Local Outpatient Clinics Research Articles

Use of opioids among pregnant women 1997–2016: A Danish drug utilization study

ObjectiveUse of opioids in pregnancy is of concern yet little is known on opioid prescription patterns in Denmark. The aim of this drug utilization study was to describe prescription patterns for opioids during pregnancy in Denmark from 1997 to 2016. Study designUsing the nationwide health care registers, we obtained information on all women with a registered pregnancy in the period 1 January 1997 to 31 December 2016. Opioids were grouped in four: opioids (N02A except codeines), opioid dependency medications (N07BC), cough medications (R05DA except codeines), and codeines (N02AJ06, N02AJ07, N02BA75, and R05DA04). We used logistic regression analyses to identify factors associated with opioid use in pregnancy and cumulative oral morphine equivalent (OMEQ) to estimate volume of use in pregnancy. ResultsPrescription patterns were similar for women with live births, non-live births, and terminations. Total use of opioids among women with live born deliveries remained stable at 19.8 per 1000 pregnancies from 1997 to 2016. Codeine use declined from 2008 onwards, while use of other opioids increased from 2007 onwards. This was dominated by a threefold increase in tramadol use (2.0–7.6 per 1000 pregnancies with live births). Codeine was the most used opioid, followed by tramadol and codeine combined with paracetamol. The number of women, who used opioids before pregnancy and continued into their pregnancy, was reduced as the pregnancy progressed. The cumulative oral morphine equivalent during pregnancy was stable until 2007, after which, use prior to pregnancy and during the first two trimesters increased. The odds ratios for opioid use were higher in pregnancies of women of lower socioeconomic status or older age. For live births, odds ratios for opioid use in pregnancy were higher among women with obesity or smoking. ConclusionsOverall use of opioids was stable from 2007 to 2016. This covers a decline in the use of codeine, but a 3-fold increase in tramadol. The number of pregnant women who continued use throughout pregnancy decreased, while OMEQ among persistent users increased. The real-world data suggest an unmet need of specific focus in local Danish Outpatient Clinics and Multidisciplinary Pain Centers both pre-conceptionally and during pregnancy.

The PONTE (PDTA FOR INTEGRATED FOLLOW-UP TERRITORY HOSPITAL OF THE PATIENT WITH CARDIAC HEART FAILURE) (BRIDGE) Heart Failure project: increased adherence to guideline-recommended therapies through web-based shared clinical database.

The aim of this study was to evaluate the effects on the adherence of drug prescription to the guideline recommendations of a chronic care model based on the close interaction between hospital and local healthcare district cardiologists through a shared web-based database. From 2018 to 2021, patients hospitalized for an episode of acute decompensated heart failure (HF) (de novo or worsening) in cardiology wards from the healthcare district of Bari, Italy, were enrolled. The follow-up programme was based on a first visit after discharge within 1 month; patients were therefore addressed to the local health district cardiologist outpatient clinics when not requiring further invasive investigations and haemodynamically stable and followed-up with at least one visit every 6 months. In order to share in-hospital patients’ data with outpatient clinics, at discharge, they were entered in a web-based database accessible for all cardiologists and centres participating in the Ponte Project. The group of patients affected by HF with reduced ejection fraction (HFrEF) were considered for the analyses. Drug prescription rates at 1-year follow-up were analysed as endpoint, as well as the re-admission for HF worsening. Out of 1200 HF patients enrolled in the project until December 2021, 56% were affected by HFrEF. At 1-year follow-up, 91% of patients were assuming beta-blockers, 86% mineralocorticoid receptor antagonists, 98% angiotensin-converting enzyme inhibitors/angiotensin receptor antagonists/neprilysin angiotensin receptor antagonists, and 13% ARNI. Compared to patients enrolled before 2020, ARNI prescription increased in 2021 (60% vs. 13%, respectively, P < 0.001). In 30% of patients, ARNI were prescribed before hospital discharge. Furthermore, in 10% of the population (most diabetics), sodium-glucose cotransporter 2 inhibitors were also prescribed. The implementation of the PONTE project was associated with an improved adherence to guidelines recommendations.

