A Review of the Current Approach and Treatment Landscape for Stage III Non-Small Cell Lung Cancer

The therapeutic landscape of the management of stage III non-small cell lung cancer (NSCLC) has drastically evolved with the incorporation of immunotherapy and targeted therapy. Stage III NSCLC accounts for one-third of the cases and the treatment strategy of these locally advanced presentations are diverse, ranging from surgical to non-surgical options; with the incorporation of chemo-immunotherapy, radiation, and targeted therapies wherever applicable. The staging of this disease has also changed, and it is essential to have a strong multidisciplinary approach to do justice to patient care. In this article, we aim to navigate the nuanced approaches in the diagnosis and treatment of stage III NSCLC and expand on the evolution of the management of this disease.

Oxygen saturation thresholds in managing sickle cell disease at US children's hospitals

BACKGROUND

Adequate oxygen saturation (SpO2 ) is crucial for managing sickle cell disease (SCD). Children with SCD are at increased risk for occult hypoxemia; therefore, understanding SpO2 threshold practices would help identify barriers to oxygen optimization in a population sensitive to oxyhemoglobin imbalances. We investigated SpO2 cutoff levels used in clinical algorithms for management of acute SCD events at children's hospitals across the United States, and determined their consistency with recommended national guidelines (SpO2  > 95%).

METHODS

Clinical pathways and algorithms used for the management of vaso-occlusive crisis (VOC) and acute chest syndrome (ACS) in SCD were obtained and reviewed from large children's hospitals in the United States.

RESULTS

Responses were obtained from 94% (140/149) of eligible children's hospitals. Of these, 63 (45%) had available clinical algorithms to manage VOC and ACS. SpO2 cutoff was provided in 71.4% (45/63) of clinical algorithms. Substantial variation in SpO2 cutoff levels was noted, ranging from ≥90% to more than 95%. Only seven hospitals (5% of total hospitals and 15.6% of hospitals with clinical algorithms available) specified oxygen cutoffs that were consistent with national guidelines. Hospitals geographically located in the South (46.8%; n = 29/62) and Midwest (54.8%; n = 17/31) were more likely to have VOC and ACS clinical algorithms, compared to the Northeast (26.5%; n = 9/34) and West (36.4%; n = 8/22).

CONCLUSION

There is inconsistency in the use of clinical algorithms and oxygen thresholds for VOC and ACS across US children's hospitals. Children with SCD could be at risk for insufficient oxygen therapy during adverse acute events.

Real-world experience of patients with sickle cell disease treated with crizanlizumab

In 2019, crizanlizumab was approved by the Food and Drug Administration (FDA) to reduce the rate of vaso-occlusive crisis in patients with sickle cell disease (SCD). We aimed to study the real-world effectiveness of crizanlizumab in our comprehensive sickle cell center. This was a retrospective cohort analysis of patients with SCD who received at least two consecutive doses of crizanlizumab. Clinically significant improvement was captured using the patient global impression of change scale (PGI-C). As of December 2022, there were 18 patients eligible for analysis with a median age of 30.5 years. Eight patients had the HbSS genotype, 7 HbSC, and 3 HbSB null genotype. Median duration of exposure to crizanlizumab was 53.6 weeks, and 16 (88.9%) patients received crizanlizumab for ≥26 weeks. Crizanlizumab was very well tolerated with no serious adverse events (grade ≥3) related to treatment. There was no significant difference in laboratory parameters. There was a remarkable improvement in patients' subjective response to crizanlizumab infusion. The median PGI-C score of our patients was 5, signifying moderately better with slight but noticeable changes. The morphine equivalent daily doses (MEDD) were lower after crizanlizumab infusion. MEDD prior to crizanlizumab was 90; after ≥2 consecutive crizanlizumab doses, it was 60. There was also a reduction in the hospital admissions, emergency, and urgent care visit for acute pain crisis in 6 (28%) patients. This study shows that crizanlizumab was associated with improvement in patients' response, both directly and indirectly related to the reduction of opioids used, which is consistent with results from the SUSTAIN trial.

Belzutifan, HIF-2α Inhibitor, and Clear Cell Renal Cell Carcinoma With Somatic Von-Hippel-Lindau Loss-of-Function Mutation

The Von-Hippel-Lindau (VHL) gene, acting as a tumor suppressor, plays a crucial role in the tumorigenesis of clear cell renal cell carcinoma (ccRCC). Approximately 90% of individuals with advanced ccRCC exhibit somatic mutations in the VHL gene. Belzutifan, orally administered small-molecule inhibitor of hypoxia-induced factor-2α, has demonstrated promising efficacy in solid tumors associated with germline loss-of-function mutations in VHL, including ccRCC. However, its impact on cases with somatic or sporadic VHL mutations remains unclear. Here, we present 2 cases where belzutifan monotherapy was employed in patients with advanced ccRCC and somatic loss-of-function mutations in VHL. Both patients exhibited a swift and sustained response, underscoring the potential role of belzutifan as a viable option in second or subsequent lines of therapy for individuals with somatic VHL mutations. Despite both patients experiencing a pulmonary crisis with respiratory compromise, their rapid response to belzutifan further emphasizes its potential utility in cases involving pulmonary or visceral crises. This report contributes valuable insights into the treatment landscape for advanced ccRCC with somatic VHL mutations.

Promising Response of Olaparib in Patient With Germline ATM-Mutated Metastatic Gastric Cancer

Gastric cancer ranks as the fifth leading cause of global cancer incidences, exhibiting varied prevalence influenced by geographical, ethnic, and lifestyle factors, as well as Helicobacter pylori infection. The ATM gene on chromosome 11q22 is vital for genomic stability as an initiator of the DNA damage response, and mutations in this gene have been associated with various cancers. Poly ADP-ribose polymerase (PARP) inhibitors, such as olaparib, have shown efficacy in cancers with homologous recombination repair deficiencies, notably in those with ATM mutations. Here, we present a case of a 66-year-old patient with germline ATM-mutated metastatic gastric cancer with very high CA 19-9 (48 000 units/mL) who demonstrated an exceptional response to the addition of olaparib to chemo-immunotherapy and subsequent olaparib maintenance monotherapy for 12 months. CA 19-9 was maintained at low level for 18 months. Despite the failure of a phase II clinical trial on olaparib in gastric cancer (NCT01063517) to meet its primary endpoint, intriguing findings emerged in the subset of ATM-mutated patients, who exhibited notable improvements in overall survival. Our case underscores the potential clinical utility of olaparib in germline ATM-mutated gastric cancer and emphasizes the need for further exploration through larger clinical trials. Ongoing research and clinical trials are essential for optimizing the use of PARP inhibitors, identifying biomarkers, and advancing personalized treatment strategies for gastric cancer.

Genomic profiling and sites of metastasis in non-small cell lung cancer

Background

We investigated the biological predisposition to site of metastasis in patients with NSCLC based on their molecular profiling and program death ligand PD-L1 status. We sought to identify any association between metastatic site and molecular profile in NSCLC patients.

Methods

This was a retrospective analysis of patients with stage IV NSCLC who were newly diagnosed from January 2014 to June 2022. Clinical characteristics, pathology, molecular reports, and imaging were retrieved and analyzed.

Results

A total of 143 patients were included in the study. Median age was 65 years, with an equal number of men (n=71) and women (n=72). The most common histology was adenocarcinoma (81.8%). At least one genetic mutation was discovered in 100 patients. Mutations with a targetable drug were found in 86 patients. The most common mutations were TP53 (25.2%), EGFR (24.5%), KRAS/NRAS (20.3%), and CDKN2A/2B (7.7%). Patients with any mutation were significantly more likely to have metastatic disease to the brain (57% vs. 37%, p=0.03), but there was no difference in metastatic disease to bone (34% vs. 26%, p=0.32). Patients without a discoverable mutation were significantly more likely to have metastatic disease to other sites (e.g., adrenal gland 91% vs. liver 66%, p=0.002). There was no difference in progression-free survival (PFS) or overall survival (OS) between those with versus without mutations. Median PFS and OS were significantly longer in patients with an EGFR mutation than those with KRAS/NRAS or TP53 mutations. Patients with PD-L1 >1% or TP53 were significantly more likely to have metastatic disease to organs other than bone or brain (p=0.047 and p=0.023, respectively). We identified four prognostic groups in metastatic NSCLC. Patients with PD-L1 <1% and no actionable mutations have the poorest prognosis, with median survival of around 20 months.

