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Rand KH, Beal SG, Cherabuddi K, Houck H, Lessard K, Tremblay EE, Couturier B, Lingenfelter B, Rindlisbacher C, Jones J. Relationship of Multiplex Molecular Pneumonia Panel Results With Hospital Outcomes and Clinical Variables. Open Forum Infect Dis 2021; 8:ofab368. [PMID: 34458392 DOI: 10.1093/ofid/ofab368] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 07/07/2021] [Indexed: 11/12/2022] Open
Abstract
Background Antibiotic treatment decisions in severely ill patients must often be made in the absence of microbiologic results. The recently Food and Drug Administration-cleared BioFire FilmArray Pneumonia Panel (PN) detects 15 bacteria semiquantitatively, 3 atypical pneumonia bacteria, 8 viruses, and 7 antimicrobial resistance markers by multiplex PCR in ~1 hour in the laboratory. Previous reports have shown that the PN Panel bacterial detections are highly accurate, even when routine culture had no growth. Methods Consecutive bronchoalveolar lavage and endotracheal specimens submitted for culture between June and September 2018 from 270 patients with sufficient clinical and laboratory data were tested with the PN Panel. Patients were divided into 3 groups: (1) both culture and PN Panel positive, (2) PN Panel positive but culture uninformative (no growth or normal flora), and (3) patients with no PN Panel detections. Results Groups 1 and 2 had significantly higher maximum temperatures on the day of culture (P = .00036, analysis of variance [ANOVA] with Bonferroni correction), higher levels of an inflammatory response as measured by percent polymorphonuclear leukocytes in bronchoalveolar lavage (P = .00025, ANOVA with Bonferroni correction), and gram stain report of white blood cells, as previously reported [1]. Conclusions Both group 1 (culture and PN Panel positive), and group 2 (PN Panel positive but culture uninformative) had higher levels of host response inflammatory responses compared with group 3, which had no targets detected, suggesting that PN Panel detections need to be interpreted in the clinical context, even if cultures are discordant. Depending on laboratory turnaround time, there could be opportunities for improved diagnosis and antibiotic stewardship.
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Cozzi N, Nelson G, Rushton M, Feenema P, Barnhart C, Anderson S, Chassee T, Jones J. 66 Impact of COVID-19 on Home-Based Community Paramedicine and High-Risk Elder Patients. Ann Emerg Med 2021. [PMCID: PMC8335434 DOI: 10.1016/j.annemergmed.2021.07.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
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Henderson A, Curley J, Mcdaid D, Clendenning G, Mcglinchey D, Bayle S, Jones J, Connolly SB. Should cardiac rehabilitation programmes be specifically targeting sedentary time? Eur J Cardiovasc Nurs 2021. [DOI: 10.1093/eurjcn/zvab060.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background / Introduction
Structured exercise classes and advice regarding regular moderate intensity physical activity are well-established components of cardiac rehabilitation (CR). Sedentary behaviour, refers to activities typically sitting or lying that do not substantially increase energy expenditure above resting, and increasing evidence suggests adults should limit their sedentary time to less than 9 hours/day as such behaviour with increased cardiovascular and all-cause mortality with additional benefits likely gained sitting less than 6-8 hours/day. Nonetheless sedentary behaviours are often overlooked or are only partially assessed via self-report in CR programmes. Due to covid restrictions (lockdown, social distancing, suspension of face-to-face CR programmes) there is concern that sedentary time may further increase in this population. Thus, it may be important to effectively monitor and target sedentary time, alongside traditional advice, to minimise its negative health impacts.
Purpose
Can a CR programme, adapted to remote delivery due to covid, objectively measure sedentary behaviour in a way that is feasible in every day practice and acceptable to patients?
Methods
Consecutive cardiovascular patients attending an initial assessment (via telephone or video) on the Our Hearts Our Minds Programme for Cardiovascular Health between December 2020 and February 2021 were asked to wear activPAL (PAL technologies Ltd., Glasgow, UK), a triaxial accelerometer, on their thigh for 7 days to measure the postural aspect of sedentary behaviour. On return of the monitor, the data was analysed using proprietary algorithms (intelligent activity classification) generating a report summarising time spent sitting, prolonged sitting, step count average, number of sit to stand transitions, moderate intensity activity minutes, most sedentary time(s) of the day and percentages spent in these activities. This personalised report was shared with the patient and their goals in terms of sedentary behaviour and physical activity were discussed and agreed.
Results
59 referrals were received between mid December 2020 and February 2021, of which 52 had an initial virtual assessment. Of these, 50 patients accepted an activPAL (96% response rate). Mean age 62.6 years. The output from the activPal is shown in table 1. The average sitting time overall was 9 hours 36 minutes. The breakdown in proportions sitting for extended periods of time are detailed in table below
Conclusion
2/3 of cardiovascular patients attending CR had levels of sitting time greater than what is recommended following their IA. Measuring sedentary time beyond self-report in CR programmes using activPal was feasible in a CR programme with 96% of consecutive patients wearing and returning activPAL. Repeat analysis at end of programme will show if use of this data results in reduction of same .
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Elerian S, Singh T, Jagodzinski NA, Norris R, Tan S, Power D, Jones J, Rajaratnam V. 173 Early Results of a Variable-Angle Volar Locking Plate for Distal Radius Fractures: A Bi-Centre Study. Br J Surg 2021. [DOI: 10.1093/bjs/znab134.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Introduction
This study examines the clinical, functional and radiological outcomes of distal radius fracture fixation with the Aptus® (Medartis, Pennsylvania) locking plate in order to determine its efficacy and to identify notable findings related to treatment variations.