КОМПЛЕКСНЫЙ АНАЛИЗ РЕЗУЛЬТАТИВНОСТИ И ЭФФЕКТИВНОСТИ ДЕЯТЕЛЬНОСТИ МЕДИЦИНСКИХ ОРГАНИЗАЦИЙ СТАВРОПОЛЬСКОГО КРАЯ, ОКАЗЫВАЮЩИХ ПЕРВИЧНУЮ МЕДИКО-САНИТАРНУЮ ПОМОЩЬ В УСЛОВИЯХ РЕАЛИЗАЦИИ ПРИНЦИПОВ БЕРЕЖЛИВОГО ПРОИЗВОДСТВА В ЗДРАВООХРАНЕНИИ

Significance. A large number of efforts of health professional, as well as many modern targeted programs and projects are aimed at developing primary health care, including the Federal project "Lean polyclinic". The principles of lean manufacturing gained momentum in the priority project "Creation of a new model of medical organization providing primary health care (2017-2022)". Increasing patient satisfaction, access to services, elimination of the existing time, financial and other losses, as well as organization of safe and comfortable workplaces for employees improve performance effectiveness and efficiency of medical organizations. The purpose of the study. Scientific substantiation of the adoption of evidence-based management decisions for developing primary healthcare sector based on results of the independent comprehensive assessment of primary care quality and accessibility in the Stavropol Territory. Material and Methods. The present study assessed the quality and accessibility of primary health care in the Stavropol Territory over the period 2014-2020 according to the improved methodology of integral indicators and well-being index with adaptation to the structural transformations in health care. All medical organizations providing outpatient medical care (multidisciplinary hospitals and central city hospitals with attached population; individual polyclinics; district hospitals and central district hospital; local hospitals and outpatient clinics) were included in the study. The methodology has been adapted and improved to reflect changes in information sources in accordance with the adjustment of federal and sectoral statistical observation forms in 2019-2020. Conclusion. A comprehensive assessment of quality and accessibility of primary health care in the Stavropol Territory in 2014-2020 showed a multidirectional well-being index as an integral assessment criterion. In the period 2014-2019, all medical organizations that provide primary health care had a pronounced positive well-being index. In the conditions of the COVID-19 pandemic, the primary health care sector has been actively involved in providing diagnostics and treatment to patients with COVID-19, reflected by the decrease in the average well-being index in dynamics in comparing 2020 to 2014. However, the study results show that the decrease in the well-being index was not pronounced due to sustaining lean manufacturing principles in the primary care sector during the COVID-19 pandemic. Scope of application. Chief physicians of medical organizations, managers, executors of the project "Lean Polyclinic" can use the study results in order to improve efficiency and effectiveness of medical organizations of the Stavropol Territory, providing primary health care.

On the prevention of agricultural injuries in the Arsk region of the TASSR

In order to understand the causes of agricultural injuries and to outline measures to reduce it, since 1959 we have conducted records of all injuries at feldsher-obstetric points, in local hospitals and outpatient clinics, in a district hospital and a polyclinic. For all cases of injuries with loss of ability to work, trauma cards are filled out, cases of injuries without loss of ability to work were registered in a separate journal in a specific form.

Investigation into the psychological resilience of family caregivers burdened with in-home treatment of patients with bipolar disorder

Family members of patients with bipolar disorder experience burden associated with in-home treatment in Guangdong Province of China. This group of people is frequently being overlooked. The aim is to investigate into the levels of burden and the psychological resilience of these caregivers. 172 family caregivers were recruited from two local outpatient clinics using questionnaires for a descriptive study. Semi-structured interviews with 12 participants were also conducted to identify themes related to the difficulties, strengths, and limitations of caregiving. The caregiver burden was moderate (33.53±14.43) and their psychological resilience score (57.34±12.09) was below the national norm. The impact of caregivers' burden on the psychological resilience was statistically significant(P<0.05). Age, occupation, and the cumulative length of time for caregiving had different effects on levels of burden and resilience. The findings indicate more support is needed for the family caregivers. The geographical location limits the generalizability of the findings and sample size. Other constraints include the convenient sampling method and individual factors.

