Digital Commons Network^™

Corticosteroids For Pain Relief In Sore Throat: Systematic Review And Meta-Analysis, Gail Hayward, Matthew J. Thompson, Carl J. Heneghan, Rafael Perera, Paul P. Glasziou, Chris B. Del Mar

Christopher Del Mar

Objective: To evaluate whether systemic corticosteroids improve symptoms of sore throat in adults and children. Design: Systematic review and meta-analysis. Data sources: Cochrane Central, Medline, Embase, Database of Reviews of Effectiveness (DARE), NHS Health Economics Database, and bibliographies. Outcome measures: Percentage of patients with complete resolution at 24 and 48 hours, mean time to onset of pain relief, mean time to complete resolution of symptoms, days missed from work or school, recurrence, and adverse events. Results: We included eight trials, consisting of 743 patients in total (369 children, 374 adults). 348 (47%) had exudative sore throat, and 330 (44%) were …

Neuraminidase Inhibitors For Preventing And Treating Influenza In Healthy Adults: Systematic Review And Meta-Analysis, Tom Jefferson, Mark Jones, Peter Doshi, Chris Del Mar

Christopher Del Mar

Objectives: To update a 2005 Cochrane review that assessed the effects of neuraminidase inhibitors in preventing or ameliorating the symptoms of influenza, the transmission of influenza, and complications from influenza in healthy adults, and to estimate the frequency of adverse effects. Search strategy: An updated search of the Cochrane central register of controlled trials (Cochrane Library 2009, issue 2), which contains the Acute Respiratory Infections Group’s specialised register, Medline (1950-Aug 2009), Embase (1980-Aug 2009), and post-marketing pharmacovigilance data and comparative safety cohorts. Selection criteria: Randomised placebo controlled studies of neuraminidase inhibitors in otherwise healthy adults exposed to naturally occurring influenza. …

Transparent Development Of The Who Rapid Advice Guidelines, Holger J. Schunemann, Suzanne R. Hill, Meetali Kakad, Gunn E. Vist, Richard Bellamy, Lauren Stockman, Torbjorn Fosen Wisloff, Chris Del Mar, Frederick Hayden, Timothy M. Uyeki, Jeremy Farrar, Yazdan Yazdanpanah, Howard Zucker, John Beigel, Tawee Chotpitayasunondh, Tran Tinh Hien, Bulent Ozbay, Norio Sugaya, Andrew D. Oxman

Christopher Del Mar

Emerging health problems require rapid advice. We describe the development and pilot testing of a systematic, transparent approach used by the World Health Organization (WHO) to develop rapid advice guidelines in response to requests from member states confronted with uncertainty about the pharmacological management of avian influenza A (H5N1) virus infection. We first searched for systematic reviews of randomized trials of treatment and prevention of seasonal influenza and for nontrial evidence on H5N1 infection, including case reports and animal and in vitro studies. A panel of clinical experts, clinicians with experience in treating patients with H5N1, influenza researchers, and methodologists …

Possible Harms Of Oseltamivir—A Call For Urgent Action, Tom Jefferson, Mark Jones, Peter Doshi, Chris Del Mar

Christopher Del Mar

Extract: Oseltamivir is a successful drug: between July, 2004, and June, 2009, more than 11·5 million new prescriptions were issued in the USA, and nearly all influenza pandemic plans recommend antiviral drugs as a mainstay of containment on a population basis and treatment on an individual basis, with oseltamivir preferred because of ease of administration and storage. Because 75% of the world production of oseltamivir has been used in Japan,¹ this is where to look for any serious harms the drug might cause. ¹ See note in article.

Acute Respiratory Infections, Sharon Sanders, Jenny Doust, Chris Del Mar

Christopher Del Mar

Extract: Acute respiratory infections may be classified in several different ways: by their symptoms (fever, sore throat, cough, ear pain, runny nose); by their clinical manifestations (coryza, pharyngitis, tonsillitis, epiglottitis, otitis media, influenza, bronchitis, pneumonia); or by causative organism. Furthermore, their symptoms and sometimes the whole clinical picture may be shared by conditions that are not infections (asthma, allergic rhinitis). Some of this complexity is shown in Figure 46.1. Elucidating the exact location or responsible organism is usually clinically unhelpful. In this chapter, we focus on diagnostic questions that have the greatest impact on the patient with an acute respiratory …

