ABSTRACT
Objectives: To evaluate how payers utilize Institute for Clinical and Economic Review (ICER) assessments to inform coverage or formulary decisions. Method(s): Double-blinded, web-based survey was fielded through Xcenda's research panel, the Managed Care Network, from June to July 2022. Result(s): A total of 51 payers from health plans (n=27), integrated delivery networks (n=12), and pharmacy benefit managers (n=12) participated in the survey. When assessing the usefulness of ICER's value assessment framework (VAF) to inform formulary decisions within their organizations, 57% of payers indicated it was extremely/very useful, 33% indicated somewhat useful, and 10% indicated not at all/not very useful. Most respondents (73%) agreed that ICER assessments are aligned with their organization's internal assessment. Utilization of ICER's VAF was most prevalent in high-cost drug or disease states (78%), rare/orphan disease states (71%), and oncology/hematology disease states (67%). Payers reported less use in primary care disease states (29%), COVID-19 (8%), and digital therapeutics (4%). In the last 24 months, 20% of payers reported ICER's recommendations often influenced coverage decisions, 59% indicated occasional influence, and 22% indicated no influence. In the last 24 months, payers indicated the top 5 ICER assessments that influenced their coverage decisions included high cholesterol (38%), Alzheimer's disease (36%), atopic dermatitis (33%), multiple myeloma (31%), and chemotherapy-induced neutropenia (28%). ICER assessments that were less impactful included beta thalassemia (3%), digital health technologies (3%), and supervised injection facilities (3%). Payers reported using ICER assessments to inform both expanded and restricted coverage decisions. Conclusion(s): Payers find ICER's VAF useful to inform their organization's formulary decisions. ICER's assessments often align with payers' internal assessments and are most frequently utilized for high-cost drugs or disease states. Payers indicate ICER assessments have affected both expansion and restriction in their coverage policies.Copyright © 2023
ABSTRACT
Aim: Although most patients with COVID-19 experience respiratory tract infections, severe reactions to the virus may cause coagulation abnormalities that mimic other systemic coagulopathies associated with severe infections, such as disseminated intravascular coagulation and thrombotic microangiopathy. Fluctuations in platelet markers, which are an indicator of the acute phase response for COVID-19, are of clinical importance. The aim of this study is to evaluate the relationship between disease severity and Platelet Mass Index (MPI) parameters in COVID-19 patients. Material(s) and Method(s): This retrospective observational study was conducted with patients who were diagnosed with COVID-19 in a tertiary hospital. The study was continued with the remaining 280 patients. All laboratory data were scanned retrospectively from patient files and hospital information system. Result(s): A very high positive correlation was found between PMI and PLT. The PMI value in women was significantly higher than in men. It was observed that PMI did not differ significantly in terms of mortality, intubation, CPAP and comorbidity. PMI vs. Pneumonia Ct Severity Score, biochemistry parameters (AST, CRP), hemogram parameters (WBC, HGB, HCT, MCV, LYM, MPV EO) and coagulation factors (aPTT and FIB) at various levels of positive/negative, weak and strong, and significant relationship was found. There was no significant relationship between hormone and D-dimer when compared with PMI. Discussion(s): Although platelet count alone does not provide information about the prognosis of the disease, PMI may guide the clinician as an indicator of lung damage in seriously ill patients.Copyright © 2022, Derman Medical Publishing. All rights reserved.
ABSTRACT
Our charity's mission is dedicated to beating blood cancer by funding research and supporting those affected. Since 1960, we have invested over 500 million in blood cancer research, transforming treatments and saving lives. Since 2015 there has been a Support Services team within the charity. This service was established to provide information that the blood cancer community can trust, in a language they can understand. By connecting and listening to our community they deepen our understanding and help shape our work. Research suggests that blood cancer patients are more likely than any other patients to leave their diagnosis appointment feeling they do not fully understand their condition. Our service can often consolidate the information given by clinicians. Patients also need advice and support on how to adapt to day-to- day life after their diagnosis. There are challenges that are unique to blood cancer, such as living with cancer as a chronic condition, being on 'watch and wait' or fluctuating remissions and relapses. In 2023 the Support Services team have a 7 day presence on our phone line, email and social media platform where people can communicate with one of our trained blood cancer support officers, or one of three Registered Nurses, all who can provide information about blood cancer diagnosis and help with emotional and practical support. We also run an online community forum where people affected by blood cancer can connect, share experiences and provide peer support. The highly experienced haematology nurses provide a clinical aspect to the support of the Blood Cancer Community that enhances the established patient centred support given historically by the charity. The nurses advanced knowledge and experience of haematological cancers, treatments, side effects, holistic care and NHS process can further guide the community. This is in addition to the invaluable information from their treatment teams. In 2023 the Support Services team are now reaching thousands of the blood cancer community. We understand that in the past 3 years the COVID-19 pandemic and the work of our charity around this will have influenced the significant increase in contacts but equally the robust and trusted services provided through this charity has contributed too.
