Immunoglobulin High Throughput Sequencing (Ig-HTS) Minimal Residual Disease (MRD) Analysis is an Effective Surveillance Tool in Patients With Mantle Cell Lymphoma.

INTRODUCTION: Mantle cell lymphoma (MCL) accounts for 4% to 6% of B-cell non-Hodgkin lymphoma with historically poor outcomes. With the advent of intensive first-line, targeted, and cellular therapies, outcomes have improved, and initial remission can be 8 to 10 years or longer. As patients experience longer remissions, this raises the question of the optimal surveillance modality. Peripheral blood minimal residual disease (MRD) analysis offers a potential alternative to surveillance imaging that is sensitive, less costly, and eliminates the risk of radiation exposure. MATERIALS AND METHODS: The clonoSEQ assay (Adaptive Biotechnologies) is an FDA-cleared commercially available Ig-HTS MRD assay with a sensitivity of 1 cell in 1,000,000. We performed a retrospective analysis of 34 patients from 2015 to 2021, who underwent MRD testing after achieving remission with first-line therapy. RESULTS: With a median follow-up of 6.5 years, 10-year progression free survival (PFS) was 60% and 10-year overall survival was 92% of the entire cohort. Among 12 patients who sustained a radiographic relapse, peripheral blood became MRD+ either at or prior to the time of relapse in 11 patients (92%). The first MRD+ test had a lead time of 0 to 24 months (median 34 days) prior to radiographic relapse. Only 1 patient had a MRD- result while being found to have progressive disease on imaging. Among 22 patients who sustained continuous clinical remission, 21 have remained MRD-. Several patients were able to enjoy 2 to 4-year intervals without surveillance imaging. CONCLUSIONS: Our data suggest that the clonoSEQ MRD assay is an effective surveillance tool for MCL patients following first-line therapy and is predictive of relapse prior to imaging.

Clinical characteristics, racial inequities, and outcomes in patients with breast cancer and COVID-19: A COVID-19 and cancer consortium (CCC19) cohort study.

Background: Limited information is available for patients with breast cancer (BC) and coronavirus disease 2019 (COVID-19), especially among underrepresented racial/ethnic populations. Methods: This is a COVID-19 and Cancer Consortium (CCC19) registry-based retrospective cohort study of females with active or history of BC and laboratory-confirmed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection diagnosed between March 2020 and June 2021 in the US. Primary outcome was COVID-19 severity measured on a five-level ordinal scale, including none of the following complications, hospitalization, intensive care unit admission, mechanical ventilation, and all-cause mortality. Multivariable ordinal logistic regression model identified characteristics associated with COVID-19 severity. Results: 1383 female patient records with BC and COVID-19 were included in the analysis, the median age was 61 years, and median follow-up was 90 days. Multivariable analysis revealed higher odds of COVID-19 severity for older age (aOR per decade, 1.48 [95% CI, 1.32-1.67]); Black patients (aOR 1.74; 95 CI 1.24-2.45), Asian Americans and Pacific Islander patients (aOR 3.40; 95 CI 1.70-6.79) and Other (aOR 2.97; 95 CI 1.71-5.17) racial/ethnic groups; worse ECOG performance status (ECOG PS ≥2: aOR, 7.78 [95% CI, 4.83-12.5]); pre-existing cardiovascular (aOR, 2.26 [95% CI, 1.63-3.15])/pulmonary comorbidities (aOR, 1.65 [95% CI, 1.20-2.29]); diabetes mellitus (aOR, 2.25 [95% CI, 1.66-3.04]); and active and progressing cancer (aOR, 12.5 [95% CI, 6.89-22.6]). Hispanic ethnicity, timing, and type of anti-cancer therapy modalities were not significantly associated with worse COVID-19 outcomes. The total all-cause mortality and hospitalization rate for the entire cohort was 9% and 37%, respectively however, it varied according to the BC disease status. Conclusions: Using one of the largest registries on cancer and COVID-19, we identified patient and BC-related factors associated with worse COVID-19 outcomes. After adjusting for baseline characteristics, underrepresented racial/ethnic patients experienced worse outcomes compared to non-Hispanic White patients. Funding: This study was partly supported by National Cancer Institute grant number P30 CA068485 to Tianyi Sun, Sanjay Mishra, Benjamin French, Jeremy L Warner; P30-CA046592 to Christopher R Friese; P30 CA023100 for Rana R McKay; P30-CA054174 for Pankil K Shah and Dimpy P Shah; KL2 TR002646 for Pankil Shah and the American Cancer Society and Hope Foundation for Cancer Research (MRSG-16-152-01-CCE) and P30-CA054174 for Dimpy P Shah. REDCap is developed and supported by Vanderbilt Institute for Clinical and Translational Research grant support (UL1 TR000445 from NCATS/NIH). The funding sources had no role in the writing of the manuscript or the decision to submit it for publication. Clinical trial number: CCC19 registry is registered on ClinicalTrials.gov, NCT04354701.

