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Recent papers on respiratory medicine

Dr Anthony Crockett shares interesting papers that have caught his eye

Dr Anthony Crockett shares interesting papers that have caught his eye

1. What treatments are effective for the common cold?

The paper

Non-antibiotic treatments for upper-respiratory tract infections (common cold). Arroll, B. Respiratory Medicine, Volume 99, Issue 12, 1 December 2005, Pages 1477-1484

Method

This paper reviewed in detail seven Cochrane reviews and presented the results as relative risks and, where possible, numbers needed to treat.

Results

The main theme is the variable quality of the primary studies. In general, the reviewers are fairly cautious about the benefits of any of the treatments other than first-dose nasal decongestants and antihistamine–decongestant combinations. Over-the-counter medication for cough seemed to have no documented benefit in children under the age of five years. For older children and adults, dextromethorphan or a sedating antihistamine/pseudoephedrine combination was significantly more effective than placebo for severity of cough. Vitamin C may have a small role in preventing the common cold, with possibly a greater role in high-intensity physical activity and sub-arctic conditions.

Conclusion

Most non-antibiotic treatments for the common cold are probably not effective. The most promising are dextromethorphan for cough, antihistamine-decongestant combinations for a wide range of symptoms, and nasal decongestants (at least for the first dose).

What I will do now

Negotiation about the likely benefits and harms of non-antibiotic treatments is warranted, as few are consistently beneficial. If adult patients and parents of older children wish to purchase treatments, I would guardedly advise short-term decongestants or antihistamine/pseudoephedrine combinations, but I will rarely be persuaded to prescribe them. Patients need to be reminded that symptoms do linger and that, at 10 days from the onset of illness with the common cold, 25 per cent still have symptoms.

2. Will inhaled steroids help my patient?

The Paper

The Predicting Response to Inhaled Corticosteroid Efficacy (PRICE) trial. Martin RJ et al for the National Heart, Lung, and Blood Institute's Asthma Clinical Research Center. J Allergy Clin Immunol 2006;119:73-80

Method Some 83 subjects with asthma off steroid were enrolled in this multicentre study which evaluated potential biomarkers of predicting short-term (six-week) response to inhaled steroid with subsequent evaluation of responders and non-responders to asthma control over a longer interval (16 additional weeks).

Results

The only strong correlation with improvements for short-term inhaled steroid success was salbutamol reversibility. For the non-responders, asthma control remained unchanged whether inhaled steroids were continued or were substituted with a placebo (P = 0.99).The good short-term responders maintained asthma control longer-term only if they were maintained on inhaled steroids (P = 0.007).

Conclusions

The decision to use long-term inhaled steroids could be based on a short-term trial – only those patients who show an improvement in peak flow or spirometry readings should continue with inhaled steroids long-term.

What I will do now

I will continue to prescribe steroids as I do now but, like so much in medicine, it is good to have proof that one's usual practice is evidence-based.

3. Should people with peanut allergies be warned on kissing?

The Pape

rPeanut allergen exposure through saliva: assessment and interventions to reduce exposure. Maloney JM, Chapman MD and Sicherer SH. J Allergy Clin Immunol 2006;118:719-724

Method

It is accepted that exposure to food allergens through saliva (kissing, sharing kitchen utensils) can cause local and systemic allergic reactions. This study measured peanut allergen in saliva after subjects ate peanut butter.

Results

Significant amounts of allergen were present in the saliva one hour after ingestion; less after a peanut-free meal.

Conclusion

Patients with peanut allergy should refrain from kissing their partner within an hour of possible peanut ingestion; eating a peanut-free meal will speed up the elimination of peanut allergen from the saliva.

What I will do now

This is an issue I have not thought about before; I will now counsel all my food-allergic patients to instruct their partners about the timing of any kisses.

4. Is washing the cat a waste of time?

The Paper

Duration of airborne Fel d 1 reduction after cat washing. Nageotte C et al. J Allergy Clin Immunol 2006;118:521-522

Method Cat allergy is common, with up to 66 per cent of patients with asthma being sensitised to cat allergen Fel d 1. An alternative to removal of the cat is to wash it by immersion.

The study measured levels of Fel d 1 in air before and after washing 12 cats.

Results There was a significant fall in mean allergen levels that only lasted 24 hours. Washing the cat is of only very temporary benefit to asthma sufferers, and the cat usually hates the bathing.

Conclusions Washing the cat is a waste of time. Currently, the only proven method of reducing exposure involves removing the animal from the home.

What I will do now

I have always thought washing the cat would lead to its disappearance anyway, as few self-respecting cats allow themselves to be bathed repeatedly. Now I shall spare patients the option of bathing the cat – they can get rid of it or keep it and their allergy.

5. Should all wheezing children receive oral steroids at the first presentation?

The Paper

Should steroids be used for first-time young wheezers? Weinberger M. Journal of Allergy and Clinical Immunology. Volume 119, number 3, March 2007, pages 567-9

Method

In this editorial, the author presents the evidence for and against the use of oral steroids in treating children with wheezing.

The author discusses several studies including a recent one in Finland (Lehtinen et al, 2007) involving 230 children with a mean age of 1.1 years prescribed prednisolone for four days (2mg/kg while in A&E, 2 mg/kg for three subsequent days).

Results

The current wisdom is that it is safer to prescribe short courses of high dose oral steroids for all wheezing children. This is the most efficacious management of acute asthma in infants, and if the diagnosis is actually bronchiolitis (and it can be almost impossible to accurately distinguish between the two), the use of oral steroids results in no worse outcomes than if oral steroids are withheld, and the use of steroids is associated with fewer and less severe relapses.

Conclusions

Use oral steroids for all children with a significant episode of first time wheezing, even if the diagnosis of asthma is in doubt.

What I will do now

Stop agonising over whether the cause of an infant's acute severe wheezing is asthma or bronchiolitis and treat them all with a short course of high-dose oral steroids.

Anthony Crockett is a GP in Shrivenham and a hospital practitioner in chest medicine at Princess Margaret Hospital, Swindon – he is also a committee member of the General Practice Airways Group

Competing interests

Dr Crockett has received speaker's fees/travel expenses/hospitality at national and international meetings from AstraZeneca, Merck Sharp & Dohme, Boehringer Ingelheim, IVAX, Pfizer and 3M

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