Capital sharing and socialization in an interprofessional student-led clinic: a Bourdieuan analysis

BACKGROUND

Interprofessional student-led clinics offer authentic clinical experiences of collaborative patient care. However, theoretical research on the sustainability of these clinics, considering forms of capital beyond the economic, remains limited. This study addresses this gap by employing Bourdieu's theoretical framework to explore how alternative conceptions of capital; both social and cultural might sustain conditions for interprofessional working in a student-led clinic serving patients living with a chronic neurological impairment.

METHODS

The teaching and learning focussed clinic was established in 2018 to mirror a clinical service. Semi-structured focus groups with participants involving 20 students from 5 professions and 11 patients gathered in-depth insights into their experiences within the clinic. A thematic analysis was guided by Bourdieu's concepts of field, habitus, and capital.

RESULTS

In the complex landscape of the student-led clinic, at the intersection of a patient support group, a hospital-based aged care facility, and university-based healthcare professions, three pivotal mechanisms emerged underpinning its sustainability: Fostering students' disposition to interprofessional care, Capitalizing on collaboration and patient empowerment, and a Culture of mutual exchange of capital. These themes illustrate how students and patients specific dispositions towards interprofessional healthcare enriched their habitus by focusing on shared patient well-being goals. Diverse forms of capital exchanged by students and patients fostered trust, respect, and mutual empowerment, enhancing the clinic experience.

CONCLUSION

This study bridges an important gap in theoretically informed explorations of the conditions for sustaining student-led clinics, drawing on Bourdieu's theory. It accentuates the significance of investment of diverse forms of capital in such clinics beyond the economic, whilst emphasizing a primary commitment to advancing interprofessional healthcare expertise. Recognizing patients as equal partners shapes clinic dynamics. In order for student clinics to thrive in a sustainable fashion, educators must shift their focus beyond solely maximizing financial resources. Instead, they should champion investments in a wider range of capital forms. This requires active participation from all stakeholders; faculties, patient partners, service providers, and students. These findings underscore the importance of investing in interprofessional learning by optimizing various forms of capital, and embracing patients as dynamic contributors to the clinic's sustainability.

Population genetics of group B Streptococcus from maternal carriage in an ethnically diverse community in London

Introduction

Maternal immunization against Group B Streptococcus (GBS) has the potential to significantly reduce the burden of neonatal GBS infections. Population genetics of GBS from maternal carriage can offer key insights into vaccine target distribution.

Methods

In this study we characterized the population structure of GBS isolates from maternal carriage (n = 535) in an ethnically diverse community in London, using whole genome sequencing.

Results

The isolates clustered into nine clonal complexes (CCs) but the majority (95%) belonged to five lineages: CC1 (26%), CC19 (26%), CC23 (20%), CC17 (13%) and CC8/10 (10%). Nine serotypes were identified, the most common were serotypes III (26%), V (21%), II (19%) and Ia (19%). Other serotypes (Ib, IV, VI, VII, IX) represented less than 10% of all isolates each. Intra-lineage serotype diversity was observed in all major CCs but was highest in CC1, which revealed nine serotypes. Nearly all isolates (99%) carried at least one of the four alpha family protein genes (alpha, alp1, alp23, and rib). All isolates were susceptible to penicillin. We found 21% and 13% of isolates to be resistant to clarithromycin and clindamycin, respectively. Prevalence of macrolide-lincosamide-streptogramin B (MLS_B) resistance genes was 22% and they were most common in CC19 (37%) and CC1 (28%), and isolates with serotypes V (38%) and IV (32%). We identified some associations between maternal ethnicity and GBS population structure. Serotype Ib was significantly less common among the South Asian compared to Black women (S. Asian: 3/142, Black: 15/135, p = 0.03). There was also a significantly lower proportion of CC1 isolates among the White other (24/142) in comparison to Black (43/135) and S. Asian (44/142) women (p = 0.04). We found a significantly higher proportion of CC17 isolates among the White other compared to S. Asian women (White other: 32/142, S. Asian: 10/142, p = 0.004).

Conclusion

Our study showed high prevalence of GBS vaccine targets among isolates from pregnant women in London. However, the observed serotype diversity in CC1 and high prevalence of MLS_B resistance genes in CC19 demonstrates presence of high risk lineages, which might act as a reservoir of non-vaccine strains and antimicrobial resistance determinants.

Situated learning in community environments (SLICE): Systems design of an immersive and integrated curriculum for community-based learning

PURPOSE

We sought to design a micro-curriculum to structure supervised clinical placements for junior medical students within a variety of community-based settings of differing clinical disciplines. Given the gaps in the literature, this paper reflects on the opportunities and challenges of our design, implementation, and evaluation strategies in constructing an integrated task-based micro-curriculum for interprofessional community-based learning in year 2 of a four-year graduate entry program.

METHODS

The design was informed by a systems thinking framework and guided by contemporary curricular theories on self-directed and interprofessional learning. Extensive consultations with stakeholders were undertaken. Alignment with relevant national level documents and curricular frameworks was ensured.

RESULTS

The systems thinking approach provided first, an experience of applying thinking tools for a deeper understanding of how various parts of this micro-curriculum and subsystems should be integrated. Second, applying the toolkit uncovered tension points on which leverage could optimise future enhancements. Eighteen types of health professions were recruited including 105 general practitioners and 253 healthcare practitioners from a range of disciplines.

CONCLUSION

Systems thinking allows for the identification of various interacting elements within the curriculum to be considered as part of an integrated whole. Insights from this model could inform the design of similar innovative curricula.

Student perspectives on programmatic assessment in a large medical programme: A critical realist analysis

BACKGROUND

Fundamental challenges exist in researching complex changes of assessment practice from traditional objective-focused 'assessments of learning' towards programmatic 'assessment for learning'. The latter emphasise both the subjective and social in collective judgements of student progress. Our context was a purposively designed programmatic assessment system implemented in the first year of a new graduate entry curriculum. We applied critical realist perspectives to unpack the underlying causes (mechanisms) that explained student experiences of programmatic assessment, to optimise assessment practice for future iterations.

METHODS

Data came from 14 in-depth focus groups (N = 112/261 students). We applied a critical realist lens drawn from Bhasker's three domains of reality (the actual, empirical and real) and Archer's concept of structure and agency to understand the student experience of programmatic assessment. Analysis involved induction (pattern identification), abduction (theoretical interpretation) and retroduction (causal explanation).

RESULTS

As a complex educational and social change, the assessment structures and culture systems within programmatic assessment provided conditions (constraints and enablements) and conditioning (acceptance or rejection of new 'non-traditional' assessment processes) for the actions of agents (students) to exercise their learning choices. The emergent underlying mechanism that most influenced students' experience of programmatic assessment was one of balancing the complex relationships between learner agency, assessment structures and the cultural system.

CONCLUSIONS

Our study adds to debates on programmatic assessment by emphasising how the achievement of balance between learner agency, structure and culture suggests strategies to underpin sustained changes (elaboration) in assessment practice. These include; faculty and student learning development to promote collective reflexivity and agency, optimising assessment structures by enhancing integration of theory with practice, and changing learning culture by both enhancing existing and developing new social structures between faculty and the student body to gain acceptance and trust related to the new norms, beliefs and behaviours in assessing for and of learning.

