Isopp 2023

The proceedings contain 109 papers. The topics discussed include: dose intensity of palbociclib and initial body weight dosage: implications on progression free survival in 220 patients with ER+/HER2-negative metastatic breast cancer;characteristics of Nirmatrelvir/Ritonavir (Paxlovid) recipients and clinical interventions by oncology pharmacists at a tertiary outpatient cancer center;safe handling of non-carcinogenic drugs in the Ghent University Hospital: development, implementation and communication of hospital-specific guidelines;case series: use of olaparib in uncommon locations in patients with impaired homologous recombination;real-world data evaluation of medicines used in special situations in oncohematology: a retrospective study from a comprehensive cancer institution;Dostarlimab in the treatment of recurrent endometrial cancer: real life experience;medication-related osteonecrosis of the jaws and CDK4/6 inhibitors in breast cancer;and efficacy and safety outcomes of generic imatinib in adults with chronic myeloid leukemia (CML) following the switch from branded imatinib.

Prescription Opioid Use Among Cancer Patients before and after the Onset of COVID-19: Evidence from Real-World Data

Objectives: Opioids play a significant role in the effective management of cancer-related pain. The COVID-19 lock down may have reduced access to opioids and caused a decline in the use of prescription of opioids among cancer survivors. This study compared opioid prescription rates among cancer survivors before and after the onset of COVID-19 pandemic using real-world electronic health records (EHR). Method(s): Cohort analyses of cancer patients using data from EHR database from the TriNetX, a global federated health research network across 76 healthcare organizations. We analyzed changes in prescription opioid use before (March 1, 2018, through March 1, 2019) and after onset of COVID-19 (April 01, 2020, through March 2021) among cancer survivors. The key outcome variable was any opioid prescription within 1 year of cancer diagnosis. One-to-one propensity score matching was used to balance the characteristics (age, sex, race, diagnoses including diabetes, hypertensive diseases, overweight, mood disorders, and visual disturbances) of the two cohorts. Data were analyzed using the TriNetX platform. Result(s): There were 1,502,143 cancer survivors before COVID-19 and 1,412,599 cancer survivors after the onset of COVID-19. The one-to-one propensity-score match yielded 1,382,561 cancer patients, mean age 64 at cancer diagnosis, and 73% were white. Percentage of opioid use among cancer patients declined from 35.6% before the COVID-19 to 35.1% after the onset of the pandemic (OR=0.976, 95% CI 0.971-0.981). Average number of opioid prescriptions within 1 year of cancer diagnosis declined from 5.7 before to 5.3 after the COVID-19 onset (p<0.001). Conclusion(s): Among cancer survivors, a small decline in prescription opioid use was observed after the onset of COVID-19 pandemic. Future studies are needed to distinguish the impact of revised guidelines, opioid prescription policy changes, and COVID-19 lock down on lower rates of prescription opioid use among cancer survivors.Copyright © 2023

Current Healthcare Policy and Environmental Status of Digital Health Medical Devices in South Korea

Objectives: COVID 19 and increasing unmet needs of health technology had accelerated an adoption of digital health globally and the major categories are mobile-health, health information technology, telemedicine. Digital health interventions have various benefit on clinical efficacy, quality of care and reducing healthcare costs. The objective of the study is to identify new reimbursement policy trend of digital health medical devices in South Korea. Method(s): Official announcements published in national bodies and supplementary secondary research were used to capture policies, frameworks and currently approved products since 2019. Result(s): With policy development, several digital health devices and AI software have been introduced as non-reimbursement by utilizing new Health Technology Assessment (nHTA) pathway including grace period of nHTA and innovative medical devices integrated assessment pathway. AI based cardiac arrest risk management software (DeepCARS) and electroceutical device for major depressive disorders (MINDD STIM) have been approved as non-reimbursement use for about 3 years. Two digital therapeutics for insomnia and AI software for diagnosis of cerebral infarction were approved as the first innovative medical devices under new integrated assessment system, and they could be treated in the market. In addition, there is remote patient monitoring (RPM) reimbursement service fee. Continuous glucose monitoring devices have been reimbursed for type 1 diabetes patients by the National Health Insurance Service (NHIS) since January 2019. Homecare RPM service for peritoneal dialysis patients with cloud platform (Sharesource) has been reimbursed since December 2019, and long-term continuous ECG monitoring service fee for wearable ECG monitoring devices (ATpatch, MEMO) became reimbursement since January 2022. Conclusion(s): Although Korean government has been developed guidelines for digital health actively, only few products had been reimbursed. To introduce new technologies for improved patient centric treatment, novel value-based assessment and new pricing guideline of digital health medical devices are quite required.Copyright © 2023

