Development and evaluation of pharmacist-provided teach-back medication counselling at hospital discharge

BACKGROUND

Pharmacists can use teach-back to improve patients' understanding of medication; however, the evidence of its impact on patient outcomes is inconsistent. From the literature, there is no standardised way to provide pharmacist-delivered medication counselling at hospital discharge, with limited reporting on training.

AIM

To develop a standardised medication counselling procedure using teach-back at hospital discharge, and to evaluate feedback from patients and pharmacists on this initiative.

METHOD

A standardised intervention procedure was developed. Participating pharmacists (n = 9) were trained on teach-back via an online education module and watching a demonstration video created by the researchers. Pharmacists provided patients with discharge medication counselling utilising teach-back and a patient-friendly list of medication changes to take home. To obtain feedback, patients were surveyed within seven days of discharge via telephone and pharmacists answered an anonymous survey online.

RESULTS

Thirty-two patients (mean age: 57 years; range: 19-91) were counselled on a mean 2.94 medications/patient with the mean counselling time as 23.6 min/patient. All patients responded to the survey, whereby 93.7% had increased confidence regarding medication knowledge and were satisfied with the counselling and the information provided. All pharmacist survey respondents (n = 8) agreed they were given adequate training and that teach-back was feasible to apply in practice.

CONCLUSION

This is the first study to evaluate patients' views on pharmacist-provided teach-back medication counselling. With positive patient outcomes, a standardised procedure, and a comprehensive description of the training, this study can inform the development of discharge medication counselling utilising teach-back going forward.

Arterial Stiffness in a Cohort of Young People Living With Perinatal HIV and HIV Negative Young People in England

Background

Antiretroviral therapy (ART) has increased life expectancy and consequently the risk of cardiovascular disease (CVD) in adults living with HIV. We investigated the levels and predictors of arterial stiffness in young people (YP) living with perinatal HIV (PHIV) and HIV negative YP in the Adolescents and Adults Living with Perinatal HIV (AALPHI) study.

Methods

AALPHI was a prospective study evaluating the impact of HIV infection and exposure to ART on YP living with PHIV (aged 13–21 years) who had known their HIV status for at least 6 months, and HIV negative YP (aged 13–23 years) who either had a sibling, friend or parent living with HIV. Participants were enrolled from HIV clinics and community services in England. Two hundred and thirteen PHIV and 65 HIV negative YP (42% siblings of PHIV) had pulse wave velocity (PWV) measurements taken (Vicorder software) from the supra-sternal notch to the middle of the thigh cuff, at their second interview in the study between 2015 and 2017. Average PWV was calculated from the three closest readings (≥3 and ≤ 12 m/s) within 0.6 m/s of each other. Linear regression examined predictors of higher (worse) PWV, including age, sex, HIV status and height as a priori, ethnicity, born outside UK/Ireland, alcohol/nicotine/drug use, weight, waist-to-hip-ratio, mean arterial pressure (MAP), caffeine 2 h before PWV and nicotine on day of PWV. A separate PHIV model included CD4, viral load, years taking ART and ART regimen.

Findings

One hundred and twenty eight (60%) PHIV and 45 (69%) HIV negative YP were female (p = 0.18), with median (IQR) age 18 (16, 20) and 18 (16, 21) years (p = 0.48) respectively. Most PHIV were taking a combination of three ART drugs from two classes. There was a trend toward higher (worse) mean PWV in the PHIV group than the HIV negative group [unvariable analysis 6.15 (SD 0.83) m/s vs. 5.93 (0.70) m/s, respectively, unadjusted p = 0.058], which was statistically significant in the multivariable analysis [adjusted p (ap) = 0.020]. In multivariable analysis being male (ap = 0.002), older age (ap < 0.001), higher MAP (ap < 0.001) and nicotine use on day of measurement (ap = 0.001) were also predictors of higher PWV. The predictors were the same in the PHIV model.

Interpretation

By late adolescence PHIV had worse PWV in comparison to HIV negative peers, and traditional risk factors for CVD (higher arterial pressure, being male and older age) were associated with higher PWV values. Regular detailed monitoring of cardiovascular risk factors should become standard of care for every young person with PHIV worldwide.

