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This secondary analysis of data of a randomized controlled trial (RCT) retrospectively investigated the performance of pulse oximetry in identifying children with severe illnesses, with and without respiratory signs/symptoms, in a cohort of children followed for morbid episodes in an intervention trial assessing the efficacy of Intermittent Preventive Treatment for malaria in infants (IPTi) in Papua New Guinea (PNG) from June 2006 to May 2010. The IPTi study was conducted in a paediatric population visiting two health centres on the north coast of PNG in the Mugil area of the Sumkar District. A total of 669 children visited the clinic and a total of 1921 illness episodes were recorded. Inclusion criteria were: age between 3 and 27 months, full clinical record (signs/symptoms) and pulse oximetry used systematically to assess sick children at all visits. Children were excluded if they visited the clinic in the previous 14 days. The outcome measures were severe illness, severe pneumonia, pneumonia, defined by the Integrated Management of Childhood Illness (IMCI) definitions, and hospitalization. Out of 1921 illness episodes, 1663 fulfilled the inclusion criteria. A total of 139 severe illnesses were identified, of which 93 were severe pneumonia. The ROC curves of pulse oximetry (continuous variable) showed an AUC of 0.63, 0.68 and 0.65 for prediction of severe illness, severe pneumonia and hospitalization, respectively. Pulse oximetry allowed better discrimination between severe and non-severe illness, severe and non-severe pneumonia, admitted and non-admitted patients, in children ≤12-months of age relative to older patients. For the threshold of peripheral arterial oxygen saturation ≤ 94% measured by pulse oximetry (SpO2), unadjusted odds ratios for severe illness, severe pneumonia and hospitalization were 6.1 (95% Confidence Interval (CI) 3.9-9.8), 8.5 (4.9-14.6) and 5.9 (3.4-10.3), respectively. Pulse oximetry was helpful in identifying children with severe illness in outpatient facilities in PNG. A SpO2 of 94% seems the most discriminative threshold. Considering its affordability and ease of use, pulse oximetry could be a valuable additional tool assisting the decision to admit for treatment.

A meta-analysis showed that PSP performed better than C-reactive protein (CRP) and procalcitonin for detecting infection among hospitalized patients, and that the combination of PSP and CRP further enhanced its accuracy [3]. In this prospective cohort study of COVID-19 patients in the emergency department (ED) of a teaching hospital in Switzerland, we assessed the accuracy of bedside clinical severity scores (Quick Sepsis-related Organ Failure Assessment (qSOFA) and CRB-65), PSP and CRP, which is associated with severity and mortality in COVID-19 [6], at clinical presentation for 7-day mortality and separately, ICU admission. Serial measurement of pancreatic stone protein for the early detection of sepsis in intensive care unit patients: a prospective multicentric study.

Abstract Background A novel ultrasensitive malaria rapid diagnostic test (us-RDT) has been developed for improved active Plasmodium falciparum infection detection. The usefulness of this us-RDT in clinical diagnosis and fever management has not been evaluated. Methods Diagnostic performance of us-RDT was compared retrospectively to that of conventional RDT (co-RDT) in 3000 children and 515 adults presenting with fever to Tanzanian outpatient clinics. The parasite density was measured by an ultrasensitive qPCR (us-qPCR), and the HRP2 concentration was measured by an enzyme-linked immunosorbent assay. Results us-RDT identified few additional P. falciparum–positive patients as compared to co-RDT (276 vs 265 parasite-positive patients detected), with only a marginally greater sensitivity (75% vs 73%), using us-qPCR as the gold standard (357 parasite-positive patients detected). The specificity of both RDTs was >99%. Five of 11 additional patients testing positive by us-RDT had negative results by us-qPCR. The HRP2 concentration was above the limit of detection for co-RDT (>3653 pg of HRP2 per mL of blood) in almost all infections (99% [236 of 239]) with a parasite density >100 parasites per µL of blood. At parasite densities <100 parasites/µL, the HRP2 concentration was above the limits of detection of us-RDT (>793 pg/mL) and co-RDT in 29 (25%) and 24 (20%) of 118 patients, respectively. Conclusion There is neither an advantage nor a risk of using us-RDT, rather than co-RDT, for clinical malaria diagnosis. In febrile patients, only a small proportion of infections are characterized by a parasite density or an HRP2 concentration in the range where use of us-RDT would confer a meaningful advantage over co-RDT. Ultrasensitive rapid diagnostic tests (RDTs) for malaria, designed for Plasmodium falciparum elimination campaigns, may be used off label in clinical practice. The diagnostic performances of ultrasensitive and conventional RDTs were similar in febrile Tanzanian outpatients, which is explained by the underlying HRP2 concentration and parasite density distributions.

