Similarities and perspectives on the two C's-Cancer and COVID-19

Continuous care needs in patients with cancer receiving chemotherapy during the recent omicron wave of COVID-19 in Shanghai: A qualitative study

Aims

This study aimed to investigate the care needs, to clarify the factors affecting the quality of homecare, and to provide reference for constructing a homecare system for patients with cancer receiving chemotherapy during the recent omicron wave of COVID-19 in Shanghai.

Methods

From March to May 2022 when the omicron wave emerged in Shanghai, 50 consecutive patients who received chemotherapy at Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, were enrolled, and underwent face-to-face or telephone-based semi-structured interviews regarding continuous care needs. Some of their homecare-givers, caring nurses, and physicians were also interviewed. The Colaizzi method was used for data analysis.

Results

Fifty patients, 4 homecare-givers, 4 nurses, and 4 physicians were interviewed. Three themes and six subthemes emerged from analysis of the interviews: The first theme was "Disease management needs," including needs for knowledge of managing adverse events associated with chemotherapy, and needs for treatment-related information. Patients expressed most concern about not being able to go to the hospital for blood review and disease evaluation in time due to the outbreak. With the COVID-19 pandemic being ongoing, factors such as pandemic panic, inconvenient medical treatment, and worry about hospital cross-infection might reduce disease management for patients with cancer. The second theme was "Medical needs," including needs for mobile healthcare and needs for medical resources. All interviewees emphasized the importance of mobile healthcare during the COVID-19 pandemic, as access to hospitals was difficult. The third theme was "Spiritual needs," including demands for psychological counseling and intervention, and needs for spiritual care. Patients and homecare-givers commonly lacked a feeling of security and needed communication, encouragement, and reassurance that medical care could be delivered to them, and patients reported that they very much wanted psychological advice.

Conclusion

For patients with cancer receiving chemotherapy during the COVID-19 pandemic, continuous care is greatly needed. Medical personnel should strengthen the healthcare education for patients and their caregivers during hospitalization, and further improve the patients' information intake rate through Internet-based digital healthcare methods during homecare, to further meet the information needs of patients after discharge from hospital.

Haematological predictors of poor outcome among COVID-19 patients admitted to an intensive care unit of a tertiary hospital in South Africa

Background

Studies from Asia, Europe and the USA indicate that widely available haematological parameters could be used to determine the clinical severity of Coronavirus disease 2019 (COVID-19) and predict management outcome. There is limited data from Africa on their usefulness in patients admitted to Intensive Care Units (ICUs). We performed an evaluation of baseline haematological parameters as prognostic biomarkers in ICU COVID-19 patients.

Methods

Demographic, clinical and laboratory data were collected prospectively on patients with confirmed COVID-19, admitted to the adult ICU in a tertiary hospital in Cape Town, South Africa, between March 2020 and February 2021. Robust Poisson regression methods and receiver operating characteristic (ROC) curves were used to explore the association of haematological parameters with COVID-19 severity and mortality.

Results

A total of 490 patients (median age 54.1 years) were included, of whom 237 (48%) were female. The median duration of ICU stay was 6 days and 309/490 (63%) patients died. Raised neutrophil count and neutrophil/lymphocyte ratio (NLR) were associated with worse outcome. Independent risk factors associated with mortality were age (ARR 1.01, 95%CI 1.0–1.02; p = 0.002); female sex (ARR 1.23, 95%CI 1.05–1.42; p = 0.008) and D-dimer levels (ARR 1.01, 95%CI 1.002–1.03; p = 0.016).

Conclusions

Our study showed that raised neutrophil count, NLR and D-dimer at the time of ICU admission were associated with higher mortality. Contrary to what has previously been reported, our study revealed females admitted to the ICU had a higher risk of mortality.

Thrombotic and bleeding complications in patients with chronic lymphocytic leukemia and severe COVID-19: a study of ERIC, the European Research Initiative on CLL

Background

Patients with chronic lymphocytic leukemia (CLL) may be more susceptible to COVID-19 related poor outcomes, including thrombosis and death, due to the advanced age, the presence of comorbidities, and the disease and treatment-related immune deficiency. The aim of this study was to assess the risk of thrombosis and bleeding in patients with CLL affected by severe COVID-19.

Methods

This is a retrospective multicenter study conducted by ERIC, the European Research Initiative on CLL, including patients from 79 centers across 22 countries. Data collection was conducted between April and May 2021. The COVID-19 diagnosis was confirmed by the real-time polymerase chain reaction (RT-PCR) assay for SARS-CoV-2 on nasal or pharyngeal swabs. Severe cases of COVID-19 were defined by hospitalization and the need of oxygen or admission into ICU. Development and type of thrombotic events, presence and severity of bleeding complications were reported during treatment for COVID-19. Bleeding events were classified using ISTH definition. STROBE recommendations were used in order to enhance reporting.

Results

A total of 793 patients from 79 centers were included in the study with 593 being hospitalized (74.8%). Among these, 511 were defined as having severe COVID: 162 were admitted to the ICU while 349 received oxygen supplementation outside the ICU. Most patients (90.5%) were receiving thromboprophylaxis. During COVID-19 treatment, 11.1% developed a thromboembolic event, while 5.0% experienced bleeding. Thrombosis developed in 21.6% of patients who were not receiving thromboprophylaxis, in contrast to 10.6% of patients who were on thromboprophylaxis. Bleeding episodes were more frequent in patients receiving intermediate/therapeutic versus prophylactic doses of low-molecular-weight heparin (LWMH) (8.1% vs. 3.8%, respectively) and in elderly. In multivariate analysis, peak D-dimer level and C-reactive protein to albumin ratio were poor prognostic factors for thrombosis occurrence (OR = 1.022, 95%CI 1.007‒1.038 and OR = 1.025, 95%CI 1.001‒1.051, respectively), while thromboprophylaxis use was protective (OR = 0.199, 95%CI 0.061‒0.645). Age and LMWH intermediate/therapeutic dose administration were prognostic factors in multivariate model for bleeding (OR = 1.062, 95%CI 1.017–1.109 and OR = 2.438, 95%CI 1.023–5.813, respectively).

