Systematic review and meta-analysis of randomised controlled trials of gastro-oesophageal reflux interventions for chronic cough associated with gastro-oesophageal reflux.

OBJECTIVE: To evaluate the efficacy of treatment for gastro-oesophageal reflux disease (GORD) on chronic cough in children and adults without an underlying respiratory disease. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Cochrane, Medline, and Embase databases, references from review articles. INCLUDED STUDIES: Randomised controlled trials on GORD treatment for cough in children and adults without primary lung disease. Two reviewers independently selected studies and extracted paediatric and adult data on primary (clinical failure) and secondary outcomes. RESULTS: 11 studies were included. Meta-analysis was limited to five studies in adults that compared proton pump inhibitors with placebo. All outcomes favoured proton pump inhibitors: the odds ratio for clinical failure (primary outcome) was 0.24 (95% confidence interval 0.04 to 1.27); number needed to treat (NNT) was 5 (harm 50 to infinity to benefit 2.5). For secondary outcomes, the standardised mean difference between proton pump inhibitors and placebo was -0.51 (-1.02 to 0.01) for mean cough score at the end of the trial and -0.29 (-0.62 to 0.04) for change in cough score at the end of the trial. Subgroup analysis with generic inverse variance analysis showed a significant mean change in cough (-0.41 SD units, -0.75 to -0.07). CONCLUSION: Use of a proton pump inhibitor to treat cough associated with GORD has some effect in some adults. The effect, however, is less universal than suggested in consensus guidelines on chronic cough and its magnitude of effect is uncertain.

Antibiotics for prolonged moist cough in children.

BACKGROUND: Cough is the most common symptom which presents to doctors. Chronic cough is reported in up to 9% of preschool aged children. American general practice guidelines suggest antimicrobial treatment may be indicated in children with cough lasting > 10 days. Questions concerning the benefits and harm of antibiotic treatment for prolonged cough in children need to be resolved. OBJECTIVES: A Cochrane systematic review was undertaken to determine the efficacy of antibiotics in treating children with chronic moist cough (excluding those with bronchiectasis or other underlying respiratory illnesses). SEARCH STRATEGY: The Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE, EMBASE, review articles and reference lists of relevant articles were searched. The latest searches were performed on 12th April 2004. SELECTION CRITERIA: All randomised controlled trials (RCTs) comparing antibiotics with a placebo or a control group in children with chronic moist cough were considered. DATA COLLECTION AND ANALYSIS: Results of searches were reviewed against pre-determined criteria for inclusion. Two independent reviewers selected, extracted and assessed the data for inclusion. Authors were contacted for further information. Data were analysed as 'intention to treat'. MAIN RESULTS: Two studies were eligible for inclusion in the review. Neither study was high quality. Both studies failed to include a prospective analysis of cough quality in their inclusion criteria, although indicating >75% of children included had moist cough (Darelid 1993). A total of 140 patients, aged seven years or less, were included in meta-analysis. Treatment with antibiotics reduced the proportion of children not cured at follow-up (primary outcome measure) in both studies; pooled odds ratio (OR) was 0.13, 95% CI 0.06 to 0.32 (using intention to treat analysis), which translates to number needed to treat (NNT) of 3 (95% CI 2 to 4). No significant heterogeneity was found (fixed and random-effects model I(2) was 4%). However for this outcome measure, the overall estimate of effect and degree of statistical heterogeneity were sensitive to the model used for meta-analysis. Progression of illness, defined by requirement for further antibiotics, was significantly lower in the treatment group (OR 0.10, 95%CI 0.03 to 0.34), NNT was 4 (95% CI 3 to 5). Adverse events were not significantly increased in the treatment group. AUTHORS' CONCLUSIONS: Antibiotics are likely to be beneficial in the treatment of children with chronic moist cough. This evidence is however limited by study quality, study design and sensitivity analysis data. The use of antibiotics however has to be balanced against their well known adverse events. Further well-designed RCTs using valid cough outcome measures are needed to answer this question conclusively.

Acute compartment syndrome complicating a distal tibial physeal fracture in a neonate.

This case report of a neonate who developed an acute compartment syndrome secondary to a minimally displaced distal tibial physeal injury represents the youngest patient to be reported with such a condition. After undergoing emergency four-compartment decompression fasciotomies, the 4-week-old child had a return of normal neuromuscular function and anatomic remodeling of the fracture. It is difficult to diagnose compartment syndrome in a neonate. The patient can neither give a history, nor follow commands to cooperate with the exam. The physician must rely primarily on the physical examination; however, the quantitative measurement of intracompartmental pressure can corroborate the diagnosis of compartment syndrome. We have found using a monometer to measure intracompartmental pressure to be helpful in conjunction with a physical exam when evaluating a neonate suspected of having a compartment syndrome.

Diet needs of patients referred to home health.

The purpose of this study was to document the dietary needs of patients referred to home health care. The charts of 812 patients taken for care by the Visiting Nurse Association of Chicago (VNA) were reviewed for the physician's diet order, number of restrictions, diagnoses, age, height, weight, and fee source. More than half of the patients had therapeutic diets ordered by their physicians. A quarter of the patients with therapeutic diets had two or more dietary modifications. An audit process was developed as a reliability check of the authors' determination of the appropriateness of the diet. Review of the charts by registered dietitians (R.D.s) showed that three-fourths of the patients appeared to need therapeutic diets. Forty-seven percent might have benefited from a different diet. More than half of the patients for whom the R.D.s recommended a special diet needed two or more modifications. This emphasizes the need for the R.D. to develop a system for monitoring the dietary requirements of all patients referred to home health care. It further underscores the need for collaboration between physician and dietitian. The registered dietitian who works in home health care agencies serving diverse age groups needs to be a generalist prepared to develop a plan for the total nutrition treatment of persons throughout the life cycle.