The COVID-19 pandemic has impacted on the delivery of healthcare across the UK. Patients with head and neck cancers (HNC) are faced with complex management strategies which are delivered by multidisciplinary teams (MDT) despite current restrictions. We present the challenges and strategies for providing cancer care.
The coronavirus pandemic of 2019–2020 is an infectious disease caused by extreme acute respiratory coronavirus syndrome 2 (SARS‐CoV‐2). The virus primarily spread among people when they closely meet each other. Due to the decreased immune-compromised state, cancer patients are at high risk. Through this whitepaper, we have enlighted about the effect of the COVID-19 on cancer patients.
BJS commission on surgery and perioperative care post covid-19Ahmad Ozair
Background: Coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO on 11 March 2020 and global surgical practice was compromised. This Commission aimed to document and reflect on the changes seen in the surgical environment during the pandemic, by reviewing colleagues’ experiences and published evidence. Methods: In late 2020, BJS contacted colleagues across the global surgical community and asked them to describe how severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) had affected their practice. In addition to this, the Commission undertook a literature review on the impact of COVID-19 on surgery and perioperative care. A thematic analysis was performed to identify the issues most frequently encountered by the correspondents, as well as the solutions and ideas suggested to address them. Results: BJS received communications for this Commission from leading clinicians and academics across a variety of surgical specialties in every inhabited continent. The responses from all over the world provided insights into multiple facets of surgical practice from a governmental level to individual clinical practice and training. Conclusion: The COVID-19 pandemic has uncovered a variety of problems in healthcare systems, including negative impacts on surgical practice. Global surgical multidisciplinary teams are working collaboratively to address research questions about the future of surgery in the post-COVID-19 era. The COVID-19 pandemic is severely damaging surgical training. The establishment of a multidisciplinary ethics committee should be encouraged at all surgical oncology centres. Innovative leadership and collaboration is vital in the post-COVID-19 era.
The coronavirus pandemic of 2019–2020 is an infectious disease caused by extreme acute respiratory coronavirus syndrome 2 (SARS‐CoV‐2). The virus primarily spread among people when they closely meet each other. Due to the decreased immune-compromised state, cancer patients are at high risk. Through this whitepaper, we have enlighted about the effect of the COVID-19 on cancer patients.
BJS commission on surgery and perioperative care post covid-19Ahmad Ozair
Background: Coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO on 11 March 2020 and global surgical practice was compromised. This Commission aimed to document and reflect on the changes seen in the surgical environment during the pandemic, by reviewing colleagues’ experiences and published evidence. Methods: In late 2020, BJS contacted colleagues across the global surgical community and asked them to describe how severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) had affected their practice. In addition to this, the Commission undertook a literature review on the impact of COVID-19 on surgery and perioperative care. A thematic analysis was performed to identify the issues most frequently encountered by the correspondents, as well as the solutions and ideas suggested to address them. Results: BJS received communications for this Commission from leading clinicians and academics across a variety of surgical specialties in every inhabited continent. The responses from all over the world provided insights into multiple facets of surgical practice from a governmental level to individual clinical practice and training. Conclusion: The COVID-19 pandemic has uncovered a variety of problems in healthcare systems, including negative impacts on surgical practice. Global surgical multidisciplinary teams are working collaboratively to address research questions about the future of surgery in the post-COVID-19 era. The COVID-19 pandemic is severely damaging surgical training. The establishment of a multidisciplinary ethics committee should be encouraged at all surgical oncology centres. Innovative leadership and collaboration is vital in the post-COVID-19 era.
Should All Patients Having Planned Procedures or Surgeries Be Tested for COVI...JohnJulie1
The current pandemic of Corona Virus Disease-2019 (COVID-19) which is caused by Severe Acute Respiratory Syndrome Corona Virus-2 (SARS-CoV-2) has resulted in lockdown in many countries culminating in a major socio-economic crisis globally. COVID-19 can remain asymptomatic and so is crucial for early diagnosis to prevent further spread of this pandemic.
