Antibiotic use during pregnancy and the risk of preterm birth: a population-based Swedish cohort study.

OBJECTIVES: To assess the impact of gestational antibiotics on the risk of preterm birth, since a healthy maternal microbiome may be protective. METHODS: Population-based cohort study including all first pregnancies in Sweden (2006-16). The association between gestational and recent pre-conception systemic antibiotics and preterm birth was assessed by multivariable logistic regression presented as ORs and 95% CIs, adjusted for comorbidities (hypo- and hyperthyroidism, hypertension, or diabetes mellitus pre-gestation), trimester, antibiotic class and treatment duration. RESULTS: Compared with non-users, antibiotic exposure was associated with increased risks of preterm birth in mothers with comorbidities (OR = 1.32, 95% CI 1.18-1.48) and without (OR = 1.09, 95% CI 1.06-1.13). Pre-conception use showed no association, while risk was increased for first and second trimester use and decreased for third trimester use. The increased risks were seen for the following antibiotic groups in mothers without and with comorbidities, respectively: macrolides, lincosamides and streptogramins (OR = 1.63, 95% CI 1.45-1.83; OR = 2.48, 95% CI 1.72-3.56); quinolones (OR = 1.60, 95% CI 1.32-1.94; OR = 2.11, 95% CI 1.12-4.03); non-penicillin ß-lactams (OR = 1.15, 95% CI 1.07-1.24; OR = 1.39, 95% CI 1.07-1.83); other antibacterials (OR = 1.09, 95% CI 1.03-1.14; 1.38, 95% CI 1.16-1.63); and penicillins (OR = 1.04, 95% CI 1.01-1.08; 1.23, 95% CI 1.09-1.40). Antibiotic indications were not available, which could also affect preterm birth. CONCLUSIONS: Antibiotic use during pregnancy was associated with an increased risk of preterm birth, especially in mothers with chronic diseases.

Plasmodium falciparum malaria occurring four years after leaving an endemic area.

We present a case of a 52-year-old woman of Ghanaian origin who developed Plasmodium falciparum malaria 4 years after leaving Africa. She had not returned to an endemic area since. We hypothesize several possible scenarios to explain this infection, of which we believe recrudescence of P. falciparum is the most plausible. This occurred most likely as a consequence of waning immunity several years after leaving a high-transmission area. She recovered after a 3-day treatment with atovaquone/proguanil.

[A practical program for outpatient parenteral antimicrobial therapy]. / Un modèle pratique pour l'antibiothérapie parentérale ambulatoire.

Some infections require prolonged parenteral antimicrobial therapy, which can be continued in an outpatient setting. The Ghent University Hospital has fifteen years of experience with Outpatient Parenteral Antimicrobial Therapy [OPAT) in the patient own home setting. As a quality improvement initiative, this process was critically reviewed in a multidisciplinary approach. Several challenges and barriers were identified, including regulatory obstacles for OPAT in Belgium, such as Lack of uniformity in ambulatory reimbursement of parenteral antimicrobials. There is no financial incentive for the patient with OPAT, as costs for the patient of outpatient therapy can be higher as compared with hospitalization. Other barriers include delayed approval of the certificate for reimbursement, low availability of medicines in the community pharmacies and limited knowledge of the medical devices for administration in ambulatory setting. All critical steps in the revised OPAT program are summarized in a flowchart with a checklist for all stakeholders. Firstly, a list with specific criteria to include patients in an OPAT program is provided. Secondly, the Multidisciplinary Infection Team received a formal mandate to review all eligible OPAT patients. In order to select the most appropriate catheter a decision tree was developed and standardized packages with medical devices were developed. Thirdly, patients receive oral and written information about the treatment with practical and financial implications. Fourthly, information is provided towards the general practitioners, community pharmacists and home care nurses. Standardization of the OPAT-program aims at improving quality and safety of intravenous antimicrobial therapy in the home setting.

Good continuum of HIV care in Belgium despite weaknesses in retention and linkage to care among migrants.