ABSTRACT
Coronavirus disease has many systemic disease symptoms and has severe consequences for the cardiovascular system. Objective. To assess the role of clinical and laboratory indicators in determining the risk of chronic heart failure (CHF) in COV-ID-19 survivors. Material and methods. In total, 151 patients treated in a monoinfectious hospital from 03.11.20 to 10.02.21 with a confirmed diagnosis of COVID-19 were retrospectively selected. Medical history and laboratory data were collected by reviewing electronic medical records. The data included age, gender, body mass index, smoking status, and comorbidities. The laboratory data included the results of hematology and blood chemistry, coagulation, and the levels of acute-phase proteins. The CHF occurrence was used as the study endpoint. Results and discussion. The study patients were divided into two groups depending on the presence of CHF: group 1 included 46 patients with CHF, and group 2 included 105 patients without CHF. The median age was 66.2 (50-92) years;91 (60.3%) were females. Laboratory tests, such as levels of the hs-C-reactive protein, lactate dehydrogenase, procalcitonin, creatinine, and bilirubin, were statistically significantly different in patients of the study groups, and the median values were higher in patients with CHF. Neutrophil-lymphocyte ratio (NLR) showed statistically significant differences between groups: in patients with CHF, the median was 4.97% compared to 3.62% (p=0.011) in those without CHF. The most significant predictors of an increased risk of CHF were age >=66 years (OR=8.038, p<0.001), procalcitonin level >=0.09 ng/mL (increased the CHF risk by 3.8 times, p<0.001), thrombocy-topenia <=220x109/L (p=0.010), an NLR ratio >=4.11% (p=0.010), and a history of chronic kidney disease (p=0.018). Conclusion. A model has been developed to determine the factors closely associated with the risk of chronic heart failure in CO-VID-19 survivors.Copyright © 2023, Media Sphera Publishing Group. All rights reserved.
ABSTRACT
Bruton tyrosine kinase inhibitors (BTKis) were approved for use at the end of 2013 and have since been used for indications including chronic lymphocytic leukaemia (CLL), Waldenstrom's macroglobulinaemia and mantle cell lymphoma. The use of BTKis has increased significantly in the UK since they achieved NICE (National Institute for Health and Care Excellence) approval for frontline treatment of CLL in 2021. However, they are associated with significant adverse cardiovascular events. In September 2021 the British Journal of Haematology published good practice guidelines for the management of cardiovascular complications of BTKis. Our aim was to see whether these guidelines had been adhered to for patients taking BTKis. Method(s): Data was collected for all patients being prescribed BTKis (ibrutinib and acalabrutinib) in the South Tees NHS Trust in July 2022. Patients' medical records were used to assess whether their management adhered to the good practice guidelines. Data was collated for 67 patients in total. Result(s): The data showed that although all patients were consented for the risk of atrial fibrillation only 6% were consented for hypertension and only 1.5% for ventricular arrhythmias and sudden cardiac death. The guidelines recommend a baseline ECG (electrocardiogram) on commencement of treatment;however, only 7% had this completed and 0% had the minimum monitoring recommendation of 6-monthly ECGs. Thirty patients (45%) had an indication for a baseline echocardiogram;however, only one had this completed. For patients reporting symptoms of syncope, dizziness or palpitations only 50% had an ECG completed. Three patients developed worsening heart failure. The recommendations suggest referral to a cardio-oncologist;however, due to lack of availability of this service the referrals were instead made to the usual cardiologist. Conclusion(s): Although there was a lack of compliance with guideline recommendations, it should be considered that most usual checks were affected by COVID-19 outbreaks and a drop in face-to- face clinics, which were replaced by phone clinics and home delivery of medications. However, the premade consent forms for BTKis need to be updated to include consent for ventricular arrhythmias and sudden cardiac death. There also needs to be routine procedures in place to ensure that regular blood pressure testing and ECG monitoring occurs and that there is prompt recognition of cardiovascular complications. Action and implementation: To ensure improved compliance with these guidelines we plan to update our consent forms and create a proforma for clinic use to ensure that clinicians are aware of the various monitoring criteria required.
