Previously unknown or unexpected pathogens may be responsible for that proportion of respiratory diseases in which a causative agent cannot be identified. The application of broad-spectrum, sequence independent virus discovery techniques may be useful to reduce this proportion and widen our knowledge about respiratory pathogens. Thanks to the availability of high-throughput sequencing (HTS) technology, it became today possible to detect viruses which are present at a very low load, but the clinical relevance of those viruses must be investigated. In this study we used VIDISCA-454, a restriction enzyme based virus discovery method that utilizes Roche 454 HTS system, on a nasal swab collected from a subject with respiratory complaints. A γ-papillomavirus was detected (complete genome: 7142 bp) and its role in disease was investigated. Respiratory samples collected both during the acute phase of the illness and 2 weeks after full recovery contained the virus. The patient presented antibodies directed against the virus but there was no difference between IgG levels in blood samples collected during the acute phase and 2 weeks after full recovery. We therefore concluded that the detected γ-papillomavirus is unlikely to be the causative agent of the respiratory complaints and its presence in the nose of the patient is not related to the disease. Although HTS based virus discovery techniques proved their great potential as a tool to clarify the etiology of some infectious diseases, the obtained information must be subjected to cautious interpretations. This study underlines the crucial importance of performing careful investigations on viruses identified when applying sensitive virus discovery techniques, since the mere identification of a virus and its presence in a clinical sample are not satisfactory proofs to establish a causative link with a disease.
PURPOSE Imaging may produce unexpected or incidental fi ndings with consequences for patients and ordering of future investigations. Chest radiography in patients with acute cough is among the most common reasons for imaging in primary care, but data on associated incidental fi ndings are lacking. We set out to describe the type and prevalence of incidental chest radiography fi ndings in primary care patients with acute cough. METHODSWe report on data from a cross-sectional study in 16 European primary care networks on 3,105 patients with acute cough, all of whom were undergoing chest radiography as part of a research study workup. Apart from assessment for specifi ed signs of pneumonia and acute bronchitis, local radiologists were asked to evaluate any additional fi nding on the radiographs. For the 2,823 participants with good-quality chest radiographs, these fi ndings were categorized according to clinical relevance based on previous research evidence and analyzed for type and prevalence by network, sex, age, and smoking status. RESULTSIncidental fi ndings were reported in 19% of all participants, and ranged from 0% to 25% by primary care network, with the network being an independent contributor (P <.001). Of all participants 3% had clinically relevant incidental fi ndings. Suspected nodules and shadows were reported in 1.8%. Incidental fi ndings were more common is older participants and smokers (P <.001).CONCLUSIONS Clinically relevant incidental fi ndings on chest radiographs in primary care adult patients with acute cough are uncommon, and prevalence varies by setting. Ann Fam Med 2012;10:510-515. doi:10.1370/afm.1384. INTRODUCTIONA cute cough is one of the most common reasons for consulting in primary care. 1,2 Prompt, accurate diagnosis of pneumonia in these patients is important to rule in the need for timely appropriate antibiotic treatment in some patients and to rule out the need for antibiotic treatment in others. Responsible general practitioners order chest radiographs in a minority of patients with acute cough. 3 These radiographs confi rm pneumonia in 5% to 19% and exclude pneumonia in most patients. 2,4,5 Imaging provides information relevant to the acute illness but may also reveal incidental fi ndings. 6-9 Such fi ndings can benefi t patients through earlier diagnosis and treatment, for example, in as yet undiagnosed heart failure or malignancy. Incidental fi ndings, however, may have unknown or doubtful clinical relevance and lead to patient anxiety, expensive workup, and potentially harmful investigations and treatment without improving quality and length of life. 10,11 The nature and prevalence of incidental fi ndings on chest radiographs of patients who consult their general practitioner for acute cough is unknown. Such data may inform decisions about clinical indications for ordering chest radiographs. We studied incidental fi ndings on chest radiographs obtained METHODSWe undertook a cross-sectional observational study using data from the GRACE-09/10a study (Genomics to comba...
BackgroundVitamin tests are increasingly ordered by GPs, but a clinical and evidence based indication is often lacking. Harnessing technology, ie, decision support tools and redesigning request forms, have been shown to reduce vitamin D requests.AimCould the number of vitamin tests also be reduced by providing a multi-level intervention programme based on training, monitoring and feedback?Design & SettingIn a Cluster Randomised Intervention Study performed in 26 primary care health-centres (200.000 patients) the relative reduction in ordered vitamin D and B12 tests was determined after introduction of two de-implementation strategies (may 2017-may 2018).MethodHealth-centres randomised to de-implementation strategy one received education and 3-monthly benchmarking of their own vitamin test ordering behaviour. Health-centres in de-implementation strategy two received the same education and benchmarking but supplemented with educational material for patients.ResultsThe number of vitamin D tests decreased 23% compared to the one-year pre-intervention period. For vitamin B12 tests an overall reduction of 20% was found. Provision of patient educational information showed additional value over training and benchmarking of GPs alone, but only for vitamin D test ordering (10% extra reduction, OR 0.88, 95% CI 0.83–0.92, compared to 4% extra reduction for vitamin B12, OR 0.96, 95% CI 0.91–1.02). Nationwide, this would result in over € 3.200.000 saving on healthcare expenditure per year.ConclusionA structured intervention programme, including training and benchmarking of GPs regarding their diagnostic test ordering resulted in a significant reduction in ordered vitamin tests. Additional information provision to patients resulted in a small but still relevant additional reduction. If implemented on a national level, a substantial cost saving can be achieved.
PURPOSE We sought to determine the prevalence of airway obstruction and bronchodilator responsiveness in adults consulting for acute cough in primary care.METHODS Family physicians recruited 3,105 adult patients with acute cough (28 days or shorter) attending primary care practices in 12 European countries. After exclusion of patients with preexisting physician-diagnosed asthma or chronic obstructive pulmonary disease (COPD), we undertook complete case analysis of spirometry results (n = 1,947) 28 to 35 days after inclusion. Bronchodilator responsiveness was diagnosed if there were recurrent complaints of wheezing, cough, or dyspnea and an increase of the forced expiratory volume in 1 second (FEV 1 ) of 12% or more after bronchodilation. Airway obstruction was diagnosed according to 2 thresholds for the (postbronchodilator) ratio of FEV 1 to forced vital capacity (FEV 1 :FVC): less than 0.7 and less than the lower limit of normal.RESULTS There were 240 participants who showed bronchodilator responsiveness (12%), 193 (10%) had a FEV 1 /FVC ratio of less than 0.7, and 126 (6%) had a ratio of less than the lower limit of normal. Spearman's correlation between the 2 defi nitions of obstruction was 0.71 (P <.001), with discordance most pronounced among those younger than 30 years and in older participants.CONCLUSIONS Both bronchodilator responsiveness and persistent airway obstruction are common in adults without established asthma or COPD who consult for acute cough in primary care, which suggests a high risk of undiagnosed asthma and COPD. Different accepted methods to defi ne airway obstruction detected different numbers of patients, especially at the extremes of age. As both conditions benefi t from appropriate and timely interventions, clinicians should be aware and responsive to potential underdiagnosis.
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