Impact of CALR and JAK2V617F Mutations on Clinical Course and Disease Outcomes in Essential Thrombocythemia: A Multicenter Retrospective Study in Turkish Patients

Objective

In this study, we investigated the effects of calreticulin (CALR) and JAK2V617F mutational status on clinical course and disease outcomes in Turkish patients with essential thrombocythemia (ET).

Materials and Methods

Seventeen centers from Türkiye participated in the study and CALR- and JAK2V617F-mutated ET patients were evaluated retrospectively.

Results

A total of 302 patients were included, of whom 203 (67.2%) and 99 (32.8%) were JAK2V617F- and CALR-positive, respectively. CALR-mutated patients were significantly younger (51 years vs. 57.5 years, p=0.03), with higher median platelet counts (987x109/L vs. 709x109/L, p<0.001) and lower median hemoglobin levels (13.1 g/dL vs. 14.1 g/dL, p<0.001) compared to JAK2V617F-mutated patients. Thromboembolic events (TEEs) occurred in 54 patients (17.9%), 77.8% of which were arterial. Compared to CALR mutation, JAK2V617F was associated with a higher risk of thrombosis (8.1% vs. 22.7%, p=0.002). Rates of transformation to myelofibrosis (MF) and leukemia were 4% and 0.7%, respectively, and these rates were comparable between JAK2V617F- and CALR-mutated cases. The estimated overall survival (OS) and MF-free survival of the entire cohort were 265.1 months and 235.7 months, respectively. OS and MF-free survival durations were similar between JAK2V617F- and CALR-mutated patients. Thrombosis-free survival (TFS) was superior in CALR-mutated patients compared to JAK2V617F-positive patients (5-year TFS: 90% vs. 71%, respectively; p=0.001). Age at diagnosis was an independent factor affecting the incidence of TEEs.

Conclusion

In our ET cohort, CALR mutations resulted in higher platelet counts and lower hemoglobin levels than JAK2V617F and were associated with younger age at diagnosis. JAK2V617F was strongly associated with thrombosis and worse TFS. Hydroxyurea was the most preferred cytoreductive agent for patients with high thrombosis risk.

Immune Thrombotic Thrombocytopenic Purpura in Elderly Patients: The Roles of PLASMIC and French Scores

Objective

In recent years, new developments have been incorporated into daily practice in the management of immune thrombotic thrombocytopenic purpura (iTTP). In particular, clinical scoring systems could help clinicians with clinical decision-making and early recognition. However, older patients frequently present with more organ involvement and in unusual ways. The ways in which age could affect these clinical prediction scoring systems remain unclear. We evaluated the use of PLASMIC and French scores in patients over 60 years of age.

Materials and Methods

We performed a retrospective cross-sectional analysis of patients over 60 years of age with a presumptive diagnosis of iTTP between 2014 and 2022 at 10 centers. We calculated PLASMIC and French scores and compared our data with a single-center analysis of younger patients presenting with thrombotic microangiopathy.

Results

Our study included 30 patients over 60 years of age and a control group of 28 patients younger than 60 years. The diagnostic sensitivity and specificity of a French score of ≥1 were lower in older patients compared to the control group (78.9% vs. 100% and 18.2% vs. 57.1%, respectively). The diagnostic sensitivity and specificity of a PLASMIC score of ≥5 were 100% vs. 95% and 27.3% vs. 100% for the study group and control group, respectively. Our study showed a higher mortality rate in older patients compared to the control group (30% vs. 7.1%, p=0.043).

Conclusion

For a limited number of patients (n=6), our results showed that rituximab can reduce mortality. Given that the reliability of clinical prediction scores for iTTP in older patients may be lower, more caution must be undertaken in interpreting their results.

Morphologic evaluation of megakaryocytes in immune thrombocytopenia patients older than 80 years

OBJECTIVE

In immune thrombocytopenia (ITP), which is a common acquired bleeding disorder, cytotoxic T-cell-mediated cellular immune response against both circulating platelets and bone marrow megakaryocytes are the most important mechanisms in the pathogenesis.

METHODS

In our study, we evaluated the features of 33 patients with ITP, over 80 years of age.

RESULTS

The median age of the patients was 90, 15 patients were female (45.4%). The mean platelet count of the patients was 39×109/L and the mean mean platelet volume was 10,33fL. Twelve patients had a target thrombocyte count greater than 30×109/L, while 20 patients had a target platelet count of 75×109/L or greater with an absolute indication of antiaggregation. In the environmental spread, 18 dysplasia findings were observed.

