Inter-professional collaboration reduces the burden of caring for patients with mental illnesses in primary healthcare. A realist evaluation study

Background:The implementation of primary care for mental health is often insufficient, whichleaves its mark on staff. A team-based approach of mental healthcare prevents poor staff mor-ale. A community health centre (CHC), therefore, set up a project promoting interprofessionalcollaboration with a mental health team (MHT).Objectives:This study aimed to understand how an MHT would influence staff morale in a pri-mary care setting, aiming to formulate some recommendations for future projects.Methods:In 2017, interviews and a focus group discussion were conducted among the staff ofa CHC. Using a qualitative approach, we aimed to unravel contextual factors and mechanismsthat determine the effect of an MHT on staff morale.Results:The project relieved the burden of the patient encounters and staff members felt morevaluable to patients. Underlying mechanisms were recognition, altered attitudes towards patientsand role clarity. Facilitating factors were intercultural care mediators and a positive team atmos-phere, whereas inhibiting factors were inefficient time management and communicative issues.Conclusion:Our study elucidated mechanisms and the contextual factors by which an MHT ingeneral practice improves staff morale

Antibiotics for acute rhinosinusitis in adults.

Background : Acute rhinosinusitis is an acute infection of the nasal passages and paranasal sinuses that lasts less than four weeks. Diagnosis of acute rhinosinusitis is generally based on clinical signs and symptoms in ambulatory care settings. Technical investigations are not routinely performed, nor are they recommended in most countries. Some trials show a trend in favour of antibiotics, but the balance of benefit versus harm is unclear. We merged two Cochrane Reviews for this update, which comprised different approaches with overlapping populations, resulting in different conclusions. For this review update, we maintained the distinction between populations diagnosed by clinical signs and symptoms, or imaging. Objectives : To assess the effects of antibiotics versus placebo or no treatment in adults with acute rhinosinusitis in ambulatory care settings. Search methods : We searched CENTRAL (2017, Issue 12), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (January 1950 to January 2018), Embase (January 1974 to January 2018), and two trials registers (January 2018). We also checked references from identified trials, systematic reviews, and relevant guidelines. Selection criteria : Randomised controlled trials of antibiotics versus placebo or no treatment in people with rhinosinusitis-like signs or symptoms or sinusitis confirmed by imaging. Data collection and analysis : Two review authors independently extracted data about cure and side effects and assessed the risk of bias. We contacted trial authors for additional information as required. Main results : We included 15 trials involving 3057 participants. Of the 15 included trials, 10 appeared in our 2012 review, and five (631 participants) are legacy trials from merging two reviews. No new studies were included from searches for this update. Overall, risk of bias was low. Without antibiotics, 46% of participants with rhinosinusitis, whether or not confirmed by radiography, were cured after 1 week and 64% after 14 days. Antibiotics can shorten time to cure, but only 5 to 11 more people per 100 will be cured faster if they receive antibiotics instead of placebo or no treatment: clinical diagnosis (odds ratio (OR) 1.25, 95% confidence interval (CI) 1.02 to 1.54; number needed to treat for an additional beneficial outcome (NNTB) 19, 95% CI 10 to 205; I-2 = 0%; 8 trials; high-quality evidence) and diagnosis confirmed by radiography (OR 1.57, 95% CI 1.03 to 2.39; NNTB 10, 95% CI 5 to 136; I-2 = 0%; 3 trials; moderate-quality evidence). Cure rates with antibiotics were higher when a fluid level or total opacification in any sinus was found on computed tomography (OR 4.89, 95% CI 1.75 to 13.72; NNTB 4, 95% CI 2 to 15; 1 trial; moderate-quality evidence). Purulent secretion resolved faster with antibiotics (OR 1.58, 95% CI 1.13 to 2.22; NNTB 10, 95% CI 6 to 35; I-2 = 0%; 3 trials; high-quality evidence). However, 13 more people experienced side effects with antibiotics compared to placebo or no treatment (OR 2.21, 95% CI 1.74 to 2.82; number needed to treat for an additional harmful outcome (NNTH) 8, 95% CI 6 to 12; I-2 = 16%; 10 trials; high-quality evidence). Five fewer people per 100 will experience clinical failure if they receive antibiotics instead of placebo or no treatment (Peto OR 0.48, 95% CI 0.36 to 0.63; NNTH 19, 95% CI 15 to 27; I-2 = 21%; 12 trials; high-quality evidence). A disease-related complication (brain abscess) occurred in one participant (of 3057) one week after receiving open antibiotic therapy (clinical failure, control group). Authors' conclusions :The potential benefit of antibiotics to treat acute rhinosinusitis diagnosed either clinically (low risk of bias, high-quality evidence) or confirmed by imaging (low to unclear risk of bias, moderate-quality evidence) is marginal and needs to be seen in the context of the risk of adverse effects. Considering antibiotic resistance, and the very low incidence of serious complications, we conclude there is no place for antibiotics for people with uncomplicated acute rhinosinusitis. We could not draw conclusions about children, people with suppressed immune systems, and those with severe sinusitis, because these populations were not included in the available trials