OP0170 PHASE 2A, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY OF THE EFFICACY AND SAFETY OF A TRANSDERMAL ALKALINIZING AND PAIN-RELIEVING TREATMENT FOR REDUCING PAIN ASSOCIATED WITH AN ACUTE GOUT FLARE

Background

Monosodium urate (MSU) deposition is pathognomonic for gouty arthropathy. MSU crystal formation and dissolution is affected by pH and theoretically, alkalinizing agents (eg, sodium bicarbonate, NaHCO₃) that raise the joint microenvironment pH, could facilitate MSU crystal dissolution1 and decrease the pain of an acute gout flare. However, oral NaHCO₃ use is fraught with intolerable gastrointestinal side effects.

Objectives

To determine if NaHCO₃ in a patented transdermal formulation could effectively and safely reduce the pain of an acute gout flare.

Methods

A Phase 2a prospective, double-blind, randomized, placebo-controlled study enrolled 418 subjects across 20 US sites. Patients with a diagnosis of gout using ACR/EULAR criteria (Score ≥ 8), ages 18-75, history of ≥ 2 gout flares in 12 months prior to randomization and on stable doses of urate lowering therapy were included. Exclusion criteria were BMI > 40kg/m2, > 12 gout flares in the year prior to randomization, history of rheumatoid arthritis, psoriatic arthritis, evidence of septic arthritis, acute polyarticular gout (≥ 4 joints), and arthritis of any other cause. Patients were randomized to receive placebo lotion or transdermal NaHCO₃. Upon flare they initiated colchicine (1.2 mg followed by 0.6 mg 1 hour later) and applied study product to the limb of the affected joint. Outcome measures included pain-numeric rating scale (NRS, 0-10), time to resolution of pain (50% reduction), rescue medication use, joint tenderness, and physical function (PROMIS PF-20). Data were collected in patient diaries for the pain and PROMIS measures at several time points from baseline through Day 7, as were adverse events. Statistical analyses utilized ANCOVA (baseline pain as a covariate), Kaplan-Meier curves for homogeneity, and two-proportion z-test, all with α=0.05.

Results

98 patients had a gout flare during the 14-month study period. Those in the active arm (ITT, N=48) had an overall responder rate of 94.5% vs. 79.3% (p=0.01) in the placebo arm (ITT, N=50) over the 7-day follow up. Rescue medication use was lower in the active arm vs. placebo (6.3% vs. 20.0%, p=0.02); and PROMIS PF-20 showed greater improvements over 7 days (22.2 vs. 16.7 points, p=0.05). The most common adverse event was hypertension (14.2%) with no significant difference between arms. Per protocol analyses were conducted to adjust for adherence on Day 1 for time to resolution of pain (Figure 1) and additional 24hr endpoints (Table 1).

Table 1.

Key 24hr Endpoints (Per Protocol, n = 57)

Active (n = 28)Placebo (n = 29)P valueMedian time to resolution, hrs124720.03Change in 24hr PROMIS PF-20 score216.79.40.01Physician-assessed moderate-to-severe joint tenderness 24hr328.0%57.1%0.02

1≥ 50% reduction in pain; K-M Est.; Subjects using rescue medication, discontinuing study drug, or missing pain scores censored

2Consists of 20, 0-5-point questions; higher scores indicate better function

3LIKERT: 0 (no pain), 1 (pain), 2 (wincing), 3 (wincing and withdrawal)

Figure 1.

Time to resolution of pain1 (per protocol population, n = 57)

Conclusion

Transdermal NaHCO₃ reduced the pain intensity and duration of an acute gout flare with higher overall response rates, faster time to resolution, improvements in physical function and a reduction in rescue medication use. The lack of adverse events makes this topical a promising therapeutic choice; especially during debilitating acute gout flares in patients with concomitant comorbidities.

References

[1]Chhana et al, BMC Musculoskelet Disord, 2015

Disclosure of Interests

Puja Khanna Consultant of: Dyve, Horizon, Selecta, Cerecor, Grant/research support from: Dyve, Horizon, Selecta, Cerecor, Ryan Beal Shareholder of: Dyve, Employee of: Dyve

Exploring complexities in the reform of assessment practice: a critical realist perspective

Although the principles behind assessment for and as learning are well-established, there can be a struggle when reforming traditional assessment of learning to a program which encompasses assessment for and as learning. When introducing and reporting reforms, tensions in faculty may arise because of differing beliefs about the relationship between assessment and learning and the rules for the validity of assessments. Traditional systems of assessment of learning privilege objective, structured quantification of learners' performances, and are done to the students. Newer systems of assessment promote assessment for learning, emphasise subjectivity, collate data from multiple sources, emphasise narrative-rich feedback to promote learner agency, and are done with the students. This contrast has implications for implementation and evaluative research. Research of assessment which is done to students typically asks, "what works", whereas assessment that is done with the students focuses on more complex questions such as "what works, for whom, in which context, and why?" We applied such a critical realist perspective drawing on the interplay between structure and agency, and a systems approach to explore what theory says about introducing programmatic assessment in the context of pre-existing traditional approaches. Using a reflective technique, the internal conversation, we developed four factors that can assist educators considering major change to assessment practice in their own contexts. These include enabling positive learner agency and engagement; establishing argument-based validity frameworks; designing purposeful and eclectic evidence-based assessment tasks; and developing a shared narrative that promotes reflexivity in appreciating the complex relationships between assessment and learning.

Senior medical students as assistants in medicine in COVID-19 crisis: a realist evaluation protocol

INTRODUCTION

The assistant in medicine is a new and paid role for final-year medical students that has been established in New South Wales, Australia, as part of the surge workforce management response to the COVID-19 pandemic. Eligibility requires the applicant to be a final-year medical student in an Australian Medical Council-accredited university and registered with the Australian Health Practitioner Regulation Agency. While there are roles with some similarities to the assistant in medicine role, such as assistantships (the UK) and physician assistants adopted internationally, this is completely new in Australia. Little is known about the functionality and success factors of this role within the health practitioner landscape, particularly within the context of the COVID-19 pandemic. Given the complexity of this role, a realist approach to evaluation has been undertaken as described in this protocol, which sets out a study design spanning from August 2020 to June 2021.

METHODS AND ANALYSIS

The intention of conducting a realist review is to identify the circumstances and mechanisms that determine the outcomes of the assistant in medicine intervention. We will start by developing an initial programme theory to explore the potential function of the assistant in medicine role through realist syntheses of critically appraised summaries of existing literature using relevant databases and journals. Other data sources such as interviews and surveys with key stakeholders will contribute to the refinements of the programme theory. Using this method, we will develop a set of hypotheses on how and why the Australian assistants in medicine intervention might 'work' to achieve a variety of outcomes based on examples of related international interventions. These hypotheses will be tested against the qualitative and quantitative evidence gathered from all relevant stakeholders.

ETHICS AND DISSEMINATION

Ethics approval for the larger study was obtained from the Western Sydney Local Health District (2020/ETH01745). The findings of this review will provide useful information for hospital managers, academics and policymakers, who can apply the findings in their context when deciding how to implement and support the introduction of assistants in medicine into the health system. We will publish our findings in reports to policymakers, peer-reviewed journals and international conferences.

