Short subcutaneous infusions for symptom control in palliative medicine

OBJECTIVES

To investigate the efficacy and safety of short subcutaneous infusions (SSCIs) for refractory symptoms in the palliative setting.

METHODS

A retrospective chart review of SSCIs in a single palliative care centre over an 18-month period. All clinical notes, medication administration records and infusion monitoring documentation were examined to ascertain therapeutic aim, efficacy and tolerability.

RESULTS

111 patients received one or more SSCIs, 28 in the community and 83 in the inpatient hospice (21% of all admissions). SSCIs were used for a wide variety of reasons including loading doses (to achieve steady state and, thus, symptom relief, sooner), as required doses (for medications too irritant to give as bolus SC injections) and regular maintenance doses (where continuous subcutaneous infusion (CSCI), were unnecessary). 84 single drug SSCIs types and 51 admixtures SSCIs types (2 or more medications) were given. One infusion was poorly absorbed, but SSCIs were otherwise well tolerated.

CONCLUSIONS

SSCIs appear to be a promising additional option for administering medicines that are too irritant or large in volume for SC bolus injection. For medications with longer half-lives (eg, phenobarbital, valproate, levetiracetam), SSCI loading doses would be expected to achieve steady state and, thus, symptom relief, sooner than CSCIs alone.

Beta-blockers for tenacious saliva: a case report

This case report describes the care of a 75-year-old gentleman with metastatic head and neck cancer who was highly symptomatic with intractable tenacious oropharyngeal secretions. The patient reported subjective benefit from oral atenolol. A literature review was undertaken and identified no previous studies on the use of β-blockers for secretions in malignant disease, although some anecdotal evidence for their use in motor neuron disease. The proposed underlying mechanism is that β1-blockade reduced the protein content of salivary secretions, hence reducing its viscosity. Further studies of both the role of β-adrenoreceptors in the control of secretion viscosity and the potential role of β-blockers in alleviating symptomatic tenacious secretions are warranted.

Efficacy and safety of subcutaneous clonidine for refractory symptoms in palliative medicine: a retrospective study

OBJECTIVES

To investigate the efficacy and safety of subcutaneous clonidine for refractory symptoms in the palliative setting.

METHODS

A retrospective chart review of the use of subcutaneous clonidine in a single palliative care centre. We reviewed the use of clonidine since it was introduced in our locality 2½ years ago. All clinical notes, medication administration records and infusion monitoring documentation were examined to ascertain therapeutic aim, efficacy and tolerability.

RESULTS

Subcutaneous clonidine was administered to 113 patients. Recipients were generally frail (median Karnofsky Score 20%) and in the last weeks of life (median survival 6 days). The the most common indications were opioid poorly responsive pain (59), agitation refractory to antipsychotics and/or benzodiazepines (18) or both (35). Symptoms appeared to improve in the majority (85/113, 75%). Some (36, 32%) required no further medication changes once clonidine was commenced. Clonidine appeared well tolerated although blood pressure was not monitored in the majority, in line with our practice to discontinue such observations in those who are nursed in bed and receiving symptom-focused care.

CONCLUSIONS

Subcutaneous administration of clonidine appears to be a promising alternative option for refractory symptoms in the last weeks of life. We suggest some possible next steps for further research.

Bleeding management in palliative medicine: subcutaneous tranexamic acid - retrospective chart review

OBJECTIVES

To investigate the efficacy and safety of subcutaneously (SC) administered tranexamic acid.

METHODS

A retrospective chart review of the use of SC tranexamic acid in a single palliative care centre. We reviewed the use of this approach since it was introduced in our locality 2 years ago. All clinical notes, medication administration records and infusion monitoring documentation were examined to ascertain therapeutic aim, efficacy and tolerability.

RESULTS

SC tranexamic acid was administered to 22 patients. The most common causes of bleeding were coagulopathy (5), bleeding tumours (9) and thrombocytopaenia (5). The therapeutic aim was either to prevent (6) or treat (16) bleeding and was achieved in 17/22 patients. During this 2-year period, our experience evolved resulting in a greater use of short bolus infusions to achieve more rapid control of bleeding events. Both short and continuous SC infusions were well tolerated with no instances of SC site reactions. One patient developed a suspected arterial thrombus in the last hours of life around the time of converting from oral (PO) to SC tranexamic acid.

CONCLUSIONS

SC administration of tranexamic acid appears to be an effective and well tolerated alternative option for the palliative management of bleeding when the PO and intravenous routes are not available. Further research is needed to clarify tranexamic acid's safety in palliative populations.

Management and treatment of children, young people and adults with systemic lupus erythematosus: British Society for Rheumatology guideline scope

The objective of this guideline is to provide up-to-date, evidence-based recommendations for the management of SLE that builds upon the existing treatment guideline for adults living with SLE published in 2017. This will incorporate advances in the assessment, diagnosis, monitoring, non-pharmacological and pharmacological management of SLE. General approaches to management as well as organ-specific treatment, including lupus nephritis and cutaneous lupus, will be covered. This will be the first guideline in SLE using a whole life course approach from childhood through adolescence and adulthood. The guideline will be developed with people with SLE as an important target audience in addition to healthcare professionals. It will include guidance related to emerging approved therapies and account for National Institute for Health and Care Excellence Technology Appraisals, National Health Service England clinical commissioning policies and national guidance relevant to SLE. The guideline will be developed using the methods and rigorous processes outlined in 'Creating Clinical Guidelines: Our Protocol' by the British Society for Rheumatology.

