Hematology Service Research Articles

A-188 Managing a Fully-automated Paperless Laboratory During a Cyber-attack

Abstract Background On 23rd Nov, 2022 a tertiary care apex medical institute in India was subject to cyberattack which disrupted the Hospital Information system (HIS) and the Laboratory Information system (LIS) servers. The services from the SmartLab, an end-to-end integrated total-lab-automation system, designed to run on paperless mode got disrupted. This is the main service laboratory with an average daily sample load of approx. 5000 including hematology, coagulation, clinical chemistry, immunoassays and serology services. Methods All lab operations were immediately shifted to manual mode. Standard operating protocols (SOPs) were designed for manual processing and circulated to OPD and IPD staff through WhatsApp. Instructions were issued to use previously used paper test-request-forms (TRFs) for sending samples. Previous stock of TRFs were retrieved from Stores and distributed to the IPD and OPDs. Staff from other areas of the hospital were mobilized.In OPD sample collection area, patients’ registrations were done by writing Patient-Id, Name, Age, Sex, Sample-Id, Treating department and Test requests in registers. A small sticker was introduced and pasted on the blood collection tubes capturing minimal relevant patient details, treating department codes and sample Id. Duplicates were pasted on OPD cards of respective patients. Traceability of patient Ids and sample Ids were maintained through data entry in registers. In the lab, the LIS were shut down on a precautionary note. Test requests corresponding to each sample Id were programmed directly on the analyzers. When done, print-outs of test results were obtained from the analyzers and hand-written results were entered by data entry operators on the TRFs. Reports were then segregated as per the treating department codes and dispatched to respective places. This continued till partial restoration of HIS services on and from 12th December, 2023. Results Despite best efforts, turn-around-time (TAT) for reports got compromised. IPD reports were prioritized and about 60% of the same could be dispatched by 9 PM same day, rest being delivered by 9 AM, next morning. TAT for OPD reports stretched up to 36 h. Inspite of introducing separate numbering systems with codes for different OPDs and IPDs, about 40% reports could not be traced to the respective OPDs. These reports were collected by the patients’ attendants from the lab itself. Manual report retrieval counters were set up outside the lab. At least 20% reports of the approx. 3000 reports generated per day remained unclaimed even after 30 days. The utilization of lab services also came down by 20%–25% during this period. About 5% reports had to be repeated with fresh samples due to inability to retrieve previous reports. The data generated during this 20-days period could not be stored electronically and hence are not available in our database now. Conclusion Cyberattacks may happen to any institution. Having a strict cyber-security protocol is a must for all institutions. However, having a back-up plan for handling such a crisis should be also in place in case of any eventuality. Sharing our experience is an endeavour to create awareness regarding the prerequisites of such a plan.

Quality outcomes for end-of-life care among people with haematological malignancies at a New Zealand cancer centre.

Little is known about the end-of-life (EOL) experience and specialist palliative care use patterns of patients with haematological malignancies (HMs) in New Zealand. This retrospective analysis sought to examine the quality of EOL care received by people with HMs under the care of Auckland District Health Board Cancer Centre's haematology service and compare it to international data where available. One hundred consecutive adult patients with HMs who died on or before 31 December 2019 were identified. We collected information on EOL care quality indicators, including anticancer treatment use and acute healthcare utilisation in the last 30 days of life, place of death and rate and timing of specialist palliative care input. During the final 14 and 30 days of life, 15% and 27% of the patients received anticancer therapy respectively. Within 30 days of death, 22% had multiple hospitalisations and 25% had an intensive care unit admission. Death occurred in an acute setting for 42% of the patients. Prior contact with hospital and/or community (hospice) specialist palliative care service was noted in 80% of the patients, and 67% had a history of hospice enrolment. Among them, 15% and 28% started their enrolment in their last 3 and 7 days of life respectively. The findings highlight the intensity of acute healthcare utilisation at the EOL and high rates of death in the acute setting in this population. The rate of specialist palliative care access was relatively high when compared with international experiences, with relatively fewer late referrals.

The case for prioritizing malignant hematology services in low- and middle-income countries

A clear case for can be made for prioritizing malignant hematology services in low- and middle-income countries based on large public health burden, convincing demonstrations of cure and control, innovation opportunities with likely worldwide implications, and sizable returns on investment for health systems and societies. We must now ensure that need and opportunity are matched by commensurate levels of investment and attention.

Changes in Patterns of Referral for Inpatient Rehabilitation Cancer Patients Due to COVID-19: A Retrospective Study.

