Real-time, simulation-enhanced interprofessional education in the care of older adults with multiple chronic comorbidities: a utilization-focused evaluation

BACKGROUND

Interprofessional education (IPE) is a curricular requirement for all healthcare professional education standards. To foster learning about, from and with each other, consistent with the Interprofessional Education Consortium's Core Competencies, many graduate schools are integrating interprofessional (IP) simulation experiences throughout their educational curricula, providing multiple opportunities for health professional students to collaborate and practice together. High-fidelity, real-time simulations help students from diverse professional backgrounds to apply their classroom learning in realistic clinical situations, utilize mobile technology to access clinical decision support (CDS) software, and receive feedback in a safe setting, ensuring they are practice-ready upon graduation.

METHODS

New York University Rory Meyers College of Nursing (NYU) and Long Island University College of Pharmacy (LIU) partnered for two consecutive years to create, coordinate and implement two interprofessional educational simulations involving patients with chronic cardiovascular disease. A utilization-focused evaluation of high-fidelity, simulation-enhanced IPE (Sim-IPE) was implemented to assess students' IP competencies before and after their participation in the IPE-simulation and their overall satisfaction with the experience. The Interprofessional Collaborative Competency Attainment Survey (ICCAS), a reliable instrument, was administered to both doctor of pharmacy students and primary care advanced practice nursing students before and after each simulation experience. Additionally, student satisfaction surveys were administered following the IPE-simulation.

RESULTS

Aggregated means revealed statistically significant improvements in each of the six domains including communication, collaboration, roles and responsibilities, collaborative patient/family approach, conflict resolution and team functioning. Student ratings revealed positive experiences with the IPE-simulations.

CONCLUSIONS

High-fidelity, real-time IPE-simulation is a powerful pedagogy to help graduate students from different professional backgrounds practice applying IP competencies in simulated experiences. Quality improvement studies and research studies are needed to assess the impact of high-fidelity, real-time simulations throughout graduate curricula with different types of patients to improve coordinated, team approaches to treatment.

Approach to the Management of Hypernatraemia in Older Hospitalised Patients

Hypernatraemia is associated with high morbidity and mortality and is more common in patients of older age, nursing home residents and those with cognitive impairment and restricted mobility. The most common cause in hospital settings is water dehydration due to reduced intake although other causes should be identified. Once identified, prompt management is necessary to avoid delayed correction as prolonged hypernatremia is associated with increased hospital stay and mortality. Comprehensive history-taking and physical examination, basic investigations and medication review are essential to identify causative and remediable factors in those admitted with hypernatraemia. Accurate calculation of fluid deficit and ongoing losses is essential in order to ensure adequate fluid replacement, The administration of appropriate, usually hypotonic, fluids is also essential to the timely restoration of eunatraemia. Although evidence of definite harm resulting from rapid correction is lacking, a serum sodium reduction rate of <12 mmol/l day is advised with the caveat that close monitoring of electrolytes is required to ensure the desired correction rate is being achieved. Medical and nursing professionals should have access to a local hospital protocol to guide management of patients with hypernatraemia to improve patient outcomes and mitigate the risk of harm, particularly from under-recognition and slow correction.

Mutations in COPA lead to abnormal trafficking of STING to the Golgi and interferon signaling

Heterozygous missense mutations in coatomer protein subunit α, COPA, cause a syndrome overlapping clinically with type I IFN-mediated disease due to gain-of-function in STING, a key adaptor of IFN signaling. Recently, increased levels of IFN-stimulated genes (ISGs) were described in COPA syndrome. However, the link between COPA mutations and IFN signaling is unknown. We observed elevated levels of ISGs and IFN-α in blood of symptomatic COPA patients. In vitro, both overexpression of mutant COPA and silencing of COPA induced STING-dependent IFN signaling. We detected an interaction between COPA and STING, and mutant COPA was associated with an accumulation of ER-resident STING at the Golgi. Given the known role of the coatomer protein complex I, we speculate that loss of COPA function leads to enhanced type I IFN signaling due to a failure of Golgi-to-ER STING retrieval. These data highlight the importance of the ER-Golgi axis in the control of autoinflammation and inform therapeutic strategies in COPA syndrome.

