Changes In Clinical Management Research Articles

Clinical Decision-Making in Practice with New Critical Care Ultrasound Methods for Assessing Respiratory Function and Haemodynamics in Critically Ill Patients.

Situations often arise in intensive care units (ICUs) for which only sparse primary evidence or guidelines are applicable or to which existing evidence cannot be applied owing to interactions of multiple disease states. To improve and guide intensive care management in complex scenarios, ultrasonography and echocardiography are invaluable. In five clinical scenarios involving acute deterioration, serial ultrasound examinations of the respiratory system, general critical care ultrasound (GCCUS), and non-invasive haemodynamic critical care echocardiography (CCE) were used routinely. Ultrasonographic results were used to guide further management and initiate experimental therapy or transition from curative to supportive care. The process of initiation of ultrasound examinations to clinical decision-making in these complex scenarios is outlined. These case vignettes highlight the utility of ultrasound and echocardiography. When clinical management is not clear, or evidence is not available, the use of ultrasound for the evaluation of the respiratory system, GCCUS, and non-invasive haemodynamic CCE can help to guide management, reveal newly developed pathologies, lead to clinical management changes, and support the decision for employing experimental therapy approaches in a dynamic way of which few other imaging modalities or monitoring tools are currently capable.

The Practice and Clinical Utility of Trace Metal Testing for Hematology Patients: A Retrospective Cohort Study

Introduction: Trace metals play a critical role in human physiology and pathology. Deficiencies or toxicities in trace metals are associated with hematologic abnormalities and disorders and are included in the investigation of some hematology patients. For example, lead, copper and zinc levels may be included in the work-up of patients with unexplained anemia. The practice and clinical utility of these trace metal testing in unselected patients referred to hematology, however, are not well described. We examined the current practice of trace metal testing including lead, copper, and zinc, in hematology patients at a single tertiary care centre with the goal of informing future laboratory utilization of these investigations by hematologists. Methods: We investigated all adult patients who underwent trace metal testing ordered by hematologists between January 1, 2017, to December 31, 2021, at London Health Science Centre in London, Ontario, Canada. A retrospective chart review was performed to extract clinical and laboratory data including lead (whole blood), copper (plasma) and zinc (plasma) levels. Abnormal trace metal results were defined based on standard laboratory reference ranges. Primary outcomes were indications for trace metal testing and frequency of abnormal tests. Secondary outcomes included associated occupational exposures and clinical utility of testing, defined as the proportion of patients with an abnormal result that impacted diagnosis or management (including interventions such as advice to reduce exposures or initiate treatment such as chelation therapy or supplementation). Results: Preliminary results on 102/189 patients within our defined cohort revealed mean age 58 years with 32 men and 70 women tested for trace metals (Table 1a). Common indications for testing of each metal included work up for cytopenias, most commonly anemia (Table 1b). The three most common trace metals tested were 48/102 (47%) lead, 91/102 (89%) zinc, and 93/102 (91%) copper. Abnormal results were identified in 49 (48%) of the 102 patients with 12/48 (25%) in lead, 39/91 (42.9%) in zinc, and 9/93 (9.7%) copper testing. For lead, all abnormal results were toxicities, all abnormal results for zinc were deficiencies, and abnormal results for copper had a mix of both deficiencies and toxicities. Clinical utility was identified in one patient (8.3%) with an abnormal lead level, three (5.1%) with abnormal zinc levels, but none in the copper group. The single occupational exposure identified was toxic lead (greater than 50 times the upper limit of normal) in a patient with normal blood counts who made lead bullets. Data analysis for the full cohort is in progress and will be presented in the future. Conclusion: In this single-centre retrospective study, we characterized the use of trace metal testing for lead, zinc and copper deficiencies and toxicities by hematologists. Abnormal levels in these three metals are relatively common (48% for the entire cohort) with the highest frequency in zinc (43%) and lead (25%). However, despite the identification of abnormal results, clinical utility was low as management of patients with abnormal levels were not affected. This may indicate that the level of abnormality was trivial and did not require intervention in the majority of these identified. With this preliminary data, we speculate that some trace metal testing may be ordered as a non-specific panel of laboratory investigations for various indications and slightly abnormal results do not lead to any change in clinical management. Further investigations to explore the degree of trace metal level abnormalities and the impact on clinical diagnosis and management in these hematology patients are underway. The role of trace metal testing, the relationship between abnormal trace metal results and cytopenias such as anemia and impact on management will help to inform future clinical practice in hematology. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Impact of the Updated IPSS-Molecular Prognostic Scoring System for Myelodysplastic Syndrome in 10,283 Real World Samples

