Differences among international pharyngitis guidelines: not just academic.

PURPOSE: Many countries have national guidelines for the treatment of pharyngitis. We wanted to compare the recommendations and the reported evidence in national guidelines for the management of acute sore throat in adults. METHODS: Guidelines were retrieved via MEDLINE and EMBASE and through a Web-based search for guideline development organizations. The content of the recommendations and the underlying evidence were analyzed with qualitative and bibliometric methods. RESULTS: We included 4 North American and 6 European guidelines. Recommendations differ with regard to the use of a rapid antigen test and throat culture and with the indication for antibiotics. The North American, French, and Finnish guidelines consider diagnosis of group A streptococcus essential, and prevention of acute rheumatic fever remains an important reason to prescribe antibiotics. In 4 of the 6 European guidelines, acute sore throat is considered a self-limiting disease and antibiotics are not recommended. The evidence used to underpin these guidelines was different in North America and Europe. North American guidelines cited more North American references than did European guidelines (87.2% vs 48.0%; ods ratio, 4.6-11.9; P<.001). CONCLUSION: Although the evidence for the management of acute sore throat is easily available, national guidelines are different with regard to the choice of evidence and the interpretation for clinical practice. Also a transparent and standardized guideline development method is lacking. These findings are important in the context of appropriate antibiotic use, the problem of growing antimicrobial resistance, and costs for the community.

Are sore throat patients who hope for antibiotics actually asking for pain relief?

PURPOSE: Antibiotics are still overprescribed for self-limiting upper respiratory tract infections such as acute sore throat, and physicians mention patient's desire for antibiotics as a driving force. We studied patients' concerns when visiting their family physician for acute sore throat, more specifically the importance they attach to antibiotic treatment and pain relief. METHODS: Family physicians in 6 peer groups in Belgium participated in an observational postvisit questionnaire survey. Patients aged 12 years and older making an office visit for acute sore throat were invited to indicate the importance of different reasons for the visit. RESULTS: Sixty-eight family physicians provided data from 298 patients. The 3 most frequently endorsed reasons for visiting the physician were examination to establish the cause of the symptoms, pain relief, and information on the course of the disease. Hopes for an antibiotic ranked 11th of 13 items. Patients who considered antibiotics very/rather important valued pain relief significantly more than patients who considered them little/not important (P <.001). Patients who hoped for antibiotics felt more unwell (P <.001), had more faith in antibiotics to speed recovery (P <.001), and were less convinced that sore throat was a self-limiting disease (P <.012). A multivariate model, adjusted for age, sex, and educational status, showed that the desire for pain relief is a strong predictor of the hope to receive a prescription for antibiotics. CONCLUSION: Our study suggests that patients with acute sore throat and who hope for antibiotics may in fact want treatment for pain. Trials are needed to test whether exploring patients' expectations about pain management and offering adequate analgesia can assist physicians in managing sore throats without prescribing antibiotics.

Predicting prognosis and effect of antibiotic treatment in rhinosinusitis.

PURPOSE: In evaluating complaints suggestive of rhinosinusitis, family physicians have to rely chiefly on the findings of a history, a physical examination, and plain radiographs. Yet, evidence of the value of signs, symptoms, or radiographs in the management of these patients is sparse. We aimed to determine whether clinical signs and symptoms or radiographic findings can predict the duration of the illness, the effect of antibiotic treatment, or both. METHODS: We analyzed data from 300 patients with rhinosinusitis-like complaints participating in a randomized controlled trial comparing amoxicillin with placebo. We used Cox regression analysis to assess the association between the presence at baseline of rhinosinusitis signs and symptoms or an abnormal radiograph and the subsequent course of the illness. We then tested for interactions to assess whether the presence of any of these findings predicted a beneficial effect of antibiotic treatment. RESULTS: Two factors at baseline were independently associated with a prolonged course of the illness: a general feeling of illness (hazard ratio = 0.77, 95% confidence interval, 0.60-0.99) and reduced productivity (hazard ratio = 0.68, 95% confidence interval, 0.53-0.88). Neither typical sinusitis signs and symptoms nor abnormal radiographs had any prognostic value. Prognosis remained unchanged whether or not patients were treated with antibiotics, no matter what symptoms patients had at baseline. CONCLUSIONS: In a large group of average patients with rhinosinusitis, neither the presence of typical signs or symptoms nor an abnormal radiograph provided information with regard to the prognosis or the effect of amoxicillin. The time to recovery was longer in patients who felt ill at baseline or who did not feel able to work, but the course of their illness was not influenced by antibiotic treatment.

