Simplified Treatment Protocol Research Articles

Simplified treatment protocols improve recovery of children with severe acute malnutrition in South Sudan: results from a mixed methods study

BackgroundAs part of COVID-19 mitigation strategies, emergency nutrition program adaptations were implemented, but evidence of the effects is limited. Compared to the standard protocol, the full adapted protocol included adapted admissions criteria, simplified dosing, and reduced visit frequency; partially adapted protocols consisting of only some of these modifications were also implemented. To enable evidence-based nutrition program modifications as the context evolved, this study was conducted to characterize how protocol adaptations in South Sudan affected Outpatient Therapeutic Feeding Program outcomes.MethodsA mixed methods approach consisting of secondary analysis of individual-level nutrition program data and key informant interviews was used. Analyses focused on program implementation and severe acute malnutrition treatment outcomes under the standard, full COVID-19 adapted, and partially adapted treatment protocols from 2019 through 2021. Analyses compared characteristics and outcomes by different admission types under the standard protocol and across four different treatment protocols. Regression models evaluated the odds of recovery and mean length of stay (LoS) under the four protocols.ResultsVery few (1.6%; n = 156) children admitted based on low weight-for-height alone under the standard protocol would not have been eligible for admission under the adapted protocol. Compared to the full standard protocol, the partially adapted (admission only) and partially adapted (admission and dosing) protocols had lower LoS of 28.4 days (CI − 30.2, − 26.5) and 5.1 days (CI − 6.2, − 4.0); the full adapted protocol had a decrease of 3.0 (CI − 5.1, − 1.0) days. All adapted protocols had significantly increased adjusted odds ratios (AOR) for recovery compared to the full standard protocol: partially adapted (admission only) AOR = 2.56 (CI 2.18–3.01); partially adapted (admission + dosing) AOR = 1.78 (CI 1.45–2.19); and fully adapted protocol AOR = 2.41 (CI 1.69–3.45).ConclusionsThis study provides evidence that few children were excluded when weight-for-height criteria were suspended. LoS was shortest when only MUAC was used for entry/exit but dosing and visit frequency were unchanged. Significantly shorter LoS with simplified dosing and visit frequency vs. under the standard protocol indicate that protocol adaptations may lead to shorter recovery and program enrollment times. Findings also suggest that good recovery is achievable with reduced visit frequency and simplified dosing.

Impact of a simplified treatment protocol for moderate acute malnutrition with a decentralized treatment approach in emergency settings of Niger

IntroductionOf the 45.4 million children under five affected by acute malnutrition in the world, the majority (31.8 million) are affected by moderate acute malnutrition (MAM). Its treatment is particularly complex in emergency settings such as the Diffa region in Niger. This study aims to evaluate the effectiveness and coverage of a simplified treatment protocol with Community Health Workers (CHWs) as treatment providers.MethodsThis study is a non-randomized controlled trial. The control group (n = 181) received the standard protocol currently used in country, delivered by nursing staff only in health centres and health posts, while the intervention group (n = 483) received the simplified protocol which included nursing at health centres and CHWs at health post as treatment providers.ResultsThe recovery rate was higher in the simplified protocol group (99.6% vs. 79.56%, p < 0.001) recording lower time to recover and higher anthropometric gain. Treatment coverage in the intervention group increased from 28.8% to 84.9% and reduced in the control group (25.3% to 13.6%). No differences were found in the recovery rate of children treated by CHWs and nursing staff.ConclusionThe outcomes using the simplified protocol exceeded humanitarian requirements and demonstrated improvements compared to the standard protocol showing that the simplified protocol could be safely provided by CHWs in an emergency context. Further research in other contexts is needed to scale up this intervention.

