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Using a diaphragm as a barrier contraceptive has received little attention in recent literature. A discussion of the role of the diaphragm to prevent pregnancy, as well as sexually transmitted diseases, is presented. A procedure for properly fitting the diaphragm is described. To ensure compliance, a review of a plan for education and practice by users is outlined.
OBJECTIVE: To reduce the prescribing of antibiotics in respiratory tract infections (RTI). DESIGN AND SUBJECTS: The Audit Odense model for registration and quality development was used for RTI. Twenty general practitioners registered their consultations for RTIs during 4 weeks in February-March (n = 1124) and November-December (n = 926) in 1995. Diagnosis, choice of antibiotics and diagnostic tools were registered. In between the two registrations an active intervention took place. Consultations for RTIs among 25 physicians (who had not participated in any intervention or follow-up discussion) served as a control. SETTING: General practice in southern Sweden. OUTCOME MEASURES: Prescribing of antibiotics before and after an intervention. RESULTS: The proportion of patients not receiving an antibiotic increased from the first to the second registration in both groups, in the intervention group from 45 to 55% (p < 0.001) and in the control group from 36 to 40% (p = 0.0298). The reduction was most evident in patients diagnosed with tonsillitis and bronchitis. This was in concordance with an increase in the use of desktop diagnostics (Strep A and CRP). CONCLUSION: These results indicate that it is possible to achieve a change in the utilisation of antibiotics in the treatment of RTIs and that the Audit Project Odense (APO) model could be a valuable tool.
BACKGROUND: Acute cough due to upper respiratory tract infection (URTI) is a common symptom. Many health practitioners recommend non-prescription over-the-counter (OTC) medicines as a first-line treatment for cough, but there is little evidence as to whether these drugs are effective. OBJECTIVES: To assess the effects of oral over-the-counter cough preparations for acute cough. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2004); MEDLINE (January 1966 to June Week 3, 2004); EMBASE (January 1990 to March 2004); and the UK Department of Health National Research Register (December 2003, http://www.update-software.com/National/nrr-frame.html). We also searched personal collections of references and reference lists of articles. We wrote to study investigators and pharmaceutical companies for information on further published or unpublished studies. There were no constraints based on language or publication status. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing oral OTC cough preparations with placebo in children and adults suffering from acute cough in ambulatory settings. We considered all cough outcomes (such as frequency and severity, continuous and categorical data, using different ways of measurement). The second outcomes of interest were adverse effects. DATA COLLECTION AND ANALYSIS: Two investigators screened potentially relevant citations independently. Any differences at any stage of the review were resolved by discussion. We also extracted data and assessed the quality of studies independently. We contacted investigators for additional information and performed quantitative analysis when appropriate data were available. MAIN RESULTS: Twenty four trials (17 in adults, seven in children) involving 3,392 people (2,876 adults and 516 children) were included. RESULTS OF STUDIES IN ADULTS: 1. Antitussives: Six trials compared antitussives with placebo. Codeine was no more effective than placebo in reducing cough symptoms. Two studies favoured dextromethorphan over placebo, whereas a third did not show an effect. Moguisteine was no more effective than placebo apart from a reduction of cough in a subgroup of participants with more severe night cough. 2. Expectorants: Two trials compared guaifenesin with placebo. In the larger study, 75 per cent of participants taking guaifenesin stated that the medicine was helpful compared to 31 per cent in the control group. In the second study, both groups showed improvement with respect to cough frequency and severity, with no statistically significant differences between groups. 3. Mucolytics: One trial compared a mucolytic with placebo. Active treatment reduced cough frequency and symptom scores on day four and eight. 4. Antihistamine-decongestant combinations: Two studies compared antihistamine-decongestant combinations with placebo. Antihistamine-decongestants were significantly more effective than placebo in one of the studies, whereas the other did not show any difference between the study groups. 