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20th April 2020
Patient communication and minimising infection risk
NG170 discusses the importance of communicating with patients, their families and carers to support their mental wellbeing during the COVID-19 pandemic to alleviate any anxieties or concerns they might have about the virus. NG170 suggests signposting patients to the Cystic Fibrosis Trust, which has information for patients on the virus as well as the NHS guidance on mental health and wellbeing aspects of COVID-19. In addition, NG170 reminds health professionals how some patients, families or carers might also need specialist psychological or social support during the current pandemic.
It is recommended that health professionals minimise face-to-face contact for consultations and make use of either via telephone or video instead and to contact patients via email or text messaging if possible. Health professionals should explore the provision of equipment for home spirometry testing and if appropriate weighing scales and facilities to collect samples remotely. However, NG170 advises that routine childhood vaccinations should continue at GP surgeries. NG170 also suggest using electronic rather than paper prescriptions need to explore alternative delivery routes for prescriptions and medicines such as pharmacy delivery services, via the post, using NHS volunteers or having drive-through pick-up points for medicines.
Patients or family members and carers should contact their cystic fibrosis team if they suspect that the patient has COVID-19 symptoms to ensure that they are appropriately assessed. Alternatively they must contact the NHS111 online coronavirus service but if seriously ill to contact emergency services. NG170 also reminds staff that pulmonary disease exacerbations may be difficult to differentiate at the initial presentation.
Patients not known to have COVID-19
NG170 stresses the need for patients and their families or carers need to follow the government advice on shielding and social distancing stringently but where this is not possible, for instance, they have a caring role, to adopt shielding measures.
Where a face-to-face appointment is deemed necessary, health professionals need to ensure appropriate measures are in place to prevent cross-infection and follow the NICE guideline on cystic fibrosis. In addition, patients are advised to attend alone or with no more than 1 family member and to avoid public transport if possible.
Patients known or suspected of having COVID-19
In cases where a patient has symptoms of COVID-19 on first presentation, NG170 advises health professional staff to follow the government guidance on investigation and initial clinical management of possible cases which provides information on testing and isolating patients.
Additionally, all healthcare staff having contact with patients either known or suspected of being infected, should follow the UK government guidance on infection prevention and control. Teams are advised to report known or suspected cases of COVID-19 to the UK cystic fibrosis registry.
Due to the risk of spreading the virus, NG170 recommends that infected patients carry out airway clearance in well-ventilated rooms, away from other family members as the sputum generated is a potentially infectious aerosol. Other family members should avoid entering the room until enough time has passed for the aerosol to clear. NG170 suggests that teams reassure patients that nebulisers are safe to use because the nebulised fluid does not contain virus particles from the patient. Furthermore, family members or carers supporting patients with equipment such as masks, need to use appropriate hand hygiene.
Treatment and care planning
NG170 advises patients and their families or carers to continue with all the usual self-care measures such as airway clearance, prophylactic treatments, cystic fibrosis transmembrane conductance regulator therapies (CFTR) and home exercise. This will include any advice on the course of action for an exacerbation. Treatments should be continued to be prescribed for no more than 30 days and clinical teams need to be aware that cystic fibrosis patients may be at a greater risk of rapid deterioration if they contract COVID-19.
Modification to usual care
NG170 recommends that specialist cystic fibrosis centres maintain contact with network and outreach clinics via telephone or video consultations and that centres maintain a sufficient number of inpatient beds for those requiring urgent hospital admission. It advises that day-case facilities may still be required for administration of first doses of intravenous antibiotics and for flushing totally implantable intravenous devices although the flushing frequency can be reduced. Finally, it is necessary to ensure that teams retain sufficient clinical expertise and capacity to support the care and needs of patients as safely as possible and wherever practicable at home.
When reviewing patient care plans, NG170 advises teams to consider patients on a case-by-case basis and to involve the multidisciplinary team in any decision-making and that any changes are recorded and fully communicated with patients, family members or carers. Hospital lung function testing can be done only where the results have a direct impact on patient care and make greater use of home spirometry.
