Is Streptococcus pyogenes a pathogen or passenger in uncomplicated acute sore throat? A systematic review and meta-analysis.

OBJECTIVES: The objective was to estimate the probability that finding a Streptococcus pyogenes (Group A Streptococcus) in a throat swab in a patient with a sore throat reflects the aetiology. We also investigated to what extent this is influenced by age, carrier rates of S. pyogenes and climate zone. METHODS: We conducted a comprehensive search of Medline and Scopus up until October 2023 for case-control studies reporting the prevalence of S. pyogenes in patients with a sore throat and healthy controls. We only included studies with separate data for children and adults. We used the positive and negative etiologic predictive value (P-EPV and N-EPV) to estimate the probability of a link between a sore throat and a finding of S. pyogenes. RESULTS: We included 15 studies in our meta-analysis. The overall P-EPV for children and adults were 63% (49-74%) and 92% (87-95%), respectively. The P-EPV rose to 83% (64-93%) for children and 94% (90-97%) for adults when only patients with 3-4 Centor criteria were included. The overall N-EPV was 97% (96-98%) for children and 96% (95-97%) for adults. CONCLUSIONS: Detecting S. pyogenes in adult patients with an uncomplicated acute sore throat is useful to rule in S. pyogenes as the likely aetiologic agent. The P-EPV significantly increased for children when those with 3-4 Centor criteria were selected. A negative throat swab is always useful for both children and adults to rule out S. pyogenes as the cause of the sore throat.

Best management of patients with an acute sore throat - a critical analysis of current evidence and a consensus of experts from different countries and traditions.

BACKGROUND: There is a very large body of publications discussing the management of patients with an acute sore throat. Advocates for a restrictive antibiotic policy and advocates for a more liberal use of antibiotics emphasise different and valid arguments and to date have not been able to unite in a consensus. Contradicting guidelines based on the same body of knowledge is not logical, may cause confusion and cause unwanted variation in clinical management. METHODS: In multiple video meetings and email correspondence from March to November 2022 and finally in a workshop at the annual meeting for the North American Primary Care Group in November 2022, experts from different countries representing different traditions agreed on how the current evidence should be interpreted. RESULTS: This critical analysis identifies that the problem can be resolved by introducing a new triage scheme considering both the acute risk for suppurative complications and sepsis as well as the long-term risk of developing rheumatic fever. CONCLUSIONS: The new triage scheme may solve the long-standing problem of advocating for a restrictive use of antibiotics while also satisfying concerns that critically ill patients might be missed with severe consequences. We acknowledge that the perspective of this problem is vastly different between high- and low-income countries. Furthermore, we discuss the new trend which allows nurses and pharmacists to independently manage these patients and the increased need for safety netting required for such management.

Achieving High Breast Cancer Survival for Women in Rural and Remote Areas.

BACKGROUND: Significant improvements in breast cancer survival have been made in the past few decades in many developed countries including Australia with a five-year relative survival of 90%. The aim of the present study is to obtain a brief estimate of the relative importance of demographic factors such as rurality, socio-economic standard and ethnicity versus traditional risk factors for women diagnosed with breast cancer in Far North Queensland, Australia. METHODS: This was a retrospective longitudinal study of all women diagnosed with their first episode of breast cancer in 1999-2013 in Far North Queensland, Australia. Cox proportional hazards regression analysis was used to identify factors independently associated with mortality for women with any type of breast cancer (in situ or invasive) and for women with invasive cancer. Life tables were used to assess five and ten-year absolute survival. Standard linear regression and binary logistic regression were used to identify any association between demographic factors and late presentation. RESULTS: Five and ten-year absolute survival was 0.90 and 0.86 respectively. Aboriginal and Torres Strait Islander status, remoteness of area of residence, and socioeconomic status were not associated with more advanced disease at presentation or increased risk of breast cancer death. Only traditional risk factors such as increased tumour size, absence of progesterone receptor, high tumour grade and presence of metastasis in axillary lymph nodes were associated with increased risk of breast cancer death. CONCLUSION: The effect of the classical risk factors on breast cancer mortality outweighs the effects of demographic factors. The fact that ethnicity, remoteness and socioeconomic status is not associated with late presentation or breast cancer death suggests that given appropriate resources it may be possible to close the gap of inequalities in breast cancer.

