Assessing Antimicrobial Resistance, Utilization, and Stewardship in Yemen: An Exploratory Mixed-Methods Study

Antimicrobial resistance (AMR), largely driven by irrational use of antimicrobials, is a global, multifaceted problem calling for a complete understanding of all contributory factors for effective containment. In conflict settings, war-wounds and malnutrition can combine with existing social determinants to increase demand for antibiotics, compounding irrational use. In this study, we focus on Yemen, a low-income country with active conflict for the last 5 years, and analyze the current status of awareness and stewardship efforts regarding AMR. We performed a survey of prescribers/physicians and pharmacists to describe perceptions of AMR prevalence, antibiotic use practices, and stewardship in Yemen, supported by a nonsystematic scoping literature review and a key informant interview. Participants (96%, N = 57) reported a perceived high AMR prevalence rate. Prescribers (74%, 20/27) reported pressure to prescribe broad-spectrum antibiotics. In the majority of cases (81%, 22/27), antimicrobial sensitivity tests (AST) were not performed to inform antibiotic choice. The main barrier to AST was cost. Most pharmacists (67%, 18/27) sold antibiotics without prescriptions. Amoxicillin (including amoxicillin-clavulanate) was the most-commonly prescribed (63%, 17/27) or dispensed (82%, 22/27) antibiotic. AST was rated the least important solution to AMR in Yemen. While there was awareness of a high AMR rate, stewardship is poor in Yemen. We note that barriers to the use of AST could be addressed through the deployment of reliable, affordable, quality rapid diagnostics, and AST kits. Compulsory continuing education emphasizing the use of AST to guide prescribing and patients’ awareness programs could help avoid irrational use.

Three-Dimensional Modeling of the Structural Microenvironment in Post-Traumatic War Wounds

BACKGROUND: The development of post-traumatic heterotopic ossification (HO) is a common, undesirable sequela in patients with high-energy (war-related) extremity injuries. While inflammatory and osteoinductive signaling pathways are known to be involved in the development and progression of post-traumatic HO, features of the structural microenvironment within which the ectopic bone begins to form remain poorly understood. Thus, increasing our knowledge of molecular and structural changes within the healing wound may help elucidate the pathogenesis of post-traumatic HO and aid in the development of specific treatment and/or prevention strategies. METHODS: In this study, we performed high-resolution microscopy and biochemical analysis of tissues obtained from traumatic war wounds to characterize changes in the structural microenvironment. In addition, using an electrospinning approach, we modeled this microenvironment to reconstitute a three-dimensional type I collagen scaffold with non-woven, randomly oriented nanofibers where we evaluated the performance of primary mesenchymal progenitor cells. RESULTS: We found that traumatic war wounds are characterized by a disorganized, densely fibrotic collagen I matrix that influences progenitor cells adhesion, proliferation and osteogenic differentiation potential. CONCLUSION: Altogether, these results suggest that the structural microenvironment present in traumatic war wounds has the potential to contribute to the development of post-traumatic HO. Our findings may support novel treatment strategies directed towards modifying the structural microenvironment after traumatic injury.

