The development of a quality improvement project to improve infection prevention and management in patients with asplenia or hyposplenia

Asplenia and hyposplenia (a/hyposplenia) are associated with increased morbidity and mortality from complications including infection. The recommended measures to reduce the risks associated with infection include patient education, vaccination and early initiation of antibiotic therapy for fever. Despite these recommendations, there is poor adherence to best practice management of patients with asplenia or hyposplenia (PWA/H). We present the development methodology and pilot data of a quality improvement project that explored whether a programme involving a novel medical alert card together with a patient and healthcare provider educational booklet increased vaccination rates and improved awareness and understanding of the infectious implications of a/hyposplenia. Our aim was to increase the proportion of those appropriately vaccinated and the proportion of patients with proper understanding of fever management by twofold in 18 months. Questionnaires were used locally as a root-cause-analysis to confirm the need for education and evaluate the effectiveness of the programme, as well as patient satisfaction. An interdisciplinary team developed a toolkit composed of a medical alert card and booklet. The toolkit was distributed to PWA/H who presented for a haematology clinic visit at a tertiary care centre. A separate set of questionnaires was then used to evaluate satisfaction and obtain feedback from patients and practitioners receiving the toolkit for the first time. Changes suggested by patients and practitioners with unanimous agreement among study investigators were made to the toolkit. The pilot study showed an increase in vaccination rates and awareness of vaccination status and appropriate fever management. The majority of the patients and practitioners found the information provided by the toolkit helpful. Given these promising single-centre findings, the intervention is being extended to another tertiary care centre with a large red blood cell disorders programme to evaluate its generalisability. The next step will be to expand the scope to paediatric PWA/H.

Distinct maternal and fetal pregnancy outcomes in women with sickle cell disease can be predicted using routine clinical and laboratory data

We aimed to identify risk factors for adverse outcomes in pregnancies of women with sickle cell disease (SCD) and develop risk prediction models. Models were derived from a retrospective cohort of pregnant women with SCD and constructed using generalised estimating equation logistic regression, with clustering by woman. Maternal event(s) consisted of acute anaemia; cardiac, pulmonary, hepatobiliary, musculoskeletal, skin, splenic, neurological or renal complications, multi‐organ failure, venous thromboembolism, admission‐requiring vaso‐occlusive events (VOE), red cell transfusion, mortality or hypertensive disorder of pregnancy. Fetal events included preterm birth, small‐for‐gestational‐age or perinatal mortality. Of 199 pregnancies, 71% and 45% resulted in adverse maternal and fetal outcomes respectively. Low first‐trimester haemoglobin, admission‐requiring VOE in the year before pregnancy, multiple transfusions before pregnancy, SCD genotype and previous cardiac complications predicted maternal risk. Younger age and SCD genotype allowed early prediction of fetal risk (model‐F1). Adding maternal event(s) and high lactate dehydrogenase enabled re‐assessment of fetal risk with advancing gestation (model‐F2). Models were well calibrated and moderately discriminative for maternal outcome (c‐statistic 0·81, cross‐validated value 0·79) and fetal outcome (model‐F1 c‐statistic 0·68, cross‐validated value 0·65; model‐F2 c‐statistic 0·72, cross‐validated value 0·68). The models will allow early identification of women with SCD at high risk of adverse events, permitting early targeted interventions and ongoing fetal risk re‐assessment enabling intensification of surveillance and optimisation of delivery timing.

Neighbourhoods and dementia: An updated realist review of the qualitative literature to inform contemporary practice and policy understanding

This realist review of the literature provided a contemporary understanding of neighbourhoods and dementia and described how people living with dementia and their neighbourhood interacted via ongoing place-making and remaking processes. Drawing on 44 articles, neighbourhoods were revealed to have fluid and dynamic qualities where people with dementia used their strength and resources to connect to significant people and places. The review also indicated that the person with dementia-neighbourhood relationship was underpinned by four themes: 'home', 'social interactions', 'activities' and 'transportation'. Further research is encouraged to use innovative, participatory methods to explore the neighbourhood-dementia nexus in depth whilst paying close attention to social inclusion and diversity.

