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Colorectal cancer (CRC) is the third most common malignancy and the second most common deadly cancer worldwide as of 2020. Unusual presentation of this cancer with locally advanced disease is rare and seen in only 5% to 22% of cases. We present the case of a 53-year-old male who had invasive cecal adenocarcinoma with phlegmon of the abdominal wall musculature at presentation and an aggressive course that did not respond to the standard lines of therapy. In the current era of ongoing tremendous developments in colorectal cancer diagnosis and treatment, this uncommon case reminds us that locally advanced CRC is still a challenge to manage. Precision medicine with treatment strategies tailored to an individual’s genetic, environmental and lifestyle factors is the current need.

Diffuse large B-cell lymphoma (DLBCL) comprises approximately 30% of all non-Hodgkin lymphomas. Multiple studies have demonstrated race-based disparities in survival among patients with DLBCL across all stages of disease, in the era both before and after rituximab. The etiology for the racial disparities in survival among patients with DLBCL is still unknown. Moreover, the Revised International Prognostic Index (R-IPI), a tool that predicts the DLBCL patients' outcome, has not yet been validated in African Americans (AA).We conducted a cohort study of patients diagnosed with DLBCL from January 1, 2007, to December 31, 2017, from our tumor registry in a single community-based inner-city cancer center. We abstracted demographic, clinical, histopathologic, treatment, and R-IPI variables. A total of 181 patients (47.5%) with biopsy-proven DLBCL were included in the retrospective analysis. The median age was 65 years, 47% were men, 41% were AA, and 44% were white.The AA group had a younger median age, higher lactate dehydrogenase levels, higher frequency of B symptoms, and higher HIV infection than the non-AA group. The AA group had significantly decreased median overall survival than the non-AA group (15.7 months; 95% confidence interval, 10.3 to 23.9, vs. 93.6 months; 95% confidence interval, 61.5 to 142.6, respectively; P .001). The survival disparities persisted after excluding patients with HIV and who did not receive chemotherapy. In addition, AA race predicts a reduced survival by univariate and multivariate analysis.AA with DLBCL may have a poorer prognosis than the non-AA population. Further studies should investigate the biology of DLBCL in the AA population.

Primary vaginal malignant melanomas are rare tumours with a limited number of cases published in the literature. They primarily affect post-menopausal women with a median age of 57-68 years and have a dismal prognosis. The 5-year survival rate, regardless of treatment, is approximately 5-25%.We present the case of an 87-year-old female who presented with haematuria and urinary incontinence. She was diagnosed with AJCC stage IIIC vaginal melanoma. Considering her age and the extent of malignancy, surgery was not a viable option and immunotherapy with nivolumab and ipilimumab was initiated as treatment.The diagnosis of vaginal melanomas includes pathological analysis and immunohistochemistry (IHC) of the mass, imaging to determine extent, and genetic testing. Surgery is the preferred treatment in suitable cases. For metastatic or unresectable cases, immunotherapy or targeted therapy is the preferred first-line treatment. Due to the lack of an adequate number of cases to conduct randomized clinical trials, prognostic factors and treatment protocols for vaginal melanomas are not clearly defined. At present, the management of these tumours is largely based on retrospective studies and anecdotal evidence accompanied by significant knowledge gaps. Our case will be a valuable addition to the existing literature on vaginal melanomas that are managed non-surgically.Vaginal melanomas are extremely rare entities that require early diagnosis to ensure the best prognosis.Providers need to stress the importance of elderly gynaecological examination so crucial diagnoses are not missed.Further research is necessary to develop the most effective treatment plan for vaginal melanomas.

Lymphoplasmacytic lymphoma (LPL) is a rare low-grade B-cell neoplasm that accounts for approximately 2% of all haematological malignancies. Most patients have the clinical syndrome of Waldenstrom macroglobulinemia (WM), which is defined as LPL with an associated immunoglobulin M (IgM) serum monoclonal protein. Roughly 5% of LPL patients secrete non-IgM paraproteins (e.g., IgG, IgA, kappa, lambda) or are non-secretory.We report the case of a 41-year-old woman who was diagnosed with non-IgM LPL with lambda light chain monoclonal paraprotein production and normal serum immunoglobulin levels. The MYD88 L265P mutation was detected on fluorescence in-situ hybridization (FISH) analysis of the bone marrow. The patient underwent treatment with a combination of ibrutinib and rituximab. There was an initial response but she died 8 months after diagnosis.Non-IgM LPL poses diagnostic and therapeutic challenges to clinicians as it is an exceptionally rare malignancy with a heterogeneous clinicopathological presentation and scarce literature. Among non-IgM LPL cases, those with lambda light chain production are even more rare. To the best of our knowledge, none have been reported to date. The addition of MYD88 L265P testing to the diagnostic armamentarium of non-IgM LPL cases is advisable for potential therapeutic reasons.Our case report and literature review provide insight into non-IgM lymphoplasmacytic lymphoma (LPL), an extremely rare malignancy.Our case report highlights the importance of the need for new treatments for non-IgM LPL.

The use of direct-acting oral anticoagulants (DOACs) has increased rapidly in the last decade; becoming the mainstay for both the prophylaxis and the treatment of venous thromboembolism in various situations including non-valvular atrial fibrillation, joint replacement surgeries and acute DVT/PE, etc. In the present times, DOACs are possibly one of the most widely prescribed medications in the developed world. The worldwide epidemic caused by COVID-19 caused significant changes in the practice of medicine worldwide. Patients who developed severe respiratory illness caused by COVID-19 were noted to develop a wide range of complications, including both arterial and venous thromboembolic complications including deep vein thrombosis and pulmonary embolism, etc. This review is an attempt to identify the role of DOACs in the treatment and prevention of these complications as well as the safety of continuing therapy with DOACs in the patients who were receiving them before contracting the infection.

Thrombosis of the portal vein (PVT) is generally seen in the setting of liver cirrhosis and to a lesser extent in the absence of cirrhosis. There is no clear guidance in relation to approaching treatment with anticoagulation in this condition. The professional societies and guidelines recommend treatment with traditional anticoagulation like low-molecular-weight heparin and vitamin-K antagonists in patients presenting with acute portal vein thrombosis. There is no clarity in relation to treatment in the setting of chronic PVT and in patients with cirrhosis. Also, the role of direct-acting oral anticoagulants (DOACs) that are becoming a preferred choice for anticoagulation for various other indications is not clear in the case of PVT. There are a very few studies in the medical literature that have investigated the role of DOACs in patients with PVT in different settings. Thus, we performed a systematic review of the literature to study the use of DOACs in PVT in patients with and without cirrhosis. The results of the available studies show that DOACS appears to be a promising choice for the treatment of patients with PVT. The availability of more data in the future along with better availability of the approved reversal agents for various DOACs is expected to make DOACS a preferred choice for the clinicians to treat patients with PVT.

