The past decade has seen significant progress in the development of new and effective therapies for multiple myeloma. Stem cell transplantation and the introduction of novel agents, such as thalidomide, lenalidomide, and bortezomib, have significantly improved outcomes of myeloma patients. In the current review, we analyzed the available data provided by published randomized clinical trials for the frontline therapy of myeloma patients. We attempted to assess the relative contribution and impact of these new therapies in the setting of both, transplant eligible and transplant ineligible patients.

Objective: This study aims to determine level of stress, resilience and moral distress among health care providers during covid-19 pandemic. Methods: This is a cross-sectional study performed using an online questionnaire. Data was collected from Health Care Providers, working in various tertiary care hospitals of Lahore, using an online questionnaire. Perceived stress scale (PSS), Connor-Davidson Resilience Scale (CD-RISC 10) and Moral Distress Thermometer were used to determine level of stress, resilience and moral stress respectively among the HCPs. Scores on the PSS can range from 0 to 40 with scores of 0-13, 14-26 and 27-40 being considered as low, moderate and high stress respectively. The Moral Distress Thermometer has scores ranging from 0-10 with value of ≥4 considered high. Data was analyzed using SPSS version.23.Descriptive variables were reported as means and frequencies. Intergroup analysis was done using Chi square test with p<0.05 taken as significant. Results: A total of 278 (n=278) HCPs participated in study. According to the PSS (Perceived Stress Scale) scores, 5.03% (14) reported low, 86.69% (241) moderate and 8.27% (23) high stress levels. The mean stress score is 21.56+/-4.32. Providing patient care (mean = 2.28+/-1.15 SD) and transmitting infection to others (mean = 3.02+/-1.10 SD) were deemed major causes of stress. The mean CD-RISC score was 23.14+/-7.81 SD. Only 10.8% (30) had a score of ≥ 32. The mean Moral Distress score was 4.2+/-2.98 SD, with 53.2% (149) participants reporting high Moral distress (score ≥4). Conclusion: The high level of stress among HCPs during COVID-19 pandemic highlights the need of urgent measures to overcome this psychological issue which if left un-addressed can affect performance of HCPs. Key Words: Stress, Resilience, HCPs How to cite: Latif A., Yaqub S., Dar A.Q., Awan S.U., Farhat Hina., Khokhar A.M., Stress, Resilience and Moral Distress among Health care Providers during COVID-19 pandemic. Esculapio 2021;17 (01):79-82

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e19029 Background: CML, although a disease of middle age, is not uncommon in younger age groups in developing countries like Pakistan. Methods: In this single center, cross sectional study, all patients diagnosed with CML below 30 years of age were enrolled. After collection, data was analyzed using Spss version 23.Quantitative variable were presented as mean and percentages. Chi-square was used for correlation between variables with p<0.05 considered significant. Results: Total 101 patients, with age range 7-30 years (mean 21.99±6.3), including 18(17.8%) below 15 years, were enrolled. Fever was most common presenting symptoms seen in 61(60.4%) followed by fatigue, abdominal distension in 40(39.6%) and 33(32.7%).Mean presenting TLC was 158.9±136.95. Of these, 97(96.03%) patients were in chronic phase, 3(2.97%) had accelerated and 1(1%) in blast phase. As per SOKAL score, 27 (26.73%), 51(50.49%) and 23(22.77%) had low, intermediate and high risk disease respectively. Imatinib was started in 80.19% while Nilotinib in 19.80% as 1st line TKI. Among these, 88.1% achieved CHR by end of 3rd month. After 1st year, 60.8% achieved a molecular response (MR≥3). 1(1%) transformed from chronic to blast phase.2nd line TKI was started in 13.8% due to lack of response. Grade ¾ thrombocytopenia and grade ½ per-orbital edema were main toxicities seen in 10.7% and 9.6% respectively. Co-relation of increasing age with high TLC (p=0.039) and better response to TKI (p=0.014) was statistically significant. Conclusions: Distinct clinical behavior of CML in children and young adults necessitates further studies to ensure better disease management.[Table: see text]

