2023 updated MASCC/ESMO consensus recommendations: prevention of nausea and vomiting following high-emetic-risk antineoplastic agents.

PURPOSE: This systematic review updates the MASCC/ESMO recommendations for high-emetic-risk chemotherapy (HEC) published in 2016-2017. HEC still includes cisplatin, carmustine, dacarbazine, mechlorethamine, streptozocin, and cyclophosphamide in doses of > 1500 mg/m2 and the combination of cyclophosphamide and an anthracycline (AC) in women with breast cancer. METHODS: A systematic review report following the PRISMA guidelines of the literature from January 1, 2015, until February 1, 2023, was performed. PubMed (Ovid), Scopus (Google), and the Cochrane Database of Systematic Reviews were searched. The literature search was limited to randomized controlled trials, systematic reviews, and meta-analyses. RESULTS: Forty-six new references were determined to be relevant. The main topics identified were (1) steroid-sparing regimens, (2) olanzapine-containing regimens, and (3) other issues such as comparisons of antiemetics of the same drug class, intravenous NK1 receptor antagonists, and potentially new antiemetics. Five updated recommendations are presented. CONCLUSION: There is no need to prescribe steroids (dexamethasone) beyond day 1 after AC HEC, whereas a 4-day regimen is recommended in non-AC HEC. Olanzapine is now recommended as a fixed part of a four-drug prophylactic antiemetic regimen in both non-AC and AC HEC. No major differences between 5-HT3 receptor antagonists or between NK1 receptor antagonists were identified. No new antiemetic agents qualified for inclusion in the updated recommendations.

Methods comparison for detecting trends in herbicide monitoring time-series in streams.

An inadvertent consequence of pesticide use is aquatic pesticide pollution, which has prompted the implementation of mitigation measures in many countries. Water quality monitoring programs are an important tool to evaluate the efficacy of these mitigation measures. However, large interannual variability of pesticide losses makes it challenging to detect significant improvements in water quality and to attribute these improvements to the application of specific mitigation measures. Thus, there is a gap in the literature that informs researchers and authorities regarding the number of years of aquatic pesticide monitoring or the effect size (e.g., loss reduction) that is required to detect significant trends in water quality. Our research addresses this issue by combining two exceptional empirical data sets with modelling to explore the relationships between the achieved pesticide reduction levels due to mitigation measures and the length of the observation period for establishing statistically significant trends. Our study includes both a large (Rhine at Basel, ∼36,300 km2) and small catchment (Eschibach, 1.2 km2), which represent spatial scales at either end of the spectrum that would be realistic for monitoring programs designed to assess water quality. Our results highlight several requirements in a monitoring program to allow for trend detection. Firstly, sufficient baseline monitoring is required before implementing mitigation measures. Secondly, the availability of pesticide use data helps account for the interannual variability and temporal trends, but such data are usually lacking. Finally, the timing and magnitude of hydrological events relative to pesticide application can obscure the observable effects of mitigation measures (especially in small catchments). Our results indicate that a strong reduction (i.e., 70-90 %) is needed to detect a change within 10 years of monitoring data. The trade-off in applying a more sensitive method for change detection is that it may be more prone to false-positives. Our results suggest that it is important to consider the trade-off between the sensitivity of trend detection and the risk of false positives when selecting an appropriate method and that applying more than one method can provide more confidence in trend detection.

Challenges of spatially extrapolating aquatic pesticide pollution for policy evaluation.

Aquatic pesticide pollution is an important issue worldwide. Countries rely on monitoring programs to observe water bodies quality and on models to evaluate pesticide risks for entire stream networks. Measurements are typically sparse and discontinuous which lead to issues in quantifying pesticide transport at the catchment scale. Therefore, it is essential to assess the performance of extrapolation approaches and provide guidance on how to extend monitoring programs to improve predictions. Here we present a feasibility study to predict pesticide levels in a spatially explicit manner in the Swiss stream network based on the national monitoring program quantifying organic micropollutants at 33 sites and spatially distributed explanatory variables. Firstly, we focused on a limited set of herbicides used on corn crops. We observed a significant relationship between herbicide concentrations and the areal fraction of hydrologically connected cornfields. Neglecting connectivity revealed no influence of areal corn coverage on the herbicide levels. Considering chemical properties of the compounds slightly improved the correlation. Secondly, we analysed a set of 18 pesticides widely used on different crops and monitored across the country. In this case, the areal fractions of arable or crop lands showed significant correlations with average pesticide concentrations. Similar results were found with average annual discharge or precipitation if two outlier sites were neglected. The correlations found in this paper explained only about 30 % of the observed variance leaving most of the variability unexplained. Accordingly, extrapolating the results from the existing monitoring sites to the Swiss river network comes with substantial uncertainty. Our study highlights possible reasons for weak matches, such as missing pesticide application data, limited set of compounds in the monitoring program, or a limited understanding of factors differentiating the loss rates from different catchments. Improving the data on pesticide applications will be essential to progress in this regard.

