Written information for patients (or parents of child patients) to reduce the use of antibiotics for acute upper respiratory tract infections in primary care

BackgroundAcute upper respiratory tract infections (URTIs) are frequently managed in primary care settings. Although many are viral, and there is an increasing problem with antibiotic resistance, antibiotics continue to be prescribed for URTIs. Written patient information may be a simple way to reduce antibiotic use for acute URTIs. ObjectivesTo assess if written information for patients (or parents of child patients) reduces the use of antibiotics for acute URTIs in primary care. Search methodsWe searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, Web of Science, clinical trials.gov, and the World Health Organization (WHO) trials registry up to July 2016 without language or publication restrictions. Selection criteriaWe included randomised controlled trials (RCTs) involving patients (or parents of child patients) with acute URTIs, that compared written patient information delivered immediately before or during prescribing, with no information. RCTs needed to have measured our primary outcome (antibiotic use) to be included. Data collection and analysisTwo review authors screened studies, extracted data, and assessed study quality. We could not meta-analyse included studies due to significant methodological and statistical heterogeneity; we summarised the data narratively. Main resultsTwo RCTs met our inclusion criteria, involving a total of 827 participants. Both studies only recruited children with acute URTIs (adults were not involved in either study): 558 children from 61 general practices in England and Wales; and 269 primary care doctors who provided data on 33,792 patient-doctor consultations in Kentucky, USA. The UK study had a high risk of bias due to lack of blinding and the US cluster-randomised study had a high risk of bias because the methods to allocate participants to treatment groups was not clear, and there was evidence of baseline imbalance. In both studies, clinicians provided written information to parents of child patients during primary care consultations: one trained general practitioners (GPs) to discuss an eight-page booklet with parents; the other conducted a factorial trial with two comparison groups (written information compared to usual care and written information plus prescribing feedback to clinicians compared to prescribing feedback alone). Doctors in the written information arms received 25 copies of two-page government-sponsored pamphlets to distribute to parents. Compared to usual care, we found moderate quality evidence (one study) that written information significantly reduced the number of antibiotics used by patients (RR 0.53, 95% CI 0.35 to 0.80; absolute risk reduction (ARR) 20% (22% versus 42%)) and had no significant effect on reconsultation rates (RR 0.79, 95% CI 0.47 to 1.32), or parent satisfaction with consultation (RR 0.95, 95% CI 0.87 to 1.03). Low quality evidence (two studies) demonstrated that written information also reduced antibiotics prescribed by clinicians (RR 0.47, 95% CI 0.28 to 0.78; ARR 21% (20% versus 41%); and RR 0.84, 95% CI 0.81 to 0.86; 9% ARR (45% versus 54%)). Neither study measured resolution of symptoms, patient knowledge about antibiotics for acute URTIs, or complications for this comparison. Compared to prescribing feedback, we found low quality evidence that written information plus prescribing feedback significantly increased the number of antibiotics prescribed by clinicians (RR 1.13, 95% CI 1.09 to 1.17; absolute risk increase 6% (50% versus 44%)). Neither study measured reconsultation rate, resolution of symptoms, patient knowledge about antibiotics for acute URTIs, patient satisfaction with consultation or complications for this comparison. Authors' conclusionsCompared to usual care, moderate quality evidence from one study showed that trained GPs providing written information to parents of children with acute URTIs in primary care can reduce the number of antibiotics used by patients without any negative impact on reconsultation rates or parental satisfaction with consultation. Low quality evidence from two studies shows that, compared to usual care, GPs prescribe fewer antibiotics for acute URTIs but prescribe more antibiotics when written information is provided alongside prescribing feedback (compared to prescribing feedback alone). There was no evidence addressing resolution of patients' symptoms, patient knowledge about antibiotics for acute URTIs, or frequency of complications. To fill evidence gaps, future studies should consider testing written information on antibiotic use for adults with acute URTIs in high- and low-income settings provided without clinician training and presented in different formats (such as electronic). Future study designs should endeavour to ensure blinded outcome assessors. Study aims should include measurement of the effect of written information on the number of antibiotics used by patients and prescribed by clinicians, patient satisfaction, reconsultation, patients' knowledge about antibiotics, resolution of symptoms, and complications.</p

On non-existence of static vacuum black holes with degenerate components of the event horizon

We present a simple proof of the non-existence of degenerate components of the event horizon in static, vacuum, regular, four-dimensional black hole spacetimes. We discuss the generalisation to higher dimensions and the inclusion of a cosmological constant.Comment: latex2e, 9 pages in A

