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Introduction: One in five pregnant women in the UKis obese. Obesity is associated with increased risk of both maternal and foetal adverse outcomes. RCOG guidelines [1] recommend that all women with a booking BMI over 40 kg/m2 should be reviewed antenatally by a senior obstetric anaesthetist to guide risk assessment, medical optimisation and shared decision-making. The 2021 MBRRACE report [2] recommends that all women should be reweighed in the third trimester for accurate VTE risk scoring and prophylactic LMWH dosing. In our institution, reconfiguration of hospital areas as part of the COVID-19 response led to loss of designated clinic space for our obstetric anaesthetic clinic. As a result, our practice since has been to initially offer a telephone consultation followed by a face-to-face review if needed. Finding space for the latter has often been a significant logistical challenge. Our project sought to assess whether our practice continued to meet national standards in the wake of these changes. Method(s): Following audit approval, we retrospectively reviewed all women with a BMI >40 kg/m2 undergoing caesarean section (CS) over a six-month period (1/4/22 to 31/9/22). Result(s): 20 women met inclusion criteria (Category 1-3 CS - 12 women;Category 4 CS - 8 women). 100% of patients had booking height, weight and BMI recorded. 20% (4/20) of patients were reweighed in the 3rd trimester. Only 55% (11/20) of patients had been referred to and reviewed in the antenatal obstetric anaesthetic clinic (Figure). Of the 11 patients referred, 6 were referred later than 30 weeks. Of the 9 patients not referred, 8 had a BMI between 40 and 45 kg/m2. By contrast, 87% (6/7) of patients with BMI over 45 kg/m2 were referred and seen. Discussion(s): Our audit showed that we are not meeting national standards. Possible reasons identified were lack of awareness of the RCOG standards and referral criteria (especially for women with a BMI of 40 to 45 kg/m2) and logistical issues in undertaking face-to-face reviews without designated clinic space. Presentation of our results at the joint anaesthetic, obstetric and midwifery governance meeting has helped identify space in the antenatal clinic for face-to-face reviews, to start from March 2023 and to raise awareness of the national standards to ensure referral of all women with a BMI over 40 kg/m2. A reaudit is planned in 6 months. [Figure presented]Copyright © 2023 Elsevier Ltd
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Objectives: During the COVID-19 pandemic, the NHS delivered a community-based remote home monitoring service for COVID-19 patients. The service came in two models characterised based on the referral method: home-based care to ensure the right people were admitted at hospital at the right time (named COVID Oximetry @ home (CO@h)) and facilitation of patients' transition when discharged home (named Covid-19 Virtual Ward (CVW)). Patients were provided with pulse oximeters and asked to regularly record and submit oxygen levels and other symptoms to a team of administrators and clinicians via digital means (tech-enable and analogue mode) and/or over the phone (analogue). Our aim was to evaluate the costs of implementing these services in England during wave 2 of the pandemic (October 2020-April 2021). Method(s): We used a top-down approach to describe the costs of setting-up and running the service. 26 sites reported the number of patients and staff members involved in the service, and other used resources. Descriptive statistics and multivariate regression analysis were used appropriately. Result(s): The mean cost per patient monitored was lower in the CO@h service compared to the CVW (527.5 vs. 599.1). The corresponding cost was lower for sites using tech-enabled and analogue data submission mode compared to sites using analogue-only mode for both CO@h (515 vs. 561) and CVW (584 vs. 612) services. The number of patients enrolled in the service and the service type significantly affected the mean cost per patient (b=0.62, p= 0.001;b=-457.99, p=0.05 correspondingly). Conclusion(s): Our analysis offers a model for future research since it covers sites of various sizes and raises questions about different practices within the overall remote monitoring services.Copyright © 2023
