ShortCuts-This Week in the Journals

March 17, 2008

shamrock.jpgCommentary by Josh Olstein MD, Associate Editor, Clinical Correlations

Let’s begin this St. Patrick’s Day edition of ShortCuts with a look across the pond. An article published in this week’s edition of The Lancet that studied the use of antibiotics for adults with acute rhinosinusitis. Anyone who’s been to clinic this winter knows that rarely a session goes by without at least one patient requesting antibiotics for this more-than-questionable indication. By performing a meta-analysis using individual patient data from nine placebo-controlled trials of antibiotic administration in acute rhinosinusitis, the authors sought to identify certain signs, symptoms, or subgroups of patients who may benefit from antibiotic use. The primary outcome was the number of patients cured in each trial as determined either through patient evaluation or diaries. The prognostic value of various signs and symptoms were also assessed. The odds ratio for cure with antibiotics was 1.35 (95% CI 1.15-1.66). The authors calculated that the number of patients with acute rhinosinusitis who would need to receive antibiotics for one additional patient to be cured was 15. No specific subgroups would have clearly benefited from therapy. This suggests we must continue to educate our patients about the appropriate use of antibiotics and reserve the use of therapy for appropriate cases as much as possible.

The obvious consequence of antibiotic overuse is the growing epidemic of resistance and no resistant bug gets more press attention than MRSA. With growing public concern about nosocomial MRSA infections, some hospitals, including our own VA, have implemented an admission screening protocol to identify and isolate MRSA carriers with the hope that doing so will prevent person-to-person transmission and reduce the number of infections. A large trial to test such a strategy was published in this week’s edition of JAMA. The authors report the results of their prospective cohort study that included over 21,000 patients on various surgical wards of a Swiss teaching hospital that were assigned to follow either standard infection control methods or a rapid MRSA screening protocol plus standard measures. The outcomes measured included nosocomial MRSA infection and surgical site MRSA infection. The data showed 93 patients in the screening group developed MRSA infections versus 76 in the standard group (p=0.29 for the incidence rates). There was also no difference in the number of surgical site infections between the groups, demonstrating that MRSA screening on admission did not reduce nosocomial MRSA infections in this population.

While resistant organisms have reduced the number of antibiotics we have in our arsenal against infection, bad press and a flawed meta-analysis helped to eliminate the use of rosiglitazone in the management of diabetes late last year. In this month’s issue of Gastroenterology, however, a new life for rosiglitazone is born as a possible therapeutic addition for active ulcerative colitis. A randomized, double-blinded, placebo-controlled trial involving 105 patients with mild to moderately active ulcerative colitis showed significant differences in the rates of clinical response and remission in those treated with 4mg of rosiglitazone twice daily for twelve weeks compared to placebo. The patients were allowed to be on other UC medications during the study that could not be adjusted during the study period. While the sample size was small and the treatment duration short, no significant differences in the rate of cardiovascular adverse events were seen!

While the cardiovascular risk of rosiglitazone is an issue of debate, no one doubts the increased risk of cardiovascular death associated with smoking. In fact, a large case-control study published in last week’s NEJM showed significant premature deaths related to smoking in India. Clinicians have struggled for years to find ways to help patients interested in quitting finally drop the habit. A new study from the British Medical Journal tested a new strategy of giving smokers their estimated “lung-age” based on spirometry data as an incentive to quit. Smokers were offered lung function assessments and those who accepted were randomized to receive their results as either an estimate of their lung age or their FEV1. Both groups were also given additional standard cessation assistance and were followed-up at one year to assess rates of smoking cessation as verified by salivary cotinine testing. Among those who received a lung-age based result, 13.6% quit smoking at one year versus 6.4% in the control group (p=0.005). While routine use of spirometry to screen for COPD may not be warranted, this unconventional use could have a significant health impact for many smokers.

One comment on “ShortCuts-This Week in the Journals

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    Why was the meta-analysis on rosiglitazone “flawed?” It certainly persuaded the FDA to change the drug’s safety categorization. Besides, every drug that’s adopted too enthusastically by doctors often suffer from a setback, and eventually a middle ground involving careful utilisation is found.

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