Introduction The International Prognostic Scoring System-Molecular (IPSS-M) is a validated prognostic method that incorporates molecular information to improve risk stratification for patients with myelodysplastic syndromes (MDS). It is a weighted sum of prognostic variables consisting of clinical, cytogenetic, and somatic mutation information (up to 31 genes), used to generate a patient-specific risk score and associated risk category assignment. To assess the impact of combining additional molecular data into MDS prognosis, we retrospectively analyzed 10,283 real world samples from patients who had been sequenced with a commercially available targeted next-generation sequencing (NGS) panel to determine the number of patients whose risk stratification could potentially be altered by IPSS-M. Methods Next-generation sequencing was performed using a panel capable of detecting and reporting single nucleotide variants and small indels across 50 genes. IPSS-M uses 19 binary molecular features incorporating somatic mutation information from 31 genes, 27 of which are targeted by the NGS panel used. Whole blood or bone marrow samples from patients with cause-for-testing for MDS or peripheral blood cytopenias were submitted for analysis by a clinician. DNA was extracted and assayed by the targeted, NGS panel and sequenced on Illumina DNA sequencers (Illumina, San Diego, CA). Results were reviewed, orthogonally confirmed unless previously validated, and reported by clinical laboratory directors. Disease status or symptoms were abstracted from test requisitions for each patient. TP53 loss of heterozygosity and KMT2A partial tandem duplications (MLLPTD) are molecular features in the IPSS-M but could not be assessed in this study. Results A total 10283 samples were analyzed including 4437 with an indication for MDS. 46.0% (4728/10283) of samples had at least one of 17 IPSS-M molecular features. The mean number of features observed was 0.83 with a range 0-6. In the IPSS-M, multiple mutations in TP53 have the strongest negative effect and this feature was observed in 2.3% of patients (236/10283). SF3B1-α, which provides the strongest positive effect, was observed in 6.5% (666/10283) of patients. The most common features were ASXL1 (15.3%, 1571/10283), DNMT3A (11.7%, 1204/10283) and SRSF2 (10.0%, 1030/10283). 629 MDS or peripheral blood cytopenia patients had serial testing performed allowing us to observe possible changes in IPSS-M risk scores over time. Patients with serial testing had a mean of 2.16 tests performed with a range of 2-5 tests. The mean interval between tests was 225 days (median = 177 days, range 0-1211 days). 63.4% (399/629) of patients with serial tests had at least one molecular feature in at least one sample. Furthermore, a change in IPSS-M molecular features was observed between tests in 44.1% (176/399) of cases potentially leading to a change of IPSS-M risk score and clinical management in these patients. Gains of features between tests were observed in 30.1% (120/399) while losses were observed in 22.1% (88/399). These changes in mutation status may be result of tumor evolution, response to therapeutic intervention, or a combination thereof. A small number of patients (n=23) showed both losses and gains of molecular features over the course of testing revealing insights into the biological evolution of MDS. Efforts are ongoing to gather clinical and cytogenetic data associated with these samples to fully assess changes in IPSS-M scores over time. Conclusion A large proportion (50.1%, 2257/4437) of MDS patients analyzed have molecular findings that allow for further clinical risk stratification. These findings show the benefit of targeting a broad panel of genes using NGS for MDS prognosis and patient risk stratification.

Genetic Testing to Inform Epilepsy Treatment Management From an International Study of Clinical Practice

It is currently unknown how often and in which ways a genetic diagnosis given to a patient with epilepsy is associated with clinical management and outcomes. To evaluate how genetic diagnoses in patients with epilepsy are associated with clinical management and outcomes. This was a retrospective cross-sectional study of patients referred for multigene panel testing between March 18, 2016, and August 3, 2020, with outcomes reported between May and November 2020. The study setting included a commercial genetic testing laboratory and multicenter clinical practices. Patients with epilepsy, regardless of sociodemographic features, who received a pathogenic/likely pathogenic (P/LP) variant were included in the study. Case report forms were completed by all health care professionals. Genetic test results. Clinical management changes after a genetic diagnosis (ie, 1 P/LP variant in autosomal dominant and X-linked diseases; 2 P/LP variants in autosomal recessive diseases) and subsequent patient outcomes as reported by health care professionals on case report forms. Among 418 patients, median (IQR) age at the time of testing was 4 (1-10) years, with an age range of 0 to 52 years, and 53.8% (n = 225) were female individuals. The mean (SD) time from a genetic test order to case report form completion was 595 (368) days (range, 27-1673 days). A genetic diagnosis was associated with changes in clinical management for 208 patients (49.8%) and usually (81.7% of the time) within 3 months of receiving the result. The most common clinical management changes were the addition of a new medication (78 [21.7%]), the initiation of medication (51 [14.2%]), the referral of a patient to a specialist (48 [13.4%]), vigilance for subclinical or extraneurological disease features (46 [12.8%]), and the cessation of a medication (42 [11.7%]). Among 167 patients with follow-up clinical information available (mean [SD] time, 584 [365] days), 125 (74.9%) reported positive outcomes, 108 (64.7%) reported reduction or elimination of seizures, 37 (22.2%) had decreases in the severity of other clinical signs, and 11 (6.6%) had reduced medication adverse effects. A few patients reported worsening of outcomes, including a decline in their condition (20 [12.0%]), increased seizure frequency (6 [3.6%]), and adverse medication effects (3 [1.8%]). No clinical management changes were reported for 178 patients (42.6%). Results of this cross-sectional study suggest that genetic testing of individuals with epilepsy may be materially associated with clinical decision-making and improved patient outcomes.

