Analysis of workload generated in the two years following first consultation by each new cancer patient: studying the past to plan the future of cancer care

Introduction

Prevalence of cancer patients is dramatically increasing. We aimed at quantifying the oncology workload generated by each new cancer patient in the two years following first consultation.

Methods

In this record-based retrospective study, we retrieved data of all newly diagnosed patients treated at the Oncology Department of Udine Academic Hospital between 01.01.2012 and 31.12.2017. We calculated mean number and standard deviation of the activity type generated by each new cancer patient during the following 2 years.

Results

Seven thousand four hundred fifty-two cancer patients generated a total of 85,338 clinical episodes. The two-years mean number of oncology episodes generated was 11.31 (i.e., for every 1,000 new cancer patients, 11,310 oncology activities are generated overall in the following two-year lapse). Patients with advanced disease generated the highest workload (24.3; SD 18.8) with a statistically significant difference compared to adjuvant and follow-up patients (p < 0.001). The workload generated in the period 0–6 and 0–12 months was significantly higher than in the following months (p < 0.001) and it was also higher for patients initially designated to treatment (p < 0.001).

Conclusion

This is the first study reporting on the mean oncology workload generated during the 2 years following first consultation. Workload is the highest for patient with advanced disease, especially in the first months and in patients in active treatment. A detailed analysis of workloads in oncology is feasible and could be crucial for planning a sustainable framework for cancer care in the next future.

Past COVID-19 and immunosuppressive regimens affect the long-term response to anti-SARS-CoV-2 vaccination in liver transplant recipients

BACKGROUND & AIMS

The long-term immunogenicity of anti-SARS-CoV-2 vaccines in liver transplant (LT) recipients is unknown. We aimed to assess the long-term antibody response of the Pfizer-BioNTech® BNT162b2 vaccine in LT recipients compared to controls.

METHODS

LT recipients underwent anti-SARS-CoV-2 anti-receptor-binding domain protein IgG (anti-RBD) and anti-nucleocapsid protein IgG antibody (anti-N) measurements at the first and 1, 4 and 6 months after the second vaccination dose.

RESULTS

One hundred forty-three LT recipients and 58 controls were enrolled. At baseline, 131/143 (91.6%) LT recipients tested anti-N negative (COVID-19 naïve), and 12/143 (8.4%) tested positive (COVID-19 recovered) compared to negative controls. Among COVID-19 naïve, 22.1% were anti-RBD positives 1 month after the first vaccine dose, while 66.4%, 77%, and 78.8% were 1, 4 and 6 months following the second vaccine dose. In contrast, 100% of controls were positive at 4 months (p <0.001). The median anti-RBD titer 4 months after the second vaccine dose was significantly lower (32 U/ml) in COVID-19 naïve than in controls (852 U/ml, p <0.0001). A higher daily dose of mycophenolate mofetil (MMF) (p <0.001), higher frequency of ascites (p = 0.012), and lower serum leukocyte count (p = 0.016) were independent predictors of anti-RBD negativity at 6 months. All COVID-19 recovered patients tested positive for anti-RBD at each time point. The median antibody titer was similar in those taking MMF (9,400 U/ml, 11,925 U/ml, 13,305 U/ml, and 10,095 U/ml) or not taking MMF (13,950 U/ml, 9,575 U/ml, 3,500 U/ml, 2,835 U/ml, p = NS) 3 weeks after the first and 1, 4 and 6 months after the second vaccine dose, respectively.

CONCLUSIONS

In COVID-19-naïve LT recipients, the immunogenicity of anti-SARS-CoV-2 vaccination was significantly lower than that in controls. MMF was the main determinant of vaccination failure in SARS-CoV-2-naïve patients.

LAY SUMMARY

The immunogenicity of anti-SARS-CoV-2 vaccination in liver transplant recipients is currently unknown. Herein, we show that liver transplant recipients who have not previously had COVID-19 are less likely to mount effective antibody responses to vaccination than a control population. The main determinant of vaccination failure was the use of the immunosuppressive drug mycophenolate mofetil.