Cutaneous manifestations of PIMS-TS: a single centre experience

Paediatric inflammatory multisystem syndrome associated with severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) infection (PIMS-TS) is defined as 'a child presenting with persistent fever, inflammation and evidence of single or multi-organ dysfunction with additional features which include a rash'.¹ The World Health Organisation's (WHO) definition further includes a 'rash or bilateral non-purulent conjunctivitis or muco-cutaneous inflammation signs'.² Previously reported mucocutaneous manifestations (MCM) in PIMS-TS have been vague. This study aimed to delineate the MCM of children presenting with PIMS-TS in more detail.

153 DIFFERENCES IN POTENTIALLY INAPPROPRIATE PRESCRIBING (PIP) AT DISCHARGE ACCORDING TO FRAILTY STATUS

Background

Frailty is a key concept in healthcare service planning development for our ageing population. Guidelines recommend that older patients requiring acute hospital care should be routinely assessed for frailty (NCPOP). Potentially Inappropriate Prescribing (PIP) encompasses both over- and under-prescribing and is associated with adverse health outcomes for older persons. The objective of this study was to investigate differences in PIP at discharge of older patients according to frailty status (robust, pre-frail and frail).

Methods: In this retrospective single-centre cohort study, a random sample of older patients (≥75 years) assessed for frailty on admission, was selected. The discharge prescriptions of 150 patients were reviewed using STOPP and START criteria to identify Potentially Inappropriate Medications (PIMs and Potential Prescribing Omissions (PPOs). Drg Burden Index (DBI) scores, a measure of anticholinergic and sedative burden, were calculated for each patient. Data was analysed using descriptive statistics.

Results

There was a significant difference in the mean number of medications between the groups (F = 12.335,p &lt; 0.001), with frailer patients prescribed more medications. Significantly more hyperpolypharmacy (≥10 regular medications) was identified in the frail group (χ2 = 17.378,p &lt; 0.001).

A high prevalence of both PIMs(72%) and PPOs (63.3%) was found, as was a significant difference in the proportion of patients with PPOs according to frailty status (χ2 = 6.507,p = 0.039). The median number of PPOs increased significantly from the robust to pre-frail and frail groups (χ2 = 8.194,p = 0.017).

DBI scores increased significantly from the robust to pre-frail and frail groups (χ2 = 7.389, p = 0.025) and there was a significant difference in the proportion of patients with high DBI exposure (scores≥1) across the groups (χ2 = 6.497,p = 0.039).

Conclusion

Frail patients were on more medications, had more instances of PPOs and a higher anticholinergic and sedative burden than their non-frail counterparts. The results of this study support the use of frailty assessments in identifying patients for targeted medication reviews aimed at reducing PIP.

A report on the impact of rapid prenatal exome sequencing on the clinical management of 52 ongoing pregnancies: a retrospective review

OBJECTIVE

Studies have shown that prenatal exome sequencing (PES) improves diagnostic yield in cases of fetal structural malformation. We have retrospectively analysed PES cases from two of the largest fetal medicine centres in the UK to determine the impact of results on management of a pregnancy.

DESIGN

A retrospective review of clinical case notes.

SETTING

Two tertiary fetal medicine centres.

POPULATION

Pregnancies with fetal structural abnormalities referred to clinical genetics via a multidisciplinary team.

METHODS

We retrospectively reviewed the notes of all patients who had undergone PES. DNA samples were obtained via chorionic villus sampling or amniocentesis. Variants were filtered using patient-specific panels and interpreted using American College of Medical Genetics guidelines.

RESULTS

A molecular diagnosis was made in 42% (18/43) ongoing pregnancies; of this group, there was a significant management implication in 44% (8/18). A positive result contributed to the decision to terminate a pregnancy in 16% (7/43) of cases. A negative result had a significant impact on management in two cases by affirming the decision to continue pregnancy.

CONCLUSIONS

We demonstrate that the results of PES can inform pregnancy management. Challenges include variant interpretation with limited phenotype information. These results emphasise the importance of the MDT and collecting phenotype and variant data. As this testing is soon to be widely available, we should look to move beyond diagnostic yield as a measure of the value of PES.

TWEETABLE ABSTRACT

Prenatal exome sequencing can aid decision-making in pregnancy management; review ahead of routine implementation in NHS.

