Information Leaflets Research Articles

Maxillary osteonecrosis of the jaw. A multidisciplinary approach, communication strategies, and technological tools for prophylaxis

Background. Maxillary osteonecrosis, particularly medication-related osteonecrosis of the jaw (MRONJ), necessitates prompt identification and a comprehensive approach for effective management. Early diagnosis and proactive dental care are crucial in mitigating the complications associated with this condition. Aims. This study aims to outline the importance of early detection, multidisciplinary collaboration, patient education, and proactive dental care in the management of maxillary osteonecrosis. Methods. The study emphasizes the utilization of standardized medical letters to facilitate communication between prescribing physicians and dentists, while ensuring the timely exchange of essential patient information. Additionally, patient education plays a pivotal role, with the distribution of informative leaflets at the initiation of Bone Modifying Agents (BMA) treatment, emphasizing the risks associated with MRONJ and the significance of maintaining oral health and making appropriate lifestyle choices. Results. Dentists are key stakeholders in the prophylaxis of MRONJ, undertaking primary and secondary prevention measures. Primary prophylaxis encompasses various dental procedures aimed at reducing bacterial load and mucosal irritation. Secondary prophylaxis involves educating patients on maintaining optimal oral health and adopting lifestyle modifications. Furthermore, an Android application assists dentists in assessing MRONJ risk factors and making informed treatment decisions based on factors such as BMA type, dose, duration of administration, and the presence of dental and general risk factors. Conclusions. In conclusion, a proactive approach to managing Maxillary Osteonecrosis involves early detection, multidisciplinary collaboration, patient education, and proactive dental care. By integrating standardized communication tools, patient education materials, and risk assessment technology, healthcare providers can optimize patient outcomes and minimize the incidence and severity of MRONJ complications.

A Quality Improvement Initiative to Increase Skin-to-Skin Care Duration in Preterm Neonates.

Skin-to-skin (STS) care effectively improves neonatal outcomes, particularly for preterm neonates. However, utilization of STS remains suboptimal for the most vulnerable preterm neonates in the first 4 weeks of life. This quality improvement (QI) project aimed to increase STS duration for neonates under 35 weeks gestation. The QI initiative was conducted in a 35-bed level IV NICU within a teaching hospital in New York City from July 2021 to January 2023. Six months of baseline data and a staff survey determined interventions across "Plan, Do, Study, Act" cycles. Interim analyses guided interventions using run charts. Interventions included parental counseling and information leaflets, discussion during rounds on STS eligibility, STS education for residents, nurses' feedback, and visual reminders. The primary outcome measure was the mean duration of STS per eligible patient day. The process measures were the age at first STS and documentation of eligibility for STS care in the electronic medical records. Balancing measures included adverse events such as apnea, bradycardia, desaturation, hypothermia, and inadvertent dislodgement of central lines and endotracheal tube. The study included 185 infants with a mean gestational age of 29.1 weeks. The mean STS duration per eligible patient day increased from a baseline of 13.3 minutes to 32.4 minutes without significantly increasing adverse events. The QI interventions implemented have successfully increased the duration of STS in preterm infants. Our interventions combined into an STS bundle can be a potential model for other NICUs to improve STS practice.

Exposure to potentially harmful excipients in medications among neonates at a state hospital in Malaysia

Objectives This study aimed to determine the incidence, types and predictors of Potentially Harmful Excipients (PHE) exposure among hospitalized neonates. Methods A prospective observational study was conducted from March to April 2022 in neonatal wards at a state hospital in Malaysia. The PHEs of interest were aspartame, benzalkonium chloride, benzyl alcohol, benzoic acid or benzoates, ethanol, parabens, polysorbate 80, propylene glycol, saccharin sodium, sorbitol and sulfites. Product information leaflets (PILs) and summaries of product characteristics (SPCs) were referred to obtain information on active pharmaceutical ingredient, strength, trade name as well as type and amount of the excipients. Results A total of 108 neonates were recruited and 97.2% of them were exposed to at least one PHE. Parabens (47.2%) and sulfites (27.5%) were the two most commonly administered PHEs. Benzyl alcohol is contraindicated in neonates but was administered to 8% of neonates in this study. The median daily dose of ethanol (24.11 mg/kg/day, IQR 19.73, 28.49) exceeded the acceptable daily intake (ADI) by four times. However, the dose was not available for all PHEs as this information is not always available in the PIL or SPC. Administration of cardiovascular drugs was associated with a higher risk of exposure to any PHE (OR 6.38, CI 2.75, 14.79, p-value < 0.001). Conclusion The exposure of PHE among neonates in this study is high with certain PHEs exceeding the ADI. It highlights the need for certain strategies to be implemented to reduce such exposure in neonates.

