Delay In Administration Research Articles

Door-to-Needle Time for Administration of Antibiotic in Children with Cancer Within the Golden Hour- an Audit from a Tertiary Cancer Hospital in a Low-Middle Income Country

Abstract Background Fever neutropenia (FN) is the commonest complication during treatment in children with cancer. Most guidelines recommend administration of intravenous antibiotics within 60 minutes of presentation to the Emergency Room (ER) to minimize life threatening complications of FN(1). We performed a 3-month audit at our ER to see if this target was being met(2). The departmental FN management policy was revised and implemented from February 2021 based on the prevailing hospital antibiogram. All children undergoing treatment in the Paediatric Oncology Department are provided with written FN Alerts/Advice (Fig. 1). All patient prescriptions include instructions on antibiotic choice and dosage. Annual educational sessions are held with the ER staff and Paediatric Oncology Residents. A stock of essential antibiotics is maintained in the ER. Methods All children on chemotherapy or radiotherapy presenting to ER with fever (≥38°C) either at home or documented at ER had blood counts and blood cultures sent both from a peripheral vein and the indwelling central venous device (if present). The first dose of antibiotics as prescribed was administered without waiting for the blood count report or assessment by the Clinician. Time of patient’s arrival at ER and time of administration of the first antibiotic dose were obtained from ER nursing records and patient drug cards. Data was entered prospectively within 24 hours and tabulated for analysis on Microsoft Excel. Fig.1: Fever Neutropenia Sticker on Patient File Results Eighty-four children presented with 129 episodes of fever during the audit period (1st April 2022-30th June 2022). Median age was 6.4 years (IQR 3.1,12). Median time interval from last chemotherapy was 6 days (IQR 2,10). All children reporting to ER were seen by a Clinician, with 106 (82%) episodes seen within 30 minutes of reporting (median 15 minutes, IQR 5,21). All children received initial intravenous antibiotics after blood sampling. Median door-to-needle time was 45 minutes (IQR 35,60 minutes) There were 2 deaths in this cohort, one due to cancer progression and the other due to an unidentified infection of the central nervous system. Conclusions Over 80% children received the first dose of antibiotics within the target of <60 minutes. There were no deaths attributable to sepsis. Though the outcome was excellent in this cohort, we need to analyse the reasons for delay in administration of the first antibiotic dose and take remedial measures to improve compliance.

QLTI-10. STANDARD WORK FOR ORAL CHEMOTHERAPY IMPROVES SAFETY WITHOUT INCREASING DELAYS

Abstract Purpose Oral chemotherapy in the outpatient setting does not have the same level of oversight as chemotherapies delivered in an infusion treatment area. This project aimed to create a standardized process to prescribe outpatient oral chemotherapy to improve patient safety. The primary process-measure was laboratory data review prior to ordering therapy, with primary outcome-measure being number of days between approval to administer therapy and actual administration. A secondary process-measure was documentation quality, and counterbalance-measure was delay in ordering due to lab review. METHODS A Failure Mode Effects Analysis was performed. Standard work was developed for each step of prescribing and roles and responsibilities were assigned for each step in the process. A checklist was developed within the medical record to review and document essential steps in the process allowing for greater visibility. Fifty-three patient encounters were reviewed prior to intervention and 39 post-intervention. RESULTS FMEA identified 7 high-risk points. For the primary process measure, prior to intervention, 34/53 (64%) encounters had laboratory data review prior to chemotherapy order. After intervention, 38/39 (97%). The change did not delay ordering; we observed a mean 2-day delay between laboratory data review and chemotherapy order (significant difference from zero [p = 0.001]) pre-intervention. After intervention, there was no statistically significant delay (mean -0.74 days, p = 0.376). Documentation improved after intervention; 23/53 (43%) chemotherapy encounters contained complete data pre-intervention, and 36/39 encounters (92%) post-intervention. CONCLUSIONS As part of our standardized process, we developed a new chemotherapy checklist and flowsheet in the medical record. While the fraction of patients with zero delay in chemotherapy administration after approval did not change, patient safety improved with more patients having laboratory review prior to chemotherapy order. This review did not increase delays in ordering therapy. Documentation quality also improved. Having a standard process increases patient safety while prescribing outpatient oral chemotherapy.

Improving Parkinson's Medicine Administration in Hospitals: The Impact of an Out-of-Hours Drug Box.

