Katharine Abba

Antimicrobial drugs for persistent diarrhoea of unknown or non-specific cause in children under six in low and middle income countries: systematic review of randomized controlled trials

BackgroundA high proportion of children with persistent diarrhoea in middle and low income countries die. The best treatment is not clear. We conducted a systematic review to evaluate the effectiveness of antimicrobial drug treatment for persistent diarrhoea of unknown or non-specific cause.MethodsWe included randomized comparisons of antimicrobial drugs for the treatment of persistent diarrhoea of unknown or non-specific cause in children under the age of six years in low and middle income countries. We searched the electronic databases MEDLINE, EMBASE, LILACS, WEB OF SCIENCE, and the Cochrane Central Register of Controlled Trials (CENTRAL) to May 2008 for relevant randomized or quasi randomized controlled trials. We summarised the characteristics of the eligible trials, assessed their quality using standard criteria, and extracted relevant outcomes data. Where appropriate, we combined the results of different trials.ResultsThree trials from South East Asia and one from Guatemala were included, all were small, and three had adequate allocation concealment. Two were in patients with diarrhoea of unknown cause, and two were in patients in whom known bacterial or parasitological causes of diarrhoea had been excluded. No difference was demonstrated for oral gentamicin compared with placebo (presence of diarrhoea at 6 or 7 days; 2 trials, n = 151); and for metronidazole compared with placebo (presence of diarrhoea at 3, 5 and 7 days; 1 trial, n = 99). In one small trial, sulphamethoxazole-trimethoprim appeared better than placebo in relation to diarrhoea at seven days and total stool volume (n = 55).ConclusionThere is little evidence as to whether or not antimicrobials help treat persistent diarrhoea in young children in low and middle income countries.

Supportive and Palliative care for Patients with Chronic Mental Illness, including dementia

Purpose of reviewPeople with preexisting mental illness are known to have difficulty accessing healthcare services including palliative care and people with dementia have similar issues accessing palliative care. Recent findingsThe review addressed the time period from January 2013 to March 2014. There were few articles addressing issues for palliative and supportive care for patients with preexisting mental health issues. The main factor that would improve care is interdisciplinary working between mental healthcare teams and palliative care teams. In contrast, there were many published articles on the palliative and supportive care needs for people with dementia. These articles included consensus statements, models of care; studies of why models of care, for example Advanced Care Planning were not being implemented; and carer reports of care in the last year of life. SummaryUrgent research is required as to how support for people with preexisting mental illness who require palliative care can be improved – excellent liaison between mental health and palliative care teams is essential. There is much research on palliative care needs for people with dementia but an apparent lack of innovative approaches to care including care of people within their family home.

Interventions to encourage discussion of end-of-life preferences between members of the general population and the people closest to them - a systematic literature review

BackgroundDiscussing end of life preferences can be beneficial, and it is thought that the best time to have these conversations is usually when people are well. This review aims to establish current evidence for the effectiveness of community-based interventions to encourage people to consider, and to discuss with those closest to them, their preferences for end of life care or what they wish to happen after their death.MethodsA systematic literature review was undertaken. A systematic search was conducted using Scopus and Google, and academic experts were contacted. Studies were included if they evaluated interventions intended to encourage people to discuss their end of life preferences with those closest to them, or to address known barriers to these discussions. Reported outcomes had to relate to attitude or behaviour change in the target group, or target group perceptions of the intervention. Studies were excluded if the intervention targeted only people with a life-limiting illness, or intended specifically to facilitate communication of end of life preferences between patients and healthcare staff. Studies were systematically described and assessed for quality. There was no attempt to combine results of different studies.ResultsThe Scopus search identified 5,743 citations, and the Google search identified over 40,000, of which the first 40 pages were scanned. Five studies were included, four identified through the Scopus search and one from a book identified through Google. Three studies reported positive results, two were less positive. A peer education programme on end of life planning for older people, featuring small discussion workshops, was positively appraised by participants. An arts project bringing hospice users and school pupils together appeared to help normalise death for school pupils. A public information ‘roadshow’ engaged people using an informal questionnaire survey, facilitating conversations between people who participated together. Public lectures by physicians intending to promoting home death as a possibility were unsuccessful in changing attitudes at six months follow-up. A module on end of life planning delivered as part of ‘expert patient’ education programme on the management of chronic illness was not well received by participants.ConclusionsAvailable evidence highlights the importance of actively engaging people rather than passively providing information, and of ensuring an appropriate context for interventions. However, data are limited and there is a need for more research and for sharing of best practice.

Pilot randomised controlled trial of focused narrative intervention for moderate to severe depression in palliative care patients: DISCERN trial

Background: Depression is poorly detected and sub-optimally managed in palliative care patients, and few trials of psychosocial interventions have been carried out in this group of patients. Aims: A pilot trial to determine the effect of a focused narrative intervention on depression in palliative care patients when used in addition to usual care. Design: Patients scoring 10 or higher on Patient Health Questionnaire-9 randomised to focused narrative intervention in addition to usual care or usual care only and followed up at 2, 4 and 6 weeks. A reduction of five points on Patient Health Questionnaire-9 was regarded as clinically significant response to treatment. Setting/participants: Palliative care patients aged over 18 recruited from hospice day care services – exclusion criteria included an estimated prognosis of 6 weeks or less, cognitive impairment and unable to understand written or spoken English. Results: Out of 57 participating patients (71% female), with mean age 65.1 years (range 36–88 years), 33 patients were randomised to the intervention and 24 to usual care only. Mean Patient Health Questionnaire-9 score at baseline was 16.4. Patients receiving intervention had greater reduction in Patient Health Questionnaire-9 score at 6-week follow-up (p = 0.04). Median survival was 157 days for intervention and 102 days for control group patients (p = 0.07). Conclusion: This pilot trial suggests a focused narrative intervention in palliative care patients with moderate to severe depression can reduce depression scores more than usual care alone. Patients receiving intervention appeared to have longer survival. These results support the need for a fully powered trial.

