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Background: Underrepresentation of care home residents in research has resulted in a poorer evidence base for health care in care homes. Fewer opportunities to take part in research, as well as assumptions made by others about their interest or wishes, creates challenges for residents' inclusion in research. Early discussions about research preferences and wishes may be beneficial. This qualitative study aimed to explore stakeholders' views about how care home residents can be supported to communicate their wishes about research participation., Method: Semi-structured interviews were conducted with 25 stakeholders: care home residents (n = 5), relatives (n = 5), care home staff (n = 5), other health and social care professionals who work with care homes (n = 6), and care home researchers (n = 4). Interviews were conducted virtually or face-to-face and data were analysed using thematic analysis., Results: Views about resident research participation, the barriers and facilitators to their inclusion, and the role of advance research planning were iteratively organized into three themes: (i) We're of no value to research; (ii) Research is difficult; and (iii) Advance research planning: good in theory, challenging in practice. Subthemes were also identified, and findings were discussed with a Patient and Public Involvement group for additional reflections., Conclusions: Stakeholders identified a number of barriers to including care home residents in research, including knowing their preferences about research. The development of interventions to facilitate communication that can be adapted to individuals' requirements are needed to support discussions and decision-making with care home residents about wishes and preferences for future research participation., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Geriatrics Society.)

Competing Interests: Conflicts of interest R.C.-J. was a NIHR HTA Associate Board Member (May 2018 to March 2020). F.C. is a consultant for UCB Pharma and received a fee from Daylong for participating in a hidradenitis suppurativa consensus meeting. L.H. has received consultancy fees from the University of Oxford for an educational grant funded by Pfizer, unrelated to the submitted work. K.H. is a member of the NIHR Research Professors Panel (2019–­present), and was a member of the NIHR HTA General Committee (2016–22) and the NIHR HTA Funding Committee Policy Group (2017–22). J.R.I. receives a stipend as Editor-in-Chief of the British Journal of Dermatology and an authorship honorarium from UpToDate. He is a consultant for Abbvie, Boehringer Ingelheim, ChemoCentryx, Citryll, MoonLake, Novartis, UCB Pharma and UNION Therapeutics, and has served on advisory boards for Insmed, Kymera Therapeutics and Viela Bio. He is co-copyright holder of HiSQOL, Investigator Global Assessment and Patient Global Assessment instruments for HS. His department receives income from the copyright of the Dermatology Life Quality Instrument (DLQI) and related instruments.

Background: Hidradenitis suppurativa (HS) is a chronic, painful disease affecting flexures and other skin regions, producing nodules, abscesses and skin tunnels. Laser treatment targeting hair follicles and deroofing of skin tunnels are standard HS interventions in some countries but are rarely offered in the UK., Objectives: To describe current UK HS management pathways and influencing factors to inform the design of future randomized controlled trials (RCTs)., Methods: THESEUS was a nonrandomized 12-month prospective cohort study set in 10 UK hospitals offering five interventions: oral doxycycline 200 mg daily; oral clindamycin and rifampicin both 300 mg twice daily for 10 weeks, extended for longer in some cases; laser treatment targeting hair follicles; deroofing; and conventional surgery. The primary outcome was the combination of clinician-assessed eligibility and participant hypothetical willingness to receive each intervention. The secondary outcomes were the proportion of participants selecting each intervention as their final treatment option; the proportion who switch treatments; treatment fidelity; and attrition rates. THESEUS was prospectively registered on the ISRCTN registry: ISRCTN69985145., Results: The recruitment target of 150 participants was met after 18 months, in July 2021, with two pauses due to the COVID-19 pandemic. Baseline demographics reflected the HS secondary care population: average age 36 years, 81% female, 20% non-White, 64% current or ex-smokers, 86% body mass index ≥ 25, 68% with moderate disease, 19% with severe disease and 13% with mild disease. Laser was the intervention with the highest proportion (69%) of participants eligible and willing to receive treatment, then deroofing (58%), conventional surgery (54%), clindamycin and rifampicin (44%), and doxycycline (37%). Laser was ranked first choice by the greatest proportion of participants (41%). Attrition rates were 11% and 17% after 3 and 6 months, respectively. Concordance with doxycycline was 52% after 3 months due to lack of efficacy, participant choice and adverse effects. Delays with procedural interventions were common, with only 43% and 26% of participants starting laser and deroofing, respectively, after 3 months. Uptake of conventional surgery was too small to characterize the intervention. Switching treatment was uncommon and there were no serious adverse events., Conclusions: THESEUS has established laser treatment and deroofing for HS in the UK and demonstrated their popularity with patients and clinicians for future RCTs., Competing Interests: Conflicts of interest J.R.I. receives a stipend as Editor-in-Chief of the British Journal of Dermatology and an authorship honorarium from UpToDate. He is a consultant for AbbVie, Boehringer Ingelheim, ChemoCentryx, Citryll, MoonLake, Novartis and UCB Pharma and has served on advisory boards for Insmed, Kymera Therapeutics and Viela Bio. He is co-copyright holder of HiSQOL, Investigator Global Assessment and Patient Global Assessment instruments for hidradenitis suppurativa (HS). His department receives income from the copyright of the Dermatology Life Quality Instrument (DLQI) and related instruments. R.C.-J. was a UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Associate Board Member (May 2018 to March 2020). F.C. is a consultant for UCB Pharma and received a fee from Daylong for participating in a HS consensus meeting. L.H. has received consultancy fees from the University of Oxford for an educational grant funded by Pfizer, unrelated to the submitted work. K.H. is a member of the NIHR HTA General Committee (2016–2022), the NIHR HTA Funding Committee Policy Group (2017–2022) and the NIHR Research Professors Panel (2019–present)., (© The Author(s) 2023. Published by Oxford University Press on behalf of British Association of Dermatologists.)

