Antimicrobial Stewardship Programmes in Community Healthcare Organisations in England: A Cross-Sectional Survey to Assess Implementation of Programmes and National Toolkits

Objective: The aim of this study was to assess antimicrobial stewardship activities in Community Healthcare Organisations (CHOs) with focus on the implementation of the two national antimicrobial stewardship toolkits, TARGET (Treat Antibiotics Responsibly, Guidance, Education, Tools) and SSTF (Start Smart, then Focus). The study utilised a web-based survey comprising 34 questions concerning antimicrobial policies and awareness and implementation of antimicrobial stewardship toolkits. This was distributed to pharmacy teams in all 26 CHOs in England. Twenty CHOs (77%) responded. An antimicrobial stewardship (AMS) committee was active in 50% of CHOs; 25% employed a substantive pharmacist post and 70% had a local antibiotic policy. Fourteen of the responding CHOs were aware of both AMS toolkits, five organisations were aware of either SSTF or TARGET, and one organisation was not aware of either toolkit. Of the organisations aware of SSTF and TARGET, eight had formally reviewed both toolkits, though three had not reviewed either. Less than half of the respondents had developed local action plans for either toolkit. National guidance in England has focused attention on initiatives to improve AMS implementation in primary and secondary care; more work is required to embed AMS activities and the implementation of national AMS toolkit recommendations within CHOs.Peer reviewedFinal Published versio

Community pharmacists\u2019 management of self-limiting infections: a simulation study in Akwa Ibom State, South-South Nigeria

Background: Inappropriate use of antibiotics, especially for treatment of self-limiting infections remains one of the major drivers of antibiotic resistance (ABR). Community pharmacists can contribute to reducing ABR by ensuring antibiotics are dispensed only when necessary. Objective: To assess community pharmacists\u2019 management of self-limiting infections. Methods: A purposive sample of 75 pharmacies participated in the study. Each pharmacy was visited by an investigator and a trained simulated patient who mimicked symptoms of common cold and acute diarrhoea, respectively. Interactions between the simulated patient and pharmacist were recorded by the investigator in a data collection form after each visit. Descriptive statistical analysis was carried out. Ethics approval was obtained from the state Ministry of Health Research Ethics Committee. Results: For common cold, 68% (51/75) of pharmacists recommended an antibiotic. Azithromycin, amoxicillin/clavulanic acid, and sulphamethoxazole/trimethoprim (43%, 24%, 20%, respectively) were the most frequently dispensed agents. For acute diarrhoea, 72% (54/75) of pharmacists dispensed one antibiotic, while 15% dispensed more than one antibiotic. The most frequently dispensed agent was metronidazole (82%), which was dispensed in addition to amoxicillin or tetracycline among pharmacists who dispensed more than one agent. In both infection scenarios, advice on dispensed antibiotics was ofered in 73% and 87% of the interactions, respectively. Conclusion: This study shows high rate of inappropriate antibiotics dispensing among community pharmacists. There is need for improved awareness of antibiotic resistance through continuing education and training of community pharmacists. Furthermore, the inclusion of antibiotic resistance and stewardship in undergraduate pharmacy curriculum is needed

The Control of Malaria among PLWHA in Calabar, Cross River State, Nigeria

The purpose of the study was to examine RBM programme’s efforts at controlling malaria among PLWHA and explore their perception of the control strategies. The study was a descriptive survey involving guided interviews of top managers of Roll Back Malaria (RBM) programme. A structured questionnaire was administered to 108 PLWHA attending an HIV/AIDS clinic in a secondary health facility in Calabar. Data were analyzed using descriptive statistics. Thematic analysis revealed that RBM programme strategies include effective case management, promotion of Long Lasting Insecticide Treated Nets (LLINs), intermittent preventive treatment (IPT) and integrated vector management (IVM). Complementary results showed that 104 (92%) admitted accessibility to malarial treatment. Although 83 (57.7%) of PLWHA have LLINs, only 63 (42.3%) use them. Majority of the respondents 89 (60%) have not heard of indoor/outdoor residual spraying (IRS). How to get IRS services and lack of money to buy it were listed as a barrier to its use. Malarial treatment was accessible to PLWHA. The barriers to the use of ITN and IRS could be addressed through free distribution of odorless ITN and IRS to PLWHA. Higher rates of utilization of the products can be achieved through behavioural change communication

A study of the M235T variant of the angiotensinogen gene and hypertension in a sample population of Calabar and Uyo, Nigeria

