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Background Understanding prognostic information can help patients know what may happen to their health over time and make informed decisions. However, communicating prognostic information well can be challenging. Purpose To conduct a systematic review to identify and synthesize research that has evaluated visual presentations that communicate quantitative prognostic information to patients or the public. Data sources MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC and the Cochrane Central Register of Controlled Trials (CENTRAL) (from inception to December 2020), and forward and backward citation search. Study selection Two authors independently screened search results and assessed eligibility. To be eligible, studies required a quantitative design and comparison of at least one visual presentation with another presentation of quantitative prognostic information. The primary outcome was comprehension of the presented information. Secondary outcomes were preferences for or satisfaction with the presentations viewed, and behavioral intentions. Data extraction Two authors independently assessed risk of bias and extracted data. Data synthesis Eleven studies (all randomized trials) were identified. We grouped studies according to the presentation type evaluated. Bar graph versus pictograph (3 studies): no difference in comprehension between the groups. Survival vs mortality curves (2 studies): no difference in one study; higher comprehension in survival curve group in another study. Tabular format versus pictograph (4 studies): 2 studies reported similar comprehension between groups; 2 found higher comprehension in pictograph groups. Tabular versus free text (3 studies): 2 studies found no difference between groups; 1 found higher comprehension in a tabular group. Limitations Heterogeneity in the visual presentations and outcome measures, precluding meta-analysis. Conclusions No visual presentation appears to be consistently superior to communicate quantitative prognostic information.

BackgroundOveruse of proton pump inhibitors (PPIs) – frequently used for relieving symptoms of gastroesophageal reflux disease (GORD) – raises long-term safety concerns, warranting evidence-based non-drug interventions. We conducted a systematic review to evaluate the effect of head-of-bed elevation on relieving symptoms of GORD in adults.MethodsWe included controlled trials comparing the effect of head-of-bed elevation interventions to control in adults with GORD. Two independent reviewers screened articles, extracted data, and assessed quality of included studies. Primary outcomes were changes in GORD symptoms and use of PPIs.ResultsWe screened 1206 records; and included five trials (four cross-over and one factorial) comprising 228 patients. All five included trials were judged to be at high-risk of performance bias and four of selection bias. Of five included trials, two used ‘bed blocks’ under the bed legs; one used ‘sleeping on a wedge’ pillow, and two used both. High heterogeneity in outcome measures and reported outcomes data precluded meta-analyses. The four studies that reported on GORD symptoms found an improvement among participants in the head-of-bed elevation; a high-quality crossover trial showed a clinical important reduction in symptom scores at 6 weeks (risk ratio of 2.1; 95% CI 1.2 to 3.6). These results are supported by the observed improvement in physiological intra-oesophageal pH measurements.ConclusionsMethodological and reporting limitations in available literature preclude definitive recommendations. However, head-of-bed elevation could be still considered as a cheap and safe alternative to drug interventions with unfavourable safety profiles.Protocol registrationOpen Science Framework:http://osf.io/2hz3j

BackgroundNon-bullous impetigo is typically treated with antibiotics. However, the duration of symptoms without their use has not been established, which hampers informed decision making about antibiotic use.AimTo determine the natural history of non-bullous impetigo.Design and settingSystematic review.MethodThe authors searched PubMed up to January 2020, as well as reference lists of articles identified in the search. Eligible studies involved participants with impetigo in either the placebo group of randomised trials, or in single-group prognostic studies that did not use antibiotics and measured time to resolution or improvement. A modified version of a risk of bias assessment for prognostic studies was used. Outcomes were percentage of participants who had either symptom resolution, symptom improvement, or failed to improve at any timepoint. Adverse event data were also extracted.ResultsSeven randomised trials (557 placebo group participants) were identified. At about 7 days, the percentage of participants classified as resolved ranged from 13% to 74% across the studies, whereas the percentage classified as ‘failure to improve’ ranged from 16% to 41%. The rate of adverse effects was low. Incomplete reporting of some details limited assessment of risk of bias.ConclusionAlthough some uncertainty around the natural history of non-bullous impetigo remains, symptoms resolve in some patients by about 7 days without using antibiotics, with about one-quarter of patients not improving. Immediate antibiotic use may not be mandatory, and discussions with patients should include the expected course of untreated impetigo and careful consideration of the benefits and harms of antibiotic use.

