Quitting Smoking in Mainland China: A New Role for Hospital-Based Nurses.

China has more than 300 million cigarette smokers and 1 million deaths every year attributed to smoking. Despite its huge economic implications, the lack of smoking and associated lifestyle-related data on China's outpatients makes it difficult for health care professionals to provide individualized assessments and targeted interventions. This study aimed to identify factors to inform nurse-led smoking behavioral assessments and cessation interventions. Clinical data from new patients attending the family medicine outpatient department from a large tertiary hospital in a major Southern China city were collected between March and December 2015. Data including basic demographics, medical history, vaccination history, current medication, and information on lifestyle risk factors were collected by frontline nurses during nursing assessment on their initial visit. Chi-square and Student's t tests were used as univariate analysis and post hoc regression analysis to explore which factors contributed toward smoking cessation. Of 7913 eligible visits, smokers and ex-smokers accounted for 13.5% and 2.4% of new patients, respectively, with a majority of them being young and male (gender ratio of 8:1) smokers. Multiple behavioral risks and comorbidities such as hypertension and diabetes mellitus in smokers were common; for example, 17.9% of smokers were also current drinkers, making alcohol users 8.5 to 16.7 times more likely to have smoked. Ex-smokers were more likely to be divorced, to be ex-drinkers, or to have higher diastolic blood pressure and concurrent hypertension. Smoking and associated lifestyle risk assessments run by registered nurses should be incorporated into current outpatient health histories and in targeted smoking cessation intervention programs.

Development and validation study of a non-alcoholic fatty liver disease risk scoring model among adults in China.

Background: Non-alcoholic fatty liver disease (NAFLD) is one of the most common liver diseases in China. It is usually asymptomatic and transabdominal ultrasound (USS) is the usual means for diagnosis, but it may not be feasible to have USS screening of the whole population. Objective: To develop a risk scoring model for predicting the presence of NAFLD using parameters that can be easily obtain in clinical settings. Methods: A retrospective study on the data of 672 adults who had general health check including a transabdominal ultrasound. Fractional polynomial and multivariable logistic regressions of sociodemographic and biochemical variables on NAFLD were used to identify the predictors. A risk score was assigned to each predictor using the scaled standardized ß-coefficient to create a risk prediction algorithm. The accuracy for NAFLD detection by each cut-off score in the risk algorithm was evaluated. Results: The prevalence of NAFLD in our study population was 33.0% (222/672). Six significant factors were selected in the final prediction model. The areas under the curve (AUC) was 0.82 (95% CI: 0.78-0.85). The optimal cut-off score, based on the ROC was 35, with a sensitivity of 76.58% (95% CI: 70.44-81.98%) and specificity of 74.89% (95% CI: 70.62-78.83%). Conclusion: A NAFLD risk scoring model can be used to identify asymptomatic Chinese people who are at risk of NAFLD for further USS investigation.

Innovative non-invasive model for screening reduced estimated glomerular filtration rate in a working population.

AIM: Most of the existing risk scores for identifying people with reduced estimated glomerular filtration rate (eGFR) involve laboratory-based factors, which are not convenient and cost-effective to use in a large population-based screening programme. We aimed at using non-invasive variables to identify subjects with reduced eGFR in a Chinese working population. METHODS: Two study populations were recruited in 2012 and 2015, respectively. The 2012 study population (n = 14 374) was randomly separated as the training dataset (n = 9621) or the internal testing dataset (n = 4753) at a ratio of 2:1, and the 2015 study population (n = 4371) was used as the external testing dataset. Stepwise logistic regression analysis with age, gender, hypertension and body mass index (BMI) status were first performed in the training dataset and then validated in both internal and external testing dataset. A nomogram was further developed based on the final model. RESULTS: Results showed that older females with higher BMI status were more likely to have reduced eGFR. The model had excellent discrimination (AUC: 0.887 [95%CI: 0.865, 0.909] in the internal validation and 0.880 [95%CI: 0.829, 0.931] in the external validation) and calibration (Hosmer-Lemeshow test, P = 0.798 and 0.397 for internal and external dataset, respectively). The probability of having reduced eGFR increased gradually from <0.1% at a total score of 0 to 26% at a total score of 58 shown in the nomogram. CONCLUSION: Non-invasive variables could help identify individuals at high risk of reduced eGFR for further kidney function testing or intervention, aiding in decision-making and resource allocation in large population screening.

