COVID-19 pandemic and transfusion medicine: the worldwide challenge and its implications.

COVID-19 pandemic has imposed worldwide challenge and has significantly affected transfusion medicine. Shortage in blood products along with concerns regarding the safety of blood products have emerged. Measures to overcome these challenges have been implemented in order to decrease the demand on blood products and to encourage blood donations while taking full precautions to minimize risk of COVID-19 transmission mainly at blood banks and medical centers. Several countries have been successful in facing these new challenges. In addition, the role of plasma therapy in the treatment of COVID-19 patients, especially in severe cases, has been proposed and current studies are being conducted to determine its efficacy. Other therapeutic options are currently being explored. So far, the use of convalescent plasma is considered a promising rescue treatment to be looked at.

Temporal trends and outcome of splenectomy in adults with immune thrombocytopenia in the USA.

Splenectomy is one of the treatments of immune thrombocytopenia (ITP) with a high response rate. However, it is an irreversible procedure that can be associated with morbidity in this setting. Our aim was to study the trends of splenectomy in adults with ITP, and the factors associated with splenectomy and resource utilization during these hospitalizations. We used the National (Nationwide) Inpatient Sample (NIS) to identify hospitalizations for adult patients with a principal diagnosis of ITP between 2007 and 2017. The primary outcome was the splenectomy trend. Secondary outcomes were (1) incidence of ITP trend, (2) in-hospital mortality, length of stay, and total hospitalization costs after splenectomy trend, and (3) independent predictors of splenectomy, length of stay, and total hospitalization costs. A total of 36,141 hospitalizations for ITP were included in the study. The splenectomy rate declined over time (16% in 2007 to 8% in 2017, trend p < 0.01) and so did the in-hospital mortality after splenectomy. Of the independent predictors of splenectomy, the strongest was elective admissions (adjusted odds ratio [aOR]: 22.1, 95% confidence interval [CI]:17.8-27.3, P < 0.01), while recent hospitalization year, older age, and Black (compared to Caucasian) race were associated with lower odds of splenectomy. Splenectomy tends to occur during elective admissions in urban medical centers for patients with private insurance. Despite a stable ITP hospitalization rate over the past decade and despite listing splenectomy as a second-line option for management of ITP in major guidelines, splenectomy rates consistently declined over time.

Hepatocellular Carcinoma in ß-Thalassemia Patients: Review of the Literature with Molecular Insight into Liver Carcinogenesis.

With the continuing progress in managing patients with thalassemia, especially in the setting of iron overload and iron chelation, the life span of these patients is increasing, while concomitantly increasing incidences of many diseases that were less likely to show when survival was rather limited. Hepatocellular carcinoma (HCC) is a major life-threatening cancer that is becoming more frequently identified in this population of patients. The two established risk factors for the development of HCC in thalassemia include iron overload and viral hepatitis with or without cirrhosis. Increased iron burden is becoming a major HCC risk factor in this patient population, especially in those in the older age group. As such, screening thalassemia patients using liver iron concentration (LIC) measurement by means of magnetic resonance imaging (MRI) and liver ultrasound is strongly recommended for the early detection of iron overload and for implementation of early iron chelation in an attempt to prevent organ-damaging iron overload and possibly HCC. There remain lacking data on HCC treatment outcomes in patients who have thalassemia. However, a personalized approach tailored to each patient's comorbidities is essential to treatment success. Multicenter studies investigating the long-term outcomes of currently available therapeutic options in the thalassemia realm, in addition to novel HCC therapeutic targets, are needed to further improve the prognosis of these patients.

Drug therapies for metastatic castration-resistant prostate cancer.

Management of metastatic castration-resistant prostate cancer has changed markedly over the last decade with major shifts in the treatment paradigm, although ultimately still will progress despite currently available therapies. The sequencing or combination of these agents is an area of active investigation, since definitive prospective randomized trials to define the optimal choice of drug sequence have yet to be done or resulted. This article will highlight pivotal trials for currently approved therapies for metastatic castration-resistant prostate cancer and a suggestion for sequencing of these agents, as well as highlighting investigations using novel therapies for advanced prostate cancer.

The lived experiences of patients with cancer during the COVID-19 pandemic: a qualitative study.

Background: The objective of this study was to explore the impact of COVID-19 on the lived experiences of patients with cancer in Lebanon. Methods: We adopted a descriptive phenomenological approach. We included adults who had been diagnosed with cancer before the pandemic and undergoing treatment at the American University of Beirut Medical Centre. We conducted virtual, semi-structured in-depth interviews with either video or audio recordings. Two team members coded the transcripts independently and identified common themes and patterns. Results: We recruited 11 participants for the study. The analysis identified the following six themes: perceived seriousness of COVID-19, fear of COVID-19 versus fear of cancer, coping mechanisms, treatment availability and accessibility, compliance with public health and social measures and precautionary measures in the healthcare system. The coping mechanisms included staying positive, seeking normalcy, using family support, religiosity and fatalism. Conclusion: Faced with many challenges during the COVID-19 pandemic, patients with cancer resorted to a range of coping strategies.

