Are people with disabilities at higher risk of COVID-19-related mortality?: a systematic review and meta-analysis.

OBJECTIVES: To undertake a systematic review and meta-analysis to estimate the relative risk of COVID-19-related mortality among people with disabilities compared to people without disabilities. STUDY DESIGN: Systematic review and meta-analysis. METHODS: We systematically searched four databases from March 1, 2020, to August 15, 2022. We included prospective studies with a baseline assessment of disability and a longitudinal assessment of the COVID-19-related mortality. Two reviewers independently assessed study eligibility, extracted data, and assessed risk of bias. We undertook random-effects meta-analyses to calculate pooled adjusted hazard ratios for COVID-19-related mortality for people with disabilities, also disaggregated by disability type and study setting. RESULTS: We identified 2596 articles throughout the electronic data search, and 56 studies were included in the review. Most (73%) had a moderate risk of bias. The pooled adjusted effect estimate for COVID-19-related mortality in people with disabilities compared to those without was 2.7 (95% confidence interval [CI]: 2.4-3.2). Heterogeneity between the studies was high (τ2 = 0.28, I2 = 97%). Effect estimates were highest for population-based samples (3.3, 95% CI: 2.7-3.9), compared to hospital settings (2.1, 95% CI: 1.7-2.7). Risk was not elevated among people with disabilities in care home settings (1.6, 95% CI: 0.7-3.5). Disaggregation by disability type showed that people with intellectual disabilities were at the highest relative risk of COVID-19 mortality. DISCUSSION: Risk of COVID-19 mortality is elevated among people with disabilities, especially people with intellectual disabilities. Efforts are needed to collect better routine data on disability and to include people with disabilities in the pandemic response for COVID-19.

Access to health care for people with stroke in South Africa: a qualitative study of community perspectives.

BACKGROUND: Incidence of stroke is increasing in sub-Saharan Africa. People who survive stroke experience disability and require long-term care. Health systems in South Africa (SA) are experiencing important challenges, and services in the public health system for people with stroke (PWS) are fragmented. We aimed to explore the perspectives and experiences of PWS related to stroke care services to inform health system strengthening measures. METHODS: In-depth interviews with 16 PWS in urban and rural areas in the Western and Eastern Cape Provinces of SA were conducted between August and October 2020. PWS were recruited through existing research networks, non-government organisations and organisations of persons with disabilities by snowball sampling. Interviews were transcribed, coded, and thematically analysed. We used the conceptual framework of access to health care as proposed by Levesque et al. to map and inform barriers to accessing health care from the user perspective. RESULTS: PWS recognised the need for health care when they experienced signs of acute stroke. Health literacy on determinants of stroke was low. Challenges to accessing stroke care include complex pathways to care, physical mobility related to stroke, long travel distances and limited transport options, waiting times and out of pocket expenses. The perceived quality of services was influenced by cultural beliefs, attitudinal barriers, and information challenges. Some PWS experienced excellent care and others particularly poor care. Positive staff attitude, perceived competence and trustworthiness went in hand with many technical and interpersonal deficits, such as long waiting times and poor staff attitude that resulted in poor satisfaction and reportedly poor outcomes for PWS. CONCLUSIONS: Strategic leadership, governance and better resources at multiple levels are required to address the unmet demands and needs for health care of PWS. Stroke care could be strengthened by service providers routinely providing information about prevention and symptoms of stroke, treatment, and services to patients and their social support network. The role of family members in continuity of care could be strengthened by raising awareness of existing resources and referral pathways, and facilitating connections within services.

Iliac arterial-enteric fistulas occurring after pelvic irradiation.

Fistulas from the iliac artery to the bowel constitute a condition that is often lethal. Excluding fistulas related to vascular grafts, a review of previously reported cases shows that they are most often due to atherosclerotic iliac aneurysms. Three unusual cases of this condition that occurred after high-dose pelvic irradiation for treatment of cancer are presented; in no case was recurrent tumor evident. These cases suggest that high-dose pelvic irradiation can predispose to the formation of iliac arterial-enteric fistulas, particularly if sepsis or inflammation develops. The definitive surgical management of these fistulas entails bowel resection, arterial ligation, and extra-anatomic bypass.

Phase-II trial of tamoxifen in advanced breat cancer.

