Cardiotoxicity is a feared side effect that may limit the clinical use of anthracyclines. It may indeed affect the quality of life and survival of patients with cancer, regardless of oncological prognosis. This paper provides an overview of anthracycline-induced cardiotoxicity in terms of definition, classification, incidence, risk factors, possible mechanisms, diagnosis, and treatment. We also report effective strategies for preventing cardiotoxicity. In addition, we discuss limiting current approaches, the need for a new classification, and early cardiotoxicity detection and treatment. Probably, anthracycline-induced cardiotoxicity is a continuous phenomenon that starts from myocardial cell injury; it is followed by left ventricular ejection fraction (LVEF) and, if not diagnosed and cured early, progressively leads to symptomatic heart failure. Anthracycline-induced cardiotoxicity can be detected at a preclinical phase. The role of biomarkers, in particular troponins, in identifying subclinical cardiotoxicity and its therapy with angiotensin-converting enzyme inhibitors (mainly enalapril) to prevent LVEF reduction is a recognized and effective strategy. If cardiac dysfunction has already occurred, partial or complete LVEF recovery may still be obtained in case of early detection of cardiotoxicity and prompt heart failure treatment.

/pdf/cardiotoxicity-of-anthracyclines-2alew54cq3.pdf

Cardiotoxicity of Anthracyclines.

In the field of cardio-oncology, it is well recognised that despite the benefits of chemotherapy in treating and possibly curing cancer, it can cause catastrophic damage to bystander tissues resulting in a range of potentially of life-threatening cardiovascular toxicities, and leading to a number of damaging side effects including heart failure and myocardial infarction. Cardiotoxicity is responsible for significant morbidity and mortality in the long-term in oncology patients, specifically due to left ventricular dysfunction. There is increasing emphasis on the early use of biomarkers in order to detect the cardiotoxicity at a stage before it becomes irreversible. The most important markers of cardiac injury are cardiac troponin and natriuretic peptides, whilst markers of inflammation such as interleukin-6, C-reactive protein, myeloperoxidase, Galectin-3, growth differentiation factor-15 are under investigation for their use in detecting cardiotoxicity early. In addition, microRNAs, genome-wide association studies and proteomics are being studied as novel markers of cardiovascular injury or inflammation. The aim of this literature review is to discuss the evidence base behind the use of these biomarkers for the detection of cardiotoxicity.

/pdf/the-role-of-biomarkers-in-cardio-oncology-4ryl8cjsn4.pdf

The Role of Biomarkers in Cardio-Oncology.

Background Previous systematic reviews indicate that progressive muscle relaxation (PMR) and guided imagery (GI) are both effective interventions to decrease the psychological impact and to alleviate the adverse events in cancer patients undergoing chemotherapy treatment. To date, no review studies have investigated the effectiveness of a combination of PMR and GI. Aim To systematically review the current state of knowledge regarding the effects of the PMR–GI combination on cancer patients receiving chemotherapy. Methods A search for relevant records was carried out in four electronic databases (AMED, Cochrane Library, Pubmed and Scopus). After removing the duplicates 342 publications were screened and 71 were considered as potentially relevant. The flow of information of this study was in line with the PRISMA statement. Original articles investigating the application of both PMR and GI through a randomized trial on patients receiving chemotherapy were included. Those using PMR or GI alone and those combining other techniques together with PMR and GI were excluded. The trials' quality was assessed using the Jadad Scale. Results Eight papers reporting the results of seven independent trials were finally included. All of them included only breast cancer patients, apart from a single trial using a mixed sample of breast and prostate cancer patients. Seven of the included trials reported beneficial effects on mental state (mood, anxiety, and depression) and on toxicity (nausea and vomiting). Three trials reported an effect on biomarkers (heart rate, blood pressure, cortisol, and immunity). Four trials scored three of five points on the Jadad Scale, two trials scored two points and a single trial scored zero. Conclusions Independent trials indicate that the PMR–GI combination is an effective way to tackle the impact of nausea and vomiting and to improve patients' mental state. However, studies involving other types of primary tumors would be useful because seven of the eight clinical trials only included breast cancer patients. Future research on the identification of potential effects on disease-related parameters (e.g., cytokines and disease-recurrence) and on patient survival is highly needed.

Investigating the Effects of the Progressive Muscle Relaxation-Guided Imagery Combination on Patients with Cancer Receiving Chemotherapy Treatment: A Systematic Review of Randomized Controlled Trials

The breakthroughs of breast cancer management have led to a significant improvement in patient survival. However, to obtain this outcome a considerable price has been paid regarding cardiovascular side effects. Indeed, cardiovascular disease is the main cause of mortality in patients with breast cancer over fifty years of age, contributing more than cancer mortality in older cancer survivors. Thus, the identification and the management of patients with breast cancer at risk for cardiovascular events has become critical in order to reduce morbidity and mortality from cardiovascular toxicity due to cancer therapy, which may blunt its effectiveness. Today, cardioncology is a novel and recognized medical discipline, which aims to encourage a close interaction between cardiology and oncology, explore new strategies, collect evidence-based indications, and develop interdisciplinary expertise with the ultimate goal of minimize the risk of developing cardiovascular disease during and after anticancer therapy, prevent the breast cancer patient cured today from becoming the heart patient of tomorrow, and avoiding the possibility that pre-existent cardiac disease be a barrier leading to a reduction of a patient's therapeutic opportunities. In this review we discussed the advantages of a cardioncology approach in terms of risk stratification, monitoring for early diagnosis, prevention, and early treatment of cardiotoxicity.