Patients can still access CFTR therapies under the NHS England policy for these drugs. NG170 reminds teams that the data collection agreement has a minimum requirement of annual assessments and that liver function test and eye monitoring are only required when clinically indicated. Data reporting by staff (for example, cystic fibrosis quality dashboard quarterly returns) can be reduced provided the deadline of 31 January 2021 is still met. It is also recommended that the transition of young people is deferred until the pressures of the COVID-19 pandemic have passed.
Healthcare workers
NG170 suggests that all NHS staff involved in all aspects of patient care (including receiving, assessing and caring) who have known or suspected COVID-19 infection or who live in a household where there is another who is known or suspected to have COVID-19, should follow the government guidance on self-isolation. If self-isolating are still able to work, suggested roles include undertaking telephone or video consultations and participation in virtual multidisciplinary meetings. These staff can also help identify patients who can be monitored remotely and those who might require more support as well as performing any routine tasks which can be done remotely.
NG169 is available online and interested readers should check this version for further updates.
However, an editorial by two US dermatologists argues against blanket discontinuation.2 The authors note how much of the lung damage from COVID-19 infection is due to an exaggerated immune response or cytokine storm, with high levels of cytokines such as tumour necrosis-factor-alpha (TNF-∝).
They suggest that clinicians consider the evidence from other viral outbreaks to help inform their decision-making. For instance, a study in mice showed how treatment with biologics such as TNF-∝ inhibitors improved outcomes by limiting the lung damage caused by the H1N1 (SARS) virus.3 Furthermore, they point to data in a US biologics registry showing how rates of serious infection were lower in patients prescribed ustekinumab and that there appears to be little difference in general infection rates between drug and placebo groups in those prescribed interleukin-17 and interleukin-23 antagonists.
They conclude that in the absence of definitive evidence that use of biologics increases the risk of COVID-19 infection, decisions to stop treatment should be made on an individual basis, balancing the likely risk of infection with the fact that discontinuation will undoubtedly lead to disease exacerbation.References
References
Until now, these conditions have typically been diagnosed using blood samples or skin prick tests but researchers in Munich have now tested a new diagnostic method.
Claudia Traidl-Hoffmann, a professor of environmental medicine at TUM and the director of the Institute of Environmental Medicine at the Helmholtz Zentrum München, and her team have studied nasal smears using a method originally developed for blood samples. With a recent development in biochip technology, practitioners have been able for some time now to measure antibody concentrations for 112 different allergens with a single small blood sample.
Prof. Traidl-Hoffmann’s team used this molecular diagnostics technology to measure concentrations of immunoglobulin E (IgE) antibodies in the blood and nasal secretions of test subjects. These antibodies play a role in certain allergic responses. The researchers studied individuals with and without sensitisation to the most common airborne allergens, including dust mite castings, grass pollen and the pollen of birch, hazelnut and alder trees.
For the same tests, the blood and nasal smears yielded similar results: They detected identical allergic sensitisation patterns, that is, the same sets of substances for which the body had developed an immune response. This was the case for all airborne allergens investigated. Previous studies had already demonstrated a link between the detection of allergy antibodies in the blood and in nasal secretions for certain aeroallergens. The researchers have now confirmed this correlation for a wide range of such allergens.
“A big advantage of allergy diagnostics with a nasal smear is that it is a good option for small children as compared to blood samples or skin prick testing. For that age group, a hyposensitisation therapy is important because allergic rhinitis can develop into allergic asthma,” says Prof. Claudia Traidl-Hoffmann. PD Dr. Stefanie Gilles adds: “We also believe that, with nasal smears, IgE antibodies specific to certain allergies can be detected that cannot be measured in a blood sample. We now need to do further studies to explore that hypothesis.”
17th April 2020
Patient communication
NG164 recognises the importance of communicating with patients to support their mental wellbeing during the pandemic and to help alleviate any anxieties or concerns that they might have about COVID-19. Patients requiring HSCT are likely to be immunosuppressed and clinics are required by the guidance to introduce measures to help minimise the potential for contracting or spreading COVID-19.
As an example, NG164 directs that healthcare staff minimise face-to-face patient contact and have telephone or video consultations. Non-essential follow-ups should be minimised and greater use made of home delivery services for medicines, or drive-through medicine pick-up points and that clinics coordinate access to blood tests for post-transplant investigations.
