Disparities in Outcomes of Hospitalizations Due to Multiple Myeloma: A Nationwide Comparison.

Background With the advent of novel treatments, there is a declining trend in the multiple myeloma (MM) mortality rate with an increasing hospitalization rate. However, there is limited population-based data on trends and outcomes of hospitalizations due to MM in the United States (US). Methods We analyzed the publicly available Nationwide Inpatient Sample (NIS) from 2007 to 2017 to identify MM hospitalizations. Results Hospitalizations for MM increased from 17,100 (8.71%) in 2007 to 19,490 (9.92%) in 2017. The in-hospital mortality rate declined from 8.4% in 2007 to 4.9% in 2017 (P <0.001) and discharge to facilities decreased from 20.4% in 2007 to 17.4% in 2017 (P <0.001). The odds of in-hospital mortality were higher with increasing age (odds ratio (OR): 1.46; 95% confidence interval (CI): 1.38 -1.54; P <0.0001), pneumonia (OR: 4.18; 95% CI: 3.63 - 4.81, P <0.0001), septicemia (OR: 2.50; 95% CI: 2.22 - 2.82; P <0.0001), renal failure (OR: 1.48; 95% CI: 1.34 -1.64; P <0.0001), uninsured/self-pay insurance status (OR: 2.69; 95% CI: 2.18 - 3.3; P <0.0001), rural hospital (OR: 2.26; 95% CI: 1.88 -2.72; P<0.0001), and urban-non-teaching hospitals (OR: 1.38; 95% CI: 1.23 - 1.56; P <0.0001). Also, increasing age (OR: 1.14; 95% CI: 1.11-1.18, P <0.0001), Black race (OR: 1.12; 95% CI: 1.02-1.23, P <0.0001), and multiple comorbidities were associated with higher disability. Conclusion Hospitalizations for MM continued to increase, whereas in-hospital mortality continued to decrease. Advanced age, sepsis, pneumonia, and renal failure were associated with higher odds of mortality in MM patients.

Brain Metastases With Malignant Peritoneal Mesothelioma: Never Reported Before.

Malignant mesothelioma is a very rare diagnosis. Malignant mesotheliomas arise from surface linings of pleura, peritoneal cavity, or tunica vaginalis and pericardium with pleural malignant mesotheliomas being the most common. The incidence of brain metastases has been very low with malignant pleural mesotheliomas, but to date, there have not been any cases reported of brain metastasis with malignant peritoneal mesotheliomas. We present a patient diagnosed with malignant peritoneal mesothelioma and was successfully treated with immunotherapy for over two years but later presented with brain metastases. Although the patient had a surgical resection followed by brain radiation, he died three months after his diagnosis of brain metastases. Immunotherapy has revolutionized the treatment of malignant mesothelioma, and patients are living longer than before. We present this patient to increase awareness of brain metastases with malignant peritoneal mesothelioma. This case also highlights that we need to investigate different treatment options for brain metastases in patients with malignant mesothelioma as conventional treatment options like surgical resection and brain radiation are not very effective.

Developmental Venous Anomaly Presenting as an Acute Stroke Mimic.

Several mimics of acute ischemic stroke may complicate the decision to administer intravenous thrombolysis. Developmental venous anomalies (DVA) are fairly common variants of normal cerebral vasculature and may occasionally present with acute focal neurologic symptoms. We report a case of DVA presenting with the acute onset of focal neurologic deficits and focal hypodensities on the CT of the brain, resulting in a dilemma regarding whether to administer intravenous tissue-type plasminogen activator (IV tPA) for stroke thrombolysis. Recognition of subtle brain changes on the CT that were inconsistent with an acute ischemic stroke led to further imaging and a definitive diagnosis. Developmental venous anomalies should be considered in the differential diagnosis of acute ischemic stroke.

Temporal Trends, Predictors, and Outcomes of Disseminated Intravascular Coagulation in Hospitalizations With Sepsis.