BACKGROUND: The Belgian HIV epidemic is largely concentrated among men who have sex with men and Sub-Saharan Africans. We studied the continuum of HIV care of those diagnosed with HIV living in Belgium and its associated factors. METHODS: Data on new HIV diagnoses 2007-2010 and HIV-infected patients in care in 2010-2011 were analysed. Proportions were estimated for each sequential stage of the continuum of HIV care and factors associated with attrition at each stage were studied. RESULTS: Of all HIV diagnosed patients living in Belgium in 2011, an estimated 98.2% were linked to HIV care, 90.8% were retained in care, 83.3% received antiretroviral therapy and 69.5% had an undetectable viral load (<50 copies/ml). After adjustment for sex, age at diagnosis, nationality and mode of transmission, we found lower entry into care in non-Belgians and after preoperative HIV diagnoses; lower retention in non-Belgians and injecting drug users; higher retention in men who have sex with men and among those on ART. Younger patients had lower antiretroviral therapy uptake and less viral suppression; those with longer time from diagnosis had higher ART uptake and more viral suppression; Sub-Saharan Africans on ART had slightly less viral suppression. CONCLUSIONS: The continuum of HIV care in Belgium presents low attrition rates over all stages. The undiagnosed HIV-infected population, although not precisely estimated, but probably close to 20% based on available survey and surveillance results, could be the weakest stage of the continuum of HIV care. Its identification is a priority along with improving the HIV care continuum of migrants.

Blood pressure in the Congolese adult population of South Kivu, Democratic Republic of Congo: Preliminary results from the Bukavu Observ Cohort Study.

BACKGROUND: Providing factual data about non-communicable diseases (NCDs) is of utmost importance in the sub-Saharan African countries where NCDs and arterial hypertension data remain scattered, scarce, and less representative given the region's heterogeneous population. Within this context, the interuniversity cooperation VLIR-UOS/Catholic University of Bukavu (Democratic Republic of Congo) has established an integrated project for monitoring hypertension and cardiovascular risk factors in the population of South Kivu. The aim of the study was to present the basic results of the determinants of blood pressure in the cohort studied. METHODS: In 2013 and 2014, trained interviewers collected the anthropometric parameters, blood pressure, and medical history of 7405 adults (3060 in urban areas and 4345 in rural areas) including 3162 males and 4243 females; the cohort is expected to be followed for 9 years. RESULTS: The average age of the entire group was 33.0±16.7 years. Compared to men, women had significantly higher obesity indices (P<0.0001), lower blood pressure between 20 and 39 years of age (P<0.0001) but higher blood pressure at 60 years of age and older (P<0.0001). Blood pressure was positively correlated with body mass index, waist circumference, and paradoxically with consumption of vegetables, but negatively correlated with the consumption of fruit, intense physical activity, and relaxation at home. CONCLUSIONS: These results show that a cohort study is feasible in the Democratic Republic of Congo. The factual data analysis can contribute to health policy orientation and setting up of preventive measures. Since most correlated risk factors are preventable, recommendations can already be made in the fight against high blood pressure in this population.

Gender differences in treatment outcomes among 15-49 year olds with smear-positive pulmonary tuberculosis in Kenya.

OBJECTIVE: To determine gender differences in treatment outcomes among 15-49 year olds with smear-positive pulmonary tuberculosis (PTB) and factors associated with poor outcomes in Kenya. DESIGN: Retrospective descriptive cohort. RESULTS: Of 16 056 subjects analysed, 38% were female and 62% male. Females had a higher risk of poor treatment outcome than males (12% vs. 10%, P < 0.001; adjusted OR 1.29, 95%CI 1.16-1.44, P < 0.001). In the first multivariate model, restricting the analysis to human immunodeficiency virus (HIV) positive patients and adjusting for risk factors and clustering, females had a non-significantly lower risk of poor outcome (OR 0.99, 95%CI 0.86-1.13, P = 0.844). In the model restricted to HIV-negative patients, a non-significantly lower risk was found (OR 0.89, 95%CI 0.73-1.09, P = 0.267). In the second model, restricting analysis to patients on antiretroviral therapy (ART) and adjusting for risk factors and clustering, females had a non-significantly lower risk of poor PTB treatment outcomes (OR 0.98, 95%CI 0.84-1.14, P = 0.792). In the model restricted to HIV-positive patients not on ART, a non-significantly higher risk was found (OR 1.15, 95%CI 0.79-1.67, P = 0.461). CONCLUSION: Females of reproductive age are likely to have poorer treatment outcomes than males. Among females, not commencing ART during anti-tuberculosis treatment seemed to be associated with poor outcomes.

Implementation of a multidisciplinary infectious diseases team in a tertiary hospital within an Antimicrobial Stewardship Program.

