Cardiovascular Adverse Events Associated With Second-generation Bruton Tyrosine Kinase Inhibitor Therapy: A Systematic Review and Meta-analysis

PURPOSE

Cardiovascular adverse events (CVAEs) are common adverse effects of first-generation Bruton tyrosine kinase inhibitors (BTKis) and limit their use considerably. This led to the development of second-generation BTKis-acalabrutinib and zanubrutinib-which are more selective, potent, and presumed to have better safety profiles than the previous group of medications. However, there have been sporadic reports of CVAEs associated with second-generation BTKis in clinical practice. To address this issue, a comprehensive meta-analysis to pool the documented CVAEs was performed, including major hemorrhage, any bleeding, atrioventricular block, atrial fibrillation/flutter, pericardial effusion, pericarditis, heart failure, cardiac arrest, myocardial infarction, hypertension, hypotension, and stroke. This meta-analysis incorporated 8 studies. Among these, 6 were Phase III trials and 2 were Phase II trials. These studies collectively enrolled a total of 2938 patients.

METHODS

Multiple databases, including PubMed, MEDLINE, Cochrane Library, Scopus, and EMBASE, were systematically searched for relevant clinical trials from inception through January 14, 2023. The effect measure used was odds ratio (OR) and 95% CI.

FINDINGS

Of a total of 1774 studies identified during the initial database search, 8 were included in the meta-analysis. The incidence of overall and cardiovascular mortality was comparable between the 2 groups. There were no significant differences observed for cardiovascular mortality (OR = 0.36; 95% CI, 0.08-1.65; n = 2588; I2 = 45%; P = 0.19). Similar results were found for all-cause mortality (OR = 0.85; 95% CI, 0.67-1.07), any bleeding (OR = 1.90; 95% CI, 0.88-4.09), major bleeding (OR = 1.07; 95% CI, 0.65-1.76), atrioventricular block (OR = 0.74; 95% CI, 0.15-3.68), atrial fibrillation/flutter (OR = 0.74; 95% CI, 0.37-1.50), and other CVAEs associated with second-generation BTKis.

IMPLICATIONS

Based on the available evidence, there is no indication of worse cardiovascular outcomes or superiority of second-generation BTKis compared with standard treatments in terms of safety profile. However, additional large-scale controlled trials are needed to provide robust support for the superior tolerability of new-generation BTKis.

Thrombophilia Testing in Stroke: A Case Report and Review of Evidence

Thrombophilia is commonly associated with venous thromboembolism, but its relationship with arterial thrombosis, specifically stroke, is not as clearly established. Several large studies have failed to establish a significant connection between inherited thrombophilia and stroke. While tests for Factor V Leiden mutation, prothrombin mutation, protein C deficiency, protein S deficiency, antithrombin deficiency, and antiphospholipid antibodies are typically done for thrombophilia diagnosis, there appears to be little or no correlation between these markers and stroke. In this article, we discuss a case of a 26-year-old male admitted with right neck pain that developed after playing basketball; he was found to have a right cerebellar infarction. He underwent extensive tests for hypercoagulable disorders, which were negative. We also review current evidence and reassess the value of thrombophilia testing in stroke patients.

Therapy-related Acute Myeloid Leukemia in Non-Hodgkin Lymphoma Survivors: Risk, Survival Outcomes and Prognostic Factor Analysis

BACKGROUND

Therapy-related acute myeloid leukemia (tAML) is a serious complication in patients with Non-Hodgkin lymphoma (NHL) exposed to chemotherapy or radiation. This extensive database study aims to quantify the risk of tAML in NHL and determine the impact of tAML on the overall survival (OS) of patients with NHL.

MATERIALS AND METHODS

Patients diagnosed with NHL and de novo AML from 2009 to 2018 were identified from the Surveillance, Epidemiology, and End Results database. Multiple primary standardized incidence ratio (SIR) sessions of the SEER*Stat software were used to calculate SIR and the absolute excess risk of tAML. Overall survival (OS) was evaluated using Kaplan-Meier curves and compared using log-rank tests. Multivariate analysis was used to study the role of each covariate on OS in patients with tAML.

RESULTS

The SIR of tAML was 4.89 (95% CI 4.41-5.41), with a higher incidence of tAML observed for age <60 years, NHL prior to 2013 and within 5 years of diagnosis, and those who received chemotherapy. NHL patients with tAML had lower OS than those without tAML (5-year OS 59% vs. 13%, p < 0.001). Patients with tAML showed worse OS than de novo AML in univariate analysis (5-year OS 13% vs. 25%, p = 0.001) but not in multivariate analysis (HR 0.93, 95% CI 0.82-1.04, p = 0.21). Age ≥60 years and lack of chemotherapy were associated with poor OS in tAML subcategory.

CONCLUSION

Age, time since NHL diagnosis, and receipt of chemotherapy directly influence the risk of development of tAML in NHL survivors.

Clinical outcomes and prognostic factors in triple-negative invasive lobular carcinoma of the breast

PURPOSE

Triple-negative invasive lobular carcinoma (TN-ILC) of breast cancer is a rare disease and the clinical outcomes and prognostic factors are not well-defined.

METHODS

Women with stage I-III TN-ILC or triple-negative invasive ductal carcinoma (TN-IDC) of the breast undergoing mastectomy or breast-conserving surgery between 2010 and 2018 in the National Cancer Database were included. Kaplan-Meier curves and multivariate Cox proportional hazard regression were used to compare overall survival (OS) and evaluate prognostic factors. Multivariate logistic regression was performed to analyze the factors associated with pathological response to neoadjuvant chemotherapy.

