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Feehan KT, Bridgewater HE, Stenkiewicz-Witeska J, De Maeyer RPH, Ferguson J, Mack M, Brown J, Ercoli G, Mawer CM, Akbar AN, Glanville JRW, Jalali P, Bracken OV, Nicolaou A, Kendall AC, Sugimoto MA, Gilroy DW. Post-resolution macrophages shape long-term tissue immunity and integrity in a mouse model of pneumococcal pneumonia. Nat Commun 2024; 15:4326. [PMID: 38773113 PMCID: PMC11109210 DOI: 10.1038/s41467-024-48138-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 04/19/2024] [Indexed: 05/23/2024] Open
Abstract
Resolving inflammation is thought to return the affected tissue back to homoeostasis but recent evidence supports a non-linear model of resolution involving a phase of prolonged immune activity. Here we show that within days following resolution of Streptococcus pneumoniae-triggered lung inflammation, there is an influx of antigen specific lymphocytes with a memory and tissue-resident phenotype as well as macrophages bearing alveolar or interstitial phenotype. The transcriptome of these macrophages shows enrichment of genes associated with prostaglandin biosynthesis and genes that drive T cell chemotaxis and differentiation. Therapeutic depletion of post-resolution macrophages, inhibition of prostaglandin E2 (PGE2) synthesis or treatment with an EP4 antagonist, MF498, reduce numbers of lung CD4+/CD44+/CD62L+ and CD4+/CD44+/CD62L-/CD27+ T cells as well as their expression of the α-integrin, CD103. The T cells fail to reappear and reactivate upon secondary challenge for up to six weeks following primary infection. Concomitantly, EP4 antagonism through MF498 causes accumulation of lung macrophages and marked tissue fibrosis. Our study thus shows that PGE2 signalling, predominantly via EP4, plays an important role during the second wave of immune activity following resolution of inflammation. This secondary immune activation drives local tissue-resident T cell development while limiting tissue injury.
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MESH Headings
- Animals
- Pneumonia, Pneumococcal/immunology
- Pneumonia, Pneumococcal/pathology
- Pneumonia, Pneumococcal/microbiology
- Pneumonia, Pneumococcal/metabolism
- Disease Models, Animal
- Mice
- Dinoprostone/metabolism
- Mice, Inbred C57BL
- Streptococcus pneumoniae/immunology
- Receptors, Prostaglandin E, EP4 Subtype/metabolism
- Receptors, Prostaglandin E, EP4 Subtype/genetics
- Macrophages/immunology
- Macrophages/metabolism
- Lung/immunology
- Lung/pathology
- Lung/microbiology
- Macrophages, Alveolar/immunology
- Macrophages, Alveolar/metabolism
- Integrin alpha Chains/metabolism
- Integrin alpha Chains/genetics
- Female
- Antigens, CD/metabolism
- Antigens, CD/genetics
- T-Lymphocytes/immunology
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Affiliation(s)
- Karen T Feehan
- Department for Experimental and Translational Medicine, Division of Medicine, 5 University Street, University College London, London, WC1E 6JJ, UK
- School of Cancer and Pharmaceutical Sciences, King's College London, London, SE1 1UL, UK
| | - Hannah E Bridgewater
- Department for Experimental and Translational Medicine, Division of Medicine, 5 University Street, University College London, London, WC1E 6JJ, UK
- Centre for Sports, Exercise and Life Science, Coventry University, Priory St, Coventry, CV1 5FB, UK
| | - Jan Stenkiewicz-Witeska
- Department for Experimental and Translational Medicine, Division of Medicine, 5 University Street, University College London, London, WC1E 6JJ, UK
| | - Roel P H De Maeyer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Windmill Road, University of Oxford, OX3 7LD, Oxford, UK
| | - John Ferguson
- Translational Science and Experimental Medicine, Research and Early Development, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Matthias Mack
- Universitätsklinikum Regensburg, Innere Medizin II/Nephrologie-Transplantation, Regensburg, Germany
| | - Jeremy Brown
- UCL Respiratory, Division of Medicine, 5 University Street, University College London, London, WC1E 6JJ, UK
| | - Giuseppe Ercoli
- UCL Respiratory, Division of Medicine, 5 University Street, University College London, London, WC1E 6JJ, UK
| | - Connar M Mawer
- UCL Respiratory, Division of Medicine, 5 University Street, University College London, London, WC1E 6JJ, UK
| | - Arne N Akbar
- Department for Experimental and Translational Medicine, Division of Medicine, 5 University Street, University College London, London, WC1E 6JJ, UK
| | - James R W Glanville
- Department for Experimental and Translational Medicine, Division of Medicine, 5 University Street, University College London, London, WC1E 6JJ, UK
| | - Parinaaz Jalali
- Department for Experimental and Translational Medicine, Division of Medicine, 5 University Street, University College London, London, WC1E 6JJ, UK
| | - Olivia V Bracken
- Department for Experimental and Translational Medicine, Division of Medicine, 5 University Street, University College London, London, WC1E 6JJ, UK
| | - Anna Nicolaou
- Laboratory for Lipidomics and Lipid Biology, Division of Pharmacy and Optometry, School of Health Sciences, The University of Manchester, Oxford Road, Manchester, M13 9PT, UK
| | - Alexandra C Kendall
- Laboratory for Lipidomics and Lipid Biology, Division of Pharmacy and Optometry, School of Health Sciences, The University of Manchester, Oxford Road, Manchester, M13 9PT, UK
| | - Michelle A Sugimoto
- Department for Experimental and Translational Medicine, Division of Medicine, 5 University Street, University College London, London, WC1E 6JJ, UK
| | - Derek W Gilroy
- Department for Experimental and Translational Medicine, Division of Medicine, 5 University Street, University College London, London, WC1E 6JJ, UK.
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Stuart B, Venekamp R, Hounkpatin H, Wilding S, Moore M, Little P, Gulliford MC. NSAID prescribing and adverse outcomes in common infections: a population-based cohort study. BMJ Open 2024; 14:e077365. [PMID: 38171621 PMCID: PMC10773344 DOI: 10.1136/bmjopen-2023-077365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 11/19/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVES Infections in primary care are often treated with non-steroidal anti-inflammatory drugs (NSAIDs). This study evaluates whether NSAID prescribing is associated with adverse outcomes for respiratory (RTIs) or urinary track (UTI) infections. OBJECTIVES To determine whether there is an association between NSAID prescribing and the rate of adverse outcomes for infections for individual consulting in primary care. DESIGN Cohort study of electronic health records. SETTING 87 general practices in the UK Clinical Practice Research Datalink GOLD. PARTICIPANTS 142 925 patients consulting with RTI or UTI. PRIMARY AND SECONDARY OUTCOME MEASURES Repeat consultations, hospitalisation or death within 30 days of the initial consultation for RTI or UTI. Poisson models estimated the associations between NSAID exposure and outcome. Rate ratios were adjusted for gender, age, ethnicity, deprivation, antibiotic use, seasonal influenza vaccination status, comorbidities and general practice. Since prescribing variations by practice are not explained by case mix-hence, less impacted by confounding by indication-both individual-level and practice-level analyses are included. RESULTS There was an increase in hospital admission/death for acute NSAID prescriptions (RR 2.73, 95% CI 2.10 to 3.56) and repeated NSAID prescriptions (6.47, 4.46-9.39) in RTI patients, and for acute NSAID prescriptions for UTI (RR 3.03; 1.92 to 4.76). Practice-level analysis, controlling for practice population characteristics, found that for each percentage point increase in NSAID prescription, the percentages of hospital admission/death within 30 days increased by 0.32 percentage points (95% CI 0.16 to 0.47). CONCLUSIONS In this non-randomised study, prescription of NSAIDs at consultations for RTI or UTIs in primary care is infrequent but may be associated with increased risk of hospital admission. This supports other observational and limited trial data that NSAID prescribing might be associated with worse outcomes following acute infection and should be prescribed with caution.
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Affiliation(s)
- Beth Stuart
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
- Primary Care Research Centre, University of Southampton Faculty of Medicine, Southampton, UK
| | - Roderick Venekamp
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, Utrecht, Netherlands
| | - Hilda Hounkpatin
- Primary Care Research Centre, University of Southampton Faculty of Medicine, Southampton, UK
| | - Sam Wilding
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Michael Moore
- Primary Care Research Centre, University of Southampton Faculty of Medicine, Southampton, UK
| | - Paul Little
- Primary Care Research Centre, University of Southampton Faculty of Medicine, Southampton, UK
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de Sévaux JLH, Damoiseaux RA, van de Pol AC, Lutje V, Hay AD, Little P, Schilder AG, Venekamp RP. Paracetamol (acetaminophen) or non-steroidal anti-inflammatory drugs, alone or combined, for pain relief in acute otitis media in children. Cochrane Database Syst Rev 2023; 8:CD011534. [PMID: 37594020 PMCID: PMC10436353 DOI: 10.1002/14651858.cd011534.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
BACKGROUND Acute otitis media (AOM) is one of the most common childhood infectious diseases. Pain is the key symptom of AOM and central to children's and parents' experience of the illness. Because antibiotics provide only marginal benefits, analgesic treatment including paracetamol (acetaminophen) and non-steroidal anti-inflammatory drugs (NSAIDs) is regarded as the cornerstone of AOM management. This is an update of a review first published in 2016. OBJECTIVES Our primary objective was to assess the effectiveness of paracetamol (acetaminophen) or NSAIDs, alone or combined, compared with placebo or no treatment in relieving pain in children with AOM. Our secondary objective was to assess the effectiveness of NSAIDs as compared with paracetamol in children with AOM. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 5, April 2023; MEDLINE (Ovid, from 1946 to May 2023), Embase (from 1947 to May 2023), CINAHL (from 1981 to May 2023), LILACS (from 1982 to May 2023), and Web of Science Core Collection (from 1955 to May 2023). We searched the WHO ICTRP and ClinicalTrials.gov for completed and ongoing trials (23 May 2023). SELECTION CRITERIA We included randomised controlled trials comparing the effectiveness of paracetamol or NSAIDs, alone or combined, for pain relief in non-hospitalised children aged six months to 16 years with AOM. We also included trials of paracetamol or NSAIDs, alone or combined, for children with fever or upper respiratory tract infections if we were able to extract subgroup data on pain relief in children with AOM either directly or after obtaining additional data from study authors. We extracted and summarised data for the following comparisons: paracetamol versus placebo, NSAIDs versus placebo, NSAIDs versus paracetamol, and NSAIDs plus paracetamol versus paracetamol alone. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We rated the overall certainty of evidence for each outcome of interest using the GRADE approach. MAIN RESULTS We included four trials (411 children) which were assessed at low to high risk of bias. Paracetamol versus placebo Data from one trial (148 children) informed this comparison. Paracetamol may be more effective than placebo in relieving pain at 48 hours (proportion of children with pain 10% versus 25%, risk ratio (RR) 0.38, 95% confidence interval (CI) 0.17 to 0.85; number needed to treat for an additional beneficial outcome (NNTB) 7; low-certainty evidence). The evidence is very uncertain about the effects of paracetamol on fever at 48 hours (RR 1.03, 95% CI 0.07 to 16.12; very low-certainty evidence) and adverse events (RR 1.03, 95% CI 0.21 to 4.93; very low-certainty evidence). No data were available for our other outcomes of interest. NSAIDs versus placebo Data from one trial (146 children) informed this comparison. Ibuprofen may be more effective than placebo in relieving pain at 48 hours (proportion of children with pain 7% versus 25%, RR 0.28, 95% CI 0.11 to 0.70; NNTB 6; low-certainty evidence). The evidence is very uncertain about the effect of ibuprofen on fever at 48 hours (RR 1.06, 95% CI 0.07 to 16.57; very low-certainty evidence) and adverse events (RR 1.76, 95% CI 0.44 to 7.10; very low-certainty evidence). No data were available for our other outcomes of interest. NSAIDs versus paracetamol Data from four trials (411 children) informed this comparison. The evidence is very uncertain about the effect of ibuprofen versus paracetamol in relieving ear pain at 24 hours (RR 0.83, 95% CI 0.59 to 1.18; 2 RCTs, 39 children; very low-certainty evidence); 48 to 72 hours (RR 0.91, 95% CI 0.54 to 1.54; 3 RCTs, 183 children; low-certainty evidence); and four to seven days (RR 0.74, 95% CI 0.17 to 3.23; 2 RCTs, 38 children; very low-certainty evidence). The evidence is very uncertain about the effect of ibuprofen versus paracetamol on mean pain score at 24 hours (0.29 lower, 95% CI 0.79 lower to 0.20 higher; 3 RCTs, 111 children; very low-certainty evidence); 48 to 72 hours (0.25 lower, 95% CI 0.66 lower to 0.16 higher; 3 RCTs, 108 children; very low-certainty evidence); and four to seven days (0.30 higher, 95% CI 1.78 lower to 2.38 higher; 2 RCTs, 31 children; very low-certainty evidence). The evidence is very uncertain about the effect of ibuprofen versus paracetamol in resolving fever at 24 hours (RR 0.69, 95% CI 0.24 to 2.00; 2 RCTs, 39 children; very low-certainty evidence); 48 to 72 hours (RR 1.18, 95% CI 0.31 to 4.44; 3 RCTs, 182 children; low-certainty evidence); and four to seven days (RR 2.75, 95% CI 0.12 to 60.70; 2 RCTs, 39 children; very low-certainty evidence). The evidence is very uncertain about the effect of ibuprofen versus paracetamol on adverse events (RR 1.71, 95% CI 0.43 to 6.90; 3 RCTs, 281 children; very low-certainty evidence); reconsultations (RR 1.13, 95% CI 0.92 to 1.40; 1 RCT, 53 children; very low-certainty evidence); and delayed antibiotic prescriptions (RR 1.32, 95% CI 0.74 to 2.35; 1 RCT, 53 children; very low-certainty evidence). No data were available on time to resolution of pain. NSAIDs plus paracetamol versus paracetamol alone Data on the effectiveness of ibuprofen plus paracetamol versus paracetamol alone came from two trials that provided crude subgroup data for 71 children with AOM. The small sample provided imprecise effect estimates, therefore we were unable to draw any firm conclusions (very low-certainty evidence). AUTHORS' CONCLUSIONS Despite explicit guideline recommendations on the use of analgesics in children with AOM, the current evidence on the effectiveness of paracetamol or NSAIDs, alone or combined, in children with AOM is limited. Paracetamol and ibuprofen as monotherapies may be more effective than placebo in relieving short-term ear pain in children with AOM. The evidence is very uncertain for the effect of ibuprofen versus paracetamol on relieving short-term ear pain in children with AOM, as well as for the effectiveness of ibuprofen plus paracetamol versus paracetamol alone, thereby preventing any firm conclusions. Further research is needed to provide insights into the role of ibuprofen as adjunct to paracetamol, and other analgesics such as anaesthetic eardrops, for children with AOM.