BackgroundAlthough uncomplicated urinary tract infection (UTI) is commonly treated with antibiotics, the duration of symptoms without their use is not established; this hampers informed decision making about antibiotic use.AimTo determine the natural history of uncomplicated UTI in adults.Design and settingSystematic review.MethodPubMed was searched for articles published until November 2019, along with reference lists of articles identified in the search. Eligible studies were those involving adults with UTIs in either the placebo group of randomised trials or in single-group prognostic studies that did not use antibiotics and measured symptom duration. A modified version of a risk of bias assessment for prognostic studies was used. Outcomes were the percentage of patients who, at any time point, were symptom free, had symptom improvement, or had worsening symptoms (failed to improve). Adverse event data were also extracted.ResultsThree randomised trials (346 placebo group participants) were identified, all of which specified women only in their inclusion criteria. The risk of bias was generally low, but incomplete reporting of some details limited assessment. Over the first 9 days, the percentage of participants who were symptom free or reported improved symptoms was reported as rising to 42%. At 6 weeks, the percentage of such participants was 36%; up to 39% of participants failed to improve by 6 weeks. The rate of adverse effects was low and, in two trials, progression to pyelonephritis was reported in one placebo participant.ConclusionAlthough some uncertainty around the natural history of uncomplicated UTIs remains, some women appear to improve or become symptom free spontaneously, and most improvement occurs in the first 9 days. Other women either failed to improve or became worse over a variable timespan, although the rate of serious complications was low.

Background Acute otitis media (AOM) is associated with high antibiotic prescribing rates. Antibiotics are somewhat effective in improving pain and middle ear effusion (MEE); however, they have unfavourable effects. Alternative treatments, such as corticosteroids as anti-inflammatory agents, are needed. Evidence for the efficacy of these remains inconclusive. We conducted a pilot study to test feasibility of a proposed large-scale randomised controlled trial (RCT) to assess the efficacy of corticosteroids for AOM. Methods We conducted a pilot, pragmatic, parallel, open-label RCT of oral corticosteroids for paediatric AOM in primary and secondary/tertiary care centres in Indonesia. Children aged 6 months–12 years with AOM were randomised to either prednisolone or control (1:1). Physicians were blinded to allocation. Our objectives were to test the feasibility of our full RCT procedures and design, and assess the mechanistic effect of corticosteroids, using tympanometry, in suppressing middle ear inflammation by reducing MEE. Results We screened 512 children; 62 (38%) of 161 eligible children were randomised and 60 were analysed for the primary clinical outcome. All study procedures were completed successfully by healthcare personnel and parents/caregivers, despite time constraints and high workload. All eligible, consenting children were appropriately randomised. One child did not take the medication and four received additional oral corticosteroids. Our revised sample size calculation verified 444 children are needed for the full RCT. Oral corticosteroids did not have any discernible effects on MEE resolution and duration. There was no correlation between pain or other symptoms and MEE change. However, prednisolone may reduce pain intensity at day 3 (Visual Analogue Scale mean difference − 7.4 mm, 95% confidence interval (CI) − 13.4 to − 1.3, p = 0.018), but cause drowsiness (relative risk (RR) 1.8, 95% CI 1.1 to 2.8, p = 0.016). Tympanometry curves at day 7 may be improved (RR 1.8, 95% CI 1.0 to 2.9). We cannot yet confirm these as effects of corticosteroids due to insufficient sample size in this pilot study. Conclusions It is feasible to conduct a large, pragmatic RCT of corticosteroids for paediatric AOM in Indonesia. Although oral corticosteroids may reduce pain and improve tympanometry curves, it requires an adequately powered clinical trial to confirm this. Trial registration Study registry number: ACTRN12618000049279. Name of registry: the Australian New Zealand Clinical Trials Registry (ANZCTR). Date of registration: 16 January 2018.

Background and Objectives Systematic reviews (SRs) are time and resource intensive, requiring approximately 1 year from protocol registration to submission for publication. Our aim was to describe the process, facilitators, and barriers to completing the first 2-week full SR. Study Design and Setting We systematically reviewed evidence of the impact of increased fluid intake, on urinary tract infection (UTI) recurrence, in individuals at risk for UTIs. The review was conducted by experienced systematic reviewers with complementary skills (two researcher clinicians, an information specialist, and an epidemiologist), using Systematic Review Automation tools, and blocked off time for the duration of the project. The outcomes were time to complete the SR, time to complete individual SR tasks, facilitators and barriers to progress, and peer reviewer feedback on the SR manuscript. Times to completion were analyzed quantitatively (minutes and calendar days); facilitators and barriers were mapped onto the Theoretical Domains Framework; and peer reviewer feedback was analyzed quantitatively and narratively. Results The SR was completed in 61 person-hours (9 workdays; 12 calendar days); accepted version of the manuscript required 71 person-hours. Individual SR tasks ranged from 16 person-minutes (deduplication of search results) to 461 person-minutes (data extraction). The least time-consuming SR tasks were obtaining full-texts, searches, citation analysis, data synthesis, and deduplication. The most time-consuming tasks were data extraction, write-up, abstract screening, full-text screening, and risk of bias. Facilitators and barriers mapped onto the following domains: knowledge; skills; memory, attention, and decision process; environmental context and resources; and technology and infrastructure. Two sets of peer reviewer feedback were received on the manuscript: the first included 34 comments requesting changes, 17 changes were made, requiring 173 person-minutes; the second requested 13 changes, and eight were made, requiring 121 person-minutes. Conclusion A small and experienced systematic reviewer team using Systematic Review Automation tools who have protected time to focus solely on the SR can complete a moderately sized SR in 2 weeks.

