Management Pathway Research Articles

562 Retrospective Study on Pain Management Pathway for Patients with Suspected Renal/ Ureteric Colic in a UK Accidents and Emergency Department

Abstract Aim To understand local compliance with the NICE guideline for pain management in suspected renal/ ureteric stones which includes use of NSAIDS, Intravenous Paracetamol and Opioids as first, second and third-line analgesics respectively and not offering antispasmodics. Method This was a retrospective single centre study wherein records of patients suspected to have renal/ ureteric colic between 18th July, 2022 and 30th September, 2022 were retrieved. Patients were identified by their presenting complaints of “loin-to-groin” pain at triage and “working diagnosis” from comprehensive history-taking and examination. We checked the first, second and third-line analgesics administered and, if Buscopan was given. Data was entered into Microsoft Excel and our pain management pathway matched against NICE guideline. Results 78 patients were suspected to have renal/ ureteric colic. M:F = 1.2:1. CT-KUB confirmed 90% to have stones and 3% to have no stones. 6% did not have CT-KUB done because they were young patients and urinalysis showed no microscopic hematuria. One patient self-discharged before CT-KUB was done. Overall, compliance with the NICE pain management guideline for suspected renal/ ureteric stones was full in 22% of cases but poor in 78% of cases. Conclusions Clinicians ability to correctly diagnose renal/ ureteric stones is remarkable. However, the low compliance rate is concerning. This may be due to poor awareness of the NICE guideline or doctors having affinity for certain analgesics as compared to others. This information will be used to explore further with the clinical team, reasons for non-compliance, develop a teaching strategy and perform a re-audit thereafter.

1149 Bringing Recycling to the Operating Department - a Sustainability Project in a DGH in London

Abstract Aim The Lancet Commissions report of 2015 suggested that tackling climate change could be the greatest global health opportunity of the 21st century. Both the Royal College of Surgeons of England and the Royal College of Anaesthetists have committed to sustainability task forces and have published guidance on improving care through small, sustainable practices including recycling waste. Method We conducted a theatre staff survey on SurveyMonkey in an operating department in an acute district general hospital without any recycling facilities on the attitudes towards recycling, and how this could be implemented. Results We received 103 responses, including a broad spectrum of the multi-disciplinary team including surgeons, anaesthetists, scrub nurses, operating department practitioners and healthcare assistants. Results showed that little to no recycling occurred (59%), 48% of respondents were not familiar with which material can be recycled, and 96% were agreeable to improving access to recycling in theatres. Two main areas identified as barriers to recycling were inadequate access to recycling bins and inadequate information on what can and what cannot be recycled. In terms of implementation, 75% of respondents indicated that posters around the department would be most useful in raising awareness and providing information on recyclable materials. Conclusions Currently, we are in conversation with the Trust and the waste management company to identify a list of recyclable materials and to incorporate recycling bins as part of the waste management pathway.

A new paradigm for vocal cord dysfunction/inducible laryngeal obstruction: Swift diagnosis and streamlined management pathways.

A new paradigm for vocal cord dysfunction/inducible laryngeal obstruction: Swift diagnosis and streamlined management pathways.

Soil management considerations for water resiliency in a changing climate

AbstractProviding adequate water for crops is a key consideration for agricultural resiliency. Climate change is expected to exert substantial pressure on crop water supplies through increased rainfall variability and increased evaporative demand. The temporal and spatial variability of these climate change impacts, in combination with many feedbacks, at times operating at different scales, makes identifying specific, yet broadly applicable “one‐size‐fits‐all” soil management solutions challenging. Adaptations that work well in one location may represent a poor management choice in another. Considering the local combinations of climate, soils, and crop production systems is fundamental for identifying appropriate strategies. Nonetheless, some broadly applicable soil management pathways for increasing soil water availability can be identified: (i) maximizing rainfall capture, (ii) maximizing soil water storage capacity (intensity × volume), and (iii) suppressing unproductive evaporative water losses, particularly during intervals when leaf area of the primary crop is low. Selecting climate, soil, and production‐system‐appropriate tillage and surface cover management practices is among the most relevant considerations for improving soil water availability. Maintaining surface cover favors evaporation suppression and increased capture of precipitation. Tillage choices affect internal soil water storage through impacts on soil properties that influence storage intensity and by altering the volume of soil available for root growth, as well as through effects on surface cover. Promoted management practices aimed at improving soil water availability for increased agricultural resiliency must be practically feasible and cost‐effective in order to support their broad adoption, and such constraints should be an important consideration in their development.

