P16 Strengthening surveillance systems for antimicrobial resistance in urinary tract infections in Kenya

Background

Urinary tract infections (UTIs) are amongst the most common conditions leading to outpatient visits and are also one of the most common causes of inappropriate antibiotic usage. Addressing antimicrobial resistance (AMR) requires strengthening surveillance system in Kenya where UTI is a problem with health systems having limited capacity for accurate laboratory identification of UTI pathogens. Empirical treatment to manage UTIs is the most common problem due to limited microbiology capacity. These include shortages of suitable training, equipment, quality control procedures and professional expertise to make an accurate clinical interpretation of urine cultures. This leads to reporting normal flora as pathogens.

Objectives

To deliver training on the identification and antibiotic susceptibility testing of bacterial isolates from urine infections at participating hospitals in the Kenyan AMR surveillance network and measure competency levels in staff participating in the training with the aim of strengthening the Kenyan surveillance system.

Methods

A 1 day baseline visit to the five sites was made between October and November 2021 using a standardized checklist to assess laboratory capacity. This was followed by urine processing training conducted between November 2021 and January 2022 in Malindi, Jaramogi, Kitale, Nakuru and Nyeri County Hospitals. Training materials were developed with the input of Aga Khan University Hospital. A 5 day in-person training course was delivered at each of the five hospitals, which targeted an average of 2–3 laboratory staff per hospital. The competencies of the laboratory staff were assessed by written pre-assessment and post-assessment tests. A standardized practical assessment was achieved by use of five different control organisms. The scores were done by doing an average performance score at each hospital laboratory.

Results

Out of 13 trainees, 8 were male and 5 were female. The median number of years since qualification for these staff was 6 (IQR 2–9). The median number of total months of microbiology training time was 2.3 (IQR 1–7). The median pre-training and post-training scores were 46% and 90%, respectively; non-parametric Wilcoxon rank test showed statistical difference (P < 0.0001) between pre-training and post-training. All participants improved from pre-to post- training assessment from the 5 day training with marked improvement amongst from staff with lowest previous level of laboratory training.

Conclusions

Training microbiology staff in the accurate processing of urine sample will be an important activity for a Kenyan AMR surveillance system. These training materials, if delivered by an experienced trainer, can achieve a clear improvement in knowledge levels and practical competence for real-life microbiology identifications.

Concordance between physiotherapists and physicians for care of patients with musculoskeletal disorders presenting to the emergency department

Background

Overcrowding in emergency departments (ED) is a major concern worldwide. To answer increasing health care demands, new models of care including advanced practice physiotherapists (APP) have been implemented in EDs. The purpose of this study was to assess diagnostic, treatment and discharge plan concordance between APPs and ED physicians for patients consulting to the ED for minor musculoskeletal disorders (MSKD).

Methods

Patients presenting to two EDs in Montréal (Canada) with a minor MSKD were recruited and independently assessed by an APP and ED physician. Both providers had to formulate diagnosis, treatment and discharge plans. Cohen’s kappa (κ) and Prevalence and Bias Adjusted Kappas (PABAK) with associated 95%CI were calculated. Chi Square and t-tests were used to compare treatment, discharge plan modalities and patient satisfaction between providers.

Results

One hundred and thirteen participants were recruited, mean age was 50.3 ± 17.4 years old and 51.3% had an atraumatic MSKD. Diagnostic inter-rater agreement between providers was very good (κ = 0.81; 95% CI: 0.72–0.90). In terms of treatment plan, APPs referred significantly more participants to physiotherapy care than ED physicians (κ = 0.27; PABAK = 0.27; 95% CI: 0.07–0.45; p = 0.003). There was a moderate inter-rater agreement (κ = 0.46; PABAK = 0.64; 95% CI: 0.46–0.77) for discharge plans. High patient satisfaction was reported with no significant differences between providers (p = 0.57).

Conclusion

There was significant agreement between APPs and ED physicians in terms of diagnosis and discharge plans, but more discrepancies regarding treatment plans. These results tend to support the integration of APPs in ED settings, but further prospective evaluation of the efficiency of these types of models is warranted.

What do primary care providers think about implementing breast cancer survivorship care?

Purpose

As cancer centres move forward with earlier discharge of stable survivors of early-stage breast cancer (bca) to primary care follow-up, it is important to address known knowledge and practice gaps among primary care providers (pcps). In the present qualitative descriptive study, we examined the practice context that influences implementation of existing clinical practice guidelines for providing such care. The purpose was to determine the challenges, strengths, and opportunities related to implementing comprehensive evidence-based bca survivorship care guidelines by pcps in southeastern Ontario.

Methods

Semi-structured interviews were conducted with 19 pcps: 10 physicians and 9 nurse practitioners.

Results

Thematic analysis revealed 6 themes within the broad categories of knowledge, attitudes, and resources. Participants highlighted 3 major challenges related to providing bca survivorship care: inconsistent educational preparation, provider anxieties, and primary care burden. They also described 3 major strengths or opportunities to facilitate implementation of survivorship care guidelines: tools and technology, empowering survivors, and optimizing nursing roles.

Conclusions

We identified several important challenges to implementation of comprehensive evidence-based survivorship care for bca survivors, as well as several strengths and opportunities that could be built upon to address those challenges. Findings from our research could inform targeted knowledge translation interventions to provide support and education for pcps and bca survivors.

