Public preferences for delayed or immediate antibiotic prescriptions in UK primary care: A choice experiment.

BACKGROUND: Delayed (or "backup") antibiotic prescription, where the patient is given a prescription but advised to delay initiating antibiotics, has been shown to be effective in reducing antibiotic use in primary care. However, this strategy is not widely used in the United Kingdom. This study aimed to identify factors influencing preferences among the UK public for delayed prescription, and understand their relative importance, to help increase appropriate use of this prescribing option. METHODS AND FINDINGS: We conducted an online choice experiment in 2 UK general population samples: adults and parents of children under 18 years. Respondents were presented with 12 scenarios in which they, or their child, might need antibiotics for a respiratory tract infection (RTI) and asked to choose either an immediate or a delayed prescription. Scenarios were described by 7 attributes. Data were collected between November 2018 and February 2019. Respondent preferences were modelled using mixed-effects logistic regression. The survey was completed by 802 adults and 801 parents (75% of those who opened the survey). The samples reflected the UK population in age, sex, ethnicity, and country of residence. The most important determinant of respondent choice was symptom severity, especially for cough-related symptoms. In the adult sample, the probability of choosing delayed prescription was 0.53 (95% confidence interval (CI) 0.50 to 0.56, p < 0.001) for a chesty cough and runny nose compared to 0.30 (0.28 to 0.33, p < 0.001) for a chesty cough with fever, 0.47 (0.44 to 0.50, p < 0.001) for sore throat with swollen glands, and 0.37 (0.34 to 0.39, p < 0.001) for sore throat, swollen glands, and fever. Respondents were less likely to choose delayed prescription with increasing duration of illness (odds ratio (OR) 0.94 (0.92 to 0.96, p < 0.001)). Probabilities of choosing delayed prescription were similar for parents considering treatment for a child (44% of choices versus 42% for adults, p = 0.04). However, parents differed from the adult sample in showing a more marked reduction in choice of the delayed prescription with increasing duration of illness (OR 0.83 (0.80 to 0.87) versus 0.94 (0.92 to 0.96) for adults, p for heterogeneity p < 0.001) and a smaller effect of disruption of usual activities (OR 0.96 (0.95 to 0.97) versus 0.93 (0.92 to 0.94) for adults, p for heterogeneity p < 0.001). Females were more likely to choose a delayed prescription than males for minor symptoms, particularly minor cough (probability 0.62 (0.58 to 0.66, p < 0.001) for females and 0.45 (0.41 to 0.48, p < 0.001) for males). Older people, those with a good understanding of antibiotics, and those who had not used antibiotics recently showed similar patterns of preferences. Study limitations include its hypothetical nature, which may not reflect real-life behaviour; the absence of a "no prescription" option; and the possibility that study respondents may not represent the views of population groups who are typically underrepresented in online surveys. CONCLUSIONS: This study found that delayed prescription appears to be an acceptable approach to reducing antibiotic consumption. Certain groups appear to be more amenable to delayed prescription, suggesting particular opportunities for increased use of this strategy. Prescribing choices for sore throat may need additional explanation to ensure patient acceptance, and parents in particular may benefit from reassurance about the usual duration of these illnesses.

Health-seeking behaviors of patients with acute respiratory infections during the outbreak of novel coronavirus disease 2019 in Wuhan, China.

We conducted two surveys to evaluate the health-seeking behaviors of individuals with acute respiratory infections (ARI) during the COVID-19 outbreak in Wuhan, China. Among 351 participants reporting ARI (10.3%, 351/3,411), 36.5% sought medical assistance. Children were more likely to seek medical assistance than other age-groups (66.1% vs. 28.0%-35.1%). This population-based study demonstrates that the majority of patients with ARI symptoms did not seek medical assistance during the COVID-19 outbreak in Wuhan. These findings may be used to refine the estimates of disease burden and clinical severity of COVID-19 and to plan for health resources allocation.

Psychosocial Vulnerabilities to Upper Respiratory Infectious Illness: Implications for Susceptibility to Coronavirus Disease 2019 (COVID-19).