RESULTS

The median age at diagnosis for women with TN-ILC was 67 years compared to 58 years in TN-IDC (p < 0.001). There was no significant difference in the OS between TN-ILC and TN-IDC in multivariate analysis (HR 0.96, p = 0.44). Black race and higher TNM stage were associated with worse OS, whereas receipt of chemotherapy or radiation was associated with better OS in TN-ILC. Among women with TN-ILC receiving neoadjuvant chemotherapy, the 5-year OS was 77.3% in women with a complete pathological response (pCR) compared to 39.8% in women without any response. The odds of achieving pCR following neoadjuvant chemotherapy were significantly lower in women with TN-ILC compared to TN-IDC (OR 0.53, p < 0.001).

CONCLUSION

Women with TN-ILC are older at diagnosis but have similar OS compared to TN-IDC after adjusting for tumor and demographic characteristics. Administration of chemotherapy was associated with improved OS in TN-ILC, but women with TN-ILC were less likely to achieve complete response to neoadjuvant therapy compared to TN-IDC.

Clinical Outcomes and Prognostic Factors in Triple-Negative Invasive Lobular Carcinoma of the Breast

Purpose: Triple-negative invasive lobular carcinoma (TN-ILC) of breast cancer is a rare disease and the clinical outcomes and prognostic factors are not well-defined. Methods: Women with stage I-III TN-ILC or triple-negative invasive ductal carcinoma (TN-IDC) of the breast undergoing mastectomy or breast-conserving surgery between 2010 and 2018 in the National Cancer Database were included. Kaplan-Meier curves and multivariate Cox proportional hazard regression were used to compare overall survival (OS) and evaluate prognostic factors. Multivariate logistic regression was performed to analyze the factors associated with pathological response to neoadjuvant chemotherapy. Results: The median age at diagnosis for women with TN-ILC was 67 years compared to 58 years in TN-IDC (p<0.001). There was no significant difference in the OS between TN-ILC and TN-IDC in multivariate analysis (HR 0.96, p=0.44). Black race and higher TNM stage were associated with worse OS, whereas receipt of chemotherapy or radiation was associated with better OS in TN-ILC. Among women with TN-ILC receiving neoadjuvant chemotherapy, the 5-year OS was 77.3% in women with a complete pathological response (pCR) compared to 39.8% in women without any response. The odds of achieving pCR following neoadjuvant chemotherapy were significantly lower in women with TN-ILC compared to TN-IDC (OR 0.53, p<0.001). Conclusion: Women with TN-ILC are older at diagnosis but have similar OS compared to TN-IDC after adjusting for tumor and demographic characteristics. Administration of chemotherapy was associated with improved OS in TN-ILC, but women with TN-ILC were less likely to achieve complete response to neoadjuvant therapy compared to TN-IDC.

Abstract P4-06-04: Clinical outcomes of loco-regional HER2-positive invasive lobular carcinoma of the breast

Background: HER2-positive invasive lobular carcinoma (ILC) of the breast is a rare entity. Treatment decisions for HER2-positive lobular breast cancer are often extrapolated from the HER2-positive ductal subtype of breast cancer but the clinical outcomes and prognostic factors are not well defined. Methodology: Women with a diagnosis of stage I to III HER2-positive ILC or invasive ductal carcinoma (IDC) of the breast between 2010 and 2018 were identified from the National Cancer Database. Baseline characteristics were compared between ILC and IDC using Chi-square test for categorical variables and the Mann-Whitney U test for continuous variables. Five-year overall survival (OS) was estimated by the Kaplan Meir method. Multivariate cox proportional hazards regression model including age, race, ethnicity, Charleston Deyo score, grade, TNM stage, and treatment modalities such as type of surgery, chemotherapy, and radiation was used to identify factors associated with OS in HER2-positive ILC. In a subset of patients receiving neoadjuvant chemotherapy, the odds of achieving a complete pathological response were compared between women with ILC and IDC in a multivariate logistic regression model adjusting for age, race, ethnicity, Charleston Deyo score, grade, and clinical stage. Results: A total of 4,197 women with HER2-positive ILC and 116,984 women with HER2-positive IDC were included in the final analysis. The median age at diagnosis was 63 years for women with HER2-positive ILC and 56 years for women with HER2-positive IDC (p&lt; 0.001). The five-year OS among women with HER2-positive ILC was 93.1%, 90.8%,and 78.8% in TNM stages I, II, and III respectively. In multivariate analysis, a significant difference in difference in overall survival was not observed between women with HER2 positive ILC and IDC (Hazard Ratio [HR]: 1.0, 95% Confidence Interval [CI]: 0.9 - 1.1, p=0.55). Among women receiving neoadjuvant chemotherapy, a complete pathological response was observed in 31.7% of women with HER2-positive ILC and 42.7% of HER2-positive IDC. In multivariate analysis, there was no difference in odds of achieving a complete pathological response to neoadjuvant chemotherapy between HER2-positive ILC and IDC (Odds Ratio [OR]: 0.8, 95%CI: 0.7 - 1.0, p=0.12). Higher odds of complete pathological response in HER2-positive ILC were observed for women with estrogen-receptor negative (OR: 2.0, 95% CI: 1.1- 3.8), p= 0.02) and progesterone-receptor negative (OR 2.4, 95%CI: 1.5- 3.7), p&lt; 0.001) tumors. The five-year OS for women with a complete pathological response, partial response, and no response after neoadjuvant chemotherapy in HER2-positive ILC were 89.6%, 84.9%, and 77.3% respectively (p=0.01). Conclusion: This study demonstrates that HER2-positive ILC has comparable clinical outcomes to HER2-positive IDC and response to neoadjuvant chemotherapy correlates with OS in HER2-positive ILC. These findings lend support to the current practice of treating HER2-positive ILC and IDC in a similar manner.

Citation Format: Suman Gaire, Pravash Budhathoki, Utsav Joshi, Anish Shah, Grace M. Choong, Siddhartha Yadav. Clinical outcomes of loco-regional HER2-positive invasive lobular carcinoma of the breast [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-06-04.

