Predicting illness progression for children with lower respiratory infections (LRTI) presenting to primary care

Background Antibiotics are commonly prescribed for children with lower respiratory tract infections (LRTIs), fuelling antibiotic resistance, and there are few prognostic tools available to inform management. Aim To externally validate an existing prognostic model (STARWAVe) to identify children at low risk of illness progression, and if model performance was limited to develop a new internally validated prognostic model. Design and setting Prospective cohort study with a nested trial in a primary care setting. Method Children aged 6 months to 12 years presenting with uncomplicated LRTI were included in the cohort. Children were randomised to receive amoxicillin 50 mg/kg per day for 7 days or placebo, or if not randomised they participated in a parallel observational study to maximise generalisability. Baseline clinical data were used to predict adverse outcome (illness progression requiring hospital assessment). Results A total of 758 children participated (n= 432 trial, n= 326 observational). For predicting illness progression the STARWAVe prognostic model had moderate performance (area under the receiver operating characteristic [AUROC] 0.66, 95% confidence interval [CI] = 0.50 to 0.77), but a new, internally validated model (seven items: baseline severity; respiratory rate; duration of prior illness; oxygen saturation; sputum or a rattly chest; passing urine less often; and diarrhoea) had good discrimination (bootstrapped AUROC 0.83, 95% CI = 0.74 to 0.92) and calibration. A three-item model (respiratory rate; oxygen saturation; and sputum or a rattly chest) also performed well (AUROC 0.81, 95% CI = 0.70 to 0.91), as did a score (ranging from 19 to 102) derived from coefficients of the model (AUROC 0.78, 95% CI = 0.67 to 0.88): a score of &lt;70 classified 89% (n= 600/674) of children having a low risk (&lt;5%) of progression of illness. Conclusion A simple three-item prognostic score could be useful as a tool to identify children with LRTI who are at low risk of an adverse outcome and to guide clinical management.</p

The First Shared Online Curriculum Resources for Veterinary Undergraduate Learning and Teaching in Animal Welfare and Ethics in Australia and New Zealand

The need for undergraduate teaching of Animal Welfare and Ethics (AWE) in Australian and New Zealand veterinary courses reflects increasing community concerns and expectations about AWE; global pressures regarding food security and sustainability; the demands of veterinary accreditation; and fears that, unless students encounter AWE as part of their formal education, as veterinarians they will be relatively unaware of the discipline of animal welfare science. To address this need we are developing online resources to ensure Australian and New Zealand veterinary graduates have the knowledge, and the research, communication and critical reasoning skills, to fulfill the AWE role demanded of them by contemporary society. To prioritize development of these resources we assembled leaders in the field of AWE education from the eight veterinary schools in Australia and New Zealand and used modified deliberative polling. This paper describes the role of the poll in developing the first shared online curriculum resource for veterinary undergraduate learning and teaching in AWE in Australia and New Zealand. The learning and teaching strategies that ranked highest in the exercise were: scenario-based learning; a quality of animal life assessment tool; the so-called ‘Human Continuum’ discussion platform; and a negotiated curriculum. Keywords: animal ethics; animal welfare; online curriculum resources; learning and teaching; scenarios; quality of life assessmentALT gran

A whole-ecosystem method for experimentally suppressing ants on a small scale

Funder: Sinar Mas Agro Resources Technology Research Institute (SMARTRI)Funder: The Isaac Newton Trust Cambridge; Id: http://dx.doi.org/10.13039/501100004815Ant suppression experiments have emerged as a powerful method for assessing the role of ants in ecosystems. However, traditional methods have been limited to canopy ants, and not assessed the role of ants on and below ground. Recent advances have enabled whole-ecosystem ant suppression in large plots, but large-scale experiments are not always feasible. Here, we develop a small-scale, whole-ecosystem suppression method. We compare techniques for monitoring suppression experiments, and assess whether habitat complexity in oil palm influences our method’s effectiveness. We conducted ant suppression experiments in oil palm agroforestry in Sumatra, Indonesia. We used targeted poison baits, a physical barrier, and canopy isolation to suppress ants in 4m-radius arenas around single palms. We sequentially tested three suppression methods that increased in intensity over 18 months. We sampled ant abundance before and after suppression by fogging, using pitfall traps, and extracting soil monoliths. We also monitored ants throughout the experiment by baiting. We tested the soil for residual poison and monitored other invertebrates (Araneae, Coleoptera, Orthoptera, and Chilopoda) to test for cross-contamination. Plots were established under four oil palm management treatments that varied in their habitat complexity: reduced, intermediate, and high understory complexity treatments in mature plantation, and a recently-replanted plantation. Post-treatment ant abundance was 92% lower in suppression than control plots. Only the most intensive suppression method, which ran for the final nine months, worked. Baiting rarely reflected the other monitoring methods. The treatment negatively affected Orthoptera, but not other taxa. We detected no residual poison in the soil. Coleoptera abundance increased in suppression plots post-treatment, potentially due to reduced competition with ants. Our findings were consistent across management treatments.Whitten Studentship, Department of Zoolog

