Oxygen prescription and administration at the Emergency Department and medical wards in Mater Dei Hospital

Aims: The aim of this study was to audit current practices on oxygen prescription in the Emergency Department (ED), and on accurate oxygen administration in the wards of Mater Dei Hospital. Method: Two hundred and forty eight adult patients attending the ED with diagnoses most likely to require oxygen therapy (mainly cardio-respiratory conditions) were randomly selected during 5 winter weeks. Data were collected on oxygen saturation, arterial blood gases, oxygen administration at the ED, oxygen prescription and its documentation, and oxygen administration in wards. The z-test was used to assess statistical significance of results and Fisher’s exact test was used to determine the effect of oxygen prescription documentation in treatment charts. Results: Oxygen treatment was indicated in 85 of the 248 patients. Of these, documented oxygen administration at the ED was only present in 23.5% (p<0.0001). Formal instructions on oxygen use were documented in 85.9% (p<0.0001), however in 51.8% of these there were incomplete details. Only 7.1% of patients in whom oxygen treatment was prescribed received oxygen therapy in the wards according to instructions (p<0.0001). It was also found that documenting oxygen prescription in treatment charts made no significant difference to the number of patients who actually received oxygen correctly in the ward. Conclusion: This study shows that there is need for better prescription, documentation and administration of oxygen in our hospital. Introduction of simple standardized oxygen charts may ensure that oxygen prescription and monitoring in the ED is carried out properly and that these instructions are then faithfully carried out in our wards.peer-reviewe

Audit on follow-up of patients with primary Osteoporosis

Aim: To document the frequency of Dual-energy X- ray absorptiometry (DEXA) scanning and Rheumatology clinic follow-up visits of patients with primary osteoporosis, and compare these with recommended guidelines. Method: Medical notes of all primary osteoporotic patients attending a hospital Rheumatology clinic were reviewed over a period of four months. Data was collected on age, gender, frequency of follow up visits, frequency of DEXA scanning, osteoporosis treatment, any changes in such treatment during the last visit, and comparison of the last two DEXA scan results. Frequency of follow up DEXA scans was compared to Group Health Osteoporosis Screening Diagnosis and Treatment guidelines.1 Results: Eighty-two patients were included, 6 males (7.3%) and 76 females (92.7%). The age range was 35-87 years (mean age was 68.6 years). In total, 42.7% of all the patients were on combined calcium and vitamin D, with added Bisphosphonates, Strontium ranelate, or Denosumab. During their last clinic visit, 61% showed improvement in T score since their previous result, and 64.6% of patients had no change in treatment. In this audit, 29.3% were being followed up on a 13 monthly basis, and 72% had annual bone mineral density scans or more frequently Conclusion: According to the guidelines, none of the patients included in this audit should have had a repeat DEXA scan within less than two years. Patients attending the clinic have too frequent DEXA scans and therefore, too frequent follow up appointments.peer-reviewe

Predictors of seasonal influenza vaccination in chronic asthma

Background: Guidelines advise annual influenza vaccination in chronic asthma. The aim of this study was to determine uptake of the influenza vaccine in a group of patients (n = 146) with moderate to severe chronic asthma and establish the main predictors of vaccination. Method: Patients attending a hospital asthma clinic were asked to complete a questionnaire in February 2012 (n = 146). These same patients were contacted a year later via telephone (n = 109 responded), and they were asked to complete the same questionnaire. Results: Vaccination rate was 50.3% in winter 2011/12, and 57.8% in 2012/13. Using binary logistic regression, the predictors for vaccination in 2012 were patient advice (Odds ratio [OR] 15.37 p = 0.001), female gender (OR 2.75, p = 0.028), past side effects (OR 0.21, p = 0.001) and comorbidity (OR 0.39, p = 0.013). Stepwise regression resulted in age as predictor (T value = 3.99, p = 0.001). On analyzing the responses from the second questionnaire at one year after attendance to asthma clinic, predictors changed to compliance to medication (OR 9.52, p= 0.001) and previous exacerbations (OR 4.19, p = 0.026). Out of the 56 patients vaccinated in 2011/12, 33 reported asthma exacerbations before 2012, and 29 reported asthma exacerbations after receiving the influenza vaccine. Out of the 46 unvaccinated patients in 2012, 27 had asthma exacerbations before 2012 and 19 patients had exacerbations in 2013. Patients vaccinated in 2011/12 needed 0.59 courses of steroid/patient/year, and 1.23 visits for nebulizer/patient/year while non-vaccinated patients needed 0.18 courses of steroids/patient/year (p = 0.048), and 0.65 visits for nebulized/patient/year (p = 0.012). Patients’ subjective statements broadly confirmed the predictors. 16/69 (23.1%) received the vaccine in winter 2012/13 despite reporting previous side effects. Conclusions: Advice to patient, female gender and patients’ age predicted vaccination, while past side effects to the influenza vaccine, and presence of comorbidities predicted non vaccination. Symptomatic asthma patients are more likely to be vaccinated. One year after the first contact, treatment compliance and previous asthma exacerbations gained statistical significance as predictors of vaccination.peer-reviewe