Seventy-eight advanced breast cancer patients, most of whom had had prior treatment, were treated with the synthetic antiestogen tamoxifen. The overall objective response rate was 27% (21/78). An additional 19% (15/78) showed disease stabilization. Sixty-seven percent (14/21) of the responses were in soft tissue sites, 24% (5/21) on bony sites and one each occurred in liver and nodular lung disease. Forty percent of patients with soft-tissue disease alone responded, while less than 10% of patients with visceral disease showed responses in visceral sites. The response rate was 28% among patients with a known positive estrogen receptor (ER) assay. It was 21% among patients who had previously received cytotoxic drugs. Toxicity was mild and was seen in nausea and vomiting, hot flushes and vaginal bleeding, and occasional myelosuppression. One patient was withdrawn from the study because of a rash. In two patients the disease flared, once with concomitant hypercalcemia. Tamoxifen is a useful agent for advanced breast cancer even in some patients with visceral disease.

Germinal vesicle breakdown is not fully dependent on MAPK activation in maturing oocytes of marine nemertean worms.

Previously, it has been shown that oocytes of marine nemertean worms resume meiosis and undergo germinal vesicle breakdown (GVBD) following treatment with either natural seawater (NSW), or the neurohormone serotonin (5-hydroxytryptamine or 5-HT). In this investigation of the nemerteans Cerebratulus lacteus and Cerebratulus sp., immunoblots and kinase assays were used to compare the roles of two regulatory kinases: mitogen-activated protein kinase (MAPK) and Cdc2/cyclin B (referred to as maturation promoting factor or MPF). Based on such analyses, an ERK (extracellular signal regulated kinase) type of MAPK was found to be activated concurrently with Cdc2/cyclin B during NSW- and 5-HT-induced maturation. MAPK activation occurred prior to GVBD and seemed to be controlled primarily by phosphorylation rather than de novo protein synthesis. Inhibition of MAPK signaling by U0126 was capable of delaying but not permanently blocking Cdc2/cyclin B activation and GVBD in 5-HT treated oocytes and subsets of NSW-treated oocytes. Collectively such data indicated that GVBD is not fully dependent on MAPK activation, since Cdc2/cyclin B can apparently be activated by MAPK-independent mechanism(s) in maturing nemertean oocytes.

5-HT causes an increase in cAMP that stimulates, rather than inhibits, oocyte maturation in marine nemertean worms.

In the nemertean worms Cerebratulus lacteus and Micrura alaskensis, 5-HT (=5-hydroxytryptamine, or serotonin) causes prophase-arrested oocytes to mature and complete germinal vesicle breakdown (GVBD). To identify the intracellular pathway that mediates 5-HT stimulation, follicle-free oocytes of nemerteans were assessed for GVBD rates in the presence or absence of 5-HT after being treated with various modulators of cAMP, a well known transducer of 5-HT signaling and an important regulator of hormone-induced maturation in general. Unlike in many animals where high levels of intra-oocytic cAMP block maturation, treatment of follicle-free nemertean oocytes with agents that elevate cAMP (8-bromo-cAMP, forskolin or inhibitors of phosphodiesterases) triggered GVBD in the absence of added 5-HT. Similarly, 5-HT caused a substantial cAMP increase prior to GVBD in nemertean oocytes that had been pre-injected with a cAMP fluorosensor. Such a rise in cAMP seemed to involve G-protein-mediated signaling and protein kinase A (PKA) stimulation, based on the inhibition of 5-HT-induced GVBD by specific antagonists of these transduction steps. Although the downstream targets of activated PKA remain unknown, neither the synthesis of new proteins nor the activation of MAPKs (mitogen-activated protein kinases) appeared to be required for GVBD after 5-HT stimulation. Alternatively, pre-incubation in roscovitine, an inhibitor of maturation-promoting factor (MPF), prevented GVBD, indicating that maturing oocytes eventually need to elevate their MPF levels, as has been documented for other animals. Collectively, this study demonstrates for the first time that 5-HT can cause immature oocytes to undergo an increase in cAMP that stimulates, rather than inhibits, meiotic maturation. The possible relationship between such a form of oocyte maturation and that observed in other animals is discussed.

Multiple triggers of oocyte maturation in nemertean worms: the roles of calcium and serotonin.

