Immediate oral versus immediate topical versus delayed oral antibiotics for children with acute otitis media with discharge: the REST three-arm non-inferiority electronic platform-supported RCT.

BACKGROUND: Acute otitis media is a painful infection of the middle ear that is commonly seen in children. In some children, the eardrum spontaneously bursts, discharging visible pus (otorrhoea) into the outer ear. OBJECTIVE: To compare the clinical effectiveness of immediate topical antibiotics or delayed oral antibiotics with the clinical effectiveness of immediate oral antibiotics in reducing symptom duration in children presenting to primary care with acute otitis media with discharge and the economic impact of the alternative strategies. DESIGN: This was a pragmatic, three-arm, individually randomised (stratified by age < 2 vs. ≥ 2 years), non-inferiority, open-label trial, with economic and qualitative evaluations, supported by a health-record-integrated electronic trial platform [TRANSFoRm (Translational Research and Patient Safety in Europe)] with an internal pilot. SETTING: A total of 44 English general practices. PARTICIPANTS: Children aged ≥ 12 months and < 16 years whose parents (or carers) were seeking medical care for unilateral otorrhoea (ear discharge) following recent-onset (≤ 7 days) acute otitis media. INTERVENTIONS: (1) Immediate ciprofloxacin (0.3%) solution, four drops given three times daily for 7 days, or (2) delayed 'dose-by-age' amoxicillin suspension given three times daily (clarithromycin twice daily if the child was penicillin allergic) for 7 days, with structured delaying advice. All parents were given standardised information regarding symptom management (paracetamol/ibuprofen/fluids) and advice to complete the course. COMPARATOR: Immediate 'dose-by-age' oral amoxicillin given three times daily (or clarithromycin given twice daily) for 7 days. Parents received standardised symptom management advice along with advice to complete the course. MAIN OUTCOME MEASURE: Time from randomisation to the first day on which all symptoms (pain, fever, being unwell, sleep disturbance, otorrhoea and episodes of distress/crying) were rated 'no' or 'very slight' problem (without need for analgesia). METHODS: Participants were recruited from routine primary care appointments. The planned sample size was 399 children. Follow-up used parent-completed validated symptom diaries. RESULTS: Delays in software deployment and configuration led to small recruitment numbers and trial closure at the end of the internal pilot. Twenty-two children (median age 5 years; 62% boys) were randomised: five, seven and 10 to immediate oral, delayed oral and immediate topical antibiotics, respectively. All children received prescriptions as randomised. Seven (32%) children fully adhered to the treatment as allocated. Symptom duration data were available for 17 (77%) children. The median (interquartile range) number of days until symptom resolution in the immediate oral, delayed oral and immediate topical antibiotic arms was 6 (4-9), 4 (3-7) and 4 (3-6), respectively. Comparative analyses were not conducted because of small numbers. There were no serious adverse events and six reports of new or worsening symptoms. Qualitative clinician interviews showed that the trial question was important. When the platform functioned as intended, it was liked. However, staff reported malfunctioning software for long periods, resulting in missed recruitment opportunities. Troubleshooting the software placed significant burdens on staff. LIMITATIONS: The over-riding weakness was the failure to recruit enough children. CONCLUSIONS: We were unable to answer the main research question because of a failure to reach the required sample size. Our experience of running an electronic platform-supported trial in primary care has highlighted challenges from which we have drawn recommendations for the National Institute for Health Research (NIHR) and the research community. These should be considered before such a platform is used again. TRIAL REGISTRATION: Current Controlled Trials ISRCTN12873692 and EudraCT 2017-003635-10. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 67. See the NIHR Journals Library website for further project information.