Molecular Tumor Board: A bottom-up approach as method for change

e13537

Background: Precision oncology represents, together with immunotherapy, the leading innovation in cancer care. As a result, a growing number of patients will be treated in accordance with their disease’s specific genomic profile rather than the sole histology. At the same time, it is becoming more and more difficult to promptly adopt organizational solutions to deliver the right treatment to the right patient. In order to manage the complexity of genomic profiling and its clinical impact, Molecular Tumor Boards (MTBs) have been established. However, there is still broad heterogeneity among recommendations about the role and aims of MTBs worldwide. Globally, a top-down approach prevails, showing significant differences in the indication of hierarchical structure, composition, and autonomy of established MTBs. In the Hub & Spoke cluster of the academic Hospital of Udine, we adopted a contrarian, bottom-up approach to address the challenge of MTB implementation in the context of a healthcare organizational project. Methods: To face the challenges of precision oncology, an MTB was established in the Friuli Centrale Local Health Authority, North East Italy, as part of a project called “Precision Oncology Pathways”. Its implementation was derived trough a bottom-up approach, focusing on the real impact of this new activity on the hospital context. The aim of this strategy was to make issues emerging from daily practice and from direct information sharing among professionals involved in the integrated care pathways (ICPs) of cancer patients. This project involved two different departments (oncology, medical laboratory) and 8 different units. A project manager was introduced to facilitate interaction among stakeholders, and semi-structured interviews were conducted to define critical hurdles for MTB implementation. Results: A proposal for a bottom-up approach to implement precision oncology clinical pathways will be presented. Organizational findings and a decision-making workflow will be illustrated. Three main aspects turned out to be critical for MTB implementation: the communication gap among stakeholders, the clinical impact of technological innovation, and the role of MTB within ICPs. Besides, interdisciplinary study groups were set up to discuss criteria for patient's referral, the informed consent submission process, quality aspects of analytical methods, essential elements of the genomic report, criteria for the interpretation of genomic tests, and verify regulatory issues and adherence to guidelines. Conclusions: A redefinition of the whole ICP is needed for effective MTB implementation in real practice, according to local peculiarities. In our vision, MTBs represent the corner stone of a new treatment paradigm, and their activity should be patient centered, integrated within ICPs, and focused on the hurdles of tumor genomic profiling (clinical, ethical, pharmaco-economic and technological).

Prevalence of urinary colonization by extended spectrum-beta-lactamase Enterobacteriaceae among catheterised inpatients in Italian long term care facilities

Background

Long Term Care Facilities (LTCFs) play a key role in guaranteeing care to patients in developed countries. Many patients, mostly elderly, access LTCFs at some time in their lives, and their healthcare pathways often require them to move back and forth between hospital and outpatient settings. These patterns bring about new challenges regarding infection control, especially healthcare associated infections.

Methods

A point prevalence study was conducted in 23 Italian LTCFs, to identify colonization in patients with urinary catheter (>24 hours). Species identification, susceptibility tests and extended spectrum beta lactamase (ESBL) production screenings were performed using Vitek 2 System. Enterobacteria identified by Vitek 2 System as ESBL-producers or suspected AmpC hyperproducers on the basis of cephamycin resistance, were sent to a research laboratory where they underwent a double-disk synergy test. Finally, ESBL-producers were screened for bla resistance genes by PCR assay.

Results

211 patients with catheter were screened, 185 out of 211 patients showed positive samples for the presence of Enterobacteriaceae, 114 of these 185 patients were colonized by extended spectrum cephalosporins resistant microorganisms. We identified a total of 257 Gram negative pathogens, of which 51.8% (133/257) were extended spectrum cephalosporins resistant. 7 out of 133 cephamycin not susceptible strains proved to be AmpC-type beta-lactamases and 125/133 ESBL-producers; 1 was not further characterized. 43 out of 257 (16.7%) E. coli, 37/257 (14.4%) P. mirabilis, 20/257 (7.8%), P. stuartii, 14/257 (5.4%) M. morganii, 7/257 (2.7%), K. pneumoniae, 4/257 (1.6%) C. koseri proved to be overall ESBL-producers by double-disk synergy test. Third and fourth generation cephalosporin resistant P. mirabilis, P. stuartii and M. morganii strains mainly harboured a blaTEM gene (95.9%), while 89.1% of E. coli were positive for the blaCTX-M determinant by PCR and sequencing. Patients with decubitus had a higher risk of colonization by at least one resistant isolate (p < 0.01). Samples of patients undergoing antibiotic therapy and patients with decubitus showed a higher risk (p < 0.05) of colonization by beta-lactam resistant microorganisms.

Conclusions

These data confirm the presence of high percentages of ESBL-positive Enterobacteria in Italian LTCFs and the predominance of CTX-M type ESBL in E. coli. The alarming presence of ESBL-producing Enterobacteriaceae in Italian LTCFs can seriously compromise the effectiveness of antibiotic therapy.acilities (LTCFs), Antimicrobial resistance.

[Hospital clinical records accuracy in traceability of healthcare associated infections]

We conducted a retrospective analysis on health care records in order to validate its accuracy in the reporting of healthcare associated infections (HAIs) for the purpose of supporting epidemiological surveillance and nursing-sensitive patient outcomes studies. The health care records have been selected on the basis of the database of alert microorganisms in a teaching Hospital of North-Eastern of Italy, for the years 2005-2006-2007 in three wards (Hematology, ICU and Surgical ward). In 80/107 (74.8%) cases of alert microorganisms a written record was found in the patient's health care records, most frequently in the nursing records (64/80, 80%). In the health care records have been reported 21 diagnosis of infection (21/107, 19.6%). The presence of written symptoms was heterogeneous among the different sources considered (medical and nursing records, vital parameters and therapy sheets). The results are not completely satisfactory from the point of view of the information accuracy. The promotion of integrated clinical health care record systems (doctors/nurses), also electronics, a more accurate compilation and periodical supervision would be needed.