ABSTRACT
NHS England Genomics introduced whole genome sequencing (WGS) with standard-of- care (SoC) genetic testing for haemato-oncology patients who meet eligibility criteria, including patients with acute leukaemia across all ages, and exhausted SoC testing. Alongside, the role of germline mutations in haematological cancers is becoming increasingly recognised. DNA samples are required from the malignant cells (somatic sample) via a bone marrow aspirate, and from non-malignant cells (germline sample) for comparator analysis. Skin biopsy is considered the gold-standard tissue to provide a source of fibroblast DNA for germline analysis. Performing skin punch biopsies is not within the traditional skillset for haematology teams and upskilling is necessary to deliver WGS/germline testing safely, independently and sustainably. A teaching programme was designed and piloted by the dermatology and haematology teams in Sheffield and delivered throughout the NHS trusts in North East & Yorkshire Genomic Laboratory Hub. The training programme consisted of a 90-min session, slides, video and practical biopsy on pork belly or synthetic skin, designed to teach up to six students at one time. To disseminate best practice, the standard operating procedure and patient information used routinely in Sheffield were shared, to be adapted for local service delivery. From January 2021 to December 2022, 136 haematology staff from 11 hospitals, including 34 consultants, 41 registrars, 34 nurses and 8 physician associates, across the NEY GLH region completed the skin biopsy training programme. Feedback from the course was outstanding, with consistently high scores in all categories. Practical components of the course were especially valued;98.6% (71/72) trainees scored the practical element of the programme a top score of 5 out of 5, highlighting that despite the challenges of delivering face-to- face teaching due to COVID-19, teaching of practical skills was highly valued;training in this way could not have been replicated virtually. Costs of the programme have been approximately 16 000, including consultant input and teaching/educational materials. Recent support has been provided by a separately funded Genomic Nurse Practitioner (GNP), with succession planning for the GNP to take over leadership from the consultant dermatologist. Plans are in place to use the remaining budget to disseminate the programme nationally. Our training programme has shown that skin biopsy can be formally embedded into training for haematology consultants, trainees, nursing team, and physician associates. Delivery of training can be effective and affordable across regional GLHs with appropriate leadership and inter-speciality coordination, and ultimately sustainable with specialist nursing staff, including GNPs.
ABSTRACT
Introduction: Following the lifting of generalised restrictions and universal masking, severe acute respiratory syndrome coronavirus 2 (SARS-CoV- 2)- infected patients, especially the clinically extremely vulnerable (CEV) haematology patients, are at an increased risk for other respiratory viral coinfections;therefore, physicians need to be cognizant about excluding other treatable respiratory pathogens. Here, we report coinfection with SARS-CoV- 2 and other respiratory pathogens in patients with haematological cancers presenting to a large tertiary care hospital. Method(s): From July 2022-December 2022, patients with haematological disorders were screened for SARS-CoV- 2 and other 10 common respiratory pathogens by PCR. We performed a retrospective analysis of patients with concurrent respiratory viruses and will prospectively evaluate the same from Jan 2023 to March 2023. Result(s): During this period a total of 322 inpatients had routine screening and additional 6213 swabs were done in the outpatient/ambulatory setting, of which 294 were positive in 221 patients. We excluded all patients who had a single positive PCR swab result and specifically analysed only patients with coinfections. We identified 30 patients (14%) who had respiratory coinfections with 73 viral infections/reactivations over 6 months period, which represented 25% of all positive swabs: 25 inpatients (19 symptomatic/6 asymptomatic) and 48 in outpatients (32 symptomatic/16 asymptomatic). The median age of the cohort was 47.3 years (21-77). Patients were post allograft (n = 15), autograft (n = 7), post CART (n = 5) and postchemotherapy (n = 4). Of the 30 cases, 13 patients had concurrent infections: 5 SARS-CoV2, 10 Respiratory syncytial virus (RSV), 7 Rhino and 4 Influenza A, with all patients having dual viral infection. The remaining 17 patients had multiple viral infections but separated by a median of 54 days (range 27-137 days): 16 SARS-CoV2, 5 RSV, 6 Rhino, 2 Parainfluenza, 2 Adeno and one each of Influenza A, Influenza B, and metapneumovirus. Of the treatable infections (n = 46), 22% were detected on routine asymptomatic swabbing, with 50% of SARS-CoV2 detected on routine swabs. All 8 patients with Influenza were treated with oseltamivir, of 16 RSV cases one was treated with oral ribavirin and of the 22 SARS-CoV2 patients, 5 were treated (4 Paxlovid and 1 Remdesivir). No patients needed intensive care support and no deaths were reported. Conclusion(s): The burden of respiratory coinfections in CEV cohort has a significant impact on respiratory isolation and management, including appropriate & timely initiation of therapy for treatable viral infections. Although mortality was not increased secondary to respiratory coinfections and none needed intensive care, larger prospective cohorts are needed to assess the exact impact.