BACKGROUND: In January 2011, as part of an antimicrobial stewardship program the Antimicrobial Management Team (AMT) at the Ghent University Hospital initiated a multidisciplinary Infectious Diseases Team (MIT) consisting of infectious diseases physicians, clinical microbiologists, and clinical pharmacists. The aim of this study is to describe the type and acceptance rate of recommendations provided by the MIT. METHOD: Prospective, observational study in a tertiary care, university teaching hospital with 1062 beds in non-consecutive hospitalized adult patients, excluding intensive care units and paediatrics. RESULTS: The MIT communicated 432 recommendations in 87 days observed. Of the 293 patients for whom a recommendation was made, the median age was 57 years (range: 16-91 years) and 169 (57·7%) were male. Skin or soft tissue infections (14%), respiratory tract infections (13%), infections without known focus (11%), abdominal infections (11%), and bone infections (8%) were most common. Recommendations were made to perform additional clinical investigation(s) [N = 137 (27%)], to adjust the dose of an antimicrobial drug [N = 42 (8%)], to stop an antimicrobial drug [N = 104 (21%)], to switch from a parenteral to an oral drug [N = 39 (8%)] or to initiate an antimicrobial drug [N = 178 (36%)], with an acceptance rate of 73·0%, 83·3%, 81·7%, 76·9%, and 84·0%, respectively. CONCLUSIONS: The MIT formulated about five recommendations a day primarily focusing on pharmacotherapy, but also on clinical investigations. In both fields, a high acceptance rate was observed.

Cutaneous metastatic tuberculous abcess in a patient with cervico-mediastinal lymphatic tuberculosis.

Metastatic tuberculous abcess or tuberculous gumma is a rare form of cutaneous tuberculosis resulting from haematogenous spread from a non-cutaneous tuberculous focus. A 26-year old patient of Pakistani origin presented at our clinic with an abcess on his right thigh that had slowly grown over a period of two months to a total size of 30 cm. Based on clinical findings, microbiology, CT thigh and CT chest, our patient was diagnosed with a tuberculous abcess and cervico-mediastinal tuberculous lymphadenitis. Antituberculosis drugs were initiated. Cutaneous tuberculosis should be included in the differential diagnosis of chronic cutaneous abcesses, especially in patients from tuberculosis endemic nations.

A rare cause of severe recurrent abdominal pain.

Recurrent abdominal pain may be enigmatic to solve. We report three cases, presenting after a protracted history of severe recurrent bouts of epigastric pain, impeding daily activities. In all cases, serology for strongyloidiasis stercoralis proved positive. In one case, stool examination was positive for larvae. Treatment with ivermectin or albendazole resulted in complete resolution of abdominal symptoms without recurrence in all three cases.

Screening for tuberculosis in pregnancy: do we need more than a symptom screen? Experience from western Kenya.

OBJECTIVES: 1) To explore the utility of tuberculosis (TB) symptom screening for symptoms of ≥2 weeks' duration in a routine setting, and 2) to compare differences in TB diagnosis between human immunodeficiency virus (HIV) infected and non-HIV-infected pregnant women in western Kenya. DESIGN: Comparative cross-sectional study among pregnant women with known HIV status screened for TB from 2010 to 2012, in Eldoret, western Kenya. RESULTS: Of 2983 participants, respectively 34 (1%), 1488 (50.5%) and 1461 (49.5%) had unknown, positive and negative HIV status. The median age was respectively 30 years (interquartile range [IQR] 26-35) and 26 years (IQR 24-31) in HIV-infected and non-infected participants. A positive symptom screen was found in respectively 8% (119/1488) and 5% (67/1461) of the HIV-infected and non-infected women. The median CD4 count at enrolment was 377 cells/µl (IQR 244-530) for HIV-infected women. One non-HIV-infected patient was sputum-positive. For HIV-infected women, TB was presumptively treated in 1% (16/1488) based on clinical symptoms and chest X-ray. Cumulatively, anti-tuberculosis treatment was offered to 0.6% (17/2949) of the participants. CONCLUSION: This study does not seem to demonstrate the utility of TB symptom screening questionnaires in a routine setting among pregnant women, either HIV-infected or non-infected, in western Kenya.

Impact of cost containment measures on medical liability.