SP8.2 Management of Acute Surgical Abscesses (MAGIC): National prospective audit

Abstract Aim Subcutaneous abscesses are common, accounting for 2% of all emergency attendances. The aim of this project was to describe the management and outcomes associated with the management of subcutaneous abscesses in surgical practice. Method A national, prospective audit was undertaken. Adult patients presenting to an acute general surgical service with a subcutaneous (non-perianal) abscess between September and December 2022 were included. Data relating to their presentation, management, and outcomes were collected. Outcomes of interest included rates of recurrence, readmission, and complications within 60 days of treatment. A centre-level survey was administered to gather data on clinical resource use and sustainable practices. Results A total of 1247 patients were included across 55 centres. The most common abscess locations were pilonidal (18.8%), posterior thorax (14.5%), and buttock (11.7%). The majority (84.4%) were treated with incision and drainage and half (51.9%) of these also received antibiotics. Surgery was mostly performed with general (65.2%) or local (33.0%) anaesthesia. The rates of recurrence (5.7% vs. 6.7%) and readmission (14.0 vs. 10.3%) were broadly similar, respectively. A quarter (26.6%) of hospitals incorporated dedicated abscess management pathways. The majority of hospitals used single-use items for abscesses drained in ambulatory/ward areas (90.2%) but not in the operating room (13.7%). Conclusions Wide variation exists in the management of subcutaneous abscesses. These data, along with other preparatory work, may justify a trial of general and local anaesthesia in appropriately selected patients.

Characterising Biosecurity Initiatives Globally to Support the Development of a Progressive Management Pathway for Terrestrial Animals: A Scoping Review.

While biosecurity is of increasing importance globally, there is still limited evidence of the factors or elements that support the progressive and sustainable scaling up of biosecurity along the value chains from the local to the global level. To gain insight into the current body of literature on biosecurity, a mixed-methods approach was used based on a scoping literature review and an online survey with subject matter experts. Six databases were searched for published literature, and textual information from titles and abstracts of all included records (n = 266) were analysed through inductive content analysis to build biosecurity-relevant categories and identify strengths, weaknesses, opportunities, and threats (SWOT) of existing biosecurity systems or initiatives (such as projects or programs). Most records focused on initiatives in high-income countries, traditional livestock species (pigs, poultry, and large ruminants), and the production stage and had a disease-specific focus. No records described a comprehensive or global framework to progressively scale up biosecurity. Overall, the findings highlight the need for initiatives such as the FAO Progressive Management Pathway for Terrestrial Animal Biosecurity (FAO-PMP-TAB), which is a stepwise approach for strengthening biosecurity management along value chains to enhance the health, resilience, and sustainability of animal sectors. The findings highlight important elements and provide recommendations useful for developing approaches or a global framework to progressively improve biosecurity management.

Pain Management in Children Admitted to the Emergency Room: A Narrative Review.

Pain is a biopsychosocial experience characterized by sensory, physiological, cognitive, affective, and behavioral components. Both acute and chronic pain can have short and long-term negative effects. Unfortunately, pain treatment is often inadequate. Guidelines and recommendations for a rational approach to pediatric pain frequently differ, and this may be one of the most important reasons for the poor attention frequently paid to pain treatment in children. This narrative review discusses the present knowledge in this regard. A literature review conducted on papers produced over the last 8 years showed that although in recent years, compared to the past, much progress has been made in the treatment of pain in the context of the pediatric emergency room, there is still a lot to do. There is a need to create guidelines that outline standardized and easy-to-follow pathways for pain recognition and management, which are also flexible enough to take into account differences in different contexts both in terms of drug availability and education of staff as well as of the different complexities of patients. It is essential to guarantee an approach to pain that is as uniform as possible among the pediatric population that limits, as much as possible, the inequalities related to ethnicity and language barriers.

