Two-third Of Patients Research Articles

Discontinuation of Tyrosine Kinase Inhibitor Therapy and Treatment Free Remission (TFR) in Chronic Myeloid Leukemia: Successful Achievement of TFR in More Than Two-Third of Patients in a Real-World Practice

BackgroundDiscontinuation of TKI therapy and treatment-free remission (TFR) have become new goals for chronic-phase chronic myeloid leukemia (CP-CML). The aim of this study was to estimate the TFR post discontinuation of TKI therapy at 3 tertiary-care centers. Patients and MethodsCP-CML patients aged ≥16 years who had an attempt to discontinue TKI therapy till June 2022, were eligible. The collected data included patients’ demographics, prognostic score, type and duration of TKI therapy, response dates, relapse dates, response to re-initiation of TKI therapy, and risk factors for relapse. ResultsFifty-five patients (35, 63.6% females) with a median age of 40 (range 16-74) years at diagnosis discontinued therapy. Forty-eight (87.3%) patients received imatinib as first line therapy. Twenty-nine (52.7%) patients were receiving imatinib at the time of TKI-discontinuation. Median time from diagnosis to TKI discontinuation was 86 months (IQR 60;132) and median duration of TKI therapy after achieving DMR was 66 months (IQR 47;114). After a median follow up of 34 (IQR 12;68) months, 15 (27.3%) patients relapsed. Median time to relapse was 5 months (range 2-38). Most of the relapses occurred during the first 6 months except 3 (20%) patients. All the relapsed patients achieved MMR after a median of 3 (range 2-6) months after restarting TKI therapy. None of the patients progressed to advanced-phase. ConclusionOur experience confirms that discontinuation of TKI therapy in CP-CML patients is feasible and safe in routine clinical practice, and can achieve TFR in more than two-third of carefully selected patients.

135 Real-World Data of Microvascular Decompression in Trigeminal Neuralgia: Analysis of 26 Tertiary Care Centers of the European Continent

INTRODUCTION: Patients with classic trigeminal neuralgia (TN) usually receive first-line treatment with carbamazapine. The known effect of wearing-off is hold against the result of expert single-center series of microvascular decompression (MVD) as a successful treatment option. However, real-world data regarding MVD is lacking. METHODS: A multicenter retrospective data analysis was performed in 26 European hospitals. Inclusion criteria were a) age >18 to 85 years, b) patients with classical TN, c) patients who underwent microvascular decompression (MVD) and d) minimum follow-up of 12 months. Primary outcome is pain-freedom at last follow up. Secondary outcome parameters were duration of symptoms prior to MVD, neurovascular conflict in MRI, time to pain recurrence, complications, and a tailored questionnaire. RESULTS: 1140 patients from 26 European institutions were analysed. Of those, 591 (346 female, 245 male, age (mean±SD) 60.1 ± 13.4 years) fulfilled the inclusion criteria. Mean duration of symptoms prior to surgery was 73.3 ± 67.0 months (6.1 ± 5.6 years). 73.3% of patients had a visible neurovascular conflict in MRI. After a follow-up 49.9 ± 36.8 months, 68.7% of patients were pain free or had occasional pain (BNI score 1 and 2). There was no correlation between symptom duration and time to pain recurrence. Involvement of SCA (61%) was associated with a high probability of pain freedom (p<0.01). Complications occurred in 31.6% of all cases, with hypoesthesia of the facial nerve being the most common event. Three out of four patients (74%) were satisfied with the treatment, and 72% would choose MVD as the preferred treatment option again. CONCLUSIONS: Microvascular decompression for trigeminal neuralgia is an effective treatment modality with excellent pain control. Two-third of patients were satisfied with the treatment.

Definitive radiation therapy with dose escalation is beneficial for patients with squamous cell cancer of the esophagus.

