Evidence Based Medicine

General practitioners/Family physicians have over the years managed bulk of the patients. They have always remained the nucleus of providing medical care. With the evolution of different specialities, all of their patients became claim of one or the other specialist. Then came the time when he was just labelled as most uneducated doctor and the starting point of all ineffeciencies. He was supposed to be updated, re educated and brought to the workshops to learn one trick or the other. All specialists became the prophets and he was the centre of sermoninzing. Despite all this nonsense he remained quiet and lost in his very absorbing job.

Then came a time when all pundits and leaders of health care providers realized that there is still some thing wrong. Optimum use of medical information is not being realized. Slowly and surely realization came to forefront that the sector which is managing most of the brunt must be strengthened.

He started organizing his thoughts and putting forward that in the language which other specialities understood. Many developments took place afterwards.

Each Medical College, University, and hospital started departments of General Practice.Lot of original research started in family medicine by general practitioners. The quality papers flooded research world from quality institutions by this faculty. Pick up any bmj, you will see general practitioners dominating.

The aim that general practice should become a firm & definite science with the same results everywhere still eluded this community of practical scientists. Same patient may receive entirely different management by different doctors or at different locations or by different specialities.

What was wrong? This was the question being debated when Oxford University. Around 1990,flooded the scientific world with its research on the topic. It proved with strong undeniable research work that many notions and ideas about management of different conditions are just empiricaly held. Solid evidence was not existing to support these methodologies. Majority of the actions of doctor’s community lacked uniformity due to this fact.

A new development took place. Now the hard evidence in the literature must support each and every component of Diagnosis/treatment plan. Most of the studies, accepted uptill now were found to be lacking by the proper scientific scrutiny. This led to a new approach. Find the evidence, in the accepted research work, before you put anything into practice.

Many leading universities started offering training programmes, which will teach how to track the required information in the Ocean of written words. They were known as evidence practitioners. Soon it was realized that each and every individual doctor can not be expected to be expert in such a job.

That is where the idea of guidelines originated. Now there are innumerable groups, which are formulating these guidelines only and only in accordance with undeniable available evidence.

This is the age of Evidence based medicine and guidelines based upon evidence. No matter how small or large an issue is, there are different guidelines for each topic. Medicine is being rewritten.

This is no fad, which will pass with the time. It is more than 10 years since this discipline is being practiced. All specialities now are practicing it. Guidelines are obviously different in primary care. At secondary or tertary levels are addressing the issues specific at that level. Now other main non-medical professions are also adopting this concept. Many associations of Lawers, Architects and Engineers are isssuing evidence based guidelines.

There are still many opponents of this concept. Their main objections revolve around two points. First they feel that if guidelines are to be practices rigourously than it will limit the freedom of individual doctor. Second main objection is very funny. Since these guidelines are most cost effective so most of the funds providing agencies (Governments, Insurance companies, counties etc) are adopting these guidelines and ensuring the implementation. These critics feel that these health budget managers will control doctors with this stick even when the associations of the same specialities prepare these guidelines.

This phase may pass without even ever coming close to us. Then for the next phase of development, we might be quite obsolete, if we are not already so!

In this issue we have tried to reproduce a series of essays (from Internet off course!) on concept of evidence based medicine. I requested 6 persons to help me in editting these articles. All 6 were unanimous that these articles must be adapted to our level of discussion, if we wish these articles to be studied by majority of our readers. So Main theme remains the same but here and there portions have been rewritten.

In the end, just, to ellaborate, we are quoting reproducing guidelines on Asthma.Just see how comprehensive these are and how strong categorical statements have been made. Please also note how thorough is grading of evidence for different statements. It gives very clear idea how scientific or unscientific our routines are on treatment of Asthma.If we wish to improve our management, how much it will take.

External clinical evidence both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious, and safer.

(Editorial Help

I circulated original articles to six persons. Dr Liaqat and Dr Mehboob Ashraf did their best as expected.3 fell flat.They have atleast tried. Dr Ehsan Assad was the sixth person. He did not have enough time. Still He covered more than half of the original manuscript. His help has been incorporated.)

Month of August is very special for all of us. How can we pay tribute to our great Quaid? His profile demands that only work and sincere work can be called a sincere tribute to him.

As doctors, family physicians or any other speciality, It is our sacred and foremost duty to keep ourselves uptodate.

Have you ever heard of Evidence Based Medicine? To be honest with you, I did not, until very recently. It is a latest mode of updating your knowledge. It is a common denominator for all speciallities. It is so firmly eastablished in developed counteries that it has become an essential component of undergraduat training. It is again an essential part of MRCGP examination.

I believe more than 50 doctors have computers and access to Internet in Gujranwala.How many of them are using this facility to get latest guidelines from different agencies? While it is so simple. You provide your address once to them and they keep on sending their very valuable guidelines regularly to you. That is so easy to keep yourself updated!

By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients'predicaments, rights, and preferences in making clinical decisions about their care.

After history and examination many questions appear in the minds of clinicians. Which is most appropriate investigation? Which operative procedure will be beneficial? Which antibiotic is suitable? In some cultures important aspect is what patient can afford or what is available withen his or her reach. There are always so many similar questions which cross the minds of clinicians. Now the quality and relevance of such questions will reflect the expertise of clinician. Here variability can be ascribed to the individual expertise. This is natural phenomenon. Problem is how best to answer these questions? That is the second part of the EBM concept.

