Feasibility of Telemedicine in the Management Strategy of Patients With Lymphoma Amid the COVID-19 Pandemic in Spain: Prospective Observational Study

BACKGROUND

On March 14, 2020, a state of alarm was declared in Spain due to the spread of SARS-CoV-2. Beyond this date, COVID-19 in the country changed the practice of oncologic care.

OBJECTIVE

Since recurrent hospital visits were a potential risk factor for contagion, the aim of this prospective observational study was to analyze the consequences of the COVID-19 pandemic in the health care of patients with lymphoma.

METHODS

All data were obtained from the electronic medical record. Variables such as age, sex, reason of the visit, use of the patient portal, changes in management, enrollment in clinical trials, and COVID-19 infection were recorded.

RESULTS

In all, 290 patients visited the lymphoma clinic, totaling 437 appointments. The median age was 66 (range 18-94) years, and 157 (54.1%) patients were male. Of them, 214 (73.8%) patients had only 1 visit to the clinic. Only 23 (7.9%) patients did not have access to the patient portal. Amid the COVID-19 pandemic, 78 (26.9%) patients remained in active treatment, 35 (12.1%) experienced delays in their treatments, and 6 (2.1%) experienced treatment discontinuation. During the follow-up, only 7 (2.4%) patients had a COVID-19 infection (6 cases with confirmed polymerase chain reaction test and 1 case with clinical suspicion). Despite the implementation of telemedicine strategies to avoid visits to the hospital, 66 (22.8%) patients had in-person visits at the lymphoma clinic. Patients who attended in-person consultations were younger than those who preferred telemedicine consultations (62 vs 66 years; P=.10) and had less use of the patient portal (17/224, 7.6% vs 6/66, 9%; P=.10), although these differences did not reach statistical significance. Patients who attended in-person visits were more likely to have had only 1 visit to the hospital (29/66, 43.9% vs 185/224, 82.6%; P<.001). Regarding the reason of in-person consultations, more patients were on active treatment in comparison to those using telemedicine resources (37/66, 56.1% vs 42/224, 18.3%; P<.001). Patients with a preference for telemedicine strategies had more surveillance visits (147/224, 65.6% vs 24/66, 36.4%; P<.001). Regarding treatment modifications, more treatment delays (29/224, 12.9% vs 6/66, 9.1%; P=.10) and more definite treatment discontinuations (6/224, 2.7% vs 0/66, 0%; P=.10) were seen in patients using telemedicine resources when compared to patients attending in-person visits, although these differences did not reach statistical significance. Regarding the type of therapy, patients attending in-person visits were more likely to receive an intravenous treatment rather than those using telemedicine (23/66, 62.2% vs 17/224, 40.5%; P<.001).

CONCLUSIONS

Telemedicine such as patient portals are feasible strategies in the management of patients with lymphoma during the COVID-19 pandemic, with a reduction of in-person visits to the hospital and a very low contagion rate.

Using Artificial Intelligence to Reduce Orthopedic Surgical Site Infection Surveillance Workload: Algorithm Design, Validation, and Implementation in Four Spanish Hospitals

BACKGROUND

Surgical site infection (SSI) surveillance is a labor-intensive endeavor. We present the design and validation of an algorithm for SSI detection after hip replacement surgery, and a report of its successful implementation in four public hospitals in Madrid, Spain.

METHODS

We designed a multivariable algorithm, AI-HPRO, using natural language processing (NLP) and extreme gradient-boosting to screen for SSI in patients undergoing hip replacement surgery. The development and validation cohorts included data from 19661 healthcare episodes from four hospitals in Madrid, Spain.

RESULTS

Positive microbiological cultures, the text variable "infection", and prescription of clindamycin were strong markers of SSI. Statistical analysis of the final model indicated high sensitivity (99.18%) and specificity (91.01%) with a F1-score of 0.32, AUC of 0.989, accuracy of 91.27% and NPV of 99.98%.

DISCUSSION

Implementation of the AI-HPRO algorithm has reduced surveillance time from 975 person/hours to 63.5 person/hours and has permitted an 88.95% reduction in total volume of clinical records to be reviewed manually. The model presents a higher NPV (99.98%) than algorithms relying on NLP alone (94%) or NLP and logistic regression (97%).

