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Background: Immune response to COVID-19 vaccine is diminished in patients with hematologic malignancy. There is limited data regarding response to vaccine doses in these patients., Purpose: To quantify the humoral immune response engendered by 4th and subsequent doses of SARS-CoV-2 vaccination as measured by anti-Spike (anti-S) antibody levels, based on dried blood spot (DBS) testing, in patients with hematologic malignancies. Anti-S binds to the spike protein of the SARS-CoV-2 virus and is indicative of vaccine immunogenicity., Methods: We conducted a prospective study of hematologic malignancies between August 2021 and January 2023 at 12 sites across Canada. Participants were followed longitudinally and submitted finger-prick DBS cards at set intervals associated with vaccination. Samples were processed via high throughput ELISA assay to detect serum antibodies against nucleocapsid (N) and spike (S) proteins., Results: We obtained 3071 samples on 790 unique patients. Of these, 372 unique participants with 1840 samples had anti-S results available post-4th, 5th or 6th COVID-19 vaccine dose and were included for analysis. Three hundred thirty-three patients of the 372 participants submitted a DBS sample post 4th dose. Of these, 257 patients (77.2%) had a positive anti-S antibody. A total of 198 patients had paired samples pre- and post-dose 4, of which 59 (29.7%) had a negative anti-S antibody pre-dose 4. Of these, 20 (33.4%) developed positive anti-S antibody post-dose 4. One hundred forty-nine patients submitted a DBS sample post-dose 5. Of these, 135 patients (90.6%) had positive anti-S antibody. A total of 52 had paired samples pre- and post-dose 5. Six (8.7%) had a negative anti-S antibody pre-dose 5, of which two (33.3%) developed positive anti-S antibody post-dose 5. Of these 372 patients, 123 (34%) reported COVID-19 infection and 4 (1%) had a COVID-19 related hospitalization. There were no reported deaths from COVID-19., Conclusions: This prospective cohort study showed that humoral immune response improved with subsequent doses of COVID-19 vaccines., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: [C. Arianne Buchan reports financial support was provided by Public Health Agency of Canada - Canadian Immunization Task Force. Sita Bhella reports a relationship with Gilead Sciences Inc that includes: consulting or advisory and travel reimbursement. Annette E. Hay reports a relationship with Roche that includes: funding grants. Annette E. Hay reports a relationship with AbbVie Inc that includes: funding grants. Annette E. Hay reports a relationship with Seattle Genetics that includes: funding grants. Annette E. Hay reports a relationship with Merck that includes: funding grants. Annette E. Hay reports a relationship with Janssen that includes: funding grants. Annette E. Hay reports a relationship with Incyte that includes: funding grants. Annette E. Hay reports a relationship with Karyopharm that includes: funding grants. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper]., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Primary central nervous system lymphoma (PCNSL) is a rare extranodal lymphoma localized to the central nervous system. Small single-center studies have suggested that patients with PCNSL may be at high risk of venous thromboembolism (VTE). This systematic review aimed to estimate the risk of VTE in patients with PCNSL. A systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. MEDLINE, Embase, and CINAHL were searched from 1990 to 2022. Prospective and retrospective observational studies as well as clinical trials were included. The primary efficacy outcome was VTE, and the primary safety outcome was major bleeding as defined by the individual studies. After screening 883 studies, 46 studies (3688 patients) with PCNSL were included. Mean age was 62.4 years. Five studies explored the use of thromboprophylaxis (acetyl salicylic acid or anticoagulation [ n  = 1]) and low-molecular-weight heparin ( n  = 4). Overall, 420 patients developed VTE (11.4%), including 17 fatal events (4% of all VTE). Two studies that reported on VTE prophylaxis representing 77 patients identified 8 breakthrough VTE events (10.4%). Most studies ( n  = 34; 74.5%) did not report major bleeding complications. Among studies reporting on bleeding, 174 major bleeding (7.4%) events were reported out of 2361 patients, 3 of which were attributed to thromboprophylaxis. Patients with PCNSL seem to be at high risk of both VTE and bleeding complications. Future clinical trials in this population should routinely collect data on incidence of VTE and bleeding to help clinicians assess the risk-to-benefit ratio of thromboprophylaxis in this high-risk patient population., (© 2024 The Authors.)

