(Guest Lecture): Lessons Learned in New York | MCRT Webcast: Experts Discuss COVID-19 and Myeloma

[Music] so dr jagannath i'd like to just start with um the first question that's on everybody's mind and we'll just go ahead and get right at it what has your experience been with myeloma patients who become infected with covid19 first of all i wanted to thank jenny and you greg for your kind introduction and also having me on your myeloma crowd roundtable and i know this is a very popular forum where a lot of patients listen to um when i was speaking to a patient in florida she told me oh one of your doctors had spoken to us and i listened on the myeloma crowd and this was josh richter so i had to place it with them so i don't say something totally different from him [Laughter] thank you very much for having me now in order to get to have you manage the patient you know let me throw a couple of sentence but i need to bring the way it impacted me especially at mount sinai so first of all i want to say the myeloma patients have done remarkably well on this kovid epidemic they did not have a higher incidence of covet and their ability to get over it was no no worse than any other patient so that is important to know and the future is dramatically improving especially as i will tell you some of the myeloma medications may be quite effective also against covet virus so we'll get to that but how did i feel it you know for me this was indeed a pandemic which suddenly exploded on us in new york state so i looked at some of the statistics you know just for this meeting i looked them up on thursday and friday globally it is increasing but 2.2 million cases okay and 147 that's this is as of thursday so 2.2 million world over okay and if you look at that in new york city you know uh this is much higher as a city if you look at the you know confirmed cases of new york state we are about 223 691 confirmed cases and out of that if i go to just new york city there are about 123 000 cases so you can see more than half of the cases in the entire state of new york was almost in new york city and if you include the greater metropolitan area we see the bulk of it so that is one thing but the next thing is i looked at the mount sinai statistics you know march 12 march 13 we had a handful of patient you know say about 20 patients or so by the time you know march 22nd came we had 500 cases by the time march 26 came we had 1 000 cases within four days we went from 500 to 1000 and within another four five days by march 31 we surprised 1500 cases in mount sinai hospital system and by you know april 5 april 6 we reached about 2 000 patients in the mount sinai health system so this is as you know monster and i took the bulk of it because number one it is it has hospitals in each of the borough in brooklyn in queens and in manhattan multiple hospitals there number two it is a teaching hospital it is a tertiary care hospital you know so we had really ramped up number of patients coming in so once your hospital gets that kind of volume of patient and almost half of them would recover require intensive care non-re-either oxygen or ventilatory support that requires all hands on deck which means we had to make very quickly in the early days as it was coming up in march in the first week itself we had to make decision how are we going to manage you know cancer patients in the tish cancer institute so we had managed patients uh you know very quickly in a different way by reducing the number of patients who have to come into the center to get infusions have the ability to isolate them socially so to speak at least six week difference not allowing the family members to go there have ability to test and have the results back this is almost getting your cbc before you give the chemotherapy you want to know and check the temperature get their history whether anybody had traveled or anybody else in the household is sick so this was a dramatic impact on and a learning uh curve and a tremendous modification in myeloma service you know we are about seven physicians even today today you know if i say you know two of the physicians are actually in the medicine ward on covet rotation each medicine ward covert rotation there are about 20 of them you know there is a physician and a fellow and a resident taking care of these patients up to 15 to 20 patients under each physician's care you know so you could imagine that then the you know anaesthetist many of them were already called in to intubate patient etc so there was a surge of patient volume and all hands on deck the nurses and physician had to be redeployed you know so we had to cancel all elective procedure elective surgery and elective investigations you know staff were you know some of the staff were getting uh sick you know and it hits us very close to home you know just to digress because we are talking about statistics but it is about people so one of my nurses in the clinic you know who acts as a coordinator for uh transplant you know she picked up she developed coronavirus but her parents picked up the coronavirus both of them ended up on ventilator and both of them passed away so you know it is very close to us you know so it is not just statistic or it's not remote we are in the thick of it and that makes a big uh difference to us okay and later on because the hospital was overwhelmed part of the infusion center which is a beautiful center with single private room kind of an approach we actually had to convert some of the infusion portion of the infusion center to manage uh cancer patients so they could be managed you know safely uh and have provided 24-hour like a hospital bed unit because they are all covered tested negative and that's why they came for the treatment there so you know for us this is a completely uh a tsunami hitting us the experience which would be different you know like you would hear from my uh colleagues from new mexico uh or from minnesota from mayo clinic you know mori goods experience or you know matthew's experience you may find it different so when i say things you've got to room by minus because i'm in the middle of a tsunami of a code which has impacted but the good news is you know after it stayed at the peak of 2000 patient up until april 14 now it is steadily declining you know more and more patients are getting successfully discharged now we have surpassed 2800 800 patients successfully treated and discharged so this is really a a remarkable accomplishment for us that it is going down but at the same time i don't know you had the question or not i i wanted to say how we all work together the government the industry the fda the academia tremendous partnership you know the fda has set up set up a separate portal for clinical trials for covid19 so a lot of covid19 clinical trials are happening at this time the nih and the department of health and human services they sent guidelines how to manage patients who are on clinical trial you know