A case of neck abscess caused by rare hypervirulent Klebsiella pneumoniae, capsular type K20 and sequence type 420

Background

This case report describes a neck abscess caused by a strain of Hypervirulent Klebsiella pneumoniae in a middle aged man with diabetes without a history of travel to East and South East Asia. This case report is of notable significance as Hypervirulent Klebsiella pneumoniae neck abscesses are rarely seen in the UK and are very infrequently documented in individuals who have not first travelled to the high prevalence areas of East and South East Asia.

Case presentation

This case report describes a 53 year old diabetic man who contracted a Hypervirulent Klebsiella pneumoniae neck abscess which led to the development of sepsis. Klebsiella pneumoniae was cultured from blood cultures and fluid aspirated from the abscess grew the pathogen with same antimicrobial susceptibility. Hypervirulence was demonstrated after the samples were analysed, at the Antimicrobial Resistance and Healthcare Associated Infections Reference Unit Public Health England Colindale, and found to contain the K20 (rmp)A and rmpA2 virulence genes.

Discussion

Hypervirulent Klebsiella pneumoniae is a Gram-negative, encapsulated, non-motile bacillus notable for its ability to metastatically spread and cause potentially life threatening infections in otherwise healthy adults, but especially in those with diabetes. Genes responsible for the production of hyperviscous mucoid polysaccharide capsules and siderophores, such as those isolated in this case, enable the bacteria to more efficiently evade the hosts immune system and disseminate and invade surrounding and distant tissues. Data from Public Health England shows Hypervirulent Klebsiella pneumoniae are rare in the UK. A review of current literature also showed Hypervirulent Klebsiella pneumoniae almost exclusively occur in those who have traveled to East and South East Asia.

Conclusions

This case reported a rare Hypervirulent Klebsiella pneumoniae neck abscess outside of, and without travel to, East and South East Asia. This raises concerns about future, potentially life threatening, Hypervirulent Klebsiella pneumoniae infections becoming more widespread without the need for endemic travel. This concern is further exacerbated by the growing global challenge of antimicrobial resistance.

POS0135 REDUCING IMMUNOGENICITY OF PEGLOTICASE (RECIPE) WITH CONCOMITANT USE OF MYCOPHENOLATE MOFETIL IN PATIENTS WITH REFRACTORY GOUT: A PHASE II RANDOMIZED CONTROLLED TRIAL

Background:

Pegloticase is a recombinant, pegylated uricase, used for treatment of gout patients who fail oral urate lowering therapy (ULT). Its use has been limited due to immunogenicity leading to infusion reactions.1

Objectives:

We evaluated if co-administration of an immunomodulatory agent could prolong the efficacy of pegloticase.

Methods:

Participants were recruited in a Phase II, double-blind, placebo-controlled trial over 18 months and randomized in a 3:1 ratio by site. Inclusion criteria were: a) Age ≥ 18 years who met 2015 ACR/EULAR gout classification criteria and b) chronic refractory gout defined as symptoms inadequately controlled with ULT or contraindications. After a 2-week run-in of mycophenolate mofetil (MMF) 1000 mg twice daily or matching placebo (PBO), they received a combination of pegloticase 8 mg biweekly with MMF or PBO for 12 weeks. Subsequent to this MMF or PBO were discontinued but pegloticase was continued for another 12 weeks. The primary endpoint was proportion of patients who sustained a serum urate (SU) level of ≤ 6 mg/dl at 12 weeks. Secondary endpoints included 24-week durability of SU ≤ 6 mg/dl and rate of adverse events (AEs). Fisher’s exact test and Wilcoxon two-sample test were used for analyses along with Kaplan-Meier estimates and log-rank tests to compare survival curves between groups. Hypothesis tests were two-tailed and p-value (p) < 0.05 indicated statistical significance.

Results:

Of 42 subjects screened, 35 were randomized, and 32 who received at least one dose of pegloticase were included in modified intention to treat analyses. Subjects were predominantly men (88%), mean age of 55.2 years (SD=9.7). Mean duration of gout was 13.4 years (SD=9.0), mean baseline sUA was 9.2 mg/dL (SD=1.6). Tophi were present in 88% and majority were on optimized ULT - 59% on allopurinol and 16% on febuxostat, with 63% reporting > 1 flare in the past year. At baseline both arms (MMF vs. PBO) had similar comorbidities – (82% vs 70%), diabetes mellitus/metabolic syndrome (14% vs 20%), coronary artery disease/peripheral vascular disease (41% vs.70%), BMI>30 (86% vs. 90%) and renal insufficiency (defined as eGFR < 90 mL/min; 73% vs. 70%). At 12 weeks, 19 of 22 (86%) in the MMF arm achieved SU ≤ 6 mg/dl compared to 4 of 10 (40%) in PBO arm (p-value = 0.01). At 24 weeks, the SU was ≤ 6 mg/dl in 68% of MMF arm vs. 30% in PBO (p-value = 0.06), and rates of AEs per month were similar between groups with the PBO arm having more infusion reactions (30% vs. 0%). The MMF arm had higher AEs compared to placebo: musculoskeletal (41% vs. 10%), gastrointestinal (18% vs. 10%), and infections (9% vs. 0%). Figure 1 shows that the percentage of subjects maintaining a sUA < 6 mg/dL at 12 weeks was significantly higher (p=0.02) in the MMF arm, and a significant difference (p=0.03) at 24 weeks indicates sustained benefit from MMF.

Conclusion:

To our knowledge this is the first randomized-controlled proof of concept trial to demonstrate the ability of an immunomodulatory agent in prolonging the efficacy of pegloticase. Short-term concomitant use of MMF therapy with pegloticase was well tolerated and showed a clinically meaningful improvement in the targeted SU ≤6 mg/dL at 12 and 24 weeks. This study suggests an innovative approach to utilize pegloticase therapy in patients with chronic gout.

References:

[1]Sundy et al. Efficacy and tolerability of pegloticase for the treatment of chronic gout in patients refractory to conventional treatment: two randomized controlled trials. JAMA. 2011;306(7):711-20.

Figure 1.

Proportion of subjects maintaining serum urate (SU) ≤ 6 mg/dL over 24 week study period in mycophenolate mofetil + pegloticase vs. placebo + pegloticase

Disclosure of Interests:

Puja Khanna Consultant of: Horizon Pharmaceuticals, Swedish Orphan Biovitrum A, Grant/research support from: Selecta, 2)DYVE, Dinesh Khanna Consultant of: Horizon Pharmaceuticals, Gary Cutter: None declared, Jeff Foster: None declared, Josh Melnick: None declared, Sara Jaafar: None declared, Stephanie Biggers: None declared, Fazlur Rahman: None declared, Hui-Chen Kuo: None declared, Michelle Feese: None declared, Kenneth Saag Consultant of: AbbVie, Inc., Bayer, Daiichi Sankyo Company LTD, Gilead Services, Inc., Horizon Pharma plc, Mallinkrodt, Radius Health, Inc., Roche/Genentech, Shanton Pharma Co., LTD, Teijin, Dyve Bioscience, LG Chem, Regeneron Pharmaceuticals., Swedish Orphan Biovitrum AB, Takeda Pharmaceuticals America, Inc.,

An observational cohort study of bacterial co-infection and implications for empirical antibiotic therapy in patients presenting with COVID-19 to hospitals in North West London

Objectives

To describe the prevalence and nature of bacterial co-infections in COVID-19 patients within 48 hours of hospital admission and assess the appropriateness of empirical antibiotic treatment they received.