Conclusion

Patients with mutations discoverable on NGS are more likely to have metastatic disease to the brain. KRAS/NRAS in particular has a predilection to metastasize to the brain and bone. PD-L1 expression and a TP53 mutation, on the other hand, tend to lead to metastasis of NSCLC to organs other than brain or bone. These results need to be corroborated in larger prospective studies.

From the archives of MD Anderson Cancer Center Castleman disease involving the thymus gland: Case report and literature review

Castleman disease is a nodal based disease and very rarely involves the thymus gland. We report a 52-year-old man who was found incidentally to have a single thymic mass by computerized tomography scan. Thymectomy was performed, and the gross specimen showed a well-circumscribed, multi-loculated cystic mass. Histologic examination showed thymus involved by Castleman disease, hyaline-vascular variant. The lesion was characterized by lymphoid follicles with wide mantle zones, variably lymphocyte-depleted germinal centers with sclerotic radial blood vessels, and prominent interfollicular/stromal changes including numerous endothelial venules with sclerotic walls and hyaline sclerosis, scattered and frequent dysplastic follicular dendritic cells and foci of dystrophic calcification. Immunohistochemical analysis showed that the follicle mantle zones were composed of numerous B-cells positive for CD20, PAX5, and IgD. Antibodies specific for CD21 and CD23 highlighted prominent follicular dendritic cell networks within follicles. There was no evidence of human herpes virus 8. We searched the literature and could identify only 10 additional cases of thymic CD. Previously reported cases included 8 unicentric and 2 multicentric, classified pathologically as plasma cell variant (n = 4), hyaline vascular variant (n = 3), and mixed (n = 3). Thymectomy, as was done in the currently reported case, most often leads to the diagnosis of Castleman disease and was a mainstay of treatment in other reported cases.

Abstract 6742: Genomic profiling and sites of metastasis in non-small cell lung cancer (NSCLC)

Introduction: Molecular genotyping of metastatic NSCLC adenocarcinoma subtypes using next generation sequencing (NGS) is currently the standard practice. However, there is limited data on the biological predisposition to site of metastasis in patients with NSCLC based on their molecular profiling. We sought to identify any association between metastatic site and molecular profile in NSCLC patients.

Method: This is a retrospective analysis conducted at UTHealth Houston/Memorial Hermann Cancer Center from January 2014 to June 2022. Clinical characteristics, pathology, NGS panel reports, and imaging were retrieved and reviewed. The χ2 test was used for categorical variables. Continuous variables were compared using Kruskal-Wallis one-way analysis of variance. Progression-free survival (PFS) and overall survival (OS) were analyzed using the Kaplan-Meier test.

Results: After excluding patients who did not have complete clinical data, a total of 143 patients were included, and their NGS panels analyzed. Median age was 65 years, with an equal number of men (n=71) and women (n=72). The most common histology was adenocarcinoma (81.8%), followed by squamous cell cancer (11.9%) and large cell carcinoma (3.5%). At least one genetic mutation was discovered in 100 patients. Mutations with a targetable drug were found in 86 patients, and many patients had &gt;1 genetic mutation. The most common mutations were TP53 (25.2%), EGFR (24.5%), KRAS/NRAS (20.3%), and CDKN2A/2B (7.7%). Patients with any mutation were significantly more likely to have metastatic disease to the brain (57% vs 37%, p=0.03), but there was no difference in metastatic disease to bone (34% vs 26%, p=0.32). Patients without a discoverable mutation were significantly more likely to have metastatic disease to other sites (e.g., adrenal gland, liver; 91% vs 66%, p=0.002). There was no difference in PFS or OS between those with versus without mutations. Median PFS was significantly longer in patients with EGFR mutation than those with KRAS/NRAS or TP53 mutations (36 vs 16.2 vs 11.9 months, p=0.03). Median OS for patients with EGFR mutation was not reached and was significantly longer than in patients with TP53 (28.7 months) or KRAS/NRAS (26 months) mutations (p=0.003).Patients with PDL-1 &gt;1% or TP53 were significantly more likely to have metastatic disease to organs other than bone or brain (p=0.047 and p=0.023, respectively). There was also no difference between rates of brain and bone metastasis with regards to mutational profile.

Conclusion: Metastatic lung cancer patients with discoverable mutations on NGS are more likely to have metastatic disease to the brain. PDL-1 expression and TP53 mutation tend to lead to disease metastatic to organs other than brain or bone. Patients with EGFR mutations, despite having a great propensity to brain metastasis, have significantly better PFS and OS than patients with KRAS/NRAS and TP53 mutations, likely due to targeted therapy options.

Citation Format: Kok Hoe Chan, Ji Lin, Arthi Sridhar, Syed H. Jafri. Genomic profiling and sites of metastasis in non-small cell lung cancer (NSCLC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 6742.

Screening for asthma in preschool children with sickle cell disease

BACKGROUND

Asthma in preschool children is poorly defined, proving to be a challenge for early detection. The Breathmobile Case Identification Survey (BCIS) has been shown to be a feasible screening tool in older SCD children and could be effective in younger children. We attempted to validate the BCIS as an asthma screening tool in preschool children with SCD.

METHODS

This is a prospective, single-center study of 50 children aged 2-5 years with SCD. BCIS was administered to all patients and a pulmonologist blinded to the results evaluated patients for asthma. Demographic, clinical, and laboratory data were obtained to assess risk factors for asthma and acute chest syndrome in this population.

RESULTS

Asthma prevalence (n = 3/50; 6%) was lower than atopic dermatitis (20%) and allergic rhinitis (32%). Sensitivity (100%), specificity (85%), positive predictive value (30%), and negative predictive value (100%) of the BCIS were high. Clinical demographics, atopic dermatitis, allergic rhinitis, asthma, viral respiratory infection, hematology parameters, sickle hemoglobin subtype, tobacco smoke exposure, and hydroxyurea were not different between patients with or without history of ACS, although eosinophil was significantly lower in the ACS group (p = 0.0093). All those with asthma had ACS, known viral respiratory infection resulting in hospitalization (3 RSV and 1 influenza), and HbSS (homozygous Hemoglobin SS) subtype.

CONCLUSION

The BCIS is an effective asthma screening tool in preschool children with SCD. Asthma prevalence in young children with SCD is low. Previously known ACS risk factors were not seen, possibly from the beneficial effects of early life initiation of hydroxyurea.

Sequential enfortumab vedotin (EV) after platinum-based chemotherapy in metastatic or locally advanced urothelial cancer: Complete response, bladder preservation and survival

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Background: For metastatic or unresectable invasive urothelial cancer (UC), standard first-line platinum-based chemotherapy achieved progression-free survival (PFS) of 4–7 months. Complete response (CR) rate is <10%. The minority of patients downstaged after chemotherapy followed by cystectomy still suffer from loss of bladder function and a high risk of recurrence. To improve PFS, CR, and bladder preservation, we explored the use of EV after platinum-based chemotherapy in patients with metastatic or locally advanced UC who desired bladder preservation. Methods: Patients with metastatic or locally advanced unresectable UC who desired bladder preservation and received EV after platinum-based chemotherapy were identified. CR was defined as no evidence of disease identified on both radiology (MRI+CT) and cystoscopy; PFS were calculated from the date of initial treatment (first-line chemotherapy) to the date of last follow-up/death or recurrence via Kaplan-Meier analysis. Results: A total of 12 patients were identified: median age was 69.5 years (range, 52–83); 10 (83%) were men; 9 (75%) partial response and 3 (25%) disease progression were observed from platinum-based chemotherapy. EV was given after platinum-based chemotherapy to all 12 patients who subsequently achieved 100% of response: CR was achieved in 7 (58%) patients, and 4 (33%) remained disease free without ongoing treatment, their disease-free survival (DFS) was 9 months (range, 4–18); 2 patients who achieved CR then recurred as carcinoma in situ (CIS), one of whom had a cystectomy with TisN0 confirmed on final pathology. 2 (17%) patients received radiation to bladder and nodal area. Eleven (92%) patients retained their bladders and no patients died. Median follow-up was 19 months (range, 3.4–53.6). The median duration of EV was 7.5 months (range, 2–20). One-year PFS with bladder intact was 83%. Detailed clinical characteristics and outcome listed on Table. Conclusions: For patients with locally advanced or metastatic UC who desired bladder preservation, platinum-based chemotherapy followed by EV with or without pembrolizumab showed encouraging CR and PFS and deserves to be explored further. [Table: see text]

