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1.
Dermatology Online Journal ; 28(1), 2022.
Article in English | EMBASE | ID: covidwho-1822545

ABSTRACT

The COVID-19 pandemic stimulated adoption of teledermatology via video and telephone modalities by outpatient dermatology clinics. However, it was unknown how patient-related factors may have impacted, whether video or phone visits were used, and if visit modality impacted management. Consequently, we conducted a retrospective cross-sectional study of teledermatology visits occurring between March 30, 2020 and May 30, 2020 at an urban tertiary care center. A total of 788 teledermatology visits including 525 video visits and 263 telephone visits, mostly supplemented by patient-uploaded images, were analyzed. Patient age (P<0.001) and visit type (new versus return patient status), (P<0.001) were significant predictors of likelihood of video visit. No significant difference between video and telephone visits was found with regard to frequency of treatment modification (P=0.52), frequency of biopsy referral (P=0.73), biopsy noncompliance rate (P=0.44), or proportion of biopsies showing a new malignant lesion (P=0.92). With age as a significant predictor of visit modality, maintaining both video and phone modalities could prove useful to maximize patient participation. It appears either can be used without concern that choice of modality would impair the ability to change treatment, recognize a lesion requiring biopsy, recognize a new malignant lesion, or negatively affect compliance with biopsy.

3.
Lung India ; 39(2):191-194, 2022.
Article in English | EMBASE | ID: covidwho-1818451

ABSTRACT

Pulmonary veno-occlusive disease (PVOD) is an important cause of pulmonary arterial hypertension (PAH) and is classified under idiopathic cause of PAH. Over a period of time, PVOD has been studied in detail in the western countries and various diagnostic criteria are formulated. Being a rapidly progressive disease, early diagnosis is of utmost importance which helps to initiate appropriate treatment. Recent studies suggest that PVOD has a genetic predisposition and has an autosomal recessive pattern of inheritance. Here, we discuss the case of siblings diagnosed with PVOD to have such genetic predisposition for this disease.

4.
Blood Purification ; 50(SUPPL 1):27, 2021.
Article in English | EMBASE | ID: covidwho-1816952

ABSTRACT

Background : Our Nephrology Department during spring period on the first wave of COVID-19 was the referral Dialysis Unit for Covid-19 positive hemodialysis (HD) patients in the district area of Athens, Greece. We used hemoperfusion (HP) as a therapeutic option in our patients. The aims of this study are to report characteristics, rates and outcomes of all patients affected by infection with SARS-CoV-2 undergoing HD and were treated under our care focusing on the impact of HP on them. Methods: This is an observational study. Our Dialysis Unit has been assigned as a referral unit for Covid-19 positive HD patients. Patients divided to 2 groups: first group of patients underwent HD sessions with Hemoperfusion (A) and the second one received HD sessions without any other extracorporeal blood purification method (B). We used resin-directed hemoadsorption cartridges (HA-330 and HA-130) manufactured by the Jafron Biomedical Company, China. We registered all the data regarding the clinical course of our patients population. Age, primary cause of end stage renal disease, weight, clinical presentation, HD history, outcome, days of hospitalization. Results: Group A 13 patients (4 males) have been enrolled in this group with mean age of 74 years old. 5 of them were presented asymptomatic at admission and 7 of them admitted with or developed during their stay pleural effusions. 4 of them were asymptomatic without effusions during the whole hospital stay. 12 patients received HP for 3 hours in our Dialysis Unit during the planned HD session and one patient received Hemoperfusion in ICU during CRRT. 6 patients had one session of Hemoperfusion (with HA130, 4 patients and with HA 330, 2 patients). 6 patients had 2 sessions (7 days interval) either with HA 130 both sessions (3 patients) or with HA 330 followed 7 days after with HA 130 (3 patients). The patients that admitted in ICU started HP the third day of her admission. The pattern was as follows: We used HA330 in 3 consecutive days during CRRT. In Day 10 we used HA130 and in Day 13 HA330. HP was performed for 3 hours. 24 days was the average hospitalization stay before starting HP for the 12 patients in boards. 9 patients discharged from the hospital after 43 days of hospitalization (range: 35-56 days). 30 days were the mean hospitalization stay for the diceased ones. We did not observe any side effects with HP cartridges (hypotension, reduction of platelets, bleeding). Group B 9 patients (7 males) with mean age of 75 years old did not receive HP during their hospitalization. All of them were presented symptomatic. 8 out of 9 patients died after 6 days of hospitalization (range: 1-14 days), 2 of them in ICU. Conclusions: To sum up, HP seems to be a helpful, safe an quite efficient tool in the battle against Covid-19 in HD patients. Despite the method is unspecific, our lack of strong evidence, our views are with the opinion that is an reliable alternative therapy. However, the real impact of HP on the patient's clinical course (time of initiation, therapeutic protocols, tools to evaluate response) has yet to be determined. The above notice does not minimize the great interest for the method that renal community should give.

