Exploration of the physical properties of the newly synthesized kagome superconductor LaIr3Ga2 using different exchange-correlation functionals.

LaIr3Ga2 is a kagome superconductor with a superconducting temperature (Tc) of 5.16 K. Here, we present the physical properties of the LaIr3Ga2 kagome superconductor computed via the DFT method wherein six different exchange-correlation functionals were used. The lattice parameters obtained using different functionals are reasonable, with a slight variation compared to experimental values. The bonding nature was explored. The elastic constants (Cij), moduli (B, G, Y), and Vickers hardness (Hv) were computed to disclose the mechanical behavior. The Hv values were estimated to be 2.56-3.16 GPa using various exchange-correlation functionals, indicating the softness of the kagome material. The Pugh ratio, Poisson's ratio, and Cauchy pressure revealed the ductile nature. In addition, mechanical stability was ensured based on the estimated elastic constants. The anisotropic mechanical behavior was confirmed via different anisotropic indices. The Debye temperature (ΘD), melting temperature (Tm), and minimum thermal conductivity (kmin) were calculated to characterize the thermal properties and predict the potential of LaIr3Ga2 as a thermal barrier coating material. The electronic density of states was investigated in detail. The McMillan equation was used to estimate Tc, and the electron-phonon coupling constant (λ) was calculated to explore the superconducting nature. The important optical constants were also calculated to explore its possible optoelectronic applications. The values of reflectivity in the IR-visible region are about 62% to 80%, indicating that the compound under study is suitable as a coating to reduce solar heating. The obtained parameters were compared with previously reported parameters, where available.

A national quality incentive scheme to reduce antibiotic overuse in hospitals: evaluation of perceptions and impact.

Background: In 2016/2017, a financially linked antibiotic prescribing quality improvement initiative Commissioning for Quality and Innovation (AMR-CQUIN) was introduced across acute hospitals in England. This aimed for >1% reductions in DDDs/1000 admissions of total antibiotics, piperacillin/tazobactam and carbapenems compared with 2013/2014 and improved review of empirical antibiotic prescriptions. Objectives: To assess perceptions of staff leading antimicrobial stewardship activity regarding the AMR-CQUIN, the investments made by hospitals to achieve it and how these related to achieving reductions in antibiotic use. Methods: We invited antimicrobial stewardship leads at acute hospitals across England to complete a web-based survey. Antibiotic prescribing data were downloaded from the PHE Antimicrobial Resistance Local Indicators resource. Results: Responses were received from 116/155 (75%) acute hospitals. Owing to yearly increases in antibiotic use, most trusts needed to make >5% reductions in antibiotic consumption to achieve the AMR-CQUIN goal of 1% reduction. Additional funding was made available at 23/113 (20%) trusts and, in 18 (78%), this was <10% of the AMR-CQUIN value. Nationally, the annual trend for increased antibiotic use reversed in 2016/2017. In 2014/2015, year-on-year changes were +3.7% (IQR -0.8%, +8.4%), +9.4% (+0.2%, +19.5%) and +5.8% (-6.2%, +18.2%) for total antibiotics, piperacillin/tazobactam and carbapenems, respectively, and +0.1% (-5.4%, +4.0%), -4.8% (-16.9%, +3.2%) and -8.0% (-20.2%, +4.0%) in 2016/2017. Hospitals where staff believed they could reduce antibiotic use were more likely to do so (P < 0.001). Conclusions: Introducing the AMR-CQUIN was associated with a reduction in antibiotic use. For individual hospitals, achieving the AMR-CQUIN was associated with favourable perceptions of staff and not availability of funding.

Sterols in infant formulas: validation of a gas chromatographic method.