Equine influenza vaccination as reported by horse owners and factors influencing their decision to vaccinate or not

BACKGROUND

Equine influenza virus is a highly contagious respiratory pathogen that causes pyrexia, anorexia, lethargy and coughing in immunologically naïve horses. Vaccines against equine influenza are available and vaccination is mandatory for horses that participate in affiliated competitions, but this group forms a small proportion of the total horse population. The aims of this study were to: i) identify the equine influenza vaccination rate as reported in 2016 by horse owners in the United Kingdom (UK); ii) examine the demographics of owners and horses which were associated with significantly lower influenza vaccination rates and iii) explore factors that influence horse owners' decisions around influenza vaccine uptake.

RESULTS

Responses from 4837 UK horse owners who were responsible for 10,501 horses were analysed. An overall equine influenza vaccination rate of 80% (8385/10501) was reported. Several owner demographic characteristics were associated with significantly lower (p<0.05) reported equine influenza vaccination rates including: some geographical locations, increasing horse owner age, annual household income of less that £15,000 and owning more than one horse. Horse-related features which were associated with significantly lower reported equine influenza vaccination rates included age ranges of <4 years and > 20 years, use as a companion or breeding animal or leaving their home premises either never or at most once a year. The most common reasons cited for failing to vaccinate horses was no competition activity, lack of exposure to influenza and expense of vaccines. In contrast, the most common underlying reasons given by horse owners who vaccinated their horse were protection of the individual horse against disease, veterinary advice and to protect the national herd. Owners of vaccinated horses had less previous experience of an influenza outbreak or adverse reaction to vaccination compared with owners of unvaccinated horses.

CONCLUSIONS

This study documented a high rate of equine influenza vaccination as reported by owners in a substantial number of horses in the UK, but this does not reflect the level of protection. Sub-populations of horses which were less likely to be vaccinated and the factors that influence each owner's decision around vaccination of their horses against equine influenza were identified, but may alter following the 2019 European influenza outbreak. This information may nevertheless help veterinary surgeons identify "at-risk" patients and communicate more personalised advice to their horse-owning clients. It may also influence educational campaigns about equine influenza directed to horse owners, which aim to improve uptake of vaccination against this pathogen.

Increased rates of hypernatraemia during modest heatwaves in temperate climates

BACKGROUND

Hypernatraemia is associated with morbidity and mortality, particularly in the older person. Last summer, Ireland experienced prolonged periods of excessive heat. The Irish meteorological service defines a heatwave as temperatures exceeding 25°C for five consecutive days.

AIM

This study sought to compare the frequency of hypernatraemia (sodium (Na+) >145 mmol/l) observed during a modest heatwave with that during average ambient temperature in the temperate Irish climate.

DESIGN

Retrospective cross-sectional analysis with nested case-control study.

METHODS

The 10-day period from 24 June to 3 July in 2017 and 2018 were chosen as the control and heatwave periods, respectively. Patients aged >65 with at least one Na+ value recorded on the laboratory information system were included. Local meteorological data, age, gender and Na+ levels were evaluated.

RESULTS

Maximum air temperatures were significantly higher during the heatwave period (mean 27°C vs. 16.8°C, P < 0.0001). Hypernatraemia was present in 3.6% (66/1840) of samples collected during the heatwave compared to 1.4% (23/1593) in the control period. The mean age of affected patients was similar in both groups, 75 years ±7 (P = 1.000). Almost half of participants (49.5%) were male. The frequency of hypernatraemia observed was not influenced by gender, P = 0.33. The median sodium concentrations were similar in both groups, P = 1.00.

CONCLUSION

Hypernatraemia was 2.5 times more frequent in samples drawn during the heatwave compared to the control period. In this study, neither age nor gender impacted the profile of patients diagnosed with hypernatraemia. A modest rise in temperatures increases hypernatraemia rates in temperate climates.

