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Case Series: Identification of Patients at Risk for Arthroplasty Failure
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Survey of Patient and Family Preparation and Satisfaction with the Oral Food Challenge (OFC) Experience E. D. Robinson, S. Noone, S. Walsh, J. Chao, A. Nowak-Wegrzyn; Mount Sinai School of Medicine, New York, NY. RATIONALE: It has been noted that children who are prepared and have support throughout their hospital stay have fewer emotional problems. OFC’s are diagnostic procedures that may last many hours, require placement of an intravenous line, and result in acute allergic symptoms, including anaphylaxis. We sought to determine the effectiveness of the current approaches to preparing children and their families for OFC and their satisfaction with OFC experience. METHODS: Parents/guardians of 100 food allergic children presenting for OFC were administered a survey that contained 15 questions (yes/no, write in, multiple choice and Likert scale) about their perception of preparedness and experience during OFC. Surveys were returned by mail within two weeks and analyzed. RESULTS: 85% of parents felt very prepared and 15% somewhat prepared. 95% of parents felt that enough information was provided to help their child know what to expect. The majority of people got the most information to prepare for the food challenge by phone when scheduling with the research coordinator and from the written information received by mail. Parents rated the food challenge experience excellent (81%), good (16%) or fair (1%). There was no correlation between rating and the outcome of the OFC (failed vs. passed). Parents were most interested in handouts as educational materials, followed by a web-based learning module, educational DVD and finally a food challenge seminar. CONCLUSIONS: As a practice we may enhance preparation and satisfaction through creation of an updated educational program that takes parental comments and feedback into consideration. Word limit: 254
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Predictors of Underuse of Controller Medications in Innercity Children with Uncontrolled Asthma P. J. Lenehan, J. Curtin-Brosnan, J. N. Saams, G. B. Diette, P. N. Breysse, E. C. Matsui; Johns Hopkins Univeristy, Baltimore, MD. RATIONALE: Minority populations continue to suffer disproportionate asthma morbidity that may be due to underuse of controller medications, but reasons for controller medication underuse are not well understood. METHODS: Medication, symptom, and demographic data were collected from parents/guardians of 92 inner-city children with moderate-severe asthma. Participants brought in asthma medications and were considered to be on a controller medication if the participant had taken it in the past 2 weeks. Controller medications included inhaled corticosteroids (n 5 58), leukotriene modifiers (n 5 7) or cromolyn/nedocromil (n 5 1). RESULTS: Participants were predominantly African American (90%) and male (57%). 28% were not on a controller medication, and 89% of these had uncontrolled asthma. Participants whose asthma was managed by a primary care provider (PCP) were less likely to be on a controller than participants who were managed by a subspecialist (67 vs 90%, p 5 0.04), and those whose parents/guardians were under-employed were also less likely to be on a controller (64 vs. 79%, p 5 0.10). Participants whose parents/ guardians did not believe that asthma medications were effective were no less likely to be on a controller than those who did (67 vs. 72% respectively, p 5 0.79), and participants whose parents/guardians were concerned about medication side effects were no less likely to be on a controller than those who were not (77 vs. 64%, p 5 0.16). CONCLUSIONS: Parent/guardian attitudes towards asthma medication use were not risk factors for lack of controller medication, but PCP asthma care and parent/guardian underemployment were. Efforts to increase controller medication prescribing by PCPs and referrals to subspecialists may improve controller medication use.
Improvement of Allergen Immunotherapy Prescriptions Using a Guideline-based Checklist K. L. Rossow, C. L. Oslie, J. T. Li; Mayo Clinic, Rochester, MN. RATIONALE: The 2007 publication Allergen Immunotherapy: A Practice Parameter provides guidelines for immunotherapy prescriptions. We implemented a prospective quality improvement review of immunotherapy prescriptions based on the 2007 practice parameters. METHODS: This prospective study was conducted in a multi-campus academic medical center involving 10 allergists. A checklist system was designed based on quality elements outlined in the 2007 Immunotherapy Practice Parameters. The checklist included: skin test results match immunotherapy prescription; appropriate dosages; appropriate mixing; and consent appropriately documented. All new immunotherapy prescriptions written in the 6 month period from March through August 2008 were reviewed. RESULTS: There were 63 prescriptions for 31 patients. There were 38 prescriptions for pollen, 10 animal, 13 mold, 7 dust mite, and 3 venom. 58/63 (92%) new allergy immunotherapy prescriptions were found to be in 100% compliance with the practice parameter checklist. Two immunotherapy prescriptions did not precisely match the skin test results. One immunotherapy prescription for box elder was for a patient with a positive skin test to maple. One immunotherapy prescription for white oak was for a patient with a positive skin test to western white oak. These two prescriptions were changed. Three prescriptions for Alternaria mixed with dust mites or cat were identified and reviewed by the prescribing physician but not modified. CONCLUSIONS: Review of immunotherapy prescriptions using an immunotherapy prescription quality checklist resulted in the modification and improvement of 2 out of 63 immunotherapy prescriptions. These modifications were minor and probably of low clinical significance.
