Ovarian Transposition Strategy in Patients with Cervical Cancer Who Undergo Pelvic Radiation: Proposal of Ovarian Placement Based on Virtual Simulations

Objective: To establish a proposal for the location for ovarian transposition, considering different irradiation techniques and time to ovarian failure. Methods: Patients with cervical cancer in childbearing age submitted to adjuvant radiotherapy were selected. Delineation of simulated positions of the ovaries and pelvic radiation planning was done in CT, with three techniques: 3D conformal radiotherapy, intensity-modulated radiotherapy, and volumetric modulated arc radiotherapy. In order to correlate the ovaries maximal doses with the time to ovarian failure, the authors have used the one adaptation of Wallace model that predicts oocytes survival rates after radiation exposure. Results: Thirteen patients who were being treated between 2008 and 2017 were studied. When the ovaries were positioned 10 cm cranially from the sacral promontory, the pelvic radiation entails a decrease of 20% in the time to ovarian failure compared with that expected for a female at the same age without irradiation exposition. The placement of the ovaries <5 cm cranially from the sacral promontory results in a decrease >90%. There was no difference in time to ovarian failure between the radiation treatment techniques tested: 3D conformal radiotherapy, intensity-modulated radiotherapy, and volumetric modulated arc radiotherapy (p=0.197). Conclusions: The present study, based on virtual simulations, is the first to use the sacral promontory as a reference for a proposal of ovarian location with transposition. The authors have correlated the position of the ovaries and percentage of decrease in time to ovarian failure. These findings can potentially improve the management and counselling of patients with cervical cancer in childbearing age and deserve clinical validation.

Therapeutic Plasma Exchange Using Convalescent Plasma Replacement Therapy in Severe COVID-19 Infections: A Potential Therapeutic Option

Currently, the coronavirus disease (COVID-19) pandemic, which is caused by severe acute respiratory syndrome coronavirus 2 (SARS CoV-2), is a major global public health emergency. Cytokine storm is a key factor and plays a major role in disease severity and clinical outcome. Recently, the literature reveals the use of therapeutic plasma exchange to reduce the inflammatory markers. Evidence also exists for the use of convalescent plasma therapy in patients with severe COVID-19. This brief communication explores the advantages on therapeutic plasma exchange with convalescent plasma in patients with moderate-to-severe COVID-19.

The Rise of Telemedicine: Lessons from a Global Pandemic

Telemedicine has been available for healthcare systems to assist patient care for many years; however, it was not until recently that the field of telemedicine exploded. Inconsistent coverage of telemedicine services as well as a general level of unfamiliarity with the technology required to perform telemedicine services contributed to the lack of its widespread use. The coronavirus disease (COVID-19) pandemic drove the institution of telemedicine in all areas of healthcare. Healthcare institutions around the world adapted both inpatient and outpatient services in order to utilise telemedicine. The implementation of telemedicine can partly be attributed to the expansion of insurance coverage as well as the relaxation of technology requirements to avoid Health Insurance Portability and Accountability Act (HIPAA) violations. During the global pandemic, telemedicine helped to preserve personal protective equipment during a worldwide shortage, protect healthcare workers from being infected, and allowed the monitoring of patients’ chronic conditions without putting them at risk by attending medical settings. The COVID-19 outbreak has highlighted the advantages that telemedicine has to offer and has served as the push many health systems needed to implement telemedicine services more widely across these institutions. This article highlights the role of telemedicine during the ongoing COVID-19 global pandemic.

General Practice Services in England During the COVID-19 Pandemic and Beyond: Patient Access and Barriers

Background: During the coronavirus disease (COVID-19) pandemic, primary care services have been forced to operate differently, limiting face-to-face consultations and relying on telemedicine. This has impacted the care received by patients in need of primary care. The aim of this article was to assess the patient needs during the pandemic, their perspectives on current interactions with primary care, and the readiness for change in operating general practices in the future. Method: A survey was conducted among patients in Leeds, UK, that explored whether patients had health needs during the pandemic, the decisions that were then taken if so, their use of online information and resources, and their satisfaction with primary care website portals and consultations. Results: Over 75% of patients gathered information online before deciding to consult. The main effect of the pandemic was that among those whose health needs remained, 37% did not consult, preferring to wait to see if their symptoms resolved by themselves. There was a significant statistical difference depending on age groups: among those patients aged <30 years, 48% did not consult a primary care physician. Conclusion: The primary care response during the pandemic led to a large number of patients to withhold their concerns, and careful consideration is needed to access how to improve accessibility in future crises.

Rapid Reconfiguration of Paediatric Services in a District General Hospital During COVID-19, Addressing Challenges, and Seeing Opportunities

The scale, speed, and impact of the coronavirus disease (COVID-19) pandemic disruption to healthcare services has been unprecedented, placing significant additional pressures on the National Health Service (NHS). COVID-19 presented exceptional challenges to vulnerable families and is placing increasing pressure on children’s services. The child population does not seem to have been severely impacted by COVID-19; however, some will require hospital care in addition to the current caseload. It is imperative that steps are taken to ensure continued delivery of urgent and emergency paediatric services and the associated maternity and neonatal services at local levels throughout the pandemic. A rapid reconfiguration of services was necessary when the pandemic reached the NHS. Healthcare services had to rethink how to deliver care in the short and medium term, better preparing them for future demands and ensuring that safe and effective care was maintained.

