The Successful Treatment of COVID-19-Induced Bullous Pemphigoid With Dupilumab.

Bullous pemphigoid (BP) is a rare autoimmune blistering condition that predominantly affects the elderly population. Typical treatment regimens target the immune system and inflammatory response. We present a case of BP in a 78-year-old male patient that occurred following the coronavirus disease 2019 (COVID-19) vaccination. This case was refractory to topical steroids and immunosuppressants. However, it responded to treatment with dupilumab, a monoclonal antibody therapy. Dupilumab is classically indicated for the treatment of asthma, eosinophilic esophagitis, atopic dermatitis, and chronic rhinosinusitis with nasal polyposis. We highlight the importance of considering the off-label use of dupilumab and its success in treating BP.

Drepmel-A Multi-Omics Melanoma Drug Repurposing Resource for Prioritizing Drug Combinations and Understanding Tumor Microenvironment.

Although substantial progress has been made in treating patients with advanced melanoma with targeted and immuno-therapies, de novo and acquired resistance is commonplace. After treatment failure, therapeutic options are very limited and novel strategies are urgently needed. Combination therapies are often more effective than single agents and are now widely used in clinical practice. Thus, there is a strong need for a comprehensive computational resource to define rational combination therapies. We developed a Shiny app, DRepMel to provide rational combination treatment predictions for melanoma patients from seventy-three thousand combinations based on a multi-omics drug repurposing computational approach using whole exome sequencing and RNA-seq data in bulk samples from two independent patient cohorts. DRepMel provides robust predictions as a resource and also identifies potential treatment effects on the tumor microenvironment (TME) using single-cell RNA-seq data from melanoma patients. Availability: DRepMel is accessible online.

Preventative Cancer Screening Rates Among Uninsured Patients in Free Clinics: A Retrospective Cohort Study of Cancer Survivors and Non-cancer Survivors.

BACKGROUND: There is limited research on screening rates among uninsured cancer survivors. Uninsured cancer survivors are at higher risk of poorer health outcomes than the insured due to limited access to preventative screening for secondary cancers. This study examines the rates of surveillance and screening of uninsured cancer survivors and compares to uninsured patients without a cancer history seen in free clinics. METHODS: Data were collected retrospectively from electronic medical records and paper charts of patients from 10 free clinics between January 2016 and December 2018 in the Tampa Bay area. The prevalence of socioeconomic characteristics, cancer diagnoses, and screening practices were compared for cancer survivors and free clinic patients without a history of cancer. Study participants were determined to be eligible for cancer screenings based on the United States Preventive Services Task Force guidelines. RESULTS: Out of 13 982 uninsured patients frequenting free clinics between 2016 and 2018, 402 (2.9%) had a documented history of cancer. Out of the 285 eligible cancer survivors, 44 (15.4%) had completed age-appropriate colon cancer screening. Among the 170 female cancer survivors, 75 (44.1%) had completed breast cancer screenings, and only 5.9% (59/246) had completed cervical cancer screenings. After adjusting for age, gender, race, salary, employment status, and household size, cancer survivors were more likely to undergo colorectal cancer screening (OR: 3.59, 95% CI: 2.10-6.15) and breast cancer screening (OR: 2.13, 95% CI: 1.30-3.84) than patients without a cancer history. This difference was not seen for cervical cancer screening (OR: 0.99, 95% CI: .62-1.58). CONCLUSIONS: Uninsured cancer survivors frequenting free clinics represent a unique population that is underrepresented in the medical literature. Our results suggest that uninsured survivors use screening services at higher rates when compared to uninsured patients without a reported cancer diagnosis. However, these rates are suboptimal when compared to national screening rates of insured cancer survivors.

Colorectal Cancer Risk Factors and Screening Among the Uninsured of Tampa Bay: A Free Clinic Study.

INTRODUCTION: Uninsured patients with low socioeconomic status are at high risk for developing colorectal cancer (CRC), and data on risk factors and prevalence of CRC in this population are limited. The purpose of this study was to assess the risk factors for CRC in uninsured patients from free clinics in the Tampa Bay area of Florida. METHODS: We conducted a retrospective cohort study among patients 50 years or older who were provided service at 9 free clinics in the Tampa Bay area between 2016 and 2018. Demographics, chronic disease characteristics, and screening data were collected via a query of paper and electronic medical records. RESULTS: Of the 13,982 patients seen, 5,139 (36.8%) were aged 50 years or older. Most were female (56.8%), non-Hispanic White (41.1%), and unemployed (54.9%). Patients with CRC screening were more likely to be employed compared with patients without CRC screening (54.4% vs 44.4%, P = .01). Within the cohort, 725 (22.7%) patients were active smokers, 771 (29.2%) patients currently consumed alcohol, and 23 patients (0.4%) had a history of inflammatory bowel disease. Patients had a median body mass index of 29.4 (interquartile range, 25.4-34.2) kg/m2, and 1,455 (28.3%) had diabetes. Documented CRC screening was found among 341 (6.6%) patients. CONCLUSION: Uninsured patients had a high prevalence of CRC risk factors but a low reported screening rate for CRC. Free clinics are uniquely positioned to provide patients at high risk for CRC with strategies to decrease their risk and to be screened for CRC.

