A doctor at a PHC clinic: A 'must-have' or 'nice-to-have'?

Background. Many patients have their healthcare needs met at primary healthcare (PHC) clinics in KwaZulu-Natal (KZN), without having to travel to a hospital. Doctors form part of the teams at many PHC clinics throughout KZN, offering a decentralised medical service in a PHC clinic. Objectives. To assess the benefit of having a medical doctor managing patients with more complex clinical conditions at PHC clinic level in uMgungundlovu District, KZN. Two key questions were researched: (i) were the patients whom the clinic doctors managed of sufficient clinical complexity that they warranted a doctor managing them, rather than a PHC nurse clinician? and (ii) what was the spectrum of medical conditions that the clinic doctors managed? Methods. Doctors collected data at all medical consultations in PHC clinics in uMgungundlovu during February 2020. A single-page standardised data tool was used to collect data at every consultation. Results. Thirty-five doctors were working in 45 PHC clinics in February 2020. Twenty-six of the clinic doctors were National Health Insurance (NHI)-employed. The 35 doctors conducted 7 424 patient consultations in February. Staff in the PHC clinics conducted 143 421 consultations that month, mostly by PHC nurse clinicians. The doctors concluded that 6 947 (93.6%) of the 7 424 doctor consultations were of sufficient complexity as to warrant management by a doctor. The spectrum of medical conditions was as follows: (i) consultations for maternal and child health; n=761 (10.2%); (ii) consultations involving non-communicable diseases (NCDs), n=4 372 (58.9%) ­ the six most common NCDs were, in order: hypertension, diabetes, arthritis, epilepsy, mental illness and renal disease; (iii) consultations involving communicable diseases constituted 1 745 (23.5%) of cases; and (iv) consultations involving laboratory result interpretation 1 180 (15.9%).Conclusion. This research showed that at a PHC clinic the more complex patient consultations did indeed require the skills and knowledge of a medical doctor managing these patients. These data support the benefit of a doctor working at every PHC clinic: the doctor is a 'must-have' member of the PHC clinic team, offering a regular, reliable and predictable medical service.

A doctor at a PHC clinic: A 'must-have' or 'nice-to-have'?

BACKGROUND: Many patients have their healthcare needs met at primary healthcare (PHC) clinics in KwaZulu-Natal (KZN), without having to travel to a hospital. Doctors form part of the teams at many PHC clinics throughout KZN, offering a decentralised medical service in a PHC clinic. OBJECTIVES: To assess the benefit of having a medical doctor managing patients with more complex clinical conditions at PHC clinic level in uMgungundlovu District, KZN. Two key questions were researched: (i) were the patients whom the clinic doctors managed of sufficient clinical complexity that they warranted a doctor managing them, rather than a PHC nurse clinician? and (ii) what was the spectrum of medical conditions that the clinic doctors managed? METHODS: Doctors collected data at all medical consultations in PHC clinics in uMgungundlovu during February 2020. A single-page standardised data tool was used to collect data at every consultation. RESULTS: Thirty-five doctors were working in 45 PHC clinics in February 2020. Twenty-six of the clinic doctors were National Health Insurance (NHI)-employed. The 35 doctors conducted 7 424 patient consultations in February. Staff in the PHC clinics conducted 143 421 consultations that month, mostly by PHC nurse clinicians. The doctors concluded that 6 947 (93.6%) of the 7 424 doctor consultations were of sufficient complexity as to warrant management by a doctor. The spectrum of medical conditions was as follows: (i) consultations for maternal and child health; n=761 (10.2%); (ii) consultations involving non-communicable diseases (NCDs), n=4 372 (58.9%) - the six most common NCDs were, in order: hypertension, diabetes, arthritis, epilepsy, mental illness and renal disease; (iii) consultations involving communicable diseases constituted 1 745 (23.5%) of cases; and (iv) consultations involving laboratory result interpretation 1 180 (15.9%). CONCLUSION: This research showed that at a PHC clinic the more complex patient consultations did indeed require the skills and knowledge of a medical doctor managing these patients. These data support the benefit of a doctor working at every PHC clinic: the doctor is a 'musthave' member of the PHC clinic team, offering a regular, reliable and predictable medical service.

