Navigating Transitions in Oncology Care: From Emergency Department to Outpatient Clinic

OBJECTIVE

This quality improvement project was a collaborative effort with Penn Medicine's emergency department (ED) and oncology nurse navigators (ONNs). The goal of the project was to streamline patient transitions from the ED to the outpatient oncology clinic by developing a standardized referral process. The main objectives were to simplify and automate the referral process using the electronic medical record, improve multidisciplinary communication across the care continuum, ensure timely follow-up, and address barriers to oncology care.

METHODS

The ED providers placed a consult to ONNs. The ONNs reached out to the patient within 48 hours of the consult. They maintained a database of patient referrals and collected information such as patient demographics, reason for referral, insurance, and patient outcomes.

RESULTS

The ED providers referred 204 patients to the ONNs from April 2022 to September 2023. The development of a standardized referral process from the ED to the outpatient oncology clinic proved successful. Of the patients referred, the ONNs facilitated 98 cancer diagnoses and 80 of those patients are receiving oncology care at Penn Medicine. The median time to the patient's first appointments was seven days, diagnosis was 15 days, and treatment initiation occurred within 32 days.

CONCLUSION

The project team achieved their goal of facilitating timely access to oncology care, ensuring continuity, and addressing patient-specific barriers.

IMPLICATIONS FOR NURSING PRACTICE

This quality improvement initiative highlights the ONNs' role in enhancing access and equity in cancer care delivery. The success of the project underscores the ONN's expertise and leadership in addressing healthcare disparities in oncology care. Collaboratively, the teams created a new referral workflow improving care transitions from the ED to the outpatient oncology clinic. The project sets a precedent for optimizing patient care transitions, demonstrating the positive impact of ONNs as key members of the multidisciplinary healthcare team.

Stigma, Communication, and Clinical Oncology Care: Three Case Studies

BACKGROUND

Health-related stigma can contribute to health inequities and poor outcomes. To address stigma-related issues in clinical oncology care, healthcare providers can identify stigma in clinical practice and apply strategies that reduce stigma.

OBJECTIVES

The aim is to identify stigma-related issues experienced by patients with cancer and to present strategies that address stigma-associated barriers to quality clinical oncology care.

METHODS

This article presents three case studies that illustrate stigma-associated issues and strategies to address those issues in clinical oncology care.

FINDINGS

Identifying intersectional stigmas in clinical care, each case study includes the patient's background information, a social assessment, and a clinical update, as well as an example of dialogue between the nurse and patient. Each case study ends with commentary and questions to further illustrate stigma-related issues in clinical oncology care. Finally, supporting the case studies, the toolbox includes inclusive language; principles of universal precautions to apply to stigma in clinical oncology care; and communication components, strategies, and resources to reduce stigma in clinical oncology care.

Stereotactic Radiosurgery for Small Intact Brain Metastasis: A Comparative Evaluation of 3 Different Single Fraction Prescription Doses

PURPOSE/OBJECTIVE(S)

While single-fraction stereotactic radiosurgery (SRS) in the treatment of small brain metastases (SBM, ≤ 2 cm) is well established, prescription dosing varies considerably across institutions and clinical trials. The choice of prescription dose is a delicate balance between local failure (LF) and radiation necrosis (RN) risks. In the modern era, historically-established dosing thresholds may no longer be applicable. To evaluate the impact of prescription dose on outcomes, we performed a comparative analysis of patients with SBM treated with definitive SRS using three different prescriptions, at a single tertiary institution.

MATERIALS/METHODS

Consecutive patients with intact SBM treated with SRS from January 2017 and December 2021 were analyzed. Baseline patient characteristics and dosing parameters were abstracted from the medical record. To limit the integral brain dose when treating multiple brain metastases, the institutional practice was to reduce prescription dose as the total number of lesions increased (i.e., 24 Gy for ≤10 lesions, 22 Gy for 11-20, and 20 Gy for >20). A per lesion analysis, where each lesion was followed from the date of SRS to the last follow-up, was conducted with primary endpoints of LF and RN. Gray's test was used to compare the cumulative incidence of the LF and RN, with death as a competing risk. Factors affecting LF were analyzed using Cox hazard regression analysis.

RESULTS

A total of 1318 SBM in 250 patients received SRS and met the inclusion criteria. The median age was 62 years (range: 18-90), median KPS was 90 (range: 50-100) and 66% were female. The most common primary tumors were lung (55.5%) and breast cancers (26.4%). With a median follow-up of 12 months, 136 (11%) LF in 44 patients and 70 (5.7%) RN events in 46 patients occurred. The actuarial 1-year cumulative rate of LF was lower in lesions treated with 24 Gy (6.4%, 95% CI: 4.7-8.6%) or 22 Gy (5.8%, 95% CI: 3.7-8.7%) compared to 20 Gy (15.4%, 95% CI: 10.9-20.5%) (p<0.01). 22 Gy and 24 Gy prescription doses were associated with a 44% and 52% reduction in risk in LF compared to 20 Gy (HR: 0.56; 95% CI: 0.36-0.9; p = 0.01 and HR: 0.48; 95% CI: 0.31-0.74; p<0.01, respectively). In a subset analysis of radiosensitive tumors, 1-year LF rate was still lower with 24 Gy (7.4%, 95% CI: 5.3-9.9%) and 22 Gy (6.1%, 95% CI: 3.7-9.4%) than 20 Gy (15.7%, 95% CI: 11.2-21%) (p = 0.01). The cumulative 1-year RN rate numerically declined with dose, but was not statistically significantly different, with 3.6% (95% CI: 2.3-5.3%) for 24 Gy, 2.6% (95% CI: 1.3-4.8%) for 22 Gy and 1.4% (95% CI: 0.4-3.7%) for 20 Gy.