5. Other drug combinations: Three studies compared combinations of drugs other than antihistamine-decongestant with placebo. Two studies were effective in reducing cough symptoms, and one study showed relief at night but not during the day. 6. Antihistamines: Three trials compared antihistamines with placebo. Antihistamines were no more effective than placebo in relieving cough symptoms. RESULTS OF STUDIES IN CHILDREN: 1. Antitussives: Antitussives were no more effective than placebo (one study) 2. Expectorants: No studies using expectorants met our inclusion criteria. 3. Mucolytics: The results of one trial favoured active treatment over placebo from day four until day 10. 4. Antihistamine-decongestant combinations: Two studies showed no difference between antihistamine-decongestant combinations and placebo. 5. Other drug combinations: One trial tested two paediatric cough syrups. Compared to placebo, both preparations showed a 'satisfactory response' in 46 per cent and 56 per cent of children compared to 21 per cent of children in the placebo group. One study compared an antitussive/bronchodilator combination in children, which showed no difference between the treatment groups. 6. Antihistamines: In one trial that tested antihistamines active treatment was no more effective than placebo. REVIEWERS' CONCLUSIONS: There is no good evidence for or against the effectiveness of OTC medicines in acute cough. The results of this review have to be interpreted with caution due to differences in study designs, populations, interventions and outcomes between studies. The numbers of studies in each group were small, and studies often showed conflicting results. Effect sizes in many studies were unclear and it is questionable as to whether all of the positive results are clinically relevant. More evidence about the effectiveness of OTC cough preparations would be helpful, as identification of effective self-care treatments may help reduce the burden of days lost at work due to acute cough as well as the number of consultations in primary care. Identification of ineffective preparations could avoid costs for consumers and health care providers.
A novel way of using teicoplanin in situ to treat central venous catheters is described. Profound immunosuppression and the fact that the lines remain indwelling for long periods are two of the main reasons for these infections. In children it is also difficult to prevent these lines being played with, which increases the likelihood of infection. The different types of infection that can occur in a central venous catheter are described and the clinical definition of a catheter infection is provided. In an initial study, infective episodes in a small group of 11 children were treated successfully with in situ amikacin. Most pathogens were Gram-negative cocci. None of the catheters had to be removed, and catheter life was prolonged by a mean of 118 d. Due to the high incidence of Staphylococcus epidermidis in the initial study, in situ teicoplanin was assessed in a subsequent study. Over the course of 1 yr, 20 line infections occurred in 12 children. Empirical amikacin therapy was instituted and switched to teicoplanin once the pathogen was confirmed as Gram-positive. An antibiotic-heparin mixture was introduced into the line and left in place for 24 h, after which time it was replaced with fresh mixture until cultures were sterile. All pathogens were sensitive to teicoplanin, all infections were treated successfully and no catheters had to be removed. Overall, catheter life was prolonged by a mean of 136 d. It was concluded that in situ teicoplanin was effective and well tolerated for line infections (no side-effects were reported during the study). A minimum of 6 d therapy was recommended. The patients with less severe infections would have been suitable for treatment at home by their parents, district nurse or general practitioner (GP).
Treatments for mild viral infections are usually directed at providing symptomatic relief. The effectiveness of the homoeopathic remedy Gripp-Heel was compared with that of conventional treatments in a prospective, observational cohort study in 485 patients with mild viral infections and symptoms such as fever, headache, muscle pain, cough or sore throat. Practitioners specialised in homoeopathy or conventional treatment, or practised both to similar extents. As evaluated by the practitioners, the homoeopathic therapy was effective to similar or greater degree than the conventional therapies: 67.9% of patients were considered asymptomatic at the end of Gripp-Heel therapy vs. 47.9% of patients in the control group. Practitioners judged homoeopathic treatments as 'successful' in 78.1% of cases vs. 52.2% for conventional therapies. Tolerability and compliance were good in both treatment groups, with the verdict 'very good' given for 88.9% of patients in the homoeopathic group vs. 38.8% in the conventional treatment group.
