A population level analysis of second hematological malignancies in chronic lymphocytic leukemia/small lymphocytic lymphoma survivors in the era of targeted therapies.

With improvement in survival after chronic lymphocytic leukemia (CLL) diagnosis, the real-world burden of second hematological malignancies (SHM) has not been comprehensively assessed in recent era. We analyzed risk, incidence, and outcomes of SHM in CLL patients between 2000 and 2019 using SEER database. CLL patients had greater risk for hematological malignancies than general population [SIR, standardized incidence ratio (95% CI):2.58 (2.46-2.70); p < 0.05]. The risk for subsequent lymphoma increased by 1.75 folds in 2015-2019 compared to 2000-2004. The duration, after CLL diagnosis, of maximum risk for SHM decreased as 60-119 months for time-period 2000-2004, 6-11 months for 2005-2009 to 2-5 months for 2010-2014 and 2015-2019. Incidence of SHM was 2.5% in CLL survivors (1736/70,346) with lymphoid SHM being more common than myeloid SHM, and DLBCL being the most common pathology (n = 610, 35% of all SHM). Male sex, age ≤65 years at CLL diagnosis, and chemotherapy treatment were associated with higher risk for SHM. The median gap between CLL and SHM diagnoses was 46 months. The median survival for de-novo-AML, t-MN, CML, and aggressive NHL was 63, 86, 95, and 96 months respectively. Although SHM remains rare, there is increased risk in recent era, likely due to improved survival in CLL patients, necessitating active surveillance strategies.

Efficacy of topical hemostatic agents in malignancy-related GI bleeding: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Despite advances in endoscopic therapies, malignancy-related GI bleeding remains difficult to manage with high rates of treatment failure and rebleeding. Topical hemostatic agents (THAs) are easier to apply to the wide bleeding surface of tumors. We conducted this systematic review and meta-analysis to evaluate the efficacy of THAs in malignancy-related GI bleeding. METHODS: We conducted a comprehensive search of multiple electronic databases to identify studies reporting on the use of THAs in malignancy-related GI bleeding. The primary outcome was the achievement of hemostasis; secondary outcomes were early rebleeding (≤3 days), delayed rebleeding (>3 days), aggregate rebleeding, all-cause mortality, and GI bleeding-related mortality. A meta-analysis of proportions was done for all outcomes. RESULTS: Out of 355 citations, 16 studies with 530 patients were included. Primary hemostasis was achieved in 94.1% (95% confidence interval [CI], 91.5-96.0). Early rebleeding was seen in 13.9% (95% CI, 9.7-19.4) and delayed rebleeding in 11.4% (95% CI, 5.8-21.1). Aggregate rebleeding was seen in 24.2% (95% CI, 18.5-31.0). All-cause mortality was 33.1% (95% CI, 23.7-44.0), whereas GI bleeding-related mortality occurred in 5.9% (95% CI, 2.2%-14.8). CONCLUSIONS: THAs are highly effective for achieving primary hemostasis in malignancy-related GI bleeding. It should be considered as an alternative to traditional endotherapy methods in malignancy-related GI bleeding. Future studies should be designed to evaluate its efficacy and safety as a primary method of hemostasis as compared with traditional endotherapy measures.

Comparable Efficacy for Push Versus Pull Technique in Esophageal Food Impaction: Systematic Review with Meta-Analysis.

