Immediate versus delayed versus no antibiotics for respiratory infections.

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.

3-Domains screening toolkit for medical assessment of older drivers: Feasibility study in Australian general practice.

BACKGROUND AND OBJECTIVES: Some general practitioners (GPs) find the older driver medical assessment challenging, citing clinical uncertainty and concerns about communicating the need for further testing or driving cessation while maintaining a trusting therapeutic relationship. A screening toolkit could help support GP decision making and communication about fitness to drive. The aim of this study was to investigate the feasibility, acceptability and utility of the 3-Domains screening toolkit for the medical assessment of older drivers in Australian general practice. METHOD: A prospective mixed-methods study was conducted in nine general practices in south-east Queensland. Participants were older drivers (age ≥75 years) attending annual driving licence medical assessment, GPs and practice nurses. The 3-Domains toolkit comprises three screening tests (Snellen chart visual acuity, functional reach, road signs recognition). We evaluated the feasibility, acceptability and utility of the toolkit. RESULTS: Practices used the toolkit in 43 older driver medical assessments (age 75-93 years; combined predictive score 13-96%). Twenty-two semistructured interviews were conducted. Older drivers felt reassured by the thorough assessment. GPs said the toolkit fitted into practice workflows, informed clinical judgement and supported conversations about fitness to drive while preserving therapeutic relationships. DISCUSSION: The 3-Domains screening toolkit is feasible, acceptable and useful for the medical assessment of older drivers in Australian general practice.

Influencing Factors to mHealth Uptake With Indigenous Populations: Qualitative Systematic Review.

BACKGROUND: The advancements and abundance of mobile phones and portable health devices have created an opportunity to use mobile health (mHealth) for population health systems. There is increasing evidence for the feasibility and acceptance of mHealth with Indigenous populations. Providing a synthesis of qualitative findings of mHealth with Indigenous populations will gain insights into the strengths and challenges to mHealth use in Indigenous populations. OBJECTIVE: This review aimed to identify and synthesize qualitative data pertaining to the experiences and perceptions of mHealth from the perspectives of end users (patients and service providers) living in the colonial settler democracies of Canada, Australia, New Zealand, the United States, the Pacific Islands, and the Sápmi region of northern Europe. METHODS: In May 2021, systematic searches of peer-reviewed, scientific papers were conducted across the 5 databases of PubMed, CINAHL, Embase, PsycINFO, and Web of Science. Qualitative or mixed method studies were included where a mHealth intervention was the primary focus for responding to health challenges with Indigenous populations. Two authors independently screened papers for eligibility and assessed the risk of bias using a modified version of the Critical Appraisal Skills Programme. A meta-aggregative approach was used to analyze the findings of included studies. RESULTS: Seventeen papers met the eligibility criteria, 8 studies with patients, 7 studies with service providers, and 2 studies that included both patients and service providers. Studies were conducted in Australia (n=10), Canada (n=2), New Zealand (n=2), Papua New Guinea (n=1), the United States (n=1), and Samoa (n=1). Our interpretation of these qualitative findings shows commonalities between Indigenous patients' and service providers' perceptions of mHealth. We summarize our findings in six themes: (1) mHealth literacy, (2) mHealth as a facilitator for connection and support, (3) mHealth content needed to be culturally relevant, (4) mHealth security and confidentiality, (5) mHealth supporting rather than replacing service providers, and (6) workplace and organizational capacity. CONCLUSIONS: This research suggests that mHealth can meet the needs of both patients and service providers when the mHealth intervention is culturally relevant, accounts for digital and health literacy, incorporates interactive components, is supported by workplaces, fits into health provider workflows, and meets security and confidentiality standards. Future mHealth research with Indigenous populations should partner with key representatives (eg, patients, service providers, and executive leaders) in the mHealth design appropriate to the purpose, people, setting, and delivery.

The acceptability and utility of Indigenous youth health assessments: a narrative systematic review.