Improving antibiotics targeting using PCR point-of-care testing for group A streptococci in patients with uncomplicated acute sore throat.

BACKGROUND AND OBJECTIVES: Evidence supports some beneficial effects of antibiotics prescribed to patients with a sore throat and proven presence of group A streptococci (GAS). METHOD: A total of 283 patients were included from North and North-West Queensland, Australia, at their first presentation for uncomplicated acute sore throat. Patterns of antibiotic prescribing were explored before and after testing for GAS using a rapid point-of-care polymerase chain reaction (PCR) test. RESULTS: The results of the study showed the Australian Therapeutic Guidelines were often not adhered to. The PCR test reduced the proportion of patients prescribed antibiotics from 46% to 40%. The decision to prescribe antibiotics was changed in 30% of patients (P <0.001): before testing only 40% of patients prescribed antibiotics had a positive GAS PCR while this increased to 97% after testing. DISCUSSION: An easy-to-use point-of-care test to detect GAS allows better targeting of antibiotic prescribing in patients with an uncomplicated acute sore throat.

External validation of the Cairns Prediction Model (CPM) to predict conversion from laparoscopic to open cholecystectomy.

BACKGROUND: Valid and user-friendly prediction models for conversion to open cholecystectomy allow for proper planning prior to surgery. The Cairns Prediction Model (CPM) has been in use clinically in the original study site for the past three years, but has not been tested at other sites. METHODS: A retrospective, single-centred study collected ultrasonic measurements and clinical variables alongside with conversion status from consecutive patients who underwent laparoscopic cholecystectomy from 2013 to 2016 in The Townsville Hospital, North Queensland, Australia. An area under the curve (AUC) was calculated to externally validate of the CPM. RESULTS: Conversion was necessary in 43 (4.2%) out of 1035 patients. External validation showed an area under the curve of 0.87 (95% CI 0.82-0.93, p = 1.1 × 10-14). CONCLUSIONS: In comparison with most previously published models, which have an AUC of approximately 0.80 or less, the CPM has the highest AUC of all published prediction models both for internal and external validation.

Presenting the improved possibility for staying well might be better than talking about change in risk: use of the non-occurrence probability increase (NOPI).

OBJECTIVE: Talking about risk with patients is problematic since the individual's risk is not addressed and is usually very low. This study aimed to see how fact presentation influenced the decision-making process for general practitioners concerning treatment for the prevention of cardiovascular disease. Rather than looking at the risk of becoming ill, often presented as high figures of relative risk reduction (RRR), it could be useful to present the probability of staying well, i.e. from the concept of non-occurrence probability (NOP) and non-occurrence probability increase (NOPI)--simply a single measure of change in NOP. DESIGN: General practitioners (GPs) had personal response keypads to answer two questions, presented differently, concerning whether they would allow themselves to be treated or not be treated for the risk of cardiovascular death. SETTING AND SUBJECTS: Five audiences consisting of general practitioners attending lectures. RESULTS: When the question was presented as RRR, 68% and 86%, respectively, of the physicians responded that they would take the decision to treat. When presented as the concept of NOPI the figures were reduced to 18% and 16%, respectively (p < 10-6). IMPLICATIONS: Developing tools to explain treatment effect is crucial to enhancing health care quality. Since NOPI is one potential way of presenting prevention of risk we encourage future research to evaluate the NOPI concept compared with RRR and absolute risk reduction (ARR).

The physician's self-evaluation of the consultation and patient outcome: a longitudinal study.

OBJECTIVE: To study whether the physician's evaluation of the consultation correlates to patient outcome one month later concerning symptom relief, sick leave, and drug compliance as perceived by the patient. The study also investigated whether the patient's evaluation of the consultation correlated to patient outcome. DESIGN: A longitudinal study using questionnaires. SETTING: A county in south-western Sweden. Subjects. Forty-six physicians and 316 primary care patients aged 16 years or more with a new complaint lasting one week or more were invited. A total of 289 patients completed a questionnaire presented at the consultation; 273 patients were reached in a follow-up telephone interview one month after the consultation. MAIN OUTCOME MEASURES: The association between each statement in the physician-patient questionnaire (PPQ) from the consultation and the answers obtained from the telephone interview were analysed by either multiple linear or logistic regression analysis. RESULTS: Five out of 10 items in the PPQ were significantly associated with patient outcome. Physician's self-evaluation of the consultation was much more strongly associated with patient outcome than the patient's evaluation. CONCLUSION: The difference between the physician's and patient's evaluation of the consultation to predict patient outcomes indicates that the physician's self-evaluation of the consultation is of importance.