Methods

In this retrospective observational cohort study, we included all adult non-pregnant patients who were admitted to two acute hospitals in North West London in March and April 2020 and confirmed to have COVID-19 infection within 2 days of admission. Results of microbiological specimens taken within 48 hours of admission were reviewed and their clinical significance was assessed. Empirical antibiotic treatment of representative patients was reviewed. Patient age, gender, co-morbidities, inflammatory markers at admission, admission to ICU and 30 day all-cause in-hospital mortality were collected and compared between patients with and without bacterial co-infections.

Results

Of the 1396 COVID-19 patients included, 37 patients (2.7%) had clinically important bacterial co-infection within 48 hours of admission. The majority of patients (36/37 in those with co-infection and 98/100 in selected patients without co-infection) received empirical antibiotic treatment. There was no significant difference in age, gender, pre-existing illnesses, ICU admission or 30 day all-cause mortality in those with and without bacterial co-infection. However, white cell count, neutrophil count and CRP on admission were significantly higher in patients with bacterial co-infections.

Conclusions

We found that bacterial co-infection was infrequent in hospitalized COVID-19 patients within 48 hours of admission. These results suggest that empirical antimicrobial treatment may not be necessary in all patients presenting with COVID-19 infection, although the decision could be guided by high inflammatory markers.

Screening for Candida auris in patients admitted to eight intensive care units in England, 2017 to 2018

BackgroundCandida auris is an emerging multidrug-resistant fungal pathogen associated with bloodstream, wound and other infections, especially in critically ill patients. C. auris carriage is persistent and is difficult to eradicate from the hospital environment.AimWe aimed to pilot admission screening for C. auris in intensive care units (ICUs) in England to estimate prevalence in the ICU population and to inform public health guidance.MethodsBetween May 2017 and April 2018, we screened admissions to eight adult ICUs in hospitals with no previous cases of C. auris, in three major cities. Swabs were taken from the nose, throat, axilla, groin, perineum, rectum and catheter urine, then cultured and identified using matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry (MALDI-TOF MS). Patient records were linked to routine ICU data to describe and compare the demographic and health indicators of the screened cohort with a national cohort of ICU patients admitted between 2016 and 2017.ResultsAll C. auris screens for 921 adults from 998 admissions were negative. The upper confidence limit of the pooled prevalence across all sites was 0.4%. Comparison of the screened cohort with the national cohort showed it was broadly similar to the national cohort with respect to demographics and co-morbidities.ConclusionThese findings imply that C. auris colonisation among patients admitted to ICUs in England is currently rare. We would not currently recommend widespread screening for C. auris in ICUs in England. Hospitals should continue to screen high-risk individuals based on local risk assessment.

Designing health professional education curricula using systems thinking perspectives

BACKGROUND

Medical students navigate complex personal learning pathways from entry into medical school, through an educational program, and into life-long practice. However, many stakeholders have called for substantive reforms in contemporary curricula, citing concerns about the lack of key abilities amongst newly graduated doctors to work in complex healthcare environments. Despite the need for educators to focus on curricula design, there is a paucity of overarching perspectives that allow synthesis of the various curricular elements in a way that lends meaningfulness and appreciation to the students in terms of navigating the immediate program requirements and beyond. Without such guidance, educators risk creating fragmented program designs that can lead to both unintended and unactionable outcomes for students as well as curriculum designers. Using systems thinking, we set out to address this gap by providing an overarching perspective for curriculum designers to appreciate the relationships and the interactions of the various curricular elements that inform and impact student's preparedness for practice.

METHODS

By framing a curriculum as a complex adaptive system, we used soft systems thinking to develop an initial prototype of a conceptual curricular toolkit, underpinned by an appraisal of relevant literature within health professional education and the broader educational context. The prototype was further refined iteratively after critical reflection by the authors with a diverse range of national and international colleagues via posters, short communications, and workshops at several conferences, and through social media.

RESULTS

We describe how the 3P-6Cs toolkit captures a learner's personal journey through an educational program into a field of practice by logically linking the three key elements: the personal, the program, and the practice. We demonstrate its application in three examples related to contemporary health profession education curricula. These are: creating integrated educational designs to capture students' developmental continua, conceptualising immersive clinical placements in non-traditional settings, and complexity-consistent evaluation of curricular interventions.

CONCLUSION

Applying the 3P-6Cs curricular toolkit to problems of curricula (re)design can provide overarching perspectives that enable educators to have a better understanding of how integration of elements within education programs can inform and impact student's preparation for lifelong practice.

To screen or not to screen women for Group B Streptococcus (Streptococcus agalactiae) to prevent early onset sepsis in newborns: recent advances in the unresolved debate

Streptococcus agalactiae, also known as Group B streptococcus (GBS) is the commonest cause of early onset sepsis in newborns in developed high-income countries. Intrapartum antimicrobial (antibiotic) prophylaxis (IAP) is recognized to be highly effective in preventing early onset Group B sepsis (EOGBS) in newborns. The key controversy is about the strategy that should be used to identify mothers who should receive IAP. There are two strategies that are followed in developed countries: screening-based or risk-factor-based identification of women requiring IAP. The debate regarding which of the two approaches is better has intensified in the recent years with concerns about antimicrobial resistance, effect on newborn’s microbiome and other adverse effects. In this review, we have discussed some of the key research papers published in the period 2015–2019 that have addressed the relative merits and disadvantages of screening versus risk-factor-based identification of women requiring IAP. Although screening-based IAP appears to be more efficacious than risk-based IAP, IAP-based prevention has several limitations including ineffectiveness in prevention of late-onset GBS infection in babies, premature and still births, impact of IAP on neonatal microbiota, emergence of antimicrobial resistance and difficulties in implementing IAP-based strategies in middle and low income countries. Alternative strategies, principally maternal immunization against GBS would circumvent use of IAP. However, no licensed vaccines are currently available for use.

THU0439 EFFICACY AND SAFETY OF ANAKINRA IN THE TREATMENT OF RECURRENT GOUT FLARES: RESULTS FROM THE EXTENSION PHASE OF THE ANAGO STUDY

Background:

The anaGO (anakinra ingout) study was a multi-center, randomized, double-blind, double-dummy, phase 2 study investigating the efficacy and safety of anakinra for recurrent gout flares. Results from subsequent flares (extension phase) are presented in relation to the previously reported results from the 1stflare (flare at study enrollment).

Objectives:

The objective of the extension phase was to evaluate the efficacy, safety and immunogenicity of two anakinra regimens (100 or 200 mg daily s.c. injections for 5 days) compared to triamcinolone (single i.m. injection 40 mg) for subsequent flares after initial study enrollment flare. The primary endpoint of the study was change in patient-assessed flare pain intensity from baseline to 24-72 hours (average of 24, 48 and 72 hours) in the most affected joint measured on a visual analogue scale (0-100 VAS). Secondary endpoints included: patient’s and physician’s assessments of global response, anti-drug antibodies (ADA) and safety.

Methods:

The study included patients with acute gout (ACR/EULAR 2015 gout classification criteria) unsuitable for anti-inflammatory therapy with NSAIDs and colchicine due to contraindication, intolerance or inefficacy. Patients were eligible for treatment of subsequent flares for up to 2 years. Each patient received the same treatment for all flares, starying with the flare at enrollment.