Ipilimumab/nivolumab-induced pseudolymphoma in a patient with malignant melanoma.

Combination therapy with ipilimumab and nivolumab is an adjuvant treatment approach for metastatic melanoma that boasts increased 3-year survival when compared with a single immunotherapy agent. Combination therapy, however, is associated with increased toxicities, especially cutaneous side-effects. Here we present a patient with metastatic melanoma and a sudden eruption of painful nodules on the face and arms 10 days after the administration of the fourth dose of combination ipilimumab/nivolumab. Biopsies demonstrated lymphoid hyperplasia, not clinically or pathologically consistent with an infectious, malignant or autoimmune etiology; a diagnosis of pseudolymphoma secondary to ipilimumab/nivolumab was made. After a steroid taper, the lesions resolved, and the patient was restarted on nivolumab monotherapy 2 weeks later without recurrence of symptoms or disease.

A Case of Allergic Bronchopulmonary Aspergillosis (ABPA) in a Patient with a History of Cocaine Use and Tuberculosis.

Aspergillosis refers to a spectrum of disorders that can occur due to colonization with the Aspergillus fungus. Allergic bronchopulmonary aspergillosis (ABPA) is an airway hypersensitivity reaction to the fungus that is almost exclusively seen in patients with cystic fibrosis or asthma. Here, we present a case of ABPA in a patient with a history of chronic cocaine use and tuberculosis and no history of asthma or cystic fibrosis. The patient had presented with progressively worsening dyspnea for three months as well as a 20-pound weight loss. Diagnosis was made with an elevated IgE against Aspergillus and chest CT findings, which included bronchiectasis and tree-in-bud nodular opacities. The patient was treated with IV methylprednisolone followed by a 4-day course of oral prednisone, with significant improvement. It is our hope to make healthcare providers aware of the potential presence of ABPA in chronic cocaine users and patients with tuberculosis, both of which are not traditionally associated with this condition.

Pyoderma Gangrenosum following Pacemaker Implantation: A Case Report and Review of Literature.

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by noninfectious, inflammatory, ulcerating lesions. Pathergy can be seen in these patients, whereby minor trauma or surgery can result in the development of PG ulcerations. Here, we present a case of PG following pacemaker implantation. A 76-year-old male with a history of rheumatoid arthritis presented to the cardiology team with symptomatic bradycardia. Indications for implantation were met, and the procedure was performed in a routine fashion. The patient returned to clinic for follow-up four days later, complaining of pain at the incision site, coupled with erythema and purulent drainage. Consultations with an infectious disease specialist and a dermatologist were requested, and the diagnosis of pyoderma gangrenosum was considered. The patient underwent device removal and received systemic corticosteroids at a dose of 1 mg/kg prednisone with complete lesion healing in 3 weeks. While being maintained on steroids, the patient underwent reimplantation of a new pacemaker on the contralateral side without complication and had a normal postoperative course. We present this case report, along with the review of literature, in order to highlight the multidisciplinary approach to management, which requires dermatologic treatment in order to achieve pacemaker success.

Anti-PD-1-Induced Pneumonitis Is Associated with Persistent Imaging Abnormalities in Melanoma Patients.

Pneumonitis may complicate anti-programmed death-1 (PD-1) therapy, although symptoms usually resolve with steroids. The long-term effects on respiratory function, however, are not well defined. We screened melanoma patients treated with anti-PD-1, with and without ipilimumab (anti-CTLA-4), and identified 31 patients with pneumonitis. Median time to radiographic findings was 4.8 months. Twenty-three patients (74%) presented with respiratory symptoms, whereas 8 (26%) were asymptomatic, and 11 (35%) were hospitalized. With 22.1 months median follow-up, 27 patients (87%) had resolution of symptoms, whereas 4 had persistent cough, dyspnea, and/or wheezing. By contrast, the rate of radiographic resolution was lower: Only 11 (35%) had complete radiographic resolution, whereas 14 (45%) had improvement of pneumonitis with persistent scarring or opacities, and 6 (19%) had persistent or worsened ground-glass opacities and/or nodular densities. Persistence (vs. resolution) of radiographic findings was associated with older age and initial need for steroids but not with need for hospitalization, timing of onset, or treatment regimen (combination vs. monotherapy). Among patients with serial pulmonary function tests, lung function improved with time. Although symptoms of anti-PD-1-induced pneumonitis resolved quickly, scarring or inflammation frequently persisted on computerized tomography. Therefore, further study of subclinical pulmonary effects of anti-PD-1 is needed.