Case Series: Identification of Patients at Risk for Arthroplasty Failure S. Fox1, M. C. Tobin1,2, A. Buvanendran1, M. Sheinkop1; 1Rush University Medical Center, Chicago, IL, 2John H. Stroger Hospital of Cook County, Chicago, IL. RATIONALE: Currently, there are no reliable methods to identify patients at risk for arthroplasty failure. A literature review suggests that aseptic loosening may result from Type IV hypersensitivity to the metals comprising the prosthesis or a reaction to a component of bone cement, polymethyl methacrylate. Patients with two or more positive patch test reactions tend to acquire contact sensitivity to new unrelated allergens. We report three cases of bone cement allergic patients who also have a significant history of Type IV hypersensitivity reactions to other sensitizers. METHODS: A detailed history regarding contact sensitivity and physical exam were completed. Patch testing to bone cement, arthroplasty components (metals) and TRUE test patches were performed on all patients. Two patients had three or more joint failures and one patient knew she was allergic to bone cement and sought advice on alternatives. RESULTS: All three patients had a history of at least two positive contact sensitivities prior to their clinic visit and were positive when tested to Zimmer Osteobond cement containing methyl methacrylate. Each patient reacted to one or more TRUE test patches that were not previously documented. Based on these methods, all three patients are doing well clinically per our recommendations. CONCLUSIONS: Patients that have a history of aseptic loosening should have patch testing to assess reactivity to prosthetic components, TRUE test patches and bone cement prior to another joint replacement. Our findings suggest that any patient with a history of two or more contact sensitivities should be considered for pre-operative evaluation.
SATURDAY
Abstracts S63
J ALLERGY CLIN IMMUNOL VOLUME 123, NUMBER 2
Survey of Patient and Family Preparation and Satisfaction with the Oral Food Challenge (OFC) Experience E. D. Robinson, S. Noone, S. Walsh, J. Chao, A. Nowak-Wegrzyn; Mount Sinai School of Medicine, New York, NY. RATIONALE: It has been noted that children who are prepared and have support throughout their hospital stay have fewer emotional problems. OFC’s are diagnostic procedures that may last many hours, require placement of an intravenous line, and result in acute allergic symptoms, including anaphylaxis. We sought to determine the effectiveness of the current approaches to preparing children and their families for OFC and their satisfaction with OFC experience. METHODS: Parents/guardians of 100 food allergic children presenting for OFC were administered a survey that contained 15 questions (yes/no, write in, multiple choice and Likert scale) about their perception of preparedness and experience during OFC. Surveys were returned by mail within two weeks and analyzed. RESULTS: 85% of parents felt very prepared and 15% somewhat prepared. 95% of parents felt that enough information was provided to help their child know what to expect. The majority of people got the most information to prepare for the food challenge by phone when scheduling with the research coordinator and from the written information received by mail. Parents rated the food challenge experience excellent (81%), good (16%) or fair (1%). There was no correlation between rating and the outcome of the OFC (failed vs. passed). Parents were most interested in handouts as educational materials, followed by a web-based learning module, educational DVD and finally a food challenge seminar. CONCLUSIONS: As a practice we may enhance preparation and satisfaction through creation of an updated educational program that takes parental comments and feedback into consideration. Word limit: 254
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228
230
Predictors of Underuse of Controller Medications in Innercity Children with Uncontrolled Asthma P. J. Lenehan, J. Curtin-Brosnan, J. N. Saams, G. B. Diette, P. N. Breysse, E. C. Matsui; Johns Hopkins Univeristy, Baltimore, MD. RATIONALE: Minority populations continue to suffer disproportionate asthma morbidity that may be due to underuse of controller medications, but reasons for controller medication underuse are not well understood. METHODS: Medication, symptom, and demographic data were collected from parents/guardians of 92 inner-city children with moderate-severe asthma. Participants brought in asthma medications and were considered to be on a controller medication if the participant had taken it in the past 2 weeks. Controller medications included inhaled corticosteroids (n 5 58), leukotriene modifiers (n 5 7) or cromolyn/nedocromil (n 5 1). RESULTS: Participants were predominantly African American (90%) and male (57%). 28% were not on a controller medication, and 89% of these had uncontrolled asthma. Participants whose asthma was managed by a primary care provider (PCP) were less likely to be on a controller than participants who were managed by a subspecialist (67 vs 90%, p 5 0.04), and those whose parents/guardians were under-employed were also less likely to be on a controller (64 vs. 79%, p 5 0.10). Participants whose parents/ guardians did not believe that asthma medications were effective were no less likely to be on a controller than those who did (67 vs. 72% respectively, p 5 0.79), and participants whose parents/guardians were concerned about medication side effects were no less likely to be on a controller than those who were not (77 vs. 64%, p 5 0.16). CONCLUSIONS: Parent/guardian attitudes towards asthma medication use were not risk factors for lack of controller medication, but PCP asthma care and parent/guardian underemployment were. Efforts to increase controller medication prescribing by PCPs and referrals to subspecialists may improve controller medication use.
