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ContextAcute lower respiratory tract infection is the most common condition treated in primary care. Many physicians still prescribe antibiotics; however, systematic reviews of the use of antibiotics are small and have diverse conclusions.ObjectiveTo estimate the effectiveness of 3 prescribing strategies and an information leaflet for acute lower respiratory tract infection.Design, Setting, and PatientsA randomized controlled trial conducted from August 18, 1998, to July 30, 2003, of 807 patients presenting in a primary care setting with acute uncomplicated lower respiratory tract infection. Patients were assigned to 1 of 6 groups by a factorial design: leaflet or no leaflet and 1 of 3 antibiotic groups (immediate antibiotics, no offer of antibiotics, and delayed antibiotics).InterventionThree strategies, immediate antibiotics (n = 262), a delayed antibiotic prescription (n = 272), and no offer of antibiotics (n = 273), were prescribed. Approximately half of each group received an information leaflet (129 for immediate antibiotics, 136 for delayed antibiotic prescription, and 140 for no antibiotics).Main Outcome MeasuresSymptom duration and severity.ResultsA total of 562 patients (70%) returned complete diaries and 78 (10%) provided information about both symptom duration and severity. Cough rated at least “a slight problem” lasted a mean of 11.7 days (25% of patients had a cough lasting ≥17 days). An information leaflet had no effect on the main outcomes. Compared with no offer of antibiotics, other strategies did not alter cough duration (delayed, 0.75 days; 95% confidence intervals [CI], −0.37 to 1.88; immediate, 0.11 days; 95% CI, −1.01 to 1.24) or other primary outcomes. Compared with the immediate antibiotic group, slightly fewer patients in the delayed and control groups used antibiotics (96%, 20%, and 16%, respectively; P

A previously well boy of 24 months is brought in by his mother in February. For 10 days he has had worsening cough, fever, and coryza. Both parents have asthma, and his mother is worried that he too might have asthma.

Editor—The article by Wennberg et al on variation in the use of healthcare resources at the end of life raises several questions.1 It implies that the frequency of use of services is associated with workforce supply, but other studies contradict this. Supplier induced demand does not explain doctor variability in Norway,2 and economists have noted the methodological difficulty of making interpretations about supplier induced demand.3 Variability is still a major phenomenon in countries with centrally planned health systems which have less scope for inducement, such as the NHS in the United Kingdom. There is a fine interpretative line between healthcare activity that is induced by supply and healthcare activity that varies because some patients face inequitable barriers to access. Even if inducement is an issue in the United States, this interpretation may not be generalisable to other countries, given the market orientation of aspects of healthcare there. The claim that greater use is associated with worse outcomes, making variability a direct risk to patient, requires caution. Given the difficulty, and perhaps even the theoretical impossibility,4 of establishing a single “correct” population rate of use for a healthcare intervention, it is difficult to interpret doctor variation as inherently bad. If it is not possible to say what the single, best, population rate of treatment should be, why should we expect clinicians not to vary in their practice when observed across populations? The results presented in this paper are interesting, but their interpretation is very complex and should be treated with caution,5 especially when trying to generalise to settings outside the United States.

Background The presence of clinical signs have implications for diagnosis, prognosis and treatment. Therefore, the aim of this study was to examine the inter-observer agreement of clinical signs in pre-school children presenting to primary care. Methods A nested study comparing two clinical assessments within a prospective cohort of 256 pre-school children with acute cough recruited from eight general practices in Leicestershire, UK. We examined agreement (using kappa statistics) between unstandardised and standardised clinical assessments of tachypnoea, chest signs and fever. Results Kappa values were poor or fair for all clinical signs (range 0.12 to 0.39) with chest signs the most reliable. Conclusions Primary care clinicians should be aware that clinical signs may be unreliable when making diagnosis, prognosis and treatment decisions in pre-school children with cough. Future research should aim to further our understanding of how best to identify abnormal clinical signs.