National Evaluation of Patient Preferences in Selecting Hospitals and Health Care Providers.

Patient utilization of public reporting has been suboptimal despite attempts to encourage use. Lack of utilization may be due to discordance between reported metrics and what patients want to know when making health care choices. The objective of this study was to identify measures of quality that individuals want to be presented in public reporting and explore factors associated with researching health care. Patient interviews and focus groups were conducted to develop a survey exploring the relative importance of various health care measures. Interviews and focus groups conducted at local outpatient clinics. A survey administered nationally on an anonymous digital platform. Likert scale responses were compared using tests of central tendency. Rank-order responses were compared using analysis of variance testing. Associations with binary outcomes were analyzed using multivariable logistic regression. Overall, 4672 responses were received (42.0% response rate). Census balancing yielded 2004 surveys for analysis. Measures identified as most important were hospital reputation (considered important by 61.9%), physician experience (51.5%), and primary care recommendations (43.2%). Unimportant factors included guideline adherence (17.6%) and hospital academic affiliation (13.3%, P<0.001 for all compared with most important factors). Morbidity and mortality outcome measures were not among the most important factors. Patients were unlikely to rank outcome measures as the most important factors in choosing health care providers, irrespective of age, sex, educational status, or income. Patients valued hospital reputation, physician experience, and primary care recommendations while publicly reported metrics like patient outcomes were less important. Public quality reports contain information that patients perceive to be of relatively low value, which may contribute to low utilization.

Correlation between physician assistant students' performance score of history taking and physical exam documentation and scores of Graduate Record Examination, clinical year grade point average, and score of Physician Assistant National Certifying Exam in the United States.

PurposeLearning to perform and document patient history taking and physical exam (H&P) entails a major component of the first year academic education of physician assistant (PA) students at Wayne State University, USA. The H&P is summative of multiple aspects of PA education, and students must master communication with patients and other health care providers. The objectives of this study were first, to determine if there was a correlation between scores on the Graduate Record Examination (GRE) component testing and scores on graded H&Ps. The second objective was to identify a correlation between proficiency with H&P documentation and academic and clinical year grade point average (GPA) and Physician Assistant National Certifying Exam (PANCE) score.MethodsSubjects included 147 PA students from Wayne State University from 2014–2016. PA students visited local hospitals or outpatient clinics during the academic year to perform and document patient H&Ps. Correlation between the H&P mean scores and GRE component scores, GPAs, and PANCE scores were analyzed.ResultsThe subjects were 26.5 years-old (+6.5) and 111 females (75.5%). There was no correlation between the GRE component score and the H&P mean score. The H&P score was positively correlated with GPA 1 (r=0.512, P<0.001), with GPA 2 (r=0.425, P<0.001) and with PANCE score (r=0.448, P<0.001).ConclusionPA student skill with H&P documentation was positively related to academic performance score during PA school and achievement score on the PANCE at Wayne State University, USA.

Features of the Organism`s Adaptation of Female Obstetrician-Gynecologists to the Existing Working Conditions

Objective: to establish the features of the organism`s adaptation of female obstetrician-gynecologists to the existing working conditions .Material and methods. The features of the organism`s adaptation of female obstetrician-gynecologists (main group, n = 64) of in-patient and maternity welfare clinics, therapists of local territorial out-patient clinics (comparison group, n = 31), as well as female employees of health organizations with higher education not providing medical care (control group, n = 31) to the existing working conditions were evaluated on the basis of sociological, hygienic, and statistical research methods.Results. The obstetrician-gynecologists worked in harmful working conditions: class 3.3. - in the in-patient hospitals and class 3.2. - in the out-patient clinics. Almost half of the examined female obstetrician-gynecologists revealed decreased adaptive reserves of the organism, whose degree of manifestation was reliably different from the women of the control group (p ˂ 0.05).Conclusion. The harmful working conditions at the workplaces of female obstetrician-gynecologists lead to the breakdown of the organism`s adaptive mechanisms and create a professional risk for the subsequent development of a wide range of somatic pathologies.