Yes. The direct oral anticoagulants rivaroxaban, edoxaban, and apixaban have been studied in cancer-associated venous thromboembolism and are increasingly replacing low-molecular-weight heparins such as dalteparin and enoxaparin for this purpose. Individualizing care by balancing risks and benefits

Renal cell carcinoma (RCC) is a common cancer that affects a significant number of patients every year around the world. The presence of sarcomatoid features in these tumors is considered a poor prognostic feature. Patients with RCC with sarcomatoid features had significantly worse outcomes when treated with sunitinib, the previous first-line standard of care therapy when compared to patients without such features. Multiple immune checkpoint inhibitors have recently been approved for the treatment of RCC. In this article, we review the literature available on the outcomes of patients with sarcomatoid RCC treated with immune checkpoint inhibitors.

We describe a rare presentation of diffuse large B-cell Lymphoma (DLBCL) with recurrent episodes of syncope. During the workup for syncope, the patient was incidentally found to have an extensive mass in the left thorax, which was later diagnosed as stage 2 bulky disease DLBCL. This is the rare case of lymphoma presenting as recurrent syncope without cardiac involvement. The patient did not have any further episodes of syncope after her successful treatment of DLBCL.

Ovarian vein thrombosis is not well understood, and there is no consensus regarding treatment. It can present with subtle symptoms and is not usually high on the list of differentials. Traditionally, most cases are linked to pregnancy and postpartum state, but our case adds to the growing list of non-puerperal patients diagnosed with ovarian vein thrombosis after an outpatient procedure. In an era where there is a drive for minimally invasive procedures and shorter hospital stays, there is a need to have specific guidelines to direct the diagnosis and treatment of this rare form of thromboembolism.

The coronavirus disease 2019 (COVID-19) pandemic has caused significant morbidity and mortality worldwide. While patients with COVID-19 most frequently present with pneumonia, respiratory failure and acute respiratory distress syndrome, increasing cases of immune-mediated disorders such as autoimmune thrombocytopenia, haemolytic anaemia and antiphospholipid syndrome have been reported. In this article we describe a rare case of cold agglutinin syndrome (CAS) in a patient with COVID-19. The patient was a 77-year-old man with a history of glucose-6-phosphate dehydrogenase (G6PD) deficiency who presented with COVID-19 infection and acute respiratory failure. Initially he was started on intravenous steroids, antibiotics and hydroxychloroquine. Laboratory analysis revealed haemolytic anaemia with a positive direct anti-globulin test (DAT) and high titres of cold agglutinins. Hydroxychloroquine was stopped due to suspicion of haemolysis due to G6PD deficiency but the haemolysis persisted. Unfortunately, the respiratory failure progressed and the patient died. In summary, this article describes a rare case of CAS associated with COVID-19. CAS is a heterogenous group of cold autoimmune haemolytic anaemias occurring secondary to infections or malignancies. No definite treatment for CAS in COVID-19 patients has been approved so far. LEARNING POINTS Autoimmune haemolytic anaemia has been reported in COVID-19 patients. Cold agglutinin syndrome (CAS) can occur in patients with COVID-19. Efforts to determine the optimal management of CAS in COVID-19 patients must continue. Keywords: Coronavirus disease 2019, cold agglutinin syndrome, case report, autoimmune hemolytic anemia INTRODUCTION Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel enveloped RNA betacoronavirus that emerged in December 2019 in Wuhan, China and rapidly spread worldwide [1]. This virus is responsible for causing a multi-system disorder called coronavirus disease 2019 (COVID-19) syndrome. It has now been established that the hyperinflammatory response induced by SARS-CoV-2 causing fulminant and fatal cytokine release is a major cause of disease severity and death in infected patients [2,3]. While hypercoagulability [4], autoimmune cytopenias[5] and anti-phospholipid antibody syndrome[4] have emerged as the most common haematological disorders in COVID-19 patients, 14 cases of autoimmune haemolytic anaemiahave also been reported [6–12]. Individuals with autoimmune haemolytic anaemiaproduce warm, coldor mixed-reactive antibodiesthat are directed against antigens on the surface of red blood cells (RBCs) [13].Cold antibody autoimmune haemolytic anaemias can be further divided into cold agglutinin disease (CAD), which is primarily a low-grade clonal lymphoproliferative disorder, and cold agglutinin syndrome (CAS), which is a rare heterogenous group of cold immune haemolytic anaemias that occur secondary to infection or malignancy [14]. Here, we report a case of acute CAS associated with SARS-CoV-2.

Background: Lung cancer is one of the leading causes of cancer mortality in the US. The use of precision medicine in the past 10 years has significantly changed the therapeutic landscape of lung cancer. Management of advanced non-small cell lung cancer (NSCLC) has transitioned from a chemotherapeutic approach to targeted treatments and immunotherapeutic agents. Several tyrosine kinase inhibitors (TKIs) have been approved for patients with targeted mutations while patients who do not have driver mutations; immunotherapy has been recently approved as frontline therapy, which has resulted in marked improvement in overall survival and added a new tool in our armamentarium. Aims: The purpose of this review is to highlight recent advancements in diagnostic approach and management strategies in patients with metastatic NSCLC. Materials and methods: Published studies included in Medline (via PubMed) and National Comprehensive Cancer Network Guidelines were reviewed for data gathering. Conclusion: The use of next generation sequencing has significantly changed our understanding of molecular oncogenic mechanisms of lung cancer. These advancements have created a paradigm shift in the treatment strategies of metastatic lung cancer from primarily chemotherapeutic approach to increasing use of targeted therapies and immune check point inhibitors (ICI) leading to better survival rates and lesser toxicity.

Background Lung cancer is one of the leading causes of cancer mortality in the United States. The use of precision medicine in the past 10 years has significantly changed the therapeutic landscape of lung cancer. Management of advanced nonsmall cell lung cancer (NSCLC) has transitioned from a chemotherapeutic approach to targeted treatments and immunotherapeutic agents. Several tyrosine kinase inhibitors (TKIs) have been approved for patients with targeted mutations and patients who do not have driver mutations; immunotherapy has been recently approved as frontline therapy, which has resulted in marked improvement in overall survival and added a new tool in our armamentarium. Aims The purpose of this review is to highlight recent advancements in diagnostic approach and management strategies in patients with metastatic NSCLC. Materials and methods A literature search was conducted on Medline (via PubMed) and National Comprehensive Cancer Network Guidelines using the keywords "precision diagnosis," "advanced non-small cell lung cancer," "target therapies," and "immunotherapy." Conclusion The use of next-generation sequencing has significantly changed our understanding of molecular oncogenic mechanisms of lung cancer. These advancements have created a paradigm shift in the treatment strategies of metastatic lung cancer from primarily chemotherapeutic approach to increasing use of targeted therapies and immune checkpoint inhibitors (ICI) leading to better survival rates and lesser toxicity.