Background: Research into dementia and other conditions connected with cognitive impairments is essential but conducting research with populations who lack capacity to provide consent involves a number of ethical, legal and practical challenges. In England and Wales, family members can act as a consultee or legal representative on behalf of someone who lacks capacity. However, there is a paucity of research about how family members make decisions concerning research participation., Objective: To explore family members' experiences of proxy decision-making for research. Understanding how proxy decisions are made could lead to interventions to support greater inclusion of individuals in research who have impaired decision-making capacity., Methods: Semi-structured interviews were conducted with a purposive sample of 17 family members who had experience as a proxy for making decisions about participation in research, including those who had agreed to participation and those who declined. Thematic analysis was used to examine experiences and generate findings for research practice and to develop future supportive interventions., Results: Proxy decision-making is highly contextualised. Proxies balance a number of factors when deciding about research participation, including the person's values and preferences, within the specific context of the study, and the practicalities of being involved. Proxies use these factors to construct a decision that is authentic to the person they care for., Conclusions: Proxy decision-making for research is a complex process with inter-woven layers of decision-making. Decisions can be problematic for some proxies who may benefit from decision support to make an informed decision about research participation on behalf of a family member., (© The Author(s) 2019. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Urine culture at the point of care minimises delay between obtaining the sample and agar inoculation in a microbiology laboratory, and quantification and sensitivity results can be available more rapidly in primary care., Objective: To identify the degree to which clinicians' interpretations of a point-of-care-test (POCT) urine culture (Flexicult™ SSI-Urinary Kit) agrees with laboratory culture in women presenting to primary care with symptoms of uncomplicated urinary tract infections (UTI)., Methods: Primary care clinicians used the Flexicult™-POCT, recorded their findings and took a photograph of the result, which was interpreted by microbiology laboratory technicians. Urine samples were additionally processed in routine care laboratories. Cross tabulations were used to identify important differences in organism identification, quantification and antibiotic susceptibility between these three sources of data. The influence of various laboratory definitions for UTI on culture were assessed., Results: Primary care clinicians identified 202/289 urine samples (69.9%) as positive for UTI using the Flexicult™-POCT, whereas laboratory culture identified 94-190 (32.5-65.7%) as positive, depending on definition thresholds. 82.9% of samples identified positive for E. coli on laboratory culture were also considered positive for E. coli using the Flexicult™ -POCT, and susceptibilities were reasonably concordant. There were major discrepancies between laboratory staff interpretation of Flexicult™ photographs, clinicians' interpretation of the Flexicult™ test, and laboratory culture results., Conclusion: Flexicult™-POCT overestimated the positivity rate of urine samples for UTI when laboratory culture was used as the reference standard. However, it is unclear whether point-of-care or laboratory based urine culture provides the most valid diagnostic information., (© The Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: currently, there is little evidence base for much of the care provided for older people in care homes. Given the wide range of topics that require further investigation, and limited resources, one solution is to identify the priorities for future research., Methods: a modified Delphi technique was used to identify research topics and develop consensus among care home staff participants. The survey was conducted across three rounds. Firstly to elicit topics that were considered by participants to require further research, secondly to prioritise the long list of research questions, followed by a third round to reach a consensus on the highest ranked 15 questions., Results: eighty-three participants responded to the initial survey, providing 144 questions. Following analysis and review against existing evidence, 76 research questions remained. Of note, 40/83 participants responded to the interim prioritisation round and 43/83 participants responded to the final round, which ranked the top 15 research questions by importance. Two other groups of health and social care professionals also participated in the final ranking. The results from these groups had a similar ordering to those of the original cohort of participants., Conclusion: this is the first study to establish a set of research priorities for older people in the UK care homes. It is hoped that sharing these results with clinicians, researchers and funding bodies will help to begin the process of ensuring that the future research agenda can be focused on the areas of greatest need. Further work to identify the priorities of other key stakeholders is required., (© The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society.)

