Ghosh, Aditya

Introduction: The incidence of cardiovascular events in the first 100 days post-HSCT was found to be 19%, with arrhythmia having the highest incidence of 12% (p<0.0001). The incidence of cardiovascular events is 6.7% in patients with multiple myeloma treated with HSCT (HSCT-MM) [1]. However, the literature on arrhythmia in HSCT-MM patients is limited. Given the high risk of cardiac events in HSCT patients, we aimed to determine the impact of arrhythmia in patients with HSCT-MM. Methods: We conducted a retrospective analysis using the National Inpatient Sample Database (2018-2021). Adult patients with HSCT-MM who were primarily admitted for life-threatening arrhythmias were identified using ICD-10 codes [2]. We performed propensity matching and multivariate regression, considering a p-value of ≤0.05 as significant. Results: In 14,232 HSCT-MM patients, 168 (1.2%) had arrhythmia. The prevalence of arrhythmia in HSCT-MM patients was higher than in the remaining HSCT recipients (1.2% vs 0.9%, p<0.01). In HSCT-MM, atrial fibrillation (69.6%) and atrial flutter (19%) were the common arrhythmias. Arrhythmia in HSCT-MM patients was more prevalent in those over the age of 60 years (84.5% vs 68.5%, p<0.001), males (72.6% vs 58.2%, p<0.001), and in the White race (84.8% vs 67.3%, p<0.001) compared to those without arrhythmia. Arrhythmia was less common in those with bone marrow dysfunction compared to those with normocellular marrow (anemia 1% vs 1.5%, p<0.01; thrombocytopenia 1% vs 1.2%, p>0.05; neutropenia 0.7% vs 1.3%, p<0.05; pancytopenia 0.9% vs 1.4%, p<0.01). Among the HSCT-MM patients with arrhythmia, long-term anticoagulation was less frequently given than those without arrhythmia (44.6% vs 55.4%, p<0.001). The arrhythmia cohort had less frequent acute kidney injury (19.1% vs 27.5%, p=0.01). The arrhythmia cohort required more vasopressors (2.4% vs 2.1%, p>0.05) but had lower mortality (1.2% vs 4.5%, p<0.05). Patients with arrhythmia had shorter hospital stays (Coefficient -3 days; 95% CI -3.8 to -2.3 days; p<0.001) and lesser hospital charges (Coefficient $-41,200; CI $-55,700 to $-26,600; p<0.001) compared to those without. However, the arrhythmia cohort had higher rates of acute heart failure (17.9% vs 9.1%, p<0.001) and the risk of acute heart failure was also higher in those with arrhythmia (adjusted odds ratio 2.2; 95% CI 1.3 to 3.6; p<0.01). In patients with acute heart failure and arrhythmia, atrial fibrillation was present in 76.7% and atrial flutter in 20%. In patients with acute heart failure and arrhythmia, bone marrow dysfunction was more common than normocellular bone marrow (anemia 22.2% vs 12.8%, p>0.05; thrombocytopenia 38.7% vs 13.1%, p=0.001; neutropenia 18.2% vs 14.3%, p>0.05; pancytopenia 8.7% vs 21.3%, p>0.05). In the arrhythmia cohort, long-term anticoagulation was commonly given in those with acute heart failure compared to those without (53.3% vs 46.7%, p>0.05), and acute kidney injury also occurred more frequently in those with heart failure (26.7% vs 17.4%, p>0.05). Conclusion: Acute heart failure is a serious risk associated with arrhythmia in multiple myeloma patients treated with HSCT, with atrial fibrillation emerging as the most common arrhythmia. It is essential to prevent heart failure in those with arrhythmia, especially in patients with thrombocytopenia. Preventive measures could include more frequent follow-ups and having a multidisciplinary team to manage renal failure, monitor anticoagulation, and ensure rhythm control in these patients. References: Aghel N, Lui M, Wang V, et al.: Cardiovascular events among recipients of hematopoietic stem cell transplantation-A systematic review and meta-analysis. Bone Marrow Transplant. 2023, 58:478-90. 10.1038/s41409-023-01928-22021 ICD-10-CM. Accessed: July 14, 2024. https://www.cms.gov/medicare/coding-billing/icd-10-codes/2021-icd-10-cm.