Sterols are components present in the fat fraction of infant formulas (IFs). Their characterization is therefore of interest, though there are no official reference methods for their analysis in these matrices. AIM: To validate a gas chromatographic method with flame ionization detection for the determination of animal (cholesterol and desmosterol) and plant sterols (brassicasterol, campesterol, stigmasterol, ß-sitosterol and sitostanol) found in IFs. All correlation coefficients obtained for the calibration curves of sterols studied were >0.99. Limits of detection (<1 µg/100 mL) and quantification (<4 µg/100 mL) are suitable for sterols determination in IFs. The within-assay precision ranged from 1.6% to 8.8%, while the between-assay precision was <10% for most of sterols. Accuracy was satisfactory and was calculated by recovery assays (ranging 93-108%). The analytical parameters obtained showed the suitability of the proposed method for the determination of sterols in IFs.

Outcomes for cervicomediastinal vascular trauma managed by a vascular subspecialistled vascular trauma service.

BACKGROUND: The management of cervicomediastinal vascular trauma is challenging. We report on our experience with the condition in a newly established vascular trauma service unit, and compare the outcomes to those reported in our parent vascular surgery department. METHOD: The details of patients with cervicomediastinal vascular injuries from January 2012 to June 2014 were retrieved for analysis from a prospective database. RESULTS: Ninety-three patients were identified, 84 of whom were male (90%), with an average age of 29 years. Most were penetrating injuries (89%), and 87% of these were due to stab wounds. There were 107 vascular injuries, 88 cervical and 19 mediastinal. Of these, 87 were arterial and 20 venous injuries. The most common arterial injury involved the subclavian artery (24%), followed by the common carotid artery (22%). Management was multimodal, and included conservative (8%), stenting and embolisation (8%), referral to a higher centre (8%), vascular repair (64%) and ligation (12%). Nineteen per cent required median sternotomy or thoracotomy. Eight patients died postoperatively (9%). Seven of them presented in extremis and died within 24 hours, and one died after a week from associated abdominal injuries. Postoperative complications were 9%. There was no incidence of a stroke or limb loss despite ligation of the arteries, including ligation of four internal carotids. CONCLUSION: The development of endovascular techniques would allow for noninvasive management of a significant number of patients. Open surgery is still necessary, and associated with significant morbidity. Comparable results were reported in our newly established vascular trauma service unit to those obtained in our parent vascular surgery department in Durban.

Blood, sweat, and tears: developing clinically relevant protein biosensors for integrated body fluid analysis.

Biosensors are being developed to provide rapid, quantitative, diagnostic information to clinicians in order to help guide patient treatment, without the need for centralised laboratory assays. The success of glucose monitoring is a key example of where technology innovation has met a clinical need at multiple levels ­ from the pathology laboratory all the way to the patient's home. However, few other biosensor devices are currently in routine use. Here we review the challenges and opportunities regarding the integration of biosensor techniques into body fluid sampling approaches, with emphasis on the point-of-care setting.

Selective angioembolisation for splenic salvage following blunt abdominal trauma.

Isolated high-grade splenic injury following blunt abdominal trauma is an uncommon finding. The selected use of catheter-directed angiography and angioembolisation for splenic salvage has been successful in haemodynamically stable patients.

A prospective audit of the use of diagnostic laparoscopy to establish the diagnosis of abdominal tuberculosis.

BACKGROUND: The incidence of abdominal tuberculosis is much higher in an HIV-positive cohort. The use of laparoscopy in the diagnostic work-up of suspected abdominal tuberculosis is underutilized and its use and efficacy in the context of HIV co-infection has never been examined. METHODS: A prospective clinical audit of the use of diagnostic laparoscopy was conducted in patients with clinically suspected abdominal tuberculosis but histologically or microbiologically unconfirmed tuberculosis at any site. RESULTS: From January 2008 to June 2010, 81 patients underwent diagnostic laparoscopy; 34 were male and 47 were female, with a mean age of 33 years, and 77 % were HIV-positive. Fifty-five patients (68 %) had positive histology or culture for tuberculosis. In 15 patients (19 %), histology revealed non-specific inflammation, no pathology was found in one patient, and no specimen was taken from one patient. Eighty percent of peritoneal deposits and 77 % of lymph nodes were positive for tuberculosis, whereas 35 % of ascitic fluid cultures were positive. In nine patients (11 %) an alternative diagnosis was found; nine patients (11 %) had conversion to laparotomy. There was no procedure-related death. Nine patients (11 %) died during the 2-month follow-up period. CONCLUSIONS: Diagnostic laparoscopy avoids the morbidity and mortality of laparotomy in chronically ill patients, and reduces the rate of misdiagnosis of other abdominal conditions and unnecessary long-term therapy. Diagnostic laparoscopy and tissue sampling is a viable and reliable strategy in patients with suspected abdominal tuberculosis.

