20-year-old injury: an unusual cause of stroke.

A 62-year-old man presented with a 2-day history of headache, nausea and dizziness on a background of recently diagnosed stage 2c prostate carcinoma and controlled hypertension. Imaging confirmed bilateral cerebellar strokes; on further investigations, he was found to have undiagnosed subclavian steal syndrome following severe injury to his left arm more than 20 years earlier.

WITHDRAWN: Decongestants and antihistamines for acute otitis media in children.

BACKGROUND: Acute otitis media (AOM) is a common and important source of morbidity in children, although most cases resolve spontaneously. While frequently recommended, decongestant and antihistamine therapy is of unclear benefit. OBJECTIVES: To determine the efficacy of decongestant and antihistamine therapy in children with AOM on outcomes of AOM resolution, symptom resolution, medication side effects, and complications of AOM. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2003); MEDLINE (January 1966 to December 2003), EMBASE (January 1990 to July 2003) and reference lists of articles for this updated review. We also contacted study authors and pharmaceutical companies. SELECTION CRITERIA: Randomized controlled trials evaluating decongestant or antihistamine treatment for children with AOM were included. Patient-oriented outcomes were considered most relevant. There were no quality or language restrictions. DATA COLLECTION AND ANALYSIS: Investigators independently evaluated studies for inclusion, performed validity assessments, and completed data extraction. Dichotomous data were pooled to generate relative risks; homogeneity was assessed using approximate chi-square tests. MAIN RESULTS: Fifteen trials involving 2695 people were included. Only the combined decongestant-antihistamine group demonstrated statistically lower rates of persistent AOM at the two week period (fixed relative risk (RR) 0.76; 95% confidence interval (CI) 0.60 to 0.96; number needed to treat (NNT) 10). No benefit was found for early cure rates, symptom resolution, prevention of surgery or other complications. There was a five to eight -fold increased risk of side effects for those receiving an intervention, which reached statistical significance for all decongestant groupings. Validity sub analyses demonstrated that lower quality studies found benefit, while analysis of those studies with higher validity scores found no benefit of treatment. AUTHORS' CONCLUSIONS: Given lack of benefit and increased risk of side effects, these data do not support the use of decongestant treatment in children with AOM. There was a small statistical benefit from combination medication use but the clinical significance is minimal and study design may be biasing the results. Thus, the routine use of antihistamines for treating AOM in children cannot be recommended.

Decongestants and antihistamines for acute otitis media in children.

BACKGROUND: Acute otitis media (AOM) is a common and important source of morbidity in children, although most cases resolve spontaneously. While frequently recommended, decongestant and antihistamine therapy is of unclear benefit. OBJECTIVES: To determine the efficacy of decongestant and antihistamine therapy in children with AOM on outcomes of AOM resolution, symptom resolution, medication side effects, and complications of AOM. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2003); MEDLINE (January 1966 to December 2003), EMBASE (January 1990 to July 2003) and reference lists of articles for this updated review. We also contacted study authors and pharmaceutical companies. SELECTION CRITERIA: Randomized controlled trials evaluating decongestant or antihistamine treatment for children with AOM were included. Patient-oriented outcomes were considered most relevant. There were no quality or language restrictions. DATA COLLECTION AND ANALYSIS: Investigators independently evaluated studies for inclusion, performed validity assessments, and completed data extraction. Dichotomous data were pooled to generate relative risks; homogeneity was assessed using approximate chi-square tests. MAIN RESULTS: Fifteen trials involving 2695 people were included. Only the combined decongestant-antihistamine group demonstrated statistically lower rates of persistent AOM at the two week period (fixed relative risk (RR) 0.76; 95% confidence interval (CI) 0.60 to 0.96; number needed to treat (NNT) 10). No benefit was found for early cure rates, symptom resolution, prevention of surgery or other complications. There was a five to eight -fold increased risk of side effects for those receiving an intervention, which reached statistical significance for all decongestant groupings. Validity sub analyses demonstrated that lower quality studies found benefit, while analysis of those studies with higher validity scores found no benefit of treatment. REVIEWERS' CONCLUSIONS: Given lack of benefit and increased risk of side effects, these data do not support the use of decongestant treatment in children with AOM. There was a small statistical benefit from combination medication use but the clinical significance is minimal and study design may be biasing the results. Thus, the routine use of antihistamines for treating AOM in children cannot be recommended.