Background This retrospective study was conducted to analyze the temporal trends, predictors, and impact of disseminated intravascular coagulation (DIC) on outcomes among septicemic patients using a nationally representative database. Methods We derived data from the National Inpatient Sample (NIS) for the years 2008-2017 for adult hospitalizations due to sepsis. The primary outcomes were in-hospital mortality and discharge to facility. The Cochran-Armitage test and multivariable survey logistic regression models were used to analyze the data. Results Out of 12,820,000 hospitalizations due to sepsis, 153,181 (1.18%) were complicated by DIC. The incidence of DIC decreased from 2008 to 2017. In multivariable regression analysis, demographics and comorbidities were associated with higher odds of DIC. During the study period, in-hospital mortality among patients with sepsis decreased, but the attributable risk percent of in-hospital mortality due to DIC increased. We observed similar trends for discharge to facility; however, the adjusted odds of discharge to facility due to DIC remained stable over the study period. Conclusion Although the incidence of sepsis complicated by DIC decreased, the attributable in-hospital mortality rate due to DIC increased during the study period. We identified several predictors associated with the development of DIC in sepsis, some of which are potentially modifiable.

Emerging Role of Antibody-Drug Conjugates and Bispecific Antibodies for the Treatment of Multiple Myeloma.

Multiple myeloma (MM) is characterized by malignant proliferation of malignant plasma cells; it is the second most common hematological malignancy associated with significant morbidity. Genetic intricacy, instability, and diverse clinical presentations remain a barrier to cure. The treatment of MM is modernized with the introduction of newer therapeutics agents, i.e., target-specific monoclonal antibodies. The currently available literature lacks the benefits of newer targeted therapy being developed with an aim to reduce side effects and increase effectiveness, compared to conventional chemotherapy regimens. This article aims to review literature about the current available monoclonal antibodies, antibody-drug conjugates, and bispecific antibodies for the treatment of MM.

Efficacy of Oral Famotidine in Patients Hospitalized With Severe Acute Respiratory Syndrome Coronavirus 2.

Introduction The clinical benefit of famotidine has been observed in the management of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, its use in the management of SARS-CoV-2 is intriguing and not well established yet. In this study, we aimed to determine the role of famotidine as adjuvant therapy in improving the outcome of patients hospitalized with coronavirus disease-2019 (COVID-19). Methods This two-arm open-label randomized interventional study was conducted in the COVID-19 unit of a tertiary care hospital in Pakistan from December 2020 to September 2021. Patients between the ages of 18 to 65 years, hospitalized with COVID-19 infection, were enrolled in the study. Participants were randomized into two groups. The intervention group received 40 mg oral famotidine daily in addition to the standard care and the control group received standard care as per national guidelines for the treatment of COVID-19 in Pakistan. Results Patients admitted with COVID-19 who received famotidine took comparatively fewer days to become symptom-free (8.5 ± 1.7 vs. 9.4 ± 1.9 days, p-value: <0.001) and spent fewer days in hospital (8.6 ± 1.6 vs. 10.3 ± 2.2 days; p-value: <0.0001). However, the overall difference in the need for mechanical ventilation and mortality between the interventional arm and placebo was not significant. Conclusion In this study, adding famotidine to standard treatment of COVID-19 was associated with faster clinical recovery and shorter stay in the hospital. However, there was no difference in the need for mechanical ventilation, need for intensive care unit, and overall mortality. Further large-scale studies are needed to understand the role of famotidine in COVID-19 and its mechanism of action in patients with COVID-19.

Gastric Antral Vascular Ectasia: Trends of Hospitalizations, Biodemographic Characteristics, and Outcomes With Watermelon Stomach.

