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The approval of anti-PD-L1 drugs, including atezolizumab/pembrolizumab in triple-negative breast cancer (TNBC), potentially improveme treatment regimens available for TNBC.We conducted a meta-analysis to review the efficacy of atezolizumab/pembrolizumab for the treatment of TNBC in both the adjuvant and neoadjuvant settings. We calculated standardized mean difference (SMD) for the associations of progression-free survival (PFS) and overall survival (OS) and odds ratios (ORs) to estimate objective response rate (ORR) and pathological complete response (pCR), using 95% confidence intervals (CIs).Six clinical trials comprising 3612 patients were included. For adjuvant therapies, the ORR (OR = 1.26, P = 0.04) of atezolizumab/pembrolizumab plus chemotherapy was higher in the intention to treat (ITT) arms than the placebo groups in TNBC. A positive effect size was found for PFS in the ITT arms (d = 1.55, P 0.001). The atezolizumab plus chemotherapy group had a positive effect size for OS compared to control groups (d = 0.52, P 0.001). In the neoadjuvant setting, patients in ITT arms had higher pCR rates than the control groups (OR = 1.61, P = 0.001).We collate evidence of atezolizumab/pembrolizumab as viable therapeutics among patients with TNBC with PD-L1 subgroups deriving higher benefits.PLAIN LANGUAGE SUMMARYImmune checkpoint inhibitors (ICI), atezolizumab and pembrolizumab, have received approval for patients with triple-negative breast cancer (TNBC) expressing PD-L1. Thus far, it has only been approved for patients with unresectable locally advanced or metastatic TNBC. With the IMpassion 130 and KEYNOTE-355 trials introducing the immunotherapy era for TNBC, ongoing trials have started exploring the outcomes of the ICIs in early-stage TNBC in combination. Recently, the ICIs have demonstrated positive efficacy outcomes in neoadjuvant settings. Both the ICIs have shown a safe profile in terms of adverse events. The recent advances made by clinical trials indicate promising results for early-stage and advanced/metastatic TNBC. However, there is a need to harmonize and explore biomarkers and endpoints in the ongoing clinical trials to enhance patient treatment protocols. As TNBC is an aggressive subtype, exploring beyond the PD-L1 positive subgroup is necessary to expand the target population receiving ICIs for TNBC.

Intracerebral hemorrhage (ICH) remains a common and debilitating form of stroke. This neurological emergency must be diagnosed and treated rapidly yet effectively. In this article, we review the medical, surgical, repair, and regenerative treatment options for managing ICH. Topics of focus include the management of blood pressure, intracranial pressure, coagulopathy, and intraventricular hemorrhage, as well as the role of surgery, regeneration, rehabilitation, and secondary prevention. Results of various phase II and III trials are incorporated. In summary, ICH patients should undergo rapid evaluation with neuroimaging, and early interventions should include systolic blood pressure control in the range of 140 mmHg, correction of coagulopathy if indicated, and assessment for surgical intervention. ICH patients should be managed in dedicated neurosurgical intensive care or stroke units where continuous monitoring of neurological status and evaluation for neurological deterioration is rapidly possible. Extravasation of hematoma may be helpful in patients with intraventricular extension of ICH. The goal of care is to reduce mortality and enable multimodal rehabilitative therapy.

ObjectiveTo identify the beneficial effects of thrombectomy capable hospitals (TCHs), by comparing the incidence of in-hospital adverse events and discharge outcomes among patients with ischemic stroke treated at thrombectomy capable and non-thrombectomy capable hospitals in the United States.MethodsWe used the data from the Nationwide Inpatient Sample from January 2012 to December 2017. Thrombectomy capable hospitals were identified based on the number of thrombectomy procedures performed by a hospital each year among patients with ischemic stroke. If a hospital performed 10 or more thrombectomy procedures, it was labelled a TCH. The inclusion criteria were age ≥18 years, and ischemic stroke (International Classification of Diseases 433 .x1-434.x1 (ICD-9) or I63 (ICD-10)) as primary discharge diagnosis. A comparative analysis of propensity-matched patient groups was done to study the influence of TCH admissions on in-hospital outcomes.ResultsA total of 2 826 334 patients with primary ischemic stroke were identified. In a multivariate logistic regression model after adjusting for age, sex, race/ethnicity, hospital teaching status, comorbidities, and all patients refined diagnosis-related groups-based disease severity, patients admitted to a TCH were found to have low incidence of in-hospital adverse events: pneumonia (OR=0.86, 95% CI 0.78 to 0.93), urinary tract infection (OR=0.87, 95% CI 0.84 to 0.91), sepsis (OR=0.91, 95% CI 0.81 to 1.02), and pulmonary embolism (OR=0.89, 95% CI 0.77 to 1.03); in-hospital death (OR=0.82, 95% CI 0.78 to 0.88); and higher rate of home discharge (OR=1.09, 95% CI 1.06 to 1.12).ConclusionsA decrease in-hospital adverse events and improved discharge outcomes were observed among patients with ischemic stroke admitted to a TCH compared with a non-TCH.