Method
This is a retrospective bi-centre study collecting patient details from a District General Hospital and a Regional Hand Unit. We assessed 61 consecutive patients with distal radius fractures (AO grade A = 19, B = 9, C = 33) fixed using Aptus® plate with a minimum of six months follow-up. Outcome measures included the DASH score, wrist range of movement and grip strength, and complications. Radiographs were reviewed to assess restoration of anatomy and union.
Results
All but two fractures united within six weeks. Mean ranges of movement were only mildly restricted compared to the normal wrist (flexion/extension = 102°; radial/ulna deviation = 53°; pronation/supination = 169°). Mean postoperative grip strength was 23.8kg which was comparable to the contralateral side at 31.5kg. The mean DASH score was 18.2. Seven patients had screws misplaced outside the distal radius although three of these remained asymptomatic.
Conclusions
Variable-angle locking systems benefit from flexibility of implant positioning and may allow enhanced inter-fragmentary reduction for accurate fixation of intra-articular fractures.
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Fletcher J, Myles C, Miskovic D, Jones J, Cahill R. 855 Patient Specific Digital Modelling And 3D Printing of Abdominal Anatomy- The Next Frontier in Surgical Simulation? Br J Surg 2021. [DOI: 10.1093/bjs/znab134.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Introduction
Innovations in digital technologies afford new opportunities in surgical education.
We describe a novel method of combining medical imaging data with virtual 3D modelling and printing techniques that could facilitate patient specific pre-operative planning and rehearsal.
Method
A series of silicone castings was produced to simulate upper abdominal viscera using a novel polyvinyl alcohol (PVA) injection moulding method. Digital models were generated by segmenting CT dual phase imaging in ITK-SNAP. A 3D polygon mesh was exported and optimised in the computer graphics software: Blender. Two 3D printers were used to manufacture a dissolvable mould of the digital models. Moulds were injected with coloured silicones and dissolved in water to reveal the multicolour/multi-material models.
Results
The silicone models retained the anatomical detail of the digitally segmented CT data sets. The multi-colour models were achieved with a single print and at very low cost (approx. £248/ model) and possessed varying shore hardness between viscera recreating lifelike fidelity.
Conclusions
The hybrid 3D printing/injection moulding method offers an avenue to realistic surgical and anatomical simulation. A combination of both virtual models and 3D physical models may provide an enhanced surgical experience for preoperative and intraoperative planning allowing patient specific rehearsal.
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Bauhadoor S, Vazir G, Jones J, Popoola J. POS-512 ASSESSMENT OF THE IMPACT OF COVID-19 on the well being of our Young Adult Dialysis population:A single centre experience. Kidney Int Rep 2021. [PMCID: PMC8049696 DOI: 10.1016/j.ekir.2021.03.540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Snape C, Triteos N, Wood CA, Robert G, Jones J. 134 A Quality Improvement Project—Physiotherapy Caseload Management on the Older Person’s Unit. Age Ageing 2021. [DOI: 10.1093/ageing/afab030.95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Complex health issues, co-morbidities and the number of patients living with frailty are critical concerns associated with the ageing population (Kojima et al, 2019). In this wider context, there is an emphasis on targeting resources efficaciously within the NHS. A consequence of capacity constraints, inpatient physiotherapy teams across the OPU at a large urban teaching hospital, prioritise their patient caseload, but lack evidence-based guidance on dosage and frequency of physiotherapy intervention, to inform the process. The aim of the quality improvement project was to design and deliver a staff education and training package to facilitate implementation of a newly-developed, evidence-based prioritisation resource.
Method
Plan-Do-Study-Act cycles and the Com-B model to influence behaviour changes were employed between October 2019 and March 2020. Stakeholders were engaged throughout the design process. Training to all 11 physiotherapists consisted of familiarisation with the resource through content discussion and “mock-use” training sessions to ensure intra/inter-rater-reliabilty. Physiotherapist staff knowledge and confidence of prioritisation was evaluated by questionnaire. Accuracy of use of the prioritisation tool was determined by comparison of staff prioritisation decision with expert opinion.
Results
From the 11 questionnaire responses, pre to post intervention physiotherapy knowledge of the prioritisation categories increased (43% to 100%), physiotherapist rated confidence using the prioritisation tool increased (mean score, 6.9 to 8.2/10) and accuracy of prioritisation of patients improved (mean 42.1% to 92.3%).
Conclusion
The education and training package developed to support implementation of the prioritisation tool resulted in improved staff knowledge and confidence of patient prioritisation and increased the accuracy of OPU physiotherapy targeting. This project has highlighted the importance of staff training in resource allocation to ensure that decisions regarding which patients receive physiotherapy intervention are efficacious. This has increased relevance in a department with a large number of rotational staff.