Leaders, Leadership And Future Primary Care Clinical Research, John Furler, Jennifer Cleland, Chris Del Mar, Barbara Hanratty, Umesh Kadam, Daniel Lasserson, Colin Mccowan, Parker Magin, Caroline Mitchell, Nadeem Qureshi, Greta Rait, Nick Steel, Mieke Van Driel, Alison Ward

Christopher Del Mar

Background: A strong and self confident primary care workforce can deliver the highest quality care and outcomes equitably and cost effectively. To meet the increasing demands being made of it, primary care needs its own thriving research culture and knowledge base. Methods: Review of recent developments supporting primary care clinical research. Results: Primary care research has benefited from a small group of passionate leaders and significant investment in recent decades in some countries. Emerging from this has been innovation in research design and focus, although less is known of the effect on research output. Conclusion: Primary care research is now …

Sore Throat, Chris Del Mar, Paul Glasziou

Christopher Del Mar

Abstract: This article considers the effects of interventions to reduce symptoms and complications of acute infective sore throat. It defines the condition and looks in detail at the areas of treatment, incidence, risk factors, methods and prognosis.

Influenza Vaccine For Preventing Acute Otitis Media In Infants And Children [Protocol], Elspeth Kay, K. Ng, A. Salmon, Chris Del Mar

Christopher Del Mar

This is the protocol for a review. The objectives are as follows: To assess the effects of influenza vaccination, compared to no vaccination, on the occurrence of acute otitis media in infants and young children.

Check Unit: Evidence Based Medicine, Chris Del Mar, Jenny Doust

Christopher Del Mar

Extract: This is an updated version of an original check unit on evidence based medicine (EBM) written by Chris Del Mar, Paul Glasziou and Chris Silagy in 1999. Our aim for this unit is to present a practical strategy in learning to use EBM in our every day practice. To practise EBM means to make clinical decisions based on the best evidence currently available. It sounds simple, however, the ‘devil’ is in the detail! Exactly how do we go about it? On completion of this unit we hope that participants will: • appreciate the role that EBM can play in …

Matters Of Life And Death: Key Writings, Chris Del Mar

Christopher Del Mar

Extract These essays from the pricker of British medical establishment conscience are thought-provoking and controversial.

Early Management Of Meningococcal Disease: Do Attitudes Of Gps Influence Practice?, Kari Jarvinen, Linda Selvey, Chris Del Mar, Michael Tilse, Robyn Pugh

Christopher Del Mar

BACKGROUND Survival from early meningococcal disease might be improved if general practitioners followed guidelines by immediately administering parenteral antibiotics (before hospital referral). METHODS Structured telephone interviews with 20 GPs who had previously treated meningococcal cases. RESULTS General practitioners knew guideline recommendations for early management of meningococcal disease: early parenteral antibiotics would be given by about half the GPs entertaining a diagnosis of meningococcal infection. Barriers to immediate treatment were: diagnostic uncertainty, regarding the case as nonurgent, and practising close to a hospital. DISCUSSION Diagnosing meningococcal disease is difficult in general practice. Early antibiotic administration for suspected cases is appropriate even …

Using N-Of-1 Trials As A Clinical Tool To Improve Prescribing, Catherine Jane Nikles, Alexandra M. Clavarino, Chris Del Mar

Christopher Del Mar

Background: N-of-1 trials are within-patient, randomised, double-blind, placebo-controlled cross-over comparisons of two drugs for chronic illnesses. We have investigated the use of these, offered to doctors as individualised medication effectiveness tests (IMETs), as a tool to improve drug prescribing. Aim: To examine patient perspectives and experiences of n-of-1 trials. Design of study: We provided n-of-1 trials for osteoarthritis (OA), comparing paracetamol and ibuprofen; and attention deficit hyperactivity disorder (ADHD), comparing dexamphetamine or methylphenidate and placebo. Patients or their carers were surveyed before and after the trials by questionnaire, and after the trial by semi-structured interview with thematic analysis. Setting: Australian …

Letter: "Drink Plenty Of Fluids" Authors' Reply, Michelle P. B. Guppy, Sharon M. Mickan, Chris Del Mar

Christopher Del Mar

"Drink plenty of fluids" - Recommendations are not supported by data - [Authors' reply]. Let us look deeper at the indirect evidence. Two case reports describe children with only infections of the upper respiratory tract with hyponatraemia and seizures. In infections of the lower respiratory tract, observational studies show that increased secretion of antidiuretic hormone occurs in bronchiolitis, where it is the norm. It is becoming standard management to advise careful monitoring and restriction of fluid intake with bronchiolitis.

