Contemporary Drug Treatment of Infective Endocarditis

Infective endocarditis (IE) occurs at a rate of approximately 0.9–6.2 per 100,000 people per year and is associated with a high morbidity and mortality despite advancements in antibiotic and surgical treatments. The general approach to the treatment of IE is initial clinical stabilization, early acquisition of blood cultures, and definitive medical and/or surgical treatment. Surgical consultation should be obtained early when indicated in order to determine the best treatment approach for each individual patient. Surgery is indicated in most cases of prosthetic valve endocarditis, Staphylococcus aureus endocarditis, fungal endocarditis, and endocarditis associated with large vegetations (≥10 mm). Initial antibiotic therapy for IE should be targeted to the culprit microorganism; however, in some cases, empiric therapy must be initiated prior to definitive culture diagnosis. Empiric antibiotics should be targeted toward the most likely pathogens, including staphylococci, streptococci, and enterococci species. Here we discuss the recommended antibiotic regimens for the most common causes of IE as indicated by the American Heart Association and European Society of Cardiology. In 2008, the ACC/AHA published guideline updates on the treatment of valvular heart disease, which included a focused update on endocarditis prophylaxis. According to the most recent guidelines, the number of patients who require antibiotic prophylaxis has decreased substantially. Treatment of IE should be targeted toward the causative microorganism and must be based on the type and location of valve involved (native, prosthetic, left or right sided), the clinical status of the patient, and the likelihood for clinical success. This requires a collaborative effort from multiple medical specialties including infectious disease specialists, cardiologists, and cardiothoracic surgeons.     

Community Health Workers Can Identify and Manage Possible Infections in Neonates and Young Infants: MINI��A Model from Nepal

The mortality rates of infants and children aged less than five years are declining globally and in Nepal but less among neonates. Most deliveries occur at home without skilled attendants, and most neonates may not receive appropriate care through the existing medical systems. So, a community-based pilot programme—Morang Innovative Neonatal Intervention (MINI) programme—was implemented in Morang district of Nepal to see the feasibility of bringing the management of sick neonates closer to home. The objective of this model was to answer the question: “Can a team of female community health volunteers and paid facility-based community health workers (collectively called CHWs) within the existing heath system correctly follow a set of guidelines to identify possible severe bacterial infection in neonates and young infants and successfully deliver their treatment?” In the MINI model, the CHWs followed an algorithm to classify sick young infants with possible severe bacterial infection (PSBI). Female Community Health Volunteers (FCHVS) were trained to visit homes soon after delivery, record the birth, counsel mothers onessential newborn care, and assess the newborns for danger-signs. Infants classified as having PSBI, during this or subsequent contacts, were treated with co-trimoxazole and referred to facility-based CHWs for seven-day treatment with injection gentamicin. Additional supervisory support was provided for quality of care and intensified monitoring. Of 11,457 livebirths recorded during May 2005–April 2007, 1,526 (13.3%) episodes of PSBI were identified in young infants. Assessment of signs by the FCHVs matched that of more highly-trained facility-based CHWs in over 90% of episodes. Treatment was initiated in 90% of the PSBI episodes; 93% completed a full course of gentamicin. Case fatality in those who received treatment with gentamicin was 1.5% [95% confidence interval (CI) 1.0-2.3] compared to 5.3% (95% CI 2.6-9.7) in episodes that did not receive any treatment. Within the existing government health infrastructure, the CHWs can assess and identify possible infections in neonates and young infants and deliver appropriate treatment with antibiotics. This will result in improvement in the likelihood of survival and address one of the main causes of neonatal mortality.Key words: Antibiotic use, Bacterial infections, Drug therapy, Health workers, Infant, Newborn, Neonatal mortality, Sepsis, Nepal     

Trust and the regulation of pharmaceuticals: South Asia in a globalised world

Background  

Building appropriate levels of trust in pharmaceuticals is a painstaking and challenging task, involving participants from different spheres of life, including producers, distributors, retailers, prescribers, patients and the mass media. Increasingly, however, trust is not just a national matter, but involves cross-border flows of knowledge, threats and promises.     

Current status of inpatient HIV care at a tertiary care center in Nepal

The success of the WHO's '3 by 5' programme will depend on the ability of developing countries to provide antiretroviral therapy. The purpose of this study was to determine the current status of HIV care at a major teaching hospital in eastern Nepal. A retrospective cohort study was conducted of admitted HIV-infected patients at BPKIHS between 1993 and 2003, evaluating reasons for admission and the care received. There were 2, 2, 2, 3, 5 and 18 admissions, respectively, from 1998 to 2003. Only 4 were female patients. Two were children, both admitted in the last y studied. 10 admissions (31% of the total) were for opportunistic infections (OIs). Seven patients were prescribed OI prophylaxis, with incorrect dosages in 6. Four patients were prescribed antiretroviral therapy, all in inappropriate dosages or combinations. 13 patients were rapidly discharged without further care as soon as a diagnosis of HIV was made. Hospital admissions of HIV-infected individuals are increasing rapidly. Important segments of the HIV-infected population such as women and children are not receiving medical services. Most admissions are not due to OIs. The care of HIV-infected patients even at a major tertiary care teaching hospital in Nepal is sub-optimal.     

