Search

BACKGROUND Financial incentives and audit plus feedback on performance are two strategies commonly used by governments to motivate general practitioners (GP) to undertake specific healthcare activities. However, in recent years, governments have reduced or removed incentive payments without evidence of the potential impact on GP behaviour and patient outcomes. This trial (known as ACCEPt-able) aims to determine whether preventive care activities in general practice are sustained when financial incentives and/or external audit plus feedback on preventive care activities are removed. The activity investigated is annual chlamydia testing for 16- to 29-year-old adults, a key preventive health strategy within this age group. METHODS/DESIGN ACCEPt-able builds on a large cluster randomised controlled trial (RCT) that evaluated a 3-year chlamydia testing intervention in general practice. GPs were provided with a support package to facilitate annual chlamydia testing of all sexually active 16- to 29-year-old patients. This package included financial incentive payments to the GP for each chlamydia test conducted and external audit plus feedback on each GP's chlamydia testing rates. ACCEPt-able is a factorial cluster RCT in which general practices are randomised to one of four groups: (i) removal of audit plus feedback-continue to receive financial incentive payments for each chlamydia test; (ii) removal of financial incentive payments-continue to receive audit plus feedback; (iii) removal of financial incentive payments and audit plus feedback; and (iv) continue financial incentive payments and audit plus feedback. The primary outcome is chlamydia testing rate measured as the proportion of sexually active 16- to 29-year-olds who have a GP consultation within a 12-month period and at least one chlamydia test. DISCUSSION This will be the first RCT to examine the impact of removal of financial incentive payments and audit plus feedback on the chlamydia testing behaviour of GPs. This trial is particularly timely and will increase our understanding about the impact of financial incentives and audit plus feedback on GP behaviour when governments are looking for opportunities to control healthcare budgets and maximise clinical outcomes for money spent. The results of this trial will have implications for supporting preventive health measures beyond the content area of chlamydia. TRIAL REGISTRATION The trial has been registered on the Australian and New Zealand Clinical Trials Registry ( ACTRN12614000595617 ).

BACKGROUND: Antibiotics provide only modest benefit in treating sore throat, although their effectiveness increases in people with positive throat swabs for group A beta‐haemolytic streptococci (GABHS). It is unclear which antibiotic is the best choice if antibiotics are indicated. This is an update of a review first published in 2010, and updated in 2013, 2016, and 2020. OBJECTIVES: To assess the comparative efficacy of different antibiotics in: (a) alleviating symptoms (pain, fever); (b) shortening the duration of the illness; (c) preventing clinical relapse (i.e. recurrence of symptoms after initial resolution); and (d) preventing complications (suppurative complications, acute rheumatic fever, post‐streptococcal glomerulonephritis). To assess the evidence on the comparative incidence of adverse effects and the risk‐benefit of antibiotic treatment for streptococcal pharyngitis. SEARCH METHODS: We searched the following databases up to 3 September 2020: CENTRAL (2020, Issue 8), MEDLINE Ovid (from 1946), Embase Elsevier (from 1974), and Web of Science Thomson Reuters (from 2010). We also searched clinical trial registers on 3 September 2020. SELECTION CRITERIA: Randomised, double‐blind trials comparing different antibiotics, and reporting at least one of the following: clinical cure, clinical relapse, or complications and/or adverse events. DATA COLLECTION AND ANALYSIS: Two review authors independently screened trials for inclusion and extracted data using standard methodological procedures as recommended by Cochrane. We assessed the risk of bias of included studies according to the methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions, and used the GRADE approach to assess the overall certainty of the evidence for the outcomes. We have reported the intention‐to‐treat analysis, and also performed an analysis of evaluable participants to explore the robustness of the intention‐to‐treat results. MAIN RESULTS: We included 19 trials reported in 18 publications (5839 randomised participants): six trials compared penicillin with cephalosporins; six compared penicillin with macrolides; three compared penicillin with carbacephem; one compared penicillin with sulphonamides; one compared clindamycin with ampicillin; and one compared azithromycin with amoxicillin in children. All participants had confirmed acute GABHS tonsillopharyngitis, and ages ranged from one month to 80 years. Nine trials included only, or predominantly, children. Most trials were conducted in an outpatient setting. Reporting of randomisation, allocation concealment, and blinding was poor in all trials. We downgraded the certainty of the evidence mainly due to lack of (or poor reporting of) randomisation or blinding, or both; heterogeneity; and wide confidence intervals. Cephalosporins versus penicillin We are uncertain if there is a difference in symptom resolution (at 2 to 15 days) for cephalosporins versus penicillin (odds ratio (OR) for absence of symptom resolution 0.79, 95% confidence interval (CI) 0.55 to 1.12; 5 trials; 2018 participants; low‐certainty evidence). Results of the sensitivity analysis of evaluable participants differed (OR 0.51, 95% CI 0.27 to 0.97; 5 trials; 1660 participants; very low‐certainty evidence). We are uncertain if clinical relapse may be lower for cephalosporins compared with penicillin (OR 0.55, 95% CI 0.30 to 0.99; number needed to treat for an additional beneficial outcome (NNTB) 50; 4 trials; 1386 participants; low‐certainty evidence). Very low‐certainty evidence showed no difference in reported adverse events. Macrolides versus penicillin We are uncertain if there is a difference between macrolides and penicillin for resolution of symptoms (OR 1.11, 95% CI 0.92 to 1.35; 6 trials; 1728 participants; low‐certainty evidence). Sensitivity analysis of evaluable participants resulted in an OR of 0.79, 95% CI 0.57 to 1.09; 6 trials; 1159 participants). We are uncertain if clinical relapse may be different (OR 1.21, 95% CI 0.48 to 3.03; 6 trials; 802 participants; low‐certainty evidence). Azithromycin versus amoxicillin Based on one unpublished trial in children, we are uncertain if resolution of symptoms is better with azithromycin in a single dose versus amoxicillin for 10 days (OR 0.76, 95% CI 0.55 to 1.05; 1 trial; 673 participants; very low‐certainty evidence). Sensitivity analysis for per‐protocol analysis resulted in an OR of 0.29, 95% CI 0.11 to 0.73; 1 trial; 482 participants; very low‐certainty evidence). We are also uncertain if there was a difference in relapse between groups (OR 0.88, 95% CI 0.43 to 1.82; 1 trial; 422 participants; very low‐certainty evidence). Adverse events were more common with azithromycin compared to amoxicillin (OR 2.67, 95% CI 1.78 to 3.99; 1 trial; 673 participants; very low‐certainty evidence). Carbacephem versus penicillin There is low‐certainty evidence that compared with penicillin, carbacephem may provide better symptom resolution post‐treatment in adults and children (OR 0.70, 95% CI 0.49 to 0.99; NNTB 14.3; 3 trials; 795 participants). Studies did not report on long‐term complications, so it was unclear if any class of antibiotics was better in preventing serious but rare complications. AUTHORS' CONCLUSIONS: We are uncertain if there are clinically relevant differences in symptom resolution when comparing cephalosporins and macrolides with penicillin in the treatment of GABHS tonsillopharyngitis. Low‐certainty evidence in children suggests that carbacephem may be more effective than penicillin for symptom resolution. There is insufficient evidence to draw conclusions regarding the other comparisons in this review. Data on complications were too scarce to draw conclusions. These results do not demonstrate that other antibiotics are more effective than penicillin in the treatment of GABHS pharyngitis. All studies were conducted in high‐income countries with a low risk of streptococcal complications, so there is a need for trials in low‐income countries and Aboriginal communities, where the risk of complications remains high.

This is the protocol for a review and there is no abstract. The objectives are as follows: The overall objective of this review is to identify interventions aimed at improving clinicians' prescribing of medications recommended by national and international guidelines for HF management and to assess their overall efficacy measured in terms of clinician prescribing behavior and patient-level HF outcomes.

