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      Tele-Medicine Services in Hematological Practice During Covid Pandemic: Its Feasibility and Difficulties

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          Abstract

          In COVID 19 pandemic, delivery and access of health care services have become challenging. Telemedicine services can be considered for management of patients with hematological diseases. This study included all patients who enrolled for telemedicine facility for hematology from May 15 to July 15, 2020. Patient’s demographic and disease related parameters were recorded during the teleconsultation call. Overall satisfaction of attending doctor and patients were also recorded. A total of 1187 teleconsultation appointments were taken, of which 944 (79.6%) were successfully attended. Median age of patients was 38 years (range- 0.5–78 years), with 38% females. 55% of successful calls were from patients suffering a malignant hematological disorder. 24% had an active complaint pertaining to their disease or treatment. Of these, 162 (17%) were asked for a physical consultation. A significant association was found between the requirement of physical consultation and diagnosis ( p < 0.001), absence of active complaint (< 0.0001) and education level of responder ( p = 0.008). Patients understand that teleconsultation is helpful in preventing COVID-19 infection (71.4%) and avoids outpatient department rush (14.5%) associated with physical appointments; and around 80% patients were satisfied with the teleconsult. With the emergence of COVID 19, many localities under partial lockdown with constant fear of contacting virus amongst patients and health care providers, we can clearly see the advantages as well as feasibility of telemedicine services for our patients. The acute surge in telemedicine could be harnessed in the future to provide comprehensive and integrated care to patients of hematological disorders.

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          Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China

          China and the rest of the world are experiencing an outbreak of a novel betacoronavirus known as severe acute respiratory syndrome corona virus 2 (SARS-CoV-2). 1 By Feb 12, 2020, the rapid spread of the virus had caused 42 747 cases and 1017 deaths in China and cases have been reported in 25 countries, including the USA, Japan, and Spain. WHO has declared 2019 novel coronavirus disease (COVID-19), caused by SARS-CoV-2, a public health emergency of international concern. In contrast to severe acute respiratory system coronavirus and Middle East respiratory syndrome coronavirus, more deaths from COVID-19 have been caused by multiple organ dysfunction syndrome rather than respiratory failure, 2 which might be attributable to the widespread distribution of angiotensin converting enzyme 2—the functional receptor for SARS-CoV-2—in multiple organs.3, 4 Patients with cancer are more susceptible to infection than individuals without cancer because of their systemic immunosuppressive state caused by the malignancy and anticancer treatments, such as chemotherapy or surgery.5, 6, 7, 8 Therefore, these patients might be at increased risk of COVID-19 and have a poorer prognosis. On behalf of the National Clinical Research Center for Respiratory Disease, we worked together with the National Health Commission of the People's Republic of China to establish a prospective cohort to monitor COVID-19 cases throughout China. As of the data cutoff on Jan 31, 2020, we have collected and analysed 2007 cases from 575 hospitals (appendix pp 4–9 for a full list) in 31 provincial administrative regions. All cases were diagnosed with laboratory-confirmed COVID-19 acute respiratory disease and were admitted to hospital. We excluded 417 cases because of insufficient records of previous disease history. 