Infectious disease management in primary care: perceptions of GPs

<p>Abstract</p> <p>Background</p> <p>It is important to keep the level of antibiotic prescribing low to contain the development of resistant bacteria. This study was conducted to reveal new knowledge about how GPs think in relation to the prescribing of antibiotics - knowledge that could be used in efforts toward rational treatment of infectious diseases in primary care. The aim was to explore and describe the variations in GPs' perceptions of infectious disease management, with special reference to antibiotic prescribing.</p> <p>Methods</p> <p>Twenty GPs working at primary care centres in a county in south-west Sweden were purposively selected based on the strategy of including GPs with different kinds of experience. The GPs were interviewed and perceptions among GPs were analysed by a phenomenographic approach.</p> <p>Results</p> <p>Five qualitatively different perceptions of infectious disease management were identified. They were: (A) the GP must help the patient to achieve health and well-being; (B) the management must meet the GP's perceived personal, professional and organisational demands; (C) restrictive antibiotic prescribing is time-consuming; (D) restrictive antibiotic prescribing can protect the effectiveness of antibiotics; and (E) patients benefit personally from restrictive antibiotic prescribing.</p> <p>Conclusions</p> <p>Restrictive antibiotic prescribing was considered important in two perceptions, was not an issue as such in two others, and was considered in one perception although the actual prescribing was greatly influenced by the interaction between patient and GP. Accordingly, to encourage restrictive antibiotic prescribing several aspects must be addressed. Furthermore, different GPs need various kinds of support. Infectious disease management in primary care is complex and time-consuming, which must be acknowledged in healthcare organisation and planning.</p

A review of open top chamber (OTC) performance across the ITEX Network

Open top chambers (OTCs) were adopted as the recommended warming mechanism by the International Tundra Experiment (ITEX) network in the early 1990’s. Since then, OTCs have been deployed across the globe. Hundreds of papers have reported the impacts of OTCs on the abiotic environment and the biota. Here we review the impacts of the OTC on the physical environment, with comments on the appropriateness of using OTCs to characterize the response of biota to warming. The purpose of this review is to guide readers to previously published work and to provide recommendations for continued use of OTCs to understand the implications of warming on low stature ecosystems. In short, the OTC is a useful tool to experimentally manipulate temperature, however the characteristics and magnitude of warming varies greatly in different environments, therefore it is important to document chamber performance to maximize the interpretation of biotic response. When coupled with long-term monitoring, warming experiments are a valuable means to understand the impacts of climate change on natural ecosystems

Towards Improved Medication Use : Increasing Understanding of Professional Efforts

Professionals and researchers have developed a number of strategies aimed at improving the quality and safety of medication use. However, studies continue to demonstrate persistent problems. For instance, the first paper in this thesis reveals the prevalence of potentially harmful drug combinations among elderly people in Europe. The following four papers focus on two professional groups and how they have approached safety and quality issues related to medication use: 1) the Swedish drug and therapeutics committees (DTCs) and 2) pharmacist involved in pharmaceutical care, an international movement. Qualitative research approaches were applied. Papers II and III focus on the DTCs: analyses indicate a development of the perception of the DTC role over time. The focus of the activities was broadened – from targeting prescribing physicians to incorporating decision-makers and patients. However, a clear patient-centered perspective was generally lacking. Moreover, the findings indicate a shift in focus from cost aspects of medication use to an increased focus on quality and safety aspects. In the studies addressing pharmaceutical care (Papers IV and V), the findings propose that different classification systems for drug-related problems had different characteristics which reflected differences in goals in the pharmaceutical care process. It was also found that the concept of pharmaceutical care was understood in different ways and that the perceptions were based on at least two different understandings of health and illness. First, a patient-centered perspective characterized by a holistic understanding of health and illness, and, second, an “EBM perspective” primarily based on a biomedical understanding of health and illness. This thesis has disclosed new aspects of how two groups of professionals perceive their work towards improved quality and safety of medication use. A patient-centered perspective among healthcare collectives is not obvious; therefore, efforts and comprehensive strategies supporting change are necessary. Strategies should focus on challenging the traditional thought patterns and care approaches among professionals and students