A non-invasive method for the assessment of gingival thickness in the aesthetic zone and the concept of the gingival geometric ratio in an Asian population.

The aim of this study was to investigate the gingival thickness and biologic width in the aesthetic zone (maxillary central and lateral incisors) in an Asian population using cone beam computed tomography (CBCT) as a non-invasive measurement method, prior to immediate implant placement. The gingival geometric ratio is introduced as a new parameter for assessing soft tissue stability and hence predicting the aesthetic outcome. The gingival thickness, biologic width category (normal, high, and low crest), and gingival geometric ratio (shape and configuration of the gingival tissues) were assessed for 171 central and 175 lateral incisors on high-resolution CBCT images. Thick gingivae were found in 93.6% of the central incisors and 64% of the lateral incisors (P < 0.001). The difference in thickness between the central and lateral incisors was statistically significant (P < 0.001). Regarding the biologic width of the facial gingival tissue, the majority of central (64.8%) and lateral (64.3%) incisors were categorized as low crest (>3 mm). The study found that most of the gingivae of the maxillary central incisors were thick, while thin gingivae were more prevalent in the lateral incisors. Therefore, an individual patient may have different gingival thickness types, and 'one individual, one gingival biotype' may not be true. Furthermore, the majority of the facial gingival tissues of the maxillary incisors were found to be low crest.

Seasonal drivers and risks of aquatic pesticide pollution in drought and post-drought conditions in three Mediterranean watersheds.

The Western Cape in South Africa has a Mediterranean climate, which has in part led to an abundance of agriculturally productive land supporting the wheat, deciduous fruit, wine, and citrus industries. South Africa is the leading pesticide user in Sub-Saharan Africa. There is limited data on the pesticide pollution of surface water over different seasons in low- and middle-income countries. We evaluated the seasonal drivers of aquatic pesticide pollution in three river catchments (Berg, Krom, and Hex Rivers) from July 2017 to June 2018 and April to July 2019, using 48 passive samplers. Our sampling followed the most severe drought (2015-2018) since recordings in 1960. Thus, our analyses focus on how drought and post-drought conditions may affect in-stream pesticide concentrations and loads. Samples were analyzed for 101 pesticide compounds using liquid chromatography - high-resolution mass spectrometry. Environmental Quality Standards (EQS) were used to assess the risks. We detected 60 pesticide compounds across the sampling periods. Our results indicate that all samples across all three catchments contained at least three pesticides and that the majority (83%) contained five or more pesticides. Approximately half the number of pesticides were detected after the drought in 2018. High concentration sums of pesticides (>1 µg/L) were detected over long time periods in the Hex River Valley (22 weeks) and in Piketberg (four weeks). Terbuthylazine, imidacloprid, and metsulfuron-methyl were detected in the highest concentrations, making up most of the detected mass, and were frequently above EQS. The occurrence of some pesticides in water generally correlated with their application and rainfall events. However, those of imidacloprid and terbuthylazine did not, suggesting that non-rainfall-driven transport processes are important drivers of aquatic pesticide pollution. The implementation of specific, scientifically sound, mitigation measures against aquatic pesticide pollution would require comprehensive pesticide application data as well as a targeted study identifying sources and transport processes for environmentally persistent pesticides.

Bilateral occipital lobe infarct neglect deficit (BLIND) syndrome.

