Adult intussusception is rare, highly associated with a malignant lead point, and often requires emergent surgical management. We report the case of a 44-year-old male who presented with generalized abdominal pain and was found to have early ileocolic intussusception secondary to a large ileocecal mass. Biopsies of the mass and an enlarged cardiophrenic lymph node, as well as pleural fluid cytology were all consistent with Burkitt lymphoma (BL). Curiously, the patient's abdominal exam was reassuring, and the intussusception and malignant bowel obstruction resolved over 36 hours with conservative management alone. With a Burkitt lymphoma international prognostic index (BL-IPI) score of 2, the patient proceeded to treatment with combination chemoimmunotherapy and attained a complete response after four cycles. There was no bowel perforation or recurrent intussusception throughout treatment. Thus, this report marks the first reported case of adult BL-associated intussusception to resolve with non-invasive management and establishes a precedent for conservative management in select patients.

Allogeneic stem cell transplantation (alloSCT) is the only known curative treatment for myelofibrosis (MF). Risk assessment remains important for patient counseling and predicting survival outcomes for relapse and nonrelapse mortality (NRM). Outcome-prediction tools can guide decision-making. Their use in MF has relied on their extrapolation from other malignancies. The primary objective of this study was to assess the performance of the Hematopoietic cell Transplantation Comorbidity Index (HCT-CI), the augmented HCT-CI (aHCT-CI), and the Endothelial Activation and Stress Index (EASIX) in predicting NRM in patients with MF undergoing alloSCT. We retrospectively reviewed patients with MF undergoing alloSCT between 2012 and 2020 at the Mayo Clinic. Data were abstracted from the electronic medical record. EASIX score was calculated before starting conditioning therapy and analyzed based on log2- transformed values. We evaluated the log2-EASIX scores by quartiles to assess the effect of increasing values on NRM. NRM was evaluated using competing risk analyses. We used the Kaplan-Meier and log-rank methods to evaluate OS. The Fine-Gray model was used to determine risk factors for NRM. The performance of HCT-CI and aHCT-CI was compared by evaluation of model concordance given the high correlation between HCT-CI and aHCT-CI (r =.75). A total of 87 patients were evaluated. The median duration of follow-up after alloSCT was 5 years (95% confidence interval [CI], 4.4 to 6.31 years). Patients with a high HCT-CI score had significantly increased cumulative incidence of NRM at 3 years (35.5% versus 11.6%; P =.011) after alloSCT. A progressively increasing 3-year NRM was observed with increasing aHCT-CI risk category, and patients with a high or very high aHCT-CI score had significantly higher 3-year NRM compared to those with intermediate-risk or low-risk aHCT-CI scores at 3 years post-alloSCT (31.9% versus 6.52%; P =.004). An increasing log2-EASIX score quartile was not associated with 3-year NRM (19.0% versus 10.1% versus 25% versus 14.3%; P =.59), and the EASIX score was not found to be a predictor of post-transplantation NRM. A high HCT-CI was associated with significantly worse 3-year overall survival (OS) (hazard ratio [HR], 4.41; 95% CI, 1.97 to 9.87; P <.001). A high or very high aHCT-CI was significantly associated with poor 3-year OS (HR, 3.99; 95% CI, 1.56 to 10.22; P =.004). An increasing log2-EASIX score quartile group was not associated with 3-year OS (3-year OS rate, 66.7% versus 80.4% versus 64.6% versus 76.2%; P =.57). The EASIX score should not be used routinely in patients with MF. Both the HCT-CI and the aHCT-CI are accurate in predicting long-term survival outcomes in this patient population. Further studies are important to validate our findings of the role of EASIX in predicting NRM in patients with MF or other myeloproliferative neoplasms undergoing alloSCT. (C) 2023 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc. (c) 2023 The American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Introduction Long-distance travel is assumed to be a risk factor for venous thromboembolism (VTE). However, the available data have not clearly demonstrated the strength of this relationship, nor have they shown evidence for the role of thromboprophylaxis. Methods We performed a systematic review of the literature. We also summarized available guidelines from 5 groups. Results We found 18 studies that addressed this question. Based on the data presented in the review, we conclude that there is an association between VTE and length of travel, but this association is mild to moderate in effect size with odds ratios between 1.1 and 4. A dose-response relationship between VTE and travel time was identified, with a 26% higher risk for every 2 h of air travel ( P=0.005) starting after 4 h. The quality of evidence for both travel length and thromboprophylaxis was low. However, low-risk prophylactic measures such as graduated compression stockings were shown to be effective in VTE prevention. There is heterogeneity among the different practice guidelines. The guidelines generally concur that no prophylaxis is necessary in travelers without known thrombosis risk factors and advocate for conservative treatment such as compression stockings over pharmacologic prophylaxis. Conclusions We conclude air travel is a risk factor for VTE and that there is a dose relationship starting at 4 h. For patients with risk factors, graduated compression stockings are effective prophylaxis.

