Better Care Through Hypofractionation

Aim: In the context of the COVID-19 pandemic, the radiation oncology department at our institution aimed to adapt its approach by analyzing and expanding the use of hypofractionation in order to be able to continue treating patients according to prescribed timelines, to reduce the risks of patient and staff exposure to COVID-19 and minimize the risks of service interruptions due to departmental outbreaks. Process: Site specific treatment groups were asked to review existing literature on hypofractionation. Practice guides were then developed for each tumour site and a hypofractionation policy was created. To ensure close follow-up of this policy, weekly meetings were established in each treatment group in which all cases were reviewed. The use of non-hypofractionated schedules had to be justified by the treating physician. Data were collected to analyze the impact of these measures on the service. Patients were surveyed to gauge the level of safety felt during their treatments. Benefits/Challenges: When the same number of patients treated per year is maintained, hypofractionation increases availability at treatment machines, allowing reallocation of human resources. For example, technologists could be allocated to other tasks such as quality improvement initiatives, patient education and research. Hypofractionation also reduces overall costs to cancer programs, where potential savings from the reduced costs could be reinvested in new technologies and radiotherapy equipment. Fewer fractions also increase patient comfort, reduce the number of visits and improve waiting room management. This approach also increases the capacity to prepare for the next wave of patients that is anticipated post-pandemic due to decreased access to diagnosis and care during the past two years. Impact/Outcomes: The use of hypofractionation quickly became common practice in our centre. In only a few months, the number of fractions given per new treatment start fell from 10.81 in 2019-2020 to 8.29 in 2020-2021. The sustainability of this practice change is maintained, as hypofractionation is now standard practice for most tumour sites at our institution. Satisfaction amongst patients regarding this change during the first wave of the pandemic was very high (70% very satisfied and 30% satisfied). Radiotherapy centres facing human resource shortages as well as the health care network as a whole would benefit from expanding the use of hypofractionation in their centres. Copyright © 2022

A SNAPSHOT ASSESSMENT OF TELEHEALTH COMPETENCIES ACROSS FOUR YEARS OF MEDICAL SCHOOL

SETTING AND PARTICIPANTS: Methods A survey was distributed to medical students of the Rutgers Robert Wood Johnson Medical School or New Jersey Medical School in March to July 2021. Self-reported frequency and quality of exposure to telemedicine-based clinical activities were compared across the four years. Knowledge-based questions to evaluate general telehealth knowledge and self-assessment questions were created based on the AAMC Telehealth Competencies guidelines. The responses were compared along different levels of education and exposure to clinical telehealth activities. DESCRIPTION: Background Telehealth services are an essential part of healthcare delivery, but only 42% of medical schools have a formal telehealth curriculum. During the SARS-CoV-2 pandemic, medical students have been exposed to more telehealth- based clinical activities. The purpose of this study is to investigate the effect of exposure to telehealth activities on medical students' telehealth-based knowledge and self-assessed competencies based on the AAMC telehealth-based competencies. EVALUATION: Results Of the 82 respondents, 89% had experience with standardized patients via telemedicine, with MS2 and MS4 students having almost double the exposure compared to the MS1 and MS3 students. 78% of students had exposure to actual patients via telemedicine with MS3 and MS4 students having triple the exposure compared to MS1 and MS2 students. During these experiences, 65% of students observed physicians conducting a patient interview while only 31% observed a physician performing a physical exam using telehealth modalities. In assessing their telemedicine knowledge, all years performed relatively equally, with higher performance in the Equity and Assessment domains and lower in the Technology and Safety domains. Self-reported confidence across several telehealth competencies domains increased from MS1 to MS4 students. Overall, MS4s demonstrated the highest confidence in their skills and had the most exposure to patients. 87% of students gave feedback that more telehealth services should be provided by physicians, and 63% felt telehealth increased patient satisfaction. DISCUSSION / REFLECTION / LESSONS LEARNED: Conclusion The results highlight the increased confidence in telehealth topics that have clinical parallels to in-person training, such as Equity and Assessment, but telehealth-specific topics like Communication and Ethics of telemedicine require more targeted education. The study advocates for integration of telehealth education into the medical school curriculum in order to foster student telehealth competencies and promote telemedicine in future stages of training.

