Cimetidine repurposed as a potential immunomodulatory agent against colorectal carcinoma: A systematic review

OBJECTIVE

To determine the survival benefit and immunomodulatory effects of cimetidine pre-, peri- or post-operatively in patients with colorectal cancer (CRC).

METHODS

A systematic review was conducted using PubMed and Cochrane Library to retrieve randomized control trials (RCTs) that investigated the effects of cimetidine on survival and immunomodulation via improvement in tumor infiltrating lymphocytes (TILs) and peripheral blood lymphocytes. The review was carried out in accordance with the extended Preferred Reporting Items for Systematic Reviews and Meta-analyses.

RESULTS

Four studies with the total of 267 patients were included in this systematic review. Treatment duration varied from 5 days to 1 year. Two studies reported a significant TIL response in the resected specimens after administering cimetidine, while one RCT showed an escalation of CD3, CD4 and CD57 lymphocytes in peripheral blood compared to the baseline following cimetidine treatment (p < 0.01). Of the three trials that examined the effects of cimetidine on survival, only two studies revealed significant survival benefit while the remaining study only showed a trend towards survival benefit.

CONCLUSION

Repurposing of existing drugs like cimetidine has a potential to offer a survival benefit by acting as an immunomodulatory agent in patients undergoing curative resection for CRC. However, the heterogeneity seen in current studies and the evolvement of adjunctive therapies for CRC warrant large-scale, well-designed prospective RCTs to establish the efficacy of cimetidine in CRC.

Caregiver strain among patients of palliative care in Sri Lanka: validation of modified caregiver strain index - Sinhala version

BACKGROUND

Care givers of Palliated patients are at risk of adverse physical, psychosocial and emotional sequelae in varied nature. Efficient and valid assessment tools facilitate early detection to take corrective measures. The Modified Caregiver Strain Index (MCSI), composed of domains associated with caregiver strain is a simple and brief tool that can be used in both clinical and field settings. This study aimed to adapt and validate this in order to cater effective palliative care services in Sri Lanka.

METHODS

After cross-cultural adaptation, 200 primary caregivers in 3 teaching hospitals were recruited. The internal consistency, item-total correlations, of the 13-item S-MCSI were performed. The criterion validity was assessed by Pearson correlation between the total scores of S-MCSI, the Karnofky Performance Scale and the Barthel index. Construct validity was determined by the principal component analysis keeping the Varimax with Keiser normalization as the rotation method. The Kaiser-Meyer-Olkin test (KMO) and Bartlett's test of sphericity statistics were also performed to determine the adequacy of the sample and correlations between items, respectively. The number of factors was determined by the Scree plot, percentage of variance explained by each component and number of Eigen values over 01 (Kaiser-Guttman rule).

RESULTS

The total MCSI score ranged 0 to 26. The overall Cronbach's alpha of the 13-item questionnaire was 0.80 while item-total corrections ranged 0.34 to 0.62, exception of one item (0.11). Inverse correlations were demonstrated in total scores of MCSI and Karnofky Performance Scale (r =- 0.32, p < 0.001) and Barthel index (r =-0.34, P < 0.001). A Kaiser-Meyer-Olkin value of 0.79 (p < 0.001) for Bartlett's test indicated adequate sampling and nonlinearity of factors. The Scree plot showed a three-factor structure explaining 57% of the variation. Items regarding personal wellbeing of caregiver loaded together while the effects on the family loaded separately. Adjustment of personal concerns and family issues along with time alteration grouped as the third factor.

CONCLUSIONS

The study showed that the Sinhala version of MCSI has adequate psychometric properties and reliability to be used as a validated tool to estimate the caregiver burden within a short time period for any health care workers.

Development of the Asia Pacific Consortium on Osteoporosis (APCO) Framework: clinical standards of care for the screening, diagnosis, and management of osteoporosis in the Asia-Pacific region

Guidelines for doctors managing osteoporosis in the Asia-Pacific region vary widely. We compared 18 guidelines for similarities and differences in five key areas. We then used a structured consensus process to develop clinical standards of care for the diagnosis and management of osteoporosis and for improving the quality of care.

PURPOSE

Minimum clinical standards for assessment and management of osteoporosis are needed in the Asia-Pacific (AP) region to inform clinical practice guidelines (CPGs) and to improve osteoporosis care. We present the framework of these clinical standards and describe its development.

METHODS

We conducted a structured comparative analysis of existing CPGs in the AP region using a "5IQ" model (identification, investigation, information, intervention, integration, and quality). One-hundred data elements were extracted from each guideline. We then employed a four-round Delphi consensus process to structure the framework, identify key components of guidance, and develop clinical care standards.