Background Totally implantable venous access ports (TIVAPs) provide patients with a safe and permanent venous access, for instance in the administration of chemotherapy for oncology patients. There are several methods for TIVAP placement, and the optimal evidence-based method is unclear. Objectives To compare the efficacy and safety of three commonly used techniques for implanting TIVAPs: the venous cutdown technique, the Seldinger technique, and the modified Seldinger technique. This review includes studies that use Doppler or real-time two-dimensional ultrasonography for locating the vein in the Seldinger technique. Search methods The Cochrane Vascular Trials Search Co-ordinator searched the Cochrane Vascular Specialised Register (last searched August 2015) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 7), as well as clinical trials registers. Selection criteria We included randomised or quasi-randomised controlled clinical trials that randomly allocated people requiring TIVAP to the venous cutdown, Seldinger, or modified Seldinger technique. Two review authors independently assessed studies for inclusion eligibility, with a third review author checking excluded studies. Data collection and analysis Two review authors independently extracted data. We assessed all studies for risk of bias. We assessed heterogeneity using Chi2 statistic and variance (I2statistic) methods. Dichotomous outcomes, summarised as odds ratio (OR) with 95% confidence interval (CI), were: primary implantation success, complications (in particular infection), pneumothorax, and catheter complications. We conducted separate analyses to assess the two access veins, subclavian and internal jugular (IJ) vein, in the Seldinger technique versus the venous cutdown technique. We used both intention-to-treat (ITT) and on-treatment analyses and pooled data using a fixed-effect model. Main results We included nine studies with a total of 1253 participants in the review. Five studies compared Seldinger technique (subclavian vein access) with venous cutdown technique (cephalic vein access). Two studies compared Seldinger (IJ vein) versus venous cutdown (cephalic vein). One study compared the modified Seldinger technique (cephalic vein) with the venous cutdown (cephalic vein), and one study compared the Seldinger (subclavian vein) versus the Seldinger (IJ vein) technique. Seldinger technique (subclavian or IJ vein access) versus venous cutdown (cephalic vein): We included seven trials with 1006 participants for analysis. Both ITT (OR 0.40; 95% CI 0.25 to 0.65) and on-treatment analysis (OR 0.59; 95% CI 0.36 to 0.98) showed that the Seldinger technique for implantation of TIVAP had a higher success rate compared with the venous cutdown technique. We found no difference between overall peri- and postoperative complication rates: ITT (OR 1.16; 95% CI 0.76 to 1.75) and on-treatment analysis (OR 0.93; 95% CI 0.62 to 1.40). In the Seldinger group, the majority of the trials reported use of the subclavian vein for venous access, with only a limited number of trials utilising the IJ vein for access. When individual complication rates of infection, pneumothorax, and catheter complications were analysed, the Seldinger technique (subclavian vein access) was associated with a higher rate of catheter complications compared to the venous cutdown technique: ITT (OR 6.77; 95% CI 2.31 to 19.79) and on-treatment analysis (OR 6.62; 95% CI 2.24 to 19.58). There was no difference in incidence of infections, pneumothorax, and other complications between the groups. Modified Seldinger technique (cephalic vein) versus venous cutdown (cephalic vein): We identified one trial with 164 participants. ITT analysis showed no difference in primary implantation success rate between the modified Seldinger technique (69/82, 84%) and the venous cutdown technique (66/82, 80%), P = 0.686. We observed no differences in the peri- or postoperative complication rates. Seldinger (subclavian vein access) versus Seldinger (IJ vein access): We identified one trial with 83 participants. The primary success rate was 84% (37/44) for Seldinger (subclavian vein) versus 74% (29/39) for the Seldinger (IJ vein). There was a higher overall complication rate in the subclavian group (48%) compared to the jugular group (23%), P = 0.02. However, when specific complications were compared individually, we found no differences between the groups. The overall quality of the trials included in this review was moderate. The methods used for randomisation were inadequate in four of the nine included studies, but sensitivity analysis excluding these trials did not alter the outcome. The nature of the interventions, either venous cutdown or Seldinger techniques, meant that it was not feasible to blind the participant or personnel, therefore we judged this to be at low risk of bias. The majority of participants in the included trials were oncology patients at tertiary centres, and the outcomes were applicable to the typical clinical scenario. For all outcomes, when comparing venous cutdown and Seldinger technique, serious imprecision was evident by wide confidence intervals in the included trials. The quality of the overall evidence was therefore downgraded from high to moderate. Due to the limited number of included studies we were unable to assess publication bias. Authors' conclusions Moderate-quality evidence showed that the Seldinger technique has a higher primary implantation success rate compared with the venous cutdown technique. The majority of trials using the Seldinger technique used the subclavian vein for venous access, and only a few trials reported the use of the internal jugular vein for venous access. Moderate-quality evidence showed no difference in the overall complication rate between the Seldinger and venous cutdown techniques. However, when the Seldinger technique with subclavian vein access was compared with the venous cutdown group, there was a higher reported incidence of catheter complications. The rates of pneumothorax and infection did not differ between the Seldinger and venous cutdown group. We identified only one trial for each of the comparisons modified Seldinger technique (cephalic vein) versus venous cutdown (cephalic vein) and Seldinger (subclavian vein access) versus Seldinger (IJ vein access), thus a definitive conclusion cannot be drawn for these comparisons and further research is recommended.

Background While there is a significant focus on the health and well-being of women during pregnancy, labour and birth, much less emphasis is placed on the care of postpartum women and their infants in primary care following the birth. Some studies have investigated the role of GPs in postpartum care, and others examined facilitators and barriers to mothers accessing care. However there is little information available to investigate the effect of practice related factors on access to care of mothers and infants at this time. Methods A 20-item questionnaire for completion by the practice managers was mailed to 497 general practices in Southern Queensland, Australia between February and July 2013. Questionnaire items included practice demographics, practice procedures and personnel including appointment scheduling, billing, practice nurse function and qualifications and a free-text option for comments. Descriptive statistics are presented as numbers and percentages. Chi Squared test compared practice location with methods of identification of postpartum women, practice size with other Queensland data and ANOVA compared practice size with the number of postpartum appointments. Logistic regression was used to predict variables that were related to booked appointment times. Free text responses were grouped in common themes. Results The response rate was 27.4 %. At 67.2 % of the practices, mothers had to self-identify as needing a postpartum consultation and most consultations were allocated 15 minutes or less. Only 20 % of practices accepted the government insurance payment (bulk-billing) for all maternal and infant services, with more practices bulk-billing children only. Out-of-pocket expenses ranged from $10-$60. Nearly 80 % of practice nurses saw postpartum mothers or infants ‘nearly always’ or ‘sometimes’. Approximately 30 % had midwifery or child health training. There were higher odds of longer booked appointment times for solo practitioner practices (unadj OR 3.30 95%CI 1.03-10.57), but no other variables predicted booked appointment times Conclusions This study identified a number of practice related factors that, if addressed, could positively impact on postpartum care. These include ensuring ongoing practice relationships to assist with booking appropriate consultation times and guaranteeing that there are no financial impediments to women accessing care. Some factors can easily be adapted within practices. Others would require changes of policy at a local or national level. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1508-1) contains supplementary material, which is available to authorized users.

Objectives To identify consumer information needs about paracetamol, the most commonly used analgesic and antipyretic worldwide. Design Retrospective analysis of medicines questions from the public. Setting Australian consumer medicines call centre. Participants Callers to National Prescribing Service Medicines Line between September 2002 and June 2010 (n=123 217). Main outcome measures Enquiry profile: demographics, enquiry type and concurrent medicines included in paracetamol calls; question themes derived from subset of call narratives. Results Paracetamol comprised part of the enquiry in 5.2% of calls (n=6367). The caller age distribution for paracetamol calls was skewed towards a younger cohort, with 45.2% made by those aged 25–44 vs 37.5% in ‘rest of calls’. Significantly more paracetamol-related calls were made for a child (23.7%) compared with ‘rest of calls’ (12.7%, p

Acute sore throat is a common condition presenting to family practitioners. It is usually self-limiting, with antibiotic treatment recommended only for high-risk presentations. Overprescribing of antibiotics contributes to individual and community resistance. Learning to prescribe in the context of diagnostic uncertainty and patient pressures is a challenge for early-career doctors. Prescribing habits develop early and tend not to change with time. To establish the prevalence and associations of antibiotic prescribing for acute sore throat by Australian vocational trainees in family practice. A cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study. This ongoing, multicentre prospective cohort study documents the nature of trainees' consultation-based clinical experiences. Univariate and logistic regression analyses were conducted on data recorded in consultations for sore throat in nine collection periods during 2010-14. Data from 856 individual trainees (response rate 95.2%) were analysed. Sore throat was managed in 2.3% encounters. Antibiotics were prescribed for 71.5% of sore throat diagnoses. The variables associated with prescribing were inner-regional location and higher socio-economic area. There was no significant association with younger age of patient or greater trainee experience. If an antibiotic was prescribed, the trainee was more likely to seek information from guidelines or a supervisor. The high frequency of antibiotic prescribing and the lack of attenuation in prescribing with increased experience suggest current educational interventions and the apprenticeship model of training is not fostering appropriate practice in this important clinical area. Targeted educational interventions, for supervisors as well as trainees, are indicated.

Objectives: Immunisation is crucial to population health. This study aimed to identify the information needs and concerns of health consumers regarding childhood vaccination. Methods: We analysed 1,342 calls concerning childhood vaccination to an Australian pharmacist‐operated medicines call centre (MCC). Data were available from September 2002 until June 2010. We identified key themes and compared these for callers from high and low immunisation coverage areas. Results: Most calls related to safety concerns (60.4%), with many questions about vaccine constituents (31.6%). In low immunisation areas, a higher level of concern persisted about vaccine preservatives (mercury and thiomersal) despite their removal from vaccines in 2000. Of specific vaccines, the measles, mumps and rubella vaccine raised most questions (29.9%). Common motivations to call the MCC were ‘inadequate information’ (54%), ‘second opinion’ (21%) ‘conflicting information’ (9%) and ‘worrying symptom’ (6%). Conclusion and implications: The consistent number of vaccine‐related calls, particularly about safety, demonstrates an information gap that can contribute to vaccination hesitancy. Health professionals need to know their local immunisation rate and associated carer concerns, to proactively address these information‐related barriers to vaccination.