The role of the humoral immune response to Clostridium difficile toxins A and B in susceptibility to C. difficile infection: a case-control study.

Antibody levels to Clostridium difficile toxin A (TcdA), but not toxin B (TcdB), have been found to determine risk of C. difficile infection (CDI). Historically, TcdA was thought to be the key virulence factor; however the importance of TcdB in disease is now established. We re-evaluated the role of antibodies to TcdA and TcdB in determining patient susceptibility to CDI in two separate patient cohorts. In contrast to earlier studies, we find that CDI patients have lower pre-existing IgA titres to TcdB, but not TcdA, when compared to control patients. Our findings suggest that mucosal immunity to TcdB may be important in the early stages of infection and identifies a possible target for preventing CDI progression.

Mountain bikers priapism: a rare phenomenon.

Soft tissue and bony injuries are well described risks of the increasingly popular sport of mountain biking. Priapism, a persisting unwanted penile erection, as a result of perineal straddle injury due to a fall astride bicycle handlebar, is rare. We present a case of a competitive mountain biker with high flow priapism after such an injury who presented late but was successfully treated by non-invasive selective arterial embolization.

Lessons from emergency laparotomy for abdominal tuberculosis in the HIV/AIDS era.

BACKGROUND: The rising incidence of HIV/AIDS has resulted in a resurgence of abdominal tuberculosis (TB) in HIV-positive patients in South Africa. These often debilitated patients frequently present with acute complications requiring surgery. METHODS: A prospective audit of all patients with abdominal TB undergoing emergency laparotomy was conducted. From January 2008 to June 2010, 49 patients had emergency laparotomy and specimens obtained from them were diagnostic of TB. Twenty-five were males and 24 females, with a median age of 32 years (range 2 - 62). Thirty-nine patients were HIV-positive (79.6%). RESULTS: Intra-operative findings were bowel perforations in 13 cases, small-bowel obstruction in seven, a frozen abdomen in ten, and enlarged lymph nodes and an ileocaecal mass in 19. Eleven patients (22.4%) underwent small-bowel resection and eight (16.3%) right hemicolectomy. Eighteen patients (36.7%) ended up with stomas, 14 (28.6%) had re-laparotomies, and 18 (36.7%) were admitted to the intensive care unit. Twenty-three patients (46.9%) required blood transfusion and 15 (30.6%) total parenteral nutrition. Three patients (6.1%) developed an enterocutaneous fistula and 19 (38.8%) died. Pre-operative illness severity indices of acidosis, anaemia and hypo-albuminaemia were significant predictors of death, but mode of presentation and surgical interventions were not. CONCLUSION: Laparotomy as currently practised for the 'acute abdomen' in patients with suspected HIV and abdominal TB is associated with very high morbidity and mortality, which is related to pre-operative severity indices. More liberal use of imaging may define cases in which a more conservative approach could improve outcome.

Appropriateness of acute-care antibiotic prescriptions for community-acquired infections and surgical antibiotic prophylaxis in England: analysis of 2016 national point prevalence survey data.