BACKGROUND: Esophageal food impaction (EFI) is a common GI emergency. Push and pull methods are used currently for EFI retrieval. We aim to review current available literature to compare success rates and evaluate adverse event rates of the two techniques. METHODS: A comprehensive literature search was performed using MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science Core Collection, KCI-Korean Journal Index, SciELO and Global Index Medicus. Odds ratio (OR) with 95% confidence interval (CI) was calculated when comparing the dichotomous variables. We aimed to evaluate technical success and adverse events for EFI comparing push and pull technique on single arm and comparator analysis. RESULTS: The search strategy yielded a total of 126 articles. 18 studies with 3528 participants were included. The technical success rate was 97.5% (CI 96.6-99.2%) in the push and 88.4% (CI 72.8-98.7%) in the pull technique with no statistical difference on comparator analysis. Overall rate of adverse events was 4.03% (CI 0.9-5.0%) in the push technique and 2.22% (CI 0-2.9%) in the pull technique with no statistical difference on comparator analysis (OR 95% CI 0.464-2.782, p = 0.78, I2 = 31.54%). There was no statistical difference between rate of lacerations and perforations either between the two techniques. CONCLUSION: Both techniques have acceptable clinical outcomes which appear within standard of care. Operator experience and individual clinical scenarios should guide decision-making regarding technique selection.

Iliac Artery-Inferior Vena Cava-Duodenal Fistula: An Unusual Cause of Massive Gastrointestinal Bleeding.

An arteriovenous-enteric fistula is a 3-way connection between the vascular and enteric system and associated with high mortality. We describe a case of iliac artery-inferior vena cava-duodenal fistula in a young female with a retroperitoneal mass presenting with sepsis and hemorrhagic shock with a catastrophic clinical course. These fistulas can be missed on endoscopy/colonoscopy and are usually diagnosed on computed tomography angiogram of the abdomen. Complex vasculoenteric fistula should be among differentials in patients presenting with gastrointestinal bleeding, especially with a history of malignancy, radiation, foreign bodies, and trauma. The management is complex and should involve a multidisciplinary approach involving vascular surgery, intervention radiology, and gastroenterologist.

Gastrointestinal treatment-related adverse events of combined immune checkpoint inhibitors: a meta-analysis.

Introduction: Combined immune checkpoint inhibitors can cause gastrointestinal adverse events. Methods: We performed a meta-analysis of pooled colonic, hepatic and pancreatic treatment-related adverse events of combined ICI. Results: 53 trials reporting treatment-related adverse events in 6581 patients. All grade diarrhea was the most common adverse event seen in 25.4% patients, followed by all grade hepatitis in nearly 13% patients and pancreatitis in nearly 7.5% patients. Conclusion: Our study provides pooled data of treatment-related adverse events from different combination immune checkpoint inhibitors use in solid tumors and demonstrates a high incidence of all grades and ≥3 grade gastrointestinal adverse events. Further studies are required to characterize these adverse events and assess their overall impact on treatment course and outcomes.

The article talks about a type of medicine called immune checkpoint inhibitors that are used to treat cancer. These medicines can sometimes cause problems in the stomach and liver when used in combination with other cancer treatments, which can lead to hospitalization or, rarely, death. We performed a study on 6581 people who took these medicines in combination with another treatment and determined exactly how often these side effects happened. We also looked at which combinations of medicines were safer. This information can help doctors identify the side effects early and treat them. It can also help scientists design more studies to learn more about these side effects and how to prevent them.

Comparing adalimumab and infliximab in the prevention of postoperative recurrence of Crohn's disease: a systematic review and meta-analysis.

Background: Crohn's disease is a relapsing disease that often requires operative management. Prevention of postoperative recurrence (POR) is critical to maintain remissions. Biologic agents have proven to be most successful in remission maintenance. We made a direct head-to-head comparison of the 2 anti-tumor necrosis factor agents, infliximab (IFX) and adalimumab (ADA), to compare endoscopic and clinical POR of Crohn's disease. Methods: We conducted a comprehensive literature search in 7 databases, including Medline, Embase, Cochrane Central Register of Controlled Trials, Web of Science Core Collection, KCI-Korean Journal Index, SciELO, and Global Index Medicus. Odds ratios (OR) were calculated with 95% confidence intervals (CI) and P-values (<0.05 considered significant). We evaluated the total rates of endoscopic recurrence, endoscopic recurrence at 1 year, and clinical recurrence rates of IFX and ADA in a direct head-to-head comparison. Results: The search strategy yielded a total of 393 articles. Three studies with a total of 268 participants were included. Our meta-analysis showed no statistically significant difference in total endoscopic recurrence rate between ADA and IFX (27.1% vs. 32.3%, OR 0.696, 95%CI 0.403-1.201; P=0.193; I 2=0%). Nor was there any significant difference between the drugs in endoscopic recurrence rate at 1 year (OR 0.799, 95%CI 0.329-1.940; P=0.620) or clinical recurrence rate (OR 0.477, 95%CI 0.477-1.712; P=0.755). Conclusions: ADA and IFX show comparable efficacy in preventing POR endoscopically and clinically. The clinical decision should be based on cost, side-effects, tolerability, and patient preferences. Additional studies, particularly randomized controlled trials, are needed to determine generalizability.