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Ritchie S, Snape C, Triteos N, Vamadevan R, Olesk L, Wood CA, Jones GD, Jones J. 132 Physical Function Comparison of Acutely Unwell COVID-Negative Older Adults Pre-Pandemic and Through-Pandemic; “Covid-Protected”. Age Ageing 2021. [PMCID: PMC7989662 DOI: 10.1093/ageing/afab030.93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction The risk of severe morbidity after COVID-19 infection is high in older adults (Lithander et al, 2020). Subsequent responsive UK Government guidance for older adults included self-isolation during the pandemic. It is therefore hypothesised that during the pandemic older adults are inadvertently deconditioned due to iatrogenic factors such as inactivity, social isolation, hospital-avoidance and malnutrition, and present with reduced resilience to illness and lower levels of function. The OPU continued to admit COVID-negative, or recently termed “COVID-protected”, patients throughout the pandemic. Data captured prior to, and during the COVID-19 pandemic has been compared to explore the implications on older adults, and elicit whether they are protected from the consequences of the pandemic? Method Demographic and physical function data (average 6 m gait-speed, Elderly Mobility Scale) were captured pre- and through-pandemic for all patients admitted to a COVID-negative OPU ward over a one month period. Ethical review was provided through local Trust governance process. Results Pre-pandemic 2019 (n = 67, mean(±SD) age 82.7(±8.2) years, 61%, hospital length-of-stay (LOS) 7.9(±7.3) days, hospital mortality-rate 7.2%) and through-pandemic 2020 (n = 73, 83.1(±8.3) years, 59%♀, LOS 9.0(±9.1) days, hospital mortality-rate 7.5%) data were captured during July 2019 and May 2020 respectively. There were no between-group differences in age [t(−.313) = 138, p = 0.755], gender [X2, 1 df, p = 0.782], LOS [t(0.78) = 134, p = 0.44], or hospital mortality-rate [X2 1 df, p = 0.96]. Through-pandemic patients had a significantly slower 6 m gait-speed (0.11(±0.05) m.s-1) than pre-pandemic (0.16(±0.24) m.s-1); [t(2.74) = 93, p = 0.007] and lower median (IQR) Elderly Mobility Scale (4(6 IQR) vs 9 (12 IQR) [u = 866, p = 0.015]). Conclusion Our data indicates this relatively short period of self-isolation might have significant implications on the physical function of older adults. The likely mechanism is iatrogenic deconditioning. Critical Public Health and policy responses are required to mitigate these unforeseen risks by deploying prehabilitative counter-measures and accurately targeted hospital and community rehabilitation.
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Stewart MJ, Heisler C, Kohansal AR, Patel S, Williams G, Williams S, Miles M, Zhu J, Kulai T, Peltekian K, Gruchy SE, Epstein I, Farina D, Jones J. A109 LINKING PRIMARY AND SPECIALTY CARE FOR THE MANAGEMENT OF DIGESTIVE HEALTH CONDITIONS: AN EVALUATION OF GUT LINK IMPLEMENTATION. J Can Assoc Gastroenterol 2021. [PMCID: PMC7989500 DOI: 10.1093/jcag/gwab002.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Severe restrictions on in-person encounters and endoscopic procedures for digestive care have occurred as a result of the COVID-19 pandemic. This has exacerbated pre-existing barriers in access to gastroenterology (GI) care across Nova Scotia (NS) for patients and primary healthcare providers (PHCPs). In response, a provincial PHCP-GI consultative service (GUT LINK) was implemented at a single tertiary care center with the goal of supporting PHCPs in the management of non-urgent GI referral conditions. Aims To implement and evaluate the acceptability, feasibility, appropriateness, and early effectiveness of the GUT LINK PHCP-GI consultation service. Methods This is an ongoing prospective observational cohort study. All referrals received through the EMR-based referral and triage management system between May and November 2020 that were deemed to be amenable to management within primary care with specialist support were returned to the PHCP with the suggestion to arrange a GUT LINK telephone consultation. GUT LINK appointments were scheduled through an administrative support telephone line with the PHCP and a GI specialist. A post-consultation e-questionnaire was distributed to PHCPs who consented to participate. Feasibility (number of and indication for referrals, PHCP participation rates), acceptability and appropriateness (satisfaction, future use, likelihood to recommend) metrics and outcomes (case resolution, re-referrals, proportion requiring endoscopic investigations) were recorded. Patient charts were reviewed to determine whether the patient ultimately required GI speciality care. Analyses were descriptive and expressed as frequencies, means (+/-SD), medians (+/-SE), and proportions (%). Results A total of 45 GUT LINK consultations were completed between May and November 2020. Of these, 20% required GI specialist care and 80% have remained within primary care, with a median follow-up of 101 (+/-9.1) days. The indications for GUT LINK consultation included lower GI symptoms (64%), abnormal imaging or investigations (17%), and upper GI symptoms (19%). To date, 21 PHCP agreed to be contacted for the post-consultation survey and 10 have been completed. All PHCPs reported that GUT LINK consultation was easy to access, while 90% found the advice helpful and 80% reported that that it resolved the issue. Following the GUT LINK appointment, 80% felt they would not need to refer their patient to GI. Conclusions The implementation of GUT LINK was acceptable, feasible, and improved access to specialist support for management of undifferentiated GI symptoms. Future research will focus on comprehensive stakeholder engagement in order to design, implement, and evaluate GUT LINK PHCP care pathways. Funding Agencies CAG
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Lim DR, Tsai M, Gruchy SE, Jones J, Williams G, Farina D, Kohansal AR. A85 THE CLINICAL IMPACT OF COVID-19 DELAYS ON PLASTIC BILIARY STENT REMOVAL IN NOVA SCOTIA. J Can Assoc Gastroenterol 2021. [PMCID: PMC7958731 DOI: 10.1093/jcag/gwab002.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The COVID-2019 pandemic continues to restrict access to endoscopy, resulting in delays or cancellation of non-urgent endoscopic procedures. A delay in the removal or exchange of plastic biliary stents may lead to stent occlusion with consensus recommendation of stent removal or exchange at three-month intervals [1–4]. We postulated that delayed plastic biliary stent removal (DPBSR) would increase complication rates.
Aims
We aim to report our single-centre experience with complications arising from DPBSR.
Methods
This was a retrospective, single-center, observational cohort study. All subjects who had ERCP-guided plastic biliary stent placement in Halifax, Nova Scotia between Dec 2019 and June 2020 were included in the study. DPBSR was defined as stent removal >=90 days from insertion. Four endpoints were assigned to patients: 1. Stent removed endoscopically, 2. Died with stent in-situ (measured from stent placement to documented date of death/last clinical encounter before death), 3. Pending removal (subjects clinically well, no liver enzyme elevation, not expired, endpoint 1 Nov 2020), and 4. Complication requiring urgent reintervention. Kaplan-Meier survival analysis was used to represent duration of stent patency (Fig.1).
