Uncovering influential factors in human antibiotic prescribing: a meta-synthesis study informed by the Theoretical Domains Framework.

This study aimed to identify modifiable determinants (facilitators and barriers) related to the choice of prescribing antibiotics in human medicine across clinical settings. Enhanced management of antibiotics can help slow the spread of resistant bacteria. A qualitative meta-synthesis approach was used, according to Sandelowski and Barroso's method. Included studies were evaluated using the Critical Appraisal Skills Programme. Findings were extracted and organized to form a qualitative meta-summary. The Theoretical Domains Framework, the Capabilities-Opportunities-Motivation (COM-B) model and the Behaviour Change Wheel were used as a coding matrix for data interpretation. The analysis of 63 included studies revealed barriers and facilitators in 12 of 14 domains specified by the Theoretical Domains Framework. Prescribers' capabilities, motivation and opportunities were found to be the main drivers of antibiotic prescribing behaviour. Knowledge, skills, beliefs, expectations, the influence of patients and colleagues, organizational culture and infrastructure characteristics have a significant impact on prescribing behaviours. A comprehensive inventory of factors related to antibiotic prescribing has been compiled. Interventions to promote appropriate antibiotic prescribing should take a systemic approach rather than focusing solely on individual-level variables. Furthermore, the adoption of co-design approaches for such interventions is desirable to ensure greater applicability and sustainability in the real-world context of organizations.

Ovarian and peripheral androgen and oestrogen levels in post-menopausal women: correlations with ovarian histology.

Ovarian and peripheral plasma levels of oestrone (E1), oestradiol (E2), androstenedione (A) and testosterone (T) were assayed in 58 post-menopausal women who underwent hysterectomy and oophorectomy (35 for endometrial carcinoma and 23 for benign gynaecological diseases). No significant difference between the two groups was seen when they were matched for percentage of ideal weight. However, significant differences were found between the ovarian and peripheral levels of the four steroids investigated. To facilitate analysis of the data, 40 of these women were classified into three groups (1, 2 and 3) according to degree of stromal hyperplasia of the ovary. Group 1 comprised those with atrophic ovaries, group 2 those with slight stromal hyperplasia and group 3 those with moderate or marked stromal hyperplasia. Ovarian levels of A and T were significantly higher than peripheral levels in all three groups, but the ovarian/peripheral oestrogen differences were significant only in groups 1 and 2. The ovarian steroid levels in group 3 were significantly higher than those in groups 1 and 2 in the cases of E1 (P less than 0.01), E2 (P less than 0.001) and A (P less than 0.001), but not in that of T. It was concluded that ovaries showing marked stromal hyperplasia can produce significant amounts not only of androgens but also of E2, and hence that any evaluation of the hormonal pattern in post-menopausal women must also take into account the microscopic characteristics of the ovary.

Ovarian and peripheral plasma levels of progestogens, androgens and oestrogens in post-menopausal women.

Ovarian and peripheral plasma concentrations of oestrone (E1), oestradiol (E2), androstenedione (A), testosterone (T), progesterone (P) and 17 alpha-hydroxy-progesterone (17 alpha OH-P) were assayed in 20 healthy post-menopausal women undergoing hysterectomy because of uterine fibromatosis. Significant differences were found between the ovarian and peripheral levels of E1 (P less than 0.01), E2 (P less than 0.001), A (P less than 0.01), T (P less than 0.001) and P (P less than 0.001). Analysis of the possible relationships between peripheral and ovarian levels of the six steroids considered and the patients' clinical characteristics revealed a positive correlation in only three cases, viz. between body weight and peripheral levels of E1 and E2, between E1 and E2 peripheral levels and between body weight and the E1/A ratio. The ovarian-peripheral gradient was calculated for each patient and was considered significant only if the ovarian peripheral difference exceeded the sum of each concentration multiplied by twice the maximal coefficient of variation of the assays used (12%). This gradient was significant in 75% of patients for T, in 45% for A, in 35% for E2, in 25% for E1, in 35% for P and in 30% for 17 17 alpha OH-P. Our findings confirm that circulating oestrogens in post-menopausal women originate mainly from the peripheral conversion of ovarian and adrenal androgens and that the ovary still continues to produce androgens. They also provide evidence that the ovary, at least in some post-menopausal subjects, can be a potential source of oestrogens and progestogens.