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1.
BMJ Open ; 12(2): e049647, 2022 02 21.
Artigo em Inglês | MEDLINE | ID: mdl-35190414

RESUMO

OBJECTIVES: The Strengthening Families Programme 10-14 (SFP10-14) is a USA-developed universal group-based intervention aiming to prevent substance misuse by strengthening protective factors within the family. This study evaluated a proportionate universal implementation of the adapted UK version (SFP10-14UK) which brought together families identified as likely/not likely to experience/present challenges within a group setting. DESIGN: Pragmatic cluster-randomised controlled effectiveness trial, with families as the unit of randomisation and embedded process and economic evaluations. SETTING: The study took place in seven counties of Wales, UK. PARTICIPANTS: 715 families (919 parents/carers, 931 young people) were randomised. INTERVENTIONS: Families randomised to the intervention arm received the SFP10-14 comprising seven weekly sessions. Families in intervention and control arms received existing services as normal. OUTCOME MEASURES: Primary outcomes were the number of occasions young people reported drinking alcohol in the last 30 days; and drunkenness during the same period, dichotomised as 'never' and '1-2 times or more'. Secondary outcomes examined alcohol/tobacco/substance behaviours including: cannabis use; weekly smoking (validated by salivary cotinine measures); age of alcohol initiation; frequency of drinking >5 drinks in a row; frequency of different types of alcoholic drinks; alcohol-related problems. Retention: primary analysis included 746 young people (80.1%) (alcohol consumption) and 732 young people (78.6%) (drunkenness). RESULTS: There was no evidence of statistically significant between-group differences 2 years after randomisation for primary outcomes (young people's alcohol consumption in the last 30 days adjusted OR=1.11, 95% CI 0.72 to 1.71, p=0.646; drunkenness in the last 30 days adjusted OR=1.46, 95% CI 0.83 to 2.55, p=0.185). There were no statistically significant between-group differences for other substance use outcomes, or those relating to well-being/stress, and emotional/behavioural problems. CONCLUSIONS: Previous evidence of effectiveness was not replicated. Findings highlight the importance of evaluating interventions when they are adapted for new settings. TRIAL REGISTRATION NUMBER: ISRCTN63550893.Cite Now.


Assuntos
Intoxicação Alcoólica , Transtornos Relacionados ao Uso de Substâncias , Adolescente , Criança , Análise Custo-Benefício , Humanos , Pais , Transtornos Relacionados ao Uso de Substâncias/prevenção & controle , Reino Unido
2.
Pediatr Emerg Care ; 37(4): e210-e211, 2021 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-30211836

RESUMO

ABSTRACT: Pediatric autoresuscitation is extremely rare, with only 4 documented cases in the literature. The longest recorded time between stopping cardio pulmonary resuscitation (CPR) and return of spontaneous circulation is 2 minutes. We report a previously well 18-month-old who attended the emergency department after an unexplained cardiac arrest. After 10 cycles of CPR, resuscitation was stopped; 6 minutes later, the patient had a return of spontaneous circulation and was transferred to the pediatric intensive care unit. The patient remains alive but with significant neurological impairment. There are a variety of theories regarding the pathology of pediatric autoresuscitation. The most commonly accepted model is that there is a degree of autopositive end-expiratory pressure impending venous return as a consequence of vigorous ventilation during CPR. This case challenges clinicians to reassess our current definition of death and reaffirms the need for clearer guidelines surrounding the certification of death.


Assuntos
Reanimação Cardiopulmonar , Parada Cardíaca , Criança , Serviço Hospitalar de Emergência , Parada Cardíaca/etiologia , Parada Cardíaca/terapia , Humanos , Lactente , Retorno da Circulação Espontânea , Síndrome
3.
Emerg Med J ; 37(6): 351-354, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32321707