Background Parkinson'sdisease (PD) is a progressive neurodegenerative condition characterised by the loss of dopaminergic neurons and the presence of Lewy bodies. PD medications, notably Levodopa, are critical in controlling patients' symptoms and improving their quality of life. These medications are time-critical, and a delay in administration can have a negative impact on a patient's mobility, quality of life and symptoms. Objective The objective of this quality improvement project (QIP) was to (1) determine the occurrence and underlying factors contributing to delays in PD medication administration at Huddersfield Royal Infirmary and (2) evaluate the impact of subsequent interventions in improving the administration of time-critical PD medications. Methods A total of 20 patients were recruited from Ward 5, a care of the elderly ward, at Huddersfield Royal Infirmary for the entire duration of this QIP; 10 in the pre-intervention phase and 10 for the post-intervention phase one month following the implementation of three interventions: 'Parkinson's Drug Box', ward-based teaching and a hospital-wide screensaver reminder. Datawascollected from the electronic patient record (EPR) to determine and compare the following measures before and after the interventions: the percentage of PD medications administered within the 30-minuterecommendedwindow, the admission-to-medication reconciliation time, scheduled-to-actual dose administration time, and factors causing delays. Results Following the implementation of three interventions, the percentage of patients receiving PD medications within the recommended 30-minute window doubled, increasing from 10% to 20%. Moreover, the average delay in patients receiving their initial PD medication dose decreased from 7.8 hours to 3.7 hours. The percentage of patients experiencing medication delays due to stock shortages also dropped from 50% to 10%. Conclusions Earlier medicines reconciliation and the availability of time-critical drugs out of hours are both key factors in helping to ensure PD medication is administered on time in hospitals. Staff education and a 'Parkinson's Drug Box' are two relatively simple measures that have resulted in improved outcomes for Parkinson's inpatients.

Reversal of pre-injury factor-Xa inhibitors with prothrombin complex concentrates in patients following traumatic brain injury

IntroductionThere is substantial debate on the best method to reverse factor Xa-inhibitors in patients following traumatic brain injury (TBI). Prothrombin complex concentrates (PCC) have been used for this indication but their role has been questioned. This study reported failure rates with PCC in patients following TBI and as a secondary objective, compared 4-factor (4 F-PCC) and activated PCC (APCC). Material and methodsConsecutive patients with TBI on factor Xa-inhibitors admitted to one of two trauma centers were retrospectively identified. Patients with penetrating TBI, delays in PCC administration (>6 h), receipt of tranexamic acid, factor VIIa or no follow up CT-scan were excluded. The primary outcome was treatment failure defined as hematoma expansion > 20% from baseline for SDH, EDH or IPH, a new hematoma not present on the initial CT scan or any expansion of a SAH or IVH. Hematoma expansion was further categorized as symptomatic or asymptomatic, designated by a change in the motor GCS score, neurologic exam or change ≥ 3 in NIH Stroke Scale. Multi-variate analysis was performed. ResultsThere were 43 patients with a mean age of 77 ± 13 years with primarily mild TBI (95%) after a ground level fall (79%). The mean dose was 41 ± 12 units/kg. Sixty percent received 4 F-PCC and 40% APCC. The incidence of treatment failure was 28% (12/43). Of the 12 patients with hematoma expansion, only 3 were symptomatic (9.3%). Hematoma expansion with 4 F-PCC and APCC were similar (27% vs. 29%,p = .859). Only sex was associated with hematoma expansion on multivariate analysis [OR (95% CI) = 6.7 (1.1 – 40.9)]. ConclusionPCC was an effective option for factor Xa inhibitor reversal following TBI. The relationship between radiographic expansion and clinical expansion was poor.

Cumulative Incidence and Characteristics of Infections Requiring Treatment, Delay in Treatment Administration or Hospitalisation in Patients with Relapsed or Refractory Multiple Myeloma Treated with Anti BCMA or Anti GPRC5D Bispecific Antibodies