Challenges in conducting paediatric trials with off-patent drugs.

INTRODUCTION: For more than two decades several initiatives have emerged to increase recruitment of paediatric patients in drug trials. While trials of newly approved drugs have successfully included paediatric patients in their drug development plan, the collection of safety and efficacy data in paediatric patients treated with off-patent drugs poses a major challenge. AIM: This paper aims to draw attention to problems and solutions across countries in investigator-initiated trials with off-patent drugs and recommendations for improvement. DISCUSSION: Off-patent drugs represent a particular challenge when they are included in a paediatric trial; these trials are frequently investigator-initiated and have limited resources, off-patent drugs are used in clinical settings and the trial protocol must accommodate e.g. flexible dosing and specimen sampling schedules, off-patent drugs typically exist in few formulations and concentrations which necessitates special or imported formulations. Paediatric trials are in some countries confined by e.g. consent from both parents, regardless of whether the Investigational Medicinal Product (IMP) is a well-known drug or a new experimental drug. CONCLUSION: Facilitation of research in off-patent drugs can improve evidence-based and safe treatment for the paediatric population. The following supportive initiatives are recommended: Harmonised regulatory change that improves the consent process in low risk trials to prevent inadequate recruitment. Pharmaceutical expertise should be prioritized to secure the best choice of IMP and supply. Constant focus on flexibility in design to accommodate a multifaceted paediatric population and ensure that trial protocols fit in well with routine clinical care and family life.

Higher chlorzoxazone clearance in obese children compared with nonobese peers.

AIMS: To test the in vivo activity of Cytochrome P450 (CYP) 2E1 in obese children vs. nonobese children, aged 11-18 years. Secondly, whether the activity of CYP2E1 in these patients is associated with NALFD, diabetes or hyperlipidaemia. METHODS: Seventy children were divided into groups by body mass index (BMI) standard deviation score (SDS). All children received 250 mg oral chlorzoxazone (CLZ) as probe for CYP2E1 activity. Thirteen blood samples and 20-h urine samples were collected per participant. RESULTS: Obese children had an increased oral clearance and distribution of CLZ, indicating increased CYP2E1 activity, similar to obese adults. The mean AUC0-∞ value of CLZ was decreased by 46% in obese children compared to nonobese children. The F was was increased twofold in obese children compared to nonobese children, P < 0.0001. Diabetic biomarkers were significantly increased in obese children, while fasting blood glucose and Hba1c levels were nonsignificant between groups. Liver fat content was not associated with CLZ Cl. CONCLUSION: Oral clearance of CLZ was increased two-fold in obese children vs. nonobese children aged 11-18 years. This indicates an increased CYP2E1 activity of clinical importance, and dose adjustment should be considered for CLZ.

White matter changes and gait decline in cerebral small vessel disease.

The relation between progression of cerebral small vessel disease (SVD) and gait decline is uncertain, and diffusion tensor imaging (DTI) studies on gait decline are lacking. We therefore investigated the longitudinal associations between (micro) structural brain changes and gait decline in SVD using DTI. 275 participants were included from the Radboud University Nijmegen Diffusion tensor and Magnetic resonance imaging Cohort (RUN DMC), a prospective cohort of participants with cerebral small vessel disease aged 50-85 years. Gait (using GAITRite) and magnetic resonance imaging measures were assessed during baseline (2006-2007) and follow-up (2011 - 2012). Linear regression analysis was used to investigate the association between changes in conventional magnetic resonance and diffusion tensor imaging measures and gait decline. Tract-based spatial statistics analysis was used to investigate region-specific associations between changes in white matter integrity and gait decline. 56.2% were male, mean age was 62.9 years (SD8.2), mean follow-up duration was 5.4 years (SD0.2) and mean gait speed decline was 0.2 m/s (SD0.2). Stride length decline was associated with white matter atrophy (ß = 0.16, p = 0.007), and increase in mean white matter radial diffusivity and mean diffusivity, and decrease in mean fractional anisotropy (respectively, ß = - 0.14, p = 0.009; ß = - 0.12, p = 0.018; ß = 0.10, p = 0.049), independent of age, sex, height, follow-up duration and baseline stride length. Tract-based spatial statistics analysis showed significant associations between stride length decline and fractional anisotropy decrease and mean diffusivity increase (primarily explained by radial diffusivity increase) in multiple white matter tracts, with the strongest associations found in the corpus callosum and corona radiata, independent of traditional small vessel disease markers. White matter atrophy and loss of white matter integrity are associated with gait decline in older adults with small vessel disease after 5 years of follow-up. These findings suggest that progression of SVD might play an important role in gait decline.

