Use of Endpoints in Phase III Randomized Controlled Trials for Hematopoietic Stem Cell Transplantation Over the Last 15 Years: A Systematic Review

This systematic review aimed to evaluate the proportion of primary and secondary endpoints in hematopoietic stem cell transplant (HSCT) phase III randomized clinical trials (RCTs) and analyze their trends in time and study sponsorship status. The Chi-square test and logistic regression analyses were performed using SPSS version 28. A total of 147 HSCT phase III RCTs from 2006 to 2021 reported 197 primary and 600 secondary endpoints. Overall survival (OS, 17 %), progression-free survival (PFS, 15 %), graft versus host disease (GVHD, 8 %), event-free survival (EFS, 8 %), and organ function (8 %) were the most common primary endpoints. GVHD (12.3 %, n = 74), safety/toxicity/adverse events (11.8 %, n = 71), OS (11.5 %, n = 69), PFS (9.3 %, n = 56), and relapse rate (RR; 7.5 %, n = 45) were the most common secondary endpoints during 2006-2021. After 2013, an increase was noted in the use of PFS as a primary endpoint (12 %-18 %, p = 0.196), while the use of OS as a primary endpoint declined (20 %-13 %, p = 0.170). An increase was observed in using the secondary endpoints RR (5 %-10 %, p = 0.047) and NRM (3 %-6 %, p = 0.047). EFS was used more (14 % vs. 4 %, p = 0.012) than ORR (11 % vs. 2 %, p = 0.003) as a primary endpoint in pharmaceutical-compared to non-pharmaceutical-sponsored studies. As secondary endpoints, the use of EFS (4 % vs. 1 %, p = 0.013) and ORR (4 % vs. 1 %, p = 0.028) was higher, whereas that of organ systems/functions (1.5 % vs. 5.5 %, p = 0.022) and GVHD (6.5 % vs. 15 %, p = 0.002) was lower in pharmaceutical-compared to non-pharmaceutical sponsored studies. GVHD-free relapse-free survival was reported as a primary endpoint in 2 % of studies, while only 5 % reported quality of life as a secondary endpoint. We described commonly used endpoints in HSCT phase III RCTs and patterns in their use over time by funding source and study intervention category.

Hypophosphatemia in Patients With Multiple Myeloma

Hypophosphatemia is among the most common electrolyte abnormalities, especially among patients with underlying malignancies, and is frequently associated with adverse prognoses. Phosphorus levels are regulated through a number of mechanisms, including parathyroid hormone (PTH), fibroblast growth factor-23 (FGF-23), vitamin D, and other electrolyte levels themselves. Clinically, the findings are nonspecific, and the diagnosis is frequently delayed. This article is a narrative literature review. The PubMed database was searched for relevant articles pertaining to hypophosphatemia causes and consequences in patients suffering from multiple myeloma. We found a variety of causes of hypophosphatemia in patients with multiple myeloma. Tumor-induced osteopenia, although more common among patients with small squamous cell carcinomas, can occur with multiple myeloma as well. Additionally, both light chains themselves and medications can trigger Fanconi syndrome, which leads to phosphorus wasting by the kidney. Bisphosphonates, in addition to being a possible cause of Fanconi syndrome, lead to a decrease in calcium levels, which then stimulates parathyroid hormone (PTH) release, predisposing the patient to significant hypophosphatemia. Additionally, many of the more modern medications used to manage multiple myeloma have been associated with hypophosphatemia. A better understanding of those mechanisms may give clinicians a clearer idea of which patients may need more frequent screening as well as what the potential triggers in the individual patient may be.

