Indolent lymphoma care delivery and outcomes during the COVID-19 pandemic in Ontario, Canada.

The treatment pattern and outcomes in patients with indolent B-cell lymphoma treated during the coronavirus disease 2019 (COVID-19) pandemic period compared to the prepandemic period are unclear. This was a retrospective population-based study using administrative databases in Ontario, Canada (follow-up to 31 March 2022). The primary outcome was treatment pattern; secondary outcomes were death, toxicities, healthcare utilization (emergency department [ED] visit, hospitalization) and SARS-CoV-2 outcomes. Adjusted hazard ratios (aHR) from Cox proportional hazards models were used to estimate associations. We identified 4143 patients (1079 pandemic, 3064 prepandemic), with a median age of 69 years. In both time periods, bendamustine (B) + rituximab (BR) was the most frequently prescribed regimen. During the pandemic, fewer patients received R maintenance or completed the full 2-year course (aHR 0.81, 95% CI 0.71-0.92, p = 0.001). Patients treated during the pandemic had less healthcare utilization (ED visit aHR 0.77, 95% CI 0.68, 0.88, p < 0.0001; hospitalization aHR 0.81, 95% CI 0.70-0.94, p = 0.0067) and complications (infection aHR 0.69, 95% CI 0.57-0.82, p < 0.0001; febrile neutropenia aHR 0.66, 95% CI 0.47-0.94, p = 0.020), with no difference in death. Independent of vaccination, active rituximab use was associated with a higher risk of COVID-19 complications. Despite similar front-line regimen use, healthcare utilization and admissions for infection were less in the pandemic cohort.

Outcomes of patients with indolent lymphoma treated with bendamustine plus rituximab compared to rituximab plus CVP or CHOP chemoimmunotherapy in Ontario.

Bendamustine (B) with rituximab (R) has become the preferred regimen for patients with indolent lymphoma in Ontario, Canada, compared to R with cyclophosphamide, vincristine, prednisone (CVP) or cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP). We conducted a propensity-matched retrospective cohort population-based study of patients treated with R-CVP/CHOP from 2005 to 2012 and patients treated with BR from 2013 to 2018. The primary outcome was 5-year overall survival (OS), and secondary outcomes included toxicities and healthcare utilization. The 5-year OS for patients treated with BR (n = 2023) and R-CVP/CHOP (n = 2023) was 80% and 75% respectively. Treatment with BR was associated with improved OS (HR 0.79, 95% CI 0.69-0.91). During the first 9 months, patients treated with BR versus R-CVP/CHOP had a higher number of admissions for infection (22% compared to 17%, p < 0.01) and a higher number of mean ED visits (mean 1.01 ± 1.68 visits vs. 0.85 ± 1.51 visits, p < 0.01). This trend persisted for 3 years. The adjusted 5-year OS for patients 75 years and older did not differ based on treatment regimen (55.5% for BR vs. 55.4% for R-CVP/CHOP). Our study supports the use of BR for patients with indolent lymphoma requiring treatment but suggests increased risk of certain toxicities warranting careful patient selection.

Evaluation of the protein gap for detection of abnormal serum gammaglobulin level: an imperfect predictor.

