Increased somatic morbidity in the first year after leaving opioid maintenance treatment: results from a Norwegian cohort study.

BACKGROUND/AIMS: Some patients on opioid maintenance treatment (OMT) leave treatment temporarily or permanently. This study investigated whether patients interrupting their OMT differed from non-interrupters in sociodemographic and drug-use characteristics and examined acute/sub-acute somatic morbidity among the interrupters, prior to, during, and after OMT. METHODS: Cohort design. OBSERVATION PERIOD: 5 years prior to, up to first 5 years during, and up to 5 years after interruption of OMT. PARTICIPANTS: The sample (n = 200) comprised 51 OMT interrupters and 149 non-interrupters. Data on patient characteristics were obtained from interviews and OMT register information. Data on somatic morbidity were gathered from hospital records. MEASUREMENTS: Key patient characteristics among OMT interrupters and non-interrupters. Incidence rates of acute and sub-acute somatic disease incidents leading to hospital treatment (drug-related/non-drug-related/injuries) prior to/during/after OMT. RESULTS: Interrupters and non-interrupters did not differ in sociodemographic characteristics, while longer duration of amphetamine and benzodiazepine dependence predicted OMT interruption. Interrupters scored significantly higher on drug-taking and overdose during OMT but still had a significant 41% reduction in drug-related treatment, episodes. After interruption of treatment, such episodes increased markedly and were 3.6 times more frequent during the first post-OMT year compared to the pre-OMT period (p < 0.001). This increase was highest during the first months after OMT interruption. 2-5 years after interruption there was no significant increase. CONCLUSIONS: Increased somatic morbidity was found among OMT interrupters during the first year after OMT, and especially during the immediate post-treatment period.

Comparison of phenoxymethylpenicillin, amoxicillin, and doxycycline for erythema migrans in general practice. A randomized controlled trial with a 1-year follow-up.

OBJECTIVES: To compare the three most commonly used antibiotics for erythema migrans (EM) in Norwegian primary care. METHODS: A randomized, parallel, controlled trial was carried out. Treatments were open to the patients, but blinded for the GPs and investigators. Patients eligible for inclusion were aged ≥18 years and clinically diagnosed with EM. Block randomization was processed in blocks of six. Patients were assigned to receive one of three antibiotic treatments for 14 days: phenoxymethylpenicillin (PCV), amoxicillin, or doxycycline. The primary outcome was the duration of EM in days in the three treatment groups. Patients kept a diary for the 14 days of treatment, in which they registered concomitant symptoms and side effects. The patients consulted their GP after 14 days of treatment and had a 1-year follow-up to monitor any development of disseminated Lyme borreliosis (LB). EMs with a duration of more than 14 days were followed until resolution. ClinicalTrials.govNCT01368341 and EU Clinical Trials Register 2010-023747-15. RESULTS: One hundred and eighty eight patients (PCV: n = 56, amoxicillin: n = 64, doxycycline: n = 68) were included by 44 Norwegian general practitioners (GPs) from June 2011 to November 2013. Follow-up was completed by December 2014. The median duration of EM was altogether 14 days (range 3-293). For the PCV group median duration was 14 days (range 5-91), for amoxicillin 13 days (range 4-179) and for doxycycline 14 days (range 3-293). The duration of EM did not differ significantly between the three antibiotic groups (p 0.277). None of the patients developed disseminated LB within the 1-year follow-up. CONCLUSIONS: We did not find 14 days of PCV, doxycycline, and amoxicillin treatments to differ in effectiveness or safety in the treatment of clinically diagnosed EM in primary care.

Labelling and patient knowledge of dispensed drugs as quality indicators in primary care in Botswana.

