Antibiotic prescribing practices for acute respiratory illness in children less than 24 months of age in Kenema, Sierra Leone: is it time to move beyond algorithm driven decision making?

BACKGROUND

Lower respiratory tract infections are the leading cause of mortality in young children globally. In many resource-limited settings clinicians rely on guidelines such as IMCI or ETAT + that promote empiric antibiotic utilization for management of acute respiratory illness (ARI). Numerous evaluations of both guidelines have shown an overall positive response however, several challenges have also been reported, including the potential for over-prescribing of unnecessary antibiotics. The aims of this study were to describe the antibiotic prescribing practices for children less than 24 months of age with symptoms of ARI, that were admitted to Kenema Government Hospital (KGH) in the Eastern Province of Sierra Leone, and to identify the number of children empirically prescribed antibiotics who were admitted to hospital with ARI, as well as their clinical signs, symptoms, and outcomes.

METHODS

We conducted a prospective study of children < 24 months of age admitted to the KGH pediatric ward with respiratory symptoms between October 1, 2020 and May 31, 2022. Study nurses collected data on demographic information, medical and medication history, and information on clinical course while hospitalized.

RESULTS

A total of 777 children were enrolled. Prior to arrival at the hospital, 224 children (28.8%) reported taking an antibiotic for this illness without improvement. Only 15 (1.9%) children received a chest radiograph to aid in diagnosis and 100% of patients were placed on antibiotics during their hospital stay.

CONCLUSIONS

Despite the lives saved, reliance on clinical decision-support tools such as IMCI and ETAT + for pediatric ARI, is resulting in the likely over-prescribing of antibiotics. Greater uptake of implementation research is needed to develop strategies and tools designed to optimize antibiotic use for ARI in LMIC settings. Additionally, much greater priority needs to be given to ensuring clinicians have the basic tools for clinical diagnosis, as well as greater investments in essential laboratory and radiographic diagnostics that help LMIC clinicians move beyond the sole reliance on algorithm based clinical decision making.

Patients' and clinicians' perspectives towards primary care consultations for shoulder pain: qualitative findings from the Prognostic and Diagnostic Assessment of the Shoulder (PANDA-S) programme

BACKGROUND

Clinical management of musculoskeletal shoulder pain can be challenging due to diagnostic uncertainty, variable prognosis and limited evidence for long-term treatment benefits. The UK-based PANDA-S programme (Prognostic And Diagnostic Assessment of the Shoulder) is investigating short and long-term shoulder pain outcomes. This paper reports linked qualitative research exploring patients' and clinicians' views towards primary care consultations for shoulder pain.

METHODS

Semi-structured interviews were conducted with 24 patients and 15 primary care clinicians. Twenty-two interviews (11 patients, 11 clinicians) were conducted as matched patient-clinician 'dyads'. Data were analysed thematically.

RESULTS

Clinicians reported attempts to involve patients in management decisions; however, there was variation in whether patients preferred treatment choice, or for decisions to be clinician-led. Some patients felt uncertain about the decisions made, due to a lack of discussion about available management options. Many General Practitioners expressed a lack of confidence in diagnosing the underlying cause of shoulder pain. Patients reported either not being given a diagnosis, or receiving different diagnoses from different professionals, resulting in confusion. Whilst clinicians reported routinely discussing prognosis of shoulder pain, patients reported that prognosis was not raised. Patients also expressed concern that their shoulder pain could be caused by serious pathology; however, clinicians felt that this was not a common concern for patients.

CONCLUSIONS

Findings showed disparities between patients' and clinicians' views towards shoulder pain consultations, indicating a need for improved patient-clinician communication. Findings will inform the design of an intervention to support treatment and referral decisions for shoulder pain that will be tested in a randomised controlled trial.

Experiential modulation of social dominance in a SYNGAP1 rat model of Autism Spectrum Disorders

Advances in the understanding of developmental brain disorders such as autism spectrum disorders (ASDs) are being achieved through human neurogenetics such as, for example, identifying de novo mutations in SYNGAP1 as one relatively common cause of ASD. A recently developed rat line lacking the calcium/lipid binding (C2) and GTPase activation protein (GAP) domain may further help uncover the neurobiological basis of deficits in children with ASD. This study focused on social dominance in the tube test using Syngap+/Δ-GAP (rats heterozygous for the C2/GAP domain deletion) as alterations in social behaviour are a key facet of the human phenotype. Male animals of this line living together formed a stable intra-cage hierarchy, but they were submissive when living with wild-type (WT) cage-mates, thereby modelling the social withdrawal seen in ASD. The study includes a detailed analysis of specific behaviours expressed in social interactions by WT and mutant animals, including the observation that when the Syngap+/Δ-GAP mutants that had been living together had separate dominance encounters with WT animals from other cages, the two higher ranking Syngap+/Δ-GAP rats remained dominant whereas the two lower ranking mutants were still submissive. Although only observed in a small subset of animals, these findings support earlier observations with a rat model of Fragile X, indicating that their experience of winning or losing dominance encounters has a lasting influence on subsequent encounters with others. Our results highlight and model that even with single-gene mutations, dominance phenotypes reflect an interaction between genotypic and environmental factors.

