The impact of cancer metastases on COVID-19 outcomes: A COVID-19 and Cancer Consortium registry-based retrospective cohort study.

BACKGROUND: COVID-19 can have a particularly detrimental effect on patients with cancer, but no studies to date have examined if the presence, or site, of metastatic cancer is related to COVID-19 outcomes. METHODS: Using the COVID-19 and Cancer Consortium (CCC19) registry, the authors identified 10,065 patients with COVID-19 and cancer (2325 with and 7740 without metastasis at the time of COVID-19 diagnosis). The primary ordinal outcome was COVID-19 severity: not hospitalized, hospitalized but did not receive supplemental O2, hospitalized and received supplemental O2, admitted to an intensive care unit, received mechanical ventilation, or died from any cause. The authors used ordinal logistic regression models to compare COVID-19 severity by presence and specific site of metastatic cancer. They used logistic regression models to assess 30-day all-cause mortality. RESULTS: Compared to patients without metastasis, patients with metastases have increased hospitalization rates (59% vs. 49%) and higher 30 day mortality (18% vs. 9%). Patients with metastasis to bone, lung, liver, lymph nodes, and brain have significantly higher COVID-19 severity (adjusted odds ratios [ORs], 1.38, 1.59, 1.38, 1.00, and 2.21) compared to patients without metastases at those sites. Patients with metastasis to the lung have significantly higher odds of 30-day mortality (adjusted OR, 1.53; 95% confidence interval, 1.17-2.00) when adjusting for COVID-19 severity. CONCLUSIONS: Patients with metastatic cancer, especially with metastasis to the brain, are more likely to have severe outcomes after COVID-19 whereas patients with metastasis to the lung, compared to patients with cancer metastasis to other sites, have the highest 30-day mortality after COVID-19.

COVID-19 severity and cardiovascular outcomes in SARS-CoV-2-infected patients with cancer and cardiovascular disease.

Background: Data regarding outcomes among patients with cancer and co-morbid cardiovascular disease (CVD)/cardiovascular risk factors (CVRF) after SARS-CoV-2 infection are limited. Objectives: To compare Coronavirus disease 2019 (COVID-19) related complications among cancer patients with and without co-morbid CVD/CVRF. Methods: Retrospective cohort study of patients with cancer and laboratory-confirmed SARS-CoV-2, reported to the COVID-19 and Cancer Consortium (CCC19) registry from 03/17/2020 to 12/31/2021. CVD/CVRF was defined as established CVD or no established CVD, male ≥ 55 or female ≥ 60 years, and one additional CVRF. The primary endpoint was an ordinal COVID-19 severity outcome including need for hospitalization, supplemental oxygen, intensive care unit (ICU), mechanical ventilation, ICU or mechanical ventilation plus vasopressors, and death. Secondary endpoints included incident adverse CV events. Ordinal logistic regression models estimated associations of CVD/CVRF with COVID-19 severity. Effect modification by recent cancer therapy was evaluated. Results: Among 10,876 SARS-CoV-2 infected patients with cancer (median age 65 [IQR 54-74] years, 53% female, 52% White), 6253 patients (57%) had co-morbid CVD/CVRF. Co-morbid CVD/CVRF was associated with higher COVID-19 severity (adjusted OR: 1.25 [95% CI 1.11-1.40]). Adverse CV events were significantly higher in patients with CVD/CVRF (all p<0.001). CVD/CVRF was associated with worse COVID-19 severity in patients who had not received recent cancer therapy, but not in those undergoing active cancer therapy (OR 1.51 [95% CI 1.31-1.74] vs. OR 1.04 [95% CI 0.90-1.20], pinteraction <0.001). Conclusions: Co-morbid CVD/CVRF is associated with higher COVID-19 severity among patients with cancer, particularly those not receiving active cancer therapy. While infrequent, COVID-19 related CV complications were higher in patients with comorbid CVD/CVRF. (COVID-19 and Cancer Consortium Registry [CCC19]; NCT04354701).

Impact of COVID-19 in patients on active melanoma therapy and with history of melanoma.

