Disseminated orbital actinomycetoma: A case report

Mycetoma is a chronic granulomatous infection. Lower extremities are commonly involved. A 20-year-old male came with complaints of multiple sinuses on scalp, left eyelid swelling with a sinus and dystopia, since one year. On examination there was relative proptosis in left eye of 2 mm. Computed tomography scan showed soft tissue swelling of the pre-septal area of the left upper eyelid with orbital involvement. Magnetic resonance imaging showed increased left orbital volume and evident dystopia. Microbiology testing of the erosive scalp and lid lesions showed genus Nocardia, suggestive of actinomycetoma. This case is presented as it shows an unusual involvement of the orbit.     

Successes and Challenges of Interprofessional Physiologic Birth and Obstetric Emergency Simulations in a Nurse‐Midwifery Education Program

This article describes childbirth simulation design and implementation within the nurse‐midwifery education program at the University of California, San Francisco. Nurse‐midwife and obstetrician faculty coordinators were supported by faculty from multiple professions and specialties in curriculum review and simulation development and implementation. The primary goal of the resulting technology‐enhanced simulations of normal physiologic birth and obstetric emergencies was to assist learners’ development of interprofessional competencies related to communication, teamwork, and patient‐centered care. Trainees included nurse‐midwifery students; residents in obstetrics, pediatrics, and family medicine; medical students; and advanced practice nursing students in pediatrics. The diversity of participant types and learning levels provided benefits and presented challenges to effective scenario‐based simulation design among numerous other theoretical and logistical considerations. This project revealed practical solutions informed by emerging health sciences and education research literature, faculty experience, and formal course evaluations by learners. Best practices in simulation development and implementation were incorporated, including curriculum revision grounded in needs assessment, case‐ and event‐based clinical scenarios, optimization of fidelity, and ample time for participant debriefing. Adequate preparation and attention to detail increased the immersive experience and benefits of simulation. Suggestions for fidelity enhancement are provided with examples of simulation scenarios, a timeline for preparations, and discussion topics to facilitate meaningful learning by maternity and newborn care providers and trainees in clinical and academic settings. Pre‐ and postsimulation measurements of knowledge, skills, and attitudes are ongoing and not reported. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.     

Repeated systematic surveillance of Kawasaki disease in Ontario from 1995 to 2006

Background: Rising incidences of Kawasaki disease (KD) have been reported worldwide. Reported herein are the results of 4 triennial KD surveillances conducted in Ontario. Methods: Between 1995 and 2006 all hospitals in Ontario were asked on 4 occasions to identify all patients with discharge diagnoses of KD and report incident cases. Results: The latest surveillance identified 697 new KD patients (100% response rate) for a total of 2378 KD patients through all 4 surveillances. Yearly incidence was 26.2/100 000 for <5 years old, 6.7/100 000 for 5–9 years old and 0.9/100 000 for 10–14 years old. KD incidence significantly increased from 1995 to 2006, although the increase seemed to plateau between the 3rd and 4th surveillance. There was an increase in the proportion of patients diagnosed with incomplete KD and a significant reduction in the rate of coronary artery abnormalities, possibly due to better disease recognition and treatment. Hospitals reporting <20 cases per surveillance were found to be more likely to report cases with incomplete KD. These patients were also less likely to be treated with i.v. immunoglobulin and aspirin but were more likely to be treated with antibiotics, suggesting uncertainties regarding diagnosis and management of KD patients in those centers. Conclusions: The incidence of KD in Ontario is possibly one of the highest outside of Asia and has been rising since 1995. Although the most recent surveillance demonstrated improved cardiac outcomes, treatment delays or absence thereof continue to be a problem. Effective diagnosis and prompt treatment remain critical aspects of KD management.     

The influence of excipients on physical and pharmaceutical properties of oral lyophilisates containing a pregabalin-acetaminophen combination

Objectives: The purpose of the study was to investigate and characterize the oral lyophilisates containing the pregabalin-acetaminophen drug combination and as xcipients mannitol with microcrystalline cellulose or hydroxypropyl methylcellulose, in order to conclude upon drug-excipient interactions and their stability implications, impact of excipients on drug release and on the physicochemical and mechanical properties of the pharmaceutical formulations.

