Use of antibiotics and other treatments in Chinese adults with acute cough: An online survey

Background

This study aimed to identify use of various treatments and their association with the use of antibiotics and patient reported clinical recovery in Chinese adults with acute cough.

Methods

An online survey recruiting people who had recently experienced cough was conducted. Their sociodemographic, clinical characteristics, treatments received and their perceived changes in symptoms were collected. Factors influencing avoidance of antibiotics and improvement in symptoms were explored.

Results

A total of 22,787 adults with recent acute cough completed the questionnaire, covering all 34 province-level administrative units in China. Most respondents were male (68.0%), young (89.4%, aged 18-45), educated to university/degree or postgraduate level (44.6%), with a median cough severity of 6/10 on a numerical rating scale. Nearly half of the participants (46.4%) reported using antibiotics, among which 93.1% were for presumed upper respiratory tract infections (URTIs). Pharmacies (48.8%) were the most common source of antibiotics. Fewer patients took antibiotics after taking CHM (14.9%), compared to those who started with home remedies (18.0%), or allopathic non-antibiotic medication (25.0%). Antibiotics, allopathic non-antibiotic medications, CHM and home remedies were all perceived beneficial in relieving cough.

Conclusions

Chinese adult responders report use of a considerable variety of treatments alone or in combination for acute cough. Patient-reported clinical recovery was similar regardless of treatment. There is likely a high proportion of inappropriate use of antibiotics for treatment of simple acute cough. As the majority of respondents did not use antibiotics as a first-line, and use of CHM was associated with relief of cough symptoms and reduction in the use of antibiotics, this presents an important opportunity for prudent antibiotic stewardship in China.

A nationwide survey on the management of the COVID-19 pandemic and respiratory disease in South Korea

Background

This study aimed to explore individual prevalence of respiratory symptoms and to describe the Korean population's treatment approaches, preventive health behaviors, and mental health conditions during the pandemic.

Methods

We analyzed responses from an online nationwide survey, conducted between February 2021 to May 2021, about people's experiences during the pandemic. Statistical analysis was also performed to see if there were any significant differences in treatment and prevention strategies between different groups of respondents (between those had respiratory symptoms, compared with those who did not, and between those tested positive for COVID-19, compared with those who did not).

Results

A total of 2,177 survey respondents completed the survey and, of these, only 142 had experienced symptoms. The most frequently reported respiratory infections related symptoms were runny or blocked nose (47.6%), cough (45.5%), fever (44.1%), sore throat (42.0%), and fatigue (30.1%). More than half of the respondents (53.1%) used complementary and alternative medicine (CAM) approaches as means of preventive measures. In terms of preventive behaviors, the more emphasized behaviors were mask-wearing (58.9%) and hand-washing after coming home (42.7%). The majority of the respondents (64.9%) did not show signs of mental health issues.

Conclusion

In South Korea, conventional medicine was mainly used for COVID-19 treatment whereas CAM was commonly used as preventive measures. COVID-19 was also found to have less impact on the general population's mental health. The findings of this study may shed light on how the pandemic impacted the general population.

Knowledge of Malaria and Its Uncomplicated Treatment with Argemone mexicana L. in Selected Districts of Jimma Zone, Oromia Regional State, Ethiopia: A Community-Based Cross Sectional Survey

Background

With the problems of increasing levels of drug resistance and difficulties to afford and access effective antimalarial drugs in poor and remote areas, herbal medicines could be an important and sustainable source of treatment. Argemone mexicana L. (AM) is a medicinal plant known long ago in several countries for treatment of numerous diseases including malaria. The aim of this study was to conduct a survey on the use of AM in the prevention and treatment of uncomplicated malaria in selected districts of Jimma Zone, Oromia Regional state, Ethiopia.

Methods

A community-based cross-sectional study was conducted in two selected districts in Jimma Zone, southwest Ethiopia. In total, 552 participants from 17 kebeles (villages/communities) and 18 traditional healers of the districts were interviewed. Data collection was conducted from April 27 to May 18, 2020 using pre-tested structured questionnaires. The data were analyzed using Epi Info 7.0 and the descriptive statistics were used to summarize the results.

Results

The study indicated that AM is available, known by 39.8% of the respondents and used for prevention and treatment of malaria by 5.7% of the population. All traditional healers interviewed knew the plant, and 44.4% use it for treatment of malaria. In addition, AM is especially used to treat malaria, amoebiasis, diarrhea, cough, and tuberculosis.

Conclusion

The availability and use of AM to treat malaria was verified in both community and traditional healers. AM, which was found effective as antimalarial plant in high Plasmodium falciparum endemicity in Mali, is also well known and accepted in these areas of Ethiopia for the treatment of malaria. Further research is needed to assess wether AM is also effective against malaria in Ethiopia where P. vivax and P. falciparum coexist.

Effectiveness of Medicinal Plants for Glycaemic Control in Type 2 Diabetes: An Overview of Meta-Analyses of Clinical Trials

Aims: To rank the effectiveness of medicinal plants for glycaemic control in Type 2 Diabetes (T2DM).

Methods: MEDLINE, EMBASE, CINAHL and Cochrane Central were searched in October 2020. We included meta-analyses of randomised controlled clinical trials measuring the effectiveness of medicinal plants on HbA1c and/or Fasting Plasma Glucose (FPG) in patients with T2DM.

Results: Twenty five meta-analyses reported the effects of 18 plant-based remedies. Aloe vera leaf gel, Psyllium fibre and Fenugreek seeds had the largest effects on HbA1c: mean difference –0.99% [95% CI−1.75, −0.23], −0.97% [95% CI −1.94, −0.01] and −0.85% [95% CI −1.49, −0.22] respectively. Four other remedies reduced HbA1c by at least 0.5%: Nigellasativa, Astragalus membranaceus, and the traditional Chinese formulae Jinqi Jiangtang and Gegen Qinlian. No serious adverse effects were reported. Several other herbal medicines significantly reduced FPG. Tea and tea extracts (Camellia sinensis) were ineffective. However, in some trials duration of follow-up was insufficient to measure the full effect on HbA1c (<8 weeks). Many herbal remedies had not been evaluated in a meta-analysis.