RESULTS

Eighteen guidelines were included. The 5IQ analysis demonstrated marked heterogeneity, notably in guidance on risk factors, the use of biochemical markers, self-care information for patients, indications for osteoporosis treatment, use of fracture risk assessment tools, and protocols for monitoring treatment. There was minimal guidance on long-term management plans or on strategies and systems for clinical quality improvement. Twenty-nine APCO members participated in the Delphi process, resulting in consensus on 16 clinical standards, with levels of attainment defined for those on identification and investigation of fragility fractures, vertebral fracture assessment, and inclusion of quality metrics in guidelines.

CONCLUSION

The 5IQ analysis confirmed previous anecdotal observations of marked heterogeneity of osteoporosis clinical guidelines in the AP region. The Framework provides practical, clear, and feasible recommendations for osteoporosis care and can be adapted for use in other such vastly diverse regions. Implementation of the standards is expected to significantly lessen the global burden of osteoporosis.

Validation of psoriasis disability index (PDI) questionnaire Sinhala version

INTRODUCTION/OBJECTIVES

Psoriasis is a chronic inflammatory dermatosis with significant physical and psychological impact leading to negative influence on the quality of life among patients with psoriasis. Other than the disease characteristics many external factors could operate in South Asian context. Lack of a reliable disease-specific instrument prevents objective estimation and monitoring of disability in patients with psoriasis and hence we aim to validate assess the psychometric properties of the Sinhala version of PDI.

METHODS

A cross-sectional study conducted at dermatology clinic at a tertiary care National Hospital in Sri Lanka. Patients with psoriasis and on therapy at least 4 weeks prior to enrollment, aged more than 18 years, were included while those with already diagnosed psoriatic arthritis and/or nail psoriasis alone without any skin involvement and generalized pustular psoriasis de novo were excluded. All patients were examined by dermatologist to obtain disease characteristics. The reliability was assessed by internal consistency using Cronbach's α and item-total correlation. Convergent validity was measured with the known groups.

RESULTS

Of 199 patients studied, the PDI Sinhala version showed Cronbach's α of 0.86 (all 15 items) and ranged from 0.57 to 0.77 for subscales. PDI score and Dermatology Life Quality Index (DLQI) showed good correlation of coefficient 0.76 (p < 0.01). Positive associations were noted with extent and severity of psoriasis when using sample medians (p < 0.05). The dimensionality of the PDI was determined using exploratory factor analysis and four factors were structured.

CONCLUSION

The PDI Sinhala version is proved to be valid and reliable tool to assess the burden of psoriasis among Sinhala conversant patients in Sri Lanka.

IQ driving QI: the Asia Pacific Consortium on Osteoporosis (APCO): an innovative and collaborative initiative to improve osteoporosis care in the Asia Pacific

Asia Pacific Consortium on Osteoporosis (APCO) comprises of clinical experts from across the Asia Pacific region, uniting to develop solutions to problems facing osteoporosis management and care. The vision of APCO is to reduce the burden of osteoporosis and fragility fractures in the Asia Pacific region.

INTRODUCTION

The Asia Pacific (AP) region comprises 71 countries with vastly different healthcare systems. It is predicted that by 2050, more than half the world's hip fractures will occur in this region. The Asia Pacific Consortium on Osteoporosis (APCO) was set up in May 2019 with the vision of reducing the burden of osteoporosis and fragility fractures in the AP region.

METHODS

APCO has so far brought together 39 clinical experts from countries and regions across the AP to develop solutions to challenges facing osteoporosis management and fracture prevention in this highly populous region of the world. APCO aims to achieve its vision by engaging with relevant stakeholders including healthcare providers, policy makers and the public. The initial APCO project is to develop and implement a Framework of pan-AP minimum clinical standards for the screening, diagnosis and management of osteoporosis.

RESULTS AND CONCLUSIONS

The Framework will serve as a platform upon which new national clinical guidelines can be developed or existing guidelines be revised, in a standardised fashion. The Framework will also facilitate benchmarking for provision of quality of care. It is hoped that the principles underlying the formation and functioning of APCO can be adopted by other regions and that every health care facility and progressively every country in the world can follow our aspirational path and progress towards best practice.

