Infectious diseases and antimicrobial prescribing: Online spaced education for junior doctors

BACKGROUND

Inappropriate antimicrobial prescribing may harm patients and drive antimicrobial resistance. Junior doctors' knowledge of infectious diseases and antimicrobial prescribing is inadequate. Online spaced case-based learning can improve knowledge.

OBJECTIVE

To develop infectious diseases and antimicrobial prescribing course content for online spaced education and assess its effectiveness and feasibility for junior doctors.

METHODS

Infectious diseases and antimicrobial course content was developed for an online spaced education platform (Qstream Inc., Burlington, MA). Junior doctors (postgraduate years 1-3) at two tertiary teaching hospitals in Sydney participated in the study. Course content was provided with Qstream at one hospital and at the other hospital via two face-to-face (FTF) tutorials from August to October 2017. Knowledge and self-confidence were compared before and after training within and between both cohorts.

RESULTS

Participation in the course was higher in the Qstream cohort with 48/127 (37.8%) completing the course compared with 44/110 (40%) attending one or both FTF sessions, of whom 22/110 (20%) attended both. Improvement in mean knowledge score from 69.7% to 81.5% in the Qstream cohort was significantly greater than the FTF cohort's minimal improvement from 67.6% to 67.9% (95% CI 2.79-20.33; P=0.01). In the Qstream cohort mean confidence rating (0-10) improvement from 5.14 to 6.55 was greater than the FTF group improvement from 5.37 to 5.85 (95% CI 0.132-1.171; P=0.02). Qstream feedback was very positive.

CONCLUSIONS

Online spaced education in infectious diseases and antimicrobial prescribing was feasible, acceptable and effective for junior doctors. It has potential to reduce inappropriate antimicrobial prescribing and warrants further investigation.

P3752Ablation of the superior left ganglionic plexus is not necessary for effective denervation of the sinoatrial and atrioventricular nodes

Background

Cardioneuroablation by targeting of atrial ganglionic plexi (GP) has been proposed as a new therapeutic option in selected patients with reflex syncope. Contribution of individual GPs to cardiac autonomic regulations is not fully established.

Purpose

Because consistent vagal responses have been observed during left superior pulmonary vein isolation in patients undergoing ablation for atrial fibrillation, we investigated whether standalone ablation of the superior left GP modifies the vagal input into the sinoatrial (SAN) and atrioventricular node (AVN).

Methods

Study hypothesis was investigated in otherwise healthy patients undergoing cardioneuroablation for symptomatic bradyarrhythmias. All had preprocedural atropine test suggesting functional disorder. Anatomically-navigated (CARTO-3) radiofrequency (RF) ablation (25–30 W/30 s/20 ml/min) at empirical GP sites was performed in general anaesthesia. Extracardiac high-frequency vagal nerve stimulation (25–60 V/30–50 Hz/0.05–0.1 ms) via right jugular vein was performed at baseline, after initial superior left GP ablation, and after the ablation of remaining septal and inferior GPs. High-frequency vagal nerve stimulation was always done in both sinus rhythm and atrial pacing. The elimination of all stimulation-induced vagal responses was the endpoint of the procedure.

Results

A study included 8 patients (34±8 years; 5 males). Six of them had recurrent syncope with cardioinhibitory response at the SAN (n=4), AVN (n=1) or both nodes (n=1); and 2 patients had symptomatic sinus bradycardia. At baseline, high-frequency vagal nerve stimulation induced long episodes of sinus arrest and advanced AV block in all patients. Cluster ablation at the superior left GP (RF time: 192±28 s) did not change the sinus rate (59±14 vs 60±15, NS), PQ interval (174±37 vs 173±37, NS), and did not induce any tangible change in SAN/AVN response to high-frequency vagal nerve stimulation. Subsequently, anterior right GP was targeted from the aspect of right atrium (n=7), from the anterior antrum of right pulmonary veins (n=6), and inferior GPs were targeted from the aspect of left atrium (n=7). This lesion set finally resulted in complete non-responsiveness of SAN and AVN to high-frequency vagal nerve stimulation in all patients. Ablation procedure overall (duration: 172±15 min; RF time: 988±306 s; radiation dose: 70±34 μGy·m2) led to sinus rate acceleration by a median of 29 (IQR: 18–38) bpm, increase of Wenckebach point by 21 (IQR: 9–28) bpm, and shortening of AVN effective refractory period by 40 (IQR: 15–73) ms.