Conclusion: Several medicinal plants appear to be as effective as conventional antidiabetic treatments for reducing HbA1c. Rigorous trials with at least 3 months’ follow-up are needed to ascertain the effects of promising plant-based preparations on diabetes.

Traditional Chinese medicine for COVID-19 pandemic and emerging challenges: An online cross-sectional survey in China

BACKGROUND

We aimed to investigate use of infection control behaviours, preventative and therapeutic interventions, and outcomes among respondents to an online survey during the COVID-19 pandemic in China.

METHODS

The survey was designed by an international team, translated and adapted to simplified Chinese, including 132 kinds of traditional Chinese medicine (TCM) preparation recommended by guidelines. It was distributed and collected from February to May 2021, with data analysed by WPS spreadsheet and wjx.cn. Descriptive statistics were used to describe demographics and clinical characteristics, diagnosis, treatments, preventative behaviours and interventions, and their associated outcomes.

RESULTS

The survey was accessed 503 times with 341 (67.8%) completions covering 23 provinces and four municipalities in China. Most (282/341, 82.7%) respondents reported no symptoms during the pandemic and the majority (290/341, 85.0%) reported having a SARS-CoV-2 PCR test at some point. Forty-five (13.2%) reported having a respiratory infection, among which 19 (42.2%) took one or more categories of modern medicine, e.g. painkillers, antibiotics; 16 (35.6%) used TCM interventions(s); while seven respondents combined TCM with modern medicine. All respondents reported using at least one behavioural or medical approach to prevention, with 22.3% taking TCM and 5.3% taking modern medicines. No respondents reported having a critical condition related to COVID-19.

CONCLUSION

We found evidence of widespread use of infection control behaviours, modern medicines and TCM for treatment and prevention of COVID-19 and other respiratory symptoms. Larger scale studies are warranted, including a more representative sample exploring TCM preparations recommended in clinical guidelines.

Hibiscus sabdariffa, a Treatment for Uncontrolled Hypertension. Pilot Comparative Intervention

In Iraq, in 2019, there were about 1.4 million Internally Displaced Persons (IDP); medical treatments were often interrupted. The feasibility of using Hibiscus sabdariffa (HS) decoction to curb hypertension was evaluated. A multicentric comparative pilot intervention for 121 participants with high blood pressure (BP) (≥140/90 mmHg) was conducted. Participants of the intervention group (with or without conventional medication) received HS decoction on a dose regimen starting from 10 grams per day. BP was measured five times over six weeks. The major active substances were chemically quantified. Results: After 6 weeks, 61.8% of participants from the intervention group (n = 76) reached the target BP < 140/90 mmHg, compared to 6.7% in the control group (n = 45). In the intervention group, a mean (±SD) reduction of 23.1 (±11.8) mmHg and 12.0 (±11.2) for systolic and diastolic BP, respectively, was observed, while in the control group the reduction was 4.4 (±10.2)/3.6 (±8.7). The chemical analysis of the starting dose indicated a content of 36 mg of total anthocyanins and 2.13 g of hibiscus acid. The study shows the feasibility of using HS decoction in IDP’s problematic framework, as hibiscus is a safe, local, affordable, and culturally accepted food product.

Head Lice at School: Traditional Medicine and Community Engagement

Purpose: The prevalence of head lice in poor rural communities and urban slums is estimated to be between 28% and 43% in Brazil, respectively. Children are among the most affected, often in clusters within schools. We launched a program intending to tackle the social stigma associated with head lice using scientific information and a local traditional remedy as a way to lower the prevalence of head lice in a low-resource community. Methods: A program involving the entire school community and the teachers addressed how to treat head lice and avoid new infestations. An affordable solution widely used in traditional Brazilian medicine was provided for the ones infested. Evaluation of the outcome was based on direct observation and was designed as a satisfaction survey. The study complied with the criteria for Standards for Reporting Qualitative Research (SRQR). Results: Two hundred and eighty participants, including parents and siblings of the school children, took part in the program. Among them, 24% (N=67) had head lice, with girls representing 85% of cases; 74.7% of participants infested with head lice were between 4 and 10 years old; 55.2% (N=37) of participants infested showed no signs of nits or adult lice after the program. Conclusions: This experience suggests that the use of playful activities associated with a well-known and accessible local product to treat head lice in low-income families gathered a high degree of community adherence and may be an important tool in overcoming health inequalities.

Hypertension treatment with Combretum micranthum or Hibiscus sabdariffa, as decoction or tablet: a randomized clinical trial

Hibiscus sabdariffa L. (local names: bissap, karkade) and Combretum micranthum (kinkeliba) are widely known in traditional medicines and popular beliefs for their antihypertensive effect. This study assessed the clinical effectiveness of these two plants in the galenic forms of tablet and brew (decoction) in noncomplicated hypertensive patients. In total, 219 hypertensive patients with systolic blood pressure (SBP) between 140 and 180 mmHg and/or diastolic blood pressure (DBP) between 90 and 110 mmHg, without cardiovascular or renal complications, were involved in a multicentric randomized clinical trial in Senegal comparing five treatment regimens: bissap tablets (2 × 375 mg/day), bissap brew (10 g of calyx/day), kinkeliba tablets (2 × 200 mg/day), kinkeliba brew (10 g of leaves/day), and captopril (2 × 50 mg/day) as control. During the 6 months' follow-up, a significant and equivalent decrease of SBP was observed with the herbal drug approach (-19.5 ± 16.1 mmHg, p < 0.001) and control group (-19.7 ± 16.7, p < 0.001). Regarding the galenic forms, the brews tended to be slightly more effective than tablets (reduction of SBP: -20.7 ± 15.1 mmHg vs -18.7 ± 16.7). The rates of clinically significant effectiveness (decrease in SBP ≥ 10 mmHg) were 75%, 67%, and 65% with bissap, kinkeliba, and captopril, respectively. After 6 months, target blood pressure of <140/90 mmHg was attained by 49% of patients with bissap, 51% with kinkeliba and 40% with captopril. Bissap and kinkeliba appeared, at doses utilized, to be as effective as captopril over the 6 months' follow-up. In subsequent studies, brews might be started with a lower dosage.