Genomic aberrations comprise hallmarks of multiple myeloma (MM), a plasma cell malignancy with an overall poor prognosis. MM is heterogeneous and has different molecularly-defined subtypes according to varying clinical and pathological features. Hyperdiploidy or non-hyperdiploidy has usually been identified as early initiating genetic events that can be followed by secondary aberrations, including copy number changes, secondary translocations, and different epigenetic modifications, which cause immortalization of plasma cell and disease progression. Even though recent advances in drug discovery have offered new perspectives of treatment, MM remains incurable. However, understanding the molecular complexity of MM would allow patients to get precision treatment. Our review focuses on current evidence in myeloma biology with special attention to genomic and molecular variations.

Triple negative breast cancer (TNBC) has a higher mRNA expression of programmed cell death ligand 1 (PD-L1) which is a ligand to programmed cell death protein 1 (PD-1). The binding of the ligand leads to suppressed activity of T-cell-mediated immune response against cancer cells. The approval of anti-PD-L1 drugs including pembrolizumab and atezolizumab in subgroups of TNBC offer potential improvement to the current treatment regimens available for TNBC. We conducted a meta-analysis to review the efficacy of pembrolizumab and atezolizumab for the treatment of TNBC in both adjuvant and neo-adjuvant settings. A systematic strategy was used as per the PRISMA 2020 statement. All statistical analyses were conducted using Review Manager 5.4. Outcome measures included objective response rate, progression free survival, overall survival in adjuvant therapy groups, and pathological complete response rates in neoadjuvant groups. Six clinical trials were included. For adjuvant therapies, the ORR (OR=1.26, P = 0.04) of Atezolizumab/Pembrolizumab plus chemotherapy was higher in intention to treat (ITT) arms than the placebo groups in TNBC. A positive effect size was found for PFS in the ITT arms (Cohen’s d = 1.55, P

Introduction Granulomatous infections are common in patients with chronic lung disease. We aim to study the incidence and clinicopathological features of granulomatous infections in a cohort of patients undergoing lung transplantation for end-stage chronic lung disease. Methods Pathology reports of 50 explanted native lungs of patients who underwent lung transplantation since 2015 at our institution were reviewed. Four cases with granulomatous lesions were identified. Correlation was made with clinical findings in the 4 cases. Results The granulomatous infections include non-necrotizing cryptococcal pneumonitis (case 1), necrotizing pneumonia due to Scedosporium sp. and Mycobacterium avium Complex (MAC) (Cases 2 and 3), and invasive Aspergillus pneumonia (Case 4). One patient received pre-transplant fungal prophylaxis (Case 4). Post-transplant infectious complications included invasive (Cases 2 and 4) and non-invasive (Case 1) fungal infections and bacterial pneumonia (Cases 1 and 2). Two patients (Cases 3 and 4) developed acute cellular rejection (ACR) in the first 30 days. The third patient (Case 1) was identified with ACR in the 9 months post-transplant and chronic lung allograft dysfunction at 29 months. In terms of mortality, 1 patient (Case 1) died at 30 months post-transplant from pseudomonal sepsis and chronic graft failure. Two patients with invasive fungal infections (Cases 2 and 4) are on secondary prophylaxis and doing well. One patient (Case 3) remains infection-free and on MAC prophylaxis. Conclusions In our case series, patients with chronic lung diseases with superimposed granulomatous infestations frequently experienced post-transplant complications. These include invasive infections and repeat ACRs that predispose patients to chronic graft dysfunction. Pre- and post-transplant antifungal prophylaxis reduces fungal load and complication risk post-transplant.