Techno-economic analysis of the co-gasification of sewage sludge and petroleum coke

In this study, the co-gasification of sewage sludge and petroleum coke is assessed with equilibrium and numerical modeling. The gasification process of these binary wastes provides a potential pathway for waste management and environmental sustainability. First, the thermodynamic equilibrium approach is used to calculate the maximum cold gasification efficiency (CGE) at different mixture ratios in an attempt to narrow down and focus on the appropriate composition of the two kinds of feedstock within the entrained flow gasifier. Furthermore, a parametric study is conducted to show the gasification metrics, i.e., CGE and feedstock conversion, and the syngas composition at different gasification conditions. The equilibrium model is based on eight unknowns in the gasification product, namely, H2, CO, CO2, H2O, CH4, O2, Csolid, and the temperature, under variable O2 and H2O molar ratios. Using three elemental mass balances, four equilibrium (Csolid) constant relations, and energy balance, the mathematical model is developed. The model incorporates the solid unburnt carbon in the product species. The temperature of gasification is determined through an iterative process. Using the result of the equilibrium model, a high-fidelity reactive flow model that accounts for the reactor geometry and the devolatilization kinetics is developed. This model accounts for an extended set of reactions covering the char combustion, water and gas shifts, Boudouard and devolatilization. Finally, economic analysis is carried out to assess the conditions when such a process can be deemed to be profitable. The result of the model shows that the maximum CGE is achieved when all the solid carbon is converted into carbon monoxide with nearly all hydrogen present in the feedstock converted into hydrogen gas. The maximum conversion was attained with sewage sludge and petroleum coke ratio of 1 at 1,200°C. The mole fraction of the syngas species obtained is XH2 = 0.4227 and XCO = 0.5774 and a small fraction of XCH4 = 0.0123. Moreover, the cold gasification efficiency (CGE) measures 87.02% for the H2 and CO syngas species and reached 91.11% for the three species, including CH4. The gasification of the sewage sludge and petroleum coke at 50:50 is economically viable at temperatures higher than 950°C. A peak net gain of 0.16 $/kg of fuel blend was achieved at 1,250°C. At temperatures lower than 950°C, net losses were realized. This could be associated with less product gas yield, which is not significant enough to counteract the input costs. For instance, the net losses were −0.03 and −0.17 $/kg of feedstock at 950 and 800°C, respectively.

The effects of a multidisciplinary pathway for perioperative management of patients with hip fracture

ABSTRACT Objectives To determine if a multidisciplinary pathway focused on non-opioid pain management, delirium assessment, and resource utilization improved outcomes in geriatric hip fracture patients. The goal was to reduce opioid usage, consultation not congruent with guidelines, and increase use of regional anesthesia to reduce delirium and improve outcomes. Methods An observational study was performed on hip fracture patients before and after the intervention. Hospitalists were educated on indications for preoperative cardiac consultation and specialized preoperative cardiac testing according to evidence-based guidelines with the inpatient cardiology service. Additional education on multimodal analgesia, limiting opioids, and peripheral nerve blocks was provided by the acute pain service. Pre-intervention outcomes from 1 July 20171 July 2017 to 31 May 201831 May 2018 (N = 92) were compared to post-intervention outcomes from 1 July 20181 July 2018 to 31 May 201931 May 2019 (N = 98) and included delirium, length of stay, 30-day readmission rate, time from arrival to procedure start time, time to first physical therapy session, and completion of cardiology consult time. We examined adherence, use of nerve blocks, and pre- and post-operative pain scores and opioid use. Results Delirium was reduced from 50.0% (N = 46/92) to 28.6% (N = 28/98); p = 0.002. Postoperative opioid use (IV morphine milligram equivalents) decreased from an average of 57.2 mg (±67.7) to 42.6 mg (±58.2),P < .0001. There was a significant decrease in mean pre-operative (5.4 ± 4.14 to 5.05 ± 2.8, P < .0001) and post-operative pain scores (4.3 ± 5.2 to 3.2 ± 2.2, P < .0001). There was a significant reduction in time to cardiology consultation from 18 h] to 12 h ; p < .001). Conclusions A multidisciplinary collaboration between hospitalists, anesthesiologists, and cardiologists for hip fracture patients was associated with a reduction in pain and delirium and time to cardiologist evaluation. Prospective studies focusing on additional patient-centered outcomes are warranted.