Fractional Exhaled Nitric Oxide Testing: Change in Clinical Management of Asthma, or Chronic Obstructive Pulmonary

Asthma and chronic obstructive pulmonary disease (COPD) are common airway inflammatory conditions that can present in isolation or a combination known as asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS). Due to similarities in clinical presentation, differentiating these conditions can be challenging. Fractional exhaled nitric oxide (FeNO) is an endogenous molecule that can be elevated in patients with airway inflammation, particularly asthma. The purpose of this study was to determine if FeNO levels can be used to change pharmacologic management (addition, in patients presenting with asthma, COPD, and ACOS. A retrospective chart review of 250 patients underwent FeNO testing; 93 patients were included in the final analysis with their FeNO levels and medications. Out of 76 patients, 34 were prescribed medications of interest (inhaled corticosteroids (ICS), Inhaled corticosteroids - long-acting beta-agonists (ICS-LABA), anticholinergics (AC) monotherapy or combination therapy). After the FeNO testing, the number of patients on ICS therapy doubled (8 to 16), and the number of patients on ICS -LABA increased by 69.2%. Lastly, the number of patients not on medication of interest, 57.1%, ended up on one after FeNO testing. Our results support the utility of FeNO as a viable test to manage patients with obstructive lung disease.

Impact of 18F-FDG-PET/CT on the management of Staphylococcus aureus bacteraemia: a retrospective observational study

ObjectivesTo assess the impact of 18F-FDG-PET/CT on the diagnosis and management of patients with Staphylococcus aureus bacteraemia (SAB). MethodsPost hoc analysis of a prospective cohort of consecutive adult patients diagnosed with SAB (January 2013–December 2017). Patients who underwent 18F-FDG-PET/CT at the discretion of the attending physician were included. Endpoints were the identification of previously unknown infectious foci and changes in clinical management, defined as changes in the duration or class of antibiotic therapy, a surgical procedure on the source of infection or a change in the decision to remove or retain an implantable device. ResultsWe included 39 patients (median age: 69 years, IQR:60–79). Fifteen (39%) patients did not have an infectious focus identified before 18F-FDG-PET/CT). Thirty new infectious foci were detected in 22/39 (56%) patients. In 11/15 (73%) patients without an identified focus at least one infectious focus was detected by 18F-FDG-PET/CT. In 22/26 (85%) patients with implantable devices, 18F-FDG-PET/CT confirmed or ruled out infection or detected local complications. Out of 13 device infections, 10 were detected by 18F-FDG-PET/CT (7/10 for the first time). In 19/39 (49%) patients 18F-FDG-PET/CT results led to changes in clinical management (15 changes in antibiotic therapy, 2 device removals, 2 surgical procedures, 1 avoidance of a surgical procedure). Conclusions18F-FDG-PET/CT may be a useful asset in the management of selected SAB cases, allowing the identification of previously undetected infectious foci and optimization of therapy, particularly in patients with endovascular devices. Indication should be made on a case-by-case basis.

Co-Test im Zervixkarzinom-Screening: Die erste Runde

BackgroundIn 2020 guidelines for an organized screening program for cervical cancer with changes in primary screening and clinical management of conspicuous findings were introduced in Germany.ObjectiveDue to the data deficit, which stems from the central documentation only beginning after a 9-month delay, the results of the complete first screening round from a routine laboratory are evaluated.MaterialIn 2020 all co-test results of women aged 35 years and over were recorded in a pathology practice. The cytological control findings, human papillomavirus (HPV) tests, colposcopy and histological findings were documented.ResultsIn the primary screening a co-test was carried out for 63,615 women. Cytology findings requiring clarification by colposcopy (groups IIp–V of the Munich nomenclature III) were found in 1.96% and the HPV positive rate was 5.82% (1.28% HPV 16, 0.42% HPV 18). When cytologically negative and HPV positive women were examined by the required co-test 12 months later, these findings persisted in 40.6%, in 19.7% positive cytology findings were found. For 973 of the 1378 women positive for co-test, the results of colposcopy are known: 10.2% cervical intraepithelial neoplasia (CIN) 1, 7.8% CIN2, 8.5% CIN3 and 0.21% carcinoma. Of the 1081 women with positive cytology findings in primary screening 979 underwent colposcopy and 19.9% CIN1, 17% CIN2, 25.1% CIN3, 0.41% adenocarcinoma in situ (AIS) and 1.43% invasive carcinoma were diagnosed. Referral for colposcopy solely on persistent positive HPV test yielded CIN3 in 3.6% and for low-risk cytology a total of 6.6%.ConclusionOur data indicate an unfavorable benefit-cost ratio for negative and low-risk cytology. The central program evaluation will show to what extent algorithms should be adapted.

