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The theoretical consequences of different hypotheses of the mechanism of precipitin reactions have been evaluated by means of computer simulation. It has been found that the formation of compositionally different complexes in different antigen/antibody mixtures provides a valid explanation of the zoning phenomenon, but this concept fails to explain the absence of free antigen and of antigen in soluble complexes at the point of maximum percipitation. It is found that the following hypothesis provides an improved qualitative and quantitative explanation of precipitin reactions. In the first stage of the total reaction a series of compositionally different complexes is formed. As the second stage of the total reaction two kinds of processes are proposed. Inherently insoluble complexes precipitate causing the remaining soluble complexes to participate in mutual rearrangements to re-establish a new state of equilibrium in the supernatant. The inherently insoluble complexes, moreover, create a hydrophobic phase, distinct from the supernatant and cause the remaining otherwise soluble complexes to distribute themselves between the two phases according to a partition coefficient. A mathematical apparatus to study the consequences of this hypothesis is presented, and it is demonstrated that the features of precipitin curves can be explained nearly completely this way. [ABSTRACT FROM AUTHOR]

Abstract Background There has been an increased interest in recruiting health professionals with a clinical background to management positions in health care. We know little about the factors that influence individuals’ decisions to engage in management. The aim of this study is to explore clinicians’ journeys towards management positions in hospitals, in order to identify potential drivers and barriers to management recruitment and development. Methods We did a qualitative study which included in-depth interviews with 30 clinicians in middle and first-line management positions in Norwegian hospitals. In addition, participant observation was conducted with 20 of the participants. The informants were recruited from medical and surgical departments, and most had professional backgrounds as medical doctors or nurses. Interviews were analyzed by systemic text condensation. Results We found that there were three phases in clinicians’ journey into management; the development of leadership awareness, taking on the manager role and the experience of entering management. Participants’ experiences suggest that there are different journeys into management, in which both external and internal pressure emerged as a recurrent theme. They had not anticipated a career in clinical management, and experienced that they had been persuaded to take the position. Being thrown into the position, without being sufficiently prepared for the task, was a common experience among participants. Being left to themselves, they had to learn management “on the fly”. Some were frustrated in their role due to increasing administrative workloads, without being able to delegate work effectively. Conclusions Path dependency and social pressure seems to influence clinicians’ decisions to enter into management positions. Hospital organizations should formalize pathways into management, in order to identify, attract, and retain the most qualified talents. Top managers should make sure that necessary support functions are available locally, especially for early stage clinician managers.

Abstract Background Knowledge about lay beliefs of etiology, transmission and treatment of TB, and lay perceptions of the relationship between TB and HIV is important for understanding patients' health seeking behavior and adherence to treatment. We conducted a study to explore lay beliefs about TB and TB/HIV co-infection in Addis Ababa, Ethiopia. Findings We conducted a qualitative study using in-depth interviews with 15 TB/HIV co-infected patients and 9 health professionals and focus group discussions with 14 co-infected patients in Addis-Ababa, Ethiopia. We found that a predominant lay belief was that TB was caused by exposure to cold. Excessive sun exposure, exposure to mud, smoking, alcohol, khat and inadequate food intake were also reported as causes for TB. Such beliefs initially led to self-treatment. The majority of patients were aware of an association between TB and HIV. Some reported that TB could transform into HIV, while others said that the body could be weakened by HIV and become more susceptible to illnesses such as TB. Some patients classified TB as either HIV-related or non-HIV-related, and weight loss was a hallmark for HIV-related TB. The majority of patients believed that people in the community knew that there was an association between TB and HIV, and some feared that this would predispose them to HIV-related stigma. Conclusion There is a need for culturally sensitive information and educational efforts to address misperceptions about TB and HIV. Health professionals should provide information about causes and treatment of TB and HIV to co-infected patients.

Abstract Background Delayed prescribing of antibiotics for respiratory tract infections (RTIs) lowers the amount of antibiotics consumed. Several national treatment guidelines on RTIs recommend the strategy. When advocating treatment innovations, the feasibility and credibility of the innovation must be taken into account. The objective of this study was to explore GPs use and patients uptake of wait-and-see prescriptions for RTIs, and to investigate the feasibility of the strategy from GPs' and patients' perspectives. Methods Questionnaire survey among Norwegian GPs issuing and patients receiving a wait-and-see-prescription for RTIs. Patients reported symptoms, confidence and antibiotics consumption, GPs reported diagnoses, reason for issuing a wait-and-see-prescription and their opinion about the method. Results 304 response pairs from consultations with 49 GPs were received. The patient response rate was 80%. The most common diagnosis for the GPs to issue a wait-and-see prescription was sinusitis (33%) and otitis (21%). 46% of the patients reported to consume the antibiotics. When adjusted for other factors, the diagnosis did not predict antibiotic consumption, but both being 16 years or more (p = 0,006) and reporting to have a fever (p = 0,012) doubled the odds of antibiotic consumption, while feeling very ill more than quadrupled the odds (p = 0,002). In 210 cases (69%), the GP found delayed prescribing a very reasonable strategy, and 270 patients (89%) would prefer to receive a wait-and-see prescription in a similar situation in the future. The GPs found delayed prescribing very reasonable most frequently in cases of sinusitis (79%, p = 0,007) and least frequently in cases of lower RTIs (49%, p = 0,002). Conclusion Most patients and GPs are satisfied with the delayed prescribing strategy. The patients' age, symptoms and malaise are more important than the diagnosis in predicting antibiotic consumption. The GP's view of the method as a reasonable approach depends on the patient's diagnosis. In our setting, delayed prescribing seems to be a feasible strategy, especially in cases of sinusitis and otitis. Educational efforts to promote delayed prescribing in similar settings should focus on these diagnoses.

