Phillippa Poole

Oral mucolytic drugs for exacerbations of chronic obstructive pulmonary disease: systematic review

Abstract Objective: To assess the effects of oral mucolytics in adults with stable chronic bronchitis and chronic obstructive pulmonary disease. Design: Systematic review of randomised controlled trials that compared at least two months of regular oral mucolytic drugs with placebo. Studies: Twenty three randomised controlled trials in outpatients in Europe and United States. Main outcome measures: Exacerbations, days of illness, lung function, adverse events. Results: Compared with placebo, the number of exacerbations was significantly reduced in subjects taking oral mucolytics (weighted mean difference −0.07 per month, 95% confidence interval −0.08 to −0.05, P<0.0001). Based on the annualised rate of exacerbations in the control subjects of 2.7 a year, this is a 29% reduction. The number needed to treat for one subject to have no exacerbation in the study period would be 6. Days of illness also fell (weighted mean difference −0.56, −0.77 to −0.35, P<0.0001). The number of subjects who had no exacerbations in the study period was greater in the mucolytic group (odds ratio 2.22, 95% confidence interval 1.93 to 2.54, P<0.0001). There was no difference in lung function or in adverse events reported between treatments. Conclusions: In chronic bronchitis and chronic obstructive pulmonary disease, treatment with mucolytics is associated with a reduction in acute exacerbations and days of illness. As these drugs have to be taken long term, they could be most useful in patients who have repeated, prolonged, or severe exacerbations of chronic obstructive pulmonary disease. What is already known on this topic Mucolytic drugs have properties that may be beneficial in chronic obstructive pulmonary disease These drugs are not prescribed in the United Kingdom and Australasia, although they are widely used in many other countries Drugs that reduce exacerbations may reduce the morbidity and healthcare costs associated with progressively severe disease What this study adds Regular use of mucolytic drugs for at least two months significantly reduces exacerbations and days of illness compared with placebo in patients with chronic bronchitis and chronic obstructive pulmonary disease Exacerbations that do occur may not be as severe, and the benefit may be greater in those with more severe disease Reductions are modest and treatment may not be cost effective

Cardioselective beta-blockers for chronic obstructive pulmonary disease: a meta-analysis.

Beta-blocker therapy has a mortality benefit in patients with hypertension, heart failure and coronary artery disease, as well as during the perioperative period. These drugs have traditionally been considered contraindicated in patients with chronic obstructive pulmonary disease (COPD). The objective of this study was to assess the effect of cardioselective beta-blockers on respiratory function of patients with COPD. Comprehensive searches were performed of the EMBASE, MEDLINE and CINAHL databases from 1966 to May 2001, and identified articles and related reviews were scanned. Randomised, blinded, controlled trials that studied the effects of cardioselective beta-blockers on the forced expiratory volume in 1 s (FEV1) or symptoms in patients with COPD were included in the analysis. Interventions studied were the administration of beta-blocker, given either as a single dose or for longer duration, and the use of beta2-agonist given after the study drug. Outcomes measured were the change in FEV1 from baseline and the number of patients with respiratory symptoms. Eleven studies of single-dose treatment and 8 of continued treatment were included. Cardioselective beta-blockers produced no significant change in FEV1 or respiratory symptoms compared to placebo, given as a single dose (-2.05% [95% CI, -6.05% to 1.96%]) or for longer duration (-2.55% [CI, -5.94% to 0.84]), and did not significantly affect the FEV1 treatment response to beta2-agonists. Subgroup analyses revealed no significant change in results for those participants with severe chronic airways obstruction or for those with a reversible obstructive component. In conclusion, cardioselective beta-blockers given to patients with COPD do not produce a significant reduction in airway function or increase the incidence of COPD exacerbations. Given their demonstrated benefit in conditions such as heart failure, coronary artery disease and hypertension, cardioselective beta-blockers should be considered for patients with COPD.

Does early pulmonary rehabilitation reduce acute health-care utilization in COPD patients admitted with an exacerbation? A randomized controlled study

Background and objective:  In COPD, hospital admissions and readmissions account for the majority of health‐care costs. The aim of this prospective randomized controlled study was to determine if early pulmonary rehabilitation, commenced as an inpatient and continued after discharge, reduced acute health‐care utilization.