Immune dysfunction is a hallmark of Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME). The purpose of this pilot study was to identify the effects of influenza vaccination on immune function in patients with CFS/ME. We included 7 patients meeting the Centre for Disease Control and Prevention criteria (CDC 1994) for ME/CFS and 8 control subjects. Bloods were collected from all participants prior to vaccination with Influvac, a trivalent inactivated influenza vaccine (TIV), 14 and 28 days following vaccination. The immune parameters examined include Natural Killer (NK) phenotypes, NK cytotoxic activity, FOXP3 and Th1/Th2/Th17 related cytokines. Flow cytometric protocols were employed. There was no significant difference in NK phenotypes and Tregs numbers between CFS/ME patients and healthy controls. However, NK activity was significantly decreased at baseline and at 28 days, while at 14 days it significantly increased in the CFS/ME patients compared to the healthy controls. Th1 pro-inflammatory cytokines increased considerably in the CFS/ME patients at 28 days compared to the non-fatigued controls. Only one Th2 cytokine, IL-4, increased in the CFS/ME participants. FOXP3 expressing Tregs only increased significantly at day 28 post vaccination in the CFS/ME patients compared to the healthy controls. Self-rated wellbeing was lower for patients at day 28 while at baseline and day 14 no differences were observed. In this pilot study immunization with influenza vaccine is accompanied by a degree of immune dysregulation in CFS/ME patients compared with controls. While vaccination may protect CFS/ME patients against influenza, it has the ability to increase cytotoxic activity and pro-inflammatory reactions post vaccination. The role of Tregs in promoting a toxic effect at 28 days post-vaccination in our patient group cannot be ruled out. The benefits of influenza vaccine still likely outweigh the risks CFS/ME patients experience following vaccination.

Background Antibiotics provide only modest benefit in treating sore throat, although effectiveness increases in participants with positive throat swabs for group A beta-haemolytic streptococci (GABHS). It is unclear which antibiotic is the best choice if antibiotics are indicated. Objectives We assessed the comparative efficacy of different antibiotics on clinical outcomes, relapse, complications and adverse events in GABHS tonsillopharyngitis. Search methods We searched The Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL 2010, Issue 3) which includes the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to July Week 4, 2010) and EMBASE (1974 to August 2010). Selection criteria Randomised, double-blind trials comparing different antibiotics reporting at least one of the following: clinical cure, clinical relapse, complications, adverse events. Data collection and analysis Two authors independently screened trials for inclusion and extracted data. Main results Seventeen trials (5352 participants) were included; 16 compared with penicillin (six with cephalosporins, six with macrolides, three with carbacephem and one with sulfonamides), one trial compared clindamycin and ampicillin. Randomisation reporting, allocation concealment and blinding were poor. There was no difference in symptom resolution between cephalosporins and penicillin (intention-to-treat (ITT) analysis; N = 5; n = 2018; odds ratio for absence of resolution of symptoms (OR) 0.79, 95% confidence interval (CI) 0.55 to 1.12). Clinical relapse was lower with cephalosporins (N = 4; n = 1386; OR 0.55, 95% CI 0.31 to 0.99); overall number needed to treat to benefit (NNTB) 50), but found only in adults (OR 0.42, 95% CI 0.20 to 0.88; NNTB 33). There were no differences between macrolides and penicillin. Carbacephem showed better symptom resolution post-treatment (N = 3; n = 795; OR 0.70, 95% CI 0.49 to 0.99; NNTB 14), but only in children (N = 2; n = 233; OR 0.57, 95% CI 0.33 to 0.99; NNTB 8.3). Children experienced more adverse events with macrolides (N = 1, n = 489; OR 2.33; 95% CI 1.06 to 5.15). Authors' conclusions Evidence is insufficient for clinically meaningful differences between antibiotics for GABHS tonsillopharyngitis. Limited evidence in adults suggests cephalosporins are more effective than penicillin for relapse, but the NNTB is high. Limited evidence in children suggests carbacephem is more effective for symptom resolution. Data on complications are too scarce to draw conclusions. Based on these results and considering the low cost and absence of resistance, penicillin can still be recommended as first choice. Plain Language Summary Different antibiotics for group A streptococcal pharyngitis Pharyngitis or tonsillitis, a throat infection that usually presents with a sore throat, is a common upper respiratory tract infection. Most sore throats are caused by viruses, but sometimes bacteria are involved. Many people carry bacteria in their throat without becoming ill. However, sometimes a bacterial throat infection can occur. Infection with a specific type of bacteria, group A beta-haemolytic streptococci (GABHS) is linked to serious complications such as acute rheumatic fever or kidney disease (post-streptococcal glomerulonephritis). In order to prevent these complications antibiotics are often prescribed to treat patients presenting to their doctor with a sore throat. A previous Cochrane review found that there is only a modest benefit of antibiotics for treating an acute sore throat, even if group A beta-haemolytic streptococci (GABHS) are present. Most throat infections, even with bacteria, are self-limiting and the risk of complications is extremely low in most populations studied (in low-income countries). However, sometimes antibiotics may be indicated. We found 17 trials with a total of 5352 participants that studied the effects of different classes of antibiotics on resolution of symptoms in patients with a sore throat and a positive culture for GABHS. Our review found that the effects of these antibiotics are very similar. All antibiotics studied also cause undesired side effects (such as nausea and vomiting, rash), but there was no strong evidence for meaningful differences between the antibiotics. The studies did not report on long-term complications and therefore it is unclear if any class of antibiotics is better in preventing these serious but rare complications. As all the identified studies were carried out in populations in high-income countries with a low risk of streptococcal complications, there is a need for trials in populations where this risk is still very high (low-income countries and Aboriginal communities). Penicillin has been used for a very long time but resistance of the GABHS to penicillin has never been reported. Also, penicillin is a cheap antibiotic. Our review therefore supports the use of penicillin as a first choice antibiotic in patients with acute throat infections caused by GABHS.

Matthys J, De Meyere M, Van Driel ML, De Sutter A. Verschillen tussen nationale faryngitisrichtlijnen niet louter academisch. Huisarts Wet 2009;52(2):63-7. Doel Veel landen hanteren nationale richtlijnen voor de behandeling van faryngitis. Wij hebben een vergelijking gemaakt van de aanbevelingen en het gerapporteerde bewijsmateriaal in nationale richtlijnen voor de behandeling van acute keelpijn bij volwassenen. Methode Voor een review verzamelden we verschillende richtlijnen met behulp van MEDLINE en EMBASE en via internet, waarbij we zochten naar organisaties die richtlijnen hebben ontwikkeld. De inhoud van de aanbevelingen en de onderliggende evidence analyseerden we met kwalitatieve en bibliometrische methoden. Resultaten We analyseerden vier Noord-Amerikaanse en zes Europese richtlijnen. Deze richtlijnen verschillen wat betreft het gebruik van de snelle antigeentest en de keelkweek, en met betrekking tot het voorschrijven van antibiotica. De Noord-Amerikaanse, Franse en Finse richtlijnen beschouwen de diagnose van groep-A-streptokokken als essentieel, waarbij de preventie van acuut reuma een belangrijke reden is voor het voorschrijven van antibiotica. Vier van de zes Europese richtlijnen beschrijven acute keelpijn als een self-limited disease en raden het gebruik van antibiotica daarom af. De samenstellers van de Noord-Amerikaanse richtlijnen gebruiken andere evidence voor de onderbouwing dan die van de Europese. Noord-Amerikaanse richtlijnen verwijzen meer naar Noord-Amerikaanse literatuur dan Europese richtlijnen (87,2% versus 48,0%; oddsratio 4,6-11,9; p < 0,001). Conclusie Hoewel evidence voor de behandeling van keelpijn gemakkelijk te vinden is, verschillen nationale richtlijnen met betrekking tot de keuze van het bewijsmateriaal en de interpretatie daarvan ten behoeve van de klinische praktijk. Bovendien bestaat er geen transparante en gestandaardiseerde methode voor de ontwikkeling van richtlijnen. Deze bevindingen zijn van belang voor de juiste toepassing van antibiotica, het probleem van toenemende antimicrobiele resistentie en dat van stijgende maatschappelijke kosten.

Purpose: To explore the effect on prescribing of policies that lift reimbursement restrictions on selected H2-antihistamines and proton pump inhibitors (PPI) and of practice recommendations. Methods: Monthly claims based data for proton pump inhibitors (PPIs) and H-antihistamines were obtained from the national health insurance database (Farmanet 1997-2005). Two policies were issued. In March 2001 two H2-antihistamines and in March 2003 two PPIs became available without restrictions. An evidence report was distributed in September 2004. Periods before and after implementation of the interventions were compared. Interrupted time series with segmented regression analysis was used to assess and compare time trends. Results: The first policy resulted in an increase of volume (1.6 million DDDs; 95% CI 1.4-1.8 million; p