Children with disabilities are often misdiagnosed initially and children with neuropsychiatric disorders are referred to adequate resources 30 months later than children with other disabilities.

Disabilities in a child may lead to low self-esteem and social problems. The lives of parents and siblings are also affected. Early intervention may decrease these consequences. To promote early intervention early referral to adequate resources is essential. In a longitudinal retrospective observational study it was found that children with neuropsychiatric disorders without mental retardation were referred 30 months later than other children. Agreement between the referrer's identification of the main disability and the habilitation center's was low with Kappa coefficient 0.44. Whereby agreement on diagnosis between referrer and habilitation centers was low, earlier referral should be promoted.

Urine culture doubtful in determining etiology of diffuse symptoms among elderly individuals: a cross-sectional study of 32 nursing homes.

BACKGROUND: The high prevalence of bacteriuria in elderly individuals makes it difficult to know if a new symptom is related to bacteria in the urine. There are different views concerning this relationship and bacteriuria often leads to antibiotic treatments. The aim of this study was to investigate the relationship between bacteria in the urine and new or increased restlessness, fatigue, confusion, aggressiveness, not being herself/himself, dysuria, urgency and fever in individuals at nursing homes for elderly when statistically considering the high prevalence of asymptomatic bacteriuria in this population. METHODS: In this cross-sectional study symptoms were registered and voided urine specimens were collected for urinary cultures from 651 elderly individuals. Logistic regressions were performed to evaluate the statistical correlation between bacteriuria and presence of a symptom at group level. To estimate the clinical relevance of statistical correlations at group level positive and negative etiological predictive values (EPV) were calculated. RESULTS: Logistic regression indicated some correlations at group level. Aside from Escherichia coli in the urine and not being herself/himself existing at least one month, but less than three months, EPV indicated no clinically useful correlation between any symptoms in this study and findings of bacteriuria. CONCLUSIONS: Urinary cultures provide little or no useful information when evaluating diffuse symptoms among elderly residents of nursing homes. Either common urinary tract pathogens are irrelevant, or urine culture is an inappropriate test.

Role of gender in sexual behaviours and response to education in sexually transmitted infections in 17-year-old adolescents.

OBJECTIVE: to investigate gender differences in high school students with respect to sexual risk behaviours, and their perceptions of the effect of an educational programme on sexually transmitted infections (STIs). In addition, this study aimed to investigate differences between students in programmes preparing for university compared with vocational programmes. PARTICIPANTS, SETTING AND DESIGN: second-year high school adolescents from two communities in south-west Sweden were invited to participate in the study, and completed a questionnaire on sexual experience, sexual risk behaviours and the impact of the educational programme on STIs. FINDINGS: males took less responsibility for STI prevention than females. Furthermore, males perceived themselves to be less influenced by the STI education than females. Females had more experience of same-sex sexuality than males. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: males take less responsibility for STI prevention than females. When planning STI education, it is important to consider gender, traditions and various learning styles. If STI education fails to reach males, the prevalence of these infections will continue to increase.

Patient-centred attitudes among medical students: gender and work experience in health care make a difference.

BACKGROUND: Previous studies of medical students' patient-centred attitudes show a decline across undergraduate education and overall higher scores for female students. AIM: To assess undergraduate students' patient-centred attitudes at various stages of education and to explore possible associations between attitudes and age, gender and work experience in health care. METHODS: In autumn 2005, medical students in Gothenburg (n = 797) were asked to answer Patient-Practitioner Orientation Scale (PPOS), a validated instrument exploring attitudes towards the doctor-patient relationship. Data including gender, age, current term and students' work experience in health care were collected. RESULTS: Of 797 students 600 (75%) answered the questionnaire. No decrease of students' PPOS score across the curriculum was observed. PPOS scores from female students were higher compared to males (p < 0.0001) and female scores were significantly higher in the later terms compared with earlier (p = 0.0011). Female students had more experience from working in health care (p = 0.0023). Extended work experience was associated with higher PPOS only among females (p = 0.0031). CONCLUSION: No decline of students' patient-centred attitudes may indicate an ongoing shift. Gender differences in patient-centred attitudes were reproduced. Work experience in health care presents a new gender difference. These gender differences should be considered when training patient-centred attitudes and skills.