An Unusual Presentation of Segmental Arterial Mediolysis.

Segmental arterial mediolysis (SAM) is a rare nonatherosclerotic and noninflammatory disease that often affects medium to large-sized arteries. We report a case of SAM involving bilateral hepatic arteries in an elderly woman. Although her initial presentation mimicked vasculitis, the clinical course and imaging led to the diagnosis of SAM. She was treated with coil embolization and stenting of the involved hepatic vessel leading to dramatic clinical improvement. It should be differentiated from vasculitis because there is no role of steroids in the management of SAM.

Acute hypotensive hematochezia due to jejunal diverticular bleed.

Small bowel diverticulum, though rare, can result in complications including diverticulitis, hemorrhage, intussusception, fistula, perforation, or bacterial overgrowth. Here, we present a case of gastrointestinal bleeding as a complication of jejunal diverticulum, resulting in hemorrhagic shock. The patient had a negative endoscopy and colonoscopy, prompting computed tomography angiogram, which identified one jejunal diverticulum with active contrast extravasation into the lumen of the small bowel. She underwent successful coil embolization, resulting in cessation of bleeding. This case demonstrates the difficult but successful identification of nonsteroidal antiinflammatory drug-induced jejunal diverticular bleeding in the acute emergent setting.

Polyserositis as a Unique Presentation of Isolated Myeloid Sarcoma: A Case Report.

BACKGROUND: Myeloid Sarcoma (MS) are tumors containing myeloid blasts occurring in a location other than the bone marrow, including lymph nodes, skin, and soft tissues. MS presenting as polyserositis however is very rare, with only a few cases in the literature. CASE REPORT: A 20-year-old male presented with cough, shortness of breath and was found to have left upper lobe consolidation, left pleural effusion, pericardial effusion, and a large anterior mediastinal mass. A transthoracic echocardiogram showed pericardial effusion with tamponade physiology. He underwent emergent pericardiocentesis and thoracentesis. The fluid studies showed flow cytometry findings consistent with MS/ acute myeloid leukemia (AML) phenotype. A bone marrow aspirate and biopsy were unremarkable and showed no immunophenotypic findings diagnostic of acute leukemia or a lymphoproliferative disorder. Cytogenetics was negative for AML abnormalities per FISH analysis. Videoassisted thoracoscopy surgery (VATS) with biopsy of the mediastinal mass, pericardium, and left upper lobe of the lung was consistent with MS. He was treated with induction cytarabine and idarubicin, and a follow up PET-CT scan showed complete remission. He is currently day 200 + post stem cell transplant with no evidence of disease recurrence. CONCLUSION: To the best of our knowledge, this is the first case of isolated myeloid sarcoma presenting as polyserositis, without prior leukemia/ bone marrow involvement. Hence, fluid studies should involve cytometry analysis and MS should be entertained as a differential for polyserositis, even without a history of prior leukemia. Timely diagnosis can expedite aggressive chemotherapy required for a potentially life-threatening disease.

Epidemiology, Genotyping, Mutational and Phylogenetic Analysis of Hepatitis B Virus Infection in North-east India.

