Parents' and clinicians' views of an interactive booklet about respiratory tract infections in children: a qualitative process evaluation of the EQUIP randomised controlled trial

Background: ‘When should I worry?’ is an interactive booklet for parents of children presenting with respiratory tract infections (RTIs) in primary care and associated training for clinicians. A randomised controlled trial (the EQUIP study) demonstrated that this intervention reduced antibiotic prescribing and future consulting intentions. The aims of this qualitative process evaluation were to understand how acceptable the intervention was to clinicians and parents, how it was implemented, the mechanisms for any observed effects, and contextual factors that could have influenced its effects.<p></p> Methods: Semi-structured interviews were conducted with 20 parents and 13 clinicians who participated in the trial. Interviews were audio-recorded and transcribed verbatim. Data were analysed using a framework approach, which involved five stages; familiarisation, development of a thematic framework, indexing, charting, and interpretation.<p></p> Results: Most parents and clinicians reported that the ‘When should I worry’ interactive booklet (and online training for clinicians) was easy to use and valuable. Information on recognising signs of serious illness and the usual duration of illness were most valued. The interactive use of the booklet during consultations was considered to be important, but this did not always happen. Clinicians reported lack of time, lack of familiarity with using the booklet, and difficulty in modifying their treatment plan/style of consultation as barriers to use. Increased knowledge and confidence amongst clinicians and patients were seen as key components that contributed to the reductions in antibiotic prescribing and intention to consult seen in the trial. This was particularly pertinent in a context where decisions about the safe and appropriate management of childhood RTIs were viewed as complex and parents reported frequently receiving inconsistent messages. Conclusions: The ‘When should I worry’ booklet, which is effective in reducing antibiotic prescribing, has high acceptability for clinicians and parents, helps address gaps in knowledge, increases confidence, and provides a consistent message. However, it is not always implemented as intended. Plans for wider implementation of the intervention in health care settings would need to address clinician-related barriers to implementation

'Experience talks': physician prioritisation of contrasting interventions to optimise management of acute cough in general practice

Background Uptake of interventions to improve quality of care by clinicians is variable and is influenced by clinicians' attitudes. The influence of clinicians' experience with an intervention on their preference for adopting interventions is largely unknown. Methods Thematic analysis of semi-structured interviews exploring views and attitudes towards an illness-focused intervention (specific communication skills training) and a disease-focused intervention (C-reactive protein, or CRP, point-of-care testing) to optimize management of lower respiratory tract infections (LRTI) among general practitioners (GPs) who had used both interventions for two years in a randomised trial (exposed GPs), and GPs without experience of either intervention (non-exposed GPs). Results All but two of the ten non-exposed GPs indicated that they would prioritise implementation of the disease-focused intervention of CRP testing over communication skills training, while all but one GP in the exposed group said that they would prioritise the illness-focused approach of communication skills training as it was more widely applicable, whereas CRP testing was confirmatory and useful in a subgroups of patients. Conclusion There are differences in attitudes to prioritising contrasting interventions for optimising LRTI management among GPs with and without experience of using the interventions, although GPs in both groups recognised the importance of both approaches to optimise management of acute cough. GPs' experiences with and attitudes towards interventions need to be taken into account when planning rollout of interventions aimed at changing clinical practice

Comment on Rishu et al. Time required to initiate outbreak and pandemic observational research

We applaud the work of Rishu and colleagues in tracking the timelines to initiation of outbreak and pandemic observational research. Through this work they highlight the challenges in being prepared with a clinical research response in the next pandemic. Pandemics are unpredictable but also recurrent. Recent experience of Ebola and Zika outbreaks highlight the devastating impact these outbreaks have on the health, economy and security of communities for generations to come

MR447: Seasonal Water Table and Temperature Relationships in Calcareous Till and Residual Soils of Central Maine