For essential clinic appointments, clinics are advised to ask patients to attend alone if possible and if not, with no more than one family member or carer. Patient wait times should be minimised through careful scheduling and patients discouraged from attending too early and to remain in their transport vehicle until sent a text message that they are ready to be seen at the clinic.
Patients known or suspected of having COVID-19
NG164 advises all staff (including those involved in receiving, assessing and caring) working with suspected or infected patients to follow the government infection and prevention control guidance.
Patients displaying new symptoms
NG164 suggests that clinics direct patients who feel unwell before an appointment, to contact their dedicated transplant programme helpline to ensure that symptoms are appropriately assessed. NG164 also reminds clinicians that immunosuppressed HSCT patients may display atypical COVID-19 symptoms although in those with a fever (with or without respiratory symptoms), neutropenic sepsis should be suspected. Because this condition can rapidly develop and is potentially life-threatening, NG164 advises that clinicians follow the NICE guideline on neutropenic sepsis and to immediately refer suspected cases to secondary or tertiary care and offer patients empiric antibiotic therapy.
If a patient is subsequently diagnosed with COVID-19 and not initially isolated, NG164 suggests that staff follow the current guidance for health professionals. Furthermore, where patients were not previously known to be infected develop new symptoms suggestive of COVID-19, staff are directed to follow guidance on investigation and initial clinical management which includes relevant information on testing and isolating patients.
Transplant recipients: pre-transplant guidance
Patients NOT known to have COVID-19
Solid organ transplant recipients are considered extremely vulnerable in the NHS shielding guidance and pre-transplant patients are advised to follow this guidance for at least two weeks before the procedure. Moreover, NG164 recommends that all patients are tested for respiratory viruses and COVID-19 at least once and 72 hours before their procedure. Further recent guidance on this topic has been produced by the British Society of Blood and Marrow Transplantation and Cellular therapy.
Autologous transplants
NG164 recommends deferral for all but exceptional cases of these transplants for myeloma, low-grade lymphoproliferative diseases and non-malignant indications and stresses that decisions should be made by a multidisciplinary team on an individual basis until the risks associated with the COVID-19 pandemic have passed.
Allogeneic transplant recipients
Equally, NG164 advises deferral for the majority of these transplants for any non-urgent indications and chronic haematological malignancies. Furthermore, NG164 instructs that allogeneic transplants should be deferred for three weeks if the recipient has been in close contact with an individual who has tested positive for COVID-19 within the last week.
Patients known or suspected of having COVID-19
NG164 advises testing patients for both COVID-19 and other respiratory viruses using the recent government guidance on investigation and initial clinical management of possible cases. This guidance directs that transplants are deferred by at least 3 months in those who test positive for COVID-19 except for patients who have a high risk of disease progression, morbidity or mortality.
However, for COVID-19 patients with a high risk of disease progression, NG164 advises that transplant is deferred until symptoms have resolved and they have at least three repeated negative PCR tests, conducted at least one week apart.
Transplant donors
Donors NOT known to have COVID-19
According to NG164, sibling donors should follow government social distance guidance for at least 4 weeks before donation and be fully informed of COVID-19 symptoms, the transmission risk and any related donation restrictions so that they are more likely to self-deter. Moreover, donation should be deferred for at least four weeks from the start of self-isolation.
For cryopreservation donations, NG164 advises testing for COVID-19 at the assessment and again at the harvest of stem cells or donor lymphocytes. If in exceptional circumstances, fresh cell donations are needed, NG164 recommends testing for COVID-19 at the assessment and again one or two days before starting conditioning.
Potential donors are advised to inform the coordinating registry and the collection centre at which they donated, if they develop any illness within two weeks after donating.
Donors known or suspected to have COVID-19
NG164 recommends that clinic staff defer donations by three months for infected or suspected infected patients from when symptoms have resolved.
If the HSCT is urgent and where there are no suitable donor available, NG164 suggests clinical staff assess the risk and liaise with the registry and explore alternative sources of haematopoietic stem cells, for example, HLA mismatched (haplo-identical) family members and cord blood. These alternatives should be discussed with the recipient and they should be kept fully informed of the donor situation.
