Safe provision of elective endocrine surgery operations amid the COVID-19 crisis

IntroductionThe aim of this study was to determine the impact of the COVID-19 pandemic on the provision of clinical services (perioperative clinical outcomes and productivity) of the department of endocrine and general surgery at a teaching hospital in the UK.MethodsA retrospective chart review was conducted of all patients who were operated in our department during two periods: 1 April to 31 October 2019 (pre-COVID-19 period) and 1 April to 31 October 2020 (COVID-19 period). The perioperative clinical outcomes and productivity of our department for the two time periods were compared.ResultsIn the pre-COVID-19 period, 130 operations were carried out, whereas in the COVID-19 group, this reduced to 89. The baseline characteristics between the two groups did not significantly differ. Parathyroid operations decreased significantly by 68% between the two study periods. Overall, during the COVID-19 phase, the department maintained 68% of its operating workload compared with the respective 2019 time period. The clinical outcomes for the patients who had a thyroid/parathyroid/adrenal operation were not statistically different for the two study periods. There were no COVID-19 related perioperative complications for any of the operated patients and no patient tested positive for COVID-19 while an inpatient. For the COVID-19 group, the department maintained 67% of its outpatient appointments for endocrine surgery and 26% for general surgery pathologies.ConclusionsThe COVID-19 pandemic significantly reduced the clinical activity of our department. However, it is possible to continue providing clinical services for urgent/cancer cases with the appropriate safety measures in place.

The effect of the pandemic on the number of examined lymph nodes following major oesophophagogastric resection

Background: Lymph node yield following oesophagogastric (OG) cancer resection remains a valuable prognosticator of overall patient survival. It is also a quality indicator of histopathological assessment and a surrogate marker of surgical technique. The Royal College of Pathologists' state a minimum lymph node yield of 15 per specimen should obtained in 100% of cases where a radical OG resection has been undertaken. It is well known that the COVID-19 pandemic placed immense strain on NHS services. This study aimed to evaluate its effect on lymph node yield reporting following major OG resection in a large volume tertiary unit. Method(s): Retrospective National OG Cancer Audit (NOGCA) metrics were collected. Histological data including total lymph node yield and positive node status were extracted from patient records. Patient data was categorised into two study periods;pre-pandemic (March 2018-Feb 2020) and pandemic (March 2020- Feb 2022) following the first UK national lockdown. Comparative analysis between the two study periods was performed and for lymph node yield >15 per specimen a X2 statistic calculated. Result(s): In the pre COVID period a total of 280 (excluding GIST) resections were performed, 75% (210) oesophagectomies v. 25% (70) gastrectomies. The median age was 69 (range 25-90, males= 189 v. females =91). In the post pandemic period a total of 188 resections were performed, 72% (135) oesophagectomies v. 28% (53) gastrectomies. The median age was 69 (38-87, males = 142 v. female= 46). Lymph node yield was available for 275 resections in pre-pandemic study period, with a median nodal yield of 20 (5-61). In the pandemic study period lymph node yield data was available for 180 patients, median 19.5 (0-69). The minimum nodal yield (>15) was obtained in 80.7% of resection specimens pre-pandemic v. 68.9% in the pandemic study period (p= 0.00382). Conclusion(s): Our study demonstrates a higher rate of inadequate nodes examined in the post pandemic study period. Despite staffing pressures, efforts should be made to improve number of nodes examined to provide robust prognostic data.