ABSTRACT
Background: This QIP was initially conducted during COVID-19 because there were concerns that many patients on the intensive care unit did not have a DNAR form. The pandemic has been a time where establishing appropriate ceilings of care is particularly important. Many of the patients on intensive care had been admitted due to haematological complications arising from COVID-19 including pulmonary embolism, thrombocytopenia and disseminated intravascular coagulation. Lack of DNAR forms has serious implications including the inappropriate use of cardiopulmonary resuscitation and uncertainty for the medical team regarding ceilings of care for critically unwell patients. These were the main drivers for change. Method(s): Data were collected over a 12-month period on ICU from the critical care electronic and written records. This included the presence of a DNAR form, time from ICU admission to DNAR form completion, as well as accuracy and detail on the form. Result(s): Only 50% of patients had a DNAR form completed and of these, cardiopulmonary resuscitation was only recommended in 27% cases. Time taken for completion of the form ranged from 0 to 20 days. Following discussion of these concerning findings in the ITU departmental meeting, several changes were made including mandatory discussions and adding DNAR status for each patient onto handover sheets, as well as electronic reminders for DNAR status. The second cycle of the QIP showed a 35% improvement with 85% of patients having a completed DNAR form. Conclusion(s): This QIP highlights the importance of DNAR form completion for all patients, given that only 27% of the 50% patients who had completed DNAR forms were deemed suitable for CPR. It also shows that introducing measures that make DNAR discussions mandatory leads to an improvement in DNAR form completion. Given the success in intensive care, this QIP has now been expanded to the high dependency unit and haematology wards to improve DNAR form completion for all haematology patients.
ABSTRACT
Introduction: Mucormycosis is a rare, severe fungal infection with an incidence of 0.005 to 0.17 per million.1 but incidence has risen recently, particularly in the Asian subcontinent, due to use of immunosuppression for Covid19.2 Presentations can vary and are classified into: rhino-orbito-cerebral, pulmonary, cutaneous, disseminated, renal and gastrointestinal. Risk factors include diabetes, immunosuppression, iron overload, malnutrition, and prematurity.1,3 Although mucormycosis has an extremely high mortality rate and disseminated infection is usually fatal, treatment options exist if diagnosed early and surgical debridement may be curative. Objective(s): We present a case of mucormycois in a female patient in her 40s who was immunosuppressed with methotrexate for rheumatoid disease. This case is discussed to increase awareness of critical illness caused by opportunistic invasive fungal infections in immunosuppressed patients and promote timely identification and management. Method(s): We detail the clinical context and management of a patient with mucormycosis and discuss relevant literature. Result(s): A female patient in her 40s who had been experiencing upper respiratory tract symptoms for several weeks, including cough and brown sputum, was admitted with a presumptive diagnosis of methotrexate toxicity after a full blood count performed by the general practitioner demonstrated pancytopenia. Initially, National Early Warning System 2 score (NEWS2) was 2 but became intensely hypertensive during blood transfusion and then profoundly shocked with an escalating NEWS2. Broad-spectrum antibiotics and fluconazole were commenced for neutropenic sepsis and the patient was referred to critical care in multiple organ failure. Computerised tomography (CT) scan of the chest, abdomen and pelvis showed "left upper lobe consolidation, which with neutropenia might represent an angioinvasive aspergillosis". She had multiple areas of skin discolouration and desquamation. Haematology and Infectious Diseases opinions were sought, and a bone marrow biopsy was performed which showed severe toxic effects consistent with sepsis/life threatening infection. Progressive proptosis was noted, and CT scan of her head was requested. Sadly, she was never stable enough for CT transfer. Beta D Glucan and aspergillus antigen serology was negative. Broncho-alveolar lavage demonstrated Candida albicans and then, later, Rhizopus arrhizus was isolated and anti-fungal treatment changed to voriconazole and then amphotericin B. Upon reviewing the notes in light of the positive culture for Rhizopus, the patient had likely been exhibiting symptomatic Mucormycosis sinus infection for some time prior to this admission with disseminated infection. The patient's condition continued to deteriorate and she sadly died. Conclusion(s): * The Early Warning Score significantly underestimated how unwell the patient was upon arrival in ED, a systems-based assessment would have demonstrated that the patient had multiple system dysfunction and significant potential to deteriorate suddenly despite having stable observations * The methotrexate level has no clinical value in diagnosing or refuting a diagnosis of methotrexate toxicity * A full examination of the immunosuppressed patient including ENT is a necessity when searching for a source of infection * Invasive fungal infections can cause multi-system symptoms and atypical presentations * As a greater proportion of patients have received systemic immunosuppression for Covid-19, vigilance for more unusual pathogens, including Mucormycosis by clinicians is advised.
