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BACKGROUND: Respiratory tract infections are the most common reason for antibiotic prescription in Sweden as in other countries. The prescription rates vary markedly in different countries, counties and municipalities. The reasons for these variations in prescription rate are not obvious. AIM: To find possible explanations for different antibiotic prescription rates in children. DESIGN OF STUDY: Prospective population based study. SETTING: All child health clinics in four municipalities in Sweden which, according to official statistics, had high antibiotic prescription rates, and all child health clinics in three municipalities which had low antibiotic prescription rates. METHOD: During one month, parents recorded all infectious symptoms, physician consultations and antibiotic treatments, from 848 18-month-old children in a log book. The parents also answered a questionnaire about socioeconomic factors and concern about infectious diseases. RESULTS: Antibiotics were prescribed to 11.6% of the children in the high prescription area and 4.7% in the low prescription area during the study month (crude odds ratio [OR] = 2.67; 95% confidence interval [CI] = 1.45 to 4.93). After multiple logistic regression analyses taking account of socioeconomic factors, concern about infectious illness, number of symptom days and physician consultations, differences in antibiotic prescription rates remained (adjusted OR = 2.61; 95% CI = 1.14 to 5.98). The variable that impacted most on antibiotic prescription rates, although it was not relevant to the geographical differences, was a high level of concern about infectious illness in the family. CONCLUSIONS: The differences in antibiotic prescription rates could not be explained by socioeconomic factors, concern about infectious illness, number of symptom days and physician consultations. The differences may be attributable to different prescription behaviour. [ABSTRACT FROM AUTHOR]

The aim of this study was to ascertain whether different types of T-cell receptor (TCR)-mediated [Ca2+]i signals could begin to explain the different cellular responses of mature and immature T cells to ligation of the TCR-CD3 complex. Using a digital fluorescence imaging system, we measured and compared [Ca2+]i of individual cells from immature and mature murine T-cell populations following application of CD3-∊ monoclonal antibody (mAb). Our approach revealed distinctions among developmental subsets which were not seen by previous measurements of [Ca2+]i in bulk cell populations. The CD3-mediated [Ca2+]i responses of individual thymocytes were very complex. Latencies to peak [Ca2+]i varied greatly among thymocytes, but the responses of splenic T cells were synchronized, novel evidence that the timing of [Ca2+]i responses may be an important informative parameter for TCR-CD3 signalling. In addition, among cells responding to CD3 mAb, higher peak [Ca2+]i responses correlated with maturity (CD4+ CD8+ thymocytes < single-positive thymocytes < splenic T cells). Examination of cells from pp59fym- deficient mice showed that pp59fym deficiency affects the amplitude and probability, but not the latency or synchrony, of CD3-mediated [Ca2+]i responses of CD4+ CD8+ and CD4+ CD8- thymocytes. All subsets showed equivalent receptor-independent mobilization of [Ca2+]i. These developmentally distinct [Ca2+]i features most probably reflect meaningful developmental changes in how the TCR-CD3 complex couples to intracellular signalling machinery including pp59fym. By clearly showing how [Ca2+]i responses change during development, these results support the hypothesis that distinctive types of (Ca2+]i responses drive thymocyte differentiation. [ABSTRACT FROM AUTHOR]

Introduction: During recent years, the world-including Scandinavia-has experienced significant challenges with shortages of antibiotics. In Scandinavia, phenoxymethylpenicillin is recommended as first-line antibiotic treatment for most acute respiratory tract infections (ARTIs). However, the Scandinavian countries each constitute rather small markets for phenoxymethylpenicillin. The aim of this discussion paper is to enlighten the differences in Scandinavian ARTI antibiotic treatment recommendations. This information is fundamental for exploring the potential of harmonizing treatment recommendations in Denmark, Norway and Sweden-to help ensure sufficient future supply of phenoxymethylpenicillin., Methods: Information from national ARTI antibiotic treatment recommendations from respectively Denmark, Norway and Sweden has been collated., Results: Several discrepancies exist in recommendations. Adult dosage varies from a minimum of 660 mg x 4 (Denmark) to a maximum of 2000 mg × 3 (Sweden). Within Norway and Sweden, variations in recommended dosage also exist between the different types of ARTIs. A main challenge is that the tablet strengths recommended, and available on the market in the three countries, differs.Also, antibiotic treatment durations vary significantly between countries and infections treated-from five to 10 days of treatment., Conclusion: In the capacity of a well-established network for antibiotic stewardship, we have enlightened the differences in Scandinavian ARTI antibiotic treatment recommendations. This paper is the first step moving forward to scrutinizing the potential for harmonizing recommendations for Denmark, Norway and Sweden-to help ensure continued supply of phenoxymethylpenicillin for use within the Scandinavian countries.