INTRODUCTION: COVID-19 particularly impacted patients with co-morbid conditions, including cancer. Patients with melanoma have not been specifically studied in large numbers. Here, we sought to identify factors that associated with COVID-19 severity among patients with melanoma, particularly assessing outcomes of patients on active targeted or immune therapy. METHODS: Using the COVID-19 and Cancer Consortium (CCC19) registry, we identified 307 patients with melanoma diagnosed with COVID-19. We used multivariable models to assess demographic, cancer-related, and treatment-related factors associated with COVID-19 severity on a 6-level ordinal severity scale. We assessed whether treatment was associated with increased cardiac or pulmonary dysfunction among hospitalized patients and assessed mortality among patients with a history of melanoma compared with other cancer survivors. RESULTS: Of 307 patients, 52 received immunotherapy (17%), and 32 targeted therapy (10%) in the previous 3 months. Using multivariable analyses, these treatments were not associated with COVID-19 severity (immunotherapy OR 0.51, 95% CI 0.19 - 1.39; targeted therapy OR 1.89, 95% CI 0.64 - 5.55). Among hospitalized patients, no signals of increased cardiac or pulmonary organ dysfunction, as measured by troponin, brain natriuretic peptide, and oxygenation were noted. Patients with a history of melanoma had similar 90-day mortality compared with other cancer survivors (OR 1.21, 95% CI 0.62 - 2.35). CONCLUSIONS: Melanoma therapies did not appear to be associated with increased severity of COVID-19 or worsening organ dysfunction. Patients with history of melanoma had similar 90-day survival following COVID-19 compared with other cancer survivors.

Clinical outcomes of COVID-19 in patients with sickle cell disease and sickle cell trait: A critical appraisal of the literature.

Individuals with sickle cell disease (SCD) and sickle cell trait (SCT) have many risk factors that could make them more susceptible to COVID-19 critical illness and death compared to the general population. With a growing body of literature in this field, a comprehensive review is needed. We reviewed 71 COVID-19-related studies conducted in 15 countries and published between January 1, 2020, and October 15, 2021, including a combined total of over 2000 patients with SCD and nearly 2000 patients with SCT. Adults with SCD typically have a mild to moderate COVID-19 disease course, but also a 2- to 7-fold increased risk of COVID-19-related hospitalization and a 1.2-fold increased risk of COVID-19-related death as compared to adults without SCD, but not compared to controls with similar comorbidities and end-organ damage. There is some evidence that persons with SCT have increased risk of COVID-19-related hospitalization and death although more studies with risk-stratification and properly matched controls are needed to confirm these findings. While the literature suggests that most children with SCD and COVID-19 have mild disease and low risk of death, some children with SCD, especially those with SCD-related comorbidities, are more likely to be hospitalized and require escalated care than children without SCD. However, children with SCD are less likely to experience COVID-19-related severe illness and death compared to adults with or without SCD. SCD-directed therapies such as transfusion and hydroxyurea may be associated with better COVID-19 outcomes, but prospective studies are needed for confirmation. While some studies have reported favorable short-term outcomes for COVID-19 patients with SCD and SCT, the long-term effects of SARS-CoV-2 infection are unknown and may affect individuals with SCD and SCT differently from the general population. Important focus areas for future research should include multi-center studies with larger sample sizes, assessment of hemoglobin genotype and SCD-modifying therapies on COVID-19 outcomes, inclusion of case-matched controls that account for the unique sample characteristics of SCD and SCT populations, and longitudinal assessment of post-COVID-19 symptoms.

A Case of Symptomatic Cerebral Radiation Necrosis for an Extra-Cranial Neoplasm from Conventional Radiotherapy With Concurrent Immunotherapy.

Cerebral radiation necrosis (RN) is a known complication of brain radiotherapy (RT). The incidence rate of RN varies with the total dose, dose fractionation, and radiotherapy modality. Concurrent treatment with immunotherapy can increase the risk factors for developing RN through a synergistic mechanism. Here, we describe a patient who developed cerebral RN after receiving conventional RT to an extra-cranial site, while he was receiving immune checkpoint inhibitor (ICI) therapy.

Hematologic Findings in Pregnancy: A Guide for the Internist.

Hematologic changes in pregnancy are common and can potentially lead to maternal and fetal morbidity. Here, we present various hematologic manifestations seen in pregnant women. Iron deficiency anemia (IDA) is the most common cause of anemia in pregnancy. Physiologically, the state of pregnancy results in increased iron demand. Iron deficiency is important to diagnose and treat early for better maternal and fetal outcomes. An algorithmic approach is used for the repletion of iron storage, starting with oral elemental iron daily and escalating to intravenous iron if necessary. Folate and cobalamin are necessary elements for deoxyribonucleic acid (DNA) synthesis, fetal growth, and maternal tissue development, and deficiency in these elements can be a cause for anemia in pregnancy. Thrombocytopenia is currently the second most common hematologic condition in pregnancy after anemia. There is a wide range of etiology for thrombocytopenia in pregnancy from benign to life-threatening causes that require prompt diagnosis and treatment. These conditions include gestational thrombocytopenia, thrombotic thrombocytopenic purpura, pregnancy-associated atypical hemolytic-uremic syndrome, and immune thrombocytopenia. Acquired bleeding disorders that can cause major complications in pregnancy include von Willebrand disease (vWD) and coagulation factor deficiencies. Women with vWD are at increased risk of pregnancy bleeding and postpartum hemorrhage. Pregnancy can also produce a physiologic hypercoagulable state, leading to life-threatening conditions like thromboembolism. Diagnosis, treatment options, and guidelines for the management of these conditions will be explored in this review.