There is a paucity of literature on the effect of COVID-19 on hospital processes. We hypothesized that COVID-19 was associated with decreased cancer physiatry referrals in 2020. This is a retrospective cohort study of consecutive patients from April to July 2019 and 2020 admitted at an academic quaternary cancer center. The main outcomes were number of hospital admissions, rate, and characteristics of inpatient rehabilitation admissions and change in percentage of physiatry referrals as the primary endpoint. Results showed that in 2019, there were 387 referrals from 10,274 inpatient admissions (3.8%; 95% confidence interval, 2.4-4.2), compared with 337 referrals from 7051 admissions in 2020 (4.8%; 95% confidence interval, 4.3-5.3, P = 0.001). Hematology services referred more patients than neurosurgery in 2020 (20.4% vs. 31.4%; 48.2% vs. 26.5%, P = 0.01). Discharge disposition reflected an increased frequency of return to acute care service in 2020 (10.2% vs. 21.8%, P = 0.03). In conclusion, there was an increase in the rate of physiatry referrals despite a decrease in hospital admissions. There was an increase in referrals by hematology, likely due to emphasis on safe discharge and the populations hospitalized.

Patient Blood Management: what specialized nursing intervention in the patient undergoing cardiac surgery?

A mathematical model was applied to the hematopoietic reconstitution study of a group of thirteen patients with Hodgkin and Non-Hodgkin Lymphoma after having undergone Autologous Transplantation of Hematopoietic Progenitors in the Hematology Service of the Surgical Clinical University Hospital "Arnaldo Malian". Based on the model, the recovery process dynamics were computationally simulated, and the hematopoietic recovery times of each patient collected in the clinical data were compared with the times predicted by the simulations. Despite the simplicity of the mathematical model, it is surprising how well the reconstitution curves coincide with the clinical data collected, in such a manner that the model is able to predict with acceptable accuracy when hematopoietic recovery occurs. Model forecasts can be used to estimate the average duration of the pre-implant transplant and the next, which, in turn, will increase the number of patients benefited by this procedure.

Factors associated with potentially inappropriate medications in elderly with multiple myeloma.

Elderly with cancer often have multimorbidity, which determines a higher risk of polypharmacy. This is related to negative clinical results such as adverse drug reaction and emergence service visits. Furthermore, polypharmacy increases the risk of using potentially inappropriate medications. To evaluate the use of potentially inappropriate medication in elderly with multiple myeloma and associated factors. The study was conducted with older adults with multiple myeloma treated at outpatient oncology and hematology services in a southeastern Brazilian capital. Potentially inappropriate medications were classified using the American Geriatric Society/Beers 2019 Criteria. Variables were described using frequency and proportions, performing multiple logistic regression to identify factors associated with the use of potentially inappropriate medications. One hundred fifty-three older adults with multiple myeloma were included, with a median age of 70.9 years. The median number of medications was 8, and 63% of patients used polypharmacy. More than half (54%) of the patients used potentially inappropriate medications, and proton pump inhibitors (46%) and benzodiazepines (8%) were the most employed therapeutic classes. Older adults who used potentially inappropriate medications differed from those who did not use them in the following characteristics: income up to three minimum wages, higher schooling level, private service, multimorbidity, hypertension, cardiovascular disease, chronic kidney disease, depression, adverse event, and polypharmacy. Higher schooling levels and polypharmacy were independently associated with the use of potentially inappropriate medications in the multivariate analysis. Potentially inappropriate medication use was high in patients with multiple myeloma studied. The use of polypharmacy and higher schooling levels were independently and positively associated with the use of potentially inappropriate medications.

The effect of physical and psychological symptoms on spiritual well-being and emotional distress in inpatient cancer patients.

This study was conducted to examine the effects of physical and psychological symptoms seen in inpatient cancer patients on spiritual well-being and emotional distress. This descriptive and cross-sectional study was conducted with 98 cancer patients treated in oncology, haematology, and stem cell services at a university hospital between April and June 2022. Socio-demographic characteristic form, Karnofsky performance scale, Nightingale Symptom Assessment Scale, Hospital Anxiety and Depression Scale, distress thermometer and spiritual well-being scale were used to collect data. Statistical analyses were made by taking the descriptive features of the data. It was determined that 55.1% of the patients were diagnosed with cancer for more than one year, 53.1% receiving treatment for more than one year, 61.2% were diagnosed with haematological cancer, and 62.2% were treated only with chemotherapy. Cancer type (p<0.01), treatment (p<0.05) and Karnofsky scores (p<0.01) had an effect on the spiritual well-being and distress scores. It was determined that 39.8% of the patients were in the yellow zone of the distress thermometer, could not manage their stress well and needed psychological support. As the psychological symptoms of the patients increased, their spiritual well-being declined (r=-0.447, p<0.01), and as their physical (r=0.222, p<0.05) and psychological (r=0.311, p<0.01) symptoms increased, their distress scores increased. It is anticipated that identifying the problems that patients have and making interventions to solve those problems by oncology nurses would significantly contribute to the patient's spiritual well-being and emotional distress.

