Systematic review of latent tuberculosis infection research to inform programmatic management in Ireland

 The World Health Organisation (WHO) End Tuberculosis (TB) Strategy and the WHO Framework Towards Tuberculosis Elimination in Low Incidence Countries state that latent tuberculosis infection (LTBI) screening and treatment in selected high-risk groups is a priority action to eliminate TB. The European Centre for Disease Prevention and Control (ECDC) advises that this should be done through high-quality programmatic management, which they describe as having six key components. The research aim was to systematically review the literature to identify what is known about the epidemiology of LTBI and the uptake and completion of LTBI screening and treatment in Ireland to inform the programmatic management of LTBI nationally. A systematic literature review was performed according to a review protocol and reported in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Twenty-eight studies were eligible for inclusion and described LTBI screening or treatment performed in one of five contexts, pre-biologic or other immunosuppression screening, people living with HIV, TB case contacts, other vulnerable populations, or healthcare workers. The risk of bias across studies with regard to prevalence of LTBI was generally high. One study reported a complete cascade of LTBI care from screening initiation to treatment completion. This systematic review has described what published research there is on the epidemiology and cascade of LTBI care in Ireland and identified knowledge gaps. A strategy for addressing these knowledge gaps has been proposed. </p

A feasibility assessment of an ambulatory care pathway for cellulitis at a tertiary referral centre in the Republic of Ireland.

IntroductionThere is a need for the development of more ambulatory care pathways to reduce the number of bed-days utilized by ambulatory care sensitive conditions in hospitals in Ireland. Healthcare policy and strategy has changed to reflect this. Our aim was to determine if an ambulatory care pathway for the management of cellulitis would be feasible in our tertiary referral centre.MethodsWe searched hospital coding data to identify all admissions with cellulitis from 1/1/2018 to 31/12/2018 in our tertiary referral centre. We estimated the cost of cellulitis admissions using guidelines from the Healthcare Pricing Office in Ireland. We used guidance from the Department of Public Expenditure and Reform to calculate the cost of staff in a proposed ambulatory care model.ResultsWe identified 249 episodes of care with cellulitis in 2018. 89.6% (223/249) were emergency episodes of care. A total of 2372 bed-days was utilized by emergency episodes of care at a cost of €1,126,369–1,129,823. The median cost of an emergency episode of care due to cellulitis was €2291 (IQR 2291–5594) with a mean cost per bed-day of €475–476. Overall, there was neither sepsis nor a surgical intervention coded in 85.2% (190/223) of emergency episodes of care. We identified a cohort of 23.8% (53/223) of emergency episodes of care that had a length of stay of 1–3 days which could potentially have been managed using an ambulatory care pathway.ConclusionEven if only a small proportion of cases were ambulated there are significant savings in terms of bed-days and costs to be made. An ambulatory care pathway for cellulitis should be established in our tertiary referral centre and this methodology could be used to inform resourcing of pathways elsewhere.</div

World Tuberculosis Day 2020: It’s time

The 24th of March was chosen as World Tuberculosis Day to raise public awareness about the disease. It is also the day Robert Koch announced his discovery of the Mycobacterium bacillus as the cause of tuberculosis (TB) in 1882. Latent tuberculosis infection (LTBI) is a state of persistent immune response to stimulation by Mycobacterium tuberculosis antigens with no evidence of clinically manifest active disease. The incidence of tuberculosis disease in Ireland is now low at 6.6/100,000 population. The World Health Organisation (WHO) has set the goal of a 90% reduction in global TB incidence by 2035 when compared to 2015. Unless improvements in TB prevention and control are made in Ireland it is unlikely we will achieve this target. The WHO End TB Strategy states that the systematic identification and management of LTBI in groups of people at high risk of reactivation is an essential part of TB elimination in low-incidence countries. The Health Protection Surveillance Centre (HPSC) Guidelines for the Prevention and Control of TB 2010 recommend the screening of people living with HIV, persons on immunosuppressive therapy, healthcare workers, people who use intravenous drugs, people who are homeless and people from countries with a high incidence of TB.</p