Introduction Venetoclax (Ven) in combination with hypomethylating agents (HMA) is frequently used for treatment of relapsed/refractory AML patients in routine practice. However, limited data exists on molecular predictors of response and survival following Ven+HMA therapy in the relapsed/refractory setting. A prior retrospective study demonstrated superior response with TET2and ASXL1 mutations (AJH, 2019). Accordingly, our primary objective was to determine the impact of mutations on response and survival in relapsed/refractory AML patients receiving Ven + HMA. Methods Patients with relapsed/refractory AML, excluding post-transplant relapse, receiving Ven+HMA outside clinical trials at the Mayo Clinic were retrospectively recruited after institutional review board approval. Cytogenetic and molecular studies were performed at the time of AML diagnosis by conventional karyotype, and next-generation sequencing (42-gene panel), respectively. All patients received either azacitidine 75 mg/m2 days 1-7 or decitabine 20 mg/m2 days 1-5 with Ven dose adjusted based on azole antifungal prophylaxis. Response was assessed according to the 2017 European Leukemia Net (ELN) criteria. Patient characteristics 87 relapsed/refractory AML patients (median age 64 years, 62% male, 51% de novo) received Ven+HMA. ELN cytogenetic risk (n=77) included favorable (1%, n=1), intermediate (57%, n=44) or adverse (42%, n=32). Mutations involved TP53 in 20 patients (23%), ASXL1 in 19 (22%), IDH1/IDH2 in 12 (14%), TET2 in 11 (13%), K/NRAS in 11 (13%), NPM1 in 9 (10%), and FLT3-ITD in 7 (8%). Frequently administered prior therapies included 7+3 (n=51), CPX-351 (n=17), enasidenib /ivosidenib (n=6). Prior HMA was documented in 18 (21%) patients. 71 (82%) patients received decitabine and the remainder azacitidine with median Ven dose of 100 mg for a median of 2 cycles. Subsequent targeted therapies following Ven+HMA included enasidenib (n=3) and gilteritinib (n=2). Predictors of response 18 (21%) patients achieved complete remission (CR), 19 (22%) CR with incomplete hematological recovery (CRi), resulting in CR/CRi in 37 (43%). In univariate analysis, age > 65 years (CR/CRi, 61% vs 29%, p=0.003) presence of IDH1/2 (75% vs 37%, p=0.01) and ASXL1 mutations (68% vs 35%, p=0.01) were associated with favorable response; adverse karyotype (25% vs 58%, p=0.004), and presence of TP53 mutations (25% vs 48%, p=0.06) predicted inferior response. Presence of FLT3-ITD (71% vs 40%; p=0.11) NPM1 (67% vs 40%, p=0.12) and TET2 mutations (64% vs 39%, p=0.13) were borderline significant. In multivariable analysis, presence of ASXL1 mutations (OR 3.4) and absence of adverse karyotype (OR 4.5) remained independent predictors of favorable response. Predictors of survival At a median follow up of 5.6 months, 69 (79%) patients have died and 20 (23%) underwent allogeneic transplant. Post-Ven+HMA median overall survival was 5.9 months (CI, 2.5-14.5 months) and longer in transplanted patients (38.7 vs 5.1 months, p<0.0001). Univariate analysis identified CR/CRi (p<0.0001), IDH1/2 mutations (p=0.002) as favorable, and TP53 (p=0.005), and adverse karyotype (p=0.04) as unfavorable risk factors for survival. Of note, two IDH2 mutated patients on enasidenib following Ven+HMA remain alive at 27 and 13 months, respectively. Despite higher CR/CRi, presence of ASXL1 mutation did not impact survival. Multivariable analysis confirmed the negative survival impact of not achieving CR/CRi (HR 3.1, 95% CI 1.9-5.4, p<0.001), absence of IDH1/2 (HR 3.1, 95% CI 1.4-6.9, p=0.01), and presence of TP53 mutations (HR 2.1, 95% CI 1.2-3.6, p=0.01). Accordingly, a three-tiered model was generated by allocating 1 adverse point each for absence of CR/CRi, absence of IDH1/2 and presence of TP53 mutations, resulting in low (0-1 point, n=34, 13.7 months), intermediate (2 points, n=39, 5.1 months) and high risk (3 points, n=14, 1.9 months) categories (p<0.0001) (Figure) which remained applicable in non-transplanted patients (9.2 vs 4.0 vs 1.9 months, p<0.0001). Conclusions The current study identifies presence of ASXL1 mutation and absence of adverse karyotype as predictors of superior response. Survival was positively influenced by presence of IDH1/2, absence of TP53 mutations and achievement of CR/CRi. Our findings require validation in prospective series, which should also take into consideration the survival impact of subsequent targeted therapies. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Background: Medical student wellness, including physical health, emotional health, and levels of perceived stress, appears to decline during training, with students reporting high levels of depression, anxiety, and burnout as early as the first year of medical school. The impact of curricular changes on health and stress remains unclear, and a modified curriculum that compresses training of the foundational sciences and its effect on wellness has not been studied. Oregon Health & Science University School of Medicine has recently instituted a unique competency-based model, which provides an important opportunity to assess the effects of curricular change on student wellness. Objective: Assess the effects of curricular change on student wellness. Design: Medical students at a single institution were administered the SF-8, an 8-item health-related quality of life survey, as well as the Perceived Stress Scale, a 10-item scale that measures the degree to which life situations are appraised as stressful, at baseline (matriculation) and at the end of Year 1, 2 and 3. Individual variables were assessed over time, as well as a trend analysis of summary domain scores over the 4 time periods. Results: Physical, emotional, and overall health were highest at baseline and lowest at the end of Year 1, after which they improved but never again reached baseline levels. Physical health declined less than emotional health. Perceived stress levels did not change over time but remained moderately high. There were no differences in health or perceived stress based on demographic variables. Conclusions: In a competency-based curriculum, physical, emotional and overall health significantly worsened during Year 1 but improved thereafter, while perceived stress remained unchanged. Early in training, stress and poor overall health may be related to concerns about self-efficacy and workload. Although advanced students show improved wellness, concerns remained about emotional difficulties, such as anxiety and irritability, and feeling a lack of control.