RESUMO

OBJECTIVES: The Burns and Scalds Assessment Template (BaSAT) is an evidence-based proforma coproduced by researchers and ED staff with the aim of (1) standardising the assessment of children attending ED with a burn, (2) improving documentation and (3) screening for child maltreatment. This study aimed to test whether the BaSAT improved documentation of clinical, contributory and causal factors of children's burns. METHODS: A retrospective before-and-after study compared the extent to which information was recorded for 37 data fields after the BaSAT was introduced in one paediatric ED. Pre-BaSAT, a convenience sample of 50 patient records of children who had a burn was obtained from the hospital electronic database of 2007. The post-BaSAT sample included 50 randomly selected case notes from 2016/2017 that were part of another research project. Fisher's exact test and Mann-Whitney U tests were conducted to test for statistical significance. RESULTS: Pre-BaSAT, documentation of key data fields was poor. Post-BaSAT, this varied less between patients, and median completeness significantly (p<0.001) increased from 44% (IQR 4%-94%) to 96% (IQR 94%-100%). Information on 'screening for maltreatment, referrals to social care and outcome' was poorly recorded pre-BaSAT (median of 4% completed fields) and showed the greatest overall improvement (to 95%, p<0.001). Documentation of domestic violence at home and child's ethnicity improved significantly (p<0.001) post-BaSAT; however, these were still not recorded in 36% and 56% of cases, respectively. CONCLUSION: Introduction of the BaSAT significantly improved and standardised the key clinical data routinely recorded for children attending ED with a burn.


Assuntos
Queimaduras/terapia , Exame Físico/métodos , Padrões de Referência , Adolescente , Distribuição por Idade , Criança , Pré-Escolar , Documentação/métodos , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/tendências , Feminino , Humanos , Lactente , Masculino , Exame Físico/normas , Estudos Retrospectivos , País de Gales
4.
Arch Dis Child Educ Pract Ed ; 105(1): 19-23, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31201217

RESUMO

The management of paediatric trauma patients can be complex, involving a coordinated multidisciplinary approach. Paediatricians form an integral part of the trauma team and are often tasked with managing circulation. In this article, we will discuss the assessment of catastrophic haemorrhage and 'circulation' through the viewpoint of a paediatrician via a case discussion. This will include initial investigations and management, noting the time critical nature in identifying and stopping catastrophic haemorrhage. The discussion will comment on how to address hypovolaemic shock and touch on the role of imaging.


Assuntos
Hemorragia/terapia , Pediatras , Papel do Médico , Choque/diagnóstico por imagem , Choque/terapia , Criança , Humanos , Equipe de Assistência ao Paciente
5.
Emerg Med J ; 37(1): 25-30, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31722885

RESUMO

OBJECTIVES: Trauma contributes significantly to adolescent morbidity and mortality. We aimed to ascertain the epidemiology of adolescent trauma to inform prevention strategies. METHODS: Data were abstracted from TARN (Trauma Audit Research Network) from English sites over a 10-year period (2008-2017). Adolescents were defined as 10-24 completed years. Descriptive statistical analysis was used in this study. RESULTS: There were 40 680 recorded cases of adolescent trauma. The majority were male (77.3%) and aged 16-24 years old (80.5%). There was a 2.6-fold increase during the study time frame (p<0.0001) in the total annual number of cases reported to TARN. To account for increasing hospital participation, the unit trauma cases per hospital per year was used, noting an increasing trend (p=0.048). Road traffic collision (RTC) was the leading cause of adolescent trauma (50.3%). Pedestrians (41.2%) and cyclists (32.6%) were more prevalent in the 10-15 year group, while drivers (22.9%) and passengers (17.8%) predominated in the 16-24 year group. Intentional injury was reported in 20.7% (alleged assault in 17.2% and suspected self-harm in 3.5%). This was more prevalent in the 16-24 year group. The proportion of trauma reported due to violence has increased with stabbings increasing from 6.9% in 2008 to 10.2% in 2017 (p<0.0001). Evidence of alcohol or drug use was recorded in 20.1% of cases. There was an increase in the number treated in major trauma centres (45.7% 2008 vs 63.5% 2017, p<0.0001). Trauma was more likely to occur between 08:00 and 00:00, at weekends and between April and October. Overall mortality rate was 4.1%. Those with a known psychiatric diagnosis had a higher mortality (6.3% vs 4.4%, p<0.001). CONCLUSIONS: RTCs and intentional injuries are leading aetiologies. Healthcare professionals and policy-makers need to prioritise national preventative public health measures and early interventions to reduce the incidence of trauma in this vulnerable age group.