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Affiliation(s)
- Joline L H de Sévaux
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Roger Amj Damoiseaux
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Alma C van de Pol
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Vittoria Lutje
- Cochrane Infectious Diseases group, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Paul Little
- Primary Care Research Centre, Primary Care Population Sciences and Medical Education Unit, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Anne Gm Schilder
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- National Institute for Health Research University College London Hospitals Biomedical Research Centre , London, UK
- evidENT, Ear Institute, University College London, London, UK
| | - Roderick P Venekamp
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Hu XY, Xia RY, Moore M, Stuart B, Wen LZ, Graz B, Lai L, Liu JP, Fei YT, Willcox M. Use of antibiotics and other treatments in Chinese adults with acute cough: An online survey. Integr Med Res 2023; 12:100920. [PMID: 36684827 PMCID: PMC9850188 DOI: 10.1016/j.imr.2022.100920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Background This study aimed to identify use of various treatments and their association with the use of antibiotics and patient reported clinical recovery in Chinese adults with acute cough. Methods An online survey recruiting people who had recently experienced cough was conducted. Their sociodemographic, clinical characteristics, treatments received and their perceived changes in symptoms were collected. Factors influencing avoidance of antibiotics and improvement in symptoms were explored. Results A total of 22,787 adults with recent acute cough completed the questionnaire, covering all 34 province-level administrative units in China. Most respondents were male (68.0%), young (89.4%, aged 18-45), educated to university/degree or postgraduate level (44.6%), with a median cough severity of 6/10 on a numerical rating scale. Nearly half of the participants (46.4%) reported using antibiotics, among which 93.1% were for presumed upper respiratory tract infections (URTIs). Pharmacies (48.8%) were the most common source of antibiotics. Fewer patients took antibiotics after taking CHM (14.9%), compared to those who started with home remedies (18.0%), or allopathic non-antibiotic medication (25.0%). Antibiotics, allopathic non-antibiotic medications, CHM and home remedies were all perceived beneficial in relieving cough. Conclusions Chinese adult responders report use of a considerable variety of treatments alone or in combination for acute cough. Patient-reported clinical recovery was similar regardless of treatment. There is likely a high proportion of inappropriate use of antibiotics for treatment of simple acute cough. As the majority of respondents did not use antibiotics as a first-line, and use of CHM was associated with relief of cough symptoms and reduction in the use of antibiotics, this presents an important opportunity for prudent antibiotic stewardship in China.
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Affiliation(s)
- Xiao-Yang Hu
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Ru-Yu Xia
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Michael Moore
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Beth Stuart
- Pragmatic Trial Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Ling-Zi Wen
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | | | - Lily Lai
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Jian-Ping Liu
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Yu-Tong Fei
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China,Corresponding authors at: Center for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, 11N 3rd Ring E Road, Chaoyang 100013, China (Y.-T. Fei); Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health center, Southampton SO16 5ST, UK (M. Willcox).
| | - Merlin Willcox
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK,Corresponding authors at: Center for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, 11N 3rd Ring E Road, Chaoyang 100013, China (Y.-T. Fei); Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health center, Southampton SO16 5ST, UK (M. Willcox).
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Zhang W, Qin C, Fei Y, Shen M, Zhou Y, Zhang Y, Zeng X, Zhang S. Anti-inflammatory and immune therapy in severe coronavirus disease 2019 (COVID-19) patients: An update. Clin Immunol 2022; 239:109022. [PMID: 35477027 PMCID: PMC9040414 DOI: 10.1016/j.clim.2022.109022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 04/12/2022] [Accepted: 04/20/2022] [Indexed: 12/15/2022]
Abstract
In March 2020, when coronavirus disease 2019 (COVID-19) was just beginning to spread around the world, we presented the potential benefits and controversies of anti-inflammatory therapy in COVID-19 patients based on the limited experience and proposed some types of anti-inflammatory drugs with potential therapeutic value, while without evidence-based data. In the past one more year, many clinical trials or real-world studies have been performed, either confirm or deny the efficacy of certain anti-inflammatory drugs in the treatment of COVID-19. In this review we summarize the progress of anti-inflammatory and immune therapy in COVID-19, including glucocorticoids, IL-6 antagonist, IL-1 inhibitor, kinase inhibitors, non-steroidal anti-inflammatory drugs and chloroquine/hydroxychloroquine.
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Affiliation(s)
- Wen Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Beijing 100730, China
| | - Chenman Qin
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Beijing 100730, China; Department of Rheumatology of Immunology, People's Hospital of Jiaozuo City, Jiaozuo 454002, China
| | - Yunyun Fei
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Beijing 100730, China
| | - Min Shen
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Beijing 100730, China
| | - Yangzhong Zhou
- Department of internal medicine, Chinese Academy of Medical Sciences (CAMS) & Peking Union Medical College Hospital, Beijing 100730, China
| | - Yan Zhang
- Department of Hematology, Chinese Academy of Medical Sciences (CAMS) & Peking Union Medical College Hospital, Beijing 100730, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Beijing 100730, China.
| | - Shuyang Zhang
- Department of Cardiology, Chinese Academy of Medical Sciences (CAMS) & Peking Union Medical College Hospital, State Key Laboratory of Complex Severe and Rare Diseases, Beijing 100730, China.
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6
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Azh N, Barzkar F, Motamed-Gorji N, Pourvali-Talatappeh P, Moradi Y, Vesal Azad R, Ranjbar M, Baradaran HR. Nonsteroidal anti-inflammatory drugs in acute viral respiratory tract infections: An updated systematic review. Pharmacol Res Perspect 2022; 10:e00925. [PMID: 35218614 PMCID: PMC8881905 DOI: 10.1002/prp2.925] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 12/26/2021] [Accepted: 01/17/2022] [Indexed: 01/08/2023] Open
Abstract
In this systematic review, we aimed to assess the efficacy and safety of nonsteroidal anti‐inflammatory drugs (NSAIDs) in treating respiratory tract infections in adults and children. PubMed, Scopus, Web of Science, Cochrane, and Embase databases were searched. A total of 34 randomized clinical trials were included in this systematic review. We assessed the risk of bias of all included studies using the Cochrane tool for risk of bias assessment. The evidence on ibuprofen, naproxen, aspirin, diclofenac, and other NSAIDs were rated for degree of uncertainty for each of the study outcomes and summarized using the grading of recommendations assessment, development, and evaluation (GRADE) approach. Our findings suggest that high‐quality evidence supports the use of NSAIDs to reduce fever in both adults and children. However, the evidence was uncertain for the use of NSAIDs to reduce cough. Most studies showed that NSAIDs significantly relieved sore throat. The evidence for mortality and oxygenation is limited. Regarding the adverse events, gastrointestinal discomfort was more frequently reported in children. For adults, our overall certainty in effect estimates was low and the increase in gastrointestinal adverse events was not clinically significant. In conclusion, NSAIDs seem to be beneficial in the outpatient management of fever and sore throat in adults and children. Although the evidence does not support their use to decrease mortality nor improve oxygenation in inpatient settings, the use of NSAIDs did not increase the rate of death or the need for ventilation in patients with respiratory tract infections. Further studies with a robust methodology and larger sample sizes are recommended.
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Affiliation(s)
- Nima Azh
- School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Farzaneh Barzkar
- Center for Educational Research in Medical Sciences, Iran University of Medical Sciences, Tehran, Iran
| | | | | | - Yousef Moradi
- Social Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Roya Vesal Azad
- School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Mitra Ranjbar
- Department of Infectious Diseases, School of Medicine, Iran University of Medical Science, Tehran, Iran
| | - Hamid Reza Baradaran
- Ageing Clinical and Experimental Research Team, Institute of Applied Health Sciences, School of Medicine, Medical Sciences, Nutrition University of Aberdeen, Aberdeen, UK.,Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
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7
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Gágyor I, Hay AD. Outcome selection in primary care antimicrobial stewardship research. J Antimicrob Chemother 2021; 77:7-12. [PMID: 34542632 DOI: 10.1093/jac/dkab347] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/23/2021] [Indexed: 11/14/2022] Open
Abstract
Clinical and antimicrobial stewardship (AMS) outcomes are highly relevant to pragmatic primary care trials, reflecting aspects, such as persistent symptoms and relapses, or antibiotic use and antimicrobial resistance. Sometimes both can be equally important. We present evidence demonstrating the wide range of outcome measures used in previous primary care trials and observe that there are no agreed standards for their design. We describe AMS interventions and outcomes in terms of intervention types and targets, and we make recommendations for future research designs. Specifically, we argue that: (i) where co-primary outcomes are considered appropriate, investigators should pre-specify interpretation of conflicting results; (ii) intervention evaluation should ensure prescriptions from sources outside of the usual provider are included in any AMS effectiveness measure; (iii) where possible, outcomes should include antimicrobial resistance; (iv) in some contexts, it may be necessary to include the antibiotics used within the intervention as part of the outcome; and (v) patient involvement is needed to establish the principles investigators should use when deciding whether the AMS or clinical outcomes should be prioritized.
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Affiliation(s)
- Ildikó Gágyor
- University Hospital Würzburg, Department of General Practice, Würzburg, Germany
| | - Alastair D Hay
- Centre of Academic Primary Care, Population Health Sciences: Bristol Medical School, Bristol, UK
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8
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Wong AY, MacKenna B, Morton CE, Schultze A, Walker AJ, Bhaskaran K, Brown JP, Rentsch CT, Williamson E, Drysdale H, Croker R, Bacon S, Hulme W, Bates C, Curtis HJ, Mehrkar A, Evans D, Inglesby P, Cockburn J, McDonald HI, Tomlinson L, Mathur R, Wing K, Forbes H, Eggo RM, Parry J, Hester F, Harper S, Evans SJ, Smeeth L, Douglas IJ, Goldacre B. Use of non-steroidal anti-inflammatory drugs and risk of death from COVID-19: an OpenSAFELY cohort analysis based on two cohorts. Ann Rheum Dis 2021; 80:943-951. [PMID: 33478953 PMCID: PMC7823433 DOI: 10.1136/annrheumdis-2020-219517] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/08/2021] [Accepted: 01/08/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To assess the association between routinely prescribed non-steroidal anti-inflammatory drugs (NSAIDs) and deaths from COVID-19 using OpenSAFELY, a secure analytical platform. METHODS We conducted two cohort studies from 1 March to 14 June 2020. Working on behalf of National Health Service England, we used routine clinical data in England linked to death data. In study 1, we identified people with an NSAID prescription in the last 3 years from the general population. In study 2, we identified people with rheumatoid arthritis/osteoarthritis. We defined exposure as current NSAID prescription within the 4 months before 1 March 2020. We used Cox regression to estimate HRs for COVID-19 related death in people currently prescribed NSAIDs, compared with those not currently prescribed NSAIDs, accounting for age, sex, comorbidities, other medications and geographical region. RESULTS In study 1, we included 536 423 current NSAID users and 1 927 284 non-users in the general population. We observed no evidence of difference in risk of COVID-19 related death associated with current use (HR 0.96, 95% CI 0.80 to 1.14) in the multivariable-adjusted model. In study 2, we included 1 708 781 people with rheumatoid arthritis/osteoarthritis, of whom 175 495 (10%) were current NSAID users. In the multivariable-adjusted model, we observed a lower risk of COVID-19 related death (HR 0.78, 95% CI 0.64 to 0.94) associated with current use of NSAID versus non-use. CONCLUSIONS We found no evidence of a harmful effect of routinely prescribed NSAIDs on COVID-19 related deaths. Risks of COVID-19 do not need to influence decisions about the routine therapeutic use of NSAIDs.