Diffusion tensor imaging of the hippocampus predicts the risk of dementia; the RUN DMC study.

INTRODUCTION: Cerebral small vessel disease is one of the most important risk factors for dementia, and has been related to hippocampal atrophy, which is among the first observed changes on conventional MRI in patients with dementia. However, these volumetric changes might be preceded by loss of microstructural integrity of the hippocampus for which conventional MRI is not sensitive enough. Therefore, we investigated the relation between the hippocampal diffusion parameters and the risk of incident dementia, using diffusion tensor imaging, independent of hippocampal volume. METHODS: The RUNDMC study is a prospective study among 503 elderly with small vessel disease, without dementia, with 5 years follow-up in 2012 (99.6% response-rate). Cox regression analysis was performed to calculate hazard ratios for dementia, of fractional anisotropy and mean diffusivity within the hippocampus, adjusted for demographics, hippocampal volume, and white matter. This was repeated in participants without evident hippocampal volume loss, because in these participants the visible damage might not yet have already started, whereas damage might have started on a microstructural level. RESULTS: 43 participants developed dementia (8.6%), resulting in a 5.5-year cumulative risk of 11.1% (95%CI 7.7-14.6). Higher mean diffusivity was associated with an increased 5-year risk of dementia. In the subgroup of participants with the upper half hippocampal volume, higher hippocampal mean diffusivity, more than doubled the 5-year risk of dementia. CONCLUSION: This is the first prospective study showing a relation between a higher baseline hippocampal mean diffusivity and the risk of incident dementia in elderly with small vessel disease at 5-year follow-up, independent of hippocampal volume and white matter volume.

HIV+ and HIV- youth living in group homes in South Africa need more psychosocial support.

Orphans and vulnerable youth who live in group homes are at risk of poor mental health and sexual and drug-using behaviors that increase the risk of HIV transmission. This study explores factors related to this risk among youth living in group homes ("children's homes") for orphans and vulnerable children in South Africa, a country afflicted by high levels of parental loss due to HIV. The study explores 1) knowledge and attitudes about HIV, 2) social support, 3) communication with group home caregivers, and 4) the relevance of an existing evidence-based HIV prevention and mental health promotion program to situations where sexual and drug risk behaviors can occur. In-depth qualitative individual interviews were conducted with 20 youth (age 10 to 16 years) residing in two children's homes in Durban, South Africa. Content analysis focused on critical themes related to coping and prevention of risk activities. Respondents exhibited inconsistent and incomplete knowledge of HIV transmission and prevention. They displayed positive attitudes toward people living with HIV, but reported experiencing or witnessing HIV-related stigma. Participants witnessed substance use and romantic/sexual relationships among their peers; few admitted to their own involvement. While relationships with childcare workers were central to their lives, youth reported communication barriers related to substance use, sex, HIV, and personal history (including parental loss, abuse, and other trauma). In conclusion, these qualitative data suggest that evidence-based HIV prevention programs that bring caregivers and youth together to improve communication, HIV knowledge, social support, youth self-esteem, and health care, reduce sexual and drug risk behaviors, and strengthen skills related to negotiating situations of sexual and substance use possibility could benefit youth and childcare workers in children's homes.

Microstructural integrity of the cingulum is related to verbal memory performance in elderly with cerebral small vessel disease: the RUN DMC study.

