ABSTRACT
Allogeneic hematopoietic stem cell transplantation (allo- HSCT) has traditionally involves administering fresh peripheral blood or bone marrow stem cells. At onset of the COVID-19 pandemic in March 2020, the National Marrow Donor Program (NDMP) mandated cryopreservation of all unrelated peripheral blood stem cell (PBSC) products to prevent interruptions in transplant plans by donor COVID-19 infection after recipient's start of conditioning chemotherapy. Since the lifting of this mandate, many centers have continued to cryopreserve grafts prior to initiation of conditioning, but the longer-term clinical outcomes of this practice including chronic graft versus host disease (cGVHD) rates of patients receiving cryopreserved stem cells have not been previously well described. Prior work has raised concern for a deleterious effect of cryopreservation on overall survival and non-relapse mortality (PMID: 33865804). However, heterogeneity in the patient population and reason for cryopreservation suggest that further study is needed to assess these outcomes. Here we report our single-institution experience of clinical outcomes using cryopreserved versus fresh URD PBSCs for allo-HSCT. We examined long-term outcomes in 387 patients who received unrelated donor (URD) PBSCs (136 cryopreserved, 251 fresh) between January 1, 2019 and July 31, 2021. The cohorts had similar baseline characteristics including donor/recipient age/sex, disease, conditioning regimen/intensity, and GVHD prophylaxis regimens. Two-year OS, PFS, relapse, NRM, and acute GVHD rates were not different between recipients of fresh versus cryopreserved PBSCs. Strikingly, 2-year incidence of cGVHD (28% vs 52%, p=0.00001) and moderate/severe cGVHD (9% vs 24%, p=0.00016) was substantially lower in recipients of cryopreserved PBSCs compared to fresh, respectively (Figure 1). This difference was only noted in patients receiving a GVHD prophylaxis regimen without post-transplantation cyclophosphamide (PTCY) (no PTCY 2-year cGVHD incidence cryopreserved vs fresh: 29% vs 57%, p=0.000016), moderate/severe cGVHD 16% vs 34%, p=0.0006) (Figure 2). For patients receiving a PTCY-containing GVHD prophylaxis regimen, there was no difference in cGVHD incidence (cGVHD cryopreserved vs fresh: 24% vs 27%, p=0.56, moderate/severe cGVHD 7% vs 9.3%, p=0.3, Figure 3). (Figure Presented) (Figure Presented) (Figure Presented) While survival and relapse rates are not different, cryopreservation is associated with a marked reduction in cGVHD rates in the setting of non-PTCy based GVHD prophylaxis. Larger multicenter or registry analyses are needed to confirm these observations and may prompt a re-assessment of the role of cryopreservation of stem cell products in clinical practice. If confirmed, it will be critical to understand the immunologic consequences of cryopreservation and how they might influence the clinical impact on chronic GVHDCopyright © 2023 American Society for Transplantation and Cellular Therapy
ABSTRACT
In 2003, an article in the Harvard Business Review by Reichheld, et al, identified a simple single investigative question – "How likely is it that you would recommend [company X] to a friend or colleague?" – that best represented customer loyalty and would predict company growth. With a renewed interest in patient satisfaction, this survey has been adapted in the healthcare community, but there are no known publications describing its use in a radiation oncology clinic. From April of 2019 through February of 2022, hard-copy forms were given to patients after CT simulation and at completion of therapy in a private room onsite. The question read, "How likely are you to refer patients who are friends or family to [Institution] Radiation Oncology?" If he or she agreed to answer the survey, the respondent used a Likert scale from 0 to 10 (least to most likely) and added comments in a free-text section. Responses with a 0 to 10 score were logged with no