An evaluation of concordance between head and neck advanced practice radiation therapist and radiation oncologists in toxicity assessment for nasopharyngeal carcinoma patients.

BACKGROUND: Weekly toxicity assessments for patients undergoing head and neck (HN) radiotherapy are essential to ensure that acute side effects are appropriately managed in order for patients to complete their treatment in a safe and timely manner. The incorporation of Advanced Practice Radiation Therapist (APRT) led treatment reviews has been reported for various subsites, but there is currently a lack of published literature regarding this role for patients with HN cancer. The purpose of this study is to assess the concordance of toxicity assessments performed during weekly radiotherapy treatment reviews for patients undergoing HN radiotherapy between the HN APRT and Radiation Oncologist (RO). METHODS: Twenty-three patients with nasopharyngeal cancer (NPC) under the care of 3 ROs were recruited from June to December 2018; weekly assessments were independently performed by HN APRT and ROs. The HN toxicity assessment was graded according to the Common Terminology Criteria for Advanced Events v4.0. Both assessors were blinded to each other's assessments. The percentage agreement of concordance and agreement level were interpreted by Cohen's Kappa statistic (κ), with the ROs' assessments deemed as the 'gold standard'. RESULTS: The overall concordance for all graded toxicity assessments between HN APRT and ROs was 78.4%. Xerostomia, dysgeusia, pharyngeal pain and dermatitis assessment were evaluated as 'Good' with agreement ranging from κ = 0.608-0.640 between the HN APRT and ROs while dysphagia scored an 'Almost Perfect' agreement of κ = 0.834. 'Moderate' agreement between the HN APRT and ROs was observed for oral pain and mucositis assessment. A scoring discrepancy of 1 and 2 grades was observed in 21.2% and 0.4% for these two toxicities. CONCLUSION:  There was high concordance in scoring of acute toxicity between the HN APRT and ROs. The results support the continuing involvement of HN APRT in weekly assessments for NPC patients.

Strategies to improve survival outcomes of out-of-hospital cardiac arrest (OHCA) given a fixed budget: A simulation study.

BACKGROUND: Our study aimed to identify a strategy that maximizes survival upon hospital discharge or 30-days post out-of-hospital cardiac arrest (OHCA) in Singapore for fixed investments of S$1, S$5, or S$10 million. Four strategies were compared: (1) no additional investment; (2) reducing response time via leasing of more ambulances; (3) increasing number of people trained in cardiopulmonary resuscitation (CPR); and (4) automated external defibrillators (AED). METHODS: We estimated the effect of ambulance response time, bystander CPR and AED on survival based on Singapore's 2010-2015 OHCA registry data. We simulated the changes in ambulance response times and likelihood of (1) CPR and (2) AED usage as a function of their increased availability, which was then combined with the effect of each factor to determine the increase in survival for each strategy. RESULTS: Survival given no additional investment was 4.03% (95% CI: 3.96%, 4.10%). The investments in ambulances, CPR training and AEDs for a given budget of S$1M changed survival to 4.03% (95% CI: 3.96%, 4.10%), 4.04% (95% CI: 3.98%, 4.11%), and 4.44% (95% CI: 4.35%, 4.54%), respectively. This generated 0, 2 and 102 additional life years saved respectively. Given a budget of S$5M or S$10M, 509 or 886 additional life years could be saved, by investing in an additional 10,000 or 20,000 AEDs respectively. The strategies reached a saturation effect whereby improvement in survival was marginal when the budget was increased to ≥S$5M for investment in ambulances and CPR training. CONCLUSIONS: Investing in AEDs had the most gain in survival.

An assessment of electronically captured data in the patient care enhancement system (PACES) for syndromic surveillance.

INTRODUCTION: A common approach to the surveillance of emerging infectious diseases and agents of bioterrorism is to analyse electronically captured data for disease syndromes. The Patient Care Enhancement System (PACES) is a form of electronic medical records presently in service in the Singapore Armed Forces (SAF). We assess the feasibility of PACES data for surveillance, describe time-trends, and identify methods of sub-analysis which could improve performance. MATERIALS AND METHODS: Medical consults from July 2000 to June 2003 were extracted. Diagnosis codes were mapped to 7 infectious disease syndromes according to the categorisation in the Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE): gastrointestinal (GI), fever (FEVER), respiratory, (RESP), coma (COMA), neurological (NEURO), dermatologic-haemorrhagic (DERMHEM) and dermatologic- infectious (DERM-INF). RESULTS: A total of 732,233 episodes of care were analysed. Weekly periodicity was observed, with decreased weekend consults; there were no obvious seasonal trends in any of the syndromes. RESP, FEVER and GI syndromes were common events. Sub-analyses, either by restricting to cases with a repeated consultation, or grouping the data by medical centres, could dramatically lower thresholds used to flag outbreaks. CONCLUSION: In spite of the level of background noise inherent in a system consisting mainly of primary care consults, sub-analysis by medical centre, or restriction to cases with repeated consults were able to yield sensitive thresholds for outbreak detection.

Inferior right hepatic veins: MR assessment of prevalence and potential clinical significance in children.

The prevalence of Inferior Right Hepatic Veins (IRHVs) in 82 children who had magnetic resonance imaging (MRI) of the abdomen was assessed. IRHVs larger than or equal in size to the Superior Right Hepatic Vein were found in 23% (19/82). In two patients with radiological evidence of Superior Hepatic Venous occlusion and without radiological evidence of portal hypertension, venous drainage was accomplished via large IRHVs. The findings suggest that, in children, IRHVs may act as efficient collaterals and help protect the liver from the consequences of high IVC obstruction.