Total neoadjuvant oxaliplatin-based therapy (TNT) before (induction) and after (consolidation) chemoradiation for advanced rectal cancer: MRI correlation on complete response and outcome

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Background: Preoperative chemoradiation with fluoropyrimidine, followed by total mesorectal excision (TME) and adjuvant chemotherapy is the standard care for locally advanced rectal cancer (LARC). Studies have shown the potential benefit of oxaliplatin based TNT approach. The benefits of using of both induction and consolidation chemotherapy with chemoradiation prior of TME is not well studied. We investigate whether the use of oxaliplatin based before (induction) and after (consolidation) neoadjuvant chemoradiation will increase the pCR and clinical Complete response (cCR), improve survival and MRI correlation. Methods: Patients treated with curative intent surgery for LARC who received oxaliplatin based induction and consolidation chemotherapy with neoadjuvant capecitabine chemoradiation were identified. Demographics and clinicopathologic data were analyzed. Multiparametric MRI was used for initial staging and restaging before surgery. The primary endpoint will be the complete response (pathological and clinical), recurrent-free survival (RFS), and overall survival (OS). Results: A total of 21 patients have been identified, all patient has T3/T4 and positive nodes N1/N2 on initial MRI staging, 2 (10%) patients had Stage IV disease with abdominal para-aortic nodes. Median age was 63 (range: 26-76); 14 (67%) male. As for the induction regimen, 9 (43%) had CAPOX/FOLFOX, 7 (33%) had short-course capecitabine, 5 (24%) had FOLFIRINOX. All patient received neoadjuvant chemoradiation with capecitabine. As for consolidation, 19 (90%) had CAPOX/FOLFOX, 1 (5%) had capecitabine and 1 (5%) had FOLFIRINOX. Median time for induction and consolidation chemotherapy was 8.5 weeks (range: 1-24) and 8 weeks (range: 2-16) respectively. Median time from starting induction chemotherapy to surgery was 6.8 months (range: 3.2-11). Eight (38%) patients had cCR and pCR. Post-treatment restaging MRI prior of resection has 100% concordant rate with pCR. All (100%) pateints had tumor downstaged after treated with TNT and chemoradiation. The sensitivity of MRI in detecting the residual lymph node post TNT/neoadjuvant chemoradiation was 55% (95% CI: 26-81%), and the negative predictive value was 75% (51-90%); the specificity was 100% (76-100%) and the positive predictive value was 100% (57-100%). There is no death and one patient had recurrence after recurrence free for 2 years. Median RFS and OS are not meet. Median follow up time is 25.7 months (range: 9.1-76.8). Conclusions: Neoadjuvant oxaliplatin based therapy before and after chemoradiation for rectal cancer potentially improves CR rate, and accurately predicted by post-treatment MRI. The use of MRI can potentially help to select candidates who desire organ preservation.

Efficacy of sequential perioperative FOLFIRNOX plus gemcitabine nab-paclitaxel for resected pancreatic and periampullary cancers

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Background: Perioperative chemotherapy with single regimen either FOLFIRINOX (FFX) or gemcitabine/nab-paclitaxel (Gem/NabP) is the current standard of care for pancreatic and periampullary cancers (PC) with overall survival (OS) of 2-3 years without pre-selected CA19-9 level. Sequential chemotherapy with FFX plus Gem/NabP has recently been investigated in metastatic PC and shown to improve OS. We investigated the outcome of patients who received sequential perioperative chemotherapy FFX plus Gem/NabP. Methods: Patients treated with curative intent surgery for PC who received perioperative sequential chemotherapy FFX plus Gem/NabP (each regimen was given at least two months) were identified. OS and recurrence-free survival (RFS) were calculated from the date of initial treatment (neoadjuvant chemotherapy or resection) to the date of last follow-up/death or recurrence via Kaplan-Meier analysis. Results: A total of 29 patients were identified: 24 (83%) patients had pancreatic cancer, 5 (17%) patients had periampullary cancer; 16 (55%) patients received neoadjuvant chemotherapy FFX plus Gem/NabP; 13 (45%) patients underwent upfront surgery and received adjuvant FFX plus Gem/NabP chemotherapy; 22 (76%) patients had resectable disease, the rest 7 (24%) patients had borderline or unresectable disease were all in the neoadjuvant cohort; node positivity was higher in the adjuvant cohort (n=8, 62%) than in the neoadjuvant cohort (n=8, 50%); 5 (17%) patients were found to have homologous recombination deficiency (HRD: BRCA2, CHEK, BARD, ATM) and received PARP inhibitors as part of the perioperative therapy combination. 10 (34%) patients had CA19-9 ≥ 500. Median age was 65 years (range, 45-79 years), 20 (69%) were male. During the study period, 4 (14%) patients died, and 6 (21%) patients had disease recurrence. Median RFS and OS were not reached with a median follow-up of 28 months (range, 10.9–119 months). The longest RFS was 10 years. The 2-years RFS and OS for the entire cohort was 76.7% and 88.8%, respectively. There was no statistical difference in RFS (log rank HR 1.72, 95% CI 0.23-13.15) or OS (log rank HR 0.99, 95% CI 0.20-4.93) for patients in the neoadjuvant cohort versus adjuvant cohort. Conclusions: Sequential perioperative chemotherapy combined FFX plus Gem/NabP for resected PC is effective and potentially prolongs survival, compared to historical controls who received single regimen.[Table: see text]

Pulmonary hypertension screening in children with sickle cell disease

BACKGROUND

Screening for pulmonary hypertension (PHT) is recommended in children with sickle cell disease (SCD). However, best approaches are poorly described. We examined the utility of PHT symptoms, echocardiogram (ECHO), N-terminal-pro hormone brain natriuretic peptide (NT-proBNP), and BNP to screen for PHT in the SCD pediatric population.

METHODS

Children (8-18 years old) with SCD-HbSS and HbSthal° were prospectively included and underwent PHT screening. The screening consisted of a comprehensive PHT symptoms evaluation, ECHO measurement, and NT-proBNP and BNP levels.

RESULTS

A total of 73 patients were included (mean age 12 ± 5.7 years; >80% on hydroxyurea), of which 37% had a symptom consistent with PHT, including exertional dyspnea (26.5%), fatigue (17.6%), palpitation (14.7%), and chest pain (10.3%). ECHO was obtained in 53 (72.6%) patients, with only ECHO of 48 patients included in the final analysis. Elevated ECHO peak tricuspid regurgitant jet velocity (TRV) >2.5 m/s or indirect findings to suggest PHT were seen in only two of 48 (4.2%). No significant differences were seen between those with and without PHT symptoms when compared for NT-proBNP, BNP, hemoglobin, pulmonary function testing, fractional exhaled nitric oxide, asthma, oxygen saturation, and sleep apnea.

CONCLUSION

PHT symptoms are not consistent with ECHO, NT-proBNP nor BNP findings in children with SCD. PHT prevalence based on TRV was low in children on hydroxyurea, therefore screening may not be warranted for this group.

Reconstructed meta-analysis of percutaneous coronary intervention versus coronary artery bypass grafting for left main disease

Background

Randomized controlled trials (RCTs) comparing percutaneous coronary intervention (PCI) with drug-eluting stents and coronary artery bypass grafting (CABG) for patients with left main coronary artery disease (LMCAD) have reported conflicting results.

Objectives

We performed a systematic review from inception to 23 May 2021 and one-stage reconstructed individual-patient data meta-analysis (IPDMA) that included 10-year mortality outcomes.

Methods

The primary outcome was 10-year all-cause mortality. Secondary outcomes included myocardial infarction (MI), stroke and unplanned revascularization at 5 years. We did IPDMA using published Kaplan-Meier curves to provide individual data points in coordinates and numbers at risk were used to increase the calibration accuracy of the reconstructed data. Shared frailty model or, when proportionality assumptions were not met, a restricted mean survival time model were fitted to compare outcomes between treatment groups.

