Childhood urinary tract infection in primary care: a prospective observational study of prevalence,diagnosis, treatment,and recovery

BackgroundThe prevalence of targeted and serendipitous treatment for, and associated recovery from, urinary tract infection (UTI) in pre-school children is unknown.AimTo determine the frequency and suspicion of UTI in children who are acutely ill, along with details of antibiotic prescribing, its appropriateness, and whether that appropriateness impacted on symptom improvement and recovery.MethodSystematic urine sampling from children aged <5years presenting in primary care with acute illness with culture in NHS laboratories.ResultsOf 6079 children’s urine samples, 339 (5.6%) met laboratory criteria for UTI and 162 (47.9%) were prescribed antibiotics at the initial consultation. In total, 576/7101 (8.1%) children were suspected of having a UTI prior to urine sampling, including 107 of the 338 with a UTI (clinician sensitivity 31.7%). Children with a laboratory-diagnosed UTI were more likely to be prescribed antibiotics when UTI was clinically suspected than when it was not (86.0% versus 30.3%, P<0.001). Of 231 children with unsuspected UTI, 70 (30.3%) received serendipitous antibiotics (that is, antibiotics prescribed for a different reason). Overall, 176 (52.1%) children with confirmed UTI did not receive any initial antibiotic. Organism sensitivity to the prescribed antibiotic was higher when UTI was suspected than when treated serendipitously (77.1% versus 26.0%; P<0.001). Children with UTI prescribed appropriate antibiotics at the initial consultation improved a little sooner than those with a UTI who were not prescribed appropriate antibiotics initially (3.5 days versus 4.0 days; P = 0.005).ConclusionOver half of children with UTI on culture were not prescribed antibiotics at first presentation. Serendipitous UTI treatment was relatively common, but often inappropriate to the organism’s sensitivity. Methods for improved targeting of antibiotic treatment in children who are acutely unwell are urgently needed.     

Exploring preferences for symptom management in primary care: a discrete choice experiment using a questionnaire survey

BackgroundSymptoms are important drivers for the use of primary care services. Strategies aimed at shifting the focus away from the GP have broadened the range of primary healthcare available.AimTo explore preferences for managing symptoms and investigate trade-offs that the public are willing to make when deciding between different primary care services.MethodA discrete choice experiment examined management preferences for three symptoms of differing seriousness (diarrhoea, dizziness, and chest pain). Willingness-to-pay estimates compared preferences between symptoms, and by sex, age, and income.ResultsPreferences differed significantly between symptoms. ‘Self-care’ was the preferred action for diarrhoea and ‘consulting a GP’ for dizziness and chest pain. ‘Waiting time’ and ‘chance of a satisfactory outcome’ were important factors for all three symptoms, although their relative importance differed. Broadly, people were more prepared to wait longer and less prepared to trade a good chance of a satisfactory outcome for symptoms rated as more serious. Generally, preferences within subgroups followed similar patterns as for the whole sample, although there were differences in the relative strength of preferences.ConclusionDespite increased choices in primary care, ‘traditional’ actions of ‘self-care’ for minor symptoms and ‘GP consultation’ for more serious symptoms were preferred. The present findings suggest, however, that people may be willing to trade between different health services, particularly for less serious symptoms. Understanding the relative importance of different factors may help inform interventions aimed at changing management behaviour or improving services.     

Inhibition of proliferative and plaque-forming cell responses by human bone-marrow-derived lymphocytes from peripheral blood by antisera to the p23, 30 antigen.

A recently described technique for the polyclonal induction of plaque-forming cells from human bone-marrow derived (B) lymphocytes of peripheral blood has been used to assess the role of a human Ia-like antigen (p23,30) in differentiation of human B cells. In particular, the effects of antisera to p23,30 on the plaque-forming cells and proliferative responses of human B cells stimulated by pokeweed mitogen or soluble products of activated human thymus-derived lymphocytes (T cells) have been examined. Antisera to p23,30 eliminated the development of plaque-forming cells induced by both T cell products and pokeweed mitogen. While these antisera also abrogated B cell proliferation induced by T cell supernatants, the proliferative response generated by pokeweed mitogen was only partially reduced. It was also determined that while the p23,30 antigen continues to be expressed on fully differentiated plaque-forming cells, antisera to this determinant exert inhibitory effects on B cell differentiation only when present during the early stages of B cell cultures. These results lend further support to the analogy between p23,30 and murine Ia antigens. Moreover, they demonstrate a major role for this antigen in the early events involved in human B cell differentiation into antibody-forming cells.     

Object identification in simultanagnosia: When wholes are not the sum of their parts

Abstract

We examined object identification in two simultanagnosic patients, ES and GK. We show that the patients tended to identify animate objects more accurately than inanimate objects (Experiments 1 and 4). The patients also showed relatively good identification of objects that could be recognised from their global shape, but not objects whose recognition depended on their internal detail (Experiment 2). Indeed, the presence of local segmentation cues disrupted global identification (Experiment 3). Identification was aided, though, by the presence of surface colour and texture (Experiment 4). We suggest that the patients could derive global representations of objects that served to recognise animate items. In contrast, they were impaired at coding parts-based representations for the identification of inanimate objects.     

Action naming with impaired semantics: Neuropsychological evidencecontrasting naming and reading for objects and verbs

We contrast naming from pictures, and reading words, for objects and verbs (actions relating to the objects) in a patient with a large, posterior left-hemisphere lesion. We present evidence for spared picture naming for verbs relative to objects, whilst the opposite pattern of sparing occurred in reading. Objects were also spared relative to verbs in tasks requiring that written words be matched to either pictures or auditory words, in the presence of semantically related or unrelated distractors. We conclude that verb semantics were more impaired than semantic knowledge for objects, and that the better semantic knowledge for object names supported word reading. With pictures, however, action verb retrieval was maintained through a nonsemantic route from vision to action, or though preserved right-hemisphere “action semantics.”     

Supported discharge service versus inpatient care evaluation (SITE): a randomised controlled trial comparing effectiveness of an intensive community care service versus inpatient treatment as usual for adolescents with severe psychiatric disorders: self-harm,functional impairment,and educational and clinical outcomes

Clinical guidelines recommend intensive community care service treatment (ICCS) to reduce adolescent psychiatric inpatient care. We have previously reported that the addition of ICCS led to a substantial decrease in hospital use and improved school re-integration. The aim of this study is to undertake a randomised controlled trial (RCT) comparing an inpatient admission followed by an early discharge supported by ICCS with usual inpatient admission (treatment as usual; TAU). In this paper, we report the impact of ICCS on self-harm and other clinical and educational outcomes. 106 patients aged 12–18 admitted for psychiatric inpatient care were randomised (1:1) to either ICCS or TAU. Six months after randomisation, we compared the two treatment arms on the number and severity of self-harm episodes, the functional impairment, severity of psychiatric symptoms, clinical improvement, reading and mathematical ability, weight, height and the use of psychological therapy and medication. At six-month follow-up, there were no differences between the two groups on most measures. Patients receiving ICCS were significantly less likely to report multiple episodes (five or more) of self-harm (OR = 0.18, 95% CI: 0.05–0.64). Patients admitted to private inpatient units spent on average 118.4 (95% CI: 28.2–208.6) fewer days in hospitals if they were in the ICCS group compared to TAU. The addition of ICCS to TAU may lower the risk of multiple self-harm and may reduce the duration of inpatient stay, especially in those patients admitted for private care. Early discharge with ICCS appears to be a viable alternative to standard inpatient treatment.