Decongestants and antihistamines for acute otitis media in children.

BACKGROUND: Acute otitis media (AOM) is a common and important source of morbidity in children, although most cases resolve spontaneously. While frequently recommended, decongestant and antihistamine therapy is of unclear benefit. OBJECTIVES: To determine the efficacy of decongestant and antihistamine therapy in children with AOM on outcomes of AOM resolution, medication side effects, and complications of AOM. SEARCH STRATEGY: Comprehensive search of Cochrane's Controlled Trials Registry, Medline and Embase was conducted. Bibliographic review and requests for information from study authors and pharmaceutical companies supplemented this. SELECTION CRITERIA: Randomized controlled trials evaluating decongestant (DC) or antihistamine (AH) treatment for children with AOM were included. Patient-oriented outcomes were considered most relevant. There were no quality or language restrictions. DATA COLLECTION AND ANALYSIS: Investigators independently evaluated studies for inclusion, performed validity assessments, and completed data extraction. Dichotomous data were pooled to generate relative risks and numbers needed to treat, and homogeneity was assessed using approximate chi-square tests. MAIN RESULTS: For the combined control groups, healing rates at 2 weeks were high, with rates of persistent AOM <23%. No additional benefit was demonstrated from intervention subgroupings DC, AH, or any medication (DC and/or AH). Only the combined treatment (DC + AH) group demonstrated statistically lower rates of persistent AOM at the 2-week period (RR 0.76, 95% CI, NNT 10.5, 95% CI). No benefit was found for other outcomes including early or late cure rates, symptom resolution, prevention of surgery or other complications. There was an increased risk of medication side effects for those receiving an intervention, which reached statistical significance for the "any medication" and decongestant groupings (NNH 16.6, 14.3 respectively, 95% CI ). Validity subanalyses demonstrated that lower quality studies found benefit, but analysis of those studies with higher validity scores found no benefit to treatment. REVIEWER'S CONCLUSIONS: Given lack of benefit and increased risk of side effects, these data do not support the use of decongestant, antihistamine, or combined DC/AH treatment in children with AOM. The small statistical benefit found in the combination medication group is of small clinical significance and study design may be biasing the results.

Are beta2-agonists effective treatment for acute bronchitis or acute cough in patients without underlying pulmonary disease? A systematic review.

OBJECTIVE: Our goal was to determine whether beta2-agonists improve the symptoms of acute bronchitis or acute cough in patients who do not have underlying pulmonary disease. STUDY DESIGN: We performed a systematic review including meta-analysis. DATA SOURCES: We included randomized controlled trials comparing beta2-agonists with placebo or alternative therapies identified from the Cochrane Library, MEDLINE, EMBASE, conference proceedings, Science Citation Index, the System for Information on Grey Literature in Europe, and letters to manufacturers of beta2-agonists. OUTCOMES MEASURED: We measured duration, persistence, severity or frequency of cough, productive cough, and night cough; duration of activity limitations; and adverse effects. RESULTS: Two trials in children with cough and no obvious airway obstruction did not find any benefits from beta2-agonists. Five trials in adults with cough and with or without airway obstruction had mixed results, but summary statistics did not reveal any significant benefits from beta2-agonists. Studies that enrolled more wheezing patients were more likely to show benefits from beta2-agonists, and in one study only patients with evidence of airflow limitation were more likely to benefit. Patients given beta2-agonists were more likely to report tremor, shakiness, or nervousness than those in the control groups. CONCLUSIONS: There is no evidence to support using beta2-agonists in children with acute cough and no evidence of airflow obstruction. There is little evidence that the routine use of beta2-agonists for adults with acute cough is helpful. These agents may reduce symptoms, including cough, in patients with evidence of airflow obstruction, but this potential benefit is not well-supported by the available data and must be weighed against the adverse effects associated with beta2-agonists.