Treatments used for malaria in young Ethiopian children: a retrospective study

Background

In Ethiopia, medicinal plants have been used to treat different diseases, including malaria, for many centuries. People living in rural areas are especially noted for their use of medicinal plants as a major component of their health care. This study aimed to study treatment-seeking and prioritize plants/plant recipes as anti-malarials, in Dembia district, one of the malarious districts in Northwest Ethiopia.

Methods

Parents of children aged under 5 years who had had a recent episode of fever were interviewed retrospectively about their child’s treatment and self-reported outcome. Treatments and subsequent clinical outcomes were analysed using Fisher’s exact test to elicit whether there were statistically significant correlations between them.

Results and discussion

Of 447 children with malaria-like symptoms, only 30% took the recommended first-line treatment (ACT) (all of whom were cured), and 47% took chloroquine (85% cured). Ninety-nine (22.2%) had used medicinal plants as their first-choice treatment. Allium sativum (Liliaceae), Justicia schimperiana (Acanthaceae), Buddleja polystachya (Scrophulariaceae) and Phytolacca dodecandra (Phytolaccaceae) were the most frequently used. Justicia schimperiana was the one associated with the best clinical outcomes (69% self-reported cure rate). However, the difference in clinical outcomes between the plants was not statistically significant.

Conclusion

In this study, only 30% of children took the recommended first-line treatment. 22% of children with presumed malaria were first treated with herbal medicines. The most commonly used herbal medicine was garlic, but J. schimperiana was associated with the highest reported cure rate of the plants. Further research is warranted to investigate its anti-malarial properties.

Trachoma: Possibilities of Prevention. A Study in the Sultanate of Oman

Using a questionnaire and direct observation, this survey aimed at providing basic information on how to design an effective trachoma prevention campaign. Among the population of rural Oman, the causal relations between Chlamydia conjunctivitis and the later complications, trichiasis, corneal ulcer and eventually blindness, are still widely unknown, so that prevention of contagion seems irrelevant in public opinion. A booklet on the prevention of blindness was very poorly understood, because the population is highly illiterate, and because even the pictures used were not appropriate. Such concepts as contagion and the importance of flies in the spread of diseases appeared to be common in the population surveyed. These ideas could provide a starting point in a picture- and television-based campaign. The results are consistent with theory that the success of a trachoma prevention campaign depends on a thorough knowledge of local sociocultural particularities.

"DAK", a traditional decoction in Palau, as adjuvant for patients with insufficient control of diabetes mellitus type II

ETHNOPHARMACOLOGICAL RELEVANCE

Can a medicinal plant be useful when standard modern treatment is insufficient? After a population survey in the Republic of Palau (retrospective treatment-outcome study, following the reverse pharmacology approach) on local treatments and associated outcomes for diabetes, a traditional drink made with Phaleria nisidai Kaneh and several other plants called "Delal A Kar", (meaning "mother of medicine") appeared as a promising therapy. This is the first clinical study on a standardized version of "Delal A Kar" called DAK.

AIMS/HYPOTHESIS

This is a study of the effect of DAK as adjuvant therapy when diabetes control is insufficient.

METHODS

In this randomized, double blind, crossover study conducted in Koror, Palau, DAK or placebo was assigned to 68 patients with type II diabetes treated with oral hypoglycemic agents and with insufficient glycaemic control. All patients received instructions on how to improve their diet and a home glucometer for blood glucose follow-up.

RESULTS

Fifty-five patients completed the study and significant improvements were observed in both groups over the 12 weeks follow-up period: weight decreased an average of 2 to -4.5 pounds (p<0,001) and HbA1C also decreased from 9.7% to 7.8% (p<0,001), with a consistent trend toward better outcomes after DAK, as compared to placebo. The average effect of Ongael was 0.5% (SD 2.5) decrease of HbA1C. Furthermore, seventy-five percent (41/55) of the patients reduced their HbA1C by at least 0.7% at 12 weeks.

CONCLUSION

The observed trends in this trial suggest that poorly controlled diabetic patients improved their control of diabetes within 12 weeks when drinking DAK for at least 6 weeks. The drink DAK, in addition to the usual prevention activities of special diet and physical exercise, was followed by improvement of diabetes control (HbA1C) and decrease of blood pressure and weight.

TRIAL REGISTRATION

The study protocol was approved by the Institutional Ethical Committee and registered by international Australia and New Zealand trial registry (Request Number: 369395) FUNDING: Pacific Academic Institute for Research office fund, Belau Medical Clinic, The Environment, Inc, Antenna Foundation, Grandjean and Michèle Berset funds and the Weil Foundation.

Assessing traditional healers: an observational clinical study of classical Arabic medicine in Mauritania, with comparison of prognosis and outcome

In a classical Arabic medicine clinic near Nouakchott, Mauritania, two general practitioners observed 170 consecutive consultations. With a follow-up rate of 66%, the studied practices appeared fairly safe and, in many chronic conditions, traditional healers performed similarly to what can be expected with modern medicine. Traditional healers and professionals from the nearby primary health care centre started a weekly joint consultation.

Intellectual property rights, benefit-sharing and development of "improved traditional medicines": A new approach

ETHNOPHARMACOLOGICAL RELEVANCE

Protection of intellectual property rights and benefit-sharing are key issues for all ethnopharmacological research. The International Society of Ethnobiology has produced helpful guidelines on access and benefit-sharing which are widely viewed as a "gold standard" but the question remains how best to apply these guidelines in practice. Difficult questions include ownership of traditional knowledge, making appropriate agreements, and how appropriately to share benefits.

MATERIALS AND METHODS

We present the case study of the development of an "improved traditional medicine" for malaria in Mali and we report how benefit-sharing was applied in this case.

