HEALTH-RELATED QUALITY OF LIFE IN PATIENTS UNDER TREATMENT WITH APIXABAN IN LATIN AMERICA

BACKGROUND

Atrial fibrillation (AF) has a strong impact on the quality of life (QoL) of patients and anticoagulation has a lot to do with it. We evaluated the QoL of patients with nonvalvular AF who start treatment with apixaban in Latin America.

METHODS

QoL was analyzed through a questionnaire developed to evaluate anticoagulated patients, which was completed by them 3 months after starting treatment.

RESULTS

We included 521 patients from Uruguay, Bolivia, Ecuador, Paraguay, and Peru. A high index of general treatment satisfaction (5.34 ± 0.46) and self-efficacy (5.11 ± 0.68) were observed; the distress index was low (1.77 ± 0.88), as was the perception of daily hassles (1.35 ± 0.49) and strain social network related to medication (1.21 ± 0.34).

CONCLUSIONS

Patients with AF who started treatment with apixaban has good satisfaction and self-efficacy scores with low index of stress, few daily limitations and social disruptions.

Isochromosome 17q, a Rare Chromosomal Abnormality in a Female Patient with Pancytopenia

Myelodysplastic syndromes present with a range of cytogenetic abnormalities that are used to guide diagnosis and management of the disease. Herein, we present the case of a 72-year-old female patient who presented with pancytopenia. Peripheral blood showed Hb 9.0 g/dl, neutrophils less than 1800/mm3, and platelets less than 100,000/mm3. Bone marrow showed erythroid hyperplasia, megaloblastic changes, dyserythropoiesis, multinuclearity, nuclear bridges, nuclear budding, atypical mitoses, and ring sideroblasts. Also, CD34 and CD117 as well as myeloperoxidase positive populations were present. On this basis, a diagnosis of myelodysplastic syndrome was rendered. Chromosome studies showed an abnormal female karyotype with an isochromosome 17q as well as deletion 20q in 17 of the 20 metaphase cells examined. The remaining three cells were cytogenetically normal. Molecular cytogenetic studies using a TP53-specific probe showed only one TP53 signal in 87% of the nuclei examined. An i(17q) as a sole cytogenetic aberration is rare among both MDS and myeloid malignancies in general, but is functionally similar to aberrations of 17p that lead to loss of TP53. This case provides further insight into the spectrum of cytogenetic abnormalities present in MDS.

P5291Is the obesity paradox in cardiac surgery really a myth? Effect of body mass index on early and late clinical outcomes

Introduction

Obesity has been considered a risk factor for cardiovascular death and for poor outcomes from a variety of surgical procedures, recent studies suggest that overweight (OW) and obese (OB) patients may paradoxically have a better prognosis in cardiac surgery (CS) compared with patients with normal body mass index (BMI). We aimed to investigate the obesity paradox and assess the effect of BMI on early and late clinical outcomes after CS

Methods

A retrospective cohort study of consecutive patients undergoing CS from January 2007 to January 2019 was carried out. Patients were divided into 4 groups defined by BMI:underweight (UW) (≤18,5 kg/m2):0.5%, n=27; normal weight (NW) (18,5–25 kg/m2): 25.7%, n=1393; OW (25–30 kg/m2): 44.7%, n=2423; OB (≥30 kg/m2): 29.1%, n=1576. Multivariable analyses was used to compare the outcomes among the different BMI groups. Overall 1-year survival of BMI categories were determined by the Kaplan-Meier method.