Experimental Demonstration of Hadron Beam Cooling Using Radio-Frequency Accelerated Electron Bunches

Cooling of beams of gold ions using electron bunches accelerated with radio-frequency systems was recently experimentally demonstrated in the Relativistic Heavy Ion Collider at Brookhaven National Laboratory. Such an approach is new and opens the possibility of using this technique at higher energies than possible with electrostatic acceleration of electron beams. The challenges of this approach include generation of electron beams suitable for cooling, delivery of electron bunches of the required quality to the cooling sections without degradation of beam angular divergence and energy spread, achieving the required small angles between electron and ion trajectories in the cooling sections, precise velocity matching between the two beams, high-current operation of the electron accelerator, as well as several physics effects related to bunched-beam cooling. Here we report on the first demonstration of cooling hadron beams using this new approach.

Investigation of a foodborne outbreak of Shigella sonnei in Ireland and Northern Ireland, December 2016: the benefits of cross-border collaboration and commercial sales data

OBJECTIVES

To describe a cross-border foodborne outbreak of Shigella sonnei that occurred in Ireland and Northern Ireland (NI) in December 2016 whilst also highlighting the valuable roles of sales data and international collaboration in the investigation and control of this outbreak.

STUDY DESIGN

A cross-border outbreak control team was established to investigate the outbreak.

METHODS

Epidemiological, microbiological, and environmental investigations were undertaken. Traditional analytical epidemiological studies were not feasible in this investigation. The restaurant chain provided sales data, which allowed assessment of a possible increased risk of illness associated with exposure to a particular type of heated food product (product A).

RESULTS

Confirmed cases demonstrated sole trimethoprim resistance: an atypical antibiogram for Shigella isolates in Ireland. Early communication and the sharing of information within the outbreak control team facilitated the early detection of the international dimension of this outbreak. A joint international alert using the European Centre for Disease Control's confidential Epidemic Intelligence Information System for Food- and Waterborne Diseases and Zoonoses (EPIS-FWD) did not reveal further cases outside of the island of Ireland. The outbreak investigation identified that nine of thirteen primary case individuals had consumed product A from one of multiple branches of a restaurant chain located throughout the island of Ireland. Product A was made specifically for this chain in a food production facility in NI. S. sonnei was not detected in food samples from the food production facility. Strong statistical associations were observed between visiting a branch of this restaurant chain between 5 and 9 December 2016 and eating product A and developing shigellosis.

CONCLUSIONS

This outbreak investigation highlights the importance of international collaboration in the efficient identification of cross-border foodborne outbreaks and the value of using sales data as the analytical component of such studies.

Sudden unexpected death in epilepsy (SUDEP) in New Zealand; a retrospective review

AIM

Sudden unexpected death in epilepsy (SUDEP) is well recognised and widely reported but remains poorly understood. SUDEP in young adults is 27 times more common than sudden death in control populations. The incidence of SUDEP in New Zealand is not known but up to 40 people with epilepsy may die from SUDEP every year. A review of coroner's reports of SUDEP was undertaken to learn more about SUDEP in New Zealand.

METHOD

Coroner's reports of all cases of possible SUDEP in New Zealand from 2007-2016 (n=190) were obtained and post-mortem and toxicology results were reviewed. Cases were categorised using published criteria.

RESULTS

We obtained reports of 190 cases from the coroner's office. Of these 190 cases, we determined that 123 were definite SUDEP, 40 were definite SUDEP plus, three were probable SUDEP, seven were possible SUDEP and 17 were probably not SUDEP. The number of cases per year varied from 11-26 (2013). Cases were aged 1.5-67 years, with 63% aged 15-45 (mean 37 years). Sixty-one percent were male. Eighty-seven percent of the deaths occurred at home, with 74% found dead in their bed or bedroom. The majority were not employed, with only 33% working or retired at the time of death; 15% were children or students. Information regarding work status was not available for 11%. Toxicology results were available for 155 cases; antiepileptic drug (AED) use was detected in 67% of these cases, with a single AED detected in 44%, two AEDs in 21%, and three AEDs in 3% of samples taken at autopsy. Approximately half who took an AED were taking either sodium valproate or carbamazepine.

