Self-reported beta-lactam allergy in government and private hospitals in Cape Town, South Africa

BACKGROUND

Up to a quarter of inpatients in high-income countries (HICs) self-report beta-lactam allergy (BLA), which if incorrect,increases the use of alternative antibiotics, worsening individual health outcomes and driving bacterial resistance. In HICs, up to 95% ofself-reported BLAs are incorrect. The epidemiology of BLA in low- and middle-income African countries is unknown.

OBJECTIVES

To describe the epidemiology and de-labelling outcomes of self-reported BLA in hospitalised South African (SA) patients.

METHODS

Point-prevalence surveys were conducted at seven hospitals (adult, paediatric, government and privately funded, district andtertiary level) in Cape Town, SA, between April 2019 and June 2021. Ward prescription records and in-person interviews were conductedto identify and risk-stratify BLA patients using the validated PEN-FAST tool. De-labelling was attempted at the tertiary allergy clinic atGroote Schuur Hospital.

RESULTS

A total of 1 486 hospital inpatients were surveyed (1 166 adults and 320 children). Only 48 patients (3.2%) self-reported a BLA,with a higher rate in private than in government-funded hospitals (6.3% v. 2.8%; p=0.014). Using the PEN-FAST tool, only 10.4% (n=5/48)of self-reported BLA patients were classified as high risk for true penicillin hypersensitivity. Antibiotics were prescribed to 70.8% (n=34/48)of self-reported BLA patients, with 64.7% (n=22/34) receiving a beta-lactam. Despite three attempts to contact patients for de-labelling atthe allergy clinic, only 3/36 underwent in vivo testing, with no positive results, and 1 patient proceeded to a negative oral challenge.

CONCLUSION

Unlike HICs, self-reported BLA is low among inpatients in SA. The majority of those who self-reported BLA were low risk fortype 1 hypersensitivity, but outpatient de-labelling efforts were largely unsuccessful.

Provision of eye care services and interventions in care homes: a narrative synthesis review

BACKGROUND

The prevalence of eye disease and visual impairment in care home residents is disproportionately higher compared to the general population. Access to eye care services and treatment can be variable for this vulnerable population.

OBJECTIVE

This paper reviews the available evidence of services and interventions for delivering eye care to care home residents. The key review questions are: (1) What is the existing evidence for eye care interventions or services (including service configuration) for care home residents? (2) Does the provision of these interventions or services improve outcomes?

METHODS

Literature search of EMBASE/MEDLINE for original papers published since 1995. Two reviewers independently reviewed abstracts/papers. Data were extracted and evaluated using narrative synthesis.

RESULTS

13 original papers met the inclusion criteria. Domiciliary optometrist services improved diagnosis and management of eye conditions, with one study showing 53% of residents benefited from direct ophthalmology intervention. Provision of interventions, such as cataract surgery, refractive error correction and low-vision rehabilitation, improved visual acuity and vision-related quality of life but did not improve cognitive or physical function, depression or health-related quality of life. There was little UK-based literature to inform eye service design or interventions to improve outcomes such as falls.

CONCLUSION

Care home-based eye assessments improve the management of eye conditions. Interventions improve visual acuity and vision-related quality of life. Further research is needed to better understand current UK services, access difficulties or examples of good practice as well as to identify and test cost-effective service models for this vulnerable group.

1210 PROVISION OF EYE CARE SERVICES AND INTERVENTIONS IN CARE HOMES - A NARRATIVE SYNTHESIS REVIEW

Introduction

The prevalence of eye disease and visual impairment in care home residents is disproportionately higher compared to the general population. Access to eye care services and treatment can be variable for this vulnerable population.

Objective

This narrative synthesis reviews the available evidence of services and interventions for delivering eye care to care home residents. The key review questions:

Methods

Literature search of EMBASE/MEDLINE for original papers published since 1995. Two reviewers independently reviewed abstracts/papers. Data was extracted and evaluated using narrative synthesis.

Results

13 original papers met the inclusion criteria. On-site optometrist-led services improved diagnosis and management of eye conditions, with one study showing 53% of residents benefited from direct ophthalmology intervention. Provision of interventions such as cataract surgery, refractive error correction and low vision rehabilitation improved visual acuity and vision-related quality of life but did not improve cognitive or physical function, depression or health-related quality of life. There was little UK-based literature to inform eye service design or interventions to improve outcomes.