identifying information and were classified as "promoters" (9 to 10) or "detractors" (0 to 6);a monthly Net Promoter Score was calculated by dividing the number of "promoters" by the sum of "promoters" and "detractors." Comments, if available, were additionally transcribed. The scores and comments were shared with the department once weekly in morning huddle. Patients filled out 1318 forms (62%). Monthly Net Promoter scores ranged from 94.44 to 100. The average response was 9.74 with marks of 9.76, 9.74, 9.75, and 10.00 for 2019, 2020, 2021, and 2022, respectively. In 2019 and 2020, replies were separated by timepoints of CT simulation (9.73 and 9.71) and after radiotherapy (9.75 and 9.78). During this timeframe, comments were further analyzed by qualitative analysis and were classified into "staff appreciation," "patient feelings/treatment," "wait times," "respect," and "communication." The Net Promotor Score is an available tool to get immediate feedback from patients, allowing rapid service recovery, if needed. In our department, scores were consistently favorable with little difference through the COVID-19 pandemic, and patients noted that they were appreciated, felt respected, and experienced short wait times. [ FROM AUTHOR] Copyright of International Journal of Radiation Oncology, Biology, Physics is the property of Pergamon Press - An Imprint of Elsevier Science and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)
ABSTRACT
Background: Botswana has a high prevalence of women living with HIV (WLHIV) and experienced a severe nationwide COVID-19 epidemic in 2021. We evaluated adverse birth outcomes among women routinely tested for COVID-19 by HIV status, during a period when few women had access to COVID-19 vaccination. Methods: The Tsepamo Study performs birth outcomes surveillance at government hospitals throughout Botswana. We analyzed data from 13 Tsepamo sites that performed routine COVID-19 screening at delivery with rapid antigen or PCR testing between Sept 1, 2020 and Sept 30, 2021 (start dates differed by site). This analysis includes singleton deliveries with known HIV status and a COVID-19 screening test between 14 days prior and 3 days after delivery. Outcomes included maternal death, preterm delivery (PTD), very preterm delivery (VPTD), small for gestational age (SGA), very small for gestational age (VSGA), stillbirth, and neonatal death. Differences in outcomes by COVID-19 and HIV status were assessed using log binomial regression adjusted for maternal age. Results: A total of 17,627 deliveries occurred at the included sites during COVID-19 screening, and 11,149 (63.3%) were screened for COVID-19;among 10,090 (99.7%) with a known HIV status, 530 (5.3%) COVID-19 tests were positive, including 141/2129 (6.6%) among WLHIV and 389/7961 (4.9%) among women without HIV (aRR 1.32, 95% CI 1.09, 1.60). Maternal deaths were reported in 19 (3.8%) women with COVID-19 and 11 (0.12%) women without COVID-19 (aRR 30.5, 95% CI 14.6, 63.7), and did not differ by HIV status. Adverse birth outcomes (any) were more common among infants born to women with COVID-19 (34.3% vs. 26.3%;aRR 1.32, 95% CI 1.16,1.49), including PTD (21.2% vs. 13.3%;aRR 1.60, 95% CI 1.34,1.90) and stillbirth (5.5% vs. 2.8%;aRR 1.89, 95% CI 1.30,2.75), and there was a trend for higher neonatal mortality (2.0% vs. 1.4%, aRR 1.5, 95% CI 0.79, 2.85). Most adverse birth outcomes were highest among infants exposed to both COVID-19 and HIV (Figure 1). Conclusion: Infants born to women with COVID-19 experienced more adverse birth outcomes than other infants, including a 2-fold risk for stillbirth. Those exposed to both COVID-19 and HIV had the highest risk for most adverse outcomes. Further research is warranted to understand the biological interaction between COVID-19, HIV infection, and adverse birth outcomes, and whether some associations were impacted by challenges in care delivery during the height of the COVID-19 epidemic in Botswana.
