Clinical insights into appropriate choice of antimicrobials for acute respiratory tract infections

BACKGROUND AND OBJECTIVES

Australia has relatively high rates of antibiotic prescribing in the community. The aim of this study was to identify clinical insights regarding antibiotic prescribing choices for the management of common upper respiratory tract infections through analysis of anonymised primary care electronic medical records (EMRs).

METHOD

EMR data relating to 1926 antimicrobial prescriptions for tonsillitis, pharyngitis and acute rhinosinusitis in adults and acute otitis media (AOM) in children were extracted from 11 general practices in Victoria and analysed for consistency with Australian Therapeutic Guidelines recommendations.

RESULTS

The analysis suggests that underdosing of amoxicillin for AOM in children, prescription of phenoxymethylpenicillin at doses not consistent with Therapeutic Guidelines recommendations for tonsillitis and pharyngitis in adults, and potential overprescription of antibiotics for patients with acute rhinosinusitis are not infrequent in general practice.

DISCUSSION

Anonymised EMR data provide an opportunity to analyse antibiotic prescribing practices at scale and provide insights relevant to clinical practice.

Evaluating the Implementation of a Pilot Quality Improvement Program to Support Appropriate Antimicrobial Prescribing in General Practice

Inappropriate antimicrobial prescribing contributes to increasing antimicrobial resistance. An antimicrobial stewardship (AMS) program in the form of quality improvement activities that included audit and feedback, clinical decision support and education was developed to help optimise prescribing in general practice. The aim of this study was to evaluate the implementation of this program (Guidance GP) in three general practices in Melbourne, Australia, between November 2019 and August 2020. Thirty-one general practitioners (GPs) participated in the program, with 11 GPs and three practice managers participating in follow-up focus groups and interviews to explore the acceptability and feasibility of the program. Our findings showed that the quality improvement activities were acceptable to GPs, if they accurately fit GPs' decision-making process and workflow. It was also important that they provided clinically meaningful information in the form of audit and feedback to GPs. The time needed to coordinate the program, and costs to implement the program were some of the potential barriers identified. Facilitators of success were a "whole of practice" approach with enthusiastic GPs and practice staff, and an identified practice champion. The findings of this research will inform implementation strategies for both the Guidance GP program and AMS programs more broadly in Australian general practice, which will be critical for general practice participation and engagement.

Review article: novel oral-targeted therapies in inflammatory bowel disease

BACKGROUND

There is a great unmet clinical need for efficacious, tolerable, economical and orally administrated drugs for the treatment of inflammatory bowel disease (IBD). New therapeutic avenues have become possible including the development of medications that target specific genetic pathways found to be relevant in other immune mediated diseases.

AIMS

To provide an overview of recent clinical trials for new generation oral targeted medications that may have a future role in IBD management.

METHODS

Pubmed and Medline searches were performed up to 1 March 2018 using keywords: "IBD", "UC", "CD", "inflammatory bowel disease" "ulcerative colitis", "Crohn's disease" in combination with "phase", "study", "trial" and "oral". A manual search of the clinical trial register, article reference lists, abstracts from meetings of Digestive Disease Week, United European Gastroenterology Week and ECCO congress were also conducted.

RESULTS

In randomised controlled trials primary efficacy endpoints were met for tofacitinib (JAK 1/3 inhibitor-phase III), upadacitinib (JAK 1 inhibitor-phase II) and AJM300 (α4-integrin antagonist-phase II) in ulcerative colitis. Ozanimod (S1P receptor agonist-phase II) also demonstrated clinical remission. For Crohn's disease, filgotinib (JAK1 inhibitor-phase II) met primary endpoints and laquinimod (quinolone-3-carboxide small molecule-phase II) was also efficacious. Trials using mongersen (SMAD7 inhibitor) and vidofludimus (dihydroorotate dehydrogenase inhibitor) have been halted.

CONCLUSIONS

This is potentially the start of an exciting new era in which multiple therapeutic options are at the disposal of physicians to treat IBD on an individualised basis. Head-to-head studies with existing treatments and longer term safety data are needed for this to be possible.

