1016 USING VIDEO TELEMEDICINE FOR INPATIENT WORKING: A NOVEL APPROACH TO REMOTE WORKING DURING THE COVID-19 PANDEMIC

Background

Orthogeriatrics inpatient ward.

Introduction

The COVID-19 pandemic changed working patterns for many trainees. Remote telephone or video outpatient consultations became established practice, with clinically vulnerable staff able to support this provision. We adapted the use of telemedicine to provide remote clinical working for inpatient care and continued speciality training opportunities.

Method

Microsoft Teams video conferencing facilitated interaction between the specialist registrar working remotely and the on-site multidisciplinary team (MDT). Daily activities included virtual handover attendance, inpatient ward round consultations and MDT discussions. A portable computer enabled the clinician to see and interact with inpatients remotely. Access to electronic patient records facilitated timely decision making and enactment of management plans. Anonymous MDT feedback was collected via online questionnaires. This project conformed to service evaluation guidelines and ethical approval was not required.

Results

Fourteen staff members completed the feedback survey. Results were overwhelmingly positive, with 78.6% of respondents strongly agreeing that the senior doctor working remotely supported the MDT, facilitated complex clinical decision making and was beneficial to patient care. Feedback noted that some patients praised the ‘clever’ and ‘innovative’ method. Limitations included technical difficulties due to Wi-Fi connection, which contributed to communication not being as fluid as face-to-face consultations and increased ward round duration. Patient factors, namely hearing and cognitive impairment, limited the interaction that patients were able to have with the clinician via video link.

Conclusion

Video inpatient ward round consultations offer an effective opportunity for physicians to continue clinical patient-facing roles whilst working remotely. Furthermore, this minimises the impact of COVID-19 on specialty trainees, by providing continued training and assessment opportunities for individuals required to shield. This novel method affords a framework transferrable to clinicians from other hospital specialties who may be required to work remotely. Future reviews of patient and relative satisfaction with this process are required.

New dosimetric guidelines for linear Boltzmann transport equations through comparative evaluation of stereotactic body radiation therapy for lung treatment planning

Purpose

To propose guidelines for lung stereotactic body radiation therapy (SBRT) when using Acuros XB (AXB) equivalent to the existing ones developed for convolution algorithms such as analytic anisotropic algorithm (AAA), considering the difference between the algorithms.

Methods

A retrospective analysis was performed on 30 lung patients previously treated with SBRT. The original AAA plans, which were developed using dynamic conformal arcs, were recalculated and then renormalized for planning target volume (PTV) coverage using AXB. The recalculated and renormalized plans were compared to the original plans based on V100% and V90% PTV coverage, as well as V105%, conformality index, D_2cm, Rx/D_max, R50, and D_min. These metrics were analyzed nominally and on variations according to RTOG and NRG guidelines. Based on the relative difference between each metric in the AAA and AXB plans, new guidelines were developed. The relative differences in our cohort were compared to previously documented AAA to AXB comparisons found in the literature.

Results

AAA plans recalculated in AXB had a significant reduction in most dosimetric metrics. The most notable changes were in V100% (4%) and the conformality index (7.5%). To achieve equal PTV coverage, AXB required an average of 1.8% more monitor units (MU). This fits well with previously published data. Applying the new guidelines to the AXB plans significantly increased the number of minor violations with no change in major violations, making them comparable to those of the original AAA plans.

Conclusion

The relative difference found between AAA and AXB for SBRT lung plans has been shown to be consistent with previous works. Based on these findings, new guidelines for lung SBRT are recommended when planning with AXB.

Determination of Total Taurine in Pet Foods by Liquid Chromatography of the Dansyl Derivative: Collaborative Study

A liquid chromatographic (LC) method for the determination of total taurine in pet foods was evaluated in a collaborative study. Ten laboratories assayed 6 blind duplicate pairs of wet and dry pet foods. The taurine in the 6 sample pairs ranged from low (170 mg/kg) to high (2250 mg/kg) concentrations as is. Collaborators also assayed a sample of known taurine concentration for familiarization purposes. Samples were hydrolyzed to release bound taurine, which was subsequently converted to the dansyl derivative and quantitated by gradient-elution LC with fluorescence detection. Repeatability relative standard deviations, RSDr, ranged from 3.2 to 10.0%; reproducibility relative standard deviations, RSDR, ranged from 6.1 to 16.1%. The method has been adopted Official First Action status by AOAC INTERNATIONAL.