Assuntos
Saúde do Adolescente , Transtornos Mentais/epidemiologia , Saúde Pública , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Ferimentos e Lesões/epidemiologia , Adolescente , Distribuição por Idade , Inglaterra/epidemiologia , Feminino , Humanos , Masculino , Formulação de Políticas , Distribuição por Sexo , Centros de Traumatologia , Violência/estatística & dados numéricos , Ferimentos e Lesões/etiologia , Adulto Jovem
6.
Arch Dis Child Educ Pract Ed ; 104(2): 74-78, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29934360

RESUMO

Burns are a relatively common injury in children accounting for over 50 000 emergency department attendances each year. An estimated 1 in 10 of these are due to maltreatment. These may present in the form of physical abuse or neglect with a reported ratio of 1:9. A burn associated with maltreatment may be a marker for future abuse or neglect and it is paramount that concerns are identified and addressed at the initial visit. Paediatricians need to be confident to identify safeguarding concerns specific to childhood burns and investigate accordingly. In this review, key variables that may aid in differentiating maltreatment from accidental burns are discussed in a case-based format, utilising up-to-date evidence to support the recommendations. Despite a proportion of burns resulting from physical abuse, the rate of child protection investigations in these patients are significantly lower than for children who present with other forms of physical injuries despite a similar proportion of positive findings. Our objective is to review the available evidence to support the safe assessment and management of children presenting with scalds or contact burns.


Assuntos
Acidentes Domésticos , Queimaduras/etiologia , Queimaduras/patologia , Maus-Tratos Infantis/diagnóstico , Criança , Proteção da Criança , Diagnóstico Diferencial , Humanos , Anamnese , Exame Físico , Fatores de Risco
7.
Nicotine Tob Res ; 21(12): 1660-1664, 2019 11 19.
Artigo em Inglês | MEDLINE | ID: mdl-30365016

RESUMO

INTRODUCTION: Reducing smoking in pregnancy was a primary outcome in our Building Blocks trial of the Family Nurse Partnership. We calibrated maternal reports of smoking using cotinine values derived from urine samples to assess tobacco use. This involves identifying the extent to which an individual accurately reports smoking and requires complete and synchronized data collection over time. However, some urine samples may be missed or collected at a different time from self-report (non-synchronized. METHODS: We used statistical validation processes to address both non-synchronized and incomplete data. First, we examined consistency in reporting behaviors at baseline and follow-up for participants grouped by extent of non-synchronized time of collection. Second, we used data from complete cases to infer values for mothers with missing urine samples at follow-up. We then used Markov chain transition rate matrix constructed to assess the robustness of such inferences. RESULTS: Maternal underreporting and overreporting of smoking were consistent across the 870 participants grouped by different levels of noncontemporary data collection (Breslow-Day test: p = .24; chi-square test: p = .69). Using participants' baseline reporting behaviors to infer their follow-ups provided comparable smoking outcomes (4.5 cigarettes/day with SD of 5.5) to the simulated counterparts (4.5 cigarettes/day with SD of 6.0). CONCLUSION: We have demonstrated consistent reporting behavior over time and minimal impact due to nonaligned follow-up urine sample collection. For studies collecting smoking data, this proposed method provided a pragmatic solution to facilitate the calibration process of self-reported tobacco use and retain adequate power without introducing undue bias. IMPLICATIONS: Synchronized and completed data collection is essential but very often hard to achieve in smoking related studies. When violated, proper statistical validation process should be followed to minimize the potential bias and loss of power in trial analyses. For this purpose, we provided the Building Block trial as an example to demonstrate how to deal with the non-synchronization and incompleteness issues in data collection.


Assuntos
Cotinina/urina , Comportamento Materno , Autorrelato , Abandono do Hábito de Fumar/estatística & dados numéricos , Uso de Tabaco/epidemiologia , Calibragem , Feminino , Humanos , Gravidez , Abandono do Hábito de Fumar/psicologia , Prevenção do Hábito de Fumar , Uso de Tabaco/psicologia , Uso de Tabaco/urina
8.
Ecancermedicalscience ; 12: 792, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29434658