For 35 years, our laboratory has been involved in identifying psychosocial factors that predict who becomes ill when they are exposed to a virus affecting the upper respiratory tract. To pursue this question, we used a unique viral-challenge design in which we assessed behavioral, social, and psychological factors in healthy adults. We subsequently exposed these adults to a cold or influenza virus and then monitored them in quarantine for 5 to 6 days for onset of respiratory illness. Factors we found to be associated with greater risk of respiratory illnesses after virus exposure included smoking, ingesting an inadequate level of vitamin C, and chronic psychological stress. Those associated with decreased risk included social integration, social support, physical activity, adequate and efficient sleep, and moderate alcohol intake. We cautiously suggest that our findings could have implications for identifying who becomes ill when exposed to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for coronavirus disease 2019 (COVID-19). This argument is based on evidence that the associations we report are replicable across multiple respiratory viruses and that the pathways found to link psychosocial factors to colds and influenza may play similar roles in COVID-19.

Occupying 'in-hospitable' spaces: Parental/primary-caregiver perceptions of the impact of repeated hospitalisation in children under two years of age.

The experience of having a child hospitalised is stressful and disrupts families in myriad ways; however, the experiences of parents/caregivers who encounter repeated admissions of a child with acute lower respiratory infections are under-researched. This project aims to explore these experiences, from a qualitative perspective, using the philosophical tenets of reflective lifeworld research. The research included 14 face-to-face interviews with parents, grandparents, or primary caregivers, of children who, whilst under two years of age, were admitted to hospital multiple times with a lower respiratory infection diagnosis. Many of the participants were from Maori or Samoan ethnic backgrounds. The findings of this single site study revealed that these parents/caregivers' experiences were characterised by feelings of powerlessness, offering descriptions of hospitals as harsh and difficult places to reside, they are 'in-hospitable'. The findings suggest that repeated hospitalisations created a cycle of stressful experiences that impacted both familial relationships and interactions with society. This study draws attention to this previously obscured population group, and calls health care practitioners and policy advisors to engage differently over issues involving families in similar positions.

Intimate partner violence and childhood illnesses in Cambodia: a cross-sectional study.

BACKGROUND: Around a quarter of Cambodian women reported being victim to intimate partner violence (IPV) from their current partner. Children's exposure to familial IPV impacts psychosocial well-being and emerging research indicates associations with physical health. OBJECTIVE: Investigate associations between maternal experience of IPV and common childhood illnesses in Cambodia. DESIGN, SETTING, PARTICIPANTS: Analysis of the Cambodia Demographic and Health Survey (2000, 2005, 2014) using logistic regression, including 5025 children under 5 years of age whose mothers responded to questions about experience of emotional, physical and sexual violence by current partner. MAIN OUTCOME MEASURES: Report of diarrhoea, acute respiratory infection (ARI) or fever, respectively, in children in the two weeks preceding the survey. RESULTS: Children of mothers with experience of any type of IPV had estimated elevated odds of diarrhoea (adjusted OR (aOR)=1.65, 95% CI 1.39 to 1.97), estimated odds of ARI (aOR=1.78, 95% CI 1.47 to 2.16) and estimated odds of fever (aOR=1.51, 95% CI 1.31 to 1.76) compared with children of mothers without reported IPV experience. Exposure to any form of IPV corresponded to an estimated 2.65 times higher odds (95% CI 2.01 to 3.51) for reporting having both diarrhoea and ARI. CONCLUSIONS: Our findings support the notion that children's susceptibility to diarrhoea, ARI and fever may be affected by mothers' experience of IPV, including emotional violence. Maternal and child health programmes should train healthcare professionals to identify domestic violence and children at risk, and link victims to appropriate health and legal services.

Hand Hygiene Compliance and Effectiveness Against Respiratory Infections Among Hajj Pilgrims: A Systematic Review.

