Departmental Protocol Research Articles

Aspirin monotherapy is a suitable standard thromboprophylactic agent following total hip arthroplasty.

Aspirin is increasingly recognised as an efficacious thromboprophylactic agent with a superior safety profile compared to alternatives. Following our institution's previously published experience we implemented a risk-stratified protocol utilising aspirin as standard. We now present retrospective review of standard use of aspirin on fatal pulmonary embolism, all-cause mortality, and venous thromboembolism (VTE) following total hip arthroplasty (THA). A consecutive series of elective THAs was identified. Prospectively maintained databases were analysed to yield demographic data and identify deaths or readmission data. Patients who died within 90 postoperative days underwent review of the complete medical record. 4204 THAs were included in the study cohort. VTE prophylaxis prescription was available in 3805. 2560 received aspirin (67.3%), 1049 enoxaparin (27.6%) and 193 warfarin (5.1%); there were no differences in 90-day all-cause mortality (p = 0.780) or VTE (p = 1) between groups. Our large series continues to demonstrate that aspirin for thromboprophylaxis following THA is effective in risk-stratified patients. Furthermore, we demonstrate that introduction of a departmental protocol establishing aspirin as standard practice was not associated with increased mortality or incidence of thromboembolism. Taken in conjunction with our previous cohort our series encompasses 11,420 consecutive THAs. There has been a single death following fatal PE in the aspirin group (0.02%) compared to 5 in the LMWH group (0.2%) and 1 in the warfarin group (0.06%). We join calls for large-scale randomised controlled trials to elucidate the place of aspirin in VTE prevention following hip arthroplasty.

Protocol driven periprocedural anticoagulation for left atrial ablation.

A weight-based heparin dosing policy adjusted for preprocedural oral anticoagulation was implemented to reduce the likelihood of subtherapeutic dosing during left atrial catheter ablation procedures. We hypothesized that initiation of the protocol would result in a greater prevalence of therapeutic activated clotting time (ACT) values and decreased time to therapeutic ACT during left atrial ablation procedures. A departmental protocol was initiated for which subjects received intravenous unfractionated heparin (UFH) to achieve and maintain a goal of ACT >300 s. Initial bolus dose was adjusted for pre-procedure oral anticoagulation and weight as follows: 50 units/kg for those receiving warfarin, 75 units/kg for those not anticoagulated, and 120 units/kg for those on direct oral anticoagulants (DOACs). A UFH infusion was initiated at 10% of the bolus per hour. One hundred consecutive left atrial ablation procedures treated with Protocol Guided heparin dosing were compared with a retrospective consecutive cohort of Usual Care heparin dosing. When the Usual Care and Protocol Guided cohorts were compared, significant findings were limited to those on pre-procedure DOAC. The initial UFH bolus increased from 99.3 ± 24.8 to 118.2 ± 22.8 units/kg (p < .001), the proportion of therapeutic ACT on the first draw after heparin administration increased from 57.7% to 76.6% (p = .010), and the time to therapeutic ACT after UFH administration decreased from 37.8 ± 19.8 to 30.2 ± 16.4 min (p = .032). A weight-based protocol for periprocedural UFH administration resulted in a higher proportion of therapeutic ACT values and decreased the time to therapeutic ACT for those on pre-procedure DOAC.