Phenobarbital and Alcohol Withdrawal Syndrome: A Systematic Review and Meta-Analysis

Alcohol withdrawal syndrome (AWS) is a complication frequently encountered among patients who are chronic alcohol abusers. It is considered to have a significant impact on the United States healthcare system. It not only has a toll on the healthcare spending but also contributes to significant morbidity and mortality. Benzodiazepines are considered first line in the treatment of AWS. Since patients with alcohol use disorder have downregulated gamma aminobutyric acid (GABA) receptors, this often leads to benzodiazepine resistance. Phenobarbital is also used in the management of alcohol withdrawal syndrome. Here we present a systematic review and meta-analysis of the efficacy and safety of the drug. We conducted an electronic database search for relevant studies published between the inception of the project and November 20, 2022, in three databases, including Medline/PubMed, Embase, and Cochrane Library. Our study included all original studies with prime focus on the baseline characteristics of patients admitted to the intensive care unit (ICU) for alcohol withdrawal syndrome and management/monitoring protocol implemented for its treatment. The primary outcomes that were the focus of our study consisted of changes in the length of hospital stay, length of ICU stay, and changes in scoring systems (for alcohol withdrawal assessment and monitoring) following the implementation of phenobarbital. The secondary outcomes included complications such as intubation and mortality. Based on our analysis, the mean difference in hospital stay was statistically significant at -2.6 (95% CI, -4.48, -0.72, P=0.007) for phenobarbital compared to the benzodiazepine group. We were unable to comment on the heterogeneity in our meta-analysis due to the standard deviation not being reported in one study. There was no statistically significant difference regarding the length of stay in the intensive care unit compared to the control/comparative arm, with a mean difference of -1.17 (95% CI, -1.17, 0.09, P=0.07), with considerable heterogeneity (I²=77%, P=0.002). Our meta-analysis also investigated the risk of intubation between the phenobarbital and the control/comparative group. There was statistically significant difference in the incidence of intubation, relative risk (RR) 0.52 (95% CI, 0.25, 1.08, P=0.08), with considerable heterogeneity (I²=80%, P=0.0001). Our study concludes that phenobarbital is an effective tool in the management of AWS in an ICU setting. However, various studies have reported contradictory results, and vital information appears to be lacking. Moreover, there is a lack of uniformity in terms of phenobarbital dosing. Drug administration should be adapted according to the severity of the symptoms. Further studies need to be conducted discussing the safety profile and adverse effects of the drug when it comes to the management of alcohol withdrawal syndrome.

Leiomyosarcoma: Lung Metastasis

Uterine leiomyosarcoma distant metastasis is common, and lung metastasis has been reported. However, unique cases have been identified either with late onset of metastatic disease or with large size of lung metastasis. A typical approach to avoid metastasis would be a hysterectomy. Nonetheless, metastatic recurrence is common. We encountered a case at our hospital with leiomyosarcoma metastatic to the lungs. Lung metastasis was noted to be 17 cm in diameter. This size has not yet been reported in the literature to the best of our knowledge.

Miliary Tuberculosis: A Case Report Highlighting the Diagnostic Challenges Associated With the Condition

End-stage renal disease requiring chronic dialysis is an immunocompromised state which increases the risk of tuberculosis development and its spread. Due to the high frequency of non-specific or “decoy” symptoms at presentation and frequent extrapulmonary involvement, diagnosis of tuberculosis is a significant challenge. Therefore, it is correctly labeled as ‘Tuberculosis; the great imitator’ as it can mimic various other disease processes, causing confusion and testing of subsystems involved in the disease process, which come back as abnormal, leading to a vicious cycle. Missing the diagnosis leads to grave consequences, especially in a patient with a miliary form of tuberculosis, as the prognosis with any delay in treatment is poor. High diagnostic suspicion is required to promptly diagnose and treat the condition, especially in a resource-rich setting where tuberculosis is uncommon. Here, we report a patient with miliary tuberculosis who presented with a chief complaint of chronic diarrhea and fecal continence, with prior recent negative interferon-gamma release assay testing. Due to every organ system involved, multiple subspecialties were on board, with a broad differential in mind, including malabsorption syndromes, neoplasia, infections, amyloidosis, and autoimmune disorders, and therefore, numerous tests were performed. However, despite all efforts, the diagnosis was delayed significantly, leading to the unfortunate demise of the patient. The case report sheds light on unique clinical features of miliary tuberculosis, diagnostic findings, and a reminder to always keep tuberculosis high in the differential in an appropriate clinical setting.

