Parents' perceptions of factors influencing sleep in pediatric intensive care units: A qualitative study

PURPOSE

The purpose of this study is to explore factors influencing sleep in pediatric intensive care units as perceived by parents of critically ill children.

DESIGN AND METHODS

This descriptive qualitative study used individual semistructured interviews. Parents were recruited through purposive sampling from two pediatric intensive care units at two locations in one university hospital in Norway. Ten parents were interviewed. The interviews were analyzed using a six-phase reflexive thematic analysis.

FINDINGS

The analysis produced 17 subthemes under four main themes: environmental factors in the pediatric intensive care unit disturb children's sleep, children need trust and safety to sleep, nurses' cooperation with parents influences children's sleep, and nurses' structuring of their practices is fundamental to sleep promotion.

CONCLUSION

The parents found that the environment disturbed their children's sleep, and environmental factors were easier to control in single rooms than in multibed rooms. Children slept better when they felt safe and trusted the nurses, and parents desired more cooperation in promoting sleep for their children, which may be an essential and overlooked part of sleep promotion. Nurses varied considerably in how they prioritized sleep and structured their practices to promote sleep.

PRACTICE IMPLICATIONS

Nurses should take parents' experiences into account to better promote sleep for patients. By limiting environmental disturbances, building relationships with children to make them feel safe, including parents in sleep promotion, and prioritizing sleep in their practices, nurses could improve sleep quality and limit the consequences of sleep disturbance.

Treatment for Stuttering in Preschool-Age Children: A Qualitative Document Analysis of Treatment Programs

PURPOSE

The purpose of this study was to identify commonalities and differences between content components in stuttering treatment programs for preschool-age children.

METHOD

In this document analysis, a thematic analysis of the content was conducted of handbooks and manuals describing Early Childhood Stuttering Therapy, the Lidcombe Program, Mini-KIDS, Palin Parent-Child Interaction Therapy, RESTART Demands and Capacities Model Method, and the Westmead Program. First, a theoretical framework defining a content component in treatment was developed. Second, we coded and categorized the data following the procedure of reflexive thematic analysis. In addition, the first authors of the treatment documents have reviewed the findings in this study, and their feedback has been analyzed and taken into consideration.

RESULTS

Sixty-one content components within the seven themes-interaction, coping, reactions, everyday life, information, language, and speech-were identified across the treatment programs. The content component SLP providing information about the child's stuttering was identified across all treatment programs. All programs are multithematic, and no treatment program has a single focus on speech, language, or parent-child interaction. A comparison of the programs with equal treatment goals highlighted more commonalities in content components across the programs. The differences between the treatment programs were evident in both the number of content components that varied from seven to 39 and the content included in each treatment program.

CONCLUSIONS

Only one common content component was identified across programs, and the number and types of components vary widely. The role that the common content component plays in treatment effects is discussed, alongside implications for research and clinical practice.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25457929.

Early Childhood Professionals' Management of Young Children Who Stutter: A Cross-Sectional Study

PURPOSE

Early childhood professionals must accurately identify, refer, and treat children who stutter (CWS) within the scope of their respective roles to ensure each child receives the best possible care. This study aimed to investigate similarities and differences between the practices of speech-language pathologists (SLPs), preschool teachers, and public health nurses when they initially meet a young child reported as stuttering.

METHOD

This cross-sectional study was conducted in Norway. A sample of 342 early childhood professionals (126 preschool teachers, 95 public health nurses, and 121 SLPs) completed an online survey about their management practices with young children reported as stuttering. Descriptive statistics, ordinal regression, and chi-square analyses were used to analyze data.

RESULTS

Initial management practices reflected the different roles and competencies of each profession. Less than 15% of SLPs reported they have access to guidelines for working with CWS. This figure was even lower for public health nurses (6.5%) and preschool teachers (12%). The most common recommendations provided to parents by all professions was giving the child time to talk and maintaining eye contact. Each profession's referral for further speech-language pathology management was most commonly influenced by stuttering severity. All professions reported collaborating about management of CWS; the most common reported collaboration was with preschool teachers.

CONCLUSIONS

Initial management practices varied between professions; however, differences largely reflected the roles and competencies of each profession. The development of guidelines and interdisciplinary seminars is recommended to develop a more complementary approach across professions to improve management practices and ensure young CWS receive the best possible care.

Introducing Nurse Practitioners Into Norwegian Primary Healthcare-Experiences and Learning

BACKGROUND AND PURPOSE

Nurse practitioners (NPs) are well established internationally, and Norway is now in the first phase of implementing their role. The aim of this study was to describe the reflections of nurse leaders and general practitioners (GPs) on the establishment of the new NP role in primary healthcare.

METHODS

This study was qualitative and longitudinal. Written reports and audio recordings from 11 meetings with nurse leaders and GPs during 3 years in 3 municipalities were analyzed by a thematic analysis.

RESULTS

Four themes were identified: the need for enhanced clinical competence among registered nurses, the need for reorganization of advanced practice, the need for negotiating professional barriers, and demanding economic situations. Nurse leaders and GPs were generally positive toward NPs, but they had difficulty in clarifying their roles and how to organize them in the existing work models. This was due to economic pressures, different needs in departments, and shift work. Nurse leaders and GPs agreed that NPs should not replace physicians but perform the tasks of advanced practice nursing in a more expert way. Nurse leaders also wanted NPs to be a resource for registered nurses. It was important to gain trust in the new role not only of GPs but also of registered nurses.