Development and Validation of a Measure to Assess Readiness to Advance Health and Equity: The Assessment for Advancing Community Transformation (AACT)

Multi-sector partnerships are core in efforts to improve population health but are often not as fully developed or positioned to advance health and equity in their communities as believed to be. Therefore, measuring the collaborations multi-sector partnerships undertake is important to document the inputs, processes, and outcomes that evolve as they work together towards achieving their goals, which ultimately creates a greater sense of shared accountability. In this study we present the development and validation of the Assessment for Advancing Community Transformation (AACT), a new tool designed to measure readiness to advance health and health equity. Development of the AACT included initial item pool creation, external evaluation from five subject matter experts, and pilot testing (including user feedback surveys) among 103 individuals. Validation of the AACT was performed using a series of confirmatory factor analyses on an expanded dataset representing 352 individuals from 49 multi-sector collaboratives across the United States. The results of our study indicate the items in the AACT align to six domains created during the scale development process, and that the tool demonstrates desirable measurement characteristics for use in research, evaluation, and practice.

Exploring the appearance of and messaging on antibiotics to address inappropriate antibiotic use - public and pharmacists views

Introduction

The purpose of medicines labelling and packaging is to provide clear unambiguous identification of the medicine and the conditions for its safe use, allowing patients to understand and act on the information.1 Inappropriate antibiotic usage, (deviation from directions provided to the patients by the prescriber, resulting in sub-optimal treatment) may result in exposing bacteria to sub-therapeutic plasma concentrations and/or environment, which are one of the main drivers of Antibiotic Resistance.2 A recent comprehensive analysis showed the global burden associated with drug-resistant infections in 2019 was an estimated 4.95 million deaths.3

Aim

To ascertain the support from pharmacists and the public and their perceptions on the likely barriers to harmonising or standardising physical appearance and/or messaging on antibiotic packaging to reduce inappropriate antibiotic usage.

Methods

This study received ethics approval from the University of Huddersfield. In partnership with NHS England Antimicrobial Stewardship lead for North-East and Yorkshire, two questionnaires (public and pharmacist) were piloted. The final version was transferred to Qualtrics (online questionnaire format). During a 5-week period public questionnaires were distributed via posters with QR codes and social media. Pharmacist questionnaires were emailed to consenting pharmacists (community, hospital, GP practice, industry) around Huddersfield, Doncaster, Rochdale, Dewsbury and Leeds. The data underwent descriptive statistical analysis.

Results

Inappropriate antibiotic usage (saving for future use) was admitted by 23.5% of the 174 public participants, sharing with others (2.5%), throwing their antibiotics in the bin (32.7%) and other inappropriate usage was reported. This compared to 22.2% returning antibiotics to the pharmacy for disposal. 100% of pharmacists (40) think inappropriate antibiotic use needs to be addressed; the majority of pharmacists (55.5%) and the public (61.4%) think a harmonised antibiotic appearance would reduce inappropriate use. ‘Putting the word “ANTIBIOTICS” on the packaging would improve antibiotic packaging appearance’ was the top improvement selected by pharmacists (38.3%) and public (35.3%). Pharmacists (38.9%) thought antibiotic manufacturers would be the greatest obstacle to harmonised packaging. The majority of public (70.5%) and pharmacists (85.3%) think a standardised messaging system would help reduce inappropriate antibiotic use. Both pharmacists (41.1%) and public (47%) highlighted that a standard leaflet for appropriate use could improve antibiotic use. Pharmacists (47.8%) thought that multiple stakeholders (e.g., MHRA, manufacturers, etc) would be the barriers to a standardised messaging.

Discussion/Conclusion

Inappropriate antibiotic use by individuals who re-use leftovers or share their antibiotics may result in a treatment failure and could to increase AMR. Improvements in antibiotic packaging and patient information leaflets with appropriate disposal instructions could help minimise AMR. Limitations of this study include the low number of practice and industrial pharmacist respondents compared to community and hospital pharmacists. Public and pharmacist respondents supported the wording “ANTIBIOTIC” on antibiotic packaging and a standardised leaflet covering increasing adherence and appropriate disposal of leftovers. This study warrants further evaluation with regulators, manufacturers and other key stakeholders.

References

1. HM Government. Best practice guidance on the labelling and packaging of medicines. Available from: https://www.gov.uk/government/publications/best-practice-in-the-labelling-and-packaging-of-medicines (Accessed: 10/09/22).

2. Gullberg, E., et al. Selection of resistant bacteria at very low antibiotic concentrations. PLoS Pathogens, 2011;7(7):e1002158. https://doi.org/10.1371/journal.ppat.1002158

3. Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet 2022. https://doi.org/10.1016/S0140-6736(21)02724-0.

Sharing is caring: a call for a new era of rare disease research and development

Scientific advances in the understanding of the genetics and mechanisms of many rare diseases with previously unknown etiologies are inspiring optimism in the patient, clinical, and research communities and there is hope that disease-specific treatments are on the way. However, the rare disease community has reached a critical point in which its increasingly fragmented structure and operating models are threatening its ability to harness the full potential of advancing genomic and computational technologies. Changes are therefore needed to overcome these issues plaguing many rare diseases while also supporting economically viable therapy development. In "Data silos are undermining drug development and failing rare disease patients (Orphanet Journal of Rare Disease, Apr 2021)," we outlined many of the broad issues underpinning the increasingly fragmented and siloed nature of the rare disease space, as well as how the issues encountered by this community are representative of biomedical research more generally. Here, we propose several initiatives for key stakeholders - including regulators, private and public foundations, and research institutions - to reorient the rare disease ecosystem and its incentives in a way that we believe would cultivate and accelerate innovation. Specifically, we propose supporting non-proprietary patient registries, greater data standardization, global regulatory harmonization, and new business models that encourage data sharing and research collaboration as the default mode. Leadership needs to be integrated across sectors to drive meaningful change between patients, industry, sponsors, and academic medical centers. To transform the research and development landscape and unlock its vast healthcare, economic, and scientific potential for rare disease patients, a new model is ultimately the goal for all.