Maintaining high volume oesophagagogastric resections during the COVID-19 pandemic: A single centres experience utilising the independent sector

Background: With many resources redirected to care for the those affected by the COVID-19 pandemic, the NHS faced unprecedented pressure to maintain oesophagogastric (OG) cancer resectional services. Our institution along with many tertiary units across the country were faced with limited access to essential critical care beds. The implementation of emergency contracts between the NHS and the independent sector (IS) allowed our unit to maintain a high volume resectional service by utilising the resources of a local private hospital with HDU/ ITU provision. We began operating within the IS shortly after the first UK lockdown in March 2020, and continued through till February 2022. During this period, we continued operating at our tertiary unit (TU) albeit at a reduced capacity. This study aimed to evaluate the surgical outcomes of patients undergoing major OG resectional surgery between the two sites. Method(s): This retrospective study included all patients who underwent major OG resectional surgery (including GIST) from March 2020-February 2022. Operation type and site were identified using OPCS-4 clinical codes and combined with National OG Cancer Audit (NOGCA) data to compare basic patient demographics, length of stay, complication rates, COVID infection rates and 90-day mortality. Descriptive and statistical analysis between the two operating sites was performed. Result(s): A total of 204 major OG resections were undertaken, 44% (89) at our TU;57 oesophagectomies and 32 gastrectomies, with 56% (115) at a local IS hospital;86 oesophagectomies and 29 gastrectomies. Additionally, 13 (6.4%) open and close procedures were performed across both sites. Median patient age was similar, 69 (45-86) years at our TU v. 68 (38-85) years at the IS site. A higher proportion of ASA 3 patients (46%) were operated on at our TU. No difference in median length of stay was observed;TU= 8 (1-93) days v. IS =9 (3-69) days, this included all patients who were repatriated to the TU. Higher complication rates seemed to occur in patients operated at the IS site v. the TU though these did not reach statistical significance;18 (15.7%) patients suffered an anastomotic leak v. 9 (10.1%) respectively (p= 0.246). 21 (18.3%) v. 13 (14.6%) patients suffered a major respiratory (p=0.487) and 4 (3.5%) v. 1 (1.1%) a major cardiac (p=0.281) complication. There were no cases of COVID infection within 30 days of primary procedure at the IS site, with 2 cases within the TU cohort. Our 90-day mortality rates were similar (IS= 4.54% v. TU=5.32%), p=0.661. Conclusion(s): Our study demonstrates that resection of patients with OG cancer is feasible in an independent sector hospital if supported by critical care. It allowed a high-volume tertiary unit to continue offering potentially curative surgery to patients whose treatment options would have otherwise been limited to oncological therapy only. Long term survival data compared to non-resecting trusts is required to determine whether this approach was superior. When considering future pandemic planning, we have demonstrated the value of this model in maintaining major OG resectional services.

Adult life-course trajectories of psychological distress and economic outcomes in midlife during the COVID-19 pandemic: evidence from the 1958 and 1970 British birth cohorts.

PURPOSE: Financial adversity in times of economic recession have been shown to have an unequal effect on individuals with prior mental health problems. This study investigated the relationship between mental health groupings across the adult life-course and change in financial situation and employment status during the COVID-19 pandemic, as well as the use of financial measures to mitigate the economic shock. METHODS: Using two nationally representative British birth cohorts, the National Child Development Study (1958) n = 17,415 and 1970 British Cohort Study n = 17,198, we identified 5 different life-course trajectories of psychological distress from adolescence to midlife which were similar but not identical across the two cohorts. We explored their relation to changes in financial and employment circumstances at different stages during the pandemic from May 2020 to March 2021, applying multinomial logistic regression and controlling for numerous early life covariates, including family socio-economic status (SES). In addition, we ran modified Poisson models with robust standard errors to identify whether different mental health trajectories were supported by government and used other methods to mitigate their financial situation. RESULTS: We found that the financial circumstances of pre-pandemic trajectories of psychological distress with differential onset, severity, and chronicity across the life-course were exacerbated by the COVID-19 economic shock. The 'stable-high' (persistent severe symptoms) and 'adult-onset' (symptoms developing in 30s, but later decreasing) groups were vulnerable to job loss. Compared to pre-pandemic trajectory groupings with no, minor, or psychological distress symptoms in early adulthood, the 'stable-high', 'midlife-onset' (symptoms developing in midlife), and 'adult-onset' trajectory groups were more likely to seek support from the UK governments economic response package. However, trajectories with pre-pandemic psychological distress were also at greater risk of reducing consumption, dis-saving, relying on increased financial help from family and friends, and also taking payment holidays (agreements with lenders to pause mortgage, credit card or loan payments for a set period) and borrowing. CONCLUSION: This work highlights different trajectories of pre-pandemic psychological distress, compared to groups with no symptoms were more vulnerable to pandemic-related economic shock and job loss. By adopting unsustainable mitigating measures (borrowing and payment holidays) to support their financial circumstances during COVID-19, these mental health trajectories are at even more risk of lasting adverse impacts and future economic difficulties.