IMPLICATIONS FOR PRACTICE

It is extremely important that an implementation group is proactive in finding a suitable model for the implementation process. Clarification of the roles, tasks, and responsibilities of NPs at an early implementation stage could make the process easier.

Variation in staff perceptions of patient safety climate across work sites in Norwegian general practitioner practices and out-of-hour clinics

Introduction

Measuring staff perceptions with safety climate surveys is a promising approach to addressing patient safety. Variation in safety climate scores between work sites may predict variability in risk related to tasks, work environment, staff behavior, and patient outcomes. Safety climate measurements may identify considerable variation in staff perceptions across work sites.

Objective

To explore variation in staff perceptions of patient safety climate across work sites in Norwegian General Practitioner (GP) practices and Out-of-hours clinics.

Methods

The Norwegian Safety Attitudes QuestionnaireAmbulatory Version (SAQ A) was used to survey staff perceptions of patient safety climate across a sample of GP practices and Out-of-hours clinics in Norway. We invited 510 primary health care providers to fill out the questionnaire anonymously online in October and November 2012. Work sites were 17 regular GP practices in Sogn & Fjordane County, and seven Out-of-hours clinics, of which six were designated as “Watchtower Clinics”. Intra–class correlation coefficients were calculated to identify what proportion of the variation in the five factor scores (Teamwork climate, Safety climate, Job satisfaction, Perceptions of management, and Working conditions) were at work site-level.

Results

Of the 510 invited health care providers, 266 (52%) answered the questionnaire. Staff perceptions varied considerably at the work site level: intra–class correlation coefficients (ICCs) were 12.3% or higher for all factors except for Job satisfaction–the highest ICC value was for Perceptions of management: 15.5%.

Conclusion

Although most of the score variation was at the individual level, there was considerable response clustering within the GP practices and OOH clinics. This implies that the Norwegian SAQ A is able to identify GP practices and OOH clinics with high and low patient safety climate scores. Patient safety climate scores produced by the Norwegian version of the SAQ A may, thus, guide improvement and learning efforts to work sites according to the level of their scores.

Serious adverse events reported for antiobesity medicines: postmarketing experiences from the EU adverse event reporting system EudraVigilance

BACKGROUND

Use of antiobesity medicines has been linked with serious cardiac and psychiatric adverse events (AEs). Spontaneous reports can provide information about serious, rare and unknown AEs occurring after the time of marketing. In Europe, information about AEs reported for antiobesity medicines can be accessed in the EudraVigilance (EV) database. Therefore, we aimed to identify and characterise AEs associated with the use of antiobesity medicines in Europe.

METHODS

AE reports submitted for antiobesity medicines (Anatomical Therapeutic Chemical (ATC) group A08A) from 2007 to 2014 and located in the EV database were analysed. AE data were categorised with respect to time, age and sex of patient/consumer, type of reporter, category and seriousness of reported AEs and medicines. Consumer AE reports were compared with reports from other types of reporters with respect to age and sex of consumer, seriousness, system organ class and medicine. The unit of analysis was one AE and one AE report, respectively.

RESULTS

We located 4941 AE reports corresponding to 13 957 AEs for antiobesity medicines in the EV database. More than 90% of all AE cases were serious, including 159 deaths. The majority of AE cases were reported for female adults. The majority of serious AEs was reported for orlistat (37%) and rimonabant (22%). The largest share of serious AEs was of the type 'cardiac disorders' (19%) and 'psychiatric disorders' (18%). Consumer AEs reporting differed from other sources with respect to share and seriousness of AEs, type of AEs (system organ class) and medicines (ATC level 5).

CONCLUSIONS

Many serious AEs were found for antiobesity medicines in EV, and consumers contributed with a relatively high share of reports. Although several products have been withdrawn from the market and new medicines are being marketed, the utilisation of antiobesity medicines is widespread, and therefore systematic monitoring of the safety of these medicines is necessary.

Patient safety culture in Norwegian primary care: a study in out-of-hours casualty clinics and GP practices

OBJECTIVE

This study aimed to investigate patient safety attitudes amongst health care providers in Norwegian primary care by using the Safety Attitudes Questionnaire, in both out-of-hours (OOH) casualty clinics and GP practices. The questionnaire identifies five major patient safety factors: Teamwork climate, Safety climate, Job satisfaction, Perceptions of management, and Working conditions.

DESIGN

Cross-sectional study. Statistical analysis included multiple linear regression and independent samples t-tests.

SETTING

Seven OOH casualty clinics and 17 GP practices in Norway.

SUBJECTS

In October and November 2012, 510 primary health care providers working in OOH casualty clinics and GP practices (316 doctors and 194 nurses) were invited to participate anonymously.

MAIN OUTCOME MEASURES

To study whether patterns in patient safety attitudes were related to professional background, gender, age, and clinical setting.

