Overcrowding in the emergency departments: challenges and opportunities for improvement

With the advent of Emergency Medicine, one can observe an increase in the number of Emergency Departments (ED) across the country. However, most EDs struggle due to an overwhelming number of patients. Overcrowding can lead to delays in patient care. For a city like Karachi which is an active disaster zone, preemptive preparedness is required in the face of terror threats and such overcrowding needs to be decreased to a bare minimum. The most frequent causes of prolonged length of stay (LOS) in the ED include non-availability of in-hospital beds, delays in response to subspecialty consultations and escalating medical expenses. All of these can negatively impact patient care by putting patient safety at risk and patient care in jeopardy. There is an increased risk of unintentional medical errors and a concomitant increase in unwanted lawsuits. A few simple interventions which may help alleviate this situation to some extent have been discussed

Decision-making factors for an autologous stem cell transplant for older adults with newly diagnosed multiple myeloma: A qualitative analysis

PurposeA utologous stem cell transplant (ASCT) remains a standard of care among older adults (aged ≥65) with multiple myeloma (MM). However, heterogeneity in the eligibility and utilization of ASCT remains. We identified decision-making factors that influence ASCT eligibility and utilization among older adults with MM.MethodsA qualitative study across two academic and two community centres in Ontario was conducted between July 2019-July 2020. Older adults with MM (newly diagnosed MM aged 65-75 in whom a decision had been made about ASCT in <12 months) and treating oncologists completed a baseline survey and a subsequent interview, which was analyzed using thematic analysis.ResultsEighteen patients completed the survey and 9 follow-up interviews were conducted. Patients were happy with their treatment decision with “trust in their oncologist” and “wanting the best treatment” as the most important to proceed with ASCT. “Afraid of side effects” was the most common reason for declining ASCT. Fifteen oncologists completed the survey and 10 follow-up interviews were conducted. Most relied on the ‘eye-ball’ test for ASCT eligibility over geriatric screening tools. The lack of both high-quality evidence and local guidelines impacted decision-making. Both oncologists and patients felt that chronological age alone should not affect ASCT eligibility.ConclusionWhile decision-making factors regarding ASCT can be variable, both oncologists and patients indicated that chronological age alone should not represent a barrier for ASCT among older adults. Future simplification and incorporation of ASCT eligibility geriatric assessment tools in studies as well as the inclusion of these tools in local guidelines may further improve ASCT decision-making

Characteristics of post hoc subgroup analyses of oncology clinical trials: A systematic review

BACKGROUND: Subgroup analyses in clinical trials assess intervention effects on specific patient subgroups, ensuring generalizability. However, they are usually only able to generate hypotheses rather than definitive conclusions. This study examined the prevalence and characteristics of post hoc subgroup analysis in oncology. METHODS: We systematically reviewed published subgroup analyses from 2000 to 2022. We included articles presenting secondary, post hoc, or subgroup analyses of interventional clinical trials in oncology, cancer survivorship, or cancer screening, published separately from the original clinical trial publication. We collected cancer type, year of publication, where and how subgroup analyses were reported, and funding. RESULTS: Out of 16 487 screened publications, 1612 studies were included, primarily subgroup analyses of treatment trials for solid tumors (82%). Medical writers contributed to 31% of articles, and 58% of articles reported conflicts of interest. Subgroup analyses increased significantly over time, with 695 published between 2019 and 2022, compared to 384 from 2000 to 2014. Gastrointestinal tumors (25%) and lymphoid lineage tumors (39%) were the most frequently studied solid and hematological malignancies, respectively. Industry funding and reporting of conflicts of interest increased over time. Subgroup analyses often neglected to indicate their secondary nature in the title. Most authors were from high-income countries, most commonly North America (45%). CONCLUSIONS: This study demonstrates the rapidly growing use of post hoc subgroup analysis of oncology clinical trials, revealing that the majority are supported by pharmaceutical companies, and they frequently fail to indicate their secondary nature in the title. Given the known methodological limitations of subgroup analyses, caution is recommended among authors, readers, and reviewers when conducting and interpreting these studies

Impact of Second Primary Malignancy Post–Autologous Transplantation on Outcomes of Multiple Myeloma: A CIBMTR Analysis