Background: Critically ill patients receive frequent routine and recurring blood tests, some of which are unnecessary., Aim: To reduce unnecessary routine phlebotomy in a 30-bed tertiary medical-surgical intensive care unit (ICU) in Toronto, Ontario., Methods: This prospective quality improvement study included a 7-month preintervention baseline, 5-month intervention and 11-month postintervention period. Change strategies included education, ICU rounds checklists, electronic order set modifications, an electronic test add-on tool and audit and feedback. The primary outcome was mean volume of blood collected per patient-day. Secondary outcomes included the number blood tubes used and red cell transfusions. Balancing measures included the timing and types of blood tests, ICU length of stay and mortality. Outcomes were evaluated using process control charts and segmented regression., Results: Patient demographics did not differ between time periods; total number of patients: 2096, median age: 61 years, 60% male. Mean phlebotomy volume±SD decreased from 41.1±4.0 to 34.1±4.7 mL/patient-day. Special cause variation was met at 13 weeks. Segmental regression demonstrated an immediate postintervention decrease of 6.6 mL/patient-day (95% CI 1.8 to 11.4 p=0.009), which was sustained. Blood tube consumption decreased by 1.4 tubes/patient-day (95% CI 0.4 to 2.4, p=0.005) amounting to 13 276 tubes (95% CI 4602 to 22 127 tubes) saved over 11 months. Red blood cell transfusions decreased from 10.5±5.2 to 8.3±4.4 transfusions/100 patient-days (incident rate ratio 0.56, 95% CI 0.35 to 0.88, p=0.01). There was no impact on length of stay (2 days, IQR 1-5) and mortality (18.1%±2.0%)., Conclusion: Iterative improvement interventions targeting clinician test ordering behaviour can reduce ICU phlebotomy and may impact red cell transfusions. Frequent stakeholder consultation, incorporating stewardship into daily workflow, and audit and feedback are effective strategies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

COVID-19 and our armamentarium of strategies to combat it have evolved dramatically since the virus first emerged in late 2019. Vaccination remains the primary strategy to prevent severe illness, although the protective effect can vary in patients with hematologic malignancy. Strategies such as additional vaccine doses and now bivalent boosters can contribute to increased immune response, especially in the face of evolving viral variants. Because of these new variants, no approved monoclonal antibodies are available for pre-exposure or postexposure prophylaxis. Patients with symptomatic, mild-to-moderate COVID-19 and risk features for developing severe COVID-19, who present within 5-7 days of symptom onset, should be offered outpatient therapy with nirmatrelvir/ritonavir (NR) or in some cases with intravenous (IV) remdesivir. NR interacts with many blood cancer treatments, and reviewing drug interactions is essential. Patients with severe COVID-19 should be managed with IV remdesivir, tocilizumab (or an alternate interleukin-6 receptor blocker), or baricitinib, as indicated based on the severity of illness. Dexamethasone can be considered on an individual basis, weighing oxygen requirements and patients' underlying disease and their perceived ability to clear infection. Finally, as CD19-targeted and B-cell maturation (BCMA)-targeted chimeric antigen receptor (CAR) T-cell therapies become more heavily used for relapsed/refractory hematologic malignancies, viral infections including COVID-19 are increasingly recognized as common complications, but data on risk factors and prophylaxis in this patient population are scarce. We summarize the available evidence regarding viral infections after CAR T-cell therapy.

