Simulation as an effective means of preparing trainees for active participation in MDT meetings.

Introduction: Cancer multi-disciplinary team (MDT) meetings are an important component of consultant workload, however previous literature has suggested trainees are not satisfied with their current curriculum in preparing for MDT working. Methods: This educational pilot assessed whether multi-speciality simulated scenarios with pre-defined learning objectives, could prepare specialist registrars for interacting within an MDT. Participants completed pre- and post-questionnaires assessing a number of areas including: current experience of training, confidence presenting patients and whether the course would alter future practice. Results: Trainee confidence increased significantly from a mean of 5 to 7 (mean to nearest whole number, p < 0.01). Trainees rated the session highly for utility and altering their future practice (mean scores of 9 for both respectively, out of 10). Conclusion: Simulation has shown success in other multidisciplinary teaching, however to our knowledge there are no cancer specific training programmes. Our results highlight a potential gap in UK specialist training, and suggest simulation may be beneficial in preparing trainees to present in MDT meetings.

International consensus is needed on a core outcome set to advance the evidence of best practice in cancer prehabilitation services and research.

Prehabilitation aims to optimise patients' physical and psychological status before treatment. The types of outcomes measured to assess the impact of prehabilitation interventions vary across clinical research and service evaluation, limiting the ability to compare between studies and services and to pool data. An international workshop involving academic and clinical experts in cancer prehabilitation was convened in May 2022 at Sheffield Hallam University's Advanced Wellbeing Research Centre, England. The workshop substantiated calls for a core outcome set to advance knowledge and understanding of best practice in cancer prehabilitation and to develop national and international databases to assess outcomes at a population level.

Impact of fatigue as the primary determinant of functional limitations among patients with post-COVID-19 syndrome: a cross-sectional observational study.

OBJECTIVES: To describe self-reported characteristics and symptoms of treatment-seeking patients with post-COVID-19 syndrome (PCS). To assess the impact of symptoms on health-related quality of life (HRQoL) and patients' ability to work and undertake activities of daily living. DESIGN: Cross-sectional single-arm service evaluation of real-time user data. SETTING: 31 post-COVID-19 clinics in the UK. PARTICIPANTS: 3754 adults diagnosed with PCS in primary or secondary care deemed suitable for rehabilitation. INTERVENTION: Patients using the Living With Covid Recovery digital health intervention registered between 30 November 2020 and 23 March 2022. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the baseline Work and Social Adjustment Scale (WSAS). WSAS measures the functional limitations of the patient; scores of ≥20 indicate moderately severe limitations. Other symptoms explored included fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue), depression (Patient Health Questionnaire-Eight Item Depression Scale), anxiety (Generalised Anxiety Disorder Scale, Seven-Item), breathlessness (Medical Research Council Dyspnoea Scale and Dyspnoea-12), cognitive impairment (Perceived Deficits Questionnaire, Five-Item Version) and HRQoL (EQ-5D). Symptoms and demographic characteristics associated with more severe functional limitations were identified using logistic regression analysis. RESULTS: 3541 (94%) patients were of working age (18-65); mean age (SD) 48 (12) years; 1282 (71%) were female and 89% were white. 51% reported losing ≥1 days from work in the previous 4 weeks; 20% reported being unable to work at all. Mean WSAS score at baseline was 21 (SD 10) with 53% scoring ≥20. Factors associated with WSAS scores of ≥20 were high levels of fatigue, depression and cognitive impairment. Fatigue was found to be the main symptom contributing to a high WSAS score. CONCLUSION: A high proportion of this PCS treatment-seeking population was of working age with over half reporting moderately severe or worse functional limitation. There were substantial impacts on ability to work and activities of daily living in people with PCS. Clinical care and rehabilitation should address the management of fatigue as the dominant symptom explaining variation in functionality.

Integration of respiratory physiology and clinical reasoning in the early years of a medical curriculum: engaging with students in a large classroom setting.

