A computational modeling approach for dosing endoscopic intratumoral chemotherapy for advanced non-small cell lung cancer

We recently developed a computational model of cisplatin pharmacodynamics in an endobronchial lung tumor following ultrasound-guided transbronchial needle injection (EBUS-TBNI). The model suggests that it is more efficacious to apportion the cisplatin dose between injections at different sites rather than giving it all in a single central injection, but the model was calibrated only on blood cisplatin data from a single patient. Accordingly, we applied a modified version of our original model in a set of 32 patients undergoing EBUS-TBNI for non-small cell lung cancer (NSCLC). We used the model to predict clinical responses and compared them retrospectively to actual patient outcomes. The model correctly predicted the clinical response in 72% of cases, with 80% accuracy for adenocarcinomas and 62.5% accuracy for squamous-cell lung cancer. We also found a power-law relationship between tumor volume and the minimal dose needed to induce a response, with the power-law exponent depending on the number of injections administered. Our results suggest that current injection strategies may be significantly over- or under-dosing the agent depending on tumor size, and that computational modeling can be a useful planning tool for EBUS-TBNI of cisplatin in lung cancer.

Analysis of Spatial Accessibility and Capacity of Multi-Level Healthcare Facilities in Greater Irbid Municipality, Jordan

Measuring the spatial accessibility and capacity of healthcare facilities is an important task to improve the quality of health services and reduce the pressure on them. This research assesses the current spatial accessibility and capacity of two-level of healthcare facilities (comprehensive healthcare centers and hospitals) in the Greater Irbid Municipality using the enhanced two-step floating catchment area (E2SFCA) method. To do this, Network analysis techniques including original-destination matrix (OD), service area, and location-allocation were employed for determining the travel time from residents' points towards every healthcare facility, the service coverage and capacity within travel time zones, and the number of served areas by every healthcare facility. Then, optimum locations for new healthcare facilities that improve the accessibility and capacity rates were determined. The results show that while all areas in the study area are located within a 30-minute drive from the hospital's locations, 18 out of 23 areas are within 15 minutes drive towards the comprehensive health centers. This means that 28.80% of the population needs more than 15 minutes of driving time to access the second level of healthcare services. In addition, the annual average of the actual patient-doctor ratio ranges from 1338 to 2900 patients per doctor in the hospitals, and 2676 to 8524 patients per doctor in the comprehensive healthcare centers, and thus, the health services are inadequate in the study area. Furthermore, the suggested new healthcare facilities in terms of the numbers and optimum location would improve the spatial accessibility and the capacity ratio.

Simultaneous radiosurgery for multiple brain metastases: technical overview of the UCLA experience

Purpose/objective(s) To communicate our institutional experience with single isocenter radiosurgery treatments for multiple brain metastases, including challenges with determining planning target volume (PTV) margins and resulting consequences, image-guidance translational and rotational tolerances, intra-fraction patient motion, and prescription considerations with larger PTV margins. Materials/methods Eight patient treatments with 51 targets were planned with various margins using Elements Multiple Brain Mets SRS treatment planning software (Brainlab, Munich, Germany). Forty-eight plans with 0 mm, 1 mm and 2 mm margins were created, including plans with variable margins, where targets more than 6 cm away from the isocenter were planned with larger margins. The dosimetric impact of the margins were analyzed with V5Gy, V8Gy, V10Gy, V12Gy values. Additionally, 12 patient motion data were analyzed to determine both the impact of the repositioning threshold and the distributions of the patient translational and rotational movements. Results The V5Gy, V8Gy, V10Gy, V12Gy volumes approximately doubled when margins change from 0 to 1 mm and tripled when change from 0 to 2 mm. With variable margins, the aggregated results are similar to results from plans using the lower of two margins, since only 12.2% of the targets were more than 6 cm away from the isocenter. With 0.5 mm re-positioning threshold, 57.4% of the time the patients are repositioned. Reducing the threshold to 0.25 mm results in 91.7% repositioning rate, due to limitations of the fusion algorithm and actual patient motion. The 90th percentile of translational movements in all directions is 0.7 mm, while the 90th percentile of rotational movements in all directions is 0.6 degrees. Median translations and rotations are 0.2 mm and 0.2 degrees, respectively. Conclusions Based on the data presented, we have switched our modus operandi from 2 to 1 mm PTV margins, with an eventual goal of using 0.5 and 1.0 mm variable margins when an automated margin assignment method becomes available. The 0.5 mm and 0.5 degrees repositioning thresholds are clinically appropriate with small residual patient movements.

