A Single Center Retrospective Study of the Impact of COVID-19 Infection on Immune-related Adverse Events in Cancer Patients Receiving Immune Checkpoint Inhibitors.

Immune checkpoint inhibitors (ICIs) can cause a variety of immune-related adverse events (irAEs). The coronavirus disease 2019 (COVID-19) is associated with increased amounts of pro-inflammatory cytokines, which may affect the outcome of irAEs. Data are limited regarding the impact of COVID-19 on irAEs in ICI-treated cancer patients. Hence, in this study, we retrospectively analyzed ICI-treated adult patients with malignant solid tumors at a single institution between August 2020 and August 2021. Patients who had the most recent ICI treatment over 1-month before or after the positive COVID-19 test were excluded from the study. For the COVID-19 positive group, only the irAEs that developed after COVID-19 infection were considered as events. A total of 579 patients were included in our study, with 46 (7.9%) in the COVID-19 positive group and 533 (92.1%) in the COVID-19 negative group. The baseline characteristics of patients in the 2 groups were similar. With a median follow-up of 331 days (range: 21-2226), we noticed a nonsignificant higher incidence of all-grade irAEs in the COVID-19 positive group (30.4% vs. 19.9%, P =0.18). The incidence of grade 3 and 4 irAEs was significantly higher in the COVID-19 positive group (10.9% vs. 3.2%, P =0.02). Multivariate analysis confirmed the association between COVID-19 infection and increased risk of severe irAE development (odds ratio: 1.08, 95% confidence interval: 1.02-1.14, P =0.01). Our study suggested that COVID-19 may pose a risk of severe irAEs in cancer patients receiving ICIs. Close monitoring and possibly delaying ICI administration could be considered when cancer patients are infected with COVID-19.

COVID-19 Outcomes in Stage IV Cancer Patients Receiving Immune Checkpoint Inhibitors.

Cancer patients are a vulnerable population in the current coronavirus disease 2019 (COVID-19) outbreak. The impact of immune checkpoint inhibitors (ICIs) on the outcomes of COVID-19 infection in cancer patients remains largely unclear. We retrospectively investigated all solid cancer patients who received at least one cycle of ICIs at a single institution between August 2020 and August 2021. All stage IV solid cancer patients who were on or ceased ICI treatment when diagnosed with COVID-19 were eligible. All COVID-19 infections were confirmed by RT-PCR. Risk factors for hospitalization, severe symptoms, and death were analyzed. A total of 56 patients were included in our study. Twenty (35.7%) patients require hospitalization, 12 (21.4%) developed severe symptoms, and 10 (17.9%) died from COVID-19 infection. ICI treatment was interrupted in 37 patients (66.1%), 24 of whom (64.9%) had treatment resumed. Eight (80%) COVID-19-related death occurred in unvaccinated individuals. Reinfection occurred in seven patients (12.5%), and three of them died from their second COVID-19 infection. Factors associated with hospitalization were high Charlson comorbidity score (OR 1.56, 95% CI 1.10-2.23, p = 0.01) and lymphocyte ≤ 1500 mm3 (OR 10.05, 95% CI 2.03-49.85, p = 0.005). Age, chemoimmunotherapy, and ICI treatment duration were not associated with increased risk of hospitalization, severe symptoms, or COVID-19-related mortality. ICI therapy does not impose an increased risk for severe COVID-19 infection in stage IV cancer patients. Vaccination should be encouraged among this population. Clinicians should be cognizant of a potential worse outcome in COVID-19-reinfected patients.

A Case Report of Reversible Cerebral Vasoconstriction Syndrome in a Patient With Systemic Scleroderma.

Reversible cerebral vasoconstriction syndrome (RCVS) is represented by recurrent severe thunderclap headache, with or without neurological symptoms. RCVS can be primary or secondary to several factors. Here, we present a case of RCVS in a patient with systemic scleroderma. A 44-year-old female patient presented to the hospital due to Raynaud's phenomenon, fingertip pain ulceration, skin tightness, and skin depigmentation. She was diagnosed with systemic scleroderma. After four days of steroids, immunosuppressants (mycophenolate mofetil), and hydroxychloroquine, the patient developed severe thunderclap headaches and left lower extremity weakness. The computed tomography angiography (CTA) showed multifocal segmental vasoconstriction of the cerebral arteries. The patient's headache and body weakness resolved after starting an oral calcium channel blocker (nimodipine).