Objective To review systematically the evidence of effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses. Data sources Cochrane Library, Medline, OldMedline, Embase, and CINAHL, without restrictions on language or publication. Data selection Studies of any intervention to prevent the transmission of respiratory viruses (isolation, quarantine, social distancing, barriers, personal protection, and hygiene). A search of study designs included randomised trials, cohort, case-control, crossover, before and after, and time series studies. After scanning of the titles, abstracts and full text articles as a first filter, a standardised form was used to assess the eligibility of the remainder. Risk of bias of randomised studies was assessed for generation of the allocation sequence, allocation concealment, blinding, and follow-up. Non-randomised studies were assessed for the presence of potential confounders and classified as being at low, medium, or high risk of bias. Data synthesis 58 papers of 59 studies were included. The quality of the studies was poor for all four randomised controlled trials and most cluster randomised controlled trials; the observational studies were of mixed quality. Meta-analysis of six case-control studies suggested that physical measures are highly effective in preventing the spread of severe acute respiratory syndrome: handwashing more than 10 times daily (odds ratio 0.45, 95% confidence interval 0.36 to 0.57; number needed to treat=4, 95% confidence interval 3.65 to 5.52), wearing masks (0.32, 0.25 to 0.40; NNT=6, 4.54 to 8.03), wearing N95 masks (0.09, 0.03 to 0.30; NNT=3, 2.37 to 4.06), wearing gloves (0.43, 0.29 to 0.65; NNT=5, 4.15 to 15.41), wearing gowns (0.23, 0.14 to 0.37; NNT=5, 3.37 to 7.12), and handwashing, masks, gloves, and gowns combined (0.09, 0.02 to 0.35; NNT=3, 2.66 to 4.97). The combination was also effective in interrupting the spread of influenza within households. The highest quality cluster randomised trials suggested that spread of respiratory viruses can be prevented by hygienic measures in younger children and within households. Evidence that the more uncomfortable and expensive N95 masks were superior to simple surgical masks was limited, but they caused skin irritation. The incremental effect of adding virucidals or antiseptics to normal handwashing to reduce respiratory disease remains uncertain. Global measures, such as screening at entry ports, were not properly evaluated. Evidence was limited for social distancing being effective, especially if related to risk of exposure—that is, the higher the risk the longer the distancing period. Conclusion Routine long term implementation of some of the measures to interrupt or reduce the spread of respiratory viruses might be difficult. However, many simple and low cost interventions reduce the transmission of epidemic respiratory viruses. More resources should be invested into studying which physical interventions are the most effective, flexible, and cost effective means of minimising the impact of acute respiratory tract infections.

PURPOSE Many countries have national guidelines for the treatment of pharyngitis. We wanted to compare the recommendations and the reported evidence in national guidelines for the management of acute sore throat in adults. METHODS Guidelines were retrieved via MEDLINE and EMBASE and through a Web-based search for guideline development organizations. The content of the recommendations and the underlying evidence were analyzed with qualitative and bibliometric methods. RESULTS We included 4 North American and 6 European guidelines. Recommendations differ with regard to the use of a rapid antigen test and throat culture and with the indication for antibiotics. The North American, French, and Finnish guidelines consider diagnosis of group A streptococcus essential, and prevention of acute rheumatic fever remains an important reason to prescribe antibiotics. In 4 of the 6 European guidelines, acute sore throat is considered a self-limiting disease and antibiotics are not recommended. The evidence used to underpin these guidelines was different in North America and Europe. North American guidelines cited more North American references than did European guidelines (87.2% vs 48.0%; ods ratio, 4.6–11.9; P

Rationale In Belgium, several policies regulating reimbursement of acid suppressant drugs and evidence-based recommendations for clinical practice were issued in a short period of time, creating a unique opportunity to observe their effect on prescribing. Aims and objectives To describe the evolution of prescriptions for acid suppressants and explore the interaction of policies and practice recommendations with prescribing patterns. Method Monthly claims-based data for proton pump inhibitors (PPIs) and H 2 -antihistamines by general practitioners, internists and gastroenterologists were obtained from the Belgian national health insurance database (1997‐2005). The evolution of reimbursed defined daily doses and expenses after introduction of reimbursement regulations and dissemination of practice recommendations was explored. Results Recommendations had no impact on prescribing. All changes can be related to concomitant policies. Lifting reimbursement restrictions for cheaper products did not control growth or save costs in the long term. Only restricting reimbursement of all PPIs managed to curb the growth. We observed an unintended increase of non-omeprazole PPIs by gastroenterologists. Conclusions Reimbursement policies influence prescribing, but their effect can be unintended. A dialogue between policymakers and guideline developers, and evidence-based policies that are linked to clinical guidelines, could be an effective way to pursue both costcontainment and quality of care.

This is the fourth article in a series providing evidence-based answers to common questions about complementary medicines from consumers and healthcare professionals.

Objective In the context of increasing over-testing and the implications for patient safety, to establish the prevalence and nature of pathology test-ordering of GP trainees, and to describe the associations of this test-ordering. Design A cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) cohort study. Setting Five of Australia's 17 general practice regional training providers, encompassing urban-to-very remote practices. Participants GP trainees. Main Outcome Measure(s) The number of pathology tests ordered per problem/diagnosis managed. Results A total of 856 individual trainees (response rate 95.2%) contributed data from 1832 trainee-terms, 108 759 encounters and 169 304 problems. Pathology test-ordering prevalence was 79.3 tests (95% CI: 78.8–79.8) per 100 encounters, 50.9 (95% CI: 50.6–51.3) per 100 problems, and at least 1 test was requested in 22.4% of consultations. Most commonly ordered was full blood count (6.1 per 100 problems). The commonest problem prompting test-ordering was ‘check-up’ (18.6%). Test-ordering was significantly associated, on multivariable analysis, with the trainee having worked at the practice previously; the patient being adult, male and new to both trainee and practice; the practice being urban; the problem/diagnosis being new; imaging being ordered; referral being made and follow-up being arranged. Trainees were significantly less likely to order tests for problems/diagnoses for which they had sought in-consultation information or advice. Conclusions Compared with the established GPs, trainees order more pathology tests per consultation and per problem managed, and in a higher proportion of consultations. Our findings will inform educational policy to enhance quality and safety in general practice training.

BACKGROUND: Control of rubella is desired because infection in early pregnancy can result in miscarriage, foetal death or congenital abnormality. Primary studies examining the effectiveness of immunoglobulins for post‐exposure prophylaxis of rubella have small sample sizes and varying results. National public health recommendations suggest a degree of effectiveness. OBJECTIVES: To assess the effectiveness of intramuscular injection or intravenous infusion of polyclonal immunoglobulins of human sera or plasma origin for preventing rubella and congenital rubella syndrome when administered to exposed susceptible people before the onset of disease. SEARCH METHODS: We searched CENTRAL (2014, Issue 7), MEDLINE (1946 to August week 2, 2014), EMBASE (1974 to August 2014), CINAHL (1981 to August 2014), LILACS (1982 to August 2014) and Web of Science (1955 to August 2014). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry on 16 October 2014. We searched the reference lists of relevant retrieved reviews and studies and identified national public health guidelines. SELECTION CRITERIA: For the outcome 'preventing cases of rubella', we included randomised controlled trials (RCTs) and quasi‐RCTs. We found several studies addressing this outcome where the design was a controlled clinical trial (CCT) (with exposure to rubella virus controlled by the investigators) but the method of allocation of participants to groups was not reported. We found an alternative report of one of these studies that indicated participants were assigned to groups randomly. We therefore included such studies as meeting criteria for RCTs or quasi‐RCTs and undertook sensitivity analyses. For the outcomes, 'congenital rubella infection' and 'congenital rubella syndrome', we included RCTs, quasi‐RCTs and prospective controlled (cohort) studies. Participants were necessarily susceptible and exposed to rubella. Polyclonal immunoglobulins derived from human sera or plasma must have been administered intramuscularly or intravenously as the only intervention in at least one group. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS: We included 12 studies (430 participants) in the review: seven RCTs and five CCTs where it was not clear whether participants were randomly allocated to groups. We did not include any unpublished studies. Participants included children and adults of both sexes. Only one study included pregnant women. All studies were conducted in high‐income countries. The quality of the 11 studies in the initial meta‐analysis was moderate, although we classified no study as having a low risk of bias on all criteria. We included 11 studies in the initial meta‐analysis of gamma‐globulin (concentrated polyclonal immunoglobulins) versus control (saline or no treatment) for rubella cases. The result favoured the intervention group (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.45 to 0.83) but was heterogenous (Chi² test = 36.59, df = 10 (P value < 0.0001); I² statistic = 73%). Heterogeneity was explained by subgrouping studies according to the estimated volume of gamma‐globulin administered per pound of bodyweight and then removing those studies where the intervention was administered more than five days after participant exposure to rubella (post hoc analysis). The test of subgroup differences demonstrated heterogeneity between subgroups according to our protocol definition (P value < 0.1; I² statistic > 60%) and there appeared to be greater effectiveness of the intervention when a greater volume of gamma‐globulin was administered ('0.027 to 0.037 ml/lb' RR 1.60 (95% CI 0.57 to 4.52); '0.1 to 0.15 ml/lb' RR 0.53 (95% CI 0.29 to 0.99); '0.2 to 0.5 ml/lb' RR 0.20 (95% CI 0.04 to 1.00)). None of the studies reported the outcome 'congenital rubella infection'. One included study reported on congenital rubella syndrome, with no cases among participants who were fewer than nine weeks pregnant at enrolment and who were randomised to one of two gamma‐globulin groups ('high' or 'low' rubella titre). However, the study did not report how congenital rubella syndrome was measured and did not report the length of follow‐up according to intervention group. This study did not include a non‐treatment group. No included study measured adverse events. AUTHORS' CONCLUSIONS: Compared to no treatment, polyclonal immunoglobulins seem to be of benefit for preventing rubella. The available evidence suggests that this intervention may be of benefit up to five days after exposure, and that effectiveness is dependent on dose. Considering the attack rate for rubella cases in the control group of the highest volume gamma‐globulin subgroup (333 per 1000), the absolute risk reduction (calculated from the RR) for this volume of gamma‐globulin was 266 (95% CI 0 to 320) and the number needed to treat to benefit is four (95% CI 3 to incalculable). The included studies did not measure rubella‐specific antibodies in the immunoglobulin products used in a standard way and thus estimation of the dose of rubella‐specific antibodies in international units administered was not possible. As the concentration of rubella‐specific antibodies in today's polyclonal immunoglobulin products may vary from those products used in the studies in the review, the volume required per pound of bodyweight to produce similar results may also vary. There is insufficient evidence to make direct conclusions about the effectiveness of polyclonal immunoglobulins for preventing congenital rubella syndrome. This is an area requiring further research.