OBJECTIVES: The value of the serum protein gap (PG, difference between total protein and albumin) in the detection of hyper- or hypogammaglobulinemia is not well established. We assessed the performance of PG for the detection of hyper- or hypogammaglobulinemia in a large sample of patients. METHODS: We reviewed all paired measurements of serum total protein, albumin, quantitative immunoglobulins, and serum protein electrophoresis tested between March 2014 and June 2017 at the Eastern Ontario Regional Laboratory Association. Sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratios of PG at thresholds between 18 and 44 g/L for the detection of hyper- and hypogammaglobulinemia were assessed. RESULTS: There were 19,575 and 5,426 simultaneous paired data points to assess hyper- and hypogammaglobulinemia identified by serum protein electrophoresis (SPE) and nephelometry, respectively. The mean PG was 36.3 g/L (SD 8.6). The prevalence of hypergammaglobulinemia (>16 g/L by SPE) and hypogammaglobulinemia (IgG <7 g/L) was 21.9 and 5.5%, respectively. High PG (≥38 g/L) had sensitivity and specificity of 76.2 and 71.5% respectively for hypergammaglobulinemia. PG ≥38 g/L had a negative predictive value (NPV) of 93.1% for monoclonal, and 96.9% for polyclonal gammopathy. A PG threshold of ≤18 g/L had of sensitivity of 0.4%, specificity of 100%, PPV of 100% and NPV of 80.1% to detect hypogammaglobulinemia (IgG <7 g/L). CONCLUSIONS: High and low PG values were not sensitive in detecting hyper- or hypogammaglobulinemia, although negative predictive values were high for both. Performance of PG should be further evaluated prospectively in specific populations at risk of for abnormal IgG levels.

Evaluation of a Personalized Subcutaneous Immunoglobulin Treatment Program for Neurological Patients.

BACKGROUND: Subcutaneous immunoglobulin (SCIg) treatment has been shown to control symptoms and improve overall satisfaction in patients with neurological disorders. However, a large injection volume can be overwhelming and a barrier to successful SCIg treatment. We established a nurse-led individualized approach program to facilitate a smooth and successful treatment transition from intravenous immunoglobulin (IVIg) to SCIg. The program involved a lead nurse to provide two or more individual educational sessions on SCIg administration, establish a written transition plan, and liaise care with physicians. OBJECTIVES: We aimed to evaluate the impact of our program to a successful transition defined as SCIg retention or adherence without a need to restart IVIg by six or twelve months. METHODS: We reviewed medical charts of all patients with immune-mediated neuromuscular disorders who were in our program during January 2010 to Dec 2016. RESULTS: Nineteen patients were identified. Mean IVIg treatment duration was 31.5 months (range 4-98) before the transition. Mean steady state SCIg dosage was 26.2 g/week (SD 10.3). All patients were initially able to switch to SCIg, with a retention rate of 17/19 (89.5%) at six months and 15/19 (78.9%) at twelve months. Two patients reverted back to IVIg treatment due to worsening of their symptoms at two and three months, while two required supplemental IVIg infusions. There were no major adverse events reported during the twelve-month period, but one minor cutaneous adverse event (redness around the injection site). CONCLUSIONS: Successful treatment transition may be achieved with the nurse led individualized approach program.

CONTEXTE: Il a été prouvé que les traitements à l'immunoglobuline par voie sous-cutanée (IgSC) permettent de contrôler les symptômes qui affectent des patients atteints de troubles neurologiques et d'améliorer leur satisfaction générale. Toutefois, de grands volumes injectés peuvent devenir accablants et représenter un obstacle à un traitement par IgSC qui soit efficace. Nous avons ainsi mis sur pied un programme reposant sur une approche individuelle et dirigé par du personnel infirmier afin de favoriser une transition en douceur efficace entre les traitements d'immunoglobuline par voie intraveineuse (IgIV) et ceux par IgSC. Un tel programme impliquait la présence d'une infirmière en chef chargée d'offrir deux séances de formation ou plus en ce qui concerne l'administration d'un traitement par IgSC mais aussi d'établir un plan écrit de transition entre les deux traitements et d'assurer une liaison avec les médecins traitants. OBJECTIFS: Nous avons cherché à évaluer l'impact de notre programme en matière de transition. C'est ainsi que nous avons voulu savoir dans quelle mesure un traitement par IgSC entraînait une forme d'adhésion thérapeutique en vertu de laquelle un traitement par IgIV n'était plus nécessaire au bout de six ou de 12 mois. MÉTHODES: Nous avons passé en revue les dossiers médicaux de tous les patients atteints de troubles neuromusculaires d'origine auto-immune ayant fait partie de notre programme de janvier 2010 à décembre 2016. RÉSULTATS: Au total, dix-neuf patients ont été sélectionnés. Avant d'amorcer notre transition, la durée moyenne d'un traitement par IgIV était de 31,5 mois (étendue : 4-98). La posologie moyenne à l'équilibre d'un traitement par IgSC était de 26,2 g/semaine (écart-type : 10,3). Au début, tous les patients ont été en mesure de passer à un traitement par IgSC, le taux d'adhésion étant de 89,5 % (17/19) au bout de six mois et de 78,9 % (15/19) au bout de douze mois. Deux patients ont recommencé à suivre un traitement par IgIV en raison d'une détérioration de leurs symptômes au bout de deux et de trois mois tandis que deux autres ont eu besoin d'injections à l'immunoglobuline additionnelles. Outre un seul événement indésirable mineur de nature cutanée, à savoir de la rougeur autour de la zone d'injection, aucun événement indésirable majeur n'a été signalé au cours de la période de transition de douze mois. CONCLUSIONS: Il est possible, au moyen d'un programme dirigé par une infirmière chef dont l'approche est individuelle, d'effectuer une transition efficace entre les deux traitements évoqués ci-dessus.