Teleneurology for Veterans in a Major Metropolitan Area.

The recent growth in telehealth has been facilitated by the need to deliver healthcare to patients living in remote or rural areas. In contrast, the role of telehealth in more urban settings is less clear. A teleneurology program was established in 2011 at the Tibor Rubin VA Medical Center (TRVAMC) in Long Beach, California. A review of teleneurology encounters was conducted to assess the feasibility of applying this telehealth modality to patients with chronic neurological disorders living in an urban setting. Teleneurology encounters were conducted by clinical video telehealth (CVT) between a provider at the TRVAMC and patients at local community-based outpatient clinics from November 2011 to December 2014. In a random sampling of veterans, they were asked to complete a patient satisfaction survey. A total of 745 teleneurology encounters were performed including 570 unique patients. Veterans with a broad range of neurological disorders were seen, including Parkinson's disease, headaches, epilepsy, dementia, cerebrovascular disease, peripheral nervous system disorders, multiple sclerosis, and other problems such as dizziness and paresthesia. Compared with patients in face-to-face clinics, patients in teleneurology clinics consistently kept their appointments. Technical problems were rare and easily resolved. The majority of patients were satisfied with the care they received through teleneurology, and preferred CVT rather than a face-to-face encounter. This report demonstrates the successful application of telehealth to evaluate and manage a diverse group of neurological disorders in an urban setting. Despite the relatively short distances involved, the majority of patients preferred telehealth over face-to-face encounters.

Associations of Toll-Like Receptor and β-Defensin Polymorphisms with Measures of Periodontal Disease (PD) in HIV+ North American Adults: An Exploratory Study

Polymorphisms in toll-like receptor (TLR) and β-defensin (DEFB) genes have been recognized as potential genetic factors that can influence susceptibility to and severity of periodontal diseases (PD). However, data regarding associations between these polymorphisms and PD are still scarce in North American populations, and are not available in HIV+ North American populations. In this exploratory study, we analyzed samples from HIV+ adults (n = 115), who received primary HIV care at 3 local outpatient HIV clinics and were monitored for PD status. We genotyped a total of 41 single nucleotide polymorphisms (SNPs) in 8 TLR genes and copy number variation (CNV) in DEFB4/103A. We performed regression analyses for levels of 3 periodontopathogens in subgingival dental plaques (Porphyromonas gingivalis [Pg], Treponema denticola [Td], and Tannerella forsythia [Tf]) and 3 clinical measures of PD (periodontal probing depth [PPD], gingival recession [REC], and bleeding on probing [BOP]). In all subjects combined, 2 SNPs in TLR1 were significantly associated with Td, and one SNP in TLR2 was significantly associated with BOP. One of the 2 SNPs in TLR1 was significantly associated with Td in Caucasians. In addition, another SNP in TLR1 and a SNP in TLR6 were also significantly associated with Td and Pg, respectively, in Caucasians. All 3 periodontopathogen levels were significantly associated with PPD and BOP, but none was associated with REC. Instrumental variable analysis showed that 8 SNPs in 6 TLR genes were significantly associated with the 3 periodontopathogen levels. However, associations between the 3 periodontopathogen levels and PPD or BOP were not driven by associations with these identified SNPs. No association was found between DEFB4/103A CNV and any periodontopathogen level or clinical measure in all samples, Caucasians, or African Americans. Our exploratory study suggests a role of TLR polymorphisms, particularly TLR1 and TLR6 polymorphisms, in PD in HIV+ North Americans.

