POS1576-PARE IMPROVING METHOTREXATE PRESCRIBING AND DISPENSING SAFETY THROUGH A SIMPLE ADJUSTMENT TO ELECTRONIC PRESCRIBING

Background

Methotrexate (MTX) is the most commonly prescribed disease-modifying antirheumatic drug (DMARD) in rheumatoid arthritis, as well as being frequently used in other rheumatic conditions. Having been discovered in 1948 1, its use is established and the toxicity profile is well recognised. In the rheumatology setting, it is prescribed as a once weekly dosing regimen. However, despite experience in the use of MTX, there still remains a concern for patient safety with regards to more frequent ingestion than the weekly dose. This can result in severe complications such as acute kidney injury, myelosuppression, mucositis and even death. According to Medicines and Healthcare products Regulatory Agency (MHRA), there were 11 adverse event reports between 2006 and 2020, and as a result, in 2020 the MHRA outlined guidance to reduce the potentially fatal dosing errors associated with the prescription of MTX 2.

Amongst this guidance, prescribers are instructed to discuss, document and include in the prescription, the specific day of the week MTX is to be taken. Dispensers are also advised to document the day of the week on the MTX drug dispensing label. At King’s College Hospital (KCH) there is an existing mandatory field for day of the week when prescribing inpatient non-cancer MTX treatment. However, this does not exist currently for outpatient electronic prescribing.

Objectives

To update practice in the KCH Rheumatology department, in line with MHRA guidance on MTX prescription.

Methods

A retrospective audit of 30 MTX new and renewal prescriptions over 1 month was conducted to assess concordance with MHRA guidance. The safety-nets of documentation of day of the week on most recent clinic letter, drug prescription and drug dispensing label were reviewed. Following this the electronic prescription system was updated to make “day of the week” a mandatory field required to complete MTX prescriptions. A sample of 30 patients post intervention was then re-audited.

Results

The percentage of new prescriptions across the 2 groups were roughly equivalent (30% vs 33%).

Prior to intervention, 44% of new MTX prescriptions had no form of documentation of the day of the week across all 3 safety-nets, and only 33% had at least 2 of the 3 safety-nets completed. Post-intervention this has increased to 100%. Of those newly prescribed MTX, the inclusion of day of the week on clinic letters rose from 22% to 40%. There were similar improvements seen in safety-nets achieved for repeat prescriptions.

Figure 1.Table 1.Percentage completedPre-interventionPost-interventionNewRenewalNewRenewalDay of the week on letter22%43%50%45%Day of the week on prescription33%38%100%100%Day of the week on packaging33%71%90%100%None of the above44%14%0%0%At least 2 of 3 of the above33%52%100%100%All 3 completed22%14%40%45%

Conclusion

A significant improvement in concordance with MHRA guidance on MTX prescribing and dispensing can be easily achieved by making “the day of the week” a mandatory field to be included on all electronic MTX prescriptions. This change also produces a significant improvement in drug dispensing label safety and clinic letter documentation for patients newly initiated on MTX.

References

[1]Farber S, Diamond LK, Mercer RD, et al. Temporary remissions in acute leukaemia in children produced by folic acid antagonist, 4-aminopteroyl-glutamic acid (aminopterin) N Engl J Med. 1948;238:787–93.

[2]MHRA. Methotrexate once-weekly for autoimmune diseases: new measures to reduce risk of fatal overdose due to inadvertent daily instead of weekly dosing. Published 23/9/2020.

Disclosure of Interests

None declared

Predictive Value of Quick Sepsis-Related Organ Failure Scores following Sepsis-Related Medical Emergency Team Calls: A Retrospective Cohort Study

We conducted a cohort study of adult ward patients who had a Medical Emergency Team (MET) call triggered by confirmed or suspected sepsis in an Australian tertiary centre to assess the predictive utility of systemic inflammatory response syndrome (SIRS) and quick Sepsis-Related Organ Failure Assessment (qSOFA) scores for 28-day mortality over a 12-month period. Sepsis was the causative aetiology in 970 MET calls for 646 patients with a mean age of 68 years and median Charlson Comorbidity score (CCS) of 3.0. Four hundred and seven (63%) patients had microbiological identification of a causative organism with 35 (9%) demonstrating multi–drug resistance. The 28-day mortality rate was 22%. Independent risk factors for 28-day mortality included age (incidence rate ratio [IRR] 1.038; P <0.001) and CCS (IRR 1.102; P <0.001). qSOFA positive patients had a threefold risk of 28-day mortality compared to those who were negative (IRR 3.15; P=0.02). Both the SIRS and qSOFA score had poor sensitivity (86% versus 62%, respectively) for mortality as a sole diagnostic tool and should be investigated as part of a multiparameter panel within a large prospective study.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Pedophiles: mental retardation, maternal age, and sexual orientation

