Clinical prediction rules combining signs, symptoms and epidemiological context to distinguish influenza from influenza-like illnesses in primary care: a cross sectional study

<p>Abstract</p> <p>Background</p> <p>During an influenza epidemic prompt diagnosis of influenza is important. This diagnosis however is still essentially based on the interpretation of symptoms and signs by general practitioners. No single symptom is specific enough to be useful in differentiating influenza from other respiratory infections. Our objective is to formulate prediction rules for the diagnosis of influenza with the best diagnostic performance, combining symptoms, signs and context among patients with influenza-like illness.</p> <p>Methods</p> <p>During five consecutive winter periods (2002-2007) 138 sentinel general practitioners sampled (naso- and oropharyngeal swabs) 4597 patients with an influenza-like illness (ILI) and registered their symptoms and signs, general characteristics and contextual information. The samples were analysed by a DirectigenFlu-A&B and RT-PCR tests. 4584 records were useful for further analysis.</p> <p>Starting from the most relevant variables in a Generalized Estimating Equations (GEE) model, we calculated the area under the Receiver Operating Characteristic curve (ROC AUC), sensitivity, specificity and likelihood ratios for positive (LR+) and negative test results (LR-) of single and combined signs, symptoms and context taking into account pre-test and post-test odds.</p> <p>Results</p> <p>In total 52.6% (2409/4584) of the samples were positive for influenza virus: 64% (2066/3212) during and 25% (343/1372) pre/post an influenza epidemic. During and pre/post an influenza epidemic the LR+ of 'previous flu-like contacts', 'coughing', 'expectoration on the first day of illness' and 'body temperature above 37.8°C' is 3.35 (95%CI 2.67-4.03) and 1.34 (95%CI 0.97-1.72), respectively. During and pre/post an influenza epidemic the LR- of 'coughing' and 'a body temperature above 37.8°C' is 0.34 (95%CI 0.27-0.41) and 0.07 (95%CI 0.05-0.08), respectively.</p> <p>Conclusions</p> <p>Ruling out influenza using clinical and contextual information is easier than ruling it in. Outside an influenza epidemic the absence of cough and fever (> 37,8°C) makes influenza 14 times less likely in ILI patients. During an epidemic the presence of 'previous flu-like contacts', cough, 'expectoration on the first day of illness' and fever (>37,8°C) increases the likelihood for influenza threefold. The additional diagnostic value of rapid point of care tests especially for confirming influenza still has to be established.</p

Respiratory physiotherapy interventions focused on exercise training and enhancing physical activity levels in people with chronic obstructive pulmonary disease are likely to be cost-effective: a systematic review

Question: What is the cost-effectiveness of respiratory physiotherapy interventions for people with chronic obstructive pulmonary disease? Design: Systematic review of full economic evaluations alongside clinical trials published between 1997 and 2021. Reviewers independently screened studies for inclusion, extracted data and assessed methodological quality. Participants: People with chronic obstructive pulmonary disease. Intervention: Respiratory physiotherapy interventions as defined in the respiratory physiotherapy curricu- lum of the European Respiratory Society. Outcome measures: Costs expressed in monetary units, effect sizes expressed in terms of disease-specific quality of life (QOL), quality-adjusted life years (QALYs) or monetary units. Results: This review included 11 randomised trials with 3,261 participants. The interventions were pulmonary rehabilitation, airway clearance techniques, an integrated disease-management program and an early assisted discharge program, including inpatient respiratory physiotherapy. Meta-analysis was consid- ered irrelevant due to the extensive heterogeneity of the reported interventions. A total of 45 incremental cost-effectiveness ratios (ICERs) were extracted. Regardless of the economic perspectives, 67% of all QOL- related ICERs and 71% of all QALY-related ICERs were situated in the north-east or south-east quadrants of the cost-effectiveness plane. Six studies could be seen as cost-effective when compared with a specified cost- effectiveness threshold per QALY gained. Conclusion: Respiratory physiotherapy interventions focusing on exercise training in combination with enhancing physical activity levels are likely to be cost-effective in terms of costs per unit QOL gained and QALYs. Some uncertainty still exists on the various estimates of cost- effectiveness due to differences in the content and intensity of the type of interventions, outcome measures and comparators. Registration: PROSPERO CRD42018088699

The Diabetes Obstacles Questionnaire

The Diabetes Obstacles Questionnaire (DOQ) is designed for completion by people who have Type 2 diabetes. There are 8 SCALES, with several ITEMS in each scale. Each scale deals with one topic and comprises a number of items. Each item deals with one obstacle in that topic. Each item should be answered by ticking one box. For an individual who has Type 2 diabetes, not all scales may be relevant, so a selection of which scales to use can be made either by the person, or by his or her clinician. Having selected the scales to be used, all items on a scale should be answered. The items are deliberately all related to obstacles and so may seem to have a negative tone to them. The items are designed to identify the obstacles for an individual person. The obstacles are those items for which the respondent has ticked the box for Agree or Strongly Agree. In a clinical setting this could then lead to the obstacles being addressed. In a research setting, the scales may be used to demonstrate change in obstacles, perhaps due to an intervention intended to reduce obstacles

Which factors prognosticate rotational instability following lumbar laminectomy?

