Remind me to wait

Bakgrunn. Unødvendig forskrivning av antibiotika til pasienter med sinusitt er en vanlig problemstilling i allmennpraksis. Overforbruk av antibiotika kan føre til resistensutvikling, og det er derfor viktig med tiltak som kan begrense bruken av antibiotika der det ikke er klart indisert. Vent og se-resept (VOS) er et slikt tiltak. Vi ønsket å se på mulige tiltak for å øke andel VOS ved sinusitt. Med bakgrunn i egen erfaring ønsket vi å vurdere om et pop-up-vindu som foreslår VOS ved forskrivning av noen typer antibiotika, samt et informasjonsskriv til pasienten, ville være veldokumenterte, gjennomførbare tiltak. Kunnskapsgrunnlaget. Vi baserte vår søkestrategi på PICO-modellen. Vi søkte hovedsakelig etter retningslinjer og oversiktsartikler i McMasterPlus. Studier viser at de fleste tilfeller av sinusitt er ukompliserte og selvbegrensende, og at bruk av VOS er en gunstig metode for å redusere bruken av antibiotika. Vi har også funnet i studier at reminders er et effektivt tiltak for å endre praksis. For å finne ut om tiltaket er gjennomførbart har vi vært i kontakt med et allmennlegekontor, i tillegg til datateknisk support for selve installeringen. Tiltak, kvalitetsindikator og metode. Med utgangspunkt i bakgrunnen og kunnskapsgrunnlaget ønsker vi å innføre to tiltak; pop-up-vindu i datasystemet ved forskrivning av antibiotika og et informasjonsskriv til pasienten. Dette for å påminne legen om VOS og bevisstgjøre både lege og pasient om viktigheten av VOS. Målet med tiltakene er å øke andel VOS til 20% av foreskreven antibiotika til pasienter med akutt sinusitt som tilfredsstiller kriteriene for VOS gitt i Antibiotikaveilederen for allmennpraksis. Vi valgte dermed en prosessindikator for å vurdere om målet nås. Vi vurderer dette ved å sammenligne andelen VOS før og etter innføring av tiltak. Organisering. Organiseringen har vi basert på PDSA-sirkelen. For å innføre tiltaket bør det organiseres et møte der prosjektplanen blir presentert. Det bør informeres om selve installasjonen av pop-up-funksjonen og om informasjonsskrivet, samt resistensutviklingen og viktigheten av VOS. Deretter installeres pop-up-funksjonen enkelt. Etter ett år vurderer vi om målet er nådd, og det vil så holdes et evalueringsmøte om endringen i praksisen har hatt den ønskede effekten. Konklusjon. Problematikken og tiltakene vi har valgt er forankret i evidensbasert kunnskap, og med bakgrunn i kontakt med et mikrosystem kan vi si at det er gjennomførbart. Til tross for mulig motstand hos lege og pasient tror vi at dette tiltaket er nyttig og gjennomførbart

Knee cartilage surgery: epidemiology, research methods and a proposal for improved surveillance

Existing treatments for focal articular cartilage defects (FCDs) involve physical training, palliating surgical procedures, and more advanced cartilage surgery. The results from clinical studies are conflicting, and no current gold-standard treatment exists. Furthermore, cartilage surgery has not been adequately compared to non-operative treatment, and the methodological quality of the majority of published studies is low. It is time for a comprehensive and standardized long-time follow-up of these patients, preferably through a register. This project outlines epidemiological data of cartilage surgery in Norway and the external validity of RCTs. Furthermore, we studied the long-term effect of FCDs and biomarkers of early OA. Resolving these issues may lead to more standardized and less variations in treatment. Finally, we performed a pilot cartilage surgery register. The results show that cartilage surgery in Norway is common and there are large variations. The external validity in RCTs on cartilage surgery is low. Long-term follow-up is challenged as we are lacking reliable biomarkers. The results from this project support the establishment of a future cartilage surgery register

Incidence of knee cartilage surgery in Norway, 2008-2011.