RESUMO

CONTEXT: UK Biobank is a prospective study of half a million subjects, almost all aged 40-69 years, identified in 22 centres across the UK during 2006-2010. OBJECTIVE: A healthy lifestyle has been described as 'better than any pill, and no side effects [5]. We therefore examined the relationships between healthy behaviours: low alcohol intake, non-smoking, healthy BMI, physical activity and a healthy diet, and the risk of all cancers, colon, breast and prostate cancers in a large dataset. METHOD: Data on lifestyle behaviours were provided by 343,150 subjects, and height and weight were measured at recruitment. 14,285 subjects were diagnosed with cancer during a median of 5.1 years of follow-up. RESULTS: Compared with subjects who followed none or a single healthy behaviour, a healthy lifestyle based on all five behaviours was associated with a reduction of about one-third in incident cancer (hazard ratio [HR] 0.68; 95% confidence intervals [CI] 0.63-0.74). Colorectal cancer was reduced in subjects following the five behaviours by about one-quarter (HR 0.75; 95% CI 0.58-0.97), and breast cancer by about one-third (HR 0.65; 95% CI 0.52-0.83). The association between a healthy lifestyle and prostate cancer suggested a significant increase in risk, but this can be attributed to bias consequent on inequalities in the uptake of the prostate specific antigen screening test. CONCLUSIONS: Taken together with reported reductions in diabetes, vascular disease and dementia, it is clearly important that every effort is taken to promote healthy lifestyles throughout the population, and it is pointed out that cancer and other screening clinics afford 'teachable moments' for the promotion of a healthy lifestyle.

9.
SSM Popul Health ; 3: 255-265, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29302612

RESUMO

PURPOSE: Process evaluations generate important data on the extent to which interventions are delivered as intended. However, the tendency to focus only on assessment of pre-specified structural aspects of fidelity has been criticised for paying insufficient attention to implementation processes and how intervention-context interactions influence programme delivery. This paper reports findings from a process evaluation nested within a randomised controlled trial of the Strengthening Families Programme 10-14 (SFP 10-14) in Wales, UK. It uses Extended Normalisation Process Theory to theorise how interaction between SFP 10-14 and local delivery systems - particularly practitioner commitment/capability and organisational capacity - influenced delivery of intended programme activities: fidelity (adherence to SFP 10-14 content and implementation requirements); dose delivered; dose received (participant engagement); participant recruitment and reach (intervention attendance). METHODS: A mixed methods design was utilised. Fidelity assessment sheets (completed by practitioners), structured observation by researchers, and routine data were used to assess: adherence to programme content; staffing numbers and consistency; recruitment/retention; and group size and composition. Interviews with practitioners explored implementation processes and context. RESULTS: Adherence to programme content was high - with some variation, linked to practitioner commitment to, and understanding of, the intervention's content and mechanisms. Variation in adherence rates was associated with the extent to which multi-agency delivery team planning meetings were held. Recruitment challenges meant that targets for group size/composition were not always met, but did not affect adherence levels or family engagement. Targets for staffing numbers and consistency were achieved, though capacity within multi-agency networks reduced over time. CONCLUSIONS: Extended Normalisation Process Theory provided a useful framework for assessing implementation and explaining variation by examining intervention-context interactions. Findings highlight the need for process evaluations to consider both the structural and process components of implementation to explain whether programme activities are delivered as intended and why.

11.
Lancet ; 387(10014): 146-55, 2016 Jan 09.
Artigo em Inglês | MEDLINE | ID: mdl-26474809

RESUMO

BACKGROUND: Many countries now offer support to teenage mothers to help them to achieve long-term socioeconomic stability and to give a successful start to their children. The Family Nurse Partnership (FNP) is a licensed intensive home-visiting intervention developed in the USA and introduced into practice in England that involves up to 64 structured home visits from early pregnancy until the child's second birthday by specially recruited and trained family nurses. We aimed to assess the effectiveness of giving the programme to teenage first-time mothers on infant and maternal outcomes up to 24 months after birth. METHODS: We did a pragmatic, non-blinded, randomised controlled, parallel-group trial in community midwifery settings at 18 partnerships between local authorities and primary and secondary care organisations in England. Eligible participants were nulliparous and aged 19 years or younger, and were recruited at less than 25 weeks' gestation. Field-based researchers randomly allocated mothers (1:1) via remote randomisation (telephone and web) to FNP plus usual care (publicly funded health and social care) or to usual care alone. Allocation was stratified by site and minimised by gestation (<16 weeks vs ≥16 weeks), smoking status (yes vs no), and preferred language of data collection (English vs non-English). Mothers and assessors (local researchers at baseline and 24 months' follow-up) were not masked to group allocation, but telephone interviewers were blinded. Primary endpoints were biomarker-calibrated self-reported tobacco use by the mother at late pregnancy, birthweight of the baby, the proportion of women with a second pregnancy within 24 months post-partum, and emergency attendances and hospital admissions for the child within 24 months post-partum. Analyses were by intention to treat. This trial is registered with ISRCTN, number ISRCTN23019866. FINDINGS: Between June 16, 2009, and July 28, 2010, we screened 3251 women. After enrolment, 823 women were randomly assigned to receive FNP and 822 to usual care. All follow-up data were retrieved by April 25, 2014. 304 (56%) of 547 women assigned to FNP and 306 (56%) of 545 assigned to usual care smoked at late pregnancy (adjusted odds ratio [AOR] 0·90, 97·5% CI 0·64-1·28). Mean birthweight of 742 babies with mothers assigned to FNP was 3217·4 g (SD 618·0), whereas birthweight of 768 babies assigned to usual care was 3197·5 g (SD 581·5; adjusted mean difference 20·75 g, 97·5% CI -47·73 to 89·23. 587 (81%) of 725 assessed children with mothers assigned to FNP and 577 (77%) of 753 assessed children assigned to usual care attended an emergency department or were admitted to hospital at least once before their second birthday (AOR 1·32, 97·5% CI 0·99-1·76). 426 (66%) of 643 assessed women assigned to FNP and 427 (66%) 646 assigned to usual care had a second pregnancy within 2 years (AOR 1·01, 0·77-1·33). At least one serious adverse event (mainly clinical events associated with pregnancy and infancy period) was reported for 310 (38%) of 808 participants (mother-child) in the usual care group and 357 (44%) of 810 in the FNP group, none of which were considered related to the intervention. INTERPRETATION: Adding FNP to the usually provided health and social care provided no additional short-term benefit to our primary outcomes. Programme continuation is not justified on the basis of available evidence, but could be reconsidered should supportive longer-term evidence emerge. FUNDING: Department of Health Policy Research Programme.