Health-related quality of life of Chinese patients with prostate cancer in comparison to general population and other cancer populations.

PURPOSE: The purpose of this study was to compare the health-related quality of life (HRQOL) of Chinese patients with prostate cancer against the general population and patients with colorectal cancer, breast cancer, nasopharyngeal cancer, and leukemia. METHODS: Chinese male patients (n = 291) with a confirmed diagnosis of prostate cancer were recruited from a urological specialist outpatient clinic in Hong Kong. HRQOL was measured by a condition-specific Functional Assessment of Cancer Therapy-Prostate (FACT-P) and a generic Chinese (HK) SF-12 Health Survey Version 2 (SF-12v2) questionnaire. Mean HRQOL scores of condition-specific and generic questionnaires were compared to available scores derived from other cancers and age-matched male general population, respectively. RESULTS: Chinese patients with prostate cancer had lower general health and vitality domains and lower mental component summary scores than the age-matched Hong Kong normative population. Patients with prostate cancer reported better condition-specific HRQOL (physical well-being, emotional well-being and function well-being) when compared to general cancer population, patients with breast cancer, colorectal cancer, nasopharyngeal cancer, and leukemia in Hong Kong. CONCLUSIONS: Patients with prostate cancer substantially perceived their HRQOL to be better, compared to patients with other cancers, with overall health, energy, and mental health below of Hong Kong general population. Interventions should target at these domains in order to improve the HRQOL of patients with prostate cancer. It is reassuring to find that prostate cancer had less negative impact on HRQOL than other cancer types did.

The internal and external responsiveness of Functional Assessment of Cancer Therapy-Prostate (FACT-P) and Short Form-12 Health Survey version 2 (SF-12 v2) in patients with prostate cancer.

PURPOSE: To examine the responsiveness of Functional Assessment of Cancer Therapy-Prostate (FACT-P) and Short Form-12 Health Survey version 2 (SF-12 v2) in prostate cancer patients because there is a lack of evidence to support their responsiveness in this patient population. METHODS: One hundred sixty-eight subjects with prostate cancer were surveyed at baseline and at 6 months using the SF-12 v2 and FACT-P version 4. Internal responsiveness was assessed using paired t test and generalized estimating equation. External responsiveness was evaluated using receiver operating characteristic curve analysis. RESULTS: The internal responsiveness of the FACT-P and SF-12 v2 to detect positive change was satisfactory. The FACT-P and SF-12 v2 could not detect negative change. The FACT-P and the SF-12 v2 performed the best in distinguishing between improved general health and worsened general health. The FACT-P performed better in distinguishing between unchanged general health and worsened general health. The SF-12 v2 performed better in distinguishing between unchanged general health and improved general health. CONCLUSIONS: Positive change detected by these measures should be interpreted with caution as they might be too responsive to detect "noise," which is not clinically significant. The ability of the FACT-P and the SF-12 v2 to detect negative change was disappointing. The internal and external responsiveness of the social well-being of the FACT-P cannot be supported, suggesting that it is not suitable to longitudinally monitor the social component of HRQOL in prostate cancer patients. The study suggested that generic and disease-specific measures should be used together to complement each other.

Implementation of secondary stroke prevention protocol for ischaemic stroke patients in primary care.

OBJECTIVE: To investigate the effectiveness of a secondary stroke prevention protocol in the general out-patient clinic. DESIGN: Cohort study with pre- and post-intervention comparisons. SETTING: Two general out-patient clinics in Hong Kong. PATIENTS: Ischaemic stroke patients who had long-term follow-up in two clinics were recruited. The patients of one clinic received the intervention (intervention group) and the patients of the second clinic did not receive the intervention (control group). The recruitment period lasted for 6 months from 1 September 2008 to 28 February 2009. The pre-intervention phase data collection started within this 6-month period. The protocol implementation started at the intervention clinic on 1 April 2009. The post-intervention phase data collection started 9 months after the protocol implementation, and ran for 6 months from 1 January 2010 to 30 June 2010. MAIN OUTCOME MEASURES: Clinical data before and after the intervention, including blood pressure, glycated haemoglobin level, low-density lipoprotein level and prescription pattern, were compared between the two groups to see whether there was enhancement of secondary stroke management. RESULTS: A total of 328 patients were recruited into the intervention group and 249 into the control group; data of 256 and 210 patients from these groups were analysed, respectively. After intervention, there were significant reductions in mean (± standard deviation) systolic blood pressure (135.2 ± 17.5 mm Hg to 127.7 ± 12.2 mm Hg), glycated haemoglobin level (7.2 ± 1.0% to 6.5 ± 0.8%), and low-density lipoprotein level (3.4 ± 0.8 mmol/L to 2.8 ± 1.3 mmol/L) in the intervention group (all P<0.01). There were no significant reductions in mean systolic blood pressure, glycated haemoglobin level, or low-density lipoprotein level in the control group. There was a significant increase in statin use (P<0.01) in both clinics. CONCLUSION: Through implementation of a clinic protocol, the standard of care of secondary stroke prevention for ischaemic stroke patients could be improved in a general out-patient clinic.