Critical factors in career decision making for women medical graduates

Background  Within the next 30 years there will be equal numbers of women and men in the medical workforce. Indications are that women are increasing their participation in specialties other than general practice, although at a slower rate than their participation in the workforce as a whole. To inform those involved in training and employment of medical women, this study investigated the influencing factors in career decision making for female medical graduates.

Case management may reduce length of hospital stay in patients with recurrent admissions for chronic obstructive pulmonary disease.

Objectives: The aim of the study was to determine whether the case management of patients with recurrent hospital admissions for chronic obstructive pulmonary disease (COPD) can reduce hospital days without reducing quality of life.

Randomised, controlled trial of N-acetylcysteine for treatment of acute exacerbations of chronic obstructive pulmonary disease [ISRCTN21676344]

BackgroundProphylactic treatment with N-acetylcysteine (NAC) for 3 months or more is associated with a reduction in the frequency of exacerbations of chronic obstructive pulmonary disease (COPD). This raises the question of whether treatment with NAC during an acute exacerbation will hasten recovery from the exacerbation.MethodsWe have examined this in a randomised, double-blind, placebo controlled trial. Subjects, admitted to hospital with an acute exacerbation of COPD, were randomised within 24 h of admission to treatment with NAC 600 mg b.d. (n = 25) or matching placebo (n = 25). Treatment continued for 7 days or until discharge (whichever occurred first). To be eligible subjects had to be ≥ 50 years, have an FEV1 ≤ 60% predicted, FEV1/VC ≤ 70% and ≥ 10 pack year smoking history. Subjects with asthma, heart failure, pneumonia and other respiratory diseases were excluded. All subjects received concurrent treatment with prednisone 40 mg/day, nebulised salbutamol 5 mg q.i.d and where appropriate antibiotics. FEV1, VC, SaO2 and breathlessness were measured 2 hours after a dose of nebulised salbutamol, at the same time each day. Breathlessness was measured on a seven point Likert scale.ResultsAt baseline FEV1 (% predicted) was 22% in the NAC group and 24% in the control group. There was no difference between the groups in the rate of change of FEV1, VC, SaO2 or breathlessness. Nor did the groups differ in the median length of stay in hospital (6 days for both groups).ConclusionsAddition of NAC to treatment with corticosteroids and bronchodilators does not modify the outcome in acute exacerbations of COPD.

Preventing Exacerbations of Chronic Bronchitis and COPD

It is important to find interventions that will reduce the frequency and severity of exacerbations of COPD, because of their effect on morbidity and healthcare expenditure. A Cochrane systematic review included 23 studies that had evaluated the effects of treatment with mucolytic agents in patients with chronic bronchitis or COPD. Mucolytic treatment was associated with a significant reduction of 0.79 exacerbations per patient per year compared with placebo, a 29% decrease. Patients who received treatment with mucolytic agents were twice as likely to remain exacerbation-free in the study period than if they had received placebo, with six patients needing regular treatment with mucolytic agents for 3–6 months to achieve one less exacerbation over that time. Treatment with mucolytic agents resulted in nearly 7 days less illness per patient per year.How mucolytic agents work is unknown, although they may reduce exacerbations by altering mucus production, antioxidation, or antibacterial or immunostimulatory effects. They do not appear to affect the decline in lung function that occurs in COPD. The treatment appears to be without any adverse effects, apart from the need to take oral medication daily. Cost-effectiveness analysis suggests that the point at which the costs of treatment and non-treatment were equal was 1.2 less exacerbations per year. This is higher than the effect observed in the Cochrane review, suggesting that treating everyone with COPD with mucolytic agents would not be cost effective. Those with more frequent and severe exacerbations appear to have the most to gain.

