Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media.

OBJECTIVE: To compare immediate with delayed prescribing of antibiotics for acute otitis media. DESIGN: Open randomised controlled trial. SETTING: General practices in south west England. PARTICIPANTS: 315 children aged between 6 months and 10 years presenting with acute otitis media. INTERVENTIONS: Two treatment strategies, supported by standardised advice sheets-immediate antibiotics or delayed antibiotics (antibiotic prescription to be collected at parents' discretion after 72 hours if child still not improving). MAIN OUTCOME MEASURES: Symptom resolution, absence from school or nursery, paracetamol consumption. RESULTS: On average, symptoms resolved after 3 days. Children prescribed antibiotics immediately had shorter illness (-1.1 days (95% confidence interval -0.54 to -1.48)), fewer nights disturbed (-0.72 (-0.30 to -1.13)), and slightly less paracetamol consumption (-0.52 spoons/day (-0.26 to -0.79)). There was no difference in school absence or pain or distress scores since benefits of antibiotics occurred mainly after the first 24 hours-when distress was less severe. Parents of 36/150 of the children given delayed prescriptions used antibiotics, and 77% were very satisfied. Fewer children in the delayed group had diarrhoea (14/150 (9%) v 25/135 (19%), chi(2)=5.2, P=0.02). Fewer parents in the delayed group believed in the effectiveness of antibiotics and in the need to see the doctor with future episodes. CONCLUSION: Immediate antibiotic prescription provided symptomatic benefit mainly after first 24 hours, when symptoms were already resolving. For children who are not very unwell systemically, a wait and see approach seems feasible and acceptable to parents and should substantially reduce the use of antibiotics for acute otitis media.

Implementation of influenza immunisation policy in general practice: 1997 to 1998.

Influenza immunisation policy and practice in primary care in central southern England was surveyed in early 1998, when national guidelines advised immunisation only for people with specified 'higher risk' medical conditions or who lived in long stay facilities such as nursing or residential homes. Three hundred and one questionnaires were returned from 441 general practices (68%). Between 71% and 82% of all respondents stated that they 'always' offered influenza immunisation to adults with the specified 'higher risk' medical conditions. For children the corresponding range was 33% to 43%. We estimated that 11.5% of the combined practice population of two million had received influenza immunisation late in 1997. The age data supplied suggested that 64% of those aged over 75 years had been immunised. Seventy-four per cent of respondents said they would be willing to follow an age based policy. The total coverage figures mask suboptimal uptake in target groups, coupled with immunisation of those outside the target groups. This could be partly addressed by rewarding high coverage of target groups such as elderly people aged over 75 years and by clarifying the guidelines for immunisation of children with 'higher risk' medical conditions.

General practitioners' perceptions of private health screening: too much paper, anxiety, and reassurance.

There is no evidence to support the practice of screening consultations that include general physical examinations and batteries of tests; however, many patients may choose, or be sent by their employers, to have private full health screening (FHS). General practitioners (GPs) are routinely sent the results of these screening examinations and are expected to deal with any subsequent care required. GPs recognize some positive aspects of FHS, but in our survey there was a groundswell of dislike for these examinations because of uncertainty about patient benefit (raised anxiety or false assurance) and a potential to irritate the GP. The implications for workload were minimal but resented. GPs would welcome a precise summary of significant findings and for the screening doctor to take greater responsibility for follow-up.

The natural history of otitis media with effusion--a three-year study of the incidence and prevalence of abnormal tympanograms in four South West Hampshire infant and first schools.

Otitis media with effusion (OME) is both extremely common in young children, and variable in its duration and severity. This study aims to gather and consider new and reliable information about the incidence and prevalence of OME in British school children. Eight hundred and fifty-six school children aged five to eight years from four South West Hampshire schools were examined over a three-year period by tympanometry, a method used to detect OME (> 90 per cent specificity and sensitivity) performed once per school term. Normal ears were recorded in 54.9 per cent of children throughout with 27 per cent recording evidence of effusion. However in only one out of 10 of the affected children did the fluid persist for a year or more. This impressive clearance is due in part to natural resolution, with the intervention of surgery occurring in about one in eight of the children with identified effusions. OME is more common in five-year-olds with an annual prevalence of 17 per cent compared to six per cent in eight-year-olds and is more common in the winter months. Because of the variability of the condition at least two screenings are recommended as a basis for good management.