Should All Patients Having Planned Procedures or Surgeries Be Tested for COVI...suppubs1pubs1
The current pandemic of Corona Virus Disease-2019 (COVID-19) which is caused by Severe Acute Respiratory Syndrome Corona Virus-2 (SARS-CoV-2) has resulted in lockdown in many countries culminating in a major socio-economic crisis globally. COVID-19 can remain asymptomatic and so is crucial for early diagnosis to prevent further spread of this pandemic. Here we highlight the importance of screening asymptomatic patients prior to elective surgery, procedure or scheduled hospital admission. This analysis was done for the month of July 2020 during which 261 asymptomatic people were screened for COVID-19. Out of this, 6 patients (2.29%) were diagnosed to have COVID-19 on nasopharyngeal/ oropharyngeal swabs and subsequently had to delay their elective procedure or surgery. This clearly shows how important it is to screen this cohort of asymptomatic people who could potentially have spread the virus to other patients as well as healthcare professionals.
Don't miss our upcoming webinars! Subscribe today!
In April, CCSN virtually met with MPPs throughout Ontario to discuss our COVID-19 and Cancer Care - Wave 2 Survey. During these meetings, we discussed the difficulty cancer patients and pre-diagnosis patients have had with accessing cancer services during the pandemic and the importance of ensuring the cancer patients receive their 1st and 2nd vaccine doses in a timely manner.
In this webinar, CCSN's Public Policy Analyst Conrad will begin by sharing some of the highlights from our meetings with Ontario MPPs. He will then turn things over to our patient advocates and they will share some of their reflections from our meetings as well as their own experiences with accessing cancer care during the pandemic. Lastly, Conrad will take a closer look at the Ontario data from our survey.
View the YouTube video: https://youtu.be/05u4i89WFfQ
Follow CCSN on social media:
Twitter - https://twitter.com/survivornetca
Facebook - https://www.facebook.com/CanadianSurvivorNet
Instagram: https://www.instagram.com/survivornet_ca/
Pinterest - https://www.pinterest.com/survivornetwork
The 2019 Diagnostic Summit brought together diagnostic developers in academia and industry as well as end-users in the pharmaceutical and healthcare sector to gain a comprehensive picture of diagnostics in prenatal, oncology, infectious disease, point-of-care, and liquid biopsy.
This important Summit enabled delegates to learn what novel technologies, platforms and applications are emerging that will impact future healthcare delivery and pharmaceutical research.
Bringing together European leading experts via presentations, workshops and case studies the Summit was a must attend event! We explored:
Current diagnostic testing in GP surgeries and Pharmacies
How Diagnostics can be funded and funding barriers
Advances in Prenatal Molecular Diagnostics
Diagnostic Regulations
Point of care testing
Advanced Diagnostics for infectious diseases
Adapting and evaluating Innovation
Education on testing and accuracy
Patient and Clinical pathways
Key health areas examined in the Summit included:
Sexual Health
Diabetes
Cancer
Antibiotic Resistance
Sepsis
Obesity
Urinary Infections
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The current pandemic of Corona Virus Disease-2019 (COVID-19) which is caused by Severe Acute Respiratory Syndrome Corona Virus-2 (SARS-CoV-2) has resulted in lockdown in many countries culminating in a major socio-economic crisis globally. COVID-19 can remain asymptomatic and so is crucial for early diagnosis to prevent further spread of this pandemic.
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Don't miss our upcoming webinars! Subscribe today!
In April, CCSN virtually met with MPPs throughout Ontario to discuss our COVID-19 and Cancer Care - Wave 2 Survey. During these meetings, we discussed the difficulty cancer patients and pre-diagnosis patients have had with accessing cancer services during the pandemic and the importance of ensuring the cancer patients receive their 1st and 2nd vaccine doses in a timely manner.
In this webinar, CCSN's Public Policy Analyst Conrad will begin by sharing some of the highlights from our meetings with Ontario MPPs. He will then turn things over to our patient advocates and they will share some of their reflections from our meetings as well as their own experiences with accessing cancer care during the pandemic. Lastly, Conrad will take a closer look at the Ontario data from our survey.
