ABSTRACT
Spitzoid melanoma is very rare tumour in the pediatric population, with clinical and non-uniform behaviour, different from adult melanoma [1]. It can be difficult to differentiate an atypical Spitz nevus from a Spitzoid melanoma, resulting in diagnostic problems. In addition, in our clinical case, the COVID-19pandemiccaused significant delays both in the diagnosis and in the surgical treatment of our patient. We present the clinical case of a 4-year-old child suffering from a localized polypoid cutaneous neoformation on the dorsum of the left hand, which started immediately before the lockdown and steadily increased during the COVID-19 pandemic. After a general clinical framing, the child underwent an excisional biopsy at our Department of Plastic and Reconstructive Surgery, at the Policlinico of Foggia. Subsequently, two independent anatomic pathology groups examined the specimen. Definitive diagnosis was made only after careful genetic analysis in combination with supporting histological and immunohistochemical examinations. This clinical case shows how during the pandemic we have been facing advanced forms of tumours, compared to the previous period and highlight show an interdisciplinary and multicenter collaboration allowed a quick diagnosis of certainty, demonstrating the utility of molecular pathology as a fundamental aid in clinical/surgical practice. © 2022 The Authors
ABSTRACT
Purpose: An interdisciplinary team approach is recommended by numerous practice guidelines for management of eating disorder (ED) care in pediatric populations. Registered dietitians (RDs), with their unique clinical nutrition knowledge and skill play a valuable role in treating adolescents with eating disorders and their inclusion on an interdisciplinary team is integral to the team approach. Despite this, there is little guidance on standards of care for RDs working in this setting, as well as limited research on outcomes of RD managed nutrition support which may result in inconsistent and inequitable care. During the COVID-19 pandemic, cases of youth presenting with eating disorders have increased causing unprecedented demands on healthcare resources. The pandemic has also resulted in the rapid evolution of care delivery models, including the wide adoption of telemedicine services. This study fills a considerable gap in the evidence base by seeking to understand RD practices across institutional pediatric outpatient eating disorder care settings. This is a vital step to inform the development of care standards and pave the way for future research to assess outcomes of RD involvement in eating disorder care. Methods: We surveyed 18 dietitians at tertiary care institutions across all regions of the United States using a 24-question web-based questionnaire. Participants were recruited by purposeful sampling of institutional program RDs following email referral by medical leadership in affiliated eating disorder programs. Our survey addressed topics such as frequency and duration of nutrition appointments, individuals present for nutrition appointments, use of family-based treatment (FBT), content and approaches included in nutrition appointments, and disciplines with whom RDs coordinated care. Results: Most RDs surveyed practiced within interdisciplinary teams utilizing a Family Based Treatment (FBT) approach. A majority of respondents used telemedicine for at least a portion of their eating disorder appointments;nearly half of respondents (47%) reported using telemedicine for 50-100% of their eating disorder appointments. Survey responses regarding care delivery topics, such as visit frequency and duration, nutrition education content, and approach were highly variable among participants. Conclusions: This study maintains that RDs prioritize individualized care, however it highlights a gap in guidance and practice standards for their role in outpatient eating disorder care. Furthermore, our results emphasize the importance of addressing variability in nutrition practice when interpreting outcomes of RD involvement in eating disorder care. With recent changes in health care delivery as a result of the COVID-19 pandemic, there is value in understanding how nutrition care is evolving in order to meet all patient's needs. Sources of Support: Seattle Children's Hospital provided statistics support. No funding was provided.
ABSTRACT
Introduction: Neutralising monoclonal antibodies (mABs) have been proposed and developed for the treatment of Coronavirus Disease-2019 (COVID-19) patients with mild to moderate diseases and to prevent further progression. The combination of Casirivimab and Imdevimab blocks the entry of virus into cells by attaching to receptor binding domain of Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2) spike glycoprotein. The mABs are utilised as a pre-emptive strategy in certain high-risk groups such as those suffering from chronic liver, kidney and respiratory disease, malignancies and other immunocompromised states where efficacy of vaccines may be suboptimal. Aim: To evaluate the clinical outcomes in COVID-19 patients who were treated with Antibody Cocktail drug (casirivimab and imdevimab). Materials and Methods: A retrospective observational study was conducted in patients confirmed positive for SARS-CoV-2 from June 2021 to January 2022 and subsequently, the collected data was analysed from May 2022 to June 2022. The study was conducted in a tertiary care referral hospital in eastern India. All eligible patient subsequently received casirivimab and imdevimab at COVID-19 facility. Monitoring of patients was done upto 12 hour postinfusion. Demographic parameters, routine investigations and clinical outcomes were assessed. Data entry was done using Microsoft Excel. Data was entered, coded and analysed using International Business Machines (IBM) Statistical Package for the Social Sciences (SPSS) version 21.0. All analysis was done at a preset alpha error of 5% and results expressed at confidence levels of 95%. Results: Total 104 eligible cases were taken in present study. Nearly, 93% of those patients who had not been vaccinated were at higher risk for having severely elevated levels of C-Reactive Protein (CRP) as compared to 48% of those with COVID-19 vaccination. Nearly, 9 out of 10 patients with moderate-severe CRP levels were at nine times more risk for longer duration of hospitalisation as compared to normal levels of CRP. All patients having moderate-severe CRP levels required mechanical ventilation in comparison to mild CRP levels. Patients with comorbidities were more likely to get severe COVID-19 infections (p-value ≤0.05). Unvaccinated subjects were more likely to have severe infections than vaccinated subjects. (p-value ≤0.05). Prolonged hospitalisation (>7 days) was statistically significant in severe COVID-19. Unvaccinated subjects had a statistically significant rise in CRP over vaccinated subjects. The majority of the patients receiving antibody cocktail did not require prolonged hospitalisation while a minor fraction required invasive ventilation. Antibody cocktail was safe, well tolerated and had good efficacy and low mortality rate as compared to other modalities of treatment in this study. Conclusion: The duration of hospitalisation and outcomes were superior in patients having mild to moderate COVID-19 who received antibody cocktail without any serious side-effects.