In their own words: a qualitative study of coping mechanisms employed by patients with acute myeloid leukemia.

Positive coping mediates improved outcomes from integrated palliative care in acute myeloid leukemia (AML). We qualitatively explored patients' coping mechanisms to better understand this relationship. We enrolled patients with high-risk AML admitted to Duke Hospital's inpatient hematologic malignancy service for intensive chemotherapy. This study is a secondary analysis of previously collected longitudinal qualitative data, with interviews conducted between February 2014 and August 2015. Interviews were coded in NVivo to identify examples of approach-oriented and avoidant coping. Patients demonstrated approach-oriented coping in many forms including acceptance, positive reframing, active coping, religious coping, and social coping. Acceptance included accepting their prognosis, the uncertainty of AML, and lifestyle changes due to the disease. Patients exhibited positive reframing by speculating about how their situation could be worse, deriving meaning from their experience, and expressing newfound appreciation for activities previously taken for granted. Social coping involved patients receiving support from their community or care team; however, some expressed guilt for being a "burden" on family. Avoidant coping included denial, behavioral disengagement, and self-blame. Some denied their prognosis, but denial was more commonly demonstrated via patients cognitively distancing themselves from their disease. Much of the behavioral disengagement described by patients was attributed to their symptoms (i.e., lethargy) which prevented patients from maintaining relationships or participating in activities previously enjoyed. These results demonstrate the diverse and nuanced applications of coping mechanisms amid a recent AML diagnosis. Future research should examine coping in the context of novel low-intensity AML therapies.

БОЛЬШИЕ ДАННЫЕ И ВИЗУАЛЬНАЯ АНАЛИТИКА В ДЕТСКОЙ ОНКОЛОГИИ И ГЕМАТОЛОГИИ

The potential of big data in healthcare relies on the ability to detect patterns and turn high volumes of data into actionable knowledge for precision medicine and decision makers. Due to constantly increasing amount of data, healthcare systems around the world are facing challenges associated with data processing and analysis while keeping costs under control. There is a number of examples where the use of big data in healthcare already provides solutions that optimize patient care and generate value for healthcare institutions. However, a further increase in the amount and variety of dynamically changing data in healthcare systems requires that all the relevant stakeholders collaborate and adapt the design and performance of their systems. To this end, it is necessary both to invest in the human capital and to build the technological infrastructure to house and converge a huge volume of healthcare data. It is also important to provide a set of tools that can improve data analytics by creating interactive visual interfaces to help analysts navigate and make sense of massive datasets. Here we provide an overview of international advanced initiatives related to big data analytics in various sectors of public healthcare that are aimed at obtaining new knowledge, improving clinical care and rationalizing epidemiological surveillance. Here we also share our own experience of applying visual analytics tools in the "Electronic Passport of Pediatric Oncology and Hematology Service." This passport was created by specialists from the Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology of Ministry of Healthcare of Russia in order to improve the quality of specialized care in the Russian regions. This software solution is based on data from checklists and questionnaires (baseline assessment) completed during an outreach event and its preparation as well as from correspondence regarding the implemented corrective measures (baseline and follow-up assessments). This system is an important tool that helps improve the quality of monitoring of the pediatric oncology and hematology service. The structured electronic database allows the user to rank the Russian regions based on a whole range of parameters as well as to generate recommendations for process optimization in regional institutions. In such a complex information system, a user-friendly interface for the processing of large volumes of heterogeneous dynamic data is crucially important.

PEDS8: Continuous Renal Replacement Therapy In Pediatric Extracorporeal Membrane Oxygenation: Life Span And Cost Of Filter Changes With Bivalirudin.