Nominalization in Arabic translations of patient information leaflets

Patient information leaflets (PILs) inserted in medicine packages constitute a genre written by experts for an audience of laymen, but studies of PILs in Arabic report low readability. According to the lay friendliness framework developed by Jensen (2013) for translated PILs, nominalization is one of the linguistic factors that contribute to PILs’ low readability. Although nominalization has been extensively studied in scientific texts including medical papers, no studies examine its use and effect on lay friendliness in PILs translated into Arabic. This study analyzes a parallel corpus of English PILs and their Arabic translations to examine the frequency and forms of nominalization introduced into the Arabic translations. Considering Givon’s (1993) definition of nominalization, all instances of finite verb phrases in the Source Texts (ST) that are fully or partially nominalized in the Target Texts (TT) were examined. Examples are discussed in terms of the level and function of nominalization in the target language.

Cost-Effectiveness of 2 Models of Pessary Care for Pelvic Organ Prolapse: Findings From the TOPSY Randomized Controlled Trial

ObjectivesPelvic organ prolapse is the descent of one or more reproductive organs from their normal position, causing associated negative symptoms. One conservative treatment option is pessary management. This study aimed to to investigate the cost-effectiveness of pessary self-management (SM) when compared with clinic-based care (CBC). A decision analytic model was developed to extend the economic evaluation. MethodsA randomized controlled trial with health economic evaluation. The SM group received a 30-minute SM teaching session, information leaflet, 2-week follow-up call, and a local helpline number. The CBC group received routine outpatient pessary appointments, determined by usual practice. The primary outcome for the cost-effectiveness analysis was incremental cost per quality-adjusted life year (QALY), 18 months post-randomization. Uncertainty was handled using nonparametric bootstrap analysis. In addition, a simple decision analytic model was developed using the trial data to extend the analysis over a 5-year period. ResultsThere was no significant difference in the mean number of QALYs gained between SM and CBC (1.241 vs 1.221), but mean cost was lower for SM (£578 vs £728). The incremental net benefit estimated at a willingness to pay of £20 000 per QALY gained was £564, with an 80.8% probability of cost-effectiveness. The modeling results were consistent with the trial analysis: the incremental net benefit was estimated as £4221, and the probability of SM being cost-effective at 5 years was 69.7%. ConclusionsResults suggest that pessary SM is likely to be cost-effective. The decision analytic model suggests that this result is likely to persist over longer durations.

Knowledge and risky behaviors of Kabul city butchers regarding Crimean-Congo hemorrhagic fever