Objectives Informational and management continuity of care assists in providing a seamless transition for women and infants from tertiary or secondary to primary care during the post partum period. Few studies have evaluated the interaction between different aspects of the health system following a woman’s discharge from hospital after the birth of her infant. The present study describes how general practitioners (GPs) experience communications with hospitals and other post partum care providers relevant to continuity of care. Methods In the present cross-sectional study, a 52-item questionnaire adapted from a previously used survey was mailed to 932 GPs in southern Queensland, Australia, between February and July 2013. Questionnaire items included participant demographics, the timeliness and usability of discharge summaries, communication with other post partum care providers and consultation practices. Results The response rate was 17.4%. Nearly one-quarter of participants never or rarely received a hospital discharge summary in a timely manner and most considered the summaries somewhat useful. Few GPs (14.3%) had contact with or received information from domiciliary midwives who conducted post partum home visits. A higher proportion (38%) had some communication with a Child and Family Health nurse in the month before the survey. Conclusions Information flow from hospital to general practice and between other post partum care providers is less than ideal and may affect ongoing care for mothers and infants, especially those at risk. Knowledge exchange between healthcare services and initiatives to improve information sharing needs to be developed and implemented. What is already known on this topic? Transitions from tertiary or secondary care to primary care and between primary care providers are often times of vulnerability for patients, including women and infants in the post partum period. There is little information documenting communications between different maternity services and GPs that facilitate ongoing care. What does this paper add? There are significant gaps in the exchange of information about post partum women and infants from hospitals to GPs and a lack of communication between GPs and other post partum care providers, such as domiciliary midwives and Child and Family Health nurses. What are the implications for practitioners? Improvements in the timeliness, presentation and content of hospital discharge summaries, as well as enhancing channels of communication, collaboration, cooperation and information sharing between providers of community post partum care, are necessary if mothers are to receive the best care possible.

Timely identification of patients who will die in the foreseeable future is essential to providing appropriate care, but such identification is difficult. This study aims to identify evidence-based early identification tools for life limiting illness in the primary care setting, and to describe their core elements. Four diagnostic tools were identified. A narrative process described and compared the identified tools with a focus on practicality in clinical care. The tools identified pave the way for the development of an international, standardized, evidence-based approach to the early identification of palliative patients.

Guidelines recommend anxiolytics and hypnotics (A/H) as second-line, short-term medications. We aimed to establish prevalence and associations of A/H prescribing by Australian general practice (GP) trainees.A cross-sectional analysis from a cohort study of vocational trainees from four GP Regional Training Providers during 2010-2013. General practice trainees act as independent practitioners (including for prescribing purposes) while having recourse to advice from a GP supervisor. Practice and trainee demographic data were collected as well as patient, clinical and educational data from 60 consecutive consultations of each trainee each training term. Analysis was at the level of individual problem managed, with the outcome factor being prescription of any anxiolytic or hypnotic.Overall, 645 registrars (response rate 94.0%) prescribed 68 582 medications in 69 621 consultations (with 112 890 problems managed). A/Hs were prescribed for 1.3% of problems managed and comprised 2.2% of all prescriptions. They were prescribed particularly for insomnia (28.2%) or anxiety (21.8%), but also for many 'off-label' indications. Significant associations of A/H prescriptions were: patient-level (greater age, Aboriginal and Torres Strait Islander status, English-speaking background, being new to the trainee but not to the practice); trainee-level (male) and consultation-level (longer duration, pre-existing problem, specialist referral not being made). Prescribing was significantly lower in one of the four Regional Training Providers.GP trainees, inconsistent with most guideline recommendations, prescribe A/Hs mainly as maintenance therapy to unfamiliar and older patients. Our results suggest that changes in management approaches are needed which may be facilitated by support for psychotherapeutic training. [Holliday SM, Morgan S, Tapley A, Henderson KM, Dunlop AJ, van Driel ML, Spike NA, McArthur LA, Ball J, Oldmeadow CJ, Magin PJ. The pattern of anxiolytic and hypnotic management by Australian general practice trainees. Drug Alcohol Rev 2017;36:261-269].

BACKGROUND: Antibiotics are sometimes used to prevent recurrent sore throat, despite concern about resistance. However, there is conflicting primary evidence regarding their effectiveness. OBJECTIVES: To assess the effects of antibiotics in patients with recurrent sore throat. SEARCH METHODS: The Cochrane Ear, Nose and Throat Disorders Group (CENTDG) Trials Search Co‐ordinator searched the CENTDG Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 5); PubMed; EMBASE; CINAHL; Web of Science; Clinicaltrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 25 June 2015. SELECTION CRITERIA: Randomised controlled trials (RCTs) of antibiotics in adults and children suffering from pre‐existing recurrent sore throat, defined as three or more sore throats in a year, examining the incidence of sore throat recurrence, with follow‐up of at least 12 months post‐antibiotic therapy. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. Multiple attempts to contact the authors of one study yielded no response. MAIN RESULTS: We identified no trials that met the inclusion criteria for the review. We discarded the majority of the references retrieved from our search following screening of the title and abstract. We formally excluded four studies following review of the full‐text report. AUTHORS' CONCLUSIONS: There is insufficient evidence to determine the effectiveness of antibiotics for preventing recurrent sore throat. This finding must be balanced against the known adverse effects and cost of antibiotic therapy, when considering antibiotics for this purpose. There is a need for high quality RCTs that compare the effects of antibiotics versus placebo in adults and children with pre‐existing recurrent sore throat on the following outcomes: incidence of sore throat recurrence, adverse effects, days off work and absence from school, and the incidence of complications. Future studies should be conducted and reported according to the CONSORT statement.

Background Although older cancer survivors commonly report psychosocial problems, the impact of both cancer and ageing on the occurrence of these problems remains largely unknown. The evolution of depression, cognitive functioning, and fatigue was evaluated in a group of older cancer patients in comparison with a group of younger cancer patients and older persons without cancer. Methods Older (≥70 years) and younger cancer patients (50 – 69 years) with breast or colorectal cancer stage I - III, and older persons without cancer (≥70 years) were included. Data were collected at baseline and one year follow-up and were available for 536 persons. Depression was evaluated with the 15-item Geriatric Depression Scale. Cognitive functioning was measured with the cognitive functioning subscale of the European Organization for Research and Treatment of Cancer. Fatigue was measured with a Visual Analogue Scale. Risk factors for depression, cognitive functioning, and fatigue were analysed using multivariate logistic regression analyses. Risk factors included cancer- and ageing-related factors such as functional status, cancer treatment, and comorbidities. Results The evolution of psychosocial problems was similar for the group of older (N = 125) and younger cancer patients (N = 196): an increase in depression (p

INTRODUCTION: Fatigue is the most common undifferentiated problem presenting in general practice. Previous studies have shown that this presentation leads to multiple investigations. There is no published literature describing the management of patients with fatigue by general practice (GP) registrars. AIM: To document the investigation-ordering behaviour of GP registrars in managing patients with a new diagnosis of unexplained fatigue. METHODS: This was a cross-sectional analysis of data from Registrar Clinical Encounters in Training (ReCEnT), an ongoing cohort study of GP registrars? consultations. We established the prevalence of new diagnoses of unexplained fatigue and associations with that diagnosis, the rate of test ordering and the number and types of investigations ordered. RESULTS: 644 registrars contributed data from 68 986 encounters. In 0.78% of patient encounters, a new diagnosis of unexplained fatigue was made. Pathology was ordered in 78.4% of these problems (versus 18.1% in non-fatigue problems), at a rate of 488 tests per 100 new fatigue problems. DISCUSSION: Our study suggests that unexplained fatigue elicits a non-rational approach to test ordering by registrars. These findings contribute to the understanding of GP registrar management of fatigue, and undifferentiated presentations more broadly, and suggest educational approaches to improve practice, including dealing with uncertainty. KEYWORDS: Diagnostic tests, routine; education, medical; family practice; fatigue; general practice

To determine the impact of the presence of a medical student on the satisfaction and process of the general practice consultation from the perspective of the general practitioner (GP), patient and student.An observational study was conducted in regional general practices accepting third-year medical students. General practitioners, patients and medical students were asked to complete a questionnaire after each consultation. The main outcome measures were: patient satisfaction; GPs' perceived ability to deliver care; medical students' satisfaction with their learning experience; length of consultation; and patient waiting times.Of the 26 GP practices approached, 11 participated in the study (42.3%). Patients returned 477 questionnaires: 252 consultations with and 225 without a student present. Thirteen GPs completed 473 questionnaires: 248 consultations with and 225 without a student. Twelve students attended 255 consultations. Most patients (83.5%) were comfortable with the presence of a student. There were no significant differences between consultations with and without a student regarding the time the patients spent in the waiting room (p = 0.6), the patients' perspectives of how the GPs dealt with their presenting problems (100% versus 99.2%; p = 0.6) and overall satisfaction with the consultation (99.2% versus 99.1%; p = 0.5). Despite these reassuring findings, a significantly higher proportion of patients in consultations without students raised sensitive or personal issues (26.3% versus 12.6%; p0.001). There were no statistically significant differences in the lengths of consultations with and without students (81% versus 77% for 6-20 minutes consultation; p = 0.1) or in the GPs' perceptions of how they effectively managed the presenting problem (95.1% versus 96.0%; p = 0.4). Students found that the majority (83.9%) of the 255 consultations were satisfactory for learning.The presence of a medical student during the GP consultation was satisfactory for all participant groups. These findings support the ongoing and increased placement of medical students in regional general practice. Medical educators and GPs must recognise that patients may not raise personal issues with a student present.