BACKGROUND: Indigenous youth are navigating the transition from childhood to adulthood while contending with challenges of ongoing colonisation and everyday lived experiences of racism. A comprehensive assessment of Indigenous youth's health could enable early diagnosis and respond to health concerns. This narrative systematic review synthesises evidence about the acceptability and utility of primary health care-based health assessments for improving the health and wellbeing of Indigenous youth. METHODS: A systematic search strategy was conducted using 20 electronic databases. Studies were included if they reported on health assessments conducted in primary health care with youth aged 12-24years who were Indigenous to Australia, New Zealand, Canada, the USA, Taiwan, and the arctic regions of Scandinavia and Russia. A narrative synthesis was undertaken. RESULTS: Of 3061 unique studies identified, seven met the eligibility criteria. Included studies showed that youth health assessments were useful for making new diagnoses, detecting social and emotional wellbeing concerns, and biomedical parameters. Co-created health assessments with Indigenous youth conducted by clinicians familiar to the community were well accepted. Digital health assessments administered using an electronic tablet provide advantages. No health outcomes were reported. Additionally, no health assessments addressed the impacts of colonisation and racism. CONCLUSION: There is insufficient evidence to make firm conclusions about the benefits of health assessments; however, health assessments can be useful for detecting new diagnoses and concerns regarding social determinants of health, and social and emotional wellbeing. Future development of Indigenous youth health assessments needs to involve Indigenous youth's perspectives and interpretations of health.

Challenges of conducting kidney health checks among patients at risk of chronic kidney disease and attending an urban Aboriginal and Torres Strait Islander primary healthcare service.

BACKGROUND: The increasing incidence of chronic kidney disease (CKD) globally highlights the importance of early targeted screening of at-risk persons in primary healthcare settings. This study investigated the early detection of CKD among Aboriginal and Torres Strait Islander patients attending an urban primary healthcare service. METHODS: Routine data extracted for all patients with an active electronic medical record on 7 December 2017 were used to identify patients who were eligible to have a kidney health check (KHC), comprising estimated glomerular filtration rate (eGFR) and urine albumin creatinine ratio (UACR) tests. A subsequent manual search of electronic health records identified the presence of CKD risk factors and follow-up KHCs. RESULTS: Of the 1181 eligible patients, 171 (15%) had a complete initial KHC. Of the eight patients with an initial abnormal eGFR, two (25%) had a repeat eGFR assessment within 3 months to confirm the presence of CKD. Of the 30 patients who had an initial abnormal UACR result, three (10%) had at least one repeat UACR measurement within 3 months. In patients with diabetes and/or hypertension and a normal initial KHC, 51% had a repeat eGFR and 36% had UACR within the recommended time frame of 12 months. Similar findings were observed for the recommended time frame of 24 months in patients without diabetes or hypertension. CONCLUSION: Accurate documentation of risk factors for CKD and processes to address the barriers to implementation of Kidney Health Australia guidelines will assist in preventing or delaying progression of CKD.

INFLATE: a protocol for a randomised controlled trial comparing nasal balloon autoinflation to no nasal balloon autoinflation for otitis media with effusion in Aboriginal and Torres Strait Islander children.

