P2498Exercise capacity and all-cause mortality in remote Indigenous and non-Indigenous populations

Background

Exercise capacity is a powerful predictor of all-cause mortality. However, its association with Indigenous populations in Central Australia, who face disproportionate health burdens, is unclear. Given the isolation from tertiary centers, exercise testing could provide useful local risk-stratification.

Purpose

To characterize the association of exercise capacity with all-cause mortality in Indigenous and non-Indigenous individuals in remote Central Australia.

Methods

Demographic, medication, and all-cause mortality data were prospectively collected from patients undergoing exercise stress tests from 2007–2017.

Results

A total of 3,414 patients (34% Indigenous) were included. At 4.8±2.9 years of follow-up, 86 (2.5%) deaths had occurred. Each 1-MET increase in exercise capacity conferred a 14% lower risk for mortality among Indigenous individuals (HR 0.86, 95% CI 0.79–0.94) and 20% lower risk for mortality among non-Indigenous individuals (HR 0.80, 95% CI 0.73–0.89) after adjusting for age, comorbidities, and medications. Mortality risk reduction for each 1-MET increase in exercise capacity was similar (p=0.32) for Indigenous and non-Indigenous individuals.

Conclusions

Exercise capacity is a significant predictor of all-cause mortality in Indigenous and non-Indigenous individuals. These findings have important clinical implications towards exercise capacity for risk-stratification and preventative importance of physical activity.

Primary biliary cirrhosis (PBC), PBC autoantibodies, and hepatic parameter abnormalities in a large population of systemic sclerosis patients

OBJECTIVE

To investigate the diagnostic accuracy of antimitochondrial antibodies (AMA), sp100, and gp210 antibodies for primary biliary cirrhosis (PBC) in a large population of patients with systemic sclerosis (SSc); to examine concordance of these antibodies with subsets of SSc. Further, to assess the association of SSc-related antibodies with hepatic parameter abnormalities.

METHODS

We obtained medical records to verify the diagnoses of SSc and PBC. Sera from all participants were examined for the presence of SSc- and PBC-related antibodies, as well as for abnormalities in hepatic parameters.

RESULTS

We examined 817 patients with SSc, of whom 16 (2%) had confirmed PBC. The sensitivity and specificity of AMA by a MIT3 ELISA for PBC were 81.3% and 94.6%, respectively. Sp100 had a sensitivity and specificity of 31.3% and 97.4%, respectively, while gp210 had an even lower sensitivity. We were able to detect all PBC cases using AMA(MIT3) and sp100 as a combined marker, resulting in a significantly improved sensitivity of 100% (p = 0.042) with an incremental decrease in specificity to 92.6%. Independent of AMA or sp100 status, there was an association of anticentromere B (CENP-B) and anti-topoisomerase antibodies (ATA) with higher alkaline phosphatase levels (p = 0.051 and p = 0.003, respectively) while anti-RNA polymerase III (anti-RNAP) was associated with lower alkaline phosphatase levels (p = 0.019) among the patients with SSc.

CONCLUSION

Utilization of AMA(MIT3) and sp100 antibodies as a combined diagnostic marker leads to an improved detection of PBC in patients with SSc. CENP-B and ATA are associated with alkaline phosphatase elevation.

Evaluation of a model for maximizing interprofessional education in an acute hospital

A one-year planning phase established a rolling programme of bi-monthly interprofessional clinical teaching workshops derived directly from patient experiences in an acute hospital. Pre-registration healthcare students from 8 professions spent an afternoon in the hospital training centre, randomly allocated to one of 6-8 small working groups. Using a problem-based methodology they analysed a ward case with patient consent, chosen to reflect the input of a wide range of health professionals. Students worked through a prepared workbook facilitated by a range of tutors from all disciplines. Each small group reported back on one aspect of team working to the entire cohort entering into debate and discussion with the support of clinical and academic tutors. Post course patient details were found on a website enabling students to progress their uni-professional knowledge, e.g., on anatomy, physiology, pharmacology etc. The questionnaire evaluation on over 126 students and 11 tutors identified that interprofessional competencies were understood and valued. Students related principles of team working and collaborative practice to their placement experiences of team work. Interactive learning enables further appreciation of professions roles and responsibilities and the importance of teamwork to optimize patient care (82.0 - 90.5%). The half-day learning model can be easily supported by busy clinical staff, led by hospital educators and accessed by students on hospital placements, at a mid-point in training, with learning supported by consenting in-patients or recent admissions prepared to share their experiences.

