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

Constriction size distributions of granular filters: a numerical study

The retention capability of granular filters is controlled by the narrow constrictions connecting the voids within the filter. The theoretical justification for empirical filter rules used in practice includes consideration of an idealised soil fabric in which constrictions form between co-planar combinations of spherical filter particles. This idealised fabric has not been confirmed by experimental or numerical observations of real constrictions. This paper reports the results of direct, particle-scale measurement of the constriction size distribution (CSD) within virtual samples of granular filters created using the discrete-element method (DEM). A previously proposed analytical method that predicts the full CSD using inscribed circles to estimate constriction sizes is found to poorly predict the CSD for widely graded filters due to an over-idealisation of the soil fabric. The DEM data generated are used to explore quantitatively the influence of the coefficient of uniformity, particle size distribution and relative density of the filter on the CSD. For a given relative density CSDs form a narrow band of similarly shaped curves when normalised by characteristic filter diameters. This lends support to the practical use of characteristic diameters to assess filter retention capability

Distribution of hydrogen peroxide and methylhydroperoxide over the Pacific and South Atlantic Oceans

The gas phase hydrogen peroxide and methylhydroperoxide concentrations were measured in the troposphere over the tropical Pacific Ocean as a component of NASA's Global Tropospheric Experiment/Pacific Exploratory Mission-Tropics A field campaign. Flights on two aircraft covered the Pacific from 70°S to 60°N and 110°E to 80°W and South Atlantic from 40°S to 15°N and 45°W to 70°E, and extending from 76 to 13,000 m altitude. H2O2 and CH3OOH have the highest concentrations at a given altitude at the equator and decrease with increasing latitude in both the northern and southern hemispheres. Above 4 km the gradient is substantially reduced for both H2O2 and CH3OOH with latitude, and at altitudes in excess of 8 km there is no latitudinal dependence. H2O2 and CH3OOH exhibit maximum mixing ratios between 1 and 2 km at all latitudes. The mean mixing ratio of H2O2 at the equator was 1600 ± 600 parts per trillion by volume (pptv) decreasing to 500 ± 250 pptv at latitudes greater than 55° north and south between 1 and 2 km altitude. CH3OOH at the equator was 1400 ± 250 pptv, decreasing to 330 ± 200 pptv at high latitudes at altitudes between 1 and 2 km. The concentration of peroxides at high latitudes in the northern hemisphere was generally a factor of 2 higher than at corresponding latitudes in the southern hemisphere. The ratio of H2O2 to CH3OOH was between 1 and 2 from 45°S to 35°N at altitudes below 4 km. Between 5° to 15°N the ratio is less than 1, due to preferential removal of H2O2 in the Intertropical Convergence Zone. Copyright 1999 by the American Geophysical Union

Editorial

Editorial for New Zealand Studies vol. 9 no. 2 1999

Using PICO to Align Medical Evidence with MDs Decision Making Models

Modern medicine is characterized by an “explosion” in clinical research information making practical application of Evidence-Based Medicine (EBM), problematic for many clinicians. We have developed a PICO-(evidence based search strategy focusing on Patient/Population, Intervention, Comparison and Outcome)-based framework for (indexing and retrieving medical evidence and we posit that the use of PICO allows for organizing evidence that is aligned with an MD’s decision making model. We describe a study where medical students evaluated our PICO-based approach and results show that students are eager to apply EBM but are hindered by a lack of specialist skills. Students reported that the PICO-based framework for organizing evidence provided an intuitive way of accessing and evaluating evidence and would be useful for their clinical tasks

Targeting the Microbiota to Address Diet-Induced Obesity: A Time Dependent Challenge

peer-reviewedLinks between the gut microbiota and host metabolism have provided new perspectives on obesity. We previously showed that the link between the microbiota and fat deposition is age- and time-dependent subject to microbial adaptation to diet over time. We also demonstrated reduced weight gain in diet-induced obese (DIO) mice through manipulation of the gut microbiota with vancomycin or with the bacteriocin-producing probiotic Lactobacillus salivarius UCC118 (Bac+), with metabolic improvement achieved in DIO mice in receipt of vancomycin. However, two phases of weight gain were observed with effects most marked early in the intervention phase. Here, we compare the gut microbial populations at the early relative to the late stages of intervention using a high throughput sequencing-based analysis to understand the temporal relationship between the gut microbiota and obesity. This reveals several differences in microbiota composition over the intervening period. Vancomycin dramatically altered the gut microbiota composition, relative to controls, at the early stages of intervention after which time some recovery was evident. It was also revealed that Bac+ treatment initially resulted in the presence of significantly higher proportions of Peptococcaceae and significantly lower proportions of Rikenellaceae and Porphyromonadaceae relative to the gut microbiota of L. salivarius UCC118 bacteriocin negative (Bac-) administered controls. These differences were no longer evident at the later time. The results highlight the resilience of the gut microbiota and suggest that interventions may need to be monitored and continually adjusted to ensure sustained modification of the gut microbiota.The authors are supported in part by Teagasc, Science Foundation Ireland (in the form of a research centre grant to the Alimentary Pharmabiotic Centre and PI awards to PWOT and PC) and by Alimentary Health Ltd