146 Ligamentization and Remnant Integration: Implications for Scapholunate Reconstruction

Introduction

Scapholunate interosseous ligament (SLIL) injuries are common but remain a therapeutic challenge. Current treatment modalities prioritize restoration of normal anatomy with reconstruction where appropriate. To date, no reconstructive technique has been described that discusses the potential benefit of the preservation of the scapholunate ligament remnant. Little is known about the ‘ligamentization’ of grafts within the wrist. However, a growing body of knee literature suggests that remnant sparing may confer some benefit. In the absence of wrist specific studies, this literature must guide areas for potential augmentation of current surgical practices.

Method

We conducted a systematic review of the literature using Pubmed, Embase and Medline. Keywords were ‘Ligament’ AND ‘Reconstruction’ AND ‘Remnant’. We identified 366 original studies for title and abstract review. A total of 5 studies were included in the final analysis.

Results

In 5 animal studies, remnant stump integration resulted in enhanced ligamentization of grafted tissue as measured by vascularity, biomechanics, and proprioception.

Conclusions

Our review demonstrates a trend towards enhanced early ligamentization in grafts that incorporate the remnant stump. Remnant preservation is not currently performed in SLIL reconstruction and may provide an avenue for enhanced therapies. As such, it is a promising area for further, wrist specific, research.

Demographic and clinical factors associated with radiographic severity of first metatarsophalangeal joint osteoarthritis: cross-sectional findings from the Clinical Assessment Study of the Foot

OBJECTIVE

To explore demographic and clinical factors associated with radiographic severity of first metatarsophalangeal joint osteoarthritis (OA) (First MTPJ OA).

DESIGN

Adults aged ≥50 years registered with four general practices were mailed a Health Survey. Responders reporting foot pain within the last 12 months were invited to undergo a clinical assessment and weight-bearing dorso-plantar and lateral radiographs of both feet. Radiographic first MTPJ OA in the most severely affected foot was graded into four categories using a validated atlas. Differences in selected demographic and clinical factors were explored across the four radiographic severity subgroups using analysis of variance (ANOVA) and ordinal regression.

RESULTS

Clinical and radiographic data were available from 517 participants, categorised as having no (n = 105), mild (n = 228), moderate (n = 122) or severe (n = 62) first MTPJ OA. Increased radiographic severity was associated with older age and lower educational attainment. After adjusting for age, increased radiographic first MTPJ OA severity was significantly associated with an increased prevalence of dorsal hallux and first MTPJ pain, hallux valgus, first interphalangeal joint (IPJ) hyperextension, keratotic lesions on the dorsal aspect of the hallux and first MTPJ, decreased first MTPJ dorsiflexion, ankle/subtalar joint eversion and ankle joint dorsiflexion range of motion, and a trend towards a more pronated foot posture.

CONCLUSIONS

This cross-sectional study has identified several dose-response associations between radiographic severity of first MTPJ OA and a range of demographic and clinical factors. These findings highlight the progressive nature of first MTPJ OA and provide insights into the spectrum of presentation of the condition in clinical practice.

Subsets of symptomatic hand osteoarthritis in community-dwelling older adults in the United Kingdom: prevalence, inter-relationships, risk factor profiles and clinical characteristics at baseline and 3-years

OBJECTIVE

To compare the population prevalence, inter-relationships, risk factor profiles and clinical characteristics of subsets of symptomatic hand osteoarthritis (OA) with a view to understanding their relative frequency and distinctiveness.

METHOD

1076 community-dwelling adults with hand symptoms (60% women, mean age 64.7 years) were recruited and classified into pre-defined subsets using physical examination and standardised hand radiographs, scored with the Kellgren & Lawrence (K&L) and Verbruggen-Veys grading systems. Detailed information on selected risk factors was obtained from direct measurement (Body Mass Index (BMI)), self-complete questionnaires (excessive use of hands, previous hand injury) and medical record review (hypertension, dyslipidaemia, type 2 diabetes). Hand pain and disability were self-reported at baseline and 3-year follow-up using Australian/Canadian Osteoarthritis Hand Index (AUSCAN).

