Clinical diagnosis of SARS-CoV-2 infection: An observational study of respiratory tract infection in primary care in the early phase of the pandemic

BACKGROUND

Early in the COVID-19 pandemic, GPs had to distinguish SARS-CoV-2 from other aetiologies in patients presenting with respiratory tract infection (RTI) symptoms on clinical grounds and adapt management accordingly.

OBJECTIVES

To test the diagnostic accuracy of GPs' clinical diagnosis of a SARS-CoV-2 infection in a period when COVID-19 was a new disease. To describe GPs' management of patients presenting with RTI for whom no confirmed diagnosis was available. To investigate associations between patient and clinical features with a SARS-CoV-2 infection.

METHODS

In April 2020-March 2021, 876 patients (9 countries) were recruited when they contacted their GP with symptoms of an RTI of unknown aetiology. A swab was taken at baseline for later analysis. Aetiology (PCR), diagnostic accuracy of GPs' clinical SARS-CoV-2 diagnosis, and patient management were explored. Factors related to SARS-CoV-2 infection were determined by logistic regression modelling.

RESULTS

GPs suspected SARS-CoV-2 in 53% of patients whereas 27% of patients tested positive for SARS-CoV-2. True-positive patients (23%) were more intensively managed for follow-up, antiviral prescribing and advice than true-negatives (42%). False negatives (5%) were under-advised, particularly for social distancing and isolation. Older age (OR: 1.02 (1.01-1.03)), male sex (OR: 1.68 (1.16-2.41)), loss of taste/smell (OR: 5.8 (3.7-9)), fever (OR: 1.9 (1.3-2.8)), muscle aches (OR: 2.1 (1.5-3)), and a known risk factor for COVID-19 (travel, health care worker, contact with proven case; OR: 2.7 (1.8-4)) were predictive of SARS-CoV-2 infection. Absence of loss of taste/smell, fever, muscle aches and a known risk factor for COVID-19 correctly excluded SARS-CoV-2 in 92.3% of patients, whereas presence of 3, or 4 of these variables correctly classified SARS-CoV-2 in 57.7% and 87.1%.

CONCLUSION

Correct clinical diagnosis of SARS-CoV-2 infection, without POC-testing available, appeared to be complicated.

Understanding satisfaction and dissatisfaction of patients with telemedicine during the COVID-19 pandemic: An exploratory qualitative study in primary care

BACKGROUND

Due to the COVID-19 pandemic, healthcare organizations had to face challenging circumstances and modify the usual modality of service provision, introducing telehealth services in their routine patient care to lessen the risk of direct human-to-human exposure. Patients expressed concerns about personal visits to healthcare units and the possibility of accessing telemedicine turned out to be an effective tool for the continuity of care. Due to the limited experience with telemedicine before the COVID-19 pandemic in Poland, we sought to fill this gap by studying the experiences of Polish patients. Our study aimed to understand how patients define satisfaction and dissatisfaction with telemedicine during the COVID-19 pandemic in primary care.

MATERIAL AND METHODS

Twenty semi-structured interviews with primary care patients in the Podlaskie Voivodeship, Poland were conducted to understand satisfaction with telemedicine. Interview transcripts were analyzed using qualitative content analysis. The qualitative content analysis process involved familiarizing ourselves with the data, extracting text regarding satisfaction and dissatisfaction with the teleconsultation, condensing it into meaningful units assigning codes to them, and organizing codes into subcategories and categories. The entire analysis process was done through reflection and discussion until a consensus was reached between the researchers.

RESULTS

From the participants' perspective, satisfaction with telemedicine was associated with receiving enough space to express their concerns. It was reported that they trusted their primary care physicians and felt comfortable during telemedicine consultations. Participants noted that connecting with a known, trusted doctor was more important than having a face-to-face visit with an unfamiliar physician. In our study, the participants equated satisfaction with treatment effectiveness. It was emphasized that in the event of unknown or unstable conditions, patients would prefer to be seen in person and receive a physical examination.

CONCLUSION

In our research telemedicine met with a positive reception and was recognized by the majority of patients who made use of it as a valuable channel of contact with a primary care physician. In order to increase the level of patient satisfaction, the focus should be on improving aspects such as physician engagement and showing empathy during telemedicine, as well as providing complete, exhaustive information on the treatment process. Respecting patient needs and preferences during performing telemedicine visits is the goal of patient-centered care.

Disease-Specific Quality Indicators for Outpatient Antibiotic Prescribing for Respiratory Infections (ESAC Quality Indicators) Applied to Point Prevalence Audit Surveys in General Practices in 13 European Countries

Up to 80% of antibiotics are prescribed in the community. An assessment of prescribing by indication will help to identify areas where improvement can be made. A point prevalence audit study (PPAS) of consecutive respiratory tract infection (RTI) consultations in general practices in 13 European countries was conducted in January–February 2020 (PPAS-1) and again in 2022 (PPAS-4). The European Surveillance of Antibiotic Consumption quality indicators (ESAC-QI) were calculated to identify where improvements can be made. A total of 3618 consultations were recorded for PPAS-1 and 2655 in PPAS-4. Bacterial aetiology was suspected in 26% (PPAS-1) and 12% (PPAS-4), and an antibiotic was prescribed in 30% (PPAS-1) and 16% (PPAS-4) of consultations. The percentage of adult patients with bronchitis who receive an antibiotic should, according to the ESAC-QI, not exceed 30%, which was not met by participating practices in any country except Denmark and Spain. For patients (≥1) with acute upper RTI, less than 20% should be prescribed an antibiotic, which was achieved by general practices in most countries, except Ireland (both PPAS), Croatia (PPAS-1), and Greece (PPAS-4) where prescribing for acute or chronic sinusitis (0–20%) was also exceeded. For pneumonia in adults, prescribing is acceptable for 90–100%, and this is lower in most countries. Prescribing for tonsillitis (≥1) exceeded the ESAC-QI (0–20%) in all countries and was 69% (PPAS-1) and 75% (PPAS-4). In conclusion, ESAC-QI applied to PPAS outcomes allows us to evaluate appropriate antibiotic prescribing by indication and benchmark general practices and countries.

