Antibiotic prescription for acute respiratory infections in preschool children in family medicine

Vodeće bolesti u djece predškolske dobi u Hrvatskoj su bolesti respiratornog sustava (oko 35%), kao i razlog za neopravdano propisivanje antibiotika. Cilj: procijeniti opterećenost ordinacija obiteljske medicine (OOM) tijekom zimskih mjeseci zbog akutnih respiratornih infekata (ARI) djece predškolske dobi, te istražiti povezanost propisivanja antibiotika sa sociodemografskim pokazateljima, zdravstvenim stanjem i zdravstvenim navikama djece, te karakteristikama konzultacije. Ispitanici i metoda:. Prospektivno istraživanje provedeno je u tri OOM, u Zagrebu kroz tri zimska mjeseca od 01. 12. 2013. - 28. 02. 2014. Obuhvaćeno je 265 djece predškolske dobi. Podaci su prikupljeni iz e-medicinskih kartona u upitnik sastavljen za ovo istraživanje. Rezultati: 105 (39,6%) djece tijekom zimskih mjeseci je posjetilo svoga liječnika zbog 146 slučajeva ARI. Antibiotik je dobilo njih 27 (25,7%). Propisivanje antibiotika je bilo statistički značajno više kod djece: starijih roditelja (pmajki = 0,002, počevi = 0,05), onih koji imaju kronične bolesti (p = 0,03), te onih koji češće posjećuju liječnika obiteljske medicine (LOM) (p < 0,001). U 21/28 antibiotik je propisao LOM i to prilikom prve posjete. Najviše antibiotika je ropisano u ponedjeljak, djeci između 5-6 godina koja su toga dana kasnije došla. Antibiotik je češće propisivan djeci s višim vrijednostima CRP-a (p = 0,017) i leukocita (p = 0,043). Najčešće dijagnoze za propisivanje antibiotika su bile: u 9/28 slučajeva nesupurativna upala srednjega uha (H65), u 8/28 akutni tonzilitis (J03), te u 4 slučaja podjednako zbog akutnog sinusitisa (J01) i akutnog bronhitisa (J20). Najčešće su propisivani penicilinski antibiotici (21/28). Logistička regresija je povezala propisivanje antibiotika s većim brojem djece u obitelji, djecom koja pohađaju vrtić, te s djecom za koje roditelji smatraju da su osjetljivija. Zaključak: Rezultat ovoga istraživanja o učestalosti propisivanja antibiotika za ARI djece predškolske dobi sukladan je rezultatima istraživanja provedenih u zemljama s niskom stopom propisivanja antibiotika. Bolja edukacija liječnika i izrada smjernica koje bi im pomogle u procesu odlučivanja o propisivanju antibiotika može unaprijediti primjerenost propisivanja, kao i senzibilizaciju javnosti.Leading diseases in preschool children in Croatia are diseases of the respiratory system (about 35%), as well as the leading reason for unjustified antibiotics prescription. Objective: To investigate the burden of family medicine practices during the winter months due to RTI in preschool children and to assess the prescription of antibiotics in relation to socioeconomic factors, health status and health habits of children and characteristics of the consultation. Patients and methods: The prospective study was conducted in three family medicine practices in Zagreb during three winter months from 1st December 2013 – 28th February 2014. The sample included 265 preschool children. Data were collected from the e - medical records in a questionnaire compiled for this study. Results: 105 (39.6 %) children during the winter months visited their general practitioners for about 146 RTI episodes. In 25.7% of these episodes an antibiotic was issued. Prescription of antibiotics was significantly higher in children: with older parents (pmum = 0.002, pdad = 0.05), with chronic diseases (p = 0.03 ), frequent attendees (p < 0.001). 21/28 antibiotics were prescribed on the first visit. Most antibiotics were prescribed on Monday and often to the children who came later that day and older children between 5-6 years. The antibiotics were often prescribed to children with higher CRP values (p = 0.017) and leukocytes (p = 0.043). The most common diagnoses for the prescribed antibiotics were: in 9/28 cases acute otitis media (H65), 8/28 acute tonsillitis (J03), and 4 cases of acute sinusitis (J01) and acute bronchitis (J20). Penicillin was the most prescribed antibiotic (21/28). Logistic regression analyses also predicted a correlation between antibiotic prescriptions and families with many children, children who attend nursery, and children with higher parental perception of child vulnerability. Conclusion: The results of our study about the frequency of antibiotic prescription to preschool children for RTI correspond to investigations conducted in countries with low antibiotic prescription rate. Better education of doctors and the development of guidelines which would help them in the decision-making process in terms of antibiotics prescription may even reduce the rate of prescription as well as sensitize the public

Breast cancer in women by HIV status: A report from the South African National Cancer Registry.