Radiologic features of hydatid disease: the importance of sonography.

Hydatid disease is commonly encountered in specific geographic areas of the world. Hydatidosis affects multiple organs and has diverse radiologic presentations. Sonography remains an important modality for diagnosing this condition, as it optimally detects cystic structures, floating membranes, and debris. Sonography forms the crux of radiologic diagnosis of hydatid disease. It not only helps diagnose the disease but also aids in guiding therapeutic interventions. The main objective of this article is to describe the imaging features of hydatid disease in its various stages. This article gives an overview of the spectrum of sonographic manifestations of hydatid disease in various locations, along with common differential diagnoses. A brief description of therapeutic management is also presented.

The risk of venous thromboembolism in primary central nervous system lymphoma: a systematic review and meta-analysis.

Primary central nervous system lymphoma (PCNSL) is a rare extranodal lymphoma localized to the central nervous system. Small single-center studies have suggested that patients with PCNSL may be at high risk of venous thromboembolism (VTE). This systematic review aimed to estimate the risk of VTE in patients with PCNSL. A systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. MEDLINE, Embase, and CINAHL were searched from 1990 to 2022. Prospective and retrospective observational studies as well as clinical trials were included. The primary efficacy outcome was VTE, and the primary safety outcome was major bleeding as defined by the individual studies. After screening 883 studies, 46 studies (3688 patients) with PCNSL were included. Mean age was 62.4 years. Five studies explored the use of thromboprophylaxis (acetyl salicylic acid or anticoagulation [n = 1]) and low-molecular-weight heparin (n = 4). Overall, 420 patients developed VTE (11.4%), including 17 fatal events (4% of all VTE). Two studies that reported on VTE prophylaxis representing 77 patients identified 8 breakthrough VTE events (10.4%). Most studies (n = 34; 74.5%) did not report major bleeding complications. Among studies reporting on bleeding, 174 major bleeding (7.4%) events were reported out of 2361 patients, 3 of which were attributed to thromboprophylaxis. Patients with PCNSL seem to be at high risk of both VTE and bleeding complications. Future clinical trials in this population should routinely collect data on incidence of VTE and bleeding to help clinicians assess the risk-to-benefit ratio of thromboprophylaxis in this high-risk patient population.

Virtual Care During the COVID-19 Pandemic for Patients With Hematologic Malignancies: A Single-Institution Experience.