Hospitals

Contemporary readers likely have a narrow view of hospitals. But prior to the 19th century, hospitals were used for many purposes: to provide charity for the needy, shelter wounded soldiers, house homeless community members, inoculate against disease, learn and teach anatomy, and heal the sick and wounded. Hospitals were nearly indistinguishable from hospices, where citizens who could prove their need could receive shelter and food. These hospitals were charged with dealing with epidemics, demographic collapse, war wounds, birth (and sometimes baptism), death, and all of the other bodily expressions of colonization, occupation, and expansion. Of course, buildings or other spaces for healing preceded European colonizers. While a few of the books discussed below provide a glimpse of pre-Columbian hospitals, this is an ample area for exploration. Early colonial hospitals were built alongside churches, buildings of state, trade houses, and houses for the wealthy. The boundary between medical and religious knowledge was blurred. Practitioners were diverse: the very indigenous and African healers who were censured by the Inquisition were also relied upon. Universities, like Guatemala’s Universidad de San Carlos (founded in 1676), offered medicine as a course of study. The Enlightenment “arrived” unevenly in Latin America. Generally, the number of hospitals grew, as did the number of the regulations concerning them. Owing to imperial anxieties, as well as epidemics and medical innovation, medicine (and hospitals) became more a part of colonial life. Enlightenment hospitals were teaching and research institutions, too. With independence, medical science became a tool of liberal state building, as it had previously been of colonial administration. Liberal governments wrested responsibility for care of the sick and the needy from religious orders. Positivism and eugenics became the drivers of much hospital work. Clinics for the degenerate and other threats to the nation promised rehabilitation. Diagnoses and specializations proliferated. Then, a number of welfare states emerged throughout the region, sometimes in response to popular demand. Some hospitals sat in uneasy balance between positivism and the welfare state. Hospitals were also laden sites in the Cold War. Mid-20th-century revolutions were fought with health care among guerrillas’ demands. Some revolutionary states managed to fulfill their promises of accessible community health care. Around the 1980s, state welfare gave way to privatization. While this has continued, proponents of community and preventive health care have won crucial victories in many places. Hospital historiography sits at the intersection of many fields. Historians of science, technology, medicine, public health, charity, nationalism, social movements, and political repression all have a stake in hospital history. Many of these fields have produced extensive bodies of knowledge, even conferences and journals dedicated to their study. But this is not the case for hospitals. Of course, the boom in scholarship on history of medicine and Science and Technology Studies (STS) has provided still more texts featuring hospitals in nuanced ways. In fact, many different types of historians consult hospital records in the course of their research. So, on the one hand, hospital history is everywhere; on the other, it is obscure.

Assessing antimicrobial resistance, utilization and stewardship in Yemen: An exploratory mixed-methods study

Antimicrobial resistance (AMR), largely driven by irrational use of antimicrobials, is a global, multi-faceted problem calling for a complete understanding of all contributory factors for effective containment. In conflict settings, war-wounds and malnutrition can combine with existing social determinants to increase demand for antibiotics, compounding irrational use. In this study, we focus on Yemen, a low-income country with active conflict for the last five years, and analyze the current status of awareness and stewardship efforts regarding AMR. We performed a survey of prescribers/physicians and pharmacists to describe perceptions of AMR prevalence, antibiotic use practices and stewardship in Yemen, supported by a non-systematic scoping literature review and a key informant interview. Participants (96%, n=57) reported a perceived high AMR prevalence rate. Prescribers (74%, 20/27) reported pressure to prescribe broad-spectrum antibiotics. In the majority of cases (81%, 22/27), Antimicrobial Sensitivity Tests (AST) were not performed to inform antibiotic choice. The main barrier to AST was cost. Most pharmacists (67%, 18/27) sold antibiotics without prescriptions. Amoxicillin (including amoxicillin-clavulanate) was the most-commonly prescribed (63%, 17/27) or dispensed (82%, 22/27) antibiotic. AST was rated the least important solution to AMR in Yemen. While there was awareness of a high AMR rate, stewardship is poor in Yemen. We note that barriers to the use of AST could be addressed through the deployment of low-cost AST kits. Compulsory continuing education emphasizing the use of AST to guide prescribing and patients’ awareness programs could help avoid irrational use.

The Italian mobile surgical units in the Great War: the modernity of the past

Medical services in WWI had to face enormous new problems: masses of wounded, most with devastating wounds from artillery splinters, often involving body cavities, and always contaminated. Tetanus, gas gangrene, wound infections were common and often fatal. Abdominal wounds were especially a problem: upon entering the war the commanders of all medical services ordered to avoid surgery, based on dismal experiences of previous wars. Surgical community divided into non-operative and operative treatment supporters. The problem seemed mainly organizational, as the wounded were rescued after many hours and treated by non-specialist doctors, in inadequate frontline settings or evacuated back with further delay of treatment. During initial neutrality, Italian Academics closely followed the debate, with different positions. Many courses and publications on war surgery flourished. Among the interventionists, Baldo Rossi, to provide a setting adequate to major operations close to the frontline, with trained surgeons and adequate instruments, realized for the Milano Red Cross three fully equipped, mobile surgical hospitals mounted on trucks, with an operating cabin-tent, with warming, illumination and sterilizing devices, post-operative tents and a radiological unit. Chiefs of the army approved the project and implemented seven similar units, called army surgical ambulances, each run by a distinguished surgeon. Epic history and challenges of the mobile units at the frontline, brilliant results achieved on war wounds and epidemics are described. After the war they were considered among the most significant novelties of military medical services. Parallels with present scenarios in war and peace are outlined.