BACKGROUND Breast cancer (BC) is the leading cause of cancer-related morbidity and mortality in women living in South Africa, a country with a high HIV burden. However, characteristics of the double burden of HIV and BC in South Africa have not been properly investigated. We described characteristics of BC cases by HIV status in South Africa. METHODS In this nationwide South African study, we obtained BC records for women aged ≥15 years diagnosed in the public health sector between January 2004 and December 2014. We included records from the National Cancer Registry that had been linked to HIV-related laboratory records from the National Health Laboratory Service. We assessed the odds of being HIV positive versus HIV negative in relation to patient-, cancer-, and municipality-related characteristics. RESULTS From 2004-2014, 40 520 BC cases were diagnosed in women aged ≥15 years. Of these, 73.5% had unknown HIV status, 18.7% were HIV negative, and 7.7% were HIV positive. The median age at BC diagnosis was 43 years (interquartile range [IQR]: 37-52) in HIV positive and 57 years (IQR: 46-68) in HIV negative women, respectively. The odds of being HIV positive was higher for women who were aged 30-34 years compared to women aged 35-39 years at cancer diagnosis (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.10-1.71), Black versus non-Black (OR 6.41, 95% CI 5.68-7.23), diagnosed with cancer in rural versus urban areas (OR 1.59, 95% CI 1.40-1.82) and diagnosed in municipalities with low and middle (OR 3.46, 95% CI 2.48-4.82) versus high socioeconomic position (OR 2.69, 95% CI 2.11-3.42). CONCLUSION HIV status was unknown for the majority of BC patients. Among those with known HIV status, being HIV positive was associated with a younger age at cancer diagnosis, being Black and receiving care in municipalities of poor socioeconomic position. Future studies should examine opportunities to integrate HIV and BC control programs

Gynaecologic and breast cancers in women living with HIV in South Africa: A record linkage study.

Breast and gynaecologic cancers account for approximately half of all cancers diagnosed amongst women in South Africa, many of whom also live with HIV. We aimed to determine the incidence of and risk factors for developing breast and gynaecologic cancers in women living with HIV (WLHIV) in South Africa. This is a longitudinal analysis of the South African HIV Cancer Match study including women aged ≥15 years with two or more HIV-related laboratory tests. We used Cox proportional hazard models to determine the association of Human Papilloma Virus (HPV)-related and hormone-related gynaecologic cancer with patient- and municipal-level characteristics. From 3 447 908 women and 10.5 million years of follow-up, we identified 11 384 incident and 7612 prevalent gynaecologic and breast cancers. The overall crude incidence rate was 108/1 00 000 person-years (pyears) (95% confidence interval [CI]: 106-110), with the highest incidence observed for cervical cancer (70/1 00 000 pyears; 95% CI: 68.5-71.7). Low CD4 cell counts and high HIV RNA viral loads increased the risk of cervical and other HPV-related cancers. Age was associated with both HPV-related and hormone-related cancers. Women accessing health facilities in high socioeconomic position (SEP) municipalities were more likely to be diagnosed with HPV-related cancers and breast cancer than women accessing care in low SEP municipalities. It is important to improve the immunologic status of WLHIV as part of cancer prevention strategies in WLHIV. Cancer prevention and early detection programmes should be tailored to the needs of women ageing with HIV. In addition, SEP disparities in cancer diagnostic services have to be addressed

VASCULITIDES IN CHILDHOOD: A RETROSPECTIVE STUDY IN A PERIOD FROM 2002 TO 2012 AT THE DEPARTMENT OF PAEDIATRICS, UNIVERSITY HOSPITAL CENTRE ZAGREB

