Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Okay. Hello and welcome, everybody. Thanks for joining us again for another edition of the be certain I R J Collaborative, a journal club. This time we're going to be talking about the cave. A trial, Um, and a big thanks to Andrew Leach, who's a newly appointed consultant. I are who's organized this session for us. Um, so I'm just going to hand over to you now and you to start the session. Thanks. Thank you very much. I'd like to add my my welcome to that of of San, um, to the situation of the of the be certain IRGC Journal club. So I'll take you through. What are your orders for the evening? So I'm going to get a bit of background, um, of, um, a central venous access devices and patients receiving systemic anti cancer therapy. I'm, uh, she said, uh, newly appointed consultant at James the hospital in Middlesborough. Following that, we've got a presentation of the article by Doctor Hanan show any leads to interventional radiology trainee and clinical research fellow at the University College, London. Following that, we'll invite our panel of experts. We have proof. John loss. Um, article author and professor of interventional radiology at the University of Glasgow. Um, Doctor Richard Hartley, consultant, Interventional radiologist, uh, colleague of mine at James University Hospital in Middlesborough. Uh, and finally, Doctor Matthew Falls, Uh, consultant, anesthetist and vascular access lead at the new castle Pontin hospitals. Uh, and so we begin with with the first statement from the from the article itself is that cancer requiring systemic anti cancer therapy is common, uh, with 100 around 175,000 patients age 25 years and older receiving therapy in the 12 month period between March 2017 and February 2018. Uh, systemic anticancer therapies are generally administered intravenously, with peripheral and central devices available. Uh, here we have an array of peripheral and central venous access, uh, devices from the ubiquitous cannula on the left, A single a single woman midline, uh, and then the central devices. We get a temporary a dual lumen temporary, um, a temporary line, a dual women pick an implanted port and a single woman tunneled Hickman style line. Okay. Patients requiring, um, central venous access for great and three months generally or with inadequate peripheral veins, should have a central venous access device cited, um, this always repeated cannulation venous occlusion, secondary to irritant infusions and tissue necrosis from extra visitation. Additional benefits include not only the administrative administrations of systemic anticancer therapies, but also blood sampling and administration of radiographic contrast media. Uh, as most of us here, radiologists have got a selection of chest radiographs here demonstrating some appropriate sighting of, uh uh, various central venous access devices. On the left, we've got a left arm pick which enters the skin in the upper arm. Uh, and then, in this case, the basilic vein follows along intravenous course. Uh, and then as the tip projected at the cable atrial junction, uh, we then have a temporary a temporary right I G line, which enters the skin at the base of the neck, enters the I G V at the base of the neck and then similarly, has its tip projected at the cable atrial junction. We then have, uh, a tunneled Hickman style line, which enters the skin on the anterior chest wall, follows the subcutaneous tunnel before entering the IgE at a remote site at the base of the neck and similarly, uh, at the junction. And finally we have, uh, implanted port, which resides in a pocket, um, in the anterior chest wall with a diaphragm, which can be repeatedly accessed with a non coated needle. Uh, the line then follows the subcutaneous course and again enters the I G V at the base of the neck with the with the tip projected at the, uh at the cable atrial junction. See that choice around the world is heterogeneous, um, with the decision making process unclear, um, and picks rising in popularity, perhaps to put a number of a number of factors, including nurse lead insertion received lower cost and the avoidance of the risks of neck access prior to cava or cava. Um, evidence. Evidence around. See the ads for systemic anti cancer therapy with sparse A 2013 systematic review and 2016 randomized controlled trials suggested ports for superior Hickman lines with less adverse events and better quality of life, and a 2020 systematic review and two randomized control trials from 2019 and 2020. Suggested picks had a higher rate of adverse events than ports. There was yet to be any study performed, evaluating all three of port segment lines and picks. And as a result, neither the American Society of Clinical Oncology or the European Society for Medical Oncology recommend a particular device due to, uh, insufficient supporting evidence. Um, and that takes us nicely onto the topic of this evening's journal club cava or cava. An important study hoping to bring clarity to the issue of central venous access devices in patients receiving systemic anti cancer therapy. I'd like to pass you on to, uh, arrange somebody who will protect the article. Uh, following this will invite our panel back for before discussion of the paper. If you have any. Particular, um, any particular item for discussion, please submit these in the chat? No, thank you very much for the introduction. Um, well, good evening, everybody. Thank you for joining giving us the evening for this general club. I'm excited to bring this back. Um, and I'm going to build on what doctor and LH was saying earlier about the different types of central venous access. And I'll describe exactly what this trial is helping. And I think it's a very important question. Um, and it's been gone unanswered for for many years. Um, so just introduce myself again. My name is and she want me. I'm a clinical research fellow PhD student at UCL and also regular trainee. Um, question is why Why is the study important? So central venous access for anti cancer therapy. Um, no matter where you are in the hospital, your radiologist, you are a funny tissue. Our surgeon, you a medic, you're a nurse in the community