To analyze the process of oocyte maturation in nemertean worms, oocytes with a large nucleus (=germinal vesicle, or GV) were removed from gravid ovaries of Cerebratulus lacteus and Micrura alaskensis. Following transfer to natural seawater (NSW), fully grown oocytes spontaneously matured as indicated by their completion of germinal vesicle breakdown (GVBD), whereas GVBD was reversibly blocked if the oocytes were initially placed in calcium-free seawater (CaFSW). Similarly, calcium ionophore treatments triggered GVBD in calcium-containing artificial seawater (ASW) but not in CaFSW, suggesting that external calcium influx may facilitate maturation. However, compared to the overall levels of maturation elicited by ASW, significantly higher percentages of GVBD were achieved with NSW or with ASW that had been conditioned with marine sediment. Moreover, calcium channel blockers decreased GVBD rates in ASW but not in NSW, which is consistent with the view that substances other than external calcium ions can trigger maturation. Accordingly, oocytes underwent equally high levels of GVBD when treated with serotonin (=5-hydroxytryptamine, or 5-HT) in ASW or CaFSW. The 5-HT-induced maturation was blocked by inhibitors of 5-HT receptors but continued to occur in the presence of calcium channel blockers or the calcium chelator BAPTA. In addition, oocytes microinjected with fluorescent calcium indicators underwent GVBD in response to 5-HT without displaying marked calcium transients during confocal imaging runs. Collectively, such findings suggest that nemertean oocytes can mature via multiple pathways that may include external calcium influx or a 5-HT-induced signaling cascade that lacks prominent calcium fluctuations. J. Exp. Zool. 287:243-261, 2000.

Calcium and endoplasmic reticulum dynamics during oocyte maturation and fertilization in the marine worm Cerebratulus lacteus.

To monitor calcium and endoplasmic reticulum (ER) dynamics during oocyte maturation and fertilization, oocytes of the marine worm Cerebratulus lacteus were injected with the calcium-sensitive indicator calcium green dextran and/or the ER-specific probe "DiI." Based on time-lapse confocal imaging of such specimens, prophase-arrested immature oocytes failed to develop normally after insemination and typically produced non-wave-like calcium transients that were lower in amplitude and less persistent than the wave-like oscillations observed during fertilizations of mature oocytes. Accordingly, the ER of DiI-loaded immature oocytes lacked an obvious substructure, whereas ER clusters, or "microdomains," began to form in maturing specimens at about the time that these oocytes became competent to undergo normal fertilization-induced calcium dynamics and cleavage. The ER microdomains of mature oocytes typically reached widths of 1-8 micrometer and disappeared approximately 1 h after fertilization, which in turn coincided with the termination of the calcium oscillations. Collectively, these findings indicate: (i) changes in ER structure are temporally correlated with the onset and cessation of the calcium oscillations required for subsequent cleavage, and (ii) such ER reorganizations may play an important role in early development by enabling mature oocytes to generate a normal calcium response.

Phase I clinical trial of spirogermanium.

Spirogermanium is a new azaspirane antitumor agent, with the metal germanium substituted for a one-carbon moiety in the ring structure. This drug inhibits DNA and RNA synthesis in HeLa cells, is cytotoxic in vitro, and has curative in vivo antitumor activity against the ascitic Walker 256 carcinosarcoma in rats. No hematologic toxicity was recorded during the preclinical toxicologic evaluation. The principal clinical toxic effects observed in this phase I trial were neurologic, manifested as lethargy, dizziness, and ataxia, while a grand mal seizure was produced after an accidental overdose. There was no evidence of hematologic, renal, or hepatic toxicity. A partial response was achieved in a patient with a well-differentiated lymphocytic lymphoma. We recommend that phase II trials be conducted with a twice or thrice weekly dose of 50-80 mg/m2, administered in a 30-minute iv infusion.

Phase II trial of streptozotocin, mitomycin-C and 5-fluorouracil (SMF) in the treatment of advanced pancreatic cancer.

Ten of 23 patients with advanced measureable adenocarcinoma of the pancreas achieved an objective response after treatment with a regimen consisting of streptozotocin, mitomycin-C and 5-fluorouracil (SMF). The median duration of response is in excess of 7 months and responding patients have lived significantly longer than patients with progressive disease (7.5 + months vs. 3 months). The SMF regimen was adequately tolerated. Principal toxicities included myelosuppression, which was generally mild, nausea and vomiting. There was reversible nephrotoxicity in the form of proteinuria in 30% of patients and persistent axotemia in 9% of patients.