Importance: Patients with cancer are known to have increased risk of COVID-19 complications, including death., Objective: To determine the association of COVID-19 vaccination with breakthrough infections and complications in patients with cancer compared to noncancer controls., Design, Setting, and Participants: Retrospective population-based cohort study using linked administrative databases in Ontario, Canada, in residents 18 years and older who received COVID-19 vaccination. Three matched groups were identified (based on age, sex, type of vaccine, date of vaccine): 1:4 match for patients with hematologic and solid cancer to noncancer controls (hematologic and solid cancers separately analyzed), 1:1 match between patients with hematologic and patients with solid cancer., Exposures: Cancer diagnosis., Main Outcomes and Measures: Outcomes occurring 14 days after receipt of second COVID-19 vaccination dose: primary outcome was SARS-CoV-2 breakthrough infection; secondary outcomes were emergency department visit, hospitalization, and death within 4 weeks of SARS-CoV-2 infection (end of follow-up March 31, 2022). Multivariable cumulative incidence function models were used to obtain adjusted hazard ratio (aHR) and 95% CIs., Results: A total of 289 400 vaccinated patients with cancer (39 880 hematologic; 249 520 solid) with 1 157 600 matched noncancer controls were identified; the cohort was 65.4% female, and mean (SD) age was 66 (14.0) years. SARS-CoV-2 breakthrough infection was higher in patients with hematologic cancer (aHR, 1.33; 95% CI, 1.20-1.46; P < .001) but not in patients with solid cancer (aHR, 1.00; 95% CI, 0.96-1.05; P = .87). COVID-19 severe outcomes (composite of hospitalization and death) were significantly higher in patients with cancer compared to patients without cancer (aHR, 1.52; 95% CI, 1.42-1.63; P < .001). Risk of severe outcomes was higher among patients with hematologic cancer (aHR, 2.51; 95% CI, 2.21-2.85; P < .001) than patients with solid cancer (aHR, 1.43; 95% CI, 1.24-1.64; P < .001). Patients receiving active treatment had a further heightened risk for COVID-19 severe outcomes, particularly those who received anti-CD20 therapy. Third vaccination dose was associated with lower infection and COVID-19 complications, except for patients receiving anti-CD20 therapy., Conclusions and Relevance: In this large population-based cohort study, patients with cancer had greater risk of SARS-CoV-2 infection and worse outcomes than patients without cancer, and the risk was highest for patients with hematologic cancer and any patients with cancer receiving active treatment. Triple vaccination was associated with lower risk of poor outcomes.

Background: In many jurisdictions, cancer patients were prioritized for COVID-19 vaccination because of increased risk of infection and death. To understand sociodemographic disparities that affected timely receipt of COVID-19 vaccination among cancer patients, we undertook a population-based study in Ontario, Canada., Methods: Patients older than 18 years and diagnosed with cancer January 2010 to September 2020 were identified using administrative data; vaccination administration was captured between approval (December 2020) up to February 2022. Factors associated with time to vaccination were evaluated using multivariable Cox proportional hazards regression., Results: The cohort consisted of 356 535 patients, the majority of whom had solid tumor cancers (85.9%) and were not on active treatment (74.1%); 86.8% had received at least 2 doses. The rate of vaccination was 25% lower in recent (hazard ratio [HR] = 0.74, 95% confidence interval [CI] = 0.72 to 0.76) and nonrecent immigrants (HR = 0.80, 95% CI = 0.79 to 0.81). A greater proportion of unvaccinated patients were from neighborhoods with a high concentration of new immigrants or self-reported members of racialized groups (26.0% vs 21.3%, standardized difference = 0.111, P < .001), residential instability (27.1% vs 23.0%, standardized difference = 0.094, P < .001), or material deprivation (22.1% vs 16.8%, standardized difference = 0.134, P < .001) and low socioeconomic status (20.9% vs 16.0%, standardized difference = 0.041, P < .001). The rate of vaccination was 20% lower in patients from neighborhoods with the lowest socioeconomic status (HR = 0.82, 95% CI = 0.81 to 0.84) and highest material deprivation (HR = 0.80, 95% CI = 0.78 to 0.81) relative to those in more advantaged neighborhoods., Conclusions: Despite funding of vaccines and prioritization of high-risk populations, marginalized patients were less likely to be vaccinated. Differences are likely due to the interplay between systemic barriers to access and