Conclusions

Cardioneuroablation guided by extracardiac high-frequency vagal nerve stimulation can achieve complete denervation of SAN and AVN by ablation of postero(para)septal and inferior GPs only. Ablation of the superior left GP appears unnecessary and can be eliminated from the lesion set design.

Estimating the upper limit of prehistoric peak ground acceleration using an in situ, intact and vulnerable stalagmite from Plavecká priepast cave (Detrekői-zsomboly), Little Carpathians, Slovakia-first results

Earthquakes hit urban centres in Europe infrequently, but occasionally with disastrous effects. Obtaining an unbiased view of seismic hazard (and risk) is therefore very important. In principle, the best way to test probabilistic seismic hazard assessments (PSHAs) is to compare them with observations that are entirely independent of the procedure used to produce PSHA models. Arguably, the most valuable information in this context should be information on long-term hazard, namely maximum intensities (or magnitudes) occurring over time intervals that are at least as long as a seismic cycle. The new observations can provide information of maximum intensity (or magnitude) for long timescale as an input data for PSHA studies as well. Long-term information can be gained from intact stalagmites in natural caves. These formations survived all earthquakes that have occurred over thousands of years, depending on the age of the stalagmite. Their 'survival' requires that the horizontal ground acceleration (HGA) has never exceeded a certain critical value within that time period. Here, we present such a stalagmite-based case study from the Little Carpathians of Slovakia. A specially shaped, intact and vulnerable stalagmite in the Plavecká priepast cave was examined in 2013. This stalagmite is suitable for estimating the upper limit of horizontal peak ground acceleration generated by prehistoric earthquakes. The critical HGA values as a function of time going back into the past determined from the stalagmite that we investigated are presented. For example, at the time of Jókő event (1906), the critical HGA value cannot have been higher than 1 and 1.3 m/s2 at the time of the assumed Carnuntum event (∼340 AD), and 3000 years ago, it must have been lower than 1.7 m/s2. We claimed that the effect of Jókő earthquake (1906) on the location of the Plavecká priepast cave is consistent with the critical HGA value provided by the stalagmite we investigated. The approach used in this study yields significant new constraints on the seismic hazard, as tectonic structures close to Plavecká priepast cave did not generate strong earthquakes in the last few thousand years. The results of this study are highly relevant given that the two capitals, Vienna and Bratislava, are located within 40 and 70 km of the cave, respectively.

Implementation of risk stratified antibiotic therapy for neutropenic fever: what are the risks?

BACKGROUND

A new national guideline for the management of febrile patients with severe neutropenia uses a risk stratification score to tailor treatment.

AIMS

To evaluate the implementation of this guideline in a metropolitan teaching hospital.

METHODS

A protocol was developed for implementation of the national guidelines for patients with neutropenic fever or at risk because of recent chemotherapy. Medical records of all patients presenting with fever to the haematology and oncology service for 3 months in 2011 were audited. Patients with a neutrophil count between 0.5 and 1.0 × 10(9) /L were classified as borderline neutropenia.

RESULTS

Eighty-one episodes of fever were treated on the protocol. Forty-three per cent of patients were neutropenic. Uptake of the policy was low (35%) despite concerted efforts. The sensitivity and specificity of the Multinational Association for Supportive Care in Cancer score was 86% and 24% respectively. The readmission rate with fever was 19.2%. Median time to antibiotics was 60 min. Outcomes were similar for the neutropenic fever and borderline groups. Increasing treatment complexity was the major barrier to implementation.