BACKGROUND: Otitis media with effusion (OME) is common and occurs at disproportionately higher rates among Indigenous children. Left untreated, OME can negatively affect language, development, learning, and health and wellbeing throughout the life-course. Currently, OME care includes observation for 3 months followed by consideration of surgical ventilation tube insertion. The use of a non-invasive, low-cost nasal balloon autoinflation device has been found beneficial in other populations but has not been investigated among Aboriginal and Torres Strait Islander children. METHODS/DESIGN: This multi-centre, open-label, randomised controlled trial will determine the effectiveness of nasal balloon autoinflation compared to no nasal balloon autoinflation, for the treatment of OME among Aboriginal and Torres Strait Islander children in Australia. Children aged 3-16 years with unilateral or bilateral OME are being recruited from Aboriginal Health Services and the community. The primary outcome is the proportion of children showing tympanometric improvement of OME at 1 month. Improvement is defined as a change from bilateral type B tympanograms to at least one type A or C1 tympanogram, or from unilateral type B tympanogram to type A or C1 tympanogram in the index ear, without deterioration (type A or C1 to type C2, C3, or B tympanogram) in the contralateral ear. A sample size of 340 children (170 in each group) at 1 month will detect an absolute difference of 15% between groups with 80% power at 5% significance. Anticipating a 15% loss to follow-up, 400 children will be randomised. The primary analysis will be by intention to treat. Secondary outcomes include tympanometric changes at 3 and 6 months, hearing at 3 months, ear health-related quality of life (OMQ-14), and cost-effectiveness. A process evaluation including perspectives of parents or carers, health care providers, and researchers on trial implementation will also be undertaken. DISCUSSION: INFLATE will answer the important clinical question of whether nasal balloon autoinflation is an effective and acceptable treatment for Aboriginal and Torres Strait Islander children with OME. INFLATE will help fill the evidence gap for safe, low-cost, accessible OME therapies. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry ACTRN12617001652369 . Registered on 22 December 2017. The Australia New Zealand Clinical Trials Registry is a primary registry of the WHO ICTRP network and includes all items from the WHO Trial Registration data set. Retrospective registration.

Mixed-methods evaluation of screening for hearing loss using the hearScreen™ mobile health application in Aboriginal and Torres Strait Islander children presenting to an urban primary healthcare service.

Recommendations for hearing screening for Aboriginal and Torres Strait Islander children aged 4 years have a limited evidence base. Using the hearScreen™ (HearX, Camden, DE, USA) mobile health application as part of a mixed-methods study, the aim of this study was to assess the proportion of 4-year-old Aboriginal and Torres Strait Islander children with hearing difficulties, as well as the feasibility and acceptability of the test itself. Of the 145 4-year-old Aboriginal and Torres Strait Islander children who were regular patients of the service during the recruitment period, 50 were recruited to the present study. Of these 50 children, 42 (84%) passed the hearing screening test, 4 (8%) did not and 4 (8%) were unable to complete the test. Nine caregivers were interviewed. Themes included the priority given to children's health by caregivers, positivity and trust in the test, preference for having the test conducted in primary care and the importance of an Aboriginal and Torres Strait Islander person providing the screening test. These findings lend support to hearing screening for school-age children in primary care provided by an Aboriginal and Torres Strait Islander healthcare worker using the hearScreen™ test.

Rapid review of five years of Aboriginal and Torres Strait Islander health research in Australia - persisting under-representation of urban populations.

OBJECTIVE: To review how published Aboriginal and Torres Strait Islander health research reflects the geographical distribution of the Indigenous population of Australia. METHODS: Rapid review using Lowitja Institute Lit.search tool for PubMed indexed Indigenous health research papers (January 2013 to January 2018). Geographic location, participant age, study type and recruitment site were identified for each paper. RESULTS: A total of 1,258 research papers were identified: 190 (15%) focused exclusively on Indigenous people living in urban areas; 563 (45%) in rural/remote areas; and 505 (40%) spanned urban and rural/remote areas. Despite similar burdens of disease, three times as many papers were published per 1,000 DALYs for rural/remote areas than urban areas. CONCLUSIONS: Indigenous health research publications have more than doubled since 2010. However, research focusing on the health needs of urban Indigenous people remains low relative to disease burden and population. Implications for public health: More research to address the health needs of Indigenous people living in urban areas is required although this should not be at the expense of research for rural and remote areas. Increased funding quarantined for Indigenous health research, coupled with self-determination of the research agenda and reporting on the geographic representativeness of research, may help address geographical inequities in research outputs.

Factors Associated with Thoughts of Self-Harm or Suicide among Aboriginal and Torres Strait Islander People Presenting to Urban Primary Care: An Analysis of De-Identified Clinical Data.

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.

Systems integration to promote the mental health of Aboriginal and Torres Strait Islander children: protocol for a community-driven continuous quality improvement approach.