BackgroundAsymptomatic bacteriuria (ASB) is common among residents of residential aged care facilities (RACFs). However, differentiating between an established urinary tract infection and ASB in older adults is difficult. As a result, the overuse of dipstick urinalysis, as well as the subsequent initiation of antibiotics, is common in RACFs.AimTo find, appraise, and synthesise studies that reported the effectiveness, harms, and adverse events associated with antibiotic treatment for older patients with ASB residing in RACFs.Design and settingA systematic review using standard Cochrane methods of RACF residents with ASB using antibiotics against placebo, or no treatment.MethodThree electronic databases (PubMed, EMBASE, and CENTRAL), clinical trial registries, and forward–backward reference checks of included studies were searched.ResultsNine randomised controlled trials, comprising 1391 participants were included; two of which used a placebo comparator, and the remaining seven used no therapy control groups. There was a relatively small number of studies assessed per outcome and an overall moderate risk of bias. Outcomes related to mortality, development of ASB, and complications were comparable between the two groups. Antibiotic therapy was associated with a higher number of adverse effects (four studies; 303 participants; risk ratio [RR] 5.62, 95% confidence interval [CI] = 1.07 to 29.55, P = 0.04) and bacteriological cure (nine studies; 888 participants; RR 1.89, 95% CI = 1.08 to 3.32, P = 0.03).ConclusionOverall, although antibiotic treatment was associated with bacteriological cure, it was also associated with significantly more adverse effects. The harms and lack of clinical benefit of antibiotic use for older patients in RACFs may outweigh the benefits.

Most antibiotics prescribed in primary care are for acute, and often self-limiting, conditions. Patients' expectations of needing antibiotics are an influential driver of general practitioners' (GPs') prescribing behaviour. Better managing patient expectations in consultations for acute infections may be important for reducing prescribing, particularly for self-limiting conditions.The aim of this article is to increase awareness about patients' beliefs and expectations about antibiotics for acute conditions and provide strategies and resources that GPs can use in collaboration with their patients for managing these expectations.Expectations of antibiotics may reflect a desire for symptomatic treatment, lack of awareness of other options or previous experience. Consultations for many acute conditions are particularly suited to shared decision making - it enables discussion about expectations and antibiotic benefits and harms and assists patients to make an informed decision. Delayed prescribing is another evidence-based strategy that can be used as part of shared decision making.

Population trends in PSA testing and prostate cancer incidence do not perfectly correspond. We aimed to better understand relationships between trends in PSA testing, prostate cancer incidence and mortality in Australia and factors that influence them. Methods We calculated and described standardised time trends in PSA tests, prostate biopsies, treatment of benign prostatic hypertrophy (BPH) and prostate cancer incidence and mortality in Australia in men aged 45–74, 75–84, and 85 + years. Results PSA testing increased from its introduction in 1989 to a peak in 2008 before declining in men aged 45–84 years. Prostate biopsies and cancer incidence fell from 1995 to 2000 in parallel with decrease in trans-urethral resections of the prostate (TURP) and, latterly, changes in pharmaceutical management of BPH. After 2000, changes in biopsies and incidence paralleled changes in PSA screening in men 45–84 years, while in men ≥85 years biopsy rates stabilised, and incidence fell. Prostate cancer mortality in men aged 45–74 years remained low throughout. Mortality in men 75–84 years gradually increased until mid 1990s, then gradually decreased. Mortality in men ≥ 85 years increased until mid 1990s, then stabilised. Conclusion Age specific prostate cancer incidence largely mirrors PSA testing rates. Most deviation from this pattern may be explained by less use of TURP in management of BPH and consequent less incidental cancer detection in TURP tissue specimens. Mortality from prostate cancer initially rose and then fell below what it was when PSA testing began. Its initial rise and fall may be explained by a possible initial tendency to over-attribute deaths of uncertain cause in older men with a diagnosis of prostate cancer to prostate cancer. Decreases in mortality rates were many fold smaller than the increases in incidence, suggesting substantial overdiagnosis of prostate cancer after introduction of PSA testing.

