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Introduction: Lung cancer patients often have a number of comorbidities which impacts patient mortality and morbidity rates. Lifestyle changes for this group of patients have the potential to positively impact both quality of life and longevity. The Yorkshire Cancer Research funded Prehabilitation Radiotherapy Exercise smoking Habit cessation And Balanced diet Study (PREHABS) was designed to determine if it is feasible to embed interventions promoting a healthier lifestyle into the radical lung radiotherapy pathway. Method(s): The PREHABS study was led by therapeutic radiographers trained in smoking cessation provision, motivational interviewing, informed consent and good clinical practice and a dietitian. Radiographers screened and consented study participants, delivered the exercise intervention and up to 12-weeks of smoking cessation support, whilst dietary advice was provided by the dietitian. Patients diagnosed with chronic obstructive pulmonary disease (COPD), were referred to a community based pulmonary rehabilitation service rather than the PREHABS exercise intervention. Ethical and regulatory approvals were secured in September 2021. Result(s): 61 patients were recruited between September 2021 and October 2022. The majority were female (n=42), mean age 73.1 years (SD 9.36 years). Discussion(s): In addition to the training requirements detailed above and the challenges of COVID-19, the radiographers had to become adept in a number of study-specific aspects including writing the study standard operating procedures (SOPs), creating a study organisational workflow and patient recruitment. The PREHABS study has broadened the radiographer's perspective beyond the radiotherapy department, by further understanding the complex comorbidities that lung cancer patients present with, how to motivate patients to positively change their lifestyle, and how the side effects caused by cancer treatment can affect a patient's ability to change their lifestyle. Conclusion(s): Therapeutic radiographers, after appropriate training, are capable of delivering lifestyle intervention support within a radical lung cancer radiotherapy pathway. Disclosure: No significant relationships.Copyright © 2023 Elsevier B.V.
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Much of today's data are represented as graphs, ranging from social networks to bibliographic citations. Nodes in such graphs correspond to records that generally represent entities, while edges represent relationships between these entities. Both nodes and edges in a graph can have attributes that characterize the entities and their relationships. Relationships are either explicitly known ( like friends in a social network), or they are inferred using link prediction (such as two babies are siblings because they have the same mother). Any graph representing real-world data likely contains nodes and edges that are abnormal, and identifying these can be important for outlier detection in applications ranging from crime and fraud detection to viral marketing. We propose a novel approach to the unsupervised detection of abnormal nodes and edges in graphs. We first characterize nodes and edges using a set of features, and then employ a one-class classifier to identify abnormal nodes and edges. We extract patterns of features from these abnormal nodes and edges, and apply clustering to identify groups of patterns with similar characteristics. We finally visualize these abnormal patterns to show co-occurrences of features and relationships between those features that mostly influence the abnormality of nodes and edges. We evaluate our approach on datasets from diverse domains, including historical birth certificates, COVID patient records, e-mails, books, and movies. This evaluation demonstrates that our approach is well suited to identify both abnormal nodes and edges in graphs in an unsupervised way, and it can outperform several baseline anomaly detection techniques.
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Much of today's data are represented as graphs, ranging from social networks to bibliographic citations. Nodes in such graphs correspond to records that generally represent entities, while edges represent relationships between these entities. Both nodes and edges in a graph can have attributes that characterize the entities and their relationships. Relationships are either explicitly known (like friends in a social network), or they are inferred using link prediction (such as two babies are siblings because they have the same mother). Any graph representing real-world data likely contains nodes and edges that are abnormal, and identifying these can be important for outlier detection in applications ranging from crime and fraud detection to viral marketing. We propose a novel approach to the unsupervised detection of abnormal nodes and edges in graphs. We first characterize nodes and edges using a set of features, and then employ a one-class classifier to identify abnormal nodes and edges. We extract patterns of features from these abnormal nodes and edges, and apply clustering to identify groups of patterns with similar characteristics. We finally visualize these abnormal patterns to show co-occurrences of features and relationships between those features that mostly influence the abnormality of nodes and edges. We evaluate our approach on datasets from diverse domains, including historical birth certificates, COVID patient records, e-mails, books, and movies. This evaluation demonstrates that our approach is well suited to identify both abnormal nodes and edges in graphs in an unsupervised way, and it can outperform several baseline anomaly detection techniques. © 2022 Copyright held by the owner/author(s).