Impacts of COVID-19 on proton therapy - Shaping the future of patient selection

Objectives: This scoping review aimed to determine whether the COVID-19 pandemic influenced any modifications to patient selection methods or prioritisation and services provided by proton therapy centres. Method(s): This review was conducted based on the PRISMA methodology and Joanna Briggs Institute scoping review guidelines.1,2 A literature search was performed in Medline, Embase, Web Of Science and Scopus as well as grey literature. Keywords including "COVID-19" and "Proton Therapy" were used. Articles published from 1 January 2020 in English were included. In total, 138 studies were identified of which 14 articles met the inclusion criteria. A scoping review design was chosen to capture the full extent of information published relating to the aim. Result(s): Six of 14 articles included statements regarding treatment of COVID-19 patients. Three publications recommended deferred or alternative treatment, two indicated to treat urgent/emergency patients and one reported continuous treatment for infectious patients. Recurring impacts on PT provision included more frequent use of alternative therapies, reduced referrals, delayed treatment starts and CT simulation, change in treatment volume and staffing limitations due to pandemic restrictions. Consequently, telehealth consults, remote work, reduction in patient visitors, screening procedures and rigorous cleaning protocols were recommended. Discussion/Conclusion: Few publications detailed patient selection or workflow methods used during the pandemic. Further research is needed to obtain more detailed information regarding current global patient selection methods in proton therapy, collecting this data could aid in future planning for proton therapy in Australia.

Salt steps and sugar checks - Making arterial line use safer in our trust

Introduction: Arterial lines are used within our intensive care unit to allow invasive blood pressure monitoring and regular blood gas analysis. Inadvertent use of dextrose containing fluids in the flush have been associated with falsely high glucose readings. When these are acted on with insulin, it can cause devastating hypoglycaemic brain injury. There have been a number of deaths and other incidents relating to the wrong fluid being used in arterial line set up reported within the UK in recent years. In 2014 the AAGBI released a safety guideline on the use of arterial lines specifically to reduce to the risk of hypoglycaemic brain injury. Objective(s): Our objective was to ensure that 100% of arterial lines in use within Royal Victoria Hospital's intensive care unit were compliant with our trust policy on the management of arterial lines. Method(s): We audited our intensive care unit's compliance with our trust policy and found that we were 80% compliant. We formed a multi-disciplinary arterial line working group in order to tackle the problem. Our quality improvement project consisted of two main approaches: 1. To educate staff on how to manage arterial lines correctly. We divided the management of arterial lines into S.A.L.T steps (a 7 step bundle on "Setting up an Arterial Line Transducer") and SUGAR checks ( a series of red flag moments to prompt staff to review the patient prior to starting or increasing insulin administration).We developed educational posters for key areas in ICU and presented our findings at departmental meetings. 2. To change the system, in order to make it easier to do the right thing. We developed a Universal Adult Arterial Pack (UAAP) containing key components in the setup of an arterial line. This also included aide memoires for the S.A.L.T steps and SUGAR checks. In order to measure the effect of these changes, we: 1. Audited compliance on a regular basis. 2. Monitored serious bundle breaches ( for example no label, wrong fluid used) 3. Assessed usage of the UAAP. Result(s): 1. Bundle compliance improved during the first half of 2021, however then reduced in the second half with the number of serious bundle breaches increasing. This coincided with COVID surge 4 - associated with reduced nursing ratios and staff redeployment. 2. UAAP usage increased throughout the project, from an average of 6 to 9 per day. 86% of staff found the packs useful and 85% thought that they reduced the potential for error. Conclusion(s): The presence of a policy does not ensure that staff will know about it or adhere to it. Although we have not yet achieved our target of 100% compliance, we have seen evidence of how our project has the potential to do so in the near future. We aim to roll out our new e-learning module for staff education, manufacture our UAAP on a bigger scale, and disseminate the project to other departments within the trust.

Refractory circulatory failure in COVID-19 patients treated with veno-arterial ECMO: A retrospective single-center experience