Cilj istraživanja bio je analizirati klinička obilježja, laboratorijske nalaze, liječenje, tijek bolesti i ishod pojedinih oblika vaskulitisa u djece. U istraživanje su bili uključeni svi bolesnici u dobi do 18 godine života kojima je u razdoblju od 2002. do 2012. godine u Klinici za pedijatriju KBC-a Zagreb utvrđena dijagnoza vaskulitisa prema kriterijima EULAR/ PRES/PRINTO. Vaskulitis je dijagnosticiran u 180 djece, 101 djevojčice i 79 dječaka, u dobi 7,19±3,7 godina. Prosječno vrijeme praćenja bolesnika bilo je 5,58±3,28 godina. Henoch- Schönleinova purpura (HSP) dijagnosticirana je u 155 bolesnika (86 %), nodozni poliarteritis (PAN) u 6 (3,3 %), izolirani kutani leukocitoklastični vaskulitis u 5 (2,8 %), Takayasuov arteritis (TA) u dva (1,1 %), Kawasakijeva bolest (KB) u dva (1,1 %), hipokomplementarni urtikarijski vaskulitis u jednog (0,5 %) te drugi vaskulitisi u 10 (5,5 %) bolesnika (vaskulitisi povezani sa sistemnim bolestima veziva u sedam i neklasifi cirani u tri bolesnika). U svih bolesnika upalni laboratorijski parameteri (C-reaktivni protein, sedimentacija eritrocita) bili su povišeni. Antineutrofi lna citoplazmatska protutijela (ANCA) bila su pozitivna u samo jednog bolesnika s mikroskopskim poliarteritisom. Potporne mjere liječenja u obliku nesteroidnih protuupalnih lijekova bili su način liječenja u većine bolesnika, dok su bolesnici sa zahvaćenim bubrežnim i gastrointestinalnim sustavom tretirani glukokortikoidima i/ili imunosupresivima. U bolesnika s najtežim simptomima primijenjena je i biološka terapija (anti-CD20, rituksimab). Tijekom praćenja umrlo je jedno dijete (0,56%) oboljelo od mikroskopskog poliarteritisa radi zatajenja bubrega. Četrdeset bolesnika (22,6%) je imalo jedan relaps, a šest (3,4%) dva relapsa bolesti. Zaključno, primijetili smo neke razlike u naših bolesnika u odnosu na literaturne podatke, poput niže učestalosti povišenih vrijednosti antistreptolizinskog O titra u bolesnika s HSP-om te veće učestalosti PAN-a u ženskog spola, dok se ostala klinička obilježja, laboratorijski nalazi, liječenje i ishod nisu razlikovali.Th e aim of our study was to analyze clinical features, laboratory fi ndings, treatment, course and outcome of diff erent types of vasculitis in children. All children aged up to 18 years that have been diagnosed with a vasculitis disorder from 2002. to 2012. at the Department of Paediatric, University Hospital Centre Zagreb according to EULAR/PRES/PRINTO criteria were included in the study. Vasculitis was diagnosed in 180 children, 101 girls and 79 boys, mean age 7.19±3.7 years, with an average follow-up of 5,58±3,28 years. Most of the children (155 or 86%) were diagnosed with Henoch-Shönlein purpura (HSP), polyarteritis nodosa (PAN) was diagnosed in 6 children (3.3%), isolated cutaneous leukocytoclastic vasculitis in 5 (2.8%), Takayasu arteritis (TA) and Kawasaki disease in 2 (1.1%) respectively, hypocomplementemic urticarial vasculitis in one patient (0.5%) and other types of vasculitis in 10 (5.5%) patients (vasculitides in systemic connective tissue disorders in 7 and unclassifi ed vasculitides in 3 patients). All patients had elevated infl ammatory markers (C-reactive protein and erythrocyte sedimentation rate). Anti-neutrophil cytoplasmatic antibodies (ANCA) were positive only in one patient, suff ering from microscopic polyangiitis. Treatment modality in most patients were NSAIDs, while children with kidney or gastrointestinal system aff ection were treated with glucocorticoids and/or immunosuppresive drugs. Biological therapy (anti-CD20, rituximab) was used in patients with most severe symptoms. One child (0.56%), suff ering from microscopic polyangiitis, died due to kidney failure during the follow-up. Forty patients (22.6%) had one disease relapse, while 6 (3.4%) had two relapses. In conclusion, we found some diff erences in laboratory parameters (e.g. lower incidence of elevated antistreptolysin O titer in HSP) and epidemiological data (e.g. higher prevalence of PAN in female children) in comparison to data from available studies, while other clinical features, laboratory fi ndings, disease outcome and treatment were similar

Immunodeficiency and Cancer in 3.5 Million People Living With Human Immunodeficiency Virus (HIV):the South African HIV Cancer Match Study

