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
In the face of COVID-19, our educational institutions shuttered their doors, moved curricula online, loosened regulations, and reimagined student engagement. Almost as quickly, society reverted to an eagerness for normality as we devolved into anti-Critical Race Theory rallies, anti-mask board meetings, and protests. In this essay, we situate education with a merry-go-round motif, and we situate the efforts we have taken toward true change on a continuum converging toward, or moving against, the "hard reset.”. © 2023 American Educational Studies Association.
Résumé
The COVID-19 pandemic brought with it many challenges for the NHS;for our neonatal unit, staffing and resource concerns necessitated a review of PN provision to our dual site neonatal managed clinical service. Our service comprises of two sites (and includes neonatal surgical cots) and has a combined capacity of 90 cots. Prior to the pandemic the usual PN requirement was between 12 and 20 patients per day, approximately 75% of the PN was individualised (bespoke) and manufactured on site in our unlicensed aseptics units. To support the nursing teams in adult critical care areas, pharmacy aseptics unit were asked to manufacture ready to use infusions;the requirement to make new products along with staff shortages challenged our capacity. Patient individualised parenteral nutrition is highly complex, requiring specific prescriber training of those involved in requesting or ordering, and those involved in ensuring clinical suitability of the prescription. In addition, bespoke compounding or manufacturing is an intricate process requiring appropriately trained staff and specialised equipment. An MDT approach was adopted to review and improve the resilience of our PN service and reduce the need for aseptics manufacture. An options appraisal of the following factors was carried out: availability of sufficient product, license status of the products, nutritional content of regimens, lipid and protein sources, time taken to prescribe, time taken to clinically validate, time taken to prepare, storage requirements, stability/ shelf life of chosen product, time taken to set up, provision of vitamins and trace elements, total fluid volume required for nutrition, supplementation of electrolytes, composition of the PN (2 phase system vs 1 phase system), pump and equipment provision. For our neonatal population Baxter Numeta G13E and G16E bags were selected as the most appropriate option. Moving away from prescribing and administering individualised PN products to using Numeta we were challenged to: design an appropriate prescription chart and regimens, ensure that we were able to prescribe and administer supplementary electrolytes and fluids, review the use of filters for fungi, bacteria and endotoxins on lines used for the administration of PN, ensure that we had sufficient stock of IV lines to enable more frequent line changes, review PN - drug IV compatibility and provide training to prescribers, nurses and pharmacists. Standard bag PN allows greater flexibility to manage unstable patients and has increased our PN capacity. For the proportion of infants for whom Numeta is not appropriate we prescribe either 'start up potassium and sodium free PN' or individualised PN for infants who require long term PN with specific micro or macronutrient requirements. Audit is required to evaluate hypercalcaemia seen in a proportion of infants less than 2kg in weight. Numeta bags do not provide 100% of normal fluid volume for most patient's, the additional fluid requirement significantly increases the number of infusion pumps required to administer PN. After 15 months, Numeta continues to be used as the primary PN product in approximately 90% of our neonatal population.