RESULTS

The knowledge about the selected plant came independently from several families and traditional healers. The IPR approach was to recognise that this traditional knowledge belongs to the people of Mali and was used for their benefit in developing a new "improved traditional medicine" (ITM). The traditional healer whose method of preparation was used, and who collaborated in clinical trials, did not request any financial reward but asked for the ITM to be named after him. The most sustainable benefit for the community was sharing the results of which preparation of which medicinal plant seemed to be the most effective for treating malaria. Attempts at providing a health centre and training a health worker for the village did not prove to be sustainable.

CONCLUSIONS

Respect for intellectual property rights and benefit-sharing are possible even in a context where the knowledge is not owned by a clearly identified person or group of people. The most sustainable benefits are intangible rather than material: namely recognition, improved knowledge about which traditional treatment is the best and how to prepare and take it.

Traditional local medicines in the republic of Palau and non-communicable diseases (NCD), signs of effectiveness

ETHNOPHARMACOLOGICAL RELEVANCE

The aim of this survey was to describe which traditional medicines (TM) are most commonly used for non-communicable diseases (NCD - diabetes, hypertension related to excess weight and obesity) in Pacific islands and with what perceived effectiveness. NCD, especially prevalent in the Pacific, have been subject to many public health interventions, often with rather disappointing results. Innovative interventions are required; one hypothesis is that some local, traditional approaches may have been overlooked.

MATERIALS AND METHODS

The method used was a retrospective treatment-outcome study in a nation-wide representative sample of the adult population (about 15,000 individuals) of the Republic of Palau, an archipelago of Micronesia.

RESULTS

From 188 respondents (61% female, age 16-87, median 48,), 30 different plants were used, mostly self-prepared (69%), or from a traditional healer (18%). For excess weight, when comparing the two most frequent plants, Morinda citrifolia L. was associated with more adequate outcome than Phaleria nishidae Kaneh. (P=0.05). In case of diabetes, when comparing Phaleria nishidae (=Phaleria nisidai) and Morinda citrifolia, the former was statistically more often associated with the reported outcome "lower blood sugar" (P=0.01).

CONCLUSIONS

Statistical association between a plant used and reported outcome is not a proof of effectiveness or safety, but it can help select plants of interest for further studies, e.g. through a reverse pharmacology process, in search of local products which may have a positive impact on population health.

Home treatments alone or mixed with modern treatments for malaria in Finkolo AC, South Mali: reported use, outcomes and changes over 10 years

BACKGROUND

In 2003, a study in Mali showed that 87% of episodes of uncomplicated malaria were first treated at home. We investigated whether treatment-seeking patterns in Mali had changed 10 years later.

METHODS

In 2013, we repeated the retrospective treatment-outcome study on 400 children with presumed malaria in the same area.

RESULTS

Most children with reported uncomplicated malaria were still first treated at home (76% [196/258] in 2013 vs 85% in 2003; p=0.006), rather than in modern health centres (20% [52/258] in 2013 vs 12% in 2003; p=0.01). Overall, 58% of children with uncomplicated malaria were treated with herbal medicine alone, a significant increase from 24% 10 years earlier (p<0.001). This was associated with an increase in use of Argemone mexicana decoction from 8% to 26% (p<0.001), with a reported cure or improvement in 100% of cases among those aged >5 years. For severe malaria, first treatment was sought less often from a traditional healer compared with 10 years earlier (4% vs 32%; p<0.001) and more often from a modern health centre (29% vs 17%; p=0.04).

CONCLUSIONS

Two trends that emerged are that there is a greater use of modern health facilities for treatment of severe malaria, and a greater use of traditional medicine alone for treatment of uncomplicated malaria.

[Dysmenorrhea: patience, pills or hot-water bottle?]

Which treatments are used for dysmenorrhea and with what reported outcome? A questionnaire was sent to 2400 students and apprentices, following the "retrospective treatment-outcome" method. The response rate was 22%. Most frequent treatments used are ibuprofene (53%), paracetamol (51%), hormonal contraception (40%), hot-water bottle (or hot pad) (35%), food supplements or medicinal plants (23%). Physicians only discuss a tiny proportion of dysmenorrhea treatment in their consultation, because it is mostly a matter of self-treatment, with the family as the source of information in 80% of the cases. Rather surprising because not mentioned in most official guidelines, hot-water bottle (or hot pad) appears as the treatment followed by the best reported outcome (satisfactory in 92% of users).

Pre-hospital risk factors for inpatient death from severe febrile illness in Malian children

BACKGROUND

Inpatient case fatality from severe malaria remains high in much of sub-Saharan Africa. The majority of these deaths occur within 24 hours of admission, suggesting that pre-hospital management may have an impact on the risk of case fatality.

METHODS

Prospective cohort study, including questionnaire about pre-hospital treatment, of all 437 patients admitted with severe febrile illness (presumed to be severe malaria) to the paediatric ward in Sikasso Regional Hospital, Mali, in a two-month period.

FINDINGS

The case fatality rate was 17.4%. Coma, hypoglycaemia and respiratory distress at admission were associated with significantly higher mortality. In multiple logistic regression models and in a survival analysis to examine pre-admission risk factors for case fatality, the only consistent and significant risk factor was sex. Girls were twice as likely to die as boys (AOR 2.00, 95% CI 1.08-3.70). There was a wide variety of pre-hospital treatments used, both modern and traditional. None had a consistent impact on the risk of death across different analyses. Reported use of traditional treatments was not associated with post-admission outcome.

INTERPRETATION

Aside from well-recognised markers of severity, the main risk factor for death in this study was female sex, but this study cannot determine the reason why. Differences in pre-hospital treatments were not associated with case fatality.

Reverse pharmacology for developing an anti-malarial phytomedicine. The example of Argemone mexicana

•

The conventional drug discovery approach is compared with the reverse pharmacology process.

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Argemone mexicana is used as a case study.

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A reverse pharmacology approach is presented for the treatment of uncomplicated malaria.

•

The conventional method led to the identification of 3 alkaloids with antiplasmodial activity.

•

The few in vitro tests available for malaria is pointed out as a limiting factor in the search for new drugs.