Patient involvement interventions for patients with kidney failure making end-of-life care decisions: a scoping review.

The objective of this review was to investigate and map empirical evidence of patient involvement interventions to support patients with kidney failure making end-of-life care decisions in kidney services. Clinical guidance integrating end-of-life care within kidney failure management pathways varies. Advance care planning interventions aimed at involving patients with kidney failure in their end-of-life care planning are established in some countries. However, there is limited evidence of the other types of patient involvement interventions integrated within services to support patients with kidney failure in making decisions about their end-of-life care. This scoping review included studies exploring patient involvement interventions evaluated for patients with kidney failure considering end-of-life care, their relatives, and/or health professionals in kidney services. Studies of children under the age of 18 years were excluded. The review was informed by JBI methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review guidelines. MEDLINE, Scopus, Embase, and CINAHL were searched for full-text studies in English, Danish, German, Norwegian, or Swedish. Two independent reviewers assessed the literature against the inclusion criteria. A relational analysis framework was used to synthesize the data extracted from the included studies, and to investigate and map different patient involvement interventions. The search identified 1628 articles, of which 33 articles met the inclusion criteria. A total of 23 interventions were described. Interventions targeted patients (n=3); health professionals (n=8); patients and health professionals (n=5); and patients, relatives, and health professionals (n=7). Intervention components included patient resources (eg, information, patient decision aids), consultation resources (eg, advance care planning, shared decision-making), and practitioner resources (eg, communication training). Patient involvement interventions were delivered within hospital-based kidney services. The review identified several ways to support patients with kidney failure to be involved in end-of-life care decisions. Future interventions may benefit from adopting a complex intervention framework to engage multiple stakeholders in the research and design of an intervention for shared decision-making between patients with kidney failure, their relatives, and health professionals about integrating end-of-life care options into their kidney disease management pathway.

Anaphylaxis management in a French pediatric emergency department: Lessons from the ANA-PED study.

Anaphylaxis is a serious systemic hypersensitivity reaction that requires immediate recognition and prompt administration of epinephrine/adrenaline. The present study aimed to assess the appropriateness of epinephrine/adrenaline use in children identified as allergic by physicians in the emergency department (ED) at the time of the reaction, and to identify factors that are possibly associated with epinephrine/adrenaline administration, auto-injector prescription, and further referral to an allergist. We performed a retrospective cross-sectional study at the pediatric ED of the University Hospital of Montpellier, France. We included all consecutive children who attended the ED between 2016 and 2020 with an allergy-related diagnosis at discharge. We included 1056 allergy-related visits, including 224 (21.2%) with a diagnosis of anaphylaxis at discharge; only 17.0% of them received an epinephrine/adrenaline injection, and 57.1% consulted an allergist after the acute episode. An auto-injector was prescribed to 63 (28.1%) patients at discharge from the ED. Besides the severity of the clinical presentation, factors associated with a guidelines-based management of the anaphylactic reaction and with an increased administration rate of epinephrine/adrenaline included presence of asthma symptoms and presence of extended skin reactions. Our study underlines persistent gaps in the management of pediatric anaphylaxis in ED, focusing on hereby identified levers. By disseminating current knowledge and guidelines on anaphylaxis and allergies, specialists could work together with emergency physicians to establish effective management algorithms and improve anaphylaxis management and care pathways for children experiencing allergic reactions, especially anaphylaxis. Clinical Trials, number NCT05112367.

With the rising trend of prostate cancer, where does northern Sri Lanka stand? A cohort study from a tertiary care centre.