BACKGROUND: Estimates of inappropriate prescribing can highlight key target areas for antimicrobial stewardship (AMS) and inform national targets. OBJECTIVES: To (1) define and (2) produce estimates of inappropriate antibiotic prescribing levels within acute hospital trusts in England. METHODS: The 2016 national Healthcare-Associated Infections (HAI), Antimicrobial Use (AMU) and AMS point prevalence survey (PPS) was used to derive estimates of inappropriate prescribing, focusing on the four most reported community-acquired antibiotic indications (CAIs) in the PPS and surgical prophylaxis. Definitions of appropriate antibiotic therapy for each indication were developed through the compilation of national treatment guidelines. A Likert-scale system of appropriateness coding was validated and refined through a two-stage expert review process. RESULTS: Antimicrobial usage prevalence data were collected for 25,741 individual antibiotic prescriptions, representing 17,884 patients and 213 hospitals in England. 30.4% of prescriptions for the four CAIs of interest were estimated to be inappropriate (2054 prescriptions). The highest percentage of inappropriate prescribing occurred in uncomplicated cystitis prescriptions (62.5%), followed by bronchitis (48%). For surgical prophylaxis, 30.8% of prescriptions were inappropriate in terms of dose number, and 21.3% in terms of excess prophylaxis duration. CONCLUSIONS: The 2016 prevalence of inappropriate antibiotic prescribing in hospitals in England was approximated to be 30.4%; this establishes a baseline prevalence and provided indication of where AMS interventions should be prioritized. Our definitions appraised antibiotic choice, treatment duration and dose number (surgical prophylaxis only); however, they did not consider other aspects of appropriateness, such as combination therapy - this is an important area for future work.

How far has the pendulum swung in the surgical management of sigmoid volvulus? Experience from the KwaZulu-Natal Teaching Hospitals and review of the literature.

AIM: Sigmoid volvulus is common in sub-Saharan Africa. The aim of the study was to document the clinicopathological patterns of sigmoid volvulus in KwaZulu-Natal. METHOD: Analysis was performed of prospectively collected data of patients presenting with sigmoid volvulus at the KwaZulu-Natal Teaching Hospitals from 2000 to 2009. Data collected included demographics, clinical presentation, operative findings, management and outcome. RESULTS: There were 135 patients (122 male) of mean age 39.3 ± 17 years. Management was by emergency surgery (103), elective surgery (23), no surgery (9). The level of the twist was at the pelvic brim. Fifty-four patients had gangrenous bowel and 81 had viable bowel. Resection was accompanied by primary anastomosis (80) and Hartmann's procedure (46). Complication and mortality rates were 47% and 17% respectively. Mortality rates for emergency and elective surgery were 19% and 9% (P = 0.330), and those for primary anastomosis and Hartmann's procedure were 14% and 24% respectively (P = 0.305). Mortality rates for gangrenous and viable bowel were 21% and 15% respectively (P = 0.624). Twenty-eight (22%) patients required intensive care in the intensive care unit (ICU) with an ICU stay of 8.8 ± 8 days. Hospital stay was 10.5 ± 14.4 days. CONCLUSION: The clinicopathological picture of sigmoid volvulus resembles that in the rest of Africa in that it affects predominantly young African males. The level of the twist is at the pelvic brim. The timing of surgery, the type of anastomosis and the viability of the bowel does not influence outcome.

Amelioration of N,N'-dimethylhydrazine induced colon toxicity by epigallocatechin gallate in Wistar rats.

Colon cancer is a life-threatening disease all over the world and is linked to constant oxidative stress and inflammation. Epigallocatechin gallate (EGCG), is a naturally occurring flavone possessing health benefiting pharmacological properties including antioxidant, anti-inflammatory and free radical scavenging properties. Our study investigates the role of EGCG on N,N'-dimethylhydrazine (DMH), a toxic environmental pollutant, induced colon toxicity. To investigate the effect of EGCG, Wistar rats were given EGCG for 7 days at the two doses of 10 and 20 mg/kg body weight and DMH was injected on the seventh day in all the group rats except the control. Our results indicate that DMH administration increased the oxidative stress (MDA) and depleted the glutathione and antioxidant enzyme activities (SOD, CAT, GR, GST and GPx) which was significantly ameliorated by EGCG treatment. Additionally DMH treatment upregulated inflammatory markers expression (NF-κB, COX-2 and IL-6) and enhanced mucosal damage in the colon. EGCG treatment significantly reduced inflammation and restored the normal histoarchitecture of the colon. We can conclude from the present study findings that EGCG protects the colon from DMH toxicity through its antioxidant and anti-inflammatory potential.