Effect of Vitamin D therapy on urinary albumin excretion, renal functions, and plasma renin among patients with diabetic nephropathy: A randomized, double-blind clinical trial

Background:

Despite different management strategies, progression of proteinuria occurs in a sizable category of patients with diabetic nephropathy (DN). Increase in serum renin levels induced by the renin–angiotensin system (RAS) may contribute to this. Vitamin D therapy is found to have an inhibitory effect on the RAS. We aimed to study the effects of Vitamin D therapy on renal functions of patients with DN.

Methods:

This was a double-blind, randomized, placebo-controlled study. Patients with DN (urinary albumin [UA] >30 mg/g of creatinine) whose estimated glomerular filtration rate (eGFR) was more than 30 mL/min were selected and their plasma renin, parathyroid hormone, serum Vitamin D, serum calcium, serum creatinine, fasting blood sugar were done as baseline measurements. Subjects were randomized into two groups and treatment group was given Vitamin D, 50000 IU (0.25 ml) intramuscularly (IM) monthly for 6 months; control group received distilled water IM. Investigations were repeated after 6 months of therapy.

Results:

Of 155 patients invited, 85 were randomly assigned to two groups. After 6 months, mean reduction of UA to creatinine ratio in the treatment and control group was 51.8 mg/g (95% confidence interval [CI]; 66.1–−37.5, P ≤ 0.001); 22.4 mg/g (95% CI; −45.7–0.8, P = 0.06), respectively (between group difference P = 0.001). Significant increase in the eGFR observed in the treatment group while eGFR remained unchanged in the control group (P = 0.03 for the between-group difference). Mean reduction in plasma renin in treatment group and control group was 5.85 pg/mL (95% CI; −6.7–−4.6) (P < 0.001) and 0.95 pg/mL (95% CI; −1.4–−0.14, P = 0.02), respectively.

Conclusions:

Vitamin D 50000 IU given IM monthly for 6 months reduces urine albumin, serum creatinine, and renin levels in patients with DN.

Factors that determine body composition of female systemic lupus erythematosus (SLE) patients in Sri Lanka: a comparative study using dual-energy x-ray absorptiometry

Studies on body composition and its determinants among SLE patients are limited. Estimation of body composition, analysis of determinants and associations of different body compartments are important in planning long-term care of these patients. The aim of the study was to identify the changes in body composition among SLE patients and assess the effect of corticosteroid use, patient and disease-related variables on body composition. We compared lean mass, fat mass, bone mineral density (BMD), and bone mineral content (BMC) determined by dual-energy x-ray absorptiometry technology, in a group of premenopausal women with SLE (n = 27) and an age-matched healthy group of women (n = 27). The median (IQR) duration of SLE was 3 (2-5) years while median (IQR) duration and dose of prednisolone therapy were 108 (88 - 172) weeks and 9730 (6160-15360) mg, respectively. No significant difference was observed in body mass index (BMI) or total fat mass between the two groups. SLE patients, however, had significantly lower lean mass (p < 0.001), BMD (p < 0.001) and BMC (p < 0.005) than healthy controls. Among cases, compared with lean mass, total body fat content showed stronger associations with total body BMD (r = 0.49, p < 0.01) and total body BMC (r = 0.63, p < 0.01). When a stepwise regression model was fitted, lean mass among controls and total fat mass among cases emerged as the best predictors of BMC/BMD. No significant correlations were found between the disease duration or cumulative glucocorticosteroid dose and total body BMD, total body BMC, lean mass or total fat content in SLE patients.

A framework for the development of guidelines for the management of glucocorticoid-induced osteoporosis

This paper provides a framework for the development of national guidelines for the management of glucocorticoid-induced osteoporosis in men and women aged 18 years and over in whom oral glucocorticoid therapy is considered for 3 months or longer.

INTRODUCTION

The need for updated guidelines for Europe and other parts of the world was recognised by the International Osteoporosis Foundation and the European Calcified Tissue Society, which set up a joint Guideline Working Group at the end of 2010.

METHODS AND RESULTS

The epidemiology of GIO is reviewed. Assessment of risk used a fracture probability-based approach, and intervention thresholds were based on 10-year probabilities using FRAX. The efficacy of intervention was assessed by a systematic review.

CONCLUSIONS

Guidance for glucocorticoid-induced osteoporosis is updated in the light of new treatments and methods of assessment. National guidelines derived from this resource need to be tailored within the national healthcare framework of each country.

An appendix to the 2012 IOF-ECTS guidelines for the management of glucocorticoid-induced osteoporosis

The use of glucocorticoids in the treatment of medical disorders can lead to rapid bone loss and increased risk of fragility fracture. Updated clinical guidelines are needed that accommodate recent advances in fracture risk assessment and new pharmacological interventions to reduce fracture risk. This document serves as an appendix to the 2012 IOF-ECTS guidelines for the management of glucocorticoid-induced osteoporosis.