Point-of-care CRP matters : normal CRP levels reduce immediate antibiotic prescribing for acutely ill children in primary care : a cluster randomized controlled trial

Objective: Antibiotics are prescribed too often in acutely ill children in primary care. We examined whether a Point-of-Care (POC) C-reactive Protein (CRP) test influences the family physicians' (FP) prescribing rate and adherence to the Evidence Based Medicine (EBM) practice guidelines. Design: Cluster randomized controlled trial. Setting: Primary care, Flanders, Belgium. Intervention: Half of the children with non-severe acute infections (random allocation of practices to perform POC CRP or not) and all children at risk for serious infection were tested with POC CRP. Subjects: Acutely ill children consulting their FP. Main outcome measure: Immediate antibiotic prescribing. Results: 2844 infectious episodes recruited by 133 FPs between 15 February 2013 and 28 February 2014 were analyzed. A mixed logistic regression analysis was performed. Compared to episodes in which CRP was not tested, the mere performing of POC CRP reduced prescribing in case EBM practice guidelines advise to prescribe antibiotics (adjusted odds ratio (aUR) 0.54 (95% Confidence Interval (CI) 0.33-0.90). Normal CRP levels reduced antibiotic prescribing, regardless of whether the advice was to prescribe (aOR 0.24 (95%CI 0.11-0.50) or to withhold (aOR 031 (95%CI 0.17-037)). Elevated CRP levels did not increase antibiotic prescribing. Conclusion: Normal CRP levels discourage immediate antibiotic prescribing, even when EBM practice guidelines advise differently. Most likely, a normal CRP convinces FPs to withhold antibiotics when guidelines go against their own gut feeling. Future research should focus on whether POC CRP can effectively identify children that benefit from antibiotics more accurately, without increasing the risks of under-prescribing

Should all acutely ill children in primary care be tested with point-of-care CRP: A cluster randomised trial