Abstract Crimean-Congo hemorrhagic fever (CCHF) is a tick-borne zoonotic disease with high morbidity and case fatality rates (CFR) in humans, especially among the high-risk groups, including butchers. Therefore, a cross-sectional study was conducted in Kabul City to determine the knowledge gaps and risky behaviors of Kabul City’s butchers about CCHF. Data were collected from 123 butchers by structured interview using a pre-designed questionnaire. The finding of the present study revealed that of the total CCHF cases in the butchers, their family members, and co-workers, 37.9% died. Nearly half of the butchers (45.0%) experienced splashing of animal blood on their faces, while 70.1% of them had cut their hands with a knife during their occupation life. In addition, 27.0% of the respondents held the knife in their mouth while dressing the animal carcasses, and 27.3% of the butchers consumed raw liver. Hand washing and PPE application were practiced by 94.3% and 22.8% of the respondents, respectively. About 92% of the respondents had heard about CCHF, and 67.4% of the participants had good knowledge about CCHF. The knowledge level of the respondents (poor or good) was statistically related to their age, history of blood splash in the face and eyes of the butchers, holding work knives in the mouth, blowing the skin of animals, hand washing with soap and water, and slaughter places ( p &lt; 0.05). A medium correlation between education and total knowledge of the butchers was observed (r = 0.3; p &lt; 0.05). It is necessary to change such high-risk behaviors by continually coordinating awareness campaigns through mass media, workshops, and informative leaflet distribution to improve knowledge. One Health impact statement CCHF is a multifaceted zoonotic disease where tick bites, direct contact with the tissue, secretions, and body fluids of the infected animals and humans, and consumption of raw milk, meat, and liver of infected animals are the main transmission methods of the disease to humans. Although livestock including cattle, sheep, goats, camels, and ostrich are the main reservoirs of the virus, they are infected in subclinical form, and humans are the only hosts where fatal clinical disease develops. Since the CCHF virus circulates in nature between tick-vertebrates-ticks, the only method that can effectively control and prevent the disease in humans is by using a targeted One Health approach between the human, veterinary, and environmental health sectors. Meanwhile, it has been proven that public awareness campaigns through the use of mass media, community leaders, and integrated workshops are the most effective tools to prevent the transmission of the CCHF virus from infected animals and ticks to humans.

The employment of dental hygienists in European countries: Report of a European Dental Hygienists Federation/European Association of Dental Public Health Survey in 2021.

This survey aimed to investigate a range of topics relating to the employment of dental hygienists in European countries, whose National Dental Hygienists Associations (NDHAs) were members of the EDHF. During 2020/2021, an online questionnaire and participant information leaflet were distributed by email in each of the 24 countries, whose NDHA is a member of the EFDH or to an EADPH member who was likely to respond. The broad term employment of dental hygienists was taken to include current numbers, place of work (public or private clinics and other locations), whether they were currently working as dental hygienists, their pay, any planned changes in their employment and their participation in continuing education. Twenty-four countries (92%) responded. Hungary and Poland reported that fewer than 35% of their qualified dental hygienists were working as dental hygienists. In 10 countries, often for family reasons, over 40% worked part-time. In 14 countries, over 70% worked in private clinics. Average annual pay ranged from €8400 in public clinics in Poland to €106,000 in dental hygienist-owned clinics in Denmark Regular participation in continuing education was mandatory in only nine countries. Dental hygienists play a different role within the oral healthcare system in each European country. There is a wide variation in their education, places of employment, annual pay and continuing education requirements.

Towards a Conscious Digital Generation: Efforts to Increase Knowledge and Attitudes about Cybersex among Adolescents

The increasing prevalence of cybersex behavior among adolescents presents a growing concern, with potential risks to their physical and mental health. The ease of access and low cost associated with this behavior contribute to its proliferation. Based on interviews with students from X High School in Pariaman, it was found that a significant portion of the student population accesses pornography on the internet when exposed to online advertisements and during casual browsing. The primary objective of this initiative is to nurture a generation of digitally aware youth by enhancing their knowledge and shaping healthier attitudes regarding cybersex. The location of the activities was SMA X Pariaman City. A combination of active and passive approaches was employed. Active methods involved delivering lectures with prepared materials and informative video presentations. Passively, students were provided with informational leaflets and banners placed strategically in the school environment. Pre-test and post-test questionnaires were administered to gauge the effectiveness of the materials and videos in influencing participants' knowledge and attitudes. Statistical analysis, including the Wilcoxon test and Gain Score, reveals a notable increase in expertise and confirms the effectiveness of the counseling efforts. In summary, this program effectively enhances knowledge and attitudes about cybersex among adolescents, marking a significant step in addressing this pressing issue.

Patient information leaflets and package inserts of ibuprofen provided in the UK and Thailand: a comparative assessment.

