Pivmecillinam versus sulfamethizole for short-term treatment of uncomplicated acute cystitis in general practice: a randomized controlled trial.

OBJECTIVE: To investigate whether short-term treatment with pivmecillinam was more effective than sulfamethizole in patients with acute uncomplicated urinary tract infection (UTI). DESIGN: Randomized controlled trial. SETTING: General practice, Denmark. SUBJECTS: Patients (n = 167) with uncomplicated UTI confirmed by positive urine phase-contrast microscopy. MAIN OUTCOME MEASURES: Drug efficacy based on clinical and bacteriological cure. RESULTS: Urinary symptoms disappeared first in patients treated with pivmecillinam, but after five days there was no significant difference in clinical cure rate between the two antibiotics. At the follow-up visit 7-10 days after initiation of treatment, 95.4% of patients treated with pivmecillinam and 92.6% of patients treated with sulfamethizole had no persistent cystitis symptoms (difference 2.8%, CI -4.5%; 10.0%). Bacteriological cure was observed in 68.8% of patients randomized to pivmecillinam and in 77.9% randomized to sulfamethizole (difference -9.2%, CI -24.7%; 6.3%). Some 26.8% of patients randomized to pivmecillinam experienced a new UTI within 6 months after treatment compared with 18.4% of patients randomized to sulfamethizole (difference 8.4%, CI -4.5%;21.4%). No patients developed septicaemia with urinary pathogens within one year after initial treatment. CONCLUSION: Patients treated with a three-day regime of pivmecillinam experienced faster relief of symptoms compared with patients treated with a three-day regime of sulfamethizole. Five days after initiation of treatment there was no significant difference in clinical and bacteriological cure between the two antibiotic regimes.

[Fewer readmissions of schizophrenic patients who have contact with their own GP]. / Faerre genindlaeggelser af patienter med skizofreni med kontakt til egen laege.

INTRODUCTION: The object of the study was to investigate to which extent the GP is part of the follow-up treatment of schizophrenic patients after their discharge from a psychiatric department. MATERIAL AND METHODS: During a period of one year, 96 schizophrenic patients were discharged and the patients' GP subsequently answered a questionnaire at six and 12 months after the discharge. The questionnaire, which was completed by 37 practices, contained information as to whether the GP had had any contact with the patients concerned and which services the patient had received. Furthermore, register information concerning the admission pattern during the first 12 months after discharge were obtained. RESULTS: The majority (73,9%) of the patients had contact with their own GP after discharge, and they had the same number of visits as the background population. The visits primarily concerned somatic problems; however, approximately 25% of the patients had psychiatric problems as the major subject of their visit. Significantly fewer of the patients who had contact with their GP were re-admitted to hospital compared with patients who had no contact with their GP, and patients with contact had needed significantly fewer bed-days at 12 months after discharge than the patients without contact to their GP. After adjustment for prognostic factors the differences remained significant. CONCLUSION: An increased shared care between the GP and the psychiatric system in connection with the treatment of patients with chronic mental disorders may reduce re-admittance and relapse and thus improve the prognosis for this group of patients.

Stability of heparin blood samples during transport based on defined pre-analytical quality goals.

BACKGROUND: In many countries and especially in Scandinavia, blood samples drawn in primary healthcare are sent to a hospital laboratory for analysis. The samples are exposed to various conditions regarding storage time, storage temperature and transport form. As these factors can have a severe impact on the quality of results, we wanted to study which combination of transport conditions could fulfil our pre-defined goals for maximum allowable error. METHODS: Samples from 406 patients from nine general practitioners (GPs) in two Danish counties were sent to two hospitals for analyses, during two periods (winter and summer). Transport conditions (mail, courier pick-up, or brought to hospital by public coach), storage time, storage temperature and centrifugation requirements were different in the two counties. Results were tested for deviation from a "0-sample", the blood sample taken, centrifuged and separated at the doctor's office within 45-60 min. This sample was considered as the best estimate of a comparison value. RESULTS: The pre-set quality goals were fulfilled for all the investigated components for samples transported to hospital by courier either as whole blood or as "on gel" after centrifugation, as long as the samples were stored at 20-25 degrees C and centrifuged/analysed within 5-6 h. A total of 4% of the samples sent by mail had mismatched identity, probably due to plasma being transferred to a new tube. CONCLUSIONS: Samples can be sent as unprocessed anticoagulated whole blood if the above mentioned conditions are met. There is no need for centrifugation in the primary sector. Neither mailing of samples with plasma "on gel" nor public transport by coach bus fulfil our analytical goals.

[Symptoms and diagnostic work-up in breast cancer]. / Symptomer og diagnostik.

Symptoms from the breast leading to suspicion of breast cancer are very common. The present review gives guidelines for a rational diagnostic strategy for women with breast symptoms. The triple assessment based on clinical examination, imaging by mammography and ultra sonography, and biopsy is central to the diagnostic work-up. The triple assessment should be performed in the integrated diagnostic system to ensure fast diagnosis and a low rate of inconclusive results. The principles of the triple-test can be deviated from in women under 25 years since breast cancer is extremely rare in this age group. Imaging is not mandatory among older women with clinically obvious cancer verified with biopsy. Breast lumps in men is rarely cancer, and imaging does not contribute to diagnostics.

