C-Reactive Protein Testing to Guide Antibiotic Prescribing for COPD Exacerbations.

BACKGROUND: Point-of-care testing of C-reactive protein (CRP) may be a way to reduce unnecessary use of antibiotics without harming patients who have acute exacerbations of chronic obstructive pulmonary disease (COPD). METHODS: We performed a multicenter, open-label, randomized, controlled trial involving patients with a diagnosis of COPD in their primary care clinical record who consulted a clinician at 1 of 86 general medical practices in England and Wales for an acute exacerbation of COPD. The patients were assigned to receive usual care guided by CRP point-of-care testing (CRP-guided group) or usual care alone (usual-care group). The primary outcomes were patient-reported use of antibiotics for acute exacerbations of COPD within 4 weeks after randomization (to show superiority) and COPD-related health status at 2 weeks after randomization, as measured by the Clinical COPD Questionnaire, a 10-item scale with scores ranging from 0 (very good COPD health status) to 6 (extremely poor COPD health status) (to show noninferiority). RESULTS: A total of 653 patients underwent randomization. Fewer patients in the CRP-guided group reported antibiotic use than in the usual-care group (57.0% vs. 77.4%; adjusted odds ratio, 0.31; 95% confidence interval [CI], 0.20 to 0.47). The adjusted mean difference in the total score on the Clinical COPD Questionnaire at 2 weeks was -0.19 points (two-sided 90% CI, -0.33 to -0.05) in favor of the CRP-guided group. The antibiotic prescribing decisions made by clinicians at the initial consultation were ascertained for all but 1 patient, and antibiotic prescriptions issued over the first 4 weeks of follow-up were ascertained for 96.9% of the patients. A lower percentage of patients in the CRP-guided group than in the usual-care group received an antibiotic prescription at the initial consultation (47.7% vs. 69.7%, for a difference of 22.0 percentage points; adjusted odds ratio, 0.31; 95% CI, 0.21 to 0.45) and during the first 4 weeks of follow-up (59.1% vs. 79.7%, for a difference of 20.6 percentage points; adjusted odds ratio, 0.30; 95% CI, 0.20 to 0.46). Two patients in the usual-care group died within 4 weeks after randomization from causes considered by the investigators to be unrelated to trial participation. CONCLUSIONS: CRP-guided prescribing of antibiotics for exacerbations of COPD in primary care clinics resulted in a lower percentage of patients who reported antibiotic use and who received antibiotic prescriptions from clinicians, with no evidence of harm. (Funded by the National Institute for Health Research Health Technology Assessment Program; PACE Current Controlled Trials number, ISRCTN24346473.).

Interrater and intrarater agreement on heart murmurs.

OBJECTIVE: To investigate interrater and intrarater agreement between physicians and medical students on heart sound classification from audio recordings, and factors predicting agreement with a reference classification. DESIGN: Intra- and interrater agreement study. SUBJECTS: Seventeen GPs and eight cardiologists from Norway and the Netherlands, eight medical students from Norway. MAIN OUTCOME MEASURES: Proportion of agreement and kappa coefficients for intrarater agreement and agreement with a reference classification. RESULTS: The proportion of intrarater agreement on the presence of any murmur was 83% on average, with a median kappa of 0.64 (range k = 0.09-0.86) for all raters, and 0.65, 0.69, and 0.61 for GPs, cardiologist, and medical students, respectively.The proportion of agreement with the reference on any murmur was 81% on average, with a median kappa of 0.67 (range 0.29-0.90) for all raters, and 0.65, 0.69, and 0.51 for GPs, cardiologists, and medical students, respectively.Distinct murmur, more than five years of clinical practice, and cardiology specialty were most strongly associated with the agreement, with ORs of 2.41 (95% CI 1.63-3.58), 2.19 (1.58-3.04), and 2.53 (1.46-4.41), respectively. CONCLUSION: We observed fair but variable agreement with a reference on heart murmurs, and physician experience and specialty, as well as murmur intensity, were the factors most strongly associated with agreement.Key points:Heart auscultation is the main physical examination of the heart, but we lack knowledge of inter- and intrarater agreement on heart sounds.• Physicians identified heart murmurs from heart sound recordings fairly reliably compared with a reference classification, and with fair intrarater agreement.• Both intrarater agreement and agreement with the reference showed considerable variation between doctors• Murmur intensity, more than five years in clinical practice, and cardiology specialty were most strongly linked to agreement with the reference.