Study on the reproducibility of the Waters' views of the maxillary sinuses.

OBJECTIVE: This study intended to investigate the reproducibility of the Waters' view for maxillary sinusitis and to define its place in clinical practice. MATERIALS AND METHOD: Radiographs of 80 maxillary sinuses of patients with suspected acute sinusitis were read by 6 radiologists, 6 ENT surgeons, 6 general practitioners (GPs). Interobserver agreement was calculated using the kappa statistic. RESULTS: Agreement was good (kappa = 0.63; 95% CI 0.58-0.68) between radiologists when the criteria used to define acute sinusitis were "important mucosal swelling, air-fluid level or complete opacity". When the criteria "air-fluid level or complete opacity" were used, agreement was fair (kappa 0.39; 95% CI 0.35-0.44). Between ENT-surgeons kappas were respectively 0.58 (95% CI 0.53-0.63) and 0.37 (95% CI 0.32-0.42). Between GPs kappas were respectively 0.30 (95% CI 0.25-0.35) and 0.28 (95% CI 0.23-0.33). CONCLUSION: The reproducibility of Waters' views of the maxillary sinuses is best when the interpretation is performed by radiologists or ENT surgeons, and when criteria for sinusitis are: important mucosal swelling, air fluid level or complete opacity. The good interobserver agreement combined with the known high negative predictive value of these diagnostic criteria makes the Waters' view only useful for ruling out acute sinusitis.

General practice based teaching exchanges in Europe. Experiences from the EU Socrates programme 'primary health care'.

This paper reviews the experience of international exchange of medical students for general practice. The experience is based on the EU Socrates programme 'Primary Health Care' that offers, since 1992, clinical attachments and research electives in primary care. This programme involves 11 university departments of general practice/primary care in eight countries: Austria - Vienna; Belgium - Gent; Germany Düsseldorf; Italy - Monza, Udine; Netherlands Nijmegen; Slovenia - Ljubljana; Sweden - Göteborg; and the UK - Edinburgh, Imperial College London and Nottingham. More than 150 students have taken part in the programme, most in the last four years. For clinical attachment communication to patients is essential, and students should be able to speak the language of the host university. A research elective in primary care is less demanding and requires students' ability to communicate in English. Despite marked differences in health care structure in the countries involved, it is quite possible to provide a valuable teaching environment in general practice, and the experience gained by students in the exchanges more than equals that what they would gain at home. The added value is in experiencing the influence of another health care system and of working in another academic primary care centre. A substantial number of research electives have been published in international peer reviewed scientific journals with the student as first (occasionally second) author and staff members of the student's host and home university as co-authors. A further benefit of the exchange programme lies in the transfer teaching innovations between universities.

Barriers to academic detailers: a qualitative study in general practice.

BACKGROUND: International research has proved that academic detailing positively influences the prescribing behaviour of physicians. In the North-East Flanders region of Belgium, a quantitative study of the feasibility and acceptability of academic detailing in general practice has demonstrated that academic detailers are appreciated by physicians. OBJECTIVE: In addition to the quantitative study, a qualitative study was carried out to determine physicians' attitudes to academic detailing and their objections against it. METHODS: This study took place in general practice in the North-East Flanders region of Belgium, using semistructured interviews. Nineteen physicians who had previously had a visit from an academic detailer in the quantitative study, and 19 who had refused were invited for an interview. RESULTS: Eighteen physicians who had been visited by an academic detailer, and nine who had refused a visit agreed to be interviewed. Although most physicians who had had a visit from an academic detailer appreciated the visit, some barriers were revealed. Physicians had doubts about the objectivity, stated that the information was not new or that they had other ways to obtain information. These barriers were also mentioned by the physicians who had refused a visit. Additional barriers were that the visits were time-consuming, meant to cut expenses, politically coloured, and patronising. CONCLUSION: Doubts about independence and objectivity of the information were stated as important barriers both by physicians who had accepted a visit from an academic detailer and by those who had not. These issues need to be dealt with when designing future interventions with academic detailers.