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This paper examined the interconnectedness of COVID-19 and stock markets in some of th e most affected countries-USA, Italy, Spain and Germany. To this end, a time-varying cointegration technique was first employed to examine for the presence of comovementsbetween daily infections and stock market changes. A time-varying wild bootstrap likelihood ratio test was then employed to determine whether COVID-19 is a significant predictor of stock market performance. Lastly, an event study analysis was conducted to investigate the short-term effect of the outbreak on stock market returns. Findings revealed the existence of comovements between COVID-19 infections and stock price indices in all the selected countries. The rejection of the null hypothesis of no predictability was also recorded in all of the countries sampled. The event study analysis revealed that significant negative cumulative abnormal returns were predominant in all the countries. The reactions of the stock markets of the three European Union member countries included in the study to the pandemic are quite similar, suggesting that countries that are regionally and economically integrated are likely to experience relatively similar effects. The USA stock market was the most resilient to the impact of the outbreak
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Background: Older patients with cancer remain at high risk for negative outcomes from COVID-19 infection, particularly those who have multimorbidities and on immunosuppressive therapy. These patients have been excluded or underrepresented in pivotal COVID-19 vaccine clinical trials and there are ongoing concerns that they may not acquire the same level of protection from the available vaccines as the immunocompetent adults. Moreover, the level of protection wanes over time making them more susceptible to emerging COVID-19 novel variants of concern. Despite the implementation of global vaccination campaigns which have successfully reduced COVID-related hospitalisations and deaths in many parts of the world, there remains many unresolved issues and challenges to address as the pandemic ensues. With aging, concerns for age-related dysregulation and immune dysfunctions called immunosenescence may lead to potentially lower immunogenicity to vaccines. Despite receiving the primary vaccination, real-world evidence showed that both patients aged > 65 years and those with cancer have a higher risk of developing breakthrough COVID-19 infections and related complications. Subsequent booster doses are found to be effective at improving immune response, particularly against the novel variants, and the vulnerable population should be given the priority in booster campaigns. Method(s): Since the beginning of the pandemic in 2020, The International Society of Geriatric Oncology set up a COVID-19 Working Group comprised of multidisciplinary specialists by developing recommendations, advocacy, and action plans based on expert opinion and evidence related to older adults with cancer. Result(s): The table below summarises the updated recommendations from the SIOG COVID-19 Working Group. Conclusion(s): The SIOG COVID-19 Working Group supports ongoing public health interventions, continued mass immunisations, and booster campaigns targeting the most vulnerable members of the society, including older adults with cancer (Table Presented).
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BACKGROUND: The COVID-19 pandemic has limited in-lab cognitive testing. While at-home alternatives exist (testing over the phone), differences in test design and delivery complicate direct comparison of most in-lab and at-home tests. Here we describe the design, infrastructure, and implementation of the California Cognitive Assessment Battery (CCAB), a cognitive test battery and administration system. Using automated remote administration over cellular networks, identical computerized cognitive tests can be administered at-home or in the lab.
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Countries in Europe have rapidly scaled-up, redeployed, repurposed, retrained and retained their workforce during COVID-19 to create surge capacity, protect the health and well-being of the workforce, and ensure effective implementation of vaccination programmes. Doing so has had enormous governance implications, including the need for intra-governmental and cross-organisational governance actions, increased transparency for planning, and delegated leadership to health employers and health workers. It is important that stakeholders continue to learn and share their experiences on the effectiveness of different workforce governance responses to allow the health workforce to recover, rebuild and repurpose.
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Background This study considers some of the effective governance tools that have been utilised to mobilise, redeploy and repurpose the health workforce during the COVID-19 pandemic to create surge capacity, protect workforce health and wellbeing and ensure effective implementation of vaccination programmes. Methods Data were systematically extracted from the Observatory/WHO Europe/European Commission Health System and Response Monitor, covering the period from March 2020 to May 2021 with a focus on four dimensions of health workforce governance: national/regional government policies;legislation;regulation;the role and remit of employers and management. Results A wide-range of governance actions across all levels were required to ensure the health workforce could provide effective pandemic responses. Creating surge capacity, for example, often required adoption of emergency legislation to facilitate exceptional hiring procedures and the changing of (re-)registration requirements, as well as additional training and development of new competencies among other actions. Putting in place physical and mental health support meanwhile required defining infection control policies, monitoring PPE supply and distribution, ensuring access to free mental health support, and implementation of breaks. Some countries also allowed “new” types of workers to vaccinate;online or in person training;adjustments to payment mechanisms;and creating new supervision requirements. Conclusions Pandemic responses have broken up sclerotic governance structures which have hampered past health workforce development and reform, new training programmes have been rapidly developed, leadership roles have been delegated to a wider-range of health professionals than before and monitoring systems that provide more rapid data on staffing levels have been put into place. Learning from and evaluating these changes will be important to help inform future pandemic responses.