Evaluation of dipstick analysis among elderly residents to detect bacteriuria: a cross-sectional study in 32 nursing homes.

BACKGROUND: Few studies have evaluated dipstick urinalysis for elderly and practically none present confidence intervals. Furthermore, most previous studies combine all bacteria species in a "positive culture". Thus, their evaluation may be inappropriate due to Yule-Simpson's paradox. The aim of this study was to evaluate diagnostic accuracy of dipstick urinalysis for the elderly in nursing homes. METHODS: In this cross-sectional study voided urine specimens were collected from 651 elderly individuals in nursing homes. Dipstick urinalysis for nitrite, leukocyte esterase and urine culture were performed. Sensitivity, specificity, positive and negative predictive values with 95% confidence intervals were calculated. Visual readings were compared to readings with a urine chemistry analyzer. RESULTS: 207/651 (32%) of urine cultures showed growth of a potentially pathogenic bacterium. Combining the two dipsticks improved test characteristics slightly compared to using only one of the dipsticks. When both dipsticks are negative, presence of potentially pathogenic bacteria can be ruled out with a negative predictive value of 88 (84-92)%. Visual and analyzer readings had acceptable agreement. CONCLUSION: When investigating for bacteriuria in elderly people at nursing homes we suggest nitrite and leukocyte esterase dipstick be combined. There are no clinically relevant differences between visual and analyzer dipstick readings. When dipstick urinalysis for nitrite and leukocyte esterase are both negative it is unlikely that the urine culture will show growth of potentially pathogenic bacteria and in a patient with an uncomplicated illness further testing is unnecessary.

More illness and less disease? A 20-year perspective on chronic disease and medication.

BACKGROUND: The implication of medication is that a drug is given against an illness. Over the last few decades an expanding number of drugs have appeared that focus on reducing risk factors and lifestyle conditions. AIMS: To investigate the apprehension in respect of chronic disease among the working population in a Swedish community in 2000 compared with 1980. METHODS: In 1980 and 2000 an analogous questionnaire assessing chronic diseases and medication was mailed to 250 randomly selected persons from a local population between 25 and 70 years of age. RESULTS: Some 80% of the persons (n = 201) replied in 1980 and 78% (n = 195) in 2000. Individuals declaring a chronic disease increased from 23% (46/201) in 1980 to 39.5% in 2000 (p = 0.0005). Corresponding figures for men were 20.6% (20/97) in 1980 and 40.8% (40/98) in 2000 (p = 0,004) and for women 25.0% (26/104) in 1980 and 38.1% (37/97) in 2000 (p = 0.064). Persons who regularly see a doctor increased from 13% to 26% (p = 0.002) and the use of drugs for chronic diseases increased from 19% to 33% (p = 0.002). In 2000 an average of 2.3 drugs per person were used among those with a chronic disease, an increase of 53% since 1980. CONCLUSION: Stated chronic diseases and use of drugs for such diseases increased greatly between1980 and 2000. Prescribing drugs for a "risk" with no apparent illness may be confused with the remedy for an illness.

Water aerobics reduces sick leave due to low back pain during pregnancy.

OBJECTIVE: To compare the effect of a land-based, physical exercise program versus water aerobics on low back or pelvic pain and sick leave during pregnancy. DESIGN: Randomized controlled clinical trial. SETTING: Three antenatal care centers. PARTICIPANTS: 390 healthy pregnant women. INTERVENTIONS: A land-based physical exercise program or water aerobic once a week during pregnancy. MAIN OUTCOME MEASURES: Sick leave, pregnancy-related low back pain or pregnancy-related pelvic girdle pain, or both. RESULTS: Water aerobics diminished pregnancy-related low back pain (p=.04) and sick leave due to pregnancy-related low back pain (p=.03) more than a land-based physical exercise program. CONCLUSIONS: Water aerobics can be recommended for the treatment of low back pain during pregnancy. The benefits of a land-based physical exercise program are questionable and further evaluation is needed.