Abstract P4-06-05: Response to neoadjuvant chemotherapy among women with triple-negative breast cancer by HER2 expression status

Background: - Low levels of HER2 expression among women with HER2-negative breast cancer is an emerging target. In addition, prior studies have suggested that low levels of HER2 expression might confer resistance to chemotherapy among women with triple-negative breast cancer (TNBC). In this study, we assess the response to neoadjuvant chemotherapy among women with TNBC with varying degrees of HER2 expression. Methodology: - Utilizing the National Cancer Database, we identified adult women treated with neoadjuvant chemotherapy for a diagnosis of clinical TNM stage I to III triple-negative invasive ductal carcinoma of the breast between the years 2010 and 2018. Baseline characteristics were compared between HER2 immunohistochemistry (IHC) scores of 0, 1 +, and 2+ (Women with HER2 2+ expression had to be negative for amplification in the HER2 gene by FISH) using Chi-square for categorical variables. The odds of achieving a complete pathological response were compared among women with different HER2 expression statuses in a multivariate logistic regression model adjusting for age, race, ethnicity, grade of the tumor, and clinical TNM stage at diagnosis. A multivariate cox proportional hazards regression model was used to identify the prognostic effect of HER2 expression on overall survival (OS) adjusting for age at diagnosis, race, ethnicity, grade of tumor, and clinical TNM stage at diagnosis. Results: - A total of 11,038 women with HER2 IHC score of 0, 8,718 women with a score of 1+ and 2,700 women with a score of 2+ were included in the final analysis. The median age at diagnosis was 52 for women with a HER2 IHC score of 0, 53 for women with a HER2 IHC score of 1+ and 54 for women with an IHC score of 2+/FISH negative. The rates of complete pathological response among women with HER2 IHC scores of 0, 1+, and 2+ were 39.5%, 38.1%, and 36.1% respectively. In multivariate analysis, a significant difference in the odds of achieving complete pathological response was not observed for women with HER2 1+ (OR: 1.1, 95% CI: 0.95-1.20, p = 0.3) or HER2 2+ (OR: 0.9, 95% CI: 0.7-1.0, p = 0.1) tumors compared to women with HER2 IHC score of 0. In multivariate Cox regression analysis, women with TNBC with HER2 IHC score 2+ were found to have a better OS (Hazard Ratio [HR]: 0.88, 95% CI: 0.80-0.97, p = 0.01) compared to women with HER2 IHC score of 0 whereas a significant difference in OS was not observed between women with HER2 IHC scores of 0 and 1+ (HR: 0.95, 95% CI: 0.89–1.01, p = 0.1). Conclusion: - This study demonstrates that HER2 expression status does not influence the rates of complete pathological response to neoadjuvant chemotherapy in women with TNBC. However, women with HER2 IHC score of 2+ were found to have a favorable prognosis, which needs to be evaluated further in future studies.

Citation Format: Pravash Budhathoki, Anish Shah, Suman Gaire, Utsav Joshi, Siddhartha Yadav. Response to neoadjuvant chemotherapy among women with triple-negative breast cancer by HER2 expression status [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-06-05.

Abstract P6-01-41: Influence of HER2 expression status in the distribution of recurrence score from the OncotypeDx assay among women with early-stage estrogen-receptor-positive/HER2-negative breast cancer

BACKGROUND: The OncotypeDX assay analyzes the expression of 21 genes, including HER2 and Grb7, to assess the predictive effect of chemotherapy in breast cancer recurrence among women with early-stage estrogen-receptor (ER) positive/HER2-negative breast cancer. In this study, we evaluate the distribution of recurrence score from the OncotypeDX assay based on the HER2 expression status by immunohistochemistry (IHC). METHODOLOGY: Utilizing the National Cancer Database, we identified adult women with a diagnosis of stage I – III ER+/HER2- invasive ductal carcinoma of the breast between the years 2010 and 2018. Recurrence scores were classified into low (&lt; 11), intermediate (11-26), and high risk (&gt;26); and the distribution of these recurrence scores cross-tabulated with different IHC scores of HER2 expression (0, 1+, and 2+) by IHC. Women with an IHC score of 2+ had to be negative for HER2 gene amplification by FISH. Multivariate logistic regression model adjusting for age, race, origin, progesterone receptor status, grade, and cancer stage was used to assess the odds of receiving a high OncotypeDx Score (≥26). RESULT: Among 198,931 women with ER+/HER2 negative breast cancer, 59,632 (30.0%) had HER2 IHC score of 0, 102,170 (51.4%) had IHC score of 1+, and 37,129 (18.6%) women were with IHC score of 2+. The median age at diagnosis of breast cancer among all three categories of HER2 expression was 59 years. The median recurrence score for women with IHC scores of 0,1+, and 2+ was 15, 15, and 16 respectively (p &lt; 0.001). A higher proportion of women with HER2 IHC score of 2+ had a high recurrence score compared to women with an IHC score of 0 (15.2% vs. 13%, p &lt; 0.001). In multivariate analysis, compared to women with HER2 IHC score of 0, women with HER2 IHC score of 2+/FISH negative were observed to have higher Odds (OR: 1.16; 95% CI: 1.11 – 1.20, p &lt; 0.001) of receiving high recurrence score. There was no significant difference in the odds of receiving a high recurrence score between women with IHC 0+ and 1+(OR: 0.99; 95% CI: 0.96 – 1.03, p 0.82). CONCLUSION: Women with a HER2 IHC score of 2+ were observed to have a higher odds of receiving high-risk recurrence scores as compared to women with IHC score of 0. This needs to be further correlated with the response to chemotherapy and the risk of recurrence.