Background. Bispecific antibodies (BsAb) are a new effective treatment for relapsed/refractory multiple myeloma (RRMM). Although these immunotherapies are well tolerated, infectious complications emerged as a predominant issue, mainly with anti-BCMA BsAb. Recent guidelines were presented to prevent and manage these complications based on clinical trials safety signals. In this study, we aimed to report incidence and characteristics of infectious complications in patients treated with anti-BCMA and anti-GPRC5D BsAb. Methods. A retrospective study was conducted in 13 tertiary centers including patients with RRMM treated by BsAb between December 2020 and February 2023. We reported infectious complications events requiring specific treatment, delay in BsAb administration or hospitalisation and occurring up to three months after interruption of treatment. Results. Among the 229 patients included, 200 (87%) received an anti-BCMA BsAb with teclistamab (n=153, 67%) or elranatamab (n=47, 20%) and 29 patients (13%) received an anti-GPRC5D BsAb with talquetamab. 40% (n=90) of patients were treated in monotherapy, 42% (n=94) had dexamethasone in addition to the BsAb after step up doses and 18% (n=41) received a combination with an anti CD38, immunomodulatory treatment, proteasome inhibitor or other. The median age was 67 years (range 38-85), median of prior line of therapy was 4 (range 0-15). 62 (32%) patients had a high cytogenetic risk and 187 (82%) had a triple refractory disease. With a median follow up of 7 months (IQR 4-12 months) 234 infectious events were documented in 142 patients (62%) including 53% grade ≥ 3 and 8.4% (n=19) deaths due to infection. All infections grade ≥ 4 (n= 48; 20.6%) occurred in patients treated with anti-BCMA BsAb. Predominant localisation was pulmonary tract (n= 97, 41%) and disseminated infection (n=52, 22%) . Among the documented infections, 91 (55%) were bacterial, 64 (39%) were viral and 8 (5%) were fungal (Figure 1A). Two (1.2%) infectious events were from a parasite. Most frequent pathogens were Enterobacteriaceae (n=28, 12%), SARS-CoV-2 (n=19, 8%), anaerobic bacteria (n=10, 4%) Pseudomonas aeroginosa (n=6, 2.5%). Invasive pulmonary aspergillosis was found in 6 (2.5%) patients, and 2 (1.2%) event was PML (progressive multifocal leukoencephalopathy) and 1 (0.6%) was disseminated toxoplasmosis. Hospitalization rate was 57% (n=131), including 13% (n=30) requiring intensive care with a median hospitalization time of 10 (range 1-111) days. Overall, n=113 (47%) of the infectious events had an impact on the course of treatment. Illustrated by interruption in n=31 (14%) events, delayed administration in n=70 (32%) events or change in frequency of administration in 2 (0.9%) events. Considering immunosuppression, 125 (68%) of these infections occurred in patients associated with hypogammaglobulinemia (<3 g/L) and 22% (n=50) in patients supplemented with intravenous immunoglobulin. Regarding infectious prophylaxis, n=104 (47%) infectious events occurred despite a bacterial prophylaxis (n=104), 91% (n=125) occurred under viral prophylaxis, 73% (n=166) with trimethoprim-sulfamethoxazole or atovaquone and 11% (n=25) with pentamidine use. Global cumulative incidence of first infection was 70% in all patients, 73% in patients treated with anti-BCMA and 51% with anti-GPR5CD. Treatment with anti-GPRC5D BsAb was independently associated with a lower risk of first infection in a multivariate model adjusted for infectious prophylaxis, and hypogammaglobulinemia, HR 0.43 (IC95% 0.23; 0.77); p=0.005 (Figure 1B). Conclusion. This study highlights the rate of infectious event with BsAb treatment in RRMM setting. We describe higher frequency of infections in patients receiving anti-BCMA agents compare to anti-GPRC5D group. Impact on treatment administration is huge and dosing intervals strategy and prophylaxis appear necessary and effective to improve the morbidity and mortality rate of this hightly effective agents.

Oncology Care at Home: A Patient-Centered Approach to Managing Care for Bone Marrow Transplant and CAR-T Cell Therapy Patients

Introduction. More than half of patients with cancer who receive cytotoxic chemotherapy and/or immunotherapies experience deleterious side effects such as febrile neutropenia, infection, neurotoxicity, and cytokine release syndrome. Early intervention and treatment for these side effects can help avoid complications and improve outcomes, but delays in treatment administration are common as most outpatient management approaches depend on patient self-assessment and patient-initiated pursuit of follow-up care. Remote patient monitoring through digital health technologies offers the opportunity to bridge this gap without imposing undue burden on either patients or healthcare providers. This feasibility study assessed the results of a technology-assisted in-home oncology care program to remotely monitor bone marrow transplant and CAR T-cell therapy patients and provide early intervention for symptomatic episodes needing clinical management. The program also offered support for patients to obtain routine lab draws, hydration, antiemetics, intravenous antibiotics, and a provider assessment at home. Technical and operational feasibility were evaluated together with perceived user experience among patients, caregivers, and providers. Methods. Ten patients between 18-89 years old participated in the study for up to 90 days following allogeneic bone marrow transplant and up to 30 days following CAR T-cell therapy or autologous bone marrow transplant. Patients used continuous-wear biometric sensors for passive vital sign monitoring around the clock seven days per week and engaged with a chatbot by SMS text for health status checks and symptom reporting. Scheduled home care was administered by licensed home health providers. Virtual care center personnel evaluated patient status based on wearable data and patient messaging and followed up directly with patients or engaged patients' treating clinicians for notification and management of urgent issues as needed. Patients and caregivers were asked to complete surveys about their experience with and perceptions of the program at midpoint and study completion, while providers were asked to complete end-of-study surveys to capture their perspectives across all patients. Patients were also asked to participate in brief interviews at study midpoint and at the end of the study. Interim Results. Eighty percent of patients participated in the program as intended through wearing devices and responding to engagement prompts. Wearable sensors detected a total of 184 outpatient alerts from patients between April and July 2023, of which 57 led to follow up with patients, 12 required further follow up with the clinical care team, and 5 required follow up care in a clinical setting due to elevated temperature or respiratory rate. Sixty percent of patients responded more than 50% of the time to requested health assessment surveys. Patient engagement with the chatbot and symptom reporting system led to 48 events needing virtual care team follow up, of which 20 were to answer patient questions and 28 were in response to reports of concerning symptoms. A total of 11 events were further referred by the virtual care team to the clinical care team, of which 5 required follow up care in a clinical setting. Study data collection will complete in August 2023. Initial Conclusions. Technology-assisted remote patient monitoring is feasible for use with bone marrow transplant and CAR T-cell therapy patients at home. Successful integration with clinical practice settings requires tailoring to existing workflows. Further assessment of patient acceptance for short-term versus long-term monitoring is recommended.