We report the long term follow-up, toxicity, and outcomes of patients with localized squamous cell carcinoma of the esophagus(ESCC) who underwent definitive chemo-radiotherapy(dCRT) at our institute. Patients diagnosed with carcinoma post cricoid, upper cervical and thoracic oesophagus and treated with dCRT between January 2000 and March 2012 were retrospectively analyzed. Radiotherapy was delivered in two phases to a maximum dose of 63Gy in daily fractions of 1.8Gy using conventional or conformal techniques. OS and PFS were defined from date of registration and were calculated by Kaplan-Meier method with comparisons between different subgroups performed using log-rank test. All data were analysed using SPSS Version 22. Three hundred and fourteen patients with ESCC treated with dCRT were included in this analysis. Median age at presentation was 56 years and median KPS at presentation was 70. Two-third of patients were treated with conformal technique. Median dose of radiation delivered was 60Gy(range 30.6Gy-70Gy). Neoadjuvant chemotherapy was administered in about 35% patients and 57% patients received concurrent chemotherapy. About 10% patients required hospitalization during treatment due to complications and 7 patients did not complete treatment. Grade 1/2 dermatitis and mucositis was seen in 77% and 71% patients respectively. Complete response at first follow up was observed in 56% of patients. At a median follow up of 56 months, 77 patients were alive with controlled disease. The 1- and 3-yr OS were 80% and 62% respectively. Median PFS was 28 months; 1- and 3-yr PFS were 66% and 46% respectively. A higher RT dose was found to be a significant predictor for OS and PFS on both uni- and multivariate analysis. Our study highlights that the delivery of higher RT doses (≥63Gy) is feasible in this patient group and that a higher RT dose was associated with significantly better PFS and OS.

FREQUENCY OF HYPERTHYROIDISM IN PATIENTS PRESENTING WITH ATRIAL FIBRILLATION TO CARDIOLOGY UNIT KHYBER TEACHING HOSPITAL PESHAWAR

Objectives: Hyperthyroidism can occur in 9–15% of patients having atrial fibrillation (AF, a-fib). Decreased level of serum thyrotropin in blood is a distinct threat for a-fib. Two-third of patients can convert into sinus rhythm with proper treatment of hyperthyroidism. Beta-blockers can be helpful in reducing left ventricular hypertrophy and atrio-ventricular arrhythmia in individuals having hyperthyroidism. Treating hyperthyroidism is a bit controversial. Thyroxine dose needs adjustment in those patients on replacement therapy and beta-blocker is also valuable in extrinsic hyperthyroidism. To determine frequency of hyperthyroidism in patients with Atrial fibrillation.
 Methodology: This descriptive cross-sectional study was conducted at Cardiology unit (OPD and In-patients), Khyber Teaching Hospital, Peshawar From Nov 17, 2019 to May 16, 2020. A sample size of 179 patients, having presentation of atrial fibrillation were enrolled in the study. All individuals having AF, confirmed by ECG, were advised to do thyroid function test and those with hyperthyroidism were enrolled.
 Results: In our sample size 108 (60.34%) were males and 71(39.66%) were females. Male vs. female ratio was 1.6:1. Subjects in this study were having an average age of 46.16years + 9.51 SD with range of 25-60 years. Subjects ages were classified into three groups, among which most common age group for atrial fibrillation was more than 50 years. The hyperthyroidism was found in 14(7.82%) patients while 165(92.18%) patients were found free of hyperthyroidism.
 Conclusion: We Hyperthyroidism is a recognized cause of atrial fibrillation. Every new onset atrial fibrillation should be investigated with serum TSH levels.

A Dexamethasone Sparing-Regimen with Daratumumab and Lenalidomide in Frail Patients with Newly-Diagnosed Multiple Myeloma: Efficacy and Safety Analysis of the Phase 3 IFM2017-03 Trial

