Oral prednisolone for acute lower respiratory tract infection in clinically unrecognised asthma: an exploratory analysis of the Oral Steroids for Acute Cough (OSAC) randomised controlled trial.

BACKGROUND: Acute lower respiratory tract infection (ALRTI) is often treated in primary care with antibiotics. The recent Oral Steroids for Acute Cough (OSAC) randomised controlled trial (RCT) showed corticosteroids were not an effective alternative in adults without a diagnosis of asthma with ALRTI. AIM: To investigate if corticosteroids are beneficial for ALRTI in patients with unrecognised asthma. DESIGN & SETTING: An exploratory analysis was undertaken of the primary care OSAC trial. METHOD: A subgroup analysis was performed in patients who responded 'yes' to the following International Primary Care Airways Group (IPCAG) question: did you have wheeze and/or at least two of nocturnal cough or chest tightness or dyspnoea in the past year. Sensitivity analyses were carried out on those who answered 'yes' to wheeze and at least two of the nocturnal symptoms. The primary outcomes were as follows: duration of cough (0-28 days, minimum clinically important difference [MCID] of 3.79 days) and mean symptom severity score (range 0-6; MCID 1.66 units). RESULTS: In total, 40 (10%) patients were included in the main analysis: mean age 49 years (standard deviation [SD] = 17.9), 52% male. Median cough duration was 3 days in both prednisolone (interquartile range [IQR] = 2-6 days) and placebo (IQR = 1-6 days) groups (adjusted hazard ratio [HR] = 1.10; 95% confidence interval [CI] = 0.47 to 2.54; P = 0.83), equating to 0.24 days longer in the prednisolone group (95% CI = 1.23 days shorter to 2.88 days longer). Mean symptom severity difference was -0.14 (95% CI = -0.78 to 0.49; P=0.65) comparing prednisolone with placebo. Similar findings were found in the sensitivity analysis. CONCLUSION: No evidence was found to support the use of corticosteroids for ALRTI in patients with clinically unrecognised asthma. Clinicians should not use the IPCAG questions to target oral corticosteroid treatment in patients with ALRTI.

Association between guidelines and medical practitioners' perception of best management for patients attending with an apparently uncomplicated acute sore throat: a cross-sectional survey in five countries.

OBJECTIVE: To investigate the relationship between guidelines and the medical practitioners' perception of optimal care for patients attending with an apparently uncomplicated acute sore throat in five countries (Australia, Germany, Sweden, UK and USA). DESIGN: International cross-sectional survey. SETTING: Primary healthcare (PHC). PARTICIPANTS: Medical practitioners working in PHC. MAIN OUTCOME MEASURES: ORs for: (A) perception of throat swabs as important, (B) perception of blood tests (C reactive protein, B-ESR and B-leucocytes) as important and (C) antibiotic prescriptions if no pathogenic bacteria isolated on throat swab. RESULTS: Guidelines differed significantly; those recommending throat swabs (Sweden and USA) were associated with practitioners perceiving them as important. The UK guideline was the only one actively discouraging the use of throat swabs. Hence, compared with the USA (reference), a throat swab showing no pathogenic bacteria increased the probability of antibiotic prescribing in the UK with OR 3.2 (95% CI 1.7 to 6.1) for adults, whereas it reduced the probability in Sweden for adults OR 0.35 (95% CI 0.13 to 0.96) and children 0.19 (95% CI 0.069 to 0.50). CONCLUSIONS: The differences between practitioners' perceptions of best management were associated with their guidelines. It remains unclear if guidelines influenced medical practitioners' perception or if guidelines merely reflect the consensus of current practice. A larger effort should be made to reach an international consensus in high-income countries about the best management of patients attending for an uncomplicated acute sore throat.

Underutilization of IV nitrates in the treatment of acute heart failure.

Acute heart failure (AHF) is a growing public health concern with high inhospital mortality and costs. Clinical practice guidelines, underpinned by positive randomized controlled trials, recommend the early use of intravenous (IV) nitrates in the treatment of AHF. However, the "real-world" usage of IV nitrates has not been clearly defined. The objective of this study was to examine the use of IV nitrates in the treatment of AHF as recommended by clinical practice guidelines. A case-record analysis was conducted of all admissions with AHF at a large teaching hospital. Of the 81 AHF patients (mean age 77 ± 11, mean SBP 130 ± 27 mmHg) enrolled for this analysis, only 5 (6%) received IV nitrates at the time of AHF admission. Forty (49%, mean age 77 ± 11, mean SBP 131 ± 27 mmHg) of these 81 patients met the guideline criteria for suitability for IV nitrates and only 5 (12%) of these received them during this admission. Patients who received IV nitrates were more likely to have higher blood pressure and all had myocardial ischemia as a precipitant. Seventy-five (93%) of the total population received loop diuretics on admission. Overall, this study shows that loop diuretics remain the first-line therapy in AHF with little use of IV nitrates, despite recommendations from clinical practice guidelines.