The Child Health Care System of Serbia

The health care system in Serbia is based on a network of public health institutions funded by the National Health Insurance and from the state budget. Access to public health institutions is free. Preventive and curative services are provided at the local level in primary health care centers. Over the past 5-7years, the number of pediatricians in primary health care centers decreased because of reduced number of applicants for pediatric training, which endangers the maintenance of the traditional model of pediatric care. Secondary medical care is offered in pediatricdepartments of local and regional general hospitals or outpatient clinics, and in specialized hospitals for children or adults. Tertiary medical care is provided by inpatient or outpatient subspecialty services in 5 major university children's clinics. The health reforms undertaken in the recent 10years have aimed at strengthening preventive health care and reducing the overall costs for pediatric care. Current initiatives of the Ministry of Healthand nationalpediatric associations are aimed at reestablishing and strengthening the capacity of the primarypediatrichealth care model by increasing the number of physicians and developing new processes of care.

THE EFFECTIVENESS OF OUTPATIENT AND HOSPITAL LIPID-LOWERING THERAPY IN PATIENTS WITH HIGH AND VERY HIGH CARDIOVASCULAR RISK DURING 2011-2015

Aim. To estimate the effectiveness of lipid-lowering therapy (LLT) at outpatient and hospital treatment stages in patients at high and very high cardiovascular risk during 2011-2015. Material and methods . In a cross-sectional epidemiological study we analyzed LLT in hospital patients for the period April-May 2011, 2012 and 2015. All data were obtained from randomly selected case-records of patients (n=548; 20% of all hospital patients over the study period). Risk categories of patients as well as target levels of low density lipoprotein (LDL) cholesterol were determined according to the current clinical guidelines for the respective year. Outpatient LLT was administered in local out-patient clinics and hospital one – in the clinic of State Research Centre for Preventive Medicine. Results . The most commonly prescribed group of lipid-lowering drugs was statins, while combined treatment or monotherapy with other lipid-lowering agents were used only in rare cases. From 2011 to 2015 the proportion of patients taking statins before admission increased from 20% to 49.8% (from 23.1% up to 29.6% of patients at high cardiovascular risk and from 28% up to 68.5% of patients at very high cardiovascular risk, respectively). During hospitalization the proportion of individuals receiving statins increased from 49.8% to 72.9%, from 29.6% to 74% and from 68.5% to 95.3% in general group, among patients at high and very high cardiovascular risk, respectively. In 2015 LDL cholesterol target levels were achieved in 14.8% and 7.1% of patients at high and very high risk, respectively. In-hospital rate of simvastatin administration reduced from 33.6% to 0.5%, whereas prescription of atorvastatin and rosuvastatin increased from 31.4% to 64.5% and from 3.6% to 9.9%, respectively. Average dose of statins (in conversion to atorvastatin) increased from 10 mg to 20 mg in high-risk patients and from 10 mg to 40 mg – in very high risk group. Conclusion . Positive trend in frequency of LLT prescription was demonstrated in patients at high and very high cardiovascular risk during 2011-2015. Nevertheless, significant number of patients in out-patient clinics still remains under non-optimal treatment.

Medical and sanitary unit of JSC «Tatneft» - an example of effective public-private partnership