Introduction: Prostate cancer is the second most common cancer among males all over the world in 2020. As per the global cancer observatory 1, 414, 259 (7.3%) cases were diagnosed in 2020 worldwide. The study aims to analyse the variations in demographic and clinico-pathological characteristics of prostate cancer in the Northern Province.&#x0D; Methods: This is a cross-sectional descriptive institution-based study that recruited all the prostate cancer patients who were treated at the Teaching hospital, Jaffna from August 2019 to August 2022. Data were extracted retrospectively from the clinic records of the patients as well as histopathology documents.&#x0D; Results: A total of 141 diagnosed patients at Teaching Hospital Jaffna were analysed. The mean age of the sample was 70.11± 8.43 years. Out of 141 patients, 30.49% were diagnosed to have localized disease and 26.24% and 43.26% with locally advanced and metastatic disease respectively. Out of those who had localized disease 68.5% were managed with radiotherapy, 23.25% with active surveillance and 11.6% with radical prostatectomy. The mean value of PSA was 70.11±8.4. The majority 97.2% had small acinar adeno carcinoma as histology. As per the D’Amico classification system for prostate cancer, 2.83% belonged to low-risk category and 80.1% belonged to high-risk category.&#x0D; Conclusion: There is a rising trend in the incidence of prostate cancer in Sri Lanka over the recent past. Most of the cases are advanced at the initial presentation. It implies the need for screening programmes with PSA in near future to detect cancer at early stages, implementation of cancer awareness programmes as practised in Western countries and strict adherence to national guidelines on management and referral pathways.

Pathways to care for psychosis in Malawi.

People with psychosis in Malawi have very limited access to timely assessment and evidence-based care, leading to a long duration of untreated psychosis and persistent disability. Most people with psychosis in the country consult traditional or religious healers. Stigmatising attitudes are common and services have limited capacity, particularly in rural areas. This paper, focusing on pathways to care for psychosis in Malawi, is based on the Wellcome Trust Psychosis Flagship Report on the Landscape of Mental Health Services for Psychosis in Malawi. Its purpose is to inform Psychosis Recovery Orientation in Malawi by Improving Services and Engagement (PROMISE), a longitudinal study that aims to build on existing services to develop sustainable psychosis detection systems and management pathways to promote recovery.

Epicardial adiposity in people with atrial fibrillation modified by physical exercise: an umbrella review

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Atrial Fibrillation (AF) affects 30% of the world’s population and accounts for 3 million deaths annually, and current management pathways often result in poor outcomes in recurrence of AF with up to 50% reoccurring post pulmonary vein isolation cardiac ablation (PVICA). Epicardial Adipose Tissue (EAT) is a metabolically active substrate implicated in the pathogenesis of AF. Increased levels of EAT thickness have been associated with the risk of developing AF and has also been associated with poorer outcomes and increased likelihood of AF recurrence after PVICA. The aim of this work was to explore current knowledge on levels of EAT in people with AF, post cardiac ablation, taking account of physical activity (PA). Objectives: Three research questions were set: · Does volume of EAT contribute to the pathogenesis and severity of AF? · Does any kind of PA modify EAT volumes? · Does PA improve outcomes in patients with AF who have undergone PVICA? Methods An umbrella review format was adopted with eligible studies from PubMed, EMBASE, the Cochrane Central Register of controlled trials (CENTRAL), Ovid MEDLINE, CINAHL, and Scopus and registered on Prospero. All results were reported adhering to Preferred Reporting items for Systematic Reviews and Meta-Analysis (PRISMA). Quality assessment evaluation involved the AMSTAR 2 tool and risk of bias evaluated using the ROBIS tool. No ethical considerations were identified for this review. Results Ten reviews were eligible for inclusion in the analysis. Five examined the relationship between EAT and AF occurrence, three examined EAT modifications with PA and two examined the effect of PA on AF outcomes. The quality of the studies was high, with a low risk of bias. Increased EAT volumes were associated with a large effect size for the development of AF Hedges’ g=0.86[0.79,0.92] for Total EAT volume and g=1.31[1.16,1.47] for Left Atrial (LA) EAT volume, and AF severity also had a large effect size for both Total and LA EAT volumes with g=0.87[0.71,1.02] and 0.99[0.69,1.3] respectively. EAT also showed a large effect on recurrence of AF post PVICA in both the Total and LA EAT groups 1.15[0.88,1.43] and 0.92[0.65,1.2]. The overall impact of PA showed a small to medium effect in reducing EAT volumes g=0.23[0,0.46]. Despite this PA was shown to significantly improve outcomes in reducing AF frequency, duration and severity and risk of mortality and serious adverse events in the intervention groups Conclusion Higher levels of EAT are associated with AF after PVICA but the influence of PA is unclear. This review highlights the need for further research evaluating the impact that physical activity has on EAT volume reduction and recurrence of AF post PVICA.