Conclusion

Care home-based eye assessments improve the management of eye conditions. Interventions improve visual acuity and vision-related quality of life. Further research and/or clinical service scoping is needed to better understand current UK services, access difficulties or examples of good practice as well as to identify and test cost-effective service models for this vulnerable group.

1226 A MULTI-DISCIPLINARY APPROACH TO TRANSFORMING EYE CARE SERVICES FOR CARE HOME RESIDENTS

Introduction

Care home residents can have variable access to eye care services and treatments. We developed a collaborative approach between optometrists, care homes, and primary and secondary care to enable personalised patient-centred care.

Objective

To develop and evaluate an integrated model of eye care for care home residents.

Methods

Small scale plan-do-study-act (PDSA) service tests were completed in three care-homes in Southwark (2 residential, 1 nursing) between November 2021 to May 2022. Processes were compared to historical feedback and hospital-based ophthalmology clinic attendances (Mar 2019-2020). Hospital-like assessments were piloted at two care homes for feasibility and acceptability. Further piloting utilised usual domiciliary optometry-led assessment with multidisciplinary meeting access (including optometrist, GP, geriatrician, ophthalmologist and care home nurse) to reduce duplication of assessments and to evaluate MDM processes and referral rates.

Results

Examination was 100% successful at home (visual acuity and pressure measurement) compared to hospital outpatients (71.7% success visual acuity, 54.5% pressures). Examination was faster than in hospital settings (16 minutes vs 45 minutes-1 hour). Residents were away from usual activities for 32 minutes vs 6 hours for hospital visits including transport. Residents were less distressed with home-based assessments. Did-Not-Attend (DNA) rates reduced (26.7% to 0%), secondary care discharge rates improved (8.4% to 32%). Hospital eye service referral were indicated in 19% -23%, half of which were for consideration of cataract surgery. Alternative conservative plans were agreed at MDM for nursing home residents who were clinically too frail or would not have been able to comply with treatments avoiding 33% unnecessary referrals.

Conclusions

Home-based eye care assessments appear better tolerated and are more efficient for residents, health and care staff. Utilising an MDM for optometrists to discuss residents with ophthalmologists and wider MDT members enabled personalised patient-centred decision-making. Future work to test this borough wide is in progress.

2022 American College of Rheumatology/EULAR Classification Criteria for Takayasu Arteritis

OBJECTIVE

To develop and validate new classification criteria for Takayasu arteritis (TAK).

METHODS

Patients with vasculitis or comparator diseases were recruited into an international cohort. The study proceeded in 6 phases: 1) identification of candidate criteria items, 2) collection of candidate items present at diagnosis, 3) expert panel review of cases, 4) data-driven reduction of candidate items, 5) derivation of a points-based classification score in a development data set, and 6) validation in an independent data set.

RESULTS

The development data set consisted of 316 cases of TAK and 323 comparators. The validation data set consisted of an additional 146 cases of TAK and 127 comparators. Age ≤60 years at diagnosis and imaging evidence of large-vessel vasculitis were absolute requirements to classify a patient as having TAK. The final criteria items and weights were as follows: female sex (+1), angina (+2), limb claudication (+2), arterial bruit (+2), reduced upper extremity pulse (+2), reduced pulse or tenderness of a carotid artery (+2), blood pressure difference between arms of ≥20 mm Hg (+1), number of affected arterial territories (+1 to +3), paired artery involvement (+1), and abdominal aorta plus renal or mesenteric involvement (+3). A patient could be classified as having TAK with a cumulative score of ≥5 points. When these criteria were tested in the validation data set, the model area under the curve was 0.97 (95% confidence interval [95% CI] 0.94-0.99) with a sensitivity of 93.8% (95% CI 88.6-97.1%) and specificity of 99.2% (95% CI 96.7-100.0%).

CONCLUSION

The 2022 American College of Rheumatology/EULAR classification criteria for TAK are now validated for use in research.

Short-term risk prediction after major lower limb amputation: PERCEIVE study

BACKGROUND

The accuracy with which healthcare professionals (HCPs) and risk prediction tools predict outcomes after major lower limb amputation (MLLA) is uncertain. The aim of this study was to evaluate the accuracy of predicting short-term (30 days after MLLA) mortality, morbidity, and revisional surgery.