•Preventing patients from developing an acute respiratory infection will obviate any need for antibiotic use downstream. Hygiene measures (such as physical barriers and hand hygiene), and possibly vaccination and exercise, may be effective for preventing some acute respiratory infections. •Patients overestimate the effectiveness of antibiotics: therefore public campaigns might contribute to minimise misconceptions.•Complementary and alternative medicines (e.g. zinc, caffeine, vitamin C, probiotics and Echinacea) are often proposed for preventing and treating acute respiratory infections, but evidence for efficacy is scarce.•General practitioners’ attitudes towards antibiotic prescribing are a major factor in the prescribing for acute respiratory infections. Professional interventions with educational components are effective, although they have modest effects, and are expensive. •General practitioners’ perceptions – that mistakenly assume as a default that patients want antibiotics for their acute respiratory infections – are often wrong. Shared decision making might be a solution, as it enables clinician and patient to participate jointly in making a health decision, having discussed the options together with the evidence for their harms as well as benefits.•General practitioners’ diagnostic uncertainty – often leading to an antibiotic prescription ‘just in case’ – might be addressed by exploiting strategies such as safety-netting, e.g. establishing with the patient a priori clearly defined actions to take if the course of the illness deviates from the expected.However, there is scant research undertaken in this area and evaluation of this strategy and its effects on patient care is needed.•The best strategies for the future are likely to focus on the best combination of the most effective interventions rather than any single one.

Background Terminally ill people experience a variety of symptoms in the last hours and days of life, including delirium, agitation, anxiety, terminal restlessness, dyspnoea, pain, vomiting, and psychological and physical distress. In the terminal phase of life, these symptoms may become refractory, and unable to be controlled by supportive and palliative therapies specifically targeted to these symptoms. Palliative sedation therapy is one potential solution to providing relief from these refractory symptoms. Sedation in terminally ill people is intended to provide relief from refractory symptoms that are not controlled by other methods. Sedative drugs such as benzodiazepines are titrated to achieve the desired level of sedation; the level of sedation can be easily maintained and the effect is reversible. Objectives To assess the evidence for the benefit of palliative pharmacological sedation on quality of life, survival, and specific refractory symptoms in terminally ill adults during their last few days of life. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 11), MEDLINE (1946 to November 2014), and EMBASE (1974 to December 2014), using search terms representing the sedative drug names and classes, disease stage, and study designs. Selection criteria We included randomised controlled trials (RCTs), quasi-RCTs, non-RCTs, and observational studies (e.g. before-and-after, interrupted-time-series) with quantitative outcomes. We excluded studies with only qualitative outcomes or that had no comparison (i.e. no control group or no within-group comparison) (e.g. single arm case series). Data collection and analysis Two review authors independently screened titles and abstracts of citations, and full text of potentially eligible studies. Two review authors independently carried out data extraction using standard data extraction forms. A third review author acted as arbiter for both stages. We carried out no meta-analyses due to insufficient data for pooling on any outcome; therefore, we reported outcomes narratively. Main results The searches resulted in 14 included studies, involving 4167 adults, of whom 1137 received palliative sedation. More than 95% of people had cancer. No studies were randomised or quasi-randomised. All were consecutive case series, with only three having prospective data collection. Risk of bias was high, due to lack of randomisation. No studies measured quality of life or participant well-being, which was the primary outcome of the review. Five studies measured symptom control, using four different methods, so pooling was not possible. The results demonstrated that despite sedation, delirium and dyspnoea were still troublesome symptoms in these people in the last few days of life. Control of other symptoms appeared to be similar in sedated and non-sedated people. Only one study measured unintended adverse effects of sedative drugs and found no major events; however, four of 70 participants appeared to have drug-induced delirium. The study noticed no respiratory suppression. Thirteen of the 14 studies measured survival time from admission or referral to death, and all demonstrated no statistically significant difference between sedated and non-sedated groups. Authors' conclusions There was insufficient evidence about the efficacy of palliative sedation in terms of a person's quality of life or symptom control. There was evidence that palliative sedation did not hasten death, which has been a concern of physicians and families in prescribing this treatment. However, this evidence comes from low quality studies, so should be interpreted with caution. Further studies that specifically measure the efficacy and quality of life in sedated people, compared with non-sedated people, and quantify adverse effects are required.

PURPOSE In evaluating complaints suggestive of rhinosinusitis, family physicians have to rely chiefly on the findings of a history, a physical examination, and plain radiographs. Yet, evidence of the value of signs, symptoms, or radiographs in the management of these patients is sparse. We aimed to determine whether clinical signs and symptoms or radiographic findings can predict the duration of the illness, the effect of antibiotic treatment, or both. METHODS We analyzed data from 300 patients with rhinosinusitis-like complaints participating in a randomized controlled trial comparing amoxicillin with placebo. We used Cox regression analysis to assess the association between the presence at baseline of rhinosinusitis signs and symptoms or an abnormal radiograph and the subsequent course of the illness. We then tested for interactions to assess whether the presence of any of these findings predicted a beneficial effect of antibiotic treatment. RESULTS Two factors at baseline were independently associated with a prolonged course of the illness: a general feeling of illness (hazard ratio = 0.77, 95% confidence interval, 0.60–0.99) and reduced productivity (hazard ratio = 0.68, 95% confidence interval, 0.53–0.88). Neither typical sinusitis signs and symptoms nor abnormal radiographs had any prognostic value. Prognosis remained unchanged whether or not patients were treated with antibiotics, no matter what symptoms patients had at baseline. CONCLUSIONS In a large group of average patients with rhinosinusitis, neither the presence of typical signs or symptoms nor an abnormal radiograph provided information with regard to the prognosis or the effect of amoxicillin. The time to recovery was longer in patients who felt ill at baseline or who did not feel able to work, but the course of their illness was not influenced by antibiotic treatment.

The increasing availability of medical evidence in clinical practice was expected to improve the quality of care. However, this has not been realized. A possible explanation is that quality of care is a complex concept and needs a wider scope. Starting from the Donabedian triangle of structure, process and outcome, a framework for the analysis of quality of care is presented. The need for three types of evidence is identified and discussed: medical, contextual and policy evidence. Although the body of medical evidence is increasing, it has major flaws and gaps hampering its applicability in primary care. There is also a need to focus on the context of the medical encounter, which has been shown to influence outcome, but is still not well researched. Finally, evidence on costs, cost utility and equity needs to be considered. Taking these different aspects of evidence into account, an agenda for research in primary care is set. The analytical framework may provide new insights in the quest for improving quality of health care.

Background and Purpose— The 2001 Revised Consolidated Standards of Reporting of Trials (CONSORT) statement requires reporting of Randomized Controlled Trials (RCTs) to include participants’ baseline demographics. This enables comparison of intervention and control groups on potential confounding variables as well as assessment of study generalizability. Socioeconomic status (SES) is associated with access to care and outcomes (mortality, functional outcome, recurrent stroke, and hospital readmission) poststroke. We aimed to document the reporting of baseline SES in reports of RCTs of stroke and transient ischemic attack. Methods— Measures of SES were extracted from studies reporting trials of stroke or transient ischemic attack published in 12 major journals in the disciplines of general medicine, general neurology, cerebrovascular disease, and rehabilitation subsequent to revised CONSORT. Percentages of studies reporting SES measures were calculated. Differences in reporting between journal categories, and temporal trends in reporting, were tested. Results— Only 12% of studies reported any SES measure. Journal categories did not differ in rate of SES reporting. SES reporting did not increase over time. Conclusions— Improving reporting of SES could enhance clinicians’ ability to evaluate RCT findings and apply them to their patients.

Antibiotic resistance is among the most important current public health issues. Most antibiotics are prescribed in primary care. There is strong consensus that they are overprescribed, especially for conditions such as upper respiratory tract infections (URTI) and acute bronchitis, where they provide limited benefit. Interventions to alter prescribing patterns have shown limited effect. Trainees in family practice may be an appropriate target, as their prescribing habits are still developing. To establish prevalence and associations of trainee prescribing of antibiotics for URTI and acute bronchitis/bronchiolitis. A cross-sectional analysis of the Registrar Clinical Encounters in Training (ReCEnT) study. ReCEnT is an ongoing cohort study of Australian General Practice (GP) trainees documenting the nature of their consultation-based clinical experiences. Trainees record details of 60 consecutive patient encounters every 6-month training term. Univariate and logistic regression analyses were conducted on data recorded in consultations related to URTI and acute bronchitis/bronchiolitis in six collection periods during 2010-12. Data from 401 trainees (94.7% response rate) were analysed. Antibiotics were prescribed in 21.6% of encounters for URTI and 73.1% of encounters for acute bronchitis/bronchiolitis. Trainees prescribing antibiotics were more likely to order tests, and to seek in-consultation advice. Logistic regression analysis demonstrated older patient age, Indigenous patient background, and practices in higher socioeconomic areas were significant predictors of antibiotic prescribing. GP trainee antibiotic prescribing is higher than justified by guidelines. Understanding factors contributing to this pattern will assist in developing educational interventions to improve evidence-based prescribing habits during the early stages of these doctors' careers.