RESULTS

The overall response rate was 52%; 72% of the nurses and 39% of the doctors answered the questionnaire. In the OOH clinics, nurses scored significantly higher than doctors on Safety climate and Job satisfaction. Older health care providers scored significantly higher than younger on Safety climate and Working conditions. In GP practices, male health professionals scored significantly higher than female on Teamwork climate, Safety climate, Perceptions of management and Working conditions. Health care providers in GP practices had significant higher mean scores on the factors Safety climate and Working conditions, compared with those working in the OOH clinics.

CONCLUSION

Our study showed that nurses scored higher than doctors, older health professionals scored higher than younger, male GPs scored higher than female GPs, and health professionals in GP practices scored higher than those in OOH clinics - on several patient safety factors.

Guidelines adherence to lower urinary tract infection treatment in out-of-hours primary care in European countries

BACKGROUND

The substantial prevalence of bacterial lower urinary tract infections (LUTIs) in out-of-hours (OOH) primary care is a reason for frequent prescription of antibiotics. Insight in guideline adherence in OOH primary care concerning treatment of LUTIs is lacking.

AIMS

To check feasibility of the use of OOH routine data to assess guideline adherence for the treatment of LUTI in OOH primary care, in different regions of Europe.

METHODS

We compared guidelines for diagnosis and treatment of uncomplicated LUTIs in nine European countries, followed by an observational study on available data of guideline adherence. In each region a convenience sample of registration data of at least 100 contacts per OOH primary care setting was collected. Data on adherence (% of contacts) was identified for type of antibiotic and for full treatment adherence (i.e. recommended type and dose and duration).

RESULTS

Six countries were able to provide data on treatment of LUTIs. Four of them succeeded to collect data on type, dosage and duration of treatment. Mostly, trimethoprim was the treatment of first choice, sometimes combined with sulfamethoxazol or sulfamethizol. Adherence with the type of antibiotics varied from 25% to 100%. Denmark achieved a full treatment adherence of 40.0%, the Netherlands 72.7%, Norway 38.3%, and Slovenia 22.2%.

CONCLUSION

Guidelines content is similar to a large extent in the participating countries. The use of OOH routine data for analysis of guideline adherence in OOH primary care seems feasible, although some challenges remain. Adherence regarding treatment varies and suggests room for improvement in most countries.

Distance and utilisation of out-of-hours services in a Norwegian urban/rural district: an ecological study

Background

Long travel distances limit the utilisation of health services. We wanted to examine the relationship between the utilisation of a Norwegian out-of-hours service and the distance from the municipality population centroid to the associated casualty clinic.

Methods

All first contacts from ten municipalities in Arendal out-of-hours district were registered from 2007 through 2011. The main outcomes were contact and consultation rates for each municipality for each year. The associations between main outcomes and distance from the population centroid of the participating municipalities to the casualty clinic and were examined by linear regression. Demographic and socioeconomic factors were included in multivariate linear regression. Secondary endpoints include association between distance and rates of different first actions taken and priority grades assessed by triage nurses. Age and gender specific subgroup analyses were performed.

Results

141 342 contacts were included in the analyses. Increasing distance was associated with marked lower rates of all contact types except telephone consultations by doctor. Moving 43 kilometres away from the casualty clinic led to a 50 per cent drop in the rate of face-to-face consultations with a doctor. Availability of primary care doctors and education level contributed to a limited extent to the variance in consultation rate. The rates of all priority grades decreased significantly with increasing distance. The rate of acute events was reduced by 22 per cent when moving 50 kilometres away. The proportion of patients above 66 years increased with increasing distance, while the proportion of 13- to 19 year olds decreased. The proportion of female patients decreased with increasing distance.

Conclusions

The results confirm that increasing distance is associated with lower utilisation of out-of-hours services, even for the most acute cases. Extremely long distances might compromise patient safety. This must be taken into consideration when organising future out-of-hours districts.

Understanding of and adherence to advice after telephone counselling by nurse: a survey among callers to a primary emergency out-of-hours service in Norway

BACKGROUND

To investigate how callers understand the information given by telephone by registered nurses in a casualty clinic, to what degree the advice was followed, and the final outcome of the condition for the patients.

METHODS

The study was conducted at a large out-of-hours inter-municipality casualty clinic in Norway during April and May 2010. Telephone interviews were performed with 100 callers/patients who had received information and advice by a nurse as a sole response. Six topics from the interview guide were compared with the telephone record files to check whether the caller had understood the advice. In addition, questions were asked about how the caller followed the advice provided and the patient's outcome.

RESULTS

99 out of 100 interviewed callers stated that they had understood the nurse's advice, but interpreted from the telephone records, the total agreement for all six topics was 82.6%. 93 callers/patients stated that they followed the advice and 11 re-contacted the casualty clinic. 22 contacted their GP for the same complaints the same week, of whom five patients received medical treatment and one was hospitalised. There were significant difference between the native-Norwegian and the non-native Norwegian regarding whether they trusted the nurse (p = 0.017), and if they got relevant answers to their questions (p = 0.005).

CONCLUSION

Callers to the out-of-hours service seem to understand the advice given by the registered nurses, and a large majority of the patients did not contact their GP or other health services again with the same complaints.

PRACTICE IMPLICATION

Medical and communicative training must be an important part of the continuous improvement strategy within the out-of-hour services.