Results:

161 patients were treated for 1 flare, 61 patients for 2 flares, 31 patients for 3, and 20 patients for 4 or more flares with 1 patient treated for 9 flares. In total, 300 flares were treated in the full study; anakinra 100 mg and 200 mg, 107 and 106 flares, respectively; and triamcinolone, 87 flares. Both anakinra doses and triamcinolone provided a clinical meaningful reduction in patient-assessed pain intensity in both the 1stand subsequent flares. Mean changes in pain intensity from baseline to 24–72 hours for total anakinra and triamcinolone were: 1stflare -41.2 and -39.4; 2ndflare -33.9 and -31.1; 3rdflare -31.8 and -51.2, respectively. Mean differences in pain reduction between anakinra and triamcinolone treatment groups were (negative value favors anakinra): 1stflare -1.8, 2ndflare -2.8 3rdflare 19.4. The majority of secondary endpoints favored anakinra, including patient’s and physician’s global assessement of response and physician’s assessement of the joint. No unexpected safety findings during subsequent flares were identified. 21 patients (19.6%) developed ADA to anakinra in low titers at some time point; 7 (6.5%) had pre-existing ADA at baseline and 12 (11.2%) developed treatment induced ADA. 2 patients had pre-existing ADA to triamcinolone at baseline. 4 patients on anakinra (3.7%) developed neutralizing antibodies (NAbs). Pre-dose 72 hour anakinra serum concentrations were in similar range for ADA+ and ADA- patients. Presence of ADA was not associated with adverse events or had an impact on pain reduction.

Conclusion:

The efficacy and safety of anakinra and triamcinolone in subsequent flares were similar to the findings from 1stflare in patients with acute gout. Patient-assessed pain in the 1stand 2ndflare was reduced to similar degrees in all treatment groups, but to a larger extent in the 3rdflare in the small triamcinolone group. Secondary endpoints were in favor of anakinra across flares 1 to 3. The overall incidence of ADA and NAb was low also after repeated anakinra dosing and did not appear to impact exposure, efficacy or safety. In conclusion, anakinra was shown to be an option in the treatment of recurrent gout flares in patients for whom conventional therapy is unsuitable.

Disclosure of Interests: :

Kenneth Saag Grant/research support from: Horizon, Sobi, Shanton, Grant/research support from: Horizon Pharma, Sobi, Shanton, Consultant of: Horizon and Sobi, Consultant of: Horizon Pharma, Amgen, Radius, LG-Pharma, Takeda, Sobi, Atom, Arthrosi, Puja Khanna Grant/research support from: Dyve, Selecta, Sobi, Consultant of: Sobi, Horizon, Robert Keenan Consultant of: Sobi, Selecta, Horizon, Sven Ohlman Shareholder of: Sobi, Employee of: Former employee of Sobi, Erik Sparve Shareholder of: Sobi, Employee of: Sobi, Daniel Lindqvist Employee of: Sobi, Ann-Charlotte Åkerblad Shareholder of: Sobi, Employee of: Sobi, Margareta Wikén Shareholder of: Sobi, Employee of: Former employee of Sobi, Alexander So Consultant of: Sobi, Grünenthal, Michael H. Pillinger Grant/research support from: Horizon, Hikma, Consultant of: Sobi, Horizon, Robert Terkeltaub Consultant of: Sobi, Selecta, Horizon, Astra-Zeneca

THU0409 A RANDOMIZED, PHASE 2 STUDY EVALUATING THE EFFICACY AND SAFETY OF ANAKINRA IN DIFFICULT-TO-TREAT ACUTE GOUTY ARTHRITIS: THE ANAGO STUDY

Background:

In gout, urate crystals deposited in and around joints trigger episodes of acute arthritis, mediated by the proinflammatory cytokine IL-1β. In uncontrolled studies, the IL-1 receptor antagonist anakinra appears effective in reducing pain and signs of acute flares in patients with difficult-to-treat gout. However, confirmatory, adequately-powered, prospective trials are lacking. The ‘anaGO-study’ (anakinra ingout) was a multi-center, randomized, double-blind, double-dummy, phase 2 study investigating the efficacy and safety of anakinra in acute gout (NCT03002974).

Objectives:

The primary objective was to evaluate the efficacy of two regimens of anakinra (100 or 200 mg daily s.c. injections for 5 days) compared to triamcinolone (single i.m. injection 40 mg) with respect to patient-assessed pain intensity. The primary endpoint was change in pain intensity from baseline to 24-72 hours (average of 24, 48 and 72 hours) in the most affected joint measured on a visual analogue scale (0-100 VAS). Secondary outcomes included: time to onset of effect, time to response, time to pain resolution, time to rescue medication use, patient’s and physician’s assessments of global response, clinical signs, inflammatory biomarkers and safety.

Methods:

Patients were recruited who had acute gout based on ACR/EULAR 2015 gout classification criteria, and were unsuitable for anti-inflammatory therapy with NSAIDs and colchicine due to contraindication, intolerance or inefficacy. Patients were randomized to each group in a 1:1:1 ratio and stratified by urate-lowering therapy use (yes/no) and BMI (<30.0 or ≥30.0 kg/m2).

Results:

165 patients were randomized; 110 to anakinra (56 to 100 mg/day, 54 to 200 mg/day) and 55 to triamcinolone; 108 and 53 were included in the primary analysis, respectively. The median (range) age was 55 (25-83) years, 87% were male, mean disease duration was 8.7 years and mean number of self-reported flares during the past year was 4.5. The pain intensity, from baseline to 24-72 hours, decreased in both treatment groups; mean (95% CI) change was -39.4 (-46.8, -32.0) for triamcinolone and -41.2 (-46.3, -36.2) for anakinra. The 100 mg and 200 mg doses of anakinra were comparably effective in decreasing pain (100 mg/day: -41.8 [-48.9, -34.8] and 200 mg/day: -40.7 [-47.9, -33.4]). Mean (95% CI) difference in pain reduction between anakinra and triamcinolone treatment groups was -1.8 (-10.8, 7.1) (p-value = 0.688 for primary endpoint). The majority of secondary efficacy endpoints were numerically in favor of anakinra, and in most instances also statistically significant, in comparison to triamcinolone, e.g. physician’s assessment of clinical signs at 72 hours and patient’s and physician’s assessment of global response at Day 8. No unexpected safety findings were identified in any of the treatment groups.

Conclusion:

Anakinra and triamcinolone reduced patient-assessed gout flare pain to similar degrees in patients for whom conventional therapy was ineffective or contraindicated. Both doses of anakinra showed comparable efficacy in pain reduction. The majority of secondary efficacy endpoints favored anakinra. Anakinra was shown to be an additional option for use during acute gout flares.

