Association of clinical factors and recent anticancer therapy with COVID-19 severity among patients with cancer: a report from the COVID-19 and Cancer Consortium

BACKGROUND

Patients with cancer may be at high risk of adverse outcomes from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We analyzed a cohort of patients with cancer and coronavirus 2019 (COVID-19) reported to the COVID-19 and Cancer Consortium (CCC19) to identify prognostic clinical factors, including laboratory measurements and anticancer therapies.

PATIENTS AND METHODS

Patients with active or historical cancer and a laboratory-confirmed SARS-CoV-2 diagnosis recorded between 17 March and 18 November 2020 were included. The primary outcome was COVID-19 severity measured on an ordinal scale (uncomplicated, hospitalized, admitted to intensive care unit, mechanically ventilated, died within 30 days). Multivariable regression models included demographics, cancer status, anticancer therapy and timing, COVID-19-directed therapies, and laboratory measurements (among hospitalized patients).

RESULTS

A total of 4966 patients were included (median age 66 years, 51% female, 50% non-Hispanic white); 2872 (58%) were hospitalized and 695 (14%) died; 61% had cancer that was present, diagnosed, or treated within the year prior to COVID-19 diagnosis. Older age, male sex, obesity, cardiovascular and pulmonary comorbidities, renal disease, diabetes mellitus, non-Hispanic black race, Hispanic ethnicity, worse Eastern Cooperative Oncology Group performance status, recent cytotoxic chemotherapy, and hematologic malignancy were associated with higher COVID-19 severity. Among hospitalized patients, low or high absolute lymphocyte count; high absolute neutrophil count; low platelet count; abnormal creatinine; troponin; lactate dehydrogenase; and C-reactive protein were associated with higher COVID-19 severity. Patients diagnosed early in the COVID-19 pandemic (January-April 2020) had worse outcomes than those diagnosed later. Specific anticancer therapies (e.g. R-CHOP, platinum combined with etoposide, and DNA methyltransferase inhibitors) were associated with high 30-day all-cause mortality.

CONCLUSIONS

Clinical factors (e.g. older age, hematological malignancy, recent chemotherapy) and laboratory measurements were associated with poor outcomes among patients with cancer and COVID-19. Although further studies are needed, caution may be required in utilizing particular anticancer therapies.

CLINICAL TRIAL IDENTIFIER

NCT04354701.

Determinants of post-partum maternal mortality at Queen Elizabeth Central Hospital, Blantyre, Malawi: a case-control study 2001-2002

The aim of this research is to identify the clinical, demographic and service-based determinants of postpartum maternal mortality within Queen Elizabeth Central Hospital, Blantyre, Malawi, during 2001 and 2002. The study uses a case-control design using all postpartum maternal deaths in 2001 and 2002 as cases, with analysis conducted using conditional logistic regression. The results indicate that the mothers' reason for admission into hospital and the outcome of the birth were significantly related to maternal death when analysing all potential explanatory variables in one model. A group of high-risk mothers can be identified using these factors. If these criteria were applied as a predictive tool in the clinical setting the resulting sensitivity and specificity would be over 85%. Identification within the hospital setting of a group of very high-risk mothers in whom serious complications are aggressively managed in a coordinated way across the medical specialties may reduce maternal mortality.

Knowledge and perceptions of antenatal women towards prevention of mother to child transmission of HIV/AIDS in Blantyre, Malawi

OBJECTIVES

To determine antenatal attendees' knowledge and perceptions towards selected aspects of prevention of mother to child transmission of HIV.

SETTING

Five rural and six urban public health centers in Blantyre District, Malawi.

SUBJECTS

126 consecutive pregnant women attending antenatal clinics.

DESIGN

Cross sectional qualitative study utilizing focus group discussions (FGDs). Analysis was based on content analysis.