Abstract Background Tuberculosis is a major public health problem in Ethiopia, and a high number of TB patients are co-infected with HIV. There is a need for more knowledge about factors influencing treatment adherence in co-infected patients on concomitant treatment. The aim of the present study is to explore patients' and health care professionals' views about barriers and facilitators to TB treatment adherence in TB/HIV co-infected patients on concomitant treatment for TB and HIV. Methods Qualitative study using in-depth interviews with 15 TB/HIV co-infected patients and 9 health professionals and focus group discussions with 14 co-infected patients. Results We found that interplay of factors is involved in the decision making about medication intake. Factors that influenced adherence to TB treatment positively were beliefs in the curability of TB, beliefs in the severity of TB in the presence of HIV infection and support from families and health professionals. Barriers to treatment adherence were experiencing side effects, pill burden, economic constraints, lack of food, stigma with lack of disclosure, and lack of adequate communication with health professionals. Conclusion Health professionals and policy makers should be aware of factors influencing TB treatment in TB/HIV co-infected patients on concomitant treatment for TB and HIV. Our results suggest that provision of food and minimal financial support might facilitate adherence. Counseling might also facilitate adherence, in particular for those who start ART in the early phases of TB treatment, and beliefs related to side-effects and pill burden should be addressed. Information to the public may reduce TB and HIV related stigma.

Abstract Background The Prescription Peer Academic Detailing (Rx-PAD) project is an educational intervention study aiming at improving GPs' competence in pharmacotherapy. GPs in CME peer groups were randomised to receive a tailored intervention, either to support a safer prescription practice for elderly patients or to improve prescribing of antibiotics to patients with respiratory tract infections. The project was based on the principles of peer group academic detailing, incorporating individual feedback on GPs' prescription patterns. We did a study to explore GPs and tutors' experiences with peer group academic detailing, and to explore GPs' reasons for deviating from recommended prescribing practice. Methods Data was collected through nine focus group interviews with a total of 39 GPs and 20 tutors. Transcripts from the interviews were analyzed by two researchers according to a procedure for thematic content analysis. Results A shared understanding of the complex decision-making involved in prescribing in general practice was reported by both GPs and tutors as essential for an open discussion in the CME groups. Tutors experienced that CME groups differed regarding structure and atmosphere, and in some groups it was a challenge to run the scheme as planned. Individual feedback motivated GPs to reflect on and to improve their prescribing practice, though feedback reports could cause distress if the prescribing practice was unfavourable. Explanations for inappropriate prescriptions were lack of knowledge, factors associated with patients, the GP's background, the practice, and other health professionals or health care facilities. Conclusions GPs and tutors experienced peer group academic detailing as a suitable method to discuss and learn more about pharmacotherapy. An important outcome for GPs was being more reflective about their prescriptions. Disclosure of inappropriate prescribing can cause distress in some doctors, and tutors must be prepared to recognise and manage such reactions.

Abstract Background Non-adherence to tuberculosis (TB) treatment is an important barrier for TB control programs because incomplete treatment may result in prolonged infectiousness, drug resistance, relapse, and death. The aim of the present study is to explore enablers and barriers in the management of TB treatment during the first five months of treatment in Addis Ababa, Ethiopia. Methods Qualitative study which included 50 in-depth interviews and two focus groups with TB patients, their relatives and health personnel. Results We found that loss of employment or the possibility to work led to a chain of interrelated barriers for most TB patients. Daily treatment was time-consuming and physically demanding, and rigid routines at health clinics reinforced many of the emerging problems. Patients with limited access to financial or practical help from relatives or friends experienced that the total costs of attending treatment exceeded their available resources. This was a barrier to adherence already during early stages of treatment. A large group of patients still managed to continue treatment, mainly because relatives or community members provided food, encouragement and sometimes money for transport. Lack of income over time, combined with daily accumulating costs and other struggles, made patients vulnerable to interruption during later stages of treatment. Patients who were poor due to illness or slow progression, and who did not manage to restore their health and social status, were particularly vulnerable to non-adherence. Such patients lost access to essential financial and practical support over time, often because relatives and friends were financially and socially exhausted by supporting them. Conclusion Patients' ability to manage TB treatment is a product of dynamic processes, in which social and economic costs and other burdens change and interplay over time. Interventions to facilitate adherence to TB treatment needs to address both time-specific and local factors.