BACKGROUND: Cerebral small vessel disease (SVD) is related to verbal memory failures. It is suggested that early white matter damage, is located, among others, in the (posterior) cingulum at an early stage in neurodegeneration. Changes in the microstructural integrity of the cingulum assessed with diffusion tensor imaging (DTI), beyond detection with conventional MRI, may precede macrostructural changes and be related to verbal memory failures. OBJECTIVE: To investigate the relation between cingular microstructural integrity and verbal memory performance in 503 non-demented elderly with cerebral SVD. METHODS: The RUN DMC study is a prospective cohort study in elderly (50-85 years) with cerebral SVD. All participants underwent T1 MPRAGE, FLAIR and DTI scanning and the Rey Auditory Verbal Learning Test. Mean diffusivity (MD) and fractional anisotropy (FA) were assessed in six different cingular regions of interests (ROIs). Linear regression analysis was used to assess the relation between verbal memory performance and cingular DTI parameters, with appropriate adjustments. Furthermore a TBSS analysis of the whole brain was performed to investigate the specificity of our findings. RESULTS: Both our ROI-based and TBSS analysis showed that FA was positively related to immediate memory, delayed recall, delayed recognition and overall verbal memory performance of the cingulum, independent of confounders. A similar distribution was seen for the inverse association with MD and verbal memory performance with TBSS analysis. No significant relations were found with psychomotor speed, visuospatial memory and MMSE. When stratified on hippocampal integrity, the MD and FA values of the cingular ROIs differed significantly between participants with a good and poor hippocampal integrity. CONCLUSION: Microstructural integrity of the cingulum, assessed by DTI, is specifically related to verbal memory performance, in elderly with SVD. Furthermore we found that when the integrity of the hippocampus is disrupted, the cingulum integrity is impaired as well.

Psychosocial challenges and protective influences for socio-emotional coping of HIV+ adolescents in South Africa: a qualitative investigation.

INTRODUCTION: While the roll-out of antiretroviral therapy in South Africa should lead to a reduction in mother to child transmission, mortality and orphaning, it will also be accompanied by a large number of children entering adolescence and adulthood with a chronic infectious disease. Adolescence is a particularly vulnerable period for HIV-infected people in relation to mental health problems and engagement in high-risk behaviours, including non-compliance with medical treatment. The goal of this qualitative study was to develop an understanding of the psychosocial challenges as well as protective influences promoting socio-emotional coping in HIV+ adolescents in order to inform mental health promotion and HIV prevention programming for this population in South Africa. METHOD: In-depth qualitative interviews were conducted with HIV+ adolescents (25) and caregivers of HIV+ children (15) at a large HIV/AIDS Clinic in South Africa. Data were analysed thematically using NVivo8 software. RESULTS: Psycho-social challenges for adolescents included dealing with loss of biological parents in the case of orphans; coming to terms with their HIV+ status including identity difficulties; external stigma and discrimination; and disclosure difficulties. For caregivers, disclosure and lack of financial, family and social support emerged as key challenges. Medication, HIV information, a future orientation and social support was identified as important for coping and general well-being of adolescents, with financial and social support emerging as key for promoting supportive caregiving contexts. CONCLUSION: While HIV+ adolescents in South Africa experience similar concerns to those in high-income countries, socio-emotional coping may be compromised by increased levels of loss due to the late roll-out of ARVS and challenges to caregiving contexts including poverty, stigma and minimally supported foster care arrangements. There is a need for mental health promotion programmes for adolescents to adopt an ecological approach, strengthening protective influences at the individual, interpersonal, community and policy levels.

The capsaicin cough reflex in patients with symptoms elicited by odorous chemicals.

Patients with multiple chemical sensitivity and eczema patients with airway symptoms elicited by odorous chemicals have enhanced cough reflex to capsaicin when applying the tidal breathing method. The aims of the present study were to test whether the capsaicin induced cough reflex was enhanced when applying the single breath inhalation method in similar groups of patients with symptoms related to odorous chemicals e.g. other persons wearing of perfume; and to investigate to what extent the reporting of lower airway symptoms influenced the cough reflex. Sixteen patients fulfilling Cullen's criteria for multiple chemical sensitivity and 15 eczema patients with airway symptoms elicited by odorous chemicals were compared with 29 age-matched, healthy controls. We measured C5--the capsaicin concentration causing five coughs or more--using the single breath inhalation test. No difference was found between groups in age, body mass index or pulmonary function. The median C5 were 129 micromol/L (control group), 48 micromol/L (multiple chemical sensitivity patients), 32 micromol/L (eczema patients). The reporting of lower airway symptoms from odorous chemicals was significantly (p<0.05) correlated to increased cough reflex sensitivity to capsaicin, independent of patient group or co-existence of asthma. The results suggest that the C5 is not reliable for diagnosing MCS but C5 can be used to verify presence of lower airway symptoms related to odorous chemicals.