Background Immunotherapy has emerged as an effective and durable treatment modality for solid cancers. However, its use in colorectal cancer (CRC) is limited to deficient mismatch repair (dMMR) tumors. As such, assessing immune regulatory proteins from the B7-CD28 family, other than PD-1, PD-L1, and CTLA-4, is critical. This study aimed to evaluate the expression of novel protein regulators in a racially diverse population of patients with CRC. Methods A tumor microarray was created for 214 samples from a multiracial patient population with metastatic CRC, and expression of HHLA2, B7-H3, PD-L1, CK7, CK20, and CDX2 was determined. The expression pattern was scored as 0 to 12, based on tumor tissue prevalence and the intensity. Clinical information was obtained by chart review and vital statistics from the National Death Index. Associations between low and high expression groups for each protein by race/ethnic groups were assessed, and Kaplan–Meier curves were plotted to evaluate association with survival. Results The median age at diagnosis was 61 years, with a female predominance. The majority of the patients were diagnosed with de novo metastatic disease with left-sided, moderately differentiated tumors. There were no racial disparities in the expression of any protein. Overall, a high frequency of tumors had no expression of B7-H3 (62.5%) or PD-L1 (43.5%). Low expression of both PD-L1 and B7-H3 was a significant prognostic biomarker associated with better survival (median overall survival, 43.3 months vs. 24.6 months; P Conclusion In this multiracial tumor microarray of CRC samples, low PD-L1 and B7-H3 expression was associated with an improved prognosis. There was no significant variation among races with respect to the relevant CRC protein markers.

Introduction: Hypereosinophilic syndrome (HES) is a rare condition characterized by eosinophilia and organ destruction secondary to eosinophilic infiltration. The coexistence of primary B-cell lymphoma and hypereosinophilic syndrome is extremely rare. We present a case of HES that preceded the diagnosis of diffuse large B-cell lymphoma. Case report: A 70-year-old man presented with a 3-month history of diarrhea and 30-pound weight loss. Complete blood count showed a white blood cell count of 7452/µL with eosinophils of 42% (absolute eosinophil count 3130). Colonoscopy showed eosinophilic infiltrate in the lamina propria and muscularis mucosa. Bone marrow biopsy showed elevated myeloid: erythroid ratio (6:1), increased mature and immature eosinophilic infiltration (10% of nucleated cells). Molecular studies were negative for Fip1-like1-platelet-derived growth factor receptor alpha (FIP1L1-PDGFRA) translocation and PDGFRB and FGFR mutations, indicating nonclonal eosinophilia. Treatment was initiated with prednisone (1 mg/kg) and hydroxyurea 500 mg twice daily. He responded with complete resolution of symptoms. Five months later, the patient presented with right lower quadrant pain. Abdominal/pelvis computed tomography (CT) showed bulky right inguinal lymphadenopathy and biopsy revealed CD10+ diffuse large B-cell lymphoma (DLBCL). Further staging workup showed the stage to be IIB. He received 6 cycles of chemotherapy and involved field radiation therapy. He achieved complete remission. Conclusion: Reviewing the literature indicates only one case of similar presentation with concomitant HES and DLBCL. Eosinophilia is routinely encountered in clinical practice and as such physicians must be aware of the rarer, more malevolent underlying associations of this condition so as to aid early diagnosis and prompt treatment.

Apart from peripheral blood stem cell (PBSC), umbilical cord blood (UCB) is now a recognized source of stem cells for transplantation. UCB is an especially important source of stem cells for minority populations, which would otherwise be unable to find appropriately matched adult donors. UCB has fewer mature T lymphocytes compared with peripheral blood, thus making a UCB transplantation (UCBT) with a greater degree of HLA mismatch possible. The limited cell dose per UCB sample is however associated with delayed engraftment and a higher risk of graft failure, especially in adult recipients. This lower cell dose can be optimized by performing double unit UCBT, ex vivo UCB expansion prior to transplant and enhancement of the capabilities of the stem cells to home to the bone marrow. UCB contains naïve and immature T cells, thus posing significant challenges with increased risk of infections, graft versus host diseases (GVHD) and relapse following UCBT. Cell engineering techniques have been developed to circumnavigate the immaturity of the T cells, and include virus-specific cytotoxic T cells (VSTs), T cells transduced with disease-specific chimeric antigen receptor (CAR T cells) and regulatory T cell (Tregs) engineering. In this article, we review the advances in UCB ex vivo expansion and engineering to improve engraftment and reduce complications. As further research continues to find ways to overcome the current challenges, outcomes from UCBT will likely improve.

Ovarian cancer is one of the leading causes of death from gynecologic cancers. In this present era of cancer treatment, therapeutic options for patients with advanced or recurrent ovarian cancer are limited. The present standard of care treatment for advanced ovarian cancer is a platinum-based doublet chemotherapy (paclitaxel and carboplatin with or without bevacizumab) after a maximum attempt of surgical cytoreduction. However, there are no promising options for the management of patients with ovarian cancer refractory to the platinum-based chemotherapy. Therefore, newer, safe, and more effective treatment modalities are required for patients with advanced or recurrent ovarian cancer. Poly(adenosine diphosphate [ADP]-ribose) polymerase (PARP) inhibitors have shown an impressive safety profile and anti-tumor efficacy in patients with breast cancer 1 and 2 (BRCA1 and BRCA2) gene-mutated ovarian cancer who were previously treated with the standard of care chemotherapy. We have done a detailed review of the literature to emphasize the role of PARP inhibitors in the treatment of advanced or relapsed ovarian cancer.

Chimeric antigen receptor (CAR) T cell therapy is a novel and innovative immunotherapy. CAR-T cells are genetically engineered T cells, carrying MHC independent specific antigen receptor and co-stimulatory molecule which can activate an immune response to a cancer specific antigen. This therapy showed great results in hematological malignancies but were unable to prove their worth in solid tumors. Likely reasons for their failure are lack of antigens, poor trafficking, and hostile tumor microenvironment. Excessive amount of research is going on to improve the efficacy of CAR T cell therapy in solid tumors. In this article, we will discuss the challenges faced in improving the outcome of CAR T cell therapy in solid tumors and various strategies adopted to curb them.

Despite advances in various chemotherapy regimens, current therapeutic options are limited for ovarian cancer patients. Immunotherapy provides a promising and novel treatment option for ovarian cancer. Recently, chimeric antigen receptor (CAR) T cell therapy has shown promising results in hematological tumors and current research is going on in various solid tumors like ovarian cancer. CAR T cells are genetically engineered T cells with major histocompatibility complex-independent, tumor-specific, immune-mediated cytolytic actions against cancer cells. Initial studies of CAR T cell therapy have shown promising results in ovarian cancer, but there are some obstacles like impaired T cell trafficking, lack of antigenic targets, cytokine release syndrome and most important immunosuppressive tumor microenvironment. Optimization of design, improving tumor microenvironment and combinations with other therapies may help us in improving CAR T cell efficacy. In this review article, we highlight the current knowledge regarding CAR T cell therapy in ovarian cancer. We have discussed basic functioning of CAR T cells, their rationale and clinical outcome in ovarian cancer with limitations.