Self-perceived disease activity was the strongest predictor of COVID-19 pandemic-related concerns in young people with autoimmune rheumatic diseases, irrespective of their gender, with females reporting higher concerns

Objectives

We report the results of a pilot young patient survey that targeted patients with JSLE and JDM, exploring well-being, resilience and general concern about the coronavirus disease 2019 (COVID-19) pandemic as well as self-assessment of disease activity.

Methods

The survey was completed anonymously by patients who had been approached via the automatically generated hospital database between June and December 2020. In addition to disease characteristics, geographic location, education and employment level, we explored young patients' resilience, mood and feelings, mental well-being, self-assessed disease activity and general COVID-19 concerns using validated tools and visual analogue scales.

Results

This pilot study found that self-perceived disease activity was the strongest predictor of COVID-19 concern, irrespective of gender, employment and education status or well-being and resilience. Generalized concerns regarding the COVID-19 pandemic were significantly higher in females, although their self-reported DASs were comparable to male respondents.

Conclusion

Our findings highlight a gender bias in the generalized concern related to the COVID-19 pandemic, irrespective of the examined potential confounders. This suggests the need for further research around young patient self-reported outcomes outside hospital visits, especially in the context of gender differences and potential challenges of future pandemics.

A learning approach to community response during the COVID-19 pandemic: Applying the Cynefin framework to guide decision-making

Introduction

The United States has been unsuccessful in containing the rapid spread of COVID-19. The complex epidemiology of the disease and the fragmented response to it has resulted in thousands of ways in which spread has occurred, creating a situation where each community needs to create its own local, context-specific learning model while remaining compliant to county or state mandates.

Methods

In this paper, we demonstrate how cross sector collaborations can use the Cynefin Framework, a tool for decision-making in complex systems, to guide community response to the COVID-19 pandemic.

Results

We explore circumstances under which communities can inhabit each of the four domains of systems complexity represented in the Cynefin framework: simple, complicated, chaotic, and complex, and describe the decision-making process in each domain that balances health, economic, and social well-being.

Conclusion

This paper serves as a call to action for the creation of community learning systems to improve community resilience and capacity to make better-informed decisions to address complex public health problems during the pandemic and beyond.

A pilot monitoring strategy for post-partum disease in an Australian dairy herd

AIMS

To design a monitoring strategy that could be applied to regular veterinary visits to dairy farms to assess the prevalence and association between health conditions (uterine disease, hyperketonaemia and suboptimal body condition score) when diagnosed and treated at 1-7 days post-calving (DPC) and then re-examined at 28-35 DPC.

METHODS

This study evaluated data from 187 high-yielding dairy cows (21 primiparous, 166 multiparous) on one South Australian dairy farm on two occasions; Visit A which was 1-7 DPC and Visit B which was 28-35 DPC. On each visit, the nature of vaginal discharge, concentration of beta-hydroxybutyrate (BOH) in blood and BCS were recorded and assigned a clinical score. This was converted to a categorical outcome denoting the presence or absence of an abnormal health event, namely metritis or endometritis, hyperketonaemia (BOH concentration ≥1.2 mm/L) and suboptimal body condition score (>0.5 from optimum score). Cows with uterine disease or hyperketonaemia at either visit were treated. The prevalence of abnormal health events at each visit was determined and the association between the prevalence of disease at Visit A and Visit B (following appropriate treatment at Visit A) was measured using regression analysis.

RESULTS

The prevalence of abnormal vaginal discharge, hyperketonaemia and suboptimal BCS at Visits A and B were 26%, 7%, 35% and 25%,16%, 33% respectively. A higher proportion of primiparous cows (Visit A: 0.86 (95% CI = 0.70-1.00); Visit B: 0.95 (95% CI = 0.86-1.00)) were found to have suboptimal BCS at both visits compared to multiparous cows (Visit A: 0.28 (95% CI = 0.20-0.35); Visit B: 0.24 (95% CI = 0.17-0.32)). A higher prevalence of hyperketonaemia at Visit B for multiparous compared to primiparous cows (19 (95% CI = 12-25)% vs. 0 (95% CI = 0-17) respectively) was identified. An increase in clinical discharge score at Visit A increased the odds of purulent vaginal discharge at Visit B (OR = 1.77 (95% CI = 1.31-2.40)). Failing to calve at target BCS was strongly associated with cows missing target BCS at Visit B (OR = 5.77 (95% CI = 2.35-13.11)) and for every unit increase in BCS at Visit A, BCS at Visit B increased by 0.40 (95% CI = 0.26-0.53).

CONCLUSIONS AND CLINICAL RELEVANCE

This study describes a pilot monitoring strategy for clinical parameters indicative of post-partum disease at 1-7 and 28-35 DPC. Determining the herd prevalence of these conditions will enable tracking of herd disease status over time.Abbreviations: BCS: Body condition score; BOH: Beta-hydroxybutyrate; DPC: Days post-calving; NEFA: Non-esterified fatty acids; SCHK: Subclinical hyperketonaemia.

Developing capacity for learning community systems: Experiences from the 100 Million Healthier Lives SCALE Initiative

Introduction

This paper explores the capabilities that contribute to community transformation and the common pathways followed by communities in the 100 Million Healthier Lives SCALE (Spreading Community Accelerators through Learning and Evaluation) initiative in their transformation journeys towards a “Culture of Health”.