Medical graduates are expected to apply scientific principles and explain the processes underlying common and important diseases. Evidence shows that integrated medical curricula, which deliver biomedical science within the context of clinical cases, facilitate student learning in preparation for practice. However, research has also shown that the student's perception of their knowledge can be lower in integrated compared to traditional courses. Thus the development of teaching methods to support both integrated learning and build student confidence in clinical reasoning is a priority. In this study, we describe the use of an audience response system to support active learning in large classes. Sessions, delivered by medical faculty from both academic and clinical backgrounds, were designed to build on the knowledge of the respiratory system in both health and disease through the interpretation of clinical cases. Results showed that student engagement was high throughout the session and students strongly agreed that the application of knowledge to real-life cases was a better way to understand clinical reasoning. Qualitative free text comments revealed that students liked the link between theory and practice and the active, integrated method of learning. In summary, this study describes a relatively simple but highly effective way of delivering integrated medical science teaching, in this case respiratory medicine, to improve student confidence in clinical reasoning. This educational approach was applied within the early years of the curriculum in preparation for teaching within a hospital setting, but the format could be applied across many different settings.NEW & NOTEWORTHY The development of teaching methods that support integrated learning and build student confidence is a priority. An audience response system was used to engage early year medical students in large classes in preparation for teaching within a hospital setting. Results showed high levels of student engagement and a greater appreciation for the link between theory and practice. This study describes a simple, active, and integrated method of learning that improves student confidence in clinical reasoning.

Real-world use of the Breathing Pattern Assessment Tool in assessment of breathlessness post-COVID-19.

INTRODUCTION: Breathing pattern disorders (BPDs) are a common cause of chronic breathlessness, including after acute respiratory illnesses such as COVID pneumonia. BPD is however underdiagnosed, partly as a result of difficulty in clinically assessing breathing pattern. The Breathing Pattern Assessment Tool (BPAT) has been validated for use in diagnosing BPD in patients with asthma but to date has not been validated in other diseases. METHODS: Patients undergoing face-to-face review in a post-COVID clinic were assessed by a respiratory physician and specialist respiratory physiotherapist. Assessment included a Dyspnoea-12 (D12) questionnaire to assess breathlessness, physiotherapist assessment of breathing pattern including manual assessment of respiratory motion, and BPAT assessment. The sensitivity and specificity of BPAT for diagnosis of BPD in post-COVID patients was assessed. RESULTS: BPAT had a sensitivity of 89.5% and specificity of 78.3% for diagnosing BPD in post-COVID breathlessness. Patients with a BPAT score above the diagnostic cut-off had higher levels of breathlessness than those with lower BPAT scores (D12 score mean average 19.4 vs 13.2). CONCLUSION: BPAT has high sensitivity and moderate specificity for BPD in patients with long COVID. This would support its use as a screening test in clinic, and as a diagnostic tool for large cohort studies.

Making the case for spirometry as part of the perioperative multidisciplinary team assessment.

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality and is significantly underdiagnosed in the community. Respiratory impairment is a key risk factor for perioperative morbidity and mortality. The National Institute for Health and Care Excellence (NICE) does not recommend routine spirometry before major surgery. However, in this article, we present the potential benefits of targeted spirometry in high-risk patient groups. Of 183 patients who underwent targeted preoperative spirometry, 25/70 (35.7%) of those with airflow obstruction had no previously known respiratory diagnosis. Of patients with known COPD, 20/46 (43.5%) were not prescribed optimum inhaled therapies for their degree of lung function deficit. Knowledge of lung function in respiratory disease helps to optimise patients perioperatively and facilitate shared decision making regarding the benefits and risk of surgeries. We propose that targeted spirometry should be used as part of the perioperative multidisciplinary team assessment of selected patients.

Development, deployment and evaluation of digitally enabled, remote, supported rehabilitation for people with long COVID-19 (Living With COVID-19 Recovery): protocol for a mixed-methods study.