View the YouTube video: https://youtu.be/05u4i89WFfQ
Follow CCSN on social media:
Twitter - https://twitter.com/survivornetca
Facebook - https://www.facebook.com/CanadianSurvivorNet
Instagram: https://www.instagram.com/survivornet_ca/
Pinterest - https://www.pinterest.com/survivornetwork
The 2019 Diagnostic Summit brought together diagnostic developers in academia and industry as well as end-users in the pharmaceutical and healthcare sector to gain a comprehensive picture of diagnostics in prenatal, oncology, infectious disease, point-of-care, and liquid biopsy.
This important Summit enabled delegates to learn what novel technologies, platforms and applications are emerging that will impact future healthcare delivery and pharmaceutical research.
Bringing together European leading experts via presentations, workshops and case studies the Summit was a must attend event! We explored:
Current diagnostic testing in GP surgeries and Pharmacies
How Diagnostics can be funded and funding barriers
Advances in Prenatal Molecular Diagnostics
Diagnostic Regulations
Point of care testing
Advanced Diagnostics for infectious diseases
Adapting and evaluating Innovation
Education on testing and accuracy
Patient and Clinical pathways
Key health areas examined in the Summit included:
Sexual Health
Diabetes
Cancer
Antibiotic Resistance
Sepsis
Obesity
Urinary Infections
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i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
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Volume 6 Issue 11 -2022 Research Article
were communicated to the team during treatment. Results will be
disseminated by publication.
1.2.5. Main outcome measures: Urgent cancer referrals, cancer
diagnostic rates, changes in pathways and investigations, face-to-
face appointments, cancer operations, palliative care referrals.
Study registration: Institutional approval was granted (Ref: 10959),
University Hospitals of Leicester UK.
1.3. Results: There were 896 urgent HNC referrals in the 2019
study months compared to 585 referrals during the COVID lock-
down in 2020. This is a 35% reduction in cancer referrals along-
side a 58% increase in late presentations. There was reduction in
face-to-face clinics and investigations (20-75%). Telephone con-
sults and direct access to radiologic tests, were used for screening.
There were pressures on staffing from shielding, re-allocation and
remote working.
1.4. Conclusions: The COVID-19 pandemic resulted in signifi-
cant reductions in urgent HNC referrals. Telephone consultations
and direct access to investigations are effective interventions dur-
ing lockdown. Staffing pressures, clinic / theatre capacity, remote
working and patient anxieties must be addressed.
2. Introduction
The worldwide outbreak of the coronavirus (COVID-19) pan-
demic that began in December 2019, has led to significant disrup-
tions in the healthcare delivery system. It is caused by the severe
acute respiratory syndrome coronavirus 2 (SARS-COV-2) which
is a positive-sense, single-stranded RNA virus that is transmitted
mainly by aerosol and droplets [1]. Transmission occurs with di-
rect or indirect contact with droplets from an infected person [2].
The World Health Organization (WHO) designates the COVID-19
pandemic, a public health emergency of international concern [3].
In the UK, there was a pandemic-enforced national lockdown
from 30th March 2020 – 4th August 2020 intended to reduce ris-
ing COVID infection rates [4]. National guidelines for limiting the
spread of the infection included social distancing and self-isola-
tion whenever required, wearing masks and the avoidance of large
gatherings. Access to healthcare was modified to accommodate
the restrictions on movement, both in primary care with general
practitioners and in secondary level care. Leicester was put into an
extended period of further local lockdown due to the rising cases
of coronavirus infections in the county compared to the rest of the
UK, with particular lessons for a multicultural population [5]. The
restructuring of the head and neck cancer services across the UK
led to challenges with providing prompt diagnosis and the delivery
of complex treatments that include surgical resections, chemother-
apy, radiotherapy, immunotherapy, speech and swallowing thera-
pies and dietary modifications. The pandemic lockdown in Leices-
ter affected staffing levels, clinic space availability for multidisci-
plinary reviews, theatre capacity for surgery, diagnostic pathways
for radiology and histopathology, patient perceptions on seeking
help, and ultimately cancer stage at presentation. Patients also had
limited access to rehabilitation during lockdown.