BACKGROUND: Systems integration to promote the mental health of Aboriginal and Torres Strait Islander children works towards developing a spectrum of effective, community-based services and supports. These services and supports are organised into a coordinated network, build meaningful partnerships with families and address their cultural and linguistic needs, to help children to function better at home, in school, in the community, and throughout life. This study is conducted in partnership with primary healthcare (PHC) and other services in three diverse Indigenous Australian communities. It entails conceptualising, co-designing, implementing, and evaluating the effectiveness of systems integration to promote the mental health and wellbeing of Indigenous school-aged children (4-17 years). This paper outlines a protocol for implementing such complex community-driven research. METHODS/DESIGN: Using continuous quality improvement processes, community co-designed strategies for improved systems integration will be informed by narratives from yarning circles with Indigenous children and service providers, and quantitative data from surveys of service providers and audits of PHC client records and intersectoral systems. Agreed strategies to improve the integration of community-based services and supports will be modelled using microsimulation software, with a preferred model implemented in each community. The evaluation will investigate changes in the: 1) availability of services that are community-driven, youth-informed and culturally competent; 2) extent of collaborative service networks; 3) identification by PHC services of children's social and emotional wellbeing concerns; and 4) ratio of children receiving services to identified need. Costs and benefits of improvements to systems integration will also be calculated. DISCUSSION: The study will provide evidence-informed, community-driven, and tested models that can be used for implementing systems integration to promote the mental health and wellbeing of Indigenous children. It will identify the situational enablers and barriers that impact systems integration and determine the extent to which systems integration improves service availability, systems and child outcomes. Evidence for the cost effectiveness of systems-level integration will contribute to national mental health policy reform.

Visual impairment among Aboriginal and Torres Strait Islander patients attending an Australian Indigenous primary health service: a cross-sectional study.

This cross-sectional study aimed to identify the period prevalence of visual impairment (VI) and blindness among Aboriginal and Torres Strait Islander people attending an Indigenous urban primary healthcare service, eye care practitioner referrals for those with VI and any opportunities to improve care delivery. Visual acuity (VA) examinations, using a Snellen chart, are performed as part of routine annual health assessments offered to children and adults. This study included patients aged ≥5 years (n=1442) who had a health assessment conducted between 1 January 2015 and 31 December 2016 and provided consent for the use of their health assessment information for research. Of patients with available data, 2.4% (33/1374) experienced VI, defined as presenting VA worse than 6/12 to 6/60 in the better-seeing eye. VI was more common in those aged ≥60 years (14/136; 10.3%) and was significantly associated with increasing age (P<0.001). No patients experienced blindness, defined as presenting VA worse than 6/60 in the better-seeing eye. All patients with VI were aged ≥16 years. Nine (27%) of the 33 patients with VI in the better-seeing eye were referred to an optometrist or an ophthalmologist. The low period prevalence of VI and no blindness in this study are positive findings. The findings also indicate that routine VA testing of older adults, especially those aged ≥60 years, should be conducted to avoid missing those not having an annual health assessment.

Identifying inequities in an urban Latin American population: a cross-sectional study in Australian primary health care.

In Australia, people from culturally and linguistically diverse backgrounds often face inequitable health outcomes and access to health care. An important, but under-researched, population is people of Latin American descent. A cross-sectional study obtained clinical data on Latin American Spanish-speaking patients from Brisbane's south-west. Extracted data included demographic characteristics, risk factors, chronic disease and service use. A total of 382 people (60.5% female, 39.5% male), mainly from El Salvador and Chile and predominantly older people (70% over 50 years), were identified. Compared with the general Australian population, the proportion of people with dyslipidaemia, diabetes, arthritis and musculoskeletal, mental health disorders and being obese or overweight was high. There was also a higher use of the 20-40min general medicine consultation than in the general population. The proportion of patients receiving health promotion and chronic disease management activities was higher than in other reports. However, there were gaps in the provision of these services. The study shows an ageing population group with significant risk factors and an important burden of chronic disease and comorbidity. Addressing inequalities in health for culturally and linguistically diverse populations demands improvements in healthcare delivery and targeted actions based on a solid understanding of their complex health needs and their health, social and cultural circumstances.