CONCLUSIONS

The majority of presentations with cancer and fever following chemotherapy do not have neutropenia but have similar outcomes when treated on the same pathway. The utility of the Multinational Association for Supportive Care in Cancer score was limited by uptake and specificity. Reducing time to antibiotics administration and readmission rates were identified as priorities. Implementation was labour-intensive and faced significant barriers. Prioritisation of evidence for translation requires attention to local priorities and implementation complexity. These results argue for a single sepsis guideline with treatment of cancer as a high-risk group.

Mycoplasma genitalium is associated with cervicitis and HIV infection in an urban Australian STI clinic population

OBJECTIVES

To investigate the prevalence of the genital mollicutes, Mycoplasma genitalium (MG), Mycoplasma hominis (MH), Ureaplasma urealyticum (UU) and Ureaplasma parvum (UP), and their associations with cervicitis in a sexually transmitted infection (STI) clinic population. Clinical correlates of MG infection were also assessed.

METHODS

527 women were enrolled in a cross-sectional study at two STI clinics in Sydney between June 2006 and January 2010. Genital mollicutes were detected by multiplex PCR testing of cervical swabs, and associations with cervicitis were analysed. Cervicitis was defined as >30 polymorphonuclear cells per high-power field in at least three non-adjacent fields of cervical mucus on Gram stain.

RESULTS

MG was found in 4.0% of women, MH in 17.1%, UU in 14.1%, and UP in 51.8%. MG was the only mollicute associated with cervicitis (unadjusted prevalence ratio (PR) 1.85, 95% CI 1.52 to 2.26, p<0.0001), and this association remained after adjustment for Chlamydia trachomatis (CT) infection (adjusted PR 1.24 (95% CI 1.04 to 1.48), p=0.02). MG was significantly associated with women being HIV positive (p=0.03), but not with age, vaginal discharge, commercial sex work, being of culturally and linguistically diverse background, or concurrent CT infection. Two of the 21 women with MG had ectopic pregnancies.

CONCLUSIONS

The authors recommend wider application of PCR testing for MG in STI services, particularly in high-risk women and those with cervicitis or HIV infection.

49. SYPHILIS SCREENING PROFILE AT SEXUAL HEALTH CLINIC, ST GEORGE HOSPITAL & SUTHERLAND HOSPITAL

A retrospective analysis was conducted to describe the cases of Syphilis identified and managed at Short Street Centre and The Sutherland Sexual Health Centre, in South Eastern Sydney and Illawarra Area, from January 2000 to June 2007. Syphilis serology is routinely offered as part of an STI screen to new and follow-up patients as appropriate. Information on the diagnoses, demographic and other variables was extracted from the clinical database Sexual Health Information Program (SHIP) and analysed in SPSS v11. Information on age, gender, relationship status, country of birth, presenting symptoms, stage of Syphilis, type of treatment and subsequent RPR levels were confirmed from patient records. An analysis of the relative frequency of the stages of Syphilis from over 130 patients will be presented and their relationship to a number of demographic and behavioural factors.

Acute Q fever and brachial neuritis: case report and literature review

Peripheral nervous system complications of Q fever are uncommon. A case of electrophysiologically documented brachial neuritis occurring during acute Coxiella burnetii infection is reported. The relevant literature is reviewed.

A topical nitric oxide-generating therapy for cutaneous leishmaniasis

Nitric oxide (NO) synthesized by macrophages is cidal to Leishmania. Since NO diffuses into tissues, we reasoned that NO-generating creams applied topically to lesions might be an effective and inexpensive treatment for cutaneous leishmaniasis (CL). NO was generated non-enzymatically by the acidification of nitrite (KNO2) by ascorbic acid (ASC) or salicylic acid (SAL). Experiments in vitro showed that the combinations of KNO2 and SAL, ASC, or KC1 all killed promastigotes and amastigotes of L. major in a dose- and time-dependent manner, but were toxic to macrophages at higher concentrations. Experiments in vivo showed modest efficacy of the combinations applied topically to L. major CL lesions of BALB/c mice. Forty patients with parasitologically proven L. tropica CL from Aleppo, Syria, were treated for 4 weeks with KNO2 in aqueous cream combined with KC1, ASC, or SAL. Only 11 (28%) of 40 patients showed improvement and only 5 (12%) of 40 were cured at 2 months. Further development of NO-generating creams is warranted.

