The role of tyrosine kinase inhibitor "Lapatinib" in pulmonary hypertension.

INTRODUCTION: Pulmonary Arterial Hypertension (PAH) and cancer share growth factor and protein kinase signaling pathways that result in smooth muscle cell proliferation and vasculopathy. There is little known about the impact of Lapatinib on the pulmonary vasculature. After reporting a case of Lapatinib-induced PAH we investigated the association of Lapatinib with the development of PAH in our institution. METHODS: We reviewed charts for all patients treated with Lapatinib at our institution between 2008 and 2013. Patients who had undergone 2D-echocardiogram both prior to and after treatment were included in the analysis. Increase in Pulmonary artery systolic pressure (PASP) was assessed. Patients were also evaluated in terms of risk factors for non-Group 1 PAH. RESULTS: A total of 27 patients were found to have 2-D echo done before and after starting treatment with Lapatinib. Six patients were found to have significant increase in their PASP after starting treatment. Right heart catheterization before and after stopping the medication was available in three patient, confirming the diagnosis of PAH with complete resolution after stopping the medication. The median pre-treatment and post treatment PASP in those 6 patients was 29 mmHg and 65.5 mmHg respectively (N = 6; p = 0.027). CONCLUSION: Lapatinib might be associated with the development of PAH. PASP should be evaluated in patients who become short of breath while on treatment, and stopping the drug in cases where no other reasons are identified could be associated with reversibility of the elevated pulmonary artery pressure.

Idiopathic erythrocytosis in dialysis patients: a case report and literature review.

Anemia is a common complication in end-stage renal disease (ESRD) patients. On the other hand, idiopathic erythrocytosis is extremely rare, with only a few cases reported in the literature. We present a case of erythrocytosis that developed after initiating hemodialysis. A 68-year-old male with a history of ESRD secondary to diabetes presented with erythrocytosis that started a few months after initiating dialysis in the absence of having received erythropoietin-stimulating agents or iron supplements. His erythropoietin level was elevated, with a negative JAK2 mutation. Blood gases showed normal oxygen and CO(2), with slightly elevated carboxyhemoglobin. Tiny foci in both kidneys were noted, representing vascular calcifications or renolithiasis. There was no radiological evidence of neoplasms or cysts. After excluding secondary causes, a diagnosis of idiopathic erythrocytosis was made. The patient underwent intermittent phlebotomies during dialysis, and his hemoglobin went from 18.5 to 14 mg/dl. Erythrocytosis in ESRD patients is very rare. So far, there is no complete understanding of the underlying pathophysiology; however, there seem to be multiple possible reasons for an increased erythropoietin level. Phlebotomy is a successful and easy way to control erythrocytosis in such patients. Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, currently being used in posttransplant erythrocytosis, might also be considered.

Outcomes of Patients with Thrombocytopenia Evaluated at Hematology Subspecialty Clinics.

BACKGROUND: Thrombocytopenia is a frequently encountered laboratory abnormality and a common reason for hematology referrals. Workup for thrombocytopenia is not standardized and frequently does not follow an evidence-based algorithm. We conducted a systematic analysis to evaluate the laboratory testing and outcomes of patients evaluated for thrombocytopenia at hematology clinics in a tertiary referral center between 2013 and 2016. PATIENT AND METHODS: We performed a comprehensive chart review for patients evaluated for thrombocytopenia during the study period. Patients were followed for 1 year from the initial hematology evaluation and assessed for the development of a hematologic malignancy, rheumatologic, or infectious diseases among other clinical outcomes. RESULTS: We evaluated 472 patients with a median (range) age of 61 (17-94) years. The majority (63.8%) had mild thrombocytopenia. Within 1 year of follow-up, 14 patients (3.0%) were diagnosed with a hematologic malignancy. A higher likelihood of developing a hematologic malignancy was noted in patients with concurrent leukopenia (hazard ratio [HR] 9.97, 95% confidence interval [CI] 3.28-30.32, p < .01) and increasing age (HR per 10-year deciles 1.52, 95% CI 1.03-2.25, p = .03). In patients with asymptomatic isolated mild thrombocytopenia, laboratory testing did not reveal any significant positive findings and patients did not receive any new major diagnosis during the follow-up period. CONCLUSION: Our findings provide basis and call for development of an evidence-based algorithmic approach for evaluation of patients with thrombocytopenia, testing, and referrals. It also supports a conservative approach mainly driven by physical exam signs, symptoms, and other laboratory findings for patients with isolated mild thrombocytopenia.