Objectives: Data about COVID-19 patients treated with veno-arterial-ECMO (VA-ECMO) is limited. Reported survival rates range from 27.9% to 77.8%, depending on VA-ECMO indication. A subgroup of patients suffers from circulatory failure due to a COVID-19 associated hyperinflammatory state (CovHI). In these patients, differentiation between inflammation and sepsis is difficult but important. In this retrospective case series, differential diagnoses of COVID-19 associated refractory circulatory failure and survival rates in different indications for VA-ECMO are investigated. Method(s): Retrospective analysis of 28 consecutive COVID-19 patients requiring VA-ECMO at the University Hospital Regensburg between March 2020 and May 2022. Specific treatment for COVID-19 was in accordance with respective guidelines. Mycotic infections were either invasive or met current definitions of COVID19-associated-pulmonary aspergillosis. Result(s): At VA-ECMO initiation, median age was 57.3 years (IQR: 51.4 - 61.8), SOFA score 16 (IQR: 13 - 17) and norepinephrine dosing 0.53mug/kg/min (IQR: 0.32 - 0.78). Virus-variants were: 61% wild-type, 14% Alpha, 18% Delta and 7% Omicron. Survival to hospital discharge was 39%. 17 patients were primarily supported with VA-ECMO only (survival 42%), 3 patients were switched from VV to VA-ECMO (survival 0%), and 8 patients were converted from VA to VAV or VV-ECMO (survival 50%). Indications for VA-ECMO support were pulmonary embolism (PE) (n=5, survival 80%), right heart failure due to secondary pulmonary hypertension (n=5, survival 20%), cardiac arrest (n=4, survival 25%), acute left heart failure (ALHF) (n=11, survival 36%) and refractory vasoplegia (n=3, survival 0%). Inflammatory markers at VA-ECMO initiation were higher in patients with ALHF or vasoplegia;in these patients a higher rate of invasive fungal infections (10/14, 71% vs. 4/14, 29%;p=0.023) compared to the other patients was found. Conclusion(s): Survival on VA-ECMO in COVID-19 depends on VA-ECMO indication, which should be considered in further studies and clinical decisions making. Circulatory failure due to vasoplegia should be considered very carefully as indication for VA-ECMO. A high rate of mycotic infections mandates an intense microbiological workup of these patients and must be considered as an important differential diagnosis to CovHI.

Differences in nosocomial infections in patients on VV-ECMO for COVID-19 and influenza

Objectives: In COVID-19 associated acute respiratory distress syndrome (ARDS) requiring VV-ECMO, ventilator-associated-pneumonia (VAP), pulmonary aspergillosis and viral reactivations are observed frequently, but there is only little knowledge on incidence, onset and causative pathogens. This study analyzes frequency of VAP, pulmonary aspergillus infections, and viral reactivations in a large cohort of patients with ARDS treated with VV-ECMO due to either COVID-19 or Influenza. Method(s): Retrospective analysis of all consecutively patients at the University Hospital Regensburg requiring VVECMO due to COVID-19 (March 2020 and May 2022) or Influenza (May 2012 and December 2022). VAP was diagnosed according to current guidelines. Pulmonary Aspergillosis met criteria of probable COVID-associated Aspergillosis according to current guidelines. Result(s): 147 patients (age (median [IQR]) 55.3 [48.7 - 61.7], SOFA at VV-ECMO initiation 9 [8 - 12], 23 [14 - 38] days on VV-ECMO) suffering from COVID-19 and 72 influenza patients (age 55.3 [46 - 61.3], SOFA at VV-ECMO initiation 13 [10 - 15], 16 [10 - 23] days on VV-ECMO) were included in the analysis. Pulmonary superinfections were more frequent in COVID-19 than in influenza (VAP: 61% vs. 39%, pulmonary Aspergillosis: 33% vs. 22%, CMV reactivation: 19% vs. 4%, HSV reactivation: 49% vs. 26%.) The first episode of VAP in COVID-19 and Influenza was detected 2 days [1 - 15] after and 1 day (-3 - 22) before ECMO initiation, respectively. First VAP-episode in COVID-19 were mainly caused by Klebsiella spp. (29%,), Staphylococcus aureus (27%) and E. coli (11%). Further VAP-episodes (30% in COVID-19) and relapses of VAP were mainly caused by Klebsiella spp. (53%, 64%, respectively). In Influenza, VAP was mainly caused by Staphylococcus aureus (28%) and Streptococcus pneumoniae(28%), further VAP episodes were not observed. Conclusion(s): Superinfections were common in patients treated with VV-ECMO and occur more frequently in COVID-19 ARDS compared to Influenza. VAP occurs early and may significantly contribute to the need of VV-ECMO. Therefore, a meticulous routine microbiologic workup is advisable. The observed differences in the spectrum of secondary infectious agents in COVID19 compared to Influenza are not understood yet.

Anaesthetic pre-assessment of obese patients in obstetrics: challenges in COVID recovery