ABSTRACT
Background: Isolated tracheobronchial mucormycosis (ITBM) is an uncommonly reported entity. Herein, we report a case of ITBM following coronavirus disease 2019 (COVID-19) and perform a systematic review of the literature. Case description and systematic review: A 45-year-old gentleman with poorly controlled diabetes mellitus presented with cough, streaky haemoptysis, and hoarseness of voice 2 weeks after mild COVID-19 illness. Computed tomography and flexible bronchoscopy suggested the presence of a tracheal mass, which was spontaneously expectorated. Histopathological examination of the mass confirmed invasive ITBM. The patient had complete clinical and radiological resolution with glycaemic control, posaconazole, and inhaled amphotericin B (8 weeks). Our systematic review of the literature identified 25 additional cases of isolated airway invasive mucormycosis. The median age of the 26 subjects (58.3% men) was 46 years. Diabetes mellitus (79.2%) was the most common risk factor. Uncommon conditions such as anastomosis site mucormycosis (in two lung transplant recipients), post-viral illness (post-COVID-19 [n = 3], and influenza [n = 1]), and post-intubation mucormycosis (n = 1) were noted in a few. Three patients died before treatment initiation. Systemic antifungals were used in most patients (commonly amphotericin B). Inhalation (5/26;19.2%) or bronchoscopic instillation (1/26;3.8%) of amphotericin B and surgery (6/26;23.1%) were performed in some patients. The case-fatality rate was 50%, primarily attributed to massive haemoptysis. Conclusion: Isolated tracheobronchial mucormycosis is a rare disease. Bronchoscopy helps in early diagnosis. Management with antifungals and control of risk factors is required since surgery may not be feasible. © 2022 Wiley-VCH GmbH.
ABSTRACT
Purpose:The purpose of this study was to assess the impact of ongoing waves of the COVID-19 pandemic and resulting guidelines on the corneal donor pool with resumption of clinical operations.Methods:A retrospective analysis of donors deemed eligible for corneal transplantation at an eye bank from July 1, 2020, through December 31, 2021. Donors ineligible due to meeting Eye Bank Association of America (EBAA) COVID-19 guidelines or a positive postmortem COVID-19 testing were examined. The correlation between COVID-19 rule outs and state COVID positivity was calculated. The number of scheduled surgeries, suitable corneas, imports, and international exports was compared with a pre-COVID period. Postmortem testing was reduced for the final 5 months of the study, and numbers were compared before and after the policy change.Results:2.85% of referrals to the eye bank were ruled out because of EBAA guidelines. 3.2% of postmortem tests were positive or indeterminate resulting in an ineligible tissue donor (0.42% of referrals). Over the 18-month period, there was a 4.30% shortage of suitable corneas compared with transplantation procedures. There was a significant correlation between postmortem testing and state COVID-19 positivity (r = 0.37, P <0.01), but not with EBAA guidelines (r = 0.19, P = 0.07). When postmortem testing was reduced, significantly more corneas were exported internationally.Conclusions:Although corneal transplant procedures were back to normal levels, there was a shortage of suitable corneal tissue. The discontinuation of postmortem testing was associated with a significant increase in international exports of corneal donor tissue. © 2023 Lippincott Williams and Wilkins. All rights reserved.