Methods

Funded by the Robert Wood Johnson Foundation (RWJF), from 2016 to 2020, between 18 to 24 community coalitions nationwide participated in SCALE, the goal of which was to co‐design, implement, test, and scale up a model called the Community of Solutions (COS) Framework, that built community capacity around a set of skills and behaviors to advance culture change and create sustainable improvement in health, well‐being, and equity. We adapted and applied two qualitative research techniques, meta‐ethnography and participatory action synthesis, to evaluate SCALE initiative data.

Results

Eight concepts emerged that represent the knowledge, capabilities and practices commonly acquired and utilized across the communities. Overall, these concepts emphasize individual and team leadership, quality improvement skills, an intentional focus on equity, and partnerships for spread and sustainment. Concepts were linked into lines of arguments which were unique storylines explaining the transformation pathways. Three stories of the transformation process emerged from the data. Causal Loop Diagrams (CLDs) were created to represent non‐linear system relationships and visually capture some of the most important dynamics of the process of transformation. Even with vast heterogeneity among the SCALE communities and the diversity of activities that the communities undertook, our analysis showed there were a few basic principles that undergirded the process of building capability for transformation.

Conclusions

The knowledge from our findings should be useful to expand further research and practice in community learning systems.

Telemedicine in rheumatology: A mixed methods study exploring acceptability, preferences and experiences among patients and clinicians

OBJECTIVES

The Covid-19 pandemic necessitated a rapid global transition towards telemedicine; yet much remains unknown about telemedicine's acceptability and safety in rheumatology. To help address this gap and inform practice, this study investigated rheumatology patient and clinician experiences and views of telemedicine.

METHODS

Sequential mixed methodology combined analysis of surveys and in-depth interviews. Between and within-group differences in views of telemedicine were examined for patients and clinicians using t-tests.

RESULTS

Surveys (Patients n = 1,340, Clinicians n = 111) and interviews (Patients n = 31, Clinicians n = 29) were completed between April 2021 and July 2021. The majority of patients were from the UK (96%) and had inflammatory arthritis (32%) or lupus (32%). Patients and clinicians rated telemedicine as worse than face-to-face consultations in almost all categories, although >60% found it more convenient. Building trusting medical relationships and assessment accuracy were great concerns (93% of clinicians and 86% of patients rated telemedicine as worse than face-to-face for assessment accuracy). Telemedicine was perceived to have increased misdiagnoses, inequalities and barriers to accessing care. Participants reported highly disparate telemedicine delivery and responsiveness from primary and secondary care. Although rheumatology clinicians highlighted the importance of a quick response to flaring patients, only 55% of patients were confident that their rheumatology department would respond within 48 hours.

CONCLUSION

Findings indicate a preference for face-to-face consultations. Some negative experiences may be due to the pandemic rather than telemedicine specifically, although the risk of greater diagnostic inaccuracies using telemedicine is unlikely to be fully resolved. Training, choice, careful patient selection, and further consultation with clinicians and patients is required to increase telemedicine's acceptability and safety.

P120 Self-reported disease activity was the main determinant of the perceived impact of COVID-19 pandemic on adolescent and young patients with juvenile dermatomyositis (JDM) and juvenile onset systemic lupus erythematosus (JSLE)

Background/Aims 

The impact of the COVID-19 pandemic on adolescent and young patients with chronic diseases is likely to be multi-factorial, and influenced by various aspects, such as age, sex, education, ethnicity, as well as disease control or personal coping strategies. Adolescents and young adults are at a time in their live when disruption in their education and social life, as well as uncertainty related to professional prospects and long-term disease outcomes are all associated with significant personal concerns. The aim of this survey was to assess the main determinants of COVID-19 associated concern in adolescent and young adults with JSLE and JDM as well as their well-being and resilience.

Methods 

Questionnaires comprising of questions related to patient and disease characteristics, wellbeing, resilience and concern about the COVID-19 pandemic were disseminated through hospital contacts and patient charities social media platforms. Participation was voluntary and implied consent. The preliminary results of this ongoing survey have been analysed using descriptive statistics and linear regression (R).

Results 

The main patient and disease characteristics, self-reported well-being, resilience and perceived concern about the COVID-19 pandemic are presented in comparison in male vs. female patients. Linear regression showed that the strongest determinant of COVID-19 concern was self-reported disease activity (p < 0.0003). The self-reported disease activity was associated with the COVID-19 concern level in both female (P = 0.003) and male patients (p = 0.004) and also with disease duration in males (P = 0.018). The COVID concern was not affected by any other factors such as, employment, education, well-being or resilience.

Conclusion 

The preliminary analysis of our survey showed that patient-reported COVID-19 concern during the pandemic was strongly determined by the self-reported disease activity irrespective of patients’ sex, despite significantly increased concern in the female compared to male patients, and association with disease duration in male patients only. We propose that further strategies for better patient support during the pandemic should focus on their optimal disease control as well as take into consideration the sex-biased patient concerns. P120 Table 1:

	Female	Male	p-value
Number	38	9
Current age mean (IQR)	22.21 (18.25- 25.75)	18.89 (14.00-26.00)
Age at diagnosis years mean (IQR)	13.01 (9.00-15.00)	9.333 (7.00-11.00)
Disease duration Mean (IQR)	9.197 (4.000-13.000)	9.556 (2.000-13.000)	0.4841
Ethnicity; White Non-white	25 (65.8%) 13 (34.2%)	7 (77.8%) 2 (22.2%)	0.4841
Location; England (%) Other (%)	35 (92.1%) 3 (7.9%)	9 (100%) 0 (0%)	0.2578091
Well-being (VAS -2 to + 2) mean (IQR)	-0.6765 (-2.0000 – 0.0000)	-0.4286 (-1.0000 – 0.0000)	0.5667
Resilience (VAS 1-7) mean (IQR)	4.906 (4.000 - 6.000)	5.0 (4.5 - 5.5)	0.8718
Self-reported disease activity (VAS 1-100) mean (IQR)	35.32 (15.00- 53.00)	18.67 (3.00-25.00)	0.06429
Self-reported COVID concern (VAS 1-100) mean (IQR)	62.92 (50.00-80.00)	32.33 (15.00- 40.00)	0.01052
Still in education No Yes Not recorded	16 (42.1%) 18 (47.4%) 4 (10.5%)	3 (33.3%) 4 (44.4%) 2 (22.2%)
Currently working No Yes Not recorded	24 (63.2%) 10 (26.3%) 4 (10.5%)	5 (55.6%) 2 (22.2%) 2 (22.2%)

Funding statement: This work was supported by Versus Arthritis (21593)

Disclosure 

A. Khatun: None. W. Wu: None. J. Peng: None. L. Hennelly: None. M. Sloan: None. M. Bosley: None. P. Howard: None. L. Jury: None. C. Ciurtin: None.

Data silos are undermining drug development and failing rare disease patients

Data silos are proliferating while research and development activity explode following genetic and immunological advances for many clinically described disorders with previously unknown etiologies. The latter event has inspired optimism in the patient, clinical, and research communities that disease-specific treatments are on the way. However, we fear the tendency of various stakeholders to balkanize databases in proprietary formats, driven by current economic and academic incentives, will inevitably fragment the expanding knowledge base and undermine current and future research efforts to develop much-needed treatments. The proliferation of proprietary databases, compounded by a paucity of meaningful outcome measures and/or good natural history data, slows our ability to generate scalable solutions to benefit chronically underserved patient populations in ways that would translate to more common diseases. The current research and development landscape sets too many projects up for unnecessary failure, particularly in the rare disease sphere, and does a grave disservice to highly vulnerable patients. This system also encourages the collection of redundant data in uncoordinated parallel studies and registries to ultimately delay or deny potential treatments for ostensibly tractable diseases; it also promotes the waste of precious time, energy, and resources. Groups at the National Institutes of Health and Food and Drug Administration have started programs to address these issues. However, we and many others feel there should be significantly more discussion of how to coordinate and scale registry efforts. Such discourse aims to reduce needless complexity and duplication of efforts, as well as promote a pre-competitive knowledge ecosystem for rare disease drug development that cultivates and accelerates innovation.

Data silos are undermining drug development and failing rare disease patients

Data silos are proliferating while research and development activity explode following genetic and immunological advances for many clinically described disorders with previously unknown etiologies. The latter event has inspired optimism in the patient, clinical, and research communities that disease-specific treatments are on the way. However, we fear the tendency of various stakeholders to balkanize databases in proprietary formats, driven by current economic and academic incentives, will inevitably fragment the expanding knowledge base and undermine current and future research efforts to develop much-needed treatments. The proliferation of proprietary databases, compounded by a paucity of meaningful outcome measures and/or good natural history data, slows our ability to generate scalable solutions to benefit chronically underserved patient populations in ways that would translate to more common diseases. The current research and development landscape sets too many projects up for unnecessary failure, particularly in the rare disease sphere, and does a grave disservice to highly vulnerable patients. This system also encourages the collection of redundant data in uncoordinated parallel studies and registries to ultimately delay or deny potential treatments for ostensibly tractable diseases; it also promotes the waste of precious time, energy, and resources. Groups at the National Institutes of Health and Food and Drug Administration have started programs to address these issues. However, we and many others feel there should be significantly more discussion of how to coordinate and scale registry efforts. Such discourse aims to reduce needless complexity and duplication of efforts, as well as promote a pre-competitive knowledge ecosystem for rare disease drug development that cultivates and accelerates innovation.

'But you don't look sick': a qualitative analysis of the LUPUS UK online forum

Lupus is a multi-system autoimmune rheumatic disease with increased morbidity and mortality. Some manifestations are life-threatening with many aspects of living with the disease, difficulties in diagnosis and accessing appropriate medical care, having an impact on quality of life. The disease itself, and these patients’ perspectives, are currently poorly understood and under-researched. The LUPUS UK forum of conversations between over 25,000 members provides a rich environment to explore the views of these patients. Conversations on the LUPUS UK online forum were qualitatively explored using virtual ethnography and thematic analysis. The forum itself and positive medical relationships were widely considered to provide a means of support, understanding and validation. Forum members expressed difficulties in diagnosis, disease management, and the psychological and physical impact of living with an unpredictable, poorly understood disease, often with life-changing symptoms. Invalidating personal, social and medical environments were perceived as exacerbating these difficulties. Delays in diagnosis and misdiagnoses were frequently discussed as causing significant damage, especially when symptoms were disbelieved or dismissed. Invalidation was the key theme with further themes of: Uncertainty, Medical (mis)communications and misunderstandings, Navigating health systems and Resilience and support. Although effective care and support was reported by some members, the negative impact of living with an incurable, life-changing disease was often exacerbated by perceived invalidation, uncertainty, and difficulties in multiple areas of members’ lives. Improved knowledge of the disease and greater support at all stages of the diagnostic journey could improve outcomes and quality of life for these patients.

'Warning: allergic to penicillin': association between penicillin allergy status in 2.3 million NHS general practice electronic health records, antibiotic prescribing and health outcomes

BACKGROUND

The prevalence of reported penicillin allergy (PenA) and the impact these records have on health outcomes in the UK general population are unknown. Without such data, justifying and planning enhanced allergy services is challenging.