Results
102 (47.2%) had plastic biliary stents placed between 2/12/2019 and 29/6/2020. 49 (48%) were female, and the median age was 68 (R 16–91). Median follow-up was 167.5 days, 60 (58.8%) subjects had stent removal, 12 (11.8%) died before replacement, 21 (20.6%) were awaiting stent removal with no complications (median 230d, R 30–332), 9 (8.8%) had complications requiring urgent ERCP. Based on death reports, no deaths were related to stent-related complications.
72(70.6%) of patients had stents in-situ for >= 90 days. In this population, median time to removal was 211.5d (R 91-441d). 3 (4.2%) subjects had stent-related complications requiring urgent ERCP, mean time to complication was 218.3d (R 94–441). Stent removal >=90 days was not associated with complications such as occlusion, cholangitis, and migration (p=1.0). Days of stent in-situ was not associated with occlusion, cholangitis, and migration (p=0.57). Sex (p=0.275), cholecystectomy (p=1.0), cholangiocarcinoma (p=1.0), cholangitis (p=0.68) or pancreatitis (p=1.0) six weeks prior to ERCP, benign vs. malignant etiology (p=1.0) were not significantly associated with stent-related complications.
Conclusions
Plastic biliary stent longevity may have been previously underestimated. The findings of this study agree with CAG framework recommendations [5] that stent removal be prioritized as elective (P3). Limitations include small sample size that could affect Kaplan-Meier survival analysis. Despite prolonged indwelling stent time as a result of COVID-19, we did not observe an increased incidence of stent occlusion or other complications.
Funding Agencies
None
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Stewart MJ, Farina D, Jones J. A112 THE IMPACT OF CENTRAL COORDINATION ON ENDOSCOPY EFFICIENCY. J Can Assoc Gastroenterol 2021. [PMCID: PMC7989430 DOI: 10.1093/jcag/gwab002.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The impacts of the COVID-19 pandemic have been far reaching and have necessitated many changes to healthcare delivery. At the QEII Health Sciences Center physical space limitations for patient check-in and recovery have restricted outpatient endoscopy to 3 of 4 available endoscopy suites. On June 1, 2020 a new system of central endoscopy triage and coordination for the Division of Digestive Care and Endoscopy (DC&E) was implemented in an effort to increase efficiency and maintain patient access to endoscopy. The components of the RESET (Re-introduce Endoscopy Safely and EfficienTly) Plan included a) a new endoscopy coordinator role to manage a common endoscopy waitlist, endoscopist schedules, and booking clerks, b) a modified triage system to improve waitlist consistency, c) a common endoscopy waitlist with patients booked in the next available appointment regardless of endoscopist, d) discontinuation of fixed endoscopy slots for endoscopists, and e) appointment scheduling no sooner than 4-weeks in advance to minimize no-shows and last-minute cancellations.
Aims
The aim of this study is to evaluate the impact of the RESET Plan on the efficiency of DC&E endoscopy.
Methods
A retrospective pre- and post-implementation study evaluating the volume and efficiency of outpatient endoscopy before and after implementation of the RESET Plan. The Pre-RESET period included all procedures performed from June 1, 2019 to October 31, 2019. The Post-RESET period included all procedures performed from June 1, 2020 to October 31, 2020. A separate endoscopy suite and triage system is used for endoscopic retrograde cholangiopancreatography (ERCP) and these cases were excluded. Early effectiveness outcomes were reported including a comparison of the number of endoscopic procedures per week and per list, pre- and post- implementation. Data analysis was primarily descriptive with data expressed as frequencies, means (SD), and proportions (%). Exploratory group comparisons were performed using independent-samples T-Test.
Results
During the 5-month Pre-RESET period, 2203 endoscopic procedures were performed. During the Post-RESET period a total of 1920 procedures were performed. Due to pandemic restrictions, there was a 29% decrease in available endoscopy lists from 2019 to 2020. There was a 24% increase in the number procedures performed per endoscopy list, from 6.4 to 8.0 (p=0.004, 95% CI 0.52–2.53), pre- and post-RESET.
Conclusions
While the COVID-19 pandemic has disrupted healthcare delivery, it has also provided an opportunity to implement health system structure and process changes. The RESET Plan resulted in significant gains in efficiency which largely offset losses in endoscopy throughput imposed by COVID-19 pandemic restrictions. Future research will determine what patient and health system factors most significantly impact system efficiency as well as the cost-effectiveness of the RESET Plan.