ABSTRACT
Coronavirus disease (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Acute respiratory distress syndrome (ARDS) is a feature of SARS-CoV-2, and transferring patients with severe ARDS is challenging owing to their condition and risk of infection during the transfer process. The hemodynamic instability of critically ill patients adds to the challenge of safe transfer, which requires thorough preparation of personnel, medication, equipment, and communication and transport methods, all of which must be organised within the infection control framework. In this case report we discuss a woman, 37 years of age, with suggested COVID-19, intubated due to severe ARDS. Owing to the hospital referral policy in Indonesia, the patient was transferred to a specialist infectious disease hospital by land ambulance, with a special transfer team formed to adhere to infection control protocols and critical patient transfer procedures. Copyright © 2020, Australasian College of Paramedicine. All rights reserved.
ABSTRACT
Objective: This study compared the aerosol-generating and non-aerosol-generating endodontic emergency procedures' success and assessed the outcome of endodontic treatments initiated before a pandemic but could not be completed in the targeted time. Material(s) and Method(s): Emergency treatments were performed according to symptoms of teeth. Treatment success or failure was determined according to patients whether not re-referral with untimely pain. Short-term outcome and complications arising from teeth, which endodontic treatments were prolonged were also recorded. A chi-square test was used in the statistical analysis, and p<0.05 was considered significant. Result(s): The aerosol-generating procedure group's success rate was 86.2%, while it was 70.0% in the non-aerosol generating procedure group (p=0.050). The short-term survival rate of teeth was 83.7% in patients whose endodontic treatment had been prolonged. Conclusion(s): Considering the pros and cons, each emergency patient should be evaluated case-by-case. Copyright ©Meandros Medical and Dental Journal, Published by Galenos Publishing House.
ABSTRACT
Objective: To discuss the challenges in establishing the paediatric neurology service locally in a resource-limited setting and how we overcame these limitations. Methods/Challenges: (1) Discussion of the service prior to 2020;(2) Training of paediatricians and the local medical board drafted pathway for subspecialty registration;(3) The difficulties in securing posts within the health system (as well as the discrepancies amongst different regions within Trinidad and Tobago);(4) Discussion of a tiered referral system;(5) Limitations in services (including investigations and treatment options);(6) The effects of COVID-19 on a new sub-specialty service. Results/Discussion Points: Prior to 2020, there was no established paediatric neurology service. Changes in local medical board paediatric training from 2020 and the impacts on sub-specialty pathway registration. Discussion on the need for a national service provision due to the discrepancies amongst RHA trained consultants. The development of paediatric epilepsy surgery service within the Caribbean. This would influence the tiered referral system both locally and regionally. The routes for accessing investigations that are not available within the public healthcare setting, including genetic testing. Pathways for accessing treatment on a case-by-case basis. The impact of COVID-19 on service provision'negative and positive aspects. Conclusion(s): With the established local training pathway for paediatrics, as well as opportunities to extend our subspecialty knowledge base in developed countries e.g. UK, Canada, we can improve the services provided. Despite being an independent nation, we are grateful to our Commonwealth leaders for continuing to guide our professional tutelage.
ABSTRACT
Objectives: To improve the efficiency of management of headaches in children presenting to Children's Assessment Unit (CAU) in a District General Hospital (DGH). To implement strategies to improve the quality of care and ensure patient safety. Method(s): Retrospective data were collected for 6 months (from September 2020 to February 2021). Documentation, diagnosis, and management plans were audited. This was compared against NICE guidelines on headaches in children and young people. Result(s): We had 23 children from 6 to 16 years. Documentation was 92% compliant in elaborating symptoms and 100% in eliciting red flags and neurological examination. Major diagnoses were migraine, tension, and cluster headaches. We had 3 (13%) children with Benign Intracranial Hypertension who were referred to tertiary hospital. We identified the following areas for improvement: Unclear management plans where the type of headache is a dilemma in the first presentation. Lack of written information given to parents. Difficulty in referral to the urgent eye clinic for fundoscopic examination. The following changes were implemented: Trust guidelines were revised giving easy access to the registrars by including a flow chart that covered headaches of diagnostic dilemmas and follow-up plan. We created an eco-friendly COVID-19 safe QR-coded parent information sheet for headaches in children with a symptom diary as an annexure. We involved the ophthalmology department and a referral form for an urgent eye clinic was created to facilitate easier communication between the departments. Conclusion(s): In summary, good quality of care was met in terms of diagnosis and documentation but needed improvement in management. The lack of pathways and access were identified as the major cause for this. Following the implementation of the above changes, the audit will be repeated.