Group A Beta-Hemolytic Streptococcus-Induced Tic-Like Movement Disorder in an Adult: A Case Report

A tic is a sudden, repeated, quick, and uncontrollable movement of a part of the body. Tic disorders have a multifactorial etiology, including genetic predisposition, autoimmunity, and environmental factors. Movement disorders following streptococcal infection are rare and typically present in the pediatric population. We present a unique case of a 31-year-old female admitted with involuntary movements of the upper extremities of three weeks duration. Her movements start as twitching before progressing to one hand hitting the other or hitting her face. She had a strong urge before giving in to complete the action. However, the movements were partially distractable, with considerable overlap between clinical features of organic and functional tics. After a detailed workup, including a negative magnetic resonance imaging (MRI) of the brain with and without contrast, MRI of the spine, computed tomography of the chest, abdomen, and pelvis for neoplasia, as well as blood work for autoimmunity, infections, and paraneoplastic syndrome, the serology came back strongly positive for antistreptolysin O and antideoxyribonuclease B titers. Additionally, a detailed psychiatric assessment ruled out conversion disorder leading to a diagnosis of streptococcus-induced movement disorder. After a failed inpatient trial of aripiprazole, the plan included initiating deutetrabenazine with close outpatient neurology follow-up after discharge.

Stenotrophomonas Maltophilia and Urinary Tract Infections: A Systematic Review

Stenotrophomonas maltophilia, a gram-negative bacillus well known to cause respiratory tract infections, is increasingly being reported to cause urinary tract infections (UTI). In our review of the literature comprising six articles, males were more prone to developing UTIs, with the mean age of the patients being 62.5 ±18.9 years. While several risk factors have been associated with the development of the disease, patients with underlying urological or nephrological diseases tend to develop a more severe illness. The organism was sensitive to trimethoprim-sulfamethoxazole (TMP-SMX) in the majority of cases. This systematic review also aims to shed light on the possible mechanisms of resistance adopted by the bacteria, modes of transmission, and strategies to prevent the transmission and development of the disease.

Carcinoma Ex Pleomorphic Adenoma of the Parotid Gland: A Rare Case

Cancer is a major cause of morbidity and mortality worldwide, with squamous cell carcinoma (SCC) being the most common type. Even though SCC is the major type of cancer found in the head and neck region, the salivary glands contribute to about 1/20 cases, of which 1/10 are said to be carcinoma ex pleomorphic adenoma (CXPA) type, and the parotid gland is found to be the most common origin of such cases. Although it usually arises later in life, it can grow rapidly, with local symptoms being late findings, if any. Even though fine needle aspiration cytology has low sensitivity for diagnosing such cancer, multiple/repeated biopsies can increase the yield and the accuracy of the test. Surgical resection is the main choice for treatment with postoperative radiation for select cases. Our case presented with CXPA with distant metastasis to multiple sites.

New-Onset Atrial Fibrillation in COVID-19 Infection: A Case Report and Review of Literature

Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, many cases of arrhythmias have been reported in patients with COVID-19 infection. We present the case of a 66-year-old female with no known cardiovascular history who presented with worsening shortness of breath and productive cough and tested positive for COVID-19 infection in the ED. The patient had a recent hospitalization for COVID-19 infection during which she was treated with dexamethasone and remdesivir therapy and her course remained uncomplicated at that time. Following this, she developed worsening shortness of breath at home for which she presented to the ED. During this hospitalization, she was treated with dexamethasone, remdesivir, and supplemental oxygen. On day six of hospitalization, the patient became tachycardic and had palpitations. Cardiac monitor and EKG showed evidence of new-onset atrial fibrillation (NOAF). Initially patient received metoprolol and diltiazem, both of which failed to achieve adequate rate control. Following this, the patient was started on carvedilol 30 mg every six hours, which attained good rate control. Her CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74, and sex category) score was 4 for which she was started on apixaban 5mg twice daily. The patient was discharged on the same medications. Despite increasing reported incidences of NOAF in COVID-19 infection, only little is known about the optimal management strategies and possible etiopathology. The aim of our review is to highlight the possible mechanisms triggering atrial fibrillation in COVID-19 infection and go over the management strategies while reviewing the available literature.