NG164 also states that suspected or infected donors should not provide other blood products (and this includes lymphocytes) for at least three months from when their symptoms resolve.
Transplant recipients: post-transplant
All transplant patients are to be managed in a strict and protective isolated environment. If procedure is required outside isolation, staff should assess the risk against the risk of exposing the patient to COVID-19 exposure. As mentioned earlier, NG164 also advises that transplant patients follow the government shielding guidance until the risks associated with COVID-19 have passed.
This advice pertains to the following recipients:
• those who have had autologous transplants within last 12 months
• those who have had allogeneic transplants with the last TWO years
• if they are having continuous immunosuppressive therapy, they have chronic graft versus host disease or if there is evidence of any on-going immunodeficiency or if they meet the criteria for any other extremely vulnerable groups after clinical assessment
For COVID-19 patients, NG164 advises that they are isolated in negative pressure cubicles or alternatively neutral pressure cubicles.
Supporting staff and those who have self-isolated
NG164 suggests how staff working with transplant patients and who need to self-isolate can continue to work, if possible. This might include video or telephone consultations, attending virtual multidisciplinary team meetings and roles such as identification of patients suitable for remote monitoring or the more vulnerable and routine work, for example, data entry.
COVID-19 positive staff are advised not return to direct work with transplant patients until they no symptoms for seven days and test negative for COVID-19 but can work in other clinical areas after self-isolation, provided they follow the government advice on households with possible COVID-19 infections.
During the pandemic, NG164 recommends that there is visible leadership within transplant departments and supportive messaging to staff in an effort to maintain morale. Furthermore, during these difficult times staff should utilise the principles of good partnership working when developing local plans.
How to prioritise HSCT
The table was developed to help clinicians assess the risks and benefits for patients having HSCT. NG164 recommends the use of this table but reminds clinicians to use a case-by-case approach to balance of risks from patient’s disease compared to the post-transplant risk of becoming seriously ill from COVID-19, the potential for critical care support and disease relapse and finally any service capacity issues.
The table is based on advice provided by the British Society of Blood and Marrow Transplantation and Cellular therapy guidance.
NG164 suggests clinicians consider using transplant outcome predictive tools such as the refined disease risk index and the haematopoietic cell transplantation-comorbidity index where these are appropriate to aid with the decision-making process but also to be mindful of the limitations of these tools.
Modification to usual service provision
NG164 advises clinical teams to review usual care with a view to making best use of resources, reducing patient exposure to the virus and assessing capacity across the region. Teams are also advised to work within clinical networks to support stem cell processing and harvesting, specialised diagnostic and cryopreservation. Furthermore, all cases of COVID-19 should be reported to the European Society for Blood and Marrow transplantation prospective survey.
Another important aspect of service modification highlighted by NG164 is the need for extra vigilance with respect to quality management systems within the HSCT programme and JACIE accreditation requirements. Where a centre cannot meet these requirements, NG164 advises that temporary closure should be considered as an option.
However, if a centre does close, staff need to liaise within the clinical network to prioritise any urgent cases (see table) and for patients having allogeneic HSCT, a backup donor should be identified or blood cord unit just in case there are any problems with harvesting or transport. In addition, if a donor tests positive for COVID-19, their cells should be moved to a marker-positive tanks unless they are to be used within four weeks.
For paediatric patients, NG164 advises that clinical staff follow the advice from the Paed BMT group.
The HSCT guideline is available online and interested readers should check for any relevant updates.
16th April 2020
The report provides a detailed analysis of all deaths in both countries between 1 and 31 March 2020 that were registered up to 6 April 2020 where COVID-19 was involved. The information is compiled from data based on certified deaths registered with local registration offices.
During March 2020 there were 47,358 deaths in England and Wales, of which 8% (3912) involved COVID-19 and in 3372 (86%) of these deaths, when COVID-19 was mentioned on the death certificate, it was found to be the underlying cause of death. In addition, of those deaths involving COVID-19, in 3563 cases (91%), there was a pre-existing condition, the most common of which was ischaemic heart disease.
