Adding the results of a recently published clinical study to a previous Cochrane review has led to a major shift in thinking. The authors now say that doctors should stop routinely giving steroids after severe brain injury because it increases death rates.
Traumatic brain injury is a leading cause of death and disability. In the US alone, over 33,000 people suffer some form of brain injury related disability each year. Since early reports of benefit in the 1960s, doctors have used corticosteroids as part of the treatment. A previous version of this review had said there was insufficient evidence to be certain about the benefits of the treatment.
Because of the inconclusive earlier review, the UK Medical Research Council set up a large trial to address this question. "The CRASH trial was larger than all the other trials put together, and gave a clear result that patients given steroids have a greater chance of dying than those who did not receive them," says Dr Phil Alderson of the UK Cochrane Centre in Oxford, who wrote the review along with Prof Ian Roberts of the London School of Hygiene and Tropical Medicine.
The Cochrane authors' conclusion is unequivocal – stop using corticosteroids routinely for people with traumatic head injury.
Review title: Alderson et al: Corticosteriods for acute traumatic brain injury. The Cochrane Database of Systematic Reviews 2005, Issue 1
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Don't take antibiotics for acute laryngitis
Penicillin V and erythromycin give little or no benefit to people suffering from acute laryngitis. Taking them only runs the risk of stimulating the growth of antibiotic resistant bacteria.
Winter is a time when many people find their throat sore, the voice hoarse and they have a fever and difficulty swallowing. Correctly thinking they have laryngitis they head off to their doctors expecting to be given a prescription for antibiotics, and are disappointed when the doctor advises against them or refuses to supply this medication.
According to the finding of this Cochrane Review the doctor was right.
The authors considered results from two different clinical trials where patients with acute laryngitis were given either an antibiotic (penicillin V or erythromycin) or a placebo. People given the placebo got better just as quickly as those on antibiotics.
There was some evidence that during the recovery phase, those on erythromycin claimed to have slightly less voice disturbance and coughing, but this was not measured objectively by an expert. "We considered the any small benefits to be outweighed by the potential harm of taking unnecessary antibiotics," says Professor Ludovic Reveiz of the Clinica Reina Sofia, Bogota, Colombia, who headed this Cochrane review.
Review title: Reveiz et al: Antibiotic for acute laryngitis in adults. The Cochrane Database of Systematic Reviews 2005, Issue 1
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WHO recommendations for treating OP poisoning questioned
Although the World Health Organization recommends giving oximes to treat patients poisoned with organophosphate pesticides, Cochrane authors conclude that there is no evidence to show that this treatment works.
Tens of thousands of people die every year from poisoning by organophosphate pesticides (OPs). Most of the deaths are in developing countries. A class of drugs known as oximes is used as part of the standard recommended treatment, even though many doctors question whether oximes do anything to aid recovery.
OPs operate by blocking the active site on acetylcholinesterase, a key enzyme in the nervous system. In theory oximes should help as they can remove this block.
The Cochrane authors, however, found that very little research has been done to see whether oximes are effective. What work has been carried out produced no evidence in favour of using oximes. However, the authors point out that the few currently available studies had many limitations. Consequently they call for more research so that a firm conclusion can be drawn.
"Hundreds of thousands of people with organophosphate poisoning are treated with oximes each year at resource poor hospitals in the developing world. Hundreds of millions of dollars more have been spent on stockpiling these unproven antidotes in the developed world because of fears of terrorist use of organophosphate nerve agents. Perhaps, it's time to find out if they work," says lead author of the review, Professor Nick Buckley.
"One issue that emerges is that, when something is mainly a problem in poor countries, precious little research gets done," says Dr Paul Chinnock, managing editor of the Cochrane Injuries Group.
Review title: Buckley et al: Oximes for acute organophosphate pesticide poisoning. The Cochrane Database of Systematic Reviews 2005, Issue 1
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Making blood more alkaline to treat organophosphate poisoning questioned by review
For the last twenty years some doctors have made people's blood more alkaline in an attempt to help people survive organophosphate poisoning. A new Cochrane review concludes that there is not enough data to say whether this works.
Poisoning with organophosphorous pesticides (OPs) regularly causes ill-health and death, particularly in developing countries where these pesticides are used most commonly. Even if the people are treated with antidotes such as atropine, oximes and benzodiazepines, between 10% and 20% will die. Animal research in the 1980s suggested that making an individual's blood more alkaline may aid their recovery.
The Cochrane authors found no high quality clinical studies aimed at evaluating the effects of adding sodium bicarbonate to the blood of people who have ingested OPs. The data they did find gave hints that the process may improve outcome, but the research wasn't strong enough to warrant alkalinisation as a standard therapy.
"Further research into alkalinisation should be a priority, particularly to see whether sodium bicarbonate can help, because this chemical showed promising outcomes in early research, is cheap, widely available, stable in climatic extremes and easily administered," says Dr Darren Roberts of Anuradhapura General Hospital, Sri Lanka.
Review title: Roberts et al: Alkalinisation for organophosphorus pesticide poisoning. The Cochrane Database of Systematic Reviews 2005, Issue 1
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Consider using ciprofloxacin or ceftriaxone to prevent bacterial meningitis
Containing an outbreak of bacterial meningitis by giving 'close contacts' the antibiotic rifampin runs the risk of generating antibiotic resistance – an alternative approach could be to use ciprofloxacin or ceftriaxone.
Neisseria meningitides is a bacterium that causes a deadly form of meningitis. It normally lives in the nostrils and throats of one in ten people without causing any disease, but occasionally infects the membranes around the brain causing sudden symptoms. Without treatment the person could be dead in hours. When someone contracts the disease, doctors try to treat all family members and close contacts with antibiotics to eradicate the bacteria and prevent the disease spreading. In addition, antibiotics can be given periodically to 'at risk' groups of people to wipe out the background population of bacteria.
Rifampin tends to be the antibiotic used, but is not ideal. People need to take tablets twice a day for two days, there are frequent side-effects, it can't be taken during pregnancy and there is no convenient way of giving it to children. In addition, mass use tends to trigger populations of rifampin-resistant bacteria.
The Cochrane authors found that ciprofloxacin and ceftriaxone are as effective as rifampin for eradicating carriage of N. meningitides and suggest that doctors consider using ciprofloxacin or ceftriaxone as alternatives. Both antibiotics are given as single doses, which would help with compliance. In addition no record of resistance development to these antibiotics was found in the included studies. They are not a perfect solution, however, because each still has its own spectrum of possible side effects and limitations.
"The antibiotics studied proved to be more or less equally effective for eradicating carriage of N. meningitides, however the differences found in development of resistance highlight the importance of addressing this issue in future trials and systematic reviews," says Dr Abigail Fraser of Rabin Medical Centre, Petah-Tikan, Israel, who is acting as the spokesperson for the authors.
Review title: Fraser et al: Antibiotics for preventing meningococcal infections. The Cochrane Database of Systematic Reviews 2005, Issue 1
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Also of interest:
Wrap up warm – you've just been born
Taking active measures to keep very preterm and low birthweight infants warm within 10 minutes of birth minimises the risk of cold stress and decrease the incidence of hypothermia. The Cochrane authors highlight good practice guidlines and recommend using interventions such as plastic wraps, skin-to-skin contact and transwarmer mattresses.
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Haloperidol plus promethazine provide swift medical response if people with schizophrenia become aggressive
People with schizophrenia and their families should be confident that if the person with mental illness becomes aggressive and out of control, he or she will receive swift, safe and effective treatment. The combination of haloperidol and promethazine can safely tackle the majority of episodes of aggression within 30 minutes of it being administered.