Research Papers Submitted To Australian Family Physician - Types And Timelines, Rachel Green, Chris Del Mar

Christopher Del Mar

BACKGROUND Articles published in the research section of Australian Family Physician (AFP) are subject to an editorial process comprising several stages. METHOD Timelines tracking the movement of each research manuscript submitted to AFP from 2002-2004 through all stages of the editorial process were constructed. Of 179 papers, 130 had sufficiently progressed to be included in this study. Manuscripts were grouped by subject matter into eight categories. RESULTS Waiting for authors' responses to editorial feedback (with reviewers' reports) was the greatest cause of delay to AFP editorial processes. Peer reviewers took 43 (SD: 102) days to return their report. Authors took …

General Practitioner, Specialist Providers Case Conferences In Palliative Care: Lessons Learned From 56 Case Conferences, Geoffrey Mitchell, Margaret Cherry, Rosemary Kennedy, Karen Weeden, Letty Burridge, Alexandra Clavarino, Peter O'Rourke, Chris Del Mar

Christopher Del Mar

OBJECTIVE: To describe the utility and acceptability to general practitioners and palliative care staff of case conferences in palliative care. METHOD: Research focussed on case conferences conducted between GPs and staff of three specialist palliative care units (in an inner urban, outer metropolitan and regional setting), at the time of referral of patients to the service. Telephone interviews were conducted with all GPs who participated in a case conference, and focus groups were conducted with palliative care staff. RESULTS: For most GPs, case conferences by teleconference were a time effective and immediate means of information transfer. The best instances for …

Topical Analgesia For Acute Otitis Media, Ruth Foxlee, Ann-Charlotte Johansson, Jessika Wejfalk, Liz Dooley, Chris Del Mar

Christopher Del Mar

Background Acute otitis media (AOM) is a spontaneously remitting disease for which pain is the most distressing symptom. Antibiotics are now known to have less benefit than previously assumed. Objectives To assess the effectiveness of topical analgesia for AOM. Search strategy We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2006), MEDLINE (1966 to May Week 3 2006), EMBASE (1990 to December 2005) and LILACS (1982 to September 2005) without language restriction, and the reference lists of articles. We also contacted manufacturers and authors. Selection criteria Double-blind randomised or quasi-randomised controlled trials comparing an …

Non-Antibiotic Treatments For Sore Throat [Protocol], D. Francis, Chris Del Mar, M. Thomas, Paul Glasziou

Christopher Del Mar

This is the protocol for a review. The objective is as follows: 1. To determine the effect of non-antibiotic treatments in the management of sore throat in children and adults.

The View From Two Sides: A Qualitative Study Of Community And Medical Perspectives On Screening For Colorectal Cancer Using Fobt, Alexandra M. Clavarino, Monika Janda, Karen L. Hughes, Chris Del Mar, Shilu Tong, Warren R. Stanton, Joanne F. Aitken, Barbara A. Leggett, Beth Newman

Christopher Del Mar

Background. Population-wide screening for people at average risk of colorectal cancer (CRC) by faecal occult blood test (FOBT) is under consideration in Australia. Methods. Qualitative methods were used to examine the views of community members who did (n = 18) or did not (n = 12) participate in a pilot program of FOBT screening. In addition, views were obtained from general practitioners (GPs) and specialist gastroenterologists directly involved in the implementation of the program. Two focus group sessions were conducted with screening participants and interviews were conducted with non-participants, GPs and gastroenterologists. Results. The findings suggest that CRC screening by …

Models Of Disease, Chris Del Mar, Jenny Doust, Paul Glasziou

Christopher Del Mar

[Excerpt] What we will do here is set out some models of disease, and then apply them to some clinical problems to see how the models shape up. The models of disease we discuss are not all mutually exclusive, but different ways of viewing the clinical problems we encounter. The models include: *Cause and effect models, and their several variants; *‘edge of the distribution’ illnesses (also known as ‘spectrum disorders’); *Spontaneously remitting and self-perpetuating illnesses; and *‘alternative’ medicine models. These are all ‘transparent box’ approaches to disease: that is, a model of how the disease works, which in turn should …