Chimeric antigen receptor (CAR) T cell therapy is genetically engineered tumor antigen-specific anticancer immunotherapy, which after showing great success in hematological malignancies is currently being tried in advanced solid tumors like pancreatic cancer. Immunosuppressive tumor microenvironment and dense fibrous stroma are some of the limitation in the success of this novel therapy. However, genetic modifications and combination therapy is the topic of the research to improve its efficacy. In this article, we summarize the current state of knowledge, limitations, and future prospects for CAR T cell therapy in pancreatic cancer.

Brain metastasis (BM) is one of the dreadful complications of malignancies. The prognosis after BM is extremely poor and life expectancy is meager. Currently, our treatment modalities are limited to radiotherapy and surgical resection, which also has poor outcomes and leads to various neurological deficits and affects the quality of life of patients. New treatment modality, i.e., immune checkpoint inhibitors, has brought revolution in management of melanoma, renal cancer, and non-small cell lung cancer (NSCLC). Immune checkpoint inhibitors basically enhance the immune response of the body to fight against cancers. Immune response in the brain is highly regulated; therefore, it is challenging to use immune-modulator drugs in BM. The microenvironment of BM is rich in cytotoxic T lymphocytes and which is the target of immune checkpoint inhibitors. Few studies have shown some hope regarding use of immune checkpoint inhibitors in management of BM. It works through inhibiting immune check point gates, i.e., CTLA-4 (cytotoxic T-lymphocyte-associated protein) and PD-1/PD-L1 (programmed cell death protein-1/program death ligand-1). This article explains the basic mechanism of immune check point inhibitors, rationale behind their usage in BM, and some of the clinical studies which have shown the efficacy of immune check point inhibitors in BM.

Introduction Diffuse Large B-cell Lymphoma(DLBCL) is the most common type of Non-Hodgkin's Lymphoma, accounting for approximately 30% of adult lymphomas. Survival among patients with DLBCL has improved significantly in past years with the introduction of effective treatment modalities including Rituximab. Despite of improvement of survival, many patients undergo course of early death and disparities related to early death in DLBCL remains unclear. Our study was aimed to identify the characteristics and associated factors in patients with early mortality by retrospective study using a single-institutional patient data. The institution is a community hospital serving medically underserved population in urban setting, which is a unique setting to address disparities study. Study design Dataset was obtained from the institutional cancer registry and retrospective chart review. Patients diagnosed with biopsy proven DLBCL between January 2007 to December 2017 were included. Survival data was updated in July 2019. A total of 159 patients were included. Median survival was 99.5 months. Overall 2-year survival was 60.4% in all included patients. 90-day and 180-day mortality was defined as patients who survived less than 90 days or 180 days from diagnosis. Chi-square test was used for descriptive statistics. Cox-proportional hazard regression was used for survival analysis. Result Among 159 patients, 25 and 34 patients (15.7% and 21.4%) had 90-day and 180-day mortality. The distribution of survival time was right skewed with more frequent death in early period(figure 1). Median survival of 90-day and 180-day mortality patients were 19 days and 33 days. Among 25 patients with 90-day mortality, causes of death included rapid progression(48%), sepsis(32%), GI bleeding (32%), tumor lysis syndrome(24%), and withdrawal of care as not a treatment candidate with co-morbidities(16%). 56% of patients were discharged to comfort measure only. 16% patients underwent CPR. 25%(5 out of 25) in 90 day mortality group were started on Rituximab or other treatment measures compared to 100%(9 out of 9) between 90 -180-day mortality group(Chi-square Patients with 90-day mortality were more likely to be older age(over 60), African-American, a resident at low average income zip code, poor performance status, having stage 4 disease, B symptoms and high R-IPI score with statistical significance. Adjusted Cox-proportional regression with demographic, tumor and clinical characteristics showed statistical significance both 90-days and 180-days with poor performance status with ECOG 2 or more(HR 15.28 and 6.22 in 90- and 180-day, both p-value Conclusion Our study suggested poor performance status and old age is the most significant variables associated with early mortality than other characteristics. R-IPI or other tumor-associated factors have been known for predicting prognosis, which was supported by our previous study using same data, however this was not applied in association of early mortality after adjustment. It is notable that two groups of patients with 90-day and with 180-day showed discrepancies in risk of mortality by being uninsured or having high LDH. Within early mortality group, there might be heterogeneity of clinical characteristics. For example, patients who not able to receive treatment or treatment was stopped with rapid progression or complications mostly died within 90 days, however patients who died between 90 days and 180 days all received Rituximab or other forms of treatment. Many of our patients were old, African-American, residing in low-income area, advanced DLBCL with high ECOG. Only 56% of patients were discharged to hospice care or comfort measure only and 16% patient underwent CPR in patients with 90-day mortality while most of patients were not able to receive any treatment. Our study also implies the special need of addressing goals of care discussion in DLBCL patients early in the setting of underserved population. Disclosures No relevant conflicts of interest to declare.

Background Plasmablastic Lymphoma (PBL) is a neoplasm first described in 1997. On the original report, all the 16 patients had involvement of the oral cavity. However, more recent studies have identified PBL in a variety of anatomic locations. The diagnosis can be difficult because of the lack of expression of usual markers and overlapping features of B-cell lymphoma and plasma-cell neoplasm. Given its rarity and high fatality, there is no prospective studies and, consequently, there is no standard of care established for PBL. Methods This was a retrospective observational study carried out at a community cancer center. We reviewed the chart of all 458 patients diagnosed with Lymphoma in our service from December 2006 to December 2016 and included patients diagnosed with PBL during this period. Patients' electronic medical charts were reviewed for detailed information regarding demographics, treatment given and response to treatment as well as complications and outcome. Diagnosis of PBL was established by histopathologic examination and immunohistochemistry studies. Results We found on our records six patients with diagnosis of PBL (Table 1), three of them presented initially without oral involvement and with Tumor Lysis Syndrome (TLS). We reviewed in detail three cases of PBL with dramatic outcome and this common feature of TLS. They were all managed appropriately with rasburicase, since this drug became broadly available after its FDA approval in 2009. Two cases were spontaneous TLS and one patient with PBL in the spleen developed TLS after high-dose steroids. All three patients died before any chemotherapy regimen could be administered. All the patients in this study were HIV-positive, only four patients had CD4 count below 200/mm3. For one patient, there was not enough data available to assess for TLS. Discussion Despite comparative studies could not demonstrate an association between HIV status and outcome in PBL, a single center study showed exceptionally good outcome in HIV-positive patients with CD4 count above 200/mm3. Another study with immunosuppressed HIV-negative patients suggests poor outcome within this scenario. Interestingly, the patients with TLS in our study had CD4 count below 200/mm3, suggesting that immunosuppression may be associated with more aggressive disease and worse prognosis. In addition, the patients with TLS in our study didn't have involvement of the oral cavity, it remains unclear if extra-oral PBL correlates with unfavorable outcome. Not only diagnosing but treating PBL poses an enormous challenge for oncologists since there is no standard of care established in treating this rare Lymphoma. At the moment of this publication, no prospective studies have been conducted and there is no publication describing spontaneous TLS in PBL. This short series of cases demonstrates a high prevalence of TLS (at least 50%), this may be an important feature to be considered in future studies. Furthermore, our report may raise awareness about the potentially poor outcome within this scenario. When diagnosis of PBL is suspected, screening for TLS should not be delayed and early aggressive management warranted. Disclosures No relevant conflicts of interest to declare.