[Nurses staffing in surgical and orthpedical wards in a sample of Italian hospitals. Preliminary results of a descriptive study]

AIM

To compare the standards of nursing personnel involved in direct care in surgical and orthopedical wards, with those of the studies of Aiken et al.

METHODS

A convenience snow ball sampling technique allowed to include 65 centres. Data were collected in an index day, in the middle of the week, in hospitals with a surgical and ortopedical ward on the following variables: number of nurses, number of nurses aids, average time of nursing care per patient over the 24 hours.

RESULTS

Sixty-five surgical and 43 ortopedical wards for overall 2286 beds were included. A nurse, on average, cares for 8.9 patients (7.2 in the morning; 9.2 in the afternoon and 13.6 during the night). Over the 24 hours patients receive 70 minutes of care from nursing personnel and 96 from nurses aids.

DISCUSSION

The number of patients cared for by Italian nurses is higher compared to that observed in Aikens' papers, although health care systems and organization are not strictly comparable. To reach the American standards 997 extra nurses would be necessary. The situation described stresses a critical problem and the need to define national standards on the number of nurses and health care personnel to guarantee to hospitalized patients.

Surveillance of hospital-acquired infections: a model for settings with resource constraints

BACKGROUND

Surveillance activities have been considered of paramount importance for effective infection control programs in health care organizations.

OBJECTIVES

Our objective was to design a capture system able to assure surveillance of hospital-acquired infections (HAI) in acute hospitals with few resources devoted to infection control.

METHODS

We performed 4 biweekly repeated prevalence studies to identify major HAI (urinary tract infections, surgical site infections, lower respiratory tract infection, bloodstream infections) as defined by the Centers for Disease Control and Prevention (CDC) criteria in 3 large hospitals in northeastern Italy (6 internal medicine departments, 5 general surgery departments, 3 intensive care units, and 1 bone marrow transplant unit).

RESULTS

One thousand five hundred fifty-four patients were screened (63.9% in medical wards, 27.5% in surgical wards, and 8.5% in intensive care units and bone transplant unit). The overall prevalence of infection was 4.9% (77/1,554); 4.5% (70/1,554) of patients were infected. A capture system based on the presence of fever >or=38 degrees C, antibiotic use, and presence of devices guarantees 100% sensitivity in detecting HAI but requires an assessment of 62% of the population. Using the presence of fever and devices as criteria guarantees a sensitivity of 98%, requiring an assessment of 41.4% of patients, whereas presence of fever and antibiotic use has the same sensitivity but requires an assessment of 50% of patients. Using nursing records, physician records, and direct patient examination as sources of documentation guarantees that all necessary data are collected while requiring a mean of 4 minutes and 42 seconds per patient (standard deviation, 1 minute and 30 seconds).

CONCLUSION

A capture system based on biweekly repeated prevalence studies that select patients for the presence of fever, antibiotics, and medical devices ensures the detection of all HAI in a resource-limited environment.

Incidence of hospital-acquired infections in Italian long-term-care facilities: a prospective six-month surveillance

This study presents results from a six-month prospective surveillance of hospital-acquired infections in four Italian long-term-care facilities (LTCFs). Eight hundred and fifty-nine patients were enrolled and 21 503 person-days were observed. Two hundred and fifty-four hospital-acquired infections (HAIs) occurred in 188 patients. The overall infection rate was 11.8 per 1000 person-days. The most frequent infections were urinary tract infections (3.2 per 1000 person-days), lower respiratory tract infections (2.7 per 1000 person-days) and skin infections (2.5 per 1000 person-days). Risks related to HAI in a multi-variate regression model were: length of stay >or=28 days [odds ratio (OR) 3.5, 95% confidence intervals (CI) 2.4-5.0]; presence of a device (OR 2.0, 95%CI 1.3-3.0); Norton scale <12 (OR 1.8, 95%CI 1.2-2.6); and being bedridden (OR 1.7, 95%CI 1.08-2.6). The presence of HAI increased the median length of stay (31 days vs 20 days, P<0.01) without a significant influence on fatal outcome (OR 1.4, 95%CI 0.7-2.7).

[Management of the patient's pain in a highly specialized health center]

The management of pain sensations is useful to enhance technical quality within hospitals: this study provides an overview of pain management in a highly specialized health center. In 69.6% of cases the patients answers matched with those of health staff: the most interesting factor is the health staff's willingness to attend training courses aimed at treating the patients pain.