Comparison of Inline R2* MRI versus FerriScan for liver iron quantification in patients on chelation therapy for iron overload: preliminary results

OBJECTIVES

MRI quantification of liver iron concentration (LIC) using R₂ or R₂* relaxometry requires offline post-processing causing reporting delays, administrative overhead, and added costs. A prototype 3D multi-gradient-echo pulse sequence, with inline post-processing, allows immediate calculation of LIC from an R₂* map (inline R₂*-LIC) without offline processing. We compared inline R₂*-LIC to FerriScan and offline R₂* calibration methods.

METHODS

Forty patients (25 women, 15 men; age 18-82 years), prospectively underwent FerriScan and the prototype sequence, which produces two R₂* maps, with and without fat modeling, as well as an inline R₂*-LIC map derived from the R₂* map with fat modeling, with informed consent. For each map, the following contours were drawn: ROIs, whole-axial-liver contour, and an exact copy of contour utilized by FerriScan. LIC values from the FerriScan report and those calculated using an alternative R₂ calibration were the reference standards. Results were compared using Pearson and interclass correlation coefficients (PCC, ICC), linear regression, Bland-Altman analysis, and estimation of area under the receiver operator curve (ROC-AUC).

RESULTS

Inline R₂*-LIC demonstrated good agreement with the reference standards. Compared to FerriScan, inline R₂*-LIC with whole-axial-liver contour, ROIs, and FerriScan contour demonstrated PCC of 94.8%, 94.8%, and 92%; ICC 93%, 92.7%, and 90.2%; regression slopes 1.004, 0.974, and 1.031; mean bias 5.54%, 10.91%, and 0.36%; and ROC-AUC estimates 0.903, 0.906, and 0.890 respectively. Agreement was maintained when adjusted for sex, age, diagnosis, liver fat content, and fat-water swap.

CONCLUSION

Inline R₂*-LIC provides robust and comparable quantification of LIC compared to FerriScan, without the need for offline post-processing.

KEY POINTS

• In patients being treated for iron overload with chelation therapy, liver iron concentration (LIC) is regularly assessed in order to monitor and adjust therapy. • Magnetic resonance imaging (MRI) is commonly used to quantify LIC. Several R₂ and R₂* methods are available, all of which require offline post-processing. • A novel R₂* MRI method allows for immediate calculation of LIC and provides comparable quantification of LIC to the FerriScan and recently published alternative R₂* methods.

Screening for Cognitive Dysfunction Using the Rowland Universal Dementia Assessment Scale in Adults With Sickle Cell Disease

IMPORTANCE

Adults with sickle cell disease (SCD) disproportionally experience early cognitive decline; however, guidance on the optimal screening strategy for cognitive dysfunction is lacking, and several available tools are biased by language, educational level, socioeconomic status, and race/ethnicity. The Rowland Universal Dementia Assessment Scale (RUDAS) was specifically designed for cognitive screening in multicultural populations.

OBJECTIVE

To ascertain the prevalence of suspected dementia in adults with SCD using the RUDAS, and to identify whether age, sex, educational level, several biological variables, and SCD complications were associated with RUDAS scores.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter, bilingual, cross-sectional study was conducted in 2 SCD comprehensive care centers in Canada (Centre Hospitalier de l'Université Montréal in Montréal and University Health Network in Toronto). Participants were adults aged 18 years or older and were enrolled in the study between July 1, 2018, and July 30, 2019. All outpatients were eligible and offered study participation, unless they had an acute medical condition that required inpatient care or they were unable to follow study instructions.

INTERVENTIONS

The RUDAS was administered by trained personnel in either French or English, according to the patient's language preference. A questionnaire on social determinants of health was also administered, and participants underwent screening for anxiety and depression.