5.
Clinical Cancer Research ; 27(6 SUPPL 1), 2021.
Article in English | EMBASE | ID: covidwho-1816888

ABSTRACT

Background The COVID-19 pandemic has necessitated a restructuring of cancer care due to resourcing demands and revised risk-benefit considerations which relate the risks of cancer progression with the risks of COVID-19 related morbidity and mortality. Specific treatment adjustments for individual patients have not been widely reported. The impact of treatment changes on the outcome of cancer patients have also not been well documented. We report the experience of a large Australian metropolitan multisite cancer service that undertook proactive review of systemic anti-cancer therapy (SACT) of all patients in response to the pandemic. The aim was to re-balance the risks and benefits of current treatment strategies in light of the pandemic. Method From March-April 2020, all current SACT orders (excluding those related to clinical trials) were reviewed by an independent team of clinicians. Patients on curative therapy, or with large perceived benefit were reviewed but not included in further processing. For all other SACT orders, a documented recommendation regarding planned treatment was sent to the patient's individual clinician for consideration. A categorical assessment of the recommendations is presented. Results 570 SACT orders were reviewed, pertaining to 317 patients. 731 individual recommendations were made. The cohort consisted of 130 males and 187 females, with a median age of 62 years. Treatment was undertaken with curative intent in 38% of patients, while 62% of patients were treated with palliative intent. Distribution by tumour types was typical of epidemiology and casemix of a metropolitan oncology service. The most frequent recommendations made by the independent review team were: no change (23%), change in formulation of same drug (9%), shorten duration of treatment (9%), treatment break (8%), re-evaluate benefit of current treatment (8%), treatment cessation (7%), and referral for home-based treatment (6%). Overall, 71% of recommendations of the review team were accepted by the patient's individual clinician. A variation to recommendations suggested by the review team was implemented for 8% of SACT orders. Recommendations which were not implemented were mostly initiated by the patient's individual clinician (70%), while 14% were due to patient choice. Conclusion This is the only dataset known to date of the impact of COVID-19 on adjustments of SACT for cancer patients at the start of the pandemic in Australia, and provides key insights into discrete adjustments made for cancer patients. The majority of patients underwent modifications in their cancer therapy made in the context of competing risks to their health posed by COVID-19.

6.
Clinical Cancer Research ; 27(6 SUPPL 1), 2021.
Article in English | EMBASE | ID: covidwho-1816886

ABSTRACT

Introduction: To ensure safe delivery of oncologic care in the COVID-19 pandemic, telemedicine has been rapidly adopted. We assessed accessibility and time to treatment initiation for thoracic oncology patients seen via telemedicine or in-person during the initial phase of the COVID-19 pandemic. Methods: We conducted a retrospective cohort study of patients with thoracic malignancies seen within a multidisciplinary team at the University of Pennsylvania Health System (UPHS) during the first surge of COVID-19 cases in Philadelphia (March 1 to June 30, 2020). Patients with an index visit for a new phase of care, defined as a new diagnosis, local recurrence, or newly discovered metastatic disease were included. Patients who did not receive subsequent oncologic care within the UPHS were excluded. Dates of referral, index visit, and treatment initiation were ed from the electronic medical record (EMR). Patients were divided into groups based on index visit type (in-person vs. telemedicine). Comparisons of time to care between groups were evaluated using the Wilcoxon rank-sum test. Results: Between March 1 and June 30, 2020, 241 distinct thoracic oncology patients were seen for a new phase of care and managed with surgery (n=78, 32.4%), radiation (including concurrent chemoradiation) (n=59, 24.5%), or systemic therapy (n=73, 30.3%). The majority of visits were for a diagnosis of a new thoracic cancer (87.1%). 133 patients (55.2%) were seen in-person and 108 (44.8%) were seen via telemedicine. Baseline characteristics of patients seen via telemedicine vs in-person were well balanced. As expected, the proportion of telemedicine to in-person visit types changed with the local phase of the pandemic with an initial increase of telemedicine during the lockdown period and a decrease during the re-opening phase. A higher proportion of visits were conducted via telemedicine when receiving systemic therapy or radiation as compared to surgery. Among patients with new diagnoses (n=210), the median time from referral to initial visit was significantly shorter amongst the patients seen via telemedicine vs. in-person (4.5 vs. 6.0 days, p=0.006), though only 67.1% had referral dates reported in the EMR. Time-to-treatment stratified by treatment modality received did not differ by type of initial visit (median values in-person vs. telemedicine: surgery 16 vs. 22 days, p= 0.48;radiation 26.5 vs. 28 days, p=0.90;systemic therapy 13.5 vs. 14 days, p=0.49). A sensitivity analysis limited to new diagnoses only (210/241) confirmed the same results. Conclusions: Rapid adoption of telemedicine sustained timely delivery of oncologic care during the initial surge of the COVID19 pandemic across a thoracic oncology multi-disciplinary clinic. While the full impact of telemedicine on long term clinical outcomes remains to be determined, faster times from referral to initial visit in the telemedicine group provide preliminary evidence that telemedicine could sustain or improve accessibility to oncologic care, especially during current and future pandemics.