Overall, COVID-19 was the third most common cause of death during March 2020, behind dementia and Alzheimer’s disease (the most common) and ischaemic heart disease.
The data suggests that the rate of death due to COVID-19 was 68.5 deaths per 100,000 people and the death rate increased with advancing age such that 1 in 5 deaths in the age group 80 to 84 years was due to COVID-19.
Reference
Office for National Statistics. Deaths involving COVID-19, England and Wales: deaths occurring in March 2020. www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsinvolvingcovid19englandandwales/deathsoccurringinmarch2020 (accessed April 2020).
Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease with variable presentation, course and prognosis.
Recommendations for its management, endorsed by the European League Against Rheumatism (EULAR), were first published in 2008. Due to the emergence of new data on treatment strategies and goals of treatment, an update of these recommendations was deemed appropriate. This involved a multidisciplinary task force and was based on combination of evidence base (in the form of a systematic literature review, period 01/2007-12/2017, to address 15 different research questions) and expert opinion.1
Treatment in SLE should aim at remission or at least low disease activity in all organ systems, and prevention of flares. The latter can be treated according to the severity of organ involvement, either by adjusting current therapies to higher doses or switching to alternative drugs.
Hydroxychloroquine (HCQ) is recommended for all patients with SLE, in the absence of contraindications, at a dose not exceeding 5mg/kg real body weight. Ophthalmological screening for retinal toxicity should be performed at baseline, after 5 years and yearly thereafter, by means of optical coherence tomography, 10-2 visual fields, or both (fundoscopy may be sufficient only for the baseline examination).
Glucocorticoid (GC) dose for chronic treatment should be minimised to less than 7.5mg/d prednisone equivalent or, when possible, withdrawn. To this end, use of pulse intravenous methylprednisolone may allow for a lower starting dose of oral GC, whereas early initiation of immunosuppressive (IS) drugs may assist in tapering and ultimately discontinuing GC.
Methotrexate (MTX), azathioprine (AZA), mycophenolate mofetil (MMF), or belimumab should be considered in patients not responding to HCQ in combination with GC, or in patients unable to reduce GC below 7.5-10 mg/d. Cyclophosphamide (CYC) should be reserved for organ- or life-threatening disease, and as a rescue therapy in refractory non-major organ manifestations.
Regarding biologic agents, belimumab should be considered in extrarenal disease with inadequate control to standard of care (combination of HCQ with GC with or without IS agents), frequent flares, and/or inability to taper GC. Patients with refractory cutaneous and musculoskeletal manifestations who are serologically active may respond better to the drug. In organ-threatening disease refractory or contraindicated to standard immunosuppressive agents (including CYC), rituximab (RTX) can be considered, despite its off-label status.
For skin manifestations of SLE, effective protection from ultraviolet exposure with sunscreens and smoking cessation are strongly recommended. First-line treatment includes topical agents (GC, calcineurin inhibitors) and antimalarials, with or without systemic GC. In non-responding cases, MTX, retinoids, dapsone, or MMF can be added.
Attribution of neuropsychiatric manifestations to SLE requires a multidisciplinary approach to rule out mimics (infections, malignancy and others). Neuroimaging, cerebrospinal fluid analysis, consideration of risk factors (type and timing of the manifestation in relation to the onset of lupus, patient age, non-neurological disease activity, presence of antiphospholipid antibodies (aPL)) are essential in the diagnostic process.
Treatment of SLE-related neuropsychiatric disease includes GC and IS agents for a presumed inflammatory process (for example, psychosis, myelopathy, acute confusional state) and antiplatelet/anticoagulants for atherothrombotic/aPL-related manifestations, especially stroke. Targeted symptomatic therapy is indicated according to the type of manifestation (for example, antipsychotics for psychosis, anxiolytics for anxiety disorders).
Haematological disorders needing IS treatment are thrombocytopenia and autoimmune haemolytic anaemia. Lupus thrombocytopenia warrants therapy for platelet counts <20-30000/mm³. First-line treatment consists of high dose GC (including pulses of intravenous methylprednisolone) with or without intravenous immunoglobulin (IVIG). For the sustainment of response, MMF, AZA or cyclosporine can be used. In refractory cases, RTX or CYC should be considered. The same general principles apply for the treatment of autoimmune haemolytic anaemia.