CONCLUSIONS

This is the first report of an algorithm combining NLP and extreme gradient-boosting to permit accurate, real-time orthopedic SSI surveillance.

Patient-reported outcome measurement (PROM) program in patients with lymphoma receiving intravenous therapy: Preliminary results of a prospective study using PRO-CTCAE to individualize healthcate and to reduce unscheduled appointments

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Background: PROMs have been included in cancer clinical trials but it is yet to come in daily clinical practice. Their implications in healthcare management have not been well stablished yet. We hypothesize that patients subscribed to these programs may benefit from a better self-perception of health status and might require fewer hospital admissions and emergency room visits, which could allow a reduction in the costs of treatment. Methods: “E-Res Salud” is a value-based healthcare program implemented in patients with hematological malignancies in our institution. Patients (pts) with diagnosis of any type of lymphoma in the need of treatment between 1st Jan 2019 and 31st Dec 2020 were included in our research. Inclusion in PROMs program was offered to every patient starting intravenous treatment in 2020. Pts who started treatment in 2019 and those who rejected inclusion in 2020 were considered the control arm of our study. The principal endpoint was to compare physician and patient-reported adverse events through a standardized questionnaire such as PRO-CTCAE. Secondary endpoints included association between inclusion in PROMs program and reduction of hospital admissions and emergency room visits. Results: A total of 142 pts were included in our study; 76 of them (53.5%) were included in a PROMs program. There were no differences in pts characteristics with regards of age or sex. Most frequent diagnoses were diffuse large B-cell, follicular and Hodgkin lymphoma. Adverse events (AEs) most frequently reported by physicians were hematological complications (76.1%), general (73.9%), gastrointestinal symptoms (59.9%) and infections (43.7%). When patients were asked to report AEs of higher intensity, the most frequently reported were general (31.6%), genitourinary (26.3%), gastrointestinal (23.7%), neurological (15.8%) and cutaneous (13.2%) symptoms. Patients included in PROMs program experienced reported fewer general (64.5% vs. 84.8%; p < 0.05) and infectious (30.3% vs. 59.1%; p < 0.05) AEs than those in the control arm. Moreover, inclusion in the PROMs program was associated with fewer number of visits to Emergencies, with 34.2% of pts vs 60% of pts not enrolled in the PROM program (p = 0.003). None of the different types of AEs were associated to an increase in the number of admissions or outpatient consultations. With such a short follow-up we have not found association between any type of AE and survival. Conclusions: This program can help to increase awareness among hematologists about patients’ perception of symptoms and what really matters to them. Our study establishes the association of PROMs with health care utilization among patients with different types of lymphoma. A longer follow-up and changes in PROMs during the treatment will be further analyzed.

Cost-effectiveness of on-site musculoskeletal ultrasound in an outpatient rheumatology clinic

OBJECTIVE

To evaluate the impact of the routine use of musculoskeletal ultrasound (MSUS) in rheumatology clinics by comparing one clinic with on-site MSUS (REU 1) and four clinics without this resource, which need to refer patients for the MSUS exams (REU 2-5).

METHODS

The electronic medical records of all new patients at five rheumatology clinics during a 12-month period were reviewed. The impact of MSUS was analysed by comparing the percentage of direct discharges of patients from the different clinics, as an outcome of effectiveness, and the number and cost of radiology referrals for imaging exams (MSUS and MRI), as an outcome of cost-saving.

RESULTS

The medical records of 4923 patients were included in the study, distributed as follows: REU 1, 1464 (29.7%); REU 2, 1042 (21.2%); REU 3, 1089 (22.1%); REU 4, 579 (11.8%); and REU 5, 749 (15.2%). There were more direct discharges from REU 1 (34.4%) than from REU 2-5 (15.6%) (P<0.001). REU 1 made radiological referrals for X-rays, MRIs or MSUS exams in 773 (52.8%) patients, compared with 2626 (75.9%) patients in REU 2-5 (P<0.001). An estimation of costs for the clinical assessment of 1000 new patients revealed a cost-saving in REU 1 of €21 413 in MSUS and of €877 in MRI exams.