Background: Point-of-care (POC) tests, including C-reactive protein (CRP) tests and rapid antigen detection tests (RADT) for group A streptococci (GAS), are widely used in Swedish primary health care (PHC). This study quantifies their use in pharyngotonsillitis and explore their association with antibiotic prescribing., Material and Methods: Retrospective data from 2012-2016 in Region Kronoberg, Sweden, included all PHC visits with a pharyngotonsillitis diagnosis. Patient characteristics, test usage and antibiotic prescriptions were linked by visit date and personal identification number. Descriptive statistics were used for POC test analysis. Logistic regression assessed the association between CRP levels and antibiotic prescribing., Results: Of 24,237 visits, 68% included RADT and 36% included a CRP test, with 89% of CRP tests performed alongside RADT. CRP testing was more frequent in patients with negative (56%) than positive RADTs (42%) ( p  < .001). Overall, 66% of RADTs were positive. Median CRP levels were 23 mg/l for positive RADT and 31 mg/l for negative RADT ( p  < .001). Antibiotics were prescribed for 95% of positive RADTs and 43% of negative RADTs ( p  < .001). In patients with negative RADTs, CRP testing was associated with higher antibiotic prescribing (57%) compared to no CRP testing (26%) ( p  < .001). Among these patients, CRP levels were associated with prescribing (aOR 1.032; 95% CI 1.029-1.035; p  < .001), with 50% of prescriptions occuring at CRP levels ≤ 20 mg/l., Conclusion: The use of RADTs and the proportion of positive test were higher than expected, indicating inappropriate use and diagnostic bias. CRP testing, contrary to guidelines, was common and associated with increased antibiotic prescribing.

Liver metabolism is central to human physiology and influences the pathogenesis of common metabolic diseases. Yet, our understanding of human liver metabolism remains incomplete, with much of current knowledge based on animal or cell culture models that do not fully recapitulate human physiology. Here, we perform in-depth measurement of metabolism in intact human liver tissue ex vivo using global 13 C tracing, non-targeted mass spectrometry and model-based metabolic flux analysis. Isotope tracing allowed qualitative assessment of a wide range of metabolic pathways within a single experiment, confirming well-known features of liver metabolism but also revealing unexpected metabolic activities such as de novo creatine synthesis and branched-chain amino acid transamination, where human liver appears to differ from rodent models. Glucose production ex vivo correlated with donor plasma glucose, suggesting that cultured liver tissue retains individual metabolic phenotypes, and could be suppressed by postprandial levels of nutrients and insulin, and also by pharmacological inhibition of glycogen utilization. Isotope tracing ex vivo allows measuring human liver metabolism with great depth and resolution in an experimentally tractable system., (© 2024. The Author(s).)

Background: There has been a notable decrease in antibiotic prescribing in the last thirty years in Sweden. Little is known about factors influencing antibiotic prescribing over several years., Objective: To compare primary care physicians who, over time, reduced their antibiotic prescribing for respiratory tract infections with those who remained either high or low prescribers regarding potentially influencing factors., Design and Setting: A register-based study including all RTI visits in primary care in Region Kronoberg, Sweden 2006-2014. The data were divided into three 3-year periods., Subjects: The data comprised all physicians who had diagnosed at least one RTI for each of the three-year periods. The antibiotic prescribing rate adjusted for the patients' sex and age group was calculated for each physician and period, and based on the change between the first and the third period, the physicians were divided into three prescriber groups: The High Prescribing Group, the Decreasing Prescribing Group, and the Low Prescribing Group., Main Outcome Measures: For the three prescriber groups, we compared factors influencing antibiotic prescribing such as the characteristics of the physicians, their use of point-of-care tests, their choice of diagnoses, and whether the patients returned and received antibiotics., Results: The High Prescribing Group ordered more point-of-care tests, registered more potential bacterial diagnoses, prescribed antibiotics at lower C-reactive protein levels, and prescribed antibiotics more often despite negative group A Streptococci test than in the Low Prescribing Group. The Decreasing Prescribing Group was between the High Prescribing Group and the Low Prescribing Group regarding these variables. The lower prescription rate in the Low Prescribing Group did not result in more return visits or new antibiotic prescriptions within 30 days., Conclusion: Point-of-care testing and its interpretation differed between the prescriber groups. Focus on interpreting point-of-care test results could be a way forward in antibiotic stewardship.

Objective: To compare management and documentation of vital signs, symptoms and infection severity in pneumonia patients seeking primary care and emergency care without referral., Design: Medical record review of vital signs, examination findings and severity of pneumonia., Setting: Primary and emergency care., Subjects: Two hundred and forty patients diagnosed with pneumonia., Main Outcome Measures: Vital signs, examination findings and severity of pneumonia. Assessments of pneumonia severity according to the reviewers, the traffic light score and CRB-65., Results: Respiratory rate, blood pressure, heart rate and oxygen saturation were less often documented in primary care ( p  < .001). Chest X-ray was performed in 5% of primary care patients vs. 88% of emergency care patients ( p  < .01). Primary care patients had longer symptom duration, higher oxygen saturation and lower respiratory rate. In total, the reviewers assessed 63% of all pneumonias as mild and 9% as severe. The traffic light scoring model identified 11 patients (9%) in primary care and 53 patients (44%) in emergency care at high risk of severe infection., Conclusions: Vital signs were documented less often in primary care than in emergency care. Patients in primary care appear to have a less severe pneumonia, indicating attendance to the correct care level. The traffic light scoring model identified more patients at risk of severe infection than CRB-65, where the parameters were documented to a limited extent.

