Shaikh Zayed Medical College and Hospital

Abstract Introduction: As of 2019, liver cirrhosis has been ranked as the 11th leading cause of death in the U.S. Despite medical advances and available therapies, overall survival outcomes remain limited for hepatorenal syndrome (HRS) and portal hypertension (PH) have remain poor. This study seeks to evaluate the comparative disparities among liver disease patients with HRS or PH. Methodology: Mortality data from the CDC WONDER database (1999–2023) was retrieved for individuals aged ≥55 years with liver disease (ICD-10 K70–K76), focusing on HRS (K76.7) and PH (K76.6) as the contributing causes of death. Joinpoint regression analysis (JPR) was used to estimate Annual Percent Change (APC) with 95% confidence intervals (CI), stratified by age, sex, race/ethnicity, U.S. Census regions, and 2013 urbanization framework. Autoregressive Integrated Moving Average ARIMA: (0,2,1) approach was used to predict AAMRs up to 2035 along with their 95% confidence intervals. We applied Ljung-Box test to validate the model’s efficacy. A threshold for statistical significance was set at <0.05. Results: From 1999–2023, there were 14,104 PH-related deaths (AAMR: 0.69) and 47,139 HRS-related deaths (AAMR: 2.35). AAMRs for HRS group and PH group are projected to reach 3.58 (95% CI: 1.48-5.67; Ljung-Box test p-value = 0.948) and 1.63 (95% CI: 0.44-2.81; Ljung-Box test p-value = 0.155) up to 2035, respectively. In HRS, males (2007-2023) and non-Hispanics (2018-2021) showed significant upward trends in mortality , with APC of 2.09 (95% CI: 1.58-2.78; p=0.001) and 7.80 (95% CI: 1.81-9.67; p=0.01), respectively. Among those with portal hypertension, females (2010-2023) and Hispanics (2009-2021) displayed significant increases in mortality trends with APC of 7.07 (95% CI: 5.22-10.88; p=0.001) and 5.78 (95% CI: 0.43-11.60; p=0.04), respectively. Whites exhibited significant rising trends in mortality from 2008-2023 with APC of 3.28 (95% CI: 2.85-3.84; p=0.001) in HRS group. Census Region 4: West showed the highest mean AAMRs of 2.81 and 0.76 in HRS and PH group, respectively. Alaska displayed the highest AAMR of 4.2 in HRS group while North Dakota stood highest in PH group with AAMR of 1.4. Conclusion: Our study reported notable disparities , particularly the substantial rise s in APCs of Males and non-Hispanics in HRS group and females and Hispanics in PH- group, highlighting the distinct mortality patterns associated with these conditions. Furthermore, the rising AAMRs predicted by ARIMA suggest the need for targeted interventions and subtle healthcare policies.

To the Editor, We read with great interest the study by Raffenot et al. on risk factors for nosocomial meningitis (NM) in patients with external ventricular drains (EVDs) [1].We commend the authors on their thorough and clinically impactful study.Their identification of factors such as cerebrospinal fluid (CSF) leakage and prolonged drainage offers valuable insight for daily practice.The authors also develop a multivariable predictive model, incorporating CSF leakage, drainage duration, beta-lactam allergy, and a combined CSF variable (glucose ratio < 0.5 and protein > 1 g/L).This model demonstrates excellent discrimination (AUC 0.89) and the authors suggest that it could help identify high-risk patients earlier and guide closer monitoring and empirical therapy.We would, however, like to highlight one methodological point central to how the model's performance and role should be understood.The authors define NM using criteria adapted from Lozier et al., in which "probable" infection is based on specific cerebrospinal fluid (CSF) abnormalities: leukocyte count > 100/mm3, CSF-to-serum glucose ratio < 0.5, and protein concentration > 0.4 g/L [1, 2].In