Molecular iodine is not responsible for cytotoxicity in iodophors.

BACKGROUND: Ten percent povidone-iodine (PVP-I) was initially promoted as 'tamed iodine' as the chemical activity of the active biocide, uncomplexed or free molecular iodine (I2), is reduced 30- to 50-fold compared with Lugol's solution. The idea that I2 is responsible for topical iodine staining and irritation remains widely held. However, there are no controlled studies that characterize the cytotoxicity and staining of the hydrophobic I2 species compared with the other hydrophilic iodine species that comprise over 99.9% of the total iodine in topical iodine disinfectants. AIMS: To compare the staining properties of the I2 species with other topical iodine disinfectants; to evaluate if the concentrations of I2 in diluted PVP-I used to reduce severe acute respiratory syndrome coronavirus-2 in the nasal cavity are potentially cytotoxic; and to determine if high concentrations of I2 can be delivered beyond the stratum corneum into the hypodermis, which could provide a mechanistic rationale for I2 out-gassing. METHODS: Five liquid compositions that contained complexed and uncomplexed (free) I2 in aqueous and non-aqueous carriers were used to evaluate the interaction of I2 with mammalian cells in culture as well as human and pig skin. FINDINGS: Concentrations of I2 (7800 ppm) that are 1500 times higher than that found in PVP-I can be applied to skin without irritation and staining. I2 is not cytotoxic at concentrations >100 times higher than that found in PVP-I, and does not contribute materially to staining of skin at concentrations found in Lugol's solution (approximately 170 ppm). I2 can partition into hypodermis tissue, remain there for hours and out-gas from skin. PVP-I and Lugol's solution are highly effective topical disinfectants, but do not facilitate diffusion of I2 through the stratum corneum. CONCLUSION: The maximum concentration of I2 found in diluted PVP, approximately 25 ppm, is not cytotoxic or irritating. The potential clinical utility of I2 has been limited by incorporating this broad-spectrum biocide into acidic aqueous formulations that contain numerous chemical species that contribute toxicity but not biocidal activity. I2 can be delivered topically into hypodermis tissue without irritation.

Frontline Therapy with Bendamustine-Rituximab (BR) in Patients with Treatment-Naïve Waldenstrom's Macroglobulinemia Confers Similar Long-Term Outcomes to R-CVP in a Real-World Setting: A Population-Based Analysis