It is important to reflect on the impact of COVID-19 on our head
and neck cancer services, identify the challenges and the strategies
implemented by all teams that ensured our patients continued to
receive the best care possible. This review of our experience in
Leicester is all the more crucial on the eve of a second wave of
COVID-19 across the UK. Our head and neck cancer multidisci-
plinary hope to share the lessons learned during this pandemic and
the ways we have adjusted to manage this crisis with our cancer
patients remaining the focus and beneficiaries of excellent care.
3. Methods
This was a retrospective analysis of data on head and neck can-
cer services at the University Hospitals of Leicester, East Mid-
lands UK. We compared the data of various disciplines involved
in multidisciplinary cancer care between the 3 months last year
pre-COVID (1st April 2019 – 30th June 2019) with the same pe-
riod this year during the COVID lockdown (1st April 2020 – 30th
June 2020). Institutional approval was granted by the quality im-
provement board (Ref: 10959), University Hospitals of Leicester
NHS Trust.
We compared the following outcome measures: total number of
urgent cancer referrals, cancer diagnostic rates, changes in diag-
nostic pathways and investigations, changes in clinic arrange-
ments, number of face-to-face appointments / clinics by allied
health, number of cancer operations, and number of referrals for
palliative treatment. We also documented the qualitative impact
of the COVID pandemic on multidisciplinary team staffing, emo-
tional well-being, remote working and the anxieties of patients and
healthcare access that could lead to delayed cancer presentations.
Patients were involved in the design and conduct of the telephone
consultations and revised follow up strategies.
Statistical analysis was done using STATA SE version 16. Mean
data for both independent time periods was analysed using an un-
paired t-test whilst categorical data was analysed with chi-square.
A p-value less than 0.05 was taken as reaching statistical signifi-
cance.
4. Results
There were 896 urgent head and neck cancer referrals from 1st
April 2019 – 30th June 2019 compared to 585 referrals during
the COVID lockdown period (1st April 2020 – 30th June 2020).
This represents a significant reduction of 35% in cancer referrals
(p<0.001; unpaired t-test). The proportion of HNC diagnosed from
these referrals was 6.4% in 2019 and 7.7% in 2020 series. There
was significant reduction in the numbers of patients seen face-
to-face in clinics by all specialties due to space constraints and
infection prevention measures (Table 1). Telephone consultations
and direct access to radiologic tests, were therefore utilised more
frequently for triaging and follow-up. There were pressures on
staffing instigated by shielding, re-allocation and remote working.
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Volume 6 Issue 11 -2022 Research Article
Table 1: COVID-19 impact on head and neck cancer services in Leicester
Cancer service
Pre-COVID-19 COVID-19 lockdown
COVID-19 Impact
1st
April – 30th
June 2020
1st
April – 30th
June 2019
2-week wait clinic referrals:
Total 896 585 35% reduction ↓
ENT Surgery 529 423 20% reduction ↓
Maxillofacial Surgery 274 162 41% reduction ↓
H&N (uncategorised) 93 0
Cancer diagnosis rate:
Cancers diagnosed 57 45 21.1% increase ↑
Total referrals 896 585 34.7% reduction ↓
% cancer diagnosis rate 6.40% 7.70% 1.3% increase ↑
Pathology reviews:
Histopathology 774 191 75.3% reduction ↓
Cytology 622 323 48.1% reduction ↓
Radiology 2ww:
CT scans 203 147 27.6% reduction ↓
MRI scans 120 97 19.2% reduction ↓
Ultrasound scans 196 144 26.5% reduction ↓
Straight to test Thyroid Ultrasound
scans
16 11 31.3% reduction ↓
Oncology:
Radical Radiotherapy 24 25 4.2% increase ↑
Palliative radiotherapy 6 11 83.3% increase ↑
Cancer stage & pathways:
Number of T3 tumours 2 (3.5%) 5 (11.1%) 7.6% increase ↑
Number of T4 tumours 3 (5.3%) 7 (15.6%) 10.3% increase ↑
Time from GP referral to review 13.7 days 11.6 days 2.1 days’ reduction↓
Time to cancer treatment 66.5 days 73.7 days 7.2 days’ increase ↑
Speech Therapy:
Laryngectomy (face to face) 48 42 12.5% reduction ↓
Laryngectomy (phone/email) 18 62 244.4% increase ↑
Outpatient (face to face) 166 46 72.3% reduction ↓
Outpatient (phone/email) 63 228 262% increase ↑
Macmillan HNC specialists
Face to face clinics 100 0 100% reduction ↓
Tracheostomy
Adult tracheostomy 20 9 55% reduction ↓
Tracheostomy for HNC 12 6 50% reduction ↓
Emergency tracheostomy HNC 2 (16.7%) 4 (66.7%) 50% increase ↑
5. Cancer referrals to ENT & Maxillofacial Surgery
During the lockdown triggered by rising cases of COVID-19 in-
fections in Leicester, the urgent 2-week wait cancer referrals from
GPs to the ENT surgery unit reduced from 529 in the pre-COVID
2019 period to 423 patients in 2020. This is a 20% reduction in
referrals. Similarly, urgent referrals to the Maxillofacial surgery
reduced by 41% as the unit were referred 274 patients in 2019
compared to 162 in 2020 in the 3 months of lockdown (Table 1).
