Disclosure of Diagnosis and Prognosis to Cancer Patients in Traditional Societies: A Qualitative Assessment from Lebanon

Background: The issue of when, how, and whether to disclose full information about cancer diagnosis and prognosis to patients is still debated in some parts of the world, including Lebanon. Despite formal academic emphasis on a larger autonomy for Lebanese patients in deciding the course of their disease, there has been no apparent impact on either clinical practices nor public expectations.  The topic of full disclosure is rarely if ever discussed in open fora, or in mass media channels in Lebanon. Subjects and Method: Seven key stakeholders were identified and interviewed regarding obstacles to spelling out clear guidelines within our national context. The interviews were transcribed and subsequently analyzed for recurrent patterns and concepts.Results: Senior oncologists interviewed generally favored gradual disclosure and most perceived a changing trend among both patients and physicians towards more disclosure. They also agreed on a need for the formal training of residents and fellows to better communicate bad news to patients. All the interviewed physicians attested to the benefits of candid disclosure in terms of patient psychology and overall wellbeing. They also mentioned that psychological services, which may facilitate the disclosure process, are greatly under-utilized in oncology. Lawyers highlighted the vagueness of the current Lebanese legislation regarding the obligation of truthful disclosure in comparison to laws in developed countries and the implications on patient autonomy. Conclusion: The study identified the need for improvements at various levels, including interventions to modify the expectations of the Lebanese public regarding cancer disclosure and to clarify existing legislative texts.Keywords: Ethics; Legislation; Middle-East; DisclosureCorrespondence: James Feghali. Faculty of Medicine, American University of Beirut (AUB), Lebanon, 1101 North Calvert Street, 610, Baltimore, Maryland, 21202. E-mail: [email protected]. Telephone: +1-(267)-595-9995.Journal of Epidemiology and Public Health (2019), 4(2): 109-116https://doi.org/10.26911/jepublichealth.2019.04.02.0

Characteristics and comparative clinical outcomes of prisoner versus non-prisoner populations hospitalized with COVID-19

Prisons in the United States have become a hotbed for spreading COVID-19 among incarcerated individuals. COVID-19 cases among prisoners are on the rise, with more than 143,000 confirmed cases to date. However, there is paucity of data addressing clinical outcomes and mortality in prisoners hospitalized with COVID-19. An observational study of all patients hospitalized with COVID-19 between March 10 and May 10, 2020 at two Henry Ford Health System hospitals in Michigan. Clinical outcomes were compared amongst hospitalized prisoners and non-prisoner patients. The primary outcomes were intubation rates, in-hospital mortality, and 30-day mortality. Multivariable logistic regression and Cox-regression models were used to investigate primary outcomes. Of the 706 hospitalized COVID-19 patients (mean age 66.7 ± 16.1 years, 57% males, and 44% black), 108 were prisoners and 598 were non-prisoners. Compared to non-prisoners, prisoners were more likely to present with fever, tachypnea, hypoxemia, and markedly elevated inflammatory markers. Prisoners were more commonly admitted to the intensive care unit (ICU) (26.9% vs. 18.7%), required vasopressors (24.1% vs. 9.9%), and intubated (25.0% vs. 15.2%). Prisoners had higher unadjusted inpatient mortality (29.6% vs. 20.1%) and 30-day mortality (34.3% vs. 24.6%). In the adjusted models, prisoner status was associated with higher in-hospital death (odds ratio, 2.32; 95% confidence interval (CI), 1.33 to 4.05) and 30-day mortality (hazard ratio, 2.00; 95% CI, 1.33 to 3.00). In this cohort of hospitalized COVID-19 patients, prisoner status was associated with more severe clinical presentation, higher rates of ICU admissions, vasopressors requirement, intubation, in-hospital mortality, and 30-day mortality

LVOT obstruction and severe aortic regurgitation caused by anterolateral muscle bundle of the left ventricle: The embryologic remnant of the bulbo-atrioventricular flange

Background An anterolateral muscle bundle runs along the wall of the left ventricular outflow tract (LVOT) and may extend up to the level of aortic valve (AV). The muscle bundle may occasionally bulge into the LVOT without causing significant obstruction. Case A 53 year old female patient presented with worsening chest discomfort and exercise intolerance. Initial TTE showed ejection fraction of 56% and AV area (AVA) of 0.66 cm2 indicative of severe stenosis, but with peak gradient of 29 mmHg. However, TEE showed very mild aortic stenosis with 3D aortic valve planimetry measuring 1.8 cm2. TEE showed hypertrophied basal septum (thick membrane connecting mitral leaflet with AV). The thickened septum was causing severe LVOT obstruction (LVOT area was 0.85 cm2) and a tertiary cord was attached to its base. The septum attaches to the right coronary cusp causing restriction and severe regurgitation. Cardiac catheterization showed severe stenosis at the LVOT. Decision-making The findings are indicative for anterolateral muscle bundle causing LVOT obstruction, rather than primary AV pathology. Hence, patient underwent septal myectomy, resection of subaortic membrane, and AV repair successfully. Post-myomectomy TTE showed minimal stenosis with AVA of 1.34 cm2. Conclusion LVOT obstruction can be caused by hypertrophied anterolateral muscle bundle in the absence of primary valvular pathology. Proper diagnosis is crucial since resection of the subaortic membrane and septal myectomy is the treatment of choice