Objectives: The volume of prescribed antibiotics is associated with antimicrobial resistance and, unlike most other antibiotic classes, flucloxacillin prescribing has increased. We aimed to describe UK primary care flucloxacillin prescribing and factors associated with subsequent antibiotic prescribing as a proxy for non-response., Patients and Methods: Clinical Practice Research Datalink patients with acute prescriptions for oral flucloxacillin between January 2004 and December 2013, prescription details, associated Read codes and patient demographics were identified. Monthly prescribing rates were plotted and logistic regression identified factors associated with having a subsequent antibiotic prescription within 28 days., Results: 3 031 179 acute prescriptions for 1 667 431 patients were included. Average monthly prescription rates increased from 4.74 prescriptions per 1000 patient-months in 2004 to 5.74 (increase of 21.1%) in 2013. The highest prescribing rates and the largest increases in rates were seen in older adults (70+ years), but the overall increase in prescribing was not accounted for by an ageing population. Prescribing 500 mg tablets/capsules rather than 250 mg became more common. Children were frequently prescribed low doses and small volumes (5 day course) and prescribing declined for children, including for impetigo. Only 4.2% of new prescriptions involved co-prescription of another antibiotic. Age (<5 and ≥60 years), diagnosis of 'cellulitis or abscess' or no associated code, and 500 mg dose were associated with a subsequent antibiotic prescription, which occurred after 17.6% of first prescriptions., Conclusions: There is a need to understand better the reasons for increased prescribing of flucloxacillin in primary care, optimal dosing (and the need to co-prescribe other antibiotics) and the reasons why one in five patients are prescribed a further antibiotic within 4 weeks., (© The Author 2016. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy.)