RESULTS

Knowledge about HIV/AIDS especially regarding causative agents of AIDS, transmission and prevention was generally high in all FGDs. One individual though, suggested that HIV was transmitted by mosquito bites and another that HIV was transmitted by being exposed to persistent coughing. The majority of 126 women identified HIV testing of pregnant women as of potential benefit and necessary for the prevention and control of HIV/AIDS. In most cases, the benefit mentioned for HIV testing was that it was good to know about one's HIV status rather than being ignorant. Other suggested benefits of HIV testing of pregnant women were: future family planning, as an incentive to reduce the number of sexual partners and to know the cause of the problem in case a child is failing to thrive rather than blame witchcraft. Male spouses were identified as both potential supporters and limiting agents towards pregnant women's acceptability of HIV testing.

CONCLUSION

HIV testing among pregnant women to ensure prevention of mother to child transmission of HIV is a complex issue. Women consider various factors before making decisions. Programme planners and implementing agencies need to be aware of these issues and work together with women and other stakeholders in order to overcome such limitations.

An audit of deliveries and outcome at Queen Elizabeth Central Hospital, Blantyre, in 1999

A one-year audit of deliveries at Queen Elizabeth Central Hospital, Blantyre, was undertaken for 1999. The main objective of the audit was to obtain baseline data on forms of deliveries and pregnancy outcome. A total of 12,293 births occurred during the study period. Of these, 11,565 were singleton deliveries, 349 twin deliveries and 10 triplets. Characteristics of singleton deliveries were analysed further when data were available. The age distribution of the mothers ranged from 10 to 55 years with a mean age of 23.4 years. Of 10,314 singleton deliveries, 8710 (84.4%) were spontaneous vertex deliveries, 1121 (10.8%) were caesarian section, 304 (2.94%) were vacuum extraction and 169 (1.63%) were assisted breech deliveries. Breech deliveries had the worst outcome. The maternal mortality rate for the year 1999 was 1224 per 100,000 live births and the perinatal mortality rate was 49.3 per 1000 live births.

Illegal abortions in Addis Ababa, Ethiopia

OBJECTIVES

To identify the primary abortionist while the patient is in the hospital; to determine the type of materials used to terminate the pregnancy; to determine the number of attempts made to terminate the index pregnancy and; to characterise women with induced abortions at five hospitals in the City of Addis Ababa.

DESIGN

Cross-sectional hospital-based descriptive multi-centre (WHO) study.

SETTING

Addis Ababa University, Faculty of Medicine.

SUBJECTS

All cases of abortions admitted to the study hospitals at five hospitals with obstetric and gynaecologic services.

MAIN OUTCOME MEASURES

Identification of the primary abortionist, the places where abortion is carried out, the number of attempts made to terminate the index pregnancy and the materials used to terminate the pregnancy and reasons for terminating the pregnancy.

RESULTS

A total of 2275 cases of abortion had been identified and managed in the five study hospitals. The study demonstrated that 984 (43.3%) were spontaneous abortions. Of the 1290 illicit or unsafe abortions admitted by the patients (certainly induced) in 455 (35.3%) of the abortions were performed by the health assistants, 366 (28.3%) self-induced, and 306 (23.7%) by cleaners working in the operation theatres. In 744 (60%) of the abortion procedures were carried out at the abortionists home while 452 (35%) at the patients' home. The remaining 94 (5%) of the abortions were done safely in the hospital or doctor's office by professionals. The most commonly used methods for inducing the abortions were; in 417 (32.3%) high doses of ampicillin per OS, and in 414 (32.1%) by inserting plastic tubes (intravenous giving set) per vagina.

CONCLUSION

The issue of abortion clearly presents an enormous complex moral and ethical dilemma. The study results are very clear. Where abortion is illegal or where the services are not readily available and/or personnel are not well trained, unsafe abortion carries a high risk of complications, permanent damage resulting in infertility and even death. The question is not really whether or not abortion should be legal or illegal but whether or not it should be prevented through modern family planning methods, safe or unsafe abortions. In all societies no matter what the legal moral or cultural status of abortion are, there will be some women who will desperately seek to terminate an unwanted or unplanned pregnancy. Unsafe abortion is a major medical and public health problem in Ethiopia. The magnitude of the problem in terms of numbers affected, and severe adverse consequences can no longer be ignored.