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Affiliation(s)
- Angel Ys Wong
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Caroline E Morton
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Anna Schultze
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Krishnan Bhaskaran
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Jeremy P Brown
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Christopher T Rentsch
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Elizabeth Williamson
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Henry Drysdale
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Seb Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - William Hulme
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | | | - Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Amir Mehrkar
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - David Evans
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Peter Inglesby
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | | | - Helen I McDonald
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Laurie Tomlinson
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Rohini Mathur
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Kevin Wing
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Harriet Forbes
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Rosalind M Eggo
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | - Stephen Jw Evans
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Liam Smeeth
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Ian J Douglas
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
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9
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Drake TM, Fairfield CJ, Pius R, Knight SR, Norman L, Girvan M, Hardwick HE, Docherty AB, Thwaites RS, Openshaw PJM, Baillie JK, Harrison EM, Semple MG. Non-steroidal anti-inflammatory drug use and outcomes of COVID-19 in the ISARIC Clinical Characterisation Protocol UK cohort: a matched, prospective cohort study. THE LANCET. RHEUMATOLOGY 2021; 3:e498-e506. [PMID: 33997800 PMCID: PMC8104907 DOI: 10.1016/s2665-9913(21)00104-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Early in the pandemic it was suggested that pre-existing use of non-steroidal anti-inflammatory drugs (NSAIDs) could lead to increased disease severity in patients with COVID-19. NSAIDs are an important analgesic, particularly in those with rheumatological disease, and are widely available to the general public without prescription. Evidence from community studies, administrative data, and small studies of hospitalised patients suggest NSAIDs are not associated with poorer COVID-19 outcomes. We aimed to characterise the safety of NSAIDs and identify whether pre-existing NSAID use was associated with increased severity of COVID-19 disease. METHODS This prospective, multicentre cohort study included patients of any age admitted to hospital with a confirmed or highly suspected SARS-CoV-2 infection leading to COVID-19 between Jan 17 and Aug 10, 2020. The primary outcome was in-hospital mortality, and secondary outcomes were disease severity at presentation, admission to critical care, receipt of invasive ventilation, receipt of non-invasive ventilation, use of supplementary oxygen, and acute kidney injury. NSAID use was required to be within the 2 weeks before hospital admission. We used logistic regression to estimate the effects of NSAIDs and adjust for confounding variables. We used propensity score matching to further estimate effects of NSAIDS while accounting for covariate differences in populations. RESULTS Between Jan 17 and Aug 10, 2020, we enrolled 78 674 patients across 255 health-care facilities in England, Scotland, and Wales. 72 179 patients had death outcomes available for matching; 40 406 (56·2%) of 71 915 were men, 31 509 (43·8%) were women. In this cohort, 4211 (5·8%) patients were recorded as taking systemic NSAIDs before admission to hospital. Following propensity score matching, balanced groups of NSAIDs users and NSAIDs non-users were obtained (4205 patients in each group). At hospital admission, we observed no significant differences in severity between exposure groups. After adjusting for explanatory variables, NSAID use was not associated with worse in-hospital mortality (matched OR 0·95, 95% CI 0·84-1·07; p=0·35), critical care admission (1·01, 0·87-1·17; p=0·89), requirement for invasive ventilation (0·96, 0·80-1·17; p=0·69), requirement for non-invasive ventilation (1·12, 0·96-1·32; p=0·14), requirement for oxygen (1·00, 0·89-1·12; p=0·97), or occurrence of acute kidney injury (1·08, 0·92-1·26; p=0·33). INTERPRETATION NSAID use is not associated with higher mortality or increased severity of COVID-19. Policy makers should consider reviewing issued advice around NSAID prescribing and COVID-19 severity. FUNDING National Institute for Health Research and Medical Research Council.
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Affiliation(s)
- Thomas M Drake
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Cameron J Fairfield
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Riinu Pius
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Stephen R Knight
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Lisa Norman
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Michelle Girvan
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Hayley E Hardwick
- Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Annemarie B Docherty
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Ryan S Thwaites
- National Heart and Lung Institute, Imperial College London, UK
| | | | - J Kenneth Baillie
- Roslin Institute, University of Edinburgh, Easter Bush Campus, Edinburgh, UK
| | - Ewen M Harrison
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Malcolm G Semple
- Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Department of Respiratory Medicine, Alder Hey Children's Hospital, Liverpool, UK
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10
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Richez C, Flipo RM, Berenbaum F, Cantagrel A, Claudepierre P, Debiais F, Dieudé P, Goupille P, Roux C, Schaeverbeke T, Wendling D, Pham T, Thomas T. Prise en charge des patients atteints de maladies rhumatismales pendant la pandémie de COVID-19 : la Société française de rhumatologie répond aux questions fréquentes posées jusqu’en mai 2020. REVUE DU RHUMATISME 2021; 88:93-100. [PMID: 33488063 PMCID: PMC7813495 DOI: 10.1016/j.rhum.2021.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 05/19/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Christophe Richez
- FHU ACRONIM, CHU de Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France
| | - René-Marc Flipo
- Service de rhumatologie, centre hospitalier régional universitaire de Lille, hôpital Roger-Salengro, rue du Professeur Émile-Laine, 59037 Lille cedex, France
| | - Francis Berenbaum
- Service de rhumatologie, CHU de Saint-Antoine, 184, rue du Faubourg Saint-Antoine, 755571 Paris cedex 12, France
| | - Alain Cantagrel
- Service de rhumatologie, CHU de Toulouse, Hôpital Purpan, place du Docteur Baylac, TSA 40031, 31059 Toulouse cedex 9, France
| | - Pascal Claudepierre
- Service de rhumatologie, CHU de Henri-Mondor, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France
| | - Françoise Debiais
- Service de rhumatologie, CHU, 2, rue de la Milétrie, BP 577, 86021 Poitiers cedex, France
| | - Philippe Dieudé
- Service de rhumatologie, groupe hospitalier universitaire Bichat-Claude Bernard, 46, rue Henri-Huchard, 75018 Paris, France
| | - Philippe Goupille
- Service de rhumatologie, centre hospitalier régional universitaire de Tours, hôpital Trousseau, 37044 Tours cedex 9, France
| | - Christian Roux
- Service de rhumatologie, CHU de Cochin, 27, rue du Faubourg Saint-Jacques, 75679 Paris cedex 14, France
| | | | - Daniel Wendling
- Service de rhumatologie, CHU de Jean-Minjoz, 1, boulevard Fleming, 25030 Besançon cedex, France
| | - Thao Pham
- Service de rhumatologie, CHU de Sainte-Marguerite, 270, boulevard de Sainte-Marguerite, 13274 Marseille cedex 9, France
| | - Thierry Thomas
- Department of Rheumatology, CHU de Saint-Étienne, Hôpital Nord, Saint-Étienne, France
- Inserm U1059, université de Lyon, université Jean-Monnet, Saint-Étienne, France
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11
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Pelargonium sidoides root extract for the treatment of acute cough due to lower respiratory tract infection in adults: a feasibility double-blind, placebo-controlled randomised trial. BMC Complement Med Ther 2021; 21:48. [PMID: 33514367 PMCID: PMC7845084 DOI: 10.1186/s12906-021-03206-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 01/05/2021] [Indexed: 12/02/2022] Open
Abstract
Background Pelargonium sidoides DC (Geraniaceae) root extract, EPs®7630 or “Kaloba®”, is a widely used herbal remedy for respiratory infections, with some evidence of effectiveness for acute bronchitis. However, it is not yet widely recommended by medical professionals in the UK. There is a need to undertake appropriately designed randomised trials to test its use as an alternative to antibiotics. The aim was to assess the feasibility of conducting a double-blind randomised controlled trial of Pelargonium sidoides root extract for treatment of acute bronchitis in UK primary care, investigating intervention compliance, patient preference for dosage form and acceptability of patient diaries. Study design Feasibility double-blind randomised placebo-controlled clinical trial. Methods We aimed to recruit 160 patients with cough (≤ 21 days) caused by acute bronchitis from UK general practices. Practices were cluster-randomised to liquid or tablet preparations and patients were individually randomised to Kaloba® or placebo. We followed participants up for 28 days through self-reported patient diaries with telephone support and reviewed medical records at one month. Outcomes included recruitment, withdrawal, safety, reconsultation and symptom diary completion rates. We also assessed treatment adherence, antibiotic prescribing and consumption, mean symptom severity (at days 2–4 after randomisation) and time to symptom resolution. We interviewed 29 patients and 11 health professionals to identify barriers and facilitators to running such a randomised trial. Results Of 543 patients screened, 261 were eligible, of whom 134 (51%) were recruited and 103 (77%) returned a completed diary. Overall, 41% (41/100) of patients took antibiotics (Kaloba® liquid group: 48% [15/31]; placebo liquid group: 23% [6/26]; Kaloba® tablet group: 48% [9/21]; placebo tablet group: 50% [11/22]). Most patients adhered to the study medication (median 19 out of 21 doses taken in week 1, IQR 18–21 - all arms combined). There were no serious adverse events relating to treatment. Most patients interviewed found study recruitment to be straightforward, but some found the diary too complex. Conclusions It was feasible and acceptable to recruit patients from UK primary care to a double-blind placebo-controlled trial of herbal medicine (Kaloba®) for the treatment of acute bronchitis, with good retention and low data attrition. Trial registration HATRIC was registered on the ISRCTN registry (ISRCTN17672884) on 16 August 2018, retrospectively registered. The record can be found at http://www.isrctn.com/ISRCTN17672884.
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12
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Mishra P, Tomar A, Kumar A, Nath A, Sharma SK, Singh GK. Pain management in COVID-19 pediatric patients-An evidence- based review. Saudi J Anaesth 2021; 15:33-39. [PMID: 33824640 PMCID: PMC8016053 DOI: 10.4103/sja.sja_635_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 06/30/2020] [Indexed: 11/17/2022] Open
Abstract
Despite our growing knowledge about the COVID pandemic, not much concern has been focused upon the effective pain management in pediatric patients suffering from this SARS CoV2 virus. Symptoms with pain like myalgia (10%–40%), sore throat (5%–30%), headache (14%–40%) and abdominal pain (10%) are common in children suffering from COVID. (3-5) We conducted a systematic review regarding analgesia for COVID positive pediatric patients. Cochrane, PubMed, and Google scholar databases were searched for relevant literature. Owing to the novel status of COVID-19 with limited literature, we included randomized controlled trials (RCTs), observational studies, case series and case reports in the descending order of consideration. Articles in languages other than English, abstract only articles and non-scientific commentaries were excluded. The Primary outcome was evaluation of pain related symptoms and best strategies for their management. Our review revealed that a multidisciplinary approach starting from non-pharmacological techniques like drinking plenty of water, removing triggers like inadequate sleep, specific foods and psychotherapy including distraction, comfort and cognitive behavioural strategies should be used. Pharmacological approaches like acetaminophen, NSAIDS, spasmolytics etc. can be used if non-pharmacological therapy is inadequate. As per the current strength of evidence, acetaminophen and ibuprofen can be safely administered for pain management in children with COVID-19. Undertreated pain is a significant contributor to increased morbidity and poor prognosis. Integration of evidence based non-pharmacotherapies in the multidisciplinary pain management will contribute towards improved functioning, early recovery and better quality care for pediatric patients suffering from COVID.
