Oral dexamethasone for the treatment of pain in children with acute pharyngitis: a randomized, double-blind, placebo-controlled trial

Revisiting dexamethasone use in the pediatric emergency department

PURPOSE OF REVIEW

Dexamethasone is an essential treatment for common pediatric inflammatory, airway, and respiratory conditions. We aim to provide up-to-date recommendations for treatment of anaphylaxis, croup, coronavirus disease, multisystem inflammatory syndrome in children, and asthma with dexamethasone for use in the pediatric emergency department.

RECENT FINDINGS

Literature largely continues to support the use of dexamethasone in most of the above conditions, however, recommendations for dosing and duration are evolving.

SUMMARY

The findings discussed in this review will enable pediatric emergency medicine providers to use dexamethasone effectively as treatment of common pediatric conditions and minimize the occurrence of side-effects caused by gratuitous corticosteroid use.

Evidence reversals in primary care research: a study of randomized controlled trials

BACKGROUND

Evidence-Based Medicine is built on the premise that clinicians can be more confident when their decisions are grounded in high-quality evidence. Furthermore, evidence from studies involving patient-oriented outcomes is preferred when making decisions about tests or treatments. Ideally, the findings of relevant and valid trials should be stable over time, that is, unlikely to be reversed in subsequent research.

OBJECTIVE

To evaluate the stability of evidence from trials relevant to primary healthcare and to identify study characteristics associated with their reversal.

METHODS

We studied synopses of randomized controlled trials (RCTs) published from 2002 to 2005 as "Daily POEMs" (Patient Oriented Evidence that Matters). The initial evidence (E1) from these POEMs (2002-2005) was compared with the updated evidence (E2) on that same topic in a summary resource (DynaMed 2019). Two physician-raters independently categorized each POEM-RCT as (i) reversed when E1 ≠ E2, or as (ii) not reversed, when E1 = E2. For all "Evidence Reversals" (E1 ≠ E2), we assessed the direction of change in the evidence.

RESULTS

We evaluated 408 POEMs on RCTs. Of those, 35 (9%; 95% confidence interval [6-12]) were identified as reversed, 359 (88%) were identified as not reversed, and 14 (3%) were indeterminate. On average, this represents about 2 evidence reversals per annum for POEMs about RCTs.

CONCLUSIONS

Over 12-17 years, 9% of RCTs summarized as POEMs are reversed. Information alerting services that apply strict criteria for relevance and validity of clinical information are likely to identify RCTs whose findings are stable over time.

Corticosteroids as standalone or add-on treatment for sore throat

BACKGROUND

Sore throat is a common condition associated with a high rate of antibiotic prescriptions, despite limited evidence for the effectiveness of antibiotics. Corticosteroids may improve symptoms of sore throat by reducing inflammation of the upper respiratory tract. This review is an update to our review published in 2012.

OBJECTIVES

To assess the clinical benefit and safety of corticosteroids in reducing the symptoms of sore throat in adults and children.

SEARCH METHODS

We searched CENTRAL (Issue 4, 2019), MEDLINE (1966 to 14 May 2019), Embase (1974 to 14 May 2019), the Database of Abstracts of Reviews of Effects (DARE, 2002 to 2015), and the NHS Economic Evaluation Database (inception to 2015). We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared steroids to either placebo or standard care in adults and children (aged over three years) with sore throat. We excluded studies of hospitalised participants, those with infectious mononucleosis (glandular fever), sore throat following tonsillectomy or intubation, or peritonsillar abscess.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included one new RCT in this update, for a total of nine trials involving 1319 participants (369 children and 950 adults). In eight trials, participants in both corticosteroid and placebo groups received antibiotics; one trial offered delayed prescription of antibiotics based on clinical assessment. Only two trials reported funding sources (government and a university foundation). In addition to any effect of antibiotics and analgesia, corticosteroids increased the likelihood of complete resolution of pain at 24 hours by 2.40 times (risk ratio (RR) 2.4, 95% confidence interval (CI) 1.29 to 4.47; P = 0.006; I² = 67%; high-certainty evidence) and at 48 hours by 1.5 times (RR 1.50, 95% CI 1.27 to 1.76; P < 0.001; I² = 0%; high-certainty evidence). Five people need to be treated to prevent one person continuing to experience pain at 24 hours. Corticosteroids also reduced the mean time to onset of pain relief and the mean time to complete resolution of pain by 6 and 11.6 hours, respectively, although significant heterogeneity was present (moderate-certainty evidence). At 24 hours, pain (assessed by visual analogue scales) was reduced by an additional 10.6% by corticosteroids (moderate-certainty evidence). No differences were reported in recurrence/relapse rates, days missed from work or school, or adverse events for participants taking corticosteroids compared to placebo. However, the reporting of adverse events was poor, and only two trials included children or reported days missed from work or school. The included studies were assessed as moderate quality evidence, but the small number of included studies has the potential to increase the uncertainty, particularly in terms of applying these results to children.