Background. Two-third of patients with newly diagnosed multiple myeloma (NDMM) are over the age of 65. Those patients have heterogeneous fitness and disparate tolerance to treatment. Frailty scoring systems have informed the stratification of elderly patients and treatment guidance. The use of long term dexamethasone is associated with multiple side effects specifically in elderly patients. Here we present the response rates and safety analysis of the randomized phase 3 IFM2017-03 trial, comparing daratumumab lenalidomide (DR) without long term dexamethasone to lenalidomide dexamethasone (Rd) in a frail population of patients with NDMM. Methods. Patients with NDMM over the age of 65 and with an ECOG proxy frailty score ≥ 2 were randomized 1:2 to receive 28-day cycles of lenalidomide (25mg/day, 21/28) and dexamethasone (20mg QW) or daratumumab (1800mg SC QW for 8 weeks, Q2W for 16 weeks and Q4W thereafter), lenalidomide (25mg/day, 21/28) and 2 cycles of dexamethasone (20mg QW for 8 weeks), until progression or unacceptable toxicity. Randomization was stratified on ISS and age. MRD by NGS at 10-5 was performed at 12 months for all patients. Interim analysis endpoints were overall response rate, VGPR or better rate, MRD rate and occurrence of grade 3 or more side effects. The present analysis was done at 12-months-therapy data cut. Results. In total, 295 patients were randomized (95 in Rd arm and 200 in DR arm). Median age was 81 years (68-92) with 84% of patients over the age of 75 years and 61% over the age of 80 years. Baseline demographics and disease characteristics were well balanced between arms. Overall response rates were 77% in Rd arm and 89% in DR arm (p=0.025). 12-months rates of VGPR or better were 42% and 58% in Rd and DR arms, respectively (p=0.013). Depth of response improved during treatment and the median time to reach VGPR was 11 months in Rd group and 5 months in DR group. Treatment benefit for DR was homogeneous across all subgroups defined by age, ECOG, Charlson, ISS, cytogenetics and creatinine clearance. Among patients with VGPR or better at 12 months, 63 were evaluable for MRD at 10-5 by NGS. MRD status at 12 months was negative in 18% of patients in Rd arm and 33% in DR arm (p=0.36). During the first year of treatment, at least one AE (grade ≥ 3) occurred in 64% and 76% of patients in Rd and DR arms, respectively (p=0.052). Patients in DR group had more grade ≥ 3 hematologic AE with neutropenia (Rd 15%, DR 44%, p<0.001) and anemia (Rd 2%, DR 11%, p=0.01) but similar grade ≥ 3 infections, with 17% in Rd and 13% in DR arms (p=0.38). Among patients with infections, 13 had COVID-19 (3 in Rd and 10 in DR). Discontinuations for AEs were similar in both arms (16% in Rd and 13% in DR, p=0.64). Conclusion. In this phase 3 trial dedicated for frail patients with NDMM, a dexamethasone-sparing regimen combining daratumumab and lenalidomide demonstrates deep and rapid responses and a favorable safety profile.

Clinical pattern of retinal detachment at the university of gondar tertiary eye care and training center, north-west ethiopia

Objective: Due to increment in volume of cataract surgery and diabetic retinopathy, the incidence of retinal detachment (RD) is expected to rise in the future. However, little is known about the clinical patterns and risk factor of RD in Ethiopia. This study was aimed to determine the clinical pattern and risk factors of RD at University of Gondar Tertiary eye care and training center (UOG-TECTC). Methods: A hospital based prospective cross sectional study was done involving all consecutive patients with retinal detachment seen over six months period at the UOG-TECTC. Structured questionnaire was used to extract the required data which included demography, ophthalmic history and clinical examination results. Data were entered into SPSS version 20 and analyzed. Results: A total of 73 eyes of 65 patients with RD were analyzed. Two-third of patients were males 42(64.6%) and the median age was 49 years. Rhegmatogenous RD (RRD) was the commonest type of RD found in 58(89.2%) patients. Three quarter of the patients, 49 (75 %), came after 1 month of the symptom occurrence; out of which 20 (41%) visited the center after 1year duration. The commonest identified risk factors were trauma 19(29%) followed by pseudophakia 11(17%). More than three-quarter of the patients 53(81.5%) had detached macula and 60 (92.3%) of the involved eyes were blind at presentation. Conclusion and recommendations: RRD was the commonest type of RD seen in our patients. Majority of the patients visited our center late after macular detachment and trauma was the commonest risk factor. People should be educated to seek health care immediately after the onset of symptoms. Ocular safety precautions should be advised to decrease the risk of ocular trauma. The center should be equipped to manage patients with RD.

Cytomegalovirus Infection in Ulcerative Colitis: An Ambispective Study from a Single Center

Abstract Background and Objectives Cytomegalovirus (CMV) is often detected in colonic tissue of patients with inflammatory bowel disease. Its role as a “bystander” or “culprit” in ulcerative colitis (UC) flares is unclear. The aim of the study is to detect the prevalence and outcomes of CMV infection in UC Materials and Methods All adult patients (both retrospective and prospective), diagnosed with UC in a tertiary care center, were included. Patients underwent colonic biopsies for histopathological examination for CMV. CMV immunoglobulin G (IgG) was also tested to ascertain seroprevalence in this population. CMV infection was defined as presence of CMV inclusions in histopathology. Treatment outcomes were defined as remission, clinical improvement, and partial response. The number of flares and outcomes of disease activity in terms of flare of disease, hospitalization, need of colectomy, and mortality was noted at follow-up. Results A total of 58 patients of UC were included (mean age was 37.3 years, males—66%). Serum CMV IgG was positive in all patients. Twelve patients (20.6%, 9 males) with active UC were found to have CMV infection in histopathology specimens with hematoxylin and eosin staining. Two-third of patients (8/12) had severe disease, while the remaining (4/12) had moderate disease activity. Nine patients (9/12) with CMV colitis achieved complete remission with standard treatment without antiviral therapy. Of the three patients who needed antiviral therapy, two underwent colectomy in follow-up. CMV-positive patients to be predominantly male (p = 0.58) had more frequent relapses (p = 0.08) and were hospitalized for their flares (p = 0.06) when compared with CMV-negative patients. None of these factors were found to be statistically significant. Conclusion CMV infection was found in one-fifth of patients of UC with flare. All patients with CMV infection had moderate-to-severe disease. Majority achieved remission without the need of antiviral therapy.