416 Background: Variable anatomy, prompted by bowel filling and respiratory motion, necessitates larger margins for planning target volumes (PTV) in radiotherapy for gastric lymphoma patients, leading to higher doses to organs at risk (OAR). The deep inspiratory breath-holding (DIBH) technique during radiotherapy has emerged as a protective method that improves OAR sparing. Therefore, this systematic review aims to systematically evaluate the benefits of DIBH compared to free breathing (FB) techniques during radiotherapy for gastric lymphomas, along with the physiological mechanisms involved. Methods: This systematic review included three comparative studies following a comprehensive search across PubMed, Google Scholar, and the Cochrane Library, involving a total of 33 patients with gastric lymphomas, in whom radiotherapy was planned under both DIBH and FB. The radiotherapeutic techniques assessed were intensity-modulated radiotherapy (IMRT), 3D-conformal radiotherapy (3D-CRT), step-and-shoot IMRT (SIMRT), volumetric-modulated arc therapy (VMAT), and tomotherapy. The dosimetric parameters included Gy (Gray), mean dose (Dmean), maximum dose (Dmax), etc. Results: Median heart dose (MHD) showed a consistent and significant reduction with DIBH across all techniques, including IMRT: 4.9→2.6 Gy; 3D: 8.54→4.46 Gy; SIMRT: 6.97→3.63 Gy; VMAT: 6.83→3.42 Gy; and tomotherapy: 7.06→3.80 Gy (all p&lt;0.001). An additional study reported a decline from 7.1 Gy (FB 1.5 cm PTV) to 3.2 Gy (DIBH 1 cm PTV) (p&lt;0.001). Kidney doses showed modest changes, with Dmean reduced from 4.3 Gy with FB 1 cm to 3.8 Gy with DIBH. For the left kidney, only one study demonstrated a significant reduction (p = 0.01). Spinal cord doses were also lower with DIBH; Dmax decreased from 19.79 to 17.56 Gy (VMAT), and Dmean from 8.7 Gy (FB 1.0 cm) and 9.7 Gy (FB 1.5 cm) to 7.9 Gy (DIBH) (p=0.02 and p=0.001). Findings in the lung were inconsistent: one study reported lower Dmean with DIBH, while others noted slight increases, e.g., left lung 3.0 vs. 2.6 Gy for FB 1 cm; 3.3 vs. 3.0 Gy for FB 1.5 cm. Liver outcomes were non-significant primarily, with reported reductions from 9.4 to 8.3 Gy and 13.91 to 12.64 Gy, although one study showed a higher Dmean with DIBH compared to FB 1 cm (p = 0.04). Conclusions: In conclusion, based on the current literature, DIBH significantly improves organ at risk (OAR) sparing, especially for the heart, right kidney, and spinal cord, during radiotherapy for gastric lymphomas. While results for the liver and lungs are mixed, no significant differences have yet been reported for the small bowel. These findings support the routine use of DIBH to minimize cardiac and critical organ radiation during radiotherapy, thereby facilitating safer clinical and patient practices.

170 Background: Colorectal cancer (CRC) remains a leading cause of cancer mortality, with limited survival in advanced disease. Immune checkpoint inhibitors (ICIs), targeting PD-1, PD-L1, and CTLA-4 pathways, have emerged as promising therapeutic strategies. Comparative data across regimens are limited. Methods: We performed a systematic review and network meta-analysis (NMA) following PRISMA-NMA guidelines. PubMed, Embase, Scopus, and ClinicalTrials.gov were searched from inception through 2024. Eligible randomized controlled trials (RCTs) included patients with CRC treated with PD-1, PD-L1, or CTLA-4 inhibitors, alone or in combination, compared against standard therapy or placebo. Primary outcomes were overall survival (OS) and progression-free survival (PFS). Secondary outcomes included objective response rate (ORR) and treatment-related adverse events (AEs). Hazard ratios (HRs) were pooled for time-to-event outcomes and odds ratios (ORs) for binary outcomes using a frequentist random- effects NMA. Heterogeneity was assessed using T ² , and inconsistency was tested with design-by- treatment interaction models. Results: Nineteen RCTs enrolling 3,488 patients were included. For OS, PD-1 inhibitors showed a significant survival benefit compared with standard therapy (HR 0.80, 95% CI 0.68–0.94, p=0.0068). For PFS, PD-1 plus CTLA-4 combination demonstrated the greatest benefit (HR 0.43, 95% CI 0.33–0.56, p&lt;0.0001), while PD-1 monotherapy also improved outcomes (HR 0.67, 95% CI 0.58–0.78, p&lt;0.0001). ORR was highest with PD-1 plus CTLA-4 therapy (OR 3.89, 95% CI 1.72–8.81, p=0.0011), followed by PD-1 monotherapy (OR 2.20, 95% CI 1.35–3.60, p=0.0015). Safety analysis showed increased grade 3–4 AEs with PD-L1 plus CTLA-4 combinations (OR 7.12, 95% CI 0.99–51.16, p=0.051), while PD-L1 monotherapy had the most favorable AE profile (OR 0.81, 95% CI 0.33–1.98, p=0.6502). Heterogeneity and inconsistency tests indicated acceptable model fit. Conclusions: This NMA suggests that PD-1 inhibitors provide the greatest overall survival benefit in CRC, while PD-1 plus CTLA-4 combinations maximize PFS and response rates at the cost of higher toxicity. PD-L1 monotherapy demonstrated the best tolerability with modest efficacy. These findings highlight the importance of balancing efficacy with safety when selecting ICIs for CRC.

