The impact of antibiotic use on the incidence and resistance pattern of extended-spectrum beta-lactamase-producing bacteria in primary and secondary healthcare settings

Aims: The objective of the present study was to study the relationship between hospital antibiotic use, community antibiotic use and the incidence of extended-spectrum beta-lactamase (ESBL)-producing bacteria in hospitals, while assessing the impact of a fluoroquinolone restriction policy on ESBL-producing bacteria incidence rates. METHODS: The study was retrospective and ecological in design. A multivariate autoregressive integrated moving average (ARIMA) model was built to relate antibiotic use to ESB-producing bacteria incidence rates and resistance patterns over a 5 year period (January 2005-December 2009). Results: Analysis showed that the hospital incidence of ESBLs had a positive relationship with the use of fluoroquinolones in the hospital (coefficient = 0.174, P= 0.02), amoxicillin-clavulanic acid in the community (coefficient = 1.03, P= 0.03) and mean co-morbidity scores for hospitalized patients (coefficient = 2.15, P= 0.03) with various time lags. The fluoroquinolone restriction policy was implemented successfully with the mean use of fluoroquinolones (mainly ciprofloxacin) being reduced from 133 to 17 defined daily doses (DDDs)/1000 bed days (P <0.001) and from 0.65 to 0.54 DDDs/1000 inhabitants/day (P= 0.0007), in both the hospital and its surrounding community, respectively. This was associated with an improved ciprofloxacin susceptibility in both settings [ciprofloxacin susceptibility being improved from 16% to 28% in the community (P <0.001)] and with a statistically significant reduction in ESBL-producing bacteria incidence rates. Discussion: This study supports the value of restricting the use of certain antimicrobial classes to control ESBL, and demonstrates the feasibility of reversing resistance patterns post successful antibiotic restriction. The study also highlights the potential value of the time-series analysis in designing efficient antibiotic stewardship. © 2011 The Authors. British Journal of Clinical Pharmacology © 2011 The British Pharmacological Society.

Violence in the Lives of Children and Youth in “Post-Conflict” Northern Ireland

While Northern Ireland experiences relative peace and political stability, its violent past is normalized in murals and commemorations, the language and posturing of opposition politics, segregated communities and social life. In “post-conflict” Northern Ireland, children and youth disproportionately experience paramilitary-style attacks and routine sectarian violence. The violence of poverty and restricted opportunities within communities debilitated by three decades of conflict is masked by a discourse of social, economic and political progress. Drawing on qualitative research, this paper illustrates the continued legacy and impacts of violence on the lives of children and youth living in post-ceasefire Northern Ireland. It discusses the prominence of violence—sectarian, racist, political, “everyday,” domestic, “informal”—in young people's accounts and the impacts on their safety, sense of belonging, identity formation, use of space and emotional well-being. The paper concludes by challenging narrow and reductionist explanations of violence, arguing the need to contextualize these within local, historical, political, cultural and material contexts.

Studies to Reduce Unnecessary Medication Use in Frail Older Adults:A Systematic Review

BACKGROUND: Overuse of unnecessary medications in frail older adults with limited life expectancy remains an understudied challenge. OBJECTIVE: To identify intervention studies that reduced use of unnecessary medications in frail older adults. A secondary goal was to identify and review studies focusing on patients approaching end of life. We examined criteria for identifying unnecessary medications, intervention processes for medication reduction, and intervention effectiveness. METHODS: A systematic review of English articles using MEDLINE, EMBASE, and International Pharmaceutical Abstracts from January 1966 to September 2012. Additional studies were identified by searching bibliographies. Search terms included prescription drugs, drug utilization, hospice or palliative care, and appropriate or inappropriate. A manual review of 971 identified abstracts for the inclusion criteria (study included an intervention to reduce chronic medication use; at least 5 participants; population included patients aged at least 65 years, hospice enrollment, or indication of frailty or risk of functional decline-including assisted living or nursing home residence, inpatient hospitalization) yielded 60 articles for full review by 3 investigators. After exclusion of review articles, interventions targeting acute medications, or studies exclusively in the intensive care unit, 36 articles were retained (including 13 identified by bibliography review). Articles were extracted for study design, study setting, intervention description, criteria for identifying unnecessary medication use, and intervention outcomes. RESULTS: The studies included 15 randomized controlled trials, 4 non-randomized trials, 6 pre-post studies, and 11 case series. Control groups were used in over half of the studies (n = 20). Study populations varied and included residents of nursing homes and assisted living facilities (n = 16), hospitalized patients (n = 14), hospice/palliative care patients (n = 3), home care patients (n = 2), and frail or disabled community-dwelling patients (n = 1). The majority of studies (n = 21) used implicit criteria to identify unnecessary medications (including drugs without indication, unnecessary duplication, and lack of effectiveness); only one study incorporated patient preference into prescribing criteria. Most (25) interventions were led by or involved pharmacists, 4 used academic detailing, 2 used audit and feedback reports targeting prescribers, and 5 involved physician-led medication reviews. Overall intervention effect sizes could not be determined due to heterogeneity of study designs, samples, and measures. CONCLUSIONS: Very little rigorous research has been conducted on reducing unnecessary medications in frail older adults or patients approaching end of life.