BACKGROUND: Gastric antral vascular ectasia (GAVE) syndrome is a rare but significant cause of acute or chronic gastrointestinal (GI) bleeding, particularly in the elderly. The primary objective of this study was to determine the biodemographic characteristics, adverse outcomes, and the impact of GAVE hospitalizations on the US healthcare system. METHODS: This retrospective database cross-sectional study used the National Inpatient Sample (NIS) from 2001 to 2011 to identify all adult hospitalizations with a primary discharge diagnosis of GAVE, with and without hemorrhage, using the International Classification of Diseases, Ninth Revision (ICD-9) codes. Individuals less than 17 years of age were excluded from the study. The outcomes included biodemographic characteristics, comorbidity measures, and inpatient mortality and the burden of the disease on the US healthcare system in terms of healthcare cost and utilization. RESULTS: We noted an increase in the total hospitalizations for GAVE from 25,423 in 2001 to 44,787 in 2011. Furthermore, GAVE hospitalizations with hemorrhage rose from 19,168 in 2001 to 27,679 in 2011 while GAVE hospitalization without hemorrhage increased from 6,255 in 2001 to 17,108 in 2011. We also noted a female predominance, the proportional trend of which did not show significant difference from 2001 to 2011. For GAVE hospitalizations, the inpatient mortality decreased from 2.20% in 2001 to 1.73% in 2011. However, the cost of hospitalization increased from $11,590 in 2001 to $12,930 in 2011. After adjusting for possible confounders, we observed that the presence of hemorrhage in GAVE hospitalizations was associated with an increased risk of mortality (odds ratio (OR): 1.27; 95% confidence interval (CI): 1.1 - 1.46; P = 0.001). CONCLUSIONS: For the study period, the total number of GAVE hospitalizations increased with an increase noted in the proportion of GAVE hospitalizations without bleeding, reflecting an improvement in diagnostic and therapeutic techniques. Although inpatient mortality for GAVE slightly decreased, we noted a significant increase in the cost of care likely secondary to increased use of advanced and expensive interventions.

Safety and Efficacy of Brivaracetam in Pediatric Refractory Epilepsy: A Single-Center Clinical Experience.

Brivaracetam is a new antiepileptic drug with limited data in children. The objective of this study was to assess the efficacy/tolerability of brivaracetam. This is a retrospective chart review of children/adolescents with refractory epilepsy treated with brivaracetam from 2016 to 2018. The primary outcome was seizure reduction (decrease in seizure frequency >50%). Twenty-three patients were identified. Mean age at initiation was 12.5 years. Fourteen were females. Epilepsy was focal in 11, generalized in 6, and mixed in 3. Average dose was 3.9 mg/kg/d. The mean duration of treatment was 8.2 months. Eight had greater than 50% decrease in seizure frequency, of which 7 had focal epilepsy, and 1 had Lennox-Gastaut/mixed epilepsy. Two had drowsiness and 3 behavioral complaints. One experienced tingling and dizziness. Our retrospective review suggests that brivaracetam is an effective therapy for refractory focal epilepsy in children older than 4 years of age.

Different Strokes: A management dilemma.

Stroke is a common medical emergency resulting from numerous pathophysiological mechanisms and with varied clinical manifestations; as such, the diagnosis of stroke requires diligent clinical assessment. When different stroke syndromes occur in the same patient, it may cause a dilemma in terms of diagnosis and management. This continuing medical education article describes an interesting patient with recurrent neurological events, highlighting the complex pathophysiological processes associated with cerebrovascular syndromes. It offers readers the opportunity to apply their own basic neuroscience knowledge and clinical skills to solve the challenges encountered during the course of diagnosing and treating this patient. Specifically, the article aims to familiarise readers with an approach to diagnosing brainstem strokes and the diverse manifestations of a common stroke syndrome.

Spectrum of Cerebral Venous Thrombosis in Oman.

