Number Of Daily Doses Research Articles

Interventional Antibiotic Treatment Replacing Antibiotic Prophylaxis during Allogeneic Hematopoietic Stem Cell Transplantation Is Safe and Feasible: A Single-Center Analysis

Background: Patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) are at increased risk of infection-related mortality during the pre-engraftment period. Systemic antibiotic prophylaxis (SAP) is widely used during the period of neutropenia but is associated with disruption of the intestinal microbiome, an increased risk of Clostridium difficile infection (CDI) and colonization with multi-drug resistant (MDR) bacteria. Aims: We retrospectively assessed the safety and efficacy of a change in our center policy from SAP to an exclusively interventional antibiotic treatment (IAT) in adult patients undergoing allogeneic HSCT. Outcome measures were overall survival (OS) and non-relapse mortality (NRM) at 3 years, antibiotic administration, incidence of blood-stream infections (BSI) and incidence and severity of acute and chronic graft-versus-host disease (GVHD). Methods: Cefotaxime was used as standard of care prophylaxis during neutropenia after HSCT prior to January 2018. After a 12 months transition time during which both strategies were employed in parallel, SAP was replaced by an IAT strategy with meropenem being administered immediately by nursing staff in case of neutropenic fever or any other signs of infection, and subsequently deescalated to piperacillin/tazobactam (pip/taz) when appropriate. We compared 67 consecutive patients undergoing HSCT in 2017, all of whom received antibiotic prophylaxis (SAP cohort) with all patients in 2019 comprising the IAT cohort (n=68). Use of antibiotics is reported as number of daily doses per 100 care days (DDD/100CD) until discharge after HSCT. Results: Patient characteristics are summarized in table 1. Median age was 56 years, 82% of patients were grafted with peripheral blood stem cells (PBSC) for acute leukemia (74%) from a matched unrelated or related donor (MUD, 61%; MRD 17%). Patient characteristics were well balanced between the SAP and IAT cohorts, except those patients transplanted in 2019 were more likely to have an HCT-CI ≥ 3 (56% vs 36%, p=0.025) and receive reduced-intensity conditioning (62% vs 40%, p=0.025). In the SAP and IAT cohort, neutropenic fever was observed in 46% and 62% of patients (p=0.085). However, the cumulative incidence (CI) of BSI by day +100 post-HSCT was significantly higher in the IAT vs SAP cohort (40% vs 13%, p<0.001), which did not result in more patients admitted to the intensive care unit (13% vs 6%, p=ns) and did not translate into a higher CI of NRM at 3 years (10% vs 9%, p=ns). With a median follow-up of 1052 days, 3-year OS was 70% and 69% for the SAP and IAT cohort, resp. (p=ns, figure 1). CI of acute GVHD grade II-IV or chronic GVHD of any grade at 3 years was 34% (p=ns) and 45% (p=ns), resp., resulting in identical survival free of acute GVHD grade III-IV, chronic GVHD requiring systemic immunosuppressive therapy and relapse-free survival (GRFS) of 36% (p=ns) in both groups. We observed a tendency to a higher CI of severe chronic GVHD in the SAP cohort (27% vs 13%, p=0.08). There was no significant difference between the two cohorts in terms of newly detected colonization with MDR bacteria during conditioning and after HSCT (VRE 17%; ESBL 5%; 3/4 MRGN 5%; MRSA 0%) and the incidence of CDI was likewise equal in both cohorts (13%, p=ns). Compared to SAP, IAT resulted in significantly fewer days of antibiotic therapy (24 vs 18, p<0.001) and accordingly less administration of cefotaxime (12.8 vs 3.8 DDD/100CD), teicoplanin (26.2 vs 6.3 DDD/100CD), vancomycin (11.5 vs 8.3 DDD/100CD) and meropenem (23.1 vs 16.7 DDD/100CD). Solely use of pip/taz increased (14.3 vs 23.6 DDD/100CD), while the amount of imipenem remained unchanged (7.6 versus 7.8 DDD/100CD). Thus, we observed a significant 40% reduction of the median antibiotic consumption (p=0.0312) in 2019. In the multivariate analysis, only age > 60 years and a high or very high disease risk index were identified as negative prognostic factor for OS. Conclusion/Summary: Our single center experience in conducting HSCT without antibiotic prophylaxis but with strict guidelines for prompt antibiotic intervention demonstrated no disadvantage in OS and NRM, despite a higher CI of BSI. IAT resulted in considerably less consumption of cefotaxime, but also carbapenem and glycopeptide antibiotics. We conclude that the proposed procedure of IAT replacing SAP is safe and feasible. Larger patient numbers are needed to confirm a possible benefit of IAT on GVHD. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Diabetes mellitus en perros

