Compliance with the National Comprehensive Cancer Network guidelines for evaluation and treatment of anemia among patients with solid tumors.

11 Background: Anemia is associated with increased morbidity, mortality and decreased quality of life among oncology patients. The National Comprehensive Cancer Network (NCCN) recommends evaluation and treatment of anemia in patients with cancer. There is a paucity of data investigating compliance with the NCCN guidelines. Methods: A retrospective study of patients diagnosed with any malignant solid tumor at our institution from 2008-2017 was performed. Tumor-registry-confirmed cancer cases were identified using International Classification of Disease-Oncology (ICD-O) codes in the Synthetic Derivative (SD) database, a de-identified copy of the electronic medical record. Patients were included if they were between the ages of 18 and 89 and had a hemoglobin (hgb) within 6 months of diagnosis. Patients were excluded if they had more than one tumor registry entry. Anemia was defined as hgb ≤11g/dL and graded using the CTCAE v.5.0. Absolute and possible functional iron deficiency were defined by NCCN guidelines. B12 and folate deficiency were defined by institutional reference values. Chi-squared tests were conducted in R (Version 3.4.4). P <.05 was interpreted as statistically significant. Results: A total of 25,018 patients met inclusion criteria. The median age was 60 years, and the most common malignancies were respiratory tract, prostate, and urologic (11% each, respectively). Of the 25,018 patients, 1,484 (17%) were noted to be anemic at time of diagnosis and 11,019 (44%) were anemic within 6 months of diagnosis. Of these patients, a plurality (N = 4,686, 43%) had grade 2 anemia and a majority (N = 9,623, 87%) had normocytic anemia. Patients with retroperitoneal/peritoneal cancers had the highest prevalence of anemia (N = 83, 75%). A total of 4,125 (37%) underwent any evaluation of their anemia, of which 1,742 (16%) had iron studies performed and 1,528 (14%) had B12 or folate studies performed. Of those with iron studies performed, 197 (11%) patients had absolute iron deficiency and 103 (6%) had possible functional iron deficiency. Of those with B12 labs, 74 (5%) had B12 deficiency and of those with folate labs, 69 (12%) had folate deficiency. Less than half of anemic patients (N = 4,318, 39%) received treatment for anemia, including blood transfusion (N = 3,528, 32%), oral iron (N = 1,279, 12%), or IV iron (N = 97, 1%). However, treatment of anemia significantly increased as grade of anemia increased (any treatment among mild: 12%; moderate: 31%; severe: 77%; χ2 [2, N = 11,019] = 3020.6; P <.001). Patients with male reproductive tract cancers had the highest prevalence of anemia evaluation (N = 57, 79%). Conclusions: Anemia is common in patients with solid tumors, yet compliance with NCCN guidelines for evaluation and treatment of anemia remains low. There are opportunities to improve compliance with NCCN guidelines for management of anemia across the spectrum of cancer care.

SARS-CoV-2 infection in a child with Fanconi anemia and determined immunosuppressed status

Introduction. SARS-CoV-2 virus infection affects all age groups. In children, the infection mainly causes asymptomatic or mildly symptomatic forms of the disease, regardless of their immune status. Case presentation. We describe the case of a 7-year-old male child, known to have Fanconi anemia, scheduled for bone marrow transplantation. The patient comes from a family outbreak of COVID-19, which is why he was tested for SARS-CoV-2 infection. He is asymptomatic at the time of admission to our clinic. The clinical examination performed at the time of admission shows a patient in good general condition, afebrile, with pale skin and mucous membranes, without respiratory changes. Paraclinically, severe neutropenia, severe normochromic normocytic anemia and severe thrombocytopenia are detected, for which transfusions of erythrocyte mass and platelet mass are performed. Due to the immunocompromised status, antibiotic therapy is instituted. If necessary, symptomatic treatment is administered. The evolution is favorable, and the SARS-CoV-2 RT-PCR control test is negative on the eighth day of hospitalization. Conclusions. Immunocompromised status is not a major risk factor for severe COVID-19 in children.