Now suppose 10 years have passed since graduation. You are in general practice. You need an update. The focus of discussion on EBM is from where to get this update.

Traditionaly you were going to be advised to consult a textbook or journal or a specialist. Let us look at all alternatives.

Now please compare our previous issues of this journal and textbooks. Which is easier to approach and which contains the material from textbooks of different disciplines at one place. Which suits better to the need of any one specific patient. Which produces the required knowledge in practicable shape. These are the factors, which discourage clinicians going near to textbooks.

We are quite used to these mediums of CME.Ask any GP what is the difference in practical prescriptions of these specialists? Each and every GP will agree that specialists use medicines in exactly the same manner as we do. But their lectures portray different picture. They will be advising on use of antibiotics in different ways and practicing exactly in the manner of family physicians. Are they dishonest? No absolutely not. They are very honest and sincere to the cause of CME.Then why this dilemma?

Their practice routines are more like their fellow physicians in family medicine than their verbal advice. So even here is a gap between preeching and practice.

We all know that education value of these colourful pamphalets is doubtful and biased in the favour of their product.

Aricles in journal are never comperehensive. These usually address any one aspect of the problem. It can hardly be predicted what is going to stay and stand the test of time.

Research by Oxford University Department of General Practice discussed these issues. Now EBM tries to answer all these questions. Name suggests that whatever we have to practice It has to be based on evidence. What evidence? That is whole issue.

Without current best evidence, the practice risks becoming rapidly out of date, to the detriment of patients.

All research papers on the topic are collected. Their quality is examined. Double blind randomized cross sectional and covering appropriate number of patients and continuing for adequate time studies are included It is examined whether some bias like funding or some group interest (like different specialities) has been ruled out or not. Then all these studies are put together and a Meta analysis is made.conclusions are made. Then a group of clinicians representing the sector, for which these guidelines are ment, sits down and decides according to their experience which and what is correct and suitable and fits into their experience and practice.

It is when asking questions about therapy that we should try to avoid the non-experimental approaches, since these routinely lead to false positive conclusions about efficacy. Because the randomised trial, and especially the systematic review of several randomised trials, is so much more likely to inform us and so much less likely to mislead us, it has become the "gold standard" for judging whether a treatment does more good than harm.

Many times’ search shows that no appropriate re research has been carried on. There we should act on the next best evidence available. Now all international research papers are collected by different agencies and catalogued. Cocharane Library is the one of many.

Evidence based medicine is not restricted to randomised trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions. To find out about the accuracy of a diagnostic test, we need to find proper cross sectional studies of patients clinically suspected of harbouring the relevant disorder, not a randomised trial. For a question about prognosis, we need proper follow up studies of patients assembled at a uniform, early point in the clinical course of their disease. And sometimes the evidence we need will come from the basic sciences such as genetics or immunology.

The argument that "everyone already is doing it" falls before following evidence.

There are striking variations between different doctor’s management. Same patient may receive entirely different management from different doctors or at different locations or at different times by the same doctor

. The difficulties that clinicians face in keeping abreast of all the medical advances reported in primary journals are obvious from a comparison of the time, a clinician can spare. For general medicine, time required for being uptodate, should be enough to read and examine 19 articles per day, 365 days per year. How much time physicians are spending?

No local figures availabe. But for British medical consultants, it is well under an hour a week even on self-reports.

So keeping this in mind that each and every clinician can not locate evidence on each point many committees have been set up. These sort out the relevant questions and then make a search in prescribed way and then formulate guidelines. These guidelines are different from what has been a practice in different institutions or of different individuals. These are based upon evidence. These are known as evidence based guidelines. Here usually evidence is graded according to quality in A B C etc. Guidelines usually mention the grading of evidence. Whether evidence is A or B or C or D grade.

Despite its ancient origins, evidence based medicine remains a relatively young discipline whose positive impacts are just beginning to be validated, and it will continue to evolve. This evolution will be enhanced as several undergraduate, postgraduate, and continuing medical education programmes adopt and adapt it to their learners' needs. These programmes, and their evaluation, will provide further information and understanding about what evidence-based medicine is and is not.

Professor NHS Research and Development Centre for Evidence Based Medicine, Oxford Radcliffe NHS Trust, Oxford OX3 9DU

Guidelines are on the rise in Germany and Italy, where a guidelines database is being developed to support national healthcare reform. In Spain, the Catalan Agency for Health Technology Assessment has begun preparing guidelines and teaches methods of guideline development. Consensus guidelines figure prominently in Catalonian healthcare reform.

Guidelines have existed in England for decades; recent years have heightened interest in guidelines as a tool for implementing health care based on proof of effectiveness. Professional bodies, encouraged by the NHS (National Health Service), are producing guidelines for use by providers to improve care and by purchasers to guide contracting and commissioning decisions. The NHS is now using a critical appraisal instrument to determine which guidelines to commend to health authorities. Although historically most British guidelines have derived from consensus conferences or expert opinion, there is growing interest in using explicit methods to develop evidence-based guidelines. The Scottish Intercollegiate Guideline Network uses a systematic multidisciplinary approach to prepare evidence-based guidelines. National guidelines are converted at the local level into formats that encourage adoption in practice.

