Effect of Antibiotic Prescription Audit and Feedback on Antibiotic Prescribing in Primary Care: A Randomized Clinical Trial.

IMPORTANCE: Antibiotics are commonly prescribed in primary care, increasing the risk of antimicrobial resistance in the population. OBJECTIVE: To investigate the effect of quarterly audit and feedback on antibiotic prescribing among primary care physicians in Switzerland with medium to high antibiotic prescription rates. DESIGN, SETTING, AND PARTICIPANTS: This pragmatic randomized clinical trial was conducted from January 1, 2018, to December 31, 2019, among 3426 registered primary care physicians and pediatricians in single or small practices in Switzerland who were among the top 75% prescribers of antibiotics. Intention-to-treat analysis was performed using analysis of covariance models and conducted from September 1, 2021, to January 31, 2022. INTERVENTIONS: Primary care physicians were randomized in a 1:1 fashion to undergo quarterly antibiotic prescribing audit and feedback with peer benchmarking vs no intervention for 2 years, with 2017 used as the baseline year. Anonymized patient-level claims data from 3 health insurers serving roughly 50% of insurees in Switzerland were used for audit and feedback. The intervention group also received evidence-based guidelines for respiratory tract and urinary tract infection management and community antibiotic resistance information. Physicians in the intervention group were blinded regarding the nature of the trial, and physicians in the control group were not informed of the trial. MAIN OUTCOMES AND MEASURES: The claims data used for audit and feedback were analyzed to assess outcomes. Primary outcome was the antibiotic prescribing rate per 100 consultations during the second year of the intervention. Secondary end points included overall antibiotic use in the first year and over 2 years, use of quinolones and oral cephalosporins, all-cause hospitalizations, and antibiotic use in 3 age groups. RESULTS: A total of 3426 physicians were randomized to the intervention (n = 1713) and control groups (n = 1713) serving 629 825 and 622 344 patients, respectively, with a total of 4 790 525 consultations in the baseline year of 2017. In the entire cohort, a 4.2% (95% CI, 3.9%-4.6%) relative increase in the antibiotic prescribing rate was noted during the second year of the intervention compared with 2017. In the intervention group, the median annual antibiotic prescribing rate per 100 consultations was 8.2 (IQR, 6.1-11.4) in the second year of the intervention and was 8.4 (IQR, 6.0-11.8) in the control group. Relative to the overall increase, a -0.1% (95% CI, -1.2% to 1.0%) lower antibiotic prescribing rate per 100 consultations was found in the intervention group compared with the control group. No relevant reductions in specific antibiotic prescribing rates were noted between groups except for quinolones in the second year of the intervention (-0.9% [95% CI, -1.5% to -0.4%]). CONCLUSIONS AND RELEVANCE: This randomized clinical trial found that quarterly personalized antibiotic prescribing audit and feedback with peer benchmarking did not reduce antibiotic prescribing among primary care physicians in Switzerland with medium to high antibiotic prescription rates. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03379194

A survey on health status of coldwater rearing and hatcheries fish farms in Iran (Mazandarn, Gilan, Ardebil, West Azerbaiejan, East Azerbaiejan and Kordestan provinces)