The role of hand hygiene in the prevention of respiratory tract infections in Hajj pilgrims has not been assessed through a focussed systematic review of the literature. Considering this, a systematic review was undertaken to synthesize the up-to-date literature on the compliance and effectiveness of hand hygiene among Hajj attendees. Major databases, including OVID Medline, were searched by using a combination of MeSH terms and text words for potentially relevant articles. Data from identified articles were abstracted, quality assessed and combined into a summary effect. Twelve observational studies containing data of 6,320 pilgrims were included. The compliance of hand washing with non-alcoholic surfactants was 77.7% (ranged from 31.5% to 90.3% in individual studies) and the compliance of hand cleaning with alcoholic products was 44.9% (ranged from 30.7% to 67.4%). Education was a key influencer of hand hygiene practice. Only three of the six studies that assessed the effectiveness of hand hygiene against clinical disease found the practice to be effective, and only one of the two studies that evaluated its effectiveness against a laboratory-confirmed infection found it to be effective. This systematic review suggests that hand hygiene using non-alcoholic products is generally acceptable among Hajj pilgrims but there is no conclusive evidence on its effectiveness.

Communication interventions to promote the public's awareness of antibiotics: a systematic review.

BACKGROUND: Inappropriate antibiotic use is implicated in antibiotic resistance and resultant morbidity and mortality. Overuse is particularly prevalent for outpatient respiratory infections, and perceived patient expectations likely contribute. Thus, various educational programs have been implemented to educate the public. METHODS: We systematically identified public-directed interventions to promote antibiotic awareness in the United States. PubMed, Google Scholar, Embase, CINAHL, and Scopus were queried for articles published from January 1996 through January 2016. Two investigators independently assessed titles and abstracts of retrieved articles for subsequent full-text review. References of selected articles and three review articles were likewise screened for inclusion. Identified educational interventions were coded for target audience, content, distribution site, communication method, and major outcomes. RESULTS: Our search yielded 1,106 articles; 34 met inclusion criteria. Due to overlap in interventions studied, 29 distinct educational interventions were identified. Messages were primarily delivered in outpatient clinics (N = 24, 83%) and community sites (N = 12, 41%). The majority included clinician education. Antibiotic prescription rates were assessed for 22 interventions (76%). Patient knowledge, attitudes, and beliefs (KAB) were assessed for 10 interventions (34%). Similar rates of success between antibiotic prescription rates and patient KAB were reported (73 and 70%, respectively). Patient interventions that did not include clinician education were successful to increase KAB but were not shown to decrease antibiotic prescribing. Three interventions targeted reductions in Streptococcus pneumoniae resistance; none were successful. CONCLUSIONS: Messaging programs varied in their designs, and many were multifaceted in their approach. These interventions can change patient perspectives regarding antibiotic use, though it is unclear if clinician education is also necessary to reduce antibiotic prescribing. Further investigations are needed to determine the relative influence of interventions focusing on patients and physicians and to determine whether these changes can influence rates of antibiotic resistance long-term.

Parental and clinician agreement of illness severity in children with RTIs: secondary analysis of data from a prospective cohort study.

BACKGROUND: Severity assessments of respiratory tract infection (RTI) in children are known to differ between parents and clinicians, but determinants of perceived severity are unknown. AIM: To investigate the (dis)agreement between, and compare the determinants of, parent and clinician severity scores. DESIGN AND SETTING: Secondary analysis of data from a prospective cohort study of 8394 children presenting to primary care with acute (≤28 days) cough and RTI. METHOD: Data on sociodemographic factors, parent-reported symptoms, clinician-reported findings, and severity assessments were used. Kappa (κ)-statistics were used to investigate (dis) agreement, whereas multivariable logistic regression was used to identify the factors associated with illness severity. RESULTS: Parents reported higher illness severity (mean 5.2 [standard deviation (SD) 1.8], median 5 [interquartile range (IQR) 4-7]), than clinicians (mean 3.1 [SD 1.7], median 3 [IQR 2-4], P<0.0001). There was low positive correlation between these scores (+0.43) and poor inter-rater agreement between parents and clinicians (κ 0.049). The number of clinical signs was highly correlated with clinician scores (+0.71). Parent-reported symptoms (in the previous 24 hours) that were independently associated with higher illness severity scores, in order of importance, were: severe fever, severe cough, rapid breathing, severe reduced eating, moderate-to-severe reduced fluid intake, severe disturbed sleep, and change in cry. Three of these symptoms (severe fever, rapid breathing, and change in cry) along with inter/subcostal recession, crackles/crepitations, nasal flaring, wheeze, and drowsiness/irritability were associated with higher clinician scores. CONCLUSION: Clinicians and parents use different factors and make different judgements about the severity of children's RTI. Improved understanding of the factors that concern parents could improve parent-clinician communication and consultation outcomes.

