Saline nasal irrigation for acute upper respiratory tract infections.

BACKGROUND: Acute upper respiratory tract infections (URTIs), including the common cold and rhinosinusitis, are common afflictions that cause discomfort and debilitation and contribute significantly to workplace absenteeism. Treatment is generally by antipyretic and decongestant drugs and sometimes antibiotics, even though most infections are viral. Nasal irrigation with saline is often employed as an adjunct treatment for URTI symptoms despite a relative lack of evidence for benefit in this clinical setting. This review is an update of the Cochrane review by Kassel et al, which found that saline was probably effective in reducing the severity of some symptoms associated with acute URTIs. OBJECTIVES: To assess the effects of saline nasal irrigation for treating the symptoms of acute URTIs. SEARCH METHODS: We searched CENTRAL (2014, Issue 7), MEDLINE (1966 to July week 5, 2014), EMBASE (1974 to August 2014), CINAHL (1982 to August 2014), AMED (1985 to August 2014) and LILACS (1982 to August 2014). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing topical nasal saline treatment to other interventions in adults and children with clinically diagnosed acute URTIs. DATA COLLECTION AND ANALYSIS: Two review authors (DK, BM) independently assessed trial quality with the Cochrane 'Risk of bias' tool and extracted data. We analysed all data using the Cochrane Review Manager software. Due to the large variability of outcome measures only a small number of outcomes could be pooled for statistical analysis. MAIN RESULTS: We identified five RCTs that randomised 544 children (three studies) and 205 adults (exclusively from two studies). They all compared saline irrigation to routine care or other nose sprays, rather than placebo. We included two new trials in this update, which did not contribute data of sufficient size or quality to materially change the original findings. Most trials were small and we judged them to be of low quality, contributing to an unclear risk of bias. Most outcome measures differed greatly between included studies and therefore could not be pooled. Most results showed no difference between nasal saline treatment and control. However, one larger trial, conducted with children, did show a significant reduction in nasal secretion score (mean difference (MD) -0.31, 95% confidence interval (CI) -0.48 to -0.14) and nasal breathing (obstruction) score (MD -0.33, 95% CI -0.47 to -0.19) in the saline group. However, a MD of -0.33 on a four-point symptom scale may have minimal clinical significance. The trial also showed a significant reduction in the use of decongestant medication by the saline group. Minor nasal discomfort and/or irritation was the only side effect reported by a minority of participants. AUTHORS' CONCLUSIONS: Nasal saline irrigation possibly has benefits for relieving the symptoms of acute URTIs. However, the included trials were generally too small and had a high risk of bias, reducing confidence in the evidence supporting this. Future trials should involve larger numbers of participants and report standardised and clinically meaningful outcome measures.

Antibiotics for bronchiolitis in children under two years of age.

BACKGROUND: Bronchiolitis is a serious, potentially life-threatening respiratory illness commonly affecting babies. It is often caused by respiratory syncytial virus (RSV). Antibiotics are not recommended for bronchiolitis unless there is concern about complications such as secondary bacterial pneumonia or respiratory failure. Nevertheless, they are often used. OBJECTIVES: To evaluate the effectiveness of antibiotics for bronchiolitis in children under two years of age compared to placebo or other interventions. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 6), which includes the Cochrane Acute Respiratory Infection Group's Specialised Register, and the Database of Abstracts of Reviews of Effects, MEDLINE (1966 to June 2014), EMBASE (1990 to June 2014) and Current Contents (2001 to June 2014). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing antibiotics to placebo in children under two years diagnosed with bronchiolitis, using clinical criteria (including respiratory distress preceded by coryzal symptoms with or without fever). Primary clinical outcomes included time to resolution of signs or symptoms (pulmonary markers included respiratory distress, wheeze, crepitations, oxygen saturation and fever). Secondary outcomes included hospital admissions, length of hospital stay, readmissions, complications or adverse events and radiological findings. DATA COLLECTION AND ANALYSIS: Two review authors independently analysed the search results. MAIN RESULTS: We included seven studies with a total of 824 participants. The results of these seven included studies were often heterogeneous, which generally precluded meta-analysis, except for deaths, length of supplemental oxygen use and length of hospital admission.In this update, we included two new studies (281 participants), both comparing azithromycin with placebo. They found no significant difference for length of hospital stay, duration of oxygen requirement and readmission. These results were similar to an older study (52 participants) that demonstrated no significant difference comparing ampicillin and placebo for length of illness.One small study (21 participants) with higher risk of bias randomised children with proven RSV infection to clarithromycin or placebo and found a trend towards a reduction in hospital readmission with clarithromycin.The three studies providing adequate data for days of supplementary oxygen showed no difference between antibiotics and placebo (pooled mean difference (MD) (days) -0.20; 95% confidence interval (CI) -0.72 to 0.33). The three studies providing adequate data for length of hospital stay, similarly showed no difference between antibiotics (azithromycin) and placebo (pooled MD (days) -0.58; 95% CI -1.18 to 0.02).Two studies randomised children to intravenous ampicillin, oral erythromycin and control and found no difference for most symptom measures.There were no deaths reported in any of the arms of the seven included studies. No other adverse effects were reported. AUTHORS' CONCLUSIONS: This review did not find sufficient evidence to support the use of antibiotics for bronchiolitis, although research may be justified to identify a subgroup of patients who may benefit from antibiotics. Further research may be better focused on determining the reasons that clinicians use antibiotics so readily for bronchiolitis, how to reduce their use and how to reduce clinician anxiety about not using antibiotics.