Understory Vegetation in Oil Palm Plantations Promotes Leopard Cat Activity, but Does Not Affect Rats or Rat Damage

The expansion of oil palm (Elaeis guineensis) plantations is a primary cause of land-use change and biodiversity loss in Southeast Asia. This has led to an increasing demand for the development of more sustainable agricultural management practices in plantations, such as Integrated Pest Management. Although populations of carnivorous mammals show declines when forest is converted to oil palm, some species, such as Leopard Cats (Prionailurus bengalensis) have been found to persist. They are often encouraged by plantation managers for their conservation value, and as agents of pest control to manage rat populations. Despite this, little is known about whether they reduce pest rat numbers, or whether plantation management affects how they use the oil palm habitat. This study was based at the Biodiversity and Ecosystem Function in Tropical Agriculture (BEFTA) Programme in mature oil palm plantations in Riau, Sumatra, where there are three management strategies altering understory vegetation structure. We quantified Leopard Cat activity, invasive rat abundance and rat damage using camera traps, live traps, and visual estimates, respectively. We collected data over a 4-year period, before and after the management strategies were applied. We recorded three species of wild mammals (Leopard Cats, Common Palm Civets, and Wild Pig) within the plantations, of which Leopard Cats made up 82% of the total number of observations. We found that Leopard Cat habitat use was higher with increased understory vegetation, but that there was no effect of the vegetation treatments on rat abundance or rat damage. There was also a trend for reduced rat abundance with increased Leopard Cat activity. These results show that management practices can significantly affect Leopard Cat habitat use, with potential benefits for pest control. They also highlight the value of large-scale long-term manipulative experiments for developing more sustainable management practices in oil palm.This work was funded by The Isaac Newton Trust Cambridge, Sinar Mas Agro Resources Technology Research Institute (SMARTRI), and the Natural Environment Research Council [grant number NE/P00458X/1]. AH was funded by the Claire Barnes Studentship from the Department of Zoology, University of Cambridge. Fieldwork was funded by SMARTRI

Antibiotics for lower respiratory tract infection in children presenting in primary care: ARTIC-PC RCT.

BACKGROUND: Antimicrobial resistance is a global health threat. Antibiotics are commonly prescribed for children with uncomplicated lower respiratory tract infections, but there is little randomised evidence to support the effectiveness of antibiotics in treating these infections, either overall or relating to key clinical subgroups in which antibiotic prescribing is common (chest signs; fever; physician rating of unwell; sputum/rattly chest; shortness of breath). OBJECTIVES: To estimate the clinical effectiveness and cost-effectiveness of amoxicillin for uncomplicated lower respiratory tract infections in children both overall and in clinical subgroups. DESIGN: Placebo-controlled trial with qualitative, observational and cost-effectiveness studies. SETTING: UK general practices. PARTICIPANTS: Children aged 1-12 years with acute uncomplicated lower respiratory tract infections. OUTCOMES: The primary outcome was the duration in days of symptoms rated moderately bad or worse (measured using a validated diary). Secondary outcomes were symptom severity on days 2-4 (0 = no problem to 6 = as bad as it could be); symptom duration until very little/no problem; reconsultations for new or worsening symptoms; complications; side effects; and resource use. METHODS: Children were randomised to receive 50 mg/kg/day of oral amoxicillin in divided doses for 7 days, or placebo using pre-prepared packs, using computer-generated random numbers by an independent statistician. Children who were not randomised could participate in a parallel observational study. Semistructured telephone interviews explored the views of 16 parents and 14 clinicians, and the data were analysed using thematic analysis. Throat swabs were analysed using multiplex polymerase chain reaction. RESULTS: A total of 432 children were randomised (antibiotics, n = 221; placebo, n = 211). The primary analysis imputed missing data for 115 children. The duration of moderately bad symptoms was similar in the antibiotic and placebo groups overall (median of 5 and 6 days, respectively; hazard ratio 1.13, 95% confidence interval 0.90 to 1.42), with similar results for subgroups, and when including antibiotic prescription data from the 326 children in the observational study. Reconsultations for new or worsening symptoms (29.7% and 38.2%, respectively; risk ratio 0.80, 95% confidence interval 0.58 to 1.05), illness progression requiring hospital assessment or admission (2.4% vs. 2.0%) and side effects (38% vs. 34%) were similar in the two groups. Complete-case (n = 317) and per-protocol (n = 185) analyses were similar, and the presence of bacteria did not mediate antibiotic effectiveness. NHS costs per child were slightly higher (antibiotics, £29; placebo, £26), with no difference in non-NHS costs (antibiotics, £33; placebo, £33). A model predicting complications (with seven variables: baseline severity, difference in respiratory rate from normal for age, duration of prior illness, oxygen saturation, sputum/rattly chest, passing urine less often, and diarrhoea) had good discrimination (bootstrapped area under the receiver operator curve 0.83) and calibration. Parents found it difficult to interpret symptoms and signs, used the sounds of the child's cough to judge the severity of illness, and commonly consulted to receive a clinical examination and reassurance. Parents acknowledged that antibiotics should be used only when 'necessary', and clinicians noted a reduction in parents' expectations for antibiotics. LIMITATIONS: The study was underpowered to detect small benefits in key subgroups. CONCLUSION: Amoxicillin for uncomplicated lower respiratory tract infections in children is unlikely to be clinically effective or to reduce health or societal costs. Parents need better access to information, as well as clear communication about the self-management of their child's illness and safety-netting. FUTURE WORK: The data can be incorporated in the Cochrane review and individual patient data meta-analysis. TRIAL REGISTRATION: This trial is registered as ISRCTN79914298. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 9. See the NIHR Journals Library website for further project information