BACKGROUND/OBJECTIVE: Hepatitis B virus (HBV) infection is a major public health problem globally. Northeast India is home to indigenous tribes with different ethnicity and high rates of drug abuse and HIV infection. The study was designed to estimate the burden of HBV infection across various spectrums of liver diseases from this region. HBV genotypes and subgenotypes play a role in the chronicity of disease, response to treatment and its progression. As very limited data are available from this region, we tried to elucidate the role of HBV genotypes, HBV mutants and their phylogenetic analysis. METHOD: We designed a prospective multicentric study, and included 7464 liver disease cases, 7432 blood donors and 650 health care workers, who were screened for HBV infection. HBV DNA positive patients were genotyped and subjected to surface protein, precore and core mutation and phylogenetic analysis. RESULTS: The prevalence of HBV infection with respect to different types of liver diseases, blood donors and health care workers was 9.9% (1550/15,546). 49.5% (768/1550) cases were found to be HBV DNA positive. The most common genotype was found to be genotype D 74.2% (570/768), followed by genotype C 6.5% (50/768), A 4.4% (34/768) and I 0.9% (7/768). CONCLUSION: This study highlights the high hepatitis B burden in Northeast India, reflecting lacunae in health care needs of the region. Also, the different genotype distribution and presence of mutations may translate into different rates of liver disease progression, prognosis and ultimately, clinical significance. However, further prospective cohort study from Northeast India is warranted, to elucidate the clinical significance of multiple genotypes and mutation in this unique population.

Vaping associated spontaneous pneumothorax - A case series of an enigmatic entity!

The use of electronic nicotine delivery devices (ENDDs) has risen to an epidemic level among high schoolers and people aged 18-34. To our knowledge there are only 7 reported cases of spontaneous pneumothorax (SP-PTX) associated with vaping, and herein we describe 4 additional cases. We propose identifying this disease process as a novel entity, Vaping-Associated Spontaneous Pneumothorax (VASP). VASP requires early interventional treatment and has a high recurrence rate, and we suggest that vaping cessation and early interventional treatment including tube thoracostomy and surgical treatment is necessary in most cases to prevent recurrences.

Atypical presentation of anti-HMGCR myopathy.

Immune-mediated necrotising myopathy is a subtype of idiopathic inflammatory myopathy characterised by muscle fibre necrosis without significant inflammatory infiltrate. Anti-3-hydroxy-3-methylglutaryl coenzyme A reductase (HMGCR) myopathy is seen in 6%-10% of idiopathic inflammatory myopathy and is diagnosed in the context of elevated serum creatine kinase levels, proximal muscle weakness and anti-HMGCR autoantibodies. We recently encountered a 61-year-old man with anti-HMGCR myopathy with an atypical skin manifestation, partially responsive to triple therapy with steroids, intravenous immunoglobulin (IVIG) and rituximab. To our knowledge, there have been only four reported cases of skin rash associated with anti-HMGCR myopathy. Our case demonstrates the importance of recognising atypical manifestations of anti-HMGCR myopathy. Early addition of IVIG and rituximab is also critical in patients not responding to steroid monotherapy. Delay in achieving remission leads to prolonged steroid use, lower likelihood of beginning physical therapy and overall worse clinical outcomes.

Cranial nerve palsies, SIADH and atrial fibrillation: a diagnostic challenge.

We recently encountered a 79-year-old Caucasian man who presented with blurring of vision and facial muscle weakness. The patient also had hyponatraemia, atrial fibrillation with rapid ventricular response and underlying Brugada type II pattern. Urine and serum osmolality were consistent with syndrome of inappropriate antidiuretic hormone secretion (SIADH). It was only after extensive imaging and workup that we were able to tie together these three different presentations of Lyme disease-cranial nerve palsies, SIADH and atrial fibrillation and treat them accordingly. To the best of our knowledge, only eight cases of SIADH in patients with Lyme neuroborreliosis have been reported in the literature. Although our patient did not have a history of arrhythmias, case findings suggest that underlying Brugada type II morphology could have been the predisposing factor, and Lyme disease the trigger.

Clinical and functional recovery in a patient with pulmonary hypertension after bariatric surgery.