Introduction: One in five pregnant women in the UKis obese. Obesity is associated with increased risk of both maternal and foetal adverse outcomes. RCOG guidelines [1] recommend that all women with a booking BMI over 40 kg/m2 should be reviewed antenatally by a senior obstetric anaesthetist to guide risk assessment, medical optimisation and shared decision-making. The 2021 MBRRACE report [2] recommends that all women should be reweighed in the third trimester for accurate VTE risk scoring and prophylactic LMWH dosing. In our institution, reconfiguration of hospital areas as part of the COVID-19 response led to loss of designated clinic space for our obstetric anaesthetic clinic. As a result, our practice since has been to initially offer a telephone consultation followed by a face-to-face review if needed. Finding space for the latter has often been a significant logistical challenge. Our project sought to assess whether our practice continued to meet national standards in the wake of these changes. Method(s): Following audit approval, we retrospectively reviewed all women with a BMI >40 kg/m2 undergoing caesarean section (CS) over a six-month period (1/4/22 to 31/9/22). Result(s): 20 women met inclusion criteria (Category 1-3 CS - 12 women;Category 4 CS - 8 women). 100% of patients had booking height, weight and BMI recorded. 20% (4/20) of patients were reweighed in the 3rd trimester. Only 55% (11/20) of patients had been referred to and reviewed in the antenatal obstetric anaesthetic clinic (Figure). Of the 11 patients referred, 6 were referred later than 30 weeks. Of the 9 patients not referred, 8 had a BMI between 40 and 45 kg/m2. By contrast, 87% (6/7) of patients with BMI over 45 kg/m2 were referred and seen. Discussion(s): Our audit showed that we are not meeting national standards. Possible reasons identified were lack of awareness of the RCOG standards and referral criteria (especially for women with a BMI of 40 to 45 kg/m2) and logistical issues in undertaking face-to-face reviews without designated clinic space. Presentation of our results at the joint anaesthetic, obstetric and midwifery governance meeting has helped identify space in the antenatal clinic for face-to-face reviews, to start from March 2023 and to raise awareness of the national standards to ensure referral of all women with a BMI over 40 kg/m2. A reaudit is planned in 6 months. [Figure presented]Copyright © 2023 Elsevier Ltd

The Study of the Correlation Betweenthe on the Diet, Sleep Quality and Perceived Stress among College Students in Taichung during the COVID-19 Pandemic Distance Learning.

Research indicates the COVID-19 epidemic changes people's health and diet, However, this has not yet been well discussed in Taiwan, especially in college students. Therefore, the purpose of this study is to investigate the impact of distance learning on college students' dietary patterns, sleep quality and perception of stress during the COVID-19 epidemic in Taiwan. 265 college students from a university in Taichung were recruited in this study. The self-administered online questionnaire was used to investigate the changes in eating behavior, sleep quality, and perception of stress before and one month after distance learning, and further analyzed the relationship among them. The questionnaire contains demographic information, dietary questionnaires (including six categories of food intake behaviors, convenience food intake frequency), the Pittsburgh Sleep Quality Index (PSQI) and Perceived Stress Scale (Chinese 14-item PSS). The results showed that the proportion of college students to meet the recommended Taiwan Dietary Guidelines amount in vegetables (21.9%), fruits (27.5%), meats and dairy products (15.8%), and nuts and seeds (11.3%) were lower during distance learning. The frequency of convenient food intake was lower during distance learning (13.31 +/- 6.10 points;never to occasionally). During the distance learning period, there was a significant negative correlation between dietary patterns and sleep quality (r = -0.160, p = 0.009), It shows that college students with higher dietary pattern scores have better sleep quality. During the distance learning period, there was a significant positive correlation between sleep quality and perceived stress (r = 0.320, p < 0.001), It shows that college students with higher levels of stress had poorer sleep quality. This study found that the lower the perceived stress of college students, the better their diet and sleep quality;conversely, the higher the perceived stress, the worse their diet and sleep quality. Studies have shown that a healthy, balanced diet can reduce the risk of getting various diseases. Therefore, in the post-epidemic era, it is recommended that schools increase the accessibility and availability of vegetables, fruits, dairy products, nuts and seeds on campus to make it easier for teachers and students to obtain such healthy food in order to achieve the goal of promoting balanced diet.Copyright © 2022 Nutrition Society in Taipei. All rights reserved.

Analysis of the assessment profile of KrasSMU students providing medical aid to COVID-19 patients.

The aim of the research. To conduct a cluster analysis of the assessment profile of students who participated in work of medical organisations providing care to COVID-19 patients to develop recommendations for its correction. Material and methods. The study was carried out at the premises of Prof. V.F. Voino-Yasenetsky Krasnoyarsk State Medical University (KrasSMU). The study group was constituted by 66 students in 3-6 years of study of the Medical and the Paediatric faculties of the University who took part in activities of medical organisations providing healthcare to patients with COVID-19. The items were presented in the form of binary questions and ranking scales. The analysis of qualitative attributes was carried out in the form of relative values with calculation of the standard error of the proportion. For ranking and nonparametric quantitative characteristics, the mode, median, centiles (Me [P25;P75]) and other nonparametric criteria for comparative statistics and communication statistics were used. For segmentation of respondents according to some criteria, depending on the answers, the method "two-step cluster analysis" and the method of "decision tree" were used. Results. The results of the study indicate a high motivational component related to practical medical activity of medical students during the difficult epidemiological situation since 94.1% of the respondents declared the readiness to support practical healthcare. Almost half of the surveyed 47.0% of students included in cluster 2, in contrast to students of clusters 1 and 3, are characterised by a high opinion on the degree of their contribution to the struggle against the COVID-19 epidemic and a high level of knowledge and skills, rating themselves at about 9.0 points out of 10 possible. In addition, the results of the study indicate an association between the level of students' self-esteem in regard to their contribution to the fight against COVID-19 with the level of the students' self-esteem of knowledge and skills and the duration of work in a medical organisation. Conclusion. The analysis performed has made it possible to formulate guidelines for support of medical students' professional attitudes within the framework of practice-oriented education, including distance learning.Copyright © 2021, Krasnoyarsk State Medical University. All rights reserved.