METHODS

The PERCEIVE (PrEdiction of Risk and Communication of outcomE following major lower limb amputation: a collaboratIVE) study was launched on 1 October 2020. It was an international multicentre study, including adults undergoing MLLA for complications of peripheral arterial disease and/or diabetes. Preoperative predictions of 30-day mortality, morbidity, and MLLA revision by surgeons and anaesthetists were recorded. Probabilities from relevant risk prediction tools were calculated. Evaluation of accuracy included measures of discrimination, calibration, and overall performance.

RESULTS

Some 537 patients were included. HCPs had acceptable discrimination in predicting mortality (931 predictions; C-statistic 0.758) and MLLA revision (565 predictions; C-statistic 0.756), but were poor at predicting morbidity (980 predictions; C-statistic 0.616). They overpredicted the risk of all outcomes. All except three risk prediction tools had worse discrimination than HCPs for predicting mortality (C-statistics 0.789, 0.774, and 0.773); two of these significantly overestimated the risk compared with HCPs. SORT version 2 (the only tool incorporating HCP predictions) demonstrated better calibration and overall performance (Brier score 0.082) than HCPs. Tools predicting morbidity and MLLA revision had poor discrimination (C-statistics 0.520 and 0.679).

CONCLUSION

Clinicians predicted mortality and MLLA revision well, but predicted morbidity poorly. They overestimated the risk of mortality, morbidity, and MLLA revision. Most short-term risk prediction tools had poorer discrimination or calibration than HCPs. The best method of predicting mortality was a statistical tool that incorporated HCP estimation.

A Holistic Approach for an Efficient Day to Day Operation for Blood Bank Market Withdrawals and Recalls Using Departmental Electronic Occurrence System: A CMCVAMC Experience

Introduction/Objective

Donor centers and reagent manufacturers may issue recalls or market withdrawals. Donor center withdrawals of blood components involve units that have a reason that may present a risk to the patient, that subsequently require discarding the product if not transfused or appropriate clinical notification and follow-up if already transfused prior to the notification. Reagent recalls involve problems with reagents that require appropriate corrective action as per the circumstances. Patient safety event reporting systems are universal in hospitals and are a backbone of efforts to detect patient safety events and quality problems. Pathology and Laboratory Medicine (P&LMS) at the Corporal Michael J. Crescenz Veteran Affairs Medical Center (CMC VAMC) has established an electronic occurrence reporting (EOR) program to track and respond to these in the blood bank. The authors explored the usefulness of the holistic approach of this initiative.

Methods/Case Report

EOR is available to all the employees of Blood Bank in P&LMS, who regularly report all received recalls and market withdrawals into the system. These are reviewed by the supervisor and blood bank medical director and co-director to ensure appropriate steps are taken. Information on all market recalls and withdrawals affecting blood bank were compiled from January 1st, 2021, to June 1st, 2022, for quality assurance review.

Results (if a Case Study enter NA)

The EOR plays a significant role in organizing the data from all the recalls and market withdrawals to guide improvement in patient care. There were seven market withdrawals during the study period, all from the donor center for blood product component withdrawals. All seven cases were recorded efficiently with review by the blood bank supervisor and blood bank medical director and co-director. Appropriate follow-up action was performed and recorded for all seven cases in the EOR.

Conclusion

The EOR for withdrawals recalls in Blood Bank is highly effective, successful program in terms of electronic organized monitoring. This monitoring is part of ensuring quality care in real time, and plays an important role as part of Veteran Affairs position as a High reliability Organization (HRO).

Review of Effective Use of the Departmental Electronic Occurrence System for the Patient Care Related Safety Events. A CMC VAMC Experience

Introduction/Objective

Electronic patient safety event reporting (e-reporting) is an effective mechanism to learn from errors and enhance patient safety. The Pathology and Laboratory Medicine (P&LMS) has established an electronic occurrence reporting (EOR) program to detect occurrences in patient results prior to the release of results, procedures for the documentation of corrected results that have been released, and any deviation to standard operating procedures. Patient safety and its monitoring is improved by using the EOR reporting system in which healthcare workers can document and learn from incidents, and thus prevent potential medical errors. The authors explore the use of the EOR in the calendar year 2021 and its effective use.