ABSTRACT
Background: Coronavirus disease 2019 (COVID-19) was classified by WHO as a global pandemic, and has gone on to affect millions of people worldwide with severe social and economic consequences. Purpose(s): Due to the global crisis the international community has been facing, many people leave their homes to have access to the medicines they needed. Moreover, many Portuguese households lost their source of income, being in a very difficult situation. Abem: Emergency COVID-19 aims to help the economic deprived citizens to have access to the medicines, health products and healthcare services they need. Method(s): Citizens in an unexpected situation of economic shortage due to the COVID-19 pandemic could be referred by local entities (Municipalities and Institutions of Social Solidarity) to be given access to their medications from local pharmacies. The beneficiaries belonging to risk groups received the medicines at their homes, through an articulation between our partners: pharmacies and local referral entities. Its transportation, articulated by pharmacies, was paid for by this initiative. The medicines and healthcare services were paid for by a Solidary Fund, to which many companies and citizens have contributed. Result(s): The Abem: Emergency COVID-19 are putting efforts in place to present effective results by the time we present the poster at the FIP Virtual 2020. Conclusion(s): This support shows the importance of pharmacies in their communities, as well as their synergic involvement with other partners, such as referral entities (Municipalities and Institutions of Social Solidarity), ANF, AFP, APIFARMA, ADIFA, Plataforma Saude em Dialogo and other local entities helping citizens in need.
ABSTRACT
Pulmonary hypertension (PH) is a severe disease that can progress to clinical decompensation, risk of hospitalization and death owing to disease-related or other diseases. In the context of coronavirus disease 2019 (COVID-19), PH was considered a risk factor for complications. The purpose of the study was to assess the mortality rate of COVID-19 in PH patients from a PH Center in Brazil. We conducted a telephone survey between June and August 2021 among all patients or relatives from the PH referral center who were followed after the first case of COVID- 19 in Brazil. Only patients with a confirmed diagnosis of PH were included in the analysis. Of the 426 patients followed in the first 18 months of the pandemic, 115 patients were excluded (lost to follow-up, post-acute PE or unconfirmed PH). Among 311 patients included, 39 had a confirmed diagnosis of COVID-19 (COVID-19 + ), and 38.5% of patients were hospitalized. The estimated incidence rate was 12.5%. Comparing the COVID-19+ versus patients without infection (COVID-19 - ) in the period, the mean age was similar (55 +/- 17 vs. 54 +/- 16 years) and the majority in the COVID-19+ group were female (85% vs. 69%, p = 0.039), respectively. There was no difference in the proportion of patients diagnosed with pulmonary arterial hypertension (PAH;49% and 42%) and chronic thromboembolic pulmonary hypertension (CTEPH;24% and 33%) between groups. All PAH patients and the majority of CTEPH patients were treated on specific therapy (combination/triple therapy, 70%). The case fatality rate in the PH-COVID-19+ group was 23%. Considering only PAH and CTEPH, the case fatality rate was 21,9%, while COVID-19 mortality was 2.9% and overall lethality in Brazil was 2.8%. In the COVID-19+ group, the mean pulmonary artery pressure was 48 +/- 14 mmHg, cardiac index 2.7 +/- 0.6 L/min/m2 and pulmonary vascular resistance 730 +/- 424 dyn.s/cm5. In conclusion, among PH patients there was high incidence and mortality from COVID-19, even in those with PHspecific therapy. Further studies are needed to evaluate the prognostic predictors in PH-COVID-19 patients.
ABSTRACT
Case report - Introduction: This is the case of an adolescent referred to rheumatology following 5 years of back pain. After years of trying a number of treatments without much success, the cause was found to be a previously undiagnosed urological pathology. The case highlights awareness of non-rheumatological causes and incidental findings which can redirect a patient towards more appropriate treatment and reduce the potential for long-term adverse health issues and anxiety. Case report - Case description: B was referred age 16 to rheumatology with a 5-year history of lower back pain. She had previously seen paediatricians with symptoms initially attributed to constipation due to intermittent straining and hard stool. However, constipation remedies had not relieved the pain which progressed gradually to a more persistent dull ache with impact on daily activities. Various analgesics (including paracetamol and non-steroidal anti-inflammatories), exercises and acupuncture had not helped. There was no history of recurrent urinary tract infections or symptom correlation with fluid intake, menstruation or bowel habit. No inflammatory features or connective tissue disease symptoms were noted and family history was unremarkable Clinical examination was normal apart from mild tenderness in the lumbar region. Rheumatoid factor was borderline positive (15 iu/mL) with the rest of blood tests normal including renal function, inflammatory markers (CRP, ESR), anti CCP and ANA. She had minimal microscopic haematuria without proteinuria. MRI spine in 2015 was normal. In view of her young age and symptoms affecting daily activities, STIR sequence spinal MRI was requested. This excluded any new or old inflammatory changes but incidentally identified a dilated left pelvi-calyceal system. Renal ultrasound confirmed a grossly hydronephrotic left kidney with hydroureter and minimal renal tissue suggesting longstanding obstruction. No calculi were seen. The patient was referred to urologists. Further investigations (including MRI abdomen) confirmed similar findings and a distal ureteric stricture. A MAG 3 renogram showed a normal right kidney but only 12% functioning of the left kidney. Urologists have advised surgery (removal of left kidney and ureter) which may relieve symptoms or a conservative non-surgical approach (continue analgesia, physiotherapy and monitoring). The patient and her family are relieved to