Caesarean Section at Full Dilatation and Risk of Major Obstetric Haemorrhage

The purpose of the study was to examine the risk factors for caesarean section (CS) at full dilatation and to assess the risk and management of haemorrhage. The study took place in a tertiary referral maternity hospital. Women who had a CS at full dilatation were included. Clinical and demographic details were recorded. There were 199 cases. The average age was 30.3 years and average BMI was 25.8kg/m2. There were 79.9 % (159) primigravidas and 20.1% (40) multigravidas. The average gestation at delivery was 39.4 weeks. Labour was induced in 46.9 % (92) and spontaneous in 53.8% (107). Oxytocin was used in 67.8 % (135). An instrumental delivery was attempted in 46.7 % (93). The rate of malposition was 46.5 % (92). The average birthweight was 3,629g and 9 babies weighed ?4.5kg. The average estimated blood loss (EBL) was 665mls and 34 had EBL>1L. Most had an oxytocin infusion (141). Other uterotonic agents were used in 70 women. Seven women had blood transfusions. The highest rate of CS at full dilatation was in primigravidas due to malposition. There was a low rate of major obstetric haemorrhage.

Impact of physician specialty on classification of physician-perceived patient severity for patients with osteoarthritis

BACKGROUND

Physicians often classify patients' osteoarthritis (OA) severity subjectively. As treatment decisions are influenced by severity classifications, it is important to understand the factors that influence physicians' OA severity ratings. This research sought to empirically identify physician and patient characteristics that lead to a patient being perceived as having more severe OA.

METHODS

Data were analyzed from the OA IX Disease Specific Program, a large cross-sectional survey of OA physicians and patients in Germany, the UK, and USA between September 2011 and January 2012. Eligible, consenting physicians completed a Patient Record Form (PRF) for 10 consecutive OA patients. The PRF asked physicians to report the patient's demographics [age, gender, body mass index (BMI), ethnicity], their assessment of the patients' symptom severity, treatment, probability for surgery, to rate their overall OA severity (mild, moderate or severe) and the factors that had influenced the rating. Chi-squared tests and analysis of variance were used to identify patient characteristics that significantly impacted physicians' OA severity ratings. Controlling for the significant patient characteristics, we then examined the impact of physician specialty on physician's OA severity ratings. Finally, we investigated the differences in physician-reported factors that influenced the physicians' rating of patients' severity between physician specialties.

RESULTS

Three hundred and sixty-three physicians [220 primary care physicians (PCPs), 48 rheumatologists, 95 orthopedic surgeons] recruited 3561 patients. Patients with greater age and BMI, worse symptoms and greater health care use were given higher OA severity ratings. Controlling for these factors, orthopedic surgeons rated their OA patients as more severe than PCPs and rheumatologists [adjusted odds ratio (OR) 1.8, 95% confidence interval (CI) 1.4-2.4]. Specialists (rheumatologists and orthopedic surgeons) were more likely than PCPs to use joint spaced narrowing based on X-ray and severity of joint deterioration radiographic severity to assess patients' OA severity (joint space narrowing: 79% and 78% vs 55%, P < 0.0001).

CONCLUSIONS

Patient age, BMI, presence and severity of symptoms and health care use significantly impacted physicians' OA severity ratings, but radiographic changes appeared to be given greater weight among orthopedic surgeons and rheumatologists than PCPs when assessing patient severity. Whether these differences translate into different treatment recommendations for similar patients is unknown, and warrants study.

Local control rates with five-fraction stereotactic body radiotherapy for oligometastatic cancer to the lung

OBJECTIVE

To report our institutional experience with five fractions of daily 8-12 Gy stereotactic body radiotherapy (SBRT) for the treatment of oligometastatic cancer to the lung.