OBJECTIVES: To assess the quality of dispensing and patient knowledge of drugs dispensed in primary care in Botswana. SETTING: Thirty randomly assigned primary healthcare facilities in three districts of Botswana. PARTICIPANTS: Patients visiting clinics and health posts. DESIGN: Analysis of data from prospective participative observations of the drug dispensing process and interview of patients about their knowledge of drugs received immediately after dispensing. The quality of drug labelling was assessed by calculating mean labelling scores composed of five dispensing attributes: name of patient, and name, strength, dosage, and volume of the drug (incorrect or no labelling=0, 1 point for each correct labelling attribute; maximum score=5). Mean knowledge scores were obtained immediately after dispensing from patient recall of name and dosage of drug, duration of treatment, and reason for prescription (incorrect recall=0, 1 point for each correct recall attribute; maximum score=4). RESULTS: 2994 consecutive patient consultations were analysed. The mean labelling score was 2.75. Family welfare educators and pharmacy technicians scored highest (3.15 and 2.98, respectively) and untrained staff lowest (2.60). Factors independently associated with the labelling score were analgesics v other drugs, district, health posts v clinics, education of prescriber (nurse best), and years of experience of prescriber (4-11 years best). The mean patient knowledge score was 2.50. The reason for prescription of the drug(s), dosage, duration of treatment, and name of the drug(s) was recalled by 92%, 83%, 44%, and 31% of patients, respectively. The qualification level of the dispenser was the strongest factor independently associated with the knowledge score. Antibiotics had the second lowest score, both for labelling (2.39) and patient knowledge (2.39). CONCLUSION: Only trained dispensing staff provided satisfactory quality of labelling. Patients had a fair knowledge of the drugs dispensed. The knowledge of drugs dispensed by family welfare educators was less than satisfactory. The labelling score is a useful indicator of the quality of dispensing, and the knowledge score of both the quality of prescribing and of dispensing. These indicators should be added to the WHO list of patient care indicators.

Influence of prescription patterns in general practice on anti-microbial resistance in Norway.

BACKGROUND: The global pandemic of antibiotic resistance is causing considerable concern, and a major reason for the growing world-wide resistance problem is the overuse of anti-infective drugs, especially the use of broad spectrum antibiotics. This is still a relatively minor problem in most of the Nordic countries where the consumption of antibiotics is less than half of that reported from southern Europe and the United States of America (USA). AIM: To describe the resistance pattern among common respiratory tract pathogens in Norwegian general practice, the national consumption of antibiotics, and GPs' prescription patterns for respiratory tract infections. To offer some suggestions as to why Norway has maintained a favourable situation regarding resistant microbes during the past 10 years. METHODS: An analysis of the prescription patterns in Norwegian general practice. RESULTS: There is a low total prescription volume of antibiotics compared with other countries. Penicillin V is the most commonly used antibiotic for the most common airway diseases in general practice in Norway. CONCLUSION: Although there is a low prevalence of antibiotic resistance in Norway, there is still a great potential for reducing the unnecessary antibiotic prescribing for the most common respiratory illnesses.

Use of symptoms, signs, and blood tests to diagnose acute sinus infections in primary care: comparison with computed tomography.

OBJECTIVES: This study evaluated different symptoms, signs, and blood tests in the diagnostic process of patients with a clinical diagnosis of acute sinusitis. METHODS: A total of 201 primary care patients in southern Norway aged 15 years or older with a clinical diagnosis of acute sinusitis were evaluated. Computed tomography (CT) was used as a reference standard to divide the patients into two groups: one with and one without confirmed sinusitis. Fluid level or total opacification of any sinus on CT were used as hallmarks of confirmed sinusitis. Blood tests that included erythrocyte sedimentation rate (ESR), C-reactive protein, and white blood count were taken. The patients were evaluated in a standardized way for the medical history and the clinical investigation. RESULTS: A total of 127 (63%) patients had fluid level or total opacification in one or more sinus regions. "Double sickening," purulent rhinorrhoea, purulent secretion in cavum nasi, and ESR > 10 had the highest likelihood ratios and were independently associated with acute sinusitis. CONCLUSIONS: This study confirms the uncertainty of the clinical diagnosis of acute sinusitis in primary care, based on the clinical evaluation alone. Only four symptoms and signs had a high likelihood ratio and were independently associated with acute sinusitis. A combination of at least three of these four symptoms and signs gave a specificity of .81 and a sensitivity of .66.

Antibiotic treatment of patients with mucosal thickening in the paranasal sinuses, and validation of cut-off points in sinus CT.

