Racial differences in P2Y12 inhibitor responsiveness in patients undergoing neuro-endovascular procedures: A cohort from the Middle East

BACKGROUND

Data on P2Y12 inhibitors responsiveness from the middle east is scarce. We sought to investigate patient responsiveness to P2Y12 inhibitors within a cohort of major races that characterize the UAE population. The secondary objective was to assess risk factors for hyper and hypo-responsiveness in this population.

METHODS

We conducted a cross-sectional study on adults who received either clopidogrel or ticagrelor treatments and had platelet responsiveness testing before undergoing neuro-endovascular interventions at our quaternary care hospital between March 2015 and April 2019.

RESULTS

During the study period, 249 subjects met the inclusion criteria. Overall, 17.3 % were hyper-responsive and 25.7 % were hypo-responsive to P2Y12 inhibitors. When comparing between the P2Y12 inhibitors, rates of hyper-responsiveness were significantly higher to ticagrelor when compared to clopidogrel (11 versus 6 %, p = 0.02 respectively). Contrarily, hypo-responsiveness rates were significantly higher in clopidogrel treated patients compared to their ticagrelor treated counterparts (23 versus 2 %, p < .001 respectively). Patients of Middle-Eastern origin showed a significantly higher rate of hypo-responsiveness to both clopidogrel and ticagrelor when compared to other races (41.1 % and 26.7 %, P < 0.001 respectively). Asians showed the highest rates of hyper-responsiveness for both agents. Multivariate logistic regression analysis showed that proton pump inhibitors and statin combination, (OR: 6.39, 95 %CI [1.60, 25.392]), and Middle East vs. Indian subcontinent patients (OR: 4.67, 95 %CI [1.79-12.14]) were independent predictors of hypo-responsiveness to both P2Y12 inhibitors.

CONCLUSION

This study demonstrated a high rate of hypo-responsiveness to P2Y12 inhibitors in a UAE cohort of patients undergoing neuro-endovascular procedures. In addition, therapeutic responsiveness to P2Y12 inhibitors varied markedly based on the racial background. Future larger studies are needed to evaluate genetic variations that may contribute to this rate of hypo-responsiveness in our population.

Insights into Exosome Transport through the Blood-Brain Barrier and the Potential Therapeutical Applications in Brain Diseases

Drug delivery to the central nervous system (CNS) is limited due to the presence of the blood-brain barrier (BBB), a selective physiological barrier located at the brain microvessels that regulates the flow of cells, molecules and ions between the blood and the brain. Exosomes are nanosized extracellular vesicles expressed by all cell types and that function as cargos, allowing for communication between the cells. The exosomes were shown to cross or regulate the BBB in healthy and disease conditions. However, the mechanistic pathways by which exosomes cross the BBB have not been fully elucidated yet. In this review, we explore the transport mechanisms of exosomes through the BBB. A large body of evidence suggests that exosome transport through the BBB occurs primarily through transcytosis. The transcytosis mechanisms are influenced by several regulators. Inflammation and metastasis also enhance exosome trafficking across the BBB. We also shed light on the therapeutical applications of exosomes for treating brain diseases. Further investigations are essential to provide clearer insights related to trafficking of exosomes across the BBB and disease treatment.

