Smrity Upadhyay

University of Delhi

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Nabin Khanal

University of Wollongong

Vijaya Raj Bhatt

University of Nebraska Medical Center

Peter T. Silberstein

Creighton University

Sumit Dahal

Walter Reed Army Institute of Research

Smith Giri

University of Alabama at Birmingham

Roopa A. Rao

Indiana University – Purdue University Indianapolis

Kashif Saleem

King Saud University

Anjan Sinha

Indiana University – Purdue University Indianapolis

Sarada Uppuluri

Rush University Medical Center

Kavita Arora

University of Delhi

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Creighton University

Indiana University School of Medicine

CHI Health Creighton University Medical Center - Bergan Mercy

Indiana University – Purdue University Indianapolis

University of Nebraska Medical Center

Indiana University Health

University of Nebraska at Omaha

Indiana University

Cardiovascular Institute of the South

Nebraska Medical Center

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Smrity Upadhyay Sumit Dahal Nabin Khanal Vijaya Raj Bhatt

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Heparin-Induced Thrombocytopenia: Current Concepts and Emerging Roles of Fondaparinux

Sumit Dahal Smrity Upadhyay Nabin Khanal Vijaya Raj Bhatt

Fondaparinux

Heparin-Induced Thrombocytopenia

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Differentiating malignant hypertension-induced thrombotic microangiopathy from thrombotic thrombocytopenic purpura

Therapeutic Advances in Hematology (2015)

Nabin Khanal Sumit Dahal Smrity Upadhyay Vijaya Raj Bhatt Philip J. Bierman

Malignant hypertension can cause thrombotic microangiopathy (TMA) and the overall presentation may mimic thrombotic thrombocytopenic purpura (TTP). This presents a dilemma of whether or not to initiate plasma exchange. The objective of the study was to determine the clinical and laboratory manifestations of malignant hypertension-induced TMA, and its outcomes.Using several search terms, we reviewed English language articles on malignant hypertension-induced TMA, indexed in MEDLINE by 31 December 2013. We also report a new case. All these cases were analyzed using descriptive statistics.A total of 19 patients, with 10 males, had a median age of 38 years at diagnosis; 58% had a history of hypertension. Mean arterial pressure at presentation was 159 mmHg (range 123-190 mmHg). All had prominent renal dysfunction (mean creatinine of 5.2 mg/dl, range 1.7-13 mg/dl) but relatively modest thrombocytopenia (mean platelet count of 60 × 103/µl, range 12-131 × 10(3)/µl). Reported cases (n = 9) mostly had preserved ADAMTS-13 activity (mean 64%, range 18-96%). Following blood pressure control, the majority had improvement in presenting symptoms (100%) and platelet counts (84%); however, only 58% had significant improvement in creatinine. More than half (53%) needed hemodialysis. One patient died of cardiac arrest during pacemaker insertion.Prior history of hypertension, high mean arterial pressure, significant renal impairment but relatively modest thrombocytopenia and lack of severe ADAMTS-13 deficiency (activity <10%) at diagnosis are clues to diagnose malignant hypertension-induced TMA. Patients with malignant hypertension respond well to antihypertensive agents and have favorable nonrenal outcomes.

Thrombotic microangiopathy

Microangiopathy

Purpura (gastropod)

Schistocyte

10.1177/2040620715571076

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Chemotherapy use in stage III colon cancer: a National Cancer Database analysis

Therapeutic Advances in Medical Oncology (2015)

Smrity Upadhyay Sumit Dahal Vijaya Raj Bhatt Nabin Khanal Peter T. Silberstein

Although adjuvant chemotherapy in stage III colon cancer improves overall survival, prior studies have shown that it is underused. We analyzed different factors that may influence its use.This is a retrospective study of stage III colon cancer patients (n = 207,718) diagnosed between 2000 and 2011 in the National Cancer Data Base (NCDB). The NCDB contains ~70% of new cancer diagnosis from >1500 American College of Surgeons accredited cancer programs in the United States and Puerto Rico. The chi-squared test was used to determine any difference in characteristics of patients who did or did not receive chemotherapy.A total of 35% of all stage III colon cancer patients, and 38% of stage III cases undergoing surgery, did not receive adjuvant chemotherapy. The use of chemotherapy had increased in recent years (64% in 2007-2011 versus 59% in 2000-2002; p < 0.0001). Its use was lower in whites (61%), females (60%), patients ⩾60 years (55%), patients with one or more comorbidities (55%), nonacademic centers (62%), those with medicare insurance (52%), lower education (61%) and income levels (59%, all p < 0.0001). The nonwhite and uninsured were more likely to be <60 years old.More than one-third did not receive adjuvant chemotherapy, although its use has increased in more recent years. Age was one of the most important determinants of chemotherapy use, which may explain higher rates in nonwhite and uninsured. In addition to patient characteristics, race, gender and socioeconomic factors influence chemotherapy use. These findings have important implications for healthcare reform.