CONCLUSION

This study suggests that people with epilepsy who die from SUDEP in New Zealand are young and are often compliant with their medication. We plan to establish a nationwide SUDEP registry using the EpiNet database to determine the incidence of SUDEP in New Zealand, and to track changes in SUDEP rates. We are also planning to take part in an international case-control study of SUDEP in the hope that we might learn more about risk factors that predispose people with epilepsy to SUDEP, and factors that might reduce the risk.

P47 Successful treatment of two cases of refractory JIA uveitis with intravenous tocilizumab and subcutaneous methotrexate

Background

There is a need for additional treatment options in refractory JIA uveitis which has responded inadequately to MTX and anti TNFα. There has been interest in the use of tocilizumab, the APTITUDE trial using SC tocilizumab in JIA uveitis and the STOP-Uveitis study comparing 2 dosing regimens of iv tocilizumab in adults. Anecdotal evidence reports JIA uveitis patients who were stable on IV tocilizumab flaring when switched to sc administration. We describe the successful use of IV tocilizumab and concurrent sc MTX in two cases.

Methods

Retrospective review of patient paper and electronic medical records.

Results

Case 1.: A five-year-old female presented with severe anterior uveitis in her right eye. She was diagnosed with idiopathic uveitis and treated with topical steroid, oral then SC MTX infliximab, mycophenolate and adalimumab, all with inadequate control of her uveitis. At the age of 12, on adalimumab, she developed arthritis and her diagnosis was changed to JIA uveitis.

7 years after initial diagnosis she was commenced on IV tocilizumab 8mgs/kg 4-weekly with improved control of her uveitis although initially still requiring some topical steroid. She required intra-articular steroids for active arthritis and agreed to restart SC MTX. On tocilizumab and MTX combined, her arthritis settled and her topical eye drops were weaned for the first time since diagnosis.

From age 5 until 14 she was continually on topical steroids, consequently developing raised intraocular pressure and a dense cataract. With improved disease control she had cataract surgery aged 14. She has maintained good disease control for the last five years on the combination of IV tocilizumab and SC MTX and has not required any further steroids.

Case 2: A 3 year old female with oligoarticular JIA had severe bilateral uveitis at presentation. Initial treatment was with oral prednisolone, topical steroid and SC MTX. 6 months after diagnosis her uveitis remained active and she was commenced on infliximab with additional IV methylprednisolone. Venous access was challenging, required a portacath to facilitate treatment.

By the age of 6 she had developed a cataract requiring surgery and still had incomplete control of her uveitis. Infliximab was increased to 10mgs/kg 4 weekly with little further benefit and at the age of 7 she was changed to adalimumab. On this she developed macular oedema requiring pulse IV methylprednisolone.

5 years after diagnosis she was commenced on IV tocilizimab initially 4 weekly, increasing after three months to 2 weekly. Her methylprednisolone was weaned and she has subsequently maintained good disease control on IV tocilizumab 10mgs/kg 2 weekly with SC methotrexate.

Conclusion

We describe two cases of refractory JIA and uveitis in whom IV tocilizumab with SC methotrexate has provided good disease control. Further studies are required to determine the optimal dosing regimen.

Conflicts of Interest

The authors declare no conflicts of interest.

P38 Never say never: new onset uveitis in adolescence

Background

To highlight the importance of considering new onset uveitis in adolescent patients with longstanding juvenile idiopathic arthritis (JIA).

Methods

We performed a retrospective review of electronic medical records.

Results

A 16 year-old girl was diagnosed in 2004, aged 15 months with extended oligoarticular JIA (ANA positive, >1/640 homogeneous). Her initial treatment included intra-articular steroid injections and approximately eighteen months later methotrexate, which she remained on for four years. During this time she received occasional intra-articular steroid injections. Etanercept was added in 2009 due to persistent active disease and she continued on this treatment regime for the next five years. Methotrexate was discontinued in 2013 due to intolerance. Etanercept was discontinued in 2014 due to disease remission but was restarted after three months when her arthritis flared.

In 2018 biologic treatment was changed due to poor disease control. Etanercept was switched to adalimumab, initially alternate weeks but increasing to weekly together with multiple joint injections. Six months later, her disease control remained poor and drug levels and antibodies were measured. She had a strongly positive anti-drug antibody level>200 AU/ml and her adalimumab level was <0.4mgs/L (normal range 5-10).