A Qualitative Study of Primary Care Physicians' Experiences with Telemedicine during the COVID-19 Pandemic in North-Eastern Poland

(1) Background: Due to the COVID-19 pandemic, primary care clinics quickly moved to provide medical consultations via telemedicine, however, information about primary care professionals' perspectives is limited. (2) Methods: Thirty semi-structured interviews with primary care professionals working in north-eastern Poland were conducted to assess their perspectives regarding the benefits and challenges of telemedicine. (3) Results: Primary care professionals highlighted that telemedicine increases access to medical services and reduces travel inconvenience. Remote consultation is not as time-consuming as in-person visits, which enables the provision of medical services to a greater number of patients which is particularly important in primary care. The inability to see patients and loss of non-verbal communication represent a significant difficulty in providing remote care. Primary care professionals indicated patients are not always able to express themselves sufficiently in a telephone call, which leads to performing medical consultations inefficiently. Physicians also pointed out that in particular medical cases, physical contact is still necessary to reach an accurate diagnosis and give the necessary treatment. Statements of the study participants also show that primary care professionals are satisfied with providing medical advice with telemedicine and show their interest in continuing remote consultation in the post-COVID era. (4) Conclusions: Primary care professionals have moved towards incorporating telemedicine into their daily routines due to the COVID-19 pandemic. Despite the many difficulties encountered, healthcare professionals have also noticed the benefits of telemedicine, especially during challenging circumstances. The study shows telemedicine to be a valuable tool in caring for patients, although it should be emphasized that face-to-face consultations cannot be fully replaced by remote consultations.

Cost-effectiveness of adding oseltamivir to primary care for influenza-like-illness: economic evaluation alongside the randomised controlled ALIC4E trial in 15 European countries

BACKGROUND

Oseltamivir is usually not often prescribed (or reimbursed) for non-high-risk patients consulting for influenza-like-illness (ILI) in primary care in Europe. We aimed to evaluate the cost-effectiveness of adding oseltamivir to usual primary care in adults/adolescents (13 years +) and children with ILI during seasonal influenza epidemics, using data collected in an open-label, multi-season, randomised controlled trial of oseltamivir in 15 European countries.

METHODS

Direct and indirect cost estimates were based on patient reported resource use and official country-specific unit costs. Health-Related Quality of Life was assessed by EQ-5D questionnaires. Costs and quality adjusted life-years (QALY) were bootstrapped (N = 10,000) to estimate incremental cost-effectiveness ratios (ICER), from both the healthcare payers' and the societal perspectives, with uncertainty expressed through probabilistic sensitivity analysis and expected value for perfect information (EVPI) analysis. Additionally, scenario (self-reported spending), comorbidities subgroup and country-specific analyses were performed.

RESULTS

The healthcare payers' expected ICERs of oseltamivir were €22,459 per QALY gained in adults/adolescents and €13,001 in children. From the societal perspective, oseltamivir was cost-saving in adults/adolescents, but the ICER is €8,344 in children. Large uncertainties were observed in subgroups with comorbidities, especially for children. The expected ICERs and extent of decision uncertainty varied between countries (EVPI ranged €1-€35 per patient).

CONCLUSION

Adding oseltamivir to primary usual care in Europe is likely to be cost-effective for treating adults/adolescents and children with ILI from the healthcare payers' perspective (if willingness-to-pay per QALY gained > €22,459) and cost-saving in adults/adolescents from a societal perspective.

Patient Satisfaction with Telemedicine during the COVID-19 Pandemic-A Systematic Review

Telemedicine is a convenient tool for providing medical care remotely. It is routinely offered as an alternative to face-to-face consultations in healthcare settings all over the world. Due to the COVID-19 pandemic and increased use of telemedicine in everyday clinical practice, the effectiveness of this modality and patient satisfaction with telemedicine is a subject of growing concern. PubMed and Google Scholar databases were searched. Papers published between January 2020 and August 2021 which met inclusion and exclusion criteria were analyzed. During the COVID-19 pandemic patients have found telemedicine a beneficial tool for consulting healthcare providers. A high level of satisfaction with telehealth was observed in each study across every medical specialty. Telemedicine is undoubtedly a convenient tool that has helped ensure continuity of medical care during the COVID-19 pandemic thanks to its considerable potential. In particular situations, telehealth may adequately replace face-to-face consultation. Regular patients’ feedback is necessary to improve the use of telemedicine in the future.

Supporting Primary Care Professionals to Stay in Work During the COVID-19 Pandemic: Views on Personal Risk and Access to Testing During the First Wave of Pandemic in Europe

Background: Minimising primary care professionals' (PCPs) risk of SARS-CoV-2 infection is crucial to ensure their safety as well as functioning health care system. PCPs' perspectives on the support they needed in the early stages of a public health crisis can inform future preparedness. Aim: To understand PCPs' experiences of providing care during the COVID-19 pandemic, with focus on personal risk from COVID-19 and testing. Design and Setting: Qualitative study using semi-structured interviews with PCPs in England, Belgium, the Netherlands, Ireland, Germany, Poland, Greece and Sweden, between April and July 2020. Method: Interviews were analysed using a combination of inductive and deductive thematic analysis techniques. Results: Eighty interviews were conducted, showing that PCPs tried to make sense of their risk of both contracting and severity of COVID-19 by assessing individual risk factors and perceived effectiveness of Personal Protective Equipment (PPE). They had limited access to PPE yet continued providing care as their "duty." Some PCPs felt that they were put in high-risk situations when patients or colleagues were not flagging symptoms of COVID-19. Not having access to testing in the initial stages of the pandemic was somewhat accepted but when available, was valued. Conclusion: Access to adequate PPE and testing, as well as training for staff and education for patients about the importance of ensuring staff safety is crucial. Given PCPs' varied response in how they appraised personal risk and their tolerance for working, PCPs may benefit from the autonomy in deciding how they want to work during health emergencies.

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.

Levels of Satisfaction, Workload Stress and Support Amongst Informal Caregivers of Patients Receiving or Not Receiving Long-Term Home Nursing Care in Poland: A Cross-Sectional Study

The role of informal caregivers was included in the Assumptions of the Long-Term Senior Policy in Poland for 2014–2020. The document acknowledged the necessity of diagnosing the needs of informal caregivers of elderly people and to implement systemic solutions that would enable the provision of assistance for them. In response, this study aimed to describe the situation of caregivers of patients receiving versus patients not receiving Long-Term Home Nursing Care (LTHNC; i.e., a formal program including regular visits by a nurse specializing in home care) in terms of caregiver socio-demographic characteristics, health self-assessment, work overload, satisfaction derived from being a caregiver, and the quality of perceived support. A cross-sectional study was conducted using the Carers of Older People in Europe (COPE) Index in 2015 in the north-eastern part of Poland involving 170 caregivers of patients supported with LTHNC and 86 caregivers of patients staying at home and not receiving LTHNC. We found that caregivers for patients receiving LTHNC were significantly less overloaded with care work than caregivers for patients without LTHNC support (p < 0.001). LTHNC support was also related to the level of satisfaction with providing care: Caregivers for patients receiving LTHNC were significantly more satisfied with performing their role and felt greater support than caregivers for patients without LTHNC (p < 0.001). Our study provides evidence for a positive relationship between LTHNC and the situation of informal caregivers of dependent elderly people at home. A formal program of visits by a nurse specializing in long-term home care may facilitate the provision by caregivers of better informal care to patients staying at home.

Patients with respiratory tract infections who do not want antibiotics: direct observational study of primary care in Poland

BACKGROUND

Requests by patients for antibiotics are known to strongly affect doctors' decisions to prescribe them.Objective. The aim of this study was to establish how frequently patients presenting with respiratory tract infections (RTIs) express their expectation not to be treated with antibiotics, which symptoms and physical findings are related to their perception of antibiotics not being helpful, and to what degree their expectations influence doctors' decisions.

METHODS

This was a direct observational study set in primary care practices in Bialystok, Poland. The observers completed a checklist while observing a patient with RTI visiting a family doctor.

RESULTS

Overall, 80 (5.5%) out of 1456 patients with RTIs openly requested not to be prescribed antibiotics. Patients not wanting antibiotics were prescribed antibiotics significantly less frequently [25/80 (31.3%)] than the remaining patients [765/1376 (55.6%), P < 0.001]. Univariate logistic regression revealed that cough and runny nose significantly increased the odds of patients not wanting antibiotics [odds ratio (OR) 1.8, 95% confidence intervals (CI): 1.01-3.20 and OR 1.6, 95% CI: 1.01-2.6, respectively] while the presence of tonsillar exudates significantly decreased the odds (OR 0.3, 95% CI: 0.08-0.86). Belief in a self-limited course (20%), recent treatments with antibiotics (16.3%), suspected viral aetiology (12.5%), and concerns about possible harm (12.5%) were the principal reasons for not wanting antibiotics.

CONCLUSIONS

A patient's wish not to be prescribed antibiotics leads to less frequent antibiotic prescribing. Antimicrobial resistance, though important from a public health viewpoint, is not seen as a priority for individual patients with infections.

Bone Metabolism Markers and Bone Mineral Density in Patients on Long-Term Acenocoumarol Treatment: A Cross-Sectional Study

The aim of this study was to evaluate levels of osteocalcin (OC), osteoprotegerin (OPG) and total soluble receptor activator of nuclear factor-κB ligand (RANKL), and bone mineral density (BMD) in patients on long-term acenocoumarol (AC) treatment. The cross-sectional study was carried out in 42 patients treated long-term with AC and 28 control subjects. Serum concentrations of OC, OPG, and sRANKL were measured using enzyme linked immunosorbent assay (ELISA) kits, and BMD at the femoral neck and lumbar spine were assessed by dual energy X-ray absorptiometry. A significantly decreased concentration of OC was found in AC users compared to control subjects (4.94 ± 2.22 vs. 10.68 ± 4.5; p < 0.001). Levels of OPG, sRANKL logarithm (log), sRANKL/OPG log ratio, and BMD were comparable between. In female AC users, positive correlations between OC and RANKL log, and between OC and RANKL/OPG log ratio (p = 0.017; p = 0.005, respectively), and a negative correlation between OC and OPG (p = 0.027) were found. Long-term AC anticoagulation significantly decreases OC concentration, but does not affect other bone metabolism markers or BMD. Our results also suggest the possibility that long-term treatment with AC may alleviate bone resorption in postmenopausal women.

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.

The Association Between Long-Term Acenocoumarol Treatment and Vitamin D Deficiency

OBJECTIVE

Both vitamin D and K2 are involved in a number of metabolic processes, including bone metabolism; however, associations between the vitamins are not fully understood. The aim of the study was to evaluate serum concentrations of 25-hydroxyvitamin D [25(OH)D] in adult patients receiving long-term acenocoumarol (AC) treatment.

PARTICIPANTS AND METHODS

In this cross-sectional study, 58 Caucasian patients (31 women, 27 men) with a median age of 65 years receiving long-term AC therapy were evaluated and compared with 35 age- and gender-matched healthy controls. The AC treatment was used due to recurrent venous thromboembolism (34.5%), atrial fibrillation (31%), or mechanical heart valve prostheses (34.5%). Medical records and a questionnaire were used to obtain information about chronic diseases, smoking habits, and the duration of therapy and weekly dose of AC. Anthropometric measurements were performed, and serum concentration of 25(OH)D and total alkaline phosphatase (ALP) activity were measured.

RESULTS

Among the 58 patients receiving long-term AC treatment, a high proportion (46.6%) demonstrated significant vitamin D deficiency with concentrations of 25(OH)D lower than 20 ng/mL. The median concentration of 25(OH)D in subjects receiving AC was significantly lower compared to the control group [20.4 (17.4; 26.1) vs. 28.2 (24; 32.7); p < 0.001]. No differences were found between women and men receiving AC therapy. In patients receiving AC, a negative correlation was found between the concentration of 25(OH)D and the weekly dose of AC (r = -0.337, p = 0.01). Patients with concentrations of 25(OH)D < 20 ng/mL were found to have a significantly higher median dose of AC, compared to those with concentrations of 25(OH)D ≥ 20 ng/mL [21 (17; 31) vs. 17 (12; 28); p = 0.045].

CONCLUSION

In conclusion, treatment with AC is associated with low 25-hydroxyvitamin D levels, although the path leading to this phenomenon is not entirely clear. Long-term administration of AC in adults may increase the risk of chronic vitamin D deficiency, thus, effective supplementation of vitamin D in these individuals needs careful consideration.

[Exposure to environmental tobacco smoke in pre-school children--a comparative study]

The objective of the work was to compare the socioeconomic situation and the structure of tobacco use in the families of children attending preschools in Bialystok in 2004 and 2012 in terms of 3-year-olds' exposure to environmental tobacco smoke (ETS). The study involved 313 children out of 1,200 3-year-olds attending 51 pre-schools in Bialystok in 2004 (Gr I) and 273 children out of 1,100 attending 49 pre-schools in 2012 (Gr I). Information on environmental conditions and the use of tobacco in the families of the studied 3-year-olds was obtained through anonymous questionnaires filled in by their parents or caregivers. The exposure of children to ETS was evaluated using the questionnaire and by determining the cotinine/creatinine ratio in urine. The children from Gr I had better educated (p<0.001) and wealthier (p=0.005) parents, and better living conditions (p=0.008). In 47.3% of the homes of children from Gr I and 31.1% of homes of children from Gr II there was at least one smoking person (p<0.001). Both in 2004 and in 2012, fathers prevailed among the smokers, but in 2012 their number was significantly lower (p<0.001). As for mothers, 23.6% of them in Gr I and 10.3% in Gr I admitted smoking every day (p<0.001). More children from Gr I than from Gr I lived with smoking grandparents. The declared number of cigarettes smoked a day by the people living with the children was similar in both Groups The Groups did not differ significantly regarding the rules of tobacco smoke applying to the family members and guests (p=0.639). The mean cotinine/ creatinine concentration [ng/mg] in the urine of children from Gr I (60.78) was significantly higher than in those from Gr II (22.75) (p<0.001). According to the survey data, in 2012 fewer three-year-olds were exposed to ETS out of home (p<0.001). The mean cotinine/ creatinine concentrations [ng/mg] depending on the declared exposure to tobacco smoke out of home: no exposure, existing exposure, unknown exposure, were for Gr I and Gr II, respectively: 51.31 vs. 35.67; (p<0.001), 76.10 vs. 38.65; (p=0.002), 76.92 vs. 47.04; (p=0.460). In 2012, as compared to 2004, the number of smokers among young parents decreased, but despite education activities in the community, only 1/4 of homes with children had the "no smoking" rule.

[The assessment of glucose and lipid parameters in children with a positive family history of hypertension]

Arterial hypertension in adults is often associated with excess body weight, and lipid or carbohydrate disorders. The incidence of hypertension in children is growing, although its connection with metabolic disorders and family history of hypertension has not been previously understood.

THE AIM OF THE STUDY

To evaluate the relationship between a family history of hypertension and metabolic parameters (carbohydrate and lipid metabolism) and anthropometric measurements in children and adolescents.

MATERIAL AND METHODS

The study group consists of 40 children (mean age 13.6 years +/-2.7 years) with a positive family history of hypertension, and a comparative group of 44 children with a negative family history of hypertension. Anthropometric measurements, blood pressure, plasma insulin, glucose, homeostasis model assessment insulin resistants (HOMA IR), and lipid profiles were determined in all children.

RESULTS

Body weight, BMI, WHR, and measurements of skinfolds did not differ significantly between the groups. Systolic blood pressure was significantly higher in the study group (108 vs. 100 Me mmgHg, p = 0.031) Significant differences were observed in the levels of glucose (80 vs. Me. 67 mg/dl, p < 0.001), and insulin (8.89 vs. Me. 5.34 microIU / ml, p = 0.024). The HOMA index showed values significantly higher in the study group (1.68 vs. 0.80 Me p = 0.007). Children with a positive family history of hypertension were characterized by insignificantly higher values of total cholesterol, TG, LDL-cholesterol, and lower HDL-cholesterol.

CONCLUSIONS

A positive family history of hypertension correlates with higher systolic blood pressure and changes in carbohydrate metabolism parameters in the direction of the development of insulin resistance in children.

Amoxicillin for acute lower-respiratory-tract infection in primary care when pneumonia is not suspected: a 12-country, randomised, placebo-controlled trial

BACKGROUND

Lower-respiratory-tract infection is one of the most common acute illnesses managed in primary care. Few placebo-controlled studies of antibiotics have been done, and overall effectiveness (particularly in subgroups such as older people) is debated. We aimed to compare the benefits and harms of amoxicillin for acute lower-respiratory-tract infection with those of placebo both overall and in patients aged 60 years or older.

METHODS

Patients older than 18 years with acute lower-respiratory-tract infections (cough of ≤28 days' duration) in whom pneumonia was not suspected were randomly assigned (1:1) to either amoxicillin (1 g three times daily for 7 days) or placebo by computer-generated random numbers. Our primary outcome was duration of symptoms rated "moderately bad" or worse. Secondary outcomes were symptom severity in days 2-4 and new or worsening symptoms. Investigators and patients were masked to treatment allocation. This trial is registered with EudraCT (2007-001586-15), UKCRN Portfolio (ID 4175), ISRCTN (52261229), and FWO (G.0274.08N).

FINDINGS

1038 patients were assigned to the amoxicillin group and 1023 to the placebo group. Neither duration of symptoms rated "moderately bad" or worse (hazard ratio 1.06, 95% CI 0.96-1.18; p=0.229) nor mean symptom severity (1.69 with placebo vs 1.62 with amoxicillin; difference -0.07 [95% CI -0.15 to 0.007]; p=0.074) differed significantly between groups. New or worsening symptoms were significantly less common in the amoxicillin group than in the placebo group (162 [15.9%] of 1021 patients vs 194 [19.3%] of 1006; p=0.043; number needed to treat 30). Cases of nausea, rash, or diarrhoea were significantly more common in the amoxicillin group than in the placebo group (number needed to harm 21, 95% CI 11-174; p=0.025), and one case of anaphylaxis was noted with amoxicillin. Two patients in the placebo group and one in the amoxicillin group needed to be admitted to hospital; no study-related deaths were noted. We noted no evidence of selective benefit in patients aged 60 years or older (n=595).