Objectives: Fusobacterium necrophorum is a common cause of pharyngotonsillitis. However, no guidelines exist on when to diagnose or treat it. We aimed to investigate associations between clinical criteria and F. necrophorum-positivity in pharyngotonsillitis and assess the predictive potential of a simple scoring system., Methods: Pharyngotonsillitis patients who were tested for F. necrophorum (PCR) and presented to hospitals in the Skåne Region, Sweden, between 2013-2020 were eligible. Data were retrieved from electronic chart reviews and registries. By logistic regression we investigated associations between F. necrophorum-positivity and pre-specified criteria: age 13-30 years, symptom duration ≤ 3 days, absence of viral symptoms (e.g. cough, coryza), fever, tonsillar swelling/exudate, lymphadenopathy and CRP ≥ 50 mg/L. In secondary analyses, associated variables were weighted by strength of association into a score and its predictive accuracy of F. necrophorum was assessed., Results: Among 561 cases included, 184 (33%) had F. necrophorum, which was associated with the following criteria: age 13-30, symptom duration ≤ 3 days, absence of viral symptoms, tonsillar swelling/exudate and CRP ≥ 50 mg/L. Age 13-30 had the strongest association (OR5.7 95%CI 3.7-8.8). After weighting, these five variables had a sensitivity and specificity of 68% and 71% respectively to predict F. necrophorum-positivity at the proposed cut-off., Conclusion: Our results suggest that F. necrophorum cases presenting to hospitals might be better distinguished from other pharyngotonsillitis cases by a simple scoring system presented, with age 13-30 being the strongest predictor for F. necrophorum. Prospective studies, involving primary care settings, are needed to evaluate generalisability of findings beyond cases presenting to hospitals., (© 2024. The Author(s).)

Aims: An increase in psychosomatic symptoms among adolescents has recently been reported. Few studies have examined the relation between food intake and psychosomatic symptoms. The aim was to study the association between food intake and overall psychosomatic burden and separate psychosomatic symptoms., Methods: In this cross-sectional study, we used data from 6248 girls and 7153 boys in south-east Sweden who turned 16 years of age during the academic years 2009/2010 to 2015/2016 and responded to a health questionnaire at the school health services. The association between overall healthy food intake and a low psychosomatic burden was calculated as odds ratios (95% confidence interval) and stratified for other lifestyle habits and gender., Results: Sixty-nine per cent of the boys and 35% of the girls had a low psychosomatic burden. There was a positive association between an overall healthy food intake and a low psychosomatic burden ( P <0.0001), regardless of other lifestyle habits and gender. An overall healthy food intake was also positively associated with a lower frequency of the separate psychosomatic symptoms of concentration difficulties, sleep difficulties, a poor appetite or dizziness ( P <0.0001)., Conclusions: A healthy food intake seems to be associated with a low psychosomatic burden among adolescents. Further knowledge is needed to explore whether an improved food intake can reduce psychosomatic symptoms and enhance mental health., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Rapid antigen detection tests (RADT) for Group A streptococci (GAS) and point-of-care tests for C-reactive protein (CRP) are commonly used in patients with pharyngotonsillitis in Sweden and Denmark although CRP testing is not supported by guidelines. We aimed to describe (1) the proportion of patients tested with RADT and/or CRP, (2) the relation between test results and antibiotic prescribing, and (3) the association between CRP level and microbial aetiology., Methods: We used a post-hoc-analysis of data collected in primary health care in a prospective aetiological study of 220 patients 15-45 years old diagnosed with pharyngotonsillitis. The outcomes of RADTs and CRP tests were related to antibiotic prescribing and microbial aetiology., Results: A RADT was used in 94% of the patients. A CRP test was used in 50% of the patients but more commonly in those with a negative RADT (59%) than in those with a positive RADT (38%) (p = 0.005). Most (74%) CRP tests were used in patients with a negative RADT. Antibiotic prescribing differed greatly between patients with a positive RADT (96%) and patients with a negative RADT (17%) (p < 0.001). In patients with a negative RADT, there was a positive association between CRP value and antibiotic prescribing (OR 1.05; 95% CI 1.02-1.07; p < 0.001). Patients with CRP values ≤ 30 mg/l were seldomly prescribed antibiotics. Patients with GAS in culture had the highest median CRP (46 mg/l), which was higher than in patients without GAS (8 mg/l; p < 0.001). However, the positive predictive value for GAS never exceeded 0.60 (95% CI 0.31-0.83) at the investigated CRP levels., Conclusions: The widespread use of tests is a major deviation from national guidelines. Most CRP tests were used in patients with a negative RADT, suggesting a belief in the added value of a CRP test, and the CRP result seemed to influence antibiotic prescribing. However, as an aetiological test, CRP is not useful for predicting GAS., (© 2024. The Author(s).)

Overexpression of specific matrix metalloproteinases (MMPs) has a key role in development of several diseases, such as cancer, neurological disorders, and cardiovascular diseases due to their critical role in degradation and remodeling of the extracellular matrix (ECM). Tissue inhibitors of metalloproteinases (TIMPs), a family of four in humans, are endogenous inhibitors of MMPs. TIMPs have a high level of sequence and structure homology, with a broad range of binding and inhibition to the family of MMPs. It is important to identify the key motifs of TIMPs responsible for inhibition of MMPs to develop efficient therapeutics targeting specific MMPs. We used DNA shuffling between the human TIMP family to generate a minimal TIMP hybrid library in yeast to identify the dominant minimal MMP inhibitory regions. The minimal TIMP variants screened toward MMP-3 and MMP-9 using fluorescent-activated cell sorting (FACS). Interestingly, several minimal TIMP variants selected after screening toward MMP-3cd or MMP-9cd, with lengths as short as 20 amino acids, maintained or improved binding to MMP-3 and MMP-9. The TIMP-MMP binding dissociation constant (K D ), in the nM range, and MMP inhibition constants (K i ), in the pM range, of these minimal TIMP variants were similar to the N-terminal domain of TIMP-1 on the yeast surface and in solution indicating the potency of these minimal variants as MMP inhibitors. We further used molecular modeling simulation, and molecular docking of the minimal TIMP variants in complex with MMP-3cd to understand the binding and inhibition mechanism of these variants., (© 2023 The Protein Society.)