OBJECTIVES

To determine: (i) prevalence of PenA records; (ii) patient characteristics associated with PenA records; and (iii) impact of PenA records on antibiotic prescribing/health outcomes in primary care.

METHODS

We carried out cross-sectional/retrospective cohort studies using patient-level data from electronic health records. Cohort study: exact matching across confounders identified as affecting PenA records. Setting: English NHS general practices between 1 April 2013 and 31 March 2014. Participants: 2.3 million adult patients. Outcome measures: prevalence of PenA, antibiotic prescribing, mortality, MRSA infection/colonization and Clostridioides difficile infection.

RESULTS

PenA prevalence was 5.9% (IQR = 3.8%-8.2%). PenA records were more common in older people, females and those with a comorbidity, and were affected by GP practice. Antibiotic prescribing varied significantly: penicillins were prescribed less frequently in those with a PenA record [relative risk (RR)  = 0.15], and macrolides (RR = 4.03), tetracyclines (RR = 1.91) nitrofurantoin (RR = 1.09), trimethoprim (RR = 1.04), cephalosporins (RR = 2.05), quinolones (RR = 2.10), clindamycin (RR = 5.47) and total number of prescriptions were increased in patients with a PenA record. Risk of re-prescription of a new antibiotic class within 28 days (RR = 1.32), MRSA infection/colonization (RR = 1.90) and death during the year subsequent to 1 April 2013 (RR = 1.08) increased in those with PenA records.

CONCLUSIONS

PenA records are common in the general population and associated with increased/altered antibiotic prescribing and worse health outcomes. We estimate that incorrect PenA records affect 2.7 million people in England. Establishing true PenA status (e.g. oral challenge testing) would allow more people to be prescribed first-line antibiotics, potentially improving health outcomes.

Is it me? The impact of patient-physician interactions on lupus patients' psychological well-being, cognition and health-care-seeking behaviour

Objective

The aim was to explore the impact of patient–physician interactions, pre- and post-diagnosis, on lupus and UCTD patients’ psychological well-being, cognition and health-care-seeking behaviour.

Methods

Participants were purposively sampled from the 233 responses to a survey on patient experiences of medical support. Twenty-one semi-structured interviews were conducted and themes generated using thematic analysis.

Results

The study identified six principal themes: (i) the impact of the diagnostic journey; (ii) the influence of key physician(s) on patient trust and security, with most participants reporting at least one positive medical relationship; (iii) disparities in patient–physician priorities, with patients desiring more support with quality-of-life concerns; (iv) persisting insecurity and distrust, which was prevalent and largely influenced by previous and anticipated disproportionate (often perceived as dismissive) physician responses to symptoms and experiences of widespread inadequate physician knowledge of systemic autoimmune diseases; (v) changes to health-care-seeking behaviours, such as curtailing help-seeking or under-reporting symptoms; and (vi) empowerment, including shared medical decision-making and knowledge acquisition, which can mitigate insecurity and improve care.

Conclusion

Negative medical interactions pre- and post-diagnosis can cause a loss of self-confidence and a loss of confidence and trust in the medical profession. This insecurity can persist even in subsequent positive medical relationships and should be addressed. Key physicians implementing empowering and security-inducing strategies, including being available in times of health crises and validating patient-reported symptoms, might lead to more trusting medical relationships and positive health-care-seeking behaviour.

Medically explained symptoms: a mixed methods study of diagnostic, symptom and support experiences of patients with lupus and related systemic autoimmune diseases

Objectives

The aim was to explore patient experiences and views of their symptoms, delays in diagnosis, misdiagnoses and medical support, to identify common experiences, preferences and unmet needs.

Methods

Following a review of LUPUS UK's online forum, a questionnaire was posted online during December 2018. This was an exploratory mixed methods study, with qualitative data analysed thematically and combined with descriptive and statistically analysed quantitative data.

Results

There were 233 eligible respondents. The mean time to diagnosis from first experiencing symptoms was 6 years 11 months. Seventy-six per cent reported at least one misdiagnosis for symptoms subsequently attributed to their systemic autoimmune rheumatic disease. Mental health/non-organic misdiagnoses constituted 47% of reported misdiagnoses and were indicated to have reduced trust in physicians and to have changed future health-care-seeking behaviour. Perceptions of physician knowledge and listening skills were highly correlated with patient ratings of trust. The symptom burden was high. Fatigue had the greatest impact on activities of daily living, yet the majority reported receiving no support or poor support in managing it. Assessing and treating patients holistically and with empathy was strongly felt to increase diagnostic accuracy and improve medical relationships.

Conclusion

Patient responses indicated that timely diagnosis could be facilitated if physicians had greater knowledge of lupus/related systemic autoimmune diseases and were more amenable to listening to and believing patient reports of their symptoms. Patient priorities included physicians viewing them holistically, with more emotional support and assistance in improving quality of life, especially in relation to fatigue.

Dietary Supplementation With Cyplexinol for Amelioration of Osteoporosis: A Case Study

A 50-y-old male in otherwise good health was diagnosed with severe osteoporosis with a lumbar spinal t score of -3.8. Further testing revealed no underlying causes other than a family history of the disease. He was placed on a trial regimen of 450 mg Cyplexinol twice daily for 4 mo. Repeat DEXA scans after 4 mo of this therapy showed an improved lumbar spinal t score of -3.3, the first time that improvement in t scores has been demonstrated in this short amount of time. Cyplexinol, the first orally consumable demineralized bone matrix consisting of a naturally derived bone morphogenetic protein complex, may be a beneficial alternative to conventional treatments for osteoporosis with an ability to reverse bone mineral density loss in as little as 4 mo.

