Canadian real-world experience of asciminib treatment in heavily pre-treated chronic myeloid leukemia (CML) patients who failed multiple lines of tyrosine kinase inhibitor (TKI) therapy.

BACKGROUND: Asciminib is a novel drug specifically targeting ABL myristoyl pocket in the ABL1 protein. METHODS: Forty one patients with chronic myeloid leukemia treated with asciminib from 2018 to 2022 were reviewed and analyzed for the efficacy and tolerability of asciminib using real-world experience data. RESULTS: The median age was 60 years (range 17-90) with a past history of a cardiovascular event in 21 patients (51%). Patients were pretreated with a median of 3 previous tyrosine kinase inhibitors (range 1-5). After a median of 12 months of asciminib (range 3-41), major molecular response (MMR) rate was 39% (n = 11/28) and 42% (n = 5/12) at 6 and 12 months, respectively. Molecular response with 2 log reduction (MR2) was noted in 54% (n = 15/28) and 50% (n = 6/12) at 6 and 12 months. The cumulative incidence of MMR and MR2 was 46.3% and 66% at 12 months. Five patients discontinued asciminib due to treatment failure (n = 3) or thrombocytopenia (n = 2). There were no cardiovascular events. Out of 7 patients treated with high dose asciminib for T315I mutation, 5 patients achieved MMR or deeper response. The event-free survival was 63% at 12 months. CONCLUSION: This study confirmed clinical efficacy and tolerability of asciminib with real-world experience.

Testing Mayo Clinic's New 20/20/20 Risk Model in Another Cohort of Smoldering Myeloma Patients: A Retrospective Study.

Background-smoldering multiple myeloma (SMM) risk of progression to multiple myeloma (MM) is highly heterogeneous and several models have been suggested to predict this risk. Lakshman et al. recently proposed a model based on three biomarkers: bone marrow plasma cell (BMPC) percentage > 20%, free light chain ratio (FLCr) > 20 and serum M protein > 20 g/L. The goal of our study was to test this "20/20/20" model in our population and to determine if similar results could be obtained in another cohort of SMM patients. Method-we conducted a retrospective, single center study with 89 patients diagnosed with SMM between January 2008 and December 2019. Results-all three tested biomarkers were associated with an increased risk of progression: BMPC percentage ≥ 20% (hazard ratio [HR]: 4.28 [95%C.I., 1.90-9.61]; p < 0.001), serum M protein ≥ 20 g/L (HR: 4.20 [95%C.I., 1.90-15.53]; p = 0.032) and FLCr ≥ 20 (HR: 3.25 [95%C.I., 1.09-9.71]; p = 0.035). The estimated median time to progression (TTP) was not reached for the low and intermediate risk groups and was 29.1 months (95%C.I., 3.9-54.4) in the high-risk group (p = 0.006). Conclusions-the 20/20/20 risk stratification model adequately predicted progression in our population and is easy to use in various clinical settings.

Localized ulcerative nodular amyloidosis presenting as ulcerative panniculitis, an unusual clinical manifestation: A case report.

INTRODUCTION AND OBJECTIVES: The main objective of this article is to present and discuss a case of localized ulcerative nodular amyloidosis with deep involvement clinically manifesting as ulcerative panniculitis and discuss its impact on the choice of treatment. METHODS AND RESULTS: We present a 73-year-old woman with a history of painful ulcerated nodules on the inferior limbs. Microscopy confirmed amyloid deposits deep in the dermis and subcutaneous fat. No systemic involvement was found. Considering that skin-directed treatments often are not able to reach subcutaneous fat or were contraindicated because of the ulcers, she was successfully treated with cyclophosphamide and prednisone. CONCLUSION: Localized ulcerative nodular amyloidosis with deep involvement is a rare clinical presentation that can present as ulcerative panniculitis. Such a clinical manifestation might be misleading. Systemic treatment might be necessary to control symptoms when conventional skin-directed therapies are contraindicated.

Retrospective Study of High Hemoglobin Levels in 56 Young Adults.

BACKGROUND: Erythrocytosis is a frequent request for consultation in the hematologic field. The diagnostic approach is well established in the general population but in a young adult, finding the etiology of erythrocytosis can be a real diagnostic challenge. METHODS: This is an observational retrospective unicentric study made at the Sherbrooke University Hospital Center, over a period of 20 years (1995 - 2015). Every patient aged between 16 and 35 years old with a significant elevation of hemoglobin or hematocrit was included (hemoglobin > 185 g/L and/or hematocrit > 0.52 in men; hemoglobin > 165 g/L and/or hematocrit > 0.48 in women). RESULTS: Totally, 426 patients met the inclusion criteria (over a total of 113,453 complete blood counts) but only 56 entered the study for investigations. The majority of patients were of male gender, 43% of the patients were obese, 59% were smokers and 38% used excess alcohol or recreational drugs. Twenty-five patients had the diagnosis of absolute erythrocytosis. Seven patients had the diagnosis of relative erythrocytosis and no cause could be identified in 24 patients. No primary erythrocytosis was found in this cohort. Among the 25 patients with secondary erythrocytosis, hypoxia was the most frequent etiology identified. Less than half of the patients in the cohort had long term follow-up. Search for JAK2 mutation and serum EPO dosage were performed in 17.9% and 23.2% of cases respectively. Seven patients were treated with aspirin and five patients had phlebotomies. CONCLUSIONS: This retrospective study reveals an actual clinical management that is often discordant with the current recommendations and a frequent lack of follow-up after initial investigations. Harmonization of management of erythrocytosis appears to be highly desirable.

