Change in parental knowledge, attitudes and practice of antibiotic use after a national intervention programme.

Background: Nation-wide multifaceted interventions to improve antibiotic use were undertaken in the former Yugoslav Republic of Macedonia in September 2014. This study aimed to assess the parental knowledge and attitudes about antibiotics, and self-medication practices in children, and evaluate the impact of interventions on these parameters. Methods: Pre-post-intervention surveys were conducted in May 2014-16 in three administrative regions in the country. Data were collected by interviewing parents of children younger than 15 years of age through a questionnaire. The analysis of knowledge, attitudes and antibiotic use involved descriptive quantitative statistics. The effects of interventions were assessed by a logistic and linear regression analysis. Results: Data from 1203 interviewees showed that 80% of parents knew that antibiotics could kill bacteria, while 40% believed antibiotics could kill viruses. One third of parents expressed potential dissatisfaction with doctors who would not agree with them on antibiotic use. More parents received information about not taking antibiotics unnecessarily after the interventions, but the rates decreased one year later. At baseline, 20% of the parents and 10% of the children who received antibiotics in previous year, took them without prescriptions. Parental self-medication rates did not change over time, while children rates decreased only in 2015. Conclusion: The insignificant and short-term changes in knowledge, attitudes and self-medication demonstrate that interventions need to be implemented for a longer period of time, at a large scale, with active health providers' engagement, and accompanied by inspections to promote appropriate use of antibiotics and discourage self-medication.

The role of hemodialysis in treatment of acute acetic acid poisonings.

INTRODUCTION: The aim of this study is to show the importance of hemodialysis as an active method in treatment of acute acetic acid poisonings. Its main role is to support the renal function during the state of the intoxication when patients develop acute renal failure. METHODS: We analyzed data from a 10-year period, a total of 71 patients who ingested acetic acid, either intentionally or accidentally. Patients with a need of hemodialysis (HD) treatment underwent 3- to 4-hour HD sessions every day or every second day, according to clinical assessment, as needed, until recovery of kidney function. RESULTS: In the period between 2006 and 2015 at the university clinic for toxicology and urgent internal medicine, we hospitalized 6,106 patients with different kinds of intoxication, of which 1.162% ingested concentrated acetic acid; 47 patients were female and 24 were male. The minimal age of patients was 18 and the maximal 74 years. A total of 28 (39.43%) of the patients developed acute renal failure and in 10 patients (14.08%) we used hemodialysis as a part of the treatment. The maximum number of performed sessions in one patient was five and the minimal number of performed sessions in one patents was only one session. The use of heparin led to fatal bleeding in 4 patients. The mortality rate was 7% and most of the cases resulted in fatalities during the first 96 hours after ingestion. CONCLUSIONS: Acetic acid poisonings are one of the most dangerous intoxications seen in clinical toxicology. The use of hemodialysis in some of the patients who develop acute renal failure can be of great importance and it should be put into official treatment protocols due to its great number of advantages in renal function support.

The Effect of Rectus Sheath Block as a Supplement of General Anesthesia on Postoperative Analgesia in Adult Patient Undergoing Umbilical Hernia Repair.

BACKGROUND: Ultrasound guided rectus sheath block can block the ventral rami of the 7th to 12th thoracolumbar nerves by injection of local anesthetic into the space between the rectus muscle and posterior rectus sheath. The aim of this randomized double-blind study was to evaluate the analgesic effect of the bilateral ultrasound guided rectus sheath block as supplement of general anesthesia on patents undergoing elective umbilical hernia repair. METHODS: After the hospital ethics committee approval, 60 (ASA I-II) adult patients scheduled for umbilical hernia repair were included in this study. The group I (n=30) patents received only general anesthesia. In the group II (n = 30) patents after induction of general anesthesia received a bilateral ultrasound guided rectus sheath block with 40 ml of 0.25% bupivacaine. In this study we assessed demographic and clinical characteristics, pain score - VAS at rest at 2, 4, 6, 12 and 24 hours after operation and total analgesic consumption of morphine dose over 24-hours. RESULTS: There were statistically significant differences in VAS scores between the groups I and II at all postoperative time points - 2hr, 4 hr, 6 hr, 12 hr and 24 hr. (P < 0.00001). The cumulative 24 hours morphine consumption after the operation was significantly lower in the group II (mean = 3.73 ± 1. 41) than the group I (mean = 8.76 ± 2.41). This difference was statistically significant (p = 0.00076). CONCLUSION: The ultrasound guided rectus sheath block used for umbilical hernia repair could reduce postoperative pain scores and the amount of morphine consumption in 24 hours postoperative period.