7.
Brain Injury ; 36(SUPPL 1):42-43, 2022.
Article in English | EMBASE | ID: covidwho-1815750

ABSTRACT

Objectives: The objective of the School Transition After Traumatic Brain Injury (STATBI) project is to rigorously evaluate the impact of BrainSTEPS, a formal return-to-school (RTS) program, on academic, social, and health outcomes for students in grades K-12 who have experienced TBI of any severity, compared to students who have no formal RTS programming. In 2020, the study shifted to examine the effects of COVID-related educational changes on students who experienced a TBI prior to the pandemic. Methods: STATBI uses a mixed method, cohort-controlled research design. The IRB-approved protocol includes electronic survey administration and virtual interviews with parents and children. The data included in this presentation is crosssectional, although the full STATBI protocol is longitudinal. Measures include standardized assessments of executive function, participation, social, and cognitive abilities, in addition to semi-structured interviews with parents, students, teachers, and BrainSTEPS team members. Between 11/2020 and 1/ 2021, 250 families were invited to participate in this portion of the study. Results: Of the 46 families that completed majority of the protocol, the average student age was 14.2 years (SD = 3.3). The sample included students with mild (n = 19), moderate (n = 12), and severe (n = 13) TBI. The average age at injury was 11.8 years (SD = 4.3) and average time since injury was 2.7 years (SD = 2.1). A total of 44 families completed the COVID questionnaire with 6.8% (n = 3) reporting that their students had been diagnosed with COVID, though none required hospitalization. Students with COVID missed 5 or more days of school. 13.6% (n = 6) of families reported a household family member having a diagnosis of COVID. Most families reported that their students were attending school in either a hybrid model (40.9%, n = 18) or fully remote (45.5%, n = 20). Families reported the following areas of accommodation were needed: physical accommodations (25%, n = 11), learning/thinking (36.4%, n = 16), and behavioral/social (22.7%, n = 10). Additional interview data regarding COVID, barriers and facilitators of COVID-related school changes for children with TBI, and performance across all measures in the protocol are currently being analyzed and will be available by the time of presentation. Conclusions: The STATBI project is unique in its focus on RTS for youth with TBI, and this data is particularly pertinent as it highlights the impact of COVID-related school changes on students who experienced a TBI prior to the beginning of the pandemic. Our sample included many students who reported having mild injuries but who continued to have academic needs that warranted a referral to the BrainSTEPS program. Majority of the enrolled participants were engaged in school via hybrid or remote options with a consistent minority requiring academic supports. Implications of COVID-related school changes on students with TBI based on data collected during the first - unique and challenging - year of a longitudinal study will be discussed.

8.
Open Access Macedonian Journal of Medical Sciences ; 10:286-289, 2022.
Article in English | EMBASE | ID: covidwho-1798858

ABSTRACT

BACKGROUND: The early warning scoring system (EWSS) during the coronavirus disease 2019 (COVID-19) pandemic is essential, because it will reduce the risk of organ damage and the death of patients with COVID-19. Health professionals argue that EWSS will be needed in electronic form, because it will be easier to use and quick to identify patient conditions in an emergency situation. There is no study that provides information on the comparison between the use of Electronic EWSS (e-EWSS) and manual EWSS in accessibility among health professionals in a clinical setting. AIM: The purpose of this study was to analyze the difference of accessibility of e-EWSS versus manual EWSS through survey research on registered nurses in Indonesia. METHODS: A survey research was designed in this study. A study was conducted from July to November 2021 on 38 nurses at the COVID-19 referral hospital in Mataram city. Data were collected by a questionnaire containing 12 questions related to the accessibility of e-EWSS and manual EWSS in 19 participants on intervention and 19 participants in the control group. RESULTS: The response to the accessibility of e-EWSS was more positive, namely, 64.5%, while the negative accessibility response was 35.5%. On the other hand, for EWSS, the response to accessibility was more negative, namely, 51.6%, while the response to accessibility was positive as much as 48.4%. The accessibility of emergency examinations of patients with COVID-19 using the e-EWSS was easier than the EWSS with p = 0.000. CONCLUSION: e-EWSS was easier in accessibility compared to EWSS by convenience, speed, and effectiveness indicators. The computerized system on the e-EWSS was capable of performing calculations automatically about patients’ emergency situations.

9.
Journal of the American College of Cardiology ; 79(15):S64-S66, 2022.
Article in English | EMBASE | ID: covidwho-1796605

