CPX-351 is not an ordinary chemotherapy combination. It encapsulates cytarabine and daunorubicin within liposomes at a fixed five-to-one molar ratio, allowing the two agents to be delivered together and to persist in the bloodstream for longer than conventional formulations. This pharmacokinetic profile improves drug uptake by leukaemic blasts and has demonstrated clinical benefit for patients whose disease arises from prior therapy or carries myelodysplasia-related genetic changes, groups that historically fared poorly with standard induction regimens. Because the drug can be administered in both inpatient and outpatient settings, clinicians have increasingly explored ambulatory delivery as a way to spare hospital beds, reduce exposure to nosocomial infections, and preserve patients’ autonomy during a demanding course of intensive treatment.

To formalize this practice, a steering group of nine haematologists with hands-on experience in outpatient CPX-351 treatment was assembled from institutions across Europe and Australia. The group drafted a series of consensus statements organized into six key domains covering patient selection, definitions of treatment settings, the anticipated benefits of outpatient care, patient and caregiver requirements, healthcare system prerequisites, and practical measures for optimizing delivery. Their statements were then subjected to validation by a much wider panel: an online survey of 200 haematologists drawn from Australia, France, Germany, Italy, the United Kingdom, and Spain, all of whom had experience with intensive chemotherapy and outpatient care for AML. Agreement was measured on a four-point Likert scale, with consensus defined as at least seventy-five percent agreement for each statement.

The results were strikingly decisive. Forty-two of the forty-three statements, ninety-eight percent of the total, achieved consensus, and thirty-one of them reached agreement levels of ninety percent or higher. Such near-unanimity among two hundred specialists spanning six countries and diverse healthcare systems is uncommon in Delphi studies and signals that the clinical community has converged on a coherent view of how outpatient CPX-351 delivery should be approached. High alignment emerged particularly around the identification of suitable patients and the definition of what constitutes an appropriate outpatient treatment setting, the foundational questions that determine whether a given individual can safely receive intensive liposomal chemotherapy without overnight admission to a hematology ward.

When it came to the benefits of outpatient treatment, the panel expressed its strongest agreement on potential advantages for hospital resourcing, an issue of acute relevance as many hematology units face chronic bed shortages. Respondents also strongly endorsed improvements in patients’ physical and psychological status and in quality of life, reflecting a broader movement in oncology toward care models that respect patients’ daily lives. For older or comorbid patients with t-AML or AML-MRC, who may already be coping with the consequences of prior malignancy treatment, the ability to undergo induction chemotherapy while sleeping in their own beds, staying connected to family, and avoiding the disorientation of prolonged hospitalization carries real therapeutic and emotional weight.

The consensus did not shy away from the prerequisites that make such a model viable. The survey highlighted significant agreement on key patient and caregiver requirements, including cognitive and physical abilities sufficient to recognize and report emerging problems, reliable communication channels with the treating team, and reasonable access to the hospital or an affiliated emergency facility. These criteria acknowledge the central paradox of ambulatory intensive chemotherapy: the treatment is administered outside the ward, but the risk of febrile neutropenia, bleeding, and other complications remains, so patients must be selected, educated, and supported with the same rigor applied to any inpatient induction regimen.

Healthcare system requirements formed another domain of strong agreement. Respondents emphasized the need for explicit hospital protocols, adequate available resources, and robust systems for managing complications when they arise. In practice, this means that outpatient CPX-351 programs cannot simply be layered onto existing services without investment. They demand dedicated staff training, clearly defined escalation pathways, rapid-access clinics or equivalent mechanisms for same-day assessment, and coordination across the multidisciplinary team, including haematologists, nurses, pharmacists, and emergency physicians who may encounter these patients between scheduled visits. The consensus framework effectively functions as a checklist for institutions considering launching such a service.

Beyond eligibility and infrastructure, the panel endorsed a set of practical measures to optimize day-to-day delivery. These included the use of patient assessment tools to standardize selection and monitoring, structured collection of patient feedback, ongoing staff education, deliberate coordination among multidisciplinary team members, and the systematic sharing of best practices across centers. Although the authors acknowledge that challenges may differ across countries and healthcare settings, with reimbursement structures, geographic distances, and staffing models varying widely, the consensus provides clear, transferable guidance on safe and effective outpatient administration. For centers with less experience in ambulatory delivery of CPX-351, the document offers a ready-made starting point grounded in the collective judgment of the international hematology community.

The significance of this work extends beyond a single drug. Intensive chemotherapy for acute myeloid leukaemia has traditionally been synonymous with weeks of hospitalization, a model that burdens patients, families, and health systems alike. As liposomal and targeted therapies broaden the options for older and frailer patients, and as ambulatory care models prove their worth in other malignancies, structured consensus documents like this one will play an increasingly important role in translating clinical trial evidence into safe everyday practice. The near-total agreement achieved here suggests that outpatient CPX-351 treatment for t-AML and AML-MRC is no longer an experimental convenience but an emerging standard of care, provided that centers adhere to the patient-selection criteria, monitoring requirements, and multidisciplinary safeguards that the international panel has now so clearly defined.