A rare case of pulmonary alveolar microlithiasis

A 47-year-old asymptomatic man with no significant family history was referred to our faculty because of an abnormal chest X-ray (CXR). The CXR, similar to his CXR 10 years previously, showed bilaterally increased interstitial markings suggestive of pulmonary fibrosis. High-resolution CT (HRCT) showed multiple bilateral branching calcifications, mostly in the lung bases (figures 1 and 2), with ground-glass opacities in the lingula, and no enlarged mediastinal lymph nodes. A repeat HRCT after 4 months remained similar. After discussion at a multidisciplinary team meeting, a diagnosis of pulmonary alveolar microlithiasis (PAM) was reached.peer-reviewe

The effect of a hospital oxygen therapy guideline on the prescription of oxygen therapy

Aim: To assess the effect of a hospital oxygen therapy guideline on oxygen prescription and administration at the emergency Department (ED) and medical wards of Mater Dei Hospital, Malta. Methods: Patients admitted to medical wards through the ED with conditions most likely to require oxygen therapy were recruited over 2 months in 2011. Data was collected on oxygen therapy prescription and administration. A hospital guideline on oxygen therapy was introduced and disseminated in 2015, following which data was collected again and compared to the 2011 data. A p value <0.05 was deemed to be statistically significant. Results: 248 and 293 patients were recruited in 2011 and 2015 respectively. Oxygen therapy was indicated in 34.3% and 31.4% of patients respectively (p=0.47). Oxygen saturation on air was not documented in 14.1% (2011) and 4.4% (2015) (p<0.01). In patients in whom oxygen therapy was indicated, correct documentation (including delivery device and flow rate) of oxygen therapy administered at ED improved from 23.5% to 73.9% (p<0.01), and correct oxygen therapy prescription in the management plan improved from 34.1% to 76.1% (p<0.01). In the medical wards, correct oxygen therapy administration according to prescription improved from 7.1% to 48.9% (p<0.01). 56.8% of patients in whom oxygen therapy was not indicated were prescribed oxygen anyway in 2011, improving to 27.1% after the guideline (p<0.05). Conclusion: Oxygen saturation, oxygen therapy prescription and documentation at the ED and oxygen therapy administration in the medical wards improved significantly at Mater Dei hospital, Malta, after a hospital guideline was introduced.peer-reviewe

The effect of a hospital oxygen therapy guideline on the prescription of oxygen therapy

Aim: To assess the effect of a hospital oxygen therapy guideline on oxygen prescription and administration at the emergency Department (ED) and medical wards of Mater Dei Hospital, Malta. Methods: Patients admitted to medical wards through the ED with conditions most likely to require oxygen therapy were recruited over 2 months in 2011. Data was collected on oxygen therapy prescription and administration. A hospital guideline on oxygen therapy was introduced and disseminated in 2015, following which data was collected again and compared to the 2011 data. A p value <0.05 was deemed to be statistically significant. Results: 248 and 293 patients were recruited in 2011 and 2015 respectively. Oxygen therapy was indicated in 34.3% and 31.4% of patients respectively (p=0.47). Oxygen saturation on air was not documented in 14.1% (2011) and 4.4% (2015) (p<0.01). In patients in whom oxygen therapy was indicated, correct documentation (including delivery device and flow rate) of oxygen therapy administered at ED improved from 23.5% to 73.9% (p<0.01), and correct oxygen therapy prescription in the management plan improved from 34.1% to 76.1% (p<0.01). In the medical wards, correct oxygen therapy administration according to prescription improved from 7.1% to 48.9% (p<0.01). 56.8% of patients in whom oxygen therapy was not indicated were prescribed oxygen anyway in 2011, improving to 27.1% after the guideline (p<0.05). Conclusion: Oxygen saturation, oxygen therapy prescription and documentation at the ED and oxygen therapy administration in the medical wards improved significantly at Mater Dei hospital, Malta, after a hospital guideline was introduced.peer-reviewe