Citation Format: Anish Shah, Pravash Budhathoki, Suman Gaire, Utsav Joshi, Siddhartha Yadav. Influence of HER2 expression status in the distribution of recurrence score from the OncotypeDx assay among women with early-stage estrogen-receptor-positive/HER2-negative breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-01-41.

Electric Cardioversion vs. Pharmacological with or without Electric Cardioversion for Stable New-Onset Atrial Fibrillation: A Systematic Review and Meta-Analysis

BACKGROUND

There is no clear consensus on the preference for pharmacological cardioversion (PC) in comparison to electric cardioversion (EC) for hemodynamically stable new-onset atrial fibrillation (NOAF) patients presenting to the emergency department (ED).

METHODS

A systematic review and meta-analysis was conducted to assess PC (whether being followed by EC or not) vs. EC in achieving cardioversion for hemodynamically stable NOAF patients. PubMed, PubMed Central, Embase, Scopus, and Cochrane databases were searched to include relevant studies until 7 March 2022. The primary outcome was the successful restoration of sinus rhythm, and secondary outcomes included emergency department (ED) revisits with atrial fibrillation (AF), hospital readmission rate, length of hospital stay, and cardioversion-associated adverse events.

RESULTS

A total of three randomized controlled trials (RCTs) and one observational study were included. There was no difference in the rates of successful restoration to sinus rhythm (88.66% vs. 85.25%; OR 1.14, 95% CI 0.35-3.71; n = 868). There was no statistical difference across the two groups for ED revisits with AF, readmission rates, length of hospital stay, and cardioversion-associated adverse effects, with the exception of hypotension, whose incidence was lower in the EC group (OR 0.11, 95% CI 0.04-0.27: n = 727).

CONCLUSION

This meta-analysis suggests that there is no difference in successful restoration of sinus rhythm with either modality among patients with hemodynamically stable NOAF.

Valvular Heart Disease Presenting as Sympathetic Crashing Acute Pulmonary Edema (SCAPE) Phenomenon: A Diagnostic and Management Paradigm

Sympathetic crashing acute pulmonary edema (SCAPE) is an acute decompensated heart failure due to sympathetic overflow. SCAPE is usually triggered by acute insults with an underlying substrate such as long-standing hypertension, chronic heart failure, and valvular heart disease. We present a case of SCAPE in a 91-year-old female due to underlying multivalvular heart disease. Because of severe acute presentation, SCAPE should be identified early, and management should be urgently done to decrease the need for invasive ventilation and prolonged hospitalization.

Risk of second primary malignancy in patients with primary myelofibrosis: a SEER database study

Prior studies report a greater incidence of second primary malignancy (SPM) among patients with myeloproliferative neoplasms, although the true risk in primary myelofibrosis (PMF) has not been elucidated. We utilized the Surveillance, Epidemiology, and End Results database to evaluate the risk of SPM in PMF patients and analyzed the effects of sociodemographic factors on the risk of SPM. Out of 5273 patients, 385 patients (7.30%) developed SPM. SPM occurred at SIR of 1.95 (95% CI 1.76-2.15) and AER of 149.01 per 10,000 population. A significantly higher incidence of melanoma (SIR 1.76, 95% CI 1.01-2.86), lymphoma (SIR 3.38, 95% CI 2.28-4.83), and leukemia (SIR 27.19, 95% CI 23.09-31.81) was observed. The risk was significantly higher in patients ≤60 years, males, chemotherapy recipients, within 5 years of PMF diagnosis, and for PMF diagnosed after 2009.

Abstract P2040: Metolazone As An Adjunct To Loop Diuretics In Acute Heart Failure: A Systematic Review And Meta-analysis

Introduction: Acute heart failure (AHF) affects a significant proportion of the US population. The first-line therapy for decompensated AHF is loop diuretics. However, diuretic resistance in AHF cases is common. In such cases, as add-on therapy, thiazide diuretics are often used to combine two different mechanisms of action. However, the certainty of effectiveness and safety profiles of combining diuretics in cases of diuretic-resistant AHF has not been evaluated in systematic review and meta-analysis considering metolazone, so this study was proposed.

Methods: The review protocol was registered in PROSPERO (CRD42022302399). PRISMA guideline was followed. Databases were searched using appropriate keywords for eligible papers published before January 5, 2022. The database was screened using the Covidence platform, and analysis was done using Review Manager (RevMan-5.1) software. Odds ratio or mean difference with 95% CI were estimated using fixed or random effect models based on heterogeneity.

Results: Eight studies among 2999 studies met the inclusion criteria (2 RCTs, six observational studies). The pooled analysis showed no difference in standardized mean difference among the metolazone group and the control group for 24-hours of total urine output (SMD 0.10, CI -0.40 to 0.60) and change in 24-hour 48-hour urine output and 72-hour urine output. There was no difference comparing the addition of metolazone or chlorothiazide to furosemide. However, pooling of the result among those studies comparing furosemide and metolazone with furosemide alone showed a significant increase in the 24-hour total urine output metolazone group (SMD 0.50, CI -0.00 to 0.99). Other outcomes like weight loss, mortality, readmission rate, adverse events did not differ across treatment and control groups.

Conclusion: Though some benefit in 24-hour urine output was noted on the addition of metolazone to furosemide, our analysis could not demonstrate the benefit of adding metolazone due to lack of adequate studies comparing similar groups in diuretic resistant AHF. Therefore, further RCTs are required in this subject to evaluate the benefit of adding metolazone in diuretic-resistant AHF patients.

Extracorporeal Membrane Oxygenation (ECMO) Dependent Acute Respiratory Distress Syndrome (ARDS): A Systematic Review and Meta-Analysis

Background: Extracorporeal membrane oxygenation (ECMO) has emerged as a newer method for managing severe acute respiratory distress syndrome (ARDS) and ARDS refractory to conventional management. However, its current role in the management of ARDS is not clear. Therefore, we conducted this meta-analysis to compare the mortality rates of ECMO over conventional management in ARDS.