CONCLUSION

Patients treated with single fraction SRS to intact SBM were at increased risk of LF with prescription doses of 20 Gy compared to 22-24 Gy, without an increased risk of RN. Even in patients with radiosensitive histologies, higher LF rates were still observed following 20 Gy compared to 22-24 Gy.

A Comparison of Local Failure and Necrosis Following Different Radiosurgery Strategies for Large Brain Metastases

PURPOSE/OBJECTIVE(S)

Large brain metastases (LBMs) are associated with poor local control with single-fraction stereotactic radiosurgery (SRS) alone. Various alternative strategies have been developed, including fractionated SRS (FSRS) and staged SRS (SSRS) for intact LBMs, and resection with postoperative-SRS (postop-SRS) or preoperative-SRS (preop-SRS) for operable LBMs. The objective of this study is to compare local failure (LF) and radiation necrosis (RN) outcomes among these four management strategies to determine the optimal treatment paradigm.

MATERIALS/METHODS

Consecutive patients diagnosed with LBM (≥2 cm in maximum dimension) between July 2017 and January 2022 and treated with one of the aforementioned strategies at a single tertiary institution were evaluated. All immobilization, target contouring, margins, dose- and prescription selection followed pre-defined institutional guidelines. Primary endpoints included LF, symptomatic RN, or a composite endpoint of these two variables. Gray's test was used to compare the cumulative incidence of the LF and the composite endpoint, with death as a competing risk.

RESULTS

A total of 234 LBMs in 188 consecutive patients met the inclusion criteria. The median age was 65 years (range: 31-98), the median KPS was 80 (range: 50-100), and 58% were female. The most common primary tumors were lung (48%) and breast cancer (17%). The median maximum tumor diameter was 3.0 cm (range: 2.0-5.6). 47 (20%) lesions were treated with FSRS, 66 (28%) with SSRS, 74 (32%) with postop-SRS, and 47 (20%) with preop-SRS. With a median follow-up of 12 months, 22 (9%) LF and 11 (5%) RN events occurred. The 6-month and 1-year cumulative incidences of LF for the entire cohort were 5% (95% CI: 3%-9%) and 8% (95% CI: 5%-12%), respectively. The 6-month and 1-year LF rates were 4% (95% CI: 1%-13%) and 8% (95% CI: 3%-20%) for FSRS; 8% (95% CI: 3%-20%) and 8% (95% CI: 3%-20%) for SSRS; 7% (95% CI: 3%-15%) and 8% (95% CI: 3%-16%) for postop-SRS; 0 and 7% (95% CI: 2%-20%) for preop-SRS (p>0.05). The 1-year OS rates were favorable in resected patients (61% for postop-SRS and 82% for preop-SRS) compared to SRS alone strategies (45% for FSRS and 56% for SSRS) (p = 0.004). Similarly, RN events were significantly lower in resected patients treated with either bimodality approach (0 for postop-SRS and 4% for preop-SRS) than SRS standalone strategies (9% for FSRS and 8% SSRS) (p = 0.024). At 12 months, the cumulative probabilities of the composite endpoint were 13% (95% CI: 5%-25%) for FSRS, 15% (95% CI: 7%-25%) for SSRS, 9% (95% CI: 3%-17%) for postop-SRS, and 12% (95% CI: 4%-24%) for preop-SRS and not significantly different between the groups.

CONCLUSION

For medically operable patients with surgically resectable LBMs, a strategy of surgery and SRS, regardless of timing, is associated with favorable local control and reduced risk for RN. For unresected patients, either SSRS or FSRS is associated with similar local control, but slightly higher RN risk. Prospective comparative evaluation is warranted.

CNS Control after First-Line Osimertinib in Patients with Metastatic EGFR-Mutant NSCLC

PURPOSE/OBJECTIVE(S)

Although osimertinib (osi) has excellent intracranial activity in EGFR-mutant metastatic non-small cell lung cancer (NSCLC), there is no consensus regarding whether to continue osi for central nervous system (CNS) control with second-line chemotherapy (chemo) at the time of systemic progression. We aimed to compare CNS outcomes after first-line osi in patients receiving second-line chemo with or without continuation of osi.

MATERIALS/METHODS

We retrospectively reviewed patients with EGFR-mutant NSCLC with brain metastases (BrM) at the time of initiating first-line osi who experienced progression and started second-line chemo. Cumulative incidence of local and distant CNS progression, and extracranial (EC) progression was calculated from time of second-line chemo initiation with death as a competing risk. Overall survival (OS) was analyzed using Kaplan-Meier.

