Recent advances in the treatment of Ebola disease: A brief overview.

Ebola disease (EBOD) remains a significant and ongoing threat to African countries, characterized by a mortality rate of 25% to 90% in patients with high viral load and significant transmissibility. The most recent outbreak, reported in Uganda in September 2022, was declared officially over in January 2023. However, it was caused by the Sudan Ebola virus (SUDV), a culprit species not previously reported for a decade. Since its discovery in 1976, the management of EBOD has primarily relied on supportive care. Following the devastating outbreak in West Africa from 2014 to 2016 secondary to the Zaire Ebola virus (EBOV), where over 28,000 lives were lost, dedicated efforts to find effective therapeutic agents have resulted in considerable progress in treating and preventing disease secondary to EBOV. Notably, 2 monoclonal antibodies-Ebanga and a cocktail of monoclonal antibodies, called Inmazeb-received Food and Drug Administration (FDA) approval in 2020. Additionally, multiple vaccines have been approved for EBOD prevention by various regulatory bodies, with Ervebo, a recombinant vesicular stomatitis virus-vectored vaccine against EBOV being the first vaccine to receive approval by the FDA in 2019. This review covers the key signs and symptoms of EBOD, its modes of transmission, and the principles guiding supportive care. Furthermore, it explores recent advancements in treating and preventing EBOD, highlighting the unique properties of each therapeutic agent and the ongoing progress in discovering new treatments.

Patterns and predictors of positive multiplex polymerase chain reaction respiratory panel among patients with acute respiratory infections in a single center in Lebanon.

BACKGROUND: Infectious agents associated with community-acquired acute respiratory infections (ARIs) remain understudied in Lebanon. We aim to assess the microbiological profiles of ARIs by employing polymerase chain reaction (PCR) and identifying predictors of positive PCR results among patients admitted for ARI. METHODS AND RESULTS: We conducted a retrospective single-center study at the American University of Beirut Medical Center, including all respiratory PCR panels performed on pediatric (< 18) and adult (≥ 18) patients presenting with an ARI from January 2015 to March 2018, prior to the onset of the COVID-19 pandemic. We aimed to identify the epidemiological patterns of ARIs and the factors associated with positive PCRs in both adult and pediatric patients. Among 281 respiratory PCRs, 168 (59.7%) were positive for at least one pathogen, with 54.1% positive PCR for viruses, 7.8% for bacteria species, and 3.9% with virus-bacteria codetection. Almost 60% of the patients received antibiotics prior to PCR testing. PCR panels yielded more positive results in pediatric patients than in adults (P = 0.005). Bacterial detection was more common in adults compared to pediatrics (P < 0.001). The most common organism recovered in the entire population was Human Rhinovirus (RhV) (18.5%). Patients with pleural effusion on chest CT were less likely to have a positive PCR (95% Cl: 0.22-0.99). On multivariate analysis, pediatric age group (P < 0.001), stem cell transplant (P = 0.006), fever (P = 0.03) and UTRI symptoms (P = 0.004) were all predictive of a positive viral PCR. CONCLUSION: Understanding the local epidemiology of ARI is crucial for proper antimicrobial stewardship. The identification of factors associated with positive respiratory PCR enhances our understanding of clinical characteristics and potential predictors of viral detection in our population.

Valorization of Citrus peels: GC/MS-based metabolites profiling, multivariate analysis, and antiaging potential.

Aging and agro-waste are major challenges. Natural ingredients are preferred in skincare. This study intended to isolate the essential oils (EO) from the leftover peels obtained from three commonly edible Citrus species fruit peels, namely Citrus paradisi (grapefruit), Citrus sinensis (sweet orange), and Citrus deliciosa (mandarin). Gas chromatography/mass spectrometry analysis identified volatile constituents in EO and headspace aroma. Multivariate analysis distinguished between the three species. The antiaging effects of Citrus EO were assessed in vitro and in silico, studying volatile interactions with target enzymes. C. sinensis peels had the highest oil yield, rich in monoterpenes. C. paradisi and C. deliciosa contained sesquiterpenes. Limonene dominated the hydrodistilled EO: 94.50% in C. paradisi, 96.80% in C. sinensis, and 80.66% in C. deliciosa. Unsupervised multivariate analysis of Citrus species revealed that  d-limonene, γ-terpinene, and ß-pinene are the key phytochemical markers contributing to their diverse chemical composition. C. paradisi exhibited the highest enzyme inhibitory activity, with IC50 values of 12.82, 27.58, and 18.16 µg/mL for tyrosinase, elastase, and collagenase, respectively. In silico studies showed that the volatiles can inhibit the tested antiaging enzymes. According to these findings, the investigated agro-waste might slow aging in skin care.

