The Role of Vertebral Augmentation Procedures in the Management of Multiple Myeloma.

Approximately 90% of patients with multiple myeloma experience significant pain from osseous involvement during their lifetime. Untreated osseous involvement results in vertebral compression fractures, leading to negative consequences for quality of life. Vertebral augmentation procedures, including percutaneous vertebroplasty and kyphoplasty, offer better and faster pain control and likely lower morbidity compared with non-operative interventions. Our review provides an up-to-date summary of the indications, contraindications, timing, outcomes, and potential complications of vertebral augmentation procedures to guide practicing oncologists in effectively managing bone disease in patients with multiple myeloma.

Sixth Nerve Palsy From Multiple Myeloma in Central Nervous System: Case Series and Review of Current Literature.

We reported two cases of the central nervous system (CNS) multiple myeloma (MM) with unusual presentation of sixth nerve palsy. The first patient developed in the setting of newly diagnosed MM and the second patient in the relapsed refractory setting. One underwent surgery, and the other received radiation. Both patients received systemic chemotherapy and noted improvement. We also performed a comprehensive literature review of previously published cases of sixth nerve palsy from MM. This review highlights the importance of recognizing this presentation of CNS multiple myeloma to avoid delays in diagnosis and to get appropriate management in time.

Acute Pancreatitis Secondary to Pembrolizumab-Induced Hypertriglyceridemia.

Pembrolizumab is a humanized monoclonal antibody targeted against programmed cell death protein 1 (PD-1) receptor of lymphocytes. It is used alone or in combination with many chemotherapy regimens for a wide variety of cancers. It has been reported to cause various side effects including endocrinopathies, colitis, rash, and pneumonitis. Hypertriglyceridemia (HTG) has been recently added to its side effect profile with a possible pathogenic mechanism involving autoantibodies against glycosylphosphatidylinositol-anchored high-density lipoprotein binding protein 1 (GP1HBP1). We are presenting a case of acute pancreatitis secondary to HTG in a cervical cancer patient. HTG was successfully treated with insulin infusion. As the patient's symptoms improved, she was started on the diet. She was discharged on statin and fibrate therapy. We are reporting this case to increase awareness of this rare side effect, inpatient management, and outpatient screening while on immunotherapy.

A Rare Case of Pancreatic Cancer: Undifferentiated Carcinoma of the Pancreas With Osteoclast-Like Giant Cells.

Ductal adenocarcinoma of the pancreas is the most common pancreatic cancer, but undifferentiated carcinoma of the pancreas with osteoclast-like giant cells (UC-OGCs) is an exceedingly rare tumor. Microscopically, this tumor is characterized by the presence of two different cellular elements, namely, spindle or ovoid mononuclear cells and osteoclast-like giant cells (OGCs). Here, we report a rare case of UC-OGCs in a 79-year-old male with a one-month history of epigastric abdominal pain and unintentional weight loss. A blood workup revealed new-onset type 2 diabetes mellitus, and a computed tomography scan of the abdomen showed acute pancreatitis with a hypodense lesion in the head of the pancreas concerning for malignancy. He underwent an endoscopic ultrasound that also revealed a mass in the head of the pancreas, but no lymphadenopathy was observed. Biopsy was obtained and histopathology revealed UC-OGCs. We present this case to increase awareness of this rare clinical entity in patients presenting with acute-onset pancreatitis.

Thromboprophylaxis in multiple myeloma.

Venous thromboembolism (VTE) in multiple myeloma (MM) can be secondary to patient-, disease-, and/or treatment-related factors. The development of VTE may result in significant morbidity with the highest risk during the first year after diagnosis. This clinical review provides an evidence-based summary to guide practicing oncologists in the use of anticoagulation to prevent VTE in multiple myeloma and includes anticoagulation efficacy and adverse effect profile. We highlight the pathophysiology of VTE in MM, the use of various risk prediction tools, and the current recommendations for the use of different anticoagulants in prophylaxis of VTE.

Feasibility of Outpatient Stem Cell Transplantation in Multiple Myeloma and Risk Factors Predictive of Hospital Admission.

