Jhawar, Nikita

ABSTRACT Immune checkpoint‐inhibitors (ICIs) have revolutionized and significantly improved cancer care through remarkable efficacy, but significant adverse effects have been observed. Among these, ICI‐induced myocarditis with myositis/myasthenia gravis overlap syndrome represents a life threatening, severe immune‐related adverse event that clinicians need to be aware of and be able to diagnose rapidly given its aggressive course. We present two patients who were treated with ICIs and subsequently developed said syndrome. Both patients experienced significant cardiac and neuromuscular manifestations and despite high‐dose intravenous steroids, intravenous immunoglobulin, and other adjunctive therapies, both patients rapidly deteriorated and elected to withdraw care. Additionally, we review the pathophysiology, diagnosis and management of ICI‐induced myocarditis with myositis/myasthenia gravis overlap syndrome. Overall, the overlap syndrome has a poor prognosis and high mortality rates requiring prompt recognition, discontinuation of ICIs and initiation of immunosuppressive therapies.

Introduction: Genomic variations among individuals can greatly affect their responses to different medications. Pharmacogenomics is the area of study that aims to understand the relationship between these various genetic variations and subsequent drug responses. Many medications used to optimize cardiovascular health are affected by these genetic variants and these relationships can subsequently impact dosing strategies in patients. Objective: This study aims to review the current literature on the clinical applications ofpharmacogenomics for commonly used cardiovascular medications such as Warfarin, Clopidogrel, Statins, Beta Blockers, and ACE-I/ARBs. Methods: Databases like PubMed were accessed to gather background information on pharmacogenomics and to collect data on relationships between genetic variants and subsequent drug response. Information on clinical applications and guidelines was obtained by accessing the CPIC and DPWG databases. Results: This article describes the most up-to-date data on pharmacogenomics relating to commonly used cardiovascular medications. It also discusses the clinical application of pharmacogenomic data as it pertains to medication selection/dosing by detailing current guidelines published by organizations such as the Clinical Pharmacogenetics Implementation Consortium and the Dutch Pharmacogenetics Working Group. Conclusion: In conclusion, this paper will help medical providers not only better understand pharmacogenomics but also apply it in their day-to-day practice. Clinical guidelines relating to the application of pharmacogenomic data were discussed both in text and graphical format, allowing providers to confidently select medications and adjust doses for common cardiovascular medications so that patients receive the maximum therapeutic benefit with minimal toxicity.

Introduction: Oncology societies have been contributing guidelines/recommendations to the limited yet growing body of literature in cardio-oncology. Research Questions: What are the levels of evidence (LOE) and classes of recommendation (COR) for cardiology-specific recommendations produced by major oncology societies? Methods: We reviewed cardiology-specific recommendations published by the American Society of Clinical Oncology (ASCO), American Society of Hematology (ASoH), NCCN (National Comprehensive Cancer Network), and European Society of Cardiology (ESC). LOE and COR were noted for each recommendation. Results: The US oncologic societies have made 81 cardiac-specific recommendations (ASCO: 54 (67%); ASoH: 14 (17%); NCCN; 13 (16%) (Tables 1-3). For ASCO, 26 (48%) were COR 1, 23 (43%) COR 2, and 5 (9%) COR 3 supported by LOE A (9%), LOE B (39%), and LOE C (52%). For ASoH, 1(8%) was COR 1, 11(85%) COR 2, and 1(8%) COR 3 supported by LOE B (7%), and LOE C (93%). NCCN made 13 COR 2 recommendations and did not provide LOE classification. The most common recommendations addressed baseline (20%) and serial (24%) assessment, specific imaging modalities (9%), chemotherapy dosing (19%), and radiation therapy (20%). Most recommendations were unique without discrepant statements, but there were some redundancies. ESC produced 271 cardio-oncology recommendations (155 COR 1; 111 COR 2; 5 COR-3) with 3% LOE A, 21% LOE B, and 76% LOE C. The major areas for ESC recommendations included baseline (18%) and serial (33%) assessment, and medications (29%). Conclusions: Oncology and cardiology professional society guidelines have provided 352 cardiac related recommendations in the setting of cancer treatment and 73% have the lowest LOE. In this developing field with a limited evidence base, close collaboration between cardiologists and oncologists will be required to provide a cohesive set of recommendations for the cardiac issues associated with cancer treatment.

Background/Objective Few studies have investigated associations between rheumatologic serology patterns and different interstitial lung disease (ILD) patterns. Methods We present novel findings of a historic cohort study (n = 454) with data collected from 2011 to 2021 within our hospital system. In this institutional review board–approved study, data regarding rheumatologic serologies and ILD patterns were noted based on chart review in patients with scleroderma. The Kruskal-Wallis rank sum and χ 2 tests were used for statistical analysis. Results Results showed a statistically significant association between anti-U1 snRNP with lymphoid interstitial pneumonia, which has not been previously described. Conclusions We demonstrated novel serologic associations with ILD patterns, which have important clinical implications. More robust and high-powered studies are needed to elucidate the role of serologic testing and their association with ILD phenotypes.

Ischemic symptoms may be explained by a multitude of coronary pathologies, including coronary artery tortuosity, atherosclerosis, fibromuscular dysplasia, vasculitis, coronary vasospasm, or microvascular disease. We present an unusual case of coronary kinking in a patient presenting with exertional jaw pain in the absence of atherosclerotic risk factors. Multimodality imaging, coronary imaging, and coronary physiology helped establish the diagnosis and guide management.

Abstract Trigeminal amyloidoma is a rare clinical phenomenon with scarce reports in the medical literature. This report presents a case of biopsy-proven trigeminal amyloidoma in a patient with cardiac amyloidosis. This case report sheds light on the differential diagnoses that may resemble trigeminal amyloidoma and strategies for workup and treatment.

Background and Objective: The published cardiology literature is critical for scientific communication, and we sought to determine if the published clinical cardiology evidence base has evolved over time. Methods: We evaluated the cardiology related publications in the medical journals (M) JAMA (J) and the New England Journal of Medicine (N) and all publications by the specialty journals (CA) Circulation (Ci) and the European Heart Journal (E) in 2000, 2010, and 2020 and added 2001, 2011, and 2021 for JAMA to account for potential annual variability. Results: Publication information is shown in the graph. For the M journals there has been an increase in the percentage of randomized controlled trials (RCT). For the CA journals there has been a significant decrease in single center studies (Si) and a proportionate increase in reanalysis (Re) of data whether from subanalysis of an RCT, registry, or meta-analysis. For CA journals there has been an increase in the size of clinical studies mainly due to the use of larger datasets from registries or claims (Ci: 2000: 4,500/study; 2010: 9,298/study; 2020: 258,725/study and E: 2000: 2,282/study; 2010: 12,652/study; 2020: 249,388/study). CA journals have an increased of studies with patients from multiple continents (Ci: 2000: 5.5%; 2010: 13%; 2020: 35% and E: 2000: 7%; 2010: 14.8%; 2020: 18.8%). There has been an increase in the percentage of clinical studies with documentation of different populations by region or color (In 2020, 58% for all Ci articles and 52% for US and multicontinental EHJ articles), although the number of nonwhites remains small in most studies unless the study was specifically addressing disparities in care. Conclusions: Over the last two decades, the published evidence base has changed with more RCT in the Med journals and more studies that reanalyze large datasets in CA journals. Published studies are now larger, more likely to involve multiple continents, and document population details.