Background: The utilization of additional extracorporeal support devices utilized in conjunction with Extracorporeal Membrane Oxygenation (ECMO) has increased with more complex and sicker patients. The use of Continuous Renal Replacement Therapy (CRRT) has increased five-fold over the past 3 years at our institution after implementing Pediatric Nephrology Stewardship (PNS) on ECMO. Bivalirudin is the primary anticoagulant used for ECMO and CRRT at our institution which has resulted in increased ECMO circuit and CRRT filter life. The Prismalflex HF1000 and HF20 filter has a prime volume of 165 ml and 58 ml, respectively, with prime components which include packed red blood cells (pRBC) and albumin. Manufacturer recommendations for changing the CRRT filter is defined as every 72 hours (3 days). We sought to extend the filter length by augmenting the indication for the CRRT filter change from manufacturer recommendation. Filter changes were determined based on monitoring the filter pressure, transmembrane pressure, and pressure drop to diagnosis clotting/clogging. CRRT filter was also changed out if disconnection from ECMO was warranted due to ECMO circuit change or travel. Methods: Retrospective ECMO and CRRT data was collected for pediatric veno-arterial or veno-venous ECMO patients at a tertiary care hospital from January 2021-December 2022. Results: CRRT was performed on 16% (7/44) of ECMO patients. 100% of the patients received bivalirudin as the anticoagulant. 71% (5/7) were supported by VA ECMO. 43% (3/7) were neonates. Mean ECMO duration was 14 days (3-133). Of the 7 ECMO patients on CRRT, 80% (265/332) of their time on ECMO included CRRT support. There was a total of 41 CRRT filter changes performed during 265 days on CRRT with an average filter change occurring every 6.46 days (table 1). Utilizing cost of CRRT filter set ($358.00) and approximate cost of 1 unit of pRBC ($200.00), there was a savings of $26,226 to the hospital ($22,878 vs. $49,104). Discussion: Utilization of an alternative indication versus manufacturer recommendation for CRRT filter change out prolonged filter length from 3 days to 6.46 days (110% decrease in filter change out). By reducing the number of CRRT filters and blood usage for a filter change, cost to the hospital and patients was significantly reduced even without considering labor for CRRT set up and blood preparation. With careful attention to detail and collaboration with Nephrology and Hematology services, it appears CRRT filter length can be safely extended past manufacturers recommendations.

A comparison study of solid tumor, malignant hematology, and general medicine inpatient services.

e13532 Background: One of the most important cancer centers in Ohio experienced an explosive growth in the number of inpatient admissions, with numerous inpatient services created between 2010 and 2022. In this abstract, we present how some financial and quality measures performed during this rapid expansion. Methods: Slicer-Dicer aggregate data was used to compare financial performance and quality measures of oncologic and general medicine inpatient (IP) services over time. General medicine services do not include the cancer and the heart disease populations, but there might be a small overlap. The cancer population is served by 9 IP oncology services. The following SlicerDicer Filters were used. Population: IP admissions. Slices: populations include these study groups, 10 inpatient medical oncology (solid tumors) (MO), 6 inpatient malignant hematology (MH) (including 1 bone marrow transplant) services were compared to 10 general medicine (GM) services. Gynecologic and central nervous system tumors are served by other services and were excluded. Measures: number of admissions, median and total payments (actual payment received), median and total expected reimbursement (reimbursement expected for DRG), mortality, readmission rates, average length of stay (LOS), percentage of patients with Medicaid, percentage of patients with Medicare. Dates: from 2011 to 2022 data. For some measures, quarterly data is presented rather than yearly data for graph simplicity. Results: The number of inpatient admissions grew by 90.77%, 130.55%, and 105.58% for GM, MO, and MH, respectively. The total expected reimbursement increased by 6.22%, 13.56% and decreased by 17.14% for GM, MO and MH, respectively. The total payment received grew by 314.29%, 283.69%, 86.80%, for MO, MH, and GM, respectively. MO, GM, and HM had a median payment increase of 76.51%, 51.96%, 20.74%, respectively. Mortality dropped for MO by 32.11%, from 76.9% to 52.2%, for MH by 49.46%, from 55.6% to 28.1% and in GM by 73.80% from 35.5 % to 9.3%. The average length of stay was 1 to 2 days longer in the MH and GM (respectively) compared to MO, with an increase from 2011 to 2022 for GM and MO, but a decrease for MH. Readmission rates decreased from 17.4% to 15.1% for MO, 12.7% to 10.3% for MH, and 14.9 to 12.5% for GM. In 2014, the percentage of Medicaid population increased in GM, and decreased in the oncology services (MO and MH) reaching 35% and 14% of the admitted patient population in 2022, respectively. Percentage of Medicare patients increased from 36.9% to 52.9%, 39.6% to 44.9%, and remained stable for MO, HM, and GM, respectively. Hospice discharge fluctuated between 1.2-1.6%, 2.5-5%, 8-12.9% of the discharged patients in GM, MH, and MO, respectively. Conclusions: In this abstract, we present a decade-trend data of important measures of inpatient oncology units.

17th International Conference on Malignant Lymphoma, Palazzo dei Congressi, Lugano, Switzerland, 13 - 17 June, 2023.