RESULTS

We included 52 patients with a median follow up of 9.6 months (range 0.4-36.4). Median OS and CNS progression-free survival (PFS) from the time of starting second-line chemo was 12.5 months (95% CI 8.1-16.9), and 5.3 months (95% CI 3.35-7.26), respectively. The 1-year cumulative incidence of local, distant CNS progression, any CNS progression, and EC progression was 14.4% (95% CI 4.5-24.2), 42.8% (95% CI 22.8-56.8), 42.8% (95% CI 22.8-56.8) and 66.8% (95% CI 53.5-80.2), respectively. After progression on first-line osi, 25 (48.1%) and 27 patients (51.9%) continued and discontinued osi, respectively. Patients who continued osi had significantly higher BrM burden than those who did not, with 17 (68%), 3 (12%), and 5 (20%) versus 26 (96%), 0, and 1 (3.7%) patient having <10 or >11 parenchymal brain lesions, or leptomeningeal disease (LMD) at the time of second line therapy, respectively (p<0.01). In those who continued osi vs those who did not, median OS (10.8 vs 12.5 months; p = 0.37), median intracranial PFS (5.3 vs 4.8 months; p = 0.99), 1-year cumulative incidence of local (8.4% versus 20 % p = 0.26), and 1-year distant CNS progression (24.8% vs 60%; p = 0.08) was not significantly different. CNS complications such as symptomatic, hospitalizations, and steroid initiation for CNS disease, and progression of LMD were not significantly different between the two groups. Eventually, 10 patients underwent salvage RT post first-line osi and median time to salvage RT was 7.8 months (range 2-9.4). Of patients who underwent salvage RT, 2 patients (20%) had continued osi with second-line chemo. Twelve patients (44.4%) who did not continue osi eventually re-started osi for progressive disease.

CONCLUSION

Patients who continued osi had significantly higher BrM tumor burden. Despite these patients being at higher risk for CNS progression, time to CNS progression and incidence of CNS complications were not significantly different in the two cohorts. Patients who discontinued osi were more likely to undergo salvage RT. Continuation of osi may allow patients to defer salvage RT.

Combined osmotic pretreatment and hot air drying: Evaluation of drying kinetics and quality parameters of adajamir (Citrus assamensis)

Adajamir (Citrus assamensis) is a highly perishable but nutritional fruit. Hot air drying is ubiquitous in food preservation but not quality friendly. However, drying pretreatments play an indispensable role preserving fruits and vegetables. The aim of this study was, therefore, to reveal the hot air drying kinetics of osmotically pretreateated adajamir and investigate the quality parameters (total phenolic contents, antioxidant capacity, and vitamin C). Adajamir slices were subjected to osmotic pretreatment (10% sucrose, 10% fructose, and 2% NaCl), subsequently, dried in a hot air dryer at 50 °C, 30% relative humidity (RH), and with a velocity of 1 ms-1. The drying kinetics were studied using three mathematical models: Newtonian model, Henderson and Pabis model, and Page model. The result depicted that effective diffusivity was highest (9.5 ± 0.2a × 10-6 m2s-1) in untreated samples compared to the treated samples, and the Page model was the one with the best fitness to explain the drying behavior. Regarding quality, the pretreatments provided better retention of all quality parameters compared to the untreated samples. In addition, osmotic treatment with sucrose had the best quality retention capability. The study will contribute to the optimization of thermal processing parameters in fruit dehydration. Eventually, this research will expedite future research pertinent to innovative combined drying techniques of citrus fruit.

Economic evaluation of tele-resuscitation intervention on emergency department pediatric visits in the Niagara Region, Canada a pilot study

Introduction

The use of telemedicine in critical care is emerging, however, there is a paucity of information surrounding the costs relative to health gains in the pediatric population. This study aimed to estimate the cost-effectiveness of a pediatric tele-resuscitation (Peds-TECH) intervention compared to the usual care in five community hospital emergency departments (EDs). Using a decision tree analysis approach with secondary retrospective data from a 3-year time period, this cost-effectiveness analysis was completed.

Methods

A mixed methods quasi-experimental design was embedded in the economic evaluation of Peds-TECH intervention. Patients aged <18 years triaged as Canadian Triage and Acuity Scale 1 or 2 at EDs were eligible to receive the intervention. Qualitative interviews were conducted with parents/caregivers to explore the out-of-pocket (OOP) expenses. Patient-level health resource utilization was extracted from Niagara Health databases. The Peds-TECH budget calculated one-time technology and operational costs per patient. Base-case analyses determined the incremental cost per year of life lost (YLL) averted, and additional sensitivity analysis confirmed the robustness of the results.

Results

Odds ratio for mortality among cases was 0.498 (95% CI: 0.173, 1.43). The average cost of a patient receiving the Peds-TECH intervention was $2,032.73 compared to $317.45 in usual care. In total, 54 patients received the Peds-TECH intervention. Fewer children died in the intervention group resulting in 4.71 YLL. The probabilistic analysis revealed an incremental cost-effectiveness ratio of $64.61 per YLL averted.

Conclusion

Peds-TECH appears to be a cost-effective intervention for resuscitating infants/children in hospital emergency departments.

Effects of in ovo Administration of Zinc Oxide Nanoparticles and Vitamin C on Hatchability Performance and Redox Status in Day Old Kadaknath Hatchlings

Background: In poultry industry, hatcheries play a vital role in connecting the poultry production chain and are expected in the productive performance, with an impact on company profits. The use of in ovo feeding support poultry embryonic development and offers the production efficiency and welfare of commercial poultry. Methods: This study investigated the impact of in ovo administration of normal saline, Zinc oxide nanoparticles and Vitamin C on hatchability, chick growth and redox status in Kadaknath hatchlings. Zinc oxide nanostructures were synthesized by chemical method and characterized for size determination. A total of 150 fertile eggs of the Kadaknath poultry breed were divided into five groups (T0 to T4) and treated with in ovo administration of 200 μl each of normal saline, zinc oxide nanoparticles (5 and 10 ppm) and Vitamin C respectively on the 18th day of incubation through air sac into amniotic fluid. Result: Rod shaped nanostructures ranging from 45 to 98 nm were synthesized and showed sharp peak positioned at 436.59 cm-1. Zinc nano composite 5 ppm and vitamin C administration had significantly (p less than 0.05) improved hatchability, hatch weight, chick weight and egg weight ratio and antioxidant status.