Radiological findings in brain MRI scans in youth with early-onset psychosis: A controlled study

There is a lack of consensus on whether routine brain magnetic resonance imaging (MRI) should be recommended as part of the initial assessment in patients with psychosis. No study so far has qualitatively assessed brain MRI in patients with early-onset psychosis (EOP), in whom neurodevelopmental factors may play a stronger role. We aimed to determine the prevalence of brain MRI findings in patients with EOP compared to healthy controls, and assess whether these findings were clinically relevant. Retrospective clinical chart review of all patients with EOP in whom a brain MRI scan was acquired during admission to an inpatient child and adolescent psychiatry unit during January 2013–December 2017, compared to age and biologically assigned gender matched healthy controls. Between group analyses tested differences in rates of qualitatively abnormal MRI scans and changes in clinical management as a result of radiological findings. A total of 256 individuals were included (128 patients with EOP and 128 healthy controls). Patients with EOP presented with a significantly higher rate of abnormal MRI scans relative to healthy controls (21.9% vs 11.7%, p = .030; OR = 2.11, [95% CI:1.06–4.17]). Radiological findings in the EOP group triggered clinical referral for further evaluation or management more often than in the healthy control group (7.0% vs 1.6%, p = .030; OR = 4.76, [95% CI:1.01–22.50]). MRI scans in youth with EOP may be characterized by an increased number of radiological abnormalities than in controls. The rates of MRI findings requiring clinical referral suggests that routine MRI acquisition may need to be considered in patients with EOP.

Decision Conflicts in Clinical Care during COVID-19: A Multi-Perspective Inquiry.

Background: The early COVID-19-pandemic was characterized by changes in decision making, decision-relevant value systems and the related perception of decisional uncertainties and conflicts resulting in decisional burden and stress. The vulnerability of clinical care professionals to these decisional dilemmas has not been characterized yet. Methods: A cross-sectional questionnaire study (540 patients, 322 physicians and 369 nurses in 11 institutions throughout Germany) was carried out. The inclusion criterion was active involvement in clinical treatment or decision making in oncology or psychiatry during the first year of COVID-19. The questionnaires covered five decision dimensions (conflicts and uncertainty, resources, risk perception, perception of consequences for clinical processes, and the perception of consequences for patients). Data analysis was performed using ANOVA, Pearson rank correlations, and the Chi²-test, and for inferential analysis, nominal logistic regression and tree classification were conducted. Results: Professionals reported changes in clinical management (27.5%) and a higher workload (29.2%), resulting in decisional uncertainty (19.2%) and decisional conflicts (22.7%), with significant differences between professional groups (p < 0.005), including anxiety, depression, loneliness and stress in professional subgroups (p < 0.001). Nominal regression analysis targeting “Decisional Uncertainty” provided a highly significant prediction model (LQ p < 0.001) containing eight variables, and the analysis for “Decisional Conflicts” included six items. The classification rates were 64.4% and 92.7%, respectively. Tree analysis confirmed three levels of determinants. Conclusions: Decisional uncertainty and conflicts during the COVID-19 pandemic were independent of the actual pandemic load. Vulnerable professional groups for the perception of a high number of decisional dilemmas were characterized by individual perception and the psychological framework. Coping and management strategies should target vulnerability, enable the handling of the individual perception of decisional dilemmas and ensure information availability and specific support for younger professionals.