Written medicine information (WMI) is important for ensuring patients understand and use their medicines optimally, but relatively little research has assessed the quality of available WMI. This study assessed the quality of WMI using a sample of leaflets for ibuprofen in the UK and Thailand. Leaflets were obtained by purchasing a product from retail outlets or community pharmacies, 18 from each country. In the UK, these were patient information leaflets (PILs); in Thailand, they were package inserts PIs not specifically designed for patients. Leaflets were assessed for content, layout, and readability using standard methods and compared to relevant guidelines. The UK PILs were uniform and conformed to EU regulatory requirements for content, whereas Thai PIs varied considerably, many failing to include important information required by Thai regulations. Several forms of Thai PIs were found, including some very short leaflets, containing minimal information. The readability of both was rated as poor, all used small font size and had less than desirable white space. Fewer Thai PIs than UK PILs met the Keystone Criteria for ibuprofen. The extent of variation in format and content of Thai WMI could potentially cause confusion and reduce willingness to read it. PILs, conforming to Thai regulatory guidelines, should be provided with medicines instead. Leaflets in both countries would benefit from improved readability and layout.

Promoting physical activity in rheumatoid arthritis through a physiotherapist led behaviour change-based intervention (PIPPRA): a feasibility randomised trial

Physical activity (PA) is recommended as a key component in the management of people with rheumatoid arthritis (RA). The objective of this study was to examine the feasibility of a physiotherapist led, behaviour change (BC) theory-informed, intervention to promote PA in people with RA who have low levels of current PA. A feasibility randomised trial (ClinicalTrials.gov NCT03644160) of people with RA over 18 years recruited from outpatient rheumatology clinics and classified as insufficiently physically active using the Godin−Shephard Leisure Time Physical Activity Questionnaire. Participants were randomised to intervention group (4 BC physiotherapy sessions in 8 weeks) delivered in person/virtually or control group (PA information leaflet only). Feasibility targets (eligibility, recruitment, and refusal), protocol adherence and acceptability were measured. Health care professionals (HCPs) involved in the study and patients in the intervention and control arms were interviewed to determine acceptability. Descriptive statistics were used to analyse the data with SPSS (v27) with interviews analysed using content analysis using NVivo (v14). Three hundred and twenty participants were identified as potentially eligible, with n = 183 (57%) eligible to participate, of which n = 58 (32%) consented to participate. The recruitment rate was 6.4 per month. Due to the impact of COVID-19 on the study, recruitment took place over two separate phases in 2020 and 2021. Of the 25 participants completing the full study, 23 were female (mean age 60 years (SD 11.5)), with n = 11 allocated to intervention group and n = 14 to control. Intervention group participants completed 100% of sessions 1 & 2, 88% of session 3 and 81% of session 4. The study design and intervention were acceptable overall to participants, with enhancements suggested. The PIPPRA study to improve promote physical activity in people with RA who have low PA levels was feasible, acceptable and safe. Despite the impact of COVID-19 on the recruitment and retention of patients, the study provides preliminary evidence that this physiotherapist led BC intervention is feasible and a full definitive intervention should be undertaken. Health care professionals involved in the study delivery and the patient participants described a number of positive aspects to the study with some suggestions to enhance the design. These findings hence inform the design of a future efficacy-focused clinical trial.

Prescriptions of homeopathic remedies at the expense of the German statutory health insurance from 1985 to 2021: scientific, legal and pharmacoeconomic analysis