The national research plan with title of "Study on health status of Iran Coldwater hatchery and rearing farms" was done in order to identification and tracking of main causative agents of recent mortality in Iran Coldwater hatchery and rearing farms and recognize of infected zones and design of landscape distribution of Epizootic Coldwater fish diseases in the country. This plan was conducted parallel and in same time in some polar provinces of Coldwater fish production such as Mazandaran, Gilan, Ardebil, West Azerbaijan, East Azerbaijan and Kurdistan in three years from 2006-2008. In this regard, about 23,21 and 20 farms in Mazandaran province, 30 farms in West and East Azerbaijan and Kurdistan provinces and 19 farms in Gilan and Ardebil were selected as randomly and tracking were done yearly from 2006-2008. This research was conducted according to regular planning consists of farms visit that was done according to statistical plan and completion of Questionnaires and sampling. The findings in Mazandaran province revealed that fish infections background and infectious diseases were increased in period of 2006-2008. In fact, 56% of all fish farms in 2006, 71% in 2007 and 85% in 2008 were recorded as infected farms. In other side, average weight of fish final products was more 500gr in consume market. So, regarding to long period of fish culture in mentioned fish occurrence of more morbidity could be expected. The streptococcus infections were most important fish bacterial diseases that have more incidence and pathogenicity in collected questionnaires. Also it revealed more occurrences in summer season in above 15oC temperature in affected fish farms. Also, Enteric Redmouth Disease (ERM) and Saprolegniasis were reported as second and third degree in examined farms. Meanwhile, findings of control, prevention and treatment of our survey revealed that using of antibiotics and detergent materials were increased in mentioned province. Indeed, 34.7% of all fish farms in 2006, 71.4% in 2007 and 75% in 2008 have applied treatment operation and using of detergent materials in affected farms. In other side, frequent using of Erythromycin antibiotic was reported several times in 2008 so fish farmer faced to Bacterial resistance and should be using from Florfenicol as alternative antibacterial. Also, in feed sampling from all fish farms about 3 fish farms in 2006 and 5 fish farms in 2008 were faced with food poisoning that originated from high TVN and peroxidase in fish food consumed. These farms revealed mass mortality that stopped after change feeding regime. In conclusion absence of fish health management could be considered as main agent of mentioned mortality in Mazandaran province. The findings of our survey in West and East Azerbaijan and Kurdistan revealed that absence of sufficient experiences in fish farmers and their neglect from water quality concepts, farm cleanness, using of suitable detergent materials for fish ponds and instruments and disability in continuous monitoring of physic-chemical factors of consumed water could be considered as most important problems. So, fish morbidity and mortality, growth decrement and low production rate were expected. Unfortunately, despite the occurrence of infectious and non- infectious diseases in examined fish farms, there were no documents and information about diseases history, clinical signs in dead fish, feeding regime, fish mortality (rate of daily mortality, age and weight of moribund fish), treatment operation, drugs usage, growth rate, physico-chemical factors and fish density. So planning for control and prevention of mentioned diseases were unsuccessful in affected fish farms. Also, occurrence of some epizootic fish viral diseases such as VHS, IPN and IHN were observed frequently with mass mortality about 40100% in some examined fish farms that produced some tragic economic lost in the mentioned provinces. Similarly, some bacterial, fungal and parasitic diseases were observed repeatedly in some inspected farms such as Flavobacterium, streptococcus infections. Also, some unknown causative agents in parasitic diseases were observed several times such as Dactylogyrus, Gyrodactylus, Ichthyophthirius multifiliis, Trichodina, Chilodonella, Diplostomum and fungal diseases such as Saprolegniasis. In conclusion it seems that absence of fish health management, inadequate rate of hygienic technical services, absence of quarantine programs for transfer of new eyed-eggs, juvenile and live broodstocks packages without health certificates from authorized organizations, uncontrolled entry of foreign eyed-eggs (France, Denmark, Australia and Armenia) and neglect in using of suitable detergent materials for fish ponds, instruments, consumed water and infected eggs, not screening of broodstocks in hatcheries could be considered as most important causative agents in occurrence of infectious diseases and main problems in affected farms in mentioned provinces. Similarly, our findings in Gilan and Ardebil provinces revealed that their problems were similar to other provinces. In fact, neglect in establish of necessary Infrastructures in fish farms and dereliction in health management concepts could be considered as main reasons of occurrence of fish infectious and non-infectious diseases in studied fish farms in mentioned provinces. In fact, often fish farms visited hadn't suitable structures without control and prevention approach. There were not observed detergent using, quarantine programs and prevention methods. Entrance of unknown persons, birds and wild animals were ordinary in mentioned farms. Unfortunately level of farmer’s knowledge was low and no training courses and extension programs were planned by authorized organizations. Meanwhile, food storages were unsuitable and food packages were stored in inappropriate situation so poisoning conditions were increased in examined farms. In conclusion it could be finalized that Coldwater fish farms in Gilan and Ardebil provinces situated in insufficient position and correction of current situation are needed urgently. In final elicitation, it would be mentioned that lack of basic infrastructures could be introduced as most important reasonfor spread of diseases, mortality and related economic losses in studied provinces. Therefore, attention to environmental affairs and access to Sustainable Development are recommended. Also consideration of biosecurity regulations and health management concepts would be important requirements for modification and reformation of Coldwater fish farms in examined provinces towards A Better Tomorrow