Quick Sequential Organ Failure Assessment (qSOFA) is a three-item clinical instrument for bedside identification of sepsis patients at risk of poor outcome. qSOFA could be a valuable triage tool in emergency departments of low-income countries, yet its performance in resource-limited settings remains unknown. The prognostic accuracy of qSOFA for 28-day all-cause mortality in febrile adults treated at the EDs in a low-income country was evaluated. Retrospective analysis of a prospective cohort study of consecutive patients (≥18 years) with fever (tympanic temperature ≥38°C and fever ≤7 days) who presented between July 2013 and May 2014 at four emergency departments in Dar es Salaam, Tanzania. Medical history, clinical examination, laboratory and microbiological data were collected to document the cause of fever. Variables for the previous and new sepsis criteria were collected at inclusion and qSOFA, SOFA and SIRS were measured at inclusion. Patients were followed up by phone at day 28. The performance (sensitivity, specificity and area under the receiver operating curve [AUROC]) of qSOFA (score ≥2), SOFA (increase of ≥2 points) and SIRS (≥2 criteria) as predictors of 28-day all-cause mortality was evaluated. Among the 519 patients (median age: 30 years) included in the analysis, 47% were female and 25% were HIV positive. Overall, 85% had a microbiologically and/or clinically documented infection and 15% a fever of unknown origin. The most common site and causes of infections were the respiratory tract (43%), dengue (26%), malaria (6%) and typhoid fever (5%). Twenty-eight-day all-cause mortality was 6%: 3% for patients with a qSOFA <2 and 24% for those with a score ≥2 (absolute difference, 21%; 95% CI 12%-31%). The prognostic accuracy of qSOFA (AUROC 0.80, 95% CI 0.73-0.87) for 28-day mortality was similar to SOFA (AUROC 0.79, 0.71-0.87; p = 0.1) and better than SIRS (AUROC 0.61, 0.52-0.71; p<0.001). Among patients with fever at emergency departments in Tanzania, qSOFA had a prognostic accuracy for 28-day mortality comparable to SOFA and superior to SIRS. These results support the use of qSOFA as a triage tool to identify patients with sepsis and at risk of poor outcome in resource-limited countries. Clinicaltrials.gov Identifier: NCT01947075.

Background There is no consensus on the antibiotic course or type of surgical treatment in streptococcal periprosthetic-joint infections (PJIs). We aimed to compare the treatment failure rate at 2 years of PJIs caused by streptococci to PJIs caused by other pathogens and identify factors associated with failure. Methods It was a single-center retrospective cohort study conducted between 2009 and 2019. We included all patients aged ≥ 18 years undergoing treatment for hip or knee PJI with a 2-year follow-up. We analyzed the treatment failure rate at 2 years of streptococcal PJIs versus PJIs caused by other pathogens with failure defined as a non-successful treatment using the Delphi-based international multidisciplinary consensus of success. We also analyzed factors associated with failure including streptococcal etiology and type of treatment. Results We included 404 patients; 62 (15%) had a streptococcal PJI, of which 14 (23%) exhibited treatment failure at 2 years. The treatment failure rate was similar to that for PJIs caused by other pathogens (21%, 71/342) ( P  = 0.78). Streptococci were not associated with failure (OR = 1.55, 95% CI 0.62–3.89, P  = 0.35). However, Streptococcus dysgalactiae (OR = 9.45, 95% CI 1.37–65.46, P  = 0.02) and debridement, antibiotics and implant retention (DAIR) (OR = 9.31, 95% CI 1.80–48.20, P  = 0.008) were associated with failure among patients with a streptococcal PJI. Conclusions The treatment failure rate of streptococcal PJIs was similar to that for PJIs caused by other pathogens. However, Streptococcus dysgalactiae and DAIR were factors associated with failure among patients with a streptococcal PJI. Our results suggest that streptococcal PJIs, especially Streptococcus dysgalactiae PJIs, should be surgically treated more aggressively with an implant exchange.