CONCLUSION

Morphologic observations suggesting dysplasia including micromegakaryocytes and a non-dysplastic but dysmegakaryopoietic finding, multiple segmented nuclei may be related to the degree of thrombocytopenia and response to treatment. Likewise, nondysplastic features including immature forms, emperipolesis, bare nucleus, hypolobulation, and hypersegmented nucleus were related to the degree of thrombocytopenia.

Current evidence on the use of direct oral anticoagulants in patients with myeloproliferative neoplasm: a systematic review

INTRODUCTION

Thromboembolic events in myeloproliferative neoplasms (MPNs) are one of the most important causes of mortality and morbidity, in which vitamin K antagonists (VKAs) have been used mostly. Recently, direct oral anticoagulants (DOACs) are used in venous thromboembolism (VTE) and cancer-associated thrombosis (CAT). With the adoption of data from CAT and VTE, the usage of DOACs in MPNs is increasing.

AREAS COVERED

In this paper, we performed a systematic review to the current literature regarding the usage of DOACs in MPNs. Eleven studies involving 944 patients were included. The reasons for initiating DOACs were secondary prophylaxis for thrombosis (arterial or venous) and atrial fibrillation (AF) in 562 and 382 patients, respectively. A total of 84 (8.9%) recurrent thrombotic (arterial or venous) events recorded. Forty-six (8.1%) events occurred in the thrombosis group (arterial or venous) and 38 (9.9%) events occurred in patients with AF.

EXPERT OPINION

Ease of management and patient comfort should be regarded as benefits of DOACs compared to VKAs. However, it would be appropriate to bring an individualized approach until we obtain high-quality data with prospectively designed studies involving more patients and longer follow-up time concerning the use of DOACs in patients with MPNs.

Subacute thyroiditis after SARS-CoV-2 BNT162b2 vaccine in a multiple myeloma patient

Viral infections emerge in the pathogenesis of subacute thyroiditis. Aside from this, subacute thyroiditis following vaccines utilizing inactivated viruses has been shown on rare occasions. Due to the COVID-19 pandemic, several vaccines have been developed all over the world; mass and unprecedented vaccination has thus been initiated. However, it is known that cases such as subacute thyroiditis have been reported, albeit rarely, after administration of COVID-19 vaccines. In this case report, we present a 59-year-old patient with multiple myeloma developing subacute thyroiditis following BNT162b2 vaccine. Patient had swelling in the neck, and his symptoms were controlled with non-steroidal anti-inflammatory drugs. Subacute thyroiditis following administration of the COVID-19 vaccine is rare; however, it is likely an under-reported condition that is difficult to detect. Clinicians should stay informed and have increased awareness of post-COVID-19 vaccine subacute thyroiditis.

The evaluation of risk factors leading to early deaths in patients with acute promyelocytic leukemia: a retrospective study

Acute promyelocytic leukemia (APL) differs from other forms of acute myeloid leukemia (AML), including coagulopathy, hemorrhage, disseminated intravascular coagulation (DIC), and treatment success with all-trans retinoic acid (ATRA). Despite ATRA, early deaths (ED) are still common in APL. Here, we evaluated factors associated with ED and applicability of scoring systems used to diagnose DIC. Ninety-one APL patients (55 females, 36 males, and median age 40 years) were included. ED was defined as deaths attributable to any cause between day of diagnosis and following 30th day. DIC was assessed based on DIC scoring system released by the International Society of Thrombosis and Hemostasis (ISTH) and Chinese Diagnostic Scoring System (CDSS). Patients' median follow-up time was 49.2 months, and ED developed in 14 (15.4% of) cases. Patients succumbing to ED had higher levels of the Eastern Cooperative Oncology Group Performance Status (ECOG PS), lactate dehydrogenase (LDH), and ISTH DIC, and lower fibrinogen levels (p <0.05). In multivariate Cox regression analysis, age >55 and ECOG PS ≥2 rates were revealed to be associated with ED. Based on ISTH and CDSS scores, DIC was reported in 47.3 and 58.2% of the patients, respectively. Despite advances in APL, ED is still a major obstacle. Besides the prompt recognition and correction of coagulopathy, those at high ED risk are recommended to be detected rapidly. Implementation of local treatment plans and creating awareness should be achieved in hematological centers. Common utilization of ATRA and arsenic trioxide (ATO) may be beneficial to overcome ED and coagulopathy in APL patients.