The objective of this study is to add useful information on the subject, seek more clarity on the definitions of Diabetes Mellitus (DM) in dogs and explore what is already known in relation to its diagnosis and treatment. DM is an endocrine disease associated with the hormone insulin, responsible for controlling blood glucose levels. Its incidence in dogs can reach 1 in every 100 animals in the population, in which females represent up to 70% of the cases. Late diagnosis raises the mortality of the disease to 50%. Its etiology has yet to be defined, but it is irrefutable that its origin is multifactorial. There is the same consensus signaling that genes involving the immune system are strongly associated with a predisposition to DM. Insulin is a pancreatic hormone secreted by ß cells, which are activated after blood glucose levels are high. Its action reduces serum glucose levels causing it to penetrate into the cell. The loss of glycemic homeostasis causes an imbalance in organic functions that, when exceeding certain limits, will be noticeable through clinical manifestations. The main signs noticed are polyuria, compensatory polydipsia, polyphagia, wasting and diabetic ketoacidosis, among others. The evaluation of laboratory tests when there is a suspicion of DM should include a measurement of blood glucose and urine test type I. The disease has no cure, therefore, it is essential that the diagnosed patient follow a treatment and thus increase their expectation and quality of life. Insulin sources are derived from a combination of purified bovine and porcine and even a recombination with human insulin. The discussion about the number of daily doses, one or two, is not done, but studies show better results in glycemic control with insulin dosage twice a day, while hypoglycemia episodes appear more often in patients who received only one dose a day.

Analysis of the consumption volumes of antithrombotic drugs used for pharmacotherapy of atrial fibrillation in Saratov Region

Objective: To study the evolution of consumption of antithrombotic drugs used for the treatment of atrial fibrillation (AF) at the outpatient stage in the Saratov Region using the ATC/DDD (Anatomical Therapeutic Chemical Classification / Defined Daily Doses) and drug utilization 90% (DU90%) analysis.Material and methods. We analyzed the outpatient stage of treatment using the data reflected in 511 case histories of AF patients hospitalized in specialized cardiology departments of the Saratov Region in 2011–2018. The study of the consumption volumes of antithrombotic drugs was carried out using the ATC/DDD- and DU90%-analysis methodology. The consumption of drugs with proven efficacy in AF was expressed as the number of daily doses (NDDD) per 1000 AF patients per day.Results. In 2011, the number of prescribed DDD of oral anticoagulants (OACs) was 5.29 NDDD per 1000 AF patients per day, and all of them were represented by warfarin; in 2018, this indicator increased up to 277.51 NDDD per 1000 AF patients per day, of which direct OACs amounted to 237.06. The consumption of antiplatelet agents remained at a high level, and in 2018, was 582.53 NDDD per 1000 AF patients per day. Acetylsalicylic acid was included in the group of drugs accounting for 90% of all antithrombotic drugs at the outpatient stage – 99.02% in 2011, 93.08% in 2012, 58.55% in 2016, 60.27% in 2017, and 46.66% in 2018.Conclusion. The consumption volumes of OACs used at the outpatient stage of treatment of AF in the Saratov Region increased significantly in the period from 2011 to 2018, mainly due to direct OACs. At the same time, the consumption volumes of antiplatelet agents remained at a high level.

ANTIMICROBIALS USE IN BROILER CHICKEN BREEDING: CASE OF THE AIN DEFLA PROVINCE (ALGERIA)

The objective of this study is to assess the use of antimicrobials in the broiler production in Algeria, through a survey completed by private veterinarians of the Ain Defla province. In this context, 65 band breeding were studied for antimicrobial use between October 2019 and June 2020. The results showed that all of the studied bands received antimicrobial treatments for at least 5 days during the breeding period. Quinolones class was the most widely used class of antimicrobials (24.4%), followed by the tetracyclines class (22.5%), sulfonamides (20.1%) and polypeptides (12.1%). Macrolides and beta-lactams come last (4.02% and 3.22% respectively). 160 mg of active compound were administered per kg of chicken meat produced. The number of daily doses (nDDkg) was 10.5, while the treated live weight (nCDkg) was 2.66. Per molecule, chickens were more exposed to colistin, doxycycline, oxytetracycline and enrofloxacin. The withdrawal period of used bands was not respected, and meat from these treated broilers was found to contain antimicrobial residues at 33.9%. The reasons for this frequent use are various: poor conditions and bad practices of breeding, poor quality of day-old chicks, veterinary practices, and difficulties of control by veterinary authorities.

Use of Busulfan in Conditioning for Allogeneic Hematopoietic Stem Cell Transplantation in Adults: A Survey By the Complications and Quality of Life Working Party of the EBMT