MAIN OUTCOMES AND MEASURES

Proportion of participants with RUDAS scores that were suggestive of dementia and the RUDAS score. Any score lower than 23 points was suggestive of dementia, a score between 23 and 27 points indicated a possible association with mild neurocognitive disorder, and a score higher than 27 points was normal.

RESULTS

A total of 252 adult patients with SCD were included (136 women [54.0%]; mean [range] age, 34.8 [18-75] years). Overall, 29 patients (11.5%) had RUDAS scores that were suggestive of dementia, and this proportion increased with age (15 [8.7%] in the 18-39 years age group, 10 [14.5%] in the 40-59 years age group, and 4 [36.4%] in the ≥60 years age group). The RUDAS scores were not associated with sex, language, SCD genotype, and SCD complications. The highest level of education was significantly associated with the RUDAS score; however, the association was small (η2 = 0.02; 95% CI, 0.00-0.07; P = .02). In a multivariable analysis, lower glomerular filtration rate (r = 0.40; 95% CI, 0.29-0.50; P < .001) and increasing age (r = -0.37; 95% CI, -0.47 to -0.26; P < .001), but not SCD genotype or disease severity, were associated with lower RUDAS scores.

CONCLUSIONS AND RELEVANCE

This study found that using the RUDAS revealed a high prevalence of suspected dementia in adult patients with SCD that was associated with worsening kidney function and age. Cognition should be screened in all adult patients with SCD, regardless of age, disease severity, and SCD genotype; further validation of the RUDAS is ongoing.

The Roles of Serotonin in Neuropsychiatric Disorders

The serotonergic system extends throughout the central nervous system (CNS) and the gastrointestinal (GI) tract. In the CNS, serotonin (5-HT, 5-hydroxytryptamine) modulates a broad spectrum of functions, including mood, cognition, anxiety, learning, memory, reward processing, and sleep. These processes are mediated through 5-HT binding to 5-HT receptors (5-HTRs), are classified into seven distinct groups. Deficits in the serotonergic system can result in various pathological conditions, particularly depression, schizophrenia, mood disorders, and autism. In this review, we outlined the complexity of serotonergic modulation of physiologic and pathologic processes. Moreover, we provided experimental and clinical evidence of 5-HT's involvement in neuropsychiatric disorders and discussed the molecular mechanisms that underlie these illnesses and contribute to the new therapies.

Exploration of Barriers and Facilitators to Optimal Emergency Department Care of Sickle Cell Disease: Opportunities for Patient-Physician Partnerships to Improve Care

Sickle cell disease patients commonly present to an emergency department (ED) due to acute vaso-occlusive pain episodes (VOEs), also known as vaso-occlusive crises (VOCs). Unsatisfactory patient care leads to preventable morbidity, mortality, and substantial financial costs. This study investigated the current use of sickle cell disease patient-directed physician education (PDPE) in the clinical setting and also explored opportunities for improvement. A qualitative phenomenologic design was used with semi-structured in-depth interviews. Open-ended questions were used to probe participant's experiences with EDs, the feasibility of a PDPE program as well as barriers and facilitators to PDPE. A total of nine patients and eight physicians participated in the study. Three major themes were identified: divergent challenges to patient recommendations, new targets for sickle cell disease education and triage process: not heard and not seen. Numerous challenges exist to the implementation and optimization of PDPE with sickle cell disease triage processes and nursing support identified as influential factors. Paramount to the process of improving PDPE is physicians perceiving patients as credible sources of information, especially as it relates to generalized concerns of opioid dosing. A patient provided written or digital education tool can be considered to facilitate PDPE to ease communication strain on patients while increasing communication efficiency.

