative bacteria, are able to enter the viable-but-non-culturable (VBNC) state when they are exposed to environmental stressors and pose the risk of being resuscitated and causing infection after the removal of the trigger. Widely used food preservatives like weak organic acids are potential VBNC inducers in food processing and packaging facilities but have only been reported for food-borne pathogens. In the present study, it is demonstrated for the first time that one such agent, formic acid (FA), can induce a VBNC state at food processing, storage, and distribution temperatures (4, 25, and 37°C) with a varied time of treatment (days 4-10) in pathogenic Gram-negative bacteria Acinetobacter baumannii and Klebsiella pneumoniae. The use of hospital-associated pathogens is critical based on the earlier reports that demonstrated the presence of these bacteria in hospital kitchens and commonly consumed foods. VBNC induction was validated by multiple parameters, e.g., non-culturability, metabolic activity as energy production, respiratory markers, and membrane integrity. Furthermore, it was demonstrated that the removal of FA was able to resuscitate VBNC with an increased expression of multiple virulence and Antimicrobial Resistance (AMR) genes in both pathogens. Since food additives/preservatives are significantly used in most food manufacturing facilities supplying to hospitals, contamination of these packaged foods with pathogenic bacteria and the consequence of exposure to food additives emerge as pertinent issues for infection control, and control of antimicrobial resistance in the hospital setting.

Defining the optimal threshold and prognostic utility of pre-treatment hemoglobin level as a biomarker for survival outcomes in head and neck cancer patients receiving chemoradiation

OBJECTIVES

We sought to define the optimal threshold for anemia in North American head and neck cancer patients and evaluate its role as a prognostic biomarker.

MATERIALS AND METHODS

A single-institution database was queried for patients with head and neck cancer who underwent chemoradiation from January 2005 to April 2021. An optimal threshold of hemoglobin (Hgb) level was defined based on maximum log-rank test statistic. Cox multivariable analysis (MVA), Kaplan-Meier, and propensity score matching were performed to evaluate treatment outcomes.

RESULTS

A total of 496 patients were identified. Threshold for Hgb was determined to be 11.4 for both overall survival (OS) and progression-free survival (PFS). Low Hgb was associated with worse OS (adjusted hazards ratio [aHR] 2.41, 95 % confidence interval [CI] 1.53-3.80, p < 0.001) and PFS (aHR 2.01, 95 % CI 1.30-3.11, p = 0.002). Similar findings were observed among 39 matched pairs for OS (5-year OS 22.3 % vs 49.0 %; HR 2.22, 95 % CI 1.23-4.03, p = 0.008) and PFS (5-year PFS 24.3 % vs 39.1 %; HR 1.78, 95 % CI 1.02-3.12, p = 0.04). Among those with HPV-negative tumors, low Hgb was associated with worse OS (aHR 13.90, 95 % CI 4.66-41.44, p < 0.001) and PFS (aHR 5.24, 95 % CI 2.09-13.18, p < 0.001). However, among those with HPV-positive tumors, low Hgb was not associated with both OS (aHR 1.75, 95 % CI 0.60-5.09, p = 0.31) and PFS (aHR 1.13, 95 % CI 0.41-3.14, p = 0.82).

CONCLUSION AND RELEVANCE

Low Hgb below 11.4 was an independent adverse prognostic factor for worse survival. It was also prognostic among patients with HPV-negative tumors, but not for HPV-positive tumors.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

High Failure Rates in Young Nonsmoker Nondrinkers With Squamous Cell Carcinoma of the Oral Tongue

OBJECTIVE(S)

There has been a disproportionate increase in the incidence of young patients with squamous cell carcinoma of the oral tongue (SCCOT). The purpose of this study was to compare young patients to older patients with SCCOT without prior drinking or smoking history as this population is poorly characterized in the literature.

METHODS

A retrospective review of patients presenting to our institution with SCCOT was performed. The clinical and pathologic characteristics, as well as, outcomes were compared between younger patients (age ≤45) and older patients (age >45). Outcome analysis was performed using Kaplan Meier method. Multivariable Cox proportional hazard models were performed for age and stage.