Ear infections are common in childhood. Some are complicated by a burst eardrum, followed by discharge from the ear. The usual treatment for this is a short course of antibiotics taken by mouth. However, alternative treatment using antibiotic drops, or a 'wait and see' policy before starting antibiotics, would result in less antibiotic use and reduce the subsequent risk of antibiotic resistance, which is bad for both patients and the environment. This study set out to see if these alternative treatments were as effective as the usual treatment for children with ear discharge. Although ear infections are common, only one in six children develops ear discharge, so only a few children might be available to take part at each general practice. We planned to use an electronic recruitment system to help us to gather enough patients. The system [called the 'TRANSFoRm' (Translational Research and Patient Safety in Europe) platform] was designed to remind busy general practitioners and nurses about the study and take them through the recruitment process step by step, as well as to support trial processes. Although the TRANSFoRm platform had been developed and tested, it had not been used in general practices before. We were surprised to find that there were many technical problems in setting up the TRANSFoRm platform in general practices, and staff were too busy and/or did not have the skills to overcome the technical issues. As a result, recruiting patients was slow and the study was halted before we had enough children to answer the main research question. In total, we managed to get 44 general practices and 22 children, but this was not enough. We still think that this kind of research and electronic trial platforms are important. We have noted many system and technical issues that need to be solved to enable funders and researchers to use this recruitment approach in the future.

Anaesthetic-analgesic ear drops to reduce antibiotic consumption in children with acute otitis media: the CEDAR RCT.

BACKGROUND: Acute otitis media (AOM) is a common reason for primary care consultations and antibiotic prescribing in children. Options for improved pain control may influence antibiotic prescribing and consumption. OBJECTIVE: The Children's Ear Pain Study (CEDAR) investigated whether or not providing anaesthetic-analgesic ear drops reduced antibiotic consumption in children with AOM. Secondary objectives included pain control and cost-effectiveness. DESIGN: A multicentre, randomised, parallel-group (two-group initially, then three-group) trial. SETTING: Primary care practices in England and Wales. PARTICIPANTS: 1- to 10-year-old children presenting within 1 week of suspected AOM onset with ear pain during the preceding 24 hours and not requiring immediate antibiotics. Participating children were logged into the study and allocated using a remote randomisation service. INTERVENTIONS: Two-group trial - unblinded comparison of anaesthetic-analgesic ear drops versus usual care. Three-group trial - blinded comparison of anaesthetic-analgesic ear drops versus placebo ear drops and unblinded comparison with usual care. MAIN OUTCOME MEASURES: The primary outcome measure was parent-reported antibiotic use by the child over 8 days following enrolment. Secondary measures included ear pain at day 2 and NHS and societal costs over 8 days. RESULTS: Owing to a delay in provision of the placebo drops, the recruitment period was shortened and most participants were randomly allocated to the two-group study (n = 74) rather than the three-group study (n = 32). Comparing active drops with usual care in the combined two-group and three-group studies, 1 out of 39 (3%) children allocated to the active drops group and 11 out of 38 (29%) children allocated to the usual-care group consumed antibiotics in the 8 days following enrolment [unadjusted odds ratio 0.09, 95% confidence interval (CI) 0.02 to 0.55; p = 0.009; adjusted for delayed prescribing odds ratio 0.15, 95% CI 0.03 to 0.87; p = 0.035]. A total of 43% (3/7) of patients in the placebo drops group consumed antibiotics by day 8, compared with 0% (0/10) of the three-group study active drops groups (p = 0.051). The economic analysis of NHS costs (£12.66 for active drops and £11.36 for usual care) leads to an estimated cost of £5.19 per antibiotic prescription avoided, but with a high degree of uncertainty. A reduction in ear pain at day 2 in the placebo group (n = 7) compared with the active drops group (n = 10) (adjusted difference in means 0.67, 95% CI -1.44 to 2.79; p = 0.51) is consistent with chance. No adverse events were reported in children receiving active drops. LIMITATIONS: Estimated treatment effects are imprecise because the sample size target was not met. It is not clear if delayed prescriptions of an antibiotic were written prior to randomisation. Few children received placebo drops, which hindered the investigation of ear pain. CONCLUSIONS: This study suggests that reduced antibiotic use can be achieved in children with AOM by combining a no or delayed antibiotic prescribing strategy with anaesthetic-analgesic ear drops. Whether or not the active drops relieved ear pain was not established. FUTURE WORK: The observed reduction in antibiotic consumption following the prescription of ear drops requires replication in a larger study. Future work should establish if the effect of ear drops is due to pain relief. TRIAL REGISTRATION: Current Controlled Trials ISRCTN09599764. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 34. See the NIHR Journals Library website for further project information. Alastair D Hay was funded by a NIHR Research Professorship (funding identifier NIHR-RP-02-12-012).