Eukaryotic translation initiation factors as promising targets in cancer therapy

The regulation of the translation of messenger RNA (mRNA) in eukaryotic cells is critical for gene expression, and occurs principally at the initiation phase which is mainly regulated by eukaryotic initiation factors (eIFs). eIFs are fundamental for the translation of mRNA and as such act as the primary targets of several signaling pathways to regulate gene expression. Mis-regulated mRNA expression is a common feature of tumorigenesis and the abnormal activity of eIF complexes triggered by upstream signaling pathways is detected in many tumors, leading to the selective translation of mRNA encoding proteins involved in tumorigenesis, metastasis, or resistance to anti-cancer drugs, and making eIFs a promising therapeutic target for various types of cancers. Here, we briefly outline our current understanding of the biology of eIFs, mainly focusing on the effects of several signaling pathways upon their functions and discuss their contributions to the initiation and progression of tumor growth. An overview of the progress in developing agents targeting the components of translation machinery for cancer treatment is also provided.

Adverse outcome of acute splenic sequestration crisis in pregnancy

Background

Acute splenic sequestration crisis, characterized by abrupt fall in hemoglobin, splenomegaly, hypovolemia, and often thrombocytopenia, occurs infrequently in adults with sickle cell disease and extremely rarely during pregnancy.

Case

A 25-year-old woman with HbSC presented at 33 weeks' gestation with vaso-occlusive pain. Sudden worsening of abdominal pain and non-reassuring fetal surveillance on day 3 of admission led to emergent delivery. Acute splenic sequestration crisis was the diagnosis of exclusion based on clinical presentation and intra-operative hemoglobin of 37 g/L. Five- and 10-minute Apgar scores were 4. Neonatal brain magnetic resonance imaging revealed significant diffuse white matter abnormalities.

Conclusion

Acute splenic sequestration crisis in pregnancy must be considered in the differential diagnosis for this patient population as it can evolve rapidly and lead to maternal and fetal compromise.

Specialist LINK and primary care network clinical pathways - a new approach to patient referral: a cross-sectional survey of awareness, utilization and usability among family physicians in Calgary

BACKGROUND

Specialist LINK is a real-time, non-urgent telephone collaboration line designed to link family doctors and specialists. The purpose was to reduce wait times, improve efficiency and enhance the coordination of patient care through enhanced communication between primary and specialty care. The aim of this study was to determine the awareness and utilization of Specialist LINK and Primary Care Network (PCN) Clinical Pathways among family physicians.

METHODS

A family physician experience cross-sectional survey was conducted from March to May 2018 in Calgary and Area. The survey was designed to assess family physicians' awareness and utilization of Specialist LINK and PCN Clinical Pathways. We also used a 1-10 scale for respondents to rate the utility of Specialist LINK (1 was least useful and 10 represented highly useful). To obtain a true representative sample, family physicians were selected through a random sampling method. We applied multiple approaches to ensure a high response rate: paper survey, telephone reminders, and an on-site survey for non-responders.

RESULTS

A total of 251 participants completed the survey of the 650 randomly selected family physicians (Response rate≈39%). Eighty-nine percent of the family physicians were aware of Specialist LINK [95% Confidence Interval (84-92%)]. The average rating was 8.1 (on a scale of 1-10) for the usefulness of Specialist LINK. We found that the odds of being aware of Specialist LINK were two times higher in female family physicians compared to male physicians. Also, those with less than 5 years of experience, the odds of being aware of Specialist LINK were around five times higher compared to those with 5 or more years of experience. Fifty-five percent of family physicians were aware of PCN Clinical Pathways (95% CI = 48-60%); of those, 82% were accessing and following PCN Clinical Pathways in their clinical practice. The average rating was 7.9 (on a scale of 1-10) for the usefulness of PCN Clinical Pathways.

CONCLUSION

Most of the respondents in Calgary and area were aware of Specialist LINK and a large proportion of them were using it to access advice for their patients.