or GP. You will never inevitably come across a patient who has a central venous Axiron because a lot of patients who are on anti cancer therapy and they will be on anti cancer therapy for months. Um, I'll reiterate that number 175,000 patients in the UK are receiving Semitic anticancer therapy, so they are receiving treatment for the cancer. And like I said, there's multiple ways to obtain central venous access. These devices are in for, uh, for the long term than more than three months. And the reason why you can't put something like a cannula in is because, you know, the drugs and medications can be toxic to your peripheral vessels. Um as, uh, Andrew explain very well. Earlier, there is heterogeneous data about which one is best and particular regarding the complications, so complications would be the line stops working the line breaks the line from both. You can aspirate from it. You can't give the medication. Those are things that may involve taking the line out, putting another line in or, you know, worst case scenario. You can develop a severe infection. These patients are immunocompromised, so this becomes quite deadly. Um, what's also really good about this trial? Uh, and I think it is, you know, it's a unique. So the point is that it's how they're sparse data on cost, effectiveness and quality of life. Of these devices, we know that this is actually really important question the reason why we have a service. Um, and the reason why we can set up a service in any chest is you know, we have, we have, we have, We have a Costco. We have business plan. Why is this cost effective? Will this help our patients? And how do we know whether it's helping our patients? That we obviously have metrics such as infection rates. We have metric, such as complication rate, but quality of life and how patients actually feel about the device is very, very important. So, um, without rehashing too much, there are three main device is that we've looked at here and a lot of people will be familiar with pickes. These are distal, you know, they're in that you can insert them on the ward, especially midlife community and award. You don't need special theater time, and you also have the Hickman's, which you have these dangling things sitting on your chest and implanted port, which are completely subcutaneous picks. The most common central venous device, especially the in Europe and the UK, arguably has the lowest technical school requirement. Doesn't say you know doesn't require skill, but it's a service that doesn't that can be nursed lead. And in many hospitals and trust across the UK, it is not red. Um, a low upfront cost, hint, hint. Um, this is, uh this is gonna be important topic addressed in the paper. But, you know, up front, they seem low cost low theater time. They're not required the time not requiring expert doctors to put them in. Um, so it can seem like a cheaper alternative and avoid critical structures You're putting in the distal arm. Of course you can cause injury and anywhere, but this is less dangerous of putting some where in the neck, Let's move on taking line. So low rates of failure question mark. Easier to manage, uh, than your PICC line. Uh, they are a bit more central, bit more protected. So of course, they it's quite easy to put things in. Put things out. Um, you start getting trapped in your shirt Last longer again. Question mark. Does it last longer than a PICC line? Um, they have argued with higher rates of infection with a Hickman line. Um, possibly related to how long they're in for possibly related to where they where they are cited and how frequently they used higher technical requirement. They require dedicated theater or catalog time. Um, there's always a risk of damage to critical structures. You, you know, use up in the neck. Um, what signature created some IR registrar somewhere in the UK has has never done this, um, more expensive, um, to, uh, put in and remove. It does involve minor surgery. This is not a straightforward PICC line where you can take which you can take out, but online does involve because it is tunneled into the skin and you're not. It's tunneled up against the needs. A minor surgery to remove implanted ports are completely implanted. So better for the patient. You don't have dangly bit's hanging on the top of your chest. You you can you don't even know it's there sometimes, uh, low risk infection. Hickman Again. Question mark. That's, uh, the estrogen state in the literature. And does it last longer? Arguably, it has the highest technical requirement. Uh, the three doesn't mean it's it's, uh, it can be learned. But again, the amount of people that can do the port is less compared to people who do take the lines, um, risk of damage to critical structures. Again, this is just comparing topics. Uh, I just hear a pop, the pneumothorax that you might have caused again, more expensive and, again removal. Of all of my surgery. There are several unanswered questions. Um, now let's move on to try and how how this trial specifically answer these questions that are sort of raised in leadership that's gone before hand. This is an open label, multi center RCT. This is not blinded. You cannot be blinded to this, so I don't think this is not a This is is difficult to blind people to the type of device inserting but comparing the three central venous devices and specifically it's not looking at. You can receive venous device central venous size for a number of issues. But the studies focused specifically on systemic therapy, and you can have it for long term antibiotics. There are other indications, um, this trial only involve patients having, uh, more than more than 12 weeks duration, and the primary outcome is complication rate. So that's the main question we want to answer. And that's important. That's how we this is, what the true question we want to answer. How did the study define complications? Because that's that is important. And they're, uh, the Matrix were inability to aspirate blood infection associated with the device the chance of venous thrombosis. And this is, uh, this is related to the device. Uh, pulmonary embolus and mechanical failure. Um, and the good thing about these complications