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Background: COVID-19 required restructuring of colorectal cancer (CRC) diagnostics. We instituted consultant telephone assessment of all urgent suspected cancer (USC) referrals. CT abdomen and pelvis (CTAP) and Faecal Immunochemical Testing (FIT) were the primary modalities of investigation in patients without rectal bleeding or anaemia. We report on efficacy and safety at 15 months follow up. Method(s): 277 USC CRC referrals were received between 1st April and 30th May 2020. Patients with rectal bleeding (n = 41) were directed to sigmoidoscopy. Consultant surgeons telephoned 236 non-bleeding patients of whom 196 were referred for FIT and CTAP, whilst 40 patients were downgraded from USC. 182 CTAP scans and 136 FIT tests were performed. Not all patients had both tests as positive CT findings prompted endoscopy referral and some patients declined further investigation. Result(s): Over two months, 16 diagnoses of CRC were made;15 from the CTAP/FIT group and one from flexible sigmoidoscopy (detection rate 5.8%). This compares to 524 USC referrals and 19 CRC diagnoses (detection rate 3.6%) over the equivalent period in 2019. Follow up at 15 months showed that no patient discharged from the USC pathway had re-presented with colorectal cancer. Conclusion(s): Combining FIT and CTAP in the USC setting draws on the developing use of FIT in CRC investigation. This was initially a pragmatic response to COVID-19, however our experience of using this pathway for exclusion of CRC will be relevant to maintenance and streamlining of USC services after the pandemic.
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Background: Cardiac Rehabilitation (CR) is a multidisciplinary approach involving exercise training and health-related education routinely available to cardiac patients, but rarely offered to people with stroke. We have shown people with stroke can be integrated into centre-based CR, but due to access difficulties, opportunities for people with stroke to participate in centre-based CR are limited. Home-based CR is well-established for people with heart disease and offers an alternative for people with stroke who are unable to access centre-based rehabilitation. Aim(s): Investigate the safety and feasibility of home-based, telehealthdelivered, stroke-adapted CR. Method(s): A single-site, prospective-cohort safety and feasibility trial. People with ischaemic stroke were screened for eligibility and invited to participate in a six-week program of exercise and education delivered via telehealth to the participant in their own home following discharge from inpatient rehabilitation (i.e. <6-weeks post-stroke). Safety and feasibility were assessed by incidence of adverse events and measures of participant recruitment, retention, and adherence. Result(s): Ninety-five people with stroke were screened, 67 (70%) were eligible to participate, and 19 (28%) consented. Of the 28 that were ineligible to participate, the main reasons for exclusion were haemorrhagic stroke (53%), nil medical clearance (18%), and nil acute stroke (14%). Of the 48 eligible participants that did not consent, 45% were not included due to the impact of COVID-19, 20% were discharged prior to being approached to participate, and 12% did not consent due to a lack of time. Three participants dropped out of the study prior to commencing the outpatient intervention. The remaining 16 participants completed the six-week intervention. Positive written and verbal feedback was received from participants on the appropriateness of the intervention. Conclusion(s): COVID-19 significantly impacted our capacity to recruit participants to this trial. Preliminary data suggests home-based, telehealthdelivered, stroke-adapted CR is safe and potentially feasible in early subacute stroke.
