BACKGROUND: There is evidence that chronic inflammation may promote atherosclerotic disease. We tested the hypothesis that acute infection and vaccination increase the short-term risk of vascular events. METHODS: We undertook within-person comparisons, using the case-series method, to study the risks of myocardial infarction and stroke after common vaccinations and naturally occurring infections. The study was based on the United Kingdom General Practice Research Database, which contains computerized medical records of more than 5 million patients. RESULTS: A total of 20,486 persons with a first myocardial infarction and 19,063 persons with a first stroke who received influenza vaccine were included in the analysis. There was no increase in the risk of myocardial infarction or stroke in the period after influenza, tetanus, or pneumococcal vaccination. However, the risks of both events were substantially higher after a diagnosis of systemic respiratory tract infection and were highest during the first three days (incidence ratio for myocardial infarction, 4.95; 95 percent confidence interval, 4.43 to 5.53; incidence ratio for stroke, 3.19; 95 percent confidence interval, 2.81 to 3.62). The risks then gradually fell during the following weeks. The risks were raised significantly but to a lesser degree after a diagnosis of urinary tract infection. The findings for recurrent myocardial infarctions and stroke were similar to those for first events. CONCLUSIONS: Our findings provide support for the concept that acute infections are associated with a transient increase in the risk of vascular events. By contrast, influenza, tetanus, and pneumococcal vaccinations do not produce a detectable increase in the risk of vascular events.

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Risk of Myocardial Infarction and Stroke after Acute Infection or Vaccination

Antimicrobial resistance is a global public health challenge, which has accelerated by the overuse of antibiotics worldwide. Increased antimicrobial resistance is the cause of severe infections, complications, longer hospital stays and increased mortality. Overprescribing of antibiotics is associated with an increased risk of adverse effects, more frequent re-attendance and increased medicalization of self-limiting conditions. Antibiotic overprescribing is a particular problem in primary care, where viruses cause most infections. About 90% of all antibiotic prescriptions are issued by general practitioners, and respiratory tract infections are the leading reason for prescribing. Multifaceted interventions to reduce overuse of antibiotics have been found to be effective and better than single initiatives. Interventions should encompass the enforcement of the policy of prohibiting the over-the-counter sale of antibiotics, the use of antimicrobial stewardship programmes, the active participation of clinicians in audits, the utilization of valid rapid point-of-care tests, the promotion of delayed antibiotic prescribing strategies, the enhancement of communication skills with patients with the aid of information brochures and the performance of more pragmatic studies in primary care with outcomes that are of clinicians’ interest, such as complications and clinical outcomes.

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Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem:

Objective: To measure patients9 perceptions of patient centredness and the relation of these perceptions to outcomes. Design: Observational study using questionnaires. Setting: Three general practices. Participants: 865 consecutive patients attending the practices. Main outcome measures: Patients9 enablement, satisfaction, and burden of symptoms. Results: Factor analysis identified five components. These were communication and partnership (a sympathetic doctor interested in patients9 worries and expectations and who discusses and agrees the problem and treatment, Cronbach9s α=0.96); personal relationship (a doctor who knows the patient and their emotional needs, α=0.89); health promotion (α=0.87); positive approach (being definite about the problem and when it would settle, α=0.84); and interest in effect on patient9s life (α=0.89). Satisfaction was related to communication and partnership (adjusted β=19.1; 95% confidence interval 17.7 to 20.7) and a positive approach (4.28; 2.96 to 5.60). Enablement was greater with interest in the effect on life (0.55; 0.25 to 0.86), health promotion (0.57; 0.30 to 0.85), and a positive approach (0.82; 0.52 to 1.11). A positive approach was also associated with reduced symptom burden at one month (β=−0.25; −0.41 to −0.10). Referrals were fewer if patients felt they had a personal relationship with their doctor (odds ratio 0.70; 0.54 to 0.90). Conclusions: Components of patients9 perceptions can be measured reliably and predict different outcomes. If doctors don9t provide a positive, patient centred approach patients will be less satisfied, less enabled, and may have greater symptom burden and higher rates of referral. What is already known on this topic Preliminary evidence suggests that patients9 perceptions of patient centredness predict outcomes better than analysing what the doctor says in a consultation What this study adds There are five distinct components of patients9 perceptions that can be measured reliably: communication and partnership, personal relationship, health promotion, positive approach to diagnosis and prognosis, and interest in the effect on life Each component predicts different consultation outcomes If doctors don9t provide a positive, patient centred approach patients will be less satisfied, less enabled, and may have greater symptom burden and use more health service resources