Management of osteoporosis in patients with chronic kidney disease

Patients with CKD have a 4-fivefold higher rate of fractures. The incidence of fractures increases with deterioration of kidney function. The process of skeletal changes in CKD patients is characterized by compromised bone strength because of deterioration of bone quantity and/or quality. The fractures lead to a deleterious effect on the quality of life and higher mortality in patients with CKD. The pathogenesis of bone loss and fracture is complex and multi-factorial. Renal osteodystrophy, uremic milieu, drugs, and systemic diseases that lead to renal failure all contribute to bone damage in CKD patients. There is no consensus on the optimal diagnostic method of compromised bone assessment in patients with CKD. Bone quantity and mass can be assessed by dual-energy x-ray absorptiometry (DXA) or quantitative computed tomography (QCT). Bone quality on the other side can be assessed by non-invasive methods such as trabecular bone score (TBS), high-resolution bone imaging methods, and invasive bone biopsy. Bone turnover markers can reflect bone remodeling, but some of them are retained by kidneys. Understanding the mechanism of bone loss is pivotal in preventing fracture in patients with CKD. Several non-pharmacological and therapeutic interventions have been reported to improve bone health. Controlling laboratory abnormalities of CKD-MBD is crucial. Anti-resorptive therapies are effective in improving BMD and reducing fracture risk, but there are uncertainties about safety and efficacy especially in advanced CKD patients. Accepting the prevalent of low bone turnover in patients with advanced CKD, the osteo-anabolics are possibly promising. Parathyroidectomy should be considered a last resort for intractable cases of renal hyperparathyroidism. There is a wide unacceptable gap in osteoporosis management in patients with CKD. This article is focusing on the updated management of CKD-MBD and osteoporosis in CKD patients. Chronic kidney disease deteriorates bone quality and quantity. The mechanism of bone loss mainly determines pharmacological treatment. DXA and QCT provide information about bone quantity, but assessing bone quality, by TBS, high-resolution bone imaging, invasive bone biopsy, and bone turnover markers, can guide us about the mechanism of bone loss.

What is a clinically meaningful survival benefit in refractory metastatic colorectal cancer?

Assessment of the clinical benefit of cancer treatments can be highly subjective, influenced by both perspective and context. Such assessments are required in regulatory and policy decision-making, but consistency between jurisdictions is often lacking. Clear and consistent standards for determining when a treatment offers a meaningful benefit, relative to the current standard of care, can help to address issues of equity and transparency in health technology assessment. For metastatic colorectal cancer (mcrc), no standardized Canadian definition of clinically meaningful benefit has yet been proposed. Colorectal Cancer Canada therefore convened a group of medical oncologists expert in colorectal cancer to review the literature about clinical significance. The resulting consensus is intended to apply to any therapeutic agent being considered in the setting of chemotherapy-refractory mcrc. It was agreed that overall survival is the appropriate measure of clinical efficacy in chemorefractory mcrc. As quantitative targets for efficacy, an improvement of 2 months or more in median overall survival or a hazard ratio for survival of 0.75 or lower (or both) are proposed as the threshold for clinically meaningful benefit. That threshold could be influenced by a treatment's effect on quality of life. Treatment toxicity is also relevant to the assessment of clinical benefit in this setting, specifically when significant differences in treatment tolerability are evident.

Association between Helicobacter pylori gastritis and dental diseases: A cross-sectional, hospital-based study in Eastern Saudi Arabia

BACKGROUND

There is inconsistent evidence about the association between Helicobacter pylori (H. pylori) and dental diseases with possible effect of environmental factors. The aims of the study were to assess (1) the association between gastric and oral H. pylori colonization and (2) the association between oral colonization of H. pylori and dental diseases.

METHODS

A cross-sectional study was conducted in King Fahad University hospital in Khobar, Eastern Saudi Arabia in 2017. Patients admitted to the Endoscopy Unit were recruited and clinically examined for plaque, decayed teeth (D), filled teeth (F), missing teeth (M), periodontal pocket depth (PPD), attachment loss (AL), and gingival bleeding in addition to assessing their age, gender, education, tooth brushing, flossing, and tobacco use with a questionnaire. Pooled dental plaque samples were collected and analyzed using nested polymerase chain reaction PCR to detect oral H. pylori. Gastroscopy was used to extract biopsies to assess gastritis and the presence of gastric H. pylori using Giemsa stain. Regression analysis was used to assess differences between patients with and without gastritis, oral H. pylori and gastric H. pylori in the percentage of sites with gingival bleeding, PPD, CAL, D, M, and F with adjustment for confounders.

RESULTS

One hundred twenty patients were included. Most of them brushed daily (82.6%) and had university education (45.7%). Of these, 34.2% had gastric H. pylori and 5% had oral H. pylori. No significant association was observed between the percentage of sites with gingival bleeding, mean PPD, AL, F, and either gastritis, the presence of oral or gastric H. pylori. Patients with gastritis had significantly higher number of D and M than patients without gastritis (P = 0.03).

CONCLUSIONS

In this study, the presence of gastric and oral H. pylori in patients with good oral hygiene and moderate socioeconomic status is not significantly associated with periodontal diseases. Patients with gastritis tend to have a higher number of decayed and missing teeth.

