A Case of Symptomatic Supratherapeutic International Normalized Ratio on Rivaroxaban

Rivaroxaban is a direct oral anticoagulant that works by inhibiting factor Xa. Direct anticoagulants have largely replaced direct vitamin K inhibitors (VKAs) due to the decreased risk of major hemorrhages and the lack of need for regular monitoring and dose adjustments. However, there have been multiple reports of elevated international normalized ratio (INR) and bleeding incidents in patients on rivaroxaban, which brings into question the potential need for monitoring. We report a case of an INR of 4.8 in a rivaroxaban-naïve patient who presented with gastrointestinal bleeding and a significant drop in hemoglobin four days after starting rivaroxaban. We present possible pharmacologic explanations. We propose the idea that specific subgroups of patients may be at risk for true INR elevations and may benefit from routine monitoring of their INR while on rivaroxaban.

Eculizumab in the Treatment of Gemcitabine-Induced Atypical Hemolytic Uremic Syndrome

Gemcitabine-induced hemolytic uremic syndrome is an often-missed condition. We present a case outlining the successful management of a patient with metastatic cholangiocarcinoma treated with gemcitabine who subsequently developed hemolytic uremic syndrome. Early recognition and stopping gemcitabine are essential in this patient population. Complement inhibitors have been used, and our patient improved on eculizumab therapy.

Carfilzomib-Induced Tumor Lysis Syndrome and Biventricular Heart Failure in a Patient With Multiple Myeloma

Carfilzomib is a proteasome inhibitor (PI) used in multiple myeloma (MM) that is resistant to other therapies. Despite its efficacy and potency, carfilzomib has been associated with kidney injuries, cardiovascular toxic effects, and hematological adverse events. Tumor lysis syndrome (TLS) following the use of PIs in MM, a malignancy not known to cause TLS, has seldom been reported. We present a case of a patient with a known diagnosis of MM who received prior therapy including bortezomib, a first-generation PI, developing worsening heart failure and new onset TLS days after the administration of carfilzomib.

Early orbital involvement in a rare diagnosis of Burkitt-like lymphoma with 11q aberration

Burkitt-like lymphoma with 11q aberration is a rare condition that poses a diagnostic challenge due to similarities with Burkitt's lymphoma. Due to the rarity of cases, no specific guidelines exist for therapy, and it is treated the same way as Burkitt's lymphoma. We present such a case with initial orbital involvement, an unusual manifestation. Our patient achieved remission with induction chemotherapy, although he will need regular follow-up given the paucity of information on long-term monitoring in these patients.

Ponatinib-Induced Cerebrovascular Accident (CVA)

Ponatinib is a highly potent tyrosine kinase inhibitor shown to have excellent outcomes in the treatment of acute and chronic leukemias. Despite its high efficacy, ponatinib has been shown to carry an increased risk for cardiovascular adverse events, not attributable to a known mechanism. We present a case of a patient with Philadelphia chromosome-positive acute lymphoblastic leukemia (ALL) who developed a cerebrovascular condition while receiving maintenance therapy with the lowest treatment dose of ponatinib for a prolonged duration.

Venetoclax and Azacitidine in the Treatment of Blastic Plasmacytoid Dendritic Cell Neoplasm Refractory to Conventional Therapy

Blastic plasmacytoid dendritic cell neoplasm is a rare and aggressive hematological malignancy associated with poor prognosis and limited treatment options. No guideline-directed therapy existed until the approval of tagraxofusp in 2018 by the Food and Drug Administration. Multiple clinical trials are undergoing as treatment options continue to evolve. We report a case refractory to tagraxofusp and pivekimab sunirine with subsequent remission achieved on venetoclax and azacitidine therapy.

Mutant PPM1D- and TP53-Driven Hematopoiesis Populates the Hematopoietic Compartment in Response to Peptide Receptor Radionuclide Therapy

PURPOSE

Hematologic toxic effects of peptide receptor radionuclide therapy (PRRT) can be permanent. Patients with underlying clonal hematopoiesis (CH) may be more inclined to develop hematologic toxicity after PRRT. However, this association remains understudied.

MATERIALS AND METHODS

We evaluated pre- and post-PRRT blood samples of patients with neuroendocrine tumors. After initial screening, 13 cases of interest were selected. Serial blood samples were obtained on 4 of 13 patients. Genomic DNA was analyzed using a 100-gene panel. A variant allele frequency cutoff of 1% was used to call CH.

RESULT

Sixty-two percent of patients had CH at baseline. Persistent cytopenias were noted in 64% (7 of 11) of the patients. Serial sample analysis demonstrated that PRRT exposure resulted in clonal expansion of mutant DNA damage response genes (TP53, CHEK2, and PPM1D) and accompanying cytopenias in 75% (3 of 4) of the patients. One patient who had a normal baseline hemogram and developed persistent cytopenias after PRRT exposure showed expansion of mutant PPM1D (variant allele frequency increased to 20% after exposure from < 1% at baseline). In the other two patients, expansion of mutant TP53, CHEK2, and PPM1D clones was also noted along with cytopenia development.