Rapid overview of systematic reviews of nocebo effects reported by patients taking placebos in clinical trials

Background Trial participants in placebo groups report experiencing adverse events (AEs). Existing systematic reviews have not been synthesized, leaving questions about why these events occur as well as their prevalence across different conditions unanswered. Objectives (1) To synthesize the evidence of prevalence of AEs in trial placebo groups across different conditions. (2) To compare AEs in trial placebo groups with AEs reported in untreated groups within a subset of randomized trials. Search methods We searched PubMed for records with the word “nocebo” in the title and “systematic” in any field. We also contacted experts and hand-searched references of included studies. Study eligibility We included any systematic review of randomized trials where nocebo effects were reported. We excluded systematic reviews of non-randomized studies. Participants and interventions We included studies in any disease area. Study appraisal and synthesis methods We appraised the quality of the studies using a shortened version of the Assessment of Multiple Systematic Reviews tool (AMSTAR) tool. We reported medians and interquartile ranges (IQRs) of AEs. Among the trials within the review that included untreated groups, we compared the prevalence of AEs in untreated groups with the prevalence of AEs in placebo groups. Results We identified 20 systematic reviews. These included 1271 randomized trials and 250,726 placebo-treated patients. The median prevalence of AEs in trial placebo groups was 49.1% (IQR 25.7–64.4%). The median rate of dropouts due to AEs was 5% (IQR 2.28–8.4%). Within the 15 of trials that reported AEs in untreated groups, we found that the AE rate in placebo groups (6.51%) was higher than that reported in untreated groups (4.25%). Limitations This study was limited by the quality of included reviews and the small number of trials that included untreated groups. Conclusions and implications of key findings AEs in trial placebo groups are common and cannot be attributed entirely to natural history. Trial methodologies that reduce AEs in placebo groups while satisfying the requirement of informed consent should be developed and implemented

Managing Oil Palm Plantations More Sustainably: Large-Scale Experiments Within the Biodiversity and Ecosystem Function in Tropical Agriculture (BEFTA) Programme