ObjectivesOwing to its ease-of-use and excellent diagnostic performance for the assessment of respiratory symptoms, point-of-care lung ultrasound (POC-LUS) has emerged as an attractive skill in resource-low settings, where limited access to specialist care and inconsistent radiology services erode health equity.To narrow down the research to practice gap, this study aims to gain in-depth insights in the perceptions on POC-LUS and computer-assisted POC-LUS for the diagnosis of lower respiratory tract infections (LRTIs) in a low-income and middle-income country (LMIC) of sub-Saharan Africa.Design and settingQualitative study using face-to-face semi-structured interviews with three pneumologists and five general physicians in a tertiary centre for pneumology and tuberculosis in Benin, West Africa. The center hosts a prospective cohort study on the diagnostic performance of POC-LUS for LRTI. In this context, all participants started a POC-LUS training programme 6 months before the current study. Transcripts were coded by the interviewer, checked for intercoder reliability by an independent psychologist, compared and thematically summarised according to grounded theory methods.ResultsVarious barriers− and facilitators+ to POC-LUS implementation were identified related to four principal categories: (1) hospital setting (eg, lack of resources for device renewal or maintenance−, need for POC tests+), (2) physician’s perceptions (eg, lack of opportunity to practice−, willingness to appropriate the technique+), (3) tool characteristics (eg, unclear lifespan−, expedited diagnosis+) and (4) patient’s experience (no analogous image to keep−, reduction in costs+). Furthermore, all interviewees had positive attitudes towards computer-assisted POC-LUS.ConclusionsThere is a clear need for POC affordable lung imaging techniques in LMIC and physicians are willing to implement POC-LUS to optimise the diagnostic approach of LRTI with an affordable tool. Successful integration of POC-LUS into clinical routine will require adequate responses to local challenges related to the lack of available maintenance resources and limited opportunity to supervised practice for physicians.

ObjectivesWe aimed to explore the acceptance and opinions of general practitioners (GPs) on the use of procalcitonin point-of-care and lung ultrasonography for managing patients with lower respiratory tract infections in primary care. We suppose that there are several factors that can influence the physician’s antibiotic prescribing decision, and the implementation of a new tool will only be possible when it can be inserted into the physician’s daily practice, helping him/her in the decision-making process.DesignSemistructured interviews; data analysis using the grounded theory method.SettingLausanne, Switzerland.Participants12 GPs who participated in the randomised clinical trial UltraPro, which evaluated the impact of the use of procalcitonin only or an algorithm combining procalcitonin and lung ultrasonography on antibiotic prescription.ResultsGPs had mostly positive attitudes towards the use of point-of-care procalcitonin in lower respiratory tract infections and uncertainties regarding the usefulness of ultrasonography. Physicians’ prescribing decisions result from interactions between three kinds of TrustS (core category): ‘self-confidence’, ‘trust in the results’ and ‘trust in the doctor–patient relationship’. Procalcitonin reinforced the three levels of trust, while ultrasonography only strengthened the physician–patient relationship. To facilitate implementation of procalcitonin, physicians pointed out the need of coverage by insurance and of clear guidelines describing the targeted patient population.ConclusionsOur data show that there is a preference for the implementation of procalcitonin rather than lung ultrasonography for the management of patients with lower respiratory tract infections in primary care. Coverage by insurance plans and updated guidelines are prerequisite to the successful implementation of procalcitonin testing in primary care.Trial Registration numberNCT03191071

IntroductionAntimicrobial resistance is a major global health threat, driven largely by the misuse and overuse of antibiotics. Point-of-care (POC) tests for inflammatory biomarkers like procalcitonin (PCT) have shown promise in reducing unnecessary antibiotic prescriptions. The hybrid type II ImpPro trial aims to evaluate the implementation and effectiveness of POC-PCT on antibiotic prescriptions by primary care physicians (PCP) in French-speaking Switzerland. Implementation is planned to include a multifaceted strategy delivered mainly, but not exclusively, via PCP quality circles. Currently, little guidance exists on how to best tailor the implementation strategies to a specific context. This study protocol describes the comprehensive approach taken within ImpPro to develop a multifaceted and multilevel strategy for POC-PCT implementation.Methods and analysisOur mixed-methods participatory implementation research study consists of four phases: (1) determinant identification; (2) determinant prioritisation; (3) implementation strategy ideation and (4) implementation strategy selection and refinement. All phases of the study will be guided by well-established implementation theories, models and frameworks. For 1, to identify the possible barriers and facilitators for implementation, we will conduct semistructured interviews with stakeholders followed by deductive coding using the updated Consolidated Framework for Implementation Research and inductive thematic analysis. In 2, to identify the key determinants, we will conduct online focus group discussions and vote on the importance and changeability of determinants. In 3, we will conduct interviews and an expert brainstorming session, followed by deductively coding implementation ideas according to the Expert Recommendations for Implementing Change compilation. In 4, we will conduct focus group discussions with experts and stakeholders about the APEASE criteria (ie, affordability, practicability, (cost-)effectiveness, acceptability, side effects and safety and equity) of these strategies, followed by a rapid data analysis approach to select the implementation strategies.Ethics and disseminationThis study does not fall within the scope of the Human Research Act, and the necessity for a formal evaluation was waived from the Cantonal Ethics Committee (Req-2023–00392). The results of our study will be shared among the Antimicrobial Stewardship in Ambulatory Care Platform network, published in peer-reviewed scientific journals, and will be presented at international and national conferences.

