Sustained Reduction in Third-generation Cephalosporin Usage in Adult Inpatients Following Introduction of an Antimicrobial Stewardship Program in a Large, Urban Hospital in Malawi.

BACKGROUND: Third-generation cephalosporins (3GC) remain the first-choice empiric antibiotic for severe infection in many sub-Saharan African hospitals. In Malawi, the limited availability of alternatives means that strategies to prevent the spread of 3GC resistance are imperative; however, suitable approaches to antimicrobial stewardship (AMS) in low-income settings are not well studied. METHODS: We introduced an AMS intervention to Queen Elizabeth Central Hospital in Blantyre. The intervention consisted of a prescribing application for smartphones and regular point-prevalence surveys with prescriber feedback. We evaluate the effects of the intervention on 3GC usage and on the cost of providing antibiotics. Using a thematic analysis of semi-structured interviews and participant observations, we additionally evaluate the acceptability of the stewardship program. RESULTS: The proportion of antibiotic prescriptions for a 3GC reduced from 193/241 (80.1%) to 177/330 (53.6%; percentage decrease, 26.5%; 95% confidence interval, 18.7-34.1) with no change in the case-fatality rate. The cost analysis estimated an annual savings of US$15 000. Qualitative research revealed trust in the guideline and found that its accessibility through smartphones helpful to guide clinical decisions. Operational health-system barriers and hierarchal clinical relationships lead to continued reliance on 3GC. CONCLUSIONS: We report the successful introduction of an antimicrobial stewardship approach in Malawi. By focusing on pragmatic interventions and simple aims, we demonstrate the feasibility, acceptability, and cost savings of a stewardship program where resources are limited. In doing so, we provide a suitable starting point for expansions of AMS interventions in this and other low-income settings.

Diagnosis and management of type 2 diabetes in youth in North Queensland and the Northern Territory: A health professional survey.

OBJECTIVE: To describe clinician practice regarding diagnosis, management and perceived barriers to the optimal management of youth-onset type 2 diabetes mellitus in North Queensland and the Northern Territory and to compare self-reported practice to guideline recommendations. DESIGN: A mailed questionnaire distributed between July and October 2017. SETTING: Clinicians practising in three tertiary hospitals and two primary care organisations in North Queensland and the Northern Territory. PARTICIPANTS: Of the 72 participants, 42 (58%) who responded were endocrinologists, diabetes educators, GPs and paediatricians. RESULTS: Of the 42 clinicians, 23 referred to the guidelines. A diabetes educator, GP, endocrinologist and dietitian were the most commonly included clinicians in the multidisciplinary team. Half of the clinicians' screen the children if additional risk factors are present. The HbA1c is the most common test used for screening and diagnosis. At diagnosis, the clinicians' recommended lifestyle change in 86% of the patients, treatment with metformin in 48%, and, when indicated, treatment with insulin in up to 45%. All clinicians believe that non-adherence is a major factor limiting optimal care. Most commonly cited barriers to optimal care were poor patient or family health literacy and limited patient or family understanding of the condition. CONCLUSION: This study demonstrates several aspects of diagnosis and management of type 2 diabetes mellitus in youth that deviate from the guidelines. Patients need improved access to social workers, psychologists and Indigenous health workers. Other key areas to address are evaluation of risk-based screening, supporting appropriate and early use of insulin and the management of youth with type 2 diabetes mellitus inclusive of their family through contextualised health care delivery.

Investigation and management of moderate to severe inpatient hyponatraemia in an Australian tertiary hospital.

BACKGROUND: Hyponatraemia is the most common electrolyte disturbance amongst hospitalised patients. Both American and European guidelines recommend fluid restriction as first line treatment for SIADH, however differ on second line recommendations. The objective of this study was to examine investigation and management of hyponatraemia in hospitalised patients in an Australian tertiary hospital. METHODS: A retrospective audit was conducted of electronic medical records and laboratory data of inpatients with serum sodium (Na) ≤125 mmol/L, admitted over a 3 month period to the Princess Alexandra Hospital, Brisbane, Australia. The main outcomes measured included: demographic characteristics, investigations, accuracy of diagnosis, management strategy, change in Na and patient outcomes. RESULTS: The working clinical diagnosis was considered accurate in only 37.5% of cases. Urine Na and osmolality were requested in 72 of 152 patients (47.4%) and in 43 of 70 euvolaemic patients (61.4%). Thyroid function tests (67.1%) and morning cortisol (45.7%) were underutilized in the euvolaemic group. In the SIADH cohort, fluid restriction resulted in a median (IQR) 7.5 mmol/L (4-10.5) increase in Na after 3 days; no treatment resulted in a median 0 mmol/L (- 0.5-1.5) change. Oral urea was utilized in 5 SIADH patients where Na failed to increase with fluid restriction alone. This resulted in a median 10.5 mmol/L (3.5-13) increase in Na from baseline to day 3. There were no cases of osmotic demyelination. The median length of stay was 8 days (4-18.5). Mortality was 11.2% (17 patients). There was a weak but significant correlation between nadir serum Na and mortality (R = 0.18, P = 0.031). CONCLUSION: Inpatient hyponatraemia is often inadequately investigated, causing errors in diagnosis. Treatment is heterogeneous and often incorrect. In cases with hyponatraemia refractory to fluid restriction, oral urea presents an effective alternative treatment.