Bendamustine/Rituximab Plus Cytarabine/Rituximab, With or Without Acalabrutinib, for the Initial Treatment of Transplant-Eligible Mantle Cell Lymphoma Patients: Pooled Data From Two Pilot Studies.

INTRODUCTION: Mantle cell lymphoma (MCL) is a moderately aggressive lymphoma subtype, generally viewed as incurable. For younger, fit patients, the standard of care remains various high-dose cytarabine-based induction regimens followed by autologous hematopoietic cell transplant and 3 years of rituximab maintenance. Despite reasonably good outcomes, with median progression-free survival in the range of 7 to 9 years, most patients eventually relapse, indicating a need to improve the safety and tolerability of remission induction strategies. METHODS: Given the impressive activity of bendamustine/rituximab (BR) in older patients with MCL, we developed an induction regimen modeled after the Nordic Regimen but substituted BR in place of R-CHOP. In a second pilot study, we incorporated the second-generation Bruton tyrosine kinase inhibitor (BTKi), acalabrutinib, into the regimen. The primary endpoint of both studies was stem cell mobilization success rate. RESULTS: All patients successfully underwent stem cell harvest in both studies. CONCLUSION: The experience from our single institution pilot study suggested that sequential rather than alternating BR and cytarabine/rituximab (CR) was easier to administer from the standpoint of toxicities and subsequent dose modifications. Safety and efficacy data from the 2 pilot studies, FitMCL 1.0 and 2.0, were similar. The pilot studies provided preliminary safety data supporting the development of the NCTN trial EA4181, assessing three different induction regimens with or without acalabrutinib.

Clinical Characteristics, Racial Inequities, and Outcomes in Patients with Breast Cancer and COVID-19: A COVID-19 and Cancer Consortium (CCC19) Cohort Study.

Background: Limited information is available for patients with breast cancer (BC) and coronavirus disease 2019 (COVID-19), especially among underrepresented racial/ethnic populations. Methods: This is a COVID-19 and Cancer Consortium (CCC19) registry-based retrospective cohort study of females with active or history of BC and laboratory-confirmed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection diagnosed between March 2020 and June 2021 in the US. Primary outcome was COVID-19 severity measured on a five-level ordinal scale, including none of the following complications, hospitalization, intensive care unit admission, mechanical ventilation, and all-cause mortality. Multivariable ordinal logistic regression model identified characteristics associated with COVID-19 severity. Results: 1,383 female patient records with BC and COVID-19 were included in the analysis, the median age was 61 years, and median follow-up was 90 days. Multivariable analysis revealed higher odds of COVID-19 severity for older age (aOR per decade, 1.48 [95% CI, 1.32 - 1.67]); Black patients (aOR 1.74; 95 CI 1.24-2.45), Asian Americans and Pacific Islander patients (aOR 3.40; 95 CI 1.70 - 6.79) and Other (aOR 2.97; 95 CI 1.71-5.17) racial/ethnic groups; worse ECOG performance status (ECOG PS ≥2: aOR, 7.78 [95% CI, 4.83 - 12.5]); pre-existing cardiovascular (aOR, 2.26 [95% CI, 1.63 - 3.15])/pulmonary comorbidities (aOR, 1.65 [95% CI, 1.20 - 2.29]); diabetes mellitus (aOR, 2.25 [95% CI, 1.66 - 3.04]); and active and progressing cancer (aOR, 12.5 [95% CI, 6.89 - 22.6]). Hispanic ethnicity, timing and type of anti-cancer therapy modalities were not significantly associated with worse COVID-19 outcomes. The total all-cause mortality and hospitalization rate for the entire cohort was 9% and 37%, respectively however, it varied according to the BC disease status. Conclusions: Using one of the largest registries on cancer and COVID-19, we identified patient and BC related factors associated with worse COVID-19 outcomes. After adjusting for baseline characteristics, underrepresented racial/ethnic patients experienced worse outcomes compared to Non-Hispanic White patients.