Serum triglyceride level in type 2 diabetes mellitus patients with or without frozen shoulder.

BACKGROUND: Musculoskeletal disorders are very common among the diabetic patients and frozen shoulder is one of the disabling conditions. The present study was conducted to compare the serum triglyceride level among the patients of type 2 diabetic presented with and without frozen shoulder. METHODOLOGY: This case control study was conducted from January 2008 to December 2009, in the department of Physical Medicine and Rehabilitation, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka with an aim to compare the serum triglyceride level among diabetic patients presented with, and without frozen shoulder. Thirty types 2 diabetic patients with frozen shoulder were selected as cases and similar number well matched type 2 diabetic patients without frozen shoulder were selected as control. RESULTS: We prospectively studied 30 diabetes mellitus (type 2) patients with the diagnosis of frozen shoulder. The blood sugar both fasting and 2 hours after breakfast, HbA1c and serum triglyceride levels were measured in all patients and compared with those in 30 diabetic patients without frozen shoulder. The blood sugar, fasting and 2 hours after breakfast, HbA1C and serum triglyceride levels were significantly elevated in the frozen-shoulder group (fasting blood sugar p = 0.012; blood sugar 2 hours after breakfast p < 0.01; HbA1c p < 0.05; and triglyceride p < 0.001). CONCLUSION: Diabetic type 2 patients presented with frozen shoulder had higher serum triglyceride level compare to the diabetic type 2 patients without frozen shoulder.

Do probiotics prevent antibiotic-associated diarrhoea? Results of a multicentre randomized placebo-controlled trial.

BACKGROUND: Antibiotic-associated diarrhoea (AAD) is a side-effect of antibiotic consumption and probiotics have been shown to reduce AAD. METHODS: A multicentre, double-blind, placebo-controlled, randomized trial was conducted to evaluate the role of Lactobacillus casei DN114001 (combined as a drink with two regular yoghurt bacterial strains) in reducing AAD and Clostridioides difficile infection in patients aged over 55 years. The primary outcome was the incidence of AAD during 2 weeks of follow-up. RESULTS: A total of 1127 patients (mean age ± standard deviation: 73.6 ± 10.5) were randomized to the active group (N = 549) or placebo group (N = 577). Both groups were followed up as per protocol. The proportion of patients experiencing AAD during follow-up was 19.3% (106/549) in the probiotic group vs 17.9% (103/577) in the placebo group (unadjusted odds ratio 1.10, 95% confidence interval 0.82-1.49, P = 0.53). CONCLUSIONS: No significant evidence was found of a beneficial effect of the specific probiotic formulation in preventing AAD in this elderly population drawn from a number of different UK hospitals. However, in the UK and in many other healthcare systems there have, in recent years, been many changes in antibiotic stewardship policies, an overall decrease in incidence in C. difficile infection, as well as an increased awareness of infection prevention, and modifications in nursing practice. In light of these factors, it is impossible to conclude definitively from the current trial that the study-specific probiotic formulation has no role in preventing AAD, and it is our view that further trials may be indicated, controlling for these variables.

Protective role of diosmin against testosterone propionate-induced prostatic hyperplasia in Wistar rats: Plausible role of oxidative stress and inflammation.

