Type 2 Diabetes Mellitus is one of the most disabling chronic conditions worldwide, resulting in significant human, social and economic costs and placing huge demands on health care systems. The ...Inala Chronic Disease Management Service aims to improve the efficiency and effectiveness of care for patients with type 2 diabetes who have been referred by their general practitioner to a specialist diabetes outpatient clinic. Care is provided by a multidisciplinary, integrated team consisting of an endocrinologist, diabetes nurse educators, General Practitioner Clinical Fellows (general practitioners who have undertaken focussed post-graduate training in complex diabetes care), and allied health personnel (a dietitian, podiatrist and psychologist).
Using a geographical control, this evaluation study tests the impact of this model of diabetes care provided by the service on patient outcomes compared to usual care provided at the specialist diabetes outpatient clinic. Data collection at baseline, 6 and 12-months will compare the primary outcome (glycaemic control) and secondary outcomes (serum lipid profile, blood pressure, physical activity, smoking status, quality of life, diabetes self-efficacy and cost-effectiveness).
This model of diabetes care combines the patient focus and holistic care valued by the primary care sector with the specialised knowledge and skills of hospital diabetes care. Our study will provide empirical evidence about the clinical effectiveness of this model of care.
Australian New Zealand Clinical Trials Registry ACTRN12608000010392.
Climate change treatments – winter warming, summer drought and increased summer precipitation – have been imposed on an upland grassland continuously for 7 years. The vegetation was surveyed yearly. ...In the seventh year, soil samples were collected on four occasions through the growing season in order to assess mycorrhizal fungal abundance. Mycorrhizal fungal colonisation of roots and extraradical mycorrhizal hyphal (EMH) density in the soil were both affected by the climatic manipulations, especially by summer drought. Both winter warming and summer drought increased the proportion of root length colonised (RLC) and decreased the density of external mycorrhizal hyphal. Much of the response of mycorrhizal fungi to climate change could be attributed to climate‐induced changes in the vegetation, especially plant species relative abundance. However, it is possible that some of the mycorrhizal response to the climatic manipulations was direct – for example, the response of the EMH density to the drought treatment. Future work should address the likely change in mycorrhizal functioning under warmer and drier conditions.
Background
Concerns exist regarding antibiotic prescribing for respiratory tract infections (RTIs) owing to adverse reactions, cost and antibacterial resistance. One proposed strategy to reduce ...antibiotic prescribing is to provide prescriptions, but to advise delay in antibiotic use with the expectation that symptoms will resolve first. This is an update of a Cochrane Review originally published in 2007, and updated in 2010, 2013 and 2017.
Objectives
To evaluate the effects on duration and/or severity of clinical outcomes (pain, malaise, fever, cough and rhinorrhoea), antibiotic use, antibiotic resistance and patient satisfaction of advising a delayed prescription of antibiotics in respiratory tract infections.
Search methods
From May 2017 until 20 August 2022, this was a living systematic review with monthly searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL and Web of Science. We also searched the WHO International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov on 20 August 2022. Due to the abundance of evidence supporting the review's key findings, it ceased being a living systematic review on 21 August 2022.
Selection criteria
Randomised controlled trials involving participants of all ages with an RTI, where delayed antibiotics were compared to immediate or no antibiotics. We defined a delayed antibiotic as advice to delay the filling of an antibiotic prescription by at least 48 hours. We considered all RTIs regardless of whether antibiotics were recommended or not.
Data collection and analysis
We used standard Cochrane methodological procedures.
Main results
For this 2022 update, we added one new trial enrolling 448 children (436 analysed) with uncomplicated acute RTIs. Overall, this review includes 12 studies with a total of 3968 participants, of which data from 3750 are available for analysis. These 12 studies involved acute RTIs including acute otitis media (three studies), streptococcal pharyngitis (three studies), cough (two studies), sore throat (one study), common cold (one study) and a variety of RTIs (two studies). Six studies involved only children, two only adults and four included both adults and children. Six studies were conducted in primary care, four in paediatric clinics and two in emergency departments.
Studies were well reported and appeared to provide moderate‐certainty evidence. Randomisation was not adequately described in two trials. Four trials blinded the outcome assessor, and three included blinding of participants and doctors. We conducted meta‐analyses for pain, malaise, fever, adverse effects, antibiotic use and patient satisfaction.