Breastfeeding in emergencies with assessment of recent humanitarian crises and the Covid-19 pandemic.

The world is becoming a place where the number of emergencies and humanitarian crises is increasing rapidly due to economic inequality and the gap between developed and underdeveloped countries, as well as climate changes leading to disruption of the natural balance and development of natural disasters. The most vulnerable groups of the population including women and children always are affected by disasters. The younger the child, the more vulnerable he/she is, especially if not naturally fed or having a mother or parents. Various humanitarian organizations have been involved in a number of crises, with the World Health Organization and UNICEF and other United Nations-related organizations leading the way. In the care of mothers, infants and young children, most important is to ensure appropriate nutrition because otherwise it can result in life-threatening health conditions. The lack of protection, support and promotion of natural nutrition (breastfeeding) and its disruption and undermining by uncritical and uncontrolled donations and distribution of infant formula are the biggest challenge due to the lack of information of mothers, those who provide support in emergencies from both governmental and non-governmental sector, without cross-sectoral cooperation, thus causing uncoordinated and sometimes harmful interventions. Therefore, it is recommended that governments issue guidelines on infant and young child nutrition prior to the occurrence of an emergency, and crisis management regulations in which the issue of infant and young child nutrition will be given due consideration.Copyright © 2020 Croatian Paediatric Society. All rights reserved.

Improving Outcomes in Oesophagectomy Patients

Introduction: Aberdeen Royal Infirmary is a low volume centre carrying out approximately 13 oesophagectomies per annum. Due to minimal exposure to post-operative oesophagectomy patients, staff had low perceived confidence in their management within the Intensive Care Unit (ICU). After an initial pause due to the COVID-19 pandemic, oesophagectomy service provision restarted in June 2020. Prior to this project, no standardised care pathway existed for post-operative oesophagectomy patients. A protocol driven management pathway was implemented within the ICU setting in October 2020. Objective(s): 1. Standardise the first 5 days of post-operative care for oesophagectamies 2. Improve 30 day mortality rate 3. Reduce opiate use on step down to High Dependency Unit (HDU) 4. Improve ICU Medical and Nursing staff perceived confidence in the management of oesophagectomy patients. Method(s): A multi-disciplinary approach was taken, with input from ICU, Surgical, Anaesthetic, Physiotherapy, Nursing, Pain and HDU teams. Standards of care for post-operative oesophagectomy patients were identified and a protocol was subsequently produced for use within ICU with reference to current Enhanced Recovery After Surgery (ERAS) guidelines.1 The protocol covered the first 5 days of post-operative care. It identified tasks to be completed each day and highlighted which staff group was responsible for performing each task. Additionally, an information sheet was distributed to Medical and Nursing ICU staff to educate them on oesophagectomy patients and recognition of potential complications that arise when caring for this patient group. Data on 30 day mortality and opiate use at step down to HDU was collected from electronic notes. This was collected retrospectively prior to implementation of the protocol from January 2019 - July 2020 and prospectively following its implementation, from October 2020 - December 2021. ICU staff perceived confidence in managing post-operative oesophagectomy patients was measured using a combined quiz and survey. It was completed by staff prior to introduction of the protocol. Following implementation of the protocol and distribution of the information sheet, the quiz and survey was repeated to evaluate improvement in staff confidence. Result(s): A total of 38 oesophagectomy cases were identified. 21 cases were reviewed prior to implementation of the protocol, with 1 mortality at 30 days. 17 cases were reviewed following implementation of the protocol, with 0 mortalities at 30 days. Qualitative scoring showed a 20% increase in staff confidence to manage this patient group. Review of drug prescription charts revealed a reduction in dose of modified release opiates at step down to HDU. Conclusion(s): Oesophagectomy is major surgery and causes significant staff anxiety in low volume centres. This protocol has successfully standardised care for this patient group and allowed continuation of this essential service provision during the COVID-19 pandemic. This protocol improved 30 day mortality, reduced opiate use at step down to HDU and improved ICU staff perceived confidence in caring for post-operative oseophagectomy patients.

