Hepatic and Renal Safety of Remdesivir in COVID-19 Patients Observational prospective study

Background: SARS-CoV-2 has been demonstrated to be inhibited by Remdesivir, a broad-spectrum antiviral medication. Remdesivir has been tried for a compassionate use in severe COVID-19 in the absence of any viable treatment for SARS-CoV-2 infection (COVID-19). Methods: In 50 patients with SARSCoV-2 infection who were given Remdesivir as part of their institutional treatment plan, we conducted an observational prospective analysis. Remdesivir 100 mg was given daily for7 days during the therapy period. The results of liver and kidney function tests were compared before and after Remdesivir administration. Results: With the administration of Re%) exhibited an improvement in their oxygen needs. Patients reported only a few minor side effects. Serious side effects, on the other hand, were rare. Conclusion: Remdesivir seems to have an excellent safety profile, while its efficacy in the treatment of COVID-19 is currently inconclusive. Remdesivir use in patients was shown to be safe, with no serious side effects or significant changes in normal test results for liver and kidney functions. Keywords: Adverse events, Covid-19, liver function, remdesivir, renal function

Covid-19 and Surgery

The severe acute respiratory syndrome (SARS) caused by the super-infectious, super-spreading, super-mutating novel coronavirus-2 (Covid-19) is responsible for the worldwide overwhelming panic and pandemic with a huge burden of suffering patients at a time. It has been causing alarming morbidity and unexpected mortality, shortening life span of many people that hadn’t happened since the second world war. It was first identified in Wuhan, China in the last months of 2019. The clinical scenario presents in the form of asymptomatic, mild, moderate and severe illnesses. More than 80% patients are either asymptomatic who transmit it to others and have a mild influenza-like illness clinically not different from common cold. The moderate and severe cases commonly need supervised home or institutional treatment. Many of the latter need intensive therapy that includes non-invasive and invasive ventilation along with other measures and medications. The treatment is principally conservative, HDU- and ICU-dependent. Surgery has no role as its primary treatment. But protection of surgical team and non-infected patients remains as a challenge to surgeons and hospital authorities. Many of the mutant variants now show resistance to antibodies generated by spike protein based and m-RNA based vaccines. The threat of infection still persists making surgeons overwhelmingly concerned while performing emergency, elective and cancer surgeries. This article describes some guidelines to be followed by the operating surgeons, hospital and regional health authorities to minimize the risks of spreading the disease and to protect the surgical team and other non-infected people from being infected. KYAMC Journal. 2021;12(3): 172-181

Burden of breast cancer in Bangladesh-current and future and financing treatment with link to willingness to pay

Breast cancer is the most common cancer type among females worldwide affecting 1 in 8 women. As of 2015, breast cancer is still a leading cancer of women in Bangladesh. It has become a hidden burden which accounts for 69% death of women within the country. The rate grows up day to day due to unawareness of the people, lack of confidence about medical treatment, improper screening, maltreatment, and lack of motivation to go for institutional treatment and management. The treatment options for breast cancer are relatively very expensive. People may be willing to sacrifice overall health to channel resources towards high priority disease areas, such as cancer to improve overall life. It is highly appropriate now to link treatment fall out and finances to the patient population. This short communication adopts a descriptive approach. First, it looks at the prevalence of breast cancer in Bangladesh, how breast cancer can be managed, how treatment can be financed and willingness to pay by individuals. This article finds that the screening can be optimized as the treatment options for breast cancer are relatively very expensive in a low resourced country such as Bangladesh. Data should be disseminated among the concerned stakeholders including the women susceptible to breast cancer, the patients, the care-givers, doctors, other health-care workers and policy-makers for better management. Improving the cancer scenario overnight is not an easy task but policy makers may become interested and push this agenda forward, if the huge health impact and economic loss caused by cancer become evident to them.

Late presentation and suboptimal treatment of breast cancer among Syrian refugees: a retrospective study

Objectives The crisis in Syria has had a profound impact on the entire region. In this study, we report the patterns of presentation and management of Syrian patients with breast cancer treated at our institution. Methods We retrospectively collected data on Syrian refugees treated for breast cancer over the past 10 years at our center. Management was compared against our approved clinical practice guidelines. Results A total of 113 patients were eligible and included. The median age (range) at diagnosis was 47 (21–84) years and most women presented with locally advanced or metastatic disease (n = 74, 65.5%). Breast-conserving surgery and breast reconstruction were performed in 27 (33.8%) and 11 (35.4%) patients, respectively. Only a few patients received targeted (35.5%) or advanced endocrine therapy (30.0%). In total, 37 (32.7%) patients had considerable deviations from our institutional treatment guidelines and had worse outcomes. Conclusions Syrian refugees with breast cancer present late, have more advanced-stage disease, and are more likely to receive delayed and suboptimal therapy. An international systematic approach for cancer care among such vulnerable populations is urgently needed.