PURPOSE: To provide nurse practitioners with the information to manage patients with chronic hepatitis C (HCV) receiving a new combination drug therapy containing ribavirin and interferon alfa-2b. DATA SOURCES: Reviews of clinical trial results including large multicenter trials, Centers for Disease Control and Prevention documents, data from the drug manufacturer. CONCLUSION: This new therapy offers the potential for HCV remission or complete cure of the HCV infection. Although virologic responses are markedly improved with combination therapy, the side effects associated with combination therapy warrant regular patient monitoring, management, and medical intervention when clinically indicated. IMPLICATIONS FOR PRACTICE: Combination therapy does not significantly worsen the side effects associated with mono-therapy, which are predictable, manageable, and reversible. However, proper patient education, symptom management, vigilance for serious side effects, and monitoring of hematologic parameters are critical to patient outcome.
BACKGROUND: Severe acute respiratory syndrome (SARS) is currently spreading in many countries. This paper proposes a simple approximate mathematical model for public health practitioners to predict the number of SARS cases and deaths. METHODS: The model is based on four parameters: R(o) (basic reproductive number), F (case-fatality rate), i (incubation period), and d (duration of disease). The calculations can be done by hand or by using a computer spreadsheet. RESULTS: The best parameters to fit Canadian data as of 6 April 2003 (before infection controls took effect) are R(o) = 1.5, F = 30%, i = 5 days, d = 14 days. On 6 April (day 40) there were 74 cases and 7 deaths. If this trend continues, SARS numbers in Canada are predicted to be as follows: 387 cases and 34 deaths by 26 April (day 60), 4432 cases and 394 deaths by 26 May (day 90), and 50 500 cases and 4489 deaths by 25 June (day 120). By comparison, the best parameters to fit Hong Kong data as of 10 April 2003 are R(o) = 2.0, F = 20%, i = 5 days, d = 14 days. CONCLUSIONS: Using the proposed mathematical model, it was estimated that about 1.5 to 2 new infectious cases were produced per infectious case every five days. Also, about 20% to 30% of the cases die within 14 days. The case-fatality may therefore be considerably higher than initially thought. The model indicates that SARS can spread very fast when there are no interventions.
Recurrent herpes simplex virus lesions of fingers, hand, or eyes are suspected to be encountered in health practitioners in greater frequency than in the general population. To determine whether an increased risk of disease contraction coincident to practicing dentistry exists and to determine the magnitude of risk, a survey of dentists practicing in the state of Michigan was conducted. An age and sex matched nondentist patient from each respondent's practice provided a control population. Frequency of herpes labialis and herpes infection of the eye were found be lower in dentists than in the control population. Conversely, herpetic whitlow was found to be more frequent in practicing dentists than in the control population. If the occurrence of herpes labialis in each of the two groups is taken as the reference point, the frequency of herpetic whitlow is significantly higher among practicing dentists than among the control population (P less than .01).
High viral burden and replication persist during all phases of human immunodeficiency virus (HIV) disease. Although monotherapy has yielded considerable benefits, these benefits are neither absolute nor durable. Combination therapy has multiple goals: to reduce viral replication and burden; to relieve drug toxicity; to attenuate viral mutations leading to resistance and possibly to conversion from non-syncytium-inducing to syncytium-inducing virus; and to broaden the spectrum of specific cells and tissues in which antiretroviral agents are active. At present, zidovudine remains the cornerstone of antiretroviral monotherapy and combination therapy. A partial list of agents tried in combinations with and without zidovudine includes the nucleoside analogues zalcitabine and didanosine; non-nucleoside reverse-transcriptase inhibitors (nevirapine, delavirdine, atevirdine, pyridinones, TIBO derivatives); protease inhibitors; inhibitors of viral regulatory functions (tat inhibitors); cytokine antagonists; acyclovir; and colony-stimulating factors. The rationales, the regimens, and the results all vary. We usually recommend combination therapy for treatment-naive patients who are asymptomatic with < 200 CD4+ cells/mm3 or who are symptomatic, and for patients who have been receiving zidovudine monotherapy and who are stable but whose CD4+ counts have fallen to < 300 cells/mm3, or who are progressing. In the absence of definitive results from clinical trials of combination therapy, the decision to embark on this route remains to be made between each individual patient and the practitioner.