because some patient cannot travel now they are in social isolation the labs cannot be done right away some patients fly in to get some of the clinical trial options how they would be considered as deviation whether they can continue so the nih and department of health and human services immediately sent out guidelines you know study visits can be conducted by phone or a video conferencing so that is okay you can take the ae con med everything over the phone you know then study visit could be delayed or missed if necessary because of travel restriction and still they can get the study medication mail to them if they need to laboratory testing or imaging can be done locally doesn't have to be done at the investigational institution and the treatment delays so you could see that a lot of people had to work together you know very hand in glove to really make this a successful way to get over this hum and in mount sinai also i got it to say we had to set up a rapid review and approval of kovit 19 research because you can see there is a surge of patient there is a death of you know lack of knowledge in this field and we want to make progress so you know this is a tertiary care medical institution with a virology department with a basic immunology genomics you know pathology all of them were called together the id and they set up a separate method process for reviewing the clinical trials quickly and approve them so there are anti-viral drugs like render severe you know randomized trial but then now expanded access so the patient can get anti-viral drug you know then when the patient has pneumonia and crs they are very sick there is anti-il-6 receptor antibody torsilizumab as well as clinical trial drugs from regeneron then there are btk inhibitors drugs which are approved for walden strom and cll all these drugs are made available in clinical trial because they will reduce the cytokine storm and make the patient come out successfully without losing the battle to the cancer there is an anti-gmcsf antibody trial you know that we are accruing patient that i know personally that when we had put the patient on the cytokines thomas come down the crp the ferritin the fever you know oxygen requirement they've all come down in the patient then in mount sinai they set up a very active convolution plasma those patients healthy patients who recovered from the core with infection you know they have developed an antibody so you check their serum for antibody titer and then if they would volunteer to give their plasma otherwise they are healthy using all the blood brand criteria and screening for all the viruses that convulsion plasma is made available for patients who are getting sick and see whether we can help them out you know then there is actually a stem cell transplant for patients who have been on respirator for a while and on peep and we think there is lung damage to help lung heal you know so you could see everybody is very very busy the entire institution resources from basic science from biology pathology people who are doing phd and lab research everybody's resource has been brought to bear in bringing the outcome better or to understand the disease better and you know we also wanted to know how long the covet becomes stays positive for instance an immuno compromised patient or a myeloma patient how long they will continue to shed when can we go back and give them chemotherapy back if they have had covet you know so all of this we are doing not only viral retesting we are doing immediately serology to find out whether they have antibody whether they have been exposed they have not been exposed and things like that so this is very very important and one of the pitch i wanted to say we all know about antiviral drug remedies aware but there is a myeloma drug cell in xor you know which was approved accelerated approval for relapse refractive myeloma and it had successfully done the phase three trial and it will be in the asco they will present the data now on the first relapse patient that is a drug which blocks the communication from the nucleus to the cytoplasm you know so the then what happens the rna virus like if they have to multiply they need some of the help from the nucleus to the cytoplasm communication and by blocking it the virus is not able to replicate so you may have a successful drug a myeloma drug which is approved for myeloma patient available and i think this company has made it available on expanded access program called keap you know career farm early access program you may want to follow up on that with that company but they have a randomized clinical trial trying to prove this drug is effective so you could see the myeloma patients who are listening they should feel comfortable that a lot of research is going on we may even we even have some antiviral drug and if they were diagnosed by the time they already were short of breath and they are developing pneumonia getting well we are able to bring the cytokine stomp down and make them feel better you know so that is very important message patient people should receive you know america you know our research capability our academic medicine they are par excellence in the world and this is really put to use and we all collaborate you know the academic centers the fda the pharma industry the uh you know nih we all work in sync and that is something you may not get easily in the news but i want you to tell that is how we are really making a big difference we might have suffered quite a bit in new york but i think as it unfolds elsewhere i think we are much better prepared and the outcome will be far far better so that's something i want to convey then i can go how i manage my individual patients if you want yes please oh yes you know this is something also important you know most of my patients have my cell phone anyway but if not when they call our you know on-call center we are notified i immediately reach out to the patient you know first and foremost is to you know screen them over the phone whether they have the uh covet symptoms or not you know typical fever dry cough shortness of breath fluidic chest pain maybe some sore throat you know they also said this is very unique loss of sense of smell and taste you know which is not something we talk about too much but that one and occasionally diary about five to ten percent of the patient can also have diarrhea as their manifestation so you screen them over the phone and then if you suspect they have then direct them to the closest place you know to get the covet testing done it is made widely available in new york you know a kind of city md so-called dock in the box type of thing so many places you can go and get it done quickly so you get it done quickly and then you come back positive and they let me know i tell them two things make sure you have a thermometer or buy a thermometer and buy a pulse oximetry for twenty dollars from i don't know duane ready or any pharmacy