Introduction Thrombocytopenia is common in liver cirrhosis patients, which often complicates with patients' frequent issue with gastrointestinal bleeding and procedural needs. Based on biologic understanding of decreased thrombopoietin(TPO) level in liver cirrhosis patients, use of TPO agonists in liver cirrhosis have been actively studied. Over the period of time, new studies have come out about 2 FDA-approved TPO agonists, Avatrombopag and Lusutrombopag, for prophylaxis before procedure in liver cirrhosis patients with thrombocytopenia. In the past, there have raised concerns of increased risk of portal vein thrombosis and other thrombotic risks in other agents. In our study, we aimed to study the effectiveness and safety of TPO receptor agonists for pre-procedural use in patients with liver cirrhosis. Study design Study was conducted from August 2018 to July 2019. Previous studies were identified through database searching MEDLINE, CENTRAL, Clinicaltrial.gov and google search. Randomized clinical trials with active treatment arm with TPO receptor agonists in the use of liver cirrhosis patients, with intention of pre-procedural prophylaxis, and having placebo for direct comparisons were included. One of the major exclusions was TPO receptor agonists to increase platelet counts for anti-viral treatment in cirrhosis patients. 14 studies were identified. Studies were reviewed and eligibility was determined by two independent clinically trained researchers. 5 duplicated studies were removed, and in total of 7 studies were included for quantitative and qualitative analysis. Details of studies were collected by 2 independent researchers and compared. When there is a discrepancy, repeat review of the study was conducted. Studies were conducted or published from 2012 to 2018. 1 trial from Eltrombopag, 3 trials from Avatrombopag, and 3 trials from Lusutrombopag were included. Result Characteristics of included studies are summarized in table 1. Our studies found that 5.5(95% CI : 4.35-7.15) times higher risk ratio(RR) of reaching platelet target before procedure compared to placebo. Target platelet number goal was 50,000 to 80,000 depending on the study. Studies showed homogenous result with I-squared was 30.8% and q-statistics of p-value 0.193.(Figure 1) Subgroup analysis by FDA-approved medication of Avatrombopag and Lusutrombopag showed statistically significant higher risk ratio of 4.74(3.36-6.68) and of 5.52(3.65-8.34) each compared to placebo. Risk ratio for preventing platelet transfusion was not able to be calculated with heterogeneity of study with I-square higher than 90%. Lusutrombopag study showed significant benefits (RR 6.33, 95% CI 2.95-13.58) with heterogeneity inside the same medications, which might be explained with different doses in studies. No statistical significance in risk ratio in a study with Avatrombopag. Subgroup analysis limited to phase 3 studies showed risk ratio of preventing transfusion of 2.87(95% CI 2.15-3.82) but heterogeneity with q-statistics of p-value at 0.029. Relative risk for adverse event related to portal vein thrombosis was not statistically significant with RR of 0.99(95% CI : 0.35-2.85) in total of 1,229 patients.(Figure 2) Study result was homogenous result by I-square 0%, q-statistics of p-value 0.794. Other severe adverse events, major bleeding risk, overall thrombosis risk were not statistically significant. Only increased risk without statistical significance was reported in trail with Eltrombopag which was early terminated. Conclusion Our meta-analysis of pre-procedural use of TPO agonist in liver cirrhosis patients showed statistically significant benefit of reaching platelet count goal by 5.58 times with risk ratio, but no benefit of preventing transfusion. Compared to prior studies including use of TPO agonists for Interferon-Ribavirin treatment, meta-analysis limited to pre-procedural use did not show statistically significant increase in portal vein thrombosis. Serious adverse events including thrombosis events and bleeding risk were not statistically significant. Most studies described that portal-vein thrombosis events were often related to high platelet counts about 200,000 and longer use of TPO agonist. In current era with lesser use of Interferon and Ribavirin as an anti-viral therapy, TPO agonists use in setting of pre-procedure mostly with lower platelet targets can be safely used. Disclosures No relevant conflicts of interest to declare.

e15127 Background: In CRC, utility of immunotherapy (IT) remains limited to persons with microsatellite instability–high (MSI-H) status. Immunotyping of CRC patients is critical towards further establishing IT's potential. Both incidence and survival rates for CRC in the United States vary between races due to multiple factors including genetic heterogeneity. In this study, we have profiled tumor samples in a racially diverse population for the expression of four different members of the B7 family of immune check point regulators. Methods: Tissue microarray (TMA) was generated from 208 CRC patients. Formalin fixed paraffin embedded (FFPE) tissues were utilized for immunohistochemistry (IHC) post- antigen retrieval. Antibodies specific for IHC staining were used for B7-H3 (D9M2L), PD-L1(E1L3N), B7-H4/B7x(D1M81) and HHLA2(566.1). Each specimen was scored for percent staining of tumor tissue (4 quartile groups) and for intensity (1-4x), and then an overall score (1-16) was calculated. The clinical outcome of interest was overall survival (OS), measured as time from diagnosis of metastatic cancer to death. Analysis for differences in OS was by log rank test, while differences between mean staining was by t test. Race was designated as non-Hispanic white (NHW, n = 41), non-Hispanic black (NHB, n = 84), Hispanic (n = 75), and others (8). Results: B7-H3 protein expression showed strong cytoplasmic distribution. NHB patients had a mean lower expression than NHW patients (0.19 vs 0.41, p = 0.02). Correspondingly, NHB patients had a worse OS than NHW patients (606 vs 759 days). No discernible differences were found in Hispanic patients. PD-L1 showed membranous distribution with 17% expression without significant difference among patients of different racial origin. HHLA2 was more widely expressed with about 35% staining but without statistical significance. B7-H4/B7x failed to show any expression. Conclusions: Expression of B7H3 varies among patients with differential racial backgrounds. It has the potential to be a prognostic biomarker and may be a reason for worse outcome among NHB patients in our population. Other B7 immune checkpoint markers failed to show clinical relevance.

