Assessing the Impact of Comorbid Hypercalcemia on Inpatient Outcomes of Patients With Diffuse Large B-cell Lymphoma During Admission for Chemotherapy.

Introduction Diffuse large B-cell lymphoma (DLBCL) may be complicated by hypercalcemia at various stages of treatment. The impact of hypercalcemia on chemotherapy admission outcomes in DLBCL is not well described.  Methods In a retrospective analysis, using the National Inpatient Sample database (2018 - 2020), patients with DLBCL admitted for chemotherapy were dichotomized based on the presence of hypercalcemia. Our primary outcome was all-cause mortality. Secondary outcomes included length of stay (LOS), total charge, rate of acute kidney injury (AKI), tumor lysis syndrome (TLS), hyperkalemia, metabolic acidosis, acute encephalopathy, septic shock, Clostridiodes difficile infection, acute respiratory failure, and venous thromboembolic events (VTE). Results We identified 78,955 patients, among whom 1,375 (1.74%) had hypercalcemia. Hypercalcemia was associated with higher odds of all-cause mortality (aOR:3.05, p-value:0.020), TLS (aOR:8.81, p-value<0.001), acute metabolic encephalopathy (aOR:4.89, p-value<0.001), AKI (aOR:5.29, p-value<0.001), hyperkalemia (aOR:2.84, p-value:0.002), metabolic acidosis (aOR:3.94, p-value<0.001) and respiratory failure (aOR:2.29, p-value:0.007) and increased LOS by 1 day and total charge by 12, 501 USD. Conclusions In patients with DLBCL admitted for inpatient chemotherapy, those with hypercalcemia compared to a cohort without had higher odds of; all-cause mortality, TLS, AKI, acute encephalopathy, acute metabolic acidosis, hyperkalemia, and acute respiratory failure as well as higher LOS and total charge.

Viral Infections and Incidence of Reactivations in Chronic Myeloid Leukemia Patients.

BACKGROUND: Viral infections remain a significant problem for patients with chronic myeloid leukemia (CML) who undergo stem cell transplants (SCTs). These infections often result from the reactivation of latent viruses. However, our understanding of the risk of viral reactivation in CML patients who have not undergone SCT is limited, and there is a scarcity of data on this topic. Tyrosine kinase inhibitors (TKIs) have revolutionized the treatment of CML as it is highly successful and has transformed the prognosis of patients with CML. However, TKI may be associated with an increased risk of infections. SUMMARY: We have performed a literature search for publications related to viral infections and their reactivations in patients with CML using PubMed, Scopus, and Google Scholar for the period 2001-2022. The population consisted of patients over 18 years old with a diagnosis of CML and no history of bone marrow transplantation. In an analysis of 41 patients, with 25 males and 16 females, M:F ratio of 1.56:1, and a median age of 50. Age ranged from 22 to 79 years. Most patients with reported viral infections or reactivations were in the chronic phase (CP) of CML, with 22 patients (76%) in the CP, 6 patients (21%) in the accelerated phase, and 1 patient (3%) in the blast phase. Most cases with reported outcomes responded to treatment for CML; only one had refractory disease and 8 cases (32%) had major molecular response. Imatinib was the most used TKI in 31 patients (77%). The most reported viral reactivations were herpes zoster in 17 cases (41%), followed by hepatitis B reactivation in 15 cases (37%). KEY MESSAGES: This review sheds light on the importance of having a hepatitis B serology checked before starting TKI therapy and close monitoring for viral infections and reactivations in patients with CML.

Follow up duration of phase III Multiple Myeloma Clinical Trials: A systematic review.

Long-term follow-up of multiple myeloma (MM) clinical trials are needed to assess long-term outcomes. We aimed to investigate the length of follow-up of all phase III MM clinical trials. Median follow-up duration of clinical trials of newly diagnosed MM was longer when compared to relapsed/refractory MM clinical trials (42.7 vs. 20.5 months, respectively). The follow-up duration of phase III clinical trials in MM is relatively short when compared to the improved outcomes in the current era. Efforts should be made to facilitate long-term clinical trials follow-up and/or publication of results of updated results.

The impact of enteric coating of aspirin on aspirin responsiveness in patients with suspected or newly diagnosed ischemic stroke: prospective cohort study: results from the (ECASIS) study.