Objective: We conducted a survey to understand the challenges faced by the staff of residential aged care facilities (RACF), during the COVID-19 pandemic. Background: In the current pandemic, the RACF workforce has been required to work under stressful conditions, with immense mental and physical pressures, resulting in anxiety and stress felt towards their jobs. Study design and methods: We electronically surveyed both clinical and non-clinical staff at public and private RACFs in Australia in June and August 2020. The survey asked a mix of open-ended and closed questions about preparedness for the pandemic, information flow, experience with personal protective equipment (PPE), management of suspected COVID cases, restrictions on visitors, and impact on RACF staff personal and home life. Quantitative data were analysed in SPSS; qualitative data using content analysis. Results: We received 371 responses: 198 from clinical staff and 168 from non-clinical staff. Respondents were between 20–71 years old, and 87% were female most commonly from Victoria (28%) or New South Wales (28%). The majority (80%) felt that Australian RACFs were well-prepared for the pandemic and 87% agreed that relevant healthcare authorities were contactable for information needed. A total of 37% reported challenges in estimating and ordering appropriate quantities of protective equipment. Ninety percent of facilities reported screening residents for possible symptoms and 77% introduced precautions or quarantine measures to protect residents. Most participants (98%) reported their RACF implemented restrictions on visitor access and 43% reported unfair or abusive treatment by family or friends of the residents. Commonly reported personal impacts included: workload increase, stress, emotional toll, family issues and fatigue. Support from colleagues as well as training, de-brief sessions and frequent meetings were identified as helpful facilitators during this time. Conclusion: We identified a wide range of practices and coping strategies among Australian RACFs. Whilst a majority of respondents reported coping well, a large proportion reported struggling both mentally and physically. Factors reported as helpful by the respondents may assist RACFs in planning for future pandemics. Implications for research, policy and practice: Understanding the challenges faced by all levels of staff within RACFs may aid decision-makers on a range of different levels – researchers, aged care providers, local/regional/state health departments and national leaders within government to help inform the development of interventions that may help the sector to recover, as well as prepare for potential future outbreaks. Of particular importance, are interventions or initiatives that focus on supporting the physical and mental health of staff i.e. those that prevent or minimise worker fatigue, emotional burnout and stress. What is already known about the topic? Nursing staff in Australian RACFs did not feel prepared for the COVID outbreak in their workplace. Early in 2020, RACF nurses experienced a greater overall workload and some had their staff hours reduced by their employers due to financial constraints caused by the outbreak. What this paper adds This paper offers a comprehensive insight into how RACF staff coped both individually and as part of the facility overall during the COVID crisis. It identified that a commonly reported source of stress was first-hand verbal abuse from family or friends of residents in response to visitor and lockdown restrictions implemented by the authorities. The paper highlighted that whilst the majority of respondents felt that RACFs were well prepared for managing residents during the pandemic, some facilities experienced significant problems with workloads, PPE and human resourcing. Furthermore, the survey showed that on an individual level, some staff experienced significant mental and physical stress during the outbreak.

BackgroundApproximately 15% of community-prescribed antibiotics are used in treating urinary tract infections (UTIs). Increase in antibiotic resistance necessitates considering alternatives.AimTo assess the impact of increased fluid intake in individuals at risk for UTIs, for impact on UTI recurrence (primary outcome), antimicrobial use, and UTI symptoms (secondary outcomes).Design and settingA systematic review.MethodThe authors searched PubMed, Cochrane CENTRAL, EMBASE, two trial registries, and conducted forward and backward citation searches of included studies in January 2019. Randomised controlled trials of individuals at risk for UTIs were included; comparisons with antimicrobials were excluded. Different time-points (≤6 months and 12 months) were compared for the primary outcome. Risk of bias was assessed using Cochrane Risk of Bias tool. Meta-analyses were undertaken where ≥3 studies reported the same outcome.ResultsEight studies were included; seven were meta-analysed. There was a statistically non-significant reduction in the number of patients with any UTI recurrence in the increased fluid intake group compared with control after 12 months (odds ratio [OR] 0.39, 95% confidence interval [CI] = 0.15 to 1.03, P = 0.06); reduction was significant at ≤6 months (OR 0.13, 95% CI = 0.07 to 0.25, PP = 0.001). Increased fluid intake reduced the overall rate of all recurrent UTIs (rate ratio [RR] 0.46, 95% CI = 0.40 to 0.54, PP = 0.08). Paucity of data precluded meta-analysing symptoms.ConclusionGiven the minimal potential for harm, patients with recurrent UTIs could be advised to drink more fluids to reduce recurrent UTIs. Further research is warranted to establish the optimal volume and type of increased fluid.