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BACKGROUND: Hepatopancreatobiliary (HPB) cancer incidence and mortality are increasing worldwide. An initial diagnostic predictor is needed for recommending further diagnostic modalities, referral, and curative or palliative decisions. There were no studies conducted in area with limited accessibility setting of the COVID-19 pandemic, coupled with limited human resources and facilities. AIM: We aimed to investigate the advantages of total bilirubin for predicting malignant obstructive jaundice, a combination of the pandemic era and limited resources settings. METHOD(S): Data from all cholestasis jaundice patients at M. Djamil Hospital in Pandemic COVID-19 period from July 2020 to May 2022 were retrospectively collected. The data included demographics, bilirubin fraction results, and final diagnosis. Bivariate analysis for obtain demographic risk factor, and Receiver Operating Characteristics (ROC) analysis for getting bilirubin value. RESULT(S): Of a total 132 patients included, 35.6% were malignant obstructive jaundice, and Pancreatic adeno ca was the most malignant etiology (34.4%). Bivariate analysis showed a significant correlation between age and malignant etiology (p = 0,024). Direct and total Bilirubin reach the same level of Area Under Curve (AUC). Total bilirubin at the cutoff point level of 10.7 mg/dl had the most optimal results on all elements of ROC output, AUC 0.88, sensitivity 76.6%, specificity 90.1%, +LR 8.14, and-LR 0.26. CONCLUSION(S): The bilirubin fraction is a good initial indicator for differentiating benign and malignant etiology (AUC 0.8-0.9) in pandemic era and resource-limited areas to improve diagnostic effectiveness and reduce referral duration.Copyright © 2023 Avit Suchitra, M. Iqbal Rivai, Juni Mitra, Irwan Abdul Rachman, Rini Suswita, Rizqy Tansa.
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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.
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Objectives: Implementation of venovenous extracorporeal membrane oxygenation (VVECMO) allowed survival of patients with severe respiratory failure associated with SARS-CoV-2 infection. However, VVECMO treatment is usually associated with long ICU stays, prolonged sedation, and neuromuscular blockage days. Functional disability, due to delirium and acquired muscle weakness, is frequently an inevitable burden causing long term disability. This study aims to analyse main characteristics of patients under ECMO due to COVID-19 pneumonia, their outcomes and functional status six months after ICU discharge. Method(s): Retrospective review of a prospectively collected database in an ECMO referral centre. All patients receiving VVECMO for SARS-CoV-2 infection were included. Epidemiological and clinical data were reviewed. Functional status at 6 months after ICU discharge was assessed with modified Rankin Scale (mRS). Result(s): Ninety-three patients were included (29% female). Median age was 54+/-12 years, mean SOFA was 5.7+/-2.9, mean SAPS II was 35.6+/-13.6. Mean time from intubation to cannulation was 5+/-5.6 days in 91 patients;awake-ECMO was performed in 2 patients. Mean ECMO run duration was 33.1+/-30 days (longest ECMO run was 194 days). A period of awake-ECMO was performed on 36.5% of patients, during 16.4+/-21.2 days. ICU-acquired weakness was diagnosed on 64.5% of patients and delirium on 63.4%. Mortality was 24.7% (23 patients) with only 1 patient deceased in hospital after ICU discharge. At 6 months follow-up, all patients were still alive and most of them (65.1%) were independent on all daily activities (mRS <= 2). Conclusion(s): Patients with severe COVID-19 treated with VVECMO support had very good functional outcomes at six-month follow-up. Despite long ICU length-of-stay, high incidence of delirium and acquired muscle weakness, full recovery at six-month post-ICU discharge was achievable in most patients.
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Objectives: During COVID pandemic, ECMO support for the patients with ARDS have saved many lives. Although its an important and effective treatment modality, management of ECMO could be done in a few specialized centers. In this study, we share our in- and out-of-city ECMO transport experience of the patients with COVID-ARDS. Method(s): A total of 75 patients (57% male- 43 %female) were included in this study. The decision ECMO support, initiation at referral hospital, and transport process of all of the patients to our centre were performed by our mobile ECMO team. All transports were done by land ambulance Results: Mean age of the patients was 43.4+/-11.5 years. Mean intubation period before ECMO support was 8.5 +/-8.3 days. We transferred 14 patients from the centers within the city and 12 patients from the centers outside the city to our hospital. Mean distance between our center and the referral center was 36,2 kms (max 269- min 1). We did not experience any major complication during transport. A total of 30 patients (38,6 %) were weaned from ECMO and discharged from hospital. Conclusion(s): ECMO support is an advanced treatment modality for pulmonary failure patients. The decision of initiation, cannulation, transport and management should be performed by experienced centers to achive acceptable results.