Testing novel strategies for patients hospitalised with HIV-associated disseminated tuberculosis (NewStrat-TB): protocol for a randomised controlled trial.

BACKGROUND: HIV-associated tuberculosis (TB) contributes disproportionately to global tuberculosis mortality. Patients hospitalised at the time of the diagnosis of HIV-associated disseminated TB are typically severely ill and have a high mortality risk despite initiation of tuberculosis treatment. The objective of the study is to assess the safety and efficacy of both intensified TB treatment (high dose rifampicin plus levofloxacin) and immunomodulation with corticosteroids as interventions to reduce early mortality in hospitalised patients with HIV-associated disseminated TB. METHODS: This is a phase III randomised controlled superiority trial, evaluating two interventions in a 2 × 2 factorial design: (1) high dose rifampicin (35 mg/kg/day) plus levofloxacin added to standard TB treatment for the first 14 days versus standard tuberculosis treatment and (2) adjunctive corticosteroids (prednisone 1.5 mg/kg/day) versus identical placebo for the first 14 days of TB treatment. The study population is HIV-positive patients diagnosed with disseminated TB (defined as being positive by at least one of the following assays: urine Alere LAM, urine Xpert MTB/RIF Ultra or blood Xpert MTB/RIF Ultra) during a hospital admission. The primary endpoint is all-cause mortality at 12 weeks comparing, first, patients receiving intensified TB treatment to standard of care and, second, patients receiving corticosteroids to those receiving placebo. Analysis of the primary endpoint will be by intention to treat. Secondary endpoints include all-cause mortality at 2 and 24 weeks. Safety and tolerability endpoints include hepatoxicity evaluations and corticosteroid-related adverse events. DISCUSSION: Disseminated TB is characterised by a high mycobacterial load and patients are often critically ill at presentation, with features of sepsis, which carries a high mortality risk. Interventions that reduce this high mycobacterial load or modulate associated immune activation could potentially reduce mortality. If found to be safe and effective, the interventions being evaluated in this trial could be easily implemented in clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov NCT04951986. Registered on 7 July 2021 https://clinicaltrials.gov/study/NCT04951986.

Barriers to screening and diagnosis of peripheral artery disease by general practitioners.

Peripheral artery disease (PAD) is a strong predictor of cardiovascular morbidity and mortality yet it is under-recognised and undertreated. General practitioners (GPs) are best positioned to detect patients with PAD. This article investigates awareness of PAD by GPs; the prevalence of screening for PAD and tools used for screening and diagnosis, in particular the ankle-brachial index (ABI); and the barriers to PAD screening and measurement of the ABI in the general practice setting. A cross-sectional survey of primary care practitioners was conducted between September 2011 and March 2012. A mail-out survey was distributed to 1120 GPs practising in Queensland, Australia: 287 (26%) responded; 61% of GPs reported screening for PAD; 58% of GPs reported 'never' measuring the ABI; and 70% reported using arterial duplex ultrasound as their first-line diagnostic tool. Equipment availability, time constraints and lack of training and skills were identified as the most significant barriers to screening and ABI testing. In conclusion, there are deficits in the utilisation of guideline recommendations relating to PAD screening and diagnosis by Australian GPs. Our data suggest that earlier detection of PAD may be achieved through GP education combined with increased access to ABI equipment or the availability of a more time-efficient test.

Peripheral arterial disease - screening in general practice.

BACKGROUND: As a manifestation of systemic atherosclerosis, peripheral arterial disease (PAD) signifies an increased risk of cardiovascular events. Peripheral arterial disease has received less attention than other atherosclerotic diseases, leading to under-diagnosis and under-treatment. Peripheral arterial disease affects approximately 10-15% of the general population, and approximately 50% of PAD patients are asymptomatic. OBJECTIVE: This article aims to review the literature on the rationale for screening for lower extremity PAD in the general practice setting, and to identify the barriers to screening for PAD experienced by general practitioners, with a focus on the Australian context. DISCUSSION: Screening for asymptomatic PAD among high risk groups has been recommended by major PAD authorities to increase early diagnosis. Screening for PAD using the ankle-brachial index can detect asymptomatic patients. Research into the effect of cardiovascular risk reduction therapies for asymptomatic patients is lacking, and available evidence is inconclusive. The prevalence of screening and barriers to screening experienced by Australian GPs has not yet been studied. Available data on the benefits of PAD screening is inconclusive, and further research is required to determine a survival benefit with treatment of asymptomatic PAD.

Peripheral arterial disease - diagnosis and management in general practice.

