Advanced clinical prioritisation in an Irish, tertiary, chronic pain management service: an audit of outcomes.

BACKGROUND: Advanced clinical prioritisation (ACP) pathways could potentially improve the interface between primary and secondary care, instigating appropriate treatment pathways with improved efficiencies. Telemedicine is a key component of ACP pathways. AIMS: Telephone consultations for new referrals (as part of a pilot ACP pathway for chronic pain) were trialled to try (a) improve efficiency of outpatient clinics, (b) expedite assessment/treatment, and (c) reduce the number of face-to-face attendances. An audit of this activity was undertaken. METHODS: The 100 longest waiting new referrals were identified. Over a 9-month period patients were contacted via telephone, undergoing an initial assessment. Treatment plans were initiated and outcomes (≥ 1) were documented. RESULTS: Average length of time on waiting list was 35.37 months. 40% patients were discharged with advice back to referrer, 8% were referred for diagnostics/imaging, 32% were offered pharmacological management, 30% were scheduled for interventional management, 9% were referred for further MDT assessment/treatment, 4% were referred directly for a pain management programme (PMP), 6% were referred for assessment by other specialist services, 9% were brought in for face-to-face consultation in our pain management OPD, 2% were uncontactable, and 1% had died before assessment could be made. CONCLUSIONS: Telemedicine as part of ACP represents an opportunity to improve speed of access to care, reducing the number of patients and time spent on waiting lists. Future studies should be directed at assessing efficacy of treatment plans initiated in telemedicine clinics whilst also looking at cost effectiveness and patient satisfaction.

A national survey of publicly funded chronic pain management services in Ireland.

BACKGROUND: Chronic pain management services have historically been under-resourced in Ireland. There is no agreed model of care for chronic pain management services in Ireland. Previous studies have assessed the extent of services in Ireland without examining waiting times for access to services. AIMS: This study aimed to quantify the extent of, geographical distribution of and waiting times for access to publicly funded chronic pain management services in Ireland. METHODS: Using the British Pain Society's Core Standards for Pain Management Services in the UK (2015) and International Association for the Study of Pain (IASP) recommendations, a questionnaire was devised. Publically funded departments in Ireland were contacted and questionnaires completed. Waiting list data was publicly available and obtained from the National Treatment Purchase Fund website. RESULTS: There was a 100% response rate. Sixteen publicly funded chronic pain management services were identified. There are 27 chronic pain management consultants (16.6 whole time equivalents (WTE)) practicing chronic pain management, amounting to 0.55 specialists (0.34 WTEs)/100,000 of the population. There are 21 WTE for non-consultant hospital doctors (NCHDs), 26.5 WTEs for nursing, 8 WTEs for physiotherapy and 6.2 WTEs for psychology, nationally. A percentage of 93.75% of departments (n = 15) provide interventional therapies, 37.5% (n = 6) provide advanced neuromodulation and 43.75% (n = 7) are managing intrathecal pump therapies. There are five pain management programmes nationally. As of January 2020, ~ 25% patients on waiting lists for outpatient appointments were waiting > 18 months, with ~ 17% patients on waiting lists for interventional treatments waiting > 12 months. CONCLUSIONS: Shortage of multidisciplinary staff is of particular concern for Irish services. Patient access is limited as evidenced by significant waiting lists. In order to improve access to care and bring services in line with international recommendations, increased resources are needed.

The diagnostic and prognostic role of neutrophil-to-lymphocyte ratio in COVID-19: a systematic review and meta-analysis.

Background: The world urgently requires surrogate markers to diagnose COVID-19 and predict its progression. The severity is not easily predicted via currently used biomarkers. Critical COVID-19 patients need to be screened for hyperinflammation to improve mortality but expensive cytokine measurement is not routinely conducted in most laboratories. The neutrophil-to-lymphocyte ratio (NLR) is a novel biomarker in patients with various diseases. We evaluated the diagnostic and prognostic accuracy of the NLR in COVID-19 patients.Methods: We searched for relevant articles in seven databases. The quantitative analysis was conducted if at least two studies were evaluating the NLR role in COVID-19.Results: We included 8,120 individuals, including 7,482 COVID-19 patients, from 32 articles. Patients with COVID-19 had significantly higher levels of NLR compared to negative individuals. Advanced COVID-19 stages had significantly higher levels of NLR than earlier stages.Expert Opinion: We found significantly higher levels of NLR in advanced stages compared to earlier stages of COVID-19 with good accuracy to diagnose and predict the disease outcome, especially mortality prediction. A close evaluation of critical SARS-CoV-2 patients and efficient early management are essential measures to decrease mortality. NLR could help in assessing the resource allocation in severe COVID-19 patients even in restricted settings.