Delayed Antibiotics For Symptoms And Complications Of Respiratory Infections [Review], Geoffrey K.P. Spurling, Chris Del Mar, Liz Dooley, Ruth Foxlee

Christopher Del Mar

Background: Providing patients with a prescription for antibiotics but suggesting delaying their use is a strategy that reduces antibiotic use. This review asks what effect this practice has on the clinical course of the illness. Objectives: To evaluate the clinical effect of delayed antibiotic use in acute upper respiratory tract infections compared to immediate use of antibiotics. Search strategy: The following electronic databases were searched: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2004), MEDLINE (January 1966 to January Week 1 2004), EMBASE (1990 to September 2003) and Current Contents (1998 to 2003). Selection criteria: …

Does Legislation Reduce Harm To Doctors Who Prescribe For Themselves?, Margaret Kay, Chris Del Mar, Geoffrey Mitchell

Christopher Del Mar

OBJECTIVE To consider the issue of legislation restricting self prescribing by doctors.

METHOD Searches of the medical literature in Medline, Australian Medical Index and CINAHL using the terms ‘medical’, ‘legislation’ and ‘physician impairment’from 1966–2003 supplemented by checking citations of review papers.

RESULTS We found 144 articles, although no trials of legislation. The remaining research was inadequate to answer the question of whether restricting self prescribing reduces doctor impairment. However, descriptive studies suggest that impairment attributed to self prescribing is most often from self administration, which is not altered by legislation to restrict self prescribing.

DISCUSSION There are important theoretical adverse …

General Practice Research, Deborah Askew, Chris Del Mar, Brian R. Mcavoy, David Lyle

Christopher Del Mar

This chapter sketches the current status of general practice research in Australia and includes suggestions for enhancing it.

Clinical Diagnosis And Management Of Suspicious Pigmented Skin Lesions: A Survey Of Gps, Peter D. Baade, Chris Del Mar, John B. Lowe, Warren R. Stanton, Kevin P. Balanda

Christopher Del Mar

BACKGROUND The ability of general practitioners to make important clinical decisions about the diagnosis and management of skin lesions is poorly understood. METHODS A questionnaire on the diagnosis and management of eight photographed skin lesions was sent to 150 GPs in southeast Queensland. RESULTS The questionnaire was completed by 114 GPs (response rate 77%). General practitioners’ provisional diagnoses and management of photographed skin lesions were mostly or always correct, and there was general high consistency between diagnosis and intended management. Pigmented seborrhoeic keratoses were the most difficult lesions for GPs to diagnose correctly. Whether a lesion was different to usual …

Safety Of Neuraminidase Inhibitors For Influenza, Mark Jones, Chris Del Mar

Christopher Del Mar

Neuraminidase inhibitors, oseltamivir and zanamivir, are used for the treatment of, and protection from, influenza. The safety of these compounds has been assessed in systematic reviews. However, the data presented are somewhat limited by the paucity of good quality adverse event data available. The majority of safety outcomes are based on evidence from just one or two randomised controlled trials. The results of the systematic reviews suggest that neuraminidase inhibitors have a reasonable side effect and adverse effect profile if they are to be used to treat or protect patients against a life-threatening disease. However, if these compounds are to …

"Drink Plenty Of Fluids": A Systematic Review Of Evidence For This Recommendation In Acute Respiratory Infections, Michelle P. B. Guppy, Sharon M. Mickan, Chris Del Mar

Christopher Del Mar

Doctors often recommend drinking extra fluids to patients with respiratory infections. Theoretical benefits for this advice are replacing insensible fluid losses from fever and respiratory tract evaporation, correcting dehydration from reduced intake, and reducing the viscosity of mucus. However there are theoretical reasons for increased fluid intake to cause harm. Giving extra fluids while antidiuretic hormone secretion is increased (reported in some lower respiratory tract infections) may theoretically lead to hyponatraemia and fluid overload. Despite a systematic review to determine whether recommending increased fluids was beneficial or harmful no randomised controlled trials comparing increased and restricted fluid regimens in patients …