Water table depths and soil temperatures were monitored for four growing seasons in six calcareous till pedons developed on gently rolling to level till plains in Corinth and Exeter, Maine. These soils are part of a new catena that supports potato production in southeastern Penobscot County. Three of these coarse-loamy to fine-loamy pedons are moderately well drained Oxyaquic Eutrudepts taxadjuncts in potato fields, and three are somewhat poorly drained Aquic Dystric Eutrudepts in predominantly deciduous forest. Soil morphology, hydrologic data, and a,a dipyridyl applications support the described subgroup classification of each pedon, along with the udic moisture regime. Despite a smooth, glaciated landscape that would suggest the presence of extensive lodgment till, five observation sites lacked a densic contact and one contained residuum (saprolite) in the substratum. Apparent water tables in the SPD very deep soils, as well as oxyaquic hydrology in the deep soils on 0 to 3 percent slopes, suggest the more permeable subglacial melt-out till predominating, rather than lodgment till in all of these pedons. Growing season concepts were compared based on frost-free season at 0 and -2.2° C thresholds, soil temperatures in the plow layer, soil temperature at 50 cms and well-water temperature. The commencement of the growing season in the spring did not differ much across all five concepts. However, in the fall there was a 4- to 8-week lag between the air or shallower soil-temperature growing-season concepts and the deeper soil or well-water-temperature growing-season concepts. Daytime air temperature during the first 2 years of monitoring differed significantly between spring and fall seasons, but not between field and forest sites within each season.https://digitalcommons.library.umaine.edu/aes_miscreports/1027/thumbnail.jp

Risk of adverse outcomes following urinary tract infection in older people with renal impairment : Retrospective cohort study using linked health record data

Funding: This report is independent research arising from a National Institute of Health Research (NIHR) Doctoral Research Fellowship awarded to HA, and supported by Health and Care Research Wales (HCRW) (grant number DRF-2014-07-010). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Data Availability: Data analysed for this study were obtained under institutional license from the Clinical Practice Research Datalink, https://www.cprd.com/intro.asp. Data are not available for sharing but can be applied for through the CPRD. Relevant information to allow acquisition of a replicable data set is available in the paper and its Supporting Information files.Peer reviewedPublisher PD

Impact of antibiotic treatment duration on outcomes in older men with suspected urinary tract infection: retrospective cohort study

Purpose Clinical guidelines recommend at least 7 days of antibiotic treatment for older men with urinary tract infection (UTI). There may be potential benefits for patients, health services, and antimicrobial stewardship if shorter antibiotic treatment resulted in similar outcomes. We aimed to determine if treatment duration could be reduced by estimating risk of adverse outcomes according to different prescription durations. Methods This retrospective cohort study included men aged greater than or equal to 65 years old with a suspected UTI. We compared outcomes in men prescribed 3, 5, 7, and 8 to 14 days of antibiotic treatment in a multivariable logistic regression analysis and 3 versus 7 days in a propensity‐score matched analysis. Our outcomes were reconsultation and represcription (proxy for treatment failure), hospitalisation for UTI, sepsis, or acute kidney injury (AKI), and death. Results Of 360 640 men aged greater than or equal to 65 years, 33 745 (9.4%) had a UTI. Compared with 7 days, men prescribed 3‐day treatment had greater odds of reconsultation and represcription (adjusted OR 1.48; 95% CI, 1.25‐1.74) but lower odds of AKI hospitalisation (adjusted OR 0.66; 95% CI, 0.45‐0.97). We estimated that treating 150 older men with 3 days instead of 7 days of antibiotics could result in four extra reconsultation and represcriptions and one less AKI hospitalisation. We estimated annual prescription cost savings at around £2.2 million. Conclusions Antibiotic treatment for older men with suspected UTI could be reduced to 3 days, albeit with a small increase in risk of treatment failure. A definitive randomised trial is urgently needed

Is the NICE traffic light system fit-for-purpose for children presenting with undifferentiated acute illness in primary care?