Classical pharmacology has been the basis for the discovery of new chemical entities with therapeutic effects for decades. In natural product research, compounds are generally tested in vivo only after full in vitro characterization. However drug screening using this methodology is expensive, time-consuming and very often inefficient.

Reverse pharmacology, also called bedside-to-bench, is a research approach based on the traditional knowledge and relates to reversing the classical laboratory to clinic pathway to a clinic to laboratory practice. It is a trans-disciplinary approach focused on traditional knowledge, experimental observations and clinical experiences. This paper is an overview of the reverse pharmacology approach applied to the decoction of Argemone mexicana, used as an antimalarial traditional medicine in Mali. A. mexicana appeared as the most effective traditional medicine for the treatment of uncomplicated falciparum malaria in Mali, and the clinical efficacy of the decoction was comparable to artesunate–amodiaquine as previously published. Four stages of the reverse pharmacology process will be described here with a special emphasis on the results for stage 4. Briefly, allocryptopine, protopine and berberine were isolated through bioguided fractionation, and had their identity confirmed by spectroscopic analysis. The three alkaloids showed antiparasitic activity in vitro, of which allocryptopine and protopine were selective towards Plasmodiumfalciparum. Furthermore, the amount of the three active alkaloids in the decoction was determined by quantitative NMR, and preliminary in vivo assays were conducted. On the basis of these results, the reverse pharmacology approach is discussed and further pharmacokinetic studies appear to be necessary in order to determine whether these alkaloids can be considered as phytochemical markers for quality control and standardization of an improved traditional medicine made with this plant.

Patterns of malaria indices across three consecutive seasons in children in a highly endemic area of West Africa: a three times-repeated cross-sectional study

OBJECTIVES

To study the manifestations of Plasmodium infection, and its relations with the malaria disease, especially when comparing dry and rainy seasons in a hyperendemic area of West Africa.

METHODS

The study was carried out in an area where malaria transmission is high, showing important seasonal variations. One thousand children, representing the total child population (1-12 year old), were observed transversally at the end of three consecutive seasons (dry/rainy/dry). The usual indicators, such as parasite density, splenomegaly, anaemia, or febrile disease were recorded and analysed.

RESULTS

The prevalence of Plasmodium falciparum was high in all age groups and seasons, constantly around 60%. The high transmission season (rainy) showed higher rates of anaemia and spleen enlargement and, in the youngest children only, higher parasite densities. There were also differences between the two dry seasons: in the first one, there was a higher rate of fever than in the second one (p < 0.001). Low parasite density (<2,000 p/μl) was never associated with fever during any season, raising some concern with regard to the usefulness of parasite detection. The possible origins of fever are discussed, together with the potential usefulness of analyzing these indices on a population sample, at a time when fever incidence rises and malaria is one potential cause among others. The distinction to be made between the Plasmodium infection and the malaria disease is highlighted.

CONCLUSIONS

These data confirm previous hypotheses of a strong difference in malaria infection and disease between dry and rainy seasons. The most relevant seasonal indicator was not mainly parasite rate and density but anaemia, spleen enlargement, prevalence and possible origin of fever.

RECOMMENDATIONS

In any situation (i.e. fever or not) and especially during the dry season, one must consider that detection of parasites in the blood is only evidence of a Plasmodium infection and not necessarily of a malaria disease. In such a situation, it seems suitable to obtain, through national malaria teams, a well-defined situation of transmission and prevalence of Plasmodium infection following zones and seasons, in order to adapt control strategies. For researchers, a systematic management of data separately for dry and rainy season appears mandatory.

What is "clinical data"? Why and how can they be collected during field surveys on medicinal plants?

ETHNOPHARMACOLOGICAL RELEVANCE

"Reverse pharmacology", also called "bedside-to-bench" or "field to pharmacy" approach, is a research process starting with documentation of clinical outcome as observed by patients with different therapeutic regimens. The treatment most significantly associated with cure is selected for future studies: first, clinical safety and efficacy; then in vivo and vitro studies. Some clinical data, i.e. details on patient status and progress, can be collected during ethnobotanical surveys; they will help clinical researchers and, once effectiveness and safety are established, will also help users of traditional medicine make safer and more effective choices. To gather clinical data successfully, ethnopharmacologists need to be backed by an appropriate team of specialists in medicine and epidemiology. Ethnopharmacologists can also gather important data on traditional medicine safety.

MATERIALS AND METHODS

The first step is to create a consensus on the meaning of "clinical data", their interest and importance. An understanding of why "a cure is not a proof of effectiveness" is a starting point to avoid faulty interpretation of the clinical observations.

RESULTS

Experience showed that, with the "bedside-to-bench" approach, a treatment derived from traditional recipe can be scientifically validated (in terms of safety and effectiveness) with a cost of less than a million euros, thus providing an end-product that is affordable, available and sustainable.

CONCLUSIONS

With rigorous clinical study results, medicinal plant users gain the possibility to refine heath strategies. The field surveyor may gain a better relationship with the population, once she/he is seen as bringing information useful for the quality of care in the community.

Offer and use of complementary and alternative medicine in hospitals of the French-speaking part of Switzerland

BACKGROUND

In 2004, complementary and alternative medicine (CAM) was offered by physicians in one-third of Swiss hospitals. Since then, CAM health policy has changed considerably. This study aimed to describe the present supply and use of CAM in hospitals in the French-speaking part of Switzerland, and to explore qualitatively the characteristics of this offer.

METHODS

Between June 2011 and March 2012, a short questionnaire was sent to the medical directors of hospitals (n = 46), asking them whether CAM was offered, where and by whom. Then, a semi-directive interview was conducted with ten CAM therapists.

RESULTS

Among 37 responses (return rate 80%), 19 medical directors indicated that their hospital offered at least one CAM and 18 reported that they did not. Acupuncture was the most frequently available CAM, followed by manual therapies, osteopathy and aromatherapy. The disciplines that offered CAM most frequently were rehabilitation, gynaecology and obstetrics, palliative care, psychiatry, and anaesthetics. In eight out of ten interviews, it appeared that the procedures for introducing a CAM in the hospital were not tightly supervised by the hospital and were mainly based on the goodwill of the therapists, rather than clinical/scientific evidence.