Adaptation of potentially preventable medication-related hospitalisation indicators for Indigenous populations in Australia using a modified Delphi technique.

OBJECTIVES: One of the outcomes of a medication review service is to identify and manage medication-related problems (MRPs). The most serious MRPs may result in hospitalisation, which could be preventable if appropriate processes of care were adopted. The aim of this study was to update and adapt a previously published set of clinical indicators for use in assessing the effectiveness of a medication review service tailored to meet the needs of Indigenous people, who experience some of the worst health outcomes of all Australians. DESIGN: A modified Delphi technique was used to: (i) identify additional indicators for consideration, (ii) assess whether the original indicators were relevant in the context of Indigenous health and (iii) reach consensus on a final set of indicators. Three rounds of rating were used via an anonymous online survey, with 70% agreement required for indicator inclusion. SETTING: The indicators were designed for use in Indigenous primary care in Australia. PARTICIPANTS: Thirteen panellists participated including medical specialists, general practice doctors, pharmacists and epidemiologists experienced in working with Indigenous patients. RESULTS: Panellists rated 101 indicators (45 from the original set and 57 newly identified). Of these, 41 were accepted unchanged, seven were rejected and the remainder were either modified before acceptance or merged with other indicators. A final set of 81 indicators was agreed. Conclusions This study provides a set of clinical indicators to be used as a primary outcome measure for medication review services for Indigenous people in Australia and as a prompt for pharmacists and doctors conducting medication reviews. TRIAL REGISTRATION NUMBER: The trial registration for the Indigenous Medication Review Service feasibility study is ACTRN12618000188235.

Knowing our patients: a cross-sectional study of adult patients attending an urban Aboriginal and Torres Strait Islander primary healthcare service.

Many Aboriginal and Torres Strait Islander people live in urban areas, but epidemiological data about their health status and health needs are lacking. This knowledge is critical to informing and evaluating initiatives to improve service delivery and health outcomes. One potential data source is de-identified routinely collected clinical data. This cross-sectional study, conducted in an urban Aboriginal and Torres Strait Islander primary healthcare service, involved randomly selecting a sample of 400 patients aged ≥15 years, and manually extracting electronic health record data. In the sample, 49% of patients were aged <35 years, 56% were female and 38% were employed. Overall, 56% of females and 47% of males aged 35-54 years had depression, 26% had experienced a bereavement within the last 12 months, and while 44% were alcohol abstainers, 35% were drinking at high-risk levels. The present study cannot demonstrate causal relationships between the observed high rates of chronic disease in older people and frequent experiences of bereavement and high levels of mental ill health in young- and middle-aged adults. However, a life course approach provides a framework to understand the interconnectedness of these results, and suggests that strategies to blunt the intergenerational burden of chronic disease need to address the social and emotional wellbeing of youth.

Unlocking the value of Cochrane reviews for general practitioners.

BACKGROUND: Cochrane reviews are difficult to construct and may be difficult to read, but they produce trusted, high-quality research responses to common clinical questions. OBJECTIVE: The objective of this article is to help clinicians navigate the Cochrane Library and Cochrane reviews. Using a common clinical scenario, we illustrate how to find the information required to guide evidence-based decision making with patients. DISCUSSION: Clinicians looking for answers to clinical questions often turn first to guidelines. However, these may not provide enough background to balance the pros and cons of a treatment. Cochrane reviews often inform guidelines and contain more in-depth clinical information for shared decision making. The introduction of Summary of Findings (SoF) tables has made the studies in Cochrane reviews more accessible. In this paper, we discuss how to read and interpret these SoF tables. Additional resources, such as journal summaries and podcasts, have also improved the accessibility of Cochrane review findings.

Delayed antibiotic prescriptions for respiratory infections.

