ABSTRACT
Background: Most patients with pancreatic cancer (PC) and biliary tract cancer (BTC) present with advanced disease. In confirmed cases, circulating tumour DNA (ctDNA) may be detected through liquid biopsy in 80-90%. Obtaining a diagnostic biopsy can be technically challenging, require complex invasive procedures and may not be feasible due to comorbidity. Reduction in capacity of aerosol generating diagnostic procedures in many healthcare systems due to COVID19 has highlighted the unmet need for simple, noninvasive diagnostic tools. We piloted the use of ctDNA to support the diagnostic pathway in patients with suspected cancer across 6 tumour types, here we present its use in PC/BTC. Methods: This single centre prospective cohort pilot trial was conducted at the Royal Marsden from June 2020 to August 2021. 16 patients were planned each in the PC and BTC cohorts. Eligibility included radiologically suspicious PC/BTC without histological diagnosis, patients with prior non-diagnostic biopsy and inaccessible tumours. Liquid biopsy for ctDNA was collected for plasma based next generation sequencing, using a custom 59 gene panel of common variants in PC/BTC tumours, including analysis for somatic, copy number and structural variants. Clonal haematopoiesis of indeterminate potential (CHIP) and germline variants were identified and subtracted. A molecular tumour board (MTB) reviewed results for interpretation and clinical context. Primary outcome was the proportion of patients with a ctDNA result consistent with a diagnosis of malignancy following MTB discussion. Results: 32 patients with suspected PC (n= 16) and BTC (n=16) were recruited. Baseline characteristics are shown in table. ctDNA was detected in 69% off, 23 patients had a subsequent biopsy. The sensitivity and specificity of ctDNA as a diagnostic tool was 80% (90% CI 49.3-96.3) and 100% (90% CI 36.8-100) for PC respectively, and 100% (90% CI 60.7-100) and 75% (90% CI 24.9- 98.7) for BTC respectively. There were 2 false negatives in the PC cohort subsequently diagnosed with PC, and 1 false positive in the BTC cohort subsequently diagnosed with oesophageal cancer. Conclusions: ctDNA can be used to support a diagnosis of cancer in patients with radiologically suspected PC/BTC. A blood first, tissue second strategy in the diagnosis of PC/BTC could improve diagnostic efficiency, speed, and add resilience to the current diagnostic pathway.
ABSTRACT
Shared decision-making and peri-operative planning is vital for successful management of patients [1];however, multidisciplinary communication comes into its own when managing patients with challenging comorbidities. We discuss a 47-year-old man who presented for a hepatectomy for liver metastases from penile cancer. He had a background of idiopathic Lambert-Eaton syndrome, a prolonged critical care admission with COVID-19, steroid-induced diabetes and non-invasive ventilation-dependent type 2 respiratory failure. Thorough peri-operative planning and cross-specialty communication ensured a successful outcome for this patient. Description Following an appointment with his surgeon, our patient was assessed by the anaesthetic team in pre-assessment clinic where extended discussions occurred between his neurologist, respiratory physician, operating surgeon and anaesthetist. He was thoroughly risk assessed and details relayed to the patient. Armed with this information;he went home to consider his options. As non-operative options would not have provided a curative result he opted for surgery and a peri-operative plan was formed. He was unable to perform cardiopulmonary exercise testing, but was referred for and received inspiratory muscle training. On arrival to theatre he had a thoracic epidural sited and underwent a general anaesthetic with propofol and remifentanil, his cords were sprayed with lidocaine and no neuromuscular blockade was used. Arterial and central venous access were sited and invasive pressures and depth of anaesthesia monitoring was established in addition to standard monitoring. His epidural was used throughout with 0.1% levobupivacaine;he received no additional systemic opioids. We established steroid cover with a hydrocortisone infusion and ensured we continued his 3,4 diaminopyridine via nasogastric tube. He was ventilated with lung-protective ventilation and recruitment manoeuvres were performed before extubation. Surgery was completed uneventfully and he was extubated onto NIV. A planned extended stay on the post-anaesthesia care unit (PACU) ensured his pain control, fluid balance and respiratory measures were optimised, he returned to the ward and was discharged 4 days postoperatively. Discussion A multidisciplinary team approach increased the information available to the patient for him to make an informed decision. Input from the patient's usual physicians, communication within the peri-operative team, involvement of specialist physiotherapists and patient empowerment to engage in rehabilitation allowed for his peri-operative success.