Subject of Research: Outpatient delivery of CPX-351 liposomal cytarabine-daunorubicin for therapy-related acute myeloid leukaemia and AML with myelodysplasia-related changes

Article Title: Optimising CPX-351 (liposomal cytarabine-daunorubicin) treatment for t-AML/AML-MRC patients in the outpatient setting: a modified Delphi consensus

Article References: Mehta, P., Martínez-Roca, A., Cahalin, P., McNamara, C., Salamero, O., Martelli, M. P., Franke, G.-N., Capelli, D., de Andrés-Nogales, F., Francia, R., Lassman, E., & Conn, J. (2026). Optimising CPX-351 (liposomal cytarabine-daunorubicin) treatment for t-AML/AML-MRC patients in the outpatient setting: a modified Delphi consensus. Annals of Hematology. https://doi.org/10.1007/s00277-026-07220-9

Image Credits: AI Generated

DOI: 10.1007/s00277-026-07220-9

Keywords: CPX-351, acute myeloid leukaemia, t-AML, AML-MRC, liposomal cytarabine-daunorubicin, outpatient care, Delphi consensus, haematology, chemotherapy, ambulatory care, patient selection, quality of life

The study was led by researchers from the Faculty of Medicine at the University of Peradeniya, including Jananie Abeygunasekera, Anushka Sachini, Malindi Kulathunga, Chathurika Abeysekara, Dulanjana Senavirathna, and microbiologist Veranja Liyanapathirana. Drawing on a descriptive cross-sectional design, the team surveyed 351 adult visitors attending the outpatient department of a tertiary care hospital. Participants were recruited consecutively using convenience sampling, meaning the researchers enrolled eligible adults as they presented, and data were collected through a structured self-administered questionnaire. The instrument probed perceptions of physicians’ attire and grooming, as well as beliefs about infection-related risks tied to what doctors wear. Statistical associations between perceptions and sociodemographic characteristics were tested using Pearson’s chi-square test or Fisher’s exact test, with significance set at a p-value below 0.05.

The headline result is unambiguous: scrubs dominate patient preferences. Some 200 participants, or 57.0 percent, identified scrubs as the preferred attire for male doctors, while 194, or 55.3 percent, said the same for female physicians. This preference was not uniform across the age spectrum. Among young adults, 65.5 percent favored scrubs for male doctors, compared with 54.2 percent of middle-aged adults and only 34.1 percent of older adults, a difference that was highly statistically significant. The same generational gradient appeared for female doctors, with 63.0 percent of young adults, 52.8 percent of middle-aged adults, and 34.1 percent of older adults preferring scrubs.

As enthusiasm for scrubs waned with age, preference for traditional attire climbed. The saree, a garment with deep cultural resonance in Sri Lanka, was favored for female physicians by 18.2 percent of young adults, 35.9 percent of middle-aged adults, and 54.5 percent of older adults, a pattern that reached strong statistical significance. The authors interpret this shift through a sociocultural lens: younger patients appear to associate modern, standardized clinical dress with professionalism and hygiene, while older patients may read traditional attire as a marker of respectability, identity, and trustworthiness. In other words, what counts as an appropriate doctor’s look is not a fixed visual code but one negotiated between global medical conventions and local cultural expectations.

Beyond aesthetics, the study tapped into a growing scientific concern: clothing as a fomite. Textiles in clinical environments can harbor bacteria and other microorganisms, and several studies worldwide have documented contamination of white coats, neckties, and sleeves. The Sri Lankan patients surveyed were notably aware of this risk. Fully 283 participants, or 80.6 percent, knew that microorganisms could survive on clothing, and 192, or 54.7 percent, perceived physicians’ attire as a potential source of infection. That more than half of ordinary outpatients independently view clothing as an infection vector underscores how far public awareness of cross-contamination has penetrated, even outside hospital wards.

When it came to ranking garments by infection risk, patients again converged on scrubs. Among those who viewed attire as a potential infection source, 136, or 70.8 percent, judged scrubs the lowest-risk option for male physicians, and 135, or 70.3 percent, said the same for female physicians. A remarkable 164 participants, or 85.4 percent of this subgroup, also considered short-sleeved attire more favorable for effective hand hygiene. This detail aligns neatly with infection control doctrine: bare forearms allow thorough hand and wrist washing, whereas long sleeves can dip into sinks, contact patients, and retain moisture and microbes. Patients, it seems, have internalized the same practical logic that guides hospital hygiene protocols.

The study fills a conspicuous gap in the literature. Much of the existing research on physician attire has been conducted in high-income settings such as the United Kingdom, the United States, and Japan, where debates have swung from the traditional white coat to bare-below-the-elbows policies. Evidence from South Asia and other low- and middle-income contexts has been sparse, despite the fact that cultural norms, climate, laundry infrastructure, and hospital resourcing differ substantially. By documenting patient perspectives at a major Sri Lankan hospital, the Peradeniya team provides data that hospital administrators and professional bodies in the region can use to ground attire policies in patient sentiment rather than imported assumptions.