INTRODUCTION: Long COVID-19 is a distressing, disabling and heterogeneous syndrome often causing severe functional impairment. Predominant symptoms include fatigue, cognitive impairment ('brain fog'), breathlessness and anxiety or depression. These symptoms are amenable to rehabilitation delivered by skilled healthcare professionals, but COVID-19 has put severe strain on healthcare systems. This study aims to explore whether digitally enabled, remotely supported rehabilitation for people with long COVID-19 can enable healthcare systems to provide high quality care to large numbers of patients within the available resources. Specific objectives are to (1) develop and refine a digital health intervention (DHI) that supports patient assessment, monitoring and remote rehabilitation; (2) develop implementation models that support sustainable deployment at scale; (3) evaluate the impact of the DHI on recovery trajectories and (4) identify and mitigate health inequalities due to the digital divide. METHODS AND ANALYSIS: Mixed-methods, theoretically informed, single-arm prospective study, combining methods drawn from engineering/computer science with those from biomedicine. There are four work packages (WP), one for each objective. WP1 focuses on identifying user requirements and iteratively developing the intervention to meet them; WP2 combines qualitative data from users with learning from implementation science and normalisation process theory, to promote adoption, scale-up, spread and sustainability of the intervention; WP3 uses quantitative demographic, clinical and resource use data collected by the DHI to determine illness trajectories and how these are affected by use of the DHI; while WP4 focuses on identifying and mitigating health inequalities and overarches the other three WPs. ETHICS AND DISSEMINATION: Ethical approval obtained from East Midlands - Derby Research Ethics Committee (reference 288199). Our dissemination strategy targets three audiences: (1) Policy makers, Health service managers and clinicians responsible for delivering long COVID-19 services; (2) patients and the public; (3) academics. TRIAL REGISTRATION NUMBER: Research Registry number: researchregistry6173.

Utility of EBUS-TBNA in diagnosing mediastinal tuberculous lymphadenitis in East London.

OBJECTIVES: To characterise and describe the diagnostic utility of Endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) in intrathoracic tuberculosis in a cohort of patients with mediastinal lymphadenopathy of unknown aetiology. METHODS: Consecutive patients with intrathoracic lymphadenopathy undergoing EBUS-TBNA between 2012 and 2016 were identified. Demographic data, biopsy cytopathology and mycobacteriology results, HIV and vitamin D status, susceptibility results and final diagnoses were recorded. Pre- and post-procedure probability scores were assigned to each case to reflect the probability of tuberculosis. RESULTS: 315 cases were identified; 54 (17.1%) had tuberculosis and 261 (82.9%) had a non-tuberculosis diagnosis. amongst TB cases, the sensitivity of EBUS-TBNA was 59.3% (95% CI 45.06-72.14), specificity 100% (95% CI 98.19-100) and the negative predictive value (NPV) was 92.23% (95% CI 88.31-94.95). 19/54 (35%) TB cases were confirmed by EBUS mycobacterial culture and 13/54 (24.1%) by cytopathology.  33 (61.1%) of the TB cases, had a low to medium pre-test probability score assigned prior to EBUS-TBNA. Amongst EBUS culture-confirmed cases, we found a resistance rate of 10.5% to one or more first line TB drugs, with one case of multi-drug resistant TB. CONCLUSIONS: We confirmed the utility of EBUS-TBNA in the diagnosis of intrathoracic tuberculosis in an undifferentiated cohort of patients with mediastinal lymphadenopathy of unknown aetiology and advocate sending samples for mycobacterial culture in all cases in high tuberculosis incidence areas.

Association between time-to-treatment and outcomes in non-small cell lung cancer: a systematic review.

BACKGROUND: National targets for timely diagnosis and management of a potential cancer are driven in part by the perceived risk of disease progression during avoidable delays. However, it is unclear to what extent time-to-treatment impacts prognosis for patients with non-small cell lung cancer, with previous reviews reporting mixed or apparently paradoxical associations. This systematic review focuses on potential confounders in order to identify particular patient groups which may benefit most from timely delivery of care. METHODS: Medline, EMBASE and Cochrane databases were searched for publications between January 2012 and October 2020, correlating timeliness in secondary care pathways to patient outcomes. The protocol is registered with PROSPERO (the International Prospective Register of Systematic Reviews; ID 99239). Prespecified factors (demographics, performance status, histology, stage and treatment) are examined through narrative synthesis. RESULTS: Thirty-seven articles were included. All but two were observational. Timely care was generally associated with a worse prognosis in those with advanced stage disease (6/8 studies) but with better outcomes for patients with early-stage disease treated surgically (9/12 studies). In one study, patients with squamous cell carcinoma referred for stereotactic ablative radiotherapy benefited more from timely care, compared with patients with adenocarcinoma. One randomised controlled trial supported timeliness as being advantageous in those with stage I-IIIA disease. CONCLUSION: There are limitations to the available evidence, but observed trends suggest timeliness to be of particular importance in surgical candidates. In more advanced disease, survival trends are likely outweighed by symptom burden, performance status or clinical urgency dictating timeliness of treatment.