Toxicity evaluation of PEDOT/biomolecular composites intended for neural communication electrodes.

Electrodes coated with the conducting polymer poly(3,4-ethylene dioxythiophene) (PEDOT) possess attractive electrochemical properties for stimulation or recording in the nervous system. Biomolecules, added as counter ions in electropolymerization, could further improve the biomaterial properties, eliminating the need for surfactant counter ions in the process. Such PEDOT/biomolecular composites, using heparin or hyaluronic acid, have previously been investigated electrochemically. In the present study, their biocompatibility is evaluated. An agarose overlay assay using L929 fibroblasts, and elution and direct contact tests on human neuroblastoma SH-SY5Y cells are applied to investigate cytotoxicity in vitro. PEDOT:heparin was further evaluated in vivo through polymer-coated implants in rodent cortex. No cytotoxic response was seen to any of the PEDOT materials tested. The examination of cortical tissue exposed to polymer-coated implants showed extensive glial scarring irrespective of implant material (Pt:polymer or Pt). However, quantification of immunological response, through distance measurements from implant site to closest neuron and counting of ED1+ cell density around implant, was comparable to those of platinum controls. These results indicate that PEDOT:heparin surfaces were non-cytotoxic and show no marked difference in immunological response in cortical tissue compared to pure platinum controls.

Vertebral fractures fixation with composite patch fibre reinforced adhesives.

PURPOSE: The aim is to investigate fixation of cervical vertebral fractures by patching it with a composite laminate of adhesive and fibres, in comparison with use of only adhesives. MATERIAL AND METHODS: The composite fixation was tested on bonded roe deer vertebrae. 25 specimens were sawed in two halves, creating a generic fracture, and thereafter bonded. The adhesives used were a dental system, Scotchbond XT, and a cyanoacrylate, M-bond 200. The fibres used were unidirectional carbon fibres and randomly distributed E-glass fibres. The composites were applied as a 7 mm wide patch circumferential along the induced fracture. Reference specimens for comparison were also made. The ultimate tensile strength was tested in an Instron 5567. The failure site was examined with a microscope. Strain vectors were tracked using Digital Speckle Analysis. RESULTS: Scotchbond XT + E-glass fibres gave best results, with a tensile strength of 3.5 N/mm circumferential length (24.3% of reference). All composites had lower stiffness than cortical bone. The dental adhesive fibre composites gave better results than the cyanoacrylate fibre composites. In all cases fibre reinforced adhesive composite gave better results than adhesive without fibre reinforcement. CONCLUSION: Fibre-adhesive composite is a promising technique for fixating cervical vertebral fractures.

Increased release of histamine in patients with respiratory symptoms related to perfume.

BACKGROUND: Environmental perfume exposure may cause respiratory symptoms. Individuals with asthma and perfume contact allergy report such symptoms more frequently than others. However, immunologic mechanisms have not been demonstrated and the symptoms are not associated with IgE-mediated allergy. The study aimed to investigate whether basophils from patients with respiratory symptoms related to perfume released more histamine in the presence of perfume as compared with healthy volunteers. METHODS: Histamine release was measured by the glass fibre method. Blood was obtained from healthy volunteers (n=20) and patients with respiratory symptoms related to perfume (n=17) attending a dermatological outpatient clinic for patch testing. The effect of an international brand perfume was investigated using the basophil histamine release test with perfume. Furthermore, basophils from a healthy non-atopic donor were incubated with participant's sera and histamine release induced by perfume was measured. RESULTS: In both groups incremental perfume concentrations showed a positive and significant (P<0.001) dose-response effect on the release of histamine. At the highest perfume concentration, the basophils released significantly (P<0.05) more histamine in patients as compared with healthy volunteers. No difference was found between the groups when sera were incubated with basophils from a healthy non-atopic donor. CONCLUSION: Perfume induces a dose-dependent non-IgE-mediated release of histamine from human peripheral blood basophils. Increased basophil reactivity to perfume was found in patients with respiratory symptoms related to perfume.