AUTHORS' CONCLUSIONS

Oral or intramuscular corticosteroids, in addition to antibiotics, moderately increased the likelihood of both resolution and improvement of pain in participants with sore throat. Given the limited benefit, further research into the harms and benefits of short courses of steroids is needed to permit informed decision-making.

ENT

This chapter illustrates many different scenarios of emergencies in pediatric ENT in question and answer format. It contains a variety of cases with potentially unusual diagnoses designed to stimulate thought and further reading in this rapidly evolving specialty.

Infections of the Neck

Infection of the neck is a relatively common emergency department complaint. If not diagnosed and managed promptly, it may quickly progress to a life-threatening infection. These infections can result in true airway emergencies that may require fiberoptic or surgical airways. This article covers common, as well as rare but emergent, presentations and uses an evidence-based approach to discuss diagnostic and treatment modalities.

Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials

Objective To estimate the benefits and harms of using corticosteroids as an adjunct treatment for sore throat.Design Systematic review and meta-analysis of randomised control trials.Data sources Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), trial registries up to May 2017, reference lists of eligible trials, related reviews.Study selection Randomised controlled trials of the addition of corticosteroids to standard clinical care for patients aged 5 or older in emergency department and primary care settings with clinical signs of acute tonsillitis, pharyngitis, or the clinical syndrome of sore throat. Trials were included irrespective of language or publication status.Review methods Reviewers identified studies, extracted data, and assessed the quality of the evidence, independently and in duplicate. A parallel guideline committee (BMJ Rapid Recommendation) provided input on the design and interpretation of the systematic review, including the selection of outcomes important to patients. Random effects model was used for meta-analyses. Quality of evidence was assessed with the GRADE approach.Results 10 eligible trials enrolled 1426 individuals. Patients who received single low dose corticosteroids (the most common intervention was oral dexamethasone with a maximum dose of 10 mg) were twice as likely to experience pain relief after 24 hours (relative risk 2.2, 95% confidence interval 1.2 to 4.3; risk difference 12.4%; moderate quality evidence) and 1.5 times more likely to have no pain at 48 hours (1.5, 1.3 to 1.8; risk difference 18.3%; high quality). The mean time to onset of pain relief in patients treated with corticosteroids was 4.8 hours earlier (95% confidence interval -1.9 to -7.8; moderate quality) and the mean time to complete resolution of pain was 11.1 hours earlier (-0.4 to -21.8; low quality) than in those treated with placebo. The absolute pain reduction at 24 hours (visual analogue scale 0-10) was greater in patients treated with corticosteroids (mean difference 1.3, 95% confidence interval 0.7 to 1.9; moderate quality). Nine of the 10 trials sought information regarding adverse events. Six studies reported no adverse effects, and three studies reported few adverse events, which were mostly complications related to disease, with a similar incidence in both groups.Conclusion Single low dose corticosteroids can provide pain relief in patients with sore throat, with no increase in serious adverse effects. Included trials did not assess the potential risks of larger cumulative doses in patients with recurrent episodes of acute sore throat.Systematic review registration PROSPERO CRD42017067808.

Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in Adults: A Randomized Clinical Trial

IMPORTANCE

Acute sore throat poses a significant burden on primary care and is a source of inappropriate antibiotic prescribing. Corticosteroids could be an alternative symptomatic treatment.