Background: Most studies on long-term follow-up of patients with COVID-19 focused on hospitalised patients. No prospective study with structured follow-up has been performed in non-hospitalised patients with COVID-19., Objectives: To assess long-COVID and post-COVID (WHO definition: symptomatic at least 12 weeks), describe lingering symptoms, their impact on daily activities, and general practice visits and explore risk factors for symptom duration in outpatients., Methods: A prospective study of adult outpatients with confirmed SARS-CoV-2 infection and symptoms consistent with COVID-19 in 11 European countries, recruited during 2020 and 2021 from primary care and the community. Structured follow-up by phone interviews (symptom rating, symptom impact on daily activities and general practice visits) was performed at weeks 2, 4, 8, and 12 by study personnel. Data was analysed descriptively by using correlation matrixes and Cox regression., Results: Of 270 enrolled patients, 52% developed long-COVID and 32% post-COVID-syndrome. When only considering the presence of moderate or (very) severe symptoms at weeks 8 and 12, these percentages were 28% and 18%, respectively. Fatigue was the most often reported symptom during follow-up. The impact of lingering symptoms was most evident in sports and household activities. About half (53%) had at least one general practice contact during follow-up. Obese patients took twice as long to return to usual health (HR: 0.5, 95%CI: 0.3-0.8); no other risk profile could predict lingering symptoms., Conclusion: Long-COVID and post-COVID are also common in outpatients. In 32%, it takes more than 12 weeks to return to usual health.