BACKGROUND AND PURPOSE: Uncertainty remains regarding the impact of enteric-coated aspirin (EC-ASA) on secondary prevention of ischemic stroke compared to plain aspirin (P-ASA). Hence, this study was designed to investigate the effect of EC formulation on ASA response via evaluating thromboxane B2 (TXB2) levels in patients with suspected or newly diagnosed stroke. METHODS: A prospective cohort study on suspected or newly diagnosed ischemic stroke patients who are aspirin-naive was conducted. Patients were received either EC aspirin or plain aspirin for at least 3 days. The primary outcome was the proportion of aspirin non-responsiveness between two groups (level of residual serum TXB2 associated with elevated thrombotic risk (< 99.0% inhibition or TXB2 > 3.1 ng/ml) within 72 h after three daily aspirin doses, while secondary outcomes were the incidence of early gastrointestinal tract (GIT) bleeding with the various aspirin preparations. (Trial registration: Clinicaltrials.gov NCT04330872 registered on 02 April 2020). RESULTS: Of 42 patients, ischemic strokes were confirmed in both P-ASA (81%) and EC-ASA (67%) arms. ASA non-responsiveness showed no significant difference between the two formulations (P-ASA vs. EC-ASA; 28.6% vs 23.8%; P = 0.726). Univariate and multivariate logistic regression analysis showed that patients treated with EC-ASA were more likely to have a lower rate of non-responders compared to P-ASA (unadjusted OR 0.78; 95% CI 0.20, 3.11); with the risk highest in type 2 diabetic patients with HBA1c > 6.5% (adjusted OR 6; 95% CI 1.02, 35.27; P = 0.047). No incidence of GIT bleeding observed throughout the study. CONCLUSION: A significant proportion of ASA non-responsiveness was recorded regardless of ASA formulation administered. The increased risk of ASA non-responsiveness in diabetic patients needs further exploration by larger prospective studies.

Efficacy and Safety of the Non-Vitamin K Antagonist Oral Anticoagulant Among Patients With Nonvalvular Atrial Fibrillation and Cancer: A Systematic Review and Network Meta-analysis.

Patients with cancer are at higher risk of atrial fibrillation (AF). Currently there are no definitive data on clinical outcomes for nonvitamin K antagonist oral anticoagulant (NOACs) and warfarin in cancer patients with AF. Therefore, we conducted a meta-analysis to evaluate the efficacy and safety of NOACs compared with warfarin. A search through Pubmed/MEDLINE, Embase, and Cochrane library was done from the databases inception to March 2022. Studies that compared NOACs to warfarin in the setting of AF and cancer were included. The primary outcomes were the incidence of major bleeding and ischemic stroke/systemic embolism (SE). Secondary outcomes were major adverse cardiovascular event (MACE), intracranial bleeding, and Major gastrointestinal bleeding. Risk ratios (RRs) with 95% confidence intervals (CI) were used to report the outcomes. A total of 11 studies were included. We found that NOACs were associated with a lower incidence of major bleeding and combined ischemic stroke/SE in patients with AF and cancer compared with warfarin (RR 0.57; 95% CI 0.44-0.75, P < 0.0001 and RR 0.59; 95% CI 0.47-0.75, P < 0.0001, respectively). Also, there was lower incidence of Intracranial and major gastrointestinal bleeding in patients who received NOACs compared with warfarin (P < 0.0001). Network analyses revealed that apixaban and dabigatran were associated with reduction of major bleeding compared with warfarin. Among patients who diagnosed with AF and cancer, NOACs were associated with lower incidence of major bleeding ischemic stroke/SE compared with warfarin. Furthermore, NOACs were associated with lower gastrointestinal and intracranial bleeding.

P2Y12 Inhibitors versus Aspirin Monotherapy for Long-term Secondary Prevention of Atherosclerotic Cardiovascular Disease Events: A Systematic Review and Meta-analysis.