Challenges and opportunities for general practice specific CME in Europe - a narrative review of seven countries.

BACKGROUND: Several changes have led to general practitioners (GPs) working in a more differentiated setting today and being supported by other health professions. As practice changes, primary care specific continuing medical education (CME) may also need to adapt. By comparing different primary care specific CME approaches for GPs across Europe, we aim at identifying challenges and opportunities for future development. METHODS: Narrative review assessing, analysing and comparing CME programs for general practitioners across different north-western European countries (UK, Norway, the Netherlands, Belgium (Flanders), Germany, Switzerland, and France). Templates containing detailed items across seven dimensions of country-specific CME were developed and used. These dimensions are role of primary care within the health system, legal regulations regarding CME, published aims of CME, actual content of CME, operationalisation, funding and sponsorship, and evaluation. RESULTS: General practice specific CME in the countries under consideration are presented and comparatively analysed based on the dimensions defined in advance. This shows that each of the countries examined has different strengths and weaknesses. A clear pioneer cannot be identified. Nevertheless, numerous impulses for optimising future GP training systems can be derived from the examples presented. CONCLUSIONS: Independent of country specific CME programs several fields of potential action were identified: the development of curriculum objectives for GPs, the promotion of innovative teaching and learning formats, the use of synergies in specialist GP training and CME, the creation of accessible yet comprehensive learning platforms, the establishment of clear rules for sponsorship, the development of new financing models, the promotion of fair competition between CME providers, and scientifically based evaluation.

The effect of atmospheric pressure on oxygen saturation and dyspnea: the Tromsø study.

A drop in atmospheric pressure, as observed at high altitudes, leads to decreased oxygen saturation. The effect of regular changes in barometric pressure at sea level has never been studied in a general population. A cohort of adults aged 40 years were examined with pulse oximetry at two separate visits, and the local barometric pressure was available from the local weather station. The study aimed at determining the effect of atmospheric pressure on oxygen saturation also called SpO2, as well as on shortness of breath. Based on spirometry, the participants were divided into two groups, with normal and decreased lung function. Decreased lung function was defined as forced expiratory volume in 1 s (FEV1) below lower limit or normal (LLN) or FEV1/FVC (FVC, forced vital capacity) below LLN, with GLI 2012 reference values. The statistical analysis included uni/multivariable linear and logistic regression. A total of 7439 participants of the Tromsø 7 cohort study were included. There was a significant association between barometric pressure and SpO2 < 96%, and we found that a reduction of 166.67 hPa was needed to get a 1% reduction in SpO2. The change in atmospheric pressure was not significantly associated with shortness of breath, also not in subjects with reduced lung function.

Antibiotic Prescribing for Acute Respiratory Tract Infections 12 Months After Communication and CRP Training: A Randomized Trial.

PURPOSE: C-reactive-protein (CRP) is useful for diagnosis of lower respiratory tract infections (RTIs). A large international trial documented that Internet-based training in CRP point-of-care testing, in enhanced communication skills, or both reduced antibiotic prescribing at 3 months, with risk ratios (RRs) of 0.68, 0.53, 0.38, respectively. We report the longer-term impact in this trial. METHODS: A total of 246 general practices in 6 countries were cluster-randomized to usual care, Internet-based training on CRP point-of-care testing, Internet-based training on enhanced communication skills and interactive booklet, or both interventions combined. The main outcome was antibiotic prescribing for RTIs after 12 months. RESULTS: Of 228 practices providing 3-month data, 74% provided 12-month data, with no demonstrable attrition bias. Between 3 months and 12 months, prescribing for RTIs decreased with usual care (from 58% to 51%), but increased with CRP training (from 35% to 43%) and with both interventions combined (from 32% to 45%); at 12 months, the adjusted RRs compared with usual care were 0.75 (95% CI, 0.51-1.00) and 0.70 (95% CI, 0.49-0.93), respectively. Between 3 months and 12 months, the reduction in prescribing with communication training was maintained (41% and 40%, with an RR at 12 months of 0.70 [95% CI, 0.49-0.94]). Although materials were provided for free, clinicians seldom used booklets and rarely used CRP point-of-care testing. Communication training, but not CRP training, remained efficacious for reducing prescribing for lower RTIs (RR = 0.7195% CI, 0.45-0.99, and RR = 0.76; 95% CI, 0.47-1.06, respectively), whereas both remained efficacious for reducing prescribing for upper RTIs (RR = 0.60; 95% CI, 0.37-0.94, and RR = 0.58; 95% CI, 0.36-0.92, respectively). CONCLUSIONS: Internet-based training in enhanced communication skills remains effective in the longer term for reducing antibiotic prescribing. The early improvement seen with CRP training wanes, and this training becomes ineffective for lower RTIs, the only current indication for using CRP testing.

