Venous thromboembolism (VTE) and stroke carry significant mortality and morbidity in cancer patients. Direct oral anticoagulants (DOACs) have been demonstrated to be effective for the treatment of VTE and prevention of stroke in atrial fibrillation (AF). Bleeding rates are variable and are based on the cancer type and the patient\'s specific risk factors. There are approved specific antidotes for DOAC-associated bleeding. Other strategies are available for bleeding reversal, including the use of prothrombin complex concentrate (PCC). No randomized studies have compared head-to-head the efficacy and safety of reversal agents. We aim to examine the safety and effectiveness of hemostatic agents in cancer patients with DOAC-related major bleeding. A retrospective chart review study of patients at MD Anderson Cancer Center with DOAC-related major bleeding between 2014 and 2019. Bleeding severity and clinical hemostasis were described based on ISTH guidelines and the Sarode criteria, respectively. The rates of thrombotic complications and mortality at 30-day from the index bleeding event were described. We identified 23 patients with DOAC-related major bleeding; 14 patients received PCC and 9 patients received andexanet alfa. The most common sites of bleeding were the gastrointestinal tract and intracranial. Effective hemostasis and 30-day mortality were similar to reported results from other reports of outcomes of reversal agents for DOAC related-bleeding in non-cancer patients. One patient in each treatment group experienced a thrombotic event. Further larger scale studies are needed to confirm our findings in cancer patients.

BACKGROUND: Refractory secondary hyperparathyroidism (SHPT) is a common complication observed in patients with end-stage renal disease and can result in ectopic calcification. Metastatic calcification involving the heart valves and the conduction system can easily lead to arrhythmias, including atrioventricular block. This case report describes a maintenance hemodialysis patient with refractory SHPT resulting in a complete atrioventricular block (CAVB), which was eventually reversed to a first-degree atrioventricular block.
METHODS: We present the case of a 31-year-old Asian female who was receiving maintenance hemodialysis because of lupus nephropathy. She developed SHPT, and an electrocardiogram revealed a first-degree atrioventricular block. Then, she underwent parathyroidectomy (PTX) with autotransplantation. Unfortunately, a few years later, she developed SHPT again, and an electrocardiogram revealed a CAVB. A few years after the second PTX surgery, the calcification of the left atrium and left ventricle improved, and her CAVB was reversed.
CONCLUSIONS: This case revealed that metastatic cardiac calcification can result in complete atrioventricular blockage. Following parathyroid surgery, calcification of the cardiac conduction system improved, leading to reversal of the atrioventricular block. It is important for dialysis patients to optimize intact parathyroid hormone therapy and pay attention to calcification metastasis.

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The palmaris longus frequently exhibits anatomical variations with palmaris longus agenesis and reversal being the most prevalent. These variations are relevant clinically, as the muscle is often used during plastic surgeries for grafting tendons. They are also relevant in pathology, as hypertrophy of the reversed muscle is related to median nerve compression. In this report, we describe an unusual case in which a male cadaver-donor exhibited a right-sided palmaris longus reversal and left-sided palmaris longus agenesis. Review of the literature documents no previous co-occurrence of these anomalies. Since the muscle has relevance in a variety of contexts within medicine and surgery, reporting on a variation like this carries significant educational and clinical value.

UNASSIGNED: The Putti-Platt procedure is a historical technique for anterior shoulder stabilization, largely abandoned because it severely restricts movement, and causes arthritis and chronic pain. Patients continue to present with these sequelae, which can be difficult to manage. Here, we present the first published subscapularis re-lengthening for the reversal of Putti-Platt.
UNASSIGNED: Patient: A 47-year-old Caucasian manual worker presented 25 years post-Putti-Platt, with chronic pain and movement restriction. External rotation was 0°, abduction was 60°, and forward flexion was 80°. He was unable to swim and struggled to work. Multiple arthroscopic capsular releases had provided no benefit. Technique: The shoulder was opened through the deltopectoral approach, and a coronal Z-incision lengthening tenotomy was made in subscapularis. The tendon was lengthened by 2 cm and the repair was reinforced using a synthetic cuff augment.
UNASSIGNED: External rotation improved to 40°, and abduction and forward flexion to 170°. Pain resolved almost completely; Oxford Shoulder Score at 2-year follow-up was 43 (22 pre-operative). The patient returned to normal activity and reported complete satisfaction.
UNASSIGNED: This is the first application of subscapularis lengthening to Putti-Platt reversal. Two-year outcomes were excellent, demonstrating potential for significant benefit. Although presentations like this one are rare, our results support the potential of subscapularis lengthening (with synthetic augmentation) in the management of stiffness resistant to conventional treatment after Putti-Platt procedure.