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Affiliation(s)
- Priyanka Mishra
- Department of Anesthesiology and Critical Care, AIIMS, Rishikesh, India
| | - Anupama Tomar
- Department of Anesthesiology and Critical Care, AIIMS, Rishikesh, India
| | - Ajit Kumar
- Department of Anesthesiology and Critical Care, AIIMS, Rishikesh, India
| | - Amborish Nath
- Department of Burns and Plastic Surgery, AIIMS, Rishikesh, India
| | - Suresh K Sharma
- Professor and Principal, College of Nursing, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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13
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Cabbab ILN, Manalo RVM. Anti-inflammatory drugs and the renin-angiotensin-aldosterone system: Current knowledge and potential effects on early SARS-CoV-2 infection. Virus Res 2021; 291:198190. [PMID: 33039544 PMCID: PMC7543703 DOI: 10.1016/j.virusres.2020.198190] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/21/2020] [Accepted: 10/05/2020] [Indexed: 12/20/2022]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the etiologic agent of coronavirus disease 19 (COVID-19), and is genetically related to the 2003 SARS and Middle East respiratory syndrome (MERS-CoV) coronaviruses. Recent studies have reported that similar to SARS-CoV, this strain expresses a spike protein (S) with a receptor binding domain (RBD) that binds to angiotensin-converting enzyme 2 (ACE2) - an enzyme expressed mostly in the endothelium, kidneys, heart, gastrointestinal tract and lungs - to facilitate viral entry and intracellular replication. Incidentally, the renin-angiotensin-aldosterone system (RAAS) is integral to physiologic control of both ACE and ACE2 expression, and is an essential system utilized by SARS-CoV-2, albeit with varying schools of thought on how it can affect viral entry. In this paper, we will review current knowledge on the RAAS and how it can be affected by non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroid use at the organ and cellular levels. We will then discuss the relevance of these interactions on organ-specific ACE2 expression, and provide scientific insights on how this mechanism can potentially affect SARS-CoV-2 infection in the early phases of disease. From the standpoint of other known viruses, we will then aim to discuss the potential uses or restrictions of these drugs in viral infection, and provide an update on relevant studies about COVID-19.
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Affiliation(s)
- Iris Louise N Cabbab
- College of Medicine - William Quasha H. Memorial, St. Luke's Medical Center, Quezon City, 1112, Philippines; National Institutes of Health, University of the Philippines Manila, Ermita, Manila, 1000, Philippines
| | - Rafael Vincent M Manalo
- College of Medicine, University of the Philippines Manila, Ermita, Manila, 1000, Philippines.
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14
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Pelzman FN, Tung J. A Symptom-Directed Paradigm for the Evaluation and Management of Upper Respiratory Tract Infections. Med Clin North Am 2021; 105:199-212. [PMID: 33246520 DOI: 10.1016/j.mcna.2020.08.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Upper respiratory tract infections are one of the most common challenges in ambulatory medicine. Effective evaluation involves identification, primarily through the history, of the dominant set of patient symptoms leading to accurate diagnosis. Certain more morbid illnesses that mimic common upper respiratory symptoms can also be excluded with this approach. Treatment should address patient preferences through an understanding of the limited utility of antibiotics and through tailored advisement of the numerous pharmacologic options for symptom relief.
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Affiliation(s)
- Fred N Pelzman
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, 505 East 70th Street, New York, NY 10021, USA.
| | - Judy Tung
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, 505 East 70th Street, New York, NY 10021, USA. https://twitter.com/JudyTungMD
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15
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Baradaran H, Hamishehkar H, Rezae H. NSAIDs and COVID-19: A New Challenging Area. PHARMACEUTICAL SCIENCES 2020. [DOI: 10.34172/ps.2020.41] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Hananeh Baradaran
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Hadi Hamishehkar
- Department of Clinical Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Haleh Rezae
- Department of Clinical Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
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16
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Soilemezi D, Leydon GM, Yan R, Simpson C, Bell M, Bostock J, Moore M, Willcox M. Herbal medicine for acute bronchitis: A qualitative interview study of patients' and health professionals' views. Complement Ther Med 2020; 55:102613. [PMID: 33221589 DOI: 10.1016/j.ctim.2020.102613] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/08/2020] [Accepted: 11/02/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Antibiotics are widely prescribed for acute bronchitis in the UK. Herbal medicine could be used instead to provide symptom relief. AIM To explore the views of patients and health professionals on using herbal medicine for acute bronchitis instead of antibiotics. DESIGN AND SETTING This was a nested qualitative study, conducted alongside a feasibility randomised clinical trial which ran from July 2018 to May 2019 in 20 GP practices in Wessex, UK. METHOD We conducted telephone semi-structured interviews with patients and with health professionals. The interview data were transcribed and analysed thematically. RESULTS Overall, 40 interviews were conducted with 29 patients, six GPs and five nurses. While some patients believed antibiotics are more effective, most were aware of resistance and were keen to try an alternative, including herbal medicine. Several patients believed herbals would be "less intrusive" than antibiotics, whereas a few disliked the taste or experienced side-effects after taking a herbal. Professionals were concerned about potential interactions with conventional medicines. Many patients trusted herbals because of their long history of use, while some did not understand them. Availability of herbals without a prescription enables patients to use them for self-care, but their cost was a barrier for some. Many patients were willing to take a herbal if advised by their GP. Most GPs were happy to recommend a herbal, if endorsed by evidence-based guidelines. CONCLUSION Many patients and health professionals would consider using herbal medicine for acute bronchitis, if based on trustworthy advice and evidence-based guidelines respectively.
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Affiliation(s)
- Dia Soilemezi
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, United Kingdom
| | - Geraldine M Leydon
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, United Kingdom
| | - Ruiyang Yan
- Medical School, University of Southampton, United Kingdom
| | - Catherine Simpson
- Southampton Clinical Trials Unit, University of Southampton and University Hospital Southampton NHS Foundation Trust, United Kingdom
| | - Margaret Bell
- Southampton Clinical Trials Unit, University of Southampton and University Hospital Southampton NHS Foundation Trust, United Kingdom
| | - Jennifer Bostock
- Southampton Clinical Trials Unit, University of Southampton and University Hospital Southampton NHS Foundation Trust, United Kingdom
| | - Michael Moore
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, United Kingdom
| | - Merlin Willcox
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, United Kingdom.
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17
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von Philipsborn P, Biallas R, Burns J, Drees S, Geffert K, Movsisyan A, Pfadenhauer LM, Sell K, Strahwald B, Stratil JM, Rehfuess E. Adverse effects of non-steroidal anti-inflammatory drugs in patients with viral respiratory infections: rapid systematic review. BMJ Open 2020; 10:e040990. [PMID: 33444207 PMCID: PMC7678345 DOI: 10.1136/bmjopen-2020-040990] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES To assess the effects of non-steroidal anti-inflammatory drugs (NSAIDs) in patients with viral respiratory infections on acute severe adverse outcomes, healthcare utilisation, quality of life and long-term survival. DESIGN Rapid systematic review. PARTICIPANTS Humans with viral respiratory infections, exposed to systemic NSAIDs. PRIMARY OUTCOMES Acute severe adverse outcomes, healthcare utilisation, quality of life and long-term survival. RESULTS We screened 10 999 titles and abstracts and 738 full texts, including 87 studies. No studies addressed COVID-19, Severe Acute Respiratory Syndrome or Middle East Respiratory Syndrome; none examined inpatient healthcare utilisation, quality of life or long-term survival. Effects of NSAIDs on mortality and cardiovascular events in adults with viral respiratory infections are unclear (three observational studies; very low certainty). Children with empyema and gastrointestinal bleeding may be more likely to have taken NSAIDs than children without these conditions (two observational studies; very low certainty). In patients aged 3 years and older with acute respiratory infections, ibuprofen is associated with a higher rate of reconsultations with general practitioners than paracetamol (one randomised controlled trial (RCT); low certainty). The difference in death from all causes and hospitalisation for renal failure and anaphylaxis between children with fever receiving ibuprofen versus paracetamol is likely to be less than 1 per 10 000 (1 RCT; moderate/high certainty). Twenty-eight studies in adults and 42 studies in children report adverse event counts. Most report that no severe adverse events occurred. Due to methodological limitations of adverse event counts, this evidence should be interpreted with caution. CONCLUSIONS It is unclear whether the use of NSAIDs increases the risk of severe adverse outcomes in patients with viral respiratory infections. This absence of evidence should not be interpreted as evidence for the absence of such risk. This is a rapid review with a number of limitations. PROSPERO REGISTRATION NUMBER CRD42020176056.
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Affiliation(s)
- Peter von Philipsborn
- Chair of Public Health and Health Services Research in its capacity as a WHO Collaborating Centre for Evidence-Based Public Health, Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Ludwig Maximilians University Munich Medical Faculty, Munchen, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Renke Biallas
- Chair of Public Health and Health Services Research in its capacity as a WHO Collaborating Centre for Evidence-Based Public Health, Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Ludwig Maximilians University Munich Medical Faculty, Munchen, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Jacob Burns
- Chair of Public Health and Health Services Research in its capacity as a WHO Collaborating Centre for Evidence-Based Public Health, Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Ludwig Maximilians University Munich Medical Faculty, Munchen, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Simon Drees
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Karin Geffert
- Chair of Public Health and Health Services Research in its capacity as a WHO Collaborating Centre for Evidence-Based Public Health, Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Ludwig Maximilians University Munich Medical Faculty, Munchen, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Ani Movsisyan
- Chair of Public Health and Health Services Research in its capacity as a WHO Collaborating Centre for Evidence-Based Public Health, Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Ludwig Maximilians University Munich Medical Faculty, Munchen, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Lisa Maria Pfadenhauer
- Chair of Public Health and Health Services Research in its capacity as a WHO Collaborating Centre for Evidence-Based Public Health, Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Ludwig Maximilians University Munich Medical Faculty, Munchen, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Kerstin Sell
- Chair of Public Health and Health Services Research in its capacity as a WHO Collaborating Centre for Evidence-Based Public Health, Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Ludwig Maximilians University Munich Medical Faculty, Munchen, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Brigitte Strahwald
- Chair of Public Health and Health Services Research in its capacity as a WHO Collaborating Centre for Evidence-Based Public Health, Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Ludwig Maximilians University Munich Medical Faculty, Munchen, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Jan M Stratil
- Chair of Public Health and Health Services Research in its capacity as a WHO Collaborating Centre for Evidence-Based Public Health, Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Ludwig Maximilians University Munich Medical Faculty, Munchen, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Eva Rehfuess
- Chair of Public Health and Health Services Research in its capacity as a WHO Collaborating Centre for Evidence-Based Public Health, Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Ludwig Maximilians University Munich Medical Faculty, Munchen, Germany
- Pettenkofer School of Public Health, Munich, Germany
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18
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Robb CT, Goepp M, Rossi AG, Yao C. Non-steroidal anti-inflammatory drugs, prostaglandins, and COVID-19. Br J Pharmacol 2020; 177:4899-4920. [PMID: 32700336 PMCID: PMC7405053 DOI: 10.1111/bph.15206] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 02/06/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of the novel coronavirus disease 2019 (COVID-19), a highly pathogenic and sometimes fatal respiratory disease responsible for the current 2020 global pandemic. Presently, there remains no effective vaccine or efficient treatment strategies against COVID-19. Non-steroidal anti-inflammatory drugs (NSAIDs) are medicines very widely used to alleviate fever, pain, and inflammation (common symptoms of COVID-19 patients) through effectively blocking production of prostaglandins (PGs) via inhibition of cyclooxyganase enzymes. PGs can exert either proinflammatory or anti-inflammatory effects depending on the inflammatory scenario. In this review, we survey the potential roles that NSAIDs and PGs may play during SARS-CoV-2 infection and the development and progression of COVID-19. LINKED ARTICLES: This article is part of a themed issue on The Pharmacology of COVID-19. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v177.21/issuetoc.
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Affiliation(s)
- Calum T. Robb
- Centre for Inflammation Research, Queen's Medical Research InstituteThe University of EdinburghEdinburghUK
| | - Marie Goepp
- Centre for Inflammation Research, Queen's Medical Research InstituteThe University of EdinburghEdinburghUK
| | - Adriano G. Rossi
- Centre for Inflammation Research, Queen's Medical Research InstituteThe University of EdinburghEdinburghUK
| | - Chengcan Yao
- Centre for Inflammation Research, Queen's Medical Research InstituteThe University of EdinburghEdinburghUK
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19
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Improving pain management in childhood acute otitis media in general practice: a cluster randomised controlled trial of a GP-targeted educational intervention. Br J Gen Pract 2020; 70:e684-e695. [PMID: 32839161 PMCID: PMC7449377 DOI: 10.3399/bjgp20x712589] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 03/15/2020] [Indexed: 12/22/2022] Open
Abstract
Background Pain management in acute otitis media (AOM) is often suboptimal, potentially leading to unnecessary discomfort, GP reconsultation, and antibiotic prescribing. Aim To assess the effectiveness of a GP-targeted educational intervention to improve pain management in children with AOM. Design and setting Pragmatic, cluster randomised controlled trial (RCT). GPs in 37 practices (intervention n = 19; control n = 18) across the Netherlands recruited 224 children with GP-confirmed AOM and ear pain (intervention n = 94; control n = 130) between February 2015 and May 2018. Method GPs in practices allocated to the intervention group were trained (online and face-to-face) to discuss pain management with parents using an information leaflet, and prompted to prescribe weight-appropriate dosed paracetamol. Ibuprofen was additionally prescribed if pain control was still insufficient. GPs in the control group provided usual care. Results Mean ear pain scores over the first 3 days were similar between groups (4.66 versus 4.36; adjusted mean difference = −0.05; 95% confidence intervals [CI] = −0.93 to 0.83), whereas analgesic use, in particular ibuprofen, was higher in the intervention group. The total number of antibiotic prescriptions during the 28-day follow-up was similar (mean rate 0.43 versus 0.47; adjusted rate ratio [aRR] 0.97; 95% CI = 0.68 to 1.38). Parents of children in the intervention group were more likely to reconsult for AOM-related complaints (mean rate 0.70 versus 0.41; aRR 1.73; 95% CI = 1.14 to 2.62). Conclusion An intervention aimed at improving pain management for AOM increases analgesic use, particularly ibuprofen, but does not provide symptomatic benefit. GPs are advised to carefully weigh the potential benefits of ibuprofen against its possible harms.