Background: Resistance to antibiotics is rising and threatens future antibiotic effectiveness. 'Antibiotic targeting' ensures patients who may benefit from antibiotics receive them, while being safely withheld from those who may not. Point-of-care tests may assist with antibiotic targeting by allowing primary care clinicians to establish if symptomatic patients have a viral, bacterial, combined, or no infection. However, because organisms can be harmlessly carried, it is important to know if the presence of the virus/bacteria is related to the illness for which the patient is being assessed. One way to do this is to look for associations with more severe/prolonged symptoms and test results. Previous research to answer this question for acute respiratory tract infections has given conflicting results with studies has not having enough participants to provide statistical confidence., Aim: To undertake a synthesis of IPD from both randomised controlled trials (RCTs) and observational cohort studies of respiratory tract infections (RTI) in order to investigate the prognostic value of microbiological data in addition to, or instead of, clinical symptoms and signs., Methods: A systematic search of Cochrane Central Register of Controlled Trials, Ovid Medline and Ovid Embase will be carried out for studies of acute respiratory infection in primary care settings. The outcomes of interest are duration of disease, severity of disease, repeated consultation with new/worsening illness and complications requiring hospitalisation. Authors of eligible studies will be contacted to provide anonymised individual participant data. The data will be harmonised and aggregated. Multilevel regression analysis will be conducted to determine key outcome measures for different potential pathogens and whether these offer any additional information on prognosis beyond clinical symptoms and signs., Trial Registration: PROSPERO Registration number: CRD42023376769., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Boateng et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Antibiotics provide only modest benefit in treating sore throat, although their effectiveness increases in people with positive throat swabs for group A beta-haemolytic streptococci (GABHS). It is unclear which antibiotic is the best choice if antibiotics are indicated. This is an update of a review first published in 2010, and updated in 2013, 2016, and 2021., Objectives: To assess the comparative efficacy of different antibiotics in: (a) alleviating symptoms (pain, fever); (b) shortening the duration of the illness; (c) preventing clinical relapse (i.e. recurrence of symptoms after initial resolution); and (d) preventing complications (suppurative complications, acute rheumatic fever, post-streptococcal glomerulonephritis). To assess the evidence on the comparative incidence of adverse effects and the risk-benefit of antibiotic treatment for streptococcal pharyngitis., Search Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2023, Issue 2), MEDLINE Ovid, Embase Elsevier, and Web of Science (Clarivate) up to 19 March 2023., Selection Criteria: Randomised, double-blind trials comparing different antibiotics, and reporting at least one of the following: clinical cure, clinical relapse, or complications and/or adverse events., Data Collection and Analysis: Two review authors independently screened trials for inclusion and extracted data using standard methodological procedures recommended by Cochrane. We assessed the risk of bias in the included studies according to the methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions, and used the GRADE approach to assess the overall certainty of the evidence for the outcomes. We reported the intention-to-treat analysis, and also performed an analysis of evaluable participants to explore the robustness of the intention-to-treat results., Main Results: We included 19 trials reported in 18 publications (5839 randomised participants): six trials compared penicillin with cephalosporins; six compared penicillin with macrolides; three compared penicillin with carbacephem; one compared penicillin with sulphonamides; one compared clindamycin with ampicillin; and one compared azithromycin with amoxicillin in children. All participants had confirmed acute GABHS tonsillopharyngitis, and ages ranged from one month to 80 years. Nine trials included only, or predominantly, children. Most trials were conducted in an outpatient setting. Reporting of randomisation, allocation concealment, and blinding was poor in all trials. We downgraded the certainty of the evidence mainly due to lack of (or poor reporting of) randomisation or blinding, or both, heterogeneity, and wide confidence intervals. Cephalosporins versus penicillin We are uncertain if there is a difference in symptom resolution (at 2 to 15 days) for cephalosporins versus penicillin (odds ratio (OR) for absence of symptom resolution 0.79, 95% confidence interval (CI) 0.55 to 1.12; 5 trials, 2018 participants; low-certainty evidence). Results of the sensitivity analysis of evaluable participants differed (OR 0.51, 95% CI 0.27 to 0.97; 5 trials, 1660 participants; very low-certainty evidence). Based on an analysis of evaluable participants, we are uncertain if clinical relapse may be lower for cephalosporins compared with penicillin (OR 0.55, 95% CI 0.30 to 0.99; number needed to treat for an additional beneficial outcome (NNTB) 50; 4 trials, 1386 participants; low-certainty evidence). Very low-certainty evidence showed no difference in reported adverse events. Macrolides versus penicillin We are uncertain if there is a difference between macrolides and penicillin for resolution of symptoms (OR 1.11, 95% CI 0.92 to 1.35; 6 trials, 1728 participants; low-certainty evidence). Sensitivity analysis of evaluable participants resulted in an OR of 0.79 (95% CI 0.57 to 1.09; 6 trials, 1159 participants). We are uncertain if clinical relapse may be different (OR 1.21, 95% CI 0.48 to 3.03; 6 trials, 802 participants; low-certainty evidence). Children treated with macrolides seemed to experience more adverse events than those treated with penicillin (OR 2.33, 95% CI 1.06 to 5.15; 1 trial, 489 participants; low-certainty evidence). However, the test for subgroup differences between children and adults was not significant. Azithromycin versus amoxicillin Based on one unpublished trial in children, we are uncertain if resolution of symptoms is better with azithromycin in a single dose versus amoxicillin for 10 days (OR 0.76, 95% CI 0.55 to 1.05; 1 trial, 673 participants; very low-certainty evidence). Sensitivity analysis for per-protocol analysis resulted in an OR of 0.29 (95% CI 0.11 to 0.73; 1 trial, 482 participants; very low-certainty evidence). We are also uncertain if there was a difference in relapse between groups (OR 0.88, 95% CI 0.43 to 1.82; 1 trial, 422 participants; very low-certainty evidence). Adverse events were more common with azithromycin compared to amoxicillin (OR 2.67, 95% CI 1.78 to 3.99; 1 trial, 673 participants; very low-certainty evidence). Carbacephem versus penicillin There is low-certainty evidence that compared with penicillin, carbacephem may provide better symptom resolution post-treatment in adults and children (OR 0.70, 95% CI 0.49 to 0.99; NNTB 14.3; 3 trials, 795 participants). Studies did not report on long-term complications, so it was unclear if any class of antibiotics was better at preventing serious but rare complications., Authors' Conclusions: We are uncertain if there are clinically relevant differences in symptom resolution when comparing cephalosporins and macrolides with penicillin in the treatment of GABHS tonsillopharyngitis. Low-certainty evidence in children suggests that carbacephem may be more effective than penicillin for symptom resolution. There is insufficient evidence to draw conclusions regarding the other comparisons in this review. Data on complications were too scarce to draw conclusions. Antibiotics have a limited effect in the treatment of GABHS pharyngitis and the results do not demonstrate that other antibiotics are more effective than penicillin. In the context of antimicrobial stewardship, penicillin can be used if treatment with an antibiotic is indicated. All studies were conducted in high-income countries with a low risk of streptococcal complications, so there is a need for trials in low-income countries and disadvantaged populations, where the risk of complications remains high., (Copyright © 2023 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Purpose: To explore hypertension management in primary healthcare (PHC)., Design: Structured interviews of randomly selected PHC centres (PHCCs) from December 2019 to January 2021., Setting: Seventy-six PHCCs in eight regions of Sweden., Main Outcome Measures: Staffing and organization of hypertension care. Methods of measuring blood pressure (BP), laboratory tests, registration of co-morbidities and lifestyle advice at diagnosis and follow-up., Results: The management of hypertension varied among PHCCs. At diagnosis, most PHCCs (75%) used the sitting position at measurements, and only 13% routinely measured standing BP. One in three (33%) PHCCs never used home BP measurements and 25% only used manual measurements. The frequencies of laboratory analyses at diagnosis were similar in the PHCCs. At follow-up, fewer analyses were performed and the tests of lipids and microalbuminuria decreased from 95% to 45% ( p  < 0.001) and 61% to 43% ( p  = 0.001), respectively. Only one out of 76 PHCCs did not measure kidney function at routine follow-ups. Lifestyle, physical activity, food habits, smoking and alcohol use were assessed in ≥96% of patients at diagnosis. At follow-up, however, there were fewer assessments. Half of the PHCCs reported dedicated teams for hypertension, 82% of which were managed by nurses. There was a great inequality in the number of patients per tenured GP in the PHCCs (median 2500; range 1300-11300) patients., Conclusions: The management of hypertension varies in many respects between PHCCs in Sweden. This might lead to inequity in the care of patients with hypertension.

When imaging (i.e., chest-x-ray or computed tomography) is used to differentiate between acute bronchitis and pneumonia, many patients are being prescribed antibiotics despite the absence of radiographic pneumonia signs. This study of lower respiratory tract infections (LRTIs) with negative chest imaging compares cases where antibiotics were prescribed and not prescribed to find characteristics that could explain the prescription. Data were extracted from the regional electronic medical record system in Kronoberg County, Sweden, for patients aged 18-79 years diagnosed with acute bronchitis or pneumonia and who had any chest radiologic imaging between 2007-2014. Of 696 cases without evidence of pneumonia on imaging, 55% were prescribed antibiotics. Age, sex, and co-morbidity did not differ between those with or without antibiotics. The median level of C-reactive protein was low in both groups but differed significantly (21 vs. 10 mg/L; p < 0.001). Resident physicians prescribed antibiotics more frequently than interns or specialists ( p < 0.001). It is unclear what features prompted the antibiotic prescribing in those with negative imaging indicating overuse of antibiotics for LRTIs.

