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Journal of Hepatology ; 77:S551, 2022.
Article in English | EMBASE | ID: covidwho-1996642


Background and aims: Hepatitis C virus (HCV) infection is a major global health problem in adults & children. The recent efficacy of Direct Acting Anti-viral therapy (DAA) has cure rates of 99% in adults and adolescents. These drugs were licensed for children 3–12 yrs during the recent coronavirus pandemic. To ensure equitable access, safe & convenient supply during lockdown, we established a virtual national treatment pathway for children with HCV in England & evaluated its feasibility, efficacy & treatment outcomes. Method: A paediatric Multidisciplinary Team Operational Delivery Network (pMDT ODN), supported by NHS England (NHSE), was established with relevant paediatric specialists to provide a single point of contact for referrals & information. Referral & treatment protocolswere agreed for HCV therapy approved byMHRA& EMA. On referral the pMDT ODN agreed the most appropriate DAA therapy based on clinical presentation & patient preferences, including ability to swallow tablets. Treatment was prescribed in association with the local paediatrician & pharmacist, without the need for children & families to travel to national centres. All children were eligible for NHS funded therapy;referral centres were approved by the pMDT ODN to dispense medication;funding was reimbursed via a national NHSE agreement. Demographic & clinical data, treatment outcomes & SVR 12 were collected. Feedback on feasibility & satisfaction on the pathway was sought from referrers. Results: In the first 6 months, 34 childrenwere referred;30- England;4-Wales;median (range) age 10 (3.9–14.5) yrs;15M;19F: Most were genotype type 1 (17) & 3 (12);2 (1);4 (4). Co-morbidities included: obesity (2);cardiac anomaly (1);Cystic Fibrosis (1);Juvenile Arthritis (1). No child had cirrhosis. DAA therapy prescribed: Harvoni (21);Epclusa (11);Maviret (2). 27/34 could swallow tablets;3/7 received training to swallowtablets;4/7 are awaiting release of granules.11/27 have completed treatment and cleared virus;of these 7/11 to date achieved SVR 12. 30 children requiring DAA granule formulation are awaiting referral and treatment. Referrers found the virtual process easy to access, valuing opportunity to discuss their patient’s therapy with the MDT & many found it educational. There were difficulties in providing the medication through the local pharmacy. However there are manufacturing delays in providing granule formulations because suppliers focused on treatments for COVID, leading to delays in referring and treating children unable to swallow tablets. Conclusion: The National HCV pMDT ODN delivers high quality treatment & equity of access for children & young people, 3–18 yrs with HCV in England, ensuring they receive care close to home with 100% cure rates.

Archives of Disease in Childhood ; 107(5):15-16, 2022.
Article in English | EMBASE | ID: covidwho-1868715


Aim In March 2020, COVID-19 triggered an NHS directive to reduce face-to-face consultations and adapt to virtual clinics. 1 Hospital pharmacies, each with their own model of care, quickly innovated to ensure patients received their medication safely. The aim of this study was to evaluate the provision of medications optimisation for paediatric patients following virtual outpatient consultations (VOC) and explore potential improvements for future implementations. Method This was a mixed method study using quantitative data;which reviewed medications sent to patients in red, amber, and green categories2 and qualitative data;using patient feedback, to evaluate the processes in three London hospitals. Pathway mapping (PM) sessions, with multidisciplinary team involvement, were conducted across these hospitals to identify areas for improvement and analyse gaps in services. Virtual PM sessions were attended by 30 representatives across the multidisciplinary team including: pharmacists, nurses, consultants, pharmacy technicians, post room attendants;and general, operational, and project managers. Semi-structured questionnaires were used to conduct one to one telephone interviews with patients' families. A separate topic guide was used to interview General practitioners (GP) and primary care network (PCN) pharmacists. The audio recordings were transcribed as 'intelligent verbatim' and analysed using Nvivo. Braun and Clarke's six phases approach was used to conduct an inductive thematic analysis.3 To improve the rigorousness of the study, more than 50% of the transcript were double coded.4 As this was a service evaluation, ethics approval was not necessary. The project was registered with each hospital's clinical audit department. Results The three process maps were analysed and potential improvements for the medicines optimisation pathway were assessed by a paediatric pharmacy subgroup using ease-impact matrix. Potential improvements include: exploration and use of Electronic Prescription Service by secondary and tertiary care, improving communication through Information Technology systems between prescribers and hospital pharmacists, and the creation of a transparent standard operating procedure regarding medication supply following VOC. Seventy-one patients' families across the sites were interviewed between January-May 2021 to reflect on their experience of receiving medications following a VOC. Four GPs and one PCN pharmacist were interviewed in May 2021 to assess on the impact of VOC on primary care. Key reflections from themes generated include the convenience of receiving medications from hospital pharmacies following VOC, satisfaction of the current process, including medicines packaging and medicines information provided to patients and their families. Other reflections included limitations of the current process and its implication on patient safety. Medicines information helplines and education provided by pharmacists were regarded by patients' families and GPs as a valuable attribute. Conclusion Patients' families appreciated the current model of care, however patients' families and primary care healthcare professionals have identified both challenges and suggestions for improvement in delivering the current model. Future research should focus on a mixed mode of integrated care with green and amber medications2 prescribed directly to community pharmacies with clinical screening and counselling conducted by hospital pharmacists.