Deep Hypothermic Circulatory Arrest in the Pediatric Population Undergoing Cardiac Surgery With Electroencephalography Monitoring: A Systematic Review and Meta-Analysis.

OBJECTIVE: Cardiac surgery for repair of congenital heart defects poses unique hazards to the developing brain. Deep hypothermic circulatory arrest (DHCA) is a simple and effective method for facilitating a bloodless surgical field during congenital heart defect repair. There are, however, some concerns that prolonged DHCA increases the risk of nervous system injury. The electroencephalogram (EEG) is used in adult and, to a lesser extent, pediatric cardiac procedures as a neuromonitoring method. The present study was performed to assess outcomes following DHCA with EEG monitoring in the pediatric population. DESIGN: In this systematic review and meta-analysis, the PubMed, Cochrane Central Register of Controlled Trials, Scopus, Institute of Science Index, and Embase databases were searched from inception for relevant articles. A fixed- or random-effects model, as appropriate, was used. SETTING: Surgical setting. PARTICIPANTS: Pediatric population (≤18 y old). INTERVENTIONS: DHCA (18°C) with EEG monitoring. MEASUREMENTS AND MAIN RESULTS: Nineteen articles with 1,267 pediatric patients ≤18 years were included. The event rate of clinical and EEG seizures among patients who underwent DHCA was 12.9% and 14.9%, respectively. Mortality was found to have a 6.3% prevalence. A longer duration of DHCA was associated with a higher risk of EEG seizure and neurologic abnormalities. In addition, seizures were associated with increased neurologic abnormalities and neurodevelopmental delay. CONCLUSIONS: EEG and neurologic abnormalities were common after DHCA. A longer duration of DHCA was found to lead to more EEG seizure and neurologic abnormalities. Moreover, EEG seizures were more common than clinical seizures. Seizures were found to be associated with increased neurologic abnormalities and neurodevelopmental delay.

Managing a National Intrathecal Pump Service During the COVID-19 Pandemic.

OBJECTIVE: The healthcare and social disruption caused by the COVID-19 pandemic could pose significant risk to patients with intrathecal pump (ITP) who may miss refill or replacement appointments. In some cases, this could be life-threatening. We designed and piloted a novel refill protocol to assess its efficacy and safety. MATERIALS AND METHODS: Screening of our ITP database for patients most at risk of harm was conducted. These patients were risk-assessed for COVID-19 infection and were enrolled in a protocol to optimize the safety and efficiency of their pump replacement or refill. RESULTS: Of note, 31 of 51 database patients were deemed to be high risk of ITP failure during the pandemic. Thirty patients were successfully refilled with only one patient refusing to leave their house for refill. There were no significant adverse outcomes. CONCLUSION: Our protocol offers a safe and efficient pathway for ITP management during a pandemic.

YEARS Algorithm Versus Wells' Score: Predictive Accuracies in Pulmonary Embolism Based on the Gold Standard CT Pulmonary Angiography.

OBJECTIVES: This study retrospectively applied Wells' score and YEARS algorithm to the same sample of patients to evaluate the predictive performance of each when compared with the gold standard CT pulmonary angiography. DESIGN: Retrospective analytical study. SETTING: A tertiary University Hospital in Ireland. PATIENTS: Data from 794 patients who underwent CT pulmonary angiography to rule out pulmonary embolism. INTERVENTIONS: Patients were analyzed using retrospective application of both Wells' score and YEARS algorithm. Sensitivity, specificity, and diagnostic odds ratio were calculated and compared. MEASUREMENTS AND MAIN RESULTS: Of 794 scans, 78 (9.8%) were positive for pulmonary embolism. The YEARS algorithm was more sensitive than the Wells' score (97.44% vs 74.36%) but was less specific (13.97% vs 33.94%). Furthermore, the diagnostic odds ratio of YEARS was higher than Wells' score (6.27 vs 1.48). YEARS provides better negative predictive value (98% vs 92.4%), and both scores have poor positive predictive value (10.9%). CONCLUSIONS: Both scores successfully exclude pulmonary embolism, although YEARS has a better negative predictive value. Both exhibit poor positive predictive value.