Efficacy of Atezolizumab Plus Bevacizumab Versus Lenvatinib in Patients with Unresectable Hepatocellular Carcinoma: a Meta-analysis.

INTRODUCTION: Hepatocellular carcinoma is a lethal disease and there has been a debate regarding the first-line treatment of its advanced and unresectable form. Observational studies have explored atezolizumab plus bevacizumab versus lenvatinib, yielding mixed results. This systematic review and meta-analysis aim to compare efficacy and safety of both treatment arms. METHODS: A systematic literature review was conducted in accordance with PRISMA guidelines. Randomized control trials, cohort studies, or case-control that included patients above age 60 with unresectable hepatocellular carcinoma confirmed by radiological imaging were included. At least one of the outcomes: overall survival (OS), progression-free survival (PFS), objective response rate (ORR), duration of response, or adverse events was included in the selected studies. RESULTS: Ten cohorts were included in the analysis with a total of 6493 patients. Nine of the included studies had patients with advanced HCC (BCLC-C) or intermediate HCC (BCLC-B) and 1 study included patients with all three stages (BCLC-A, BCLC-B, and BCLC-C). Of these patients, 2524 patients received atezolizumab plus bevacizumab (A + B) combination while 3969 received lenvatinib. The overall survival was better statistically in the A + B group then the lenvatinib group (MD: - 5.06; 95% CI: - 7.79 to - 2.33; p = 0.0003, I2 = 0%). The progression-free survival was significantly improved in A + B arm as well group (MD: - 4.96; 95% CI: - 7.67 to - 2.26; I2 = 0%, p = 0. 0003). There was no significant difference in objective response rate, disease control rate, and frequency of adverse events in either of the group. CONCLUSION: Our study concluded that combination therapy with atezolizumab plus bevacizumab could increase the survival duration without affecting the disease course. Moreover, while the severity of adverse events was greater in the A + B group, their frequency was comparable to the lenvatinib group.

Motives Driving Non-healthcare Community Organizations to Engage in Health Promotion Activities.

While health promotion is not the primary mission of many community organizations (e.g., libraries, religious organizations), it is well documented that many still engage in health promotion activities, even when their resources may be constrained. What is less understood are the driving forces that spur community organizations to divert finite resources to health promotion when it may not directly align with their primary mission. The current study explores the reasons why various community organizations might choose to engage in health promotion, particularly in the context of the COVID-19 pandemic. We conducted interviews with leaders of 22 mosques, public libraries, low-income housing communities, and university-affiliated fraternities/sororities in the state of Maryland and qualitatively analyzed the data using template analysis. Four themes detailing reasons these community organizations engage in health promotion were identified including Organizational perceptions of health, Identifying and addressing issues of accessibility, Organizational responsibility, and Member interest and initiative. Understanding the reasons community organizations outside of the healthcare setting engage in health promotion, especially during a global pandemic, can allow public health researchers and practitioners to develop increasingly relevant and, in turn, effective strategies for recruitment of community organizations and sustainment of partnerships with these organizations. This has implications for population-level health impacts by improving reach to those that may not engage with traditional healthcare providers.

Rectal Dieulafoy's lesion: a comprehensive review of patient characteristics, presentation patterns, diagnosis, management, and clinical outcomes.

Dieulafoy's lesion is an abnormally large, tortuous, submucosal vessel that erodes the overlying mucosa, without primary ulceration or erosion. Although these lesions predominantly involve the stomach and upper small intestine, they are being detected with increasing frequency in the rectum. We conducted a systematic literature search of MEDLINE, Cochrane, Embase, and Scopus databases for adult rectal Dieulafoy's lesion. After careful review of the search results, a total of 101 cases were identified. The data on patient characteristics, clinical features, colonoscopy findings, diagnosis, treatment, and clinical outcomes were collected and analyzed. The mean age of presentation was 66±17 years (range, 18-94 years), with 54% of cases reported in males. Clinical presentation was dominated by acute lower gastrointestinal bleeding in the form of bright-red blood per rectum 47% and hematochezia 36%, whereas 16% of patients were admitted with symptoms related to other medical conditions. Major underlying disorders were hypertension 29%, diabetes mellitus 21%, and chronic kidney disease 16%. The average number of colonoscopies required for the diagnosis of rectal Dieulafoy's lesion was 1.5±0.7. In regard to treatment, endoscopic therapy was applied in 80%, direct surgical suturing in 12%, angiographic embolization in 4%, and endoscopic therapy followed by surgical ligation was performed in 4% of patients. The endoscopic treatment was a feasible choice for rectal disease, with a primary hemostasis rate of 88%. Although the overall mortality rate was 6%, the causes of death were unrelated to this entity. This review illustrates that patients with rectal Dieulafoy's lesion can have a favorable clinical outcome. Prompt diagnosis and appropriate management are of paramount importance to prevent serious hemodynamic complications. The best therapeutic modality remains to be determined but the data presented here support the use of mechanical endoscopic methods as safe and effective.