Background: Diabetes self-management education and support (DSMES) is a cornerstone in the treatment of type 2 diabetes mellitus (T2DM). It is unclear whether delivering DSMES as a digital health intervention (DHI) might meet the needs experienced by patients with T2DM and diabetes specialist nurses (DSN) of the primary health care system in Sweden., Methods: Fourteen patients with T2DM and four DSN participated in three separate focus groups: two groups comprised patients and one group comprised DSN. The patients discussed the questions: "What needs did you experience after your T2DM diagnosis?" and "How might these needs be met with a DHI?" The DSN discussed the questions: "What needs do you experience when treating a patient with newly diagnosed T2DM?" and "How might these needs be met with a DHI?". Furthermore, data were collected in the form of field notes from group discussions at a meeting including 18 DSNs working with T2DM in PHCCs. The discussions from focus groups were transcribed verbatim and analyzed together with the field notes from the meeting using inductive content analysis., Results: The analysis yielded the overall theme: "Overcoming the struggle of living with T2DM", which was summarized in two categories: "learning and being prepared" and "giving and receiving support". Important findings were that, for success, a DHI for DSMES must be integrated into routine care, provide structured, high-quality information, suggest tasks to stimulate behavioral changes, and provide feedback from the DSN to the patient., Conclusion: This study highlighted several important aspects, from the perspectives of both the patient with T2DM and the DSN, which should be taken into consideration for the successful development and use of a DHI for DSMES., (© 2023. The Author(s).)

Objective: The aim was to compare rapid antigen detection test (RADT) and throat culture for group A streptococci (GAS) among patients recently treated with penicillin V for GAS pharyngotonsillitis., Design and Setting: The study was a secondary analysis within a randomized controlled trial comparing 5 versus 10 days of penicillin V for GAS pharyngotonsillitis. Patients were recruited at 17 primary health care centres in Sweden., Subjects: We included 316 patients ≥ 6 years of age, having 3-4 Centor criteria, a positive RADT and a positive throat culture for GAS at inclusion, and also having a RADT and throat culture for GAS taken at a follow-up visit within 21 days., Main Outcome Measures: RADT and conventional throat culture for GAS., Results: This prospective study showed 91% agreement between RADT and culture at follow-up within 21 days. Only 3/316 participants had negative RADT with a positive throat culture for GAS at follow-up, and 27/316 patients with positive RADT had a negative culture for GAS. Log rank test did not reveal any difference in the decline over time of positive tests between RADT and throat culture ( p  = 0.24). Agreement between RADT and throat culture for GAS at the follow-up was not associated with treatment duration, number of days from inclusion until follow-up, throat symptoms at follow-up, gender, or age., Conclusion: RADT and culture for GAS agreed to a high extent also after recent penicillin V treatment. RADT for GAS means a low risk for missing the presence of GAS.KEY POINTSTesting for group A streptococci (GAS) before antibiotic treatment can reduce antibiotic prescription for pharyngotonsillitis. It has been proposed that rapid antigen detection tests (RADT) for group A streptococci after recent penicillin V treatment may be falsely positive due to possible persisting antigens from non-viable bacteria.The decline of the presence of GAS was similar between RADT and conventional throat culture in patients who had recently completed penicillin V treatment for GAS pharyngotonsillitisRADT for GAS is useful in identifying the presence of GAS after recent penicillin V treatment.

Background: The intestinal microbiota functions as a reservoir of antibiotic resistance., Objectives: To evaluate penicillin V (phenoxymethylpenicillin) effects on the faecal microbiota with focus on beta-lactam resistance., Methods: We included 31 primary care patients with group A streptococcal pharyngotonsillitis treated with penicillin V for 5 (800 mg × 4) or 10 days (1000 mg × 3). Twenty-nine patients contributed with three faecal swab samples each. The faecal specimens were collected at the start of penicillin V treatment, after the last dose and at follow-up 7-9 days after completed treatment. Samples were inoculated semiquantitatively on selective screening agar plates to study beta-lactam resistance, species shifts among Enterobacterales and enterococci, and colonization with Candida spp. and Clostridioides difficile . Representative colonies were identified using MALDI-TOF. Results were analysed by non-parametric statistical methods., Results: An increase in the proportion of patients colonized with ampicillin-resistant Enterobacterales, from 52% to 86% ( P  = 0.007), and Enterobacterales with decreased susceptibility to third-generation cephalosporins, from 32% to 52% ( P  = 0.034), was observed between the first and second samples. This increase was no longer significant at follow-up. New colonization with ampicillin-resistant Enterobacterales species and non-Enterobacterales Gram-negative species was observed, and persisted at follow-up., Conclusions: Following treatment with penicillin V, we observed decreased susceptibility to ampicillin and third-generation cephalosporins, and prolonged colonization with non- Escherichia coli Gram-negative species. These findings challenge the perception that penicillin V has limited ecological effect on the intestinal microbiota, and emphasizes the importance of avoiding even narrow-spectrum antimicrobials when possible., (© The Author(s) 2023. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy.)