Background A perennial challenge of primary care quality improvement is to establish why interventions work in some circumstances, but not others. This study aimed to identify factors explaining variations in the impact on clinical practice of a facilitation led vascular health intervention in Australian family practice. Methods Our mixed methods study was embedded within a cluster randomised controlled trial of a facilitation intervention designed to increase the uptake of evidence-based prevention of vascular disease in family practices. The study was set in four Australian states using eight of the study’s 16 intervention practices. Facilitators worked with intervention practices to develop and implement improvements in preventive care informed by a vascular risk factor audit. We constructed case studies of each practice’s “intervention narrative” from semi-structured interviews with clinicians, facilitators and other staff, practice observation, and document analysis of facilitator diaries. The intervention narratives were combined with pre- and post-intervention audit data to generate typologies of practice responses to the intervention. Results We found substantial variability between practices in the changes made to vascular risk recording. Context (i.e. practice size), adaptive reserve (i.e. interpersonal relationships, manager and nurse involvement), and occasional data idiosyncrasies interacted to influence this variability. Conclusion The findings emphasise the importance of tailoring facilitation interventions to practice size, clinician engagement and, critically, the organisation of, and relationships between, the members of the practice team. Trial registration The trial was registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12612000578808 (29/5/2012). This trial registration is retrospective as our first patient returned their consent on the 21/5/2012. Patient recruitment was ongoing until 31/10/2012. Electronic supplementary material The online version of this article (10.1186/s12875-019-0995-7) contains supplementary material, which is available to authorized users.

Background and objectives Evidence supports some beneficial effects of antibiotics prescribed to patients with a sore throat and proven presence of group A streptococci (GAS). Methods A total of 283 patients were included from North and North-West Queensland, Australia, at their first presentation for uncomplicated acute sore throat. Patterns of antibiotic prescribing were explored before and after testing for GAS using a rapid point-of-care polymerase chain reaction (PCR) test. Results The results of the study showed the Australian Therapeutic Guidelines were often not adhered to. The PCR test reduced the proportion of patients prescribed antibiotics from 46% to 40%. The decision to prescribe antibiotics was changed in 30% of patients (P

PURPOSE: To determine whether acute respiratory infection (ARI) decision aids and a general practitioner (GP) training package reduces antibiotic dispensing rate and improves GPs’ knowledge of antibiotic benefit-harm evidence. METHODS: A cluster randomized trial of 27 Australian general practices (13 intervention, 14 control) involving 122 GPs. Intervention group GPs were given brief decision aids for 3 ARIs (acute otitis media, acute sore throat, acute bronchitis) and video-delivered training. Primary outcome was dispensing rate of target antibiotic classes (routinely used for ARIs), extracted for 12 months before, and following, randomization. Secondary outcomes were GPs’ knowledge of antibiotic benefit-harm evidence; prescribing influences; acceptability, usefulness, and self-reported resource use; and dispensing rate of all antibiotics. RESULTS: The baseline mean dispensing rate of ARI-related antibiotics was 3.5% (intervention GPs) and 3.2% (control GPs) of consultations. After 12 months, mean rates decreased (to 2.9% intervention; 2.6% control): an 18% relative reduction from baseline but similar in both groups (rate ratio 1.01; 95% CI, 0.89-1.15). Greater increases in knowledge were seen in the intervention group than control; a significant increase (average 3.6; 95% CI, 2.4-4.7, P

ObjectivesTo describe the development and initial evaluation of a brief e-learning course as a means of teaching shared decision making and risk communication skills to clinicians of all specialties.DesignComparison pre-course and post-course of scores in subjective confidence and objective knowledge about shared decision making and risk communication.SettingOnline and open to all specialties and levels of clinical experience, including students.ParticipantsThe course is freely available online and all who started the course from September 2018 to May 2020 were invited to participate in the evaluation study.InterventionThe self-guided e-learning course is made up of four modules and takes approximately 2 hours to complete. It is hosted on the website of the Winton Centre for Risk Communication and the UK’s National Health Service e-learning platform.Main outcome measuresPre-course and post-course confidence in performing shared decision making (as measured by a 10-item scale adapted from the OPTION tool; total score range 10–50), and objective knowledge about basic principles of shared decision making and risk communication, as measured by performance on four knowledge questions and three calculations. At course commencement, a single item from the Berlin Numeracy Test, and the eight-item Subjective Numeracy Test were also asked.ResultsOf 366 unique participants who consented and commenced the course, 210 completed all modules and the final post-course test. Participants’ mean age was 38.1 years, 69% were in current clinical practice and had a mean of 10.5 years of clinical practice. Numeracy was relatively low, with 50.7% correctly answering the Berlin Numeracy Test item pre-course. Participants who completed the course showed a significant improvement in their confidence by a mean summed score of 3.7 units (95% CI 2.9 to 4.6, pConclusionsThis online, free e-learning course was successful in increasing participants’ confidence in, and some aspects of knowledge about, shared decision making and risk communication. It also highlighted the need for improvements in clinicians’ numerical skills as a vital part of training. We suggest that the course is used in combination with practical face-to-face experience and more intensive numerical skills training.