Background : With the introduction of an intravenous formulation, options for the administration of busulfan in conditioning for allogeneic hematopoietic stem cell transplantation have increased. Practical issues in which the policies of transplant centers are likely to vary include the route of administration, number of daily doses, and the use of pharmacokinetic (PK) measurements for dose adjustment. Following the general policy of the European Society for Blood and Marrow Transplantation (EBMT) to aim at standardizing transplantation procedures, the Complications and Quality of Life Working Party has carried out a survey among EBMT centers about their practice in the use of busulfan for conditioning in allogeneic transplantation.Results : All allogeneic transplant centers reporting to the EBMT and treating adult patients were invited to participate. One hundred and nine centers (28 %) sent their report. One hundred and five of these centers used busulfan for conditioning, 4 did not. One hundred and one centers used it in full conventional doses, 92 centers in lower doses for reduced intensity conditioning (RIC). The oral dose in conventional conditioning was 16 mg/kg, the intravenous dose usually 12.8 mg/kg. Six centers determined the dose according to body surface area. The most common indications for conventional dose myeloablative conditioning were AML (99 centers), MDS (87), CML (75), ALL (56), lymphoma (26), thalassemia and other hemoglobinopathies (22), CLL (17), and myeloproliferative disorders (MPD, 6 centers). Lower doses of busulfan (RIC) were most commonly used for MDS (69 centers), AML (66), CML (49), ALL (37), lymphoma (36), CLL (31), and MPD (11 centers). The busulfan dose in RIC conditioning was usually 8 mg/kg in oral administration, in i.v. administration most often (66% of the centers) 6.4 mg/kg. Four centers determined the dose according to body surface area. Eleven centers gave full conventional dose busulfan orally and 94 i.v., while in RIC transplantations the drug was given orally in 10 and i.v. in 77 centers. Overall, 17 of the 105 centers used PK measurements to adjust busulfan doses. Busulfan concentration was measured using liquid chromatography (+ mass spectrometry in 8 centers). With one exception, the parameter used for dose adjustment was AUC. The details of the sampling for PK measurements as well as the method of AUC calculation varied. There was no difference between centers giving oral and those giving i.v. busulfan in the use of PK for dose adjustment, in full dose conditioning 2/11 vs. 14/94 centers, respectively. In RIC transplantations, PK-based dose adjustment was used in 1/10 centers giving oral busulfan and 8/77 using i.v. busulfan. The centers using oral busulfan or those adjusting the doses according to PK did not differ significantly from the rest of the centers in center experience, transplant numbers, JACIE accreditation, or gross national income of their country.Full conventional doses were always given in 4 days. Oral busulfan was given in 4 daily doses with one exception (2 doses). In i.v. administration, the number of daily doses was one in 46 centers, four in 42 centers, and two in 4 centers. In RIC conditioning, busulfan was in most cases given in 2 days, i.v. busulfan usually in one (35 centers) or four (28 centers) daily doses. Twenty-seven centers reported having alternative busulfan administration schedules depending on the disease, 20 centers depending on other components of the conditioning regimen. In myeloablative conditioning, 73 centers adjusted the dose of busulfan in obese patients, whereas 25 centers did not. Thirty-two centers reported defining obesity based on body mass index, whereas 28 centers used actual body weight in relation to ideal body weight. In obese patients, the busulfan dose was determined according to actual body weight (12 centers), ideal body weight (15), AIBW-25 (ideal body weight + 0.25 x (actual body weight - ideal body weight)) (46), AIBW-40 (10), or other (11 centers). In RIC, busulfan doses were adjusted because of obesity in 52 centers but not in 32 centers.Conclusions : There is marked variation between centers in the details of busulfan administration for conditioning in allogeneic transplantation. The clinical impact of this variation remains uncertain. The present results are useful in the production of recommendations toward a more standardized use of busulfan in the conditioning. DisclosuresMohty:Sanofi: Honoraria, Speakers Bureau.

The epidemiology of polypharmacy in a large cohort with linked health records in Scotland

Abstract Background Our understanding of the potential harm of taking multiple medications in older, multi-morbid populations is limited. We aimed to investigate the prevalence of polypharmacy and its association with hospitalisation in a large cohort with linked health data. Methods Prescription data and hospital admission records of the Aberdeen Children of the 1950s (ACONF) Cohort were extracted from the National Health Services Scotland database and linked from 2011-2016. We estimated polypharmacy by measuring monthly drug exposure for 1) total number of prescribed medications and 2) total number of defined daily doses (DDDs). Cox proportional hazard models (adjusted for demographics, socioeconomic circumstances and health conditions) were used to examine the association of polypharmacy and hospitalisation. Results Prescription records were linked for 8,713 cohort members. Mean age at baseline was 58.5 years (SD = 1.5) and 50% were female. 1,994 individuals (23%) had at least one health condition and 8% of population had multimorbidity. The proportion of cohort with polypharmacy assessed using taking 5+ medications and taking 5+ DDDs at baseline were 12.7% (female=12.6% vs male=12.7%, P = 0.179), and 15.5% (female=13.8% vs male=17.1%, P &amp;lt; 0.001) respectively. Of all the cohort, 4,365 admitted to hospital (mean follow-up of 3.5 years, total 30,269 person-years). Adjusted hazard ratios for hospitalisation were 1.51 (95 % CI 1.39,1.64, P &amp;lt; 0.001) for polypharmacy measured by number of medications and 1.40 (95 % CI 1.29,1.51 P &amp;lt; 0.001) for polypharmacy estimated by number of daily doses. Conclusions Polypharmacy is independently associated with increased risk of hospitalisation. This association could signify polypharmacy as a risk factor and a marker of poor outcome. Data linkage can generate evidence-based information for future policy and health services to improve polypharmacy measurement and management. Key messages Data linkage is a cost effective and contemporary return on the investment in data collection and research in public health. Improvement in evidence to better understand the relationship between polypharmacy and health outcomes should be a priority to optimise treatment in older people with various chronic conditions.