Abstract 140: Implementation Of The World Health Organization Hearts Package Lowers Blood Pressure And Improves Hypertension Control In Rural Bangladesh: A Quasi Experimental Trial

Background: The World Health Organization (WHO) promotes the HEARTS technical package for improving hypertension control worldwide, but its effectiveness has not been evaluated. Methods: We conducted a quasi-experimental trial in primary healthcare facilities, Upazila Health Complexes (UHC), in rural Bangladesh. We enrolled a total of 3935 patients (mean age 52.3y, 70.5% female) with uncontrolled hypertension (blood pressure [BP] ≥140/90 mmHg): 1950 patients from 7 UHCs implementing HEARTS and 1985 patients from 7 matched usual care UHCs. The HEARTS package intervention components were 1) simplified treatment protocol, 2) reliable medication supply, 3) team-based care, 4) standardized follow-up, and 5) a mobile app to record BPs and medications. The primary outcome was systolic BP at 6 months measured at the patients' home; secondary outcomes were diastolic BP, hypertension control rate (<140/90 mmHg), and loss to follow-up. We ran multivariable mixed-effect linear and Poisson models. Results: At baseline, mean systolic BP was 158.4 mmHg in the intervention arm and 158.8 mmHg in the usual care arm. Follow-up was 95.5%. Compared to usual care, the intervention significantly lowered systolic and diastolic BP (Figure) and improved BP control (62.0% vs. 49.7%, p<0.001). Loss-to-follow-up was lower in the intervention arm (8.8% vs. 39.3%, p<0.001). Conclusions: The WHO HEARTS package implemented in rural Bangladesh significantly lowered BP and improved hypertension control. These results support use of the WHO HEARTS package to control hypertension in Bangladesh and provide a strong rationale for its implementation in other low and middle-income countries.

Definitive Relief of Severe Dry Socket Pain with Eugenol in Two Minutes

The etiology of dry socket after tooth extraction is still controversial, perhaps due to the lack of interest in researching this pathology, which heals spontaneously in a period of two weeks on average. Various proposed models have unsuccessfully attempted to explain the causal mechanisms of the lack of blood clots inside the dental socket. The main symptom and true protagonist of this pathology, that is, the intense pain perceived by 100% of the patients who have suffered this postoperative complication of extraction, has been underestimated by dental professionals for decades. Treatment orientation should focus on immediate pain relief. Thirty-seven patients were treated with a conservative but intensive treatment of the dental alveolus by washing with 3% hydrogen peroxide. The cavity is immediately filled without compression with gauze soaked in the purest eugenol whose objective is to eliminate pain definitively two minutes after starting the protocol. The simplified treatment protocol with eugenolate gauze allows immediate cessation of pain and eliminates the need for analgesic-antiinflammatory medication. Eugenol gauze is changed periodically until definitive symptomatic remission in approximately 2 weeks.

Treatment outcomes and associated factors for hospitalization of children treated for acute malnutrition under the OptiMA simplified protocol: a prospective observational cohort in rural Niger.

Globally, access to treatment for severe and moderate acute malnutrition is very low, in part because different protocols and products are used in separate programs. New approaches, defining acute malnutrition (AM) as mid-upper arm circumference (MUAC) < 125 mm or oedema, are being investigated to compare effectiveness to current programs. Optimizing Malnutrition treatment (OptiMA) is one such strategy that treats AM with one product - ready-to-use therapeutic food, or RUTF - at reduced dosage as the child improves. This study aimed to determine whether OptiMA achieved effectiveness benchmarks established in the Nigerien National Nutrition protocol. A prospective cohort study of children in the rural Mirriah district evaluated outcomes among children 6-59 months with uncomplicated AM treated under OptiMA. In a parallel, unconnected program in one of the two trial sites, all non-malnourished children 6-23 months of age were provided small quantity lipid-based nutritional supplements (SQ-LNS). A multivariate logistic regression identified factors associated with hospitalization. From July-December 2019, 1,105 children were included for analysis. Prior to treatment, 39.3% of children received SQ-LNS. Recovery, non-response, and mortality rates were 82.3%, 12.6%, and 0.7%, respectively, and the hospitalization rate was 15.1%. Children who received SQ-LNS before an episode of AM were 43% less likely to be hospitalized (ORa=0.57; 0.39-0.85, p = 0.004). OptiMA had acceptable recovery compared to the Nigerien reference but non-response was high. Children who received SQ-LNS before treatment under OptiMA were less likely to be hospitalized, showing potential health benefits of combining simplified treatment protocols with food-based prevention in an area with a high burden of malnutrition such as rural Niger.