METHODS

Thirty-four consecutive patients with oligometastatic cancers to the lung were treated with image-guided SBRT between 2008 and 2011. Patient age ranged from 38 to 81 years. There were 17 males and 17 females. Lung metastases were from the following primary cancer types: colon cancer (n=13 patients), head and neck cancer (n=6), breast cancer (n=4), melanoma (n=4), sarcoma (n=4) and renal cell carcinoma (n=3). The median prescription dose was 50 Gy in five fractions (range, 40-60 Gy) to the isocenter, with the 80% isodose line encompassing the planning target volume (PTV) [defined as gross tumor volume (GTV) + 7-11 mm volumetric expansion]. The follow-up interval ranged from 2.4-54 months, with a median of 16.7 months.

RESULTS

The 1-, 2-, and 3-year patient local control (LC) rates for all patients were 93%, 88%, and 80% respectively. The 1-, 2-, and 3-year overall survival (OS) rates were 62%, 44%, and 23% respectively. The 1- and 2-year patient LC rates were 95% and 88% for tumor size 1-2 cm (n=25), and 86% for tumor size 2-3 cm (n=7). The majority (n=4) of local failures occurred within 12 months. No patient experienced local failure after 12 months except for one patient with colon cancer whose tumors progressed locally at 26 months. All five patients with local recurrences had colorectal cancer. Statistical analyses showed that age, gender, previous chemotherapy, previous surgery or radiation had no significant effect on LC rates. No patient was reported to have any symptomatic pneumonitis at any time point.

CONCLUSIONS

SBRT for oligometastatic disease to the lung using 8-12 Gy daily fractions over five treatments resulted in excellent 1- and 2-year LC rates. Most local failures occurred within the first 12 months, with five local failures associated with colorectal cancer. The treatment is safe using this radiation fractionation schedule with no therapy-related pneumonitis.

The association of lactate and vasopressor need for mortality prediction in survivors of cardiac arrest

BACKGROUND

Currently there are few tools available for clinicians to predict outcomes in cardiac arrest survivors. Our objective was to determine if the combination of simple clinical parameters (initial blood lactate and vasopressor use) can predict outcome in post-cardiac arrest patients.

METHODS

The design was a retrospective medical record review. The study was carried on in two urban, tertiary-care, university teaching hospitals. As for patients, inclusion criteria were: 1) age ≥18 years; 2) non-traumatic out-of-hospital cardiac arrest with return of spontaneous circulation; 3) lactic acid measured within one hour of return of circulation. No interventions was performed.

RESULTS

Patients were divided into groups based on two variables: 1) vasopressor status (receipt of vasopressors vs. no vasopressors); and 2) initial blood lactate (categories defined as lactate <5 mmol/L, lactate 5 to 10 mmol/L, lactate ≥10 mmol/L); 128 out-of-hospital cardiac arrest patients met study inclusion criteria. Overall mortality was 71% (95%CI 63-79%). Patients who received vasopressors had significantly higher mortality rates compared to patients who did not receive vasopressors (80% vs. 52%; P=0.002). A stepwise increase in mortality is associated with increasing lactate levels (39% lactate <5 mmol/L, 67% lactate 5 mmol/L to10 mmol/L, and 92% lactate ≥10 mmol/L; P<0.001). The AUC for our model was 0.82.

CONCLUSION

The combination of two clinical parameters, vasopressor need and lactic acid levels, is an accurate severity of illness classification system and can predict mortality in patients following out-of-hospital cardiac arrest. Prospective validation of these variables in post-cardiac arrest is needed.

Emergency department consultations for patients with neurological emergencies

BACKGROUND

The spectrum of neurological emergencies that front-line physicians encounter is diverse. Appropriate assessment and neurological consultation is essential to good patient outcomes because many of these conditions depend on the rapid initiation of proper therapy.

METHODS

In this retrospective study, we reviewed patients for whom the emergency physician elected to consult a neurologist to categorize the types of complaints, resources utilized, patient disposition and final diagnoses.

