Australians with chronic lymphocytic leukaemia continue to have high rates of second primary malignancies in the modern era.

Population-based studies have demonstrated a high risk of second cancers, especially of the skin, among patients with chronic lymphocytic leukaemia (CLL). We describe age-standardised incidence ratios (SIRs) of second primary malignancies (SPM) in Australian patients with relapsed/refractory CLL treated with at least two lines of therapy, including ibrutinib. From December 2014 to November 2017, 156 patients were identified from 13 sites enrolled in the Australasian Lymphoma and Related Diseases Registry, and 111 had follow-up data on rates of SPM. At 38.4 months from ibrutinib therapy commencement, 25% experienced any SPM. SIR for melanoma and all cancers (excluding nonmelanomatous skin cancers) were 15.8 (95% confidence interval (CI): 7.0-35.3) and 4.6 (95% CI: 3.1-6.9) respectively. These data highlight the importance of primary preventive interventions and surveillance, particularly as survival from CLL continues to improve.

Acquired Hemophilia A following Pfizer-BioNTech SARS CoV-2 mRNA vaccine, successfully treated with prednisolone and rituximab.

INTRODUCTION: Acquired haemophilia A (AHA) is a rare bleeding disorder, characterised by the presence of autoantibodies to clotting factor VIII (FVIII). AHA can be idiopathic or occur in the context of malignancy, autoimmune disease, drugs, or pregnancy. Recently, cases of AHA following both COVID-19 infection and vaccination have been reported. CASE REPORT: We report the case of a 95-year-old female who was immunised with the Pfizer-BioNTech SARS CoV-2 mRNA vaccine, with doses given three weeks apart. Spontaneous bruising over her extremities appeared one week after the initial dose, with hospital admission occurring three weeks after the second. Examination revealed a large haematoma on the dorsum of the right hand with resultant bleeding and widespread ecchymoses. Investigations confirmed a diagnosis of AHA. MANAGEMENT AND OUTCOME: Initial management included high dose prednisolone, recombinant Factor VIII and tranexamic acid. There was no significant clinical improvement after three days, so intravenous rituximab 100 mg weekly for four weeks was commenced. The activated partial thromboplastin time (aPTT) normalised after two doses and Factor VIII level reached 0.68U/ml on day + 22. The patient was successfully discharged from hospital after 37 days. DISCUSSION: Four cases of AHA following administration of COVID mRNA vaccines (Pfizer and Moderna) have been documented. AHA should be a differential in patients presenting with bleeding following COVID-19 vaccination, in the presence of a normal platelet count. Rapid recognition, prompt initiation of immunosuppressive treatment and rigorous supportive cares are required to minimise morbidity and mortality.

A meta-analysis of the efficacy of allopurinol in reducing the incidence of myocardial infarction following coronary artery bypass grafting.

BACKGROUND: The xanthine oxidase inhibitor allopurinol that is commonly used to treat gout, has been suggested to have pleiotropic effects that are likely to reduce the incidence of myocardial infarction (MI) in at risk individuals. The aim of this meta-analysis was to assess the efficacy of allopurinol treatment in reducing the incidence of MI. METHOD: MEDLINE, Scopus, Web of Science, and Cochrane Library databases were searched for randomised controlled trials examining the efficacy of allopurinol in reducing the incidence of MI. The quality of study methodology was assessed by two independent reviewers using the Cochrane Collaboration's tool for assessing risk of bias. This meta-analysis was conducted using a fixed-effects model, and heterogeneity was assessed with the I2 index. RESULTS: One thousand one hundred twenty-three citations were screened and only six studies satisfied the inclusion criterion. Published between 1988 and 1995, all studies examined the cardioprotective efficacy of allopurinol in the setting of coronary artery bypass graft (CABG). From a total pooled sample size of 229, MI was reported in 2 (1.77%) allopurinol and 14 (12.07%) control patients. A fixed-effects meta-analysis (I2 = 0%) identified a statistically significant reduced incidence of myocardial infarction (RR 0.21, 95% CI: 0.06, 0.70, p = 0.01) in patients allocated to allopurinol. However, in the leave-one-out sensitivity analyses, the treatment effect became non-significant with the removal of one of the studies. CONCLUSION: Based on the limited evidence available, allopurinol appears to reduce the incidence of perioperative MI following CABG. Further research is required to confirm these findings.