Recent reports highlighting the global significance of cryptosporidiosis among children, have renewed efforts to develop control measures. We have optimized the gnotobiotic piglet model of acute diarrhea to evaluate azithromycin (AZR), nitazoxanide (NTZ), or treatment with both against Cryptosporidium hominis, the species responsible for most human cases. Piglets, animals reproducibly clinically susceptible to C. hominis, when inoculated with 106 oocysts, developed acute diarrhea with oocyst excretion in feces within 3 days. Ten day-treatment with recommended doses for children, commencing at onset of diarrhea, showed that treatment with AZR or NTZ relieved symptoms early in the treatment compared with untreated animals. Piglets treated with AZR exhibited no reduction of oocyst excretion whereas treatment with NTZ significantly reduced oocyst shedding early, increasing however after 5 days. While treatment with AZR+NTZ led to considerable symptomatic improvement, it had a modest effect on reducing mucosal injury, and did not completely eliminate oocyst excretion. Doubling the dose of AZR and/or NTZ did not improve the clinical outcome, confirming clinical observations that NTZ is only partially effective in reducing duration of diarrhea in children. This investigation confirms the gnotobiotic piglet as a useful tool for drug evaluation for the treatment of cryptosporidiosis in children.

Background Reports from the Learning Disability Mortality Register (2020) demonstrate that people with learning disabilities die younger than other adults. Many deaths are not in the place of choice, and people experience barriers to being involved in, and receiving, end-of-life care (Tuffrey-Wijne & Davidson, 2018. Int J Palliat Nurs. 24: 598). National documents,(Hospice UK, 2021; PCPLD Network and NHS England, 2017) and local council audits, also identify that domiciliary staff, caring for adults with learning disabilities, receive little education and support to care for the dying. Aim To improve the end-of-life care for adults with learning disabilities in Essex, by increasing confidence and knowledge of care agency staff in the essentials of end-of-life care, and creating support networks to reduce barriers to care. Method A local council, and three local hospices, have worked together since 2018, to create and deliver a three-day course to upskill domiciliary care agency staff giving end-of-life care (Griffith, Richmond, Harwood et al., 2021. BMJ Support Palliat Care. 11). This award-winning course was adapted to help address the inequality in care that adults with learning disabilities currently receive. Using an already well-evaluated course structure, with funding streams sourced by the council, allowed the adapted course to be delivered free-of-charge to agency staff. Results So far, forty-four carers have attended the adapted face-to-face cascade training. 100% of the attendees felt that this course increased their confidence and ability to give endof-life care. Areas of greatest improvement were advance care planning and communicating about dying. All attendees also felt confident to cascade the teaching to their colleagues, meaning that even more carers will benefit. Staff who attended can now join the collaboration's Champions' Days, held annually, to continue their learning in care of the dying, developing even stronger links with the council, their local hospice teams and other agencies, and address key areas highlighted in reports (Tuffrey-Wijne & Davidson, 2018). Conclusion This project demonstrates the power of collaborative working to improve end-of-life care, and offers a model for other counties to replicate.

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more patients to be cared for in their place of choice. However, for a very small number of complex patients, the lack of inpatient facilities had proved problematic. To avoid this consequence during the second wave, a new plan to open a virtual ward, staffed by some of the inpatient team, was devised. Aim To ensure that dying patients with complex needs were given equitable and appropriate care whilst the inpatient unit was closed. Method Clinical staff were once more re-located to the community teams, but this time with 24-hour provision of nursing care, rather than the usual four times daily visits. Medications were administered in a more timely way, and delivery of personal care was given at the patient's convenience, rather than set times, with increased support for families. Closer liaison with the multi-disciplinary team (MDT) also improved the patient experience, with daily MDT discussion. Results Eight patients who required complex medical intervention, were admitted to other local hospices. However, 47 patients were admitted to the virtual ward, averaging 8.6 admissions per month. Identification of the last weeks of life was greatly improved by the internal referral process, reflected in an average length of stay of 7 days (range 3-13 days). Conclusion By offering complex care to people at end of life in their own homes, this approach fulfilled the ideal criteria of 'providing everyone the right care, from the right person at the right time' and reduced prior inequality of care provision (Thomas, 2021).

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