Background Studies suggest that persons with Huntington's disease (HD) benefit from intensive rehabilitation. Aims To assess preliminary results of a multidisciplinary rehabilitation programme on quality of life, cognitive and motor function. Methods 12 patients with early and middle stage (stages I–III of the Shoulson and Fahn Rating Scale) HD underwent a 3 week rehabilitation programme of up to 8 h 5 days per week including cognitive training, speech, physical and occupational therapy, group discussions and lectures on topics such as nutrition. A family member participated during the first week of the programme. Inclusion criteria: mild or moderate grade of HD, age 18+ years, no severe psychiatric illness, none/slight reduction in cognitive function and full/mostly full independence in Active Daily Living functions. Results Mean age was 48 years with an average of 6 years since symptom debut. Mean total functional capacity (TFC) score was 9 (not working and in need of light assistance i ADL function), mean Mini-Mental State Examination indicated a reduced general cognitive function (24 of 30) and mean Hospital Anxiety and Depression Scale score of 9 showed slight depression. Mean on Activity Specific Confidence scale showed 81% confidence to maintain balance in different situations. All subjects showed improvement in gait (6 min walking test (mean change +31.42 m (p=0.03); 10 m walking test (mean change −0.80 s (p=0.02); stand up and go test (mean change −1.24 s (p=0.003)). Bergs Balance Scale showed significant improvement (mean change 2 points, p=0.03). Conclusion A multidisciplinary intensive rehabilitation programme is associated with improved balance and walking function in persons in the early and middle stages of HD. [ABSTRACT FROM PUBLISHER]

Myotonic dystrophy type 1 (DM1) is an autosomal dominant neuromuscular disease. The disease is slowly progressive, and motor signs include muscle weakness and myotonia. Early motor signs are handgrip myotonia and distal weakness, and weakness of neck and abdominal flexors. Monitoring of motor function is important to track disease progression and to assess effects of prescribed exercise or medical treatment. The 32-item Motor Function Measure (MFM32) is a tool to assess motor function, developed for patients with neuromuscular disorders. MFM32 is validated in people between 6 and 60, and a range of different neuromuscular disorders including DM1. MFM32 consists of 32 items, scored on a scale from 0: Cannot perform the task to 3: Performs the task fully and normally. The items are classified in 3 domains: D1; Standing and transfers. D2; Axial and proximal motor function and D3; Distal motor function. Item scores in each domain are added up. The sum is divided by the maximum score of the domain and multiplied by 100 to give a percentage score. The sum of the 3 domains divided by 96 and multiplied by 100 constitutes the total percentage score. In this study, we use data from a large cross-sectional study "Symptoms and outcome measures for upper limb function in myotonic dystrophy type 1" (the SOUL-DM1 study) to assess the intra- and inter-rater reliability of MFM32 in DM1. A total of 60 participants will be recruited to perform MFM32, and recruitment is ongoing. Performance is recorded on video and stored on a platform for secure data at the University of Oslo. Intra- and inter-rater reliability of the MFM32 is conducted by two assessors. Both are certified as MFM raters and are specialized physiotherapists with knowledge and experience in neuromuscular disorders. Test of participants, video filming and initial scoring (S1) is conducted by assessor 1. Subsequently assessor 1 performs two scorings, around 3 (S2) and 6 (S3) months post S1. Assessor 2 does a scoring of the MFM32 (A1) at the same time as assessor 1 does S2. All assessor scoring is based on the recorded videos of the participants performing the MFM32 except for S1 which is done live during the performance. Preliminary results based on the first 30 participants' total percentage score show excellent ICC2,1 values of both intra- and inter-rater reliability. ICC with 95% confident intervals were calculated using SPSS statistical package version 29 (SPSS Inc, Chicago, IL) based on a single-rating, absolute-agreement, 2-way random-effects model. Intra-rater reliability based on physical scoring (S1) and digital scoring at three months (S2) show excellent reliability with an ICC of 0,994 (0,988-0,997). Intra-rater reliability at three months (S2) and six months (S3) show excellent reliability with an ICC of 0,999 (0,997-1). Inter-rater reliability between assessor 1 (S2) and assessor 2 (A1) show excellent reliability with an ICC of 0,998 (0,998-1). [ABSTRACT FROM AUTHOR]