ABSTRACT
Statement of purposeTo use data from a state-wide opioid overdose surveillance system in Michigan to evaluate changes in opioid overdose frequency during the COVID-19 pandemic.Methods/ApproachThe System for Opioid Overdose Surveillance (SOS) is a near real-time overdose surveillance system in the state of Michigan run out of the University of Michigan Injury Prevention Center, in collaboration with the Michigan HIDTA. SOS receives daily data feeds containing all EMS encounters involving naloxone administration, and daily data on suspected fatal overdoses from medical examiners covering ∼80% of the state’s population. We used SOS data to compare spatial and temporal changes in suspected opioid overdoses after 3/1/20, the approximate timing of the intensification of the COVID-19 pandemic, and compared those changes to those seen at the same time in 2019.ResultsFrom 3/1/20–9/16/20, suspected fatal overdoses were 15.0% higher than during the same time in 2019, and naloxone administrations by EMS were 28.8% higher;a majority of counties and cities saw analogous changes, though the magnitude varied. Rates of both suspected fatal overdoses and EMS naloxone administrations were higher in 2020 prior to March, but the difference increased following the start of the pandemic. By late August, rates of suspected fatal overdoses returned to 2019 levels, but EMS naloxone administration rates remained nearly 40% higher than the same time in 2019.ConclusionsEvidence suggests that overdose and the COVID-19 pandemic are interwoven crises, and resources are required to address both the isolation and stress of the pandemic, and the medical system excess burdens, which all may intensify substance use, and reduce the likelihood of seeking treatment.SignificanceOverdose remains a leading cause of death, and that burden has increased during the pandemic in Michigan. Approaches are needed to address secondary effects of the COVID-19 pandemic.
ABSTRACT
Statement of purposePreventing opioid misuse and opioid use disorder (OUD) is necessary given the opioid epidemic. Prevention programs for adolescents/young adults are needed to alter risk trajectories. We developed interventions using telemedicine (synchronous video conference) and a patient portal-like messaging system to address risk factors for opioid misuse/OUD among young Emergency Department (ED) patients. Our presentation describes these promising interventions and their feasibility and acceptability.Methods/ApproachIn Spring 2020, N = 40 ED patients ages 16–30 who were at risk for opioid misuse/OUD enrolled in a pilot trial involving screening/baseline assessments, motivational interviewing-based remote interventions (baseline telemedicine brief intervention [BI], 1-month of portal messaging), and a 1-month follow-up. Before COVID-19, N = 10 enrolled in the ED (in-person cohort: IPC);during COVID-19, N = 30 recent ED patients enrolled via phone recruitment (remote cohort: RC). Feasibility data are presented by cohort;acceptability data are combined.ResultsAmong the N=40, the sample had a mean age of 22.9 years. Gender was: 70% female, 5% non-conforming, 25% male. Race was: 75% White, 15% Black/African American, and 10% other racial identities;17.5% were Hispanic/Latinx. Regarding feasibility, eligibility rates were similar (IPC: 17%, RC: 15%);consenting rates differed (IPC: 100%, RC: 56%), likely due to the RC’s telephone approach. Portal engagement increased from the IPC (60%) to the RC (93%), possibly due to addressing technical difficulties and IPC user feedback. BI and portal satisfaction were high (M = 9.3 on a 1–10 scale and M = 8.5, respectively). Interventions exceeded motivational interviewing fidelity thresholds (adapted for portal messaging). Follow-up rates were high (IPC: 80%, RC: 93%).SignificancePreventing opioid misuse is critical to avoiding escalation of opioid use and overdoses, and emergency department patients are at increased risk. This study demonstrates the feasibility and acceptability of these intervention approaches via telemedicine for preventing future injuries.