scholarly journals P18 Audit on pre-methotrexate screening in a paediatric rheumatology centre

Rheumatology ◽  
2019 ◽  
Vol 58 (Supplement_4) ◽  
Author(s):  
Rebecca Foster ◽  
Samundeeswari Deepak ◽  
Kishore Warrier ◽  
Satyapal Rangaraj ◽  
Nikki Camina
Keyword(s):  
Conflicts Of Interest ◽  
Digital Health ◽  
Routine Practice ◽  
Nurse Specialist ◽  
Health Records ◽  
Clinical Nurse ◽  
Risk Patients ◽  
Lost To Follow Up ◽  
Positive Results

Abstract Background The BSPAR section council consensus-based guidance is the most widely used guideline on the use of methotrexate. This recommends that varicella immunity status is checked prior to commencing methotrexate and to consider immunisation if the child is non-immune. It also suggests considering checking measles status and testing for TB in high risk patients. We aim to evaluate our practice of screening paediatric rheumatological patients prior to commencing them on methotrexate. All patients in our centre have methotrexate teaching with a clinical nurse specialist prior to commencing treatment. Methods This study included paediatric patients who were prescribed methotrexate in all forms (subcutaneous, intravenous and orally) for rheumatological conditions and uveitis during a 2-year period (2016 – 2018) regardless of when it was first commenced. Digital health records were accessed to obtain the data retrospectively. Patients were excluded if they had been started on methotrexate prior to joining our centre, or were lost to follow up during the study period or if the required data was unavailable. Results 123 patients were identified to have been prescribed methotrexate during the 2-year study period and 102 patients were included in the study. 28 patients were commenced on methotrexate during 2016 /17 and others were commenced anytime between 2008 -2015. 91 (89%) patients had their varicella status checked prior to commencing methotrexate and 7 patients were checked after treatment was commenced. It was not checked in 4 patients (1 sample rejected and not repeated). Of those checked 20 patients were non-immune and 16 were vaccinated. 57 patients had had measles serology checked, 31 of these prior to commencing methotrexate. 35 patients had TB Quantiferon checked prior to methotrexate being started and 39 after. There were no positive results and 6 (8%) indeterminate of which 5 were repeated and 4 were negative. Of the indeterminate results 4 samples were taken prior to commencing methotrexate and 2 after. Conclusion This study shows that local adherence to checking varicella status prior to commencing methotrexate and vaccinating non-immune patients is good. Routine practice for checking measles, hepatitis and TB is varied. The data was captured over a 2-year period but actually included practice of methotrexate commencement over 9 years and thus time span and change in doctors will have contributed to the variation in practice. We believe some results from outreach clinics were not captured. All four tests are often carried out if it is felt the patient is likely to go on to require biologics. An updated guideline would help streamline the pre-DMARD screening and may limit the number of unnecessary investigations. Conflicts of Interest The authors declare no conflicts of interest.

scholarly journals Number of Biopsies in Diagnosing Pulmonary Nodules

2010 ◽  
Vol 4 ◽  
pp. CCRPM.S4816 ◽  
Author(s):  
M. Wehrschuetz ◽  
E. Wehrschuetz ◽  
H.R. Portugaller
Keyword(s):  
Benign Lesion ◽  
Pulmonary Nodules ◽  
Ct Guided ◽  
Biopsy Needle ◽  
Pulmonary Lesions ◽  
Introducer Needle ◽  
Lost To Follow Up ◽  
Work Up ◽  
Positive Results

Purpose To determine the number of specimens to be obtained from pulmonary lesions to get the highest possible accuracy in histological work-up. Materials and methods A retrospective evaluation (January 1999 to April 2004) covered 260 patients with thoracic lesions who underwent computer tomography (CT)-guided core-cut biopsy in coaxial technique. All biopsies were performed utilizing a 19 gauge introducer needle and a 20 gauge core-cut biopsy needle. In all, 669 usable biopsies were taken (from 1-5 biopsies in each setting). The specimens were marked sequentially and each biopsy was worked up histologicaly. The biopsy results were correlated to histology after surgery, clinical follow-up or autopsy. The number of biopsies was determined that is necessary to achieve the highest possible accuracy in diagnosing pulmonary lesions. Results In 591 of 669 biopsies (88.3%), there were correct positive results. The overall accuracy was 87.4%. In 193 of 260 (74.2%) patients, a suspected malignancy was confirmed. In 50 of 260 (19.2%) patients, a benign lesion was correctly diagnosed. Seventeen (6.5%) patients were lost to follow-up. The first, second and third biopsies had cumulative accuracies of 63.6%, 89.2% and 91.5%, respectively ( P < 0.02). More biopsies did not show any higher impact on accuracy. Conclusion For the highest possible accuracy in diagnosing pulmonary lesions by CT-guided core-cut biopsy, at least three usable specimens are recommended to be taken.