18 (1%; 95% CI 0·61–1·65) of 1590 COVID-19 cases had a history of cancer, which seems to be higher than the incidence of cancer in the overall Chinese population (285·83 [0·29%] per 100 000 people, according to 2015 cancer epidemiology statistics 9 ). Detailed information about the 18 patients with cancer with COVID-19 is summarised in the appendix (p 1). Lung cancer was the most frequent type (five [28%] of 18 patients). Four (25%) of 16 patients (two of the 18 patients had unknown treatment status) with cancer with COVID-19 had received chemotherapy or surgery within the past month, and the other 12 (25%) patients were cancer survivors in routine follow-up after primary resection. Compared with patients without cancer, patients with cancer were older (mean age 63·1 years [SD 12·1] vs 48·7 years [16·2]), more likely to have a history of smoking (four [22%] of 18 patients vs 107 [7%] of 1572 patients), had more polypnea (eight [47%] of 17 patients vs 323 [23%] of 1377 patients; some data were missing on polypnea), and more severe baseline CT manifestation (17 [94%] of 18 patients vs 1113 [71%] of 1572 patients), but had no significant differences in sex, other baseline symptoms, other comorbidities, or baseline severity of x-ray (appendix p 2). Most importantly, patients with cancer were observed to have a higher risk of severe events (a composite endpoint defined as the percentage of patients being admitted to the intensive care unit requiring invasive ventilation, or death) compared with patients without cancer (seven [39%] of 18 patients vs 124 [8%] of 1572 patients; Fisher's exact p=0·0003). We observed similar results when the severe events were defined both by the above objective events and physician evaluation (nine [50%] of 18 patients vs 245 [16%] of 1572 patients; Fisher's exact p=0·0008). Moreover, patients who underwent chemotherapy or surgery in the past month had a numerically higher risk (three [75%] of four patients) of clinically severe events than did those not receiving chemotherapy or surgery (six [43%] of 14 patients; figure ). These odds were further confirmed by logistic regression (odds ratio [OR] 5·34, 95% CI 1·80–16·18; p=0·0026) after adjusting for other risk factors, including age, smoking history, and other comorbidities. Cancer history represented the highest risk for severe events (appendix p 3). Among patients with cancer, older age was the only risk factor for severe events (OR 1·43, 95% CI 0·97–2·12; p=0·072). Patients with lung cancer did not have a higher probability of severe events compared with patients with other cancer types (one [20%] of five patients with lung cancer vs eight [62%] of 13 patients with other types of cancer; p=0·294). Additionally, we used a Cox regression model to evaluate the time-dependent hazards of developing severe events, and found that patients with cancer deteriorated more rapidly than those without cancer (median time to severe events 13 days [IQR 6–15] vs 43 days [20–not reached]; p<0·0001; hazard ratio 3·56, 95% CI 1·65–7·69, after adjusting for age; figure). Figure Severe events in patients without cancer, cancer survivors, and patients with cancer (A) and risks of developing severe events for patients with cancer and patients without cancer (B) ICU=intensive care unit. In this study, we analysed the risk for severe COVID-19 in patients with cancer for the first time, to our knowledge; only by nationwide analysis can we follow up patients with rare but important comorbidities, such as cancer. We found that patients with cancer might have a higher risk of COVID-19 than individuals without cancer. Additionally, we showed that patients with cancer had poorer outcomes from COVID-19, providing a timely reminder to physicians that more intensive attention should be paid to patients with cancer, in case of rapid deterioration. Therefore, we propose three major strategies for patients with cancer in this COVID-19 crisis, and in future attacks of severe infectious diseases. First, an intentional postponing of adjuvant chemotherapy or elective surgery for stable cancer should be considered in endemic areas. Second, stronger personal protection provisions should be made for patients with cancer or cancer survivors. Third, more intensive surveillance or treatment should be considered when patients with cancer are infected with SARS-CoV-2, especially in older patients or those with other comorbidities.
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            Is Open Access