Post-Translational Inhibition of IP-10 Secretion in IEC by Probiotic Bacteria: Impact on Chronic Inflammation

Background: Clinical and experimental studies suggest that the probiotic mixture VSL#3 has protective activities in the context of inflammatory bowel disease (IBD). The aim of the study was to reveal bacterial strain-specific molecular mechanisms underlying the anti-inflammatory potential of VSL#3 in intestinal epithelial cells (IEC).

Methodology/Principal Findings: VSL#3 inhibited TNF-induced secretion of the T-cell chemokine interferon-inducible protein (IP-10) in Mode-K cells. Lactobacillus casei (L. casei) cell surface proteins were identified as active anti-inflammatory components of VSL#3. Interestingly, L. casei failed to block TNF-induced IP-10 promoter activity or IP-10 gene transcription at the mRNA expression level but completely inhibited IP-10 protein secretion as well as IP-10-mediated T-cell transmigration. Kinetic studies, pulse-chase experiments and the use of a pharmacological inhibitor for the export machinery (brefeldin A) showed that L. casei did not impair initial IP-10 production but decreased intracellular IP-10 protein stability as a result of blocked IP-10 secretion. Although L. casei induced IP-10 ubiquitination, the inhibition of proteasomal or lysosomal degradation did not prevent the loss of intracellular IP-10. Most important for the mechanistic understanding, the inhibition of vesicular trafficking by 3-methyladenine (3-MA) inhibited IP-10 but not IL-6 expression, mimicking the inhibitory effects of L. casei. These findings suggest that L. casei impairs vesicular pathways important for the secretion of IP-10, followed by subsequent degradation of the proinflammatory chemokine. Feeding studies in TNF Delta ARE and IL-10(-/-) mice revealed a compartimentalized protection of VSL#3 on the development of cecal but not on ileal or colonic inflammation. Consistent with reduced tissue pathology in IL-10(-/-) mice, IP-10 protein expression was reduced in primary epithelial cells.

Conclusions/Significance: We demonstrate segment specific effects of probiotic intervention that correlate with reduced IP-10 protein expression in the native epithelium. Furthermore, we revealed post-translational degradation of IP-10 protein in IEC to be the molecular mechanism underlying the anti-inflammatory effect.

Interventions to improve the appropriate use of polypharmacy for older people

Background
Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, hence interest in appropriate polypharmacy, where many medicines may be used to achieve better clinical outcomes for patients, is growing.

Objectives
This review sought to determine which interventions, alone or in combination, are effective in improving the appropriate use of polypharmacy and reducing medication-related problems in older people.

Search methods
In November 2013, for this first update, a range of literature databases including MEDLINE and EMBASE were searched, and handsearching of reference lists was performed. Search terms included 'polypharmacy', 'medication appropriateness' and 'inappropriate prescribing'.

Selection criteria
A range of study designs were eligible. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people 65 years of age and older in which a validated measure of appropriateness was used (e.g. Beers criteria, Medication Appropriateness Index (MAI)).

Data collection and analysis
Two review authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. Study-specific estimates were pooled, and a random-effects model was used to yield summary estimates of effect and 95% confidence intervals (CIs). The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to assess the overall quality of evidence for each pooled outcome.

