Qualitative study of antibiotic prescription patterns and associated drivers in Sudan, Guinea-Bissau, Central African Republic and Democratic Republic of Congo

OBJECTIVES

The objective of this study was to address the knowledge gap regarding antibiotic use in Medecins Sans Frontiéres (MSF) projects located in Africa by exploring antibiotic prescription and consumption habits and their drivers at different healthcare levels.

DESIGN

This study used an exploratory study design through thematic analysis of semistructured, in-depth interviews, focus group discussions (FGDs) and field observations in order to understand the main drivers influencing current antibiotics prescription habits and consumption habits of patients in different geographical settings.

SETTING

The study took place in MSF centres and towns across four countries: Guinea-Bissau, Central African Republic (CAR), Democratic Republic of Congo (DRC) and Sudan.

PARTICIPANTS

384 respondents participated in the study, which includes project staff, prescribers, community members, patients, among other groups.

RESULTS

Treatment protocols were physically present in all countries except DRC, but compliance to protocols varied across contexts. A failing health system and barriers to accessing healthcare were perceived as major drivers of overuse and inconsistent prescription practices. Patient demands influenced prescription decisions, and self-medication was commonly reported in the context of failing health systems. Additionally, there was a strong demand for quick cures and communities preferred injections over pills. Patients tended to stop antibiotic treatment once symptoms abated and had major gaps in understanding antibiotic intake instructions and functions.

CONCLUSIONS

While there were specific findings in each context, the larger trend from these four MSF projects in Africa indicates widespread use of antibiotics based on unclear assumptions, which are often influenced by patient demands. There needs to be a broader focus on the balance between access and excess, especially in such fragile contexts where access to healthcare is a real challenge.

Regulation of electrolyte and fluid metabolism in multi-stage ultra-marathoners

The purposes of this study were (i) to determine the prevalence of exercise-associated hyponatremia (EAH) in multi-stage ultra-marathoners and (ii) to gain more insight into fluid and electrolyte regulation during a multi-stage race. Body mass, sodium concentration ([Na⁺]), potassium concentration ([K⁺]), creatinine, urea, specific gravity, and osmolality in urine were measured in 25 male ultra-marathoners in the 'Swiss Jura Marathon' 2008 with 11,000 m gain of altitude over 7 stages covering 350 km, before and after each stage. Haemoglobin, haematocrit, creatinine, urea, [Na⁺], [K⁺], and osmolality were measured in plasma before stage 1 and after stages 1, 3, 5, and 7. Two athletes (8%) showed plasma [Na⁺] <135 mmol/l. Body mass, plasma [Na⁺], and plasma [K⁺] remained unchanged (p>0.05). Urine specific gravity (p<0.001) and osmolality in both plasma (p<0.01) and urine (p<0.001) were increased and haematocrit (p<0.0001), haemoglobin (p<0.0001) and plasma albumin were decreased (p<0.001). Plasma volume (p<0.01) and plasma urea (p<0.001) were increased. The K⁺/Na⁺ ratio in urine increased >1.0 after each stage and returned to <1.0 the morning of the next stage (p<0.001). To summarize, more sodium than potassium was excreted during rest. The increased urinary sodium losses during rest are compatible with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) or the cerebral salt-wasting syndrome (CSWS). Further studies are needed to determine the antidiuretic hormone (ADH) and both the atrial natriuretic peptide (ANP) and the brain natriuretic peptide (BNP) during multi-stage races.

Effect of a multistage ultraendurance triathlon on aldosterone, vasopressin, extracellular water and urine electrolytes