ABSTRACT
The treatment landscape in myeloma has rapidly changed over the last few years with the advent of an ever increasing number of funded novel therapies. At the same time, the COVID-19 pandemic has caused a paradigm shift in the burden of infection within the community. Clinical trials often exclude older and more comorbid patients and so there is a paucity of data of the effect of infection on patients with myeloma in the 'real world'. We performed a restrospective audit of all patients with myeloma admitted with infection to our level 2b haematology centre over a 3-year period from November 2019 to November 2022. We collected data on patient demographics and characteristics, infection status, microbiology results, length of stay and outcome of admission. During the audit period there were 87 admissions from 52 patients. The median number of admissions per patient was 1 (range 1-6). The median age at admission was 72 (range 41-90). Patients had a median of two major comorbidities (range 0-8). Performance status was <2 in 63% of patients (33/52). In terms of disease characteristics, International Staging Score (ISS) was stage 1 in 12% of patients, stage 2 in 38%, stage 3 in 38% and unavailable in 12%. Revised ISS (R-ISS) was stage 1 in 2% of patients, stage 2 in 44%, stage 3 in 17% and unavailable in 37%. The median line of treatment was 2 (range 0-6). Respiratory tract infection was the most common site of infection in 51% of admissions. Microbiology was negative in over half of infection admissions (50/87). Fifteen per cent (13/87) had a positive COVID-19 PCR. A positive blood culture result was identified in 8% (7/87). The median length of stay was 9 days (range 1-58). The mortality rate of admissions with infection was 17% (15/87). Overall, our real-world results show the continuing burden of infection in myeloma in the era of modern treatment. Despite the omnipresence of the COVID-19 pandemic over the last 2 and a half years, this contributed to only a small number of admissions. Infections happened in patients of all ages and many patients had good performance status, limited comorbidities and intermediate risk disease. The mortality rate of our cohort was surprisingly high at 17%. In summary, infection remains a major complication of myeloma. Given our results we now plan a trial of prophylactic antibiotics for patients on active treatment.
ABSTRACT
As a district general hospital (DGH) registrar, clinical duties are varied. The geographical location of these clinical duties can vary in different hospital settings. In our trust, the inpatient Haematology ward was reallocated to become the designated 'COVID ward' at the start of the pandemic, due to a lack of availability of side rooms in the hospital. Haematology inpatients are now managed on general medical wards, with no specific Haematology ward available. This has further increased the geographical spread of registrars' clinical duties. In order to quantify the impact of this geographical spread, we undertook an audit of physical activity over a four-week period. We included the physical activity during working hours recorded by the attending haematology registrar and an on call medical registrar for comparison. We collected data using smart devices on steps walked, distance travelled, time spent walking and calories burnt whilst walking. We collected data for all day shifts worked from 09:00-17: 00 for all days of the week. Overall, the attending haematology registrar walked an average of 10 241 steps a day, covering 7.87 km over a period of 107 min and burning 410 calories whilst active. The medical registrar walked an average of 7498 steps a day, covering 5.76 km over a period of 79 min and burning 300 calories whilst active. By comparison the attending haematology registrar covered 37% more steps per day than the medical registrar, a statistically significant difference (p-value 0.002, students unpaired t-test). During a 7.5 h working day (taking into account a contractual 30-min unpaid lunch break), our DGH haematology registrars spend 107 min walking, which is 24% of their working hours. Our results highlight the time pressures on DGH haematology registrars. Time pressures on registrars in London have become more important as a result of Health Education England's (HEE) medical specialty redistribution programme, which will see the number of specialty trainees in London reduced by 46% over 5 years. Addressing the geographical spread of clinical duties could help to reduce the time pressures on registrars allowing them to spend more time on providing a clinical service. We have presented our data to trust management as evidence to lobby for the creation of a new haematology ward, which has now been included in the plans for a new hospital at our trust.