Use of Prephase Steroids in Older Patients Treated for Diffuse Large B-Cell Lymphoma

Background Treatment related morbidity and mortality (TRM) are significant contributors to overall morbidity and mortality for elderly patients with diffuse large B-cell lymphoma (DLBCL). Several studies have shown that TRM is greatest during the first two cycles of treatment. While attenuated doses of standard-of-care treatment regimens (such as R-mini-CHOP) are commonly used to reduce TRM, one additional strategy that has shown promise is the use of glucocorticoids prior to initiation of systemic chemoimmunotherapy (CIT). This approach, defined as prephase steroid use, has been evaluated in small studies, primarily single-center and retrospective in nature. However, older patients with comorbidities are both at greatest risk of TRM and less frequently included in clinical trials. Moreover, patient populations may differ across clinical settings. We conducted an analysis of prephase steroid use in a broader, real-world population treated across multiple centers. Methods We used longitudinal data from the US nationwide, Flatiron Health electronic health record-derived de-identified database. We included patients aged >60 with a diagnosis of DLBCL treated with CIT. This included high-grade B-cell lymphoma, but omitted diagnoses of Burkitt's or primary CNS lymphoma. We utilized a prespecified data analysis plan to determine whether outcomes differed by our exposure of interest, use of prephase steroids. The primary outcome measure was the combined endpoint of time to start of next treatment or death (real-world time to next treatment [rwTTNT]). The secondary outcome was real-world overall survival (rwOS). Outcomes were measured from frontline treatment start date. We also assessed rates of dose delays to evaluate whether prephase steroid use facilitates the maintenance of dose intensity. Prephase steroid use (the exposure) was defined as an order or administration for steroids occurring 5-21 days prior to the start of antineoplastic therapy (excluding steroids used as part of a standard treatment regimen). Patients were stratified by use of anthracycline-based CIT, with sensitivity analyses conducted limited to the anthracycline CIT group. To reduce confounding, we used propensity score-based inverse probability of treatment weighting (IPTW) for the primary analysis. Time to event endpoints were assessed using weighted Kaplan-Meier curves and log-rank tests. Odds of dose delays were assessed using weighted logistic regression. Results We included 3587 patients meeting our criteria, of whom 569 (15.9%) received prephase steroids prior to first-line CIT. A greater percentage of patients treated with anthracycline-based CIT received prephase steroids as compared to those treated with non-anthracyline CIT: 16.3% vs 12.4%, respectively (Table 1). In adjusted analysis using IPTW, there was no significant difference in the rwTTNT by prephase steroid use (p=0.807, Figure 1). Median rwTTNT was 41.2 months (95% CI, 34.6 to 52.4) vs 40.8 months (95% CI, 35.1 to 46.7) with and without prephase steroids, respectively. There was no difference in median rwOS by prephase steroid use: 65.7 months (95% CI, 52.4 to 84.8) vs 74.8 months (95% CI, 67.4 to 82.5) (p=0.707). No differences were seen in sensitivity analyses limiting to patients treated with anthracycline-based CIT. For dose delays, adjusted analysis showed a numerically lower odds of dose delay in patients administered prephase steroids in the total study population: 40.6% vs 50.7% (OR 0.796; p=0.0569). Discussion In this retrospective study of 3587 real-world, elderly patients with DLBCL, prephase steroid use within 21 days of induction CIT did not improve the rwTTNT or rwOS. There was a suggestion that use of prephase steroids may promote maintenance of dose intensity by reducing delays in CIT administration, though this finding did not reach statistical significance. The strengths of this analysis included use of a large, nationwide, real-world dataset and propensity score methods to control for confounding. Limitations include the retrospective nature of the study and potential for unmeasured confounding. In summary, in a real-world cohort of older patients with DLBCL, use of prephase steroids was not associated either with longer TTNT/death, or with longer OS. However, it may be associated with maintenance of CIT dose intensity. This finding is worth exploring in future studies.