Last week (31 January, p 276) we presented the case of Ms Reynolds, a 25 year old woman who presented to her general practitioner when eight weeks pregnant complaining of nausea and vomiting with light headedness. After an unsuccessful trial of prochlorperazine, she asked about alternatives to conventional drugs. We invited responses on which therapeutic options are safe to consider or recommend in pregnancy, what study design might provide evidence for their relative efficacy in an individual patient, and what proportion of patients and pregnant women use complementary therapies. To look at the discussion of the case so far go to bmj.com One of us (NH) is interested in complementary medicine and suggested a trial of vitamin B-6 (pyridoxine) to relieve the patient's symptoms. We searched Medline (1996 onwards, limiting our search to review articles) using the …

EDITOR—Hodson and Marsh say that ultra-sound may be a promising screening or diagnostic test for detecting osteoporosis.1 Clarification is necessary before their findings can be accepted. Their population, selected on the basis of perceived risk, has a higher risk (16%) than would normally be expected in primary care (4%).2 Interpretation of diagnostic data …

Researchers from the United States and Australia have found that deciduous teeth have robust stem cells in their dental pulp. The finding is important, because such teeth may serve as an easily obtainable alternative to embryonic stem cells, the use of which has proved controversial. Moreover, like umbilical cord blood, they may serve as a ready source of autologous and bankable stem cells, the study says (published online before print in the Proceedings of the National Academy of Science of the United States of America , www.pnas.org). Stem cells have …

Aims: To determine the effectiveness of over the counter (OTC) cough medicines for acute cough in children. Methods: Systematic review of randomised controlled trials (RCTs). An all language search of the Cochrane Acute Respiratory Infections Group specialised register, Cochrane Controlled Trials Register, Medline, Embase, and the UK Department of Health National Research Register was performed. RCTs comparing oral OTC cough preparations with placebo in children suffering from acute cough as a result of upper respiratory tract infection (URTI) in ambulatory settings, using cough symptoms as an outcome, were included. Results: Six trials involving 438 children met all inclusion criteria. Antitussives, antihistamine–decongestant combinations, other fixed drug combinations, and antihistamines were no more effective than placebo in relieving symptoms of acute cough. Based on a single study, the mucolytic preparation letosteine was superior to placebo, with differences in cough scores ranging from 0.1 to 0.3 points from day 4 to day 10. Most drugs appeared to be well tolerated with a low incidence of mostly minor adverse effects. Conclusion: OTC cough medicines do not appear more effective than placebo in relieving symptoms of acute cough. Even if statistically significant, effect sizes were small and of doubtful clinical relevance. The number of trials in each category was small, and the results of this systematic review have to be interpreted with caution. Based on the available evidence from a small number of studies, we cannot recommend OTC cough medicines as a first line treatment for children with acute cough.

To the Editor: In their Rational Clinical Examination article, Dr Bent and colleagues evaluated the accuracy and precision of the clinical history and examination for the diagnosis of urinary tract infection (UTI). Clinicians often rely on a single symptom or sign to establish the diagnosis, so it is important that they be aware of the pretest probability. However, the pretest probability of infection that Bent et al cite (48%) seems very high to us. One of us (T.F.) has calculated a 25% to 29% pretest probability of UTI in patients attending 8 primary care practices in the United Kingdom. We are also aware of another study that found a pretest probability of 35%. We therefore reexamined the studies that Bent et al used, added the study by Dobbs and Fleming, and performed a meta-analysis on only those articles that exclusively studied women with symptoms suggestive of UTI. We excluded studies if they included men or women with suspected vaginal infection. There was no heterogeneity (P=.12), so a fixed-effects model was used. This analysis yielded a combined pretest probability estimate of 35.6% (95% confidence interval, 32.1%-39.0%). We then repeated the posttest calculations by Bent et al based on our pretest probability of 35.6%. The results are shown in the TABLE. These data suggest that the most useful symptoms are the absence of vaginal symptoms, while dysuria and frequency do not markedly increase the posttest probability of UTI. We did not calculate the product of likelihood ratios as Bent et al did because this method assumes the likelihood ratios are independent and can give rise to inflated overall figures. In practice, patients with dysuria are also likely to have urinary frequency; therefore, if likelihood ratios are to be combined, regression methods should be used to establish the independent value of symptoms. In summary, we find little evidence on which to base a reliable pretest probability of UTI. More evidence is needed in unselected populations in primary care. Clinicians frequently prescribe antibiotics on the basis of single symptoms, which do not appear to alter the posttest probabilities sufficiently to rule in or rule out UTI.

