Patients with respiratory tract infections who do not want antibiotics: direct observational study of primary care in Poland.

BACKGROUND: Requests by patients for antibiotics are known to strongly affect doctors' decisions to prescribe them.Objective. The aim of this study was to establish how frequently patients presenting with respiratory tract infections (RTIs) express their expectation not to be treated with antibiotics, which symptoms and physical findings are related to their perception of antibiotics not being helpful, and to what degree their expectations influence doctors' decisions. METHODS: This was a direct observational study set in primary care practices in Bialystok, Poland. The observers completed a checklist while observing a patient with RTI visiting a family doctor. RESULTS: Overall, 80 (5.5%) out of 1456 patients with RTIs openly requested not to be prescribed antibiotics. Patients not wanting antibiotics were prescribed antibiotics significantly less frequently [25/80 (31.3%)] than the remaining patients [765/1376 (55.6%), P < 0.001]. Univariate logistic regression revealed that cough and runny nose significantly increased the odds of patients not wanting antibiotics [odds ratio (OR) 1.8, 95% confidence intervals (CI): 1.01-3.20 and OR 1.6, 95% CI: 1.01-2.6, respectively] while the presence of tonsillar exudates significantly decreased the odds (OR 0.3, 95% CI: 0.08-0.86). Belief in a self-limited course (20%), recent treatments with antibiotics (16.3%), suspected viral aetiology (12.5%), and concerns about possible harm (12.5%) were the principal reasons for not wanting antibiotics. CONCLUSIONS: A patient's wish not to be prescribed antibiotics leads to less frequent antibiotic prescribing. Antimicrobial resistance, though important from a public health viewpoint, is not seen as a priority for individual patients with infections.

Is medical marijuana legalisation possible in Poland?

OBJECTIVES: In some countries of the world it is legal to use plant-based marijuana for therapeutic purposes. When we had learned that 7,000 petitioners (including doctors) signed the petition to enable access to marijuana for patients in the Czech Republic, we decided to examine the knowledge about marijuana's medical properties among Polish medical students. METHODS: Anonymous questionnaire study was conducted on a group of 181 of students of the last (sixth) year of medical school. RESULTS: It was demonstrated that students are not provided with sufficient information about therapeutic administration of plant-based marijuana during medical studies. The majority of interviewees mentioned only one indication for medical marijuana use. All students did not interchange medical conditions for which marijuana is used in 30 USA states or Canada. DISCUSSION: Marijuana smoking for medical purposes differs from recreational smoking, and its effect does not depend on occurrence of symptoms from the central nervous system. Few studies, that were carried out along with numerous previously unreported cases of patients, demonstrated that plant-derived marijuana had therapeutic effect on many diseases where conventional medicine was of no help. CONCLUSION: All doctors, including medical students, should receive more information about the therapeutic properties of marijuana.

Knowledge of family medicine trainers concerning HIV/AIDS ­ pilot study

AIM: The objective of the study was to assess knowledge of doctors during their residency training in family medicine about HIV infection, routes of transmission and diagnosis of AIDS METHODS: We developed an anonymous questionnaire with questions concerning knowledge about routes of infection, possibility of diagnosis of HIV infection based on presenting symptoms, risk of vertical transmission, risk of acquiring of HIV infection during occupational activities RESULTS: The obtained results revealed insufficient knowledge about routes of transmission as well as about symptoms which should prompt a general practitioner to suspect an HIV infection. Almost 20% of doctors regarded their risk of acquiring the HIV infection during their professional activities as quite high, while 10% of them stated that they would refuse to help an HIV-positive patient or that they did not know what they would do in such a situation. Majority (71.4%) of the respondents claimed that within the last 2 years they had undertaken a training oncerning HIV/AIDS CONCLUSIONS: The results of our study suggest that still more training is needed

Combined assessment of clinical and patient factors on doctors' decisions to prescribe antibiotics.