5-fluorouracil, adriamycin, and mitomycin-C (FAM) combination chemotherapy in the treatment of advanced gastric cancer.

Thirty-six patients with advanced measurable gastric cancer were treated with a new combination chemotherapy program consisting of 5-fluorouracil, Adriamycin and mitomycin-C (FAM). Fifty percent of patients achieved an objective partial response. The median duration of remission was 9.5 months and the median survival for responding patients was 13.5 months, with 2 remaining alive at 14 and 26 months. The median survival for nonresponding patients was 3.0 months and all were dead by 6 months after initiation of therapy. The median survival of all 36 patients treated with FAM was 5.5 months. An analysis of possible prognostic variables including initial performance status, resectability of the primary gastric tumor and histologic differentiation of the neoplasm failed to account for differences in patient response and survival. The FAM regimen was well tolerated, and produced only moderate bone marrow suppression. These results demonstrate that some patients with advanced gastric cancer can be effectively palliated with FAM chemotherapy. Phase III trials are warranted to assess the effect of the FAM regimen on the survival of patients with advanced gastric cancer.

5-Fluorouracil (5-FU), methyl-CCNU, and vincristine in the treatment of advanced colorectal cancer: phase II study utilizing weekly 5-FU.

We report a phase II trial of 5-fluorouracil (5-FU), methyl-CCNU, and vincristine (FMV) combination chemotherapy in advanced colorectal carcinoma. Ten of 25 patients (40%) achieved an objective tumor regression after treatment with FMV chemotherapy. The main toxicities of FMV were hematologic and gastrointestinal. 5-FU was administered in a weekly rather than a loading-dose schedule which allowed for sensitive adjustment of drug dosages according to hematologic toxicity; only 16% of the patients (four of 25) had a wbc count less than 2000 cells/mm3. FMV is significantly more active than 5-FU alone in the treatment of advanced colorectal cancer; however this regimen does not significantly improve survival in responding patients.

5-Fluorouracil, doxorubicin, and mitomycin (FAM) combination chemotherapy for advanced gastric cancer.

Sixty-two patients with advanced measurable gastric cancer were treated with a combination chemotherapy program of 5-fluorouracil, doxorubicin, and mitomycin (FAM). Forty-two percent of patients achieved an objective partial response. The median duration of remission was 9 months and the median survival for responding patients, 12.5 months. The median survival for nonresponding patients was 3.5 months; all patients were dead by 8 months after initiation of therapy. The median survival of all 62 patients treated with FAM was 5.5 months. An analysis of possible prognostic variables including initial performance status, resectability of the primary gastric tumor, and histologic differentiation of the neoplasm failed to account for differences in patient response and survival. The FAM regimen was well tolerated, producing only moderate bone marrow suppression. These results show that patients with metastatic gastric cancer can be effectively palliated with FAM chemotherapy. The efficacy of this regimen should now be tested in patients with less advanced stages of this disease.

A phase II trial of ftorafur: adriamycin and mitomycin-C (FAM II) in advanced gastric adenocarcinoma.

Fifteen patients with advanced gastric cancer were treated with the combination of Ftorafur, Adriamycin and mitomycin-C (FAM II). Three patients showed partial responses, in five the disease remained stable for at least 3 months and seven showed progression while on treatment. All responding patients showed survival in excess of 12 months. Hematologic toxicity was of only moderate severity. Median white count nadir was 3500 cells/mm3 and median platelet nadir was 187,000 cells/mm3. Four patients had white count nadirs from 2000--2500 cells/mm3 and three had nadirs from 500--1500 cells/mm3; also there were four with platelet nadirs less than 100,000/mm3. However, no drug-related infections occurred and no platelet transfusions were required. The major non-hematologic toxicities of the regimen were nausea, vomiting, dizziness, vertigo, and rhinorrhea. These toxicities were limiting and resulted in termination of the trial because of poor patient acceptance and the failure of the combination to exhibit a therapeutic advantage over the similar combination (FAM) that employed weekly 5-fluorouracil in place of Ftorafur.