Background: Depression and anxiety often reduce people's ability to cope with everyday occupations. There is a lack of knowledge about such problems in people of working age with depression and anxiety., Aim: To describe which problems people with depression or anxiety disorders experience when performing everyday occupations and which occupations are affected., Materials and Methods: Data based on the Canadian Occupational Performance Measure was used in this cross-sectional study. A total of 118 participants aged 18-65 years, with depression or anxiety, were recruited from primary healthcare and general mental healthcare services. The data were analysed with descriptive statistics and directed content analysis., Results: The participants rated a low level of occupational performance, and their satisfaction with performance even lower. They described a great number of problems with their everyday occupations. The most frequent problem areas concerned household management, socialization and personal care. Detailed descriptions of which type of problem they experienced during everyday occupations are included., Conclusions: This study provides knowledge of which problems people with depression and anxiety disorders experience in everyday occupations within self-care, productivity, as well as leisure. Furthermore, they rate performance and satisfaction with performance of the five occupations they find the most important to change in everyday life.

Background: Quality of life (QOL), sense of coherence (SOC) and occupational balance (OB) have been found to increase after rehabilitation among people living with depression and anxiety. However, these aspects have not been investigated over time in participants with different paid work situations, such as being on sick leave or not., Objective: To describe and compare the self-rated QOL, SOC and OB after participation in occupational therapy in three groups of people with depression and anxiety disorders based on their work situation during the study period: continuous sick leave, return to work and continuous work., Methods: Forty-seven women and seven men, 19-60 years old with depression and anxiety were followed over time. They completed questionnaires on QOL, SOC and OB on four occasions. Data were analyzed with non-parametric statistics., Results: No statistically significant differences between the groups were identified. All groups improved in at least one of the studied areas over time: the sick leave group in OB; the return-to-work group in QOL and OB; and the Work group in QOL and SOC., Conclusion: The results indicate variations in QOL, SOC and OB between people with different work situations over time after occupational therapy. Studies with larger samples are, however, warranted.

Background: Sore throat is a common reason for prescribing antibiotics in primary care, and 10 days of treatment is recommended for patients with pharyngotonsillitis with group A streptococcus (GAS). Our group recently showed that penicillin V (PcV) four times daily for 5 days was non-inferior in clinical outcome to PcV three times daily for 10 days. This study compares duration, intensity of symptoms, and side effects in patients with a Centor Score (CS) of 3 or 4 respectively, after treatment with PcV for 5 or 10 days and evaluates whether all patients with pharyngotonsillitis with a CS of 3 or 4 should be treated for 5 days or if severity of symptoms or CS suggest a longer treatment period., Method: Data on symptoms and recovery from patient diaries from 433 patients included in a RCT comparing PcV 800 mg × 4 for 5 days or PcV 1 g × 3 for 10 days was used. Patients six years and older with CS-3 or CS-4 and positive rapid antigen detection test for GAS-infection were grouped based on CS and randomized treatment. Comparisons for categorical variables were made with Pearson's chi-squared test or Fisher's exact test. Continuous variables were compared with the Mann-Whitney U test., Results: Patients with CS-3 as well as patients with CS-4 who received PcV 800 mg × 4 for 5 days self-reported that they recovered earlier compared to patients with CS-3 or CS-4 who received treatment with PcV 1 g × 3 for 10 days. In addition, the throat pain as single symptom was relieved 1 day earlier in patients with CS-4 and 5 days of treatment compared to patients with CS-4 and 10 days of treatment. No differences in side effects between the groups were found., Conclusion: Intense treatment with PcV four times a day for 5 days seems clinically beneficial and strengthens the suggestion that the 4-dose regimen with 800 mg PcV for 5 days may be the future treatment strategy for GAS positive pharyngotonsillitis irrespectively of CS-3 or CS-4. Trail registration ClinicalTrials.gov ID: NCT02712307 (3 April 2016)., (© 2022. The Author(s).)

Since the start of the Swedish National Research School in General Practice, 120 Swedish PhD candidates in general practice have been admitted to the school, out of whom 89 during the first 10-year period. We have evaluated the academic achievements of the 53 (60%) PhD candidates that finished their thesis 2011-2020 by a questionnaire and bibliometric data collected from the Web of Science Core Collection. The questionnaire was answered by 52 (98%) and showed that 45 (87%) had continued with research work after their dissertation. Ten (19%) had done a post doc and four (8%) had become associate professors, out of whom one (2%) was a full professor. We found 519 peer-reviewed scientific publications authored by the alumni. The co-authors of these publications were affiliated all around the world, mainly in Sweden, followed by Australia and Germany. The National Research School will continue to strive towards increased quality of primary care research.

Introduction: Depression and anxiety disorders affect individuals' everyday lives, and treatments that can help them to perform everyday occupations are needed. Occupational therapy for this group has been evaluated from a short-term perspective but not from a long-term perspective; further research is thus warranted. The aim of the study was to investigate the longitudinal outcomes of the Tree Theme Method (TTM) compared with care as usual, provided by occupational therapists, in terms of everyday occupations, psychological symptoms, and health-related aspects., Methods: This randomised controlled trial comprised a follow-up 3 and 12 months after an intervention. A total of 118 participants (19-64 years) with depression or anxiety disorders and problems with everyday occupations completed the base line questionnaires, 100 completed the follow-up at 3 months, and 84 completed the follow-up at 12 months. Imputations of missing data were performed using the last observation, and parametric analysis was used., Results: Both groups showed significant improvements (P value ≤ 0.01) in everyday occupations, psychological symptoms and health-related aspects after 3 and 12 months. No significant differences were found between the groups., Conclusion: This study contributes with knowledge about the outcomes of occupational therapy for clients living with depression and anxiety disorders. Both TTM and care as usual lead to significant improvements over time concerning everyday occupations, psychological symptoms, and health-related aspects. The fact that both occupational therapy methods were associated with improvements for clients with depression and anxiety supports client-centredness in enabling an occupational therapist to choose the method best suited for the individual., (© 2022 The Authors. Australian Occupational Therapy Journal published by John Wiley & Sons Australia, Ltd on behalf of Occupational Therapy Australia.)