Cough (four studies): we found no differences amongst delayed, immediate and no prescribed antibiotics for clinical outcomes in any of the four studies.
Sore throat (six studies): for the outcome of fever with sore throat, four of the six studies favoured immediate antibiotics, and two found no difference. For the outcome of pain related to sore throat, two studies favoured immediate antibiotics, and four found no difference. Two studies compared delayed antibiotics with no antibiotic for sore throat, and found no difference in clinical outcomes.
Acute otitis media (four studies): two studies compared immediate with delayed antibiotics ‐ one found no difference for fever, and the other favoured immediate antibiotics for pain and malaise severity on Day 3. Two studies compared delayed with no antibiotics: one found no difference for pain and fever severity on Day 3, and the other found no difference for the number of children with fever on Day 3.
Common cold (two studies): neither study found differences for clinical outcomes between delayed and immediate antibiotic groups. One study found delayed antibiotics were probably favoured over no antibiotics for pain, fever and cough duration (moderate‐certainty evidence).
Adverse effects: there were either no differences for adverse effects or results may have favoured delayed over immediate antibiotics with no significant differences in complication rates (low‐certainty evidence).
Antibiotic use: delayed antibiotics probably resulted in a reduction in antibiotic use compared to immediate antibiotics (odds ratio (OR) 0.03, 95% confidence interval (CI) 0.01 to 0.07; 8 studies, 2257 participants; moderate‐certainty evidence). However, a delayed antibiotic was probably more likely to result in reported antibiotic use than no antibiotics (OR 2.52, 95% CI 1.69 to 3.75; 5 studies, 1529 participants; moderate‐certainty evidence).
Patient satisfaction: patient satisfaction probably favoured delayed over no antibiotics (OR 1.45, 1.08 to 1.96; 5 studies, 1523 participants; moderate‐certainty evidence). There was probably no difference in patient satisfaction between delayed and immediate antibiotics (OR 0.77, 95% CI 0.45 to 1.29; 7 studies, 1927 participants; moderate‐certainty evidence).
No studies evaluated antibiotic resistance. Reconsultation rates and use of alternative medicines were similar for delayed, immediate and no antibiotic strategies. In one of the four studies reporting use of alternative medicines, less paracetamol was used in the immediate group compared to the delayed group.
Authors' conclusions
For many clinical outcomes, there were no differences between prescribing strategies. Symptoms for acute otitis media and sore throat were modestly improved by immediate antibiotics compared with delayed antibiotics. There were no differences in complication rates. Delaying prescribing did not result in significantly different levels of patient satisfaction compared with immediate provision of antibiotics (86% versus 91%; moderate‐certainty evidence). However, delay was favoured over no antibiotics (87% versus 82%). Delayed antibiotics achieved lower rates of antibiotic use compared to immediate antibiotics (30% versus 93%). The strategy of no antibiotics further reduced antibiotic use compared to delaying prescription for antibiotics (13% versus 27%).
Delayed antibiotics for people with acute respiratory infection reduced antibiotic use compared to immediate antibiotics, but was not shown to be different to no antibiotics in terms of symptom control and disease complications. Where clinicians feel it is safe not to prescribe antibiotics immediately for people with RTIs, no antibiotics with advice to return if symptoms do not resolve is likely to result in the least antibiotic use while maintaining similar patient satisfaction and clinical outcomes to delayed antibiotics. Where clinicians are not confident in not prescribing antibiotics, delayed antibiotics may be an acceptable compromise in place of immediate prescribing to significantly reduce unnecessary antibiotic use for RTIs, while maintaining patient safety and satisfaction levels.
Further research into antibiotic prescribing strategies for RTIs may best be focused on identifying patient groups at high risk of disease complications, enhancing doctors' communication with patients to maintain satisfaction, ways of increasing doctors' confidence to not prescribe antibiotics for RTIs, and policy measures to reduce unnecessary antibiotic prescribing for RTIs.
Background
Adolescent and young adult (AYA) women with sickle cell disease (SCD) have increased pregnancy‐related health risks and are prescribed potentially teratogenic medications, yet limited data ...are available regarding pediatric SCD provider contraceptive practices. We aimed to assess pediatric hematology providers’ beliefs, practices, motivators, and barriers for providing contraceptive care to female AYAs with SCD.