We compared the efficacy of penicillin V and amoxycillin treatment with placebo in 70 adult patients from Norwegian family practice with a clinical diagnosis of acute sinusitis and mucosal thickening on CT, but without fluid level or total opacification. The study was randomized and double-blind. Three different outcomes were evaluated; subjective status after 10 days of treatment, difference in clinical score between day 0 and day 10, and duration of the illness episode. Amoxycillin and penicillin V gave no better response to treatment than placebo, evaluated by all three outcome measures. The median duration of the sinusitis episode was 10 days in the amoxycillin- and placebo groups and 13 days in the penicillin-V group. In patients with a clinical diagnosis of acute sinusitis, fluid level and total opacification on CT are good criteria to differentiate between groups of patients that need or do not need antibiotic treatment.

Randomised, double blind, placebo controlled trial of penicillin V and amoxycillin in treatment of acute sinus infections in adults.

OBJECTIVES: To compare the effectiveness of penicillin V and amoxycillin with placebo in treatment of adult patients with acute sinusitis. DESIGN: Randomised, double blind, placebo controlled trial. SETTING: Norwegian general practice. SUBJECTS: 130 adult patients with a clinical diagnosis of acute sinusitis confirmed by computed tomography. MAIN OUTCOME MEASURES: Subjective status after three and 10 days of treatment, difference in clinical severity score between day 0 and day 10 as evaluated by the general practitioner, difference in score from computed tomography on day 0 and day 10, and duration of sinusitis. RESULTS: Amoxycillin and penicillin V led to significantly faster and better recovery than placebo. By day 10, 71 patients receiving antibiotic treatment- (86%) considered themselves to be recovered or much better compared with 25 (57%) receiving placebo. The mean (95% confidence interval) reductions in clinical severity scores by day 10 were 5.4 (5.0 to 5.8) for penicillin V, 5.5 (4.9 to 6.0 for amoxycillin, and 3.4 (2.8 to 4.0) for placebo. For the antibiotic groups combined the number of patients with the greatest degree of improvement on computed tomography (scale 0-16)-that is, score 5-16 on day 10-was 31/83 (37%) compared with 10/44 (23%) receiving placebo. The median duration of the sinusitis was nine days in the amoxycillin group, 11 days in the penicillin V group, and 17 days in the placebo group. CONCLUSION: Penicillin V and amoxycillin are significantly more effective than placebo in the treatment of acute sinusitis.

[How does music affect the human body?]. / Hvordan virker musikk på menneskekroppen?

Music therapy has developed its practice and research approaches within a qualitative framework more related to humanistic traditions than to medical science. Music medicine has therefore developed as a separate discipline, endeavouring to incorporate the legitimate therapeutic use of music within a medical framework. This paper argues that more extensive communication and collaboration between the methods developed within the music therapy community, and research based on medical science, could lead to a better understanding of the place of music as a therapeutic tool, both as regards its efficacy and its limits. Research has shown that music may influence central physiological variables like blood pressure, heart rate, respiration, EEG measurements, body temperature and galvanic skin response. Music influences immune and endocrine function. The existing research literature shows growing knowledge of how music can ameliorate pain, anxiety, nausea, fatigue and depression. There is less research done on how music, and what type of music, is utilized and administered specifically for optimum effect in specific clinical situations.

[Examples of the use of music in clinical medicine]. / Eksempler på bruk av musikk i klinisk medisin.

Music has been an element in medical practice throughout history. There is growing interest in music as a therapeutic tool. Since there is no generally accepted standard for how, when and where music should be applied within a medical framework, this literature study endeavours to present an overview of central areas of application of music in medicine. It further attempts to find tentative conclusions that may be drawn from existing clinical research on the efficacy of music as a medical tool. Traditionally, music has been linked to the treatment of mental illness, and has been used successfully to treat anxiety and depression and improve function in schizophrenia and autism. In clinical medicine several studies have shown analgetic and anxiolytic properties that have been used in intensive care units, both in diagnostic procedures like gastroscopy and in larger operations, in preoperative as well as postoperative phases, reducing the need for medication in several studies. The combination of music with guided imagery and deep relaxation has shown reduction of symptoms and increased well-being in chronic pain syndromes, whether from cancer or rheumatic origin. Music has been used as support in pregnancy and gestation, in internal medicine, oncology, paediatrics and other related fields. The use of music with geriatric patients could prove to be especially fruitful, both in its receptive and its active aspect. Studies have shown that music can improve function and alleviate symptoms in stroke rehabilitation, Parkinson's disease, Alzheimer's disease and other forms of dementia. The role of music in medicine is primarily supportive and palliative. The supportive role of music has a natural field of application in palliative medicine and terminal care. Music is well tolerated, inexpensive, with good compliance and few side effects.

