Résumé
The treatment landscape in myeloma has rapidly changed over the last few years with the advent of an ever increasing number of funded novel therapies. At the same time, the COVID-19 pandemic has caused a paradigm shift in the burden of infection within the community. Clinical trials often exclude older and more comorbid patients and so there is a paucity of data of the effect of infection on patients with myeloma in the 'real world'. We performed a restrospective audit of all patients with myeloma admitted with infection to our level 2b haematology centre over a 3-year period from November 2019 to November 2022. We collected data on patient demographics and characteristics, infection status, microbiology results, length of stay and outcome of admission. During the audit period there were 87 admissions from 52 patients. The median number of admissions per patient was 1 (range 1-6). The median age at admission was 72 (range 41-90). Patients had a median of two major comorbidities (range 0-8). Performance status was <2 in 63% of patients (33/52). In terms of disease characteristics, International Staging Score (ISS) was stage 1 in 12% of patients, stage 2 in 38%, stage 3 in 38% and unavailable in 12%. Revised ISS (R-ISS) was stage 1 in 2% of patients, stage 2 in 44%, stage 3 in 17% and unavailable in 37%. The median line of treatment was 2 (range 0-6). Respiratory tract infection was the most common site of infection in 51% of admissions. Microbiology was negative in over half of infection admissions (50/87). Fifteen per cent (13/87) had a positive COVID-19 PCR. A positive blood culture result was identified in 8% (7/87). The median length of stay was 9 days (range 1-58). The mortality rate of admissions with infection was 17% (15/87). Overall, our real-world results show the continuing burden of infection in myeloma in the era of modern treatment. Despite the omnipresence of the COVID-19 pandemic over the last 2 and a half years, this contributed to only a small number of admissions. Infections happened in patients of all ages and many patients had good performance status, limited comorbidities and intermediate risk disease. The mortality rate of our cohort was surprisingly high at 17%. In summary, infection remains a major complication of myeloma. Given our results we now plan a trial of prophylactic antibiotics for patients on active treatment.
Résumé
As a district general hospital (DGH) registrar, clinical duties are varied. The geographical location of these clinical duties can vary in different hospital settings. In our trust, the inpatient Haematology ward was reallocated to become the designated 'COVID ward' at the start of the pandemic, due to a lack of availability of side rooms in the hospital. Haematology inpatients are now managed on general medical wards, with no specific Haematology ward available. This has further increased the geographical spread of registrars' clinical duties. In order to quantify the impact of this geographical spread, we undertook an audit of physical activity over a four-week period. We included the physical activity during working hours recorded by the attending haematology registrar and an on call medical registrar for comparison. We collected data using smart devices on steps walked, distance travelled, time spent walking and calories burnt whilst walking. We collected data for all day shifts worked from 09:00-17: 00 for all days of the week. Overall, the attending haematology registrar walked an average of 10 241 steps a day, covering 7.87 km over a period of 107 min and burning 410 calories whilst active. The medical registrar walked an average of 7498 steps a day, covering 5.76 km over a period of 79 min and burning 300 calories whilst active. By comparison the attending haematology registrar covered 37% more steps per day than the medical registrar, a statistically significant difference (p-value 0.002, students unpaired t-test). During a 7.5 h working day (taking into account a contractual 30-min unpaid lunch break), our DGH haematology registrars spend 107 min walking, which is 24% of their working hours. Our results highlight the time pressures on DGH haematology registrars. Time pressures on registrars in London have become more important as a result of Health Education England's (HEE) medical specialty redistribution programme, which will see the number of specialty trainees in London reduced by 46% over 5 years. Addressing the geographical spread of clinical duties could help to reduce the time pressures on registrars allowing them to spend more time on providing a clinical service. We have presented our data to trust management as evidence to lobby for the creation of a new haematology ward, which has now been included in the plans for a new hospital at our trust.
Résumé
Background: Tocilizumab reduces the need and the duration of organ support and provides a survival benefit for patients at the early stages of COVID-19 (Coronavirus Disease 2019) that have increasing oxygen needs and a significant inflammatory response. Contrary to expectations that this treatment would, also, break the vicious cycle of immunothrombosis of COVID-19, it has been debated whether it is associated with a conversely increased venous thromboembolism (VTE) incidence. In the interim, society guidelines have updated their recommendations advising a prophylactic over that of an intermediate or treatment dose of anticoagulation but there is a lack of evidence based for this group of patients. Aim(s): The purpose of this study was to compare the incidence of VTEs in patients with COVID-19 treated with Tocilizumab in relationship to the thromboprophylaxis dose determined by NICE guidelines. Method(s): A retrospective, cohort study was performed including all patients with COVID-19 admitted at NHS Hillingdon Hospital (UK) who required Tocilizumab between December 2020 and September 2021. Result(s): Sixty-three patients (20 females;43 males) with a median age of 63 y.o. (17-83) were analysed (Table 1). A Spearman's rank correlation was run to determine the relationship between the anticoagulation strategy and the thromboembolic risk in this context. A moderate negative correlation was found between the anticoagulation intensity and the risk of a VTE, r (61) = -0.470, p = 0.000. Binary logistic regression was then used to determine the relationship between anticoagulation intensity and VTEs and Multinomial Logistic Regression for the opposite relationship. Treatment dose thromboprophylaxis is related with more VTEs however this is likely a reflection that patients with VTEs receive appropriate antithrombotic therapy (Table 2). Conclusion(s): The present study suggests that patients with COVID-19 that receive Tocilizumab are not at increased thromboembolic risk and thus standard thromboprophylaxis should suffice. Findings should be confirmed in randomized controlled trials. (Table Presented).