Liquid Chromatographic Method for Determination of Diquat and Paraquat Herbicides in Potatoes: Collaborative Study

A liquid chromatographic (LC) method for the determination of diquat and paraquat herbicides/desiccants in potatoes was collaboratively studied in 6 laboratories. Analytes are extracted from 5 g sample with dilute acid by using a microreflux procedure; the hydrolysate is adjusted to pH 9–10 and passed through a disposable silica cartridge for rapid cleanup and preconcentration. Analytes are separated on a reversed-phase LC column and are measured as their heptanesulfonate ion pairs by UV detection. Each collaborator determined diquat and paraquat at 4 levels (0.05,0.1,0.5, and 1.0 ppm) in blind duplicate samples plus 2 blind negative control samples. Potatoes, obtained from each participant’s region, were spiked by the collaborators with unknown aqueous solutions containing no analyte or a mixture of diquat and paraquat standards. Repeatability and reproducibility relative standard deviations (RSDr and RSDR) averaged 17.1 and 29.0%, respectively, for determination of diquat and 10.8 and 29.5%, respectively, for paraquat. For analysis of standard solutions, RSDr and RSDR values were 6.3 and 12.0%, respectively, for diquat and 7.3 and 13.9%, respectively, for paraquat. Accuracy, measured by comparison with true spiking values (absolute recovery) averaged 77.6 and 76.2% for diquat and paraquat, respectively, and ranged from 71.8 to 88.0% for both compounds. The method was adopted first action by AOAC International.

Impact of a transition program with navigator on loss to follow-up, medication adherence, and appointment attendance in hemoglobinopathies

BACKGROUND

Transition from pediatric to adult care is a period of high risk for loss to follow-up, morbidity, and mortality in adolescents and young adults (AYA) with hemoglobinopathies. The purpose of this study was to determine whether a transition program with transition navigator (TN) reduced loss to follow-up and hospitalizations and improved medication adherence and appointment attendance compared with an unstructured transfer.

PROCEDURE

A retrospective observational study compared all AYA with hemoglobinopathies who turned 18 one year prior to (n = 51) and one year after (n = 61) the initiation of the transition program. Data from one year prior to last pediatric appointment and one year following first adult appointment were collected from each patient.

RESULTS

The transition program with TN reduced loss to follow-up from 29% to 7% (P = 0.034). A greater proportion of patients in the transition cohort maintained or improved adherence to hydroxyurea or iron chelation to ≥4 days/week; exposure to the program was independently associated with such improvement (P = 0.047). A trend toward improvement or maintenance of ≥90% attendance to appointments was observed (P = 0.096). Frequency of hospitalization was not significantly different between the two cohorts (P = 0.985).

CONCLUSIONS

A transition program with TN significantly reduced loss to follow-up, and significantly improved and maintained fair to good medication adherence. Further analysis of economic benefit and patient satisfaction will be conducted.

Deferiprone exerts a dose-dependent reduction of liver iron in adults with iron overload

OBJECTIVE

While doses of deferiprone up to 75 mg/kg/d have been demonstrated to be effective in cardiac iron removal, their efficacy in the reduction of liver iron has been equivocal. The aim of this study was to evaluate the effect of deferiprone dose on liver iron concentrations in adult iron overload patients.

METHODS

A single-centered, retrospective, cohort observational study was conducted involving 71 patients exposed to deferiprone doses up to 113 mg/kg/d between January 2009 and June 2015 for a median of 33 months.

RESULTS

At the end of the study period, liver iron measured by R2 MRI was reduced by a mean 1.7 mg/g dw. A dose effect was observed, with incremental reductions of 2.8 mg/g dw in end of study LIC for every 10 mg/kg/d higher dose of deferiprone (P < 0.001). A dose effect was also observed in end of study ferritin and cardiac iron concentration measured by T2* MRI (P < 0.0001 and P = 0.048, respectively). No associations between adverse effects and deferiprone dose were observed, but there was a trend toward higher rates of agranulocytosis at higher doses and two of three hereditary hemochromatosis patients developed this complication.

CONCLUSION

The present study failed to demonstrate that the use of deferiprone at >90 mg/kg/d was associated with increased risk of agranulocytosis or neutropenia, but did demonstrate more effective liver iron control in iron overload patients.

