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Education Education from the JOURNALS Edited Highlights of Richard Lehman’S Blog On education education FROM THE JOURNALS Edited highlights of Richard Lehman’s blog on http://bmj.co/Lehman Uselessness: a key outcome The authors are fond of eosinophils for diabetes drugs as the current fashionable marker, I’m an old man and I have long but I’m not so sure. The point is that since said all I want to about drugs we keep flexibility in our diagnostic for diabetes. I’ll just commend to thinking, and don’t go too far up your attention two of the latest any one mechanistic byway. abstract summaries from the ̻ Lancet doi:10.1016/S0140- world’s most prestigious journal: 6736(17)30879-6 “Among patients with type 1 diabetes who were receiving Removing axillary nodes in insulin, the proportion of early breast cancer surgery patients who achieved a glycated Here’s a 10 year survival study of haemoglobin level lower than 7.0% women who underwent localised with no severe hypoglycaemia or resection and radiotherapy diabetic ketoacidosis was larger in for T1-2 breast cancer. If 1-2 the group that received sotagliflozin metastases were found in the than in the placebo group. However, sentinel nodes, they were the rate of diabetic ketoacidosis was randomised either to sentinel higher in the sotagliflozin group.” node resection only or to complete Q: In that case, why would you use axillary node resection. Got sotagliflozin in type 1 diabetes? that? It took me a couple of goes. Next: “Among patients with Return of reflux Survival was actually slightly type 2 diabetes with or without “Laparoscopic anti-reflux better in the women who had previous cardiovascular disease, surgery was associated with a sentinel node removal alone. the incidence of major adverse relatively high rate of recurrent They also presumably had a cardiovascular events did not differ gastroesophageal reflux disease lower incidence of lymphoedema, significantly between patients who requiring treatment, diminishing though disappointingly I can’t see received exenatide and those who some of the benefits of the any mention of that in the paper. received placebo.” Q: Why not give operation.” What’s your idea of ̻ JAMA doi:10.1001/jama.2017.11470 them placebo then? a “relatively high rate” in this ̻ New Engl J Med doi:10.1056/ situation? Relative to what? Diagnostic reasoning: NEJMoa1708337 Actually, in this Swedish follow-up an endangered skill? ̻ New Engl J Med doi:10.1056/ study lasting a mean of 5.6 years, If you’re interested in lifelong NEJMoa1612917 recurrence of symptoms only learning and being a good occurred in 17.7% of patients, diagnostician, do try to get hold of Reconsidering respiratory and the majority of these opted this article. If you’re not interested labels for medical treatment, therefore in lifelong learning and being a One key to progress in medicine the overall proportion of the total good diagnostician, consider a is to reconsider diagnostic cohort who underwent further different career. And yet we do so labels. “Asthma” used to mean surgery was less than 3%. little as a profession to encourage breathlessness generally, crudely ̻ JAMA doi:10.1001/jama.2017.10981 a deep exchange of skills across divided into cardiac asthma and a lifetime in medical practice. pulmonary asthma. Nowadays for asthma and to acknowledge Arabella Simpkin’s snapshot of we just cling to the latter, but isn’t the assumptions associated with how diagnostic thinking is taught it time to let go? I’m glad to see them. Airways diseases should be to junior residents at Massachusetts an article on the Lancet website deconstructed into traits that can General Hospital is inspiring, but arguing for just that. be measured and, in some cases, only hints at what should be going “We suggest that the only way modified (ie, treatable traits), and on from entry into medical school we can make progress in the future which are set in the context of social up to the point where we hang up is to be much more clear about and environmental factors and our stethoscopes. the meaning of the labels used extrapulmonary comorbidities.” ̻ Ann Intern Med doi:10.7326/M17-0163 the bmj | 23 September 2017 451 RAPID RECOMMENDATIONS Corticosteroids for sore throat Bert Aertgeerts,1 2 Thomas Agoritsas,3 4 Reed A C Siemieniuk,3 5 Jako Burgers,6 7 Geertruida E Bekkering,1 2 Arnaud Merglen,8 Mieke van Driel,9 Mieke Vermandere,1 Dominique Bullens,10 11 Patrick Mbah Okwen,12 Ricardo Niño,13 Ann van den Bruel,14 15 Lyubov Lytvyn,16 Carla Berg-Nelson,17 18 Shunjie Chua,19 Jack Leahy,20 Jennifer Raven,21 Michael Weinberg,22 Behnam Sadeghirad,3 23 Per O Vandvik,15 24 Romina Brignardello-Petersen2 25 1 Academic Centre for General Practice, Department of Public Health and Primary HOW THE RECOMMENDATION WAS CREATED Care, KU Leuven, Belgium READING Our