Background: Waldenström macroglobulinemia (WM) is a rare, indolent B-cell lymphoproliferative disorder. After the STiL-1 trial (Rummel MJ. Lancet. 2013;381(9873):1203-1210) demonstrated significant benefit in a subgroup analysis as well as reduced toxicity using bendamustine and rituximab (BR) compared to R-CHOP (N=41 enrolled WM patients), BR became the preferred immunochemotherapy (IC) regimen for all patients with symptomatic treatment naïve (TN) WM in British Columbia (BC) since 2014. Prior to the introduction of BR, the combination of rituximab, cyclophosphamide, vincristine, and prednisone (RCVP), was the standard of care in BC for this population since 2004, given its widespread use across a broad range of indolent B-cell lymphomas. We report a population-based analysis evaluating outcomes in TN-WM patients comparing BR with RCVP. Methods: The BC Cancer Centre for Lymphoid Cancer Database was used to identify TN-WM patients treated with BR or RCVP as their first systemic therapy between August 1, 2004 - August 1, 2020. A period of observation but no prior to systemic therapy was permitted. All patients had clinicopathologically confirmed lymphoplasmacytic lymphoma and measurable monoclonal IgM. Event-free survival (EFS) was defined as time from start of IC to progression, relapse, initiation of alternative therapy, histologic transformation, or death due to any cause. Early progression (POD24) was defined as relapse or progression, death from lymphoma, or treatment toxicity within 24 months of initiation of systemic therapy. Outcomes were compared with a historical cohort of patients treated with frontline RCVP. Responding patients were eligible to receive maintenance rituximab (MR) every 3 months for 2 years since 2006;however this was discontinued in 2020 when a subgroup analysis of the MAINTAIN trial (Rummel MJ. Blood 2019;134 (Supplement_1): 343), showed a lack of PFS benefit after BR, coupled with safety and vaccine response concerns during the COVID-19 pandemic. Results: A total of 111 patients with WM were identified;57 treated with BR, 54 treated with RCVP. Median age was 69 years (range 33-89) and baseline characteristics (Table 1), were well-balanced. A higher proportion of RCVP-treated patients received >4 cycles of chemotherapy (81% vs 65%, p=0.049). After IC, 75 (68%) received MR, with 36 (63%) and 39 (72%) in the BR and RCVP groups respectively (p=0.3). Median follow-up from diagnosis for all living patients was 5.9 years (range 0.8-19.2), with median 4.4y vs 9.8y for BR and RCVP respectively. EFS estimates at 4-years achieved with BR were 57% (95% CI 40-71%) compared to RCVP 60% (95% CI 45-72%), p=0.5 (Figure 1). Median EFS was established for RCVP due to longer duration of follow up at 6.3 years (95% CI 3.6-11.8y). Overall survival (OS) estimates at 4-years were 74% (95% CI 57-85%) and 81% (95% CI 67-89%) for BR and RCVP patients respectively, p=0.6. Worse performance status (≥2) was the only pre-treatment factor identified as significant for inferior EFS. A sub-analysis limited to patients that received >4 cycles of IC also showed no clear difference in outcomes between BR and RCVP. Median time to transformation was 6.5y (5.5-13y), with only 3 late biopsy-proven events. Early progression (POD24) has occurred in 19 (18%) patients, with inferior survival observed in patients that had an early event compared with a reference cohort (2-years event free), however this did not reach statistical significance (p=0.3) (Figure 1). Conclusion: This population-based analysis of TN-WM patients treated with upfront IC confirms the excellent outcomes that can be achieved with a finite course of therapy. In contrast to prior studies, similar outcomes were observed with RCVP and BR. Further, regardless of front-line therapy, POD24 may be associated with inferior outcome but larger studies are needed. To our knowledge, this study is the first to make a direct comparison between BR and RCVP, and one of the largest restricted to IC-treated TN-WM. This data supports RCVP as a viable option, and should ser e to inform clinicians, patients, and policy makers in decision-making when considering upfront therapeutic options, and when considering indefinite alternative regimens such as BTK inhibitors. [Formula presented] Disclosures: Gerrie: AbbVie: Honoraria, Research Funding;Janssen: Honoraria, Research Funding;Astrazeneca: Honoraria, Research Funding;Sandoz: Honoraria;Roche: Research Funding. Savage: Servier: Consultancy, Honoraria;Astra-Zeneca: Consultancy, Honoraria;BMS: Consultancy, Honoraria, Other: Institutional clinical trial funding;Seattle Genetics: Consultancy, Honoraria;Merck: Consultancy, Honoraria, Other: Institutional clinical trial funding;Takeda: Other: Institutional clinical trial funding;AbbVie: Consultancy, Honoraria;Roche: Research Funding;Beigene: Other: Institutional clinical trial funding;Genentech: Research Funding. Villa: Roche: Honoraria;Janssen: Honoraria;Lundbeck: Honoraria;Celgene: Honoraria;Seattle Genetics: Honoraria;AbbVie: Honoraria;AstraZeneca: Honoraria;Gilead: Honoraria;NanoString Technologies: Honoraria. Scott: BC Cancer: Patents & Royalties: Patent describing assigning DLBCL COO by gene expression profiling–licensed to NanoString Technologies. Patent describing measuring the proliferation signature in MCL using gene expression profiling.;Abbvie: Consultancy;Janssen: Consultancy, Research Funding;AstraZeneca: Consultancy;Rich/Genentech: Research Funding;Celgene: Consultancy;Incyte: Consultancy;NanoString Technologies: Patents & Royalties: Patent describing measuring the proliferation signature in MCL using gene expression profiling. Craig: Bayer: Consultancy. Slack: Seagen: Consultancy, Honoraria. Sehn: Debiopharm: Consultancy;Novartis: Consultancy;Genmab: Consultancy. Freeman: Amgen: Honoraria;Celgene: Honoraria;Sanofi: Honoraria, Speakers Bureau;Incyte: Honoraria;Abbvie: Honoraria;Teva: Research Funding;Roche: Research Funding;Bristol Myers Squibb: Honoraria, Speakers Bureau;Janssen: Honoraria, Speakers Bureau;Seattle Genetics: Honoraria.