Survey on health status in aquaculture sturgeons centers (Mazandaran, Guilan And Golestan Provinces)

Study of survey health management and diseases in hatcheries and fish farms can help us to knowledge and application control methods such as: prevention, treatment and increase high levels of production in hatchery and farms, finally. This survey carried out from 2005 to 2008 for 4 years in sturgeon hatcheries and farms of Golestan province. Sturgeon fishes include Huso Huso, Ship sturgeon, Acipenser persicus collected and for virology, bacteriology, fungius and hematology examined. Also, physicochemical parameters measured and recorded in different stages of culture. Results of this study showed that all of samples in virology was negative and did not observe any doubetful causes. In bacteriology CFU was variation from 3/9 ×105 to 6/9×10. The most parasites that detected in this survey was Cocolanus espherolanus, Sceria binopsulus semiarmatus and Amphilina fuliacea that separates from Acipenser Percicus, especially. The results about hematology parameters some important hematological indices of ship sturgeon include: The total RBC for female and mail specimens measured as 5.3±1.5 ×10^5, 4.8±0.5×10^5 per mm^3 respectively. The amount of haematocrit and hemoglobin for female and mail determined: 34.3±2.8, 35±1.4 percent and 10.3±0.9, 8.9±0.8 gr/dl .The MCV: 216.3± 96.2, 736.5± 102.5, MCH: 720.2±309.5, 186±0.7 and MCHC: 30±0.8, 25.5±3.4 percent respectively.The total WBC were (female, male): 21320±1054, 20580±777 per mm^3 and neutrophil: 16.4±2.5, 17±1.4 percent and lymphocyte: 74.4±2.4, 73.5± 0.7 percent and eosinophil: 6±1.4, 6.4±0.5 percent, monocyte: 2.8±0.8, 3.5±0.7 percent. There was not any significant differences (p>0.05) between mentioned parameters in male and female (students t-test). Also evaluation of hematological parameters in bluga ( Huso huso) include: total RBC were (male , female) 5±0.3 ×105 , 4.9±0.6 ×105 per mm^3 ,respectively and hematocrit: 33.2±6.7 , 35.4±3.4 percent and hemoglobin: 11.2±1.5 , 12.2±1gr/dl and MCV: 669.9±172.2, 723.9±982.4 and MCH: 226.2±42.5, 249.5±35.4 and MCHC: 34.1±2.4, 34.6±3.6 percent respectively. The totals WBC were (male, female): 24800±707.1, 23042±1375.4 per mm^3 and neutrophil: 18.5±0.7, 21.4±1.1 percent and lymphocyte: 73.5±1.4, 68.4±1.1 percent and eosinophil: 5±2.8, 7±1.2 percent and monocyte: 3.5±3.5, 3.2±0.8 percent. According to statistically study the count of lymphocyte had significant difference between male and female fish and this count in male was higher than female. (p≥0.05)

Beneficiation of oxide ores using dense medium cyclones. A simulation study

Recent investigations of particle behavior and segregation phenomena in a cyclone underline that little is known about particle distribution within a heavy medium separation. For this purpose, density profiles in a heavy medium cyclone (HMC) is measured with techniques such as computational fluid dynamics (CFD) in combination with discrete element modelling (DEM), electrical resistance tomography (ERT), X-ray tomography, particle dynamics analyzer (PDA) etc. Along with these modern efforts of determining the performance of HMC, traditional methods depending on empirical inferences based on experimental data are still important and in progress. The aim of this research was to investigate the possibility of using HMC for the concentration of problematic ores which are not coarsely aggregated. Towards this purpose, current empirical methods were applied to experimental data which were derived from float-sink tests of selected heavy minerals and Fe, Mn, and Cr ore samples. Low density difference between particles made the enrichment difficult using other gravity methods like jigs and shaking tables. After determining physical and mineralogical properties of the samples, appropriate size fractions were prepared for float-sink tests. Combination of sodium polytungstate and tungsten carbide powder were used to prepare non-toxic heavy liquids with density up to 3.5 g/cm3. Using the sink-float test results and existing empirical models for high-density DMC plants simulations were performed. The results of the simulations followed by experimental studies showed that HMCs are applicable to process Fe, Mn, and Cr ores with acceptable grade and recovery