Abstract Background Despite the availability of multiple COVID-19 vaccines, challenges remain in prevention and control. This systematic review and meta-analysis assess the safety and efficacy of BCG vaccination in COVID-19 prevention. Methods A comprehensive search was conducted in PubMed, Cochrane, Scopus, Web of Science, and Embase until March 2024. Primary outcomes included COVID-19 infection rate, mortality, hospitalization rate, and ICU admission. Secondary outcomes focused on adverse events. Results Fifteen RCTs with 16,347 participants were included. BCG vaccination did not significantly reduce COVID-19 infection (RR = 1.06, 95% CI [0.96–1.17], p = 0.27), ICU admission (RR = 0.44, 95% CI [0.14–1.42], p = 0.17), or hospitalization rate (RR = 0.90, 95% CI [0.60–1.36], p = 0.62). There were fewer deaths in the BCG group (RR = 0.52, 95% CI [0.25–1.08], p = 0.08). Regarding adverse events, BCG vaccination was strongly associated with erythema and may slightly increase cough risk, while other systemic symptoms (nausea, muscle/joint pain, sore throat) showed no significant association. Conclusion BCG vaccination does not significantly reduce the risk of COVID-19 infection, hospitalization, or ICU admission. While there is a potential reduction in mortality, the result is not statistically significant. Adverse event analysis confirms a strong association with erythema and a slight increase in cough risk, but no consistent association with other systemic symptoms. These findings suggest that BCG vaccination does not provide substantial protection against COVID-19 but is generally well tolerated. Disclosures All Authors: No reported disclosures

Obesity has alarmingly risen across the globe as a significant public health concern and is increasingly recognized as a complex systemic disease with widespread metabolic and inflammatory consequences. While its associations with cardiovascular, hepatic, and metabolic disorders are well established, the impact of obesity on the pancreas has received comparatively less attention. Emerging evidence highlights that pancreatic steatosis is closely linked to obesity, type 2 diabetes, metabolic syndrome, and fatty liver disease. Fatty pancreas contributes to both endocrine and exocrine dysfunction through lipotoxicity, oxidative stress, and adipokine-mediated inflammation. In acute pancreatitis, obesity exacerbates disease severity by amplifying systemic inflammatory responses, promoting lipolysis of peripancreatic fat, and delaying immune resolution, all of which increase complications and mortality. The role of obesity in chronic pancreatitis is less defined, though intrapancreatic fat accumulation appears to predispose to parenchymal injury and progression. Obesity is increasingly considered an independent risk factor for pancreatic cancer, with excess adiposity driving neoplastic transformation through chronic inflammation, insulin resistance, hyperinsulinemia, and activation of oncogenic pathways. Weight reduction is associated with reduced pancreatic steatosis and may lower risk; however, causal data are limited, and further longitudinal studies are required. Taken together, obesity represents a major modifiable determinant of pancreatic health, with implications spanning steatosis, inflammatory diseases, and malignancy. Increasing scientific data on the obesity-pancreatic diseases conundrum also necessitates the need for integrating obesity-related markers into risk stratification and prognostic models, as well as exploring targeted therapeutic strategies in obesity-associated pancreatic disease.

Current ESC/EACTS guidelines recommend standard-duration dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI). However, the subsequent transition to either extended DAPT or single antiplatelet therapy (SAPT) remains debated due to limited comparative outcome data. This Bayesian meta-analysis and meta-regression evaluate the clinical safety of DAPT versus SAPT, and the impact of potential confounders on all-cause mortality. Following PRISMA guidelines, a systematic search of PubMed, Embase, Cochrane Library, ScienceDirect, and Scopus was conducted till April 2025 to identify randomized clinical trials (RCTs) and cohort studies. Primary outcomes were all-cause mortality and bleeding events. Bayesian random-effects meta-analysis was performed using the brms package in R with Markov Chain Monte Carlo sampling and weakly informative priors. Bayesian meta-regression of log-transformed odds ratios (OR) assessed associations with relevant covariates. Fourteen studies (9 RCTs and 5 cohort studies) comprising 56,572 patients were included. Compared with SAPT, DAPT was associated with increased all-cause mortality (OR 1.25; 95% credible interval [CrI], 1.04-1.51; posterior probability of harm, Pr[OR > 1] = 84%). DAPT also increased the risk of net adverse clinical events [NACE] (OR, 1.29; 95% CrI, 1.08-1.53), minor bleeding (OR, 1.60; 95% CrI, 1.10-2.33), major bleeding (OR, 1.70; 95% CrI, 1.30-2.23), and BARC 2-5 bleeding (OR, 1.78; 95% CrI, 1.40-2.26) with Pr [OR > 1] >90% for all outcomes. No significant differences were observed in cardiac death, cardiovascular mortality, major adverse cardiac and cerebrovascular events (MACCE), myocardial infarction (MI), stent thrombosis, or stroke. Meta-regression revealed that higher baseline odds of dyslipidemia (-0.89), hypertension (-1.19), prior MI (-0.94), and previous revascularization (-0.30) were associated with greater mortality benefit from DAPT. However, in the DAPT cohort, increased odds of adverse events, including cardiac death (0.41), MACCE (0.55), stroke (0.60), MI (0.29), and NACE (0.98), were significantly associated with higher all-cause mortality. Extended DAPT is associated with a higher all-cause mortality, bleeding events, and NACE. While DAPT may benefit high-risk populations, the increased odds of adverse events are significantly associated with mortality, warranting that it be carefully considered and monitored in post-PCI patients.