Prevalence of physical health comorbidities and long-term functional outcomes among community-reintegrated veterans following lower limb amputation in Sri Lanka.

INTRODUCTION: Lower limb amputation (LLA) poses significant health challenges, including physical health comorbidities (PHCs) and functional limitations. Military veterans, who typically undergo traumatic LLA at a young age, endure these challenges for an extended period. Understanding the extent of these challenges is vital to designing tailored and feasible postamputation care for them. In this study, we evaluated the prevalence of PHCs and long-term functional outcomes among community-reintegrated veterans following LLA in Sri Lanka. METHODS: A comparative cross-sectional study was conducted in five districts in Sri Lanka. Prevalence of PHCs and functional outcomes were compared between community-reintegrated veterans with war-related traumatic LLA and a matched able-bodied cohort. Data on PHCs were collected from participants' medical records and through a self-administered questionnaire. Timed-Up-and-Go (TUG) and 2 min walk test (2MWT) were used to compare functional outcomes between the groups. Veterans' functional level was identified using the K-level classification. RESULTS: Veterans were active prosthetic users who had undergone LLA >10 years ago. Sixty-six (77.6%) veterans reported experiencing phantom limb pain. A significantly higher prevalence of diabetes mellitus (34.2%), hypertension (22.4%), knee osteoarthritis (18.8%), knee pain (20%) and back pain (69.4%) was observed among veterans compared with the able-bodied group (p<0.05). Veterans demonstrated significantly lower levels of functional mobility (2MWT: mean (SD): 113.6 (14.8); increased risk of falling (TUG): mean (SD): 10.6 (1.8)) compared with able-bodied individuals (150.8 (11.9) and 7.2 (0.9), respectively, p<0.001). The majority of the veterans belonged to the K3 functional level (71.8%). CONCLUSIONS: The higher prevalence of PHCs and impaired functional outcomes underscores the multifaceted health challenges faced by veterans with LLA living in low-resource community settings with limited access to rehabilitation. These findings provide insights into the unique rehabilitation needs of individuals with similar backgrounds, informing the design and implementation of tailored rehabilitation interventions.

Correction to: Implementation and impact of pediatric antimicrobial stewardship programs: a systematic scoping review.

The original article [1] contains an error in Fig. 1 whereby the number of selected articles of the first box is incorrect.

Implementation and impact of pediatric antimicrobial stewardship programs: a systematic scoping review.

Background: Antibiotics are the most common medicines prescribed to children in hospitals and the community, with a high proportion of potentially inappropriate use. Antibiotic misuse increases the risk of toxicity, raises healthcare costs, and selection of resistance. The primary aim of this systematic review is to summarize the current state of evidence of the implementation and outcomes of pediatric antimicrobial stewardship programs (ASPs) globally. Methods: MEDLINE, Embase and Cochrane Library databases were systematically searched to identify studies reporting on ASP in children aged 0-18 years and conducted in outpatient or in-hospital settings. Three investigators independently reviewed identified articles for inclusion and extracted relevant data. Results: Of the 41,916 studies screened, 113 were eligible for inclusion in this study. Most of the studies originated in the USA (52.2%), while a minority were conducted in Europe (24.7%) or Asia (17.7%). Seventy-four (65.5%) studies used a before-and-after design, and sixteen (14.1%) were randomized trials. The majority (81.4%) described in-hospital ASPs with half of interventions in mixed pediatric wards and ten (8.8%) in emergency departments. Only sixteen (14.1%) studies focused on the costs of ASPs. Almost all the studies (79.6%) showed a significant reduction in inappropriate prescriptions. Compliance after ASP implementation increased. Sixteen of the included studies quantified cost savings related to the intervention with most of the decreases due to lower rates of drug administration. Seven studies showed an increased susceptibility of the bacteria analysed with a decrease in extended spectrum beta-lactamase producers E. coli and K. pneumoniae; a reduction in the rate of P. aeruginosa carbapenem resistance subsequent to an observed reduction in the rate of antimicrobial days of therapy; and, in two studies set in outpatient setting, an increase in erythromycin-sensitive S. pyogenes following a reduction in the use of macrolides. Conclusions: Pediatric ASPs have a significant impact on the reduction of targeted and empiric antibiotic use, healthcare costs, and antimicrobial resistance in both inpatient and outpatient settings. Pediatric ASPs are now widely implemented in the USA, but considerable further adaptation is required to facilitate their uptake in Europe, Asia, Latin America and Africa.

