Telemedicine in hematology; long-term implications of a short-term experience during COVID-19 pandemic

Telemedicine is healing at a distance, and it was under-utilized ever since its reintroduction till this COVID-19 pandemic. COVID-19 has moved the field of telemedicine and almost every health specialty has embraced it to provide remote, timely, safe health-care services to their patients from the comfort of their home and prevent undesired exposure to COVID-19 infection. With the reach of smart phones and cheaper internet data, this has reached tier II/III cities and is also making inroads in the rural areas. Telemedicine in hematology is becoming increasingly popular because many of the hematology patients are immunocompromised and are more prone to various infections including COVID-19. It is very beneficial in follow-up visits for benign disorders such as anemia, immune thrombocytopenia as well as certain chronic leukemias such as Myeloproliferative neoplasms and for the patients on oral therapy. Astronaut getting treated on NASA mission from the earth is ultimate telemedicine. COVID-19 pandemic has reinvented telemedicine which is helping not only patients in getting medical advice but also physicians and medical students in attending medical conferences and keep them up to date with advances in their field. After this pandemic end, telemedicine is here to stay along with the age-old personal visit like a hand in gloves.

Altered L-Arginine Metabolic Pathways in Gastric Cancer: Potential Therapeutic Targets and Biomarkers

There is a pressing need for molecular targets and biomarkers in gastric cancer (GC). We aimed at identifying aberrations in L-arginine metabolism with therapeutic and diagnostic potential. Systemic metabolites were quantified using mass spectrometry in 293 individuals and enzymes’ gene expression was quantified in 29 paired tumor-normal samples using qPCR and referred to cancer pathology and molecular landscape. Patients with cancer or benign disorders had reduced systemic arginine, citrulline, and ornithine and elevated symmetric dimethylarginine and dimethylamine. Citrulline and ornithine depletion was accentuated in metastasizing cancers. Metabolite diagnostic panel had 91% accuracy in detecting cancer and 70% accuracy in differentiating cancer from benign disorders. Gastric tumors had upregulated NOS2 and downregulated ASL, PRMT2, ORNT1, and DDAH1 expression. NOS2 upregulation was less and ASL downregulation was more pronounced in metastatic cancers. Tumor ASL and PRMT2 expression was inversely related to local advancement. Enzyme up- or downregulation was greater or significant solely in cardia subtype. Metabolic reprogramming in GC includes aberrant L-arginine metabolism, reflecting GC subtype and pathology, and is manifested by altered interplay of its intermediates and enzymes. Exploiting L-arginine metabolic pathways for diagnostic and therapeutic purposes is warranted. Functional studies on ASL, PRMT2, and ORNT1 in GC are needed.

Monoclonal antibodies used for management of hematological disorders

Objectives: Monoclonal antibodies (MAs) are increasingly becoming part of therapeutic armamentarium for hematologists and hemato-oncologists. There is paucity of review on majority of these antibodies in one place. The objective of this review is an attempt to fill the gap in paucity of review on majority of these monoclonal antibodies (MAs) in one place. Material and Methods: ‘Pubmed’ and ‘Scopus’ database was explored focusing on monoclonal antibodies (MAs) in clinical hematological practice. Emphasis was given to the more recently published review articles on different monoclonal antibodies (MAs). Results: In the present review, a total of 23 different monoclonal antibodies (MAs) were discussed; some are very frequently used and some rarely. Monoclonal antibodies (MAs) are used for treatment of diverse hematological conditions, i.e. malignant and benign disorders and at various phases of stem cell transplantation. These antibodies were used either alone or in combination with various chemotherapeutic agents, targeted small molecules or as immunoconjugates. Some of the side effect profiles of these antibodies were common and some were unique to the particular monoclonal antibody (MA). Unusual infections or organ dysfunctions were noted. Improved function of antibodies by protein engineering is also advancing rapidly. Dosage, frequency and route of administration depended on the convenience and condition for which the antibody is used. Conclusion: Monoclonal antibodies (MAs) are going to stay for hematological practice. Some amount of familiarity with their usage, advantages, disadvantages and side effects are essential in clinical practice.

Effects of COVID-19 pandemic in a breast unit: Is it possible to avoid delays in surgical treatment?