Intellectual functioning, parental age, and sexual orientation in 991 male sexual offenders were investigated. Sources of data included semistructured interviews, clinical charts, phallometric tests, and self-administered questionnaires. The results suggest two main conclusions: (i) Among pedophiles in general, erotic preference moves away from adult women along two dimensions: age and sex. The extent of this movement is greater, along both dimensions, for pedophiles with lower levels of intellectual functioning. (ii) High maternal age (or some factor it represents) increases the likelihood of exclusive sexual interest in boys. Intellectual deficiency (or some factor it represents) decreases the likelihood of exclusive sexual interest in girls. These two factors summate, so that a pedophile with both factors is more likely to be sexually interested in boys than a pedophile with only one.

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Surgeons have long been concerned that cancer may be disseminated by shedding of tumour cells into the bloodstream during surgery. Early claims that cancer operations induced an increase in the number of tumour cells shed into the circulation were subsequently discredited, and the issue has remained unresolved. We used immunocytochemistry for cytokeratins to detect tumour cells in effluent blood from breast carcinomas in 18 patients undergoing surgery. Tumour cells were detectable in 6/18 patients during surgery, in only one patient before operation and in none post-operatively (P = 0.025). Circulating cells were associated with vascular invasion within the primary tumour (P = 0.032). No cytokeratin-positive cells were found in blood from ten normal volunteers or four patients undergoing surgery for other breast conditions. These results confirm that cancer surgery in humans results in an increase in the shedding of tumour cells into the circulation. The implications for prognosis and practice should be determined by larger prospective studies.

Association between tumour angiogenesis and tumour cell shedding into effluent venous blood during breast cancer surgery

Tumour angiogenesis is a powerful prognostic indicator in breast cancer. Shedding of tumour cells into the bloodstream is essential for haematogenous metastasis. The relation between cell shedding and angiogenesis in human cancer is not known. We studied vascular density and cell shedding in 16 women undergoing breast cancer surgery. Circulating cells were found in one patient before, in six during, and none after operation. Vascular density was related to detection of circulating tumour cells during surgery (correlation coefficient for first intraoperative sampling = 0.56, p = 0.024, 95% CI 0.08 to 0.83). Tumour cell shedding during surgery is related to vascular density; the relevance of this relation to the prognostic significance of vascular density in breast cancer merits further study.

Streptokinase inhibits pulmonary tumor seeding in an animal experimental model

One aspect of the metastatic process involves entrapment of tumor cells within the microcirculation of organs in a "fibrin-platelet mesh." We postulate that destruction of this mesh by fibrinolysis might discourage tumor seeding, thereby inhibiting metastasis. To study this hypothesis, the effect of intravenous streptokinase on pulmonary tumor seeding was examined in a rodent model. In vitro experiments demonstrated that streptokinase had no cytotoxic or cytostatic effect on the Mtln3 cell line. Pharmacokinetic studies showed that at 30,000 U/kg, streptokinase caused systemic fibrinolysis in the Fischer rat, as demonstrated by the thrombin time and fibrin plate lysis assay. Streptokinase administered at this dose, 30 min after tumor cell injection, caused a significant decrease in pulmonary tumor seeding (median 23.0 in the streptokinase-treated group vs. 67.5 in untreated controls, P < 0.0001, Mann-Whitney U-test). Analysis of fibrin degradation products in the streptokinase-treated group suggested that this effect might be secondary to fibrinolysis. The implications of these findings are discussed.

Oculocutaneous albinism associated with Apert's syndrome

Five of nine patients with Apert's syndrome (acrocephalosyndactyly) showed an associated hypopigmentation of hair, skin, and eyes. The hair color of these five patients ranged from light brown to blond, the skin was pale, and the irides hazel or blue. Iris transillumination and hypopigmentation of the fundus were present and associated with absent or diffuse foveal reflexes. Unlike most forms of classic oculocutaneous albinism, however, there was good visual acuity and no pendular nystagmus. The evidence indicated that the lack of pigmentation associated with the characteristic skeletal anomalies of Apert's syndrome resulted from a disturbance of independent, genetically related, processes occurring at a common point in gestation.

Congenital ophthalmoplegia in oculoauriculovertebral dysplasia-hemifacial microsomia (Goldenhar-Gorlin syndrome). A clinicopathologic study and review of the literature

Two patients with Goldenhar-Gorlin syndrome showed paralysis of one or more extraocular eye movements on neurologic examination. At autopsy, a third patient showed unilateral agenesis of trochlear and abducens nerves and corresponding brain stem nuclei. Congenital ophthalmoplegia is not infrequent in Goldenhar-Gorlin syndrome and may be due to hypoplasia or agenesis, or both, of extraocular muscles, extraocular nerves, and brain stem nuclei.