CONCLUSION

The number of hospitals offering CAM in the French-speaking part of Switzerland seemed to have risen since 2004. The selection of a CAM to be offered in a hospital should be based on the same procedure of evaluation and validation as conventional therapy, and if the safety and efficiency of the CAM is evidence-based, it should receive the same resources as a conventional therapy.

Exploratory survey about dietary supplement use: a hazardous and erratic way to improve one's health?

INTRODUCTION

Dietary supplement (DS) use increased rapidly in recent years. However, evidence of benefits of many DSs for healthy users is scarce and may not equate with known risks of overdose, drug interaction and recently discovered negative long-term effects. This exploratory study aimed to investigate the perceptions and motivations of DS users in Lausanne, Switzerland.

METHOD

A convenience sample (n = 147) was recruited at the entrances of local sales points. Data were collected in on-site semistructured interviews that assessed dietary supplementation habits.

RESULTS

The majority of DSs were all-in-one products, containing a mixture of minerals and vitamins, or products containing only minerals. Among the 147 users, 72 (49%) used one all-in-one product and 3 (2%) used two all-in-one products. Thirty-one (21%) consumers did not know for at least one product what the purpose of their DS use was. Seventy-five percent of participants thought that DS use presents no risk or nearly no risk. Only 49% of participants stated that their physicians were informed about their consumption. Although men searched more often for potential risks (p <0.001), they turned less frequently to health professionals to get this information (p = 0.007).

DISCUSSION

As in other surveys performed elsewhere, our study shows that, in Lausanne (Switzerland), DSs are commonly used as mixed products. Risk perception seems generally low among DS users. Physicians should be trained to evaluate patients' perceived needs and DS consumption in order to provide good evidence-based information or to propose alternatives to DS use.

"Test and treat" or presumptive treatment for malaria in high transmission situations? A reflection on the latest WHO guidelines

Recent WHO guidelines recommend a universal "test and treat" strategy for malaria, mainly by use of rapid diagnostic test (RDT) in all areas. The evidence for this approach is questioned here as there is a risk of over-reliance on parasitological diagnosis in high transmission situations, which still exist. In such areas, when a patient has fever or other malaria symptoms, the presence of Plasmodium spp neither reliably confirms malaria as the cause of the fever, nor excludes the possibility of other diseases. This is because the patient may be an asymptomatic carrier of malaria parasites and suffer from another disease.

To allow clinicians to perform their work adequately, local epidemiologic data are necessary. One size does not fit all. If parasite prevalence in the population is low, a diagnostic test is relevant; if the prevalence is high, the test does not provide information of any clinical usefulness, as happens with any test in medicine when the prevalence of the tested characteristic is high in the healthy population. It should also be remembered that, if in some cases anti-malarials are prescribed to parasite-negative patients, this will not increase selection pressure for drug resistance, because the parasite is not there.

In high transmission situations at least, other diagnoses should be sought in all patients, irrespective of the presence of malaria parasites. For this, clinical skills (but not necessarily physicians) are irreplaceable, in order to differentiate malaria from other causes of acute fever, such as benign viral infection or potentially dangerous conditions, which can all be present with the parasite co-existing only as a "commensal" or silent undesirable guest.

To what extent can traditional medicine contribute a complementary or alternative solution to malaria control programmes?

Recent studies on traditional medicine (TM) have begun to change perspectives on TM effects and its role in the health of various populations. The safety and effectiveness of some TMs have been studied, paving the way to better collaboration between modern and traditional systems. Traditional medicines still remain a largely untapped health resource: they are not only sources of new leads for drug discoveries, but can also provide lessons and novel approaches that may have direct public-health and economic impact. To optimize such impact, several interventions have been suggested, including recognition of TM's economic and medical worth at academic and health policy levels; establishing working relationships with those prescribing TM; providing evidence for safety and effectiveness of local TM through appropriate studies with malaria patients; spreading results for clinical recommendations and health policy development; implementing and evaluating results of new health policies that officially integrate TM.

A "reverse pharmacology" approach for developing an anti-malarial phytomedicine

A “reverse pharmacology” approach to developing an anti-malarial phytomedicine was designed and implemented in Mali, resulting in a new standardized herbal anti-malarial after six years of research. The first step was to select a remedy for development, through a retrospective treatment-outcome study. The second step was a dose-escalating clinical trial that showed a dose-response phenomenon and helped select the safest and most efficacious dose. The third step was a randomized controlled trial to compare the phytomedicine to the standard first-line treatment. The last step was to identify active compounds which can be used as markers for standardization and quality control. This example of “reverse pharmacology” shows that a standardized phytomedicine can be developed faster and more cheaply than conventional drugs. Even if both approaches are not fully comparable, their efficiency in terms of public health and their complementarity should be thoroughly considered.

Is parasite clearance clinically important after malaria treatment in a high transmission area? A 3-month follow-up of home-based management with herbal medicine or ACT

Argemone mexicana (AM), a validated herbal medicine for uncomplicated malaria, seems to prevent severe malaria without completely clearing parasites in most patients. This study, in a high transmission area of South Mali, explores whether residual parasitaemia at day 28 was associated with subsequent malaria episodes and/or anaemia. Three hundred and one patients were randomly assigned to AM or artesunate/amodiaquine as first line treatment, of whom 294 were followed up beyond the standard 28 days, to 84 days. From day 29 to day 84, there were no significant differences between treatment groups in new clinical episodes of uncomplicated malaria (0.33 vs 0.31 episodes/patient), severe malaria (< 6% per month of patients aged ≤ 5 years) or moderate anaemia (hematocrit < 24%: 1.1% in both groups at day 84). Total parasite clearance at day 28 was not correlated with incidence of uncomplicated or severe malaria or of moderate anaemia over the subsequent two months. Total parasite clearance at day 28 was not clinically important in the context of high transmission. If this finding can be confirmed, some antimalarials which are clinically effective but do not completely clear parasites could nevertheless be appropriate in high transmission areas. Such a policy could be tested as a way to delay resistance to artemisinin combination therapies.