Background: COVID-19 pandemic has caused fear all around the world. With people avoiding hospitals, there has been a significant decrease in outpatient clinics. In this study, we aimed to compare and explore the first-peak of the pandemic period by studying its effects on patient applications, new diagnoses, and treatment approaches in a non-infected hospital. Methods: We collected data from the first peak of the pandemic period in Turkey, from the pandemic’s declaration (March 11, 2020) to social normalization (June 1, 2020), and compared it with data from a pre-pandemic period with a similar length of time. We analyzed the data of breast cancer patients from application to surgery. Results: The data of 34,577 patients were analyzed for this study. The number of patients who applied to outpatient clinics decreased significantly during the pandemic period. After excluding control patients and benign disorders, a figure was reached for the number of patients who had a new diagnosis of breast cancer (146 vs 250), were referred to neoadjuvant treatment (18 vs 34), and were treated with surgery (121 vs 229). All numbers decreased during the pandemic period, except for surgeries after neoadjuvant treatment (29 vs 27). Surgical treatment approaches also changed. However, the rate of newly diagnosed breast cancer patients treated with surgery was similar in both periods. None of these patients were diagnosed with COVID-19 or died during the pandemic. Conclusion: This study shows that non-infected hospitals can be useful in avoiding delays in the surgical treatment of cancer patients.

Malignant mesothelioma of the spermatic cord mimicking a benign inguinoscrotal swelling: case report with review of literature

Background Spermatic cord malignant mesotheliomas (SCM) are extremely rare tumours arising from the tunica vaginalis of the spermatic cord (only 18 cases reported—worldwide in the literature). Paratesticular malignant mesotheliomas (PMM) account for about 0.3–1.4% of all mesotheliomas, while those from the spermatic cord account for less than 10% of paratesticular tumours. Spermatic cord mesotheliomas may be overlooked commonly owing to its unique ability to mimic benign disorders associated with a thickened cord, leading to loss of timely management in many cases. Hence, this case report hence serves to provide pointers to the urologist/surgeon and alerts them towards timely diagnosis and early management of SCM’s besides adding to its limited literature. Case presentation We present a case of spermatic cord mesothelioma (SCM) in a 39-year-old male presenting to our clinic with persistentcomplaints of left inguinoscrotal swelling with a vague dull-aching, poorly localising pain sensation over the inguinoscrotal region associated with a persistent dragging sensation for more than a year. Initial evaluation suggested and inclined us towards the diagnosis a benign pathology (spermatocele); however, the persistence of symptoms (pain and swelling) despite prior therapeutic measures initiated elsewhere prompted us to consider an FNAC (which was benign) and surgical exploration which surprisingly revealed the diagnosis of SCM. Owing to the wide spread nature of the disease, the patient was started on palliative chemotherapy. He is currently is doing clinically well on a 1-year follow-up. Conclusion Spermatic cord malignant mesothelioma is an extremely rare tumour with an unique tendency to masquerade and mimic cord thickening also associated with several other benign groin/inguinoscrotal swellings. In all such cases, a high index of suspicion should be entertained by the urologist, even in the absence of classical risk factors for SCM like prior asbestos exposure while evaluating patients presenting with persistent expanding inguinoscrotal swellings associated with non-resolving symptoms.

Nonimmunoglobulin Crystal-Storing Histiocytosis (CSH): Case Report and Literature Review

Crystal-storing histiocytosis (CSH) is an uncommon condition in which histiocytes accumulate a crystalline matter within their cytoplasm. Generally, those crystals are composed of either monoclonal or polyclonal immunoglobulin chains, which have a strong association with an underlying lymphoproliferative or plasma cell disorder (LP-PCD). Rarely, CSH has been reported as local or generalized manifestation of a variety of benign disorders. These cases are associated with crystals composed of nonimmunoglobulin substances. We are reporting an exceptional case of a local colonic CSH with Charcot–Leyden crystals. This patient underwent a screening colonoscopy that detected some polyps. The biopsy reported tubular adenomas, with a markedly dense, transmural inflammatory infiltrates, which were predominantly composed of eosinophils and crystal-storing histiocytes containing Charcot–Leyden crystals. The patient had a negative workup for LP-PCD and autoimmune conditions, including a normal skeletal survey and bone marrow aspirate/biopsy. The only positive laboratory workup was an elevated absolute eosinophil count and a positive IgG anti-Strongyloides antibody. Giving those findings, this parasitic infection is the most likely etiology of the CSH in our patient. Although there was an initial negative evaluation for LP-PCD, close monitoring of patients with either immunoglobulin or nonimmunoglobulin CSH is recommended.