Severe drug-induced headache with its possible recurrent statuses in a patient with chronic tension headache

The paper deals with the actual problem of managing patients with drug-induced headache (DIH) in patients with primary headaches. It describes a clinical case of extremely severe DIH in a patient with chronic tension headache (TH). The paper analyzes the typical and atypical manifestations of DIH and discusses the role of prolonged stress in the development of TH. Special attention is paid to the problems with therapy and compliance during a long-term follow-up of the patient. Based on the clinical features of pain syndrome in the described patient, the authors suggest for the first time that the use of extremely high number of daily doses of combined narcotic analgesics for many years can result in recurrent DIH statuses. The paper discusses whether it is expedient to introduce the concept “DIH severity” and whether an additional clinical parameter “the number of doses of painkillers per month” can be of informative value, which has not been proposed yet in the literature. All the issues given in the paper are conjectural and are raised by the authors for further investigation of the DIH problem.

P0003ADHERENCE BENEFITS OF ADV7103, AN INNOVATIVE PROLONGED-RELEASE ORAL COMBINATION PRODUCT, IN PATIENTS WITH DISTAL RENAL TUBULAR ACIDOSIS

Abstract Background and Aims Distal renal tubular acidosis (dRTA) is a rare disorder leading to impaired net acid excretion by the kidney inducing hyperchloremic metabolic acidosis and hypokalemia. The therapeutic effect of the standard of care is of short duration and requires multiple day and night administrations; it is also often accompanied by gastrointestinal discomfort and poor palatability impacting medication adherence. ADV7103, the first advanced therapy for dRTA, consists of a combination of prolonged-release potassium citrate and prolonged-release potassium bicarbonate granules providing round-the-clock alkali and potassium coverage with twice daily administration. Long-term adherence with ADV7103 is reported, along with acceptability of the product. Method B22CS is a multicentre, open-label long-term extension study, evaluating safety, tolerability, acceptability and efficacy of ADV7103 in adult and paediatric patients with dRTA. Adherence was assessed at each study visit up to 24 months, based on accountability of study drug retrieval, laboratory results, and interview of the patients in a diary and expressed as the proportion of patients that presented adherence lower than 50%, between 50% and 74%, between 75 and 90%, and higher than to 90%. Treatment acceptability as well as quality of life of the patients and their parents were assessed using a 100-mm visual analogue scales (VAS). Results Table 1 shows the evolution of compliance between Month 6 and Month 24. Overall, of the 29 patients remaining in the study after 24 months, 18 (62%) had adherence rates &amp;gt;90%, 5 (17%) had adherence rates of 75-90%, 6 (21%) had adherence rates of 50-74%, and there were no patients with adherence &amp;lt;50%. Adherence was good in all age groups, with rates of ≥75% in 100% of adults, 63% of adolescents 85% of children, and 67% of infants and toddlers. Compared to the alkalising treatments they had before the study, more than 80% of the patients perceived both the improvement of the formulation and of the number of daily doses at scores ≥ 75 mm. The overall improvement of quality of life reported by the patients was of 89 ± 19 mm and that reported by their parents was of 90 ± 14 mm after 24 months of treatment. Conclusion Adherence to treatment was maintained at a high level throughout the 24 months of the study confirming the good acceptance of ADV7103 therapy.

P355 Acceptability of treatment regimen in inflammatory bowel disease: Results from a prospective nationwide study (ACCEPT2)

Abstract Background The multiplication of therapeutic options with close efficacy and safety, leads to consider acceptability of treatment regimen as a key point for therapeutic decision in inflammatory bowel disease (IBD). We aimed to compare acceptability of IBD treatment regimen and to identify its associated factors. Methods From a nationwide prospective study conducted in 24 public or private centres, IBD patients were consecutively included for 6 weeks. A dedicated questionnaire was developed, tested and validated for the study. It was administered to each included patient and his/her related physician. Acceptability was graded with an acceptability numerical scale (ANS) from 0 (absolutely not acceptable) to 10 (totally acceptable). Results Overall, 1850 patients were included (65.9% with Crohn’s disease (CD), mean age = 41.0 ± 14.7, 22.2% experiencing IBD flare at inclusion). The medications at inclusion were none in 9.0%, oral (PO) monotherapy in 17.3%, subcutaneous (SC) injections in 29.2% and intra-venous (IV) infusions in 44.5% of the patients. The ANS were 8.68 ± 2.52 for PO, 7.67 ± 2.94 for SC and 6.79 ± 3.31 for IV (p &amp;lt; 0.001 for each comparison). The patients reported PO, SC and IV as their first choice in 65.8%, 21.4% and 12.8%, respectively. The reasons for reduced acceptability were the need to come to the hospital (63.0%) for IV infusion, none for SC injections and the fear to forget to take pills (30.5%), the number of daily dose (28.4%) and daily medication as a reminder of disease every day (24.8%) for PO therapy. In multivariable analyses, the following factors were associated with a better acceptability of IV infusion (current IBD flare: p = 0.003 and current IV therapy for IBD: p &amp;lt; 0.001), SC injections (Private practice: p = 0.006 and current SC injections for IBD: p &amp;lt; 0.001) and PO medication (male gender: p = 0.018, higher studies level: p &amp;lt; 0,001 and current oral medication: p = 0.002). The mean ANS for all IBD treatment regimen were compared in the 1850 patients (Figure 1). No difference was observed between CD and UC. In biologics-naïve patients (n = 315), the treatment regimens were ranked in the following order: PO once daily (8.8 ± 2.2), SC/12 weeks (week) (7.9 ± 3.0), SC/8 week and PO twice daily (7.2 ± 3.2 et 6.9 ± 3.4; ns), SC/4 week (6.2 ± 3.4), SC/2 week et IV/8 week (5.1 ± 3.4 and 5.0 ± 3.5; ns)(p &amp;lt; 0.001 except if ns was mentioned). For the patients, the acceptable loss of efficacy to receive a more convenient medication was 5.2% (non-inferiority trial limit). Conclusion While PO administration was preferred by most of IBD patients, the acceptability of treatment regimen is highly impacted by the interval between two doses and the previous medications. Our data could be helpful to guide therapeutic decision in daily practice in IBD.