Navigating Hemostasis of Bleeding Among Children With β-Thalassemia.

Bleeding phenotype is reported in β-thalassemia patients. However, the underlying etiology remains elusive. We aimed to assess coagulation profile and the platelet aggregation in β-thalassemia children with bleeding diathesis. Fifty β-thalassemia children with a positive bleeding history were recruited. Bleeding phenotype was explored through full history taking and thorough clinical examination. Complete blood count, prothrombin time, international normalized ratio, and platelets aggregometry were performed for children with negative workup. Mucosal bleeding was manifest among most of our patients (96%). Two-third of patients had decreased aggregation with ristocetin (68%), adenine di-phosphate (64%), and arachidonic acid (64%). While half of the patients (48%) had deficient response to epinephrine. Collagen, ristocetin, and arachidonic acid induced aggregation were negatively correlated to frequency of blood transfusion (P=0.021, r=-0.325; P<0.001, r=-0.465; P=0.018, r=-0.333, respectively). Aggregation to collagen and epinephrine demonstrated a negative correlation with age (P=0.04, r=-0.287; P=0.03, r=-0.315). Deferiprone was associated with a deficient response to ristocetin and collagen when compared with deferasirox or no chelation (P=0.021 and 0.006, respectively). Impaired ristocetin response was linked to hydroxyurea (P=0.035). Platelets function defect should be considered in β-thalassemia patients with bleeding symptoms.

Correlation of Clinicopathological Profile, Prognostic Factors, and Survival Outcomes with Baseline Alfa-Fetoprotein Levels in Patients With Hepatocellular Carcinoma: A Biomarker that is Bruised but Not Broken

The role of Alfa-fetoprotein (AFP) in the management of hepatocellular carcinoma (HCC) is still debated, with differences in recommendations between international guidelines. We analyzed the relationship of the clinicopathological profile, prognostic features, and survival outcomes with baseline serum AFP levels in patients with HCC. Retrospective analysis of a prospectively accrued dataset of consecutive HCC patients was done. 508 treatment naive patients were included in the analysis. AFP at presentation was normal (<10ng/ml) in 18% patients. Patients with very high AFP (>400ng/ml) had poor hepatic reserves (higher mean serum bilirubin, AST, ALT, INR, and lower mean albumin) and advanced disease at presentation (higher incidence of extrahepatic metastasis, and less proportion of patients with well-differentiated tumors). AFP >400ng/ml was an independent predictor for presence of portal vein tumor thrombosis (PVTT) (OR, 4.08; 95% CI, 2.34-7.12; P<0.001), higher tumor size (OR, 2.19; 95% CI, 1.36-3.54, P= 0.001) and advanced BCLC stage (OR, 4.19; 95% CI, 2.51-7.03; P<0.001). Two-third of patients with small HCC (MTD <3cm) and more than half with early-stage HCC (BCLC stage 0/A) had elevated AFP levels. No significant relationship was seen between overall survival (OS) and baseline AFP in patients who underwent surgery, but median OS in patients subjected to nonsurgical therapies was 19.4,10.5 and 5.7 months in patients having AFP <10ng/ml, 10-400ng/ml and >400ng/ml respectively (P= 0.003). AFP >400ng/ml was an independent predictor of survival in patients receiving any form of therapy (HR=2.23; 95% CI=1.19-4.18, P= 0.012). AFP as a biomarker still has a significant role to play in the management of HCC patients and is here to stay till the search for an ideal biomarker in HCC is over.