Results

We included 5419 patients (72% male, mean age 65,8±12.1). The BMI groups were significantly different regarding pre-surgical variables, UW patients were statistically more comorbid and severe clinical presentation. Categorical mortality was 7% in UW, 5,2% in NW, 3,2% in OW, 4,3% in the OB group, P=0,016. The risk of death according to BMI exhibited a reverse J-shaped curve. Low cardiac output syndrome, medical and surgical bleeding and longer hospital stay was more frequent in the UW group (P<0,05), and mediastinitis, hyperglycemia and prolonged mechanical ventilation in OB group (P<0,05). Univariable regression detected the following significant predictors of in-hospital mortality: Age, female, non-elective surgery, non isolated coronary surgery, vascular peripheral disease, chronic obstructive pulmonary disease, severe left ventricular fraction ejection, chronic renal disease, anemia, stroke, myocardial infarction, heart failure and BMI categories (P<0.05): NW (odds ratio (OR), 1,49; 95% CI: 1,09–1,9, P=0,01), in contrast, OW had a significantly lower risk of death (OR 0,66; 95% CI: 0,5–0,88, P=0,005), with no statistical significance in the UW and OB categories. After adjusting for other risk factors at the multivariate analysis, BMI as a continuous variable was not an independent predictor of in-hospital mortality. One-year follow-up was completed in 95%, during this period 223 (4,12%) died. The analysis of unadjusted long-term mortality did not show a significant difference between BMI categories (P log rank = 0,16).

Conclusion

In our population OW patients had lower mortality and better outcomes after cardiac surgery. However, when other preoperative variables are taken into account, BMI did not have independent effect on in-hospital and one-year mortality, questioning the existence of an “obesity paradox”. Its effect on mortality could be indirect, being mediated through other comorbidities.

Natural radioactivity in groundwater and estimates of committed effective dose due to water ingestion in the state of Chihuahua (Mexico)

The activity concentration of 222Rn, 226Ra and total uranium in groundwater samples collected from wells distributed throughout the state of Chihuahua has been measured. The values obtained of total uranium activity concentration in groundwater throughout the state run from <0.03 up to 1.34 Bq l-1. Generally, radium activity concentration was <0.16 Bq l-1, with some exceptions; in spring water of San Diego de Alcalá, in contrast, the value reached approximately 5.3 Bq l-1. Radon activity concentration obtained throughout the state was from 1.0 to 39.8 Bq l-1. A linear correlation between uranium and radon dissolved in groundwater of individual wells was observed near Chihuahua City. Committed effective dose estimates for reference individuals were performed, with results as high as 134 microSv for infants in Aldama city. In Aldama and Chihuahua cities the average and many individual wells showed activity concentration values of uranium exceeding the Mexican norm of drinking water quality.

Radon concentrations in ground and drinking water in the state of Chihuahua, Mexico

This paper reports (222)Rn concentrations in ground and drinking water of nine cities of Chihuahua State, Mexico. Fifty percent of the 114 sampled wells exhibited (222)Rn concentrations exceeding 11Bq/L, the maximum contaminant level (MCL) recommended by the USEPA. Furthermore, around 48% (123 samples) of the tap-water samples taken from 255 dwellings showed radon concentrations over the MCL. There is an apparent correlation between total dissolved solids and radon concentration in ground-water. The high levels of (222)Rn found may be entirely attributed to the nature of aquifer rocks.

[Floating thrombus in the aortic arch: a rare case of peripheral arterial embolic events (report of a clinical case)]

Floating thrombus in the aortic arch is a rare and often under-diagnosed source of peripheral arterial embolic events. We report a case of a patient seen with arterial embolic events: ischemia of the left superior limb and transient stroke. The diagnosis was performed with transesophageal echocardiography and computed tomography. The thrombus completely disappeared after 15 days of oral anticoagulant therapy. Although rare, this diagnosis mustn't be overlooked in the search for an etiology of recurrent and disseminated peripheral ischemic events because the detrimental functional risk related to a delayed diagnosis.

Uranium-238 and thorium-232 series concentrations in soil, radon-222 indoor and drinking water concentrations and dose assessment in the city of Aldama, Chihuahua, Mexico

High-resolution gamma spectrometry was used to determine the concentration of 40K, 238U and 232Th series in soil samples taken from areas surrounding the city of Aldama, in Chihuahua. Results of indoor air short-time sampling, with diffusion barrier charcoal detectors, revealed relatively high indoor radon levels, ranging from 29 to 422 Bq/m3; the radon concentrations detected exceeded 148 Bq/m3 in 76% of the homes tested. Additionally, liquid scintillation counting showed concentrations of radon in drinking water ranging from 4.3 to 42 kBq/m3. The high activity of 238U in soil found in some places may be a result of the uranium milling process performed 20 years ago in the area. High radon concentrations indoor and in water may be explained by assuming the presence of uranium-bearing rocks underneath of the city, similar to a felsic dike located near Aldama. The estimated annual effective dose of gamma radiation from the soil and radon inhalation was 3.83 mSv.