Assessing Professional Students' Application of the International Classification of Functioning, Health, and Disability Model and Patient-Reported Outcome Measures During Patient Care

Context The International Classification of Functioning, Health, and Disability (ICF) model and patient-reported outcome measures (PROMs) are concepts that must be addressed in professional education. Objective Describe a class assignment that allows students to integrate the concepts of the ICF model and PROMs into actual patient care. Background Adult learners, including professional athletic training students, thrive on learning experiences where they can apply concepts and integrate new knowledge with existing knowledge. In addition, existing research suggests that most athletic trainers are not integrating PROMs into their clinical practice; therefore, students are most likely not seeing the use of PROMs during clinical education. Faculty can facilitate the application of the ICF model and PROMs into patient care with a course-based assignment. Description The assignment requires students to use the ICF model as an assessment tool with an actual patient, which helps shape their therapeutic interventions. Students recorded baseline and follow-up PROMs with this patient over a time period of at least 3 weeks while documenting their interventions and the patient's change over time. Students addressed reflection prompts in the assignment by describing their successes and challenges, in addition to describing their future plans for integrating the ICF model and PROMs into their clinical practice. Clinical Advantage(s) Students described this assignment as beneficial because it helped them treat their patients more holistically. Students self-reported increased knowledge and confidence with using the ICF model and PROMs in their clinical practice. Students described a plan to integrate these concepts into their clinical practice in a limited fashion. Conclusion(s) Faculty may consider integrating an applied, patient-based assignment such as this to assess students' application of the ICF model and PROMs to an actual patient. This assignment can also be easily condensed or expanded to fit different courses, student background knowledge, and assessment of different curricular content standards.

TELENURSING IN PHYSICAL AND OCCUPATIONAL THERAPISTS’ TRAINING

The necessity of distance learning of specialists practitioners, in particular in the field of knowledge «Health care», which is induced by COVID-19, causes a significant public response. This is due to a possible decline in the quality of higher education, and therefore the security of citizens and the state. Consequently, the search of modern, effective methods and means of learning and training for healthcare specialists is relevant. Quarantine restrictions of educational communication have sharpened attention, firstly, to telecommunication means, secondly, to active learning methods, and thirdly, to the mobilization of internal reserves to expand the practical educational component. This is how the idea of simulated professional support arose. It was realized by the students of physical therapy during the rehabilitation period of a university lecturer. It was the postoperative period of endoprosthesis and simulated professional support was provided with the help of telenursing. The essence of the simulation was that the real rehabilitation period had already passed, but it was agreed to repeat it for a didactic purpose. 46 first-year students of the specialty «Physical Therapy, Occupational Therapy» took part in the experiment. At first, they were trained a set of exercises (according to the recommendations of the clinic), while paying attention to the practical, psychological and pedagogical aspects of interaction. Then, students conducted rehabilitation classes with the help of telecommunication means, which lasted for a month. An incoming survey was conducted (based on motivation of professional activity): among the students and it showed that 32 of them (69.6%) are positively professionally motivated, 45 respondents (97.8%) felt subjective satisfaction with their professional choice. The final study (an interview) with the question «How has the attitude to professional activity changed») represents that 31 (67.4%) respondents were ready for practical conduction of similar professional support. Telenursing proves its effectiveness not only as a means of actual patient care (according to the literature), but also as a kind of learning, using a case study (according to our data). However, the telecommunication means, which were chosen for rehabilitation, including video communication via Viber and Messenger as more common among the potential customers, did not fully satisfy students who preferred Microsoft Teams and Google Meet as less related to social media and personal profiles data, as well as with better possibilities of lesson planning. This indicates the formation of professional competencies that are based on the combination of psychological and pedagogical, information and communication competencies, hence, the effectiveness of the proposed method.