have a possible cause identified and are considering the surgical option due to ongoing flank discomfort. Case report - Discussion: This was an interesting finding of hydroureter and hydronephrosis causing longstanding back pain presenting to rheumatologists. Until completion of the spondyloarthropathy protocol MRI (STIR images), aetiology had been unclear. Hydronephrosis and hydroureter has no specific age or racial predilection. Signs and symptoms may depend on whether obstruction is acute/chronic. Chronic cases may be asymptomatic or present as a dull discomfort (like this case). Some cases may only present in adulthood with pain precipitated by fluid intake. Blood tests may show impaired kidney function. Post-mortem studies suggest 50% of people have at least one renal abnormality (e.g., renal cysts, duplex ureters) with autopsy series incidence of hydronephrosis reported as 3.1%. Causes include anatomical abnormalities such as vesico-ureteric reflux, urethral strictures (usually present in childhood), calculi, benign prostatic hyperplasia, or intrapelvic neoplasms, pregnancy and infections (e.g., TB). Sudden onset unilateral renomegaly was reported in one case of primary Sjogren's with lymphocytic interstitial nephritis and positive Sjogren's autoantibodies. Our patient has no clinical or serological evidence of connective tissue disease. Minor pelvi-calyceal distension can occur as a normal finding in wellhydrated patients and pregnancy. However, significant hydronephrosis requires assessment to determine cause as it may affect long term renal function. Imaging via computed tomography, ultrasound and urograms can help guide further management. In this case the preceding cause and duration of pathology is unknown. Sterile, giant hydronephrosis treatment options include observation and ureteric stent or nephrostomy in patients unfit for surgery. Nephrectomy is advised for pain and recurrent infection in a non-functioning kidney. Complications may include bowel perforation, vascular injury and urine leakage. Both open and minimally invasive procedures have good reported outcomes. The COVID-19 pandemic and exams have affected timing of any elective procedures and the patient understands surgery may or may not offer complete symptom resolution. Case report - Key learning points: . Non-inflammatory causes of back pain should always be considered in cases of persistent back pain, particularly in young people to ascertain if there is a treatable cause . Hydronephrosis cases can be asymptomatic or present with vague, intermittent, non-specific abdominal symptoms with normal physical examination with or without haematuria. This can cause diagnostic uncertainty and delay referral to urology and appropriate renal investigations . Assessment of renal function (including MAG 3 renogram) is important to guide further management . Surgical interventions (pyeloplasty/nephrectomy) may ease symptoms long term but there is no guarantee of a successful outcome and operative risks need to be considered too . Left undiagnosed, potentially this patient could have had further disruption to daily activities and both physical and mental well being.
ABSTRACT
Introduction: Our institution cares for a largely underserved urban population, treating about 120 children annually with radiation therapy;roughly 10% are referred for proton therapy elsewhere. COVID-19 led to some decreases in medical care due to uncertainties regarding the state of public health. The purpose of this study is to evaluate existing socioeconomic disparities using the University of Wisconsin Area Deprivation Index (ADI) and whether the pandemic impacted this referral pattern. Method(s): Over the last twenty years, approximately 2,275 children have presented to our institution for radiation treatment. A retrospective chart review was conducted and a patient database of demographic and clinical information was created. We used demographic data to obtain the ADI, and compared relative disparity rankings between proton therapy recipients and a random sample of patients from the 25 most common zip codes (representative of over 20% of the total cohort). We compared the number of patients treated only at the closest proton facility before and after the onset of the pandemic. Result(s): The demographic make-up of our patient population is approximately 53.7% Latino, 22.6% White, 9.5% African American, 9.2% Asian, and 5% Other. Of these patients, about 500 had diagnoses typically referred for proton therapy (such as brain tumors, neuroblastoma, sarcomas, and Hodgkin lymphoma). At baseline, we found a statistically significant difference in the median state ADI decile of 3 and 7 for protons and photons, respectively, reflecting lower socioeconomic disadvantage in the proton group. There was a difference in the median household income (based on zip code) of $102,028 and $70,479 between the proton and photon groups (p < 0.0001). There was also a difference in median household income of $57,871 and $76,808 between Latino and Non-Latino patients (p < 0.0001). Demographic data for the proton therapy cohort showed that 46.2% of these patients were White, 15.4% were Latino, 15.4% were African American, 7.7% were Asian, and 15.4% were Other. At the closest proton facility, between 2014-2019, 16 of our patients received radiation therapy. Since the beginning of pandemic associated restrictions in March 2020, 19 patients have received proton therapy at this center. Conclusion(s): Disparities preventing patients from receiving proton therapy have been described. Our work adds granular census block data and uses the ADI which takes into account median family income, unemployment rate, households without access to a vehicle, English language proficiency and more. Those with lower ADI risk rankings were overrepresented in the proton therapy group. Despite the pandemic and added referral challenges, the number of patients able to receive proton therapy did not decrease which we hypothesize may be due to many factors, including the unanticipated flexibility of remote work amongst those with lower ADI rankings. Latinos were least likely to have proton therapy, and further research is needed to ameliorate the disparities and barriers to care which they face.