EDITOR—McManus et al show the difficulties inherent in using currently available risk scoring systems for cardiovascular disease, with only moderate agreement between methods.1 They also show the methods' relatively low accuracy when compared with independently calculated Framingham risk estimates. Much of the inaccuracy was due to a lack of risk factor information in case records and use of risk scoring in people with diagnosed cardiovascular disease, who should be considered at high risk and treated accordingly. As in previous comparison studies, the Framingham …

To investigate the effect of patients' preferences in the treatment of atrial fibrillation by using individualized decision analysis in which probability and utility assessments are combined into a decision tree.Observational study based on interviews with patients.8 general practices in Avon, England.260 randomly selected patients aged 70 to 85 years with atrial fibrillation.Patients' treatment preferences regarding anticoagulation treatment (warfarin sodium) after individualized decision analysis; comparison of these preferences with treatment guidelines on the basis of comorbidity and absolute risk and compared with current prescription.Of 195 eligible patients, 97 participated in decision making using decision analysis. Among these 97, the decision analysis indicated that 59 (61%; 95% confidence interval, 50%-71%) would prefer anticoagulation treatment, considerably fewer than those who would be recommended treatment according to guidelines. There was marked disagreement between the decision analysis and guideline recommendations (kappaor =0.25). Of 38 patients whose decision analysis indicated a preference for anticoagulation, 17 (45%) were being prescribed warfarin; on the other hand, 28 (47%) of 59 patients were not being prescribed warfarin, although the results of their decision analysis suggested they wanted to be.In the context of shared decision making, individualized decision analysis is valuable in a sizable proportion of elderly patients with atrial fibrillation. Taking account of patients' preferences would lead to fewer prescriptions for warfarin than under published recommendations. Decision analysis as a shared decision-making tool should be evaluated in a randomized controlled trial.

Editor—Wauters et al report on the diagnostic value of rectal bleeding in terms of subsequent development of colorectal cancer.1 We feel that this study requires clarification for several reasons. Firstly, the authors do not report the pre-test probability of colorectal cancer in age specific categories in their population. The diagnostic value of a symptom such as rectal bleeding and the impact on post-test probability and subsequent referral threshold are maximised when the pre-test probability of the disease is known.2 Secondly, they fail to mention that less than half of patients with rectal bleeding have no other symptoms.3 More often it is associated with other bowel symptoms that have higher diagnostic value than rectal bleeding alone.4 Thirdly, the reported positive likelihood ratio of 68.3 “rules in” a diagnosis of colorectal cancer, irrespective of the pre-test probability of the disease.2 The reported specificity of 99.5% has the same effect of ruling in the target disorder of colorectal cancer. These findings imply that any patients attending their general practitioner with rectal bleeding need referral and further evaluation. Our own clinical experience and other community based studies of rectal bleeding indicate that such a high specificity and likelihood ratio is unlikely and may well be misleading.4,5 Finally, the most likely explanation for the results relates to general practitioners underreporting rectal bleeding in the prospective arm of the study. Wauters et al chose “rectal bleeding as the reason for visiting a general practitioner” as the inclusion criterion for their study. They should clarify whether this means that patients in whom rectal bleeding was not the primary reason for consulting their general practitioner were excluded. A prospective study in the Netherlands showed that among patients presenting with rectal bleeding, 51% stated this as the primary reason for consulting their general practitioner; 49% consulted for a different reason, but rectal blood loss was subsequently mentioned during the consultation.4 Another prospective study found that 3% (95% confidence interval 1.4% to 5.8%) of patients with rectal bleeding subsequently developed colorectal cancer, and even in this study patients with “clinically relevant rectal bleeding” were overrepresented.5 In Wauters et al's study, 27 patients with rectal bleeding (7%, 4.6% to 10%) developed colorectal cancer. In summary, there may have been a systematic bias in excluding less severe forms of rectal bleeding which may have not been the primary reason for consulting a general practitioner. This has resulted in inflated values for specificity and positive likelihood ratio. Before their results are incorporated into clinical practice Wauters et al should clarify their inclusion criteria and provide age specific two by two tables so that readers can judge for themselves the diagnostic value of isolated rectal bleeding in general practice.

