Ibuprofen, paracetamol, and steam for patients with respiratory tract infections in primary care: pragmatic randomised factorial trial

Objective: To assess strategies for advice on analgesia and steam inhalation for respiratory tract infections.Design: Open pragmatic parallel group factorial randomised controlled trial.Setting: Primary care in United Kingdom.Participants: Patients aged ?3 with acute respiratory tract infections.Intervention: 889 patients were randomised with computer generated random numbers in pre-prepared sealed numbered envelopes to components of advice or comparator advice: advice on analgesia (take paracetamol, ibuprofen, or both), dosing of analgesia (take as required v regularly), and steam inhalation (no inhalation v steam inhalation).Outcomes: Primary: mean symptom severity on days 2-4; symptoms rated 0 (no problem) to 7 (as bad as it can be). Secondary: temperature, antibiotic use, reconsultations.Results: Neither advice on dosing nor on steam inhalation was significantly associated with changes in outcomes. Compared with paracetamol, symptom severity was little different with ibuprofen (adjusted difference 0.04, 95% confidence interval ?0.11 to 0.19) or the combination of ibuprofen and paracetamol (0.11, ?0.04 to 0.26). There was no evidence for selective benefit with ibuprofen among most subgroups defined before analysis (presence of otalgia; previous duration of symptoms; temperature >37.5°C; severe symptoms), but there was evidence of reduced symptoms severity benefit in the subgroup with chest infections (ibuprofen ?0.40, ?0.78 to ?0.01; combination ?0.47; ?0.84 to ?0.10), equivalent to almost one in two symptoms rated as a slight rather than a moderately bad problem. Children might also benefit from treatment with ibuprofen (ibuprofen: ?0.47, ?0.76 to ?0.18; combination: ?0.04, ?0.31 to 0.23). Reconsultations with new/unresolved symptoms or complications were documented in 12% of those advised to take paracetamol, 20% of those advised to take ibuprofen (adjusted risk ratio 1.67, 1.12 to 2.38), and 17% of those advised to take the combination (1.49, 0.98 to 2.18). Mild thermal injury with steam was documented for four patients (2%) who returned full diaries, but no reconsultations with scalding were documented.Conclusion: Overall advice to use steam inhalation, or ibuprofen rather than paracetamol, does not help control symptoms in patients with acute respiratory tract infections and must be balanced against the possible progression of symptoms during the next month for a minority of patients. Advice to use ibuprofen might help short term control of symptoms in those with chest infections and in children

Randomised controlled feasibility trial of a web-based weight management intervention with nurse support for obese patients in primary care

<b>Background</b><p></p> There is a need for cost-effective weight management interventions that primary care can deliver to reduce the morbidity caused by obesity. Automated web-based interventions might provide a solution, but evidence suggests that they may be ineffective without additional human support. The main aim of this study was to carry out a feasibility trial of a web-based weight management intervention in primary care, comparing different levels of nurse support, to determine the optimal combination of web-based and personal support to be tested in a full trial.<p></p> <b>Methods</b><p></p> This was an individually randomised four arm parallel non-blinded trial, recruiting obese patients in primary care. Following online registration, patients were randomly allocated by the automated intervention to either usual care, the web-based intervention only, or the web-based intervention with either basic nurse support (3 sessions in 3 months) or regular nurse support (7 sessions in 6 months). The main outcome measure (intended as the primary outcome for the main trial) was weight loss in kg at 12 months. As this was a feasibility trial no statistical analyses were carried out, but we present means, confidence intervals and effect sizes for weight loss in each group, uptake and retention, and completion of intervention components and outcome measures.<p></p> <b>Results</b><p></p> All randomised patients were included in the weight loss analyses (using Last Observation Carried Forward). At 12 months mean weight loss was: usual care group (n = 43) 2.44 kg; web-based only group (n = 45) 2.30 kg; basic nurse support group (n = 44) 4.31 kg; regular nurse support group (n = 47) 2.50 kg. Intervention effect sizes compared with usual care were: d = 0.01 web-based; d = 0.34 basic nurse support; d = 0.02 regular nurse support. Two practices deviated from protocol by providing considerable weight management support to their usual care patients.<p></p> <b>Conclusions</b><p></p> This study demonstrated the feasibility of delivering a web-based weight management intervention supported by practice nurses in primary care, and suggests that the combination of the web-based intervention with basic nurse support could provide an effective solution to weight management support in a primary care context

Investigation of low 5-year relative survival for breast cancer in a London cancer network

BACKGROUND: Breast cancer 5-year relative survival is low in the North East London Cancer Network (NELCN). METHODS: We compared breast cancer that was diagnosed during 2001-2005 with that in the rest of London. RESULTS: North East London Cancer Network women more often lived in socioeconomic quintile 5 (42 vs 21%) and presented with advanced disease (11 vs 7%). Cox regression analysis showed the survival difference (hazard ratio: 1.27, 95% confidence interval (CI): 1.15-1.41) reduced to 1.00 (95% CI: 0.89-1.11) after adjustment for age, stage, socioeconomic deprivation, ethnicity and treatment. Major drivers were stage and deprivation. Excess mortality was in the first year. CONCLUSION: Late diagnosis occurs in NELCN

Shared decision-making in back pain consultations: An illusion or reality?

Purpose: Amid a political agenda for patient-centred healthcare, shared decision-making is reported to substantially improve patient experience, adherence to treatment and health outcomes. However, observational studies have shown that shared decision-making is rarely implemented in practice. The purpose of this study was to measure the prevalence of shared decision-making in clinical encounters involving physiotherapists and patients with back pain. Method: Eighty outpatient encounters (comprising 40 h of data) were observed audio-recorded, transcribed verbatim and analysed using the 12-item OPTION scale. The higher the score, the greater is the shared decision-making competency of the clinicians. Results: The mean OPTION score was 24.0 % (range 10.4-43.8 %). Conclusion: Shared decision-making was under-developed in the observed back pain consultations. Clinicians' strong desire to treat acted as a barrier to shared decision-making and further work should focus on when and how it can be implemented. © 2014 Springer-Verlag Berlin Heidelberg

Discrimination of the neutral low back sitting posture in people with and without low back pain, before and after a shift of work

Background: The "neutral" lumbar posture is considered the position least likely to cause low back pain, with errors as little as 2° from the neutral spinal posture substantially decreasing the axial compressive load capacity of the spine. Accurate sensory feedback from, and activation of, appropriate trunk muscles is essential for appreciation and maintenance of the neutral spinal posture. If these muscles are dysfunctional due to low back pain and/or workrelated activity and fatigue, this might impair people’s ability to discriminate the neutral spinal posture. This study investigated whether LBP or a shift ofwork alters people’s ability to discriminate the neutral low back sitting posture.Methods: Sixty one subjects with, and forty subjects without, a history of LBP were recruited. Each subject’s spinal position sense was assessed before and after a shift of work by an electro-goniometer placed over the lumbar sacral spine. Subjects were blindfolded and instructed to actively locate the neutral low back sitting posture – the "test" position. They were then asked to flex or extend their low back and stop at a random position for 3 seconds, before returning to the neutral low back sitting position; the position they returned to was the "reproduced" position. This procedure was repeated 20 times in total. The absolute error between the "test" position and each "reproduced" position was calculated in degrees. The average mean error was then calculated and compared between the two groups using an independent-samples t test.Results: Data was not normally distributed and therefore log-transformed before analysis. Anti-logged (returning data to original scale) values are also presented. LBP subjects had slightly higher average mean error values before work, showing that they found it more difficult than NLBP subjects to discriminate the neutral low back sitting posture, but the difference was nonsignificant. Conclusions: The ability of people with and without LBP to appreciate the neutral low back sitting posture was similar, both before and after a shift of work