[Allergology in Denmark 2006]. / Allergologi i Danmark 2006.

Allergic diseases are prominent, possibly life threatening, and a cause of worldwide concern. Evidence-based education of doctors in the specialty of allergology is a prerequisite for correct diagnosis and treatment of patients with allergic diseases. Recently, the specialty of allergology has been abolished in Denmark, without any upgrading of the education of doctors in related specialties. As a consequence, one could fear that allergy expertise will be disappearing. We propose collaboration among experts from related specialties with joint mediation of knowledge through a centre of allergology, common educational programs for doctors in training and physician specialists, and collaboration in regional centres of allergology.

[Infection Control in primary health care]. / Infektionshygiejne i laegepraksis.

Infection control in primary health care Infection control in primary health care is underreported and often underestimated. Cross contamination can happen by indirect contact, and general hygienic precautions should be established in all procedures where HCWs are at risk of contact with organic material. This article suggests infection control measures that can be established in primary health care regarding hand hygiene, cleaning and reprocessing of utensils.

[Skin prick tests of patients with hay fever carried out in general practices compared with those carried out in a specialist outpatient clinic]. / Priktest af patienter med høfeber i almen praksis sammenlignet med i specialambulatorium.

INTRODUCTION: The aim of our study was to assess whether general practitioners and their staff (practices) who had attended a short CME course with technical instruction in the skin prick test could diagnose and treat unselected patients with allergic rhinoconjunctivitis at the same quality level as the allergy outpatient clinic. MATERIAL AND METHODS: We performed a multicentre study with the participation of 38 general practices and the Allergy Centre at Odense University Hospital (OUH). After a two-day course for the general practitioner and his practice staff, every practice performed a skin prick test on 10 consecutive adult patients with symptoms of allergic rhinoconjunctivitis during the spring and summer. A standardised questionnaire was also filled in and sent to the Allergy Centre, where the patient subsequently had another skin prick test carried out. The results of the tests were determined in duplicate and then compared. RESULTS: No significant differences in the quality of the skin prick test for 10 allergens or histamine control were found between the general practice and the Allergy Centre. Discordant results were found in 9%, i.e., a positive result either at the practice or the Allergy Centre, but not at both. CONCLUSION: After a training course, general practitioners and their staff are fully able to perform and validate skin prick tests for inhalation allergens.

[Screening for cervical cancer in the county of Funen. Status of 25 years of development and experiences]. / Screening for livmoderhalskraeft i Fyns Amt. 25 års udvikling og erfaring.

INTRODUCTION: Since 1979 screening against cervical cancer has been conducted in the County of Funen. In the period 1979-1988 the screening against cervical cancer was opportunistic, where women aged 25-55 years had a PAP-smear taken once a year by their GP or gynaecologists at the hospitals. In this period the coverage was only about 50% and the number of cervical cancer was not decreasing as seen in Counties with organised screening programmes. Since 1989 the screening has been organised in the County of Funen, which will be described in the following, including updating and quality improvements such as implementation of liquid based cytology and semiautomated screening (ThinPrep Imaging System, Cytyc). MATERIAL AND METHOD: The programme is based on an automated call-recall system designed to invite women aged 23-59 years. The offer is free of charge and the PAP-smears are taken by the general practitioners. All cervical cytological samples from the County are processed and screened at the Department of Pathology Odense University Hospital. Since 2001 the liquid based technique, ThinPrep-Paptest, has been used, and from 2004 an assisted screening (ThinPrep Imaging System) has been implemented in the routine screening. RESULTS: Switching from opportunistic to organised screening and implementation of liquid based cytology has resulted in a reduction in the number of samples, about 6,500 per year. The diagnostic quality has increased; the number of incidences of cervical cancer was reduced from 62 in 1988 to 18 in 2004 and the mortality from 29 in 1988 to 12 in 2001. CONCLUSION: Since implementation of the organized screening programme and later of the liquid based cytology the coverage and diagnostic quality have increased. The incidence and mortality of cervical cancer have decreased.

[Quality improvement of referrals from practising physicians. An example of a practicable strategy]. / Kvalitetsforbedring af henvisninger fra praksissektoren. Et eksempel på en brugbar strategi.