CONCLUSION

The implementation of on-site MSUS in a new-patient rheumatology clinic is cost-effective, facilitating the direct discharge of patients and reducing the number and cost of radiological referrals for imaging exams.

EUROQoL-5D as a valid patient-reported outcome measurement (PROM) tool to predict health-related quality of life (HRQoL) and survival in patients with hematological malignancies

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Background: Patient-Reported Outcome Measurement (PROM) is the way to collect not only Health-Related Quality of Life (HRQoL) but also symptoms. EUROQOL-5D is a PROM tool explored widely in patients with cancer, although is not specific for cancer patients. The primary end-point of this project is to analyse the significance of impairments in EUROQOL-5D domains in overall survival of patients with hematological malignances, and the utility to incorporate as a PROM tool in a daily clinical practice. Methods: Patients with hematologic malignancies attended at Fundacion Jimenez Diaz University Hospital were assessed with EUROQOL-5D prior to receive any therapy. Self-reported health status stated as better, equal or worse was recorded at the time of assessment. Other variables such as age, sex, diagnosis and ECOG was collected to analyze their impact in survival. Results: From January 1, 2017 to December 31, 2019, 390 consecutive patients were included. Median age was 72 years (range 18-92), 194 (49.7%) were female, with a diagnosis of lymphoma in 257 (65.9%) and myeloma in 70 (17.9%), and ECOG 0-1 in 78.2% of patients. With a median follow-up of 10.5 months (range 0-32 months), we registered 72 events for overall survival. In the univariate analysis, age > 76 years (AUC 0.739, Likelyhood Ratio 3.321, p < 0.0001), ECOG 2-4 (OR 11.161, 95% CI 5.276-23.610, p < 0.0001), impairment in EUROQOL-5D domains such us mobility (OR 2.896, 95%CI 1.406-5.967, p = 0.003), self-care (OR 3.959, 95%CI 1.732-9.050, p = 0.001) and usual activities (OR 3.190, 95%CI 1.573-6.467, p = 0.001), but not pain/disconfort nor anxiety/depression were identified as prognostic factors for shorter survival. Self-reported health status (OR 3.975, 95%CI 1.845-8.565, p < 0.0001) was also a prognostic factor for survival. Impairments in EUROQOL-5D were also prognostic in patients with ECOG 0-1 (p < 0.001). In the multivariate analysis, only ECOG 2-4 and self-reported health status remained with statistical significance. Conclusions: EUROQOL-5D is a valid tool to be incorporated as a PROM tool in pacients with hematological malignancies. Impairments in mobility, self-care and usual activities will identify a poorer prognosis group that would need closer monitoring.

Network approach identifies Pacer as an autophagy protein involved in ALS pathogenesis

BACKGROUND

Amyotrophic lateral sclerosis (ALS) is a multifactorial fatal motoneuron disease without a cure. Ten percent of ALS cases can be pointed to a clear genetic cause, while the remaining 90% is classified as sporadic. Our study was aimed to uncover new connections within the ALS network through a bioinformatic approach, by which we identified C13orf18, recently named Pacer, as a new component of the autophagic machinery and potentially involved in ALS pathogenesis.

METHODS

Initially, we identified Pacer using a network-based bioinformatic analysis. Expression of Pacer was then investigated in vivo using spinal cord tissue from two ALS mouse models (SOD1^G93A and TDP43^A315T) and sporadic ALS patients. Mechanistic studies were performed in cell culture using the mouse motoneuron cell line NSC34. Loss of function of Pacer was achieved by knockdown using short-hairpin constructs. The effect of Pacer repression was investigated in the context of autophagy, SOD1 aggregation, and neuronal death.

RESULTS

Using an unbiased network-based approach, we integrated all available ALS data to identify new functional interactions involved in ALS pathogenesis. We found that Pacer associates to an ALS-specific subnetwork composed of components of the autophagy pathway, one of the main cellular processes affected in the disease. Interestingly, we found that Pacer levels are significantly reduced in spinal cord tissue from sporadic ALS patients and in tissues from two ALS mouse models. In vitro, Pacer deficiency lead to impaired autophagy and accumulation of ALS-associated protein aggregates, which correlated with the induction of cell death.