Household number associated with middle ear disease at an urban Indigenous health service: a cross-sectional study.

Few epidemiological studies of middle ear disease have been conducted in Aboriginal and Torres Strait Islander populations, yet the disease is common and causes hearing impairment and poorer educational outcomes. The objective of this study is to identify factors associated with abnormal middle ear appearance, a proxy for middle ear disease. Aboriginal and Torres Strait Islander children aged 0-14 years receiving a Child Health Check (CHC) at an urban Indigenous Health Service, Brisbane, Australia were recruited from 2007 to 2010. Mixed-effects models were used to explore associations of 10 recognised risk factors with abnormal middle ear appearance at the time of the CHC. Ethical approval and community support for the project were obtained. Four hundred and fifty-three children were included and 54% were male. Participants were Aboriginal (92%), Torres Strait Islander (2%) or both (6%). Abnormal middle ear appearance was observed in 26 (6%) children and was significantly associated with previous ear infection (odds ratio (OR), 8.8; 95% confidence interval (CI), 3.2-24.0) and households with eight or more people (OR, 3.8; 95% CI, 1.1-14.1) in the imputed multivariable mixed-effects model. No significant associations were found for the other recognised risk factors investigated. Overcrowding should continue to be a core focus for communities and policy makers in reducing middle ear disease and its consequences in Aboriginal and Torres Strait Islander peoples.

Health and well-being of urban Aboriginal and Torres Strait Islander women at their first antenatal visit: a cross-sectional study.

The first antenatal visit is a valuable opportunity to influence the health and well-being of the mother and child during pregnancy, birth and beyond. Our primary-care-based cross-sectional study of urban Aboriginal and Torres Strait Islander women found that 81% presented for their first antenatal visit within the first 10 weeks. Consequently, there can be up to 30 weeks in which health professionals can provide lifestyle and parenting education and psychosocial support.

Implementing computerised Aboriginal and Torres Strait Islander health checks in primary care for clinical care and research: a process evaluation.

