Self-reported prevalence of warts in children and GP consultation

Objective: Respiratory infections are a frequent causes of medical attendance. Influenza viruses increases this phenomena. The aim of this study was to prospectively identify GPs’ increased work in terms of visits and time. Methods: Over a period of five months 5 GPs recorded sex, age, number and place of visits, telephone consultations of the patients visited for acute respiratory disease (ARD)which included acute respiratory infections (ARI), influenza (FLU) and Influenza-like illness (ILI). Upper respiratory tract infections (URTI) were classified as sinusitis, rhinitis, otitis, tonsillitis, pharyngitis, laryngitis, Lower respiratory tract infections (LRTI) were classified as tracheitis, bronchitis, pneumonia, bronchopneumonia, acute episodes of chronic obstructive pulmonary disease (COPD) and asthma. FLU and ILI were considered two different entities on the basis of symptoms. Results: Acute respiratory disease increase of 22 patients attending every GP's office monthly (from 176 to 198 total visits). 6542 patients were observed. The incidence of ARD was 33.5% (2191: 1091 female and 1100 males). URTI affected 944 patients, LRTI 739, FLU 328 and ILI 180. The increase in home visits grew from 10 to 36. Each home visit took from 15 to 45 minutes. In a high number of cases (236), home visits were necessary for sick-leave certificates. FLU (54%) and LRTI (37.5%) required more attention, and they were the primary causes for visits. Telephone consultations took place for all ILI or FLU of minor severity and in young people.

Conclusion: During the winter there is an increased work-load for GPs due to the diffusion of influenza virus and respiratory tract diseases. “Burn out syndrome” is increasing among the GPs. Territorial GPs’ action is highly efficacious. Patients self-certification should be evaluated. Vaccine therapy could be more effective if done on a larger population. More research is needed.     

Calling acute bronchitis a chest cold may improve patient satisfaction with appropriate antibiotic use

BACKGROUND: Overuse of antibiotics for acute respiratory infections is an important public health problem and occurs in part because of pressure on physicians by patients to prescribe them. We hypothesized that if acute respiratory infections are called "chest colds" or "viral infections" rather than "bronchitis," patients will be satisfied with the diagnosis and more satisfied with not receiving antibiotics. METHODS: Family medicine patients were presented with a written scenario describing a typical acute respiratory infection where they were given one of 3 different diagnostic labels: chest cold, viral upper respiratory infection, and bronchitis, followed by a treatment plan that excluded antibiotic treatment. Data was analyzed for satisfaction with the diagnosis and treatment plan based on the diagnostic label. A total of 459 questionnaires were collected. RESULTS: Satisfaction (70%, 63%, and 68%) and dissatisfaction (11% 13%, and 13%) with the diagnostic labels of cold, viral upper respiratory infection, and bronchitis, respectively, showed no difference (chi(2) = 0.368, P = .832). However, more patients were dissatisfied with not receiving an antibiotic when the diagnosis label was bronchitis. A total of 26% of those that were told they had bronchitis were dissatisfied with their treatment, compared with 13% and 17% for colds and viral illness, respectively, (chi(2) = 9.380, P = .009). Binary logistic regression showed no difference in satisfaction with diagnosis for educational attainment, age, and sex (odds ratio (OR) = 1.09, 1.00, 0.98, respectively), or for satisfaction with treatment (OR = 1.1, 1.02, 1.00, respectively). CONCLUSIONS: Provider use of benign-sounding labels such as chest cold when a patient presents for care for an acute respiratory infection may not affect patient satisfaction but may improve satisfaction with not being prescribed an antibiotic.     

Is co-morbidity taken into account in the antibiotic management of elderly patients with acute bronchitis and COPD exacerbations?