BACKGROUND: Antibiotic overprescription is a worldwide problem. Decisions regarding antibiotic prescription for respiratory tract infections (RTIs) are influenced by medical and non-medical factors. METHODS: In family medicine practices in Bialystok, Poland, family medicine residents directly observed consultations with patients with RTI symptoms. The observing residents completed a questionnaire including patient data, clinical symptoms, diagnosis, any prescribed antibiotic, and assessment of ten patient pressure factors. RESULTS: Of 1546 consultations of patients with RTIs, 54.26 % resulted in antibiotic prescription. Antibiotic prescription was strongly associated with rales (OR 26.90, 95 % CI 9.00-80.40), tonsillar exudates (OR 13.03, 95 % CI 7.10-23.80), and wheezing (OR 14.72, 95 % CI 7.70-28.10). The likelihood of antibiotic prescription was increased by a >7-day disease duration (OR 3.94, 95 % CI 2.80-5.50), purulent nasal discharge (OR 3.87, 95 % CI 2.40-6.10), starting self-medication with antibiotics (OR 4.11, 95 % CI 2.30-7.30), and direct request for antibiotics (OR 1.87, 95 % CI 1.30-2.80). Direct request not to prescribe antibiotics decreased the likelihood of receiving antibiotics (OR 0.34, 95 % CI 0.27-0.55). CONCLUSION: While clinical signs and symptoms principally impact prescribing decisions, patient factors also contribute. The most influential patient pressure factors were starting self-medication with antibiotics, and directly requesting antibiotic prescription or no antibiotic prescription. Interventions aiming to improve clinical sign and symptom interpretation and to help doctors resist direct patient pressure could be beneficial for reducing unnecessary antibiotic prescribing.

Outpatient use of systemic antibiotics in Poland: 2004-2008.

OBJECTIVES: The goal of this study was to evaluate the quantity and pattern of outpatient antibiotic use in Poland between 2004 and 2008 and to determine the trends in prescribing practice. To investigate the oral and parenteral outpatient antibiotic use in Poland. MATERIAL AND METHODS: Data concerning outpatient use of systemic antibiotics between 2004 and 2008 were obtained from Polish National Health Fund databases expressed as the number of defined daily doses (DDD) per 1000 inhabitants per day (DID) according to the international Anatomical Therapeutic Chemical ATC classification system of the World Health Organization (WHO, version 2009). RESULTS: Total outpatient antibiotic use in Poland varied from the lowest 17.88DID in 2004 to the highest 21.39DID in 2007. Penicillins (J01C) represented the most frequently prescribed antibiotics constituting more than 50% of the total outpatient antibiotic use. The other most popular groups of antibiotics were tetracyclines (J01A), macrolides (J01F). On the fourth and fifth position were cephalosporins (J01D) and quinolones (J01M), respectively. The parenteral antibiotic use did not exceed 1% of the total outpatient antibiotics prescribed with cefuroxime being the most frequently prescribed drug. CONCLUSIONS: Total outpatient use of antibiotics in Poland in 2004-2008 was comparable to the median European level. The consumption of all antibiotics slightly increased from 2004 to 2007, and decreased in 2008. The most often prescribed antibiotics were penicillins, mainly amoxicillin and amoxicillin with enzyme inhibitor. During the study period the use of the older (narrow-spectrum) antibiotics decreased in favour of the newer (broad-spectrum) antibiotics. The results suggest the discrepancy between national recommendations and choice of antibiotics by physicians.

HIV infections in otolaryngology.

HIV (human immunodeficiency virus) infection may produce no clinical symptoms for 10 years on average. However, after many years of infection most people develop symptoms that indicate progression of the disease. There are no regular characteristic symptoms or early stage, and no logical sequence of AIDS indicator disorders has been observed. People who are not aware of the infection are referred to physicians of various specializations, including otolaryngologists. It is on their knowledge about HIV infections, among other factors, that early diagnosis of the disease depends. Appropriate and quick introduction of anti-retroviral drugs may let a person with HIV live decades longer.

Consequences of the commercialisation of plasma and blood in China.