Patient presentation and physician management of upper respiratory tract infections: a retrospective review of over 5 million primary clinic consultations in Hong Kong.

BACKGROUND: Upper respiratory tract infection (URTI) has a significant healthcare burden worldwide. Considerable resources are consumed through health care consultations and prescribed treatment, despite evidence for little or no effect on recovery. Patterns of consultations and care including use of symptomatic medications and antibiotics for upper respiratory tract infections are poorly described. METHODS: We performed a retrospective review of computerized clinical data on patients presenting to all public primary care clinics in Hong Kong with symptoms of respiratory tract infections. International Classification of Primary care (ICPC)codes used to identify patients included otitis media (H71), streptococcal pharyngitis (R72), acute URTI (R74), acute sinusitis (R75), acute tonsillitis (R76), acute laryngitis (R77), and influenza (R80). Sociodemographic variables such as gender, age, chronic illness status, attendance date, type and duration of drug prescribed were also collected. RESULTS: Of the 5,529,755 primary care consultations for respiratory symptoms from 2005 to 2010, 98% resulted in a prescription. Prescription patterns of symptomatic medication were largely similar across the 5 years. In 2010 the mean number of drugs prescribed per consultation was 3.2, of which the commonly prescribed medication were sedating antihistamines (79.9%), analgesia (58.9%), throat lozenges (40.4%) and expectorant cough syrup (33.8%). During the study period, there was an overall decline in antibiotic prescription (8.1% to 5.1%). However, in consultations where the given diagnosis was otitis media (H71), streptococcal pharyngitis (R72), acute sinusitis (R75) or acute laryngitis (R76), over 90% resulted in antibiotic prescription. CONCLUSION: There was a decline in overall antibiotic prescription over the study period. However, the use of antibiotics was high in some conditions e.g. otitis media and acute laryngitis a. Multiple symptomatic medications were given for upper respiratory tract infections. Further research is needed to develop clinical and patients directed interventions to reduce the number of prescriptions of symptomatic medications and antibiotics that could reduce costs for health care services and iatrogenic risk to patients.

Prevalence of complications among Chinese diabetic patients in urban primary care clinics: a cross-sectional study.

BACKGROUND: A territory-wide diabetes management program (Risk Assessment Management Program - RAMP) was recently established, providing comprehensive management for all diabetics, helping to delineate current level of control and complications prevalence among primary care diabetic patients in Hong Kong. METHOD: This cross-sectional study captured anonymous clinical data from RAMP patients. Data obtained include sociodemographic details, type of diabetes, illness duration, family history, drug usage, coexisting illnesses, diabetic complications and other clinical parameters. RESULTS: Data from 15,856 type 2 diabetic patients were analyzed. 57.1% were above 60 years old, with mean disease duration of 7.3 years. Hypertension was the commonest coexisting chronic illness (57.6%). 30.2% and 61.8% have their systolic and diastolic pressure controlled to below 130 mmHg and 80 mmHg respectively. Over half (51.5%) had an HbA1c level of less than 7.0%. 88.4% did not achieve target lipid level. 15% were on diet control alone. Only 22.2% were on statins. In patients with microalbuminuria and macroalbuminuria, 40.7% and 54.5% were on angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) respectively. 12.9%, 38.8% and 2.4% had diabetic retinopathy, nephropathy and neuropathy respectively. Overall, 37.9%, 7.3% and 0.4% had single, two and three concurrent microvascular complications respectively. CONCLUSION: The level of diabetic control is comparable with other developed countries. We demonstrated a high prevalence of microvascular complications among Chinese primary care patients despite achieving adequate HbA1c levels, highlighting the importance of managing all aspects of diabetes including weight, lipid and blood pressure. Efforts to improve holistic management must be tailored according to the needs of our population, with the challenges that the majority have low educational background and in the older age group.