The prescription of homeopathic remedies at the expense of the statutory health insurance (SHI) system in Germany has been criticized for years due to a lack of evidence. Now, on the planned abolition of the reimbursement of homeopathic medicines in Germany, the debate on this topic has been reignited. The aim of this paper is to show the costs and their development over time incurred by homeopathic remedies in the healthcare system from 1985 to 2021. For this purpose, 15 selected homeopathic medicines were chosen from the drug prescription report (Arzneiverordnungsreport) and analyzed with regard to their development of DDD (Defined Daily Dose) using data from the Wissenschaftliches Institut der Ortskrankenkassen (WidO, Scientific Institute of the General Local Health Insurance Funds) and compared with their respective rational pharmacological alternatives. The price comparison was based on the DDD costs and the pharmacy retail price of the smallest packaging in each case. The clinical study situation for the preparations was also analyzed. For this purpose, the clinical studies provided by the manufacturer and those on PubMed were divided into evidence levels and analyzed. In addition, the presentation of homeopathic remedies on company websites, in online pharmacies, in specialist information and package leaflets was analyzed with regard to side effects, interactions, indication, and information on the alleged effect/proof of efficacy. In many media, information on homeopathic medicines remained incomplete, and non-compliance with the Therapeutic Product Advertising Act (Heilmittelwerbegesetz) was noted. Naming of the products if often very suggestive, too. Manufacturers’ claims of efficacy go far beyond what can be considered proven in terms of evidence-based medicine and the quality of most clinical studies is poor. Homeopathic remedies are on average significantly more expensive than their rational pharmacological alternatives. Furthermore, DDD costs have continued to rise over the years analyzed. In aggregate, from a pharmacoeconomic, legal, and scientific perspective, abolition of reimbursement of homeopathic medicines in Germany at the expense of the SHI system is well justified.

A multi-component intervention increased access to smoking cessation treatment after hospitalization for atherosclerotic cardiovascular disease: a randomized trial.

To evaluate the effects of a multi-component intervention for smokers hospitalized for atherosclerotic cardiovascular disease (ASCVD) on the participation rate in community-based cessation programmes and the use of cessation drugs. Additionally, to explore the impact on the cessation rates at 6 months. A randomized parallel-group study was conducted at a Norwegian secondary care hospital in 2021. The intervention group was: (i) counselled using motivational interviewing techniques during hospitalization; (ii) given an information leaflet, detailing the cessation programme; and (iii) referred to the community-based smoking cessation treatment including a post-discharge pro-active telephone invitation. The control group received usual care and the same information leaflet containing clear contact details for initiating participation. Data were collected at baseline, 1, 3, and 6 months. Among 99 smokers hospitalized with ASCVD, 40 were excluded. Of 59 randomized patients, 4 were lost to follow-up and 55 completed the study. The mean age was 65.1 (standard deviation 9.3) years, 35% were female, and 88% had smoked >20 years. Co-morbidity was prevalent (mean Charlson score 4.8). The intervention group was more likely to participate in the smoking cessation treatment {48 vs. 7%, difference: 41% [95% confidence interval (CI): 14%, 63%]} and used cessation drugs more frequently [59 vs. 21%, difference: 38% (95% CI: 17%, 59%)]. At the 6 months point prevalence, we observed notable between-group differences in self-reported cessation rate (48 vs. 25%). The intervention significantly increased the participation rate at community-based smoking cessation programmes and the use of cessation drugs among multi-morbid smokers hospitalized for ASCVD.

Evaluation of ChatGPT for Pelvic Floor Surgery Counseling.

Large language models are artificial intelligence applications that can comprehend and produce human-like text and language. ChatGPT is one such model. Recent advances have increased interest in the utility of large language models in medicine. Urogynecology counseling is complex and time-consuming. Therefore, we evaluated ChatGPT as a potential adjunct for patient counseling. Our primary objective was to compare the accuracy and completeness of ChatGPT responses to information in standard patient counseling leaflets regarding common urogynecological procedures. Seven urogynecologists compared the accuracy and completeness of ChatGPT responses to standard patient leaflets using 5-point Likert scales with a score of 3 being "equally accurate" and "equally complete," and a score of 5 being "much more accurate" and much more complete, respectively. This was repeated 3 months later to evaluate the consistency of ChatGPT. Additional analysis of the understandability and actionability was completed by 2 authors using the Patient Education Materials Assessment Tool. Analysis was primarily descriptive. First and second ChatGPT queries were compared with the Wilcoxon signed rank test. The median (interquartile range) accuracy was 3 (2-3) and completeness 3 (2-4) for the first ChatGPT query and 3 (3-3) and 4 (3-4), respectively, for the second query. Accuracy and completeness were significantly higher in the second query (P < 0.01). Understandability and actionability of ChatGPT responses were lower than the standard leaflets. ChatGPT is similarly accurate and complete when compared with standard patient information leaflets for common urogynecological procedures. Large language models may be a helpful adjunct to direct patient-provider counseling. Further research to determine the efficacy and patient satisfaction of ChatGPT for patient counseling is needed.

