Antibiotic prescribing in patients with COVID-19: rapid review and meta-analysis

BackgroundThe proportion of patients infected with SARS-CoV-2 that are prescribed antibiotics is uncertain, and may contribute to patient harm and global antibiotic resistance.ObjectiveThe aim was to estimate the prevalence and associated factors of antibiotic prescribing in patients with COVID-19.Data SourcesWe searched MEDLINE, OVID Epub and EMBASE for published literature on human subjects in English up to June 9 2020.Study Eligibility CriteriaWe included randomized controlled trials; cohort studies; case series with ≥10 patients; and experimental or observational design that evaluated antibiotic prescribing.ParticipantsThe study participants were patients with laboratory-confirmed SARS-CoV-2 infection, across all healthcare settings (hospital and community) and age groups (paediatric and adult).MethodsThe main outcome of interest was proportion of COVID-19 patients prescribed an antibiotic, stratified by geographical region, severity of illness and age. We pooled proportion data using random effects meta-analysis.ResultsWe screened 7469 studies, from which 154 were included in the final analysis. Antibiotic data were available from 30 623 patients. The prevalence of antibiotic prescribing was 74.6% (95% CI 68.3–80.0%). On univariable meta-regression, antibiotic prescribing was lower in children (prescribing prevalence odds ratio (OR) 0.10, 95% CI 0.03–0.33) compared with adults. Antibiotic prescribing was higher with increasing patient age (OR 1.45 per 10 year increase, 95% CI 1.18–1.77) and higher with increasing proportion of patients requiring mechanical ventilation (OR 1.33 per 10% increase, 95% CI 1.15–1.54). Estimated bacterial co-infection was 8.6% (95% CI 4.7–15.2%) from 31 studies.ConclusionsThree-quarters of patients with COVID-19 receive antibiotics, prescribing is significantly higher than the estimated prevalence of bacterial co-infection. Unnecessary antibiotic use is likely to be high in patients with COVID-19.     

Effectiveness of the Cobb–Stainsby excision arthroplasty

Background

Dislocated metatarsophalangeal joints from clawed or hammer toes can be a disabling consequence of several conditions. The Cobb–Stainsby forefoot arthroplasty combines partial phalangectomy (Stainsby) with extensor tendon transfer to the metatarsal head (Cobb). We present a retrospective, three surgeon case series of 215 toes in 126 patients.

The angiogenic factor platelet-derived endothelial cell growth factor/thymidine phosphorylase is up-regulated in breast cancer epithelium and endothelium.

Tumour angiogenesis is a complex multistep process regulated by a number of angiogenic factors. One such factor, platelet-derived endothelial cell growth factor has recently been shown to be thymidine phosphorylase (TP). TP catalyses the reversible phosphorylation of thymidine to deoxyribose-1-phosphate and thymine. Although known to be generally elevated in tumours, the expression of this enzyme in breast carcinomas is unknown. Therefore, we used ribonuclease protection assays and immunohistochemistry to examine the expression of TP in 240 primary breast carcinomas. Nuclear and/or cytoplasmic TP expression was observed in the neoplastic tumour epithelium in 53% of tumours. Immunoreactivity was also often present in the stromal, inflammatory and endothelial cell elements. Although endothelial cell staining was usually focal, immunoreactivity was observed in 61% of tumours and was prominent at the tumour periphery, an area where tumour angiogenesis is most active. Tumour cell TP expression was significantly inversely correlated with grade (P = 0.05) and size (P = 0.003) but no association was observed with other tumour variables. These findings suggest that TP is important for remodelling the existing vasculature early in tumour development, consistent with its chemotactic non-mitogenic properties, and that additional angiogenic factors are more important for other angiogenic processes like endothelial cell proliferation. Relapse-free survival was higher in node-positive patients with elevated TP (P = 0.05) but not in other patient groups. This might be due to the potentiation of chemotherapeutic agents like methotrexate by TP. Therefore, this enzyme might be a prediction marker for response to chemotherapy.     

Apoptosis in the myelodysplastic syndromes

Myelodysplastic syndromes (MDS) are neoplastic dyscrasias characterized by peripheral cytopenia, despite a normocellular or hypercellular bone marrow. In the past decade, it has become apparent that this ineffective hemopoiesis is largely caused by excessive apoptosis of myeloid precursors. There is no evidence for gain-of-function mutations within the apoptotic machinery in MDS. It appears that the apoptosis is a reactive phenomenon fueled by cytokines. The provoking stimulus for the proapoptotic intramedullary milieu in MDS is unknown. The evolution of MDS from early relatively chronic to aggressive and frankly leukemic phenotype is accompanied by a suppression of apoptosis. This metamorphosis correlates with changes in intracellular levels of Bcl-2-family proteins, but the genetic basis for this shift has not been elucidated clearly. Expression profiling and proteomic technologies may offer the best means to unravel this process.     