Telephone triage by nurses in primary care out-of-hours services in Norway: an evaluation study based on written case scenarios

Background

The use of nurses for telephone-based triage in out-of-hours services is increasing in several countries. No investigations have been carried out in Norway into the quality of decisions made by nurses regarding our priority degree system. There are three levels: acute, urgent and non-urgent.

Methods

Nurses working in seven casualty clinics in out-of-hours districts in Norway (The Watchtowers) were all invited to participate in a study to assess priority grade on 20 written medical scenarios validated by an expert group. 83 nurses (response rate 76%) participated in the study. A one-out-of-five sample of the nurses assessed the same written cases after 3 months (n=18, response rate 90%) as a test–retest assessment.

Results

Among the acute, urgent and non-urgent scenarios, 82%, 74% and 81% were correctly classified according to national guidelines. There were significant differences in the proportion of correct classifications among the casualty clinics, but neither employment percentage nor profession or work experience affected the triage decision. The mean intraobserver variability measured by the Cohen kappa was 0.61 (CI 0.52 to 0.70), and there were significant differences in kappa with employment percentage. Casualty clinics and work experience did not affect intrarater agreement.

Conclusion

Correct classification of acute and non-urgent cases among nurses was quite high. Work experience and employment percentage did not affect triage decision. The intrarater agreement was good and about the same as in previous studies performed in other countries. Kappa increased significantly with increasing employment percentage.

[Organization of Norwegian out-of-hours primary health care services]

BACKGROUND

The organization of out-of-hours primary health care services in Norway is currently changing from municipal-based to larger inter-municipal co-operations with regular employees and improved competence. The Norwegian Medical Association and others have encouraged the establishment of larger out-of-hours primary health care units that include all municipalities and regular GPs and serve the entire population. More data are needed to study the situation for out-of-hours services in Norway.

MATERIAL AND METHODS

The National Centre for Emergency Primary Health Care sent questionnaires to all 433 municipalities in Norway the autumn of 2005 to study how the out-of-hours primary health services are organized.

RESULTS

Out-of-hours primary health services is an inter-municipality endeavour in two-thirds of Norwegian municipalities and one third of the remaining municipalities have plans to start such co-operation. Regular GPs participate in out-of-hours services to a varying degree. In half of the municipalities all regular GPs participate in out-of-hours duty. Participation decreases with increasing numbers of inhabitants and regular GPs in the municalities. We found a distinct variation in the number of phone calls per inhabitant to municipal out-of-hours services. Due to geographical factors, there are also variations in patient transport time and availability of ambulances to the out-of-hours offices.

INTERPRETATION

We observed distinct variations in the organization of the out-of-hours emergency primary health services in Norway. Some of these differences are due to differences in population density and geographical factors.

[Locations, facilities and routines in Norwegian out-of-hours emergency primary health care services]

BACKGROUND

Limited data are available on casualty clinic facilities and localisation, inter-municipal co-operation and routines for out-of-hours services in the 433 Norwegian municipalities. The National centre for emergency primary health care collected data on these issues from October 2005 until February 2006.

METHOD

Questionnaires concerning organisation of the out-of-hours services, casualty clinic facilities, locations and routines were sent to every Norwegian municipality.

RESULTS

282 of the 433 municipalities are in charge of out-of-hours services in 262 districts in the evenings and 230 districts during nights and weekends. There is inter-municipal cooperation in 100 of the districts. Most out-of-hours services are located in one casualty clinic in the host municipality and have the same locations as GP surgeries and laboratories. Most clinics offered the same services, but some routines were different. About half of the casualty clinics had a system for training of doctors and other health personnel. Half of the doctors on duty were available on the emergency communications system (radio). User assessments were collected, telephone calls documented and discrepancies reported to a varying degree, and medical histories were not consistently sent to regular GPs.

INTERPRETATION

Inter-municipal co-operations are most common in areas with a high population density, i.e. in southern and eastern parts of Norway. Varying routines in out-of-hours service districts indicate that several municipalities do not fulfil all the obligations in regulations from the Ministry of health and care services in Norway.

[Differences in requests to out-of-hours services]

BACKGROUND

Out-of-hours services in Norway have not been systematically assessed and no national statistics exist. This article reports a pilot study of requests to three casualty clinics and the activities related to these requests.

MATERIAL AND METHODS

All requests to the three clinics, day and night for four weeks in the spring of 2006, were recorded. Variables and definitions were discussed with all participating personnel before start. A coordinator at each casualty clinic was responsible for ensuring data quality and sending data to the study centre weekly.

RESULTS

5,041 requests were recorded. Contact rates per 1,000 inhabitants ranged from 29 to 84. In two casualty clinics a large majority of the contacts were given the priority grade "not urgent". In one casualty clinic the rate "acute" was more than twice the rate in the two others. The rate of consultation with GPs differed, but the rate of home visits and acute response by ambulance and GP was low in all the casualty clinics.

INTERPRETATION

Large differences were identified regarding several factors affecting requests to casualty clinics in Norway. This pilot study supports the need for a larger and more representative study.

Socio-economic status and adherence to tuberculosis treatment: a case-control study in a district of Nepal

SETTING

A western hill district in Nepal, where tuberculosis (TB) treatment under DOTS was offered by the regional tuberculosis centre, two primary health centres, eight health posts, three sub-health posts and one ward of sub-metropolitan Pokhara.