1090. Does calculation method matter for targeting vancomycin AUC?

Background Recent vancomycin (VAN) guidelines recommend targeting an area under the curve (AUC) concentration of 400-600 for treatment of methicillin resistant Staphylococcus aureus infections. Multiple strategies for calculating AUC exist, including first order pharmacokinetic (foPK) equations and Bayesian models. Most clinical applications of foPK assume unchanged patient status and project ideal administration times to estimate exposure. Bayesian modeling provides the best estimate of true drug exposure and can incorporate changing patient covariates and exact doses. We compared two commonly used foPK methods to Bayesian estimates of VAN AUC. Graphs depict calculated AUCs using the three different methods: 1) Population PK estimated (foPOPPK) 2) Two-level first dose estimated (foFDPK) 3) Bayesian estimated. Methods First order equations were performed using population PK estimates (foPOPPK) to estimate steady state (SS) AUC and initial doses. Two concentrations after first dose were used to estimate SS AUC (foFDPK). A 2-compartment Bayesian model allometrically scaled for weight and adjusted for creatinine clearance was used to determine 24-48 hour AUCs. Differences between AUCs were compared using a mixed-effects analysis, and correlation of foPK equations to Bayesian estimates was described using Spearman’s correlation. Patient results from each method were classified as below (< 400), within (400-600), or above ( >600) targets. Results 65 adult patients were included. The median and IQR for calculated AUCs using foPOPPK, foFDPK, and Bayesian methods were 495.6 (IQR: 76.6), 498.2 (IQR: 107.4), and 472.1 (IQR: 177.9), respectively with p >0.65 for both foPK methods vs. the Bayesian method. AUCs predicted by foPK equations were poorly correlated with Bayesian AUCs (Spearman’s rho= -0.08, p=0.55), while AUCs from foFDPK better correlated with Bayesian AUCs (Spearman’s rho= 0.48, p=0.00). AUCs were within, above, and below target for 54%, 20%, and 26% for the Bayesian model; 95%, 5% and 0% for foPOPPK; and 74%, 12%, and 14% for foFDPK. foPK AUC estimates concurred with Bayesian estimates only 52% of the time. Conclusion AUCs calculated by the three methods did not differ on average, but dosing recommendations for foPK at the patient level varied substantially compared to the Bayesian method. This difference is because Bayesian estimation incorporates actual patient exposures while foPK equations rely on idealized dose timing to predict AUCs. Disclosures Kimberly C. Claeys, PharmD, GenMark (Speaker’s Bureau) Marc H. Scheetz, PharmD, MSc, Nevakar (Grant/Research Support)SuperTrans Medical (Consultant)US Patent #10688195B2 (Other Financial or Material Support, Patent holder)

Follow-Up Care Barriers for Patients with Orofacial Clefts

Objective The aim of this study was to evaluate whether a patient with a cleft's age, associated syndrome, cleft phenotype or travel distance affects their follow-up rate. Design This study is a retrospective review of patients with CL/P treated by a craniofacial clinic. Setting The setting was a craniofacial clinic at a tertiary care university hospital. Patients, Participants Candidates were patients seen by the craniofacial clinic between January 2007 and December 2019. An initial pool of 589 patients was then reduced to 440 due to exclusion criteria. Interventions None Main Outcome Measure(s) The outcome measure was actual patient attendance to the craniofacial team compared to the team goal expectation of annual return visits. Results The mean age of participants at the end of the study was 9.0 ± 5.4 years with a mean follow-up period (total possible follow-up period length based on patient age at presentation and study window) of 5.5 ± 3.6 years. There was no association between cleft phenotype, type of syndrome, or distance to the clinic with attendance. Children with syndromes had an 11% decrease in the odds of attending follow-up visits with each 1-year increase in age compared to a 4% decrease in children without syndromes. Conclusions The only significant factors determining patient attendance were the presence of a syndrome and increasing age.

Surgical Navigation Systems Based On AR/VR Technologies

This study considers modern surgical navigation systems based on augmented reality technologies. Augmented reality glasses are used to construct holograms of the patient's organs from MRI and CT data, subsequently transmitted to the glasses. Thus, in addition to seeing the actual patient, the surgeon gains visualization inside the patient's body (bones, soft tissues, blood vessels, etc.). The solutions developed at Peter the Great St. Petersburg Polytechnic University allow reducing the invasiveness of the procedure and preserving healthy tissues. This also improves the navigation process, making it easier to estimate the location and size of the tumor to be removed.We describe the application of developed systems to different types of surgical operations (removal of a malignant brain tumor, removal of a cyst of the cervical spine). We consider the specifics of novel navigation systems designed for anesthesia, for endoscopic operations. Furthermore, we discuss the construction of novel visualization systems for ultrasound machines. Our findings indicate that the technologies proposed show potential for telemedicine.

EP.FRI.574 Screening tool to improve patient referral to acute surgical care from Emergency Department

Introduction The study aimed to audit the appropriateness of surgical referrals to general surgery; and, secondly, to devise a screening tool for use in the emergency department to screen patients that are safe to be discharged and to be seen in surgical ambulatory clinics. Methods The first phase of the study was an audit to check appropriateness of the surgical referrals (1st-18th February 2020). In the second part, a screening tool questionnaire was prospectively tested (1st February-24th March 2020) on the surgical referrals. The accuracy of the screening tool outcome was compared to actual patient consultation outcomes. The sensitivity and specificity of the questionnaire was assessed using an ROC curve. Results In the first audit, 68.9% patients were discharged on the same day with or without follow up in the ambulatory surgical clinic. In the prospective questionnaire phase of the study, there were 98 patients and the most common presentation was abdominal pain (n = 60) followed by urological symptoms (n = 11), symptoms of hernia complication (n = 10), abscess (n = 7) and testicular pain (n = 2). The sensitivity and specificity of the screening tool was 60.7% and 100%, respectively with overall accuracy being 88.82%. The area under the ROC curve was 0.80. Conclusion A large proportion of the patients referred to the acute surgical unit can be deferred and seen in the ambulatory clinic. The screening tool has the potential to screen patients who can be seen in the ambulatory clinic and safe to identify patients who require urgent surgical admission.