Urgent uncategorised head and neck referrals to the MDT from
non-standard pathways also dropped precipitously from 93 to 0
cases. The clinic capacity for head and neck services was affected
with the necessary infection control measures limiting the number
of patients that could be seen at any one time.
Theatre capacity for complex head and neck cancer surgery was
also significantly affected with few theatre lists available for all
surgeons during COVID lockdown. This was due to the rede-
ployment of theatre staff to intensive care unit and the strict in-
fection prevention guidelines on aerosol generating procedures
with protocols on use of personal protective equipment, theatre
airflows, decontamination procedures which all added to the total
time available per operation. Patients who may have required ma-
jor resections for their cancers alongside with microvascular flap
reconstruction were offered non-surgical treatment with chemo-
radiation. This became necessary due to cancer presentations in
advanced stage and the lack of post-operative intensive care unit
capacity which was under stretch from care of COVID positive
patients on ventilato
6. Radiology Services
Diagnostic radiology was universally affected due to the reduced
numbers of cancer referrals for scans. Cross-sectional imaging
with CT scans reduced from 203 scans to 147 scans (27.6% reduc-
tion) in the same 3 months’ period pre and post-COVID shown in
Table 1. There was also a 19.2% reduction in the number of MRI
scans performed for cancers from 120 to 97 during lockdown. Ul-
trasound scans were offered in joint clinics with clinicians to pro-
vide an effective service however scans reduced from 196 to 144
(26.5% reduction) during lockdown.
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Volume 6 Issue 11 -2022 Research Article
A unique Leicester initiative called ‘straight to test ultrasound’ser-
vice established to facilitate prompt diagnosis of suspected thyroid
malignancies allows General Practitioners to request ultrasound
thyroid scans if there were clinical concerns prior to reviews in
secondary care. In the pre-COVID months in 2019, this service
performed 16 thyroid ultrasound scans but this reduced to 11 scans
during COVID lockdown in 2020 (31.3% reduction).
7. Pathology Services
At the time of the initial lock down, there was a dramatic reduction
in the number of routine head and neck cases being submitted for
pathology review. Over the 3 months April – June compared, there
were 774 histopathology reviews in 2019 and 191 such reviews
in 2020. This is a significant reduction of 75.3% directly due to
the COVID-19 pandemic (Table 1). Since the easing of national
lockdown, the number of cases has gradually increased to approx-
imately 50% of pre-COVID numbers. Anecdotally the complexity
of the cases seems to have increased, although this is likely to be
explained by them not hiding amongst the routine work.
Cytological examination with fine needle aspiration (FNA) and
frozen sections were suspended during the initial phases of the
COVID-19 pandemic, following recommendations from the Roy-
al College of Pathologists. These services are now restored. There
was discontinuation of the joint rapid on-site evaluation clinic
done with radiologists for adequacy assessments which are yet to
be restored. Reduced theatre capacity for surgeons also affected
the number of cancer resections sent for histopathologic exami-
nation.