The Adaptive Systemic Approach: Catalysing more just and sustainable outcomes from sustainability and natural resources development research

AbstractIt has become increasingly common to include participatory processes, several academic disciplines, and additional wide‐ranging ways of knowing, in using research to tackle the escalating environmental problems of the 21st Century. There are barriers to the success of these efforts. In this paper we present the Adaptive Systemic Approach (ASA). The ASA is designed to provide a clear pathway for research related to sustainability issues, river basin problems and natural resource development, and to deliver change towards improved ecological health and social justice outcomes. The design of the ASA rests on three key concepts: complex social‐ecological systems, transdisciplinarity, and transformative social learning, together with Strategic Adaptive Management as the theoretically consistent operational process. We identify logical connections between the concepts and Strategic Adaptive Management so that the ASA emerges as a coherent and practical research and praxis pathway. The ASA process is then outlined to support uptake and wider application. We present findings from ASA praxis in a collaborative African research program considering river basin problems in seven countries, where key contextual learnings led to the recognition of five barriers to effective research impact outcomes: (1) Lack of an integrative conceptual grounding. (2) Participatory stakeholder engagement flawed by epistemic injustice. (3) Inadequate transdisciplinary team building. (4) Insufficient inclusion of learning, reflection, and systemic adaptation. (5) Inflated claims of probable impact in terms of creating change towards improved ecological health and social justice. We reflect on the ways the ASA contributes to breaching these barriers. Early key learnings from ASA praxis leads us to suggest that the ASA has practical value for policy makers, practitioners and researchers seeking pathways for fair and sustainable river management, and more broadly in natural resource development.

Pediatric Blunt Abdominal Trauma Evaluation and Management Pathways

Pediatric Blunt Abdominal Trauma Evaluation and Management Pathways

Comprehensive Review: Unveiling the Pro-Oncogenic Roles of IL-1ß and PD-1/PD-L1 in NSCLC Development and Targeting Their Pathways for Clinical Management.

In the past decade, targeted therapies for solid tumors, including non-small cell lung cancer (NSCLC), have advanced significantly, offering tailored treatment options for patients. However, individuals without targetable mutations pose a clinical challenge, as they may not respond to standard treatments like immune-checkpoint inhibitors (ICIs) and novel targeted therapies. While the mechanism of action of ICIs seems promising, the lack of a robust response limits their widespread use. Although the expression levels of programmed death ligand 1 (PD-L1) on tumor cells are used to predict ICI response, identifying new biomarkers, particularly those associated with the tumor microenvironment (TME), is crucial to address this unmet need. Recently, inflammatory cytokines such as interleukin-1 beta (IL-1β) have emerged as a key area of focus and hold significant potential implications for future clinical practice. Combinatorial approaches of IL-1β inhibitors and ICIs may provide a potential therapeutic modality for NSCLC patients without targetable mutations. Recent advancements in our understanding of the intricate relationship between inflammation and oncogenesis, particularly involving the IL-1β/PD-1/PD-L1 pathway, have shed light on their application in lung cancer development and clinical outcomes of patients. Targeting these pathways in cancers like NSCLC holds immense potential to revolutionize cancer treatment, particularly for patients lacking targetable genetic mutations. However, despite these promising prospects, there remain certain aspects of this pathway that require further investigation, particularly regarding treatment resistance. Therefore, the objective of this review is to delve into the role of IL-1β in NSCLC, its participation in inflammatory pathways, and its intricate crosstalk with the PD-1/PD-L1 pathway. Additionally, we aim to explore the potential of IL-1β as a therapeutic target for NSCLC treatment.