Cortical blindness is characterized by loss of vision due to dysfunction of the visual cortices, most commonly secondary to bilateral ischemic infarcts of the occipital lobe. Other causes include surgery such as aortic valve replacement, laryngeal surgery, craniotomy, cerebral angiography, head trauma, and partial seizures. Visual anosognosia is a distinct feature of cortical blindness, wherein patients claim they can see and confabulate visual perceptions, despite loss of sight. We herewith present a rare phenomenon known as Anton Syndrome, an eponym named after the Austrian neurologist and psychiatrist, Gabriel Anton (1858-1933). There are a limited number of cases of Anton's Syndrome in the literature, with only 28 case reports published from 1965-2016. Although he was bestowed a neurologic eponym, Anton was an advocate of eugenics and racial hygiene. He publicly advocated for 'superior breeding' and 'selection' in order to 'build a brave and noble race.' We therefore propose replacing the eponym with Bilateral Occipital Lobe Infarct Neglect Deficit (BLIND) Syndrome, with intention of raising awareness of this unique presentation as well as of the widespread interest in eugenics in the early 1900s amongst physicians, notably Gabriel Anton.

A successful case of extracorporeal membrane oxygenation for COVID-19: walking home without oxygen supplementation.

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged from Wuhan, China in December 2019 and is the strain of coronavirus that causes coronavirus disease 2019 (COVID-19). Approximately one-third of the patients with COVID-19 require intensive care unit (ICU) admission, and almost 30% of the patients develop acute respiratory distress syndrome (ARDS). Extracorporeal membrane oxygenation (ECMO) is used as salvage therapy for severe ARDS. The role of ECMO in the treatment of COVID-19 remains unclear, although there is emerging evidence that this approach may be an effective salvage therapy for severe ARDS. Case Presentation: We present a case of a previously healthy 39-year-old Hispanic male who presented to the hospital with flu-like symptoms, including headache, fatigue, and myalgia for 8 days in late April 2020. He denied dyspnea on exertion. The patient's symptoms progressed, resulting in pneumonia and acute respiratory distress syndrome (ARDS). The patient was managed with prone positioning, convalescent plasma and veno-venous extracorporeal membrane oxygenation (VV-ECMO) for 35 days. The patient successfully recovered and was able to ambulate independently and was discharged home from an acute care hospital without oxygen supplementation on hospital day 63. Conclusion: We present one of the first few documented cases of ECMO for severe ARDS due to COVID-19. After a prolonged hospital course requiring VV-ECMO, the patient was discharged home from an acute care hospital without oxygen requirement and ambulated independently, likely as a result of daily aggressive mobility-focused rehabilitation.

A review of long-term pesticide monitoring studies to assess surface water quality trends.

Aquatic pesticide pollution from both agricultural and urban pest control is a concern in many parts of the world. Making an accurate assessment of pesticide exposure is the starting point to protecting aquatic ecosystems. This in turn requires the design of an effective monitoring program. Monitoring is also essential to evaluate the efficacy of mitigation measures aimed to curb pesticide pollution. However, empirical evidence for their efficacy can be confounded by additional influencing factors, most prominently variable weather conditions. This review summarizes the experiences gained from long-term (>5 years) pesticide monitoring studies for detecting trends and provides recommendations for their improvement. We reviewed articles published in the scientific literature, with a few complements from selected grey literature, for a total of 20 studies which fulfill our search criteria. Overall, temporal trends of pesticide use and hydrological conditions were the two most common factors influencing aquatic pesticide pollution. Eighteen studies demonstrated observable effects to surface water concentrations from changes in pesticide application rates (e.g., use restriction) and sixteen studies from interannual variability in hydrological conditions during the application period. Accounting for seasonal- and streamflow-related variability in trend analysis is important because the two factors can obscure trends caused by changes in pesticide use or management practices. Other mitigation measures (e.g., buffer strips) were only detectable in four studies where concentrations or loads were reduced by > 45%. Collecting additional agricultural (e.g., pesticide use, mitigation measures) and environmental (e.g., precipitation, stream flow) data, as well as establishing a baseline before the implementation of mitigation measures have been consistently reported as prerequisites to interpret water quality trends from long-term monitoring studies, but have rarely been implemented in the past.

Peritoneal carcinomatosis, unilateral malignant pleural effusion with bilateral hydronephrosis post-radical gastrectomy in a signet-ring gastric cancer patient: a case report.

Gastric cancer is the fifth most common cancer in the world and the third leading cause of cancer-related deaths. Signet-ring cell type is the most malicious subtype. We report a case of advanced stage gastric adenocarcinoma case post-radical gastrectomy who presented with nausea, vomiting, and diarrhea. Though there were no signs of bowel obstruction on abdominal CT and PET imagine studies, and the cytology of body fluid was initially negative, the patient had unilateral malignant pleural effusion, a moderate amount of ascites and bilateral hydronephrosis. After laparoscopic surgery, the patient was diagnosed with local cancer relapse causing jejunojejunal anastomosis obstruction and peritoneal carcinomatosis causing hydronephrosis. We urge broadening the indication of EGD in the evaluation of advanced stage gastric carcinoma to include mechanic bowel obstruction.