Main results
Two studies were added to this review to bring the total number of included studies to 12. One intervention consisted of computerised decision support; 11 complex, multi-faceted pharmaceutical approaches to interventions were provided in a variety of settings. Interventions were delivered by healthcare professionals, such as prescribers and pharmacists. Appropriateness of prescribing was measured using validated tools, including the MAI score post intervention (eight studies), Beers criteria (four studies), STOPP criteria (two studies) and START criteria (one study). Interventions included in this review resulted in a reduction in inappropriate medication usage. Based on the GRADE approach, the overall quality of evidence for all pooled outcomes ranged from very low to low. A greater reduction in MAI scores between baseline and follow-up was seen in the intervention group when compared with the control group (four studies; mean difference -6.78, 95% CI -12.34 to -1.22). Postintervention pooled data showed a lower summated MAI score (five studies; mean difference -3.88, 95% CI -5.40 to -2.35) and fewer Beers drugs per participant (two studies; mean difference -0.1, 95% CI -0.28 to 0.09) in the intervention group compared with the control group. Evidence of the effects of interventions on hospital admissions (five studies) and of medication-related problems (six studies) was conflicting.

Authors' conclusions
It is unclear whether interventions to improve appropriate polypharmacy, such as pharmaceutical care, resulted in clinically significant improvement; however, they appear beneficial in terms of reducing inappropriate prescribing.

How well do midwives use skills and knowledge in examining newborns?

Physical examination of the newborn (PEN) was established as part of postnatal care in the late 1960s. The role of discharging babies within the first 72 hours of birth was traditionally undertaken by junior doctors. Currently midwives, nurses, advanced nurse practitioners, and health visitors are being trained to undertake the PEN (NHS Screening Programmes, 2010). However, only a fraction of midwives utilize their acquired skills in clinical practice. A survey by Townsend et al (2004) showed that 2% of babies in England were examined by midwives while 83% were examined by junior doctors.This study aimed to evaluate how well midwives who undertook the PEN course between 2002 and 2005 (n = 40) at a large London University utilized the skills acquired on the course. Questionnaires with a series of open and closed questions were sent out by post followed by phone and email reminders. The eight that responded were midwives. All respondents said they were appropriately trained and felt well prepared for their role to examine babies. However, they felt they were not provided with opportunities to use the skills. Guidelines based on this extended role are available in the workplace but only a few midwives seemed to have negotiated time to implement these and may need greater managerial support for the role.

From Frank Miller to Zack Snyder, and Return: Contemporary Superhero Comics and Post-Classical Hollywood

Film adaptations of superhero comic-books offer a particularly rich case study to analyse narrative strategies of contemporary Hollywood cinema. The serial structures adopted by the comics they are based on, as well as their use of the spectacular potential of the image, provide a successful model for current audiovisual productions. Without completely abandoning classical techniques, these adaptations try to find a new balance between narrative and digital phantasmagoria. This paper discusses some significant examples of this genre, including adaptations of classical DC and Marvel franchises and more recent series, as well as other comic-book influenced films such as The Matrix and Unbreakable.

Counter-Revolution by Ideology? Law and development's vision(s) for post-revolutionary Egypt

Law and development, as both movement and practice, has led a tumultuous life: a hurried zenith cut short by a fatal critique followed by an opportunistic resurrection. The name alone is su?cient to trigger a range of reactions, extending from the complimentary to the condemnatory. In this article I track law and development’s evolution via an examination of its role in the remodelling of Egyptian society in the post-Nasser era. While the 2011 revolution has encouraged institutions such as USAID to hasten their legal reform e?orts, I argue that these are more akin to counter-revolution by ideology than genuine revolution by law. Nevertheless, rather than relegate the movement to the annals of imperial intrigue, I conclude by proposing the use of legal pluralism to revive, and possibly ignite, law and development’s emancipatory potential.