Background: Enterococci are the third most common cause of healthcare-associated infections in the United States, affecting 10-12% of all transplant recipients worldwide. Approximately 46% of patients with acute myeloid leukemia (AML) were found to be colonized with Enterococcus [1]. The risk of infection and its complications increases in patients treated with hematopoietic stem cell transplantation (HSCT). Given the high rates of Enterococcus colonization, we aimed to study the impact of Enterococcus infection in AML patients treated with HSCT. Methods: We conducted a retrospective analysis using the National Inpatient Sample Database (2018-2021). Adults over the age of 18 who were treated with HSCT for AML and had Enterococcus infections were identified using ICD-10 codes [2]. We performed the analysis using descriptive statistics and multivariate regression, with a p-value of less than 0.05 considered significant. Results: Of 40,462 HSCT patients, 1.3% (n=531) were admitted with Enterococcus infection. Among the HSCT recipients, Enterococcus infection was seen in 344 (1.4%) of 23,930 patients with all forms of Leukemia and in 134 (2.4%) of 5,693 patients with AML. There were no significant differences in sociodemographic factors such as age over 60 years, gender, or race between those with and without Enterococcus infection in the AML population (p>0.5). The AML-Enterococcus cohort had longer hospital stays (20.8 vs. 9.5 days, p<0.001) and higher total costs as compared to the AML-non-Enterococcus cohort ($373,619 vs. $147,075, p<0.001). Additionally, the AML-Enterococcus cohort had a higher prevalence of urinary tract infections (28.4% vs. 5.2%, p<0.001), fungal infections (13.4% vs. 8.6%, p<0.05), and acute respiratory failure (26.1% vs. 15.5%, p<0.001). Enterococcus infection was more common among patients with bone marrow dysfunction such as neutropenia (33.6% vs. 20.9%, p<0.001), anemia (79.9% vs. 57.6%, p<0.001), and pancytopenia (61.9% vs. 42.7%, p<0.001). Enterococcus infection also was associated with higher rates of severe sepsis (22.4% vs. 9.4%, p<0.001) and vasopressor usage (6.7% vs. 3%, p<0.05). Crude analysis indicated a higher mortality rate in the AML-Enterococcus cohort compared to the AML-non-Enterococcus cohort (16.1% vs. 8.8%, p<0.05). However, after adjusting for confounders, the mortality risk between the two cohorts was not significantly different (adjusted odds ratio 0.9, 95% CI 0.4-1.7, p>0.05). Similarly, the utilization of palliative care services did not differ between the two cohorts (12.7% vs. 9.8%, p>0.05). Conclusion: Enterococcus infection in the AML population who undergo HSCT poses a significant healthcare burden, resulting in longer hospital stays and higher healthcare costs. Patients with bone marrow dysfunction are at increased risk of Enterococcus infection and other opportunistic infections. For AML patients who have previously undergone transplantation and are hospitalized for sepsis, urinary tract infection, or respiratory failure, aggressive treatment with broad-spectrum antibiotics for Enterococcus is necessary. Due to the high crude mortality rate, it is essential to provide multidisciplinary care to reduce hemodynamic compromise and the potential need for vasopressor usage in these patients. It is important to consider Enterococcus as a differential diagnosis for any AML patient with HSCT presenting with a urinary tract infection or respiratory failure. Early recognition and treatment of Enterococcus infection could prevent lengthy hospital stays and reduce costs. References: Scheich S, Lindner S, Koenig R, et al.: Clinical impact of colonization with multidrug-resistant organisms on outcome after allogeneic stem cell transplantation in patients with acute myeloid leukemia. Cancer. 2018, 124:286-96. 10.1002/cncr.31045 2021 ICD-10-CM. Accessed: July 14, 2024. https://www.cms.gov/medicare/coding-billing/icd-10-codes/2021-icd-10-cm.