Lactulose-Induced Ischemic Colitis: A Rare Presentation and an Overview of Possible Etiologies of the Disease

Ischemic colitis is one of the most common ischemic pathologies of the gastrointestinal system and can be divided into non-gangrenous and gangrenous forms. The pathophysiology involves restricted blood supply to the colonic mucosa. Several risk factors have been implicated in the development of ischemic colitis. Lactulose, one of the mainstay therapies for the treatment of hepatic encephalopathy in patients with cirrhosis, has been rarely reported as a cause of ischemic colitis. To the best of our knowledge, there has been only one case report associating lactulose use with the development of ischemic colitis. The exact pathophysiology is unknown but might be associated with the fermentation of lactulose by intestinal bacteria, causing gaseous distention and increasing the intraluminal pressure. We present the case of a 77-year-old African American male, a known case of non-alcoholic liver cirrhosis with portal hypertension and esophageal varices, brought in by his family to the emergency department for altered mental status, non-bilious vomiting, abdominal distension, and pain for one day. On physical examination, the patient had upper extremity asterixis and was alert but disoriented to place and person. Diagnostic paracentesis was performed, which revealed leukocytosis, predominantly neutrophils. The patient was admitted for spontaneous bacterial peritonitis and hepatic encephalopathy with decompensated liver cirrhosis. The patient was started lactulose with a goal of three to four bowel movements per day. Despite adequate treatment, the patient continued to develop worsening mental function and abdominal distension. This was later followed by a bloody bowel movement. Laboratory assessment showed an elevated white blood cell count, worsening kidney function, and high anion gap metabolic acidosis. CT scan revealed dilated loops of bowel with air and fluid along with submucosal wall edema, findings suggestive of ischemic colitis. Given the poor prognosis and the patient's condition, colonoscopy was deferred. Lactulose was discontinued, as it was thought to be a contributing cause of the patient's ischemic colitis. His condition continued to deteriorate, and he passed away on Day 18 of admission.

Large-Cell Esophageal Neuroendocrine Tumor Leading to Hepatorenal Syndrome

Neuroendocrine tumors are tumors that arise from the enterochromaffin cells in the neuroendocrine tissue found throughout the body, particularly the digestive tract, pancreas, and thymus. Neuroendocrine tumors of the esophagus are extremely rare and highly aggressive in nature. We present the case of a 55-year-old Hispanic male who initially presented to the emergency department with right-sided abdominal pain. Imaging revealed innumerable lesions occupying half of the liver parenchyma. Subsequent endoscopy with biopsy of the esophageal and liver lesions along with immunohistochemistry staining was suggestive of a large cell neuroendocrine tumor. He later presented with generalized weakness and right-sided abdominal pain with worsening hepatic and renal function. Over the course of the patient's stay in the hospital, his mental status progressively deteriorated. Given the deranged hepatic and renal function, chemotherapy could not be initiated. The patient's family decided against hemodialysis considering his poor prognosis and the patient expired on day 15 of admission. The case report highlights the aggressiveness of one of the rare esophageal malignancies. It is crucial to establish diagnosis at the earlier stages of the disease with prompt treatment in order to avoid serious complications such as hepatorenal syndrome, which resulted in rapid deterioration of our patient's clinical status. More research is necessary in order to establish guidelines to treat neuroendocrine tumors of the esophagus.

Bronchopleural Fistula and Endobronchial Valve Placement in a Patient With COVID-19 Pneumonia: A Case Report With Literature Review

Bronchopleural fistulas (BPFs) are associated with high morbidity and mortality. Though most commonly seen after surgical interventions, they are increasingly reported as complications of COVID-19 infection. We present the case of an 86-year-old man with COVID-19 pneumonia and subsequent bronchopleural fistula (BPF) with persistent air leak. Endobronchial valves were placed in apical and posterior segments of the right upper lobe resulting in successful cessation of the air leak. The purpose of the case report and literature review is to help guide the management of persistent air leak.

