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PubMed2004

Economic evaluation of Helicobacter pylori eradication in the CADET-Hp randomized controlled trial of H. pylori-positive primary care patients with uninvestigated dyspepsia.

BACKGROUND: Adult Helicobacter pylori-positive patients by 13C-urea breath test with uninvestigated dyspepsia symptoms were randomized to 1-week eradication treatment with omeprazole, metronidazole and clarithromycin (OMC) vs. omeprazole and placebo antimicrobials (OPP) in the Canadian Adult Dyspepsia Empiric Treatment-H. pylori-positive (CADET-Hp) study. AIM: To perform an economic evaluation of this 1-year study. METHODS: Following blind eradication treatment, family practitioners managed patients according to their usual practices. Health resource utilization information was collected prospectively. From the mean costs of the health resources consumed and the treatment outcomes, the incremental cost-effectiveness ratios and incremental net benefits of eradication treatment vs. OPP were determined. RESULTS: Eradication therapy significantly improved dyspepsia symptoms (treatment success: OMC, 50%; OPP, 36%; P = 0.02). The incremental cost-effectiveness ratio of OMC vs. OPP was - 387 Canadian dollars (CAD$) per treatment success (90% CI, - CAD$1707, CAD$607), indicating a lower cost with treatment success. The incremental net benefit analysis showed that H. pylori eradication was cost-effective if the willingness-to-pay value exceeded a nominal figure of CAD$100 from a health service perspective or CAD$607 from the societal perspective. CONCLUSION: In uninvestigated patients presenting with dyspepsia at the primary care level, eradication of H. pylori in those who are H. pylori positive leads to a cost-effective improvement in dyspepsia symptoms compared with a strategy of not eradicating H. pylori in these patients.

Adolescent↗
PubMed2002

Housing and health: time again for public health action.

Poor housing conditions are associated with a wide range of health conditions, including respiratory infections, asthma, lead poisoning, injuries, and mental health. Addressing housing issues offers public health practitioners an opportunity to address an important social determinant of health. Public health has long been involved in housing issues. In the 19th century, health officials targeted poor sanitation, crowding, and inadequate ventilation to reduce infectious diseases as well as fire hazards to decrease injuries. Today, public health departments can employ multiple strategies to improve housing, such as developing and enforcing housing guidelines and codes, implementing "Healthy Homes" programs to improve indoor environmental quality, assessing housing conditions, and advocating for healthy, affordable housing. Now is the time for public health to create healthier homes by confronting substandard housing.

Accidents, Home↗
PubMed1991

Universal precautions and mortuary practitioners: influence on practices and risk of occupationally acquired infection.

Embalming, the most common funeral practice in the United States, may expose the embalmer to infectious diseases and blood. We surveyed the 860 members of the National Selected Morticians in 1988 to estimate the incidence of self-reported occupational contact with blood and infectious disease, assess morticians' knowledge of acquired immunodeficiency syndrome (AIDS), determine their adherence to universal precautions, and identify predictors of practices designed to reduce risk of occupational exposure to infections. Of 539 (63%) respondents, 212 (39%) reported needle-stick injuries in the past 12 months, and 15 (3%) reported percutaneous exposures to the blood of a decedent with AIDS. Those rating the risk of occupationally acquired human immunodeficiency virus infection as very high or high (194/539 [36%]) were more likely to decline funerals of decedents with antemortem diagnosis of AIDS (59/194 [30%]) and/or to charge more for such funerals (133/194 [69%]) than those who rated the risk as low to moderate (31/345 [9%], 174/135 [51%]).

Acquired Immunodeficiency Syndrome↗
PubMed1995

Targeting fungi: a challenge.

Invasive fungal infections are more commonly identified in various categories of patients, mainly in cancer patients but also in those undergoing organ transplantation, patients in intensive care units, and those with AIDS. There is a great need to increase the awareness of practitioners who are still underestimating the morbidity and mortality relating to invasive fungal infections, and to stress the economic burden for the society and healthcare systems of invasive fungal infections. The list of fungal pathogens causing life-threatening complications has also increased recently, with the emergence of unusual fungi being more frequently identified in such settings. Early diagnosis of invasive fungal infections is still a major challenge for the clinician at the bedside. Identification of state-of-the-art management is also a difficult task for the clinical scientist involved in the assessment of optimal strategies to prevent and to treat those invasive fungal infections, although major progress has occurred in the last 5 years with the development of new, safe, and effective antifungal agents. Empiric therapy remains a very controversial issue that should be further investigated in high-quality clinical trials. Overall, clinical research in this difficult field requires independent and objective analysis; only large multicenter clinical trials can address these critical issues and rapidly provide convincing results leading to a better prognosis of patients with invasive fungal infections. These complications still represent too often an obstacle to successful control of severe underlying diseases. Clinical research on the appropriate ways to target fungi will not only define state-of-the-art management but also identify ineffective or redundant treatments. Such an approach will make a substantial contribution to the care of the high-risk patients within the next decade and will preserve our capacity for medical excellence.