Initial presenting manifestations in 16,486 patients with inborn errors of immunity include infections and noninfectious manifestations

Inborn errors of immunity (IEI) are rare diseases, which makes diagnosis a challenge. Abetter description of the initial presenting manifestations should improve awareness and avoid diagnostic delay. Although increased infection susceptibility is a well-known initial IEI manifestation, less is known about the frequency of other presenting manifestations. We sought to analyze age-related initial presenting manifestations of IEI including different IEI disease cohorts. We analyzed data on 16,486 patients of the European Society for Immunodeficiencies Registry. Patients with autoinflammatory diseases were excluded because of the limited number registered. Overall, 68% of patients initially presented with infections only, 9% with immune dysregulation only, and 9% with a combination of both. Syndromic features were the presenting feature in 12%, 4% had laboratory abnormalities only, 1.5% were diagnosed because of family history only, and 0.8% presented with malignancy. Two-third of patients with IEI presented before the age of 6 years, but a quarter of patients developed initial symptoms only as adults. Immune dysregulation was most frequently recognized as an initial IEI manifestation between age 6 and 25 years, with male predominance until age 10 years, shifting to female predominance after age 40 years. Infections were most prevalent as a first manifestation in patients presenting after age 30 years. An exclusive focus on infection-centered warning signs would have missed around 25% of patients with IEI who initially present with other manifestations.

The economic and psychological impact of cancellations of elective spinal surgeries in the COVID-19 era

Background The adoption of health care restrictions due to the COVID-19 pandemic led to the cancellation of elective surgical care. However, the impact on patients is unknown. Objective To evaluate the psychological and economic impact of the cancellation of scheduled spinal operations. Methods We identified 50 patients with cancelled surgeries between 16 March 2020 and 24 April 2020. Forty-nine (98%) participants were contacted, with whom the modified WES-Pi questionnaire was filled in during a telephone interview. Results Of the 49 respondents, 28 (57.2%) were aged <65 years. The most often reported problem (85.7%) was an ongoing limitation in basic daily activities. At least moderate sadness was experienced by 65.3% and disappointment by 73.5% of the patients. More than 80% reported concerns about the continuation and 73.5% about the progression of their symptoms. Out of 27 employees (55.1%), 63% could not work due to severe pain or movement limitation (p < .001). The inability to work was associated with anger (p = .037). The work-related impact of the cancellation was associated with stress (p < .0001) and concerns about continuing the symptoms (p = .004). Two-third of patients would undergo immediate surgery despite the current epidemic situation. Conclusions The cancellations of elective spinal surgeries have a serious psychological impact on patients. This together with potential economic consequences is especially evident in employees unable to work due to pain or movement disability. The information is beneficial for health management. Every effort should be made to resume planned surgical treatment if the epidemiological situation allows it.

High Sensitive C- Reactive Protein in Patients with Angiographically Proved Coronary Artery Disease

Introduction: Atherosclerosis is associated with increased inflammatory activity and risk of vascular disease. The hypothesis is that, the hs-CRP testing might have prognostic usefulness for patients with CAD. Considering a major role of hs-CRP in atherothrombosis, its measurements can provide a novel method to detect individuals at high risk of rupture of plaque.&#x0D; Aim of the Work: This study was performed to find out the relation of high sensitive CRP (hs-CRP) with angiographically proved coronary artery disease (CAD) and its severity.&#x0D; Methodology: Total 125 patients underwent CAG in present study, of them 36% were females and 64% were males, predominated by male sex (‘p’ &lt;0.001.&#x0D; Results: The mean for hs-CRP levels was 1.67(±0.85) mg/L and significantly high in patient with CAD. Strong correlation was formed between age ≥ 45 years and hs-CRP 1-3 mg/ L in present cohort of CAD. About one third of population with CAD had dyslipidemia of them majority (2/3rd) had hs-CRP 1-3 mg/L. Two-third of patients with CAD with tobacco consumption in any form had hs-CRP 1-3 mg/L and was significant than &lt; 1 mg/L and &gt;3 mg/L hs-CRP level. The hs-CRP level associated favorably with the frequency and extent of the CAD in present study (r=0.664).&#x0D; Conclusion: High sensitive CRP offers better risk stratification, predictive and prognostic value, in patients with CAD. Further studies and interventions are mandatory to identify the independent role of hs-CRP as a CAD risk factor and its cost effectiveness in a population of a developing country like India.

Palliative Hypofractionated Radiotherapy in Advanced Squamous Cell Carcinoma of Head and Neck