High-dose chemotherapy followed by autologous stem cell transplantation (ASCT) remains the standard of care for multiple myeloma (MM) patients. Although outpatient ASCT has been shown to be safe and feasible, the procedure is overall rare with most patients in the US undergoing inpatient ASCT. Furthermore, hospitalization rates for patients that undergo outpatient ASCT remain high. Adequate markers that predict hospitalization during outpatient ASCT are lacking, yet would be of great clinical value to select patients that are suited to outpatient ASCT. In this study we aimed to elucidate differences between planned outpatient and inpatient ASCT and further evaluated clinical characteristics that are significantly associated with hospitalization during planned outpatient hospitalization. Factors that were significantly associated with a planned inpatient ASCT included an advanced MM disease stage, worse performance status as well as non-Caucasian race, while low albumin levels and female gender were significantly associated with hospitalization during outpatient ASCT. The results of this analysis provide crucial knowledge of factors that are associated with planned inpatient ASCT and hospitalization during outpatient ASCT and could guide the treating physician in decision-making and further facilitate outpatient transplantation.

Comparative analysis of revascularization with percutaneous coronary intervention versus coronary artery bypass surgery for patients with end-stage renal disease: a nationwide inpatient sample database.

BACKGROUND: The role of percutaneous coronary intervention (PCI) vs coronary artery bypass grafting (CABG) in patients with coronary artery disease (CAD) and concomitant end-stage renal disease (ESRD) remains unknown. RESEARCH DESIGN & METHODS: The National Inpatient Sample (NIS) (2002-2017) was queried to identify all cases of CAD and ESRD. The relative merits of PCI vs CABG were determined using a propensity-matched multivariate logistic regression model. Adjusted odds ratios (aOR) for mortality and other in-hospital complications were calculated. RESULTS: A total of 350,623 [CABG = 112,099 (32%) and PCI = 238,524 (68%)] hospitalizations were included in the analysis. The overall adjusted odds for major bleeding (aOR 1.28, 95% CI 1.25-1.31, P < 0.0001), post-procedure bleeding (aOR 5.19, 95% CI 4.93-5.47, P < 0.0001), sepsis (aOR 1.29, 95% CI 1.26-1.33, P < 0.0001), cardiogenic shock (aOR 1.23, 95% CI 1.20-1.26, P < 0.0001), and in-hospital mortality (aOR 1.65, 95% CI 1.61-1.69, P < 0.0001) were significantly higher for patients undergoing CABG compared with PCI. The need for intra-aortic balloon pump (IABP) placement (aOR 2.52, 95% CI 2.45-2.59, P < 0.001) was higher in the CABG group, while the adjusted odds of vascular complications were similar between the two groups (aOR 0.99, 95% CI 0.94-1.06, P = 0.82). As expected, patients undergoing CABG had a higher mean length of stay and mean cost of hospitalization. CONCLUSION: CABG in ESRD may be associated with higher in-hospital complications, increased length of stay, and higher resource utilization.

Meta-analysis comparing valve-in-valve TAVR and redo-SAVR in patients with degenerated bioprosthetic aortic valve.

INTRODUCTION: The comparative efficacy and safety of valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) and redo-surgical AVR (redo-SAVR) in patients with degenerated bioprosthetic aortic valves remain unknown. METHOD: Digital databases were searched to identify relevant articles. Unadjusted odds ratios for dichotomous outcomes were calculated using a random effect model. A total of 11 studies comprising 8326 patients (ViV-TAVR = 4083 and redo-SAVR = 4243) were included. RESULTS: The mean age of patients undergoing ViV-TAVR was older, 76 years compared to 73 years for those undergoing SAVR. The baseline characteristics for patients in ViV-TAVR vs. redo-SAVR groups were comparable. At 30-days, the odds of all-cause mortality (OR 0.45, 95% CI 0.30-0.68, p = .0002), cardiovascular mortality (OR 0.44, 95% CI 0.26-0.73, p = .001) and major bleeding (OR 0.29, 95% CI 0.15-0.54, p = .0001) were significantly lower in patients undergoing ViV-TAVR compared to redo-SAVR. There were no significant differences in the odds of cerebrovascular accidents (OR 0.91, 95% CI 0.52-1.58, p = .74), myocardial infarction (OR 0.92, 95% CI 0.44-1.92, p = .83) and permanent pacemaker implantation (PPM) (OR 0.54, 95% CI 0.27-1.07, p = .08) between the two groups. During mid to long-term follow up (6-months to 5-years), there were no significant differences between ViV-TAVR and redo-SAVR for all-cause mortality, cardiovascular mortality and stroke. ViV-TAVR was, however, associated with higher risk of prosthesis-patient mismatch and greater transvalvular pressure gradient post-implantation. CONCLUSION: ViV-TAVR compared to redo-SAVR appears to be associated with significant improvement in short term mortality and major bleeding. For mid to long-term follow up, the outcomes were similar for both groups.