Mapping HIV/STI behavioural surveillance in Europe

BACKGROUND

Used in conjunction with biological surveillance, behavioural surveillance provides data allowing for a more precise definition of HIV/STI prevention strategies. In 2008, mapping of behavioural surveillance in EU/EFTA countries was performed on behalf of the European Centre for Disease prevention and Control.

METHOD

Nine questionnaires were sent to all 31 member States and EEE/EFTA countries requesting data on the overall behavioural and second generation surveillance system and on surveillance in the general population, youth, men having sex with men (MSM), injecting drug users (IDU), sex workers (SW), migrants, people living with HIV/AIDS (PLWHA), and sexually transmitted infection (STI) clinics patients. Requested data included information on system organisation (e.g. sustainability, funding, institutionalisation), topics covered in surveys and main indicators.

RESULTS

Twenty-eight of the 31 countries contacted supplied data. Sixteen countries reported an established behavioural surveillance system, and 13 a second generation surveillance system (combination of biological surveillance of HIV/AIDS and STI with behavioural surveillance). There were wide differences as regards the year of survey initiation, number of populations surveyed, data collection methods used, organisation of surveillance and coordination with biological surveillance. The populations most regularly surveyed are the general population, youth, MSM and IDU. SW, patients of STI clinics and PLWHA are surveyed less regularly and in only a small number of countries, and few countries have undertaken behavioural surveys among migrant or ethnic minorities populations. In many cases, the identification of populations with risk behaviour and the selection of populations to be included in a BS system have not been formally conducted, or are incomplete. Topics most frequently covered are similar across countries, although many different indicators are used. In most countries, sustainability of surveillance systems is not assured.

CONCLUSION

Although many European countries have established behavioural surveillance systems, there is little harmonisation as regards the methods and indicators adopted. The main challenge now faced is to build and maintain organised and functional behavioural and second generation surveillance systems across Europe, to increase collaboration, to promote robust, sustainable and cost-effective data collection methods, and to harmonise indicators.

[Complementary and alternative medicines (CAM): towards an "evidence-based" consensus in the university hospital]

While a popular vote supported a new article on complementary and alternative medicines (CAM) in the Swiss Constitution, this assessment in 14 wards of the University Hospital of Lausanne, Switzerland, attempted at answering the question: How can CAM use be better taken into account and patients informed with more rigor and respect for their choices? Confronted with a review of the literature (> 2000 publications in "Evidence-based complementary medicines" since 1998), respondents declared their ignorance of the clinical data presently available on CAM. All were in favour of more teaching and information on the subject, plus an official statement from the Hospital direction, ensuring production and diffusion of rigorous and clinically significant information on CAM.

Blood glucose and prognosis in children with presumed severe malaria: is there a threshold for 'hypoglycaemia'?

OBJECTIVES

Hypoglycaemia (glucose <2.2 mmol/l) is a defining feature of severe malaria, but the significance of other levels of blood glucose has not previously been studied in children with severe malaria.

METHODS

A prospective study of 437 consecutive children with presumed severe malaria was conducted in Mali. We defined hypoglycaemia as <2.2 mmol/l, low glycaemia as 2.2-4.4 mmol/l and hyperglycaemia as >8.3 mmol/l. Associations between glycaemia and case fatality were analysed for 418 children using logistic regression models and a receiver operator curve (ROC).

RESULTS

There was a significant difference between blood glucose levels in children who died (median 4.6 mmol/l) and survivors (median 7.6 mmol/l, P < 0.001). Case fatality declined from 61.5% of the hypoglycaemic children to 46.2% of those with low glycaemia, 13.4% of those with normal glycaemia and 7.6% of those with hyperglycaemia (P < 0.001). Logistic regression showed an adjusted odds ratio (AOR) of 0.75 (0.64-0.88) for case fatality per 1 mmol/l increase in baseline blood glucose. Compared to a normal blood glucose, hypoglycaemia and low glycaemia both significantly increased the odds of death (AOR 11.87, 2.10-67.00; and 5.21, 1.86-14.63, respectively), whereas hyperglycaemia reduced the odds of death (AOR 0.34, 0.13-0.91). The ROC [area under the curve at 0.753 (95% CI 0.684-0.820)] indicated that glycaemia had a moderate predictive value for death and identified an optimal threshold at glycaemia <6.1 mmol/l, (sensitivity 64.5% and specificity 75.1%).

CONCLUSIONS

If there is a threshold of blood glucose which defines a worse prognosis, it is at a higher level than the current definition of 2.2 mmol/l.

Argemone mexicana decoction versus artesunate-amodiaquine for the management of malaria in Mali: policy and public-health implications

A classic way of delaying drug resistance is to use an alternative when possible. We tested the malaria treatment Argemone mexicana decoction (AM), a validated self-prepared traditional medicine made with one widely available plant and safe across wide dose variations. In an attempt to reflect the real situation in the home-based management of malaria in a remote Malian village, 301 patients with presumed uncomplicated malaria (median age 5 years) were randomly assigned to receive AM or artesunate-amodiaquine [artemisinin combination therapy (ACT)] as first-line treatment. Both treatments were well tolerated. Over 28 days, second-line treatment was not required for 89% (95% CI 84.1-93.2) of patients on AM, versus 95% (95% CI 88.8-98.3) on ACT. Deterioration to severe malaria was 1.9% in both groups in children aged </=5 years (there were no cases in patients aged >5 years) and 0% had coma/convulsions. AM, now government-approved in Mali, could be tested as a first-line complement to standard modern drugs in high-transmission areas, in order to reduce the drug pressure for development of resistance to ACT, in the management of malaria. In view of the low rate of severe malaria and good tolerability, AM may also constitute a first-aid treatment when access to other antimalarials is delayed.