Introduction: Lymphoma is one of the most prevalent cancers diagnosed in the Republic of Ireland, with approximately 800 cases of Non-Hodgkin lymphoma and 150 cases of Hodgkin lymphoma (HL) diagnosed annually. Previous studies have demonstrated that time to diagnosis can range substantially, with diagnosis to treatment interval associated with survival outcomes. Aims & Methods: The primary aim of this study was to compare the diagnostic efficiency according to histology specimen type. The secondary aims included time to lymphoma diagnosis, and predictors associated with diagnostic delays. A retrospective analysis was performed on all patients diagnosed at a tertiary (non-fee paying) centre in Ireland between 2016 and 2021. Baseline demographic data and diagnostics were obtained from electronic records. Referral to treatment interval (RTI) was calculated from the date of initial review in the referral centre to commencement of therapy. Results: A total of 225 new lymphoma diagnoses were made during the study period. The median age was 63.3 years (IQR 44.2, 73.6) Males accounted for 54.7% (n = 123) of the population. DLBCL was the most common subtype (n = 94; 41.8%); followed by classical HL (n = 40; 17.8%) and Follicular lymphoma (n = 32; 14.2%). Fifty four percent (n = 122) had their diagnostic histology attained during an inpatient episode. The median time to diagnosis was 24 days (IQR 13.0, 58.0). A total of 350 histology specimens were attained. Core biopsy yielded a diagnosis in 64% (n = 144), excision biopsy in 35.6% (n = 80) and FNA in 0.4% (n = 1). The positive diagnostic rate was 69.5% for core biopsy, 93% for excision biopsy and 1.7% for FNA. The median financial cost of diagnosis was €13714 (IQR €4050, €24044). The total cost for this patient group was €3.7 million over a 5 year period. The median RTI was 47 days (IQR 23.0, 91.0). In the univariate analysis, we confirmed patients with older age are more likely to have longer RTI (p = 0.0007). Diagnostic biopsy performed as inpatient was associated with a shorter RTI (p ≤ .0001). Patients referred direct to haematology services had a longer RTI (p = 0.0004). In the multivariable analysis, patients with older age remained significant associated with prolonged RTI (p = 0.0251). Diagnostic biopsy performed as an inpatient remained significant (p ≤ .0001). Similarly, patients referred directly to Haematology services has significantly longer RTI (p = 0.0051). Conclusion: In this review, we confirm the higher diagnostic yield of excision biopsy for diagnosis. Older age at presentation and referral direct to haematology was associated with longer RTI. Inpatient diagnostic’s was associated with shorter RTI. We confirm an over reliance on inpatient diagnostics. With the increasing financial burden of healthcare and increased demand on resources including bed utilisation, the appropriate choice of investigations and diagnostic sampling is ever more critical. Encore Abstract - previously submitted to regional or national meetings (up to <1000 attendees) Keywords: cancer health disparities, diagnostic and prognostic biomarkers, Imaging and Early Detection - Other No conflicts of interests pertinent to the abstract.

Tinidazole efficacy for amebic colitis therapeutic prophylaxis in patients with de novo acute leukemia receiving intensive chemotherapy.

In Mexico, seroprevalence of Entamoeba histolytica is 8.4%. The intestinal amebiasis in patients with acute leukemia of novo, after the start of chemotherapy (CT) in the Hematology Service of the CMN 20 de Noviembre is 12%, even if patients show a negative baseline coprological test. To find out if the administration of tinidazole, in patients with acute leukemia and negative coprological test, at the beginning of the CT, decreases the incidence of amoebic colitis during the induction to remission. Prospective and not comparative study. Patients with de novo diagnosis of acute leukemia who initiate induction and initial coprological CT. Tinidazole was indicated, 2 g/day for 5 days in the first week of CT started. They were monitored until the induction was concluded and hematopoietic recovery started. 38 patients, 15 women and 23 men with a mean age of 44 years (16-72), with acute lymphoblastic leukemia 19, myeloblastic 16 and promyelocytic 3. Cases without and with intestinal amebiasis were 35 and 3, respectively. Patients with amebiasis only received tinidazole for 3 days and it was given 2 days after the CT started. Tinidazole, in patients with acute de novo leukemia who initiate induction CT, is effective in the prevention of intestinal amebiasis, during the induction stage, if administered at 2 g/day, for five days, starting on day 1 of the CT.