Predictors of correct technique in patients using pressurized metered dose inhalers

Background: Correct inhaler technique is recommended by guidelines for optimum asthma care. The objective of the study is to determine real life predictors of correct pressurized metered dose inhaler (pMDI) technique in Asthma and COPD patients. Methods: Two hundred eight adult patients aged 18+ from respiratory outpatients (69.2%) and the community on regular pMDI for a diagnosis of Asthma (78.9%) or COPD, were recruited. A questionnaire containing 31 possible predictors was administered and pMDI technique with or without spacer was observed by trained researchers on 12 point steps, of which 4 were considered critical. Results: 23.1% of patients had no errors in inhaler technique and 32.2% had no critical errors. Patients had a median of 10 correct steps (IQR9-11), and 3(IQR2-4) correct critical steps. Using binary logistic regression the predictors of 10 correct steps were, other healthcare professional (pharmacist, nurse, physiotherapist) explained OR 3.73(1.63–8.54, p = 0.001), male gender 2.70(1.35–5.39, p = 0.004), self-score 1–10 1.21(1.05–1.39, p = 0.007), spacer use 0.38(0.19–0.79, p = 0.007), inhaled steroid 3.71(1.34–10.25, p = 0.01), heart disease 0.31(0.13–0.77, p = 0.01), pneumococcal vaccine 2.48(1.0–6.15, p = 0.043), education level 1–4 1.44(1.00–2.06, p = 0.05) and respiratory physician explained 0–7 times, 1.11(0.99–1.26, p = 0.08). Using ordinal logistic regression, predictors for correct critical steps 0–4, were: technique self-score 1–10 1.2(1.05–1.42, p = 0.006), inhaled corticosteroid use 2.78(1.1–7.31, p = 0.03) and education level 1–4 1.41(1.02–1.95, p = 0.03 Times respiratory physician explained inhaler technique 0–7 1.1(0.98–1.24, p = 0.1), married status 1.55(0.85–2.82, p= 0.15), hypercholesterolaemia 0.52(0.25–1.01, p = 0.054) and male gender 1.76(0.97–3.18, p = 0.06). Conclusions: Known predictors of correct pMDI use, such as gender and education level were confirmed, while age and concomitant use of dry powder inhaler were not. Pneumococcal vaccination and awareness of steroid side effects were possible novel positive predictors, while the use of a spacer and co-morbidity with heart disease were found to be negative predictors. Patients’ self-assessment correlated well with actual performance. This information may be useful in defining approaches to optimize inhaler techniques which are so susceptible to human error.peer-reviewe