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 and 2013. OBJECTIVES: To evaluate the effects on clinical outcomes, antibiotic use, antibiotic resistance, and patient satisfaction of advising a delayed prescription of antibiotics in respiratory tract infections. SEARCH METHODS: For this 2017 update we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, Issue 4, 2017), which includes the Cochrane Acute Respiratory Infection Group's Specialised Register; Ovid MEDLINE (2013 to 25 May 2017); Ovid Embase (2013 to 2017 Week 21); EBSCO CINAHL Plus (1984 to 25 May 2017); Web of Science (2013 to 25 May 2017); WHO International Clinical Trials Registry Platform (1 September 2017); and ClinicalTrials.gov (1 September 2017). SELECTION CRITERIA: Randomised controlled trials involving participants of all ages defined as having an RTI, where delayed antibiotics were compared to immediate antibiotics 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. Three review authors independently extracted and collated data. We assessed the risk of bias of all included trials. We contacted trial authors to obtain missing information. MAIN RESULTS: For this 2017 update we added one new trial involving 405 participants with uncomplicated acute respiratory infection. Overall, this review included 11 studies with a total of 3555 participants. These 11 studies involved acute respiratory infections 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 (one study). Five studies involved only children, two only adults, and four included both adults and children. Six studies were conducted in a primary care setting, three in paediatric clinics, and two in emergency departments.Studies were well reported, and appeared to be of moderate quality. Randomisation was not adequately described in two trials. Four trials blinded the outcomes assessor, and three included blinding of participants and doctors. We conducted meta-analysis for antibiotic use and patient satisfaction.We found no differences among delayed, immediate, and no prescribed antibiotics for clinical outcomes in the three studies that recruited participants with cough. For the outcome of fever with sore throat, three of the five studies favoured immediate antibiotics, and two found no difference. For the outcome of pain related to sore throat, two studies favoured immediate antibiotics, and three found no difference. One study compared delayed antibiotics with no antibiotic for sore throat, and found no difference in clinical outcomes.Three studies included participants with acute otitis media. Of the two studies with an immediate antibiotic arm, one study found no difference for fever, and the other study favoured immediate antibiotics for pain and malaise severity on Day 3. One study including participants with acute otitis media compared delayed antibiotics with no antibiotics and found no difference for pain and fever on Day 3.Two studies recruited participants with common cold. Neither study found differences for clinical outcomes between delayed and immediate antibiotic groups. One study favoured delayed antibiotics over no antibiotics for pain, fever, and cough duration (moderate quality evidence for all clinical outcomes - GRADE assessment).There were either no differences for adverse effects or results favoured delayed antibiotics over immediate antibiotics (low quality evidence - to GRADE assessment) with no significant differences in complication rates. Delayed antibiotics resulted in a significant reduction in antibiotic use compared to immediate antibiotics prescription (odds ratio (OR) 0.04, 95% confidence interval (CI) 0.03 to 0.05). However, a delayed antibiotic was more likely to result in reported antibiotic use than no antibiotics (OR 2.55, 95% CI 1.59 to 4.08) (moderate quality evidence - GRADE assessment).Patient satisfaction favoured delayed over no antibiotics (OR 1.49, 95% CI 1.08 to 2.06). There was no significant difference in patient satisfaction between delayed antibiotics and immediate antibiotics (OR 0.65, 95% CI 0.39 to 1.10) (moderate quality evidence - GRADE assessment).None of the included studies evaluated antibiotic resistance. 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 quality evidence). However, delay was favoured over no antibiotics (87% versus 82%). Delayed antibiotics achieved lower rates of antibiotic use compared to immediate antibiotics (31% versus 93%) (moderate quality evidence). The strategy of no antibiotics further reduced antibiotic use compared to delaying prescription for antibiotics (14% versus 28%). 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 respiratory infections, 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 delaying prescription of antibiotics. Where clinicians are not confident in using a no antibiotic strategy, a delayed antibiotics strategy may be an acceptable compromise in place of immediate prescribing to significantly reduce unnecessary antibiotic use for RTIs, and thereby reduce antibiotic resistance, while maintaining patient safety and satisfaction levels.Editorial note: As a living systematic review, this review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.