Primary care for patients with respiratory tract infection before and early on in the COVID-19 pandemic: an observational study in 16 European countries

OBJECTIVE

To describe primary health care (consultation characteristics and management) for patients contacting their general practitioner (GP) with a respiratory tract infection (RTI) early on in the COVID-19 pandemic in contrasting European countries, with comparison to prepandemic findings.

SETTING

Primary care in 16 countries (79 practices), when no routine SARS-CoV-2 testing was generally available.

DESIGN AND PARTICIPANTS

Before (n=4376) and early in the pandemic (n=3301), patients with RTI symptoms were registered in this prospective audit study.

OUTCOME MEASURES

Consultation characteristics (type of contact and use of PPE) and management characteristics (clinical assessments, diagnostic testing, prescribing, advice and referral) were registered. Differences in these characteristics between countries and between pandemic and prepandemic care are described.

RESULTS

Care for patients with RTIs rapidly switched to telephone/video consultations (10% in Armenia, 91% in Denmark), and when consultations were face-to-face, GPs used PPE during 97% (95% CI 96% to 98%) of contacts. Laboratory testing for SARS-CoV-2 in primary care patients with RTIs was rapidly implemented in Denmark (59%) and Germany (31%), while overall testing for C reactive protein decreased. The proportion of patients prescribed antibiotics varied considerably between countries (3% in Belgium, 48% in UK) and was lower during the pandemic compared with the months before, except for Greece, Poland and UK. GPs provided frequent and varied COVID-related advice and more frequently scheduled a follow-up contact (50%, 95% CI 48% to 52%). GPs reported a slightly higher degree of confidence in the likely effectiveness of their management in face-to-face (73% (very) confident, 95% CI 71% to 76%) than in virtual consultations (69%, 95% CI 67% to 71%).

CONCLUSIONS

Despite between-country variation in consultation characteristics, access to SARS-CoV-2 laboratory testing and medication prescribing, GPs reported a high degree of confidence in managing their patients with RTIs in the emerging pandemic. Insight in the highly variable pandemic responses, as measured in this multicountry audit, can aid in fine-tuning national action and in coordinating a pan-European response during future pandemic threats.

Altered gene expressions in periferal blood cells of first-degree non-diabetic relatives of type 2 diabetic patients

Introduction and aim: We were looking for altered gene expression on peripheral blood cells significant to type 2 diabetes causing the world epidemic. Method: Muscle biopsy samples of healthy volunteers with (n = 6) or without (n = 6) first degree type 2 diabetic relatives were analyzed by mRNS microarray. After confirmation of microarrays results by quantitative real-time PCR, the expression of eight differently expressed genes were further investigated on peripheral blood cells of 58 healthy volunteers without diabetic relatives and 58 healthy ones with first-degree type 2 diabetic relatives. Results: The expressions of SERPINF1 gene were significantly lover in blood cells both from females (relative quantification: FC - female: = 0.69, p<6*10^-3) and males (FC - male: = 0.65, p<2*10^-3) with diabetic relatives. This change may not be the consequence of worsening metabolic state as it was identical in cells of type 2 diabetic patients and in healthy volunteers with diabetic relatives. We suggest that the altered SERPINF1 gene expression in peripheral mononuclear blood cells could be a genetic definiteness. Conclusion: With the help of SERPINF1 gene expression in white blood cells and lipid and biochemical blood parameters we suggest a mathematical formula for the augury of type 2 diabetes that should be checked on a larger population, but we hope it could be used as a diabetic marker. The expression of LAMP2 gene did not differ between the two healthy groups, but it showed a maternal parent of origin effect. In the case of maternal inheritance, we found higher LAMP2 expression suggesting that gene from the mother has a determining effect. Orv Hetil. 2020; 161(18): 738-746.

Antivirals for influenza-Like Illness? A randomised Controlled trial of Clinical and Cost effectiveness in primary CarE (ALIC4 E): the ALIC4 E protocol

INTRODUCTION

Effective management of seasonal and pandemic influenza is a high priority internationally. Guidelines in many countries recommend antiviral treatment for older people and individuals with comorbidity at increased risk of complications. However, antivirals are not often prescribed in primary care in Europe, partly because its clinical and cost effectiveness has been insufficiently demonstrated by non-industry funded and pragmatic studies.

METHODS AND ANALYSIS

Antivirals for influenza-Like Illness? An rCt of Clinical and Cost effectiveness in primary CarE is a European multinational, multicentre, open-labelled, non-industry funded, pragmatic, adaptive-platform, randomised controlled trial. Initial trial arms will be best usual primary care and best usual primary care plus treatment with oseltamivir for 5 days. We aim to recruit at least 2500 participants ≥1 year presenting with influenza-like illness (ILI), with symptom duration ≤72 hours in primary care over three consecutive periods of confirmed high influenza incidence. Participant outcomes will be followed up to 28 days by diary and telephone. The primary objective is to determine whether adding antiviral treatment to best usual primary care is effective in reducing time to return to usual daily activity with fever, headache and muscle ache reduced to minor severity or less. Secondary objectives include estimating cost-effectiveness, benefits in subgroups according to age (<12, 12-64 and >64 years), severity of symptoms at presentation (low, medium and high), comorbidity (yes/no), duration of symptoms (≤48 hours/>48-72 hours), complications (hospital admission and pneumonia), use of additional prescribed medication including antibiotics, use of over-the-counter medicines and self-management of ILI symptoms.