Assuntos
Enfermagem Familiar , Serviços de Assistência Domiciliar , Enfermagem Materno-Infantil , Adolescente , Peso ao Nascer , Aleitamento Materno , Desenvolvimento Infantil , Serviço Hospitalar de Emergência/estatística & dados numéricos , Inglaterra/epidemiologia , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Bem-Estar do Lactente , Recém-Nascido , Gravidez , Autoeficácia , Fumar/epidemiologia , Apoio Social , Adulto Jovem
12.
BMC Public Health ; 14: 49, 2014 Jan 17.
Artigo em Inglês | MEDLINE | ID: mdl-24438460

RESUMO

BACKGROUND: Prevention of alcohol, drug and tobacco misuse by young people is a key public health priority. There is a need to develop the evidence base through rigorous evaluations of innovative approaches to substance misuse prevention. The Strengthening Families Programme 10-14 is a universal family-based alcohol, drugs and tobacco prevention programme, which has achieved promising results in US trials, and which now requires cross-cultural assessment. This paper therefore describes the protocol for a randomised controlled trial of the UK version of the Strengthening Families Programme 10-14 (SFP 10-14 UK). METHODS/DESIGN: The trial comprises a pragmatic cluster randomised controlled effectiveness trial with families as the unit of randomisation, with embedded process and economic evaluations. Participating families will be randomised to one of two treatment groups - usual care with full access to existing services (control group), or usual care plus SFP 10-14 UK (intervention group). The trial has two primary outcomes - the number of occasions that young people report having drunk alcohol in the last 30 days, and drunkenness during the last 30 days, both dichotomised as 'never' and '1-2 times or more'. The main follow-up is at 2 years past baseline, and short-term and intermediate outcomes are also measured at 9 and 15 months. DISCUSSION: The results from this trial will provide evidence on the effectiveness and cost-effectiveness of an innovative universal family-based substance misuse prevention programme in a UK context. TRIAL REGISTRATION: Current Controlled Trials ISRCTN63550893.


Assuntos
Intoxicação Alcoólica/prevenção & controle , Alcoolismo/prevenção & controle , Avaliação de Programas e Projetos de Saúde , Adolescente , Consumo de Bebidas Alcoólicas , Criança , Análise Custo-Benefício , Família , Feminino , Humanos , Masculino , Projetos de Pesquisa , Reino Unido
13.
BMC Pediatr ; 13: 114, 2013 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-23919573