Spectrum of breast diseases in a rural himalayan region of Western Nepal: a hospital based study

Background: Breast diseases, among the most common diseases in females occur in various pat­terns from benign to malignant. Their identification is crucial as some of the benign disorders pose threat to turn into malignancy. This study was aimed to determine the spectrum of breast diseases. Methods: This was a hospital based retrospective study among all the patients in General Surgery OPD of Karnali Academy of Health Sciences, Teaching Hospital, diagnosed with breast diseases during one year period from August 2019 to July 2020 AD. Data were extracted and entered in SPSS version 16 for further analysis. Results: Out of 110 cases, only 4 (3.96%) were male. Almost half 54 (49.09%) of the cases were in the age group of 21-30 years. Fibrocystic disease, Breast Abscess and fibroadenoma, and cracked nipple were 39 (35.45%), 38 (34.54%, 15 (13.63%) and 8 (7.28%) respectively. The benign diseases were seen mostly in the younger population while malignant breast diseases were seen in the older population. Mastalgia was mostly seen in the twenties (17.3%) and the thirties (10%) while Breast abscess was commonly encountered in the twenties (16.4%) and the teens (11.8%). The gynaecomastia were seen only in four males. Conclusions: Fibrocystic breast diseases, Mastitis with or without abscess, fibroadenoma and cracked nipples were the first four most common breast diseases in females. The younger popula­tion had predilection towards the benign diseases which occurred most frequently in the third decade while the malignant occurred in sixth and seventh decade.

Prognostic Relevance of Significantly Raised CA 19-9 with Choledocholithiasis to Malignant Pathologies of HBS: An Early Experience in Dept. of Hepatobiliary Surgery at ShSMCH, Dhaka

Background: Conventionally it is assumed that raised level of CA 19-9 (Carbohydrate antigen 19-9) is related to malignancies of liver, pancreas and biliary tract. Through our early experience in Shaheed Suhrawardy Medical College Hospital we found that raised level of CA 19-9 is not associated only with malignancies but also with other benign disorders of HBS. The aim of this study was to explore the relationship of raised CA 19-9 with hepatobiliary disorders other than malignancies. Result: We encountered a total of 57 cases at our department of Hepatobiliary Surgery where patients presented with classical features of obstructive jaundice with pain, anorexia and vomiting. Routine investigations of USG and MRCP revealed stone disease in the CBD. Fiftyseven patients with obstructive jaundice were studied retrospectively. Serum CA19-9 levels and some additional biochemical parameters were evaluated before and after treatment. CA 19-9 levels were significantly elevated in most patients, along with levels of total bilirubin, alkaline phosphatase (ALP), and gamma glutamyl transpeptidase (GGT), and 10 patients with benign disorders had extraordinarily high levels of these markers (> 1000 U/mL). The mean CA 19-9 level in the malignant group was greater than that in the benign group (826.83 ± 557.34 vs. 401.92 ± 483.92 U/mL, P = 0.005), and the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for CA19-9 were 100%, 7.69%, 33.33% and 47.47%, respectively. CA19-9 levels in the whole cohort were correlated with ALP (r = 0.77, P < 0.001), GGT (r = 0.83, P < 0.001), bilirubin (r = 0.69, P < 0.001), and CRP (r = 0.37, P = 0.004). The reduction in serum level of CA19-9 after treatment in the malignant group was remarkably less than that observed in the benign group (97.26 ± 123.24 U/mL vs. 352.71 ± 397.29 U/mL, P < 0.001). CA 19-9 levels may not be sufficient to distinguish between malignant and benign obstructive jaundice diseases. So raised CA 19-9 can obviously denote any hepatobiliary disease other than malignancy that will start to decline 1 to 28 days later after extraction of stone. Conclusion: In conclusion, it is obvious that raised level of CA 19-9 is associated not only with malignancies but also with other benign disorders of HBS to a larger scale. J Shaheed Suhrawardy Med Coll, December 2019, Vol.11(2); 119-123

Miscellaneous Exogenous Hormones and Breast Diseases: A Matter of Concern for the Gynecologist

Background: The effect of exogenous sex hormones on the risk of breast cancer has been shown for some compounds but for other compounds it is under detailed investigation. This study, as part of a quadruple of articles reviewing the consequences of using sex hormones in women with various breast conditions, discusses the prescription of non-oral hormonal contraceptives and miscellaneous exogenous steroid hormones. Methods: We browsed international clinical guidelines and carried out a comprehensive search in the literature by relevant keywords in order to extract data about the effects of hormone-releasing intrauterine devices, injectable depot-medroxyprogesterone acetate, contraceptive implants, cyproterone acetate, finasteride, and spironolactone on the breast. Results: Studies are scarce for most of these compounds, and information comes mainly from researches about oral contraceptives and hormone replacement therapy. Although none is recommended for use in patients with breast cancer, administration in benign disorders of the breast, women with positive family history of breast cancer and general women is acceptable with minor risks. Conclusions: Most non-oral hormonal methods of contraception and miscellaneous available hormone compounds prescribed for the treatment of hormonal disorders are safe for temporary use, except for women with breast cancer. For them, analogues of gonadotropin-releasing hormones may be considered a safe hormonal prescription.