Funding Agencies
CAG
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Stewart MJ, Kohansal AR, Peltekian K, Jones J. A107 IMPROVING ACCESS TO URGENT GASTROENTEROLOGICAL CONSULTATION: A POSITIVE PANDEMIC IMPACT. J Can Assoc Gastroenterol 2021. [PMCID: PMC7989445 DOI: 10.1093/jcag/gwab002.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background The global COVID-19 pandemic has resulted in a dramatic re-alignment of clinical service delivery. In mid-March 2020 the Division of Digestive Care and Endoscopy at Dalhousie University leveraged eHealth technology to rapidly implemented a new referral management and triage system and established a new rapid outpatient consultation service to facilitate urgent virtual and face-to-face appointments. Standardized procedures for triaging, booking, and staffing the urgent gastroenterology consultation service were implemented. Aims The aim of this study was to evaluate the impact of the implementation of a standardized triage and consultation process on access to urgent gastroenterology consultative services at a single tertiary care center during the COVID-19 pandemic. Methods We performed a pre- and post-implementation study comparing efficiency metrics for urgent triage and urgent consultation. The pre-implementation cohort included all patients referred and triaged to an urgent clinic appointment between April 1, 2019 to September 30, 2019. The post-implementation cohort included all patients referred and triaged to an urgent clinic appointment between April 1, 2020 to September 30, 2020. Healthcare efficiency data was extracted through electronic record review with specific dates and times for referral receipt (a), triage completion (b), appointment wait-listing (c), and clinic appointment (d). The time to triage (TT), time to visit (TV), and total time to consult (TC) were calculated (TT = c - a; TV = d - c; TC = TT + TV) for each patient. The Mann–Whitney U test was used to compare TT, TV, CT between patient cohorts. Results A total of 429 patients were booked for urgent clinic consultation, 176 during the pre-implementation period and 253 in the post-implementation period. The mean TT for the pre-and post-implementation cohorts was 4.8 days and 3.3 days, respectively (U=18,149, p=0.001). Mean TV was decreased from 16.2 days for the pre-implementation cohort to 3.6 days for the post-implementation cohort (U=6095, p=0.000). The mean time from a referral being received to the patient being seen in consultation (TC) decreased by 67% from 21 days to 6.9 days, Figure 1 (U=6,419, p=0.000). Conclusions The COVID-19 pandemic has had a dramatic impact on healthcare delivery in Nova Scotia. One positive result is that it facilitated the motivation and alignment needed to make a large health system change that may not have otherwise been possible. This study demonstrates that a standardized pathway for urgent outpatient gastroenterology assessment improves the timeliness of care delivery. ![]()
Funding Agencies None
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Elfghi M, Jordan F, Dunne D, Gibson I, Jones J, Flaherty G, Sultan S, Tawfick W. The effect of lifestyle and risk factor modification on occlusive peripheral arterial disease outcomes: standard healthcare vs structured programme-for a randomised controlled trial protocol. Trials 2021; 22:138. [PMID: 33581715 PMCID: PMC7881542 DOI: 10.1186/s13063-021-05087-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 02/01/2021] [Indexed: 11/10/2022] Open
Abstract
Background Peripheral arterial disease (PAD) affects more than 200 million of the global population. PAD represents a marker for premature cardiovascular events. Patients with PAD, even in the absence of a history of myocardial infarction or ischemic stroke, have approximately the same relative risk of death from cardiovascular causes as patients with a history of coronary or cerebrovascular disease. Despite the high prevalence of PAD and the strong association with cardiovascular morbidity and mortality, patients with PAD are less likely to receive appropriate treatment for their atherosclerotic risk factors than those who are being treated for coronary artery disease. Atherosclerotic risk factor identification and modification play an important role in reducing the number of adverse outcomes among patients with atherosclerosis. Risk reduction therapy decreases the risk of cardiovascular mortality and morbidity in patients with PAD. In this study, we aim to evaluate the effectiveness of a lifestyle and risk factor modification intervention programme in achieving treatment goals for PAD risk factors. Methods This is a randomised, parallel group, active-control trial to compare the effectiveness of the risk factor modification intervention programme to standard healthcare in a tertiary vascular care centre, in the reduction of modified risk factors in PAD patients. The primary outcome of this study is to evaluate the effectiveness of a lifestyle and risk factor modification intervention programme in achieving treatment goals for PAD risk factors at 3 and 12 months. The secondary outcomes are to compare the impact of the programme on clinical outcomes in PAD patients at 12 months. Secondary outcomes include amputation-free survival, clinical improvement, haemodynamic improvement, need for revascularisation procedures, outcomes of revascularisation procedures, changes in quality of life and the incidence of adverse events. Discussion This study will provide clear evidence on the effectiveness of a lifestyle and risk factor modification intervention programme in achieving treatment goals for PAD risk factors, through a high-quality, well-powered clinical trial. Trial registration This trial was registered (11/07/2017) on the European Clinical Trials Database (EudraCT number 2017-002964-41) and ClinicalTrials.gov (NCT03935776) which was registered on 02 May 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05087-x.
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Small KL, Henthorn NT, Angal-Kalinin D, Chadwick AL, Santina E, Aitkenhead A, Kirkby KJ, Smith RJ, Surman M, Jones J, Farabolini W, Corsini R, Gamba D, Gilardi A, Merchant MJ, Jones RM. Evaluating very high energy electron RBE from nanodosimetric pBR322 plasmid DNA damage. Sci Rep 2021; 11:3341. [PMID: 33558553 PMCID: PMC7870938 DOI: 10.1038/s41598-021-82772-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 12/07/2020] [Indexed: 01/18/2023] Open
Abstract
This paper presents the first plasmid DNA irradiations carried out with Very High Energy Electrons (VHEE) over 100-200 MeV at the CLEAR user facility at CERN to determine the Relative Biological Effectiveness (RBE) of VHEE. DNA damage yields were measured in dry and aqueous environments to determine that ~ 99% of total DNA breaks were caused by indirect effects, consistent with other published measurements for protons and photons. Double-Strand Break (DSB) yield was used as the biological endpoint for RBE calculation, with values found to be consistent with established radiotherapy modalities. Similarities in physical damage between VHEE and conventional modalities gives confidence that biological effects of VHEE will also be similar-key for clinical implementation. Damage yields were used as a baseline for track structure simulations of VHEE plasmid irradiation using GEANT4-DNA. Current models for DSB yield have shown reasonable agreement with experimental values. The growing interest in FLASH radiotherapy motivated a study into DSB yield variation with dose rate following VHEE irradiation. No significant variations were observed between conventional and FLASH dose rate irradiations, indicating that no FLASH effect is seen under these conditions.