OBJECTIVE

To assess the clinical effectiveness of oral corticosteroids for acute sore throat in the absence of antibiotics.

DESIGN, SETTING, AND PARTICIPANTS

Double-blind, placebo-controlled randomized trial (April 2013-February 2015; 28-day follow-up completed April 2015) conducted in 42 family practices in South and West England, enrolled 576 adults recruited on the day of presentation to primary care with acute sore throat not requiring immediate antibiotic therapy.

INTERVENTIONS

Single oral dose of 10 mg of dexamethasone (n = 293) or identical placebo (n = 283).

MAIN OUTCOMES AND MEASURES

Primary: proportion of participants experiencing complete resolution of symptoms at 24 hours. Secondary: complete resolution at 48 hours, duration of moderately bad symptoms (based on a Likert scale, 0, normal; 6, as bad as it could be), visual analog symptom scales (0-100 mm; 0, no symptom to 100, worst imaginable), health care attendance, days missed from work or education, consumption of delayed antibiotics or other medications, adverse events.

RESULTS

Among 565 eligible participants who were randomized (median age, 34 years [interquartile range, 26.0-45.5 year]; 75.2% women; 100% completed the intervention), 288 received dexamethasone; 277, placebo. At 24 hours, 65 participants (22.6%) in the dexamethasone group and 49 (17.7%) in the placebo group achieved complete resolution of symptoms, for a risk difference of 4.7% (95% CI, -1.8% to 11.2%) and a relative risk of 1.28 (95% CI; 0.92 to 1.78; P = .14). At 24 hours, participants receiving dexamethasone were not more likely than those receiving placebo to have complete symptom resolution. At 48 hours, 102 participants (35.4%) in the dexamethasone group vs 75 (27.1%) in the placebo group achieved complete resolution of symptoms, for a risk difference of 8.7% (95% CI, 1.2% to 16.2%) and a relative risk of 1.31 (95% CI, 1.02 to 1.68; P = .03). This difference also was observed in participants not offered delayed antibiotic prescription, for a risk difference of 10.3% (95% CI, 0.6% to 20.1%) and a relative risk of 1.37 (95% CI, 1.01 to 1.87; P = .046). There were no significant differences in any other secondary outcomes.

CONCLUSIONS AND RELEVANCE

Among adults presenting to primary care with acute sore throat, a single dose of oral dexamethasone compared with placebo did not increase the proportion of patients with resolution of symptoms at 24 hours. However, there was a significant difference at 48 hours.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN17435450.

Efficacy of orally administered prednisolone versus partial endodontic treatment on pain reduction in emergency care of acute irreversible pulpitis of mandibular molars: study protocol for a randomized controlled trial

BACKGROUND

Irreversible pulpitis is a highly painful inflammatory condition of the dental pulp which represents a common dental emergency. Recommended care is partial endodontic treatment. The dental literature reports major difficulties in achieving adequate analgesia to perform this emergency treatment, especially in the case of mandibular molars. In current practice, short-course, orally administered corticotherapy is used for the management of oral pain of inflammatory origin. The efficacy of intraosseous local steroid injections for irreversible pulpitis in mandibular molars has already been demonstrated but resulted in local comorbidities. Oral administration of short-course prednisolone is simple and safe but its efficacy to manage pain caused by irreversible pulpitis has not yet been demonstrated. This trial aims to evaluate the noninferiority of short-course, orally administered corticotherapy versus partial endodontic treatment for the emergency care of irreversible pulpitis in mandibular molars.

METHODS/DESIGN

This study is a noninferiority, open-label, randomized controlled clinical trial conducted at the Bordeaux University Hospital. One hundred and twenty subjects will be randomized in two 1:1 parallel arms: the intervention arm will receive one oral dose of prednisolone (1 mg/kg) during the emergency visit, followed by one morning dose each day for 3 days and the reference arm will receive partial endodontic treatment. Both groups will receive planned complete endodontic treatment 72 h after enrollment. The primary outcome is the proportion of patients with pain intensity below 5 on a Numeric Scale 24 h after the emergency visit. Secondary outcomes include comfort during care, the number of injected anesthetic cartridges when performing complete endodontic treatment, the number of antalgic drugs and the number of patients coming back for consultation after 72 h.