Results

Of 583 articles retrieved, 5 RCTs were included. A total of 4595 patients from these 5 RCTs were randomly assigned to PCI (N=2297) or CABG (N=2298). The cumulative 10-year all-cause mortality after PCI and CABG was 12.0% versus 10.6% respectively (HR 1.093, 95% CI: 0.925–1.292; p=0.296). PCI conferred similar time-to-MI (RMST ratio 1.006, 95% CI: 0.992–1.021, p=0.391) and stroke (RMST ratio 1.005, 95% CI: 0.998–1.013, p=0.133) at 5 years. Unplanned revascularization was more frequent following PCI compared with CABG (HR 1.807, 95% CI: 1.524–2.144, p&lt;0.001) at 5 years.

Conclusion

This meta-analysis using reconstructed participant-level time-to-event data showed no statistically significant difference in cumulative 10-year all-cause mortality between PCI versus CABG in the treatment of LMCAD.

Funding Acknowledgement

Type of funding sources: None.

Coronary artery bypass grafting versus percutaneous coronary intervention with stenting for multivessel coronary artery disease without left main coronary disease:reconstructed individual patient data

Background and aims

Data are emerging on 10-year mortality comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) with stenting for multivessel disease (MVD) without left main (LM) involvement. We conducted an updated two-stage meta-analysis using reconstructed individual patient data to compare long-term mortality between CABG and PCI for patients with MVD without significant LM coronary disease.

Methods

Medline and Embase databases were searched for articles comparing CABG with PCI for MVD. A two-stage meta-analysis was conducted using reconstructed patient level survival data for all-cause mortality with subgroups by SYNTAX score. The shared-frailty and stratified Cox models were fitted to compare survival endpoints.

Results

We screened 1496 studies and included six randomized controlled trials with 7181 patients. PCI was associated with greater 10-year all-cause mortality risk (HR: 1.282, CI: 1.118–1.469, p&lt;0.001) compared with CABG. In patients with low SYNTAX score, 10-year all-cause mortality after PCI was comparable to CABG (HR: 1.102, 0.822–1.479, p=0.516). However, in patients with moderate to high SYNTAX score, 10-year all-cause mortality was significantly higher after PCI compared with CABG (HR: 1.444, 1.122–1.858, p&lt;0.001; HR: 1.856, 1.380–2.497, p&lt;0.001 respectively).

Conclusion

This updated reconstructed individual patient-data meta-analysis revealed a sustained lower cumulative all-cause mortality of CABG over PCI for multivessel disease without LM involvement.

Funding Acknowledgement

Type of funding sources: None.

Improving new cancer diagnosis education in a metropolitan cancer center

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Background: Oncologists are faced with sharing complex information to their patients when making new cancer diagnoses. Patients often find themselves overwhelmed with the amount of information given to them at this initial visit. This challenging and emotionally charged context often result in patient dissatisfaction. Currently, most patient education is done verbally despite studies showing that patients only retain 14% of verbal communication, compared to 85% when using visual aids (VA).. Gunn et al. showed that cancer patients may be vulnerable to poorer outcomes during treatment if they lack the necessary skills such as health literacy to meet the high informational demands and manage psychosocial stressors. Garcia-Retamero et al showed that the use of VA enables patients across all literacy levels to arrive at better diagnostic inferences; however, the quality and quantity of VA used is not uniform nationwide and little data exists on their use in cancer diagnosis education. Our initiative aims to improve the patient education process at our cancer center. Methods: We developed VA for breast, colon, gastric, and lung cancer clinics. New patients were divided into two, a control arm (CA) which received the current standard education and an intervention arm (IA), which also received VA. Patient surveys based on physician consensus were used to collect patient outcomes. The primary outcomes included patients’ understanding of their diagnosis, the stage of their cancer, and the goal of treatment (cure versus life prolongation). Secondary outcomes included duration of clinic visit and retention of information assessed in a follow up phone call. Results: Sixteen (16) patients participated in the study with 8 in the CA and 8 in the IA group, including 11 females and 5 males. There were 8 Caucasian, 4 African American, 2 Asian and 2 Hispanic patients. Five patients (63%) had breast cancer and 3 (38%) had lung cancer in each arm. CA had 5 patients (63%) with Stage IV disease and IA had 4 patients (50%) with Stage IV disease. IA had better understanding of the goal of treatment (100% IA vs 75% CA, p = 0.13); on follow up, IA were able to better recall the stage of their cancer (88% IA vs 63% CA, p = 0.17) and treatment goal (88% IA vs 50% CA, p = 0.08). IA arm expressed better ability to understand what was communicated to them during the visit (mean score: CA = 4.83, IA = 3.67, p = 0.01). All patients who received the pictorial educational material felt that it helped them better understand the medical information. The total visit time in minutes was 58.67 in in the CA and 44.50 in the IA (p = 0.16). Conclusions: Despite being a small study, we demonstrated a trend towards improved understanding of cancer stage and treatment goal in patients with the use of VA vs standard verbal education. In patients with newly diagnosed breast and lung cancer, the intervention also resulted in lower total visit time. This proof of concept should be reproduced in a larger study.

Warm autoimmune haemolytic anaemia seen in association with primary sclerosing cholangitis in the setting of Klebsiella pneumoniae bacteraemia

Warm autoimmune haemolytic anaemia mediated by warm agglutinins is a rare and heterogeneous disease which can be idiopathic or secondary to an underlying disease. Primary sclerosing cholangitis is a chronic autoimmune cholangiopathy that is very rarely associated with haemolytic anaemia. Infections can also act as triggers for immune haemolytic anaemia. Here, we report a case of a woman in her 50s with a history of primary sclerosing cholangitis and a positive direct antiglobulin test with no evidence of haemolysis who developed overt warm autoimmune haemolytic anaemia in the setting of cholangitis and Klebsiella pneumoniae bacteraemia. She was treated conservatively with appropriate antibiotics and cautious red blood cell transfusion with complete resolution of haemolysis; immunosuppression was avoided given sepsis on presentation. This case highlights a rare association of warm immune haemolytic anaemia in the setting of K. pneumoniae bacteraemia and the role of a tailored treatment approach to treat this heterogeneous disease.

A rare case of marijuana associated with ascending aorta thrombosis complicated with stroke and bilateral renal infarcts

Ascending aortic is an uncommon site for arterial thrombosis and ascending aortic thrombosis is a very rare phenomenon with a high fatality rate. Marijuana is the most commonly used psychoactive drug in the United States and a few cases have been reported on the association of marijuana with vascular thromboembolism. However, the pathophysiology and exact mechanism are still not well studied. Herein, we present a case of a 44-year-old female with active marijuana use presented with ascending aortic thrombus associated with acute arterial occlusion of the right vertebral artery and bilateral renal artery. The unique part of this case is that the patient did not have the classical risk factors for vascular thromboembolic disease. The only risk factor was marijuana smoking. To our best knowledge, this is one of the unique cases of marijuana-associated with ascending aorta thrombosis.

A Rare Ocular Manifestation of Idiopathic Hypertrophic Cranial Pachymeningitis

Idiopathic hypertrophic cranial pachymeningitis (IHCP) is a rare form of thickening of the dura mater. There are limited reports on the ocular manifestation of IHCP and its treatment. Up to our knowledge, there is no report on bilateral superior ophthalmic veins (SOV) dilatation with IHCP and there are only a few reports on anterior scleritis with IHCP. We report a 62-year-old gentleman with underlying hypertension and chronic headache who presented with fever, headache, and unresolving both eyes redness as manifestations of bilateral anterior scleritis, anterior uveitis, secondary glaucoma, and multiple cranial nerve palsies. Magnetic resonance imaging of the brain showed global thickening and enhancement of the pachymeninges with bilateral SOV dilatations. The diagnosis of IHCP was made after ruling out infective and autoimmune causes. The patient was treated with oral prednisolone, oral azathioprine, topical timolol maleate, topical dexamethasone, and topical moxifloxacin. The patient was successfully treated and was stable throughout two years review. In conclusion, unresolved red eyes with headaches can be an early presentation of IHCP. Pathophysiology and treatment of the ocular manifestations and IHCP were discussed.

Dilemma of Anticoagulation Therapy in Mild or Asymptomatic COVID-19 Cases

Severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2) infection can be a life-threatening disease, which has emerged as a public health hazard. Thrombotic events have been reported in hospitalized patients with severe disease however scarce data is available regarding the screening of thromboembolic disease and pulmonary embolism in those with mild or asymptomatic infection. Herein, we describe the development of pulmonary embolism in two asymptomatic patients with COVID-19 and suggest the need for close monitoring and anticoagulation to prevent this life-threatening complication.

