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Acquired hemophilia A (AHA) is a clotting disorder characterized by the presence of neutralizing antibodies that inhibit factor VIII, resulting in increased bleeding risk. Known etiologies include malignancy, autoimmune conditions, graft-vs-host disease, and more recently coronavirus disease 2019 (COVID-19) infection. In this case report, we describe an 86-year-old female who was found to have AHA incidentally during preoperative workup for meningioma resection. She was subsequently found to have COVID-19 infection which was the likely cause of her development of AHA. She was treated with factor eight inhibitor bypassing agent (FEIBA) and recombinant factor VII (rVII) for a small hematoma on her right arm along with prednisone and cyclophosphamide. She then developed disseminated intravascular coagulation (DIC) initially secondary to FEIBA and subsequently rFVII. DIC resolved after these factor concentrates were withheld. The aim of this case report was to emphasize the importance of monitoring partial thromboplastin time (PTT) in patients with COVID-19 and proceeding with AHA workup if indicated. It is also imperative to know and understand the potentially life-threatening, albeit rare, adverse effects of DIC associated with the administration of factor concentrates, especially in the elderly population and withholding these factor concentrates once DIC is suspected.

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Thrombotic Thrombocytopenic Purpura (TTP) is a challenging thrombotic diathesis which requires prompt diagnosis and therapeutic intervention in order to avoid life-threatening consequences. There are two forms of TTP, congenital and acquired, with the acquired form constituting about 90% of cases. Both forms are associated with a deficiency of ADAMTS-13, a metalloproteinase enzyme responsible for cleaving ultra-large von Willebrand factor (uLvWF), preventing its pathologic accumulation. Within the last year, many of the diverse and serious effects of the COVID-19 virus have come to recognition, with some of the most dire consequences involving devastating vascular and hematologic complications. As with many viruses, it seems that the endothelium and the vasculature are often prime targets. Here, we report a case of a 30 year old male who was diagnosed with TTP approximately one week after a positive COVID-19 test result. He responded appropriately to plasma exchange (PLEX), caplacizumab, and steroids. We believe it is important to investigate a potential link between these two conditions, as TTP has significant morbidity and mortality risk if left unattended. We hope that our report will contribute to a better understanding of this potential link.

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OBJECTIVE: To determine whether guideline non-adherence is associated with Black race. METHODS: A retrospective review of National Cancer Database records of women diagnosed with epithelial ovarian cancer from 2012 to 2016 who identified as "White" or "Black" was performed. Exposure was adherence or non-adherence to National Comprehensive Cancer Network guidelines for treatment. Outcomes were differences in disease characteristics and overall survival in months. RESULTS: Of the 29,948 eligible patients, 93% (n = 27,744) were White and 7% (n = 2204) were Black. Having stage IV disease (OR 1.45, 95% CI 1.23-1.70; P < 0.001) and treatment in a comprehensive (OR 1.58, 95% CI 1.16-2.15; P = 0.0039) or academic (OR 2.30, 95% CI 1.70-3.12; P < 0.001) treatment facility were associated with Black race. Adherence to guidelines did not predict Black race (OR for adherence 1.0021, 95% CI 0.89-1.13; P = 0.97). Median survival for White patients with adherent care was 63.4 months and 51.4 months for Black patients (P = 0.0001). Median survival for White patients with non-adherent care was 60.5 months and 47.2 months for Black patients (P < 0.0001). Median overall survival was 61.1 months in White patients and 49.3 months in Black patients (P < 0.0001). CONCLUSIONS: Our data suggest that while Black patients and patients who receive non-NCCN guideline directed care have worse survival outcomes, guideline adherence is not independently associated with Black race. We must consider other socioeconomic, environmental and system factors that are contributing to the survival discrepancy in Black patients with ovarian cancer.

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INTRODUCTION: Acute purulent pericarditis is an exceedingly rare entity most often caused by direct intrathoracic contamination or hematogenous spread of a bacterial infection. Mortality nears 100% when left untreated. We present here a rare case of idiopathic bacterial pericarditis caused by methicillin-sensitive Staphylococcus aureus (MSSA). CASE: A 69-year-old male presented with chest pain and abdominal pain. He was found to have a pericardial effusion and tamponade and underwent emergent pericardiocentesis. Pericardial fluid culture grew methicillin-sensitive Staphylococcus aureus. The patient required multiple pericardial washouts and was then treated with four weeks of intravenous antibiotics. CONCLUSION: While uncommon, clinical suspicion for purulent pericarditis should remain high due to the associated high mortality.

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BACKGROUND/AIM: Cutaneous manifestations of disease are exceedingly rare and commonly overlooked in clinical practice. Allergies or contact dermatitis, autoimmune disease or skin cancer are the most common conditions typically associated with skin lesions. Rarely, cutaneous lesions may be the first sign of internal malignancy, or even resemble recurrent disease in those with history of cancer. CASE REPORT: Herein, we report a case of an otherwise healthy male who presented to his primary care provider (PCP) with a skin lesion misdiagnosed as a furuncle, which eventually led to diagnosis of metastatic esophageal cancer. The patient was a 64-year-old male, presenting with a fungating lesion on the tip of his nose which was biopsied, confirming adenocarcinoma likely from a gastrointestinal source. Staging imaging showed extensive lung, liver, and boney metastatic disease. He was initially treated with chemotherapy and trastuzumab. CONCLUSION: Cutaneous lesions are a rare presenting sign of malignancy, but rapidly growing lesions should be evaluated for possible metastatic disease.