Detection of Paralytic Shellfish Toxins in Mussels and Oysters Using the Qualitative Neogen Lateral-Flow Immunoassay: An Interlaboratory Study

Paralytic shellfish toxins (PSTs) in bivalve molluscs represent a public health risk and are controlled via compliance with a regulatory limit of 0.8 mg saxitoxin (STX)⋅2HCl equivalents per kilogram of shellfish meat (eq/kg). Shellfish industries would benefit from the use of rapid immunological screening tests for PSTs to be used for regulation, but to date none have been fully validated. An interlaboratory study involving 16 laboratories was performed to determine the suitability of the Neogen test to detect PSTs in mussels and oysters. Participants performed the standard protocol recommended by the manufacturer and a modified protocol with a conversion step to improve detection of gonyautoxin 1&4. The statistical analysis showed that the protocols had good homogeneity across all laboratories, with satisfactory repeatability, laboratory, and reproducibility variation near the regulatory level. The mean probability of detection (POD) at 0.8 mg STX⋅2HCl eq/kg using the standard protocol in mussels and oysters was 0.966 and 0.997, respectively, and 0.968 and 0.966 using the modified protocol. The estimated LOD in mussels was 0.316 mg STX⋅2HCl eq/kg with the standard and 0.682 mg STX⋅2HCl eq/kg with the modified protocol, and 0.710 and 0.734 mg STX⋅2HCl eq/kg for oysters, respectively. The Neogen test may be acceptable for regulatory purposes for oysters in accordance with European Commission directives in which the standard protocol provides, at the regulatory level, a probability of a negative response of 0.033 on 95% of occasions. Its use for mussels is less consistent at the regulatory level due to the wide prediction interval around the POD.

Customisable 3D printed microfluidics for integrated analysis and optimisation

The formation of smart Lab-on-a-Chip (LOC) devices featuring integrated sensing optics is currently hindered by convoluted and expensive manufacturing procedures. In this work, a series of 3D-printed LOC devices were designed and manufactured via stereolithography (SL) in a matter of hours. The spectroscopic performance of a variety of optical fibre combinations were tested, and the optimum path length for performing Ultraviolet-visible (UV-vis) spectroscopy determined. The information gained in these trials was then used in a reaction optimisation for the formation of carvone semicarbazone. The production of high resolution surface channels (100-500 μm) means that these devices were capable of handling a wide range of concentrations (9 μM-38 mM), and are ideally suited to both analyte detection and process optimisation. This ability to tailor the chip design and its integrated features as a direct result of the reaction being assessed, at such a low time and cost penalty greatly increases the user's ability to optimise both their device and reaction. As a result of the information gained in this investigation, we are able to report the first instance of a 3D-printed LOC device with fully integrated, in-line monitoring capabilities via the use of embedded optical fibres capable of performing UV-vis spectroscopy directly inside micro channels.

Differential binding and internalization of Clostridium difficile toxin A by human peripheral blood monocytes, neutrophils and lymphocytes

Colitis due to Clostridium difficile infection is mediated by secreted toxins A and B and is characterized by infiltration by cells from the systemic circulation. The aim of our study was to investigate interactions between fluorescently labelled toxin A and peripheral blood monocytes, neutrophils and lymphocytes. Purified toxin A was labelled with Alexa Fluor® 488 (toxin A(488)) and incubated with isolated human peripheral blood mononuclear cells or washed whole blood cells for varying time intervals at either 37 or 4 °C/ice. The ability of trypan blue to quench cell surface-associated (but not cytoplasmic) fluorescence was also investigated. At 37 °C, toxin A(488) -associated fluorescence in monocytes peaked at 1 h (majority internalized), with subsequent loss associated with cell death. In contrast to monocytes, binding of toxin A(488) in neutrophils was greater on ice than at 37 °C. Studies using trypan blue suggested that over 3 h at 37 °C, most of the toxin A(488)-associated fluorescence in neutrophils remained at the cell surface. Over 48 h (37 °C and ice/4 °C), there was minimal toxin A(488)-associated fluorescence in lymphocytes. These studies suggest major differences in interactions between toxin A and circulating cells that infiltrate the mucosa during colonic inflammation in C. difficile infection.

The clinical spectrum of Lyme neuroborreliosis

Lyme disease is a multisystem infectious disease, endemic in parts of Europe, including the West of Ireland. Neurological manifestions (neuroborreliosis) are variable. Presenting neurological syndromes include meningitis, cranial neuropathies, myeloradiculitis and mononeuritis multiplex. A lack of specificity in serological diagnosis may add to diagnostic confusion. We reviewed thirty cases of acute Lyme disease in the West of Ireland and found neurological syndromes in 15 (50%), with painful radiculopathy (12 patients; 80%) and cranial neuropathy (7 patients; 46%) occurring frequently. Neuroborreliosis needs to be considered in the differential diagnosis of these neurological syndromes in the appropriate clinical context.