international panel—including general practitioners, Correspondence to: B Aertgeerts [email protected] general internists, paediatricians, an otorhinolaryngologist, Full author details can be found on bmj.com. 0.5 HOURS epidemiologists, methodologists, statisticians, and people This BMJ Rapid Recommendation article is one of a series that provides with lived experience of sore throat—decided the scope clinicians with trustworthy recommendations for potentially practice changing evidence. of the recommendation and the outcomes that are most important to patients. After a systematic review on the benefits and harms of corticosteroids,16 and a systematic What is the role of a single dose of oral corticosteroids search for evidence about patients’ values and preferences for those with acute sore throat? In this article an (appendix 1 on bmj.com), the panel met to formulate expert panel makes a weak recommendation in favour a recommendation. No person had financial conflicts of corticosteroid use, using the GRADE framework of interest; intellectual and professional conflicts were according to the BMJ Rapid Recommendation process. minimised and managed (appendix 2 on bmj.com). The panel followed the BMJ Rapid Recommendations These recommendations are based on a linked procedures for creating a trustworthy recommendation,26 27 systematic review (see p 437) triggered by a large including using the GRADE approach to critically appraise randomised trial published in April 2017. This trial the evidence and create recommendations (appendix 3 on reported that corticosteroids increased the proportion bmj.com).28 of patients with complete resolution of pain at 48 hours. Acute sore throat is defined as pain in the throat for less than with sore throat will have a mononucleosis infection caused 14 days. Acute sore throat could be caused by pharyngitis, by an Epstein-Barr virus, which could prolong the duration nasopharyngitis, tonsillitis, peritonsillar abscess, or of symptoms.8 retropharyngeal abscess. Some patients with sore throat Some patients experience unacceptable morbidity and also experience headache, fever, muscle stiffness, cough, inconvenience, and miss school or work due to recurrent and general malaise. sore throat.9 Pain is a common reason for work or school Acute sore throat is common, but only a minority of absence. Complications of sore throat are rare: about patients will visit their general practitioner.1 0.2% of patients with tonsillitis will develop a peritonsillar Acute sore throat is a self limiting disease and typically abscess.10 resolves after 7-10 days in adults and 2-7 days in children.7 The diagnosis of an acute sore throat is based on signs Most infections are of viral origin; only a few are caused by a and symptoms. bacterial infection. About 2% of patients initially presenting Most guidelines recommend paracetamol or ibuprofen as the first choice treatment.13 The use of corticosteroids is WHAT YOU NEED TO KNOW mentioned in few, and is generally discouraged. Antibiotics are probably not helpful for pain relief in an episode of acute International guidance varies about whether to use corticosteroids • sore throat caused by viruses, but may help those with a to treat acute sore throat, but a trial published in April 2017 bacterial infection.14 15 suggested that costicosteroids might be effective We make a weak recommendation to use a single dose of oral • The evidence corticosteroids in those presenting with acute sore throat after The linked systematic review (page 437) reports the effects performing a systematic review of the new evidence in this rapid of corticosteroids when added to standard care in patients recommendation with acute sore throat.16 Figure 1 (overleaf) gives an The recommendation is weak because corticosteroids did not help • overview of the trials included. all patient reported outcomes and patients’ preferences varied The panel identified eight patient-important outcomes substantially needed to inform the recommendation: complete resolution Steroids somewhat reduced the severity and duration of pain by • of pain, time to onset of pain relief, pain severity, need for one day, but time off school or work was unchanged. Harm seems antibiotics, days missed from school or work, recurrence of unlikely with one steroid dose.The treatment is inexpensive and likely to be offered in the context of a consultation that would symptoms, duration of bad or non-tolerable symptoms, and have taken place anyway adverse effects. The included studies reported on all patient- important outcomes, except for duration of bad or 452 23 September 2017 | the bmj the bmj | 23 September 2017 453 Population This recommendation applies to almost all patients with sore throat: Children 5 years and older and all adults Severe and not severe sore throat
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