Cigarette Smoking and Oxidative Stress in Patients with Coronary Artery Disease.

AIM: To determine whether cigarette smoking, as a risk factor for CAD, affects (anti)oxidant status. MATERIAL AND METHODS: The study included patients with CAD, divided according to their smoking status and the number of cigarettes smoked during a day. Biological markers of oxidative stress (concentration of oxidants and activity of antioxidant enzymes) were measured in all subjects. RESULTS: The study included 300 patients with CAD, (average age of 63 ± 11 years), predominantly males. Of the total, 34.0% were active smokers, 23.0% were former smokers, and 43.0% were non-smokers. Most of the active smokers smoked 1-20 cigarettes/day. In terms of concentration of oxidants (MDA and HP) there was not a significant difference between smokers versus non-smokers. As for the activity of antioxidant enzymes (SOD, CAT and GPX), a statistically significant difference was found in the activity of GPX among the active smokers with CAD and the non-smokers with CAD (p = 0.039). CONCLUSION: Smoking as a risk factor for CAD is closely associated with increased oxidative stress, and the number of cigarettes smoked plays an important role in increasing the level of oxidative damage and reducing antioxidant defence.

Radiolabeled tirofiban - a potential radiopharmaceutical for detection of deep venous thrombosis.

AIM: The aim of this study was to investigate the possibility of using 99mtechnetium (99mTc)-labeled tirofiban (a reversible antagonist of glycoprotein IIb/IIIa) for detection of deep venous thrombosis (DVT) in rats without causing an antiplatelet effect. METHODS: The ability of in vitro tirofiban to inhibit adenosine 5'-diphosphate (ADP)-induced platelet aggregation was evaluated using optical aggregometer. Binding of 99mTc-tirofiban to platelets was evaluated. Serum levels of unlabeled (a validated high performance liquid chromatography method) and 99mTc-tirofiban after single intravenous injection were evaluated in male Wistar rats with or without induced DVT (femoral vein ligation model), and the rats were also subjected to whole body scintigraphy. RESULTS: Tirofiban in vitro inhibits ADP-induced aggregation of human platelets in a dose- and concentration-dependent manner (10 nM to 2 µM), but only if it is added before ADP and not after ADP. 99mTc labeling did not affect the ability of tirofiban to bind to either human or rat platelets, nor did it affect tirofiban pharmacokinetics in intact rats or in animals with induced DVT. When 99mTc-tirofiban was injected to rats after induction of DVT, at a molar dose lower than the one showing only a weak antiaggregatory effect in vitro, whole body scintigraphy indicated localization of 99mTc-tirofiban around the place of the induced DVT. CONCLUSION: 99mTc labeling of tirofiban does not affect its ability to bind to glycoprotein IIb/IIIa or its in vivo pharmacokinetics in rats, either intact or with DVT. A low, nonantiaggregatory dose of 99mTc-tirofiban may be used to visualize DVT at an early stage.

Effect of Adding Dexamethasone as a Ropivacaine Adjuvant in Ultrasound-Guided Transversus Abdominis Plane Block for Inguinal Hernia Repair.