RESULTS

Eighty-two patients (38 young, 44 old) were included in this study. Median follow-up was 29.4 months. When compared to the older cohort (age >45), the younger cohort (age ≤45) demonstrated lower rates of 5-year locoregional control (LC) (79.6% vs. 52.5%, p = 0.043) and distant metastasis-free survival (88.1% vs. 61.8%, p = 0.006). Both cohorts demonstrated similar overall survival rates (55.5% vs. 58.1%) and disease-specific survival (66.2% vs. 58.1%). Of patients experiencing locoregional failure with available radiation therapy plans and PET scans in younger cohorts (n = 7), 100% demonstrated in-field failures. Multivariable Cox proportional hazards demonstrated age was an independent predictor of DMFS (p = 0.004) and the advanced stage was a predictor of DSS (p = 0.03).

CONCLUSIONS

Young, nondrinker, nonsmokers with SCCOT demonstrate high rates of locoregional recurrence, distant metastasis, and in-field failures. Future studies are warranted to determine underlying mechanisms driving pathogenesis in this unique cohort.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Management of Older Adults with Locally Advanced Head and Neck Cancer

Simple Summary

Approximately one third of patients with head and neck cancer are older adults. The number of older adults with head and neck cancer continues to rise especially as life expectancy increases. However, this population remains significantly underrepresented in clinical trials. Due to this, there is no clear consensus regarding the optimal treatment for older adults with head and neck cancer. In general, older adults are a complex cohort due to variations in functional and performance status, medical comorbidities, and medication management. Treatment for head and neck cancer involves surgery, radiation therapy, systemic therapy, or a combination. These treatments are highly demanding. Additionally, they are associated with toxicity which can be especially difficult for older adults to tolerate. This may lead to treatment interruptions and compromised outcomes. In order to understand the optimal treatment for older adults with head and neck cancer, novel predictive scores are being developed. Additionally, ongoing clinical trials are investigating less intensive treatments for older adults. This review provides an overview of current clinical data, treatment considerations, and future areas of investigation for older adults with head and neck cancer.

Abstract

Thirty percent of patients with head and neck squamous cell carcinoma (HNSCC) are at least 70 years of age. This number continues to rise as life expectancy continues to increase. Still, older adults with HNSCC remain underrepresented in clinical trials, resulting in ambiguity on optimal management. Older adults are a complex patient population, often requiring increased support due to issues relating to functional and performance status, medical comorbidities, and medication management. Furthermore, in older adults with HNSCC, many of these conditions are independently associated with increased toxicity and worse outcomes. Toxicity in the older adult remains difficult to predict and to understand, and as treatment decisions are based on treatment tolerability, it is essential to understand the toxicities and how to minimize them. Novel predictive scores are being developed specifically for older adults with HNSCC to understand toxicity and to assist in personalized treatment decisions. There are clinical trials presently underway that are investigating shortened radiation courses and novel, less toxic systemic treatments in this population. In the forthcoming sections, we provide a detailed overview of the clinical data, treatment paradigms, and considerations in this population. This review provides a comprehensive overview of existing clinical data and clinical considerations in the older adult head and neck cancer population. Additionally, we provide a detailed overview of pertinent current and ongoing clinical trials, as well as future areas for investigation.

Brain Abnormalities and Epilepsy in Patients with Parry-Romberg Syndrome

BACKGROUND AND PURPOSE

Parry-Romberg syndrome is a rare disorder characterized by progressive hemifacial atrophy. Concomitant brain abnormalities have been reported, frequently resulting in epilepsy, but the frequency and spectrum of brain involvement are not well-established. This study aimed to characterize brain abnormalities in Parry-Romberg syndrome and their association with epilepsy.

MATERIALS AND METHODS

This is a single-center, retrospective review of patients with a clinical diagnosis of Parry-Romberg syndrome and brain MR imaging. The degree of unilateral hemispheric atrophy, white matter disease, microhemorrhage, and leptomeningeal enhancement was graded as none, mild, moderate, or severe. Other abnormalities were qualitatively reported. Findings were considered potentially Parry-Romberg syndrome-related when occurring asymmetrically on the side affected by Parry-Romberg syndrome.

RESULTS

Of 80 patients, 48 (60%) had brain abnormalities identified on MR imaging, with 26 (32%) having abnormalities localized to the side of the hemifacial atrophy. Sixteen (20%) had epilepsy. MR imaging brain abnormalities were more common in the epilepsy group (100% versus 48%, P < .001) and were more frequently present ipsilateral to the hemifacial atrophy in patients with epilepsy (81% versus 20%, P < .001). Asymmetric white matter disease was the predominant finding in patients with (88%) and without (23%) epilepsy. White matter disease and hemispheric atrophy had a higher frequency and severity in patients with epilepsy (P < .001). Microhemorrhage was also more frequent in the epilepsy group (P = .015).