Introduction and Aims: Guidelines recommend anxiolytics and hypnotics (A/H) as second-line, short-term medications. We aimed to establish prevalence and associations of A/H prescribing by Australian general practice (GP) trainees. Design and Methods: A cross-sectional analysis from a cohort study of vocational trainees from four GP Regional Training Providers during 2010–2013. General practice trainees act as independent practitioners (including for prescribing purposes) while having recourse to advice from a GP supervisor. Practice and trainee demographic data were collected as well as patient, clinical and educational data from 60 consecutive consultations of each trainee each training term. Analysis was at the level of individual problem managed, with the outcome factor being prescription of any anxiolytic or hypnotic. Results: Overall, 645 registrars (response rate 94.0%) prescribed 68 582 medications in 69 621 consultations (with 112 890 problems managed). A/Hs were prescribed for 1.3% of problems managed and comprised 2.2% of all prescriptions. They were prescribed particularly for insomnia (28.2%) or anxiety (21.8%), but also for many ‘off-label’ indications. Significant associations of A/H prescriptions were: patient-level (greater age, Aboriginal and Torres Strait Islander status, English-speaking background, being new to the trainee but not to the practice); trainee-level (male) and consultation-level (longer duration, pre-existing problem, specialist referral not being made). Prescribing was significantly lower in one of the four Regional Training Providers. Discussion and Conclusions: GP trainees, inconsistent with most guideline recommendations, prescribe A/Hs mainly as maintenance therapy to unfamiliar and older patients. Our results suggest that changes in management approaches are needed which may be facilitated by support for psychotherapeutic training. [Holliday SM, Morgan S, Tapley A, Henderson KM, Dunlop AJ, van Driel ML, Spike NA, McArthur LA, Ball J, Oldmeadow CJ, Magin PJ. The pattern of anxiolytic and hypnotic management by Australian general practice trainees. Drug Alcohol Rev 2017;36:261-269].

Objective: General practice is central to Aboriginal and Torres Strait Islander health care, and this area is a core element of Australian general practice (GP) training. We aimed to describe the prevalence, nature and associations of GP registrar encounters with Aboriginal and Torres Strait Islander patients. Methods: A cross‐sectional analysis from a cohort study of GP registrars’ clinical consultations 2010–2013. Registrars record demographic, clinical and educational details of consecutive patient encounters. Multivariable associations were tested with logistic regression. Results: A total of 592 registrars contributed data from 69,188 consultations. Encounters with Aboriginal and Torres Strait Islander patients comprised 1.0% of consultations. Significant positive associations included younger patient age; new patient to the registrar; lower socioeconomic status of practice location; non‐urban practice setting; more problems managed; and follow‐up arranged. A greater proportion of Aboriginal and Torres Strait Islander patients’ problems were psychological/social and a lesser proportion were cardiovascular. Consultation duration did not differ between the two groups Conclusions: GP registrars encounter Aboriginal and Torres Strait Islander patients less than do established GPs. Our results suggest possible variability in registrar experience of Aboriginal and Torres Strait Islander health. Implications: Our findings will inform training of a culturally and clinically competent workforce in this area.

Background The vast health inequities experienced by people with intellectual disability remain indisputable. Persistent and contemporary challenges exist for primary healthcare providers and researchers working to contribute to improvements to the health and well-being of people with intellectual disability. Over two decades after the only review of supports for primary healthcare providers was published, this paper contributes to an evolving research agenda that aims to make meaningful gains in health-related outcomes for this group. Methods The present authors updated the existing review by searching the international literature for developments and evaluations of multinational models of care. Results Based on our review, we present three strategies to support primary healthcare providers: (i) effectively using what we know, (ii) considering other strategies that offer support to primary healthcare professionals and (iii) researching primary health care at the system level. Conclusions Strengthening primary care by supporting equitable provision of health-related care for people with intellectual disability is a much needed step towards improving health outcomes among people with intellectual disability. More descriptive quantitative and qualitative research, as well as intervention-based research underpinned by rigorous mixed-methods evaluating these strategies at the primary care level, which is sensitive to the needs of people with intellectual disability will assist primary care providers to provide better care and achieve better health outcomes. Accessible Abstract Many people with intellectual disability have poor health. The authors reviewed what has been written by other researchers about how to improve the health of people with intellectual disability. In the future, people who support adults with intellectual disability should continue doing what they do well, think of other ways to improve health, and do more research about health. At all times, the needs of people with intellectual disability should be the greatest concern for those trying to support them.

Objectives: To document the frequency of recording of Aboriginal and Torres Strait Islander status in general practice (GP) clinical records and to establish associations of this recording. Methods: Cross‐sectional analysis of recording of patients’ Aboriginal and Torres Strait Islander status in GP clinical records from GP training practices in four Australian states. Results: Of the 9,704 clinical records examined, the patients’ Aboriginal and Torres Strait Islander status had been documented in 5,165 (53.2%). Higher rates of recording were associated with older patient age, practices outside a major city, patients who were not new to the practice and the patient being Aboriginal and Torres Strait Islander. In encounters with Aboriginal and Torres Strait Islander patients, the patient's status had been documented in 82% of records. Those attending larger practices were less likely to have had their status recorded. Conclusions: This is the first report of Aboriginal and Torres Strait Islander status recording in GP clinical records. Almost 20% of Aboriginal and Torres Strait Islander patients did not have their status recorded in the clinical record, with indications that recording may be unsystematic. Implications: Our findings reinforce the need for a systematic approach to identification of Aboriginal and Torres Strait Islander status in general practice and will inform policy and practice in this important area.

This is the protocol for a review and there is no abstract. The objectives are as follows:To dete rmine the efficacy and safety of methylphenidate for 1) features of ADHD such as hyperactivity, impulsivity, and concentration,and 2) the core features of ASD (social, communication, and behavioural pr oblems) in children aged six to 18 years with ASD.

Fatigue is a common reason for presentation to the general practitioner. There is a wide range of possible diagnoses, some potentially serious, but somatic pathology is uncommon. Presentations of fatigue lead to high rates of test ordering, but abnormal results leading to significant diagnoses are uncommon. A number of guidelines for the assessment and investigation of fatigue have been developed, including in Australia.The objective of this article is to outline a rational approach to the investigation of fatigue, informed by the international literature and recently published Australian guidelines.On the basis of current literature, we recommend the following practical approach to the patient presenting with fatigue: a comprehensive history and examination, consideration of a period of watchful waiting in the absence of red flags and judicious use of tests once the decision to investigate is made.

PURPOSE: Little is known about consumer information needs regarding antipsychotic medicines. Medicines call centre (MCC)-derived data are underutilised; and could provide insight into issues of importance to consumers. This study aimed to explore consumers' information needs about antipsychotic medication sought from a national MCC in Australia.METHODS: Questions received by the National Prescribing Service Medicines Line relating to antipsychotic medication from September 2002 to June 2010 were examined by antipsychotic subclass and in relation to other medication queries.RESULTS: We identified 6,295 calls related to antipsychotic medication. While female callers predominated, the percentage of males with antipsychotic questions was statistically significantly higher than for other medication calls (33.9 vs 22.6 %; p < 0.001). There were distinct gender differences in medicines information seeking across age ranges. Younger men asked about second-generation antipsychotics, shifting toward first-generation antipsychotics after 45 years of age. Female interest in both subclasses was comparable, irrespective of age. Most callers asking about antipsychotics sought information for themselves (69.4 %). Callers were primarily concerned about safety (57.0 %), especially adverse drug reactions (28.8 %), and were more often prompted by a worrying symptom (23.8 %) compared with the rest of calls (17.2 %). Trends of antipsychotic questions received corresponded with antipsychotic prescription data.CONCLUSIONS: The number of calls received by this MCC over time reveals an ongoing consumer need for additional, targeted information about antipsychotics. Noticeable was the relatively high frequency of young male callers asking about antipsychotics, indicating that call centres could be a way to reach these traditionally poor users of health services.

Background: While many women and infants have an uneventful course during the postpartum period, others experience significant morbidity. Effective postpartum care in the community can prevent short, medium and long-term consequences of unrecognised and poorly managed problems. The use of rigorously developed, evidence-based guidelines has the potential to improve patient care, impact on policy and ensure consistency of care across health sectors. This study aims to compare the scope and content, and assess the quality of clinical guidelines about routine postpartum care in primary care. Methods: PubMed, the National Guideline Clearing House, Google, Google Scholar and relevant college websites were searched for relevant guidelines. All guidelines regarding routine postpartum care published in English between 2002 and 2012 were considered and screened using explicit selection criteria. The scope and recommendations contained in the guidelines were compared and the quality of the guidelines was independently assessed by two authors using the AGREE II instrument. Results: Six guidelines from Australia (2), the United Kingdom (UK) (3) and the United States of America (USA) (1), were included. The scope of the guidelines varied greatly. However, guideline recommendations were generally consistent except for the use of the Edinburgh Postnatal Depression Scale for mood disorder screening and the suggested time of routine visits. Some recommendations lacked evidence to support them, and levels or grades of evidence varied between guidelines. The quality of most guidelines was adequate. Of the six AGREE II domains, applicability and editorial independence scored the lowest, and scope, purpose and clarity of presentation scored the highest. Conclusions: Only one guideline provided comprehensive recommendations for the care of postpartum women and their infants. As well as considering the need for region specific guidelines, further research is needed to strengthen the evidence supporting recommendations made within guidelines. Further improvement in the editorial independence and applicability domains of the AGREE ll criteria would strengthen the quality of the guidelines.