BACKGROUND: Guidelines on acute lower respiratory tract infections recommend restrictive use of antibiotics, however, in patients with relevant co-morbid conditions treatment with antibiotics should be considered. Presently, it is unknown whether GPs adhere to these guidelines and target antibiotic treatment more often at patients with risk-elevating conditions. OBJECTIVES: We assessed whether in elderly primary care patients with acute bronchitis or exacerbations of chronic pulmonary disease (COPD), antibiotics are more often prescribed to patients with risk-elevating co-morbid conditions. METHODS: Using the Utrecht GP research database, we analysed 2643 episodes in patients of 65 years of age or older with a GP-diagnosed acute bronchitis or exacerbation of COPD. Multivariable logistic regression analysis was applied to determine independent determinants of antibiotic use. RESULTS: Antibiotic prescribing rates were high in both acute bronchitis (84%) and in exacerbations of COPD (53%). In acute bronchitis, only age was an independent determinant of antibiotic use [odds ratio (OR) 1.03, 95% confidence interval (CI) 1.003-1.048], whereas in exacerbations of COPD antibiotics were more often prescribed to male patients (OR 1.3, 95% CI 1.0-1.5), patients with diabetes (OR 1.7, 95% CI 1.1-2.4) and heart failure (OR 1.3, 95% CI 1.0-1.7). CONCLUSION: Dutch GPs prescribe antibiotics in the majority of elderly patients with acute bronchitis and in half of the episodes of exacerbations of COPD. Tailoring their antibiotic treatment according to the presence or absence of high-risk co-morbid conditions could help GPs in improving antibiotic use in patients with respiratory tract infections in primary care.     

Does acute bronchitis really exist? A reconceptualization of acute viral respiratory infections

BACKGROUND: Considerable overlap exists in patient presentations and physical findings in viral upper respiratory tract infections (URIs) and acute bronchitis. Our goal was to determine whether there are any clinical cues that could help physicians differentiate between these 2 conditions. METHODS: We performed a retrospective chart audit on 135 patients who had been given a diagnosis of acute bronchitis and a random sample of 409 patients with URIs over a 2.5-year period. Patient and provider characteristics, patient symptoms, and physical findings were compared with bivariate analyses and then entered into a logistic regression model. RESULTS: In bivariate analyses, a number of demographic variables, symptoms, and signs were associated with acute bronchitis. Multivariate analysis showed that the strongest independent predictors of acute bronchitis were cough (adjusted odds ratio [AOR]=21.12; 95% confidence interval [CI], 6.01-74.26), and wheezing on examination (AOR=12.16; 95% CI, 5.39-27.42). Nausea was the strongest independent predictor that the diagnosis would not be acute bronchitis (AOR=0.01; 95% CI, 0.01-0.85). However, there was considerable overlap between the 2 conditions, and the logistic model explained only 37% of the variation between the diagnoses. CONCLUSIONS: We hypothesize that sinusitis, URI, and acute bronchitis are all variations of the same clinical condition (acute respiratory infection) and should be conceptualized as a single clinical entity, with primary symptoms related to different anatomic areas rather than as different conditions.     

Clinical features and treatment of acute bronchitis

Although several surveys rank acute bronchitis as one of the ten most frequent diagnoses made by primary care physicians, its clinical features are poorly defined and treatment with antibiotics is controversial. This study was designed to determine the clinical characteristics that providers use to diagnose acute bronchitis and to examine the use of antibiotics in treating this illness. Charts of patients with the diagnosis of acute bronchitis or upper respiratory tract infection (URI) were randomly selected and progress notes from these visits were reviewed. Signs, symptoms, laboratory tests, and antibiotics prescribed were recorded. Patients with a diagnosis of acute bronchitis had more productive cough, purulent sputum, and abnormal lung examinations than patients with a diagnosis of URI (P less than .05 for each characteristic). Laboratory tests, including chest roentgenograms, were not frequently used in making the diagnosis of acute bronchitis. Antibotics were prescribed for 27 of 29 patients (92 percent) with a diagnosis of acute bronchitis but for only 4 of 19 patients (21 percent) with a diagnosis of URI. Erythromycin was prescribed for 60 percent of patients with acute bronchitis. From this study it can be concluded that providers use the term acute bronchitis to designate a specific clinical syndrome that they treat with antibiotics. Further clinical trials are needed to evaluate the efficacy of such antibiotic therapy.     

The practice guideline 'Acute cough' from the Dutch College of General Practitioners; a response from the perspective of general practice

The practice guideline 'Acute cough' from the Dutch College of General Practitioners stresses the fact that a cough of less than 3 weeks' duration seldom heralds serious pathology. However, for sound reassurance of patients presenting with a cough of short duration, the general practitioner needs to know much about the signs and symptoms connected to low-prevalence serious pathology in these patients. The practice guideline distinguishes upper and lower respiratory tract infections and defines serious lower respiratory tract infection. The diagnostic value of symptoms and laboratory findings like a sedimentation rate or C-reactive protein in order to make such distinctions, is not explained in detail. Antibiotics are reserved for serious lower respiratory tract infection with the exception of acute bronchitis, croup and bronchiolitis, which can be treated without antibiotics. Recommendations for treatment of acute bronchiolitis with bronchodilators or corticosteroids, and croup with corticosteroids are based on consensus. This practice guideline can be considered as a clear and valuable piece of work for all physicians in primary and secondary care.     