Prolonged endurance exercise over several days induces increase in extracellular water (ECW). We aimed to investigate an association between the increase in ECW and the change in aldosterone and vasopressin in a multistage ultraendurance triathlon, the 'World Challenge Deca Iron Triathlon' with 10 Ironman triathlons within 10 days. Before and after each Ironman, body mass, ECW, urinary [Na(+)], urinary [K(+)], urinary specific gravity, urinary osmolality and aldosterone and vasopressin in plasma were measured. The 11 finishers completed the total distance of 38 km swimming, 1800 km cycling and 422 km running within 145.5 (18.8) hours and 25 (22) minutes. ECW increased by 0.9 (1.1) L from 14.6 (1.5) L prerace to 15.5 (1.9) L postrace (P < 0.0001). Aldosterone increased from 70.8 (104.5) pg/mL to 102.6 (104.6) pg/mL (P = 0.033); vasopressin remained unchanged. The increase in ECW was related neither to postrace aldosterone nor to postrace vasopressin. In conclusion, ECW and aldosterone increased after this multistage ultraendurance triathlon, but vasopressin did not. The increase in ECW and the increase in aldosterone were not associated.

Swimming in ice cold water

INTRODUCTION

We investigated two athletes swimming in 4°C for 23 min (1.3 km, swimmer 1) and 42 min (2.2 km, swimmer 2), respectively.

MATERIALS AND METHODS

Pre swim, percent body fat was determined; post swim, core temperature was measured.

RESULTS

The core temperature of swimmer 2 was: 37.0°C immediately before the start, 32°C 20 min after getting out of the water, and 35.5°C 80 min after finishing the swim.

CONCLUSION

We assume that the higher skin-fold thickness and body fat of swimmer 2 enabled him to perform longer. In addition to this, mental power and experience in cold water swimming must be considered. In any athlete aiming at swimming in water of less than 5°C, body core temperature and heart rate should be continuously monitored in order to detect a body core temperature below 32°C and arrhythmia to pull the athlete out of the water before life-threatening circumstances occur.

[Change of body composition in an 81 year old runner in a 100 km run]

An 81-year-old runner completed successfully a 100-km-run within 19 h 45 min one year after coronary artery bypass surgery in recently diagnosed atherosclerotic coronary heart disease. Prior and shortly after the run, percent body fat, lean body mass, skeletal muscle mass and percent body water were determined non invasively both by the bioelectrical impedance analysis (BIA) and the traditional anthropometrical method. In addition, blood and urine samples were collected in order to evaluate fluid homeostasis. Proton nuclear magnetic resonance ((1)H-NMR) spectroscopy of the urine was performed in order to detect changes in metabolites of carbohydrate, fat and protein metabolism. Body mass increased by 1.9 kg, calculated skeletal muscle mass increased by 0.1 kg, calculated fat mass from anthropometric method decreased by 0.2 kg and from BIA by 3.1 kg. Calculated body water from BIA increased by 1.2 l and plasma volume decreased by 19%. Haematocrit, nitrogen urea, urinary specific gravity decreased whilst sodium increased. (1)H-NMR spectroscopy revealed an increase of ketone bodies after the run. To demonstrate a decrease of skeletal muscle mass after a 100-km-run, we should wait with the measurements of body masses until body water has reached pre race value. The increase of body water is unclear. In future studies, additional methods should be performed to provide information whether skeletal muscle mass decreased after endurance performance and whether metabolites of skeletal muscle mass degradation may impair renal function.

[The effect of a multi-stage ultra-endurance triathlon over ten times an iron-man-triathlon on fat mass and skeletal muscle mass--the world challenge deca iron 2006]

The present study investigated the change of body composition in 8 ultra-endurance triathletes during a multi-stage ultra-endurance triathlon, where athletes had to perform one Ironman distance over 3.8 km swimming, 180 km cycling and 42.2 km running per day for 10 consecutive days. In the only 8 male successful finishers, body mass, skin fold thicknesses and circumferences of extremities were measured pre and post race in order to calculate skeletal muscle mass, percent body fat and fat mass. Bioelectrical impedance analysis was performed at the same time to determine lean body mass, percent body fat and total body water. Body mass did not change (p > 0.05), whereas skeletal muscle mass statistically significantly decreased by 1.1 kg (p < 0.05) and fat mass significantly decreased by 0.9 kg (p < 0.05).

