Can a multifaceted educational intervention targeting both nurses and physicians change the prescribing of antibiotics to nursing home residents? A cluster randomized controlled trial.

OBJECTIVES: To assess the impact of a multifaceted educational intervention concerning treatment of infections in the nursing home setting. METHODS: We used a cluster randomized controlled trial. Fifty-eight nursing homes in Sweden were randomly assigned either to educational intervention or control. The intervention consisted of small educational group sessions with nurses and physicians, feedback on prescribing, presentation of guidelines and written materials. The primary outcome was the proportion of quinolones prescribed for lower urinary tract infection (UTI) in women. Secondary outcomes were for all infections: number of UTIs per resident, proportion of recorded infections treated with an antibiotic, proportion of infections handled by physicians as 'wait and see', and for lower UTI in women, proportion of nitrofurantoin. RESULTS: Of the 58 nursing homes, 46 completed the study. A total of 702 and 540 infections were recorded pre- and post-intervention. The proportion of quinolones decreased significantly in the intervention and control groups, by -0.196 (9/93 to 36/123) and -0.224 (4/66 to 31/109), respectively [95% confidence interval (CI) -0.338, -0.054 and -0.394, -0.054], but the difference between intervention and control groups was not significant, with an absolute risk reduction of 0.028 (95% CI -0.193, 0.249). The changes in proportion of infections treated with antibiotics and proportion of infections handled by physicians as 'wait and see' was significant in comparison with controls: -0.124 (95% CI -0.228, -0.019) and 0.143 (95% CI 0.047, 0.240). No intervention effect could be seen for the other outcomes. CONCLUSIONS: The educational intervention had no effect on the primary outcome, but decreased the overall prescribing of antibiotics.

A survey of public knowledge and awareness related to antibiotic use and resistance in Sweden.

OBJECTIVES: To examine the level of knowledge about antibiotic treatment and awareness of antibiotic resistance among the general public in Sweden. METHODS: A quantitative, cross-sectional interview study based on a structured questionnaire used during telephone interviews. The sample comprised 1000 randomly selected individuals aged 21-80 years throughout Sweden. Demographic data as well as level of agreement with various statements concerning antibiotics and antibiotic use were provided by the respondents. RESULTS: The response rate was 74.7%. Of the respondents, 19.1% agreed that antibiotics cure common colds more quickly; this belief was higher in those who had not previously received antibiotics. A high proportion, 80.7%, agreed that bacteria could become resistant to antibiotics. Trust in doctors was high, and significantly more respondents reported trusting the doctor not prescribing an antibiotic, 87.0%, than the doctor prescribing an antibiotic, 81.0%. The respondents showed some confusion surrounding the terms 'bacteria' and 'viruses', and the meaning of these in relation to the prescribing decision. CONCLUSIONS: The high level of trust in restrictive prescribing as well as the awareness of antibiotic resistance expressed by the Swedish public should be recognized by health professionals and utilized in future campaigns.

Can incentives undermine intrinsic motivation to participate in epidemiologic surveys?

Response rates to surveys are decreasing. The purpose of this study was to evaluate the use of lottery tickets as incentives in an epidemiologic control group. A self-administered questionnaire was sent to parents in the municipality of Stockholm, Sweden, who were to be used as a control group in a study addressing stress in parents of children with cancer. A stratified random sample of 450 parents were randomized into three incentive groups: (a) no incentive; (b) a promised incentive of one lottery ticket to be received upon reply; (c) a promised incentive of one lottery ticket to be received upon reply and an additional lottery ticket upon reply within 1 week. The overall response rate across the three groups was 65.3%. The response rate was highest in the no incentive group (69.3%) and lowest in the one plus one lottery ticket group (62.0%). In a survival analysis, the difference between the two response curves was significant by the log-rank test (P = 0.04), with the no incentive group having a shorter time to response than the incentive group. Our findings suggest that the use of lottery tickets as incentives to increase participation in a mail questionnaire among parents may be less valuable or even harmful. Incentives may undermine motivation in studies in which the intrinsic motivation of the respondents is already high.

