An evaluation of antimicrobial stewardship in community pharmacy

This study investigated several aspects of antimicrobial stewardship by gathering information from community pharmacists and members of the public. The aim was to identify how community pharmacists implement antimicrobial stewardship guidelines and influence patients on the use of antibiotics. This study required and received approval from the University of Huddersfield Ethics Committee. Information and opinions of community pharmacists in the Kirklees and Calderdale areas, and surrounding local areas, and of members of the public in Huddersfield town centre, were gathered using two different questionnaires. These focused on initiatives regarding antibiotic resistance, development of the competencies required for medicines optimisation and antimicrobial stewardship, patient education by pharmacists, monitoring of antibiotic prescribing and pharmacy access to records. The results obtained were then analysed. The study consisted of 50 participating pharmacists and 100 participating members of the public. It was identified that eight pharmacists had undertaken recent professional development regarding antimicrobial stewardship, 11 had made an Antibiotic Guardian pledge and eight monitored antibiotic prescribing. It was also discovered that, when handing out a prescription for antibiotics, five pharmacists (all of whom work in an independent pharmacy) always questioned the indication and seven always provided extra self-care information. Finally, 92 members of the public selected that they would be comfortable allowing their indication (the condition that the antibiotic is being used to treat) to be provided on prescriptions for antibiotics, and 83 selected that they would be comfortable with pharmacies having access to medical records. This study suggests that increased awareness is necessary of the resources that are available to pharmacists regarding antibiotic resistance initiatives and monitoring of antimicrobial prescribing. In addition, an improvement is required concerning patient education by community pharmacists. Finally, the public should be appropriately educated regarding patient confidentiality and the benefits of pharmacies having access to patient information

Black hole pair creation in de Sitter space: a complete one-loop analysis

We present an exact one-loop calculation of the tunneling process in Euclidean quantum gravity describing creation of black hole pairs in a de Sitter universe. Such processes are mediated by $S^2\times S^2$ gravitational instantons giving an imaginary contribution to the partition function. The required energy is provided by the expansion of the universe. We utilize the thermal properties of de Sitter space to describe the process as the decay of a metastable thermal state. Within the Euclidean path integral approach to gravity, we explicitly determine the spectra of the fluctuation operators, exactly calculate the one-loop fluctuation determinants in the $\zeta$-function regularization scheme, and check the agreement with the expected scaling behaviour. Our results show a constant volume density of created black holes at late times, and a very strong suppression of the nucleation rate for small values of $\Lambda$.Comment: 63 pages, 4 eps figures, references and thanks added, to appear in Nucl.Phys.

Outcomes after perioperative SARS-CoV-2 infection in patients with proximal femoral fractures: an international cohort study

Objectives Studies have demonstrated high rates of mortality in people with proximal femoral fracture and SARS-CoV-2, but there is limited published data on the factors that influence mortality for clinicians to make informed treatment decisions. This study aims to report the 30-day mortality associated with perioperative infection of patients undergoing surgery for proximal femoral fractures and to examine the factors that influence mortality in a multivariate analysis. Setting Prospective, international, multicentre, observational cohort study. Participants Patients undergoing any operation for a proximal femoral fracture from 1 February to 30 April 2020 and with perioperative SARS-CoV-2 infection (either 7 days prior or 30-day postoperative). Primary outcome 30-day mortality. Multivariate modelling was performed to identify factors associated with 30-day mortality. Results This study reports included 1063 patients from 174 hospitals in 19 countries. Overall 30-day mortality was 29.4% (313/1063). In an adjusted model, 30-day mortality was associated with male gender (OR 2.29, 95% CI 1.68 to 3.13, p80 years (OR 1.60, 95% CI 1.1 to 2.31, p=0.013), preoperative diagnosis of dementia (OR 1.57, 95% CI 1.15 to 2.16, p=0.005), kidney disease (OR 1.73, 95% CI 1.18 to 2.55, p=0.005) and congestive heart failure (OR 1.62, 95% CI 1.06 to 2.48, p=0.025). Mortality at 30 days was lower in patients with a preoperative diagnosis of SARS-CoV-2 (OR 0.6, 95% CI 0.6 (0.42 to 0.85), p=0.004). There was no difference in mortality in patients with an increase to delay in surgery (p=0.220) or type of anaesthetic given (p=0.787). Conclusions Patients undergoing surgery for a proximal femoral fracture with a perioperative infection of SARS-CoV-2 have a high rate of mortality. This study would support the need for providing these patients with individualised medical and anaesthetic care, including medical optimisation before theatre. Careful preoperative counselling is needed for those with a proximal femoral fracture and SARS-CoV-2, especially those in the highest risk groups. Trial registration number NCT0432364