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The breast cancer patient in the cardioncology unit

Cardiotoxicity is one of the major side effects of anti-cancer therapy affecting the overall prognosis of patients and possibly leading to the discontinuation of chemotherapy. Traditional cardiovascular tests such as electrocardiography and transthoracic echocardiography have limited sensitivity and specificity for the early detection of myocardial injury. Cardiovascular imaging generally detects cancer therapy-related cardiac dysfunction (CTRCD) at advanced stages, whereas biomarkers are inexpensive, easily detected, reproducible, and capable of detecting even minimal cardiomyocyte damage or mild hemodynamic fluctuations. The presence of circulating cardiac biomarkers has been investigated as early indicators of cardiotoxicity and predictors of subsequent CTRCD. Currently, the most frequently used cardiac biomarkers are cardiac troponin (cTn) and natriuretic peptides (NPs). This review presents the evidence gathered so far regarding the usefulness and limitations of cardiac biomarkers in the field of cardio-oncology.

/pdf/cardiac-biomarkers-for-the-detection-and-management-of-msg25ty8.pdf

Cardiac Biomarkers for the Detection and Management of Cancer Therapy-Related Cardiovascular Toxicity

Background: Anthracyclines are one of the most effective chemotherapeutic agents in management of Breast cancer, however Anthracycline induced cardiotoxicity remains a matter of special concern Detection of early toxicity by use of biomarkers like Troponins has been the focus of interest in recent years We measured Troponin I levels after chemotherapy with anthracyclines and correlated it with ECG, Echocardiography and clinical findings Methods: Patients with early Breast cancer eligible for chemotherapy were included in the study All patients underwent clinical evaluation, Left Ventricular Ejection Fraction (LVEF) measurement by echocardiography at baseline and every 03 monthly for first year Serum samples for TNI were obtained immediately after chemotherapy and after 24 hrs Results: A total of 82 patients (all females) were included in the study Median age was 47 (range 30–64) years Anthracycline mediated cardiotoxicity occurred in 6 patients (7%) and was more frequent in patients with TNI elevation ( p <0001) Five patients (83%) recovered from cardiotoxicity At multivariate analysis, TNI elevation was the only independent predictor of cardiotoxicity (95% CI 00007879 to 02821) and of lack of LVEF recovery (95% CI 0002484 to 1680) Conclusion: Measurements of Trop I levels after Anthracyclines can be useful in detecting early cardiotoxicity and tailoring further therapy Keywords: Anthracyclines; Cardiotoxicity; Breast cancer; Troponin I; Left ventricular dysfunction

Left Ventricular Systolic Dysfunction Predicted By Early Troponin I Release After Anthracycline Based Chemotherapy In Breast Cancer Patients.

OBJECTIVE To determine the clinical predictors of anticipatory emesis in patients treated with chemotherapy at a tertiary care cancer hospital. METHODS This was a cross-sectional study conducted on 200 patients undergoing first line chemotherapy with minimum of two cycles at inpatient department and chemotherapy bay of Shaukat Khanum Memorial Cancer Hospital and Research Centre Pakistan. Anticipatory nausea and vomiting develops before administration of chemotherapy. Clinical signs and symptoms in patients with or without anticipatory emesis were compared using chi square test statistics. RESULTS The mean age of the study participants was 36.68 years (SD±12.23). The mean numbers of chemotherapy cycles administered were 3.23 (SD±1.2). Chemotherapy related nausea and vomiting was experienced by 188 (94%) patients and anticipatory nausea vomiting was reported in 90 (45%) of patients. Greater proportions of patients with anticipatory emesis were females. Fourteen (15.5%) p-value=0.031 patients with anticipatory emesis had history of anxiety and depression. Fifty nine (65.5%) p-value =< 0.0001 patients with anticipatory emesis had severe nausea after last chemotherapy cycle. Forty six (51.11%) p=<0.0001 patients had motion sickness. CONCLUSION Female gender, history of motion sickness, anxiety and depression, severe nausea and vomiting experienced in pervious cycle of chemotherapy were clinical predictors of anticipatory nausea and vomiting.

Clinical predictors of anticipatory emesis in patients treated with chemotherapy at a tertiary care cancer hospital.

