Exploring medicines reconciliation in the emergency assessment unit: staff perceptions and actual waiting times

Background Medicines reconciliation is the process of creating and maintaining the most accurate list possible of all medicines a patient is taking. If medicines reconciliation cannot be completed in a timely manner in hospital emergency assessment units (EAUs), delays in treatment can occur, potentially leading to deterioration of long-term and acute conditions, patient distress and complaints. Aim To obtain the perspectives of staff working on an EAU regarding the time patients wait for their medicines to be prescribed, including their awareness of practice and protocols. To determine the time from admission to the EAU until medicines reconciliation, and to identify if there was any time difference in medicines reconciliation according to the day of admission. Method This was a service evaluation in which staff working in one EAU in a teaching hospital in the north east of England were asked to complete a survey in December 2017. The staff survey aimed to ascertain: whether staff were aware of any guidance relating to medicines reconciliation times; how long they thought the average waiting time was for medicines reconciliation; and if they thought there were implications for patients or staff as a result of time spent waiting for medicines reconciliation. In addition, an audit was performed analysing medicines reconciliation times for all patients admitted to the EAU during the month of December 2017. Results A total of 30 staff members responded to the survey. While 40% (n=12) of respondents believed that the EAU had an efficient system in place for timely medicines reconciliation, 90% (n=27) believed the unit could still improve. Almost half the respondents (47%, n=14) perceived a delay in medicines reconciliation could result in exacerbation of patients’ physical conditions. The clinical audit identified considerable variation in medicines reconciliation times, ranging from seven minutes to almost 24 hours. However, most medicines (82%) were reconciled within six hours. Conclusion This service evaluation found that the median time after arrival in the EAU until completion of medicines reconciliation was two hours 48 minutes. However, almost one fifth of patients had to wait for more than six hours, and in one instance almost 24 hours. One potential solution could be increasing the involvement of hospital pharmacists or pharmacy technicians in medicines reconciliation

Primary Sjögren's syndrome: Longitudinal real-world, observational data on health-related quality of life

Introduction Primary Sjögren’s syndrome (pSS) is a chronic inflammatory condition, which presents with symptoms of dryness, pain, fatigue and often symptoms of anxiety and depression. Health related quality of life is significantly reduced in pSS and the direct and indirect health costs of pSS are substantial. This study aims to determine how symptom burden, disease activity and demographics associate with HRQoL longitudinally over a median of 24-month follow-up period in pSS. Methods Longitudinal EQ-5D-3L data from the Newcastle pSS cohort (n=377) were evaluated using a survival analysis strategy. Kaplan-Meier and Cox proportional hazards analysis were performed using baseline Newcastle Sjogren’s Stratification Tool (NSST) subgroup, EULAR Sjogren’s Syndrome Patient Reported Index (ESSPRI), EULAR Sjogren’s Syndrome Disease Activity Index (ESSDAI), disease duration, age, and sex as covariates including polypharmacy and comorbidity score, where data were available (n = 191). Results Of the 377 pSS participants analysed in this study 16% experienced a decline in HRQoL to a health state comparable to or worse than death. NSST subgroup and ESSPRI score had a significant relationship with time to ‘EQ-5D event’ whereas baseline ESSDAI, age, disease duration and sex did not. Conclusion In pSS symptom burden and to a great extent NSST subgroup, rather than systemic disease activity, has a significant relationship with HRQoL longitudinally. Improvements in symptom burden have the potential to produce significant impacts on long-term HRQoL in pSS

Adenosine metabolic signature in circulating CD4+ T cells predicts remission in rheumatoid arthritis

\ua9 Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.Objectives Long-term outcomes in rheumatoid arthritis (RA) depend on early and effective disease control. Methotrexate (MTX) remains the first-line disease modifying therapy, however there are no biomarkers with which to identify those most likely to achieve remission. To address this unmet need we explored metabolic pathways involved in MTX mechanism of action within circulating CD4+T cells in a cohort of treatment naive patients with early RA. Methods Purified CD4+T cells were isolated from peripheral blood of 68 patients with early RA commencing MTX. The expression of a range of putative MTX metabolism and mechanism of action targets were explored by flow-cytometry and transcriptional analysis. From these data significant predictors of Disease Activity Score 28-C reactive protein (DAS28-CRP) remission (<2.4 at 6 months) were determined by logistic regression (clinical; flow-cytometry data) and linear modelling (gene expression data). Results Low baseline DAS28-CRP was associated with remission at 6 months (p=0.02). Expression of the ectonucleotidase CD39, involved in ATP-ADP conversion during adenosine synthesis, was higher on CD4+CD25 High regulatory T cells at baseline in those achieving remission (molecules of equivalent fluorescence 1264 vs 847; p=0.007). Expression of other adenosine signalling elements in CD4+T cells were also upregulated at baseline in patients achieving remission: AMPD1 (p<0.001), ADORA2b (p=0.039) and ADORA3 (p=0.047). When combined into a single predictive metric, a combination of these variables outperformed baseline DAS28-CRP in prediction of early remission (area under the curve 0.92 vs 0.67, p=0.001) Conclusions Adenosine signalling is important in the achievement of early remission with MTX in RA and biomarkers of adenosine activity may hold utility for the stratification of therapy in early disease

Developing a service user informed intervention to improve participation and ability to perform daily activities in primary Sjögren’s syndrome: a mixed-methods study protocol