RESULTS

Of the 500 patients analyzed in our study, the most common chief complaints were focal weakness (22%), headache (18.2%), dizziness or vertigo (16%), and seizure (14.2%). The most common reasons for neurological consultation were specific symptom (70.6%), concern for a specific diagnosis (17.4%), specific radiologic finding (9.2%), and ambiguity in the diagnosis (2.8%). Overall stroke accounted for 18.6% of the cases in our study. Non-contrast brain computed tomography was the most common imaging study (72.2%), and 37.0% of patients received advanced neuroimaging. The presentation of patients varied as 47% presented without having been seen by another healthcare professional, 24% were referred to the emergency department (ED) following by some other outpatient provider for evaluation, and 29% were transferred from another ED.

CONCLUSIONS

Patients with neurological emergencies are common and consume a disproportionate amount of resources in the ED. Emergency physician training must target the modern evaluation of patients with a large variety of neurological emergencies and place special emphasis on the evaluation of patients with weakness, seizures, headache, and dizziness.

Civilian-military coordination in the emergency response in Indonesia

Military and civilian humanitarian interventions in severely affected Indonesian province of Aceh are described following the tsunami of December 26. Specific events and activities illustrate the comparative roles of these types of agencies and how collaboration should recognize the abilities and limitations of each.

Determination of total taurine in pet foods by liquid chromatography of the dansyl derivative: collaborative study

A liquid chromatographic (LC) method for the determination of total taurine in pet foods was evaluated in a collaborative study. Ten laboratories assayed 6 blind duplicate pairs of wet and dry pet foods. The taurine in the 6 sample pairs ranged from low (170 mg/kg) to high (2250 mg/kg) concentrations as is. Collaborators also assayed a sample of known taurine concentration for familiarization purposes. Samples were hydrolyzed to release bound taurine, which was subsequently converted to the dansyl derivative and quantitated by gradient-elution LC with fluorescence detection. Repeatability relative standard deviations, RSDr, ranged from 3.2 to 10.0%; reproducibility relative standard deviations, RSDR, ranged from 6.1 to 16.1%. The method has been adopted Official First Action status by AOAC INTERNATIONAL.

Immunobiology of xenogeneic cornea grafts in mouse eyes. I. Fate of xenogeneic cornea tissue grafts implanted in anterior chamber of mouse eyes

BACKGROUND

The cornea is an immune privileged tissue that, when grafted orthotopically, forms the anterior surface of the immune privileged anterior chamber. We have recently reported that allogeneic cornea fragments implanted in the anterior chamber of mouse eyes resist immune rejection, although such graft fragments are rejected outside the eye. We wished to determine the extent to which xenogeneic cornea fragments placed in the eyes of normal mice are vulnerable to immune rejection.

METHODS

Guinea pig corneas, deprived surgically of epithelium, were cut into fragments and inserted into the anterior chamber of eyes of BALB/c and severe combined immune deficient (SCID) mice, adjacent to the central cornea of the recipient. The fate of the grafts was assessed clinically by biomicroscopy and histologically for 8 weeks postimplantation.

RESULTS

The majority of guinea pig cornea fragments devoid of epithelium came to rest with the raw stroma adjacent to recipient endothelium. These fragments remained clear for the 8-week observation interval in both BALB/c and severe combined immune deficient mice. Clear grafts displayed viable guinea pig keratocytes and endothelial cell layers for 4 weeks. The endothelium was then replaced by murine cells by 8 weeks. A minority of guinea pig cornea fragments were oriented with donor endothelium adjacent to recipient endothelium. Although these grafts in severe combined immune deficient eyes eventually acquired an endothelial layer that faces the anterior chamber and remained clear, similar fragments in BALB/c eyes became opaque, failed to acquire a proper lining of endothelium that faces the anterior chamber, and incited an inflammatory reaction in adjacent recipient cornea.

CONCLUSIONS

Immune privilege is afforded to xenografts of guinea pig cornea placed as stromal: endothelial cell fragments in the anterior chamber of mouse eyes, but only if the surface of the fragments that faces the anterior chamber is promptly covered with corneal endothelium. The possible roles of corneal endothelium in promoting immune privilege of corneal xenografts are discussed.

Epithelium-deficient corneal allografts display immune privilege beneath the kidney capsule

PURPOSE

To determine whether corneal tissue as an allograft displays immune privilege in a nonprivileged site and, if so, whether CD95 ligand expression contributes to the privileged status.