EFFECT OF CLASS OF BETA-BLOCKERS, CARDIOSELECTIVE VERSUS NON-CARDIOSELECTIVE, ON COPD EXACERBATIONS IN PATIENT WITH COPD AND CARDIOVASCULAR DISEASES

Background: Several guideline committees and experts advocate cardioselective beta-blockers (βB) over non-cardioselective βB use in patients with heart disease and chronic obstructive pulmonary disease (COPD), as a safer option to reduce COPD exacerbations. We sought to test this hypothesis using a meta-analysis and meta-regression of available studies. Methods: Pubmed, and MEDLINE were searched for relevant studies. Risk ratio (RR) of COPD exacerbations was calculated using the Mantel Haenszel random effect model and a meta-regression analysis was performed using the percentage of patients using cardioselective βB in each trial as a moderator variable. Results: Data from 10 studies comprising 75,504 patients were included. There was no statistically significant difference in the rate of COPD exacerbations and/or COPD related hospitalizations with cardioselective vs non-cardioselective βB (RR: 1.02, 95% CI: 0.88 - 1.18), figure 1A. When controlling for the percentage of cardioselective βB use in each trial as a moderate variable, there was no significant change in heterogeneity (Tau2: 0.09, p \u3c0.001) and there was no correlation between the percentage of patients used cardioselective βB in each study and the change in COPD exacerbations and/or COPD related hospitalizations, figure 1B. Conclusion: We found no evidence to support that cardioselective βB were associated with a lower risk of COPD exacerbations compared to non-cardioselective βB

EFFECT OF BETA-BLOCKERS CLASS, CARDIOSELECTIVE VERSUS NON-CARDIOSELECTIVE, ON MORTALITY IN PATIENTS WITH COPD AND CARDIOVASCULAR DISEASE

Background: Chronic obstructive pulmonary disease (COPD) and cardiovascular disease often coexist, and the presence of heart disease increases mortality in patients with COPD and vice versa. Whenever indicated, cardioselective beta-blockers (βB) are often recommended over non-cardioselective βB in patients with COPD. We sought to clarify the evidence supporting this approach. Methods: We searched Pubmed and MEDLINE for relevant studies. We calculated the risk ratio (RR) of mortality using the Mantel Haenszel random effect model. We performed a meta-regression analysis using the percentage of patients using cardioselective βB in each trial as a moderator variable. Results: Data from 14 studies comprising 91,714 patients were included. There was no significant difference in overall mortality between patients who received cardioselective vs. non-cardioselective βB (RR: 1.01, 95% CI: 0.90 - 1.12), figure 1A. However, when using the percentage of patients taking cardioselective βB as a moderator variable, heterogeneity became moderate (Tau2: 0.01, P: 0.01, R2: 0.79), and there was a strong correlation between the percentage of cardioselective βB used in each trial and the reduction in mortality, such as when the percentage of patients using cardioselective βB in the study increases, the reduction in mortality is higher, figure 1B. Conclusion: Cardioselective βB use may be associated with lower mortality in COPD patients. This hypothesis should be tested in a formal randomized controlled trial

Cryptococcus neoformans automated implantable cardioverter-defibrillator (aicd) endocarditis: A challenging case of a rare fungal endocarditis

Background Fungal endocarditis is a rare form of endocarditis accounting for less than 2% of all cases. Common offending pathogens include: Candida and Aspergillus. Cryptococcal endocarditis is extremely rare with only ten prior cases reported. To our knowledge, only one prior case of AICD-associated cryptococcal endocarditis was described in the literature. Case A 57-year-old female patient presented to the emergency department with headache, fatigue, and a near-syncope event. Her past medical history includes ischemic cardiomyopathy with AICD implantation and vasculitis (on prednisone and cyclophosphamide). Examination was unremarkable. CT scan of the head was negative for acute intracranial process. In lieu of persistent headache, lumbar puncture (LP) was performed revealing lymphocytic pleocytosis. Transthoracic and transesophageal echocardiography revealed vegetations on the ventricular lead of the defibrillator measuring 2.0 × 0.67 cm. Decision-making Patient was initially started on IV vancomycin before adding flucanzole empirically to the regimen given her immunosuppressed status and lymphocytic pleocytosis on LP. On the 4th day of admission, two sets of blood cultures grew Cryptococcal Neoformans. Hence, patient was switched into amphotericin B and flucytosine for 2 weeks before resuming fluconazole. Concomitantly, a decision was made to remove the AICD device along with leads to achieve source control. Despite lack of data on proper duration of treatment, high-dose fluconazole was continued for a total of 4 weeks (one year is typically recommended in cryptococcal meningitis). Patient improved gradually before achieving complete recovery, without relapse. Conclusion Cryptococcal endocarditis is an extremely rare event with no prior standardized treatment protocol established. Hence, treatment duration with antifungals need to be individualized. Following an initial inductive phase, prolonged suppressive therapy with Fluconazole might be warranted to prevent recurrence, especially in immunocompromised patients. AICD-related infections mandate device removal. Surgical intervention has no clear indication but should be considered