Background: Antibiotic treatment recommendations based on susceptibility data from routinely submitted urine samples may be biased because of variation in sampling, laboratory procedures and inclusion of repeat samples, leading to uncertainty about empirical treatment., Objective: To describe and compare susceptibilities of Escherichia coli cultured from routinely submitted samples, with E. coli causing urinary tract infection (UTI) from a cohort of systematically sampled, acutely unwell children., Methods: Susceptibilities of 1458 E. coli isolates submitted during the course of routine primary care for children <5 years (routine care samples), compared to susceptibilities of 79 E. coli isolates causing UTI from 5107 children <5 years presenting to primary care with an acute illness [systematic sampling: the Diagnosis of Urinary Tract infection in Young children (DUTY) cohort]., Results: The percentage of E. coli sensitive to antibiotics cultured from routinely submitted samples were as follows: amoxicillin 45.1% (95% confidence interval: 42.5-47.7%); co-amoxiclav using the lower systemic break point (BP) 86.6% (84.7-88.3%); cephalexin 95.1% (93.9-96.1%); trimethoprim 74.0% (71.7-76.2%) and nitrofurantoin 98.2% (97.4-98.8%). The percentage of E. coli sensitive to antibiotics cultured from systematically sampled DUTY urines considered to be positive for UTI were as follows: amoxicillin 50.6% (39.8-61.4%); co-amoxiclav using the systemic BP 83.5% (73.9-90.1%); co-amoxiclav using the urinary BP 94.9% (87.7-98.4%); cephalexin 98.7% (93.2-99.8%); trimethoprim 70.9% (60.1-80.0%); nitrofurantoin 100% (95.3-100.0%) and ciprofloxacin 96.2% (89.4-98.7%)., Conclusion: Escherichia coli susceptibilities from routine and systematically obtained samples were similar. Most UTIs in preschool children remain susceptible to nitrofurantoin, co-amoxiclav and cephalexin., (© The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: the risk factors for and frequency of antibiotic prescription and antibiotic-associated diarrhoea (AAD) among care home residents are unknown., Aim: to prospectively study frequency and risks for antibiotic prescribing and AAD for care home residents., Design and Setting: a 12-month prospective cohort study in care homes across South Wales., Method: antibiotic prescriptions and the development of AAD were recorded on case report forms. We defined AAD as three or more loose stools in a 24-h period occurring within 8 weeks of exposure to an antibiotic., Results: we recruited 279 residents from 10 care homes. The incidence of antibiotic prescriptions was 2.16 prescriptions per resident year (95% CI: 1.90-2.46). Antibiotics were less likely to be prescribed to residents from dual-registered homes (OR compared with nursing homes: 0.38, 95% CI: 0.18-0.79). For those who were prescribed antibiotics, the incidence of AAD was 0.57 episodes per resident year (95% CI: 0.41-0.81 episodes). AAD was more likely in residents who were prescribed co-amoxiclav (hazards ratio, HR = 2.08, 95% confidence interval, CI: 1.18-3.66) or routinely used incontinence pads (HR = 2.54, 95% CI: 1.26-5.13) and less likely in residents from residential homes (HR compared with nursing homes: 0.14, 95% CI: 0.06-0.32)., Conclusion: residents of care homes, particularly of nursing homes, are frequently prescribed antibiotics and often experience diarrhoea following such prescriptions. Co-amoxiclav is associated with greater risk of AAD., (© The Author 2015. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Valid clinical predictors of influenza in patients presenting with lower respiratory tract infection (LRTI) symptoms would provide adequate patient information and reassurance., Aim: Assessing the validity of an existing diagnostic model (Flu Score) to detect influenza in LRTI patients., Design and Setting: A European diagnostic study recruited 1801 adult primary care patients with LRTI-like symptoms existing ≤7 days between October and April 2007-2010., Method: History and physical examination findings were recorded and nasopharyngeal swabs taken. Polymerase chain reaction (PCR) for influenza A/B was performed as reference test. Diagnostic accuracy of the Flu Score (1× onset <48 hours + 2× myalgia + 1× chills or sweats + 2× fever and cough) was expressed as area under the curve (AUC), calibration slopes and likelihood ratios (LRs)., Results: A total of 273 patients (15%) had influenza on PCR. The AUC of the Flu Score during winter months was 0.66 [95% CI (95% confidence internal) 0.63-0.70]. During peak influenza season, both influenza prevalence (24%) and AUC were higher [0.71 (95% CI 0.66-0.76], but calibration remained poor. The Flu Score assigned 64% of the patients as 'low-risk' (10% had influenza, LR - 0.6). About 12% were classified as 'high risk' of whom 32% had influenza (LR + 2.7). During peak influenza season, 60% and 14% of patients were classified as low and high risk, respectively, with influenza prevalences being 14% (LR - 0.5) and 50% (LR + 3.2)., Conclusion: The Flu-Score attributes a small subgroup of patients with a high influenza risk (prevalence 32%). However, clinical usefulness is limited because this group is small and the association between predicted and observed risks is poor. Considerable diagnostic imprecision remains when it comes to differentiating those with influenza on clinical grounds from the many other causes of LRTI in primary care. New point of care tests are required that accurately, rapidly and cost effectively detect influenza in patients with respiratory tract symptoms in primary care., (© The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background and Aims: Psychological interventions are used in patients with inflammatory bowel disease (IBD) but there is uncertainty about who the optimal target population is. Multi-convergent therapy (MCT) is a form of psychotherapy that combines mindfulness meditation with aspects of cognitive behavioural therapy and has been used in the management of irritable bowel syndrome (IBS). This study aimed to assess the feasibility and efficacy of MCT in the management of IBD patients with either functional abdominal symptoms or high perceived stress levels., Methods: Sixty-six IBD patients in clinical remission with either IBS-type symptoms or high perceived stress levels were randomly allocated to a 16-week MCT course or waiting list control group. Patients were followed-up for one year with the Inflammatory Bowel Disease Questionnaire (IBDQ) as the primary outcome measurement., Results: A higher mean IBDQ score was observed in the active group compared to controls at the 4-month assessment (167 vs. 156, p=0.081), but this was not statistically significant nor did it reached the predefined clinically significant difference of 20. In patients with IBS-type symptoms at baseline there was a significantly higher mean IBDQ score in the active group compared to controls (161 vs. 145, p=0.021). There was no difference between groups in relapse rate based on faecal calprotectin measurement., Conclusions: IBS-type symptoms in patients with IBD represent a potential therapeutic target to improve quality of life. This study suggests that MCT may be useful in the management of these symptoms but larger studies are required to confirm this., Clinical Trial Registration Number: NCT01426568., (Copyright © 2014 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved.)