OBJECTIVE

To analyse the contribution of socioeconomic status to non-adherence to DOTS.

DESIGN

Case-control study. Data were collected by questionnaire-based face-to-face interviews. The study sample consisted of 50 cases and 100 controls. The participation rate was 80% for cases (non-adherents) and 95% for controls.

RESULTS

Logistic regression analysis showed that the risk of non-adherence to TB treatment was significantly associated with unemployment (odds ratio [OR] 9.2), low status occupation (OR 4.4), low annual income (OR 5.4), and cost of travel to the TB treatment facility (OR 3.0). Factors significant in the bivariate analyses--living conditions, literacy and difficulty in financing treatment--were not found to be significantly associated with non-adherence when adjusted for other risk factors in the multivariate regression model.

CONCLUSION

Low socio-economic status and particularly lack of money are important risk factors for non-adherence to TB treatment in a poor country such as Nepal.

Use of six main drug therapeutic groups across educational groups: self-reported survey and prescription records

OBJECTIVES

To assess whether the use of six main therapeutic groups was congruent with the occurrence of related diseases across educational groups.

METHODS

Two data sources were analysed: (i) Interview data from The Danish Health and Morbidity Survey 2000 on a representative sample of the Danish population ages 16 years and above (n = 16,690); (ii) Prescription records linked to a health survey on a representative sample of the population of Funen County 2000-2001 (n = 3,422). The use of six therapeutic main groups (ATC groups A, B, C, M, N and R) and related diseases in educational groups was analysed by indirect standardization. Age and gender standardized prevalence ratios (SPRs) and 95% confidence intervals were calculated on the basis of the total study population.

RESULTS

In general, respondents in the two least educated groups used medicines more frequently and a higher proportion of them reported the related disease than could be expected from indirect standardization. The opposite picture appeared for respondents in the two highest educational groups (SPR < 100). The overall patterns were similar for the six medicine groups, although some of the SPRs were not significant.

CONCLUSION

The results show the uneven distribution of disease in the general population. The distribution of medicine use generally followed this pattern, which means that those in the greatest medical need used the most medicine. Hence, individual co-payment for medicine did not seem to be a barrier to access to medicine in any of the educational groups.

Effect of environmental and physiological factors on the antibacterial activity of Curvularia haloperoxidase system against Escherichia coli

AIMS

The aim of this study was to investigate the influence of environmental and physiological factors on the susceptibility of Escherichia coli to the Curvularia haloperoxidase system.

METHODS AND RESULTS

The Curvularia haloperoxidase system is a novel enzyme system that produces reactive oxygen species which have an antimicrobial effect. Escherichia coli MG1655 was exposed to the Curvularia haloperoxidase system under different temperatures and NaCl concentrations and after exposure to different stress factors. Temperature clearly affected enzymatic activity with increasing antibacterial effect at increasing temperature. The presence of NaCl interfered with the enzyme system and in the presence of 1% NaCl, no antibacterial effect could be observed at pH 7. Cells grown at pH 8.0 were in one experiment more resistant than cells grown at pH 6.5, whereas cells grown in the presence of 2% NaCl were more susceptible to the Curvularia haloperoxidase system.

CONCLUSIONS

Environmental and physiological factors can affect the antibacterial activity of the Curvularia haloperoxidase system.

SIGNIFICANCE AND IMPACT OF THE STUDY

The study demonstrates a systematic approach in assessing the effect of environmental and physiological factors on microbial susceptibility to biocides. Such information is crucial for prediction of application as well as potential side-effects.

The provision of pharmaceutical care in Denmark: a cross-sectional survey

BACKGROUND

Pharmaceutical care was a concept initially defined in the early 1990s. It had its roots within clinical pharmacy, in the USA. In Denmark, pharmaceutical care has been part of the professional standards of practice for community pharmacy since 1995.

OBJECTIVE

The objective of the present study was to investigate the provision of pharmaceutical care in community practice in Denmark. A focus of the study was the estimation of the frequency of medicine-related problem identification and the process of problem management in the Danish pharmacies.

METHODS

A cross-sectional questionnaire-based survey of all Danish community pharmacies was conducted (n = 288). The variables included: detection and identification of medicine-related problems, goal-setting for solving medicine-related problems, and documentation of efforts to solve these. The response rate was 75.7%. A non-respondent analysis was performed.

RESULTS

On average three medicine-related problems per pharmacy were found within the working week prior to the survey. For two-thirds of those cases the type of problem involved was identified. For the other third, goals had been set to resolve the problem. Minimal documentation of these activities was reported. The primary collaborators in problem management were general practitioners and patients.

CONCLUSION

Pharmaceutical care, in its fullest sense, as defined in policy documents in Denmark, was not evident in practice. While some aspects of pharmaceutical care were being performed, almost no documentation of efforts was taking place in community pharmacy.

Ethical dilemmas in antibiotic prescribing: analysis of everyday practice

OBJECTIVE

To explore general practitioners' (GP's) views on their obligations with respect to diagnosing infections and prescribing antibiotics.

METHODS

The GP's reflections and prioritization were studied by means of interviews and observations. We analysed how their prioritization complied with an ethical guidance that ranked patient autonomy and welfare highest, then competence obligations and obligations to society, followed by fraternal obligations.