Predictors for a dementia gene mutation based on gene-panel next-generation sequencing of a large dementia referral series

Next-generation genetic sequencing (NGS) technologies facilitate the screening of multiple genes linked to neurodegenerative dementia, but there are few reports about their use in clinical practice. Which patients would most profit from testing, and information on the likelihood of discovery of a causal variant in a clinical syndrome, are conspicuously absent from the literature, mostly for a lack of large-scale studies. We applied a validated NGS dementia panel to 3241 patients with dementia and healthy aged controls; 13,152 variants were classified by likelihood of pathogenicity. We identified 354 deleterious variants (DV, 12.6% of patients); 39 were novel DVs. Age at clinical onset, clinical syndrome and family history each strongly predict the likelihood of finding a DV, but healthcare setting and gender did not. DVs were frequently found in genes not usually associated with the clinical syndrome. Patients recruited from primary referral centres were compared with those seen at higher-level research centres and a national clinical neurogenetic laboratory; rates of discovery were comparable, making selection bias unlikely and the results generalisable to clinical practice. We estimated penetrance of DVs using large-scale online genomic population databases and found 71 with evidence of reduced penetrance. Two DVs in the same patient were found more frequently than expected. These data should provide a basis for more informed counselling and clinical decision making.

Analysis of historical negative control group data from the rat in vivo micronucleus assay

A database of micronuclei counts for historical negative control data from rat in vivo micronuclei tests performed in 10 different laboratories was established. Data were available from over 4000 negative control rats from 10 laboratories. The mean frequency of micronucleated cells (MN)/1000 cells ranged from 0.44 to 2.22, a 5-fold range. Overall there were no major sex or strain differences in frequency, although there were some small but statistically significant differences within laboratories. There was appreciable variability between experiments compared with variability within experiments in some laboratories. No specific factor was identified which could explain this variability although it was noted that many different vehicles were used in the experiments. It is hoped that these data will help laboratories beginning studies with the rat micronucleus assay and those involved in the assessment of micronucleus assay results.

LPS-inducible responses in severe combined immunodeficiency (SCID) mice

Lipopolysaccharide (LPS) is a potent bacterial product that has been shown to act on many different cell types both in vivo and in vitro. Injection of immunologically competent mice with LPS results in increased serum cytokine levels, followed by an array of pathophysiologic alterations that can ultimately lead to death. In this study, we examined the response of severe combined immunodeficient (SCID) mice to LPS. These mice lack mature T and B cells and have been shown to be an important model for analyzing the contribution of innate immune responses to infectious agents. Injection of SCID mice with LPS resulted in increases in CSF, TNF, and IFN levels in serum that were similar to the responses of immunocompetent controls. In response to LPS, both SCID and control mice exhibited similar levels of hypoglycemia. LPS-induced toxicity was assessed in D(+)-galactosamine-sensitized animals. SCID mice were comparably sensitive to the lethal effects of LPS as control BALB/c mice. To assess the role of natural killer (NK) cells in LPS-induced cytokine responses, BALB/c and SCID mice were injected with anti-asialo-GM1 antibody prior to injection of LPS. No significant effect on LPS-induced CSF or blood glucose levels were seen, although NK-depleted SCID mice produced somewhat more IFN in response to LPS than normal mice. Thus, NK cells are not a major source of these early LPS-induced cytokines. These data suggest that mature T and B cells and NK cells do not contribute to the initial wave of cytokines produced in response to LPS, but may contribute as secondary producers of cytokines involved in the cytokine cascade elicited by LPS injection.

Spline modelling electron insert factors using routine measurements

There are many methods available to predict electron output factors; however, many centres still measure the factors for each irregular electron field. Creating an electron output factor prediction model that approaches measurement accuracy--but uses already available data and is simple to implement--would be advantageous in the clinical setting. This work presents an empirical spline model for output factor prediction that requires only the measured factors for arbitrary insert shapes. Equivalent ellipses of the insert shapes are determined and then parameterised by width and ratio of perimeter to area. This takes into account changes in lateral scatter, bremsstrahlung produced in the insert material, and scatter from the edge of the insert. Agreement between prediction and measurement for the 12 MeV validation data had an uncertainty of 0.4% (1SD). The maximum recorded deviation between measurement and prediction over the range of energies was 1.0%. The validation methodology showed that one may expect an approximate uncertainty of 0.5% (1SD) when as little as eight data points are used. The level of accuracy combined with the ease with which this model can be generated demonstrates its suitability for clinical use. Implementation of this method is freely available for download at https://github.com/SimonBiggs/electronfactors.