How much do elders with chronic conditions know about their medications?

BACKGROUND: Patients with chronic diseases often undertake multiple medication regimes to manage their condition, prevent complications and to maintain their quality of life. A patient's medication knowledge has been defined as the awareness of drug name, purpose, administration schedule, adverse effects or side-effects and special administration instructions. Poor medication knowledge can have a negative impact on medication adherence and patient safety and, in increasing the use of medical resources. The objective of the study is to assess the medication knowledge of elderly patients with chronic disease conditions and the factors affecting this knowledge. METHODS: A cross-sectional survey was conducted in patients aged ≥ 60 with chronic disease conditions or their caregivers were recruited from two general outpatient clinics and two medical outpatient clinics in the public sector. Participants were approached by trained interviewers to complete a semi-structured questionnaire to assess their understanding of the instructions and information relating to their regular medications, which included medication name, regimen, purpose and common side-effects and precautions. RESULTS: A total of 412 patients were recruited with the mean age of 72.86 ± 7.70. Of those, 221 (54.2%) were male and 226 (55.4%) were of primary school educational level or below. The mean number of medications taken per patient was 3.75 ± 1.93. Overall, 52.7% of patients felt that healthcare staff or clinic pharmacists had very clearly explained the administration instruction of the prescribed medications whilst 47.9% had very clear explanations of drug purpose but only 11.4% felt they had very clear explanations of side-effects. 396 patients (96.1%) failed to recall any side effects or precautions of each of their prescribed medications, although 232 patients (58.4%) would consult a doctor if they encountered problems with their medications. Logistic regression analysis showed that for every additional medication prescribed, the likeliness of patients to recall side-effects of all the medications prescribed was significantly lowered by 35% (OR = 0.65; 95% CI = 0.44-0.94; P = 0.023). In addition, those who finished secondary school or higher education were likely to possess more knowledge of side-effects (OR = 9.88; 95% CI = 2.11-46.25; P = 0.004). CONCLUSIONS: Patients who take medications for their chronic diseases generally lack knowledge on side-effects of their medications which could potentially affect medication compliance and medication safety.

Effect of facemasks on empathy and relational continuity: a randomised controlled trial in primary care.

BACKGROUND: There is limited evidence to support the use of facemasks in preventing infection for primary care professionals. Negative effects on communication has been suggested when the physician wears a facemask. As communication skills and doctor patient relationship are essential to primary care consultations, the effects of doctor's facemask wearing were explored. METHOD: A randomised controlled study was conducted in primary care to explore the effects of doctors wearing facemasks on patients' perception of doctors' empathy, patient enablement and patient satisfaction. Primary care doctors were randomized to mask wearing and non mask wearing clinical consultations in public primary care clinics in Hong Kong. Patients' views were gathered using the Consultation and Relational Empathy (CARE) Measure, Patient Enablement Instrument (PEI) and an overall satisfaction rating scale. The effects of face mask wearing were investigated using multilevel (hierarchical) modelling. RESULTS: 1,030 patients were randomised to doctor-mask wearing consultations (n = 514) and non mask wearing consultations (n = 516). A significant and negative effect was found in the patients' perception of the doctors' empathy (CARE score reduction -0.98, p-value = 0.04). In the more established doctor-patient relationship, the effect of doctors' mask wearing was more pronounced (CARE score reduction -5.67, p-value = 0.03). CONCLUSION: This study demonstrates that when doctors wearing a facemask during consultations, this has a significant negative impact on the patient's perceived empathy and diminish the positive effects of relational continuity. Consideration should be taken in planning appropriate use of facemasks in infectious disease policy for primary care and other healthcare professionals at a national, local or practice level. CLINICAL TRIAL REGISTRATION: This trial was registered on Chinese Clinical Trial Register (ChiCTR). Registration no.: ChiCTR-TTRCC-12002519. URL: http://www.chictr.org/en/proj/show.aspx?proj=3486. Due to administrative error, registration of trial did not take place until after the trial started on 1st August 2011 and registration number was released on 21st September 2012.