A national quality incentive scheme to reduce antibiotic overuse in hospitals: evaluation of perceptions and impact

Background

In 2016/2017, a financially linked antibiotic prescribing quality improvement initiative Commissioning for Quality and Innovation (AMR-CQUIN) was introduced across acute hospitals in England. This aimed for >1% reductions in DDDs/1000 admissions of total antibiotics, piperacillin/tazobactam and carbapenems compared with 2013/2014 and improved review of empirical antibiotic prescriptions.

Objectives

To assess perceptions of staff leading antimicrobial stewardship activity regarding the AMR-CQUIN, the investments made by hospitals to achieve it and how these related to achieving reductions in antibiotic use.

Methods

We invited antimicrobial stewardship leads at acute hospitals across England to complete a web-based survey. Antibiotic prescribing data were downloaded from the PHE Antimicrobial Resistance Local Indicators resource.

Results

Responses were received from 116/155 (75%) acute hospitals. Owing to yearly increases in antibiotic use, most trusts needed to make >5% reductions in antibiotic consumption to achieve the AMR-CQUIN goal of 1% reduction. Additional funding was made available at 23/113 (20%) trusts and, in 18 (78%), this was <10% of the AMR-CQUIN value. Nationally, the annual trend for increased antibiotic use reversed in 2016/2017. In 2014/2015, year-on-year changes were +3.7% (IQR -0.8%, +8.4%), +9.4% (+0.2%, +19.5%) and +5.8% (-6.2%, +18.2%) for total antibiotics, piperacillin/tazobactam and carbapenems, respectively, and +0.1% (-5.4%, +4.0%), -4.8% (-16.9%, +3.2%) and -8.0% (-20.2%, +4.0%) in 2016/2017. Hospitals where staff believed they could reduce antibiotic use were more likely to do so (P < 0.001).

Conclusions

Introducing the AMR-CQUIN was associated with a reduction in antibiotic use. For individual hospitals, achieving the AMR-CQUIN was associated with favourable perceptions of staff and not availability of funding.

Bisphosphonates: AHFS 92:24

Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. Additional content is available via www.medicinescomplete.com. The series editors welcome feedback on the articles (hq@palliativedrugs.com).

Levetiracetam

Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. Additional content is available on www.palliativedrugs.com. The series editors welcome feedback on the articles (hq@palliativedrugs.com).

Denosumab: AHFS 92:24

Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. Additional content is available on www.palliativedrugs.com. Country-specific books (Hospice and Palliative Care Formulary USA, and Palliative Care Formulary, British and Canadian editions) are also available and can be ordered from www.palliativedrugs.com. The series editors welcome feedback on the articles (hq@palliativedrugs.com).

Is the rate of revision of 36 mm metal-on-metal total hip arthroplasties with Pinnacle acetabular components related to the year of the initial operation? an interrupted time-series analysis using data from the National Joint Registry for England and Wales

AIMS

The aim of this study was to determine whether the rates of revision for metal-on-metal (MoM) total hip arthroplasties (THAs) with Pinnacle components varied according to the year of the initial operation, and compare these with the rates of revision for other designs of MoM THA.

PATIENTS AND METHODS

Data from the National Joint Registry for England and Wales included 36 mm MoM THAs with Pinnacle acetabular components which were undertaken between 2003 and 2012 with follow-up for at least five years (n = 10 776) and a control group of other MoM THAs (n = 13 817). The effect of the year of the primary operation on all-cause rates of revision was assessed using Cox regression and interrupted time-series analysis.

RESULTS

For MoM THAs involving Pinnacle components, those undertaken between 2007 and 2012 had higher rates of revision compared with those undertaken between 2004 and 2006 (hazard ratio (HR) 2.01; 95% confidence interval (CI) 1.57 to 2.57; p < 0.001). For THAs undertaken during and after 2007, the number of revisions per 1000 implant-years at risk significantly increased by 5.20 (95% CI 0.52 to 9.89; p = 0.033) compared with those undertaken before this time. In the control group, THAs undertaken between 2007 and 2012 also had higher rates of revision (HR 1.77; 95% CI 1.49 to 2.10; p < 0.001), with revisions per 1000 implant-years for those undertaken during and after 2007 significantly increasing by 6.13 (95% CI 1.42 to 10.83; p = 0.016).

CONCLUSION

The five-year revision rates were significantly increased for all primary MoM THAs undertaken from 2007 onwards. Contrary to recent reports, this finding was not specific to those involving Pinnacle acetabular components and may be explained by increased surveillance and recent lowering of the threshold for revision. Cite this article: Bone Joint J 2018;100-B:33-41.

Fatal pulmonary embolism following elective total knee replacement using aspirin in multi-modal prophylaxis - A 12year study

BACKGROUND

The National Institute for Health and Clinical Excellence (NICE) has issued guidelines on which thromboprophylaxis regimens are suitable following lower limb arthroplasty. Aspirin is not a recommended agent despite being accepted in orthopaedic guidelines elsewhere. We assessed the incidence of fatal pulmonary embolism (PE) and all-cause mortality following elective primary total knee replacement (TKR) with a standardised multi-modal prophylaxis regime in a large teaching district general hospital.

METHODS

We utilised a prospective audit database to identify those that had died within 42 and 90days postoperatively. Data from April 2000 to 2012 were analysed for 42 and 90day mortality rates. There were a total of 8277 elective primary TKR performed over the 12year period. The multi-modal prophylaxis regimen used unless contraindicated for all patients included 75mg aspirin once daily for four weeks. Case note review ascertained the causes of death. Where a patient had been referred to the coroner, they were contacted for post mortem results.

RESULTS

The mortality rates at 42 and 90days were 0.36 and 0.46%. There was one fatal PE within 42days of surgery (0.01%) who was taking enoxaparin because of aspirin intolerance. Two fatal PE's occurred at 48 and 57days post-operatively (0.02%). The leading cause of death was myocardial infarction (0.13%).