Improvement of Allergen Immunotherapy Prescriptions Using a Guideline-based Checklist K. L. Rossow, C. L. Oslie, J. T. Li; Mayo Clinic, Rochester, MN. RATIONALE: The 2007 publication Allergen Immunotherapy: A Practice Parameter provides guidelines for immunotherapy prescriptions. We implemented a prospective quality improvement review of immunotherapy prescriptions based on the 2007 practice parameters. METHODS: This prospective study was conducted in a multi-campus academic medical center involving 10 allergists. A checklist system was designed based on quality elements outlined in the 2007 Immunotherapy Practice Parameters. The checklist included: skin test results match immunotherapy prescription; appropriate dosages; appropriate mixing; and consent appropriately documented. All new immunotherapy prescriptions written in the 6 month period from March through August 2008 were reviewed. RESULTS: There were 63 prescriptions for 31 patients. There were 38 prescriptions for pollen, 10 animal, 13 mold, 7 dust mite, and 3 venom. 58/63 (92%) new allergy immunotherapy prescriptions were found to be in 100% compliance with the practice parameter checklist. Two immunotherapy prescriptions did not precisely match the skin test results. One immunotherapy prescription for box elder was for a patient with a positive skin test to maple. One immunotherapy prescription for white oak was for a patient with a positive skin test to western white oak. These two prescriptions were changed. Three prescriptions for Alternaria mixed with dust mites or cat were identified and reviewed by the prescribing physician but not modified. CONCLUSIONS: Review of immunotherapy prescriptions using an immunotherapy prescription quality checklist resulted in the modification and improvement of 2 out of 63 immunotherapy prescriptions. These modifications were minor and probably of low clinical significance.
Case Series: Identification of Patients at Risk for Arthroplasty Failure S. Fox1, M. C. Tobin1,2, A. Buvanendran1, M. Sheinkop1; 1Rush University Medical Center, Chicago, IL, 2John H. Stroger Hospital of Cook County, Chicago, IL. RATIONALE: Currently, there are no reliable methods to identify patients at risk for arthroplasty failure. A literature review suggests that aseptic loosening may result from Type IV hypersensitivity to the metals comprising the prosthesis or a reaction to a component of bone cement, polymethyl methacrylate. Patients with two or more positive patch test reactions tend to acquire contact sensitivity to new unrelated allergens. We report three cases of bone cement allergic patients who also have a significant history of Type IV hypersensitivity reactions to other sensitizers. METHODS: A detailed history regarding contact sensitivity and physical exam were completed. Patch testing to bone cement, arthroplasty components (metals) and TRUE test patches were performed on all patients. Two patients had three or more joint failures and one patient knew she was allergic to bone cement and sought advice on alternatives. RESULTS: All three patients had a history of at least two positive contact sensitivities prior to their clinic visit and were positive when tested to Zimmer Osteobond cement containing methyl methacrylate. Each patient reacted to one or more TRUE test patches that were not previously documented. Based on these methods, all three patients are doing well clinically per our recommendations. CONCLUSIONS: Patients that have a history of aseptic loosening should have patch testing to assess reactivity to prosthetic components, TRUE test patches and bone cement prior to another joint replacement. Our findings suggest that any patient with a history of two or more contact sensitivities should be considered for pre-operative evaluation.
SATURDAY
Abstracts S63
J ALLERGY CLIN IMMUNOL VOLUME 123, NUMBER 2