Frequency and mutational spectrum of PIK3CA gene mutations in breast cancer patients: Largest and first report from Lebanon.

The PIK3CA pathway is one of the most frequently altered pathways in human cancers, especially in breast cancer with approximately 40% of HR+/HER2- advanced breast cancer cases exhibiting mutations in the PIK3CA gene. While the mutations can occur across the entire gene, the most common are observed in exon 9 corresponding to the helical domain, and in exon 20 encompassing the kinase domain. This study constitutes the first attempt at determining the frequency and mutational spectrum in Lebanese breast cancer patients. For this purpose, DNA samples from 280 breast cancer patients from across Lebanon were screened for PIK3CA mutations using the Therascreen® PIK3CA RGQ Real-time PCR assay. In line with previous reports, 38.57% of cases were positive for at least one PIK3CA mutation, among which approximately 59% were in exon 9 and 37% in exon 20. However, PIK3CA mutations are breast cancer are heterogeneous whereby 20% of known PIK3CA mutants might not be detected by compact PCR based assays. Thus, the adoption of comprehensive Next Generation Sequencing based panels to decipher the complete clinical, molecular and immunohistochemical profile of breast cancer tumor requires further investigation.

Tumor Lysis Syndrome: A Rare Complication of Metastatic Gastric Cancer and a Possible Indicator of Disease Progression.

Tumor lysis syndrome (TLS) is an oncologic emergency that is usually associated with hematologic malignancies either spontaneously or following early chemotherapy and is caused by massive tumor cell lysis. However, it has been rarely reported in solid tumors. We report a case of 25-year-old lady recently diagnosed with metastatic gastric adenocarcinoma who developed TLS after the fourth cycle of chemoimmunotherapy (FOLFOX plus Nivolumab). She presented with abdominal pain, decrease in oral intake and decreased urine output. Laboratory studies showed acute kidney injury with electrolyte disturbances and was diagnosed initially with autoimmune nephritis secondary to Nivolumab but was later found to have TLS and recovered after appropriate treatment. Soon after this complication, our patient was found to have disease progression on imaging which makes the incidence of TLS an indicator of disease progression.

Oxaliplatin-induced thrombotic microangiopathy: a case report.

BACKGROUND: Oxaliplatin-based chemotherapy represents a standard of care in the treatment of metastatic colorectal cancer. We report a rare case of fulminant oxaliplatin-induced thrombotic microangiopathy, clinically suggestive of hemolytic-uremic syndrome, occurring in a female patient with a prolonged history of exposure to oxaliplatin for the treatment of metastatic colon cancer. CASE PRESENTATION: A 73-year-old Caucasian female with a treatment history including several lines of chemotherapy for the management of metastatic colon cancer was reinitiated on chemotherapy with oxaliplatin, fluorouracil, and leucovorin with bevacizumab for disease progression. She presented to the emergency department with malaise, headache, vomiting, and decreased urine output appearing a few hours after chemotherapy administration. Clinical symptoms and laboratory findings were suggestive of thrombotic microangiopathy, with a triad of microangiopathic hemolytic anemia, pronounced thrombocytopenia, and acute renal failure. The predominance of the severe renal failure was evocative of hemolytic-uremic syndrome. The rapid development of the thrombotic microangiopathy was linked to exposure to oxaliplatin. The patient was promptly managed with daily plasma exchange and high-dose corticosteroids, platelet, and red blood cell transfusions in conjunction with intermittent hemodialysis, and she recovered progressively. CONCLUSION: Our case confirms the risk of hemolytic-uremic syndrome as a rare and life-threatening complication of oxaliplatin-based chemotherapy. A dose-dependent, drug-induced toxicity mechanism is suggested. Physicians need to maintain a high level of clinical suspicion to diagnose and treat this acute life-threatening disorder.

Role of urine studies in asymptomatic febrile neutropenic patients presenting to the emergency department.