ABSTRACT
Introduction: Patients with chronic lymphocytic leukaemia (CLL) are at increased risk of infection. CLL is associated with a secondary immunodeficiency and impaired response to vaccination. Recent British Society of Haematology guidelines recommend that patients with CLL should receive vaccination against pneumococcal infection at diagnosis, an annual influenza vaccine and COVID-19 vaccination. Patients aged 70-79 years should also receive the Shingrix vaccine. Patients with CLL should not receive live vaccines. In response to this guideline, a letter detailing vaccination requirements was created for patients to give to their general practitioner (GP). The local process for vaccination referral has since changed. Previously, vaccination requirements were communicated to the GP via letter. There is now a dedicated Vaccination Hub to which clinicians can directly refer patients for appropriate vaccinations. Aim(s): The aim of this project was to assess vaccination referral and vaccination status in patients with newly diagnosed CLL. Method(s): All new diagnoses of CLL from 2021 to 2022 were identified by review of the Haematology Multi-Disciplinary Team meeting electronic registration forms. Electronic patient records were reviewed to determine vaccination referral completion and vaccination status. Result(s): A total of 29 patients were identified as new diagnoses of CLL. Seventeen patients were diagnosed in 2021 and 12 in 2022. Sixty-nine percent of the patients were male and the average age was 70.9 years. Vaccination was discussed with 11 patients (38%) and 10 patients (34%) were referred for vaccination. Eleven patients (38%) had never received a pneumococcal vaccine. Nine patients (31%) had previously received the vaccine but not within the past 5 years. Five patients (17%) patients had received one dose of Pneumovax 23 following referral. No patients had received the initial Prevenar 13 vaccine. Twelve patients (41%) had not received an influenza vaccine. Of those who had received the vaccine, the majority (70%) had received this routinely. Similarly, 71% of patients had received the COVID-19 vaccine routinely as opposed to three patients who received this postreferral. Of those who were eligible, 50% had received the Shingrix vaccine. Conclusion/Discussion: Local rates of vaccination in patients with CLL are low. Numbers were too small to allow for comparison between the methods of referral. Of those referred, not all received the appropriate vaccinations. Further work is therefore required to improve both the number and completion of the referrals. Future steps will include local teaching on vaccinations in CLL and the referral pathway.
ABSTRACT
Aims: Onco-hematologic diseases (lymphomas, myeloma, leukemia) require intensive treatment regimens and represent a burden at the affective and instrumental level for their caregivers. The aim of this study was to investigate the link between caregiving burden and depressive symptoms in caregivers of onco-hematologic patients during the SARS-CoV-2 pandemic. Method(s): A convenience sample of 101 caregivers of onco-hematologic patients were recruited at the Hematology Unit of the Holy Spirit Hospital, Pescara, Italy. Most of the caregivers were female (80%) with an average age of 41 years old (SD = 14.01). Participants were administered the Caregiver Burden Inventory (CBI), the Patient Health Questionnaire-9 (PHQ-9) for depression, and the Fear of Covid-19 Scale (FCV-19S) during two months of the COVID-19-related stay-at-home period (April-May 2021). Result(s): Moderate-to-severe depression (PHQ-9 > 10) were reported by 36% of caregivers. Depressive symptoms were associated with caregivers' time-dependence (r = 0.43), developmental (r = 0.61), physical (r = 0.72), social (r = 0.60), and emotional burden (r = 0.43) (all ps < 0.001). CBI explained 53% of the PHQ-9 variance, particularly the physical (beta = 0.54, p < 0.001) and the social (beta = 0.30, p < 0.01) dimensions of burden. Unexpectedly, COVID-19 was not associated with caregiver burden and depressive symptoms. Conclusion(s): Caregivers of onco-hematologic patients may experience depression due to the burden of caregiving, which is related mostly to the patients' disease rather than extraordinary, even dramatic events such as the pandemic. Psychological interventions are needed for them.Copyright © 2023
ABSTRACT