[Probiotics--from empirical medicine to therapeutic standard]. / Probiotika--von der Erfahrungsmedizin zum therapeutischen Standard.

Due to the lack of proven efficacy and an unidentified mode of action, probiotics were dismissed by the traditional medical sector for many years. In the meantime, the clinical efficacy of some probiotics has clearly been substantiated in GCP-compliant studies. In addition, modes of action have been demonstrated which prove the effects of probiotics on a cellular level and replace the concept of "restoring the disturbed intestinal microbial balance". Different probiotics have distinct modes of action and the clinical efficacy of various probiotics has been proven in distinct indications. Today, some probiotics represent therapeutic standards in certain indications.

A study of collaboration inpatient treatment between the community psychiatric health services and a psychiatric hospital in Norway.

The aim of this study was to examine factors that may have an influence on the collaboration between the health-care professionals in a psychiatric hospital and two communities' psychiatric health service departments. Interviews were conducted with three psychiatric nurses, one medical practitioner, one health and social manager and one cultural worker; thus a total of nine informants. The transcribed interview texts were analysed by means of qualitative content analysis. The main results showed that the community psychiatric nurses felt a need for more systematic interdisciplinary collaboration. The existing collaboration was characterized by ad hoc meetings. In addition, the need for information about their colleagues' professional competence was reported. The respondents called for a more regular forum for professional guidance and coordination in relation to particular client cases in order to improve the quality of psychiatric care. There was also a need for collaboration within community health care and a link to psychiatric hospital care in order to better evaluate the outcomes of care provided. In conclusion, the lack of continuity in the collaboration between health-care professionals may affect the quality of community health services because continuity is a vital component of care.

Lateral gas transport in soil adjacent to an old landfill: factors governing emissions and methane oxidation.

Field investigations of lateral gas transport and subsequent emissions in soil adjacent to an old landfill in Denmark were conducted during a 1-year period. A significant seasonal variation in the emissions with high carbon dioxide and low methane fluxes in the summer (May to October) was observed. This was attributed to methane oxidation. Diurnal measurements during a drop in barometric pressure showed that the fluxes of landfill gas changed dramatically within a very short time. The concentrations and the soil moisture content in the upper part of the soil profile had significant influence on the fluxes, as did the distance from the landfill border, temperature, barometric pressure and the pressure gradient. Statistical analyses proved that soil moisture described the largest part of the variation. No methane is emitted during the summer. Calculations and isotope analyses showed that very high fractions of the laterally migrating methane were oxidised.

Effect of mammary secretions on functions of polymorphonuclear leukocytes in pigs.

OBJECTIVE: To determine the effects of porcine mammary secretions on polymorphonuclear (PMN) leukocyte function and to relate concentrations of estradiol-17beta and cortisol in mammary secretions to PMN cell function. SAMPLE POPULATION: Mammary secretions from 10 healthy sows and blood PMN leukocytes from 27 healthy sows. PROCEDURE: Mammary secretions were collected within 24 hours after parturition (colostrum) and 12 to 13 days later (milk). Chemoattractant properties were assessed by use of a cell migration assay. Phagocytic capacity of PMN cells in colostrum and milk was assessed by recording chemiluminescence following phagocytosis of Escherichia coli or zymosan. Estradiol-17beta and cortisol concentrations were determined by use of radioimmunoassays. RESULTS: Chemoattractant properties of colostrum and milk were significantly greater than that of zymosan-activated serum. However, chemoattractant properties did not differ significantly between the 2 types of secretions. The capacity of PMN cells in colostrum to phagocytose either zymosan or E. coli was less, compared with cells in milk, and the ability of cells in either type of mammary secretion to phagocytose E. coli was greater than the ability to phagocytose zymosan. Concentrations of estradiol-17beta and cortisol were greater in colostrum, compared with milk. No clear relation was evident between PMN cell activity and hormone concentrations in mammary secretions. CONCLUSIONS AND CLINICAL RELEVANCE: Although chemoattractant properties of colostrum and milk did not differ, the phagocytic capacity of PMN cells in colostrum was significantly less than that of cells in milk. This may predispose sows to coliform mastitis during the early postparturient period.