Nonlinear Relationship Between Macrocytic Anemia and Decompensated Hepatitis B Virus Associated Cirrhosis: A Population-Based Cross-Sectional Study

Background: Mean corpuscular volume (MCV) is major used as an indicator for the differential diagnosis of anemia. Macrocytic anemia in decompensated cirrhosis is common. However, the relationship between macrocytic anemia and decompensated hepatitis B virus (HBV) associated cirrhosis has not been fully addressed.Methods: In this cross-sectional study, a total of 457 patients diagnosed decompensated HBV associated cirrhosis who met all inclusion criteria from 2011 to 2018 were analyzed. Association between macrocytic anemia and the liver damaged (Model for End Stage Liver Disease (MELD) score) were examined using multiple logistic regression analyses and identified using smooth curve fitting.Results: Compared with normocytic anemia, MCV and MELD are significantly positively correlated in macrocytic anemia (p &lt; 0.001). A non-linear relationship of MCV and MELD association was found though the piecewise linear spline models in patients with decompensated HBV associated cirrhosis. MCV positive correlated with MELD when the MCV was greater than 98.2 fl (regression coefficient = 0.008, 95% CI 0.1, 0.4).Conclusion: Macrocytic anemia may be a reliable predictor for mortality because it is closely related to the degree of liver damage in patients with decompensated HBV associated cirrhosis.

Serological and Hematological Study of Toxoplasmosis in Blood of Newly Born Babies

Serological identification and blood pictures were done for specific IgM and IgG.10% of cases were positive IgM of Toxoplasmosis because have 10 IU/ml (mean) in comparison with control group were 0.11 IU/ml (mean). On other hand 20% of diagnosed cases were positive IgG of Toxoplasmosis because have 11 IU/ml .Two cases were followed for their history one from group IgM and other IgG , first one suffered from three abortion and now have five child three of them healthy while two have congenital defects. Second case (IgG positive ) have four abortion and now have three child , two healthy and one have congenital defect. Blood picture reveal 40% suffered from Normocytic anemia , these cases classified to three groups , first Toxoplasma group 30% (positive in ELISA test). Second group (Unknown causes), these cases not only normocytic anemia also have high total leukocytes 17 x10 (mean) and high MCV (103 ft). Third group have low MCV 78ft.

‘Unique does not mean impossible: infant presenting with complicated course of ulceroglandular tularemia.’

ABSTRACT Tularemia is a disease caused by Francisella tularensis—gram-negative coccobacillus. The ulceroglandular type characterized by skin ulcers and painful regional adenopathy is recognized as the most common. A 1-year-old patient was admitted with severe normocytic anemia, high fever and hepatosplenomegaly. A nonspecific lesion in the axillary region with a homogenous nodal reaction was found, combined with a history of a tick-bite in the pectoral muscle. Primary differentiation included leukemia, lymphoma, mononucleosis, borrelial lymphoma and simple abscess. All of the above were excluded. A further search for diagnosis focused on tick-borne diseases: TIBOLa or anaplasmosis. The ulceroglandular tularemia was eventually confirmed serologically. Besides the fact that tularemia is a rare diagnosis nowadays, it is still necessary to include this disease in the differentiation of a nonresolving tick-bite abscess with lymphadenopathy. Diagnostic vigilance is the key to effective treatment because other obvious symptoms such as severe anemia might delay the diagnosis.