Tacrolimus (FK506) in the treatment of severe, refractory rheumatoid arthritis: initial experience in 12 patients

OBJECTIVE

To determine if tacrolimus (FK506) has potential as a therapeutic agent in patients with severe and/or refractory rheumatoid arthritis (RA).

METHODS

Twelve patients with RA who had severe and active disease and had failed an average of 5.3 disease modifying antirheumatic drugs (DMARD) were treated with tacrolimus 2-6 mg/day in an open label study. Patients were assessed monthly with respect to RA outcomes and drug related toxicities.

RESULTS

Of the 12 patients, 7 were able to complete 6 months of treatment. In these 7 patients, significant improvements were seen in tender joint count (from 26.4 +/- 4.2 to 11.7 +/- 3.2; p = 0.007), swollen joint count (from 17.7 +/- 2.5 to 4.1 +/- 1.3; p = 0.001), and other RA outcomes. All 7 patients achieved the 20% response criteria of the American College of Rheumatology (ACR), and 5 of 7 patients met the ACR 50% response criteria. The other 5 patients withdrew in the first 3 months of treatment due to gastrointestinal symptoms (3), chest pain (1), and neuropathic pain (1). Serum creatinine levels were unchanged in all patients, and hypertension was not seen.

CONCLUSION

Tacrolimus was tolerated by only 7 of 12 patients, but in 5 of these 7 patients with severe and refractory disease, the clinical responses were very good.

Audit of catheter urine culture requests

An audit to assess the appropriateness of catheter urine culture requests was carried out for a period of one month. The requests were followed up by members of the Infection Control Team at ward level. The laboratory report had no impact on the removal of the catheter in asymptomatic or symptomatic patients, although the reports did aid antibiotic prescribing in symptomatic patients.

Intraperitoneal penetration of ticarcillin/clavulanic acid (Timentin)

Thirty-eight patients undergoing elective abdominal surgery were given 3.0 g ticarcillin plus 0.2 g clavulanic acid as a single intravenous injection at varying times prior to the operation. Sterile assay discs were placed on the peritoneal surface in order to measure peritoneal fluid levels of each agent. Simultaneous serum levels were also measured. A total of 38 serum and peritoneal samples were analysed. There was rapid penetration of both agents into peritoneal fluid. The mean peritoneal fluid levels of ticarcillin were 70% (S.D. 13) of the serum level and 67% (S.D. 4) for clavulanic acid. The peritoneal levels of both agents declined in parallel to the serum levels (the half-lives being about 1 h) and the ratio of ticarcillin-clavulanic acid in serum and peritoneal fluid did not vary significantly with time.

In vitro activity of Ro 23-6240, a new difluoroquinolone derivative, compared with that of other antimicrobial agents

Ro 23-6240 is a new difluorinated quinolone antimicrobial agent. Its in vitro activity against a wide range of bacteria was compared with those of other quinolones and beta-lactams. Generally, members of the family Enterobacteriaceae were inhibited by low concentrations of Ro 23-6240 (MIC90 [MIC for 90% of isolates tested], less than or equal to 1 microgram/ml). Ninety percent of Staphylococcus aureus (including methicillin-resistant strains) and Neisseria gonorrhoeae isolates were inhibited by 0.5 microgram/ml. Pseudomonas aeruginosa (MIC90, 2 micrograms/ml) and Bacteroides fragilis (MIC90, 4 micrograms/ml) showed intermediate susceptibility, and Streptococcus pneumoniae (MIC90, 8 micrograms/ml) was less susceptible. Strains resistant to nalidixic acid were less susceptible to all the quinolones tested. The protein binding of Ro 23-6240 (5 micrograms/ml) was 27%.