Transient Receptor Potential Channels and Itch.

Transient Receptor Potential (TRP) channels are multifunctional sensory molecules that are abundant in the skin and are involved in the sensory pathways of itch, pain, and inflammation. In this review article, we explore the complex physiology of different TRP channels, their role in modulating itch sensation, and their contributions to the pathophysiology of acute and chronic itch conditions. We also cover small molecule and topical TRP channel agents that are emerging as potential anti-pruritic treatments; some of which have shown great promise, with a few treatments advancing into clinical trials-namely, TRPV1, TRPV3, TRPA1, and TRPM8 targets. Lastly, we touch on possible ethnic differences in TRP channel genetic polymorphisms and how this may affect treatment response to TRP channel targets. Further controlled studies on the safety and efficacy of these emerging treatments is needed before clinical use.

Utilization of Airway Pressure Release Ventilation as a Rescue Strategy in COVID-19 Patients: A Retrospective Analysis.

BACKGROUND: Airway Pressure Release Ventilation (APRV) is a pressure controlled intermittent mandatory mode of ventilation characterized by prolonged inspiratory time and high mean airway pressure. Several studies have demonstrated that APRV can improve oxygenation and lung recruitment in patients with Acute Respiratory Distress Syndrome (ARDS). Although most patients with COVID-19 meet the Berlin criteria for ARDS, hypoxic respiratory failure due to COVID-19 may differ from traditional ARDS as patients often present with severe, refractory hypoxemia and significant variation in respiratory system compliance. To date, no studies investigating APRV in this patient population have been published. The aim of this study was to evaluate the effectiveness of APRV as a rescue mode of ventilation in critically ill patients diagnosed with COVID-19 and refractory hypoxemia. METHODS: We conducted a retrospective analysis of patients admitted with COVID-19 requiring invasive mechanical ventilation who were treated with a trial of APRV for refractory hypoxemia. PaO2/FIO2 (P/F ratio), ventilatory ratio and ventilation outputs before and during APRV were compared. RESULTS: APRV significantly improved the P/F ratio and decreased FIO2 requirements. PaCO2 and ventilatory ratio were also improved. There was an increase in tidal volume per predicted body weight during APRV and a decrease in total minute ventilation. On multivariate analysis, higher inspiratory to expiratory ratio (I: E) and airway pressure were associated with greater improvement in P/F ratio. CONCLUSIONS: APRV may improve oxygenation, alveolar ventilation and CO2 clearance in patients with COVID-19 and refractory hypoxemia. These effects are more pronounced with higher airway pressure and inspiratory time.

Design of an immunohistochemistry biomarker panel for diagnosis of pancreatic adenocarcinoma.

BACKGROUND: Challenges still exist in differentiating pancreatic adenocarcinoma from benign disease. The use of adjuvant testing of tissue biopsies has demonstrated potential diagnostic value. We designed a proof of concept study to first validate four individual immunohistochemistry biomarkers and then combine them into a panel to boost overall diagnostic sensitivity. METHODS: Malignant and benign pancreas from 27 pancreaticoduodenectomy specimens underwent immunohistochemistry staining with VHL, IMP3, S100A4, S100P. Using ROC curve analysis, threshold criteria for number of cells staining were chosen for each biomarker. Biomarkers were then evaluated as a panel for their ability to discriminate malignant from benign specimens. RESULTS: Diagnostic sensitivity of VHL, IMP3, S100A4, and S100P were 75.0%, 79.2%, 45.8%, and 0%. When VHL, IMP3, and S100A4 were grouped into a panel, they were able to distinguish cancer from normal tissue with a sensitivity of 100% and a specificity of 96%. CONCLUSIONS: The high diagnostic value of an IHC panel consisting of VHL, IMP3, and S100A4 on surgical specimens suggests the need for future prospective studies of these biomarkers on biopsy specimens.