Benign prostatic hyperplasia (BPH) is an important key health concern for aging men. Polyphenolic compounds have been found to possess important roles in the inhibition of numerous ailments that involve reactive oxygen species and inflammation. Diosmin is a citrus flavone that possesses antioxidant, anti-inflammatory, antiproliferative, and anticancer activities, so based on these properties of diosmin, we decided to evaluate its effect on testosterone propionate (TP)-induced BPH. A total of 30 Wistar rats were randomly assigned to five groups having six animals in each. This study was of 28 days in which TP (5 mg kg-1) was administered to induce BPH in the last 10 days of the study. It was found that diosmin at the doses of 20 and 40 mg kg-1 significantly reduced malondialdehyde and xanthine oxidase formation in a dose-dependent manner; however, it replenished catalase, glutathione (GSH), and GSH-dependent enzymes, that is, glutathione peroxidase, glutathione reductase, and glutathione-S-transferase significantly against TP-induced BPH. Further, immunohistochemical study showed that diosmin alleviated inflammatory markers (nuclear factor kappa-light-chain-enhancer of activated B cells, cyclooxygenase-2, and interleukin-6). It was also found that diosmin downregulated the expression of androgen receptor and decreased the prostate-specific antigen concentration dose-dependently, significantly against TP-induced BPH. Diosmin also restored histoarchitecture of the prostate in a dose-dependent manner. Findings from the present study revealed the protective role of diosmin against TP-induced BPH in Wistar rats.

Optimizing design of research to evaluate antibiotic stewardship interventions: consensus recommendations of a multinational working group.

BACKGROUND: Antimicrobial stewardship interventions and programmes aim to ensure effective treatment while minimizing antimicrobial-associated harms including resistance. Practice in this vital area is undermined by the poor quality of research addressing both what specific antimicrobial use interventions are effective and how antimicrobial use improvement strategies can be implemented into practice. In 2016 we established a working party to identify the key design features that limit translation of existing research into practice and then to make recommendations for how future studies in this field should be optimally designed. The first part of this work has been published as a systematic review. Here we present the working group's final recommendations. METHODS: An international working group for design of antimicrobial stewardship intervention evaluations was convened in response to the fourth call for leading expert network proposals by the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR). The group comprised clinical and academic specialists in antimicrobial stewardship and clinical trial design from six European countries. Group members completed a structured questionnaire to establish the scope of work and key issues to develop ahead of a first face-to-face meeting that (a) identified the need for a comprehensive systematic review of study designs in the literature and (b) prioritized key areas where research design considerations restrict translation of findings into practice. The working group's initial outputs were reviewed by independent advisors and additional expertise was sought in specific clinical areas. At a second face-to-face meeting the working group developed a theoretical framework and specific recommendations to support optimal study design. These were finalized by the working group co-ordinators and agreed by all working group members. RESULTS: We propose a theoretical framework in which consideration of the intervention rationale the intervention setting, intervention features and the intervention aims inform selection and prioritization of outcome measures, whether the research sets out to determine superiority or non-inferiority of the intervention measured by its primary outcome(s), the most appropriate study design (e.g. experimental or quasi- experimental) and the detailed design features. We make 18 specific recommendation in three domains: outcomes, objectives and study design. CONCLUSIONS: Researchers, funders and practitioners will be able to draw on our recommendations to most efficiently evaluate antimicrobial stewardship interventions.

Management of Spinal Injuries in Polytrauma Patients: An Experience of Tertiary Care Hospital.

Spine injuries, a common component in Polytrauma are usually affects the young people and is a major cause of morbidity and poses a significant health care expenditure and considerable threats to survival and quality of life. We retrospectively assess the demographics, incidence, mode of trauma, associated spine injuries, complications, neurological improvement and mortality. Records of total 1695 admitted patients, spinal injuries were 262 patients. Among them 30(11.45%) patients were associated with Polytrauma victims. Eleven patients (36.67%) were admitted through Ortho emergency dept, 14(46.67%) patients through Intensive care unit (ICU), 5(16.66%) patients through other department (CVS, Urology). Most (56%) of the patients were young in the age range of 16 to 40 years. Cervical spines were most commonly (44%) affected followed by lumbar (31%), thoracic (13%), thoraco-lumbar (9%) and Cervico-thoracic (3%) spines. Road traffic accident was the common cause (80%). Twelve patients (40%) had problems at various steps of management and maximum problems occur in step III. Nineteen patients (63.33%) management needs co-ordination between various specialties. Significant number of patients (76.67%) required operative treatment (p<0.05) and 13.33% were managed conservatively. Mortality rate (10%) was insignificant (p>0.05%). Of these patients, 73.33% had shown neurological improvement of at least one ASIA grade. The treatment of spinal injury in polytrauma patient should follow the principle of Advanced Trauma Life Support (ATLS). Once life and limb-threatening injuries have been identified and addressed, suspected spinal cord injury patients should be immobilized as early as possible to reduced the secondary injury, improve motor and sensory function as well as reduced the extend of permanent paralysis.