Disclosure of Interests: :

Kenneth Saag Grant/research support from: Horizon, Sobi, Shanton, Grant/research support from: Horizon Pharma, Sobi, Shanton, Consultant of: Horizon and Sobi, Consultant of: Horizon Pharma, Amgen, Radius, LG-Pharma, Takeda, Sobi, Atom, Arthrosi, Alexander So Consultant of: Sobi, Grünenthal, Puja Khanna Grant/research support from: Dyve, Selecta, Sobi, Consultant of: Sobi, Horizon, Robert Keenan Consultant of: Sobi, Selecta, Horizon, Sven Ohlman Shareholder of: Sobi, Employee of: Former employee of Sobi, Torbjörn Kullenberg Shareholder of: Sobi, Employee of: Former employee of Sobi, Lisa Osterling Koskinen Shareholder of: Sobi, Employee of: Sobi, Michael H. Pillinger Grant/research support from: Horizon, Hikma, Consultant of: Sobi, Horizon, Robert Terkeltaub Consultant of: Sobi, Selecta, Horizon, Astra-Zeneca

THU0430 RENAL URATE DEPOSITION: SUMMARY OF PUBLISHED EVIDENCE

Background:

Gout is the most common inflammatory arthropathy in U.S. adults. Although the severity of this debilitating disease is often defined by the presence of tophi in the joints, systemic deposition of urate in major organ systems including the renal parenchyma is not as well established. Urate is primarily cleared through the kidneys and patients with gout often have concomitant renal disease along with other comorbidities such diabetes, coronary artery disease, and hypertension; however, a causal role between these entities has not yet been carefully established. We hypothesize that urate deposits serve as a trigger in the inflammatory nidus to propogate subclinical tissue damage that results in the chronicity of the disease. This could potentially explain its independent role in the development and progression of chronic kidney disease in gout patients.

Objectives:

To review the published literature for evidence of urate deposition in the renal parenchyma in patients with gout and summarize the histopathology and imaging findings.

Methods:

PubMed (from 1940 to 2020) was used to identify reports of autopsy, pathology and radiology imaging demonstrating urate deposition within the native renal parenchyma in patients with gout. Key words included: gout nephropathy, chronic urate nephropathy, renal tophi, gouty kidney, autopsy findings in gout, and renal imaging in gout. The reference lists from these publications were also used to identify additional articles. Literature referencing urate nephrolithiasis and renal transplants were excluded from the study.

Results:

There were 25 articles documenting renal parenchymal urate deposition in gout patients confirmed by autopsy, biopsy and/or radiology imaging in native kidneys. Among the 19 articles examining urate deposition by autopsy and/or biopsy, 100% found urate deposition in the collecting ducts and adjacent medullary interstitium. Based on these findings, the most commonly proposed mechanism for urate deposition is urate crystal precipitation in the collecting ducts with eventual desquamation of the collecting duct walls from inflammation and/or tubular obstruction with subsequent extrusion of crystals into the medullary interstitium. 89% of reports documented inflammatory cells and/or tubulointerstitial fibrosis adjacent to the renal urate deposits. 68% reported cortical thinning or scarring. In addition, 74% of included publications reported renal vascular pathology including arteriosclerosis, glomerosclerosis and nephrosclerosis. There were 6 imaging articles that all reported abnormal renal ultrasound findings with hyperechogenic renal medullas that were attributed to urate deposition.

Conclusion:

There is a growing body of literature documenting urate deposition in the renal parenchyma in gout patients based on autopsy, pathology and imaging findings. Inflammation and fibrosis adjacent to regions of urate deposition and vascular changes were common. Given the strong association of gout with renal disease, there is a critical need to elucidate the mechanism by which urate impairs the renal tissue. Thus dedicated investigation is key to determine the prevalence and clinical significance of urate deposition in the kidneys of gout patients.

References:

[1]Nickeleit, V, et al.Nephrol Dial Transplant.(1997) 12:1832-1838.

[2]Tchacarski, V, et al.Intl Urol Nephrol.1992; 24(6): 649-655.

[3]Modern, FW.Med Clin North Am.1952;21: 941-51.

[4]Linnane, JW, et al.Nephron.1981; 29: 216-22

[5]Greenbaum, D, et al. Br Med J. 1961 May 27; 1(5238): 1502–1504

[6]Bluestone, R, et al.Seminars in Arthr and Rheum.1977;7(2).

[7]Brown, J, et al.NEJM.1950; 243: 325-329.

[8]Braga, T., et al.Sci Rep.2017; 7: 39884.

Disclosure of Interests: :

Puja Khanna Grant/research support from: Dyve, Selecta, Sobi, Consultant of: Sobi, Horizon, Brad Marder Employee of: Horizon Therapeutics, Brian LaMoreaux Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Ada Kumar Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics

Machine Learning Techniques for the Diagnosis of Alzheimer’s Disease

Alzheimer’s disease is an incurable neurodegenerative disease primarily affecting the elderly population. Efficient automated techniques are needed for early diagnosis of Alzheimer’s. Many novel approaches are proposed by researchers for classification of Alzheimer’s disease. However, to develop more efficient learning techniques, better understanding of the work done on Alzheimer’s is needed. Here, we provide a review on 165 papers from 2005 to 2019, using various feature extraction and machine learning techniques. The machine learning techniques are surveyed under three main categories: support vector machine (SVM), artificial neural network (ANN), and deep learning (DL) and ensemble methods. We present a detailed review on these three approaches for Alzheimer’s with possible future directions.

Is whole genome sequencing the answer for identifying Shigella bacteraemia?

We present a rare case of Shigella flexneri bacteraemia and the challenges of differentiating Escherichia coli and Shigella spp using conventional and newer laboratory techniques in diagnostic laboratories. The organism was identified only after whole genomic sequencing .

Educational renewal of physician training in Australia and New Zealand: Multiple educational innovations in a complex environment

AIM

The Royal Australasian College of Physicians is renewing its specialty training programs and shifting towards competency-based medical education. Our aim is to improve the quality and rigor of training and graduate outcomes, and promote high standards of physician practice to serve the health of patients, families, and communities in a changing healthcare environment.

METHODS

We are progressing holistic change and multiple educational innovations in a complex environment. Numerous stakeholders, a disparate training landscape and a largely volunteer supervisor workforce pose challenges in supporting effective implementation. This paper describes our progress and experience with three key components of our education renewal program: curricular renewal, a new selection process and faculty development. It offers reflections on the practical challenges, lessons learned and factors critical for success.

CONCLUSIONS

Our experience highlights opportunities for training organizations to maximize their influence over workplace training experiences and outcomes by taking a systems approach to the design, delivery and evaluation of the components of education renewal. We found that design, development and delivery of our multiple educational innovations have benefited from co-design approaches, progressive and concurrent development, continual exploration of new strategies, and implementation as soon as viable with a commitment to iterative improvements over time.

Utility of selection methods for specialist medical training: A BEME (best evidence medical education) systematic review: BEME guide no. 45

BACKGROUND

Selection into specialty training is a high-stakes and resource-intensive process. While substantial literature exists on selection into medical schools, and there are individual studies in postgraduate settings, there seems to be paucity of evidence concerning selection systems and the utility of selection tools in postgraduate training environments.

AIM

To explore, analyze and synthesize the evidence related to selection into postgraduate medical specialty training.

METHOD

Core bibliographic databases including PubMed; Ovid Medline; Embase, CINAHL; ERIC and PsycINFO were searched, and a total of 2640 abstracts were retrieved. After removing duplicates and screening against the inclusion criteria, 202 full papers were coded, of which 116 were included.