Sham acupuncture is as efficacious as true acupuncture for the treatment of IBS: A randomized placebo controlled trial

BACKGROUND

Irritable bowel syndrome (IBS) patients increasingly seek out acupuncture therapy to alleviate symptoms, but it is unclear whether the benefit is due to a treatment-specific effect or a placebo response. This study examined whether true acupuncture is superior to sham acupuncture in relieving IBS symptoms and whether benefits were linked to purported acupuncture mechanisms.

METHODS

A double blind sham controlled acupuncture study was conducted with Rome I IBS patients receiving twice weekly true acupuncture for 4 weeks (n=43) or sham acupuncture (n=36). Patients returned at 12 weeks for a follow-up review. The primary endpoint of success as determined by whether patients met or exceeded their established goal for percentage symptom improvement. Questionnaires were completed for symptom severity scores, SF-36 and IBS-36 QOL tools, McGill pain score, and Pittsburg Sleep Quality Index. A subset of patients underwent barostat measurements of rectal sensation at baseline and 4 weeks.

KEY RESULTS

A total of 53% in the true acupuncture group met their criteria for a successful treatment intervention, but this did not differ significantly from the sham group (42%). IBS symptom scores similarly improved in both groups. Scores also improved in the IBS-36, SF-36, and the Pittsburg Sleep Quality Index, but did not differ between groups. Rectal sensory thresholds were increased in both groups following treatment and pain scores decreased; however, these changes were similar between groups.

CONCLUSIONS & INFERENCES

The lack of differences in symptom outcomes between sham and true treatment acupuncture suggests that acupuncture does not have a specific treatment effect in IBS.

Parental supply of alcohol and alcohol consumption in adolescence: prospective cohort study

BACKGROUND

Parents are a major supplier of alcohol to adolescents, yet there is limited research examining the impact of this on adolescent alcohol use. This study investigates associations between parental supply of alcohol, supply from other sources, and adolescent drinking, adjusting for child, parent, family and peer variables.

METHOD

A cohort of 1927 adolescents was surveyed annually from 2010 to 2014. Measures include: consumption of whole drinks; binge drinking (>4 standard drinks on any occasion); parental supply of alcohol; supply from other sources; child, parent, family and peer covariates.

RESULTS

After adjustment, adolescents supplied alcohol by parents had higher odds of drinking whole beverages [odds ratio (OR) 1.80, 95% confidence interval (CI) 1.33-2.45] than those not supplied by parents. However, parental supply was not associated with bingeing, and those supplied alcohol by parents typically consumed fewer drinks per occasion (incidence rate ratio 0.86, 95% CI 0.77-0.96) than adolescents supplied only from other sources. Adolescents obtaining alcohol from non-parental sources had increased odds of drinking whole beverages (OR 2.53, 95% CI 1.86-3.45) and bingeing (OR 3.51, 95% CI 2.53-4.87).

CONCLUSIONS

Parental supply of alcohol to adolescents was associated with increased risk of drinking, but not bingeing. These parentally-supplied children also consumed fewer drinks on a typical drinking occasion. Adolescents supplied alcohol from non-parental sources had greater odds of drinking and bingeing. Further follow-up is necessary to determine whether these patterns continue, and to examine alcohol-related harm trajectories. Parents should be advised that supply of alcohol may increase children's drinking.

Clinical presentation and outcome of tuberculosis patients infected by M. africanum versus M. tuberculosis

SETTING

A tuberculosis (TB) case contact study in the Gambia.

OBJECTIVE

To test whether Mycobacterium africanum, which has lost around 68 kb compared with M. tuberculosis sensu stricto, causes less severe TB disease.

DESIGN

We genotyped mycobacterial isolates and compared clinical and radiological characteristics as well as outcome data of M. africanum-infected TB patients with those infected with M. tuberculosis.

RESULTS

Of 317 index cases, 301 had a mycobacterial isolate available, 290 of which had an interpretable spoligotype pattern. Of these, 110 isolates (38%) were M. africanum and 180 (62%) were M. tuberculosis. M. africanum cases had lower body mass indices (17 vs. 17.45 for M. tuberculosis-infected patients, P = 0.029) and their radiographic disease was more extensive (96% vs. 89% had at least moderately severe radiographic changes, P = 0.031). Outcome on treatment was similar (2.8% of human immunodeficiency virus [HIV] negative M. africanum patients died on treatment vs. 3.0% of M. tuberculosis patients, P = 0.95).

CONCLUSION

M. africanum causes sputum smear-positive tuberculosis disease that is at least as severe as that caused by M. tuberculosis sensu stricto. Further clinical comparisons may be helpful in smear-negative patients and HIV-TB co-infected patients, and to identify whether there is any difference in time to develop disease.

Post-operative pain relief in children following extraction of carious deciduous teeth under general anaesthesia: a comparison of nalbuphine and diclofenac

In a randomized double-blind study 60 children, undergoing the extraction of carious deciduous teeth under day-case general anaesthesia, were assigned to receive either intravenous nalbuphine hydrochloride 0.3 mg kg-1 (n = 21), one or more diclofenac suppositories 12.5 mg to a dose of 1-2 mg kg-1 (n = 19), or no analgesia (n = 20). The duration of anaesthesia was longer in the diclofenac group (9.6 min, SD 3.5) compared with control (7.2 min, SD 2.6) and nalbuphine (6.9 min, SD 3.0) groups respectively (P < 0.05). There were no statistically significant differences in post-operative pain scores during the 45 min post-operative period studied between the three groups using an objective pain score. We conclude that using this methodology we were unable to demonstrate any statistically significant differences between the analgesic effects of either intravenous (i.v.) nalbuphine or diclofenac suppositories compared with control.