At this time our patient now aged 16 presented with a four-week history of intermittent reduced vision in her right eye. Ophthalmology review found bilateral anterior uveitis. This patient had regular eye screening from her JIA diagnosis until her 11th birthday, showing no previous evidence of uveitis.

Following diagnosis of uveitis she was commenced on steroid eye drops and IV methylprednisolone to treat both her uveitis and arthritis. Infliximab, (6mg/kg) was commenced then increased (10mg/kg) for ongoing uveitis and methotrexate was restarted. Despite this treatment she has persistent low grade right uveitis. Her left eye has settled and she has no lens opacities or raised intraocular pressures. She continues with joint discomfort secondary to her hypermobility but her arthritis is currently quiescent.

Conclusion

Type of arthritis and age at onset historically dictated the risk of developing uveitis. However uveitis can present in any age group and in patients with any type of JIA. In our case uveitis developed for the first time almost 15years after diagnosis.

With disease modifying treatments now widely used early in the management of JIA, uveitis may be masked and therefore present late or atypically. It is rare for uveitis to present so long after diagnosis, however this case highlights that rheumatology teams should be aware that it can still develop. Therefore we should never say never!

Conflicts of Interest

The authors declare no conflicts of interest.

183 Risk of Hypoglycaemia in Older Patients in Residential Care on Oral Hypoglycaemic Medication

Background

Diabetes mellitus (DM) is common in older patients in residential care(RC) with prevalence ranging from 11-36%.Guidlines(1) on glucose targets to avoid the risk of hypoglycaemia or hyperglycaemia respectively in older people recommend avoiding a fasting glucose on treatment of 6mmol/L or a random glucose level higher than 11.0mmol/L. An HbA1c of 53to 59mmol/mol(7-7.5%) should be aimed for although this may need adjusting in RC and StoppFrail guidelines suggest a target of HbA1c of <8%(64mmol/mol). We assessed the prevalence, drug treatment and glycaemic control in 107 older patients in residential care at two sites in Dublin.

Methods

Patients with DM were identified from review of medical notes. Hypoglycaemic treatment whether oral hypoglycemic drugs(OHD) or insulin, capillary blood glucose measurements(CBGM) over the previous 28 day period, HbA1c values and weight change over the previous year respectively were tabulated from patient records.

Results

Sixteen patients (15%) aged 66-93 were documented with DM. Eight (50%) were on no hypoglycaemic treatment in whom OHD had been discontinued in 2 patients over the previous 6 months because of risk of hypoglycaemia.. Six patients (38%) were only on OHD, whilst 2 were on insulin. Of the 6 patients on OHD, CABGM were below 6mmol/L in 3 patients (50%) with no values above 11mmol/L. All 3 patients had lost weight ( 2.5-6.8Kg) over the previous year and HbA1c levels were below 53mmol/mol (7%) in all 3 patients.

Conclusion

Although our numbers are small, 50% of our patients in residential care on OHD are at risk of hypoglycemia possibly related to weight loss. Reducing or discontinuing their OHD may be appropriate.

Impact of Introduction of a Clinical Pathway for the Management of Pyelonephritis on Obstetric Patients: a Quality Improvement Project

Aim To determine whether the introduction of a clinical pathway for the treatment of pyelonephritis in obstetric patients would improve outcomes. Methods This was a retrospective study conducted in a maternity hospital using quantitative analysis methods. Patients who met laboratory and clinical criteria for pyelonephritis during data collection were included. Results The study included analysis of 23 patients pre-intervention and 19 post-intervention. Baseline and patient characteristics were similar for both groups. A statistically significant difference was seen in 3 of 7 outcome measures. Increased use of gentamicin (13% Vs 52% p=0.006), Increased number of renal ultrasounds (17% Vs 47%, p=0.04) and increased use of prophylaxis (21% Vs 68%, p=0.003). The proportion of patients receiving ≥ 10 days of IV antimicrobials decreased from 48% to 21% post-intervention (p=0.07). Discussion This study has shown that the introduction of a pathway for the treatment of pyelonephritis in pregnancy had a positive impact on several important clinical outcomes.