[Traumatic rupture of the triceps brachii tendon and ipsilateral Achilles tendon]

We report on a 71-year-old male farmer who sustained an injury to the tendons of the triceps brachii and the Achilles tendon on the left side. The diagnosis was based on clinical investigations and ultrasound. The triceps brachii tendon was repaired with open transosseous sutures. Six weeks after the operation we only allowed passive mobilization. The Achilles tendon rupture was treated with a semi-open procedure. Four weeks after the operation the ankle was fixed in 30 degrees plantar flexion, followed by 2 weeks in neutral position. Full weight bearing was allowed. Six months after the operation the patient no longer had any problems with his injury. Injuries of the tendon of the triceps brachii are very rare, with an incidence of 0.8%. We could not find case reports of a simultaneous injury to another tendon in the literature.

Upper arm circumference is associated with race performance in ultra-endurance runners

OBJECTIVE

To investigate the association of anthropometric parameters to race performance in ultra-endurance runners in a multistage ultra-endurance run.

DESIGN

Descriptive field study.

SETTING

The Deutschlandlauf 2006 race in Germany, where athletes had to run 1200 km within 17 consecutive days. There were no interventions.

SUBJECTS

In total, there were 19 male Caucasian ultra-endurance runners (mean (SD) 46.2 (9.6) years, 71.8 (5.2) kg, 179 (6) cm, BMI 22.5 (1.9) kg/m(2)).

MAIN OUTCOME MEASUREMENTS

Determination of body mass, body height, length of lower limbs, skin-fold thicknesses, circumference of limbs, body mass index (BMI), percentage skeletal muscle mass (%SM), and percentage body fat (%BF) in 19 successful finishers in order to correlate anthropometric parameters with running performance.

RESULTS

A significant association of upper arm circumference with the total running time was found (p<0.05, r2 = 0.26). No significant association was found with the directly measured anthropometric properties body height, body mass, average skin-fold thickness and the circumference of thigh and calf (p>0.05). Furthermore, no significant association was observed between the running time and the calculated parameters BMI, %BF, and %SM (p>0.05).

CONCLUSIONS

In an ultra-endurance run over 1200 km within 17 consecutive days, circumference of the upper arm was the only factor associated with performance in well-experienced ultra-endurance runners. Body mass, BMI, body height, length of limbs, skin-fold thicknesses, circumference of limbs and the calculated percentage body composition of skeletal muscle mass and body fat showed no association with running performance.

[Swimming for 12 hours leads to no reduction of adipose subcutaneous tissue--a case study]

In a 12-hour swimming event, an athlete with constant body weight lost 1.1 kg of muscle mass and 21 of total body fluids whereas fat mass remained stable. Based both on the urine's specific gravity and haematological parameters, the athlete did not suffer from dehydration. We assume that loss of skeletal muscle mass occurred due to degradation of intramyocellular lipids and muscle glycogen. In order to confirm these results obtained in a case study regarding the decrease of skeletal muscle mass with stable fat mass during prolonged swimming exercise, a larger number of athletes would have to be analyzed.

[12 hours running results in a decrease of the subcutaneous adipose tissue]

A runner has completed 80 km in a 12-hour run. Prior and shortly after the run, fat and skeletal muscle mass were determined non invasively both by the bioelectrical impedance analysis and the classic skin fold method. In addition, blood and urine samples were taken in order to assess fluid balance. By applying the bioelectrical impedance analysis, the runner has increased body mass by 1.5 kg, fat-free body mass by 4.2 kg and muscle mass by 1.0 kg, whereas fat mass decreased by 4.4 kg. Since body water increased by 4.9 l, the determination of haematocrit, haemoglobin and sodium showed a haemodilution and the specific gravity of urine indicated no dehydration, we assume a substantial decrease of subcutaneous adipose tissue for energy production and intracellular oedemas. The difference between determining fat mass with the skin fold method or with the bioelectrical impedance analysis is discussed.