474 Does timing of triple I diagnosis during labor has influence on maternal and neonatal outcomes?

To assess the impact of the timing of suspected TRIPLE I (intra-amniotic infection) diagnosis during term labor on maternal and neonatal complications rate A retrospective cohort study (6/2015-3/2019) of women who had a body temperature measurement ≥38°C during term labor (≥37 wks). Women were retrospectively classified into “isolated maternal fever” (IMF) or “suspected triple I" (III) according to the 2017 ACOG criteria. Those with III were further grouped according to the timing of diagnosis during labor: 1st stage or 2nd stage. Composite maternal and neonatal complications rates (Table 1) were compared between groups Out of the 27,344 deliveries during the study period, 595 women (2.17%) met the inclusion criteria, of whom, 93 (15.6%) had IMF and 502 (84.4%) had IiI. Of women with IiI, 324 (64.5%) were diagnosed in the 1st stage and 178 (35.5%) during the 2nd stage of labor, all received empiric antibiotics per the department protocol. Compared to women diagnosed during the 1st stage, those diagnosed during the 2nd stage of labor had a lower Cesarean delivery (CD) rate (29.3% vs. 6.7%, respectively; p<0.001) and a lower composite maternal complications rate (17.6% vs.10.1%, respectively; p=0.026). When only women who had a vaginal delivery were included (to control the difference in the CD rate), this difference did not remain significant between the groups (1st stage: 14.4% vs. 2nd stage: 10.2%, p=0.28). The composite neonatal complications rate didn't differ significantly between the groups (1st stage: 13.3% vs. 2nd stage: 9.6%, p=0.25). Although women diagnosed during the 2nd stage of labor had a significantly lower composite maternal complications rate, this difference disappeared when only vaginal deliveries were included to control the expected difference in the CD rates between groups. Similarly, there were no significant differences in the composite neonatal complications rate. Collectively, these data suggest that once III has been detected during labor and antibiotic treatment was given, its duration has limited impact on maternal and neonatal outcomes.

The Use of In Situ Simulation to Enhance COVID-19 Pandemic Preparedness in Obstetrics.

Simulation’s benefits in medical education are well established. However, its use for pandemic preparedness in obstetrics is lacking. Management of obstetrical patients with suspected COVID-19 infection is a complex task with safety considerations for mother, fetus and healthcare workers. Implementation of new workflow algorithms to ensure safety is critical but is challenging to implement in real-time. We sought to improve pandemic preparedness by designing and deploying a high-fidelity simulation exercise involving the admission of a labouring obstetrical patient with suspected COVID-19 into a labour room, urgent transfer to the operating room and neonatal resuscitation. The creation of the simulation scenario was a multi-disciplinary effort with input from a focus group of key clinical stakeholders from within and outside of our centre to ensure clinical validity. Simulations were performed on the clinical unit during regular work hours so workflow could be observed in real-time with access to the equipment and personnel in which this clinical scenario would occur. We completed a total of 11 simulation sessions involving 42 participants. Feedback, obtained from debrief sessions and anonymous surveys, was categorized based on the human factors framework, and used as part of an iterative process to adapt, revise and improve the simulation scenario. The result of this iterative process was the creation of validated departmental infection control protocols that continue to be implemented through the second wave of the COVID-19 pandemic.

Addressing the Need of a Translational Approach in Peripheral Neuropathy Research: Morphology Meets Function.

Peripheral neuropathies (PNs) are a type of common disease that hampers the quality of life of affected people. Treatment, in most cases, is just symptomatic and often ineffective. To improve drug discovery in this field, preclinical evidence is warranted. In vivo rodent models allow a multiparametric approach to test new therapeutic strategies, since they can allow pathogenetic and morphological studies different from the clinical setting. However, human readouts are warranted to promptly translate data from the bench to the bedside. A feasible solution would be neurophysiology, performed similarly at both sides. We describe a simple protocol that reproduces the standard clinical protocol of a neurophysiology hospital department. We devised the optimal montage for sensory and motor recordings (neurography) in mice, and we also implemented F wave testing and a short electromyography (EMG) protocol at rest. We challenged this algorithm by comparing control animals (BALB/c mice) with a model of mild neuropathy to grasp even subtle changes. The neurophysiological results were confirmed with neuropathology. The treatment group showed all expected alterations. Moreover, the neurophysiology matched the neuropathological analyses. Therefore, our protocol can be suggested to promptly translate data from the bench to the bedside and vice versa.

Prioritizing Delivery of Cancer Treatment During a COVID-19 Lockdown: The Experience of a Clinical Oncology Service in India.

