Delayed antibiotic prescriptions for respiratory infections

Background: Concerns exist regarding antibiotic prescribing for respiratory tract infections (RTIs) owing to adverse reactions, cost, and antibacterial resistance. One proposed strategy to reduce antibiotic prescribing is to provide prescriptions, but to advise delay in antibiotic use with the expectation that symptoms will resolve first. This is an update of a Cochrane Review originally published in 2007, and updated in 2010 and 2013. Objectives: To evaluate the effects on clinical outcomes, antibiotic use, antibiotic resistance, and patient satisfaction of advising a delayed prescription of antibiotics in respiratory tract infections. Search methods: For this 2017 update we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, Issue 4, 2017), which includes the Cochrane Acute Respiratory Infection Group's Specialised Register; Ovid MEDLINE (2013 to 25 May 2017); Ovid Embase (2013 to 2017 Week 21); EBSCO CINAHL Plus (1984 to 25 May 2017); Web of Science (2013 to 25 May 2017); WHO International Clinical Trials Registry Platform (1 September 2017); and ClinicalTrials.gov (1 September 2017). Selection criteria: Randomised controlled trials involving participants of all ages defined as having an RTI, where delayed antibiotics were compared to immediate antibiotics or no antibiotics. We defined a delayed antibiotic as advice to delay the filling of an antibiotic prescription by at least 48 hours. We considered all RTIs regardless of whether antibiotics were recommended or not. Data collection and analysis: We used standard Cochrane methodological procedures. Three review authors independently extracted and collated data. We assessed the risk of bias of all included trials. We contacted trial authors to obtain missing information. Main results: For this 2017 update we added one new trial involving 405 participants with uncomplicated acute respiratory infection. Overall, this review included 11 studies with a total of 3555 participants. These 11 studies involved acute respiratory infections including acute otitis media (three studies), streptococcal pharyngitis (three studies), cough (two studies), sore throat (one study), common cold (one study), and a variety of RTIs (one study). Five studies involved only children, two only adults, and four included both adults and children. Six studies were conducted in a primary care setting, three in paediatric clinics, and two in emergency departments. Studies were well reported, and appeared to be of moderate quality. Randomisation was not adequately described in two trials. Four trials blinded the outcomes assessor, and three included blinding of participants and doctors. We conducted meta-analysis for antibiotic use and patient satisfaction. We found no differences among delayed, immediate, and no prescribed antibiotics for clinical outcomes in the three studies that recruited participants with cough. For the outcome of fever with sore throat, three of the five studies favoured immediate antibiotics, and two found no difference. For the outcome of pain related to sore throat, two studies favoured immediate antibiotics, and three found no difference. One study compared delayed antibiotics with no antibiotic for sore throat, and found no difference in clinical outcomes. Three studies included participants with acute otitis media. Of the two studies with an immediate antibiotic arm, one study found no difference for fever, and the other study favoured immediate antibiotics for pain and malaise severity on Day 3. One study including participants with acute otitis media compared delayed antibiotics with no antibiotics and found no difference for pain and fever on Day 3. Two studies recruited participants with common cold. Neither study found differences for clinical outcomes between delayed and immediate antibiotic groups. One study favoured delayed antibiotics over no antibiotics for pain, fever, and cough duration (moderate quality evidence for all clinical outcomes - GRADE assessment). There were either no differences for adverse effects or results favoured delayed antibiotics over immediate antibiotics (low quality evidence - to GRADE assessment) with no significant differences in complication rates. Delayed antibiotics resulted in a significant reduction in antibiotic use compared to immediate antibiotics prescription (odds ratio (OR) 0.04, 95% confidence interval (CI) 0.03 to 0.05). However, a delayed antibiotic was more likely to result in reported antibiotic use than no antibiotics (OR 2.55, 95% CI 1.59 to 4.08) (moderate quality evidence - GRADE assessment). Patient satisfaction favoured delayed over no antibiotics (OR 1.49, 95% CI 1.08 to 2.06). There was no significant difference in patient satisfaction between delayed antibiotics and immediate antibiotics (OR 0.65, 95% CI 0.39 to 1.10) (moderate quality evidence - GRADE assessment). None of the included studies evaluated antibiotic resistance. Authors' conclusions: For many clinical outcomes, there were no differences between prescribing strategies. Symptoms for acute otitis media and sore throat were modestly improved by immediate antibiotics compared with delayed antibiotics. There were no differences in complication rates. Delaying prescribing did not result in significantly different levels of patient satisfaction compared with immediate provision of antibiotics (86% versus 91%) (moderate quality evidence). However, delay was favoured over no antibiotics (87% versus 82%). Delayed antibiotics achieved lower rates of antibiotic use compared to immediate antibiotics (31% versus 93%) (moderate quality evidence). The strategy of no antibiotics further reduced antibiotic use compared to delaying prescription for antibiotics (14% versus 28%). Delayed antibiotics for people with acute respiratory infection reduced antibiotic use compared to immediate antibiotics, but was not shown to be different to no antibiotics in terms of symptom control and disease complications. Where clinicians feel it is safe not to prescribe antibiotics immediately for people with respiratory infections, no antibiotics with advice to return if symptoms do not resolve is likely to result in the least antibiotic use while maintaining similar patient satisfaction and clinical outcomes to delaying prescription of antibiotics. Where clinicians are not confident in using a no antibiotic strategy, a delayed antibiotics strategy may be an acceptable compromise in place of immediate prescribing to significantly reduce unnecessary antibiotic use for RTIs, and thereby reduce antibiotic resistance, while maintaining patient safety and satisfaction levels. Editorial note: As a living systematic review, this review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review