Evaluating "The REST of Your Life," a Workplace Health Program to Improve Employee Sleep, Health, Energy, and Productivity.

PURPOSE: Sleep is critical for employee health, well-being, and productivity. Our purpose is to evaluate a sleep-focused interactive workplace health promotion program. DESIGN: We evaluate sleep and mental health before and after exposure to the program using a pre/post quasi-experimental pilot study design with surveys administered at baseline and 1-, 6-, and 12 months post-exposure (Phase 1). We design program evaluation surveys for dissemination when the program is offered broadly to hospital employees (Phase 2). SETTING: The study was conducted at a large teaching hospital in the Southeast U.S. in 2016. SUBJECTS: Subjects were full-time hospital employees. INTERVENTION: The program was presented to subjects in one four-hour interactive session. MEASURES: In Phase 1 (n = 55), surveys included the validated Apnea Risk Evaluation System, Dysfunctional Beliefs About Sleep, Generalized Anxiety Disorder-7, Pittsburgh Sleep Quality Index and Patient Health Questionnaire. Phase 2 (n = 3935) utilized program evaluation surveys. ANALYSIS: We compare survey responses between pre- and post-program using a repeated measures analysis of variance with post-hoc tests. RESULTS: Statistically significant improvement in all sleep and mental health domains was demonstrated. In Phase 2, 81.9% reported "strongly agree" to willingness to recommend the program to co-workers. CONCLUSION: We demonstrate improvement in employee sleep and mental health after exposure to a novel workplace health promotion program to improve sleep.

An Unusual Case of Cavitary Lung Lesion and a Brief Review of Literature.

Large cavitary pulmonary infarctions are extremely rare. Here, we report an unusual case of large pulmonary infarction due to pulmonary embolism (PE). This was complicated by secondary infection with Actinomyces leading to cavitary abscess formation. The patient had minimal non-specific symptoms despite extensive involvement and was treated with lobectomy, antibiotics, and anticoagulation, with expedited recovery. This case depicts a rare association between PE/pulmonary infarction and pulmonary actinomycosis. Furthermore, it highlights a high index of suspicion needed to diagnose these two conditions in low-risk individuals without traditional risk factors.

Residents or Consultants: Who Writes Orders for Patients Taken Care of by the Internal Medicine Residency Service?

Background and aims The Accreditation Council for Graduate Medical Education (ACGME) mandates that Internal Medicine residents shall place all the orders for their patients. The purpose of this rule is to assure comprehensive knowledge of patient information and direct involvement in decision-making. However, there is a general perception that a large proportion of orders for patients taken care of by the residents are being written by consultants or other providers. The objective of the study was to determine the proportion of routine orders placed by Internal Medicine residents in comparison to consultants/subspecialty providers for patients under the care of the Internal Medicine Residency Service (IMRS).   Material and methods All the orders on patients admitted to the IMRS at AdventHealth Orlando from July 9, 2017, to July 15, 2017, were documented. Of these, Emergency Department (ED) orders, "STAT/ASAP/NOW orders," "discharge by consultant" orders, and "consent for procedure" orders were excluded. The main outcome measure was the proportion of orders placed by Internal Medicine residents as compared to consultants and all other providers. Results A total of 6471 orders placed on 90 patients admitted to the IMRS and with at least one consultant were included in the study. Of them, 96.8% of all orders were placed by Internal Medicine residents. Only 3.1% of all orders were placed by consultants and other providers. Of them, the majority of the orders were specialty-specific orders and were appropriate. Only 1.1% of all orders were "routine" orders placed inappropriately by consultants and other providers. A total of 121 consultations were made, and there were no new consultations initiated by consultants and other providers during the study period. Conclusion The vast majority of orders for patients taken care of by the IMRS were placed by the Internal Medicine residents themselves. Only a very small proportion of the orders were placed by consultants and other providers in this limited timeframe study. The findings are consistent with the ACGME mandate that residents write all orders for patients under their care except in special circumstances.

BK Virus-associated Nephropathy in a Patient with T Cell Leukemia/Lymphoma Syndrome.