Collaborative text-annotation resource for disease-centered relation extraction from biomedical text

Agglomerating results from studies of individual biological components has shown the potential to produce biomedical discovery and the promise of therapeutic development. Such knowledge integration could be tremendously facilitated by automated text mining for relation extraction in the biomedical literature. Relation extraction systems cannot be developed without substantial datasets annotated with ground truth for benchmarking and training. The creation of such datasets is hampered by the absence of a resource for launching a distributed annotation effort, as well as by the lack of a standardized annotation schema. We have developed an annotation schema and an annotation tool which can be widely adopted so that the resulting annotated corpora from a multitude of disease studies could be assembled into a unified benchmark dataset. The contribution of this paper is threefold. First, we provide an overview of available benchmark corpora and derive a simple annotation schema for specific binary relation extraction problems such as protein-protein and gene-disease relation extraction. Second, we present BioNotate: an open source annotation resource for the distributed creation of a large corpus. Third, we present and make available the results of a pilot annotation effort of the autism disease network.

Comparative analysis of neurological disorders focuses genome-wide search for autism genes

The behaviors of autism overlap with a diverse array of other neurological disorders, suggesting common molecular mechanisms. We conducted a large comparative analysis of the network of genes linked to autism with those of 432 other neurological diseases to circumscribe a multi-disorder subcomponent of autism. We leveraged the biological process and interaction properties of these multi-disorder autism genes to overcome the across-the-board multiple hypothesis corrections that a purely data-driven approach requires. Using prior knowledge of biological process, we identified 154 genes not previously linked to autism of which 42% were significantly differentially expressed in autistic individuals. Then, using prior knowledge from interaction networks of disorders related to autism, we uncovered 334 new genes that interact with published autism genes, of which 87% were significantly differentially regulated in autistic individuals. Our analysis provided a novel picture of autism from the perspective of related neurological disorders and suggested a model by which prior knowledge of interaction networks can inform and focus genome-scale studies of complex neurological disorders.

Recent advances in Clostridium difficile-associated disease

The main purpose of this article is to review recent developments in the management of acute and recurrent Clostridium difficile-associated disease, with consideration of existing and new antibiotic and non-antibiotic agents for treatment. Details of the current developmental stage of new agents are provided and the role of surgery in the management of severe disease is discussed. Infection control measures considered comprise prudent use of antimicrobials, prevention of cross-infection and surveillance. Other topics that are covered include the recent emergence of an epidemic hypervirulent strain, pathogenesis, clinical presentation and approaches to rapid diagnosis and assessment of the colonic disease.

Principles of management of basal and squamous cell carcinoma of the skin

There are a number of options available to the physician for the primary management of basal cell and squamous cell carcinoma of the skin. The most commonly used treatment modalities are primary resection, radiation therapy, and Mohs' micrographic surgery. Although each of these modalities can be used to treat most skin cancers in a variety of settings, each of these forms of cancer treatment is more appropriate in some settings and less appropriate in others. The role of each mode of therapy is discussed, based on effectiveness for cure, short and long term side effects, and cost of treatment. The appropriate role of the physician treating skin carcinoma is to choose the most effective treatment based on the above criteria and not to make the tumor fit any particular treatment modality.

Elevated pulmonary vascular resistance in patients dying from multiple organ failure

Twenty-one patients with multiple organ failure were studied with hemodynamic monitoring. The five survivors were compared with the 16 nonsurvivors. Significant differences were found in the cardiac index (CI), the left ventricular stroke work index (LVSWI), and the pulmonary vascular resistance index (PVRI). The CI was higher in survivors (4.38 +/- 1.71) than in nonsurvivors (3.43 +/- 1.49). The LVSWI was also higher (43.0 +/- 16.8, 28.7 +/- 12.8) than in nonsurvivors (47.4 +/- 2.91). The PVRI was lower in survivors (168 +/- 122) than in nonsurvivors (474 +/- 291). It is postulated that the elevated PVRI in MOF is related to the adult respiratory distress syndrome.

Delayed-onset pulmonary insufficiency in primates resuscitated from hemorrhagic shock

Forty-one unanesthetized cynomolgus monkeys were subjected to 2 hours of hemorrhagic hypotension at various mean arterial pressures (MAP) between 40 and 60 mm Hg. Resuscitation and maintenance of MAP were provided by lactated Ringer's solution and homologous blood. Thirty-eight per cent (57% of those surviving greater than 24 hours) developed a delayed-onset (18 to 24 hours) pulmonary insufficiency in spite of good urinary output, and which did not respond to furosemide. The group in which this caused death (24%) showed significantly decreased PaO2, PaCO2, dynamic compliance, and FECO2, and increased minute volume, Qs/Qt, pulmonary artery pressure, and VD/VT before death. Their lungs were heavier, with abnormal pressure/volume curves and increased minimum surface tension. During the entire post-resuscitation phase, this group remained in a high-output, low-resistance hemodynamic state in contract to survivors and those dying of shock. The implications regarding current practices of monitoring and resuscitating patients with traumatic shock are discussed.