Real-world impact on monthly glucose-lowering medication cost, HbA1c, weight, and polytherapy after initiating a GLP-1 receptor agonist

ObjectiveGlucagon-like peptide-1 (GLP-1) receptor agonists are preferred injectable therapies for type 2 diabetes, but their high cost is an area of concern. This study evaluated monthly glucose-lowering medication cost and clinical impact after initiating a GLP-1 receptor agonist. DesignA retrospective, pre-post cohort study evaluated monthly glucose-lowering medication cost, glycated hemoglobin (HbA1c), weight, and polytherapy impact (name, dose, and number of daily doses or injections) when a GLP-1 receptor agonist was initiated (baseline) and after 6-12 months (follow-up). The population was analyzed overall and as subgroups, based on baseline medication regimen and demographics. Setting and participantsThe study was performed at 8 ambulatory care sites (7 federally qualified health centers and a Program of All-Inclusive Care for the Elderly) in the greater Boston, MA, area. Patients were included in the analyses (n = 120) if they had a documented diagnosis of type 2 diabetes, were 18 years of age or older, had an HbA1c ≥ 7.5% measured within 3 months prior to the initiation of a GLP-1 receptor agonist, and an HbA1c measured 6 to 12 months following the initiation of a GLP-1 receptor agonist. Outcome measuresPrimary outomes were changes in glucose-lowering medication cost, HbA1c, and weight. Secondary outcome analyses included the impact to the glucose-lowering medication regimen in terms of dose, number of medications, and number of daily doses or injections. ResultsThe study population was largely female, aged 55.8 ± 11.7 years, obese, 76% non-Caucasian, equally English and non-English speaking, had a high tablet and injection burden, and had an average baseline HbA1c of 10%. After the addition of a GLP-1 receptor agonist, monthly glucose-lowering medication cost increased $586.86 (overall), $741.69 (oral only baseline regimen), and $530.55 (insulin ± oral baseline regimen) (all P < 0.001). Mean decrease in HbA1c was 1.7% (18 mmol/mol) (P < 0.001) and was similar across all subgroups. Weight decreased overall (−1.8 kg, P < 0.001), and there was a significant shift toward taking fewer oral agents and insulin and fewer daily injections. No statistically significant differences in the primary outcomes were noted in terms of age, gender, English-speaking status, or race. ConclusionAlthough a positive impact was observed in glycemic control, weight, and reduced polytherapy 6-12 months after initiating a GLP-1 receptor agonist, the increase in monthly glucose-lowering medication cost was significant and may serve as a barrier to treatment.

High-Resolution Monitoring of Antimicrobial Consumption in Vietnamese Small-Scale Chicken Farms Highlights Discrepancies Between Study Metrics.

Chicken is, among farmed species, the target of the highest levels of antimicrobial use (AMU). There are considerable knowledge gaps on how and when antimicrobials are used in commercial small-scale chicken farms. These shortcomings arise from cross-sectional study designs and poor record keeping practiced by many such farmers. Furthermore, there is a large diversity of AMU metrics, and it is not clear how these metrics relate to each other. We performed a longitudinal study on a cohort of small-scale chicken farms (n = 102) in the Mekong Delta (Vietnam), an area regarded as a hotspot of AMU, from October 2016 to May 2018. We collected data on all medicine products administered to 203 flocks with the following aims: (1) to describe types and quantities of antimicrobial active ingredients (AAIs) used; (2) to describe critical time points of AMU; and (3) to compare AMU using three quantitative metrics: (a) weight of AAIs related to bird weight at the time of treatment (mg/kg at treatment); (b) weight of AAIs related to weight of birds sold (mg/kg sold); and (c) “treatment incidence” (TI), or the number of daily doses per kilogram of live chicken [Vietnamese animal daily dose (ADDvetVN)] per 1,000 days. Antimicrobials contained in commercial feed, administered by injection (n = N = 6), or antimicrobials for human medicine (n = N = 16) were excluded. A total of 236 products were identified, containing 42 different AAIs. A total of 76.2% products contained AAIs of “critical importance” according to the World Health Organization (WHO). On average, chickens consumed 791.8 (SEM ±16.7) mg/kg at treatment, 323.4 (SEM ±11.3) mg/kg sold, and the TI was 382.6 (SEM ±5.5) per 1,000 days. AMU was more common early in the production cycle and was highly skewed, with the upper 25% quantile of flocks accounting for 60.7% of total AMU. The observed discrepancies between weight- and dose-based metrics were explained by differences in the strength of AAIs, mortality levels, and the timing of administration. Results suggest that in small-scale chicken production, AMU reduction efforts should preferentially target the early (brooding) period, which is when birds are most likely to be exposed to antimicrobials, whilst restricting access to antimicrobials of critical importance for human medicine.