Adolescent pregnancies in Addis Ababa

OBJECTIVE

To determine the pattern, obstetric outcome, knowledge and practice of modern family planning methods and factors that predispose to pregnancy among adolescent mothers.

DESIGN

A descriptive study comparing findings in adolescent and mature mothers.

SETTING

Two teaching Hospitals in Addis Ababa.

SUBJECTS

Adolescent mothers under 20 years of age and mature mothers aged between 20 and 34 years.

MAIN OUTCOME MEASURES

Age at pregnancy, demographic variables, gestational age, parity, antenatal care attendance, modes of deliveries, birthweight, Apgar scores, condition of babies at birth and knowledge and utilisation of modern contraceptive methods.

RESULTS

Five hundred and sixty nine (74%) of the adolescents were single compared with 226 (29%) of mature mothers (p<0.001, OR 6.83, 95%; CI=5.47-8.45). There were 391 (51%) unemployed adolescents compared with 99 (13%) of mature mothers (p<0.001, OR 7.0, 95% CI 3.06-5.05). Five hundred and twelve (67%) of the adolescent pregnant mothers failed to attend antenatal clinic compared with 344 (45%) of the mature mothers (p<0.001, OR 0.41, 95% CI=0.33, 0.5). Two hundred (26%) of adolescent mothers underwent Caesarean section compared with 82 (11%) of mature mothers (p<0.001, OR 2.44, 95% CI=1.90, 4.56). Two hundred and fifty six (33%) of the adolescent mothers delivered low birthweight babies compared with 106 (14%) of mature mothers (p<0.001, OR 3.12, 95% CI=2.4, 3.99). The one and five minute Apgar scores were less than seven in 301 (39%) babies born to adolescent mothers compared with 20 (27%) babies born to mature mothers (p<0.001, OR 1.73, 95% CI=1.39, 2.14. Five hundred and twelve (67%) of adolescent mothers had no knowledge about modern contraceptive methods compared with 147 (19%) mature mothers (p<0.001, OR 0.12, 95% CI=0.45-0.49).

CONCLUSION

Adolescent pregnancy is common in the city of Addis Ababa. Adolescent pregnancy study revealed low birthweight, high Caesarean section rate and foeto-pelvic disproportion as a consequence of incomplete development of the bony pelvis. Improved education and contraceptive services are needed to reduce the incidence of adolescent pregnancy.

Caesarean section deliveries at Tikur Anbessa Teaching Hospital, Ethiopia

This prospective hospital-based study was done at Tikur Anbessa Teaching Hospital (TATH) between July 1991 and July 1992 in order to obtain base-line data on the rates of caesarean section, pregnancy out-come, major indications for caesarean and caesarean section complications. Out of a total of 3237 deliveries conducted during the study period, 318(10%) were caesarean section. The leading or the major indication for abdominal deliveries were: repeat caesarean section, 103(32.4%), cephalo-pelvic disproportion, 93(29.2%), placenta previa and abruptio-placentae 40(12.6%). Age ranged from 15-40 years, 58(18.2%) were women under the age of 20, and 182(57%) were between 20 and 30 years of age which is the safest period to bear children. Eighty one (25%) of the mothers were primiparae, 158(50%) were between para one and para four, 79(25%) were grand multiparae. Seventy six (24%) of the cases were not registered for antenatal care in any health institutions. Two hundred and fifteen (67.6%) of the mothers had primary caesarean section. The chance of repeat caesarean section was statistically significant (P < 0.001). Fifty seven (18%) had elective caesarean section and 261 (82%) were emergency caesarean section. On eight (2.5%) of the patient, obstetric hysterectomy was performed. There were five maternal deaths among the caesarean section cases. The main cause of maternal death was failure to control bleeding during the caesarean section. These were preventable deaths in experienced hands. There were nine (2.8%) stillbirths and 15(4.7%) early neonatal deaths. A foetal wastage of 24(7.5%) was noted in the study. The mean birthweight among booked caesarean section were 3108 grams and unbooked caesarean section were 2991 grams. The major obstetric complications in the cases were antepartum haemorrhage, and 34(11%), pregnancy induced-hypertensive disorder, 32(10%). Sixty one (19%) had blood transfusion. The blood loss was significantly more in operations done by residents compared to consultants even using the most crude measurement as estimated by the operator at the time.

