For routine, office-based diagnoses of acute sinusitis, we’ve seen that antibiotics are unlikely to be beneficial. The other theory behind treatment is attenuation of the inflammatory response, promoting sinus drainage. Intranasal steroid sprays have inconclusive data. This is a trial of systemic steroids, theorizing that intranasal steroids suffer from inadequate tissue penetration.
There are a lot of issues with this trial. Whether it’s clinically significant or not, the 30mg/day dose of prednisolone is below the typically used doses of 50mg or 60mg. There were 54 treatment locations and 68 family physicians involved in this study over a 2 1/2 year period – and only managed to enroll 185 patients. For a problem “frequently encountered” in primary care, it’s a little hard to have confidence there aren’t biases present with enrollment.
The authors followed many different clinical outcomes, as well as the SNOT-20 score, at several different time points, and the easiest way to sum it up is to say there are probably no clinically relevant differences between groups. The trends nearly all favored prednisolone, but the absolute differences in outcomes provided NNT between 10 and 33. A larger trial might have detected a statistically significant benefit to steroids – or it might not – but most enrolled patients had symptom improvement, regardless.
“Systemic corticosteroid monotherapy for clinically diagnosed acute rhinosinusitis: a randomized controlled trial”
www.ncbi.nlm.nih.gov/pubmed/22872770
Month: September 2012
It’s Too Hot To Fight & Other Fables
There’s a mythology regarding temperature and violent crime – both increase in tandem up until a certain point, at which it becomes “too warm”. This study, a retrospective analysis of violent crime from a six-year period in Dallas, TX, generally confirms the increase in violence as the temperature increases.
The authors additionally propose, however, a curvilinear relationship based on the data that interprets an inflection point at 80-89 degrees a bit aggressively, considering they only have one data point above 80-89 with which to define the further trend. The absolute differences between total numbers of violent assaults in each temperature bracket are small enough, it’s a little hard to confidently say there’s a point at which it becomes too hot for violent crime. It makes sense, of course, but that’s more editorializing.
Perhaps they could attempt to externally validate these findings in Iraq – which seems awfully hot and violent. They also note there is a strong correlation between temperature and hours of daylight – but it seems as though that’d be rather difficult to control for one or the other.
And, tying this entire issue into climate change is another unusual matter entirely….
“Temperature and Violent Crime in Dallas, Texas: Relationships and Implications of Climate Change”
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3415828/
The End of IABP?
Adding to the “don’t do anything, just stand there!” file, another relatively frequently used cardiovascular support tool – intra-aortic balloon counterpulsation – might be on the chopping block.
Typically used in cases of severe cardiogenic shock secondary to acute myocardial infarction, IABP is used to reduce strain on the stunned myocardium. The first IABP-SHOCK pilot of 45 patients showed no mortality difference, but a significant improvement in BNP levels with IABP use. This is the follow-up study, enrolling 600 patients to IABP or best available medical therapy.
Both groups were similarly ill – the IABP group had 6% more anterior STEMIs – and had nearly identical outcomes. There were 1.5% more survivors in the IABP group, but the p value was 0.69. Adverse events were similar – although the control group tended towards increased sepsis, which seems a little odd. There was an expected random assortment of subgroups favoring one therapy or another, but nothing that would seem to be specifically hypothesis generating.
In the end, the authors rather grimly state that, despite some surrogate markers appearing to be improved in the IABP group, there is no evidence to support routine use of IABP in cardiogenic shock secondary to acute myocardial infarction.
“Intraaortic Balloon Support for Myocardial Infarction with Cardiogenic Shock”
http://www.nejm.org/doi/full/10.1056/NEJMoa1208410