Convolutional Neural Network for Breathing Phase Detection in Lung Sounds.

We applied deep learning to create an algorithm for breathing phase detection in lung sound recordings, and we compared the breathing phases detected by the algorithm and manually annotated by two experienced lung sound researchers. Our algorithm uses a convolutional neural network with spectrograms as the features, removing the need to specify features explicitly. We trained and evaluated the algorithm using three subsets that are larger than previously seen in the literature. We evaluated the performance of the method using two methods. First, discrete count of agreed breathing phases (using 50% overlap between a pair of boxes), shows a mean agreement with lung sound experts of 97% for inspiration and 87% for expiration. Second, the fraction of time of agreement (in seconds) gives higher pseudo-kappa values for inspiration (0.73-0.88) than expiration (0.63-0.84), showing an average sensitivity of 97% and an average specificity of 84%. With both evaluation methods, the agreement between the annotators and the algorithm shows human level performance for the algorithm. The developed algorithm is valid for detecting breathing phases in lung sound recordings.

Impaired left ventricular filling is associated with decreased pulse oximetry values.

OBJECTIVES: The aim of this study was to investigate the association between echocardiographic measures of diastolic left ventricular dysfunction and decreased arterial oxyhaemoglobin saturation measured with pulse oximetry (SpO2). DESIGN: This is a cross-sectional population-based survey of Norwegian adults. Values obtained using echocardiography, pulse oximetry, and spirometry were included. The primary outcome was abnormal mitral Doppler inflow, defined as normal: E/A ratio 0.75-1.5 and EDT ≥ 140 ms; abnormal: E/A ratio <0.75 or >1.5 or EDT <140 ms. The associations between this outcome and possible predictors, including SpO2 ≤ 95%, were analysed using univariable and multivariable logistic regression. RESULTS: A total of 1782 participants aged 50 years or older (54% women, mean age 67.5 years) were included in the analysis. Abnormal mitral Doppler inflow was found in 595 participants. After adjusting for age, gender, previous myocardial infarction, smoking history, dyspnoea, obesity, and decreased lung function, SpO2 ≤ 95% predicted abnormal mitral Doppler flow with an odds ratio (OR) of 1.6 [95% confidence interval (CI) 1.1-2.4]. Hypertension and BMI > =30 were also significant predictors of impaired filling, with OR of 1.7 (95% CI 1.1-2.7) OR and 1.5 (95% CI 1.2-1.9), respectively. CONCLUSION: Decreased SpO2 was a significant predictor of abnormal mitral Doppler flow. Diastolic dysfunction should be considered when SpO2 ≤ 95% is found.

The added value of C-reactive protein measurement in diagnosing pneumonia in primary care: a meta-analysis of individual patient data.