Background Stroke patients' care in hospital tends to be poorly organised, with poor communication and a lack of information being frequent sources of complaint. The purpose of this study was to evaluate whether a patient-held record (PHR) would result in greater patient satisfaction and better care planning for stroke patients. Methods A time series control (6 months) - intervention (8 months) - control (6 months) was used among London teaching hospital general medical and geriatric medicine inpatient wards. All stroke patients admitted to the wards during the intervention phase received a PHR and were instructed in its use. Demographic, stroke severity, social factors and outcomes were collected from all stroke patients during all phases of the study. Results Of 252 stroke patients aged 46 to 98 years entered into the study, by six months after admission 118 (46.8%) had died. PHR and control group patients were well matched in terms of socio-demographic characteristics and pre-stroke ability. At six months after admission, 119 (97%) patients responded to the questionnaire. Just over half (56%, 13) of intervention group patients recalled receiving a PHR. Of those patients, 59% reported reading the PHR, 27% had lost their PHR, and two-thirds said they had difficulties encouraging staff to write in the PHR. Half felt that possession of the PHR was more trouble than it was worth. PHR group patients were more satisfied with the recovery they had made (79% vs. 59%, p=0.04), but felt less able to talk to staff about their problems (61% vs. 82%, p=0.02). PHR group patients reported receiving fewer explanations about their condition (18% vs. 33%, p=0.12) and treatment (26% vs. 45%, p=0.07), and were more afraid of asking doctors questions (21% vs. 4%, p=0.01) than controls. PHR group patients were no better prepared for hospital discharge than control group patients, and both groups were ill-informed about services and benefits that might have helped after discharge from hospital. Conclusions Stroke patients received poor information and explanations regardless of whether they received a PHR. A PHR did not appear to improve patient satisfaction or discharge planning, and may have reduced opportunities for communication and explanation.

(1999) Am J Med 107, 62. Bent S, Saint S, Vittinghoff E, et al. . Antibiotics in acute bronchitis: a meta-analysis. . Jul; . : . –7 . [OpenUrl][1][PubMed][2][Web of Science][3] QUESTION: In patients with acute bronchitis, do antibiotics reduce sputum production, cough, or days off work? English language studies were identified in Medline (1966 to April 1998) by using the terms drug therapy, bronchitis, and acute disease; the reference lists of relevant articles were reviewed, and experts in the field were contacted. Studies were selected if they were randomised controlled trials that compared antibiotics with placebo in patients who had acute bronchitis but no history of chronic lung disease or pneumonia, therapy was given for ≥5 days, and effect sizes could … [1]: {openurl}?query=rft.jtitle%253DThe%2BAmerican%2Bjournal%2Bof%2Bmedicine%26rft.stitle%253DAm%2BJ%2BMed%26rft.aulast%253DBent%26rft.auinit1%253DS.%26rft.volume%253D107%26rft.issue%253D1%26rft.spage%253D62%26rft.epage%253D67%26rft.atitle%253DAntibiotics%2Bin%2Bacute%2Bbronchitis%253A%2Ba%2Bmeta-analysis.%26rft_id%253Dinfo%253Apmid%252F10403354%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10403354&link_type=MED&atom=%2Febmed%2F5%2F2%2F42.atom [3]: /lookup/external-ref?access_num=000081396100010&link_type=ISI