A leadership framework to support the use of e-learning resources

Aim
This inquiry aims to apply the NHS leadership framework to nurse education for the implementation of e-learning.
Background
Recognition needs to be given to the emerging postgraduate nursing students new status of consumer and the challenge now for nurse education is how to remain relevant and competitive in this consumer led market. The move towards an e-learning paradigm has been suggested as a competitive and contemporary way forward for the student consumer. The successful introduction of e-learning in nurse education will require leadership and a strong organisational management system.
Discussion
Each element of the NHS leadership framework is described and interpreted for application in a higher education setting for the implementation of e-learning.
Conclusions
Change in the delivery of post graduate nurse education is necessary to ensure it remains current and reflective of consumer need in a competitive marketplace. By applying a leadership framework that acknowledges the skills and abilities of staff and encourages the formation of collaborative partnerships from within the wider university community, educators can begin to develop skills and confidence in teaching using e-learning resources.

Non-apologies and prolonged silences in post-conflict settings: The case of post-colonial Cyprus

Despite the growing use of apologies in post-conflict settings, cases of non-apology remain unaddressed and continue to puzzle scholars. This article focuses on the absence of apology by non-state and anti-state actors by examining the case of the Cypriot armed group EOKA, which has refused to offer an apology to the civilian victims of its ‘anti-colonial’ struggle (1955–1959). Using field data and parliamentary debates, and drawing on comparisons, this article analyses the factors that contributed to a lack of apology. It is argued that the inherited timelessness of Greek nationalism, and the impression of a perpetual need for defence, set up textbook conditions for the development of a hegemonic discourse and prevented an apology for human rights violations.

Post mastectomy radiotherapy in breast cancer: a survey of current United Kingdom practice

Purpose: Radiotherapy (RT) is increasingly used following mastectomy for breast cancer While indications for post-mastectomy radiotherapy (PMRT) are clear in patient groups at high risk of local recurrence, guidelines are less clear in intermediate-risk patients and patients with ductal carcinoma in situ (DCIS). This study aimed to determine variations in the use of PMRT in the United Kingdom (UK).

Methods: A postal survey of all consultant breast surgeon members of the Association of Breast Surgery in the UK.

Results: Tumour size and nodal status were confirmed as the most important indications for PMRT There was significant variation in the influence of other factors such as tumour grade, lymphovascular invasion and margin status. Nineteen per cent of respondents stated that they would consider the use of PMRT in cases of DCIS alone.

Conclusions: There is significant variation in practice across the UK with regard to the use of PMRT in intermediate risk breast cancer and patients with DCIS. Further work is required to determine which patients in these groups are likely to benefit from the use of PMRT.

Post-diagnostic prescriptions for low-dose aspirin and breast cancer-specific survival: a nested case-control study in a breast cancer cohort from the UK Clinical Practice Research Datalink

INTRODUCTION: Recent observational studies indicate that post-diagnostic use of aspirin in breast cancer patients may protect against cancer progression perhaps by inhibiting cyclooxygenase-2 dependent mechanisms. Evidence also supports a crucial role for interactions between tumour cells and circulating platelets in cancer growth and dissemination, therefore, use of low-dose aspirin may reduce the risk of death from cancer in breast cancer patients.

METHODS: A cohort of newly diagnosed breast cancer patients (1998 to 2006) were identified in the UK Clinical Practice Research Datalink (and confirmed by cancer registry linkage). Cancer-specific deaths were identified up to 2011 from Office for National Statistics mortality data. A nested case-control analysis was conducted using conditional logistic regression to compare post-diagnostic aspirin exposure using General Practice prescription data in 1,435 cases (breast cancer deaths) with 5,697 controls (matched by age and year of diagnosis).

RESULTS: After breast cancer diagnosis, 18.3% of cancer-specific deaths and 18.5% of matched controls received at least one prescription for low-dose aspirin, corresponding to an odds ratio (OR) of 0.98 (95% CI 0.83, 1.15). Adjustment for potential confounders (including stage and grade) had little impact on this estimate. No dose response relationship was observed when the number of tablets was investigated and no associations were seen when analyses were stratified by receipt of prescriptions for aspirin in the pre-diagnostic period, by stage at diagnosis or by receipt of prescriptions for hormone therapy.

CONCLUSIONS: Overall, in this large population-based cohort of breast cancer patients, there was little evidence of an association between receipt of post-diagnostic prescriptions for low-dose aspirin and breast cancer-specific death. However, information was not available on medication compliance or over-the-counter use of aspirin, which may have contributed to the null findings.