Gemcitabine induced pneumonitis: a case report and review of literature.

We are reporting a case of pneumonitis in an 81 year old-aged woman due to gemcitabine who was successfully managed with steroids. We also reviewed the literature and found previous case reports of gemcitabine induced pneumonitis.We reported this case to alert physicians to be aware of this infrequent and sometimes fatal complication from gemcitabine.

Predictability of CRP and D-Dimer levels for in-hospital outcomes and mortality of COVID-19.

BACKGROUND: Systemic inflammation elicited by a cytokine storm is considered a hallmark of coronavirus disease 2019 (COVID-19). This study aims to assess the clinical utility of the C-reactive protein (CRP) and D-Dimer levels for predicting in-hospital outcomes in COVID-19. METHODS: A retrospective cohort study was performed to determine the association of CRP and D-Dimer with the need for invasive mechanical ventilation (IMV), dialysis, upgrade to an intensive care unit (ICU) and mortality. Independent t-test and multivariate logistic regression analysis were performed to calculate mean differences and adjusted odds ratios (aOR) with its 95% confidence interval (CI), respectively. RESULTS: A total of 176 patients with confirmed COVID-19 diagnosis were included. On presentation, the unadjusted odds for the need of IMV (OR 2.5, 95% CI 1.3-4.8, p = 0.012) and upgrade to ICU (OR 3.2, 95% CI 1.6-6.5, p = 0.002) were significantly higher for patients with CRP (>101 mg/dl). Similarly, the unadjusted odds of in-hospital mortality were significantly higher in patients with high CRP (>101 mg/dl) and high D-Dimer (>501 ng/ml), compared to corresponding low CRP (<100 mg/dl) and low D-Dimer (<500 ng/ml) groups on day-7 (OR 3.5, 95% CI 1.2-10.5, p = 0.03 and OR 10.0, 95% CI 1.2-77.9, p = 0.02), respectively. Both high D-Dimer (>501 ng/ml) and high CRP (>101 mg/dl) were associated with increased need for upgrade to the ICU and higher requirement for IMV on day-7 of hospitalization. A multivariate regression model mirrored the overall unadjusted trends except that adjusted odds for IMV were high in the high CRP group on day 7 (aOR 2.5, 95% CI 1.05-6.0, p = 0.04). CONCLUSION: CRP value greater than 100 mg/dL and D-dimer levels higher than 500 ng/ml during hospitalization might predict higher odds of in-hospital mortality. Higher levels at presentation might indicate impending clinical deterioration and the need for IMV.

False, Reversed but Not True: A Curious Case of Hyperkalemia.

Falsely elevated potassium levels are common in routine laboratory tests and should be differentiated from true hyperkalemia. If the patient is inappropriately treated for hyperkalemia, the resulting hypokalemia can lead to life-threatening cardiac arrhythmias. We present the case of a 67-year-old woman with a past medical history of stable chronic lymphocytic leukemia, who presented for chest pain and had an elevated potassium level of 5.8 mEq/L, which, upon repeat laboratory testing, was then 6.7 mEq/L. She was initially treated for hyperkalemia. Laboratory test results showed creatine kinase levels at 43 U/L, lactate dehydrogenase levels at 177 U/L, phosphorus levels at 4.5 mg/dL, and uric acid levels at 6.4 mg/dL, indicating no evidence of tumor lysis syndrome. The patient was later diagnosed with reverse pseudohyperkalemia, indicated by falsely elevated plasma potassium levels in the presence of serum potassium levels within normal limits and venous blood gas samples.

A Case of Docetaxel-Induced Rhabdomyolysis.