Vigilance for early recognition of signs of kidney involvement and performance of kidney biopsy for the diagnosis of lupus nephritis (LN) are essential to ensure better outcomes. For initial (“induction”) treatment, MMF and low-dose CYC (Euro-Lupus regimen) are recommended, as they have the best efficacy/toxicity ratio.
In severe forms of LN, associated with increased risk of progression into end-stage kidney disease (reduced glomerular filtration rate, histological presence of fibrous crescents or fibrinoid necrosis, or tubular atrophy/interstitial fibrosis), high-dose intravenous CYC can also be considered. For subsequent (“maintenance”) therapy, MMF or AZA should be used, the former being associated with fewer relapses. MMF may be combined with low dose of a calcineurin inhibitor (especially tacrolimus) in class V LN, podocytopathy or in proliferative disease with refractory nephrotic syndrome.
In cases with incomplete renal response (persistent proteinuria> 0.8-1gr/24h after at least one year of IS treatment) or nephritic flares, repeat biopsy can distinguish chronic from active lesions or a possible histologic transition, respectively.
All patients with SLE should be screened for aPL at diagnosis. Patients with SLE and high-risk aPL profile (persistently positive medium/high titres or multiple positivity), should receive primary prophylaxis with antiplatelet agents, especially if additional atherosclerotic/thrombophilic factors are present. For secondary prevention, treatment should not differ from the treatment of primary antiphospholipid syndrome (APS).2
Increased risk of infection in SLE is attributed to both disease-related and treatment-related factors. High-dose GC therapy, CYC, MMF and RTX are related with an increased risk of infection, as is the case with high disease activity, severe leukopenia and kidney involvement. General preventive measures, including vaccinations, and early recognition and treatment of infection are recommended.
SLE is an independent risk factor for cardiovascular disease (CVD) and patients should undergo regular assessment for traditional and disease-related risk factors such as persistent disease activity, history of LN, presence of aPL and use of GC. Lupus patients may be candidates for CVD-preventive strategies, including lipid-lowering agents and low-dose aspirin, based on individual risk stratifications and calculation of the 10-year cardiovascular risk.
Sofia Koutsoviti MD
Antonis Fanouriakis MD, PhD
Department of Rheumatology, “Asklepieion” General Hospital, Athens, Greece
15th April 2020
Patient communication
The initial focus of NG161 is to ensure that staff engage in effective communication with patients in receipt of systemic cancer treatments to support their mental wellbeing. It is particularly relevant for this patient group because both cancer and chemotherapy can weaken the immune system and thus lead to serious complications should someone become infected with COVID-19. NG161 therefore advises that healthcare staff minimise face-to-face contact with patients and to undertake more telephone or video consultations, especially for non-essential follow-up appointments and pre-treatment consultations. In addition, NG161 recommends the use of home delivery services for medicines, or alternatively drive-through medicine pick-up points as well as local services for blood tests wherever possible.
When patients do have to attend clinic appointments, NG161 recommends that they adhere to government suggested social distancing guidance and to attend appointments alone wherever possible. In addition, the guidance recommends that clinics carefully schedule visits and ask patients to remain in their car or with transport if possible until they receive a text message from the clinic confirming that they are ready to see them.
Patients with confirmed or suspected COVID-19
When a patient is identified as having COVID-19, the guidance recommends following appropriate infection prevention and control measures for healthcare workers. Specific guidance for COVID-19 has been recently produced and adapted from previous pandemic documents and is considered good practice in light of the current situation. The guidance contains information using personal protective equipment and states that patients are not infectious until the onset of symptoms (section 2.2) but that once an individual becomes symptomatic, they should be isolated in negative pressure rooms (section 6.2.1).