ETHICS AND DISSEMINATION

Research ethics committee (REC) approval was granted by the NRES Committee South Central (Oxford B) and Clinical Trial Authority (CTA) approval by The Medicines and Healthcare products Regulatory Agency. All participating countries gained national REC and CTA approval as required. Dissemination of results will be through peer-reviewed scientific journals and conference presentations.

TRIAL REGISTRATION NUMBER

ISRCTN27908921; Pre-results.

A genetikai diabeteskockázat hatása a csontanyagcsere–energia-háztartás kapcsolatokra

Introduction: Type 2 diabetes is associated with increased risk of bone fractures, and the connection between bone remodeling and carbohydrate homeostasis is decoupled. It is not known whether these phenomena are the consequence of the deteriorating glucose metabolism, and the increasing insulin resistance or they belong to the genetic risk of type 2 diabetes. Aim: The aim of the authors was to clarify the impact of genetic risk on bone and carbohydrate homeostasis connections. Method: Hyperinsulinemic-normoglycemic clamps, and oral and iv. glucose loads were done to select 18 metabolically healthy females with first degree type 2 diabetic relatives -and 26 without diabetic relatives. Results: The connections between total body glucose utilization and the activity of the bone metabolic unit were missing in healthy females with the genetic risk of type 2 diabetes, like in those with manifest diabetes. In this risk group the level of low-density-large molecular sized LDL lipids were decreased, while the high-density LDL group with low molecular size was increased. The latter change was in significant connection with increased interleukin-6 levels and increased bone resorption within the bone metabolic unit. Conclusions: These data suggest that the missing connection between glucose and bone metabolism is not the consequence of the developing insulin resistance and deteriorating glucose metabolism, but rather it belongs to the inherited diabetes risk. The etiology of this early alteration, which develops prior to glucose intolerance and insulin resistance is unknown and needs further investigations. Orv. Hetil., 2015, 156(25), 1007–1013.

Metabolic differences in healthy first-degree female relatives of type 2 diabetic patients

Introduction: Today the prevalence of type 2 diabetes reached an epidemic level. It is known that type 2 diabetes could only be prevented before the manifestation, during the “prediabetic” state, urging the development of diagnostic tests to recognize the group at risk in time. Aim: The authors explored metabolic differences between healthy, normal glucose tolerant, normal insulin resistant females having first degree relatives with and without type 2 diabetes. Method: Healthy, normal insulin sensitive females without (n = 26) and with (n = 18) type 2 diabetic relatives were investigated. Results: Healthy females with first degree diabetic relatives had lower low density lipoproteins and higher high density lipoproteins as well as higher glucose and insulin levels at the 120 min of oral glucose test as compared to those without first degree diabetic relatives. Conclusions: These results suggest that the appearance of insulin resistance is preceded by hepatic insulin resistance and impaired lipid metabolism in the symptom-free prediabetic period of genetically suceptible females. Orv. Hetil., 154 (44), 1747–1753.

[Metabolic alteration in healthy men with first degree type 2 diabetic relatives]

INTRODUCTION

The recognition of prediabetic patients with the genetic risk of type 2 diabetes is very important as prediabetes is the last stage when manifestation of diabetes could be prevented by life style modification or drug intervention. This suggests the need for diagnostic processes to trace the risk of patients in time.

AIMS

The authors looked for metabolic differences between age and BMI in adjusted healthy men with or without first degree type 2 diabetic relatives.

METHODS

The study included 73 healthy men (21 with and 52 without) first-degree relatives with type 2 diabetes.

RESULTS

Total body and muscle tissue glucose utilization, glucose tolerance did not differ between the two groups, but free fatty acid levels were not suppressed by glucose load in subjects with diabetic relatives. In addition the body fat content, leptin and IL-6 levels were higher, while adiponectin and the free fatty acid/adiponectin ratio were significantly lover in healthy men with diabetic relatives. In this group HDL cholesterol, and the large buoyant LDL fraction were lower whereas the high density LDL - small molecular lipid fraction was higher than those measured in subjects without diabetic relatives.

CONCLUSIONS

These data suggest that deteriorations of insulin sensitivity and glucose tolerance is preceded by disturbances of fatty acid metabolism. The observed alteration in free fatty acid/adiponectin ratio, and/or the absence of free fatty acid suppression during glucose tolerance tests could be a screening tool for diabetes risk among men.

Application of blood-based polymerase chain reaction for detection of Chlamydia pneumoniae in acute respiratory tract infections

The aim of this study was to investigate whether blood-based polymerase chain reaction could serve as a diagnostic tool to identify individuals with acute respiratory Chlamydia pneumoniae infection. Respiratory specimens and peripheral blood mononuclear cells of 58 patients were analyzed using nested polymerase chain reaction and cell culture. Fifteen patients were polymerase chain reaction-positive for Chlamydia pneumoniae. Nine patients were positive in only the respiratory specimen; two in both the respiratory and blood sample (time intervals between onset of symptoms and sample collection, 3-10 days and 3-4 weeks, respectively); and four in only the blood sample. Detection of Chlamydia pneumoniae DNA in peripheral blood mononuclear cells does not seem to be a suitable marker for acute respiratory Chlamydia pneumoniae infection.