Introduction: A significant proportion of patients with primary Sjögren’s syndrome (PSS) is functionally impaired and experience difficulties participating in various aspects of everyday life. There is currently no evidence of efficacy for non-pharmacological interventions aimed specifically at supporting the patients with PSS to improve their participation and ability to perform daily activities. This paper describes a research protocol for a mixed-methods study to develop an intervention to improve these outcomes. The protocol follows the Medical Research Council framework for complex interventions. Methods and analysis: We will use group concept mapping with the patients, adults who live with them and healthcare professionals to identify factors which prevent people with PSS from participating in daily life and performing daily activities. The factors will be prioritised by participants for importance and feasibility and will inform an intervention to be delivered within a National Health Service (NHS) setting. Evidence-based intervention techniques will be identified for the prioritised factors and combined into a deliverable intervention package. Key stakeholders will comment on the intervention content and mode of delivery through focus groups, and the data will be used to refine the intervention. The acceptability and feasibility of the refined intervention will be evaluated in a future study. Ethics and dissemination: The study has been approved by an NHS Research Ethics Committee, REC Reference: 13/NI/0190. The findings of this study will be disseminated in peer-reviewed journals and through presentation at national and international conferences. Trial registration number: UKCRN Study ID: 15939

Patient Self-Testing of Kidney Function at Home, a Prospective Clinical Feasibility Study in Kidney Transplant Recipients

IntroductionPeople with long-term health conditions often attend clinics for kidney function tests. The Self-Testing Own Kidneys (STOK) study assessed feasibility of kidney transplant recipients using hand-held devices to self-test kidney function at home and investigated agreement between home self-test and standard clinic test results.MethodsA prospective, observational, single-center, clinical feasibility study (TRN: ISRCTN68116915), with N = 15 stable kidney transplant recipients, investigated blood potassium and creatinine results agreement between index self-tests at home (patient self-testing of capillary blood, using Abbott i-STAT Alinity analyzers [i-STAT]) and reference tests in clinic (staff sampled venous blood, analyzed with laboratory Siemens Advia Chemistry XPT analyzer) using Bland-Altman and error grid analysis.ResultsThe mean within-patient difference between index and reference test in creatinine was 2.25 μmol/l (95% confidence interval [CI]: −12.13, 16.81 μmol/l) and in potassium was 0.66 mmol/l (95% CI: −1.47, 2.79 mmol/l). All creatinine pairs and 27 of 40 (67.5%) potassium pairs were judged clinically equivalent. Planned follow-up analysis suggests that biochemical variables associated with potassium measurement in capillary blood were predominant sources of paired test result differences. Paired patient and nurse i-STAT capillary blood test potassium results were not statistically significantly different.ConclusionsThis small feasibility study observed that training selected patients to competently use hand-held devices to self-test kidney function at home is possible. Self-test creatinine results showed good analytical and clinical agreement with standard clinic test results. Self-test potassium results showed poorer agreement with standard clinic test results; however, patient use of hand-held devices to self-test at home was not a statistically significant source of paired potassium test result differences

Differential MicroRNA Expression Levels in Cutaneous Acute Graft-versus Host Disease

Allogeneic haematopoietic stem cell transplantation (allo-HSCT) is a curative treatment for numerous haematological malignancies. However, acute graft-versus-host disease (aGvHD) is a major complication affecting 40-70% of all transplant patients, whereby the earliest and most frequent presentation is in the skin. MicroRNAs play a role in varied biological process and have been reported as potential biomarkers for aGvHD. More recently, microRNAs have received added attention as circulatory biomarkers that can be detected in biofluids. In the present study we performed global microRNA expression profiling using a discovery cohort of diagnostic cutaneous aGvHD biopsies (n=5, stage 1-3) and healthy volunteers (n=4), in order to identify a signature list of microRNAs that could be used as diagnostic biomarkers for cutaneous aGvHD. Candidate microRNAs (n=8) were then further investigated in a validation cohort of post-HSCT skin biopsies (n=17) for their association with aGvHD. Expression of miR-34a-5p (p<0.001), miR-34a-3p (p=0.013), miR-503-5p (p=0.021) and let-7c-5p (p=0.037) was elevated in cutaneous aGvHD and significantly associated with survival outcome (miR-34a-3p ROC AUC=0.93, p=0.003, Log Rank p=0.004; miR-503-5p ROC AUC=0.83 p=0.021, Log Rank p=0.003). There was no association with relapse. A statistical interaction between miR-34a-3p and miR-503-5p (p=0.016) was diagnostic for aGvHD. Expression levels of the miR-34a-5p protein target p53 were assessed in the epidermis of the skin, and an inverse correlation was identified (r2=0.44, p=0.039). Expression of the validated candidate microRNAs was also assessed at day 28 post-HSCT in the sera of transplant recipients, in order to investigate their potential as circulatory microRNA biomarkers. Expression of miR-503-5p (p=0.001), miR-34a-5p (p=0.005) and miR-34a-3p (p=0.004) were significantly elevated in the sera of patients who developed aGvHD vs. no-aGvHD (n=30) and miR-503-5p was associated with overall survival (ROC AUC=0.80, p=0.04, Log Rank p=0.041). In conclusion, this investigation reports that microRNA expression levels in clinical skin biopsies, obtained at the time of cutaneous aGvHD onset, show potential as diagnostic biomarkers for aGvHD and as predictive biomarkers for overall survival. Additionally, the same microRNAs can be detected in the circulation and show predictive association with post-HSCT outcomes