8. Oncology Services
There was a significant increase in referrals from the head and
neck MDT for palliative radiotherapy during COVID lockdown
2020 when compared to the same 3 months in 2019. In pre-COV-
ID April – June 2019, palliative radiotherapy was administered to
6 patients compared with 11 patients in 2020 lockdown. This rep-
resents an 83.3% increase which was directly due to the increase
in advanced cancer presentations. There was a 7.6% increase in
T3 tumours and a 10.3% increase in T4 tumours treated during
the COVID lockdown. There was no significant change in rad-
ical radiotherapy treatments delivered during COVID lockdown
although there was a slight 4.3% increase. The lack of theatre and
intensive care unit capacity for all major cancer resections for our
surgeons also created a shift towards radiotherapy +/- chemother-
apy for curative treatment instead for some patients. This led to a
backlog of treatment schedules and some delay in time from GP
referral to commencement of cancer treatment of a week (Table 1).
9. Speech & Language Therapy
The COVID-19 pandemic has impacted significantly on the de-
livery of the speech and language therapy (SLT) service. All face
to face clinics were discontinued resulting in a lack of capacity
for supporting patients with their swallow assessments, voice and
speech rehabilitation. Usually clinics would allow joined up care
by allied health professionals but the reorganisation of clinic space
for a COVID-safe environment resulted in loss of a clinic room for
SLT. A number of solutions were put in place including setting up
telephone clinics for pre-surgery assessments and post treatment
reviews. In addition, there were assessments of radiotherapy pa-
tients in mask fit appointments, ad-hoc laryngectomy valve chang-
es and regular telephone contacts. Extensive written emergency
care advice for laryngectomy patients, increase in home visit as-
sessment and reviews, set up of video consultations, and working
from home wherever possible, were also solutions.
All instrumental assessments for swallowing were also discontin-
ued. The SLT solution was the development of the RAG rating
for video-fluoroscopy (VF) which highlighted urgent cases to be
reviewed. The SLT Royal College stated that SLT’s should discon-
tinue fibreoptic endoscopic evaluation of swallowing (FEES) im-
mediately during the first wave. There was also the lack of access
to GPs and follow up care. SLT however has access to ‘Systemone’
which is a community electronic system for recording notes which
has helped with communication. There are still difficulties liaising
with GPs about patients in the community given the remote work-
ing arrangements. This has led to an increase in patients contacting
SLT to resolve issues. Patients cannot receive rehabilitation in the
community as services are not running or are running with a back-
log e.g. physio, lymphedema, and occupational therapy.
A Virtual MDT occasionally had variable connection leading to
limited SLT contribution. This resulted in communication via
email or at other points in the week, which was more time-con-
suming. The RCSLT states that a swallow assessment is an aerosol
generating procedure (AGP). Therefore initially during the pan-
demic, SLT had issues getting hold of adequate PPE for swallow
assessments. Going forward it means that any swallow assessment
needs to be carried out in a space which can be used for AGP as-
sessment. This has reduced SLT ability to assess patient in clinics.
Access to rehabilitation for speech, swallow and voice remains
reduced including suspension of the laryngectomy support group.
10. Dietetics
COVID-19 has significantly affected the dietetic service that is pro-
vided to Head and Neck Cancer patients. The cessation of all face
to face outpatient clinics impacted the pre-treatment assessment of
patients, monitoring of those on chemotherapy and radiotherapy
and the follow up of patients post treatment. These clinics were
predominantly transferred to telephone consultations but the as-
sessment and care it is possible to provide in this manner is greatly
diminished compared to seeing patients face to face. It is also diffi-
cult to build relationships with patients and nearly impossible with
family members when you do not see them in person. Towards the
beginning of the summer we started to see patients for pre-assess-
ment within existing face to face appointments in the radiotherapy
department. Whilst this is much better for patient care, it is harder
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Volume 6 Issue 11 -2022 Research Article
to manage within the caseload due to the ad hoc nature of these
appointments. We have adapted to working from home to allow for
social distancing within offices and this has forced the availability
of adequate IT and virtual systems to connect with UHL. Online
meetings have also proved more time efficient although IT issues
have affected full participation of dietetics in the virtual MDT.
Due to the limited PPE within the Trust initially, Dietetic staff were
not permitted to attend the wards in person. For 3 months all inpa-
tient dietetic reviews were done using ‘nerve centre’- the hospital
online portal, and speaking to ward staff over the telephone. This
clearly negatively impacted the service provided.