Ear infections are common in children < 10 years of age, with 40% of these children suffering from an ear infection at least once per year. During the infection, germs multiply in the confined space of the middle ear, resulting in a build-up of pressure that pushes on and stretches the ear drum. This causes severe pain and distress to the child, which in turn leads to disrupted family life. Although there is world-class evidence showing that antibiotics do not help, and the National Institute for Health and Care Excellence advises against their use, > 85% of UK children with middle ear infections (acute otitis media) are prescribed an antibiotic, which is a higher percentage than for any other childhood infection. Antibiotics do not treat the child's pain and, in most cases, they do not help to treat the infection (because many ear infections are caused by viruses that do not respond to antibiotics), but they can cause side effects (such as diarrhoea) and increase the problem of antibiotic resistance, which is a major public health concern. The Children's Ear Pain Study (CEDAR) wanted to find out whether or not painkilling ear drops [benzocaine­phenazone otic solution (Auralgan^®) currently manufactured by Pfizer Consumer Healthcare(Pfizer Inc., New York, NY USA)] can, by treating children's ear pain, reduce the number of parents giving their children antibiotics for acute otitis media. Children were given the painkilling drops, placebo (dummy) drops or usual care. The study found that, if the children were given the painkilling drops, significantly fewer of them were given antibiotics. Unfortunately, there were not enough children who took part in the study to change advice on how doctors treat ear infections. However, these results suggest that ear drops help reduce unnecessary antibiotic use and should be investigated in a further larger study.

Improving access to school based education for South African children in rural areas who have a tracheostomy: A case series and recommendations.

OBJECTIVES: Currently few children with tracheostomies attend rural mainstreams schools in South Africa limiting their ability to gain an education. We sought to document the current school experience for the few children attending school who have tracheostomies and devise educational tools for teachers and administrators that will facilitate greater acceptance and safety in classrooms for this population. METHODS: The four patients that are currently attending school with a tracheostomy were identified from the patient records of a tertiary hospital with a pediatric tracheostomy home based care service. With the aid of a Zulu language translator, the mothers and classroom teachers completed a semi structured interview and closed item questionnaire in their home and school, respectively. Schools were visited to understand and describe the settings in which the children and their teachers were being asked to function. Tools for education were developed in conjunction with key stakeholders at schools already hosting such children. RESULTS: The key teacher-identified barriers to enrollment were: teacher unfamiliarity with tracheostomies, uncertainty about the school's liability, and concerns about the response of other children. The safety barriers identified were: greater than 60 children per classroom - limiting teacher's ability to attend to the child with a tracheostomy, lack of running water, pit latrines separate from school threatening hygiene and isolating the child when they leave to use the latrines & sandy classrooms which can result in sand entering the airway. Identified needs for successful school placement include providing tracheostomy supplies and suctioning equipment, hand hygiene materials and training teachers in: identification of respiratory distress, performance of emergency tracheostomy changes, CPR. CONCLUSIONS: Children with tracheostomies could likely successfully attend South African rural mainstream public schools with a training program for teachers. As a first step, an introductory booklet for teachers that explains tracheostomies and provides educational and safety suggestions was created. A list of recommendations for successful inclusion of students in the school system was developed together with and delivered to key stakeholders.