Parvovirus B19 infection in children with acute lymphoblastic leukemia is associated with cytopenia resulting in prolonged interruptions of chemotherapy.

BACKGROUND: Parvovirus B19 infection causes severe cytopenia and can mimic a leukemic relapse or therapy-induced cytopenia in patients with hematologic malignancies. We evaluated the complications of parvovirus B19 infection, including delays in the scheduled course of chemotherapy, in children with acute lymphoblastic leukemia (ALL). METHODS: Consecutive bone marrow samples were collected from 117 children with ALL and were analyzed for parvovirus B19 DNA by polymerase chain reaction. Clinical and laboratory data were collected from the Nordic Childhood Leukemia Registry and from medical records. RESULTS: Among the 117 children with ALL, 18 (15%) were found to be parvovirus B19 DNA positive. The infection was suspected on clinical grounds in only 1 of these 18 patients. Patients with viremia at diagnosis or during therapy for infection had lower viral loads (median viral load, 7 x 10(4) copies/mL) than did those who became viremic during maintenance therapy (median viral load, 2 x 10(8) copies/mL). The former group also had fewer clinical complications. Indeed, when parvovirus B19 DNA was present during the maintenance treatment, the number of complications (including cytopenia) increased, causing significantly longer periods without chemotherapy (median duration without chemotherapy, 59 days vs. 30 days; P < or = .05) and a higher number of blood transfusions (P = .018) in parvovirus B19 DNA-positive patients than in parvovirus B19 DNA-negative patients. CONCLUSIONS: Children with ALL who were infected with parvovirus B19 became cytopenic, leading to reduced treatment intensity and to complications during treatment. Screening for parvovirus B19 DNA by quantitative polymerase chain reaction in pediatric patients with ALL and unexplained cytopenia is suggested.

mRNAs of tyrosine hydroxylase and dopa decarboxylase but not of GD2 synthase are specific for neuroblastoma minimal disease and predicts outcome for children with high-risk disease when measured at diagnosis.

Several transcripts have been claimed to be clinically valuable for detecting minimal disease in neuroblastoma, but they have not been prospectively compared in a standardized manner. Tyrosine hydroxylase (TH), dopa decarboxylase (DDC) and GD2 synthase (GD2S) mRNAs were analyzed in 554 blood (PB) and bone marrow (BM) samples from 58 children with neuroblastoma. Samples from 44 children with other diseases served as controls. High transcript concentrations of TH, GD2S or DDC in PB or BM at diagnosis were associated with poor prognosis. TH in BM above median indicated worse outcome for a homogenous cohort with high-risk neuroblastoma (survival probability 91% for TH below median versus 33% for TH above median, p = 0.009). The number of children with localized neuroblastoma with increased results in PB did not differ between the three transcripts. In these children, all without morphologically detectable neuroblastoma in BM, the number of patients with elevated GD2S in BM at diagnosis was significantly higher than for the other transcripts (10/16 elevated, p = 0.012). GD2S was elevated in PB from 10/28 controls without neuroblastoma compared to 1/28 for TH and DDC (p < 0.001). In BM from these children GD2S was significantly elevated. We conclude that high expression of TH and DDC both in PB and BM corresponds to metastatic neuroblastoma at diagnosis, residual disease, and poor outcome. Children with high-risk neuroblastoma and low levels of TH in BM at diagnosis may be cured by current therapy. GD2S is less specific than TH and DDC mRNA for neuroblastoma detection in PB and BM.

Health providers' competence in the management of reproductive tract infections in Vientiane, Lao People's Democratic Republic.

