Management of Acquired Factor VIII Inhibitors With NovoSeven and Obizur.

Acquired hemophilia A (AHA) is a rare hemorrhagic disorder caused by the production of autoantibodies against coagulation factor VIII (FVIII). AHA is associated with significant morbidity and mortality primarily as a result of bleeding. Although many disorders are associated with the development of these inhibitors, up to 50% of cases remain idiopathic. The approach to therapy involves an initial strategy often to control acute bleeding episodes followed by definitive treatment to eradicate the inhibitor with immunosuppressive agents. We present the case of a 63-year-old Caucasian male hospitalized for severe Covid-19 who developed bleeding due to an acquired FVIII inhibitor that had never been treated definitively. Our case presentation focuses on in-hospital management of this patient's acute bleeding episodes with by-passing agents and recombinant porcine factor VIII.

Salivary Duct Carcinoma: Case Reports and Brief Review of the Literature.

Salivary duct carcinoma (SDC) is an uncommon and highly aggressive tumor associated with high morbidity and mortality. According to the World Health Organization, it is an extremely rare malignancy with an estimated incidence of 1-1.2 in 1,000,000 patients. Standard treatment for SDC is wide surgical resection along with lymph node dissection followed by adjuvant radiation therapy. The role of adjuvant chemotherapy is not known. In this report, we present three cases of SDC. A 71-year-old female with T1N0M0 disease was treated with total parotidectomy, ipsilateral neck dissection, and adjuvant radiotherapy without evidence of disease recurrence at 5 months. The second is a 59-year-old female with TXN1M0 disease who was treated with total parotidectomy with ipsilateral level I-IV neck dissection and adjuvant radiotherapy without evidence of disease occurrence at 21 months. The third case is a 79-year-old male with widely metastatic disease, including brain metastases, treated with cranial irradiation, leuprolide, and lapatinib who remains under home hospice care.

Infection Masquerading as Recurrence of Pancreatic Ductal Adenocarcinoma: A Cautionary Tale.

We present a case of a 59-year-old male undergoing adjuvant chemotherapy for his pancreatic adenocarcinoma post-surgical resection. He had an acute rise in carbohydrate antigen (CA) 19-9 level, which raised suspicion of metastatic disease. Instead, the patient was diagnosed to have a liver abscess, the treatment of which brought the CA 19-9 level back to normal. Unfortunately, although CA 19-9 is Food and Drug Administration (FDA)-approved tumor marker for pancreatic cancer, it is also elevated in several benign conditions, causing fear of cancer and unnecessary diagnostic workup. Hence, caution is necessary for interpreting the significance of its elevation.

Retrospective Analysis of Inflammatory Markers and Patient Characteristics in Hospitalized Covid-19 Patients: An Early Experience in Louisiana.

Background The community transmission of coronavirus disease 2019 (Covid-19) was detected in Baton Rouge, Louisiana, in March 2020. Several previous studies have reported elevations of inflammatory markers in Covid-19 positive patients and suggested a possible correlation to disease severity. Methods We identified 69 patients from Baton Rouge General (BRG) Hospital who were admitted with acute hypoxic respiratory failure and laboratory confirmed positive severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) between March 13 and April 5, 2020. Demographic and laboratory data were obtained through a review of medical records. Statistical analysis was performed on several inflammatory markers in association with clinical disease severity. Results We identified 69 patients with confirmed Covid-19 infection. The mean (±SD) age of the patients was 65±14 years, 68% were male and 32% were female. A total of 13 patients (19%) were considered to have mild disease, 25 (36%) had moderate disease, and 31 (45%) were considered to have severe disease. A total of nine patients died (13%), 25 (36%) have been discharged from the hospital, 20 (29%) remain in the ICU, and 15 (22%) remain admitted to the hospital at the time of writing. Lymphopenia was common among hospitalized patients (39%) and was found to be statistically more pronounced in patients with severe disease (p<0.05). Inflammatory marker elevations were also seen in several patients, with statistically significant elevations in C-reactive protein (CRP) and lactate dehydrogenase (LDH) (p <0.05). We found no statistically significant associations between ferritin, D-dimer, troponin I, body mass index (BMI), or creatine kinase (CK) with disease severity. Conclusions During the first three weeks of the Covid-19 outbreak in Baton Rouge, Louisiana, the most common reason for admission amongst Covid-19 positive patients was acute hypoxic respiratory failure. Previously, several studies have suggested a correlation between elevated inflammatory markers and disease severity. The presence of lymphopenia and elevations of CRP and LDH may be helpful in the risk stratification of these patients. In an effort to guide clinical decision making and provide insight into disease severity, further characterization of Covid-19 infection in hospitalized patients is urgently needed.

Ibrutinib-Associated Cardiac Tamponade with Concurrent Antiplatelet Therapy.