The impact of COVID-19 on hospitalised COPD exacerbations in Malta

Introduction and Aims. The first COVID-19 case in Malta was confirmed on the 7th of March 2020. This study is aimed at investigating a significant difference between the number of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) admissions and their inpatient outcome at Mater Dei Hospital during the COVID-19 pandemic when compared to the same period in 2019. Furthermore, we aim to determine predictors of mortality in AECOPD inpatients. Method. Data was collected retrospectively from electronic hospital records during the periods 1st March until 10th May in 2019 and 2020. Results. There was a marked decrease in AECOPD admissions in 2020, with a 54.2% drop in admissions (n = 119 in 2020 vs. n = 259 in 2019). There was no significant difference in patient demographics or medical comorbidities. In 2020, there was a significantly lower number of patients with AECOPD who received nebulised medications during admission (60.4% in 2020 vs. 84.9% in 2019; p ≤ 0:001). There were also significantly lower numbers of AECOPD patients admitted in 2020 who received controlled oxygen via venturi masks (69.0% in 2020 vs. 84.5% in 2019; p = 0:006). There was a significant increase in inpatient mortality in 2020 (19.3% [n = 23] and 8.4% [n = 22] for 2020 and 2019, respectively, p = 0:003). Year was found to be the best predictor of mortality outcome (p = 0:001). The lack of use of SABA pre-admission treatment (p = 0:002), active malignancy (p = 0:003), and increased length of hospital stay (p = 0:046) were also found to be predictors of mortality for AECOPD patients; however, these parameters were unchanged between 2019 and 2020 and therefore could not account for the increase in mortality. Conclusions. There was a decrease in the number of admissions with AECOPD in 2020 during the COVID-19 pandemic, when compared to 2019. The year 2020 proved to be a significant predictor for inpatient mortality, with a significant increase in mortality in 2020. The decrease in nebuliser and controlled oxygen treatment noted in the study period did not prove to be a significant predictor of mortality when corrected for other variables. Therefore, the difference in mortality cannot be explained with certainty in this retrospective cohort study.peer-reviewe

Management of solitary fibrous tumours of the pleura:a systematic review and meta-analysis

Background:Solitary fibrous tumours of the pleura (SFTP), or pleural fibromas, are rare tumours that generally, but not universally, follow a benign course. Surgical resection is the standard treatment, but there are no evidence-based guidelines regarding the management of these tumours. Methods:Five databases were searched from inception to April 1, 2019 for studies reporting on SFTP management. Results:Twenty-seven studies met the inclusion criteria (1542 patients, all non-comparative case series); 98% of these patients underwent resection and all SFTP included were pathologically diagnosed. 394 out of 1299 cases (30.5%, 95% CI 27.8-32.8%) were malignant with recurrence rates of between 0% and 42.9%. A pleural effusion was always associated with a negative outcome, but no other features were consistently reported to have negative associations. Preoperative biopsies incorrectly reported malignant histology in two studies. Over 25% of cases of recurrence occurred when a complete (R0) resection had been achieved. The first recurrence occurred >5 years after the initial resection in at least 23% of cases. Conclusions:There is strong evidence to support long-term surveillance after surgical resection of SFTP, even where a complete (R0) resection has been achieved; however, there is no clear evidence to inform clinicians regarding the selection of patients who should undergo resection. The rates of malignant SFTP and SFTP recurrence are higher than previously reported. Only those that were pathologically diagnosed or resected were included, which may bias the data towards more aggressive tumours. Data collection on radiologically diagnosed SFTP is required to draw conclusions regarding the timing and need for intervention

Critical analysis of the utility of initial pleural aspiration in the diagnosis and management of suspected malignant pleural effusion

INTRODUCTION:Current guidelines recommend an initial pleural aspiration in the investigation and management of suspected malignant pleural effusions (MPEs) with the aim of establishing a diagnosis, identifying non-expansile lung (NEL) and, at times, providing a therapeutic procedure. A wealth of research has been published since the guidelines suggesting that results and outcomes from an aspiration may not always provide sufficient information to guide management. It is important to establish the validity of these findings in a 'real world' population. METHODS:A retrospective analysis was conducted of all patients who underwent pleural fluid (PF) sampling, in a single centre, over 3 years to determine the utility of the initial aspiration. RESULTS:A diagnosis of MPE was confirmed in 230/998 (23%) cases, a further 95/998 (9.5%) were presumed to represent MPE. Transudative biochemistry was found in 3% of cases of confirmed MPE. Positive PF cytology was only sufficient to guide management in 45/140 (32%) cases. Evidence of pleural thickening on CT was associated with both negative cytology (&#x3C7;2 1df=26.27, p&lt;0.001) and insufficient samples (&#x3C7;2 1df=10.39, p=0.001). In NEL 44.4% of patients did not require further procedures after pleurodesis compared with 72.7% of those with expansile lung (&#x3C7;2 1df=5.49, p=0.019). In patients who required a combined diagnostic and therapeutic aspiration 106/113 (93.8%) required further pleural procedures. CONCLUSIONS:An initial pleural aspiration does not achieve either definitive diagnosis or therapy in the majority of patients. A new pathway prioritising symptom management while reducing procedures should be considered