Patient information videos via QR codes: An innovative and sustainable approach in ophthalmology.

We explore an innovative approach by transforming patient information leaflet (PILs) into Quick Response (QR) code linked patient information videos (PIVs) in ophthalmology. Our objectives are to assess the subjective utility of a PIV on glaucoma and analyse the use of QR codes as a delivery method. A prospective study was conducted in Ninewells Hospital, NHS Tayside. A glaucoma PIV was created and linked to a QR code provided to 130 glaucoma patients. Pre- and post-video questionnaires evaluated the patients' perception of using a QR code and subjective improvement in their understanding of glaucoma. Out of 102 responses collected, 55% of patients had no prior experience with QR codes. However, 81% of patients were able to watch the PIV. The average view duration of the video was 3:26, with 82.5% view retention. Statistically significant improvement in glaucoma knowledge was observed across all six areas questioned (p < 0.001) using a 5-point Likert scale. Overall, 70% of patients preferred PIVs over PILs, and 77% acknowledged that PIVs could be a sustainable alternative. QR codes for delivering PIVs were well-received, with patients finding them easy to use. Our PIV on glaucoma effectively enhanced patients' understanding of the condition.

Patient leaflets on respiratory tract infections did not improve shared decision making and antibiotic prescriptions in a low-prescriber setting

Patient information leaflets can reduce antibiotic prescription rates by improving knowledge and encouraging shared decision making (SDM) in patients with respiratory tract infections (RTI). The effect of these interventions in antibiotic low-prescriber settings is unknown. We conducted a pragmatic pre-/post interventional study between October 2022 and March 2023 in Swiss outpatient care. The intervention was the provision of patient leaflets informing about RTIs and antibiotics use. Main outcomes were the extent of SDM, antibiotic prescription rates, and patients’ awareness/knowledge about antibiotic use in RTIs. 408 patients participated in the pre-intervention period, and 315 patients in the post- intervention period. There was no difference in the extent of SDM (mean score (range 0–100): 65.86 vs. 64.65, p = 0.565), nor in antibiotic prescription rates (no prescription: 89.8% vs. 87.2%, p = 0.465) between the periods. Overall awareness/knowledge among patients with RTI was high and leaflets showed only a small effect on overall awareness/knowledge. In conclusion, in an antibiotic low-prescriber setting, patient information leaflets may improve knowledge, but may not affect treatment decisions nor antibiotic prescription rates for RTIs.

Development and Validation of Patient Information Leaflet for Schizophrenia

Abstract Context: People with severe mental illnesses like schizophrenia demonstrate a high rate of therapeutic noncompliance in contrast to other forms of mental illnesses. Educating patients regarding the disease and treatment helps to overcome the barriers of their resistance toward the prescribed regimen. Numerous tools have been developed for educating patients and the most convenient and cost-effective form of educational tool is a leaflet. Aims: The study aims to develop and validate a patient information leaflet (PIL) for patients with schizophrenia. Methods: The PIL contents were generated from various sources of literature and discussion with several experts in the fields of psychiatry, dietetics, and pharmacy, followed by validation using the content validation index (CVI) method. The Flesch reading ease (FRE) and Flesch–Kincaid Grade Level (FKGL) formulas were employed to assess readability and evaluate layout and design, Baker-Able Leaflet Design (BALD) criteria were utilized. Results: The prepared draft PIL obtained CVI scores of 0.94 (relevance) and 0.84 (clarity), indicating good content validity. The readability scores 74.4 (FRE) and 4 (FKGL) denoted that the textual contents in the PIL are relatively easy to read by any person with an educational grade of four and above. The BALD scores of 29 (English) and 26 (Malayalam and Kannada) represent the PIL good layout and design. Conclusion: A draft PIL for patients with schizophrenia is prepared and validated. Further user-testing analysis is needed to evaluate the PIL’s efficiency in the target population.