Objectives: The objective of this research was to determine the occurrence of Dyslipidemia and Microalbuminuria among those patients who have recently been diagnosed as Hypertensive. Methodology: This research was carried out at Mayo Hospital, Lahore from April 2017 to June 2018 on a total of 200 newly diagnosed hypertensive patients (both male and female) who were in the age bracket of 30 years to 50 years. The renal function test was normal among these patients (S/ Creatinine < 0.5 – 1.5 mg/dl). Patients were assessed for blood pressure, systolic pressure and diastolic pressure after being in a steady state for five minutes. First Krotokoff sound was considered as systolic blood pressure and the disappearance of the sound was considered as diastolic blood pressure. The calculation of Microalbuminuria was made with the estimation of Albumin within twenty-four hours of urine sample which was taken in sterilized bottles for the determination of Microalbuminuria occurrence among hypertensive patients. Serum Fasting lipid profile was taken after eight hours overnight fasting for the assessment of dyslipidemia among patients who were diagnosed or not diagnosed with Microalbuminuria. Results: Majority of the patients (n = 76, 38%) were in the age range of 41 years to 45 years followed by 55 patients (27.5%) in the age range of 46 years to 50 years. The age bracket of 36 years to 40 years included 42 patients (21%); whereas, the least common age bracket of 30 years to 35 years included 27 patients (13.5%). The age of the patients was in the range of 30 – 50 years with a mean age of (38.65 ± 3.43) years. In total research sample of 200 patients, there were 117 males (57.5%) and 83 females (42.5%). Microalbuminuria frequency was found among 76 newly diagnosed hypertensive patients (38%); whereas, 124 patients (62%) did not present an onset of microalbuminuria. We found dyslipidemia in 73 patients (36.5%). Conclusion: Newly diagnosed hypertensive patients presented a higher frequency of both dyslipidemia and microalbuminuria. Therefore, the treatment and management of both dyslipidemia and microalbuminuria are very much essential for newly developed hypertension among patients. Keywords: Hypertension, Hypertensive, Frequency, Occurrence, Dyslipidemia, Microalbuminuria, Blood Pressure, Diastolic, Systolic and Renal Function.

Background: To know about non-cardiac chest pain is burden step on health resources. It requires various expensive medical testing. Objective: this study aims at identification and examination of low risk chest pain admissions in term of stress testing. Duration: Time period for this study was 4 months. research was completed at Mayo Hospital Lahore from Feb, 2017 to Jan 2018. Patients and Methods: Patients with atypical chest pain having no prior history of coronary artery disease, were selected. Risk factors for coronary artery disease was elevated. Adverse cardiac events regarding patients were reviewed and 30 days’ re-hospitalization was done. Results: Total 164 patients were selected with mean age of 60 years. Males were 33.5% various risk factors were taken into account such as hypertension, smoking etc. two patients had positive troponin and undergoes through subsequent negative stress tests. In 48% patients, stress test was performed 2.6% test were positive and 97.4% were negative. Positive test shows normal coronary arteries. Conclusion: Stress testing in low risk chest pain patients is not beneficial. Keywords: Stress testing, Chest Pain, Cardiac pain, low risk.

Context Palliative care (PC) physicians are vulnerable for burnout given the nature of practice. The burnout frequency may be variable and reported between 24% and 38% across different countries. Objective The main objective of our study was to determine the frequency of burnout among PC physicians participating in PC continuing medical education course. Methods A survey including the Maslach Burnout Inventory—General along with 41 custom questions were administered to determine the frequency of burnout among physicians attending the 2018 Hospice and Palliative Medicine Board review course. Results Of 110 physicians, 91 (83%) completed the survey. The median age was 48 years with 65% being females, 81% married, 46% in community practice, 38% in practice for 6–15 years. PC was practiced ≥50% of the time by 62%, and 76% were doing clinical work. About 73 (80%) reported that PC is appreciated at their work, 58 (64%) reported insurance to be a burden, and 58 (64%) reported that the electronic medical record was a burden. About 82 (90%) felt optimistic about continuing PC in future. Maslach Burnout Inventory results suggest that 35 (38%) participants reported at least one symptom of burnout. Only being single/separated showed trend toward significance with burnout (P = 0.056). Conclusion Burnout among PC physicians who attended a board review course was 38%. Being single/separated showed trend toward association with burnout. Physicians who choose to attend continuing medical education may have unique motivating characteristics allowing them to better cope with stress and avoid burnout.