AIDS-Related Opportunistic Infections↗
PubMed2002

Energy medicine for the internist.

Growing bodies of clinical experience and research suggest there are major benefits for patients, physicians, and CAM practitioners with the integration of energy medicine with conventional medical care. Conventional medical practice is excellent for infections, surgically correctable problems, hormonal dysfunctions, and some genetic defects. There are many illnesses for which conventional medicine can offer treatment, with medications and surgical interventions. Side effects of medications may be troublesome, and risks may include fatalities. Energy medicine interventions may complement conventional care and have minimal risks. Patients report high satisfaction with energy medicine interventions perhaps because CAM therapists often offer patients significant amounts of time to talk about their problems. Most energy medicine practitioners are not familiar with conventional medical diagnoses or research methodology. Conventional medical wisdom can inform and enhance energy medicine practice by encouraging further research. It is hoped that the future will bring more collaboration, greater acceptance of integrative care, and greater appreciation of energy medicine.

Acupuncture↗
PubMed1995

Diagnosing salmonellosis in horses. Culturing of multiple versus single faecal samples.

Three rectal faecal samples were taken at 24-hour intervals from 136 horses in order to investigate whether multiple faecal cultures yield a greater number of Salmonella-positive horses compared to single faecal cultures. Of these 136 horses, 89 were suspected of salmonellosis on clinical grounds and 47 belonged to a control group. From the 'Salmonella suspected' group, 22 horses (25%) were Salmonella positive on one or more occasions. Only twelve of these 22 positive horses (55%) were positive at first sampling. Of the control group, only three horses (6%) were positive for Salmonella. Thirty-one (69%) of the 45 positive cultures from the 'Salmonella suspected' group were found only after enrichment in Selenite broth. From the results of the present study it is concluded that multiple faecal cultures are superior to single faecal cultures for diagnosing clinical salmonellosis in horses and that there is no relation between the course of the disease and whether the Salmonellae were cultured directly or indirectly, after enrichment in Selenite broth. Salmonellae were cultured from the faeces of horses treated with antibiotics before their referral, even when the isolated strain was sensitive to the antimicrobial drug used by the practitioner.

Animals↗
PubMed1992

Microbiological testing in the diagnosis of periodontal disease.

The oral microbiota plays a primary role in the initiation and progression of the most common forms of periodontal disease. Because of the multiplicity of factors that control the establishment and long-term evolution of the oral microbiota, a great deal of heterogeneity exists in the composition of the periodontal microbiota among individual subjects. Despite these individual differences and the complex interactions between bacteria and the host and among bacteria, an association has been demonstrated between certain species and various forms of periodontal disease. However, the predictive value of either positive or negative tests for selected bacterial species has not proved to be high enough for routine use in clinical practice. Nevertheless, bacteriological tests have been of value in the management of patients with juvenile periodontitis and refractory forms of periodontal disease. The increasing availability of diagnostic laboratory services and diagnostic kits for office use will make it easier for the practitioner to select appropriate antimicrobial treatments and monitor patients undergoing antimicrobial therapy.

Bacteria↗
PubMedDate not supplied

UTI in patients with urethral catheters: an audit tool.

This article presents an audit tool for the evaluation of practice relating to urinary tract infection in hospital patients with indwelling urethral catheters. It has been formulated primarily because urinary tract infection is a known complication of catheterization, and because studies have shown practitioners' knowledge in this area to be poor. Although health professionals have an obligation to ensure their practice is evidence based, this requires substantial time and skills in critical appraisal. The standard presented here is based on evidence from an extensive literature review on how best to minimize urinary tract infection during catheter insertion, meatal hygiene and management of the drainage system. The audit tool offers the potential for improved practice and demonstration of clinical effectiveness through measurable reduction in rates of urinary tract infection. Moreover, it provides an ideal opportunity for nurses to take the lead in clinical audit activity, which is so often medically led. The supplementary information will also provide a useful guide for nurses to undertake and initiate clinical audit activity in the future.