Antibiotic prescriptions in acute otitis media and pharyngitis in Italian pediatric outpatients.

BACKGROUND: Acute otitis media (AOM) and pharyngitis are very common infections in children and adolescents. Italy is one of the European countries with the highest rate of antibiotic prescriptions. The aim of this study is to describe first-line treatment approaches for AOM and pharyngitis in primary care settings in Italy over six years, including the prevalence of 'wait and see' for AOM, where prescription of antibiotics is delayed 48 h from presentation, and differences in prescribing for pharyngitis when diagnostic tests are used. METHODS: The study is a secondary data analysis using Pedianet, a database including data at outpatient level from children aged 0-14 in Italy. Prescriptions per antibiotic group, per age group and per calendar year were described as percentages. "Wait and see" approach rate was described for AOM and pharyngitis prescriptions were further grouped according to the diagnostic test performed and test results. RESULTS: We identified 120,338 children followed by 125 family pediatricians between January 2010 and December 2015 for a total of 923,780 person-years of follow-up. Among them 30,394 (mean age 44 months) had at least one AOM diagnosis (n = 54,943) and 52,341 (mean age 5 years) had at least one pharyngitis diagnosis (n = 126,098). 82.5% of AOM diagnoses were treated with an antibiotic within 48 h (mainly amoxicillin and amoxicillin/clavulanate) and the "wait and see" approach was adopted only in 17.5% of cases. The trend over time shows an increase in broad spectrum antibiotic prescriptions in the last year (2015). 79,620 (63%) cases of pharyngitis were treated and among GABHS pharyngitis confirmed by rapid test 56% were treated with amoxicillin. The ones not test confirmed were treated mainly with broad spectrum antibiotics. CONCLUSIONS: Despite guidance to use the 'wait and see' approach in the age group analyzed, this strategy is not often used for AOM, as previously noted in other studies in hospital settings. Broad-spectrum antibiotic prescription was more frequent when pharyngitis was not confirmed by rapid test, in keeping with evidence from other studies that diagnostic uncertainty leads to overuse of antibiotics.

Impact of HIV-1 Infection and Antiretroviral Therapy on Bone Homeostasis and Mineral Density in Vertically Infected Patients.

Daily assumption of antiretroviral drugs and HIV-related immune activation lead to important side effects, which are particularly evident in vertically infected patients. Bone homeostasis impairment and reduction of bone mineral density (BMD) is one of the most important side effects. Primary aim of this study is to assess the prevalence of bone homeostasis alterations in a group of vertically infected patients; secondary aim is to analyze the relationship between bone homeostasis alterations and anthropometric data, severity of HIV infection, and antiretroviral therapy. We studied 67 patients with vertically transmitted HIV-1 (aged 6-31 years), followed by the Pediatric Infectious Disease Unit of the University Hospital of Padua, Italy. We analyzed bone turnover markers (P1NP and CTx) and we performed lumbar spine and femoral dual energy X-ray absorption densitometry (DXA). Personal and anthropometric data and information on HIV-infection severity and antiretroviral therapy were collected for all patients. We found that BMD values recorded by DXA showed a significant correlation with age, race, BMI, physical activity, and antiretroviral therapy duration. P1NP was increased in 43% of patients, while CTX in 61% of them. P1NP alteration was related to age, race, BMI, physical activity, therapy duration, and ever use of protease inhibitors and nucleotide reverse transcriptase inhibitors. CTX alteration was found to be correlated only with age. In conclusion, our study confirms that a wide percentage of HIV vertically infected patients show reduced BMD and impaired bone homeostasis. Strict monitoring is needed in order to early identify and treat these conditions.