[Tympanometry at a health center]. / Tympanometri på helsestasjonen.

We wanted to assess how much additional information could be gained from the results of tympanometry after first performing a clinical hearing examination at a mother and child clinic. 182 children aged from six months up to four years, had their hearing first examined clinically and afterwards by tympanometry. Pathological tympanograms were seen in 39% of the ears we examined, but most of them reverted to normal spontaneously at a later stage. There was little concordance between tympanometry and BOEL test in children aged six months and one year. Concordance between tympanometry and audiometry was fairly good in four-year old children. 27 children were referred to an ear, nose and throat specialist for evaluation, 11 of them as a result of tympanometry. Operative treatment was recommended for 17 of the children. In the anamnesis there was a connection between the parents perception of their child's hearing and the child having a cold and referral to an ear, nose and throat specialist. Tympanometry contributes to an early diagnosis of secretory otitis media, as well as being a means of helping parents understand the periodically poor middle ear function of their child.

[C-reactive protein in general practice. An important diagnostic tool in infections]. / C-reaktivt protein i allmennpraksis. Et viktig diagnostisk hjelpemiddel ved infeksjoner.

In just a few years C-reactive protein (CRP) has become an important test in the rapid elucidation of infections in Norwegian general practice. 33 general practitioners in the southern part of Vestfold county, continuously registered 546 consultations where a CRP analysis was performed. The protein was analyzed in 10% of all the consultations (range 3-31%). The general practitioners stated that the CRP analysis has great diagnostic impact in the elucidation of acute infections, but significantly less impact in routine examinations. The result contributed to a change in diagnosis in 30% of the patients where a diagnosis involving infection was considered. C-reactive protein contributed to a reduction in the prescribing of antibiotics in a quarter of the consultations. C-reactive protein is an important supplement to clinical investigation in the elucidation of infections in Norwegian general practice.

Predictors of duration of acute sinusitis episodes treated with antibiotics.

OBJECTIVE: To evaluate which factors present at the onset of acute sinusitis predict the duration of illness among adult patients treated with antibiotics. DESIGN: Cohort study with a 30-day follow-up. SETTING: Norwegian general practice. SUBJECTS: Eighty-six adult patients with a clinical diagnosis of acute sinusitis confirmed by Computed Tomography. METHODS: Signs, symptoms and other variables present at the onset of treatment were dichotomized and analysed bivariately with duration of the sinusitis episode, using the log-rank test. Age, gender, and factors with p-values under 0.15 were modelled in a Cox regression analysis to assess independent predictors for illness duration. MAIN OUTCOME MEASURE: Duration of illness. RESULTS: Illness duration was significantly and positively associated with increasing age and with a higher clinical severity score at the onset of treatment. No other factors were independent predictors of illness duration. CONCLUSION: The age of the patient and the clinical severity of the sinusitis at the onset of treatment were independent predictors of illness duration in adult patients treated with antibiotics.

[Sinusitis in general practice--a diagnostic challenge]. / Sinusitt i allmennpraksis--en diagnostisk utfordring.

Sinusitis is a common problem in general practice, but diagnosis is often difficult. The greatest clinical challenge is to distinguish between purulent and nonpurulent sinusitis. This differential diagnosis has consequences for treatment. A questionnaire was sent to a randomized sample of Norwegian general practitioners and to all ear, nose and throat specialists in private practice. 79% of the general practitioners felt that diagnosis is more uncertain for sinusitis than for otitis media. When anamnestic questions and clinical findings were grouped, it was shown that general practitioners consider pain to be much more relevant in the differential diagnosis than purulent secretion. The ear, nose and throat specialists consider pain and purulent secretion to be equally important in the differential diagnosis. Pain in cheek and forehead, and pain in the upper teeth are regarded as the most relevant single anamnestic symptoms. Duration of illness is considered to have little differential diagnostic relevance. Among supplementary tests only C-reactive protein is regarded as helpful. X-ray and erythrocyte sedimentation rate are evaluated as far less relevant.