Early discharge from maternity ward in response to the COVID-19 pandemic: Impact on emergency attendance.

BACKGROUND: In response to the coronavirus disease 2019 (COVID-19) epidemic, our maternity department had to rapidly implement a protocol for early postpartum discharge. We evaluated the benefits and risks of early postpartum discharge. METHODS: We performed an observational, single-center case-control study over a 3 month-period during the COVID-19 outbreak (from June 1 to August 31, 2020), following implementation of the early discharge policy. Newborns were classified into an early discharge group (within 48-72 h of a vaginal delivery and within 72-96 h of a cesarean delivery) or a standard discharge group (more than 72 h after a vaginal delivery and more than 96 h after a cesarean delivery). The primary outcome measure was inappropriate pediatric emergency department visits within 28 days of delivery. RESULTS: A total of 546 newborns were included. A total of 22 (8.9%) of the 246 newborns in the early discharge group attended the pediatric emergency department vs. 30 (10.0%) of the 300 newborns in the standard discharge group (p = 0.65). Nine visits (40.9%) were considered inappropriate in the early discharge group vs. 13 (43.3%) in the standard discharge group (p = 0.83). Likewise, the intergroup difference in the hospital readmission rate was not statistically significant. DISCUSSION: The implementation of early discharge and early follow-up did not result in a significantly greater need (vs. standard discharge) for inappropriate emergency visit or hospital readmission during the first 28 days postpartum, regardless of the parity and breastfeeding status.

Changes in anticancer treatment plans in patients with solid cancer hospitalized with COVID-19: analysis of the nationwide BSMO-COVID registry providing lessons for the future.

BACKGROUND: Solid cancer is an independent prognostic factor for poor outcome with COVID-19. As guidelines for patient management in that setting depend on retrospective efforts, we here present the first analyses of a nationwide database of patients with cancer hospitalized with COVID-19 in Belgium, with a focus on changes in anticancer treatment plans at the time of SARS-CoV-2 infection. METHODS: Nineteen Belgian hospitals identified all patients with a history of solid cancer hospitalized with COVID-19 between March 2020 and February 2021. Demographic, cancer-specific and COVID-specific data were pseudonymously entered into a central Belgian Society of Medical Oncology (BSMO)-COVID database. The association between survival and primary cancer type was analyzed through multivariate multinomial logistic regression. Group comparisons for categorical variables were carried out through a Chi-square test. RESULTS: A total of 928 patients were registered in the database; most of them were aged ≥70 years (61.0%) and with poor performance scores [57.2% Eastern Cooperative Oncology Group (ECOG) ≥2]. Thirty-day COVID-related mortality was 19.8%. In multivariate analysis, a trend was seen for higher mortality in patients with lung cancer (27.6% versus 20.8%, P = 0.062) and lower mortality for patients with breast cancer (13.0% versus 23.3%, P = 0.052) compared with other tumour types. Non-curative treatment was associated with higher 30-day COVID-related mortality rates compared with curative or no active treatment (25.8% versus 14.3% versus 21.9%, respectively, P < 0.001). In 33% of patients under active treatment, the therapeutic plan was changed due to COVID-19 diagnosis, most frequently involving delays/interruptions in systemic treatments (18.6%). Thirty-day COVID-related mortality was not significantly different between patients with and without treatment modifications (21.4% versus 20.5%). CONCLUSION: Interruption in anticancer treatments at the time of SARS-CoV-2 infection was not associated with a reduction in COVID-related mortality in our cohort of patients with solid cancer, highlighting that treatment continuation should be strived for, especially in the curative setting.