The challenges of implementing national policies to contain antibiotic resistance in Swedish healthcare : A qualitative study of perceptions among healthcare professionals

Objective To explore and describe how healthcare policymakers and healthcare practitioners from different levels of Swedish healthcare perceived the everyday practice of putting national policies to contain antibiotic resistance into effect. Method A strategic sample of four healthcare policymakers, three healthcare practitioners working in hospital care, and six working in primary care were recruited and interviewed in person. A manifest and latent content analysis was carried out on the transcribed interview data. Results Analysis revealed how the everyday practice of containing antibiotic resistance in different healthcare levels could be perceived as successful, difficult, or a dilemma. The informants’ perceptions are presented in three categories which describe first; informants’ perceptions of antibiotic use and antibiotic resistance in Sweden; secondly, informants’ perceptions of definable efforts in containing antibiotic resistance in Sweden, most notably responsible use of antibiotics, prevention of infection, improving public knowledge of antibiotic resistance, and international collaboration; and thirdly, informants’ perceptions of problem areas in containing antibiotic resistance in Sweden, such as behavior, attitudes and knowledge among healthcare practitioners and the public, work environment, and resources. Reflection on the underlying meaning of these perceptions led to identification of the latent theme, labelled “A sense of relative success, and many challenges yet to overcome”. Conclusion This study has given in-depth insight into how a group of healthcare policymakers and practitioners perceived the everyday practice of containing antibiotic resistance, and revealed their perceptions of successful efforts to combat antibiotic resistance so far. It has identified problem areas in different healthcare levels, bringing to light challenges yet to overcome, and areas to focus on in future policies, most notably more emphasis on attitude and behavior change, and increasing awareness of antibiotic resistance among both healthcare practitioners and patients

Swedish Efforts to Contain Antibiotic Resistance in the Environment—A Qualitative Study among Selected Stakeholders

Antibiotic resistance is a serious global threat to human and animal health. In this study, we explored perceptions of work to contain antibiotic resistance with a focus on the environment. Nine stakeholders from six different areas were interviewed in 2018. A short information update was given by informants from four of the areas in 2021. Interview transcripts were analyzed by conventional content analysis. The stakeholders’ perceptions were concluded in three categories: “examples of actions taken to combat antibiotic resistance”, “factors influencing work”, and “factors hindering work”. All informants reported having a role to play. Some of them were very engaged in this issue, whereas among others, antibiotics and resistance were just one part of a general engagement. To be able to act, the policymaker stakeholders asked for more knowledge about antibiotics in the environment and possible actions to take. Actions from the government were requested by several informants. Coordination of the work to combat antibiotic resistance in the environment was not recognized and the One Health approach was known at policy level but not among practitioners. Still, actions seemed to be coordinated, but this was, according to the stakeholders, based on findings from research in their area rather than on strategies developed by national authoritie

Patient-centredness as a quality domain in Swedish healthcare : results from the first national surveys in different Swedish healthcare settings

Objectives: Patients' perception of the quality and patient-centredness of healthcare has gained increasing interest in the last decade in Sweden, as in other countries. The purpose of the study was to evaluate to what extent patients perceived Swedish healthcare as patient-centred and to explore the satisfaction levels related to gender, education level and to having or not having Swedish as one's mother tongue. Design and settings: This study has a cross-sectional design. Analyses were based on the first national patient surveys in Sweden, conducted between 2009 and 2010. The surveys included responses from 232 518 patients who had been in contact with primary, outpatient, inpatient, or emergency care units. Survey questions related to indicators of patient-centred care and sociodemographic variables were selected for the analysis. The patients' level of satisfaction in the selected indicators was analysed and compared by sociodemographic and background factors. Multivariable logistic regression models were used for analysis. Results: The patients expressed high levels of satisfaction in questions related to the 'Respect' indicator (81-96% satisfied) but lower levels in most of the other indicators of patient-centred care. Only 25-30% of the patients reported they had been told about possible warning signs of their condition or treatment and 58-66% said they had received enough information about their condition. Group differences were detected. The most satisfied patient groups were men, individuals with low levels of education and those with Swedish as their mother tongue. Conclusions: According to these first national patient surveys, achieving patient-centred healthcare for all citizens is a challenge for Swedish healthcare authorities. Future analyses of national patient surveys should show whether national efforts to encourage acceptance of patient-centred approaches and strategies for equal care will give intended results