Ed Leone Ridsdale Harcourt Brace, £17.50, pp 176 ISBN 0 443 05889 X Rating: ![Graphic][1] ![Graphic][2] ![Graphic][3] Using external evidence to inform clinical decision making is now acknowledged as an important and necessary ingredient of good clinical practice. However, using external evidence depends on formulating an answerable question, finding and appraising evidence, and applying the evidence to the individual patient. Leone Ridsdale is to be congratulated on editing a relevant and accessible book that shows how evidence based medicine … [1]: /embed/inline-graphic-1.gif [2]: /embed/inline-graphic-2.gif [3]: /embed/inline-graphic-3.gif

EDITOR,—John Shanks and colleagues mention the value of morbidity data collected in general practice.1 Remarkably little is known about the completeness and validity of data on health promotion and chronic diseases. The definition of asthma for the purposes of management of chronic disease has been reported to differ …

Purpose The purpose of this study is to establish the prevalence of potentially inappropriate prescribing (PIP) in middle-aged adults (45–64 years) in two populations with differing socio-economic profiles, and to investigate factors associated with PIP, using the PROMPT (PRescribing Optimally in Middle-aged People’s Treatments) criteria. Methods A retrospective cross-sectional study was conducted using 2012 data from the Enhanced Prescribing Database (EPD), covering the full population in Northern Ireland and the Health Services Executive Primary Care Reimbursement Service (HSE-PCRS) database, covering the most socio-economically deprived third of the population in this age group in the Republic of Ireland. The prevalence for each PROMPT criterion and overall prevalence of PIP were calculated. Logistic regression was used to investigate the association between PIP and gender, age group and polypharmacy. Results This study included 441,925 patients from the EPD and 309,748 patients from the HSE-PCRS database. Polypharmacy was common in both datasets (46.7 % in the HSE-PCRS and 20.3 % in the EPD). The prevalence of PIP was 42.9 % (95%CI 42.7, 43.1) in the HSE-PCRS and 21.1 % (95%CI 21.0, 21.2) in the EPD. Age group, female gender and polypharmacy were significantly associated with PIP in both populations (p

Ms Reynolds, a 25 year old woman, primiparous with one miscarriage, presented to her general practitioner when eight weeks pregnant complaining of nausea and vomiting. These symptoms were associated with a feeling of light headedness. Ms Reynolds had no relevant medical history and had not suffered from nausea and vomiting in her two previous pregnancies. Initially she was treated with prochlorperazine, which she took for five days, but this did not relieve her symptoms. …

Background Evidence-based advice on alcohol consumption is required for pregnant women and women planning a pregnancy. Our aim was to investigate the prevalence, predictors and perinatal outcomes associated with peri-conceptional alcohol consumption. Methods A cohort study of 61,241 women who booked for antenatal care and delivered in a large urban maternity hospital between 2000 and 2007. Self-reported alcohol consumption at the booking visit was categorised as low (0-5 units per week), moderate (6-20 units per week) and high (>20 units per week). Results Of the 81% of women who reported alcohol consumption during the peri-conceptional period, 71% reported low intake, 9.9% moderate intake and 0.2% high intake. Factors associated with moderate alcohol consumption included being in employment OR 4.47 (95% CI 4.17 to 4.80), Irish nationality OR 16.5 (95% CI 14.9 to 18.3), private health care OR 5.83 (95% CI 5.38 to 6.31) and smoking OR 1.86 (95% CI 1.73 to 2.01). Factors associated with high consumption included maternal age less than 25 years OR 2.70 (95% CI 1.86 to 3.91) and illicit drug use OR 6.46 (95% CI 3.32 to 12.60). High consumption was associated with very preterm birth ( Conclusions Public Health campaigns need to emphasise the importance of peri-conceptional health and pre-pregnancy planning. Fetal Alcohol Syndrome is likely to be under-reported despite the high prevalence of alcohol consumption in this population.