Precorneal retention time of ocular lubricants measured with fluorophotometry in healthy dogs

OBJECTIVE

Determine the precorneal retention time of five different ocular lubricants commonly used in dogs.

ANIMALS STUDIED

Six healthy Beagle dogs (n = 12 eyes).

PROCEDURES

Five ocular lubricants were studied: Artificial Tears Solution® (1.4% polyvinyl alcohol), I-Drop® Vet Plus (0.25% hyaluronate), Optixcare® Eye Lube Plus (0.25% hyaluronate), Systane® Ultra (0.4% polyethylene glycol 400 and 0.3% propylene glycol), and Artificial Tears Ointment® (mineral oil/white petrolatum). Each lubricant was mixed with 10% sodium fluorescein to achieve 1% fluorescein formulations. Following topical administration of 35 mg in each eye, tear fluid was collected with capillary tubes at selected times (0, 1, 5, 10, 20, 30, 40, 50, 60, 90, 120, 180 min) and fluorescein concentrations were measured with a computerized scanning ocular fluorophotometer.

RESULTS

Tear fluorescence was significantly greater with Artificial Tears Ointment® compared with other lubricant formulations from 1 to 20 min post-administration. Median (range) precorneal retention times were significantly different among the 5 lubricants, ranging from 40 minutes (20-90 min) for Artificial Tears Ointment®, 35 min (20-90 min) for Systane® Ultra, 30 min (10-60 min) for I-Drop® Vet Plus, 25 min (10-60 min) for Optixcare® Eye Lube Plus, and 10 min (10-20 min) for Artificial Tears Solution®. Precorneal retention time was significantly lower for Artificial Tears Solution® compared with the other 4 formulations.

CONCLUSIONS

This study established normative data for the retention time of common lubricants on the ocular surface of dogs, which may be used to guide clinicians with their choice of lubricant and frequency of administration.

A membrane-based green and low-cost system for ensuring safe drinking water in a selenium-affected region

Towards an efficient, low-cost solution to the problem of contamination of groundwater by selenium leached out from earth's mineral crust, a new system is developed using a novel graphene-based nanocomposite membrane. The system not only purified selenium-contaminated groundwater with high degree but also ensured safe disposal of the rejected selenium through algorithmic chemical stabilization in a mineral matrix. All experiments were conducted with live contaminated water from selenium affected area rather than using synthetic solution in a semi-pilot unit involving a largely fouling-free flat sheet cross-flow membrane module. Pure water flux of up to 190 Lm^-2h^-1(LMH) with 96-97% selenium rejection at an optimum operating pressure of only 14 bar could be achieved. Rejected selenium was stabilized in mineral matrix through chemical coagulation-precipitation using suitable coagulants following prior optimization of the critical operating parameters by Model-based calibration toolbox (MATLAB R2020a). A high degree of stabilization efficiency (99.8%) could be achieved as reflected in an error-index of only 1.13%. For selenium-affected region, the membrane-integrated hybrid treatment system proved to be a potential candidate technology offering safe drinking water at an approximate cost of only 1.77 $/m³ which was found to be affordable to the consumers in subsequent willingness to pay survey.

Transitions in care for ER patients with a suspected cancer diagnosis

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Background: The oncology nurse navigators (ONNs) at Penn Medicine’s Abramson Cancer Center (ACC) observed that patients seen in the Emergency Room (ER) and found to have a suspicion of cancer were being told to call a medical oncologist. The oncologist in the ACC are highly specialized and since the patient has not had a confirmed cancer diagnosis, they were being told they couldn’t schedule an appointment. Some patients waited for the ACC to call them to schedule. When this didn’t happen they would call the ACC a week later. These barriers led to delays in care, poor patient experience, and a financial loss for the health system. The ONNs identified this as an opportunity to change the process to improve patient care. Methods: The initiative formally began in June 2021 when the ONNs reached out to the ER leadership to collaborate on a quality improvement project to streamline the process from ER visit to oncology work up and diagnosis. Direct referral to oncology nurse navigation from the ER facilitates timely navigation assessment and coordination of care. The Plan Do Study Act (PDSA) methodology was utilized. A “Consult to Nurse Navigation” order was built into the electronic medical record (EMR) for ER providers to directly refer patients to the navigation team. The ONNs contacted the patient within one business day to assess next steps. The ONNs scheduled the patient with the appropriate oncology specialist. The ONNs follows the patient through the diagnostic phase of care and assists with decreasing barriers to care. Data collection is ongoing to assess the impact of the interventions. Results: The EMR consult to ONNs went live April 2022. It includes 3 hospital ERs in the health system with diverse populations that often have limited access to health care. To date, 90% were appropriate referrals and triaged to cancer specialists for diagnostic workup and treatment. 90% had insurance accepted by the health system. Patients with unacceptable insurance plans were referred to ER social work and financial advocates. 70% were diagnosed with cancer and began treatment. Conclusions: ONNs are vital in identifying and removing barriers to care. The ONN team’s clinical knowledge, assessment skills, and expertise of the Penn health system have closed a gap in care while increasing patient satisfaction, patient retention, and downstream revenue. The ONNs leadership has directly enhanced the diagnostic process and timeliness to care for patients newly effected by cancer.