Methods: The oral tablets were made by using a Christ freeze-dryer alpha 2–4-LSC lyophilizer, and evaluated for stability, drug-excipient compatibility and homogeneity of the prepared pharmaceutical formulations. The formulations were evaluated for in vivo absorption in rabbits by histopathological exams.

Results: FTIR and thermogravimetric analyses, DLS technique, SEM and NIR-CI studies confirmed the compatibility between compounds. From the determined physical and biochemical parameters of the formulations it was established that they are stable, homogeneous, and meet the conditions for orally disintegrating tablets.

Conclusion: In the case of the investigated pharmaceutical formulations the study evidenced the assembling through physical bonds between the excipients and the ‘codrug’ complex, which do not affect the release of the bioactive compounds.     

Aclidinium bromide and formoterol fumarate for the maintenance treatment of chronic obstructive pulmonary disease

ABSTRACT

Introduction: Treatment options for COPD have evolved rapidly in the last decade and inhaled bronchodilators have largely supplanted the use of oral bronchodilators because of their increased efficacy and excellent safety with topical delivery to the lung. Recently added to the therapeutic armamentarium are fixed-dose combinations (FDC) of two long acting bronchodilators. LAMAs (long acting muscarinic antagonists) and LABAs (long acting beta agonists) are the main classes available and use different pathways to effectively produce bronchial smooth muscle relaxation.

Areas covered: The most recent inhaled FDC LAMA/LABA to come to market is Aclidinium Bromide and Formoterol Fumarate. We searched databases of PubMed, Cochrane Library, and manufacturers’ websites and retrieved all the randomized-controlled trials (RCTs) conducted with these drugs up to September 2019.

Expert opinion: It is likely that FDCs will become the core of our COPD pharmacotherapy for all but the mildest COPD patients. These individual drugs have excellent efficacy and safety records for the maintenance treatment of COPD. Studies have demonstrated that twice daily treatment with aclidinium/formoterol resulted in significant improvement in lung function and an improved exercise tolerance when compared to placebo. Adverse effects are within the range of what is seen with other LAMA/LABA combinations.     

The evolving role of the personal support worker in home care in Ontario,Canada

To meet increasing demand for home care, the role of personal support workers (PSWs) is shifting from providing primarily personal and supportive care to include care activities previously provided by regulated health professionals (RHPs). Much of the research examining this shift focuses on specialty programmes, with few studies investigating the daily care being provided by PSWs, frequency of care activities being provided by PSWs, and characteristics of the population receiving more complex tasks. Between January and April 2015, a review of 517 home‐care service user charts was undertaken in Ontario, Canada, to: (1) describe the range of tasks being performed by PSWs in home care, (2) identify tasks transferred by RHPs to PSWs, and (3) examine characteristics of service users receiving transferred care. Findings indicate that normally, PSWs provide personal and supportive care commensurate with their training. However, in approximately one quarter of care plans reviewed, PSWs also completed more complex care activities transferred to them by RHPs. Service users receiving transferred care were older and had higher levels of cognitive and functional impairment. Although there is potential for the expansion of home‐care services through increased utilisation of PSWs, healthcare leadership must ensure that the right provider is being utilised at the right time and in the right place to ensure safe and effective quality care. Thus, several actions are recommended: PSW core competencies be clearly articulated, processes used to transfer care activities from RHPs to PSWs be standardised and a team‐based approach to the delivery of home‐care services be considered. Utilisation of a team‐based model can help establish positive relationships among home‐care providers, provide increased support for PSWs, allow for easier scheduling of initial training and ensure regular reassessments of PSW competence among PSWs providing added skills.     

Investigation of Clinical Pharmacokinetic Variability of an Opioid Antagonist Through Physiologically Based Absorption Modeling

Identifying the source of inter- and/or intrasubject variability in pharmacokinetics (PK) provides fundamental information in understanding the pharmacokinetics-pharmaco- dynamics relationship of a drug and project its efficacy and safety in clinical populations. This identification process can be challenging given that a large number ofpotential causes could lead to PK variability. Here we present an integrated approach of physiologically based absorption modeling to investigate the root cause of unexpectedly high PK variability of a Phase I clinical trial drug. LY2196044 exhibited high intersubject variability in the absorption phase of plasma concentration-time profiles in humans. This could not be explained by in vitro measurements of drug properties and excellent bioavailability with low variability observed in preclinical species. GastroPlus? modeling suggested that the compound’s optimal solubility and permeability characteristics would enable rapid and complete absorption in preclinical species and in humans. However, simulations of human plasma concentration-time profiles indicated that despite sufficient solubility and rapid dissolution of LY2196044 in humans, permeability and/or transit in the gastrointestinal (GI) tract may have been negatively affected. It was concluded that clinical PK variability was potentially due to the drug’s antagonism on opioid receptors that affected its transit and absorption in the GI tract.     