Medical patients' affective well-being after emergency department admission: The role of personal and social resources and health-related variables.

BACKGROUND: Medical emergency admissions are critical life events associated with considerable stress. However, research on patients' affective well-being after emergency department (ED) admission is scarce. This study investigated the course of affective well-being of medical patients following an ED admission and examined the role of personal and social resources and health-related variables. METHODS: In this longitudinal survey with a sample of 229 patients with lower respiratory tract infections and cardiac diseases (taken between October 2013 and December 2014), positive and negative affect was measured at ED admission (T1) and at follow-up after 7 days (T2), and 30 days (T3). The role of personal and social resources (emotional stability, trait resilience, affect state, and social support) as well as health-related variables (self-rated health, multimorbidity, and psychological comorbidity) in patients' affective well-being was examined by controlling for demographic characteristics using regression analyses. RESULTS: The strength of the inverse correlation between positive and negative affect decreased over time. In addition to health-related variables, higher negative affect was predicted by higher psychological comorbidity over time (T1-T3). In turn, lower positive affect was predicted by lower self-rated health (T1-T2) and higher multimorbidity (T3). In terms of personal and social resources, lower negative affect was predicted by higher emotional stability (T2), whereas higher positive affect was predicted by stronger social support (T1-T2). CONCLUSION: Knowledge about psychosocial determinants-personal and social resources and health-related variables-of patients' affective well-being following ED admission is essential for designing more effective routine screening and treatment.

Health-related impediments to learning among dental and oral surgery students.

Dental education is a challenging experience that places significant demands on students' intellectual, financial, and psychosocial well-being. Dental students who simultaneously experience physical illness, emotional upset, or interpersonal difficulty may be at greater risk of experiencing negative academic consequences. It is well documented that stress affects student learning, however, the impact of other health concerns on academic success is less understood. The purpose of this manuscript is to document the prevalence and perceived academic impact of 24 health concerns on the academic performance of a sample of 130 undergraduate dental students as measured by the National College Health Assessment (NCHA). Health concerns that were most prevalent among dental students were generally also perceived to be most detrimental to their learning. These included upper respiratory infections (cold, flu, sore throat), interpersonal concerns (concerns about a troubled friend or family member, and relationship difficulty), and mental health issues (depression/anxiety/seasonal affective disorder, and stress).

Distress during airway sampling in children with cystic fibrosis.

BACKGROUND: Oropharyngeal suction and oropharyngeal swab are two methods of obtaining airway samples with similar diagnostic accuracy in children with cystic fibrosis (CF). The primary aim was comparing distress between suctioning and swabbing. A secondary aim was establishing the reliability of the Groningen Distress Rating Scale (GDRS). METHODS: Randomised oropharyngeal suction or swab occurred over two visits. Two physiotherapists and the child's parent rated distress using the GDRS. Heart rate (HR) was also measured. RESULTS: 24 children with CF, mean age of 3 years, participated. Both physiotherapist and parent rating showed significantly higher distress levels during suction than swab. Inter-rater reliability for the GDRS was very good between physiotherapists, and good between physiotherapist and parents. CONCLUSION: The study found that oropharyngeal swab is less distressing in obtaining samples than oropharyngeal suction and that the GDRS was reliable and valid.

Influenza Vaccine Intention After a Medically Attended Acute Respiratory Infection.