Improving comprehensive genotyping in patients with newly diagnosed non-squamous NSCLC: Results from a prospective trial of a behavioral nudge intervention

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Background: Despite current guidelines, less than 50% of patients with metastatic (m) non-squamous (NSq) NSCLC undergo comprehensive molecular genotyping. At our institution, based on improved comprehensiveness of genotyping with use of concurrent tissue (T) and plasma (P) next generation sequencing (NGS), we designed an electronic medical record (EMR)-based “nudge intervention” to auto-generate an order for P NGS at the time of initial consultation, while T NGS was carried out reflexively based on institutional pathways. Methods: A prospective study was conducted at the Abramson Cancer Center and 2 community sites within the University of Pennsylvania Health System after IRB approval. A provider team-focused EMR-based “nudge intervention” was designed to order P NGS at the time of new patient consultation. Eligible patients for the nudge were identified using an EMR based checklist, that included 3 criteria i. newly diagnosed, ii. treatment naïve, iii. mNSq NSCLC. Results from the intervention period (4/2021-12/2021) were compared to baseline data from similar patients treated at our institution between 01/2019 and 03/2021. Categories of NCCN guideline recommended molecular genotyping were defined as: i) comprehensive: EGFR, ALK, BRAF, ROS1, MET, RET, NTRK testing, and ii) incomplete or no testing performed. The proportion of patients with comprehensive molecular genotyping prior to 1st-line therapy were compared in the pre- and post-intervention groups using the chi-square test. Results: 526 patients with mNSq NSCLC were included in this analysis: 381 in the pre-intervention cohort, 145 in the post-intervention cohort. After implementation of the EMR-based nudge, a higher proportion of patients underwent concurrent T+P testing resulting in improved comprehensive molecular genotyping. In addition, a greater proportion of patients had comprehensive genotyping available prior to 1st-line therapy in the post-intervention vs pre-intervention cohort (Table). Conclusions: Across 3 practice sites, a provider team-focused EMR-based nudge intervention was associated with a significantly higher proportion of patients with mNSq NSCLC undergoing comprehensive molecular genotyping, both overall and prior to 1st-line therapy. These findings demonstrate that behavioral, EMR-based nudges can promote guideline concordant diagnostic testing at both community and academic sites and should be studied further as a tool to improve rates of molecular testing in NSCLC.[Table: see text]

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Physical function and physical activity in adults with X-linked hypophosphatemia

We described physical function and activity in UK adults with X-linked hypophosphatemia (XLH). Our data indicate that low physical activity and impaired mobility are common in adults with XLH. Deficits in lower limbs muscle power and functional capacity contribute to the loss of physical function in adults with XLH.

INTRODUCTION

There is a dearth of literature on physical function and physical activity in adults with X-linked hypophosphatemia (XLH). We described muscle strength and power, functional capacity, mobility and physical activity level and explored the relationships among these variables in adults with XLH.

METHODS

Participants were recruited as part of a UK-based prospective cohort study, the RUDY Study. They underwent a clinical visit and physical examination, including assessment of handgrip strength, jump power (mechanography), six-minute walk test (6MWT) and short physical performance battery (SPPB), and completed the International Physical Activity Questionnaire (IPAQ). Performance data were analysed using parametric and non-parametric tests, whereas correlations were assessed by univariate analysis.

RESULTS

Twenty-six adults with XLH (50% males) with a mean age of 44 ± 16.1 years were recruited. Jump power and 6MWT distances (p < 0.0001) were 54.4% and 38.6% lower respectively in individuals with XLH compared with normative values. These deficits were not associated with age or sex. Handgrip strength values were similar to expected values. Deficits in muscle power were more pronounced than those reported at 6MWT (p < 0.0001). Univariate analysis revealed only a correlation between total physical activity and muscle power (r = 0.545, p = 0.019).

CONCLUSIONS

Adults with XLH have a marked deficit in lower limb muscle power and a reduced functional capacity, with a high incidence of impaired mobility and inactivity. In addition to metabolic effects of XLH, low physical activity may contribute to deficits in lower limb power. Further studies are required to develop novel treatment approaches to improve physical function and mobility.

Glomus tumour of the nipple in a male patient

A glomus tumour is a benign mesenchymal tumour. It is extremely rare in the breast. We report a case of glomus tumour of the nipple in a 54-year-old man. To the best of the authors' knowledge, this is the first case report of a glomus tumour of the nipple. We describe the different presenting symptoms, method of diagnosis and treatment.

Metastatic melanoma to the ovary in pregnancy: A case report

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Metastatic melanoma to the ovary is uncommon and can occur years after initial diagnosis.

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Ovarian metastatic melanoma can mimic various benign lesions on imaging and clinical history is key.

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If any suspicion in pregnancy, placenta should be evaluated due to possibility of transplacental transmission.

Metastatic melanoma to the ovary is an uncommon presentation. We report a case of metastatic melanoma to the ovary that presented as a growing left adnexal mass during pregnancy and was thought to be benign by imaging and frozen section pathology. Here we discuss the challenges in radiologic and pathologic diagnosis, as well as considerations for the mother and newborn.

Impact of telemedicine adoption on accessibility and time to treatment in patients with thoracic malignancies during the COVID-19 pandemic

Background

To ensure safe delivery of oncologic care during the COVID-19 pandemic, telemedicine has been rapidly adopted. However, little data exist on the impact of telemedicine on quality and accessibility of oncologic care. This study assessed whether conducting an office visit for thoracic oncology patients via telemedicine affected time to treatment initiation and accessibility.

Methods

This was a retrospective cohort study of patients with thoracic malignancies seen by a multidisciplinary team during the first surge of COVID-19 cases in Philadelphia (March 1 to June 30, 2020). Patients with an index visit for a new phase of care, defined as a new diagnosis, local recurrence, or newly discovered metastatic disease, were included.