Murine dendritic cells internalize Leishmania major promastigotes, produce IL-12 p40 and stimulate primary T cell proliferation in vitro

Metacyclic Leishmania promastigotes (PM), transmitted by sand-fly bite, are likely to interact initially with cells of the dendritic cell (DC) lineage(s) in the epidermis or dermis. Epidermal Langerhans cells internalize L. major amastigotes (AM) and transport them to draining lymph nodes (Moll, H., Fuchs, H., Blank, C. and Röllinghoff, M., Eur. J. Immunol. 1993. 23: 1595) but little is known about the interaction of DC with PM. The present study demonstrates that DC are able to internalize PM and that the fate of the parasites within DC differs from that within macrophages (Mphi). DC took up small numbers of PM which did not differentiate into AM but appeared to be degraded; Mphi internalized large numbers of PM into parasitophorous vacuoles where they differentiated into AM. In response to direct stimulation with PM, DC from both C3H ("resistant" to L. major infection) and BALB/c ("susceptible") up-regulated production of IL-12 p40. In contrast, IL-12 production by Mphi was not detected. DC exposed to either metacyclic PM or PM culture supernatants were also able to stimulate proliferative responses in lymph node T cells from naive mice. These data indicate that DC have the capacity to promote protective Th1 immune responses in Leishmania infection and suggest that DC exposed to PM may be useful in immunotherapy and vaccination.

Hyperamylasaemia in asymptomatic HIV patients

We studied serum amylase and its isoenzymes prospectively in 163 consecutive asymptomatic patients, 149 men and 14 women, infected with HIV and attending an HIV out-patient clinic. Six patients were receiving dideoxyinosine (DDI), a drug known to cause pancreatitis. No patient, however, had clinical signs suggestive of pancreatitis. Serum total amylase was increased in 39 of 163 patients (24%), in 11 of whom (28%), this was due to increased pancreatic (P) isoamylase alone, in 17 (42%) it was due to salivary (S) type alone and in six (17%) it was due to increase of both P and S fractions. In five patients (13%), macroamylase was detected. Pancreatic amylase was elevated in four of the six patients on DDI. The remaining two had macroamylase. Our results show that asymptomatic hyperamylasaemia is a common finding in HIV patients and that it appears to be heterogenous, i.e. elevation may be due to increase in P or S, both enzyme fractions or macroamylase. The high incidence of macroamylasaemia in HIV patients was an unexpected finding.

Positive serology to Legionella longbeachae in patients with adult respiratory distress syndrome

In an observational study we measured the Legionella longbeachae antibody titre rise in patients mechanically ventilated for more than eight days during a two-month period. The patients were divided into two groups on the basis of the presence or absence of the adult respiratory distress syndrome (ARDS). In nine patients with ARDS all showed an antibody rise consistent with recent infection with Legionella longbeachae with a rise in titre (six patients) or a high titre after eight to ten days of ventilation (three patients). Three patients without ARDS did not show a rise in titre. Culture of the environment, ventilator circuits, humidifiers and humidification water did not reveal an environmental source of Legionella longbeachae in the Intensive Care Unit. Legionella longbeachae may be implicated as a pathogenic organism in ARDS, or as a secondary nosocomial infection. Alternatively the antibody titre rise may represent an epiphenomenon and may not be related to Legionella longbeachae infection.