The integral role of the clinical pharmacist in drug-assisted intubation at a newly established children's major trauma center.

This commentary outlines how the clinical pharmacist can support the safe administration of emergency medications in trauma anesthesia for seriously injured children. Promoting the professional development of the clinical pharmacist provided an opportunity to strengthen a key step in our trauma care pathway. We describe the implementation of this process in a new hospital, which was to become the designated children's trauma center for an entire country. Although the literature documents the use of pharmacists in emergency intubation, ours was a unique set of circumstances, where empowering the pharmacist in frontline clinical care provided additional quality assurance for rapid sequence induction and intubation in trauma. Medical simulation was a core part of socializing the advanced clinical practice role of pharmacy within the trauma team. It was our experience that the pharmacist helps to promote confidence and decision making among other members of the trauma team.

Gastro-oesophageal reflux is not a major cause of brief resolved unexplained events in infants.

Although it is often stated that gastro-oesophageal reflux is the most common cause of a brief resolved unexplained event or apparent life-threatening event, there are very few data to support the hypothesis of cause and effect http://bit.ly/2FjknUy.

Anti-N-methyl-D-aspartate Receptor Encephalitis Associated with Ictal Torsades de Pointes and Cardiac Arrest.

Anti-N-methyl-D-aspartate (anti-NMDA) receptor encephalitis is a rare clinical entity that typically presents with psychiatric disturbances and neurological deficits. It is commonly associated with ovarian teratomas. Although these patients demonstrate a predilection to develop cardiac arrhythmias, such complications are frequently self-limited. We chronicle here a unique case of a young woman with adnexal teratoma who experienced a tonic-clonic seizure and cardiac arrest. Electrocardiogram showed polymorphic ventricular tachycardia, consistent with torsade de pointes. Based on extensive diagnostic workup and exclusion of probable etiologies, she was diagnosed with anti-NMDA receptor encephalitis. To the best of our knowledge, this report represents the first case of anti-NMDA receptor encephalitis complicated by ictal torsades de pointes, leading to cardiac arrest. This paper illustrates that patients with anti-NMDA receptor encephalitis can develop life-threatening cardiac dysrhythmia and cardiac arrest, requiring urgent management. Clinicians should be vigilant for severe autonomic dysfunction as prompt etiology establishment is of paramount importance in these patients.

Association of lactate/albumin ratio level to organ failure and mortality in severe sepsis in a pediatric intensive care unit in Egypt.

Moustafa AA, Antonios MAM, Abdellatif EM, Hussain AH. Association of lactate/albumin ratio level to organ failure and mortality in severe sepsis in a pediatric intensive care unit in Egypt. Turk J Pediatr 2018; 60: 691-701. This study aimed at investigating the lactate to albumin ratio, as a newly introduced biomarker of multiple organ dysfunction syndrome (MODS) and mortality compared to the classic lactate clearance in pediatric patients. We designed a prospective cohort study and 155 patients with severe sepsis or septic shock admitted to a Pediatric Intensive Care Unit were included, starting from January 2016 to March 2017. The data of 119 patients who completed the study, were analyzed. Results revealed that lactate clearance (6h, 24h) was significantly lower and lactate/albumin ratio (0h, 6h, 24h) was significantly higher in patients who developed MODS and in those who passed away. The univariate logistic regression showed that both lactate clearance and lactate/albumin ratio were significant prognostic factors of MODS and mortality. According to the AUC, lactate/albumin ratio (0h, 6h, 24h) showed better discrimination of MODS development (with AUC of 0.729, 0.814, and 0.819, respectively) compared to lactate clearance (6h, 24h; AUC of 0.738, and 0.672, respectively). Again the lactate/albumin ratio (0h, 6h, 24h) showed better discriminatory power of mortality (0.681, 0.741, and 0.856, respectively) compared to the lactate clearance (6h, 24h; 0.638 and 0.77, respectively). The Youden Index specified a lactate/albumin ratio (0h, 6h, 24h) of 1.17, 1.07, and 1.1 to be the cut-off discriminating values, respectively. The Kaplan-Meier curves revealed that the cumulative of survival is significantly better for the group of patients with a lactate/albumin ratio less than the cut-off values. It was concluded that lactate/albumin ratio is a better discriminator of MODS development and mortality than lactate clearance in pediatric patients with severe sepsis or septic shock.