The US public health system and primary health care providers must be prepared to address varied biologic agents, including pathogens that are rarely seen in the United States. The increased frequency of international travel, combined with the current national concerns regarding bioterrorism, create an imperative for health practitioners to be more knowledgeable about specific biologic agents. Smallpox poses a serious bioterrorist threat to the US population at this time. Thus, if an outbreak occurred, prompt recognition and the implementation of control measures would be important.
In a national disaster, the medical profession would lose physicians and auxiliary personnel and would need assistance. Canada's 22,000 physicians and 85,000 nurses are located for the most part in potential target areas. Survivors among Canada's 6396 dentists could supply 30% reinforcement. The dentist's training, his manual dexterity and experience acquired in the management of hemorrhage, shock, débridement, suturing, reduction and immobilization of fractures, and control of pain and infection would be valuable. Additional functions he could perform would be first-aid, including but not limited to artificial respiration, early management of chest wounds, preparation of casualties for movement, and assistance in general surgical procedures. Dentists with special training in anesthesia, oral surgery or public health could be of particular value in relieving anesthetists, surgeons, radiologists and public health officers of some of their duties. Joint training of physicians and dentists in mass casualty care could increase the efficiency of the team work in disaster and is being considered by many medical and dental faculties.
Long discussed in the public health arena, the concept of empowerment has only recently entered the discourse on the primary prevention of HIV/AIDS in the United States. Despite its broad appeal, empowerment has not been systematically incorporated into theory-based interventions, which may reflect a lack of consensus on the meaning of empowerment, how to measure it, and the intervention strategies it implies. The purpose of this paper is to consider the relevance of empowerment to community interventions for persons at risk for HIV, particularly women. The origins of empowerment are reviewed; community empowerment as an intervention framework is described and its core assumptions defined. There is some evidence of the growing influence of empowerment and related concepts in recent HIV-related policy, research, and programs funded through the Centers for Disease Control and Prevention. However, adoption of an empowerment framework for HIV prevention will require further theory and measurement development, as well as changes in how public health researchers and practitioners work with the communities they serve.
After the New York outbreak of West Nile Virus encephalitis in the summer of 1999, awareness that vulnerable children and adolescents may be at risk for this mosquito-borne viral infection intensified. The Nurse Practitioner can play an invaluable critical role to recognize and diagnose this arthropod-borne virus. Pathophysiology, vector transmission, clinical manifestations and laboratory findings are discussed in this article. Emphasis is placed on the PNP's role of providing anticipatory guidance concerning prevention of outbreaks and physical management that focuses on the elimination of mosquito-breeding areas, reducing personal exposure, and biological control of mosquito populations.
INTRODUCTION: Butamirate citrate containing medicines are marketed in Hungary since 1991. Every year several hundred thousands of children and adults are treated with these pharmaceutical products. Aim of the study was to compare the prescription habits with the directions provided in the Summary of Product Characteristics and to get an overview on the safety and efficacy of these products. METHODS: The study results are based on the evaluation of 3215 questionnaires provided by 276 general practitioners and pulmonologists having medical practice in many regions and the capital of Hungary. Responses were included into the evaluation only if the name of the physician, the address and type of the practice, the therapeutic indication could be precisely identified and if the patient returned for at least one control visit. RESULTS: The main therapeutic indication of butamirate was cough due to acute lower respiratory tract infections (tracheitis, laryngitis, bronchitis). The treatment interval was usually 1-2 weeks. Depot tablets were prescribed according to the Summary of Product Characteristics. The doses of syrup and drops were frequently and notoriously below the one proposed in the Summary of Product Characteristics. In 14% of the cases the syrup was prescribed for the treatment of children below 3 years of age. All three products were regarded as effective. Adverse events (nausea, vomiting, diarrhoea, skin exanthemas) were reported at 0.5-1% of the patients. CONCLUSIONS: The prescribed average daily doses of drops between the ages 1 month-12 years and the syrup between the ages 6-12 years were 20-30% below the recommended amounts. In Hungary the butamirate citrate containing medicines are regarded to be effective. The adverse events were rare and non-serious.