Background Objective assessment of skills after training is essential for safe implementation of lung point-of-care ultrasound (POCUS). In low-and middle-income countries (LMIC) there is a need for assessment tools without onsite experts to scale up POCUS access. Our objective is to develop a web-based assessment tool and evaluate trainees across different countries and at different time points after initial lung POCUS training. Methods We adapted the objective and validated lung ultrasound score (LUS-OSAUS) to a web-based tool with quiz and practical skills test. Trainees were evaluated after a short (4-day) standardized lung POCUS training and were classified in distinct groups according to (i) their geographical location (Benin vs. South-Africa) and (ii) time elapsed since training (Benin 0 months vs. Benin 6 months). The Benin 6 months group had minimal continuous education. Skills test images were read by two blinded experts. We report the overall success rates and then compare these rates based on location and timing since training, using the Fischer’s exact test. Results A total of 35 out of 43 participants completed the online LUS-OSAUS quiz and skills test. The overall success rate was 0.84 (95%CI 0.80–0.88), with lower success rates for “correct depth” 0.54 (0.37–0.71), “correct assessment of pleura” 0.63 (0.45–0.79) and “conclusion” 0.71 (0.54–0.85). There were no differences based on location, with respective rates of 0.86 (0.80–0.92) and 0.83 (0.75–0.91) ( p -value = 0.125) for Benin and South Africa at 0 months, respectively. Similarly, there were no differences according to timing with success rates of 0.86 (0.80–0.92) and 0.82 (0.72–0.93) ( p -value = 0.563) for Benin at 0 months and 6 months, respectively. Conclusion Web-based objective and structured assessment of lung POCUS skills in LMIC following a short-standardized training is feasible and has a good overall success rate with consistent results across regions and up to 6 months after training given minimal continuous education. Overall, technical and POCUS-based clinical conclusion skills are the most difficult to acquire.

Background Although the incidence of dengue across Africa is high, severe dengue is reported infrequently. We describe the clinical features and the outcome of dengue according to raceduring an outbreak in Dar es Salaam, Tanzania that occurred in both native and expatriate populations. Methods Adults with confirmed dengue (NS1 and/or IgM on rapid diagnostic test and/or PCR positive) were included between December 2013 and July 2014 in outpatient clinics. Seven-day outcome was assessed by a visit or a call. Association between black race and clinical presentation, including warning signs, was assessed by logistic regression adjusted for age, malaria coinfection, secondary dengue and duration of symptoms at inclusion. The independent association between demographic and comorbidities characteristics of the patients and severe dengue was evaluated by multivariate logistic regression that included potential confounders. Results After exclusion of 3 patients of mixed race, 431 patients with dengue (serotype 2, genotype Cosmopolitan) were included: 241 of black and 190 of non-black race. Black patients were younger (median age 30 versus 41 years; p  < 0.001) and attended care after a slightly longer duration of symptoms (median of 2.9 versus 2.7 days; p  = 0.01). Malaria coinfection was not significantly different between black (5%) and non-black (1.6%) patients ( p  = 0.06). The same proportion of patients in both group had secondary dengue (13 and 14%; p  = 0.78). Among warning signs, only mucosal bleed was associated with race, black race being protective (adjusted OR 0.44; 95% CI 0.21–0.92). Overall, 20 patients (4.7%) presented with severe dengue. Non-black race (adjusted OR 3.9; 95% CI 1.3–12) and previously known diabetes (adjusted OR 43; 95% CI 5.2–361) were independently associated with severe dengue. Conclusions Although all patients were infected with the same dengue virus genotype, black race was independently protective against a severe course of dengue, suggesting the presence of protective genetic or environmental host factors among people of African ancestry. The milder clinical presentation of dengue in black patients might partly explain why dengue outbreaks are under-reported in Africa and often mistaken for malaria. These results highlight the need to introduce point-of-care tests, beside the one for malaria, to detect outbreaks and orientate diagnosis. Trial registration Clinicaltrials.gov Identifier: NCT01947075 , retrospectively registered on the 13 of September 2014.