COVID-19 admissions among patients with cancer, characterization, and at-home monoclonal antibody treatment

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Background: Cancer patients are at risk for severe Covid-19 infection. We characterized Covid-related hospitalizations across a large health system in Central Florida. We then used this analysis to target at home treatment for Covid-19. Methods: Retrospective chart review was conducted for all Covid-related admissions in cancer patients 1/2021-7/2021 at Orlando Health. Cancer type, discharge, vaccination and treatment status were collected. Distribution of cancer type among patients admitted was compared to the population treated at the cancer institute using chi-square test. Casirivimab and imdevimab monoclonal antibody (intravenous or subcutaneous) was provided at home through partnership with a home health agency. All patients received follow-up for patient satisfaction and resolution of symptoms. Results: 104 patients with Covid-related admissions were identified. 83% were diagnosed with solid and 17% with hematologic malignancy. The most common cancers were breast, genitourinary, lung, head and neck and upper gastrointestinal cancers. Proportion of patients with hematologic malignancies (lymphoma, leukemia, myeloma) were significantly higher among Covid admissions compared to the population of patients treated at the cancer institute (19/104 versus 320/4127, p < 0.01). 9% of patients died in hospital. 91% were discharged alive, 72% to home. 78% were unvaccinated (15% two, 7% one dose). 30% were on active treatment within 90 days, 52% received cytotoxic agents, 48% received targeted therapy or immunotherapy. Oncology clinics caring for hematologic malignancy patients were then targeted to offer Covid treatment at home.18 patients requested treatment from 8/17/21-10/25/21. 13 patients were treated at home, 1 went to the emergency room before receiving therapy and 4 were denied by insurance. Patients and providers were highly satisfied, with net promoter scores of 85 (n = 13) and 100 (n = 7) respectively. No infusion reactions occurred. Follow-up with all patients indicated resolution of symptoms, no patients were hospitalized for Covid after 7 days. Conclusions: Covid admissions among cancer patients at a large health system were consistent with published reports noting increased risk for patients with hematologic malignancies. Identification of this population translated to a targeted approach to offering monoclonal antibody treatment at home. In this small cohort, at home treatment was safe and associated with high patient and provider satisfaction.

Implementing a discharge intervention to reduce 30-day readmission and mortality in patients with high-risk cancer: A real-world prospective quality improvement study

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Background: One in four patients admitted with metastatic cancer are readmitted within 30 days. We created a bundled multipronged intervention to reduce 30-day readmission, unplanned (ED) visits, and mortality among high-risk stage IV cancer patients. Methods: We conducted a prospective quality improvement study to reduce readmissions and 30-day mortality among high-risk oncology patients. Baseline patients were identified 1/2022-3/2022. The electronic medical record (Epic) was leveraged to automatically identify patients admitted with cancer diagnosis and set risk factors (readmission, low albumin, fluids/antibiotics, head imaging, low oxygen saturation). Dashboard was reviewed three times per week and stage IV solid malignancy confirmed. Starting 3/2022, intervention included three components: coordination of care (CC), patient education and symptom management (PESM), and post-discharge follow-up (PDF). In CC, a dedicated scheduler coordinated visits with the primary oncology team within 7 business days, with options for palliative care, nutrition, and integrative medicine. In PESM, the attending physician was notified, referred to oncology nurse navigation and encouraged to use the oncology urgent care. In PDF, patients were contacted after discharge to collect hospital readmission, unplanned ED visit, mortality outcome and satisfaction. Patients discharged with hospice were excluded. Control charts were used to assess special cause and chi-square to compare pre and post intervention cohorts. Results: As of 6/2022, 36 baseline and 125 patients have been identified. Of 117 discharged patients, 23 were discharged on hospice, of the remaining 94, 98% were contacted by the concierge scheduler and 53% received an appointment within 7 days. Among the intervention patients, the most common tumor type was lung (n = 16), prostate (n = 14), and colon (n = 13). The most common reason for admission was pain (n = 30), and respiratory/dyspnea (n = 21). During the baseline period, mean 30-day readmission rate was 25.5% and 30-day mortality 19.6%. Preliminary data reveal early improvement in readmission and 30-day mortality (Table). Conclusions: We have demonstrated that identifying high-risk cancer patients using the electronic medical record is feasible and identifies a group at high risk for readmission and mortality. By prospectively identifying patients, we were able to provide a multi-pronged intervention at a tertiary hospital.[Table: see text]

Potential relationships between the presence of HIV, macrophages, and astrogliosis in SCID mice with HIV encephalitis

The pathogenesis of HIV encephalitis (HIVE) has not been determined although increased numbers of mononuclear phagocytes (macrophages and microglia), some of which are HIV-infected, and reactive astrogliosis are important pathological findings in this condition. For this experiment, fifty-one SCID mice were inoculated intracerebrally either with human cells and HIV-1, human cells only or HIV only and then sacrificed at various time points. HIV gag mRNA was detected by reverse transcriptase polymerase chain reaction (PCR) distant from the site of inoculation in 73% of mouse brains inoculated with HIV and human cells attesting to the pervasiveness of HIV infection in SCID brain. HIV mRNA was detected as long as 91 days after inoculation of human cells and virus and the presence of HIV gag, nef, and tat/rev mRNA in HIV-infected SCID brains indicates ongoing HIV mRNA synthesis. Brain tissue sections were immunostained for HIV, human macrophages, and astrocytes from a subset of mice (n = 29) from the above groups and qualitatively assessed. PCR data for HIV mRNA was correlated with staining results and these data suggested that the greatest astrogliosis was present in mice inoculated with HIV and human cells, consistent with previously reported data. The data further suggest that astrogliosis is greater when HIV is detected. Taken together the data are consistent with a synergistic effect between macrophages and HIV in the development of astrogliosis.

Acute multiple sclerosis characterized by extensive mononuclear phagocyte infiltration

In this study, we examine the clinical, neuroradiological, and immunohistochemical findings of a 51 year old white female who died 27 months after onset of acute multiple sclerosis despite treatment with interferon-beta, azathioprine, corticosteroids, and cyclophosphamide. Immunohistochemical studies revealed extensive gliosis and mononuclear phagocyte infiltration with corresponding upregulation of proinflammatory cytokines (eg. IFN-alpha, TNF-alpha). The significance of immunohistochemical findings with respect to clinical presentation is discussed.

New treatment strategies for malignant gliomas

Although survival in patients with malignant gliomas remains limited, there is renewed optimism with the emergence of novel treatment strategies. Cytotoxic agents such as temozolomide and CPT-11 have shown promising clinical activity. Biological treatments for brain tumors, including antisense oligonucleotides, gene therapy, and angiogenesis inhibitors, are also being evaluated in clinical trials. Delivery strategies have been developed to overcome challenges presented by the blood-brain barrier. These noteworthy treatments, alone or in combination, may ultimately prolong survival and enhance quality of life in this group of patients.