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Carbapenem administration is an important therapy for nosocomial infections due to MDRO, especially Acinetobacter baumannii. The global increase in carbapenem-resistant A. baumannii (CRAB) that causes this pathogen has significantly threatened public health due to the lack of adequate treatment options due to the very few currently available antimicrobial agents that actively fight CRAB. Antimicrobial resistance is a major negative impact of inappropriate antimicrobial prescribing. Ineffective empiric treatment (initial antibiotic regimen not sensitive to identified pathogens based on in vitro sensitivity test results) is associated with a higher rate of deaths compared to effective empiric treatment. In this study, we analyzed the correlation between the suitability of empiric and definitive antibiotics and the clinical outcomes of patients with bacteremia due to CRAB treated in the inpatient ward of Dr. Soetomo Tertiary Referral Hospital, Surabaya. There were 227 isolates of bacteremia due to CRAB, consisting of 156 carbapenem-resistant A. baumanni and 71 carbapenem-sensitive A. baumannii. There were 88 isolates that met the inclusion and exclusion criteria, and all of them were resistant to ceftriaxone, cefepime, and ciprofloxacin. A total of 29.5% of the isolates were sensitive to cotrimoxazole, 3.4% of the isolates were sensitive to tigecycline, and 2.3% of the isolates were sensitive to amikacin, levofloxacin, and cefoperazone sulbactam. Adequate empirical antibiotics and definitive antibiotics (sensitive based on culture sensitivity test) amounted to 12.5% and 27.3%, respectively. There is no significant correlation between the suitability of empiric and definitive therapies with the patients' clinical outcomes (death and length of stay).Copyright © 2022 Phcogj.Com.
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Throughout the COVID-19 pandemic, OnTrackNY teams provided coordinated specialty care (CSC) in a radically shifted environment. This presentation describes adaptations to OnTrackNY's model implemented during the pandemic. Method(s): OnTrackNY providers were recruited to participate in indepth, qualitative interviews conducted using phone and video platforms. The project team co-developed the qualitative interview guides with OnTrack Central trainers for each of the six team member roles. A coding team used the FRAME to identify the top three role-based adaptations to the OnTrackNY model from transcripts of qualitative interviews. Result(s): Twenty-three providers (n = 3-4 providers per role) discussed challenges and adaptations of providing CSC services during the pandemic. Use of telehealth was a major adaptation applied across all roles. Adaptations to outreach included narrowing community outreach to inpatient and emergency settings, increasing communication with referral sources, increasing contact with newly referred participants and families. Peer specialist adaptations include conducting physically-distanced groups, discussing current events and expanding online resources for engagement. SEES adaptations included monitoring evolving employment opportunities, conducting mock job interviews remotely, and supporting online learning. Adaptations to PCP/RN roles included sending equipment home for monitoring heath, changing methods and frequency of administering medication, and providing education regarding COVID-19 and vaccination. Adaptations to the Primary Clinician role included increasing informal 'check-ins', using screen sharing to complete assessments and safety plans, and addressing increased stress due to the pandemic. Conclusion(s): Adaptations to CSC were common with providers most frequently making changes to format and setting of care delivery and content modifications. Future work will examine implications of adaptations and OnTrackNY fidelity indicators.
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Introduction: The people worldwide have been affected by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) infection since its appearance in December, 2019. Kawasaki disease-like hyperinflammatory shock associated with SARS-CoV-2 infection in previously healthy children has been reported in the literature, which is now referred to as a multisystem inflammatory syndrome in children (MIS-C). Some aspects of MIS-C are similar to those of Kawasaki disease, toxic shock syndrome, secondary hemophagocytic syndrome, and macrophage activation syndrome. Case Presentation: This study reported an 11-year-old boy with MIS-C presented with periorbital and peripheral edema, abdominal pain, elevated liver enzymes, severe right pleural effusion, moderate ascites, and severe failure of right and left ventricles. Conclusion(s): Due to the increasing number of reported cases of critically ill patients afflicted with MIS-C and its life-threatening complications, it was recommended that further studies should be carried out in order to provide screening tests for myocardial dysfunction. Adopting a multidisciplinary approach was found inevitable.Copyright © 2023, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.