cultural or social influences affecting uptake., (© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Transitioning nonemergency, ambulatory medical care to virtual visits in light of the COVID-19 global pandemic has been a massive shift in philosophy and practice that naturally came with a steep learning curve for patients, physicians, and clinic administrators., Objective: We undertook a multimethod study to understand the key factors associated with successful and less successful experiences of virtual specialist care, particularly as they relate to the patient experience of care., Methods: This study was designed as a multimethod patient experience study using survey methods, descriptive qualitative interview methodology, and administrative virtual care data collected by the hospital decision support team. Six specialty departments participated in the study (endoscopy, orthopedics, neurology, hematology, rheumatology, and gastroenterology). All patients who could speak and read English and attended a virtual specialist appointment in a participating clinic at St. Michael's Hospital (Toronto, Ontario, Canada) between October 1, 2020, and January 30, 2021, were eligible to participate., Results: During the study period, 51,702 virtual specialist visits were conducted in the departments that participated in the study. Of those, 96% were conducted by telephone and 4% by video. In both the survey and interview data, there was an overall consensus that virtual care is a satisfying alternative to in-person care, with benefits such as reduced travel, cost, time, and SARS-CoV-2 exposure, and increased convenience. Our analysis further revealed that the specific reason for the visit and the nature and status of the medical condition are important considerations in terms of guidance on where virtual care is most effective. Technology issues were not reported as a major challenge in our data, given that the majority of "virtual" visits reported by our participants were conducted by telephone, which is an important distinction. Despite the positive value of virtual care discussed by the majority of interview participants, 50% of the survey respondents still indicated they would prefer to see their physician in person., Conclusions: Patient experience data collected in this study indicate a high level of satisfaction with virtual specialty care, but also signal that there are nuances to be considered to ensure it is an appropriate and sustainable part of the standard of care., (©Katie N Dainty, M Bianca Seaton, Antonio Estacio, Lisa K Hicks, Trevor Jamieson, Sarah Ward, Catherine H Yu, Jeffrey D Mosko, Charles D Kassardjian. Originally published in JMIR Medical Informatics (https://medinform.jmir.org), 28.06.2022.)

Choosing Wisely is a medical stewardship and quality-improvement initiative led by the American Board of Internal Medicine Foundation in collaboration with leading medical societies in the United States. The American Society of Hematology (ASH) has been an active participant in the Choosing Wisely project. In 2019, ASH and the American Society of Pediatric Hematology/Oncology (ASPHO) formed a joint task force to solicit, evaluate, and select items for a pediatric-focused Choosing Wisely list. By using an iterative process and an evidence-based method, the ASH-ASPHO Task Force identified 5 hematologic tests and treatments that health care providers and patients should question because they are not supported by evidence, and/or they involve risks of medical and financial costs with low likelihood of benefit. The ASH-ASPHO Choosing Wisely recommendations are as follows: (1) avoid routine preoperative hemostatic testing in an otherwise healthy child with no previous personal or family history of bleeding, (2) avoid platelet transfusion in asymptomatic children with a platelet count >10 × 103/μL unless an invasive procedure is planned, (3) avoid thrombophilia testing in children with venous access-associated thrombosis and no positive family history, (4) avoid packed red blood cells transfusion for asymptomatic children with iron deficiency anemia and no active bleeding, and (5) avoid routine administration of granulocyte colony-stimulating factor for prophylaxis of children with asymptomatic autoimmune neutropenia and no history of recurrent or severe infections. We recommend that health care providers carefully consider the anticipated risks and benefits of these identified tests and treatments before performing them., (© 2022 by The American Society of Hematology. Licensed under Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0), permitting only noncommercial, nonderivative use with attribution. All other rights reserved.)