Osteomyelitis in Cat-Scratch Disease: A Never-Ending Dilemma-A Case Report and Literature Review.

BACKGROUND: We performed a review of published case studies of osteomyelitis associated with cat-scratch disease to consolidate existing information on clinical presentation, diagnostic tools, therapy, and outcome, as well as presenting a case of disseminated cat-scratch disease in a 12-year-old female with skull osteomyelitis and spleen involvement. METHODS: A search for articles indexed in PubMed, Embase, and Google Scholar was performed with the search terms "Bartonella," "bone," "osteomyelitis," "osteolytic," and "cat-scratch disease" limited to the immunocompetent pediatric population and articles in English. RESULTS: 51 cases were identified. The average age was 7.8 years with equal sex distribution. Fever (84.3%), often with a prolonged course (64.7%), and osteoarticular pain (88.2%) were the most common clinical findings. Lymphadenopathy was present in 64.7% of patients. Vertebral body was mainly involved (51.9%). MRI (50%) and bone scintigraphy (48.1%) were favored to confirm osteomyelitis, while serology was the preferred microbiological diagnostic. Various antibiotics were prescribed in combined or sequential regimens, with median duration of therapy of 23 days. About 12.5% of patients did not receive any treatment. Most patients had excellent prognosis; in particular, all patients not receiving any therapy showed complete recovery and no recurrence of symptoms. CONCLUSIONS: Bartonella henselae should be considered in differential diagnosis of localized lymphadentitis. Osteoarticular pain or limitation during cat-scratch disease in children should always be investigated for bone spreading. Owing to good prognosis, invasive procedures to obtain the bone material should be avoided. Serology is the gold standard diagnostic tool and MRI is the best radiographic technique to define bone and surrounding tissue involvement. Treatment represents a never-ending dilemma: surgical intervention or use of antibiotics is still controversial, and more studies are needed to define the best antimicrobial regimen.

Antibiotics Prescriptions in the Neonatal Intensive Care Unit: How to Overcome Everyday Challenges.

Antimicrobial prescriptions in neonatal intensive care units (NICUs) represent a point of concern for the emergence of MDROs and for morbidity associated with prolonged antibiotic exposure (e.g., invasive candidiasis, necrotizing enterocolitis, and late-onset sepsis). Antimicrobial stewardship programs (ASPs) have shown to be a valuable tool for the prevention of resistance with the goals of optimizing clinical outcomes while decreasing unnecessary prescribing. The most frequent ASP strategies include the correct collection and interpretation of microbiological specimens, prescription of the narrowest-spectrum antibiotic appropriate for a particular case, and de-escalation or discontinuation of therapy in defined situations. A robust ASP requires everyday multidisciplinary collaboration between ID physicians, neonatologist, clinical pharmacists, clinical microbiologists, infection control professionals, hospital epidemiologists, and information services specialists. Education and clinical pathways (e.g., sepsis or surgical prophylaxis pathways) are an excellent starting point if followed by proactive interventions such as prospective audits and feedback and formulary restriction with prior antimicrobial authorization. The current review outlines the problems faced in NICU antimicrobial prescribing and presents various solutions from the literature.

Community-Acquired Rotavirus Gastroenteritis Compared with Adenovirus and Norovirus Gastroenteritis in Italian Children: A Pedianet Study.

Background. Rotavirus (RV) is the commonest pathogen in the hospital and primary care settings, followed by Adenovirus (AV) and Norovirus (NV). Only few studies that assess the burden of RV gastroenteritis at the community level have been carried out. Objectives. To estimate incidence, disease characteristics, seasonal distribution, and working days lost by parents of RV, AV, and NV gastroenteritis leading to a family pediatrician (FP) visit among children < 5 years. Methods. 12-month, observational, prospective, FP-based study has been carried out using Pedianet database. Results. RVGE incidence was 1.04 per 100 person-years with the highest incidence in the first 2 years of life. Incidences of AVGEs (1.74) and NVGEs (1.51) were slightly higher with similar characteristics regarding age distribution and symptoms. Risk of hospitalisation, access to emergency room (ER), and workdays lost from parents were not significantly different in RVGEs compared to the other viral infections. Conclusions. Features of RVGE in terms of hospitalisation length and indirect cost are lower than those reported in previous studies. Results of the present study reflect the large variability of data present in the literature. This observation underlines the utility of primary care networks for AGE surveillance and further studies on community-acquired gastroenteritis in children.