Signet ring cell carcinoma metastasis in the bone marrow accompanied by cancer related thrombotic microangiopathy as a first presentation

Cancer related thrombotic microangiopathies usually cause a diagnostic dilemma for hematologists and clinicians. In this case report, we presented a fifty-nine-year-old man who was admitted to our hospital with microangiopathic hemolytic anemia and thrombocytopenia due to the carcinoma metastasis to the bone marrow. As a result of rapid evaluations, it was revealed that the histological subtype of the cancer was signet ring cell carcinoma, and despite all the interventions, the patient died at a very short time after the initial presentation. Regardless of all the innovations in the diagnosis and treatment of thrombotic microangiopathies, cancer-associated thrombotic microangiopathy is still fatal and deadly today.

The Utility of CONUT Score in Diffuse Large B Cell Lymphoma Patients

Background

Assessment of nutritional status is gaining more importance in cancer patients because nutritional status is associated with response to chemotherapy, side effects of cancer treatment and disease progression. Several studies that were performed on patients with solid malignancies have shown the clinical significance of CONUT score (Controlling nutritional status).

Aims

Therefore we tried to show the utility of CONUT score in newly diagnosed Diffuse Large B Cell Lymphoma (DLBCL) patients which is the most frequently seen B Cell Lymphoma type.

Methods

Data of the 81 patients diagnosed with DLBCL were retrospectively evaluated. The primary endpoint of our study was to evaluate and classify newly diagnosed DLBCL patients according to the CONUT score and secondary endpoint was to show any relationship with CONUT score and overall survival. Patients' demographics, treatment details, stages, extranodal involvements, the presence of bulky disease, response to treatment options and overall survivals were evaluated from medical recordings.

Results

Univariate cox regression analysis CONUT score was associated with overall survival (HR: 2.34-95% CI: 1.55-3.24 P = 0.040). On multivariate Cox regression analysis model CONUT score ≥5 was found to be an independent prognostic factor for overall survival (HR: 4.96-95% CI: 1.77-13.97- P = 0.002).

Conclusion

The value of obtaining nutritional status in cancer patients is underestimated and CONUT score is simple, easily applicable and in our opinion is going to fill the gap especially in DLBCL patients.

Could Anti-Nuclear Antibody Positivity be a Factor for Affecting Treatment Response in Immune Thrombocytopenia Patients on Eltrombopag?

Objective

Eltrombopag remains a prominent option in the treatment of steroid-dependent or steroid-refractory Immune thrombocytopenia (ITP) patients. Unfortunately, a group of patients did not respond to eltrombopag. Antinuclear Antibody (ANA) positivity can be seen up to 30 % in ITP patients. Despite being widely used, markers to show the response for eltrombopag are lacking and needed. In the present study, we aimed to show the association between ANA positivity and eltrombopag response in ITP patients.

Material and Methods

Patients who were diagnosed with ITP at Trakya University Faculty of Medicine Hematology and who received eltrombopag treatment due to their resistance to steroids and other treatments were included in our study. ANA measurement was made with indirect fluorescent antibody and titers of 1:160 and above were considered positive and ANA measurement was made before starting eltrombopag.

Results

Forty-five patients were included in our study. 33 were female and 12 were male. The mean age of the patients was 45, 73. Years. There were 14 patients with ANA positivity and 31 patients found to be ANA negative. Response rates were higher in ANA negative patients compared to ANA positive patients in the first and sixth months of the eltrombopag treatment (p < 0, 05).

Conclusion

ANA positivity in ITP may indicate unresponsiveness to eltrombopag treatment, and this should be supported by prospective studies involving more patients.

Comparison of Clinical Scoring Systems in the Management of Patients with Microangiopathic Hemolytic Anemia and Thrombocytopenia

Objective:

Several clinical scoring systems have been developed for the differential diagnosis of thrombotic microangiopathies (TMAs), all to predict and identify patients with ADAMTS13 deficiency and to start treatment as soon as possible. The first scoring system in this regard was the Bentley score, and the French score and PLASMIC score were developed afterwards.

Materials and Methods:

We aimed to evaluate the laboratory parameters and clinical features of patients who underwent plasma exchange with a prediagnosis of TTP at our clinic between 2007 and 2019 and whose ADAMTS13 enzyme levels were measured and to compare the findings with the scoring systems.

Results:

Data of 35 patients were evaluated. Twelve patients were evaluated as high risk according to all three scoring systems. A statistically significant relation was observed between all three scoring systems and ADAMTS13 levels.

