COVID 19 (SARS-COV-2) disease expression remains uncertain. Immunocompromised individuals may be at particular risk of increased mortality. Lung transplant recipients provide a unique phenotype because the allograft is a preferred host location for the SARS-COV-2. We conducted a single centre review of all lung transplant recipients SARS-COV-2 PCR positive between 17th March and June 2020. 7 of a total of 266 lung transplant recipients were SARS-COV-2 positive. 4 cases had a descriptive analysis of the immune microenvironment. There was no association between COVID 19 disease severity and time from transplant. The most prevalent comorbidities were chronic kidney disease (86%), hypertension (71%) and diabetes mellitus (42%). One case died and 6 recovered. Forty-two percent of cases had established chronic allograft dysfunction. Six patients were receiving Azithromycin 500mg, 3 times per week prior COVID 19. Immunosuppression was altered in the three severe cases with calcineurin inhibitor (CNI) reduction and antimetabolite withdrawal. The frequency of both CD4 and CD8 T cell subtypes were low in all 4 patients analysed. In the 2 severe cases CD8 subpopulations responsible for cellular antiviral response were profoundly diminished. The recipient requiring mechanical ventilation demonstrated an increased CD4/CD8 ratio of 5.9 and significantly reduced NK cells. NK cell reduction corresponded with disease severity. The indirect potential COVID 19 prophylaxis with Azithromycin may have mitigated disease expression and mortality. Decreased anti-viral immune surveillance associated with a reduction in CD8 positive cytotoxic lymphocytes and raised CD4/CD8 ratio was associated with disease severity and may be a tool to identify high risk cases.
Introduction: Identification of risk factors that predict poor survival can aid clinical decision making and allow optimization of any potentially modifiable factors (Stephenson, A.L. et al. J Heart Lung Transplant 2015;34:1139–1145). This may facilitate improved patient selection and ultimately improve overall outcomes. Aims: To describe the Irish experience of co-morbidity post-transplant for cystic fibrosis and to investigate potential non-pulmonary pre-transplant risk factors that could impact on long term survival. Methods: We performed a retrospective review of all 61 patients who received a lung transplant for cystic fibrosis between 2008-2017 at The Irish National Lung Transplant Centre. We recorded patient demographics, co-morbidities and survival. A t-test was used for comparison of mean values. Results: The overall 5-year survival post-transplant is 73.8%. The mean age at transplant is 29.8 years (range 17.8-59.9) with a male predominance (69%). 64% were homozygous ∆F508 genotype. When comparing the 13 patients who have subsequently died to the 48 patients currently alive, the mean age at transplant was significantly lower (25 vs 31 years, p=0.034), mean BMI prior to transplant was lower (19.1 v 20.8, p=0.045) and creatinine clearance prior to transplant was reduced (103 v 136, p=0.031). Of the 48 patients who remain under review, chronic kidney disease is common with 54% of patients having an eGFR <60ml/min. The prevalence of diabetes increased from 38% at listing to 71% at follow–up. Conclusions: There is a high prevalence of non-graft complications post-transplant. Pre-transplant factors that are most predictive poor outcomes in our centre include younger age, lower BMI and reduced renal function.
A multidisciplinary panel chose the percentage of medicines orders for intermittent therapy that have been reviewed by a pharmacist for safe prescribing as a valid and feasible performance indicator for the Mater Misericordiae University Hospital (MMUH) clinical pharmacy service. Fatalities have been reported due to errors in the prescribing and administration of intermittent medicines. Pharmacists have a recognised role in clearly communicating intermittent medicines orders.
Purpose
To develop a performance indicator descriptor and data collection tool for the chosen indicator. To measure the percentage of medicines orders for intermittent medicines that had been reviewed by a pharmacist for safe prescribing.
Materials and Methods
A performance indicator descriptor and data collection tools were developed and piloted. 100 in-patient beds were randomly selected. All patients supplied with methotrexate or an erythropoiesis stimulating agent 14 days prior to data collection were included. Pharmacists were not informed data collection was taking place. An independent pharmacist collected the data to reduce bias. Data collection was checked for inter-rater reliability. Intermittent medicines were defined as ‘safely prescribed’ if the day(s) of the week that the medicine was to be taken were stated and the day(s) when the medicine was not to be taken were crossed out in the administration section of the drug chart. Medicines orders were classified as fully ‘reviewed’ by a pharmacist when (in addition to checking the dose and frequency of the prescribed medicine) the above parameters, if not entered by the prescriber, were completed by the pharmacist as outlined by the Clinical Pharmacy Services Standard Operating Procedure (SOP).
Results
79% (48/61) of medicines orders for intermittent medicines were ‘reviewed’ by a pharmacist for ‘safe prescribing’. 21% (13/61) had been signed as clinically reviewed but did not fully meet the criteria of a safely prescribed intermittent medicines. 11% (7/61) were prescribed as per MMUH prescribing policy and did not require further endorsements by a clinical pharmacist.
Conclusions
A valid tool was developed that measured the baseline performance of the MMUH clinical pharmacy service for the safe prescribing of intermittent medicines. Clarification of the clinical pharmacy services SOP will lead to improved performance as pharmacists had varying interpretations of the SOP. No conflict of interest.