Methods
Guided by the Health Belief Model (HBM), we developed a 25‐question, web‐based survey to assess practices. Survey links were distributed nationwide to pediatric SCD and/or general hematology providers through their publicly available emails and by request to directors of U.S.‐accredited Pediatric Hematology‐Oncology fellowship programs for distribution to their SCD providers. Data analysis included descriptive statistics, chi‐square analysis, and logistic regression.
Results
Of 177 respondents, 160 surveys meeting inclusion criteria were analyzed. Most providers reported counseling (77.5%) and referring female AYA patients for contraception (90.8%), but fewer reported prescribing contraception (41.8%). Proportionally fewer trainees provided counseling compared with established providers (54% vs. 85%, p < .001), with a similar trend for prescribing (p = .05). Prescription practices did not differ significantly by provider beliefs regarding potential teratogenicity of hydroxyurea. Key motivators included patient request and disclosure of sexual activity. Key barriers included inadequate provider training, limited visit time, and perceived patient/parent interest.
Conclusion
Provider contraceptive practices for female AYAs with SCD varied, especially by provider status. Health beliefs regarding teratogenic potential of hydroxyurea did not correlate with contraceptive practices. Clinical guidelines, provider training, and patient/parent decision‐making tools may be tested to assess whether provider contraceptive practices could be improved.
Aged residential care (ARC) admission needs are increasing beyond the available capacity in many countries, including New Zealand. Therefore, identifying modifiable factors which may prevent or delay ...ARC admissions is of international importance. Hearing impairment is common among older adults and thought to be an important predictor, although the current evidence-base is equivocal. Using the largest national database to date, competing-risk regression analysis was undertaken on 34,277 older adults having standardised home care assessments between 1 July 2012 and 31 May 2014, aged ≥65 years, and still living in the community 30 days after that assessment. Minimal hearing difficulty was reported by 10,125 (29.5%) participants, moderate difficulty by 5,046 (14.7%), severe difficulty/no hearing by 1,334 (3.9%), while 17,769 (51.8%) participants reported adequate hearing. By 30 June 2014, the study end-point, 6,389 (18.6%) participants had an ARC admission while 6,082 (17.7%) had died. In unadjusted competing-risk regression analyses, treating death as a competing event, hearing ability was significantly associated with ARC admission (p < 0.001). However, in adjusted analyses, this relationship was completely confounded by other variables (p = 0.67). This finding implies that screening for hearing loss among community-living older adults is unlikely to impact on ARC admission rates.
1. The association between seed size and habitat shade within the British flora was investigated using a data set of seed masses, life histories and quantitative measures of habitat shade for 504 ...species; the association between seed size and seed longevity was investigated using a data set of seed masses, life histories and seed longevities for 301 species. 2. The data were analysed using the method of phylogenetically independent contrasts (PICs) calculated using the software package CAIC (Comparative Analysis by Independent Contrasts). 3. Seed mass was found to be positively correlated with habitat shade and negatively correlated with seed longevity, after variation owing to life history had been accounted for.
Suicide amongst Aboriginal and Torres Strait Islander people is a major cause of premature mortality and a significant contributor to the health and life expectancy gap. This study aimed to estimate ...the prevalence of thoughts of self-harm or suicide in Aboriginal and Torres Strait Islander people attending an urban primary health care service and identify factors associated with these thoughts. Multilevel mixed-effects modified Poisson regression models were employed to analyse three years of data gathered during the annual Aboriginal and Torres Strait Islander health assessments. At their first health assessment, 11.5% (191/1664) of people reported thoughts of suicide or self-harm in the prior two weeks. Having children, participating in sport or community activities or being employed full-time decreased the risk of such thoughts. Conversely, factors relating to social exclusion including homelessness, drug use, unemployment and job insecurity increased the risk of thoughts of self-harm or suicide. Individual clinicians, health services, and policy-makers all have a role in suicide prevention. Clinicians need appropriate training to be able to respond to people expressing these thoughts. Aboriginal and Torres Strait Islander community organisations need sovereignty and self-determination over resources to provide programs that promote cultural connectivity and address social exclusion, thereby saving lives.
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