PS-P12-5: CHALLENGES FOR REGISTERED PATIENTS RECEIVING HYPERTENSION CARE FROM PRIMARY HEALTH CENTERS IN BANGLADESH

Introduction: One in every five adults in Bangladesh suffers from Hypertension. There is a high prevalence of undetected hypertensive patients. Among the detected cases, the control rate of hypertension is poor. Since 2018, the National Heart Foundation of Bangladesh has undertaken an intensive hypertension control program along with the Non-Communicable Disease Control (NCDC) program, the Government of Bangladesh at primary health care settings. This control program implements a number of proven strategies which are a standard simplified treatment protocol, community-based care and task sharing, regular supply of medication, and patient-centered care. Irregular follow up visit and non-adherent to medication fail to control hypertension and increase premature death among patients. Objectives: To identify the challenges and barriers to the adherence of antihypertensive medication. Design and method: A cross sectional study where total number of 6498 registered hypertensive patients of four Upazila Health Complexes (UHC)s in Sylhet district, northeast part of Bangladesh is selected from April 2019 to August 2020 for this study purpose. These patients are identified since they missed all of their three consecutive monthly follow-up visits at their respective UHCs.. A digital android based application is used as the monitoring tool in the program through which patients are identified as overdue. Data were collected by a questionnaire through an interview over telephone. Result: Among 6498 registered hypertensive patients, 3548 patients were contacted. Among those 47% mentioned the distance to the UHCs and long waiting time as challenging factors for receiving antihypertensive medications monthly from their assigned facilities. Due to poor treatment compliance, a number of patients (2.9%) did not return. Moreover, 3.3% of the respondents switched to private practitioners and 0.2% moved to the secondary or tertiary hospital. 0.6% of the respondents could not receive the antihypertensive medication from UHC due to their physical illness and 0.3% migrated to another location. The interviewer found 0.4% overdue patients dead. 12.9% did not receive the call and 8.6% did not mention any reason. 23.5% of the overdue patients gave wrong phone number during their registration. Conclusion: This study revealed a number of challenges mentioned by the respondents receiving hypertension care from primary health centers. Addressing these challenges might be effective to improve the hypertension care. Hypertension treatment at community level from the nearest health facility should be included to overcome the barriers.

Cost-effectiveness of routine versus indicated antibiotic therapy in the management of severe wasting in children

BackgroundIn the outpatient management of severe wasting, routine antibiotic therapy is recommended for all children upon admission regardless of whether clinical signs of infection are present. Indicated antibiotic therapy, where antibiotics are provided only upon presentation of clinical signs of infection, may be considered for its potential to allow for more prudent antibiotic use and greater program coverage, reducing the risk of antibiotic resistance as well as costs and logistical burdens associated with treatment. We therefore conducted a cost-effectiveness analysis to measure the effects of indicated antibiotic therapy compared to routine antibiotic therapy in terms of incremental cost-per-life-year saved in Niger.MethodsWe used a cohort model to conduct a cost-effectiveness analysis from a healthcare system perspective to project and weigh the lifetime discounted costs and effects of indicated antibiotic therapy compared to routine antibiotic therapy in the treatment of uncomplicated severe wasting in children in Niger. We calculated incremental cost-effectiveness ratios (ICERs) in terms of treatment-related healthcare costs per discounted life-years saved (LYS), and conducted program coverage scenario and sensitivity analyses to assess model uncertainty.ResultsThe ICER for indicated antibiotic therapy compared to routine antibiotic therapy was $8.5/LYS, which is under the cost-effectiveness threshold for Niger. The probability of the indicated strategy being optimal was 76.1% when program coverage was equal to coverage associated with routine therapy but was 100% likely to be optimal in probabilistic sensitivity analysis scenarios where indicated program coverage improved 5 percentage points.ConclusionsIndicated antibiotic therapy likely represents a cost-effective strategy, particularly if indicated treatment can result in expanded coverage. With the risk of increasing antibiotic resistance worldwide, antibiotic stewardship and simplified treatment protocols for severe wasting using indicated antibiotic therapy may represent good value for money in some low risk populations.

Hypertension in Low- and Middle-Income Countries.