RESUMO

BACKGROUND: The Nurse Family Partnership programme was developed in the USA where it is made available to pregnant young mothers in some socially deprived geographic areas. The related Family Nurse Partnership programme was introduced in England by the Department of Health in 2006 with the aim of improving outcomes for the health, wellbeing and social circumstances of young first-time mothers and their children. METHODS / DESIGN: This multi-centre individually randomised controlled trial will recruit 1600 participants from 18 Primary Care Trusts in England, United Kingdom. The trial will evaluate the effectiveness of Family Nurse Partnership programme and usual care versus usual care for nulliparous pregnant women aged 19 or under, recruited by 24 weeks gestation and followed until the child's second birthday. Data will be collected from participants at baseline, 34-36 weeks gestation, 6, 12, 18 and 24 months following birth. Routine clinical data will be collected from maternity, primary care and hospital episodes statistics. Four primary outcomes are to be reported from the trial: birth weight; prenatal tobacco use; child emergency attendances and/or admissions within two years of birth; second pregnancy within two years of first birth. DISCUSSION: This trial will evaluate the effectiveness and cost effectiveness of the Family Nurse Partnership in England. The findings will provide evidence on pregnancy and early childhood programme outcomes for policy makers, health professionals and potential recipients in three domains (pregnancy and birth, child health and development, and parental life course and self-sufficiency) up to the child's second birthday. TRIAL REGISTRATION: Trial registration number: ISRCTN23019866.


Assuntos
Adaptação Psicológica , Protocolos Clínicos , Enfermagem Familiar/métodos , Visita Domiciliar/economia , Mães/psicologia , Relações Enfermeiro-Paciente , Serviços Preventivos de Saúde/economia , Adolescente , Análise Custo-Benefício , Inglaterra , Feminino , Humanos , Idade Materna , Comportamento Materno , Gravidez , Serviços Preventivos de Saúde/métodos , Avaliação de Programas e Projetos de Saúde , Fatores de Risco , Adulto Jovem
14.
Int J Antimicrob Agents ; 33(3): 255-7, 2009 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-19091516

RESUMO

The emergence of antibiotic resistance is a major threat to public health. In the UK, most antibiotics are prescribed in general practice but the extra costs to general practice of resistant infections have not previously been well described. We compared the costs of treating patients presenting with resistant Escherichia coli urinary tract infections (UTIs) (resistant to ampicillin, trimethoprim or at least one antibiotic) with the costs of treating patients with UTIs that were sensitive to all six tested antibiotics (ampicillin, trimethoprim, amoxicillin/clavulanic acid, cefalexin, ciprofloxacin and nitrofurantoin) with regard to re-consultations and antibiotics prescribed. There were significantly higher antibiotic costs (mean extra antibiotic cost 1.19 pounds/1.75 euros), re-consultation costs ( 2.42 pounds/3.55 euros) and total costs ( 3.62 pounds/5.31euros) for patients whose infections were resistant to at least one antibiotic compared with those with sensitive infections even after accounting for potentially confounding factors. Although these per-patient costs may appear small, they do not take into account the full additional costs of resistant UTIs in the community and, given the high prevalence of UTIs, the overall costs to the health service are substantial.


Assuntos
Antibacterianos/economia , Antibacterianos/uso terapêutico , Farmacorresistência Bacteriana , Infecções por Escherichia coli/tratamento farmacológico , Escherichia coli/efeitos dos fármacos , Encaminhamento e Consulta/economia , Infecções Urinárias/tratamento farmacológico , Infecções por Escherichia coli/microbiologia , Medicina de Família e Comunidade , Gastos em Saúde , Humanos , Reino Unido , Infecções Urinárias/microbiologia
15.
Br J Gen Pract ; 57(543): 785-92, 2007 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-17925135

RESUMO

BACKGROUND: GPs are urged to prescribe antibiotics less frequently, despite lack of evidence linking reduced antibiotic prescribing with reductions in resistance at a local level. AIM: To investigate associations between changes in antibiotic dispensing and changes in antibiotic resistance at general-practice level. DESIGN OF STUDY: Seven-year study of dispensed antibiotics and antibiotic resistance in coliform isolates from urine samples routinely submitted from general practice. SETTING: General practices in Wales. METHOD: Multilevel modelling of trends in resistance to ampicillin and trimethoprim, and changes in practice total antibiotic dispensing and amoxicillin and trimethoprim dispensing. RESULTS: The primary analysis included data on 164 225 coliform isolates from urine samples submitted from 240 general practices over the 7-year study period. These practices served a population of 1.7 million patients. The quartile of practices that had the greatest decrease in total antibiotic dispensing demonstrated a 5.2% reduction in ampicillin resistance over the 7-year period with changes of 0.4%, 2.4%, and -0.3% in the other three quartiles. There was a statistically significant overall decrease in ampicillin resistance of 1.03% (95% confidence interval [CI] = 0.37 to 1.67%) per decrease of 50 amoxicillin items dispensed per 1000 patients per annum. There were also significant reductions in trimethoprim resistance in the two quartiles of practices that reduced total antibiotic dispensing most compared with those that reduced it least, with an overall decrease in trimethoprim resistance of 1.08% (95% CI = 0.065 to 2.10%) per decrease of 20 trimethoprim items dispensed per 1000 patients per annum. Main findings were confirmed by secondary analyses of 256 370 isolates from 527 practices that contributed data at some point during the study period. CONCLUSION: Reducing antibiotic dispensing at general-practice level is associated with reduced local antibiotic resistance. These findings should further encourage clinicians and patients to use antibiotics conservatively.