Objective A systematic and long-term data collection on the treatment of focal cartilage defects (FCDs) of the knee is needed. This can be achieved through the foundation of a National Knee Cartilage Defect Registry. The aim of this study was to establish the nationwide burden of knee cartilage surgery, defined as knee surgery in patients with an FCD. We also aimed to identify any geographical differences in incidence rates, patient demographics or trends within this type of surgery. Setting A population-based study with retrospective identification of patients undergoing knee cartilage surgery in Norway through a mandatory public health database from 2008 to 2011. Participants We identified all patients undergoing cartilage surgery, or other knee surgery in patients with an FCD. All eligible surgeries were assessed for inclusion on the basis of certain types of ICD-10 and NOMESKO Classification of Surgical Procedures codes. Primary and secondary outcome measures The variables were diagnostic and surgical codes, geographic location of the performing hospital, age and sex of the patients. Yearly incidence and incidence rates were calculated. Age-adjusted incidences for risk ratios and ORs between geographical areas were also calculated. Results A total of 10 830 cases of knee cartilage surgery were identified, with slight but significant decreases from 2008 to 2011 (p<0.0003). The national incidence rate was 56/100 000 inhabitants and varied between regions, counties and hospitals. More than 50% of the procedures were palliative and nearly 400 yearly procedures were reparative or restorative. Conclusions Knee cartilage surgery is common in Norway, counting 2500 annual cases with an age-adjusted incidence rate of 68.8/100 000 inhabitants. There are significant geographical variations in incidence and trends of surgery and in trends between public and private hospitals. We suggest that a national surveillance system would be beneficial for the future evaluation of the treatment of these patients

No degeneration found in focal cartilage defects evaluated with dGEMRIC at 12-year follow-up

Background and purpose — The natural history of focal cartilage defects (FCDs) is still unresolved, as is the long-term cartilage quality after cartilage surgery. It has been suggested that delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) is a biomarker of early OA. We aimed to quantitatively evaluate the articular cartilage in knees with FCDs, 12 years after arthroscopic diagnosis. Patients and methods — We included 21 patients from a cohort of patients with knee pain who underwent arthroscopy in 1999. Patients with a full-thickness cartilage defect, stable knees, and at least 50% of both their menisci intact at baseline were eligible. 10 patients had cartilage repair performed at baseline (microfracture or autologous chondrocyte implantation), whereas 11 patients had either no additional surgery or simple debridement performed. Mean follow-up time was 12 (10–13) years. The morphology and biochemical features were evaluated with dGEMRIC and T2 mapping. Standing radiographs for Kellgren and Lawrence (K&L) classification of osteoarthritis (OA) were obtained. Knee function was assessed with VAS, Tegner, Lysholm, and KOOS. Results — The dGEMRIC showed varying results but, overall, no increased degeneration of the injured knees. Degenerative changes (K&L above 0) were, however, evident in 13 of the 21 knees. Interpretation — The natural history of untreated FCDs shows large dGEMRIC variations, as does the knee articular cartilage of surgically treated patients. In this study, radiographic OA changes did not correlate with cartilage quality, as assessed with dGEMRIC

Development of osteoarthritis in patients with degenerative meniscal tears treated with exercise therapy or surgery: a randomized controlled trial

Objective: To evaluate progression of individual radiographic features 5 years following exercise therapy or arthroscopic partial meniscectomy as treatment for degenerative meniscal tear. Design: Randomized controlled trial including 140 adults, aged 35–60 years, with a magnetic resonance image verified degenerative meniscal tear, and 96% without definite radiographic knee osteoarthritis. Participants were randomized to either 12-weeks of supervised exercise therapy or arthroscopic partial meniscectomy. The primary outcome was between-group difference in progression of tibiofemoral joint space narrowing and marginal osteophytes at 5 years, assessed semi-quantitatively by the OARSI atlas. Secondary outcomes included incidence of radiographic knee osteoarthritis and symptomatic knee osteoarthritis, medial tibiofemoral fixed joint space width (quantitatively assessed), and patient-reported outcome measures. Statistical analyses were performed using a full analysis set. Per protocol and as treated analysis were also performed. Results: The risk ratios (95% CI) for progression of semi-quantitatively assessed joint space narrowing and medial and lateral osteophytes for the surgery group were 0.89 (0.55–1.44), 1.15 (0.79–1.68) and 0.77 (0.42–1.42), respectively, compared to the exercise therapy group. In secondary outcomes (full-set analysis) no statistically significant between-group differences were found. Conclusion: The study was inconclusive with respect to potential differences in progression of individual radiographic features after surgical and non-surgical treatment for degenerative meniscal tear. Further, we found no strong evidence in support of differences in development of incident radiographic knee osteoarthritis or patient-reported outcomes between exercise therapy and arthroscopic partial meniscectomy