Willingness to accept H1N1 pandemic influenza vaccine: a cross-sectional study of Hong Kong community nurses.

BACKGROUND: The 2009 pandemic of influenza A (H1N1) infection has alerted many governments to make preparedness plan to control the spread of influenza A (H1N1) infection. Vaccination for influenza is one of the most important primary preventative measures to reduce the disease burden. Our study aims to assess the willingness of nurses who work for the community nursing service (CNS) in Hong Kong on their acceptance of influenza A (H1N1) influenza vaccination. METHODS: 401 questionnaires were posted from June 24, 2009 to June 30, 2009 to community nurses with 67% response rate. Results of the 267 respondents on their willingness to accept influenza A (H1N1) vaccine were analyzed. RESULTS: Twenty-seven percent of respondents were willing to accept influenza vaccination if vaccines were available. Having been vaccinated for seasonable influenza in the previous 12 months were significantly independently associated with their willingness to accept influenza A (H1N1) vaccination (OR = 4.03; 95% CI: 2.03-7.98). CONCLUSIONS: Similar to previous findings conducted in hospital healthcare workers and nurses, we confirmed that the willingness of community nurses to accept influenza A (H1N1) vaccination is low. Future studies that evaluate interventions to address nurses' specific concerns or interventions that aim to raise the awareness among nurses on the importance of influenza A (H1N1) vaccination to protect vulnerable patient populations is needed.

Comparison of primary care experiences among adults in general outpatient clinics and private general practice clinics in Hong Kong.

BACKGROUND: The main goal of Hong Kong's publicly-funded general outpatient clinics (GOPCs) is to provide primary medical services for the financially vulnerable. The objective of the current study was to compare the primary care experiences of GOPC users and the users of care provided by private general practitioners (GPs) in Hong Kong via a territory-wide telephone survey. METHODS: One thousand adults in Hong Kong aged 18 and above were interviewed by a telephone survey. The modified Chinese translated Primary Care Assessment Tool was used to collect data on respondents' primary care experience. RESULTS: Our results indicated that services provided by GOPC were more often used by female, older, poorer, chronically-ill and less educated population. GOPC participants were also more likely to have visited a specialist or used specialist services (69.7% vs. 52.0%; p < 0.001), although this difference in utilization of specialist services disappeared after adjusting for age (55.7% vs. 52.0%, p = 0.198). Analyses were also performed to asses the relationship between healthcare settings (GOPCs versus private GPs) and primary care quality. Private GP patients achieved higher overall PCAT scores largely due to better accessibility (Mean: 6.88 vs. 8.41, p < 0.001) and person-focused care (Mean: 8.37 vs. 11.69, p < 0.001). CONCLUSIONS: Our results showed that patients primarily receiving care from private GPs in Hong Kong reported better primary care experiences than those primarily receiving care from GOPCs. This was largely due to the greater accessibility and better interpersonal relationships offered by the private GPs. As most patients use both GOPCs and private GPs, their overall primary care experiences may not be as different as the findings of this study imply.

Will the community nurse continue to function during H1N1 influenza pandemic: a cross-sectional study of Hong Kong community nurses?

BACKGROUND: Healthcare workers have been identified as one of the high risk groups for being infected with influenza during influenza pandemic. Potential levels of absenteeism among healthcare workers in hospital settings are high. However, there was no study to explore the attitudes of healthcare workers in community setting towards the preparedness to the novel H1N1 influenza pandemic. The aim of this study was to explore the willingness of community nurses in Hong Kong to work during H1N1 influenza pandemic. METHODS: A cross-sectional survey was conducted among all 401 community nurses employed by the Hospital Authority in Hong Kong when the WHO pandemic alert level was 6. RESULTS: The response rate of this study was 66.6%. 76.9% participants reported being "not willing" (33.3%) or "not sure" (43.6%) to take care of patients during H1N1 influenza pandemic. The self-reported reasons for being unwilling to report to duty during H1N1 influenza pandemic were psychological stress (55.0%) and fear of being infected H1N1 influenza (29.2%). The reported unwillingness to report to duty was marginally significantly associated with the request for further training of using infection control clinical guideline (OR: 0.057; CI: 0.25-1.02). Those who reported unwillingness or not being sure about taking care of the patients during H1N1 influenza pandemic were more depressed (p < 0.001) and found work more emotionally stressful (p < 0.001). CONCLUSIONS: Interventions to provide infection control training and address community nurses' psychological needs might increase their willingness to provide care to patients in the community during H1N1 influenza pandemic. This would help to ensure an effective and appropriate health system response during the H1N1 influenza pandemic.