Risk factors in otitis media with effusion. A 1 year case control study in 5-7 year old children.

What are the associations and risk factors for otitis media with effusion (glue-ear)? A 1 year case control study in 5-7 year old children from four south-west Hampshire schools examined some of the factors highlighted by the literature. A history of frequent ear problems over the previous year, a history of earache at any time in the child's life, bottle feeding, a red drum at otoscopy and the new finding of night cough all carried an increased relative risk.

Problems with implementing guidelines: a randomised controlled trial of consensus management of dyspepsia.

OBJECTIVE: To determine the feasibility and benefit of developing guidelines for managing dyspepsia by consensus between general practitioners (GPs) and specialists and to evaluate their introduction on GPs' prescribing, use of investigations, and referrals. DESIGN: Randomised controlled trial of effect of consensus guidelines agreed between GPs and specialists on GPs' behaviour. SETTING: Southampton and South West Hampshire Health District, United Kingdom. SUBJECTS: 179 GPs working in 45 practices in Southampton district out of 254 eligible GPs, 107 in the control group and 78 in the study group. MAIN MEASURES: Rates of referral and investigation and costs of prescribing for dyspepsia in the six months before and after introduction of the guidelines. RESULTS: Consensus guidelines were produced relatively easily. After their introduction referral rates for upper gastrointestinal symptoms fell significantly in both study and control groups, but no significant change occurred in either group in the use of endoscopy or radiology, either in terms of referral rates, patient selection, or findings on investigation. No difference was observed between the control and study group in the number of items prescribed, but prescribing costs rose by 25% (from 2634 pounds to 3215 pounds per GP) in the study group, almost entirely due to an increased rate of prescription of ulcer-healing agents. CONCLUSION: Developing district guidelines for managing dyspepsia by consensus between GPs and specialists was feasible. However, their acceptance and adoption was variable and their measured effects on some aspects of clinical behaviour were relatively weak and not necessarily associated with either decreased costs or improved quality of care.

Acute red ear in children: controlled trial of non-antibiotic treatment in general practice.

OBJECTIVE: To examine the efficacy and safety of conservative management of mild otitis media ("the acute red ear") in children. DESIGN: Double blind placebo controlled trial. SETTING: 17 group general practices (48 general practitioners) in Southampton, Bristol, and Portsmouth. PATIENTS: 232 children aged 3-10 years with acute earache and at least one abnormal eardrum (114 allocated to receive antibiotic, 118 placebo). INTERVENTIONS: Amoxycillin 125 mg three times a day for seven days or matching placebo; 100 ml paracetamol 120 mg/5 ml. MAIN OUTCOME MEASURES: Diary records of pain and crying, use of analgesic, eardrum signs, failure of treatment, tympanometry at one and three months, recurrence rate, and ear, nose, and throat referral rate over one year. RESULTS: Treatment failure was eight times more likely in the placebo than the antibiotic group (14.4% v 1.7%, odds ratio 8.21, 95% confidence interval 1.94 to 34.7). Children in the placebo group showed a significantly higher incidence of fever on the day after entry (20% v 8%, p less than 0.05), mean analgesic consumption (0.36 ml/h v 0.21 ml/h, difference 0.14, 95% confidence interval 0.07 to 0.23; p = 0.0022), mean duration of crying (1.44 days v 0.50 days, 0.94; 0.50 to 1.38; p less than 0.001), and mean absence from school (1.96 days v 0.52 days, 1.45; 0.46 to 2.42; p = 0.0132). Differences in recorded pain were not significant. The prevalence of middle ear effusion at one or three months, as defined by tympanometry, was not significantly different, nor was there any difference in recurrence rate or in ear, nose, and throat referral rate in the follow up year. No characteristics could be identified which predicted an adverse outcome. CONCLUSIONS: Use of antibiotic improves short term outcome substantially and therefore continues to be an appropriate management policy.