Characteristics of victims of violence admitted to a specialized medico-legal unit in Switzerland

To improve care and services to victims of interpersonal violence, a medico-legal consultation unit was set up at the Lausanne University Hospital, Switzerland in 2006. Adult victims of violence are referred to the consultation by the emergency department. Patients are received by forensic nurses for support, forensic examination and community orientation. A descriptive study of medical reports filled for the 2006 population was conducted in 2007 with the aim to explore characteristics of this specific population and to better orient prevention. Among the 422 patients in 2006, 57% were men and 43% women, with a median age of 31 years old. Violent episodes took place in a public place for 90% of male victims and at home for 70% of female victims. The perpetrators were mostly unknown to male victims (62% of all men victims) and mostly known (usually the partner or a former partner) to female victims (90% of all women victims). For 80% of the women and 47% of the men, the violent event which brought them to the consultation, was not the first one. Because 90% of all patients under study were victimized by men., not only is it necessary to target prevention program to match the potential victims, prevention messages must also focus on potential offenders, especially on young men.

Rapid diagnostic tests for the home-based management of malaria, in a high-transmission area

Rapid diagnostic tests (RDT) are sometimes recommended to improve the home-based management of malaria. The accuracy of an RDT for the detection of clinical malaria and the presence of malarial parasites has recently been evaluated in a high-transmission area of southern Mali. During the same study, the cost-effectiveness of a 'test-and-treat' strategy for the home-based management of malaria (based on an artemisinin-combination therapy) was compared with that of a 'treat-all' strategy. Overall, 301 patients, of all ages, each of whom had been considered a presumptive case of uncomplicated malaria by a village healthworker, were checked with a commercial RDT (Paracheck-Pf). The sensitivity, specificity, and positive and negative predictive values of this test, compared with the results of microscopy and two different definitions of clinical malaria, were then determined. The RDT was found to be 82.9% sensitive (with a 95% confidence interval of 78.0%-87.1%) and 78.9% (63.9%-89.7%) specific compared with the detection of parasites by microscopy. In the detection of clinical malaria, it was 95.2% (91.3%-97.6%) sensitive and 57.4% (48.2%-66.2%) specific compared with a general practitioner's diagnosis of the disease, and 100.0% (94.5%-100.0%) sensitive but only 30.2% (24.8%-36.2%) specific when compared against the fulfillment of the World Health Organization's (2003) research criteria for uncomplicated malaria. Among children aged 0-5 years, the cost of the 'test-and-treat' strategy, per episode, was about twice that of the 'treat-all' (U.S.$1.0. v. U.S.$0.5). In older subjects, however, the two strategies were equally costly (approximately U.S.$2/episode). In conclusion, for children aged 0-5 years in a high-transmission area of sub-Saharan Africa, use of the RDT was not cost-effective compared with the presumptive treatment of malaria with an ACT. In older patients, use of the RDT did not reduce costs. The question remains whether either of the strategies investigated can be made affordable for the affected population.

["Bientraitance": conceptual exploration and an example of its application in public health. An experience from Fribourg, Switzerland]

Since the year 2000, the concept of "bientraitance" (for which no equivalent term has yet emerged in either the English or German language) has gained widespread credence among educators, sociologists and health professionals in France and Belgium. This concept emphasizes a constructive approach to care and education rather than merely one of prevention of disasters. Applied in public health, and in particular to mental health promotion, the use of the concept of "bientraitance" can help promote both effectiveness and meaning in the design and planning of community interventions. The article presents an example of an intervention for children and adolescents in Fribourg, Switzerland. The underpinning hypothesis is that the children and youth groups (such as sports clubs, artistic and cultural associations, scouts and guides) represent largely untapped, or under-tapped, informal health resources with a favourable cost-effectiveness profile. "Bientraitance" criteria are used in selecting certain associations offering structured extracurricular group educational activities and collective out-of-school (or after school) programmes. Support is provided to the organisations selected for recruiting new members, in particular those with potentially lower levels of access, for example disabled children or new migrants. The results will be evaluated for the impact of participation in various out-of-school activities on health and health determinants from a prospective and comparative perspective. This paper shows how the concept of "bientraitance" can be useful in the development of a public health intervention.

Sublingual sugar for hypoglycaemia in children with severe malaria: a pilot clinical study

Background

Hypoglycaemia is a poor prognostic indicator in severe malaria. Intravenous infusions are rarely feasible in rural areas. The efficacy of sublingual sugar (SLS) was assessed in a pilot randomized controlled trial among hypoglycaemic children with severe malaria in Mali.

Methods

Of 151 patients with presumed severe malaria, 23 children with blood glucose concentrations < 60 mg/dl (< 3.3 mmol/l) were assigned randomly to receive either intravenous 10% glucose (IVG; n = 9) or sublingual sugar (SLS; n = 14). In SLS, a teaspoon of sugar, moistened with a few drops of water, was gently placed under the tongue every 20 minutes. The child was put in the recovery position. Blood glucose concentration (BGC) was measured every 5–10 minutes for the first hour. All children were treated for malaria with intramuscular artemether. The primary outcome measure was treatment response, defined as reaching a BGC of >= 3.3 mmol/l (60 mg/dl) within 40 minutes after admission. Secondary outcome measures were early treatment response at 20 minutes, relapse (early and late), maximal BGC gain (CGmax), and treatment delay.

Results

There was no significant difference between the groups in the primary outcome measure. Treatment response occurred in 71% and 67% for SLS and IVG, respectively. Among the responders, relapses occurred in 30% on SLS at 40 minutes and in 17% on IVG at 20 minutes. There was one fatality in each group. Treatment failures in the SLS group were related to children with clenched teeth or swallowing the sugar, whereas in the IVG group, they were due to unavoidable delays in beginning an infusion (median time 17.5 min (range 3–40).

Among SLS, the BGC increase was rapid among the nine patients who really kept the sugar sublingually. All but one increased their BGC by 10 minutes with a mean gain of 44 mg/dl (95%CI: 20.5–63.4).

Conclusion

Sublingual sugar appears to be a child-friendly, well-tolerated and effective promising method of raising blood glucose in severely ill children. More frequent repeated doses are needed to prevent relapse. Children should be monitored for early swallowing which leads to delayed absorption, and in this case another dose of sugar should be given. Sublingual sugar could be proposed as an immediate "first aid" measure while awaiting intravenous glucose. In many cases it may avert the need for intravenous glucose.