are is patient care affected if a patient is receiving anticancer therapy, the inability aspirate blood music are you know, the patients have bad veins. They need the, you know, the cancer therapy may be interrupted. They may need to go back to the to get this done again, Uh, venous thrombosis again. This can affect patient's the all these All these complications can affect patient care. So these are important questions. These are these important metrics measure now the secondary outcomes. Again. What I really like about this paper is how it, you know, you look at the quality of life measurements, and it's costing analysis and are the which one is cost effective and which one best improves the patient's quality of life. So this is a study, and for, uh, this is the trial and how many patients were included, How many patients enter the study and you see, it's a little bit complicated. Um, What? I'm trying to just break it down. You have 1061 patients were randomized. Um, and there were four randomization arms. So you have 265 comparing Hickman to pick support. You have 212 randomized to pick this Hickman 397 to report this Hickman and 107 randomized to put this pick. How If you're trying to compare all three, you think initially you want this first you don't. You don't want to look at studies with the first number, 265 randomized treatment. How can you really compare Picks versus Higgins report if there's 34 different randomization arms? So the way they've done this is taken each randomization all and try to compare the different, uh, different venous techniques. And they've done something called the network Meta analysis. So, um, in one study, you could say, you know, the 397 and my supporters. Hickman, you can say that ports are better than Hickman's in terms of, um, in terms of complication rates, you could say that in the in the other randomization harm that Hickman is better than pick uh, in terms of complication rates. However, with the network Met analysis, what you can do is compare the outcomes and indirectly. You can say that because ports are better than Hickman lines and Hickman lines are better than PICC lines. Ports are. You can say that airports are better than picks, so this is how they've done is they've used network met analysis technique to compare the different organization groups so into the primary outcome, which is complication rates, um, again. And look at the top pick pick versus Hickman line. It's about the same. You can't say that there's the way they powered the study. They can't say it's not diarrhea, but they have similar complication rates. Looking at port versus Higman port has markedly reduced complication rates and port versus pick again. Port has less, uh, less complication rates. Now this is the the arms comparing. This is the single arms where the complication rates are compared between groups. However, once you look at the results of the network market analysis, um, you can create odd ratios. So on a good ratio for people, uh, don't know, odds ratio is the chance of an event. Is the odds of an event happening? So, um pictures Higman. If the alteration is 1.1, that means that in in the in the PICC Line group, the the odds of the complications are slightly higher. However, if you look at the confidence that 95% confidence interval and no 950.78 to 1.5, this lives between 9.78 to 1.55 because this number crosses one and you can see. You can't say that this is statistically significant. However, um, this is under powered for noninferiority, which means that you can't really say that Pixar worsen Hickman's picks a lot worse than the lines looking at port for second line. You see, the alterations are low, which means also having a complication of lower in the port group compared to take the line and then imports just pick the alteration of 5.5. Which means that also developing complications are less than than if you had a PICC line so going to determine the cost, the cost. So how do you determine the cost of the device? Because, as I said earlier, you have a PICC line. PICC lines are cheap compared to Hickman Lines of ports. Um, obviously you got the cost of the staff. You got the cost of maintenance so you can develop a total cost. But what we know from experience is that actually, sometimes even though they might be cheap, they might be cheaper. You know, they might not last as long. Um, so a better way and a better metric to measure. This is cost per week after week, when you look at the cost per capita week. Although PICC lines are cheaper, uh, than, uh, than him a report. Uh, you see that? Obviously, the pecan versus Higman, The Pixar Cheaper cost back after a week. But the ports are actually cheaper than the picks, and the Hickman's in both of the randomization arms. So pair cattle week. The ports are cheap, so you see in the in the paper, they list the total cost, and so the cost is higher. But the more the metric is cost per capita week, and over the course of patient's treatment, they may be having treatment for months or maybe up to a year. Um, it is what is important. How How much How frequently are they changing? If you're changing a PICC line every several weeks, uh, or you're changing report every six months. Uh, the cost back after a week is a more important metric to measure than the initial upfront cost or the total costs. So the effect of quality life This is something again that is not people haven't researched this in literature. Um, and so this is really, really nice about the paper. How does it affect them? How does Because patients are gonna be in the hospital entire time, they're going to go home. They're going to go to sleep. They're going to go to you know, they're going to go out. They're going to go shopping. How does this impact their life? So what they've done they've created This is a questionnaire that they distributed to all the patients and includes basic active Tuesday living. Um, and these are the results. Again. You can see that anything bold means it's significant in General Port Port perform better than Hickman Lines and PICC Lines and Hickman Line. Uh, it's about the same support is about the same support, uh, PICC lines. But I think the most important, I