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Dual antiplatelet therapy (DAPT), defined as administration of a P2Y12 receptor inhibitor (clopidogrel, prasugrel, or ticagrelor) and aspirin, is recommended after percutaneous coronary intervention. We describe a case of a 50-year-old gentleman with intolerance to the three previously mentioned P2Y12 inhibitors following the placement of a drug-eluting stent to the left anterior descending artery. To our knowledge, based on a thorough review of the literature, this is the second case reporting a similar medical dilemma. We have discussed the multidisciplinary approach implemented to overcome this clinical challenge, which involved the use of clopidogrel with simultaneous administration of a six-day course of oral steroids.

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Sickle cell anemia patients often present to the hospital with acute vaso-occlusive pain crisis. Symptoms can include, but are not limited to, chest pain, abdominal pain, and musculoskeletal pain. These symptoms are brought about due to the pathology of the disease. Abnormal hemoglobin S causes red blood cells to band together, otherwise known as "sickling." These patients also often present with very low hemoglobin levels on initial evaluation. In most cases, packed red blood cell transfusions are needed in order to replenish these patient's functional hemoglobin supply. Unfortunately, transfusing sickle cell patients can lead to an unwanted consequence, that of hyperhemolysis syndrome, in which blood transfusions prompt further hemolysis of the already sickled red blood cells. When this complication arises, caution must be exercised in deciding the next steps of treatment.

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BACKGROUND: The standard of care for non-metastatic squamous cell carcinoma of the anal canal (SCCA) is concurrent chemoradiotherapy. It is postulated that chemotherapy could be omitted for the earliest stages without worsening outcomes. METHODS: We queried the NCDB from 2004-2016 for patients with cT1N0M0 SCCA treated non-operatively with radiation, with and without chemotherapy, and at least two months of follow-up. Of the 2,959 patients meeting eligibility, 92% received chemotherapy (n = 2722) and 8% (n = 237) did not. Most patients were white (n = 2676), female (n = 2019), had private insurance (n = 1507) and were treated in a comprehensive cancer center (n = 1389). Average age was 58.5 years. RESULTS: Predictors of chemotherapy omission were age > 58 years (OR 0.66, 95% CI [0.49-0.90], P = 0.0087), higher comorbidity score (OR 0.62, 95% CI [0.38-0.99], P = 0.0442), African American race (OR 0.57, 95% CI [0.36-0.90], P = 0.0156) and treatment at the start of the study period (OR 1 for years 2004-2006). HR for single-agent chemotherapy was 0.70 (95% CI [0.50-0.96], P = 0.0288) and 0.48 for multi-agent (95% CI [0.38-0.62], P <0.0001). Overall survival was 86% in those that received chemotherapy vs 65% in those who did not (P <0.0001). CONCLUSIONS: In conclusion, patients with early-stage squamous cell cancer of the anus who are treated with combination chemoradiation continue to demonstrate better overall survival than those who undergo radiotherapy alone.

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Background The American Society of Clinical Oncology recommends that patients with advanced cancer receive palliative care services in concurrence with active treatment. While the benefits of palliative care are clear, integration of palliative care can be challenging. We aim to review rates of palliative care consultation in patients with advanced pancreatic cancer at our institution, intending to improve these rates. Methods We retrospectively reviewed the electronic records of all patients with pancreatic cancer treated at Allegheny General Hospital diagnosed between 2009-2020. Summary statistics are presented as percentages for categorical data and median with interquartile range for quantitative data. Results Of the 171 patients reviewed, 121 completed all treatment and evaluation within our health network (Pittsburgh, United States). The median age was 63 years (IQR 40-91 years); 55 patients (45%) were male; the majority were white (107 patients, 88%). At the time of diagnosis, 28% of our patients had stage IV disease (34 patients), and 19.8% of patients who developed stage IV disease had palliative care referrals. Conclusions Palliative care is an integral part of usual care for advanced pancreatic cancer. Our analysis showed that palliative care is underutilized in our hospital. We aim to improve palliative care integration in our patients' care by adding a hard stop to electronic medical records to remind physicians to offer palliative care to our patients with pancreatic cancer and to arrange lecture series to emphasize the importance of palliative care in this setting.

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BACKGROUND/AIM: Our study evaluated the survival of women with early-stage ovarian cancer treated with neoadjuvant chemotherapy (NAC) vs. primary debulking surgery (PDS). PATIENTS AND METHODS: We used the 2004-2015 National Cancer Database to identify women with early ovarian cancer treated with multiagent chemotherapy or surgery. Logistic regression was used to identify predictors of NAC. Overall survival estimates were compared using Kaplan-Meier analysis and Cox proportional hazards regression models were used to examine variables. RESULTS: In total, 14,627 women were included. The majority (96%) underwent PDS while (4%) underwent NAC. Median survival time was 40 months (95%CI=37.190-47.280, p<0.0001) in the NAC group and 91 months (95%CI=84.4-110.290, p<0.0001) in the PDS group. Five-year overall survival was 36% for the NAC cohort and 65% for the PDS cohort. CONCLUSION: Women treated with neoadjuvant chemotherapy (NAC) had worse overall and 5-year survival. This finding agrees with the accepted convention of reserving NAC for women with advanced, unresectable disease.

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