Conclusion:

A moderate correlation was found between all three scoring systems and ADAMTS13 levels. We observed similar potential strength of all three scoring systems to predict TTP among other TMAs and we conclude that they are applicable in daily practice.

A case of refractory chronic lymphocytic leukaemia with an unusual course

Chronic lymphocytic leukaemia (CLL) is a heterogeneous disease with uncertain course. Treatment should be tailored to the patient's disease as well as the prognostic subgroup. With the increased use of rituximab as well as other selective and non-selective immunomodulatory agents, the incidence of infectious complications and second malignancies has also increased. Progressive multifocal leucoencephalopathy (PML) is a complication of rituximab in HIV-negative patients. A 56-year-old male with CLL had been treated and relapsed four times in 6 years. Rituximab was added to the combination after the second relapse and repeated in the third relapse in combination with bendamustine. In the seventh year of diagnosis, relapse of CLL and an ulcerated tumorous lesion was observed in the left index finger, which progressed in 3 months and was later diagnosed as angiosarcoma. The cancer was treated with local radiotherapy and combination chemotherapy. One year after the last rituximab exposure, progressive muscle weakness developed and polyoma JC virus DNA was observed with increased titres in the cerebrospinal fluid, and the patient was diagnosed as having PML. The patient died 2 months later. Our patient had an unusual course of CLL over 8 years, with relapses, complicated with a secondary malignancy and an infectious complication.

Sarcopenia in Hodgkin's lymphoma evaluated with 18-FDG PET/CT, focus on age, performance, and treatment

Sarcopenia is defined as a progressive and generalized muscle disorder associated with certain physiological and pathological conditions. We aimed to evaluate the prevalence of sarcopenia in patients with HL using 18-fluoro deoxyglucose (FDG) PET/CT, which would provide a data of muscle mass with the CT compartment and also data of muscle metabolism with the 18-FDG compartment of the imaging modality. Fifty-nine patients diagnosed with HL were included in the study. PET/CT images before and after treatment were evaluated with regard to lumbar muscle mass and metabolism. Mean lumbar muscle evaluation with CT before treatment was 92, 40 HU, and after treatment was 89, 41 HU. Mean metabolic tumor volume (MTV) evaluated with FDG PET before treatment was 4, 13 mm³ while after treatment was 4, 10 mm³. The lumbar muscle mass in terms of HU which was evaluated with CT was observed to be decreased after treatment. Likewise, the metabolic evaluation was observed to be also decreased after treatment. Despite the decline in muscle mass after treatment in the whole group, this decline was particularly observed in the better initial performance group. In patients with BMI > 32, there was a significant decline in muscle mass. Abdominal nodal involvement was related with poorer muscle mass and quality. In HL care, particular attention should be given to patients who are younger and with better physical condition in terms of preserving the muscle reserves and preventing sarcopenia.

Evaluation of Sarcopenia with F-18 FDG PET/CT and relation with disease outcomes in patients with multiple myeloma

INTRODUCTION

Multiple myeloma (MM) is a potentially incurable haematological malignancy with devastating manifestations including lytic bone lesions leading to fractures and renal insufficiency. As a disease of patients with a mean age of 66 years, both the disease and the continuous efforts of treatments lead to frailty and devastation. From this stand point, we aimed to evaluate the development of muscle loss in MM patients and also with a new method of sarcopenia evaluation, F-18 FDG PET/CT. While used for bone disease routinely, this method brings a fresh perspective of metabolic quantitation of alteration of muscles which may be regarded as muscle quality.

MATERIALS AND METHODS

Data and images of 105 patients with MM both before and after treatment were evaluated in a retrospective manner.

RESULTS

Both female and male patients were observed to be effected after MM treatment in terms of lumbar and femoral muscle evaluations with CT. Metabolic evaluations confirmed a loss of quality in muscles in terms of metabolic volume and total lesion glycolysis.

CONCLUSION

Sarcopenia should be evaluated in every patient and regarded as a treatment target. FDG PET/CT is an easy and handy tool to assess muscle mass and quality as well as MM disease status.

Autonomic and diastolic dysfunction association with quality of life impairment in cirrhotic patients

BACKGROUND AND STUDY AIMS

Cirrhosis is a multisystem disorder characterized by hyperdynamic circulation which can progress to multiple organ dysfunctions. Recent studies have demonstrated autonomic dysfunction and cirrhotic cardiomyopathy including diastolic dysfunction, systolic dysfunction with electrophysiologic abnormalities in patients with cirrhosis. Due to the long and complicated course of the disease, health related quality of life is affected. We aimed to evaluate the frequency of diastolic dysfunction and autonomic dysfunction in cirrhosis, and the effects on health-related quality of life.