https://www.bmj.com/content/bmj/323/7318/908.full.pdf

Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations

In 1990 it was estimated that 4123 million of the world's 5267 million population—78%—lived in developing countries. Of the 39.5 million deaths in the developing world, 9.2 million were estimated to have been caused by infectious and parasitic disease; infections of the lower respiratory tract were the third most common cause of death worldwide, and diarrhoeal diseases were the fourth.1 Ninety eight per cent of deaths in children occur in the developing world, mostly as a result of infections.

Projections of disability adjusted life years (that is, the years of life without disability) for the year 2020 show great improvement in developing regions: people are living longer without disabilities.2 However, even the most pessimistic model analysed did not take into account the possibility that the development of new antimicrobial drugs might slow or cease, and that rates of drug resistance in bacteria such as pneumococci, Mycobacterium tuberculosis , or Staphylococcus aureus might increase. We chart the progress and impact of bacterial resistance to antimicrobial drugs in the developing world. The information in this review has been assembled from searches of the computerised databases Medline and Bath Information and Data Services, discussions with colleagues, and personal knowledge.

#### Summary points

Although even the most potent and recently developed antimicrobial drugs are available throughout the world, …

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Antimicrobial resistance in developing countries.

Objective To identify patient’s preferences for patient centred consultation in general practice. Design Questionnaire study. Setting Consecutive patients in the waiting room of three doctors’ surgeries. Main outcome measures Key domains of patient centredness from the patient perspective. Predictors of preferences for patient centredness, a prescription, and examination. Results 865 patients participated: 824 (95%) returned the pre›consultation questionnaire and were similar in demographic characteristic to national samples. Factor analysis identified three domains of patient preferences: communication (agreed with by 88›99%), partnership (77›87%), and health promotion (85›89%). Fewer wanted an examination (63%), and only a quarter wanted a prescription. As desire for a prescription was modestly associated with desire for good communication (odds ratio 1.20; 95% confidence interval 0.85 to 1.69), partnership (1.46; 1.01 to 2.09), and health promotion (1.61; 1.12 to 2.31) this study may have underestimated preferences for patient centredness compared with populations with stronger preferences for a prescription. Patients who strongly wanted good communication were more likely to feel unwell (very, moderately, and slightly unwell; odds ratios 1, 0.56, 0.39 respectively, z trend P < 0.001), be high attenders (1.70; 1.18 to 2.44), and have no paid work (1.84; 1.21 to 2.79). Strongly wanting partnership was also related to feeling unwell, worrying about the problem, high attendance, and no paid work; and health promotion to high attendance and worry. Conclusion Patients in primary care strongly want a patient centred approach, with communication, partnership, and health promotion. Doctors should be sensitive to patients who have a strong preference for patient centredness—those vulnerable either psychosocially or because they are feeling unwell.

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Preferences of patients for patient centred approach to consultation in primary care: observational study.