Comparative study of hematopoietic reconstitution in patients of the Arnaldo Milian Hospital from Santa Clara

A mathematical model was applied to the hematopoietic reconstitution study of a group of thirteen patients with Hodgkin and Non-Hodgkin Lymphoma after having undergone Autologous Transplantation of Hematopoietic Progenitors in the Hematology Service of the Surgical Clinical University Hospital "Arnaldo Malian". Based on the model, the recovery process dynamics were computationally simulated, and the hematopoietic recovery times of each patient collected in the clinical data were compared with the times predicted by the simulations. Despite the simplicity of the mathematical model, it is surprising how well the reconstitution curves coincide with the clinical data collected, in such a manner that the model is able to predict with acceptable accuracy when hematopoietic recovery occurs. Model forecasts can be used to estimate the average duration of the pre-implant period, in which severe aplasia and immunodeficiency condition the occurrence of hemorrhagic and infectious complications that are often severe. In addition, it is an important tool for planning next patient´s transplant by the team, thereby reducing the time spent in planning the logistics required between one transplant and the next, which, in turn, will increase the number of patients benefited by this procedure.

HLA alleles and haplotypes in a population from the northeast of Mexico treated at the blood and bone marrow transplant center of the hematology service of a university hospital

HLA alleles and haplotypes in a population from the northeast of Mexico treated at the blood and bone marrow transplant center of the hematology service of a university hospital

Состояние и перспективы развития гематологической службы субъектов Центрального федерального округа Российской Федерации

Improving the quality of medical care is one of the priority objectives of the state policy, for the solution of which the resources of the national project «Healthcare» and its constituent federal projects are used. Purpose of the study is the development of high-cost, resource-intensive and socially significant healthcare industry, such as the Hematology service. The aim of this study was to assess the organization and state of the Hematology service in the Central Federal District (CFD) of Russia – the leader both in terms of population and in terms of the number of subjects included in it – which is necessary to develop organizational and methodological measures aimed at its improvement. Materials and methods. Official statistical data and analytical materials of Federal State Statistics Service, the Cancer Registry, open sources of information, data from check-out work of the National Medical Research Center for Hematology in СFD. Statistical data analyzed with the Excel‑2007 package. The main research methods: study and generalization of the available information, informationanalytical, statistical, bibliographic. Results. The analysis of the performance indicators of Hematology in the CFD identified its main components, taken together of which it is possible to assess the quality of the organization of the provision of specialized medical care with subsequent rating, and made it possible to identify key points for further improvement of the hematological service. Conclusions. The results of the study indicate the need for constant monitoring of the main indicators of the Hematology service (staffing, bed fund, availability of specialized high-tech research methods for the blood system diseases), taking into account certain directions and the course of the state policy pursued in this direction.

Interventions to Improve Advanced Practitioner Work-Related Quality of Life and Patient Satisfaction.

Across the United States, an incremental need for cancer care continues to emerge. Specialty nurse practitioners and physician assistant teams have helped in meeting this demand. However, there is a need for evidence-based recommendations to inform appropriate provider-patient staffing ratios that encompass complex cancer treatments and ensure optimal care. A literature review identified a gap in existing research with regard to recommended inpatient provider-patient ratios for hematology and oncology services. The conceptual framework of ICU nursing workload was utilized to ensure a comprehensive understanding of an inpatient specialty cancer provider's duties. Within the unit, job, patient, and situation workload levels, there were multiple interventions implemented to streamline systems and improve workplace conditions for providers, as measured by the work-related quality of life (WRQoL) scale. Patient satisfaction scores improved an average of 4% across multiple criteria and exceeded benchmark rankings by 10.7% surrounding communication with nurses and physicians (a 6.3% increase). Discharge efficiency improved, with 6.1% more discharges occurring by 11:00 am, and length of stay was noted to be 8.8 days fewer than teaching services treating the same cancer diagnosis. Finally, additional shift pay was greatly reduced and turnover decreased by 17%. Application of the conceptual framework of ICU nursing workload provided a scientific assessment of specialty inpatient cancer services within one institution. Interventions resulted in improved working conditions, patient satisfaction, discharge efficiency, and reduced turnover, ultimately ensuring the provision of high-quality cancer care.

The Promise of Next-Generation Sequencing in Improving the Diagnosis of Rare Genetic Disorders in Developing Countries