ABSTRACT
Introduction/Background: Following first reports of paediatric inflammatory multisystem syndrome temporally associated with COVID-19 (PIMS-TS) in April 2020, services have rapidly been developed to manage these patients. In our tertiary paediatric rheumatology service a daily virtual PIMS-TS multidisciplinary (MDT) team meeting was set up in January 2021. This meeting facilitates discussions between the tertiary centre (routinely including paediatric rheumatology and infectious diseases/immunology teams) and general paediatric teams in district general hospitals (DGHs) and within our centre. The aim of this project was to evaluate the service and understand general paediatric opinion in order to consider the future direction of the meeting. Description/Method: We looked at a one month period after meetings were initiated and compared it with a one month period a year later (February 2021 and February 2022) to define patient numbers and outcomes. Alongside this we constructed an online survey aimed at general paediatricians to determine opinion of the current structure of the MDT and how it may be developed in the future. The survey was sent to general paediatricians within our own centre and in the eleven DGHs falling within our region. Results were analysed descriptively. Discussion/Results: During February 2021, 19 new referrals were discussed within the PIMS-TS MDT;each referral was discussed for a median of 5 days (interquartile range (IQR) 3-6 days). Of these, 11/19 (58%) had a final primary diagnosis of PIMS-TS and 5/19 (26%) patients were transferred for tertiary care (of whom 4/5 (80%) had PIMS-TS). In February 2022, 14 new referrals were discussed for a median of 2.5 days (IQR 2-5.75 days). Of these, 3/14 (21%) had a final diagnosis of PIMS-TS and 2/14 (14%) were transferred for tertiary care (of whom neither had PIMS-TS). We received responses from 20 general paediatricians covering 9/11 (82%) DGHs within our region plus our own centre. Most clinicians had discussed up to 6 patients in the meeting (9/20 (45%) 1-3 patients;9/20 (45%) 4-6 patients;2/20 (10%) >6 patients). All clinicians felt the MDT helped facilitate appropriate diagnostic work-up and treatment decisions. 18/20 (90%) felt that the meeting helped avoid unnecessary tertiary paediatric transfers. Interestingly, 9/20 (45%) felt that a routine PIMS-TS MDT meant they were more likely to discuss a patient with rheumatology (1/20 (5%) less likely). All clinicians felt the meeting improved care for patients and most felt it increased their confidence in looking after patients with PIMS-TS (19/20, 95%) and was useful for continuing professional development/training experience (19/20, 95%). Considering the future direction of the meeting, all clinicians felt it should be continued but most (16/20, 80%) felt it should be aimed at a wider patient group. 11/20 (55%) felt a later time of day would be more convenient (currently 11am). Over half (11/20, 55%) thought it should be combined with a currently separate meeting for acute COVID-19 patients (7/20 (35%) don't know;2/20 (10%) no). A minority (4/20, 20%) reported difficulty accessing the meeting. Key learning points/Conclusion: As the initial phase of the pandemic draws to a close and numbers of PIMS-TS cases decline this is important data to reflect on how services can go forward into the next phase. While numbers of PIMS-TS cases reduced, the meeting was still wellused and evolved to include patients with other diagnoses. The survey confirms that most general paediatricians believe it improves patient care and would like the meeting to continue but that review of the format may be helpful. Particular considerations are to broaden the scope of the meeting beyond PIMS-TS, revise the timing and consider how to improve ease of access to the meeting for all. Further work will focus on evaluating patient numbers and diagnoses over the full period of the PIMS-TS MDT and adapting the format of the current MDT in response to the feedback received.
ABSTRACT
The COVID-19 pandemic has accelerated the growth of telemedicine. Advantages include patient convenience, reduced waiting time, minimising hospital commute and the risk of virus transmission and healthcare cost-savings [1]. Compared with other specialties, anaesthesiology is less engaged with telemedicine- based clinical work and challenges in implementation exist [2]. To align with the Ministry of Health, Singapore COVID-19-safe management measures, pre-anaesthetic assessment via video consultation (VC) workflow was implemented in Sengkang General Hospital, Singapore, in December 2020;however, the referral rate amongst our surgical colleagues remained low. Therefore the aim was to increase the number of VCs by 50% within 12 months (from June 2021) and evaluate patients' experiences. Methods Eligibility criteria included low-risk surgeries (duration < 4 h) with minimal expected blood loss, patients aged 21-65 years, ASA status 1 or 2, body mass index < 35 and the patient's ability to use the Zoom video-conferencing application. Post-consultation, patients were invited to complete an electronic patient satisfaction survey. The main reasons for the low VC referral rate were identified based on ground engagement and feedback. Two plan-do-study-act (PDSA) cycles were conducted to address these issues. PDSA cycle 1 (June 2021): to increase awareness amongst surgeons, surgical champions were engaged to promote VC within their departments;however, the VC referral rate remained low. Therefore, a second PDSA cycle was undertaken. PDSA cycle 2 (October 2021): to increase patient and staff awareness by placing posters publicising VC and enlisting the help of Patient Service Associates (PSAs) to screen for patient eligibility. This led to a significant increase in VC referrals. The current workflow will be evaluated for sustainability. Results Pre-intervention, the average number of monthly VCs was 3, and remained unchanged during PDSA cycle 1. This was increased to 14 during PDSA cycle 2. Discussion VC referrals have increased after the modified workflow, achieving high patient satisfaction and no surgical cancellations. Future work includes developing an automated VC workflow for low-risk surgeries. (Figure Presented).