455. Diagnostic Value of Hematological Parameters in Different Stages of the Disease in Covid-19 Patients

Background

COVID-19 infection is associated in some individuals with a rapid onset of systemic proinflammatory state leading to cytokine storm followed by multisystem organ failure. We are interested in studying the prognostic value of complete blood count parameters in different stages of the diseases based on the serology.

Methods

This is a retrospective cohort study of patients with confirmed COVID-19 admitted to our hospital between 10/1/2020 to 2/28/2021. Study individuals had complete CBC profile and COVID-19 serology with well-defined clinical outcome (discharged alive or expired). They were divided in 3 groups based on serology results: group 1 (early disease) had no antibodies, group 2 (immune phase) had + IgM, and group 3 (late phase) had only + IgG. Demographic, clinical and laboratory data were reviewed. Simple t-test was used for continuous variables and chi-square test was used for categorical variables. Anova test was used to compare the difference across multiple groups. GraphPad PRISM was used for all analysis.

Results

A total of 202 confirmed covid 19 cases were included in the study. There was no difference between the 3 groups in terms of age, gender, and body mass index (BMI). We did observe an increase in incidence in Latinx (group 1, 34%; group 2, 51%; group 3, 38%). Hypertension and diabetes were major co-morbidities in these patients. Absolute neutrophil count (ANC) and platelet count (PC) showed significant changes across the 3 groups: mean ANC for group 1, 4.868 (SD 3.117); group 2, mean 6.951 (SD 3.843); and group 3 mean 5.59 (SD 3.236). PC in group 1 mean 193.2 (SD 90.25); group 2 mean 271.1 (SD 143.4); and group 3 mean 228.6 (SD 75.33) p-value 0.0008. The difference can be seen in the derived monocyte platelet rationMPR, neutrophil lymphocyte ratio NLR, platelet lymphocyte ratio PLR and aggregate index of systemic inflammation AISI values and they tend to be higher in group 2 (MPR p-value 0.0067, NLR p-value 0.0123, PLR p-value 0.0294, AISI p-value of 0.0190).

Baseline characteristic

Conclusion

The study demonstrates that MPR, NLR, PLR and AISI have a potential role in categorizing the disease stage based on only CBC profiling.Properly designed prospective studies with a larger sample size should be performed to confirm the disease stratification ability of derived CBC indices like MPR, NLR, PLR and AISI.

Disclosures

All Authors: No reported disclosures

Cardiac Tamponade Associated with Human Immunodeficiency Virus-Associated Immune Complex Kidney Disease

Cardiac tamponade is a life-threatening emergency, characterized by rapid accumulation of pericardial fluid. There are multiple risk factors for cardiac tamponade, nephrotic syndrome is an uncommon one, especially in adults. Herein, we are reporting a 35-year-old African American woman with membranoproliferative glomerulonephritis secondary to human immunodeficiency virus-associated immune complex kidney disease (HIVICK), who presented with cardiac tamponade. The patient had pericardiocentesis and was discharged, with outpatient follow-up with cardiology, nephrology, and infectious disease. To the best of our knowledge, this is the first report of HIVICK nephrotic syndrome associated with cardiac tamponade.

A Case Series of SARS-CoV-2 and Influenza Co-infection

The novel coronavirus 2019, a disease associated with SARS-CoV-2 infections has resulted in significant morbidity and mortality across the globe. In the United States, influenza has been one of the leading causes of hospitalization during the winter season. To date, the co-infection of SARS-CoV-2 and influenza virus has created a unique challenge for healthcare workers, especially during the cold season. Both viruses have similar clinical presentation and transmission characteristics. Many reports are available for either SARS-CoV-2 and influenza individual infections, but limited data are available for the co-infection. Herein, we present a case series of five cases of SARS-CoV-2 and influenza co-infection as well as their clinical characteristics, laboratory findings, management, and outcome.

The Roles of Fibrosis Index Based on Four Factors and Aspartate Transaminase-to-Platelet Ratio Index Scoring Systems as an Alternative to Transient Elastography Liver Stiffness in Liver Fibrosis Staging in Human Immunodeficiency Virus and Hepatitis C Virus Co-Infected Patients

Background

Liver biopsy used to be the gold standard to assess liver fibrosis in patients infected with hepatitis C virus (HCV). Nonetheless, due to its invasive nature, techniques such as transient elastography liver stiffness (TE-LS), fibrosis index based on four factors (FIB-4) and aspartate transaminase-to-platelet ratio index (APRI) scores are currently being used. FIB-4 and APRI scores have the advantage of low cost and are readily available, compared with TE-LS. Herein, we evaluated the diagnostic performance of these scoring systems as compared to TE-LS in assessing liver fibrosis in patients with human immunodeficiency virus (HIV) and HCV co-infection.

Methods

The medical records of patients with HIV and HCV co-infection who had TE-LS done at our facility between August 1, 2013 and January 1, 2020 were extracted and analyzed. Exclusion criteria include: 1) patients co-infected with hepatitis B virus; 2) invalid TE-LS assessment; 3) have ≥ 10th upper limit of normal (ULN) alanine aminotransferase (ALT) levels; and 4) excessive alcohol use. Patient demographics, medical history, biochemical and clinical data were retrieved. For each patient, we calculated the FIB-4 and APRI score. Descriptive analysis was performed and correlation of FIB-4 and APRI with TE-LS was assessed with GraphPad Prism statistical software.

Results

Five hundred forty-seven patients underwent TE-LS during the study period. After excluding those without complete laboratory parameters, the total study population was 344. Their age was 56 ± 10.4 years and 234 (68%) were male. The average aspartate aminotransferase (AST) and ALT were 27.95 and 30.73. The average platelet count was 224 and the average TE-LS was 7.29. Fourteen patients (4.1%) had TE-LS values between 9 and 11.9 kPa and were classified as F3, while 29 (8.5%) had TE-LS ≥ 12 kPa and were classified as F4. With the correlation analysis, both APRI (correlation coefficient, r = 0.1097, 95% confidence interval (CI) 0.0403 - 0.2130; P = 0.042) and FIB-4 (r = 0.0424, 95% CI -0.0634 - 0.1474; P = 0.4335) were not correlated with TE-LS stages of fibrosis.

Conclusion

In our cohort, we failed to demonstrate that APRI and FIB-4 are reliable alternatives for screening liver fibrosis in patients with HIV and HCV co-infection. Nonetheless, APRI score still has a potential role as a screening tool instead of TE-LS measurement, which is costly and not readily available. It will be important to corroborate these findings in another large cohort, since this may have an important impact on patient management.

Cerebral Air Embolism After Gastrointestinal Procedure: A Case Report and Literature Review

Esophagogastroduodenoscopy (EGD) is one of the forefronts of minimally invasive modalities with excellent safety records and tremendous capability but despite its accolades and functions, there are still very rare complications including air embolism. It is a life-threatening condition that could lead to a significant increase in morbidity and mortality. However, there are limited data for incidence of air embolism in association with gastrointestinal endoscopy. Diagnosis of air embolism after or during gastrointestinal endoscopy might be a difficult task due to overlapping presentations with anesthesia effects on the cardiopulmonary and the neurological systems, as a result, there should be increased awareness allowing clinicians to quickly rule out air embolism in patient with altered mental status or cardiopulmonary changes after or during gastrointestinal endoscopy. Herein, we report a unique case of cerebral air embolism after EGD in a 79-year-old female patient. In addition, we also performed a systematic review of cases based on PRISMA guideline, with the aim to investigate the demographics and clinical outcomes associated with this complication. This systematic review of cases hopes to increase the awareness about this rare entity.

A Rare Case of Severe Lactic Acidosis in a Patient With Mantle Cell Lymphoma

Lactic acidosis is an extremely rare paraneoplastic manifestation of hematological malignancies, and often carries an extremely poor prognosis. Mantle cell lymphoma is an aggressive and rare form of non-Hodgkin lymphoma. To the best of our knowledge, it is extremely rare to have severe lactic acidosis in patients with mantle cell lymphoma. In this article, we are reporting a rare case of mantle cell lymphoma diagnosed with typical cluster differentiation (CD markers) in bone marrow examination with persistent lactic acidosis refractory to intravenous hydration that responded well to chemotherapy. Malignant lactic acidosis is a medical emergency that needs rapid evaluation and identification that shows improved prognosis after the introduction of chemotherapy.