Expression, genetic localization and phylogenic analysis of NAPlr in piscine Streptococcus dysgalactiae subspecies dysgalactiae isolates and their patterns of adherence

Streptococcus dysgalactiae, the long recognized mammalian pathogen, has currently received a major concern regarding fish bacterial infection. Adhesion to host epithelial cells and the presence of wall-associated plasminogen binding proteins are prerequisites to Streptococcus infection. This is the first study of the occurrence of nephritis-associated plasminogen-binding receptor (NAPlr) and α-enolase genes in piscine S. dysgalactiae subspecies dysgalactiae (SDSD) isolates. Further characterization of surface localized NAPlr of fish SDSD revealed a similar immune-reactive band of 43 KDa as that from porcine S. dysgalactiae subsp. equisimilis (SDSE). The phylogenetic analysis revealed that NAPlr of fish SDSD is more associated with those of mammalian SDSE and Streptococcus pyogenes rather than of other streptococci. Our findings warrant public attention to the possible implication of these virulence genes in dissemination of SDSD to different tissues of infected hosts and to get advantage to new niches. The SDSD adherence patterns were also studied to better understand their pathogenicity. The patterns of adherence of SDSD on two different cell lines showed a different pattern of adherence. Such difference gives an insight about the variance in host susceptibility to infection.

Genetic diversity of geographically distinct Streptococcus dysgalactiae isolates from fish

Streptococcus dysgalactiae is an emerging pathogen of fish. Clinically, infection is characterized by the development of necrotic lesions at the caudal peduncle of infected fishes. The pathogen has been recently isolated from different fish species in many countries. Twenty S. dysgalactiae isolates collected from Japan, Taiwan, Malaysia and Indonesia were molecularly characterized by biased sinusoidal field gel electrophoresis (BSFGE) using SmaI enzyme, and tuf gene sequencing analysis. DNA sequencing of ten S. dysgalactiae revealed no genetic variation in the tuf amplicons, except for three strains. The restriction patterns of chromosomal DNA measured by BSFGE were differentiated into six distinct types and one subtype among collected strains. To our knowledge, this report gives the first snapshot of S. dysgalactiae isolates collected from different countries that are localized geographically and differed on a multinational level. This genetic unrelatedness among different isolates might suggest a high recombination rate and low genetic stability.

Orogen styles in the East African Orogen: A review of the Neoproterozoic to Cambrian tectonic evolution

The East African Orogen, extending from southern Israel, Sinai and Jordan in the north to Mozambique and Madagascar in the south, is the world́s largest Neoproterozoic to Cambrian orogenic complex. It comprises a collage of individual oceanic domains and continental fragments between the Archean Sahara-Congo-Kalahari Cratons in the west and Neoproterozoic India in the east. Orogen consolidation was achieved during distinct phases of orogeny between ∼850 and 550 Ma. The northern part of the orogen, the Arabian-Nubian Shield, is predominantly juvenile Neoproterozoic crust that formed in and adjacent to the Mozambique Ocean. The ocean closed during a protracted period of island-arc and microcontinent accretion between ∼850 and 620 Ma. To the south of the Arabian Nubian Shield, the Eastern Granulite-Cabo Delgado Nappe Complex of southern Kenya, Tanzania and Mozambique was an extended crust that formed adjacent to theMozambique Ocean and experienced a ∼650-620 Ma granulite-facies metamorphism. Completion of the nappe assembly around 620 Ma is defined as the East African Orogeny and was related to closure of the Mozambique Ocean. Oceans persisted after 620 Ma between East Antarctica, India, southern parts of the Congo-Tanzania-Bangweulu Cratons and the Zimbabwe-Kalahari Craton. They closed during the ∼600-500 Ma Kuungan or Malagasy Orogeny, a tectonothermal event that affected large portions of southern Tanzania, Zambia, Malawi, Mozambique, Madagascar and Antarctica. The East African and Kuungan Orogenies were followed by phases of post-orogenic extension. Early ∼600-550 Ma extension is recorded in the Arabian-Nubian Shield and the Eastern Granulite-Cabo Delgado Nappe Complex. Later ∼550-480 Ma extension affected Mozambique and southern Madagascar. Both extension phases, although diachronous,are interpreted as the result of lithospheric delamination. Along the strike of the East African Orogen, different geodynamic settings resulted in the evolution of distinctly different orogen styles. The Arabian-Nubian Shield is an accretion-type orogen comprising a stack of thin-skinned nappes resulting from the oblique convergence of bounding plates. The Eastern Granulite-Cabo Delgado Nappe Complex is interpreted as a hot- to ultra-hot orogen that evolved from a formerly extended crust. Low viscosity lower crust resisted one-sided subduction, instead a sagduction-type orogen developed. The regions of Tanzania and Madagascar affected by the Kuungan Orogeny are considered a Himalayan-type orogen composed of partly doubly thickened crust.

