Capacity building to address antimicrobial resistance in remote Australia: The inaugural HOT NORTH Antimicrobial Academy

BACKGROUND

Rates of antimicrobial resistance (AMR) for some pathogens in Australia are considerably higher in rural and remote compared to urban regions. The inaugural Hot North Antimicrobial Academy was a 9-month educational programme aimed to build workforce knowledge and capacity in antimicrobial use, audit, stewardship, surveillance and drug resistance in remote primary health care.

METHODS

The Academy was advertised to Aboriginal and Torres Strait Islander, regional and remote healthcare workers. Participants were Aboriginal health practitioners, nurses, pharmacists and doctors from Queensland, Northern Territory, South Australia and Western Australia working in remote primary health care with a focus on Indigenous health. Due to COVID-19 restrictions, the Academy ran virtually from February-November 2021 using Microsoft Teams. The Academy was evaluated using surveys and yarning circles to assess impact and knowledge gain.

RESULTS

Participants and faculty from across Australia attended 19 lectures and mentorship sessions. Eleven participants commenced and eight (73%) completed the Academy. The Academy raised participants awareness of AMR guidelines, governance and generating change; built confidence in advocacy; grew knowledge about drug resistant infections; and created a community of AMR champions in Indigenous health.

CONCLUSION

The evaluation confirmed the Academy met the needs of participants, provided opportunities to move stewardship from tertiary hospitals into Indigenous and remote clinics and developed skills in research, audit, stewardship and advocacy for all involved. All sessions were recorded for future use, with facilitation by the National Aboriginal Community Controlled Health Organisation (NACCHO) in future years.

AB0980 Hand Osteoarthritis: investigating Pain Effects in a randomised placebo-controlled feasibility study of estrogen-containing therapy (HOPE-e): report on the primary feasibility outcomes

Background

There is an unmet need for new treatments for hand osteoarthritis (OA). Symptomatic hand OA is more common in women and its incidence increases round the age of menopause. Pre-clinical, epidemiological and post hoc studies in Hormone Replacement Therapy (HRT) trials implicate estrogen deficiency as of likely importance in OA aetiopathogenesis. No clinical trials of HRT have been carried out in hand OA to date. The licensed HRT Duavive (conjugated estrogens + SERM bazedoxifene) was selected on its potential for efficacy and tolerability.

Objectives

We set out to determine the feasibility and acceptability of this form of HRT in post-menopausal women with hand OA, to generate proof of concept data and refine methods for a full study.

Methods

ISRCTN12196200. Females aged 40-65 yrs and 1-10yrs after final menstrual period with hand OA fulfilling ACR criteria and 2+ painful hand joints were recruited. Eligibility incorporated best practice for HRT prescription but did not require menopausal symptoms. Recruitment was at 3 sites in primary/secondary care, including directly from the community. Design was parallel group, double-blind 1:1 randomisation of Duavive or placebo, orally once daily for 24 weeks, then weaning for 4 weeks before stopping. Routes and rates of recruitment and the acceptability of randomisation, medication (compliance, retention), and proposed outcomes were measured, and the likelihood of unblinding. Measures related to hand pain and function, menopause symptoms and joint appearance. Patient and Public Involvement actively informed study rationale, design and materials. An end of study questionnaire and 2 participant focus groups provided further acceptability data.

Results

Recruitment was for 12/possible 18 months, interrupted due to COVID-19. Some study procedures were modified to allow reopening whilst collecting all primary outcomes. 434 enquiries/referrals were received, leading to 96 telephone pre-screens, of which 33 gave written informed consent and attended face to face screening. 28/33 screened (85%) were eligible and randomised. The highest number of randomisations was from study web presence (n=7) followed by SMS text from GP surgeries (n=5). Of 401 not proceeding, 250 (62%) were ineligible, most commonly due to contraindicated medication, followed by medical contraindication, whilst 55 (14%) decided not to take part, for reasons including not wanting to take a hormone-based drug or difficulty attending study visits. Retention and compliance were excellent. All 28 participants completed all study follow ups, with only 3 withdrawals from treatment due to AEs, 2 of these at week 24 and all in the placebo arm. There were no serious AEs. High levels of completeness of all study outcome measures were achieved. Bang’s blinding index suggested that participants/investigators were well blinded. There were overall high/good levels of satisfaction with taking part in the study. 26/28 (92%) would recommend taking part to others with hand OA (irrespective of study arm). Many found the flexibility offered by a combination of remote and face to face visits (due to the pandemic) attractive. Additional insights from focus groups were to include hand stiffness as well as pain measures but to reduce the overall number of questions.