In recent decades low- and middle-income countries (LMICs) have been witnessing a significant shift toward raised blood pressure; yet in LMICs, only 1 in 3 are aware of their hypertension status, and ≈8% have their blood pressure controlled. This rising burden widens the inequality gap, contributes to massive economic hardships of patients and carers, and increases costs to the health system, facing challenges such as low physician-to-patient ratios and lack of access to medicines. Established risk factors include unhealthy diet (high salt and low fruit and vegetable intake), physical inactivity, tobacco and alcohol use, and obesity. Emerging risk factors include pollution (air, water, noise, and light), urbanization, and a loss of green space. Risk factors that require further in-depth research are low birth weight and social and commercial determinants of health. Global actions include the HEARTS technical package and the push for universal health care. Promising research efforts highlight that successful interventions are feasible in LMICs. These include creation of health-promoting environments by introducing salt-reduction policies and sugar and alcohol tax; implementing cost-effective screening and simplified treatment protocols to mitigate treatment inertia; pooled procurement of low-cost single-pill combination therapy to improve adherence; increasing access to telehealth and mHealth (mobile health); and training health care staff, including community health workers, to strengthen team-based care. As the blood pressure trajectory continues creeping upward in LMICs, contextual research on effective, safe, and cost-effective interventions is urgent. New emergent risk factors require novel solutions. Lowering blood pressure in LMICs requires urgent global political and scientific priority and action.

Cost and cost-effectiveness of a real-world HCV treatment program among HIV-infected individuals in Myanmar

IntroductionOver half of those hepatitis C virus (HCV)/HIV coinfected live in low-income and middle-income countries, and many remain undiagnosed or untreated. In 2016, Médecins Sans Frontières (MSF) established a direct-acting...

CROSS-SECTIONAL DISEASE REGISTRY ON INTENSIFICATION OF INSULIN THERAPY IN UNCONTROLLED INSULINIZED T2DM PATIENTS IN CURRENT PRACTICE IN TUNISIA

Ponte Academic JournalDec 2021, Volume 77, Issue 12 CROSS-SECTIONAL DISEASE REGISTRY ON INTENSIFICATION OF INSULIN THERAPY IN UNCONTROLLED INSULINIZED T2DM PATIENTS IN CURRENT PRACTICE IN TUNISIAAuthor(s): Leila Ben Salem ,Ben Aissa Emna, Hsairi Mohamed, Zidi BorniJ. Ponte - Dec 2021 - Volume 77 - Issue 12 doi: 10.21506/j.ponte.2021.12.4 Abstract:Introduction : The aim of this observational study based on a disease registry was to assess the insulin therapy intensification practice in Tunisia and their benefits in patients with T2DM not controlled by basal insulin or mixed insulins. Methods: Multicentre, observational, cross sectional disease registry, non-interventional on the therapeutic strategy, with one planned visit. T2DM adults uncontrolled (HbA1c &amp;gt;7%) with ≥1 OADs and basal insulin or premixed insulin, who provided written informed consent were recruited in this registry. Results: 22 endocrinologists randomly selected from the national list base of 180 Tunisian endocrinologists participated to this study, 20 consecutive patients were included per center, a total of 413 were recruited in this registry. The mean ±SD age was 59.6 ±10.5 years and 53.8% were female. This study revealed that, at the end, 47.2% of T2DM adults included received basal plus or basal bolus regimen. Various strategies of insulin intensification were observed : 42.1% who received at first basal insulin were switched to basal plus or bolus; 3.2% who received at first basal insulin were switched to premix insulin. Among patients who were treated at first with premix insulin, 26.2% were switched to basal plus or basal bolus, while 16.7% were treated with increasing the injections number or the dose of premix insulin. In addition it seems important to underline that 142 of T2DM adults included (34.5% of total patients) had no change of their initial insulin regimen and keeping the same doses. The absence of intensification of insulin was significantly more common among patients with university educational level (p=0.01), very satisfactory socioeconomic level (p&amp;lt;0.001), patients whose insulin initiation started more than two years (p&amp;lt;0.001) and patients with hypertension (p=0.04). The absence of intensification of insulin was significantly lower in patients with lower mean fasting blood glucose (p=0.007) and HbA1c (p&amp;lt;0.001) and in patients initially treated with basal regimen. Good adherence to ADA/EASD recommendations was observed in only 47.8% of cases. Conclusions : Although this study enrolled 413 uncontrolled diabetes patients treated with OADs+ inulines, 34.5% of total patients remain without change of initial insulin regimen and keep the same doses. There is also a suboptimal adherence to the ADA/EASD recomandation as good adherence to ADA/EASD recommendations was observed in less than half of the cases, whren we know that insulin therapy with basal insulin, basal bolus or premixed insulin will eventually need to be optimized, to avoid long-term diabetes complications. Probably, current international guideline recommendations should be adapted to real-life clinical practice. Simplified treatment protocols, associated with patient education, could allow physicians to become efficient prescribers of insulin intensification in clinical practice. Download full text:Check if you have access through your login credentials or your institution Username Password

Acute malnutrition recovery energy requirements based on mid-upper arm circumference: Secondary analysis of feeding program data from 5 countries, Combined Protocol for Acute Malnutrition Study (ComPAS) Stage 1.