Catheters, Indwelling↗
PubMed1996

Do patients with sore throat benefit from penicillin? A randomized double-blind placebo-controlled clinical trial with penicillin V in general practice.

BACKGROUND: The effect of antibiotic therapy in sore throat is questionable and this dilemma has been complicated by the emergence of multiple resistant strains of micro-organisms. AIM: A randomized double-blind placebo-controlled clinical trial was undertaken in patients aged 4-60 years to assess the efficacy of penicillin V on the clinical course and bacteriological response in patients with sore throat in general practice. METHOD: Two hundred and thirty-nine patients presenting with an acute sore throat to 37 general practices in the Netherlands who were clinically suspected of group A beta-haemolytic streptococci (GABHS) were randomized for treatment with penicillin V (n = 121) or placebo (n = 118). Resolution of sore throat, fever and return to daily activities were evaluated by the general practitioner 2 days after the start of treatment and by the patients keeping a diary for 7 days. The result of throat culture after 2 days was evaluated. RESULTS: A difference in resolution of sore throat was present after 2 days in all patients, but was a result of GABHS-positive patients (n = 111; 46%) in favour of those randomized for penicillin V (adjusted odds ratio 5.3; 95% CI 1.9-15.1). An effect in the course of fever was also seen in GABHS-positive patients (adjusted odds ratio 5.3; 95% CI 1.02-27.7). A difference of 1-2 days was seen in clinical recovery. No difference was found in daily activities between the treatment groups. After 2 days, 4% of the penicillin-treated patients harboured GABHS compared with 75% of the placebo group. CONCLUSION: Only GABHS-positive patients benefit from penicillin V in their clinical cure in the first few days. Therefore, rapid testing is necessary. Treatment may be beneficial with regard to the clinical course, but it is not necessary.

Adolescent↗
PubMed1997

Reducing reconsultations for acute lower respiratory tract illness with an information leaflet: a randomized controlled study of patients in primary care.

BACKGROUND: General practitioners (GPs) prescribe antibiotics to three-quarters of patients who consult with a lower respiratory tract illness (LRTi). In spite of this management, around a quarter of patients reconsult for the same symptoms within a month. AIM: To investigate the impact of providing a simple leaflet regarding the natural history of lower respiratory tract symptoms on reconsultation rates for previously well adults presenting to their GP with an LRTi. METHOD: Seventy-six GPs studied 1014 previously well adults presenting with an illness defined as an LRTi. Management was left to the GP's discretion. Half of the patients were randomly allocated to receive an information leaflet at the end of the consultation, blinded from the GP. The endpoint was reconsultation for the same symptoms within one month. RESULTS: Follow-up data was available for 1006 adults, of whom 182 (18%) reconsulted. Fewer patients who received the leaflet (75/505; 14.9%) returned to the surgery compared with those who did not (107/501; 21.4%; P = 0.007). The same benefit was found for the 723 (72%) adults treated initially with antibiotics; 16% (60/369) in the leaflet group returned compared with 23% (81/354) in the no leaflet group (P = 0.02). CONCLUSION: Informing previously well patients about the natural history of LRTi symptoms is an effective strategy for reducing reconsultations, benefiting the patient and the GP; it is likely to reduce antibiotic prescriptions and future patient consultation habits.

Acute Disease↗
PubMed2005

Newer antistaphylococcal agents.

PURPOSE OF REVIEW: As antibiotic resistance in staphylococci continues to evolve, the ability to treat infections in children with confidence using first-generation cephalosporins, penicillins, and macrolides is decreasing. Knowledge of the local trends in resistance is important in making decisions of empiric antibiotic therapy. The antibiotic resistance pattern for the child's pathogen should be assessed whenever possible, to allow the practitioner to properly judge the risks and benefits of alternative antibiotic agents, should they be required for definitive therapy. RECENT FINDINGS: Options for therapy of most methicillin-resistant and macrolide-resistant community-acquired strains of Staphylococcus aureus include vancomycin, linezolid, and, in communities with a high proportion of susceptible strains, clindamycin. Daptomycin, a lipopeptide antibiotic with activity against virtually all strains of S. aureus, was recently approved by the United States Food and Drug Administration for adults. Second-generation glycopeptide antibiotics similar to vancomycin are in clinical trials in adults, including dalbavancin and oritavancin. Several new compounds, including cephalosporins active against methicillin-resistant S. aureus, are in preclinical development as well. SUMMARY: The recent worldwide emergence and rapid spread of community-acquired methicillin-resistant S. aureus has prompted a change in the approach to therapy of staphylococcal infections in both the outpatient clinic and the hospital. Newer agents active against methicillin-resistant S. aureus such as linezolid have been recently approved for children and other agents recently approved for adults are under investigation in children. Older agents for which relatively few data from prospective, controlled, comparative studies exist in the treatment of staphylococcal infections may also offer effective and less costly options for therapy.