DISCUSSION

This randomized trial will assess the ability of short-term corticotherapy to reduce pain in irreversible pulpitis as a simple and rapid alternative to partial endodontic treatment and to enable planning of endodontic treatment in optimal analgesic conditions.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT02629042 . Registered on 7 December 2015. (Version n°1.1 28 July 2015).

Duration of symptoms of respiratory tract infections in children: systematic review

OBJECTIVE

To determine the expected duration of symptoms of common respiratory tract infections in children in primary and emergency care.

DESIGN

Systematic review of existing literature to determine durations of symptoms of earache, sore throat, cough (including acute cough, bronchiolitis, and croup), and common cold in children.

DATA SOURCES

PubMed, DARE, and CINAHL (all to July 2012).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials or observational studies of children with acute respiratory tract infections in primary care or emergency settings in high income countries who received either a control treatment or a placebo or over-the-counter treatment. Study quality was assessed with the Cochrane risk of bias framework for randomised controlled trials, and the critical appraisal skills programme framework for observational studies.

MAIN OUTCOME MEASURES

Individual study data and, when possible, pooled daily mean proportions and 95% confidence intervals for symptom duration. Symptom duration (in days) at which each symptom had resolved in 50% and 90% of children.

RESULTS

Of 22,182 identified references, 23 trials and 25 observational studies met inclusion criteria. Study populations varied in age and duration of symptoms before study onset. In 90% of children, earache was resolved by seven to eight days, sore throat between two and seven days, croup by two days, bronchiolitis by 21 days, acute cough by 25 days, common cold by 15 days, and non-specific respiratory tract infections symptoms by 16 days.

CONCLUSIONS

The durations of earache and common colds are considerably longer than current guidance given to parents in the United Kingdom and the United States; for other symptoms such as sore throat, acute cough, bronchiolitis, and croup the current guidance is consistent with our findings. Updating current guidelines with new evidence will help support parents and clinicians in evidence based decision making for children with respiratory tract infections.

Use of Topical or Systemic Steroids in Children with Upper Respiratory Tract Infection

Steroids have long been used to improve a number of clinical conditions because of their role in reducing inflammatory responses, but their use has always been limited because of their possible long-term side effects. The aim of this review is to establish whether steroids can have a positive effect on the outcome of some pediatric upper respiratory tract infections. We used PubMed to select all of the studies on topical or systemic steroids, and their therapeutic use in children with rhinosinusitis (RS), acute otitis media (AOM), otitis media with effusion (OME), acute pharyngitis (AP), or periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA), published over the last 15 years. Although a generally significant improvement in signs and symptoms has been observed with the use of intranasal steroids in children with RS, it is not clear which molecule should be recommended, how long treatment should be continued, or whether the benefits are limited to allergic children. No high-quality studies on the use of topical or systemic steroids in AOM have been carried out, and the results of studies of OME are controversial. The potential positive effects of steroids in children with AP are too slight to justify their use, and their possible adverse effects (particularly in the case of repeated administration) have not been clearly evaluated. Oral corticosteroids seem to be effective in resolving the symptoms of PFAPA, although they do not prevent future fever cycles. These findings show that further randomised and controlled studies are required in order to approach upper respiratory tract infections correctly and avoid the risks associated with frequent steroid use.

Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America

The guideline is intended for use by healthcare providers who care for adult and pediatric patients with group A streptococcal pharyngitis. The guideline updates the 2002 Infectious Diseases Society of America guideline and discusses diagnosis and management, and recommendations are provided regarding antibiotic choices and dosing. Penicillin or amoxicillin remain the treatments of choice, and recommendations are made for the penicillin-allergic patient, which now include clindamycin.

Corticosteroids as standalone or add-on treatment for sore throat

BACKGROUND

Sore throat is a common condition associated with a high rate of antibiotic prescriptions, despite limited evidence for the effectiveness of antibiotics. Corticosteroids may improve symptoms of sore throat by reducing inflammation of the upper respiratory tract.

OBJECTIVES

To assess the clinical benefit and safety of corticosteroids for symptoms of sore throat in adults and children.