Sickle Cell Disease and COVID-19 Infection: Importance of COVID-19 Testing and Approach to Management

Sickle cell disease is an autosomal recessive disorder resulting in the substitution of CTG by CAG in the sixth codon of the beta-globin gene. As a result of this, the hydrophilic glutamic acid residue is replaced by hydrophobic valine residue, leading to the formation of hemoglobin tetramer HBS. This alteration in the beta-globin chain makes the red blood cells prone to sickling, especially in the presence of risk factors such as stress, hypoxia, and infection. These sickled red blood cells have the tendency to adhere to the endothelium and lead to vessel occlusion and distal tissue ischemia. The recent coronavirus disease 2019 (COVID-19) outbreak has impacted millions across the globe, putting individuals with co-morbidities at particularly high risk, and patients with sickle cell disease are no exception.

We present the case of a 47-year-old African American male presenting to the emergency department with subjective fevers and a two-day history of pain in the arms, legs, and chest. A diagnosed case of sickle cell disease, the patient was on hydromorphone for pain management but ran out of his medications a few weeks before presentation. On examination, the patient was saturating well with mild tenderness upon palpation of the arms, legs, and chest. On complete blood count, the patient had a hemoglobin of 11.3 g/dL and a white cell count of 13.1 x10(3)/mcL. The patient had a normal mean corpuscular volume with reticulocytosis, hypochromia, ovalocytosis, poikilocytosis, polychromasia, and target cells. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) was positive. The chest X-ray did not reveal any significant findings. He was admitted to the medicine floor for the management of sickle cell crisis and was placed under airborne and droplet precautions. The patient was started on hydromorphone for pain management and intravenous fluid hydration. On the second day of admission, the patient reported increasing shortness of breath. He was saturating 90% on room air and 94% on 2 liters of supplemental oxygen. The white blood cell count increased to 18.42 x10(3)/mcL and the chest X-ray revealed reticular densities with patchy alveolar opacities in the left lung. Given the decline in respiratory status, the patient was started on remdesivir. Over the course of his hospital stay, the patient's pain and respiratory status improved, with the patient saturating 97% on room air. He was discharged home with instructions to follow isolation precautions for at least two weeks, folic acid, and adequate pain management. An appointment was also scheduled for the patient to follow with a sickle cell nurse practitioner upon discharge.

High performance and remarkable cyclic stability of a nanostructured RGO–CNT-WO3 supercapacitor electrode

One of the most pressing concerns in today's power networks is ensuring that consumers (both home and industrial) have access to efficient and long-lasting economic energy. Due to improved power accessibility and high specific capacitance without deterioration over long working times, supercapacitor-based energy storage systems can be a viable solution to this problem. So, here, tungsten trioxide (WO₃) nanocomposites containing reduced graphene oxide and carbon nanotubes i.e. (RGO-WO₃), (CNT-WO₃), and (RGO–CNT-WO₃), as well as pure WO₃ nanostructures as electrode materials, were synthesized using a simple hydrothermal process. The monoclinic phase of WO₃ with high diffraction peaks is visible in X-ray diffraction analysis, indicating good crystallinity of all electrode materials. Nanoflowers of WO₃ were well-decorated on the RGO/CNTs conductive network in SEM micrographs. In a three-electrode system, the specific capacitance of the RGO–CNT-WO₃ electrode is 691.38 F g⁻¹ at 5 mV s⁻¹ and 633.3 F g⁻¹ at 2 A g⁻¹, which is significantly higher than that of pure WO₃ and other binary electrodes. Furthermore, at 2 A g⁻¹, it achieves a coulombic efficiency of 98.4%. After 5000 cycles, RGO–CNT-WO₃ retains 89.09% of its capacitance at 1000 mV s⁻¹, indicating a promising rate capability and good cycling stability performance.

One of the most pressing concerns in today's power networks is ensuring that consumers (both home and industrial) have access to efficient and long-lasting economic energy.