Introduction: Laboratory training is an integral part of haematology specialty training. Trainees at ST3 usually have limited experience of laboratory functions and find approaching this daunting. Sound grounding in laboratory processes and techniques and rapport with the biomedical scientists is important in the first year. In the West Midlands, specialty trainees have dedicated ST3 laboratory induction time. Local discussions suggest variation in experiences and that training has been negatively impacted by the COVID-19 pandemic. Method(s): To assess baseline laboratory induction, an electronic survey was sent to registrars who commenced ST3 haematology training in the West Midlands during the pandemic (February 2020 to February 2022). Questions assessed time spent in the laboratory, activities undertaken and self-reported confidence understanding tests and techniques before and after their placement. A range of strategies to improve and standardise laboratory training were proposed. The Laboratory Induction Workbook was designed and written by senior registrars in the West Midlands Deanery to complement existing training as part of a quality improvement project. Result(s): 7/8 (88%) trainees completed the survey. All trainees reported minimal prior experience of a haematology laboratory;during laboratory induction 3/7 (43%) were not provided with a local checklist or framework. Trainees spent most time on blood film morphology, with an increase in confidence reported by 7/7 (100%) trainees. Conversely, only 4/7 (57%) trainees visited blood bank, 2/7 (29%) learned about immunophenotyping, and 0/7 (0%) trainees explored genetic testing during this training period. A Laboratory Induction Workbook in three sections was developed: (1) An introduction to blood film and bone marrow morphology, (2) 22 cases covering the breadth of the curriculum and highlighting important topics and (3) signposting to key resources/contacts. The workbook focussed on linking clinical aspects with laboratory tests, encouraging self-directed study and empowering registrars to seek out learning opportunities in their local laboratory and within the region. The workbook was distributed to all new starting haematology trainees in the West Midlands in August 2022. Conclusion(s): Initial feedback has been positive, formal feedback is awaited. Future work includes the addition of extra cases to the workbook, transferring it into an interactive electronic format with use of QR coding, and regular review to ensure content is up to date. We also plan to extend the scope of the workbook for more senior trainees as an exam revision resource.
ABSTRACT
Following an increased need for individual patient escalation plans during the COVID-19 pandemic we recently created a working group to embed Advance Care Planning (ACP) into our service. Modern ACP is not only about end-of- life planning, it involves meaningful conversations and supporting patients to make decisions throughout all stages of their disease and treatment. With early conversations and the opportunity to pre plan, the stress and anxiety attached to the difficult decisions at a time when someone may be acutely unwell should become easier (from the perspective of both staff and patients). We carried out a preproject audit to ascertain patient opinions on how we could embed ACP into our service. 50 patients were offered a questionnaire, 38 chose to partake. Result(s): 100% (38) of patients had never been approached by a nurse to discuss ACP. 82% (31 out of 38) said they would not want to be approached about ACP. 18% (7 pts) would like to be approached but 13% (5pts) noted only if end of life. On asking when the best time to be approached: three patients said 'at diagnosis', two said 'anytime', one said 'never', five said 'when ready' and seven said 'end of life only'. Suggestions on the best way to raise ACP issues, five said poster displays (one noting the need for this poster to be positive and also available in Welsh), four suggested routine discussions in the current appointment and five people suggested a separate appointment. Other comments included, I only want to discuss these issues with my solicitor, I would like my family to be involved, make sure the nurses can answer questions. Average age was 68.5 years (range 49-85). Discussion(s): This was a limited audit on an outpatient population, but it raised a number of important issues. The actual carrying out of an audit on an emotive subject highlighted one the difficulties of embedding ACP initiatives into a service with a quarter of patients choosing not to answer the questionnaire, and of those who chose to answer 83% said they did not necessarily want to be approached to discuss ACP. In addition, the terminology 'ACP' appeared confusing, many people linking it to end-of- life discussions or to legal aspects such as writing of Wills. The barriers this audit has highlighted, has helped to shape the future direction of our working group and highlighted the need for increased training.