Purpose: Reduced strength and stiffness of lumbar spinal motion segments following laminectomy may lead to instability. Factors that predict shear biomechanical properties of the lumbar spine were previously published. The purpose of the present study was to predict spinal torsion biomechanical properties with and without laminectomy from a total of 21 imaging parameters. Method: Radiographs and MRI of ten human cadaveric lumbar spines (mean age 75.5, range 59-88 years) were obtained to quantify geometry and degeneration of the motion segments. Additionally, dual X-ray absorptiometry (DXA) scans were performed to measure bone mineral content and density. Facet-sparing lumbar laminectomy was performed either on L2 or L4. Spinal motion segments were dissected (L2-L3 and L4-L5) and tested in torsion, under 1,600 N axial compression. Torsion moment to failure (TMF), early torsion stiffness (ETS, at 20-40 % TMF) and late torsion stiffness (LTS, at 60-80 % TMF) were determined and bivariate correlations with all parameters were established. For dichotomized parameters, independent-sample t tests were used. Results: Univariate analyses showed that a range of geometric characteristics and disc and bone quality parameters were associated with torsion biomechanical properties of lumbar segments. Multivariate models showed that ETS, LTS and TMF could be predicted for segments without laminectomy (

The effect of giving influenza vaccination to general practitioners: a controlled trial [NCT00221676]

BACKGROUND: No efficacy studies of influenza vaccination given to GPs have yet been published. Therefore, our purpose was to assess the effect of an inactivated influenza vaccine given to GPs on the rate of clinical respiratory tract infections (RTIs) and proven influenza cases (influenza positive nose and throat swabs and a 4-fold titre rise), while adjusting for important covariates. METHODS: In a controlled trial during two consecutive winter periods (2002–2003 and 2003–2004) we compared (77 and 100) vaccinated with (45 and 40) unvaccinated GPs working in Flanders, Belgium. Influenza antibodies were measured immediately prior to and 3–5 weeks after vaccination, as well as after the influenza epidemic. During the influenza epidemic, GPs had to record their contact with influenza cases and their own RTI symptoms every day. If they became ill, the GPs had to take nose and throat swabs during the first 4 days. We performed a multivariate regression analysis for covariates using Generalized Estimating Equations. RESULTS: One half of the GPs (vaccinated or not) developed an RTI during the 2 influenza epidemics. During the two influenza periods, 8.6% of the vaccinated and 14.7% of the unvaccinated GPs had positive swabs for influenza (RR: 0.59; 95%CI: 0.28 – 1.24). Multivariate analysis revealed that influenza vaccination prevented RTIs and swab-positive influenza only among young GPs (ORadj: 0.35; 95%CI: 0.13 – 0.96 and 0.1; 0.01 – 0.75 respectively for 30-year-old GPs). Independent of vaccination, a low basic antibody titre against influenza (ORadj 0.57; 95%CI: 0.37 – 0.89) and the presence of influenza cases in the family (ORadj 9.24; 95%CI: 2.91 – 29) were highly predictive of an episode of swab-positive influenza. CONCLUSION: Influenza vaccination was shown to protect against proven influenza among young GPs. GPs, vaccinated or not, who are very vulnerable to influenza are those who have a low basic immunity against influenza and, in particular, those who have family members who develop influenza

How do GP practices and patient characteristics influence the prescription of antidepressants? A cross-sectional study

BACKGROUND: Under-prescription of antidepressants (ADs) among people meeting the criteria for major depressive episodes and excessive prescription in less symptomatic patients have been reported. The reasons influencing general practitioners’ (GPs) prescription of ADs remain little explored. This study aimed at assessing the influence of GP and patient characteristics on AD prescription. METHODS: This cross-sectional study was based on a sample of 816 GPs working within the main health care insurance system in the Seine-Maritime district of France during 2010. Only GPs meeting the criteria for full-time GP practice were included. The ratio of AD prescription to overall prescription volume, a relative measure of AD prescription level, was calculated for each GP, using the defined daily dose (DDD) concept. Associations of this AD prescription ratio with GPs’ age, gender, practice location, number of years of practice, number of days of sickness certificates prescribed, number of home visits and consultations, number and mean age of registered patients, mean patient income, and number of patients with a chronic condition were assessed using univariate and multivariate analysis. RESULTS: The high prescribers were middle-aged (40–59) urban GPs, with a moderate number of consultations and fewer low-income and chronic patients. GPs’ workload (e.g., volume of prescribed drug reimbursement and number of consultations) had no influence on the AD prescription ratio. GPs with more patients with risk factors for depression prescribed fewer ADs, however, which could suggest the medications were under-prescribed among the at-risk population. CONCLUSIONS: Our study described a profile of the typical higher AD prescriber that did not include heavy workload. In future work, a more detailed assessment of all biopsychosocial components of the consultation and other influences on GP behavior such as prior training would be useful to explain AD prescription in GP’s practice. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s12991-015-0041-7) contains supplementary material, which is available to authorized users