Disrupted Resolution Mechanisms Favor Altered Phagocyte Responses in COVID-19.

[Figure: see text].

Post-COVID symptoms reported at asynchronous virtual review and stratified follow-up after COVID-19 pneumonia.

BACKGROUND: The COVID-19 pandemic has strained healthcare systems and how best to address post-COVID health needs is uncertain. Here we describe the post-COVID symptoms of 675 patients followed up using a virtual review pathway, stratified by severity of acute COVID infection. METHODS: COVID-19 survivors completed an online/telephone questionnaire of symptoms after 12+ weeks and a chest X-ray. Dependent on findings at virtual review, patients were provided information leaflets, attended for investigations and/or were reviewed face-to-face. Outcomes were compared between patients following high-risk and low-risk admissions for COVID pneumonia, and community referrals. RESULTS: Patients reviewed after hospitalisation for COVID pneumonia had a median of two ongoing physical health symptoms post-COVID. The most common was fatigue (50.3% of high-risk patients). Symptom burden did not vary significantly by severity of hospitalised COVID pneumonia but was highest in community referrals. Symptoms suggestive of depression, anxiety and post-traumatic stress disorder were common (depression occurred in 24.9% of high-risk patients). Asynchronous virtual review facilitated triage of patients at highest need of face-to-face review. CONCLUSION: Many patients continue to have a significant burden of post-COVID symptoms irrespective of severity of initial pneumonia. How best to assess and manage long COVID will be of major importance over the next few years.

Candidates registered for reasonable adjustments underperform compared to other candidates in the national undergraduate Prescribing Safety Assessment: Retrospective cohort analysis (2014-2018).

AIMS: Candidates with disabilities are eligible for reasonable adjustments (RA) while undertaking the national Prescribing Safety Assessment (PSA). The PSA is a novel open-book, time-constrained, multiformat assessment that may pose challenges to candidates with dyslexia and other disabilities. METHODS: Retrospective cohort analysis of 36 140 UK candidates undertaking first-sitting of the PSA (2014-2018). RESULTS: Of the 36 140 candidates, 9.1% (3284) were registered for RA. The RA group had lower pass rates (absolute difference 1.94%, 95% confidence interval 1.01-2.87%; P < .001) and assessment scores (1.16 percentage marks, 95% confidence interval 0.83-1.48; P < .001) compared with the non-RA group. This absolute difference is small relative to overall variability. This difference persists after adjusting for confounding factors (medical school and paper), and was present for all 8 different question types. The attainment gap within each medical school is negatively correlated with the school's overall performance, both in terms of pass rate (P < .001) and scores (P = .01). The RA group were also less likely to perceive the PSA as an appropriate test, having easy to follow layout/presentation or clear/unambiguous questions, even after adjusting for candidate performance. CONCLUSION: This analysis identifies slight differences in academic performance of candidates requiring RA in a national undergraduate assessment. The study is limited by the unavailability of data on ethnicity, sex, age, diagnosis and time of diagnosis. While further research is required to determine the cause of the attainment gap, this study emphasises the need to maintain a careful review on the fairness and validity of all aspects of the assessment.

COVID-19 and pneumothorax: a multicentre retrospective case series.

INTRODUCTION: Pneumothorax and pneumomediastinum have both been noted to complicate cases of coronavirus disease 2019 (COVID-19) requiring hospital admission. We report the largest case series yet described of patients with both these pathologies (including nonventilated patients). METHODS: Cases were collected retrospectively from UK hospitals with inclusion criteria limited to a diagnosis of COVID-19 and the presence of either pneumothorax or pneumomediastinum. Patients included in the study presented between March and June 2020. Details obtained from the medical record included demographics, radiology, laboratory investigations, clinical management and survival. RESULTS: 71 patients from 16 centres were included in the study, of whom 60 had pneumothoraces (six with pneumomediastinum in addition) and 11 had pneumomediastinum alone. Two of these patients had two distinct episodes of pneumothorax, occurring bilaterally in sequential fashion, bringing the total number of pneumothoraces included to 62. Clinical scenarios included patients who had presented to hospital with pneumothorax, patients who had developed pneumothorax or pneumomediastinum during their inpatient admission with COVID-19 and patients who developed their complication while intubated and ventilated, either with or without concurrent extracorporeal membrane oxygenation. Survival at 28 days was not significantly different following pneumothorax (63.1±6.5%) or isolated pneumomediastinum (53.0±18.7%; p=0.854). The incidence of pneumothorax was higher in males. 28-day survival was not different between the sexes (males 62.5±7.7% versus females 68.4±10.7%; p=0.619). Patients aged ≥70 years had a significantly lower 28-day survival than younger individuals (≥70 years 41.7±13.5% survival versus <70 years 70.9±6.8% survival; p=0.018 log-rank). CONCLUSION: These cases suggest that pneumothorax is a complication of COVID-19. Pneumothorax does not seem to be an independent marker of poor prognosis and we encourage continuation of active treatment where clinically possible.

