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URTI

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Empiricism. Opportunities. Education. Future consultations. Self management. Empowerment. ... Satisfaction with the consultation was independent predictor of ... – PowerPoint PPT presentation

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Title: URTI


1
URTI
  • Dr Bruce Davies

2
Scope
  • Throats.
  • Noses.
  • Coughs.
  • Sinuses.
  • Otitis media.
  • Otitis externa.

3
Points to Consider
  • Frequency.
  • Alterable?
  • Manageable?
  • Why?
  • Costs.
  • To patients.
  • To NHS.
  • To GPs.
  • Treatment.
  • Abx or not.
  • Other treatments.
  • Research.
  • Uncertainties.
  • Empiricism.

4
Opportunities
  • Education.
  • Future consultations.
  • Self management.
  • Empowerment.
  • Other stuff (opportunistically).

5
Role of Investigation
  • Swabs.
  • X-rays.
  • Examination findings.
  • PCR.
  • Temperature.

6
Inequality
  • Different doctors.
  • Different patients.
  • Different standards.
  • Expectations.
  • The doctors state of mind.
  • The doctors experiences.

7
Research
  • Heaps and heaps.
  • A lot still leaves questions un-answered.
  • What follows is a personal selection.

8
Research Sore Throats
  • Satisfaction with the consultation was
    independent predictor of illness duration.
  • 700 patients randomised to no Abx, Abx
    immediately, delayed Abx.
  • Consultation satisfaction better predictor of
    patient satisfaction than prescribing decision.
  • Psychosocial factors better predictor of duration
    than physical findings.
  • BMJ 1999 319 736-7.

9
Research Sore Throats and Nephritis
  • ANTIBIOTICS, SORE THROATS AND ACUTE NEPHRITIS
  • No effect
  • JL Taylor and JGR Howie JRCGP 1983 33 783-6

10
Research Sore throats
  • You cant tell from appearances.
  • Remains a clinical decision.
  • Pen V or erythromycin remain drugs of choice if
    anything is used.
  • Drug and Therapeutics Bulletin 33 2 9-12

11
Research Sore Throats
  • 716 patients aged 4years or more with a sore
    throat and an abnormal physical sign in the
    throat were randomised to receive a prescription
    for 10 days of antibiotics, no prescription or a
    prescription for antibiotics to be obtained in a
    further three days if symptoms were not beginning
    to settle by that time.

12
  • Prescribing antibiotics only marginally affects
    the resolution of symptoms but enhances belief in
    antibiotics and intention to consult in future.
    Psychosocial factors are important in the
    decision to see a general practitioner and in
    predicting the course of illness.

13
Research Sore Throat
  • Complications and early return from no or delayed
    prescribing of antibiotics for sore throat are
    rare.Current and previous prescribing both
    increase re-attendance rates. To avoid
    unnecessary treatment of a self-limiting illness
    and help to control demand for limited
    consultations most sore throats should be managed
    with no prescription or a delayed prescription.
  • P little et al. BMJ 1997 315 350-2.

14
Research Otitis Media
  • Masterly review as expected from the DTB.
  • Drug and Therapeutics Bulletin 33 2 12-15.

15
Research Otitis Media
  • Are antibiotics indicated as initial treatment
    for children with acute OTITIS media? A
    meta-analysis.
  • C del mar et al. BMJ 1997 314 1526-9.

16
Research Otitis Media
  • 60 of placebo-treated children are pain free by
    24hours after presentation and antibiotics do not
    improve on this. At 2-7 days after presentation
    (only 14 of children have pain at this time)
    early use of antibiotics reduces the risk of pain
    by 43.

17
Research Otitis Media
  • Longer term end points show no definite benefits
    for antibiotic use.
  • Antibiotics are associated with a near doubling
    of the risk of vomiting, diarrhoea or rashes.
    Even in the younger age group who develop otitis
    media as under-twos (who have been described as
    being possibly an otitis media-prone sub-set) the
    current high prescribing rates are not supported
    by the evidence with no statistical difference
    between children treated.

18
Research Management Of Feverish Children At Home
  • Giving paracetamol is more effective and more
    acceptable to parents than tepid sponging or
    removing clothing from hot children. Sponging
    works quicker than paracetamol and adds to its
    effectiveness.
  • A-L Kinmouth et al BMJ 1992 305 1134-6.

19
Research Repeat Consultations
  • REPEAT CONSULTATIONS AFTER ANTIBIOTIC PRESCRIBING
    FOR RESPIRATORY INFECTION A STUDY IN ONE GENERAL
    PRACTICE.
  • P Davey et al BJGP 1994 44 509-13.

20
Research Repeat Consultations
  • It is sometimes argued, often by drug companies,
    that use of newer antibiotics in primary care
    can be justified on the basis of fewer repeat
    consultations - either for treatment failure or
    because of a higher incidence of side effects
    with established drugs. This study shows that
    repeat consultations are not common with any
    treatment for respiratory infections , and there
    is therefore little evidence to support the use
    of newer antibiotics on this basis.

21
Research Adult Sinusitis
  • In 130 adults with a CT diagnosis of acute
    sinusitis both penicillin V and amoxycillin are
    more effective than placebo in the treatment of
    acute sinusitis.
  • M Lindbaek et al BMJ 1996 313 325-9.

22
Research Cough Re-attendance
  • These studies illustrate that patient
    expectations rather than significant bacterial
    infections are important determinants of both the
    initial consultation with a LRTI and any
    subsequent consultation. Changing patients
    perceptions of their illness remains a key part
    of any policy on treating LRTIs.
  • WF Holmes et al. BJGP 1997 47 815-8.

23
Research Cough Why Attend?
  • Yet more evidence that exploring patients
    concerns is an essential part of even the most
    routine expectations.
  • In the group of patients who consulted with their
    symptom of cough, among the reasons for attending
    were understanding that the cough was unusually
    severe and would interfere with usual social
    activities (not so surprising).

24
Research Cough Why Attend?
  • Both groups were concerned about pollution.
  • The study was undertaken in Middlesborough.

25
Research Cough Why Attend?
  • However, other reasons reported were concern
    about their heart (50 of those consulting).
    Neither group distinguished between bacteria and
    viruses, nor did they differ in their beliefs
    about the effectiveness of antibiotics.
  • CS Cornford. BJGP 1998 48 1751-4.

26
Research Acute Cough in Adults
  • A analysis of 6 trials. (700 patients).
  • Use of Abx.
  • Defined as a cough of less than 2 weeks duration
    with no abnormal chest findings.

27
Research Acute Cough in Adults
  • No significant effect on cough resolution.
  • No significant effect on findings on
    re-examination.
  • No significant effect on incidence of side
    effects.
  • BMJ 1998 316906-10.

28
Do We Want to Stop?
  • Gains for GP
  • Gains for patient
  • Any health gain?
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