Effects of a Deca Iron Triathlon on body composition: a case study

We investigated energy balance and change of body composition in one athlete in a multistage triathlon, the World Challenge Deca Iron Triathlon 2006, where athletes had to perform one Ironman triathlon of 3.8 km swimming, 180 km cycling and 42.195 km running per day for ten consecutive days. In one well-experienced male ultra-endurance triathlete, we measured body mass, skinfold thicknesses and perimeters of extremities, in order to calculate skeletal muscle mass, fat mass and percentage of body fat. Energy intake was measured by analysis of nutrition, and energy expenditure was calculated using a portable heart rate monitor. This was performed to quantify energy deficit. In addition, bio-impedance measurements were performed to determine fluid metabolism. The athlete finished the race in 128 hours, 22 minutes and 42 seconds in 3rd position. Body mass decreased by 1 kilogram, skeletal muscle mass decreased by 0.9 kilograms and calculated fat mass decreased by 0.8 kilograms. Total body water increased by 2.8 liters. Total energy expenditure for the Deca Iron was 89,112 kilocalories and a total energy deficit of 11,480 kilocalories resulted. We presume that energy deficit was covered by consumption of adipose subcutaneous tissue as well as skeletal muscle mass; the degradation of muscle mass seems to lead to hypoproteinemic edemas.

[A 12 hour indoor cycling marathon leads to a measurable decrease of adipose subcutaneous tissue]

In a 12 hour indoor cycling marathon, an athlete has lost 0.4 to 1.2 kg of body mass depending on the time of measurement. Fat mass has decreased by 0.9 kg independent of the time of measurement. Calculated skeletal muscle mass increased by 0.27 to 0.67 kg - depending on the time of measurement. Due to the specific weight of urine, a possibly minimum dehydration was objectified, whereas specific weight right after exercise and 24 h after exercise had the same value. We assume that there was a substantial loss of fat mass, since repeated measurements after exercise showed an increasingly lower body weight and a constantly lower fat mass after exercise independent of the time of measurement. Increase of calculated muscle mass is considered to be due to an intramuscular oedema. In order to confirm results obtained in a case study, a larger number of athletes would have to be analyzed. A possible oedema would have to be objectified by a bioelectrical impedance analysis.

Effect of a multistage ultra-endurance triathlon on body composition: World Challenge Deca Iron Triathlon 2006

OBJECTIVE

To investigate the effect of a multistage ultra-endurance triathlon on body composition in ultra-triathletes.

DESIGN

Descriptive field study.

SETTING

The "World Challenge Deca Iron Triathlon 2006" in Monterrey, Mexico, in which every day for 10 consecutive days athletes had to perform the distance of one Ironman triathlon.

SUBJECTS

Eight male ultra-endurance athletes (mean (SD) age 40.6 (10.7) years, weight 76.4 (8.4) kg, height 175 (4) cm and body mass index (BMI) 24.7 (2.2) kg/m2).

INTERVENTIONS

None.

MAIN OUTCOME MEASUREMENTS

Determination of body mass, protein mass, body fat, per cent body fat, mineral mass, total body water, intracellular water, extracellular water and lean body mass with a direct segmental multifrequency bioelectrical impedance method before the race and after each stage in order to show changes in body composition.

RESULTS

A statistically significant decrease of body mass (-2.4 kg, p = 0.014), body fat (-5 kg, p = 0.0078) and per cent body fat (-6.4%, p = 0.0078) occurred at the end of the first day compared to values taken in the pre-race period. In contrast, at the same time, a statistically significant increase of protein mass (+0.7 kg, p = 0.035), mineral mass (+0.2 kg, p = 0.04), total body water (+1.8 litres, p = 0.042), intracellular water (+1.6 litres, p = 0.034) and lean body mass (+2.6 kg, p = 0.023) was shown. After the first day until the end of the challenge, body fat (-3 kg, p>0.05) and per cent body fat (-3.9%, p>0.05) showed a statistically significant decrease, whereas the other parameters showed no changes.

CONCLUSIONS

Athletes taking part in a multistage ultra-endurance triathlon over 10 Ironman triathlon distances in 10 consecutive days lost 3 kg of body fat; skeletal muscle mass, mineral mass and body water were unchanged.

Inter-observer agreement of ultrasonographic measurement of alpha and beta angles and the final type classification based on the Graf method

BACKGROUND

The aim of our study was to investigate the agreement of the assessment of hip ultrasonograms by different observers.