Purification of monospecific polyclonal antibodies from hyperimmune bovine whey using immunoaffinity chromatography

Whey, a by-product of cheese production, is a potential source of proteins. Immunization of dairy cows in mid-lactation with mouse IgG and dinitrophenyl-keyhole limpet hemocyanin resulted in the formation of antibodies to these antigens in both blood serum and milk. The antibodies remained in whey during cheese making, and were isolated by immunoaffinity chromatography on matrices with immobilized antigens. The isolated monospecific antibodies were pure and retained their reactivity to antigens.

Study of cell-free protein synthesis in aqueous two-phase systems

Protein synthesis in an aqueous two-phase system is reported here as a novel type of extractive bioconversion. Translation of BMV RNA was studied using either rabbit reticulocyte lysate or wheat-germ extract in aqueous dextran-PEG systems. Both polymers inhibited protein synthesis and the translation system partitioned into both phases. In the rabbit reticulocyte two-phase system, protein synthesis reached 30% of that in free solution, while in wheat-germ extract it was 60% of that in free solution. Protein was found mainly in the dextran (lower) phase but its partitioning was related to the polymer concentration, and molecular weight, as well as the ionic strength of the system. Protein synthesis was highly influenced by PEG concentration, potassium chloride concentration, and dextran molecular weight.

Chromatographic purification of immunoglobulin G from bovine milk whey

We used thiophilic chromatography on T-gel, a resin of the structure agarose-O-CH2CH2SO2CH2 CH2SCH2CH2OH, to purify immunoglobulin G from "sweet" cheese whey. The purity of immunoglobulin G, as indicated by radial immunodiffusion, was 74% after a single chromatography on T-gel. Preparation of samples for adsorption onto thiophilic gels requires only the addition of salt (sodium/potassium sulfate) to the samples. Thus, this method may be suitable for large-scale whey IgG isolation.

Reversible immobilization of antibodies on magnetic beads

A streptavidin-biotin system was utilized to prepare an antibody-polyadenylic acid conjugate which was subsequently attached to commercially available magnetic beads, Dynabeads oligo(dT)25. Biotinylated polyadenylic acid was combined with streptavidin and the resulting polyadenylic acid-streptavidin was conjugated with an antibody-biotin derivative. The immobilized antibody-polyadenylic acid conjugate was separated from the reaction mixture by hybridization with complementary oligonucleotide immobilized on the surface of Dynabeads oligo(dT)25. The immobilized antibody-polyadenylic acid can be released from the carrier, utilizing low-ionic-strength buffers. The system is intended to be utilized in cell sorting, using immobilized antibodies against cell surface antigens. Dissociation of antibody-containing conjugate from magnetic beads is essential for the isolation of viable cells via positive cell sorting.

Prostaglandin E1 in erectile dysfunction. Efficiency and incidence of priapism

Prostaglandin E1 (PGE1) was used for diagnostic and therapeutic purposes in 149 men with erectile dysfunction over a period of 20 months (February 1987-October 1988). The intracavernous application of PGE1 in varying doses resulted in an erection sufficient for sexual intercourse in 79% of cases. In order to differentiate between vascular and non-vascular impotence, 5 micrograms PGE1 were found to be a sufficiently high and safe dose for the first intracavernous injection. Local discomfort, ranging from mild to severe pain after injection, was recorded in 40% of patients. A significant difference in severe side effects was found between arterial, venous and non-vasculogenic impotence, the highest incidence of local pain occurring in non-vasculogenic patients. The most striking result was the occurrence of 4 cases of priapism, all in the non-vascular group, 1 of these occurring after the injection of only 5 micrograms PGE1.

Acute fluoride poisoning

Fluoride poisoning is a potentially severe environmental hazard for children. A case of fluoride poisong is presented which was manifested by severe hypocalcemia, ventricular arrhythmias, and respiratory failure. Treatment of this poisoning, including peritoneal dialysis, is discussed. The kinetics of fluoride distribution as measured in this patient suggest a rapid binding of ingested fluoride to bone, followed by gradual release and excretion. Peritoneal dialysis resulted in no significant fluoride removal.