Integrating biomarkers and multi-parametric MRI to provide enhanced clinical diagnosis for prostate cancer

Prostate cancer (PCa) risk assessment can incorporate clinical features, gene expression, protein ‘biomarkers’ or imaging. In this review the benefits of layering multiparametric magnetic resonance imaging (mpMRI) with other risk assessment methods is considered. mpMRI is an increasingly utilized risk assessment tool in prostate cancer. The European Association of Urology, National Comprehensive Cancer Network (NCCN) and American Urological Association (AUA) guidelines call for mpMRI utilization in the prostate cancer management pathway. As such, the NCCN Guidelines and AUA guidelines emphasize differing levels of reliance on mpMRI preceding prostate biopsy. However, like all risk assessment tools, mpMRI has strengths and limitations. This include dependencies on reader expertise and interpretation, equipment and process standardization, tumor size, tumor multifocality, tissue architecture, ethnic and racial disparity, and cost. Thus, layering complementary risk assessment methods to mitigate the limitations of each approach, enables the most informed clinical management. The goal of ongoing biomarker/mpMRI studies is to provide insight into the clinically helpful integration of the two approaches. For new technologies to be adapted or layered together synergistically, five specific competencies must be considered acceptable: (1) efficacy, (2) potential side effect levels, (3) ease of use of technology, (4) cost vs. clinical benefit, and (5) durability.

Impact of the SARS-CoV-2 Pandemic on Treatment Pathways and Outcomes of Esophagogastric Cancer: A Pre- Versus Post-Pandemic Comparison of International Prospective Cohort Data

Introduction: This study aimed to characterize the outcomes of esophagogastric (OG) cancer patients and compare perioperative outcomes with pre-pandemic data. Methods: Three international prospective cohort studies were included in this analysis. First, COVIDSurg-Cancer (n = 1999) included patients with an OG cancer planned for surgery from the start of the pandemic up to 14th April 2020 with follow-up until 31st August 2020. Treatment pathways and outcomes were compared against patients undergoing treatment for OG cancers before the pandemic, Oesophagogastric Anastomosis Audit (OGAA, n = 2246) and GlobalSurg 3 (n = 1256) study. The surgical composite outcome was defined as in patients achieving margin negative resection, resectability and no postoperative mortality. Results: This study included 1999 patients during the COVID-19 pandemic, of which 32.4% had a change from standard pre-pandemic management. Patients with delay to surgery had significantly higher rates of no surgery (24.7%vs 7.5%, P &lt; .001) and less likely to have achieve a composite outcome (57.8%vs 73.4%, P &lt; .001) than those without any delay in surgery. There was no significant difference in 30-day mortality (3.5% vs 3.4%; OR: 0.98, CI95%: 0.69-1.37) or anastomotic leak rate (10.9% vs 10.2%%; OR: 1.11, CI95%: 0.90-1.37) but higher reoperation rates (13.6% vs 10.4%; OR: 1.59, CI95%: 1.30-1.92) in patients between pre-pandemic and pandemic cohorts. Conclusion: The pandemic appears to have led to widespread changes in management pathways affecting one-third of patients. Developing elective surgical pathways resilient to periods of system “stress” are key to minimizing future harm from treatment delay for OG cancer patients.

Pediatric status epilepticus management by Emergency Medical Services (the pSERG cohort)

PurposeDelayed treatment in status epilepticus (SE) is independently associated with increased treatment resistance, morbidity, and mortality. We describe the prehospital management pathway and Emergency Medical Services (EMS) timeliness in children who developed refractory convulsive status epilepticus (RCSE). MethodsRetrospective multicenter study in the United States using prospectively collected observational data from June 2011 to March 2020. We selected pediatric patients (one month–21 years) with RCSE initiated outside the hospital and transported to the hospital by EMS. ResultsWe included 91 patients with a median (percentile25-percentile75) age of 3.0 (1.5–7.3) years. The median time from seizure onset to hospital arrival was 45 (30–67) minutes, with a median time cared for by EMS of 24 (15–36) minutes. Considering treatment by caregivers and EMS before hospital arrival, 20 (22%) patients did not receive any anti-seizure medications (ASM) and 71 (78%) received one to five doses of benzodiazepines (BZD), without non-BZD ASM. We provided the prehospital treatment flow path of these patients through caregivers and EMS including relevant time points. Patients with a history of SE were more likely to receive the first BZD in the prehospital setting compared to patients without a history of SE (adjusted HR 3.25, 95% CI 1.72–6.12, p<0.001). ConclusionIn this multicenter study of pediatric RCSE, prehospital treatment may be streamlined further. Patients with a history of SE were more likely to receive prehospital rescue medication.