The Mater Misericordiae University Hospital (MMUH) formulary recommendations for oral anticoagulants (OACs) are in line with the Health Service Executive (HSE) Medicines Management Programme.1 2 Warfarin is the OAC of choice. Apixaban is the preferred direct oral anticoagulant (DOAC) if warfarin is unsuitable. Edoxaban, dabigatran and rivaroxaban are third-line options.1 2 In 2014, warfarin was prescribed in 81% of cases in the MMUH. National data indicate DOACs are now prescribed more often than warfarin.2
Aim and objectives
To identify current MMUH OAC prescribing practice and compare results with 2014 data.
Material and methods
A point prevalence audit was completed in November 2018 by clinical pharmacists, across 30 wards on all patients receiving OACs. The OAC, indication, dose, prescribing team speciality and if treatment was commenced on this MMUH admission were recorded. Results were collated, analysed and compared with an identical 2014 audit.
Results
More MMUH patients were prescribed OACs in 2018 (n=87) than in 2014 (n=53) (p<0.01). Apixaban was the most commonly prescribed OAC (48%), followed by rivaroxaban (20%), warfarin (16%), dabigatran (14%) and edoxaban (2%). In 2014, warfarin was the most commonly prescribed OAC (81%), followed by rivaroxaban (15%), apixaban (2%) and dabigatran (2%). DOAC prescribing was mainly for licensed indications and doses. Medicines for the elderly speciality had the most patients on OACs in both 2018 (n=29) and 2014 (n=14). The majority of patients prescribed OACs in both 2014 and 2018 were aged 60 years or over. In 2014, all patients <60 years of age requiring oral anticoagulation were on warfarin. In 2018, all these patients were on DOACs. The number of patients starting OACs during MMUH admission was almost 10% higher in 2018 (n=27) than in 2014 (n=11) (p=0.18).
Conclusion and relevance
Apixaban was the most commonly prescribed OAC in the MMUH. Use of warfarin has decreased from 81% in 2014 to 16% in 2018 and is now surpassed by DOAC prescribing (p<0.01). Increased OAC prescribing means increased pharmacy workload in terms of medication review and patient education.
References and/or acknowledgements
1. MMUH. Prescriber's guide, chapter 5.8. Information on DOACs. Last updated December 2018. 2. HSE. Oral anticoagulants for stroke prevention in non-valvular atrial fibrillation. V.1.1. Medicines Management Programme. Updated September 2018. No conflict of interest.
Influenza is a significant cause of morbidity and mortality following lung transplant. We employ trivalent vaccination as per National Policy in our centre. The trivalent inactivated vaccine (TIV) is not protective against the 2017-18 circulating stain of Influenza B. We reviewed the outcomes in 221 lung transplants recipients post vaccination. All Patients are subject to influenza surveillance. Data include viral swabs, severity of symptoms, history of vaccination, immunosuppression and outcomes for lung transplant patients from November 2017 to date. Ten patients have Influenza DNA detection of which 2 Influenza A and 8 Influenza B. The 10 cases had been vaccinated with the TIV vaccine. The cases presented in January 2018, were stratified as 1) mild, which were discharge home, or 2) severe, which required hospitalisation. All cases were treated with Oseltamivir (nebulised Zanamivir was added in the one of the Influenza B cases). Admission rates from Influenza B were 40%, and 1 patient admitted to intensive care unit died. All Influenza B cases were confirmed as B/Phuket/3073/2013-like (B/Yamagata lineage) virus. The costs for admission were €60,000 as per HSE reimbursement versus a total of €6000 Quadrivalent vaccination (QIV). In our cohort, 80% were infected by Influenza B/Yamagata strain, poorly covered by TIV. Immunocompromised patients may benefit from QIV vaccination leading to a cost benefit by reducing hospitalization, morbidity and mortality.
A 24-hour flow chart has been used for prescribing and documenting medication administration in the intensive therapy unit/high-dependency unit for many years. Transcription errors arising from rewriting inpatient drug charts have been recognised as a major factor contributing to medication errors. A project was undertaken to assess these errors in order to devise a new chart that would minimise them and improve patient safety.
Alpha-1 antitrypsin deficiency (AATD) accounts for 5% of lung transplants performed worldwide. Ireland has a high frequency of 1 in 25 for the Z allele and 1 in 10 for the S allele [1]. These variants are associated with decreased production of alpha-1 antitrypsin (AAT), which predisposes to unprotected proteolytic activity of neutrophil elastase (NE) and proteinase 3 (PR3), linked to an increased risk of emphysema and hepatic disease. Associated inflammatory conditions such as vasculitis, panniculitis and inflammatory bowel disease are also suspected to be caused by uncontrolled neutrophil proteinase activity [2–4]. Vascular problems, including aortic aneurysm, in AATD patients are more severe and may reflect abnormal elastic tissue properties potentially impacting on wound healing [5]. Our study suggests an association between timing of withdrawal of replacement therapy and bronchial anastomotic complications after lung transplantation
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