think the most valuable comment from the paper was an idea of what we can say to our patients. And what we can say to our patients is, um, the patients who are involved in the study, they repeat, the patients with the ports repeatedly stressed that it was easy to forget about the device, and that's where we want our patients. We don't want them to have a constant reminder of that. They don't need a constant reminder that they're receiving cancer therapy that they're having having a line dangling off their arm off the chest. The port being completely portable, they can forget about it. Is there? And what? Only when they need the treatment is it being used. So that summarizes my, uh, look into the paper. I do have some follow up questions. Uh, and having the the chief investigator of the paper is quite nice to have, um, and hopefully people can come back on stage. I don't know if, uh, uh, Andrew can meet himself in the first came back on, Thank you very much, you know? And that was very a very good description and insight into the into the article. Thank you very much. Um, uh, I'd like to, uh, invite our, uh, our expert panel, uh, on two for some discussion. So I actually have the first question for, uh, professor mosque, if that's okay. Um, and, uh, my question was, uh, after after reading this paper and after after actually doing the paper, how should we change our practice? My suggestion is that we, uh, that ports are much better than Hickman's and pick. Should we just get rid of the lines and picks, and you just replace the ports. We just have this mass initiative. Just, um, always a walkable if he comes and picks. Yeah, well, thank you. Thank you, everyone. Initially, for just for your interest in the in the study. I mean, I'm retired now, which is why I'm, uh, drinking a beer. And you guys are all going to work tomorrow. Um mm. What we are now being faced with is this is actually happening. This just started about a month ago is that we have been asked to implement the evidence. So I think what the the grant fund is that the government is saying, Well, you know, there's no point doing a trial that shows is better than be if you can actually change practice. And I think in the drug in the drug world, I'm led to believe that practices There's a lot of pressure to change practice through nice, their guidelines with devices. It's it's far, it's far more loose, and I think we just have to think about that. So, um, you know, there's no point publishing a paper even in The Lancet and expecting things to change without sort of following that up with some sort of pressure. Um, and I'm just sort of learning at the moment how we should possibly do that. Um, so health, health improvement. Scotland has just started to look at this now as a property of interest. And that's one thing you can do. Um, the the grandfathers, the NIH are disappointingly don't seem to do much in the way of supporting people. Like our cells are quite happy to give you a million and a half pounds. But then you produce the report. The X ray report published it, and nothing happens. Um, so we've also engaged now with this guy, you can see this guy. It was actually ahead of the game. Actually, he's, uh, anaesthetist in, uh um, Sweden tax broke. So he was the guy that published before us just to pick first. His port study showing the porch was superior. And there's also a guy in the United States called Vinny Chopra who writes guidelines as an Indian guy that works in the US and he's a real power horse, really, for change and guidance. So we are engaging with them as well. And there's somebody in Australia trying to work out what to do. But I think there are lots of problems. And also there are lots of solutions, I think, as I you know, when I went around the UK trying to get everybody in to sit in this trial, there was a lot of resistance, mainly from centers where PICC lines were dominant to the most centers. Actually, um, there was reluctance to change. The nurses didn't really want to get involved with this. Um, the radiologists were kind of variable, but we have pockets of interest, which was good. Um, so, yeah, it's It's, I think, at the end of the day, um, the way ahead is to try and get nice involved, try and produce guidelines to put something down in writing that we should be. I think the best way to do it is to say we should be offering patients the choice report. We're not saying that every patient should have a port were saying that patients should be offered the choice of report versus a pick or or even a Hickman. Um, I think the pressure is from social media, uh, patients sort of interacting through network groups. I believe there are these things for particularly breast cancer, where somebody in Birmingham my pipe up and say, Look, you know, uh, well, let's let's use the Christian, which is a really good models that in Manchester that if you get everything there and all done by nurses as a complete model of excellence uh, so patient there will say, you know, I'm getting a port. Then patient in Glasgow says, Well, that's strange angle breast cancer. I wasn't even offered report, so I think there's pressure there as well. I'm going to stop talking. No, no, thank you so much. It's really good to hear because it's I know it's been sort of almost 14 years in the making. 