The impact of classic Hodgkin lymphoma (cHL) on informal caregivers: Results from the cHL-Real-world observations from physicians, patients, and caregivers on the disease and its treatment (CONNECT) study

Background: The health and work productivity burden informal cHL patient (pt) caregivers face is unknown. As part of the US-based CONNECT study, we evaluated caregivers' burden and role in treatment (tx) decisions by relation to the pt: spouse/partner (SP) vs other (parent, child, friend, other relative). Methods: The CONNECT caregiver survey was an IRB-approved online survey administered from Dec 2020-Mar 2021 to self-identified current or former adult cHL pt caregivers. Health-related quality of life (HRQoL, PROMIS-Global), work impact (WPAI), decision-making, tx selection, and physician communication were assessed. Statistical significance was at the 95% confidence level. Results: 209 caregivers (58% women;median age 47 yrs;54% employed;53% SP) completed the survey. At completion, 69% cared for pts diagnosed in the past 1-2 yrs;48% of pts cared for had stage III/IV cHL and 58% were in remission/not receiving active tx. While caregiver HRQoL was similar to that of the general population on the PROMIS-Global, employed caregivers had work impairment (29%) from caregiving activities (Table) which was higher when the pt was on vs off tx. Caregiving began at pt symptom onset for more SP vs other caregivers (61 vs 27%), and after the pt's first tx for more other vs SP caregivers (34 vs 5%). 88% of caregivers discussed tx options with the pt. Cure, caregivers' top tx goal (49%), was rated higher by SP vs other caregivers (56 vs 42%). Tx decisions with the pt (54 vs 23%) and tx option discussions with the doctor (52 vs 28%) were more common for SP vs other caregivers. More SP vs other caregivers had extensive tx option discussions with the pt (88 vs 68%), said it was important the doctor discussed managing side effects (94 vs 84%), felt the doctor provided adequate information about side effects (91 vs 71%), and felt aligned with the pt's tx goals (93 vs 79%). Caregivers noted COVID-19 impacts like limiting daily activities to reduce COVID-19 risks (72%). Conclusions: Although cHL pt caregivers reported good HRQoL, caregiving impacted their work productivity regardless of relation to the pt. Cure was caregivers' top tx goal. SP vs other caregivers were more involved and earlier, reporting alignment with pt tx goals and decision-making.

READING the WAVES: IDENTIFYING DISTINCT PHENOTYPES of MULTISYSTEM INFLAMMATORY SYNDROME in CHILDREN in A SINGLE CANADIAN CENTER during the 2020-2021 COVID-19 PANDEMIC