The findings carry practical implications for hospitals weighing dress codes. Because scrubs are simultaneously the most preferred attire and the garment perceived as carrying the lowest infection risk, they occupy a rare sweet spot where patient preference and infection prevention goals coincide. Uniform scrub programs could, in principle, strengthen both patient confidence and hygiene practice, particularly if paired with short sleeves and institutional laundering, which reduces the burden on individual clinicians to maintain garment cleanliness. At the same time, the age-dependent preference for traditional attire suggests that any transition toward standardized dress should be communicated sensitively, since older patients may experience such changes as a loss of familiarity or respect. Grooming, too, emerged as part of the equation, with tidy appearance functioning in patients’ eyes as a proxy for both professionalism and safety.

The researchers caution that their findings come from a single tertiary care outpatient department and used convenience sampling, so the results may not generalize to all Sri Lankan patients or to inpatient settings. Still, the study, which received no external funding and was approved by the Ethics Review Committee of the Faculty of Medicine at the University of Peradeniya under protocol number 2024/EC/SP/02, adds an important data point to a global conversation about how doctors should dress. Its central message resonates well beyond Central Sri Lanka: a physician’s appearance is never merely cosmetic. To the patients who watch clinicians walk into the examination room, clothing communicates competence, cleanliness, and care, and it can either reassure or quietly alarm. As hospitals worldwide refine attire policies in the name of infection control, this study is a reminder that patients are not passive observers of those choices. They bring their own expectations, shaped by generation and culture, about what a safe and trustworthy doctor looks like, and those expectations deserve a seat at the policy table.

The symbolic weight of the white coat is worth recalling when interpreting these results. The garment entered medical fashion in the late nineteenth century, when physicians adopted laboratory dress to signal that medicine was becoming a scientific discipline grounded in germ theory and antiseptic practice. Over the following century the coat became so entrenched that many institutions staged formal ceremonies in which students received their first coat as a rite of passage. The Sri Lankan findings suggest that this historical emblem no longer commands automatic deference, at least among younger outpatients, who appear to associate standardized clinical uniforms rather than traditional professional dress with modern, hygienic care.

The study’s methodology merits some attention for readers weighing its conclusions. Because participants were surveyed with a self-administered questionnaire in an outpatient waiting area, the results capture stated perceptions rather than observed behavior. Perception and behavior can diverge: a patient may prefer scrubs yet still trust a physician in a saree once a consultation begins. The cross-sectional design also means the age gradient documented by the researchers could reflect either generational differences that will persist as younger cohorts age, or a life-stage effect in which attitudes toward traditional dress shift with maturity. Longitudinal work would be needed to separate these possibilities.

The finding that 80.6 percent of participants knew microorganisms can survive on clothing is striking given that textile contamination is a relatively technical concept. Research in other settings has recovered pathogenic bacteria, including staphylococci and enteric organisms, from the sleeves, pockets, and lapels of clinical garments, and contamination rates appear to rise with the frequency of patient contact and the interval between laundering. Whether contaminated attire translates into actual transmission of infection to patients remains difficult to prove, and direct evidence linking physician clothing to hospital-acquired infections is limited. This uncertainty has shaped policy debates, since some national guidance has restricted long sleeves and neckties on precautionary grounds even without definitive transmission data.

The Sri Lankan context adds further nuance. In tropical climates, lightweight and easily laundered garments offer practical advantages, and institutional laundering of hospital-owned scrubs can guarantee washing temperatures and detergent standards that home laundering of personal coats may not achieve. For hospitals in resource-constrained settings, however, supplying multiple sets of scrubs to every clinician carries real costs, which helps explain why traditional attire and personal white coats remain widespread across South Asia. Any move toward uniform programs must therefore balance patient preferences and infection control logic against procurement, laundry capacity, and staff acceptance.

Finally, the study highlights how patients themselves have become sophisticated participants in infection prevention culture. Public experience with hand hygiene campaigns and, more recently, pandemic-era messaging has familiarized ordinary people with concepts such as fomites and cross-contamination. That more than half of surveyed outpatients spontaneously identified clothing as a potential infection source indicates that hospitals can no longer assume attire is a neutral or invisible element of care. Patient-facing communication about dress codes, including why particular garments are chosen, may itself become a tool for building confidence in outpatient settings.

Subject of Research: Patient perceptions of physician attire and grooming and their perceived infection risks in outpatient care in Sri Lanka

Article Title: Patient perceptions of physician attire and perceived infection risk associated with attire and grooming in outpatient care at a tertiary care hospital in Central Sri Lanka

Article References: Abeygunasekera, J., Sachini, A., Kulathunga, M., Abeysekara, C., Senavirathna, D., & Liyanapathirana, V. (2026). Patient perceptions of physician attire and perceived infection risk associated with attire and grooming in outpatient care at a tertiary care hospital in Central Sri Lanka. Discover Social Science and Health. https://doi.org/10.1007/s44155-026-00481-9

Image Credits: AI Generated

DOI: 10.1007/s44155-026-00481-9

Keywords: physician attire, patient perceptions, infection control, cross infection, scrubs, ambulatory care, hand hygiene, cultural factors, Sri Lanka, developing countries, tertiary care hospital, grooming