Association of QTc Formula With the Clinical Management of Patients With Cancer

Monitoring of the corrected QT interval (QTc) for patients with cancer receiving chemotherapy is not standardized. Selection of QTc formula may be associated with adverse event grading and chemotherapy delivery. To describe the association of QTc formula selection with adverse event grading and chemotherapy delivery. This retrospective observational cohort study used data from January 2010 to April 2020 and included adult patients seen at the University of North Carolina Cancer Hospital who had an electrocardiogram (ECG) performed. Adjusted QTc using the Bazett, Fridericia, and Framingham formulae. The main outcome was QTc prolongation using the Common Terminology Criteria for Adverse Events (CTCAE). Consistency between formulae was evaluated. Subsequently, appropriateness of clinical management due to prolonged QTc was assessed for a subset of patients being treated with chemotherapy agents associated with a prolonged QT interval. We hypothesized that use of the Bazett formula would be associated with higher rates of QTc prolongation and inappropriate modifications to chemotherapy. A total of 19 955 ECGs from 6881 adult patients (3055 [44.4%] women, 3826 [55.6%] men; median [IQR] age at first ECG, 60 [47-68] years) were analyzed. The percentage of ECGs with grade 3 QTc prolongation differed by formula (all patients: Framingham, 1.8%; Fridericia, 2.8%; and Bazett, 9.0%; patients receiving QT-prolonging chemotherapy [2340 ECGs]: Framingham, 2.7%; Fridericia, 4.5%; and Bazett, 12.5%). The Bazett formula resulted in a median QTc value 26.4 milliseconds higher than Fridericia and 27.8 milliseconds higher than Framingham. Of the 1786 ECGs classified as grade 3 by Bazett, 1446 (81.0%) were grade 2 or less by either Fridericia or Framingham. A total of 5 of 28 (17.9%) evaluated clinical changes associated with prolonged QTc were deemed inappropriate when using either Fridericia or Framingham formula. Findings of this cohort study suggest that the Bazett formula resulted in higher QTc values associated with a 3-fold increase in grade 3 CTCAE toxic effects compared with other common formulae. Use of the Bazett formula likely was associated with inappropriate changes in clinical management. These data support the use of a standard QTc formula (such as Fridericia or Framingham) for QTc correction in oncology.

Development and validation of an early warning model for hospitalized COVID-19 patients: a multi-center retrospective cohort study

BackgroundTimely identification of deteriorating COVID-19 patients is needed to guide changes in clinical management and admission to intensive care units (ICUs). There is significant concern that widely used Early warning scores (EWSs) underestimate illness severity in COVID-19 patients and therefore, we developed an early warning model specifically for COVID-19 patients.MethodsWe retrospectively collected electronic medical record data to extract predictors and used these to fit a random forest model. To simulate the situation in which the model would have been developed after the first and implemented during the second COVID-19 ‘wave’ in the Netherlands, we performed a temporal validation by splitting all included patients into groups admitted before and after August 1, 2020. Furthermore, we propose a method for dynamic model updating to retain model performance over time. We evaluated model discrimination and calibration, performed a decision curve analysis, and quantified the importance of predictors using SHapley Additive exPlanations values.ResultsWe included 3514 COVID-19 patient admissions from six Dutch hospitals between February 2020 and May 2021, and included a total of 18 predictors for model fitting. The model showed a higher discriminative performance in terms of partial area under the receiver operating characteristic curve (0.82 [0.80–0.84]) compared to the National early warning score (0.72 [0.69–0.74]) and the Modified early warning score (0.67 [0.65–0.69]), a greater net benefit over a range of clinically relevant model thresholds, and relatively good calibration (intercept = 0.03 [− 0.09 to 0.14], slope = 0.79 [0.73–0.86]).ConclusionsThis study shows the potential benefit of moving from early warning models for the general inpatient population to models for specific patient groups. Further (independent) validation of the model is needed.

Infection control in cystic fibrosis: evolving perspectives and challenges.

This article reviews the impact of some of the most recent changes in clinical care management in cystic fibrosis on infection prevention practice and advice for people with cystic fibrosis. People with cystic fibrosis (CF) consistently highlight infection control as one of their major concerns. Infection prevention guidance and practice has facilitated successful decreases in rates of many transmissible CF pathogens. The coronavirus disease 2019 pandemic highlighted the clinical significance of respiratory viral infections and has accelerated the implementation of remote monitoring and telemedicine consultations as standard practice in CF. The continued improvement in health of the CF population is being further augmented by the introduction of new therapies, in particular cystic fibrosis transmembrane conductance regulator modulators. Infection prevention will remain pertinent to CF care, but these recent changes in clinical practice will have ongoing implications for infection prevention guidance in CF. Recent changes in CF clinical care have implications that will lead to further evolution of infection control practice and advice.

Utility of Follow-Up Echocardiograms in Uncomplicated PDA Device Closures Performed During Infancy.

Guidelines recommend lifelong follow-up with transthoracic echocardiograms (TTE) for patients who had a patent ductus arteriosus (PDA) device closure via catheterization. The goal of this study was to determine the utility of follow-up TTE in patients who underwent an uncomplicated PDA device closure during infancy. Chart review was performed on patients who had a PDA closure at not more than 1year of age between January1, 2002 and June1, 2020. Patients were excluded if they had other congenital heart disease, did not have a follow-up TTE at least 3months after procedure, or had a velocity greater than 2.0m/s in the left pulmonary artery (LPA) or descending aorta (DAo) on the first TTE at least 3months after device placement. Time points included the first TTE after the procedure, first TTE at least 3months after procedure, and the most recent TTE. Total of 147 infants met the inclusion criteria. Age and weight at initial procedure were 141 ± 217days and 4.2 ± 2.8kg. There was no significant difference in DAo velocity between initial and most recent TTE. LPA velocity and left ventricular diastolic Z score significantly decreased between initial and most recent TTE. Seventy-eight patients had repeat echocardiograms more than 1year after PDA procedure with no change in clinical management. No patient underwent an intervention on the LPA or DAo for stenosis. In patients who underwent an uncomplicated PDA closure during infancy, TTE parameters either stayed stable or improved over time. These findings need to be corroborated in larger studies with longer follow-up. If verified, the long-term TTE guidelines may need to be simplified for this patient population.