OBJECTIVES: Cerebral venous thrombosis (CVT) can have varied and life-threatening manifestations. This study aimed to examine the spectrum of its clinical presentations and outcomes in a tertiary hospital in Oman. METHODS: This retrospective study was conducted at the Sultan Qaboos University Hospital, Muscat, Oman, between January 2009 and December 2017. The medical records of all patients with CVT were reviewed to determine demographic characteristics, clinical features and patient outcomes. RESULTS: A total of 30 patients had CVT. The mean age was 36.8 ± 11 years and the male-to-female ratio was 2:3. Common manifestations included headache (83%), altered sensorium (50%), seizures (43%) and hemiparesis (33%). Underlying risk factors were present in 16 patients (53%). Computed tomography or magnetic resonance imaging of the brain was abnormal in all patients, with indications of infarcts (40%) and major sinus thrombosis (100%). There were five cases (20%) of deep CVT. The patients were treated with low-molecular-weight heparin, mannitol and anticonvulsants. The majority (77%) had no residual neurological deficits at follow-up. CONCLUSION: These findings indicate that CVT is a relatively uncommon yet treatable disorder in Oman. A high index of suspicion, early diagnosis, prompt anticoagulation treatment and critical care may enhance favourable patient outcomes.

Fatal Strongyloides Hyperinfection Syndrome in an Immunocompromised Patient.

BACKGROUND: Currently, it is normal to screen for Strongyloides as part of the workup in pre-transplant patients who have eosinophilia. Given the high mortality rates in Strongyloides hyperinfection, this article illustrates the need to screen all patients with eosinophilia who will be started on immunosuppression. CASE REPORT: We present here an interesting case of a 76-year-old man with membranous glomerulopathy who developed a severe Strongyloides hyperinfection that required an ICU stay and ultimately led to his death a few weeks after initiation of cyclophosphamide and steroids. CONCLUSIONS: We recommend that a detailed workup to detect or rule out this parasitic infection be conducted prior to the initiation of immunosuppression in any patient with eosinophilia.

Development of stable flaxseed oil emulsions as a potential delivery system of ω-3 fatty acids.

The objective of the present study was to develop a stable flaxseed oil emulsion for the delivery of omega-3 (ω-3) fatty acids through food fortification. Oil-in-water emulsions containing 12.5 % flaxseed oil, 10 % lactose and whey protein concentrate (WPC)-80 ranging from 5 to 12.5 % were prepared at 1,500, 3,000 and 4,500 psi homogenization pressure. Flaxseed oil emulsions were studied for its physical stability, oxidative stability (peroxide value), particle size distribution, zeta (ζ)-potential and rheological properties. Emulsions homogenized at 1,500 and 4,500 psi pressure showed oil separation and curdling of WPC, respectively, during preparation or storage. All the combinations of emulsions (homogenized at 3,000 psi) were physically stable for 28 days at 4-7 ºC temperature and did not show separation of phases. Emulsion with 7.5 % WPC showed the narrowest particle size distribution (190 to 615 nm) and maximum zeta (ζ)-potential (-33.5 mV). There was a slight increase in peroxide value (~20.98 %) of all the emulsions (except 5 % WPC emulsion), as compared to that of free flaxseed oil (~44.26 %) after 4 weeks of storage. Emulsions showed flow behavior index (n) in the range of 0.206 to 0.591, indicating higher shear thinning behavior, which is a characteristic of food emulsions. Results indicated that the most stable emulsion of flaxseed oil (12.5 %) can be formulated with 7.5 % WPC-80 and 10 % lactose (filler), homogenized at 3,000 psi pressure. The formulated emulsion can be used as potential omega-3 (ω-3) fatty acids delivery system in developing functional foods such as pastry, ice-creams, curd, milk, yogurt, cakes, etc.

A rapid reversed-phase thin layer chromatographic protocol for detection of adulteration in ghee (clarified milk fat) with vegetable oils.

Detection of milk fat adulteration with foreign fats/oils continues to be a challenge for the dairy industry as well as food testing laboratories, especially in the present scenario of rampant adulteration using the scientific knowledge by unscrupulous persons involved in the trade. In the present investigation a rapid reversed-phase thin layer chromatographic (RP-TLC) protocol was standardized to ascertain the purity of milk fat. RP-TLC protocol did not show any false positive results in the genuine ghee (clarified butter fat) samples of known origin. Adulteration of ghee with coconut oil up to 7. 5 %, soybean oil, sunflower oil and groundnut oil up to 1 %, while, designer oil up to 2 % level could be detected using the standardized RP-TLC protocol. The protocol standardized is rapid and convenient to use.

