PRImary care Streptococcal Management (PRISM) study:In vitro study, diagnostic cohorts and a pragmatic adaptive randomised controlled trial with nested qualitative study and cost-effectiveness study

Background: Antibiotics are still prescribed to most patients attending primary care with acute sore throat, despite evidence that there is modest benefit overall from antibiotics. Targeting antibiotics using either clinical scoring methods or rapid antigen detection tests (RADTs) could help. However, there is debate about which groups of streptococci are important (particularly Lancefield groups C and G), and uncertainty about the variables that most clearly predict the presence of streptococci. Objective: This study aimed to compare clinical scores or RADTs with delayed antibiotic prescribing. Design: The study comprised a RADT in vitro study; two diagnostic cohorts to develop streptococcal scores (score 1; score 2); and, finally, an open pragmatic randomised controlled trial with nested qualitative and cost-effectiveness studies. Setting: The setting was UK primary care general practices. Participants: Participants were patients aged ≥ 3 years with acute sore throat. Interventions: An internet program randomised patients to targeted antibiotic use according to (1) delayed antibiotics (control group), (2) clinical score or (3) RADT used according to clinical score. Main outcome measures: The main outcome measures were self-reported antibiotic use and symptom duration and severity on seven-point Likert scales (primary outcome: mean sore throat/difficulty swallowing score in the first 2-4 days). Results: The IMI TestPack Plus Strep A (Inverness Medical, Bedford, UK) was sensitive, specific and easy to use. Lancefield group A/C/G streptococci were found in 40% of cohort 2 and 34% of cohort 1. A five-point score predicting the presence of A/C/G streptococci [FeverPAIN: Fever; Purulence; Attend rapidly (≤ 3 days); severe Inflammation; and No cough or coryza] had moderate predictive value (bootstrapped estimates of area under receiver operating characteristic curve: 0.73 cohort 1, 0.71 cohort 2) and identified a substantial number of participants at low risk of streptococcal infection. In total, 38% of cohort 1 and 36% of cohort 2 scored ≤ 1 for FeverPAIN, associated with streptococcal percentages of 13% and 18%, respectively. In an adaptive trial design, the preliminary score (score 1; n = 1129) was replaced by FeverPAIN (n = 631). For score 1, there were no significant differences between groups. For FeverPAIN, symptom severity was documented in 80% of patients, and was lower in the clinical score group than in the delayed prescribing group (-0.33; 95% confidence interval -0.64 to -0.02; p = 0.039; equivalent to one in three rating sore throat a slight rather than moderately bad problem), and a similar reduction was observed for the RADT group (-0.30; -0.61 to 0.00; p = 0.053). Moderately bad or worse symptoms resolved significantly faster (30%) in the clinical score group (hazard ratio 1.30; 1.03 to 1.63) but not the RADT group (1.11; 0.88 to 1.40). In the delayed group, 75/164 (46%) used antibiotics, and 29% fewer used antibiotics in the clinical score group (risk ratio 0.71; 0.50 to 0.95; p = 0.018) and 27% fewer in the RADT group (0.73; 0.52 to 0.98; p = 0.033). No significant differences in complications or reconsultations were found. The clinical score group dominated both other groups for both the cost/quality-adjusted life-years and cost/change in symptom severity analyses, being both less costly and more effective, and cost-effectiveness acceptability curves indicated the clinical score to be the most likely to be cost-effective from an NHS perspective. Patients were positive about RADTs. Health professionals' concerns about test validity, the time the test took and medicalising self-limiting illness lessened after using the tests. For both RADTs and clinical scores, there were tensions with established clinical experience. Conclusions: Targeting antibiotics using a clinical score (FeverPAIN) efficiently improves symptoms and reduces antibiotic use. RADTs used in combination with FeverPAIN provide no clear advantages over FeverPAIN alone, and RADTs are unlikely to be incorporated into practice until health professionals' concerns are met and they have experience of using them. Clinical scores also face barriers related to clinicians' perceptions of their utility in the face of experience. This study has demonstrated the limitation of using one data set to develop a clinical score. FeverPAIN, derived from two data sets, appears to be valid and its use improves outcomes, but diagnostic studies to confirm the validity of FeverPAIN in other data sets and settings are needed. Experienced clinicians need to identify barriers to the use of clinical scoring methods. Implementation studies that address perceived barriers in the use of FeverPAIN are needed

Quantifying functional consequences of habitat degradation on a Caribbean coral reef

