Significant uncertainty exists in regard to the efficacy of maintenance therapy after high-dose chemotherapy (HDC) as well as autologous stem cell transplantation (ASCT) for the treatment of patients with aggressive lymphoma. A systematic review was performed to evaluate the effectiveness of post-ASCT maintenance therapy in patients with relapsed/refractory lymphoma. A comprehensive literature search yielded 4476 studies and a total of 42 studies (11 randomized controlled trials [RCT], 9 retrospective comparative studies, and 22 single-arm studies) were included in the systematic review. There was significant heterogeneity in study design, chemotherapeutic regimens, post-ASCT maintenance strategies, patient enrollment criteria, and study endpoints. Our findings suggest that post-ASCT maintenance immune-targeting strategies, including PD-1/PD-L1 blocking antibodies, rituximab, and brentuximab, may improve progression-free survival but not overall survival. Collectively, the results indicate a need for testing new strategies with well-designed and adequately powered RCTs to better address the role of post-ASCT maintenance in relapsed/refractory lymphomas.

BACKGROUND Pregnancy-associated spontaneous coronary artery dissection (PSCAD) is an important cause of chest pain and acute myocardial infarction in pregnant and postpartum women. Pregnancy is considered an isolated risk factor for spontaneous coronary artery dissection. The etiology, pathogenesis, and incidence of PSCAD are not known. CASE SUMMARY We present a case of a 33-year-old postpartum female who presented with sudden onset chest pain and was diagnosed with spontaneous coronary artery dissection and needed urgent catheterization revealing left anterior descending coronary artery dissection. She underwent emergent coronary artery bypass graft surgery with good post-operative recovery. CONCLUSION Most patients with PSCAD can be managed conservatively with medical management and have good outcomes. Patients with high-risk presentations benefit from the invasive approach. Coronary artery bypass graft may be required in select few patients based on angiography findings. Due to the risk of recurrent spontaneous coronary artery dissection, subsequent pregnancies are discouraged.

A 70-year-old woman was hospitalized for elevated creatinine of 2.1 mg/dL dL and elevated blood pressures. Her urinalysis revealed 11-20 RBCs and elevated urine protein-creatinine ratio of 2.5 g/g. Autoimmune workup was positive for anti-Scl-70 antibody, negative for ANA, Ds DNA, citrulline antibody, rheumatoid factor, myeloperoxidase, and antiprotease 3. ADAMTS 13 activity was normal, and peripheral smear examination was negative for schistocytes. Her blood pressures were controlled with captopril 25 mg three times a day. Creatinine continued to uptrend from 2.1 mg/dL to 5.9 mg/ dL. Her kidney biopsy revealed thrombotic microangiopathy. (Figure 1). Over the next 2 weeks, she had progressive dyspnea, chest pain, and bilateral lower extremity edema. Her serum blood urea nitrogen levels were elevated ranging from 90 mg/dL to 144 mg/dL. She was hypotensive and echocardiogram revealed pericardial effusion with tamponade physiology. (Figure 2) She underwent pericardiocentesis with pericardial drain placement and was initiated on dialysis and remained dialysis-dependent. Systemic sclerosis (SS) is a connective tissue disease involving multiple organ systems. SS is associated with TMA in 10% of cases and is referred to scleroderma renal crisis (SRC), which carries a terrible prognosis with mortality rate up to 30%-50% in 5 years. 1 Blood pressure control with renin-angiotensin-aldosterone (RAAS) blockade therapy is recommended. In our patient, pericardial effusion was attributed to Scleroderma or uremic pericarditis. Pericardial effusion with tamponade physiology is life-threatening and requires emergent pericardiocentesis and dialysis initiation. 2 50% of patients with scleroderma renal crisis progress to ESRD. Renal recovery in scleroderma patients is 7%-10%. 3 ACKNOWLEDGMENTS Nothing to disclose. Published with written consent of the patient. CONFLICT OF INTEREST None.

Intracardiac thrombi are not uncommon, but right atrial (RA) thrombi are exceedingly rare. Thrombi can lead to a variety of complications, such as systemic and pulmonary embolism. While various imaging modalities are helpful in the diagnosis, an echocardiogram is the most commonly used one. Principle management of the condition involves anticoagulation. However, management can vary among different patient groups, depending on the location and size of thrombi. We present a case of an RA thrombosis due to dilation of the atria and trauma from an infected central venous catheter in a patient with a past medical history of pulmonary artery hypertension (PAH).

No abstract