A systematic review of midwife led interventions to address post traumatic stress syndrome

Objective
to systematically identify interventions that midwives could introduce to address post-traumatic stress in women following childbirth.

Methods
a search strategy was developed and relevant papers were identified from databases including Cinahl, Cochrane Library, EMBASE, Maternity and Infant Care, MEDLINE, PsycINFO, and Web of Science. Key search terms used were post-traumatic stress, post partum, intervention, controlled trial and review. Papers eligible for inclusion were primary studies and reviews of research published from 2002–2012, focusing on interventions which could be implemented by midwives for the prevention and/or management of PTSD. For primary studies, RCTs, controlled clinical trials, and cohort studies with a control group were eligible. Eligible reviews were those with a specified search strategy and inclusion/exclusion criteria. Methodological quality was assessed using recognised frameworks.

Findings
six primary studies and eight reviews were eligible for inclusion. The majority of included studies or reviews focused on debriefing and/or counselling interventions; however the results were not consistent due to significant variation in methodological quality and use of dissimilar interventions. Two of the reviews considered the general management of post partum PTSD and one broadly covered anxiety during pregnancy and the post partum, incorporating a section on PTSD. The majority of women reported that the opportunity to discuss their childbirth experience was subjectively beneficial.

Conclusions and implications for practice
no evidence-based midwifery interventions were identified from this systematic review that can be recommended for introduction into practice to address PTSD. It is recommended that future research in this area should incorporate standardised interventions with similar outcome measures to facilitate synthesis of results. Further research on interventions used in non-maternity populations is needed in order to confirm their usefulness in addressing post partum PTSD.

Impact of electric vehicles on a carbon constrained power system—a post 2020 case study

Electric vehicles (EVs) offer great potential to move from fossil fuel dependency in transport once some of the technical barriers related to battery reliability and grid integration are resolved. The European Union has set a target to achieve a 10% reduction in greenhouse gas emissions by 2020 relative to 2005 levels. This target is binding in all the European Union member states. If electric vehicle issues are overcome then the challenge is to use as much renewable energy as possible to achieve this target. In this paper, the impacts of electric vehicle charged in the all-Ireland single wholesale electricity market after the 2020 deadline passes is investigated using a power system dispatch model. For the purpose of this work it is assumed that a 10% electric vehicle target in the Republic of Ireland is not achieved, but instead 8% is reached by 2025 considering the slow market uptake of electric vehicles. Our experimental study shows that the increasing penetration of EVs could contribute to approach the target of the EU and Ireland government on emissions reduction, regardless of different charging scenarios. Furthermore, among various charging scenarios, the off-peak charging is the best approach, contributing 2.07% to the target of 10% reduction of Greenhouse gas emissions by 2025.

Digoxin use after diagnosis of breast cancer and survival: a population-based cohort study

Digoxin has been shown to have an estrogenic effect and is associated with increased risk of gynecomastia and estrogen-sensitive cancers such as breast and uterus cancer. These findings, particularly recent observations of increased breast cancer risk, raise questions about the safety of digoxin use in breast cancer patients. Therefore, we investigated whether digoxin use after breast cancer diagnosis increased the risk of breast cancer-specific mortality in breast cancer patients. A cohort of 17,842 breast cancer patients newly diagnosed from 1998 to 2009 was identified from English cancer registries (from the National Cancer Data Repository). This cohort was linked to the UK Clinical Practice Research Datalink (to provide digoxin and other prescription records) and to the Office of National Statistics mortality data (to identify breast cancer-specific deaths). Using time-dependent Cox regression models, unadjusted and adjusted hazard ratios (HR) and 95 % confidence intervals (CIs) were calculated for the association between post-diagnostic exposure to digoxin and breast cancer-specific and all-cause mortality. In 17,842 breast cancer patients, there were 2219 breast cancer-specific deaths. Digoxin users appeared to have increased breast cancer-specific mortality compared with non-users (HR 1.73; 95 % CI 1.39–2.15) but this association was entirely attenuated after adjustment for potential confounders (adjusted HR 0.91; 95 % CI 0.72–1.14). In this large population-based breast cancer cohort study, there was little evidence of an increase in breast cancer-specific mortality with digoxin use after diagnosis. These results provide some reassurance that digoxin use is safe in breast cancer patients.