BACKGROUND: The transverses abdominals plane block (TAP) is a regional anesthesia technique that provided analgesia to the parietal peritoneum, skin and muscles of the anterior abdominal wall. The aim of this randomized double-blind study was to evaluate postoperative analgesia on patients undergoing open inguinal hernia repair under general anesthesia (GA), (GA + TAP) block preformed with ropivacaine and (GA + TAP-D) block preformed with ropivacaine and 4 mg dexamethasone. METHODS: 90 (ASA I-II) adult patients for unilateral open inguinal hernia repair were included in this study. In group I (n = 30) patents received only general anesthesia (GA). Patients in group II (n = 30) received GA and unilateral TAP block with 25 ml of 0.5% ropivacaine and the patients in group III (n = 30) received GA and unilateral TAP-D block with 25 ml of 0.5% ropivacaine + 4 mg Dexamethadsone. In this study we assessed the pain score - VAS at rest at 2, 4, 6, 12 and 24 hours after the operation and the total analgesic consumption of morphine over 24 hours. RESULTS: There were statistically significant differences in the VAS scores between group I, group II and group III at all postoperative time points - 2(hr), 4(hr), 6(hr), 12(hr) and 24(hr). (p < 0.00001). The cumulative 24 hours morphine consumption after the operation was significantly lower in group III (5.53 1.21 mg) than in group II (6.16 2.41 mg) and group I (9.26 2.41 mg). This difference is statistically significant (p < 0.00001). CONCLUSION: Concerning the inguinal hernia repair we found better postoperative pain scores and 24 hours reduction of the morphine consumption in group III (GA and TAP-D block) compared with group I (GA) and group II (GA + TAP block).

Antibiotics for upper respiratory infections: public knowledge, beliefs and self-medication in the Republic of Macedonia.

Self-medication as part of the irrational use of antibiotics contributes to the spread of antimicrobial resistance. The aim of this community-based survey in Macedonia was to determine public knowledge, beliefs and self-medication with antibiotics for upper respiratory infections. A cross-sectional study was conducted in three administrative regions in Macedonia in April 2012. 402 eligible participants answered an anonymous questionnaire. The analysis of answers involved descriptive quantitative statistics (frequencies and percentages). We also tested for significant associations between demographic characteristics and non-prescription use of antibiotics. Our respondents demonstrated a relatively low level of public knowledge about antibiotics and upper respiratory infection treatments in comparison to the EU countries. The study found that 71.4% of participants stored antibiotics at home, and 43.3% purchased antibiotics over-the-counter in the last year, despite national regulation that restricts antibiotics as prescription-only medicines. Actual self-medication with antibiotics for a recent upper respiratory infection episode was reported in 17.8% of adults and 1.8% of children aged 0-4 years. We did not find any significant association between participants demography and non-prescription use of antibiotics. Our results put in the group of eastern and southern EU countries with the highest rates for non-prescription use of antibiotics in Europe. Multifaceted interventions are needed to prevent self-medication with antibiotics, including: enforcement of regulations that restrict over-the-counter sales of antibiotics, monitoring of antibiotic use and antimicrobial resistance rates and combined public education strategies.

Heroin dependence duration influences the metabolic parameters: mechanisms and consequences of impaired insulin sensitivity in hepatitis C virus seronegative heroin dependents.

OBJECTIVE: Carbohydrate metabolism disorder in heroin dependence is an issue with long history and contradicting results. The aim of the study was to evaluate basal insulin sensitivity in hepatitis C virus seronegative heroin dependents with normal body mass index, taking into consideration the duration of heroin dependence. METHOD: 78 heroin dependents and 32 healthy controls were enrolled in the cross-sectional, prospective study. The dependents were observed in 2 groups: group 1 with dependence duration less than or equal to 3 years and group 2 with more than 3 years. Homeostasis Model Assessment for Insulin Resistance (HOMA-IR) and ß-cell function (HOMA-B%) were used to define basal glucose-insulin homeostasis. RESULTS: The group with longer dependence duration had HOMA-IR (2.23 ± 3.15) significantly higher compared with the control group (1.23 ± 0.53, P = 0.016) but lower compared with the group with the shorter dependence duration (2.65 ± 2.66, P = 0.024), after adjustment for HOMA-B%, waist circumference, and aspartate aminotransferase. The decrease in HOMA-IR during prolonged heroin addiction was significantly associated with the reduced ß-cell function (P < 0.001) and waist circumference (P = 0.004). CONCLUSIONS: Heroin dependence is associated with increased insulin resistance in hepatitis C virus seronegative heroin dependents. Prolonged heroin use is associated with reduction of basal ß-cell pancreatic function with decreased insulin resistance controlled for waist circumference, but still inducing significantly decreased basal insulin sensitivity.