Archives of Disease in Childhood ; 107(5):4, 2022.
Article in English | EMBASE | ID: covidwho-1868713


Aim On 12 March 2020, the COVID-19 outbreak was declared as a pandemic by the World Health Organisation.1 During this time, paediatric services saw dramatic reductions in children accessing emergency care and routine operations were cancelled, which enabled the paediatric intensive care unit (PICU) team to support the adult critical care expansion by repurposing paediatric beds to open an adult intensive care unit (AICU). Here we describe the pharmacy experience, challenges and learning outcomes faced in converting a PICU to an AICU. Method A trust-wide multidisciplinary critical care tactical group including pharmacy representation was established to coordinate strategy planning, troubleshoot operational and clinical difficulties, and manage communications on a wider scale. Within pharmacy, clinical and operational lead pharmacists led the pharmacy response and supported the front-line pharmacy teams to coordinate and make quick informed decisions to daily challenges. The challenges were made even greater by the need to co-deliver a mixed paediatric/adult unit meaning we had to ensure the safety of both the adults and children receiving medicines. Results Paediatric pharmacy staff were upskilled by the adult critical care pharmacy team, extrapolating existing PICU knowledge and experience and expanding on key differences, as well as offering weekly shadowing opportunities. The use of a mnemonic pharmaceutical tool to review patients enabled paediatric pharmacists to ask the right questions and ensure medicines were managed appropriately. In addition, a quick reference guide to common adult drug doses, bite size educational sessions and use of an app called Clinibee® were developed to disseminate important adult learning points and new guidance. The PICU electronic prescribing system Metavision® was adapted and configured for adult dosing and administration. To reduce prescribing errors and improve safety, doctors on the unit were assigned to either managing adults or paediatric patients. Further informatic changes were required in real time in response to drug supply chain and equipment shortages and changes in clinical policies. A risk assessment of adult medicine stock holding, including high-risk medicines and location of them on the unit helped reduce the risk of mis-selection. Extra nursing support was provided by pharmacy by manufacturing ready to administer injectables and existing medicines management policies adapted. Regular check-ins and staff huddles kept staff updated and provided support where needed. Conclusion Providing an AICU on PICU was one of the biggest challenges ever faced but provided excellent cooperation and collaboration between pharmacy teams. PICU pharmacists have a strong foundation of ICU knowledge to enable them to be redeployed to AICU. Strong clinical and operational leadership is required to navigate uncertain times when staff are working outside their normal practice. Good communication is vital, both upwards, downwards and to the front line to ensure safe ways of working. Resilience planning including staffing, drug and equipment shortages ensured that resources were prioritised. Teamwork with a dedicated focus on wellbeing enabled staff to be supported where needed and ensured our patients received the most clinically effective care.

International Journal of Infectious Diseases ; 116:S86, 2022.
Article in English | EMBASE | ID: covidwho-1734445


Purpose: The origin of the current COVID-19 pandemic is unknown but horseshoe bats, of the family Rhinolophidae, are natural hosts to a suite of sarbecoviruses. Global surveillance is key to monitoring potentially pathogenic viral strains and improving the capacity for surveillance across Europe will bolster our understanding of viral populations within zoonotic reservoirs. Methods & Materials: Faecal samples were collected from Lesser horseshoe bats (Rhinolophus hipposideros) in the UK during annual population monitoring surveys, stored in RNAlater and frozen prior to genomic analysis. For metagenomic analysis, the Sequence-independent Single-Primer Amplification (SISPA) method was employed and sequencing completed using Illumina Nextera and the Oxford Nanopore GridION platforms. Results: A De novo hybrid assembly utilising shorter Illumina reads with longer Nanopore reads acting as a scaffold, generated a 29kb contig named RhGB01. Mapping raw reads against RhGB01 demonstrated a combined depth of 50x across the genome. Sequence alignment exhibits genomic organisation comparable to other sarbecoviruses isolated from animal and human hosts. Within the receptor binding domain, but excluding the receptor binding motif, RhGB01 has 77% and 81% amino acid homology compared to SARS-CoV-2 and SARS respectively. Maximum likelihood phylogenies inferred from the nucleotide sequence of RNA dependent RNA polymerase, spike glycoprotein and entire coding sequence exhibit clustering with the only other fully sequenced zoonotic Sarbecovirus from Europe which was isolated from Rhinolophus blasii. The structure of the receptor binding domain of RhGB01 was predicted by homology modelling using a crystal structure of the receptor binding domain of SARS-CoV as a template. This model was selected with a Global Model Quality Estimate (GMQE) > 0.7 and Quaternary Structure Quality Estimate (QMEAN) of -2.18. Structural comparisons between the predicted receptor binding domain of RhGB01 and SARS-CoV-2 highlight structurally different regions which house hACE2 contact residues. Conclusion: Phylogenetic inference and structural modelling suggest an absence of pathogenic potential for RhGB01. However, the discovery of a novel Sarbecovirus at the western limit of Lesser horseshoe bats demonstrates their presence throughout the entire horseshoe bat distribution and indicates the need for viral surveillance systems in Western Europe.