Introduction: A significant proportion of patients with advanced squamous cell carcinoma of head and neck (HNSCC) are unsuitable for radical treatment and we aim to evaluate the acute toxicity, symptom relief and disease response after palliative hypo fractionated radiotherapy in such patients.&#x0D; Methods: A prospective observational study was conducted from November 2014 to November 2015 at the Department of Radiation Oncology, B.P. Koirala Memorial Cancer Hospital, Bharatpur in 30 patients with stage III or stage IV HNSCC who received radiotherapy of 30 Gy in 10 fractions over two weeks. Pain, dysphagia, insomniaand dyspnoea at presentation were assessed using 11 point numerical scale. Acute treatment toxicities we reassessed using Common Terminology Criteria for Adverse Events (CTCAE) at the end of two weeks. After six weeks of completion of radiotherapy, percentage of symptom relief and disease response based on Response Evaluation Criteria in Solid Tumors (RECIST) were recorded. A few patients were selected for further curative radiotherapy.&#x0D; Results: Common symptoms were pain (86.7%) and dysphagia (50%). Two-third of patients with pain and dysphagia, and about 90% patients with dyspnoea and insomnia had more than 75% symptom relief. An objective response rate of 70% and disease progression of 13.3% were observed. Acute radiation toxicities were acceptable with no grade 3 or 4 toxicities. It was observed that 46.3% of patients had mucositis, 13.3% had dysphagia, and 6.7 % had hoarseness and dermatitis each.&#x0D; Conclusion: Palliative radiotherapy is a suitable modality of treatment for patients with advanced HNSCC for symptom relief and tumour control, with acceptable toxicity.

Hypoglycemia at the time of Covid-19 pandemic

BackgroundHypoglycemia is the limiting factor in the glycemic management of diabetes, which need to be addressed critically to avoid complications. Lockdown because of new coronavirus strain (COVID-19) pandemic has further complicated the issue of hypoglycemia due to limitations in access to food, outpatient clinics, pathological services and medicines. AimTo assess the factors associated with the risk of hypoglycemia during April–May 2020 lockdown in people with type 2 diabetes mellitus. MethodologyWe analyzed the data retrospectively from 146 patients of type 2 diabetes mellitus (T2DM) reporting to the emergency department (ED) during lockdown period with symptoms suggestive of hypoglycemia. ResultsThe majority of patients were male (90/146) with a mean age of 59.88 ± 10.09 years and a mean random blood glucose level of 57.67 ± 9.00 mg/dL. Two-third of patients (70.83%) had level 1 hypoglycemia, while level 2 hypoglycemia was reported in 29.16% of patients. A combination of Metformin and Sulfonylureas (SU) was most commonly associated with the risk of hypoglycemia (65.75%) followed by insulin (33.56%). Subjects who received insulin reported a lower blood glucose value (50.75 ± 8.20 mg/dL) as compared to those receiving a combination of metformin and SU (60.95 ± 7.10 mg/dl). 330.56% of patients who had received prophylaxis hydroxychloroquine (HCQ) 400 mg twice a day along with the routine anti-hyperglycemic agents without their dose adjustment reported hypoglycemia. Patients with hypertension, micro-vascular, macro-vascular complications, and coexistent with each other had a higher propensity to the risk of hypoglycemia (46.58%, 33.56%, 23.29%, and 32.88%) respectively. ConclusionThe COVID-19 lockdown has shown to influence the risk of hypoglycemia in patients with T2DM, especially those receiving SU, insulin, HCQ especially in patients with associated co-morbidities. Patient education, support, and telemedicine plays a pivotal role to prevent hypoglycemia.

Impact of DAA-Based Regimens on HCV-Related Extra-Hepatic Damage: A Narrative Review.

Two-third of patients with chronic hepatitis C show extrahepatic manifestations due to HCV infection of B lymphocytes, such as mixed cryoglobulinemia and non-Hodgkin B-cell lymphoma, or develop a chronic inflammatory status that may favor the development of adverse cardiovascular events, kidney diseases or metabolic abnormalities.DAAs treatments induce HCV eradication in 95% of treated patients, which also improves the clinical course of extrahepatic manifestations, but with some limitations. After HCV eradication a good compensation of T2DM has been observed, but doubts persist about the possibility of obtaining a stable reduction in fasting glucose and HbA1c levels.Chronic HCV infection is associated with low total and LDL cholesterol serum levels, which however increase significantly after HCV elimination, possibly due to the disruption of HCV/lipid metabolism interaction. Despite this adverse effect, HCV eradication exerts a favorable action on cardiovascular system, possibly by eliminating numerous other harmful effects exerted by HCV on this system.DAA treatment is also indicated for the treatment of patients with mixed cryoglobulinemia syndrome, since HCV eradication results in symptom reduction and, in particular, is effective in cryoglobulinemic vasculitis. Furthermore, HCV eradication exerts a favorable action on HCV-related lymphoproliferative disorders, with frequent remission or reduction of clinical manifestations.There is also evidence that HCV clearance may improve impaired renal functions, but same conflicting data persist on the effect of some DAAs on eGFR.