INTERPRETATION

When pneumonia is not suspected clinically, amoxicillin provides little benefit for acute lower-respiratory-tract infection in primary care both overall and in patients aged 60 years or more, and causes slight harms.

FUNDING

European Commission Framework Programme 6, UK National Institute for Health Research, Barcelona Ciberde Enfermedades Respiratorias, and Research Foundation Flanders.

Airway obstruction and bronchodilator responsiveness in adults with acute cough

PURPOSE

We sought to determine the prevalence of airway obstruction and bronchodilator responsiveness in adults consulting for acute cough in primary care.

METHODS

Family physicians recruited 3,105 adult patients with acute cough (28 days or shorter) attending primary care practices in 12 European countries. After exclusion of patients with preexisting physician-diagnosed asthma or chronic obstructive pulmonary disease (COPD), we undertook complete case analysis of spirometry results (n = 1,947) 28 to 35 days after inclusion. Bronchodilator responsiveness was diagnosed if there were recurrent complaints of wheezing, cough, or dyspnea and an increase of the forced expiratory volume in 1 second (FEV(1)) of 12% or more after bronchodilation. Airway obstruction was diagnosed according to 2 thresholds for the (postbronchodilator) ratio of FEV(1) to forced vital capacity (FEV(1):FVC): less than 0.7 and less than the lower limit of normal.

RESULTS

There were 240 participants who showed bronchodilator responsiveness (12%), 193 (10%) had a FEV(1)/FVC ratio of less than 0.7, and 126 (6%) had a ratio of less than the lower limit of normal. Spearman's correlation between the 2 definitions of obstruction was 0.71 (P <.001), with discordance most pronounced among those younger than 30 years and in older participants.

CONCLUSIONS

Both bronchodilator responsiveness and persistent airway obstruction are common in adults without established asthma or COPD who consult for acute cough in primary care, which suggests a high risk of undiagnosed asthma and COPD. Different accepted methods to define airway obstruction detected different numbers of patients, especially at the extremes of age. As both conditions benefit from appropriate and timely interventions, clinicians should be aware and responsive to potential underdiagnosis.

Incidental chest radiographic findings in adult patients with acute cough

PURPOSE

Imaging may produce unexpected or incidental findings with consequences for patients and ordering of future investigations. Chest radiography in patients with acute cough is among the most common reasons for imaging in primary care, but data on associated incidental findings are lacking. We set out to describe the type and prevalence of incidental chest radiography findings in primary care patients with acute cough.

METHODS

We report on data from a cross-sectional study in 16 European primary care networks on 3,105 patients with acute cough, all of whom were undergoing chest radiography as part of a research study workup. Apart from assessment for specified signs of pneumonia and acute bronchitis, local radiologists were asked to evaluate any additional finding on the radiographs. For the 2,823 participants with good-quality chest radiographs, these findings were categorized according to clinical relevance based on previous research evidence and analyzed for type and prevalence by network, sex, age, and smoking status.

RESULTS

Incidental findings were reported in 19% of all participants, and ranged from 0% to 25% by primary care network, with the network being an independent contributor (P <.001). Of all participants 3% had clinically relevant incidental findings. Suspected nodules and shadows were reported in 1.8%. Incidental findings were more common is older participants and smokers (P <. 001).

CONCLUSIONS

Clinically relevant incidental findings on chest radiographs in primary care adult patients with acute cough are uncommon, and prevalence varies by setting.

Understanding patient satisfaction with family doctor care

RATIONALE, AIMS AND OBJECTIVES

Patient satisfaction is receiving increased attention in the evaluation of health care quality. However, qualitative methods have seldom been used to study patient satisfaction. The purpose of this study was to explore how satisfaction is understood from the perspective of patients receiving care from family doctors.

METHOD

We used a qualitative approach consisting of in-depth interviews with 36 patients attending clinics in Poland. Interviews were audiotaped and transcribed, and content analysis performed.

RESULTS

There was no single definition of satisfaction among study participants; however, some core characteristics of satisfaction emerged. These characteristics were: (1) good doctor-patient interaction; (2) health improvement or resolution of health problems; (3) fulfillment of prior expectations; (4) availability of health care; (5) combination of multiple characteristics; and (6) absence of dissatisfaction.

CONCLUSION

Because patients have differing concepts of satisfaction with health care provided by family doctors, quality assessments should focus on components of satisfaction whereas questions about satisfaction itself should be avoided.

Which factors hinder the decision of Polish HIV-positive patients to take up antiretroviral therapy?

The implementation of highly active antiretroviral therapy (HAART) in 1996 has significantly reduced mortality and morbidity for HIV-positive patients worldwide. However not all eligible persons start HAART. To identify reasons for therapy refusal by HIV-positive persons we performed a questionnaire study. The investigation was conducted among 321 HIV-positive individuals and focused on the decision to take up antiretroviral treatment. Out of 71 untreated patients, 34 (47.9%) admitted that in their case the therapy was not indicated, whereas 20 (28.3%) were afraid of potential side effects that might change their appearance, e.g. face lipoatrophy. Only the treated patients had been prepared to take up therapy, although 17 patients (6.0%) had not received any explanation of the therapy principles, aims or necessity to comply with medication regime. The therapy is generally not discussed with the patients for whom it is not currently indicated, which may contribute to the fixation of fears and prejudices. Doctors who treat HIV-positive patients should be aware of the prejudices and fears their patients have towards antiretroviral therapy in order to react properly and by means of the available antiretroviral drugs help prolong life and improve its quality.

[Sequences of human immunodeficiency virus infection (HIV)]

The clinical profile of HIV infection has changed from lethal disease, gradually destroying patient's immunologic system and progressing inevitably to AIDS, into a chronic manageable condition as it is now. The introduction of combined antiretroviral therapy in 1996 dramatically improved prognosis. In developed countries the estimated survival for a young person diagnosed with HIV infection in the late highly active antiretroviral therapy approaches the survival of general population. Despite the benefits of early diagnosis, majority of people living with HIV are unaware of their HIV status. Both poor knowledge of transmission routes and long asymptomatic phase of the infection contribute to delayed diagnosis. When the disease progresses towards symptomatic phase many patients seek help of physicians of varied specialities. The correct diagnosis of HIV infection being the cause of the reported symptoms depends on physicians' knowledge of HIV clinical features. In the age of combined antiretroviral therapy the diagnosis of HIV infection saves patient's life, and in case of pregnant women it additionally decreases significantly the risk of vertical transmission.