CONCLUSIONS

Ipsilateral MR imaging brain abnormalities are common in patients with Parry-Romberg syndrome, with a higher frequency and greater severity in those with epilepsy. The most common findings in both groups are white matter disease and hemispheric atrophy, both presenting with greater severity in patients with epilepsy.

Giant celiac artery aneurysm – a rare experience

Giant celiac artery aneurysm is a rare entity. We describe a case of a 45-year-old male with chronic kidney disease who presented with abdominal pain for the past 6 months. CT showed a celiac artery aneurysm of size 6×6.2cm involving the common hepatic artery and compressing the portal vein posteriorly. During the procedure the supra celiac aorta was exposed, and the neck of the aneurysm was identified. After taking control of branches of the celiac and common hepatic arteries, the neck of the aneurysm was clamped and divided. In view of diminished flow in the hepatic arteries aorto hepatic bypass was done using PTFE graft from supra celiac aorta to right hepatic artery; as there was retrograde flow from the left hepatic artery it was ligated. Post operatively the patient's liver functions were normal, and he was followed up by Doppler sonography which detected good flow in the hepatic artery distal to anastomosis. Celiac artery aneurysms are rare, and management options vary from the endovascular to surgery; regardless of the approach used, revascularisation is needed if there is no adequate collateral flow.

Quality of Life Analysis of HPV-Positive Oropharyngeal Cancer Patients in a Randomized Trial of Reduced-Dose Versus Standard Chemoradiotherapy: 5-Year Follow-Up

Background

Human papillomavirus-positive oropharyngeal carcinoma (HPVOPC) portends a more favorable prognosis compared to environmentally related oropharynx cancer (EROPC). Patients with HPVOPC may be overtreated and endure unnecessary long-term toxicities.

Methods

Patients with untreated locally advanced HPVOPC received induction chemotherapy with docetaxel, cisplatin, and 5-fluorouracil (TPF) and were randomized to standard chemoradiotherapy (sdCRT) (70 Gy) or reduced-dose chemoradiotherapy (rdCRT) (56 Gy) with weekly carboplatin. Patients were followed for changes in five validated quality of life (QoL) surveys: MD Anderson Dysphagia Inventory and Symptom Inventory for head and neck cancer (MDADI, MDASI-HN), Xerostomia Questionnaire (XQ), and European Organization for Research and Treatment of Cancer Questionnaire (EORTC) with head and neck module (EORTC HN). The secondary endpoints of this study were 5-year progression-free survival (PFS) and overall survival (OS).

Results

Twenty patients were enrolled and randomized to rdCRT (n = 12) or sdCRT (n = 8). Median follow-up was 88 months. At 5 years, difference in QoL changes all favored the rdCRT arm and two QoL scales reached statistical significance (EORTC global health score: 11.49 vs. -23.94, P = 0.014; EORTC symptom scale: -7.76 vs. 15.19, P = 0.015). The 5-year PFS and OS were 87.5% and 83.3% for sdCRT and rdCRT, respectively.

Conclusions

Therefore, rdCRT after TPF in HPVOPC is feasible in accordance with the earlier results of the Quarterback Trial and long-term follow-up. These limited results are more favorable in specific QoL domains compared to those of sdCRT and demonstrate equivalent long-term survival.

Clinical Trial Registration

https://clinicaltrials.gov/ct2/show/NCT01706939, The Quarterback Trial [NCT 01706939].

Evaluation of Optimal Threshold of Neutrophil-Lymphocyte Ratio and Its Association With Survival Outcomes Among Patients With Head and Neck Cancer

IMPORTANCE

Given the role of inflammation in cancer progression, neutrophil-lymphocyte ratio (NLR) from peripheral blood has been suggested as a readout of systemic inflammation and a prognostic marker in several solid malignant neoplasms. However, optimal threshold for NLR in US patients with head and neck cancer remains unclear.

OBJECTIVE

To evaluate the optimal NLR threshold as a potential prognostic biomarker for survival outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study was conducted at a single institution. Participants included 496 patients with nonmetastatic head and neck cancer who underwent chemoradiation from April 2007 to March 2021. Statistical analysis was performed from September to December 2021.