Aim. To present the experience of the regional medical diagnostic center of Medical and sanitary unit of JSC «Tatneft» and the city of Almetyevsk, considering timeliness, availability and quality of high-tech medical aid.Methods. This paper presents an analysis of high-tech medical care provided to patients with cardiovascular diseases in the private hospital under the state order. A retrospective analysis of the high-tech medical aid of «interventional cardiology» and «cardiovascular surgery» sections provided in 2009-2014.Results. Analysis of the results for the last 5 years showed an annual increase in the number of ongoing research and surgeries in the areas of «interventional cardiology and arrhythmology», «cardiovascular surgery». Hospital mortality from myocardial infarction in Medical and sanitary unit of JSC «Tatneft» and the city of Almetyevsk in the last 3 years did not exceed 9%. Actively launched «Hybrid Surgery» project allowed to perform complex operations on the aorta and aortic valve in patients with a high risk at open surgery. «Electronic out-patient clinic», the system for data management, is introduced at the medical and sanitary unit, allowing to abandon paper outpatient charts, simplify and accelerate the work of outpatient services. Information-analytical system of the Ministry of Health of the Republic of Tatarstan allows electronic records for performed interventions, following up outpatients who underwent surgeries, timely providing them with preferential drugs through local outpatient clinics. Electronic data management increased the quality of the medical aid, improved its availability and provided better control. Surgical and endovascular treatment of patients with coronary artery disease, hybrid surgery, arrhythmology are the most promising areas in the healthcare development in the southeast of the Republic.Conclusion. Medical and sanitary unit of JSC «Tatneft» and the city of Almetyevsk is an example of effective public-private partnership, using the funding from the state budget of the Republic of Tatarstan and «Tatneft» for completing the state order on providing high-tech medical aid to patients with cardiovascular diseases.

PP.02.05

Objective: Dietary sodium intake has been associated with hypertension and CVD progression. However, the relationship between dietary sodium and nighttime blood pressure (BP) variations is largely unknown. We investigated the association between systolic (SBP) and diastolic (DBP) nighttime BP values and dietary sodium intake reflected by 24-hours (24-h) urinary sodium excretion in Austrian hypertensive patients enrolled in the Styrian Hypertension Trial. Design and method: We recruited 417 hypertensive patients (mean age: 61.7 ± 10.1y; 53.4% women) at local outpatient clinics at the Medical University of Graz who underwent 24-h urine collection and in parallel 24-h ambulatory BP monitoring. Results: Pearson correlation analysis revealed a positive association between 24-h urinary sodium levels (median: 147.0 mmol/24-h = 3.8 g/24-h) and nighttime SBP (r = 0.106; P = 0.030) and DBP (r = 0.125; P = 0.010), respectively. Using multiple regression analysis, 24-h urinary sodium concentration was independently related to nighttime SBP (adjusted beta = 0.144; P = 0.007) and with borderline significance to nighttime DBP (beta = 0.163; P = 0.073). In multivariate adjusted analyses of covariance (ANCOVA) nighttime SBP (mean difference between tertile 1 and 3: 4.3 mmHg; P = 0.030) but not nighttime DBP (mean difference between tertile 1 and 3: 1.7mmHg; P = 0.163) values increased steadily from the first (reference) to the third tertile of 24-h urinary sodium. Conclusions: Cardiovascular risk related to dietary sodium intake might be substantially accounted for by variations of nighttime SBP values according to urinary sodium excretion. Future mechanistic and interventional studies should explore mechanisms and therapeutic strategies behind the dietary sodium and nocturnal BP association and relevant modifying factors.

PO-0045 A Review Of The Availability Of Pec (paediatrician With Expertise In Cardiology) Services In The Uk

Background A national survey completed in 2008 reported that PEC services were available in only 35% of non-specialist paediatric cardiology hospitals in the UK. In 2012, the NHS Specialised Services Commission recommended that there should be an increased level of PEC services in all hospitals as part of their ‘Safe and Sustainable’ review. Aim To determine the availability of PEC services in the UK. Methods An internet-based questionnaire was sent out via PECSIG and NICHe (Neonatologists with Interest in Cardiology and Haemodynamics) contact databases and an NHS directory. Non-responders were followed up via telephone. Results The response rate was 72% (129 of 179 hospitals). Of these hospitals, 69% had established PEC services with at least 1 PEC employed and 19% had two or more PECs. In all centres echocardiograms were performed by either PEC consultants or specialist paediatricians, with support from echo-technicians in 36%. Local PEC-led outpatient clinics ran at least fortnightly in two-thirds (66%) of hospitals, whilst 63% of hospitals held out-reach clinics with a paediatric cardiologist from a specialist centre at least monthly. However, 12 of the hospitals without any PEC services reported that they never held out-reach clinics either. Conclusion There has been a substantial increase in PEC availability in non-specialist paediatric cardiology hospitals (69% as compared to 35% in 2008) but still 31% had no established PEC services. In most but not all hospitals without PEC services, support is offered by tertiary-centres for paediatric cardiology through out-reach clinics.

