Digital Antibiotic Allergy Decision Support Tool Improves Management of β-Lactam Allergies

BACKGROUND

Frontline providers frequently make time-sensitive antibiotic choices, but many feel poorly equipped to handle antibiotic allergies.

OBJECTIVE

We hypothesized that a digital decision support tool could improve antibiotic selection and confidence when managing β-lactam allergies.

METHODS

A digital decision support tool was designed to guide non-allergist providers in managing patients with β-lactam allergy labels. Non-allergists were asked to make decisions in clinical test cases without the tool, and then with it. These decisions were compared using paired t tests. Users also completed surveys assessing their confidence in managing antibiotic allergies.

RESULTS

The tool's algorithm was validated by confirming its recommendations aligned with that of five allergists. Non-allergist providers (n = 102) made antibiotic management decisions in test cases, both with and without the tool. Use of the tool increased the proportion of correct decisions from 0.41 to 0.67, a difference of 0.26 (95% CI, 0.22-0.30; P < .001). Users were more likely to give full-dose antibiotics in low-risk situations, give challenge doses in medium-risk situations, and avoid the antibiotic and/or consult allergy departments in high-risk situations. A total of 98 users (96%) said the tool would increase their confidence when choosing antibiotics for patients with allergies.

CONCLUSIONS

A point-of-care clinical decision tool provides allergist-designed guidance for non-allergists and is a scalable system for addressing antibiotic allergies, irrespective of allergist availability. This tool encouraged appropriate antibiotic use in low- and medium-risk situations and increased caution in high-risk situations. A digital support tool should be considered in quality improvement and antibiotic stewardship efforts.

Do as I Do: Physician- and Learner-Led Mind-Body Medicine Group Visits

Introduction

Care of patients with chronic medical and mental health conditions can be a source of frustration for primary care clinicians and may present a challenge in modeling effective interventions for medical learners. Mind-body medicine (MBM) interventions have shown success for a variety of conditions, and training in MBM has been associated with decreased burnout and improved professional satisfaction.8 We piloted MBM collaborative visits led by faculty physicians and facilitated by medical learners. We then assessed their efficacy treating patients with complex needs.

Methods

We conducted a series of eight weekly 2.5-hour MBM interventions for groups of five to eight participants (52 in total) with chronic health conditions. Matched-pair hypothesis t tests analyzed nine health indicators measured pre- and postintervention: the Patient Health Questionnaire-9 (PHQ-9) as well as participants' perceived mental and physical health, stress and stress coping, agency, and capacity to connect with others. We made conservative calculations of effect size using Hedges' g.

Results

Participants showed significant, large improvements in their PHQ-9 scores ( P<.005, g=0.807), and moderate improvements in ability to cope with stress (P<.005, g=0.502), sense of control over their diagnoses (P<.05, g=0.413), and perceived overall mental health (P<.05, g=0.424). Other outcomes were nonsignificant, including a small improvement in participants' perceived overall health ( P=.071, g=0.286).

Conclusions

Patients completing the intervention enjoyed largely improved outcomes despite unchanged stress at work and home. Physician-led MBM collaborative visits comprise a feasible, reproducible, and reimbursable treatment option for improving patient care. They also immerse medical learners in an evidence-based practice model supportive of professional satisfaction.

Polymorphonuclear Leucocytes Have Two Opposing Roles in Fibrinolysis

Polymorphonuclear leucocytes (PMN) are important in the resolution of human thrombi, with u-PA as a key player. We have shown that the u-PA activity of PMN depends on the presence of plasma; the study presented here provides an explanation for that requirement. Here we show that PMN degraded scu-PA and also tcu-PA, t-PA and plasmin, resulting in loss of fibrinolytic activity. Plasma protected against this degradation; α1-antitrypsin was identified as a protective factor. Purified human neutrophil elastase mirrored the effects of PMN, again neutralized by plasma inhibitors. These findings illustrate the dual role of PMN in the breakdown of thrombi, in that they contribute both u-PA, which lyses fibrin, and other proteases, including elastase, which can cleave fibrin and plasminogen activators/plasmin. Similarly, plasma can potentiate fibrinolysis by neutralization of PMN elastase, in addition to direct inhibition of fibrinolytic proteases. Our previous studies show that PMN in thrombi are mostly pro-fibrinolytic; the antifibrinolytic role defined here may be important in other pathologies where fibrin persists.

Polymorphonuclear leukocytes from patients with severe sepsis have lost the ability to degrade fibrin via u-PA

Fibrin persistence in the vasculature is an important complication of sepsis that can often lead to mortality. We have previously established that polymorphonuclear leukocytes (PMN) from healthy individuals have the capacity to degrade fibrin via urokinase-type plasminogen activator (u-PA). We have also demonstrated an increase in u-PA antigen in the plasma of patients suffering from septic shock. In this study, we investigate the hypothesis that PMN from patients with sepsis have lost their fibrinolytic ability and that this might contribute to the persistence of fibrin deposits. We show here that PMN from these patients do not express any u-PA activity, despite retaining some u-PA antigen. Additionally, thrombi prepared from the whole blood of the patients exhibit reduced endogenous lysis compared with those from healthy individuals. These data indicate that loss of fibrinolytic activity from PMN may be a contributing factor in fibrin persistence in the microvasculature in sepsis.

Is there a relationship between risk assessment and observation level?