Introduction Genetic testing is frequently required for aiding and confirming the diagnosis, selecting treatment and predicting prognosis in patients with hematological disorders (1). However, large-scale genetic studies based on whole exome or genetic panel sequencing have not been a primary focus of developing countries due to lack of awareness, a dearth of genetic testing laboratories in clinical facilities, and the limited financial resources of affected families. As a result, the underlying genetic patterns in these patients often go undetected. Nevertheless, these countries constitute a rich source of clinical data with atypical phenotypes and novel mutations due to large family sizes, inter-family marriages, and potential founder effects (2). These genotype and phenotype data are worth being presented in the international data repositories for better identification of pathogenic variants in this population (3). Armed Forces Bone Marrow Transplant Centre (AFBMTC) is the country's largest hospital providing clinical hematology and stem cell transplantation services to a catchment area of over 560,000 Km2. We sought to identify underlying genetic causes of various difficult-to-diagnose rare hematological disorders with heterogenous/overlapping symptoms and challenging clinical presentation using next-generation sequencing (NGS). Materials and Methods Peripheral blood samples from 33 individuals with diverse hematological diseases were sent to Invitae Corporation (USA) or Centogene GmbH (Germany) for panel sequencing or whole exome sequencing, respectively. These samples were from patients who were difficult-to-diagnose, required risk stratification or genetic testing for selecting appropriate treatment. Results Whole exome sequencing or panel sequencing was performed in a cohort of 33 patients with various hematological disorders (figure 1). A total 115 variants were identified in these patients including 15 pathogenic variants (13%), 7 likely pathogenic variants (6%), 82 variants of uncertain significance-VUS (71%), 9 benign variants (7.8%) and 1 increased risk allele variant (0.86%). A total of 42 variants were found in musculoskeletal disorders panel, 20 in primary immunodeficiency panel, 11 each in bone marrow failure syndrome panel and dyskeratosis congenita panel, 9 in comprehensive deafness panel and 9 in hereditary hemolytic anemia panel among others. The most frequent diagnosis in our cohort was inherited bone marrow failure syndromes (27.3%), followed by hemolytic anemias (15.2%), immunodeficiency disorders (12.2%), inherited platelet function disorders (12.2%), myelofibrosis disorders (12.2%), skeletal disorders (12.2%) and miscellaneous disorders (9.1%). Patients clinical and demographic characteristics are summarized in table 1. Conclusion Use of high-throughput NGS in our clinical hematology setting has proven to be useful in identifying genetic variants for accurate diagnosis, selecting appropriate therapies, and predicting prognosis. We intend to develop a genetic facility that will provide genetic testing and identify ways to make it more accessible for people of all socioeconomic backgrounds. A second objective is establishing the prevalence of most frequent genetic disorders in the country. The high number of variants of uncertain significance (VUS) is most likely driven by a lack of sufficient population-based genetic data and proof of functional impact, though the patients identified having VUS were phenotypically disease presenting. Thus, supporting the hypothesis that these VUS may eventually be classified as pathogenic after appropriate testing on larger scales and animal models. To achieve a dependable and precise categorization of VUS, we plan to include functional genomics in our research focus to support the clinical database of this region. 1. Haferlach TJh. The time has come for next-generation sequencing in routine diagnostic workup in hematology. 2021;106(3):659. 2. MALTESE P, Poplavskaia E, Malyutkina I, Sirocco F, Bonizzato A, Capodicasa N, et al. Genetic tests for low-and middle-income countries: a literature review. 2017;16(1). 3. Gutierrez-Rodrigues F, Calado RTJH, Transfusion, Therapy C. The interpretation of rare or novel variants: Damaging vs. disease-causing. 2018;40:3-4. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

In Their Own Words: A Qualitative Study of Coping Mechanisms Employed By Patients with Acute Myeloid Leukemia

