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Topical antibiotics for acute bacterial conjunctivitis: Cochrane systematic review and meta-analysis update.
BackgroundUncertainty remains about the extent to which findings from our previously published systematic review and meta-analysis of double-blind, randomised controlled trials of topical antibiotics compared with placebo in the management of patients with acute bacterial conjunctivitis treated in secondary care outpatient settings are generalisable to the management of the condition in primary care settings. We updated our review, undertaking searches, methodological assessment, data extraction and analysis according to a pre-defined protocol. In addition to the previous three included studies, we identified two additional double-blind primary care trials, one which compares fusidic acid gel with placebo gel and one which compares chloramphenicol eye drops with placebo eye drops in children. Meta-analyses of clinical and microbiological remission data reveal that topical antibiotics are of benefit in improving early (days 2-5) clinical (relative risk [RR] = 1.24, 95% confidence interval [CI] = 1.05 to 1.45) and microbiological (RR = 1.77, 95% CI = 1.23 to 2.54) remission rates; later (days 6-10) data reveal that these early advantages in clinical (RR = 1.11, 95% CI = 1.02 to 1.21) and microbiological cure rates are reduced (RR 1.56, 95% CI = 1.17 to 2.09), but persist. Most cases of acute bacterial conjunctivitis resolve spontaneously. While topical antibiotics are associated with significantly improved rates of early (days 2-5) clinical remission, this benefit is marginal for later remission (days 6-10).
Ethnic variations in incidence of asthma episodes in England & Wales: national study of 502,482 patients in primary care.
BackgroundRecent studies have demonstrated marked international variations in the prevalence of asthma, but less is known about ethnic variations in asthma epidemiology within individual countries and in particular the impact of migration on risk of developing asthma. Recent within country comparisons have however revealed that despite originating from areas of the world with a low risk for developing asthma, South Asian and Afro-Caribbean people in the UK are significantly (3x and 2x respectively) more likely to be admitted to hospital for asthma related problems than Whites.MethodsUsing data from the Fourth National Study of Morbidity Statistics in General Practice, a one-percent broadly representative prospective cohort study of consultations in general practice, we investigated ethnic variations in incident asthma consultations (defined as new or first consultations), and compared consultation rates between those born inside and outside the UK (migrant status). Logistic regression models were used to examine the combined effects of ethnicity and migration on asthma incident consultations.ResultsResults showed significantly lower new/first asthma consultation rates for Whites than for each of the ethnic minority groups studied (mean age-adjusted consultation rates per 1000 patient-years: Whites 26.4 (95%CI 26.4, 26.4); South Asians 30.4 (95%CI 30.3, 30.5); Afro-Caribbeans 35.1 (95%CI 34.9, 35.3); and Others 27.8 (27.7, 28.0). Within each of these ethnic groups, those born outside of the UK showed consistently lower rates of incident asthma consultations. Modelling the combined effects of ethnic and migrant status revealed that UK-born South Asians and Afro-Caribbeans experienced comparable risks for incident GP consultations for asthma to UK-born Whites. Non-UK born Whites however experienced reduced risks (adjusted OR 0.82, 95%CI 0.69, 0.97) whilst non-UK born South Asians experienced increased risks (adjusted OR 1.33, 95%CI 1.04, 1.70) compared to UK-born Whites.ConclusionThese findings strongly suggest that ethnicity and migration have significant and independent effects on asthma incidence. The known poorer asthma outcomes in UK South Asians and Afro-Caribbeans may in part be explained by the offspring of migrants experiencing an increased risk of developing asthma when compared to UK-born Whites. This is the first study to find heterogeneity for incident asthma consultations in Whites by migrant status.
Concordance between supervised and postal administration of the Mini Asthma Quality of Life Questionnaire (MiniAQLQ) and Asthma Control Questionnaire (ACQ) was very high.
Background and objectiveThere is increasing international interest in using patient-based outcome measures to evaluate interventions. We compared responses to postal administration of Mini Asthma Quality of Life Questionnaire (MiniAQLQ) and Asthma Control Questionnaire (ACQ) with the gold standard of supervised self-completion.Study design and settingValidation study involving 96 adults, recruited from U.K. general practice, sent the postal questionnaires with an instruction sheet 1 week before supervised self-completion. Responses for those whose quality of life (n=56) or asthma control (n=61) had 'not changed' between postal and supervised completions were compared using paired-sample t-tests, Pearson's correlation coefficient (r), and intraclass correlation coefficient (ICC).ResultsFor the MiniAQLQ, overall mean scores were similar in both groups: Postal=5.14 (SD=1.42) vs. Supervised=5.17 (SD=1.39), with mean difference of -0.03 (95% CI=-0.14, 0.08; P=.59), with a high degree of correlation (r=.96, PConclusionsCorrelation and concordance between supervised and postal administration of the MiniAQLQ and ACQ are very high. Users may confidently choose the mode of administration most appropriate to their needs.
Management of allergic rhinitis in UK primary care: baseline audit.