Conclusion

Despite COVID-19 and a reduced recruitment period, this study recruited sufficient numbers to assess feasibility outcomes. Randomisation of eligible people and retention rates were high. A mixture of remote and face to face visits due to COVID-19 probably improved recruitment and retention and was supported by participants, who were generally satisfied with the study design and medication. The study provided useful insight and improvements that would be incorporated into a future study. Overall, this feasibility study showed that with clear messaging on eligibility and a defined recruitment strategy, recruitment and retention to a study testing this treatment is possible.

Acknowledgements

This research was funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0416-20023). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The study team thank the sites and the participants who made this research possible.

Disclosure of Interests

Jennifer A.E. Williams: None declared, Mae Chester-Jones: None declared, Anne Francis: None declared, Ioana Marian: None declared, Megan Goff: None declared, Gretchen Brewer: None declared, Malvika Gulati: None declared, Lucy Eldridge: None declared, Patrick Julier: None declared, Catherine Minns Lowe: None declared, Vicki Barber: None declared, Victoria Glover: None declared, Charles Mackworth-Young: None declared, Tonia Vincent Consultant of: Pfizer, Grant/research support from: Grant support from Fidia, Biosplice, Novartis, Pfizer as part of their contribution to an international consortium., Sarah E Lamb: None declared, Katy Vincent: None declared, Susan J Dutton: None declared, Fiona E Watt Consultant of: Pfizer, Grant/research support from: Pfizer and from Astellas Pharma (> 3 years ago)

Impact of newly adopted guidelines for management of children with isolated skull fracture

PURPOSE

In an effort to standardize practices and reduce unnecessary hospital resource utilization, we implemented guidelines for management of patients with isolated skull fractures (ISF). We sought to examine the impact of these guidelines.

METHODS

Patients with nondisplaced/depressed fracture of the skull vault without intracranial hemorrhage were prospectively enrolled from February 2010 to February 2014.

RESULTS

Eighty-eight patients (median age=10months) were enrolled. Fall was the most common mechanism of injury (87%). The overall admission rate was 57%, representing an 18% decrease from that reported prior to guideline implementation (2003-2008; p=0.001). Guideline criteria for admission included vomiting, abnormal neurologic exam, concern for abuse, and others. Forty-two percent of patients were admitted outside of the guideline, primarily because of young age (20%). Patients transferred from another hospital (36%) were more likely to be admitted, though the majority (63%) did not meet admission criteria. No ED-discharged patient returned for neurologic symptoms, and none reported significant ongoing symptoms on follow-up phone call.

CONCLUSIONS

Implementation of a new guideline for management of ISF resulted in a reduction of admissions without compromising patient safety. Young age remains a common concern for practitioners despite not being a criterion for admission. Interhospital transfer may be unnecessary in many cases.

Complete VACTERL evaluation is needed in newborns with rectoperineal fistula

PURPOSE

Given that a rectoperineal fistula is developmentally the most mature lesion in the spectrum of anorectal malformations, it is not clear whether it merits a complete VACTERL evaluation. We sought to determine if the same evaluation is required to rule out associated anomalies in newborns with rectoperineal fistula as those with more complex anorectal malformations.

METHODS

We performed a retrospective review of the pediatric colorectal center database at our tertiary care children's hospital from 2000 to 2012. Patients with anorectal malformations were categorized as rectoperineal fistula or "other" using the Krickenbeck classification. Records were reviewed to identify associated anomalies.

RESULTS

308 patients (156 males) were treated at our institution during the time period (rectoperineal fistula=102). Thirty-five (34%) patients with a perineal fistula had at least one associated anomaly. The most common anomalies were cardiac lesions (29% excluding PFO and PDA), genitourinary (20.6%), and malformations of the spine (15.7%). The overall occurrence of anomalies was lower than the "other" group.

CONCLUSION

Our review demonstrates that newborns with a rectoperineal fistula frequently have associated anomalies and should undergo an evaluation similar to more complex lesions. These findings illustrate the importance of a structured approach to the evaluation of even the most straightforward lesions.