PATIENTS AND METHODS

Hundred cirrhotic patients were enrolled in the study. According to the Child-Pugh classification 35 patients were of Child A, 36 of Child B and 29 of Child C. The proportion of autonomic dysfunction was 52%, and diastolic dysfunction 51%. Autonomic dysfunction was diagnosed using bedside maneuvers and tests; diastolic dysfunction was diagnosed using the E/A ratio in echocardiographic findings. Health-related quality of life measurements was obtained from an SF-36 questionnaire.

RESULTS

Patients with advanced Child-Pugh classifications were found to have significantly lower health-related quality of life values (p < 0.05). Likewise, health-related quality of life values were observed to be significantly lower in patients with autonomic dysfunction (p < 0.05). No significant difference was found in health related quality of life measurements between patients with and without diastolic dysfunction.

CONCLUSION

Our study showed that autonomic dysfunction and diastolic dysfunction are found in patients with cirrhosis. Further studies are needed to assess the effects of autonomic dysfunction and diastolic dysfunction on health-related quality of life.

Chronic myeloid leukaemia after chemoradiotherapy for solid malignancies

Haematological malignancies associated with chemoradiotherapy (CRT) are often acute myeloid leukaemias and myelodysplastic syndromes. Chronic myeloid leukaemia (CML) has been reported rarely in these situations. Cytogenetics of CRT-associated CML is not different from de novo CML, and there are not enough data about its prognosis. We report two patients who had CRT because of lung cancer and squamous cell carcinoma of head and neck, who subsequently developed CML.

Invasive fungal infection with a rare organism in a patient with acute myeloid leukaemia

Invasive fungal infections are a major cause for morbidity and mortality in patients with acute myeloid leukaemia (AML). Long duration of hospitalization and increased costs are secondary burdens for patients and caregivers. The clinical manifestations are variable with a spectrum of different organs or systems. Factors related with invasive fungal infections may be categorized as host-related including the underlying disease, treatment and colonization status and pathogen-related including the capacity of the microorganism for defence, growth, tolerance and tissue affinity. The diagnosis of invasive fungal infection is confirmed with histopathological or microbiological demonstration of the microorganism, and commonly treatments are based on probability rather than definitive diagnosis due to patients fragile conditions preventing interventions. We aimed to present the less frequent yet difficult-to-treat organism, Verticillium causing invasive fungal infection in a patient with AML undergoing remission induction therapy.

Genetic Diagnosis of Hereditary Hemorrhagic Telangiectasia: Four Novel Pathogenic Variations in Turkish Patients

Aims:

Hereditary hemorrhagic telangiectasia is an autosomal dominant disorder characterized by telangiectasia, epistaxis, and vascular malformations. Pathogenic mutations were found in ENG, AVCRL1, SMAD4, and GDF genes. In this study, we present our database of patients with hereditary hemorrhagic telangiectasia regarding the phenotype-genotype relations and discuss two novel ENG gene pathogenic variations in two unrelated families.

Methods:

Next Generation Sequencing analysis was performed on the peripheral blood of nine patients with hereditary hemorrhagic telangiectasia in four unrelated families. All patients were diagnosed with hereditary hemorrhagic telangiectasia according to the Curaçao criteria. Data on treatment and screenings of visceral involvement were recorded from files.

Results:

We have found a pathogenic variation in either the ENG or ACVRL1 gene in each family. Two novel pathogenic variations in the ENG gene, including NM_000118.3 (ENG): c.416delC (p.P139fs*24) and NM_000118.3(ENG): c.1139dupT (p.Leu380PhefsTer16), were found in the same family. The NM_000020.2(ACVRL1): c.1298C>T (p.Pro433Leu) pathogenic variation in the ACVRL1 gene in our first family and a novel heterozygous likely pathogenic NM_000020.2(ACVRL1): c.95T>C (p.Val32Ala) variation was found in our second family. Seven of the nine patients were treated with thalidomide for controlling bleeding episodes. All patients responded to thalidomide. In one patient, the response to thalidomide was lost and switched to bevacizumab.

Conclusion:

In hereditary hemorrhagic telangiectasia, certain types of mutations correlate with disease phenotypes and with next generation sequencing methods. New pathogenic variations can be revealed, which might help manage patients with hereditary hemorrhagic telangiectasia.