PURPOSE: The use of virtual care rapidly increased during the COVID-19 pandemic and has persisted as a routine method of care delivery. Much of the literature on virtual care in oncology has focused on solid tumors, and little is known about its application in malignant hematology. METHODS: We performed a retrospective review of patients with hematologic malignancies at Princess Margaret Cancer Centre from October 2019 to March 2021 to determine the use of virtual care during this period, cost-savings associated with virtual visits, and patient satisfaction. Patient satisfaction was assessed using the Your Voice Matters survey, a provincially administered survey to evaluate patient experience. RESULTS: Overall, 12.1% (1,122/9,295) of patients had a virtual visit during the study period (0% from October 2019 to February 2020, 36% from March to August 2020, and 30% from September 2020 to March 2021), of which 36% were in the lymphoma clinic and 46% were in the myeloma clinic. The mean two-way opportunity cost for an in-person visit was $168.00 CAD per person with public transit, and $120.40 CAD per person driving. Responses to the Your Voice Matters survey indicated that patients with a virtual visit reported that physical symptoms were discussed appropriately (mean 4.73/5), and were more likely to ask for a follow-up virtual visit compared with patients with in-person visits (mean 4.50/5 v 3.02/5, respectively; P < .01). CONCLUSION: These findings suggest that virtual care may be a feasible and well-received tool for delivering care to a substantial proportion of patients with hematologic malignancies, while enabling substantial cost-savings to patients.

The Use of Virtual Care in Patients with Hematologic Malignancies: A Scoping Review.

There is increasing interest from cancer patients and their healthcare providers in the use of virtual care in routine clinical practice. In the setting of hematologic malignancy, where patients often undergo complex and immunodepleting treatments, understanding how to use virtual care safely and effectively is critically important. We aimed to describe the use of virtual care in patients with hematologic malignancies and to examine physician- and patient-reported outcomes in the form of a systematic scoping review. An electronic search of PubMed, Ovid MEDLINE, Elsevier Embase, Scopus, and EBSCO CINAHL was conducted from January 2000 to April 2021. A comprehensive search strategy was used to identify relevant articles, and data were extracted to assess the study design, population, setting, patient characteristics, virtual care platform, and study results. Studies were included if they described the use of virtual care for patients with hematologic malignancies; commentaries were excluded. Fifteen studies met the inclusion criteria after abstract and full-text review. Three studies found that app-based tools were effective in monitoring patient symptoms and triggering alerts for more urgent follow-up. Four studies described the use of phone-based interventions. Five studies found that videoconferencing, with both physicians and oncology nurses, was highly rated by patients. Emerging themes included high levels of patient satisfaction across all domains of virtual care. Provider satisfaction scores were rated lower than patient scores, with concerns about technical issues leading to challenges with virtual care. Four studies found that virtual care allowed providers to promptly respond to patient concerns, especially when patients were experiencing side-effects or had questions about their treatment. Overall, the use of virtual care in patients with hematologic malignancies appears feasible, and resulted in high patient satisfaction. Further research is needed in order to evaluate the optimal method of integrating virtual care into clinical practice.

Tuberculosis conundrum - current and future scenarios: A proposed comprehensive approach combining laboratory, imaging, and computing advances.

Tuberculosis (TB) remains a global threat, with the rise of multiple and extensively drug resistant TB posing additional challenges. The International health community has set various 5-yearly targets for TB elimination: mathematical modelling suggests that a 2050 target is feasible with a strategy combining better diagnostics, drugs, and vaccines to detect and treat both latent and active infection. The availability of rapid and highly sensitive diagnostic tools (Gene-Xpert, TB-Quick) will vastly facilitate population-level identification of TB (including rifampicin resistance and through it, multi-drug-resistant TB). Basic-research advances have illuminated molecular mechanisms in TB, including the protective role of Vitamin D. Also, Mycobacterium tuberculosis impairs the host immune response through epigenetic mechanisms (histone-binding modulation). Imaging will continue to be key, both for initial diagnosis and follow-up. We discuss advances in multiple imaging modalities to evaluate TB tissue changes, such as molecular imaging techniques (including pathogen-specific positron emission tomography imaging agents), non-invasive temporal monitoring, and computing enhancements to improve data acquisition and reduce scan times. Big data analysis and Artificial Intelligence (AI) algorithms, notably in the AI sub-field called "Deep Learning", can potentially increase the speed and accuracy of diagnosis. Additionally, Federated learning makes multi-institutional/multi-city AI-based collaborations possible without sharing identifiable patient data. More powerful hardware designs - e.g., Edge and Quantum Computing- will facilitate the role of computing applications in TB. However, "Artificial Intelligence needs real Intelligence to guide it!" To have maximal impact, AI must use a holistic approach that incorporates time tested human wisdom gained over decades from the full gamut of TB, i.e., key imaging and clinical parameters, including prognostic indicators, plus bacterial and epidemiologic data. We propose a similar holistic approach at the level of national/international policy formulation and implementation, to enable effective culmination of TB's endgame, summarizing it with the acronym "TB - REVISITED".