Finally, the effects of lockdown have had significant impacts on
a number of patients. Many have presented with large tumours,
significant dysphagia and often needed emergency admissions for
feeding. They then have reduced treatment options and poorer out-
comes. In this second wave of the pandemic, dietetics will utilise
telephone consultations and continue to plan face-to-face meetings
that coincide with the treatment pathways for chemo-radiation.
11. Macmillan Head and Neck CNS
There were peculiar challenges during the COVID pandemic and
resulting lockdown on the delivery of specialist Macmillan nurs-
ing care. The necessary emotional bond we create for our patients
and the outlet we provide for helping them through their cancer
diagnosis, answering their questions and providing support, were
all stretched. Our team of three nurses was further affected by the
reassignment of staff to critical areas of need. The lack of face-to-
face consultations was particularly challenging before and during
treatment especially as we also lost clinic space due to the hos-
pital infection control restrictions. Strategies adapted included
telephone and video consultations, timing patient contacts to those
times when they attend hospital for radiotherapy (alongside allied
health professionals), and sending emails / texts and letters with
all the required information. We contributed regularly at the virtual
MDT and continued to be advocates for our vulnerable patients.
There were more referrals for palliative radiotherapy during COV-
ID lockdown as patients presented in advanced stage (Table 1).
These were cases where both the patients and their relatives re-
quired a lot of our support.
12. Emergency Services / Tracheostomy
During the COVID lockdown, there was a 50% reduction in the
number of semi-elective tracheostomy done for patients with head
and neck cancers partly due to the reduced numbers of complex
resections. These tracheostomy cases were performed as part of
their major cancer operations to protect their airway and micro-
vascular reconstruction. There was however a 50% increase in
the number of emergency tracheostomy done during the COVID
lockdown 2020 (Table 1). These patients presented to the accident
and emergency department with advanced head and neck cancers
and airway compromise. The on-call team had to intervene with
often awake tracheostomy under local anaesthetic, panendoscopy,
biopsies and tumour debulking prior to treatment discussions at
the MDT meeting.
13. Discussions
The challenges from the COVID pandemic and lockdown have led
to evolutions in our way of working as a multidisciplinary cancer
team delivering head and neck services. These include the develop-
ment of innovative diagnostic pathways, triage systems, and treat-
ment strategies that minimise the risk of infection transmission to
both healthcare workers and the population. People affected with
cancers are a particularly vulnerable group and it is essential that
measures are in place to ensure the continued delivery of excellent
care despite the COVID pandemic. Head and neck cancers can
be distressing for patients and challenging to manage given the
consequences on daily functions like breathing and swallowing.
Early diagnosis and individualised treatment therefore determines
survival, quality of life and the risk of cancer recurrence.
13.1. 2-week wait cancer referrals
It is important to implement a system that enables early identi-
fication of possible malignant conditions. This helps in early di-
agnosis and appropriate management of these cancers improving
their prognosis. The efficacy of the two-week wait (2ww) system
in identifying HNC patient has always been a subject of interest,
as it helps in improving patient care, with a UK study reporting the
targets were met during lockdown,[6]. NICE guidelines have pro-
vided an urgent referral check list which helps GP to triage their
referral. We found that the number of patients referred to head and
neck services on 2ww referral has reduced by 35% during lock-
down. This may be due to limited access of patients to GPs during
this pandemic. Moreover, with the number of GP clinics reduced
significantly during lockdown, these reduced 2ww referrals were
anticipated. The cancer diagnosis rate from these referrals has
increased from 6.4% in 2019 to 7.7% in 2020. This increase in
conversion rate may be due to overall reduction in the number of
2-week wait referrals. A systematic review studied a total of 1,809
2ww referrals which yielded 199 cancer patients [7]. The propor-
tion of 2ww referrals that were positive for head and neck cancer
also ranged from 6.3% to 14.6% among the included studies. They
suggested that this low yield may be due to inappropriate referral
or the guideline for referral has low specificity. In order to improve
the accuracy, we have started straight to test referral which enables
appropriate triage of the patients by GP.