RESULTS

Crude population prevalence estimates for symptomatic hand OA subsets in the adult population aged 50 years and over were: thumb base OA (22.4%), nodal interphalangeal joint (IPJ) OA (15.5%), generalised hand OA (10.4%), non-nodal IPJ OA (4.9%), erosive OA (1.0%). Apart from thumb base OA, there was considerable overlap between the subsets. Erosive OA appeared the most distinctive with the highest female: male ratio, and the most disability at baseline and 3-years. A higher frequency of obesity, hypertension, dyslipidaemia, and metabolic syndrome was observed in this subset.

CONCLUSION

Overlap in the occurrence of hand OA subsets poses conceptual and practical challenges to the pursuit of distinct phenotypes. Erosive OA may nevertheless provide particular insight into the role of metabolic and cardiovascular risk factors in the pathogenesis of OA.

Radiographic hand osteoarthritis: patterns and associations with hand pain and function in a community-dwelling sample

OBJECTIVE

Patterns of radiographic osteoarthritis (ROA) of the hand are often examined by row, with the four joints of the thumb studied inconsistently. The objectives of this study were to determine relationships of ROA at different hand joints, use the findings to define radiographic sub-groups and investigate their associations with pain and function.

METHODS

Sixteen joints in each hand were scored for the presence of ROA in a community-dwelling cohort of adults, 50-years-and-over, with self-reported hand pain or problems. Principal components analysis (PCA) with varimax rotation was used to study patterns of ROA in the hand joints and identify distinct sub-groups. Differences in pain and function between these sub-groups were assessed using Australian/Canadian Osteoarthritis Index (AUSCAN), Grip Ability Test (GAT) and grip and pinch strength.

RESULTS

PCA was undertaken on data from 592 participants and identified four components: distal interphalangeal joints (DIPs), proximal interphalangeal joints (PIPs), metacarpophalangeal joints (MCPs), thumb joints. However, the left thumb interphalangeal (IP) joint cross-loaded with the PIP and thumb groups. On this basis, participants were categorised into four radiographic sub-groups: no osteoarthritis (OA), finger only OA, thumb only OA and combined thumb and finger OA. Statistically significant differences were found between the sub-groups for AUSCAN function, and in women alone for grip and pinch strength. Participants with combined thumb and finger OA had the worst scores.

CONCLUSION

Individual thumb joints can be clustered together as a joint group in ROA. Four radiographic sub-groups of hand OA can be distinguished. Pain and functional difficulties were highest in participants with both thumb and finger OA.

Discrepancies between self-report and objective measures for stimulant drug use in HIV: cognitive, medication adherence and psychological correlates

While it has long been recognized that self-reported drug use may be at variance with objectively obtained evidence such as urine toxicology assays, few studies have explored the behavioral correlates of such discrepancies. Here we compared self-reported and objective measures of stimulant drug use for 162 HIV infected individuals and identified a sub-group with discrepancies between data obtained via the two methods. Results showed poorer neurocognitive performance (attention, learning/memory) and lower medication adherence rates for the discrepant group as compared to those who either acknowledged their drug use or accurately denied recent stimulant use. Using the Millon Clinical Multiaxial Inventory-III, it was also found that those in the discrepant group were more hesitant to reveal psychopathology. Comparisons of self-reported and objectively measured medication adherence data are also discussed.

Regulation of telomerase by human papillomaviruses

The E6 oncoprotein of human papillomaviruses (HPVs) induces telomerase activity in primary human epithelial cells. This activity is dependent on association of E6 with E6AP, a cellular ubiquitin ligase. E6 activates the transcription of hTERT, the catalytic subunit of telomerase. E boxes near the start of hTERT transcription are required for E6; however, acetylated histones are only present in the E6 cells. We identified two isoforms of NFX1, a new binding partner of E6/E6AP. The NFX1- 91 isoform binds to an X-box motif located adjacent to the proximal E box, binds Sin3A and HDACs, repressing hTERT transcription. It preferentially binds E6/E6AP and is targeted for ubiquitin-mediated degradation. The NFX1-123 isoform has the opposite activity, increasing hTERT transcription or translation. This is the first example of viral oncoproteins disrupting regulation of telomerase, a critical event in tumorigenesis.