Developing interventions to improve detection of depression in primary healthcare settings in rural Ethiopia.

The poor detection of depression in primary healthcare (PHC) in low- and middle-income countries continues to threaten the plan to scale up mental healthcare coverage. To describe the process followed to develop an intervention package to improve detection of depression in PHC settings in rural Ethiopia. The study was conducted in Sodo, a rural district in south Ethiopia. The Medical Research Council's framework for the development of complex interventions was followed. Qualitative interviews, observations of provider-patient communication, intervention development workshops and pre-testing of the screening component of the intervention were conducted to develop the intervention. A multicomponent intervention package was developed, which included (a) manual-based training of PHC workers for 10 days, adapted from the World Health Organization's Mental Health Gap Action Programme Intervention Guide, with emphasis on depression, locally identified depressive symptoms, communication skills, training by people with lived experience and active learning methods; (b) screening for culturally salient manifestations of depression, using a four-item tool; (c) raising awareness among people attending out-patient clinics about depression, using information leaflets and health education; and (d) system-level interventions, such as supportive supervision, use of posters at health facilities and a decision support mobile app. This contextualised, multicomponent intervention package may lead to meaningful impact on the detection of depression in PHC in rural Ethiopia and similar settings. The intervention will be pilot tested for feasibility, acceptability and effectiveness before its wider implementation.

N-of-1 Trials of Antimicrobial Stewardship Interventions to Optimize Antibiotic Prescribing for Upper Respiratory Tract Infection in Emergency Departments: Protocol for a Quasi-Experimental Study.

Antimicrobial stewardship programs attempting to optimize antibiotic therapy and clinical outcomes mainly focus on inpatient and outpatient settings. The lack of antimicrobial stewardship program studies in the emergency department (ED) represents a gap in tackling the problem of antimicrobial resistance as EDs treat a substantial number of upper respiratory tract infection cases throughout the year. We intend to implement two evidence-based interventions: (1) patient education and (2) providing physician feedback on their prescribing rates. We will incorporate evidence from a literature review and contextualizing the interventions based on findings from a local qualitative study. Our study uses a quasi-experimental design to evaluate the effects of interventions over time in the EDs of 4 public hospitals in Singapore. We will include an initial control period of 18 months. In the next 6 months, we will randomize 2 EDs to receive 1 intervention (ie, patient education) and the other 2 EDs to receive the alternative intervention (ie, physician feedback). All EDs will receive the second intervention in the subsequent 6 months on top of the ongoing intervention. Data will be collected for another 6 months to assess the persistence of the intervention effects. The information leaflets will be handed to patients at the EDs before they consult with the physician, while feedback to individual physicians by senior doctors is in the form of electronic text messages. The feedback will contain the physicians' antibiotic prescribing rate compared with the departments' overall antibiotic prescribing rate and a bite-size message on good antibiotic prescribing practices. We will analyze the data using segmented regression with difference-in-difference estimation to account for concurrent cluster comparisons. Our proposed study assesses the effectiveness of evidence-based, context-specific interventions to optimize antibiotic prescribing in EDs. These interventions are aligned with Singapore's national effort to tackle antimicrobial resistance and can be scaled up if successful. ClinicalTrials.gov NCT05451863; https://clinicaltrials.gov/study/NCT05451836. DERR1-10.2196/50417.