Creating a safe place for pediatric care: A no hit zone.

Our goal was to create and implement a program, Kosair Children's Hospital's No Hit Zone, which trains health care workers in de-escalation techniques to address parental disruptive behaviors and physical discipline of children commonly encountered in the hospital environment. The Child Abuse Task Force, a multidisciplinary group, along with key hospital administrators developed specific content for the policy, as well as marketing and educational materials. The No Hit Zone policy designates Kosair Children's Hospital as "an environment in which no adult shall hit a child, no adult shall hit another adult, no child shall hit an adult, and no child shall hit another child. When hitting is observed, it is everyone's responsibility to interrupt the behavior as well as communicate system policy to those present." Via a multidisciplinary, collaborative approach, the No Hit Zone was successfully implemented at Kosair Children's Hospital in 2012. Cost was nominal, and the support of key hospital administrators was critical to the program's success. Education of health professionals on de-escalation techniques and intervention with families at the early signs of parental stress occurred via live sessions and online training via case-based scenarios. The No Hit Zone is an important program used to provide a safe and caring environment for all families and staff of Kosair Children's Hospital. Demand for the program continues, demonstrated by the establishment of No Hit Zones at other local hospitals and multiple outpatient clinics. This article offers information for other organizations planning to conduct similar initiatives.

Effect of antimicrobial treatment of acute otitis media on the daily disappearance of middle ear effusion: a placebo-controlled trial.

Antimicrobial treatment reduces the symptoms of acute otitis media (AOM). The effect of antimicrobial treatment on the duration of middle ear effusion (MEE) and concomitant hearing impairment is not known. To determine whether the antimicrobial treatment of AOM reduces the duration of MEE. This randomized, double-blind, placebo-controlled trial involved a total of 84 children with AOM between 6 months and 15 years of age. Participants were recruited from September 14, 1999, to January 4, 2000; October 10, 2005, to December 16, 2005; and September 22, 2009, to June 4, 2012, from among children attending an AOM prevention trial and children visiting local outpatient clinics in Oulu, Finland. Children were randomly allocated to receive either 40 mg/kg of amoxicillin-clavulanate or a placebo mixture per day for 7 days. The primary outcome measure was the time to the disappearance of MEE as defined by a normal tympanogram finding (A curve) from both ears on 2 consecutive measurement days. Parents performed daily tympanometry at home. The study physician performed tympanometry and otoscopy at study entry, after 3 and 7 days, and then weekly until both ears were healthy. The main secondary outcome measures were the time to normal otoscopy findings and the proportion of children without persistent MEE at 14 days and 2 months. Middle ear effusion disappeared 2.0 weeks (13.7 days) earlier (P = .02) in the antimicrobial group (mean time, 2.7 weeks; 95% CI, 1.7-3.7) than in the placebo group (4.7 weeks; 95% CI, 3.6-5.7). Normal otoscopy findings were observed 1.4 weeks sooner in the antimicrobial group than in the placebo group (P = .02). On day 14, 69% of children in the antimicrobial group and 38% in the placebo group had normal tympanometry findings (number needed to treat, 3.2; 95% CI, 2.0-10.5). On day 60, 2 children (5%) in the antimicrobial group and 10 children (24%) in the placebo group had persistent MEE (P = .01). Antimicrobial treatment effectively reduced the duration of MEE and possible concomitant hearing impairment in children with AOM. Antimicrobial treatment also reduced the risk for persistent MEE. clinicaltrials.gov Identifier: NCT01244581.