RESULTS

Balancing of pros and cons was prominent in our informants' decision making but often resulted in decisions that deviated from the ethical guidance. The ranking varied much between the GPs. The highest priorities in the GPs' practice were related to the patient's everyday life (sometimes autonomy, sometimes beneficence in a broad sense), doctor-patient relationship (communication competence), the patient's perceived importance on the job market (society) and relationship with colleagues (fraternal). Perceived lack of resources and uncertainty with respect to both diagnostic and treatment decisions frequently influenced decision making.

Treatment of upper respiratory tract infections--a comparative study of dispensing and non-dispensing doctors

BACKGROUND

The reported results are part of an overall evaluation of drug management by dispensing (DDs) and non-dispensing doctors (NDDs). This study focuses on appropriate prescription. Other studies assess good pharmacy practice. Whereas rationality of prescription has been studied based on simple indicators, appropriate prescription in relation to diagnoses and symptoms has not been assessed.

OBJECTIVE

To analyse prescriptions by DDs and NDDs for patients diagnosed with upper respiratory tract infection.

METHODS

Cohort study of 28 private sector DDs and 28 NDDs, using retrospective registry data from a mean of 14.5 and 16.0 patient records per practice, respectively.

OUTCOME MEASURES

Drug choice, frequency of the drugs being used, use of antibiotics and dosages for respiratory infections where antibiotics are/are not justified.

RESULTS

DDs were associated with a greater number of drugs per encounter (P < = 0.001), a greater number of injections (P = < 0.002), more use of analgesic drugs (P = < 0.001), cough and cold preparations (P < 0.001) and psycholeptics (P = < 0.03). The choice of antibiotics for upper respiratory tract infection (URTI) was assessed as rational, although different for the two practices, but both practices over-prescribe antibiotics frequently. Dispensing doctors frequently prescribe sub-curative dosages and fewer curative dosages (P = < 0.001), compared with NDDs.

CONCLUSION

Irrational prescription for URTI is widespread by both dispensing doctors and to a lesser extent, by NDDs. Symptomatic treatments with 'a drug for each symptom' was common, particularly by the DDs. There was also over-prescription of antibiotics and use of sub-therapetitic dosages. This poly-pharmacy, poses a safety risk, a risk of development of resistance and, unnecessarily costly treatment.

Telephone prescribing of antibiotics. General practitioners' views and reflections

BACKGROUND

In this era of increasing problems with resistance, rational prescribing of antibiotics is extremely important. Therefore, rationales for prescribing require analyses. The objective of this study was to explore general practitioners' (GPs') reasons for prescribing antibiotics by telephone.

METHODS

Qualitative analysis of semistructured interviews with and observations of GPs in Iceland enquiring about the rationale for prescribing antibiotics was used. Ten GPs were interviewed for 45 min to 2 h each including three who were observed between 3 and 10 h.

RESULTS

The GPs generally indicated a restrictive attitude to telephone prescribing, although they all gave examples of their prescribing by telephone. The prescribing was mostly but not always based on some kind of diagnosis. The factors influencing diagnosis and prescribing were largely non-clinical: knowledge of the patients as persons, including their complaint threshold, confidence in their descriptions, the GPs' communication strategies and the travelling distance between patients and GPs. The clinical factors were the patients' description of signs and symptoms and knowledge of their history. Prescriptions not based on diagnosis were 'therapeutic trial' or GP-approved self-medication. Sometimes, the GPs requested to see a patient even though the diagnosis was based on history, signs and symptoms.

CONCLUSIONS

Multiple factors affected the decision-making process when antibiotics were prescribed by telephone, most of which were non-clinical. The diagnosis, if there was one, was generally presumptive. GPs' general attitudes correlated well with current knowledge but were contrasted by the reality of their daily work conditions.

Experiences of long-term tranquillizer use: a psychodynamic perspective

The aim of the article is to analyse narrative descriptions and experiences of long-term tranquillizer use. The analysis is based on a Danish in-depth study of 50 informants with a self-diagnosed dependency on tranquillizers. The theoretical analysis is dependent on psychodynamic reasoning. Further, the psychodynamic perspective is integrated within a multi-dimensional model that considers biological, cognitive, identity, gender and social learning factors. The analysis reveals the possibility of achieving a detailed understanding of the dynamic processes involved in the development of long-term tranquillizer use. Important themes frequently mentioned in the clients' descriptions are traumatic childhood experiences, identity problems, life crises in adulthood and difficulties in stopping taking psychotropic drugs.

Quality assessment of drug sales data: the case of antibacterials in Iceland

BACKGROUND

Two sets of drug sales data, published by the Icelandic Ministry of Health, did not match for antibacterials in 1989. The search for causes turned out to be a project in itself.

OBJECTIVE

To analyze quality problems in the sales data on antibacterials and describe a method for systematic quality assessment of drug sales data.

METHODS

Documentary analysis based on the following sources: 1) Nordic Statistics on Medicines, 1975-95; 2) Drug Use (Notkun Iyfja), 1975-93; 3) Icelandic Drug Market, 1975-94; 4) Unpublished data from the Icelandic Ministry of Health. The following framework was developed to evaluate the quality of drug sales data: 1. Completeness of registration; 2. Accuracy and degree of completeness of data; 3. Size and coverage of the data source; 4. Data format; 5. Data accessibility, availability and cost.