Clinicopathological implications of prkar1a mutation in patients with cardiac myxoma: Pooled data analysis from 101 myxoma cases

Background PRKAR1A is a novel genetic mutation traditionally linked to Carney Complex (CNC) and cardiac myxoma. We hypothesized that presence of PRKAR1A mutation (Mut+) identifies a subset of cardiac myxoma patients with distinct clinicopathologic features from those without the mutation (Mut-). Methods We searched PubMed, Web of Science, and Scopus from inception to September 2019 to identify individual patient data of cardiac myxoma cases. Cases were included if the mutational status of PRKAR1A gene was reported. Extracted data included: mutational status, age at diagnosis, gender, location of myxoma, multifocality, recurrence, and concomitant extra-cardiac myxomas. Results Twenty-six articles reporting on 101 individual myxoma cases with known PRKAR1A mutational status were identified. Mean age at diagnosis was 36.6 ± 16.1 years. Two-third of the cases were females (n=62), 82% of cases were Mut+ (n=83), and 93.9% (n=78) met criteria for CNC. Mean age at diagnosis for the Mut+ group and Mut- group were 35.2 and 43.3 years, retrospectively (p-value = 0.058). Overall, left atrium was the most common location for myxomas (58%). While all myxoma cases in the Mut- group were localized to the left atrium, multi-chamber myxomas occurred exclusively in patients with the mutation (p-value= 0.003). Similarly, 96% of all cases of multiple cardiac myxomas occurred in the Mut+ group. The risk of developing multiple myxomas was significantly higher in the Mut+ compared to Mut- group (RR= 4.1, p-value= 0.03). Myxoma recurrence after resection occurred in 20.8% (n=21) of all cases, 20 of them were in the Mut+ group. Time duration from surgical resection to recurrence had a mean of 7.3 ± 5.7 years. Similarly, Mut+ carried a significantly higher risk of developing extra-cardiac myxomas compared to Mut- (p-value= 0.009), as 90.6% of extra-cardiac myxomas occurred in individuals harboring the mutation. Conclusion PRKAR1A mutation identifies a subset of cardiac myxoma patients with dismal clinicopathologic features, including higher risk for multifocality, recurrence, and developing extra-cardiac myxomas. Screening for PRKAR1A mutation might need to be considered routinely at the time of diagnosis

Beta-blocker use in patients with chronic obstructive pulmonary disease: A systematic review: A systematic review of βB in COPD

Beta-blockers (βB) are a frequently used class of medications. Although βB have many indications, those related to cardiovascular disease are among the most common and important. However, in patients with chronic obstructive pulmonary disease (COPD), βB are used less often due to concerns about an unfavorable impact on respiratory morbidity and mortality. We performed a systematic review to assess the safety of βB in patients with COPD. We included a total of 2 randomized controlled trials and 28 observational studies. The majority found statistically significant reductions in mortality. The two higher quality observational studies reported increased mortality with βB. The risk of COPD exacerbations was reduced in about half of the studies. Nonetheless, there were significant biases that confounded the results. The highest quality RCT found a significant increase in severe and very severe COPD exacerbations with βB use. In conclusion, data on the safety of βB in patients with COPD are conflicting. However, given higher quality evidence showed harm with their use, βB should be prescribed with caution in patients with COPD, including patients with cardiac indication for βB

Disclosure of Diagnosis and Prognosis to Cancer Patients in Traditional Societies: A Qualitative Assessment from Lebanon

Background: The issue of when, how, and whether to disclose full information about cancer diagnosis and prognosis to patients is still debated in some parts of the world, including Lebanon. Despite formal academic emphasis on a larger autonomy for Lebanese patients in deciding the course of their disease, there has been no apparent impact on either clinical practices nor public expectations. The topic of full disclosure is rarely if ever discussed in open fora, or in mass media channels in Lebanon. Subjects and Method: Seven key stakeholders were identified and interviewed regarding obstacles to spelling out clear guidelines within our national context. The interviews were transcribed and subsequently analyzed for recurrent patterns and concepts. Results: Senior oncologists interviewed generally favored gradual disclosure and most perceived a changing trend among both patients and physicians towards more disclosure. They also agreed on a need for the formal training of residents and fellows to better communicate bad news to patients. All the interviewed physicians attested to the benefits of candid disclosure in terms of patient psychology and overall wellbeing. They also mentioned that psychological services, which may facilitate the disclosure process, are greatly under-utilized in oncology. Lawyers highlighted the vagueness of the current Lebanese legislation regarding the obligation of truthful disclosure in comparison to laws in developed countries and the implications on patient autonomy. Conclusion: The study identified the need for improvements at various levels, including interventions to modify the expectations of the Lebanese public regarding cancer disclosure and to clarify existing legislative texts