2008, Doctor. Wasn't it that you mentioned that you just talked about it? Um but no, that's I think, um, individual, I think all of it is work force, workforce availability, people willing interest. And it is a local driving local push. And if it comes from not only local keen, uh, clinicians, but also patient groups and external sort of groups that you can you can rely on nice guidelines to say, actually, nice guidance. You know they recommend ports instead. So we've got they've got something to rely on. Um, no, thank you so much. I think the next question I have, uh, So, Doctor, I think you I think the deliverable is the most difficult bit. I started teaching radiographers and nurses, and over the years, I've had more success in terms of long term colleagues teaching radiographers to do procedures rather than nurses. Um, but started teaching them how to put Hickman lines in back in about 2006. And so we now have a very much a radiography for lead Hickman and line insertion service. And I think the things that I have taken away, but not yet delivered from this are both getting my eye, our colleagues, all of them putting in ports. And the next thing is starting to think about how to teach the radiographers to put in ports. The next thing is, there's a bit of a time penalty. Um, I will take maybe 20 minutes to put a hitman line in my port. Insertion time is about 45 minutes. Um, it might drop to 40 but I don't think it will drop much more than that. So it's a bit of a time penalty time, but I think that, um, social media might make a difference. But working in middle school and living in North Yorkshire social media hasn't penetrated this area. It certainly has when it comes to fibroid embolization and that completely drove fibroid embolization in the southeast. And yet the women around here seem to have hardly heard of it. Um, so I don't think that will drive it. I think we have to have the availability of the service and people doing it. Otherwise, no matter what pressure we get from night or somebody else, we can't make it move. Uh, and and certainly, um uh, part of the reason I invited you to join the panel for this discussion is that your the vascular access lead and lead and ODP delivered pick service. Um, what are your What are your thoughts on, uh on what? What can be offered and perhaps what should be offered? It's I mean, it's already been, um, explored that it is really difficult to actually get a service and and build something to deliver a bigger portfolio than it has at the time. That you're looking at it. So we we've sort of just getting to the combination of a around about five year project to develop and deliver a line service, uh, vascular access to this that predominantly does just deliver mid lines and picks at the moment. Um, it just took a very long time to get our choice to be able to recognize that this was something that needed to invest in. Even though it's not a lot of money, really. We're talking about a quarter of a million quick to be able to manage a service that can deal with what we need in a relatively big trust. Newcastle. Um, but we've got this is our sort of phase one, and we've we've got three phases with the third phase being moving on to having our nurses and, oh, DPS trained up to be able to insert the ports, for example, because I think that that that is going to be an important growth area. But you know, there is such a pressure on the theater availability, having the right kind of approvals and back up when you're when you're developing this stuff from from the beginning, it's actually quite hard sometimes to move against the machine. So what John was talking about about having black and white guidance that helps people develop these and these type of services and in various trust will be really helpful, very important. And the Carbo trial certainly is a very, very good first step. And it's interesting, though, that we, you know, the one of the questions that I think he had sort of, uh, posted there was. Is this the end of picks? And Hickman's, uh, I mean, clearly it has to be part of a tapestry, doesn't it? Because, uh, the port is not a suitable line for someone who doesn't need access for that long. And some of our patients, when they have infection issues that clearly not it's not the right time to put a port in. So it might be the right part of a bridging strategy. Um, so being able to have a process where you can get a decent access in, uh, and be able to deliver the therapy still, but try and do it in a way that that is the least risky, uh, is still important, I think. Absolutely sorry. Uh, that's hardly, uh, I also have some concerns having had issues in the past, about if you're going to access the port at daily or multiple times a day for weeks on end in that the skin. If these patients they're likely to be a bit malnourished and frail. And if you keep putting a needle into a port twice or three times a day for a couple of months, the skin over the top falls apart. And actually, they don't really get any benefits over Hickman line or a PICC line. So, um, ports are great for things like cystic fibrosis. The patients get antibiotics for 10 days, then they hardly use support for three months. Perfect. But if you have somebody with bacterial endocarditis need antibiotics three times a day for a couple of months, something that sticks out of the skin be the Hickman line or a pic is much better option? No, absolutely good, I think. I think that's what I was trying to allude to, um, when you know, obviously you know there's a there's a very situation dependent, patient dependent, um, and clearly smaller than the card you're going to put a port in. But you know something something more temporary, appropriate. I think that that sort of runs on. My next question is, um, about the you know how generalized all the results. You know, we were talking about services Where even a big hospital such as New Castle, where we've got a nurse. That service where we have, um, enough trained staff. What about, you know, a d j h out in the sticks, You know, somewhere where they only have one sort of part time. I are. And they have no nurses who know how to do pick lines. Um, how do they decide when? What do you do? They decide. We use PICC lines, and we use We use PICC lines because they actually say because no one else knows how to put in Hickman lines. Is that the best option for them that even for the long term care therapies? Or should we just referring all these patients to tertiary centers who just know how to, you know, put those in? If someone seemed suitable for port, do they just go to a tertiary center? I mean, I think, um, as math, you said, You know, all these devices have a role and we should be excluding them. You know, we're talking about offering patients a choice. This is the cancer patients, at least. You know, if you are needing hemodialysis, then it's going to be difficult to do that to report. We did put so many years ago in Glasgow the massive things that were came out for a while. I forgot the name of them, but it was a real job getting something