Background: The COVID-19-associated multisystem infammatory syndrome in children (MIS-C) is characterized by Kawasaki disease (KD)-like features and circulatory shock [1]. The genesis of SARS-CoV-2 variants triggered successive waves of mass infections followed by MIS-C outbreaks. Objectives: To compare MIS-C phenotypes across the waves of the COVID-19 pandemic. To identify predictors of pediatric intensive care unit (PICU) admission and treatment with biologic agents. Methods: Youth aged 0-18 years, fulflling the WHO case defnition of MIS-C, and admitted to the Alberta Children's Hospital during the COVID-19 pandemic (May 2020-December 2021) were included. Clinical, laboratory, imaging, and treatment data were captured (KD-like manifestations, signs of shock and/or hypotension, peak C-reactive protein (CRP) and ferritin, platelet count nadir, peak NT-proBNP and troponin, liver enzyme abnormalities, sodium and albumin nadir, echocardiogram fndings, biologic agents). Results: 57 consecutive MIS-C patients (median age 6 years, IQR 4-6;72% males) were included. 31 patients (54%) required PICU admission. All received immunoglobulins, 44 (77%) received corticosteroids, 8 patients (14%) were treated with biologic agents. Patients presenting during the third (mainly driven by Alpha variant) or fourth wave (mainly driven by Delta variant) presented with higher ferritin and NT-proBNP levels, and more liver enzyme abnormalities, hypoalbuminemia and thrombocytopenia compared to those presenting during the frst or second wave (Table 1, Figure 1). PICU admission was associated with the presence of shock/hypotension, higher CRP, ferritin, and NT-proBNP levels, lower albumin levels, and the presence of ventricular dysfunction on echocar-diogram (Table 1). A logistic regression model combining peak NT-proBNP, tro-ponin and ferritin levels explained 70% (Nagelkerke R2) of the variance in PICU admission and correctly classifed 91% of the cases. NT-proBNP was the sole signifcant contributor (p=0.017). Treatment with biologic agents was associated with higher CRP (mean 148.8 mg/l versus 251.7 mg/l;p=0.024) and ferritin (797 μg/l versus 1280 μg/l;p=0.049) levels. Conclusion: A shift in MIS-C phenotype was identifed across the successive COVID-19 waves, including the predominance of features associated with macrophage activation syndrome in later stages. These fndings may refect the impact of distinct SARS-CoV-2 variants. NT-proBNP emerged as the most important MIS-C feature predicting PICU admission, underscoring the importance of monitoring.

Interpretable Hierarchical Bayesian Modeling of Cell-Type Distributions in COVID-19 Disease

High-throughput sequencing of ribonucleic acid molecules is used increasingly to understand gene expression in organs, tissues, and therapies, at a single-cell level. To facilitate the discovery of the heterogeneity and cell-specific factors of the COVID-19 disease, we use an interpretable computational approach that derives cell mixtures from peripheral blood mononuclear cells of healthy donors, and influenza, asymptomatic, mild and severe COVID-19 patients. Cell mixtures are generated using hierarchical Bayesian modeling and are subsequently used as features in the gradient boosting tree classifier. Balanced accuracy of five-fold cross-validation was 68%, significantly higher than expected by random chance. Moreover, 11 out of 19 donors' samples were classified accurately. The main advantage of the mixture-based approach compared to the traditional feature-based classification, is its ability to capture associations between genes as well as between cells. © 2022 IEEE.

Classical Hodgkin Lymphoma;Real-World Observations from Physicians, Patients, and Caregivers on the Disease and Its Treatment (CONNECT): Observations of Physicians on Treatment and Interim PET-Adapted Regimens