Field-dependence, sensation-seeking, and preference of paintings

College students (122 males and 88 females) completed the Group Embedded Figures Test measure of field-dependence, and Sensation-Seeking Scale, and performed preference ratings on 40 slides of paintings. Factor analysis revealed six hypothesized and one unhypothesized preference dimensions that underlay preference ratings of paintings. It was hypothesized that the cognitive structuring ability associated with field-dependence would result in certain relationships between field-dependence and preference for paintings. Further, it was hypothesized that preference for novel, complex, and dynamic experiences, associated with sensation-seeking, would result in certain relationships between sensation-seeking and preference for paintings. For the full sample, three of five hypothesized relationships between field-dependence and preference for paintings were obtained, while three of four hypothesized relationships were found between sensation-seeking and preference for paintings.

Behavioral treatment of hypertensive heart disease in African Americans: rationale and design of a randomized controlled trial

African Americans experience higher morbidity and mortality than Whites do as a result of hypertension and associated cardiovascular disease. Chronic psychosocial stress has been considered an important contributing factor to these high rates. The authors describe the rationale and design for a planned randomized controlled trial comparing Transcendental Meditation, a stress-reduction technique, with lifestyle education in the treatment of hypertension and hypertensive heart disease in urban African Americans. They pretested 170 men and women aged 20 to 70 years over a 3-session baseline period, with posttests at 6 months. Outcomes included clinic and ambulatory blood pressure, quality of life, left ventricular mass measured by M-mode echocardiography, left ventricular diastolic function measured by Doppler, and carotid atherosclerosis measured by beta-mode ultrasound. This trial was designed to evaluate the hypothesis that a selected stress reduction technique is effective in reducing hypertension and hypertensive heart disease in African Americans.

A failed fall prevention study in an acute care setting: lessons from the swamp

Designing and implementing fall intervention studies in acute care settings presents researchers with a number of challenges. To date, there are no fall prevention interventions that have unequivocal empirical support in these settings. Based on the best available evidence a multistrategy fall prevention program was implemented using a pretest-post-test design over a 12-month period. The results indicated no reduction in the fall rate. Contrary to the expected result, the fall rate increased post the implementation of the multistrategy fall prevention program. To assist other researchers understand the contextual and methodological barriers to conducting fall prevention research in acute care settings, this paper discusses the difficulties experienced in this study.

Nurses' use of restraints and their attitudes toward restraint use and the elderly in an acute care setting

A descriptive correlation study was conducted in an acute-care hospital to explore the relationship between nurses' use of restraints and their attitudes toward restraint use and the elderly. A total of 201 nurses returned a questionnaire that collected demographic information and included two research instruments: (i) Perceptions of Restraint Use Questionnaire and (ii) Attitudes toward the Aged Semantic Differential. Results showed slightly positive attitudes towards the elderly and toward the use of restraints, although there was no correlation between scores on the two scales. Furthermore, nurses' attitudes did not predict their self-reported use of restraints.

Effects of stress reduction on carotid atherosclerosis in hypertensive African Americans

BACKGROUND AND PURPOSE

African Americans suffer disproportionately higher cardiovascular disease mortality rates than do whites. Psychosocial stress influences the development and progression of atherosclerosis. Carotid intima-media thickness (IMT) is a valid surrogate measure for coronary atherosclerosis, is a predictor of coronary outcomes and stroke, and is associated with psychosocial stress factors. Stress reduction with the Transcendental Meditation (TM) program decreases coronary heart disease risk factors and cardiovascular mortality in African Americans. B-mode ultrasound is useful for the noninvasive evaluation of carotid atherosclerosis.

METHODS

This randomized controlled clinical trial evaluated the effects of the TM program on carotid IMT in hypertensive African American men and women, aged >20 years, over a 6- to 9-month period. From the initially enrolled 138 volunteers, 60 subjects completed pretest and posttest carotid IMT data. The assigned interventions were either the TM program or a health education group. By use of B-mode ultrasound, mean maximum IMT from 6 carotid segments was used to determine pretest and posttest IMT values. Regression analysis and ANCOVA were performed.

RESULTS

Age and pretest IMT were found to be predictors of posttest IMT values and were used as covariates. The TM group showed a significant decrease of -0.098 mm (95% CI -0. 198 to 0.003 mm) compared with an increase of 0.054 mm (95% CI -0.05 to 0.158 mm) in the control group (P=0.038, 2-tailed).

CONCLUSIONS

Stress reduction with the TM program is associated with reduced carotid atherosclerosis compared with health education in hypertensive African Americans. Further research with this stress-reduction technique is warranted to confirm these preliminary findings.