Aims: Antimicrobial resistance presents an increasingly serious threat to global public health, which is directly related to how antibiotic medication is used in society. Actions aimed towards the optimised use of antibiotics should be implemented on equal terms and according to the needs of the population. Previous research results on differences in antibiotic use between socio-economic and demographic groups in Sweden are not entirely coherent, and have typically focused on the effects of singular socio-economic variables. Using an intersectional approach, this study provides a more precise analysis of how the dispensation of antibiotic medication was distributed across socio-economic and demographic groups in Sweden in 2016-2017. Methods: Using register data from a nationwide cohort and adopting an intersectional analysis of individual heterogeneity and discriminatory accuracy, we map the dispensation of antibiotics according to age, sex, country of birth and income. Results: While women and high-income earners had the highest antibiotic dispensation prevalence, no large differences in the dispensation of antibiotics were identified between socio-economic groups. Conclusions: Public-health interventions aiming to support the reduced and optimised use of antibiotics should be directed towards the whole Swedish population rather than towards specific groups. Correspondingly, an increased focus on socio-economic or demographic factors is not warranted in interventions aimed at improving antibiotic prescription patterns among medical practitioners.

There is limited knowledge about the associations between intakes of different foods and inconsistency in the literature of the relation between the quality of food intake and bodyweight in adolescents. The aim of this study is to explore how healthy self-reported food intakes are associated with each other and with overweight/obesity in adolescents. This is a cross-sectional study of seven cohorts of adolescents ( n 13 451) who turned sixteen from 2009/2010 up to 2015/2016 and responded to a health questionnaire used by the School Health Services in southeast Sweden. Associations between intakes of ten self-reported foods as well as between food intakes and weight groups based on the International Obesity Task Force standards (isoBMI) were explored by multivariable logistic regression. Healthy intakes of different foods were mostly associated with each other with the strongest association between a high intake of fruit and a high intake of vegetables (odds ratio (OR) = 25 (95 % confidence interval (CI) 20⋅0-33⋅1)). A low-frequency intake of sweets/snacks (OR = 2⋅35 (95 % CI 1⋅84-3⋅00)) was associated with overweight/obesity as well as a healthy choice of butter/margarine (≤40 % fat) (OR = 1⋅82 (95 % CI 1⋅39 to 2⋅41)), but a high-frequency intake of vegetables was negatively associated with overweight/obesity 0⋅77 (0⋅62-0⋅95). To promote health and achieve a healthy weight among adolescents, it is important to take both diet quality and total food amount into consideration., (© The Author(s) 2022.)

Objective: Antimicrobial resistance is a growing worldwide problem and is considered to be one of the biggest threats to global health by the World Health Organization. Insights into the determinants of antibiotic prescribing may be gained by comparing the antibiotic usage patterns of Australia and Sweden., Design: Publicly available data on dispensed use of antibiotics in Australia and Sweden between 2006 and 2018. Medicine use was measured using defined daily dose per 1,000 inhabitants per day (DDD/1000/day) and the number of dispensed prescriptions per 1000 inhabitants (prescriptions/1000)., Results: The use of antibiotics increased over the study period in Australia by 1.8% and decreased in Sweden by 26.3%. Use was consistently higher in Australia, double that of Sweden in 2018. Penicillin with extended spectrum was the most used class of antibiotics in Australia followed by penicillin with beta lactamase inhibitors. In Sweden, the most used class was beta lactamase-sensitive penicillin and the least used class was penicillin with beta lactamase inhibitors., Conclusion: Antibiotic use in Australia is higher than in Sweden, with a higher proportion of broad-spectrum penicillin, including combinations with beta lactamase inhibitors, and cephalosporins. Factors that may contribute to these differences in antibiotic use include differences in guidelines, the duration of national antimicrobial stewardship programs, and differences in funding mechanisms.Key pointsAustralia has had a consistently higher dispensed use of antibiotics compared to Sweden from 2006 to 2018; and up to twice the use in 2018•A higher proportion of dispensed antibiotics in Australia were broad-spectrum penicillin, including combinations with beta lactamase inhibitors, and cefalosporins.•The most commonly used class of antibiotics in Australia is penicillin with extended spectrum, compared to beta lactamase sensitive penicillin in Sweden.•Use of macrolides, sulphonamides and trimethoprim, cephalosporins, penicillin with beta lactamase inhibitors and penicillin with extended spectrum was consistently higher in Australia, whereas in Sweden use of fluoroquinolones, lincosamides, beta lactamase-resistant penicillin and beta lactamase sensitive penicillin was higher.•The observed differences could be explained by antibiotic choice recommended in guidelines, prevalence of point-of-care testing, models of primary care funding, the presence and duration of national antimicrobial stewardship programmes, and cultural differences.