Barriers to and facilitators of effective management of fever episodes in hospitalised Kenyan children with cancer: protocol for convergent mixed methods study

IntroductionFebrile neutropenia is an oncological emergency in children with cancer, associated with serious infections and complications. In low-resourced settings, death from infections in children with cancer is 20 times higher...

Evaluation of Antiviral Activity of Ivermectin against Infectious Bovine Rhinotracheitis Virus in Rabbit Model.

Infectious bovine rhinotracheitis (IBR) caused by bovine herpes virus 1 (BoHV-1) can lead to enormous economic losses in the cattle industry. Vaccine immunization is preferentially used to decrease its transmission speed and resultant clinical signs, rather than to completely stop viral infection. Therefore, a drug effective in treating IBR is urgently needed. Our previous work demonstrated that ivermectin significantly inhibited viral replication in a cell infection model. This study aimed to investigate its antiviral effects in vivo by using a rabbit infection model. The viral inhibition assay was first used to confirm that ivermectin at low concentrations (6-25 nM) could reduce viral titers (TCID50) significantly (p < 0.001) at 24 h post-infection. In rabbits, ivermectin was administrated with one to three doses, based on the recommended anti-parasite treatment dosage (0.2 mg/kg bodyweight) through subcutaneous injection at different days post-infection in the treated IBRV infection groups, while non-treated infection group was used as the control. The infected rabbits showed hyperthermia and other clinical signs, but the number of high-fever rabbits in the ivermectin treatment groups was significantly lower than that in the non-treated infection group. Furthermore, in ivermectin treatment groups, the cumulative clinical scores correlated negatively with drug doses and positively with delay of administration time post-infection. The overall nasal shedding time in ivermectin-treated groups was two days shorter than the non-treated challenge group. At the same time point, the titer of neutralizing antibodies in the treatment group with triple doses was higher than the other two-dose groups, but the difference between the treatment groups decreased with the delay of drug administration. Correspondingly, the serious extent of lung lesions was negatively related to the dosage, but positively related to the delay of drug administration. The qPCR with tissue homogenates showed that the virus was present in both the lung tissues and trigeminals of the infected rabbits. In conclusion, ivermectin treatment had therapeutic effect by decreasing clinical signs and viral shedding, but could not stop virus proliferation in lung tissues and trigeminals.

Surfactant delivery strategies to prevent bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) is one of the most devastating morbidities of preterm infants. Antenatal factors like growth restriction and inflammation are risk factors for its development. Use of oxygen and positive pressure ventilation, which are often necessary to treat respiratory distress syndrome (RDS), increase the risk for development of BPD. Continuous positive airway pressure (CPAP) as primary respiratory support allows for avoidance of positive pressure ventilation in many cases but may lead to a delay of surfactant administration which is a proven therapy for RDS. Several alternative surfactant delivery strategies, including nebulization of surfactant, pharyngeal instillation of surfactant, delivery of surfactant via supraglottic airway device or surfactant delivery via a thin endotracheal catheter have been described which allow for the benefit of surfactant therapy while on CPAP. This review reports available data and discusses the existing evidence of their value in preventing BPD as well as further research directions.

Clinical Outcomes Associated With Overestimation of Oxygen Saturation by Pulse Oximetry in Patients Hospitalized With COVID-19