RATIONALE: Owing to the growing health care expenditure and the need to improve efficiency, public authorities have since the 1980s changed their policy with respect to health care. Financial pressures encouraged them to investigate methods to control health care costs. One recent method is the enactment of cost containment measures based on clinical practice guidelines (CPGs) that provide financial or administrative sanctions. AIMS AND OBJECTIVES: This article describes the legal value of CPGs, the evolution towards cost containment measures based on CPGs, and finally the legal value of these new cost containment measures. It questions whether these measures may have an impact on the medical liability rules and it wants to open the debate on the legal value of these measures based vis-à-vis the professional autonomy of the physician and patients' rights on quality care. METHODS: The research for this article is based on a comparative analysis of the legal literature and jurisprudence of a number of legal systems. RESULTS AND CONCLUSIONS: The article concludes that, as a result of the rising costs, it becomes increasingly difficult for a physician to balance his duty to take care on the one hand and his duty to control costs on the other. Maintaining a high standard of care towards patients becomes difficult. Consequently, one wonders whether the law should then allow the standard of care to be adjusted according to the available means. Until now, courts in a fault based system have not been willing to accept such an adjustment of the standard of care, but it might well be possible that this attitude will change in case of no-fault compensation systems.

Bilateral blindness after starting highly active antiretroviral treatment in a patient with HIV infection and cryptococcal meningitis.

A 26-year-old HIV-seropositive Caucasian man with cryptococcal meningitis developed permanent bilateral blindness shortly after starting highly active antiretroviral treatment. The blindness may have been a consequence of an immune reactivation inflammatory syndrome caused by this treatment.

Recommendations for European health data protection legislation.

In year 1 of the SEISMED project, the Katholieke Universiteit Leuven coordinated the inventory and analysis of medical personal data protection legislation in Europe. A report on legal issues of medical data protection legislation in Europe was written by the Vrije Universiteit Amsterdam, the Centre National pour la Recherche Scientifique (Paris) and the University College Dublin. This report served as a basis for a second important legal deliverable, i.e. the Health Informatics Deontology Code. In this third and final report, we take into account the results of the other two legal reports and we formulate recommendations for the national and European legislator. This report analyses critically the upcoming privacy directive. We propose several recommendations which should be taken into account by the European and national legislator. We focused quite extensively on the use of medical data for research purposes. We had several reasons to do this. One of them is the fact that the use of medical data for research purposes is very popular, in particular now the health care sector is becoming more and more 'standardized' by using computers, networksystems and telematics. Legislation is therefore needed. Moreover, the use of medical data for research purposes involves the transfer of data from one Member State to another. Therefore, a harmonized legislation is really needed. We hope that the recommendations we propose, will be taken into consideration by the European legislator.

The automatic processing of medical data in Belgium: is the individual protected?

Medical data are collected, stored, transferred and used in Belgium as in many other western countries. Most of these countries have statutes for the protection of the individual with regard to (automatic) processing of medical data. Belgium, however, does not have such statutes or regulations. This article, firstly, describes briefly the processing of medical data on different levels in Belgium. It secondly illustrates the lack of personal medical data protection of the individual in Belgium. When more and more states started ratifying Council of Europe Convention No 108, the Belgian attitude was at times embarrassing. To make things worse, a Proposal for a Council Directive of 27 July 1990 has been published. The proposal, providing a deadline for the member states, aims at establishing throughout the community a high level of data protection on the basis of the internationally acknowledged principles of Convention No 108 and taking into account more recent national legislations in line with current technological developments. Special protection is provided for sensitive medical data. As said before, Belgium does not yet have legislation for medical data protection. There is, however, a draft concerning the protection of a person's data with regard to the processing of personal data. This draft, which might soon become law, is critically analysed, more particularly its protection of the individual in relation to the processing of medical data.

IVF in the USA, who pays for it?

A decade has passed since the first American 'test-tube baby' was born at the Eastern Virginia Medical School in Norfolk. The announcement of this medical achievement was an excellent source of inspiration for many legal scholars to write about the problems of IVF. The Spanish, English and Swedish legislators were the first to be seduced by these scholars. They enacted very sophisticated statutes concerning fertilization and embryology. The American legislation did not seem (at first sight) to fall under the spell of lawyers. In this article, it is shown how more and more American state legislators, by enacting statutes to mandate insurers to cover IVF treatment, are indirectly regulating IVF.