ABSTRACT
Background and Aims Hepatitis C virus (HCV) infection is a major global health problem in adults & children. The recent efficacy of Direct Acting Anti-viral therapy (DAA) has cure rates of 99% in adults and adolescents. These drugs were licensed for children 3-12 yrs during the recent coronavirus pandemic. To ensure equitable access, safe & convenient supply during lockdown, we established a virtual national treatment pathway for children with HCV in England & evaluated its feasibility, efficacy & treatment outcomes. Method A paediatric Multidisciplinary Team Operational Delivery Network (pMDT ODN), supported by NHS England (NHSE), was established with relevant paediatric specialists to provide a single point of contact for referrals & information. Referral & treatment protocols were agreed for HCV therapy approved by MHRA & EMA. On referral the pMDT ODN agreed the most appropriate DAA therapy based on clinical presentation & patient preferences, including ability to swallow tablets. Treatment was prescribed in association with the local paediatrician & pharmacist, without the need for children & families to travel to national centres. All children were eligible for NHS funded therapy;referral centres were approved by the pMDT ODN to dispense medication;funding was reimbursed via a national NHSE agreement. Demographic & clinical data, treatment outcomes & SVR 12 were collected. Feedback on feasibility & satisfaction on the pathway was sought from referrers. Results In the first 6 months, 34 children were referred;30- England;4 - Wales;median (range) age 10 (3.9 - 14.5) yrs;15M;19F: Most were genotype type 1 (17) & 3 (12);2 (1);4(4). Co-morbidities included: obesity (2);cardiac anomaly (1);Cystic Fibrosis (1);Juvenile Arthritis (1). No child had cirrhosis. DAA therapy prescribed: Harvoni (21);Epclusa (11);Maviret (2) .27/34 could swallow tablets;3/7 received training to swallow tablets;4/7 are awaiting release of granules.11/27 have completed treatment and cleared virus;of these 7/11 to date achieved SVR 12. 30 children requiring DAA granule formulation are awaiting referral and treatment. Referrers found the virtual process easy to access, valuing opportunity to discuss their patient's therapy with the MDT & many found it educational. There were difficulties in providing the medication through the local pharmacy. However there are manufacturing delays in providing granule formulations because suppliers focused on treatments for COVID, leading to delays in referring and treating children unable to swallow tablets. Conclusion The National HCV pMDT ODN delivers high quality treatment & equity of access for children & young people, 3- 18 yrs with HCV in England, ensuring they receive care close to home with 100% cure rates.
ABSTRACT
Background: The coronavirus disease 2019 (COVID-19) pandemic has limited healthcare delivery for patients with chronic diseases, including Systemic Lupus Erythematosus (SLE). This study aims to describe the outcomes of patients with SLE in a national COVID-19 referral center in the Philippines. Method(s): A review of records of all patients with SLE seen in the University of the Philippines-Philippine General Hospital (UP-PGH) from March 2020 to December 2021 was done. Data about patient characteristics, health encounters, and outcomes before and after the first visit during the study period were extracted. Descriptive statistics were employed. Result(s): Our population of 403 patients was predominantly young (mean age 34.53 +/- 11.14 years), female, and unemployed. This consisted of 370 known cases of SLE, 92 were diagnosed in institutions outside UP-PGH, and 33 new patients. Over the 22-month study period, there were 2,093 medical encounters, most of them were teleconsultations (81.70%). During an average gap of 53.6 +/- 26.7 weeks between the last consultation and the first visit within the pandemic study period, 84 patients (22.70%) discontinued at least one of their SLE control medications, 68 (18.38%) patients developed a lupus flare, and 79 (21.35%) were hospitalized for various reasons. On their return to the rheumatology clinic during the pandemic, 37.47% were in lupus flare, 28.29% needed to be hospitalized, and 20 died. However, 86.75% of flares were controlled. During subsequent health encounters, 48 patients had a new flare (43 of these were controlled) and 20 died. The most common reason for hospitalization (n = 160) was lupus disease flare and the most common cause of death (n = 40) was pneumonia. Sixty patients acquired COVID-19 infection from which most recovered and four died. Conclusion(s): Audio teleconsultation was the most common method used by our lupus cohort to interact with their doctors during the pandemic. There was an average of a year-long interruption in medical care for 62.70%. More than a third developed a disease flare and 15% acquired COVID-19 but outcomes were good in more than 85%. Despite the challenges posed by the pandemic, the majority of our lupus cohort who were able to continue their treatment had favorable outcomes.