Cost-Effectiveness of Sentinel Lymph Node Biopsy for Head and Neck Cutaneous Squamous Cell Carcinoma.

BACKGROUND: Sentinel lymph node biopsy (SLNB) has shown promise in identifying subclinical nodal metastasis in patients with high-risk cutaneous squamous cell carcinoma. However, low metastasis rates may indicate that performing such a procedure in all patients may be unnecessary and costly. MATERIALS AND METHODS: A decision model was developed to analyze costs and survival in patients with head and neck cutaneous squamous cell carcinoma based on their tumor and nodal metastasis staging and whether or not they received an SLNB. Incremental cost-effectiveness ratios were calculated based on the change in quality-adjusted life years (QALYs) and costs (US$) between the different options, with a threshold of $100,000 to determine the most cost-effective strategy. One-way, two-way, and probabilistic sensitivity analyses were performed to validate the results. RESULTS: Not performing an SLNB results in 12.26 QALYs and a cost of $3712.98. Performing an SLNB resulted in a 0.59 decrease in QALYs and an increase in cost of $1379.58 for an incremental cost-effectiveness ratio of -2338.27. This trend remained the same across all tumor stages and remained consistent within most sensitivity analyses. CONCLUSIONS: In patients with head and neck cutaneous squamous cell carcinoma, the most cost-effective strategy is to not perform SLNBs, regardless of the patient's stage. Low rates of nodal metastasis in addition to low disease-specific death rates were the significant factors in this outcome. Increasing the sensitivity of SLNB would not impact this recommendation unless the rate of nodal metastasis was significantly higher.

Revisiting Milan cervical cancer study: Do the original findings hold in the era of chemotherapy?

BACKGROUND: The primary treatment of early stage cervical carcinoma (IB-IIA) is either surgery or radiation therapy based on the pivotal Milan randomized study published twenty years ago. In the presence of high-risk features, the gold standard treatment is concurrent chemotherapy and radiation therapy (CRT) whether it is the in the postoperative or the definitive setting. Using the National Cancer Data Base (NCDB), the goal of our study is to compare the outcomes of surgery and radiation therapy in the chemotherapy era. METHODS: Between 2004 and 2013, 5478 patients diagnosed with early stage cervical cancer were divided into 2 groups based on their primary treatment: non-surgical (n=1980) and surgical groups (n=3498). The distribution of patient/tumor characteristics and treatment variables with their relation to overall survival and proportional regression models were assessed to investigate the superiority of one approach over the other. Propensity score analysis adjusted for imbalance of covariates to create a well-matched-patient cohort. FINDINGS: At 46months median follow-up, the 5-year overall survival was similar between both groups (73·8% vs. 75.7%; p=0.619) after applying propensity score analysis. On multivariate analysis, high Charlson comorbidity score, stage IIA disease, larger tumor size, positive lymph nodes and high-grade disease were significant predictors of poor outcome while older age and treatment approach were not. INTERPRETATION: Our analysis suggests that surgery (followed by adjuvant RT or CRT) and definitive radiotherapy (with or without chemotherapy) result in equivalent survival. Prospective studies are warranted to establish this paradigm in the chemotherapy era.

Can chemotherapy boost the survival benefit of adjuvant radiotherapy in early stage cervical cancer with intermediate risk factors? A population based study.

PURPOSE: The Gynecologic Oncology group (GOG) 0263 trial is currently exploring whether adding chemotherapy to adjuvant radiotherapy improves recurrence-free and/or overall survival in stage IB-IIA cervical cancer patients with pathologic intermediate-risk factors. Using the National Cancer Data Base, we evaluated the benefit of adjuvant chemoradiotherapy over adjuvant radiotherapy alone in the community practice setting. MATERIALS: The analysis included 869 stage IB-IIA cervical cancer patients who underwent radical hysterectomy retrieving intermediate-risk factors justifying adjuvant therapy. Adjuvant chemoradiotherapy and adjuvant radiotherapy were delivered in 440 and 429 patients, respectively. Chi-square test assessed the distribution of variables in each group and the overall survival was estimated using the Kaplan-Meier method. Proportional hazard models were performed to evaluate the impact of the different prognostic factors on survival and propensity score analysis adjusted variables imbalanced distribution. RESULTS: Adding chemotherapy to ART did not show a survival benefit at 48months median follow-up; the 5-year overall survival was 87% and 81% (p=0.6) in the adjuvant chemoradiotherapy and adjuvant radiotherapy groups, respectively. On univariate analysis, age older than 60, a higher comorbidity score, and stage IIA were significantly associated with worse survival, while none of the other covariates were significant prognosticator on multivariate analysis. The same findings held after propensity score analysis. CONCLUSION: Our analysis could not detect a significant survival benefit for adjuvant chemoradiotherapy over adjuvant radiotherapy in women with intermediate-risk factors. Until GOG 0263 results become available, the benefits of adjuvant chemoradiotherapy should be considered on an individual basis within a multidisciplinary approach.