Community collaborative youth-focused HIV/AIDS prevention in South Africa and Trinidad: preliminary findings.

BACKGROUND: South Africa and Trinidad and Tobago are disproportionately impacted by high rates of HIV/AIDS among adolescents. OBJECTIVE: The article describes the HIV crises in these countries; outlines a community participatory research framework to adapt and deliver family-based prevention; and presents preliminary data from intervention pilots in each setting. METHODS: Adapted interventions were piloted with N = 140 families in South Africa and N=16 families in Trinidad and Tobago to refine recruitment and retention efforts and to assess the adapted interventions' impact on family and risk-related constructs. RESULTS: Both settings reported promising results including high recruitment and retention and favourable pre to post changes in parent/youth frequency and comfort in talking about sensitive subjects, HIV transmission knowledge and attitudes about persons with HIV/AIDS. CONCLUSION: International HIV-prevention alliances are increasing. Such alliances are challenged by trust issues, power-differentials and ideological differences. Recommendations are provided on how some challenges can be overcome.

Increased CD80(+) B cells in active multiple sclerosis and reversal by interferon beta-1b therapy.

Costimulatory molecules help determine T cell responses. CD80 (B7-1) and CD86 (B7-2), costimulatory proteins on antigen-presenting cells, bind to CD28 on T cells. When costimulation is coupled with a signal through the T cell receptor (TCR), T cell proliferation and cytokine secretion are induced. However, TCR signaling without CD80/CD86CD28 costimulation causes anergy. During multiple sclerosis (MS) exacerbations, circulating immune cells are activated, Th1 cytokine levels in the blood are elevated, and blood-derived immune cells destroy brain oligodendroglia. In the experimental autoimmune encephalomyelitis model of MS, CD80 on antigen-presenting cells induces Th1 cell responses; CD86 enhances generation of Th2 cells. Variation in CD80 and CD86 expression is likely to influence immune regulation in MS. We demonstrate that the number of circulating CD80(+) lymphocytes is increased significantly during MS exacerbations, but is normal in stable MS. These CD80(+) lymphocytes are predominantly B cells, based on two-color flow cytometry. The number of CD71(+) and HLA-DR+ lymphocytes and monocytes is also increased in active MS. Therapy with IFN beta-1b markedly reduces the number of circulating CD80(+) B cells and increases CD86(+) monocyte number. HLA-DR+, CD71(+), and CD25(+) mononuclear cell numbers are also reduced by therapy. The number of CD80(+) cells may be a useful surrogate marker during IFN-beta therapy, and reduction of CD80-mediated costimulation may be one therapeutic mechanism by which IFN-beta acts in MS.

Cellular composition of cervical smears taken by general practitioners.

The quality of the cervical smears taken by general practitioners, and also by some practice assistants, of the Dutch Screening Programme in the region of Nijmegen was evaluated. Of 18,398 preventive cervical smears taken by GPs in this region, 437 (2%) were diagnosed as "class" 0 and 2907 (16%) smears did not contain endocervical cells (EC-). The quality of the smears per general practitioner varied enormously. The percentage of smears without endocervical cells taken by six practice assistants was 18. During the screening period the percentage of smears without endocervical cells taken by GPs decreased from 19 (1989) to 14 (1992). In February 1990 the six practice assistants followed a theoretical and practical course on cervical smear-taking. Remarkable was the decrease in the percentage of smears without an endocervical component from 25% in 1990 to 13% in 1991. The quality of smears taken by GPs would improve if the general practitioner had more experience in smear-taking. We recommend to offer GPs the opportunity to take practical training courses in smear-taking, just as the practice assistants in this project.