BK virus-associated nephropathy develops in renal transplant patients with the main manifestation of tubulointerstitial nephritis or ureteral stenosis. Nephrotic syndrome is a rare manifestation of BK virus-associated nephropathy. Here we report a case of a 69-year-old female presenting with nephrotic and nephritic syndrome related to BK virus infection. Kidney biopsy revealed severe acute tubular injury, collapsing glomerulopathy, and focal microangiopathic changes. Four weeks of leflunomide and intravenous immunoglobulin (IVIG) resulted in the recovery of kidney function and improvement of proteinuria.

Gelatinous Abdomen: A Rare Case of Pseudomyxoma Peritonei Arising from Metastatic Gastric Adenocarcinoma.

Pseudomyxoma peritonei (PMP) is a rare condition that is typically associated with appendicular adenocarcinoma. Other origins are rarely reported. Here, we report a rare case of abdominal PMP, which originated as gastric adenocarcinoma. The prognosis of the patient consisted of pathological diagnosis, with samples from exploratory laparotomy, radiological visualization, abdominal computed tomography (CT), and abdominal magnetic resonance imaging (MRI). We employed the standard treatment protocol for our patient, which was essentially surgical, applying a cytoreductive technique, in an attempt to remove all visible evidence of the disease, plus intraperitoneal chemotherapy.

Improving breast cancer screening rates in a primary care setting.

Biannual mammogram has been recommended for all women aged 50-74 years by USPSTF. Our aim was to improve the screening rates of biannual mammogram among women aged 50-74 years in a primary care clinic. Medical records were reviewed. Patients who were not up-to-date with their breast cancer screening, were contacted by telephone or a letter was sent. Our screening rate was found to be 64.7%. After 6 months, 38.5% had undergone mammograms after our intervention. This improved the compliance rate from 64.7% to 76.6%. Hence discussion of breast cancer screening status between a patient and provider can significantly increase compliance.

Plasma cell leukemia - one in a million: A case report.

BACKGROUND: Plasma cell leukemia (PCL) is diagnosed by the presence of an absolute plasma cell count of > 2 × 109/L or 20% plasma cells in the peripheral blood. Because the incidence of PCL is relatively low, our case report study presents a rare opportunity to describe the clinical and pathological characteristics of this leukemia, as well as different modalities of treatment and outcomes of primary PCL (pPCL). CASE SUMMARY: A 56-year-old male with a history of hypertension complained of pain in the left flank area which started four months prior to admission. On admission, his vital signs were stable, and physical examination was completely benign. Laboratory evaluation showed hemoglobin of 5.1 g/dL, white blood cell count of 6.6 cells per cubic millimeter with 16% atypical lymphocytes, and platelet count of 51000 per microliter. Peripheral smear showed more than 10%-15% of plasma cells (Figure 1), and flow cytometry of peripheral blood confirmed PCL with 24% plasma cells CD138+. Bone marrow biopsy demonstrated 80% plasma cells (38+, 138+, 117+, 10-, 19-, 20-, 56-) with 90% cellularity. The Oncology team was consulted, and VCD therapy was started. After completing therapy at 1, 4, 8, and 11 d, the patient was discharged home. The patient was being considered for a bone marrow transplant evaluation within two months of discharge. CONCLUSION: PCL is a rare and aggressive form of leukemia with a poor prognosis. Multi-center studies and clinical trials should be conducted to develop accurate criteria for the initial diagnosis and prompt treatment of this disease.

Targeted Serum Metabolite Profiling Identifies Metabolic Signatures in Patients with Alzheimer's Disease, Normal Pressure Hydrocephalus and Brain Tumor.

Progression to AD is preceded by elevated levels of 2,4-dihydroxybutanoic acid (2,4-DHB), implicating hypoxia in early pathogenesis. Since hypoxia may play a role in multiple CNS disorders, we investigated serum metabolite profiles across three disorders, AD, Normal Pressure Hydrocephalus (NPH) and brain tumors (BT). Blood samples were collected from 27 NPH and 20 BT patients. The profiles of 21 metabolites were examined. Additionally, data from 37 AD patients and 46 controls from a previous study were analyzed together with the newly acquired data. No differences in 2,4-DHB were found across AD, NPH and BT samples. In the BT group, the fatty acids were increased as compared to HC and NPH groups, while the ketone body 3-hydroxybutyrate was increased as compared to AD. Glutamic acid was increased in AD as compared to the HC group. In the AD group, 3-hydroxybutyrate tended to be decreased with respect to all other groups (mean values -30% or more), but the differences were not statistically significant. Serine was increased in NPH as compared to BT. In conclusion, AD, NPH and BT have different metabolic profiles. This preliminary study may help in identifying the blood based markers that are specific to these three CNS diseases.