Qualitative test for the detection of extraneous thiocyanate in milk.

Thiocyanate is one of the three components of lactoperoxidase system for preserving the milk under the conditions where chilling facilities do not exist due to economic and technical reasons. In 1988, International Dairy Federation (IDF) has recommended the levels and the code of practices for the application of LP-system. As the excessive use of thiocyanates beyond the recommended limits can lead to human health hazards, its rapid detection in milk at the reception dock of dairy, where milk is tested for quality before its acceptance or rejection, is necessary. For simple and rapid detection of added thiocyanates in milk, two types of qualitative tests have been developed in this study, of which one is applicable directly to milk and the other is applicable to TCA filtrate of milk. The results of the test reveal that as low as 0.6 ppm of added thiocyanate (equivalent to 1 ppm of potassium thiocyanate) can be detected. The orange to orange-red color obtained in the test solution can be considered the basis of rejecting milk assuming that it has added levels of thiocyanate.

Predictors of the intracerebral hemorrhage volume in hypertensive patients.

BACKGROUND: Hemorrhage volume is an important predictor of outcome in patients with intracerebral hemorrhage (ICH). It is not clear why in some patients ICH volume is larger than in others. Identification of modifiable factors responsible for large-volume hemorrhage in hypertensive patients may help to reduce ICH-related morbidity and mortality. OBJECTIVE: The objective of this study was to identify predictors of large-volume ICH in hypertensive patients. METHODS: At a tertiary care center in Karachi (Pakistan), 157 hypertensive patients with ICH were prospectively analyzed in 2008-2009, and hemorrhage volumes were determined using CT or MRI and various factors, including duration of hypertension, medical treatment, compliance, co-morbidity, and hematologic and coagulation profiles. Logistic regression analysis was used to identify predictors of high-volume hemorrhage. A volume >30 mm(3) was defined as high-volume hemorrhage. RESULTS: Of 157 patients with hypertensive ICH evaluated, 133 patients were included in the study, and 24 patients with brain stem, cerebellum and pure intraventricular hemorrhage were excluded. The mean age of the study patients was 55 years; 56 patients (70%) were male. High-volume hemorrhage (>30 mm(3)) was noted in 47 (35%) patients. Mortality was significantly increased in patients with high-volume ICH (32 vs. 6% in patients with low-volume ICH). In univariate analysis, factors significantly associated with large-volume ICH were male gender (p = 0.002), hypertension lasting >10 years (p = 0.03), warfarin treatment (p = 0.05), use of >1 anti-hypertensive agent (p = 0.001) and poor compliance with medication (p = 0.001). In multivariate analysis, use of >1 anti-hypertensive agent and poor compliance were also predictors of large-volume ICH. CONCLUSION: High-volume hemorrhage was less common (28%) in our patients with hypertension and ICH. Use of >1 anti-hypertensive agent and poor compliance were predictors of large-volume ICH.

Study of microporosity of active carbon spheres using inverse gas chromatographic and static adsorption techniques.

Active carbon spheres (ACSs) with different porous structures prepared in the laboratory were characterized by static adsorption studies and inverse gas chromatographic (IGC) technique. Surface properties such as BET surface area, micropore volume and pore size in different regions of porosity were determined using different theoretical approaches. Thermodynamic parameters such as isosteric heat of adsorption, free energy of adsorption and dispersive component of the surface energy were determined using IGC technique from corrected retention volume of normal alkanes and corresponding branched alkanes. Thermodynamic parameters were used to assess the molecular sieving property of ACSs. It is observed that thermodynamic properties strongly depend on microporous character of ACSs. The variations observed in pore size determined by both of the techniques that is by static adsorption measurements and IGC may be attributed to the variation in analysis temperature, i.e. liquid N2 temperature for adsorption studies and elevated temperature for IGC technique.