Introduction: Acute Myeloid Leukemia (AML) is a heterogeneous disease affecting over 20,000 adults in the U.S. each year. People diagnosed with AML experience a period of shock compounded by the need to make quick treatment decisions. Coping not only with the direct symptoms of disease and treatment (e.g., fatigue, nausea, pain), but also lifestyle changes (e.g., inability to live independently, inability to conduct usual activities) is integral to the patient experience. Coping has also been shown to mediate the impact of integrated palliative care on improving outcomes. While several studies analyze coping mechanisms in AML using predetermined scales, less is known about how patients themselves describe their coping strategies when asked open-ended questions about their experience. We aimed to explore patients' coping methods, through their own words, using qualitative methods. Methods: We enrolled patients with high-risk AML admitted to Duke Hospital's inpatient hematologic malignancy service for high dose chemotherapy treatment. This study is a secondary analysis of previously collected longitudinal qualitative data, with patient interviews conducted between February 2014 and March 2015 (up to three semi-structured interviews per patient). Interviews were coded in NVivo using open and axial coding to identify coping mechanisms. Coping mechanisms were divided into two broader categories: approach-oriented coping (acceptance, positive reframing, meaning-focused coping, relying on faith, active coping, and social coping) and avoidant coping (behavioral disengagement, self-blame, and denial). Results: Of the 32 patients in the study, the mean age was 61.8 years. Similar proportions of patients in the study had normal karyotype (53.1%, n=17) and complex karyotype (46.9%, n=15) and most patients were newly diagnosed (68.8%, n=22). One approach-oriented coping strategy employed by patients was acceptance-accepting one's prognosis, consequent lifestyle changes, and new normal: "[I will] be monitored, y'know continuously for the rest of my life. I accept that." Others accepted the uncertainty of AML: "You don't know what to expect. You just go with the flow. There is no expectation with cancer." Many patients used positive reframing by keeping perspective, either by hypothesizing about how it could be worse or comparing their situation to others: "There are millions and millions of people who have so much less than I do, who are in such pain, who don't have roofs over their head." Other patients found greater admiration for activities previously taken for granted: "[AML] made me want to go back and appreciate some of the things that I didn't appreciate. Just a good long walk, working in the garden, being with my friends." Another coping strategy included deriving meaning from their own experience, either by focusing on lessons learned or feeling that they could help others. Finally, social coping fell into two categories: patients feeling support from their medical team and from their community. Notably, some also felt guilt for being a "burden" on family members who drive them to medical appointments and take care of them. Avoidant coping mechanisms were present in the form of behavioral disengagement-pulling away from loved ones or feeling "numb," as well as self-blame when treatment did not work. However, the most common avoidant coping mechanism patients discussed was denial, either in the form of emotional suppression or manipulation of the truth, as is the case with a patient who stated, "I call it cured. Doctor said it's in remission, but I don't know. I call it cured." Yet, there were instances in which avoidance of full information appeared to be adaptive, for example if the patient decided to break their treatment into more manageable subsections: "If there's going to be several stages, let's focus on Stage 1 and get through it; there's a mile marker to get to where we are and then we will go on from there." Conclusion: These results demonstrate the diverse applications of coping mechanisms in the wake of an AML diagnosis. Specifically, within broad categories of coping strategies (e.g., positive reframing), important subdivisions exist, and must be understood in order to best support patients. Future research should aim to further elucidate these nuances and how they affect the emotional wellbeing of patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Clinical Features and Mutational Landscape of Patients Referred for Suspected Essential Thrombocytosis: A Descriptive Study Using a 'Real-World’ Database

Background: Essential Thrombocythemia (ET) is a myeloproliferative neoplasm characterized by persistent thrombocytosis and often associated with mutations in JAK2, CALR, or MPL. Next Generation Sequencing (NGS) has become widely used in patients with suspected hematologic malignancies but its role in the investigation of unselected patients referred for thrombocytosis remains to be defined. This project describes the characteristics and mutational landscape of patients referred for isolated thrombocytosis with the aim of developing a clinical prediction rule for ET to help guide diagnosis and improve utilization of genomic testing. Methods: All adult patients referred to the Hematology Service at London Health Sciences Centre, Ontario, Canada, between January 1, 2018, and May 31, 2021 were reviewed for thrombocytosis (≥ 450 x 109 cells /L). NGS testing was performed using the Oncomine Myeloid Research Assay (Thermofisher Scientific, MA, USA). Patients were classified into two groups: Clinical ET and secondary thrombocytosis. Clinical ET was defined as any patient meeting the World Health Organization (WHO) 2016 criteria for ET or any patient meeting all criteria but lacking a bone marrow biopsy. Results: 446 consecutive patients were evaluated for thrombocytosis with NGS testing. 102 patients were excluded due to meeting criteria for other WHO defined conditions such as chronic myeloid leukemia, polycythemia vera, other myeloproliferative neoplasms and/or myelodysplastic syndromes. In the remaining, 342 patients, the overall yield of molecular testing was 188 (55.0%). Mutations in JAK2, CALR, MPL were identified in 84.7% of patients with clinical ET (JAK2 in 48.9%, CAL-R type 1 or 2 in 27.6%, and MPL in 8.5%), with triple negative making up the remaining 8.5%. There was no statistically significant difference between CBC parameters, ferritin, ESR, and CRP between clinical ET and secondary thrombocytosis groups. In contrast, clinical factors such as previous history of arterial thrombosis were highly predictive of ET, whilst active malignancy, chronic inflammatory disease and post splenectomy and iron deficiency were all associated with secondary thrombocytosis. Conclusion: Overall yield of molecular testing for this population of patients referred for thrombocytosis was high (55.0%), suggesting appropriate use of NGS testing, but the identification of clinical factors predicting secondary causes might suggest further improvement in utilization. In our cohort, CBC parameters did not readily distinguish between ET and secondary thrombocytosis. Clinical factors such as smoking, active malignancy, chronic inflammatory disease and post splenectomy and iron deficiency are associated with secondary thrombocytosis. These results may help inform development of a clinical prediction rule to assist in determining the pre-test probability of ET in patients referred for thrombocytosis. #co-first authors Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal