The way forward: the International Primary Care Respiratory Group 2nd World Conference, Melbourne, 19-22 February 2004

The document attached has been archived with permission from the editor of the Medical Journal of Australia. An external link to the publisher’s copy is included.Justin J Beilby, Nicholas J Glasgow and H John Fard

Endoscopic sclerotherapy compared with no specific treatment for the primary prevention of bleeding from esophageal varices. A randomized controlled multicentre trial [ISRCTN03215899]

BACKGROUND: Since esophageal variceal bleeding is associated with a high mortality rate, prevention of bleeding might be expected to result in improved survival. The first trials to evaluate prophylactic sclerotherapy found a marked beneficial effect of prophylactic treatment. These results, however, were not generally accepted because of methodological aspects and because the reported incidence of bleeding in control subjects was considered unusually high. The objective of this study was to compare endoscopic sclerotherapy (ES) with nonactive treatment for the primary prophylaxis of esophageal variceal bleeding in patients with cirrhosis. METHODS: 166 patients with esophageal varices grade II, III of IV according to Paquet's classification, with evidence of active or progressive liver disease and without prior variceal bleeding, were randomized to groups receiving ES (n = 84) or no specific treatment (n = 82). Primary end-points were incidence of bleeding and mortality; secondary end-points were complications and costs. RESULTS: During a mean follow-up of 32 months variceal bleeding occurred in 25% of the patients of the ES group and in 28% of the control group. The incidence of variceal bleeding for the ES and control group was 16% and 16% at 1 year and 33% and 29% at 3 years, respectively. The 1-year survival rate was 87% for the ES group and 84% for the control group; the 3-year survival rate was 62% for each group. In the ES group one death occurred as a direct consequence of variceal bleeding compared to 9 in the other group (p = 0.01, log-rank test). Complications were comparable for the two groups. Health care costs for patients assigned to ES were estimated to be higher. Meta-analysis of a large number of trials showed that the effect of prophylactic sclerotherapy is significantly related to the baseline bleeding risk. CONCLUSION: In the present trial, prophylactic sclerotherapy did not reduce the incidence of bleeding from varices in patients with liver cirrhosis and a low to moderate bleeding risk. Although sclerotherapy lowered mortality attributable to variceal bleeding, overall survival was not affected. The effect of prophylactic sclerotherapy seems dependent on the underlying bleeding risk. A beneficial effect can only be expected for patients with a high risk for bleeding

Preoperative cross-matching in major head and neck surgery:a study of a department's current practice and eligibility for electronic cross-matching

ObjectiveThe maximum surgical blood ordering schedule (MSBOS) has reduced but not eliminated the over-ordering and wastage of blood products. Electronic cross-matching (ECM) may be a suitable alternative method to provide blood on demand in eligible cases. The purpose of this study was to assess the department's current blood ordering policy and to identify patients eligible for ECM.Study DesignThis was a retrospective observational study of 88 consecutive maxillofacial surgical oncology patients.ResultsA total of 383 units of blood were cross-matched, of which 43% were not transfused. Of these, 38% were reallocated and 5% discarded. Of all cross-matched blood, 82% was eligible for ECM; 18% was not eligible, 6% because of the presence of antibodies and 12% because of lack of a second historical sample.ConclusionsECM is recommended as a safe method for elective surgery. Blood can be provided on demand, reducing workload and costs for transfusion services and minimizing wastage

The national asthma audit : Bridging the gap between guidelines and practice

ObjectiveThis pilot study was undertaken to assess the need and acceptability of a theoretically based audit model to assist GPs improve their asthma care.MethodSeventeen GPs from two GP divisions conducted a chart audit and patient survey of asthma patients presenting during the 8 week audit period. Audit results were discussed at a workshop providing a forum for GP peer groups to review their asthma care against current guidelines. This workshop allowed the GPs to develop strategies to improve their asthma care in the context of the resources of their individual practice, GP division, local community and health services.ResultsOf the 243 asthma patients audited 177 (72.8%) had a review of their asthma recorded in the past 12 months, 138 (56.8%) were prescribed regular preventive therapy and 118 (48.2%) had been given an asthma action plan. Despite the time commitment required to participate in the activity, 16 respondents who answered the audit evaluation questionnaire reported that the audit was a useful process and 15 (93.8%) stated that it had motivated them to change their practice.ConclusionThe results confirmed the need for improved asthma care in general practice and demonstrated the feasibility of the GP-peer led, regionally coordinated, audit-workshop model