PURPOSEA COVID-19 lockdown in India posed significant challenges to the continuation of radiotherapy (RT) and systemic therapy services. Although several COVID-19 service guidelines have been promulgated, implementation data are yet unavailable. We performed a comprehensive audit of the implementation of services in a clinical oncology department.METHODSA departmental protocol of priority-based treatment guidance was developed, and a departmental staff rotation policy was implemented. Data were collected for the period of lockdown on outpatient visits, starting, and delivery of RT and systemic therapy. Adherence to protocol was audited, and factors affecting change from pre-COVID standards analyzed by multivariate logistic regression.RESULTSOutpatient consults dropped by 58%. Planned RT starts were implemented in 90%, 100%, 92%, 90%, and 75% of priority level 1-5 patients. Although 17% had a deferred start, the median time to start of adjuvant RT and overall treatment times were maintained. Concurrent chemotherapy was administered in 89% of those eligible. Systemic therapy was administered to 84.5% of planned patients. However, 33% and 57% of curative and palliative patients had modifications in cycle duration or deferrals. The patient’s inability to come was the most common reason for RT or ST deviation. Factors independently associated with a change from pre-COVID practice was priority-level allocation for RT and age and palliative intent for systemic therapy.CONCLUSIONDespite significant access limitations, a planned priority-based system of delivery of treatment could be implemented.

Outcome of Elastic Stable Intramedullary Nailing (ESIN) for tibia fractures in children.

Objectives: To determine outcome in displaced tibial shaft fracture in children treated with elastic stable intra-medullary nailing. Study Design: Descriptive, Case Series study. Setting: Department of Orthopedic, Bahawal Victoria Hospital, Bahawalpur, HBS Medical &amp; Dental College, Islamabad and HITEC-IMS Taxila Cantt, Pakistan. Period: 2012 to 2019. Material &amp; Methods: A total of 62 cases of displaced tibial shaft fracture presenting within 7 days of the injury, 6 to 11 years of age of either gender were included. Patients with segmental tibial shaft fractures and open tibial shaft fractures, Gustilo Grade II &amp; III were excluded. The titanium elastic nails system (TENS) was used in all patients according to the departmental protocols. The sampling technique was consecutive with non-probability. All the patients were followed up in OPD at 2 weeks interval up to 24 weeks after surgery and union of fracture was recorded at 24th week. Results: Mean age was8.55 ± 1.77 years. Out of these 62 patients, 45 (72.58%) were male and 17 (27.42%) were females with ratio of 2.65:1. Mean duration of fracture was 3.10 ± 1.95 days. Mean duration of union in displaced tibial shaft fracture in children treated with elastic stable intra-medullary nailing was 19.40 ± 3.35 weeks. Conclusion: This study concluded that use of elastic stable intra-medullary nailing for displaced tibial shaft fracture in children leads to shorter duration of union reliably with minimal complications.

Active Surveillance—Is It Feasible for Intermediate-risk Localised Prostate Cancer?

BackgroundAlthough active surveillance (AS) is a well-recognised treatment option for localised low-risk prostate cancer (LRPC), its role in the management of localised intermediate-risk prostate cancer (IRPC) is not clear yet and the available literature is slightly contradictory. ObjectiveTo compare the outcome of AS between LRPC and IRPC patients. Design, setting, and participantsBetween November 2002 and August 2019, 372 men with localised prostate cancer (PC) underwent AS in our hospital based on local departmental protocol. Outcome measurements and statistical analysisThe primary outcome measures were overall survival, disease progression–free survival, treatment-free survival, and biochemical recurrence–free survival. Survival times in the low- and intermediate-risk groups were compared using Cox regression analysis. Results and limitationsOut of 372 localised PC patients, 276 (74%) had LRPC and 96 (26%) IRPC. Overall, 86 (31.2%) low-risk and 25 (26%) intermediate-risk patients developed disease progression, and 86 (31.2%) low-risk and 22 (23%) intermediate-risk patients underwent active treatment. Among the treated patients, eight (2.9%) LRPC patients and one (1%) IRPC patient developed biochemical recurrence. In total, only one patient (from the low-risk group) had metastasis and 25 patients passed away (18 from the low-risk and seven from the intermediate-risk group). No death was recorded due to PC in the cohort. There was no difference in any of the survival outcomes between LRPC and IRPC patients in unadjusted analysis as well as when analysis was performed after adjusting the potentially confounding factors. Limitations include relatively short median follow-up time and failure to objectively define the criteria for the selection of IRPC patients suitable for AS. ConclusionsThe option of AS could be considered for carefully selected and well-informed patients with IRPC provided close structured monitoring is maintained. Patient summaryIn this report, we looked at various survival outcomes of active surveillance between low- and intermediate-risk prostate cancer patients in a large British population. There was no difference in any of the survival outcomes between the two groups. We concluded that carefully selected intermediate-risk prostate cancer patients could be offed the option of active surveillance.