A new approach to managing follow-up patients with sino-nasal disorders: the rhinology panel

2020 ◽  
Vol 26 (3) ◽  
pp. 88-93
Author(s):  
Abdulaziz Abushaala ◽  
Helen Sargent ◽  
Jennifer McLean ◽  
Deborah Grech-Marguerat ◽  
Hisham Khalil
Keyword(s):  
Patient Safety ◽  
Waiting List ◽  
Nurse Specialist ◽  
Review Panel ◽  
Clinical Nurse ◽  
New Approach ◽  
Specialist Registrar ◽  
Face To Face ◽  
Clinical Records

Background/aims There is a growing backlog of patients with sino-nasal disorders waiting for a follow-up appointment. This study aimed to identify rhinology patients on the outpatient follow-up list who could be removed from the waiting list for a face to face follow-up appointment and instead either given a phone consultation by a clinical nurse specialist or discharged from the service. Methods The clinical records of patients on the waiting list for a follow-up appointment at a nasal disorders clinic were reviewed by a panel comprising a consultant rhinologist, a rhinology fellow, a specialist registrar and two nurse specialists. Results A total of 300 clinical records of patients on the follow-up list of the Rhinology clinic were identified, of which 253 were found to have a sino-nasal disorder. Of these, 137 patients (54%) were discharged from the rhinology face to face follow-up clinics, while 116 patients (46%) were given face to face review appointments. Conclusions A multi-professional rhinology review panel is an effective way of managing the waiting list of an outpatient rhinology clinic and providing nurse-led telephone consultations could decrease the strain on resources while maintaining patient safety.

scholarly journals 099 Do clinical nurse specialist led stroke follow-up clinics reduce post-stroke hospital readmissions and recurrent vascular events?

2019 ◽  
Vol 90 (e7) ◽  
pp. A32.2-A32
Author(s):  
Alex Kao ◽  
Jeremy Lanford ◽  
Lai-Kin Wong ◽  
Anna Ranta
Keyword(s):  
Hospital Readmission ◽  
Readmission Rate ◽  
Clinical Nurse Specialist ◽  
Vascular Event ◽  
Nurse Specialist ◽  
Vascular Events ◽  
Clinical Nurse ◽  
One Year ◽  
The One

IntroductionPost-discharge stroke follow-up clinics have been associated with improved outpatient care and reduced readmission. Pre-2014 there was no consistent follow-up care offered at Wellington Hospital. Our aim was to determine whether the establishment of a clinical nurse specialist (CNS) follow-up clinic reduced the readmission 12-monthrate.MethodsThis is a sequential comparison of patient admitted with stroke one year prior and one year after the clinic was established in 2013. The primary outcome was hospital 12-month hospital readmission rate; main secondary outcome was recurrent vascular event. Patients were identified from the hospital discharge records and underwent detailed electronic chart review. Results were adjusted for differences in baseline characteristics.ResultsWe identified 874 patients; 439 pre- and 435 post-nurse clinic implementation. There was no significant difference between the one-year readmission rate after the establishment of the stroke follow up clinic (adjusted OR=1.06; 95% CI, 0.85–1.64; p=0.804) and no difference in recurrent composite vascular events at one-year (adjusted OR=1.20; 95% CI, 0.68–2.11; p=0.528). The median (IQR) time to follow-up to clinic after discharge was 85 (63–98.5) days. There was a trend towards a reduction in vascular events when limiting the analysis to patients who actually attended clinic, but this trend disappeared when adjusting for baseline inter-group differences.ConclusionsThere was no reduction in the one-year hospital readmission or vascular event recurrence rate for patients with stroke following the establishment of a nurse specialist led stroke follow up clinic. Earlier timed follow-up and the psychosocial value offered by these clinics requires further evaluation.