Transient Anti-Phospholipid Antibodies in Two Patients With COVID-19.

We report two cases of coronavirus disease 2019 (COVID-19) in patients who developed pulmonary embolism and transient anti-phospholipid antibodies. At the time of presentation with acute pulmonary embolism, both patients had leukocytosis and increased levels of anti-cardiolipin antibodies, which resolved at testing 12 weeks after initial presentation. Studying cases of pulmonary embolism and increased anti-phospholipid antibodies in the context of COVID-19 could be one of the factors for elucidating the possible connection between severe acute respiratory syndrome coronavirus 2 infection, anti-phospholipid antibodies, and thrombosis.

A Case of Chronic Eosinophilic Leukemia in a Patient With Recurrent Cough, Dyspnea, and Eosinophilia.

We report the case of a 40-year-old man with no significant past medical history who had been hospitalized multiple times over the course of one year with recurring cough, dyspnea, pruritic rash, and variable degrees of eosinophilia. He was variably diagnosed with asthma and pneumonia. After his last hospitalization with severe symptoms, the patient was referred for pulmonary evaluation where hypereosinophilia (HE) led to a hematologic workup. Fluorescence in situ hybridization revealed the FIP1L1-PDGFRA gene fusion and bone marrow analysis confirmed a diagnosis of chronic eosinophilic leukemia. The patient was treated with daily imatinib and prednisone and he was symptom-free at a four-week follow-up examination.

Guillain-Barré Syndrome in a Patient with Sickle Cell Anemia.

Description A 24-year-old African American male with a history of sickle cell anemia (Hb S/S) presented to an outside hospital with acute colitis, acute renal failure and sickle cell crisis and was treated with supportive measures. On day 3 of hospitalization, he developed bilateral ascending paralysis with sacral numbness. Magnetic resonance imaging (MRI) demonstrated epidural lipomatosis, which was attributed as the cause of his paralysis. He was transferred to our facility for neurosurgery evaluation. Based on the physical examination, Guillain-Barré Syndrome (GBS) was suspected. This conclusion lead to a lumbar puncture with cerebrospinal fluid (CSF) analysis that confirmed the diagnosis. He was then treated with intravenous immunoglobulin (IVIg), which resolved his symptoms. We present this case to highlight the importance of a physical exam rather than relying heavily on imaging studies. Physical exam findings lead to a diagnosis, which was then confirmed with appropriate testing.

Impact of COVID-19 Infection on 24 Patients with Sickle Cell Disease. One Center Urban Experience, Detroit, MI, USA.

The city of Detroit has a large population of individuals with sickle cell disease, and hospitals in Detroit have seen some of the highest numbers of cases of coronavirus disease-19 (COVID-19) in 2020. The purpose of this study was to examine the pathophysiological characteristics of COVID-19 in patients with sickle cell disease or trait to determine whether these patients have unique manifestations that might require special consideration. This retrospective analysis included 24 patients with confirmed COVID-19 and sickle cell disease or trait who were seen at the Henry Ford Hospital, Detroit, MI, USA, between March 1 and April 15 2020. Of the 24 patients, 18 (75.0%) had heterozygous sickle cell trait, one (4.0%) was a double heterozygote for Hb S (HBB: c.20A>T)/ß+-thalassemia (ß+-thal), four had sickle cell anemia (ßS/ßS) and one (4.0%) had Hb S/Hb C (HBB: c.19G>A) disease. A total of 13 (54.0%) patients required hospitalization. All four patients with sickle cell anemia, developed acute pain crisis. We observed one patient who developed acute pulmonary embolism and no patients developed other sickle cell associated complications. Additionally, three (13.0%) patients required packed red blood cell transfusion without the need of exchange transfusion, and one patient required admission to the intensive care unit (ICU), mechanical ventilation and subsequently died. Patients with sickle cell disease or trait and laboratory-confirmed COVID-19 had a generally mild, or unremarkable, course of disease, with lower chances of intubation, ICU admission and death, but with a slightly longer hospitalization.

Hematology/Oncology Fellowship Emergency Restructuring in Response to the COVID-19 Pandemic-Henry Ford Hospital, Michigan.