BACKGROUND: C-reactive protein (CRP) is increasingly being included in the diagnostic work-up for community-acquired pneumonia in primary care. Its added diagnostic value beyond signs and symptoms, however, remains unclear. We conducted a meta-analysis of individual patient data to quantify the added value of CRP measurement. METHODS: We included studies of the diagnostic accuracy of CRP in adult outpatients with suspected lower respiratory tract infection. We contacted authors of eligible studies for inclusion of data and for additional data as needed. The value of adding CRP measurement to a basic signs-and-symptoms prediction model was assessed. Outcome measures were improvement in discrimination between patients with and without pneumonia in primary care and improvement in risk classification, both within the individual studies and across studies. RESULTS: Authors of 8 eligible studies (n = 5308) provided their data sets. In all of the data sets, discrimination between patients with and without pneumonia improved after CRP measurement was added to the prediction model (extended model), with a mean improvement in the area under the curve of 0.075 (range 0.02-0.18). In a hypothetical cohort of 1000 patients, the proportion of patients without pneumonia correctly classified at low risk increased from 28% to 36% in the extended model, and the proportion with pneumonia correctly classified at high risk increased from 63% to 70%. The number of patients with pneumonia classified at low risk did not change (n = 4). Overall, the proportion of patients assigned to the intermediate-risk category decreased from 56% to 51%. INTERPRETATION: Adding CRP measurement to the diagnostic work-up for suspected pneumonia in primary care improved the discrimination and risk classification of patients. However, it still left a substantial group of patients classified at intermediate risk, in which clinical decision-making remains challenging.

Self-treatment of acute exacerbations of chronic obstructive pulmonary disease requires more than symptom recognition - a qualitative study of COPD patients' perspectives on self-treatment.

BACKGROUND: Self-treatment of acute exacerbations of COPD with antibiotics and/or oral corticosteroids has emerged as a promising strategy to reduce hospitalization rates, mortality and health costs. However, for reasons little understood, the effect of self-treatment, particularly when not part of comprehensive self-management programs, remains unclear. Therefore, this study aims to get insight into the patients' perspective on self-treatment of acute exacerbations of COPD, focusing specifically on how patients decide for the right moment to start treatment with antibiotics and/or oral corticosteroids, what they consider important when making this decision and aspects which might interfere with successful implementation. METHODS: We interviewed 19 patients with chronic obstructive pulmonary disease using qualitative semi-structured interviews, and applied thematic analysis for data analysis. RESULTS: Patients were well equipped with experiential knowledge to recognize and promptly respond to worsening COPD symptoms. Worries regarding potential adverse effects of antibiotics and oral corticosteroids played an important role in the decision to start treatment and could result in hesitation to start treatment. Although self-treatment represented a practical and appreciated option for some patients with predictable symptom patterns and treatment effect, all patients favoured assistance from a medical professional when their perceived competence reached its limits. However, a feeling of obligation to succeed with self-treatment or distrust in their doctors or the health care system could keep patients from timely help seeking. CONCLUSION: COPD patients regard self-treatment of exacerbations with antibiotics and/or oral corticosteroids as a valuable alternative. How they engage in self-treatment depends on their concerns regarding the medications' adverse effects as well as on their understanding of and preferences for self-treatment as a means of health care. Caregivers should address these perspectives in a collaborative approach when offering COPD patients the opportunity for self-treatment of exacerbations.

COPD and risk of venous thromboembolism and mortality in a general population.

The relationship between chronic obstructive pulmonary disease (COPD) and risk of venous thromboembolism (VTE) has been scarcely studied in the general population. We aimed to investigate the association between COPD and risk of VTE and mortality in a population-based cohort.Spirometry was conducted in 8646 males and females, participating in the fifth (2001-02) and sixth (2007-08) surveys of the Tromsø Study. Incident VTE events during follow-up were registered from the date of inclusion to December 31, 2011. Cox-regression models with COPD stages and confounders as time varying covariates were used to calculate hazard ratios with 95% confidence intervals for VTE and all-cause mortality.During a median follow-up of 6.2 years, 215 subjects developed VTE. Subjects with COPD stage III/IV had a two-fold higher risk of secondary VTE compared to subjects with normal airflow (HR 2.05, 95% CI 1.02-4.10). COPD patients, particularly those with stage III/IV disease, with VTE had a higher mortality rate than COPD patients without VTE (50.2% versus 5.6% per year).Our findings suggest that patients with severe COPD may have increased risk of secondary VTE, and that COPD patients with VTE have a higher mortality rate than COPD patients without VTE.

Towards the standardisation of lung sound nomenclature.