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Introduction and Aim: India experienced the peak of the second wave of COVID-19 during April to June 2021. Massive surge of cases resulting in shortage of beds and oxygen, home care was recommended as a strategy for management of asymptomatic/mild COVID-19 cases. The present study was undertaken to perform home visits and monitor COVID 19 patients who are a part of home-based care programme (HBCP) in Puttur taluk of Dakshina Kannada district, identification and immediate referral of patients with red flag signs/ symptoms and to identify barriers/challenges faced by health care staff in implementing the programme. Methodology: The present study was a cross-sectional study with universal sampling. It was carried out as part of a district programme for management of home isolation COVID-19 patients. The team visited the houses of COVID-19 patients and evaluated them. Result(s): A total of 112 COVID-19 patients were in home isolation during the study period in Puttur Taluk. Hypertension (29.5%) was the most common co-morbidity and nearly two-fifths (41.1%) of the study participants had one or more comorbidities. Almost two-third (63%) of the patients with comorbidities were symptomatic compared to only 29.4% of patients without any comorbidities. Of the six patients who had saturation of less than 95% five were more than 60 years of age, only one had received vaccination against COVID-19 and all had comorbidities. The HBCP had to face several challenges as the team members could not be in full PPE because of long distances between the houses and hard to reach areas. Conclusion(s): Overall, it is a helpful initiative for patients as the health services were provided at the doorstep during the time of restriction of movement. This can be an important tool in managing not only COVID pandemic but also future outbreaks that may follow.Copyright © 2023, Indian Association of Biomedical Scientists. All rights reserved.
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Introduction: In 2019/20 a total of 171,900 people were admitted to adult general intensive care units (ICU) across England, Wales and Northern Ireland, with a survival rate of 79.6% at hospital discharge.1 Patients who survive critical illness and admission to ICU often experience ICU-related long-term physical and non-physical impairments and disability following hospital discharge.2 National guidance advocates multidisciplinary team (MDT) follow up to identify and manage the unmet health needs of this patient population.3-4 The UK has seen an increase in the number of follow up services available in the last 7 years.2 The Covid-19 pandemic further highlighted the need to provide this service, locally resulting in the establishment of the Belfast Health and Social Care Trust (BHSCT) ICU follow up clinic in July 2020. The follow up clinic is offered to patients aged = 18 years, an ICU length of stay of = 4 days, who have been discharged from an inpatient setting within the last 12 weeks and do not receive follow up from any other established care pathway. The clinic consists of an ICU Nurse, Doctor, Clinical Psychologist and Physiotherapist. Patients are offered either a virtual, face-to-face or telephone appointment. Objective(s): To identify unmet rehabilitation needs and onward referral requirements of patients presenting at an ICU follow-up clinic in Northern Ireland. Method(s): Data was gathered retrospectively using an excel database detailing patient demographics, appointment details and onward referrals generated from the clinic. Data was analysed for a set time period between the 01/12/2021 - 09/02/2022. The type of referral and the profession responsible were captured. Result(s): During the time period eight post ICU follow up clinics were completed. A total of 36 patient's attended (14 male and 22 female). Six appointments were attended virtually via MS Teams, 12 via telephone and 18 face-to-face. Twenty-three (64%) of the patients required at least one onward health referral. A total of 61 onward health referrals were generated from this population. Table 1 details the number of onwards referrals by speciality. Conclusion(s): Approximately 64% of patients who attended the post ICU follow up clinic, during a 10 week period, demonstrated unmet rehabilitation needs resulting in onward health referrals. This data supports the need for a post ICU follow up clinic at BHSCT to identify ongoing need, ensure transition of care to relevant services and optimise patient's physical and psychological outcomes. One limitation of this study is that not all recommended allied health professionals are commissioned for the clinic which may impact on the health needs identified. Future work should consider the impact of this and discussions regarding the need for a commissioned post ICU follow up clinic which is truly MDT for this patient population should be considered.