The overall survival (OS) has improved significantly in multiple myeloma (MM) over the last decade with the use of proteasome inhibitor and immunomodulatory drug-based combinations, followed by high-dose melphalan and autologous hematopoietic stem cell transplantation (auto-HSCT) and subsequent maintenance therapies in eligible newly diagnosed patients. However, clinical trials using auto-HSCT followed by lenalidomide maintenance have shown an increased risk of second primary malignancies (SPM), including second hematological malignancies (SHM). We evaluated the impact of SPM and SHM on progression-free survival (PFS) and OS in patients with MM after auto-HSCT using CIBMTR registry data. Adult patients with MM who underwent first auto-HSCT in the United States with melphalan conditioning regimen from 2011 to 2018 and received maintenance therapy were included (n = 3948). At a median follow-up of 37 months, 175 (4%) patients developed SPM, including 112 (64%) solid, 36 (20%) myeloid, 24 (14%) SHM, not otherwise specified, and 3 (2%) lymphoid malignancies. Multivariate analysis demonstrated that SPM and SHM were associated with an inferior PFS (hazard ratio [HR] 2.62, P \u3c .001 and HR 5.01, P \u3c .001, respectively) and OS (HR 3.85, P \u3c .001 and HR 8.13, P \u3c .001, respectively). In patients who developed SPM and SHM, MM remained the most frequent primary cause of death (42% vs 30% and 53% vs 18%, respectively). We conclude the development of SPM and SHM leads to a poor survival in patients with MM and is an important survivorship challenge. Given the median survival for MM continues to improve, continued vigilance is needed to assess the risks of SPM and SHM with maintenance therapy post-auto-HSCT

Secondary Stabbing Headache Associated with COVID-19: a Case Report

Although COVID-19 is mainly an acute viral illness, persistent symptoms are common. However, headache is not a frequent sequela of this disease. Furthermore, stabbing/ice-pick cephalalgia has been reported in \u3c 10% of cases of COVID-19, and recurrent forms occurring after vaccination against the disease have not been published yet. We present here an unusual short-lasting unilateral stabbing/ice-pick headache with recurrent periodicity over 10 months, which may represent a sequela of COVID-19. The cephalalgia presented in a 55-year-old male with no significant medical problems approximately 4 months after the acute onset of COVID-19, and recurred twice 12 days after the second dose of COVID-19 vaccination with BNT162b2 (Pfizer). This report represents a contribution to the semiological pattern of COVID-19-related cephalea

Validating a point of care lactate meter in adult patients with sepsis presenting to the emergency department of a tertiary care hospital of a low- to middle-income country

Background: Timely identification of high blood lactate levels in septic patients may allow faster detection of those patients requiring immediate resuscitation. Point-of-care (POC) testing is being increasingly utilized in the emergency department (ED). We examined the accuracy and time-saving effect of a handheld POC lactate device for the measurement of fingertip and whole blood lactate as compared with reference laboratory blood testing in septic ED patients.Methods: A convenience sample of adult ED patients receiving serum lactate testing were enrolled prospectively in the ED of a multidisciplinary tertiary care hospital serving the population of one of the major cities of Pakistan. Participants underwent fingertip POC lactate measurement with a portable device simultaneous whole blood sampling for analysis by both the POC lactate device and standard laboratory method. Lactate measurements were compared by intraclass correlation (ICC) and Bland and Altman plots.Results: Forty-three septic patients were included in the study. The fingertip POC & whole blood POC lactate measurements each correlated tightly with the reference method (ICC=0.93 & ICC=0.92, respectively). Similarly at 6 hours, the fingertip POC & whole blood POC lactate measurements demonstrated satisfactory correlation with the reference method (ICC=0.95 & ICC=0.97, respectively).Conclusion: Fingertip POC lactate measurement is an accurate method to determine lactate levels in septic ED patients

Gender disparities in multiple myeloma publications

Abstract Gender disparities exist in academia and are disproportionately affecting females. We conducted a cross‐sectional study to analyze gender disparities in multiple myeloma (MM) publications. A total of 679 publications with 8898 authorships were analyzed. The mean number of authors for females vs. males, per publication, was 4.4 and 8.7, respectively. Females constituted a third of the total authors. Female first authors, corresponding authors, and last/senior authors were 34%, 21%, and 18%, respectively. Note that, 17% of authors of clinical trial publications were females. Gender disparities in MM publications exist and are more obvious in the last/corresponding authorship. Efforts should be made to identify factors that contribute to these disparities and work to resolve them