2 Minute Medicine Rewind April 24, 2017

Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in Adults

Acute sore throat is one of the most common complaints in patients that present to primary care facilities. Frequently, patients are treated unnecessarily with antibiotics, despite low risks of suppurative complications and limited symptomatic benefit. The use of short-course corticosteroids, however, may offer patients symptomatic relief while avoiding inappropriate prescribing of antibiotics. No prior studies have looked at such steroid use in primary care settings. In this randomized controlled trial, 565 patients with acute onset sore throat and odynophagia not requiring immediate antibiotics were randomized to receive either a single dose of 10 mg of oral dexamethasone or placebo to study the primary outcome of complete resolution of sore throat at 24 hours. At 24 hours, there was no significant difference between groups, where 22.6% of participants in the dexamethasone group achieved complete resolution of symptoms compared to 17.7% of patients in the placebo group (RR 1.28, 95% CI 0.92 to 1.78, p = 0.14). However, a significant difference was found at 48 hours with 35.4% of dexamethasone patients achieving resolution of symptoms compared to 27.1% of placebo (RR 1.31, 95% CI 1.02 to 1.68, p = 0.03, NNT = 12). Also, in patients who were not offered an antibiotic, significantly more patients in the dexamethasone group achieved symptom resolution (RR 1.19, 95% CI 0.79 to 1.79, p = 0.41). Only one adverse event was observed during the trial, where a patient required hospital admission with parapharyngeal abscess. Repeat visits to primary care settings were similar between groups. Limitations of this study include the exclusion of severely ill patients and those who required immediate antibiotics. Children were also not included, however, prior studies have shown benefit in the use of corticosteroids with antibiotics in children. Nonetheless, a significant difference can be found with dexamethasone treatment for acute sore throat in primary care settings.

The Concordance of Parent and Child Immunization

Parental hesitancy concerning vaccines is a major contributor to incomplete childhood immunizations, and has notable impacts on public health, where clusters of unimmunized children have led to an increase of outbreaks in diseases, such as pertussis. Studies have not previously assessed whether parents’ own immunization behavior is connected to the immunizations their children receive. In this retrospective cohort study, investigators analyzed the Oregon ALERT immunization information system to assess the likelihood of adult-child concordance of influenza immunization per influenza season from 2010-2011 and 2014-2015 influenza seasons. The receipt of adult immunization was also assessed for its relation to the receipt of non-influenza recommended immunizations for children. In a total of 450,687 adult caregiver-child pairs, children of immunizing adults were 2.77 times more likely to receive the influenza vaccine (95% CI 2.74 to 2.79), with similar results throughout all influenza seasons. Also, when caregivers that had not been immunized in the previous season received an influenza vaccine, their children were 5.44 times more likely to be vaccinated (95% CI 5.35 to 5.53). When caregivers changed from immunizing to non-immunizing across seasons, their children were also 1.78 times more likely to not be immunized for influenza (95% CI 1.76 to 1.81). There were high levels of concordance between parent and child immunization behavior across all ages of children and all influenza seasons. This study also showed that immunized adult caregivers were 2.97 times more likely to have their children aged 9 months to 3 years be vaccinated with DTaP (95% CI 2.65 to 3.34), and 2.06 times more likely have their adolescents aged 11 to 17 years be vaccinated against HPV (95% CI 2.03 to 2.10). Overall, these findings indicate that targeting parental immunization rates could greatly improve childhood vaccination.

Associations of Maternal Antidepressant Use During the First Trimester of Pregnancy With Preterm Birth, Small for Gestational Age, Autism Spectrum Disorder, and Attention-Deficit/Hyperactivity Disorder in Offspring

With a rise in antidepressant use amongst pregnant women, there has been increased concern over the safety of use during pregnancy. Notably, prenatal antidepressant use has been associated with birth and neurodevelopmental problems. In this retrospective cohort study, multiple Swedish registries were used to study the effect of first trimester exposure to any antidepressants on several primary birth outcomes, including preterm birth and small for gestational age. The authors also examined the relationship between first trimester exposure to antidepressants and neurodevelopmental outcomes, specifically, the diagnosis of autism spectrum disorder and attention-deficit/hyperactivity disorder. Included in this study were 1,580,629 offspring born between 1996 and 2012, with 1.4% of subjects having been exposed to antidepressants according to maternal self-report of antidepressant use. Of these, 82% were exposed to Selective Serotonin Reuptake Inhibitors (SSRIs). Upon adjusting for pregnancy, maternal, and paternal traits, researchers found that first trimester antidepressant exposure was significantly associated with preterm birth (OR 1.34, 95% CI 1.18 to 1.52). There was no significant relationship between first trimester antidepressant exposure and small for gestational age (OR 1.01, 95% CI 0.81 to 1.25), autism spectrum disorder (HR 0.83, 95% CI 0.62 to 1.13), or attention-deficit/hyperactivity disorder (HR 0.99, 95% CI 0.79 to 1.25). For preterm birth, having been dispensed medication during the first trimester was more strongly associated (OR 1.40, 95% CI 1.33 to 1.47) than with dispensing before pregnancy (OR 1.17, 95% CI 1.07 to 1.28). Dispensation during and after pregnancy use was not significantly associated with preterm birth. This study therefore shows that there may be an increased risk of preterm birth with the use of antidepressants during the first trimester, however, the use of these medications does not appear to increase the risk of delivering an infant that is small for gestational age, or the likelihood of developing certain neurodevelopmental disorders.