ABSTRACT

Clinical Information Patient Initials or Identifier Number: R Relevant Clinical History and Physical Exam: A 64-year-old lady with underlying dyslipidemia presented to our emergency department with typical chest pain. Immediate electrocardiogram was performed which showed sinus rhythm, ST elevation at lead 1, aVL and V1, hyperacute T wave at V2 till V3 with ST depression at leads II, III and aVF. Hence a diagnosis of acute anterolateral myocardial infarction, Killip 1 was given and urgent referral to cardiologist was made. Subsequently, she was subjected for primary angioplasty. Relevant Test Results Prior to Catheterization: Blood results showed sodium of 134 mmol/L, potassium of 3.5 mmol/L, urea of 3.2 mmol/L and creatinine of 67 mmol/L. Liver enzymes were within normal limits with aspartate transaminase of 38 U/L and alkaline phosphatase of 91 U/L. Creatinine kinase was 330 U/L but increased to 2861 U/L during subsequent day. In addition, COVID-19 RTK antigen was negative. Relevant Catheterization Findings: Coronary angiogram revealed mild disease at proximal right coronary artery and proximal left circumflex. Minimal disease was noted at distal left main stem, but severe disease was observed from proximal left anterior descending till mid left anterior descending. Heterogenous plague suggesting thrombus was seen at ostial first diagonal as well. [Formula presented] [Formula presented] Interventional Management Procedural Step: Right femoral assess was obtained with 7Fr sheath, and SL 3.5 7Fr guiding catheter was engaged to left coronary artery. Intracoronary heparin and tirofiban were given prior to wiring. First diagonal was wired with Sion Blue while left anterior descending was wired with Runthrough Floppy. Post-wiring both vessels, coronary flow remained TIMI 3 and hence we decided to proceed with IVUS. From IVUS, noted fibrous elastic plague with heavy thrombus burden. Intracoronary streptokinase was given and noted improvement of thrombus from IVUS. BMW wired to left circumflex. Lesion predilated with scoring balloon and associated with no reflow events, resolved post vasodilators. Left main stem was stented with Onyx 3.5 x 26 mm and deployed at 16 atm. Both side branches wires were rewired into same branches via Crusade microcatheter. LMS stent was post dilated with NC Euphora 4.5 mm at nominal pressure. Noted impingement of both ostium diagonal and circumflex branches. Balloon kissing inflation was performed for both LAD/Diagonal bifurcation and LMS/LAD/circumflex bifurcation. POT was performed post balloon kissing inflation with NC Euphora 3.5 mm and 4.5 mm for both LAD and LMS respectively. Next, IVUS was repeated for mid LAD stent length and Onyx 3.0 mm X 15 mm was deployed at nominal pressure. IVUS repeated and noted under-expansion of overlapped segments and post dilated with NC Euphora 3.0 mm at high pressure. [Formula presented] [Formula presented] [Formula presented] [Formula presented] Conclusions: Our clinical vignette demonstrated few learning points including utilization of IVUS during primary angioplasty. Understanding of plague characteristic ensures adequate stents expansion especially with fibro elastic plague. In addition, we also demonstrated several precautions in dealing with bifurcation lesions including usage of double lumen microcatheter for wiring the side branches. Even though we opted for provisional stenting, balloon kissing inflation played pivotal role in preserving flow into side branches.

10.
European Heart Journal Cardiovascular Imaging ; 23(SUPPL 1):i569, 2022.
Article in English | EMBASE | ID: covidwho-1795305

ABSTRACT

Introduction: Stress echocardiography (SE) can assess the significance of moderate/severe stenoses found on CT coronary angiography (CTCA), as a gatekeeper to invasive coronary angiography (ICA). In 2017, the UK National Institute for Health and Care Excellence (NICE), recommended CT fractional flow reserve (CTFFR) on all patients with coronary stenoses on CTCA to reduce downstream ICA and reduce costs. Aim We describe our experience of using CTFFR and compare this with previously accepted practice of judicious use of SE in patients with moderate/ severe CTCA stenosis, and subsequent rate of ICA. Method: An electronic patient record identified patients undergoing CTFFR between January 2019 and March 2020, and CTCA between January 2017 and June 2018, at our centre. We assessed downstream testing following CT evidence of moderate/severe stenoses and undertook a cost analysis per patient (PP) with the following NHS tariffs;CTCA=£220, CTFFR=£530, SE=£177, ICA=£1000. Results: 140 patients were referred for CTFFR with 125 analysed (rejection rate 11%) of which 81 had moderate/severe stenoses. The baseline audit comprised 652 patients undergoing CTCA of which 92 had moderate/severe stenoses. Moderate CTCA stenosis: Baseline audit: 58 had moderate stenosis, 18 (31%) underwent SE, with 1 positive and subsequent ICA. 36 (62%) were referred directly for ICA. In total 17 (46%) were revascularised. Cost of £1224 PP. CTFFR audit: 44 had moderate stenosis, with 35 negative and 9 positive CTFFR. 9 (26%) and 7 (78%) following negative and positive CTFFR respectively, were subsequently referred for ICA. In total 16 (36%) were referred for ICA, and 44% revascularised. Cost of £1425 PP. Severe CTCA stenosis: Baseline audit: 34 had severe stenosis, 1 (3%) underwent SE. 33 (97%) were referred directly for ICA. In total 18 (60%) were revascularised. Cost of £1418 PP. CTFFR audit: 37 had severe stenoses, with 10 negative CTFFR and 27 positive CTFFR. 5 (50%) and 22 (81%) following negative and positive CTFFR respectively were referred for ICA. In total 27 (73%) were referred for ICA and 70% revascularised. Cost of £1719 PP. Importantly 14 patients underwent ICA following negative CTFFR with 29% revascularised. Conclusion: CTFFR use in all patients with moderate/severe stenosis reduced the rate of downstream ICA compared with previous judicious use of SE, albeit at greater cost and similar revascularisation rates. A small number of patients underwent ICA despite negative CTFFR due to clinical concerns. The NICE guidance recommending CTFFR on all patients with moderate/severe CTCA stenosis reduces ICA. However, assuming equal efficacy, based on the non-invasive arm of the Platform trial1, SE would achieve this at lower cost. Notably, CTFFR benefits from completing assessment within a single visit, which is pertinent in the COVID-19 era and negates inherent delays between multiple tests.