355P - Cost analysis and overview of single versus multiple fraction palliative radiotherapy for painful bone metastasis

BackgroundRadiotherapy is an effective treatment for pain palliation in cancer patients with bone metastasis. Although both single and multiple fractionation schedules are equally effacious in pain control, various factors like re-irradiation rate, cost involved, opioid usage and radiotherapy machine load differs between the two schedules. Here, we have done a retrospective review of patients receiving palliative radiotherapy in our institute. MethodsCase records, radiotherapy treatment plans and charts of patients who received palliative radiotherapy for painful bone metastasis in our institute between June 2017 to May 2018 were reviewed. The demographic features, sites of primary, metastatic bone sites, fractionation schedule used, re-irradiation rates and cost analysis were studied. ResultsThe study included 60 patients. Median age was 54 years (25-78). Male to female ratio was 1.1:1. Most common site of primary was lung (40%), followed by breast (21.66%) and site of bone metastasis was vertebra (51.8%), followed by pelvis (16.4%) and long bones (31.8%). Two-third of patients had metastasis to multiple bones. Multi-fraction radiotherapy was more preferred than single fraction (33.3%). Out of 60 patients, 4 were irradiated for second time and 7 underwent re-irradiation subsequently. Among single fraction RT, only 2 patients required re-irradiation. Average cost for single fraction RT is Rs.13500. Whereas for multi-fraction schedules, the treatment cost ranges from Rs.20000 to 30000 and an additional cost for hospital stay, food and transportation ranges from Rs.10000 to Rs. 65000 based fractionation size, type of radiation, in patient ward charges. ConclusionsIn a high volume center, single fractionation can be a cost-effective alternative for pain palliation with reduced rates of re-irradiation and radiotherapy machine load. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

Modern Innovative Solutions in Improving Outcomes in Chronic Obstructive Pulmonary Disease (MISSION COPD): Mixed Methods Evaluation of a Novel Integrated Care Clinic.

BackgroundChronic obstructive pulmonary disease (COPD) is the second-leading cause of death in the United Kingdom and accounts for 1.7% of bed days in acute hospitals. An estimated two-third of patients with COPD remain undiagnosed.ObjectiveModern Innovative Solutions in Improving Outcomes in Chronic Obstructive Pulmonary Disease (MISSION COPD) aimed to proactively identify patients from primary care who were undiagnosed or had uncontrolled COPD and to provide a comprehensive integrated multidisciplinary clinic to address the needs of this complex group for improving diagnosis, personalizing therapy, and empowering patients to self-manage their condition.MethodsThis clinic was led by a respiratory specialist team from Portsmouth Hospitals NHS Trust working with five primary care surgeries in Wessex. A total of 108 patients were reviewed, with 98 patients consenting to provide additional data for research. Diagnoses were changed in 14 patients, and 32 new diagnoses were made.ResultsReductions were seen across all aspects of unscheduled care as compared to the prior 12 months, including in emergency general practitioner visits (3.37-0.79 visits per patient, P<.001), exacerbations (2.64-0.56 per patient, P=.01), out-of-hours calls (0.16-0.05 per patient, P=.42), and hospital admissions (0.49-0.12 per patient, P=.48). Improvements were observed in the quality of life and symptom scores in addition to patient activation and patient-reported confidence levels.ConclusionsThis pilot demonstrates that the MISSION model may be an effective way to provide comprehensive gold-standard care that is valued by patients and to promote integration across sectors.

Mortality and deciding factors for no revascularization in cardiogenic shock patients; a cross sectional study

To assess the frequency of acute coronary syndrome patients with cardiogenic shock and not undergoing revascularisation, their in- hospital outcome and reasons underlying management decisions.The retrospective cross-sectional study was conducted at Tabba Heart Institute, Karachi, and comprised data from July 2013 to December 2017 of acute coronary syndrome with hypotension and not having under gone revascularisation. Data was analyzed using Stata 12.1.Of the 383 patients, 55(14.3%) did not undergo revascularisation. Overall mean age was 63.2±9.8years. Overall mortality was 45(81.8%). Revascularisation was intended in 28(51%) patients of whom 19(68%) died before undergoing cardiac catheterisation. Another 9(32%) patients died after cardiac catheterisation but before revascularisation. Common clinical reasons in the remaining 27(49%) patients not considered for revascularisation were hypoxic brain injury secondary to cardiac arrest, patient refusal, perceived patient frailty, multi-organ failure, sepsis or pre-existing stroke/ malignancy.Cardiogenic shock complicating myocardial infarction not treated by revascularization had a very poor early outcome. In the two-third of patients before treatment was initiated, there was cardiac arrest with failed resuscitation or poor recovery.