Developing a new wound care formulary and guidelines

Following an audit of the existing wound care formulary and guidelines, an updated version was developed, containing additional products and information. This was revised following advice from a range of professionals, then pilot tested on ward-based nurses. The nurses found the updated formulary useful, and made recommendations for changes to the wound care ordering system in the trust. Future guidelines will be regularly updated as developments in wound care occur.     

Oral Absorption of Peptides Through the Cobalamin (Vitamin B12) Pathway in the Rat Intestine

Purpose. This study was aimed at examining the extent and mechanismof uptake of cobalamin (Cbl)-conjugated peptides in vitro and in vivo. Methods. To enable acquisition of quantitative absorption data ofCbl-peptides, metabolically stable octapeptides (DP3), with (Cbl-Hex-DP3)or without a hexyl spacer (Cbl-DP3), were coupled to Cbl andradiolabeled. For comparison, LHRH coupled to Cbl was used as metabolicallysusceptible peptide. Biological recognition of Cbl-peptides was studiedin the physiological order: binding by Intrinsic Factor (IF), recognitionand transport of the IF-complexes by IF-Cbl receptors (IFCR) onCaco-2 monolayers and oral absorption of the Cbl-conjugates in the rat. Results. All Cbl-peptides bound to IF and the IF-complexes wererecognized by IFCR receptors on Caco-2 monolayers. Binding wassaturable and could be inhibited by a 20-fold excess of IF-Cbl, but notof Non-intrinsic Factor (NIF)-Cbl. Oral administration of these ligandsto rats resulted in absorption of 53%, 45%, 42%, and 23% of theapplied radioactivity for Cbl, Cbl-LHRH, Cbl-Hex-DP3, and Cbl-DP3,respectively. Simultaneous administration of a >10⁵-fold excess ofunlabeled Cbl reduced uptake of all compounds to <4%. Tissuedistribution and elimination of the metabolically stable Cbl-conjugates werecomparable to Cbl. Conclusions. The endogenous Cbl uptake pathway can be exploitedfor oral peptide delivery as indicated by the specific and high (40–45%)uptake of metabolically stable Cbl-coupled octapeptides.Deceased     

Transition from paediatric to adult care for persons with cystic fibrosis: patient and parent perspectives

OBJECTIVES: To gauge the perspectives of adolescents and adults with cystic fibrosis (CF) and their parents regarding the transition from paediatric to adult-oriented health care. METHODS: Cross-sectional survey using an anonymous, semi-structured questionnaire. The study population consisted of adolescents and adults attending a paediatric and an adult CF clinic in Cape Town, South Africa and their parents. RESULTS: Forty-seven of the 61 subjects completed the questionnaire (response rate 77%). Autonomy in health care was 'extremely important' to most persons with CF. Transfer at the age of 16-18 years of age was the preferred option for most respondents. Whereas over 80% of parents felt their children needed more CF-related information, only 38% of adolescents expressed this need (P < 0.05). Adolescents also reported little need for general health information. More than 80% of respondents were 'unsure' about transfer. Over 90% felt that a transition clinic would be useful. As viewed by the respondents, its main purpose would be to provide information about the adult clinic and an opportunity to meet the CF doctor in the adult clinic. CONCLUSION: There are significant concerns about the transition process in this population. Given the expressed need for autonomy and a transition clinic, the basis for a smoother transition in the future has been laid.     

Shortcomings of the National Joint Registry: a survey of consultants' views

INTRODUCTION: The National Joint Registry (NJR) for England and Wales was launched in April 2003. The UK Department of Health (DoH) awarded the contract to run the NJR to Atomic Energy Authority (AEA) Technology in September 2002. The aim was to etablish the views of a large group of orthopaedic consultants on the new NJR. METHODS: A questionnaire was sent by post to 405 orthopaedic consultants in the Midlands and South West. RESULTS: Overwhelming support was found for the idea of a national joint replacement register that is used for peer-run audit. However, there was wide-spread concern about the lack of orthopaedic representation on the steering committee. The majority of surgeons have concerns about the possible use of NJR data for the production of league tables.