Category: Hematology/Oncology
Posted: 10/28/2024 by Sarah Dubbs, MD
(Updated: 11/1/2024)
Click here to contact Sarah Dubbs, MD
Cardiovascular disease (CVD) and cancer are leading global causes of illness and death, and evidence increasingly shows they are interconnected. There is strong epidemiological data that the two disease entities share modifiable risk factors such as hypertension, hyperlipidemia, diabetes, obesity, smoking, diet, physical activity, and social determinants of health.
Shared mechanisms underlying both CVD and cancer include:
Take home points:
Keep all this in mind especially when seeing cancer and CVD patients in your ED!
Wilcox NS, Amit U, Reibel JB, Berlin E, Howell K, Ky B. Cardiovascular disease and cancer: shared risk factors and mechanisms. Nat Rev Cardiol. 2024 Sep;21(9):617-631. doi: 10.1038/s41569-024-01017-x. Epub 2024 Apr 10. PMID: 38600368; PMCID: PMC11324377.
Koene RJ, Prizment AE, Blaes A, Konety SH. Shared Risk Factors in Cardiovascular Disease and Cancer. Circulation. 2016 Mar 15;133(11):1104-14. doi: 10.1161/CIRCULATIONAHA.115.020406. PMID: 26976915; PMCID: PMC4800750.
Category: Hematology/Oncology
Posted: 9/24/2024 by Sarah Dubbs, MD
(Updated: 11/1/2024)
Click here to contact Sarah Dubbs, MD
The FDA approved two cell-based gene therapies for the treatment of Sickle Cell Disease in December, 2023. These therapies show potential to dramatically improve the outcomes and quality of life for patients with SCD. You may soon encounter patients who received one of these treatments in the ER, so here is an intro to what they are:
Casgevy is an FDA-approved gene therapy for sickle cell disease in patients 12 and older with recurrent vaso-occlusive crises. It uses CRISPR/Cas9 genome editing to modify blood stem cells, increasing fetal hemoglobin (HbF) production, which prevents red blood cell sickling.
Lyfgenia, also a gene therapy for sickle cell disease, uses a lentiviral vector to modify stem cells to produce HbAT87Q, a hemoglobin that reduces sickling. Both therapies involve modifying the patient's own stem cells, followed by myeloablative chemotherapy, and are given as a single infusion.
Long-term safety and effectiveness is still being studied. More to come in the future!
Frangoul H, Altshuler D, Cappellini MD, Chen YS, Domm J, Eustace BK, Foell J, de la Fuente J, Grupp S, Handgretinger R, Ho TW, Kattamis A, Kernytsky A, Lekstrom-Himes J, Li AM, Locatelli F, Mapara MY, de Montalembert M, Rondelli D, Sharma A, Sheth S, Soni S, Steinberg MH, Wall D, Yen A, Corbacioglu S. CRISPR-Cas9 Gene Editing for Sickle Cell Disease and ?-Thalassemia. N Engl J Med. 2021 Jan 21;384(3):252-260. doi: 10.1056/NEJMoa2031054. Epub 2020 Dec 5. PMID: 33283989. https://www.nejm.org/doi/10.1056/NEJMoa2031054?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
Interesting read from NPR featuring the first patient to receive this therapy:
Category: Hematology/Oncology
Keywords: Oncology, Endocrine, Hypercalcemia, Electrolyte (PubMed Search)
Posted: 8/26/2024 by Sarah Dubbs, MD
(Updated: 11/1/2024)
Click here to contact Sarah Dubbs, MD
We see patients with nausea, fatigue, altered mental status, and other vague symptoms all day, every day in the ED. Let's not forget about hypercalcemia in the differential, especially in patients with a known malignancy! Many tumor types secrete a Parathyroid hormone (PTH)- related protein that mimics PTH and leads to high calcium levels.
Here are some clinical pearls on hypercalcemia of malignancy:
Category: Hematology/Oncology
Keywords: Hematology, Anemia (PubMed Search)
Posted: 7/22/2024 by Sarah Dubbs, MD
Click here to contact Sarah Dubbs, MD
Iron-deficiency anemia affects 10% of women of child-bearing age. Guidelines to treat iron deficiency recommend daily oral iron, but this may decrease fractional iron absorption and increase side effects which also impacts medication adherence. A double-masked, randomized, placebo-controlled trial, which included 150 women demonstrated that:
at equal total iron doses, compared to consecutive day dosing of iron, alternate day dosing did not result in higher serum ferritin but reduced iron deficiency at 6 months and triggered fewer gastrointestinal side effects.
Take home point: Dosing iron every other day had similar effect with less side effects. Consider prescribing it this way to your patients, especially if they have had issues with side effects in the past!
von Siebenthal HK, Gessler S, Vallelian F, Steinwendner J, Kuenzi UM, Moretti D, Zimmermann MB, Stoffel NU. Alternate day versus consecutive day oral iron supplementation in iron-depleted women: a randomized double-blind placebo-controlled study. EClinicalMedicine. 2023 Nov 3;65:102286. doi: 10.1016/j.eclinm.2023.102286. PMID: 38021373; PMCID: PMC10659995.
https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(23)00463-7/fulltext
Category: Hematology/Oncology
Keywords: Cancer, ACS, AMI, troponin (PubMed Search)
Posted: 2/26/2024 by Sarah Dubbs, MD
(Updated: 11/1/2024)
Click here to contact Sarah Dubbs, MD
Evidence is mounting that individuals with active or past history of cancer are at increased risk for acute cardiovascular events such as as acute myocardial infarction. This secondary analysis from the APACE (Advantageous Predictors of Acute Coronary Syndromes Evaluation) study- a multicenter, international, prospective diagnostic study looked at the prevalence of MI in patients with history of cancer presenting to the ED with acute chest pain, diagnostic accuracy of high-sensitivity troponins and diagnostic algorithms (European Society of Cardiology algorithm- see paper for details), among a few other parameters.