HIV infection as a consequence of blood transfusions and blood by-products has occurred in many developed countries from the outset of the HIV/AIDS epidemic. In China the introduction of the market economy and commercialisation of blood and blood products after 1989 has lead to the spread of HIV infection among poor peasants living in the Chinese interior. In this review a history of HIV infections was presented showing that blood and blood products cannot be treated as commercial goods.

Where and how do Polish patients contract HIV?

Until now, few studies have focused on the relationship between place of living, the level of education and HIV infection in Poland. The anonymous questionnaires containing questions about place of living and level of education one year before diagnosis of HIV infection were distributed among HIV-infected patients during their meetings or were sent to patients of the HIV/AIDS reference treatment centres in Poland. Among patients who responded to questionnaire women contracting HIV infection through injecting psychoactive drugs and by heterosexual contacts predominate. Prior to diagnosis, most injection drug users who responded to questionnaire (66.4%) lived in villages and small towns (up to 100,000 inhabitants), usually with parents, and the majority (69.8%) were poorly educated (still continued or already completed primary or basic vocational school). Better educated were those who contracted the infection trough heterosexual contacts. In this group, no differences were observed in relation to the place of living. HIV infected men who have sex with men were better educated, most of them lived in Warsaw and other large cities. Despite all the limitations, the findings suggest that majority of HIV infections in Poland are acquired by young people living in small towns and villages who are poorly educated. So the most urgent need exist to enhance HIV prevention amongst young people in Poland.

Does the poor HIV/AIDS knowledge among medical students may contribute to late diagnosis?

In Poland, as in many other countries, HIV infection is often detected at a late stage. We conducted this study to determine if Polish medical students possess adequate HIV/AIDS knowledge and diagnostic skills needed to improve HIV detection and care in Poland. Between 2004 and 2006, sixth-year (senior) medical students at the Medical University of Bialystok were asked to complete an anonymous questionnaire with questions about HIV transmission route and clinical characteristics. Although more than 50% of student respondents estimated their knowledge of HIV/AIDS as good or very good, HIV/AIDS knowledge assessment results did not support this self-reported level of proficiency. More than 40% of students answered that there are no symptoms associated with HIV infection that would make primary care physicians suspect the diagnosis. A significant majority of students could not name AIDS indicator diseases. To improve public health and quality of care for persons infected with HIV, it is necessary to better educate physicians-in-training about the clinical characteristics and transmission routes for HIV/AIDS, as well as approaches to discuss human sexuality and sexually transmitted infection prevention with patients.

Risk of needle stick injuries in health care workers: bad habits (recapping needles) last long.

In order to assess the nurses' knowledge concerning the risk of hepatitis B and C viruses or human immunodeficiency virus infection while performing their professional duties, an anonymous questionnaire developed by the authors was distributed in 2008. Surprisingly 64% respondents occasionally recapping needles after injections, although they know the procedures which are obligatory at the ward. The first step in preventing percutaneous injuries should focus on efforts to eliminate the practice of recapping needles, though education and convenient placement of puncture-resistant containers for the disposal of used sharps.

[Knowledge of patients from the rural environment on the risk factors and prevention of cardiovascular diseases]. / Wiedza pacjentów ze srodowiska wiejskiego na temat czynników ryzyka i profilaktyki chorób ukladu krazenia.