EXPOSURES

High vs low NLR.

MAIN OUTCOMES AND MEASURES

Overall survival (OS) and cancer-specific survival (CSS).

RESULTS

A total of 496 patients (411 male patients [82.9%]; 432 White patients [87.1%]; 64 patients with other race or ethnicity [12.9%]; median [IQR] age, 61 [55-67] years) were identified. Median (IQR) follow-up was 44.4 (22.8-74.0) months. Thresholds of NLR for both OS and CSS were 5.71. High NLR above 5.71 was associated with worse OS (adjusted hazard ratio [aHR], 1.97; 95% CI, 1.26-3.09; P = .003) and CSS (aHR, 2.33; 95% CI, 1.38-3.95; P = .002). On logistic multivariable analysis, patients were more likely to have high NLR if they had higher T and N staging (T3-4: aOR, 4.07; 95% CI, 1.92-9.16; P < .001; N2: aOR, 2.97; 95% CI, 1.04-9.17; P = .049; N3: aOR, 11.21; 95% CI, 2.84-46.97; P < .001), but less likely if they had a good performance status (Karnofsky Performance Status 90-100: aOR, 0.29; 95% CI, 0.14-0.59; P < .001). Among 331 patients (66.7%) with available human papillomavirus (HPV) data, high NLR was not associated with OS (HPV-negative: aHR, 2.46; 95% CI, 0.96-6.31; P = .06; HPV-positive: aHR, 1.17; 95% CI, 0.38-3.56; P = .78) and CSS (HPV-negative: aHR, 2.55; 95% CI, 0.81-7.99; P = .11; HPV-positive: aHR, 1.45; 95% CI, 0.44-4.76; P = .54).

CONCLUSIONS AND RELEVANCE

High NLR was associated with worse survival. Patients with substantial disease burden and poor performance status were more likely to have high NLR. These findings suggest that further studies would be warranted to investigate the role of such prognostic marker to identify patients at risk to tailor interventions.

Gallbladder perforation: A single-center experience in north India and a step-up approach for management

BACKGROUND

Spontaneous gallbladder perforation (GBP) is an uncommon diagnosis. This study presented the experience of managing spontaneous GBP over nine years at a large, tertiary care university hospital in north India and investigated the outcomes and treatment strategies.

METHODS

A retrospective review of prospectively maintained digital database of consecutive patients was performed. All patients received medical and/or surgical treatment for spontaneous GBP in our department between January 2010 and June 2018.

RESULTS

We identified 151 patients (81 females and 70 males) with mean age of 53 years. Most common presenting features were pain (96.7%), fever (54.3%) and jaundice (31.1%). Most common cause was gallbladder stones (84.8%) followed by common bile duct stones (30.5%), xanthogranulomatous cholecystitis (17.9%) and malignancy (11.9%). As per Niemeier classification, 8.6% had type 1 GBP (free perforation in peritoneal cavity), 76.2% had type 2 GBP (localized perforation) and 13.2% had type 3 GBP (cholecysto-enteric fistula). About 60% of the perforations were diagnosed preoperatively. Type 1 was more common in patients with diabetes and also had the worst prognosis. Surgery was performed in 109 patients (72.2%). Seven patients (4.6%) had a postoperative morbidity of Clavien-Dindo III or higher. There were three mortalities in patients who underwent surgery.

CONCLUSIONS

High index of suspicion is required for preoperative diagnosis of GBP, especially in types 2 and 3. Laparoscopic cholecystectomy can be difficult in these patients and patients may require open or partial cholecystectomy. Early diagnosis and step-up approach for the treatment of GBP is critical.

Role of twitter user profile features in retweet prediction for big data streams

To study the various factors influencing the process of information sharing on Twitter is a very active research area. This paper aims to explore the impact of numerical features extracted from user profiles in retweet prediction from the real-time raw feed of tweets. The originality of this work comes from the fact that the proposed model is based on simple numerical features with the least computational complexity, which is a scalable solution for big data analysis. This research work proposes three new features from the tweet author profile to capture the unique behavioral pattern of the user, namely "Author total activity", "Author total activity per year", and "Author tweets per year". The features set is tested on a dataset of 100 million random tweets collected through Twitter API. The binary labels regression gave an accuracy of 0.98 for user-profile features and gave an accuracy of 0.99 when combined with tweet content features. The regression analysis to predict the retweet count gave an R-squared value of 0.98 with combined features. The multi-label classification gave an accuracy of 0.9 for combined features and 0.89 for user-profile features. The user profile features performed better than tweet content features and performed even better when combined. This model is suitable for near real-time analysis of live streaming data coming through Twitter API and provides a baseline pattern of user behavior based on numerical features available from user profiles only.