in. And you had to put it in the vena cava to get the get the flow rates, and it just didn't work. So, you know, for hemodialysis. Nobody will put a port or a pic. So that's for the hitman. Uh, they weren't in this trial. I think if you look at the hematological malignancies, we had a huge problem getting engagement from the dermatologists. And in fact, the only hospital that really got it on board was yours. Matthew the Freeman in Newcastle. The guy called to buy as many as it was really open with this, but in Glasgow, I mean, I was almost falling off a building for suggesting that you could put a port in for somebody who had a hematologic malignancies and and as you said, Richard, you know, they often get a needle quite quite frequently. And in fact, people misquoted the Carbatrol suggesting that supports our best for all cancers. And it's not the case. So for hematologic malignancies, we have so few we really couldn't say anything but the highest infection rate. I'm not sure it was actually in the paper. The whole group was hematological. Malignancies is you have a port. So maybe the hematologists are right that, you know, ports are not for these blood cancers. So I think that's a definite place for a hitman line or or a pick. Um, yeah. As as far as these other groups are concerned, you know, we can only we can only hypothesize whether there will be a benefit or not. I mean, I I don't know if the the parental nutrition I mean, um, infection rates are high. They're presenting with putting in sugar solutions. Um, I think some centers do use ports for nutrition, but I'd like to talk to you guys really ask you guys what? What? The dominant strategy is for, frankly, nutrition Now in the UK Do you think it's basically a hitman? type line. I mean, what's actually I'm retired now, So I mean, what's actually happening in clinical practice for parental nutrition, TPN, we're using Single Lumen is relatively large caliber line, sort of 9, 9.5 French, single line or peripheral? Uh, no. Hickman lines, tunnel taken lines single. Lumen. Whether that's the best thing or not, I don't know, but that's what we're using. Um, back to an endocarditis. That kind of stuff were still on picks and Higman lines. Um, got a few patients running contentedly on ports who have got high output. Stone is that kind of stuff who give themselves a couple of liters of fluid twice or three times a week to sort of balance out the fluid requirements. That seems to work quite well through a port patients with high output stoners. Um, I'm kind of using it on horses for courses basis. Uh, a lot of things is how often I think it'll be accessed. Sorry if I if I may just run on a little bit from something that I think John and Richard both alluded to that, which is that I think the selection of the line it is obviously really important has to be tailored to what the patient wants and what the condition is and and the best evidence base. But the point of putting the line in and then sending the patient out the door is probably the lowest risk point for a complication in terms of, uh, any kind of thrombosis or infection risk. And so a big part of the process that we put in place because we've developed this faster access service from right from the beginning is that it's actually a massive package of education and support for the ward's as well, and to move out into all of the outpatient work as well, because there is, uh, obviously very important point in terms of delivering the access and being able to get therapies. But if it then ends up in having high levels of complications in terms of the port sites becoming infected, which is obviously a complete disaster and tissue breakdown or picks that are not looked after property and become blocked quickly and that that just creates more work, um, and more morbidity mortality. So our driver new customers to try and get a a process where that the whole thing was all brought together so that it all worked in in unison, which obviously made it learns more complicated, but it surely should be the right way to do it. And that's a great thing about these webinars hearing things like that, which you've done it in a more structured way than I have. But I worked out quite a while ago that ports don't survive well in environment, where people that don't have any idea how to look after them. So the areas where I found Port survived well is curiously hematology and oncology. And whilst John had a lot of resistance from the hematologists, which is the oncological hematologists because my hematologist also deal with the sickle cell patients, uh, the hematology nurses and hematologists are familiar with ports because pretty much all all the sickle cell patients will have a port as well. So that's an area where there's a good pool of experienced nurses who can rely upon to use the port and flush it afterwards and all the rest of these, uh, important measures. You know, I I couldn't agree more with just being said about, you know, the total package of care and I think, you know, radiologists are so bad Just closing the door as soon as the patient leaves The angio theatre were just so bad, you know. You know, we don't We just like to say we don't follow anything, you know, we know nothing about follow up. You know, it's we're getting slightly better, but they're still so, you know, I think you know, I always said And when I was putting ports in that you know, the problems start now, Once we put the once, they close the skin. You know, the easy buddies put the thing in, and then they wander out there either to the wards or to the community. And all sorts of different people get engaged with looking after this device or not. I think you know, uh, you know, we were huge problems with the Carbatrol. The centers really keen The radiologist, for example, anything is really keen to start. Let's start doing this. It's a good idea. And then, of course, the district nurses saying, Hey, wait a minute. We know nothing about this. And then we had organized course is to train the district. Nurses with industry involved come along organize something. You know, one nurse will come because they couldn't spare the other nurses. So the other nine didn't