Enhancing departmental preparedness for COVID-19 using rapid-cycle in-situ simulation.

In response to coronavirus disease 2019 (COVID-19), a rapid-cycle in-situ simulation (ISS) programme was developed to facilitate identification and resolution of systems-based latent safety threats. The simulation involved a possible COVID-19 case in respiratory failure, using a mannequin modified to aerosolize phosphorescent secretions. Thirty-six individuals participated in five ISS sessions over 6 weeks, and a further 20 individuals observed these sessions. Debriefing identified latent safety threats from four domains: personnel, personal protective equipment, supply/environment and communication. These threats were addressed and resolved in later iterations. Ninety-four percent of participants felt more prepared to care for a potential case of COVID-19 after the ISS.

Brain-derived neurotrophic factor (BDNF) expression and function in the mammalian reproductive Tract.

BACKGROUND: Neurotrophins of the nerve growth factor family are soluble polypeptides that are best known for their role in nerve growth, survival and differentiation in the central nervous system. A growing body of literature shows that neurotrophins and their receptors are also expressed throughout the reproductive tract. OBJECTIVE AND RATIONALE: Neurotrophins are key regulatory proteins in reproductive physiology during development and throughout adult life. Of the neurotrophins, the literature describing the expression and function of brain-derived neurotrophic factor (BDNF) and its high-affinity receptor, neurotrophin receptor kinase-2 (NTRK2), has been expanding rapidly. We therefore conducted a systematic inductive qualitative review of the literature to better define the role of the BDNF in the reproductive tract. We postulate that BDNF and NTRK2 are central regulatory proteins throughout the reproductive system. SEARCH METHODS: An electronic search of Medline (PubMed) and Web of Science for articles relating to BDNF and the reproductive system was carried out between January 2018 and February 2019. OUTCOMES: In the ovary, BDNF expression and levels have been linked with follicle organisation during ovarian development, follicle recruitment and growth and oocyte maturation. In the endometrium, BDNF is involved in cell proliferation and neurogenesis. In contrast, literature describing the role of BDNF in other reproductive tissues is sparse and BDNF-NTRK2 signalling in the male reproductive tract has been largely overlooked. Whilst estradiol appears to be the primary regulator of BDNF expression, we also identified reports describing binding sites for glucocorticoid and myocyte enhancer factor-2, a calcium-response element through activation of an N-methyl-D-aspartate (NMDA) receptor, and aryl hydrocarbon receptor nuclear transporter protein-4 (ARNT) response elements in promoter regions of the BDNF gene. Expression is also regulated by multiple microRNAs and post-translational processing of precursor proteins and intracellular shuttling. BDNF-NTRK2 signalling is modulated through tissue specific receptor expression of either the full-length or truncated NTRK2 receptor; however, the functional importance remains to be elucidated. Dysregulation of BDNF expression and circulating concentrations have been implicated in several reproductive disorders including premature ovarian failure, endometriosis, pre-eclampsia, intra-uterine growth restriction (IUGR) and several reproductive cancers. WIDER IMPLICATIONS: We conclude that BDNF and its receptors are key regulatory proteins central to gonadal development, ovarian regulation and uterine physiology, as well as embryo and placenta development. Furthermore, dysregulation of BDNF-NTRK2 in reproductive diseases suggests their potential role as candidate clinical markers of disease and potential therapeutic targets.

Carcinoid tumor causing ileoceccal intussusception in an adult patient.