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Introduction: The COVID-19 pandemic has disrupted health care systems worldwide, but the specific impact on pediatric surgery in low-and-middle-income countries has received little attention. This study evaluated the changes in pediatric surgical case volume at a central referral hospital in Malawi from 2019 through 2021 to quantify the impact of COVID-19. Method(s): We retrospectively reviewed all pediatric surgical cases performed at our institution from May-August 2019, 2020, and 2021. These months were chosen because they coincided with the first major wave of COVID cases in Malawi in 2020. We compared the number of cases performed per week between years and analyzed case numbers by specialty (general, orthopedic, plastic, neurosurgery, ENT, and urology). Result(s): A total of 1032 procedures were performed. There was a 32% reduction in case volume between 2019 to 2020 (344 to 235 cases, 19.5 vs 13.8 per week, p=0.04), with a subsequent 93% increase from 2020 to 2021 (235 to 435 cases, 13.8 vs 26.4 per week, p<0.001). The most significantly impacted specialties were ENT and plastics, both with 78% fewer procedures in 2020 compared with 2019, and a subsequent 4-fold and 22-fold increase in cases from 2020 to 2021, respectively (Chi-Square;p=0.007 and p<0.001). Orthopedic and Neurosurgical case numbers were impacted the least, with reductions ranging from 22% to 35%. Conclusion(s): The COVID-19 pandemic significantly reduced the number of pediatric surgical cases performed at the central referral hospital in Malawi across all specialties, thereby further limiting essential surgical services to an already marginalized patient population.
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Objectives: It is well known that severe COVID-19 is associated with complex immunological and inflammatory dysregulation. Both these physiopathological events translate to a high risk of major thrombotic or hemorrhagic events. In patients treated with venovenous extracorporeal membrane oxygenation (VVECMO), membrane dysfunction might affect systemic oxygenation and limit its duration-expectancy. This study aimed to assess the possible causes of extracorporeal membrane failure in COVID-19 patients and its impact on outcome. Method(s): Retrospective, single-center, observational case-control study involving adult COVID-19 patients admitted to an ECMO referral centre in a tertiary university hospital. All patients required VVECMO for acute respiratory failure, including 48 cases who needed one or more extracorporeal membrane exchanges and 45 controls (no membrane exchange). These two groups were compared for demographic characteristics, severity of the disease using validated scores (SAPS II and SOFA), duration of ECMO run, coagulation assessment, cumulative anticoagulation dose, associated complications, and outcomes (ICU and hospital mortality). Result(s): Most patients were males (71.0%) and younger than 50 years (79.5%). Median ECMO run duration was significantly longer in the case group (35.0 vs 14.0 days, p <0.001), as well as ICU length-of-stay (45.5 vs 28 days, p <0.001). Membrane exchange tended to be associated with sepsis (56% vs 33%, p=0.037), major hemorrhage (58% vs 43%, p=0.022), heparin-induced thrombocytopenia (25% vs 9%, p=0.054), higher D-dimer title (17.36 ng/dL vs 7.5 ng/dL, p=0.07) and lower platelet counts (133.000/muL vs 154.000/muL). Median SAPS II (32.0 vs 33.0, p=0.20) and the mortality (27% vs 24%, p >0.99) were similar between these groups. Conclusion(s): In patients with SARS-CoV-2 pneumonia and severe hypoxemia treated with VVECMO support the emergence of infection, coagulopathy and inflammation were associated with high risk of membrane dysfunction. No impact on mortality could be confirmed from these data. Anticoagulation monitoring and dosing strategies should be reinforced to promote membrane protection.