Decongestants and antihistamines for acute otitis media in children.

BACKGROUND: Acute otitis media (AOM) is a common and important source of morbidity in children, although most cases resolve spontaneously. While frequently recommended, decongestant and antihistamine therapy is of unclear benefit. OBJECTIVES: To determine the efficacy of decongestant and antihistamine therapy in children with AOM on outcomes of AOM resolution, medication side effects, and complications of AOM. SEARCH STRATEGY: Comprehensive search of Cochrane's Controlled Trials Registry, Medline and Embase was conducted. Bibliographic review and requests for information from study authors and pharmaceutical companies supplemented this. SELECTION CRITERIA: Randomized controlled trials evaluating decongestant (DC) or antihistamine (AH) treatment for children with AOM were included. Patient-oriented outcomes were considered most relevant. There were no quality or language restrictions. DATA COLLECTION AND ANALYSIS: Investigators independently evaluated studies for inclusion, performed validity assessments, and completed data extraction. Dichotomous data were pooled to generate relative risks and numbers needed to treat, and homogeneity was assessed using approximate chi-square tests. MAIN RESULTS: For the combined control groups, healing rates at 2 weeks were high, with rates of persistent AOM <23%. No additional benefit was demonstrated from intervention subgroupings DC, AH, or any medication (DC and/or AH). Only the combined treatment (DC + AH) group demonstrated statistically lower rates of persistent AOM at the 2-week period (RR 0.76, 95% CI, NNT 10.5, 95% CI). No benefit was found for other outcomes including early or late cure rates, symptom resolution, prevention of surgery or other complications. There was an increased risk of medication side effects for those receiving an intervention, which reached statistical significance for the "any medication" and decongestant groupings (NNH 16.6, 14.3 respectively, 95% CI ). Validity subanalyses demonstrated that lower quality studies found benefit, but analysis of those studies with higher validity scores found no benefit to treatment. REVIEWER'S CONCLUSIONS: Given lack of benefit and increased risk of side effects, these data do not support the use of decongestant, antihistamine, or combined DC/AH treatment in children with AOM. The small statistical benefit found in the combination medication group is of small clinical significance and study design may be biasing the results.

The evaluation and treatment of adults with gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is defined as symptoms or tissue damage that results from the abnormal reflux of gastric contents into the esophagus. A systematic review of population-based studies estimates that heartburn or regurgitation symptoms occur in 21% to 59% of the population during a given year. The frequency of GERD in specific populations is provided in Table 1. Although only 1 in 5 patients with upper intestinal symptoms that occur at least weekly seeks medical attention, nearly 1% of all visits to a family physician's office are for GERD or related conditions. GERD significantly affects the quality of patients' lives. In a survey of patients presenting for upper endoscopy with symptoms of at least 3 months' duration, those with a diagnosis of GERD reported low scores at baseline for general well-being. Fortunately, follow-up data reported 4 weeks after treatment note improvement in gastrointestinal symptoms, general well-being, general health, vitality, and depression.

A systematic review of troponin T and I for diagnosing acute myocardial infarction.