Intrathoracic extensive-stage small cell lung cancer: assessment of the benefit of thoracic and brain radiotherapy using the SEER database.

BACKGROUND: Extensive-stage small cell lung cancer (ESCLC) includes metastatic disease and locally advanced disease confined to the thorax that cannot be encompassed in a typical radiation portal. We assessed and then compared the benefits of thoracic radiotherapy (TRT) and/or brain radiotherapy (BRT) on overall survival (OS) between the intrathoracic (T-ESCLC) and metastatic (M-ESCLC) groups using the Surveillance Epidemiology and End Results database. METHODS: TRT and BRT data were available for 10150 patients treated from 1988-1997. The T-ESCLC group included 1774 patients. The Kaplan-Meier method was used to estimate OS and the proportional hazards model was used to estimate OS hazard ratios for prognostic factors including age, gender, race, tumor size, T/N stage, TRT, and BRT. RESULTS: The 2-year OS for T-ESCLC was 7.8 % compared to 3 % in the M-ESCLC group (p < 0.001). In the T-ESCLC group, TRT and BRT were delivered to 750 and 102 patients, respectively. The 2-year OS was 13 % in the TRT group compared to 4.1 % in the no-TRT group (p ≤ 0.001) and 22.5 % in the BRT group compared to 7 % in the no-BRT group (p < 0.001). In the M-ESCLC group, TRT and BRT were delivered to 3093 and 1887 patients, respectively. The 2-year OS was 4.4 % in the TRT group compared to 2.8 % in the no-TRT group (p < 0.001) and 4.3 % in the BRT compared to 2.6 % in the no-BRT group (p < 0.001). Age, gender, TRT and BRT were significant OS prognostic factors in both groups. CONCLUSIONS: Our study suggests that T-ESCLC is a disease entity distinct from M-ESCLC. Prospective studies to determine whether TRT should be recommended for the thoracic-only subgroup are warranted.

Breast Molecular Profiling and Radiotherapy Considerations.

The last decade has seen major changes in the management of breast cancer. Heterogeneity regarding histology, therapeutic response, dissemination patterns, and patient outcome is evident. Molecular profiling provides an accurate tool to predict treatment outcome compared with classical clinicopathologic features. The genomic profiling unveiled the heterogeneity of breast cancer and identified distinct biologic subtypes. These advanced techniques were integrated into the clinical management; predicting systemic therapy benefit and overall survival. Utilizing genotyping to guide locoregional management decisions needs further characterization. In this chapter we will review available data on molecular classification of breast cancer, their association with locoregional outcome, their radiobiological properties and radiotherapy considerations.

The evolution of regional nodal irradiation in breast cancer.

Breast cancer regional node management has witnessed many changes over the last decade. Advances in surgical techniques establishing sentinel lymph node biopsy as an alternative to axillary dissection, use of microarray technology for subtyping breast cancer to guide systemic therapy selection, and the expansion of the systemic therapy armamentarium including targeted agents have contributed to changing our strategy from one size fits all to a more tailored approach. There have also been recent landmark studies reported that significantly impact clinical practice in the regional nodal management of breast cancer. As the molecular era of personalized medicine is approaching, we hereby revisit the rational, benefit, and controversies of regional nodal irradiation in the light of the most recent publications.

Crossed pulmonary arteries with double aortic arch: a rare association.

Crossed pulmonary arteries is a rare, benign congenital anomaly. Both pulmonary arteries cross each other on their course to each respective lung, thus forming a crisscross pattern. We report an infant with crossed pulmonary arteries and a complete vascular ring formed by double aortic arch.