ABSTRACT
Background: The COVID-19 pandemic strained healthcare systems worldwide, delaying breast cancer screening and surgery. In 2019, approximately 80% of breast cancers in the U.S. were diagnosed on screening examinations, with 76.4% of eligible Medicare patients undergoing screening at least every two years. Since the start of the pandemic, many women have been reluctant to seek elective screening mammography, even with the lifting of "lock-down". We describe the effect of the COVID-19 pandemic on breast cancer presentation at an academic medical center in a city hit hard by the pandemic. Materials and Methods: The institutional IRB-approved Breast Cancer Registry Database was queried for patients enrolled during two time periods, those undergoing first surgical procedure before the start of the pandemic (4/1/2019-3/31/2020) to those the year after the pandemic started (4/1/2020-3/31/2021). Elective cancer surgery was paused for 3 weeks, ending 4/20/2020, and access to routine breast care was limited for 3 months. Variables included age, method of detection, palpability, histologic subtype and staging, neoadjuvant systemic therapy, cancer specific treatments, and radiation uptake. Results: 349 patients were in the 2019 cohort;246 in the 2020 cohort. No differences in baseline characteristics, including age at presentation, nodal status, or operation type. Fewer cancers were detected on routine mammography post-COVID vs. pre-COVID. Increase in detection of breast cancer through self-Sexams in 2020 was seen compared to 2019. Palpability on presentation also increased. More patients were treated with neo-adjuvant therapy chemotherapy, and 36 of 45 (80%) eligible early-stage breast cancer patients accepted neoadjuvant hormonal therapy during the period that elective cancer surgery was on hold. Patients received radiation therapy less frequently during the pandemic. The proportion of patients diagnosed with invasive ductal cancers was higher in the 2020 cohort and the proportion of patients diagnosed with ductal carcinoma in situ (DCIS) and for invasive lobular cancers (ILC) was lower. Conclusions: Patients at an academic New York City medical center presented with more palpable and invasive breast cancers during the COVID-19 pandemic compared to the preceding year, and fewer patients with DCIS and ILC, cancers typically detected following screening mammography. While stage migration with an increase in diagnosis of late stage cancers has been described, in our population the stage shift occurred in early stage breast cancer, with decreases in DCIS and increases in Stages I-II, with the higher stages III-IV essentially unchanged. This reflects the effect of delay in our previously highly-screened population, with an average screening delay of 3 + months, and many patients missing their yearly screening altogether. While many medical interactions during COVID-19 were via telemedicine, radiation therapy requires daily office visits, and fear of exposure contributed to the lower rate of radiation. Given the increase in invasiveness and stage of breast cancers diagnosed during the COVID-19 pandemic, this study emphasizes the importance of screening for diagnosis and treatment of breast cancer, even in the face of a concurrent health crisis.
ABSTRACT
Objective: While some surgical subspecialties have investigated the impact of the COVID-19 pandemic on the education of their residents and fellows, the field of urogynecology has mostly yet to explore this. We surveyed current FPMRS fellows to better describe some of the adversities they have faced during this time and how the pandemic has impacted their training. Methods: An original 24 item questionnaire to assess the impact of COVID-19 in FMPRS fellow- residents was created using Qualtrics™(Provo, Utah, USA). The survey collected information from different domains, including demographics, year of training, burnout effect, changes in the residency program, and its impact on the number of surgeries. The questionnaire was distributed to all residency Program Directors (PD) and/or Program Coordinators (PC). Then the link was forwarded to the residents. Results: Seventy-five fellows completed the survey. Only 22.3%of the fellows reported that they took direct care of a patient who was diagnosed with COVID 19. During the pandemic the fellows reported a drastic decrease of the number of cases per week, with most of the mdoing just on average 1 to 3 cases (79.3%) and just a minority doing more than 4 (20.7%). 65.4% of the fellows reported that they were suggested to be on research block or were pulled away from clinical duties at some point during the pandemic. None were asked to take vacations and 25.2% were asked to cover gyn cases and gyn emergencies. Most of the fellows reported that they felt that at some extent their training has been affected (75%). Despite the residents had no more working hours compared to prior to the pandemic, most of them (77.8%) reported feeling more burned out than prior to the pandemic. All the graduating fellows reported some concerns about their ability to find jobs with 66.6% of them reporting that there are not enough jobs available and the rest reporting concerns about the future of the economy in the country. Conclusions: The COVID-19 pandemic has influenced medical education, including the FPMRS fellowship training. Overall, the fellows reported doing fewer surgeries. Still, they considered that the decreased number of surgeries will not have an overall impact on their training. The pandemic's long-term effect on the fellow's training is unknown, and further studies will be necessary to assess this.