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20
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Venekamp RP, van Uum RT, Konstantinidis M, Lutje V, Schilder AGM, Hay AD, Damoiseaux RAMJ, Little P. Non-steroidal anti-inflammatory drugs (NSAIDs) for acute sore throat. Hippokratia 2020. [DOI: 10.1002/14651858.cd013709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Roderick P Venekamp
- Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht, Utrecht University; Utrecht Netherlands
| | - Rick T van Uum
- Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht, Utrecht University; Utrecht Netherlands
| | | | - Vittoria Lutje
- Cochrane Infectious Diseases Group; Liverpool School of Tropical Medicine; Liverpool UK
| | | | - Alastair D Hay
- Centre for Academic Primary Care, NIHR School for Primary Care Research, Bristol Medical School: Population Health Sciences; University of Bristol; Bristol UK
| | - Roger AMJ Damoiseaux
- Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht, Utrecht University; Utrecht Netherlands
| | - Paul Little
- Primary Care and Population Sciences, Faculty of Medicine; Aldermoor Health Centre, University of Southampton; Southampton UK
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21
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Sodhi M, Khosrow-Khavar F, FitzGerald JM, Etminan M. Non-steroidal Anti-inflammatory Drugs and the Risk of Pneumonia Complications: A Systematic Review. Pharmacotherapy 2020; 40:970-977. [PMID: 32715498 DOI: 10.1002/phar.2451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
There have been concerns regarding the safety of nonsteroidal antiinflammatory drugs (NSAIDs) in patients with respiratory infections. However, to date, the quality of the evidence has not been systematically assessed. The purpose of this systematic review was to evaluate the role of NSAIDs on pneumonia complications. OVID MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, and Google Scholar were searched. Studies that examined pneumonia complications in patients who had taken NSAIDs before onset of symptoms were identified. Quality assessment was conducted using the Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) assessment tool, which was adapted to include biases that were pertinent to this question. The search strategy identified 1721 potential studies through the 5 primary databases and searching reference lists. Of these, 10 studies met the inclusion criteria, including 5 nested case-control studies, 2 population-based case-control studies, and 3 cohort studies. In total, 59,724 adults were included from 4 of the studies (range = 57-59,250) and 1217 children from 5 studies (range = 148-540). All studies demonstrated a positive association; in adults (odds ratio/risk ratio range = 1.8-8.1) and children (odds ratio/risk ratio range = 1.9-6.8). Studies were limited by moderate or serious risk of confounding bias, exposure misclassification, and protopathic biases and sparse data bias. The results of this review demonstrate that published studies on the effect of NSAIDs use and risk of pneumonia complications are subject to a number of biases. These results should not be extrapolated as evidence of harm for NSAIDs, including ibuprofen, in respiratory ailments but highlight the need for more methodologically robust studies to evaluate this potential relationship.
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Affiliation(s)
- Mohit Sodhi
- Department of Ophthalmology and Visual Sciences, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - John Mark FitzGerald
- Centre for Heart and Lung Health, UBC Institute for Heart and Lung Health, The Lung Centre Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Mahyar Etminan
- Department of Ophthalmology and Visual Sciences, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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22
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Pasquarelli-do-Nascimento G, Braz-de-Melo HA, Faria SS, Santos IDO, Kobinger GP, Magalhães KG. Hypercoagulopathy and Adipose Tissue Exacerbated Inflammation May Explain Higher Mortality in COVID-19 Patients With Obesity. Front Endocrinol (Lausanne) 2020; 11:530. [PMID: 32849309 PMCID: PMC7399077 DOI: 10.3389/fendo.2020.00530] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/30/2020] [Indexed: 12/18/2022] Open
Abstract
COVID-19, caused by SARS-CoV-2, is characterized by pneumonia, lymphopenia, exhausted lymphocytes and a cytokine storm. Several reports from around the world have identified obesity and severe obesity as one of the strongest risk factors for COVID-19 hospitalization and mechanical ventilation. Moreover, countries with greater obesity prevalence have a higher morbidity and mortality risk of developing serious outcomes from COVID-19. The understanding of how this increased susceptibility of the people with obesity to develop severe forms of the SARS-CoV-2 infection occurs is crucial for implementing appropriate public health and therapeutic strategies to avoid COVID-19 severe symptoms and complications in people living with obesity. We hypothesize here that increased ACE2 expression in adipose tissue displayed by people with obesity may increase SARS-CoV-2 infection and accessibility to this tissue. Individuals with obesity have increased white adipose tissue, which may act as a reservoir for a more extensive viral spread with increased shedding, immune activation and pro-inflammatory cytokine amplification. Here we discuss how obesity is related to a pro-inflammatory and metabolic dysregulation, increased SARS-CoV-2 host cell entry in adipose tissue and induction of hypercoagulopathy, leading people with obesity to develop severe forms of COVID-19 and also death. Taken together, it may be crucial to better explore the role of visceral adipose tissue in the inflammatory response to SARS-CoV-2 infection and investigate the potential therapeutic effect of using specific target anti-inflammatories (canakinumab or anakinra for IL-1β inhibition; anti-IL-6 antibodies for IL-6 inhibition), anticoagulant or anti-diabetic drugs in COVID-19 treatment of people with obesity. Defining the immunopathological changes in COVID-19 patients with obesity can provide prominent targets for drug discovery and clinical management improvement.
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Affiliation(s)
| | | | - Sara Socorro Faria
- Laboratory of Immunology and Inflammation, Department of Cell Biology, University of Brasilia, Brasilia, Brazil
| | - Igor de Oliveira Santos
- Laboratory of Immunology and Inflammation, Department of Cell Biology, University of Brasilia, Brasilia, Brazil
| | - Gary P. Kobinger
- Département de Microbiologie-Infectiologie et d'Immunologie, Université Laval, Quebec City, QC, Canada
- Centre de Recherche en Infectiologie du CHU de Québec - Université Laval, Quebec City, QC, Canada
| | - Kelly Grace Magalhães
- Laboratory of Immunology and Inflammation, Department of Cell Biology, University of Brasilia, Brasilia, Brazil
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23
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Arca KN, Smith JH, Chiang CC, Starling AJ, Robertson CE, Halker Singh RB, Schwedt TJ, Kissoon NR, Garza I, Rozen TD, Boes CJ, Whealy MA, VanderPluym JH. COVID-19 and Headache Medicine: A Narrative Review of Non-Steroidal Anti-Inflammatory Drug (NSAID) and Corticosteroid Use. Headache 2020; 60:1558-1568. [PMID: 32648592 PMCID: PMC7404408 DOI: 10.1111/head.13903] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/18/2020] [Accepted: 06/18/2020] [Indexed: 12/17/2022]
Abstract
Objective To summarize the current literature on non‐steroidal anti‐inflammatory drug and corticosteroid use during the coronavirus disease 2019 (COVID‐19) pandemic, recognizing that these are commonly used treatments in the field of headache medicine. Background The use of non‐steroidal anti‐inflammatory drugs and corticosteroids in patients during the COVID‐19 pandemic has been a controversial topic within the medical community and international and national health organizations. Lay press and social media outlets have circulated opinions on this topic despite the fact that the evidence for or against the use of these medications is sparse. In the field of headache medicine, these medications are used commonly and both patients and clinicians may have questions or hesitations pertaining to their use during the COVID‐19 pandemic. Methods A detailed search of the scientific and popular literature was performed. Results There is limited literature pertaining to the safety of non‐steroidal anti‐inflammatory drugs and corticosteroids during the COVID‐19 pandemic. To date, there are no clear scientific data that preclude the use of non‐steroidal anti‐inflammatory drugs in the general population who may acquire COVID‐19 or in those acutely infected with the virus. Several health organizations have concluded that treatment with corticosteroids during active infection should be avoided due to concerns of prolonged viral shedding in the respiratory tract and the lack of survival benefit based on the data from past coronaviruses and influenza virus; specific exceptions exist including treatment for underlying asthma or chronic obstructive pulmonary disease, septic shock, and acute respiratory distress syndrome. Conclusion Scientific information regarding the COVID‐19 pandemic is constantly evolving, and limited or contradictory information can lead to confusion for both patients and clinicians. It is recommended that prior to prescribing non‐steroidal anti‐inflammatory drugs and steroids for the treatment of headache, clinicians have open discussions with their patients about the potential risks and benefits of using these medications during the COVID‐19 pandemic. This manuscript summarizes the currently available evidence and understanding about these risks and benefits to help clinicians navigate such discussions.
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Affiliation(s)
- Karissa N Arca
- Department of Neurology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Jonathan H Smith
- Department of Neurology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Chia-Chun Chiang
- Department of Neurology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Amaal J Starling
- Department of Neurology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | | | | | - Todd J Schwedt
- Department of Neurology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | | | - Ivan Garza
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Todd D Rozen
- Department of Neurology, Mayo Clinic Florida, Jacksonville, FL, USA
| | | | - Mark A Whealy
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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24
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Affiliation(s)
- Nicholas Moore
- Bordeaux PharmacoEpi, INSEMR CIC 1401, Universityd of Bordeaux, 146 rue Leo Saignat, 33076, Bordeaux, France.
| | - Bruce Carleton
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Patrick Blin
- Bordeaux PharmacoEpi, INSEMR CIC 1401, Universityd of Bordeaux, 146 rue Leo Saignat, 33076, Bordeaux, France
| | - Pauline Bosco-Levy
- Bordeaux PharmacoEpi, INSEMR CIC 1401, Universityd of Bordeaux, 146 rue Leo Saignat, 33076, Bordeaux, France
| | - Cecile Droz
- Bordeaux PharmacoEpi, INSEMR CIC 1401, Universityd of Bordeaux, 146 rue Leo Saignat, 33076, Bordeaux, France
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25
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Perricone C, Triggianese P, Bartoloni E, Cafaro G, Bonifacio AF, Bursi R, Perricone R, Gerli R. The anti-viral facet of anti-rheumatic drugs: Lessons from COVID-19. J Autoimmun 2020; 111:102468. [PMID: 32317220 PMCID: PMC7164894 DOI: 10.1016/j.jaut.2020.102468] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 04/07/2020] [Accepted: 04/10/2020] [Indexed: 02/07/2023]
Abstract
The outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has posed the world at a pandemic risk. Coronavirus-19 disease (COVID-19) is an infectious disease caused by SARS-CoV-2, which causes pneumonia, requires intensive care unit hospitalization in about 10% of cases and can lead to a fatal outcome. Several efforts are currently made to find a treatment for COVID-19 patients. So far, several anti-viral and immunosuppressive or immunomodulating drugs have demonstrated some efficacy on COVID-19 both in vitro and in animal models as well as in cases series. In COVID-19 patients a pro-inflammatory status with high levels of interleukin (IL)-1B, IL-1 receptor (R)A and tumor necrosis factor (TNF)-α has been demonstrated. Moreover, high levels of IL-6 and TNF-α have been observed in patients requiring intensive-care-unit hospitalization. This provided rationale for the use of anti-rheumatic drugs as potential treatments for this severe viral infection. Other agents, such as hydroxychloroquine and chloroquine might have a direct anti-viral effect. The anti-viral aspect of immunosuppressants towards a variety of viruses has been known since long time and it is herein discussed in the view of searching for a potential treatment for SARS-CoV-2 infection.
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Affiliation(s)
- Carlo Perricone
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Paola Triggianese
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", University of Rome Tor Vergata, Via Montpellier 1, 00133, Rome, Italy
| | - Elena Bartoloni
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Giacomo Cafaro
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Angelo F Bonifacio
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Roberto Bursi
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Roberto Perricone
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", University of Rome Tor Vergata, Via Montpellier 1, 00133, Rome, Italy
| | - Roberto Gerli
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy.