ABSTRACT
Background: Although recognized as the most lethal breast cancer, inflammatory breast cancer (IBC), a NCI designated rare cancer and a cancer health disparity, is severely understudied. Given the unique presentation of diffuse tumor spread without a solid mass, not easily detected by selfbreast exams or mammograms, IBC patients often face delays in diagnosis and treatment leading to poor outcomes. Moreover, reproductive risk factors in IBC and high incidence in younger women, minoritized and marginalized populations highlight the significance of primary care providers (PCP) who are often the first point of contact when patients begin to notice symptoms. Method(s): In this study, we evaluated the knowledge gaps and barriers amongst PCP (physicians, physician assistants, nurse practitioners) in their ability to recognize the signs and coordinate care effectively for IBC. To assess PCP experiences with IBC in their practices and overall breast cancer care during COVID, we first conducted semi-structured interviews (n=11) with providers selected from a convenience sample at Duke University and in the local clinics. Based on data from these interviews and additional cognitive interviews, we developed and disseminated a comprehensive online survey (n=78). Result(s): In this study, access to care was identified as the single most important barrier to treating rare cancers. Furthermore, majority of the PCPs in this cohort identified only a moderate ability to recognize IBC in patients (mean = 3.3, range 1-7), thereby limiting early diagnosis. From the semi-structured interviews, PCPs recognized that IBC is not likely to be part of typical differential diagnosis when patients present with mastitis or breast changes, and most had not seen IBC in their practice. Only 31% (n=78) reported ever suspecting IBC in a patient. Delays in referrals to specialized large clinical centers were also reported as a major barrier. In particular, 62.8% (n=49) reported some delay in referrals for diagnostic imaging. In addition, since the COVID-19 pandemic started, 33% reported diagnosing less breast cancer cases and 63% reported that they experienced breast cancer referral delays. When asked what methods providers would find most helpful to learn more about diagnosing and caring for patients with IBC, the top three modes of preferred education were online CME options (53%);lunchtime, or other in-service training (33%);and website for patients and providers (32%). Conclusion(s): We succeeded in developing a survey instrument and to our knowledge first mixed methods study to assess PCP knowledge gaps and barriers to timely diagnosis and care of IBC patients. Results underscore need to develop PCP training modules and care coordination tools to improve guideline-concordant care. This survey instrument also has the potential to serve as a blueprint to design, implement, and evaluate interventions for other rare cancers.
ABSTRACT
Background: While lung cancer is a leading cause of death in the U.S., annual lung cancer screening (LCS) rates remain low at 12.7%. The WUSTL research group began a community intervention to increase LCS called I-STEP (Increasing Screening Through Engaging Primary Care Providers) to address this quality gap. A customizable Toolkit was administered to a collaborative of six hospital systems in Missouri and Illinois, encompassing LCS eligibility and follow up guidelines, navigating LCS referral, and smoking cessation. The COVID-19 pandemic prompted brief suspension of screening, with lingering effects on LCS delivery and I-STEP implementation. Method(s): This was a step-wedged cluster randomized control trial from January 2019 - March 2021. Six hospital systems sequentially entered a three-month training phase, followed by I-STEP implementation into primary care settings. Primary outcomes were mean number of screenings and mean percent change in LCS from baseline. Data were collated into a dashboard. Analyses compared outcomes within I-STEP sites pre- and post- intervention. To investigate whether I-STEP sites recovered screening numbers during the pandemic, we compared I-STEP sites to six comparator hospitals within the collaborative that did not participate in the intervention. Result(s): Mean LCS increased by 63% amongst I-STEP sites (130.8 to 212). Mean screenings increased significantly from pre- to post-intervention phases within I-STEP sites (p = 0.0272). Across I-STEP sites and comparator hospitals, mean LCS increased significantly following emergence of the pandemic in March 2020 (p = 0.0002, LSM difference -72.0, 95% CI [-100.9, -43]) - data adjusted for the three-month period in which LCS was suspended. Findings were similar for mean percent change in LCS. There was no difference in outcomes between I-STEP and comparator sites. Conclusion(s): I-STEP implementation successfully increased mean LCS from pre-intervention baseline. Findings suggest a possible effect of the I-STEP intervention in promoting increased LCS amidst the pandemic.