The literature is divided into two sections, one on assessment and one on observation, with only one study that tries to make any connection between them. This study, conducted in both acute and forensic areas, attempts to show that there are some direct relationships between assessment criteria and observation levels in both these areas. An instrument was designed and implemented prospectively to collect data about both assessment criteria and the resulting decisions about observation level. Logistic Regression Analysis, descriptive, and inferential statistics, such as Chi-square and cross-tabulations, were used to analyse the data. The results showed that there is a relationship between the risk assessment and the enhanced observation level that patients are placed on at the time of admission. The nature of the relationship was limited to seven variables from the 12 in the risk assessment used. This implies that the variables may be different in risk assessment content and extent in each clinical area and we can speculate that there may be individual profiles of the assessment-observation level relationship in each clinical area.

Polymorphonuclear leucocytes have two opposing roles in fibrinolysis

Polymorphonuclear leucocytes (PMN) are important in the resolution of human thrombi, with u-PA as a key player. We have shown that the u-PA activity of PMN depends on the presence of plasma; the study presented here provides an explanation for that requirement. Here we show that PMN degraded scu-PA and also tcu-PA, t-PA and plasmin, resulting in loss of fibrinolytic activity. Plasma protected against this degradation; alpha1-antitrypsin was identified as a protective factor. Purified human neutrophil elastase mirrored the effects of PMN, again neutralized by plasma inhibitors. These findings illustrate the dual role of PMN in the breakdown of thrombi, in that they contribute both u-PA, which lyses fibrin, and other proteases, including elastase, which can cleave fibrin and plasminogen activators/plasmin. Similarly, plasma can potentiate fibrinolysis by neutralization of PMN elastase, in addition to direct inhibition of fibrinolytic proteases. Our previous studies show that PMN in thrombi are mostly pro-fibrinolytic; the anti-fibrinolytic role defined here may be important in other pathologies where fibrin persists.

Polymorphonuclear leucocytes mediate endogenous thrombus lysis via a u-PA-dependent mechanism

Many human thrombi lyse spontaneously without the administration of lytic drugs and cause no clinical symptoms. The mechanisms by which this occurs are incompletely understood. We found that model thrombi prepared from whole human blood in a Chandler loop also exhibited significant spontaneous lysis. Lysis was inhibited by chemical protease inhibitors, consistent with proteolysis resulting primarily from serine proteases, with a small contribution from matrix metalloproteinases. Whole blood was fractionated into platelet-rich plasma and cell populations. Significant spontaneous lysis was observed in platelet-rich thrombi enriched with polymorphonuclear leucocytes (PMNs), whereas mononuclear cells (MCs) and erythrocytes did not contribute to lysis. Incorporation of antibodies to urokinase (u-PA) and its receptor u-PAR neutralized a large proportion of the activity. Incubation of plasma with PMNs generated free u-PA activity, which was also detectable in model thrombi and in vivo human thrombi. Purified neutrophils, free of eosinophils, generated activity identical to PMNs. Smaller contributions to lysis by tissue-type plasminogen activator (t-PA), elastase and cathepsin G were also identified. These findings suggest a major role for circulating PMNs in endogenous thrombus lysis.

Myeloid leukaemic cells can lyse fibrin directly

Purified preparations of circulating leukaemic blast cells from patients with acute myeloid (M1-7) or acute lymphoblastic leukaemia, and the myeloid or lymphoid cells from patients with chronic myeloid or lymphocytic forms of leukaemia, were incorporated into clots prepared from fibrinogen and plasminogen. Patterns of lysis were followed and measured by light transmission in a microtitre plate reader. Mature polymorphonuclear and mononuclear cell fractions from normal individuals were studied concurrently for comparison. Blast cells from the myeloid forms of acute leukaemia (M2-4) and 'myeloid' cell fractions from patients with chronic myeloid leukaemia were capable of lysing plasminogen-containing clots; this activity was neutralized by addition of immunoglobulin against urokinase plasminogen activator (u-PA), but not by anti-tissue plasmogen activator (t-PA). Mature polymorphonuclear and mononuclear cells from normal individuals lacked lytic activity, as did the leukaemic cells from patients with acute lymphoblastic or chronic lymphocytic leukaemia. Lysed blast cells showed the presence of free plasminogen activator on sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE) with overlay zymography, also neutralized by anti-u-PA, whereas normal polymorphonuclear and mononuclear cells did not. These observations suggest that mechanisms underlying some forms of severe bleeding in acute myeloid leukaemias have a critical fibrinolytic component generated by the blast cells themselves.

More than a sympathetic ear? A report on the first year of a writer in residence in a unit for young, physically disabled people

OBJECTIVE

To describe a writer in residence scheme and report the views of patients and staff.

DESIGN

Qualitative study including interviews with patients, a questionnaire survey of staff, and dialogue with the writer.

SETTING

A unit for young people with physical disability.

SUBJECTS

A convenience sample of patients admitted to the unit and members of the multidisciplinary rehabilitation team.

INTERVENTION

A writer in residence working 15 hours per week in the unit.

RESULTS

A small number of patients worked regularly with the writer and this led to the publication of a play, short stories and poems. Patients described wide ranging benefits including improvements in mood state. Staff regarded the writer in residence scheme as enhancing their treatment and care and thought it helpful in addressing their own psychological needs. The writer saw herself as a catalyst 'for the creativity of others'.

CONCLUSION

Such schemes have an important role to play in rehabilitation settings.