Definition of low respiratory tract infections

Lower respiratory tract infection is easily suggested on clinical signs (cough and sputum) associated with fever. To discriminate between pneumonia and acute bronchitis is crucial because of the mortality associated with pneumonia and of its specific management. Chest X-ray is a key exam for the diagnosis and should be performed on the basis of validated clinical signs that are however of weak diagnostic value. Clinical as well as radiological signs cannot be reliably used to identify the causative germ. Sputum examination, the search for pneumococcal and legionella urinary antigens are of good diagnostic value. An associated COPD may lead to an acute respiratory failure. Acute exacerbation of chronic bronchitis results from various causes but infection is involved in about 50% of the cases, mostly viral and most often due to a rhinovirus. Viral infection can be associated to bacterial infection and the most frequently isolated germs are Streptococcus pneumoniae, Haemophilus influenzae, and B. catarrhalis. Severity assessment relies on the value of basal FEV1 that is often non available. Therefore Afssaps suggests using a dyspnea index to assess exacerbation severity.     

Improving quality or shifting diagnoses? What happens when antibiotic prescribing is reduced for acute bronchitis?

BACKGROUND: A quality improvement project in an academic practice demonstrated a reduction in antibiotic prescribing for acute bronchitis. However, it was unclear whether this represented a reduction in antibiotic use or whether physicians assigned new diagnoses to the same patients to avoid scrutiny and continue to use antibiotic therapy. OBJECTIVE: To examine whether a substantial amount of diagnostic shifting occurred while antibiotic prescribing for acute bronchitis decreased during a 14-month period (from January 1, 1996, to February 28, 1997). METHODS: All patient diagnoses of acute bronchitis, acute sinusitis, upper respiratory tract infection, and pneumonia were determined for the 14 months of the acute bronchitis intervention. The relative distribution of patients among these 4 diagnostic categories was compared to determine if the percentage of patients with acute bronchitis decreased while those with acute sinusitis and pneumonia increased during the acute bronchitis intervention. RESULTS: The percentage of patients with the diagnosis of acute bronchitis remained unchanged during the 14-month period while antibiotic use for this condition decreased from 66% of cases to less than 21% of cases. Instead of the patients being assigned a different diagnosis such as acute sinusitis so that antibiotic prescribing would not be scrutinized, as we hypothesized, the relative number of diagnoses for acute sinusitis compared with acute bronchitis actually declined during the 14 months. No change was noted in the relative frequency of acute bronchitis cases compared with pneumonia cases. CONCLUSION: During a 14-month period when an intervention was successful at reducing antibiotic use for acute bronchitis, there was no evidence that physicians shifted patients from the diagnosis of acute bronchitis to other diagnoses.     

Pandemic (H1N1) 2009 infection in patients with hematologic malignancy

To assess outcomes of patients with hematologic malignancy and pandemic (H1N1) 2009 infection, we reviewed cases during June-December 2009 at the University of California San Francisco Medical Center. Seventeen (63%) and 10 (37%) patients had upper respiratory tract infection (URTI) and lower respiratory tract infection (LRTI), respectively. Cough (85%) and fever (70%) were the most common signs; 19% of patients had nausea, vomiting, or diarrhea. Sixty-five percent of URTI patients were outpatients; 35% recovered without antiviral therapy. All LRTI patients were hospitalized; half required intensive care unit admission. Complications included acute respiratory distress syndrome, pneumomediastinum, myocarditis, and development of oseltamivir-resistant virus; 3 patients died. Of the 3 patients with nosocomial pandemic (H1N1) 2009, 2 died. Pandemic (H1N1) 2009 may cause serious illness in patients with hematologic malignancy, primarily those with LRTI. Rigorous infection control, improved techniques for diagnosing respiratory disease, and early antiviral therapy can prevent nosocomial transmission and optimize patient care.     

Lower incidence of the upper respiratory tract infections among general practitioners as compared to their patients

A retrospective cohort study suggest that general practitioners (GPs) run a significant reduced risk (more then 50%) to develop an upper respiratory tract infection (URTI) with fever compared to their patients. This difference can't be explained by variables such as gender, age, children and particularly young children, vaccination against influenza, presence of chronic illness or allergies, medication taken on a regular basis, smoking habits and regular physical exercise.     

