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Hedin K.,Lund University | Hedin K.,Unit for Research and Development | Strandberg E.L.,Lund University | Grondal H.,Uppsala University | And 6 more authors.
Scandinavian Journal of Primary Health Care | Year: 2014

To explore how a group of Swedish general practitioners (GPs) manage patients with a sore throat in relation to current guidelines as expressed in interviews. Design. Qualitative content analysis was used to analyse semi-structured interviews. Setting. Swedish primary care. Subjects. A strategic sample of 25 GPs. Main outcome measures. Perceived management of sore throat patients. Results. It was found that nine of the interviewed GPs were adherent to current guidelines for sore throat and 16 were non-adherent. The two groups differed in terms of guideline knowledge, which was shared within the team for adherent GPs while idiosyncratic knowledge dominated for the non-adherent GPs. Adherent GPs had no or low concerns for bacterial infections and differential diagnosis whilst non-adherent GPs believed that in patients with a sore throat any bacterial infection should be identified and treated with antibiotics. Patient history and examination was mainly targeted by adherent GPs whilst for non-adherent GPs it was often redundant. Non-adherent GPs reported problems getting patients to abstain from antibiotics, whilst no such problems were reported in adherent GPs. Conclusion. This interview study of sore throat management in a strategically sampled group of Swedish GPs showed that while two-thirds were non-adherent and had a liberal attitude to antibiotics one-third were guideline adherent with a restricted view on antibiotics. Non-adherent GPs revealed significant knowledge gaps. Adherent GPs had discussed guidelines within the primary care team while non-adherent GPs had not. Guideline implementation thus seemed to be promoted by knowledge shared in team discussions. © 2014 The Author(s). Source

Andre M.,Linkoping University | Grondal H.,Uppsala University | Strandberg E.-L.,Lund University | Brorsson A.,Lund University | And 2 more authors.
BMC Family Practice | Year: 2016

Background: Uncertainty is inevitable in clinical practice in primary care and tolerance for uncertainty and concern for bad outcomes has been shown to vary between physicians. Uncertainty is a factor for inappropriate antibiotic prescribing. Evidence-based guidelines as well as near-patient tests are suggested tools to decrease uncertainty in the management of patients with respiratory tract infections. The aim of this paper was to describe strategies for coping with uncertainty in patients with pharyngotonsillitis in relation to guidelines. Methods: An interview study was conducted among a strategic sample of 25 general practitioners (GPS). Results: All GPS mentioned potential dangerous differential diagnoses and complications. Four strategies for coping with uncertainty were identified, one of which was compliant with guidelines, "Adherence to guidelines", and three were idiosyncratic: "Clinical picture and C-reactive protein (CRP)", "Expanded control", and "Unstructured". The residual uncertainty differed for the different strategies: in the strategy "Adherence to guidelines" and "Clinical picture and CRP" uncertainty was avoided, based either on adherence to guidelines or on the clinical picture and near-patient CRP; in the strategy "Expanded control" uncertainty was balanced based on expanded control; and in the strategy "Unstructured" uncertainty prevailed in spite of redundant examination and anamnesis. Conclusion: The majority of the GPS avoided uncertainty and deemed they had no problems. Their strategies either adhered to guidelines or comprised excessive use of tests. Thus use of guidelines as well as use of more near-patient tests seemed associated to reduced uncertainty, although the later strategy at the expense of compliance to guidelines. A few GPS did not manage to cope with uncertainty or had to put in excessive work to control uncertainty. © 2016 Andre et al. Source

Rudolph A.,German Cancer Research Center | Hein R.,German Cancer Research Center | Hoffmeister M.,German Cancer Research Center | Forsti A.,German Cancer Research Center | And 6 more authors.
International Journal of Cancer | Year: 2012