Laboratory Investigation of Myeloproliferative Neoplasms (MPNs): Recommendations of the Canadian Mpn Group.

OBJECTIVES: To standardize diagnostic investigations for myeloproliferative neoplasms (MPNs) to increase homogeneity in patient care and to streamline diagnostic approaches in the most efficient and cost-effective manner. METHODS: The development of Canadian expert consensus recommendations for the diagnosis of MPNs began with a review of the following: clinical evidence, daily practice, existing treatment guidelines, and availability of diagnostic tools. Each group member was assigned a specific topic, which they discussed with the entire group during several consensus meetings. RESULTS: This document provides the Canadian MPN group's recommendations, proposed diagnostic algorithms, and background evidence upon which decisions were made. CONCLUSIONS: Standardization of diagnostic investigations will increase homogeneity in patient care and provide a foundation for future clinical research in this rapidly evolving therapeutic area. Streamlining diagnostic approaches in the most efficient and cost-effective manner will also result in significant cost saving for the health care system.

Some perspectives on saccade adaptation.

The saccadic system is an ideal model for the study of how the brain optimizes its motor behavior. Here we review some recent research that points to exciting new areas of investigation relative to the multiple time scales of and the influence of context and consolidation on motor learning. These findings suggest new ways of thinking about the processes that underlie the short-term adaptive mechanisms that maintain accuracy of eye movements and so ensure optimal vision.

Changes in control of saccades during gain adaptation.

In a typical short-term saccadic adaptation protocol, the target moves intrasaccadically either toward (gain-down) or away (gain-up) from initial fixation, causing the saccade to complete with an endpoint error. A central question is how the motor system adapts in response to this error: are the motor commands changed to bring the eyes to a different goal, akin to a remapping of the target, or is adaptation focused on the processes that monitor the ongoing motor commands and correct them midflight, akin to changes that act via internal feedback? Here, we found that, in the gain-down paradigm, the brain learned to produce a smaller amplitude saccade by altering the trajectory of the saccade. The adapted saccades had reduced peak velocities, reduced accelerations, shallower decelerations, and increased durations compared with a control saccade of equal amplitude. These changes were consistent with a change in an internal feedback that acted as a forward model. However, in the gain-up paradigm, the brain learned to produce a larger amplitude saccade with trajectories that were identical with those of control saccades of equal amplitude. Therefore, whereas the gain-down paradigm appeared to induce adaptation via an internal feedback that controlled saccades midflight, the gain-up paradigm induced adaptation primarily via target remapping. Our simulations explained that, for each condition, the specific adaptation produced a saccade that brought the eyes to the target with the smallest motor costs.

Spontaneous recovery of motor memory during saccade adaptation.

It is possible that motor adaptation in timescales of minutes is supported by two distinct processes: one process that learns slowly from error but has strong retention, and another that learns rapidly from error but has poor retention. This two-state model makes the prediction that if a period of adaptation is followed by a period of reverse-adaptation, then in the subsequent period in which errors are clamped to zero (error-clamp trials) there will be a spontaneous recovery, i.e., a rebound of behavior toward the initial level of adaptation. Here we tested and confirmed this prediction during double-step, on-axis, saccade adaptation. When people adapted their saccadic gain to a magnitude other than one (adaptation) and then the gain was rapidly reversed back to one (reverse-adaptation), in the subsequent error-clamp trials (visual target placed on the fovea after the saccade) the gain reverted toward the initially adapted value and then gradually reverted toward normal. We estimated that the fast system was about 20-fold more sensitive to error than the slow system, but had a time constant of 28 s, whereas the slow system had a time constant of nearly 8 min. Therefore short-term adaptive mechanisms that maintain accuracy of saccades rely on a memory system that has characteristics of a multistate process with a logarithmic distribution of timescales.

Adaptive control of saccades via internal feedback.

Ballistic movements like saccades require the brain to generate motor commands without the benefit of sensory feedback. Despite this, saccades are remarkably accurate. Theory suggests that this accuracy arises because the brain relies on an internal forward model that monitors the motor commands, predicts their sensory consequences, and corrects eye trajectory midflight. If control of saccades relies on a forward model, then the forward model should adapt whenever its predictions fail to match sensory feedback at the end of the movement. Using optimal feedback control theory, we predicted how this adaptation should alter saccade trajectories. We trained subjects on a paradigm in which the horizontal target jumped vertically during the saccade. With training, the final position of the saccade moved toward the second target. However, saccades became increasingly curved, i.e., suboptimal, as oculomotor commands were corrected on-line to steer the eye toward the second target. The adaptive response had two components: (1) the motor commands that initiated the saccades changed slowly, aiming the saccade closer to the jumped target. The adaptation of these earliest motor commands displayed little forgetting during the rest periods. (2) Late in saccade trajectory, another adaptive response steered it still closer to the jumped target, producing curvature. Adaptation of these late motor commands showed near-complete forgetting during the rest periods. The two components adapted at different timescales, with the late-acting component displaying much faster rates. It appears that in controlling saccades, the brain relies on an internal feedback that has the characteristics of a fast-adapting forward model.