Clinical Correlates of Response to Anti-PD-1-based Therapy in Patients With Metastatic Melanoma.

Anti-PD-1 agents, alone or in combination with ipilimumab, produce durable responses in some melanoma patients. Tumor features that correlate with response are not well defined. We collected clinical data from metastatic melanoma patients treated at 2 centers who received anti-PD-1 (n=303) or anti-PD-1+ipilimumab (n=57). We correlated number of metastases, diameter of largest tumor (tumor bulk), and organ involvement with response rate (RR), progression-free survival (PFS), and overall survival (OS). Patients with diameter of largest tumor ≤2 cm had a 53% RR, whereas those with largest tumor >2 cm had a 38% RR (P=0.009). Those with liver metastases had lower RR (25% vs. 43%; P=0.002). RR to anti-PD-1 was greater in patients with ≤10 metastases compared with those with >10 (39% vs. 27%; P=0.027). In multivariable analyses, size of the largest tumor was independently associated with PFS (P=0.0005), OS (P<0.0001), and RR (P=0.02), whereas AJCC stage, lactate dehydrogenase, liver metastases, ECOG performance status, number of metastases, and prior therapies were not. In patients treated with anti-PD-1+ipilimumab, however, tumor bulk was not associated with outcomes, although number of metastases was associated with PFS (P=0.035) and RR (P=0.009) but not OS. Pathologic analysis did not reveal differences in T-cell infiltration in bulky versus small tumors. Tumor bulk, defined by diameter of largest tumor, was strongly and independently associated with clinical outcomes in anti-PD-1 but not in anti-PD-1+ipilimumab. In conjunction with molecular biomarkers, clinical predictors may help guide selection of immunotherapy agents.

Dermatologic care of uninsured patients managed at free clinics.

BACKGROUND: Uninsured patients are not well tracked within the health care system and therefore not commonly recorded in databases. Epidemiologic data regarding patients-specifically, those with dermatologic concerns visiting free clinics-are limited. OBJECTIVE: The purpose of this study was to explore the prevalence of dermatologic complaints among uninsured patients who visit free clinics. METHODS: A cross-sectional chart review of 5553 uninsured patients seen across 8 free clinics in Tampa, Florida, during 2016 was carried out to determine the prevalence of dermatologic chief complaints and patient demographics. RESULTS: Across 8 free clinics, a total of 5553 patients were seen in 2016. Of these patients, 444 (8%) presented with dermatologic complaints. The most common complaints pertained to rash, followed by lesions: localized rash (n = 83 [18.7%]), genital rash (n = 51 [11.5%]), generalized rash (n = 50 [11.3%]), questionable lesions (n = 35 [7.9%]), and genital lesions (n = 18 [4.1%]). LIMITATIONS: There are notable variations in medical documentation practices among free clinics, thereby limiting data collection. CONCLUSIONS: Free clinics have the potential to relieve a great dermatologic burden throughout the uninsured population. The findings from this study can inform other free clinics of the dermatologic conditions that are most likely to be seen among their patient population so that they can better provide their patients with higher-quality care.

Comorbidities, risk, and socioeconomic factors of uninsured cancer survivors.

Cancer patients can be well-connected to resources during treatment but become lost to follow-up and subsequently may receive treatment in free clinics for chronic morbidities. Few studies have examined outcomes for uninsured patients with cancer histories in free clinics, but research examining socioeconomic determinants emphasizes poor cancer outcomes for patients with lower socioeconomic statuses (SES).Demographic data and chronic disease measures were extracted from medical charts of patients treated in 8 free clinics in 2016 in Tampa Bay. Descriptive statistics and Pearson correlation coefficients were used to demonstrate relationships between socioeconomic factors, cancer diagnoses, and comorbidities. Charlson Comorbidity Index (CCI) was used to assess mortality risk and severity of disease burden.The histories of 4804 uninsured patients were evaluated, identifying 86 (1.7%) as having had cancer. They were predominantly female (65.1%) and significantly older than those without cancer histories. Average duration from initial diagnosis was approximately 8.53 years (standard deviation [SD] 7.55). Overall, cancer patients had higher CCI scores (3.04 [1.928 SD] versus 0.90 [1.209 SD]; P <.001); thus reflecting more weighted comorbidities than patients without cancer (P <.001). Other factors of chronic disease including obesity and substance abuse correlated with cancer history.Among uninsured patients, those with cancer histories had greater mortality risk by CCI than those without. Chronic conditions such as diabetes, cerebrovascular disease, and chronic pulmonary disease existed in patients with cancer histories, affecting their mortality risk. Uninsured patients with a history of cancer are in greater need for chronic disease management and prevention.