RESULTS

Four discrepancies were found, two due to changes in DDD, and two larger ones stemming from errors in calculating DDD, resulting in an overestimation of the contribution of the respective products to the total DDD/1000 inhabitants/day. Errors were detected in available sales data at least back to 1980, resulting in sales being overestimated by up to 13%. The reasons for the discrepancies were found mostly under point 2 in the framework.

CONCLUSION

The errors uncovered by this study indicate a possible low quality of drug statistics which might lead to wrong conclusions about the level and development of sales of drugs. As a tool, the framework might be used for quality assessment of drug sales data.

The quality of immunization data from routine primary health care reports: a case from Nepal

Reported high immunization coverage achieved in Nepal over the last ten years is expected to reduce child mortality in the country. The present study, carried out in hill district in mid-west Nepal, aimed to assess the quality of immunization data in Nepal. The number of children who received different vaccines during one year was obtained from three sources: 1) the Immunization REgister of three Primary Health Care Service Outlets (PHCSOs) where each immunized child is recorded; 2) monthly PHC Reports, which are based on the Immunization Register; 3) monthly DHO Reports, which are based on the above PHC Reports (the DHO reports are the source of official statistics). The number of children in the PHC Reports was higher than the number in the Immunization REgisters for all vaccines. The number of immunizations in the DHO Reports was higher than the number in the PHC Reports for BCG, DPT, and measles; the number was lower for poliomyelitis. The overall number of immunizations was higher in the DHO Reports than in the Immunization Registers, by 31% for BCG, 44% for DPT, 155% for polio, and 71% for measles. We conclude that the official report overestimates the immunization coverage in the district. The immunization programme, therefore, might not result in the expected reduction of morbidity and mortality despite the investment in the programme and reported high coverage.

The effect of hyperbaric oxygen on irradiated oral tissues: transmucosal oxygen tension measurements

PURPOSE

This study measured the effect of hyperbaric oxygen (HBO) treatment on transmucosal oxygen tension in irradiated human oral mucosa.

PATIENTS AND METHODS

Ten patients received 30 dives of HBO as part of their treatment for mandibular osteoradionecrosis. A noninvasive, nonheated oxygen electrode was used to measure the tissue surface transmucosal oxygen tension directly on the attached gingiva. Measurements were done before, during, and after HBO treatment. The normal level of gingival surface transmucosal oxygen tension was measured in five healthy volunteers.

RESULTS

During HBO treatment, the transmucosal oxygen tension increased significantly after five dives of HBO (P < .05). After 30 dives, the increases were from a mean of 50% to a mean of 86% of the transmucosal oxygen tension of normal healthy gingiva.

CONCLUSION

An increase in the transmucosal oxygen tension is based on neo-angiogenesis. Patients with subischemic tissues, such as the study population with postirradiation mucosal and osseous necrosis, therefore may benefit from treatment with HBO.

Principles and applications of flow injection analysis in biosensors

In practical applications biosensors are often forced to operate under less than optimal conditions. Because of their construction, and the physical processes and chemical reactions involved in their operation, compromise conditions are frequently required to synchronize all events taking place. Therefore, and in order to implement functions such as periodic calibration, conditioning and possible regeneration of the biosensor, and, very importantly, to yield the freedom to select the optimum detection means, it is advantageous to use these devices in a flow-through mode, particularly by employing the flow injection (FI) approach. The capacity of FI, as offering itself as a complementary facility to augment the performance of biosensors, and in many cases as an attractive alternative, is demonstrated by reference to selected examples, comprising assays based on enzymatic procedures with optical and thermal detection procedures, and via description of a recently introduced technique for immunoassays, termed flow injection renewable surface immunoassays, which promises to entail powerful potentials and to yield compatible or better economy of operation than existing approaches.

Determination of minute amounts of ATP by flow injection analysis using enzyme amplification reactions and fluorescence detection

A flow-injection system for assay of trace levels of ATP is described that incorporates a small column reactor containing co-immobilized hexokinase, pyruvate kinase and glucose-6-phosphate dehydrogenase. In the presence of appropriate cofactors, ATP is by the synergistic operation of the enzymes repeatedly recycled, resulting in substrate amplification. The ultimately generated NADH is measured fluorometrically. By this approach, where the enzymatic degradation step and the detection step are completely separated, it is possible to operate them individually under optimal conditions. The amplification factor is directly proportional to the residence time of the sample zone within the enzyme reactor, which time might be manipulated by altering the flow-rate and in the extreme by performing stopped-flow experiments. Amplification factors between 15 and 1000 were obtained, but it was found that increased amplifications did not lead to significantly lower detection limits; thus, it appears that a practical lower limit of detection is of the order of 1-5 nM. An investigation of this paradoxical feature, and a possible explanation for it, is given.

Technology assessment in a user perspective--experiences with drug technology

Drugs have a central place among medical technologies, and medical technology assessment can learn from the established regulation of drug technology. This article outlines how users' experiences are not part of the basis on which decisions are made today, although this knowledge is imperative for identifying the problems that are not uncovered or foreseen by today's drug assessments. Further, users' interests might not be part of assessments that are based on the controlled clinical trial. A framework for drug technology assessments based on a user perspective is suggested.