Evaluation of the Khorana score for prediction of venous thromboembolism in patients with multiple myeloma.

BACKGROUND: Guidelines recommend thromboprophylaxis for patients with multiple myeloma (MM) at high risk for venous thromboembolism (VTE). However, the optimal risk prediction model for VTE in MM remains unclear. Khorana et al developed a VTE risk score (Khorana score) in ambulatory cancer patients receiving chemotherapy. We aimed to evaluate the predictive ability of the Khorana score in patients with MM. METHODS: We identified patients with MM within the Veterans Affairs health care system between 2006 and 2013. The Khorana score was calculated before treatment initiation. Using logistic regression, the relationship between risk group and VTE was assessed at 3 and 6 months. We tested model discrimination using the concordance statistic. RESULTS: In the cohort of 2870 patients with MM, there were 1328 at low risk (0 points), 1521 at intermediate risk (1-2 points), and 21 at high risk (≥3 points) for VTE by the Khorana score. The 6-month cumulative incidence of VTE was 5.1% (95% confidence interval [CI], 4.0%-6.4%) in low risk, 3.9% (95% CI, 3.0%-5.0%) in intermediate risk, 4.8% (95% CI, 0.3%-20.2%) in high risk. The Khorana score did not strongly discriminate between patients who did and did not develop VTEs at 3 or 6 months (concordance statistic, 0.58; 95% CI, 0.54-0.63; and 0.53, 95% CI, 0.50-0.57, respectively. CONCLUSIONS: In conclusion, in this cohort of 2870 patients with MM, the Khorana score did not predict VTE. Our study supports the need to use myeloma-specific risk models to predict VTE risk in patients with MM.

Rituximab/bendamustine and rituximab/cytarabine induction therapy for transplant-eligible mantle cell lymphoma.

The addition of high-dose cytarabine to rituximab/bendamustine (RB) induction could improve outcomes for transplant-eligible patients with mantle cell lymphoma (MCL). We conducted a pooled analysis of 2 phase 2 trials and an off-trial cohort each testing 3 cycles of RB and 3 cycles of rituximab/high-dose cytarabine (RC) followed by autologous stem cell transplantation (ASCT) among untreated, transplant-eligible patients with MCL. Dana-Farber Cancer Institute (DFCI) and Washington University in St. Louis (WUSTL) led separate phase 2 trials testing sequential and alternating cycles of RB/RC, respectively. Patients treated at DFCI with sequential RB/RC off trial were retrospectively identified. Minimal residual disease (MRD) was assessed in the DFCI trial. A total of 88 patients (23 DFCI trial, 18 WUSTL trial, and 47 off trial) received RB/RC; 92% of patients completed induction, and 84% underwent planned consolidative ASCT. Grade 3 or 4 adverse events among trial patients included lymphopenia (88%), thrombocytopenia (85%), neutropenia (83%), and febrile neutropenia (15%). There were no treatment-related deaths during induction and 2 following ASCT. Among 87 response-evaluable patients, the end-of-induction overall and complete response rates were 97% and 90%, respectively. After a median follow-up of 33 months, 3-year progression-free survival and overall survival were 83% and 92%, respectively. Patients undergoing MRD testing experienced prolonged MRD negativity after ASCT with emergence of MRD occurring in only 1 patient who subsequently relapsed. RB/RC followed by ASCT achieves high rates of durable remissions in transplant-eligible patients with MCL. These trials were registered at www.clinicaltrials.gov as #NCT01661881 (DFCI trial) and #NCT02728531 (WUSTL trial).

Evolving treatment strategies in mantle cell lymphoma.

Mantle cell lymphoma is an incurable, moderately aggressive B cell lymphoma. While a small proportion of patients with indolent disease can be managed expectantly, most patients require treatment. The therapeutic approach is driven by physician recommendation, patient choice, age, fitness and comorbidities. Young, fit patients often receive combination chemoimmunotherapy, including high dose cytarabine, with autologous stem cell transplant. Recent data has indicated benefit from maintenance rituximab following autologous stem cell transplant. Ongoing trials are investigating combinations of chemotherapy and targeted agents as well as the role of minimal residual disease guided therapy. Older, less fit patients often receive bendamustine and rituximab or anthracycline based regimens. Maintenance rituximab is typically administered in older MCL patients after anthracycline based chemotherapy although its use after bendamustine based therapy is not supported by current data. Current trials focus on refining this regimen with the addition of targeted agents. In the relapsed and refractory setting, novel agents have demonstrated activity although durability of responses remains unsatisfactory.