Bacterial nanocellulose: Reinforcement of compressive strength using an adapted Mobile Matrix Reservoir Technology and suitable post-modification strategies.

Bacterial nanocellulose (BNC) is a highly interesting biomaterial due to some outstanding properties especially when used in medical therapeutics and diagnostics. BNC is absolutely bioinert and is characterised by intrinsic properties such as high tensile stiffness and elasticity, high porosity, exceptional water uptake and swelling capacity. Furthermore, these properties can be adjusted in a very defined way by specifically changing the cultivation conditions or performing post-modifications such as crosslinking, functionalisation with additives, dehydration or drying. Especially the high tensile strength of the nanofibrillar material has been the subject of many investigations in the past couple of years. Nevertheless, the enormous tensile strength and elasticity of BNC is contrary to an almost purely viscous behaviour under compressive load. In the present study, different methods to influence the mechanical behaviour under compression with respect to load bearing applications of BNC are systematically investigated. The possibilities and limitations of the variable layer-by-layer cultivation known as Mobile Matrix Reservoir Technology (MMR-Tech) as well as the effect of different post-modification strategies of BNC are thoroughly investigated. Beside of commonly used indentation tests for characterising the mechanical properties of BNC, we introduce a novel evaluation methodology based on mechanical relaxation measurements and an evolutionary regression algorithm for the derivation of a viscoelastic material law, which for the first time allows standardised, comparative viscoelastic investigations of soft-matter biomaterials to be performed independently of the measurement setup. Using this methodology, we are able to show, that cultivation conditions for BNC and suitable post-modifications can result in different effects on the viscoelastic behaviour of the fabricated composites. We show that the cultivation conditions for BNC primarily affect the height of dispersion and the frequency of the relaxation centre which corresponds roughly to the mean value of the logarithmic distributed relaxation times, and that these effects could be enhanced by post-modifications. However, we also identify parameters, such as the width of the relaxation region, which corresponds roughly to the standard deviation of the logarithmic distributed relaxation times, on which the type of cultivation obviously shows no influence but which can be influenced exclusively by post-modifications. Our methodology enables for the first time a clear identification of those parameters which represent a significant factor of influence to the viscoelastic material behaviour, which should enable a more targeted and application-relevant development of BNC composites in the future.

P-selectin expression assay in a repeatedly serotonin-release assay-negative patient with heparin-induced thrombocytopenia.

Heparin-induced thrombocytopenia (HIT) is an immune complication of heparin therapy caused by antibodies to complexes of platelet factor 4 (PF4) and heparin. Pathogenic antibodies to PF4/heparin bind and activate platelets to propagate a hypercoagulable state culminating in life-threatening thrombosis. The serotonin-release assay (SRA) is considered the gold-standard test to diagnose HIT. However, the sensitivity of the SRA was questioned with reported cases of clinical diagnosis of HIT and negative SRA. Herein, we present the utility of platelet factor 4-dependent P-selectin expression assay (PEA) in diagnosing HIT in a patient with thrombocytopenia and recurrent thrombosis who repeatedly tested negative with SRA.

Overcoming the hydrophilicity of bacterial nanocellulose: Incorporation of the lipophilic coenzyme Q10 using lipid nanocarriers for dermal applications.

Although used in a wide range of medical and pharmaceutical applications, the potential of the natural biopolymer bacterial nanocellulose (BNC) as drug delivery system is by far not fully exploited. Particularly, the incorporation of lipophilic drugs is still considered as an unsolved task. In the present study, the homogeneous incorporation of the lipophilic coenzyme Q10 (CoQ10) into BNC was accomplished by several post-synthesis techniques utilizing different nanoemulsions and liposomes. All colloidal carriers were in the range of about 90-120 nm with negative zeta potentials and storage stabilities up to 30 days. The biphasic drug release profiles of loaded BNC were found to be dependent on the type of colloidal carrier and the loading technique. Favorable characteristics such as high mechanical stability and high loading capacity were retained after the incorporation of the lipophilic components. Penetration studies using excised porcine skin revealed CoQ10 distributions also in deeper skin layers dependent on the type of the colloidal carrier system. In conclusion, hydrophilic BNC could be loaded with water-insoluble drugs as shown for the model drug CoQ10 by the use of lipidic colloidal carriers which offers new possibilities of application in pharmacy and medicine.