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26
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Lund LC, Reilev M, Hallas J, Kristensen KB, Thomsen RW, Christiansen CF, Sørensen HT, Johansen NB, Brun NC, Voldstedlund M, Støvring H, Thomsen MK, Christensen S, Pottegård A. Association of Nonsteroidal Anti-inflammatory Drug Use and Adverse Outcomes Among Patients Hospitalized With Influenza. JAMA Netw Open 2020; 3:e2013880. [PMID: 32609352 PMCID: PMC7330719 DOI: 10.1001/jamanetworkopen.2020.13880] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE During the ongoing coronavirus disease 2019 pandemic, case reports have suggested that the use of nonsteroidal anti-inflammatory drugs (NSAIDs) may lead to adverse outcomes. OBJECTIVE To study the association of NSAID use with adverse outcomes in patients hospitalized with influenza or influenza pneumonia. DESIGN, SETTING, AND PARTICIPANTS This cohort study used propensity score matching among 7747 individuals aged 40 years or older who were hospitalized with influenza, confirmed by polymerase chain reaction or antigen testing, between 2010 and 2018. Data were collected using Danish nationwide registers. All analyses reported were performed on May 29, 2020. EXPOSURES Prescription fill of an NSAID within 60 days before admission. MAIN OUTCOMES AND MEASURES Risk ratio (RR) and risk difference (RD) with 95% CIs for intensive care unit admission and death within 30 days of admission. RESULTS A total of 7747 patients (median [interquartile range] age, 71 [59-80] years, 3980 [51.4%] men) with confirmed influenza were identified. Of these, 520 (6.7%) were exposed to NSAIDs. In the unmatched cohorts, 104 of 520 patients (20.0%) who used NSAIDs and 958 of 7227 patients (13.3%) who did not use NSAIDs were admitted to the intensive care unit. For death within 30 days of admission, we observed 37 events (7.1%) among those who used NSAIDs compared with 563 events (7.8%) among those who did not. Current NSAID use was associated with intensive care unit admission (RR, 1.51; 95% CI, 1.26 to 1.81; RD, 6.7%; 95% CI, 3.2% to 10.3%), while NSAID use was not associated with death (RR, 0.91; 95% CI, 0.66 to 1.26; RD, -0.7%; 95% CI, -3.0% to 1.6%). In the matched cohorts, risks were unchanged for patients who used NSAIDs, while 83 ICU admissions (16.0%) and 36 deaths (6.9%) were observed among matched individuals who did not use NSAIDs. Matched (ie, adjusted) analyses yielded attenuated risk estimates for intensive care unit admission (RR, 1.25; 95% CI, 0.95 to 1.63; RD, 4.0%; 95% CI, -0.6% to 8.7%) and death (RR, 1.03; 95% CI, 0.66 to 1.60; RD, 0.2%; 95% CI, -2.9% to 3.3%). Associations were more pronounced among patients who used NSAIDs for a longer period (eg, for intensive care unit admission: RR, 1.90; 95% CI, 1.19 to 3.06; RD, 13.4%; 95% CI, 4.0% to 22.8%). CONCLUSIONS AND RELEVANCE In this cohort study of adult patients hospitalized with influenza, the use of NSAIDs was not associated with 30-day intensive care unit admission or death in adjusted analyses. There was an association between long-term use of NSAIDs and intensive care unit admission.
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Affiliation(s)
- Lars Christian Lund
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Mette Reilev
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Department of Clinical Biochemistry and Clinical Pharmacology, Odense University Hospital, Odense, Denmark
| | - Kasper Bruun Kristensen
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | | | | | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Center for Population Health and Sciences, Stanford University, Stanford, California
| | - Nanna Borup Johansen
- Department of Medical Evaluation and Biostatistics, Danish Medicines Agency, Copenhagen, Denmark
| | - Nikolai Constantin Brun
- Department of Medical Evaluation and Biostatistics, Danish Medicines Agency, Copenhagen, Denmark
| | | | - Henrik Støvring
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Department of Public Health–Biostatistics, Aarhus University, Aarhus, Denmark
| | | | - Steffen Christensen
- Department of Anaesthesia and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Hospital Pharmacy Funen, Odense University Hospital, Odense, Denmark
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27
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Ragni E, Mangiavini L, Viganò M, Brini AT, Peretti GM, Banfi G, de Girolamo L. Management of Osteoarthritis During the COVID-19 Pandemic. Clin Pharmacol Ther 2020; 108:719-729. [PMID: 32438454 PMCID: PMC7280639 DOI: 10.1002/cpt.1910] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 05/15/2020] [Indexed: 12/12/2022]
Abstract
The pandemic spread of the new coronavirus disease 2019 (COVID‐19) infection in China first, and all over the world at present, has become a global health emergency due to the rapidly increasing number of affected patients. Currently, a clear relationship between COVID‐19 infection incidence and/or complications due to chronic or occasional treatments for other pathologies is still not clear, albeit the COVID‐19 pandemic may condition the treatment strategy of complex disorders, such as osteoarthritis (OA). Importantly, OA is the most common age‐related joint disease, affecting more than 80% of people older than the age of 55, an age burden also shared with the highest severity in COVID‐19 patients. OA patients often show a large array of concomitant pathologies, such as diabetes, inflammation, and cardiovascular diseases that are again shared with COVID‐19 patients and may therefore increase complications. Moreover, different OA treatments, such as NSAIDs, paracetamol, corticosteroids, opioids, or other molecules have a wide array of iatrogenic effects, potentially increasing COVID‐19 secondary infection incidence or complications. In this review we critically analyze the evidence on either negative or positive effects of drugs commonly used to manage OA in this particular scenario. This would provide orthopedic surgeons in particular, and physicians, pharmacologists, and clinicians in general, a comprehensive description about the safety of the current pharmacological approaches and a decision‐making tool to treat their OA patients as the coronavirus pandemic continues.
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Affiliation(s)
- Enrico Ragni
- IRCCS Istituto Ortopedico Galeazzi, Laboratorio di Biotecnologie Applicate all'Ortopedia, Milan, Italy
| | - Laura Mangiavini
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.,Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Marco Viganò
- IRCCS Istituto Ortopedico Galeazzi, Laboratorio di Biotecnologie Applicate all'Ortopedia, Milan, Italy
| | - Anna Teresa Brini
- IRCCS Istituto Ortopedico Galeazzi, Laboratorio di Applicazioni Biotecnologiche, Milan, Italy.,Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Giuseppe Michele Peretti
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.,Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Giuseppe Banfi
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Laura de Girolamo
- IRCCS Istituto Ortopedico Galeazzi, Laboratorio di Biotecnologie Applicate all'Ortopedia, Milan, Italy
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28
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Abstract
In the current COVID-19 pandemic, there has been concern regarding the use of ibuprofen and other nonsteroidal anti-inflammatory agents by COVID-19 infected patients. Aminosalicylates (5-ASAs) are structurally similar and have anti-inflammatory functions that resemble those of nonsteroidal anti-inflammatory agents. Since 5-ASAs are a mainstay treatment for inflammatory bowel disease, the authors review the pharmacology of both classes of drugs and discuss the potential relevance of 5-ASAs in the ongoing discussion of medication use in patients infected with COVID-19.
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Kennedy NA, Jones GR, Lamb CA, Appleby R, Arnott I, Beattie RM, Bloom S, Brooks AJ, Cooney R, Dart RJ, Edwards C, Fraser A, Gaya DR, Ghosh S, Greveson K, Hansen R, Hart A, Hawthorne AB, Hayee B, Limdi JK, Murray CD, Parkes GC, Parkes M, Patel K, Pollok RC, Powell N, Probert CS, Raine T, Sebastian S, Selinger C, Smith PJ, Stansfield C, Younge L, Lindsay JO, Irving PM, Lees CW. British Society of Gastroenterology guidance for management of inflammatory bowel disease during the COVID-19 pandemic. Gut 2020; 69:984-990. [PMID: 32303607 PMCID: PMC7211081 DOI: 10.1136/gutjnl-2020-321244] [Citation(s) in RCA: 198] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 04/03/2020] [Accepted: 04/06/2020] [Indexed: 02/07/2023]
Abstract
The COVID-19 pandemic is putting unprecedented pressures on healthcare systems globally. Early insights have been made possible by rapid sharing of data from China and Italy. In the UK, we have rapidly mobilised inflammatory bowel disease (IBD) centres in order that preparations can be made to protect our patients and the clinical services they rely on. This is a novel coronavirus; much is unknown as to how it will affect people with IBD. We also lack information about the impact of different immunosuppressive medications. To address this uncertainty, the British Society of Gastroenterology (BSG) COVID-19 IBD Working Group has used the best available data and expert opinion to generate a risk grid that groups patients into highest, moderate and lowest risk categories. This grid allows patients to be instructed to follow the UK government's advice for shielding, stringent and standard advice regarding social distancing, respectively. Further considerations are given to service provision, medical and surgical therapy, endoscopy, imaging and clinical trials.
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Affiliation(s)
- Nicholas A Kennedy
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- University of Exeter, Exeter, UK
| | - Gareth-Rhys Jones
- University of Edinburgh, Edinburgh, UK
- Western General Hospital, Edinburgh, UK
| | - Christopher A Lamb
- Newcastle University, Newcastle upon Tyne, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Richard Appleby
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - R Mark Beattie
- Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Stuart Bloom
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Alenka J Brooks
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rachel Cooney
- Queen Elizabeth Hospital Birmingham NHS Foundation Trust, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | - Robin J Dart
- King's College London, London, UK
- The Royal Free Hospital, London, UK
| | | | - Aileen Fraser
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Daniel R Gaya
- Glasgow Royal Infirmary, Glasgow, UK
- University of Glasgow, Glasgow, UK
| | - Subrata Ghosh
- Queen Elizabeth Hospital Birmingham NHS Foundation Trust, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | | | - Richard Hansen
- University of Glasgow, Glasgow, UK
- Royal Hospital for Children, Glasgow, UK
| | - Ailsa Hart
- St Mark's Hospital, London, UK
- Imperial College London, London, UK
| | | | - Bu'Hussain Hayee
- King's College London, London, UK
- King's College Hospital NHS Foundation Trust, London, UK
| | - Jimmy K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
- University of Manchester, Manchester, UK
| | | | - Gareth C Parkes
- Barts and the London School of Medicine and Dentistry, London, UK
- The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Miles Parkes
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Kamal Patel
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Richard C Pollok
- St George's University Hospitals NHS Foundation Trust, London, UK
- St George's, University of London, London, UK
| | - Nick Powell
- Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Chris S Probert
- Liverpool University Hospitals NHS Foundation Trusts, Liverpool, UK
- University of Liverpool, Liverpool, UK
| | - Tim Raine
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | | | - Philip J Smith
- Liverpool University Hospitals NHS Foundation Trusts, Liverpool, UK
| | | | - Lisa Younge
- Crohn's and Colitis UK, St Albans, Hertfordshire, UK
| | - James O Lindsay
- Barts and the London School of Medicine and Dentistry, London, UK
- The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Peter M Irving
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Charlie W Lees
- University of Edinburgh, Edinburgh, UK
- Western General Hospital, Edinburgh, UK
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Brewster CT, Choong J, Thomas C, Wilson D, Moiemen N. Steam inhalation and paediatric burns during the COVID-19 pandemic. Lancet 2020; 395:1690. [PMID: 32422125 PMCID: PMC7228710 DOI: 10.1016/s0140-6736(20)31144-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/12/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Colin T Brewster
- Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.
| | - Jia Choong
- Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Clare Thomas
- Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - David Wilson
- Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Naiem Moiemen
- Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
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Richez C, Flipo RM, Berenbaum F, Cantagrel A, Claudepierre P, Debiais F, Dieudé P, Goupille P, Roux C, Schaeverbeke T, Wendling D, Pham T, Thomas T. Managing patients with rheumatic diseases during the COVID-19 pandemic: The French Society of Rheumatology answers to most frequently asked questions up to May 2020. Joint Bone Spine 2020; 87:431-437. [PMID: 32473418 PMCID: PMC7255274 DOI: 10.1016/j.jbspin.2020.05.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/19/2020] [Indexed: 02/09/2023]
Abstract
BACKGROUND Rheumatologists must contend with COVID-19 pandemic in the management of their patients and many questions have been raised on the use of both anti-inflammatory drugs and disease-modifying anti-rheumatic drugs (DMARD). The French Society of Rheumatology (SFR) selected the most critical ones to the daily practice of a rheumatologist and a group of 10 experts from SFR and Club Rheumatism and Inflammation (CRI) boards proposed responses based on the current knowledge of May 2020. METHODS Following the availability of the first 18 questions and statements, 1400 individuals consulted the frequently asked questions between the March 31, 2020 and April 12, 2020. As a result, 16 additional questions were forwarded to the SFR, and answered by the board. An additional round of review by email and video conference was organized, which included updates of the previous statements. The scientific relevance of 5 of the questions led to their inclusion in this document. Each response received a final assessment on a scale of 0-10 with 0 meaning no agreement whatsoever and 10 being in complete agreement. The mean values of these votes for each question are presented as the levels of agreement (LoA) at the end of each response. This document was last updated on April 17, 2020. RESULTS Based on current scientific literature already published, in most circumstances, there is no contraindication to the initiation or continuation of anti-inflammatory drugs as well as DMARDs. If signs suggestive of infection (coronavirus or other) occur, treatments should be discontinued and resumed, if necessary, after 2 weeks without any symptoms. Only, some signals suggest that people taking an immunosuppressive dose of corticosteroid therapy are at greater risk of developing severe COVID-19. Intra-articular injections of glucocorticoids are allowed when there is no reasonable therapeutic alternative, and providing that precautions to protect the patient and the practitioner from viral contamination are adopted, included appropriate information to the patient. CONCLUSIONS Currently available data on managing patients with rheumatic diseases during the COVID-19 pandemic are reassuring and support continuing or initiating symptomatic as well as specific treatments of these diseases, the main target of their management remaining their appropriate control, even during this pandemic.