Feasibility of setting up a pre-operative optimisation 'pre-hab' service for lung cancer surgery in the UK.

Pre-operative optimisation 'pre-hab' is a growing area in peri-operative medicine. This is usually undertaken with the aim of reducing post-operative complications. In the case of early-stage lung cancer, surgery is the treatment modality with the best-proven cure rates. With this in mind, we set up a pre-hab service, not merely to reduce the risk of post-operative complications, but to enable patients of borderline fitness for surgery to safely undergo this potentially lifesaving treatment. We believe this service to be one of the first of its kind in the UK, here we describe the challenges we faced in setting it up and the outcomes from our first 50 patients.

Use of an antiviral filter attached to a pleural drain bottle to prevent aerosol contamination with SARS-CoV-2.

Pneumothoraces (1%) and pleural effusions (5%) are two of the less common complications of infection with COVID-19. Following a referral for a pleural drain insertion for a pneumothorax in a patient with COVID-19, we reassessed the infection risks involved in this procedure and its aftercare. Pleural drainage tubes attached to an underwater seal drain allow expulsion of aerosol and larger droplets via the vent from the bottle into the surrounding environment, potentially leading to infection of other patients and staff.Consequently, we chose to attach an antiviral filter to the venting port of an underwater seal drain bottle to mitigate this risk. A fluorescein dye experiment was used to demonstrate the reduction in aerosol emission output from the bottle with our described technique, allowing an antiviral filter to be attached to a pleural underwater seal drainage bottle for added protection of patients and staff in the local environment.

Role of a high throughput biodosimetry test in treatment prioritization after a nuclear incident.

PURPOSE: We introduce and evaluate a high throughput biodosimetry test system (REDI-Dx) suitable for testing of thousands of potential radiation victims following a mass scale nuclear event caused by detonation of a nuclear device or a nuclear accident, as part of an overall strategy for effective medical management of the crisis. MATERIALS AND METHODS: The performance of a high throughput biodosimetry test was evaluated by collecting samples of both non-irradiated presumed healthy donors as well as irradiated subjects collected as part of either cancer treatment regimens or banked from previous studies. The test measures the gene expression of a set of radiation responsive genes based on the DxDirect® genomic platform. The potential diagnostic accuracy of REDI-Dx was evaluated as a predictor of actual dose of radiation. While the REDI-Dx test has been calibrated to provide a quantitative measure of actual absorbed dose, we compared the performance of the REDI-Dx test (sensitivity and specificity) as a qualitative result at the most commonly applied thresholds 2.0 Gy and 6.0 Gy. RESULTS: The test demonstrated high specificity and lack of effect of medical conditions. Using receiver operating characteristic (ROC) curve analysis, REDI-Dx was shown to be a good predictor of actual dose for determining treatment category based on either 2.0 or 6.0 Gy, with a 98.5% sensitivity and 90% specificity for 2.0 Gy, and 92% sensitivity and 84% specificity for 6.0 Gy. Results were reproducible between clinical laboratories with an SD of 0.2 Gy for samples ≤2.0 Gy and a CV of 10.3% for samples from 2.0 to 10.0 Gy. CONCLUSIONS: Use of a biodosimetry test, like REDI-Dx test system would provide valuable information that would improve the ability to assign patients to the correct treatment category when combined with currently available biodosimetry tools, as compared to the use of existing tools alone. The REDI-Dx biodosimetry test system is for investigational use only in the U.S.A. The performance characteristics of this product have not been established.