Methods: PubMed, PubMed Central, Embase, and Scopus were searched using appropriate keywords. We selected studies in adults with ARDS that compared the outcomes of patients treated with ECMO vs. conventional management. Cochrane Risk of Bias (RoB) 2.0 and the JBI (Joanna Briggs Institute) quality assessment tools were used for assessing the risk of bias in RCTs and observational studies, respectively. The I² statistic was used to evaluate heterogeneity, and quantitative synthesis was performed using fixed or random effects to pool studies based on heterogeneities. Meta-analysis was conducted using Revman 5.4.

Result: Twelve studies were included in this meta-analysis. As compared to the conventional management (mechanical ventilation: MV), patients treated with ECMO had lower odds of 30-days mortality (OR, 0.56; 95% CI, 0.37 to 0.84) and 90 days mortality (OR, 0.59; 95% CI, 0.41 to 0.85). However, there was no significant difference between in-hospital mortality (OR, 0.75; 95% CI, 0.40 to 1.41) and intensive care unit (ICU) mortality (OR, 1.00; 95% CI, 0.36 to 2.79). Similarly, length of hospital stays (LOS) (MD, 3.92; 95% CI, -6.26 to 14.11) did not show statistically significant differences across the two groups. However, the average ICU stay (ICU LOS) was 7.28 days longer in the ECMO group compared with the MV group (MD, 7.28; 95% CI, 2.55 to 12.02).

Conclusion: Twenty-eight days and 90-days mortality were decreased in patients managed with ECMO compared with the MV group. Also, ICU LOS was found to be longer in the ECMO group. Furthermore, no statistical difference was found between the two groups for in-hospital mortality and hospital LOS. 

Risk, overall survival, and prognostic analysis of therapy-related acute myeloid leukemia in non-Hodgkin lymphoma survivors

e19037

Background: Therapy-related acute myeloid leukemia (tAML) is a serious complication in patients with Non-Hodgkin lymphoma (NHL) exposed to chemotherapy or radiation. tAML demonstrates high risk characteristics and poorer outcomes compared with de novo AML. We aimed to quantify the risk of tAML in NHL, determine factors associated with overall survival (OS) in tAML, and compare them with de novo AML. Methods: Patients with a histologic diagnosis of NHL and de novo AML from 2009 to 2018 were identified from the Surveillance, Epidemiology, and End Results (SEER) 18 database. AML that developed at least 1 year after the diagnosis of NHL was classified as tAML. Multiple primary standardized incidence ratio (SIR) sessions of the SEER*Stat software (version 8.3.9) were used to calculate SIR and absolute excess risk (AER) of tAML based on - age, sex, race, year of diagnosis, chemotherapy, radiotherapy, and interval from NHL diagnosis. The 95% confidence intervals (CI) and p-values were generated using multivariate Poisson regression model. OS of both tAML and de novo AML was assessed using Kaplan Meier curves and then compared using log rank test. The roles of various factors on OS in tAML and de novo AML were evaluated using multivariate cox proportional hazard regression. Results: A total of 373 patients with tAML (N for NHL = 301,903) and 23,360 patients with de novo AML were included in the analysis. More de novo AML cases were ≥70 years compared to tAML (41.1% vs 32.7%, p < 0.001). The risk of development of tAML was significantly higher in ages < 60 years compared to 60-69 years and ≥70 years (SIR 14.0, 95% confidence interval [CI] 11.79-16.51 vs SIR 4.87, 95% CI 4.00-5.86 vs SIR 2.80, 95% CI 2.32-3.34, p < 0.0001). Patients who received chemotherapy were more likely to develop tAML than the non- recipients (SIR 8.44, 95% CI 7.51-9.44 vs SIR 1.75, 95% CI 1.37-2.21, p < 0.0001). The risk of tAML was higher within 5 years of NHL diagnosis (SIR 5.05, 95% CI 4.49-5.67 vs SIR 4.39, 95% CI 3.49-5.45, p < 0.001). There was no statistically significant difference in SIR based on sex, race, receipt of radiotherapy, and year of diagnosis. The median OS and 5-year OS were- 8 months and 13.1% for tAML and 10 months and 27.6% for de novo AML. On multivariate analysis, tAML was not found to be an independent predictor of OS (HR 0.93, 95% CI 0.82-1.04, p = 0.21). Age ≥60 years (age 60-69 years: HR 1.53, 95% CI 1.08-2.15, p = 0.01, age ≥70 years: HR 1.93, 95% CI 1.40-2.66, p < 0.001) and no chemotherapy (HR 1.82, 95% CI 1.40-2.35, p < 0.001) were associated with poor OS in tAML subcategory. Conclusions: Our large population-based study shows increased risk of tAML within the first 5 years of NHL diagnosis, younger NHL survivors, and chemotherapy recipients. Older age and no chemotherapy predispose to dismal OS in tAML.

Risk of second primary malignancy in patients with primary myelofibrosis: A SEER database study