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Affiliation(s)
- Christophe Richez
- Centre Hospitalier Universitaire de Bordeaux, FHU ACRONIM, place Amélie-Raba-Léon, 33076 Bordeaux, France
| | - René-Marc Flipo
- Service de Rhumatologie, Centre Hospitalier Régional Universitaire de Lille, Hôpital Roger Salengro, rue du Professeur-Emile-Laine, 59037 Lille cedex, France
| | - Francis Berenbaum
- Service de Rhumatologie, Centre Hospitalier Universitaire Saint-Antoine, 184, rue du Faubourg-Saint-Antoine, 755571 Paris cedex 12, France
| | - Alain Cantagrel
- Service de Rhumatologie, Centre Hospitalier Universitaire de Toulouse, Hôpital Purpan, place du Docteur-Baylac, TSA 40031, 31059 Toulouse cedex 9, France
| | - Pascal Claudepierre
- Service de Rhumatologie, Centre Hospitalier Universitaire Henri Mondor, 51 avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France
| | - Françoise Debiais
- Service de Rhumatologie, Centre Hospitalier Universitaire, 2, rue de la Milétrie, BP 577, 86021 Poitiers cedex, France
| | - Philippe Dieudé
- Service de Rhumatologie, Groupe Hospitalier Universitaire Bichat-Claude Bernard, 46, rue Henri-Huchard, 75018 Paris, France
| | - Philippe Goupille
- Service de Rhumatologie, Centre Hospitalier Régional Universitaire de Tours, Hôpital Trousseau, 37044 Tours cedex 9, France
| | - Christian Roux
- Service de Rhumatologie, Centre Hospitalier Universitaire Cochin, 27, rue du Faubourg-Saint-Jacques, 75679 Paris cedex 14, France
| | - Thierry Schaeverbeke
- Centre Hospitalier Universitaire de Bordeaux, FHU ACRONIM, place Amélie-Raba-Léon, 33076 Bordeaux, France
| | - Daniel Wendling
- Service de Rhumatologie, Centre Hospitalier Universitaire Jean-Minjoz, 1, boulevard Fleming, 25030 Besançon cedex, France
| | - Thao Pham
- Service de Rhumatologie, Centre Hospitalier Universitaire Sainte Marguerite, 270, boulevard de Sainte-Marguerite, 13274 Marseille cedex 9, France
| | - Thierry Thomas
- Department of Rheumatology, Hôpital Nord, CHU Saint-Étienne, Inserm U1059, Université de Lyon-Université Jean-Monnet, Saint-Étienne, France.
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Preckel B, Schultz MJ, Vlaar AP, Hulst AH, Hermanides J, de Jong MD, Schlack WS, Stevens MF, Weenink RP, Hollmann MW. Update for Anaesthetists on Clinical Features of COVID-19 Patients and Relevant Management. J Clin Med 2020; 9:E1495. [PMID: 32429249 PMCID: PMC7291059 DOI: 10.3390/jcm9051495] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 05/09/2020] [Accepted: 05/14/2020] [Indexed: 02/07/2023] Open
Abstract
When preparing for the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the coronavirus infection disease (COVID-19) questions arose regarding various aspects concerning the anaesthetist. When reviewing the literature it became obvious that keeping up-to-date with all relevant publications is almost impossible. We searched for and summarised clinically relevant topics that could help making clinical decisions. This is a subjective analysis of literature concerning specific topics raised in our daily practice (e.g., clinical features of COVID-19 patients; ventilation of the critically ill COVID-19 patient; diagnostic of infection with SARS-CoV-2; stability of the virus; Covid-19 in specific patient populations, e.g., paediatrics, immunosuppressed patients, patients with hypertension, diabetes mellitus, kidney or liver disease; co-medication with non-steroidal anti-inflammatory drugs (NSAIDs); antiviral treatment) and we believe that these answers help colleagues in clinical decision-making. With ongoing treatment of severely ill COVID-19 patients other questions will come up. While respective guidelines on these topics will serve clinicians in clinical practice, regularly updating all guidelines concerning COVID-19 will be a necessary, although challenging task in the upcoming weeks and months. All recommendations during the current extremely rapid development of knowledge must be evaluated on a daily basis, as suggestions made today may be out-dated with the new evidence available tomorrow.
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Affiliation(s)
- Benedikt Preckel
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (A.H.H.); (W.S.S.); (M.F.S.); (R.P.W.); (M.W.H.)
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands; (M.J.S.); (A.P.V.)
| | - Marcus J. Schultz
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands; (M.J.S.); (A.P.V.)
- Department of Intensive Care, and Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok 10400, Thailand
- Nuffield Department of Medicine, University of Oxford, Old Road Campus Research Build, Roosevelt Dr, Headington, Oxford OX3 7DQ, UK
| | - Alexander P. Vlaar
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands; (M.J.S.); (A.P.V.)
- Department of Intensive Care, and Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands
| | - Abraham H. Hulst
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (A.H.H.); (W.S.S.); (M.F.S.); (R.P.W.); (M.W.H.)
| | - Jeroen Hermanides
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (A.H.H.); (W.S.S.); (M.F.S.); (R.P.W.); (M.W.H.)
| | - Menno D. de Jong
- Department of Medical Microbiology & Infection prevention, Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands;
| | - Wolfgang S. Schlack
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (A.H.H.); (W.S.S.); (M.F.S.); (R.P.W.); (M.W.H.)
| | - Markus F. Stevens
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (A.H.H.); (W.S.S.); (M.F.S.); (R.P.W.); (M.W.H.)
| | - Robert P. Weenink
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (A.H.H.); (W.S.S.); (M.F.S.); (R.P.W.); (M.W.H.)
| | - Markus W. Hollmann
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (A.H.H.); (W.S.S.); (M.F.S.); (R.P.W.); (M.W.H.)
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands; (M.J.S.); (A.P.V.)
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Non-steroidal anti-inflammatory drugs, pharmacology, and COVID-19 infection. Therapie 2020; 75:355-362. [PMID: 32418728 PMCID: PMC7204680 DOI: 10.1016/j.therap.2020.05.003] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 05/05/2020] [Indexed: 01/08/2023]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) have an optional prescription status that has resulted in frequent use, in particular for the symptomatic treatment of fever and non-rheumatic pain. In 2019, a multi-source analysis of complementary pharmacological data showed that using NSAIDs in these indications (potentially indicative of an underlying infection) increases the risk of a severe bacterial complication, in particular in the case of lung infections. First, the clinical observations of the French Pharmacovigilance Network showed that severe bacterial infections can occur even after a short NSAID treatment, and even if the NSAID is associated with an antibiotic. Second, pharmacoepidemiological studies, some of which minimized the protopathic bias, all converged and confirmed the risk. Third, experimental in vitro and in vivo animal studies suggest several biological mechanisms, which strengthens a causal link beyond the well-known risk of delaying the care of the infection (immunomodulatory effects, effects on S. pyogenes infections, and reduced antibiotics efficacy). Therefore, in case of infection, symptomatic treatment with NSAIDs for non-severe symptoms (fever, pain, or myalgia) is not to be recommended, given a range of clinical and scientific arguments supporting an increased risk of severe bacterial complication. Besides, the existence of a safer drug alternative, with paracetamol at recommended doses, makes this recommendation of precaution and common sense even more legitimate. In 2020, such recommendation is more topical than ever with the emergence of COVID-19, especially since it results in fever, headaches, muscular pain, and cough, and is further complicated with pneumopathy, and given experimental data suggesting a link between ibuprofen and the level of expression of angiotensin-converting enzyme 2.
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Abstract
The COVID-19 pandemic is putting unprecedented pressures on healthcare systems globally. Early insights have been made possible by rapid sharing of data from China and Italy. In the UK, we have rapidly mobilised inflammatory bowel disease (IBD) centres in order that preparations can be made to protect our patients and the clinical services they rely on. This is a novel coronavirus; much is unknown as to how it will affect people with IBD. We also lack information about the impact of different immunosuppressive medications. To address this uncertainty, the British Society of Gastroenterology (BSG) COVID-19 IBD Working Group has used the best available data and expert opinion to generate a risk grid that groups patients into highest, moderate and lowest risk categories. This grid allows patients to be instructed to follow the UK government’s advice for shielding, stringent and standard advice regarding social distancing, respectively. Further considerations are given to service provision, medical and surgical therapy, endoscopy, imaging and clinical trials.
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Stuart B, Becque T, Moore M, Little P. Clustering of continuous and binary outcomes at the general practice level in individually randomised studies in primary care - a review of 10 years of primary care trials. BMC Med Res Methodol 2020; 20:83. [PMID: 32293280 PMCID: PMC7158044 DOI: 10.1186/s12874-020-00971-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 04/07/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In randomised controlled trials, the assumption of independence of individual observations is fundamental to the design, analysis and interpretation of studies. However, in individually randomised trials in primary care, this assumption may be violated because patients are naturally clustered within primary care practices. Ignoring clustering may lead to a loss of power or, in some cases, type I error. METHODS Clustering can be quantified by intra-cluster correlation (ICC), a measure of the similarity between individuals within a cluster with respect to a particular outcome. We reviewed 17 trials undertaken by the Department of Primary Care at the University of Southampton over the last ten years. We calculated the ICC for the primary and secondary outcomes in each trial at the practice level and determined whether ignoring practice-level clustering still gave valid inferences. Where multiple studies collected the same outcome measure, the median ICC was calculated for that outcome. RESULTS The median intra-cluster correlation (ICC) for all outcomes was 0.016, with interquartile range 0.00-0.03. The median ICC for symptom severity was 0.02 (interquartile range (IQR) 0.01 to 0.07) and for reconsultation with new or worsening symptoms was 0.01 (IQR 0.00, 0.07). For HADS anxiety the ICC was 0.04 (IQR 0.02, 0.05) and for HADS depression was 0.02 (IQR 0.00, 0.05). The median ICC for EQ. 5D-3 L was 0.01 (IQR 0.01, 0.04). CONCLUSIONS There is evidence of clustering in individually randomised trials primary care. The non-zero ICC suggests that, depending on study design, clustering may not be ignorable. It is important that this is fully considered at the study design phase.
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Affiliation(s)
- Beth Stuart
- Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Aldermoor Close, Southampton, SO16 5ST, UK.
| | - Taeko Becque
- Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Michael Moore
- Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Paul Little
- Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Aldermoor Close, Southampton, SO16 5ST, UK
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Updated Guidelines for the Management of Acute Otitis Media in Children by the Italian Society of Pediatrics: Treatment. Pediatr Infect Dis J 2019; 38:S10-S21. [PMID: 31876601 DOI: 10.1097/inf.0000000000002452] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND New insights into the diagnosis, treatment and prevention of acute otitis media (AOM) have been gained in recent years. For this reason, the Italian Paediatric Society has updated its 2010 guidelines. METHODS A literature search was carried out on PubMed. Only pediatric studies published between January 1, 2010 and December 31, 2018 in English or Italian were included. Each included study was assessed according to the GRADE methodology. The quality of the systematic reviews was assessed using AMSTAR 2. The recommendations were formulated by a multidisciplinary panel of experts. RESULTS Prompt antibiotic treatment is recommended for children with otorrhea, intracranial complications and/or a history of recurrence and for children under the age of 6 months. For children 6 months to 2 years of age, prompt antibiotic treatment is recommended for all forms of unilateral and bilateral AOM, whether mild or severe. Prompt antibiotic treatment is also recommended for children over 2 years with severe bilateral AOM. A watchful-waiting approach can be applied to children over 2 years with mild or severe unilateral AOM or mild bilateral AOM. High doses of amoxicillin, or amoxicillin-clavulanic acid for patients with a high risk of infection by Beta-lactamase producing strains, remain the first-line antibiotics. CONCLUSIONS AOM should be managed on a case-by-case basis that takes account of the child's age, the severity of the episode and whether it is unilateral or bilateral. In patients under 2 years, prompt antibiotic treatment is always recommended.