AbstractA common molecular variant of the angiotensinogen gene had been reported to predispose some ethnic groups to hypertension. This case–control study was designed to determine the frequency and association of the angiotensinogen M235T allele with hypertension in residents of Calabar and Uyo cities, south–south Nigeria.The study involved 1308 subjects, 612 patients and 696 controls. The M235T variant was investigated using an allele specific polymerase chain reaction and enzymatic digestion to determine allele frequencies. Hypertensinogenic factors such as dietary habits, physical activity, smoking and drinking habits were assessed using questionnaires. Descriptive statistics, chi-square and multiple regression analysis were used to analyze the data obtained.The M235T allele frequency was high (0.94 for hypertensives and 0.96 for controls) though it was not associated with hypertension status. The odds ratio for hypertension was 0.64 (95% confidence interval: 0.39–1.06) there were no significant differences between the genotype frequency of hypertensives and controls. By multiple regression, Hypertension was observed to be associated with age and was a predictor for systolic blood pressure in both patient r2=0.359; p<0.05 and control groups r2=0.26.Age and body mass index were predictors for diastolic blood pressure in the control group, r2=0.28.Although the frequency of the M235T variant was high, it was not a significant risk factor for hypertension in the study population

Insulin and glucagon secretion in essential fatty acid deficient rats

Insulin and glucagon secretion in response to common secretagogues were ascertained in the perfused pancreas isolated from essential fatty acid deficient rats. The pattern of insulin secretory response to glucose (16.7 mmol/l) by isolated rat pancreas perfused for 30 min was biphasic in EFA-deficient and control rat pancreas. The amplitude of glucose-stimulated acute secretion (phase I) was significantly greater (p0.05). However, arginine (10 mmol/l)-stimulated insulin release was significantly higher in EFA-deficient than in control rats. Growth hormone (100 nmol/l)-induced glucagon and insulin secretion was variable in the two groups but significantly higher than basal secretion. The level of L-leucine (10 mmol/l)-stimulated glucagon and insulin secretion in EFA-deficient rats was minimal but significant. Our results show that isolated pancreata of rats devoid of precursors for endogenous prostaglandin synthesis secreted insulin and glucagon in response to common secretagogues. On the basis of our data, it is concluded that endogenous prostaglandins are probably not obligatory for normal secretory functions of islets of Langerhans.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/47974/1/592_2005_Article_BF02099000.pd

Outbreak of Fatal Childhood Lead Poisoning Related to Artisanal Gold Mining in Northwestern Nigeria, 2010.

Background: In May 2010, a team of national and international organizations was assembled to investigate children's deaths due to lead poisoning in villages in northwestern Nigeria. Objectives: To determine the cause of the childhood lead poisoning outbreak, investigate risk factors for child mortality, and identify children aged <5 years in need of emergency chelation therapy for lead poisoning. Methods: We administered a cross-sectional, door-to-door questionnaire in two affected villages, collected blood from children aged 2-59 months, and soil samples from family compounds. Descriptive and bivariate analyses were performed with survey, blood-lead, and environmental data. Multivariate logistic regression techniques were used to determine risk factors for childhood mortality. Results: We surveyed 119 family compounds. One hundred eighteen of 463 (25%) children aged <5 years had died in the last year. We tested 59% (204/345) of children, aged <5 years, and all were lead poisoned (≥10 µg/dL); 97% (198/204) of children had blood-lead levels ≥45 µg/dL, the threshold for initiating chelation therapy. Gold ore was processed inside two-thirds of the family compounds surveyed. In multivariate modeling significant risk factors for death in the previous year from suspected lead poisoning included: the child's age, the mother performing ore-processing activities, community well as primary water source, and the soil-lead concentration in the compound. Conclusion: The high levels of environmental contamination, percentage of children aged <5 years with elevated blood-lead levels (97%, >45 µg/dL), and incidence of convulsions among children prior to death (82%) suggest that most of the recent childhood deaths in the two surveyed villages were caused by acute lead poisoning from gold ore-processing activities. Control measures included environmental remediation, chelation therapy, public health education, and control of mining activities

Dissociation of vascular resistance with endocrine pancreas secretion: The effects of epoxymethano analogs of PGH2

The epoxymethano analogs of PGH2 caused rapid and persistent increase in perfusion pressure in isolated rat pancreata without significant effect on glucagon and insulin secretory responses to PGH2 and PGE2. The changes in perfusion pressure are interpreted as alterations in vascular resistance since the flow rate was kept constant at 2.5 mL per min. PGH2 alone caused significant elevation in pressure. However, PGH2 administration superimposed upon an infused epoxymethano analog of PGH2, decreased perfusion pressure significantly, whereas PGH2 induced hormone release was not decreased. The analogs neither stimulated nor inhibited the endocrine pancreas secretion. These studies provide evidence for complete dissociation of vascular constriction from pancreatic hormone release and further suggest that the effects of PGH2 on islet hormone secretion may result from the conversion of PGH2 to other prostanoids.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/24186/1/0000445.pd

Description of 3,180 courses of chelation with dimercaptosuccinic acid in children ≤ 5 y with severe lead poisoning in Zamfara, Northern Nigeria: a retrospective analysis of programme data.