7541 Background: Non-Hodgkin’s Lymphoma (NHL) is a heterogeneous group of hematologic malignancy from immature or mature lymphocytes or natural killer cells. It is the 9th leading cause of death for both sexes. Diffuse Large B Cell Lymphoma (DLBCL), a subset of NHL, comprises 30 – 40% of all NHL. The etiology for the racial disparities in survival among patients with DLBCL is still unknown. The Revised International Prognostic Index (R-IPI), a tool which predicts the outcome of DLBCL patients, has not yet been fully validated in African Americans (AA). Methods: We conducted a single cohort study of patients diagnosed with DLBCL from January 1, 2007 to December 31, 2017 from our tumor registry in a single community-based cancer center. We abstracted demographic, clinical, histopathologic, treatment, and R-IPI variables. Our primary endpoint was overall survival (OS). Our secondary endpoints were factors that determine mortality through Cox multivariate analysis. Results: Among 381 patients with NHL, 181 (47.5%) patients had biopsy-proven DLBCL. Median age was 65 years old, 47% were males, 41% were AA, 44% were Caucasians, 46% were stage IV by Ann-Arbor staging. African-Americans (AA) had a median OS of 15.7 months (95% CI, 10.31 to 23.90) compared to non-AA 93.6 months (95% CI, 61.48 to 142.57). Even after adjusting for race, R-IPI was correlated with mortality on all patients. Lactate dehydrogenase levels were significantly higher in AA (P

Syndrome of Inappropriate Secretion of Antidiuretic Hormone (SIADH) is one of the most common causes of hyponatremia in hospitalized patients. The distinct aetiologies and co-morbidities associated with hyponatremia pose substantial challenges in identifying and managing this disorder. Several infectious causes of SIADH are reported but hyponatremia associated with SIADH and influenza virus infection is less commonly seen. We present a case of hyponatremia associated with influenza, which was subsequently diagnosed as SIADH.

Apart from peripheral blood stem cell (PBSC), umbilical cord blood (UCB) is now a recognized source of stem cells for transplantation. UCB is an especially important source of stem cells for minority populations, which would otherwise be unable to find appropriately matched adult donors. UCB has fewer mature T lymphocytes compared with peripheral blood, thus making a UCB transplantation (UCBT) with a greater degree of HLA mismatch possible. The limited cell dose per UCB sample is however associated with delayed engraftment and a higher risk of graft failure, especially in adult recipients. This lower cell dose can be optimized by performing double unit UCBT, ex vivo UCB expansion prior to transplant and enhancement of the capabilities of the stem cells to home to the bone marrow. UCB contains naïve and immature T cells, thus posing significant challenges with increased risk of infections, graft versus host diseases (GVHD) and relapse following UCBT. Cell engineering techniques have been developed to circumnavigate the immaturity of the T cells, and include virus-specific cytotoxic T cells (VSTs), T cells transduced with disease-specific chimeric antigen receptor (CAR T cells) and regulatory T cell (Tregs) engineering. In this article, we review the advances in UCB ex vivo expansion and engineering to improve engraftment and reduce complications. As further research continues to find ways to overcome the current challenges, outcomes from UCBT will likely improve.

Abstract Study Objective-Heparin Induced Thrombocytopenia (HIT) is a life-threatening immunological response to heparin. The objectives for this study were to determine if the 4T scoring system was being utilized as a tool for predicting HIT, and to look at the costs associated with HIT panels. Methods-This was a retrospective chart review of patients greater than 18 years of age who had HIT panels performed between January 2013 and June 2014 in a community hospital. Any duplicate HIT panels sent during the same admission period were excluded. Study investigators were trained in two 30-minute intervals in the area of data collection and retrospective calculation of 4T score. Results- Of the 154 patients studied, 73 (47.4%) were male, and 81 (52.6%)were female. All patients had a 4T score calculated by study investigators during data analysis, and 1.29% (n=2) had a 4T score calculated before a HIT panel was sent by the team taking care of the patient. 62.3% (n=96) of patients had a low 4T score and 37. 7%( n=58) had an intermediate to high 4T score. Hematology was consulted on 57.7% (n=89) and anticoagulant administration was stopped on 74 % (n=114), while in 26 % ( 40/ 154) heparin was continued despite sending HIT. 25.4%(29/114) were started on alternate anti- coagulants after stopping heparin . Throughout the course of the study, 20 patients died, with only 1 of these patients being HIT positive. If 100 unnecessary HIT panels were performed in a year, the hospital would be charged more than $20,000 by the diagnostic lab. Additional costs include the halting of Heparin administration and starting an alternate anticoagulant such as Argatroban. 24 hour administration of Argatroban costed $1,000 for continuous infusion. HIT panels have a turnaround time of 4-5 days, resulting in the additional charge of $5,000 just for Argatroban administration. A lengthened stay in the hospital due to HIT panel turnaround time is also a source of increased costs. Combined, the ordering of a HIT panel, alternate anticoagulant administration, and bed charges could amount to $40,000 over the course of four days. This time and money could be put to better use treating the underlying disease of the patient, instead of focusing on the testing for HIT. Conclusion-Management of HIT in community hospital was sub-optimal. Lack of utilization of the 4T scoring system led to unnecessary ordering of HIT panels. This increased duration of hospital stay, elevated the cost of treatment, and resulted in the holding of prophylactic anticoagulants. Disclosures No relevant conflicts of interest to declare.

Introduction: Multiple Myeloma (MM) accounts for 13% of all hematologic malignancies. Plasma cells (PC) proliferation is mainly restricted to the bone marrow (BM) in most of the patients. Extramedullary myeloma (EMM) is defined by the PCs outside the bone marrow. The prevalence of EMM in myeloma patients has been reported at 7 to 15 percent in newly diagnosed patients and from 6 to 20 percent in relapsed setting. Patients with EMM have poor prognosis with a median overall survival of < 6 months. This abstract presents two cases of MM with initial presentation as a liver infiltrate. Cases: Case one: 74-year-old female presented with epigastric pain. Physical exam was unremarkable. Labs showed Hemoglobin (Hb) 8.3 g/dL, Creatinine (Cr) 2.0 mg/Dl and normal liver function test. Ultrasound showed multiple hypoechoic liver nodules. Biopsy of the liver nodule confirmed plasma cells. Her kappa/lambda ratio 3338, Lactate dehydrogenase (LDH) 423 IU/L, beta2 microglobulin was 9 mg/L. Serum and urine immunofixation(IFE) both confirmed a monoclonal kappa light chain clone. Skeletal survey was negative. BM biopsy showed 30 % kappa clonal plasma cells. Fluorescence in situ hybridization was positive for hyperdiploidy of chromosomes 7, 9, 11, 14, and 17 with partial deletion of IgH gene. Treatment with CyBorD (weekly dexamethasone 20 mg, bortezomib 1.3 mg/m2, and cyclophosphamide 300mg/m2) was started. After 6 months therapy, patient achieved partial response. Then her regimen was switched from CyBorD to VRD (Revlimid 10 mg, bortezomib 1.3 mg/m2 and dexamethasone 40 mg) because of severe side effect. She achieved a good partial response. Case two: 57-year-old male presented with right upper quadrant abdominal pain. Physical exam showed diffuse tenderness but no rigidity or guarding. Initial labs showed Hb 8.4g/dL, Cr 1. 7 mg/dL, total bilirubin of 3 mg/ dl, alanine aminotransferase 81 U/ l and aspartate aminotransferase 98 U/ l. CT abdomen pelvis showed metastatic disease to omental implants, splenomegaly and an enlarged liver. Patient underwent surgery in which it was noticed that omentum was adhered to stomach wall whose wedge resection showed plasma cells infiltrate. Liver biopsy also showed diffuse myeloma infiltration. His kappa /lambda ratio 0.0029, LDH 2187 IU/ L, beta 2 microglobulin was 8 mg/L. Serum electrophoresis showed M spike 3. 8 g with IFE confirmed IgG lambda band. Skeletal survey showed several osteolytic lesions in iliac bone. BM biopsy showed hypercellularity with 90 % plasma cells. Patient was started on CyBorD regimen. Repeat labs after first cycle was significant for rising free lambda light chain making us refer the patient to a University Hospital for further treatments. He was recently started on VDT- PACE ( bortezomib, dexamethasone, thalidomide, cisplatin, doxorubicin, cyclophosphamide, and etoposide). Conclusion: EMM with liver metastasis as initial presentation is rare. Since the low incidence of EMM there are no specific treatment guidelines. There are no clear prognostication factors for EMM. Patients are treated in same way as MM. The current initial treatment relies on whether the patient is a transplant candidate or not. Our first patient showed a good response to treatment. However the second patient had primary refractory disease. Given his young age more intensive chemotherapy like VDT-PACE is a good choice If necessary, should be followed by a autologous transplantation or even allogenic transplantation and/ or involving CAR T- cell therapy. A better understanding of how myeloma cells grow and thrive, as well as the biology of extramedullary tumors, is needed in order to develop better strategies for the treatment of EMM in future. Disclosures No relevant conflicts of interest to declare.