SEARCH METHODS

We searched The Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 5) which includes the Acute Respiratory Infections (ARI) Group's Specialised Register, the Database of Reviews of Effects and the NHS Health Economics Database, MEDLINE (1966 to November Week 4, 2012) and EMBASE (1974 to June 2012).

SELECTION CRITERIA

We included randomised controlled trials that compared steroids to either placebo or standard care in adults and children (older than three years of age) with sore throat. We excluded studies of hospitalised participants, those with infectious mononucleosis, sore throat following tonsillectomy or intubation, or peritonsillar abscess.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed and selected trials from searches, assessed and rated study quality, and extracted relevant data.

MAIN RESULTS

We included eight trials involving 743 participants (369 children and 374 adults). All trials gave antibiotics to both placebo and corticosteroid groups; no trials assessed corticosteroids as standalone treatment for sore throat. In addition to any effect of antibiotics and analgesia, corticosteroids increased the likelihood of complete resolution of pain at 24 hours by more than three times (risk ratio (RR) 3.2, 95% confidence interval (CI) 2.0 to 5.1, P < 0.001, I(2) statistic 44%) and at 48 hours by 1.7 times. Fewer than four people need to be treated to prevent one person continuing to experience pain at 24 hours. Corticosteroids also reduced the mean time to onset of pain relief and the mean time to complete resolution of pain by 6 and 14 hours, respectively, although significant heterogeneity was present. At 24 hours, pain (assessed by visual analogue scores) was reduced by an additional 14% by corticosteroids. No difference in rates of recurrence, relapse or adverse events were reported for participants taking corticosteroids compared to placebo, although reporting of adverse events was poor.

AUTHORS' CONCLUSIONS

Oral or intramuscular corticosteroids, in addition to antibiotics, increase the likelihood of both resolution and improvement of pain in participants with sore throat. Further trials assessing corticosteroids in the absence of antibiotics and in children are warranted.

No evidence for the effectiveness of systemic corticosteroids in acute pharyngitis, community-acquired pneumonia and acute otitis media

Corticosteroids have been used to treat infectious diseases for more than 50 years but, although it has been shown that they are highly effective in improving the clinical course of some diseases, their effects have not been clearly defined in others. Nevertheless, they are still used by a considerable number of physicians. This review analyses the role of systemic corticosteroids in the treatment of acute pharyngitis (AP), community-acquired pneumonia (CAP) and acute otitis media (AOM). A number of trials involving patients with AP have been carried out, but most are marred by methodological flaws that do not allow any firm conclusions to be drawn. The number of trials involving CAP patients is even higher, and the data suggest that corticosteroids may reduce the risk of death only in patients with severe disease. There are very few data concerning AOM, and there is currently no reason for prescribing corticosteroids to treat it. Overall, the data showed that there is, currently, no indication for the universal use of systemic corticosteroids in any of the reviewed diseases and, further, high-quality studies of all of these respiratory tract infections are needed in order to identify the patients for whom the prescription of corticosteroids is rationally acceptable.

Adverse effects of steroid therapy in children with pharyngitis with unsuspected malignancy

Pharyngitis is a common clinical complaint for children and accounts for 3.1% of all visits to selected ambulatory care settings. Most children with pharyngitis have benign, self-limited disease with infrequent complications such as peritonsillar abscess, mastoiditis, or lymphadenitis. Recent studies have touted the benefits of steroids in the treatment of children with pharyngitis for pain control. These studies do not address the potential life-threatening complication of steroids in patients with pharyngitis or lymphadenopathy in the setting of undiagnosed acute lymphocytic leukemia (ALL) or lymphoma. We report 4 cases of children treated with steroids for pharyngitis or adenitis that subsequently were diagnosed with ALL or lymphoma. If steroids are to be used in children with pharyngitis or adenitis, the following recommendations should be strongly considered: Careful history and physical examination should be obtained. Presence of hepatosplenomegaly or lymphadenopathy outside the cervical region should raise suspicions regarding an underlying malignancy. Normal results of complete blood cell count in the setting of clear cut pharyngitis with exudates and a lack of significant adenopathy essentially rules out the diagnosis of ALL. Because traditional analgesics are available, which do not affect the curability of ALL or lymphoma, the routine use of steroids in pharyngitis in children should be considered only in rare circumstances.