Exploring the One Health Perspective in Sweden's Policies for Containing Antibiotic Resistance

Antibiotic resistance is considered to be a major threat to global health. The main driver of antibiotic resistance is antibiotic use. Antibiotics are used in humans, animals, and food production and are released into the environment. Therefore, it is imperative to include all relevant sectors in the work to contain antibiotic resistance, i.e., a One Health approach. In this study, we aimed to describe and analyse Sweden's policies related to containing antibiotic resistance, from a One Health perspective. Twenty-three key policy documents related to containment of antibiotic resistance in Sweden were selected and analysed according to the policy triangle framework. Sweden started early to introduce policies for containing antibiotic resistance from an international perspective. Systematic measures against antibiotic resistance were implemented in the 1980s, strengthened by the creation of Strama in 1995. The policies involve agencies and organisations from human and veterinary medicine, the environment, and food production. All actors have clear responsibilities in the work to contain antibiotic resistance with a focus on international collaboration, research, and innovation. Sweden aims to be a model country in the work to contain antibiotic resistance and has a strategy for achieving this through international cooperation through various fora, such as the EU, the UN system, and OECD

Ethyl Acetate Extract of Sterculia nobilis Induces Apoptosis of Triple Negative Breast Cancer Cells Through the Overexpression of Apoptosis Inducing Factor