Long-term outcomes of deep brain stimulation in severe Parkinson’s disease utilizing UPDRS III and modified Hoehn and Yahr as a severity scale

ObjectivesDeep brain stimulation (DBS) is the surgical treatment of choice for moderate to severe Parkinson’s Disease (PD). However, few studies have assessed its efficacy in severe PD as defined by the modified Hoehn and Yahr scale (HY). This study evaluates long-term and medication outcomes of DBS in severe PD. Patients and methodsWe retrospectively collected the data of 15 patients from 2008 to 2014 with severe PD treated with DBS. Retrospective assessment with the modified Hoehn and Yahr scale and motor subset of the Unified Parkinson’s Disease Rating Scale (UPDRS III) were used to objectively track severity and motor function improvement, respectively. Levodopa equivalence daily doses (LEDD), number of anti-PD medications and number of daily medication doses were used to measure improvements in medication burden. Data was evaluated using univariate analyses, one sample paired t-test, two sample paired t-test, and Wilcoxon signed-rank test. ResultsThe mean post-operative follow-up was 44.63 months, average age at diagnosis and the average age at time of DBS was 51.3 years and 61.5 years, respectively, and the time from diagnosis to treatment was 13.2 years. Significant decreases were seen in UPDRS III scores (pre-op = 44.533; post-op = 26.13; p = 0.0094), LEDD (pre-op = 1679.34 mg; post-op = 837.48 mg; p = 0.0049), and number of daily doses (pre-op = 21.266; post-op 12.2; p = 0.0046). No significant decrease was seen in the number of anti-PD medications (pre-op = 3.8; post-op = 3.2; p = 0.16). ConclusionFollowing DBS, severe PD patients demonstrated significant improvements in motor function and medication burden during long-term follow-up. We believe our results prove that DBS is efficacious in the management of severe PD, and that further research should follow to expand DBS criteria to include severe disease.

Consumption of antibiotics in a burns intensive care unit

Burn-injured patients are at particularly high risk of infection; as such one would expect an increased requirement of antibiotics compared to other intensive care patients. There is no data in the literature investigating this hypothesis in Germany. The aim of this study was to determine the antibiotic consumption in severe burn patients and to compare this data with those from surgical intensive care units. The retrospective study included 136 patients treated in the period from 2013 to 2016 due to a severe burn in the ICU intensive care unit of a regional burn centre. The use of antibiotics was recorded using the electronic medical record. The number of daily doses in Recommended Daily Dose (RDD) and Defined Daily Dose (DDD) based on patient days was calculated. Median [interquartile range] age and total burned surface area were 56.5y [43-75y] and 17 % [8,75; 31] with an ABSI 7 [6; 9]. Antibiotic therapy was given to 82 patients (60.3 %). Antibiotic consumption totaled 77.38 RDD/100 PT or 937.64 DDD/1000 PT. This result was marginally lower than for surgical intensive care units. The most frequently used antibiotics in the burn care setting were fluorquinolones (16.90 RDD/100 PT, 259.91 DDD/1000 PT), followed by carbapenems (12.76 RDD/100 PT, 128.44 DDD/1000 PT) and aminopenicillins/ BLI (11.54 RDD/100 PT, 115.39 DDD/1000 PT). Whilst, the most frequently detected pathogens were Staphylococcus aureus (54.4 %), Enterococcus faecalis (54.4 %), E. coli (37.5 %) and Pseudomonas aeruginosa (36.8 %). The total antibiotic consumption in severe burns was not increased compared to other surgical intensive care patients. With regard to individual substance classes, peculiarities can be identified reflecting the particular germ spectrum in this cohort.

Titanium dioxide (TiO2) as a marker to estimate fecal output in sheep

ABSTRACT: Titanium dioxide (TiO2) is an external marker used to estimate fecal output based on forage intake of grazing ruminants; however, its use as marker for grazing sheep still needs attention. In the present study the TiO2 role to estimate fecal output of sheep grazing annual ryegrass was tested. Two essays were conducted in sequence using the same forage and animals. Six lacaune lambs were housed in metabolic cages. Lambs were administered 1 g TiO2 in a single (at 8:30 am, essay 1), or in two daily doses (at 8:30 am and 4:30 pm, essay 2). In both essays the TiO2 administration was followed by a 7-day period to stabilize the fecal excretion of the marker and then by a 5-day period for total collection of feces. Observed and TiO2-based estimated fecal outputs were compared, with or without correction for TiO2 fecal recovery rate (kTiO2). The kTiO2 was around 1.0 and the estimated fecal outputs were similar to the observed ones (p&gt;0.05), regardless the number of daily doses. These results suggested that TiO2, administered in single or two daily doses, can be used as an external marker in grazing sheep.

