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Biomedical subjects

Les Toop

Publications and source records attributed to Les Toop.

15 recordsLinked to original sources
PubMed2005

Increased rates of trimethoprim resistance in uncomplicated urinary tract infection: cause for concern?

AIMS: To assess changes in trimethoprim resistance over 2 years in bacteria causing uncomplicated urinary tract infections (UTIs) presenting to a representative group of general practitioners (GPs) in Christchurch. METHODS: Seventy-six randomly selected GPs in Christchurch (the Christchurch Sentinel network) participated in the study. Using the same methodology as in the previously reported 2000 collection, midstream urine (MSU) samples were prospectively collected for standard microbiological analysis on all women between the ages of 16 and 50 years presenting with symptoms of dysuria and frequency and who had positive dipstick testing for either nitrites, leucocytes, or both. MSUs were submitted for bacterial colony counts and resistance testing of isolates present in numbers >105 cfu/ml of urine. RESULTS: 216 dipstick positive specimens were collected in the survey period; 105 of these fulfilled criteria for significant bacteriuria. Trimethoprim resistance was found in 16 (15.2%) overall, with a resistance rate for Escherichia coli (E. coli) to trimethoprim of 17.7%. When compared to the proportions of organisms resistant in the 2000 study, there were apparent but non significant increases in the total resistance among pathogens (+6.7%) and E. coli resistance (+5.8%). Rates of antibiotic resistance of all organisms to nitrofurantoin (2.9%) and norfloxacin (0.95%) remain low. There was a statistically significant increase in resistance among all women presenting with symptoms and a positive dipstick test (+5.3%; 95% CI: 1.5%-9.1%). For a woman in this age group presenting with symptoms of urinary tract infection and a positive dipstick test, we estimate that her probability of having a trimethoprim-resistant organism in 2002 was 7.4% compared with 2.7% in 2000. CONCLUSION: Trimethoprim resistance of E. coli causing uncomplicated UTI appears to be rising in Christchurch. This may reflect the promotion and extensive use of this agent as first-line treatment. Whilst these data indicate that trimethoprim remains a reasonable first-line empiric treatment in this condition, this may change if trimethoprim resistance continues to rise. The apparent increase over a relatively short period (2-3 years) demonstrates the importance of regular surveillance. A third study is required to confirm whether this is a significant trend.

Adolescent↗
PubMed2005

Response to antibiotics of women with symptoms of urinary tract infection but negative dipstick urine test results: double blind randomised controlled trial.

OBJECTIVE: To assess the effectiveness of antibiotic treatment of women with symptoms of urinary tract infection but negative urine dipstick testing. DESIGN: Prospective, double blind, randomised, placebo controlled trial. SETTING: Primary care, among a randomly selected group of general practitioners in Christchurch, New Zealand. PARTICIPANTS: 59 women aged 16-50 years presenting with a history of dysuria and frequency in whom a dipstick test of midstream urine was negative for both nitrites and leucocytes. Participants with complicated urinary tract infection were excluded. INTERVENTION: Trimethoprim 300 mg daily for three days or placebo. MAIN OUTCOME MEASURES: Self reported diary of symptoms for seven days, recording the presence or absence of individual symptoms each day, followed by a structured telephone questionnaire after seven days. The main clinical outcome was resolution of dysuria at three and seven days and median time to resolution. Secondary outcomes were resolution of other symptoms. RESULTS: The median time for resolution of dysuria was three days for trimethoprim compared with five days for placebo (P = 0.002). At day 3, five (24%) of patients in the treatment group had ongoing dysuria compared with 20 (74%) in the placebo group (P = 0.005). This difference persisted until day 7: two patients (10%) in the treatment group v 11 (41%) in the placebo group; P = 0.02). The number needed to treat was 4. The median duration of constitutional symptoms (feverishness, shivers) was reduced by four days. CONCLUSIONS: Although a negative dipstick test for leucocytes and nitrites accurately predicted absence of infection when standard microbiological definitions were used (negative predictive value 92%), it did not predict response to antibiotic treatment. Three days' treatment with trimethoprim significantly reduced dysuria in women whose urine dipstick test was negative. These results support the practice of empirical antibiotic use guided by symptoms. Balancing the competing interests of symptom relief and the minimisation of antibiotic use remains a dilemma-further research is needed to determine clinical predictors of response to antibiotics.

Adolescent↗
PubMed2004

Randomised controlled trial of intravenous antibiotic treatment for cellulitis at home compared with hospital.