Background Acute lower respiratory tract infections (LRTIs) (e.g. pneumonia) are a major cause of morbidity and mortality and management focuses on early treatment. Chest radiographs (X-rays) are one of the commonly used strategies. Although radiological facilities are easily accessible in high-income countries, access can be limited in low-income countries. The efficacy of chest radiographs as a tool in the management of acute LRTIs has not been determined. Although chest radiographs are used for both diagnosis and management, our review focuses only on management. Objectives To assess the effectiveness of chest radiographs in addition to clinical judgement, compared to clinical judgement alone, in the management of acute LRTIs in children and adults. Search methods We searched CENTRAL 2013, Issue 1; MEDLINE (1948 to January week 4, 2013); EMBASE (1974 to February 2013); CINAHL (1985 to February 2013) and LILACS (1985 to February 2013). We also searched NHS EED, DARE, ClinicalTrials.gov and WHO ICTRP (up to February 2013). Selection criteria Randomised controlled trials (RCTs) of chest radiographs versus no chest radiographs in acute LRTIs in children and adults. Data collection and analysis Two review authors independently applied the inclusion criteria, extracted data and assessed risk of bias. A third review author compiled the findings and any discrepancies were discussed among all review authors. We used the standard methodological procedures expected by The Cochrane Collaboration. Main results Two RCTs involving 2024 patients (1502 adults and 522 children) were included in this review. Both RCTs excluded patients with suspected severe disease. It was not possible to pool the results due to incomplete data. Both included trials concluded that the use of chest radiographs did not result in a better clinical outcome (duration of illness and of symptoms) for patients with acute LRTIs. In the study involving children in South Africa, the median time to recovery was seven days (95% confidence interval (CI) six to eight days (radiograph group) and six to nine days (control group)), P value = 0.50, log-rank test) and the hazard ratio for recovery was 1.08 (95% CI 0.85 to 1.34). In the study with adult participants in the USA, the average duration of illness was 16.9 days versus 17.0 days (P value > 0.05) in the radiograph and no radiograph groups respectively. This result was not statistically significant and there were no significant differences in patient outcomes between the groups with or without chest radiograph. The study in adults also reports that chest radiographs did not affect the frequencies with which clinicians ordered return visits or antibiotics. However, there was a benefit of chest radiographs in a subgroup of the adult participants with an infiltrate on their radiograph, with a reduction in length of illness (16.2 days in the group allocated to chest radiographs and 22.6 in the non-chest radiograph group, P < 0.05), duration of cough (14.2 versus 21.3 days, P < 0.05) and duration of sputum production (8.5 versus 17.8 days, P < 0.05). The authors mention that this difference in outcome between the intervention and control group in this particular subgroup only was probably a result of "the higher proportion of patients treated with antibiotics when the radiograph was used in patient care". Hospitalisation rates were only reported in the study involving children and it was found that a higher proportion of patients in the radiograph group (4.7%) required hospitalisation compared to the control group (2.3%) with the result not being statistically significant (P = 0.14). None of the trials report the effect on mortality, complications of infection or adverse events from chest radiographs. Overall, the included studies had a low or unclear risk for blinding, attrition bias and reporting bias, but a high risk of selection bias. Both trials had strict exclusion criteria which is important but may limit the clinical practicability of the results as participants may not reflect those presenting in clinical practice. Authors' conclusions Data from two trials suggest that routine chest radiography does not affect the clinical outcomes in adults and children presenting to a hospital with signs and symptoms suggestive of a LRTI. This conclusion may be weakened by the risk of bias of the studies and the lack of complete data available.

Background: Croup is an acute viral respiratory infection with upper airway mucosal inflammation that may cause respiratory distress. Most cases are mild. Moderate to severe croup may require treatment with corticosteroids (from which benefits are often delayed) and nebulised epinephrine (adrenaline) (which may be short-lived and can cause dose-related adverse effects including tachycardia, arrhythmias, and hypertension). Rarely, croup results in respiratory failure necessitating emergency intubation and ventilation. A mixture of helium and oxygen (heliox) may prevent morbidity and mortality in ventilated neonates by reducing the viscosity of the inhaled air. It is currently used during emergency transport of children with severe croup. Anecdotal evidence suggests that it relieves respiratory distress. This review updates versions published in 2010 and 2013. Objectives: To examine the effect of heliox compared to oxygen or other active interventions, placebo, or no treatment, on relieving signs and symptoms in children with croup as determined by a croup score and rates of admission and intubation. Search methods: We searched CENTRAL, which includes the Cochrane Acute Respiratory Infections Group's Specialised Register; MEDLINE; Embase; CINAHL; Web of Science; and LILACS in January and February 2018. We also searched the World Health Organization International Clinical Trials Registry Platform (apps.who.int/trialsearch/) and ClinicalTrials.gov (clinicaltrials.gov) on 8 February 2018. We contacted British Oxygen Company, a leading supplier of heliox (BOC Australia 2017). Selection criteria: Randomised controlled trials (RCTs) and quasi-RCTs comparing the effect of heliox in comparison with placebo or any active intervention(s) in children with croup. Data collection and analysis: We used standard methodological procedures expected by Cochrane. We reported data that could not be pooled for statistical analysis descriptively. Main results: We included 3 RCTs with 91 children aged between 6 months and 4 years. Study duration was from 7 to 16 months; all studies were conducted in emergency departments in the USA (two studies) and Spain. Heliox was administered as a mixture of 70% heliox and 30% oxygen. Risk of bias was low in two studies and high in one study due to an open-label design. We added no new trials for this update. One study of 15 children with mild croup compared heliox with 30% humidified oxygen administered for 20 minutes. There may be no difference in croup score changes between groups at 20 minutes (mean difference (MD) -0.83, 95% confidence interval (CI) -2.36 to 0.70). The mean croup score at 20 minutes postintervention may not differ between groups (MD -0.57, 95% CI -1.46 to 0.32). There may be no difference between groups in mean respiratory rate (MD 6.40, 95% CI -1.38 to 14.18) and mean heart rate (MD 14.50, 95% CI -8.49 to 37.49) at 20 minutes. The evidence for all outcomes in this comparison was of low quality, downgraded for serious imprecision. All children were discharged, but information on hospitalisation, intubation, or re-presenting to emergency departments was not reported. In another study, 47 children with moderate croup received one dose of oral dexamethasone (0.3 mg/kg) with either heliox for 60 minutes or no treatment. Heliox may slightly improve croup scores at 60 minutes postintervention (MD -1.10, 95% CI -1.96 to -0.24), but there may be no difference between groups at 120 minutes (MD -0.70, 95% CI -4.86 to 3.46). Children treated with heliox may have lower mean Taussig croup scores at 60 minutes (MD -1.11, 95% CI -2.05 to -0.17) but not at 120 minutes (MD -0.71, 95% CI -1.72 to 0.30). Children treated with heliox may have lower mean respiratory rates at 60 minutes (MD -4.94, 95% CI -9.66 to -0.22), but there may be no difference at 120 minutes (MD -3.17, 95% CI -7.83 to 1.49). There may be no difference in hospitalisation rates between groups (OR 0.46, 95% CI 0.04 to 5.41). We assessed the evidence for all outcomes in this comparison as of low quality, downgraded due to imprecision and high risk of bias related to open-label design. Information on heart rate and intubation was not reported. In the third study, 29 children with moderate to severe croup received intramuscular dexamethasone (0.6 mg/kg) and either heliox with one to two doses of nebulised saline, or 100% oxygen with one to two doses of adrenaline for three hours. Heliox may slightly improve croup scores at 90 minutes postintervention, but may have little or no difference overall using repeated measures analysis. We assessed the evidence for all outcomes in this comparison as of low quality, downgraded due to high risk of bias related to inadequate reporting. Information on hospitalisation or re-presenting to the emergency department was not reported. The included studies did not report on adverse events, intensive care admissions, or parental anxiety. We could not pool the available data because each comparison included data from only one study. Authors' conclusions: Due to very limited evidence, uncertainty remains about the effectiveness and safety of heliox. Heliox may not be more effective than 30% humidified oxygen for children with mild croup, but may be beneficial in the short term for children with moderate to severe croup treated with dexamethasone. The effect may be similar to 100% oxygen given with one or two doses of adrenaline. Adverse events were not reported, and it is unclear if these were monitored in the included studies. Adequately powered RCTs comparing heliox with standard treatments are needed to further assess the role of heliox in the treatment of children with moderate to severe croup.

Last June, the European Journal of General Practice (EJGP) was proud to announce that its impact factor rose to 1.217, an increase of no less than 50%. This results in a steep climb in its rank of ...

To assess the validity of surgical versus procedural interventions for CPPE or pleural empyema.