e19079

Background: Primary myelofibrosis (PMF) carries a poorer prognosis compared to other BCR-ABL-negative myeloproliferative diseases (MPD), and there is increased risk of early mortality due to blast transformation, thrombosis, bleeding complications, and progression of disease. Prior studies report greater incidence of second primary malignancy (SPM) among MPD patients, although the true risk in PMF has not been elucidated. We performed a large database study to evaluate the risk of SPM in PMF patients and analyzed the effects of sociodemographic factors on the risk of SPM. Methods: We used the Surveillance, Epidemiology, and End Results (SEER) database to identify all patients with a histologic diagnosis of PMF from 2009 to 2018. SPM was defined as any subsequent malignancy that developed at least 1 year after the diagnosis of PMF. Using multiple primary standardized incidence ratio (SIR) session of the SEER*Stat software (version 8.3.9), we calculated SIR and absolute excess risk (AER) of SPM for the entire cohort of PMF and also stratified based on age, sex, race, marital status, receipt of chemotherapy, follow-up duration, and year of diagnosis. We generated the 95% confidence intervals (CI) and p-values assuming Poisson distribution of the observed incidences of SPM. Results: A total of 5,273 patients with PMF were included in the analysis, of which 342 patients (6.4%) developed SPM. SPM occurred at SIR of 1.97 (95% CI 1.77-2.18, p<0.05) and AER of 151.87 per 10,000 population. A significantly higher incidence of melanoma (SIR 1.96, 95% CI 1.14-3.14, p<0.05), lymphoma (SIR 3.45, 95% CI 2.31-4.96, p<0.05), and leukemia (SIR 26.87, 95% CI 22.69-31.59, p<0.05) was observed. There was no statistically significant difference in SIR based on sex, race, marital status, follow-up duration, and receipt of chemotherapy. The risk was significantly higher in patients ≤60 years vs patients >60 years (SIR 2.34, 95% CI 1.89-2.86 vs SIR 1.86, 95% CI 1.65-2.10, p 0.01) and for PMF diagnosed after 2009 vs ≤2009 (SIR 2.64, 95% CI 2.26-3.07 vs SIR 1.61, 95% CI 1.40-1.85, p<0.001). Conclusions: Patients with PMF are at a high risk of developing SPM, especially leukemia and lymphoma. Data suggests higher incidence of SPM in patients aged ≤60 years and in the decade after 2009. The impact of ruxolitinib, which was approved in 2011, on the incidence of SPM deserves further study. [Table: see text]

Vasopressin versus norepinephrine as the first-line vasopressor in septic shock: A systematic review and meta-analysis

Background and Aim

Norepinephrine is currently the first-line vasopressor for septic shock. We conducted this meta-analysis to examine the outcomes of adult patients with septic shock who received vasopressin instead of norepinephrine.

Methods

We selected studies in adults with septic shock that compared the outcomes of patients treated with vasopressin versus norepinephrine. Cochrane ROB 2.0 and the Joanna Briggs Institute quality assessment tools were used to assess the risk of bias in RCTs and observational studies. Meta-analysis was conducted using RevMan 5.4.

Results

Eight studies were included in this meta-analysis. There were no significant differences in 28-day mortality rates (OR, 1.07; CI, 0.80-1.44) and intensive care unit (ICU) mortality (OR, 0.74; CI, 0.21-2.67) between the two groups. Similarly, length of ICU stay, length of hospital stay, mean arterial pressure at 24 h, urine output at 24 h, and serious adverse events also did not differ significantly. However, the odds of renal replacement therapy (RRT) requirement in the vasopressin group were substantially lower than in the norepinephrine group (OR, 0.68; CI, 0.47-0.98).

Conclusion

There were no differences in mortality, duration of hospitalization, and adverse effects in adults with septic shock across the two groups. However, the patients treated with vasopressin had lower chances of requiring RRT.

Relevance for Patients

Vasopressin use as the first-line vasopressor in septic shock showed a significant reduction in RRT, though there were no significant differences in terms of mortality and other adverse events. Therefore, vasopressin can be considered as a first-line vasopressor in septic shock patients with other risk factors which may contribute to renal failure requiring RRT.

POEMS (Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal Protein, and Skin Changes): A Case Report of a Rare Paraneoplastic Syndrome

POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, and skin changes) syndrome is a multisystem disorder. Peripheral neuropathy and monoclonal plasma cell disorder are the most common manifestations of POEMS. Although osteosclerotic or mixed sclerotic-lytic lesions are typical, osteolytic lesions are rarely encountered. We present a case of a 39-year-old male with a history of multiple endocrine disorders who presented with paresthesia, edema, and hyperpigmentation and was eventually diagnosed with POEMS syndrome. Patients with unexplained neuropathy should be evaluated for POEMS syndrome, especially when it is associated with other findings like endocrinopathy, organomegaly, skin changes, or edema.

Hypothermia versus normothermia after out-of-hospital cardiac arrest: A systematic review and meta-analysis of randomized controlled trials

Background

The current guidelines recommend targeted temperature management (TTM) as part of the post-resuscitation care for comatose patients following out-of-hospital cardiac arrest. These recommendations are based on the weak evidence of benefit seen in the early clinical trials. Recent large multicentered trials have failed to show a meaningful clinical benefit of hypothermia, unlike the earlier studies. Thus, to fully appraise the available data, we sought to perform this systematic review and meta-analysis of randomized controlled trials.

Methods

We searched four databases for randomized controlled trials comparing therapeutic hypothermia (32–34 °C) with normothermia (≥36 °C with control of fever) in adult patients resuscitated after out-of-hospital cardiac arrest. Independent reviewers did the title and abstract screening, full-text screening, and extraction. The primary outcome was mortality six months after cardiac arrest, and secondary outcomes were neurological outcomes and adverse effects.

Relevance for patients

Six randomized controlled trials were included in this review. There was no significant difference between the hypothermia and normothermia groups in mortality till 6 months follow up after out-of-hospital cardiac arrest (OR 0.88, 95% CI 0.67–1.16; n = 3243; I² = 51%), or favorable neurological outcome (OR 1.31, 95% CI 0.93–1.84; n = 3091; I² = 68%). Rates of arrhythmias were notably higher in the hypothermia group than the normothermia group (OR 1.43, 95% CI 1.20–1.71; n = 3029; I² = 4%). However, odds for development of pneumonia showed no significant differences across two groups (OR 1.13, 95% CI 0.98–1.31; n = 3056; I² = 22%). Therefore, targeted hypothermia with a target temperature of 32–34 °C does not provide mortality benefit or better neurological outcome in patients resuscitated after the out-of-hospital cardiac arrest when compared with normothermia.