UNLABELLED: Cardiovascular diseases (CVDs) are the leading cause of death in Poland. The aim of the study was to assess the knowledge of patients from the rural environment on the risk factors and prevention CVDs. MATERIAL AND METHODS: In the period from January to February 2006. one hundred and twenty patients [69 (57.5%) females and 51 (42.5%) males] from Primary Care Practice in Zabludow living in rural areas in the vicinity of Bialystok were interviewed using questionnaires developed by the authors of the work. It contained questions on demographic data (gender, age, education and residence), health status and level of knowledge about risk factors and prevention CVDs. RESULTS: The vast majority of patients had a thorough understanding of risk factors CVDs. The least known factor is diabetes--just as the second test (55.8%) believe that it contributes to the formation of CVDs. As prophylaxis 77.5% of respondents reported a diet low in salt, and 75%--regular physical activity. Advancing our knowledge about the disease as an existing preventive recognized 70.8% of respondents. Comparing knowledge of patients with the knowledge of healthy CVDs participating in the survey stated that they know more about risk factors and prevention CVDs than the differences are statistically significant (p < 0.05). Better educated person knows more about risk factors and prevention of CVDs than the less educated people. These differences were statistically significant (p < 0.05). CONCLUSIONS: Examined patients living in rural areas have a wide knowledge on risk factors and prevention CVDs. This applies especially to people with higher education or with known cardiovascular diseases. People with lower education require more attention and education. Emphasis should be given to promoting information on the impact of diabetes on the development of CVDs.

[HIV infection prophylaxis in Uganda]. / Zapobieganie zakazeniom HIV w Ugandzie.

Uganda is one of the few countries where rates of HIV infection decreased, from about 18 percent in the early 1990s to about five percent in 2001. Although at the end of 2005, UNAIDS estimated that 6.7 percent of adults were HIV-infected, in recent years the number of infections has started to rise again. Uganda receives funds from the Unites States President's Emergency Plan for AIDS Relief (PEPFAR), which promotes the ABC approach focusing on sexual abstinence. Many experts argue that by emphasizing abstinence over condom use, the approach leaves women at risk of infection, because currently in Uganda marital sex continues to pose a particular risk for women.

[Is male circumcision an effective method of controlling HIV spread worldwide?]. / Czy obrzezanie mezczyzn jest dobrym sposobem na zahamowanie rozprzestrzeniania sie zakazenia HIV na swiecie?

After early ending of controlled randomized studies in three African countries, where it has been shown that male circumcision diminishes the risk of their HIV infection even by 60%, campaigns recommending such procedures were undertaken in many countries. However circumcision does not provide to males absolute protection against HIV and it is necessary to apply other strategies diminishing the risk of infection, like delaying sexual initiation, reducing the number of sexual partners and consistent and proper use of condoms. It has not been unequivocally clarified so far how male circumcision affects the risk of infection of their female sexual partner. There are very few studies concerning the influence of hygiene of sexual organs on the risk of acquiring sexual transmitted diseases, including HIV. It would be advisable to explore those issues before recommending male circumcision, particularly in those countries where HIV infected women outnumber HIV-infected men.

[Female circumcision--a new issue for gynecologists practicing in the E.U. countries?]. / Obrzezanie kobiet--nowy problem w praktyce lekarza ginekologa w krajach Unii Europejskiej?

An increasing number of immigrants from countries practicing female genital mutilation (FGM) has begun to concern Europe as well. The aim of this article is to present recent medical data about FGM which, in the age of globalisation and migration of people, may become essential for gynaecologists working in Poland, but also those practising abroad.

[Pathogenesis and risk of HIV infection in women--review of recent literature]. / Patogeneza i ryzyko zakazenia HIV u kobiet--przeglad aktualnego pismiennictwa.

In Poland, as well as worldwide, HIV prevalence is increasing among women and their children. Women acquire the infection mainly through heterosexual contacts, while children get it from their mothers. Identification of the factors leading to the infection is essential in order to work out effective strategies for prevention of HIV transmission among women and children. In Polish literature there are no detailed clinical guidelines how to prevent mother-to-child HIV infection--a fact which is not without meaning as it put Poland in an unfavourable position when comparing to other European countries with a higher number of infected children. In this review authors present recent data concerning women susceptibility to HIV infection, virus pathogenesis, the role of co-infections with other pathogens, as well as the role of sex hormones on HIV infection risk. Authors hope that the information will help to establish Polish standards on prevention of HIV infection in women and their children, and that they will soon be put into practice.

[Sequences of human immunodeficiency virus infection (HIV)]. / Nastepstwa zakazenie ludzkim wirusem uposledzenia odpornosci (HIV).

