Thrombotic Thrombocytopenic Purpura Following Pfizer-BioNTech COVID-19 Vaccination in a Patient With Multiple Myeloma: Case Report and Literature Review.

The vaccines developed to prevent infection and mitigate morbidity and mortality in patients with COVID-19 demonstrated high efficacy in clinical trials but were associated with adverse events, most of which were mild and transient. However, some adverse events were rather serious, with grave prognoses. Of note, a few cases of autoimmune hematological conditions such as thrombotic thrombocytopenic purpura (TTP), immune thrombocytopenic purpura (ITP), and vaccine-induced immune thrombotic thrombocytopenia (VITT) were reported. TTP following Pfizer-BioNTech mRNA vaccination is exceptionally rare, with very scant literature. This case report describes an interesting case of a 61-year-old woman who presented 22 days after receiving the third dose of the Pfizer-BioNTech mRNA COVID-19 vaccine with malaise, bloody stools, and jaundice. Her medical history was significant for multiple myeloma previously treated with autologous bone marrow transplant and in remission with chemotherapy. She also had a history of chronic heart failure with preserved ejection fraction (HFpEF) and neuropathy treated with daily vitamins. The diagnosis was predicted by her classic presentation and was clinched by low ADAMTS13 activity. She was treated with plasmapheresis, steroids, and monoclonal antibodies. Intriguingly, her hospital stay was further complicated by an episode of generalized tonic-clonic seizure requiring intubation and mechanical ventilation for airway protection. Albeit infrequent, COVID-19 vaccine-associated TTP is associated with substantial morbidity and mortality. Hence, early diagnosis and treatment are essential in patients presenting with thrombocytopenia after COVID-19 vaccination.

Mixed Epithelial Stromal Tumor of the Kidney With a Mesenteric Lymph Node: A Case Report and Literature Review.

Mixed epithelial and stromal tumor (MEST) of the kidney belongs to the broad spectrum of renal neoplasms, distinguished by their varying composition of stromal to epithelial components. The histopathological display of the biphasic growth pattern of mesenchymal and epithelial elements, often with estrogen and progesterone receptor positivity, clinches the diagnosis. It is typically benign, with low recurrence rates and excellent prognosis after surgical resection. MEST constitutes a rare and unique subset, with limited research and understanding, requiring differentiation from other renal tumors. Our patient's presentation of a morphologically benign renal MEST with an imaging-positive inferior mesenteric lymph node renders this case exceptionally rare.

Pembrolizumab induced remission of recurrent and metastatic sinonasal squamous cell carcinoma after overcoming checkpoint-inhibitor pneumonitis: A case report and literature review.

BACKGROUND: For programmed death-ligand-1 (PD-L1) positive recurrent and metastatic head and neck squamous cell carcinoma (R/M-HNSCC), KEYNOTE-048 and KEYNOTE-040 clinical trials recently approved pembrolizumab monotherapy as first-line treatment. However, recurrent and metastatic sinonasal squamous cell carcinoma (R/M-SNSCC) was excluded from these clinical trials and treatment reports of immune-checkpoint inhibitor (ICI) in R/M-SNSCC are sparse. Immune-related adverse events (irAEs) are known to occur during ICI treatment and some of these such as checkpoint-inhibitor pneumonitis (CIP) can be fatal. ICI rechallenge after severe irAEs is debated. CASE: We describe a case of a 65-year-old male with R/M-SNSCC who is currently in remission with pembrolizumab monotherapy. He developed high-grade pneumonitis during the course of treatment warranting ICI discontinuation but has since tolerated full-dose pembrolizumab for 10 months now which is holding his disease stable. Our approach toward restarting full-dose pembrolizumab was by monitoring the patient's response to an initial low dose of pembrolizumab with concomitant oral steroid immunosuppression to control CIP. CONCLUSION: Clinicians should weigh the risk-to-reward ratio of ICI rechallenge after improvement of high-grade CIP, particularly for selected patients with aggressive tumors such as R/M-SNSCC and prior treatment response. Under close monitoring, ICI resumption at a low dose and assessing patient tolerance with concomitant immunosuppression may be a reasonable approach to reintroducing ICI after high-grade CIP in these patients.

Physician behavior impact when revenue shifted from drugs to services.

OBJECTIVES: In partnership with a large nonprofit healthcare insurer for the Mid-Atlantic region of the United States, we launched the first cancer clinical pathway in the United States in August 2008. Due to its early success with regard to savings and physician participation and compliance, a second-generation pathways program-the Oncology Medical Home-was piloted in 2011. This program offered a physician reimbursement model that shifted the source of revenue from drug reimbursement margin to professional charges for cognitive services (evaluation and management codes). We report our observations of the impact of that reimbursement model on physician prescribing behavior. STUDY DESIGN: This was a retrospective analysis. METHODS: A select group of practices that participated in the first-generation pathways program were invited to voluntarily participate in the Oncology Medical Home and its cognitive weighted reimbursement design. A matched control group was chosen from the first-generation pathways participants. Comparisons of physician behavior parameters were made pre- and postimplementation and between the Oncology Medical Home practices and the first-generation pathways control group. RESULTS: Physician behavior was not significantly modified by cognitive weighted reimbursement. No significant change in frequency of office visits for established patients was observed. No change in chemotherapy prescribing was observed. Observed increases in generic regimen use were no different than matched control. CONCLUSIONS: Observations from this oncology medical home pilot program suggest that reimbursement methodology alternatives to the prevailing fee-for-service may have less impact on prescribing behavior than has been conjectured. Future research is ongoing to validate these observations and assess additional influences on prescribing behavior.