Background: The stroke is third leading cause of death in world and most patients die with an acute event in stroke. Various clinical variables have been investigated as risks factors of stroke. The study was aimed to identify these risks factors for stroke. Methods: This prospective study included 205 consecutive patients of stroke admitted in Combined Military Hospital/Sheik Khalifa Bin Zyad Hospital Muzaffarabad Azad Kashmir. The risk factors of stroke were investigated. Examination included clinical, neurological evaluation, laboratory tests, and brain CT. The follow-up at 14 days were done for all patients. Patients included were with acute first ever stroke onset of 48 hours of hospital admission. All patients completed a structured questionnaire and a physical examination and most provided blood for relevant investigations. Results: Two hundred and five cases stroke sub-types were (n=156, 76%, with ischemic stroke (CI); n=49, 24%, with intra-cerebral hemorrhagic stroke (ICH). The significant risk factors for all stroke were: Hypertension ( p =0.003), diabetes ( p =<0.001), Hypercholesterolemia ( p =0.686); atrial fibrillation ( p =0.445), cardiac diseases ( p =0.938), smoking ( p =0.926) for brain infarction and hypertension ( p =0.002), diabetes ( p =<0.001), Hypercholesterolemia ( p =0.018); atrial fibrillation ( p =0.449), cardiac diseases ( p =0.749), smoking ( p =0.829) for hemorrhagic stroke. Age significance (CI; p =0.247 vs. ICH; p =0.013) and age category significance were (CI; p =<0.001 vs. ICH; p =0.871) for subtype of stroke. High mRS ( p <0.001) low GCS score ( p <0.001) on admission were associated with worst outcome for both stroke subtype. These risk factors were all significant for CI as well as ICH . Conclusions: This study signifies the association of risks factors with acute stroke. Targeted interventions that reduce these risk factors could substantially reduce the burden of stroke Keywords: Acute stroke; Risk factors, Outcome

/pdf/piperacillin-tazobactam-as-a-cost-effective-monotherapy-in-45bw300jqr.pdf

Piperacillin-tazobactam as a cost effective monotherapy in febrile neutropenia

Background: Dermatophytoses invade the stratum corneum of the skin and other keratinized tissues derived from the epidermis. They are quite common and can be fairly accurately identified by a simple laboratory test. We conducted this study to identify the common dermatophytic infections in our setting.Methods: Clinically suspected tinea infections were referred to the Department of Microbiology of SKIMS Medical College Hospital, a tertiary-care teaching hospital in Srinagar, Kashmir. The affected area was cleaned with 70% alcohol, and scrapings were obtained. 10% KOH was used for keratinolysis. Samples were thoroughly examined for the presence of filamentous, septate, branched hyphae.Results: A total of 206 samples were analyzed. The overall KOH positivity rate was 44.7%. Of the 206 patients, 119 (57.8%) were males, and 142 (68.9%) resided in rural areas. The mean age of the patients was 32 years (range 4-72). Tinea corporis was the typical clinical manifestation (58.3%).Conclusions: Young and middle-aged males and people living in rural areas are at a higher risk of dermatophyte infections.

Dermatophytosis in patients referred for evaluation at a tertiary care teaching hospital in Kashmir, India

BACKGROUND
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection started in Wuhan, China, and spread to the rest of the world to become a pandemic affecting over 385 million people throughout the world to date. Coronavirus disease 2019 (COVID-19) is primarily started as a respiratory tract infection. Recent studies indicate that it should be regarded as a systemic disease involving multiple systems including the hematopoietic system. Complete blood count and its parameters are important investigative tools in its prognosis. However, very few studies highlight the importance of peripheral blood cell morphology in this disease.


AIM
To study the hematological parameters (complete blood count and peripheral blood film) of COVID-19-positive patients and to compare the hematological parameters of those admitted in intensive care units (ICUs) with those admitted in non-ICUs of the hospitals.


MATERIALS AND METHODS
This retrospective study was carried out at a COVID-19 dedicated tertiary care center over a period of 3 months from July 2020 to September 2020. In our study, all 79 patients had complete blood counts performed at the time of admission. Complete blood count was repeated during the hospital stay for all severe cases. The data which provided information on the age and gender of each patient were obtained from the Laboratory Information System (LIS) of the hospital.


RESULTS
The mean age of our study group was 46.05 years. Out of 79 cases, lymphopenia was seen in 16.5% with five patients presenting with severe lymphopenia (<0.5 × 109 /L). All the patients that required ICU care presented with moderate to severe lymphopenia. The patients in the ICU setting showed significant neutrophilia (mean 14.16 × 109 /L) on follow-up complete blood count. Thrombocytopenia was observed in 35.3% of cases. It was observed that the mean neutrophil- lymphocyte ratio was higher in ICU admitted patients as compared to the non-ICU admitted patients. Among the ICU patients, 80% showed a neutrophil-lymphocyte ratio above the baseline cutoff (3.1). A wide array of morphological changes were observed in the peripheral blood smear including toxic-like granules in neutrophils, fetus-like C-shaped nucleus, lymphoplasmacytoid cells, bizarre cells, and apoptotic cells.


CONCLUSION
The study highlights that at the time of admission older age, decreased lymphocyte count, and raised neutrophil-lymphocyte ratio were closely associated with ICU admissions. Also, the morphological changes in peripheral blood film reveal atypical changes predominantly in the white blood cell (WBC) lineage.

/pdf/hematological-profile-with-peripheral-blood-smear-morphology-1yyqbs53.pdf

Hematological Profile with Peripheral Blood Smear Morphology of Admitted COVID-19 Infected Patients: A Study at a COVID Dedicated Hospital in Kashmir.

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