Assuntos
Antibacterianos/administração & dosagem , Resistência Microbiana a Medicamentos , Padrões de Prática Médica/tendências , Infecções Urinárias/tratamento farmacológico , Amoxicilina/administração & dosagem , Anti-Infecciosos Urinários/administração & dosagem , Prescrições de Medicamentos , Medicina de Família e Comunidade , Humanos , Trimetoprima/administração & dosagem , Resistência a Trimetoprima , Infecções Urinárias/microbiologia , Infecções Urinárias/urina , País de Gales
16.
J Antimicrob Chemother ; 60(1): 92-9, 2007 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-17540675

RESUMO

BACKGROUND: To assess the effect of previous antibiotic use on the risk of a resistant Escherichia coli urinary tract infection (UTI), we undertook a case-control study with prospective measurement of outcomes in 10 general practices in the UK. METHODS: Urinary samples from all patients with symptoms suggestive of UTIs were sought, and those with a laboratory-proven E. coli infection were interviewed and their medical records examined. Case patients were those with ampicillin- or trimethoprim-resistant infections and control patients had infections that were susceptible to antibiotics, including ampicillin and trimethoprim. RESULTS: Risk of ampicillin-resistant E. coli infection in 903 patients was associated with amoxicillin prescriptions of >or=7 days duration in the previous 1 month [odds ratio (OR)=3.91, 95% CI 1.64-9.34] and previous 2-3 months (2.29, 1.12-4.70) before illness onset. For prescriptions <7 days duration, there was no statistically significant association. Higher doses of amoxicillin were associated with lower risk of ampicillin resistance. For trimethoprim-resistant E. coli infections, the OR was 8.44 (3.12-22.86) for prescriptions of trimethoprim of >or=7 days in the previous month and 13.91 (3.32-58.31) for the previous 2-3 months. For trimethoprim prescriptions of <7 days, the OR was 4.03 (1.69-9.59) for the previous month but prescribing in earlier periods was not significantly associated with resistance. CONCLUSIONS: Within the community setting, exposure to antibiotics is a strong risk factor for a resistant E. coli UTI. High-dose, shorter-duration antibiotic regimens may reduce the pressure on the emergence of antibiotic resistance.


Assuntos
Antibacterianos , Infecções Comunitárias Adquiridas , Farmacorresistência Bacteriana , Infecções por Escherichia coli , Infecções Urinárias , Antibacterianos/administração & dosagem , Antibacterianos/farmacologia , Antibacterianos/uso terapêutico , Anti-Infecciosos Urinários/administração & dosagem , Anti-Infecciosos Urinários/farmacologia , Anti-Infecciosos Urinários/uso terapêutico , Estudos de Casos e Controles , Infecções Comunitárias Adquiridas/tratamento farmacológico , Infecções Comunitárias Adquiridas/epidemiologia , Infecções Comunitárias Adquiridas/microbiologia , Uso de Medicamentos , Escherichia coli/efeitos dos fármacos , Infecções por Escherichia coli/tratamento farmacológico , Infecções por Escherichia coli/epidemiologia , Infecções por Escherichia coli/microbiologia , Humanos , Testes de Sensibilidade Microbiana , Resistência às Penicilinas , Penicilinas/administração & dosagem , Penicilinas/farmacologia , Penicilinas/uso terapêutico , Fatores de Risco , Trimetoprima/administração & dosagem , Trimetoprima/farmacologia , Trimetoprima/uso terapêutico , Resistência a Trimetoprima , Reino Unido/epidemiologia , Infecções Urinárias/tratamento farmacológico , Infecções Urinárias/epidemiologia , Infecções Urinárias/microbiologia
17.
J Antimicrob Chemother ; 58(6): 1303-6, 2006 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-17062608