OBJECTIVE: To assess the medicalising effect of prescribing antibiotics for sore throat. SETTING: 11 general practices in England. DESIGN: Randomised trial of three approaches to sore throat: a 10 day prescription of antibiotics, no antibiotics, or a delayed prescription if the sore throat had not started to settle after three days. PATIENTS: 716 patients aged 4 and over with sore throat and an abnormal physical sign: 84% had tonsillitis or pharyngitis. OUTCOME MEASURES: Number and rate of patients making a first return with sore throat, pharyngitis, or tonsillitis. Early returns (within two weeks) and complications (otitis media, sinusitis, quinsy). Outcomes were documented in 675 subjects (94%). RESULTS: Mean follow up time was similar (antibiotic group 1.07 years, other two groups 1.03 years). More of those initially prescribed antibiotics initially returned to the surgery with sore throat (38% v 27%, adjusted hazard ratio for return 1.39%, 95% confidence interval 1.03 to 1.89). Antibiotics prescribed for sore throat during the previous year had an additional effect (hazard ratio 1.69, 1.20 to 2.37). Longer duration of illness (> 5 days) was associated with increased return within six weeks (hazard ratio 2.90, 1.70 to 4.92). Prior attendance with upper respiratory conditions was also associated with increased reattendance. There was no difference between groups in early return (13/238 (5.5%) v 27/437 (6%)), or complications (2/236 (0.8%) v 3/434 (0.7%)). CONCLUSIONS: Complications and early return resulting from no or delayed prescribing of antibiotics for sore throat are rare. Both current and previous prescribing for sore throat increase reattendance. To avoid medicalising a self limiting illness doctors should avoid antibiotics or offer a delayed prescription for most patients with sore throat.

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Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics.

OBJECTIVE: To assess three prescribing strategies for sore throat. DESIGN: Randomised follow up study. SETTING: 11 general practices in the South and West region. SUBJECTS: 716 patients aged 4 years and over with sore throat and an abnormal physical sign in the throat; 84% had tonsillitis or pharyngitis. Patients were randomised to three groups: prescription for antibiotics for 10 days (group 1,246 patients); no prescription (group 2,230 patients); or prescription for antibiotics if symptoms were not starting to settle after three days (group 3; 238 patients). MAIN OUTCOME MEASURES: Duration of symptoms; satisfaction and compliance with and perceived efficacy of antibiotics; time off school or work. Outcomes were documented in 582 subjects (81%). RESULTS: Median duration of antibiotic use differed significantly in the three groups (10 v 0 v 0 days, P < 0.001); 69% of patients in group 3 did not use their prescription. The proportion of patients better by day 3 did not differ significantly (37% v 35% v 30%, P = 0.28), nor did the duration of illness (median 4 v 5 v 5 days, P = 0.39), days off work or school (median 2 v 2 v 1, P = 0.13), or proportion of patients satisfied (96% v 90% v 93%, P = 0.09), although group 1 had fewer days of fever (median 1 v 2 v 2 days, P = 0.04). More patients in group 1 thought the antibiotics were effective (87% v 55% v 60%, P < 0.001) and intended coming to the doctor in future attacks (79% v 54% v 57%, P < 0.001). "Legitimation" of illness-to explain to work or school (60%) or family or friends (37%)-was an important reason for consultation. Patients who were more satisfied got better more quickly, and satisfaction related strongly to how well the doctor dealt with patient's concerns. CONCLUSION: Prescribing antibiotics for sore throat only marginally affects the resolution of symptoms but enhances belief in antibiotics and intention to consult in future when compared with the acceptable strategies of no prescription or delayed prescription. Psychosocial factors are important in the decision to see a general practitioner and in predicting the duration of illness.

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Open randomised trial of prescribing strategies in managing sore throat.

Sore throat is one of the commonest reasons for visiting general practitioners yet little is known about what factors are important in its natural course. This is important since people with prolonged illness after the consultation—the 36% with illness lasting more than five days after seeing the doctor (the median)—are much more likely to reattend.1 Providing patients with information about duration of illness can reduce expectation and reattendance.2 We studied factors that affect duration of sore throat and assessed whether satisfaction with the consultation independently predicts duration of illness.3

The methods are reported in full elsewhere.3 General practitioners documented the clinical characteristics of 716 patients presenting with sore throat, who were then randomised to one of three prescribing strategies (antibiotics, no antibiotics, delayed antibiotics). Patients recorded satisfaction with the consultation and how well their concerns had been dealt with on four point Likert scales (very, …

https://www.bmj.com/content/bmj/319/7212/736.full.pdf

M Gantley

Papers

Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics.

Open randomised trial of prescribing strategies in managing sore throat.

Clinical and psychosocial predictors of illness duration from randomised controlled trial of prescribing strategies for sore throat.