Improving drug therapy for patients with asthma-part 2: Use of antiasthma medications.

OBJECTIVES: To describe the use of antiasthma drugs among the study patients and to evaluate whether therapeutic outcomes monitoring (TOM) is associated with improved quality of drug therapy. DESIGN: Prospective, controlled, multicenter study. Consumption of antiasthma medications was measured as the number of defined daily doses (DDDs) purchased. Data were collected from the pharmacies' computer systems for a period beginning 6 months before the start of the study (period 1) and during its first and second half-years (periods 2 and 3). Treatment changes for TOM patients were classified on the basis of drug regimens at periods 1 and 3. SETTING: Community pharmacies in Denmark (16 intervention, 15 control). PATIENTS: Five hundred patients with asthma aged 16 to 60 years who were being treated in primary health care; this study used data from 350 patients from this sample. INTERVENTION: TOM. MAIN OUTCOME MEASURES: Changes in the use of individual drugs and changes in therapeutic patterns--distribution of purchased drugs; proportion of corticosteroid users; frequency of drug regimens used; treatment changes for TOM patients. RESULTS: TOM patients' consumption of beta2-agonists decreased by 12% overall from period 1 through period 3, while control patients' consumption of these medications decreased by only 1%. TOM patients' use of inhaled corticosteroids increased by more than 50% compared with 9% among controls. In both groups, about one-half of all purchased DDDs were for inhaled beta2-agonists. The proportion of inhaled corticosteroids increased from 27% to 42% of total DDDs for the TOM group and remained constant for controls. Of patients using beta2-agonists, 68% also used inhaled steroids initially in both the TOM and control groups. The proportion of inhaled steroid users in the TOM group increased to 84%, and to 70% among controls. The most common regimen was inhaled short-acting beta2-agonists and corticosteroids in combination, and the second most common regimen was monotherapy with short-acting beta2-agonists. With time, the regimens changed more toward consensus guidelines among TOM patients. Changes in drug therapy totaled 451, averaging 2.4 changes per TOM patient. The largest number of changes (49%) involved inhaled corticosteroids. CONCLUSION: Changes in medication use among TOM patients were toward improved asthma treatment. Our results show that community pharmacists, physicians, and patients, working together, can improve prescribing, solve drug therapy problems, and improve outcomes for patients with moderate-to-severe asthma.

An independent evaluation of a new method for automated interpretation of lung scintigrams using artificial neural networks.

The purpose of this study was to evaluate a new automated method for the interpretation of lung perfusion scintigrams using patients from a hospital other than that where the method was developed, and then to compare the performance of the technique against that of experienced physicians. A total of 1,087 scintigrams from patients with suspected pulmonary embolism comprised the training group. The test group consisted of scintigrams from 140 patients collected in a hospital different to that from which the training group had been drawn. An artificial neural network was trained using 18 automatically obtained features from each set of perfusion scintigrams. The image processing techniques included alignment to templates, construction of quotient images based on the perfusion/template images, and finally calculation of features describing segmental perfusion defects in the quotient images. The templates represented lungs of normal size and shape without any pathological changes. The performance of the neural network was compared with that of three experienced physicians who read the same test scintigrams according to the modified PIOPED criteria using, in addition to perfusion images, ventilation images when available and chest radiographs for all patients. Performances were measured as area under the receiver operating characteristic curve. The performance of the neural network evaluated in the test group was 0.88 (95% confidence limits 0.81-0.94). The performance of the three experienced experts was in the range 0.87-0.93 when using the perfusion images, chest radiographs and ventilation images when available. Perfusion scintigrams can be interpreted regarding the diagnosis of pulmonary embolism by the use of an automated method also in a hospital other than that where it was developed. The performance of this method is similar to that of experienced physicians even though the physicians, in addition to perfusion images, also had access to ventilation images for most patients and chest radiographs for all patients. These results show the high potential for the method as a clinical decision support system.