11.
Cancer Research ; 82(4 SUPPL), 2022.
Article in English | EMBASE | ID: covidwho-1779465

ABSTRACT

Background: During the SARS-CoV-2 pandemic in 2020, the use of routine screening mammography (SM) and diagnostic mammography (DM) was limited for several months in order to reduce patient exposure and redeploy medical personnel. Previous studies suggest such delays result in more late-stage breast cancer diagnoses. We hypothesized that this impact would vary between institutions depending on regional variations in shutdown periods and the ability and willingness of patients to resume screening. Methods: Patients diagnosed with invasive breast cancers from 2016-2020 were identified using the Beth Israel Deaconess Medical Center (BIDMC) and the Duke University Medical Center (DUMC) cancer registries. Rates of mammography were ascertained from billing data. Baseline patient characteristics, demographics, and clinical information were gathered and cross-referenced with the electronic medical record. Late-stage was defined as Anatomic Stage III-IV disease (AJCC 8th edition). Chi-squared analysis was used to examine monthly distributions in stage at presentation for diagnosis in 2016-2019 compared to in 2020 at each institution. Results: There were 5907 patients diagnosed with invasive breast cancer between 2016-2019 (1597 at BIDMC and 4310 at DUMC) and 1075 in 2020 (333 and 742, respectively). Mammography was limited from 3/16/20-6/8/20 at BIDMC and from 3/16/20-4/20/20 Sa t DUMC. There were fewer SM at each institution during their respective shutdown periods in 2020 than in the same months in 2019: BIDMC 1713 versus 8566 (80% reduction) and at DUMC 1649 versus 5698 (71% reduction). Following the pandemic shutdown, SM volume increased in July-December 2020 compared to July-December 2019 (108% at BIDMC and 116% at DUMC). The proportion of patients diagnosed with late-stage disease at BIDMC was greater in 2020 than in 2016-2019, at 12.6% and 6.6%, respectively (p < 0.001);86% of late-stage diagnoses and 68% of all diagnoses in 2020 at BIDMC occurred from July-December following the initial shutdown period. The proportion of patients diagnosed with late-stage disease at DUMC in these two cohorts were 14.3% in 2020 and 16.2%% in 2016-2019 (p = 0.1);50% of late-stage diagnoses and 51% of all diagnoses in 2020 at DUMC occurred in the period following the initial shutdown from July-December. Conclusion: We identified variation between two large academic medical centers in the impact of the SARS-CoV-2 pandemic shutdown on the proportion of late-stage breast cancer diagnoses. These dissimilar outcomes may be the result of differences in referral patterns as well as regional differences in the approach to SM during the pandemic. In particular, a shorter closure time and substantial increase in SM volume following the initial shutdown period in the Southeast region may have prevented an increase in late-stage diagnoses. Further information and analysis may help suggest additional strategies to minimize adverse effects of reduced cancer screening in future public-health emergencies.

12.
Cancer Research ; 82(4 SUPPL), 2022.
Article in English | EMBASE | ID: covidwho-1779455

ABSTRACT

Background: When the first wave of COVID-19 hit globally in early 2020, concerns were raised about access to surgical interventions for cancer patients. It was considered that neoadjuvant therapy (NAT) although conventionally given to locally advanced breast cancer may need to also be provided to earlier-stage disease. In addition, due to the temporary closure of breast cancer screening programs during the pandemic, concerns were raised about patients presenting with later-stage disease at initial diagnosis. This project aims to assess the impact of COVID-19 on the volume of neoadjuvant referrals at a large cancer centre, as well as any stage migration, impact on treatment timelines and impact on outcomes for breast cancer patients compared to the pre-pandemic population. Methods: The BC Cancer Vancouver centre has a neoadjuvant breast cancer program to ensure high quality of care is maintained. This program's prospective database of breast cancer patients referred for and treated with NAT between the years 2012-2021 was queried to assess data on neoadjuvant referrals, clinical stage, receptor status, treatment timelines, and outcomes between January 1, 2019-December 31, 2020. Data from the years 2019 and 2020 were compared to evaluate the impact of COVID-19 on NAT. Summary data available from earlier years were also utilized as reference. Results: The COVID-19 pandemic resulted in a 51% increase in Sthe number of patients referred to the neoadjuvant program, with 102 patients referred for NAT in 2019, whereas 154 patients were referred in 2020. This proportional increase in referrals is higher than any other year since the database inception. Of note, during 2020 there were no COVID related closures for cancer surgeries in the province. The proportion of patients referred who received NAT remained similar between 2019 and 2020 (69.1% vs 70.8% in 2020). The trend in referrals by month varied between the two years. In 2019, the majority of patients were referred between April to July with the lowest proportion of referrals in October to December. In 2020, the opposite occurred with the lowest proportion of referrals transpiring between January-June, and the greatest proportion in October to December. The proportion of patients who presented with de-novo metastatic disease was consistent between the two years (7.8% in 2019 vs 9.7% in 2020). Despite the closure of all screening mammography programs between March-June of 2020, the clinical stage and receptor status are equivalent between 2019 and 2020. With regards to treatment timelines, there was a 3 day increase in the median time between referral date and medical oncology consultation in 2020 compared to 2019. No other treatment timeline delays were found between 2019 and 2020. With regards to outcomes, 34.9% of patients achieved pCR in 2019, but only 24.1% achieved pCR in 2020, despite similar stage and receptor subtypes. Conclusion: During the COVID-19 pandemic in 2020, a higher volume of patients were referred for NAT than had ever before been referred, despite the fact that there were no closures of operating rooms in our province for COVID-19. From a quality of care perspective there was a delay in referral to consultation for medical oncology, but no delay on referral to treatment, treatment to surgery, or surgery to radiation. However, and a significantly lower pCR rates was seen in 2020 compared to 2019. The 10% decrease in pCR rates may have resulted from increased complexity in breast cancer cases. This trend may continue, as the impact of COVID-19 on breast cancer outcomes will likely take many years to fully appreciate. Attention should be paid to encouraging women to return to regular breast screening programs to decrease the number of patients needing neoadjuvant therapy.