Background. Little is known about vaccine intention behavior among patients recovering from a medically attended acute respiratory infection. Methods. Adults ≥ 18 years old with an acute respiratory infection in the 2014-2015, 2015-2016, and 2016-2017 influenza seasons were tested for influenza and completed surveys. Across seasons, unvaccinated participants were grouped into those who intended to receive the influenza vaccine in the following season (vaccine intention) and those who did not (no vaccine intention). In 2016-2017, participants were asked the reasons for their vaccination behavior. Results. Of the 837 unvaccinated participants, 308 (37%) intended to be vaccinated the next season. The groups did not differ in demographic or overall health factors. In logistic regression, non-Whites, those reporting wheezing or nasal congestion, and those receiving an antiviral prescription were more likely to be in the vaccine intention group. That group was significantly more likely to cite perceived behavioral control reasons for not being vaccinated (forgot), while the no vaccine intention group was significantly (p < .001) more likely to report knowledge/attitudinal reasons (side effects). Conclusion. Because influenza vaccine is given annually, adults must make a conscious decision to receive the vaccine each year. Understanding the factors related to vaccination behavior and intent can help shape interventions to improve influenza vaccination rates. A medical visit at the time of an acute respiratory illness, especially one in which the provider suspects influenza, as evidenced by an antiviral prescription, is an ideal opportunity to recommend influenza vaccine in the next season, to prevent a similar experience.

Meditation or exercise for preventing acute respiratory infection (MEPARI-2): A randomized controlled trial.

BACKGROUND: Practice of meditation or exercise may enhance health to protect against acute infectious illness. OBJECTIVE: To assess preventive effects of meditation and exercise on acute respiratory infection (ARI) illness. DESIGN: Randomized controlled prevention trial with three parallel groups. SETTING: Madison, Wisconsin, USA. PARTICIPANTS: Community-recruited adults who did not regularly exercise or meditate. METHODS: 1) 8-week behavioral training in mindfulness-based stress reduction (MBSR); 2) matched 8-week training in moderate intensity sustained exercise (EX); or 3) observational waitlist control. Training classes occurred in September and October, with weekly ARI surveillance through May. Incidence, duration, and area-under-curve ARI global severity were measured using daily reports on the WURSS-24 during ARI illness. Viruses were identified multiplex PCR. Absenteeism, health care utilization, and psychosocial health self-report assessments were also employed. RESULTS: Of 413 participants randomized, 390 completed the trial. In the MBSR group, 74 experienced 112 ARI episodes with 1045 days of ARI illness. Among exercisers, 84 had 120 episodes totaling 1010 illness days. Eighty-two of the controls had 134 episodes with 1210 days of ARI illness. Mean global severity was 315 for MBSR (95% confidence interval 244, 386), 256 (193, 318) for EX, and 336 (268, 403) for controls. A prespecified multivariate zero-inflated regression model suggested reduced incidence for MBSR (p = 0.036) and lower global severity for EX (p = 0.042), compared to control, not quite attaining the p<0.025 prespecified cut-off for null hypothesis rejection. There were 73 ARI-related missed-work days and 22 ARI-related health care visits in the MBSR group, 82 days and 21 visits for exercisers, and 105 days and 24 visits among controls. Viruses were identified in 63 ARI episodes in the MBSR group, compared to 64 for EX and 72 for control. Statistically significant (p<0.05) improvements in general mental health, self-efficacy, mindful attention, sleep quality, perceived stress, and depressive symptoms were observed in the MBSR and/or EX groups, compared to control. CONCLUSIONS: Training in mindfulness meditation or exercise may help protect against ARI illness. LIMITATIONS: This trial was likely underpowered. TRIAL REGISTRATION: Clinicaltrials.gov NCT01654289.

Longitudinal study of quality of life among children with acute respiratory infection and cough.

PURPOSE: Acute respiratory infections (ARIs), and associated symptoms such as cough, are frequently experienced among children and impose a burden on families (e.g., use of medical resources and time off work/school). However, there are little data on changes in, and predictors of, quality of life (QoL) over the duration of an ARI with cough (ARIwC) episode. We therefore aimed to determine cough-specific QoL and identify its influencing factors among children with ARIwC, at the time of presentation to a pediatric emergency department (ED), and over the following 4 weeks. METHODS: Data from 283 children aged < 15 years were included in our analyses. We used the validated parent-proxy children's acute cough-specific QoL questionnaire (PAC-QoL) at each time-point. Linear regression and mixed effect modeling were used to identify factors influencing QoL at baseline and over the follow-up period. RESULTS: Median PAC-QoL at baseline was 2.7 (IQR 2.1-3.6) and significantly improved by Day-7 (4.9, IQR 3.8-6.1) and Day-14 (6.59, IQR 5.1-7.0), both p < 0.001. The improvements in median PAC-QoL between Days-14, -21, and -28 were not significant. Regression modeling identified that day-cough severity, night-cough severity, and financial concerns had the highest impact on both baseline, and follow-up, PAC-QoL scores. There were five additional independent significant factors at baseline and six at follow-up. CONCLUSIONS: Quality of life is considerably impaired at presentation to ED, but improves significantly by Days-7 and -14. As cough severity and financial concerns had the highest impact on QoL, effectively managing cough to reduce the clinical and financial burden on children and families is important.