The patient's view of the acceptability of the primary care in Poland

OBJECTIVE

The aim of the study was to determine how the time factor affected the patients' perception of the acceptability of the primary health care system and to assess their satisfaction with family physician care.

DESIGN

A series of cross-sectional studies was conducted in 1998, 2002 and 2006, using face-to-face interviews with structured questionnaires.

SETTING

The study was performed in Gizycko, Poland, where family physician services were introduced in 1995.

STUDY PARTICIPANTS

Three surveys were conducted, each involving 1000 subjects. Every time, random sample was taken, after selecting a subgroup of patients using medical service within the previous week.

MAIN MEASURES

Acceptability of the primary health care system (accessibility, the patient-practitioner relationship, the amenities of care, patient's preferences), perception of the changes in primary care and overall satisfaction with family physician care.

RESULTS

Between 1998 and 2002, an improvement was noted, lasting till 2006, in such accessibility components as the possibility of making an appointment by phone or at a definite hour. Some aspects of the patient-doctor relationship indicate that family physician care is directed at illness rather than health-oriented. The level of patient satisfaction was high.

CONCLUSIONS

Generally, patients are satisfied with primary care reform and implementation of the family physician system. However, it is easier to improve accessibility of services than physician's personal qualities and the patient-practitioner relationship. Expressive functions of a physician (listening and reassuring) and activities regarding health promotion require special attention in the process of education of family physicians.

Changing HCV genotypes distribution in Poland--relation to source and time of infection

BACKGROUND

Understanding the distribution of HCV genotypes has implications for prognosis and therapy of hepatitis C.

OBJECTIVES

To describe the distribution of HCV genotypes in Poland in relation to route of transmission and year of infection.

STUDY DESIGN

Patients with chronic liver disease were evaluated at the Department of Infectious Diseases, Bialystok (Poland). HCV genotype was determined by means of 5'UTR sequencing and comparison with known sequences of particular genotypes.

RESULTS

The genotypes mostly frequently detected were genotype 1 (57.5%); genotype 3 (31.3%); and genotype 4 (8.4%). Genotype 1 constituted the majority of HCV infections caused by blood transfusion (68.8%) and only 34.8% of HCV infections in the intravenous drug use (IVDU) group (p<0.05). In contrast genotype 3 constituted the majority of HCV infections in the IVDU group (56.5%). We observed a significant increase in the proportion of genotype 3 infections detected after 2000--from 19.1% to 38.9%.

CONCLUSIONS

The relative proportion of genotype 1b in Poland has decreased and that of genotype 3a has increased, especially among IVDU.

Management of sore throat in Polish primary care facilities: an example from the country with rare use of microbiological testing

OBJECTIVE

To describe sore throat management by primary care physicians in Poland.

METHODS

We sent questionnaires to all primary care doctors in Podlaskie voievodship (north-eastern Poland) with clinical vignettes depicting patients with symptoms of sore throat. The probability of bacterial (streptococcal) infection was estimated using Centor's scale (assessment of four items--presence of tonsillar exudates, fever, lymphadenopathy and absence of cough--scores 0 and 1 indicate low probability of streptococcal infection). The respondents were asked for the suspected diagnosis (viral or bacterial pharyngitis), choose additional tests (if required to decide on management), and finally to decide on whether an antibiotic should be prescribed.

RESULTS AND DISCUSSION

Two-hundred and twenty-five of 610 doctors surveyed provided usefull answers. In cases with a very low probability of bacterial infection and a score of '0', antibiotics were prescribed by 1.8-43.7% of physicians. Only 1.8% would prescribe an antibiotic to an adult with a 1-day history of sore throat and a '0' score but as many as 43.7% when the patient consulted with the same symptoms and signs again (P < 0.05). Younger age of the patient was also significantly associated with higher rate of the antibiotic prescribing--7.6% would prescribe an antibiotic to a 5-year-old child with a '0' score while only 1.8% would prescribe an antibiotic for an adult with a similar score, P < 0.05.

CONCLUSIONS

Primary care physicians in Poland tend to prescribe antibiotics for sore throats even for patients with a low risk of bacterial infection when influenced by factors like repeat visits of the patient or young age. Avoiding antibiotics in such low risk of bacterial infection patients is an important and achievable goal.

Improvement in the accessibility and organization of services of family physicians in a small town in Poland: a comparison of patient opinions between 1998 and 2002

PURPOSE

The institution of a family physician was introduced in Poland to improve organization and quality of primary health care. Thus, it seems important to find out how the time factor (4 years) and the organizational changes that took place during that time have affected patients' views on primary health service accessibility. The aim of the study was to compare patients' opinions on selected aspects of the access and organization of health care provided by family physicians between the years 1998 and 2002.

MATERIAL AND METHODS

Two independent surveys conducted in 1998 and 2002 using face-to-face interviews with structured questionnaires. The study was carried out in a small town in Poland. The study group consisted of two samples of patients randomly selected. Altogether 1000 interviews were obtained in survey I (1998) and 1000 from another sample in survey II (2002).

RESULTS

The surveys carried out at a 4-year interval showed that the accessibility of family physician services improved between 1998 and 2002. This was reflected by: more common use of registration by phone and better overall evaluation of the registration system, shorter time spent in the waiting room to see a family physician, making an appointment for a definite hour, better opinion of the visit duration and more frequent use of phone consultations.

CONCLUSIONS

The results our study show that primary health care reform in Poland has a positive impact on the patients' opinions about access and organization of services of family physicians.

Four-year follow up of hepatitis C patients vaccinated against hepatitis B virus

AIM: Patients with chronic hepatitis C have been recommended to receive vaccinations against hepatitis B. Our study aimed at evaluating the hepatitis B immunogenicity and efficacy against hepatitis B virus infection 4 years after primary immunization series in a group of patients with chronic hepatitis C.

METHODS: We recruited 36 out of 48 hepatitis C virus (HCV) infected individuals who were vaccinated against hepatitis B virus (20 μg of recombinant HBsAg at 0-1-6 mo schedule) in 1998. Here we measured anti-HBs titers and anti-HBc 4 years after delivery of the third dose of primary immunization series.