Patient perception and satisfaction with a smartphone-based teledermatology service initiated during the COVID-19 pandemic at a tertiary care hospital in North India

BACKGROUND

Telemedicine is being increasingly used to provide healthcare to patients, particularly during the COVID-19 pandemic.

AIMS

The study aimed to study patient perception and satisfaction with a smartphone-based hybrid teledermatology service initiated during the COVID-19 pandemic.

METHODS

This was a cross-sectional telephonic survey including patients ≥18 years of age who had received a teledermatology consultation. After noting the demographic, clinical and teleconsultation details, patients were administered the Telemedicine Satisfaction Questionnaire and an additional 6-item questionnaire. Patients were also asked to give qualitative feedback and suggestions for improvement using a semi-structured interview guide.

RESULTS

We interviewed 201 subjects. The most common diagnoses were pemphigus (27, 13.4%), superficial fungal infections (24, 11.8%), psoriasis (22, 10.9%) and dermatitis (21, 10.4%). The overall mean Telemedicine Satisfaction Questionnaire score was 4.20± 0.71. One hundred seventy-one (85.1%) patients responded that they would use teledermatology services again, while 168 (83.6%) reported satisfaction with the quality of services. A majority of the patients were largely satisfied with the various components involved, though some concerns were raised about the care perceived as not at par with physical consultations, difficulty in procuring medicines, lack of confidence in photographic diagnoses and the lack of a personal touch. Patients with urticaria (P=0.020), those who were advised a change in treatment (P=0.029) and those with improvement in their skin disease (P=0.026) were more likely to be satisfied.

LIMITATIONS

Our study was conducted during the COVID-19 pandemic when patient acceptability was likely to be higher. Only follow-up patients were included in the study.

CONCLUSION

Patient satisfaction levels were generally high with teledermatology. Addressing lacunae that negatively impact patient perception and satisfaction will help in greater acceptance of teledermatology services.

Extra-pulmonary Manifestations of COVID-19 in Western India

SARS-CoV-2 is well known disorder to affect respiratory system, although it can also influence several extrapulmonary organs through variety of pathological mechanism. In this study, we aimed to discuss the prevalence of atypical and/or extrapulmonary manifestations in COVID-19, therefor action for early isolation and diagnosis can be initiated to prevent spread of infection.

METHODS

This retrospective observational study included 4200 admitted COVID-19 patients. The patient's data concerning medical history, clinical symptoms at presentation and during course of hospitalization, laboratory and radiological diagnosis and underlying chronic medical illness were extracted from their medical records. Data of extrapulmonary and/or atypical presentations of COVID-19 were compiled and tabulated to know prevalence of these manifestations.

RESULTS

In this study, 1260 patients (30%) had symptomatic presentation. Major extrapulmonary clinical manifestation includes fatigue in 72.22% patients, impaired sense of taste (ageusia) in 58.73%, loss of appetite in 52.78%, impaired sense of smell (anosmia) in 46.83%, palpitation in 33.33%, headache in 33.17%, nausea/vomiting in 31.43%, diarrhoea in 25.40% patients. Among symptomatic COVID-19 patients, 95.56% patients had sinus tachycardia, 38.49% had lymphocytopenia, 36.83% had hepatitis, 35.48% had leukopenia, 27.83% had gastroenteritis, 22.22% had sepsis, 20.87% had proteinuria, 17.30% had coronary artery disease and 16.34% had acute kidney injury in decreasing order. Prevalence of coagulation defect associated disorder were found to be deep venous thrombosis in 15.56% patients, acute coronary syndrome in 7.78%, brain infarct in 6.35%, pulmonary artery thrombosis in 3.25% and SMA thrombosis in 0.32% of symptomatic patients.

CONCLUSION

Patients of SARS-CoV-2 had widespread organ-specific manifestations with involvement of almost all organ system of body. Clinicians must have knowledge of these extrapulmonary symptoms or atypical presentation of COVID-19 as it assists in early diagnosis, isolation of suspected patients and limit the transmission of infection in the hospital settings.