Background The National Institute of Clinical Excellence (NICE) traffic light system uses children’s symptoms and signs to categorise acute infections into red, amber and green. To our knowledge, no study has described the proportion of children with acute undifferentiated illness who fall into these categories in primary care, which is important since red and amber children are considered at higher risk of serious illness requiring urgent secondary care assessment. Aim To estimate the proportion of acutely unwell children presenting to primary care classified by the NICE traffic light system as red, amber or green, and to describe their initial management. Design and setting Secondary analysis of the Diagnosis of Urinary Tract infection in Young children prospective cohort study. Method 6797 children under 5 years presenting to 225 general practices with acute undifferentiated illness were retrospectively mapped to the NICE traffic light system by a panel of general practitioners. Results 6406 (94%) children were classified as NICE red (32%) or amber (62%) with 1.6% red and 0.3%, respectively, referred the same day for hospital assessment; and 46% and 31%, respectively, treated with antibiotics. The remaining 385 (6%) were classified green, with none referred and 27% treated with antibiotics. Results were robust to sensitivity analyses. Conclusion The majority of children presenting to UK primary care with acute undifferentiated illness meet red or amber NICE traffic light criteria,with only 6% classified as low risk, making it unfit for use in general practice. Research is urgently needed to establish as triage system suitable for general practice

Severe Lumbar Disability Is Associated With Decreased Psoas Cross-Sectional Area in Degenerative Spondylolisthesis

Study Design: Retrospective cohort. Objectives: Alterations in lumbar paraspinal muscle cross-sectional area (CSA) may correlate with lumbar pathology. The purpose of this study was to compare paraspinal CSA in patients with degenerative spondylolisthesis and severe lumbar disability to those with mild or moderate lumbar disability, as determined by the Oswestry Disability Index (ODI). Methods: We retrospectively reviewed the medical records of 101 patients undergoing lumbar fusion for degenerative spondylolisthesis. Patients were divided into ODI score ≤40 (mild/moderate disability, MMD) and ODI score \u3e40 (severe disability, SD) groups. The total CSA of the psoas and paraspinal muscles were measured on preoperative magnetic resonance imaging (MRI). Results: There were 37 patients in the SD group and 64 in the MMD group. Average age and body mass index were similar between groups. For the paraspinal muscles, we were unable to demonstrate any significant differences in total CSA between the groups. Psoas muscle CSA was significantly decreased in the SD group compared with the MMD group (1010.08 vs 1178.6 mm2, P =.041). Multivariate analysis found that psoas CSA in the upper quartile was significantly protective against severe disability (P =.013). Conclusions: We found that patients with severe lumbar disability had no significant differences in posterior lumbar paraspinal CSA when compared with those with mild/moderate disability. However, severely disabled patients had significantly decreased psoas CSA, and larger psoas CSA was strongly protective against severe disability, suggestive of a potential association with psoas atrophy and worsening severity of lumbar pathology. © The Author(s) 2018

Biogeochemical Characterization of Metal Behavior from Novel Mussel Shell Bioreactor Sludge Residues

Acid mine drainage (AMD) remediation commonly produces byproducts which must be stored or utilized to reduce the risk of further contamination. A mussel shell bioreactor has been implemented at a coal mine in New Zealand, which is an effective remediation option, although an accumulated sludge layer decreased efficiency which was then removed and requires storage. To understand associated risks related to storage or use of the AMD sludge material, a laboratory mesocosm study investigated the physio-chemical and biological influence in two conditions: anoxic storage (burial deep within a waste rock dump) or exposure to oxic environments (use of sludge on the surface of the mine). Solid phase characterization by Scanning Electron Microscopy (SEM) and selective extraction was completed to compare two environmental conditions (oxic and anoxic) under biologically active and abiotic systems (achieved by gamma irradiation). Changes in microbial community structure were monitored using 16s rDNA amplification and next-generation sequencing. The results indicate that microbes in an oxic environment increase the formation of oxyhydroxides and acidic conditions increase metal mobility. In an oxic and circumneutral environment, the AMD sludge may be repurposed to act as an oxygen barrier for mine tailings or soil amendment. Anoxic conditions would likely promote the biomineralization of sulfide minerals in the AMD sludge by sulfate reducing bacteria (SRB), which were abundant in the system. The anoxic conditions reduced the risk of trace metals (Zn) associated with oxides, but increased Fe associated with organic material. In summary, fewer risks are associated with anoxic burial but repurposing in an oxic condition may be appropriate under favorable conditions