Spectrophotometric flow injection determination of trace amounts of thiocyanate based on its reaction with 2-(5-bromo-2-pyridylazo)-5-diethylaminophenol and dichromate: assay of the thiocyanate level in saliva from smokers and non-smokers

A simple and very sensitive spectrophotometric flow injection (FI) procedure for the determination of trace amounts of thiocyanate is described. The proposed method is based on the reaction between thiocyanate and 2-(5-bromo-2-pyridylazo)-5-diethylaminophenol, which, in 2 mol dm-3 acidic media in the presence of a strong oxidizing agent, produces an intensely coloured product. Several oxidants are potentially applicable, but it is shown that dichromate is preferable. As the reaction product formed is unstable and the signal inherently is recorded on a high background level, it is demonstrated that FI constitutes an ideal method in order to monitor reproducibly and repeatedly the kinetically transient signal that is obtained. Based on optimization by a factorial experimental design, the detection limit of the procedure was found to be 3.5 mumol dm-3, and the standard deviation between samples was 0.16 mumol dm-3. No significant interferences were observed; a 1000-fold excess of cyanide could readily be tolerated within the experimental error. With a sample volume of 50 microliters being injected, the sampling frequency was 60 samples h-1. The system was tested with saliva samples from non-smokers and smokers, and the results show that it is possible to distinguish between these two categories of individuals. As an added benefit, the detection limit of the analytical procedure allows the samples to be diluted 100-fold, so that centrifugation for 5 min is the only preliminary sample preparation that is necessary.

Development, use and evaluation of drugs: the dominating technology in the health care system

The article presents various perspectives of drug technology and health care policy in Denmark. Drugs dominate as the most widely used treatment technology in the health care system and the use of drugs is steadily increasing. The pharmaceutical industry's development of drugs is based on an economic estimate of developments, expenditures, marketing costs and the anticipated share of the market. Controlled clinical trials have become the main form of documentation required by the health authorities. This method is insufficient to evaluate the (side) effects of the drugs when in actual use. Drugs fit perfectly the technical perception of disease, a perception which prevails in the pharmaceutical industry, medical science and in the treatment of disease. This perception believes that a disease is due to an attack or dysfunction in the biological-mechanical conditions of the individual. Drugs offer a standard solution to health problems independent of the individuals' social life. Thus drugs become a tool which function in agreement with the disintegrated and achievement-orientated approach to disease as it is organized today. In general the statements in this article are not limited to special Danish circumstances but are valid for other countries as well [1, 2]. (Norris R. Pills, Pesticides & Profits. North River Press, 1982; Braithwaite J. Corporate Crime in the Pharmaceutical Industry. Routledge & Kegan Paul, London, 1984) The empirical data in this article derive from Denmark, however.

The active medicine user

The purpose of the study is to analyse medicine behaviour seen from the user's point of view. The study intends to generate ideas to specify topics of problems and to try out a combination of qualitative research methods. The practitioners and four asthmatic patients attached to a health centre in Billund, Denmark, were interviewed. The patients kept a diary based on topics, the notes of which were elaborated by weekly telephone interviews. In a final interview all participants evaluated the course of the study. The combination of qualitative methods has been very suitable to provide the perspective of the user. The results of the study question the ideal picture of the patient as a passive user of medicine. The main trends show that: the users develop different strategies to evaluate medication therapy; it has negative consequences to the patient when medication is changed regardless of patient experience; the therapy improves when the doctor draws on the experience of the patient. The study contributes to the present, sparse knowledge about the consciously acting user of medicine and indicates the importance of incorporating the user's experience and life situation in the health care system's handling of health problems.

Number and type of psychotropic drugs on the Scandinavian market in 1950-1977

This article describes the number and types of psychotropic drugs on the market in Denmark, Finland, Norway, and Sweden from 1950-1977. The total number of drugs on the market in each country depended greatly on how psychotropic drugs were defined, but trends with time and differences between the countries were less affected by this definition. The number of drugs was highest in Finland and lowest in Norway. In all countries, the number of drugs increased from 1950 to the mid-1960s, most abruptly in Finland. They then quickly decreased in Finland and Sweden, but remained fairly constant in Denmark and Norway. The number of different active substances was much smaller than the number of drugs, and the differences between the countries were also smaller. The proportions of combination and hidden psychotropic drugs in relation to all psychotropics were considerable in Finland and Sweden, and the varying numbers of combination drugs contributed greatly to the wide differences in the number of drugs. From the medical point of view, far too many drugs were on the market in that period.

Hydroxychloroquine sulphate in prevention of deep venous thrombosis following fracture of the hip, pelvis, or thoracolumbar spine

One hundred and fifty-three patients, forty-eight to ninety-seven years old, were included in a double-blind placebo-controlled investigation of the usefulness of hydroxychloroquine sulphate for the prevention of deep venous thrombosis in patients with fractures of the hip, pelvis, or thoracolumbar spine. The results indicated that this drug can reduce the number of thrombeombolic complications significantly (p less than 0.005), a finding that corresponds to the results obtained with other drugs such as coumarin derivatives or dextran 70.