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Background: Incidence of rectal cancer and disease at younger age is increasing. Unlike colon cancer, only age and gender are the strong associated risk factors of rectal cancer. Surgical resection remains main stay of treatment for rectal carcinoma which appears to be inadequate in case of LARC (stage II/III) necessitating multimodality approach using chemotherapy and radiotherapy with various sequences, allowing better tumor control.Methods: A total of 108 patients with LARC were randomly divided in 2 equal arms. Arm A received SCRT (25 Gy in 5 fractions) followed by 2 months of chemotherapy with folfox4 while arm B was treated with conventional long-course RT (45-50 Gy in 25-30 fractions) and concomitant 5-FU infusion. Radiological response to the treatment was assessed at 11-12 weeks of its start using RECIST criteria. Treatment related toxicities were noted using CTCAE V 4.0. All the cases were discussed in MDT meeting and selected ones underwent surgery. Pathological response was determined on histopathogy specimen. Data was entered and analyzed using SPSS v.23. Initial frequencies, mean and percentages of data were obtained. Independent sample t test with confidence interval of 95% was used for comparison between two arms with <0.05 taken as significant.Results: According to RECIST criteria, Objective Response Rate (ORR) was seen in 41(75.9%) patients in arm A and 33(61.1%) patients in arm B (p¼0.131). Stable disease (SD) was seen in 7(13%) patients in both the arms while 6(11.1%) in arm A and 14(25.9%) in arm B showed disease progression on Radiological investigations. After MDT discussion, 41(75.9%) patients in arm A and 33(61.1%) in arm B underwent surgical resection. Pathological Complete Response (pCR) was achieved in 7(17.1%) patients in arm A and 4(12.1%) in arm B (p¼0.745). Comparing both arms, febrile neutropenia (p¼0.023) and grade III/IV proctitis (p¼0.000) were found to be significantly common in arm A. Conclusions:No statistically significant difference in ORR and pCR was seen between two arms. However, febrile neutropenia and proctitis was found to be significantly more common in short course RT arm.Legal entity responsible for the study: The authors.

Objective: Diffuse large B cell lymphoma (DLBCL) is a lymphoid B cells neoplasm with a diffuse pattern and high proliferation rate. Cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP) was considered effective as other complicated regimens with more toxicity profile. Rituximab is a monoclonal antibody directed against CD20 positive B cell. It has good activity therapeutically in patients of DLBCL. It increases response rates and survivals when added to CHOP chemotherapy. Although R-CHOP is more effective but due to high cost of Rituximab it is usually not incorporated with chemotherapy in most of our patients and CHOP is still used extensively. Due to heterogeneity of disease and difference in ethnicity, there may be difference in outcomes of two regimens. This study will help us in tailoring our management plan that will result in better outcome of patients. Methods: 70 patients aged between 20-65 years having DLBCL were taken in this study. We rando-mized patients by lottery method into two groups. Group I received CHOP with dose of Cyclophosphamide 750mg/m2, Doxorubicin 50mg/m2, Vincristine 1.4 mg/m2 and prednisolone 40mg/m2.Chemotherapy was given on Day-1 while prednisolone was given for 5 days from Day-1 of chemotherapy. Group II received R- CHOP which includes same chemotherapy with same dosage. Rituximab was included in Group II with dose of Rituximab 375 mg /m2. Each cycle was given at three weeks interval. Response in terms of CR (Complete Response), PR (Partial Response), SD (Stable Disease) or PD (Progressive Disease) was evaluated as per leukemia network after 4 cycles of chemotherapy. The quantitative variables were calculated by taking mean and standard deviation. The response was assessed in percentage and frequencies and compared by applying chi square test. Results: Group I had 37.1% while Group II had 68.6% complete response with p value of 0.019. Partial response was 48.6% in Group I while 20.0% in Group II. 14.3% in Group I and 8.6% in Group II either had stable disease or progressive disease. Conclusions: R-CHOP has superior response rates as compared to CHOP, therefore, whenever possible Rituximab should be added as target therapy in chemotherapy. Key Words: Diffuse large B cell lymphoma, CHOP, R- CHOP How to Cite: Lodhi F.R, Zafar A, Khokhar M.A, Goraya AW, Ashraf S, Yaqub S. Comparison of R-CHOP with CHOP in patients of diffuse large B cell lymphoma. Esculapio.2020;16(04):79-82.

Objectives: This study is done to determine knowledge and attitude of cancer patients towards COVID-19 pandemic. Methods: The study was conducted at Oncology Department, Mayo Hospital Lahore during August-October 2020. A questionnaire was used to determine knowledge and attitude of cancer patients towards COVID-19 pandemic. Data was analyzed using Spss version.23. Descriptive variables like gender, marital status, residence and disease characteristics were reported as means and frequencies. Intergroup analysis was done using Chi square test with p<0.05 taken as significant. Results: Of 269 enrolled patients, majority had advanced/metastatic disease (82.4%) and were being treated on outdoor basis (71.6%). Almost all (99.6%) were aware of COVID, electronic/print media being commonest source of information (62.7%). Though having different views, 81.5% considered it a natural calamity. During first wave,22.4% had delayed their investigations while 34.7% faced treatment interruptions with average duration of delay being 55±27 days. Traveling difficulties due to lock down was common reason of delay (54.8%). During this period 62.4% either noted worsening of symptoms or new symptoms. Despite all chaos, 89.9% selected for treatment continuation if provided with a chance and appropriate facilities. Correlation of delay in therapy with high level of education (p=0.013) and perception about COVID-19 a natural calamity (p=0.041) was found to be statistically significant. Conclusion: Patients' perspective is important and should be taken into account in special circumstances like COVID. It will help in future in making efficient management planning of disease during unusual situations. Key Words: COVID-19, cancer patients, Knowledge How to cite: Yaqub S., Jamil Z., Butt. B.N., Zafar A., Lodhi R.F., Khokhar A.M. Knowledge and attitude of cancer patients towards COVID-19 pandemic. Esculapio 2021;17(01):26-29