Triggers, Timescales, and Treatments for Cytokine-Mediated Tissue Damage

Inflammation, an essential cytokine-mediated process for generating a neutralising immune response against pathogens, is generally protective. However, aberrant or excessive production of proinflammatory cytokines is associated with uncontrolled local and systemic inflammation, resulting in cell death and often irreversible tissue damage. Uncontrolled inflammation can manifest over timescales spanning hours to years and is primarily dependent on the triggering event. Rapid and potentially lethal increases in cytokine production, or ‘cytokine storm’, develops in hours to days, and is associated with cancer cell-based immunotherapies, such as chimeric antigen receptor T-cell therapy. On the other hand, some bacterial and viral infections with high microbial replication or highly potent antigens elicit immune responses that result in supraphysiological systemic cytokine concentrations, which manifest over days to weeks. Immune dysregulation in autoimmune diseases can lead to chronic cytokine-mediated tissue damage spanning months to years, which often occurs episodically. Upregulation of IL-1, IL-6, IFN-γ, TNF, and granulocyte macrophage colony-stimulating factor frequently coincides with cytokine storm, sepsis, and autoimmune disease. Inhibition of proinflammatory molecules via antagonist monoclonal antibodies has improved clinical outcomes, but the complexity of the underlying immune dysregulation results in high variability. Rather than a ‘one size fits all’ treatment approach, an identification of disease endotypes may permit the development of effective therapeutic strategies that address the contributors of disease progression. Here, the authors present a literature review of the cytokine-associated aetiology of acute and chronic cytokine-mediated tissue damage, describe successes and challenges in developing clinical treatments, and highlight advancements in preclinical therapeutic strategies for mitigating pathological cytokine production.

Digit-all: Rare Diseases

Rare diseases are increasingly recognised as a global public health priority and contribute to significant and disproportionately high health system impacts. Accordingly, they present clinical and public health challenges, as well as opportunities for digital health solutions across the lifespan, including improved diagnosis, treatment, navigation and care coordination, and integration and coordination for broader societal and patient wellbeing. People living with rare diseases, individually and cumulatively, are digital disruptors. In this manuscript the authors describe some of the unique dynamics of the rare disease domain as they currently, or have the potential to in the future, apply to digital health; highlight some recent international rare diseases digital health initiatives; and touch upon implications for those with more common disorders.

A Path for Translation of Machine Learning Products into Healthcare Delivery

Despite enormous enthusiasm, machine learning models are rarely translated into clinical care and there is minimal evidence of clinical or economic impact. New conference venues and academic journals have emerged to promote the proliferating research; however, the translational path remains unclear. This review undertakes the first in-depth study to identify how machine learning models that ingest structured electronic health record data can be applied to clinical decision support tasks and translated into clinical practice. The authors complement their own work with the experience of 21 machine learning products that address problems across clinical domains and across geographic populations. Four phases of translation emerge: design and develop, evaluate and validate, diffuse and scale, and continuing monitoring and maintenance. The review highlights the varying approaches taken across each phase by teams building machine learning products and presents a discussion of challenges and opportunities. The translational path and associated findings are instructive to researchers and developers building machine learning products, policy makers regulating machine learning products, and health system leaders who are considering adopting a machine learning product.

Utility of Perioperative Warming for the Prevention of Surgical Site Infection and Patient Rehabilitative Complications: A Systematic Review

Overview: Surgical site infection (SSI) is a leading cause of postoperative complication, rehospitalisation, and patient mortality after invasive clinical interventions. Surgical risks compounded by SSI introduce greater medical, economic, and quality-of-life challenges for both patients and providers alike, and to better inform clinical practice, empirical evaluation of modern surgical warming techniques is relevant. This systematic review and meta-analysis qualitatively examined the efficacy of both active and passive perioperative warming interventions upon SSI presentation versus standardised (i.e., non-warming) care. Methods: This review analysed available literature on active and passive warming application across general anaesthesia procedures, containing longitudinal data on patient outcomes and SSI. The primary outcome studied was occurrence of post-surgical SSI; secondary outcomes included rehabilitative length of stay, attributable SSI-related mortality, and incidence of re-admittance. Results: Meta-analysis demonstrated a significantly reduced risk ratio for SSI in patients receiving any surgical warming intervention (odds ratio: 0.36; 95% confidence interval: 0.18–0.87; p<0.01) compared to individuals treated under standard care conditions, with limited further data supporting improved active warming effect in contrast with passive implementation. Secondary postoperative outcomes, including length of rehabilitative stay or wound healing score (ASEPSIS), correspondingly demonstrated greater outcomes for surgical patients receiving perioperative warming. Introduction of warming interventions consistently correlated with reduced patient-reported pain experiences (p<0.05) and downstream care expenditures (p<0.01). Conclusion: The present review identified evidence supporting a statistically significant correlation between both active and passive perioperative warming interventions to SSI prevention. These findings strongly support the recommendation of standardised perioperative warming implementation with continued investigation of relative efficacy contrasting active and passive methodologies, and across more diverse and substantial patient population sizes.