Guidelines, protocols, and care pathways developed by professional societies and other groups are common in American hospitals and health plans, where they are used for quality improvement and cost control. Although some evidence based guidelines produced by government panels and medical societies have received prominent attention, many healthcare organisations purchase commercially produced guidelines that emphasise shortened lengths of stay and other resource savings.

Canadian health care is largely stated funded, but a similar proportion of organisations as in the United States use guidelines. The massive guideline industry in America has created special problems such as information overload. Directories and newsletters have become necessary to monitor the hundreds of guideline topics and sponsoring organisations. Americans have articulated evidence-based methods in manuals and other reports. This expertise has not always found its way into actual guidelinesmost of which remain rooted in consensus or opinion.

The Dutch College of General Practitioners has produced guidelines since 1987,issuing more than 70 guidelines at a rate of 8-10 topics per year. A rigorous procedure involves an analysis of the scientific literature, combined with consensus discussions among ordinary general practitioners and content experts. A systematic implementation programme follows guideline development. Updating of the guidelines has recently begun. Guidelines figure prominently in Dutch health policy.

In Finland, national and local bodies have issued more than 700 guidelines since 1989.A programme for evidence based guideline development have been started recently. Guidelines in Sweden appear in reports by the Swedish Council on Technology Assessment in Health Care, an internationally consulted technology assessment agency, and in recommendations from other government bodies. Guidelines in Australia date to the late 1970s, when the state health authority began endorsing guideline booklets, and they continue on a large scale today. There is an increasing emphasis on the need for evidence based methods.

In France, the Agence Nationale de l'Accréditation ET d'Évaluation en Santé has published over 100 guidelines based on consensus conferences or modified guidelines from other countries. It has also developed more than 140 références médicales, guidelines on procedural indications for use in setting coverage policy. The guidelines are disseminated through networks of general practitioners, and their effectiveness is evaluated through local audits. Guidelines in New Zealand emanate directly from national health policy. New Zealand's choosing to restrict services at the point of service through guidelines received international attention in debates about rationing. One guideline on hypertension and a subsequent cholesterol guideline from the New Zealand National Heart Foundation broke new ground methodologically by linking recommendations to patients' absolute risk probabilities rather than to generic treatment criteria.

We are stilling nowhere on the map. Pakistan is waiting for the brave men who will ignore all the apathy, cynism, and lack of co-operation from Government.They will form into team, train themselves on the required skills, formulate questions on relevant practice points and then do an extensive search of literature to formulate rough guidelines. In the end they will create a consensus on what is applicable and what is not. That is how we will have scientific evidence based guidline for us. These will save lot of headache of clinicians and at the same time, and at the same time with the help of these we can properly manage the meagre resources we have for health.

Starting Point someone should come forward to collect and then to distribute these guidelines to all family physicians. Everybody will not have computer immediately. PSFP Gujranwala is waiting for volunteers. Anyone!

Guidelines based on a critical appraisal of scientific evidence (evidence based guidelines) clarify which interventions are of proved benefit and document the quality of the supporting data.

They alert clinicians to interventions unsupported by good science, reinforce the importance and methods of critical appraisal, and call attention to ineffective, dangerous, and wasteful practices.

Healthcare systems and payers may be harmed by guidelines if following them escalates utilisation, compromises operating efficiency, or wastes limited resources. Some clinical guidelines, especially those developed by medical and other groups unconcerned about financing, may advocate costly interventions that are unaffordable or that cut into resources needed for more effective services.

This article presents a combination of the literature about guideline development and the results of combined experience in guideline development in North America and Britain.It considers the five steps in the initial development of an evidence based guideline

Group members. Identifying stakeholders involves identifying all the groups whose activities would be covered by the guideline or who have other legitimate reasons for having input into the process. When presented with the same evidence a single specialty group will reach different conclusions than a multidisciplinary group the specialty group will be systematically biased in favour of performing procedures in which it has a vested interest. Individuals’ biases may be better balanced in multidisciplinary groups, and such balance may produce more valid guidelines. Ideally the group should have at least six but no more than 12-15 members;

Performing a systematic review best does identifying and assessing the evidence. The purpose of a systematic review is to collect all available evidence, assess its potential applicability to the clinical question under consideration, inspect the evidence for susceptibility to bias, and extract and summarise the findings.

Identifying the clinical questions of interest will help set the boundaries for admissible evidence (types of study designs, year of publication, etc). For example, questions of the efficacy of interventions usually mean that randomised controlled trials should be sought, while questions of risk usually mean that prospective cohort studies should be sought.

The first step in gathering the evidence is to see if a suitable, recent systematic review has already been published. The Cochrane Library will also identify relevant Cochrane review groups, which should also be contacted to see if a review is in progress.

If a current systematic review is not available, a computer search of Medline and Embase is the usual starting point, using search strategies tailored to appropriate types of studies.

Opinion will be used to interpret evidence and also to derive recommendations in the absence of evidence. When evidence is being interpreted, opinion is needed to assess issues such as the generalisability of evidence, for example, to what degree evidence from small randomised clinical trials or controlled observational studies may be generalised, or to extrapolate results from a study in one population to the population of interest in the guideline (extrapolating a study in a tertiary, academic medical centre to the community population of interest to potential users of the guideline).