Acetamides↗
PubMed2005

Sexually transmitted diseases in Zimbabwe: a qualitative analysis of factors associated with choice of a health care facility.

BACKGROUND: The control of sexually transmitted diseases (STDs) through rapid and effective treatment is critical in reducing the transmission of HIV infection. This is only possible when STD patients access appropriate STD care services. OBJECTIVES: To examine factors associated with choice of STD health care facility in Zimbabwe. METHODS: Focus Group Discussions (FGDs) were used to collect data from the following settings: Antenatal clinics, well baby clinics, long distance bus stops/market places, bars, areas (compounds) behind bars, factory sites and youth clubs. Data from 26 FGDs attended by 281 antenatal clinic attendees, 34 FGDs of 350 women attending well baby clinics, 8 FGDs of 82 women recruited at long distance bus stops/market places, 9 FGDs of 115 sex workers, 11 FGDs of 124 male factory workers, and 5 FGDs of 44 female adolescents belonging to youth clubs were analysed. RESULTS: In total 93 FGDs were held of which 76 (81.7%) took place in urban areas and 17 in rural areas. Asked which health facility they would attend if they had an STD, all the different groups of the population mentioned a local clinic except for sex workers who preferred a hospital or a traditional practitioner, and male factory workers who preferred a factory clinic. Among the factors that would be considered in choosing a health facility were accessibility and affordability (stated by all groups), and privacy/ confidentiality, health care providers' attitudes, caring or professionalism (stated by all groups except male factory workers). CONCLUSION: Although accessibility and affordability were the common factors mentioned by all the groups, it is important to consider group specific factors in the choice of health care facilities.

Adolescent↗
PubMed1993

Descriptive and normative ethics: class, context and confidentiality for mothers with HIV.

This descriptive analysis reports on how institutional imperatives and professional assessments define, constrain, and even override normative claims for confidentiality in health care for mothers with HIV/AIDS. The analysis draws upon interviews with seventy-two health, social work, administrative, research, and advocacy professionals who work with mothers and infants with HIV/AIDS in nine sites in the U.S. and Puerto Rico and upon three analytical focus groups involving multidisciplinary groups of practitioners, lawyers, social scientists, and ethicists. Decisions regarding confidentiality for mothers with HIV/AIDS are likely to be influenced by (1) the relative lack of authority over information flow granted by medical institutions and professionals to patients and (2) professionals' class-based assumptions about mothers' needs for confidentiality and the consequences of withholding or disclosing information. Two normative conclusions for confidentiality practice in health care are drawn from and rooted in the descriptive findings of the research. First, if confidentiality practice is to be an expression of patient autonomy and rights, according to the principles generally held in medical settings, patients' control over information must be increased. Second, to avoid discrimination in the practice of confidentiality, decisions should be based on individual circumstances, not stereotypical generalities about social class.

Acquired Immunodeficiency Syndrome↗
PubMed2004

Effectiveness of a multiple intervention to reduce antibiotic prescribing for respiratory tract symptoms in primary care: randomised controlled trial.