If a patient attends for an appointment and has symptoms suggestive of COVID19, NG161 suggests that healthcare staff follow the government advice which provide information on testing and isolating such patients. Although patients may exhibit symptoms of COVID-19, NG161 alerts clinicians to the possibility of alternative diagnoses such as neutropenic sepsis which according to an earlier NICE guideline is a potentially fatal complication of anticancer treatment. Another potential diagnosis is pneumonitis and NG161 makes reference to how both neutropenic sepsis and pneumonitis may be difficult to differentiate from COVID-19 on initial presentation. NG161 however, does advise that if patients have a fever but no respiratory symptoms, then neutropenic sepsis should be suspected. Because this can rapidly progress and is life-threatening, staff are advised to follow the neutropenic sepsis NICE guideline which recommends immediate referral of suspected cases to secondary or tertiary care and considering the condition as a medical emergency.
NG161 also discusses a course of action for patients who present at appointments with symptoms of COVID-19.
As with all the rapid new COVID-19 guidelines, NG161 recommends that healthcare workers who come into contact with dialysis patients follow the guidance on infection prevention and control.
NG161 also suggests that self-isolating staff should, if possible, undertake video or telephone consultations and attend virtual multidisciplinary team meetings. Self-isolating staff could also perform other roles including the identification of patients suitable for remote monitoring or those who are more vulnerable and in need of more support and undertake tasks such as data entry.
How to prioritise patient treatment
Due to the pandemic and the potential for resource limitations, NG161 defines a process for prioritisation of patients for systemic anticancer treatment. NG161 advises that prioritisation decisions (see table) are made by a multidisciplinary team and on an individual basis considering both the level of immunosuppression associated with the patient’s treatment and any relevant capacity issues. These decisions and the reasoning behind those decisions should be recorded and clearly communicated to the patient and their family or carers.
Modification to usual service provision
NG161 suggests that cancer teams seek to modify usual care in the wake of COVID-19 with a view to making best use of resources and reducing patient exposure to the virus. Suggested changes to usual care include:
• Delivery of different or fewer immunosuppressive anticancer regimes, delivery via a different location or if possible, alternative routes such as changing from intravenous to subcutaneous or oral (subject to agreement from commissioners)
• Using shorter regimes
• Decreasing the frequency of regimes for example, from four-weekly to six-weekly
• Providing repeat prescriptions of oral medicines or other at-home treatments so that patients do not need to attend the hospital/using home delivery of oral medicines where possible
• Deferring treatments that prevent long-term complications such as bone disease
• Using treatment breaks for treatments longer than six weeks.
Although treatment breaks were a suggested change in NG161, the guidance also notes that such breaks will not be applied during the COVID-19 pandemic. Nevertheless, where a break is needed, NG161 advises that clinicians document that the treatment break is due to COVID-19. Such breaks are likely to be approved provided that the clinician indicates that there is a reasonable chance that disease control can be achieved on re-starting therapy and that it should be reviewed after two or three cycles after re-starting.
NG161 advises that patients and their families should be fully informed of the reasons behind any treatment changes. The guideline also considers the possibility of re-training nurses who have previously undertaken relevant cancer training.
The guideline is available online and interested readers should check for any relevant updates.
In the severe acute respiratory syndrome (SARS) outbreak, it was found that thrombocytopenia occurred in up to 55% of patients and was considered as a significant mortality risk factor.
Whether or not thrombocytopenia was also a predictor of more severe disease severity in COVID-19 was the subject of a recent meta-analysis.
In a recent paper published in Clin Chem Acta, Lippi and colleagues identified a total of nine studies that included 1779 patients with COVID-19 infection and 399 with severe disease were included in the analysis.
In seven of these studies, patients with more severe disease displayed a lower platelet count compared with those with mild disease, although in two of the studies, the platelet count was lower in those with less severe disease.
Overall, the authors reported that thrombocytopenia was associated with a threefold enhanced risk of severe COVID-19. The possible reasons for thrombocytopenia in those with COVID-19 remain unclear and are likely to be multifactorial.
Nevertheless, it was suggested that a patient’s platelet count might represent a simple and easily obtainable parameter for the discrimination of patients with mild and more severe disease but further work was needed to confirm these findings.
Patients with IBD have particular concerns for their risk for infection and management of their medical therapies during the COVID-19 pandemic. This clinical practice update (AGA Clinical Practice Update on Management of Inflammatory Bowel Disease During the COVID-19 Pandemic: Expert Commentary) incorporates the emerging understanding of COVID-19 and summarises available guidance for patients with IBD and the providers who take care of them.
