Posted by Paul Rega, MD — published on November 22nd, 2007
N Engl J Med. 2007; 357(16):1598-607 (ISSN: 1533-4406)
Sullivan FM ; Swan IR ; Donnan PT ; Morrison JM ; Smith BH ; McKinstry B ; Davenport RJ ; Vale LD ; Clarkson JE ; Hammersley V ; Hayavi S ; McAteer A ; Stewart K ; Daly F
Scottish School of Primary Care, University of Dundee, Dundee, United Kingdom. f.m.sullivan@chs.dundee.ac.uk
BACKGROUND: Corticosteroids and antiviral agents are widely used to treat the early stages of idiopathic facial paralysis (i.e., Bell’s palsy), but their effectiveness is uncertain. METHODS: We conducted a double-blind, placebo-controlled, randomized, factorial trial involving patients with Bell’s palsy who were recruited within 72 hours after the onset of symptoms. Patients were randomly assigned to receive 10 days of treatment with prednisolone, acyclovir, both agents, or placebo. The primary outcome was recovery of facial function, as rated on the House-Brackmann scale. Secondary outcomes included quality of life, appearance, and pain. RESULTS: Final outcomes were assessed for 496 of 551 patients who underwent randomization. At 3 months, the proportions of patients who had recovered facial function were 83.0% in the prednisolone group as compared with 63.6% among patients who did not receive prednisolone (P<0.001) and 71.2% in the acyclovir group as compared with 75.7% among patients who did not receive acyclovir (adjusted P=0.50). After 9 months, these proportions were 94.4% for prednisolone and 81.6% for no prednisolone (P<0.001) and 85.4% for acyclovir and 90.8% for no acyclovir (adjusted P=0.10). For patients treated with both drugs, the proportions were 79.7% at 3 months (P<0.001) and 92.7% at 9 months (P<0.001). There were no clinically significant differences between the treatment groups in secondary outcomes. There were no serious adverse events in any group. CONCLUSIONS: In patients with Bell’s palsy, early treatment with prednisolone significantly improves the chances of complete recovery at 3 and 9 months. There is no evidence of a benefit of acyclovir given alone or an additional benefit of acyclovir in combination with prednisolone. (Current Controlled Trials number, ISRCTN71548196 [controlled-trials.com].).
Posted by Paul Rega, MD — published on November 22nd, 2007
Ann Emerg Med. 2007; 50(5):552-63 (ISSN: 1097-6760)
Singh A ; Alter HJ ; Littlepage A
Department of Emergency Medicine, Alameda County Medical Center-Highland Hospital, Oakland, CA 94602, USA. amasingh@acmedctr.org
STUDY OBJECTIVE: Acute renal colic is a common presenting complaint to the emergency department. Recently, medical expulsive therapy using alpha-antagonists or calcium channel blockers has been shown to augment stone passage rates of moderately sized, distal, ureteral stones. Herein is a systematic evaluation of the use of medical expulsive therapy to facilitate ureteral stone expulsion. METHODS: We searched the databases of MEDLINE, EMBASE, and the Cochrane Controlled Trials Register. Additional sources included key urologic journals and bibliographies of selected articles. We included studies that incorporated a randomized or controlled clinical trial design, patients older than 18 years, treatment in which an alpha-antagonist or calcium channel blocker was compared to a standard therapy group, and studies that reported stone expulsion rates. A random effects model was used to obtain summary risk ratios (RRs) and 95% confidence intervals (CIs) for stone expulsion rate. RESULTS: A pooled analysis of 16 studies using an alpha-antagonist and 9 studies using a calcium channel blocker suggested that the addition of these agents compared to standard therapy significantly improved spontaneous stone expulsion (alpha-antagonist RR 1.59; 95% CI 1.44 to 1.75; number needed to treat 3.3 [95% CI 2.1 to 4.5]; calcium channel blocker RR 1.50; 95% CI 1.34 to 1.68; number needed to treat 3.9 [95% CI 3.2 to 4.6]) in patients with distal ureteral stones. Subgroup analysis of trials using concomitant medications (ie, low-dose steroids, antibiotics, and elimination of trials using an anticholinergic agent) yielded a similar improvement in stone expulsion rate. Adverse effects were noted in 4% of patients receiving alpha-antagonist and in 15.2% of patients receiving calcium channel blockers. CONCLUSION: Our results suggest that “medical expulsive therapy,” using either alpha-antagonists or calcium channel blockers, augments the stone expulsion rate compared to standard therapy for moderately sized distal ureteral stones.
Posted by Paul Rega, MD — published on November 16th, 2007
11/16, Bankhead) reports that in the first six years of the decade, the “frequency of ocular methicillin-resistant Staphylococcus aureus (MRSA) increased by almost 60 percent,” according to research presented at the American Academy of Ophthalmology meeting in New Orleans, La. “The proportion of MRSA isolates in ocular specimens rose from 18.3 percent in 2000 to 29.1 percent in 2005,” reported Darlene Miller, D.H.Sc., of the Bascom Palmer Eye Institute in Miami, Fla. MedPage continues, “Usually associated with hospital acquisition, ocular MRSA isolates consistent with community-acquired MRSA accounted for almost 20 percent of the total,” according to Dr. Miller. In light of the findings, Dr. Miller pointed out that the “conjunctiva and lids” may “serve as potential reservoirs for community-acquired MRSA.” Furthermore, the findings “indicate that common ocular antimicrobial agents, such as erythromycin and tetracycline, might be inappropriate for treatment of MRSA,” Dr. Miller said.
Posted by Paul Rega, MD — published on November 2nd, 2007
Med J Aust. 2007; 187(6):333-6 (ISSN: 0025-729X)
Yap KS ; Kalff V ; Turlakow A ; Kelly MJ
Department of Nuclear Medicine, The Alfred Hospital, Melbourne, VIC, Australia. kskyap@yahoo.com
OBJECTIVE: To assess whether a cumulative clinical risk score (Wells score) can optimise imaging strategies in patients with suspected pulmonary embolism (PE). DESIGN, SETTING AND PARTICIPANTS: Prospective, consecutive series of 633 studies on 595 patients referred to a major teaching hospital for ventilation/perfusion (V/Q) scanning for suspected acute PE between September 2004 and November 2005. Ventilation scintigraphy was performed using technetium-99m Technegas, and V/Q results were interpreted in conjunction with Wells scores. MAIN OUTCOME MEASURES: Likelihood of PE for each Wells score interval; overall prevalence of PE. RESULTS: The likelihood of PE for a given Wells score in our study was not significantly different from the likelihood in the original study by Wells et al. Scores of < 2 in our study were associated with a 4% risk of PE, scores between 2 and 6 with a 13% risk, and scores > 6 with a 67% risk. The overall prevalence of PE in our study was significantly less than that in the original study (9% v 16%; P < 0.01), attributable to a significantly larger proportion of our patients having scores of < 2 (66% v 40%; P < 0.0001). CONCLUSION: The Wells score remains a robust clinical tool for stratifying the likelihood of PE. Patients with Wells scores of > 2 warrant imaging assessment for PE, but for those with scores < 2, further imaging may be problematic.