Eden Baysal Dental Trauma Index: Face and content validation

BACKGROUND/AIM

Recording of traumatic dental injuries in the emergency situation with a simple and easily recordable index that will also enable computer registration is advantageous. The aim of this paper is to present a new index to facilitate recording traumatic dental injuries and assess its face and content validity.

MATERIALS AND METHODS

The index included information on the type of injury related to the affected structures (enamel, dentin, cement, pulp, periodontal ligament, and alveolar bone) in accordance with Andreasen's classification. In addition, injuries to the alveolar bone and the maturity of the root were included. Fifteen dental trauma experts from 11 different countries rated the codes and content of the "Eden Baysal Dental Trauma Index" using the RAND modified e-Delphi consensus method. A statement was considered valid after reaching 75% consensus among panel members. Two rounds were necessary for reaching consensus on seven statements and the definition. The last version of the index was then presented online to a feedback group that included 10 experts from five countries to determine the external validity by representative cases.

RESULTS

The wording of the definition showed 92.8% agreement in the first round. Statements 1 and 2 gave information about the structure of the index and both reached 90% agreement in the first round. Definition and statements from 1 to 7 reached agreement as 93.3%, 93.3%, 100%, 93.3%, 80%, 93.3%, 80%, and 93.3%, respectively, in the second round. Most of the experts in the feedback group reported that the index was useful and user-friendly.

CONCLUSION

After a total of two rounds with the panel members and one round with the feedback group, the "Eden Baysal Dental Trauma Index" was approved for face and content validity and external validity was obtained.

Reproductive toxic effects and possible mechanisms of zonisamide in male rats

Zonisamide (ZNS) is an anticonvulsant which is used to treat the symptoms of epilepsy. Although it is frequently used during reproductive ages, studies that investigated the effects of ZNS on reproductive system are limited. Therefore, we aimed to assess the effects of ZNS on male reproductive system by oral administration to rats in 25, 50, and 100 mg/kg doses for 28 days. After the exposure period, sperm concentration, motility, morphology, and DNA damage, as biomarkers of reproductive toxic effects, were determined, and histopathological examination of testis was performed. In addition, levels of the hormones that play a role in the regulation of reproductive functions, such as follicle-stimulating hormone, luteinizing hormone (LH), and testosterone were measured and the levels of oxidative stress biomarkers that take part in the reproductive pathologies such as catalase, superoxide dismutase, glutathione, and malondialdehyde, were determined. Reproductive toxic effects related to ZNS administration were shown by the significant decrease of sperm concentration and normal sperm morphology in ZNS groups. Additionally, pathological findings were observed in the testicular tissues of ZNS-administered groups dose dependently. In addition, serum LH and testosterone levels were significantly decreased in the ZNS groups. Decreased catalase activities and increased malondialdehyde levels in ZNS groups were evaluated as oxidative stress findings in the testis tissue. It could be expressed that ZNS administration induced dose-dependent reproductive toxic effects in rats, and pathological findings associated with the reproductive system could be the result of that hormonal changes and testicular oxidative stress, which in turn might be considered as possible mechanisms of male reproductive toxicity.

The relationship between mean platelet volume and neutrophil/lymphocyte ratio with inflammation and proteinuria in chronic kidney disease

Atherosclerosis, which develops as a result of inflammation, is the most important cause of morbidity and mortality in chronic kidney disease (CKD). In this study, we investigated the relationship of mean platelet volume (MPV) and neutrophil/lymphocyte ratio (NLR) with inflammation and proteinuria in patients with CKD Stage 3-4. Healthy individuals who applied to nephrology clinic for checkup purposes acted as controls. Fifty-three patients and 30 healthy controls were included in the study. Patients with diabetes mellitus, active infection, malignancy, and coronary artery disease were excluded from the study. Biochemistry values and hemograms were recorded for all patients and for control group. NLR was calculated. The relationship between MPV/NLR and protein, fibrinogen, and proteinuria was evaluated. Our study showed a statistically significant difference between CKD group and healthy control (HC) group in uric acid, fibrinogen, C-reactive protein, and NLR values (P <0.01, P <0.01, P = 0.01, P <0.01, respectively). No statistically significant difference was found between CKD and HC groups for MPV (P = 0.307). Correlation analysis revealed a statistically significant relationship between NLR and creatinine (P <0.00, r = 0.571), uric acid (P <0.00, r = 0.436), glomerular filtration rate (P <0.00, r = -0.418), 24 h urine protein (P = 0.004, r = 0.311), and 24 h urine microalbumin (P = 0.001, r = 0.354). A statistically significant relationship was detected between MPV and platelet count (P <0.001, r = -0.422), age (P = 0.004, r = -0.312), uric acid (P = 0.04, r = -0.226), and fibrinogen (P = 0.023, r = -0.249). Whereas, a statistically significant relationship was detected between NLR and microalbuminuria/proteinuria, there was no statistically significant relationship between MPV and microalbuminuria/proteinuria. Our study showed that the NLR is high in CKD group and is correlated with uric acid and proteinuria, which are known to be associated with atherosclerosis, in patients with CKD. NLR may be a determinant of inflammation and atherosclerosis in patients with CKD.