Left ventricular thrombus complicated by acute limb ischemia in a patient with HIV

Left ventricular thrombus typically occurs in patients with impaired left ventricular function such as aneurysm, dilated cardiomyopathy, or post-myocardial infarction. Untreated HIV infection is known to increase the risk of venous thromboembolism and cardiovascular disease. However, the pathophysiology remains uncertain; some studies have proposed chronic inflammation as the underlying etiology. Nonetheless, left ventricular thrombus is extremely rare among persons living with HIV with no known underlying cardiac disease. Herein, we report an unusual case of a 55-year-old homeless and heterosexual male with past medical history of HIV, who has mildly reduced left ventricular function and a nonmobile, medium size left ventricular thrombus. Patient was initially treated with therapeutic dose of enoxaparin, and subsequently developed acute embolic occlusion of right femoral artery that lead to an above knee amputation. To our knowledge, left ventricular thromboembolism complicated with acute embolic ischemia in persons living with HIV is extremely rare. The presenting case will definitely add to the current body of knowledge and will raise awareness among physicians, in recognizing the rare association between HIV and arterial thromboembolism.

Cryoglobulinemia unmasked by nivolumab in a patient with hepatitis C-induced hepatocellular carcinoma: A case report and literature review

Hepatocellular carcinoma (HCC) is ranked the fifth-most common cancer in men and ninth most common cancer in women. Immunotherapy has been shown effective in malignancies refractory to chemotherapy and has been used as a second-line therapies in many advanced cancers, including HCC. The advent of immunotherapy has resulted in a brand-new set of side effects, and it has been proposed that it was related to over activated immune system. Herein, we presented the case of 59-year-old African American gentlemen who was diagnosed with HCC caused by Hepatitis C virus, for which he was started on chemotherapy and immunotherapy. However, the patient developed cryoglobulinemia that prompted stopping both therapies and giving rituximab and steroids. We believe that the mixed cryoglobulinemia was unmasked by immunotherapy in our patient. To our knowledge, this is one of the few first cases to describe such adverse effect from immune checkpoint inhibitors.

Roles and Interplay of SARS-CoV-2 Serology With Clinical Stages of Disease in COVID-19

Background

Currently, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serology is recommended only for seroprevalence. We think it could be useful in differentiating coronavirus disease 2019 (COVID-19) stages, which could in terms of helping improve our therapeutic interventions.

Methods

The medical records of adult patients admitted to the hospital with probable COVID-19 were extracted and analyzed. We excluded patients with no serology and no clear outcome at the end of data collection. Patient demographics, medical history, and biochemical and clinical data were retrieved.

Results

A total of 202 patients were included; 57% were males, the majority were Hispanic (45%), followed by African Americans (22%). Hypertension is the most common comorbidity, followed by diabetes mellitus and chronic kidney disease. We classified them into three groups based on their serology: subacute stage (47 patients) with both immunoglobulin M (IgM) and IgG negative; acute stage (116 patients) with IgM positive and late-stage (39 patients) with IgM negative and IgG positive. We found that elevated lactate dehydrogenase (LDH) and ferritin were present in the IgM+ and IgM-/IgG+ subgroups (p-value of 0.0061 and p-value 0.0013, respectively) while C-reactive protein (CRP) and D-dimer were more elevated in the IgM-/IgG- and IgM+ subgroups (P <0.0001 and p-value of 0.0452, respectively). The IgM+ group had the worst prognosis, with high mortality despite receiving remdesivir and dexamethasone.

Conclusion

Our findings suggest that the use of serology in patients hospitalized with COVID-19 could predict prognosis; this will need to be validated in a larger prospective study.

A rare presentation of transient hypothermia in HIV infection: A case report and systematic review of cases

Hypothermia defined as a core body temperature less than 35°C causes hundreds of deaths annually in the United States. It can occur in a variety of clinical settings, including environmental exposure, shock, infection, metabolic disorders, alcohol, or drug toxicity, and malnutrition. This condition can affect many different organ systems and may lead to serious complications including cardiac arrhythmia. Hypothermia is extremely rare in people living with HIV but can be seen in severely malnourished patients or those who are not receiving antiretroviral therapy (ART). It is a life-threatening situation that should be treated aggressively. To the best of our knowledge, there are only a few cases that have been reported for people living with HIV presenting with hypothermia and sinus bradycardia. Herein, we are reporting a very rare case of people living with AIDS who presented with hypothermia complicated by sinus bradycardia. In addition, we also performed a systematic review of cases based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline, to investigate the clinical characteristics and outcomes associated with this rare complication. This systematic review of cases hopefully can increase the awareness of this rare entity and help improve its outcome.

Tocilizumab and Thromboembolism in COVID-19: A Retrospective Hospital-Based Cohort Analysis

Background

Tocilizumab, an interleukin-6 (IL-6) receptor antagonist, has been used in patients with coronavirus disease 2019 (COVID-19) as an anti-cytokine agent. IL-6 also plays a complex role in hemostasis and thrombosis. We observed a transient elevation of D-dimer in our patients who received tocilizumab, which triggered this study.

Methods

A retrospective hospital-based cohort analysis of patients with confirmed COVID-19 who received tocilizumab during the study period of March 15, 2020, to May 20, 2020, was conducted. We retrieved demographic, clinical, and laboratory data, and patients who were receiving therapeutic anticoagulation therapy prior to tocilizumab administration were excluded. Descriptive analysis was performed, and the cause of death and trends of D-dimer and inflammatory markers were studied.

Results

Out of the 436 confirmed COVID-19 patients admitted during the study period, 24 met the inclusion criteria. Their median age was 47.5 years. They were 18 males and 6 females; 15 patients survived and nine expired. Of the group that survived, 12 received therapeutic anticoagulation. Of the seven patients who did not receive therapeutic anticoagulation, four expired (one from sepsis and three probably from thromboembolic complications) compared to five deaths in the 17 patients who received therapeutic anticoagulation (four from sepsis and one possibly from thromboembolic complications).

Conclusions

The interplay between IL-6, IL-6 receptor antagonist, and venous thromboembolism is complex. We observed a transient elevation of D-dimer in COVID-19 patients who received tocilizumab, and a trend toward increased death secondary to thromboembolism. This observation is novel and highlights the potential thrombophilic side effects of tocilizumab.

Persistent Hypercoagulable State in COVID-19: A Case Series of COVID-19 Associated Pulmonary Embolism

Coronavirus disease 2019 (COVID-19) has swept through the world with millions of cases and hundreds of thousands of deaths. COVID-19-associated coagulopathy has been recognized as the major cause of morbidity and mortality. To the best of our knowledge, a majority of the cases of coagulopathy have been reported in patients with moderate-to-severe COVID-19 and limited to observations during the recovery/postcytokine storm state. Herein, we report a case series of two patients with COVID-19 who developed pulmonary embolism in the late phase of the disease. This raised the hypothesis that the risk of hypercoagulability in patients with COVID-19 can persist until the recovery phase, which would warrant a follow-up with D-dimer and fibrinogen trending, as well as postdischarge thromboprophylaxis for at least 2 weeks during the recovery phase.

A Case of Co-occurrence of COVID-19 and Group A Streptococcal Pharyngitis

Coronavirus disease 2019 (COVID-19) has swept the world with over hundred million of cases and millions of deaths. Upper respiratory tract symptoms including acute pharyngitis are the common symptoms of COVID-19, with a reported incidence of about 5%-17.4%. Group A Streptococcus (GAS) pharyngitis is a common cause of bacterial pharyngitis, with highest incidence between age 5 and 15, and it can still occur in adults with peak incidence at age 40. Herein, we report a case of co-occurrence of GAS and COVID-19 in a middle-aged man who presented with fever, sore throat, cough, and runny nose. To the best of our knowledge, we are the first to report this unique co-occurrence. Our case report aimed to raise the awareness among physician particularly in ambulatory and emergency department of not to have a singular focus on COVID-19 and forget to screen patient with acute pharyngitis for GAS.

Marantic Endocarditis Associated with COVID-19: A Rare Case Report of a Potentially Deadly Disease

Coronavirus disease 2019 (COVID-19) has overwhelmed healthcare globally with millions of cases and over 2 million deaths worldwide. The hypercoagulable state associated with COVID-19 is a well-recognized complication that carries a poor prognosis. Marantic endocarditis, or non-bacterial thrombotic endocarditis (NBTE), is caused by a sterile vegetation on the cardiac valves resulting from the deposition of fibrin and platelet aggregates. It is highly associated with the hypercoagulable and acquired inflammatory states. Herein, we report a unique and rare case of COVID-19 presenting with NBTE.