Background: Clinician-parent interaction and health system influences on parental acceptance of prescribing decisions for children with respiratory tract infections (RTIs) may be important determinants of antibiotic use., Objective: To achieve a deeper understanding of parents' acceptance, or otherwise, of clinicians' antibiotic prescribing decisions for children with RTIs., Methods: Qualitative interviews with parents of child patients who had recently consulted in primary care with a RTI in four European countries, with a five-stage analytic framework approach (familiarization, developing a thematic framework from interview questions and emerging themes, indexing, charting and interpretation)., Results: Fifty of 63 parents accepted clinicians' management decisions, irrespective of antibiotic prescription. There were no notable differences between networks. Parents ascribed their acceptance to a trusting and open clinician-patient relationship, enhanced through continuity of care, in which parents felt able to express their views. There was a lack of congruence about antibiotics between parents and clinicians in 13 instances, mostly when parents disagreed about clinicians' decision to prescribe (10 accounts) rather than objecting to withholding antibiotics (three accounts). All but one parent adhered to the prescribing decision, although some modified how the antibiotic was administered., Conclusions: Parents from contrasting countries indicated that continuity of care, open communication in consultations and clinician-patient trust was important in acceptance of management of RTI in their children and in motivating adherence. Interventions to promote appropriate antibiotic use in children should consider a focus on eliciting parents' perspectives and promoting and building on continuity of care within a trusting clinician-patient relationship.

Background: Adherence to medication is an issue of great importance for patients with ulcerative colitis. Once daily mesalazine seems to be no worse than divided doses in preventing relapse in remitting patients. Although this has been attributed to improved adherence, detailed measures of adherence have been lacking from previous studies., Methods: A 1-year substudy was conducted alongside a trial that compared 2 different dosing regimens (once daily versus three times daily) of mesalazine for patients in remission with ulcerative colitis. Participants in the substudy had their adherence monitored electronically using the medication event monitoring system, self-report, and tablet counts. We compared measures, determined factors associated with adherence and associations between adherence and relapse, modeled adherence over time, and explored behavioral aspects., Results: We included 58 participants. Adherence was high across all measures (89.3% self-report, 96.7% tablet counts, and 89.2% medication event monitoring system). Agreement between the measures was poor at times. Adherence according to the medication event monitoring system best distinguished between the participants who relapsed (71.4%) and those who remained in remission (93.4%), although this difference was not statistically discernible at the 5% level. Adherence deteriorated over the study period, with three times daily participants generally less adherent than once-daily participants (odds ratio, 0.03; 95% confidence interval, 0.01-0.08). Adherence was higher on weekdays (odds ratio, 1.47; 95% confidence interval, 1.31-1.65) and around clinic visit dates (odds ratio, 1.43; 95% confidence interval, 1.18-1.72)., Conclusions: Simple dosing regimens are preferable to multiple daily dosing regimens. Electronic monitoring of adherence should be used more often in clinical studies. Self-reported adherence and tablet counts may underestimate adherence. Adherence declined over time, and adherence was generally lower and more varied for those allocated to the three times daily regimen.

Objectives: To explore and compare primary care clinicians' perceptions of antibiotic resistance in relation to the management of community-acquired lower respiratory tract infection (LRTI) in contrasting European settings., Methods: Qualitative interview study with 80 primary care clinicians in nine European countries. Data were subjected to a five-stage analytical framework approach (familiarization; developing a thematic framework from the interview questions and the themes emerging from the data; indexing; charting; and mapping to search for interpretations in the data). Preliminary analysis reports were sent to all network facilitators for validation., Results: Most clinicians stated that antibiotic resistance was not a problem in their practice. Some recommended enhanced feedback about local resistance rates. Northern European respondents generally favoured using the narrowest-spectrum agent, motivated by containing resistance, whereas southern/eastern European respondents were more motivated by maximizing the potential of a rapid treatment effect and so justified empirical use of broad-spectrum antibiotics. Antibiotic treatment failure was ascribed largely to viral aetiology rather than resistant bacteria. Clinicians generally agreed that resistance will become more serious without enhanced antibiotic stewardship or new drug discovery., Conclusions: If current rates of antibiotic resistance are likely to result in important treatment failures, then provision of local resistance data is likely to enhance clinicians' sense of importance of the issue. Interventions to enhance the quality of antibiotic prescribing in primary care should address perceptions, particularly in the south and east of Europe, that possible advantages to patients from antibiotic treatment in general, and from newer broad-spectrum compared with narrow-spectrum agents, outweigh disadvantages to patients and society from associated effects on antibiotic resistance.