Background The aim of this study was to apply recommendations from randomized controlled trials and guidelines on the detection and control of hypertension in the elderly to a district health authority population. Methods A cross-sectional audit of Northamptonshire general practitioners' (GPs') records from February to June 1993 was carried out. Results A total of 2428 notes of men and women aged 65 or over registered with their GP was audited. A large proportion of patients, 86 per cent (95 per cent CI 84.6-87.4 per cent), had a blood pressure record taken in the last 10 years. Of those with raised blood pressure (BP > or = 160/90 mmHg) 49 per cent (95 per cent CI 46.2-51.8 per cent) were untreated, and 58 per cent (95 per cent CI 54-61.9 per cent) of those labelled as hypertensive were not adequately controlled. The prevalence of labelled hypertension was 25 per cent (95 per cent CI 23.3-26.7 per cent). Conclusions From these results it is estimated that between 11 and 29 fatal and non-fatal strokes could be prevented in the 65-74-year-old age population of Northamptonshire each year if current guidelines were followed. Improved detection and management of elderly hypertensive patients in primary care could contribute significantly towards the target for stroke reduction set in the Health of the nation strategy.

STUDY OBJECTIVE: To assess the effect of computers and computer-based clinical decision support systems on the management of hypertension. DESIGN: Systematic review of randomised controlled trials. SETTING: Ambulatory hypertension clinics, community-based health centres, and general practices. PARTICIPANTS: 11,962 patients enrolled in seven trials retrieved from a systematic search (electronic databases, contact with authors, reference lists; no restriction on language). MAIN RESULTS: Individual trials report on a diverse population of patients (newly diagnosed or established hypertensive patients), interventions (computers used for case finding, recall and registration, feedback on quality of blood pressure control and prescribing information), and outcomes (administration, physician performance and blood pressure control). Four of five trials reported an improvement in patient administration using a computer. Two of three trials reported an improvement in physician performance using a computer. Two of six trials. reported an improvement in blood pressure control in patients using a computer. However, positive findings in two trials should be regarded cautiously because of the potential effects of cluster randomisation. CONCLUSIONS: It seems that computers have a favourable effect on the uptake and follow up of patients in hypertension management. The effect of computers on physician knowledge, recording of information, and blood pressure control in patients is less conclusive and further studies are required.

The shared model of medical decision making has been proposed as the preferred method of determining patients' treatment. However, agreement may be more difficult to achieve if patients' and clinicians' preferences are polarised. The aim of this paper is to explore how closely patients and clinicians agree in their preferences for different treatment options. Only studies that made quantifiable estimates of preferences were included. There is some evidence that patients and health professionals often do not agree on treatment preference in the areas of cardiovascular disease, cancer, obstetrics and gynaecology, and acute respiratory illness. However, the magnitude and direction of these differences vary and may depend on the condition of interest. Most of the research to date is cross sectional; longitudinal research is required to investigate whether preferences change over time and are related to treatment choice, adherence to medication if taken, and health outcomes.

Background In this paper, we give an overview of methadone treatment in Ireland and outline the rationale for designing an electronic health record (EHR) with extensibility, interoperability and decision support functionality. Incorporating several international standards, a conceptual model applying a problem orientated approach in a hierarchical structure has been proposed for building the EHR. Methods A set of archetypes has been designed in line with the current best practice and clinical guidelines which guide the information-gathering process. A web-based data entry system has been implemented, incorporating elements of the paper-based prescription form, while at the same time facilitating the decision support function. Results The use of archetypes was found to capture the ever changing requirements in the healthcare domain and externalises them in constrained data structures. The solution is extensible enabling the EHR to cover medicine management in general as per the programme of the HRB Centre for Primary Care Research. Conclusions The data collected via this Irish system can be aggregated into a larger dataset, if necessary, for analysis and evidence-gathering, since we adopted the openEHR standard. It will be later extended to include the functionalities of prescribing drugs other than methadone along with the research agenda at the HRB Centre for Primary Care Research in Ireland.