LEARNING POINTS

COVID-19 has caused a major global pandemic, with high morbidity and mortality.One of the complications of COVID-19 infection is a hypercoagulable state.To the best of our knowledge, we present only the second case of marantic endocarditis in a patient with COVID-19, in the hope of raising awareness among physicians of this potential rare association.

Concurrent Serotonin Syndrome and Prolong QT Interval Induced by Paroxetine Overdose With Isotretinoin

The use of serotonergic drugs has increased in the last decade especially selective serotonin reuptake inhibitors (SSRIs) with increased indications. Serotonin syndrome (SS) and QT prolongation are serious adverse reactions of SSRI use, they usually occur with concomitant use of two or more serotonergic medication. Herein, we are presenting an interesting unique case of SS and prolongation of QT interval after a suicidal attempt in a patient on isotretinoin with paroxetine overdosing. The prolongation of QT interval observed in this case could be related to isotretinoin synergistic effect. The risk of suicide and side effects of SSRI with isotretinoin, especially in patient with psychiatric illness would be a huge concern. This case hopes to raise the awareness of the risks when prescribing SSRI and isotretinoin in this group of patients.

Diffuse bone metastasis from cholangiocarcinoma involving the sternum: A case report and review of literature

Cholangiocarcinoma (CCA) is a rare cancer of the bile duct epithelial cells and it commonly spreads to the regional lymph nodes, liver, and lungs. Bone metastasis has been reported in patients with CCA, involving both the axial and appendicular skeleton. Herein, we report a case of extrahepatic CCA with extensive bone metastases involving the calvarium, sternum, bilateral ribs and scapulae, entire spine, pelvis, and bilateral femur. To our knowledge, this is the first case report on sternum metastasis in CCA. The case presentation and review of literature highlighted the rarity of this metastasis, and health-care providers should be aware of the rare presentation of CCA.

Bleeding Diathesis in Multiple Myeloma: A Rare Presentation of a Dreadful Emergency With Management Nightmare

Multiple myeloma is a neoplastic disorder of plasma cells. An abnormal coagulation profile, though commonly seen in multiple myeloma, can rarely manifest as life-threatening hemorrhagic complications. Bleeding tendencies in multiple myeloma can be explained by a variety of mechanisms such as dysfibrinogenemia, paraprotein-induced platelet dysfunction, shortened platelet survival, damage to the vascular endothelium, and acquired von-Willebrand syndrome. Herein, we report a 61-year-old female who presented with the signs and symptoms of hemorrhagic shock with multiple myeloma, which remained refractory to a massive transfusion protocol. Her condition stabilized when she was started on dexamethasone and antifibrinolytic infusion targeting acquired dysfibrinogenemia. To the best of our knowledge, hemorrhagic shock secondary to dysfibrinogenemia is an unusual phenomenon in multiple myeloma.

A Case of Bordetella bronchiseptica Bacteremia in a Patient With Decompensated Liver Cirrhosis

Bordetella bronchiseptica is a rare cause of respiratory tract infection in humans, most commonly found in immunocompromised individuals exposed to infected animals. It colonizes the respiratory tract and can lead to infection in dogs, cats, rabbits, and others. In immunocompromised patients, it has been reported to result in life-threatening infections but rarely affects immunocompetent individuals. Here, we are the first to report a case B. bronchiseptica bacteremia in a patient with decompensated liver cirrhosis without known animal exposure.

A Rare Case Report of Persistent Hiccups as an Atypical Presentation of COVID-19

Sudden, involuntary spasm of the diaphragm associated with closure of the glottis will lead to a hiccup sound. Brief episodes of hiccups are often self-limiting and may be physiologically encountered in everyday life. However, prolonged attacks of hiccups are associated with significant morbidity. Herein, we present a rare and interesting case of coronavirus disease 2019 (COVID-19) induced persistent hiccups in a 61-year-old gentleman with no signs or symptoms of gastric pathology. As the patient required less oxygen supplementation, with inflammatory markers down-trending, his hiccups improved. The timeline of the symptom presentation and his response to treatment highly suggested that his hiccups were associated with COVID-19 infection. To the best of our knowledge, there are only two cases of persistent hiccups secondary to COVID-19 that have been reported thus far. Our case will add to the existing literature and highlight the potential association of COVID-19 with hiccups.

Sensory Axonopathy Associated With Vitamin E Deficiency

Vitamin E deficiency can be observed in patients with malabsorption syndromes or inherited diseases such as ataxia. It is unusual for it to be a result of dietary insufficiency due to its presence in a wide variety of foods. Patients with vitamin E deficiency can present with neuromuscular disorders such as ataxia, hyporeflexia, spinocerebellar syndrome, as well as loss of vibration and proprioceptive sensation. Herein, we are presenting a case in which a previously healthy adult with no family history of genetic defects and malabsorption syndrome presented with a characteristic sensory axonopathy associated with vitamin E deficiency without any evidence of fat malabsorption. Patient reported a markedly improvement of symptoms after three-month supplementation of vitamin E. The unique part of this case was that the patient presented with neuropathic pain associated with vitamin E deficiency without any family history of inherited deficiency or any malabsorption syndrome.

950. Venous Thromboembolism in Persons Living with HIV (PLWH): A Single Center Retrospective Cohort Study

Background

Data on risk of thromboembolism in PLWH is limited. HIV is often recognized as a chronic inflammatory disease and has been recognized as a prothrombotic condition. We aimed to analyze the incidence and demographic of venous thromboembolism such as pulmonary embolism and deep vein thrombosis in PLWH admitted to our hospital.

Methods

We conducted a retrospective hospital cohort study on PLWH ≥ 18 years old who were admitted to our hospital between 09/01/2018 and 09/01/2019. Study individuals were recruited if they had complete laboratory profile and well-defined clinical outcomes. Demographic, clinical and laboratory data were reviewed and retrieved. Descriptive analysis was employed to describe the demographic profile of PLWH with venous thromboembolism.

Results

Out of the 192 hospitalized PLWH during the study period, 15 (8%) patients had documented deep vein thrombosis (DVT) and/or pulmonary embolism (PE). History of DVT/PE was present in 5 (33%) patients while the rest had new onset of DVT/PE. Out of the 15 patients, 4 (27%) had DVT and PE, 4 (27%) had only DVT and 7 (46%) had only PE. The median age was 57 years, ranged from 40 to 74 years; 4 males and 11 females. As for ethnicities, 2 Caucasian, 12 were African American and 1 Hispanic.

The average D-dimer was 4491. The median CD4 count for PLWH with venous thromboembolism was 487 and a median viral load of 900. In contrary, the median CD4 count of PLWH without venous thromboembolism was 420 and median viral load of 140. Though not statistically significance, higher viral load seems to associate with risk of venous thromboembolism. Surprisingly, female gender is an independent risk factor for venous thromboembolism in PLWH (z-score 2.75, p=0.0059; odds ratio [OR], 4.67; 95% confidence interval [CI], 1.56-13.69).

Conclusion

Our observation of PLWH with venous thromboembolism suggest that this population has an increased risk of venous thromboembolism as compared to general population. Female gender is an independent risk factor for venous thromboembolism in PLWH and higher HIV viral load seems to associate with higher risk. Larger prospective studies in this population are needed to dissect the interplay between HIV and venous thromboembolism.

Disclosures

All Authors: No reported disclosures

533. Demographic and Prognostic Indicators in COVID-19 Patients with ESRD: A Single Center Retrospective Study

Background

The first reported case of COVID-19 in the United States was in January 2020 and has since become a pandemic spreading rapidly worldwide. There is limited data on the epidemiology and prognosis of COVID-19 in end stage renal disease (ESRD) patients on hemodialysis (HD). In this study we describe our experience with 39 such patients who contracted COVID-19 disease.

Methods

We conducted a retrospective hospital cohort study on patients ≥ 18 years old with ESRD on HD and confirmed COVID-19, who were admitted to our hospital between 03/15/2020 and 05/25/2020. Study individuals were recruited if they had a well-defined clinical outcome (discharged alive or expired). Demographic, clinical and laboratory data were reviewed and retrieved. Descriptive analysis, univariate and multivariate logistic regression methods were employed to describe the demographic and to identify prognostic markers associated with mortality.