Analysis of weighted networks

The connections in many networks are not merely binary entities, either present or not, but have associated weights that record their strengths relative to one another. Recent studies of networks have, by and large, steered clear of such weighted networks, which are often perceived as being harder to analyze than their unweighted counterparts. Here we point out that weighted networks can in many cases be analyzed using a simple mapping from a weighted network to an unweighted multigraph, allowing us to apply standard techniques for unweighted graphs to weighted ones as well. We give a number of examples of the method, including an algorithm for detecting community structure in weighted networks and a new and simple proof of the max-flow/min-cut theorem.Comment: 9 pages, 3 figure

Impact of Brown Midrib Trait on the Decomposition Rate of Sorghum-Sudangrass Residue in Pastures

Sorghum-sudangrass (Sorghum bicolor var. bicolor x bicolor var. sudanense) can provide high quality summer grazing. Some varieties possess the brown midrib (BMR) trait which results in reduced lignin resulting in higher digestibility and animal performance. If microbes in the rumen can digest BMR sorghum-sudangrass more completely, then soil macro/micro flora and fauna may do so as well. This could result in nutrients being returned to the soil faster from plants containing the BMR trait. The objective of this study was to determine the decomposition rate of BMR and non-BMR sorghumsudangrass. The experimental design was a random complete with four replications. Sorghum-sudangrass with and without the BMR trait was placed in litter decomposition bags as whole plants or divided into leaves and stems. A composite sample was taken when bags were loaded to determine initial dry matter. Loaded bags were then placed on the soil surface in a pasture and collected at 1, 2, 3, 4, 6, 8, 10, 12, 14, or 16 weeks after placement. Upon collection plant material was dried for 3-days at 55°C in a forced air oven. Dry weights at each collection date were subtracted from the initial dry weight to determine total DM loss. The BMR trait did not impact dry matter loss in the leaves. Stems possessing the BMR trait lost dry matter at a greater rate resulting in dry matter losses at 14 weeks of 78 and 68% and 59 and 47% for the BMR and non-BMR varieties in trials 1 and 2, respectively. Whole plants showed limited differences in dry matter loss at 14 weeks after placement

An assessment of the torrefaction of North American pine and life cycle greenhouse gas emissions

Bioenergy is increasingly being used to meet EU objectives for renewable energy generation and reducing greenhouse gas (GHG) emissions. Problems with using biomass however include high moisture contents, lower calorific value and poor grindability when compared to fossil fuels. Torrefaction is a pre-treatment process that aims to address these issues. In this paper four torrefaction treatments of pine were performed and a mass-energy balance calculated. Using experimental data, a pellet production supply chain incorporating torrefaction was modelled and compared to an existing wood pellet system to determine life-cycle GHG emissions. Two utility fuels, wood chips and natural gas, were considered to provide process heat in addition to volatile gases released during torrefaction (torgas). Experimental results show that torrefaction reduces the moisture content and increases the calorific value of the fuels. Increasing torrefaction temperature and residence time results in lower mass and energy yields. GHG emissions reduce with increasing torrefaction severity. Emissions from drying &amp; torrefaction and shipping are the highest GHG contributors to the supply chain. All 4 torrefaction conditions assessed outperformed traditional wood pellet supply chain emissions but more land is required which increases with temperature and residence time. Sensitivity analysis results show that emissions increase significantly where natural gas is used for utility fuel and no torgas is utilised.</p