BackgroundUrinary tract infections (UTIs) are often treated with antibiotics and are a source of antibiotic overuse.AimTo systematically review randomised controlled trials (RCTs) of adult women in the community with a history of recurrent UTIs and who use methenamine hippurate prophylactically.Design and settingSystematic review of women in the UK, Australia, Norway, and US (aged ≥18 years) with recurrent UTIs receiving methenamine hippurate against placebo or no treatment, and antibiotics.MethodThe authors searched three databases, clinical trial registries, and performed forward–backward citation analysis on references of included studies.ResultsSix studies involving 557 participants were included (447 were analysed). Of the six studies, five were published and one was an unpublished trial record with results, three compared methenamine hippurate against placebo or control, and three compared methenamine hippurate with antibiotics. For the number of patients who remained asymptomatic, methenamine hippurate showed a non-statistically significant trend of benefit versus antibiotics over 12 months (risk ratio [RR] 0.65, 95% confidence interval [CI] = 0.40 to 1.07, I2 49%), versus control over 6 or 12 months (RR 0.56, 95% CI = 0.13 to 2.35, I2 93%), and a non-statistically significant trend versus any antibiotic for abacteruria (RR 0.80, 95% CI = 0.62 to 1.03, I2 23%). A similar non-statistically significant trend of benefits for methenamine hippurate for the number of UTI or bacteriuric episodes was found, and a non-statistically significant difference in the number of patients experiencing adverse events between methenamine hippurate and any comparator, with a trend towards benefit for the methenamine hippurate, was identified. Antibiotic use and resistance were not consistently reported.ConclusionThere is insufficient evidence to be certain of the benefits of methenamine hippurate to prevent UTI. Further research is needed to test the drug’s effectiveness in preventing UTIs and as an alternative for antibiotic treatment for UTI.

ObjectiveTo compare the effectiveness of hand hygiene using alcohol-based hand sanitiser to soap and water for preventing the transmission of acute respiratory infections (ARIs), and assess the relationship between the dose of hand hygiene and the number of ARI, influenza-like illness (ILI), or influenza events.MethodsSystematic review of randomised trials that compared a community-based hand hygiene intervention (soap and water, or sanitiser) with a control, or trials that compared sanitiser with soap and water, and measured outcomes of ARI, ILI, or laboratory-confirmed influenza or related consequences. Searches were conducted in CENTRAL, PubMed, Embase, CINAHL and trial registries (April 2020) and data extraction completed by independent pairs of reviewers.ResultsEighteen trials were included. When meta-analysed, three trials of soap and water versus control found a non-significant increase in ARI events (Risk Ratio (RR) 1.23, 95%CI 0.78-1.93); six trials of sanitiser versus control found a significant reduction in ARI events (RR 0.80, 95%CI 0.71-0.89). When hand hygiene dose was plotted against ARI relative risk, no clear dose-response relationship was observable. Four trials were head-to-head comparisons of sanitiser and soap and water but too heterogeneous to pool: two found a significantly greater reduction in the sanitiser group compared to the soap group; two found no significant difference between the intervention arms.ConclusionAdequately performed hand hygiene, with either soap or sanitiser, reduces the risk of ARI virus transmission, however direct and indirect evidence suggest sanitiser might be more effective in practice.

OBJECTIVETo assess the effectiveness of hand hygiene, surface disinfecting, and other hygiene interventions in preventing or reducing the spread of illnesses from respiratory viruses.DESIGNUpdate of a systematic review and meta-analysis focussing on randomised controlled trials (RCTs) and cluster-RCTs (c-RCTs) evidence only.DATA SOURCESEligible trials from the previous Cochrane review, search of the Cochrane Central Register of Controlled Trials, PubMed, Embase and CINAHL from 01 October 2010 to 01 April 2020, and forward and backward citation analysis of included studies.DATA SELECTIONRCTs and c-RCTs involving people of any age, testing the use of hand hygiene methods, surface disinfection or cleaning, and other miscellaneous barrier interventions. Face masks, eye protection, and person distancing are covered in Part 1 of our systematic review. Outcomes included acute respiratory illness (ARI), influenza-like illness (ILI) or laboratory-confirmed influenza (influenza) and/or related consequences (e.g. death, absenteeism from school or work).DATA EXTRACTION AND ANALYSISSix authors working in pairs independently assessed risk of bias using the Cochrane tool and extracted data. The generalised inverse variance method was used for pooling by using the random-effects model, and results reported with risk ratios (RR) and 95% confidence intervals (CIs).RESULTSWe identified 51 eligible trials. We included 25 randomised trials comparing hand hygiene interventions with a control; 15 of these could be included in meta-analyses. We pooled 8 trials for the outcome of ARI. Hand hygiene showed a 16% relative reduction in the number of participants with ARI (RR 0.84, 95% CI 0.82 to 0.86) in the intervention group. When we considered the more strictly defined outcomes of ILI and influenza, the RR for ILI was 0.98 (95% CI 0.85 to 1.14), and for influenza the RR was 0.91 (95% CI 0.61 to 1.34). Three trials measured absenteeism. We found a 36% relative reduction in absentee numbers in the hand hygiene group (RR 0.64, 95% CI 0.58 to 0.71). Comparison of different hand hygiene interventions did not favour one intervention type over another. We found no incremental effects of combining hand hygiene with using face masks or disinfecting surfaces or objects.CONCLUSIONSDespite the lack of evidence for the impact of hand hygiene in reducing ILI and influenza, the modest evidence for reducing the burden of ARIs, and related absenteeism, justifies reinforcing the standard recommendation for hand hygiene measures to reduce the spread of respiratory viruses. Funding for relevant trials with an emphasis on adherence and compliance with such a measure is crucial to inform policy and global pandemic preparedness with confidence and precision.