BackgroundSevere and moderate acute malnutrition (SAM and MAM) are currently treated with different food products in separate treatment programs. The development of a unified and simplified treatment protocol using a single food product aims to increase treatment program efficiency and effectiveness. This study, the first stage of the ComPAS trial, sought to assess rate of growth and energy requirements among children recovering from acute malnutrition in order to design a simplified, MUAC-based dosage protocol.MethodsWe obtained secondary data from patient cards of children aged 6–59 months recovering from SAM in outpatient therapeutic feeding programs (TFPs) and from MAM in supplementary feeding programs (SFPs) in five countries in Africa and Asia. We used local polynomial smoothing to assess changes in MUAC and proportional weight gain between clinic visits and assessed their normalized differences for a non-zero linear trend. We estimated energy needs to meet or exceed the growth observed in 95% of visits.ResultsThis analysis used data from 5518 patients representing 33942 visits. Growth trends in MUAC and proportional weight gain were not significantly different, each lower at higher MUAC values: MUAC growth averaged 2mm/week at lower MUACs (100 to <110mm) and 1mm/week at higher MUACs (120mm to <125mm); and proportional weight gain declined from 3.9g/kg/day to 2.4g/kg/day across the same MUAC values. In 95% of visits by children with a MUAC 100mm to <125mm who were successfully treated, energy needs could be met or exceeded with 1,000 kilocalories a day.ConclusionTwo 92g sachets of Ready-to-Use Therapeutic Food (RUTF) (1,000kcal total) is proposed to meet the estimated total energy requirements of children with a MUAC 100mm to <115mm, and one 92g sachet of RUTF (500kcal) is proposed to meet half the energy requirements of children with a MUAC of 115 to <125mm. A simplified, combined protocol may enable a more holistic continuum of care, potentially contributing to increased coverage for children suffering from acute malnutrition.

Performance of low-literate community health workers treating severe acute malnutrition in South Sudan.

Previous studies have described barriers to access of childhood severe acute malnutrition (SAM) treatment, including long travel distances and high opportunity costs. To increase access in remote communities, the International Rescue Committee developed a simplified SAM treatment protocol and low-literacy-adapted tools for community-based distributors (CBD, the community health worker cadre in South Sudan) to deliver treatment in the community. A mixed-methods pilot study was conducted to assess whether low-literate CBDs can adhere to a simplified SAM treatment protocol and to examine the community acceptability of CBDs providing treatment. Fifty-seven CBDs were randomly selected to receive training. CBD performance was assessed immediately after training, and 44 CBDs whose performance score met a predetermined standard were deployed to test the delivery of SAM treatment in their communities. CBDs were observed and scored on their performance on a biweekly basis through the study. Immediately after training, 91% of the CBDs passed the predetermined 80% performance score cut-off, and 49% of the CBDs had perfect scores. During the study, 141 case management observations by supervisory staff were conducted, resulting in a mean score of 89.9% (95% CI: 86.4%-96.0%). For each performance supervision completed, the final performance score of the CBD rose by 2.0% (95% CI: 0.3%-3.7%), but no other CBD characteristic was associated with the final performance score. This study shows that low-literate CBDs in South Sudan were able to follow a simplified treatment protocol for uncomplicated SAM with high accuracy using low-literacy-adapted tools, showing promise for increasing access to acute malnutrition treatment in remote communities.

Comparison of 2 and 4 Intratympanic Steroid Injections in the Treatment of Idiopathic Sudden Sensorineural Hearing Loss.