Comparison of longterm exocrine and endocrine function following duct to mucosa versus dunking pancreaticojejunostomy in pancreaticoduodenectomy

Aim: Though survival following Pancreaticoduodenectomy (PD) has improved, long term impairment of exocrine and endocrine function remains problematic. This study aims at evaluating any difference in long term pancreatic function between those who underwent Duct to Mucosa Vs. Dunking PJ (pancreaticojejunostomy) following PD. Methodology: Patients who underwent PD between the year 2010-18 and were disease free on follow up were evaluated. Patients with chronic pancreatitis were excluded. All survivors beyond 18 months were evaluated for their pancreatic exocrine (Fecal Elastase-1) and endocrine (FBS/PPBS; HbA1c) function as per the Departmental protocol. The risk of developing nutritional impairment was assessed using the Mini Nutritional Assessment (MNA®) tool and by Serum albumin and Hemoglobin. Results: 136 patients satisfied the inclusion criteria. 30 day mortality was 5, 26 had expired and 53 were lost to follow up. Of the remaining 52 who were evaluated, 32 had dunking PJ, 20 had duct to mucosa PJ. Exocrine insufficiency was present in 29/32(90.6%) of dunking PJ and 17/20(85%) of duct to mucosa PJ (P = 0.24). 11(34.4%) & 4 (20%) had endocrine insufficiency in dunking and duct to mucosa groups respectively (P=0.21). Endocrine insufficiency was significantly higher in adjuvant chemoradiotherapy group (P=0.04). The relative risk of developing nutritional impairment in presence of severe pancreatic exocrine insufficiency was 2.68. Conclusion: Exocrine and Endocrine dysfunction post PD can occur irrespective of the type of pancreatic anastomosis and is comparable between the two groups. There appears to be a significant risk of nutritional impairment post PD.

Correlation of Neurocortical Atrophy Scores on Imaging with Mini-Mental Status Examination

Introduction: The term “Cognitive impairment” is used for decline of memory and behaviour, depicting its progressive nature, of which the most common cause is Alzheimer’s followed by vascular injury. Magnetic Resonance Imaging (MRI) and Mini-Mental State Examination (MMSE) together have an established role to identify aetiology and also to distinguish normal ageing from demented patients. Final diagnosis by brain biopsy is an invasive method, hence structural MRI scores are used to differentiate and characterise the course and prognosis of disease. Aim: This study was done to correlate the various imaging scores of dementia like Schelten’s, Davies-Mattis-Kipps, Fazekas, Pasquier and Koedam scores with the severity of cognitive impairment on MMSE scores. Materials and Methods: It was a cross-sectional study done on 100 patients based on purposive sampling techniques of exclusion and inclusion criteria. All patients above 18 years of age referred for the evaluation of cognitive impairment were included after taking informed and written consent. Magnetic Resonance Imaging (MRI) Brain was performed using a 1.5 T MRI scanner (PHILIPS ACHIEVA 16 channel system) as per the department protocol. The axis was taken perpendicular to long axis of hippocampus on sagittal, and perpendicular to the commissures intersecting the mamillary bodies on coronal. The MMSE and lobar cortical atrophy scores (Schelten’s, Davies- Mattis-Kipps, Fazekas, Pasquier and Koedam) were recorded for each patient and imaging diagnosis was made. The data was then analysed for statistics. Frequency percentage distribution of range of MMSE, Pearson Coefficient of Correlation and Fisher’s exact test, Chi-squared Test and Sig. (2-tailed) correlation were used. Statistical measurement was done using Statistical Package for Social Sciences (SPSS), version 21. Results: There was statistically significant association (p&lt;0.05) between Schelten’s and Mattis imaging scores with MMSE. This determines that there exists relationship between degree of cognitive impairment and neurodegeneration predominantly temporal lobe. However, linear coefficient of correlation (r&gt;0.3) was noted between MMSE severity and Schelten’s, Davies-Mattis-Kipps and Fazekas grading. This determines that there is a moderately positive linear relationship between the two variables. Conclusion: MRI Brain is the investigation of choice in patients with cognitive impairment to categorise the patients based on aetiology and stage the disease that could be misdiagnosed on clinical assessment alone. MRI also diagnoses stage of dementia that affects the prognosis and outcome of the patient. Patients with cognitive impairment irrespective of MMSE score severity need to undergo neuroimaging that helps in improvising patient management at the earliest.