BACKGROUND: Paper-based Aboriginal and Torres Strait Islander health checks have promoted a preventive approach to primary care and provided data to support research at the Inala Indigenous Health Service, south-west Brisbane, Australia. Concerns about the limitations of paper-based health checks prompted us to change to a computerised system to realise potential benefits for clinical services and research capability. We describe the rationale, implementation and anticipated benefits of computerised Aboriginal and Torres Strait Islander health checks in one primary health care setting. METHODS: In May 2010, the Inala Indigenous Health Service commenced a project to computerise Aboriginal and Torres Strait Islander child, adult, diabetic, and antenatal health checks. The computerised health checks were launched in September 2010 and then evaluated for staff satisfaction, research consent rate and uptake. Ethical approval for health check data to be used for research purposes was granted in December 2010. RESULTS: Three months after the September 2010 launch date, all but two health checks (378 out of 380, 99.5%) had been completed using the computerised system. Staff gave the system a median mark of 8 out of 10 (range 5-9), where 10 represented the highest level of overall satisfaction. By September 2011, 1099 child and adult health checks, 138 annual diabetic checks and 52 of the newly introduced antenatal checks had been completed. These numbers of computerised health checks are greater than for the previous year (2010) of paper-based health checks with a risk difference of 0.07 (95% confidence interval 0.05, 0.10). Additionally, two research projects based on computerised health check data were underway. CONCLUSIONS: The Inala Indigenous Health Service has demonstrated that moving from paper-based Aboriginal and Torres Strait Islander health checks to a system using computerised health checks is feasible and can facilitate research. We expect computerised health checks will improve clinical care and continue to enable research projects using validated data, reflecting the local Aboriginal and Torres Strait Islander community's priorities.

Urban Aboriginal and Torres Strait Islander children's exposure to stressful events: a cross-sectional study.

OBJECTIVES: To determine the frequency and types of stressful events experienced by urban Aboriginal and Torres Strait Islander children, and to explore the relationship between these experiences and the children's physical health and parental concerns about their behaviour and learning ability. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional study of Aboriginal and Torres Strait Islander children aged ≤ 14 2013s presenting to an urban Indigenous primary health care service in Brisbane for annual child health checks between March 2007 and March 2010. MAIN OUTCOME MEASURES: Parental or carer report of stressful events ever occurring in the family that may have affected the child. RESULTS: Of 344 participating children, 175 (51%) had experienced at least one stressful event. Reported events included the death of a family member or close friend (40; 23%), parental divorce or separation (28; 16%), witness to violence or abuse (20; 11%), or incarceration of a family member (7; 4%). These children were more likely to have parents or carers concerned about their behaviour (P < 0.001) and to have a history of ear (P < 0.001) or skin (P = 0.003) infections. CONCLUSIONS: Children who had experienced stressful events had poorer physical health and more parental concern about behavioural 1s than those who had not. Parental disclosure in the primary health care setting of stressful events that have affected the child necessitates appropriate medical, psychological or social interventions to ameliorate both the immediate and potential lifelong negative impact. However, treating the impact of stressful events is insufficient without dealing with the broader political and societal 1s that result in a clustering of stressful events in the Aboriginal and Torres Strait Islander population.

Delayed antibiotics for respiratory infections.

BACKGROUND: Concerns exist regarding antibiotic prescribing for acute respiratory tract infections (ARTIs) owing to adverse reactions, cost and antibacterial resistance. One strategy to reduce antibiotic prescribing is to provide prescriptions but to advise delay in the hope symptoms will resolve first. This is an update of a Cochrane Review originally published in 2007 and updated in 2010. OBJECTIVES: To evaluate the use of delayed antibiotics compared to immediate or no antibiotics as a prescribing strategy for ARTIs. We evaluated clinical outcomes including duration and severity measures for pain, malaise, fever, cough and rhinorrhoea in sore throat, acute otitis media, bronchitis (cough) and the common cold. We also evaluated the outcomes of antibiotic use, patient satisfaction, antibiotic resistance and re-consultation rates and use of alternative therapies. SEARCH METHODS: We searched CENTRAL (The Cochrane Library 2013, Issue 2), which includes the Acute Respiratory Infection Group's Specialised Register; Ovid MEDLINE (January 1966 to February Week 3 2013); Ovid MEDLINE In-Process & Other Non-Indexed Citations (28 February 2013); EMBASE (1990 to 2013 Week 08); Science Citation Index - Web of Science (2007 to May 2012) and EBSCO CINAHL (1982 to 28 February 2013). SELECTION CRITERIA: Randomised controlled trials (RCTs) involving participants of all ages defined as having an ARTI, where delayed antibiotics were compared to antibiotics used immediately or no antibiotics. DATA COLLECTION AND ANALYSIS: Three review authors independently extracted and collected data. Important adverse effects, including adverse effects of antibiotics and complications of disease, were included as secondary outcomes. We assessed the risk of bias of all included trials. We contacted trial authors to obtain missing information where available. MAIN RESULTS: Ten studies, with a total of 3157 participants, were included in this review. Heterogeneity of the 10 included studies and their results generally precluded meta-analysis with patient satisfaction being an exception.There was no difference between delayed, immediate and no prescribed antibiotics for the clinical outcomes evaluated in cough and common cold. In patients with acute otitis media (AOM) and sore throat immediate antibiotics were more effective than delayed for fever, pain and malaise in some studies. There were only minor differences in adverse effects with no significant difference in complication rates.Delayed antibiotics resulted in a significant reduction in antibiotic use compared to immediate antibiotics. A strategy of no antibiotics resulted in least antibiotic use.Patient satisfaction favoured immediate antibiotics over delayed (odds ratio (OR) 0.52; 95% confidence interval (CI) 0.35 to 0.76). Delayed and no antibiotics had similar satisfaction rates with both strategies achieving over 80% satisfaction (OR 1.44; 95% CI 0.99 to 2.10).There was no difference in re-consultation rates for immediate and delayed groups.None of the included studies evaluated antibiotic resistance. AUTHORS' CONCLUSIONS: Most clinical outcomes show no difference between strategies. Delay slightly reduces patient satisfaction compared to immediate antibiotics (87% versus 92%) but not compared to none (87% versus 83%). In patients with respiratory infections where clinicians feel it is safe not to prescribe antibiotics immediately, no antibiotics with advice to return if symptoms do not resolve is likely to result in the least antibiotic use, while maintaining similar patient satisfaction and clinical outcomes to delayed antibiotics.