Late onset left ventricular dysfunction and cardiomyopathy induced with ibrutinib

INTRODUCTION

Ibrutinib, an oral inhibitor of Bruton's tyrosine kinase, has altered the treatment perspective of chronic lymphocytic leukemia and showed modest activity against several types of non-Hodgkin's lymphomas. According to phase studies and real-world data, reported serious adverse effects included atrial fibrillation, diarrhea, and bleeding diathesis. However, heart failure was not reported to be a probable adverse effect linked with ibrutinib.

CASE REPORT

In this paper, we present a 66-year-old female chronic lymphocytic leukemia patient who developed significant and symptomatic left ventricular dysfunction at the 13th month of ibrutinib treatment.

MANAGEMENT AND OUTCOME

Following cessation of ibrutinib, ejection fraction and clinical findings of the left ventricular dysfunction alleviated.

DISCUSSION

Although the use of ibrutinib is generally well tolerated, cardiac functions should be monitored occasionally in all patients.

Polypharmacy and potentially inappropriate medication use in older patients with multiple myeloma, related to fall risk and autonomous neuropathy

Purpose

Multiple myeloma is a chronic, uncurable hematological cancer with the involvement of multiple organ systems. As a disease affecting older patients, the treatment of multiple myeloma should be based on individual patient characteristics. Polypharmacy is an increasing problem in the care of older patients and in patients with multiple myeloma, polypharmacy is almost inevitable. We aimed to evaluate the applicability of polypharmacy definitions and the relation of polypharmacy with disease outcomes in patients with multiple myeloma.

Methods

Eighty patients older than 65 years and diagnosed with multiple myeloma were retrospectively enrolled. Patient files, prescriptions, evaluations for polypharmacy were determined according to Beers and START/STOPP criteria. Outcomes were recorded from files in terms of fractures, autonomous neuropathy, and renal functions.

Results

Polypharmacy with ≥4 drugs was observed in 65 patients while polypharmacy with ≥5 drugs was observed in 51 patients. Autonomous neuropathy, polypharmacy with more than four or five medications, and use of multiple medications in the same category were related with poor ECOG performance status in women, while prolonged use of benzodiazepines and central nervous system (CNS) affecting drugs and inappropriate polypharmacy were more frequent in men with poor ECOG performance status. The majority of patients aged 75–84 years were observed to use inappropriate polypharmacy. Autonomous neuropathy and fall risk were observed to be significantly related with inappropriate polypharmacy.

Conclusions

Drugs affecting balance and perception should be reconsidered in patients with multiple myeloma.

Thalidomide for the Management of Bleeding Episodes in Patients with Hereditary Hemorrhagic Telangiectasia: Effects on Epistaxis Severity Score and Quality of Life

Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominantly inherited disorder characterized by bleeding episodes. These episodes tend to happen spontaneously and reduce the quality of life. Patients are often unresponsive to local measures. With the pathophysiological role of angiogenesis in HHT, antiangiogenic drugs including thalidomide are used to control bleeding episodes. In our study, we evaluated 6 patients with HHT, calculating their Epistaxis Severity Score (ESS) and performing a quality of life assessment with the 36-Item Short Form Health Survey Questionnaire (SF-36), and we studied the alterations of these evaluations with thalidomide treatment. Three patients were male and three were female. Mean age was 60.50 years. No side effects were observed during the treatment period. Improvements of certain SF-36 dimensions including physical functioning, physical component summary, and mental component summary and of the ESS were observed after treatment. Thalidomide may be effective to control bleeding episodes with a reasonable tolerance profile in patients with HHT.