Effectiveness of corticosteroid treatment in acute pharyngitis: a systematic review of the literature

OBJECTIVES

The objective was to examine the effectiveness of corticosteroid treatment for the relief of pain associated with acute pharyngitis potentially caused by group A beta-hemolytic Streptococcus (GABHS).

METHODS

This was a systematic review of the literature. Data sources used were electronic databases (Cochrane Library, MEDLINE, EMBASE, Biosis Previews, Scopus, and Web of Science), controlled trial registration websites, conference proceedings, study references, experts in the field, and correspondence with authors. Selection criteria consisted of randomized controlled trials (RCTs) in which corticosteroids, alone or in combination with antibiotics, were compared to placebo or any other standard therapy for treatment of acute pharyngitis in adult patients, pediatric patients, or both. Two reviewers independently assessed for relevance, inclusion, and study quality. Weighted mean differences (WMDs) were calculated and are reported with corresponding 95% confidence intervals (CIs).

RESULTS

From 272 potentially relevant citations, 10 studies met the inclusion criteria. When compared to placebo, corticosteroids reduced the time to clinically meaningful pain relief (WMD = -4.54 hours; 95% CI = -7.19 to -1.89); however, they provided only a small reduction in pain scores at 24 hours (WMD = -0.90 on a 0-10 visual analog scale; 95% CI = -1.5 to -0.3). Heterogeneity among pooled studies was identified for both outcomes (I(2) = 81 and 74%, respectively); however, the GABHS-positive subgroup receiving corticosteroid treatment did have a significant mean reduction in time to clinically meaningful pain relief of 5.22 hours (95% CI = -7.02 to -3.42; I(2) = 0%). Short-term side effect profiles between corticosteroids and placebo groups were similar.

CONCLUSIONS

Corticosteroid administration for acute pharyngitis was associated with a relatively small effect in time to clinically meaningful pain relief (4.5-hour reduction) and in pain relief at 24 hours (0.9-point reduction), with significant heterogeneity in the pooled results. Decision-making should be individualized to determine the risks and benefits; however, corticosteroids should not be used as routine treatment for acute pharyngitis.

Steroids as adjuvant therapy for acute pharyngitis in ambulatory patients: a systematic review

PURPOSE

This review summarizes the evidence regarding the efficacy of adjuvant steroids for pain reduction in acute pharyngitis.

METHODS

We searched for randomized controlled trials, using MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews, published between 1966 and December 2008. Two reviewers assessed the quality of each retrieved article and summarized the data.

RESULTS

Our review found 8 relevant randomized controlled trials (RCTs) with a total of 806 patients. There were 5 RCTs with adult patients and 3 with children. All RCTs found a statistically significant faster reduction of pain or complete pain relief from steroid use compared with placebo. The trials used different steroids (dexamethasone, betamethasone, prednisone), and most participants had received antibiotics at least initially. Analgesic medication, such as acetaminophen, was allowed in all studies, but this factor was not always controlled. No serious adverse side effects were reported.

CONCLUSIONS

Steroids are effective in relieving pain in acute pharyngitis. Although no serious adverse effects were observed, the benefits have to be balanced with possible adverse drug effects. There are safe and effective over-the-counter medications to relieve throat pain. Most patients received concomitant antibiotics; however, reducing the prescription of antibiotics for generally benign upper respiratory tract infection is a public health goal. We therefore recommend further studies to establish both the safety of steroids without antibiotic coverage and the additional benefits of steroids when used with regular administration of over-the-counter analgesic medications.

Ibuprofen provides analgesia equivalent to acetaminophen-codeine in the treatment of acute pain in children with extremity injuries: a randomized clinical trial

OBJECTIVES

This study compared the analgesic effectiveness of acetaminophen-codeine with that of ibuprofen for children with acute traumatic extremity pain, with the hypothesis that the two medications would demonstrate equivalent reduction in pain scores in an emergency department (ED) setting.