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Aims: In 2008, only two US states supported first-episode psychosis (FEP) programs. Today every state in the United States has a plan for supporting FEP programs, and over 350 programs currently operate across the country. In this presentation, we will describe the milestones and factors that have marked the growth of U.S. early psychosis programs and their characteristics. Method(s): Data were drawn from two national surveys fielded in 2018 and 2022. The 2018 survey data included responses from leadership at 215 early psychosis programs across the United States, and the 2022 survey data includes responses from U.S. state mental health authorities. The surveys provide information about a variety of key programmatic features of FEP clinics across the United States, including, program size, client capacity, duration of care, referral sources, services offered, funding, and outcomes measurement. Results and Discussion: Nearly 70% of the programs tie their start date to after the 2014 influx of federal funding. Services offered by the FEP programs have many similarities despite programs prescribing to specific FEP models (e.g., NAVIGATE, EASA, OnTrackNY, etc.). The surveys show program-level changes that have occurred between 2018 and 2022 and offer historical and data-driven explanations for how FEP programs have developed. The 2022 survey data also provide information regarding how States have chosen to implement the additional COVID-19 emergency funds designated for early psychosis programming.
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Introduction: Critically-ill obstetric patients admitted to general intensive care units (ICU) are a rare and unique population for whom excellent care is essential to prevent devastating physical and psychological morbidity. Admissions are often unanticipated and can present challenges to obstetric and intensive care MDTs. 2018 Enhanced Maternal Care (EMC) Guidelines provide standards for caring for these women, and the 2022 Ockenden review exposed the association of peripartum ICU admission with undertreated psychological trauma and a desire for individualised debriefing [1,2]. We audited the care of obstetric admissions to general ICUs in our quaternary centre. We sought evidence of psychological morbidity to improve follow-up pathways in line with 2022 Ockenden actions. Method(s): Retrospective online case note review of maternity admissions to general ICUs between 1/1/2021-1/1/2022 compared to EMC audit standards. Exclusion criteria: <22/40 gestation, >6/52 postpartum and admissions to our level 2 labour ward high dependency unit. Result(s): 25 patients were admitted to general ICUs over 12 months. Median age was 35-39 years, mean parity was 1. The commonest indication was obstetric haemorrhage (n = 10). 15 of 25 patients required level 3 care, median length of stay was 1.5 days. Documentation of daily obstetric MDT ward round was variable, as was mother-baby contact. 0 of 25 women were seen in obstetric anaesthesia clinic after discharge, only 1 received outpatient ICU follow-up. 50% of postnatal admissions (n = 14) had documentation of significant psychological distress. In response a local checklist was developed with key colleagues to support collaborative working and standardise quality care. It includes automatic referral into obstetric anaesthesia clinic and access to a novel perinatal mental health service. Discussion(s): A peripartum admission to ICU is highly likely to be experienced as traumatic [2]. The incidence of obstetric ICU admissions may increase in the context of greater clinical complexity of the UK pregnant population and COVID-19, whilst the non-anaesthetic ICU workforce may have little obstetric training. Obstetric anaesthetists are therefore uniquely skilled to facilitate quality resuscitation and referral to ICU, but gold-standard holistic care extends beyond admission. We believe regular audit and dedicated local care pathways which incorporate proactive debriefing and psychological health can improve the care of this important group of women.Copyright © 2023 Elsevier Ltd
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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.