本篇研究利用蘋婆果莢乙酸乙酯精萃物(Ethyl acetate extract shell of Pod Sterculia Nobililis，簡稱為EPSN)針對人類三陰性乳癌細胞株BT-20與MDA-MB-231進行細胞毒殺實驗。藉由細胞存活率測試(MTT assay)，經EPSN處理48小時的IC50，BT-20為40-50 μg/mL，和前人研究結果相類似(30-40 μg/mL)。由前人研究得知BT-20經EPSN處理後可能是藉由細胞凋亡誘導因子(Apoptosis-inducing factor，AIF)經凋亡蛋白酶非依賴型路徑(caspase-independent pathway)來調控細胞凋亡。 本篇研究調整EPSN處理細胞的時間並於收取細胞蛋白時分離細胞質與粒線體兩部分，經西方墨點法分析發現BT-20與MDA-MB-231皆於加入EPSN 2小時後，AIF在細胞質中有過度表現(overexpression)的情形，進一步利用Real-time PCR觀察BT-20經EPSN處理3小時後的AIF mRNA表現量，發現AIF mRNA有明顯上升趨勢，由此可得知蘋婆果莢乙酸乙酯精萃物在短時間內即具有誘導三陰性乳癌細胞凋亡的能力。In previous studies at our laboratory, we found that the Ethyl acetate extract, isolated from shell of pod of Sterculia nobililis (EPSN), can induce the apoptosis of human triple-negative breast cancer cell line BT-20 through the regulation of apoptosis-inducing factor (AIF) in caspase-independent pathway. In this study, we used EPSN to treat BT-20 cells for cytotoxicity test (48 Hr IC50：40-50 μg/mL) and to investigate how does AIF regulate the mechanism of apoptosis in cancer cells. The results of Western blotting analysis revealed that, in both BT-20 and MDA-MB-231 cell lines, AIF was started to overexpress in cytosol compartment after 2 hours treatment of EPSN. We further used Real-time PCR to observe the mRNA expression level AIF in BT-20 after the treatment of EPSN. The data showed that there was indeed a signicant increment expressed in mRNA level of AIF after 3 hours treatment of EPSN. These results demonstrated that EPSN can induce apoptosis at the early stage in triple-negative breast cancer cells with the mRNA and protein overexpressions of AIF leading to the cell death through the caspase-independent pathway.誌謝.......................................................I 中文摘要..................................................III Abstract..................................................IV 目錄.......................................................V 圖表目錄.................................................VIII 第一章 緒論.................................................1 一、癌症....................................................1 (一) 乳癌簡介與分期..........................................2 (二) 乳癌成因...............................................3 (三) 病理分類...............................................4 (四) 三陰性乳癌(Triple negative breast cancer，TNBC)及其治療策略.........................................................5 二、蘋婆....................................................7 (一) 生理介紹...............................................7 (二) 相關文獻探討............................................8 三、細胞週期(cell cycle)....................................10 (一) 定義及分期.............................................10 (二) 細胞週期之調控..........................................11 四、細胞凋亡(apoptosis).....................................13 (一) 凋亡蛋白酶依賴型(caspase-dependent)途徑 ..................13 1. 外源性路徑(Extrinsic pathway)...........................14 2. 內源性路徑(Intrinsic pathway)...........................15 (二) 凋亡蛋白酶非依賴型(caspase-independent)途徑..............16 五、細胞凋亡誘導因子(Apoptosis-inducing factor，AIF)..........17 (一) AIF簡介及其異構蛋白(isoform)............................17 (二) AIF其他生理功能........................................18 第二章 研究動機.............................................19 一、本實驗室蘋婆研究文獻回顧...................................19 二、研究動機................................................23 第三章 材料與方法............................................24 一、實驗材料................................................24 (一) 萃取物材料.............................................24 (二) 細胞株................................................24 (三) 藥品與試劑.............................................24 (四) 抗體..................................................26 1. 