Kansas City Cardiomyopathy Questionnaire Utility in Prediction of 30-Day Readmission Rate in Patients with Chronic Heart Failure.

Background. Heart failure (HF) is one of the most common diagnoses associated with hospital readmission. We designed this prospective study to evaluate whether Kansas City Cardiomyopathy Questionnaire (KCCQ) score is associated with 30-day readmission in patients hospitalized with decompensated HF. Methods and Results. We enrolled 240 patients who met the study criteria. Forty-eight (20%) patients were readmitted for decompensated HF within thirty days of hospital discharge, and 192 (80%) patients were not readmitted. Compared to readmitted patients, nonreadmitted patients had a higher average KCCQ score (40.8 versus 32.6, P = 0.019) before discharge. Multivariate analyses showed that a high KCCQ score was associated with low HF readmission rate (adjusted OR = 0.566, P = 0.022). The c-statistic for the base model (age + gender) was 0.617. The combination of home medication and lab tests on the base model resulted in an integrated discrimination improvement (IDI) increase of 3.9%. On that basis, the KCQQ further increased IDI of 2.7%. Conclusions. The KCCQ score determined before hospital discharge was significantly associated with 30-day readmission rate in patients with HF, which may provide a clinically useful measure and could significantly improve readmission prediction reliability when combined with other clinical components.

I smell a rat: a case report and literature review of paradoxical thrombosis and hemorrhage in a patient with brodifacoum toxicity.

Brodifacoum poisoning occurs as a result of ingestion of rodenticide compounds. It acts as a superwarfarin, inhibiting vitamin K epoxide reductase, in an irreversible fashion much like warfarin but with a much longer half-life. A 48-year-old female patient reported 4 days of mild dyspnea, dry cough, bilateral popliteal fossae pain and diffuse upper abdominal pain. She had no history of liver disease or alcohol or illicit substance abuse. Initial physical examination was remarkable only for mildly pale conjunctivae and mild abdominal tenderness and pain in the left popliteal fossa. A complete blood count and complete metabolic panel were normal. Prothrombin time (PT) was above 100 s, partial thromboplastin time (PTT) was above 200 s and international normalized ratio was reported as above 12.0. Urinalysis revealed hematuria. Venous Doppler ultrasound of lower extremities demonstrated left popliteal vein thrombosis. Computed tomography scan of the abdomen demonstrated transmural hematoma, and fecal occult blood test was positive. A full anticoagulant work-up showed critical reduction of vitamin K-dependent factors II, VII, IX and X. PT and PTT corrected with mixing studies proving factor deficiency as the cause of the coagulopathy. Lupus anticoagulant studies were negative. Superwarfarin toxicity was suspected and confirmed with an anticoagulant poison panel positive for brodifacoum. The patient was hospitalized and successfully treated with fresh frozen plasma, cryoprecipitate and vitamin K. In conclusion, paradoxical thrombosis and hemorrhage should raise the suspicion for superwarfarin toxicity in the appropriate clinical setting. Further studies are required to define the management of these patients.

Thymolipoma with sebaceous differentiation: a hitherto unreported variant of thymolipoma.

Thymolipoma is a very rare anterior mediastinal mass of thymic origin, accounting for only 2% to 10% of all thymic neoplasm. Histologically, the tumor is usually composed of adipose tissue interspersed with thymic tissues. We report a case of a 58-year-old man who presented with a few weeks history of shortness of breath, cough, and chest pain, found to have a retrocardiac infiltrate on chest X-ray. Computed tomography scan of the chest showed a large anterior mediastinal mass. Surgical excision revealed an ovoid fatty mass, which on histological examination displayed thymic tissue intermixed with lipomatous tissue consistent with a thymolipoma. Of note was the presence of a microscopic nodule of thymic epithelial proliferation with sebaceous differentiation and focal cylindroma-like architecture. Although sebaceous tissue has been rarely reported in thymic tissue, to the best of our knowledge, this is the first case report of sebaceous differentiation in a thymolipoma.