BACKGROUND: In 2010, Médecins Sans Frontières (MSF) discovered extensive lead poisoning impacting several thousand children in rural northern Nigeria. An estimated 400 fatalities had occurred over 3 mo. The US Centers for Disease Control and Prevention (CDC) confirmed widespread contamination from lead-rich ore being processed for gold, and environmental management was begun. MSF commenced a medical management programme that included treatment with the oral chelating agent 2,3-dimercaptosuccinic acid (DMSA, succimer). Here we describe and evaluate the changes in venous blood lead level (VBLL) associated with DMSA treatment in the largest cohort of children ≤ 5 y of age with severe paediatric lead intoxication reported to date to our knowledge. METHODS AND FINDINGS: In a retrospective analysis of programme data, we describe change in VBLL after DMSA treatment courses in a cohort of 1,156 children ≤ 5 y of age who underwent between one and 15 courses of chelation treatment. Courses of DMSA of 19 or 28 d duration administered to children with VBLL ≥ 45 µg/dl were included. Impact of DMSA was calculated as end-course VBLL as a percentage of pre-course VBLL (ECP). Mixed model regression with nested random effects was used to evaluate the relative associations of covariates with ECP. Of 3,180 treatment courses administered, 36% and 6% of courses commenced with VBLL ≥ 80 µg/dl and ≥ 120 µg/dl, respectively. Overall mean ECP was 74.5% (95% CI 69.7%-79.7%); among 159 inpatient courses, ECP was 47.7% (95% CI 39.7%-57.3%). ECP after 19-d courses (n = 2,262) was lower in older children, first-ever courses, courses with a longer interval since a previous course, courses with more directly observed doses, and courses with higher pre-course VBLLs. Low haemoglobin was associated with higher ECP. Twenty children aged ≤ 5 y who commenced chelation died during the period studied, with lead poisoning a primary factor in six deaths. Monitoring of alanine transaminase (ALT), creatinine, and full blood count revealed moderate ALT elevation in <2.5% of courses. No clinically severe adverse drug effects were observed, and no laboratory findings required discontinuation of treatment. Limitations include that this was a retrospective analysis of clinical data, and unmeasured variables related to environmental exposures could not be accounted for. CONCLUSIONS: Oral DMSA was a pharmacodynamically effective chelating agent for the treatment of severe childhood lead poisoning in a resource-limited setting. Re-exposure to lead, despite efforts to remediate the environment, and non-adherence may have influenced the impact of outpatient treatment. Please see later in the article for the Editors' Summary

Treatment priorities and regret in older adults with head and neck cancer: A systematic review

AbstractBackgroundThe majority of head and neck cancer (HNC) diagnoses are seen in people aged 70 and older; these numbers are set to increase. Greater understanding of treatment needs of older patients with HNC is essential. These older patients often have co‐existing health conditions, are prone to frailty and may not prioritise survival when considering treatment options. This systematic review examines the current research with regard to priorities and factors influencing treatment regret in older people with HNC.MethodsStudies were eligible for inclusion if they (i) reported data from patients with a mean age of 65 years or older who had a confirmed diagnosis of HNC and had been treated using surgery, chemotherapy and/or radiotherapy with either palliative or curative intent, (ii) considered patient's priorities or preferences or examined treatment regret as one of the primary outcomes of the study (iii) were published in English.ResultsPilot search identified n = 7222 articles; however, following screening, only four papers met the inclusion criteria. Narrative synthesis was indicated to analyse quantitative and qualitative evidence in parallel, as meta‐analyses were not possible.DiscussionThere is a paucity in the literature examining older adults with HNC. There is an indication that older adults prioritise maintaining independence when making treatment decisions and treatment regret is seen in those with high levels of depression with level of frailty also a contributing factor. Clinicians should consider patient's social circumstances, premorbid status and priorities in maintaining independence and managing symptoms when making treatment decisions in this cohort.</jats:sec