Intravenous difelikefalin for the treatment of hemodialysis pruritus.

INTRODUCTION: Patients with chronic kidney disease (CKD) undergoing hemodialysis often experience significant itch secondary to their condition and a subsequent reduction in their overall quality of life. Current treatments are underwhelming, necessitating the search for new, effective therapeutic options to combat itch in this population. AREAS COVERED: The purpose of this review is to explore the available data for the use of intravenous difelikefalin in patients with CKD undergoing hemodialysis. The pathophysiology of CKD-associated itch is multifactorial, with one proposed mechanism involving an imbalance in the endogenous opioid system, favoring upregulation of itch-activating µ-opioid receptors (MORs) and downregulation of itch-inhibiting κ-opioid receptors (KORs). Dysregulation of the immune system is also involved. Difelikefalin is a recent FDA approved treatment that functions as peripherally acting KOR agonist, targeting this imbalance in the endogenous opioid system seen in CKD patients with itch and having an anti-inflammatory effect on immune cells. Clinical data on intravenous difelikefalin is promising regarding its ability to reduce itch in CKD patients on hemodialysis and improve patient quality of life, with few, mild adverse side effects. EXPERT OPINION: As intravenous difelikefalin becomes more widely used in the clinical setting, further studies assessing long-term efficacy and safety will be needed.

Novel Topical Treatments for Itch.

The experience of itch often poses a burden on patient quality of life and has the capacity to inflict significant suffering. Topical therapies are a mainstay of treatment for many cutaneous and systemic diseases and afford patients the opportunity to manage their conditions without many of the systemic side effects of non-topical therapies. We review a multitude of new topical medications targeting the skin, immune system, and neural receptors. The list includes Janus kinase inhibitors, tyrosine kinase inhibitors, phosphodiesterase inhibitors, transient receptor vanilloid inhibitors, topical cannabinoids, and topical acetaminophen. Many of the topical therapies reviewed show promising data in phase 2-3 clinical trials, but further research is needed to compare therapies head-to-head and test their efficacy on a broader range of conditions.

Locally Advanced Gastric Cancer Management: A Cost-Effectiveness Analysis.

Across the nation, patients with locally advanced gastric cancer (LAGC) are managed with modalities including upfront surgery (US) and perioperative chemotherapy (PCT). Preoperative therapies have demonstrated survival benefits over US and thus long-term outcomes are expected to vary between the options. However, as these 2 modalities continue to be regularly employed, we sought to perform a decision analysis comparing the costs and quality-of-life associated with the treatment of patients with LAGC to identify the most cost-effective option. We designed a decision tree model to investigate the survival and costs associated with the most commonly utilized management modalities for LAGC in the United States: US and PCT. The tree described costs and treatment strategies over a 6-month time horizon. Costs were derived from 2022 Medicare reimbursement rates using the third-party payer perspective for physicians and hospitals. Effectiveness was represented using quality-adjusted life-years (QALYs). One-way, two-way, and probabilistic sensitivity analyses were utilized to test the robustness of our findings. PCT was the most cost-effective treatment modality for patients with LAGC over US with a cost of $40,792.16 yielding 3.11 QALYs. US has a cost of $55,575.57 while yielding 3.15 QALYs; the incremental cost-effectiveness ratio (ICER) was $369,585.25. One-way and two-way sensitivity analyses favored PCT in all variations of variables across their standard deviations. Across 100,000 Monte Carlo simulations, 100% of trials favored PCT. In our model simulating patients with LAGC, the most cost-effective treatment strategy was PCT. While US demonstrated improved QALYs over PCT, the associated cost was too great to justify its use.

Burden of Disease and Unmet Needs in the Diagnosis and Management of Atopic Dermatitis in the Arabic Population of the Middle East.

Atopic dermatitis (AD) affects diverse ethnic groups with significant disparities in prevalence, disease progression, clinical outcomes, and access to care. There are limited data on AD in the Arabic population of the Middle East, yet there is a substantial economic and psychosocial burden of AD in this region with a large unmet need with regards to disease management that is critical to address. There is a trend of increasing prevalence of AD in the Arab Middle East; however, due to the large environmental, socioeconomic, and sociocultural heterogeneity of this region, prevalence varies greatly across and within countries. Similarly, clinical differences in disease presentations exist across the region, although data are limited. In this review, we will present clinical phenotypes of AD common in different regions of the Arab Middle East, and data on prevalence, genetic variations, and challenges of treatment. Further studies exploring molecular biomarkers, genetic polymorphisms, immune factors, and the microbiome of patients in the region will help to elucidate the mechanism behind ethnic differences in AD in this population as well as to understand susceptibilities and treatment response.