Mutation Clearance after Transplantation for Myelodysplastic Syndrome.

BACKGROUND: Allogeneic hematopoietic stem-cell transplantation is the only curative treatment for patients with myelodysplastic syndrome (MDS). The molecular predictors of disease progression after transplantation are unclear. METHODS: We sequenced bone marrow and skin samples from 90 adults with MDS who underwent allogeneic hematopoietic stem-cell transplantation after a myeloablative or reduced-intensity conditioning regimen. We detected mutations before transplantation using enhanced exome sequencing, and we evaluated mutation clearance by using error-corrected sequencing to genotype mutations in bone marrow samples obtained 30 days after transplantation. In this exploratory study, we evaluated the association of a mutation detected after transplantation with disease progression and survival. RESULTS: Sequencing identified at least one validated somatic mutation before transplantation in 86 of 90 patients (96%); 32 of these patients (37%) had at least one mutation with a maximum variant allele frequency of at least 0.5% (equivalent to 1 heterozygous mutant cell in 100 cells) 30 days after transplantation. Patients with disease progression had mutations with a higher maximum variant allele frequency at 30 days than those who did not (median maximum variant allele frequency, 0.9% vs. 0%; P<0.001). The presence of at least one mutation with a variant allele frequency of at least 0.5% at day 30 was associated with a higher risk of progression (53.1% vs. 13.0%; conditioning regimen-adjusted hazard ratio, 3.86; 95% confidence interval [CI], 1.96 to 7.62; P<0.001) and a lower 1-year rate of progression-free survival than the absence of such a mutation (31.3% vs. 59.3%; conditioning regimen-adjusted hazard ratio for progression or death, 2.22; 95% CI, 1.32 to 3.73; P=0.005). The rate of progression-free survival was lower among patients who had received a reduced-intensity conditioning regimen and had at least one persistent mutation with a variant allele frequency of at least 0.5% at day 30 than among patients with other combinations of conditioning regimen and mutation status (P≤0.001). Multivariate analysis confirmed that patients who had a mutation with a variant allele frequency of at least 0.5% detected at day 30 had a higher risk of progression (hazard ratio, 4.48; 95% CI, 2.21 to 9.08; P<0.001) and a lower 1-year rate of progression-free survival than those who did not (hazard ratio for progression or death, 2.39; 95% CI, 1.40 to 4.09; P=0.002). CONCLUSIONS: The risk of disease progression was higher among patients with MDS in whom persistent disease-associated mutations were detected in the bone marrow 30 days after transplantation than among those in whom these mutations were not detected. (Funded by the Leukemia and Lymphoma Society and others.).

Evaluation of Response to Enzalutamide Consecutively After Abiraterone Acetate/Prednisone Failure in Patients With Metastatic Castration-resistant Prostate Cancer.

INTRODUCTION: Treatment of metastatic castration-resistant prostate cancer (mCRPC) has evolved significantly during the past decade, and the preferred combination and/or sequence of these treatments remains controversial. In this retrospective study, we explored clinical and pathologic factors that could predict response to consecutive treatment with enzalutamide (ENZA) after disease progression (PD) on abiraterone acetate and prednisone (AA/P). PATIENTS AND METHODS: Data were collected from 40 consecutive patients with mCRPC who were treated with ENZA without other interim therapy after progression on AA/P. RESULTS: The median time from prostate cancer initial diagnosis to AA/P treatment was 6.2 (range, 0.9-16.3) years. The median prostate-specific antigen (PSA) progression-free survival (PSA-PFS) from treatment initiation was 8.5 months (95% confidence interval [CI], 7.1-10.1 months) and 2.3 months (95% CI, 1.8-3.4 months) on AA/P and ENZA, respectively. The median time to PD from treatment initiation was 9.7 months (95% CI, 7.1-12.4 months) and 3 months (95% CI, 2.3-4.1 months) on AA/P and ENZA, respectively. The correlations were weak between the best percent change in PSA on ENZA and time from diagnosis to AA/P initiation, best absolute or percentage change in PSA on AA/P, time to PSA progression or PD on AA/P. Patients with longer than the median duration of treatment with AA/P (11.73 months) had longer PSA-PFS on ENZA (median 2.8 vs. 1.9 months; P = .035). CONCLUSIONS: In this retrospective analysis, we did not find any clinical or pathologic factors associated with response to ENZA administered consecutively after AA/P. Patients with longer than median AA/P treatment duration had longer PSA-PFS on ENZA. Further evaluations and validation are greatly needed.