Maternal Stress During Pregnancy and Allergic Diseases in Children During the First Year of Life.

BACKGROUND: Many recent studies indicate that prenatal maternal distress increases the risk of allergic diseases in children. The mechanisms that favor it are still unclear. OBJECTIVES: We aimed to assess the association between exposure to different kinds of prenatal stress and the occurrence of atopic dermatitis, food allergy, wheezing, and recurrent respiratory tract infections in children. METHODS: The study population consisted of 370 mother-child pairs from a Polish Mother and Child Cohort (REPRO_PL). The analysis was restricted to the women who worked at least one month during the pregnancy period. Maternal psychological stress during pregnancy was assessed based on the Subjective Work Characteristics Questionnaire, the Perceived Stress Scale, and the Social Readjustment Rating Scale. The presence of atopic dermatitis, food allergy, wheezing, and recurrent respiratory tract infections in children was evaluated by doctors at 12 months of age. RESULTS: In a univariate model, we showed significant association between maternal life stress (according to the Perceived Stress Scale) and stressful life events (according to the Social Readjustment Rating Scale) and infant wheezing (at least 1 episode of wheezing during the first year of life). A multivariate model of logistic regression analysis revealed that maternal stress during pregnancy, described by the Social Readjustment Rating Scale, increased the risk of wheezing in children (OR 1.09, 95% CI 1.01-1.02) independently from other predictors of wheezing previously determined in this cohort, such as the number of infections and maternal smoking. We observed also significant positive association between maternal life stress during pregnancy measured by the Perceived Stress Scale and the risk of recurrent respiratory tract infections in the first year of life, however it was not significant after adjustment for confounding variables. CONCLUSIONS: Maternal stress during pregnancy increases the risk of childhood wheezing. The effects of stress during pregnancy on the onset of allergic diseases in children should be developed and translated into early prevention strategies.

Perceptions of barriers to the management of respiratory tract infections in general practice settings in Australia.

Inappropriate prescribing of antibiotics for the management of respiratory tract infections (RTIs) has contributed to increased prevalence of antibiotic resistance, and this remains a challenge. The aim of this study was to evaluate the effect of general practitioners' (GPs) participation in the Antibiotics: Clinical e-Audit, a quality-improvement activity, on GP self-reported knowledge and practice change, and explored barriers encountered in the management of respiratory tract infections (RTIs). Participants completed a survey at the end of the activity to assess the usefulness of the audit, any reported changes made and barriers encountered to their clinical practice. More than half of the 872 participants reported the audit assisted them in reviewing patients with RTIs. The majority of GP registrars (48.2%, N=66) indicated that the clinical e-Audit had changed their practice in terms of identifying patients for whom an antibiotic was recommended. GPs identified several barriers to achieving best practice in the management of RTIs, including patient or carer expectations for an antibiotic prescription and non-adherence to symptomatic management by patients. Empowering GPs to overcome these barriers should be the aim of future education and behaviour change programs.

Consultation expectations among patients with respiratory tract infection symptoms.