Cost-benefit analysis for commissioning decisions in GEO600

Gravitational wave interferometers are complex instruments, requiring years of commissioning to achieve the required sensitivities for the detection of gravitational waves, of order 10^-21 in dimensionless detector strain, in the tens of Hz to several kHz frequency band. Investigations carried out by the GEO600 detector characterisation group have shown that detector characterisation techniques are useful when planning for commissioning work. At the time of writing, GEO600 is the only large scale laser interferometer currently in operation running with a high duty factor, 70%, limited chiefly by the time spent commissioning the detector. The number of observable gravitational wave sources scales as the product of the volume of space to which the detector is sensitive and the observation time, so the goal of commissioning is to improve the detector sensitivity with the least possible detector down time. We demonstrate a method for increasing the number of sources observable by such a detector, by assessing the severity of non-astrophysical noise contaminations to efficiently guide commissioning. This method will be particularly useful in the early stages and during the initial science runs of the aLIGO and adVirgo detectors, as they are brought up to design performance.Comment: 17 pages, 17 figures, 2 table

Comprehension as social and intellectual practice: Rebuilding curriculum in low socioeconomic and cultural minority schools

This article reframes the concept of comprehension as a social and intellectual practice. It reviews current approaches to reading instruction for linguistically and culturally diverse and low socioeconomic students, noting an emphasis on comprehension as autonomous skills. The Four Resources model (Freebody &amp; Luke, 1990) is used to make the case for the integration of comprehension instruction with an emphasis on student cultural and community knowledge, and substantive intellectual and sociocultural content in elementary school curricula. Illustrations are drawn from research underway on the teaching of literacy in primary schools in low SES communities

Search for Flavoured Multiquarks in a Simple Bag Model

We use a bag model to study flavoured mesonic $(Qq\bar q\bar q)$ and baryonic $({\overline Q}qqqq)$ states, where one heavy quark $Q$ is associated with light quarks or antiquarks, and search for possible stable multiquarks. No bound state is found. However some states lie not too high above their dissociation threshold, suggesting the possibility of resonances, or perhaps bound states in improved models.Comment: REVTEX, VERSION 3.

I=3/2 KπK \pi Scattering in the Nonrelativisitic Quark Potential Model

We study $I=3/2$ elastic $K\pi$ scattering to Born order using nonrelativistic quark wavefunctions in a constituent-exchange model. This channel is ideal for the study of nonresonant meson-meson scattering amplitudes since s-channel resonances do not contribute significantly. Standard quark model parameters yield good agreement with the measured S- and P-wave phase shifts and with PCAC calculations of the scattering length. The P-wave phase shift is especially interesting because it is nonzero solely due to $SU(3)_f$ symmetry breaking effects, and is found to be in good agreement with experiment given conventional values for the strange and nonstrange constituent quark masses.Comment: 12 pages + 2 postscript figures, Revtex, MIT-CTP-210

Gupta-Bleuler quantization for minimally coupled scalar fields in de Sitter space

We present in this paper a fully covariant quantization of the minimally-coupled massless field on de Sitter space. We thus obtain a formalism free of any infrared (e.g logarithmic) divergence. Our method is based on a rigorous group theoretical approach combined with a suitable adaptation (Krein spaces) of the Wightman-G\"{a}rding axiomatic for massless fields (Gupta-Bleuler scheme). We make explicit the correspondence between unitary irreducible representations of the de Sitter group and the field theory on de Sitter space-time. The minimally-coupled massless field is associated with a representation which is the lowest term of the discrete series of unitary representations of the de Sitter group. In spite of the presence of negative norm modes in the theory, no negative energy can be measured: expressions as \le n_{k_1}n_{k_2}...|T_{00}|n_{k_1}n_{k_2}...\re are always positive.Comment: 20 pages, appear in class. quantum gra