Differences in Stakeholders' Perception of the Impact of COVID-19 on Clinical Care and Decision-Making.

Simple SummaryPandemics induce many changes in clinical management. The consequences and extent of these changes are perceived in an individual manner and differ between various stakeholder groups. Using a cross-sectional questionnaire in 11 German institutions we evaluated the different perceptions of related risks and decision-making processes. All the investigated groups share concerns about the impact of the COVID-19 pandemic on healthcare management and clinical processes, but to very different extent. Their perception is dissociated in projection towards other stakeholders. Specific awareness should avoid this dissociation that potentially results in impaired shared decision-making.Background: Pandemics are related to changes in clinical management. Factors that are associated with individual perceptions of related risks and decision-making processes focused on prevention and vaccination, but perceptions of other healthcare consequences are less investigated. Different perceptions of patients, nurses, and physicians on consequences regarding clinical management, decisional criteria, and burden were compared. Study Design: Cross-sectional OnCoVID questionnaire studies. Methods: Data that involved 1231 patients, physicians, and nurses from 11 German institutions that were actively involved in clinical treatment or decision-making in oncology or psychiatry were collected. Multivariate statistical approaches were used to analyze the stakeholder comparisons. Results: A total of 29.2% of professionals reported extensive changes in workload. Professionals in psychiatry returned severe impact of pandemic on all major aspects of their clinical care, but less changes were reported in oncology (p < 0.001). Both patient groups reported much lower recognition of treatment modifications and consequences for their own care. Decisional and pandemic burden was intensively attributed from professionals towards patients, but less in the opposite direction. Conclusions: All of the groups share concerns about the impact of the COVID-19 pandemic on healthcare management and clinical processes, but to very different extent. The perception of changes is dissociated in projection towards other stakeholders. Specific awareness should avoid the dissociated impact perception between patients and professionals potentially resulting in impaired shared decision-making.

Early-onset eating disorders in Australian children: A national surveillance study showing increased incidence.

The aim of this study was to collect prospective national data on early-onset eating disorders (EOEDs) in children in Australia to document changes in clinical presentations, medical complications, management, and incidence since initially described in 2002-2005. Each month pediatricians reported children aged 5-13 years newly diagnosed with an eating disorder to the Australian Paediatric Surveillance Unit and provided de-identified clinical data. Between 2016 and 2018, 184 children were confirmed with EOED with a minimum estimated national incidence of 2.79 per 100,000 children aged 5-13 years (95% confidence interval [CI] 2.40-3.23), nearly double the previously recorded incidence. The mean age at diagnosis was 12.2 years; 43(24%) were boys who were younger than girls (11.85 vs. 12.33 years; p= .03). All had food avoidance. Common symptoms included fear of weight gain 140 (76%), preoccupation with body weight 134 (73%), and misperception of body size 116 (63%). Bradycardia was present in 83 (45%) and 117 (64%) who required hospital admission. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5) criteria for anorexia nervosa were met for 144 (78%). Children with eating disorders continue to present with severe illness. Near doubling in incidence in just over a 10-year period highlights the need for increased clinical resourcing and comparable international data. The incidence of new presentations of eating disorders in children aged 5-13 years has nearly doubled since a similar study was conducted over 10 years ago. Children were unwell for an average of 8 months before diagnosis; approximately 80% had a clear diagnosis of anorexia nervosa and 64% needed hospital admission due to medical complications. This highlights the need for improvements in education and clinical resources for this age group.

Endoscopic Ultrasound Through-The-Needle Biopsy of Pancreatic Cysts: Toward Procedure Standardization