A sustainable outpatient transformation project for metabolic stone assessment: A specialist stone nurse led non-face-to-face (F2F) clinic

Introduction: Recent NHSEI policy and the COVID-19 pandemic are increasing the proportions of consultations occurring non-face-to-face (F2F). Here we describe a nurse-led non-F2F clinic for the metabolic assessment of kidney stone patients. Method: A metabolic assessment may be indicated in patients forming urate stones, CaPO4 stones, or recurrent stones or with clinical features suggesting a metabolic cause. In otherwise uncomplicated clinical scenarios, these patients are reviewed in a non-F2F clinic run by an endo-urological specialist nurse. A stone history is taken by telephone. Blood tests are arranged in primary care. A collapsible 24-hour urine collection container is posted to the patient and returned via the primary care sample collection service. The cases are reviewed at the Metabolic Stone MDT by the nurse, nephrologist and urologist. Results: A total of 145 patients were eligible with six DNAs, leaving 139 patients reviewed through the non-F2F clinic between March 2020 and June 2021. Demographics were 81 males: 58 females, age range 17-83. About 126 of 139 (91%) patients completed the tests, which is a significantly higher rate than completion rates typically reported. Stone analysis was also available in 97 patients (28 CaOx;54 CaPO4;15 urate). Around 102 patients (81%) were discharged with dietary advice, while 24 patients (19%) were referred for consultant review. Two patients had primary hyperparathyroidism. Nineteen patients had hypercalciuria, all requiring consultant review. Conclusion: Nurse-led non-F2F review streamlines the metabolic assessment of stone-formers, reducing the need for hospital attendances and reducing consultant workload.

Assessment of repeatability and uptake quantification of 68GaNOTA-anti-HER2 sdAb PET/CT in patients with locally advanced or metastatic breast cancer

Background: Human epidermal growth factor receptor 2 (HER2) status is an important predictive biomarker in breast cancer (BC). Tumor heterogeneity has been described, with changes in HER2 expression levels between lesions and over the disease course. HER2 expression is assessed on tissue biopsies, at primary diagnosis and in metastatic lesions. A whole-body imaging technique such as PET/CT could help understand expression levels in different lesions. A 68Ga-labeled single domain antibody (sdAb) targeting the HER2 receptor has been developed and proven safe (Keyaerts et al., 2016). Imaging is performed at 90 min post-injection (pi). We report results of a phase II trial to assess the repeatability of the technique in 20 patients and the correlation of tracer uptake with HER2 tissue expression of the lesions present at the time of imaging. Methods: Twenty patients (pts) with a locally advanced or metastatic BC with at least one lesion of minimum 12 mm were included. Pts were injected intravenously with a typical protein mass of 100 μ g and a radioactive dose ranging from 98-168 MBq 68GaNOTA-anti-HER2 sdAb. PET/CT images were Sobtained at 90 min pi. A second tracer injection followed by PET/CT was done with a maximal interval of 8 days. To assess repeatability, up to 5 lesions per pt were selected, with no more than 2 in a single organ. Peak Standard Uptake Values (SUVpeak) of the lesions were measured on both scans and compared with a t-test and Bland-Altman Plots. Images were compared to other available medical or imaging data and interpreted considering the subject's disease course. Serum and plasma samples were collected before injection and between 60 and 365 days pi and stored for future detection of anti-drug antibodies (ADA) and liquid biopsies analysis for the presence of HER2 amplification. Tissue samples were assessed by central labs using mass spectrometry, immunohistochemistry and in fluorescence situ hybridization. Results: Twenty women with BC (6 HER2+, 14 HER2-) with a mean age of 58.6 y (37-81) were included. Three pts were scanned only once (2 due to withdrawal of consent, 1 due to covid pandemic). Repeatability of the technique was visually scored as excellent. For quantification, 50 lesions were compared on both scans in 17 pts without significant differences between the two measurements (p=0.40). The repeatability coefficient (RC) was 38.2%. The mean absolute percentage difference (MAPD) was 13.6%, comparable to repeat values reported for 18F-FDG. In 3 out of 6 HER2-positive (HER2+) patients, lesions showed high uptake, even better visible than using 18F-FDG in 2 of them. In 2 HER2+ subjects with a negative scan, lesions were confirmed to be true negatives: one patient did not relapse from BC but had tuberculosis;the other was confirmed to have a radiopneumonitis after radiotherapy and no relapse. In 1 HER2+ patient, the uptake was unexpectedly low. However, the HER2 status was also not reconfirmed in the metastatic setting for this subject. In 1 HER2-negative patient, the tumor HER2 status was changed from negative to positive based on a subsequent image-guided biopsy performed in this study. High tracer uptake was also seen in many of the patients presenting with HER2-low BC (IHC 1+ or 2+), indicating the potential of the tracer to detect low-level HER2 expression. Additional correlation to centrally performed tissue and blood analysis is ongoing. Conclusion: 68GaNOTA-Anti-HER2 PET/CT shows high uptake in HER2-expressing BC lesions but also in HER2-low lesions. The technique shows good repeatability and, in some cases, even better sensitivity than 18F-FDG PET/CT. Specificity was confirmed in relapse-free lesions such as tuberculosis and radiopneumonitis. Its sensitivity makes it a promising technique to assess HER2+ and HER2-low lesions in BC patients.