Comparison of phalangeal bone mineral content and density between the dominant and non-dominant sides

OBJECTIVES

Compared to the non-dominant side, higher bone mineral content (BMC) and density (BMD) have been demonstrated in the forearm bones in the dominant side. Clinicians are compelled to scan the dominant side when deformities or artifacts are found in the non-dominant side. This study was done to evaluate the differences in phalangeal BMC and BMD, measured using accuDXA, between the dominant and non-dominant hands. Design and participants A group of 333 subjects, comprising 267 healthy volunteers (185 women and 82 men) and 66 women with rheumatoid arthritis. Phalangeal BMD and BMC, were measured using accuDEXA, both in the non-dominant and dominant hands. Main results BMC and BMD showed strong correlations between the two sides (r = 0.95, p < 0.001 for both). Compared to the non-dominant side, dominant side BMC was 5% higher (mean values =1.54 and 1.47, mean difference = 0.064, 95% CI for the mean difference = 0.048-0.081 g, p < 0.001) and BMD was 4% higher (mean values = 0.480 and 0.463, mean difference = 0.018, 95% CI for the mean difference = 0.014-0.021 g/cm2, p < 0.001). In the subgroup analysis, percentage differences of BMD between the two sides were found to be similar among men (n=82), women (n=251), people below 50 years (n=24), people above 50 years (n=122) and also among patients with rheumatoid arthritis (n=66). Conclusions When the non-dominant hand is not suitable for scanning, the clinician should consider scanning the dominant hand instead. However, the differences in BMD between the two hands should be taken into consideration when interpreting results.

An association between respiratory function and hip bone mineral density in older men: a cross-sectional study

The association between respiratory function and bone mineral density (BMD) among women living in the community has been reported previously. We examined the association between forced expiratory volume in 1 s (FEV(1)) and BMD measured at hip using dual-energy X-ray absorptiometry in a group of 947 men (aged 65 to 76 years) recruited from general practice age-sex registers in Cambridge between 1991 and 1995. A positive and significant correlation was seen between FEV(1) and BMD measured at total hip, femoral neck, and trochanter. A unit change (1 l) in FEV(1) was associated with a change of BMD by 0.019, 0.017, and 0.026 g/cm(2) in the total hip, femoral neck, and tochanteric region, respectively. These associations were independent of possible confounding factors such as age, height, weight, smoking habit, major disease prevalence, and medications, which might affect bone metabolism. In categorical analyses, the highest BMD was seen in the highest FEV(1) quartile, while the lowest BMD was seen in the lowest FEV(1) quartile. This pattern was seen in all three skeletal sites and was independent of covariates listed above. Compared with the bottom FEV(1) quartile, mean hip BMDs in the top quartile were 2-3.5% higher. The exact mechanism of this association is not clear to us. One plausible explanation is that respiratory function and bone health both reflect common but as yet unknown determinants.

An association between respiratory function and bone mineral density in women from the general community: a cross sectional study

Respiratory function has been associated with bone mineral density (BMD) in patients with respiratory diseases. We examined the relationship between bone density measured at the hip and respiratory function in women from the general community. A total of 4830 women aged 45-76 years were recruited from general practice age-sex registers in Cambridge between 1991 and 1995. At baseline survey, data collection included health questionnaires, measures of anthropometry, respiratory function, as well as bone mineral density BMD measured using dual energy X ray absorptiometry. BMD at total hip, femoral neck and trochanter significantly and positively correlated with FEV(1). This association was independent of age, weight, height, smoking habit, history of respiratory diseases, corticosteroids and use of hormone replacement therapy. After adjustment for these factors, an increase in FEV(1) of 1 l/s was associated with 0.026, 0.021 and 0.026g/cm(2) increase in bone mineral density at total hip, femoral neck and trochanter respectively. The association was consistent and similar in magnitude among current smokers and current non-smokers and across all age groups. The magnitude of the association was comparable to that associated with an age difference of 6 years or weight difference of 5 kg. Women in the bottom compared to top quartile of respiratory function had about double the risk of low bone density independent of other factors. Respiratory function measured using FEV(1) is positively and independently related to BMD in these middle-aged and older women across the whole normal distribution of these physiologic measures. This may reflect underlying common determinants such as physical activity. Even in healthy women, respiratory function may be a marker for women at increased risk of osteoporosis and associated fractures.