Antibiotic prescribing patterns in the pediatric emergency department at Georgetown Public Hospital Corporation: a retrospective chart review.

BACKGROUND: The increase in antimicrobial-resistant infections has led to significant morbidity, mortality, and healthcare costs. The impact of antimicrobial resistance is greatest on low-income countries, which face the double burden of fewer antibiotic choices and higher rates of infectious diseases. Currently, Guyana has no national policy on rational prescribing. This study aims to characterize antibiotic prescribing patterns in children discharged from the emergency department at Georgetown Public Hospital Corporation (GPHC), as per the World Health Organization (WHO) prescribing indicators. METHODS: A retrospective chart review of pediatric patients (aged 1 month-13 years) seen in the GPHC emergency department between January and December 2012 was conducted. Outpatient prescriptions for eligible patients were reviewed. Patient demographics, diagnosis, and drugs prescribed were recorded. The following WHO Prescribing Indicators were calculated: i) average number of drugs prescribed per patient encounter, ii) percentage of encounters with an antibiotic prescribed, iii) percentage of antibiotics prescribed by generic name, and iv) percentage of antibiotics prescribed from essential drugs list or formulary. RESULTS: Eight hundred eleven patient encounters were included in the study. The mean patient age was 5.55 years (s = 3.98 years). 59.6 % (n = 483) patients were male. An average of 2.5 drugs were prescribed per encounter (WHO standard is 2.0). One or more antibiotic was prescribed during 36.9 % (n = 299) of all encounters (WHO standard is 30 %). 90.83 % of antibiotics were prescribed from the essential drugs formulary list and 30 % of the prescriptions included the drug's generic name. The average duration of antibiotic therapy was 5.73 days (s = 3.53 days). Of the 360 antibiotics prescribed, 74.7 % (n = 269) were broad-spectrum. B-lactam penicillins were prescribed most frequently (51.4 %), with amoxicillin being the most popular choice (33.9 %). The most common diagnoses were injuries (25.8 %), asthma (20 %), respiratory infections (19.5 %), and gastrointestinal infections (12.1 %). CONCLUSIONS: Per WHO prescribing indicators, the pediatric emergency department at GPHC has higher than standard rates of antibiotic use and polypharmacy. The department excels in adhering to the essential drug formulary. Our findings provide support for investigating drug utilization in other Guyanese settings, and to work towards developing a national rational prescribing strategy.

Methemoglobin and nitric oxide therapy in Ugandan children hospitalized for febrile illness: results from a prospective cohort study and randomized double-blind placebo-controlled trial.

BACKGROUND: Exposure of red blood cells to oxidants increases production of methemoglobin (MHb) resulting in impaired oxygen delivery to tissues. There are no reliable estimates of methemoglobinemia in low resource clinical settings. Our objectives were to: i) evaluate risk factors for methemoglobinemia in Ugandan children hospitalized with fever (study 1); and ii) investigate MHb responses in critically ill Ugandan children with severe malaria treated with inhaled nitric oxide (iNO), an oxidant that induces MHb in a dose-dependent manner (study 2). METHODS: Two prospective studies were conducted at Jinja Regional Referral Hospital in Uganda between 2011 and 2013. Study 1, a prospective cohort study of children admitted to hospital with fever (fever cohort, n = 2089 children 2 months to 5 years). Study 2, a randomized double-blind placebo-controlled parallel arm trial of room air placebo vs. 80 ppm iNO as an adjunctive therapy for children with severe malaria (RCT, n = 180 children 1-10 years receiving intravenous artesunate and 72 h of study gas). The primary outcomes were: i) masimo pulse co-oximetry elevated MHb levels at admission (>2 %, fever cohort); ii) four hourly MHb levels in the RCT. RESULTS: In the fever cohort, 34 % of children admitted with fever had elevated MHb at admission. Children with a history of vomiting, delayed capillary refill, elevated lactate, severe anemia, malaria, or hemoglobinopathies had increased odds of methemoglobinemia (p < 0.05 in a multivariate model). MHb levels at admission were higher in children who died (n = 89) compared to those who survived (n = 1964), p = 0.008. Among children enrolled in the iNO RCT, MHb levels typically plateaued within 12-24 h of starting study gas. MHb levels were higher in children receiving iNO compared to placebo, and MHb > 10 % occurred in 5.7 % of children receiving iNO. There were no differences in rates of study gas discontinuation between trial arms. CONCLUSIONS: Hospitalized children with evidence of impaired oxygen delivery, metabolic acidosis, anemia, or malaria were at risk of methemoglobinemia. However, we demonstrated high-dose iNO could be safely administered to critically ill children with severe malaria with appropriate MHb monitoring. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01255215 (Date registered: December 5, 2010).