This cross-sectional study aimed to assess health providers' reported knowledge and practice competence regarding management of reproductive tract infections (RTIs) including sexually transmitted infections (STIs) in Vientiane, Laos. All 272 health providers (medical doctors/assistants, midwives/nurses and drug sellers) working with RTI/STI patients in one urban and one rural district were invited to fill in a self-completed questionnaire including four written simulated case scenarios, and 93% participated in the study. Of 252 respondents, 34% scored below 50% regarding both the case scenarios and reported knowledge, and 87% gave inadequate advice regarding health education. Only 34% gave correct advice on contact tracing, 38% on counselling, 52% regarding compliance and 59% on condom promotion. Drug sellers scored lowest in all aspects of RTI/STI management. Urban respondents were more likely to report adequate knowledge. Continuous training in syndromic approach and supervision are recommended to improve the quality of RTI/STI management, particularly at private pharmacies and in rural areas.

Quality of interaction between primary health-care providers and patients with type 2 diabetes in Muscat, Oman: an observational study.

BACKGROUND: A good patient-physician interaction is particularly important in chronic diseases like diabetes. There are so far no published data regarding the interaction between the primary health-care providers and patients with type 2 diabetes in Oman, where diabetes is a major and growing health problem. This study aimed at exploring how health-care providers interact with patients with type 2 diabetes at primary health-care level in Muscat, Oman, focusing on the consultation environment, and some aspects of care and information. METHODS: Direct observations of 90 consultations between 23 doctors and 13 diabetes nurses concerned with diabetes management during their consultations with type 2 diabetes patients in six primary health-care centres in the Muscat region, using checklists developed from the National Diabetes Guidelines. Consultations were assessed as optimal if more than 75% of observed aspects were fulfilled and sub-optimal if less than 50% were fulfilled. RESULTS: Overall 52% of the doctors' consultations were not optimal. Some important aspects for a positive consultation environment were fulfilled in only about half of the doctors' consultations: ensuring privacy of consultation (49%), eye contact (49%), good attention (52%), encouraging asking questions (47%), and emphasizing on the patients' understanding of the provided information (52%). The doctors inquired about adverse effects of anti-diabetes drugs in less than 10% of consultations. The quality of the nurses' consultations was sub-optimal in about 75% of 85 consultations regarding aspects of consultation environment, care and information. CONCLUSION: The performance of the primary health-care doctors and diabetes nurses needs to be improved. The role of the diabetes nurses and the teamwork should be enhanced. We suggest a multidisciplinary team approach, training and education to the providers to upgrade their skills regarding communication and care. Barriers to compliance with the guidelines need to be further explored. Improving the work situation mainly for the diabetes nurses and further improvement in the organizational efficiency of diabetes services such as lowering the number of patients in diabetes clinic, are suggested.

Infections and antibiotic prescribing in Swedish nursing homes: a cross-sectional study.

The aim of this study was to present and assess the treatment of infections in Swedish nursing homes. It included 58 nursing homes with 3002 residents. During 3 months, nurses in the nursing homes recorded all infections requiring a physician's opinion. Of the 889 infectious episodes, 84% were treated with antibiotics. Many of the antibiotics were issued after indirect contact with the physician (38%). Indications for antibiotics were in 55% of the cases urinary tract infections (UTI), in 17% skin and soft-tissue infections and in 15% respiratory tract infections (RTI). The most common antibiotics were penicillins (38%), followed by quinolones (23%) and trimethoprim (18%). For the major indication, lower UTI in women, half of the cases were not treated according to the recommendations. The main concerns were length of treatment and overprescribing of quinolones. For the second major diagnosis, pneumonia, the high use of doxycycline could be questioned. Continuing education on infections and their treatment in nursing homes is needed. Training should preferably include both physicians and nurses as a high proportion of antibiotics is issued without direct contact with the physician.

Health information, an area for competition in Swedish pharmacies.