Objectives: To investigate the association between hospital presentation for paediatric pneumonia or empyema and prior antibiotic use for respiratory tract infection (RTI)., Methods: Case-control study of children aged 6 months to 16 years presenting to hospital with radiographic evidence of pneumonia or empyema and a history of general practitioner (GP) consultation for the index illness. Cases were recruited from seven hospitals in South Wales between October 2008 and December 2009. Controls were children from the same age group who were diagnosed with an uncomplicated RTI in general practice in the same area and at a similar time of year. Primary data were collected from carers by a self-complete questionnaire, with a subsample compared against general practice records., Results: We recruited 89 eligible cases and 166 eligible controls. Cases were less likely than controls to have been prescribed antibiotics at the first GP consultation for the index illness [odds ratio (OR) 0.53; 95% confidence interval (95% CI) 0.31-0.90]. Stratified analyses revealed that this association was limited to children who consulted a GP <3 days after illness onset (OR 0.23; 95% CI 0.10-0.50). Cases were also less likely to have taken antibiotics before the date of index hospital presentation, but this finding was not statistically significant after adjustment for confounding factors (adjusted OR 0.84; 95% CI 0.47-1.49)., Conclusions: Antibiotics prescribed at the first GP consultation for an RTI may protect against subsequent hospital presentation for pneumonia or empyema in some children. Given the strong rationale against unnecessary antibiotic prescribing, further research is needed to identify which children are most likely to benefit from early antibiotic treatment.

Background: Point of care tests (POCTs) are being promoted to better target antibiotic prescribing with the aim of improving outcomes and containing antibiotic resistance., Objective: We aimed to explore clinician and patient views about POCTs to assist with the diagnosis and management of lower respiratory tract infection (LRTI) in primary care., Methods: Multi-country European qualitative interview study with 80 primary care clinicians and 121 adult patients in nine primary care networks who had recently consulted with symptoms of acute cough/LRTI. Transcripts were subjected to a five-stage analytic framework approach (familiarization, developing a thematic framework from the interview questions and the themes emerging from the data, indexing, charting, and mapping to search for interpretations in the data), with local network facilitators commenting on preliminary reports., Results: Clinicians who did not routinely use POCTs for acute cough/LRTI felt that the tests' advantages included managing patient expectations for antibiotics. Perceived disadvantages included questionable test performance, problems interpreting results, a detraction from clinical reasoning, costs, time and patients not wanting, or demanding, the tests. Clinicians who routinely used POCTs echoed these disadvantages. Almost all patients would be happy to be managed with the addition of a POCT. Patients with experience of POCTs accepted it as part of routine care., Conclusions: Acceptability of POCTs to clinicians is likely to be improved if tests perform well on accuracy, time to result, simplicity and cost. Including POCTs in the routine management of acute cough/LRTI is likely to be acceptable to most patients.

Objective: In-depth knowledge of existing practice is required to inform interventions aimed at antibiotic prescribing quality improvement. We set out to describe the presentation, antimicrobial management and associated outcome of adults presenting in general practice with acute cough/lower respiratory tract infection (LRTI) in Poland., Methods: Observational study of 301 adults with acute cough/LRTI. Clinicians completed a case report form (CRF) describing presentation, history and management and patients completed a symptom diary for up to 28 days after consultation., Results: Two hundred and twenty-one patients (with CRF and symptom diary completed) were analysed. The median duration of feeling unwell before presentation was 4 days. Clinicians recorded an average of eight symptoms for patients at presentation. Apart from cough, patients most commonly reported feeling generally unwell (91.9%), limitation of normal activities (80.5%), coryza (80.1%) and phlegm production (76.0%). Auscultation abnormalities were present in 55.0%. Overall, medicines were prescribed for 95.0%; 72.4% were prescribed antibiotics [mostly macrolides/lincosamides (38.8%) and amoxicillin/co-amoxiclav (36.3%)) with 11.3% advised to take antibiotics only if still necessary after a specified delay. Mucolytics were prescribed for 61.1%. Antibiotic prescription was strongly associated with a diagnosis of LRTI and the presence of auscultation abnormalities. The median duration of cough after presentation was 8 days., Conclusions: Antibiotics continue to be frequently prescribed for acute cough/LRTI in Poland, and the decision to prescribe was strongly associated with clinicians' findings of abnormalities on auscultation and diagnosis of LRTI. Delayed prescribing was infrequent. Mucolytics were commonly prescribed despite evidence of no effect.