Retinal photography for diabetic retinopathy screening in Indigenous primary health care: the Inala experience.

OBJECTIVE: We aimed to determine the impact of clinic based retinal photography on access to appropriate screening for diabetic retinopathy (DR). DESIGN, SETTING AND PARTICIPANTS: We opportunistically recruited patients undergoing their annual diabetic cycle of care over a two year period in the urban Indigenous primary health care clinic. Data were collected on retinal outcomes, health variables and referral patterns. MAIN OUTCOME MEASURES: Access to appropriate screening and ophthalmic follow up, prevalence of DR, acceptability and feasibility of clinic-based retinal photography were the main outcome measures of this study. RESULTS: One hundred and thirty-two of a possible 147 patients consented to participate. 30% of participants had DR. Appropriate screening and ophthalmic follow up increased six fold, from 20 to 124 participants, following the introduction of the retinal camera. Most participants felt very positive about DR screening. CONCLUSIONS: Primary care DR screening using retinal photography can improve access to DR screening for indigenous patients, reduce the burden on busy outpatient departments and should reduce visual loss. Policy-makers could contribute to screening sustainability by funding a medicare item-number for primary care based DR screening associated with the annual diabetic cycle of care. An upfront Practice Incentive Program (PIP) payment could offset set up costs.

Adult health checks for Indigenous Australians: the first year's experience from the Inala Indigenous Health Service.

OBJECTIVE: To evaluate the role of the adult health check for Aboriginal and Torres Strait Islander people aged 15-54 years, in an urban Indigenous primary health care setting. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional study of Indigenous patients recruited opportunistically from the Inala Indigenous Health Service between 1 June 2007 and 31 July 2008. MAIN OUTCOME MEASURES: Newly identified cardiovascular risk factors, investigations ordered and performed, interventions and new diagnoses made. RESULTS: 413 patients out of a possible 509 consented to participate (93% were Aboriginal). High prevalences of cardiovascular risk factors such as smoking (67%), being overweight and obese (61%), harmful levels of alcohol consumption (36%), and depression (23%) were found. The adult health checks resulted in new investigations (in 82% of participants), lifestyle advice (67%), vaccinations (42%), referrals (62%) and new medications (49%). New diagnoses resulting from the health checks included depression (6%), a harmful level of alcohol consumption (4%), chlamydia infection (4%), hypertension (3%) and diabetes (3%). Pap smears were performed in 47% of women as a result of the health check. CONCLUSIONS: The adult health check for Aboriginal and Torres Strait Islanders aged 15-54 years is a viable vehicle for evaluating health status, identifying chronic disease risk factors and for implementing preventive health care.