CONCLUSIONS

Fatal PE following elective TKR with a multi-modal prophylaxis regime is a very rare cause of mortality.

A feasibility service evaluation of screening and treatment of group A streptococcal pharyngitis in community pharmacies

OBJECTIVES

The UK 5 year antimicrobial resistance strategy recognizes the role of point-of-care diagnostics to identify where antimicrobials are required, as well as to assess the appropriateness of the diagnosis and treatment. A sore throat test-and-treat service was introduced in 35 community pharmacies across two localities in England during 2014-15.

METHODS

Trained pharmacy staff assessed patients presenting with a sore throat using the Centor scoring system and patients meeting three or all four of the criteria were offered a throat swab test for Streptococcus pyogenes, Lancefield group A streptococci. Patients with a positive throat swab test were offered antibiotic treatment.

RESULTS

Following screening by pharmacy staff, 149/367 (40.6%) patients were eligible for throat swab testing. Of these, only 36/149 (24.2%) were positive for group A streptococci. Antibiotics were supplied to 9.8% (n = 36/367) of all patients accessing the service. Just under half of patients that were not showing signs of a bacterial infection (60/123, 48.8%) would have gone to their general practitioner if the service had not been available.

CONCLUSIONS

This study has shown that it is feasible to deliver a community-pharmacy-based screening and treatment service using point-of-care testing. This type of service has the potential to support the antimicrobial resistance agenda by reducing unnecessary antibiotic use and inappropriate antibiotic consumption.

Homelessness, Unsheltered Status, and Risk Factors for Mortality: Findings From the 100 000 Homes Campaign

OBJECTIVES

People who live in unsheltered situations, such as the streets, often have poorer health, less access to health care, and an increased risk of premature mortality as compared with their sheltered counterparts. The objectives of this study were to (1) compare the characteristics of people experiencing homelessness who were sleeping primarily in unsheltered situations with those who were accessing homeless shelters and other sheltered situations, (2) identify correlates of unsheltered status, and (3) assess the relationship between unsheltered status and increased risk of mortality.

METHODS

Using primary data collected as part of the 100    000 Homes Campaign-a national effort to help communities find homes for vulnerable and chronically homeless Americans-we estimated 2 generalized linear mixed models to understand the correlates of unsheltered status and risk factors for mortality. Independent variables included demographic characteristics; history of homelessness, incarceration, foster care, and treatment for mental illness or substance use; sources of income; and past and present medical conditions. The study sample comprised 25489 people experiencing homelessness who responded to an assessment of their housing and health as part of the 100    000 Homes Campaign from 2008 to 2014.

RESULTS

In the full model, the following characteristics were associated with unsheltered status: being a veteran (adjusted odds ratio [aOR] = 1.10); having <high school education (aOR = 1.09); accessing informal income (aOR = 2.37); and having a history of foster care (aOR = 1.14), chronic homelessness (aOR = 1.36 for 1-5 years, aOR = 1.95 for >5 years), incarceration (aOR = 1.32), or substance use (aOR = 1.10 for ever abusing drugs or alcohol, aOR = 1.13 for ever using intravenous drugs, aOR = 1.98 for drinking alcohol every day for past month). Being unsheltered (aOR = 1.12), being female (aOR = 1.22), or receiving entitlements (aOR = 1.63) increased respondents' odds of having risk factors for mortality.

CONCLUSIONS

These findings highlight the need to assertively reach out to vulnerable populations and provide interventions to assist them during their transition-for example, as they exit incarceration or age out of foster care. Such a response could prevent unsheltered homelessness and thereby address increased mortality risk. Connecting people with resources to increase their access to employment, benefits, and other sources of income is especially important.

The impact of the introduction of fidaxomicin on the management of Clostridium difficile infection in seven NHS secondary care hospitals in England: a series of local service evaluations

Clostridium difficile infection (CDI) is associated with high mortality. Reducing incidence is a priority for patients, clinicians, the National Health Service (NHS) and Public Health England alike. In June 2012, fidaxomicin (FDX) was launched for the treatment of adults with CDI. The objective of this evaluation was to collect robust real-world data to understand the effectiveness of FDX in routine practice. In seven hospitals introducing FDX between July 2012 and July 2013, data were collected retrospectively from medical records on CDI episodes occurring 12 months before/after the introduction of FDX. All hospitalised patients aged ≥18 years with primary CDI (diarrhoea with presence of toxin A/B without a previous CDI in the previous 3 months) were included. Recurrence was defined as in-patient diarrhoea re-emergence requiring treatment any time within 3 months after the first episode. Each hospital had a different protocol for the use of FDX. In hospitals A and B, where FDX was used first line for all primary and recurrent episodes, the recurrence rate reduced from 10.6 % to 3.1 % and from 16.3 % to 3.1 %, with a significant difference in 28-day mortality from 18.2 % to 3.1 % (p < 0.05) and 17.3 % to 6.3 % (p < 0.05) for hospitals A and B, respectively. In hospitals using FDX in selected patients only, the changes in recurrence rates and mortality were less marked. The pattern of adoption of FDX appears to affect its impact on CDI outcome, with maximum reduction in recurrence and all-cause mortality where it is used as first-line treatment.

Rifampin (INN Rifampicin)

Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. Additional content is available on www.palliativedrugs.com. Country-specific books (Hospice and Palliative Care Formulary USA, and Palliative Care Formulary, British and Canadian editions) are also available and can be ordered from www.palliativedrugs.com. The series editors welcome feedback on the articles (hq@palliativedrugs.com).