CONCLUSION

The shifts in hematopoietic clonal dynamics in our study were accompanied by emergence and persistence of cytopenias. These cytopenias likely represent premalignant state, as PPM1D-, CHEK2-, and TP53-mutant clones by themselves carry a high risk for transformation to therapy-related myeloid neoplasms. Future studies should consider CH screening and longitudinal monitoring as a key risk mitigation strategy for patients with neuroendocrine tumors receiving PRRT.

Mutant PPM1D and TP53 populate the hematopoietic compartment after peptide receptor radionuclide therapy (PRRT) exposure

10605

Background: Mutations in TP53 and PPM1D are putative drivers associated with therapy related-myeloid neoplasm (T-MN) and have been identified in pre-treatment blood samples obtained at the time of primary malignancy, predating clinically evident T-MN. Genomic analysis of patients(pts) who undergo leukemogenic therapies will help understand T-MN biology and devise risk mitigation strategies. PRRT (Lu 177) for neuroendocrine tumors is associated with enhanced risk of T-MNs. The mechanism for T-MN induced by PRRT is largely elusive due to the novelty of this drug. Methods: We analyzed initial (n=13) and serial blood samples (n=4) prior to and following PRRT for clonal mutations in order to elucidate the role of PRRT in exerting selective pressures on HSCs. Genomic DNA was analyzed using a targeted myeloid 100-gene panel and a variant allele frequency (VAF) cutoff 1% was used to call clonal hematopoiesis (CH). Results: Fifty-four percent pts had CH, despite relatively young age of cohort (median age 58 years, range 41-75) and minimal chemo-radiotherapy exposure; baseline characteristics and molecular profile of cohort is published [Singh et al. Blood 2020; 136 (Supplement 1): 35–36]. Serial sample analysis in 4 pts (Table 1) demonstrates that PRRT exposure is associated with clonal evolution and accompanying cytopenias in 75% (3/4) pts. Pt-1 (age 67) with normal baseline hemogram developed persistent cytopenias after PRRT, accompanied by emergence and expansion of mutant- PPM1D (m PPM1D; VAF 20%). These data suggest that cytopenias result from repopulation of the HSC compartment by m PPM1D cells. In Pts 2 and 3 (age 74 and 75), we note expansion of m TP53 and m PPM1D clones respectively, also associated with the development of cytopenias. Pt-4 was younger (age 59) and developed no cytopenias. Exposure to PRRT was associated with loss of m TET2 and m DDX41, possibly due to lack of clonal fitness of m TET2/DDX41 clones and the relatively young HSC microenvironment. Conclusions: We conclude that mutations in PPM1D and TP53 are clinically relevant, contribute to clonal cytopenias and may increase risk of future T-MN. The temporal association of m TP53 and m PPM1D expansion with PRRT exposure in our analysis suggests selection of these clones in response to PRRT-induced stress, outcompeting wild type and less therapy-resistant HSCs. Our study along with others will inform future efforts to strategize methods of surveillance and early detection for clonality assessment and chemoprevention, to reduce adverse effects of leukemogenic therapies.[Table: see text]

Utility of bone marrow aspirate and biopsy in staging of patients with T-cell lymphoma in the PET-Era - tissue remains the issue

The role of 18F-fluoro-2-deoxy-D-glucose positron emission tomography combined with computerized tomography (PET-CT) in evaluation of bone marrow involvement (BMI) in patients with T-cell lymphoma (TCL) is poorly understood. We investigated whether PET-CT could replace bone marrow aspiration and biopsy (BMAB) in TCL. Sixty patients with newly diagnosed TCL who underwent both diagnostic PET-CT and BMAB were identified. BMI was tissue-confirmed in 15 (25%) cases, however only 8 of these 15 showed BMI on PET-CT (sensitivity of 53.3%, specificity of 100%). BMI by BMAB was associated with lower progression-free survival (PFS) (p = 0.038) and overall survival (OS) (p = 0.003) while PET-CT BMI was associated only with OS (p = 0.02). BMI detected by BMAB in the setting of a negative PET-CT had similar inferior prognosis as BMI identified on PET-CT. Thus, PET-CT in TCL misses BMI in almost half of the cases detected by BMAB and hence cannot substitute BMAB in evaluation of TCL.