Ibrutinib is approved for the first-line treatment of chronic lymphocytic leukemia (CLL). A well-known side effect of ibrutinib therapy is increased bleeding risk, which ranges from mild mucocutaneous bleeding to rarely life-threatening hemorrhage. The increased bleeding tendency associated with ibrutinib is thought to be related to its effect on several platelet signaling pathways, which can be exacerbated in the setting of concurrent antiplatelet or anticoagulant therapy. We present an 82-year-old male with CLL on ibrutinib and concurrent antiplatelet therapy who developed cardiac tamponade due to a hemorrhagic pericardial effusion requiring emergent placement of a pericardial window. This case further highlights the risk of major bleeding in patients treated with ibrutinib and concurrent antiplatelet therapy.

Microdrilling Surgery Augmented With Intra-articular Bone Marrow Aspirate Concentrate, Platelet-Rich Plasma, and Hyaluronic Acid: A Technique for Cartilage Repair in the Knee.

The ideal treatment of large full-thickness chondral lesions in the knee, especially "kissing lesions" and osteoarthritis, has not been determined. Microdrilling surgery augmented with injections of peripheral blood stem cells and hyaluronic acid has been used to treat patients with a wide range of articular cartilage disease including patients with bipolar lesions and joint space narrowing. Excellent results in this difficult patient population have been reported, and second-look biopsy has shown repair tissue very similar to native hyaline cartilage. Because of Food and Drug Administration regulations, this technique is not currently allowed in the United States. We describe a Food and Drug Administration-compliant modification of this technique using microdrilling augmented with intra-articular bone marrow aspirate concentrate, platelet-rich plasma, and hyaluronic acid.

Combination treatment with weekly docetaxel and gemcitabine for advanced non-small-cell lung cancer in elderly patients and patients with poor performance status: results of a Minnie Pearl Cancer Research Network phase II trial.

The purpose of this study was to evaluate the feasibility, toxicity, and efficacy of the combination of weekly docetaxel and gemcitabine in patients with advanced non-small-cell lung cancer (NSCLC) who are either elderly or have poor performance status (PS). Patients with stage IIIB or IV NSCLC who had received no previous chemotherapy and were = 70 years of age were eligible for this clinical trial. Patients < 70 years of age were also eligible if they had poor PS or were considered poor candidates for standard platinum-based combination chemotherapy regimens. All patients received chemotherapy with gemcitabine 800 mg/m2 and docetaxel 30 mg/m2, both drugs administered by 30-minute intravenous infusions on days 1, 8, and 15. Treatment courses were repeated every 28 days. Patients were reevaluated after completion of 2 treatment courses; responding patients continued treatment until disease progression or for a maximum of 6 courses. Between August 1999 and June 2000, 64 patients (73% with stage IV disease) were treated at 17 participating sites in the Minnie Pearl Cancer Research Network. Eighteen of 64 patients enrolled (28%) had objective response to treatment; an additional 25 patients (39%) had stable disease. Median survival was 7 months, with 1- and 2-year survival rates of 30% and 17%, respectively. Treatment was well tolerated by most patients. Grade 3/4 leukopenia occurred in 7 patients (11%), but no patient required hospitalization for neutropenia/fever. One patient developed fatal bilateral pneumonitis, which was possibly treatment-related. The combination of weekly docetaxel/gemcitabine is active and relatively well tolerated in most patients with advanced age or poor PS with advanced NSCLC. A randomized comparison of this regimen versus single-agent weekly docetaxel is in progress.

Phase I trial of gemcitabine, administered as a standard and constant dose-rate infusion, in combination with paclitaxel in patients with advanced solid tumors (LOA-2).

The major purposes of this study were to determine the maximally tolerated dose (MTD), dose-limiting toxicity (DLT), toxicity profile, and antitumor activity of gemcitabine and paclitaxel combination therapy when administered to patients with advanced solid tumors, using two infusion schedules of each agent. Paclitaxel was administered on day 1, followed by gemcitabine, and gemcitabine alone was administered on day 8, of each 21-day treatment course. In the initial phase of the trial, paclitaxel was administered during 3 hours and gemcitabine during 30 minutes (schedule A). After the MTD was determined on this schedule, patients were then treated with paclitaxel during 1 hour and gemcitabine at a fixed dose-rate of 10 mg/m(2)/min (schedule B). Forty-six patients were treated with 176 courses at 7 dose levels. The MTD for schedule A was 1,300 mg/m(2) and 200 mg/m(2) and for schedule B was 1,000 mg/m(2) and 200 mg/m(2) for gemcitabine and paclitaxel, respectively. The DLT for schedule A was neutropenia and for schedule B was neutropenia and thrombocytopenia. Nonhematologic toxicity was relatively mild. Gemcitabine and paclitaxel, using both schedules of administration in the current trial, is a promising chemotherapeutic regimen.