Conclusions

Patients with CLL affected by severe COVID-19 are at a high risk of thrombosis if thromboprophylaxis is not used, but also at increased risk of bleeding under the LMWH intermediate/therapeutic dose administration.

D-dimers-"Normal" Levels versus Elevated Levels Due to a Range of Conditions, Including "D-dimeritis," Inflammation, Thromboembolism, Disseminated Intravascular Coagulation, and COVID-19

D-dimers reflect a breakdown product of fibrin. The current narrative review outlines how D-dimers can arise in normal individuals, as well as in patients suffering from a wide range of disease states. D-dimers in normal individuals without evident thrombosis can arise from background fibrinolytic activity in various tissues, including kidney, mammary and salivary glands, which ensures smooth flow of arising fluids where any blood contamination could be immediately lysed. In addition, healthy individuals can also regularly sustain minor injuries, often unbeknown to them, and wound healing follows clot formation in these situations. D-dimers can also arise in anxiety and following exercise, and are also markers of inflammation. Lung inflammation (triggered by microbes or foreign particles) is perhaps also particularly relevant, since the hemostasis system and fibrinolysis help to trap and remove such debris. Lung inflammation in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may contribute to D-dimer levels additive to thrombosis in patients with COVID-19 (coronavirus disease 2019). Indeed, severe COVID-19 can lead to multiple activation events, including inflammation, primary and secondary hemostasis, and fibrinolysis, all of which may contribute to cumulative D-dimer development. Finally, D-dimer testing has also found a role in the diagnosis and triaging of the so-called (COVID-19) vaccine-induced thrombotic thrombocytopenia.

Thrombosis, cancer, and COVID-19

Cancer and coronavirus disease 2019 (COVID-19) have unusual similarities: they both result in a markedly elevated risk of thrombosis, exceptionally high D-dimer levels, and the failure of anticoagulation therapy in some cases. Cancer patients are more vulnerable to COVID-19 infection and have a higher mortality rate. Science has uncovered much about SARS-CoV-2, and made extraordinary and unprecedented progress on the development of various treatment strategies and COVID-19 vaccines. In this review, we discuss known data on cancer-associated thrombosis (CAT), SARS-CoV-2 infection, and COVID-19 vaccines and discuss considerations for managing CAT in patients with COVID-19. Cancer patients should be given priority for COVID-19 vaccination; however, they may demonstrate a weaker immune response to COVID-19 vaccines than the general population. Currently, the Centers for Disease Control and Prevention recommends an additional dose and booster shot of the COVID-19 vaccine after the primary series in patients undergoing active cancer treatment for solid tumors or hematological cancers, recipients of stem cell transplant within the last 2 years, those taking immunosuppressive medications, and those undergoing active treatment with high-dose corticosteroids or other drugs that suppress the immune response. The mainstay of thrombosis treatment in patients with cancer and COVID-19 is anticoagulation therapy.

Venous thromboembolism risk, prophylaxis and management in cancer patients with COVID-19: An unmet medical need

Cancer patients exhibit an increased risk of venous thromboembolism (VTE), with VTE being the second leading cause of morbidity and mortality in these patients. The implementation of lockdowns following the COVID-19 pandemic has resulted in decreased mobility and delayed access to care, thus further increasing the susceptibility to VTE. Cancer patients may also be at a higher risk of SARS-CoV-2 infection and have been shown to be more likely to experience severe COVID-19 disease compared to patients without cancer. Given that both cancer and COVID-19 exhibit a hypercoagulable state, stasis of blood flow, and endothelial injury, cancer patients with COVID-19 constitute a vulnerable population with a high risk of thrombosis and bleeding. However, to date there are limited studies evaluating whether cancer patients infected with SARS-CoV-2 have a higher VTE incidence than COVID-19 patients without cancer, how to assess the risk of VTE, prophylaxis and treatment in this special population. Herein, we highlight the urgent need for studies in cancer patients with COVID-19 to ensure appropriate patient care and improve clinical outcomes.

D-dimers: a most misunderstood test

The role of D-dimers in the management of venous thromboembolism is well established and testing for D-dimers has become common in most acute settings. Although it has been validated for the purpose of excluding venous thromboembolism, the test is increasingly ordered to 'diagnose' venous thromboembolism. Furthermore, in the COVID-19 pandemic, heavy reliance has been put on this test with the inclusion of D-dimers to guide treatment pathways. This review summarises the appropriateness of D-dimer tests in these different clinical settings.

Lessons learnt from COVID-19 coagulopathy

The coronavirus disease 2019 (COVID‐19) pandemic has already left an indelible mark in human lives. Despite the havoc it created, this pandemic also saw significant advances in the management of an infectious disease wherein worldwide collaborative efforts from health care professionals have been unprecedented. One of the commonest complications recognised early in the pandemic is the development of coagulopathy. In this review, the lessons learnt from COVID‐19 coagulopathy are summarised with some perspectives on future clinical and research strategies. These include how local versus systemic coagulopathy can matter, how we can put D‐dimers to effective use, exhort more input into identifying a simple platelet activation marker, rethink the role of fibrinogen, look differently at lupus anticoagulant and heparin‐induced thrombocytopenia, bring back disseminated intravascular coagulation into our differential diagnosis slate and most importantly channel more funding into haemostasis and thrombosis research.