Development and characterization of bacterial nanocellulose loaded with Boswellia serrata extract containing nanoemulsions as natural dressing for skin diseases.

The combination of the anti-inflammatory lipophilic Boswellia serrata extract with the natural hydropolymer bacterial nanocellulose (BNC) for the treatment of skin diseases is counteracted by their different hydro/lipophilicity. To overcome the hydrophilicity of the BNC, the water in its network was exchanged by single and double nanoemulsions. Incorporation of the Boswellia serrata extract in the nanoemulsions formed particles of about 115 to 150 nm with negative zeta potential and storage stability over 30 days at temperatures between 4 and 32 °C. Their loading into the BNC did not change the preferential characteristics of the nanocellulose like water absorption and retention, softness, and pressure stability in a relevant way. Loaded BNC could be sterilized by an electron-beam procedure. A biphasic drug release profile of lead compounds was observed by Franz cell diffusion test. The biocompatibility of the loaded BNC was confirmed ex ovo by a shell-less hen's egg test. Tape stripping experiments using porcine skin determined a dependency of the drug penetration into skin on the type of nanoemulsion, single vs. repeated applications and the incubation time. In conclusion, the hydrophilicity of BNC could be overcome using nanoemulsions which offers the possibility for the anti-inflammatory skin treatment with Boswellia serrata extract.

Clinical impact of metformin in diabetic diffuse large B-cell lymphoma patients: a case-control study.

Molecular studies have shown metformin to have a promising effect in lymphoma; however, there is lack of studies translating this effect into clinical settings. This was a case-control study to assess the clinical effect of metformin in diabetic diffuse large B-cell lymphoma (DLBCL) patients. Case subjects were diabetic on metformin with a new diagnosis of DLBCL. A total of 24 case subjects were identified, and for each case a control was matched. Outcomes of this study were to assess overall response rate, complete remission rate, progression free survival, and overall survival between the two groups. There was a significant increase in overall response rate, complete remission rate, and improved progression free survival in the metformin group compared to the control group, however, no significant overall survival difference was observed. Metformin use might be associated with an improved response rates and progression-free survival in diabetic DLBCL patients.

Isolated Ocular Manifestation of Relapsed Chronic Myelogenous Leukemia Presenting as Myeloid Blast Crisis in a Patient on Imatinib Therapy: A Case Report and Review of the Literature.

Blast phase in chronic myelogenous leukemia (CML) has rarely been reported to involve extramedullary sites like skin, lymph nodes, and central nervous system. Clinical history, characteristic hematologic findings (elevated leukocyte counts, myelocytic predominance, and basophilia), and Philadelphia chromosome are of high diagnostic significance especially in isolated extramedullary presentations. We describe a unique case of CML relapse with blast phase involving the eye. A 66-year-old man with a known diagnosis of CML on imatinib and in molecular remission for 3 years presented with a painful blind eye. Histologic examination revealed diffuse involvement of choroid, iris, vitreous humor, and the optic nerve by blast cells. The blasts expressed CD34, aberrant TdT, and a myeloid phenotype (CD13, CD33, and CD117). Fluorescence in situ hybridization (FISH) of vitreous fluid detected BCR-ABL1 gene rearrangement. Additionally, trisomy 8 and gains of 9 and 22 were seen which were not present in the initial diagnostic marrow study 3 years ago. At relapse, the bone marrow, peripheral blood, and the cerebrospinal fluid were not involved by CML. Patient received induction chemotherapy and single dose prophylactic intrathecal methotrexate and was maintained on antityrosine kinase therapy and eventually underwent allogenic stem cell transplantation.

Spontaneous intestinal haematoma associated with neurofibromatosis type-1.

Vasculopathy in patients with neurofibromatosis-1 are rare but serious and have potentially life-threatening complications. It mostly involves the thoracic, abdominal and intracranial vessels. In this case study we describe the first reported case of spontaneous intestinal haematoma in a young male patient. The first episode occurred at the age of 30, following which 2 years later the second episode was noted at the same anatomical site, which was spontaneous without any inciting event.