BACKGROUND Randomized controlled trials (RCTs) are increasingly being used to evaluate the effectiveness of health care interventions. Systematic reviews of RCTs form the basis of the Cochrane Collaboration, which aims to synthesize all RCTs concerned with the provision of health care. This paper reports the quantity and methodological quality of RCTs published in five UK public health journals, which were searched as part of a planned register of RCTs in public health. METHODS Five journals were hand searched: The International Journal of Epidemiology, Health Trends, Journal of Public Health Medicine, Public Health and The Journal of Epidemiology and Community Health. All RCTs were identified and their methodological characteristics reviewed. RESULTS Ninety-one trials were identified from the five journals. A wide variety of topics were covered, the most common being prevention strategies )46 percent of the trials). Although the actual number of reports of RCTs published increased over time, there was no detectable improvement in the quality of reports. The aspect of bias most well controlled was control of bias at entry (randomization), in 83 (91 per cent) of trials. However, even in these trials details about the process of randomization were poor. CONCLUSION These trials will form the basis of a register of RCTs in public health. The diversity of topics covered illustrates the broad-based nature of public health. For this reason, many other RCTs relevant to the practice of public health are likely to be found in non-public health journals.

Background Patients with high blood pressure (hypertension) in the community frequently fail to meet treatment goals - a condition labelled as "uncontrolled" hypertension. The optimal way to organize and deliver care to hypertensive patients has not been clearly identified. Objectives To determine the effectiveness of interventions to improve control of blood pressure in patients with hypertension. To evaluate the effectiveness of reminders on improving the follow-up of patients with hypertension. Search methods All-language search of all articles (any year) in the Cochrane Controlled Trials Register (CCTR) and Medline; and Embase from January 1980. Selection criteria Randomized controlled trials (RCTs) of patients with hypertension that evaluated the following interventions: (1) self-monitoring (2) educational interventions directed to the patient (3) educational interventions directed to the health professional (4) health professional (nurse or pharmacist) led care (5) organisational interventions that aimed to improve the delivery of care (6) appointment reminder systems Outcomes assessed were: (1) mean systolic and diastolic blood pressure (2) control of blood pressure (3) proportion of patients followed up at clinic Data collection and analysis Two authors extracted data independently and in duplicate and assessed each study according to the criteria outlined by the Cochrane Handbook. Main results 72 RCTs met our inclusion criteria. The methodological quality of included studies varied. An organized system of regular review allied to vigorous antihypertensive drug therapy was shown to reduce systolic blood pressure (weighted mean difference (WMD) -8.0 mmHg, 95% CI: -8.8 to -7.2 mmHg) and diastolic blood pressure (WMD -4.3 mmHg, 95% CI: -4.7 to -3.9 mmHg) for three strata of entry blood pressure, and all-cause mortality at five years follow-up (6.4% versus 7.8%, difference 1.4%) in a single large RCT- the Hypertension Detection and Follow-Up study. Other interventions had variable effects. Self-monitoring was associated with moderate net reduction in systolic blood pressure (WMD -2.5 mmHg, 95% CI: -3.7 to -1.3 mmHg) and diastolic blood pressure (WMD -1.8 mmHg, 95% CI: -2.4 to -1.2 mmHg). RCTs of educational interventions directed at patients or health professionals were heterogeneous but appeared unlikely to be associated with large net reductions in blood pressure by themselves. Nurse or pharmacist led care may be a promising way forward, with the majority of RCTs being associated with improved blood pressure control and mean SBP and DBP but these interventions require further evaluation. Appointment reminder systems also require further evaluation due to heterogeneity and small trial numbers, but the majority of trials increased the proportion of individuals who attended for follow-up (odds ratio 0.41, 95% CI 0.32 to 0.51) and in two small trials also led to improved blood pressure control, odds ratio favouring intervention 0.54 (95% CI 0.41 to 0.73). Authors' conclusions Family practices and community-based clinics need to have an organized system of regular follow-up and review of their hypertensive patients. Antihypertensive drug therapy should be implemented by means of a vigorous stepped care approach when patients do not reach target blood pressure levels. Self-monitoring and appointment reminders may be useful adjuncts to the above strategies to improve blood pressure control but require further evaluation.