Risk of Thromboembolic Events in ET and Early/Prefibrotic PMF: The Relevance of an Accurate Histological Diagnosis

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 1735-1735
Author(s):  
Serena Rupoli ◽  
Gaia Goteri ◽  
Picardi Picardi ◽  
Lucia Canafoglia ◽  
Giorgia Micucci ◽  
...  
Keyword(s):  
Risk Factors ◽  
Conflicts Of Interest ◽  
Myeloproliferative Neoplasm ◽  
Primary Myelofibrosis ◽  
Vascular Events ◽  
Bone Marrow Trephine Biopsy ◽  
Increased Risk ◽  
Risk Patients ◽  
Early Primary

Abstract Abstract 1735 Background: Essential Thrombocytemia (ET) is a myeloproliferative neoplasm characterized by increased risk of vascular events. Established thrombosis risk factors are age and previous vascular events. The clinical and prognostic relevance of WHO histologic criteria for ET and prefibrotic/early Primary Myelofibrosis (PMF) has been well recognized. Our aim was to evaluate the correlation between histologic interpretation and vascular events in our series of thrombocytemias. Material and methods: From our files, we retrieved all patients consecutively diagnosed as having ET with complete clinical data (N = 283) who had undergone to a bone marrow trephine biopsy before any treatment at or within 1 year of diagnosis (N= 133). The histologic slides were reviewed in order to separate true ET cases from early/prefibrotic PMF; vaso-occlusive events at diagnosis and in the follow-up were than compared in the two groups. Results: Histologic review reclassified 61 cases as ET and 72 cases as prefibrotic/early PMF. Prefibrotic/early PMF showed a significant higher prevalence of thrombosis history and thrombotic events at diagnosis, and an increased leukocyte count than ET (22% vs 8%, 15.2% vs 1.6%, 8389/mmc vs 7500/mmc, respectively); furthermore, venous thromboses (mainly atypical) were relatively common in PMF, as opposed to WHO-defined ET. During follow-up, patients with prefibrotic PMF, although younger, showed a significant higher risk of developing thrombosis: the 15-year risk of thrombosis was 48% in prefibrotic PMF (grade 0), 16% in early PMF (grade 1, 2) and 17% in ET. Multivariate analysis confirmed that age and histopathology are independent risk factors for thrombosis during follow-up. Patients older than 60 or with prefibrotic PMF are high risk patients whereas those younger and with non prefibrotic PMF or ET should be considered at low risk (20-year risk of thrombosis 47% vs 4%, p=0.005). Conclusion: The results of present study indicate prefibrotic PMF as a myloproliferative neoplasm with the highest tendency to develop vascular events compared to early PMF and ET. Therefore we suggest to include histopathology interpretation in the risk stratification of so-called ET patients. Disclosures: No relevant conflicts of interest to declare.

scholarly journals A Health Records Review of Outpatient Referrals from the Emergency Department

2019 ◽  
Vol 2019 ◽  
pp. 1-7
Author(s):  
Nicholas Prudhomme ◽  
Edmund S. H. Kwok ◽  
Laura Olejnik ◽  
Shannon White ◽  
Venkatesh Thiruganasambandamoorthy
Keyword(s):  
Emergency Department ◽  
Waiting Times ◽  
Health Records ◽  
Ottawa Hospital ◽  
Outpatient Consultation ◽  
Adult Outpatient ◽  
Ed Visits ◽  
Lost To Follow Up ◽  
Qualitative Mapping