Calibration of diffusion barrier charcoal detectors using a semi-empirical expression

Several calibration settings of diffusion barrier charcoal canister (DBCC) detectors for measuring radon concentration in air were studied. A set of functions and graphs were developed for relations between radon concentration in air and adsorbed activity in DBCC, when calibrated in small chambers. Both the integration time for 10% of DBCC of a batch, and the radon adsorption coefficient for the activated charcoal used in these detectors, were determined. Thus, a semi-empirical expression for detector calibration was applied.

Coexisting chordal papillary fibroelastoma and leaflet Lambl's tumour of the mitral valve

Cardiac papillary fibroelastoma (CPF) is a rare and histologically benign tumour. It is the most common valvular tumour and the third cardiac benign tumour, after myxoma and lipoma (less then 16% of all cardiac tumours). CPF is a surgically correctable cause of cerebrovascular and myocardial infarction, making its identification by echocardiography beneficial. We report an unusual case of double localization on both chordae and leaflet of the mitral valve.

Phase I trial of continuous infusion flavopiridol, a novel cyclin-dependent kinase inhibitor, in patients with refractory neoplasms

PURPOSE

We conducted a phase I trial of the cyclin-dependent kinase inhibitor, flavopiridol (National Service Center [NSC] 649890), to determine the maximum-tolerated dose (MTD), toxicity profile, and pharmacology of flavopiridol given as a 72-hour infusion every 2 weeks.

PATIENTS AND METHODS

Seventy-six patients with refractory malignancies with prior disease progression were treated with flavopiridol, with first-cycle pharmacokinetic sampling.

RESULTS

Forty-nine patients defined our first MTD, 50 mg/m2/d x 3 with dose-limiting toxicity (DLT) of secretory diarrhea at 62.5 mg/kg/d x 3. Subsequent patients received antidiarrheal prophylaxis (ADP) to define a second MTD, 78 mg/m2/d x 3 with DLT of hypotension at 98 mg/m2/d x 3. Other toxicities included a proinflammatory syndrome with alterations in acute-phase reactants, particularly at doses >50 mg/ m2/d x 3, which in some patients prevented chronic therapy every 2 weeks. In some patients, ADP was not successful, requiring dose-deescalation. Although approximately 70% of patients displayed predictable flavopiridol pharmacology, we observed unexpected interpatient variability and postinfusion peaks in approximately 30% of cases. At the two MTDs, we achieved a mean plasma flavopiridol concentration of 271 nM (50 mg/m2/d x 3) and 344 nM (78 mg/m2/d x 3), respectively. One partial response in a patient with renal cancer and minor responses (n=3) in patients with non-Hodgkin's lymphoma, colon, and renal cancer occurred.

CONCLUSION

The MTD of infusional flavopiridol is 50 mg/m2/d x 3 with dose-limiting secretory diarrhea at 62.5 mg/m2/d x 3. With ADP, 78 mg/m2/d x 3 was the MTD, with dose-limiting hypotension at 98 mg/m2/d x 3. Based on chronic tolerability, 50 mg/m2/d x 3 is the recommended phase II dose without ADP. Antitumor effect was observed in certain patients with renal, prostate, and colon cancer, and non-Hodgkin's lymphoma. Concentrations of flavopiridol (200 to 400 nM) needed for cyclin-dependent kinase inhibition in preclinical models were achieved safely.

Treatment of refractory myositis: a randomized crossover study of two new cytotoxic regimens

OBJECTIVE

To assess the clinical usefulness of 2 novel therapies for treatment-resistant myositis.

METHODS

Thirty patients with refractory myositis, of whom 25 had an inadequate or no response to previous cytotoxic therapy, were randomized to begin either a combination of weekly oral methotrexate and daily azathioprine (MTX/AZA) or intravenous methotrexate with leucovorin rescue (I.V. MTX) every 2 weeks for 6 months. Crossover to the alternate therapy occurred according to defined rules; evaluations of muscle strength and functional abilities were performed at the beginning, and after 3 and 6 months, of each treatment.