Can an entry-level 3D printer create high-quality anatomical models? Accuracy assessment of mandibular models printed by a desktop 3D printer and a professional device

This study was performed to determine whether an in-house printed mandible model is sufficiently accurate for daily clinical practice. Ten example mandible models were produced with a desktop 3D printer (fused filament fabrication, FFF) and compared with 10 equivalent mandible models fabricated using a professional-grade 3D printer (selective laser sintering, SLS). To determine the precision of the printed models, each model was scanned with an optical scanner. Subsequently, every model was compared to its original standard tessellation language (STL) file and to its corresponding analogue. Mean±standard deviation and median (interquartile range) differences were calculated. Overall these were -0.019±0.219mm and -0.007 (-0.129 to 0.107) mm for all 10 pairs. Furthermore, correlation of all printed models to their original STL files showed a high level of accuracy. Comparison of the SLS models with their STL files revealed a mean difference of -0.036±0.114mm and median difference of -0.028 (-0.093 to 0.030) mm. Comparison of the FFF models with their STL files yielded a mean difference of -0.055±0.227mm and median difference of -0.022 (-0.153 to 0.065) mm. The study findings confirm that in-house 3D printed mandible models are economically favourable as well as suitable substitutes for professional-grade models, in particular considering the geometric aspects

Treatments for subacute cough in primary care: systematic review and meta-analyses of randomised clinical trials

Background Subacute cough following an unspecific viral infection lasting 3 to 8 weeks is common. Aim To provide a systematic overview of treatment options and outcomes evaluated in randomised clinical trials (RCTs). Design and Setting Systematic review and meta-analyses Method We systematically searched PubMed/MEDLINE and the Cochrane Central Register of Controlled Trials (last search March 2017) for RCTs in adult patients with subacute cough. We considered trials evaluating any outcome of any drug or non-drug treatments apart from traditional Chinese and Asian medicines. We combined treatment effects on cough-related outcomes in random-effects meta-analyses. Results 6 eligible RCTs including 724 patients were identified. They assessed montelukast, salbutamol plus ipratropium-bromide, gelatine, fluticasone propionate, budesonide, nociception-opioid-1-receptor agonist and codeine. 5 studies reported effects on various cough severity scores at various time-points. No treatment option was associated with a clear benefit on cough recovery or other patient-relevant outcomes in any of the studies or in meta-analyses for cough outcomes at 14 and 28 days. Reported adverse events were rather mild and reported for 14% of patients across all treatments. Conclusions Evidence on treatment options for subacute cough is weak. There is no treatment showing clear patient-relevant benefits in clinical trials.</p

Impact of the COVID-19 pandemic on antibiotic prescribing in high-prescribing primary care physicians in Switzerland.

OBJECTIVES: The aim of this study was to evaluate antibiotic prescribing of medium-to-high prescribing primary care physicians being followed up after the completion of a Swiss national intervention trial of antibiotic prescription audit and feedback in the first SARS-CoV-2 pandemic year. METHODS: We used health insurer based claims data to calculate monthly antibiotic prescription rates per 100 consultations (primary endpoint) and applying interrupted time series (ITS) analysis methods, we estimated the immediate (step change) and sustained effects (slope) of the SARS-CoV-2 epidemic in 2020 on antibiotic prescribing compared to the pre-pandemic trial period from 2017-2019. RESULTS: We analysed data of 2945 of 3426 physicians (86.0%) from the trial with over 4 million consultations annually, who were in 2020 still in practice. Consultations dropped by 43% during the first pandemic year compared with 2017. Median monthly antibiotic prescription rates per 100 consultations in 2017 were 8.44 (Interquartile range [IQ] 6.32-11.50) and 8.35 (6.34-11.74) in the intervention and control groups, respectively, and increased to 15.63 (10.69-23.81) and 16.31 (10.65-24.72) per 100 consultations in 2020. ITS-derived incidence rate ratios for overall antibiotic prescriptions were 2.32 (95% CI 2.07-2.59) for the immediate pandemic effect, and 0.96 (0.95-0.98) for the sustained effect (change in slope in 2020 compared with 2017-2019). DISCUSSION: The SARS-CoV-2 pandemic had a major impact on antibiotic prescription patterns in primary care in Switzerland. For future viral pandemics, intervention plans with timely activation steps to minimize unjustified antibiotic consumption in primary care should be prepared