Neural influence on slow muscle properties: inactivity with and without cross-reinnervation

The effects of altering (cross-reinnervation, CR) and/or eliminating (spinal isolation, SI) the activation-dependent neural input to the cat soleus for 8 months on its mechanical and biochemical properties were determined. The percent fast fibers was 0, 27, 38, and 54% for normal control (NC), NC-CR, SI, and SI-CR cats. Calcium-activated whole muscle myofibrillar adenosine triphosphatase activity was higher in SI-CR and NC cats. Isometric twitch speed properties and frequency of stimulation:tension response were faster in all experimental groups compared to NC. Maximum twitch and tetanic (Po) force, physiological cross-sectional area (PCSA), and specific tension (Po/PCSA) were unaffected in NC-CR cats, but reduced in SI and SI-CR cats. The soleus was more fatigable in SI-CR compared to NC cats. Alpha-glycerophosphate dehydrogenase activity was higher in all experimental groups compared to NC. All eight parameters reflecting the type of muscle were shifted toward those observed in a "faster" muscle in SI-CR vs. SI cats. These data suggest that electrically silent motoneurons can influence type-related skeletal muscle properties.

Assessing consumption of high-fat foods: the effect of grouping foods into single questions

Questionnaires on the frequency of consumption of foods are commonly used to measure dietary intake in epidemiologic research. To reduce the burden on respondents, questionnaires are often shortened by combining inquiries on similar foods into a single question. The effect of this practice on the reporting of dietary intake has never been investigated, however. To address this issue, we used two food frequency questionnaires in a telephone survey designed to rank adult residents of Alabama by their intake of dietary fat. One questionnaire included 29 questions about separate high-fat foods, whereas the other grouped these same foods into 14 questions. Compared with the 443 respondents interviewed using the 29-item separated-foods questionnaire, the 465 respondents responding to the 14-item grouped-foods questionnaire reported lower average intakes of the foods. In addition, a substantially higher percentage of respondents to the grouped-foods questionnaire reported never consuming the foods.

Efficacy of vaginal spaying and anabolic implants on growth and carcass characteristics in beef heifers

Ninety crossbred beef heifers averaging 260 kg were blocked by weight and allotted randomly to 15 pens of six heifers each, with three replicates per treatment. The treatments were spayed heifers (S); intact heifers (I); S + Synovex-H7 (SH); I + Synovex-H (IH); and S + Synovex-S7 (SS). The heifers were spayed vaginally with a Willis instrument; intact heifers were rectally palpated for reproductive soundness. Heifers were fed a growing diet (55 d), re-implanted and subsequently fed a finishing ration (73 or 101 d). All heifers were observed for estrus daily at approximately 0600 and 2000 until d 69. A jugular vein blood sample was obtained from each heifer on d 48, 55, 62 and 69 for blood progesterone analysis. Results of blood progesterone analysis and reproductive tract examination indicated that two spayed heifers were incompletely spayed, a 96% success rate. The SH and SS heifers continued to exhibit estrous behavior despite being successfully spayed. Heifers implanted with Synovex-H had greater (P less than .01) ADG and were more efficient (P less than .03) than nonimplanted heifers. The SS heifers had greater ADG (P less than .05) during the finishing phase than SH heifers, but no advantage of SS over SH was apparent during the growing phase. The overall ADG response to implantation was fourfold greater (P less than .07) in the spayed heifers than in the intact heifers (32 vs 8%). Heifers implanted with Synovex-H had greater adjusted hot carcass weight (P less than .02) and ribeye area (P less than .002) than nonimplanted heifers. For adjusted live weight and ribeye area, the response to implantation was approximately threefold greater in the spayed heifer than the intact heifer. These results demonstrate that spaying and implanting heifers can increase rates and efficiency of gain even though behavioral estrus is not eliminated.