Is primary ureteroscopy more cost-effective than ureteral stenting for obstructing ureteral calculi?

INTRODUCTION AND OBJECTIVE: The increasing prevalence of nephrolithiasis represents a significant economic burden worldwide making cost-reduction essential. Given that 20% of patients with ureteral colic require acute surgical intervention, there is a lack of data reviewing the cost-effectiveness of current treatment modalities. We present a costeffectiveness analysis between primary treatment and ureteral stenting in patients with ureteral stones in the emergency setting. METHODS: We performed a retrospective analysis of patients requiring emergency intervention for a ureteral calculus at a single institution between January and December 2019. All patients underwent ureteral stenting, primary ureteroscopy (URS) or shock wave lithotripsy (SWL). The overall secondary care cost was calculated to include the cost of the procedure, inpatient hospital bed days, emergency room (ER) attendances, additional procedures such as nephrostomy insertion and secondary definitive procedure. RESULTS: A total of 244 patients were included. Ureteral stenting was performed in 152 patients (62.3%) and primary treatment in 92 patients (37.7%), of those, 83 patients (34.0%) underwent primary URS and 9 patients (3.6%) had SWL. Those undergoing ureteral stenting had a significantly higher ER reattendance rate (25.7% vs 10.9%, >p=0.02). The overall secondary care cost was greater in the ureteral stenting group (£4485.42 vs £3536.83;>p=0.65). The average cost per patient related to ER reattendances was significantly higher in the ureteral stenting group compared with the primary treatment group (£61.05 vs £20.87;>p < 0.001). CONCLUSIONS: The current study highlights the potential overall cost-reduction when performing primary treatment in patients presenting with acute ureteral colic, predominantly related to reduced ER attendances. This is particularly relevant in the COVID-19 pandemic where it is crucial to avoid unnecessary attendances to the ER and reduce the backlog of delayed definitive procedures. Both primary URS and SWL in the acute setting should be considered, in concordance with clinical judgement and factors such as patient preference, equipment availability and operator experience.

Primary ureteroscopy versus ureteric stenting in the emergency setting: A costeffectiveness analysis

Introduction: Nephrolithiasis represents a significant economic burden worldwide, yet there is a lack of data reviewing the cost-effectiveness of current treatment modalities. We present a cost-effectiveness analysis between primary treatment and ureteric stenting in patients with ureteric stones in the emergency setting. Patients and Methods: We conducted a retrospective analysis of patients requiring emergency intervention for a ureteric calculus at our institution between January and December 2019. Secondary care cost (SCC) was calculated to include cost of the intervention, inpatient bed days, emergency department (A&E) attendances, additional procedures such as nephrostomy and secondary definitive procedure. Results: A total of 244 patients were included. Patients underwent ureteric stenting (62.3%) or primary treatment (37.7%), to include primary URS (34%) and shock wave lithotripsy (3.6%). Those undergoing primary treatment had significantly less A&E reattendances (10.9% vs 25.7%, p=0.02). SCC was greater in the stenting group (£4485.42 vs £3536.83;p = 0.65). The cost-per-patient related to A&E reattendances was significantly higher in the stenting group (£61.05 vs £20.87;p < 0.001). Conclusions: Performing primary treatment in patients presenting with acute ureteric colic may infer a cost benefit, notably related to fewer A&E attendances. This is particularly relevant in the COVID-19 era where it is crucial to avoid unnecessary attendances to A&E and reduce the backlog of delayed definitive procedures. Primary treatment should be considered, in concordance with clinical judgement and factors such as patient preference, equipment availability and operator experience.