            Rapid assessment of regional SARS-CoV-2 community transmission through a convenience sample of healthcare workers, the Netherlands, March 2020

            To rapidly assess possible community transmission in Noord-Brabant, the Netherlands, healthcare workers (HCW) with mild respiratory complaints and without epidemiological link (contact with confirmed case or visited areas with active circulation) were tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Within 2 days, 1,097 HCW in nine hospitals were tested; 45 (4.1%) were positive. Of six hospitals with positive HCW, two accounted for 38 positive HCW. The results informed local and national risk management.
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              Chronic myeloid leukemia management at the time of the COVID-19 pandemic in Italy. A campus CML survey

              It has been reported that imatinib may have a specific protective role in blocking the fusion of the protein S of the Coronavirus belonging to the viral surface with cell membranes [1]. This role could prevent the endocytosis necessary for the viral activation of different viral species (Sars-COV, MERS-CoV, and IBV) [2]. No in vivo information has been reported so far. The only information related to chronic myeloid leukemia (CML) comes from a relatively small series from the Hubei Province where it was found that relatively few COVID-19+ CML patients were reported [3]. The Campus CML is an ongoing program aimed at creating a network of physicians in Italy involved in different aspects of the management of patients with CML, sharing experiences and updates for the diagnosis, treatment of the disease, identification and prevention of the specific toxicity of the drugs used but also on possible future therapeutic approaches. Considering the current COVID-19 emergency in Italy, we asked Italian clinicians about the incidence of infections among their CML patients and about the management of the disease in this unique pandemic period. On April 6 we sent an ad hoc questionnaire to 51 Campus CML centers throughout the country and 47 centers (92%) have completed the online survey. Nineteen centers were from the most affected regions: Lombardia, Piemonte, Veneto, Emilia-Romagna. Twelve centers (42.5%) reported a decrease in the incidence of new CML cases in this period. Data from a large cohort of 6883 CML patients were gathered: only 12 cases of confirmed COVID-19 infection were reported (0.17%) up to the middle of April. Two of the 12 cases were healthcare professionals and 8 have been infected in the most affected Italian regions. Only two deaths have been recorded, one in a patient aged 91 years. Other five patients were suspected based on the symptoms presented, but tested negative. The majority of participants (89%) declared that CML patients were tested only in case of fever and/or related symptoms and/or who had been in close contact with a positive subject, but not routinely. In Italy, testing is routinely performed on inpatients. Eight centers (17%) reported difficulties in performing a baseline diagnostic work-up and molecular monitoring to detect MRD during treatment. Sixty-six percent of centers postponed the molecular analysis by 1–2 months during this emergency if patients were at least in MR3 or if they were in deep and stable molecular response. Patients who did not have to perform a molecular monitoring were checked prevalently by telephone or by email during the COVID-19 pandemic. The COVID-19 emergency had a repercussion on the treatment-free remission (TFR) strategy: 58% of participating physicians did not propose a possible discontinuation and 24% of patients already in TFR have had to modify the molecular monthly monitoring approach. We recorded changes also in the delivery of drugs: while imatinib delivery was not affected due to local pharmacy distributions, 36% of physicians reported consequences for second-generation TKIs subject to AIFA (the Italian Medicine Agency) monitoring in Italy. In some instances, delivery was carried out directly at the patient’s home (12%) or a supply for more months has been granted (10%) by the treating center. The activity of ongoing CML trials has already been affected by the emergency: 34% of physicians have stopped enrollment and 8% have continued with the ongoing trials with some difficulties in the planned follow-up of enrolled patients. AIFA issued a decree that allowed patients enrolled in a trial and not able to reach the center to perform the requested tests at a hospital near home with a complete reimbursement: 51% of interviewed centers adopted this strategy. These results of our survey show that the incidence of COVID-19 infection has so far proven extremely low in CML patients treated with TKIs. These data are in line with what observed in adult patients with Ph+ acute lymphoblastic leukemia (Ph+ ALL) in Italy, where patients are induced with a TKI plus steroids and no systemic chemotherapy, and could continue to be managed even at the peak of the COVID-19 outbreak [4]. Taken together, the data gathered on over 7000 cases of CML and Ph+ ALL support a potential role of TKIs in protecting patients from COVID-19 infection. To conclusively answer this question a randomized study (EudraCT 2020-001236-10) is verifying the effect of imatinib in preventing pulmonary vascular leak in patients with severe COVID-19 disease. Although the likelihood of developing a symptomatic COVID-19 infection in CML patients in Italy is close to zero and lower than that of the general population in Italy, the current pandemic emergency is, however, already negatively impacting on different aspects of the day-to-day management of patients, on disease monitoring and on treatment decisions, as well as on the enrollment in and compliance to clinical trials.
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                Author and article information

                Contributors
                doctorpkgmu@gmail.com
                mukulmamc@gmail.com
                rishidhawan@doctors.org.uk
                drjasmita@gmail.com
                ganeshpgi@gmail.com
                visunita@ymail.com
                nargissaleem2004@gmail.com
                jsalwayswins@gmail.com
                nehaganju@gmail.com
                tejasvinivaid@gmail.com
                monavijayran1@gmail.com
                tribikramvss@gmail.com
                gstithap@gmail.com
                balu.sahitya@gmail.com
                doc.akash22@gmail.com
                renjith.verghese@gmail.com
                drseematyagi@hotmail.com
                drtulikaseth@gmail.com
                mrmahapatra@hotmail.com
                Journal
                Indian J Hematol Blood Transfus
                Indian J Hematol Blood Transfus
                Indian Journal of Hematology & Blood Transfusion
                Springer India (New Delhi )
                0971-4502
                0974-0449
                20 November 2020
                : 1-6
                Affiliations
                GRID grid.413618.9, ISNI 0000 0004 1767 6103, Department of Hematology, , All India Institute of Medical Sciences, ; New Delhi, India
                Article
                1385
                10.1007/s12288-020-01385-7
                7678769
                33250594
                008d5490-9771-4c23-b9e7-d1a607bee675
                © Indian Society of Hematology and Blood Transfusion 2020

                This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.

                History
                : 8 October 2020
                : 12 November 2020
                Categories
                Original Article

                covid 19 pandemic,telemedicine,hematological diseases

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