Correction: Antibiotic resistance rates and physician antibiotic prescription patterns of uncomplicated urinary tract infections in southern Chinese primary care.

[This corrects the article DOI: 10.1371/journal.pone.0177266.].

Nurse-led hypertension management was well accepted and non-inferior to physician consultation in a Chinese population: a randomized controlled trial.

The objective of this study is to evaluate if nurse-led repeated prescription (NRP) could ensure non-inferior disease control and would be accepted in Chinese patients with controlled hypertension (HT) in primary care clinics. A 12-month follow-up non-inferiority randomized trial was conducted. The non-inferior margins for systolic and diastolic blood pressure were 6.6 mmHg and 3.7 mmHg, respectively. Eligible patients (>18 years of age) with HT were randomized to the NRP and usual care (UC) groups for their regular clinical follow-up. We used ANCOVA to study the difference-of-difference of the blood pressures between the two groups. The levels of patient acceptance and experience of NRP were assessed by the observed opt-out rate and a qualitative analysis. We found no statistically significant differences in BP blood pressure between the NRP (N = 194) and UC (N = 199) groups. Only 4 of the participants in the NRP group opted out due to a preference for assessment by a physician. The interviewed participants (N = 12) felt positive about NRP, because they experienced more relaxed communication with the nurse and believed that the eligibility to join the NRP program was an indication of optimal BP control. We observed no adverse events. The findings show that NRP was well accepted and found to be non-inferior to physician consultation for HT management.

Antibiotic resistance rates and physician antibiotic prescription patterns of uncomplicated urinary tract infections in southern Chinese primary care.

Uncomplicated urinary tract infections (UTI) are common in primary care. Whilst primary care physicians are called to be antimicrobial stewards, there is limited primary care antibiotic resistance surveillance and physician antibiotic prescription data available in southern Chinese primary care. The study aimed to investigate the antibiotic resistance rate and antibiotic prescription patterns in female patients with uncomplicated UTI. Factors associated with antibiotic resistance and prescription was explored. A prospective cohort study was conducted in 12 primary care group clinics in Hong Kong of patients presenting with symptoms of uncomplicated UTI from January 2012 to December 2013. Patients' characteristics such as age, comorbidity, presenting symptoms and prior antibiotic use were recorded by physicians, as well as any empirical antibiotic prescription given at presentation. Urine samples were collected to test for antibiotic resistance of uropathogens. Univariate analysis was conducted to identify factors associated with antibiotic resistance and prescription. A total of 298 patients were included in the study. E. coli was detected in 107 (76%) out of the 141 positive urine samples. Antibiotic resistance rates of E. coli isolates for ampicillin, co-trimoxazole, ciprofloxacin, amoxicillin and nitrofurantoin were 59.8%, 31.8%, 23.4%, 1.9% and 0.9% respectively. E. coli isolates were sensitive to nitrofurantoin (98.1%) followed by amoxicillin (78.5%). The overall physician antibiotic prescription rate was 82.2%. Amoxicillin (39.6%) and nitrofurantoin (28.6%) were the most common prescribed antibiotics. Meanwhile, whilst physicians in public primary care prescribed more amoxicillin (OR: 2.84, 95% CI: 1.67 to 4.85, P<0.001) and nitrofurantoin (OR: 2.01, 95% CI: 1.14 to 3.55, P = 0.015), physicians in private clinics prescribed more cefuroxime and ciprofloxacin (P<0.05). Matching of antibiotic prescription and antibiotic sensitivity of E. coli isolates occurred in public than private primary care prescriptions (OR: 6.72, 95% CI: 2.07 to 21.80 P = 0.001) and for other uropathogens (OR: 6.19, 95% CI: 1.04 to 36.78 P = 0.034). Mismatching differences of antibiotic prescription and resistance were not evident. In conclusion, nitrofurantoin and amoxicillin should be used as first line antibiotic treatment for uncomplicated UTI. There were significant differences in antibiotic prescription patterns between public and private primary care. Public primary care practitioners were more likely to prescribe first line antibiotic treatment which match antibiotic sensitivity of E. coli isolates and other uropathogens. Further exploration of physician prescribing behaviour and educational interventions, particularly in private primary care may helpful. Meanwhile, development and dissemination of guidelines for primary care management of uncomplicated UTI as well as continued surveillance of antibiotic resistance and physician antibiotic prescription is recommended.