Results

240 distinct patients with thoracic malignancies were seen: 132 patients (55.0%) were seen initially in-person vs 108 (45.0%) via telemedicine. The majority of visits were for a diagnosis of a new thoracic cancer (87.5%). Among newly diagnosed patients referred to the thoracic oncology team, the median time from referral to initial visit was significantly shorter amongst the patients seen via telemedicine vs. in-person (median 5.0 vs. 6.5 days, p < 0.001). Patients received surgery (32.5%), radiation (24.2%), or systemic therapy (30.4%). Time from initial visit to treatment initiation by modality did not differ by telemedicine vs in-person: surgery (22 vs 16 days, p = 0.47), radiation (27.5 vs 27.5 days, p = 0.86, systemic therapy (15 vs 13 days, p = 0.45).

Conclusions

Rapid adoption of telemedicine allowed timely delivery of oncologic care during the initial surge of the COVID19 pandemic by a thoracic oncology multi-disciplinary clinic.

Mosquito Identification From Bulk Samples Using DNA Metabarcoding: a Protocol to Support Mosquito-Borne Disease Surveillance in Canada

Approximately 80 species of mosquitoes (Diptera: Culicidae) have been documented in Canada. Exotic species such as Aedes albopictus (Skuse) (Diptera: Culicidae) are becoming established. Recently occurring endemic mosquito-borne diseases (MBD) in Canada including West-Nile virus (WNV) and Eastern Equine Encephalitis (EEE) are having significant public health impacts. Here we explore the use of DNA metabarcoding to identify mosquitoes from CDC light-trap collections from two locations in eastern Canada. Two primer pairs (BF2-BR2 and F230) were used to amplify regions of the cytochrome c oxidase subunit I (CO1) gene. High throughput sequencing was conducted using an Illumina MiSeq platform and GenBank-based species identification was applied using a QIIME 1.9 bioinformatics pipeline. From a site in southeastern Ontario, Canada, 26 CDC light trap collections of 72 to >300 individual mosquitoes were used to explore the capacity of DNA metabarcoding to identify and quantify captured mosquitoes. The DNA metabarcoding method identified 33 species overall while 24 species were identified by key. Using replicates from each trap, the dried biomass needed to identify the majority of species was determined to be 76 mg (equivalent to approximately 72 mosquitoes), and at least two replicates from the dried biomass would be needed to reliably detect the majority of species in collections of 144-215 mosquitoes and three replicates would be advised for collections with >215 mosquitoes. This study supports the use of DNA metabarcoding as a mosquito surveillance tool in Canada which can help identify the emergence of new mosquito-borne disease potential threats.

Effect of boiling and roasting on physicochemical and antioxidant properties of dark red kidney bean (Phaseolus vulgaris)

The effects of two processing methods (boiling and roasting) on physicochemical qualities of dark red kidney bean (Phaseolus vulgaris) were investigated. Changes in total polyphenol content (TPC) and antioxidant activity due to processing were also analyzed by using Folin–Ciocaltue method and 1,1 diphenyl-2-picrylhydrazyl (DPPH) assay, respectively. Analysis of physicochemical properties exhibited substantial variations (p<0.05) in the levels of moisture, ash, protein, fat, carbohydrate, gross energy and pH of raw and processed beans. Meanwhile, there was no considerable difference (p<0.05) in the fibre content of fresh and processed beans. Investigation of total phenolic content showed the significant (p<0.05) reduction of phenolic compounds in boiled (5.53±0.74 mg GAE/ g) and roasted (8.15±1.60 mg GAE/g) beans than raw samples (12.55±1.42 mg GAE/g). DPPH radical scavenging activity was also decreased significantly (p<0.05) in boiled and roasted samples with IC50 value of 0.0608±0.0765 mg/mL and 0.0523±0.0026 mg/mL, respectively. In the case of household cooking, keeping boiling water would be advised for the preservation of minerals, vitamins and phenolic compounds. The roasting process may be used to develop high-quality health-promoting dark red kidney bean products.

Bioactive compounds and antioxidant activity of black and green tea available in Bangladesh

People in Bangladesh are traditionally used to consume mainly black tea. However, some tea manufacturing companies are now producing green tea, though in a small scale. To create new knowledge as well as awareness about the consumption of green tea, the present study was carried out to compare the black and green tea available in Bangladesh based on their bioactive compounds and antioxidant activity. A total of eight brands of black tea and two brands of green tea were bought from the supermarkets. Total phenolics, total tannin, total flavonoids, and caffeine content were measured as bioactive compounds, and antioxidant activity was evaluated by using two different methods such as DPPH (1,1- diphenyl-2-picrylhydrazyl) radical-scavenging activity and ABTS+ radical scavenging activity of methanol extracts of black and green tea. Every bioactive compound in black and green tea was found to be significantly different (P < 0.05). The total phenolic content, on average, was measured at 242.46 mg GAE/g dry extract and 763.41 mg GAE/ g dry extract in black and green tea, respectively. Black tea contained 6.47 mg TAE/g dry extract tannin, whereas green tea had much more tannin content, 14.51 mg TAE/g dry extract, which is more than double in amount. On the other hand, the total flavonoid content was almost double in black tea (61.82 mg QE/g dry extract) compared to green tea (31.85 mg QE/g dry extract). Antioxidant activities were determined at different concentrations of tea samples. At every concentration, green tea presented higher ABTS+ and DPPH radical scavenging activity than black tea. The highest percentage of inhibition was observed at 20 ppm both in black and green tea, finding 98.50 % and 99.07 % inhibition, respectively. Overall, significantly (P < 0.05) higher amount of phenolic compounds as well as antioxidant activity were observed in green tea.