Background Homeless populations experience poorer physical and mental health, and more barriers to accessing adequate healthcare. This study investigates the health of this population, following the provision of a free to access primary care service for homeless people in Dublin (Safetynet). The health of this group will be compared to previous studies on homelessness conducted in Dublin prior to the establishment of this service (in 1997 and 2005). Methods Participants were recruited through Safetynet clinics. A 133-item questionnaire was administered to determine participants’ physical and mental well-being, use of health services and healthcare needs. Prescription data was extracted from participants’ electronic health records. Results A total of 105 participants were recruited. The majority were

Background Stratifying patients with a sore throat into the probability of having an underlying bacterial or viral cause may be helpful in targeting antibiotic treatment. We sought to assess the diagnostic accuracy of signs and symptoms and validate a clinical prediction rule (CPR), the Centor score, for predicting group A β-haemolytic streptococcal (GABHS) pharyngitis in adults (> 14 years of age) presenting with sore throat symptoms. Methods A systematic literature search was performed up to July 2010. Studies that assessed the diagnostic accuracy of signs and symptoms and/or validated the Centor score were included. For the analysis of the diagnostic accuracy of signs and symptoms and the Centor score, studies were combined using a bivariate random effects model, while for the calibration analysis of the Centor score, a random effects model was used. Results A total of 21 studies incorporating 4,839 patients were included in the meta-analysis on diagnostic accuracy of signs and symptoms. The results were heterogeneous and suggest that individual signs and symptoms generate only small shifts in post-test probability (range positive likelihood ratio (+LR) 1.45-2.33, -LR 0.54-0.72). As a decision rule for considering antibiotic prescribing (score ≥ 3), the Centor score has reasonable specificity (0.82, 95% CI 0.72 to 0.88) and a post-test probability of 12% to 40% based on a prior prevalence of 5% to 20%. Pooled calibration shows no significant difference between the numbers of patients predicted and observed to have GABHS pharyngitis across strata of Centor score (0-1 risk ratio (RR) 0.72, 95% CI 0.49 to 1.06; 2-3 RR 0.93, 95% CI 0.73 to 1.17; 4 RR 1.14, 95% CI 0.95 to 1.37). Conclusions Individual signs and symptoms are not powerful enough to discriminate GABHS pharyngitis from other types of sore throat. The Centor score is a well calibrated CPR for estimating the probability of GABHS pharyngitis. The Centor score can enhance appropriate prescribing of antibiotics, but should be used with caution in low prevalence settings of GABHS pharyngitis such as primary care.

This study assessed whether risk stratification in patients with atrial fibrillation (AF) in the community had a bearing on the likelihood of receiving aspirin or warfarin therapy. Seven hundred and fifty patients were identified from 14 practices by means of diagnostic READ codes or repeat prescriptions for digoxin from practice computers. The study demonstrates that general practitioners appreciate the importance of antithrombotic therapy in patients who have suffered stroke, but take poor account of increasing age and other independent risk factors. A more proactive approach to risk identification and treatment seems justified.

General practice pp (p 1120) -35 Distilling evidence from randomised controlled trials and observational studies into valid and usable guidelines is not easy. Despite unequivocal evidence that lowering cholesterol concentrations reduces mortality from coronary heart disease,1 producing guidelines on prevention that meet with universal agreement has proved difficult.2 Four articles in this week's issue illuminate the difficulties. Unwin et al show that the application of different cholesterol guidelines leads to considerable variations in decisions to screen and to treat when applied to a representative population (p 1125).3 This is not surprising when the content and recommendations of the cholesterol guidelines are studied (see their table 1). A previous study in the United States showed a similar magnitude of disagreement between older and newer versions of the US guidelines, Canadian guidelines, and a coronary risk model derived from Framingham data.4 In the US study the Framingham model proved to be the most accurate method to predict future coronary heart disease mortality. On this basis it is comforting to see that two of the guidelines analysed by Unwin et al—the Sheffield and European guidelines—base their recommendations on …