Our study has confirmed delayed presentation of head and neck
cancers in some patients during the COVID lockdown in Leices-
ter. The proportion of advanced cancers (T3 and T4) managed by
our MDT increased by 7.3% and 10.3% respectively. The factors
contributing to delayed presentations will include patient factors
like anxieties and the fear of a cancer diagnosis, access to clini-
cal examinations given the majority of the increased primary care
consultations were conducted over the telephone as well as the re-
strictions on movement in the community due to a surge of COV-
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Volume 6 Issue 11 -2022 Research Article
ID infections.
The average time it took from GP referrals to commencement
of cancer treatment was 67 days pre-COVID and increased by a
week to 74 days during the COVID lockdown. The lack of the-
atre and ICU capacity for some cancer resections led to curative
intent treatment with radiotherapy +/- chemotherapy and a longer
wait time to get through appointments. There was pressure also
on the alternative treatment modality of chemoradiation as there
were more patients needing planning CT scans, mould-making and
delivery of radiation over 6 weeks. There was less time availa-
ble for surgery during COVID lockdown particularly because our
trained perioperative staff were redeployed to acute areas such as
the intensive care unit. There were also reduced theatre lists with
the head and neck surgeons (ENT & Maxillofacial) sharing an all-
day list twice a week. Aside reduced lists, it was imperative that
new strict protocols on the perioperative use of personal protective
equipment (doffing & donning) as well as the extra taken to de-
contaminate a used theatre and ensure appropriate air flows. This
trend is nationally recognised as many units had to make these
difficult decisions with less operating time. It is not only the cancer
cases that suffered an impact this way as it also includes significant
waits for elective surgery, with the RCS confirming approximately
5 million people are on the elective surgery waiting lists across
the UK.
Challenges during the COVID-19 lockdown included reductions
in the physical space available for outpatient clinics to review
urgent cancer referrals. This was due to the strict guidelines on
ensuring infection prevention in a pandemic with all attendees to
clinics required to wear face masks and adequate spacing between
patients in the waiting room area. Aerosol generating procedures
such as tracheostomy manipulations, flexible nasendoscopy were
performed in a designated, well-ventilated procedures clinic room
with decontamination of equipment after each use. These COV-
ID-related challenges to the delivery of speech and language ther-
apy, instrumentation, nutritional assessments and support for head
and neck cancer patients has been highlighted by a UK discussion
paper [8].
A number of strategies were adopted to ensure prompt identifica-
tion of any head and neck cancers and delivery of excellent care
by our MDT. One of such diagnostic pathway modifications was
the utilisation of the ‘straight to test thyroid ultrasound scan’ ser-
vice run by our head and neck radiology team. Any patients with a
thyroid lump and suspicious clinical features, was referred direct-
ed for an ultrasound scan by their General Practitioner. The scan
images and results were then reviewed by our thyroid MDT. This
led to a reduction in the time to either a cancer diagnosis, further
investigations or return to GP for discharge if benign pathology
was identified.
A telephone triaging service was widely utilised by our MDT es-
pecially allied health specialists. Our team ensured holistic contact
with our cancer patients, reassuring them of their treatment pro-
gress, and promptly recognising whenever there was deterioration
in speech or swallowing from radiation effects. Modifications to
optimise nutritional intake and treatment outcomes were achieved
using the telephone service. There are however challenges to the
use of telemedicine for head and neck cancer surveillance broadly
during this COVID pandemic that include preference of patients
for face-to-face visits, technology barriers and the need to clini-
cally assess [9].
14. Conclusions
The COVID-19 pandemic has affected head and neck cancer ser-
vices in Leicester where lockdown restrictions have been in place
longer than most UK cities. Our study shows an increase in ad-
vanced stage cancers during lockdown and an increase in pallia-
tive cancer treatment as a consequence. There has been a reduction
in the number of urgent cancer referrals from primary care during
lockdown and our service has continued to deliver an excellent
service by adapting to the use of telemedicine. Challenges of lock-
down included reduction in available clinic space for face-to-face
reviews as well as the limited theatre and intensive care unit capac-
ity for major cancer resections.
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