Stigma and Attitudes toward Patients with Psychiatric Illness among Postgraduate Indian Physicians.

BACKGROUND: Due to paucity of psychiatrists in India, psychiatric patients often present to other doctors. We aimed to study nonpsychiatric residents' attitude and stigma toward psychiatric patients. METHODS: A total of 57 postgraduate trainees participated in a cross-sectional study in a tertiary hospital in New Delhi. Attitudes to psychiatric patients were assessed using the attitude to mental illness questionnaire (AMIQ) and the perceived stigma questionnaire. This was correlated with sociodemographic information. RESULTS: Over 70% residents accepted mentally ill patients as friends and felt they were equally employable. However, AMIQ demonstrated a negative attitude towards patients with schizophrenia. Perceived competence in dealing with psychiatric patients was associated with adequate undergraduate exposure (Chi-square = 7.270, P = 0.026) and correlated with positive attitudes (t-test, P = 0.0008). CONCLUSIONS: While the questionnaires revealed some prejudice toward psychiatric patients with schizophrenia, the postgraduate trainees who felt competent to deal with the mentally ill had the most positive attitudes toward them.

Dealing with requests for pharmacological cognitive enhancement from healthy students.

The use of drugs to enhance cognitive function and academic performance is clearly a global phenomenon, with the reported prevalence of stimulant use among medical students ranging from 15-20%. A multi-institution study from the USA reported a 6.9% lifetime prevalence of non-prescription use of cognitive enhancers among college students. A comprehensive systematic review indicates a 16-29% use of non-prescribed stimulants among all students for reasons that include increasing concentration and alertness. While mental health professionals and guidance counsellors anecdotally recall requests for pharmacological cognitive enhancement from otherwise healthy students, the exact magnitude of this problem in the Indian context is not clear.

Recurrent venous thromboembolism in glioblastoma.

BACKGROUND: Patients with glioblastoma (GBM) are at increased risk of initial and recurrent venous thromboembolism (VTE) but rates of recurrence and real-world treatment choices are incompletely understood. OBJECTIVES: We aim to describe the treatment of incident VTE, report incidence and risk factors for recurrence. PATIENTS/METHODS: We conducted a retrospective cohort study of consecutive Cleveland Clinic patients with GBM presenting with objectively diagnosed deep vein thrombosis (DVT) or pulmonary embolism (PE) from 2007 to 2013 with at least 6-month follow-up. We collected information on patient demographics, VTE incidence, treatment and recurrence. Data were analyzed using multivariate logistic regression analysis. RESULTS: Of 450 patients with GBM, 145 (32.2%) developed VTE and comprised the study population. Of these, 11 (7.6%) experienced PE, 117 (80.7%) had DVT and 16 (11%) had DVT as well as PE. Fifty five (37.9%) VTE events occurred in the first 30 post-operative days and 56 (38.6%) during chemotherapy. Thirty one (21.4%) patients were untreated. Treatments included enoxaparin (N=36, 24.8%), warfarin (15, 10.3%) or vena cava filters either alone (N=39, 26.9%) or in combination with anticoagulation (N=21, 14.5%). Recurrent VTE occurred in 39 patients (26.9%).In multivariate analysis, lack of long term anticoagulation (HR 11.2, CI 1.5-86.3, p<0.05) and the presence of second primary malignancy (HR 3.69, CI 1.2-11.1, p<0.05) were significantly associated with recurrent VTE. CONCLUSION: VTE and recurrent VTE are highly prevalent throughout the disease course among patients with GBM. Long term anticoagulation is associated with reduced risk of recurrent VTE but is often not utilized.

Intracranial hemorrhage in setting of glioblastoma with venous thromboembolism.