Comparison of UMAT scores and GPA in prediction of performance in medical school: a national study

Medical Education 2012: 46 : 163–171

Traditional Chinese medicine in the treatment of acute respiratory tract infections

Summary Aims To review the evidence from Cochrane systematic reviews for the effectiveness of traditional Chinese medicinal (TCM) herbs for treating acute respiratory tract infections (ARTIs) and to discuss the limitations of current clinical trials of TCM. Findings Evidence from six Cochrane systematic reviews was weak owing to the lack of high-quality TCM trials. Limitations were usually due to biases that influenced the validity of results. Conclusions TCM is widely used for treating ARTIs. However, none of the identified studies has been well designed or conducted. In this overview, we suggest that clinical trials of TCM for ARTIs need to be re-run in accordance with internationally recognized standards.

On the maldistribution of the medical workforce

At a recent medical education conference (MedEd 2007), the keynote speakers, Drs Haikerwal and Horvath, presented a common viewpoint that the ‘pendulum had swung too far’ to subspecialist practice. There are 48 general physician trainees in Australia, about a quarter of the number of either relevant vacancies (The Internal Medicine Society of Australia and New Zealand estimate) or the Royal Australasian College of Physians (RACP) cardiology trainees. Although problems for generalists and their patients are global, solutions need to be local. In New Zealand, we are ‘contracted’ to develop a local medical workforce and are obliged by way of the Treaty of Waitangi to maintain Maori taonga, which include health. Consequently, attention to workforce maldistributions in our medical programme is not discretionary. Medical workforce maldistributions can be variously disciplinary, cultural and demographic. The already-cited disciplinary maldistribution within the RACP contrasts with the relative economic and outcome utility of general scopes of practice. A generalist perspective is an advantage for clinical decisions, which involve concepts of relative benefit, and needs to be valued. There is little comfort for either Americans or Australians and New Zealanders in the related observations that the number of US graduates entering general practice training schemes decreased by 51% between 1998 and 2006 and more than half of all general practice trainees in the USA in 2006 were overseas graduates. These data suggest a close alignment of career interest and remuneration. Generalists will be disadvantaged as long as health financiers place an excess value on procedures. Fortunately, this driver of maldistributions should be easily fixed through remunerative and service parity. In addition to relatively lower remuneration and status, general physicians and trainees often have disproportionate amounts of on-call duties. The recommendations of the original ‘relative values’ study were not ratified federally, but we are delighted that new attendance items for complex assessments by physicians have been included in the 2007 Australian Budget. The anticipated ‘cost of health’ in Australia and New Zealand by 2020 may be such that politicians might at last override the selfinterests of the financially privileged elements of the medical profession. Judicious incentives, such as debt forgiveness for entering training schemes leading to jobs of need and high utility, may be helpful. The effects of the dual experiments of ‘bonding’ 25% of Australia’s medical students and of another 25% being domestic full fee payers are being watched with interest. Other frequently perverse drivers are the relative status of different medical disciplines and the effect of training schemes that are inaccessible and/or inflexible. As we have opined, the latter is important for an increasingly femaledominated profession. Flexibility not only applies to the opportunity for accelerated and interrupted and part-time learning, but also to recognition of prior learning, credit for conjoint training and broader community roles, development of common, across-disciplinary educational modules and facilitation of re-training and re-deployment. Affirmative and immersion programmes are needed throughout the education continuum. Affirmative schemes are the only way to diversify medical student populations sufficiently to create a cohort of practitioners that will address the health needs of indigenous and other minority populations. The professional colleges must ensure that students from such programmes progress seamlessly. Immersion programmes into regional and rural settings do result in increased local workforce capacities. The broader implications of the success of Australian rural medical schools must not be overlooked and it is time to apply the lessons learnt in Wagga Wagga to underresourced urban and metropolitan areas and to undersubscribed disciplines. The strategies and tactics so well used to advocate for rural general practitioners might work as well for urban psychiatrists. The role of the doctor in 2020 should be agreed before aligning health needs to resources and manipulating career choices to develop an effective health workforce. Doctor maldistributions will be easier to address when the roles of a professional, scientifically predicated, evidencebased cohort of health workers (i.e. doctors) are agreed and alternative fit-for-purpose health workers can be employed. An unpublished survey of junior doctors in an Auckland hospital showed that less than 15% of their employed time was spent doing things for which a medical education was necessary. There may already be enough doctors, at the least in the USA; the problem is that the