METHODS

This was a randomized, double-blinded equivalence trial. Pediatric ED patients 5 to 17 years of age with acute traumatic extremity pain received acetaminophen-codeine (1 mg/kg as codeine, maximum 60 mg) or ibuprofen (10 mg/kg, maximum 400 mg). The patients provided Color Analog Scale (CAS) pain scores at baseline and at 20, 40, and 60 minutes after medication administration. The primary outcome measured was the difference in changes in pain score at 40 minutes, compared to a previously described minimal clinically significant change in pain score of 2 cm. The difference was defined as (change in ibuprofen CAS score from baseline) - (change in acetaminophen-codeine CAS score from baseline); negative values thus favor the ibuprofen group. Additional outcomes included need for rescue medication and adverse effects.

RESULTS

The 32 acetaminophen-codeine and the 34 ibuprofen recipients in our convenience sample had indistinguishable pain scores at baseline. The intergroup differences in pain score change at 20 minutes (-0.6, 95% confidence interval [CI] = -1.5 to 0.3), 40 minutes (-0.4, 95% CI = -1.4 to 0.6), and 60 minutes (0.2, 95% CI = -0.8 to 1.2) were all less than 2 cm. Adverse effects were minimal: vomiting (one patient after acetaminophen-codeine), nausea (one patient after ibuprofen), and pruritus (one after acetaminophen-codeine). The three patients in each group who received rescue medications all had radiographically demonstrated fractures or dislocations.

CONCLUSIONS

This study found similar performance of acetaminophen-codeine and ibuprofen in analgesic effectiveness among ED patients aged 5-17 years with acute traumatic extremity pain. Both drugs provided measurable analgesia. Patients tolerated them well, with few treatment failures and minimal adverse effects.

Effect of topical nasal steroid spray in the treatment of non-specific recurrent / chronic pharyngitis - a trial study

OBJECTIVE

Non-Specific Chronic/Recurrent Pharyngitis is a diagnosis with no definite effective treatment. An array of drugs and therapies has been tried from local applications like Mandl's paint and throat gargles to anxiolytics. None have proved of therapeutic benefit. This trial study is a Pilot study of its kind in to the effectiveness of nasal steroid spray in the treatment of non-specific chronic pharyngitis. This is a prospective randomized study.

SETTING

Study done in medical college with ambulatory patients centre.

PATIENTS

53 patients were taken up for the study though only 42 could be followed up for a period of 1-2.5 years. Selection done on the basis of symptoms avoiding extreme age groups and subjective persistent relief was central to be considered proof of effectiveness of the treatment. Fluticasone Nasal Spray was used in the study.

RESULTS

35 patients (83.3%) reported some degree of relief in symptoms. 68% had >90% relief of symptoms with only a total of 1-2 sprays. There were 7 failures. Side effects were negligible.

CONCLUSION

Nasal steroid spray is therefore recommended as a most cost-effective, safe treatment method for well-selected cases of Chronic Non-Specific Pharyngitis.

Clinical efficacy of dexamethasone for acute exudative pharyngitis

The objective of this study was to investigate whether treatment with single-dose dexamethasone can provide relief of symptoms in acute exudative pharyngitis. A prospective, randomized, double-blinded, placebo-controlled clinical trial was undertaken over a 3-month period in a university-based Emergency Department. The study included all consecutive patients between 18 and 65 years of age presenting with acute exudative pharyngitis, sore throat, odynophagia, or a combination, and with more than two Centor criteria. Each patient was empirically treated with azithromycin and paracetamol for 3 days. The effects of placebo and a fixed single dose (8 mg) of intramuscular injection of dexamethasone were compared. The patients were asked to report the exact time to onset of pain relief and time to complete relief of pain. After completion of the treatment, telephone follow-up regarding the relief of pain was conducted. A total of 103 patients were enrolled. Thirty patients with a history of recent antibiotic use, pregnancy, those who were elderly (>65 years of age) and patients who failed to give informed consent were excluded. Forty-two patients were assigned to the placebo group and 31 were assigned to the intramuscular dexamethasone group (8-mg single dose). Time to perceived onset of pain relief was 8.06+/-4.86 h in steroid-treated patients, as opposed to 19.90+/-9.39 h in the control group (p=0.000). The interval required to become pain-free was 28.97+/-12.00 h in the dexamethasone group, vs. 53.74+/-16.23 h in the placebo group (p=0.000). No significant difference was observed in vital signs between the regimens. No side effects and no new complaints attributable to the dexamethasone and azithromycin were observed. Sore throat and odynophagia in patients with acute exudative pharyngitis may respond better to treatment with an 8-mg single dose of intramuscular dexamethasone accompanied by an antibiotic regimen than to antibiotics alone.