Docetaxel is an antimicrotubule agent with activity in a variety of cancers. Its toxicity profile includes myelosuppression, fluid retention/edema, and peripheral neuropathy. It is also associated with myalgias but the frequency and extent of this toxicity are not well described. Here, we present a case of a 48-year-old female with breast cancer who developed bilateral proximal leg pain and inability to walk two weeks after the third cycle of docetaxel and cyclophosphamide. Initial workup showed elevated creatinine kinase (CK) levels which trended up to 9000 U/L suggesting rhabdomyolysis. She was treated with IV isotonic fluids without renal complications. Her CK was 1800 U/L at discharge and normalized two weeks post-discharge. To our knowledge, this is one of the few reports of docetaxel-induced rhabdomyolysis. The purpose of this report is to alert physicians of this rare but morbid complication.

Takotsubo cardiomyopathy: a rare complication of acute viral gastroenteritis.

Takotsubo Cardiomyopathy (TCM) is characterized by a transient but reversible ventricular dysfunction in post-menopausal females following, but not always, a recent emotional or physical stress. Typically, chest pain is reported as a presenting symptom in the majority of patients. The severe diarrheal illness secondary to acute viral gastroenteritis is not commonly reported as the stressor event prior to TCM. We report a unique case of a middle-aged male presented with syncope shortly after loose bowel movements. He was diagnosed with TCM and was successfully managed with supportive care. The purpose of this case is to make clinicians aware of this rare association.

Hypercalcemia Due to Paraneoplastic Production of 1,25- Dihydroxyvitamin D in a Young Female with Dysgerminoma.

Humoral hypercalcemia of malignancy (HHM) can be caused by ectopic paraneoplastic production of 1, 25 dihydroxy vitamin D due to the hyperactivity of the 1 alpha-hydroxylase enzyme. We present a case of a 19-year-old female who was admitted with bilateral dysgerminomas and significant hypercalcemia. Hypercalcemia was initially managed medically and then resolved with the surgical resection of the tumors. Although most cases are attributed to a high parathyroid hormone-related peptide (PTHrP) and bone metastases, <1% of cases can result from paraneoplastic production of 1,25 dihydroxyvitamin D due to increased activity of 1 alpha-hydroxylase.This is one of the rare cases of hypercalcemia, which not only adds to the limited number of cases of hypercalcemia associated with dysgerminoma but also is the first case report showing that vitamin D can be a paraneoplastic factor itself.

Combined Immunotherapy in Metastatic Melanoma with Unknown Primary.

Melanoma is skin cancer arising from melanocytes. It may metastasize to unusual areas of the body. Metastatic melanoma with unknown primary (MUP) is relatively uncommon. We present a case of MUP in a 55-year-old male, who underwent adjuvant treatment with combined immunotherapy and showed a good response. We report this case to alert fellow physicians that immunotherapy can be used in MUP with excellent outcomes.

Optic Neuritis: A Rare Paraneoplastic Phenomenon of Hodgkin's Lymphoma.

Hodgkin's lymphoma (HL) is a hematological disorder that has a high cure rate. It usually presents as asymptomatic lymphadenopathy or a mass on chest radiograph along with constitutional symptoms ("B" symptoms such as fever, night sweats, or unintended weight loss) in less than half the cases. Optic neuritis is a demyelinating condition that is rarely associated with HL. We present a case of HL that presented with optic neuritis as a paraneoplastic syndrome.

Fluorouracil (5-FU)-induced Cardiomyopathy.

Fluorouracil (5-FU) is a pyrimidine analog widely used in oncology. It is mainly used in the treatment of solid tumors. It is also used along with radiotherapy because of its radiosensitizing properties. As with all chemotherapy drugs, 5-FU is associated with adverse effects. Cardiotoxicity is one of them. It can present in a variety of ways and, sometimes, it can be lethal too. The reported case is of a 42-year-old male who presented with atypical chest pain after the first dose of 5-FU and was finally diagnosed with 5-FU-induced cardiotoxicity. His cardiac function normalized after the withdrawal of the drug.

Immune-mediated Colitis from Dual Checkpoint Inhibitors.

Melanoma is a deadly disease with immunotherapy treatment options that emerged in the last few years and have changed the disease outcome. However, it is associated with immune-related toxic effects despite improving survival. We present the case of a 53-year-old woman who had two weeks of diarrhea after she was treated with dual immunotherapy agents for her advanced melanoma. The final workup revealed pancolitis, possibly due to immunotherapy adverse effects. Initial conservative treatment, unfortunately, did not lead to a clinical improvement until a steroid was introduced. We are reporting this case to alert our fellow physicians about the immune-mediated toxicities of the relatively new checkpoint inhibitors.