John Smucny

There are no clearly effective treatments for the cough of acute bronchitis, and beta2‐agonists are often prescribed, perhaps because clinicians suspect many patients also have reversible airflow restriction contributing to the symptoms. To determine whether beta2‐agonists improve symptoms of acute bronchitis in patients who do not have underlying pulmonary disease. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2005, issue 4) which contains the Acute Respiratory Infections Group's Specialized Register, MEDLINE (January 1966 to November 2005) and EMBASE (1974 to November 2005). Trials in which patients (adults or children over two years of age) who were diagnosed with acute bronchitis or acute cough (without known pulmonary disease and without other cause) were randomized to beta2‐agonist versus placebo, no treatment or alternative treatment. Three authors independently selected outcomes and evaluated trial quality while blinded to study results, they then extracted data. Trials in children and in adults were analyzed separately. Two trials in children (n = 109) with acute cough and no evidence of airway obstruction did not find any benefits from beta2‐agonists. Combined data did not show a significant difference in daily cough scores between patients given oral beta2‐agonists and those in the control groups. Five trials in adults (n = 418) with acute cough or acute bronchitis had mixed results but overall summary statistics did not reveal any significant benefits from oral (three trials) nor inhaled (two trials) beta2‐agonists. There were no significant differences in daily cough scores nor in the number of patients still coughing after seven days (control rate 73%; relative risks (RR) 0.77, 95% CI 0.54 to 1.09). Subgroups of patients with evidence of airflow limitation had lower symptom scores if given beta2‐agonists, in one trial. Furthermore, the trials that did note quicker resolution of cough in patients given beta2‐agonists were those that had a higher proportion of patients with wheezing at baseline. Patients given beta2‐agonists were more likely to report tremor, shakiness or nervousness than patients in the control groups (for trials in children: control rate 0%; RR 6.76, 95% CI 0.86 to 53.12; number needed to harm (NNH) 9, 95% CI 5 to 100; for trials in adults: control rate 11%; RR 7.94, 95% CI 1.17 to 53.94; NNH 2.3, 95% CI 2 to 3). There is no evidence to support the use of beta2‐agonists in children with acute cough who do not have evidence of airflow obstruction. There is also little evidence that the routine use of beta2‐agonists is helpful for adults with acute cough. These agents may reduce symptoms, including cough, in patients with evidence of airflow obstruction. However, this potential benefit is not well‐supported by the available data and must be weighed against the adverse effects associated with beta2‐agonists.

The Rural Medical Education Program (RMED) of the State University of New York (SUNY) Upstate Medical University is a 36-week clinical experience in rural communities for medical students that began in 1989. The authors sought to assess RMED’s success in providing a valuable educational experience for students that assists rural communities recruit physicians. In 2004, the authors used the Physician Masterfiles of the American Medical Association to compare practice locations of SUNY Upstate graduates who completed RMED with those who did not; surveyed former RMED students to assess their satisfaction with their practice location and the importance of RMED in helping them choose a location; interviewed hospital administrators in communities that have hosted RMED students to understand the impact of RMED on host communities; and compared United States Medical Licensing Examination Step 2 scores of RMED students with those of non-RMED students to evaluate educational attainment. A greater percentage of former RMED students practiced in rural locations [22/86 (26%)] than did non-RMED students [95/1,307 (7%)]. Ninety-one percent (69/76) of former RMED students were satisfied with their location, and 84% (64/76) believed that RMED was important in helping them choose a location. Hospital administrators viewed the program highly because it helped them recruit physicians and benefitted their medical staff. RMED students had higher adjusted mean Step 2 scores than did non-RMED students (212.3 versus 199.1). The RMED program has successfully met its goals of providing a valuable educational experience for medical students and assisting rural communities recruit physicians.

Web-based curricula can decrease classroom time and provide self-paced, active learning experiences for medical students. In our family medicine clerkship, we implemented a Web-based module on applying diagnostic reasoning to determine the likelihood that a patient has Group A beta-hemolytic streptococcal pharyngitis based on the history, physical examination, and diagnostic tests. Students rated the module more favorably than other classroom sessions and homework assignments. Most students accurately calculated pretest and posttest probabilities in a write-up of an actual patient with a sore throat. This Web-based module was well received and effective.