Total parenteral nutrition in treatment of patients with inflammatory bowel disease.

Patients with Inflammatory Bowel Disease (IBD) are exposed to nutritional risk. Malnutrition in Crohn's Disease (CD) and to a somewhat lesser in Ulcerative Colitis (UC) is very frequent. Depending on the severity of the disease, weight loss has been reported in 65% to 76% of those with CD and in 18% to 62% of those with UC. The role of Total Parenteral Nutrition (TPN) is essential in very severe cases where enteral nutrition is not tolerated or standard drug therapy is not effective. Nutritional therapy is important for the correction of nutritional deficiency, especially in cases where elective surgical treatment is required. This study examined the effects of preoperative TPN administration in patients with IBD. Since 1990, 29 pts, 13 (44.8%) male and 16 (55.2%) female with severe IBD; 16 (55.2%) with UC and 13 (44.8%) with CD were treated with TPN in our department in the preoperative period. Evaluation of this group was compared with a group which was not treated with TPN preoperatively: 61 pts, 34 (55.7%) male, 27 (44.3%) female; 50 (82%) with CD, 11 (18%) with UC. Evaluation of this group was compared with the group of patients who were subjected to surgical procedure without prior TPN administration, in total a number of 61, of whom 34 (55.7%) were male and 27 (44.3%) female patients. In this group, the number of patients with CD and UC was 50 (82%) and 11(18%) respectively. During the course of the study, the following parameters were examined: Body mass index (BMI), Disease Activity Index (CDAI/AI), laboratory parameters and the number of hospital days. The parameters were analysed before the surgical intervention, and one week and six months after the surgical intervention. The duration of the application of TPN was 12.5 +/- 5 days. The analysis of these parameters has shown that there is no statistically significant difference in the number of hospital days in both groups, which was 18.9 +/- 8.9 in the intervention group and 18.9 +/- 6.5 days in the control group, p = 0.9808, but analysis of the Disease Activity (CDAI/AI) has shown that patients who were on TPN were in a more severe stage of the disease. In the TPN treated group of patients none, 0 pts (0%), of the pts had no Index of Activity, 1.7 pts (24.1%) had Index 2 and 22 (75.9%) had Index 3. In the other group 3 pts (4.9%) had Index 1; 39 pts (63.9%) had Index 2 and 19 pts (31.2%) had Index of Activity 3. During the monitoring period of six months the activity of the disease was lower in patients treated with TPN. The BMI in the group of patients treated with TPN was lower in both sexes. It was lower than 18.4 in 7 males and 5 females; between 18.4 and 19.9 in 2 males and 4 females; between 19.9 and 25 in 3 males and 6 females; between 25 and 19.9 in 1 male and 1 female; there were no pts with BMI higher than 29.9. In the control non-TPN group, 5 males and 3 females had BMI < or = 18.4; 2 males and 5 females had between 18.4 and 19.9; 23 males and 13 females had between 19.9 and 25; 3 males and 5 females had between 25 and 29.9 and 1 male and 1 female had BMI higher than 29.9. The BMI had an increasing trend in the postoperative period in both groups. The laboratory parameters that we examined were: number of erythrocytes and sedimentation, number of leukocytes, haemoglobin levels, total number of lymphocytes, albumin level, C-reactive protein, orosomucoid, electrolytes; sodium, potassium, calcium and serum iron, the enzymes (AP, AST and ALT); level of bilirubin and urea and creatinine. The results were analysed using the Tukey honest significant difference test (HSD), ANOVA and Student t-test. Statistically significant differences were observed between preoperative and postoperative period in both groups. The intergroup comparison showed significant differences in the level of albumin, AST, ALT and bilirubin.