RESULTS

Of the 15 patients initially randomized to oral MTX/AZA, 8 improved with oral therapy and 1 improved with I.V. MTX during the crossover period. Of the 15 patients initially randomized to I.V. MTX therapy, 3 improved with the I.V. therapy and 4 with the oral combination during the crossover period. Although the study lacked the power to directly compare both treatments, intention-to-treat analysis showed a trend in favor of those patients who first received oral combination therapy (P = 0.025). There were 0.09 adverse events per patient-month with oral combination therapy and 0.16 per patient-month with I.V. therapy (P = 0.09).

CONCLUSION

Combination oral MTX/AZA may benefit patients with treatment-resistant myositis, including those who previously had inadequate responses to either MTX or AZA alone. I.V. MTX with leucovorin rescue may also benefit some patients with refractory myositis.

Combinations of paclitaxel and vinblastine and their effects on tubulin polymerization and cellular cytotoxicity: characterization of a synergistic schedule

Paclitaxel (PTX) and vinblastine (VBL) represent 2 classes of drugs that target tubulin but have separate binding properties and opposing mechanisms of action. To evaluate the potential use of these agents together in a chemotherapeutic regimen, we investigated their effects on the dynamics of tubulin polymerization and cellular cytotoxicity, when administered singly or in combination. In human epidermoid carcinoma KB cells and MCF-7 breast carcinoma cells, we observed a time- and dose-dependent effect on cytoskeletal dynamics for both PTX and VBL. Tubulin polymerization induced by PTX was stable for more than 24 hr. When PTX treatment was followed by VBL, a time- and dose-dependent reversal of tubulin polymerization was observed. In contrast, rapid tubulin polymerization occurred when VBL was followed by PTX. When both agents were added simultaneously, a diminution of PTX-induced tubulin polymerization was observed with increasing doses of VBL; a maximum reduction was achieved when equal concentrations were used. Examination of the tubulin pattern by immunofluorescence in MCF-7 breast cancer cells confirmed and extended our findings. Bundle formation followed treatment with PTX. Addition of increasing concentrations of VBL prevented bundling; however, the normal cytoskeletal architecture was not restored. Cytotoxicity studies carried out using the median dose effect principles and the combination index analysis showed synergism when VBL and PTX were administered sequentially and antagonism for simultaneous administration. Our results demonstrate changes in tubulin dynamics following drug treatment and provide a rationale for combined PTX/VBL therapy after careful evaluation of the schedule of administration.

An intra-abdominal small round cell neoplasm with features of primitive neuroectodermal and desmoplastic round cell tumor and a EWS/FLI-1 fusion transcript

We report an intra-abdominal round cell tumor in a young man which exhibited the light and electron microscopic appearance of a peripheral primitive neuroectodermal tumor (PNET), in addition to the clinical and topographic characteristics, desmoplasia and a complex immunophenotypic profile of the intra-abdominal desmoplastic round cell tumor (DSRCT). Reverse transcription polymerase chain reaction revealed a EWS/FLI-1 fusion transcript as in PNET/Ewing's sarcoma, instead of the EWS/WT1 transcript of DSRCT. The tumor was also strongly positive for the mic2 protein. This is a unique case of a hybrid tumor arising in the peritoneal cavity of a young male. The existence of such a hybrid tumor in this location suggests that DSRCT and PNET may be related and possibly share a common histogenesis.

Update on therapy for refractory dermatomyositis and polymyositis

Evaluation of new therapies for the inflammatory myopathies is complicated by the heterogeneity of these syndromes as well as by the lack of internationally accepted definitions of disease categories and assessments of disease activity and chronicity. This review covers our opinion of therapies and emphasizes the need for an early rehabilitation evaluation for these patients. Oral corticosteroids are the first line of therapy for the inflammatory myopathies, but because of their side effects and the existence of a subset of patients in whom disease is controlled only with high-dose corticosteroids, we recommend considering the early use of a second-line immunomodulating agents or pulse intravenous methylprednisolone. A stepwise progression of therapies is suggested for patients who have increasing muscle weakness resulting from active disease.