Therapy-related Acute Myeloid Leukemia in Non-Hodgkin Lymphoma Survivors: Risk, Survival Outcomes and Prognostic Factor Analysis.

BACKGROUND: Therapy-related acute myeloid leukemia (tAML) is a serious complication in patients with Non-Hodgkin lymphoma (NHL) exposed to chemotherapy or radiation. This extensive database study aims to quantify the risk of tAML in NHL and determine the impact of tAML on the overall survival (OS) of patients with NHL. MATERIALS AND METHODS: Patients diagnosed with NHL and de novo AML from 2009 to 2018 were identified from the Surveillance, Epidemiology, and End Results database. Multiple primary standardized incidence ratio (SIR) sessions of the SEER*Stat software were used to calculate SIR and the absolute excess risk of tAML. Overall survival (OS) was evaluated using Kaplan-Meier curves and compared using log-rank tests. Multivariate analysis was used to study the role of each covariate on OS in patients with tAML. RESULTS: The SIR of tAML was 4.89 (95% CI 4.41-5.41), with a higher incidence of tAML observed for age <60 years, NHL prior to 2013 and within 5 years of diagnosis, and those who received chemotherapy. NHL patients with tAML had lower OS than those without tAML (5-year OS 59% vs. 13%, p < 0.001). Patients with tAML showed worse OS than de novo AML in univariate analysis (5-year OS 13% vs. 25%, p = 0.001) but not in multivariate analysis (HR 0.93, 95% CI 0.82-1.04, p = 0.21). Age ≥60 years and lack of chemotherapy were associated with poor OS in tAML subcategory. CONCLUSION: Age, time since NHL diagnosis, and receipt of chemotherapy directly influence the risk of development of tAML in NHL survivors.

Prevalence, Associated Factors, and Impact of Workplace Violence among Physicians.

BACKGROUND: There is a dearth of objective data and studies pertaining to the prevalence and consequences of workplace violence against physicians in Nepal. This study aims to assess the prevalence, associated factors, and implications of workplace violence on Nepalese physicians. METHODS: We conducted a cross-sectional study from March 2021 to August 2021. Nepal Medical Council-certified physicians currently working in Nepal were included in the study. Baseline characteristics, types of violence experienced, patterns, psychosocial impacts, and changes in patient management were collected. RESULTS: Out of 318 responses received, 302 responses met the inclusion criteria and were included in the final analysis. One-hundred and ninety (62.9%) respondents had ever faced workplace violence. Madhesh Province had the highest prevalence (81.5%). Verbal abuse (93.2%) was the most common type of violence encountered. We found a significant association between workplace violence and hours worked each week. We also found an association between workplace violence and years of experience. Our study found a significant increase in stress/depression/anxiety/idea of persecution, sense of defeat, job turnover, and loss of productivity/income with the increase in severity of workplace violence. CONCLUSIONS: Workplace violence is largely prevalent among Nepalese physicians. In the aftermath of workplace violence, a physician can undergo a multitude of adverse psychosocial consequences leading to a further decrease in productivity. More insights through research, formal training, and policy implementation are necessary to overcome this largely ignored problem of the medical fraternity in Nepal.

Risk of second primary malignancy in patients with primary myelofibrosis: a SEER database study.

Prior studies report a greater incidence of second primary malignancy (SPM) among patients with myeloproliferative neoplasms, although the true risk in primary myelofibrosis (PMF) has not been elucidated. We utilized the Surveillance, Epidemiology, and End Results database to evaluate the risk of SPM in PMF patients and analyzed the effects of sociodemographic factors on the risk of SPM. Out of 5273 patients, 385 patients (7.30%) developed SPM. SPM occurred at SIR of 1.95 (95% CI 1.76-2.15) and AER of 149.01 per 10,000 population. A significantly higher incidence of melanoma (SIR 1.76, 95% CI 1.01-2.86), lymphoma (SIR 3.38, 95% CI 2.28-4.83), and leukemia (SIR 27.19, 95% CI 23.09-31.81) was observed. The risk was significantly higher in patients ≤60 years, males, chemotherapy recipients, within 5 years of PMF diagnosis, and for PMF diagnosed after 2009.

Effect of Age and Socioeconomic Factors in the Utilization of Chemotherapy in Acute Lymphoblastic Leukemia (ALL): A SEER Database Study of 16,196 Patients.

INTRODUCTION: The use of multiagent chemotherapy in acute lymphoblastic leukemia (ALL) has resulted in improvement in overall survival (OS), albeit to a different extent across various age groups. This large database study aims to assess the disparity in the utilization of chemotherapy in ALL in the real-world setting. MATERIALS AND METHODS: Using the Surveillance, Epidemiology, and End Results database, patients with ALL diagnosis from 2006 to 2016 were identified. Baseline characteristics were compared between the groups who did vs. did not receive chemotherapy using χ2 test. Multivariable logistic regression was used to evaluate the association between various sociodemographic factors and the receipt of chemotherapy in the entire cohort and in different age groups. RESULTS: Out of 16,196 patients, 1258 patients (8%) did not receive chemotherapy. There was a steady increase in the number of patients who did not receive chemotherapy with advancing age: 2.5% (0-18 years), 5.2% (19-40 years), 9.3% (41-65 years), and 36.2% (>65 years). There was an upward trend in the receipt of chemotherapy in patients >65 years over the last decade. In multivariate analysis, the likelihood of receiving chemotherapy decreased with advancing age, single or widowed status, low income and educational status, and lack of insurance. Insurance status was an independent predictor of receipt of chemotherapy across each age category. CONCLUSION: A significant proportion of patients >65 years do not receive chemotherapy in the United States. Age, marital status, income, education, and insurance status contribute to the disparity in utilization of chemotherapy.