The impact of the COVID-19 pandemic on clinical guidance, risk assessment and support for UK obstetric sonographers

UK obstetric sonographers adapted their working practices during the COVID-19 pandemic in response to new guidance issued by professional organisations, and requirements for on-going departmental risk assessments. This study aimed to provide an insight into the implementation of this guidance, completion of risk assessments and perception of support within UK obstetric ultrasound departments during the pandemic period. Obstetric sonographers working in the UK (n=138) used the Qualtrics XMTM platform to complete an anonymous, online, cross-sectional survey about their working experiences during the pandemic. Participants responded to closed questions about national guidance, risk assessments and their perception of support whilst providing fetal ultrasound screening services. Respondents provided additional detail about their experiences in these areas via free-text boxes. Over 90% of respondents were aware of, or had read guidance issued by professional organisations, although sonographers rated the overall usefulness of new guidelines at an average of 5.2/10 (where 0 = not useful at all, and 10 = extremely useful). Challenges for the implementation of guidance in departments were also identified, mostly related to the clinical working environment, including limitations of physical space (76.3%), time constraints (67.5%) and ventilation (61.3%). Most sonographers (77.2%) were aware that a departmental risk assessment had been undertaken, with waiting areas, scan rooms and clinically vulnerable staff highlighted as the most concerning factors. Sonographers felt most supported by their ultrasound colleagues (83.5%) and line managers (41.2%). They felt least supported by senior management and leadership personnel (60.8%), other antenatal colleagues (51.5%) and professional organisations (41.2%). Whilst most sonographers were aware of published COVID-19 guidance, challenges for its implementation in clinical departments were identified. Local risk mitigation strategies often did not prioritise the scan room environment, despite it being highlighted as a concern. Support from the wider, senior service team and professional organisations will be essential to facilitate post-pandemic recovery of the workforce.

Preoperative evaluation and timing of surgery for adult patients after covid-19 infection: Recommendations of peking union medical college hospital (2023).

With the adjustment of China's epidemic prevention and control guidelines regarding coronavirus disease of 2019(COVID-19), the preoperative evaluation and timing of surgery for patients after COVID-19 infection have become the focus of attention for both healthcare workers and patients. Based on the latest study and related clinical experience, Peking Union Medical College Hospital (PUMCH) has therefore compiled this multidisciplinary, evidence-based recommendation for concise, individualized, and practical preoperative evaluation and timing of surgery for patients after COVID-19 infection. The recommendations emphasize patients' COVID-19 infection history, the severity of symptoms, and medical/physiologic recovery status during preoperative evaluation. The determination of appropriate length of time between recovery from COVID-19 and surgery/procedure should take into account of patients' underlying health conditions, the severity of the COVID-19 infection course, and the types of surgery and anesthesia scheduled, to minimize postoperative complications. The recommendations are intended to aid healthcare workers in evaluating these patients, scheduling them for the optimal timing of surgery, and optimizing perioperative management and postoperative recovery.Copyright © 2023, Peking Union Medical College Hospital. All rights reserved.

Teclistamab in combination with daratumumab and lenalidomide in multiple myeloma (MajesTEC-2 study)

Introduction: Combination of daratumumab (Dara) and lenalidomide (Len) may enhance the function of teclistamab (Tec), potentially resulting in improved antimyeloma activity in a broader population. We present initial safety and efficacy data of Tec-Dara- Len combination in patients with multiple myeloma (MM) in a phase 1b study (MajesTEC-2;NCT04722146). Method(s): Eligible patients who received 1-3 prior lines of therapy (LOT), including a proteasome inhibitor and immune-modulatory drug, were given weekly doses of Tec (0.72-or- 1.5 mg/kg with step-up dosing) + Dara 1800 mg + Len 25 mg. Responses per International Myeloma Working Group criteria, adverse events (Aes) per CTCAE v5.0, and for cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) per ASTCT guidelines, were assessed. Result(s): 32 patients received Tec-Dara- Len (0.72 mg/kg, n = 13;1.5 mg/kg, n = 19). At data cut-off (11 July 2022), median follow-up (range) was 5.78 months (1.0-10.4) and median treatment duration was 4.98 months (0.10-10.35). Median age was 62 years (38-75);87.5% were male. Median prior LOT was 2 (1-3), 18.8% were refractory to Dara and 28.1% refractory to Len. CRS was most frequent AE (81.3% [n = 26], all grade 1/2), 95% occurred during cycle1. Median time to onset was 2 days (1-8), median duration was 2 days (1-22). No ICANS were reported. Frequent Aes (>=25.0% across both dose levels) were neutropenia (75.0% [n = 24];grade 3/4: 68.8% [n = 22]), fatigue (43.8% [n = 14];grade 3/4: 6.3% [n = 2]), diarrhoea (37.5% [n = 12];all grade 1/2), insomnia (31.3% [n = 10];grade 3/4: 3.1% [n = 1]), cough (28.1% [n = 9];all grade 1/2), hypophosphatemia (25.0% [n = 8];all grade 1/2), and pyrexia (25% [n = 8];grade 3/4: 6.3% [n = 2]). Febrile neutropenia frequency was 12.5% (n = 4). Infections occurred in 24 patients (75.0%;grade 3/4: 28.1% [n = 9]). Most common were upper respiratory infection (21.9% [n = 7]), COVID-19 (21.9% [n = 7]), and pneumonia (21.9% [n = 7]). Three (9.4%) had COVID-19 pneumonia. One (3.1%) discontinued due to COVID-19 infection and this patient subsequently died of this infection. Overall response rate (ORR, median follow-up) was 13/13 (8.61 months) at 0.72 mg/kg and 13/16 evaluable patients (less mature at 4.17 months) at 1.5 mg/kg. 12 patients attained very good/better partial response at 0.72 mg/kg dose, and response was not mature for 1.5 mg/kg group. Median time to first response was 1.0 month (0.7-2.0). Preliminary pharmacokinetic concentrations of Tec-Dara- Len were similar as seen with Tec monotherapy. Tec-Dara- Len- treatment led to proinflammatory cytokine production and T-cell activation. Conclusion(s): The combination of Tec-Dara- Len has no new safety signals beyond those seen with Tec or Dara-Len individually. Promising ORR supports the potential for this combination to have enhanced early disease control through the addition of Tec. These data warrant further investigation.