Objectives: Acute cough/lower respiratory tract infection (LRTI) is one of the commonest reasons for consulting and antibiotic prescribing. There are theoretical reasons why treatment with particular antibiotic classes may aid recovery more than others, but empirical, pragmatic evidence is lacking. We investigated whether treatment with a particular antibiotic class (amoxicillin) was more strongly associated with symptom score resolution and time to patients reporting recovery than each of eight other antibiotic classes or no antibiotic treatment for acute cough/LRTI., Methods: Clinicians recorded history, examination findings, symptom severity and antibiotic treatment for 3402 patients in a 13 country prospective observational study of adults presenting in 14 primary care research networks with acute cough/LRTI. 2714 patients completed a symptom score daily for up to 28 days and recorded the day on which they felt recovered. A three-level autoregressive moving average model (1,1) model investigated logged daily symptom scores to analyse symptom resolution. A two-level survival model analysed time to reported recovery. Clinical presentation was controlled for using clinician-recorded symptoms, sputum colour, temperature, age, co-morbidities, smoking status and duration of illness prior to consultation., Results: Compared with amoxicillin, no antibiotic class (and no antibiotic treatment) was associated with clinically relevant improved symptom resolution (all coefficients in the range -0.02 to 0.01 and all P values greater than 0.12). No antibiotic class (and no antibiotic treatment) was associated with faster time to recovery than amoxicillin., Conclusions: Treatment by antibiotic class was not associated with symptom resolution or time to recovery in adults presenting to primary care with acute cough/LRTI.

Objectives: To explore GPs' attitudes to and experiences of introducing C-reactive protein (CRP) point-of-care testing (POCT) for lower respiratory tract infections (LRTI) in primary care., Methods: Semi-structured interview study with 20 GPs who participated in the IMPAC(3)T randomized trial evaluating the effect of GP use of CRP POCT on management of LRTI. Main outcomes were GPs' experiences and views about CRP POCT in general practice, including its role in guiding antibiotic prescribing decisions and applicability and implementation in daily practice., Results: GPs expressed mainly positive attitudes. Test results were rapidly available to support diagnostic and therapeutic processes for LRTI and other common infections, enhancing patient and GP confidence in prescribing decisions and empowering GPs to prescribe antibiotics less often. GPs were concerned about responding to ambiguous test results. They regarded financial reimbursement for using the test as essential for successful uptake., Conclusions: GPs were generally positive about CRP POCT, and they felt that it empowered them to safely prescribe fewer antibiotics for LRTI without alienating their patients. Successful wider implementation should address reimbursement and updating management guidelines to include the place of CRP POCT.

Background: The epidemiology of melanoma is changing and its current management is variable, with some lesions being removed in general practice. We aimed to determine the quality of excision and time to diagnosis relating to the excising surgeon and the place of excision., Method: Analysis of data from the North Wales Melanoma Database., Results: In total, 578 cases were diagnosed 1993-2001. There was a gender difference with anatomical location, with 107 (65%) males with lesions on their trunk compared to 57 (35%) females. Median Breslow thickness was 1.10 mm (range 0.05-16.0 mm). Ninety-five (16%) lesions were removed in general practice, of which 49 (52%) were referred on to hospital. In total, 266 (61%) lesions were excised with 'adequate' margins and 170 (39%) excised with margins narrower than the guidelines. General practice excisions were from a younger group than hospital excisions. There were no differences in quality of excision between general practice and hospital excisions. Time to diagnosis was shorter overall for general practice excisions than hospital excisions (median 12 versus 41 days, P < 0.001)., Conclusion: These findings are of policy importance in that there is no evidence from this study that general practice excisions are managed poorly or have a worse prognosis.

Objectives: Women presenting in primary care with symptoms suggestive of uncomplicated urinary tract infection (UTI) are commonly managed without urine culture. We therefore do not know how successful general practitioners (GPs) are at targeting antibiotic treatment to women who would have had a microbiologically confirmed UTI, or at avoiding antibiotics in those who would have had a negative culture, had all patients with a suspected UTI been sampled. We therefore explored the association between antibiotic prescribing and urine culture results when culture was performed in all symptomatic patients., Methods: GPs in nine general practices in South Wales were asked to submit urine specimens from all women consulting with clinically suspected, uncomplicated UTI. Patients were followed up 2 weeks later by questionnaire., Results and Conclusions: One hundred and thirteen adult women with a median age of 54 years were included and 61% received empirical antibiotics. There was very low agreement between the decision to prescribe empirically and subsequent culture result (Kappa = 0.04), with 60% of those prescribed empirical antibiotics subsequently found to have a negative culture, and 25% of those found to have a positive culture not prescribed empirical antibiotics. Current strategies to target empirical antibiotic prescribing in clinically suspected, uncomplicated UTI require review.