RESULTS

Gaps in underlying selection frameworks were illuminated. Frameworks defined by locally derived selection criteria, and heavily weighed on academic parameters seem to be giving way to the evidencing of competency-based selection approaches in some settings. Regarding selection tools, we found favorable psychometric evidence for multiple mini-interviews, situational judgment tests and clinical problem-solving tests, although the bulk of evidence was mostly limited to the United Kingdom. The evidence around the robustness of curriculum vitae, letters of recommendation and personal statements was equivocal. The findings on the predictors of past performance were limited to academic criteria with paucity of long-term evaluations. The evidence around nonacademic criteria was inadequate to make an informed judgment.

CONCLUSIONS

While much has been gained in understanding the utility of individual selection methods, though the evidence around many of them is equivocal, the underlying theoretical and conceptual frameworks for designing holistic and equitable selection systems are yet to be developed.

Optimal reference genes for RT-qPCR normalization in the newborn

It is difficult to identify reliable reference genes for transcriptomic analyses in biofluids such as saliva. This situation is particularly relevant for the newborn population, where rapid development is associated with dynamic changes in gene expression. Real-time gene expression monitoring holds great promise for elucidating disrupted pathways that result in morbidities unique to this population, such as retinopathy of prematurity, but its impact depends on identifying stable and consistently expressed genes across a wide range of gestational ages. We extracted total RNA from 400 neonatal saliva samples (postconceptional ages: 32 5/7 to 48 2/7 weeks), converted it to cDNA, and pre-amplified and analyzed it by qPCR for three commonly used reference genes, ACTB, GAPDH, and YWHAZ. Relative quantification was determined using the Δ Ct method. Data were analyzed as a whole and also stratified by age and sex. Descriptive statistics and homogeneity of variance were performed to identify optimal reference genes. Data analyzed from all ages and both sexes showed significant expression variation for ACTB, while GAPDH and YWHAZ showed greater stability. Male infants exhibited increased expression variation compared to females for ACTB, but neither GAPDH nor YWHAZ showed significant variance for either sex. We suggest that ACTB is an unreliable reference gene for the newborn population. Males showed significantly more variation in ACTB expression compared to females, which suggests a sex-specific developmental role for this biomarker. By contrast, GAPDH and YWHAZ were less variable and therefore preferable for use in neonates. Our findings may improve the use of reference genes for the RT-qPCR platform in the newborn over a wide range of gestational ages, thereby minimizing the likelihood of erroneous interpretation of gene expression during rapid growth, development, and differentiation.

Outcome of a screening programme for the prevention of neonatal invasive early-onset group B Streptococcus infection in a UK maternity unit: an observational study

BACKGROUND

Against a background of failure to prevent neonatal invasive early-onset group B Streptococcus infections (GBS) in our maternity unit using risk-based approach for intrapartum antibiotic prophylaxis, we introduced an antenatal GBS carriage screening programme to identify additional women to target for prophylaxis.

OBJECTIVES

To describe the implementation and outcome of an antepartum screening programme for prevention of invasive early-onset GBS infection in a UK maternity unit.

DESIGN

Observational study of outcome of screening programme (intervention) with comparison to historical controls (preintervention).

SETTING

Hospital and community-based maternity services provided by Northwick Park and Central Middlesex Hospitals in North West London.

PARTICIPANTS

Women who gave birth between March 2014 and December 2015 at Northwick Park Hospital.

METHODS

Women were screened for GBS at 35-37 weeks and carriers offered intrapartum antibiotic prophylaxis. Screening programme was first introduced in hospital (March 2014) and then in community (August 2014). Compliance was audited by review of randomly selected case records. Invasive early-onset GBS infections were defined through GBS being cultured from neonatal blood, cerebrospinal fluid or sterile fluids within 0-6 days of birth.

MAIN OUTCOME

Incidence of early-onset GBS infections.

RESULTS

6309 (69%) of the 9098 eligible women were tested. Screening rate improved progressively from 42% in 2014 to 75% in 2015. Audit showed that 98% of women accepted the offer of screening. Recto-vaginal GBS carriage rate was 29.4% (1822/6193). All strains were susceptible to penicillin but 11.3% (206/1822) were resistant to clindamycin. Early onset GBS rate fell from 0.99/1000 live births (25/25276) in the prescreening period to 0.33/1000 in the screening period (Rate Ratio=0.33; p=0.08). In the subset of mothers actually screened, the rate was 0.16/1000 live births (1/6309), (Rate Ratio=0.16; p<0.05).

CONCLUSIONS

Our findings confirm that an antenatal screening programme for prevention of early-onset GBS infection can be implemented in a UK maternity setting and is associated with a fall in infection rates.

Efficacy of epidural local anesthetic and dexamethasone in providing postoperative analgesia: A meta-analysis

BACKGROUND

Dexamethasone is a potent anti-inflammatory, analgesic, and antiemetic drug. Individual randomized controlled trials found a possible benefit of epidural dexamethasone. The purpose of this meta-analysis is to estimate the benefit of epidural dexamethasone on postoperative pain and opioid consumption and to formulate a recommendation for evidence-based practice.

MATERIALS AND METHODS

Prospective, randomized controlled trials comparing the analgesic efficacy of epidural local anesthetic and dexamethasone combination, with local anesthetic alone for postoperative pain management after abdominal surgery, were planned to be included in this meta-analysis. PubMed, PubMed Central, Scopus, and Central Register of Clinical Trials of the Cochrane Collaboration (CENTRAL) databases were searched for eligible controlled trials using the following search words: "Epidural", "dexamethasone", and "postoperative pain", until February 20, 2015.

RESULTS

Data from five randomized control trials have been included in this meta-analysis. Epidural dexamethasone significantly decreased postoperative morphine consumption (mean difference -7.89 mg; 95% confidence interval [CI]: -11.66 to -3.71) and number of patients required postoperative rescue analgesic boluses (risk ratio: 0.51; 95% CI: 0.41-0.63).

CONCLUSION

The present data shows that the addition of dexamethasone to local anesthetic in epidural is beneficial for postoperative pain management.

Antibiotics for tonsillitis: should the emergency department emulate general practice?

Objectives

To determine whether antibiotics are prescribed appropriately for acute tonsillitis in an emergency department (ED).

Methods

Cross-sectional observational study in large district general hospital in London. Patients diagnosed and coded with ‘acute tonsillitis’ in the ED over a 3-month period in 2015. Medical records were reviewed for Centor criteria, which is a clinical scoring system to guide antibiotic prescribing in UK general practice. Drug charts were reviewed for the specific antibiotic(s) prescribed, and throat swab (TS) cultures were recorded.

Results

273/389 patients with tonsillitis were analysed—186 children, 87 adults. Exclusions were missing patient records (86), patients had/awaiting tonsillectomy (22), receiving antibiotics (6) and immunocompromised (2). Centor score (CS) was not recorded for any patient. Based on derived CS from documented signs/symptoms, antibiotics were prescribed inappropriately to 196/273 patients (80%; 95% CI 74% to 85%) including broad-spectrum antibiotics to 25%. These included co-amoxiclav (18%), amoxicillin (6%), azithromycin (0.5%) and ceftriaxone (0.5%). TSs were taken in 66/273(24%) patients; 10/66 were positive for group A streptococcus (GAS). However, 48/56 GAS negative patients were prescribed antibiotics.