Assessment of healthcare costs of amputation and prosthesis for upper and lower extremities in a Qatari healthcare institution: a retrospective cohort study

ObjectivesTo evaluate the healthcare cost of amputation and prosthesis for management of upper and lower extremities in a single institute.DesignRetrospective cohort study conducted between 2000 and 2014.ParticipantsAll patients who underwent...

Real World Management of Patients with Acute Myeloid Leukemia: Results from French Cancer Population-Based Registries

Introduction:Cancer registries are required for the analysis of incidence and mortality rates and trends but are also useful as complement to clinical studies to support decision on individual patient management. Acute myeloid leukemia (AML) is more common in older people, with a continuous slow rise in young adulthood turning into rapidly increasing incidence by age from approximately 50 years. Clinical studies have criteria for inclusion and exclusion, which impose selection. This has less implication in younger patients because most of them receive intensive treatment, fewer have secondary AML, and few have severely impaired performance status. Many clinically relevant questions cannot be answered in randomized studies, because of limited patient numbers, problems with randomization, or resource availability.Population-based registries provide a way to achieve new information through the study of geographic differences. Healthcare authorities are interested in geographic variation to ensure equal level of health care for the citizens and the general population to know where to go for the best of care.The aim of this study was to describe the management and outcomes of adult AML patients diagnosed and reported to 3 different regional cancer population-based registries considered representative of the whole French population between years 2006 and 2012.Patients and methods:A total of 1106 patients were available in the 3 registries (446 in Gironde department, 472 in Basse-Normandie, and 188 in Côte d'Or department); 584 (53%) were males, age at diagnosis was comparable between the 3 departments with median of 66 years (range: 18-99), 431 (39%) were less than 65 years old and 437 (39%) were older than 75 years. Therapy-related AML was diagnosed in 126 (11%) patients, cytogenetic analysis was not homogeneously performed among the three departments, and also among those who had it done (N=815, 74%), 29% were normal, and from the remaining with abnormal cytogenetics, 69 (8%) were favorable prognosis, 121 (15%) intermediate, and 359 (44%) were unfavorable.Results:Two-third of patients (N=725, 66%) were followed in university hospitals, 7% in anti-cancer centers and the rest were followed in other hospitals. Among the total population, 915 (83%) were treated for their AML, most of them were <75 years old, and the rest of patients were not treated or received palliative care, only 67% of patients > 75 years were treated. There was no statistical difference in terms of overall survival (OS) between males and females (p=0.99). When stratifying according to age < 60, 60-65, 66-75 and > 75 years, OS probability at 5 years was 50% (95%CI: 44-56), 20% (95%CI: 12-27), 16% (95%CI: 11-21), 2% (95%CI: 1-4) respectively. OS was not different between the 3 departments. Information about inclusion in clinical trials was available for 50% of patients, among them 174 (19%) were included in clinical trials and 284 (31%) not. There was a clear significant survival advantage for patients included in clinical trial independently from age, p<0.001. OS was significantly better for patients treated in university hospitals and anti-cancer centers than those followed in other centers p<0.001. When evaluating the impact of period of treatment, survival outcome significantly improved during years 2010-2012 compared to years 2006-2009, p=0.04 only for patients aged less than 65 years, while patients older than 65 years did not have survival improvement over time, p=0.41. In addition patients who received allogeneic hematopoietic cells transplantation (allo-SCT) had a better OS, p=0.01. In multivariate analysis, age <65 years (HR=0.45, 95% CI: 0.38-0.54, p<0.001), favorable cytogenetics (HR=0.26, 95% CI: 0.15-0.45, p<0.001), unfavorable cytogenetics (HR=1.61, 95% CI: 1.32-1.97, p<0.001) and allo-SCT (HR=0.49, 95% CI: 0.38-0.64, p<0.001) significantly impacted OS.Conclusion:This analysis allowed to point out some disparities in the real world management of AML patients. Interestingly, the fact that survival outcome for patients treated in clinical trials is different from the rest of the population reflects an important point to consider by health authorities. In addition, we observed a lack of improvement over time for older patients that needs more attention. A prognostic evaluation is ongoing to verify patients deemed eligible for allo-SCT to find out among them the proportion of those really transplanted. DisclosuresTroussard:Gilead: Other: scientific advisory board. Michallet:Octapharma: Membership on an entity's Board of Directors or advisory committees; Chugai: Consultancy; Novartis: Research Funding.