Study Objective According to the National Health and Nutrition Examination Survey (NHANES) data from 2003-2006 the prevalence of folic acid deficiency in the United States has decreased from 16% to 0.5% since the dietary folic acid fortification program started in the late 1990s. Routine testing for folic acid deficiency remains quite common in the workup of anemia, dementia, alcoholism and other high risk populations. The objective for this study were to determine the prevalence of folic acid deficiency in order to analyze whether routine testing for deficiency should be discouraged or targeted to specific patient populations. In addition to this, we want to assess the economic burden that folic acid level testing adds to the high cost of care of our health system. Methods Cross sectional chart review of all adults tested for folic acid level from March 2014 to March 2015 from the Hospital and Ambulatory Care Center of the Community Hospital was undertaken. Folic acid deficiency was defined as ≤4ng/dl. Folic acid level were further classified as low (≤10ng/dl ), intermediate (10-20ng/dl) and high (>20ng/dl). Age, race, body mass index, hemoglobin, mean corpuscular volume levels and billing details were recorded of all patients and information was also collected regarding known conditions correlated to the folic acid levels including Vitamin B12 deficiency( Results A total of 957 charts of patients who were tested for folic acid between March 2014 to March 2015 at our Heath- Care System were reviewed. 413 (43%) patients were male and 544 (57%) were female. There were 394 (41 %) Hispanics, 325 (34%) African American, 202 (21%) Caucasian and 36 (4%) were from other ethnicity. The mean age was 59.7 years and a mean Hb was 11. 6 g/ dl. Mean folic acid level was 14.5 ng/dl. 16 patients from total of 957 (2 %) had folic acid deficiency with value ≤4ng/dl . Additional results from the study are described in Table 1, Table 2 and Table 3. Conclusion The prevalence of folic acid deficiency was 2%, About 33,000 dollars per year were used to identify such a low prevalent disease which can be treated at a low cost (2 cents/day) by oral supplementation. Low levels of folic acid were statistically associated with male sex, African American race, dementia and coexistence of vitamin B12 deficiency. Empiric supplementation of folic acid and possibly limiting testing for folic acid level to this group of patients may represent a more cost effective strategy. Disclosures No relevant conflicts of interest to declare.

Sir, Chorea or choreoathetosis is a hyperkinetic syndrome characterized by brief, abrupt involuntary movements resulting from a continuous flow of random muscle contractions [1]. These movements are described in patients with Addison’s disease, vasculitis, pregnancy, viral exanthemas, drugs and other diseases. Enhanced physiological tremors are the most common movement disorder seen in hyperthyroidism, occurring in up to 97% of patients. Chorea is only rarely associated with hyperthyroidism (less than 2% of patients with mostly in patient’s suffering from Grave’s Disease). Here we present a case of chorea in a young female who presented with uncontrolled hyperthyroidism. A 25-year-old female with past medical history of hypertension, hyperthyroidism, anxiety, bipolar disorder, depression, substance abuse presented with muscle spasm of the left shoulder and arm. Patient’s vitals were stable. On examination, she was found to have tenderness in the left shoulder around the joint line. Episodic rhythmic jerks mostly involving the left shoulder and choreiform movements of the left arm were noticed. Her head was deviated to the left and occasional dystonic movements were also seen. Painless thyromegaly was also noted. Lab results were remarkable for only TSH of 0.01 IU/ml and a free T4 of 6.2 ng /dl. She was started on metoprolol 25 mg and methimazole 30 mg. A Neck CT with contrast confirmed multi-nodular goiter. She was discharged home on metoprolol and methimazole. Her follow up visit one week later showed improvement in involuntary movements. Lab results revealed a decreased free T4 of 2.3 ng /dl. Literature was reviewed to find out the mechanism of action and treatment for the condition. Hyperthyroidism may induce a reversible functional alteration in the dopamine turnover or receptor site response to dopamine in the corpus striatum. Studies have shown a reduction in the production and turnover of the level of homo-vanillic acid, a metabolite of dopamine, in the cerebrospinal fluid in hyperthyroid patients. This is in concordance with alleviation of symptoms after administering dopamine antagonist [2]. Another hypothesis suggests functional modification of adrenergic receptors, supported by the fact that the chorea disappears when treated with a beta blocker and worsens with isoproterenol challenge [3]. Multiple reports have reiterated the connection between increased serum thyroxine and movement disorders, including chorea associated with thyroxine replacement therapy [4]. Physicians must be aware about such an association so that these movement disorders are not over looked as a non-specific finding. Early detection and treatment can improve the patient’s quality of life.

Immune thrombocytopenic purpura (ITP) is defined as an acquired thrombocytopenia with antibodies detected against platelet surface antigens, and it is the most common form of thrombocytopenia in otherwise asymptomatic adults. ITP secondary to an underlying condition is a diagnosis of exclusion that is essential to establish for treatment efficacy. Secondary thrombocytopenia caused by cytomegalovirus (CMV) is common; however, case reports associated with diagnosis in immunocompetent adults are rare, and to the best of our knowledge only 20 publications have been associated with this diagnosis. Our report is based on a clinical presentation of a 37-year-old female complaining of petechiae, heavy menses, shortness of breath, and a platelet count of 1 × 109/L. Treatment with IVIG and steroids failed to improve platelet count. Subsequently, an infectious laboratory workup was performed, detecting CMV infection, and treatment with antiviral agents was initiated, causing platelet count to increase as viral load decreased.