Orthopaedic surgeon in Covid-19 pandemic: Indian scenario

COVID-19 pandemic has revolutionized global healthcare in an unprecedented way with unimaginable consequences. SARS-CoV-2 has spread worldwide and WHO declared it a pandemic on March 11th, 20201,2. Hospitals have been restructured to provide the best care to COVID-19 patients while adhering to preventive strategies not to increase infection spread. Due to huge burden on healthcare services, COVID-19 has even affected specialities that are indirectly related to its clinical effects such as orthopedic surgery.. Healthcare providers have been recruited in COVID-19 management despite their original specialty. Indications for elective treatments have been reprioritized. Outpatient department protocols have been restructured to reduce contacts between patients and the hospital staff. Orthopaedic patient management has also been significantly affected by the pandemic. In this review, our aim is to analyze how Indian orthopaedic practice has been affected by COVID-19 pandemic crisis. Attention has been given to enlist surgical indication, perioperative care and safe management of both inpatients and outpatients.

986. Improvement in Administration of HIV Post-Exposure Prophylaxis in the Emergency Department Following Sexual Assault

BackgroundNonoccupational post exposure prophylaxis (nPEP) following sexual assault can prevent HIV transmission. A standardized Emergency Department (ED) protocol for evaluation, treatment, and follow up for post assault victims was implemented to improve compliance with CDC nPEP guidelines.MethodsA single-center observational study of post sexual assault patients before/after implementation of an ED nPEP protocol was conducted by comparing the appropriateness of prescriptions, labs, and necessary follow up. A standardized order-set based on CDC nPEP guidelines, with involvement of an HIV pharmacist and ID clinic, was implemented during the 2018-2019 academic year. Clinical data from pre-intervention period (07/2016-06/2017) was compared to post-intervention period (07/2018-08/2019) following a 1-year washout period.ResultsDuring the study, 147 post-sexual assault patients (59 Pre, 88 Post) were included. One hundred thirty-three (90.4%) were female, 68 (46.6%) were African American and 133 (90.4%) were candidates for nPEP. Median time to presentation following assault was 12.6 hours. nPEP was offered to 40 (67.8%) and 84 (95.5%) patients (P< 0.001) and ultimately prescribed to 29 (49.2%) and 71 (80.7%) patients (P< 0.001) in pre and post periods respectively.Renal function (37.3% vs 88.6%; P< 0.001), pregnancy (39.0% vs 79.6%; P< 0.001), syphilis (3.4% vs 89.8%; P< 0.001), hepatitis B (15.3% vs 95.5%; P< 0.001) and hepatitis C (27.1% vs 94.3%) screening occurred more frequently during the post period.Labratory, nPEP Prescription and Follow up Details for Patients Prescribed nPEP ConclusionThe standardization of an nPEP ED protocol for sexual assault victims resulted in increased nPEP administration, appropriateness of prescription, screening for other sexually transmitted infectious and scheduling follow up care. While guideline compliance dramatically improved, further interventions are likely warranted in this vulnerable population.DisclosuresRyan K. Dare, MD, MS, Accelerate Diagnostics, Inc (Research Grant or Support)

“Is surgery delayed surgery denied?”- How we managed hepatobiliary pancreatic surgeries among Bangladeshi patients during COVID-19 era