and these patients then they check and they text me twice a day their pulse socks and their temperature why this is important because i want you to understand what is happening in in a pandemic stricken city like new york city when you go in with a covalent you know you are admitted to the hospital you are immediately isolated you are isolated from your family members there is nobody coming and visiting you you are in the hospital you are isolated that's something you got to keep in mind and then on top of it if you need oxygen non-reed breathing etc you are not able to text and communicate necessarily with your family so you become non-communicado for the family and the family is worrying so much you know then you know healthcare people are so busy so they give you periodic update twice or three times a day at the moment so the family is fretting the poor patient is in that so also you go to the emergency room unless you meet a certain criteria that the pulse ox is less than 92 you're short of breath some other thing they don't necessarily admit you they will send you home and so what i do is i tell them buy the pulse ox machine do the temperature you don't have to go to the emergency room we will decide this is what we want whether your pulse ox goes below 92 or not and you know keep well hydrated at home your spouse is giving you excellent care and this is important when you know kobet comes into the house hold it is very funny there could be you know many of us have a family there will be two kids and a father a mother you know it doesn't affect just everybody doesn't get sick they'll be one person may get sick the others may be healthy so i had a 78 year old myeloma patient you know he actually it was so funny he actually felt very faint and his heart was beating fast he didn't even have a fever he called this physician he told you go to the mountain emergency room send him there you know so wife everybody was in that household so the ambulance came to get him to the emergency room and he got admitted so immediately the wife calls me he's admitted so because then i can look at this chart because it's electronic epic and keep the wife informed how things are going because then he needed non-representative oxygen for a while then afterwards he got better and then when he got better the discharge son came oh how do we send him home or what do we do i said send him home because his wife is not tested but she is already covered positive i know because she is the one who was with him when she called all the emergency and this virus you know spreads so easily and you know it is highly uh contagious disease so my feeling was the wife is already exposed so we don't have all the testing necessary to test them to make sure yes they have antibody or not and of course he went home and the wife and the patient felt so happy that i was there to hold their hand let him come home you know that isolation was there then she was concerned about her you know at that time you know the son-in-law and her daughter and the children were also upstairs in the same building i told them it doesn't matter you know so the husband came home and we have to then bring him back to test whether he has become covered negative so one of my patients who was discharged home you know then she needed treatment she was a relatively newly diagnosed myeloma as usual with a lot of lesions in her bone she had impending pathologic fracture it was so funny she got her treatment she had a dramatic response but she needed you know the nailing of her left hip and nailing off her left upper arm so unfortunately it was about march 8 you know just when the covet surge was happening for us and she got the nailing done and somehow she her husband at home had covered who used to work so she couldn't go home and so we sent her to a rehab and in the rehab she picked up the kovit and came right back to mount sinai and then finally got better and sent home and in her case when she came back to start a treatment this is two weeks later she was still corona virus positive so we have to see when she gets negative and when to start a treatment she had an excellent response but we have to tailor the therapy according to her becoming covered negative because she's not only a risk for herself we have to see how we give her the chemotherapy in what setting and that's where the oral medications comes to health so myeloma is a unique disease because everybody said we have so many different drugs and each of those drugs gives up so much ability to manage the patient effectively okay so for this particular patient i organized her to get a cell index or one tablet monday wednesday friday i'm gonna test her next week hopefully that antiviral medicine for myeloma medicine would have cleared her then i could start her back on treatment preferably oral regimen at this time so you could see what a big difference it could make keeping the patient letting them tell you the vital signs not necessarily getting them into the hospital then you have to worry about discharges and then there are patients with myeloma they have family members no one lady calls me and tells that her mother-in-law was admitted with the pneumonia and she has to go with positive and she has to come home what do i do about it you know so you have to help her how to isolate that patient in her own home and how to help manage because they have no other option okay so i think we need to come with it but i told her i have a lot of patience with the myeloma who have contracted kobe and they've all gotten better and i have patients in whom you know the spouse has gotten covered and the patient herself is covered free and how do you say that he is a healthy well-built gentleman you know he's actually a truck driver and here's the woman with the myeloma she was getting treatment she was getting ivig because she used to get frequent infection and her husband got it i told her don't worry you probably are exposed look you're standing there and you don't have fever so you don't have to worry you'll be covered positive come back next week and get tested we will find out whether you are not but you don't have to worry you're going to do well so that is why it is important to say that even with myeloma somehow the immunity is there and the science is trying to understand it i know myeloma patients are considered immunocompromised they don't make antibody effectively but for viruses quite often it is the t cell immunity is much more important so some of these reasons why myoma patients are doing well i believe that t cell is able to still support them just like patients with myeloma get over the flu also so i don't want my enema patient panic and i can tell you from the heart of a place which had a pandemic hit us you know like a blizzard where we can't see anywhere so i can tell you a lot of progress is being made a lot of help is coming in your way and i'm happy to answer any questions you have you