Severe pulmonary hypertension (PH) in obese patients pose a challenge to treat despite advances in medical therapeutics. Current treatment options are limited for patients who are not responding to maximal medical therapy. Here, we present a case of multifactorial PH, not responsive to ambrisentan, tadalafil, and treprostinil, even after optimization of cardiac and pulmonary function and had a poor prognosis. She demonstrated weight loss after bariatric surgery, improving her restrictive lung disease, obstructive sleep apnea and PH, and overall functionality. Bariatric surgery may offer a potential therapeutic option, in patients with morbid obesity and PH resistant to maximal medical therapy.

Pancreatic cancer Masquerading as lung nodules: A Diagnostic Dilemma.

To our knowledge, this is the first report of isolated pulmonary nodules as an initial presentation of underlying pancreatic cancer. We present a case of metastatic pancreatic cancer which manifested as worsening bilateral pulmonary nodules and normal abdominal imaging in a 72-year-old female patient. A navigational bronchoscopy with biopsy of lung nodules was performed which showed poorly differentiated adenocarcinoma. Carcinoembryonic antigen and CA 19-9 levels were elevated so endoscopic ultrasound with fine needle aspiration was done which revealed an underlying occult pancreatic adenocarcinoma. The patient was treated with chemotherapy. Patients with pulmonary metastasis have been shown to confer longer survival as compared to metastatic disease involving other organs. We have briefly reviewed the epidemiology, clinical characteristics and management of such cases in our report.

Primary Esophageal Small Cell Carcinoma Masquerading as Non-Hodgkin Lymphoma in a Young Patient.

BACKGROUND/AIM: Small cell cancer of the esophagus (SCCE) is an extremely rare entity with an aggressive clinical course, thus early diagnosis and treatment are important for improved survival. CASE REPORT: A 35-year-old male presented with dysphagia, loss of appetite and weight loss. Diagnostic workup revealed an esophageal mass, which was diagnosed as primary non-Hodgkin lymphoma (NHL) on initial biopsy. Despite receiving rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) chemotherapy for 3 months, there was an interval increase in the size of the esophagus mass, which unveiled underlying SCCE. A re-review of the previous biopsy specimen with immunohistochemical staining confirmed the initial diagnosis as SCCE as well. Despite 4 cycles of platinum-based chemotherapy and radiotherapy, the malignancy progressed and proved fatal. CONCLUSION: SCCE and non-Hodgkin lymphomas are rare entities, whose morphologies can be diagnostically challenging, hence they require special immunostaining for accurate diagnosis. Prompt diagnosis and initiation of treatment can confer better quality of life and survival.

A 5-year Single-Center Experience of Hepatitis E Virus Infection During Pregnancy.

OBJECTIVE: The study was designed to examine the hypothesis whether the course and severity of hepatitis E virus (HEV)-related liver disease is worse during pregnancy. METHOD: The prospective study included 1088 patients (550 pregnant; 538 nonpregnant) with clinically and biochemically confirmed acute viral hepatitis (AVH) or acute liver failure (ALF) and were subjected to a complete panel of hepatitis serology. RESULTS: In the pregnant cohort, HEV was the cause of infection in 80.36% (442/550) of cases, whereas non-HEV accounted for 19.63 (108/550) of cases. In the ALF pregnant group, the prevalence of HEV was observed in 73.38% (102/139) of cases, whereas other viruses accounted for 26.61% (37/139) of illness. Ninety-eight of 129 (75.96%) cases of HEV-infected pregnant women died, whereas non-HEV infection was responsible for only 31 of 129 (24.04%) cases' death in comparison. Serum viral load in the ALF group was also significantly higher than that in the AVH group in the pregnant (24578.6 ± 12410.3 vs. 6821.9 ± 1832.7, respectively) cohort and nonpregnant cohort (583.6 ± 187.34 vs. 298.68 ± 65.77, respectively). CONCLUSION: HEV infection has a higher incidence, more severe course, and greater mortality in the pregnant cohort than in the nonpregnant cohort.