INTRODUCTION: Referrals from practising physicians to hospital departments are of varying quality. This increases the risk of inappropriate or even incorrect patient treatment courses. We examined the quality of referrals to a large department of nuclear medicine before and after initiatives aimed at improving the information and feedback to the practising physicians. MATERIALS AND METHODS: An evaluation of the quality of referrals (n = 579) from praticising physicians to the Department of Nuclear Medicine, Odense University Hospital, Denmark, recorded during two periods of three months each before and after (1) publication of a referral guideline and (2) a feedback response to those physicians whose referrals were insufficient. A general practitioner (GP) and a specialist in nuclear medicine (NM) judged independently whether the referrals were good, acceptable or unacceptable. RESULTS: During the two periods, 281 and 298 referrals were received, respectively. Of these, 37% and 27%, respectively, were from practising specialists (PSs). After intervention, 23% more referrals were received from GPs, and the share of "good" referrals also increased (before/after: 48%/72% (GP), 61%/84% (NM)). In contrast, there was a 23% decrease in referrals from PSs, whereas the share of "good" referrals remained unchanged or increased (before/after: 64%/66 % (GP), 64%/96% (NM)). In addition, there was a change in the referral pattern from both GPs and PSs. CONCLUSION: Relatively simple and inexpensive intervention caused an increase in the number and quality of referrals from GPs and a fall in referrals from PSs without an obvious improvement in quality.

[Quality control of whole-body bone scintigraphy. Patient surveys]. / Kvalitetsudvikling af helkropsknogleskintigrafi. Patientundersøgelser.

INTRODUCTION: The quality of health care is but sparsely elucidated; surveys of complete patient courses hardly exist. We established and used benchmarks for a major nuclear medicine examination: whole-body bone scintigraphy. MATERIALS AND METHODS: The study material included 458 out of 512 consecutive examinations. Patients were referred by general practitioners (12%), practising specialists (16%) and hospital departments (72%). The survey dealt with waiting times and information provided, as judged by the patient, the referring physician and the Department of Nuclear Medicine (DNM) in relation to referrals, reporting and the passing on of the results to the patient. The DNM judged the quality of the examinations, and the referring physician assessed the implications for diagnosis and treatment. RESULTS: In 10% of the cases, the patient felt that the waiting time was unsatisfactory, as the referring physician might take up to 150 days to send the referral and because 11% had, after two months, still not been informed of the examination result. Supplementary tomography was used in 38 examinations (8%); of these, only one (3%) provided new evidence. Based on the examination results, the referring physician could make a diagnosis and/or wanted to change management for 61% of patients. CONCLUSION: Referrals were delayed mainly by the referring physicians, who often forgot to inform their patients of the examination results. Special admissions seldom yielded extra information. The examination result had important clinical implications in almost two thirds of patients.

[Can we rely on the results of urine microscopy and culture when tests are performed in general practice?]. / Kan man stole på urinmikroskopi og dyrkning, der er udført i almen praksis?

INTRODUCTION: Urinary tract infections (UTI) account for 2-5% of consultations in general practice, but only about half the patients with dysuria have significant bacteriuria (> 100,000 bacteria per ml). A microbiological diagnosis can be made by examination of a urine sample, and in Danish family practice the diagnosis of UTI is often reached by a microscopic analysis or a dip-slide culture test. These methods have a high validity when performed in hospital, but we need knowledge about the validity of microbiological urine examinations when performed in general practice. The aim of this study was to validate detection of bacteriuria by urine microscopy and dip-slide culture in general practice. MATERIAL AND METHODS: Urine specimens artificially produced by adding a known quantity of bacteria (Escherichia coli, Proteus mirabilis, Enterobacter cloacae, Staphylococcus epidermidis and Enterococcus faecalis) to sterile urine were sent to 25 general practices for microscopic examination and dip-slide culture. No prior instruction in testing procedure was given. As the gold standard, the results of a standardised culture method performed by skilled laboratory technicians at the Department of Microbiology, University of Southern Denmark, were used. RESULTS: Significant bacteriuria was identified by microscopy with a sensitivity of 95% and a specificity of 83%. The corresponding figures for urine culture were 95% and 96%. The morphology of bacteria was interpreted correctly in 80% of microscopic examinations, and 60% of the bacteria strains were classified correctly in terms of their motility. DISCUSSION: The results of urine microscopy and culture performed in general practice are to be relied on.

[Resistance tests in general practice. Validity can be improved by standardized procedures]. / Resistensbestemmelse i almen praksis. Validiteten kan forbedres ved standardiserede procedurer.

INTRODUCTION: Susceptibility testing of bacteria in urine is one of the commonest laboratory tests in general practice in Denmark. It is quick and easy to perform, but recent studies have shown low validity when the test is performed in general practice. If it is to continue as a diagnostic tool in general practice, its quality should be improved. The aim of this study was to investigate the effect of an intervention to improve the quality of susceptibility testing in general practice. MATERIAL AND METHODS: Twenty-three randomly selected general practices took part in the study. The intervention consisted of visits by laboratory technicians who instructed the practitioners in standardised procedures for susceptibility testing. Before and after the intervention, urine specimens containing monocultures of typical uropathogenic bacteria were sent to the practices. The practitioners performed susceptibility testing by the Sensicult and the Iso-Resagar methods, and the validity of the results before and after the intervention was compared. Results from susceptibility testing at the bacteriological laboratory, Odense University Hospital, were used as the gold standard. RESULTS: The median frequency of correct results increased from 82% to 98% for susceptibility testing by the Sensicult method (p = 0.001) and from 90% to 96% by the Iso-Resagar method (p = 0.05). DISCUSSION: The validity of susceptibility testing in general practice improves when preceded by instruction in standardised procedures.