How Are Emerging Data Translated Into Clinical Practice? A Mixed Methods Investigation of Coronavirus Disease 2019 Institutional Treatment Protocols

Background Early in the coronavirus disease 2019 (COVID-19) pandemic, there was minimal data to guide treatment, and we lacked understanding of how clinicians translated this limited evidence base for potential therapeutics to bedside care. Our objective was to systematically determine how emerging data about COVID-19 treatments was implemented by analyzing institutional treatment protocols. Methods Treatment protocols from North American healthcare facilities and recommendations from guideline-issuing bodies were collected. Qualitative data on treatment regimens and their applications were extracted using an adapted National Institutes of Health/US Food and Drug Administration experimental therapeutics framework. Structured data on risk factor and severity of illness scoring systems were extracted and analyzed using descriptive statistics. Results We extracted data from 105 independent protocols. Guideline-issuing organizations published recommendations after the initial peak of the pandemic in many regions and generally recommended clinical trial referral, with limited additional guidance. Facility-specific protocols favored offering some treatment (96.8%, N = 92 of 95), most commonly, hydroxychloroquine (90.5%), followed by remdesivir and interleukin-6 inhibitors. Recommendation for clinical trial enrollment was limited largely to academic medical centers (19 of 52 vs 9 of 43 community/Veterans Affairs [VA]), which were more likely to have access to research studies. Other themes identified included urgent protocol development, plans for rapid updates, contradictory statements, and entirely missing sections, with section headings but no content other than “in process.” Conclusions In the COVID-19 pandemic, emerging information was rapidly implemented by institutions into clinical practice and, unlike recommendations from guideline-issuing bodies, heavily favored administering some form of therapy. Understanding how and why evidence is translated into clinical care is critical to improve processes for other emerging diseases.

Multimodal CT or MRI for IV thrombolysis in ischemic stroke with unknown time of onset

ObjectiveTo investigate differences in procedure times, safety, and efficacy outcomes comparing 2 different protocols to enable thrombolysis in the extended or unknown time window after stroke onset with either multimodal CT or MRI.MethodsPatients with ischemic stroke in the extended or unknown time window who received IV thrombolysis between January 2011 and May 2019 were identified from an institutional registry. Imaging-based selection was done by multimodal CT or MRI according to institutional treatment algorithms.ResultsIV thrombolysis was performed in 100 patients (54.3%) based on multimodal CT imaging and in 84 patients (45.7%) based on MRI. Baseline clinical data, including stroke severity and time from last seen normal to hospital admission, were similar in patients with CT and MRI. Door-to-needle times were shorter in patients with CT-based selection (median [interquartile range] 45 [37–62] minutes vs 75 [59–90] minutes; mean difference [95% confidence interval (CI)] −28 minutes [−35 to −21]). No differences were detected regarding the incidence of symptomatic intracranial hemorrhage (2 [2.0%] vs 4 [4.8%]; adjusted odds ratio [aOR] [95% CI] 0.47 [0.08–2.83]) and favorable outcome at day 90 (25 [33.8%] vs 33 [42.9%]; aOR 0.95 [0.45–2.02]).ConclusionIV thrombolysis in ischemic stroke in the unknown or extended time window appeared safe in CT- and MRI-selected patients, while the use of CT imaging led to faster door-to-needle times.Classification of evidenceThis study provides Class IV evidence that for patients with ischemic stroke in the extended or unknown time window, imaging-based selection for IV thrombolysis by multimodal CT compared to MRI led to shorter door-to-needle times.

Institutional Anticoagulation Protocol for Septic DIC is Associated with Differences in In-Hospital Mortality. J-SEPTIC DIC STUDY (A Nationwide Registry Study)

Background: We analyzed data from Japanese nationwide registry study of severe sepsis/septic shock to determine the influence of institutional treatment protocol, which has not been evaluated, on in-hospital mortality rate in septic DIC. Methods: From among all sepsis patients (n=3193), we selected those (n=1856) diagnosed with DIC according to the JAAM criteria, then divided them into three groups depending on DIC treatment protocol: patients admitted to hospitals providing basically no anti-coagulation therapy (NO-TX group: n=287); those admitted to hospitals routinely providing such treatment (anti-thrombin concentrate and/or rh-thrombomodulin or other anti-coagulants such as heparin/heparinoids: DO-TX group: n=1202); and those admitted to hospitals providing treatment at the discretion of the physician-in-charge (DEP-TX group: n=446). Results: In DIC patients only, in-hospital mortality was much higher in the NO-TX group (46.2%) than in the DO-TX group (34.1%) despite comparable APACHE II scores. The hazard ratio (HR) of mortality was much lower in the DO-TX group (0.76, 95% CI: 0.61-0.96) than in the NO-TX group (set at 1.0). When non-DIC subjects whose records contained complete information on JAAM and ISTH scores were also included (n=2513), however, different treatment protocols were no longer associated with differences in HR. Nevertheless, in-hospital mortality rates still differed among the three groups even after non-DIC patients were included. Conclusions: Thus, the present results support the use of anti-coagulation treatments for septic DIC and suggest that outcomes are affected by other institutional factors besides anti-coagulation protocol, such as an institutional approach to sepsis. The mechanisms underlying this effect should be clarified.