INTRODUCTION: Antibiotic resistance is a growing threat to public health, and antibiotic prescribing increases. About 90% of antibiotics are prescribed in general practice, mostly for acute respiratory tract infections. It is well known that patient expectations and general practitioners' misinterpretation of patients' expectations are associated with antibiotic overuse. The aim of this study was to explore Danish patients' expectations when consulting a general practitioner with symptoms of acute respiratory tract infection, and to determine predictors for these expectations. METHODS: A questionnaire survey was conducted in Danish primary care during 2014. Patients aged ≥ 18 years were asked about their expectations to the consultation when consulting with symptoms of acute respiratory tract infections. Associations between socio-demographic characteristics, self-reported antibiotic prescription and patients' expectations were also explored. RESULTS: A total of 567 patients with symptoms of acute respiratory tract infections were recorded as interested in receiving a questionnaire, 361 of whom responded. The majority expected an examination (94.6%) and an explanation (85.9%). About one third expected antibiotic treatment (32.3%). Patients who expected an antibiotic were more than eight times more likely to be prescribed one than were patients not expecting an antibiotic (odds ratio = 8.6 (95% confidence interval: 4.63-16.03); p < 0.001). CONCLUSIONS: Most Danish patients expected an examination and/or an explanation of their symptoms when consulting with their general practitioner. FUNDING: The study was, in part, funded by The Council for Quality Assurance in Primary Care in both The Region of Southern Denmark and Region Zealand. Malene Plejdrup Hansen received a postdoctoral scholarship in general practice and family medicine from The Novo Nordic Foundation. The sponsors have not been involved in the design or the development of the study. TRIAL REGISTRATION: This study was registered with the Danish Data Protection Agency (R. no. 2013-41-2582).

Sickness behavior in feverish children is independent of the severity of fever. An observational, multicenter study.

BACKGROUND. OBJECTIVES: Behavioral changes in a febrile child are usually considered to stem from the fever. We studied sickness behavior (SB) in terms of its clinical components and its relation to fever. METHODS: This observational, multicenter study included children aged 6 months to 3 years who were either febrile (fever ≥12 hours, ≥ 39°C and ≥38°C at inclusion) or non-febrile and well. The child had to have been awake for the 2 hours preceding the consultation and cared for by the parent who brought him/her to the doctor. SB was evaluated according to 6 parameters over this 2-hour period: time spent playing, distance covered, time spent seeking comfort, time spent whining or crying, time spent in a state of irritation or of anger, most distorted facial expression. Two parameters were assessed for the 24-hour period preceding the consultation: time spent sleeping and appetite. The parent reported the degree of change in these parameters compared with the usual situation, using rating scales. RESULTS: 200 febrile children (most with nonspecific upper respiratory infections) and 200 non-febrile children were included. The mean values of the 8 parameters differed significantly (p<0.001) between the 2 groups and were independent of the height of fever at inclusion in the febrile children. In the study conditions, paracetamol failed to improve SB when the child was still feverish. CONCLUSION: The 8 parameters suggested that SB and fever are two independent manifestations that are activated simultaneously during an infection. This independence is in harmony with recommendations to treat the discomfort of SB and not the fever.

Pathway from PTSD to respiratory health: Longitudinal evidence from a psychosocial intervention.

OBJECTIVE: Respiratory illness and posttraumatic stress disorder (PTSD) are common debilitating conditions that frequently co-occur. Observational studies indicate that PTSD, independently of smoking, is a major risk and maintenance factor for lower respiratory symptoms (LRS). The current study experimentally tested this etiologic pathway by investigating whether LRS can be reduced by treating PTSD symptoms. METHOD: Ninety daily smokers exposed to the World Trade Center (WTC) disaster (mean age 50 years, 28% female; 68% White) completed 8-session group-based weekly comprehensive trauma management and smoking cessation treatment that focused on skills to alleviate PTSD symptoms. LRS, PTSD symptoms, and smoking were assessed weekly. Data was analyzed using multilevel models of within-person associations between LRS, PTSD symptoms, smoking, and treatment dose across 8 weekly sessions with concurrent and lagged outcomes. RESULTS: LRS improved significantly with treatment (reduction of .50 standard deviations). Reduction in PTSD symptoms uniquely predicted improvement in LRS at consecutive sessions 1 week apart and fully accounted for the treatment effect on LRS. The effect of PTSD symptoms was stronger than that of smoking, and the only effect to remain significant when both entered the model. Notably, reduction in LRS did not predict future improvement in PTSD symptoms. CONCLUSIONS: The results are in line with the etiologic pathway suggesting that PTSD symptoms are a risk and maintenance factor for chronic LRS and that treatment of PTSD can help to alleviate LRS in trauma-exposed populations. PTSD is emerging as a novel and important treatment target for chronic respiratory problems. (PsycINFO Database Record