肺炎支原体诊断试剂盒在诊断呼吸道感染患儿中的价值

目的:了解住院患儿呼吸道肺炎支原体(MP)感染的疾病种类及其分布,探讨Serodia-MycoⅡ(简称MycoⅡ)试剂盒检测MP-IgM的应用价值。方法:用肺炎支原体抗体检测试剂盒MycoⅡ做微粒凝集试验,对疑诊MP感染的患儿尤其呼吸道MP感染的患儿,进行血清MP特异性抗体IgM检测。结果:353例MP-IgM阳性者中以呼吸道感染为主诉的334例(94.62%),占同期住院呼吸道感染的20.07%。10例于起病早期MP-IgM阴性,1周后动态检测转阳性。呼吸道MP感染的疾病种类和构成比依次为急性支气管炎58.98%、上呼吸道感染(简称上感)30.84%、支气管肺炎6.59%、支气管哮喘3.59%,上述病种占同期住院患儿同病种的比例分别为29.62%、14.39%、15.07%、8.76%。结论:小儿呼吸道MP感染在小儿呼吸道感染中发生率较高,以上呼吸道感染、急性支气管炎多见;MycoⅡ试剂盒检测血清MP-IgM简便快捷,敏感性及特异性较高,值得临床推广;对于高度疑诊MP感染的患儿可动态检测MP-IgM,抽血检测时间最好在起病1周后,必要时可提前至起病4～6天,以提高阳性率。     

基于医疗大数据的流感人群患病情况分析

目的对上海市健康网中2016-2017年医疗机构门急诊期间,经国际疾病分类法(ICD10)诊断编码为J11(流行性感冒)的6651名患者,追踪其在2013-2018年间的门急诊记录,进行患病情况分析。方法采用Apriori算法对上述患者的罹患疾病进行关联分析。结果流感患者年龄分布无显著差异,疾病分类统计显示呼吸道疾病和慢性非传染性常见疾病占多数。Apriori算法结果显示,患急性上呼吸道感染的患者占总流感患者的50.97%;患者罹患急性上呼吸道感染、支气管炎和患急性上呼吸道感染、肺炎支原体急性支气管炎概率达40.51%;患者患急性上呼吸道感染、支气管炎和肺炎支原体急性支气管炎的概率为10.43%。结论流感患者中,中青年占比高,应加强社会流感预防知识普及。医疗大数据的共享应用作为公共卫生监测工作的适当补充,是实现精准预防的可行方向。     

Predictors of an antibiotic prescription by GPs for respiratory tract infections: a pilot

BACKGROUND: Antibiotics are over-prescribed for respiratory tract infections in Australia. OBJECTIVES: The aim of this study was to describe the clinical predictors of GPs' prescribing of antibiotics. METHODS: We used Clinical Judgment Analysis to study the responses of GPs to hypothetical paper-based vignettes of a 20-year-old with a respiratory tract infection. The nature of four symptoms and signs (colour of nasal mucous discharge; soreness of the throat; presence of fever; and whether any cough was productive of sputum) was varied and their effect on prescribing measured using logistic regression. RESULTS: Twenty GPs participated. The nature of each symptom and sign significantly predicted prescribing of an antibiotic. Cough productive of yellow sputum; presence of sore throat; fever; and coloured nasal mucus increased the probability of an antibiotic being prescribed. CONCLUSIONS: GPs are influenced by clinical signs and symptoms to use antibiotics for respiratory infections for which there is poor evidence of efficacy from the literature.     

Validation of the diagnosis of childhood morbidity using maternal health interviews

The diagnosis of childhood illness by maternal health interview surveys is widely used to estimate the prevalence of childhood morbidity in developing countries. To determine the validity of interview-based diagnoses, and to define simple, sensitive and specific diagnostic algorithms, we compared symptoms and signs reported by mothers during structured interviews with physicians' diagnoses for 271 children on the Philippine island of Cebu. The 271 children had 318 physician diagnosed illnesses: 105 acute lower respiratory infections (ALRI), 121 diarrhoeas, 36 measles, 50 upper respiratory infections (URTI), 5 roseola infantums and one milaria rubria. An algorithm for measles (age greater than or equal to 120 days, rash and fever greater than or equal to 3 days and fading of rash) had a sensitivity and specificity of 94%. For ALRI an algorithm of cough, dysponea and fever had a sensitivity of 82%, but specificity was lower in comparison with URTI (58%) than with children who had no respiratory illness (79%). Inclusion of signs of respiratory distress (flaring of nostrils, intercostal retraction) raised the specificity to 83-84%, but reduced sensitivity to 68%. Diagnosis of diarrhoea based on frequent loose or liquid stools had a sensitivity of 95-97% and specificity of 80% in children with or without concomitant non-diarrhoeal illnesses. Addition of questions on numbers of stools (greater than or equal to 6 per day), and no signs of dehydration increased specificity to 95% but reduced the sensitivity to 84-86%. However, specific signs of dehydration were not well reported by the mothers.(ABSTRACT TRUNCATED AT 250 WORDS)     