RESUMO

OBJECTIVES: We do not know how representative reported levels of resistance to antibiotics in urinary tract infections (UTIs) are as there is wide variation in the rate of urine specimens submitted to microbiology laboratories by general practices. We used a questionnaire to investigate variation in sampling for patients with suspected UTI to explore any systematic bias that may influence interpretation of surveillance data based on routine data. METHODS: We sent a questionnaire to a stratified random sample of general practitioners (GPs) in Wales for self-completion. The GPs were presented with six clinical scenarios and asked about their proposed clinical management. RESULTS: We found that nearly all of the GPs indicated they would request a specimen for scenarios representing a probable UTI in a female child and a probable asymptomatic UTI in pregnancy. There was some variation between the GPs about sampling in a situation of treatment failure in an older woman and recurrent UTI in a male diabetic, with 90% and 81%, respectively, indicating they would request a specimen for these scenarios. The greatest variation was in relation to scenarios concerning the management of a probable uncomplicated UTI, and early patient symptoms with pressure to prescribe, with 56% and 33% of GPs, respectively, indicating they would request a urine specimen for laboratory analysis. CONCLUSIONS: In the light of this reported sampling behaviour, it is likely that there is a systematic bias in surveillance data based on routinely collected data, with samples from cases of uncomplicated UTI being under represented, potentially leading to an overestimation of true resistance rates.


Assuntos
Antibacterianos/uso terapêutico , Gerenciamento Clínico , Medicina de Família e Comunidade/métodos , Infecções Urinárias/tratamento farmacológico , Infecções Urinárias/microbiologia , Urina/microbiologia , Resistência a Medicamentos , Feminino , Humanos , Masculino , Inquéritos e Questionários , Infecções Urinárias/diagnóstico , País de Gales
18.
Br J Gen Pract ; 56(530): 686-92, 2006 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-16954001

RESUMO

BACKGROUND: Antimicrobial resistance is considered to be one of the major threats to public health. However, the practical implications for patients and workload in primary care are largely unknown. AIM: To determine outcomes for patients managed in primary care with an antibiotic resistant compared to an antibiotic sensitive Escherichia coli (E. coli) urinary tract infection (UTI). DESIGN: Nested case control study with prospective measurement of outcomes. SETTING: Ten general practices in South Wales. METHOD: Patients consulting with symptoms suggestive of UTI identified through systematic sampling, and with a laboratory proven E. coli infection, were followed up by interview 1 month after their consultations and by searching of their medical records. RESULTS: Nine hundred and thirty-two patients were interviewed and had their medical records reviewed. The risk of patients reporting 'feeling poorly', 'frequency or pain on urinating' and being 'out of action' for more than 5 days after consulting was significantly increased for patients with resistant compared to sensitive infections. After adjusting for risk factors, there was an increased risk of 'frequency or pain on urinating' and 'being out of action' for those infected with a resistant E. coli. The median number of maximum reported days with at least one symptom was 12 days for patients with E. coli infections resistant to trimethoprim, 7 days for infections resistant to ampicillin, 7 days for infections resistant to any antibiotic, and 5 days for infections sensitive to all tested antibiotics. Even if treated with an appropriate antibiotic, infections caused by a resistant strain were symptomatic for longer. For those infected with an organism resistant to at least one antibiotic, the odds ratio (OR) for re-visiting their GP within the next 30 days for the UTI was 1.47 (95% confidence interval [CI] = 1.10 to 1.95). The OR was 1.49 (95% CI = 1.11 to 2.00) for ampicillin resistance and 2.48 (95% CI = 1.70 to 3.59) for trimethoprim resistance. CONCLUSIONS: Resistant E. coli UTIs are symptomatic for longer and cause increased work load in general practice.


Assuntos
Antibacterianos/uso terapêutico , Farmacorresistência Bacteriana , Infecções por Escherichia coli/tratamento farmacológico , Infecções Urinárias/microbiologia , Adulto , Idoso , Estudos de Casos e Controles , Estudos de Coortes , Escherichia coli/isolamento & purificação , Infecções por Escherichia coli/urina , Medicina de Família e Comunidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sensibilidade e Especificidade , Resultado do Tratamento , Infecções Urinárias/tratamento farmacológico , Infecções Urinárias/urina , País de Gales/epidemiologia , Carga de Trabalho
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