Background: Evidence suggests that the UK primary care management of people with allergic rhinitis is sub-optimal. Common deficiencies are thought to include under-diagnosis, mis-diagnosis and sub-optimal treatment.Objectives: We sought to assess GPs' understanding and perspectives on key issues in the management of allergic rhinitis, comparing these with recommendations contained in the Consensus statement on the treatment of allergic rhinitis.Methods: Sampling frame of 210GPs with a self-declared interest in the management of allergic and respiratory disorders from 70GP practices in the UK. Semi-structured interviews were used to assess GPs' knowledge and views on clinical practice. Trained personnel conducted all interviews. Interviews were taped and transcribed; each transcript was scrutinised to see if GP knowledge and practice was consistent with the standards set. STANDARDS AND CRITERIA:: We used the most recent Consensus statement on the treatment of allergic rhinitis as our standard, aiming to assess quality of care in four main domains: identification of symptoms; collection of information to support a clinical diagnosis; examination and investigations performed to support the clinical diagnosis; treating and managing the condition.Results: We successfully interviewed 90% (n=188) of GPs. Only 14% (n=26) of GPs satisfied all the criteria set for Standard 1 (identification of symptoms); 23% (n=43) satisfied criteria for Standard 2 (collection of information to support a clinical diagnosis); 0% (n=0) satisfied criteria for Standard 3 (examination and investigations performed to support the clinical diagnosis); and 0.6% (n=1) satisfied criteria set for Standard 4 (adequate treatment issued).Conclusions: This national baseline audit of GPs with a self-declared interest in allergic and respiratory disorders reveals considerable scope for improvement in GP awareness and management of allergic rhinitis.
Management of allergic problems in primary care: time for a rethink?
Allergic diseases affect 20-30% of the UK population and when severe are associated with considerable morbidity and occasional mortality. Initiatives to improve allergy services in the UK have been led by consultant allergists and have focussed on increasing the number of hospital training posts to improve access to specialist services. A high profile campaign to raise awareness of the lack of allergy services has so far failed to generate further training numbers for allergy as a single specialty. Although the campaign to improve tertiary allergy services continues, most mild or moderate allergy symptoms (e.g. hayfever, allergic asthma, urticaria and some food allergy problems), can be managed successfully in primary care with appropriate interest and training. Despite the high and increasing numbers of patients with allergy and the ease with which the majority of symptoms can be controlled, many doctors in primary care are reluctant to take a more proactive approach to managing allergic conditions. This appears to be due to concerns about overburdening an already busy service, but may also be due to recommendations from allergy specialists which have implied that high quality allergy care is not possible without identification of specific allergic triggers using skin prick tests or blood tests. In reality, symptoms can usually be controlled using pharmacotherapy, although a working knowledge of the appropriate guidelines is helpful. In this paper, we propose minimum levels of knowledge for all practitioners in order to raise the standards of primary care allergy management, and provide recommendations for training for those wishing to manage successfully more difficult allergy cases and allergy diagnosis.
Handheld computers and the 21st century surgical team: a pilot study.
BackgroundThe commercial development and expansion of mobile phone networks has led to the creation of devices combining mobile phones and personal digital assistants, which could prove invaluable in a clinical setting. This pilot study aimed to look at how one such device compared with the current pager system in facilitating inter-professional communication in a hospital clinical team.MethodsThe study looked at a heterogeneous team of doctors (n = 9) working in a busy surgical setting at St. Mary's Hospital in London and compared the use of a personal digital assistant with mobile phone and web-browsing facilities to the existing pager system. The primary feature of this device being compared to the conventional pager was its use as a mobile phone, but other features evaluated included the ability to access the internet, and reference data on the device. A crossover study was carried out for 6 weeks in 2004, with the team having access to the personal digital assistant every alternate week. The primary outcome measure for assessing efficiency of communication was the length of time it took for clinicians to respond to a call. We also sought to assess the ease of adoption of new technology by evaluating the perceptions of the team (n = 9) to personal digital assistants, by administering a questionnaire.ResultsDoctors equipped with a personal digital assistant rather than a pager, responded more quickly to a call and had a lower of failure to respond rate (RR: 0.44; 95%CI 0.20-0.93). Clinicians also found this technology easy to adopt as seen by a significant reduction in perceptions of nervousness to the technology over the six-week study period (mean (SD) week 1: 4.10 (SD 1.69) vs. mean (SD) week 6: 2.20 (1.99); p = 0.04).ConclusionThe results of this pilot study show the possible effects of replacing the current hospital pager with a newer, more technologically advanced device, and suggest that a combined personal digital assistant and mobile phone device may improve communication between doctors. In the light of these encouraging preliminary findings, we propose a large-scale clinical trial of the use of these devices in facilitating inter-professional communication in a hospital setting.
Investigating the relationship between affluence and elective caesarean sections.
The proportion of women delivering by caesarean section has increased dramatically in England and many westernised countries. It has been suggested that one important reason for this increase is the growing proportion of women opting for elective caesareans for lifestyle reasons, a trend that is, it is argued, most common among the affluent. We investigated the hypothesis that affluent women are more likely to deliver by elective caesarean section. Logistic regression modelling was used to analyse data from half a million women who delivered in English NHS hospitals between 1996 and 2000. We found that women living in the most affluent areas of England were significantly more likely to have an elective caesarean section than their deprived counterparts.
Patient safety features of clinical computer systems: questionnaire survey of GP views.
AimTo investigate general practitioners' (GPs') stated knowledge, use and training needs related to the patient safety features of computerised clinical systems in England.DesignQuestionnaire survey.Subjects and settingGPs from six English primary care trusts.Outcome measuresGPs' views on the importance of specified patient safety features on their computer system; their knowledge of the presence of specified safety features; previous training and perceived future training needs.ResultsThree hundred and eighty one GPs (64.0%) completed and returned the questionnaire. Although patient safety features were considered to be an important part of their computer system by the vast majority of GPs, many were unsure as to whether the system they were currently using possessed some of the specified features. Some respondents erroneously believed that their computers would warn them about potential contraindications or if an abnormal dose frequency had been prescribed. Only a minority had received formal training on the use of their system's patient safety features.ConclusionsPatient safety was an issue high on the agenda of this GP sample. The importance of raising GPs' awareness of both the potential use and deficiencies of the patient safety features on their systems and ensuring that appropriate training is available should not be underestimated.