REMOVAL OF SOFT CAST AT HOME AFTER PAEDIATRIC TRAUMA IS SAFE AND CONVENIENT FOR CAREGIVERS

At-home softcast removal with no routine clinical follow-up has shown to be safe and effective following paediatric orthopaedic trauma. It minimises clinician contact time and reduces cost. However, there is limited data on the caregiver experience.Retrospective analysis of paediatric fractures requiring application of circumferential softcast that was later removed at home. Two time points were included: (1)July–September 2022, (2)February–April 2023. Demographics data included age, fracture classification, angulation, manipulation requirement, complications or unplanned re-attendance. Caregivers were given an information leaflet on cast removal. Caregivers completed a telephone Likert questionnaire reviewing time taken to remove cast, qualitative descriptors of cast removal and overall satisfaction.77 families were contacted at mean 93 days post injury. Mean age was 7.5 years. 41(53%) were distal radius and 20(26%) both-bone forearm fractures. The remaining were hand, elbow or tibia injuries. 40(52%) injuries required manipulation under procedural sedation with mean sagittal angulation 24 degrees. 13(17%) patients re-attended with cast problems. Caregivers estimated a mean 13 minutes to remove cast. 83% found it ‘extremely’ or ‘somewhat’ easy. 75% were ‘extremely’ or ‘somewhat’ satisfied. 71% were ‘extremely’ or ‘somewhat’ likely to recommend at-home cast removal. Qualitative descriptors ranged from from ‘traumatising’ to ‘fun’ and ‘straightforward’.The experience at our tertiary centre confirms at-home softcast removal with no further orthopaedic follow-up is safe and feasible, even in those requiring manipulation under sedation. The majority of families reported a positive experience; this however is not universal. Adequate patient information resources are integral to a positive caregiver's experiences.

Brief Intervention as a Method to Reduce Z-Hypnotic Use by Older Adults: Feasibility Case Series.

Z-hypnotics or z-drugs are commonly prescribed for insomnia and sleep difficulties in older adults. These drugs are associated with adverse events and dependence and are not recommended for long-term use. Despite evidence of older adults being more sensitive to a wide array of adverse events and clinical guidelines advocating limiting use, inappropriate use in this population is still prevalent. Previous intervention studies have focused mainly on prescriber information. Simple, individually focused intervention designs are less studied. Brief intervention (BI) is a simple, easily transferable method mainly used to treat patients at risk of alcohol overuse. Our objective was to design and test the feasibility and acceptability of a BI intervention adapted to address individual, inappropriate use of z-hypnotics among older adults. This preparatory study aimed to optimize the intervention in advance of a quantitative randomized controlled trial investigating the treatment effect in a larger population. This feasibility case series was conducted at Akershus University Hospital, Norway, in autumn 2021. We included 5 adults aged ≥65 years with long-term (≥4 weeks) use of z-hypnotics and 2 intervening physicians. Additionally, 2 study investigators contributed with process evaluation notes. The BI consists of information on the risk of inappropriate use and individualized advice on how to reduce use. The focus of the intervention is behavioral and aims, in cooperation with the patient and based on shared decision-making, to change patient behavior regarding sleep medication rather than physician-based detoxification and termination of z-hypnotic prescriptions. Qualitative and descriptive quantitative data were collected from intervening physicians, study investigators, and participants at baseline, immediately after the intervention, and at the 6-week follow-up. Data were obtained from 2 physicians, 2 study investigators, and 5 participants (4 women) with a median age of 84 years. The average time spent on the BI consultation was 15 minutes. All 5 participants completed the intervention without problems. The participants and 2 intervening physicians reported the intervention as acceptable and were satisfied with the delivery of the intervention. After the intervention, 2 participants stopped their use of z-hypnotics completely and participated in the follow-up interview. Study investigators identified logistical challenges regarding location and time requirements. Identified aspects that may improve the intervention and reduce dropouts included revising the intervention content, focusing on rebound insomnia, adding an information leaflet, and supporting the patient in the period between the intervention and follow-up. The notion that the intervention should best be located and conducted by the patient's own general practitioner was supported by the participants. We identified important aspects to improve the designed intervention and found that the BI is feasible and acceptable for incorporation into a larger randomized trial investigating the treatment effect of BI for reducing z-hypnotic use by older adults. ClinicalTrials.gov NCT03162081; http://tinyurl.com/rmzx6brn.