Aldosterone to Active Renin Ratio Is Associated With Nocturnal Blood Pressure in Obese and Treated Hypertensive Patients: The Styrian Hypertension Study

High aldosterone levels are considered to play a key role in arterial hypertension. Data on the relationship between the aldosterone to active renin ratio (AARR), a quantity of aldosterone excess, and ambulatory blood pressure (BP) monitoring (ABPM) during the night are, however, sparse. Hypertensive patients were recruited from local outpatient clinics who underwent 24-hour urine collection and in parallel ABPM. Plasma aldosterone and renin concentrations were measured by radioimmunoassay. A total of 211 patients (age, 60.2±10.2years; 51.9% female) with a mean systolic/diastolic ABPM value of 128.7±12.8/77.1±9.2mmHg were evaluated. In backwards linear regression analyses adjusted for age, sex, body mass index, smoking, glomerular filtration rate, hemoglobin A1c , N-terminal prohormone of brain natriuretic peptide, urinary sodium/potassium ratio, and ongoing antihypertensive medication, AARR was significantly associated with nocturnal systolic (ß-coefficient: 0.177; P=.017) and diastolic BP (ß-coefficient: 0.162; P=.027). In patients with arterial hypertension, a significant association between AARR and nighttime BP even after adjustment for a broad panel of confounders was found.

Value of prophylactic antibiotics for invasive dental procedures unclear.

The Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, the US National Institutes of Health Trials Register and the metaRegister of Controlled Trials. Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) would be included where available. Due to the low incidence of bacterial endocarditis it was anticipated that few such trials would be found. Cohort and case-control studies were included where suitably matched control or comparison groups had been studied. Two review authors independently selected studies for inclusion then assessed risk of bias and extracted data from the included study. Only one case controlled study met the inclusion criteria. It collected all the cases of endocarditis in the Netherlands over two years, finding a total of 24 people who developed endocarditis within 180 days of an invasive dental procedure, definitely requiring prophylaxis according to current guidelines, and who were at increased risk of endocarditis due to a pre-existing cardiac problem. This study included participants who died because of the endocarditis (using proxies). Controls attended local cardiology outpatient clinics for similar cardiac problems, had undergone an invasive dental procedure within the past 180 days, and were matched by age with the cases. No significant effect of penicillin prophylaxis on the incidence of endocarditis could be seen. No data were found on other outcomes. There remains no evidence that antibiotic prophylaxis is either effective or ineffective against bacterial endocarditis in people considered at risk who are about to undergo an invasive dental procedure. It is not clear whether the potential harms and costs of penicillin administration outweigh any beneficial effect. Ethically, practitioners need to discuss the potential benefits and harms of antibiotic prophylaxis with their patients before a decision is made about administration.

Local psychiatric beds appear to decrease the use of involuntary admission: a case-registry study.

BackgroundStudies on the effect of organizational factors on the involuntary admission of psychiatric patients have been few and yielded inconclusive results. The objective was to examine the importance of type of service-system, level of care, length of inpatient stay, gender, age, and diagnosis on rates of involuntary admission, by comparing one deinstitutionalized and one locally institutionalized service-system, in a naturalistic experiment.Methods5538 admissions to two specialist psychiatric service-areas in North Norway were studied, covering a four-year period (2003-2006). The importance of various predictors on involuntary admission were analyzed in a logistic regression model.ResultsInvoluntary admission to the services was associated with the diagnosis of psychosis, male sex, being referred to inpatient treatment, as well as type of service-system. Patients from the deinstitutionalized system were more likely to be involuntarily admitted.ConclusionsSeveral factors predicted involuntary status, including male sex, the diagnosis of psychosis, and type of service-system. The results suggests that having psychiatric beds available locally may be more favourable than a traditional deinstitutionalized service system with local outpatient clinics and central mental hospitals, with respect to the use of involuntary admission.