Hickam’s dictum, Occam’s razor, and Crabtree’s bludgeon: a case of renal failure and a clavicular mass

Objectives Our discussant’s thoughtful consideration of the patient’s case allows for review of three maxims of medicine: Occam’s razor (the simplest diagnosis is the most likely to be correct), Hickam’s dictum (multiple disease entities are more likely than one), and Crabtree’s bludgeon (the tendency to make data fit to an explanation we hold dear). Case presentation A 66-year-old woman with a history of hypertension presented to our hospital one day after arrival to the United States from Guinea with chronic daily vomiting, unintentional weight loss and progressive shoulder pain. Her labs are notable for renal failure, nephrotic range proteinuria and normocytic anemia while her shoulder X-ray shows osseous resorption in the lateral right clavicle. Multiple myeloma became the team’s working diagnosis; however, a subsequent shoulder biopsy was consistent with follicular thyroid carcinoma. Imaging suggested the patient’s renal failure was more likely a result of a chronic, unrelated process. Conclusions It is tempting to bludgeon diagnostic possibilities into Occam’s razor. Presumption that a patient’s signs and symptoms are connected by one disease process often puts us at a cognitive advantage. However, atypical presentations, multiple disease processes, and unique populations often lend themselves more to Hickam’s dictum than to Occam’s razor. Diagnostic aids include performing a metacognitive checklist, engaging analytic thinking, and acknowledging the imperfections of these axioms.

Unusual Presentation of Pustular Eruption in Kawasaki Disease Shock Syndrome: A Case Report

The present study case report described a 46-month-old girl with Kawasaki disease shock syndrome (KDSS) who presented with five days of fevers, unilateral cervical lymphadenitis, pustular eruption, maculopapular rashes, erythema of palms and soles, conjunctivitis, cracked lips, and shock. Laboratory results showed elevated ESR & CRP, leukocytosis, normocytic anemia, and transaminitis. Pustular eruption Gram and Wright stains demonstrated numerous neutrophils. Echocardiogram showed normal results. Fluid resuscitation, broad spectrum antibiotics, inotropic drug, IVIG, and high dose aspirin were given. Diagnosis of Kawasaki disease was supported by clinical and laboratory features at the acute phase, in conjunction with periungual peeling of fingers and toes and thrombocytosis at the subacute phase. The patient made a complete recovery.The present study case showed an unusual pustular eruption in KDSS. Clinicians should consider these presentations to the diagnosis of KDSS and timely prescribed IVIG, to prevent coronary artery aneurysm. Keywords: Pustular eruption; Kawasaki disease shock syndrome

Biomarkers of Glyco-Metabolic Control in Hemodialysis Patients: Glycated Hemoglobin vs. Glycated Albumin

Background and Objectives: Glycated hemoglobin (HbA1c) dosage is considered the gold standard in glycol-metabolic monitoring, but it presents limits, which can underestimate the glycemia trend. In this regard, it was introduced the glycated albumin (GA). The aim of the study is to verify the predictivity of the GA compared to HbA1c in identifying glyco-metabolic alterations in non-diabetic and diabetic hemodialysis (HD) patients. Materials and Methods: For this purpose, we conducted a multicenter study involving one analysis laboratory and six dialysis centers in the Lazio region (Rome, Italy). Both diabetic and non-diabetic HD patients represent the study population, and the protocol included five time points. Results: The analyzed data highlighted the ability of GA to predict changes in glycemic metabolism in HD patients, and GA values are not significantly influenced, like HbA1c, by dialysis therapy itself and by comorbidities of the uremic state, such as normochromic and normocytic anemia. Thus, GA seems to reflect early glyco-metabolic alterations, both in patients with a previous diagnosis of diabetes and in subjects without diabetes mellitus. As part of this study, we analyzed two HD patients (one diabetic and one non-diabetic) in which GA was more predictive of glycol-metabolic alterations compared to HbA1c. Our study confirms the need to compare classical biomarkers used for the monitoring of glyco-metabolic alterations with new ones, likely more reliable and effective in specific subgroups of patients in which the classic biomarkers can be influenced by the preexisting pathological conditions. Conclusions: In conclusion, our evidence highlights that in uremic patients, GA shows a better ability to predict glyco-metabolic alterations allowing both an earlier diagnosis of DM and a prompt modulation of the hypoglycemic therapy, thus improving the clinical management of these patients.