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Ioannou N, Hagner PR, Stokes M, Gandhi AK, Apollonio B, Fanous M, Papazoglou D, Sutton LA, Rosenquist R, Amini RM, Chiu H, Lopez-Girona A, Janardhanan P, Awan FT, Jones J, Kay NE, Shanafelt TD, Tallman MS, Stamatopoulos K, Patten PEM, Vardi A, Ramsay AG. Triggering interferon signaling in T cells with avadomide sensitizes CLL to anti-PD-L1/PD-1 immunotherapy. Blood 2021; 137:216-231. [PMID: 33024998 PMCID: PMC7820876 DOI: 10.1182/blood.2020006073] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 09/26/2020] [Indexed: 12/14/2022] Open
Abstract
Cancer treatment has been transformed by checkpoint blockade therapies, with the highest anti-tumor activity of anti-programmed death 1 (PD-1) antibody therapy seen in Hodgkin lymphoma. Disappointingly, response rates have been low in the non-Hodgkin lymphomas, with no activity seen in relapsed/refractory chronic lymphocytic leukemia (CLL) with PD-1 blockade. Thus, identifying more powerful combination therapy is required for these patients. Here, we preclinically demonstrate enhanced anti-CLL activity following combinational therapy with anti-PD-1 or anti-PD-1 ligand (PD-L1) and avadomide, a cereblon E3 ligase modulator (CELMoD). Avadomide induced type I and II interferon (IFN) signaling in patient T cells, triggering a feedforward cascade of reinvigorated T-cell responses. Immune modeling assays demonstrated that avadomide stimulated T-cell activation, chemokine expression, motility and lytic synapses with CLL cells, as well as IFN-inducible feedback inhibition through upregulation of PD-L1. Patient-derived xenograft tumors treated with avadomide were converted to CD8+ T cell-inflamed tumor microenvironments that responded to anti-PD-L1/PD-1-based combination therapy. Notably, clinical analyses showed increased PD-L1 expression on T cells, as well as intratumoral expression of chemokine signaling genes in B-cell malignancy patients receiving avadomide-based therapy. These data illustrate the importance of overcoming a low inflammatory T-cell state to successfully sensitize CLL to checkpoint blockade-based combination therapy.
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Howlett N, Bottoms L, Chater A, Clark AB, Clarke T, David L, Irvine K, Jones A, Jones J, Mengoni SE, Murdoch J, Pond M, Sharma S, Sims EJ, Turner DA, Wellsted D, Wilson J, Wyatt S, Trivedi D. A randomised controlled trial of energetic activity for depression in young people (READY): a multi-site feasibility trial protocol. Pilot Feasibility Stud 2021; 7:6. [PMID: 33390189 PMCID: PMC7779325 DOI: 10.1186/s40814-020-00734-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 11/24/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Prevalence of depression is increasing in young people, and there is a need to develop and evaluate behavioural interventions which may provide benefits equal to or greater than talking therapies or pharmacological alternatives. Exercise could be beneficial for young people living with depression, but robust, large-scale trials of effectiveness and the impact of exercise intensity are lacking. This study aims to test whether a randomised controlled trial (RCT) of an intervention targeting young people living with depression is feasible by determining whether it is possible to recruit and retain young people, develop and deliver the intervention as planned, and evaluate training and delivery. METHODS The design is a three-arm cluster randomised controlled feasibility trial with embedded process evaluation. Participants will be help-seeking young people, aged 13-17 years experiencing mild to moderate low mood or depression, referred from three counties in England. The intervention will be delivered by registered exercise professionals, supported by mental health support workers, twice a week for 12 weeks. The three arms will be high-intensity exercise, low-intensity exercise, and a social activity control. All arms will receive a 'healthy living' behaviour change session prior to each exercise session and the two exercise groups are energy matched. The outcomes are referral, recruitment, and retention rates; attendance at exercise sessions; adherence to and ability to reach intensity during exercise sessions; proportions of missing data; adverse events, all measured at baseline, 3, and 6 months; resource use; and reach and representativeness. DISCUSSION UK National Health Service (NHS) policy is to provide young people with advice about using exercise to help depression but there is no evidence-based exercise intervention to either complement or as an alternative to medication or talking therapies. UK National Institute for Health and Care Excellence (NICE) guidelines suggest that exercise can be an effective treatment, but the evidence base is relatively weak. This feasibility trial will provide evidence about whether it is feasible to recruit and retain young people to a full RCT to assess the effectiveness and cost-effectiveness of an exercise intervention for depression. TRIAL REGISTRATION ISRCTN, ISRCTN66452702 . Registered 9 April 2020.
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Pitchford JM, Jones J, Hebart ML, Pitchford WS. The use of Hereford sires over mature Angus dams can add value to Angus cattle herds. ANIMAL PRODUCTION SCIENCE 2021. [DOI: 10.1071/an21100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Context
Overseas studies have quantified production differences of Hereford × Angus compared with purebred Angus for a range of traits including growth, carcass and reproductive traits.
Aim
This study aims to provide a comparison of Hereford × Angus and purebred Angus under modern grazing conditions in southern Australia.
Methods
Thirty Hereford and 22 Angus sires were mated to 1100 Angus cows and heifers in a large commercial herd run on pasture at Musselroe Bay, Tasmania. Approximately 1650 calves were born. Steers were grown on pasture for an average of 23 months and then slaughtered.
Results
Hereford sired calves were heavier at birth (+8.8%) and weaning (+4.1%). Hereford-sired calves from heifers (but not from mature cows) had more assisted births (+8.2%) and more calf deaths (10.0% vs 5.1%). Hereford-sired steers had higher hot standard carcass weight (+4.1%) and eye-muscle area (+3.2%) but when hot standard carcass weight was fitted as a covariate, eye-muscle area was no longer significant. Carcass quality measures (AUSMEAT marbling –25.8%, Meat Standards Australia marbling –10.5%, Meat Standards Australia index –1.0%) were poorer for Hereford-sired steers and fat colour (+6.9%) was darker. Meat samples from Hereford-sired steers had significantly lower colour indicators (L and b). There was no difference in cooking loss and shear force, and intramuscular fat was lower (3.0% vs 4.1%).