Return of fertility after an IUD removal for planned pregnancy: a six year prospective study

This study was conducted in a series of 810 women who opted to use copper T-200 as a reliable form of contraception. The objective of the study was to determine the return of fertility after the removal of the IUD and to identify IUD related complications in an African setting. The study focused on 810 women who had requested for the removal of their IUDs at the time of planned pregnancy. Out of 810 cases, only 780 cases were analysed. In eight (1%) of the cases, the IUD was removed because of full blown pelvic infection and 22 (2.8%) of the cases lost to follow up. The mean age was 29 years. Twenty five (3.2%) of the cases were nulligravidae, 729 (93.5%) multipara, and 45 (3.3%) grand multipara. Six hundred and fifty (83.3%) were married. All the clients who entered the study could afford to go to private clinic for family planning services. Conception occurred in 160 (20.5%) in the first two cycles, 201 (25.8%) between the third and fifth cycle, 250 (32%) between the sixth and eight cycles and 60 (7.7%) between the ninth and twelfth cycle. The remaining 109 (13.9%) of the cases failed to conceive within one year after the removal of IUCD. They have unprotected sexual intercourse for a period of one year. Finally, the pregnancy out come showed the following results: spontaneous abortion 57 (7.3%), preterm birth 25 (3.2%), term delivery 589 (75.5%) and no pregnancy after the removal of the IUD in 109 (13.9%), respectively.

Intrauterine devices: results of a separate clinical and ultrasound follow-up study

A separate clinical and ultrasound study was carried out in 20 unselected patients receiving an IUD (ML Cu 250 or Cu T-200). Clinical adverse effects were studied in relation to ultrasound findings after 0, 2 and 6 months of insertion. Using both the sound length and initial ultrasound measurements, it was possible to calculate that none of the 20 IUDs reached the fundal wall of the uterine cavity (distance 0.1-2.4 cm). The mean initial distance between the top of the uterine fundal wall and the top of the IUD (TOP) was 2.0 cm (range 1.3-2.4 cm). A downward displacement of more than 0.5 cm in consecutive measurements was observed in 3 patients. Malposition of one or two arms of the IUD was found in 8 patients. In 6 of these patients clinical complaints were present.

Evaluation of 24 patients with IUD-related problems: hysteroscopic findings

The clinical and diagnostic findings in 24 patients with IUD-related abnormal uterine bleeding or missing IUDs have been evaluated with special reference to hysteroscopy. For the IUD-related abnormal uterine bleeding no gross uterine or tissue pathology has been revealed except for chronic inflammatory reaction of the endometrium. In half of the cases the IUD showed embedment, displacement within the uterine cavity or migration into the uterine wall, which may be a possible cause of the IUD-related abnormal uterine bleeding. For the detection and removal of IUDs with missing strings, partially embedded and perforated IUDs or retained broken parts of it, the hysteroscopic procedure appeared to be invaluable and in our opinion should be the method of choice.

In vivo measurements of uterine cavities in 795 women of fertile age

The uterine sound length, the functional length of the cervix including the zone of internal cervical os and the fundus transversal were determined in 795 fertile women in vivo using a measuring device, the Cavimeter. The functional cavity length was calculated by subtracting the functional length of the cervix from the uterine sound length. With growing parity, the uterine length and width increase, but with advance in age, the uterine cavity changes are not so distinct. The wide ranges found by the investigation demonstrate the individuality of the uterine cavity and the desire to measure it prior to fitting an IUD. The use of adapted IUDs according to the size of the uterine cavity leads to a remarkable reduction of side effects, particularly expulsion, bleeding and cramps caused mainly by dimensional incompatibility. Therefore prefit uterine cavity measurement can lead to better efficacy of IUDs, increased rates of acceptance and higher continuation rates.