BACKGROUND: Peripheral arterial disease (PAD) is a manifestation of systemic atherosclerosis. It affects 10-15% of the general population, and is often asymptomatic; leading to under-diagnosis and under-treatment. Atherosclerotic risk factors are often not intensively managed in PAD patients. OBJECTIVE: To summarise the information around the diagnosis and management of PAD in the general practice setting. DISCUSSION: Careful history, clinical examination, and measurement of ankle-brachial index remain the initial means of diagnosing PAD. More detailed anatomic information from duplex imaging, computed tomography angiography and magnetic resonance angiography, is usually unnecessary unless endovascular or surgical intervention is being considered, or if abdominal aortic aneurysm or popliteal aneurysm need to be excluded. Management is focused on lifestyle modification, including smoking cessation and exercise; medical management of atherosclerotic risk factors, including antiplatelet agents, statins, antihypertensive therapy; and agents to improve walking distance, such as cilostazol and ramipril. Endovascular or surgical interventions are usually considered for lifestyle limiting intermittent claudication not responding to conservative therapies, and for critical limb ischaemia.

BARIATRIC SURGERY FOR PRE-OPERATIVE WEIGHT REDUCTION IN A PATIENT WITH PHEOCHROMOCYTOMA.

OBJECTIVE: Obesity is a predictor of adverse outcomes in patients undergoing adrenalectomy. Pre-adrenalectomy weight reduction is becoming an increasingly common challenge in view of the rising prevalence of obesity. This case report describes the clinical course of a morbidly obese gentleman who underwent bariatric surgery prior to pheochromocytoma resection. METHODS: A morbidly obese man with a body mass index of 43 kg/m2 had an incidental finding of an 8.5 cm right-sided pheochromocytoma. Dietary and pharmacologic methods of weight loss lead to a 6 kg weight loss over a 12-month period. Multidisciplinary discussion concluded that weight loss and tumor resection were priority and the patient proceeded to laparoscopic sleeve gastrectomy with appropriate peri-operative alpha- and beta-blockade. RESULTS: Laparoscopic sleeve gastrectomy proceeded without complication and lead to a further 23 kg of weight loss and the pheochromocytoma was resected 2 months later. CONCLUSION: Bariatric surgery for pre-operative weight loss in medically prepared patients with pheochromocytoma should be considered for morbidly obese patients in whom nonsurgical weight loss is unsuccessful.

Opportunities and prospects of biorefinery-based valorisation of pulp and paper sludge.

The paper and pulp industry is one of the major industries that generate large amount of solid waste with high moisture content. Numerous opportunities exist for valorisation of waste paper sludge, although this review focuses on primary sludge with high cellulose content. The most mature options for paper sludge valorisation are fermentation, anaerobic digestion and pyrolysis. In this review, biochemical and thermal processes are considered individually and also as integrated biorefinery. The objective of integrated biorefinery is to reduce or avoid paper sludge disposal by landfilling, water reclamation and value addition. Assessment of selected processes for biorefinery varies from a detailed analysis of a single process to high level optimisation and integration of the processes, which allow the initial assessment and comparison of technologies. This data can be used to provide key stakeholders with a roadmap of technologies that can generate economic benefits, and reduce carbon wastage and pollution load.

Techno-economics of integrating bioethanol production from spent sulfite liquor for reduction of greenhouse gas emissions from sulfite pulping mills.

BACKGROUND: Flow sheet options for integrating ethanol production from spent sulfite liquor (SSL) into the acid-based sulfite pulping process at the Sappi Saiccor mill (Umkomaas, South Africa) were investigated, including options for generation of thermal and electrical energy from onsite bio-wastes, such as bark. Processes were simulated with Aspen Plus® for mass- and energy-balances, followed by an estimation of the economic viability and environmental impacts. Various concentration levels of the total dissolved solids in magnesium oxide-based SSL, which currently fuels a recovery boiler, prior to fermentation was considered, together with return of the fermentation residues (distillation bottoms) to the recovery boiler after ethanol separation. The generation of renewable thermal and electrical energy from onsite bio-wastes were also included in the energy balance of the combined pulping-ethanol process, in order to partially replace coal consumption. The bio-energy supplementations included the combustion of bark for heat and electricity generation and the bio-digestion of the calcium oxide SSL to produce methane as additional energy source. RESULTS: Ethanol production from SSL at the highest substrate concentration was the most economically feasible when coal was used for process energy. However this solution did not provide any savings in greenhouse gas (GHG) emissions for the concentration-fermentation-distillation process. Maximizing the use of renewable energy sources to partially replace coal consumption yielded a satisfactory economic performance, with a minimum ethanol selling price of 0.83 US$/l , and a drastic reduction in the overall greenhouse gas emissions for the entire facility. CONCLUSION: High substrate concentrations and conventional distillation should be used when considering integrating ethanol production at sulfite pulping mills. Bio-wastes generated onsite should be utilized at their maximum potential for energy generation in order to maximize the GHG emissions reduction.