METHODS

Syngenic and allogeneic corneal tissues deprived of epithelium were transplanted beneath the kidney capsule of normal mice. Syngeneic BALB/c, allogeneic C57BL/6, and allogeneic B6Smn.C3H-gld (CD95 ligand-deficient) mice were used as donors for BALB/c recipients, and syngeneic C3H/HeJ-gld (CD95 ligand-deficient) mice were used for normal C3H/HeJ recipients. Allogeneic conjunctival segments served as positive grafting controls. Graft fate was assessed by visual inspection at 4, 7, 14, and 21 days and was confirmed by histologic study. Viability of graft endothelium was assessed by immunocytochemical analysis.

RESULTS

Syngeneic corneas and C57BL/6 corneas survived almost indefinitely beneath the kidney capsule. Both the stroma and the endothelial layers remained healthy and intact. Allogeneic conjunctiva evoked a strong inflammatory response attended by neovascularization. Similarly, B6-gld corneas deficient in CD95 ligand expression showed acute destruction beneath the kidney capsule. Circumstantial evidence implicates alloimmune rejection as the mechanism.

CONCLUSIONS

Epithelium-deprived corneas from normal mice possess inherent immune privilege that protects them from alloimmune rejection even at nonprivileged sites. Constitutive expression of CD95 ligand contributes to the privileged status. It is inferred that the extraordinary success of orthotopic corneal allografts owes as much to the qualities of the graft as an immune-privileged tissue as to the qualities of the eye as an immune-privileged site.

Use of phthaloyl protecting group for the automated synthesis of 3'-[(hydroxypropyl)amino] and 3'-[(hydroxypropyl)triglycyl] oligonucleotide conjugates

The chemical stability of oligonucleotides (ODNs) containing 3'-propanolamine was investigated. Invariably, all the ODNs synthesized from Fmoc-protected 3-aminopropane-1,2-diol-CPG support gave a mixture of three compounds at the end of automated synthesis as analyzed by denaturing PAGE and HPLC. On the basis of analytical procedures, these compounds were identified to be 3'-[N-acetyl-N-(hydroxypropyl)amino],3'-[(hydroxypropyl)amino], and 3'-hydroxyl ODNs. The instability of the amino protecting group under the synthesis conditions was responsible for this observed heterogeneity. In order to evaluate the stability, a comparative study on the chemical stability of the ODN containing amino-protecting groups such as [(9-fluorenylmethyl)oxy]carbonyl (Fmoc), trifluoroacetyl (TFA), and phthaloyl was undertaken. The results indicate that the phthaloyl group provided the best stability for the synthesis of 3' amine-modified ODNs, and the protecting group is cleaved and deprotected in concentrated ammonium hydroxide:40% aqueous methylamine, 1:1, for 5-10 min, at 56 degrees C. The 3'-hydroxypropyl)triglycyl] ODN conjugates were also synthesized from Fmoc- and phthaloyl-protected (hydroxypropyl)triglycine-CPG supports.

Synergism of oxacillin and gentamicin against enterococci

Strains of enterococci isolated from 34 patients were studied for susceptibility to oxacillin and gentamicin alone and in combination. The minimal bactericidal concentrations of oxacillin and gentamicin for these strains ranged from 16 to 250 mug/ml (median 32 mug/ml) for oxacillin and 12 to 48 mug/ml (median 24 mug/ml) for gentamicin. The minimal bactericidal concentration of oxacillin for 50% of strains in the presence of 12, 6, 3, and 1.5 mug of gentamicin per ml, respectively, was 2, 8, 16, and 32 mug/ml. The combination of oxacillin and gentamicin at clinically attainable serum levels was synergistically bactericidal against 27/34 (80%) of these strains using strict criteria. This report reconfirms the original observation that antibiotics which affect the synthesis of bacterial cell walls combine synergistically with aminoglycosides against enterococci. This is so even though enterococci are far more resistant to oxacillin than to penicillin or ampicillin. In addition, this report suggests that the combination of oxacillin and gentamicin administered in the usual dosages includes enterococci in its bactericidal spectrum.