Pharyngitis and epiglottitis

Acute pharyngitis is one of the most common illnesses for which patients visit primary care physicians. Most cases are of viral origin, and with few exceptions these illnesses are both benign and self-limited. The most important bacterial cause is the beta-hemolytic group A streptococcus. There are other uncommon or rare types of pharyngitis. For some of these treatment is required or available, and some may be life threatening. Among those discussed in this article are diphtheria, gonorrhea, HIV infection, peritonsillar abscess, and epiglottitis.

Suspected peritonsillar abscess in children

OBJECTIVES

(1) To describe the demographic features and clinical course of children diagnosed with suspected peritonsillar abscess (PTA), (2) to determine the incidence of suspected and confirmed PTA in children younger than 18 years, and (3) to examine the factors associated with corticosteroid use and outpatient management of suspected PTA.

METHODS

We conducted a population-based, retrospective chart review. The study was conducted within the Calgary Health Region (CHR). Patients met inclusion criteria if they were younger than 18 years, resided in the CHR, and were diagnosed with PTA (International Classification of Diseases, Ninth Revision 475) in the CHR between March 1994 and December 2001.

RESULTS

We identified 229 children (cases) who presented with 249 unique episodes of suspected PTA. The incidence of suspected PTA among children in the CHR was 14 cases per 100,000 person-years at risk. The incidence was highest among adolescents (40 cases per 100,000 person-years). The incidence of confirmed PTA was 3 cases per 100,000 person-years at risk. Among those with suspected PTA, surgical intervention, intravenous antibiotics, and corticosteroids were provided to 34%, 87%, and 37%, respectively. One hundred fifty-seven patients (69%) were initially managed as outpatients. Of these, 12 (8%) had subsequent uncomplicated hospital admissions.

CONCLUSIONS

Peritonsillar abscess is primarily a problem of adolescence, but the disease does occur in young children. Corticosteroid use was common but without either clear benefit or adverse outcomes. Two thirds of patients were managed as outpatients without any apparent increase in adverse outcomes.

A pilot study of 1 versus 3 days of dexamethasone as add-on therapy in children with streptococcal pharyngitis

BACKGROUND

Studies in adults, but not in children, have shown a beneficial effect of one dose of steroid on the severity and duration of throat pain in acute pharyngitis. The effectiveness of longer steroid treatment has not been evaluated in children.

METHODS

We performed a randomized, double-blind, 3-arm, placebo-controlled trial to estimate the effectiveness of one dose versus 3 daily doses of oral dexamethasone in the treatment of 4- to 21-year-old patients with group A beta-hemolytic streptococcal (GABHS) pharyngitis. Participants used the Wong-Baker FACES scale to rate their symptoms at enrollment and twice daily for 5 days. Patient-completed diaries and telephone interviews provided follow-up data. Primary end points-severity of throat pain, improvement in general condition and improvement in activity level-were evaluated by survival analysis.

RESULTS

Ninety patients were enrolled. For each end point, we rejected the null hypothesis of a common survival experience for the 3 study arms. With the exception of 2 days for throat pain in participants receiving one dose of dexamethasone, the median time to improvement for all end points was 1 day for both arms of dexamethasone and 2 days for placebo. There was no difference between study arms in return to a clinical setting for symptoms related to GABHS pharyngitis or absenteeism from work/school. No patient experienced complications related to GABHS pharyngitis in the 30 days after enrollment.

CONCLUSIONS

In this pilot study, children with GABHS pharyngitis who receive dexamethasone as add-on therapy have a more rapid improvement in general condition and level of activity and, for those receiving 3 daily doses of dexamethasone, in resolution of throat pain.