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1.  Carers’ perspectives on the presentation of community-acquired pneumonia and empyema in children: a case series 
BMJ Open  2012;2(5):e001500.
Objective
To describe carers’ perceptions of the development and presentation of community-acquired pneumonia or empyema in their children.
Design
Case series.
Setting
Seven hospitals with paediatric inpatient units in South Wales, UK.
Participants
Carers of 79 children aged 6 months to 16 years assessed in hospital between October 2008 and September 2009 with radiographic, community-acquired pneumonia or empyema.
Methods
Carers were recruited in hospital and participated in a structured face-to-face or telephone interview about the history and presenting features of their children's illnesses. Responses to open questions were initially coded very finely and then grouped into common themes. Cases were classified into two age groups: 3 or more years and under 3 years.
Results
The reported median duration of illness from onset until the index hospital presentation was 4 days (IQR 2–9 days). Pain in the torso was reported in 84% of cases aged 3 or more years and was the most common cause for carer concern in this age group. According to carer accounts, clinicians sometimes misjudged the origin of this pain. Almost all carers reported something unusual about the index illness that had particularly concerned them—mostly non-specific physical symptoms and behavioural changes.
Conclusions
Pain in the torso and carer concerns about unusual symptoms in their child may provide valuable additional information in a clinician's assessment of the risk of pneumonia in primary care. Further research is needed to confirm the diagnostic value of these features.
doi:10.1136/bmjopen-2012-001500
PMCID: PMC3437434  PMID: 22952163
Tropical Medicine; Epidemiology; Paediatrics; Paediatric thoracic medicine; Thoracic Medicine; Respiratory infections; Paediatric palliative care; Paediatric infectious disease & immunisation
2.  Clinical influences on antibiotic prescribing decisions for lower respiratory tract infection: a nine country qualitative study of variation in care 
BMJ Open  2012;2(3):e000795.
Objectives
There is variation in antibiotic prescribing for lower respiratory tract infections (LRTI) in primary care that does not benefit patients. This study aims to investigate clinicians' accounts of clinical influences on antibiotic prescribing decisions for LRTI to better understand variation and identify opportunities for improvement.
Design
Multi country qualitative interview study. Semi-structured interviews using open-ended questions and a patient scenario. Data were subjected to five-stage analytic framework approach (familiarisation, developing a thematic framework from the interview questions and emerging themes, indexing, charting and mapping to search for interpretations), with interviewers commenting on preliminary reports.
Setting
Primary care.
Participants
80 primary care clinicians randomly selected from primary care research networks based in nine European cities.
Results
Clinicians reported four main individual clinical factors that guided their antibiotic prescribing decision: auscultation, fever, discoloured sputum and breathlessness. These were considered alongside a general impression of the patient derived from building a picture of the illness course, using intuition and familiarity with the patient. Comorbidity and older age were considered main risk factors for poor outcomes. Clinical factors were similar across networks, apart from C reactive protein near patient testing in Tromsø. Clinicians developed ways to handle diagnostic and management uncertainty through their own clinical routines.
Conclusions
Clinicians emphasised the importance of auscultation, fever, discoloured sputum and breathlessness, general impression of the illness course, familiarity with the patient, comorbidity, and age in informing their antibiotic prescribing decisions for LRTI. As some of these factors may be overemphasised given the evolving evidence base, greater standardisation of assessment and integration of findings may help reduce unhelpful variation in management. Non-clinical influences will also need to be addressed.
Article summary
Article focus
Clinicians' accounts of clinical influences on antibiotic prescribing decisions for LRTI.
Understand variation and identify opportunities for improvement.
Key messages
Clinicians reported four main clinical factors that guided their antibiotic prescribing decision: auscultation findings, fever, discoloured sputum and breathlessness. Clinical factors were similar across networks, apart from C reactive protein near patient testing used in Tromsø.
These clinical factors were considered alongside a general impression of the patient derived from consideration of illness course, intuition and familiarity with the patient.
Clinicians developed ways to handle diagnostic and management uncertainty through their own clinical routines.
Strengths and limitations of this study
This is the first study to use semi-structured qualitative interviews to capture clinicians' views about LRTI management across a broad range of contrasting European countries.
The clinicians who participated were affiliated to a research network so may not have been representative of all general practitioners in their country.
Qualitative interviews gather reports of behaviour and attitude rather than actual behaviour, but by allowing clinicians to introduce and elaborate on themes spontaneously, we were able to gain an impression of the themes that held most prominence to the clinicians themselves.
doi:10.1136/bmjopen-2011-000795
PMCID: PMC3364454  PMID: 22619265

Results 1-2 (2)