Objectives. Many patients discharged home from the emergency department (ED) require urgent outpatient consultation with a specialty service. We sought to identify the best- and worst-performing services with regard to time to outpatient consultation, the proportion of patients lost to follow-up, the rate of related return ED visits prior to consultation, and common strategies used by our top-performing clinics. Methods. We conducted a health records review of The Ottawa Hospital ED visits during four 1-week periods. All consecutive adult outpatient consultation requests were included for chart review and were followed up to 12 months. Outcome measures included demographics, referral attendance rates, incomplete referrals, return ED visits, and time intervals. Services with at least 15 consultation requests were included for data analysis and qualitative mapping of their referral processes. Results. Of the 963 patients who met inclusion criteria, 803 (83.4%) attended their appointment, while 160 (16.6%) were lost to follow-up. The overall median time to successful consultation was 9 days (IQR = 2–27). 92 (9.6%) patients returned to the ED with a related complaint. The top-performing clinics included ophthalmology, orthopedics, and thrombosis (median = 1, 8, 1 days; incomplete consultation = 3%, 4%, 6%; return ED visits = 0%, 6%, 2% respectively). The bottom-performing clinics included otorhinolaryngology, neurology, and gynecology (median = 47, 39, 27 days; incomplete consultation = 50%, 41%, 37%; return ED visits = 11%, 15%, 26%, respectively). Processes incorporated by top-performing clinics included reserving appointment slots for emergency referrals, structured referral forms, and centralized booking. Conclusions. We found a substantial variability in both the waiting times and reliability of outpatient referrals from the ED. Top-performing clinics incorporate common referral processes.

Transfusion Need at Diagnosis or Its Development During the First Year of Diagnosis in Primary Myelofibrosis: Effect On Survival and Correlation with JAK2 and TET2 Mutational Status.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 1909-1909
Author(s):  
Ayalew Tefferi ◽  
Sergio Siragusa ◽  
Rakhee Vaidya ◽  
Susan Schwager ◽  
Kebede Hussein ◽  
...  
Keyword(s):  
Median Survival ◽  
Conflicts Of Interest ◽  
Multivariable Analysis ◽  
Primary Myelofibrosis ◽  
First Year ◽  
Prognostic Impact ◽  
Mutational Status ◽  
Risk Patients ◽  
One Year

Abstract Abstract 1909 Poster Board I-932 Background: The International Prognostic Scoring System (IPSS) for primary myelofibrosis (PMF) utilizes five independent predictors of inferior survival; of these, a hemoglobin level <10 g/dL has the highest impact on survival (Cervantes et al. Blood 2009;113:2895). In the current study, we examined the additional prognostic impact of transfusion need at diagnosis or becoming transfusion-dependent in the first year of diagnosis. These events were also correlated with JAK2 or TET2 mutational status. Methods: Patients were selected from the Mayo Clinic PMF database based on availability of bone marrow histology and IPSS-relevant information at diagnosis and follow-up transfusion history at one year from diagnosis. WHO criteria were used for PMF diagnosis. Patients who underwent allogeneic hematopoietic cell transplantation were censored at time of transplant. Patient records were updated in July, 2009. Survival curves were constructed using the Kaplan-Meier method and compared by the log-rank test. Multivariable survival was analysed using Cox regression model. Results: A consecutive cohort of 254 patients was studied (median age 59 years; range 28-87; 159 males). IPSS risk category was low, intermediate (int)-1, int-2 and high in 75, 71, 62 and 46 patients, respectively. JAK2V617F was present in 118 (62%) of 192 patients and TET2 mutations in 6 (13%) of 45 patients evaluated. Transfusion need at diagnosis was documented in 62 patients whereas an additional 22 patients became transfusion-dependent during the first year of their diagnosis. The remaining 170 patients remained transfusion-independent for at least one year post-diagnosis. To date, 139 patients have died. In patients who are alive, median follow-up was 5.3 years. Median survivals in IPSS high, Int-2, Int-1 and low risk patients were, 3, 3.9, 6.8 and 12.8 years, respectively (p<0.0001). Median survival for patients requiring transfusions at diagnosis was similar to that of patients who became transfusion-dependent in their first year of diagnosis, and both were significantly shorter than the median survival seen in patients who remained transfusion-free during the first year post-diagnosis: 2.9, 2.2 and 9.7 years, respectively (p<0.0001; figure). Multivariable analysis confirmed the IPSS-independent prognostic value of transfusion status-based risk stratification. Neither JAK2 nor TET2 mutational status correlated with transfusion need. Conclusions: In PMF, becoming transfusion-dependent in the first year of diagnosis is prognostically as detrimental as requiring transfusions at initial presentation. These events are not affected by JAK2 or TET2 mutational status and confer an IPSS-independent adverse prognosis. The ability to identify Int-1 risk patients with shortened survival (Figure) holds major treatment implications. Disclosures: No relevant conflicts of interest to declare.