Recommendations based solely on clinical judgment and experience are likely to be more susceptible to bias and self-interest. Therefore, after deciding what role expert opinion is to play, the next step is deciding how to collect and assess expert opinion. There is currently no optimal method for this, but the process needs to be made as explicit as possible.

Grading recommendations

It is common to grade each recommendation in the guideline. Such information provides the user with an indication of the guideline development group's confidence that following the guideline will produce the desired health outcome. Given the factors that contribute to a recommendation, strong evidence does not always produce a strong recommendation, and the classification should allow for this. The classification is probably best done by the group panel, using a democratic voting process after group discussion of the strength of the evidence.

Reviewing and updating guidelines

Guidelines should receive external review to ensure content validity, clarity, and applicability. External reviewers should cover three areas: people with expertise in clinical content, who can review the guideline to verify the completeness of the literature review and to ensure clinical sensibility; experts in systematic reviews or guideline development, or both, who can review the method by which the guideline was developed; and potential users of the guideline, who can judge its usefulness. In Britain there is a further review process whereby guidelines are appraised by an independent unit to assess whether the NHS Executive can commend them to the NHS.

The guideline can be updated as soon as each piece of relevant new evidence is published, but it is better to specify a date for updating the systematic review that underpins the guideline.

Q U I N O B I O T I C
Ciprofloxacin 250 mgs & 500 mgs.tablets.

For Quick Response in

Lower respiratory Tract Infections
Various Urogenital Tract Infections.
Bone & Joint Infections.
Skin & Soft Tissue infections.
Typhoid.

Using clinical guidelines

Adapted from BMJ 1999; 318:728-730 (13 March)

Use of guidelines by clinicians

Outside a formal structure for the implementation of clinical guidelines within an organisation, individual clinicians may use guidelines as an information source for continuing professional education. Clinicians may also use guidelines to answer specific clinical questions arising out of their day to day practice. A key step is to frame the clinical question of interest in such a way that it can be answered by specifying the patient or problem, the intervention of interest, and possible comparison interventions, and the outcomes of interest. This allows the clinician to identify what sort of evidence to search for. Under these circumstances clinical guidelines are only one type of relevant evidence along with systematic reviews, individual trials, and expert advice.

Any clinician can explore Internet during clinic time or later on, to get whatever he needs. You can use home page of any search engine. Go on to the section of health. Search for Family Medicine or General Practice.Soon you will be in the section of your choice. Second method is you can search through following sites.

Some useful Sites.

(Send me your e mail address. I will mail you this page. Preserve it on your desktop. Afterwards copy these addresses and paste it where you have to write the address in your browser. Once you have opened these pages successfully then you can bookmark these pages or add these to your favourite’s list. Next time just double click this bookmark and you can reach your destination in no time. Dr Saleem Rana. Drsar@brain.net.pk)

www.guideline.gov/

This is most useful site in my experience. You open this site. This will automatically ask you on which topic you need guidelines. Whether you need summary of details or everything available on this topic. It gives you guidelines prepared by all relevant, recognised and government approved agencies on your requested topic withen 1 minute. You can copy it and then paste it anywhere in your library.

You provide your Internet address on this site; you start receiving guidelines weekly in your mailbox without any charge. These are usually very very usefull for your clinical practice. Many undefined areas in your practice even in Pakistant are automatically defined.

http://www.bmj.com

Open this site and here is whole of bmj in front of you. This is weekly. Title page will guide you how to search any article or topic covered in bmj since 1994.These searches will again lead you to almost whole of the information available related to your topic or author on whole of the web.

You can search many other databases through bmj.

http://www.wonca.org/wonca_home.htm

This is site of WONCA, world organization of national colleges associations and academies of family physicians. Through this site you can search multiple journals on family medicine containing quality information.

www.onhealth.com/

www.circulationaha.org

http://text.nlm.nih.gov/ftrs/dbaccess/ahcpr

http://www.ahcpr.gov/cgi-bin/gilssrch.pl)

http://text.nlm.nih.gov/ftrs/dbaccess/ahcpr

Canadian Medical Association Clinical Practice Guidelines Infobase index of clinical practice guidelines includes downloadable full text versions or abstracts for most guidelines

(http://www.cma.ca/cpgs/)

Scottish Intercollegiate Guidelines Networkfull text versions of guidelines and quick

Reference guides (http://pc47.cee.hw.ac.uk/sign/home.htm)

http://www.ahcpr.gov/cgi-bin/gilssrch.pl

Www.nice.org.uk.

www.omni.ac.uk/

Basic thing is that you spend some time on Internet. Initially you feel some difficulty and frustration on the time consumed but slowly and surely you learn how to get your required information withen minimum time. Go ahead spend few minutes daily and you will see how quickly your knowledge is world class and how many precious tips you can receive by spending few pennies in few minutes.

http://www.vh.org/Providers/ClinRef/FPHandbook/FPContents.html

This is a handbook on family medicine. Whole of the book is available free of charge to you. You can copy and save any chapter in your library. This is written by family physician for family physicians. First section of first chapter is being quoted at the end.

Using clinical guidelines within healthcare organisations

In the same way as topics for guideline development need to be prioritised, organisations need a process, by which they can set and pursue their clinical priorities. These can reflect national priorities or can be set at a local level by health authorities, trusts, primary care groups, or individual general practices. Whatever the level at which priorities are set, explicit criteria can help guide a rational.