The optimal treatment for acute bronchitis is not clear. Because many patients with acute bronchitis have airflow limitation as well as cough, beta2-agonists may be useful. To determine whether beta2-agonists improve the symptoms of acute bronchitis in patients who do not have underlying pulmonary disease. The Cochrane Library (through August 2000), MEDLINE (1966 to 2000), EMBASE (1974 to 2000), and Conference Proceedings using "bronchodilator (exp)", "adrenergic beta-agonist (exp)", or "sympathomimetics (exp)" and "bronchitis" or "cough"; Science Citation Index for referenced publications; and letters to manufacturers of beta2-agonists. An updated search of the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 3, 2003); MEDLINE (January 2000 to July 2003); EMBASE (January 2000 to July 2003) was run in July 2003. Trials in which patients (adults or children over two years of age) without known pulmonary disease who were diagnosed with acute bronchitis or acute cough without other cause were randomized to beta2-agonist versus placebo, no treatment, or alternative treatment. Three reviewers independently first selected outcomes and evaluated trial quality while blinded to study results, and then extracted data. Trials in children and in adults were analyzed separately. Two trials in children (n = 109) with acute cough and no evidence of airway obstruction did not find any benefits from beta2-agonists. Combined data did not show a significant difference in daily cough scores between patients given oral beta2-agonists and those in the control groups. Five trials in adults (n = 418) with acute cough or acute bronchitis had mixed results, but overall summary statistics did not reveal any significant benefits from oral (three trials) nor inhaled (two trials) beta2-agonists. There were no significant differences in daily cough scores nor in the number of patients still coughing after seven days (control rate 73%; RR = 0.77, 95% CI 0.54-1.09). Subgroups of patients with evidence of airflow limitation had lower symptom scores if given beta2-agonists in one trial; and the trials that did note quicker resolution of cough in patients given beta2-agonists were those that had a higher proportion of patients with wheezing at baseline. Patients given beta2-agonists were more likely to report tremor, shakiness, or nervousness than patients in the control groups (for trials in children control rate 0%; RR 6.76, 95% CI 0.86 to 53.12, NNH 9, 95% CI 5 to 100; for trials in adults, control rate 11%; RR 7.94, 95% CI 1.17 to 53.94, NNH 2.3, 95% CI 2 to 3). There is no evidence to support using beta2-agonists in children with acute cough who do not have evidence of airflow obstruction. There is also little evidence that the routine use of beta2-agonists for adults with acute cough is helpful. These agents may reduce symptoms, including cough, in patients with evidence of airflow obstruction; but this potential benefit is not well-supported by the available data and must be weighed against the adverse effects associated with beta2-agonists.

Antibiotic treatment of acute bronchitis, which is one of the most common illnesses seen in primary care, is controversial. Most clinicians prescribe antibiotics in spite of expert recommendations against this practice. The objective of this review was to assess the effects of antibiotic treatment for patients with a clinical diagnosis of acute bronchitis. We searched MEDLINE, EMBASE, reference lists of articles and the authors' personal collections up to 1996, and Scisearch from 1989 to 1996; we also wrote to study authors and drug manufacturers. An updated search of the Cochrane Controlled Trials Register and MEDLINE was conducted in 2000. Randomised trials comparing any antibiotic therapy with placebo in acute bronchitis or acute productive cough without other obvious cause in patients without underlying pulmonary disease. At least two reviewers extracted data and assessed trial quality. Authors were contacted for missing data. Nine trials involving over 750 patients aged eight to over 65 and including smokers and non‐smokers were included in the primary analysis. The quality of the trials was variable. A variety of outcome measures were assessed. Overall, patients receiving antibiotics had better outcomes than did those receiving placebo. At a follow‐up visit, they were less likely to have a cough (relative risk 0.64, 95% confidence interval 0.49 to 0.85; number needed to treat 5, 95% CI 3 to 14), show no improvement on physician assessment (RR 0.52, 95% CI 0.31 to 0.87; NNT 14, 95% CI 8 to 50), or have abnormal lung findings (RR 0.48, 95% CI 0.26 to 0.89; NNT 11, 95% CI 6 to 50); and had shorter durations of cough (weighted mean difference 0.58 days, 95% CI 0.01 to 1.16 days), productive cough (WMD 0.52 days, 95% CI 0.01 to 1.03 days), and feeling ill (WMD 0.58 days, 95% CI 0.00 to 1.16 days). There were no significant differences regarding the presence of night cough, productive cough, or activity limitations at follow‐up, or in the mean duration of activity limitations. The benefits of antibiotics were less apparent in a sensitivity analysis that included data from two other studies of patients with upper respiratory tract infections with productive cough. Antibiotic‐treated patients reported significantly more adverse effects (RR 1.48, 95% CI 1.02 to 2.14; number needed to harm 17, 95% CI 9 to 100) such as nausea, vomiting, headache, skin rash or vaginitis. Overall, antibiotics appear to have a modest beneficial effect in patients who are diagnosed with acute bronchitis. The magnitude of this benefit, however, is similar to that of the detriment from potential adverse effects. Furthermore, patients with other symptoms of the common cold who have been ill for less than one week are not likely to have any benefit from antibiotics.