BACKGROUND: Venous thromboembolism (VTE) is a complication of glioblastoma. Anticoagulating patients with glioblastoma carries a theoretical risk of intracranial hemorrhage (ICH). METHODS: We performed a retrospective cohort study of consecutive glioblastoma patients (2007-2013) diagnosed with VTE. RESULTS: The study population comprised of 523 glioblastoma patients of whom 173 (33%) had VTE events. Seventeen (10%) had ICH: 6 (35%) subdural hematomas and 11 (65%) intratumoral hemorrhages. In total, 4 patients with ICH required neurosurgical intervention. Enhancement in the area of subsequent intratumoral hemorrhage was noted in 9 of 10 with available pre-ICH scans. Multivariable regression did not show associations between ICH and tumor enhancement diameter or use of vascular-endothelial-growth-factor inhibitor. Fifteen (16%) patients receiving anticoagulation had ICH compared with 2 (2.6%) not receiving anticoagulation (P = .005). The method of anticoagulation was not associated with development of ICH. Median survival times from nondistal VTE diagnosis to death were 8.0 and 3.5 months (P = .05) in patients receiving anticoagulation and those not on anticoagulation, respectively. CONCLUSION: Patients with glioblastoma and VTE on anticoagulation have increased incidence of ICH. However, development of ICH was not associated with lower median survival from time of VTE. Intratumoral hemorrhage occurred within the enhancing portion of tumor; however, no relationship was identified between the development of ICH and (i) the median diameter of enhancement or (ii) type of anticoagulant used. However, patients with absence of enhancing tumor did not have intratumoral bleed, suggesting gross total resection may limit this adverse outcome. It is appropriate to initiate anticoagulation in glioblastoma patients with VTEs.

The emergency physician's assessment of suicide risk in intentional self-poisoning using the modified SAD PERSONS scale versus standard psychiatric evaluation in a general hospital in South India: a cross-sectional study.

INTRODUCTION: The reliable identification, by emergency physicians, of those with intentional self-poisoning at risk of repeating attempts is crucial, particularly in countries with a shortfall of mental health professionals. METHODS: This cross-sectional study of intentional self-poisoning in India compared an emergency physician's assessment for the need for psychiatric referral, using the modified SAD PERSONS Scale (MSPS) as an interview guide, with a standard psychiatric interview. RESULTS: In 67 consecutive adults with intentional self-poisoning, MSPS cut-off scores of 5 or more best approximated psychiatric assessments for the need for psychiatric referral (positive likelihood ratio 2.9, 95% confidence interval [CI] 0.8-10.2; negative likelihood ratio 0.5, 95% CI 0.3-0.8). CONCLUSIONS: MSPS-guided emergency physicians' assessments after self-poisoning showed modest concordance with psychiatric assessments of suicide-risk. Concordance with psychiatric assessments may improve if risk factors prevalent in different settings are identified and incorporated in the MSPS.

Job stress, satisfaction, and coping strategies among medical interns in a South Indian tertiary hospital.

BACKGROUND: It has previously been demonstrated that there is a significant drop in all domains of quality of life among interns during internship. AIMS: A modified version of the health consultant's job stress and satisfaction questionnaire (HCJSSQ) was used to assess and quantify aspects of internship that were perceived as stressful and satisfying. Methods used to cope with work place stress were explored. SETTINGS AND DESIGN: A prospective cohort study was undertaken among 93 medical interns doing a rotating internship at the Christian Medical College and Hospital, a tertiary-care hospital in southern India. MATERIALS AND METHODS: After completion of 6 months of internship, the modified version of the HCJSSQ was administered to all participants. STATISTICAL ANALYSIS: The data were entered into Statistical Package for the Social Sciences (SPSS) Version 9 by double data entry technique. Percentages of interns reporting high levels of stress, satisfaction were calculated. RESULTS: While 63.4% of interns reported high levels of satisfaction, 45.2% of the interns experienced high levels of stress, 17.6% coped with work stress by using alcohol and nicotine, and 37% coped through unhealthy eating habits. CONCLUSION: More people found internship satisfying than stressful. However, a high proportion found it stressful, and many reported unhealthy coping mechanisms.

Quality of life among interns at a southern Indian tertiary care hospital: a cohort study.