13.
Cancer Research ; 82(4 SUPPL), 2022.
Article in English | EMBASE | ID: covidwho-1779453

ABSTRACT

The value of genetic counseling and testing to cancer prevention, early detection, and treatment options to ensure optimal outcomes is widely acknowledged by providers, payers and patients. However, many individuals who should receive genetic counseling are never offered this service. All patients with early onset (<=age 45), triple negative (<=60) and metastatic HER2 negative breast cancer should be offered genetic counseling and testing (GC/GT) per National Comprehensive Cancer Network guidelines. A quality improvement project to actively identify and offer genetic counseling to all women with early onset, triple negative and metastatic breast cancer was implemented. Baseline information on the number of early onset (<=45), triple negative and metastatic HER2 negative breast cancers diagnosed January 2018-June 2019 was collected and cross-referenced with the Cancer Genetics Risk Assessment patient database and the electronic health record (EHR) to see how many had GC/GT in our department or the breast surgeons' office. We developed questions for an electronic screening tool used by the navigation team when meeting with patients for the first time, screening for personal or family history criteria that would flag patients at increased risk for hereditary cancer. If any questions were flagged, the patient was asked by the navigator if they would be interested in a genetic counseling appointment to consider genetic Stesting. Training was provided to the navigation team so that they could answer basic questions, biweekly meetings were set up to discuss patients, and a flier and informational videos were made available to patients who wanted more information about GC/GT. If a patient was agreeable to genetic counseling, an automated email was triggered to the genetics team, who contacted the patient for an appointment. A standing order was obtained from willing breast surgeons and oncologists within our network to streamline the referral process. In the 18-month baseline period, there were 126 patients diagnosed with early onset, 36 with triple negative <=60 and 30 with metastatic HER2 negative breast cancer. Of these, 57.1% of early onset, 66.7% triple negative and 3.3% of those with metastatic breast cancer had documentation of GC/GT. A paper screening tool was implemented in July 2019 with implementation of an electronic version in November 2019. In the 18-month intervention period, there were 100 patients diagnosed with early onset, 39 with triple negative and 22 patients with metastatic breast cancer. Of these, 86% of early onset, 87.2% of triple negative and 31.8% of metastatic breast cancer patients had documented GC/GT.A limitation of this project is that some patients leave the system to be treated elsewhere after diagnosis and some may have been tested in their private practitioner's office that does not connect with our EHR. Additionally, some may have been offered GC/GT but declined or were unwilling/unable to complete an appointment. Finally, the pandemic likely had an impact on this project, since fewer women were undergoing mammography screening due to COVID-19 restrictions, resulting in fewer diagnoses of breast cancer. By leveraging the navigation team's interaction with breast cancer patients, we were able to improve identification and referral of more patients with early onset, triple negative <=60 and metastatic HER2 negative breast cancer for GC/GT. One barrier to genetic counseling that has been previously identified is a lack of physician referral. Active engagement with a breast navigator can circumvent this barrier. De-identified aggregate data from this quality improvement project was shared with the Association for Community Cancer Centers as part of a larger project, supported by a grant from Pfizer.