Background Current NCCN guidelines recommend 1 of 3 first-line (1L) regimens for stage III or IV classical Hodgkin lymphoma (cHL): ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine), A+AVD (brentuximab vedotin, doxorubicin, vinblastine, dacarbazine), or escalated BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone);preferred regimens vary by region (e.g., North America vs Europe). The NCCN recommends positron emission tomography/computerized tomography (PET/CT) imaging after cycle 2 (interim PET2) to guide ABVD escalation or de-escalation. We surveyed physicians on their cHL treatment decision-making process and how PET/CT scan access, reimbursement, and comprehension influence their choices as part of CONNECT, the first real-world survey of physicians, patients, and caregivers in cHL. Methods Medical oncologists, hematologist/oncologists, or hematologists who treat cHL were invited to participate in an Institutional Review Board-approved, 30-minute online anonymous survey. Eligible participants had ≥2 years of practice experience in the United States (US) and treated ≥1 adult (aged ≥18 years) with stage III or IV cHL and ≥1 adult with cHL in the 1L setting within the prior 12 months. Surveys were completed from October 19, 2020-November 16, 2020. Results Of 301 participating physicians, 80% were hematologist/oncologists with a median practice duration of 15 years;62% practiced in community and 38% in academic settings. Participants were located in the US (South, 34%;Northeast, 26%;West, 21%;Midwest, 20%) and spent 90% of their professional time in direct patient care. In the preceding 12 months, participants treated a median (interquartile range) of 16 (7-40) patients with active cHL (stage III [median], 4;stage IV, 5) and 15 (8-40) cHL survivors. When treating cHL, 88% of participants reported giving NCCN guidelines somewhat/significant consideration. Overall, 94% of participants (n=284) reported using a PET/CT combined scan to diagnose/stage cHL, in line with current guideline recommendations. Of these participants, 97% reported typically getting an interim PET/CT scan for stage III or IV cHL with 65% typically getting the scan after cycle 2 (Figure A). Participants reported both escalating and de-escalating treatment based on interim PET/CT results (Figure B) with 61% making decisions after cycle 2. Of participants using a PET/CT scan, 42% reported receiving both a Deauville score and a standardized uptake value (SUV;Figure C) with 62% of participants noting that the Deauville score was the primary system used for reviewing PET/CT results (Figure D). However, 19% of participants reported challenges interpreting PET/CT results. Among participants using a Deauville score (n=209), consensus was limited on what defined a positive scan (≥3, 44%;≥4, 37%). Challenges obtaining PET/CT scans were reported by 16% of participants using PET/CT scans. However, despite not reporting challenges 55% of participants on average were unable to obtain a PET/CT scan 20% of the time. Of participants using PET/CT scans, 86% reported typically receiving results within 2 business days and 14% within 3-5 business days. Twenty-one percent of participants reported that delays in PET/CT results affected their ability to use a PET-adaptive approach. Forty-nine percent of those using PET/CT scans reported increased difficulty in PET/CT access for stage III or IV cHL due to lack of insurance coverage. In absence of a PET/CT scan, 36% of participants reported using an interim biopsy and 63% an interim CT scan to inform treatment choices. Among all participants, 36% reported increased difficulty in getting patients with cHL access to PET/CT scans due to COVID-19. Conclusions Although participants consider NCCN guidelines when treating cHL, interim PET scans are not universally obtained after cycle 2 for stage III or IV cHL, with 65% of participants who use PET/CT scans obtaining an interim PET scan after cycle 2 for stage III or IV cHL. When PET/CT scans are obtained, Deau ille scores are commonly provided;however, there is variability in what is termed a positive or negative Deauville score. Challenges in obtaining PET/CT scans, with increased difficulty during COVID-19, were reported. Also, there are other barriers, such as lack of insurance, that may prohibit the optimal adherence to guidelines on interim PET/CT utilization. [Formula presented] Disclosures: Parsons: SeaGen: Consultancy. Yu: Seagen, Inc: Current Employment, Current equity holder in publicly-traded company. Liu: Seagen, Inc: Current Employment, Current equity holder in publicly-traded company. Kumar: Seagen, Inc: Consultancy. Fanale: Seagen, Inc: Current Employment, Current equity holder in publicly-traded company. Flora: Seagen, Inc: Research Funding.

Is a Requirement to Wear a Mask Economically Valid During COVID-19?