BACKGROUND: . Changes in the quality of life of medical students through their internship period have not been studied previously in India. We aimed to quantify the change from the beginning to just after 6 months of internship and identify potential contributing factors. METHODS: We prospectively evaluated the quality of life issues among 93 medical students doing a rotating internship at the Christian Medical College and Hospital, Vellore, a tertiary care hospital in southern India. The quality of life was assessed before and halfway during their internship using a sociodemo-graphic profile and the WHO Quality of Life Assessment Instrument Brief Version (WHO-QOL BREF). RESULTS: The WHO-QOL BREF score decreased during the course of internship in all four domains of the instrument (p<0.001). A significant decline in score of 5 points or more was present among women, those who reported poor sleep and individuals who had an obligation of compulsory rural service after internship. CONCLUSION: While internship led to a decline in all domains of quality of life, the decline was most marked among women, individuals with poor sleep and those who had an obligation of compulsory rural service after internship.

Relationship between clock and star drawing and the degree of hepatic encephalopathy.

PURPOSE OF THE STUDY Current hepatic encephalopathy grading tools are limited because of complexity or subjectivity. The degree of constructional apraxia could serve as a simple, objective and reproducible tool to grade encephalopathy. STUDY DESIGN In this cross-sectional study of patients with chronic liver disease, the degree of constructional apraxia was judged by their ability to copy a star and clock face and compared with conventional encephalopathy grading by the West Haven Criteria (WHC) and the Porto Systemic Encephalopathy Index (PSEI). Three blinded observers independently graded the figures. Sensitivity, specificity and positive predictive value (PPV) of clock and star scores (score 0 implying no encephalopathy and >0 hepatic encephalopathy) were assessed against conventional scoring systems (WHC grade >0 or PSEI ≥0.33 indicating encephalopathy). Mosaic and box plots were generated to assess if the degree of constructional apraxia correlated with the severity of encephalopathy. RESULTS 71 patients were studied between October 2008 and July 2009; 11 (15.4%) had WHC grade 0, 32 (45%) grade 1, and 28 (39.4%) grades 2 and 3 encephalopathy. The sensitivity, specificity and PPV of the clock drawing for the diagnosis of encephalopathy was 85%, 80%, and 96%, respectively, and 77%, 70%, and 94%, respectively, for the star drawing. Box plots and intervals on mean PSEI showed an increasing relationship between clock/star scores and PSEI. There was substantial agreement between WHC and clock (weighted κ 0.61) and star scores (weighted κ 0.71). Inter-observer reliability was at least 0.70 for star and at least 0.79 for the clock score. CONCLUSION Clock and star drawing may serve as reproducible, inexpensive bedside tools for diagnosing and grading the severity of hepatic encephalopathy.

Mycophenolate mofetil in Takayasu's arteritis.

Mycophenolate mofetil (MMf) has recently been reported as a useful alternative immunosuppressive drug in autoimmune diseases. There is paucity of literature on its use in Takayasu's arteritis (TA). The aim of this study was to assess the safety and efficacy of MMf in Asian Indian patients with Takayasu's arteritis. Records of 21 consecutive patients with TA on treatment with oral MMF attending our centre from January 2005 to August 2008 were studied. The clinical, laboratory and angiography findings were noted and disease activity assessment was done using Indian Takayasu's arteritis activity score (ITAS) and physician's global observation score at baseline and last follow-up. Eleven patients were on steroids alone at baseline while ten patients had received azathioprine prior to administration of mycophenolate. The mean duration of follow-up on mycophenolate was 9.6 (+/-6.4) months. Nineteen patients (90%) received mycophenolate due to active disease, while in the other two patients, it was given to facilitate steroid tapering. Mycophenolate had to be discontinued in one patient due to skin rash. At the last visit, all the remaining 20 patients who continued mycophenolate had improvement in disease activity as evident by the drop in median ITAS [7 (range 0-19) versus 1 (range 0-7); p=0.001]. A similar trend was noted in laboratory markers of inflammation with a reduction in mean Erythrocyte Sedimentation Rate (ESR) (68+/-36.5 versus 43.2+/-34 mm/first hour; p=0.003) and mean C - Reactive protein (CRP) (31+/-46.7 versus 17.3+/-23.9 mg/L; p=1.00). All patients received concomitant steroids, but there was a significant decrease in steroid dosage from 36 (+/-16) mg/day at baseline to 19 (+/-14) mg/day at last follow-up (p<0.001). This study is the largest series till date establishing the use of mycophenolate as a safe and effective steroid-sparing immunosuppressant in Takayasu's arteritis.