RESULTS: After 4 years a total of 13/36 (36%) HCV infected patients had seroprotective titers of anti-HBs compared with 9/10 (90%) in the control group, (P<0.05). Similarly the mean concentration of anti-HBs found in hepatitis C patients was significantly lower than that found in healthy subjects (18.3 and 156.0 mIU/mL respectively (P<0.05). None of the HCV infected patients or controls became infected with HBV during the study period as confirmed by anti-HBc negativity.

CONCLUSION: We demonstrated that 4 years after HBV immunizations’ more than 60% of vaccinated HCV patients did not maintain seroprotective levels of anti-HBs, which might put them at risk of clinically significant breakthrough infections. Further follow-up studies are required to clarify whether memory B and T lymphocytes can provide protection in chronic hepatitis C patients in the absence or inadequate titers of anti-HBs.

The role of the therapeutic team in shaping eating habits and lifestyle in children with dietary calcium deficiency

PURPOSE

Assessment of the effect of low-calcium diet on bone mineral content in children and adolescents.

MATERIAL AND METHODS

The study involved 89 children (49 girls and 40 boys) aged 5-18 years, in whom diseases affecting bony metabolism had been excluded. Children with a history of dietary calcium content below 500 mg/day were recruited. The study group was divided according to age: group I, age 5-9 years (children before puberty); group II, age 9-15 years (early puberty); group III, 15-18 years (late puberty). Dual energy X-ray absorptiometry (DEXA) was used for densitometric measurements. Bone mineral density (BMD) was assessed in the whole skeleton (total BMD), in vertebrae L2-L4 (spine BMD) in g/cm2 and as Z-score. Concentrations of Ca, Ca2, P, activity of alkaline phosphatase (AP) and its bony isoenzyme were determined in the serum.

RESULTS

Total bone mass below 5th percentile (according to the norm for age and gender) was found in 56.98% of the children involved in the study. A significant reduction was noted in the spine mineral mass in boys (p < 0.01) as compared to girls (0.731 +/- 0.17 g/cm2 and 0.835 +/- 0.19 g/cm2, respectively). The lowest mean Z-score (-1.850) was observed in group III as compared to group I (-1.194) (p < 0.01) and group II (-1.201) (p < 0.05). There were statistically significantly positive correlations between total and spine BMD and BMI. The correlation coefficient was r = 0.56 and r = 0.41 (p < 0.001), respectively.

CONCLUSIONS

In the majority of the children (c. 60%), a reduction in bone mineral content was found. The lowest Z-score (-1.850) was revealed in the oldest children, which may disturb the process of reaching the optimum level of the peak bone mass.

[Detection of HCV infection among clients of an anonymous testing center for HIV infection]

The aim of the study was to determine the prevalence and risk factors for HCV infection among clients of the centre of anonymous testing for HIV infection. Two hundred and eleven clients of anonymous testing centre for HIV infection in Białystok were additionally tested for anti-HCV antibodies and the relationship between HCV infection and risk factors was analysed Main observations: Anti-HCV were detected in 6/211 individuals (2,4%). Increased risk of HCV infection was observed among intravenous drug users, unemployed, residents of other woiewodships (administrative regions), and in those who had been tested for HIV infection in the past. Centres for anonymous testing for HIV infection is also a feasible place for screening for HCV infection. It is reasonable to limit testing for HCV to patients with risk factors

Medical procedures and the risk of iatrogenic hepatitis C infection: case-controlled study in north-eastern Poland

Many hepatitis C virus (HCV)-infected individuals do not have any obvious risk factors and one of the putative sources of infection may be inadvertent exposure to infected blood or body fluids in the clinical setting. The aim of this study was to assess the role of medical procedures in transmission of hepatitis C in north-eastern Poland. In total, 194 patients with chronic hepatitis C were eligible for the study. The control group consisted of 275 age- and sex-matched individuals. Patients with a history of intravenous drug use were excluded. On multivariate analysis, transfusions [odds ratio (OR) = 3.7, 95% confidence interval (CI) 2.2-6.3], minor surgery (OR = 3.2, 95% CI 1.5-6.7) and dental care (OR = 2.3, 95% CI = 1.4-4.0) were independently associated with HCV infection. We conclude that apart from transfusion, minor medical procedures and dental care may carry a significant risk of hepatitis C infection. Improvements in basic hygiene routines and strict adherence to universal precautions may be essential to prevent iatrogenic transmission of the infection.

Search for hepatitis delta virus (HDV) infection in hepatitis C patients in north-eastern Poland. Comparison with anti-HDV prevalence in chronic hepatitis B

Hepatitis C virus and hepatitis D virus have been shown to suppress HBsAg synthesis. Thus it is possible that HDV infection occurs despite the lack of detectable HBsAg. The aim of our study was to (a) determine the prevalence of HDV infection in patients with chronic hepatitis C (b) compare it with the prevalence of HDV infection in HBsAg positive patients with hepatitis B. The study group consisted of 51 chronic hepatitis C patients, 30 HIV infected drug addicts (27 of them were also positive for anti-HCV) and 102 hepatitis B patients. The participants were tested for anti-HDV, anti-HCV and HBsAg. All anti-HCV positive patients were negative for anti-HDV. Four individuals with anti-HDV belonged to hepatitis B group and constituted 3.9% of all HBsAg positive subjects. We conclude that (a) there is currently no evidence of HDV infection among HCV infected patients in our region (b) hepatitis delta infection is rare in north-eastern Poland.

Does previous hepatitis A infection affect the clinicopathological status of chronic hepatitis C?

BACKGROUND/AIMS

The aim of the study was to evaluate the effect of previous infection with hepatitis A virus on histopathological and biochemical changes in chronic hepatitis C.

METHODOLOGY

Anti-hepatitis A virus antibodies, liver histopathology and alanine aminotransferase activity were determined in 82 patients with chronic hepatitis C. The liver biopsy specimen of each patient was examined according to Scheuer's classification to indicate the severity of the inflammatory cell infiltration in the portal/periportal and parenchymal area (grading) in a 0-4 scale and fibrous stage (staging) in a 0-4 scale.