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Background: Severe restrictions on in-person encounters and endoscopic procedures for digestive care have occurred as a result of the COVID-19 pandemic. This has exacerbated pre-existing barriers in access to gastroenterology (GI) care across Nova Scotia (NS) for patients and primary healthcare providers (PHCPs). In response, a provincial PHCP-GI consultative service (GUT LINK) was implemented at a single tertiary care center with the goal of supporting PHCPs in the management of non-urgent GI referral conditions. Aims: To implement and evaluate the acceptability, feasibility, appropriateness, and early effectiveness of the GUT LINK PHCP-GI consultation service. Methods: This is an ongoing prospective observational cohort study. All referrals received through the EMR-based referral and triage management system between May and November 2020 that were deemed to be amenable to management within primary care with specialist support were returned to the PHCP with the suggestion to arrange a GUT LINK telephone consultation. GUT LINK appointments were scheduled through an administrative support telephone line with the PHCP and a GI specialist. A post-consultation e-questionnaire was distributed to PHCPs who consented to participate. Feasibility (number of and indication for referrals, PHCP participation rates), acceptability and appropriateness (satisfaction, future use, likelihood to recommend) metrics and outcomes (case resolution, re-referrals, proportion requiring endoscopic investigations) were recorded. Patient charts were reviewed to determine whether the patient ultimately required GI speciality care. Analyses were descriptive and expressed as frequencies, means (+/-SD), medians (+/-SE), and proportions (%). Results: A total of 45 GUT LINK consultations were completed between May and November 2020. Of these, 20% required GI specialist care and 80% have remained within primary care, with a median follow-up of 101 (+/-9.1) days. The indications for GUT LINK consultation included lower GI symptoms (64%), abnormal imaging or investigations (17%), and upper GI symptoms (19%). been completed. All PHCPs reported that GUT LINK consultation was easy to access, while 90% found the advice helpful and 80% reported that that it resolved the issue. Following the GUT LINK appointment, 80% felt they would not need to refer their patient to GI. Conclusions: The implementation of GUT LINK was acceptable, feasible, and improved access to specialist support for management of undifferentiated GI symptoms. Future research will focus on comprehensive stakeholder engagement in order to design, implement, and evaluate GUT LINK PHCP care pathways.
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Background: The COVID-2019 pandemic continues to restrict access to endoscopy, resulting in delays or cancellation of non-urgent endoscopic procedures. A delay in the removal or exchange of plastic biliary stents may lead to stent occlusion with consensus recommendation of stent removal or exchange at three-month intervals [1-4]. We postulated that delayed plastic biliary stent removal (DPBSR) would increase complication rates. Aims: We aim to report our single-centre experience with complications arising from DPBSR. Methods: This was a retrospective, single-center, observational cohort study. All subjects who had ERCP-guided plastic biliary stent placement in Halifax, Nova Scotia between Dec 2019 and June 2020 were included in the study. DPBSR was defined as stent removal >=90 days from insertion. Four endpoints were assigned to patients: 1. Stent removed endoscopically, 2. Died with stent in-situ (measured from stent placement to documented date of death/last clinical encounter before death), 3. Pending removal (subjects clinically well, no liver enzyme elevation, not expired, endpoint 1 Nov 2020), and 4. Complication requiring urgent reintervention. Kaplan-Meier survival analysis was used to represent duration of stent patency (Fig.1). Results: 102 (47.2%) had plastic biliary stents placed between 2/12/2019 and 29/6/2020. 49 (48%) were female, and the median age was 68 (R 16-91). Median follow-up was 167.5 days, 60 (58.8%) subjects had stent removal, 12 (11.8%) died before replacement, 21 (20.6%) were awaiting stent removal with no complications (median 230d, R 30-332), 9 (8.8%) had complications requiring urgent ERCP. Based on death reports, no deaths were related to stent-related complications. 72(70.6%) of patients had stents in-situ for >= 90 days. In this population, median time to removal was 211.5d (R 91-441d). 3 (4.2%) subjects had stent-related complications requiring urgent ERCP, mean time to complication was 218.3d (R 94-441). Stent removal >=90 days was not associated with complications such as occlusion, cholangitis, and migration (p=1.0). Days of stent in-situ was not associated with occlusion, cholangitis, and migration (p=0.57). Sex (p=0.275), cholecystectomy (p=1.0), cholangiocarcinoma (p=1.0), cholangitis (p=0.68) or pancreatitis (p=1.0) six weeks prior to ERCP, benign vs. malignant etiology (p=1.0) were not significantly associated with stent-related complications. Conclusions: Plastic biliary stent longevity may have been previously underestimated. The findings of this study agree with CAG framework recommendations [5] that stent removal be prioritized as elective (P3). Limitations include small sample size that could affect Kaplan-Meier survival analysis. Despite prolonged indwelling stent time as a result of COVID-19, we did not observe an increased incidence of stent occlusion or other complications.