Two of the most important categories of government intervention in response to COVID-19 are business closures and mask mandates. The scientific literature supports the efficacy of mask-wearing to reduce the transmission of respiratory viruses (including COVID-19). However, the efficacy is greater in stopping outbound transmission (meaning that my mask protects you) than inbound transmission (meaning that my mask protects me). Evidence suggests that the full benefits to society of wearing masks are far greater than the full costs to society of wearing masks. The author argues that mask-wearing is far more cost effective than business closures in controlling the spread of COVID-19. Moreover, the author argues that highly infectious diseases have an externality dimension. The person infected with COVID-19 makes a decision regarding whether to wear a mask based on their own perceived costs and benefits of mask-wearing, but that decision has consequences for those they come in contact with: the infected person's decision not to wear a mask imposes costs on others that are external to the infected person's decision process not to do so. The author further argues that some possible methods by which to deal with such an external cost (individual negotiations, a tax on spreading COVID-19, or as subsidy for wearing masks) are impractical. This makes a mask-wearing government mandate economically valid.

Safe provision of elective endocrine surgery operations amid the COVID-19 crisis.

INTRODUCTION: The aim of this study was to determine the impact of the COVID-19 pandemic on the provision of clinical services (perioperative clinical outcomes and productivity) of the department of endocrine and general surgery at a teaching hospital in the UK. METHODS: A retrospective chart review was conducted of all patients who were operated in our department during two periods: 1 April to 31 October 2019 (pre-COVID-19 period) and 1 April to 31 October 2020 (COVID-19 period). The perioperative clinical outcomes and productivity of our department for the two time periods were compared. RESULTS: In the pre-COVID-19 period, 130 operations were carried out, whereas in the COVID-19 group, this reduced to 89. The baseline characteristics between the two groups did not significantly differ. Parathyroid operations decreased significantly by 68% between the two study periods. Overall, during the COVID-19 phase, the department maintained 68% of its operating workload compared with the respective 2019 time period. The clinical outcomes for the patients who had a thyroid/parathyroid/adrenal operation were not statistically different for the two study periods. There were no COVID-19 related perioperative complications for any of the operated patients and no patient tested positive for COVID-19 while an inpatient. For the COVID-19 group, the department maintained 67% of its outpatient appointments for endocrine surgery and 26% for general surgery pathologies. CONCLUSIONS: The COVID-19 pandemic significantly reduced the clinical activity of our department. However, it is possible to continue providing clinical services for urgent/cancer cases with the appropriate safety measures in place.

Substance use behaviours and the UK furlough scheme: evidence from eight longitudinal population surveys

Disruptions to economic activity such as job loss can impact substance use behaviours. During the COVID-19 pandemic many countries implemented a furlough scheme to prevent job loss. We examine how furlough was associated with respondents' substance use behaviours in the initial stages of the pandemic in the UK. Data were from over 27,000 participants in eight adult longitudinal surveys. Participants self-reported economic activity (furlough or job loss vs stable employment) and smoking (any current), vaping (any current) and drinking alcohol (>4 days/week or 5+ drinks per typical occasion) both before and during the initial stages of the pandemic. Changes in frequency/quantity of substance use were also examined. Risk ratios were estimated within each study using modified Poisson regression, adjusting for a range of potential confounders, including pre-pandemic behaviour (though this was excluded in analyses of behaviour change). Findings were synthesised using a random effects meta-analysis. Compared to stable employment, participation in the furlough scheme was associated with smoking (risk ratio: 1.24 [95% CI: 1.08-1.42];I2=0%) while job loss was associated with vaping (1.72 [1.10-2.71];I2=25%) and heavier drinking (1.21 [1.02-1.43];I2=2%), but these associations were largely accounted for by confounders (adjusted risk ratios: smoking: 1.06 [0.96-1.16];I2=8%;vaping: 1.55 [0.93-2.56];I2=42%;and drinking: 1.03 [0.89-1.20];I2=35%). Furlough was associated with drinking more than before the pandemic (adjusted risk ratio: 1.15 [1.00-1.33];I2=70%), and with increases in vaping behaviour (1.54 [1.14-2.07];I2=0%). Increased drinking associated with furlough is concerning, while increased vaping likely represents moves to reduce smoking and may be positive.