Antibiotics for cough

Most primary care doctors now think twice before prescribing antibiotics to patients with a simple cough, but the debate rumbles on because of limited evidence from decent randomised trials. In search of a definitive answer, researchers from the United Kingdom spent five years recruiting and studying 800 primary care patients with cough but no signs of pneumonia. Patients were given immediate antibiotics, no antibiotics, or a prescription they could pick up from the practice receptionist if they weren't better within two weeks.

Immediate antibiotics (10 days of amoxicillin or erythromycin) did not reduce the duration or severity of patients' coughs, although other symptoms such as wheeze and disturbed sleep got better about one day earlier than with no antibiotics. Since patients in this trial coughed for a mean of nine days before going to their doctor and for a mean of nearly 12 days afterwards, one day less of other symptoms is arguably a poor trade off against the well known risks of antibiotic resistance caused by liberal prescribing. Results for vulnerable subgroups such as elderly people and those with green sputum were no more convincing. If anything, older people did worse after immediate treatment with antibiotics.

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Variations in surgical care

Variations in surgical care have been recognised since the early 1980s and are generally interpreted as evidence of uncertainty among practitioners regarding optimal care. The prescription for remedying variations in surgical practice has generally included development of better medical evidence to identify best practices, dissemination of medical evidence to surgeons, and use of practice guidelines and care pathways to streamline care. More than 20 years later, there is still abundant evidence that surgical care varies substantially. Why do variations in surgical care persist? And what can be done about them?

In a recent issue of the BMJ was a report of the results of a survey of lead surgeons in five north European countries regarding processes of care for colorectal surgery. These processes included use of preoperative bowel preparation, routine postoperative nasogastric decompression, and use of epidural analgesia in the postoperative surgical ward. The survey identified substantial international variation in the use of such peri-operative interventions. In many cases, this variation occurred in spite of abundant, high quality medical evidence.

There is broad recognition that much of current surgical practice is not informed by solid medical evidence and that the application of methods such as randomised controlled trials  to surgical questions is often difficult or impractical. The quality of evidence supporting surgical care must be improved and we need innovative methods for disseminating evidence into practice.

Surgery is disadvantaged when it comes to health research. Unlike trials of new drug treatments, research on surgical procedures has no natural sponsor. The lack of strict regulatory mechanisms for the approval of surgical procedures and devices in most countries leads to a situation where large randomised trials are not necessary for surgical interventions to be adopted.

This study reminds us that much may be achieved simply by raising the quality of surgical care according to existing evidence. In many ways, this is a far more difficult task than simply doing more research. Translating best evidence into surgical practice will require the engagement of large numbers of individual practitioners, in a multitude of healthcare contexts, and using a variety of techniques.

Evidence from before and after studies in several countries shows that surgeons' behaviour can be changed and the quality of surgical care can be improved. In Norway, surgeons concerned with poor outcomes of surgery for rectal cancer initiated a multi-faceted intervention in 1994 to improve the quality of care according to best practices.

This initiative led to a voluntary registry of treatment for rectal cancer with feedback to hospitals as well as postgraduate courses for surgeons and pathologists on optimal surgical techniques. After the intervention, the rate of local recurrence of rectal cancer fell from 28% to 8%, and five year survival increased from 55% to 71%.

In the United States, the Northern New England Cardiovascular Disease Study Group initiated a regional intervention in 1990 to improve the outcomes of coronary artery bypass graft surgery. After the intervention, mortality from coronary artery bypass graft surgery decreased by 24%.

A key factor underlying successful programmes for quality improvement in surgery seems to be the engagement of individual surgeons both locally and regionally, through developing communities of practice.

We now know more about what it takes to translate evidence into knowledge for practising surgeons. Innovative interventions that bring surgeons together may require substantial investment, but they will be worth while if they deliver evidence based surgery.

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Funduscopy in  hypertension

This was a study to evaluate the additional value of funduscopy in the routine management of patients with hypertension.

It was a systematic review of  adults aged 19 or more with hypertensive retinopathy.

The review included studies that assessed hypertensive retinopathy with blinding for blood pressure and cardiovascular risk factors. Studies on observer agreement had to be assessed by two or more observers and expressed as a chi-square statistic.

Studies on the association between hypertensive retinopathy and hypertensive organ damage were carried out in patients with hypertension.

The association between hypertensive retinopathy and cardiovascular risk was carried out in unselected normotensive and hypertensive people without diabetes mellitus.

Results showed that the assessment of microvascular changes in the retina is limited by large variations between observers. The positive and negative predictive values for the association between hypertensive retinopathy and blood pressure were low (47% to 72% and 32% to 67%, respectively).

Associations between retinal microvascular changes and cardiovascular risk were inconsistent, except for retinopathy and stroke. The increased risk of stroke, however, was also present in normotensive people with retinopathy. These studies did not adjust for other indicators of hypertensive organ damage.

In conclusion evidence is lacking that routine funduscopy is of additional value in the management of hypertensive patients.

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