Adaptation and implementation of the ARK (Antibiotic Review Kit) intervention to safely and substantially reduce antibiotic use in hospitals: a feasibility study.

BACKGROUND: Antimicrobial stewardship initiatives in secondary care depend on clinicians undertaking antibiotic prescription reviews but decisions to limit antibiotic treatment at review are complex. AIM: To assess the feasibility and acceptability of implementing ARK (Antibiotic Review Kit), a behaviour change intervention made up of four components (brief online tool, prescribing decision aid, regular data collection and feedback process, and patient leaflet) to support stopping antibiotic treatment when it is safe to do so among hospitalized patients; before definitive evaluation through a stepped-wedge cluster-randomized controlled trial. METHODS: Acceptability of the different intervention elements was assessed for a period of 12 weeks by uptake of the online tool, adoption of the decision aid into prescribing practice, and rates of decisions to stop antibiotics at review (assessed through repeated point-prevalence surveys). Patient perceptions of the information leaflet were assessed through a brief questionnaire. FINDINGS: All elements of the intervention were successfully introduced into practice. A total of 132 staff encompassing a broad range of prescribers and non-prescribers completed the online tool (19.4 per 100 acute beds), including 97% (32/33) of the pre-specified essential clinical staff. Among 588 prescription charts evaluated in seven point-prevalence surveys over the 12-week implementation period, 82% overall (76-90% at each survey) used the decision aid. The median antibiotic stop rate post implementation was 36% (range: 29-40% at each survey) compared with 9% pre implementation (P < 0.001). CONCLUSION: ARK provides a feasible and acceptable mechanism to support stopping antibiotics safely at post-prescription reviews in an acute hospital setting.

The quality of studies evaluating antimicrobial stewardship interventions: a systematic review.

BACKGROUND: Antimicrobial stewardship aims to optimize antibiotic use and minimize selection of antimicrobial resistance. The methodological quality of published studies in this field is unknown. AIMS: Our objective was to perform a comprehensive systematic review of antimicrobial stewardship research design and identify features which limit validity and translation of research findings into clinical practice. SOURCES: The following online database was searched: PubMed. STUDY ELIGIBILITY CRITERIA: Studies published between January 1950 and January 2017, evaluating any antimicrobial stewardship intervention in the community or hospital setting, without restriction on study design or outcome. CONTENT: We extracted data on pre-specified design quality features and factors that may influence design choices including (1) clinical setting, (2) age group studied, (3) when the study was conducted, (4) geographical region, and (5) financial support received. The initial search yielded 17 382 articles; 1008 were selected for full-text screening, of which 825 were included. Most studies (675/825, 82%) were non-experimental; 104 (15%) used interrupted time series analysis, 41 (6%) used external controls, and 19 (3%) used both. Studies in the community setting fulfilled a median of five out of 10 quality features (IQR 3-7) and 3 (IQR 2-4) in the hospital setting. Community setting studies (25%, 205/825) were significantly more likely to use randomization (OR 5.9; 95% CI 3.8-9.2), external controls (OR 5.6; 95% CI 3.6-8.5), and multiple centres (OR 10.5; 95% CI 7.1-15.7). From all studies, only 48% (398/825) reported clinical and 23% (190/825) reported microbiological outcomes. Quality did not improve over time. IMPLICATIONS: Overall quality of antimicrobial stewardship studies is low and has not improved over time. Most studies do not report clinical and microbiological outcome data. Studies conducted in the community setting were associated with better quality. These limitations should inform the design of future stewardship evaluations so that a robust evidence base can be built to guide clinical practice.