Background: Corona virus disease 2019 (COVID-19) is a disease entity caused by the Severe Acute Respiratory Syndrome coronavirus 2 (SARS COV-2). Although it is not a surgical disease, it significantly influences the management of surgical illness in many ways. Delaying the surgery may be considered as denying the treatment. Authorities all over the world formulated different guidelines and recommendations. Considering current pandemic situation and our patients, we are performing surgeries following our hospital and departmental protocol. Delaying the surgery may negate the treatment and may influence the overall outcome that seem like justice delayed justice denied.&#x0D; Methods: In this prospective observational study, we observed different management approaches to 100 Bangladeshi individuals with hepatobiliary and pancreatic surgical disorders from April 2020 to September 2020, in BIRDEM General Hospital and other hospitals of Dhaka. Patients were thoroughly screened, evaluated and prepared to plan the appropriate management strategy. They were triaged according to presentation and were managed accordingly. Patients consented were only enrolled in this study.&#x0D; Results: The study includes 100 consecutive patients between ages of 21 and 70 years, of them, 77 patients were 4th and 6th decade and only 11 patients (11%) were in 3rd decade of life. Highest 28 patients (28%) were in between 40-49 years and 26 patients in 50-59 years age group. We found 48 patients (48 %) were male and 52 patients (52%) were female. Study showed a slight female predominance and presented at an earlier age than male. The pandemic has created a panic in the society, we were getting less number of patients for HPB surgery in March. Since the end of April 2020 onwards and from July, August and September we have performed 39 surgeries.&#x0D; Conclusion: This article is based on real-time experiences of Hepato-biliary-Pancreatic surgery department of BIRDEM General Hospital and BRB hospitals, Dhaka by the same surgical team. Our experience with COVID-19 positive surgical patients is not gratifying. Modern imaging techniques ensure early detection with better understanding of magnitude of disease, which is essential for proper treatment planning.. Both elective and emergency surgeries can be performed safely with proper precautions. Patients with bridging procedures responded well to planed definitive management. Strategies like neoadjuvant therapy and endotherapies for planned definitive surgical care ensures promising results. Postoperative pneumonia in COVID-19 detected patients is a challenging complication. Optimal management strategy requires a multidisciplinary approach for successful outcome.&#x0D; Birdem Med J 2020; 10, COVID Supplement: 63-70

The proportion of computed tomography kidneys, ureters and bladder (CTKUB) scans that comply with scan extent protocol in an emergency department: a clinical audit and dose ramification study.

IntroductionTo assess computed tomography kidneys, ureters and bladder (CTKUB) scan extent protocol compliance and associated doses in the Emergency Department (ED) of an Australian tertiary hospital.MethodsA retrospective clinical audit of 150 consecutive ED CTKUB cases was completed. For each patient, scan extent compliance at the superior (kidneys) and inferior (pubic symphysis) borders, in reference to the protocol was recorded. Compliance and non‐compliance (over‐/under‐scanning) was identified, described (superior/inferior), quantified (via IMPAX measurements) and recorded via a purpose‐built audit tool. In addition, a PBU40 phantom was scanned to assess the percentage of dose (DLP) increase per centimetre of over‐scanning to contextualise results.ResultsA notable non‐compliance with department protocol was noted. Eight cases (5.3%) demonstrated overall CT scan extent compliance. The remaining 142 cases (94.7%) demonstrated some form of non‐compliance; superiorly, inferiorly or both. Analysing the 150 superior and 150 inferior data points independently, the most common non‐compliance was over‐scanning at the kidneys by 4 cm to5 cm (19 cases, ~10% extra DLP) beyond tolerance and over‐scanning inferiorly at the pubic symphysis by 1 cm to 2 cm (29 cases, ~6.4% extra DLP). Estimated dose increases of up to 35% to 45% were found when clinical audit results were simulated using a PBU40.ConclusionsOver‐scanning is a predominant occurrence in CTKUB scans in this department. Reasons for over‐scanning weren't investigated. It's anticipated this audit will lead to greater awareness of scan extent compliance and dose ramifications of non‐compliance. The usage of more easily identified anatomical landmarks and a follow‐up audit is suggested.

Fecal impaction is associated with postoperative urinary retention after hip fracture surgery.