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Introduction: Active cancer increases the odds of death among patients with COVID-19.1 Cancer patients may be at increased risk of complications and mortality from COVID-19 owing to the systemic effects of malignancy, immune suppression after chemotherapy, treatment-related complications and presence of co-morbidities.2 They may develop serious complications necessitating ICU admission. In a meta-analysis, the pooled mortality in cancer patients with COVID-19 admitted to an ICU was 60.2%.3 Our hospital is a tertiary referral cancer centre, and the ICU admitted cancer patients with Covid-19 throughout the pandemic. Objective(s): To determine the 30-day in-hospital mortality of adult cancer patients with Covid-19 admitted to the ICU. We also aimed to determine the factors associated with mortality in cancer patients with Covid-19. Method(s): After approval from the Institutional Ethics Committee, data of all cancer patients (age = 16 years) with Covid-19 admitted to the ICU between March 2020 and March 2021 were retrieved from the hospital records. In case of multiple ICU admissions, data from the first admission was recorded. Data recorded included demographic details, type of cancer (solid, haematological), surgical status, APACHE-II and SOFA scores, C-reactive protein, and interventions in ICU. The primary outcome was 30-day in-hospital mortality. Data were analysed using Man-Whitney test and chi-square test. A multivariable regression analysis was carried out to determine factors associated with mortality. Result(s): Data of 127 cancer patients with Covid-19 was analysed. The median [interquartile range, IQR] age was 55 (43-62) years, and there were 50 females (39.3%). Comorbidities were present in 46 (36%) patients, the commonest being diabetes (29 patients) and hypertension (31 patients). The median [IQR] APACHE-II and SOFA scores were 15[8-20] and 4[2-7], respectively. Overall, 62/127 patients died, and 30-day hospital mortality was 49%. There were 30 patients with haematological malignancy and 97 with solid tumours with 30-day in-hospital mortality rates of 46.7% and 49.5%, respectively;p = 0.84). Amongst patients with solid tumours, there was no difference in mortality in surgical patients compared to non-surgical patients (43.3% vs. 52.2%;p = 0.42). Table 1 summarises the parameters and interventions in survivors and non-survivors. On multivariable analysis, only the change in SOFA score from Day 1 to Day 3 was independently associated with outcome (Odds ratio 1.36 (95% confidence interval 1.01-1.84, p-0.04). Conclusion(s): In patients with cancer and Covid-19 and age =16 years admitted to our ICU, the crude 30-day hospital mortality was 47%. There was no association of mortality with cancer type or surgical status. The only independent predictor of mortality was progression of organ failure. Cancer patients with Covid-19 have a reasonable outcome and should be given a trial of intensive care.
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Objectives: Death from SARS-CoV-2 pneumonia resulted from progressive respiratory failure in most patients. Whenever accessible, venovenous extracorporeal membrane oxygenation (VVECMO) was implemented to rescue patients with refractory hypoxemia. Reported mortality in this population reached values from 20 to 50 percent, but the direct causes of death were not so widely acknowledged. The aim of our study was to characterize mortality in patients treated with VVECMO support. Method(s): Retrospective review of a prospectively collected database in an ECMO referral centre. All patients with diagnosis of SARS-CoV-2 infection treated with VVECMO support were included. Survivors and nonsurvivors were compared using t-student and chi2 methods. A Cox regression analysis was performed to identify predictors of mortality at admission. Result(s): Ninety-three patients were included (29% female). Median age was 54+/-12 years, mean SOFA was 5.7+/-2.9 and SAPS II was 35.6+/-13.6. Hospital mortality was 24.7%. Main causes of death were septic shock in 39.1% (9 patients), irreversible lung fibrosis 30.4% (7 patients) and catastrophic hemorrhage in 4.3% (4 patients). End-of-life care measures (withdrawal or withholding) were adopted in 65.2% of non-survivals. Patients who died were older (55 vs 48 years, p<0.05), had longer disease course (19 vs 15.3 days, p<0.05), longer invasive mechanical ventilation course before cannulation (8.5 vs 5 days, p<0.05), lower static lung compliance (25.5 vs 31.8 mL/cmH2O, p<0.05) and were ventilated with lower PEEP (8 vs 10 cmH2O, p<0.05) on cannulation. On a Cox-regression model, only prone ventilation before cannulation (HR 9,7;CI 95% 1,4- 68,6;p<0.05) and SAPS II (HR 1.04;CI 95% 1,001- 1,083;p<0.05) predicted mortality. Conclusion(s): Mortality in patients with severe SARSCoV-2 pneumonia treated with VVECMO was exceedingly low in our study, when compared with other series. Only one-third died from progressive lung disease, which suggests that protocol improvement can further reduce mortality.