Pregnancy outcomes in adolescents in the UK and Ireland growing up with HIV

OBJECTIVES

Adolescents with HIV infection acquired perinatally or in early childhood are becoming sexually active, but little is known about fertility and pregnancy outcomes. Multicentre data on pregnancy outcomes in this population are described here.

METHODS

A retrospective case note review of pregnant women with perinatal/early acquired HIV infection, conceiving before 1 September 2009 and attending participating centres in the UK and Ireland, was carried out.

RESULTS

Among 252 women with perinatal/early acquired infection aged 12 years and older under follow-up in 21 centres, 42 pregnancies were reported in 30 women (19 women with a single pregnancy, 10 women with two pregnancies, and one woman with three pregnancies). Fifteen women (50%) had previous AIDS-defining diagnoses. The median age at first reported pregnancy was 18 years (range 14-22 years). Of the 42 pregnancies, 34 (81%) were reportedly unplanned, 31 (74%) involved regular partners, and in 21 (50%) of the 42 pregnancies the partners were reported to be unaware of maternal HIV status. Fifteen of the 42 pregnancies (36%) were electively terminated, six of the 42 (14%) resulted in first-trimester miscarriages and 21 of the 42 (50%) resulted in live births. Maternal viral load was detectable close to delivery in seven of 21 pregnancies (33%). Four infants required neonatal intensive care, three of whom were delivered preterm. One infant is HIV infected, there are ongoing concerns about the development of three of 21 infants (14%), and two of 21 (10%) have been fostered.

CONCLUSIONS

Despite access to ongoing sexual health and contraceptive services, unplanned pregnancies are occurring in young women growing up with HIV. Pregnancy care and prevention of onward transmission require complex case management for this emerging population.

Validation and automation of the DYNJAWS component module of the BEAMnrc Monte Carlo code

The purpose of this work is to validate and automate the use of DYNJAWS; a new component module (CM) in the BEAMnrc Monte Carlo (MC) user code. The DYNJAWS CM simulates dynamic wedges and can be used in three modes; dynamic, step-and-shoot and static. The step-and-shoot and dynamic modes require an additional input file defining the positions of the jaw that constitutes the dynamic wedge, at regular intervals during its motion. A method for automating the generation of the input file is presented which will allow for the more efficient use of the DYNJAWS CM. Wedged profiles have been measured and simulated for 6 and 10 MV photons at three field sizes (5 cm × 5 cm, 10 cm × 10 cm and 20 cm × 20 cm), four wedge angles (15°, 30°, 45° and 60°), at d (max) and at 10 cm depth. Results of this study show agreement between the measured and the MC profiles to within 3% of absolute dose or 3 mm distance to agreement for all wedge angles at both energies and depths. The gamma analysis suggests that dynamic mode is more accurate than the step-and-shoot mode. The DYNJAWS CM is an important addition to the BEAMnrc code and will enable the MC verification of patient treatments involving dynamic wedges.

Local heterogeneities in early batches of EBT2 film: a suggested solution

To enhance the utility of radiochromic films for high-resolution dosimetry of small and modulated radiotherapy fields, we propose a means to negate the effects of heterogeneities in EBT2 (and other) films. The results of using our simple procedure for evaluating radiation dose in EBT2 film are compared with the results of using the manufacturer's recommended procedure as well as a procedure previously established for evaluating dose in older EBT film. It is shown that Newton's ring-like scanning artefacts can be avoided through the use of a plastic frame, to elevate the film above the scanner's surface. The effects of film heterogeneity can be minimized by evaluating net optical density, pixelwise, as the logarithm of the ratio of the red-channel pixel value in each pixel of each irradiated film to the red-channel pixel value in the same pixel in the same film prior to irradiation. The application of a blue-channel correction was found to result in increased noise. It is recommended that, when using EBT2 film for radiotherapy quality assurance, the films should be scanned before and after irradiation and analysed using the method proposed herein, without the use of the blue-channel correction, in order to produce dose images with minimal film heterogeneity effects.