Attitudes and feelings towards menstruation and womanhood in girls at menarche.

AIM: To elucidate early adolescent girls' attitudes, thoughts and feelings towards menstruation and their bodies. METHODS: 309 12-y-old girls answered questionnaires. One part of the questionnaire dealt with thoughts and feelings towards menstruation. The other part dealt with thoughts and feelings towards menstruation and sex and ability to communicate on aspects of womanhood. RESULTS: Postmenarcheal girls were less positive towards menstruation than premenarcheal girls (p = 1 x 10(-6)). Many girls (43%) did not reaffirm the statement "I like my body" and almost one quarter stated being teased for their appearance. Many of the girls claimed that they had been called "cunt" (38%) or "whore" (46%). If called "cunt" or "whore", 17% stated that they felt alone, 76% felt anger and 50% were offended. Mothers were those with whom girls could most easily "chat" about their period. Sixty-seven per cent received information about menstruation from school nurses. CONCLUSION: Wanting to be an adult and liking that their body develops seem to be associated with a more positive feeling towards menstruation. Furthermore, mothers' timing and ability to communicate attitudes towards menstruation and the body are as important as those in a girl's immediate environment.

Improving pre- and postmenarcheal 12-year-old girls' attitudes toward menstruation.

Adolescence is a time of rapid changes, including risk for unwanted pregnancies and sexually transmitted infections. Education may improve understanding and attitudes toward menstruation among adolescents thus increasing their awareness of risks and enabling them to protect themselves accordingly. To investigate effects of education on attitudes, two interventions were compared in 345 12-year-old girls. The new, active intervention given to premenarcheal girls just before menarche resulted in improvements in attitudes toward menstruation compared with standard intervention. Thus, just before menarche girls should be offered education modeled after the active intervention. The education must be concrete and based on multisensory learning.

The effect of acupuncture on allergic rhinitis: a randomized controlled clinical trial.

Allergic rhinitis is a common health problem usually treated with drug therapy. Some patients experience side effects of drug therapy while others fear the use of drugs. Acupuncture is an interesting alternative to traditional treatment. The few studies evaluating acupuncture indicate a possible clinical effect on allergic rhinitis. This study compared active versus sham acupuncture in 40 consecutive patients with a history of allergic rhinitis and a positive skin test. Patients were randomized and assessed prior to treatment and then reassessed after 12 months. Improvements in symptoms using visual analogue scales, reduction in skin test reactions and levels of specific immunoglobin E (IgE) were used to compare the effect of treatment. For one allergen, mugwort, a greater reduction in levels of specific IgE (p = 0.019, 0.039) and skin test reaction (p = 0.004) was seen in the group receiving active acupuncture compared to the group receiving sham acupuncture. However, this finding might be an artifact. No differences in clinical symptoms were seen between active versus sham acupuncture, thus the conclusion being that the effect of acupuncture on allergic rhinitis should be further evaluated in larger randomized studies.

What happened to the prescriptions? A single, short, standardized telephone call may increase compliance.

BACKGROUND: Patients' compliance with prescribed prescriptions and doctors' advice is a prerequisite for successful treatment. Compliance is estimated to be

The predictive value of microbiologic diagnostic tests if asymptomatic carriers are present.

If a proper gold standard is not available, then the predictive value of a test cannot be estimated. In this paper the concept of etiologic predictive value (EPV) is introduced. It is a quantity that will yield the predictive value of a test to predict presence of a specified disease in situations for which no proper gold standard is available. This is achieved by using information obtained from a healthy control population. This quantity requires that the marker in our test is present in all individuals having the specified disease, as in the case where the marker is the aetiologic factor for the specified disease. Furthermore this quantity requires that asymptomatic carriers are present. This means that not all individuals with the marker has the specified disease. EPV is developed with special reference to the evaluation of bacterial cultures, or rapid tests to detect a bacterium, but the quantity might be used in other circumstances as well. EPV is applied to an example in which conventional throat culture is evaluated. Further information concerning EPV can be found at http://www.infovice.se/fou/epv.