Non-aqueous formulations for ram and screen extrusion-spheronisation

The use of non-aqueous cellulose-based formulations for extrusion-spheronisation (E-S) is investigated. A 10 wt% hydroxypropyl cellulose/isopropyl alcohol solution (HPC/IPA) was identified as a suitable sticky liquid binder for preparing non-aqueous pastes. Preliminary tests were performed on a series of pastes using a ram as well as a laboratory roller screen extruder, since the former is commonly used in batch testing and the latter replicates the shear range in a manufacturing screen extruder. Pellets with acceptable size and shape distributions were obtained with Avicel® HFE-102 NF/HPC/IPA for ram E-S, and with Avicel® RC-591/HPC/IPA for screen E-S. Further investigation was performed with calcium carbonate added as a model active pharmaceutical ingredient. Both formulations were able to generate pellets with acceptable size and shape characteristics at up to 50 wt% carbonate loading: further work is required to optimise yields.

Development of a patient-reported outcomes symptom measure for patients with nontransfusion-dependent thalassemia (NTDT-PRO© )

β‐Thalassemia, a hereditary blood disorder caused by reduced or absent synthesis of the β‐globin chain of hemoglobin, is characterized by ineffective erythropoiesis, and can manifest as nontransfusion‐dependent thalassemia (NTDT) or transfusion‐dependent thalassemia (TDT). Many patients with NTDT develop a wide range of serious complications that affect survival and quality of life (QoL). Patient‐reported outcomes (PRO), including health‐related QoL (HRQoL), are important tools for determining patient health impairment and selecting appropriate treatment. However, there are currently no disease‐specific PRO tools available to assess symptoms related to chronic anemia experienced by patients with NTDT. This study aimed to develop a new, US Food and Drug Administration (FDA)‐compliant PRO of chronic anemia symptoms, the NTDT‐PRO^© tool, for use in patients with NTDT. Participants had a median age of 36 years (range, 18‐47) and 60% were female. The initial development of the NTDT‐PRO tool involved concept‐elicitation interviews with 25 patients from 3 centers (in Lebanon, Greece, and Canada); subsequent interview discussions and clinical input resulted in the generation of 9 items for inclusion in the draft NTDT‐PRO. Following a round of cognitive interviews involving 21 patients from 2 centers (in Lebanon and Greece), 4 items (Pain, Headaches, Ability to Concentrate, and Paleness) were removed from the draft NTDT‐PRO. The final NTDT‐PRO comprises 6 items that measure Tiredness, Weakness, and Shortness of Breath, with or without Physical Activity. The NTDT‐PRO is a new disease‐specific HRQoL tool for patients with NTDT, developed using a thorough methodology based on FDA 2009 PRO development guidelines.

‘Overjoyed that I can go outside’: Using walking interviews to learn about the lived experience and meaning of neighbourhood for people living with dementia

This study explores the relationships between people living with dementia and their neighbourhood as they venture out from home on a regular and often routine basis. Here, we report findings from the Swedish field site of an international 5-year project: Neighbourhoods: our people, our places. The aims of this study were to investigate the lived experience of the neighbourhood for people with dementia and through this to better understand the meaning that neighbourhood held for the participants. In this study, we focus on the walking interviews which were conducted with 14 community-dwelling people with dementia (11 men and 3 women) and were analysed using an interpretative phenomenological method. Four themes were revealed from these interviews: life narratives embedded within neighbourhood; the support of selfhood and wellbeing through movement; the neighbourhood as an immediate social context; and restorative connections to nature. These themes were distilled into the ‘essence’ of what neighbourhood meant for the people we interviewed: A walkable area of subjective significance and social opportunity in which to move freely and feel rejuvenated. We have found that the neighbourhood for community-dwelling people with dementia holds a sense of attachment and offers the potential for freedom of movement. Our research indicates that a dementia diagnosis doesn’t necessarily reduce this freedom of movement. The implications for practice and policy are considered: future research should explore and pay closer attention to the diverse living conditions of people living with dementia, and not least the particular challenges faced by people living alone with dementia.