Neural influences on the distribution of troponin I isotypes in the cat

An immunohistochemical technique was used to study changes in the distribution of fast and slow forms of troponin I (TN-I) in response to alterations in the nerve supply. Hind limb muscles from normal, spinal-isolated, and cordotomized cats, one leg of which had undergone cross innervation between slow (soleus) and fast (flexor hallucis longus, FHL) muscles, were examined. At 8 months after cross innervation of normal soleus by the FHL nerve, the number of fast TN-I-positive cells had increased from 0.26 to 22.1%. At 8 months after cross innervation of normal FHL muscle with the soleus nerve, the number of fast TN-I-positive cells had decreased from 86.5 to 30.5%. The number of intermediate cells staining for both fast and slow TN-I, increased considerably after cross innervation of both soleus and FHL muscles. Spinal isolation by itself had a dramatic effect on the distribution of fast and slow TN-I, converting almost all the originally slow fibers in the FHL and 60.0% of the soleus fibers to fast TN-I-positive cells in 8 months. Cordotomy, in contrast, produced an increase of only 15.6% in the soleus, and did not change the FHL. There was no quantitative difference in the crossed-and uncrossed muscles of spinal isolated cats. In cordotomized cats, cross innervation of the soleus by the FHL nerve resulted in 32.3% fast TN-I-positive cells, with some fiber type grouping. Thus, distribution of fast and slow forms of TN-I changed after each neural manipulation which altered amounts and patterns of muscle contraction and stretch.

Lumbosacral spinal isolation in cat: surgical preparation and health maintenance

This paper describes a preparation in which the skeletal neuromuscular system of the hind limb of the adult cat is rendered permanently quiet with respect to electrical and contractile activity. The surgical method, regime for maintaining the health of the cats, and the condition of the cats are reported in detail. The characteristics of the isolated neuromuscular system are briefly summarized. The lumbosacral spinal cord carrying the innervation to the lower hind limb was surgically isolated from excitatory inputs from both dorsal root afferent fibers and upper motoneurons. This was accomplished by a bilateral dorsal rhizectomy between two transections of the cord, just rostral to the L5 segment and approximately at the S3 segment. The laminectomy was restricted to retain laminar structures sufficient to protect the cord from mechanical stimulation. During the rostral transection, the ventral artery was spared, preserving the blood supply to the ventral region of isolated cord. Daily maintenance and surveillance procedures were extremely important, but simple and brief. With strict adherence to procedures for both surgery and care, the cats remained healthy except for bladder infections, and their hind legs were in chronic flaccid paralysis.

Vertebral location of cord segments innervating cat hind limb musculature

To facilitate future studies requiring efficient surgical access to spinal cord segments innervating cat hind limb muscles, lumbosacral cord segments L3 through S2 were located with reference to the dorsolateral tips of the rostral articular processes of the surrounding vertebrae. A map showing means and ranges of vertebral loci of these segments from 20 cats was constructed. Correlation analysis was then used to find a practical way of narrowing the predicted range of loci of segments supplying the lower hind limb muscles in a particular cat. Several of the midlumbar junctions were determined to be good predictors of the position of the S2-S3 junction, the caudal limit of hind limb innervation. However, L4-L5 was found to be the most feasible to use experimentally, because of the ease of exposing and identifying it. Because all of the lumbosacral segments L3 through S2 in a given cat show a similar tendency with regard to relative length, the positions of the segments L6 through S1 can be interpolated from the prediction of the S2-S3 junction.

Spinal innervation of flexor hallucis longus in the cat

The segmental levels of the innervation of the flexor hallucis longus (FHL) in the cat have been unclear. To clarify the location of the spinal innervation of the FHL, physiologic techniques were used both to identify the ventral roots supplying the FHL and to relate the distribution of its segmental innervation to that of another calf muscle, the soleus, in the same cat. The soleus was used as a reference because its innervation has been consistently located by several investigators using a variety of techniques. The contributions of the various lumbosacral ventral roots were assessed by measuring the muscle contractions produced by electrically stimulating individual roots. The FHL was found to be supplied only by roots L6 and L7 and the soleus, as reported by previous investigators, only by L7 and S1. In every cat, at least some part of the innervation to the FHL was rostral to that of the soleus. Comparison of these results with those of Sherrington, Romanes, and Jefferson strongly suggests that the FHL in the present study corresponds to the adjacent synergistic muscle labeled flexor digitorum longus by Sherrington and Romanes.

Alterations in cat skeletal neuromuscular junctions following prolonged inactivity

1. The distributions of acetylcholine (ACh) receptors, cholinesterase (ChE) activity and nerve terminals were studied on cat muscle fibres which had been inactive for 2-3 years. 2. Neuromuscular junctions increased in size as a result of sprouting of terminal branches. In addition some fibres were multiply innervated at separate sites. 3. In muscles from two cats, some areas at the junction showed ChE activity but had only a relatively low density of ACh receptors. 4. The extrajunctional receptor density was higher than in normal muscles but lower than in muscles denervated for up to 10 months.