Support for children identified with acute flaccid paralysis under the global polio eradication programme in Uttar Pradesh, India: a qualitative study

BackgroundCases of polio in India declined after the implementation of the polio eradication programme especially in these recent years. The programme includes surveillance of acute flaccid paralysis (AFP) to detect and diagnose cases of polio at early stage. Under this surveillance, over 40,000 cases of AFP are reported annually since 2007 regardless of the number of actual polio cases. Yet, not much is known about these children. We conducted a qualitative research to explore care and support for children with AFP after their diagnosis.MethodsThe research was conducted in a district of western Uttar Pradesh classified as high-risk area for polio. In-depth interviews with parents of children with polio (17), with non-polio AFP (9), healthcare providers (40), and key informants from community including international and government officers, religious leaders, community leaders, journalists, and academics (21) were performed.ResultsMinimal medicine and attention were provided at government hospitals. Therefore, most parents preferred private-practice doctors for their children with AFP. Many were visited at homes to have stool samples collected by authorities. Some were visited repetitively following the sample collection, but had difficulty in understanding the reasons for these visits that pertained no treatment. Financial burden was a common concern among all families. Many parents expressed resentment for their childrens disease, notably have been affected despite receiving multiple doses of polio vaccine. Both parents and healthcare providers lacked information and knowledge, furthermore poverty minimised the access to available healthcare services. Medicines, education, and transportation means were identified as foremost needs for children with AFP and residual paralysis.ConclusionsDespite the high number of children diagnosed with AFP as part of the global polio eradication programme, we found they were not provided with sufficient medical support following their diagnosis. Improvement in the quality and sufficiency of the healthcare system together with integration of AFP surveillance with other services in these underprivileged areas may serve as a key solution.

PA17 Interventions to improve upstream communication about death and dying.

Background Death is universal. Only 37% of adults have a will and 48% have stated their wishes regarding cremation or burial.1 Planning and communication can help prevent some of the distress associated with dying and bereavement. Aim To evaluate an intervention to encourage people to plan for the end of their life and to communicate their wishes to those closest to them. Method Two interventions were delivered via community groups: ‘Awareness’ presentations aimed to raise awareness of benefits of preparing and talking about end of life issues. ‘How to’ workshops aimed to give people confidence and tools to open relevant conversations. To evaluate their impact, we conducted a 3-stage questionnaire survey; administered before, immediate after and 3 months after events. Results At baseline (n = 498; 76% female) 76% had previously discussed end of life care or wishes after death. Most were comfortable talking about these subjects, giving a mean score of 8.28/10. At follow-up (n = 133); 60% indicated they had made changes following the event; 43% had talked about their own end of life wishes, 9% for the first time; and 39% reported making other changes. The change in the proportion of people who had ever talked about their own end of life wishes was statistically significant (p = 0.033). Conclusion Well designed community events can improve planning and communication of end of life preferences among general population. Reference Dying Matters Survey http://www.comres.co.uk/polls/Dying_Matters_Public_April12.pdf

Rapid Diagnostic Testing for Plasmodium vivax and Nonfalciparum Malaria in Endemic Areas

CLINICAL QUESTION How sensitive and specific are rapid diagnostic tests (RDTs) for diagnosing Plasmodium vivax and nonfalciparum malaria in endemic areas? BOTTOM LINE Vivax-specific RDTs were highly sensitive and specific when compared with microscopy (the gold standard) for detecting P vivax malaria. RDTs that can only distinguish Plasmodium falciparum from nonfalciparum malaria were less sensitive.

PA20 Views on talking about death, dying and loss

Background Societal barriers to open discussion of personal feelings and preferences relating to death may hinder planning for end of life and supporting people who are dying or bereaved. Aim To explore views about talking about death, dying and loss. Method Semi-structured interviews were conducted with 31 people; age range 30 to 83 years. Results Making wills and communicating end of life wishes were considered very important; mostly for the sake of the family left behind. Participants also valued confidence to discuss other people’s end of life wishes and support them appropriately if they were dying or bereaved. Many participants were very comfortable talking about their own death. Identified barrier to talking about end of life wishes included not wanting to upset others; others not listening; not being about to find an appropriate moment; not knowing enough about the options available; and fear of death, especially of the unknown. Financial costs were seen as a barrier to making a will. Participants talked of the importance of raising awareness of what death and dying involves; what end of life options available; and the importance of communication. Information on the process of normal grieving and how to support somebody who has been bereaved were also suggested. Conclusion Being able to talk about end of life wishes and know how to support people who are dying or bereaved are important to many people, and they would welcome interventions to facilitate this at a societal level.