Brief Behavioral Therapy for Pediatric Anxiety and Depression in Primary Care

Mood disturbances and anxiety disorders are especially prevalent in youth, with 30% of youth being affected. However, studies have shown that these individuals are less likely to be treated compared to patients affected by other mental disorders. There is increasing support for trans-diagnostic cognitive behavioral interventions for emotional disorders in adults, but limited evidence in youth. In this randomized controlled trial, 185 youths (aged 8 to 16.9 years) were randomized to receive either brief behavioral therapy (BBT) or standard assisted referral to care (ARC) to assess the change in Clinical Global Impression-Improvement scale (score ≤2). BBT consisted of 8 to 12 weekly 45-minute sessions of behavioral therapy delivered in outpatient settings, while patients in the ARC group received referrals to mental healthcare and check-in calls to support accessing care. Researchers found that youths in the BBT group had a significantly higher rate of improvement in clinical symptoms (56.8% vs. 28.2%, p < 0.001, NNT = 4), along with a greater reduction in symptoms, and more rapid improvement in function. There were stark differences when taking into account ethnicity, where Hispanic youth had a significantly stronger response to BBT (76.5%) compared to ARC (7.1%) (p < 0.001, NNT = 2). The results of this study add to the body of evidence promoting the inclusion of behavioral techniques in complex psychosocial intervention packages. This study, by design, also demonstrates the value of colocation of behavioral health specialists alongside primary care physicians, as was the case for BBT in this study. Further studies require a larger sample size to improve generalizability, nonetheless, this study does offer a protocol that could be useful in addressing ethnic disparities in mental health services.

Frequency of Evidence-Based Screening for Retinopathy in Type 1 Diabetes

Poor glucose control in type 1 diabetes mellitus remains a common cause of blindness among adults in the United States. Loss of vision can be mitigated by the timely identification of macular edema or vision-threating proliferative diabetic retinopathy. In this retrospective cohort study, investigators used retinal photographs from the Epidemiology of Diabetes Interventions and Complications (EDIC) study and the Diabetes Control and Complications Trial (DCCT) to develop a rational screening frequency for retinopathy. Markov modeling was used with the aim of determining the likelihood of progression to proliferative diabetic retinopathy or macular edema in patients stratified by initial retinopathy levels (no retinopathy, mild, moderate of severe non-proliferative diabetic retinopathy), with inclusion of known risk factors for retinopathy. Researchers found that the probability of progression to proliferative diabetic retinopathy or significant macular edema was found in only 5% of patients at retinal screening exams. Participants with no retinopathy (state 1) had only a 2.9% chance of progression to state 5 (proliferative diabetic retinopathy or clinically significant macular edema) over the next 4 years, while those in state 2 had only a 3.7% chance of doing so by 3 years. This is in contrast to patients with state 3 or state 4 disease, where the probabilities of progression to state 5 were found to be 6.6% over 6 months and 14.4% over 3 months, respectively. These risks were also closely related to mean glycated hemoglobin levels (HbA1c), where each 1% increase in mean HbA1c was associated with a 15.4% higher risk of progression from state 1 to state 2 retinopathy (HR 1.15, 95% CI 1.12 to 1.19), and a 12.4% lower chance of regression from state 2 to state 1 of retinopathy (HR 0.88, 95% CI 0.83 to 0.92). The risk of progression from state 1 or no retinopathy to state 5 was 1.0% over 5 years in patients with an HbA1c of 6%, while those with HbA1c of 10% had a 4.3% risk over 3 years. Ultimately, the risk assessment carried out in this study led to a variable evidence-based screening schedule that maintains efficacy in screening while decreasing the cost of routine annual retinal exams, taking into account current retinopathy status and HbA1c levels.

Image: PD

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