Frailty, family, and church support among urban African American elderly

A community-based survey of 507 African Americans aged 60 and older from South Central Los Angeles was conducted to estimate the prevalence of frailty and describe the correlation between frailty, social support from family and church, and use of community services. Persons were considered frail if they met criteria for any of four conditions: functional impairment, depression, urinary incontinence, falls. Sixty-seven percent met criteria for frailty. Analyses revealed that frail elderly were significantly less likely to report feeling very close to family. Family contact, feeling that church was important, and receiving church support were similar for the frail and nonfrail. Frail elderly were more likely to use community services. These findings suggest that frail elderly in this population may not receive more support from family and church than nonfrail elderly. There is a need for caution when assuming families and churches in urban African American communities are able to support the most vulnerable elderly.

American Academy of Pediatrics. Committee on Practice and Ambulatory Medicine and Committee on Medical Liability. Pediatric physician profiling

Employers, insurers, and other purchasers of health care services collect data to profile the practice habits of pediatricians and other physicians. This policy statement delineates a series of recommendations that should be adopted by health care purchasers to guide the development and implementation of physician profiling systems.

Racial differences in functional status among elderly U.S. migrants from the South

This study describes patterns of functional status among older blacks and whites by their history of birth in and migration out of the South. We used multivariate regression to analyze data on functional status of US-born non-Hispanic blacks (N = 1868) and whites (N = 13469) age 60 years or above. In general, the functional status of blacks who were born in the South and migrated was similar to that of blacks born outside the South and better than those born in the South who did not migrate. Whites who migrated from the South had functional status similar to those who did not migrate and worse than those born outside of the South. Socioeconomic status did not explain differences by race and migration history. These results differ sharply from mortality studies, which have found a consistent pattern of high mortality among black migrants from the South. Differences among race groups by migration history vary across health measures. Selective migration and selective survival may account for the complex patterns of racial differences in geographic distributions of function and health.

Neurochemical alterations in asymptomatic abstinent cocaine users: a proton magnetic resonance spectroscopy study

Cocaine can cause a variety of neuropsychiatric and neurobehavioral complications; however, it is uncertain whether cocaine causes persistent cerebral structural and neurochemical abnormalities in asymptomatic users. We studied 52 African-American men (26 human immunodeficiency virus-negative asymptomatic heavy cocaine users and 26 normal subjects). Ventricle-to-brain ratio (VBR) and white matter lesions (WML) were quantified on magnetic resonance imaging. N-acetyl-containing compounds (NA), total creatine, choline-containing compounds, myo-inositol, and glutamate + glutamine were measured with in vivo proton magnetic resonance spectroscopy, VBR and WML were not significantly different in the cocaine users compared to the normal controls. Elevated creatine (+7%; p = .05) and myo-inositol (+18%; p = .01) in the white matter were associated with cocaine use. NA, primarily a measure of N-acetyl aspartate and neuronal content, was normal. Normal NA suggest no neuronal loss or damage in the brain regions examined in these cocaine users. Therefore, we conclude that neurochemical abnormalities observed might result from alterations in nonneuronal brain tissue.

Psychological characteristics related to cocaine use during pregnancy: a postpartum assessment

This study assessed four psychological factors that have been suggested by previous research to be highly correlated with drug use. Twenty-one postpartum urban African-American women served as the research participants. At parturition, 10 infants tested positive for cocaine and 11 did not. Measures of depression (Beck Depression Index), anxiety (Spielberger Trait Anxiety Inventory), anger/self-control (Self-Analysis Questionnaire), and sociopathy (California Personality Inventory subscale) were obtained from the mothers within 6 weeks of delivery. Women who gave birth to cocaine-positive infants were significantly more depressed and had significantly higher sociopathy scores than their cocaine-negative counterparts. No differences with respect to anxiety and anger were obtained. The implications of these findings, as well as the potential adverse effects of cocaine use during pregnancy, are discussed.

Cerebral perfusion and neuropsychological consequences of chronic cocaine use

Research indicates that cocaine significantly constricts the cerebral vasculature and can lead to ischemic brain infarction. Long-term effects of intermittent or casual cocaine use in patients without symptoms of stroke or transient ischemic attack were investigated. Single-photon emission computed tomography with xenon-133 and [99mTc]hexamethylpropyleneamine oxime, magnetic resonance imaging, and selected neuropsychological measures were used to study cerebral perfusion, brain morphology, and cognitive functioning. Patients were drug free for at least 6 months before evaluation. All showed regions of significant cerebral hypoperfusion in the frontal, periventricular, and/or temporal-parietal areas. Deficits in attention, concentration, new learning, visual and verbal memory, word production, and visuomotor integration were observed. This study indicates that long-term cocaine use may produce sustained brain perfusion deficits and persistent neuropsychological compromise in some subgroups of cocaine-abusing patients.