Does amoxicillin improve outcomes in patients with purulent rhinorrhea? A pragmatic randomized double-blind controlled trial in family practice.

OBJECTIVE: To compare the efficacy of amoxicillin vs placebo in patients with an acute upper respiratory tract infection and purulent rhinorrhea. STUDY DESIGN: Double-blind randomized placebo-controlled trial. POPULATION: The 416 patients included from 69 family practices were 12 years or older, presenting with acute upper respiratory complaints, and having a history of purulent rhinorrhea and no signs of complications of sinusitis. OUTCOMES MEASURED: Therapy success (disappearance of symptoms that most greatly affected the patient's health) at day 10 and duration of general illness, pain, and purulent rhinorrhea. RESULTS: Therapy was successful in 35% of patients with amoxicillin and in 29% of patients with placebo (relative risk [RR] 1.14, 95% confidence interval [CI], 0.92-1.42). There was no effect on duration of general illness or pain. Duration of purulent rhinorrhea was shortened by amoxicillin (9 days vs 14 for clearing of purulent rhinorrhea in 75% of patients; P =.007). Diarrhea was more frequent with amoxicillin (29% vs 19%, RR 1.28, 95% CI, 1.05-1.57). No complications were reported. One patient (0.5%) receiving amoxicillin and 7 (3.4%) receiving placebo discontinued trial therapy because of exacerbation of symptoms (RR 0.25, 95% CI 0.04-1.56, P =.07). All 8 patients recovered with antibiotic therapy. CONCLUSIONS: Amoxicillin has a beneficial effect on purulent rhinorrhea caused by an acute infection of the nose or sinuses but not on general recovery. The practical implication is that all such patients, whatever the suspected diagnosis, can be safely treated with symptomatic therapy and instructed to return if symptoms worsen.

Patients' ideas, concerns, and expectations (ICE) in general practice: impact on prescribing.

BACKGROUND: Although studies are available on patients' ideas, concerns, and expectations in primary care, there is a scarcity of studies that explore the triad of ideas, concerns, and expectations (ICE) in general practice consultations and the impact on medication prescribing. AIM: To evaluate the presence of ICE and its relation to medication prescription. DESIGN OF STUDY: Cross-sectional study. SETTING: Thirty-six GP teaching practices affiliated with the University of Ghent, in Flanders, Belgium. METHOD: Participants were all patients consulting on 30 May 2005, and their doctors. Reasons for an encounter (consultation or home visit) with new and follow-up contacts, the identification of ICE, and the prescription of medication were recorded by 36 trainee GPs undergoing observational training. The study included 613 consultations. RESULTS: One, two, or three of the ICE components were expressed in 38.5%, 24.4%, and 20.1% (n = 236, 150, 123) of contacts respectively. On the other hand, in 17.0% (104/613) of all contacts, and in 22% (77/350) of the new contact reasons, no ICE was voiced, and the GPs operated without knowing this information about the patients. Mean number of ICE components per doctor and per contact was 1.54 (standard deviation = 0.54). A logistic regression analysis of the 350 new contacts showed that the presence of concerns (P = 0.037, odds ratio [OR] 1.73, 95% confidence interval [CI] = 1.03 to 2.9), and expectations (P = 0.009, OR = 2.0, 95% CI = 1.2 to 3.4) was associated with not prescribing new medication (dichotomised into the categories present/absent); however, other patient, doctor, and student variables were not significantly associated with medication prescription. CONCLUSION: An association was found between the presence of concerns and/or expectations, and less medication prescribing. The data suggest that exploring ICE components may lead to fewer new medication prescriptions.