A ‘spoon full of sugar’ helps the medicine go down: how a participant friendly version of a psychophysics task significantly improves task engagement, performance and data quality in a typical adult sample

Few would argue that the unique insights brought by studying the typical and atypical development of psychological processes are essential to building a comprehensive understanding of the brain. Often, however, the associated challenges of working with non-standard adult populations results in the more complex psychophysical paradigms being rejected as too complex. Recently we created a child (and clinical group) friendly implementation of one such technique – the reverse correlation Bubbles approach and noted an associated performance boost in adult participants. Here, we compare the administration of three different versions of this participant-friendly task in the same adult participants to empirically confirm that introducing elements in the experiment with the sole purpose of improving the participant experience, not only boost the participant’s engagement and motivation for the task but results in significantly improved objective task performance and stronger statistical results

The Association Between Self-Reported Symptoms of Recent Airway Infection and CRP Values in a General Population: The Tromsø Study: Tromsø 6

C-reactive protein (CRP) is a much used biomarker for respiratory tract infection; however, the influence of airway infection on the CRP level in the general population has not been well described. The study aimed to evaluate the impact of recent symptoms of airway infection on the CRP level and how the predictive power of other known CRP predictors is influenced by taking respiratory symptoms into account. A total of 6,325 participants, aged 38–87 years, in the Tromsø Study, a repeated population-based survey, were examined with questionnaires, measurements of height and weight, spirometry, and high-sensitivity CRP analyses. The mean CRP value was 2.86 mg/L, and the geometric mean was 1.51 mg/L. Geometric means above 2.0 mg/L were found in the subgroups with the following characteristics: self-reported COPD, diabetes, recent symptoms of airway infection, forced expiratory volume in 1 s (FEV1) <80% predicted, body mass index (BMI) ≥30, and subjects treated with inhaled or oral corticosteroids. Among the subjects who reported recent airway infection, 10.5% had a CRP value of ≥10 mg/L, compared to 3.3% among the remaining participants. By multivariate analysis, BMI was the strongest independent predictor of the CRP level, followed by recent airway infection, FEV1% predicted, age, and current smoking. The study clearly demonstrates that a report of recent symptoms of airway infection strongly predicts the CRP level in the population. Such symptoms were shared rather equally between subgroups with increased CRP level, and the risk of being an important confounder in epidemiological studies is probably low. In the clinical setting, care should be taken when using the CRP level as a guide for medical prevention of chronic diseases

A decision aid to rule out pneumonia and reduce unnecessary prescriptions of antibiotics in primary care patients with cough and fever

BACKGROUND: Physicians fear missing cases of pneumonia and treat many patients with signs of respiratory infection unnecessarily with antibiotics. This is an avoidable cause for the increasing worldwide problem of antibiotic resistance. We developed a user-friendly decision aid to rule out pneumonia and thus reduce the rate of needless prescriptions of antibiotics. METHODS: This was a prospective cohort study in which we enrolled patients older than 18 years with a new or worsened cough and fever without serious co-morbidities. Physicians recorded results of a standardized medical history and physical examination. C-reactive protein was measured and chest radiographs were obtained. We used Classification and Regression Trees to derive the decision tool. RESULTS: A total of 621 consenting eligible patients were studied, 598 were attending a primary care facility, were 48 years on average and 50% were male. Radiographic signs for pneumonia were present in 127 (20.5%) of patients. Antibiotics were prescribed to 234 (48.3%) of patients without pneumonia. In patients with C-reactive protein values below 10 μg/ml or patients presenting with C-reactive protein between 11 and 50 μg/ml, but without dyspnoea and daily fever, pneumonia can be ruled out. By applying this rule in clinical practice antibiotic prescription could be reduced by 9.1% (95% confidence interval (CI): 6.4 to 11.8). CONCLUSIONS: Following validation and confirmation in new patient samples, this tool could help rule out pneumonia and be used to reduce unnecessary antibiotic prescriptions in patients presenting with cough and fever in primary care. The algorithm might be especially useful in those instances where taking a medical history and physical examination alone are inconclusive for ruling out pneumonia

The added value of C-reactive protein to clinical signs and symptoms in patients with obstructive airway disease: results of a diagnostic study in primary care