METHODS

In the period from June 3rd to December 9th 2002, four different (by experience and field) groups of observers rated all first time sonograms obtained in our hospital. The results in terms of angle and type classification were compared.

RESULTS

158 ultrasonographic images were evaluated. The inter-observer agreement for the classification "normal" (type I) versus "abnormal" (types IIa+ to IV) varied from 83% to 90% with kappa coefficients which indicated moderate (kappa 0.55) to substantial (kappa 0.71) inter-observer agreement. For one pair of observers, a better agreement could be demonstrated for the assessment of immature hips than for mature ones. The deviation for the a-angle was 0 to 16 degrees with a standard deviation of 3.15 degrees (95% CI 2.95, 3.37), and for the b-angle 0 to 26 degrees with a standard deviation of 6.1 degrees (95% CI 5.7, 6.5). The intra-class correlation coefficient was estimated to be 0.72 and 0.34 for the alpha and beta angles respectively. If the hip was immature there was no increase in the discrepancy in assessment between observers. The least agreement existed between the less experienced and the most experienced. It has not been possible to make a statement on the discrepancy with regard to initial signs of instability or decentralization of the hip joints because of the small number of hips of this type.

CONCLUSIONS

Although the spread in measured a- and b-angles is large, the inter-observer agreement for the classification showed good results. No disagreement occurred in the diagnosis of normal vs. dysplastic hips, so no severe cases have been missed. The experience and training of the investigators seemed to play an important role with regard to variability and agreement. The agreement in the assessment of immature hips was better than that of mature hips. Therefore, ultrasound examination of infant hips would appear to be a trustworthy screening method.

[Epiphyseal dysplasia--symptoms and differential diagnostic aspects]

AIM

Children complaining of hip pain most likely suffer from Perthes' disease. Similar morphological changes are seen in the hereditary diseases of the epiphyseal dysplasias which have a prevalence of about 40 of 100 000 inhabitants. We now show the differentiation between bilateral Perthes' disease, epiphyseal dysplasia and skeletal disorders like mucopolysaccharidosis and pseudoachondroplasia.

METHOD

We describe the diseases of multiple epiphyseal dysplasia and spondyloepiphyseal dysplasia on the basis of two case reports. Furthermore, we discuss differential diagnostic aspects, therapeutic options and prognosis.

RESULTS

Epiphyseal dysplasias are classified as osteochondral dysplasia. The characteristic feature of these heredopathies is short statue due to skeletal dysplasias at various sites. Multiple epiphyseal dysplasia is caused by an abnormality of enchondral ossification. A distinction is made between the severe Fairbank form, the milder Ribbing form and a mild but rather localised Meyer form. In addition to the femoral head, the spinal bodies can also be affected by the same enchondral ossification disorders and this is defined as spondyloepiphyseal dysplasia.

CONCLUSION

The diagnosis of a Perthes' disease can be made from an X-ray of the hip, showing either an advanced necrosis of the femoral head or early signs of it. Typical radiological findings allow the differentiation to other skeletal dysplasias like epiphyseal dysplasia and metabolic disorders.

Inter-observer agreement of ultrasonographic measurement of alpha and beta angles and the final type classification based on the Graf method

BACKGROUND

The aim of our study was to investigate the agreement of the assessment of hip ultrasonograms by different observers.

METHODS

In the period from June 3rd to December 9th 2002, four different (by experience and field) groups of observers rated all first time sonograms obtained in our hospital. The results in terms of angle and type classification were compared.

RESULTS

158 ultrasonographic images were evaluated. The inter-observer agreement for the classification "normal" (type I) versus "abnormal" (types IIa+ to IV) varied from 83% to 90% with kappa coefficients which indicated moderate (kappa 0.55) to substantial (kappa 0.71) inter-observer agreement. For one pair of observers, a better agreement could be demonstrated for the assessment of immature hips than for mature ones. The deviation for the a-angle was 0 to 16 degrees with a standard deviation of 3.15 degrees (95% CI 2.95, 3.37), and for the b-angle 0 to 26 degrees with a standard deviation of 6.1 degrees (95% CI 5.7, 6.5). The intra-class correlation coefficient was estimated to be 0.72 and 0.34 for the alpha and beta angles respectively. If the hip was immature there was no increase in the discrepancy in assessment between observers. The least agreement existed between the less experienced and the most experienced. It has not been possible to make a statement on the discrepancy with regard to initial signs of instability or decentralization of the hip joints because of the small number of hips of this type.