Impact of blanching pretreatment on physicochemical properties, and drying characteristics of cabbage (Brassica oleracea)

Cabbage (Brassica oleracea) is popular winter vegetables cultivated all over Bangladesh and contains essential nutrients. This study aimed to evaluate the efficacy of pre-blanching on the preservation of cabbage by drying. In this research work, cabbage was blanched at 80°C, 90°C, and 100°C temperature for 12, 8, and 2 mins, respectively. Then the samples were dried at 60°C maintaining 60% relative humidity. The moisture and ash content of untreated and treated dried samples was in the range of 16.07±0.04 to 10.80±0.01% and 5.71±0.06 to 3.81±0.02%, respectively. The total phenolic content in cabbage was 74.47±0.63 mg GAE/100g at 100°C blanching temperature for a short time of 2 mins, which was higher compared to 61.91±0.48 mg GAE/100g at 80°C for 12 mins. It was observed that the antioxidant activity and two water-soluble vitamins-ascorbic acid and beta carotene decreased in pre-blanched dried samples in contrast with fresh ones. Blanching at higher water temperature and a short period was found useful for the retention of total phenolic content and greenness of cabbage. Blanching pre-treatments were also found to have better color retention capacity than untreated dried cabbage. A proper combination of drying time and temperature, along with the incorporation of blanching pretreatment, might be useful to preserve cabbage for a long time.

Future directions for the concept of salutogenesis: a position article

Aaron Antonovsky advanced the concept of salutogenesis almost four decades ago (Antonovsky, Health, Stress and Coping. Jossey-Bass, San Francisco, CA, 1979; Unravelling the Mystery of Health. Jossey-Bass, San Francisco, CA, 1987). Salutogenesis posits that life experiences shape the sense of coherence (SOC) that helps to mobilize resources to cope with stressors and manage tension successfully (determining one's movement on the health Ease/Dis-ease continuum). Antonovsky considered the three-dimensional SOC (i.e. comprehensibility, manageability, meaningfulness) as the key answer to his question about the origin of health. The field of health promotion has adopted the concept of salutogenesis as reflected in the international Handbook of Salutogenesis (Mittelmark et al., The Handbook of Salutogenesis. Springer, New York, 2016). However, health promotion mostly builds on the more vague, general salutogenic orientation that implies the need to foster resources and capacities to promote health and wellbeing. To strengthen the knowledge base of salutogenesis, the Global Working Group on Salutogenesis (GWG-Sal) of the International Union of Health Promotion and Education produced the Handbook of Salutogenesis. During the creation of the handbook and the regular meetings of the GWG-Sal, the working group identified four key conceptual issues to be advanced: (i) the overall salutogenic model of health; (ii) the SOC concept; (iii) the design of salutogenic interventions and change processes in complex systems; (iv) the application of salutogenesis beyond health sector. For each of these areas, we first highlight Antonovsky's original contribution and then present suggestions for future development. These ideas will help guide GWG-Sal's work to strengthen salutogenesis as a theory base for health promotion.

Community outreach workers: Perceived practices and impacts on families and young children

Background

Community outreach workers support individuals accessing healthcare and other services that could be useful to respond to their needs. Even though community outreach workers have been working in the province of Quebec (Canada) for the past 40 years, their practice is poorly documented and evaluated, especially with respect to young children aged 0 to 5 years. This study aimed to document the practice of community outreach workers and its perceived impacts among children and families.

Methods

A qualitative methodology with a descriptive research design was used. We performed a content analysis on 55 scientific and grey literature documents, 24 individual interviews, and 3 focus groups with stakeholders including parents, community outreach workers, healthcare employees, and inter-sectoral partners.

Results

Our analysis reveals three main themes: 1) characteristics of the population served, 2) concrete actions performed by community outreach workers, and 3) perceived impacts of community outreach on families and children. Community outreach workers were perceived as essential to reach families with vulnerable circumstances and children with special needs. With respect to concrete actions, community outreach workers were reported to tailor their interventions to respond in different but complementary ways to the healthcare system. Perceived impacts included increased access for children and families to appropriate services, decreased social isolation, increased empowerment (especially with respect to parental abilities), increased social capital of families, and confidence towards the healthcare system. Results showed that community outreach workers helped to reduce inequalities in health

Conclusions

Community outreach work help the healthcare system to fulfill its legal mandate to protect citizen and increase health and well-being. It is crucial that such type of proximity approaches be not only encouraged but also sustained.

Key messages

Community outreach workers adapt their practices to act in a complementary way to the healthcare system. Community outreach workers help to reduce inequalities in health.

The Cognitive Control of Eating and Body Weight: It's More Than What You "Think"

Over the past decade, a great deal of research has established the importance of cognitive processes in the control of energy intake and body weight. The present paper begins by identifying several of these cognitive processes. We then summarize evidence from human and nonhuman animal models, which shows how excess intake of obesity-promoting Western diet (WD) may have deleterious effects on these cognitive control processes. Findings that these effects may be manifested as early-life deficits in cognitive functioning and may also be associated with the emergence of serious late-life cognitive impairment are described. Consistent with these possibilities, we review evidence, obtained primarily from rodent models, that consuming a WD is associated with the emergence of pathophysiologies in the hippocampus, an important brain substrate for learning, memory, and cognition. The implications of this research for mechanism are discussed within the context of a “vicious-cycle model,” which describes how eating a WD could impair hippocampal function, producing cognitive deficits that promote increased WD intake and body weight gain, which could contribute to further hippocampal dysfunction, cognitive decline, and excess eating and weight gain.