Jasmonate and phytochrome A signaling in Arabidopsis wound and shade responses are integrated through JAZ1 stability.

Jasmonate (JA) activates plant defense, promotes pollen maturation, and suppresses plant growth. An emerging theme in JA biology is its involvement in light responses; here, we examine the interdependence of the JA- and light-signaling pathways in Arabidopsis thaliana. We demonstrate that mutants deficient in JA biosynthesis and signaling are deficient in a subset of high irradiance responses in far-red (FR) light. These mutants display exaggerated shade responses to low, but not high, R/FR ratio light, suggesting a role for JA in phytochrome A (phyA) signaling. Additionally, we demonstrate that the FR light-induced expression of transcription factor genes is dependent on CORONATINE INSENSITIVE1 (COI1), a central component of JA signaling, and is suppressed by JA. phyA mutants had reduced JA-regulated growth inhibition and VSP expression and increased content of cis-(+)-12-oxophytodienoic acid, an intermediate in JA biosynthesis. Significantly, COI1-mediated degradation of JASMONATE ZIM DOMAIN1-beta-glucuronidase (JAZ1-GUS) in response to mechanical wounding and JA treatment required phyA, and ectopic expression of JAZ1-GUS resulted in exaggerated shade responses. Together, these results indicate that JA and phyA signaling are integrated through degradation of the JAZ1 protein, and both are required for plant responses to light and stress.

Effect of magnetic fields on cryptochrome-dependent responses in Arabidopsis thaliana.

The scientific literature describing the effects of weak magnetic fields on living systems contains a plethora of contradictory reports, few successful independent replication studies and a dearth of plausible biophysical interaction mechanisms. Most such investigations have been unsystematic, devoid of testable theoretical predictions and, ultimately, unconvincing. A recent study, of magnetic responses in the model plant Arabidopsis thaliana, however, stands out; it has a clear hypothesis-that seedling growth is magnetically sensitive as a result of photoinduced radical-pair reactions in cryptochrome photoreceptors-tested by measuring several cryptochrome-dependent responses, all of which proved to be enhanced in a magnetic field of intensity 500 muT. The potential importance of this study in the debate on putative effects of extremely low-frequency electromagnetic fields on human health prompted us to subject it to the 'gold standard' of independent replication. With experimental conditions chosen to match those of the original study, we have measured hypocotyl lengths and anthocyanin accumulation for Arabidopsis seedlings grown in a 500 microT magnetic field, with simultaneous control experiments at 50 microT. Additionally, we have determined hypocotyl lengths of plants grown in 50 microT, 1 mT and approximately 100 mT magnetic fields (with zero-field controls), measured gene (CHS, HY5 and GST) expression levels, investigated blue-light intensity effects and explored the influence of sucrose in the growth medium. In no case were consistent, statistically significant magnetic field responses detected.

4-(1,3-Thiazol-2-yl)morpholine derivatives as inhibitors of phosphoinositide 3-kinase.

4-(1,3-Thiazol-2-yl)morpholine derivatives have been identified as potent and selective inhibitors of phosphoinositide 3-kinase. The SAR data of selected examples are presented and the in vivo profiling of compound 18 is shown to demonstrate the utility of this class of compounds in xenograft models of tumor growth.

COPD and coping with breathlessness at home: a review of the literature.

Patients with COPD and their partners often feel isolated while trying to cope with the psychological and physical effects of their condition and the change in their quality of life. Research studies support the fact that some patients with COPD cope better with their breathlessness at home with appropriate community support. This support may be provided by nurses and other health professionals. However, there appears to be an imbalance in the provision of community support/palliative care for COPD patients who have a life-limiting illness compared to other patients with a life limiting illness and a cancer diagnosis. Where 'hospital at home' and support in the community for COPD patients occurs it is provided in many different ways and has been shown to reduce the necessity for acute hospital admissions.

Pulsed low intensity ultrasound enhances mineralisation in preosteoblast cells.