Diffuse large B-cell lymphoma transformed from mucosa-associated lymphoid tissue lymphoma arising in a female urethra treated with rituximab for the first time

A 30-year-old female patient presented to the gynecology clinic with a small (painless) swelling at the urethral orifice. She underwent surgical excision of the lesion. Pathological examination revealed non-Hodgkin's lymphoma of diffuse large B-cell type and mucosa-associated lymphoid tissue type, stage IE. The patient refused radiotherapy. Accordingly, we started CHOP-R chemotherapy. She received a total of 6 cycles of CHOP and 8 cycles of rituximab. Patient follow-up was done 3 months later through CT scan and cytoscopy confirming the complete remission. The patient has been disease-free for 4 years. We reviewed 26 cases of this rare entity reported previously.

Risk factors of brain metastasis in a series of Egyptian breast cancer patients: A single-institution experience

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Background: Incidence of cerebral metastasis is increasing among breast cancer patients. Many factors have been reported associated with increased risk of brain metastasis. The aim of this retrospective analysis is to investigate the predictive factors for the development of brain metastasis in breast cancer patients.

Methods: We retrospectively analyzed histologically proven breast cancer patients who presented to Cairo Oncology Center (COC) in the period from 1999 till 2008, with follow up period of 6 months at least for those in adjuvant setting. The following factors were analyzed: age, tumor size and grade, nodal status, ER, PgR and HER2 over-expression status.

Results: Our study included 2,338 patients. 96 patients (4.1%) experienced brain metastasis during the course of their disease. 3 patients had brain metastasis among other sites of distant spread at first presentation to COC. 30 out of 96 patients (31.25%) with localized breast cancer had brain metastasis at first relapse with 13 (13.5%) of them had isolated brain metastasis. In a median follow-up of 37.1 months (6-277) the median time to develop brain metastasis was 26.5 months (0-144). Based on univariate analysis, the following variables were associated with shorter time to develop brain metastasis: tumor size more than 5 cm (HR = 2.1, 95% CI 1.14-3.87), lymph node involvement at diagnosis (HR = 1.57, 95%CI 1.17-2.10), ER negativity (HR = 1.58, 95%CI 1.33-1.73), PgR negativity (HR = 1.55, 95%CI 1.29-1.72) and HER2-neu over-expression (HR = 2.68, 95%CI 1.51-4.75). On multivariate analysis, only patients with lymph node involvement at diagnosis and those with HER2-neu positive breast cancer were associated with shorter time to develop brain metastasis.

Conclusions: We concluded that HER2 over-expression as well as lymph node involvement are the 2 main factors associated with shorter time to develop brain metastasis. These patients could be good candidates for trials investigating the role of any prophylactic intervention to decrease their risk to develop brain metastases.

New findings: a very high natural radiation area in Afra hot springs, Jordan

A high natural radiation zone was investigated for the first time in Afra hot springs of Jordan. The radiation levels were measured using a portable Geiger-Muller counter and an Na(Tl) detector. The measured absorbed dose rates in air ranged from 10 to 1800 nGy h(-1), suggesting that the concentration of natural radioactive materials is very high compared with their normal abundance in crustal rocks. A single high-radiation zone was also found in a nearby area where a gamma radiation dose rate of 4.0 mGy h(-1) was measured. On the basis of this measurement, the area was marked as a high-radiation zone. This region is far from tourist areas and not easily reached. No intervention measures are needed to protect people because the spa area is not well inhabited, having only daily visitors (average frequency of 10 days per year per individual). The dose received by workers in the spa area should be considered and the worker should be monitored by personal radiation dosimeters, such as thermoluminescent dosimeters.