The aza-Michael reaction: towards semi-crystalline polymers from renewable itaconic acid and diamines

This paper reports, for the first time, semi-crystalline polymers based on bis-pyrrolidone dicarboxylic acids (BPDA) obtained from the aza-Michael reaction between renewable itaconic acid and various diamines.

Differential interference contrast microscopy for cells using hard x-ray holography

We propose a differential interference contrast method for cells using hard x-ray Gabor holography and knife-edge filtering in the spatial frequency domain, without relying on beam shearing. A phase object is holographically recorded and reconstructed by computer. Interference between the wavefronts of zeroth order weighted by e^jπ/2 in the positive frequency region produces a dark image. Similarly, interference between the wavefronts of the zeroth order weighted by e^j3π/2 in the negative frequency region produces a bright image. By adding these two intensity distributions, good quality phase-contrast images of 8-μm-diameter polystyrene beads and human HeLa cells were obtained.

Self-monitoring has no adverse effect on disordered eating in adults seeking treatment for obesity

OBJECTIVES

Although monitoring is considered a key component of effective behaviour change, the development of apps has allowed consumers to constantly evaluate their own diet, with little examination of what this might mean for eating behaviour. The aim of this study was to investigate whether self-monitoring of diet using the app MyFitnessPal or daily self-weighing increases the reported occurrence of eating disorders in adults with overweight/obesity following a weight loss programme.

METHODS

Two hundred fifty adults with body mass index ≥ 27 kg/m2 received diet and exercise advice and were randomized to one of four monitoring strategies (daily self-weighing, MyFitnessPal, brief monthly consults or self-monitoring hunger) or control for 12 months. The Eating Disorder Examination Questionnaire 6.0 was used to assess eating disorder symptoms and behaviours for the previous 28 d at 0 and 12 months.

RESULTS

There were no significant differences in the global Eating Disorder Examination Questionnaire score or the subscales between those in the four monitoring groups and the control at 12 months (all p ≥ 0.164), nor were there differences in binge eating, self-induced vomiting, laxative misuse or excessive exercise at 12 months (p ≥ 0.202). The overall prevalence of one or more episodes of binge eating was 53.6% at baseline and 50.6% at 12 months, with no change over time (p = 0.662).

CONCLUSIONS

There was no evidence that self-monitoring, including using diet apps like MyFitnessPal or daily self-weighing, increases the reported occurrence of eating disorder behaviours in adults with overweight/obesity who are trying to lose weight.

Community based kangaroo mother care for low birth weight babies: A pilot study

Background & objectives:

Kangaroo mother care (KMC - early continuous skin-to-skin contact between mother and infants) has been recommended as an alternative care for low birth weight infants. There is limited evidence in our country on KMC initiated at home. The present study was undertaken to study acceptability of KMC in different community settings.

Methods:

A community-based pilot study was carried out at three sites in the States of Odisha, Gujarat and Maharashtra covering rural, urban and rural tribal population, respectively. Trained health workers provided IEC (information, education and communication) on KMC during antenatal period along with essential newborn care messages. These messages were reinforced during the postnatal period. Outcome measures were the proportion of women accepting KMC, duration of KMC/day and total number of days continuing KMC. Focus group discussions and in-depth interviews were also carried out.

Results:

KMC was provided to 101 infants weighing 1500-2000 g; 57.4 per cent were preterm. Overall, 80.2 per cent mothers received health education on KMC during antenatal period, family members (68.3%) also attended KMC sessions along with pregnant women and 55.4 per cent of the women initiated KMC within 72 h of birth. KMC was provided on an average for five hours per day. Qualitative survey data indicated that the method was acceptable to mothers and family members; living in nuclear family, household work, twin pregnancy, hot weather, etc., were cited as reasons for not being able to practice KMC for a longer duration.

Interpretation & conclusions:

It was feasible to provide KMC using existing infrastructure, and the method was acceptable to most mothers of low birth infants.

Atlantoaxial Instability in down Syndrome-Guidelines for Screening and Detection

A community survey was conducted in all adults with Down syndrome living in three health districts to see if there was any correlation between radiological and neurological abnormalities which could indicate the presence of atlantoaxial instability. There was no difference in the proportion of individuals with neurological abnormalities in the group with radiological abnormalities suggestive of atlantoaxial instability (6/14) compared with individuals with normal X-rays (50/123) as determined by the chi square test (0.01463: not significant). The clinical and ethical implications for screening of people with Down syndrome living in the community are discussed in view of these findings.

A community survey establishing the prevalence rate of autistic disorder in adults with learning disability

AIMS AND METHOD

Most studies into autistic disorder have concentrated on children. This study aims to establish a prevalence rate of autistic disorders in an adult population with learning disabilities. Adults accessing learning disability services were diagnosed as having an autistic disorder by a two-stage process. The first stage was screening using the Pervasive Developmental Disorder – Mental Retardation Scale and then those identified by screening were diagnosed clinically.

RESULTS

An overall population rate of 7.7/10 000 for autistic disorder was obtained, which is a prevalence rate of 30% in those with learning disability. The prevalence rate was higher in intensive service settings.

CLINICAL IMPLICATIONS

Specific funding and interventions need to be targeted for the treatment of autistic disorders.