Methods/Case Report

The EOR is available to all the employees of P&LMS. This EOR allows the recording of all information pertinent to the occurrence (including pre-analytical, analytical, and post analytical issues) and a variety of issues (i.e., safety events, notifications, recalls, correction of released results, changed, results, or any unexpected standard operating procedure deviation). The section supervisor will initiate an investigation including root causes and outcomes of the occurrence and propose corrective action, recommendations, and follow-up in the Occurrence Detection Database. This is also reviewed at the quality management meeting and by the sectional pathologist director. For quality assurance review, the EOR’s usage for January 1st, 2021, to December 31st, 2021, was reviewed.

Results (if a Case Study enter NA)

The EOR successfully allowed the full documentation of all 870 reported occurrences during the study period in an organized fashion allowing appropriate tracking and investigation for quality improvement. All reported occurrences were handled appropriately with organized data to ensure quality assurance and improvement.

Conclusion

The EOR is a highly effective, successful program in terms of monitoring and assisting in ensuring timely action is taken in real time for patient care. Electronic reporting and documentation of incidents should be well supported by continuous staff training, help, and feedback. The ERO plays an important role in the maintenance of Veteran Affairs’ position as a High Reliability Organization (HRO).

Initial results from near-infrared spectroscopy on ADITYA-U tokamak

Spectroscopy in vacuum ultraviolet (VUV) and visible ranges plays an important role in the investigation and diagnosis of tokamak plasmas. However, under harsh environmental conditions of fusion grade devices, such as ITER, VUV-visible systems encounter many issues due to the degradation of optical components used in such systems. Here, near-infrared (NIR) spectroscopy has become an effective tool in understanding the edge plasma dynamics. Considering its importance, a NIR spectroscopic diagnostic has been developed and installed on the ADITYA-U tokamak. The system consists of a 0.5 m spectrometer having three gratings with different groove densities, and it is coupled with a linear InGaAs photodiode array. Radiation from the ADITYA-U edge plasma has been collected using a collimating lens and optical fiber combination and transported to the spectrometer. The spectrum in the NIR range from the ADITYA-U plasma has been recorded using this system, in which Pa_β and Pa_γ along with many spectral lines from neutral and singly ionized impurities have been observed. The influxes of H and C have been estimated from measurements. The H influx value is found to be 2.8 × 10¹⁶ and 1.9 × 10¹⁶ particles cm^-2 s^-1 from neutral hydrogen lines H_α and Pa_β, respectively, and the C influx value is found to be 3.5 × 10¹⁵ and 2.9 × 10¹⁵ particles cm^-2 s^-1 from the neutral carbon and singly ionized carbon, respectively. A good agreement is seen between these results and the results obtained by using a routine photomultiplier tube based diagnostic.

232 WORKING-UP DEMENTIA, A RETROSPECTIVE COHORT STUDY OF REFERRALS TO A SPECIALIST DEMENTIA SERVICE

Background

Rates of dementia in Ireland are rapidly increasing in line with our ageing population. Cases are predicted to more than double in the next 30 years from a prevalence of 55,000 in 2018, to 141,000 in 2050. Dementia services will be placed under significant pressure. It is essential that patients referred to specialist memory services are appropriately worked-up prior to referral, to ensure efficiency and optimise the running of these services, and also to improve patient experience.

Methods

We carried out a retrospective review of patients referred to the Psychiatry of Later Life Team for specialist dementia care by General Practitioners. We obtained date of referral to the service, and carried out an electronic chart review to evaluate the work-up performed prior to referral. Our standard work-up criteria consisted of neuroimaging (CT brain or MRI brain), and blood tests including B12, folate, and thyroid function tests within 12-months. Results were analysed descriptively.

Results

104 patients were included in the study, from referrals dated Nov 2014-June 2019. Neuroimaging had been performed in 79.8% (n=83) prior to referral- 89.1% CT, 9.6% MRI, 1.2% both CT and MRI. Of those who had neuroimaging, n=37 had been performed in the previous 12-months, representing 35.6% of overall cohort. In terms of blood work-up, 23.1% (n=24) had bloods performed in the 12 months prior to referral- 70.8% B12, folate and thyroid function tests; 20.8% TFTS only; 8.3% B12 and folate levels only).

Conclusion

Referrals to specialist memory services by General Practice often lack the appropriate first line investigations, which introduces delay in review and the need for further assessment once baseline investigations have been done. There is a need for a standardised work-up prior to referral for optimum running of such services.

A systematic review of the effectiveness of community interventions to improve parent health literacy

Background

Many community-based interventions have been developed to increase parent/caregiver health literacy, yet no systematic review of their effectiveness has been published. Therefore, the aim of this systematic review was to examine the effectiveness of community-based health literacy interventions in improving the health literacy of parents/caregivers.