BACKGROUND: To evaluate the diagnostic accuracy of clinical signs and symptoms, C-reactive protein (CRP) and spirometric parameters and determine their interrelation in patients suspected to have an obstructive airway disease (OAD) in primary care. METHODS: In a cross sectional diagnostic study, 60 adult patients coming to the general practitioner (GP) for the first-time with complaints suspicious for obstructive airway disease (OAD) underwent spirometry. Peak expiratory flow (PEF)-variability within two weeks was determined in patients with inconspicuous spirometry. Structured medical histories were documented and CRP was measured. The reference standard was the Tiffeneau ratio (FEV(1)/VC) in spirometry and the PEF-variability. OAD was diagnosed when FEV(1)/VC ≤ 70% or PEF-variability > 20%. RESULTS: 37 (62%) patients had OAD. The best cut-off value for CRP was found at 2 mg/l with a diagnostic odds ratio (OR) of 4.4 (95% CI 1.4–13.8). Self-reported wheezing was significantly related with OAD (OR 3.4; CI 1.1–10.3), whereas coughing was inversely related (OR 0.2; CI 0.1–0.7). The diagnostic OR of CRP increased when combined with dyspnea (OR 8.5; 95% CI 1.7–42.3) or smoking history (OR 8.4; 95% CI 1.5–48.9). CRP (p = 0.004), FEV(1 )(p = 0.001) and FIV(1 )(p = 0.023) were related with the severity of dyspnea. CRP increased with the number of cigarettes, expressed in pack years (p = 0.001). CONCLUSION: The diagnostic accuracy of clinical signs and symptoms was low. The diagnostic accuracy of CRP improved in combination with dyspnea and smoking history. Due to their coherence with the severity of dyspnea and number of cigarettes respectively, CRP and spirometry might allow risk stratification of patients with OAD in primary care. Further studies need to be done to confirm these findings

Diagnostic and prognostic accuracy of clinical and laboratory parameters in community-acquired pneumonia

BACKGROUND: Community-acquired pneumonia (CAP) is the most frequent infection-related cause of death. The reference standard to diagnose CAP is a new infiltrate on chest radiograph in the presence of recently acquired respiratory signs and symptoms. This study aims to evaluate the diagnostic and prognostic accuracy of clinical signs and symptoms and laboratory biomarkers for CAP. METHODS: 545 patients with suspected lower respiratory tract infection, admitted to the emergency department of a university hospital were included in a pre-planned post-hoc analysis of two controlled intervention trials. Baseline assessment included history, clinical examination, radiography and measurements of procalcitonin (PCT), highly sensitive C-reactive protein (hsCRP) and leukocyte count. RESULTS: Of the 545 patients, 373 had CAP, 132 other respiratory tract infections, and 40 other final diagnoses. The AUC of a clinical model including standard clinical signs and symptoms (i.e. fever, cough, sputum production, abnormal chest auscultation and dyspnea) to diagnose CAP was 0.79 [95% CI, 0.75–0.83]. This AUC was significantly improved by including PCT and hsCRP (0.92 [0.89–0.94]; p < 0.001). PCT had a higher diagnostic accuracy (AUC, 0.88 [0.84–0.93]) in differentiating CAP from other diagnoses, as compared to hsCRP (AUC, 0.76 [0.69–0.83]; p < 0.001) and total leukocyte count (AUC, 0.69 [0.62–0.77]; p < 0.001). To predict bacteremia, PCT had a higher AUC (0.85 [0.80–0.91]) as compared to hsCRP (p = 0.01), leukocyte count (p = 0.002) and elevated body temperature (p < 0.001). PCT, in contrast to hsCRP and leukocyte count, increased with increasing severity of CAP, as assessed by the pneumonia severity index (p < 0.001). CONCLUSION: PCT, and to a lesser degree hsCRP, improve the accuracy of currently recommended approaches for the diagnosis of CAP, thereby complementing clinical signs and symptoms. PCT is useful in the severity assessment of CAP

Treating patients not diagnoses: challenging assumptions underlying the investigation and management of LRTI in general practice.

OBJECTIVES: Many clinicians treat patients with a lower respiratory tract infection (LRTI) due to bacterial infection with antibiotics, and regard antibiotic treatment as obligatory for patients with radiographic evidence of pneumonia. The necessity of antibiotic treatment is largely unknown and rarely challenged. PATIENTS AND METHODS: Twenty-five general practitioners (GPs) recorded clinical information on 247 adult patients presenting with LRTI. Standard microbiological, susceptibility and serological analysis, and chest radiography was performed for all patients. At 28 days after entry into the study, the GPs took a history and conducted a physical examination again and decided whether or not the patient was fully recovered. RESULTS: Thirty of 63 patients with cultured pathogenic bacteria were either not treated with antibiotics, or treated with an antibiotic to which the cultured bacterium was non-susceptible. All but one recovered spontaneously, although it took more than 28 days for two patients. The other patient recovered with an additional course of antibiotics. Five patients from this cohort with radiological evidence of pneumonia fully recovered without antibiotic treatment. CONCLUSIONS: Not all patients with bacterial LRTI and/or pneumonia require antibiotic treatment in order to recover. Managing the patient rather than treating a diagnosis appears safe and effective in general practice