Postoperative urinary retention (POUR) is a common hip fracture (HF) complication. Although fecal impaction (FI) is one of the oft-cited causes of POUR in clinical practice, evidence regarding this association is scarce. The aim of this study was to determine whether FI was associated with POUR after HF surgery in older patients. All patients consecutively admitted after a HF surgery in a geriatric perioperative unit were included in this cross-sectional study. FI was systematically assessed by a digital rectal exam at admission and according to clinical suspicion during the hospital stay. The dependent variable was POUR, systematically screened according to the department protocol and defined as a bladder volume>400ml requiring catheterization. The association between FI and POUR was assessed by multivariable analysis. A total of 256 patients were included (mean [SD] age 86 [6] years), (76% women): 108 (42%) presented FI and 63 (25%) POUR. The frequency of FI was higher with than without POUR (73% vs. 32%, P<0.001). On multivariable analysis, after adjusting for age, sex, Cumulative Illness Rating Scale score and anticholinergic load, FI was the only factor independently associated with POUR (odds ratio 4.78) [95% confidence interval 2.44-9.71], P<0.001. FI was the only independent factor associated with POUR after HF surgery in older adults. Further studies are needed to optimize perioperative geriatric care including FI and POUR assessment and management.

Dose assessment in high dose rate brachytherapy with cobalt-60 source for cervical cancer treatment: a phantom study

Abstract Transition from low dose rate brachytherapy to high dose rate brachytherapy at our department necessitated the performance of dose verification test, which served as an end-to-end quality assurance procedure to verify and validate dose delivery in intracavitary brachytherapy of the cervix and the vaginal walls based on the Manchester system. An in-house water phantom was designed and constructed from Perspex sheets to represent the cervix region of a standard adult patient. The phantom was used to verify the whole dose delivery chain such as calibration of the cobalt-60 source in use, applicator, and source localization method, the output of treatment planning with dedicated treatment planning system, and actual dose delivery process. Since the above factors would influence the final dose delivered, doses were measured with calibrated gafchromic EBT3 films at various points within the in-house phantom for a number of clinical implants that were used to treat a patient based on departmental protocol. The measured doses were compared to those of the treatment planning system. The discrepancies between measured doses and their corresponding calculated doses obtained with the treatment planning system ranged from -29.67 to 40.34% (mean of ±13.27%). These compared similarly to other studies.

Diagnostic Computed Tomography Enabled Planning for Palliative Radiation Therapy: Removing the Need for a Planning Computed Tomography Scan

PurposeThis study aimed to investigate the feasibility of using diagnostic computed tomography (dCT) for palliative radiation planning, removing the need for a planning computed tomography (pCT) scan. Methods and materialsA sequential 2-stage study was performed. Stage 1 was a retrospective analysis of 150 patients’ dCTs and pCTs to review potential barriers to radiation planning, as well as assess the field of view (FOV), patient positioning, couch curvature, and Hounsfield unit (HU) variation, and its dosimetric impact. Stage 2 was a clinical implementation of dCT planning into the clinical care path. Eligible patients were simulated per the standard department protocol in the dCT position. Treatment was planned on the dCT and replicated on the pCT as a backup and comparator. The dCT plan was delivered with cone beam computed tomography (CT) image guidance. After treatment, the delivered plan was recalculated on the modified dCT to compare planned with delivered planning target volume (PTV) dose. ResultsPositron emission tomography-CT imaging was the most suited for diagnostic treatment planning. Metastases in the pelvis, abdomen, thoracic, and lumbar spines were the most reproducible. A curved, full-body vac-bag was designed to enable better replication of the posterior body curvature of dCT for treatment. There was minimal variation in mean HU from dCT to pCT scans. Dose difference due to HU variation in the thorax region due to the low-density tissue had the greatest variation. All patients in stage 2 (n = 30) were successfully treated using the dCT plan. Dosimetric evaluations were conducted comparing dCT and modified dCT plans, with the 95% dose coverage change in PTV between –2% to +2.5%. ConclusionsFor palliative patients with bony and soft-tissue metastases, clinically acceptable plans can be produced using dCT. Diagnostic position can be replicated at treatment, eliminating the need for pCT with implications for streamlining and improving care for patients who require palliative radiation therapy.