BACKGROUND: The role of urine studies in the detection of urinary tract infection (UTI) in febrile neutropenic patients with urinary symptoms (having a urinary catheter or having a positive urine analysis) is inarguable. However, the evidence is scarce regarding the indication for urine studies in asymptomatic (i.e., without urinary symptoms) patients with febrile neutropenia (FN) presenting to the emergency department (ED). The aim of this study is to evaluate the need for obtaining urine studies in asymptomatic febrile neutropenic patients. METHODS: This was a retrospective cohort study conducted on adult cancer patients who presented to the ED with FN and had no urinary symptoms. We included all ED presentations of eligible patients between January 2013 and September 2018. Student's t-test and Wilcoxon rank-sum test were used for continuous data, while Chi-square and Fisher's exact tests were used for categorical data. Participants were divided into two groups based on their urine culture (UC) results: negative and positive UCs. Two cut-offs were used for positive UC results: ≥105 cfu/mL and ≥104 cfu/mL. RESULTS: We included 284 patients in our study. The age of our patient population was 48.5±18.5 years. More than two-thirds (68.7%) of patients had severe neutropenia, while only 3.9% and 9.9% of the patients had positive UCs at ≥105 cfu/mL and ≥104 cfu/mL, respectively. UCs were expectedly positive in most patients with urinalysis (UA) abnormalities. However, 27.3% and 32.1% of patients with positive UCs at ≥105 cfu/mL and ≥104 cfu/mL respectively had a normal UA. CONCLUSIONS: In our study, the incidence of UTI in adult febrile neutropenic cancer patients who present to the ED without urinary symptoms is low. Consequently, routine urine testing may not be warranted in this population, as it adds unnecessary financial burdens on the patients and delays timely management.

Zoledronic acid for the treatment of prostate cancer.

INTRODUCTION: Prostate cancer remains the most common solid tumor afflicting men in the developed world. Metastatic prostate cancer is a source of great morbidity and mortality especially due to osseous involvement that gives rise to significant symptoms of pain or pathologic fractures or cord compression. Bisphosphonates had been widely used in the treatment of metastatic prostate bone metastases given their demonstrated benefit with a delay of skeletal-related events (SREs) but without prostate-specific antigen (PSA) response or overall survival benefit. Areas covered: In this review, the authors summarize the available literature on the clinical studies that led to the development and regulatory approval of zoledronic acid in men with metastatic prostate cancer. The authors also provide their expert opinion and future perspectives on this therapeutic. Expert opinion: Zoledronic acid is an established adjunctive treatment and bone-targeted therapy for the supportive care of men with metastatic castration-resistant prostate cancer. Efforts to study its utility in earlier phases of metastatic hormone-sensitive prostate cancer has not shown superior outcomes compared with standard androgen deprivation therapy (ADT) or docetaxel alone.

Bariatric venous thromboembolism prophylaxis: an update on the literature.

Introduction: Rates of obesity have been increasing worldwide and with the current situation obesity now represents an epidemic. Bariatric surgery is one the most effective ways to help reduce weight and sustain weight loss. Venous thromboembolism is a major cause of morbidity and mortality among bariatric surgery patients with no clearly established guidelines on prophylaxis. Areas covered: In this review the authors summarize clinical studies evaluating unfractionated heparin (UFH) and low molecular weight heparins (LMWH) in bariatric surgery patients. The authors present studies that assessed venous thromboembolic (VTE)-related risk stratification but also various dosing regimens of heparin products in this population of patients. Moreover, the authors will also present the feasibility of using direct oral anticoagulants (DOACs) for venous thromboembolism (VTE) prevention along with providing a summary of few current guidelines for VTE prevention in bariatric surgery patients. Expert opinion: Based on the data presented in this review, the authors conclude that LMWHs may be better options than UFH for VTE prophylaxis in bariatric surgery patients. We also conclude that risk stratifying bariatric patients may be a better approach when deciding on the best thromboprophylaxis modality, dose and duration.

Peritoneal metastases from malignant degeneration of ectopic gastric epithelium in Meckel's diverticulum: A case report.

BACKGROUND: Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract, resulting from incomplete obliteration of the omphalomesenteric duct in early fetal development. The diverticulum frequently contains ectopic gastrointestinal epithelial tissue, most commonly gastric or pancreatic. Adenocarcinoma can arise from either of these epithelia but is extremely rare, with less than 50 cases reported in the world literature. METHODS: In a patient with peritoneal metastases from ectopic gastric mucosae in a Meckel's diverticulum a multidisciplinary treatment plan was initiated. RESULTS: Diagnosis was evident from study of the resected specimen of small bowel in a patient with acute abdominal pain. A multiagent chemotherapy regimen using oxaliplatin, mitomycin C, doxorubicin, and capecitabine (O-Max) resulted in a clinical and radiologic response. A second surgery with extensive sampling of tissues from the abdomen and pelvis confirmed a complete response to systemic chemotherapy. At four years from onset of disease the patient has no evidence of recurrence. CONCLUSIONS: Peritoneal metastases from malignant degeneration of ectopic gastric epithelium in a Meckel's diverticulum was reported. Multidisciplinary treatments were beneficial.

The use of direct oral anticoagulants in the treatment of acute venous thromboembolism in cancer patients.