Monascus purpureus Went rice in nephrotic hyperlipidemia

BACKGROUND

Nephrotic dyslipidemia is a risk factor for the development of systemic atherosclerosis; and may aggravate glomerulosclerosis and enhance progression of glomerular disease. We aimed to assess the efficacy and safety of Monascus purpureus Went rice vs. fluvastatin therapy in the management of nephrotic dyslipidemia.

MATERIALS AND METHODS

Seventy-two patients with persistent idiopathic nephrotic syndrome (NS) with secondary dyslipidemia were included. They were randomly allocated into three age and sex-matched groups. The first group comprised 20 cases and were given M. purpureus Went rice in a dose of 600 mg twice/day for 1 month then once daily, the second group comprised 30 cases were given fluvastatin in a daily dose of 20 mg. The remaining 22 received no antidyslipidemic therapy and constituted a control group. All of these patients were subjected to thorough laboratory investigations including renal function tests and lipogram. Moreover, the neuromuscular status was evaluated with electromyography and nerve conduction velocity.

RESULTS

Our results showed that both fluvstatin and M. purpureus Went rice were well tolerated with no evidence of significant side effects including neuromuscular functions. Both of them significantly reduced cholesterol after 6 months and 1 year.

CONCLUSION

Monascus purpureus Went rice is safe, effective, and economic treatment strategy for nephrotic dyslipidemia.

Primary refractory Hodgkin's lymphoma: outcome after high-dose chemotherapy and autologous SCT and impact of various prognostic factors on overall and event-free survival. A single institution result of 66 patients

We report our experience with high-dose chemotherapy (HDC) and autologous SCT (ASCT) in 66 patients with primary refractory Hodgkin's lymphoma (PR-HL) who received salvage chemotherapy followed by BEAM as HDC. Median age at ASCT was 23 years. Before salvage chemotherapy, stages I:II:III:IV were 2:21:14:29, bulky disease 27%, involvement of mediastinum 79%, spleen 26% and extranodal site 47%, 92% had ESHAP as salvage. Post-ASCT evaluation showed response in 50 patients (76%); complete response (CR) 37 (56%), partial response 14 (21%), no response or stable disease 3 (5%) and progressive disease in 10 (15%). Another five patients achieved CR after radiation therapy and one after surgery, making total CR 43 (65%). From diagnosis and HDC, median follow-up is 38.5 and 22.8 months and median overall survival (OS) 78 and 57 months, respectively. Event-free survival (EFS) and OS are 36 and 64%, respectively. In all, 47% patients are in CR. Twenty-two patients (33%) died due to disease. Multivariate analysis showed elevated lactate dehydrogenase (LDH) for EFS (P=0.041) and mediastinal involvement for OS (P=0.038) as negative prognostic factors. In conclusion, EFS and OS are only 36 and 64%, respectively. Elevated LDH and mediastinal involvement are poor prognostic factors.

Easily coupled whispering gallery plasmons in dielectric nanospheres embedded in gold films

A new self-aligned robust method for coupling to whispering gallery modes (WGMs) of submicron microspheres utilizes their periodic arrangement without relying on nanopositioned external coupling devices. The microspheres are embedded in a nanostructured gold surface supporting delocalized plasmonic crystal modes that mediate the coupling, and can be tuned by the geometry. Detailed measurements of the angle- and orientation-dependent reflectivity reveal localized plasmonic WGMs whose energies scale with sphere diameter and agree closely with Mie calculations. Coupling between these plasmonic WGMs leads to mode splitting and the formation of plasmonic minibands of a controllable bandwidth.

Plasmonic band gaps and trapped plasmons on nanostructured metal surfaces

Nanostructured metal surfaces comprised of periodically arranged spherical voids are grown by electrochemical deposition through a self-assembled template. Detailed measurements of the angle- and orientation-dependent reflectivity reveal the spectral dispersion, from which we identify the presence of both delocalized Bragg and localized Mie plasmons. These couple strongly producing bonding and antibonding mixed plasmons with anomalous dispersion properties. Appropriate plasmon engineering of the void morphology selects the plasmon spatial and spectral positions, allowing these plasmonic crystal films to be optimized for a wide range of sensing applications.