Plasmon Modes of Graphene Nanoribbons with Periodic Planar Arrangements

Among their amazing properties, graphene and related low-dimensional materials show quantized charge-density fluctuations-known as plasmons-when exposed to photons or electrons of suitable energies. Graphene nanoribbons offer an enhanced tunability of these resonant modes, due to their geometrically controllable band gaps. The formidable effort made over recent years in developing graphene-based technologies is however weakened by a lack of predictive modeling approaches that draw upon available ab initio methods. An example of such a framework is presented here, focusing on narrow-width graphene nanoribbons, organized in periodic planar arrays. Time-dependent density-functional calculations reveal unprecedented plasmon modes of different nature at visible to infrared energies. Specifically, semimetallic (zigzag) nanoribbons display an intraband plasmon following the energy-momentum dispersion of a two-dimensional electron gas. Semiconducting (armchair) nanoribbons are instead characterized by two distinct intraband and interband plasmons, whose fascinating interplay is extremely responsive to either injection of charge carriers or increase in electronic temperature. These oscillations share some common trends with recent nanoinfrared imaging of confined edge and surface plasmon modes detected in graphene nanoribbons of 100-500 nm width.

Increased left atrial size in obese children and its association with insulin resistance: a pilot study

Subclinical cardiac abnormalities represent predisposing factors for cardiovascular disease (CVD) in obese subjects. The aim of this study was to evaluate early cardiac abnormalities in obese youth and the potential association with insulin resistance (IR). Thirty obese (12 males (M)/18 females (F); age = 11.5 ± 2.4 years; body mass index (BMI)-standard deviation score (SDS) = +2.1 ± 0.5) and 15 normal weight (10 M/5 F; age = 12.8 ± 3.1 years; BMI-SDS = +0.3 ± 0.9) children and adolescents underwent Doppler two-dimensional echocardiographic assessments of left atrial (LA) and ventricular (LV) geometry and LV diastolic function (peak early [E] and late waves, E wave deceleration time, myocardial flow velocities). Homeostasis model assessment of IR (HOMA-IR) was used as an IR index. LA size was increased in obese children, as indicated by higher LA diameter (4.9 ± 0.5 vs 4.1 ± 0.4 cm, p < 0.001), area (14.3 ± 2.5 vs 10.7 ± 2.0 cm(2), p < 0.001), and volume (33.8 ± 10.6 vs 23.7 ± 6.4 ml, p = 0.003). LV mass was also increased in obese children (87.0 ± 16.6 vs 68.8 ± 13.2 g, p = 0.003), who also showed subtle diastolic dysfunctions, as indicated by higher values of E (97.1 ± 14.3 vs 86.2 ± 11.9 cm/s, p = 0.02). All the above parameters were significantly associated with BMI-SDS (p < 0.05). In addition, HOMA-IR was independently associated with LA diameter, area, and volume (β = 0.314, p = 0.040; β = 0.415, p = 0.008; β = 0.535, p = 0.001).

CONCLUSION

Obese children feature increased LA size, which emerged to be mainly correlated to, and possibly driven by IR, suggesting an increased CVD risk.

WHAT IS KNOWN

Left atrial and ventricular alterations have been reported in obese adults, and they represent predisposing factors for cardiovascular disease. There is some evidence suggesting that obese children show increased left ventricular mass and also increased atrial size, although with conflicting results.

WHAT IS NEW

Obese normotensive children showed a moderately increased atrial size, subtle alterations in left cardiac diastolic function, and ventricular mass. An association between insulin resistance and left cardiac changes was found, although its mechanism remains to be determined.

Phase transitions in strongly coupled three-dimensional Z(N) lattice gauge theories at finite temperature

We perform an analytical and numerical study of the phase transitions in three-dimensional Z(N) lattice gauge theories at finite temperature for N>4, exploiting equivalence of these models with a generalized version of the two-dimensional vector Potts models in the limit of vanishing spatial coupling. In this limit the Polyakov loops play the role of Z(N) spins. The effective couplings of these two-dimensional spin models are calculated explicitly. It is argued that the effective spin models have two phase transitions of BKT type. This is confirmed by large-scale Monte Carlo simulations. Using a cluster algorithm we locate the position of the critical points and study the critical behavior across both phase transitions in details. In particular, we determine various critical indices and compute the helicity modulus, the average action, and the specific heat. A scaling formula for the critical points with N is proposed.

Phase transitions in two-dimensional Z(N) vector models for N>4

We investigate both analytically and numerically the renormalization group equations in two-dimensional (2D) Z(N) vector models. The position of the critical points of the two phase transitions for N>4 is established and the critical index ν is computed. For N=7 and 17 the critical points are located by Monte Carlo simulations, and some of the corresponding critical indices are determined. The behavior of the helicity modulus is studied for N=5, 7, and 17. Using these and other available Monte Carlo data we discuss the scaling of the critical points with N and some other open theoretical problems.