Auscultation of the lung remains an essential part of physical examination even though its limitations, particularly with regard to communicating subjective findings, are well recognised. The European Respiratory Society (ERS) Task Force on Respiratory Sounds was established to build a reference collection of audiovisual recordings of lung sounds that should aid in the standardisation of nomenclature. Five centres contributed recordings from paediatric and adult subjects. Based on pre-defined quality criteria, 20 of these recordings were selected to form the initial reference collection. All recordings were assessed by six observers and their agreement on classification, using currently recommended nomenclature, was noted for each case. Acoustical analysis was added as supplementary information. The audiovisual recordings and related data can be accessed online in the ERS e-learning resources. The Task Force also investigated the current nomenclature to describe lung sounds in 29 languages in 33 European countries. Recommendations for terminology in this report take into account the results from this survey.

Global Lung Function Initiative 2012 reference equations for spirometry in the Norwegian population.

We studied the fit of the Global Lung Function Initiative (GLI) all-age reference values to Norwegians, compared them with currently used references (European Community for Steel and Coal (ECSC) and Zapletal) and estimated the prevalence of obstructive lung disease.Spirometry data collected in 30 239 subjects (51.7% females) aged 12-90 years in three population-based studies were converted to z-scores.We studied healthy non-smokers comprising 2438 adults (57.4% females) aged 20-90 years and 8725 (47.7% female) adolescents aged 12-19 years. The GLI-2012 prediction equations fitted the Norwegian data satisfactorily. Median±sd z-scores were respectively 0.02±1.03, 0.01±1.04 and -0.04±0.91 for forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and FEV1/FVC in males, and -0.01±1.02, 0.07±0.97 and -0.21±0.82 in females. The ECSC and Zapletal references significantly underestimated FEV1 and FVC. Stricter criteria of obstruction (FEV1/FVC GLI-2012 LLN. Corresponding comparison regarding myocardial infarction showed a four-fold higher risk for women.The GLI-2012 reference values fit the Norwegian data satisfactorily and are recommended for use in Norway. Correspondingly, the FEV1/FVC GLI-2012 LLN identifies higher risk of obstructive characteristics than FEV1/FVC <0.7.

Patient experiences and the association with organizational factors in general practice: results from the Norwegian part of the international, multi-centre, cross-sectional QUALICOPC study.

BACKGROUND: General practitioners (GPs) constitute a vital part of a strong primary health care system. We need further knowledge concerning factors that may affect the patients' experiences in their meetings with the GPs. We investigated to what degree organizational factors and GP characteristics are associated with patients' communicative experiences in a consultation. METHODS: We used data from the Norwegian part of the international, multi-center study Quality and Costs of Primary Care in Europe (QUALICOPC). We included 198 Norwegian GPs and 1529 patients. The patients completed a survey concerning experiences in a consultation with a GP on the inclusion day. The GPs completed a survey regarding organizational aspects of their own practice. Main outcome measures were seven statements concerning how the patients experienced the communication with the GP during the consultation. A generalized estimating equation logistic regression model was used to identify variations in patient experiences associated with characteristics of the GPs and their practices. RESULTS: The patients reported overall positive experiences with their GP consultations. Patients who consulted a GP with a short patient list were less likely than patients who consulted a GP with a medium sized list to regard the GP as polite (Odds Ratio (OR) 0.2; 95 % CI 0.1-0.7), to report that the GP asked questions about their health problems (OR 0.6; 0.4-1.0) or that the GP used sufficient time (OR 0.5; CI 0.3-0.9). Patients who consulted a GP with a long patient list compared to patients who consulted a GP with a medium sized list were less likely to feel that they could cope better after the GP visit (OR 0.5; 0.3-0.9) and more likely to feel that the GP hardly looked at them while talking (OR 1.8; 1.0-3.0). No associations with patient experiences were found with the average duration of the consultations, whether the GP worked in a fee-for-service model or whether the GP was the patient's regular doctor. CONCLUSIONS: Norwegian patients report predominantly positive experiences when consulting a GP. Positive communication experiences are most likely to be reported when the GP has a medium sized patient list.

Low oxygen saturation and mortality in an adult cohort: the Tromsø study.