ABSTRACT
El virus SARS-CoV-2 continúa infectando a millones de individuos en el mundo. Aunque los síntomas más frecuentes observados en los pacientes con COVID-19 son fiebre, fatiga y tos, en los casos severos la hipercoagulabilidad y la inflamación son dos condiciones que pueden producir complicaciones y causar daño en órganos, poniendo en riesgo la vida del paciente. Con el fin de clasificar a los pacientes durante el triaje, se han explorado diferentes marcadores hematológicos, incluidos el recuento de plaquetas, linfocitos y eosinófilos, y la relación neutrófilos/ linfocitos, entre otros. Por su parte, para la evaluación de las coagulopatías, se vienen determinando marcadores como el dímero D y el fibrinógeno. En esta revisión se abordan las coagulopatías y los parámetros hematológicos en pacientes con COVID-19, al igual que las anormalidades en la coagulación como la trombocitopenia trombótica inmune inducida por las vacunas contra el SARS-CoV-2
The SARS-CoV-2 virus continues to infect millions of individuals around the world. Although the most frequent symptoms observed in patients with COVID-19 are fever, fatigue and cough, in severe cases hypercoagulability and inflammation are two conditions that can cause complications and organ failure, putting the patient's life at risk. In order to classify patients during triage, different hematological markers have been explored, including platelet, lymphocyte, and eosinophil counts, and the neutrophil/lymphocyte ratio, among others. Furthermore, for the evaluation of coagulopathies, markers such as D-dimer and fibrinogen are being evaluated. This review addresses the coagulopathies and hematological parameters in patients with COVID-19, as well as coagulation abnormalities such as immune thrombotic thrombocytopenia induced by SARS-CoV-2 vaccines
Subject(s)
Humans , COVID-19 , Prognosis , Reference Standards , Thrombosis , Blood Coagulation , Blood Coagulation Disorders , Blood Platelets , Vaccines , Antigens, Differentiation , SARS-CoV-2 , HematologyABSTRACT
Abstract This study aimed to evaluate the hematological and coagulation parameters according to the clinical outcomes of coronavirus disease (COVID-19). We analyzed the hematological and coagulation parameters of hospitalized patients with COVID-19 at admission, and two and three weeks during hospitalization. To assess the performance of these parameters in predicting poor outcomes, receiver operating characteristic (ROC) curves were created. We studied 128 patients with COVID-19 (59.2±17.7 years, 56% male). Non-survivors (n=54, 42%) presented significant alterations in hematological and coagulation parameters at admission, such as increased in white blood cells (WBC), neutrophil, and band cell counts, as well as elevated prothrombin time (PT), activated partial thromboplastin time, and D-dimer levels. During follow-up, the same group presented a gradual increase in D-dimer and PT levels, accompanied by a reduction in PT activity, hemoglobin, and red blood cell count (RBC). ROC curves showed that WBC, neutrophil, and band cell counts presented the best area under the curve (AUC) values with sensitivity and specificity of >70%; however, a logistic regression model combining all the parameters, except for RBC, presented an AUC of 0.89, sensitivity of 84.84%, and specificity of 77.41%. Our study shows that significant alterations in hematological and coagulation tests at admission could be useful predictors of disease severity and mortality in COVID-19.
ABSTRACT
There are many uncertainties on the future management of the coronavirus disease 19 (COVID-19) in Africa. By July 2021, Africa had lagged behind the rest of the world in Covid-19 vaccines uptake, accounting for just 1.6% of doses administered globally. During that time COVID 19 was causing an average death rate of 2.6% in Africa, surpassing the then global average of 2.2%. There were no clear therapeutic guidelines, yet inappropriate and unnecessary treatments may have led to unwanted adverse events such as worsening of hyperglycemia and precipitating of ketoacidosis in administration of steroid therapy. in order to provide evidence-based policy guidelines, we examined peer-reviewed published articles in PubMed on COVID 19, or up-to date data, we focused our search on publications from 1st May 2020 to 15th July, 2021. For each of the studies, we extracted data on pathophysiology, selected clinical chemistry and immunological tests, clinical staging and treatment. Our review reports a gross unmet need for vaccination, inadequate laboratory capacity for immunological tests and the assess-ment of individual immune status, clinical staging and prediction of disease severity.We recommend selected laboratory tools in the assessment of individual immune status, prediction of disease severity and de-termination of the exact timing for suitable therapy, especially in individuals with co-morbidities.