Acquired cutis laxa type II (Marshall syndrome) in a 3-month-old boy

Acquired cutis laxa type II (Marshall syndrome) is a post-inflammatory elastolysis occurring in infancy and childhood. It is challenging to treat with very few effective treatment options available. Herein, we describe the case of a 3-month-old boy with acquired cutis laxa type II secondary to a neutrophilic dermatosis. Early treatment of the initial inflammatory phase is essential to reduce the permanent sequelae.

A192 CONSUMPTION OF FOOD LOWER IN TRYPTOPHAN IS ASSOCIATED WITH SIGNIFICANT ANXIETY IN PATIENTS WITH CELIAC DISEASE

Background

Tryptophan, an essential amino acid found in many protein-based foods, has been involved in the pathogenesis of mood disorders and celiac disease (CeD). However, dietary tryptophan consumption has not been investigated in CeD.

Aims

To estimate 1) differences in tryptophan content in food consumed in CeD patients compared to matched healthy controls (HC), and 2) whether consumption of tryptophan is associated with the presence of anxiety and depression in patients with CeD.

Methods

This prospective observational study examined adult patients with a diagnosis of CeD, based on positive specific serology and confirmed by duodenal biopsies, enrolled in the Celiac Registry at McMaster University. A group of sex matched HC were recruited from within the community. Participants completed several questionnaires to evaluate, gastrointestinal symptoms (GSRS), Anxiety and Depression (HADS), and dietary intake of tryptophan (Modified Food Frequency Questionnaire). In addition, CeD patients were assessed for celiac disease activity (CSI), gluten-free diet (GFD) adherence (CDAT) and nutritional status. HADs >11 denoted significant anxiety or depression. Cut-off for low vs high amount of tryptophan content in food was established based on the median tryptophan food content in the HC population.

Results

A total of 443 participants were enrolled in the study; 222 with CeD and 221 controls. The majority of participants were female (74.3%) and the adherence to the GFD was very good (Median CDAT=13; IQR 11–15). The CeD patients were older than HC (Median age, yrs. CD= 40 vs HC= 35; p<0.01). Patients with CeD consumed higher amount of tryptophan compared with HC (Median tryptophan g/day CeD=4.41 vs HC=3.31; p<0.01). There were 157 active CeD patients (CSI ≧ 30). There was no difference in tryptophan consumption between patients with and without active CeD (OR=1.021; 95%CI 0.86–1.21; p=0.88). There was no association between tryptophan consumption and gastrointestinal symptoms or depression scores. Fifteen % of the overall population and 18% of the CeD population had anxiety. There was an increased risk of anxiety in the overall population that consumed low amount of tryptophan (OR=1.87; 95%CI 1.01–3.11; p=0.04), and the risk was greater in the CeD population (OR=4.57; 95%CI 1.26–16.41; p<0.01).

Conclusions

Consumption of food with lower amounts of tryptophan in patients with CeD is associated with significant anxiety, which may influence disease management. Future studies should evaluate whether increasing tryptophan in the diet compared to supplements improves outcomes in CeD population, especially in those with anxiety.

Funding Agencies

None

Effectiveness of two tobacco cessation methods among TB patients

BACKGROUND: Tobacco and TB are the world´s two greatest public health problems. Exposure to tobacco has been shown to be associated with higher risk of acquiring TB and adverse outcomes such as relapse and TB mortality.OBJECTIVE: To assess and compare self-reported tobacco quit status and biochemically verified cotinine levels among TB patients at different time intervals among two study groups.METHODS: A cluster, randomised controlled trial was conducted on TB patients attending DOTS centres in Delhi, India, who reported using tobacco in any form. Participants were assigned into one of two treatment groups. Centres were randomly assigned to two intervention groups: 1) integrated intervention using behavioural counselling with nicotine replacement therapy (NRT) gum, and 2) intervention using behavioural counselling alone (50 each in intervention and control group). The subjects were followed at Week 1, Month 1, Month 3 and Month 6 for tobacco cessation.RESULTS: At the end of 6 months, patients who received the integrated intervention had significantly higher rate of success in quitting tobacco than those who received the conventional TB treatment alone (78.7% vs. 57.8%; P < 0.03).CONCLUSION: DOTS with tobacco use dependence treatment was successful in our study in helping TB patients to quit tobacco dependence and should therefore be offered to every tobacco user.