When clinical guidelines to improve patient care are introduced, several characteristics of the organisation will be important. An organisation that can adapt to frequent change will offer different barriers and facilitators than will one that is oriented towards maintaining the status quo. At the simplest level, the size and complexity of the organisation will affect the feasibility of different strategies. Strategies for a primary care group or a single general practice may be inappropriate in a large acute trust.

The skills needed at an organisational level are:

Knowledge of the theoretical basis of behaviour change among healthcare professionals and the empirical evidence about the effectiveness of different dissemination and implementation strategies;
Good interpersonal skills; and knowledge of methods of guideline development and appraisal.
Specific skills for monitoring the use of guidelinesdata processing skills for audit and feedback

Data or data collection skills for non-routine clinical datamay also be needed.

Finding valid guidelines to use

Most healthcare organisations do not have the resources and skills to develop valid guidelines from scratch. They should try to identify previously developed rigorous guidelines and adapt these for local use.

Identifying published clinical guidelines is problematic. Many guidelines are not indexed in the commonly available bibliographic databases. Some clinical guidelines are catalogued on the Internet and such sites may become the best source for identifying guidelines. An increasing number include full text versions or abstracts.

Identifying guidelines

Search terms for common bibliographic databases:

Medline and Healthstar"guideline" (publication type) and "consensus development conference" (publication type). Healthstar includes journals not referenced in Medline and grey literature such as AHCPR guidelines CINAHL"practice guidelines" (publication type). Includes full text version of some guidelines, including AHCPR guidelines

EMBASE"practice guidelines" (subject heading). This is used for articles about guidelines and for those that contain practice guidelines; the term was introduced in 1994

Useful websites: Mentioned in earlier section.

If organisations cannot find published valid guidelines relevant to their identified priorities they can amend their priorities or develop a guideline themselves. If they decide to develop a guideline, they should use as rigorous a method as possible within the resources available and be explicit about the method of development and its potential limitations. The increasing availability of high quality systematic reviews in the Cochrane database of systematic reviews and the Cochrane controlled trials register (both available in the Cochrane Library) makes this task slightly less daunting than previously.

After identifying proper guidelines following processing should be undertaken before these are implemented.

Evaluation ensures that the process of care reflects guideline recommendations. The data needed for this should be specified at the outset and should be linked to areas of strong evidence within the guideline. Reminder or prompt sheets can be designed to encourage the recording of specific data Items.

Medical or clinical audit advisory groups for general practice and clinical audit/clinical effectiveness departments in trusts have a key role to play in collecting, analysing, and feeding back these data. Clinical governance, a central concept in a recent policy paper on the health service will depend on accurate and meaningful data about quality of care. We believe that criteria for clinical governance should be derived, at least in part, from the recommendations framed in evidence based clinical guidelines.

Conclusions

Clinical guidelines are increasingly part of current practice and will become more common over the next decade. Great care needs to be taken both to maximise the validity of guidelines and to ensure their use within clinical practice. The latter requires adaptation for a local setting and tailoring evidence based implementation strategies to local factors. However, guidelines will not address all the uncertainties of current clinical practice and should be seen as only one strategy that can help improve the quality of care that patients receive.

Guideline for the primary cares management of asthma in adults

North of England Asthma Guideline Development Group

(Please purchases a peak flow meter. It costs only few hundreds)

The aim of this guideline is to provide recommendations (evidence based when possible) to guide primary health care professionals in their management of adult patients with asthma. Recommendations may not be appropriate for use in all circumstances

Scope of guideline

Aspects covered by the guideline are the use of peak flow measurement in diagnosis and Management, drug treatment, non-drug treatment, and referral. All recommendations are for primary health care professionals and apply to adult patients attending general practice with asthma.

Aims of treatment

Comment--British Thoracic Society guidelines state the aims of treatment as patients having the least possible symptoms; the least possible need for relieving bronchodilators; the least possible limitation of activity; the least possible circadian variation in peak flow; the least possible adverse effects from medicine; and the best peak flow possible. It is preferable to adjust treatment to cover exposure to day to day triggers such as exercise and cold air because avoidance imposes inappropriate restrictions on lifestyle. Specific comments about adjusting the dosages of drugs are made within the relevant sections on drug treatment.

Peak flow: diagnosis and management (Grading of evidence shown as A or B etc)

* Peak flow variability can be used to help in the diagnosis of recurrent wheeze (B)

* The routine home use of peak flow meters for self-management is not mandatory (A)

* Morning "dipping" should be regarded as a sign of transient poor control (B)

* Peak flow monitoring can be useful to assess patients and inform management (C).

Peak flow variability can be used to help in the diagnosis of recurrent wheeze (II). Though

Monitoring peak flow can be useful to assess patients and inform management (III), the routine home use of peak flow meters does not alter patient outcome (I). Morning "dipping" of peak flow values reflects transient rather than long-term poor control (II). Additionally, in acute situations peak flow can be used to predict outcome (III).

Drugs used in the treatment of asthma

Comment--All recommendations for treatment apply only in the absence of recognised

Contraindications, side effects, or interactions as documented in the British National Formulary.

Compliance /RECOMMENDATION

* Compliance with treatment is important and should be checked regularly, especially if symptom control is poor or treatment is about to be increased (C).