Abstract Purpose In 2019, the National Comprehensive Cancer Network (NCCN) recommended genetic testing for all patients with pancreatic ductal adenocarcinoma (PDAC). To evaluate the status of implementation of these guidelines in a loco-regional setting, we performed a retrospective, observational study among patients with newly diagnosed PDAC who received oncologic care at Northeast Georgia Medical Center in Georgia. Methods Chart abstraction of patients with newly diagnosed PDAC from January 1, 2020 to December 31, 2021, was performed to include information on genetic testing recommendation and completion, and time from diagnosis to testing. The deidentified dataset was then analyzed using appropriate descriptive and associative statistical testing. Results Of the cohort of 109 patients, 32 (29.4%) completed genetic screening; 16 (14.7%) were screened within 10 days of diagnosis. Among the 77 (70.6%) patients who did not receive genetic screening, 45 (41.3%) were not recommended genetic screening despite treatment intent with standard of care therapy. However, 32 (29.4%) were not recommended genetic screening in conjunction with a desire to pursue palliative care/hospice/or due to terminal illness. Conclusions The study highlighted the gap in implementation of NCCN guideline-directed genetic testing in PDAC patients as only a third underwent testing suggesting the need for systematic processes to facilitate testing. The test was more likely to be completed if done early in the course, especially soon after the diagnosis. Research is needed to explore discussing genetic testing for the large proportion of patients who are terminally ill at diagnosis where genetic screening would potentially benefit the family members.

Objective Persistent post-COVID symptoms are estimated to occur in up to 10% of patients who have had COVID-19. These lingering symptoms may persist for weeks to months after resolution of the acute illness. This study aimed to add insight into our understanding of certain post-acute conditions and clinical findings. The primary purpose was to determine the persistent post COVID impairments prevalence and characteristics by collecting post COVID illness data utilizing Patient-Reported Outcomes Measurement Information System (PROMIS ® ). The resulting measures were used to assess surveyed patients physical, mental, and social health status. Methods A cross-sectional study and 6-months Mayo Clinic COVID recovered registry data were used to evaluate continuing symptoms severity among the 817 positive tested patients surveyed between March and September 2020. The resulting PROMIS ® data set was used to analyze patients post 30 days health status. The e-mailed questionnaires focused on fatigue, sleep, ability to participate in social roles, physical function, and pain. Results The large sample size (n = 817) represented post hospitalized and other managed outpatients. Persistent post COVID impairments prevalence and characteristics were determined to be demographically young (44 years), white (87%), and female (61%). Dysfunction as measured by the PROMIS ® scales in patients recovered from acute COVID-19 was reported as significant in the following domains: ability to participate in social roles (43.2%), pain (17.8%), and fatigue (16.2%). Conclusion Patient response on the PROMIS ® scales was similar to that seen in multiple other studies which used patient reported symptoms. As a result of this experience, we recommend utilizing standardized scales such as the PROMIS ® to obtain comparable data across the patients’ clinical course and define the disease trajectory. This would further allow for effective comparison of data across studies to better define the disease process, risk factors, and assess the impact of future treatments.

Insulin regulates many cellular processes, but the full impact of insulin deficiency on cellular functions remains to be defined. Applying a mass spectrometry–based nontargeted metabolomics approach, we report here alterations of 330 plasma metabolites representing 33 metabolic pathways during an 8-h insulin deprivation in type 1 diabetic individuals. These pathways included those known to be affected by insulin such as glucose, amino acid and lipid metabolism, Krebs cycle, and immune responses and those hitherto unknown to be altered including prostaglandin, arachidonic acid, leukotrienes, neurotransmitters, nucleotides, and anti-inflammatory responses. A significant concordance of metabolome and skeletal muscle transcriptome–based pathways supports an assumption that plasma metabolites are chemical fingerprints of cellular events. Although insulin treatment normalized plasma glucose and many other metabolites, there were 71 metabolites and 24 pathways that differed between nondiabetes and insulin-treated type 1 diabetes. Confirmation of many known pathways altered by insulin using a single blood test offers confidence in the current approach. Future research needs to be focused on newly discovered pathways affected by insulin deficiency and systemic insulin treatment to determine whether they contribute to the high morbidity and mortality in T1D despite insulin treatment.