BACKGROUND We analysed associations between immunodeficiency and cancer incidence in a nationwide cohort of people living with the human immunodeficiency virus (HIV) in South Africa. METHODS We used data from the South African HIV Cancer Match study built on HIV-related laboratory measurements from the National Health Laboratory Services and cancer records from the National Cancer Registry. We evaluated associations between time-updated CD4 cell count and cancer incidence rates using Cox proportional hazards models. We reported adjusted hazard ratios (aHR) over a grid of CD4 values and estimated the aHR per 100 CD4 cells/µl decrease. RESULTS Of 3,532,266 people living with HIV (PLWH), 15,078 developed cancer. The most common cancers were cervical cancer (4,150 cases), Kaposi sarcoma (2,262 cases), and non-Hodgkin lymphoma (1,060 cases). The association between lower CD4 cell count and higher cancer incidence rates was strongest for conjunctival cancer (aHR per 100 CD4 cells/µl decrease: 1.46, 95% confidence interval [CI] 1.38-1.54), Kaposi sarcoma (aHR 1.23, 95% CI 1.20-1.26), and non-Hodgkin lymphoma (aHR 1.18, 95% CI 1.14-1.22). Among infection-unrelated cancers, lower CD4 cell counts were associated with higher incidence rates of oesophageal cancer (aHR 1.06, 95 CI 1.00-1.11), but not breast, lung, or prostate cancer. CONCLUSIONS Lower CD4 cell counts were associated with an increased risk of developing various infection-related cancers among PLWH. Reducing HIV-induced immunodeficiency may be a potent cancer prevention strategy among PLWH in sub-Saharan Africa, a region heavily burdened by cancers attributable to infections

Cervical cancer prevention in countries with the highest HIV prevalence: a review of policies.

INTRODUCTION Cervical cancer (CC) is the leading cause of cancer-related death among women in sub-Saharan Africa. It occurs most frequently in women living with HIV (WLHIV) and is classified as an AIDS-defining illness. Recent World Health Organisation (WHO) recommendations provide guidance for CC prevention policies, with specifications for WLHIV. We systematically reviewed policies for CC prevention and control in sub-Saharan countries with the highest HIV prevalence. METHODS We included countries with an HIV prevalence ≥ 10% in 2018 and policies published between January 1st 2010 and March 31st 2022. We searched Medline via PubMed, the international cancer control partnership website and national governmental websites of included countries for relevant policy documents. The online document search was supplemented with expert consultation for each included country. We synthesised aspects defined in policies for HPV vaccination, sex education, condom use, tobacco control, male circumcision,cervical screening, diagnosis and treatment of cervical pre-cancerous lesions and cancer, monitoring mechanisms and cost of services to women while highlighting specificities for WLHIV. RESULTS We reviewed 33 policy documents from nine countries. All included countries had policies on CC prevention and control either as a standalone policy (77.8%), or as part of a cancer or non-communicable diseases policy (22.2%) or both (66.7%). Aspects of HPV vaccination were reported in 7 (77.8%) of the 9 countries. All countries (100%) planned to develop or review Information, Education and Communication (IEC) materials for CC prevention including condom use and tobacco control. Age at screening commencement and screening intervals for WLHIV varied across countries. The most common recommended screening and treatment methods were visual inspection with acetic acid (VIA) (88.9%), Pap smear (77.8%); cryotherapy (100%) and loop electrosurgical procedure (LEEP) (88.9%) respectively. Global indicators disaggregated by HIV status for monitoring CC programs were rarely reported. CC prevention and care policies included service costs at various stages in three countries (33.3%). CONCLUSION Considerable progress has been made in policy development for CC prevention and control in sub Saharan Africa. However, in countries with a high HIV burden, there is need to tailor these policies to respond to the specific needs of WLHIV. Countries may consider updating policies using the recent WHO guidelines for CC prevention, while adapting them to context realities

Cervical cancer prevention and care in HIV clinics across sub-Saharan Africa: results of a facility-based survey.

INTRODUCTION To eliminate cervical cancer (CC), access to and quality of prevention and care services must be monitored, particularly for women living with HIV (WLHIV). We assessed implementation practices in HIV clinics across sub-Saharan Africa (SSA) to identify gaps in the care cascade and used aggregated patient data to populate cascades for WLHIV attending HIV clinics. METHODS Our facility-based survey was administered between November 2020 and July 2021 in 30 HIV clinics across SSA that participate in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. We performed a qualitative site-level assessment of CC prevention and care services and analysed data from routine care of WLHIV in SSA. RESULTS Human papillomavirus (HPV) vaccination was offered in 33% of sites. Referral for CC diagnosis (42%) and treatment (70%) was common, but not free at about 50% of sites. Most sites had electronic health information systems (90%), but data to inform indicators to monitor global targets for CC elimination in WLHIV were not routinely collected in these sites. Data were collected routinely in only 36% of sites that offered HPV vaccination, 33% of sites that offered cervical screening and 20% of sites that offered pre-cancer and CC treatment. CONCLUSIONS Though CC prevention and care services have long been available in some HIV clinics across SSA, patient and programme monitoring need to be improved. Countries should consider leveraging their existing health information systems and use monitoring tools provided by the World Health Organization to improve CC prevention programmes and access, and to track their progress towards the goal of eliminating CC