Methods

A systematic review of six databases; MEDLINE, PsycINFO, CINAHL, Cochrane Library, Embase, and Education Source were conducted to identify relevant articles. Risk of bias were assessed using version two of the Cochrane risk of bias tool for randomised controlled trials or the Cochrane Collaboration Risk of Bias in Non-Randomised Studies of Interventions. The study findings were grouped and synthesised following the Synthesis Without Meta-analysis framework.

Results

Eleven community-based health literacy interventions for parents/caregivers were identified. Study design included randomised controlled trials (n = 4), non-randomised studies with comparison group (n = 4), and non-randomised studies without a comparison group (n = 3). Interventions were delivered digitally, in person or a combination of the two. The main findings of the studies showed some potential for both in person and digital interventions to increase parental health literacy. The risk of bias was high in over half the studies (n = 7) Studies were heterogeneous preventing a meta-analysis.

Discussion

Although no definitive conclusion of the effectiveness of community-based interventions can be drawn there are suggestions of improvement in many of the studies included in this review. The review has brought into question whether the health literacy measurement tools used met the needs of assessing the interventions outcomes. When comparing the cost and resources needed for digital with in person interventions, the findings of this review have implications for both practise and research.

Key messages

Lipoprotein(a), cardiovascular events, and benefit of P2Y12 inhibition: insights from the PEGASUS-TIMI 54 trial

Background

Lp(a) plays a causal role in atherogenesis and may exert pro-thrombotic effects by inhibiting fibrinolysis owing to its structural homology with plasminogen. Patients with higher Lp(a) concentrations may derive greater benefit from anti-thrombotic therapy.

Purpose

We assessed whether patients with higher Lp(a) derive greater risk reduction from P2Y12 inhibition with ticagrelor vs. placebo on a background of aspirin therapy.

Methods

Lp(a) concentration was measured (Randox) in a prospective nested cohort of 8,967 pts enrolled in PEGASUS-TIMI 54, a randomized trial of ticagrelor vs. placebo in patients 1–3 years post MI (median follow-up: 2.7 y). Lp(a) was dichotomized at 200 nmol/L as an established threshold of risk. The prespecified MACE endpoint was CV death, MI or stroke, with KM rates reported at 3y. Cox proportional hazards were used to assess the relationship between Lp(a), MACE and treatment benefit. Models were adjusted for relevant baseline characteristics including apolipoprotein B.

Results

The median Lp(a) was 29 (25th-75th percentile: 12–137) nmol/L. A total of 1,053 pts (11.7%) had a high Lp(a) (≥200 nmol/L). In the pooled trial population, high Lp(a) concentration was associated with a 29% higher risk of MACE (9.1% vs 7.6%; adjusted hazard ratio [adj HR] 1.29, 95% confidence interval [CI] 1.02–1.62; p=0.03), including a 37% higher risk of MI (6.9% vs. 5.3%; adj HR 1.37, 95% CI 1.05–1.79; p=0.02). The hazard ratios for MACE with ticagrelor vs. placebo were 0.73 (95% CI 0.48–1.11) for patients with higher Lp(a) and 0.88 (95% CI 0.74–1.05) for patients with lower Lp(a) (p-interaction=0.41; Figure 1). The absolute risk reductions were 2.4% and 1.2%, respectively.

Conclusion

Lp(a) above 200 nmol/L identifies patients with prior MI at increased risk of MACE who may derive greater absolute risk reduction from treatment with ticagrelor. These exploratory observations provide insights for therapeutics that are evaluating the clinical benefit of Lp(a) reduction.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The PEGASUS-TIMI 54 trial was funded by AstraZeneca

High-resolution fiber imaging for pulsed power experiments

This work presents a novel approach for imaging the visible emissions from plasmas in pulsed power experiments using high-resolution plastic optical fibers. The diagnostic consists of a 2 mm diameter core commercial cable constructed of 13 000 individual acrylic fibers. The fibers are fused together to create a single high-resolution bundle. Different designs were investigated to cover a wide range of resolutions and fields of view (3-700 µm and 0.05-45 mm, respectively). The system was tested on the 1-MA Mykonos accelerator at Sandia National Laboratories and successfully imaged visible emission from a hybrid x-pinch target. Diagnostic development and preliminary results are presented.