一級抗體(primary antibody)..............................26 2. 二級抗體(secondary antibody)............................26 (五) 主要儀器與耗材..........................................26 二、實驗用溶液配方...........................................29 三、實驗方法................................................32 1. 蘋婆果莢乙酸乙酯(Ethyl acetate)萃取.......................32 2. 細胞培養與繼代...........................................32 3. 細胞冷凍保存.............................................33 4. 冷凍細胞活化.............................................33 5. 細胞存活率測試(MTT assay)................................33 6. 蛋白質萃取..............................................34 A. 全細胞蛋白質萃取.........................................34 B. 細胞質與粒線體蛋白質之分離.................................35 7. 蛋白質濃度測定(定量)與蛋白質樣品製備.........................36 8. 蛋白質電泳分析(SDS-PAGE).................................37 9. 西方墨點法(Western Blotting)............................37 10. 細胞RNA萃取(RNA extraction)............................39 11. RNA反轉錄(reverse transcription).......................40 12. 即時定量聚合酶鏈鎖反應(Real-time Quantitative Polymerase Chain Reaction，簡稱Real-time PCR或qPCR)...................41 第四章 實驗結果.............................................44 一、驗證蘋婆果莢乙酸乙酯精萃物對三陰性乳癌細胞株BT-20的毒殺能力.....44 二、探討蘋婆果莢乙酸乙酯精萃物對三陰性乳癌細胞株BT-20的凋亡蛋白酶依賴型(caspase-dependent)細胞凋亡路徑.............................46 三、探討蘋婆果莢乙酸乙酯精萃物對三陰性乳癌細胞株的凋亡蛋白酶非依賴型(caspase-independent)細胞凋亡路徑...........................49 四、探討蘋婆果莢乙酸乙酯精萃物對三陰性乳癌細胞株BT-20所誘導的AIF過度表現(overexpression)是否在mRNA層級(level)即產生影響..............55 第五章 討論與結論............................................58 參考文獻...................................................62   圖表目錄 附圖 1、台灣地區民國99及100年國人十大死因統計圖 ...................1 附圖 2、台灣地區民國99及100年十大癌症死亡率統計圖.................2 附圖 3、蘋婆花序.............................................7 附圖 4、蘋婆果實.............................................8 附圖 5、細胞週期相關調控因子之綜觀..............................10 附圖 6、不同Cyclin在細胞週期中表現量變化圖......................12 附圖 7、細胞凋亡的外源性及內源性路徑............................14 附圖 8、蘋婆果莢乙酸乙酯精萃物(EPSN)對三陰性乳癌細胞株MDA-MB-231及BT-20之毒性測試 19 附圖 9、蘋婆果莢乙酸乙酯精萃物對三陰性乳癌細胞株BT-20之細胞週期影響........................................................20 附圖 10、蘋婆果莢乙酸乙酯精萃物對三陰性乳癌細胞株BT-20作用24小時，細胞週期調控蛋白(Cyclin E及Cyclin D1)之影響......................21 附圖 11、蘋婆果莢乙酸乙酯精萃物誘導三陰性乳癌細胞株BT-20死亡方式之偵測........................................................22 圖 1、蘋婆果莢乙酸乙酯精萃物對三陰性乳癌細胞株BT-20之毒性測試.......45 圖 2、蘋婆果莢乙酸乙酯精萃物對三陰性乳癌細胞株BT-20在不同時間點條件下凋亡蛋白酶家族(caspase)的影響..................................47 圖 3、蘋婆果莢乙酸乙酯精萃物對三陰性乳癌細胞株BT-20在不同時間點條件下DNA修補蛋白(PARP)的影響.....................................48 圖 4、蘋婆果莢乙酸乙酯精萃物對三陰性乳癌細胞株BT-20在不同濃度及不同時間點條件下，細胞凋亡誘導因子(AIF)於總量蛋白中的影響.................50 圖 5、蘋婆果莢乙酸乙酯精萃物對三陰性乳癌細胞株BT-20在不同濃度下處理24小時之細胞凋亡誘導因子(AIF)於細胞質蛋白及粒線體蛋白質的影響..........51 圖 6、蘋婆果莢乙酸乙酯精萃物對三陰性乳癌細胞株BT-20以含50 μg/mL劑量EPSN的培養液處理細胞至不同時間點之細胞凋亡誘導因子(AIF)於細胞質蛋白及粒線體蛋白質的影響.............................................52 圖 7、蘋婆果莢乙酸乙酯精萃物對三陰性乳癌細胞株BT-20以含50 μg/mL劑量EPSN的培養液處理細胞至不同時間點之細胞凋亡誘導因子(AIF)於細胞質蛋白及粒線體蛋白質的影響.............................................53 圖 8、蘋婆果莢乙酸乙酯精萃物對三陰性乳癌細胞株MDA-MB-231以含40 μg/mL劑量EPSN的培養液處理細胞至不同時間點之細胞凋亡誘導因子(AIF)於細胞質蛋白及粒線體蛋白質的影響.........................................53 圖 9、蘋婆果莢乙酸乙酯精萃物對三陰性乳癌細胞株BT-20以含50 μg/mL劑量EPSN的培養液處理細胞至不同時間點之細胞凋亡誘導因子(AIF) mRNA level的影響......................................................56 圖 10、蘋婆果莢乙酸乙酯精萃物對三陰性乳癌細胞株BT-20以含50 μg/mL劑量EPSN的培養液處理細胞至不同時間點之細胞凋亡誘導因子(AIF) mRNA level的影響......................................................57 表 1、乳癌亞型之受體表現.......................................5 表 2、Real-time PCR上機專用的96 well部分區域示意圖.............43 附錄 1、Real-time PCR實驗所使用的Primer序列...................6