Antimicrobial Prophylaxis for Postoperative Urinary Tract Infections in Transurethral Resection of Bladder Tumors: A Systematic Review and Meta-analysis

The administration of antimicrobial prophylaxis (AMP) for postoperative urinary tract infections (UTIs) following transurethral resection of bladder tumors (TURB) is controversial. We aimed to systematically review evidence on the potential effect of AMP on postoperative UTI and asymptomatic bacteriuria (ABU).; We conducted a systematic search in Embase, Medline, and the Cochrane Central Register of Controlled Trials. Randomized controlled trials (RCTs) and nonRCTs assessing the effect of any form of AMP in patients with TURB on postoperative UTI or ABU were included. Risk of bias was assessed using RoB 2.0 or the Newcastle-Ottawa Scale. Fixed- and random-effects meta-analyses were conducted. As a potential basis for a scoping review, we exploratorily searched Medline for risk factors for UTI after TURB. The protocol was registered on PROSPERO (CRD42019131733).; Of 986 screened publications, seven studies with 1,725 participants were included; the reported effect sizes varied considerably. We found no significant effect of AMP on UTI: the pooled odds ratio (OR) of the random-effects model was 1.55 (95%-CI: 0.73-3.31). The random-effects meta-analysis examining the effect of AMP on ABU showed an OR of 0.43 (0.18-1.04). Risk of bias was moderate. Our exploratory search identified three studies reporting age, preoperative pelvic radiation, preoperative hospital-stay, duration of operation, tumor size, preoperative ABU, and pyuria as risk factors for UTI following TURB.; We observed insufficient evidence supporting routine AMP in patients undergoing TURB for the prevention of postoperative UTIs; our findings may inform harmonization of international guidelines

Prognosis of Patients With Familial Hypercholesterolemia After Acute Coronary Syndromes.

BACKGROUND: Patients with heterozygous familial hypercholesterolemia (FH) and coronary heart disease have high mortality rates. However, in an era of high-dose statin prescription after acute coronary syndrome (ACS), the risk of recurrent coronary and cardiovascular events associated with FH might be mitigated. We compared coronary event rates between patients with and without FH after ACS. METHODS: We studied 4534 patients with ACS enrolled in a multicenter, prospective cohort study in Switzerland between 2009 and 2013 who were individually screened for FH on the basis of clinical criteria according to 3 definitions: the American Heart Association definition, the Simon Broome definition, and the Dutch Lipid Clinic definition. We used Cox proportional models to assess the 1-year risk of first recurrent coronary events defined as coronary death or myocardial infarction and adjusted for age, sex, body mass index, smoking, hypertension, diabetes mellitus, existing cardiovascular disease, high-dose statin at discharge, attendance at cardiac rehabilitation, and the GRACE (Global Registry of Acute Coronary Events) risk score for severity of ACS. RESULTS: At the 1-year follow-up, 153 patients (3.4%) had died, including 104 (2.3%) of fatal myocardial infarction. A further 113 patients (2.5%) experienced nonfatal myocardial infarction. The prevalence of FH was 2.5% with the American Heart Association definition, 5.5% with the Simon Broome definition, and 1.6% with the Dutch Lipid Clinic definition. Compared with patients without FH, the risk of coronary event recurrence after ACS was similar in patients with FH in unadjusted analyses, although patients with FH were &gt;10 years younger. However, after multivariable adjustment including age, the risk was greater in patients with FH than without, with an adjusted hazard ratio of 2.46 (95% confidence interval, 1.07-5.65; P=0.034) for the American Heart Association definition, 2.73 (95% confidence interval, 1.46-5.11; P=0.002) for the Simon Broome definition, and 3.53 (95% confidence interval, 1.26-9.94; P=0.017) for the Dutch Lipid Clinic definition. Depending on which clinical definition of FH was used, between 94.5% and 99.1% of patients with FH were discharged on statins and between 74.0% and 82.3% on high-dose statins. CONCLUSIONS: Patients with FH and ACS have a &gt;2-fold adjusted risk of coronary event recurrence within the first year after discharge than patients without FH despite the widespread use of high-intensity statins