We studied the effect of intratympanic steroid administration with different total injection times on hearing outcomes in patients with idiopathic sudden sensorineural hearing loss (ISSNHL). The subjects were 191 consecutive patients (192 ears) with ISSNHL (hearing level ≥40 dB, interval between onset and treatment ≤30 days). They received systemic prednisolone (100 mg followed by tapered doses) combined with intratympanic injection of dexamethasone (4 mg/ml). Intratympanic injection was performed 4 times (days 1, 2, 4, and 7) in 92 patients (92 ears) or 2 times (days 1 and 2) in 99 patients (100 ears). The hearing outcomes were evaluated at 1 week from the start of treatment and 1 to 2 months after the completion of treatment. There was no significant difference in hearing outcomes between the 4- and 2-injection groups at either time point. Multiple regression analysis also showed that the hearing level after treatment did not depend on the total number of intratympanic steroid injections. These results indicate that a protocol using only 2 intratympanic steroid injections exerts a sufficient effect on the hearing outcomes of ISSNHL. This simplified treatment protocol would be greatly beneficial to relieve the physical and mental stress of patients.

Hot topic: Early postpartum treatment of commercial dairy cows with nonsteroidal antiinflammatory drugs increases whole-lactation milk yield

Previous research has shown that postpartum administration of the nonsteroidal antiinflammatory drug (NSAID) sodium salicylate can increase 305-d milk yield in older dairy cattle (parity 3 and greater). However, in this prior work, sodium salicylate was delivered to cows via the drinking water, a method that does not align well with current grouping strategies on commercial dairy farms. The objective of the current study was to replicate these results on a commercial dairy farm with a simplified treatment protocol and to compare sodium salicylate with another NSAID, meloxicam. Dairy cattle in their second lactation and greater (n=51/treatment) were alternately assigned to 1 of 3 treatments at parturition, with treatments lasting for 3d. Experimental treatments began 12 to 36h after parturition and were (1) 1 placebo bolus on the first day and 3 consecutive daily drenches of sodium salicylate (125g/cow per day; SAL); (2) 1 bolus of meloxicam (675mg/cow) and 3 drenches of an equal volume of water (MEL); or (3) 1 placebo bolus and 3 drenches of water (CON). Blood samples were collected on the first day of treatment, immediately following the last day of treatment, and 7d after the last day of treatment; plasma was analyzed for glucose, β-hydroxybutyrate (BHB), free fatty acids, haptoglobin, and paraoxonase. Milk production, body condition score, reproductive status, and retention in the herd were monitored for 365d posttreatment, and effects of treatment, parity, days in milk, and interactions were evaluated in mixed effects models. Significance was declared at P<0.05. Whole-lactation milk and protein yields were greater in NSAID-treated cows, although 305-d fat production was not affected. There was a significant interaction of treatment and parity for plasma glucose concentration; MEL increased plasma glucose concentrations compared with CON and SAL in older cows. Sodium salicylate decreased plasma BHB concentration compared with MEL at 7d posttreatment, although no difference was detected immediately following treatment. Haptoglobin concentrations were elevated in SAL cows compared with CON. There was a tendency for CON cows to be removed from the herd more quickly than MEL cows (42 vs. 26% at 365d posttreatment). Body condition score, concentrations of plasma free fatty acids and paraoxonase, and time to pregnancy were not affected by treatment. These results indicate that NSAID administration in postpartum cows has the potential to be a viable way to improve productivity and potentially longevity in commercial dairies, although further research is necessary to optimize recommendations for producers.

Implant protected occlusion: A comprehensive review

Complexities in the study of occlusion have set tough challenges for both under graduate and post-graduate students and the introduction of osseointegrated implants has further complicated these challenges. The principles of occlusion are applied by dentists for the natural dentition directly to implant-supported and retained restorations. Although successful, this rationale at times may result in overly complex or simplified treatment protocols and outcomes. The focus of this review is mainly on currently available scientific literature involving dental implant occlusion. The authors reviewed the English peer-reviewed literature prior to 1996 in a comprehensive manner, and the material post 1996 was reviewed electronically using MEDLINE. Electronic searches of the literature were performed in MEDLINE using key words - cohort studies, complete denture occlusion, clinical trial, case studies, dental implant function, dental implant occlusion, dental implant occlusion research, dental implant functional loading, dental implants, dental occlusion, dental occlusion research, denture function, denture occlusion, dentures, implant function, implant functional loading, implant occlusion, occlusion, and removable partial denture occlusion - in various combinations to obtain potential references for review. A total of 4445 English language titles were obtained, many of which were duplicates due to multiple searches. Manual hand searching of the MEDLINE reference list was performed to identify any articles missed in the original search.