OBJECTIVE: To investigate the views and expectations of a selected group of customers regarding health information in Swedish pharmacies. METHODS: A repeated cross sectional, questionnaire study carried out in 2004 and 2005. Customers buying calcium products answered questions on osteoporosis and general questions on health promotion and information. RESULTS: Respondents had a positive attitude towards receiving health information from the pharmacies and towards the pharmacies' future role in health promotion. However, only 30% of the respondents expected to get information on general health issues from the pharmacy. In spite of this, 76% (2004) and 72% (2005) of the respondents believed that the pharmacies could influence people's willingness to improve their health. CONCLUSION: There is a gap between the respondents' positive attitudes towards the Swedish pharmacies and their low expectations as regards the pharmacies' ability to provide health information. In the light of the upcoming change to the state monopoly on medicine sales, this gap could be an important area for competition between the actors in the new situation for medicine sales in Sweden.

Diagnosis-prescribing surveys in 2000, 2002 and 2005 in Swedish general practice: consultations, diagnosis, diagnostics and treatment choices.

The aim of this study is to present diagnostic patterns, diagnostics used and antibiotic treatment in relation to guidelines in 3 repeated diagnosis-prescription studies conducted simultaneously in general practice in 5 Swedish counties, during 1 week in November 2000, 2002 and 2005. General practitioners (GPs) at the participating health centres were asked to complete a form for all patients with symptoms of an infectious disease. During the studied periods a total of 15,371 consultations was registered. Consultations with GPs diagnosed as respiratory tract infection (RTI), especially consultations for sore throat, decreased considerably between y 2000 and 2005. The percentage of patients allocated an RTI diagnosis and prescribed an antibiotic declined significantly from 54% to 49% and the decline was most pronounced among children. Penicillin V remained the dominant antibiotic prescribed throughout the study periods. For lower urinary tract infections there was a significant change in choice of prescribed antibiotics with an increase for pivmecillinam and nitrofurantoin and a decrease for trimethoprim, in accordance with recommendations. The results indicate a quite close adherence to current guidelines, with changes in the pattern of consultations as well as in the management of infectious diseases in general practice in Sweden.

Health information, an area for competition in Swedish pharmacies / Información sanitaria, un área de competencia en las farmacias suecas

Objective: To investigate the views and expectations of a selected group of customers regarding health information in Swedish pharmacies. Methods: A repeated cross sectional, questionnaire study carried out in 2004 and 2005. Customers buying calcium products answered questions on osteoporosis and general questions on health promotion and information. Results: Respondents had a positive attitude towards receiving health information from the pharmacies and towards the pharmacies’ future role in health promotion. However, only 30% of the respondents expected to get information on general health issues from the pharmacy. In spite of this, 76% (2004) and 72% (2005) of the respondents believed that the pharmacies could influence people’s willingness to improve their health. Conclusion: There is a gap between the respondents’ positive attitudes towards the Swedish pharmacies and their low expectations as regards the pharmacies’ ability to provide health information. In the light of the upcoming change to the state monopoly on medicine sales, this gap could be an important area for competition between the actors in the new situation for medicine sales in Sweden (AU)

Objetivo: Investigar las visiones y expectativas de un grupo seleccionado de clientes en relación a la información en las farmacias suecas. Métodos: Un cuestionario repetido transversal realizado en 2004 y 2005. Los clientes que compraban productos con calcio respondieron a preguntas sobre osteoporosis y preguntas generales sobre promoción de la salud e información. Resultados: Los respondentes tenían una actitud positiva hacia recibir información de las farmacias y hacia el futuro papel del farmacéutico en la promoción de la salud. Sin embargo, solo el 30% de los respondentes esperaba obtener información sobre aspectos generales de salud en la farmacia. A pesar de esto, el 76% (2004) y 72% (2005) de los respondentes creían que las farmacias podrían influir en la voluntad de las personas para mejorar su salud. Conclusión: Hay una brecha entre las actitudes positivas de los respondentes hacia las farmnacias suecas y sus bajas expectativas sobre la capacidad de las farmacias de proporcionar información sobre la salud. A la vista del inminente cambio en el monopolio estatal de la venta de medicamentos, esta brecha podría ser un área importante de competencia entre los actores de esta nueva situación de venta de medicamentos en Suecia (AU)