Current and Emerging Therapies for Chronic Spontaneous Urticaria: A Narrative Review.

Chronic spontaneous urticaria (CSU) is a condition in which wheals, angioedema, and pruritus occur spontaneously and recurrently for at least 6 weeks. The etiology of this disease is partially dependent on production of autoantibodies that activate and recruit inflammatory cells. Although the wheals can resolve within 24 h, symptoms have a significant detrimental impact on the quality of life of these patients. Standard therapy for CSU includes second-generation antihistamines and omalizumab. However, many patients tend to be refractory to these therapies. Available treatments such as cyclosporine, dapsone, dupilumab, and tumor necrosis factor alpha (TNFa) inhibitors have been used with success in some cases. Furthermore, various biologics and other novel drugs have emerged as potential treatments for this condition, and many more are currently under investigation in randomized clinical trials.

Prevalence of Chronic Pruritus in Elderly Black and White Inpatients: A Comparative Population Study.

BACKGROUND: Black and geriatric patients were reported in small scale studies to have more intense chronic pruritus (CP). Studies comparing itch across geriatric racial groups are lacking. OBJECTIVES: To compare the prevalence of CP in Black and White inpatients ≥ 65 years old as well as the top primary diagnoses of these populations. METHODS: We used data from the National Inpatient Sample from 2016-2019 to analyze CP prevalence and ICD10-CM to identify diseases. The top five primary diagnoses were calculated for a subpopulation with CP. Sample characteristics were described, and the data was pooled and analyzed using IBM SPSS® Complex Sample modules. RESULTS: Among hospitalized Black inpatients ≥ 65 years old, the prevalence of CP was 0.26% while in the White cohort it was 0.22%. The top five primary diagnoses in the Black population with itch were sepsis (4.2%); hypertensive heart and chronic kidney disease (CKD) with heart failure (HF) and stage 1-4 CKD, or unspecified CKD (4.1%); acute kidney failure (4.0%); hypertensive heart and CKD with HF with stage 5 CKD, or end-stage renal disease (2.1%); and hypertensive heart disease with HF (1.7%). The top five primary diagnoses in the White population were sepsis (4.25%); acute kidney failure (3.0%); hypertensive heart and CKD with HF and stage 1-4 CKD, or unspecified CKD (2.5%); cellulitis of left lower limb (1.9%); and unilateral primary osteoarthritis, right knee (1.9%). CONCLUSIONS: Geriatric hospitalized Black patients demonstrated a higher prevalence of chronic itch compared with the White cohort, which may be related to the higher prevalence of chronic kidney disease in different stages of severity in this population.

Itch: from the skin to the brain - peripheral and central neural sensitization in chronic itch.

Similar to chronic pain, chronic itch is frequently linked to neural sensitization, a phenomenon wherein the nervous system becomes hypersensitive to stimuli. This process of neural sensitization of chronic itch is orchestrated by various signaling pathways and mediators in both the peripheral and central nervous systems. At the level of the peripheral nervous system, inflammation and neuroimmune interactions induce plastic changes to peripheral nerve fibers, thereby amplifying the transmission of itch signaling. Neural sensitization in the central nervous system occurs at both the spinal cord and brain levels. At the level of the spinal cord, it involves hyperactivity of itch-activating spinal pathways, dysfunction of spinal inhibitory circuits, and attenuation of descending supraspinal inhibitory pathways. In the brain, neural sensitization manifests as structural and functional changes to itch-associated brain areas and networks. Currently, we have a diverse array of neuroimmune-modulating therapies targeting itch neural sensitization mechanisms to help with providing relief to patients with chronic itch. Itch research is a dynamic and continually evolving field, and as we grow in our understanding of chronic itch mechanisms, so will our therapeutic toolbox. Further studies exploring the peripheral and central neural sensitization mechanisms in the context of chronic itch are needed.