Dyslipidaemia in woman with polycystic ovarian syndrome: a case control study in tertiary care hospital of Karachi.

OBJECTIVE: To compare lipid profile in lean and obese women with polycystic ovary syndrome with normal weight and obese controls. METHOD: The case-control study was conducted at the Department of Chemical Pathology, Liaquat National Hospital, Karachi, from March 2006 to April 2007. It comprised 50 cases of polycystic ovary syndrome along with 50 healthy controls matching for age, gender and weight. SPSS 14 was used for statistical analysis. RESULT: The mean fasting levels of triglyceride and Low density lipoprotein cholesterol were considerably higher in women with polycystic ovary syndrome than those in the control group (p < 0.05), while high-density lipoprotein cholesterolwas significantly low in patients than the controls (p <0.001). Obese patients had high triglyceride value (p < 0.05). There was significant interaction between polycystic ovary syndrome, obesity and triglyceride levels (p < 0.05). CONCLUSION: Polycystic ovary syndrome is associated with a more pronounced atherogenic lipid profile. Lipid parameters were adversely affected in a subgroup that was obese. As such, women with polycystic ovary syndrome are at high risk of developing cardiovascular disease due to the presence of dyslipidaemia.

Cyclosporine induced nephrotoxicity in renal transplant recipients: clinical significance of fractional excretion of sodium, potassium and magnesium.

OBJECTIVE: Evaluation of fractional excretion of Sodium, Potassium and Magnesium as indicators of cyclosporine (CsA) toxicity in de-novo renal transplant recipients. METHODS: A prospective study was conducted on 59 live related renal allograft recipients. Fractional excretion(FE) of sodium (Na+), potassium (K+) and magnesium (Mg2+) were calculated on day 1, 3, 5 and 10 post transplant. Graft dysfunctions were evaluated by colour-Doppler, CsA levels and renal biopsy. Normal ranges were determined on 30 healthy subjects. RESULTS: The mean creatinine on day 1 was 3.1 +/- 1.3 mg/dl and declined to 1.6 +/- 1.2 on day 10. FE of Na+, K+ and Mg2+ were 12 +/- 9%, 34 +/- 20% and 13 +/- 10% respectively on day 1 and reduced to 2.2 +/- 2%, 11 +/- 14% and 11 +/- 14% on day 10. Of the 59 recipients, 38 (64%) had uneventful recovery (group A), 21(36%) had graft dysfunction [6 acute rejection (group B) and 15 either acute tubular necrosis or high CsA(group C)]. In group A, on day 1, FENa+, FEK+ and FEMg2+ were 5 +/- 4%, 24 +/- 12% and 6.6 +/- 3% respectively and these declined to 1.2 +/- 0.6%, 4.6 +/- 0.7% and 6 +/- 3% respectively on day 10. Compared to group A, group C had significantly high values on day 1, FENa+ 15 +/- 8%, FEK+ 36 +/- 24% and FEMg2+ 21 +/- 10% (p < 0.0001) and on day 10, FENa+ 3.7 +/- 2.7%, FEK+ 20 +/- 15% and FEMg2+ 15 +/- 8% (p < 0.05). In the group B, day 1 and day 10 levels were FENa+ 6 +/- 3%, FEK+ 26 +/- 13% and FEMg2+ 7 +/- 2.8% and FENa+ 1.2 +/- 0.7%, FEK+ 4.2 +/- 0.5%, FEMg2+ 7 +/- 4% respectively. CsA levels and AUC did not correlate with CsA toxicity. CONCLUSION: FE of magnesium is a useful marker of CsA toxicity independent of CsA blood levels. FE studies can supplement renal biopsy findings.