A survey of latent tuberculosis screening and treatment practices in a tertiary centre

Aim  Knowledge of latent tuberculosis infection (LTBI) screening and treatment practices are lacking in Ireland, where LTBI is not programmatically surveyed or managed. The aim of this research was to describe current clinical practice when screening and treating patients for LTBI in a tertiary referral centre in Ireland.  Methods  A 17-question survey relating to LTBI screening and management practices with both open-ended questions and close ended multiple-choice questions was created using SurveyMonkey. The survey target sample was healthcare workers in the tertiary centre who direct LTBI screening and treatment for patients at risk of TB disease in their respective departments.  Results  The response rate to the survey was 45% (21/47). Seventy-one percent (15/21) of those surveyed responded to the question “What barriers exist to screening patients for latent TB in your clinical practice?”. Fifty-three percent (8/15) said that they found it difficult to access LTBI testing and 27% (4/15) cited accessing the interferon-gamma release assay (IGRA) result as a barrier. Forty-three percent (9/21) responded that there was not a clear referral pathway for patients that they would like specialist input on when diagnosing and managing patients with LTBI.  Conclusion  Access to LTBI testing, LTBI test results, TB specialist services and the use of rifamycin-based regimens should be improved in this tertiary centre. Consideration should be given to developing a national LTBI education programme for healthcare professionals and updating national LTBI treatment guidelines.</p

A new tool for the assessment and improvement of clinical record keeping

A Patient Medical Record is a legally binding document and remains a core element in the continuity of patient care. We feel that not enough emphasis is placed on the importance of high-quality note taking in Irish hospitals. During the course of my intern year in a busy tertiary-referral hospital, one of the most notable difficulties I have found has been making good clinical assessments and decisions for patients about whom the patient medical record has not clearly summarized the reason for admission, clinical course and current issues. This is particularly relevant during on-call shifts, where the patients are often not known to the medical staff on duty.</p

COVID-19 contamination of high-touch surfaces in the public domain

The virus that causes COVID-19 disease (SARS-CoV2) is a major global threat to public health, with mortality and serious morbidity rates of up to 5 and 15%, respectively [1, 2]. It is also very damaging to the global economy. The virus can be transmitted by airborne spread or by direct contact with contaminated surfaces [3, 4]. It is thus crucial to determine if high-touch public surfaces are contaminated. This could have important public health implications by identifying contaminated surfaces and reinforcing the important public health messages regarding hand hygiene, especially in children. In this project, we focused on playground equipment in public spaces, public toilet surfaces and buttons at pedestrian crossings throughout Dublin because these are high-touch public surfaces that may contribute to the spread of the virus. </p

Outpatient parenteral antimicrobial therapy (OPAT) for aortic vascular graft infection; a five-year retrospective evaluation

Objectives: An estimated 1% of endovascular aneurysm repair (EVAR) devices become infected, carrying a high mortality rate. Surgical explantation is recommended and prognosis is guarded. This retrospective cohort analysis focuses on the role of outpatient parenteral antimicrobial therapy (OPAT) in the management of aortic vascular graft infections following EVAR. Methods: Patients who received OPAT for aortic graft infections (AGI) following EVAR from 2014 to 2018 inclusive were identified using the OPAT database. Clinical, microbiological and radiological data were collected. Survivors were followed up for a median of 36 months (range 25-60) after first presentation with infection. Outcomes were assessed. Results: Eleven cases with 20 OPAT episodes were identified: 10/11 male, median age 76 (IQR 71-81). Median time to presentation was 7 months (range 0-81 months) after EVAR. OPAT lead to a 55% reduction in length of hospital stay. One patient had graft explantation; four others had temporising measures. Eight of 11 were alive a median of 36 months after presentation with infection, having had a median of 2 re-treatments on OPAT (range 1-3). Seven of the eight survivors were on continuous suppressive oral antimicrobials; three were also intermittently on intravenous antibiotics for flares of infection. Patient/ infection outcomes were cure (1/11), improved (7/11), failure (3/11). Conclusion: AGI following EVAR usually presents in the first year after graft deployment. OPAT has an important peri-operative role in patients suitable for curative surgery. OPAT followed by oral suppressive antimicrobial therapy can be a feasible long-term treatment for non-curative management of AGI. Survival in our cohort was longer than expected, and OPAT was feasible despite the complexity of these infections. OPAT can avoid multiple and lengthy hospital admissions and maximise time at home and quality of life in this cohort with life-limiting infection.</p