儿童急性呼吸道感染578例病毒检测分析

目的 了解三门峡地区儿童急性呼吸道感染(ARI)的病毒病原学构成,指导临床诊断与治疗。方法 采集578例ARI住院患儿的鼻咽拭子,采用直接免疫荧光法检测7种病毒即呼吸道合胞病毒(RSV)、腺病毒(ADV)、副流感病毒Ⅰ、Ⅱ、Ⅲ(PIVⅠ～Ⅲ)、流感病毒A、B型(IVA、IVB)。结果 儿童ARI的病毒总检出率为61.59%,混合感染占45.22%。病毒总检出率冬季最高(77.35%)、夏季最低(25.00%)。下呼吸道感染的病毒总检出率高于上呼吸道感染。RSV、PIVⅢ、IVA的检出率位居前三位,分别为30.62%、28.89%、21.97%。RSV及PIVⅢ在秋冬季、下呼吸道感染、3岁以下患儿中检出率较高;IVA在冬季、上呼吸道感染患儿中检出率较高。结论 RSV 、PIVⅢ、IVA是三门峡地区儿童急性呼吸道感染的主要病毒病原。RSV 、PIVⅢ是秋冬季节婴幼儿下呼吸道感染的主要病原;IVA是冬季各年龄患儿上呼吸道感染的主要病原。通过检测儿童ARI的病毒病原,对尽早明确病毒病原,避免滥用抗生素具有重要意义。     

急性呼吸道感染性疾病监测研究

用病史前瞻性研究方法，于１９９１年４月至１９９２年３月对平邑县和高密县四个自然村的１１６４户４３７９人进行了急性呼吸道感染（ＡＲＩ）性疾病监测。共监测４３６５．９２人年，发病率为０．４５４２次／人年，无死亡病例，户发病率６８．９９％，各村发病率０．３７００～０．６３１２次／人年。共监测１８种疾病，以普通感冒、上呼吸道感染、支气管炎发病率最高，具有明显的家庭聚集性。难产、低出生体重、发育差、营养差、吸烟、文盲、人均年收入低、居室通凤差、居室采光差、居住条件差等是与ＡＲＩ发病有关的危险因素。     

Why are antibiotics prescribed for patients with acute bronchitis? A postintervention analysis

BACKGROUND: Despite the findings in controlled trials that antibiotics provide limited benefit in the treatment of acute bronchitis, physicians frequently prescribe antibiotics for acute bronchitis. The aim of this study was to determine whether certain patient or provider characteristics could predict antibiotic use for acute bronchitis in a system where antibiotic use had already been substantially reduced through quality-improvement efforts. METHODS: A retrospective chart review was performed in an academic family medicine training center that had previously instituted a quality-improvement project to reduce antibiotic prescribing for acute bronchitis. Patients who had acute bronchitis diagnosed during an 18-month period and who had no other secondary diagnosis for respiratory distress or a condition that would justify antibiotics were selected from a computerized-record database and included in the study (n = 135). Charts were reviewed to document patient symptoms, physical findings, provider and patient characteristics, and treatment. RESULTS: Thirty-five (26%) patients received antibiotics for their acute bronchitis. Adults were more likely to receive antibiotics than children (34% vs 3%, P < .001). Analysis of 20 different symptoms and physical findings showed that symptoms and signs were poor predictors of antibiotic use. Likewise, no significant differences were found based on prescribing habits of individual providers or provider level of training. CONCLUSION: In a setting where antibiotic use for acute bronchitis had been decreased through an ongoing quality-improvement effort, it did not appear that providers selectively used antibiotics for patients with certain symptoms or signs. Other factors, such as nonclinical cues, might drive antibiotic prescribing even after clinical variation is suppressed.