Background and Aims: EUS-guided through-the-needle microforceps biopsy (EUS-TTNB) was introduced as a new diagnostic tool to establish pancreatic cyst histotype and help to better risk stratify the patients. The aim of this study was to describe the technical success, diagnostic yield, and adverse events of through-the-needle biopsy and discuss the technique variations, focusing on future procedure standardization. Methods: We performed a prospective single-center study including patients with presumed mucinous cysts harboring worrisome features or indeterminate cyst type on imaging, submitted to EUS-TTNB using Moray® microforceps between March 2018 and September 2021. Specimens were processed as a cell-block. Results: We included 40 patients. Technical success was 97.5%. The diagnostic yield was 72.5% for TTNB whereas for cyst fluid cytology/analysis it was 27.5%. Moreover, without TTNB 5 mucinous lesions would not have been diagnosed. TTNB had a sensitivity of 76% and a specificity of 91%, while FNA cytology had a sensitivity and specificity of 35% and 91%, respectively. Moreover for IPMN lesions, subtyping was possible in 63% of cases. TTNB resulted in change in clinical management in 20% of patients. We registered three adverse events: 2 self-limited intracystic bleeding and 1 patient with abdominal pain not associated with pancreatitis. Conclusion: TTNB proved superior to cyst fluid analysis and cytology for the definition of cyst histotype and mucinous cyst diagnosis with acceptable risk profile. Further studies should explore the best steps for procedure standardization.

Evaluating a structured applied physics case-based course for radiation oncology and radiation physics residents

Background We supplemented applied physics textbook learning and clinic learning with case-based discussions. The purpose of this study was to review this applied physics course, in terms of structure and teaching evaluations. Methods We reviewed the 6 year applied physics teaching experience (2016-2021) in a multi-hospital site university affiliated accredited training program. A unique component of the course is the intentional inter-professional education, due to the inclusion of both radiation oncology and medical physics learners and faculty. This course ran weekly from September to May for a total of 29 weeks. All sessions were 1 hour long and case based except for 5 didactic sessions. Each session was taught by a pair of faculty members (one radiation oncologist and one medical physicist). The cases in the syllabus were reviewed yearly by teaching faculty and adjusted for updated clinical management and technological changes. A final examination was given to each trainee consisting of 3 clinical case scenarios, with written and oral questions on applied physics concepts learned throughout the course. In 2020 and 2021, during the pandemic, the applied physics course syllabus was shortened to 8 weekly video sessions (2 hour class per week) and given from April to May. Results The number of trainees who took the course ranged from 7-14 per year. Ninety-four percent of trainees passed the final exam. Trainees who did not pass the final exam were given a supplemental exam. Feedback was given to each trainee who did not pass the first exam. All trainees who did not pass the final exam, were successful in passing the supplemental exam. For the years 2016-2021, the mean and median teaching evaluation scores were 4.65 and 5 respectively, where 1 represents the worst teaching quality and 5 represents the best. In 2020-2021, due to the covid-19 pandemic, the teaching evaluations administered included 2 questions regarding the virtual format of the course. For these 2 questions relating to the virtual format of the course, the mean and median responses were 4.14 and 5 respectively. Discussion The structured syllabus of cases, case based questions and discussions were ranked highly by the trainees for teaching effectiveness. The success of this course is also dependent on faculty who demonstrate excellent teaching skills. Our experience indicated that the nature of this course was adaptable to a virtual format and could be useful for small programs without a structured applied physics curriculum. We supplemented applied physics textbook learning and clinic learning with case-based discussions. The purpose of this study was to review this applied physics course, in terms of structure and teaching evaluations. We reviewed the 6 year applied physics teaching experience (2016-2021) in a multi-hospital site university affiliated accredited training program. A unique component of the course is the intentional inter-professional education, due to the inclusion of both radiation oncology and medical physics learners and faculty. This course ran weekly from September to May for a total of 29 weeks. All sessions were 1 hour long and case based except for 5 didactic sessions. Each session was taught by a pair of faculty members (one radiation oncologist and one medical physicist). The cases in the syllabus were reviewed yearly by teaching faculty and adjusted for updated clinical management and technological changes. A final examination was given to each trainee consisting of 3 clinical case scenarios, with written and oral questions on applied physics concepts learned throughout the course. In 2020 and 2021, during the pandemic, the applied physics course syllabus was shortened to 8 weekly video sessions (2 hour class per week) and given from April to May. The number of trainees who took the course ranged from 7-14 per year. Ninety-four percent of trainees passed the final exam. Trainees who did not pass the final exam were given a supplemental exam. Feedback was given to each trainee who did not pass the first exam. All trainees who did not pass the final exam, were successful in passing the supplemental exam. For the years 2016-2021, the mean and median teaching evaluation scores were 4.65 and 5 respectively, where 1 represents the worst teaching quality and 5 represents the best. In 2020-2021, due to the covid-19 pandemic, the teaching evaluations administered included 2 questions regarding the virtual format of the course. For these 2 questions relating to the virtual format of the course, the mean and median responses were 4.14 and 5 respectively. The structured syllabus of cases, case based questions and discussions were ranked highly by the trainees for teaching effectiveness. The success of this course is also dependent on faculty who demonstrate excellent teaching skills. Our experience indicated that the nature of this course was adaptable to a virtual format and could be useful for small programs without a structured applied physics curriculum.

Impact of ultrasound enhancing agents on clinical management.