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Targeted hypothermia did not provide significant differences in mortality after OHCA (OR 0.88, 95% CI 0.67–1.16).

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Similarly, neurological outcome did not show significant differences between two arms (OR 1.31, 95% CI 0.93–1.84).

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Arrhythmias were more in the hypothermia group than normothermia group (OR 1.43, 95% CI 1.20–1.71).

A Case of Advanced Non-Small-Cell Lung Cancer With Response to Alectinib and Favorable Quality of Life

Lung cancer is the leading cause of cancer death globally and in the United States. Non-small-cell lung cancer (NSCLC) accounts for approximately 85% of lung cancer cases. A progressive increase in morbidity and mortality is seen with advanced disease. Identifying specific driver mutations, such as anaplastic lymphoma kinase (ALK) mutations and directed therapy, has improved the quality of life and survival in ALK-positive NSCLC patients. Here, we present the case of a 37-year-old female who was diagnosed with stage IV NSCLC (adenocarcinoma) with a positive ALK mutation six years ago. Our case report highlights a rare ALK mutation NSCLC treated with targeted ALK inhibitor therapy. Despite having advanced-stage cancer, the treatment significantly impacted her survival with an improved quality of life.

Long-Term Favorable Outcome With Nivolumab in a Case of Advanced Non-Small Cell Lung Cancer: A Case Report

Non-small cell lung cancer (NSCLC) constitutes around 85% of lung cancer cases. Advanced non-small cell lung cancer has a poor prognosis. Immunotherapy plays a pivotal role in managing advanced non-small cell lung cancer not positive for driver mutations. Nivolumab is a monoclonal antibody against programmed death-ligand 1 (PDL1). It is approved as a second-line treatment for patients with advanced non-small cell lung cancer who progress on or after chemotherapy. We present a case of a 71-year-old female with advanced non-small cell lung cancer without any driver mutations diagnosed four years ago. Her disease progressed while on conventional chemotherapy, and she was started on nivolumab three and a half years ago. Her lung nodules resolved, she did not show signs of progression, and her performance status improved while on nivolumab. This case report highlights the current role of nivolumab in the management of NSCLC. Patients whose condition worsens while on conventional chemotherapy can respond very well to modern targeted immunotherapy.

A Case Report of Acute Transient Encephalopathy Following a Trans-esophageal Echocardiography

Methemoglobinemia is caused due to an increase in methemoglobin in the blood, impairing oxygen transfer to tissues. Acquired methemoglobinemia is caused by various drugs like local anesthetics, antibiotics, nitrates, nitrites, and food additives. We present a case of a 73-year-old male who presented with cyanosis, altered mental status, and hypoxia following transesophageal echocardiography. Arterial blood gas analysis revealed methemoglobinemia. He had been given topical lidocaine and benzocaine spray before the procedure. He improved after the administration of methylene blue. The case highlights the importance of considering methemoglobinemia in patients presenting with cyanosis, altered mental status, and hypoxia after endoscopic procedures.

A Narrative Review of Existing Options for COVID-19-Specific Treatments

The new coronavirus disease 2019 (COVID-19) was declared a global pandemic in early 2020. The ongoing COVID-19 pandemic has affected morbidity and mortality tremendously. Even though multiple drugs are being used throughout the world since the advent of COVID-19, only limited treatment options are available for COVID-19. Therefore, drugs targeting various pathologic aspects of the disease are being explored. Multiple studies have been published to demonstrate their clinical efficacy until now. Based on the current evidence to date, we summarized the mechanism, roles, and side effects of all existing treatment options to target this potentially fatal virus.

Behcet's disease in an adult male from Nepal: A case report

This case report highlights considering Behcet's disease as a diagnosis in orogenital ulcers and uveitis, although its prevalence is unknown in Nepal due to underreporting. Also, collaboration for patient care among relevant specialties is required.

Outlet Ventricular Septal Defect in an Elderly Male

Ventricular septal defect (VSD) is the most common congenital cardiac anomaly in children and the second most common congenital cardiac anomaly in adults. The hemodynamic compromise associated with VSD is due to the shunt formation created by the abnormal communication between the right and left ventricles. While 85%-90% of small VSDs close spontaneously during the first year of life, some do not close spontaneously. If spontaneous closure does not occur during childhood, a VSD may persist into adulthood and may first be recognized after the development of a complication. We present a case of outlet VSD with secondary aortic insufficiency due to the prolapse of the aortic valve leaflet, especially in the right coronary cusp (RCC) sparing the left coronary cusp. RCC prolapse is an important finding in outlet VSD as the prolapse has the potential to cause permanent aortic insufficiency and closure is indicated regardless of the size of VSD.

Utilizing the Most Accurate Preoperative Risk Calculator

The most commonly used preoperative assessment tools include the American College of Surgeons National Surgical Quality Improvement Program and the Revised Cardiac Risk Index. These tools seek to predict the risk of an individual experiencing postoperative complications, including but not limited to mortality, myocardial infarction, pneumonia, stroke, venous thromboembolism, and pneumonia. Many published studies have sought to objectively quantify the utility of the preoperative risk calculations by retrospectively compiling data for patients who underwent the same or comparable surgeries to compare actual complications to predicted complications. Therefore, we searched these studies to review the literature to draw more general conclusions and recommend which risk calculator is best for different types of surgeries.

Scedosporium apiospermum Pneumonia in an Immunocompetent Host

Invasive fungal infections are being increasingly identified recently. Scedosporium is a significant cause of non-Aspergillus mold infection. It can cause disseminated disease in an immunocompromised host and localized pulmonary infection in immunocompetent ones, especially in those with preformed lung cavities. We present a case of scedosporiosis in an elderly female with bronchiectasis who presented with refractory pulmonary symptoms and infiltrates. The case emphasizes the need to keep the fungal infection in the differential diagnosis of refractory infiltrates in immunocompetent individuals without preformed cavities if they have bronchiectasis. Voriconazole monotherapy can be used as the first-line in proven cases of scedosporiosis.