BACKGROUND: Oxygen saturation has been shown in risk score models to predict mortality in emergency medicine. The aim of this study was to determine whether low oxygen saturation measured by a single-point measurement by pulse oximetry (SpO2) is associated with increased mortality in the general adult population. METHODS: Pulse oximetry was performed in 5,152 participants in a cross-sectional survey in Tromsø, Norway, in 2001-2002 ("Tromsø 5"). Ten-year follow-up data for all-cause mortality and cause of death were obtained from the National Population and the Cause of Death Registries, respectively. Cause of death was grouped into four categories: cardiovascular disease, cancer except lung cancer, pulmonary disease, and others. SpO2 categories were assessed as predictors for all-cause mortality and death using Cox proportional-hazards regression models after correcting for age, sex, smoking history, body mass index (BMI), C-reactive protein level, self-reported diseases, respiratory symptoms, and spirometry results. RESULTS: The mean age was 65.8 years, and 56% were women. During the follow-up, 1,046 (20.3%) participants died. The age- and sex-adjusted hazard ratios (HRs) (95% confidence intervals) for all-cause mortality were 1.99 (1.33-2.96) for SpO2 ≤ 92% and 1.36 (1.15-1.60) for SpO2 93-95%, compared with SpO2 ≥ 96%. In the multivariable Cox proportional-hazards regression models that included self-reported diseases, respiratory symptoms, smoking history, BMI, and CRP levels as the explanatory variables, SpO2 remained a significant predictor of all-cause mortality. However, after including forced expiratory volume in 1 s percent predicted (FEV1% predicted), this association was no longer significant. Mortality caused by pulmonary diseases was significantly associated with SpO2 even when FEV1% predicted was included in the model. CONCLUSIONS: Low oxygen saturation was independently associated with increased all-cause mortality and mortality caused by pulmonary diseases. When FEV1% predicted was included in the analysis, the strength of the association weakened but was still statistically significant for mortality caused by pulmonary diseases.

Predictors of treatment with antibiotics and systemic corticosteroids for acute exacerbations of asthma and chronic obstructive pulmonary disease in primary care.

BACKGROUND: Antibiotic and oral corticosteroid prescribing rate in patients suffering from acute exacerbations of chronic obstructive pulmonary disease (COPD) or asthma in general practice are only sparsely described. Our aim was to identify predictors for such prescribing when results from CRP testing, spirometry, and pulse oximetry are available. METHODS: Patients aged 40 years or more diagnosed with asthma, COPD or both, the previous five years from seven general practice offices in Norway, were invited to a baseline examination and asked to visit their GPs during exacerbations the following 12 months. At all visits, symptoms, chest findings, and results from spirometry, pulse oximetry and CRP testing were registered. RESULTS: Out of the 376 who took part in baseline examination, 95 patients with an exacerbation were included in the analysis. Based on the diagnosis made by GPs, 46 patients (48.4%) were only registered with asthma, and 49 (51.6%) with COPD (or both diagnosis). 11 patients had taken antibiotics and 16 had taken systemic corticosteroids prior to their visit to their GPs. After excluding those already treated, antibiotics were prescribed in 34.9% and systemic corticosteroids in 42.5% of patients diagnosed with COPD compared to 14.6% and 30.8% respectively in patients only diagnosed with asthma (P = 0.02, P = 0.2). In the COPD group, antibiotic prescribing was not significantly associated with purulence or other respiratory symptoms, but increased phlegm was a significant predictor of antibiotic prescribing in the whole sample (P = 0.04). Prolonged expiration, wheezes and diminished breath sounds also predicted the prescribing of both antibiotics and systemic corticosteroids in the whole sample with P values < 0.01. The prescribing rate of antibiotics and systemic corticosteroids also increased with increasing CRP value (P = 0.001 and P = 0.01, respectively) and with decreasing oxygen saturation (P = 0.01 and P = 0.003, respectively). FEV1/FVC < 0.7 at baseline was as significant predictor in patients with COPD and in the whole sample of patients regarding treatment with antibiotics (P = 0.004 and P = 0.001, respectively) and treatment with systemic corticosteroids (P = 0.004 and P = 0.001, respectively). CONCLUSION: Chest findings, raised CRP value and decreased oxygen saturation were stronger predictors of prescribing of antibiotics and systemic corticosteroids than were respiratory symptoms. Further evaluation of the importance of these findings to guide treatment of asthma and COPD exacerbations is warranted.

Should pulse oximetry be included in GPs' assessment of patients with obstructive lung disease?