Take home points:
Translation to practice:
Be more conservative with cancer patients presenting to the ED with acute chest pain!
Bima, P, Lopez-Ayala, P, Koechlin, L. et al. Chest Pain in Cancer Patients: Prevalence of Myocardial Infarction and Performance of High-Sensitivity Cardiac Troponins. J Am Coll Cardiol CardioOnc. 2023 Oct, 5 (5) 591–609.
https://doi.org/10.1016/j.jaccao.2023.08.001
Category: Hematology/Oncology
Keywords: CVC, Central Line Placement, Thrombocytopenia, Platelets, Transfusion (PubMed Search)
Posted: 1/22/2024 by Sarah Dubbs, MD
Click here to contact Sarah Dubbs, MD
The routine use of ultrasound guidance has decreased CVC-related complications, especially in patients at risk for bleeding. To this day, however, platelet transfusion threshold guidelines range widely from 20,000 - 50,000 platelets per cubic millimeter, and also lack good-quality evidence.
This multicenter, randomized, controlled, noninferiority trial randomly assigned patients with severe thrombocytopenia (platelet count 10,000 to 50,000 per cubic millimeter) to receive either one unit of prophylactic platelet transfusion or no platelet transfusion before ultrasound-guided CVC placement.
Author's Conclusions: Withholding prophylactic platelet transfusion before CVC placement in patients with a platelet count of 10,000 to 50,000 per cubic millimeter did NOT meet the predefined margin for noninferiority and resulted in more CVC-related bleeding events than prophylactic platelet transfusion.
BUT…taking a closer look at this study reveals many nuanced points. Many of the study patients were heme/onc patients possibly having bleeding issues outside of low platelets, bleeding complications trended with subclavian and femoral locations as well as lower initial platelet counts. All this suggests that additional studies need to be done to move towards more specific evidenced-based guidelines.
To read more details on the study, click the referenced link.
Category: Hematology/Oncology
Keywords: Transfusion, Anemia, MI, ACS, hematology (PubMed Search)
Posted: 11/27/2023 by Sarah Dubbs, MD
Click here to contact Sarah Dubbs, MD
Hot off the NEJM press, published November 11, 2023:
Restrictive or Liberal Transfusion Strategy in Myocardial Infarction and Anemia (Carson, Brooks, Hebert, et al Myocardial Ischemia and Transfusion (MINT) Investigators)
3504 pateints were included in this study. A primary-outcome event occurred in 295 of 1749 patients (16.9%) in the restrictive-strategy group and in 255 of 1755 patients (14.5%) in the liberal-strategy group. More specifically, death occurred in 9.9% of the patients with the restrictive strategy and in 8.3% of the patients with the liberal strategy; myocardial infarction occurred in 8.5% and 7.2% of the patients, respectively.
Conclusions from the study: Liberal transfusion strategy did NOT significantly reduce the risk of recurrent MI or death at 30 days.
N Engl J MedCarson JL, Brooks MM, Hébert PC, et al. Restrictive or Liberal Transfusion Strategy in Myocardial Infarction and Anemia. . Published online November 11, 2023. doi:10.1056/NEJMoa2307983
Category: Hematology/Oncology
Keywords: Neutropenic Fever, Phamacology, Infectious Disease, Oncology (PubMed Search)
Posted: 9/25/2023 by Sarah Dubbs, MD
Click here to contact Sarah Dubbs, MD
Treatment of neutropenic fever is evolving, especially in the context of multidrug-resistant (MDR) organisms. This article reviews an update on best practices and describes two approaches to antimicrobial therapy- "escalation" and "de-escalation". Escalation begins with a narrow spectrum of antimicrobials and increases based on patient response, suitable for uncomplicated cases. De-escalation starts with broad-spectrum antibiotics and narrows down, recommended for complicated cases. The choice depends on the institution's MDR prevalence. Initial antimicrobials like cefepime or carbapenems are selected based on resistance rates. De-escalation timing varies per guidelines, but clinical trials support its safety and efficacy. Benefits include reducing C. difficile risk, antimicrobial resistance, and complications. Despite these advantages, some centers lack explicit de-escalation guidance, emphasizing the need for clear protocols to optimize patient outcomes by minimizing antibiotic therapy duration.
Molina KC. Best Practices in the Management of Infectious Complications for Patients With Cancer: Management of Febrile Neutropenia. J Adv Pract Oncol. 2023 Apr;14(3):201-206. doi: 10.6004/jadpro.2023.14.3.4. Epub 2023 Apr 1. PMID: 37197726; PMCID: PMC10184844.