Management of cardiovascular complications of BTKis: Are we complying with the good practice guidelines?

Bruton tyrosine kinase inhibitors (BTKis) were approved for use at the end of 2013 and have since been used for indications including chronic lymphocytic leukaemia (CLL), Waldenstrom's macroglobulinaemia and mantle cell lymphoma. The use of BTKis has increased significantly in the UK since they achieved NICE (National Institute for Health and Care Excellence) approval for frontline treatment of CLL in 2021. However, they are associated with significant adverse cardiovascular events. In September 2021 the British Journal of Haematology published good practice guidelines for the management of cardiovascular complications of BTKis. Our aim was to see whether these guidelines had been adhered to for patients taking BTKis. Method(s): Data was collected for all patients being prescribed BTKis (ibrutinib and acalabrutinib) in the South Tees NHS Trust in July 2022. Patients' medical records were used to assess whether their management adhered to the good practice guidelines. Data was collated for 67 patients in total. Result(s): The data showed that although all patients were consented for the risk of atrial fibrillation only 6% were consented for hypertension and only 1.5% for ventricular arrhythmias and sudden cardiac death. The guidelines recommend a baseline ECG (electrocardiogram) on commencement of treatment;however, only 7% had this completed and 0% had the minimum monitoring recommendation of 6-monthly ECGs. Thirty patients (45%) had an indication for a baseline echocardiogram;however, only one had this completed. For patients reporting symptoms of syncope, dizziness or palpitations only 50% had an ECG completed. Three patients developed worsening heart failure. The recommendations suggest referral to a cardio-oncologist;however, due to lack of availability of this service the referrals were instead made to the usual cardiologist. Conclusion(s): Although there was a lack of compliance with guideline recommendations, it should be considered that most usual checks were affected by COVID-19 outbreaks and a drop in face-to- face clinics, which were replaced by phone clinics and home delivery of medications. However, the premade consent forms for BTKis need to be updated to include consent for ventricular arrhythmias and sudden cardiac death. There also needs to be routine procedures in place to ensure that regular blood pressure testing and ECG monitoring occurs and that there is prompt recognition of cardiovascular complications. Action and implementation: To ensure improved compliance with these guidelines we plan to update our consent forms and create a proforma for clinic use to ensure that clinicians are aware of the various monitoring criteria required.

Our journey from the Peripatetic Ultrasound Trainers to the Ultrasound Training Academy - HEE (South East)

In 2016, an innovative project of three ultrasound trainers evolved to support multi-professional trainees in Obstetric and Gynaecology ultrasound across the Wessex region. The aim of the project was to deliver a high-quality ultrasound training programme. One of the project's successes resulted in establishing the Sonographer Training Network Forum which allowed ultrasound leads from seven Trusts to meet and share ideas, which ultimately led to the development of regional ultrasound guidelines. From 2016 to early 2020, we have supported 75 trainees in O&G ultrasound. The vision was to create a dedicated ultrasound training centre to support trainees in a safe environment. Late 2019, with the support and funding from Health Education England South-East, the plans were set in motion to create the first Ultrasound Training Academy in the South- East Region. A briefing paper was submitted to the Trust Investment Group for approval. Approval from TIG acknowledged the Trust's support in the project as well as supporting the sonography workforce. This began the search for space that would accommodate the academy. Frustratingly, COVID stopped all activities, however, with reflection, COVID gave us the time to plan accordingly for the Ultrasound Training Academy. Without the normal pressure of a time frame, it was an opportunity to find an ideal location as well as purchasing the required equipment befitting the academy. The Ultrasound Training Academy - HEE (South-East) is based in the Princess Anne Hospital (University Hospital Southampton NHS FT). The advantages based within a hospital setting allowed the academy to follow the Trust's governance as well as absorbing some of the capacity from the ultrasound department. We have two ultrasound rooms and a dedicated space for simulation training. We have plans to create a third ultrasound room.