come. And then they say, Well, we'll send another one next week and say, Well, you know, we can't really training girls usually once girls one at a time, Can we not get 10 of you along? And of course, that's again the radiologist. Not really understand that you can't get you can't take the 10 practice nurse is out of the community and bring them into the hospital environment for half a day and train them because what's going to happen at the community? So, yeah, it's, um I mean, I think some of the best ways forward is to use the centers that I've got this in place already. And, you know, the Christie is one of them where it's a totally nurse lead service. They're supervised. They're either supervised by underneath of this sort of radiology. It doesn't really matter. But the bulk of the work is done by the nurses and the doctors. Really just there in a supervisory. Well, I think that that leads to myself. The next question we had was just about how this can be generalized outside that, you know, this is the UK, a high income country with, you know, a lot compared to a lot of emerging country's. A lot of resources. Lot of what we do very well in any chest is community. It's not really about The device is about the package of care involved. And if you don't have that system, it can it can be useless. Sorry, Doctor. I think you just want to add something over there. Oh, I was going to ask them in the Christie. John, Are the nurses putting Hickman's in as well as putting ports in as well as Hickman's and picks? Yeah, yeah, yeah. And the And the important thing as well is they take them out. So taking these things out is something you need to just be aware of. And I didn't really appreciate this properly. Um, so the PICC lines, obviously, I/O, you know, you could just patient to take it out. Just give it a yank. Uh, the Hickman line. Um, so, you know, remember, training in surgery years ago in a surgical at the store was just about to do anything. First time without any supervision. I mean, the first time I did a splenectomy. I've never done one before. And a consultant just said, Boss, you've seen one. Uh, so you just did it. Now, as you know, these days are completely gone. So trying to persuade something, not just to do a splenectomy for solo as a junior member of staff, but to take out a Hickman line. I've gone in Glasgow. It is. Seems like you know, this is like opening the chest to some people to dig out a cuff. Um, the the only doctors that I am aware of that are familiar with it of the hematologist. And that's why they're one of the reasons they like Hitman Lines and why they don't like ports because they know a port. It's going to involve a bit more that dermatologists don't feel comfortable about. And then you got the extra hassle of who actually takes it out was disciplined. So I was really disappointed when I went to Manchester, not the Christie, but Manchester Royal. We were going to participate in the car for a trial, and it was all fine. And then, uh, the Hematologists and the oncologist said. That's fine. They were there at the meeting. They said Now, by the way, when they get infected, who's going to take them out? And I said, Well, the person and put them in It's the radiologist. They take them out And to be honest, the radiologists they were there. They said we're not taking them out as a surgical procedure And the surgeon said, Cough, if you put them in, you take them out. To be honest, I was told to be on the surgeons there. I was really disappointed that radiology We're happy to put them in but wouldn't take them out. And guess what? So that the doctor looking after the patient, uh, the oncologist hematologist got to cope with that. And it said, We can't use sports, you know, if if we can't get them out. And sometimes I mean, I personally have been called a couple of times two in the morning to take the port out just because rampant infection and they call you and they do that. So that is the downside of the port. If he doesn't need to take it out quickly, can you access the person broke your person to remove it. Um, that comes around quite nicely to a question about about the about the study, which I had, which is, um, given the difficulty with removing a port and also sometimes the lack of necessity to remove support because, um, you know, it may not be being used, which means that the chance of infection, um and the general complications is reduced. Um, for adjusted for capita dwelling time, ports came out as a lower risk of infection and, uh, cheaper than the other two. But is that perhaps this is me being devil's advocate? Is that perhaps artificial? Because ports we're happy to be left in, or perhaps more tricky, to arrange removal of Yeah, that's a good point under. Yeah, yeah, I think you know, if you're clearing an infection with these three devices, then, um, you're the doctor looking at the patient on the board and basically a bit sick. You get antibiotics, but it's very tempting, isn't it? Just pull out that PICC line and just get that out of the way. That's it. Whereas the port well, think about it a little bit longer. Let's give antibiotics for longer and long. Behold they get over the effective episode and you preserve the port. So, yeah, it is a It is a confounding factor. Yeah, Can I just ask a couple of questions on that at one Is four points on that one is that I think quite a few patients get through a cycle of chemotherapy and they'll often stick with airport. This is particularly the case with colorectal cancers. They'll get the chemotherapy. They'll get in some kind of remission. They'll, between them and the oncologist decided, going to have a break from chemo for six months, or until they start to progress again. And if you got a port, they'll often just put up with that port and just ignore it. You know, maybe flush it every two months, and I always say, flush it Every month they'll flush it from time to time. And then when they progress in six months' time to start using it again, patients virtually never do that with a PICC of the Hickman line. Yeah, I think some patients with dye with the port in situ, you know, yeah, they'll finish the treatment. Either it's been curative or