Metabolic Acidosis in Neonatal Calf Diarrhea—Clinical Findings and Theoretical Assessment of a Simple Treatment Protocol

Clinical assessment of metabolic acidosis in calves with neonatal diarrhea can be difficult because increased blood concentrations of d-lactate and not acidemia per se are responsible for most of the clinical signs exhibited by these animals. To describe the correlation between clinical and laboratory findings and d-lactate concentrations. Furthermore, the theoretical outcome of a simplified treatment protocol based on posture/ability to stand and degree of dehydration was evaluated. A total of 121 calves with diagnosis of neonatal diarrhea admitted to a veterinary teaching hospital during an 8-month study period. Prospective blinded cohort study. Physical examinations were carried out following a standardized protocol. Theoretical outcome of treatment was calculated. Type and degree of metabolic acidosis were age dependent. The clinical parameters posture, behavior, and palpebral reflex were closely correlated to base excess (r = 0.74, 0.78, 0.68; P < .001) and d-lactate concentrations (r = 0.59, 0.59, 0.71; P < .001), respectively. Thus, determining the degree of loss of the palpebral reflex was identified as the best clinical tool for diagnosing increase in serum d-lactate concentrations. Theoretical outcome of treatment revealed that the tested dosages of sodium bicarbonate are more likely to overdose than to underdose calves with diarrhea and metabolic acidosis. The degree of metabolic acidosis in diarrheic calves can be predicted based on clinical findings. The assessed protocol provides a useful tool to determine bicarbonate requirements, but a revision is necessary for calves with ability to stand and marked metabolic acidosis.

Insulin initiation and intensification in patients with T2DM for the primary care physician

Type 2 diabetes mellitus (T2DM) is characterized by both insulin resistance and inadequate insulin secretion. All patients with the disease require treatment to achieve and maintain the target glycosylated hemoglobin (A1C) level of 6.5%–7%. Pharmacological management of T2DM typically begins with the introduction of oral medications, and the majority of patients require exogenous insulin therapy at some point in time. Primary care physicians play an essential role in the management of T2DM since they often initiate insulin therapy and intensify regimens over time as needed. Although insulin therapy is prescribed on an individualized basis, treatment usually begins with basal insulin added to a background therapy of oral agents. Prandial insulin injections may be added if glycemic targets are not achieved. Treatments may be intensified over time using patient-friendly titration algorithms. The goal of insulin intensification within the primary care setting is to minimize patients’ exposure to chronic hyperglycemia and weight gain, and reduce patients’ risk of hypoglycemia, while achieving individualized fasting, postprandial, and A1C targets. Simplified treatment protocols and insulin delivery devices allow physicians to become efficient prescribers of insulin intensification within the primary care arena.

The WHO public-health approach to antiretroviral treatment against HIV in resource-limited settings

WHO has proposed a public-health approach to antiretroviral therapy (ART) to enable scaling-up access to treatment for HIV-positive people in developing countries, recognising that the western model of specialist physician management and advanced laboratory monitoring is not feasible in resource-poor settings. In this approach, standardised simplified treatment protocols and decentralised service delivery enable treatment to be delivered to large numbers of HIV-positive adults and children through the public and private sector. Simplified tools and approaches to clinical decision-making, centred on the "four Ss"--when to: start drug treatment; substitute for toxicity; switch after treatment failure; and stop--enable lower level health-care workers to deliver care. Simple limited formularies have driven large-scale production of fixed-dose combinations for first-line treatment for adults and lowered prices, but to ensure access to ART in the poorest countries, the care and drugs should be given free at point of service delivery. Population-based surveillance for acquired and transmitted resistance is needed to address concerns that switching regimens on the basis of clinical criteria for failure alone could lead to widespread emergence of drug-resistant virus strains. The integrated management of adult or childhood illness (IMAI/IMCI) facilitates decentralised implementation that is integrated within existing health systems. Simplified operational guidelines, tools, and training materials enable clinical teams in primary-care and second-level facilities to deliver HIV prevention, HIV care, and ART, and to use a standardised patient-tracking system.