BackgroundPopulation trends in PSA screening and prostate cancer incidence do not perfectly correspond. We aimed to better understand relationships between trends in PSA screening, prostate cancer incidence and mortality in Australia.MethodsDescription of age standardised time trends in PSA tests, prostate biopsies, cancer incidence and mortality within Australia for the age groups: 45-74, 75-84, and 85+ years.ResultsPSA testing increased from its introduction in 1989 to a peak in 2008. It then declined in men aged 45-84 years. Prostate biopsies and cancer incidence declined from 1995 to 2000, in parallel with decrease in trans-urethral resections of prostate (TURP). After 2000, changes in biopsies and cancer incidence paralleled PSA screening in men 45-84 years, while in men ≥85 years, biopsies stabilised and incidence declined. More recently a reduction in TURP correlated with increased Dutasteride and Tamsulosin usage. Prostate cancer mortality in men aged 45-74 years remained low throughout. Mortality in men 75-84 years gradually increased until the mid 1990s, then gradually decreased. Mortality in men ≥85 years increased until the mid 1990s, then stabilised.ConclusionsAge specific prostate cancer incidence largely mirrors PSA screening rates. Most deviation may be explained by changes in management of benign prostatic disease and incidental cancer detection. The timing of the small mortality reduction in men 75-84 years is more consistent with benefits from advances in treatment than with early detection through PSA. The large increases in prostate cancer incidence with minimal changes in mortality suggest overdiagnosis.

ObjectiveIdentifying optimal strategies for managing patients of any age with varying risk of acute rheumatic fever (ARF) attending for an apparently uncomplicated acute sore throat, also clarifying the role of point-of-care testing (POCT) for presence of group A beta-haemolytic Streptococcus (GABHS) in these settings.DesignWe compared outcomes of adhering to nine different strategies for managing these patients in primary healthcare.Setting and participantsThe nine strategies, similar to guidelines from several countries, were tested against two validation data sets being constructs from seven prior studies.Main outcome measuresThe proportion of patients requiring a POCT, prescribed antibiotics, prescribed antibiotics having GABHS and finally having GABHS not prescribed antibiotics, if different strategies had been adhered to.ResultsIn a scenario with high risk of ARF, adhering to existing guidelines would risk many patients ill from GABHS left without antibiotics. Hence, using a POCT on all of these patients minimised their risk. For low-risk patients, it is reasonable to only consider antibiotics if the patient has more than low pain levels despite adequate analgesia, 3–4 Centor scores (or 2–3 FeverPAIN scores or 3–4 McIsaac scores) and a POCT confirming the presence of GABHS. This would require testing only 10%–15% of patients and prescribing antibiotics to only 3.5%–6.6%.ConclusionsPatients with high or low risk for ARF needs to be managed very differently. POCT can play an important role in safely targeting the use of antibiotics for patients with an apparently uncomplicated acute sore throat.