it's been palliative, but they will receive no more. Uh, there's a lot of things going on in their lives, and they just decided to just leave it. Yeah, maybe not. Security groups. You don't really want a catheter dangling in your SV. See, for the rest of your life. But but certainly the palliative group. A lot of stuff going on. Yeah. Can I ask a question costing question? John, I looked a Petri. The paper about the cost things. Did you include the cost of the nurse is going out to flush and dress Hickman lines and all the rest of it in the cost things? Uh, we did. Yes, we did. The costing costing paper is still not not yet been published. So we're working on that. I have to say I find health economics really difficult. And the paper, in my view, is pretty unintelligible. At least it is to me. So the goal to send it to the BMJ shortly. Um, yeah, but there's a lot of modeling and implementation. It's, uh, sounds a bit like a Tory party, but to be honest, it's, uh yeah, it's, uh yeah, you can spin it one way or the other, but at the end of the day they are. They're arguing that from the cost effectiveness perspective, ports are better. But it is relying on that cost per capita day with all the limitations. But that has, you know. So I know we just got five minutes left of our of our webinar, so I don't I just want to wrap this up before I wrap it up. But I want to just ask you a couple questions from the audience. Um, I think one of them from Katrina heartburn. And she said, as an eye are training, I've had limited access to training ports. Any suggestions for how we can train to do these procedures? My only suggestion, if the center you working doesn't do them, is to try to organize a brief period of about a program experience, um, to go to a center that does put ports in, and that won't need to be months and months and months will be a week or two and find someone that does put them in. Now. I'm pretty sure that venous access and ports are firmly embedded in the latest version of the curriculum. So whoever your post graduate dean is your health education outpost will be supportive of a spell of out of program experience. Um, if your local center isn't delivering the curriculum and the other thing is, we need to we need to organize some training courses. Supports. It's not difficult. We we've been running one in Glasgow for a while, but there's no reason why we couldn't have a lot more of these running. So there's a surgical skills unit in in Glasgow. There is, you know, basically for surgeons, and we use freshly frozen cadavers. So all sorts of things go on, you know, show them out to all the chest and the abdomen and the body is putting in the hip. So for those instead, easy. Um, we just puncture the vein, make a cut, uh, very report. And, um, it gives everybody just a chance to look around with, You know, I did six years. Surgeries is quite easy for me to stitch because I've never forgotten how to do that. But, you know, I always thought originally had to stitch by mid wife as a medical student, so we can teach each other here. And so I think the cadaver model is quite good I know there's a surgical skills unit in Manchester. Uh, I'm sure there'll be. These things will be all over the place. Um, so I think we need to look at that. The younger people do. Just getting getting people along. Um, some form of certification to say that they can. They can now cut the skin. They can put a stitch in. I appreciate the problems they can. They know with surgical instruments to to use as well, because it can seem very early, and I think to to a non surgeon initially, you know, how many bits of stuff do you need? If you ask us for a basic park from the theater, they'll give you something that what you do have hernia repair. You know, uh, you just don't need all that. So, you know, we need a little pack just for Buster access. There's no reason why I can't get this organized as well. So So, yeah, I think I think courses and learning on models and insurgents have been doing this for years. Uh, stitching arteries together and gut, you know, animal type models in a lifetime scenario. Perfect. Well, thank you very much. Uh, sorry, Richard. Do you have a close just to say thank you, John? It was one of the best papers I had read in many years. Well, thank you. I have to say, I would never do it again. It took 10 years. That and, uh, I was actually tired when it when it finished. And writing that up was I was just part of a big team was a huge effort. And, um, you know, I just like to thank all the all the co authors, you know, it was my colleague with the room. She's healthy economists, but also, you know, clinically, uh, some people that really helped me was one and the bad news, Uh, anaesthetist and, uh, in leaves a bit like me, you know, it's an old fart. Now he's kind of retired and popping around something and still coming in and doing stuff. But he was very supportive, as was, you know, to buy as many from the Freeman that that the hematologist. So these people were extremely helpful. Um, but even so, it was it was a real effort to to write the paper and particularly get it in the Lancet. They're they're pretty hard team to deal with. But what I've learned is once once you get involved with a journal like that, we are the same with the New England Journal of Medicine. It of five different trials is that once once they click on to you, they're starting to help you, and you get a lot of heavy weight editing. And, you know, when they start doing that almost certainly going to get older than you know. Yeah. Uh, well, I'd like I'd like to thank all of our members of the panel for a very, very interesting discussion this evening. And thank you again for for presenting present in the paper. Uh, most importantly, I'd like to thank everybody who who is, uh, hang on to it, um, to, um to watch this evening. Um, thank you. Um, we'll meet this, um, this this has been recorded. And so that's what the plan will be to make this, uh, to make them available following the event and provided our panel and speaker are happy for that. Um, so thank you very much indeed. Thank you for organizing. Thanks for the invitation. Thank you. Thank you. Thank you.