Many pulse oximeters have been shown to overestimate oxygen saturation in persons of color, and this phenomenon has potential clinical implications. The relationship between overestimation of oxygen saturation with timing of COVID-19 medication delivery and clinical outcomes remains unknown. To investigate the association between overestimation of oxygen saturation by pulse oximetry and delay in administration of COVID-19 therapy, hospital length of stay, risk of hospital readmission, and in-hospital mortality. This cohort study included patients hospitalized for COVID-19 at 186 acute care facilities in the US with at least 1 functional arterial oxygen saturation (SaO2) measurement between March 2020 and October 2021. A subset of patients were admitted after July 1, 2020, without immediate need for COVID-19 therapy based on pulse oximeter saturation (SpO2 levels of 94% or higher without supplemental oxygen). Self-reported race and ethnicity, difference between concurrent SaO2 and pulse oximeter saturation (SpO2) within 10 minutes, and initially unrecognized need for COVID-19 therapy (first SaO2 reading below 94% despite SpO2 levels of 94% or above). The association of race and ethnicity with degree of pulse oximeter measurement error (SpO2 - SaO2) and odds of unrecognized need for COVID-19 therapy were determined using linear mixed-effects models. Associations of initially unrecognized need for treatment with time to receipt of therapy (remdesivir or dexamethasone), in-hospital mortality, 30-day hospital readmission, and length of stay were evaluated using mixed-effects models. All models accounted for demographics, clinical characteristics, and hospital site. Effect modification by race and ethnicity was evaluated using interaction terms. Among 24 504 patients with concurrent SpO2 and SaO2 measurements (mean [SD] age, 63.9 [15.8] years; 10 263 female [41.9%]; 3922 Black [16.0%], 7895 Hispanic [32.2%], 2554 Asian, Native American or Alaskan Native, Hawaiian or Pacific Islander, or another race or ethnicity [10.4%], and 10 133 White [41.4%]), pulse oximetry overestimated SaO2 for Black (adjusted mean difference, 0.93 [95% CI, 0.74-1.12] percentage points), Hispanic (0.49 [95% CI, 0.34-0.63] percentage points), and other (0.53 [95% CI, 0.35-0.72] percentage points) patients compared with White patients. In a subset of 8635 patients with a concurrent SpO2 - SaO2 pair without immediate need for COVID-19 therapy, Black patients were significantly more likely to have pulse oximetry values that masked an indication for COVID-19 therapy compared with White patients (adjusted odds ratio [aOR], 1.65; 95% CI, 1.33-2.03). Patients with an unrecognized need for COVID-19 therapy were 10% less likely to receive COVID-19 therapy (adjusted hazard ratio, 0.90; 95% CI, 0.83-0.97) and higher odds of readmission (aOR, 2.41; 95% CI, 1.39-4.18) regardless of race (P for interaction = .45 and P = .14, respectively). There was no association of unrecognized need for COVID-19 therapy with in-hospital mortality (aOR, 0.84; 95% CI, 0.71-1.01) or length of stay (mean difference, -1.4 days; 95% CI, -3.1 to 0.2 days). In this cohort study, overestimation of oxygen saturation by pulse oximetry led to delayed delivery of COVID-19 therapy and higher probability of readmission regardless of race. Black patients were more likely to have unrecognized need for therapy with potential implications for population-level health disparities.

The outcomes of cardiopulmonary resuscitation and their predictors during the coronavirus 2019 pandemic in Iran

BackgroundCoronavirus disease 2019 (COVID-19) can negatively affect different healthcare-related outcomes. Nonetheless, there is limited information about its effects on different healthcare-related outcomes. This study aimed at evaluating the outcomes of cardiopulmonary resuscitation (CPR) and their predictors during the COVID-19 pandemic in Iran.MethodsThis cross-sectional study was conducted on 1253 patients who had undergone CPR in the emergency wards of teaching hospitals in the west of Iran from the beginning of the first wave to the end of the third epidemic wave of COVID-19 in Iran, between February 20, 2020, and January 20, 2021. Data were collected using the National CPR Documentation Forms developed based on the Utstein Style and routinely used for all patients with cardiac arrest (CA). The SPSS (v. 20.0) program was used to analyze the data through the Chi-square, Fisher’s exact, and Mann-Whitney U tests and logistic regression analysis.ResultsParticipants’ age mean was 64.62 ± 17.54 years. Age mean among participants with COVID-19 was eight years more than other participants. Most participants were male (64.09%) and had at least one underlying disease (64.99%). The total rates of the return of spontaneous circulation (ROSC) and CPR–discharge survival were respectively 15.3% and 3.8% among all participants, 20.25% and 5.17% among participants without COVID-19, and 8.96% and 2.04% among participants with COVID-19. The significant predictors of ROSC were age, affliction by COVID-19, affliction by underlying diseases, baseline rhythm, delay in epinephrine administration, and epinephrine administration time interval, while the significant predictors of CPR–discharge survival were age and baseline rhythm.ConclusionsThe total rates of ROSC and CPR–discharge survival were respectively 15.3% and 3.8% among all participants. The rates of ROSC and CPR to discharge survival among patients without COVID-19 are respectively 2.26 and 2.53 times more than the rates among patients with COVID-19.

Impact of Physician Dual Practices on a Pediatric-Oncology Outreach-Program.

Physician dual practices (PDP) can be defined as 'doctors combining clinical work in public and private health-sector.' This study explores the impact of PDP on a long-term pediatric-oncology outreach-program between large referral hospitals in the Netherlands, Indonesia and Kenya. This cross-sectional descriptive study used a self-administered semi-structured survey. The most senior doctor from each partner site was interviewed in June 2022. The survey contained 70 closed-ended and 7 open-ended questions and took 30-45 minutes to complete. Closed-ended questions were evaluated on 2-5 point rating scales. Informed consent was acquired and respondents endorsed the final report. In the Netherlands an estimated 0-20% of senior doctors combine work in public and private-sector, while 60-80% do so in Indonesia and Kenya according to the respondents. In Indonesia and Kenya, most of doctors are involved in PDP to augment low government salaries. Impact of PDP on pediatric-oncology care is minimal in the Netherlands, but detrimental in Indonesia and Kenya: shortage of experienced doctors, limited supervision of junior staff, slow diagnostics and delays in chemotherapy administration ultimately lead to undermining of the quality of care and adverse patient outcomes. PDP adversely impact patient care at the Indonesian and Kenyan partner sites of a pediatric-oncology outreach-program. Strategies addressing PDP in resource-poor settings are required to improve treatment outcomes and survival of children with cancer.