Rheumatoid arthritis in a sickle cell patient: a dangerous association?

Introduction - The diagnosis of rheumatoid arthritis remains a challenge because sickle cell disease can result in various rheumatological manifestations, including joint and bone pain. The concomitant presence of rheumatoid arthritis and sickle cell disease makes the therapeutic management of both conditions problematic. Observation - A 24-year-old man, a nurse by profession, has been followed for 10 years for homozygous sickle cell disease at the Sickle Cell Disease Research Center (CRLD) of Bamako, Mali. He has presented for 8 months symmetrical polyarthritis with morning stiffness of 3 hours, distinct from the usual vaso-occlusive crisis. The Analog Visual Scale was estimated at 80/100. He reported unquantified weight loss and asthenia. The physical examination showed a deformity in bilateral ulnar deviation, flexion of the right elbow, twelve painful joints, and five swollen joints. Normochromic normocytic anemia (hemoglobin 8.3g/dl), inflammatory syndrome with C - Reactive Protein (CRP) 130.91 mg, and Sedimentation Rate (ESR) 72mm at the first hour were noted. Rheumatoid Factor was weakly positive at 21.3 IU and Anti Citrullinated Peptide Antibodies at 385.2 IU. The radiography discovered bilateral erosive carpets without associated tarsitis and osteonecrosis of both femoral heads. The diagnosis of a very active immunopositive erosive rheumatoid arthritis meeting the criteria of ACR / EULAR 2010 was retained. A treatment based on prednisone 10 mg per day was initiated, associated with methotrexate at a dosage of 15 mg weekly in single-dose, folic acid, calcium, and vitamin D. Conclusion - The coexistence of rheumatoid arthritis in sickle cell patients makes the diagnosis of polyarthritis difficult.

Anemia in Patients with Takayasu’s Arteritis and its Correlation with Disease Activity

Background Anemia is a common clinical condition in autoimmune disease, but there are few related studies in Takayasu’s arteritis (TAK). The purpose of this study is to detect clinical characteristics of anemia patients with TAK and to explore the relationship between the hemoglobin level and the disease activity in TAK. Methods This retrospective study included 160 cases of hospitalized patients with TAK and 110 cases of age-and sex-matched healthy people. According to the hemoglobin level, 160 TAK patients were divided into two groups with and without anemia, the immune indexes were compared between the two groups. 28 patients with anemia in TAK were followed up and the changes of immune indexes before and after treatment were compared.Results Hemoglobin in TAK patients is significantly lower than that of healthy control group. Among the 160 cases of TAK, 67 cases of anemia are mild to moderate anemia, and most of which are normocytic anemia. In anemia patients with TAK, women was more common (P=0.014), age at admission was more younger (P=0.002), the disease duration was shorter (P=0.017). The levels of erythrocyte sedimentation rate (ESR, P=0.000), C-reactive protein (CRP, P=0.000), interleukin-6 (IL-6, P=0.036) and disease activity scores (NIH P=0.000, ITASA P=0.001, ITAS2010 P=0.030) were significantly higher in anemia patients with TAK. The risk of anemia in TAK patients with elevated CRP was 2.35 times than that of TAK patients without elevated CRP (OR = 2.350, 95% CI 1.055-5.234, P = 0.037). After followed up for 3-6 months, hemoglobin levels increased significantly (P=0.001), ESR (P=0.000), CRP (P=0.039) and disease activity scores (NIH P=0.001, ITASA P=0.000, ITAS2010 P=0.000) decreased significantly through effective treatment without iron supplementation, and the changes of hemoglobin after treatment were negatively correlated with the changes of ESR (P=0.046) and CRP (P=0.002).Conclusion Anemia patients with TAK were more common in young women, and the disease activity was higher. Anemia can be significantly improved without iron supplementation through effective treatment to reduce disease activity of TAK.