The COVID-19 pandemic has wreaked havoc and created challenges in various subspecialty training programs, including hematology/oncology fellowship programs. The challenge of social distancing, providing care for those infected by COVID-19, continuing appropriate treatment of time-sensitive diseases, and the looming threat of health care worker infections required swift planning and restructuring of training programs. The Accreditation Council for Graduate Medical Education provided leeway to tackle the challenges faced by institutions and training programs in the setting of the COVID-19 pandemic. Currently, there is no established guideline specific to hematology and oncology fellowship programs. While understanding that there is no one-size-fits-all, shared experiences can assist training programs to incorporate best practices and customize their programs to provide an active educational environment that balances patient care needs, didactics, scholarly activities, and wellbeing during the process of rapid changes and adaptation. We share our hematology/oncology fellowship program's restructuring approach in response to the COVID-19 pandemic.

Sarcoidosis presenting as massive splenomegaly and severe epistaxis, case report.

Sarcoidosis is a multisystem disorder of unknown etiology. Extrapulmonary sarcoidosis can involve any organ, but isolated spleen involvement is rare. Diagnosis can be challenging as other etiologies may have similar presentations. A 58-year-old African American female presented with life threatening epistaxis, anemia, refractory thrombocytopenia, and massive splenomegaly. Lymphoproliferative, infectious, and autoimmune etiologies were eliminated with laboratory testing and bone marrow biopsy. The patient had multiple splenic artery aneurysms precluding an open diagnostic splenectomy. Partial splenic artery embolization was performed, which normalized the platelet count and resolved the spontaneous bleeding. This allowed diagnostic splenectomy and splenic artery repair to be safely performed. Surgical pathology demonstrated extensive non-caseating granulomas consistent with sarcoidosis. We present this case to demonstrate the omnipotent nature of sarcoidosis and a complex multi-disciplinary approach for successful diagnosis and treatment.

Acute Plasma Cell Leukemia Presenting as Primary Hyperammonemic Encephalopathy.

Primary plasma cell leukemia (PPCL) is a rare form of multiple myeloma (MM) and is a rare aggressive disease with a median overall survival of 6 - 11 months. We present a case of acute hyperammonemic encephalopathy as the initial presentation of PPCL in a 78-year-old woman to highlight an atypical presentation of this disorder.

Massive Gastrointestinal Bleeding Secondary to Ileal Invasion by Ventral Hernioplasty Mesh.

Surgical mesh migration is a very rare cause of gastrointestinal (GI) bleeding. We report a 56-year-old woman who presented with massive GI bleeding 10 years after ventral hernioplasty with mesh. Esophagoduodenoscopy and colonoscopy were normal. Computed tomographic angiography of the abdomen showed no active GI bleeding or bowel perforation. Tagged red blood cell scan suggested active bleeding in the proximal ileum. Exploratory laparotomy showed the ventral hernia mesh eroding into the ileum. This case emphasizes the limitations of radiologic imaging in evaluating GI bleeding and the recognition of ventral mesh migration and invasion as a potential etiology of small-bowel bleeding.

Policing, massive street drug testing and poly-substance use chaos in Georgia - a policy case study.

BACKGROUND: Since early 2000, intensive policing, wide scale street drug testing, and actions aimed at limiting the availability of specific drugs have been implemented in Georgia. Supporters of this approach argue that fear of drug testing and resulting punishment compels drug users to stop using and prevents youth from initiating drug use. It has been also stated that reduction in the availability of specific drugs should be seen as an indication of the overall success of counter-drug efforts. The aim of the current review is to describe the drug-related law enforcement response in Georgia and its impact on illicit drug consumption and drug-related harm. METHOD: We reviewed relevant literature that included peer-reviewed scientific articles, stand-alone research reports, annual drug situation reports, technical reports and program data. This was also supplemented by the review of relevant legislation and judicial practices for the twelve year period between 2002 and 2014. RESULTS: Every episode of reduced availability of any "traditional" injection drug was followed by the discovery/introduction of a new injection preparation. The pattern of drug consumption was normally driven by users' attempts to substitute their drug of choice through mixing together available alternative substances. Chaotic poly-substance use and extensive utilization of home-made injection drugs, prepared from toxic precursors, became common. Massive random street drug testing had little or no effect on the prevalence of problem drug use. CONCLUSIONS: Intensive harassment of drug users and exclusive focus on reducing the availability of specific drugs did not result in reduction of the prevalence of injecting drug use. Repressive response of Georgian anti-drug authorities relied heavily on consumer sanctions, which led to shifts in drug users' behavior. In most cases, these shifts were associated with the introduction and use of new toxic preparations and subsequent harm to the physical and mental health of drug consumers.