Pregnancy Outcomes in Women with Sickle Cell Disease in Ireland: A Retrospective Review

Background: Sickle cell disease (SCD) is one of the most common single gene disorders worldwide and is characterised by significant morbidity and early mortality.[1] Pregnancy in SCD is associated with an increased risk of maternal and foetal complications.[2,3] The 2011 RCOG and the 2021 BSH guidelines[5,6] on the management of pregnancy in SCD have provided the basis for best practice care in the UK over the past decade and is the guidance which we follow in Ireland. To date, there is no published data on outcomes for pregnant women with SCD in Ireland. The number of Irish patients with SCD has risen over the past 20 years. Without a national database, the exact prevalence is not known but currently there are at least 600 adults and children with SCD in Ireland, whose population is just over 5 million.[4] Aims: Our study assesses outcomes of pregnant patients with SCD from 2015 to 2022. Our aims were to: * Assess adherence to current guidelines * Assess pregnancy outcomes and maternal complications * Assess transfusion rates amongst our patient cohort. Method(s): This is a retrospective cohort study. We do not have a directly matched cohort, but have compared our findings to published data on Irish pregnancy outcomes from the Irish Maternity Indicator System National Report and have correlated our findings with studies of women with SCD who were managed in UK centres.[8,9,10] Results: We reviewed outcomes of 29 pregnancies in 19 women over a 7-year period. The median age was 29 (range 20-41) and the predominant maternal sickle genotype was HbSS (65.5%). Before conception, 55.2% of cases had pre-existing complications of SCD, including acute chest syndrome (ACS), pulmonary hypertension (PHTN) and prior stroke. In accordance with current guidelines, 100% of women (n=29) were prescribed folic acid, penicillin, and aspirin prophylaxis. 51.7% (n=15) of women had documented maternal complications during pregnancy, including ACS (34%), vaso-occlusive crisis (34%), gestational diabetes (10%), VTE (3%) and UTI (3%). Two women (7%) developed Covid-19 pneumonitis despite vaccination. There was one case of maternal bacteraemia (3%). 65.5% of cases (n=19) required blood transfusion during pregnancy. One woman was already on a blood transfusion programme for disease modification prior to pregnancy. In 6 cases (20.6%), a transfusion programme was commenced during pregnancy due to prior pregnancy complications or intrauterine growth restriction. During pregnancy, 27.6% (n=8) of women required emergency red cell exchange for ACS. Prior studies have suggested that between 30% and 70% of pregnant women with SCD require at least one blood transfusion during pregnancy.[8,9,10] By comparison, only 2.6% of the Irish general obstetric population required transfusion during pregnancy.[7] 20.6% (n=6) of births were preterm at <37 weeks' gestation. There was one live preterm birth (3%) at <34 weeks and one intrauterine death (3%) at 23 weeks' gestation. Similar to UK data[9], 31% of women required critical care stay (n=9) during pregnancy, in comparison with 1.44% nationwide in 2020.[7] Conclusion(s): It is well established that pregnancy in SCD is high risk, and despite adherence to current guidelines, we have shown very high rates of critical care admission, significant transfusion requirement and hospital admissions. Our findings are comparable to published UK outcomes and they further support the need for a comprehensive specialist care setting for this patient cohort.

Hand Surgical Simulation in the Pandemic Era: A Systematic Review

Introduction: The COVID-19 pandemic and duty hour restrictions have illuminated a role for surgical simulation in trainees that permits meaningful technical experience outside the operating room. There is a need for the implementation of surgical simulation infrastructure adjacent to clinical training with practical considerations for complexity and cost. This systematic review analyzes surgical simulations that train hand surgical techniques and procedures with subjective or objective competency assessment. Method(s): A systematic review was conducted according to PRISMA- P guidelines using the PubMed, Medline, Scopus, Embase, Web of Science, and Cochrane databases. Selected search terms included procedures relevant to the field of hand surgery and various types of simulation training. Data, including skills and techniques taught and assessed, model type, equipment, cost, and emphasis placed in training for each article, were extracted. Result(s): Of 2,519 articles, 40 met inclusion criteria. Models were described as: synthetic benchtop/3D-printed (40.0%), animal (22.5%), cadaveric (20.0%), augmented and virtual reality (AR/ VR;12.5%), and other computer simulation (12.5%). Three models incorporated both a physical benchtop component and an AR/ VR component. The procedures most represented included tendon repair (30.0%), fracture fixation (27.5%), wrist arthroscopy (15.0%), and carpal tunnel release (15.0%). Sixty-five percent of articles emphasized the importance of surgical simulation in a surgeon's training. Conclusion(s): A diversity of surgical simulation models exist for the practice of various aspects of hand surgery. The existing literature demonstrates their utility for increasing expertise with surgical techniques and procedures in a low-risk setting.