OBJECTIVES: To compare the efficacy, safety, and acceptability of treatment with intravenous antibiotics for cellulitis at home and in hospital. DESIGN: Prospective randomised controlled trial. SETTING: Christchurch, New Zealand. PARTICIPANTS: 200 patients presenting or referred to the only emergency department in Christchurch who were thought to require intravenous antibiotic treatment for cellulitis and who did not have any contraindications to home care were randomly assigned to receive treatment either at home or in hospital. MAIN OUTCOME MEASURES: Days to no advancement of cellulitis was the primary outcome measure. Days on intravenous and oral antibiotics, days in hospital or in the home care programme, complications, degree of functioning and pain, and satisfaction with site of care were also recorded. RESULTS: The two treatment groups did not differ significantly for the primary outcome of days to no advancement of cellulitis, with a mean of 1.50 days (SD 0.11) for the group receiving treatment at home and 1.49 days (SD 0.10) for the group receiving treatment in hospital (mean difference 0.01 days, 95% confidence interval -0.3 to 0.28). None of the other outcome measures differed significantly except for patients' satisfaction, which was greater in patients treated at home. CONCLUSIONS: Treatment of cellulitis requiring intravenous antibiotics can be safely delivered at home. Patients prefer home treatment, but in this study only about one third of patients presenting at hospital for intravenous treatment of cellulitis were considered suitable for home treatment.

Adolescent↗
PubMed2003

The use of inhaled and related respiratory medications in Christchurch rest homes.

AIM: To describe the use of inhaled and related respiratory medications ('asthma medications') and associated management amongst Christchurch rest-home residents. METHODS: Fifty per cent of Christchurch rest homes were randomly selected. All residents on asthma medications, the rest-home managers, care-giving staff, and the residents' general practitioners were interviewed using specific questionnaires. RESULTS: All of the rest homes, residents using asthma medications and senior staff members participated. Seventy five per cent of caregivers and 73% of general practitioners took part. Asthma medications were used by 13% of 1416 rest-home residents. Eighty four per cent of these used a preventer medication, mostly inhaled steroids. Some daily doses exceeded current treatment guidelines. One third of residents using inhalers had an inadequate technique. Some staff and residents chose the wrong inhaler to manage 'shortness of breath'. Regular bronchodilator dosing, rather than 'as required', was common. Those using a spacer device usually had a good technique. Residents appreciated non-pharmacological strategies for breathlessness. Staff identified a need for clear written management plans. CONCLUSIONS: There were significant deficiencies in the staff and residents' knowledge of obstructive airways management and medications. Regular review of inhaler technique, greater use of spacers, and regular staff education may improve residents' respiratory management. Inhaled corticosteroids may be used in too high a dose. Inconsistent management of acutely deteriorating asthma/chronic obstructive pulmonary disease may be addressed by greater use of written management plans in residents' notes.

Administration, Inhalation↗
PubMed2003

Improving the effectiveness of smoking cessation in primary care: lessons learned.

AIMS: The 'Smokescreen' smoking cessation programme was introduced in Christchurch in 1995, with an initial study showing six-month, self-reported quit rates of 10% and 17% (with a validated deception rate) in primary and secondary care settings. Substantial modifications were made to try to improve this rate in the primary care setting and the programme has been implemented widely. Our primary aim was to estimate programme utilisation and six-month quit rates for enrolled patients in this general primary care setting. We also aimed to use a wide range of patient, practice and environmental variables to estimate any predictive effect on outcome. METHODS: Prospective longitudinal cohort study. The nicotine replacement therapy (NRT) -based programme was implemented by Pegasus Health, an independent practitioner association (IPA) situated in the Christchurch urban area, to which the majority of Christchurch-based GPs belong. A cohort of 516 patients enrolling in the programme over a two-month period were contacted six months after their nominated quit date. The main outcome measure was the six-month, self-reported quit rate. RESULTS: Of the 516 participants, 334 (65%) were contacted by mail or telephone. The overall six-month quit rate was 36% (95% Confidence Interval (CI) 31-41). Univariate analysis initially showed duration of NRT (p = 0.03) and age band (p = 0.004) were significant predictors of quitting, while living with a smoker (p = 0.02), having made no previous quit attempts (p = 0.02) and having heart disease (p = 0.01) were all significant predictors of continued smoking at six months. Factors that did not predict whether respondents were smoking at six months included previous use of NRT, sex, ethnicity, who delivered the intervention, years of smoking, cigarette dose, and NZDep96 score. However, there was interaction between these factors as after multivariate analysis the only significant predictors of outcome were having others living in the house who smoked (odds ratio (OR) 0.55, 95% CI 0.33--0.93, p = 0.03) and having made no previous quit attempts (OR 0.29, 95% CI 0.12-0.71, p = 0.02). Both these factors were significantly associated with continuing to smoke. CONCLUSIONS: This programme compares favourably with six-month quit rates for NRT-based programmes reported in the international literature of 14-22%. The effectiveness of an NRT-based smoking cessation programme in a general primary care setting appears to have been significantly enhanced by local adaptation, the flexibility of a primary-care-team approach and subsidisation of NRT, together with facilitation responsive to individual practice needs. The success of this programme in helping individual patients quit, as well as its successful implementation in a wide primary care setting, suggests General Practice can play an important role in smoking cessation in a country with a high burden of disease from smoking-related illnesses. The programme is congruent with the current, national, smoking cessation guidelines endorsed by the RNZCGP. Widespread adoption of this kind of model in IPA/primary health organisation (PHO) settings throughout New Zealand should be encouraged and supported.