Copy number variations (CNVs) of the glutathione-S-transferase θ-1 (GSTT1) and glutathione-S-transferase μ-1 (GSTM1) gene loci can lead to complete lack of enzyme and have been associated with colorectal cancer (CRC) risk. As GSTs are involved in the detoxification of xenobiotics, CNVs may modify CRC risk associated with smoking exposure and menopausal hormone therapy (MHT) use. We investigated CRC risk associated with GSTT1 and GSTM1 CNVs and their interaction with smoking in 1,796 cases and 1,806 age-, sex- and residence-matched controls from a German population-based case-control study (DACHS). The interaction with MHT was assessed in the subset of 684 postmenopausal female cases and 681 controls. Trimodular genotypes (0/0, 1/0 and 1/1) were determined with relative quantification based on multiplex real-time polymerase chain reaction. The associations with CRC risk as well as possible effect modifications were evaluated using conditional logistic regression analysis. CNVs of GSTT1 and GSTM1 were not significantly associated with CRC risk. Compared to the 1/1 genotype, odds ratios (ORs) for the 0/1 genotype and the 0/0 genotype were 0.89 [95% confidence interval (CI): 0.77-1.04] and 0.97 (95% CI: 0.80-1.18) for GSTT1, and 0.99 (95% CI: 0.78-1.27) and 1.03 (95% CI: 0.81-1.31) for GSTM1. Compared to the nonnull genotype, ORs for the null-genotype were 1.04 (95% CI: 0.87-1.23) for GSTT1 and 1.03 (95% CI: 0.91-1.18) for GSTM1. No significant interaction with smoking and MHT use was observed. Our study does not provide evidence for a strong association between CRC risk and CNVs of GSTT1 or GSTM1 or for an effect modification of smoking or MHT use. © 2012 UICC. Source

Ji J.,Center for Primary Health Care Research | Zoller B.,Center for Primary Health Care Research | Sundquist J.,Stanford University | Sundquist K.,Stanford University
International Journal of Cancer | Year: 2016

The risk of solid and hematological malignancy in patients with Turner syndrome, characterized by X chromosome monosomy in women, and Klinefelter syndrome, characterized with two and more X chromosomes in men, is not well established, but such evidence may have etiological implications on cancer development. We identified a total of 1,409 women with Turner syndrome and 1,085 men with Klinefelter syndrome from the Swedish Hospital Discharge and Outpatient Register. These individuals were further linked to the Swedish Cancer Register to examine the standardized incidence ratios (SIRs) of cancer using the general population without Turner and Klinefelter syndromes as reference. The overall risk of cancer was 1.34 for women with Turner syndrome; it was increased only for solid tumors. For a specific type of tumor, the risk of melanoma and central nervous system tumor was significantly increased. For persons with Klinefelter syndrome, the risk of solid tumors was decreased (SIR=0.66), whereas the risk of hematological malignancy was increased (SIR=2.72). Non-Hodgkin lymphoma and leukemia showed an increased SIR of 3.02 and 3.62, respectively. Our study supported the hypothesis that X chromosome plays an important role in the etiology of solid tumors. The underlying mechanisms for the increased incidence of non-Hodgkin lymphoma and leukemia in persons with Klinefelter syndrome need to be investigated further. © 2016 UICC. Source

Sainz J.,German Cancer Research Center | Rudolph A.,German Cancer Research Center | Hein R.,German Cancer Research Center | Hoffmeister M.,German Cancer Research Center | And 12 more authors.
Endocrine-Related Cancer | Year: 2011

The incidence rates and relative risks for colorectal cancer (CRC) are higher in men than in women. Sex steroids may play a role in this gender-associated difference in CRC risk. This study was conducted to explore the relationship of single nucleotide polymorphisms (SNPs) in steroid hormone signaling (ESR1, ESR2, PGR, NR1I2, and SHBG), phase I- and II-metabolizing enzyme (COMT, HSD17B1, CYP1A1, CYP17A1, CYP1A2, CYP1B1, CYP2C9, CYP3A4, CYP2C19, and GSTP1), and hormone transporter (ABCB1) genes with the risk of CRC in German women and men, separately. From the population-based DACHS study (South Germany), 47 putatively functional SNPs were genotyped in 1798 CRC cases (746 women and 1052men) and 1810 controls (732 women and 1078 men). Significant allele dose-response associations were observed with ESR2-rs1255998, ESR2-rs928554, HSD17B1-rs605059, and ABCB1-rs2229109 in women (P trend=0.004, 0.05, 0.03, and 0.05 respectively) and with ABCB1-rs1045642, ABCB1-rs9282564, and SHBG-rs6259 in men (P trend=0.01, 0.03, and 0.02 respectively). The ESR2-rs1255998-G allele showed the most significant association with risk for CRC in women, with a per-allele odds ratio (OR) of 0.68 (95% confidence interval (CI) 0.52-0.88). This finding was replicated in an independent study from North Germany including 1076 female CRC cases and 1151 controls (OR=0.84, 95% CI 0.71-1.04), yielding a per-allele OR of 0.80 (95% CI 0.69-0.93, P trend=0.003) in the pooled sample. These findings implicate a role of ESR2 in the risk for developing CRCin women and suggest that HSD17B1, ABCB1, and SHBG genes may contribute to sex steroid-mediated effects on CRC development. © 2011 Society for Endocrinology. Source

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