Search

Objectives: To develop and implement an educational outreach programme for the integrated case management of priority respiratory diseases (practical approach to lung health in South Africa; PALSA) and to evaluate its effects on respiratory care and detection of tuberculosis among adults attending primary care clinics., Design: Pragmatic cluster randomised controlled trial, with clinics as the unit of randomisation., Setting: 40 primary care clinics, staffed by nurse practitioners, in the Free State province, South Africa., Participants: 1999 patients aged 15 or over with cough or difficult breathing (1000 in intervention clinics, 999 in control clinics)., Intervention: Between two and six educational outreach sessions delivered to nurse practitioners by usual trainers from the health department. The emphasis was on key messages drawn from the customised clinical practice guideline for the outreach programme, with illustrative support materials., Main Outcome Measures: Sputum screening for tuberculosis, tuberculosis case detection, inhaled corticosteroid prescriptions for obstructive lung disease, and antibiotic prescriptions for respiratory tract infections., Results: All clinics and almost all patients (92.8%, 1856/1999) completed the trial. Although sputum testing for tuberculosis was similar between the groups (22.6% in outreach group v 19.3% in control group; odds ratio 1.22, 95% confidence interval 0.83 to 1.80), the case detection of tuberculosis was higher in the outreach group (6.4% v 3.8%; 1.72, 1.04 to 2.85). Prescriptions for inhaled corticosteroids were also higher (13.7% v 7.7%; 1.90, 1.14 to 3.18) but the number of antibiotic prescriptions was similar (39.7% v 39.4%; 1.01, 0.74 to 1.38)., Conclusions: Combining educational outreach with integrated case management provides a promising model for improving quality of care and control of priority respiratory diseases, without extra staff, in resource poor settings., Trial Registration: Current controlled trials ISRCTN13438073.

Objectives: To determine the occurrence of respiratory morbidity during infancy after very premature birth and to identify risk factors., Design: Prospective follow up study., Setting: The United Kingdom oscillation study., Patients: 492 infants, all born before 29 weeks gestation., Interventions: Structured questionnaires were completed by local paediatricians when the infants were seen in outpatients at 6 and 12 months of age corrected for prematurity., Main Outcome Measures: Cough, wheeze, and treatment requirements and the composite measure of respiratory morbidity (cough, frequent cough, cough without infection, wheeze, frequent wheeze, wheeze without infection, and use of chest medicine) and their relation to 13 possible explanatory variables., Results: At 6 and 12 months of corrected age, 27% of the infants coughed and 6% had frequent (more than once a week) cough, and 20% and 3% respectively had wheeze or frequent wheeze. At 6 and 12 months, 14% of infants had taken bronchodilators and 8% inhaled steroids. After adjustment for multiple outcome testing, four factors were associated with increased respiratory morbidity: male sex, oxygen dependency at 36 weeks postmenstrual age, having older siblings aged less than 5 years, and living in rented accommodation., Conclusions: Male infants are particularly vulnerable to respiratory morbidity in infancy after very premature birth. It is important to identify a safe and effective strategy to prevent chronic oxygen dependency.

Though many of the treatment strategies used in palliative care have never been subjected to clinical trial, it has been argued that advances in palliative care have outstripped those in many other specialties. This article is not a comprehensive review of therapeutic options, nor even of recent advances in this topic, but concentrates on the latest developments and controversies in the pharmacological treatment of four frequent and important symptoms: neuropathic pain, anorexia and cachexia, intestinal obstruction, and breathlessness. It is difficult to perform blinded, randomised trials in patients with advanced disease and poor performance status, yet it is these patients who may gain most from the adoption of new well evaluated treatment strategies.