Pulsed low intensity ultrasound has been shown to be highly efficacious in the treatment of nonunion fractures and in the acceleration of fresh fracture healing. MC3T3-E1 subclone 14 cells were cultured for up to 25 days either with or without a daily treatment with low intensity pulsed ultrasound. It was determined that, on day 10 there was a dramatic increase in alkaline phosphatase and MMP-13 mRNA levels detected in ultrasound-treated cultures compared with untreated controls. The activity of alkaline phosphatase was significantly increased at days 6, 8 and 10. On day 10, the amount of mineralisation within cultures, assessed using alizarin red staining, was significantly increased in ultrasound-treated cultures compared with untreated controls. These results suggest that one of the mechanisms that low intensity pulsed ultrasound has on fracture repair is to enhance the process of endochondral ossification where the soft callus is converted to mineralised hard callus.

Is our student portfolio valued?

A student portfolio was introduced for pre-registration nursing students at the University of Glamorgan in October 1997. The impetus for doing so was the recognised need to address:the 'theory-practice' divide;the need to provide nurse students with skills that will enable them to maintain the Professional Profile for registration purposes (). This article reports a research study evaluating the student portfolio. The main objectives of the evaluation were to investigate whether the portfolio addressed the perceived needs and to identify if students were experiencing potential benefits by using the portfolio. Semi-structured interviews and focus groups were conducted with students and staff about their usage and perceptions of the portfolio. These findings were used to inform the design of the questionnaire to investigate students' experiences of using the portfolio, and their views about its usefulness. The questionnaires (n=219) confirmed the impression that students are not making frequent use of the portfolio. Students mainly discussed sections relating to academic aspects of the course. The summative assessment (essays) section was discussed by the greatest proportion of students (51% n=108). More students (74%) felt that too little time was spent on the portfolio than any other aspect of the course. Although many students and staff appreciate the potential value of using the portfolio, it is not a requirement of the course and so tends not to be treated as a high priority. Many of the recommendations from this study focussed on ways of integrating the portfolio into the course in order to increase its use. The results of this study have informed the development of an All Wales Student Portfolio introduced in April 2002 (Welsh Assembly Government, 2002).

Hair follicle dermal cells repopulate the mouse haematopoietic system.

Skin and hair follicle stem cell biology is the focus of increasing interest, not least because the adult hair follicle has well defined dermal and epithelial populations that display distinct developmental properties. Recent evidence suggests that a number of adult cell populations have much broader stem cell capabilities than previously thought. To examine whether this applied to the hair follicle, and with a view to developing the follicle as a stem cell model system we investigated whether adult hair follicles were capable of demonstrating haematopoietic stem cell activity. To investigate haematopoietic activity in hair follicles we first used in vitro haematopoietic colony assays. This demonstrated that rodent hair follicle end bulbs as well as micro-dissected dermal papilla and dermal sheath cells actively produced cells of erythroid and myeloid lineages but that follicle epithelial cells did not. As a more stringent test, we then transplanted cultured dermal papilla or dermal sheath cells from transgenically marked donor mice into lethally irradiated recipient mice and observed multi-lineage haematopoietic reconstitution when assayed at intervals of up to one year. Colony assays from bone marrow of primary recipients revealed that over 70% of clonogenic precursors were derived from donor hair follicle cells. When bone marrow from primary mice was harvested and used to repopulate secondary myeloablated recipients, multi-lineage haematopoietic engraftment was observed. Our data show that dermal but not epidermal compartments of the adult hair follicle have much broader stem cell activities than previously described. Although the treatment for many forms of blood disorder, such as leukemia, often requires transplantation of haematopoietic stem cells (HSC), their availability can be rate limiting. Given its easy accessibility, our identification of the hair follicle as a source of extramedullary haematopoietic stem cell activity makes it an attractive potential source for blood stem cell therapeutics and highlights its value as a model system in adult stem cell biology.