Parasellar myxoid chondrosarcoma: a rare variant of cranial chondrosarcoma

Primary cranial chondrosarcoma in an uncommon cartilaginous tumours of which the myxoid variant is the least reported in the literature. This tumour accounts for 0.15% of all primary intracranial lesions and 6% of all skull base tumours. Chondrosarcomas are frequently misdiagnosed as chordomas, which have a different prognosis. Differential diagnosis is very important because, when treated with similar aggressive treatment strategies, chondrosarcoma has a much better prognosis than chordoma. We describe a 54-year-old female with a 9-month history of left ophtalmoplegia and increasing headache. MR imaging of the head showed a sellar and left parasellar mass. We performed a gross total removal of the mass via a left pterional approach. The histopathologic diagnosis was of a myxoid chondrosarcoma. A post-operative contrast-enhanced computed tomography (CT) scan of the head showed a total removal of the neoplasm. After surgery, the patient showed a transitory dysphasia with right hemiparesis, but they both considerably improved before discharge. Review of the literature was identified using the Medline database: only 10 cases in the worldwide literature were identified to report on this kind of tumour. We present a case report of myxoid chondrosarcoma, a rare variant of chondrosarcoma, with sellar and left parasellar localization. This histopathological type is a low-grade variant and its total removal is effective.

Spontaneous chronic subdural hematoma in a young adult

Chronic subdural hematoma (CSDH) is a common pathology in the elderly but very rare in young adults. When CSDH occurs in this age group, severe head injury or some promotive factors are usually present. This article reports the case of a 29-year-old female presented at our Emergency Department with a few days' history of progressive frontal headache. Computed tomography scan of the head showed a right frontal CSDH. Only a decreased level of consciousness without focal deficits was present at clinical examination and her medical history was negative for trauma or promotive factors. Blood count showed a mild sideropenic anemia while coagulation tests were normal. No vascular malformations were shown at digital subtraction angiography. The patient underwent craniotomic evacuation. After surgery, the patient showed a full neurological recovery. Spontaneous CSDH in young adults is very rare. In the worldwide literature, many cases of non-traumatic CSDH are reported, but a promotive factor is generally present. We described a case of spontaneous CSDH, whose etiology remains unknown.

[Elevated levels of lipoprotein(a) are present in subjects with early ischemic cardiopathy and with a familial history of ischemic cardiopathy]

BACKGROUND

Elevated levels of lipoprotein(a) are associated with a greater risk of atherothrombotic cardiovascular diseases. Since the Lp(a) levels are genetically determined and fairly stable in the course of life and a family history appears to be an independent risk factor of cardiovascular diseases, we evaluated the behavior of Lp(a) levels in patients with early events of coronary heart disease (CHD) and also in subjects with positive family history of ischemic heart diseases.

METHODS

The levels of lipoprotein (a) [Lp(a)] were measured in 254 subjects, 138 males and 116 females with an average age of 48.6 +/- 13.8 years (range 20-76 years). Diabetic subjects, females submitted to oestrogen treatment and those already in treatment with hypolipidaemic drugs were excluded from the study. Forty of the 254 patients (15.7%), 27 males and 13 females, had CHD (29 a previous myocardial infarction and 11 a stable angina). A positive family history for CHD was considered present (102 of the 254 patients) if one or more first degree relatives had angina or myocardial infarction before the age of 60 years in men and 65 in women.

RESULTS

The levels of Lp(a) were higher (p < 0.01) in women (25.1 +/- 28.3 mg/dl) compared to men (17.6 +/- 18.4 mg/dl), without differences in relation to age. The Lp(a) plasmatic levels were not correlated with age, body mass index, total cholesterol, LDL and HDL, triglycerides, apo B, apo AI, fibrinogen and there were no differences in Lp(a) levels in presence or absence of other known cardiovascular risk factors such as hypertension and smoking. The Lp(a) levels were not different between subjects with CHD (28.15 +/- 31.7 mg/dl) and controls (20.3 +/- 22.8 mg/dl). The subjects with CHD were older and had higher levels of fibrinogen and a significantly greater prevalence of hypertension and family history of CHD. Fifteen of the 40 subjects with CHD had an early onset of CHD (before 50 years of age) and only in such patients the Lp(a) levels were significantly greater compared to controls (35.8 +/- 33.2 mg/dl vs 20.3 +/- 22.8 of the controls, p < 0.01), independently of other variables (age, BMI, smoking, hypertension, cholesterol, triglycerides, HDL-c, LDL-c, fibrinogen). Furthermore the Lp(a) plasmatic levels were higher in subjects with a family history of CHD (28.3 +/- 27.6 mg/dl vs 16.3 +/- 18.6 mg/dl of the subjects without a family history of CHD, p < 0.01) even if they had or not had a previous coronary ischemic event.

CONCLUSIONS

Such data confirm the importance of high levels of Lp(a) above all for the early events of CHD and for the subjects with a family history of CHD, which could be expression of a greater predisposition for cardiovascular events.