Background Little research has examined whether shared decision making (SDM) occurs in consultations for acute respiratory infections (ARIs), including what, and how, antibiotic benefits and harms are discussed. We aimed to analyse the extent and nature of SDM in consultations between GPs and patients with ARIs, and explore communication with and without the use of patient decision aids. Methods This was an observational study in Australian general practices, nested within a cluster randomised trial of decision aids (for acute otitis media [AOM], sore throat, acute bronchitis) designed for general practitioners (GPs) to use with patients, compared with usual care (no decision aids). Audio-recordings of consultations of a convenience sample of consenting patients seeing a GP for an ARI were independently analysed by two raters using the OPTION-12 (observing patient involvement in decision making) scale (maximum score of 100) and 5 items (about communicating evidence) from the Assessing Communication about Evidence and Patient Preferences (ACEPP) tool (maximum score of 5). Patients also self-completed a questionnaire post-consultation that contained items from CollaboRATE-5 (perceptions of involvement in the decision-making process), a decisional conflict scale, and a decision self-efficacy scale. Descriptive statistics were calculated for each measure. Results Thirty-six consultations, involving 13 GPs, were recorded (20 for bronchitis, 10 sore throat, 6 AOM). The mean (SD) total OPTION-12 score was 29.4 (12.5; range 4–54), with item 12 (need to review decision) the highest (mean = 3) and item 10 (eliciting patients’ preferred level of decision-making involvement) the lowest (mean = 0.1). The mean (SD) total ACEPP score was 2 (1.6), with the item about discussing benefits scoring highest. In consultations where a decision aid was used (15, 42%), compared to the 21 usual care consultations, mean observer-assessed SDM scores (OPTION-12, ACEPP scores) were higher and antibiotic harms mentioned in all (compared to only 1) consultations. Patients generally reported high decision involvement and self-efficacy, and low decisional conflict. Conclusions The extent of observer-assessed SDM between GPs and patients with ARIs was generally low. Balanced discussion of antibiotic benefits and harms occurred more often when decision aids were used. Electronic supplementary material The online version of this article (10.1186/s12875-018-0854-y) contains supplementary material, which is available to authorized users.

Background Acute otitis media (AOM) is an acute inflammation of the middle ear commonly found in children, for which antibiotics are frequently prescribed. However, antibiotics are beneficial for only one third of AOM cases, and then, with only modest benefit. Since antibiotic use leads to risk of side effects and resistance, effective alternative treatments are required. Corticosteroids are a candidate because of their anti-inflammatory effects, although evidence of their efficacy and harms is insufficient. Accordingly, we plan a large, rigorous clinical trial to test this. Initially, we will test pre-specified methods and procedures (including the overall process, resources, management, and scientific components) in a pilot study of corticosteroids for AOM, which will inform a future, definitive trial. Methods This is a pilot pragmatic, randomised, open-label, single-blind, controlled study of corticosteroids as either monotherapy or an addition to antibiotics in 60 children aged 6 months to 12 years with AOM in two cities (Jakarta and Bekasi) in Indonesia. We will randomise eligible children to prednisolone or control. We will also stratify by disease severity and randomise those with mild AOM to expectant observation plus prednisolone or observation alone and those with severe AOM to prednisolone plus antibiotic or antibiotic alone. Our outcomes are to determine (1) recruitment rates, (2) the success of the study procedures, (3) the ability to measure planned outcomes of the proposed main study, (4) the compliance to study visits and study medication, and (5) verification of the sample size calculation for the main study. We will also assess middle ear effusion using tympanometry as part of a mechanistic sub-study. Discussion This study will test all procedures in preparation for the main study, including several potential obstacles and challenges from the perspective of participating physicians, nurses, pharmacists, and the parents of eligible children. This information will be useful for developing strategies to overcome practical and procedural issues. This study may also provide information about the effects of corticosteroids on middle ear effusion in AOM. Trial registration Study registry number: ACTRN12618000049279. Name of registry: the Australian New Zealand Clinical Trials Registry (ANZCTR). Date of registration: 16 January 2018. Electronic supplementary material The online version of this article (10.1186/s40814-018-0337-x) contains supplementary material, which is available to authorized users.

Background Large quantities of antimicrobials are given to food animals, particularly in feed, potentially increasing antimicrobial resistance in humans. However, the magnitude of this effect is unclear. Methods We searched PubMed, Embase and Web of Science for studies on interventions that limited antimicrobial use in food animals, in any setting and context, to reduce antimicrobial resistance 1) in those food animals; and 2) in humans. We validated our strategy by testing whether it identified known relevant studies. Data from included studies were extracted into pre-designed and pilot-tested forms. Results We included 104 articles containing 93 studies. Heterogeneity (different animal species, environs, antimicrobial classes, interventions, administration routes, sampling, and methods), was considerable, precluding meta-analysis. The evidence was therefore synthesised narratively. A total of 89 studies (3 directly, 86 indirectly) addressed whether limiting antimicrobial exposure in food animals led to decreased antimicrobial resistance in those animals. The evidence was adequate to conclude this, although the magnitude of the effect could not be quantified. Four studies (1 directly, 3 indirectly) examined whether withdrawal of antibiotics changed resistance of potential pathogens in retail food for human consumption, and in bacteria of humans themselves. The direct (observational) study of broiler hatchery in ovo antimicrobial injection found a credible effect in terms of size reduction and time sequences. Interpretation Limiting antimicrobial use in food animals reduces antimicrobial resistance in food animals, and probably reduces antimicrobial resistance in humans. The magnitude of the effect cannot be quantified.