Conclusions

CS was not being used in the ED to guide antibiotic prescribing for acute tonsillitis. Antibiotic prescribing was based on clinical judgement. Based on derived CS (<3), 80% of patients were inappropriately prescribed antibiotics, particularly broad-spectrum antibiotics. Further studies need to assess use of CS to guide antibiotic prescription in ED. TSs were commonly performed in the ED but did not either improve diagnosis or guide antibiotic prescription.

Smoking cessation advice for people with serious mental illness

BACKGROUND

People with a serious mental illness are more likely to smoke more and to be more dependent smokers than the general population. This may be due to a wide range of factors that could include a common aetiology to both smoking and the illness, self medication, smoking to alleviate adverse effects of medications, boredom in the existing environment, or a combination of these factors. It is important to undertake this review to facilitate improvements in both the health and safety of people with serious mental illness who smoke, and to reduce the overall burden of costs (both financial and health) to the smoker and, eventually, to the taxpayer.

OBJECTIVES

To review the effects of smoking cessation advice for people with serious mental illness.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Specialized Trials Register up to 2 April 2015, which is based on regular searches of CENTRAL, BIOSIS, PubMed, MEDLINE, EMBASE, CINAHL, PsycINFO, and trial registries. We also undertook unsystematic searches of a sample of the component databases (BNI, CINHAL, EMBASE, MEDLINE, and PsycINFO), up to 2 April 2015, and searched references of all identified studies

SELECTION CRITERIA

We planned to include all randomised controlled trials (RCTs) that focussed on smoking cessation advice versus standard care or comparing smoking cessation advice with other more focussed methods of delivering care or information.

DATA COLLECTION AND ANALYSIS

The review authors (PK, AC, and DB) independently screened search results but did not identify any trials that fulfilled the inclusion criteria of this review.

MAIN RESULTS

We did not identify any RCTs that evaluated advice regarding smoking cessation for people with serious mental illness. The excluded studies illustrate that randomisation of packages of care relevant to smokers with serious mental illness is possible.

AUTHORS' CONCLUSIONS

People with serious mental illness are more likely to smoke than the general population. Yet we could not find any high quality evidence to guide the smoking cessation advice healthcare professionals pass onto service users. This is an area where trials are possible and needed.

Rate of Latent Tuberculosis Infection Detected by Occupational Health Screening of Nurses New to a London Teaching Hospital

The prevalence of latent tuberculosis infection in a cohort of nurses new to a London hospital was 7.6% (13 of 171), using an interferon-γ(IFN-γ) release assay, and 16.2% (24 of 148), using the tuberculin skin test. On multivariate analysis, birth in a country with tuberculosis prevalence of more than 40 cases per 100,000 population was associated with positive results of both the IFN-γ release assay and the tuberculin skin test.

Aripiprazole versus other atypical antipsychotics for schizophrenia

BACKGROUND

In most western industrialised countries, second generation (atypical) antipsychotics are recommended as first-line drug treatments for people with schizophrenia. In this review, we specifically examine how the efficacy and tolerability of one such agent - aripiprazole - differs from that of other comparable second generation antipsychotics.

OBJECTIVES

To review the effects of aripiprazole compared with other atypical antipsychotics for people with schizophrenia and schizophrenia-like psychoses.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (November 2012), inspected references of all identified studies for further trials and contacted relevant pharmaceutical companies, drug approval agencies and authors of trials for additional information.

SELECTION CRITERIA

We included all randomised clinical trials (RCTs) comparing aripiprazole (oral) with oral and parenteral forms of amisulpride, clozapine, olanzapine, quetiapine, risperidone, sertindole, ziprasidone or zotepine for people with schizophrenia or schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we calculated risk ratios (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis based on a random-effects model. Where possible, we calculated illustrative comparative risks for primary outcomes. For continuous data, we calculated mean differences (MD), again based on a random-effects model. We assessed risk of bias for each included study and used GRADE approach to rate quality of evidence.

MAIN RESULTS

We now have included 174 trials involving 17,244 participants. Aripiprazole was compared with clozapine, quetiapine, risperidone, ziprasidone and olanzapine. The overall number of participants leaving studies early was 30% to 40%, limiting validity (no differences between groups).When compared with clozapine, there were no significant differences for global state (no clinically significant response, n = 2132, 29 RCTs, low quality evidence); mental state (BPRS, n = 426, 5 RCTs, very low quality evidence); or leaving the study early for any reason (n = 240, 3 RCTs, very low quality evidence). Quality of life score using the WHO-QOL-100 scale demonstrated significant difference, favouring aripiprazole (n = 132, 2 RCTs, RR 2.59 CI 1.43 to 3.74, very low quality evidence). General extrapyramidal symptoms (EPS) were no different between groups (n = 520, 8 RCTs,very low quality evidence). No study reported general functioning or service use.When compared with quetiapine, there were no significant differences for global state (n = 991, 12 RCTs, low quality evidence); mental state (PANSS positive symptoms, n = 583, 7 RCTs, very low quality evidence); leaving the study early for any reason (n = 168, 2 RCTs, very low quality evidence), or general EPS symptoms (n = 348, 4 RCTs, very low quality evidence). Results were significantly in favour of aripiprazole for quality of life (WHO-QOL-100 total score, n = 100, 1 RCT, MD 2.60 CI 1.31 to 3.89, very low quality evidence). No study reported general functioning or service use.When compared with risperidone, there were no significant differences for global state (n = 6381, 80 RCTs, low quality evidence); or leaving the study early for any reason (n = 1239, 12 RCTs, very low quality evidence). Data were significantly in favour of aripiprazole for improvement in mental state using the BPRS (n = 570, 5 RCTs, MD 1.33 CI 2.24 to 0.42, very low quality evidence); with higher adverse effects seen in participants receiving risperidone of general EPS symptoms (n = 2605, 31 RCTs, RR 0.39 CI 0.31 to 0.50, low quality evidence). No study reported general functioning, quality of life or service use.When compared with ziprasidone, there were no significant differences for global state (n = 442, 6 RCTs, very low quality evidence); mental state using the BPRS (n = 247, 1 RCT, very low quality evidence); or leaving the study early for any reason (n = 316, 2 RCTs, very low quality evidence). Weight gain was significantly greater in people receiving aripiprazole (n = 232, 3 RCTs, RR 4.01 CI 1.10 to 14.60, very low quality evidence). No study reported general functioning, quality of life or service use.When compared with olanzapine, there were no significant differences for global state (n = 1739, 11 RCTs, very low quality evidence); mental state using PANSS (n = 1500, 11 RCTs, very low quality evidence); or quality of life using the GQOLI-74 scale (n = 68, 1 RCT, very low quality of evidence). Significantly more people receiving aripiprazole left the study early due to any reason (n = 2331, 9 RCTs, RR 1.15 CI 1.05 to 1.25, low quality evidence) and significantly more people receiving olanzapine gained weight (n = 1538, 9 RCTs, RR 0.25 CI 0.15 to 0.43, very low quality evidence). None of the included studies provided outcome data for the comparisons of 'service use' or 'general functioning'.

AUTHORS' CONCLUSIONS

Information on all comparisons is of limited quality, is incomplete and problematic to apply clinically. The quality of the evidence is all low or very low. Aripiprazole is an antipsychotic drug with an important adverse effect profile. Long-term data are sparse and there is considerable scope for another update of this review as new data emerge from ongoing larger, independent pragmatic trials.