OBJECTIVES: To assess the effectiveness of a multiple intervention aimed at reducing antibiotic prescription rates for symptoms of the respiratory tract in primary care. DESIGN: Randomised controlled trial. SUBJECTS: Twelve peer review groups including 100 general practitioners with their collaborating pharmacists in the region of Utrecht, Netherlands. INTERVENTION: The intervention consisted of group education meetings, with a consensus procedure on indication for and type of antibiotics and with training in communication skills; monitoring and feedback on prescribing behaviour; group education for assistants of general practitioners and pharmacists; and education material for patients. The control group did not receive any of these elements. MAIN OUTCOME MEASURES: Antibiotic prescription rates for acute symptoms of the respiratory tract and patients' satisfaction. RESULTS: 89 general practitioners completed the study (89%). At baseline, prescription rates for antibiotics for respiratory tract symptoms did not differ between intervention and control group (27% v 29%, respectively). After nine months, the prescription rates in the intervention group fell to 23%, whereas the control group's rose to 37% (mean difference in change -12%, 95% confidence interval -18.9% to -4.0%). Multilevel analysis confirmed the results of the unadjusted analysis (intervention effect -10.7%, -20.3% to -1.0%). Patients' satisfaction was high and did not differ in the two groups at baseline or after the intervention. CONCLUSIONS: A multiple intervention reduced prescribing rates of antibiotics for respiratory tract symptoms while maintaining a high degree of satisfaction among patients. Further research should focus on the sustainability and cost effectiveness of this intervention.

Adult↗
PubMed1996

Diagnosing latent and active pulmonary tuberculosis: a review for clinicians.

Tuberculosis (TB) is once again a major public health concern. Primary care providers play a key role in controlling its spread, both by case-finding patients with active TB and providing preventive therapy to persons at high risk for developing it. This article describes the natural history and different stages of illness (latent infection, active disease, and old healed disease) in terms of direct implications for management. Diagnostic tools are examined in detail. Pitfalls in administration and interpretation of tuberculin skin tests are reviewed, including the factors that may cause false-negative and false-positive readings. Radiographic findings are explained and illustrated. Sputum analysis is discussed in detail in terms of specimen collection, laboratory methodologies for performing smears and cultures, and their respective specificity and sensitivity. A basic approach to workup and management is also outlined, distinguishing screening from diagnosis and emphasizing how to identify those persons at greatest risk for TB.

Acute Disease↗
PubMedDate not supplied

Hand-to-hand combat: Preventing MRSA infection.

PURPOSE: To provide practitioners with a general overview of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) and hospital-acquired methicillin-resistant Staphylococcus aureus (HA-MRSA) and their diagnoses and treatment. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in preventing, diagnosing, and treating MRSA infection. OBJECTIVES: After reading this article and taking the test, the participant should be able to: 1. Discuss the microbiology, demographics, and epidemiology of CA-MRSA and HA-MRSA. 2. Explain the diagnosis, treatment, and preventative care associated with MRSA infections.

Algorithms↗
PubMed2003

[Incidence and clinical characteristics of maculopapular exanthemas of viral aetiology].

OBJECTIVE: To estimate the incidence of maculo-papular viral exanthemas and to describe the epidemiological and clinical patterns. DESIGN: Observational descriptive study with a sample design. PARTICIPANTS AND SETTING: 154 practitioners from the Castilla y León Sentinel Network with a surveilled population of 23 237 people-year under 15 years old, notified in 2002 the cases of diseases by means of a standard form with the variables and inclusion and exclusion criteria. MAIN MEASUREMENTS: It was included the maculo-papular exanthemas associated to a presumable systemic virus disease in patients under 15 years old. It was excluded the infectious mononucleose, the chickenpox, and other non viral infections or exanthemas. RESULTS: 368 cases were notified which represent a incidence rate of 158.37 cases per 10 000 (95% CI, 142.31-174.42). The incidence was maximum under four years old, more than 350 per 10 000, decreasing significantly in children over this age. Erythema infectiousum presented the highest rate, followed by exanthema subitum. The exanthemas caused by measles or rubella were insignificants. CONCLUSIONS: Childhood exanthematous diseases of presumable viral etiology have an important incidence in primary care, although the majorities are banal and self-limited diseases. Clinical characteristics supported the suspicion diagnosis, which was consistent with the observed epidemiological description and expected presentations of each disease. Although serological analysis could diminish the uncertainly on notification and control of diseases submited to especial programs of vaccination and eradication, they would not improve substantially the diagnosis and treatment of these patients.

Adolescent↗
PubMed2001

[Geriatric problems seen in general practice in patients in nursing homes].

The general practitioner meets in long stay geriatrics polypathologic and frail patients. He is confronted with many problems: Staphylococcus aureus resistant to the methylpenicilline, ulcers of pressure, pain, depression, dementia, falls, etc. He will remain vigilant with ill-treat and the disorders of the nutrition. The communication will be improved by the use of validated scales. The nomination of a doctor coordinator will have to help to promote global geriatric assessment. The demography will involve the number of old patients. Sufficient financial means will have to be released in order to allow everyone to receive care of quality.

Activities of Daily Living↗