Introduction Mantle cell lymphoma (MCL) is a rare B-cell non-Hodgkin lymphoma that most commonly affects men above the age of 60 years. The disease is called MCL because the tumor cells originate from the mantle zone of the lymph node. The most commonly affected sites are the lymph nodes, bone marrow, gastrointestinal tract, Waldeyer's ring and rarely the skin, breast and central nervous system. Only 22 cases with skin manifestation of MCL have been reported so far. Case We report the case of a 73-year-old woman who was diagnosed with MCL and underwent treatment, but later relapsed and presented with an ulcerated mass over her right foot. She underwent 6 cycles of chemotherapy with bendamustine plus rituximab and responded with resolution of the foot lesion. Discussion and conclusions MCL is an aggressive lymphoma with a median overall survival of 3-5 years for advanced disease, while early-stage disease has a better prognosis. It rarely involves the skin. Since cutaneous lesions can be the first manifestation of MCL, awareness of this less common presentation is crucial to establish an early diagnosis and pursue treatment as early as possible, as it significantly impacts the survival rate.

Pembrolizumab is an immune checkpoint inhibitor that significantly improves clinical outcomes in numerous solid organ malignancies. Despite successful therapeutic responses, this new drug comes with a constellation of adverse reactions. Herein, we chronicle the case of a patient with metastatic non-small-cell lung cancer treated with pembrolizumab. After two cycles, he developed new-onset dyspnoea on exertion. Electrocardiogram showed idioventricular rhythm with diffuse ST-segment elevations. Echocardiography revealed severe biventricular cardiac dysfunction. Based on diagnostic workup and exclusion of probable aetiologies, the patient was diagnosed with pembrolizumab-induced myocarditis. The treatment was initiated with corticosteroids and guideline-conform heart failure therapy. He demonstrated a marked clinical response with resolution of congestive heart failure symptoms. This article summarises the clinical evidence regarding the epidemiology, pathophysiology, clinical features, diagnostic modalities and management of patients with pembrolizumab-associated myocarditis. In addition, it highlights that programmed death receptor-1 inhibition can cause a spectrum of autoimmune adverse events requiring clinical monitoring and periodic screenings.

Meditation is a complex process involving change in cognition, memory, and social and emotional control, and causes improvement in various cardiovascular, neurological, autoimmune, and renal pathologies. Meditation also become widely used in medical and psychological treatment therapies for stress-related physical and mental disorders. But still, biological mechanisms in terms of effect on brain and body are poorly understood. This paper explains the basic changes due to meditation in cerebral cortex, prefrontal area, cingulate gyrus, neurotransmitters, white matter, autonomic nervous system, limbic system, cytokines, endorphins, hormones, etc. The following is a review of the current literature regarding the various neurophysiological mechanisms, neuro-endocrine mechanisms, neurochemical substrates, etc. that underlies the complex processes of meditation.

Background: The 23-hour Observation Unit (OU) is a novel and an effective means for tackling overcrowding in busy Paediatric Emergency Departments (PED) worldwide. However, unexpected hospitalisations in the OU involve transfer of care and they reduce the efficiency of the OU. Hence, we aimed to study the presenting diagnoses which were responsible for the unexpected hospitalisations in a 23-hour OU. Methods and Design: A prospective cohort study Setting: The PED at a tertiary care teaching hospital. Duration: 15th Feb-15th March 2011. Protocol: Consecutive children were triaged at presentation to the PED, according to the WHO paediatric emergency triage algorithm. Those who were transferred to the 23-hour OU, were further followed up for duration of the stay, the hospital course, and the outcome (discharge/hospitalisation). Results: Three hundred (228 males, 72 females) consecutive children who attended the PED over one month were enrolled. All the children, at presentation, were triaged by the medical intern/s who was/were posted in the PED, and they were crosschecked by a PED consultant. A majority (55%, n=165) of the children were triaged as non-urgent, 32% (n=97) as priority and 13% (n=38) as emergent. Out of the 300 children, 173(58%) were transferred to the 23-hour OU. Of these, 16 (9.1%) required unexpected hospitalisations. The children who required hospitalisations had the following diagnoses: bronchiolitis (4), bronchopneumonia (4), seizure (2), viral hepatitis (2), high fever (1), bronchial asthma (1), severe anaemia (1), and urticaria (1). The mean duration of the stay in the OU was 19 hours for those who needed hospitalisation, as against 13 hours for those who were discharged from the OU. Conclusion: The children with respiratory complaints (bronchiolitis and bronchopneumonia) need frequent monitoring in the 23-hour OU, as they have high hospitalisation rates in the OU.

Background: Menstruation disorders are also responsible for emotional, physical, behavioural and dietary practice changes. These changes affect their normal functioning and social life. The present study was carried out to find the prevalence of menstrual problems among unmarried girls of Chandigarh, India and to compare their knowledge and beliefs regarding menstruation in different sub–groups. Methodology: A community based cross-sectional study was conducted among 744 unmarried females in Rural, Urban and Slum strata of UT Chandigarh, India. Data were collected using a self-administered structured questionnaire on menstruation. Chi–square value was used for testing statistical significance. Results: The mean age of the respondents was 16.84±3.05 years. Maximum respondents (40.9%) were educated up to 10th standard/High school. 448 (60.2%) were aware of menstruation before starting of menarche. Awareness was found to be significantly associated (p=0.02) with age. Socio–economic status and prior knowledge of respondents was also found to be significantly associated (p< 0.001). 61% (454) of the respondents had a regular flow during menses. Normal flow was reported by 70.2 %(522) of the respondents. Dysmenorrhea was found to be the most common problem suffered by 429 (57.7%) respondents. Conclusion: Menstrual hygiene is an issue that needs to be addressed at all levels. A variety of factors are known to affect menstrual behaviors, the most influential ones being economic status. It is essential to design a mechanism to address and for the access of healthy menstrual practices.

Background : Shortcomings in the delivery of primary health care services at state-run centers and more dependence on private health care service providers has resulted in lesser utilization rates. Feedback from patients is vital if deficiencies are to be identified and improvements achieved. This study attempts to assess client satisfaction of the PHC services provided by a rural health training center. Objectives : The main objective of the study is to measure the satisfaction of OPD patients at a rural health center, and also (1) to know the relationships between the various determinants and OPD patients satisfaction and (2) to correlate patient satisfaction with the sociodemographic profile. Materials and Methods : A cross-sectional study was done to assess the satisfaction of services provided at the rural health center which caters to population of around 40,000. The response was rated on a 5-point Likert scale. SPSS version 15 was used to analyze the data. Average satisfaction of each patient was taken and the overall mean and SD was calculated to know about the overall satisfaction. Results : The mean age is 33.45 ± 10.719 years. The mean waiting time for consultancy was 11.84 ± 8.932 min. The mean consultation time by the physician was 6.06 ± 3.002 min. The mean waiting time for drugs is 5.93 ± 5.213 min. Only 28.5% were highly satisfied with the available lab investigations. 58.5% of the clients were highly satisfied with the doctor's relationship with the patients. 63% felt that adequate privacy was given during consultation. Conclusions : The results of the present study showed that although the overall satisfaction was high, some aspects of services indicated some degree of dissatisfaction.