ABSTRACT
Purpose: We describe short-term outcomes as well as peri- and post-transplant complications in patients with prior coronavirus disease 2019 (COVID-19) who subsequently underwent kidney transplantation. Methods: This was a single-center, retrospective cohort study of all recipients of isolated living- or deceased-donor kidney transplants between 4/1/2020-10/1/2020. Patients with prior PCR confirmed COVID-19 were considered candidates for kidney transplantation if they were at least 4 weeks post-infection, had resolution of symptoms, and had one negative nasopharyngeal PCR swab specimen. Standard doses of induction and maintenance immunosuppression were administered at the time of transplant and included anti-thymocyte globulin, tacrolimus, mycophenolate, and tapering corticosteroids. Patients were followed from the date of transplantation until study conclusion (11/1/2020), to compare short-term patient and allograft outcomes between those with prior COVID-19 and COVID-19 naïve controls transplanted during the same time-period. Results: 81 patients received isolated kidney transplants during the review period, 13 (16.0%) of whom had recovered from prior COVID-19 infection. The median time between COVID-19 diagnosis and transplantation was 71 (IQR=56.5-135) days, and all 10 patients who were tested had evidence of significant antibody titers to the SARS-CoV-2 spike protein. The majority of patients had mild disease (69.2%), while 3 patients required hospital admission and supplemental oxygen, and 1 patient required mechanical ventilation. Baseline characteristics were similar between COVID-19 positive and negative patients, with the exception of more Hispanic/ Latino patients in the prior COVID-19 group (53.8% vs 17.6%;p<0.01). At study conclusion, after a median follow-up of 3.6 months, patient and allograft survival were similar between COVID-19 positive and negative patients (92.3%/92.3% vs 100.0%/98.5%), and mean baseline serum creatinine was 1.5 mg/dL in both groups. One patient with prior mild COVID-19 died due to a pulmonary embolism within 1-month of transplant;however, no differences were observed in the overall rate of thromboembolism (7.7% vs 4.4%;p=0.61). Index hospital length of stay and readmission rate within 30-days of transplant were also similar between groups, but patients with prior COVID-19 did have a higher incidence of delayed extubation posttransplant (15.4% vs 1.5%;p=0.02). No cases of COVID-19 re-infection or biopsy proven allograft rejection were observed among patients with prior COVID-19. Conclusions: In our preliminary experience, patients with prior COVID-19 infection appeared to have similar short-term outcomes when compared with COVID-19 naive patients. We did observe a potential signal for increased peri-operative respiratory complications in patients with prior COVID-19, which may warrant additional monitoring and further study in multi-center cohorts.
ABSTRACT
Purpose: Kidney transplant recipients are thought to be at high risk for mortality from COVID-19 due to the necessity for chronic immunosuppressive therapy to prevent graft rejection. However, the optimal immunosuppressant management strategy for patients with COVID-19 remains unknown. Methods: We conducted a single-center, retrospective review of all kidney or kidneypancreas transplant recipients with a functioning graft who were hospitalized with COVID-19 between 3/15/2020-5/15/2020. Patients were followed from the date of admission, up until 1 month following hospital discharge or study conclusion (6/15/2020). Multivariable logistic regression was used to identify potential patient or immunosuppression characteristics associated with the development of severe COVID-19 and in-hospital mortality. Results: 69 (3.2%) patients followed longitudinally at our center were hospitalized with COVID-19 during the review period, 38 of whom were admitted to the study institution. Patients were ethnically diverse, and the majority were receiving tacrolimus (84.2%), mycophenolate (89.5%), and corticosteroids (81.6%) at baseline. Following COVID-19 diagnosis, median tacrolimus trough levels decreased by-11% (-26%-+17%) during hospitalization and mycophenolate doses were reduced by at least 50% in 33 patients. Adjunctive therapy included hydroxychloroquine (68.4%), convalescent plasma (26.3%), anticoagulation (52.6%), and participation in clinical trials (10.5%). Twenty patients developed severe disease, and 11 (28.9%) died during hospitalization. Admission characteristics associated with increased risk for mortality included age (OR=2.0;1.0-4.0) and history of HIV (OR=22.6;1.1-483.7). No association was found between baseline tacrolimus trough levels, mycophenolate dosing, or the number of immunosuppressants prescribed and COVID-19 mortality. Similarly, the degree of immunosuppression reduction following hospital admission was not associated with survival or severe disease progression. No differences were observed in the prescription of adjunctive therapies, with the exception of a higher daily dose of prednisone equivalents in patients who died (37.0 vs 15.4;p=0.02). Among survivors, death-censored allograft survival was 96.2% at 1-month, and no cases of biopsy proven rejection were observed during the review period. Conclusions: The findings from our study confirm age as a significant risk factor for COVID-19 mortality in kidney transplant recipients, and suggest HIV status as an additional risk factor that may warrant further investigation. Pre-emptive immunosuppression reduction does not appear to be warranted, as baseline immunosuppression intensity and dose modulation following diagnosis of infection were not associated with hospital outcomes. However, no episodes of acute rejection were observed, so providers may wish to consider immunosuppression reduction on a case-by-case basis.