The clinical profile of HIV infection has changed from lethal disease, gradually destroying patient's immunologic system and progressing inevitably to AIDS, into a chronic manageable condition as it is now. The introduction of combined antiretroviral therapy in 1996 dramatically improved prognosis. In developed countries the estimated survival for a young person diagnosed with HIV infection in the late highly active antiretroviral therapy approaches the survival of general population. Despite the benefits of early diagnosis, majority of people living with HIV are unaware of their HIV status. Both poor knowledge of transmission routes and long asymptomatic phase of the infection contribute to delayed diagnosis. When the disease progresses towards symptomatic phase many patients seek help of physicians of varied specialities. The correct diagnosis of HIV infection being the cause of the reported symptoms depends on physicians' knowledge of HIV clinical features. In the age of combined antiretroviral therapy the diagnosis of HIV infection saves patient's life, and in case of pregnant women it additionally decreases significantly the risk of vertical transmission.

[Educational role of community nurse in care of patients treated with oral anticoagulation therapy]. / Edukacyjna rola pielegniarki srodowiskowej w opiece nad pacjentami leczonymi acenokumarolem w poradni lekarza rodzinnego.

UNLABELLED: Different methods allowing for assessment of anticoagulation effects in patients receiving oral anticoagulants (OAC) are applied. Among them estimation of total time of international normalized ratio (INR) within the therapeutic range (time in therapeutic range--TTR) is used. The aim of the study was to assess the knowledge of patients about safety measures when on acenocumarol (AC) therapy as well as to measure TTR and potential impact of education provided by community nurse on TTR. MATERIAL AND METHODS: The study lasted for 20 months since August 2006 till March 2008. Twenty-five patients remaining under care of a family physician were interviewed about safety rules while on treatment with AC. In May 2007 an educational intervention was provided by a trained community nurse. RESULTS: We have shown that older age was related to lower number of correct responses to questions (p < 0.064). Individuals with higher number of correct responses measured their INR more frequently, statistically significant difference (p < 0.045). TTR of all subjects before education was 48% and increased after education to 52%. We have shown that changes of TTR after education were related to education, age group and gender. The biggest improvement of TTR was observed among people younger than 75 years of age and those with higher education (not statistically significant differences). CONCLUSIONS: Education has biggest effect in persons under 75 years and with higher education. Older persons and those less educated require longer education and monitoring by health care professionals to maintain INR in the therapeutic range. Patients with better knowledge about DAK--monitor INR more frequently and their anticoagulation is better controlled.

[The risk of vertical transmission of HIV--the knowledge of gynaecologists and midwives]. / Wiedza ginekologów i poloznych na temat ryzyka transmisji wertykalnej HIV.

AIM: The aim of the study was to assess the knowledge of gynaecologist and midwives concerning the risk of vertical transmission of HIV. MATERIAL AND METHODS: Anonymous questionnaires have been filled in by thirty gynaecologists/obstetricians and thirty midwives who work at hospital wards and ambulatory gynaecological surgeries in Bialystok. RESULTS: When asked about chances of an HIV positive woman, aware of her infection, giving birth to a healthy baby, only 3 doctors (10%) and 4 midwives (13.3%) provided the correct answer, namely that such chances exceed 98%. Natural delivery was considered safer for the baby by 12 doctors (36.7%) and 7 (23.3%) midwives. The others chose elective caesarean section as the preferred mode of delivery. Twenty-five doctors (13.3%) and 23 midwives (76.7%) were aware that HIVinfected women should not breast-feed. Four doctors (13.3%) and 6 midwives (20.0%) favoured breast-feeding. Only 7 doctors (23.3%) and 9 midwives (30.0%) knew that the diagnosis whether a child is infected or not, based on anti-HIV antibodies, is possible only after the child reaches the age of 18 months. CONCLUSIONS: Being aware of the limitations of our study, it is possible to formulate the following conclusion: Knowledge of gynaecologists/obstetricians and midwives about possibilities of HIV vertical transmission is insufficient for effective transmission prophylaxis.