Adjuvant Chemotherapy

10.1177/1758834015587867

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Systemic therapy in stage IV pancreatic cancer: a population-based analysis using the National Cancer Data Base

Therapeutic Advances in Medical Oncology (2015)

Nabin Khanal Smrity Upadhyay Sumit Dahal Vijaya Raj Bhatt Peter T. Silberstein

Pancreatic cancer accounts for approximately 7% of all cancer deaths. More than half of all pancreatic cancers are stage IV at diagnosis, where systemic chemotherapy is used with the goal of life prolongation as well as palliation. The patient characteristics and health system factors that drive the use of systemic therapy are unknown.This is a retrospective study of stage IV pancreatic cancer patients (n = 140,210) diagnosed between 2000 and 2011 in the NCDB. NCDB contains approximately 70% of new cancer diagnosis from more than 1500 accredited cancer programs in the United States and Puerto Rico. Chi-squared test was used to determine any differences in characteristics of patients who did or did not receive systemic therapy.Our study demonstrated that only 49.1% of stage IV pancreatic cancer patients received systemic therapy. The use of systemic therapy is significantly lower in female, African American/Hispanic, patients older than 40 years, those without insurance or with Medicare and Medicaid, higher Charlson Comorbidity Score, poor economic and educational status and in nonacademic centers.This is the largest study to evaluate the determinants of systemic therapy use in stage IV pancreatic cancer. The use of systemic therapy was significantly lower in patients older than 40 years, lower educational status, nonprivate insurance and with higher Charlson Comorbidity Scores. In addition, the use of systemic therapy was lower with female sex, African Americans/Hispanic, and lower socio-economic status. Understanding the barriers in the use of systemic therapy as well as appropriate utilization of systemic therapy can both optimize cancer care.

Systemic therapy

10.1177/1758834015579313

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Colorectal Carcinoma and Emerging Targeted Therapies.

PubMed (2015)

Nabin Khanal Smrity Upadhyay Peter T. Silberstein

Targeted therapies for specific mutations in colorectal cancer have led to an increase in patient overall survival.

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Fulminant Myocarditis: Covid Or Not COVID? Reinfection Or co-infection?

Future Cardiology (2021)

Ramya Yeleti Maya Guglin Kashif Saleem Sasikanth Adigopula Anjan Sinha

We describe a unique case of fulminant myocarditis in a patient with presumed SARS-CoV-2 reinfection. Patient had initial infection 4 months backand had COVID-19 antibody at the time of presentation. Endomyocardial biopsy showed lymphocytic myocarditis, that is usually seen in viral myocarditis. The molecular diagnostic testing of the endomyocardial biopsy for cardiotropic viruses was positive for Parvovirus and negative for SARS-CoV-2. Authors highly suspect co-infection of SARS-CoV-2 and Parvovirus, that possibly triggered the immune cascade resulting in fulminant myocarditis. Patient was hemodynamically unstable with ventricular tachycardia and was supported on VA ECMO and Impella CP. There was impressive recovery of left ventricular function within 48 hours, leading to decannulation of VA ECMO in 72 h. This unique case was written by the survivor herself.

Fulminant

2019-20 coronavirus outbreak

Betacoronavirus

Pandemic

10.2217/fca-2020-0237

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Exertional Chest Pain and Dyspnea From Hyperviscosity Syndrome Related to Marginal Zone Lymphoma

World Journal of Oncology (2014)

Prajwal Dhakal Vijaya Raj Bhatt Smrity Upadhyay Nabin Khanal Apar Kishor Ganti

Hyperviscosity syndrome is usually seen in Waldenstrom macroglobulinemia with the serum viscosity > 4 cP. It commonly manifests as skin or mucosal bleeding, visual abnormalities and neurological symptoms. We describe a case of a 65-year-old man, who presented with chronic exertional chest pain and dyspnea without other manifestation and had hyperviscosity syndrome related to marginal zone lymphoma (MZL) even with a marginally elevated plasma viscosity. The symptoms resolved after initiation of chemotherapy. This case illustrates that MZL can cause hyperviscosity syndrome, which can manifest with cardiopulmonary symptoms without other clinical features even at a marginally elevated plasma viscosity. Atypical cases of hyperviscosity syndrome can, thus, present diagnostic challenges and require a high index of suspicion.

Hyperviscosity syndrome

Hyperviscosity

Macroglobulinemia

10.14740/wjon837w

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A National Cancer Database (NCDB) analysis of factors affecting survival in stage II and III colon cancer.