Immune Thrombocytopenic Purpura Following Pfizer-BioNTech COVID-19 Vaccine in an Elderly Female

Mass vaccination campaigns are being run all over the globe to combat the ongoing COVID-19 pandemic. There have been several reports of immune thrombocytopenic purpura (ITP) occurrence following COVID-19 vaccination. However, ITP due to the Pfizer-BioNTech vaccine has been rarely reported, and a causal link has not been identified. The pathophysiology behind immune thrombocytopenia is similar to heparin-induced thrombocytopenia. The management is also similar to other secondary immune thrombocytopenia. We present a case of a 67-year old female diagnosed with immune thrombocytopenia following Pfizer-BioNTech vaccination. The treatment was resistant to high-dose steroids, intravenous immunoglobulin (IVIG), and rituximab and eventually responded to a thrombopoietin-stimulating agent.

Prevalence of Chronic Kidney Disease, Its Risk Factors and Outcome in Nepal: A Systematic Review and Meta-analysis

BACKGROUND

Hypertension, diabetes, glomerulonephritis, obesity, and family history of kidney diseases are major risk factors for chronic kidney disease. Due to the paucity of data on a national level regarding the prevalence, risk factors, and complications of chronic kidney disease, we performed this meta-analysis.

METHODS

We searched online databases from January 2000 till October 2020. Two reviewers screened articles using Covidence software. Comprehensive Meta-Analysis Software version 3 was used for data analysis.

RESULTS

Among chronic kidney disease patients, 35.96% were found to have high LDL, 34.22% had hypercholesterolemia, 39.18% had hypertriglyceridemia, and 42.23% had low HDL. Pigmentary changes were reported in 37.71%, pruritus in 30.96%; and xerosis in 48.55%. Among the reported nail problems, the brown nail was reported in 7.19%, half and half nail in 6.07%, and white nail in 20.65%.

CONCLUSIONS

The prevalence of chronic kidney disease among high-risk cohorts in Nepal was significant among risk group with hypertension and diabetes being the most common risk factors. The most common stage of chronic kidney disease was Stage V, and the common complications were skin problems and dyslipidemia.

Continuous Subcutaneous Apomorphine Infusion in Advanced Parkinson's Disease: A Systematic Review

Parkinson's disease (PD), a neurodegenerative disorder, is caused due to the loss of dopaminergic neurons in substantia nigra pars compacta, and it mainly affects the motor function of the diseased individual. The most effective treatment for PD to date is levodopa, the precursor molecule for dopamine which ultimately helps overcome the loss of dopamine in the brain. However, long-term levodopa therapy significantly impairs patients' quality of life by causing various disabling motor and non-motor complications. We conducted this study intending to review the available literature that has compared the efficacy and safety of continuous subcutaneous apomorphine infusion (CSAI) with other available treatment options like deep brain stimulation, intestinal levodopa gel, and oral dopaminergic agents. We searched PubMed, Embase, and Scopus databases using the appropriate search strategy. The studies which compared the safety and efficacy of continuous subcutaneous apomorphine infusion to other available treatment options in advanced Parkinson's disease were included in our study. The bias assessment of the studies was done using Cochrane Risk of Bias 2.0 tool for randomized controlled trials, Risk of Bias In Non-Randomized Studies - of Interventions (ROBINS-I) tool for non-randomized interventional studies, and Joanna Briggs Institute Critical Appraisal tools (JBI) for cohort studies. We included eight articles in our systematic review including a randomized controlled trial. None of the included studies had a high risk of bias. We found that in patients with advanced Parkinson's, CSAI demonstrated definite improvement in off-time duration. CSAI has also been shown to improve various non-motor functions, including neuropsychiatric problems in these patients. CSAI has demonstrated safety and efficacy in patients with advanced Parkinson's disease. However, the decision-making is multifactorial. Hence, further studies are required that directly compare the available treatment options with one another and study their overall effects on patients' quality of life.

Palliative Care and Chronic Obstructive Pulmonary Disease (COPD) Readmissions: A Narrative Review

Despite all the advances in the treatment and management of chronic obstructive pulmonary disease (COPD), COPD readmissions remain a major challenge nationwide. Increasing evidence suggests that palliative care involvement with a holistic approach towards end-of-life care can significantly improve outcomes related to the quality of life and survival for late-stage cancers and chronic progressive illnesses like COPD, chronic heart failure, and end-stage renal disease. Some studies have attempted to evaluate an association between the involvement of palliative care and readmission reduction, the effect of which remains elusive, especially with regards to COPD readmissions. This review examined the existing literature to analyze the relationship between palliative care involvement for COPD patients and its effect on COPD readmissions.

Moyamoya Disease in an adult female from Nepal: A case report

Introduction and importance

Moyamoya is a progressive vasoocclusive disease of large intracranial arteries with characteristic collaterals formation. It has a bimodal distribution and more frequent in females compared to males.

Case presentation

We present a case of 38 years female who presented with a loss of consciousness following headache. She was investigated with a head CT, cerebral angiogram, and digital subtraction angiography which led to a diagnosis of Moyamoya disease. She was treated conservatively and scheduled for follow-up.

Clinical discussion

Although ischemic attacks are the common presenting symptoms in cases of Moyamoya disease, hemorrhagic forms are seen too especially among adults compared to children. Identifying Moyamoya disease can significantly affect the treatment options and give insight into managing the chronic nature of the disease to both the physicians and patients.

Conclusion

This case highlights the importance of searching for underlying cause in a young female presenting with intracranial haemorrhage for the first time and keeping Moyamoya disease as a differential.