OBJECTIVE: To explore the associations between decreased pulse oximetry values (SpO2) and clinical, laboratory, and demographic variables in general practice patients diagnosed with asthma or chronic obstructive pulmonary disease (COPD), including those with both COPD and asthma in combination. DESIGN/SETTING: A cross-sectional study in seven Norwegian general practices of patients aged 40 years or over who were diagnosed by their general practitioner (GP) with asthma and/or COPD. The patients were examined during a stable phase of their disease. Patients diagnosed with COPD (including those with combined COPD/asthma) and those diagnosed with asthma only were analysed separately. MAIN OUTCOME MEASURES: Decreased SpO2 values (≤ 95% and ≤ 92%). RESULTS: Of 372 patients included (mean age 61.5 years, 62% women), 82 (22.0%) had SpO2 ≤ 95%, of which 11 had SpO2 ≤ 92%. In both asthma and COPD patients, SpO2 ≤ 95% was significantly associated with reduced lung function (spirometry), a diagnosis of coronary heart disease and older age (≥ 65 years). In the COPD group, haemoglobin above normal was associated with SpO2 ≤ 95%. These associations were confirmed by multivariable logistic regression, where FEV1% predicted < 50 was the strongest predictor of SpO2 ≤ 95% (odds ratio 6.8, 95% confidence interval 2.8-16.4). CONCLUSION: Pulse oximetry represents a useful diagnostic adjunct for assessing the severity of obstructive pulmonary disease. Decreased pulse oximetry values in stable-phase patients with asthma and/or COPD should prompt the GP to consider revising the diagnosis and treatment and to look for co-morbidities. Key Points Despite its common use in general practice, the diagnostic benefits of pulse oximetry remain to be established. Decreased pulse oximetry values are associated with both reduced lung function (spirometry) and with a diagnosis of coronary heart disease. Decreased pulse oximetry values may reflect suboptimal treatment and/or undiagnosed comorbidity. Pulse oximetry may therefore be a useful measure in the follow-up of asthma and COPD patients in general practice.

Effects of internet-based training on antibiotic prescribing rates for acute respiratory-tract infections: a multinational, cluster, randomised, factorial, controlled trial.

BACKGROUND: High-volume prescribing of antibiotics in primary care is a major driver of antibiotic resistance. Education of physicians and patients can lower prescribing levels, but it frequently relies on highly trained staff. We assessed whether internet-based training methods could alter prescribing practices in multiple health-care systems. METHODS: After a baseline audit in October to December, 2010, primary-care practices in six European countries were cluster randomised to usual care, training in the use of a C-reactive protein (CRP) test at point of care, in enhanced communication skills, or in both CRP and enhanced communication. Patients were recruited from February to May, 2011. This trial is registered, number ISRCTN99871214. RESULTS: The baseline audit, done in 259 practices, provided data for 6771 patients with lower-respiratory-tract infections (3742 [55·3%]) and upper-respiratory-tract infections (1416 [20·9%]), of whom 5355 (79·1%) were prescribed antibiotics. After randomisation, 246 practices were included and 4264 patients were recruited. The antibiotic prescribing rate was lower with CRP training than without (33% vs 48%, adjusted risk ratio 0·54, 95% CI 0·42-0·69) and with enhanced-communication training than without (36% vs 45%, 0·69, 0·54-0·87). The combined intervention was associated with the greatest reduction in prescribing rate (CRP risk ratio 0·53, 95% CI 0·36-0·74, p<0·0001; enhanced communication 0·68, 0·50-0·89, p=0·003; combined 0·38, 0·25-0·55, p<0·0001). INTERPRETATION: Internet training achieved important reductions in antibiotic prescribing for respiratory-tract infections across language and cultural boundaries. FUNDING: European Commission Framework Programme 6, National Institute for Health Research, Research Foundation Flanders.

Trust, openness and continuity of care influence acceptance of antibiotics for children with respiratory tract infections: a four country qualitative study.