Journal of Clinical Oncology (2016)

Smrity Upadhyay Smith Giri Nabin Khanal Peter T. Silberstein

e15146 Background: The goal of our study was to analyze how factors other than adjuvant chemotherapy affect survival among patients with stage II and stage III colon cancer. Methods: This is a retrospective study of NCDB database that included adult patients ( > 18 years old) with stage II and III colon cancer patients diagnosed between 1998 and 2012. Kaplan Meier survival curve and Cox regression analysis was used to determine to study the impact of chemotherapy and other covariates on survival. Results: Out of a total of 294,255 patients, 45% received chemotherapy. The 3 year overall survival with and without adjuvant chemotherapy was 81.4% versus 79.7% (p value < 0.001). On multivariate analysis, use of chemotherapy, older age, African American race, higher stage, male sex, larger tumor size, positive margins, lymph node positivity, uninsured status, higher co-morbidities, treatment at community hospitals and diagnosis prior to 2003 were associated with poor survival. Conclusions: This is the one of largest studies demonstrating the effect of different demographic variables on survival in stage II and III Colon Cancer patients. Multivariate Cox proportional hazards survival analysis. Variables Hazards Ratio (95% Confidence Interval) Chemotherapy None Referent Yes 0.51 (0.49-0.52) Age : < 50 Referent 50-75 1.39 ( 1.34-1.44) > 75 3.08 (2.97-3.20) Stage II Referrent III 1.40 (1.28-1.54) Sex: Male Referrent Female 0.84 (0.83-0.85) Size : < 2 cm referrent 2-5 cm 1.13 (1.09-1.17) 5-10 cm 1.24 (1.19-1.28) > 10 cm 1.40 (1.33-1.47) Surgical Margin : Negative referrent Positive 2.05 (2.00- 2.11) Node: N0 Referrent N1 1.16 (1.06-1.27) N2 or more 2.13 (1.94-2.34) Race: White Referrent Black 1.15 (1.13-1.19) Others 0.77 (0.73-0.81) Insurance : Uninsured Referrent Insured 0.91 (0.86-0.96) Facility type: Community Referrent Comprehensive community 0.92 (0.90-0.94) Academic 0.87 (0.84-0.89) Charlson score: 0 Referrent 1 1.29 (1.27- 1.32) 2 1.89 (1.84- 1.94) Year of diagnosis: Referrent Before 2003 0.96 (0.94 -0.98) 2003-2007 0.88 (0.86-0.90) After 2007 (* p < 0.01 unless specified, HR < 1.0 signifies improved outcome compared to referrent)

10.1200/jco.2016.34.15_suppl.e15146

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Systemic therapy use in stage IV pancreatic cancer: A population-based analysis using National Cancer Data Base (NCDB).

Journal of Clinical Oncology (2014)

Nabin Khanal Smrity Upadhyay Vijaya Raj Bhatt Peter T. Silberstein

e15190 Background: Pancreatic cancer accounts for ~7% of all cancer deaths. More than half of all pancreatic cancers are stage IV at diagnosis, where, systemic chemotherapy is used with the goal of life prolongation as well as palliation (J Clin Oncol. 1997 Jun;15(6):2403-13.)The patient characteristics and health system factors that drive the use of systemic therapy are unknown. Methods: This is a retrospective study of stage IV pancreatic cancer patients (n=140,366) diagnosed between 2000 and 2011 in the NCDB. NCDB contains ~70% of new cancer diagnosis from >1,500 accredited cancer programs in the United States and Puerto Rico. Chi-square test was used to determine any differences in characteristics of patients who did or did not receive systemic therapy. Results: Our study demonstrated that only 49% of stage IV pancreatic cancer patients received systemic therapy. The use of systemic therapy is significantly lower in female, black/hispanic, patients >40 years (49% vs 69% in <40 years), those without insurance or with Medicare and Medicaid, higher Charlson comorbidity score, poor economic and educational status and in non-academic centers (Table). Conclusions: This is the largest study to evaluate the determinants of systemic therapy use in stage IV pancreatic cancer. The use of systemic therapy was significantly lower in female, black/hispanic, patients >40 years and with higher Charlson comorbidity score. In addition, economic and educational level, hospital and insurance types can affect the use of systemic therapy. Understanding the barriers in the use of systemic therapy can optimize cancer care. Systemic therapy use in stage IV pancreatic cancers. Variables Systemic therapy use (%) Age < 40 69 40-49 65 50-59 62 60-69 57 70-79 46 > 80 24 Sex Male 51 Female 47 Race White 50 Black 45 Hispanic 45 Insurance Private 62 Medicare 49 Not insured 44 Medicaid 42 Charlson comorbidity score Score 0 53 Score ≥ 1 43 Household income > 28,000 50 < 28,000 42 Education (% without high school degree) < 12% 53 > 12% 48 Hospital type Academic centers 52 Nonacademic center 47 P-value significant <0.001 for all comparisons.

Systemic therapy

10.1200/jco.2014.32.15_suppl.e15190

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