RESULTS

The overall prevalence of anti-hepatitis A virus antibodies was 63.1%. Anti-HAV-positive patients were significantly older than anti-HAV-negative ones (mean age 42.5 and 33.1 years respectively, p < 0.05). After stratifying the study sample into two age groups (< 40 years and > or = 40 years) the percentage of anti-HAV-positive individuals was similar irrespective of grading, staging score or presence of steatosis. No remarkable differences were observed between the anti-HAV-positive and -negative group in the mean ALT activity.

CONCLUSIONS

The results of our study indicate that previous hepatitis A is not associated with progressive course of chronic hepatitis C.

Prevalence of hepatitis B markers in patients with hepatitis C infection in north-eastern Poland: risk factors and vaccine use

We evaluated the prevalence of hepatitis B virus (HBV) markers and established HBV vaccination status among 111 patients with hepatitis C virus (HCV) infection. A history of HBV immunisation was recorded in 30 patients (27.0%) and only 17/30 (66.7%) had anti-HBs level > or =10 mIU/ml. All patients were HBsAg-negative and 22.2% of nonvaccinated subjects had evidence of HBV infection as determined by anti-HBc presence. Among patients with anti-HBc in 7/18 cases (38.9%) anti-HBc was the only marker of HBV infection (without anti-HBs). The prevalence of anti-HBc was significantly higher among patients who reported a history of acute hepatitis. In conclusion the prevalence of HBV markers in patients with HCV infection in north-eastern Poland is similar to the prevalence in general population, which suggests no increased risk for nosocomial HBV infection among those individuals. HCV infection seems to favour unusual serological pattern of HBV infection with anti-HBc as the only marker. HBV vaccine use is low among patients with HCV infection in north-eastern Poland.

[Chronic hepatitis C and risk for hepatitis A infection]

The aim of this study was to determine the prevalence of anti-HAV antibodies and factors associated with HAV infection amongst patients with chronic hepatitis C. The prevalence of anti-HAV antibodies in hepatitis C patients was 69.2% and did not differ significantly from 63.3% observed in the group of healthy controls. In patients with chronic hepatitis C the occurrence of HAV antibodies was not associated with the duration of HCV infection, history of transfusions and surgeries. There was a tendency towards higher prevalence of anti-HAV in persons with history of numerous hospitalizations (60.8% of persons with the history of up to 5 hospitalizations were positive for anti-HAV and more than 84.6% of those with more than 5 hospitalizations). Only 38.5% of patients under 35 years had anti-HAV antibodies. In conclusion immunization against hepatitis A should be recommended for hepatitis C patients under 35 years of age, most of whom are not immune to HAV. Testing for anti-HAV prior to vaccination should be performed in individuals older than 35 because natural immunity is common.

Hepatitis B virus vaccine for patients with hepatitis C virus infection

Hepatitis C is a disease with varying rates of progression. The role of hepatitis B virus (HBV) as a cofactor in the development of hepatitis C virus (HCV)-related cirrhosis and hepatocellular carcinoma (HCC) has been suggested and the use of HBV vaccine in all HCV-infected patients has been advocated. This review presents the implications of HBV and HCV coinfection and addresses the issues of HBV vaccine immunogenicity and safety in patients with chronic HCV infection.

[Prophylaxis after occupational exposure to human immunodeficiency virus (HIV)]

Reasons for seeking consultation among health care workers due to potential or supposed risk of HIV infection were analyzed. From August 1990 till July 1996 41 health care providers were consulted including: 22 nurses, 1 student of nursing college, 3 midwives, 4 laboratory workers and 7 physicians (surgeons and gynaecologist). Type of exposure to HIV and applying of safety precautions were evaluated in each case. In 10 cases the offer of postexposure prophylaxis with zidovudine was accepted (6 nurses, 1 student of nursing college, 3 surgeons). Exposure to HIV was described as: needlestick immediately after it was used in a HIV/AIDS patient, injury with a surgical needle while operating on an HIV infected blood. In the remaining cases the fear of HIV infection was due to work without protective gloves (nurses, laboratory workers), performing surgery on HIV (+) patient, (surgeons, nurses) or short-time contact of HIV infected blood with undamaged skin (nurses). Following conclusions can be drawn from our study: 1. Health care workers undertake safety precautions only when they are informed about HIV seropositivity of the patient. 2. Patients whose HIV serologic status is not known are considered not to create health risk for medical staff. 3. The level of knowledge of health care workers about risk of acquiring HIV infection, lack of risk and ways of diminishing the risk is poor. 4. None of followed health care workers was HIV-seropositive after occupational exposure to HIV.

[Multiorgan changes in AIDS in a reported case]

The clinical course of HIV infection and results of autopsy examination in 49 years old patient was shown. The attention was paid to difficulties of diagnosis of opportunistic infections in a patients with advanced HIV disease. Variety of infectious factors, that could affect a patient with significant immunodeficiency was outlined.

Clinical picture of tick-borne encephalitis among patients hospitalized in 1994 in the Department of Infectious Diseases Medical School Białystok

In 1994 20 patients of the Department of Infectious Diseases, Medical School Białystok were diagnosed to have tick-borne encephalitis. The etiologic agent was identified by serologic studies of the serum and cerebrospinal fluid (FSME IgM ELISA Immuno Austria). 12 patients (60%) reported a tick bite preceding the disease. Following clinical manifestations were found in the analyzed groups of patients: fever > 37.5 degrees C-20 patients (100%), headache--20 patients(100%), nuchal rigidity-14 patients (70%), abdominal pain -3 patients (15%), arthralgia and myalgia-3 patients (15%), drowsiness and mental confusion -3 patients(15%). Total cell count in CSF ranged from 18 to 348 cells (mean-175). Lymphocytes predominated in 13 cases (68%). The FSME-IgM antibodies were present in serum of 19 patients (95%) and in CSF of only 4 patients (20%). The hospitalization lasted 12-58 days (mean 24 days). In one case the disease was complicated by acute psychosis requiring psychiatric treatment. Severe neurologic complications have been not observed. The prognosis in all cases was good. Our study confirms that tick-borne encephalitis is a current problem in north-eastern Poland. Noteworthy is the fact that only a part of patients give the history of tick bite.