Timing of antibiotics in febrile children meeting sepsis criteria at a paediatric emergency department.

Delay in antibiotic administration in paediatric sepsis is associated with increased mortality and prolonged organ dysfunction. This pre-intervention study evaluated performance in paediatric sepsis management. Retrospective cohort study of febrile children admitted through the ED at The Children's Hospital at Westmead, Sydney, between 1 May and 31 July 2017. Participants were children aged 29 days to 60 months excluding children with simple febrile seizures, neonates and children who had received intravenous antibiotics elsewhere. We assessed the timing of antibiotic administration in children meeting local sepsis guidelines. We conducted a survey of clinicians in ED in 2018 to describe contributing factors. There were 160 febrile children admitted and 144 presentations were included in the analysis. Male 53% (n = 76); median age 20.1 months (interquartile range [IQR] 3.9-37 months). Thirty-seven (26%) febrile children met local sepsis criteria. The median time from triage to first dose of intravenous antibiotic was 109 min (IQR 62-183 min). Delay (>60 min) occurred in 26 (76%) children. Reported reasons contributing to delay included high patient load, long waiting times, difficult intravenous access, delayed prescribing, inadequate staffing and difficulty distinguishing between a viral infection and serious bacterial infection. There was frequent delay in administering antibiotics in children meeting local sepsis criteria, more commonly in young infants. Reasons contributing to delay were specific to young children along with departmental factors that will require addressing through targeted quality improvement interventions.

Development and clinical application of a tool to identify frailty in elderly patients with gynecological cancers

ObjectiveFrailty is more reliable than chronological age in predicting the effectiveness and tolerability of treatments in cancer patients. An increasing number of screening tools have been proposed, however none have...

Challenges in care of snake envenomation in rural Pakistan: a narrative review

Snake envenomation remains a neglected tropical disease in Pakistan per the World Health Organization, with approximately 40,000 bites and 8,200 fatalities annually. To understand the factors leading to increased mortality, we performed a narrative review of the medical literature pertaining to snake envenomation in Pakistan and surrounding countries. Several factors have led to increased mortality in rural communities. First, geographical variations in snake venom composition between countries lead to a decreased efficacy of polyvalent antivenom in Pakistan that is produced using snake species from different areas. Furthermore, healthcare providers in rural communities are inadequately trained on antivenom dosing regimens or adverse reactions. Long transport times and the use of traditional healers lead to delays in administration of antivenom. Additionally, many types of antivenom must be stored at 2-8 degrees Celsius. Lack of refrigeration to store antivenom limits access in rural locations. Research advances are being developed to create new generations of antivenom that may be better suited for rural communities. Lastly, increased educational efforts may further reduce mortality.

P34 Gentamicin labels: improving the timing of gentamicin levels and reducing delay in dose administrations

Abstract Background Due to its narrow therapeutic index and significant risks of ototoxicity and nephrotoxicity, gentamicin requires meticulous prescribing, administration and monitoring. Despite readily available guidelines, gentamicin use continues to be associated with errors, with recent Datix reports within NHS Lothian recording incidents such as incorrectly prescribed doses or frequencies, missed levels, and delayed or omitted doses. In response to this, an audit was undertaken to investigate errors in gentamicin use within the Acute Medical Unit (AMU) at the Royal Infirmary of Edinburgh and evaluate the barriers to adherence to guidelines to unearth possible areas for improvement. Methods The initial audit studied patients prescribed gentamicin in AMU within a 3-week period, excluding those who received prophylactic or single one-off doses of gentamicin. The following parameters were examined both on their paper and electronic prescribing charts: (i) dose, (ii) dosing interval/frequency, (iii) time of level sampling, and (iv) administration times of the first and second gentamicin doses. After identifying issues with delayed gentamicin levels and subsequent dose administration times, we introduced the use of gentamicin labels in each AMU bay, in hopes of increasing staff awareness towards patients on gentamicin, thereby promoting timely level sampling and dose administration. The aforementioned parameters were re-audited for a further 3 weeks following this intervention. Results The baseline audit highlighted that only 23/31 (74%) patients had levels taken within the recommended window, and 23/31 (74%) received their second gentamicin doses at the right time. Following the introduction of the gentamicin labels, the second audit observed a slight improvement, with 31/40 (78%) patients having their levels taken within the recommended window, and 30/40 (75%) patients receiving their subsequent doses at the right interval. Noteworthily, in both the pre- and post-intervention groups, the majority of patients who had their second doses delayed received their first doses in the emergency department (ED) prior to admission to AMU. Conclusions In addition to improving staff awareness towards patients on gentamicin, a further overarching issue needs to be addressed: the delays in gentamicin administration which more commonly occurs for patients who transition from ED into AMU. Further interventions should therefore target improving the handover of time-critical medicines between ED and AMU.

