Diagnosis-linked antibiotic prescribing in Swedish primary care - a comparison between in-hours and out-of-hours.

BACKGROUND: The rise in antibiotic resistance is a global public health concern, and antibiotic overuse needs to be reduced. Earlier studies of out-of-hours care have indicated that antibiotic prescribing is less appropriate than that of in-hours care. However, no study has compared the out-of-hours treatment of infections to in-hours treatment within the same population. METHODS: This retrospective, descriptive study was based on data retrieved from the Kronoberg Infection Database in Primary Care (KIDPC), which consists of all visits to primary care with an infection diagnosis or prescription of antibiotics during 2006-2014. The purpose was to study the trends in antibiotic prescribing and to compare consultations and prescriptions between in-hours and out-of-hours. RESULTS: The visit rate for all infections was 434 visits per 1000 inhabitants per year. The visit rate was stable during the study period, but the antibiotic prescribing rate decreased from 266 prescriptions per 1000 inhabitants in 2006 to 194 prescriptions in 2014 (mean annual change - 8.5 [95% CI - 11.9 to - 5.2]). For the out-of-hours visits (12% of the total visits), a similar reduction in antibiotic prescribing was seen. The decrease was most apparent among children and in respiratory tract infections. When antibiotic prescribing during out-of-hours was compared to in-hours, the unadjusted relative risk of antibiotic prescribing was 1.37 (95% CI 1.36 to 1.38), but when adjusted for age, sex, and diagnosis, the relative risk of antibiotic prescribing was 1.09 (95% CI 1.08 to 1.10). The reduction after adjustment was largely explained by a higher visit rate during out-of-hours for infections requiring antibiotics (acute otitis media, pharyngotonsillitis, and lower urinary tract infection). The choices of antibiotics used for common diagnoses were similar. CONCLUSIONS: Although the infection visit rate was unchanged over the study period, there was a significant reduction in antibiotic prescribing, especially to children and for respiratory tract infections. The higher antibiotic prescribing rate during out-of-hours was small when adjusted for age, sex, and diagnosis. No excess prescription of broad-spectrum antibiotics was seen. Therefore, interventions selectively aiming at out-of-hours centres seem to be unmotivated in a low-prescribing context.

Acute type A aortic dissection in-hours versus out-of-hours: A systematic review and meta-analysis.

OBJECTIVE: We sought to compare clinical outcomes in patients with acute type A aortic dissection that undergone surgical repair during in-hours (IH) versus out-of-hours (OOH). METHODS: An electronic literature search was done till March 2020 to include studies with comparative cohorts of IH versus OOH. Primary outcomes were 30-day mortality, stroke, and reoperation for bleeding; secondary outcomes were acute kidney injury, total hospital stay, and intensive care unit stay. RESULTS: Six articles with a total of 3744 patients met the inclusion criteria. Mean age was similar, 60 ± 12 versus 60 ± 13 in IH versus OOH (p = .25). Aortic root and total arch replacement were similar in both cohorts, 22% in IH versus 25% in OOH (risk ratio [RR], 1.10; 95% confidence interval [CI: 0.78, 1.55]; p = .58) and 29% in IH versus 32% in OOH (RR, 0.96; 95% CI [0.89, 1.04], p = .37) respectively. Reoperation for bleeding and stroke rate were similar, with 18% in IH versus 23% in OOH (RR, 0.89; 95% CI [0.73, 1.08]; p = .24), and 12% in IH versus 13% in OOH (RR, 0.83; 95% CI [0.66, 1.03]; p = .09) respectively. Thirty-day mortality was significantly lower in IH (RR, 0.81; 95% CI [0.72, 0.90]; p = .0001). CONCLUSION: There was higher 30-day mortality rate during OOH surgery, yet this difference diminished following sensitivity analysis. There were no significant differences in major postoperative outcomes. Therefore, operating on such cases should be decided on clinical priority without delay.

Temporal and spatial variability of traffic-related noise in the City of Toronto, Canada.

The majority of studies that assessed population-level exposure to traffic-related noise were conducted in European countries and less is known about the exposure to traffic noise in North America, particularly in Canadian cities. This study explored the temporal and spatial variability of traffic noise in the City of Toronto, the largest city in Canada. We conducted two cycles of intensive field measurement campaign to collect real-time measurements of traffic noise at 554 locations across Toronto between June 2012 and January 2013. At each site, we collected measurements for a period of 30 min during daytime. Repeated measurements were made in cycle two at 62 locations randomly selected from cycle one, which exhibited high correlation (Pearson's correlation coefficient (r): 0.79). In addition, continuous measurements of noise were recorded for seven days at ten sites. We observed that noise variability was predominantly spatial in nature, rather than temporal: spatial variability accounted for 60% of the total observed variations in traffic noise. Traffic volume, length of arterial road, and industrial area were three most important variables, explaining the majority of the spatial variability of noise (R(2)=0.68 to 0.74, depending on the cycle). In comparison to the 16-h equivalent sound level guideline for outdoor locations set out by the Ministry of the Environment of the Province of Ontario, 80% of our sampled locations exceeded this guideline (i.e. 55 dBA,16 h). These findings suggested ubiquitous traffic noise exposure across Toronto and that noise variability was explained mostly by spatial characteristics.