1. CRITICAL READING Stephen Newell. December 2003

2. Reading a paper – R-E-A-D-ER  Relevant?  Educational? Does it add anything?  Applicable? Primary-care based?  Discrimination - does it answer the questions it set out to? Any patients excluded? Appropriate design / statistics? Concepts understood – risk, NNT, etc?  Evaluation (oveRall) “RCT of the READER method of critical appraisal in general practice”. MacAuley et al, BMJ 1997; 316:134 (11/4/97).

3. Paper for discussion “Systematic review of randomised controlled trials of over the counter cough medicines for acute cough in adults”. Schroeder, K and Fahey, T. BMJ 2002; 324:329-31 (9/2/02).

4. Tasks Read the paper Write the abstract using the following headings: Objectives Design Data sources Included studies Results Conclusion

5. Objectives: To determine whether OTC cough medicines are effective in adults. Design: Systematic review of RCTs. Data sources: Search of the Cochrane Acute Respiratory Infections Group specialised register, Cochrane Controlled Trials Register, Medline, Embase, and the UK Department of Health National research Register in all languages. Included studies: All RCTs that compared OTC cough preparations with placebo in adults with acute cough due to URTI in ambulatory settings and that had cough as an outcome. BMJ abstract

6. Results: 15 trials involving 2166 participants met all the inclusion criteria. Antihistamines seemed to be no better than placebo. There was conflicting evidence on the effectiveness of antitussives, expectorants. Antihistamine-decongestant combinations, and other drug combinations compared with placebo Conclusion: OTC cough medicines for acute cough cannot be recommended because there is no good evidence for their effectiveness. Even when trials had significant results, the effect sizes were small and of doubtful clinical relevance. Because of the small number of trials in each category the results have to interpreted cautiously.

7. Subsequent BMJ correspondence 3 letters in edition of 11/5/02 First – “If current advice on cough medicines is changed to appease the EBM purists, patients with uncomplicated URTI are likely to consult their doctor. Not only is this an unnecessary use of a scare resource but it is also likely to increase the number of inappropriate prescriptions for antibiotics”.

8. Second – “Absence of evidence is not evidence of absence... Annually over £100 million is spent in the UK on OTC cough medicines”. Third – “... We give them things to do while they wait for the viral illness to get better on its own… Don’t let us confuse pharmacological efficacy with the real world of managing human emotions alongside physical illness”.

9. R-E-A-D-ER  Relevant?  Educational? Does it add anything?  Applicable? Primary-care based?  Discrimination. Does it answer the questions it set out to?  Evaluation (oveRall)

10. So, what is the overall opinion about this paper?