Readability of online COVID-19 health information: a comparison between four English speaking countries

Background: The internet is now the first line source of health information for many people worldwide. In the current Coronavirus Disease 2019 (COVID-19) global pandemic, health information is being produced, revised, updated and disseminated at an increasingly rapid rate. The general public are faced with a plethora of misinformation regarding COVID-19 and the readability of online information has an impact on their understanding of the disease. The accessibility of online healthcare information relating to COVID-19 is unknown. We sought to evaluate the readability of online information relating to COVID-19 in four English speaking regions: Ireland, the United Kingdom, Canada and the United States, and compare readability of website source provenance and regional origin.Methods: The Google® search engine was used to collate the first 20 webpage URLs for three individual searches for 'COVID', 'COVID-19', and 'coronavirus' from Ireland, the United Kingdom, Canada and the United States. The Gunning Fog Index (GFI), Flesch-Kincaid Grade (FKG) Score, Flesch Reading Ease Score (FRES), Simple Measure of Gobbledygook (SMOG) score were calculated to assess the readability.Results: There were poor levels of readability webpages reviewed, with only 17.2% of webpages at a universally readable level. There was a significant difference in readability between the different webpages based on their information source (p Conclusion: Much of the general public have relied on online information during the pandemic. Information on COVID-19 should be made more readable, and those writing webpages and information tools should ensure universal accessibility is considered in their production. Governments and healthcare practitioners should have an awareness of the online sources of information available, and ensure that readability of our own productions is at a universally readable level which will increase understanding and adherence to health guidelines.</div

Genomic evidence of SARS-CoV-2 reinfection in Ireland

Presentation  A 40-year-old healthcare worker (HCW) presented with cough, headache, sore throat, fatigue and myalgia seven months after primary infection with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Symptoms were milder and recovery was faster on the second episode.  Diagnosis  Reinfection with phylogenetically distinct SARS-CoV-2 was confirmed by whole-genome sequencing (WGS).  Treatment  Management involved symptomatic treatment and self-isolation.  Discussion  The incidence of SARS-CoV-2 reinfection is not well characterised. Infection control precautions may still be required in healthcare facilities, even in previously infected and possibly in vaccinated individuals while SARS-CoV-2 remains in circulation. Further research on the nature and duration of immunity is required to inform public health and infection control policy.</p

Online search trends influencing anticoagulation in patients with COVID-19: observational study

Background: Early evidence of COVID-19-associated coagulopathy disseminated rapidly online during the first months of 2020, followed by clinical debate about how best to manage thrombotic risks in these patients. The rapid online spread of case reports was followed by online interim guidelines, discussions, and worldwide online searches for further information. The impact of global online search trends and online discussion on local approaches to coagulopathy in patients with COVID-19 has not been studied.Objective: The goal of this study was to investigate the relationship between online search trends using Google Trends and the rate of appropriate venous thromboembolism (VTE) prophylaxis and anticoagulation therapy in a cohort of patients with COVID-19 admitted to a tertiary hospital in Ireland.Methods: A retrospective audit of anticoagulation therapy and VTE prophylaxis among patients with COVID-19 who were admitted to a tertiary hospital was conducted between February 29 and May 31, 2020. Worldwide Google search trends of the term "COVID-19" and anticoagulation synonyms during this time period were determined and correlated against one another using a Spearman correlation. A P value of Results: A statistically significant Spearman correlation (PConclusions: We described a correlation of local change in clinical practice with worldwide online dialogue and digital search trends that influenced individual clinicians, prior to the publication of formal guidelines or a local quality-improvement intervention.</p