NCOG-01. STEREOTACTIC RADIOSURGERY FOR BRAIN METASTASES AT THE GUY’S CANCER CENTER, LONDON: AN AUDIT FOR THE FIRST 17 MONTHS

Abstract INTRODUCTION Stereotactic radiosurgery (SRS) commenced at Guy’s Cancer Hospital in August 2017. We report our first seventeen months’ data (August 2017 to December 2018) for brain metastases SRS. METHOD Patients referred via Neuro Oncology MDT were assessed for suitability for SRS via clinical review and 1mm-slice MRI. Treatment was planned on Eclipse v15.6 and delivered using Truebeam STx Linac(FFF) and Align RT v5.1 for matching. Dose prescription, according to departmental protocol, was set at 100% isodose, ranging from 18Gy to 25Gy, with fractionation varying from single to five fractions depending on factors including size, volume and locations. Post-treatment, patients were discharged back to their primary treating team for 3-monthly MRI. RESULTS Between Aug-17 to Dec-18, 70 patients with brain metastases were treated with a total of 122 lesions. Mean age was 66 years (range 37-93) and Median follow-up 9 months. Primary tumour sites mainly included lung 34(48.5%), breast 16(22.8%) and melanoma 17(24.3%). Brain-only metastases, including small volume primary with brain metastases were found in 85.4% cases, whilst visceral disease with brain metastases were found in 14.5% patients. Out of 122 lesions, the majority were treated in the primary setting; 95(77.8%) vs 27(22.1%) in the adjuvant setting. At 9-months follow up, local failure rate was in 26(21.3%) sites and 17 new sites in distant brain appeared. 31(44.2%) patients received no systemic therapy after SRS, whilst immunotherapy was received by 14(20%), with the remaining receiving hormones or chemotherapy. Median Overall Survival was 9.2 months (95% CI: 4.5-13.8) and Median progression-free survival was 5.9 months (95% CI: 7.0-10.4). CONCLUSION Overall Survival results were encouraging with initial auditing proving SRS as effective approach. Local control rates correlate well with randomized control trials results for SRS in brain metastases.

In-House Production of Dialysis Solutions to Overcome Challenges During the Coronavirus Disease 2019 Pandemic

In-House Production of Dialysis Solutions to Overcome Challenges During the Coronavirus Disease 2019 Pandemic

Long-term maintenance rituximab for ANCA-associated vasculitis:relapse and infection prediction models.

ObjectivesFollowing a maintenance course of rituximab (RTX) for ANCA-associated vasculitis (AAV), relapses occur on cessation of therapy, and further dosing is considered. This study aimed to develop relapse and infection risk prediction models to help guide decision making regarding extended RTX maintenance therapy.MethodsPatients with a diagnosis of AAV who received 4–8 grams of RTX as maintenance treatment between 2002 and 2018 were included. Both induction and maintenance doses were included; most patients received standard departmental protocol consisting of 2× 1000 mg 2 weeks apart, followed by 1000 mg every 6 months for 2 years. Patients who continued on repeat RTX dosing long-term were excluded. Separate risk prediction models were derived for the outcomes of relapse and infection.ResultsA total of 147 patients were included in this study with a median follow-up of 63 months [interquartile range (IQR): 34–93]. Relapse: At time of last RTX, the model comprised seven predictors, with a corresponding C-index of 0.54. Discrimination between individuals using this model was not possible; however, discrimination could be achieved by grouping patients into low- and high-risk groups. When the model was applied 12 months post last RTX, the ability to discriminate relapse risk between individuals improved (C-index 0.65), and once again, clear discrimination was observed between patients from low- and high-risk groups. Infection: At time of last RTX, five predictors were retained in the model. The C-index was 0.64 allowing discrimination between low and high risk of infection groups. At 12 months post RTX, the C-index for the model was 0.63. Again, clear separation of patients from two risk groups was observed.ConclusionWhile our models had insufficient power to discriminate risk between individual patients they were able to assign patients into risk groups for both relapse and infection. The ability to identify risk groups may help in decisions regarding the potential benefit of ongoing RTX treatment. However, we caution the use of these prediction models until prospective multi-centre validation studies have been performed.