Background and Objectives: Vitiligo is a skin disorder characterized by hypopigmented macules occurring due to melanocyte destruction. An interplay of several biochemical mechanisms has been proposed to explain the etiopathogenesis of vitiligo, such as genetic, autoimmune responses, generation of inflammatory mediators, oxidative stress, and melanocyte detachment mechanisms. There is no cure for vitiligo; however, pharmacological treatment measures (cosmetic camouflage creams, steroids, psoralen and ultraviolet A (PUVA) therapy, narrowband UVB) are available, but they could have certain side effects. We reported an interesting case of vitiligo in Saudi Arabia that showed reversal of vitiligo, which is an extremely rare phenomenon, with the objective of probing the probable reasons for this reversal. To the best of our knowledge, there is no study on vitiligo that has reported spontaneous reversal of vitiligo in Saudi Arabia so far. Materials and Method: The patient presented to the Family Medicine clinic with a history of restoration of melanin pigment in his lesions after 3 years of the onset of vitiligo. Patients history was taken carefully along with clinical examination, carried out necessary biomedical lab investigations and compiled the data. The data at the time of pigment restoration were compared to the previous data when he developed the lesions. Result: The probable reasons for vitiligo reversal could be markedly decreased psychological stress, regular consumption of an antioxidant-rich herbal drink made of curcumin and honey, and dietary switchover to vegetarianism and an alcohol-free lifestyle. Conclusions: Curcumin-based herbal remedies could be an alternative option to treat vitiligo. These methods must be further explored through clinical trials as they are safer, easily available, and more affordable.

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Intracranial atherosclerotic stenosis is one of the main causes of ischemic stroke and transient ischemic attack. High-resolution magnetic resonance imaging allows us to directly observe the intracranial artery wall, accurately assess the condition of the vascular wall, and quantitatively analyze the vascular wall and intracranial atherosclerotic plaque load. We report a case of acute cerebral infarction with left middle cerebral artery stenosis. During the first 3 weeks, the patient was treated with aspirin 100 mg and clopidogrel 75 mg daily. Afterwards, the patient continued to be given aspirin, and cilostazol 100 mg twice daily was given instead of clopidogrel. After 24 months of follow-up, we observed a significant reversal of intracranial atherosclerotic plaque using high-resolution MRI (HR-MRI) and discussed the advantages of HR-MRI in evaluating drug therapy for intracranial atherosclerotic plaque.

The ongoing controversy regarding optimal reversal agent for factor Xa-inhibitors is mainly due to lack of comparative data of andexanet alfa (AA) to 4-factor prothrombin complex concentrate (4F-PCC), institutional formulary restrictions, and navigation of clinical scenarios involving patients clinically worsen despite initial reversal efforts. The combination use of 4F-PCC and AA has not been evaluated in clinical trials and the outcomes of such patients with FXA-inhibitor associated intracranial hemorrhage (ICH) are unknown. A total of five patients, including four outside hospital transfers, received 4F-PCC prior to AA for FXa-inhibitor associated ICH (n = 3 apixaban, n = 2 rivaroxaban; n = 4 ICH, n = 1 TBI). The doses of 4F-PCC ranged from 25 to 60 units/kg and were administered within a range of 1.5-4.2 h prior to AA. One patient required surgical intervention with craniotomy and three patients underwent external ventricular drain placement. Two of the five patients developed an ischemic or thromboembolic complication within one week from 4F-PCC and AA administration. This case series discusses multiple unique patient cases in which 4F-PCC and AA were both administered for FXa-inhibitor associated ICH. The results highlight the potentially increased thrombotic risk associated with combination use. Ongoing post-marketing data collection of real patient case scenarios are essential to the establishment of consensus guidelines on how to prioritize initial reversal efforts and manage these patients during the course of their bleed.

To manage factor Xa (FXa) inhibitor-associated bleeding, andexanet alfa or 4-factor prothrombin concentrate (4F-PCC) has been used to restore hemostasis. However, literature on the outcomes for patients who received both andexanet alfa and 4F-PCC is limited.
We report a case series of 5 patients who received andexanet alfa plus 4F-PCC for reversal of FXa inhibitor-associated bleeding. Patients were included in this case series if they received both andexanet alfa and 4F-PCC for reversal of FXa inhibitor-associated bleeding. They were followed to either discharge or death, and in-hospital complications related to concurrent use of andexanet alfa and 4F-PCC were documented. We report an incidence of thromboembolism of 40% (2 of 5 cases) and an in-hospital mortality rate of 60% (3 of 5 cases). Taking these cases together with those in the existing literature, we found a total of 23 reported cases of safety outcomes with andexanet alfa plus 4F-PCC. The overall incidence of thromboembolism was 35% (8 of 23 cases).
This case series adds to the limited literature describing the outcomes for patients receiving andexanet alfa plus 4F-PCC. We encourage other institutions to report safety data on administering both agents.