A recent study concludes that a 7-day penicillin treatment for a sore throat is superior to a 3-day treatment or a placebo, because the symptoms are resolved two days earlier. Prior to this study, the difference--based on the conclusions of a Cochrane review--was thought to be just 8 hours. The total number of patients included was too small to conclude that penicillin could reduce the number of short-term and long-term complications. In the guidelines of the Dutch College of General Practitioners, a 7-day penicillin treatment for a sore throat is only recommended in severe cases. It is still quite acceptable for Dutch GPs to discuss the treatment options for a sore throat with their patients. A change to the current guidelines is not necessary.
The Serious Hazards of Transfusion (SHOT) haemovigilance scheme for the United Kingdom and Republic of Ireland has clearly indicated that there are avoidable risks to which recipients of blood transfusion are exposed. Sometimes errors in practice have led to serious and even fatal consequences, particularly when a haemolytic response occurs due to an incompatible transfusion. Despite the risks, blood transfusion is an important and frequently life-saving therapy and its use in clinical practice is common. This paper discusses recently published national guidelines for the care of recipients of blood transfusion in the light of a review of the literature relevant to the administration of blood transfusions to adults in general hospital settings. Recommendations for practitioners, managers and teachers are offered in relation to preventing errors and to patient care associated with blood transfusion in the context of contemporary emphasis upon evidence based care.
The need for skin disinfection before insertion of an acupuncture needle is controversial and there is no specific research on this topic. However research and observations on the effect of, and the need for, skin disinfection before injections forms a good analogy of acupuncture. Whilst micro-organisms present on the surface of the skin are accessible to disinfection, those located under the surface in ducts, glands and follicles are out of reach and can be inoculated into the sterile tissues below by needle insertion. Fortunately, the bacteria resident on the skin have a low potential to cause infection if host immunity is not severely impaired or compromised by the long-term presence of foreign material, such as a surgical stitch. Disinfection of clean skin before injection is not generally considered necessary and observations of lack of infection following injections without prior skin disinfection support this; however, contamination by micro-organisms not normally resident on skin can pose a higher risk of infection. If skin is visibly soiled, it should be washed and if needle insertion is near an infected or contaminated site, it should be disinfected with alcohol. Practitioner hand hygiene between patients is important, even if gloves are worn. Hands should be washed with soap or detergent and water, or an alcohol handrub can be used if hands are physically clean.
OBJECTIVES: The existence of chronic neuroborreliosis is controversial. The aim of our study was to investigate the existence and kind of persistent symptoms in patients previously treated because of neurological symptoms as a result of neuroborreliosis. MATERIALS AND METHODS: A total of 106 patients with neuroborreliosis, according to established criteria, and a control group of 123 patients with Borrelia induced erythema migrans diagnosed in a general practitioner office were studied. A questionnaire was sent to patients and controls concerning their health situation. Time from onset of neurological symptoms to the questionnaire send out was 32 months (mean) for the patients with neuroborreliosis and 33 months (mean) for the controls. RESULTS: Fifty per cent of the individuals in the patient group compared with 16% of the individuals in the control group showed persistent complaints after their Borrelia infection (P < 0.0001). The most significant differences between the groups were the presence of neuropsychiatric symptoms such as headache, attention problems, memory difficulties and depression. Paresthesia, pain and persistent facial palsy was also significantly more common in patients treated because of neuroborreliosis. CONCLUSION: Our study shows that persisting neurological symptoms are common after a neuroborreliosis infection. The pathological mechanisms that lay behind the development of chronic symptoms, however, are still uncertain.