CONCLUSIONS

This study, therefore, identifies Pacer as a new regulator of proteostasis associated with ALS pathology.

Adsorptive voltammetry and hydrolysis kinetics of loprazolam mesilate

Loprazolam is determined by square-wave adsorptive stripping voltammetry in 0.04M ammonium chloride at pH 4.0, with an accumulation potential of -0.25 V vs. Ag/AgCl/KCl(s), at which the nitro group is reduced to a hydroxylamine group, with adsorption of the product. Cathodic stripping results in reduction of the azomethine bond of the adsorbed product. With a deposition time of 120 sec the detection limit is 2.5 x 10(-10)M. The relative standard deviation is 1.7% for 5 x 10(-8)M loprazolam (60 sec deposition). Reversible hydrolysis of the azomethine group occurs in sulfuric or hydrochloric acid. The reaction is initially first-order, followed by an apparent second-order reaction. First-order rate constants and half-lives are reported for 0.1-1M sulfuric acid and 0.02M hydrochloric acid media and compared with the values for nitrazepam hydrolysis.

Air reduction of intussusception

AIM

To show that intussusception in children is reducible in most cases, using air.

METHODS

Initially we used a barium enema to treat paediatric intussusception. Now we use an air enema. We consider the latter reduction technique to be the method of choice in the treatment of intussusception in childhood.

RESULTS

Over a period of 21 years, we have treated 151 patients presenting with intussusception. In a group of 130 children treated with barium enema we managed to reduce the intussusception in 110 cases (84.6 %). We used air pressure to treat a second group of 21 children; the success rate in this group was 100 %.

CONCLUSIONS

In order to avoid a surgical operation this technique must become more generally known. We are of the opinion that if the method is applied correctly, it is almost always possible to correct intussusception using air.

Pulmonary interstitial edema in the pig after heavy exercise

During exercise (especially in hypoxia), the alveolar-arterial O2 tension difference increases. This impairment of pulmonary gas exchange is caused partly by diffusion disequilibrium, but it has also been shown that an exercise-induced increase in ventilation-perfusion (VA/Q) inequality develops. Possible explanations of increased VA/Q mismatch include nonuniform pulmonary vasoconstriction, reduced gas mixing in the large airways, airway obstruction, and the development of interstitial pulmonary edema. To directly determine whether the latter develops in high-intensity short-term exercise, we exercised pigs on a motor-driven treadmill at the highest speed that they could sustain for 6-7 min. Heart rate reached 274 +/- 5 min-1 in the exercised group, confirming that the pigs reached a near-maximal level of exercise. While running, the pigs were killed by an intravenous overdose of pentobarbital. Postmortem, the lungs were immediately removed, drained of blood, weighed, and then airway fixed with 10% formaldehyde. Four tissue blocks of the right lung of each pig were taken from the ventral and dorsal areas of the upper and lower lobes, respectively. They were stained with hematoxylin and eosin and prepared for histological examination by light microscopy. There was no difference in the lung-to-body weight ratio between exercised pigs (7.72 +/- 0.87 g/kg) and a nonexercised control group (7.70 +/- 0.68 g/kg). However, we found a significantly higher percentage of pulmonary arteries with perivascular edema in exercised (33.8 +/- 3.4%) than in nonexercised pigs (20.0 +/- 4.0%; P < 0.02). Thus, perivascular edema (and thus possibly also parenchymal interstitial edema) can occur during short-term heavy exercise.(ABSTRACT TRUNCATED AT 250 WORDS)

Positional hypoxemia during artificial ventilation

The effect of body position was studied in 8 patients with predominantly unilateral lung disease, who were admitted to an ICU and placed under artificial ventilation. Significant changes in PaO2 were observed when body position was changed from supine to lateral decubitus. PaO2 increased from 149 to 227 torr when the sick lung was up (p less than .01), but decreased to 106 torr when the sick lung was down (p less than .02). Both differences were statistically significant. The values were not different for right vs. left lung disease.