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

Understanding Oral Cancer - A Lifeworld Approach

Dental involvement with oral cancer patients during their treatment and rehabilitation can be long and intense. How can dental personnel better understand their role in the treatment of these patients? How does treatment affect the patients and their spouses? In searching for answers, the theories of phenomenography, phenomenology and hermeneutics are used to describe and interpret the experiences of the hospital dental treatment teams, oral cancer patients, and their spouses. Study I reveals that hospital dental treatment teams perceive the encounter with head and neck cancer patients in three qualitatively different ways; as an act of caring, as a serious and responsible task, and as an overwhelming emotional situation, indicating that they are not always able to lean on education and professional training in dealing with situations with strong emotional impact. Study II gives insight into the lifeworld of oral cancer patients, and how the patient becomes embodied in a mouth that is increasingly `uncanny´, as it slowly ceases to function normally. Study III shows that oral cancer puts a hold on the lifeworld of the patients’ spouses which can be described as `living in a state of suspension´. These findings suggest that the support needs of patients and spouses appear to be greatest at treatment end, when, upon returning home, they are faced with the accumulated impact of the patients’ sickness and treatment. Study IV gives insight into what it may mean to live with the consequences of oral cancer, revealing a silent physical, emotional and existential struggle to adjust to a changed way of living. This thesis raises the question if todays’ organisation of oral cancer care can meet the varying emotional and existential needs of treatment teams, patients and spouses that were brought to light

A meta-ethnographic synthesis on phenomenographic studies of patients' experiences of chronic illness

Phenomenography is a qualitative research approach developed within an educational framework, focusing on the qualitative experience of learning. It is also being used, to a lesser degree, in healthcare research. In the present study, we conducted a meta-ethnographic synthesis of phenomenographic studies on chronic illness, in order to give a broader perspective of how chronic illness can be experienced. Our aim was not to describe patients' various individual experiences of illness, but instead to identify the different ways chronic illness can be experienced by patients. Our synthesis and phenomenographic interpretation of 12 selected articles found that patients' experiences of chronic illness can be described in terms of a different lived body, a struggle with threat to identity and self-esteem, a diminished lifeworld, and a challenging reality. These experiences relate to each other in a process of recurring loops, where the different ways of experiencing continue to influence each other over time. According to these findings, the use of phenomenography as a research approach has the potential to add to the understanding of how chronic illness can be experienced. Patients may benefit from seeing that their illness can be experienced in many different ways and that it has many aspects, which then can lead to a better understanding and coping with their illness. We suggest that it may be worthwhile to expand the scope of phenomenography outside pedagogics. This presupposes a revision of the application to include a wider and more comprehensive description, for instance, of the different ways illness and healthcare phenomena can be experienced, and how these different ways are related to each other, with less focus on hierarchical relations

Ways of understanding nursing in psychiatric inpatient care : A phenomenographic study

Background: Nursing in psychiatric care is marginalized with ambiguous role definitions and imperceptible activities. Nurse managers' capabilities to establish a direction and shared vision are crucial to motivate nursing staff to take part in practice development. However, before establishing a shared vision it is important to identify the different ways nursing can be understood. Methods: Sixteen individual semi‐structured interviews with nursing staff members were analysed using a phenomenographic approach. Results: Five ways of understanding nursing were identified. These understandings were interrelated based on the way that the patient, nursing interventions and the goal of nursing were understood. Conclusion: The diversity of identified understandings illuminates the challenges of creating a shared vision of roles, values and goals for nursing. Implications for Nursing Management: Awareness of staff members' different understandings of nursing can help nurse managers to establish a shared vision. To be useful, a shared vision has to be implemented together with clear role definitions, professional autonomy of nurses and support for professional development. Implementation of such measures serves as a foundation to make nursing visible and thereby enhance the quality of patient care

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

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

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

General practitioners' perceptions of delayed antibiotic prescription for respiratory tract infections : A phenomenographic study

BACKGROUND: Antibiotic use is a major driver of antibiotic resistance. Although delayed antibiotic prescription is a recommended strategy to reduce antibiotic use, practices vary; it appears less commonly used in southern European countries where antibiotic consumption is highest. Despite these variations, few qualitative studies have explored general practitioners' perceptions of delayed antibiotic prescription. We therefore aimed to explore and describe the perceptions of delayed antibiotic prescription for respiratory tract infections among general practitioners in Malta. METHODS: This qualitative phenomenographic study was conducted in Malta. A semi-structured interview guide was developed in English, pilot tested and revised accordingly. Interview topics included views on antibiotic resistance, antibiotic use and delayed antibiotic prescription for respiratory tract infections, and barriers and facilitators to antibiotic prescription. Individual, face-to-face interviews were held in 2014 with a quota sample of 20 general practitioners and transcribed verbatim. Data were subsequently analysed using a phenomenographic approach. FINDINGS: General practitioners perceived delayed antibiotic prescription in five qualitatively different ways: (A) "The Service Provider"-maintaining a good general practitioner-patient relationship to retain patients and avoid doctor-shopping, (B) "The Uncertainty Avoider"-reaching a compromise and providing treatment just in case, (C) "The Comforter"-providing the patient comfort and reassurance, (D) "The Conscientious Practitioner"-empowering and educating patients, and limiting antibiotic use, and (E) "The Holder of Professional Power"-retaining general practitioner responsibility by employing a wait-and-see approach. Although general practitioners were largely positive towards delayed antibiotic prescription, not all supported the strategy; some preferred a wait-and-see approach with follow-up. Many delayed antibiotic prescription users selectively practiced delayed prescription with patients they trusted or who they believed had a certain level of knowledge and understanding. They also preferred a patient-led approach with a one to three day delay; post-dating delayed antibiotic prescriptions was uncommon. CONCLUSIONS: In this study we have shown that general practitioners hold varying perceptions about delayed antibiotic prescription and that there is variation in the way delayed antibiotic prescription is employed in Malta. Whilst delayed antibiotic prescription is utilised in Malta, not all general practitioners support the strategy, and motivations and practices differ. In high consumption settings, formal and standardised implementation of delayed antibiotic prescription could help curb antibiotic overuse. Diagnosis-specific delayed antibiotic prescription recommendations should also be incorporated into guidelines. Finally, further investigation into patients' and pharmacists' views on delayed antibiotic prescription is required. TRIAL REGISTRATION NUMBER: NCT03218930