14.
European Heart Journal, Supplement ; 23(SUPPL F):F24-F25, 2021.
Article in English | EMBASE | ID: covidwho-1769265

ABSTRACT

Background: Takotsubo cardiomyopathy (TC) presents as a result of catecholamine surge. There are increase of TC among COVID-19 patients, which is induced by cytokine storm. TC is previously known as a self-limiting and benign cardiac manifestation, but it has been uncovered that TC can be associated with fatal cardiac outcome due to cardiogenic shock and life-threatening arrhythmia. Clinical Presentation: A 54-year-old woman presented to the emergency department with a fever since 9 days before admission accompanied by DOE, PND, and fatigue that worsened since 5 days before admission. Fifteen days before her complaints, she experience bereavement from his son death from motorcycle accident. She was referred from regional hospitals due to respiratory failure necessitating ventilator support. Physical examination revealed normal blood pressure and desaturation. ECG shows tachycardia with global ST-elevation. CXR shows cardiomegaly (CTR 62%) and pneumonia. The laboratory demonstrated increased Neutrophil to Lymphocyte Ratio (NLR), C-Reactive Protein, Troponin, and positive PCR COVID-19 swab. An echocardiography presented regional wall motion abnormality with apical ballooning appearance and reduced systolic function with LVEF of 51% resembling Takutsubo cardiomyopathy. Despite maximal ventilatory and pharmacology, she experienced malignant ventricular tachycardia not responding to defibrillation and expired in only 6 hours Discussion: The presence of cardiac arrhythmia followed by cardiac arrest in COVID-19 patient complicated by TC can be a direct effect of catecholamine surge and myocardial injury or indirect effect from QT-prolongation and inflammatory process. Concurrent COVID-19 pneumonia and TC may progress with dismal prognosis, so that in need of prompt referral system.

15.
British Journal of Surgery ; 109(SUPPL 1):i3-i4, 2022.
Article in English | EMBASE | ID: covidwho-1769191

ABSTRACT

Introduction: Virtual fracture clinics (VFC) have been shown to be a safe and cost-effective way of managing outpatient referrals to the orthopaedic department. During the coronavirus pandemic there has been a push to reduce unnecessary patient contact whilst maintaining patient safety. Method: A protocol was developed by the clinical team on how to manage common musculoskeletal presentations to A&E prior to COVID as part of routine service development. Patients broadly triaged into 4 categories;discharge with advice, referral to VFC, referral to face to face clinic or discussion with on call team. The first 9 months of data were analysed to assess types of injury seen and outcomes. Results: In total 2489 patients were referred to VFC from internal and external sources. 734 patients were discharged without follow-up and 182 patients were discharged for physiotherapy review. Only 3 patients required admission. Regarding follow-ups, 431 patients had a virtual follow-up while 1036 of patients required further face to face follow up. 87 patients were triaged into subspecialty clinics. 37 patients were felt to have been referred inappropriately. Conclusions: BOA guidelines state all patients must be reviewed within 72 hours of their orthopaedic injury. Implementation of a VFC allows this target to be achieved and at the same time reduce patient contact. Almost half the patients were discharged following VFC review, the remaining patients were followed up. This is especially relevant in the current pandemic where reducing unnecessary trips to hospital will benefit the patient and make the most of the resources available.

16.
British Journal of Surgery ; 109(SUPPL 1):i6-i7, 2022.
Article in English | EMBASE | ID: covidwho-1769188

ABSTRACT

Aim: Approximately 2.6 million people see their GP for lower back pain (LBP) each year. Referrals for spinal surgery are increasing with varying effectiveness. Screening for neurosurgical red flags is critical to quickly identify the rare but serious causes of LBP, such as CES. The primary aim was to explore what effect COVID-19 had on the management pathway of these patients in primary care to investigate causes of LBP including ruling out CES. Method: A service evaluation of all patients presenting to a large primary care provider in West Yorkshire with lower back pain who underwent MRI lumbar/sacral spine investigation between March 2020 and March 2021 was conducted. Results: A total of 105 patients with matched MRI scans were included. Neurosurgical red flag screening was performed by virtual appointment only in 32 (30.5%) of patients. In 10 cases (9.5%), red flag screening was not documented. Radiological outcomes revealed three (2.9%) cases of CES. Thirty (28.6%) required onward referral to neurosurgery. The majority (n=56;53%) had demonstrated radiological pathology amenable to conservative management. Conclusions: During the pandemic, almost a third of patients in primary care did not receive a face-to-face examination to rule out red flags in lieu of virtual appointments and history alone. The majority of imaging revealed pathology that was amenable to conservative management. The safety of virtual consultations including telephone appointments to screen for neurosurgical pathology needs further investigation. If deemed safe, virtual patient pathways may be optimised to achieve effective recognition patients at risk of CES requiring neurosurgical intervention.

17.
British Journal of Surgery ; 109(SUPPL 1):i36, 2022.
Article in English | EMBASE | ID: covidwho-1769180

ABSTRACT

Aim: A pooled waiting list model is where patients are treated in turn by the first available surgeon and works to use existing resources more efficiently to better match demand. Aim is to compare quantitative data of patients on the pooled list and named-consultant' list and to determine the superiority of either list based on favourable outcomes. Method: This single centre, retrospective study compared outcomes of primary elective hip and knee arthroplasty for osteoarthritis in patients from pooled and 'named-consultant' waiting lists over a 1-year period. The study period was before the corona virus pandemic. 371 total knee replacements (TKR) and 373 total hip replacements (THR) were included. Baseline characteristics were compared between patients from pooled and named-consultant lists. Results: In the pooled TKR group, a significantly higher proportion of patients were older with higher BMI and ASA grade (p=0.027, p= 0.479, p<0.001 respectively). There was no difference in baseline characteristics in the THR cohort. Waiting time to surgery was less in the pooled TKR group (mean=4.17months) with no significant difference in mortality, revision and infection rates, length of stay, operative blood loss, DVT/PE rate, proportion requiring pain team referral and the number with unsatisfactory range of motion at follow-up. There was no significant difference in any outcomes between two groups in the THR cohort. Conclusions: Pooled lists can therefore be an excellent tool in primary THR/TKR to efficiently utilize all available resources (surgeons and theatre time) without compromising on patient outcomes and prompting use in all UK arthroplasty centres.