Sequencing of treatment

Comment--There is little evidence to answer the important clinical questions of appropriate sequencing of treatment and the relative places of various agents in drug management. Drugs are therefore considered in the order of presentation in the British National Formulary.ted

Sequencing is provided after consideration of the drugs.

Short acting ß2 agonists RECOMMENDATIONS

* Short acting ß2 agonists are effective bronchodilator (A)

* They should be used on an as required basis to relieve symptom (C)

* They should be used before exercise in-patients who have exercise induced bronchospasm (A).

Though short acting ß2 agonists is effective as judged by an increase in peak expiratory flow (I), there is conflicting evidence on the issue of as required versus regular dosage (I). For patients who need four daily doses of a short acting ß2 agonist the two studies identified give contradictory findings. Salbutamol is effective for exercise induced bronchospasm and is more effective than sodium cromoglycate (I).

Long acting inhaled ß2 agonists

Comment--We identified no evidence to suggest whether long acting ß2 agonists should be used before or after inhaled anti-inflammatory drugs. At the time of completion of the guideline the only prescribable long acting inhaled ß2 agonist was salmeterol.

RECOMMENDATIONS

* Most patients treated with salmeterol will achieve satisfactory control with 50 µg twice daily. If it is used in higher dose attention must be paid to inquiring about side effects (A)

* In patients using short acting ß2 agonists four times daily regular salmeterol should be added to treatment (A)

* The short acting ß2 agonist should be continued on an as required basis (C)

* Salmeterol should be considered if overnight relief is required (A).

Salmeterol produces appreciable bronchodilatation for 12 hours; there is little additional effect from dosages above 50 µg twice daily and side effects increase (I). Used twice daily it is more effective than short acting inhaled ß2 agonists used four times daily (as a metered dose inhaler or powder) (I). In one short term evaluation salmeterol was as safe as a short acting ß2 agonist (I), though this was a negative study without a power calculation.

Comment--If the introduction of salmeterol is based on frequency of short acting ß2 agonist use there is benefit in using it in line with the recommendation above. We identified no evidence on the use of salmeterol at lower frequencies of short acting ß2 agonist use, nor any evidence in relation to frequency of inhaled anti-inflammatory use.

Inhaled anti-inflammatory agents Steroids RECOMMENDATIONS

* Patients requiring short acting ß2 agonists more than two or three doses a day should be treated with inhaled steroids (A)

* Inhaled steroids are effective on a twice-daily basis (A)

* If symptoms are not controlled on twice daily dosing and there is concern about the total daily dose, then increasing the dosage frequency to four times daily but at the same total daily dose should be tried (A)

* If symptoms are not controlled with standard doses (up to a daily equivalent of 800 µg

Beclomethasone) higher doses of inhaled steroids should be used up to a daily equivalent of 2000 µg beclomethasone (A)

* A one to three month period of stability should be shown before stepwise reduction in inhaled steroids is undertaken, decreasing the dose by 25-50% at each step (C)

* As there is no good evidence of clinically important differences between differing inhaled steroids, patients should be treated with the cheapest inhaled steroid that they can use and which controls their symptoms (C).

Inhaled steroids are effective (I) and can allow a reduction of oral steroid dosage in steroid dependent patient’s (I). There are no clinically important differences in effectiveness between the various inhaled steroids that cannot be addressed by dosage adjustment (I). The clinical relevance of differences in cortisol suppression between different agents is unclear (III). In patients requiring short acting ß2 agonists more than two or three times a day adding an inhaled steroid improves peak flow and symptoms and reduces short acting ß2 agonist use (I).

Comment--Though there may be benefit from introducing inhaled steroids at a lower level of use of ß2 agonists, as suggested by the British Thoracic Society guidelines, we did not identify any evidence for this. We identified no evidence on the use of inhaled steroids as first line treatment.

Inhaled steroids are slightly more effective when used four times daily than when used twice daily and are more effective when used twice daily than when used once daily; differences in lung function, however, are not large (I). Of the five studies that examined the effectiveness of differing dosage frequencies of inhaled steroids, all were small and four were negative studies without a power calculation and therefore at risk of type II errors. The group recognised the importance of compliance with treatment, though this was not formally studied; in most patients twice daily dosing is acceptable. Symptom control is better with high rather than low doses of inhaled steroid (I), though surprisingly few studies were identified to support this widely held clinical view. We identified no direct evidence on when to decrease the dose of inhaled steroids. One study indirectly suggested that some patients using inhaled steroids might be receiving an unnecessarily high dose (III).

Other inhaled anti-inflammatory agents RECOMMENDATION

* Nedocromil or sodium cromoglycate may be useful in occasional patients as an adjunct to inhaled steroids or as an alternative in those patients who cannot tolerate or do not wish to take inhaled steroids. They should be considered as second line treatment to inhaled steroids. We identified no evidence to prefer nedocromil to sodium cromoglycate or vice versa (C).

Though nedocromil is more effective than placebo as a first line anti-inflammatory agent, its effect is not large and it has a questionable effect as a second line anti-inflammatory drug (I). Sodium cromoglycate is more effective than placebo as a first line anti-inflammatory drug and is effective delivered in either a metered dose inhaler or a spinhaler (I). There is no evidence to prefer nedocromil to sodium cromoglycate or vice versa (I).