Impact of Insurance on Overall Survival in Acute Lymphoblastic Leukemia: A SEER Database Study.

INTRODUCTION: Insurance status at diagnosis remains an important barrier to health care access and adherence to treatment. Here, we aim to assess the impact of insurance status, and age on overall survival (OS) in patients with acute lymphoblastic leukemia (ALL). MATERIALS AND METHODS: Using the Surveillance, Epidemiology, and End Results database, we identified all patients younger than 65 years of age diagnosed with ALL from 2010 to 2016. OS was estimated for each group using the Kaplan Meier curves and compared based on insurance type using a log-rank test. Multivariate analysis using Cox proportional hazard regression model was used to assess the effect of insurance status on OS. RESULTS: A total of 9057 patients were included in the analysis. Medicaid beneficiaries had worse 5-year OS than insured patients (HR 1.33, 95% CI 1.08-1.63, P = .006) in 0-18 years age group. Despite chemotherapy, patients older than 18 years showed poor OS in all insurance categories. Patients on Medicaid showed inferior OS compared to insured in 19-40 years (HR 1.46, 95% CI 1.21-1.76, P < .001) and 41-65 years age group (HR 1.27, 95% CI 1.09-1.49, P = .003). Interestingly, no significant difference was observed in the OS between the Medicaid and uninsured groups in each age category. CONCLUSION: Our large database study demonstrates that insured status is associated with better OS in ALL across all age groups. Further studies to develop effective strategies to bridge health care disparities areessential.

Primary Duodenal Adenocarcinoma: Uncommon Tumor, Uncommon Presentation. A Case Report and Review of the Literature.

INTRODUCTION: The symptoms of primary duodenal adenocarcinoma, which is a rare but aggressive tumor, are vague and nonspecific and often result in a delayed diagnosis or misdiagnosis. This results in a tumor being diagnosed at an advanced stage when it becomes unresectable secondary to local and distant spread. CASE PRESENTATION: A 64-year-old Nepalese female presented to our hospital with epigastric pain, anorexia, and significant weight loss that developed over two-and-a-half months. Upper gastrointestinal endoscopy showed an ulceroproliferative growth in the first part of the duodenum with no features of duodenal stenosis. Contrast-enhanced computed tomography of the abdomen revealed heterogeneously enhancing, circumferential, asymmetrical thickening in the first part of the duodenum and multiple liver metastases. Biopsy of the mass revealed features suggestive of moderately differentiated adenocarcinoma of the duodenum. She was managed with palliative care during her hospital stay. The unique presentation in our case was that the tumor did not cause stenosis and the patient could consume food till the last day of her life. CONCLUSION: In patients with primary duodenal adenocarcinoma, the non-stenotic lesion is also a possibility. Clinicians should always maintain a high degree of suspicion to avoid the delay in diagnosis or misdiagnosis.

Profile of Neurosurgical Patients in a Tertiary Level Intensive Care Unit in Nepal.

BACKGROUND: Neurosurgery has developed as a separate specialty and neurosurgical patients are some of the most common admitted in the intensive care unit. The objective of the study was to study the profile of neurosurgical patients admitted in level III mixed, medical-surgical intensive care unit in a tertiary level teaching hospital in Nepal with the view to identify the causes of intensive care unit admission, types of neurosurgery performed, outcome of the patients, in terms of intensive care unit stay, mechanical ventilation days and mortality. METHODS: A retrospective study was designed and all neurosurgical patients admitted to the intensive care unit of our center between 13 April 2017 and 13April 2018 (1st Baisakh 2074 to 30th Chaitra 2074) were enrolled in this study. RESULTS: A total of 813 patients were admitted in ICU over a period of one year (2074 B.S.) of which 199 (24.48 %) were neurosurgical cases. Among these 170 (85.42%) cases were post-surgical, with 29 (14.58%) being pre-operative patients. One hundred forty nine patients (74.9%) were on mechanical ventilation. One hundred and thirty two (66.3%) patients improved and were transferred to a step down ward. Forty-three (22.5%) died in the intensive care unit, 14 (7.03%) left the hospital against medical advice and 9 (4.5%) patients expired after withdrawal of life support. CONCLUSIONS: Despite improved care over the recent years the mortality and morbidity of neurosurgical patients is high.

An Audit of An Intensive Care Unit of A Tertiary Care Hospital.

INTRODUCTION: The patients with the most severe and life threatening illnesses requiring constant monitoring and support are admitted in the intensive care unit. Tribhuvan University Teaching Hospital is the oldest and tertiary referral center hospital in the country with eleven-bedded level III mixed medical surgical ICU. This audit was performed to study the profile of critically ill patients under different headings like diagnosis at admission, primary specialty, outcome of the patients, etc. Methods: A descriptive cross-sectional study was designed and all patients admitted to the intensive care unit of our center between 13 April 2017 and 13 April 2018 (1st Baisakh 2074 to 30th Chaitra 2074) were selected for this study. RESULTS: A total of 813 patients were admitted in TUTH ICU over a period of one year (2074 B.S.) with male patients being more common. Neurosurgical cases were most common at 199 (24.48 %), followed by respiratory cases at 149 (18.32%) and so on. The overall mortality was 246 (32.8%). The overall surgical cases were more common than medical cases with better outcomes. CONCLUSIONS: This audit presents the profile of patients admitted in a tertiary level hospital in Nepal, their indications and mortality. The most common patients being admitted were Neurosurgical patients and the mortality was significantly higher compared to ICUs in developed countries.