Ocrelizumab extended-interval dosing in multiple sclerosis during SARS-CoV-2 pandemic: a real-world experience.

During the COVID-19 pandemic, ocrelizumab administration was frequently postponed because of a lack of safety information and to favour vaccination. The clinical implications of ocrelizumab administration delay in multiple sclerosis (MS) patients were assessed. Relapsing (RMS) and primary progressive (PPMS) MS patients receiving ocrelizumab for at least 6 months at our centre were retrospectively classified, according to the possible occurrence of a delay (≥4 weeks) in treatment administration. Patients were categorized in the extended-interval dosing (EID) group in the presence of at least one delayed infusion; otherwise they were considered as part of the standard interval dosing (SID) cohort. MS history, magnetic resonance imaging examinations and B-cell counts were also retrospectively collected and analysed. A total of 213 RMS and 61 PPMS patients were enrolled; 115 RMS and 29 PPMS patients had been treated according to the SID regimen, whilst 98 RMS and 32 PPMS patients were included in the EID cohort. Average follow-up after delay was 1.28 ± 0.7 years in the EID cohort. In RMS, comparing SID and EID patients, no differences were found considering the occurrence of clinical relapses (9.6% vs. 16.3%, p = 0.338), magnetic resonance imaging activity (9.8% vs. 14.1%, p = 0.374) or disability progression (11.3% vs. 18.4%, p = 0.103). Similar findings were observed in PPMS patients. In the pooled EID group, treatment delay correlated with CD19-positive relative (r = 0.530, p < 0.001) and absolute (r = 0.491, p < 0.001) cell counts, without implications on disease activity. Sporadic ocrelizumab administration delay granted sustained treatment efficacy in our cohort. Prospective data should be obtained to confirm these observations and set up systematic extended-interval regimens.

Factors associated with mortality after snakebite envenoming in children: a scoping review.

Snakebite envenoming is an important public health issue in many tropical and subtropical countries, where the burden of morbidity and mortality falls particularly on impoverished rural communities. Children are an especially vulnerable group. This scoping review provides an overview of the extent, type and content of peer-reviewed evidence regarding factors associated with mortality in snakebite-envenomed children. A comprehensive literature search of MEDLINE and the Global Index Medicus yielded 623 articles, of which 15 met the criteria for inclusion; 67% of studies were conducted in India, with the remaining studies taking place in Papua New Guinea, Morocco and The Gambia. There was a notable scarcity of eligible studies from sub-Saharan Africa and Latin America despite the high burden of envenoming in these regions. The risk factors for mortality that were identified by the greatest number of studies were younger patient age (n=4), delay in administration of antivenom (n=4) and acute kidney injury (n=3). Identification of poor prognostic factors can assist clinicians in making timely referrals to centres with paediatric critical care capability. Future research must address the lack of studies from key geographical regions so that evidence-based improvements to the care of this vulnerable group can be implemented.

Elaborate biologic approval process delays care of patients with moderate-to-severe asthma.

mAbs (biologics) are indicated in patients with poorly controlled moderate-to-severe asthma. The process of prior authorization and administration of a biologic requires exceptional commitment from clinical teams. Our aim was to evaluate the process of approval and administration of biologics for asthma and determine the most common reasons associated with denials of biologics and delays in administration. We examined the records of patients with asthma who were prescribed biologics from January 2018 to January 2020 at 2 centers, Montefiore Medical Center (Bronx, NY) and Scripps Clinics (San Diego, Calif). Demographics, insurance information, and details on the approval process were collected. After querying of electronic health records, the records of 352 and 70 patients with moderate-to-severe asthma were included from Montefiore and Scripps, respectively. Most patients at Montefiore (58.2%) were insured under Managed Care Medicaid (MC Medicaid), whereas most patients at Scripps (61.4%) had commercial insurance. The median times from prescription to administration of a biologic were similar: 34 days (interquartile range [IQR]= 18-63 days) and 34 days (IQR= 22.5-56.0 days) (P= .97) for Montefiore and Scripps, respectively. However, the median approval time for Montefiore was 6 days (IQR= 1-20 days) and that for Scripps was 22 days (IQR= 10-36 days) (P< .001). Approval times for prescriptions requiring appeals were significantly longer than for prescriptions approved after the initial submission: 23 days versus 2.5 days and 40.5 days versus 15.5 days (for Montefiore and Scripps, respectively [P< .001 for both]). Lengthy appeals contribute to delays between prescribing and administering a biologic. Site-specific practices and insurance coverage influence approval timing of the biologics for asthma.