Augmentation of literature review of COVID-19 radiology.

We suggest an augmentation of the excellent comprehensive review article titled "Comprehensive literature review on the radiographic findings, imaging modalities, and the role of radiology in the coronavirus disease 2019 (COVID-19) pandemic" under the following categories: (1) "Inclusion of additional radiological features, related to pulmonary infarcts and to COVID-19 pneumonia"; (2) "Amplified discussion of cardiovascular COVID-19 manifestations and the role of cardiac magnetic resonance imaging in monitoring and prognosis"; (3) "Imaging findings related to fluorodeoxyglucose positron emission tomography, optical, thermal and other imaging modalities/devices, including 'intelligent edge' and other remote monitoring devices"; (4) "Artificial intelligence in COVID-19 imaging"; (5) "Additional annotations to the radiological images in the manuscript to illustrate the additional signs discussed"; and (6) "A minor correction to a passage on pulmonary destruction".

Implanted vascular access device related deep vein thrombosis in oncology patients: A prospective cohort study.

BACKGROUND: Implanted vascular access devices (IVADs) have significantly improved the management of cancer patients. These patients are at an increased risk of venous thromboembolism and IVADs are a known risk factor. We sought to assess the incidence of IVAD-related upper extremity deep vein thrombosis (IVAD-related UEDVT) associated with BioFlo® IVADs (Angiodynamics, Inc.). METHODS: A total of 394 cancer patients were enrolled over 12 months. The primary outcome was the incidence of IVAD-related UEDVT confirmed by diagnostic imaging. IVAD-related UEDVT was defined as symptomatic ipsilateral upper extremity (axillary vein or proximal) deep vein thrombosis and symptomatic pulmonary embolism (PE). Patients were followed until initiation of therapeutic anticoagulation, catheter removal, death, or up to 12 months. RESULTS: 389 patients were included in the analysis. The median age of the cohort was 58.2 years; 68% (n = 273) were females. Sixty-six percent had gastrointestional cancer (including pancreatic cancer) and 68% had metastases. Eighty four percent of IVADs were right sided insertions. Ninety eight percent of catheter tip placements were distal superior vena cava (n = 237), cavo-atrial junction (n = 67) or atrium (n = 90). Overall, 5 patients had symptomatic IVAD-related UEDVT (1.29%, 95% CI 0.2 to 2.4%). CONCLUSION: IVAD-related UEDVT is an infrequent complication in cancer patients with BioFlo® IVADs.

Disseminated cryptococcal infection in a patient with treatment-naïve chronic lymphocytic leukemia (CLL).

We report a case of disseminated cryptococcosis in a treatment-naïve chronic lymphocytic leukemia (CLL) patient. A 60-year-old man presented with a two-week history of intermittent fevers, frontal headaches, night sweats, weight loss and multiple pink papules on hands and face. Cryptococcemia was found by blood culture unexpectedly. Further investigation confirmed cryptococcal meningitis and skin disease. He responded to two week amphotericin B and flucytosine followed by four-week amphotericin B and fluconazole, three-month high dose fluconazole (800 mg/day), and maintenance fluconazole (400 mg/day) thereafter. CSF pleocytosis persisted until day 203 while cryptococcal antigen in the CSF persisted at day 334 of treatment.