Preliminary Evaluation of Filtration Efficiency and Differential Pressure ASTM F3502 Testing Methods of Non-Medical Masks Using a Face Filtration Mount

Research surrounding the mandated use of non-medical fabric masks is inconsistent and often confusing when compared to the standard N95. A recently published standard from ASTM International and the Centers for Disease Control and Prevention attempts to normalize evaluation procedures. The purpose of this study is to conduct a preliminary evaluation of the new methods for testing filtration efficiency of masks outlined by ASTM International F3502, where results can be directly compared to standards outlined for non-medical fabric masks. Eleven consumer non-medical fabric masks were tested for filtration efficiency and airflow resistance using a face filtration mount in accordance with the newly released ASTM International standard for facial barriers. The mean FE% (SD) ranged from 0.46% (0.44) to 11.80% (2.76) with the 3-layer athletic mesh having the highest performance and the highest deviations. All the masks tested following the procedure failed to meet to minimum FE of 20%;however all masks performed below the minimum upper limits for airflow resistance. Using a non-medical fabric masks as the sole mitigation strategy may not be as effective, as previously reported. With efforts to standardize and regulate the non-medical fabric mask market, this study demonstrates a variety of currently available consumer mask products do not meet the minimum standards nor are these remotely close to the standards of surgical or N95 masks.

Emerging lessons from the commissioning and delivery of a gambling treatment service.

OBJECTIVES: Gambling is a public health concern, given the multiplicity of harms for individuals, families and communities. This article reports on the commissioning and delivery of a problem gambling treatment service in a metropolitan area in England, where the concentration of problem gambling is often higher than the national average. STUDY DESIGN: This is a cross-sectional study, using purposively sampled 'experts' and stakeholders involved in the conception and set-up of the service. METHODS: Individual semistructured interviews were used to ascertain the depth of information required to fully appreciate the nuances and complexities of the service. Eight participants took part in the interviews, with an additional respondent providing written comments in relation to the interview schedule as a workaround to accommodate the organisational impacts of COVID-19. RESULTS: The article identifies several factors contributing to the successful delivery of the service. Well-managed collaborative provision with expertise from across sectors is critical, but this needs to be balanced against the challenges faced by bridging cultural variances in practice and language. Adopting evidence-based models of delivery was central to practice, and moreover, geographical location is a key consideration to encourage access for those facing gambling problems and discourage feelings of stigma. CONCLUSIONS: This article offers a unique contribution to understanding more about the provision of gambling treatment services. This is crucial, given that a greater number of people face challenges as a consequence of gambling harms, and such services should be seen part of forming a coherent public health response.

A Double-Edged Sword: Neurologic Complications and Mortality in Extracorporeal Membrane Oxygenation Therapy for COVID-19-Related Severe Acute Respiratory Distress Syndrome at a Tertiary Care Center.

In this clinical case series, we report our experience to date with neurologic complications of extracorporeal membrane oxygenation therapy for COVID-19 Acute Respiratory Distress Syndrome. We have found an unexpectedly increased rate of complications as demonstrated by neuroimaging compared with meta-analysis data in extracorporeal membrane oxygenation therapy for all Acute Respiratory Distress Syndrome etiologies over the past few decades and compared with the most recent baseline data describing the incidence of neurologic complication in all patients with COVID-19. For our 12-patient cohort, there was a rate of intracranial hemorrhage of 41.7%. Representative cases and images of devastating intracranial hemorrhage are presented. We hypothesize that the interplay between hematologic changes inherent to extracorporeal membrane oxygenation and inflammatory and coagulopathic changes that have begun to be elucidated as part of the COVID-19 disease process are responsible. Continued analysis of extracorporeal membrane oxygenation therapy in this disease paradigm is warranted.