Experience of the Orthopedic Surgeon in the Management of War Victims

Surgery for victims of war is different from surgery for civilian injuries. War wounds are always extremely contaminated, and missiles may cause massive destruction of soft tissues, bones, and other structures. The principles of surgery for war wounds have been known for decades but need to be relearned by each new generation of surgeons working in a war situation. People were not at all prepared for a physical fight. Similarly, the medical institutes were not specially prepared for such a sea of casualties all of a sudden. The study’s aim was to analyze the result of the experience in the surgical management of the gunshot patients admitted to Al-Bayda teaching hospital during the first month of the Libyan revolution of February 2011. The total number of patients admitted to Al-Bayda teaching hospital in the period from 16\2\2011 to 16\3\2011 was 288 patients. Debridement and repair of the wounds and fixation of fractures in different settings and follow-up was carried out for 7 months. Orthopedic morbidity rate was 9 %, and infection was recorded in 30 patients 21%. As a team of orthopedic, vascular, and general surgeons, very good exposure and experience was gained to manage war or civilian unrest victims.

The effectiveness of Dakin’s solution in wound care after debridement in Fournier’s gangrene

Background: Fournier's gangrene (FG) is a specific form of necrotizing fasciitis seen in the external genital organs and perianal region. The basic management of Fournier's gangrene is based on critical surgical debridement. Dakin's solution (sodium hypochlorite) was originally developed to treat war wounds. In this study, we aimed to show potentially efficient of Dakin’s solution on wound healing and reoperation rate.Methods: Thirty-three patients who were debrided due to Fournier Gangrene during 2012-2020 were included in the study. After debridement, wound care was done twice a day by dressing with a sponge moistened with Dakin's solution. Patients' age, concomitant disease, involvement site, re-debridement requirement, complications, and discharge times were recorded.Results: The mean age of 33 male patients who participated in the study was (51-74) 63.93±15.36. Although all patients had scrotal involvement, nine patients had perineal (27.2%), 12 patients had inguinal (36.3%), four patients had a penis and pubic spread (12.1%). The mortality rate was 6%. The average length of hospital stay was 13.1±4.2 days, and the average number of debridements was 1.Conclusions: Fournier gangrene is an important disease characterized by necrotizing infection of the genital, perineal, and perianal region and progresses with high mortality. Our mortality rate was lower than literature and we have linked our mortality rate to using Dakin's solution for wound care. Dressing with Dakin's solution is an effective and reliable method for wound care in FG patients.

Tibullus

Despite playing a relatively minor role in Tibullan elegy, Jupiter exhibits a remarkable range of activities and symbolic valences. Book 1 makes the god, like Messalla, primarily a foil and competitor to the values of the elegiac world. As Messalla is introduced fighting on land and sea while the poet languishes before his mistress’s troublesome door, so Jupiter is introduced as the wielder of the rain and thunderbolts that could penetrate that door. Jupiter the dominus, in fact, is the one who brought into being Messalla’s world of war, wounds, and “roads” of death. Priapus’s insistence that Jupiter forbade lovers’ oaths to be binding implicitly casts Jupiter as one with a background in amorous perjury; as with Messalla’s imagined epiphany in the following poem, the god enters the elegiac sphere to succeed where the poet fails. The Nile’s supplantation of “rainy Jupiter” as the all-encompassing husband and father aligns with Tibullus’s covert exclusion of Augustus from his pastoral world. Jupiter’s transformation in book 2 into the victorious god of Rome signals Tibullus’s changing purposes. Like Virgil, Tibullus hints at the inherent instability of the Golden Age ideal, since Jupiter’s expulsion of Saturn signals the end of a utopian era even as Augustus’s victory clears the way for a new one. When Jupiter assigns the Laurentian fields to the proto-Romans, he is lodged between flitting Love and flitting Victory. Whether stability or instability will predominate is something not even the Sibyl can foresee.