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Context: When authentic clinical experiences are unavailable, instructors may need to consider alternatives for evaluating clinical reasoning. Objective: Describe an educational technique that simulates clinical experiences to allow students to demonstrate clinical reasoning. Background: The COVID-19 pandemic created a situation where providing clinical experiences became impossible. Yet, students still needed to exercise clinical judgement as part of their athletic training education program. The unfolding case study technique aligns well with Kolb's Theory of Experiential Learning and can be used to help students improve clinical reasoning and critical thinking skills. Description: An unfolding case study was used to simulate a clinical experience for students when clinical sites became unavailable to students due to COVID-19. The technique involves using a case study over time where the student receives information, evaluates the information, makes a clinical decision in response to the information, and receives further information and feedback based on their decision. This repeats until the student reaches the conclusion of the case. Clinical Advantages: Students found this assignment to be beneficial as it allowed them to practice clinical reasoning and critical thinking in a realistic, yet low risk environment. Students were able to learn new skills in documentation and billing for services. The assignment allows for critical feedback to be given to the students at multiple points. Conclusions: The unfolding case study can be an effective substitute for a clinical experience in extreme situations. The unfolding case study allows students to exercise clinical judgement in a safe environment.
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Digital health tools hold the potential to improve the efficiency, accessibility and quality of care. Before the pandemic, efforts had been made to support implementation across Europe over many years, but widespread adoption in practice had been difficult and slow. The greatest barriers to adoption of digital health tools were not primarily technical in nature, but instead lay in successfully facilitating the required individual, organizational and system changes. During the COVID-19 pandemic many digital health tools moved from being viewed as a potential opportunity to becoming an immediate necessity, and their use increased substantially. Digital health tools have been used during the pandemic to support four main areas: communication and information, including tackling misinformation;surveillance and monitoring;the continuing provision of health care such as through remote consultations;and the rollout and monitoring of vaccination programmes. Greater use of digital health tools during the pandemic has been facilitated by: policy changes to regulation and reimbursement;investment in technical infrastructure;and training for health professionals. As the pandemic comes under control, if health systems are to retain added value from greater use of digital health tools, active strategies are needed now to build on the current momentum around their use. Areas to consider while developing such strategies include: Ensuring clear system-level frameworks and reimbursement regimes for the use of digital health tools, while allowing scope for co-design of digital health solutions by patients and health professionals for specific uses. Combining local flexibility with monitoring and evaluation to learn lessons and ensure that digital health tools help to meet wider health system goals.
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Aim: The ongoing Covid-19 pandemic has interrupted surgical treatment of colorectal cancer (CRC). This systematic review will assess literature concerning the risk of delay of elective surgery for CRC patients, focusing on overall survival (OS) and disease-free survival (DFS). Methods: A systematic review was performed as per PRISMA guidelines (PROSPERO ID: CRD42020189158). Medline, EMBASE and Scopus were searched. Patients over 18 with a diagnosis of colon or rectal cancer who received elective surgery as primary treatment were included. Delay was defined as the period between CRC diagnosis and day of surgery. Metanalyses of the outcomes OS and DFS were conducted. Forest plots, funnel plots, tests of heterogeneity, and estimated Number Needed to Harm (NNHs) were produced. Results: Of 3753 articles identified, seven met the inclusion criteria. Encompassing 314560 patients, three of the seven studies showed a delay to elective resection was associated with poorer OS or DFS. OS was assessed at a one-month delay, the HR for six datasets was 1.13 (95%CI 1.02-1.26, p=0.020) and at three months the HR for three datasets was 1.57 (95%CI 1.16-2.12, p=0.004). Estimated NNHs for a delay at one month and three months were 35 and 10 respectively. Delay was nonsignificantly negatively associated with DFS on metanalysis. Conclusions: This review recommends elective surgery for CRC patients is not postponed longer than four weeks, as evidence suggests extended delays from diagnosis are associated with poorer outcomes. Focused research is essential so patient groups can be prioritized based on risk-factors for future pandemics.