Background: Vitamin B(12) deficiency is common, increasing with age. Most people are treated in primary care with intramuscular vitamin B(12). Several studies have reported equal efficacy of oral administration of vitamin B(12)., Objectives: We set out to identify randomized controlled trial (RCT) evidence for the effectiveness of oral versus intramuscular vitamin B(12) to treat vitamin B(12) deficiency., Methods: We conducted a systematic review searching databases for relevant RCTs. Outcomes included levels of serum vitamin B(12), total serum homocysteine and methylmalonic acid, haemoglobin and signs and symptoms of vitamin B(12) deficiency., Results: Two RCTs comparing oral with intramuscular administration of vitamin B(12) met our inclusion criteria. The trials recruited a total of 108 participants and followed up 93 of these from 90 days to 4 months. In one of the studies, mean serum vitamin B(12) levels were significantly higher in the oral (643 +/- 328 pg/ml; n = 18) compared with the intramuscular group (306 +/- 118 pg/ml; n = 15) at 2 months (P < 0.001) and 4 months (1005 +/- 595 versus 325 +/- 165 pg/ml; P < 0.0005) and both groups had neurological responses. In the other study, serum vitamin B(12) levels increased significantly in those receiving oral vitamin B(12) and intramuscular vitamin B(12) (P < 0.001)., Conclusions: The evidence derived from these limited studies suggests that 2000 microg doses of oral vitamin B(12) daily and 1000 microg doses initially daily and thereafter weekly and then monthly may be as effective as intramuscular administration in obtaining short-term haematological and neurological responses in vitamin B(12)-deficient patients.

Background: Suspected acute viral upper respiratory tract infection (SAVURTI) is the commonest acute reason why children consult in general practice. The clinical course varies widely and about one in five children re-consult for the same SAVURTI episode. If clinicians had feasible tools for predicting which children are likely to suffer a prolonged course, then additional explanations and possibly treatments could be provided at the initial consultation that might enable carers to manage the condition without re-consulting., Objective: To identify features available on the day of consulting that might predict a prolonged clinical course among children with SAVURTI., Method: Regression analysis using Canadian Respiratory Illness and Flu Scale (CARIFS) data from a randomized controlled trial cohort of children aged from 6 months to 12 years consulting in general practice with SAVURTI., Results: Two variables from the clinician's records ('age' and 'cough') and two variables from the CARIFS completed by carers on the day of consulting ('fever' and 'low energy, tired') explained approximately 15% of the variation present in CARIFS scores on day seven., Conclusion: Children and carers may benefit from a clear account of the evidence that the clinical course of RTIs in children varies widely and may be longer that expected, and that prediction for individuals is difficult.

Background: For findings of randomized controlled trials in primary care to be applicable, both the sample of clinicians implementing the trial and the recruited patients should be as representative as possible. The processes of conducting trials should be made "user-friendly" to clinician investigators in order to maximize their participation in research. Formal evaluations of trial implementation are unusual. This study reports clinicians' perspectives on acting as a clinician investigator in a randomized controlled trial (the SAVIT study) in general practice., Objective: Our purpose was to explore clinicians' accounts of taking part in a randomized controlled trial in which subjects were recruited opportunistically during general practice consultations., Method: Individual semi-structured interviews were conducted with nine GPs and one practice nurse practising in the Bro Taf area of South Wales who recruited children into the SAVIT study. A structured interview guide was used and data were analysed using the qualitative method of pattern coding., Results: Major emerging themes included recruitment difficulties and concerns about the safety of the study medication. Participants also outlined positive aspects of the study (clarity and simplicity of the study, potential benefits to clinicians and patients and study team follow-up of recruited patients). Recommendations for possible improvements in study implementation included the simplification and reduction of patient reading materials and improved presentation of study materials., Conclusions: Difficulty in recruiting patients was the most frequently mentioned problem by clinician investigators. Insufficient time in the consultation was perceived as the main barrier. Ingredients of successful trial implementation include good organization, simple documentation and study procedures, and the ability to allay concerns about patient safety. Findings from this evaluation may assist researchers in the design and implementation of future community-based randomized controlled trials.