[Factors influencing activity of oral anticoagulants. Interactions with drugs and food]. / Czynniki wplywajace na dzialanie doustnych antykoagulantów. Interakcje z lekami i pozywieniem.

Oral anticoagulants (OAC) are commonly used as a life-long therapy in prevention of systemic embolism in patients with atrial fibrillation, valvular heart disease and prosthetic hart valves and in the primary and secondary prevention of venous thromboembolism. They are also used for the prevention of thromboembolic events in patients with acute myocardial infarction and with angina pectoris, in patients with biological hart valves and after some types of orthopaedics surgery. The International Normalized Ratio (INR) is used to evaluate the efficacy of anti-coagulant therapy. The risk of thromboembolic and haemorrhagic complications increases when the INR is out of the therapeutic range. The aim of this study was to present information about the factors influencing activity of oral anticoagulants and interactions between oral anticoagulants and drugs or food. The effect of oral anticoagulants is influenced by genetic and environmental factors such as: medicines, food, diseases and pre-existing conditions. A common mutation in the gene coding for the cytochrome P450 (CYP2C9), with one or more combinations of its polymorphisms, is responsible for the reduced warfarin requirements or for the resistance to warfarin. A mutation in the factor IX is responsible for the risk of bleeding during OAC therapy without excessive prolongation of the prothrombin time (PT). Drugs, herbs and multivitamin supplements can alter the absorption, pharmacokinetics or pharmakodynamics of OAC. Nonsteroid anti-inflammatory drugs and paracetamol in combination with OAC seem to be the most dangerous because they are available without prescription and are used without medical consultation. Patients on OAC therapy are sensitive to changing dietary intake of vitamin K, which is supplied from phylloquinones in plants or from vitamin K-containing medicines. The effect of OAC can be influenced by other existing factors like: fever, diarrhoea, alcohol abuse or physical hyperactivity. Some malignancies or other diseases like cardiac insufficiency, hyperthyroidism and hypothyroidism or hepatic dysfunction may also affect OAC therapy. This treatment requires patients and doctors to be knowledgeable about factors influencing the activity of oral anticoagulants. For this reason educational programme on OAC therapy should be conducted among patients and doctors.

[Use of oral anticoagulants in outpatient setting]. / Stosowanie doustnych antykoagulantów w ramach opieki ambulatoryjnej.

Oral anticoagulants (OAC) have been used for more than 60 years and are being prescribed to a steadily increasing number of patients as a life-long therapy The Intenational Normalized Ratio (INR) is used to evaluate the efficacy of anti-coagulant therapy. The risk of thromboembolic and haemorrhagic complications increases when the INR is above the therapeutic range. The aim of our study was to provide information about oral anticoagulant therapy and how to treat patients on OAC therapy in specific situations such as: pregnancy, intramuscular injection, tooth extraction and small invasive procedures performed in outpatient setting. INR needs to be frequently monitored during treatment and in many countries this is done in specialist anticoagulant clinics. Such clinics do not presently exist in Poland and patients on OAC treatment typically fall under the care of doctors of different specialization including general practitioners. OAC therapy is safe until fourth--sixth week of pregnancy, after his time anticoagulant treatment should be replaced by heparins. Intramuscular injections are contra-indicated during OAC therapy. In most cases general dental treatment and straightforward single dental extractions can be performed without discontinuing OAC, provided INR is in the therapeutic range of 2,0-3,5. Risk of bleeding can be minimized by the use of mouthwashes (used three or four times a day for 2 days) containing 4,8% tranexamid or 25% e-aminocapronicum acid. Prior to undergoing invasive procedures with a middle risk of bleeding and single extraction in patients with a risk of major bleeding should consult with a physician specializing in the use of anticoagulants to discuss the treatment and to assess the risk of bleeding and thromboembolism. This is why education about the therapeutic range of INR and procedures which need to be adopted in specific situations, is very important and the educational programme on OAC therapy should be targeted at patients and doctors of different specialization including general practitioners.