Recommendations for gastroenterologists and their patients who have IBD are:
14th April 2020
This is the finding of a new analysis from Imperial College London and Sechenov University in Moscow.
In the paper, published in JAMA Pediatrics, the team found that around 1% of children have cow’s milk allergy, but up to 14% of families believe their child to have the condition.
The team point to official guidelines for detecting cow’s milk allergy as a possible cause for the overdiagnosis.
The researchers analysed nine official guidelines for cow’s milk allergy published between 2012 and 2019.
These guidelines were from a range of medical organisations in a number of countries, predominantly in Europe. The team found that many of the guidelines named symptoms such as excessive crying, regurgitating milk and loose stools as indications of cow’s milk allergy – but the authors argue that these symptoms are common in normal, healthy babies.
The team found that in a recent European birth cohort study following over 12,000 infants in nine countries, less than 1% of infants had cow’s milk allergy. However, they also found that in some studies up to 14% of families believe their infant has a cow’s milk allergy.
In addition to this, the analysis suggests the prescription of specialist formulas for babies with cow’s milk allergy had increased significantly between 2000 and 2018 in countries such as Australia and England, without any evidence for an increase in cow’s milk allergy.
The team analysed the number of authors of the guidelines who had declared a conflict of interest with formula manufacturers, and found eight out of ten of all guideline authors reported a conflict of interest.
The team also found seven of the nine guidelines advised breast-feeding women to cut out all dairy from their diet if their child has a suspected cow’s milk allergy. However, their analysis of 13 studies of breastmilk composition suggests less than one millionth of the protein from cow’s milk travels through to breast milk, and this would be too small to trigger a reaction in most allergic children.
Dr Robert Boyle, Consultant Allergy Specialist and lead author of the research from Imperial’s National Heart and Lung Institute, explained: “Many infants who are labelled as having milk allergy don’t have the condition. Having a child with suspected milk allergy can be a stressful time for any family. Misdiagnosing milk allergy could lead to another condition with similar symptoms being missed, or breast-feeding mothers needlessly following restricted diets – or even stopping breast-feeding altogether. It can also lead to families and the NHS unnecessarily paying for expensive specialist formula.”
Milk allergy is most common in children under two, and is categorised into two different types – IgE mediated, and non-IgE mediated. In IgE-mediated, symptoms including vomiting, hives and in very rare cases, anaphylaxis.
The symptoms of non-IgE mediated reactions may include vomiting, diarrhoea or excessive crying. However, the team point out that the nature of these symptoms means they are often confused with normal symptoms in young babies.
Dr Daniel Munblit, Associate Professor of Paediatrics from Sechenov University and first author of the paper, explained: “In the nine guidelines we studied, seven of them suggested including milder symptoms as indication of non-IgE cow’s milk allergy, such as regurgitating milk, crying and rashes – but many of these symptoms are present normally in babies, and will get better with time. Non-IgE cow’s milk allergy affects less than 1% of infants whereas troublesome vomiting, crying or eczema each affect 15-20% of babies.”
The team analysed data on the amount of a type of cow’s milk protein known to trigger allergic reactions, called betalactoglobulin. Their analysis revealed that the amount of this protein in breast milk was just micrograms per litre. The team also calculated that this amount is too low to trigger a reaction through breastfeeding for over 99% of children with cow’s milk allergy.
The team also found that three guidelines were directly supported by formula manufacturers or marketing consultants, and 81% of all guideline authors reported a conflict of interest with formula manufacturers. A conflict of interest means receiving funding from a company that could make a profit from the advice included in the guideline.
Dr Boyle explained: “Formula manufacturers may gain from promoting increased cow’s milk allergy diagnosis – by influencing practitioners and parents to use a specialised formula in place of a cheaper formula, and by potentially undermining women’s confidence in breastfeeding, so that specialised formula is used in place of breastmilk. “
He added: “We must not only critically appraise our current guidelines, and dissociate the development of guidelines from those who may profit from them, but also ensure we are giving each family the best possible care by avoiding overdiagnosis of cow’s milk allergy.”
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