INTRODUCTION: After the CLOT study, LMWHs (low-molecular weight heparins) have gradually replaced warfarin as the treatment of choice for VTE (venous thromboembolism) in cancer patients. Randomized controlled studies comparing DOACs (direct oral anticoagulants) to LMWHs in cancer patients are still limited. However, new emerging data are supporting the use of DOACs in cancer-associated thrombosis. Areas covered: This review will discuss the recent studies that addressed the utilization of such agents in the treatment of VTE in cancer patients. It will also address challenges that can be encountered while using these agents particularly in cancer patients. Expert commentary: Up until the Hokusai VTE Cancer study, data on the use of DOACs in cancer patients have been limited but supportive of their use in such patients. The Hokusai VTE Cancer study shows that edoxaban is non-inferior to dalteparin in prevention of recurrent VTE but at expense of higher major bleeding namely in patients with gastrointestinal cancer. Although further studies involving other DOACs may reinforce the efficacy of DOACs in this population of patients, studies looking at subpopulation of cancer patients may be of more clinical value to clinicians who are trying to balance between treatment of thrombosis and risks of bleeding.

Immune-based Therapies for Non-small Cell Lung Cancer.

Lung cancer is the leading cause of cancer-related death worldwide. Treatment of non-small cell lung cancer has evolved tremendously over the past decade. Specifically, immune checkpoint inhibitors have become an increasingly interesting target of pharmacological blockade. These immune inhibitors have shown promising results in front-line therapy and after failure of multiple lines, as well as in monotherapy and combination with other therapies. Vaccination in non-small cell lung cancer is also an emerging field of research that holds promising results for the future of immunotherapy in non-small cell lung cancer. This review presents a concise update on the most recent data regarding the role of checkpoint inhibitors as well as vaccination in non-small cell lung cancer.

Characterization of Differences Between Prostate Cancer Patients Presenting With De Novo Versus Primary Progressive Metastatic Disease.

BACKGROUND: Men who present with metastatic disease can have de novo or primary progressive disease. We characterized and compared the outcomes between these 2 groups. PATIENTS AND METHODS: A retrospective cross-sectional analysis from a single institution of de novo versus primary progressive metastatic patients during a 2-year consecutive period was undertaken. Patient characteristics such as demographics, Gleason score, duration of hormone sensitivity, and treatment were obtained. The t test, Mann-Whitney U test, and Fisher exact test were used to test differences in patient and disease characteristics between the de novo and primary progressive metastatic groups. Differences in the Kaplan-Meier survival curves were compared using the log-rank test. RESULTS: A total of 90 patients (n = 38 with de novo and 52 with primary progressive disease) were included. Statistically significant median differences were found for the prostate-specific antigen level at the development of metastases: de novo 63.1 ng/ml vs primary progressive 12.5 ng/ml, p= <.001; albumin and hemoglobin, P = .03 and P = .045, respectively). The median duration of hormone sensitivity was 372 days (range, 54-3753 days) in the de novo group versus 1613 days (range, 7-4314 days) in the primary progressive group (P = .00006). Overall survival was worse in the de novo arm, with a median survival of 6.2 years compared with a median survival in the primary progressive group of 11.6 years (P = .027). CONCLUSION: Although the reported samples were small, our data revealed a potential difference in disease aggressiveness in those presenting with de novo metastatic cancer with higher risk disease and shorter time to castration resistance and worse survival. These data could have implications for earlier and more aggressive treatment for men presenting with de novo metastatic prostate cancer.

Plasmablastic Lymphoma: Case Report of Prolonged Survival of an Advanced Human Immunodeficiency Patient and Literature Review.

Clinical Practice Points. Plasmablastic lymphoma (PBL) is a rare and highly aggressive variant of diffuse large B cell lymphoma with median survival of advanced stage patients varying between 6 and 15 months in previous reports. We report here a human immunodeficiency virus-infected patient surviving over 12 years following treatment for advanced PBL with EPOCH chemotherapy and intrathecal therapy. This case highlights the potential for improved survival in PBL with intensive chemotherapy. Further, literature review suggests promising prospects utilizing novel targeted therapies to increase the rate of prolonged responses.

Advanced prostate cancer - patient survival and potential impact of enzalutamide and other emerging therapies.

The advent of exponential growth of novel agents tested and approved for the treatment of patients with metastatic castration-resistant prostate cancer (mCRPC) has brought about a need for understanding of the mechanism of action, side-effects, and clinical efficacy of these drugs as they relate to these patients. This review will provide a synopsis of the treatment landscape in mCRPC as varying agents such as abiraterone acetate, cabazitaxel, sipuleucel-T, radium, and selected emerging agents are presented. A distinct focus on the utilization of enzalutamide, its mechanism of action, key pivotal trials that brought about its US Food and Drug Administration approval, as well as patient-focused perspectives and clinical implications are discussed herein.