Results

Out of the 427 confirmed COVID-19 hospitalized patients during the study period, 39 ESRD patients on HD were included in this study, 19 (49%) expired, and 20 (51%) were discharged alive. Demographic analysis was tabulated in Table 1.

The non-parametric analysis showed a significant difference in ethnicity, history of COPD, need of mechanical ventilation, ferritin, LDH, lymphocyte-ferritin ratio (LFR), lymphocyte-CRP ratio (LCR) and AST/ALT ratio between survival and non-survival groups (Table 1, 2). Mechanical ventilation is independently associated with mortality in ESRD patients with COVID-19 (odds ratio [OR] 21.11; 95% confidence interval [CI], 3.00–238.9). In addition, low AST/ALT ratio has an odd of survival in this group of patients (OR 0.45; 95% CI, 0.19–0.88).

Table 1: Demographic Analysis of all ESRD patients with COVID-19. (HTN – Hypertension, DM – Diabetes mellitus, CAD – Coronary artery disease, CHF – Congestive heart failure, COPD – Chronic obstructive pulmonary disease)

Conclusion

Our observation of COVID-19 disease in patients with ESRD on HD confirms that this population is at the highest risk for mortality from SARS-CoV-2 infection, and that a low AST/ALT ratio is independently associated with decreased mortality, while mechanical ventilation had an increased mortality. Larger prospective studies in this population may help us understand better those prognostic markers and suggest how to intervene in order to decrease this catastrophic rate of mortality

Disclosures

Jihad Slim, MD, Abbvie (Speaker’s Bureau)Gilead (Speaker’s Bureau)Jansen (Speaker’s Bureau)Merck (Speaker’s Bureau)ViiV (Speaker’s Bureau)

360. A Case Control Study of COVID-19 in Patients with End Stage Renal Disease (ESRD)

Background

COVID-19 is a major global pandemic. Since the first case reported in Wuhan, China, COVID-19 has spread across the globe with more than 7.6 million individuals affected worldwide. Several studies have tried to investigate the risk factors for mortality but there has bot been a definitive study in patients with ESRD. Herein, we aimed to investigate whether ESRD is associated with mortality as compared to age, gender and comorbidities matched cohorts.

Methods

A retrospective case control study was performed on patients 18-year-old with confirmed SARS-CoV-2 admitted to our hospital during the study period (03/15/2020 to 05/15/2020). Demographic, characteristics and clinical outcome were retrieved and reviewed. We found 39 ESRD patients, we matched them for 5 variables: Age, gender, diabetes mellitus (DM), hypertension (HTN), and body mass index (BMI). Age was stratified into 3 groups (&lt; 30, 30 to 60, &gt;60), history of DM and HTN were defined by reviewing the admission medications, and BMI was divided into 2 categories (&lt; 30 and 30 kg/m2). The primary endpoint was percentage of inpatient mortality.

Results

We had 39 ESRD patients with COVID-19 out of the 400 patients admitted during the study period with known clinical outcome. Nineteen patients (49%) were between 30 to 60 years old while the rest (51%) were older than 60 years old. As for gender, 25 (64%) were males and 14 (36%) females. Additional comorbidities were present in 38 patients with hypertension (92%) being the most common, followed by DM (64%) and BMI &gt;30 kg/m2 (49%). With the 5 variables, we were able to match with 177 controls.

Nineteen individuals expired out of the 39 ESRD patients (49%), as compared to 46 patients from the 177 matched cohort (26%) (z-score 2.80, p=0.0051; odds ratio [OR], 2.71; 95% confidence interval [CI], 1.28–5.41).

Conclusion

Our results suggest that ESRD patients is an independent risk factor for increased mortality in patients with COVID 19 disease. Larger prospective studies will need to confirm this finding and try to find ways to mitigate this very high mortality in this vulnerable population.

Disclosures

Jihad Slim, MD, Abbvie (Speaker’s Bureau)Gilead (Speaker’s Bureau)Jansen (Speaker’s Bureau)Merck (Speaker’s Bureau)ViiV (Speaker’s Bureau)

552. Could Anticoagulant Use Prior to Infection with COVID-19 Decrease Mortality?

Background

The novel coronavirus (COVID-19) has resulted in substantial morbidity and mortality worldwide. Infection with COVID-19 has been associated with coagulopathy and inflammation. This prothrombotic state has been identified in the literature as an indicator of poor prognosis and those with COVID-19 who receive anticoagulation therapy may have better outcomes. Due to this prothrombotic state, patients who are currently receiving anticoagulation therapy for other indications prior to infection with COVID-19 may have better outcomes.

Methods

This was a retrospective case control study conducted at an inner city hospital. Patients were eligible if they were hospitalized between March 15, 2020 and May 15, 2020 and had confirmed infection due to COVID-19. Patients were matched by age, sex, body mass index (BMI), diabetes mellitus (DM), hypertension (HTN) and estimated glomerular filtration rate (eGFR) by chronic kidney disease (CKD) state. This study evaluated morality in patients who were receiving long term anticoagulation therapy prior to infection with COVID-19 compared to those who were not.

Results

Of the 436 patients hospitalized with confirmed infection due to COVID-19, 400 were eligible for analysis. Twenty-two were on anticoagulation therapy prior to admission. Among those patients, 68% were male and 32% were female. The majority of the patients were greater than 60 years of age (82%). Comorbidities were present in 21 patients and were as follows: HTN (95%), CKD (67%), DM (57%), obesity (36%). Of the 22 patients, five expired due to COVID-19 infection compared to 52 patients from the 149-patient matched cohort [z-score 1.13, p = 0.26; odds ratio (OR) 1.82; 95% confidence interval [CI], 0.69–4.71].

Conclusion

Prior long-term anticoagulation use does not appear to have a protective effect in patients with COVID-19 infection. Studies with larger sample size will be needed to answer this important question.

Disclosures

Jihad Slim, MD, Abbvie (Speaker’s Bureau)Gilead (Speaker’s Bureau)Jansen (Speaker’s Bureau)Merck (Speaker’s Bureau)ViiV (Speaker’s Bureau)

361. A Case Control Study of COVID-19 Outcome in Patients with HIV

Background

Little is known regarding outcome of patients living with HIV (PLWH) when they get admitted to a hospital for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection. We decided to conduct a case-controlled study to try to answer the question if PLWH are at higher risk of mortality compared to individuals without HIV infection but with the same risk factors that affects outcome in COVID-19 disease.

Methods

A retrospective case matched control study was performed from 03/15/2020 to 05/15/2020. We reviewed all confirmed SARS-CoV-2 infected patients who were admitted to our hospital during the study period and retrieved 7 variables: Age, gender, diabetes mellitus (DM), hypertension (HTN), body mass index (BMI), chronic kidney disease (CKD), HIV status. We divided the age in 3 groups (< 30, 30 to 60, > 60), we defined the presence of DM and HTN by reviewing the admission medications, BMI > 30 defined obesity, and CKD was present if eGFR < 45 ml/min prior to the current admission. We found 12 PLWH, we matched them for the 6 variables, we found 94 controls. The primary endpoint was percentage of inpatient mortality.

Results

Of the 436 confirmed SARS-CoV-2 infection admitted between 03/15/20 and 05/15/20, 36 were still hospitalized. Twelve were PLWH out of the 400 patients with known outcome; 7 patients (58%) have the age range between 30 to 60 years old while the rest (42%) have age > 60 years old. Male to female ratio was 1:1 (6 patients each). Comorbidities were present in 10 patients (83%) with HTN (83%) being the most common, followed by CKD (58%), obesity (33%), and DM (33%).

Only 1 patient expired out of the 12 PLWH (8%) admitted with COVID-19, as compared to 26 patients from the 98 matched cohort (27%) (z-score 1.38, p=0.17; odds ratio [OR], 3.972; 95% confidence interval [CI], 0.62–44.37).

Conclusion

Our study suggests that PLWH do not have a worse prognosis than their matched controls for the most significant comorbid conditions affecting outcome in COVID-19 disease. Further studies with a larger sample size are urgently needed to confirm this finding.

Disclosures

Jihad Slim, MD, Abbvie (Speaker’s Bureau)Gilead (Speaker’s Bureau)Jansen (Speaker’s Bureau)Merck (Speaker’s Bureau)ViiV (Speaker’s Bureau)