Rituximab Treatment in Childhood Chronic Immune Thrombocytopenic Purpura (ITP).

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 4461-4461 ◽  
Author(s):  
Ji Yoon Kim ◽  
Kun Soo Lee ◽  
Hyoung Jin Kang ◽  
Hoon Kook ◽  
Hong Hoe Koo ◽  
...  
Keyword(s):  
Platelet Count ◽  
Immune Thrombocytopenic Purpura ◽  
Medical Records ◽  
Conflicts Of Interest ◽  
Complete Response ◽  
Thrombocytopenic Purpura ◽  
Chronic Itp ◽  
New Treatment ◽  
Lost To Follow Up

Abstract Abstract 4461 Background Immune thrombocytopenic purpura (ITP) is characterized by mucocutaneous purpura and thrombocytopenia caused by circulating anti-platelet auto-antibodies. ITP is usually self-limited in children, but around 20% of patients will develop chronic ITP. The conventional treatments for children chronic ITP include intravenous immunoglobulin (IVIG), corticosteroid therapy, anti-D immune globulin, or splenectomy. Some children with chronic ITP are refractory to these treatments and nowadays begun to try new treatment agents such as rituximab. Rituximab as a monoclonal antibody to CD-20, has shown promising reports to these patients with refractory chronic ITP in adults groups and a few children groups. We investigated this study to evaluate the efficacy of rituximab for childhood chronic ITP in Korea. Methods We reviewed the questionnaires and medical records about the clinical progresses and results in thirteen children from eight clinical institutes, retrospectively. Complete response (CR) was considered if the platelet count was > 100,000/uL. Results Thirteen patients with chronic thrombocytopenia who had been treated with rituximab were investigated. Two patients were lost to follow-up after rituximab. Finally eleven patients were evaluated including one patient with Evans syndrome. Median age was 6.5 year (range, 0.5 ∼ 15.4). Median platelet count at baseline was 13,700/uL (3,000∼46,000). All patients had been treated with conventional therapy including IVIG and steroids. One had done splenectomy. Median follow-up duration was 2.8 years (1.1-5.9). Among 11 patients, CR was achieved in 3 patients (27%). Their platelet count prior to rituximab were < 10,000/uL. They were treated as the regimen of 375 mg/m2/dose weekly for 4 doses. Time from the first rituximab dose to achievement of complete response was 3.9, 4.9 and 5.7 weeks respectively. One patient who was relapsed 6months after the first course of rituximab was received second course of rituximab using the same regimen and achieved a new CR at 9.3 weeks after. There were no reports about severe complication or interruption of medication. Conclusions Therefore, we suggest that rituximab is effective treatment choice in childhood refractory chronic ITP and well tolerated. Disclosures: No relevant conflicts of interest to declare.

scholarly journals Peer buddy mentoring project for nurses’ career development

2017 ◽  
Vol 5 (4) ◽  
pp. 82 ◽  
Author(s):  
Lauretta Luck ◽  
Harrison Ng Chok ◽  
Lesley Wilkes
Keyword(s):  
Career Development ◽  
Survey Design ◽  
Low Cost ◽  
Nurse Specialist ◽  
Effective Strategy ◽  
Mutual Support ◽  
Clinical Nurse ◽  
Face To Face ◽  
Qualitative Survey

Objective: The aim of the paper is to describe the implementation of a peer buddy mentoring model to support the career development of Registered Nurses (RNs) seeking Clinical Nurse Specialist (CNS) positions.Methods: A qualitative survey design was used to collect data during the workshops, with follow-up semi-structured telephone or face-to-face interviews. Data were also collected via the researchers’ notes.Results: A total of 32 participants attended the program and 31 completed the surveys. The participants’ reported needing more support when applying for a CNS position. Despite these issues, the participants recommend the use of peer buddy mentoring as a motivational, supportive and instructive model.Conclusions: Peer buddy mentoring, and facilitated workshops, is a relatively low cost and effective strategy to support nurses aspiring to advance their careers. Participants valued the development of the peer buddy relationship and the mutual support and motivation it engendered.

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