Ultrasound enhancing agents (UEAs), microbubbles which are composed of lipid or albumin shells containing high molecular weight gases with nonlinear acoustic properties in the ultrasound field, are important components of the diagnostic armamentarium in echocardiography. This review highlights the substantial value of UEAs in delineating endocardial border definition and influencing downstream decision-making in cardiovascular ultrasound. In this article, we review recent updates to the clinical applications of UEAs, special circumstances regarding use, the impact of use on downstream testing and cost-effectiveness, and recommended approaches for optimizing workflow in the echocardiography laboratory with UEAs. In multiple studies, UEAs have been identified as a useful tool in echocardiography, improving study accuracy and reader confidence, while reducing downstream testing and procedures and resulting in significant changes in clinical management. Despite their proven efficacy and cost-effectiveness, recent studies have suggested utilization remains low, in part due to perceived concerns and workflow issues that impair uptake. With an increasingly broader list of indications for echocardiography, UEAs will continue to play an important role in the diagnosis and management of patients with cardiovascular and noncardiovascular diseases.

Image-guided percutaneous bone biopsy for pediatric osteomyelitis: correlating MRI findings, tissue pathology and culture, and effect on clinical management.

Bone biopsy remains the gold standard for diagnosis of osteomyelitis while MRI results in a radiologic diagnosis that generally precedes biopsy. This study's purpose is to examine the diagnostic yield and effect of biopsy results on clinical management in children with suspected osteomyelitis and positive MRI findings. A retrospective review was performed at a tertiary care children's hospital. Search of the EMR and radiology PACS identified patients below 18years who underwent bone biopsy with interventional radiology for osteomyelitis and had positive MRI findings for osteomyelitis prior to biopsy. Data was collected on patient demographics, MRI findings, biopsy procedural details, tissue culture, histopathology results, and clinical management before and after biopsy. Changes in management were categorized as antibiotic type/quantity, duration, or diagnosis. A total of 82 biopsies in 79 patients with suspicion for osteomyelitis and positive MRIs prior to biopsy were performed over 5years from 2014 to 2019. All biopsies were successful and sent for tissue culture. 22/82 biopsies (27%) yielded positive cultures. Of those with tissue cultures, 16/22 (72%) resulted in change in clinical management. Of all biopsies, 18/82 (22%) resulted in a change in management (15 antibiotic, 1 duration, 2 diagnosis). The 2 changes in diagnosis included one biopsy done which was positive for cancer and a second which was found to not demonstrate osteomyelitis on histology. In the pediatric population, bone biopsy is a reasonably low morbidity procedure. However, there is a relatively low rate of positive tissue cultures even with MRI findings suspicious for osteomyelitis. Approximately 1 in 5 biopsies resulted in a change in clinical management, mostly in antibiotic selection. Bone biopsy may have a higher clinical impact in pre-specified circumstances.

Special issue "The advance of solid tumor research in China": 68Ga-PSMA-11 PET/CT for evaluating primary and metastatic lesions in different histological subtypes of renal cell carcinoma.

Conventional imaging examinations are not sensitive enough for the early detection of recurrent or metastatic lesions in renal cell carcinoma (RCC) patients. We aimed to explore the role of 68 Ga-prostate specific membrane antigen (PSMA)-11 positron emission tomography (PET)/computed tomography (CT) in the detection of primary and metastatic lesions in such patients. We retrospectively analyzed 50 RCC patients who underwent 68 Ga-PSMA-11 PET/CT from November 2017 to December 2020. We observed a higher median accuracy and tumor-to-background maximum standard uptake value (SUVmax ) ratio (TBR) of 68 Ga-PSMA-11 PET/CT in clear cell RCC (ccRCC; 96.57% and 6.00, respectively) than in non-clear cell RCC (ncRCC; 82.05% and 2.99, respectively). The accuracies in detecting lesions in the renal region, bone, lymph nodes and lungs in ccRCC were 100.00%, 95.00%, 98.08% and 75.00%, respectively, and those in the renal region, bone and lymph nodes in ncRCC were 100.00%, 86.67% and 36.36%, respectively. The median TBRs of the lesions from the above locations were 0.38, 10.96, 6.69 and 13.71, respectively, in ccRCC and 0.13, 4.02 and 0.73, respectively, in ncRCC. The PSMA score evaluated with immunohistochemistry was correlated with the SUVmax (P=.046) in RCC. Higher PSMA scores were observed in ccRCC than in ncRCC (P=.031). 68 Ga-PSMA-11 PET/CT resulted in changes in clinical management in 12.9% (4/31) of cases because of the discovery of new metastases not detected with conventional imaging. These results indicate that 68 Ga-PSMA-11 PET/CT is a promising method for the detection of metastatic lesions in ccRCC, especially for those in the bone and lymph nodes.