Outcomes of cataract surgery: a population-based developing world study in the Bhaktapur district, Nepal

Background: To evaluate the visual outcome after cataract surgery in a population of Nepal. Design: Population‐based cross‐sectional study. Participants: Forty years and above residing in Bhaktapur district. Methods: Subjects were selected from 30 clusters using cluster sampling procedure. All underwent a detailed examination at the base hospital, including logarithm of minimal angle of resolution visual acuity, refraction, applanation tonometry, cataract grading, retinal examination and perimetry when indicated. Main Outcome Measures: Visual acuity after cataract surgery. Results: Out of 4003 subjects examined, 151 had undergone cataract surgery. Pseudophakia was present in 142 (94.0%), aphakia in nine (6%). Presenting and best‐corrected visual acuity ≥6/18 was achieved in 123 (54.4%) and 164 (72.4%) eyes, respectively. Among the pseudophakic eyes, at presentation 122 (57.5%), 72 (33.9%), 18 (8.5%) and after best correction 162 (76.2%), 33 (15.8%), 17 (8.0%) had visual acuity of ≥6/18, <6/18–≥6/60 and <6/60, respectively. Retinal disease (35.5%), surgical complications (27.4%) and posterior capsular opacification (14.5%) were the principle causes of visual impairment after best correction in all eyes. There was no significant association in visual outcome based on age, sex, literacy and the duration of surgery. Conclusion: Correction of refractive errors, preoperative screening of coincidental diseases, reduction in surgical complication rates and monitoring of postoperative follow‐up care has to be addressed seriously in order to improve the outcome of cataract surgery to meet standards proposed by the World Health Organization. In the future, longitudinal studies need to be undertaken to provide specific information on the outcomes of cataract surgery in this community.     

Prevalence of visual impairment, cataract surgery and awareness of cataract and glaucoma in Bhaktapur district of Nepal: The Bhaktapur Glaucoma Study

Background

The present study investigates two different treatment options for convergence insufficiency CI for a group of children with reading difficulties referred by educational institutes to a specialist eye clinic in Vienna.

Methods

One hundred and thirty four subjects (aged 7-14 years) with reading difficulties were referred from an educational institute in Vienna, Austria for visual assessment. Each child was given either 8Δ base-in reading spectacles (n = 51) or computerised home vision therapy (HTS) (n = 51). Thirty two participants refused all treatment offered (clinical control group). A full visual assessment including reading speed and accuracy were conducted pre- and post-treatment.

Results

Factorial analyses demonstrated statistically significant changes between results obtained for visits 1 and 2 for total reading time, reading error score, amplitude of accommodation and binocular accommodative facility (within subjects effects) (p < 0.05). Significant differences were also demonstrated between treatment groups for total reading time, reading error score and binocular accommodative facility (between subjects effects) (p < 0.05).

Conclusions

Reading difficulties with no apparent intellectual or psychological foundation may be due to a binocular vision anomaly such as convergence insufficiency. Both the HTS and prismatic correction are highly effective treatment options for convergence insufficiency. Prismatic correction can be considered an effective alternative to HTS.     

Biological and Pathobiological Functions of Gelatinase Dimers and Complexes

The two matrix metalloproteinases, MMP-2 and MMP-9, are known to form various dimer complexes. In the present review, some of these complexes are described along with their biological and pathobiological functions.     

Venous thromboembolism in patients with hematologic malignancy and thrombocytopenia

The optimal management of hematologic malignancy‐associated venous thromboembolism (VTE) in patients with moderate‐to‐severe thrombocytopenia is unclear. This is a retrospective study of 128 adult patients with hematologic malignancies who were diagnosed with VTE. The outcome of patients with significant thrombocytopenia (≤50,000/µL) was compared with those without. Forty‐seven patients (36.7%) had a platelet count ≤50,000/µL during a period of time of perceived need for new or continued anticoagulation. The median nadir platelet count in those with significant thrombocytopenia was 10,000/µL (range 2,000–45,000/µL) versus 165,000/µL (50,000–429,000/µL) in those without (P < 0.001). The median duration of significant thrombocytopenia in the first group was 10 days (1–35 days). Therapy during the period of significant thrombocytopenia included prophylactic‐dose low‐molecular‐weight heparin ( LMWH) (47%), therapeutic‐dose LMWH or heparin (30%), warfarin (2%), inferior vena cava filter (2%), and observation (17%). Patients without thrombocytopenia were managed with the standard of care therapy. At a median follow‐up of more than 2 years, the risk of clinically significant bleeding (11% vs 6%, P = 0.22) including major bleeding (6% vs 2%) and clot progression or recurrence (21% vs 22%, P = 1.00) were similar in patients with or without significant thrombocytopenia. In a multivariate analysis, the risk of recurrence/progression (hazard ratio, HR 0.59, 95% CI 0.21–1.66, P = 0.31) and hemorrhage rate (HR 0.29, 95% CI 0.05–1.56, P = 0.15) did not differ based on the presence of significant thrombocytopenia. Within the limits of this retrospective study, cautious use of prophylactic‐dose LMWH may be safe in thrombocytopenic patients with hematologic malignancy‐associated VTE. Am. J. Hematol. 91:E468–E472, 2016. © 2016 Wiley Periodicals, Inc.