Assessment of trazodone-induced cardiotoxicity after repeated doses in rats

Trazodone (TRZ) is an antidepressant drug commonly used in the treatment of depression, anxiety, and insomnia. Although some studies demonstrated the adverse effects of TRZ related to cardiovascular system, the conflicting results were observed in these studies. Therefore, we aimed to investigate the cardiac adverse effects of TRZ in rats at repeated doses in our study. In accordance with this purpose, TRZ was administered orally to rats at 5, 10, and 20 mg/kg doses for 28 days. Electrocardiogram records, serum aspartate aminotransferase (AST), lactate dehydrogenase, creatine kinase-myoglobin band, cardiac troponin-T (cTn-T) levels, DNA damage in cardiomyocytes, and histologic view of heart tissues were evaluated. In addition, glutathione (GSH) and malondialdehyde (MDA) levels were measured to determine the oxidative status of cardiac tissue after TRZ administration. Heart rate was decreased, PR interval was prolonged, and QRS and T amplitudes were decreased in 20 mg/kg TRZ-administered group compared to the control group. Serum AST and cTn-T levels were significantly increased in 10 and 20 mg/kg TRZ-administered rats with respect to control rats. DNA damage was significantly increased in these groups. Additionally, degenerative histopathologic findings were observed in TRZ-administered groups. Although there was no difference in MDA levels between groups, GSH levels were significantly decreased in 10 and 20 mg/kg TRZ-administered groups compared to the control group. Our results have shown that TRZ induced cardiotoxicity in rats dose-dependently. It is assumed that oxidative stress related to GSH depletion may be accompanied by these adverse effects.

Drug Induced Thrombotic Microangiopathy with Certolizumab Pegol

Background:

Certolizumab pegol is used to treat ankylosing spondylitis, Crohn’s disease, psoriatic arthritis, and rheumatoid arthritis. Unlike other monoclonal antibodies such as infliximab and adalimumab, certolizumab does not contain an Fc fraction and hence does not induce complement activation. In this report, we describe the case of a patient with thrombotic microangiopathy caused due to certolizumab pegol, with a brief description about the pathophysiological approach to thrombotic microangiopathy.

Case Report:

A-39-year-old man suffering from ankylosing spondylitis for the past 10 years presented with fatigue. He had been on certolizumab pegol treatment for 6 months, starting with 400 and 200 mg every 2 weeks. He had significant nonimmune hemolytic anemia and thrombocytopenia without a disseminated intravascular coagulopathy. Schistocytes were observed in more than 10% of the erythrocytes per field. Plasma exchange along with corticosteroid treatment was started. There was a dramatic improvement within a week, and after 10 sessions of plasma exchange, the patient was discharged on corticosteroids with a tapering plan. ADAMTS13 enzyme activity was determined to be normal.

Conclusion:

The development of drug-induced thrombotic microangiopathy may be either immune-mediated or dose-dependent toxicity-mediated Anti-drug antibodies and their immunological aspects are still unclear and yet to be elucidated.

In the search for new anticancer drugs. 28. Synthesis and evaluation of highly active aminoxyl labeled amino acid derivatives containing the [N'-(2-chloroethyl)-N'-nitrosoamino]carbonyl group

The aminoxyl (nitroxyl) labeled (2-chloroethyl)nitrosocarbamoyl (CNC) derivatives of amino acids, i.e., N-[[N'-(2-chloroethyl)-N'-nitrosoamino]carbonyl]-A-(1-oxy-2,2,6,6- tetramethylpiperidin-4-yl)amides, A = glycyl (10a), A = L-alanyl (10b), A = L-valyl (10c), A = L-phenylalanyl (10d), were synthesized and evaluated in vitro for their anticancer activities against the murine lymphocytic leukemia P388. Compounds 10a-d possessed activities ranging from 242 to 456% increase in life span (%ILS). All CDF1 male mice treated with the highly active compounds 10b and 10c at 12 mg/kg/day for 9 days were alive after 30 days. Compounds 10a-d were then tested in vivo against the murine lymphoid leukemia L1210. Compounds 10a-d exhibited, on day 60, a %ILS of 496, 663, 663, and 581, respectively. All CDF1 male mice treated with the highly active compounds 10b and 10c at 12 mg/kg/day for 9 days were alive after 60 days. The lipophilicities of compounds 10a-d were determined using the UV method. The %ILS parameters obtained against the P388 and L1210 tumor lines were correlated with the corresponding lipophilicities, and a trend was generally observed toward an increase in cytotoxicity with a concomitant decrease in hydrophobicity.