Mathieu twining characters for K3

The analogue of the McKay-Thompson series for the proposed Mathieu group action on the elliptic genus of K3 is analysed. The corresponding NS-sector twining characters have good modular properties and satisfy remarkable replication identities. These observations provide strong support for the conjecture that the elliptic genus of K3 carries indeed an action of the Mathieu group M24.Comment: 19 page

Characterization of 40-Gbit/s pulses generated using a lithium niobate modulator at 1550 nm using frequency resolved optical gating

The characteristics of 40-Gbit/s pulses generated by exploiting the nonlinear characteristics of a Mach-Zender Lithium Niobate modulator are presented. A high spectral resolution frequency resolved optical gating apparatus has been developed to allow for the complete characterization of the intensity and phase of these pulses. The use of these measurements to simplify the design and optimization of an 80-Gbit/s pulse source, based on this 40-Gbit/s source followed by a nonlinear fiber compressor and multiplexer, is also demonstrated

On Israel-Wilson-Perjes black holes

We show, under certain conditions, that regular Israel-Wilson-Perj\'es black holes necessarily belong to the Majumdar-Papapetrou family

Very Extended E8E_8 and A8A_8 at low levels, Gravity and Supergravity

We define a level for a large class of Lorentzian Kac-Moody algebras. Using this we find the representation content of very extended $A_{D-3}$ and $E_8$ (i.e. $E_{11}$) at low levels in terms of $A_{D-1}$ and $A_{10}$ representations respectively. The results are consistent with the conjectured very extended $A_8$ and $E_{11}$ symmetries of gravity and maximal supergravity theories given respectively in hep-th/0104081 and hep-th/0107209. We explain how these results provided further evidence for these conjectures.Comment: 16 pages, plain tex (equation 3.3 modified and one reference expanded

Far-infrared observations of young clusters embedded in the R Coronae Austrinae and RHO Ophiuchi dark clouds

Multicolor far infrared maps in two nearby dark clouds, R Coronae Austrinae and rho Ophiuchi, were made in order to investigate the individual contribution of low mass stars to the energetics and dynamics of the surrounding gas and dust. Emission from cool dust associated with five low mass stars in Cr A and four in rho Oph was detected; their far infrared luminosities range from 2 far infrared luminosities L. up to 40 far infrared luminosities. When an estimate of the bolometric luminosity was possible, it was found that typically more than 50% of the star's energy was radiated longward of 20 micrometers. meaningful limits to the far infrared luminosities of an additional eleven association members in Cr A and two in rho Oph were also obtained. The dust optical depth surrounding the star R Cr A appears to be asymmetric and may control the dynamics of the surrounding molecular gas. The implications of the results for the cloud energetics and star formation efficiency in these two clouds are discussed

Noncommutative Solitons of Gravity

We investigate a three-dimensional gravitational theory on a noncommutative space which has a cosmological constant term only. We found various kinds of nontrivial solutions, by applying a similar technique which was used to seek noncommutative solitons in noncommutative scalar field theories. Some of those solutions correspond to bubbles of spacetimes, or represent dimensional reduction. The solution which interpolates $G_{\mu\nu}=0$ and Minkowski metric is also found. All solutions we obtained are non-perturbative in the noncommutative parameter $\theta$, therefore they are different from solutions found in other contexts of noncommutative theory of gravity and would have a close relation to quantum gravity.Comment: 29 pages, 5 figures. v2: minor corrections done in Section 3.1 and Appendix, references added. v3, v4: typos correcte

Genetic distance predicts trait differentiation at the subpopulation but not the individual level in eelgrass, Zostera marina.

Ecological studies often assume that genetically similar individuals will be more similar in phenotypic traits, such that genetic diversity can serve as a proxy for trait diversity. Here, we explicitly test the relationship between genetic relatedness and trait distance using 40 eelgrass (Zostera marina) genotypes from five sites within Bodega Harbor, CA. We measured traits related to nutrient uptake, morphology, biomass and growth, photosynthesis, and chemical deterrents for all genotypes. We used these trait measurements to calculate a multivariate pairwise trait distance for all possible genotype combinations. We then estimated pairwise relatedness from 11 microsatellite markers. We found significant trait variation among genotypes for nearly every measured trait; however, there was no evidence of a significant correlation between pairwise genetic relatedness and multivariate trait distance among individuals. However, at the subpopulation level (sites within a harbor), genetic (FST) and trait differentiation were positively correlated. Our work suggests that pairwise relatedness estimated from neutral marker loci is a poor proxy for trait differentiation between individual genotypes. It remains to be seen whether genomewide measures of genetic differentiation or easily measured "master" traits (like body size) might provide good predictions of overall trait differentiation