CONCLUSIONS

Although the spread in measured a- and b-angles is large, the inter-observer agreement for the classification showed good results. No disagreement occurred in the diagnosis of normal vs. dysplastic hips, so no severe cases have been missed. The experience and training of the investigators seemed to play an important role with regard to variability and agreement. The agreement in the assessment of immature hips was better than that of mature hips. Therefore, ultrasound examination of infant hips would appear to be a trustworthy screening method.

Experiences in diagnosis and treatment of hip dislocation and dysplasia in populations screened by the ultrasound method of Graf

Ultrasound investigation of the hip according to Graf is performed, whenever possible, as a routine screening test for hip dysplasia and dislocation in neonates. However, in spite of screening, hip dysplasia and/or dislocation is identified in a number of children after the third month of life only. The present study presents an analysis of reasons and causes. Between August 1999 and July 2001 children aged between six months and five years were documented, in whom the diagnosis of hip dysplasia or dislocation was made, despite normal ultrasound findings at primary investigation and who required non operative or operative treatment by a specialist surgeon working in Switzerland in paediatric orthopaedics. The study included 26 children (17 girls / 9 boys). Hip dysplasia and/or dislocation was diagnosed between the age of 6 days and 41 months. Twelve children had to be excluded from the sample (n = 26), four were infants who had basic neurological disorders or multiple anomalies and there were eight children from abroad whose original documentation could not be obtained. Analysis of the remaining 14 children showed that 43% were misdiagnosed (n = 6) and a treatment error occurred in 36% (n = 5) of cases. One child presented with a teratogenic hip dislocation. In two other infants with normal primary ultrasound findings, hip dysplasia was identified radiographically once the child started to walk. Delayed diagnosis can be the result of technical errors or misinterpretation. The six patients meeting the criteria of misinterpretation can be expressed as a rate of 0.04% of all births. However, even if the disorder is correctly diagnosed, its identification and treatment may be inadequate or fail to produce the desired results. This was the case for five of the children, that is, for a rate of 0.03% of births.

Experiences in diagnosis and treatment of hip dislocation and dysplasia in populations screened by the ultrasound method of Graf

Ultrasound investigation of the hip according to Graf is performed, whenever possible, as a routine screening test for hip dysplasia and dislocation in neonates. However, in spite of screening, hip dysplasia and/or dislocation is identified in a number of children after the third month of life only. The present study presents an analysis of reasons and causes. Between August 1999 and July 2001 children aged between six months and five years were documented, in whom the diagnosis of hip dysplasia or dislocation was made, despite normal ultrasound findings at primary investigation and who required non operative or operative treatment by a specialist surgeon working in Switzerland in paediatric orthopaedics. The study included 26 children (17 girls / 9 boys). Hip dysplasia and/or dislocation was diagnosed between the age of 6 days and 41 months. Twelve children had to be excluded from the sample (n = 26), four were infants who had basic neurological disorders or multiple anomalies and there were eight children from abroad whose original documentation could not be obtained. Analysis of the remaining 14 children showed that 43% were misdiagnosed (n = 6) and a treatment error occurred in 36% (n = 5) of cases. One child presented with a teratogenic hip dislocation. In two other infants with normal primary ultrasound findings, hip dysplasia was identified radiographically once the child started to walk. Delayed diagnosis can be the result of technical errors or misinterpretation. The six patients meeting the criteria of misinterpretation can be expressed as a rate of 0.04% of all births. However, even if the disorder is correctly diagnosed, its identification and treatment may be inadequate or fail to produce the desired results. This was the case for five of the children, that is, for a rate of 0.03% of births.