Child poverty. Ways forward for the paediatrician: A comprehensive overview of poverty reduction strategies requiring paediatric support.

The harmful effects of child poverty are well documented. Despite this, progress in poverty reduction in Canada has been slow. A significant gap exists between what is known about eradicating poverty and its implementation. Paediatricians can play an important role in bridging this gap by understanding and advancing child poverty reduction. Establishment of a comprehensive national poverty reduction plan is essential to improving progress. The present review identifies the key components of an effective poverty reduction strategy. These elements include effective poverty screening, promoting healthy child development and readiness to learn, ensuring food and housing security, providing extended health care coverage for the uninsured and using place-based solutions and team-level interventions. Specific economic interventions are also reviewed. Addressing the social determinants of health in these ways is crucial to narrowing disparities in wealth and health so that all children in Canada reach their full potential.

Les effets néfastes de la pauvreté des enfants sont bien attestés. Pourtant, les progrès sont lents au Canada en matière de réduction de la pauvreté. Il y a un écart important entre ce que l'on sait sur l'éradication de la pauvreté et ce qui est fait. Les pédiatres peuvent jouer un rôle important pour corriger cet écart s'ils comprennent la pauvreté des enfants et font progresser les mesures de réduction. Il est essentiel de créer un plan national détaillé de réduction de la pauvreté pour améliorer ces progrès. La présente analyse présente les principaux éléments d'une stratégie efficace de réduction de la pauvreté. Ces éléments comprennent un dépistage efficace de la pauvreté, la promotion d'un développement sain de l'enfant et de la préparation à apprendre, l'assurance de la sécurité alimentaire et de la sécurité de logement, l'offre d'une couverture étendue d'assurance-maladie aux non-assurés et l'utilisation de solutions territoriales et d'interventions d'équipes. Des interventions économiques précises sont également examinées. Il est essentiel de se pencher sur les déterminants sociaux de la santé pour réduire les disparités sur le plan de la richesse et de la santé, afin que tous les enfants du Canada réalisent leur plein potentiel.

Health 2.0-Lessons Learned: Social Networking With Patients for Health Promotion.

The advent of social networking as a major platform for human interaction has introduced a new dimension into the physician-patient relationship, known as Health 2.0. The concept of Health 2.0 is young and evolving; so far, it has meant the use of social media by health professionals and patients to personalize health care and promote health education. Social networking sites like Facebook and Twitter offer promising platforms for health care providers to engage patients. Despite the vast potential of Health 2.0, usage by health providers remains relatively low. Using a pilot study as an example, this commentary reviews the ways in which physicians can effectively harness the power of social networking to meaningfully engage their patients in primary prevention.

Glucosamine-supplementation promotes endoplasmic reticulum stress, hepatic steatosis and accelerated atherogenesis in apoE-/- mice.

OBJECTIVES: To determine the effects of glucosamine-supplementation on endoplasmic reticulum (ER) stress levels and atherogenesis, and to investigate the potential role of glucosamine in hyperglycemia-associated accelerated atherosclerosis. METHODS: Five week old apolipoprotein E-deficient (apoE-/-) mice were provided with normal drinking water or water supplemented with 5% glucosamine (w/v) or 5% mannitol (w/v). To induce hyperglycemia, a separate group of apoE-/- mice received multiple low dose injections of streptozotocin (STZ). All mice were provided with a standard chow diet and were euthanized at 15 weeks of age. Hepatic and vascular ER stress levels and atherosclerotic lesion area at the aortic root were determined. RESULTS: STZ-induced hyperglycemic and glucosamine-supplemented mice had significantly larger and more advanced atherosclerotic lesions than control mice. Indications of ER stress were increased in the livers and atherosclerotic lesions of hyperglycemic and glucosamine-supplemented mice but not in the controls. In glucosamine-supplemented mice accelerated atherosclerosis was independent of detectable changes in blood glucose concentration, glucose tolerance, plasma insulin, or plasma lipid levels. CONCLUSION: Similar to hyperglycemia, glucosamine-supplementation promotes ER stress, hepatic steatosis and accelerated atherosclerosis. These findings support a model by which hyperglycemia promotes hepatic and vascular complications via a glucosamine intermediate.