Introduction: Little is known about adult intussusception, but current evidence suggests that malignancy, polyps, and diverticula are usual etiologies. We present a case of adult ileoceccal intussusception secondary to carcinoid tumor. Case Presentation: A 53-year-old African American male presented with hematochezia and non-radiating constant left upper quadrant pain accompanied by nausea and vomiting. CT of the pelvis demonstrated a pathognomic 'target' sign, consistent with ileoceccal intussusception and early small bowel obstruction. Two years prior to this current presentation, the patient had experienced an episode of hematochezia for which he underwent colonoscopy and polypectomy, with subsequent pathology results negative for colon cancer. He denies diarrhea, constipation, weight loss, decreased appetite or skin flushing. Due to persistent symptoms of bowel obstruction, he underwent exploratory laparotomy. During the surgery a white-colored, chalky mass indicative of penetrating tumor was noted 13 cm proximal to the ileocecal valve. An extended right hemi-colectomy followed the discovery of the mass. Pathology showed a well-differentiated neuroendocrine tumor consistent with carcinoid tumor. Evaluation for metastatic disease using 5-HIAA and chromogranin A was unremarkable, and the resection of the right colon carcinoid tumor was felt to be curative. Conclusion: It is uncommon for adults to present with intussusception; in such cases, malignancy should be ruled out as an underlying cause. Carcinoid should be listed among the other secondary causes, which include inflammatory bowel disease, diverticulitis, polyps, scar tissue, adhesions, and lipomas. Abbreviation: CT (Computer tomography), 5-HIAA (5-hydroxyindole acetic acid), NCCN (National Comprehensive Cancer Network).

A rare presentation of angioedema with isolated retropharyngeal and supraglottic involvement.

Angiotensin converting-enzyme (ACE) inhibitors are commonly prescribed drugs with multiple indications including congestive heart failure, hypertension, and diabetic nephropathy. ACE inhibitor induced angioedema is commonly seen across emergency departments and clinics, with transient swelling of lips, tongue, and other facial structures being the common presentation. Isolated airway obstruction as a result of pharyngeal and laryngeal swelling without facial swelling is a rare presentation. We present a case of a patient on lisinopril therapy for one year who experienced severe airway compromise without the classic symptoms of ACE inhibitor induced angioedema. He required emergent cricothyroidotomy to secure his airway, as fiberoptic laryngoscopy showed 90% obstruction and inability to visualize true vocal cords. His ACE inhibitor therapy was discontinued, and he was discharged home within a few days with no residual symptoms.

miR-151a induces partial EMT by regulating E-cadherin in NSCLC cells.

miR-151a and its host gene, focal adhesion kinase, FAK, are located in a region of chromosome 8q that is frequently amplified in solid tumors, including lung cancer. Lung cancer is the leading cause of cancer deaths worldwide and metastasis remains the major challenge in battling lung cancer mortality. Here, we demonstrate that miR-151a is overexpressed in non-small cell lung cancer (NSCLC) patient specimens, as compared to healthy lung. In addition, miR-151a overexpression promotes proliferation, epithelial-to-mesenchymal transition (EMT) and induces tumor cell migration and invasion of NSCLC cells. Blocking miR-151a expression using anti-miR-151a approaches significantly reduced NCSLC cell proliferative and motility potential. Furthermore, we determined that miR-151a significantly regulates E-cadherin expression. Finally, functional rescue experiments determined that overexpression of E-cadherin in miR-151a NSCLC cell lines potently repressed miR-151a-induced partial EMT and cell migration of NSCLC cells. In conclusion, our findings suggest that miR-151a functions as an oncomiR in NSCLC by targeting E-cadherin mRNA and inducing proliferation, migration and partial EMT.

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians.

Description: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on noninvasive treatment of low back pain. Methods: Using the ACP grading system, the committee based these recommendations on a systematic review of randomized, controlled trials and systematic reviews published through April 2015 on noninvasive pharmacologic and nonpharmacologic treatments for low back pain. Updated searches were performed through November 2016. Clinical outcomes evaluated included reduction or elimination of low back pain, improvement in back-specific and overall function, improvement in health-related quality of life, reduction in work disability and return to work, global improvement, number of back pain episodes or time between episodes, patient satisfaction, and adverse effects. Target Audience and Patient Population: The target audience for this guideline includes all clinicians, and the target patient population includes adults with acute, subacute, or chronic low back pain. Recommendation 1: Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation). Recommendation 2: For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation). Recommendation 3: In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence).

Diagnosis of Acute Gout: A Clinical Practice Guideline From the American College of Physicians.

Description: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the diagnosis of gout. Methods: This guideline is based on a systematic review of published studies on gout diagnosis, identified using several databases, from database inception to February 2016. Evaluated outcomes included the accuracy of the test results; intermediate outcomes (results of laboratory and radiographic tests, such as serum urate and synovial fluid crystal analysis and radiographic or ultrasonography changes); clinical decision making (additional testing and pharmacologic or dietary management); short-term clinical (patient-centered) outcomes, such as pain and joint swelling and tenderness; and adverse effects of the tests. This guideline grades the evidence and recommendations by using the ACP grading system, which is based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. Target Audience and Patient Population: The target audience for this guideline includes all clinicians, and the target patient population includes adults with joint inflammation suspected to be gout. Recommendation: ACP recommends that clinicians use synovial fluid analysis when clinical judgment indicates that diagnostic testing is necessary in patients with possible acute gout. (Grade: weak recommendation, low-quality evidence).

Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians.

Description: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the management of gout. Methods: Using the ACP grading system, the committee based these recommendations on a systematic review of randomized, controlled trials; systematic reviews; and large observational studies published between January 2010 and March 2016. Clinical outcomes evaluated included pain, joint swelling and tenderness, activities of daily living, patient global assessment, recurrence, intermediate outcomes of serum urate levels, and harms. Target Audience and Patient Population: The target audience for this guideline includes all clinicians, and the target patient population includes adults with acute or recurrent gout. Recommendation 1: ACP recommends that clinicians choose corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), or colchicine to treat patients with acute gout. (Grade: strong recommendation, high-quality evidence). Recommendation 2: ACP recommends that clinicians use low-dose colchicine when using colchicine to treat acute gout. (Grade: strong recommendation, moderate-quality evidence). Recommendation 3: ACP recommends against initiating long-term urate-lowering therapy in most patients after a first gout attack or in patients with infrequent attacks. (Grade: strong recommendation, moderate-quality evidence). Recommendation 4: ACP recommends that clinicians discuss benefits, harms, costs, and individual preferences with patients before initiating urate-lowering therapy, including concomitant prophylaxis, in patients with recurrent gout attacks. (Grade: strong recommendation, moderate-quality evidence).

A t(17;19)(q22;p13.3) Involving TCF3, a t(1;9)(p13;p13), and a 5' IGH Deletion in a Case of Adult B-cell Acute Lymphoblastic Leukemia.

TCF3 (19p13.3) abnormalities are relatively common in B-cell acute lymphoblastic leukemia (B-ALL). The t(1;19)(q23;p13) involving PBX1 is the most common of these rearrangements. The t(17;19)(q22;p13.3), resulting in the TCF3-HLF fusion gene, is also seen in B-ALL and is associated with an extremely poor prognosis. Herein, we present the case of a 25-year-old male diagnosed with B-ALL whose initial karyotype showed a t(17;19)(q22p13.3). FISH confirmed TCF3 involvement and also revealed a 5' IGH deletion. After treatment, the patient relapsed, at which point conventional cytogenetic studies showed a t(17;19), loss of the 5' IGH region, and a t(3;10) not seen in initial studies. After hematopoietic stem cell transplantation, the patient relapsed again, at which point conventional cytogenetic studies showed a complex karyotype with t(17;19), t(1;9)(p13;p13), and structural anomalies involving chromosomes 5, 7, and 14, but no IGH abnormalities by FISH. The t(1;9) has been shown to involve PAX5, which plays numerous regulatory roles in B-cell differentiation. Other PAX5 rearrangements have been detected in B-ALL cases of young adults and adolescents, but with unclear clinical significance. To the best of our knowledge, this is the first reported case of t(17;19)-ALL with concomitant 5' IGH deletion and t(1;9)(p13;p13) potentially involving PAX5, albeit at different time points in disease progression. This case provides insight into the clonal evolution of t(17;19)-ALL and the potential involvement of PAX5 and IGH aberrations in the evolution of this malignancy.

The emperor's new clothes: hypersensitivity of the new cardiac isoenzymes.

Right ventricular (RV) myocardial infarction (MI) and pulmonary embolism (PE) are commonly recognized as two of the most challenging and vexing entities in clinical practice. When either is considered in a differential diagnosis, they warrant close consideration because of the life-threatening nature of these conditions. Their signs and symptoms overlap and, on rare occasions, they both can be simultaneously present in a single patient. Cardiac troponins are considered reliable markers of myocardial injury and are critical to the diagnosis of acute coronary syndromes. However, they can also be elevated in cases of PE. We herewith present a case of a woman who initially presented with syncope and then subsequently dyspnea. She manifested elevated cardiac isoenzymes, right-sided electrocardiogram abnormalities, and RV hypokinesis on echocardiography. She was initially diagnosed with RV infarct and managed with an interventional cardiology approach. However, her symptom of dyspnea persisted and the patient was eventually diagnosed with PE. Clinicians should entertain the diagnosis of PE in patients with elevated troponin I and evidence of right-sided cardiac compromise.