Drug delivery devices RECOMMENDATIONS

* Health care professionals advising patients should use the cheapest drug delivery device that the patient can use and comply with effectively (C)

* Large volume spacer devices should be used with inhaled drugs when the aim is to increase their effectiveness without increasing the dose. Additionally, they should be used with high dose inhaled steroids to decrease oral candidiasis (A)

* In acute situations large volume spacer devices are an effective alternative to nebulisers for delivering high dose bronchodilators (A).

Comment--A range of drug delivery devices is available; given this range the evidence on the relative merits and the therapeutic place of differing inhaler devices is sparse.

Metered dose inhalers are as effective as powder device (I), and autohalers are no more

Effective than metered dose inhalers (I). The use of spacer devices increases the effectiveness of inhaled drugs and decreases oral candidiasis in-patients using inhaled steroids (I). Additionally, spacer devices can be as effective as nebulisers in delivering drugs for acute asthma (I).

Inhaler technique RECOMMENDATIONS

* Health care professionals should ensure that patients could use their inhalers adequately (C)

* Inhaler technique should be rechecked whenever control is in doubt (C).

The only paper addressing inhaler technique evaluated an electronic meter to improve technique; it conferred no advantage (I).

Oral bronchodilators RECOMMENDATION

* Oral bronchodilators should be considered as second line treatment to inhaled bronchodilators(C). Oral bronchodilators act more slowly than inhaled agents and are much less suitable for short-term relief of symptom (III). Oral theophylline is more effective than placebo (I) and produces similar therapeutic effects to oral salbutamol (I) When theophylline is added to oral salbutamol it produces a rise in peak expiratory flow, greatest in-patients with the lowest initial peak expiratory flow and with higher doses of theophylline (I).

Sustained release terbutaline is more effective than short acting oral salbutamol (I) and equivalent to inhaled steroids in terms of controlling nocturnal symptoms (I). Bambuterol is no better than milligram equivalent doses of controlled release terbutaline (I).

Oral steroids RECOMMENDATIONS

* Steroids should be used in exacerbations of asthma (A)

* They should be given by mouth, as intravenous administration offers no advantage (A)

* When used in short courses of up to two weeks the dose of oral steroids does not need to be tapered; oral steroids can be stopped from full dosage (C).

Steroid treatment provides important benefits to patients presenting with acute exacerbations of asthma; oral and intravenous dosing is equally effective (I). When used in short courses oral steroids are safe; they produce very low rates of gastrointestinal bleeding. The greatest risk is in-patients with a history of gastrointestinal bleeding or taking anticoagulant (III).

Comment--The British National Formulary states: "Corticosteroid therapy is weakly linked with peptic ulceration; the use of soluble or enteric-coated preparations to reduce risk is speculative only.

Intravenous therapy in acute asthma RECOMMENDATION

* Intravenous therapy should not be used in preference to inhaled ß2 agonists in the treatment of acute asthma (I), and nebulised salbutamol is more effective than intravenous salbutamol in acute asthma (I).

Drug sequencing chronic asthma: sequencing drugs RECOMMENDATIONS

* The trigger to increasing treatment at all stages is if the short acting inhaled ß2 agonist is being used more than two or three times daily or symptom control is not good (British Thoracic Society guidelines define good control as minimal (ideally, no) chronic symptoms; minimal (that is, infrequent) exacerbations; minimal need for relieving bronchodilators; no limitations on activities) (C)

* Compliance should be checked before any treatment increase (C)

* A one to three month period of stability should be shown before stepwise reduction in treatment is undertaken (C).

Chronic asthma: sequencing drug delivery devices RECOMMENDATIONS

* Patients should initially be treated with a metered dose inhaler (C)

* If they cannot comply with a metered dose inhaler, then a large volume spacer device should be added (C)

* If they cannot comply with a metered dose inhaler plus large volume spacer, then they should be treated with the cheapest powder or automatic aerosol inhaler that they can comply with (C)

* If they find a metered dose inhaler plus large volume spacer difficult to carry during the day because of its bulk, then they should be treated with the cheapest powder or automatic aerosol inhaler that they can comply with (C).

Uncontrolled asthma: sequencing drugs RECOMMENDATION

Patients with uncontrolled asthma should be treated as follows:

* Prednisolone 30-40 mg daily should be given until the episode has resolved, symptoms are controlled, and lung function values have returned to previous best. Though seven days' treatment will often be sufficient, treatment may need to be continued for up to 21 days (C)

* Depending on the severity of the episode patients may need a short acting inhaled ß2 agonist

Delivered via a nebuliser or a large volume spacer device (C).

Comment--British Thoracic Society guidelines suggest that the indications for rescue courses of steroids should include day by day worsening of symptoms and peak expiratory flow; fall in peak expiratory flow to below 60% of patient's best; sleep disturbance by asthma; persistence of morning symptoms till midday; diminishing response to inhaled bronchodilators; emergency use of nebulised or injected bronchodilators.

Non-drug treatment Acupuncture and yoga RECOMMENDATION

* Patients should not be treated solely with acupuncture or yoga (A).

Neither acupuncture nor yoga has been shown to be of therapeutic benefit in asthma (I). The one identified study of yoga bronchial reactivity decreased.