Adolescent↗
PubMed2003

Do clinical practice education groups result in sustained change in GP prescribing?

BACKGROUND: Concern has been expressed at the poor uptake of evidence into clinical practice. This is despite the fact that continuing education is an embedded feature of quality assurance in general practice. There are a variety of clinical practice education methods available for dissemination of new evidence. Recent systematic reviews indicate that the effectiveness of these different strategies is extremely variable. OBJECTIVE: Our aim was to determine whether a peer-led small group education pilot programme used to promote rational GP prescribing is an effective tool in changing practice when added to prescribing audit and feedback, academic detailing and educational bulletins, and to determine whether any effect seen decays over time. METHODS: A retrospective analysis of a controlled trial of a small group education strategy with 24 month follow-up was carried out. The setting was an independent GPs association (IPA) of 230 GPs in the Christchurch New Zealand urban area. All intervention and control group GPs were already receiving prescribing audit and feedback, academic detailing and educational bulletins. The intervention group were the first 52 GPs to respond to an invitation to pilot the project. Two control groups were used, one group who joined the pilot later and a second group which included all other GPs in the IPA. The main outcome measures were targeted prescribing data for 12 months before and 24 months after each of four education sessions. RESULTS: An effect in the expected direction was seen in six of the eight key messages studied. This effect was statistically significant for five of the eight messages studied. The effect size varied between 7 and 40%. Where a positive effect was seen, the effect decayed with time but persisted to a significant level for 6-24 months of observation. CONCLUSION: The results support a positive effect of the education strategy on prescribing behaviour in the intervention group for most outcomes measured. The effect seen is statistically significant, sustained and is in addition to any effect of the other pharmaceutical educational initiatives already undertaken by the IPA.

Drug Prescriptions↗
PubMed2002

Factors affecting general practitioner involvement in a randomised controlled trial in primary care.

AIMS: To investigate factors associated with patient recruitment by general practitioners (GPs) in a randomised controlled trial in primary care. METHODS: Cross sectional survey of 100 GPs who had agreed to recruit patients for a randomised controlled trial. A postal questionnaire was sent to the 100 GPs to collect information on factors associated with recruitment in the randomised controlled trial. RESULTS: The response rate to the survey was 97%. GPs who reported that practice nurses were involved in the research project were significantly more likely to recruit patients into the trial. Age, sex, membership of an independent practitioner association (IPA), number of half days worked, and the number of GPs working in a practice were not associated with recruitment. CONCLUSIONS: Involvement of practice nurses together with GPs may improve recruitment of patients in randomised controlled trials in primary care in New Zealand.

Adult↗
PubMed2002

Plasma brain natriuretic peptide after long-term treatment for heart failure in general practice.

AIM: Plasma brain natriuretic peptide (BNP) concentrations are known to have high sensitivity and specificity in the diagnosis of heart failure in newly symptomatic patients. The relationship of plasma BNP to cardiac function in stable patients on long-term established treatment for heart failure is unknown. Plasma BNP was assessed for its ability to predict echocardiographic abnormality in 100 patients receiving long-term treatment in general practice for a provisional diagnosis of heart failure. METHODS AND RESULTS: BNP >35 pmol/l had a sensitivity and specificity of 69% and 67%, respectively, for a left ventricular ejection fraction of <45%. However, 19% of patients had an LVEF of below 45% whilst BNP was below 35 pmol/l. These patients, in whom a diagnosis of heart failure had been made years previously (mean 3.9 years), were all clinically stable on treatment. CONCLUSION: These findings support the view that BNP can be restored to normal levels in well-compensated patients despite persisting significant systolic dysfunction and suggest that BNP assays may be helpful for monitoring adequacy of therapy. BNP assays will have limited utility in the diagnosis of cardiac impairment once anti-failure therapy is well established and symptoms have been abolished.

Aged↗