Conclusions
Hereford × Angus calves were heavier at birth than were purebred Angus, but had more calving difficulty and deaths associated with heifer dams. Hereford × Angus carcasses were heavier but had lower indicators of quality than did purebred Angus.
Implications
As Hereford × Angus steers produced a 4.1% heavier carcass, pure Angus steers would need to attract a premium of at least 4.1% for the additional marbling to give more value. Hereford bulls could be mated to Angus cows and not Angus heifers to avoid calving difficulties. Alternatively, good calving Hereford bulls could be selected using estimated breeding values when mating to Angus heifers.
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Cozzi N, Stevens K, Pillay Y, Moore D, Flannigan M, Barnes M, Singh M, Gagrica M, Kolacki C, Bach J, McNinch D, Orwig D, Jones J. Diagnosis of Central Retinal Artery Occlusion in the Emergency Department Using POCUS: A Case Series. POCUS JOURNAL 2021; 6:73-75. [PMID: 36895673 PMCID: PMC9979917 DOI: 10.24908/pocus.v6i2.14974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Introduction: Central Retinal Artery Occlusion is a cause of vision loss that warrants emergent evaluation. Ocular Point of Care Ultrasound (POCUS) is a non-invasive, inexpensive, and rapid modality to establish diagnosis with reduced time to consultation and treatment. Methods: This was a retrospective case series of patients evaluated at seven hospitals with diagnosis of CRAO over a two-year period. All patients underwent ocular POCUS performed by an emergency medicine clinician. Results: Nine patients were evaluated with mean vision loss of 21 hours. Overall, 88% of patients were diagnosed with CRAO, 75% possessing US confirmed retrobulbar spot sign (RBBS), and 38% confirmed diagnosis with fundoscopy. Conclusion: Ocular POCUS is an examination all emergency medicine clinicians should be able to perform. A rapid diagnosis of CRAO provides opportunity for vision improvement with initiation of treatment. The lack of guidelines for treatment of CRAO represents an opportunity for a multi-speciality collaboration to develop a diagnostic and treatment algorithm.
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Abayomi JC, Charnley MS, Cassidy L, Mccann MT, Jones J, Wright M, Newson LM. A patient and public involvement investigation into healthy eating and weight management advice during pregnancy. Int J Qual Health Care 2020; 32:28-34. [PMID: 32022232 DOI: 10.1093/intqhc/mzz081] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 05/03/2019] [Accepted: 05/13/2019] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To conduct patient and public involvement (PPI) to gain insight into the experience of healthy eating and weight management advice during pregnancy. DESIGN PPI in the planning and development of health interventions, aiming to ensure patient-centred care. Optimum nutrition and weight management are vital for successful pregnancy outcomes, yet many services report poor attendance and engagement. SETTING Community venues in Liverpool and Ulster (UK). PARTICIPANTS Two PPI representatives were involved in all aspects of the study: design, interview questions, recruitment and collection/analysis of feedback. INTERVENTION Feedback was collected via note taking during group discussions, two in Liverpool (n = 10 & 5); two in Ulster (n = 7 & 9) and an interview (n = 1, in Ulster). MAIN OUTCOME MEASURES Transcript data were collated and thematic analysis was applied in analysis. RESULTS Thematic analysis identified three themes: (i) weight gain is inevitable in pregnancy; (ii) healthy eating advice is important but currently lacks consistency and depth and (iii) expectations regarding the type of knowledge/support. CONCLUSIONS PPI provides opportunity to enhance research design and offers valuable insight towards the needs of healthcare users. Pregnant women want positive health messages, with a focus on what they can/should do, rather than what they should not do. Midwives need to consider their communication with pregnant women, to ensure that their unique relationship is maintained, especially when the topics of diet and weight management are addressed. A well-designed digital intervention could improve access to pregnancy-specific nutrition information; empowering midwives to communicate patient-centred, healthy eating messages with confidence. This has the potential to change dietary and weight management behaviour in pregnant women.
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Bensaaud A, Seery S, Gibson I, Jones J, Flaherty G, Mcevoy J, Jordan F, Tawfick W, Sultan S. Dietary approaches to stop hypertension (DASH) for the primary and secondary prevention of cardiovascular diseases: A protocol for a cochrane systematic review and meta-analysis. Atherosclerosis 2020. [DOI: 10.1016/j.atherosclerosis.2020.10.743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Caley MP, Martins VL, Moore K, Lashari M, Nissinen L, Kähäri VM, Alexander S, Jones E, Harwood CA, Jones J, Donaldson M, Marshall JF, O'Toole EA. Loss of the laminin subunit alpha-3 induces cell invasion and macrophage infiltration in cutaneous squamous cell carcinoma. Br J Dermatol 2020; 184:923-934. [PMID: 32767748 DOI: 10.1111/bjd.19471] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Cutaneous squamous cell carcinoma (cSCC) is a common cancer that invades the dermis through the basement membrane. The role of the basement membrane in poorly differentiated cSCC is not well understood. OBJECTIVES To study the effect that loss of the laminin subunit alpha-3 (α3) chain from the tumour microenvironment has on tumour invasion and inflammatory cell recruitment. METHODS We examined the role of the basement membrane proteins laminin subunits α3, β3 and γ2 in SCC invasion and inflammatory cell recruitment using immunohistochemistry, short hairpin RNA knockdown, RNA-Seq, mouse xenograft models and patient tumour samples. RESULTS Analysis of SCC tumours and cell lines using antibodies specific to laminin chains α3, β3 and γ2 identified a link between poorly differentiated SCC and reduced expression of laminin α3 but not the other laminin subunits investigated. Knockdown of laminin α3 increased tumour invasion both in vitro and in vivo. Western blot and immunohistochemical staining identified increased phosphorylated myosin light chain with loss of laminin α3. Inhibition of ROCK (rho-associated protein kinase) but not Rac1 significantly reduced the invasive potential of laminin α3 knockdown cells. Knockdown of laminin subunits α3 and γ2 increased monocyte recruitment to the tumour microenvironment. However, only the loss of laminin α3 correlated with increased tumour-associated macrophages both in xenografted tumours and in patient tumour samples. CONCLUSIONS These data provide evidence that loss of the laminin α3 chain in cSCC has an effect on both the epithelial and immune components of cSCC, resulting in an aggressive tumour microenvironment.