ABSTRACT
Objectives: The objetive of this study is to describe the cases trasferred to an ECMO referral;s centre (Hospital Universitario 12 de Octubre, Madrid (Spain)), to investigate characteristics before ECMO and while the patient was on ECMO, to analyse the presence or not of complications secondary to transfer and cannulation and finally to analyse the ICU outcome. Method(s): This is a Prospective study done from November 1st, 2020 to December 31st, 2022. The cases were accepted either for emergency ECMO cannulation in the hospital of origin and retrieval or for conventional transfer. We analysed basic decriptive variables such as male proportion, age, IMC and etiology of ARDS and variables before ECMO such as prone position, duration of non-invasive ventilation, invasive ventilation and ICU leght of stay before ECMO. We recorded ELSO, SOFA and APACHE Severity Scores. We also analysed several variables on ECMO: if prone position on ECMO was done, median days of ECMO and succesfull weaning from ECMO. We also recorded whether there were complications or not in the transfer and cannulation. Finally ICU survival was examined. Result(s): 31 cases were accepted. 22 (71 %) were male. 29 cases were accepted for emergency ECMO cannulation. Median age was 47 years and IMC 31.1. The etiology of SDRA was COVID 19 infection in 23 cases (74% cases). Lenght of non invasive and invasive ventilation before ECMO were 4 days and 3 days respectively and lenght of ICU admission before ECMO was 2 days. Prone position was 1 day and 2 prone sessions were done before ECMO. Severity scores: APACHE 10 , SOFA 4 , ELSO 3 . On ECMO Prone position was done on 15 cases(48.4%) . Median days on ECMO were 13.5 days. Succesfull weaning from ECMO were achieved on 20 cases(61%), 2 cases remain on ECMO. No complications were seen on transfer or cannulation. ICU Survivors were 16(51.6%). Conclusion(s): After 2 years of experience on ECMO retrieval in the region of Madrid ECMO availability was achieved. Our results are similar than ELSO mortality.
ABSTRACT
Introduction: It is well documented that survivors of ICU admissions struggle to return to pre-admission level of function because of both physical and psychological burden. Current guidance therefore recommends a follow-up service to review patients 2-3 months post discharge [NICE 2009]. Prior to 2020 University Hospitals Bristol and Weston had no such service. With the increase in patient numbers seen during the COVID-19 pandemic, funding was received to provide a follow-up clinic to COVID-19 survivors. Objective(s): To provide a service that supports and empowers patients with their recovery from critical illness. Improving quality of life, speed of recovery and reducing longer term health care needs. Method(s): Referral criteria for the clinic included COVID-19 patients who received advanced respiratory support within intensive care and the high dependence unit. 8 weeks post discharge patients had a telephone appointment where ongoing symptoms could be identified. Advice around recovery, signposting to resources and onward referrals to appropriate specialities were provided. At 10 weeks post discharge patients had lung function tests and a chest X-ray which were reviewed by respiratory consultants. Based on the combination of these assessments, patients would be discharged or referred into the multidisciplinary team (MDT) follow-up clinic. The face to face clinic consisted of appointments with an intensivist, clinical psychologist, physiotherapist, and occupational therapist. Where needed patients would also be seen by a speech and language therapist or dietitian. Patients were seen only once in follow up clinic but again would be referred onto appropriate services within trust or the community, including but not exclusively community therapy services, secondary care services, SALT, dietetic or psychology clinics. Result(s): One of the key outcomes was the need for 147 onward referrals (an average of 1.13 referrals per patient). This included, 31 referrals to musculoskeletal physiotherapy outpatients for problems originating or made worse by their admission. 20 referrals to secondary care, including cardiology and ENT. 16 referrals to community occupational therapy, for provision of equipment, home adaptations and support in accessing the community. Subjectively, patient feedback was excellent. When asked what they felt was the most valuable thing they had taken from the clinic they reported: "Reassurance";"To know I'm not alone, others feel like this";"They listened to me and gave advice";"The ability to ask anything I wanted and the obvious kindness and support from all the clinicians I saw". Conclusion(s): Onward referral rates made by the follow-up clinic highlight the many issues faced by patients following discharge from ICU and hospital. With timely recognition and management, we can prevent a majority of these symptoms manifesting into chronic problems. This has the potential to lower the long-term burden on health care and improve quality of life for patients in both the short and long term. Without the follow-up clinic, these issues may have been missed or delayed. This reinforces the importance of the follow-up clinic and the need for ongoing investment.