Background: Point-of-care blood C-reactive protein (CRP) testing has diagnostic value in helping clinicians rule out the possibility of serious infection. We investigated whether it should be offered to all acutely ill children in primary care or restricted to those identified as at risk on clinical assessment. Methods: Cluster randomised controlled trial involving acutely ill children presenting to 133 general practitioners (GPs) at 78 GP practices in Belgium. Practices were randomised to undertake point-of-care CRP testing in all children (1730 episodes) or restricted to children identified as at clinical risk (1417 episodes). Clinical risk was assessed by a validated clinical decision rule (presence of one of breathlessness, temperature ≥ 40 °C, diarrhoea and age 12-30 months, or clinician concern). The main trial outcome was hospital admission with serious infection within 5 days. No specific guidance was given to GPs on interpreting CRP levels but diagnostic performance is reported at 5, 20, 80 and 200 mg/L. Results: Restricting CRP testing to those identified as at clinical risk substantially reduced the number of children tested by 79.9 % (95 % CI, 77.8-82.0 %). There was no significant difference between arms in the number of children with serious infection who were referred to hospital immediately (0.16 % vs. 0.14 %, P = 0.88). Only one child with a CRP < 5 mg/L had an illness requiring admission (a child with viral gastroenteritis admitted for rehydration). However, of the 80 children referred to hospital to rule out serious infection, 24 (30.7 %, 95 % CI, 19.6-45.6 %) had a CRP < 5 mg/L. Conclusions: CRP testing should be restricted to children at higher risk after clinical assessment. A CRP < 5 mg/L rules out serious infection and could be used by GPs to avoid unnecessary hospital referrals

Prevalence of chromosomal abnormalities and timing of karyotype analysis in patients with recurrent implantation failure (RIF) following assisted reproduction

Aims: To analyze the prevalence and type of karyotype abnormalities in RIF patients and to evaluate the adequate timing for analysis and the presence of possible risk factors. Methods: 615 patients (317 women and 298 men) with RIF, having undergone at least 3 sequential failed IVF/ICSI cycles prior to karyotype analysis, were included in this study. Anomaly rates found were compared with published series. Results: Chromosomal abnormalities were diagnosed in 2.1% of patients (13/615): 8 females (2.5%) and 5 males (1.7%) which is significantly higher for the females than in unselected newborns (0.8%) and normo-ovulatory women (0.6%) but lower than in women with high-order implantation failure (10.8%). No significant differences were found with couples at the start of IVF/ICSI (2.0%). Karyotyping all patients prior to IVF/ICSI results in a higher cost than selecting RIF patients. Two subgroups showed an increased prevalence of abnormalities: secondary infertile women with a history of only miscarriages (9.1%) and women with female infertility (6.0%). Conclusion: A karyotype analysis is indicated in all women with RIF. Nulliparous women with a history of mis-carriage and women with documented infertility are at greater risk of CA and are to be advised to undergo karyotyping

Analytical accuracy and user-friendliness of the Afinion point-of-care CRP test

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Predicting Prognosis and Effect of Antibiotic Treatment in Rhinosinusitis

PURPOSE In evaluating complaints suggestive of rhinosinusitis, family physicians have to rely chiefly on the findings of a history, a physical examination, and plain radiographs. Yet, evidence of the value of signs, symptoms, or radiographs in the management of these patients is sparse. We aimed to determine whether clinical signs and symptoms or radiographic findings can predict the duration of the illness, the effect of antibiotic treatment, or both. METHODS We analyzed data from 300 patients with rhinosinusitis-like complaints participating in a randomized controlled trial comparing amoxicillin with placebo. We used Cox regression analysis to assess the association between the presence at baseline of rhinosinusitis signs and symptoms or an abnormal radiograph and the subsequent course of the illness. We then tested for interactions to assess whether the presence of any of these findings predicted a beneficial effect of antibiotic treatment. RESULTS Two factors at baseline were independently associated with a prolonged course of the illness: a general feeling of illness (hazard ratio = 0.77, 95% confidence interval, 0.60–0.99) and reduced productivity (hazard ratio = 0.68, 95% confidence interval, 0.53–0.88). Neither typical sinusitis signs and symptoms nor abnormal radiographs had any prognostic value. Prognosis remained unchanged whether or not patients were treated with antibiotics, no matter what symptoms patients had at baseline. CONCLUSIONS In a large group of average patients with rhinosinusitis, neither the presence of typical signs or symptoms nor an abnormal radiograph provided information with regard to the prognosis or the effect of amoxicillin. The time to recovery was longer in patients who felt ill at baseline or who did not feel able to work, but the course of their illness was not influenced by antibiotic treatment