Detection and source tracking of Escherichia coli,harboring intimin and Shiga toxin genes,isolated from the Little Bighorn River,Montana

The Little Bighorn River flows through the Crow Indian Reservation in Montana. In 2008, Escherichia coli concentrations as high as 7179 MPN/100 ml were detected in the river at the Crow Agency Water Treatment Plant intake site. During 2008, 2009, and 2012, 10 different serotypes of E. coli, including O157:H7, harboring both intimin and Shiga toxin genes were isolated from a popular swim site of the Little Bighorn River in Crow Agency. As part of a microbial source tracking study, E. coli strains were isolated from river samples as well as from manure collected from a large cattle feeding operation in the upper Little Bighorn River watershed; 23% of 167 isolates of E. coli obtained from the manure tested positive for the intimin gene. Among these manure isolates, 19 were identified as O156:H8, matching the serotype of an isolate collected from a river sampling site close to the cattle feeding area.     

What's the diagnosis? Organisational culture and palliative care delivery in residential aged care in New Zealand

Organisational culture has been shown to impact on resident outcomes in residential aged care (RAC). This is particularly important given the growing number of residents with high palliative care needs. The study described herein (conducted from January 2013 to March 2014) examined survey results from a convenience sample of 46 managers, alongside interviews with a purposively selected sample of 23 bereaved family members in order to explore the perceptions of organisational culture within New Zealand RAC facilities in one large urban District Health Board. Results of the Organisational Culture Assessment Instrument (OCAI) completed by managers indicated a preference for a ‘Clan’ and the structured ‘Hierarchy’ culture. Bereaved family interviews emphasised both positive and negative aspects of communication, leadership and teamwork, and relationship with residents. Study results from both managers’ OCAI survey scores and next of kin interviews indicate that while the RAC facilities are culturally oriented towards providing quality care for residents, they may face barriers to adopting organisational processes supportive of this goal.     

Use of multiple opportunities for improving feeding practices in under-twos within child health programmes

Objectives: In a community randomized trial, we aimed to promoteexclusive breastfeeding and appropriate complementary feedingpractices in under-twos to ascertain the feasibility of usingavailable channels for nutrition counselling, their relativeperformance and the relationship between intensity of counsellingand behaviour change. We also assessed whether using multipleopportunities to impart nutrition education adversely affectedroutine activities. Methods: We conducted a community randomized, controlled effectivenesstrial in rural Haryana, India, with four intervention and fourcontrol communities. We trained health and nutrition workersin the intervention communities to counsel mothers at multiplecontacts on breastfeeding exclusively for 6 months and on appropriatecomplementary feeding practices thereafter. The interventionwas not just training health and nutrition workers in counsellingbut included community and health worker mobilization. Findings: In the intervention group, about 32% of caregiverswere counselled by traditional birth attendants at birth. Themost frequent sources of counselling from birth to 3 monthswere immunization sessions (45.1%) and home visits (32.1%),followed closely by weighing sessions (25.5%); from 7 to 12months, home visits (42.6%) became more important than the othertwo. An increase in the number of channels through which caregiverswere counselled was positively associated with exclusive breastfeedingprevalence at 3 months (p = 0.002), consumption of milk/cerealgruel or mix use at 9 months (p = 0.004) and 18 months (p =0.003), undiluted milk at 9 months (p<0.0001) and 24 hournon-breast-milk energy intakes at 18 months (p = 0.023), aftercontrolling for potential confounding factors. Interventionareas, compared with the control, had higher coverage for vitaminA (45% vs. 11.5%) and iron folic acid (45% vs. 0.4%) supplementation. Conclusions: Using multiple available opportunities and workersfor counselling caregivers was feasible, resulted in high coverageand impact, and instead of disrupting ongoing services, resultedin their improvement.