OBJECTIVE: Elevations of serum troponin T and I values are being used to diagnose acute myocardial infarction (AMI) and to rule out the condition in patients before their discharge from the emergency department (ED). However, the sensitivity and specificity of these tests vary considerably. Our goal was to systematically review the data on the accuracy of troponin T and I for the diagnosis of AMI in the ED. SEARCH STRATEGY: We searched the MEDLINE database using the following strategy: troponin (text word) and diagnosis (medical subject heading [MeSH]) or troponin/diagnostic use (MeSH). The references of articles meeting our inclusion criteria were searched for additional articles. SELECTION CRITERIA: We evaluated each study for quality. Only prospective blinded cohort studies with an adequate reference standard were included in the analysis. DATA COLLECTION/ANALYSIS: Data from each study were abstracted by 2 investigators. We graphed sensitivity and specificity for different points in time from arrival in the ED or from the onset of pain and calculated summary estimates when appropriate and possible. MAIN RESULTS: Sensitivity increases for both troponin T and I from 10% to 45% within 1 hour of the onset of pain (depending on the cutoff) to more than 90% at 8 or more hours. Specificity declines gradually from 87% to 80% from 1 to 12 hours after the onset of chest pain for troponin T and is approximately 95% for troponin I. The peak abnormal value in the first 24 hours after admission to the ED has an area under the receiver operating characteristic curve of 0.99 and is very useful at ruling out AMI if negative. CONCLUSIONS: Although troponin T and I values are useful tools for the diagnosis of AMI, they must be interpreted according to the number of hours from the onset of chest pain. The test is particularly useful at ruling out MI when the value is negative at 8 or more hours after the onset of chest pain.

Bacterial vaginosis in pregnancy and the risk of prematurity: a meta-analysis.

OBJECTIVE: We conducted this meta-analysis to determine the magnitude of risk conferred by bacterial vaginosis during pregnancy on preterm delivery. SEARCH STRATEGY: We selected articles from a combination of the results of a MEDLINE search (1966-1996), a manual search of bibliographies, and contact with leading researchers. SELECTION CRITERIA: We included case control and cohort studies evaluating the risk of preterm delivery, low birth weight, preterm premature rupture of membranes, or preterm labor for pregnant women who had bacterial vaginosis and those who did not. DATA COLLECTION AND ANALYSIS. Two investigators independently conducted literature searches, applied inclusion criteria, performed data extraction, and critically appraised included studies. Summary estimates of risk were calculated as odds ratios (ORs) using the fixed and random effects models. MAIN RESULTS: We included 19 studies in the final analysis. Bacterial vaginosis during pregnancy was associated with a statistically significant increased risk for all outcomes evaluated. In the subanalyses for preterm delivery, bacterial vaginosis remained a significant risk factor. Pooling adjusted ORs yielded a 60% increased risk of preterm delivery given the presence of bacterial vaginosis. CONCLUSIONS: Bacterial vaginosis is an important risk factor for prematurity and pregnancy morbidity. Further studies will help clarify the benefits of treating bacterial vaginosis and the potential role of screening during pregnancy.

Should we patch corneal abrasions? A meta-analysis.

BACKGROUND: Eye patching is commonly recommended for treating corneal abrasions. This advice seems based more on anecdotes or disease-oriented evidence theorizing that there is faster healing or less pain when the eye is patched. This meta-analysis was performed to determine if eye patching is a useful treatment for corneal abrasions. METHODS: We conducted a comprehensive search of both MEDLINE (1966 to 1997) and Science Citation Index to locate relevant articles. We reviewed the bibliographies of included studies, and ophthalmology and primary care texts. Local ophthalmologists and authors were contacted to identify any unpublished data. Controlled trials that evaluated eye patching compared with no patching in patients older than 6 years with uncomplicated corneal abrasions were considered. The outcomes of interest were healing rates and degree of pain. RESULTS: Seven trials were identified for inclusion, of which five could be statistically combined. Healing rates were similar in the two groups. The summary ratios (95% confidence interval) of healing rates in the patch group as compared with the no-patch group were 0.87 (0.68 to 1.13) and 0.90 (0.75 to 1.10) at days 1 and 2, respectively. Six studies evaluated pain: four found no difference and two favored not patching. No differences in complication rates were noted between the patched and nonpatched groups. CONCLUSIONS: Eye patching was not found to improve healing rates or reduce pain in patients with corneal abrasions. Given the theoretical harm of loss of binocular vision and possible increased pain, we recommend the route of harmless nonintervention in treating corneal abrasions.