BACKGROUND: Clinician-parent interaction and health system influences on parental acceptance of prescribing decisions for children with respiratory tract infections (RTIs) may be important determinants of antibiotic use. OBJECTIVE: To achieve a deeper understanding of parents' acceptance, or otherwise, of clinicians' antibiotic prescribing decisions for children with RTIs. METHODS: Qualitative interviews with parents of child patients who had recently consulted in primary care with a RTI in four European countries, with a five-stage analytic framework approach (familiarization, developing a thematic framework from interview questions and emerging themes, indexing, charting and interpretation). RESULTS: Fifty of 63 parents accepted clinicians' management decisions, irrespective of antibiotic prescription. There were no notable differences between networks. Parents ascribed their acceptance to a trusting and open clinician-patient relationship, enhanced through continuity of care, in which parents felt able to express their views. There was a lack of congruence about antibiotics between parents and clinicians in 13 instances, mostly when parents disagreed about clinicians' decision to prescribe (10 accounts) rather than objecting to withholding antibiotics (three accounts). All but one parent adhered to the prescribing decision, although some modified how the antibiotic was administered. CONCLUSIONS: Parents from contrasting countries indicated that continuity of care, open communication in consultations and clinician-patient trust was important in acceptance of management of RTI in their children and in motivating adherence. Interventions to promote appropriate antibiotic use in children should consider a focus on eliciting parents' perspectives and promoting and building on continuity of care within a trusting clinician-patient relationship.

Association between serum 25-hydroxyvitamin D concentration and symptoms of respiratory tract infection in a Norwegian population: the Tromsø Study.

OBJECTIVE: Previous studies have suggested anti-infection effects of vitamin D, although the associations reported between vitamin D (serum 25-hydroxyvitamin D (25(OH)D) concentration) and respiratory tract infection (RTI) are conflicting. The main aim of the present study was to explore this association in a Norwegian population. DESIGN: We examined the association between serum 25(OH)D and recent RTI symptoms in 6350 middle-aged and elderly participants in the Tromsø Study 6. The main outcome measurement was self-reported RTI symptoms in the previous week. SETTING: Tromsø, Norway, 69 °N. SUBJECTS: Six thousand three hundred and fifty middle-aged and elderly residents of Tromsø. RESULTS: Of the 6350 included, 791 (12.5%) reported RTI symptoms in the previous week. We classified serum 25(OH)D concentrations into quartiles and adjusted the data for current smoking habit and month of attendance. The prevalence of RTI symptoms did not increase with decreasing serum 25(OH)D level, was highest in quartile 3 (15.0%) followed by quartile 4 (12.4%), and was lowest in quartiles 1 and 2 (11.1% and 11.4%). There was no trend for increasing duration of illness with decreasing serum 25(OH)D. The prevalence of RTI symptoms was not significantly associated with the intake of fish, n-3 capsules or vitamin and/or mineral supplements, or sun exposure. Only use of cod-liver oil or fish oil capsules daily or sometimes was significantly associated with fewer RTI symptoms during the preceding 7 d (P = 0.04). CONCLUSIONS: Low serum 25(OH)D was not associated with increased prevalence of recent RTI symptoms. Our findings do not support the idea that vitamin D supplementation can reduce the incidence of RTI in Norway.

Usefulness of C-reactive protein testing in acute cough/respiratory tract infection: an open cluster-randomized clinical trial with C-reactive protein testing in the intervention group.

BACKGROUND: Point of care testing for C-reactive protein (CRP) has shown promise as a measure to reduce unnecessary antibiotic prescribing in respiratory tract infections (RTI), but its use in primary care is still controversial. We aimed to evaluate the effect of CRP testing on the prescription of antibiotics, referral for radiography, and the outcome of patients in general practice with acute cough/RTI. METHODS: An open-cluster randomized clinical trial was conducted, with CRP testing performed in the intervention group. Antibiotic prescribing and referral for radiography were the main outcome measures. RESULTS: A total of 179 patients were included: 101 in the intervention group and 78 in the control group. The two groups were similar in clinical characteristics. In the intervention group, the antibiotic prescribing rate was 37.6%, which was significantly lower than that in the control group (58.9%) (P=0.006). Referral for chest X-ray was also significantly lower in the intervention group (55.4%) than in the control group (75.6%) (P=0.004). The recovery rate, as recorded by the GPs, was 92.9% and 93.6% in the intervention and control groups, respectively. CONCLUSION: The study showed that CRP testing in patients with acute cough/RTI may reduce antibiotic prescribing and referral for radiography, probably without compromising recovery. TRIAL REGISTRATION: The trial was registered in the ClinicalTrials.gov Protocol Registration System (identification number: NCT01794819).