Patients with established atherosclerotic cardiovascular disease (ASCVD) need long-term antiplatelet therapy to decrease the risk of future ASCVD events. We searched PubMed, Cochrane Library, and ClinicalTrials.gov (inception through September 2021) for randomized controlled trials (RCTs) evaluating P2Y12 inhibitors vs aspirin for secondary prevention of ASCVD events. Seven RCTs including a total of 56,982 patients were included in this analysis. The median follow-up duration was 22.8 (IQR 12) months. When P2Y12 inhibitors were compared with aspirin as long-term antiplatelet therapy for secondary prevention of ASCVD events, there was a significant decrease in the risk of myocardial infarction [RR: 0.83; 95% CI: 0.72-0.94], and stroke [RR: 0.90; 95% CI: 0.83-0.99]. However, there was no significant difference in all-cause mortality [RR: 1.02; 95% CI: 0.92-1.12], or cardiovascular mortality [RR: 0.95; 95% CI: 0.83-1.08] between P2Y12 inhibitors and aspirin users. Additionally, there was no significant difference in major bleeding events [RR: 0.88; 95% CI: 0.74-1.04], or all bleeding events [RR: 1.09; 95% CI: 0.90-1.33] between P2Y12 inhibitors and aspirin groups. Use of P2Y12 inhibitor monotherapy is associated with lower rates of myocardial infarction and stroke in ASCVD patients without any significant difference in mortality, or bleeding compared to aspirin monotherapy.

Tuberculous Pancreatic and Liver Abscesses Presenting as Obstructive Jaundice in an Immunocompetent Patient.

Isolated hepatobiliary, pancreatic, and peripancreatic tuberculosis (TB) is an extremely rare disease, particularly in immunocompetent individuals. To the best of our knowledge, the presentation of combined pancreatic and liver abscesses is a particularly uncommon presentation among the reported cases in the literature. This presents a significant challenge in clinical diagnosis. In this report, we discuss the case of a 24-year-old Nepalese man who presented with epigastric pain and jaundice. Further, tuberculous pancreatic and liver abscesses were detected by abdominal CT and MRI, which were later confirmed by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with pus smear and polymerase chain reaction (PCR) test. These tests were positive for acid-fast bacilli (Mycobacterium tuberculosis). The patient responded well to anti-tubercular therapy (ATT). As the clinical presentation is often unclear and radiological imaging may be misleading, physicians should have a high index of suspicion for TB, especially if the patient is young and belongs to an area highly endemic for TB.

An Association of Varicella Zoster Virus, Facial Palsy, and Meningitis in a Young Immunocompetent Male.

Varicella zoster is a secondary infection caused by the virus of chickenpox, after becoming latent in neurons of dorsal root ganglia or trigeminal ganglia. Varicella zoster virus (VZV) can be reactivated years later to produce shingles (zoster), generally in immunocompromised adults to produce neurological deficits and rash. Meningeal involvement of VZV is also reported and can be diagnosed. Herein, we report a 39-year-old immunocompetent male adult with a rare manifestation caused by VZV. The report is an association between facial nerve palsy and a polymerase chain reaction-confirmed VZV meningitis, even without the dermal typical rash. The patient eventually recovered after receiving acyclovir intravenously.

An investigation into the impact of enteric coated of aspirin in patients with newly diagnosed ischemic stroke (ECASIS).

INTRODUCTION: Uncertainty remains regarding the impact of enteric-coated (EC) aspirin as it relates to the reduction of cardiovascular risk. We hypothesize that EC formulation based on a previous report may blunt aspirin response as evidenced by reduced Thromboxane A2 (TXA 2) levels in diabetic patients. Thus, it was imperative to ascertain and validate the effect of the EC formulation of Aspirin on the Thromboxane B2 (TXB2) level. METHODS/DESIGN: An open-label consecutive randomized interventional controlled trial. Patients with newly diagnosed ischemic stroke who are just about to start Aspirin were assessed for eligibility and inclusion in our trial. Consecutive patients (admitted to the stroke unit of Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar) will be randomized to receive either EC aspirin or plain Aspirin. They will be required to continue taking them throughout the study (3 days). Demographics and laboratory records of the study participants will be abstracted from online records. Further study variables will be obtained manually in designated case record forms (CRF). The primary outcomes are the incidence of aspirin non-responders (level of residual serum TXB2 associated with elevated thrombotic risk (<99.0% inhibition or TXB2 >3.1 ng/mL) within 72 h after three daily aspirin doses). Whereas secondary outcomes are the incidence of GIT bleeding of various preparations of Aspirin. The study was approved by MRC and IRB of Hamad Medical Corporation (MRC number: 01-18-156). DISCUSSION: This trial will determine potential differences in the efficacy of EC Aspirin and plain Aspirin on the Thromboxane B2 level. Additionally, it will ascertain the tolerability and safety of both formulations of Aspirin in patients with newly diagnosed ischemic stroke. These results will either support the current notion of no difference between the two formulations. However, if a difference is found, this will invite for future trials exploring clinical outcomes occurrence between various formulations. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov NCT04330872 registered on April 2, 2020.