Pola Penggunaan Insulin Pada Pasien Diabetes Melitus Tipe 2 Rawat Inap Di Rumah Sakit X Pekanbaru Tahun 2014

Insulin is one of pharmacological treatment of type 2 diabetes mellitus (DM). The aim of this study was to know thepattern of insulin use in hospitalized patients with type 2 diabetes Hospital X Pekanbaru. The type of research wasdescriptive. Data retrieved from 63 the medical records of patients with type 2 diabetes at Hospital X Pekanbaruperiod January - December 2014. The most characteristics of subject was average of age 55.40 (± 10.91) years, theaverage of RBG level 313.37 (± 135.81) mg / dL, female (55.6%), financing with BPJS (49.2%), housewives (49.2%),the diagnosis of type 2 diabetes with complications (38.1 %). The most insulin usage according to duration of actionwas short-acting insulin (46.4%), the number of daily doses was &lt;20 IU from all type of insulin. The most combinationof different insulin types (7.9%) was long-acting insulin with rapid-acting insulin and the most combination of insulinand OHD (6.3%) was a short-acting insulin with gluconeogenesis inhibitor and premixed insulin with gluconeogenesisinhibitor.

Compreensão da prescrição de medicamentos em uma unidade básica de saúde: autorrelato do usuário e aferição pelo pesquisador

Aims: To evaluate the understanding of drug prescriptions by patients, comparing the user self-report with the researcher assessment.Methods: A cross-sectional study was conducted from November 2013 to February 2014 at a Basic Health Unit in the city of Belo Horizonte, Minas Gerais, Brazil. Users 18 years of age or older who sought medicines in the unit's pharmacy, for themselves or for minors under their care, were interviewed. The selection of the sample was non-probabilistic, for convenience. During the interview, the users informed if they had understood the following data of the prescriptions: drug name, dose and frequency of administration. Participants then repeated the data for researchers, being allowed to check the prescriptions at the same time. After the interviews, the answers to the questions were interpreted by the researchers, who evaluated the agreement between the information provided by the users and the actual instructions of the recipes, using the Kappa test.Results: Data were collected from 69 users of the unit's pharmacy (corresponding to 69 delivered prescriptions). Fifty-nine (85.5%) users reported having understood all the prescriptions data (self-report), while according to the measurement of the researchers, 23 (33.3%) were the respondents who simultaneously understood all data, relating to the name of the drug, number of daily doses and schedule. Kappa test indicated a degree of agreement between self-report and measurement of researchers of 0.138 (slight) considering all items of the prescription, and specifically on the number of doses the agreement was -0.055 (poor).Conclusions: Self-reported rate of patient's understanding of drug prescriptions was higher than the assessed by the researchers. This result suggests that self-report of patients with respect to the understanding of prescriptions has limitations and should be interpreted with caution both in research and in clinical practice. It is recommended to enhance the means of providing information to patients, in order to contribute to the proper understanding of drug prescriptions.

Évaluation d’interventions éducatives auprès du patient dialysé

The treatment of end-stage renal disease requires a significant number of drug treatments. At patient level, daily management is somewhat difficult: Number of prescribed pills, medication side effects, treatment of asymptomatic diseases… The objective of the study was to investigate the effect of guidance tailored to each patient receiving hemodialysis, performed by the pharmacist (educational interventions). Adult haemodialysis patients with hyperphosphatemia despite phosphate binders were eligible for study entry. The study was controlled with a retrospective group. The primary end point was a change in serum phosphate levels. The secondary end points were therapy adherence, knowledge regarding phosphate management and patient satisfaction with the programme. Sixteen patients in each group participated in the study. The mean serum phosphate level at endpoint was decreased by 0.25 mmol/L in the intervention group (0.41 mmol/L for patients with expectancy for this reduction) and by 0.11 mmol/L in the control group. Five patients normalized their serum phosphate level in the intervention group against three patients in the control group. The mean score of adherence decreased from 1.75 to 1.50. The main factors affecting adherence were forgetfulness or carelessness in taking medications and number of daily doses. This study showed the feasibility of an improvement in serum phosphate level and adherence driven by therapeutic education, though effect was highly amplified by the motivation induced by pharmaceutical guidance. Patients emphasize the importance of the involvement of pharmacist in their care.