Precipitants Allergen avoidance

Comment--British Thoracic Society guidelines suggest that allergens (such as house dust mite, domestic pets, and pollens) should be considered and avoided when relevant.

Smoking and smoking cessation RECOMMENDATIONS

* The current smoking status of all patients should be known (C)

* Patients who smoke should be advised to stop (C)

* There is no one strategy that is effective for all patients (C)

* Advice and strategies should be tailored to individual circumstance (C)

* Patients should avoid passive smoking (C).

Nicotine patches can help patients stop smoking (I). 70 71

Patient education RECOMMENDATION

* Patients should be offered education about their condition and its management (C).

Patient education can improve knowledge and beneficially alter behaviour (I).

Referral

Comment--We could identify no evidence concerning the referral of patients with asthma, either from primary to secondary care or between health care professionals within primary care. These recommendations are based on British Thoracic Society guidelines.

Referral to a chest physician RECOMMENDATIONS

Referral to a respiratory physician is appropriate for:

* Patients in whom there is diagnostic doubt

* Patients with possible occupational asthma

* Patients who present a problem in management (C).

Comment the guideline development group made additional points of

* Occupational asthma should be referred for confirmation of the diagnosis, management of sensitiser avoidance, and management of other workers in the workplace (C)

* Patients whom a general practitioner is considering for long term oral steroids or home use of a nebuliser should be referred to a respiratory physician for assessment (C)

* Patients who have recently been discharged from hospital should have their treatment reviewed; this does not need hospital review if primary health care professionals have the relevant skills and resources (C)

* Patient preference should be accommodated in the decision to refer (C)

* Primary health care professionals should be aware of the range of skills and facilities available within their practice and should refer within the practice when appropriate (C).

University of Iowa Family Practice Handbook, 3rd Edition, Chapter 1

Emergency Medicine: The Management of Acute Chest Pain in the Emergency Room Setting

Mark A. Graber, M.D.

Department of Family Medicine, University of Iowa, and Peer Review Status: Externally Peer Reviewed by Mosby

A. Obtain an ECG as well as a CXR film, CBC count, cardiac enzymes (troponin T or I and myoglobin may be appropriate depending on your institutional standard), and electrolytes. A metabolic cause for angina may be found such as anemia or pneumonia. Do not withhold treatment until laboratory results are available; transfuse as needed.

B. Differential diagnosis of chest pain is complex. Partial list provided in Table 1-1.

C. Administer oxygen to all patients with chest pain.

D. For cardiac pain:

1.Nitrates

Either SL nitroglycerin 0.4 mg or IV nitroglycerin 10 to 300 µg/min, should be administered by titration up by 20 µg/min every 5 minutes until pain is relieved or the blood pressure begins to be unacceptably low. Occasionally a patient will get quite hypotensive after the SL administration of NTG, and so prior establishment of an IV dose is prudent though not mandatory. Hypotension will respond to fluids and is self-limited. This is not a contraindication to the judicial use of IV NTG. Prolonged or severe hypotension related to the use of nitrates should be suggestive of a right ventricular infarction, which is often associated with an inferior wall MI and can be diagnosed by the use of right chest leads (see Chapter 2). Hypotension from nitrates in a ventricular infarction will respond to fluid as well. Tolerance to nitrates may develop within 24 hours

2.Aspirin 325 mg (non-enteric coated)

Should be administered to any patient with angina that does not have a contraindication such as active bleeding.

3.Morphine

Given in 2 to 4 mg aliquots IV can be helpful in relieving chest pain and cardiac ischemia. The total dose should not exceed 12 to 14 mg in the usual circumstance. 4.Heparin

5000 units as an IV bolus with a drip at 1000 units/hour is helpful in the patient with unstable angina or evidence of MI and can be used in addition to aspirin in the patient without contraindications. More recently, weight-based nomograms that are more likely to reach therapeutic levels have been developed. Start with a bolus of 80 U/kg followed by a drip of 18 U/kg/hr. Enoxaparin shows promise in this setting but cannot be recommended at this time.

5.Beta-blockers

Such as metoprolol 15 mg IV in 5-mg aliquots every 5 minutes can be helpful in patients without failure and a hyperdynamic state. Contraindications include heart block, COPD, bradycardia, and hypotension among others.

6.Calcium-channel blockers.

a.Diltiazem. recent evidence indicates that IV diltiazem 25 mg over 2 minutes followed by a drip at 5 mg/hr may be useful for refractory angina. IV diltiazem should not be used in combination with IV beta-blockers. May cause AV conduction disturbances. b. Nifedipine as a 10-mg capsule chewed and swallowed may result in the relief of angina pain. However, it may exacerbate tachycardia and cause hypotension. Nifedipine is not absorbed through the buccal mucosa and overall does not have any effect on the progression to MI. Other therapies are more effective.

7.Thrombolytics

May be indicated in the event of a MI. See section on myocardial infarction in Chapter 2 for management details.

8.Patients should be admitted

For unstable angina as well as for R/O or actual MI. The decision should be based on the history, since the ECG may not reflect an abnormality in 50% of those with an acute MI. Enzymes are also not helpful in deciding who to admit, since the CPK and troponin-T may not be elevated for up to 6 hours after an infarction.

Table 1-1 Partial Differential Diagnosis of Acute Chest Pain

This table can not be produced as a whole due to shortage of space. It discusses conditions under following headings.