Rituximab Twice Weekly for Refractory Thrombotic Thrombocytopenic Purpura in a Critically Ill Patient with Acute Respiratory Distress Syndrome.

Thrombotic thrombocytopenic purpura (TTP) is a rare, serious, life-threatening disease characterized by microangiopathic hemolytic anemia, thrombocytopenia, and hypercoagulability. The etiology is a deficiency of ADAMTS13 which is usually caused by acquired antibodies. Plasma exchange and steroids is the standard of care in the treatment of TTP. However, there are refractory cases of TTP which require further management. Rituximab appears to be a safe and effective therapy for refractory and relapsing TTP. Here we report a challenging case of TTP that responded to treatment with rituximab twice weekly. According to our knowledge, rituximab twice weekly has never been used for TTP before.

Acute Myeloid Leukemia after Low-Dose Radioiodine Therapy for Papillary Thyroid Carcinoma.

Papillary thyroid carcinoma is the most common primary thyroid cancer. Most frequently treated with surgical resection, some cases require radioactive iodine (RAI) therapy. Studies have suggested that there is an increase in second primary malignancy after RAI therapy amongst thyroid cancer survivors including acute myeloid leukemia (AML) as an infrequent cancer related to RAI therapy; it has a higher relative risk ratio in patients on higher doses of radiation exposure. We would like to report a 30-year-old lady who was diagnosed with papillary thyroid carcinoma. She underwent total thyroidectomy and received a low-dose RAI 131I therapy at a dose of 150 mCi, after which she developed therapy-related AML. Here we would like to highlight the association of AML with low-dose RAI as an infrequent cause of a second primary tumor compared to high doses.

Outcome of Pregnancy in the Era of PEGylated Interferon-α2a in Females with Chronic Myeloid Leukemia: An Experience from Qatar.

Chronic myelogenous leukemia (CML), also known as chronic myeloid leukemia, is a myeloproliferative neoplasm characterized by increased proliferation of the granulocytic cell line without loss of its capacity to differentiate. It accounts for 20% of all adults affected by leukemia. Tyrosine kinase inhibitors revolutionized the treatment for CML and improved quality of life. Fertility is an important issue for both males and females. Here, we report our experience with a pregnant female with CML, and shed light on safety and efficacy of PEGylated interferon-αa in pregnant women with CML and its outcome.

Imatinib-Induced Tremor in a Patient with Chronic Myeloid Leukemia in Chronic Phase.

Chronic myeloid leukemia (CML) is a myeloproliferative neoplasm characterized by three phases: chronic, accelerated, and blast phase. However; first- and second-generation tyrosine kinase inhibitors are used for the treatment of CML with common and uncommon adverse events. Here, we report a 24-year-old male with CML in chronic phase started on imatinib as upfront medication who developed tremor and recovered spontenously after 3 years.

Portomesenteric Thrombosis Secondary to Acute Cholecystitis: A Case Report.

Portomesenteric venous thrombosis (PMVT) is an uncommon clinical problem. Common risk factors include intra-abdominal infections, abdominal surgeries, malignancy, cirrhosis, and inherited thrombophilia. Early recognition and treatment of PMVT are important to avoid serious complications like mesenteric ischemia and infarction. Acute cholecystitis is a clinical condition encountered daily but rarely may be complicated by development of portomesenteric venous thrombosis. Only few cases have been reported of superior mesenteric vein thrombosis secondary to cholecystitis. We report a case of a forty-one-year-old male patient who developed partial portal and superior mesenteric vein thrombosis after mild acute cholecystitis for which surgery had been deferred. Patient had no other identifiable risk factors for thrombosis. Patient was successfully treated with 6 months of anticoagulation with warfarin and complete recanalization of portomesenteric veins was achieved at the end of treatment.