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British Journal of Surgery ; 109(SUPPL 1):i47, 2022.
Article in English | EMBASE | ID: covidwho-1769152

ABSTRACT

Aim: The COVID-19 pandemic continues to present unprecedented challenges for healthcare systems. This has resulted in the pragmatic shift in practice of plastic surgery units worldwide. Many units reported a significant fall in urgent melanoma referrals, leading to patients presenting with advanced disease. Our objective was to evaluate our unit's experience with both non-invasive and invasive melanoma during the COVID-19 pandemic and compare it to the UK, mainland Europe and North America. Method: A Retrospective chart review was performed on all patients diagnosed with invasive and non-invasive cutaneous melanoma between March to December of 2019 (control) compared to 2020 (COVID-19 pandemic) in a single plastic surgery unit in Ireland. Results: A total of 589 patients were included in the study. Of these, 314 (53%) with invasive melanoma, compared to 275 (47%) with noninvasive disease. Overall, more patients were diagnosed with both invasive and non-invasive melanoma in 2020 than 2019 (p<0.05). However, significantly longer waiting times in 2020 (64 days) compared to 2019 (28 days) (p<0.05) with the majority of referral being from GP in 2019 (83%) compared to 61% in 2020. Positive sentinel lymph node was higher in 2019 at 56% (n=28) compared to 24% (n=22) in 2020. There was no statistically significant difference in the tutor characteristics or metastasis status. Conclusions: Our study highlights that with prompt efficient restructuring of services, including governmental agreement to utilise private sector to continue urgent elective surgery, virtual triaging and follow-up and most importantly virtual complex skin multidisciplinary team meeting, we could reserve successful management of skin cancer even in the most devastating times.

19.
British Journal of Surgery ; 109(SUPPL 1):i47, 2022.
Article in English | EMBASE | ID: covidwho-1769149

ABSTRACT

Introduction: Studies have shown that men are more likely to sustain head injuries (HI) due to a higher likelihood of participation in high-risk behaviours. However, the COVID-19 lockdown caused substantial alterations to the daily routines of the Welsh population. We aimed to describe the demographical changes of HI patients caused by this large-scale restriction of public social activity. Method: A retrospective review of our neurosurgical referral database was performed between 1/1/19 to 31/12/20 to extract patient demographics and referral outcomes (admission/advice only) of adult head injury patients. Referrals during lockdown in Wales (26/3/20 - 1/6/20 and 31/10/20 and 2/12/20) were compared with non-lockdown periods in 2019 and 2020. Results: There was no significant difference in HI referral volume in 2019 (n=1228) vs 2020 (n=1179) (OR: 0.71;95% CI: 0.53 - 0.96, p= 0.02). Women were less likely to be admitted in 2019 (OR: 0.60, 95%CI: 0.39 - 0.91, p=0.02) and 2020 (OR: 0.52, 95%CI: 0.31-0.88, p=0.01). We observed evidence of interaction by age and sex in lockdown vs nonlockdown (p=0.02). Most strikingly, there was higher odds of admission in women aged 40-70 years during lockdown (OR: 10.4, 95%CI: 1.13 - 95.8, p=0.04). Conclusions: We observed significant demographical shifts in HI during lockdown periods, with striking increases in admission rates of men under 40 years and women aged 40-70. The cause of these substantial changes need clarification and have important public health implications. Given likely reduced road traffic accidents during lockdown, other factors such as alcohol or assault need considering.

20.
British Journal of Surgery ; 109(SUPPL 1):i121, 2022.
Article in English | EMBASE | ID: covidwho-1769146

ABSTRACT

Introduction: Covid-19 has had a significant impact on all aspects of healthcare. We aimed to characterise our experience of oncological general surgery during the first 4-months of the pandemic and compare with the same period in 2019. Method: A prospective cohort study was performed from 23/03/20 to 08/ 07/20. All elective oncological operations were included. Data on patient demographics, waiting times, inpatient characteristics and oncological outcomes were recorded. Statistical analysis was used to compare with retrospective data from 2019. Results: 78 patients were included in total, 38 in 2019 and 40 in 2020. There were no differences in length of stay (2.5 vs 3.5 days, p=0.355) or waiting list time (27.2 vs 24.2 days, p=0.574). Oncological outcomes were comparable with no statistical difference in clear resection margin status (94.4 vs 84.6%, p=0.168) or positive nodal status (24.1 vs 37.1%, p=0.298). The percentage of staging CT scans requested externally was higher in 2020 (4 vs 32%, p=<0.05). There was no difference in time from urgent referral to first assessment (30.5 vs 26.4 days, p=0.384) or time to operation (96.6 vs 85.7 days, p= 0.618). Conclusions: Oncological surgery during Covid-19 can be performed safely with favourable oncological outcomes. The longer-term effects from delayed diagnoses remain to be evaluated.

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