Conversion of tropical forest to agriculture results in reduced habitat heterogeneity, and associated declines in biodiversity and ecosystem functions. Management strategies to increase biodiversity in agricultural landscapes have therefore often focused on increasing habitat complexity; however, the large-scale, long-term ecological experiments that are needed to test the effects of these strategies are rare in tropical systems. Oil palm (Elaeis guineensis Jacq.)—one of the most widespread and important tropical crops—offers substantial potential for developing wildlife-friendly management strategies because of its long rotation cycles and tree-like structure. Although there is awareness of the need to increase sustainability, practical options for how best to manage oil palm plantations, for benefits to both the environment and crop productivity, have received little research attention. In this paper we introduce the Biodiversity and Ecosystem Function in Tropical Agriculture (BEFTA) Programme: a long-term research collaboration between academia and industry in Sumatra, Indonesia. The BEFTA Programme aims to better understand the oil palm agroecosystem and test sustainability strategies. We hypothesise that adjustments to oil palm management could increase structural complexity, stabilize microclimate, and reduce reliance on chemical inputs, thereby helping to improve levels of biodiversity and ecosystem functions. The Programme has established four major components: (1) assessing variability within the plantation under business-as-usual conditions; (2) the BEFTA Understory Vegetation Project, which tests the effects of varying herbicide regimes; (3) the Riparian Ecosystem Restoration in Tropical Agriculture (RERTA) Project, which tests strategies for restoring riparian habitat; and (4) support for additional collaborative projects within the Programme landscape. Across all projects, we are measuring environmental conditions, biodiversity, and ecosystem functions. We also measure oil palm yield and production costs, in order to assess whether suggested sustainability strategies are feasible from an agronomic perspective. Early results show that oil palm plantation habitat is more variable than might be expected from a monoculture crop, and that everyday vegetation management decisions have significant impacts on habitat structure. The BEFTA Programme highlights the value of large-scale collaborative projects for understanding tropical agricultural systems, and offers a highly valuable experimental set-up for improving our understanding of practices to manage oil palm more sustainably.This work was funded by The Isaac Newton Trust Cambridge, Golden Agri Resources, ICOPE (the International Conference on Oil Palm and the Environment), and the Natural Environment Research Council [grant number NE/P00458X/1]

Resilience of ecological functions to drought in an oil palm agroecosystem

Abstract Oil palm is a major habitat in the tropics. It is highly productive and contributes substantially to the economies of producing countries, but its expansion has caused widespread deforestation, with negative consequences for biodiversity. Such biodiversity losses may have substantial impacts on ecosystem functions within oil palm and resilience of functions to changing rainfall patterns, with impacts on yield. However, although the direct effects of water deficit on yield have been studied, little work has investigated ecosystem processes within plantations or the resilience of functions to changing rainfall. We conducted ecosystem function experiments within mature oil palm at the Biodiversity and Ecosystem Function in Tropical Agriculture (BEFTA) Programme site in Sumatra, Indonesia. We measured rates of leaf litter decomposition, seed removal, mealworm predation, and herbivory at multiple time points spanning the 2015–2016 El Niño - Southern Oscillation (ENSO) event that caused widespread drought within Southeast Asia. We found that mealworm predation, seed removal, and decomposition rates were high, whilst herbivory levels were low, indicating a healthy ecosystem with high levels of pest control and organic matter breakdown. Exclusion tests showed that the presence of invertebrates was associated with higher levels of seed removal and decomposition and the presence of vertebrates with higher predation. All functions were relatively robust to changes in rainfall. Yet, whilst seed removal and herbivory did not alter with rainfall, decomposition and predation showed more complex effects, with levels of both processes increasing with current rainfall levels when rainfall in preceding time periods was low. This suggests that both processes are resilient to change and able to recover following drought. Our results indicate that the ecosystem processes measured within oil palm plantations are healthy and resilient to changing rainfall patterns. This is hopeful and suggests that the crop may be fairly robust to future changes in precipitation.Isaac Newton Trust Cambridge Sinar Mas Agro Resources and Technology Research Institut

A Model for Interprofessional Health Disparities Education: Student-Led Curriculum on Chronic Hepatitis B Infection

Although health disparities are commonly addressed in preclinical didactic curricula, direct patient care activities with affected communities are more limited. To address this problem, health professional students designed a preclinical service-learning curriculum on hepatitis B viral (HBV) infection, a major health disparity affecting the Asian/Pacific Islander (API) population, integrating lectures, skills training, and direct patient care at student-run clinics. An urban health professions campus. Medical and other health professional students at University of California, San Francisco, organized a preclinical didactic and experiential elective, and established two monthly clinics offering HBV screening, vaccination, and education to the community. Between 2004 and 2009, 477 students enrolled in the student-led HBV curriculum. Since the clinics’ inception in 2007, 804 patients have been screened for chronic HBV; 87% were API immigrants, 63% had limited English proficiency, and 46% were uninsured. Serologically, 10% were found to be chronic HBV carriers, 44% were susceptible to HBV, and 46% were immune. Our student-led didactic and experiential elective can serve as an interprofessional curricular model for learning about specific health disparities while providing important services to the local community