A randomized placebo controlled trial of vitamin B12 supplementation to prevent cognitive decline in older diabetic people with borderline low serum vitamin B12.

BACKGROUND & AIMS: Older diabetic people are at risk of cognitive decline. Vitamin B12 deficiency in older people is associated with cognitive impairment and Alzheimer's disease. Vitamin B12 deficiency may therefore contribute to cognitive decline in older diabetic people. We therefore performed a randomized placebo-controlled trial of vitamin B12 supplementation to prevent cognitive decline in older diabetic people with mild vitamin B12 deficiency. METHODS: 271 diabetic non-demented outpatients aged 70 years or older with plasma vitamin B12 150-300 pmol/L in outpatient clinics were randomly assigned to take either methylcobalamin 1000 µg or two similar looking placebo tablets once daily for 27 months. All subjects were followed up at 9 monthly intervals. The primary outcome is cognitive decline as defined by an increase in clinical dementia rating scale (CDR) global score. The secondary outcomes included Neuropsychological Test Battery (NTB) z-scores, serum methymalonic acid (MMA) and homocysteine. RESULTS: The subjects in the trial groups were well matched in clinical characteristics, except that active intervention group had more smokers. 46.5% and 74.1% had elevated serum methymalonic acid (≥0.21 µmol/L) and homocysteine (≥13 µmol/L) respectively. 44% of the subjects had CDR score of 0.5 suggesting questionable dementia. At month 9 and 27, serum MMA and homocysteine was significantly reduced in the active treatment group, when compared with placebo group. (P < 0.0001, student t test) At month 27, there was no significant group difference in changes in CDR or NTB z-scores. Exclusion of smokers did not alter the results. Subgroup analysis of high MMSE and serum MMA showed similar results. CONCLUSION: Vitamin B12 supplementation did not prevent cognitive decline in older diabetic patients with borderline vitamin B12 status. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov: NCT02457507.

How do general practitioners implement decision-making regarding COPD patients with exacerbations? An international focus group study.

PURPOSE: To explore the decision-making of general practitioners (GPs) concerning treatment with antibiotics and/or oral corticosteroids and hospitalization for COPD patients with exacerbations. METHODS: Thematic analysis of seven focus groups with 53 GPs from urban and rural areas in Norway, Germany, Wales, Poland, Russia, the Netherlands, and Hong Kong. RESULTS: Four main themes were identified. 1) Dealing with medical uncertainty: the GPs aimed to make clear medical decisions and avoid unnecessary prescriptions and hospitalizations, yet this was challenged by uncertainty regarding the severity of the exacerbations and concerns about overlooking comorbidities. 2) Knowing the patient: contextual knowledge about the individual patient provided a supplementary framework to biomedical knowledge, allowing for more differentiated decision-making. 3) Balancing the patients' perspective: the GPs considered patients' experiential knowledge about their own body and illness as valuable in assisting their decision-making, yet felt that dealing with disagreements between their own and their patients' perceptions concerning the need for treatment or hospitalization could be difficult. 4) Outpatient support and collaboration: both formal and informal caregivers and organizational aspects of the health systems influenced the decision-making, particularly in terms of mitigating potentially severe consequences of "wrong decisions" and concerning the negotiation of responsibilities. CONCLUSION: Fear of overlooking severe comorbidity and of further deteriorating symptoms emerged as a main driver of GPs' management decisions. GPs consider a holistic understanding of illness and the patients' own judgment crucial to making reasonable decisions under medical uncertainty. Moreover, GPs' decisions depend on the availability and reliability of other formal and informal carers, and the health care systems' organizational and cultural code of conduct. Strengthening the collaboration between GPs, other outpatient care facilities and the patients' social network can ensure ongoing monitoring and prompt intervention if necessary and may help to improve primary care for COPD patients with exacerbations.