This is the final version. Available on open access from the European Geosciences Union via the DOI in this recordCode and data availability: Data and R code will be made available on requestCoral reefs are declining worldwide. The abundance of corals has decreased alongside a rise of filter feeders, turf, and algae in response to intensifying human pressures. This shift in prevalence of functional groups alters the biogeochemical processes in tropical water ecosystems, thereby influencing reef functioning. An urgent challenge is to understand the functional consequences of these shifts to develop suitable management strategies that aim at preserving the biological functions of reefs. Here, we quantify biogeochemical processes supporting key reef functions (i.e. net community calcification (NCC) and production (NCP) and nutrient recycling) in situ for five different benthic assemblages currently dominating shallow degraded Caribbean reef habitats. To this end, a transparent custom-made enclosure was placed over communities dominated by either one of five functional groups - coral, turf and macroalgae, bioeroding sponges, cyanobacterial mats, or sand - to determine chemical fluxes between these communities and the overlying water, during both day and night. To account for the simultaneous influence that distinct biogeochemical processes have on measured variables, the rates were then derived by solving a model consisting of differential equations describing the contribution of each process to the measured chemical fluxes. Inferred rates were low compared to those known for reef flats worldwide. Reduced accretion potential was recorded, with negative or very modest net community calcification rates for all communities. Net production during the day was also low, suggesting limited accumulation of biomass through photosynthesis and remineralisation of organic matter at night was relatively high in comparison, resulting in net heterotrophy over the survey period for most communities. Estimated recycling processes (i.e. nitrification and denitrification) were high but did not fully counterbalance nutrient release from aerobic mineralisation, rendering all substrates sources of nitrogen. Results suggest similar directions and magnitudes of key biogeochemical processes of distinct communities on this shallow Curaçaoan reef. We infer that the amount and type of organic matter released by abundant algal turfs and cyanobacterial mats on this reef likely enhances heterotroph activity and stimulates the proliferation of less diverse copiotrophic microbial populations, rendering the studied reef net heterotrophic and drawing the biogeochemical "behaviour"of distinct communities closer to each other

Lecture archiving on a larger scale at the University of Michigan and CERN

The ATLAS Collaboratory Project at the University of Michigan has been a leader in the area of collaborative tools since 1999. Its activities include the development of standards, software and hardware tools for lecture archiving, and making recommendations for videoconferencing and remote teaching facilities. Starting in 2006 our group became involved in classroom recordings, and in early 2008 we spawned CARMA, a University-wide recording service. This service uses a new portable recording system that we developed. Capture, archiving and dissemination of rich multimedia content from lectures, tutorials and classes are increasingly widespread activities among universities and research institutes. A growing array of related commercial and open source technologies is becoming available, with several new products introduced in the last couple years. As the result of a new close partnership between U-M and CERN IT, a market survey of these products was conducted and a summary of the results are presented here. It is informing an ambitious effort in 2009 to equip many CERN rooms with automated lecture archiving systems, on a much larger scale than before. This new technology is being integrated with CERN's existing webcast, CDS, and Indico applications.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/85420/1/jpconf10_219_082003.pd

How communication affects prescription decisions in consultations for acute illness in children:a systematic review and meta-ethnography

BACKGROUND: Communication within primary care consultations for children with acute illness can be problematic for parents and clinicians, with potential misunderstandings contributing to over–prescription of antibiotics. This review aimed to synthesise the evidence in relation to communication and decision making in consultations for children with common acute illness. METHODS: A systematic search of MEDLINE, EMBASE, CINAHL, PsycINFO, SSCI, SIGLE, Dissertation Express and NHS economic evaluation databases was conducted. Studies of primary care settings in high income countries which made direct observations of consultations and reported qualitative data were included. Included studies were appraised using the process recommended by the Cochrane Qualitative Methods Group. Credibility was assessed as high for most studies but transferability was usually assessed low or unclear. Data were synthesised using a meta–ethnographic approach. RESULTS: Thirty–five papers and 2 theses reporting on 13 studies were included, 7 of these focussed on children with respiratory tract infections (RTI) and the remaining 6 included children with any presenting illness. Parent communication focussed on their concerns and information needs, whereas clinician communication focussed on diagnosis and treatment decisions. During information exchanges, parents often sought to justify the need for the consultation, while clinicians frequently used problem minimising language, resulting in parents and clinicians sometimes talking at cross–purposes. In the context of RTIs, a range of parent communication behaviours were interpreted by clinicians as indicating an expectation for antibiotics; however, most were ambiguous and could also be interpreted as raising concerns or requests for further information. The perceived expectation for antibiotics often changed clinician decision making into clinician–parent negotiation. CONCLUSIONS: Misunderstandings occurred due to parents and clinicians talking at cross purposes about the ‘seriousness’ of the illness and because parents’ expressions of concern or requests for additional information were sometimes perceived as a challenge to the clinicians’ diagnosis or treatment decision. This modifiable problem may be an important contribution to the unnecessary and unwanted prescribing of antibiotics. Primary care clinicians should be offered training to understand parent communication primarily as expressions of concern or attempts at understanding and always to check rather than infer parental expectations

P. robustu

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