FATORES QUE AFETAM A QUALIDADE DE VIDA DOS DOENTES HIPERTENSOS

Abstract:FACTORS AFFECTING THE QUALITY OF LIFE OF HYPERTENSIVE PATIENTSCardiovascular disease affects both the physical, psychological and social well-being, thereby the need for assess quality of life. Consequently a good treatment of hypertension requires concern about the quality of life of the patient. Aim: To assess the influence of sociodemographic and clinical factors, in the quality of life of patients with hypertension. Methods: We performed an observational, cross-sectional study, in hypertensive patients followed in community pharmacies. Patients were selected at the pharmacy when they bought an antihypertensive drug or measure blood pressure. To each patient was administered a questionnaire evaluating the gender and age, drug sideeffects, duration of hypertension, blood pressure control, co morbidity, daily therapy, as independent variables and quality of life (assessed by HYPER questionnaire) as the dependent variable. Results: The sample consisted of 1876 hypertensive patients (44% men and 56% women) with a mean age of 60.48 ± 2.17 years. The mean duration of hypertension was 10.56 ±9.25 years. The amounts of drugs taken daily were (4.10 ±2.39) and the number of daily doses (2.50 ±1.09) was highly variable. The most frequent co morbidity was high cholesterol (42% of patients). Stand out that 81.3% of the hypertensive patients had blood pressure controlled. A better quality of life was independently predicted by achieving a controlled blood pressure, an absence of drug side effects and fewer drugs consumed per day. Conclusion: The results show the need to get involved in these patients in terms of representations of the disease when they have an impact on their quality of life. An intervention in patients with hypertension is necessary if we want to promote quality and adaptation to the disease.Keywords: hypertension, quality of life, blood pressure controlResumo:A doença cardiovascular afecta simultaneamente o bem-estar físico, psicológico e social do individuo, justificando que se investigue a sua qualidade de vida. Assim, quando se pretende um bom tratamento da hipertensão, deveremos igualmente preocupar-nos com a qualidade de vida do doente. Objetivo: Avaliação da influência dos factores sóciodemográficos e clínicos na qualidade de vida dos doentes com hipertensão. Metodologia: foi realizado um estudo observacional e transversal, quantitativo e analítico em doentes hipertensos seguidos nas farmácias comunitárias. Os doentes foram seleccionados quando se dirigiam à farmácia para comprar um anti-hipertensor ou medir a pressão arterial. A cada um dos doentes foi aplicado um questionário que avaliava as variáveis sexo e idade, os sintomas presentes no último mês, a duração da hipertensão, o controlo da pressão arterial, comorbilidades, terapêutica diária, como variáveis independentes e a qualidade de vida (avaliada pelo questionário HYPER), como variável dependente. Resultados: A amostra foi constituída por 1876 doentes com hipertensão (44% homens e 56% mulheres), com média etária de 60.48±2.17 anos. O tempo médio de duração da hipertensão foi de 10.56±9.25 anos. A quantidade de fármacos diários (4.10±2.39) e o número de tomas diárias (2.50±1.09) foram muito variáveis. A comorbilidade mais frequente foi o colesterol elevado (42% dos doentes). Destacam-se 81.3% hipertensos com pressão arterial controlada. Os fatores preditivos independentes para a qualidade de vida foram a ausência de efeitos secundários, o controlo da pressão arterial e o menor consumo de fármacos diários. Conclusão: Os resultados mostram a necessidade de intervir nestes doentes em termos das representações da doença quando estas tenham um impacto na sua qualidade de vida. Uma intervenção em doentes com hipertensão é necessária se quisermos promover a qualidade e adaptação à doença por parte destes.Palavras-chave: hipertensão, qualidade de vida, controlo da pressão arterial

Fixed-Dose Combination Inhalers.

In asthma and chronic obstructive pulmonary disease (COPD), an important step in simplifying management and improving adherence with prescribed therapy is to reduce the dose frequency to the minimum necessary to maintain disease control. Fixed-dose combination (FDC) therapy might enhance compliance by decreasing the number of medications and/or the number of daily doses. Furthermore, they have the potential for enhancing, sensitizing, and prolonging the effects of monocomponents. Combination therapy with an inhaled corticosteroid (ICS) and a long-acting β-agonist (LABA) is considered an important approach for treating patients with asthma and patients with severe COPD who have frequent exacerbations. Several ICS/LABA FDCs are now commercially available or will become available within the next few years for the treatment of COPD and/or asthma. Several studies demonstrate that there are a number of added benefits in using combinations of β2-agonists and antimuscarinic agents. In particular, LABA/long-acting antimuscarinic agent (LAMA) combination seems to play an important role in optimizing bronchodilation. Several once-daily and twice-daily LABA/LAMA FDCs have been developed or are in clinical development. LAMA/ICS FDCs seem to be useful in COPD and mainly in asthma, in patients with severe asthma and persistent airflow limitation. The rationale behind the ICS/LABA/LAMA FDCs seems logical because all three agents work via different mechanisms on different targets, potentially allowing for lower doses of the individual agents to be used, accompanied by improved side effect profiles. In effect, in clinical practice, concomitant use of all three compounds is common, especially in more severe COPD but also in the treatment of adults with poorly controlled asthma despite maintenance treatment with high-dose ICS and a LABA.

Pharmacotherapy review: a proposal to improve medication adherence among hypertensive patients

Abstract Pharmacotherapy review is a structured assessment of medicines, which aims to obtain a partnership with patients to achieve drug treatment goals and agreement about drug dosage, as well as when and how the drugs should be administered. The objective was to analyze the influence of pharmacotherapy review, by scheduling drug administration to improve medication adherence among antihypertensive patients. This study was an uncontrolled intervention developed in three distinct stages. The first stage included data collection on the profile of patients and their medications, and a preliminary assessment of medication adherence. In the second stage, the review report was delivered to patients. In the third stage, the results of blood pressure and medication adherence were assessed. The influence of the revision was measured through statistical tests (p&lt;0.05). The study included 40 patients with a mean age of 58.0 (SD:11.3) years; 72.5% were women. Thirty-three (82.5 %) patients required some intervention, after when there was a significant increase in the number of daily doses (p=0.039) and drug intakes (p=0.025). There was a significant increase in the adherence rate, according to both the Morisky-Green test (p&lt;0.001) and self-reported assessment (p=0.004). There was also an improvement in the levels of systolic (p&lt;0.001) and diastolic (p=0.002) blood pressure and in the number of patients with controlled hypertension (p=0.006). The pharmaceutical service enhanced medication adherence and control of systemic blood pressure; however, it increased the complexity of treatment.