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Kwan J, Xu W, Sandhu V, Demidov V, Shi W, Williams J, Vitkin A, Jones J, Haykal S, Haibe-Kains B, Brooks D, Yip K, Liu F. The Role of Cytokine Signaling in the Reversal of Chronic Lymphedema. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Brown A, Nikroo N, Yassin S, Beasley K, Kraus N, Houseman J, Jones J. Can emergency department patients safely remove their own sutures at home? Am J Emerg Med 2020; 46:718-719. [PMID: 33082064 DOI: 10.1016/j.ajem.2020.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 10/01/2020] [Accepted: 10/07/2020] [Indexed: 10/23/2022] Open
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Liu EJ, Aiuppa A, Alan A, Arellano S, Bitetto M, Bobrowski N, Carn S, Clarke R, Corrales E, de Moor JM, Diaz JA, Edmonds M, Fischer TP, Freer J, Fricke GM, Galle B, Gerdes G, Giudice G, Gutmann A, Hayer C, Itikarai I, Jones J, Mason E, McCormick Kilbride BT, Mulina K, Nowicki S, Rahilly K, Richardson T, Rüdiger J, Schipper CI, Watson IM, Wood K. Aerial strategies advance volcanic gas measurements at inaccessible, strongly degassing volcanoes. SCIENCE ADVANCES 2020; 6:6/44/eabb9103. [PMID: 33127674 PMCID: PMC7608812 DOI: 10.1126/sciadv.abb9103] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 09/18/2020] [Indexed: 06/11/2023]
Abstract
Volcanic emissions are a critical pathway in Earth's carbon cycle. Here, we show that aerial measurements of volcanic gases using unoccupied aerial systems (UAS) transform our ability to measure and monitor plumes remotely and to constrain global volatile fluxes from volcanoes. Combining multi-scale measurements from ground-based remote sensing, long-range aerial sampling, and satellites, we present comprehensive gas fluxes-3760 ± [600, 310] tons day-1 CO2 and 5150 ± [730, 340] tons day-1 SO2-for a strong yet previously uncharacterized volcanic emitter: Manam, Papua New Guinea. The CO2/ST ratio of 1.07 ± 0.06 suggests a modest slab sediment contribution to the sub-arc mantle. We find that aerial strategies reduce uncertainties associated with ground-based remote sensing of SO2 flux and enable near-real-time measurements of plume chemistry and carbon isotope composition. Our data emphasize the need to account for time averaging of temporal variability in volcanic gas emissions in global flux estimates.
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Thangavadivel S, Zhao Q, Epperla N, Rike L, Mo X, Badawi M, Bystry DM, Phelps MA, Andritsos LA, Rogers KA, Jones J, Woyach JA, Byrd JC, Awan FT. Early Intervention with Lenalidomide in Patients with High-risk Chronic Lymphocytic Leukemia. Clin Cancer Res 2020; 26:6187-6195. [PMID: 32958702 DOI: 10.1158/1078-0432.ccr-20-1280] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/24/2020] [Accepted: 09/16/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Infectious complications constitute a leading cause of morbidity and mortality in chronic lymphocytic leukemia (CLL). Patients respond poorly to vaccines, particularly pneumococcal polysaccharide and influenza vaccines. In addition, patients with genetically high-risk disease are at increased risk for early disease progression and death. Lenalidomide, an oral immunomodulatory agent with demonstrated clinical activity in CLL, can potentially restore immune system dysfunction associated with CLL while improving disease outcomes. PATIENTS AND METHODS Phase II study randomized 49 patients with genetically high-risk CLL or small lymphocytic lymphoma [SLL; defined as unmutated Ig heavy chain variable region, deletion(17p) or (11q), and/or complex abnormal karyotype], to receive lenalidomide either concurrent (arm A) or sequential to (arm B) two doses of 13-valent protein-conjugated pneumococcal vaccine (PCV13) administered 2 months apart, in patients not meeting International Workshop on Chronic Lymphocytic Leukemia treatment criteria. RESULTS Four serotypes (3, 4, 5, 6B) achieved the additional seroprotection definition of a fourfold increase in arm A, and six serotypes (3, 4, 5, 6B, 19A, 19F) in arm B. All patients achieved the defined concentration of 0.35 μg/mL for at least one serotype tested. No significant difference was observed with the addition of lenalidomide. At median time on treatment of 3.6 years, median progression-free survival (PFS) was 5.8 years [95% confidence interval (CI), 3.1-not reached]. PFS at 1, 2, and 3 years was 85% (95% CI, 72-93), 79% (95% CI, 64-88), and 72% (95% CI, 57-83), respectively. CONCLUSIONS Lenalidomide is efficacious with manageable toxicities as an early intervention strategy in patients with high-risk CLL, but did not enhance humoral response to PCV13 vaccine.
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