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Lucas S, Leach MJ, Kumar S, Phillips AC. Complementary And Alternative Medicine Practitioner's Management Of Acute Respiratory Tract Infections In Children - A Qualitative Descriptive Study. J Multidiscip Healthc 2019; 12:947-962. [PMID: 31819469 PMCID: PMC6875505 DOI: 10.2147/jmdh.s230845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 10/29/2019] [Indexed: 01/01/2023] Open
Abstract
Background Acute respiratory tract infection (ARTI) is one of the most prevalent types of infection among children and a common reason for hospital admission. Although parents frequently consult complementary and alternative medicine (CAM) practitioners to assist with the management of childhood ARTI, little is known about the treatments that CAM practitioners recommend and why. The aim of this research was to understand what CAM practitioners typically prescribe for the management of childhood ARTI and how practitioners formulate decisions regarding the management of this condition. Method The research was guided by a qualitative descriptive framework. CAM practitioners across Greater Melbourne (Victoria, Australia) who had treated children aged 0–12 years with ARTI in the past 12 months were eligible to participate. Data were captured using semi-structured interviews, which were audio-recorded and transcribed verbatim. Multiple strategies to improve trustworthiness were implemented (e.g., triangulation of data). Data were analysed using inductive content analysis. Results Twenty-four CAM practitioners from ten different disciplines participated in the interviews. Most participants were female (75%), and more than half (54%) were practicing naturopaths. The treatments most commonly recommended were lifestyle modification (95%), nutrition/diet-based treatments (91%), and vitamin/mineral supplementation (87%). Practitioners’ decision-making process was underpinned by four key concepts namely: the approach to management, individualisation, do no harm, and collaborative practice. Individualisation and the safety of the child are cornerstones of treatment in the practitioner’s decision-making process. Conclusion This research sheds light on commonly used CAM interventions, many of which build on easily accessible and readily available treatments (such as soups) and are aligned with mainstream recommendations (such as rest). Practitioners’ decision-making process too aligns well with mainstream health care where the focus is on safety and informed by a biopsychosocial-cultural approach.
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Affiliation(s)
- Sandra Lucas
- School of Health Sciences, Division of Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Matthew J Leach
- Department of Rural Health, University of South Australia, Adelaide, SA, Australia
| | - Saravana Kumar
- School of Health Sciences, Division of Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Anna C Phillips
- School of Health Sciences, Division of Health Sciences, University of South Australia, Adelaide, SA, Australia
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Whitehead A, Simpson C, Willcox M, Webley F, Hay AD, Butler C, Yao L, Wrixon E, Bell M, Bostock J, Little P, Griffiths G, Moore M. HATRIC: a study of Pelargonium sidoides root extract EPs®7630 (Kaloba®) for the treatment of acute cough due to lower respiratory tract infection in adults-study protocol for a double blind, placebo-controlled randomised feasibility trial. Pilot Feasibility Stud 2019; 5:98. [PMID: 31384480 PMCID: PMC6668164 DOI: 10.1186/s40814-019-0478-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 07/09/2019] [Indexed: 12/13/2022] Open
Abstract
Background Acute lower respiratory tract infection is a common acute infection managed in primary care. The current dominant management strategy in the UK is antibiotics, despite widespread publicity regarding antimicrobial resistance and evidence that the small benefits of antibiotics do not outweigh the harms. There is a need to address the rising problem of antibiotic resistance by providing credible alternative strategies, which reduce symptom burden. There is sufficient evidence to recommend the use of Pelargonium sidoides root extract in order to warrant undertaking an independent clinical trial. We propose a feasibility study to demonstrate our ability to recruit and retain patients and conduct a placebo-controlled trial of Pelargonium sidoides extract EPs®7630 in lower respiratory tract infection where pneumonia is not suspected. Both the tablet and liquid formulations will be included. Methods The HATRIC trial is a double-blind randomised placebo-controlled feasibility study aiming to determine the potential to conduct a fully powered trial of Pelargonium sidoides root extract as an alternative to the inappropriate use of antibiotics for acute bronchitis in UK primary care. Primary care sites will be equally randomised to one of two formulation groups (tablet or liquid preparation). Additionally, within each site, patients will be evenly randomised to active or placebo treatment. Antibiotic consumption will be monitored during the trial, but the use of a delayed prescription strategy is encouraged. The target sample size for this study is 160 patients overall or 40 per arm, recruited from approximately 20 primary care sites. The analysis will be descriptive focusing on estimation with no formal comparison of groups taking place. Discussion If this trial demonstrates the feasibility of recruitment and delivery, we will seek funding for a fully powered placebo-controlled trial of Pelargonium sidoides root extract for the treatment of lower respiratory tract infections in primary care. Trial registration HATRIC was registered on the ISRCTN registry (ISRCTN17672884) on 16 August 2018.
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Affiliation(s)
- Amy Whitehead
- 1Southampton Clinical Trials Unit, Faculty of Medicine, University of Southampton MP131, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD UK
| | - Catherine Simpson
- 1Southampton Clinical Trials Unit, Faculty of Medicine, University of Southampton MP131, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD UK
| | - Merlin Willcox
- 2Primary Care and Population Science, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, SO16 5ST UK
| | - Frances Webley
- 1Southampton Clinical Trials Unit, Faculty of Medicine, University of Southampton MP131, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD UK
| | - Alastair D Hay
- 3Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS UK
| | - Chris Butler
- 4Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, OX2 6GG UK
| | - Lily Yao
- 5Department of Health Sciences, University of Leicester, Leicester, LE1 7RH UK
| | - Emma Wrixon
- 1Southampton Clinical Trials Unit, Faculty of Medicine, University of Southampton MP131, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD UK
| | - Margaret Bell
- 2Primary Care and Population Science, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, SO16 5ST UK
| | - Jennifer Bostock
- 2Primary Care and Population Science, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, SO16 5ST UK
| | - Paul Little
- 2Primary Care and Population Science, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, SO16 5ST UK
| | - Gareth Griffiths
- 1Southampton Clinical Trials Unit, Faculty of Medicine, University of Southampton MP131, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD UK
| | - Michael Moore
- 2Primary Care and Population Science, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, SO16 5ST UK
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Cots JM, Moragas A, García-Sangenís A, Morros R, Gomez-Lumbreras A, Ouchi D, Monfà R, Pera H, Pujol J, Bayona C, de la Poza-Abad M, Llor C. Effectiveness of antitussives, anticholinergics or honey versus usual care in adults with uncomplicated acute bronchitis: a study protocol of an open randomised clinical trial in primary care. BMJ Open 2019; 9:e028159. [PMID: 31101700 PMCID: PMC6530348 DOI: 10.1136/bmjopen-2018-028159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Despite the frequent use of therapies in acute bronchitis, the evidence of their benefit is lacking, since only a few clinical trials have been published, with low sample sizes, poor methodological quality and mainly in children. The objective of this study is to compare the effectiveness of three symptomatic therapies (dextromethorphan, ipratropium or honey) associated with usual care and the usual care in adults with acute bronchitis. METHODS AND ANALYSIS This will be a multicentre, pragmatic, parallel group, open randomised trial. Patients aged 18 or over with uncomplicated acute bronchitis, with cough for less than 3 weeks as the main symptom, scoring ≥4 in either daytime or nocturnal cough on a 7-point Likert scale, will be randomised to one of the following four groups: usual care, dextromethorphan 30 mg three times a day, ipratropium bromide inhaler 20 µg two puffs three times a day or honey 30 mg (a spoonful) three times a day, all taken for up to 14 days. The exclusion criteria will be pneumonia, criteria for hospital admission, pregnancy or lactation, concomitant pulmonary disease, associated significant comorbidity, allergy, intolerance or contraindication to any of the study drugs or admitted to a long-term residence. SAMPLE 668 patients. The primary outcome will be the number of days with moderate-to-severe cough. All patients will be given a paper-based symptom diary to be self-administered. A second visit will be scheduled at day 2 or 3 for assessing evolution, with two more visits at days 15 and 29 for clinical assessment, evaluation of adverse effects, re-attendance and complications. Patients still with symptoms at day 29 will be called 6 weeks after the baseline visit. ETHICS AND DISSEMINATION The study has been approved by the Ethical Board of IDIAP Jordi Gol (reference number: AC18/002). The findings of this trial will be disseminated through research conferences and peer-review journals. TRIAL REGISTRATION NUMBER NCT03738917; Pre-results.
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Affiliation(s)
- Josep M Cots
- Primary Healthcare Centre La Marina, Barcelona, Spain, Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Ana Moragas
- Primary Healthcare Centre Jaume I, Universitat Rovira i Virgili, Tarragona, Catalonia
| | - Ana García-Sangenís
- Medicines Research Unit, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Catalonia
- UICEC IDIAP Jordi Gol, Plataforma SCReN, Barcelona, Catalonia
| | - Rosa Morros
- Medicines Research Unit, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Catalonia
- Departament de Farmacologia i Terapèutica, Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, Barcelona, Catalonia
| | - Ainhoa Gomez-Lumbreras
- Medicines Research Unit, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Catalonia
| | - Dan Ouchi
- Institut Universitari d’Investigació en Atenció Primària (IDIAP) Jordi Gol, Barcelona, Catalonia
| | - Ramon Monfà
- Institut Universitari d’Investigació en Atenció Primària (IDIAP) Jordi Gol, Barcelona, Catalonia
| | - Helena Pera
- Medicines Research Unit, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Catalonia
- UICEC IDIAP Jordi Gol, Plataforma SCReN, Barcelona, Catalonia
| | | | | | | | - Carl Llor
- Primary Healthcare Centre Barcelona-2B (via Roma), Barcelona, Catalonia
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Radman M, Babic A, Runjic E, Jelicic Kadic A, Jeric M, Moja L, Puljak L. Revisiting established medicines: An overview of systematic reviews about ibuprofen and paracetamol for treating pain in children. Eur J Pain 2019; 23:1071-1082. [DOI: 10.1002/ejp.1380] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 02/01/2019] [Accepted: 02/17/2019] [Indexed: 12/15/2022]
Affiliation(s)
| | - Andrija Babic
- Institute of Emergency Medicine in Split‐Dalmatia County Split Croatia
| | - Edita Runjic
- Department of Pediatrics University Hospital Split Split Croatia
| | | | - Milka Jeric
- Department of Dermatovenerology General Hospital Zadar Zadar Croatia
| | - Lorenzo Moja
- Unit of Clinical Epidemiology IRCCS Istituto Ortopedico Galeazzi Milan Italy
- Department of Biomedical Sciences for Public Health Università degli Studi di Milano Milan Italy
| | - Livia Puljak
- Center for Evidence‐Based Medicine and Health Care Catholic University of Croatia Zagreb Croatia
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Vik I, Bollestad M, Grude N, Bærheim A, Damsgaard E, Neumark T, Bjerrum L, Cordoba G, Olsen IC, Lindbæk M. Ibuprofen versus pivmecillinam for uncomplicated urinary tract infection in women-A double-blind, randomized non-inferiority trial. PLoS Med 2018; 15:e1002569. [PMID: 29763434 PMCID: PMC5953442 DOI: 10.1371/journal.pmed.1002569] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 04/16/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Although uncomplicated urinary tract infections (UTIs) are often self-limiting, most patients will be prescribed antibiotic treatment. We assessed whether treatment with ibuprofen was non-inferior to pivmecillinam in achieving symptomatic resolution by day 4, with a non-inferiority margin of 10%. METHODS AND FINDINGS This was a randomized, controlled, double-blind non-inferiority trial. We recruited patients from 16 sites in a general practice setting in Norway, Sweden, and Denmark. Non-pregnant women aged 18-60 years presenting with symptoms of uncomplicated UTI were screened for eligibility from 11 April 2013 to 22 April 2016. Patients with informed consent were randomized (1:1 ratio) to treatment with either 600 mg ibuprofen or 200 mg pivmecillinam 3 times a day for 3 days. The patient, treating physician, and study personnel were blinded to treatment allocation. The primary outcome was the proportion of patients who felt cured by day 4, as assessed from a patient diary. Secondary outcomes included the proportion of patients in need of secondary treatment with antibiotics and cases of pyelonephritis. A total of 383 women were randomly assigned to treatment with either ibuprofen (n = 194, 181 analyzed) or pivmecillinam (n = 189, 178 analyzed). By day 4, 38.7% of the patients in the ibuprofen group felt cured versus 73.6% in the pivmecillinam group. The adjusted risk difference with 90% confidence interval was 35% (27% to 43%) in favor of pivmecillinam, which crossed the prespecified non-inferiority margin. Secondary endpoints were generally in favor of pivmecillinam. After 4 weeks' follow-up, 53% of patients in the ibuprofen group recovered without antibiotic treatment. Seven cases of pyelonephritis occurred, all in the ibuprofen group, giving a number needed to harm of 26 (95% CI 13 to 103). Five of these patients were hospitalized and classified as having serious adverse events; 2 recovered as outpatients. A limitation of the study was the extensive list of exclusion criteria, eliminating almost half of the patients screened. We did not register symptoms in the screening process; hence, we do not know the symptom burden for those who declined to participate. This might make our results less generalizable. CONCLUSIONS Ibuprofen was inferior to pivmecillinam for treating uncomplicated UTIs. More than half of the women in the ibuprofen group recovered without antibiotics. However, pyelonephritis occurred in 7 out of 181 women using ibuprofen. Until we can identify those women who will develop complications, we cannot recommend ibuprofen alone as initial treatment to women with uncomplicated UTIs. TRIAL REGISTRATION ClinicalTrials.gov NCT01849926 EU Clinical Trials Register (EU-CTR), EudraCT Number 2012-002776-14.
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Affiliation(s)
- Ingvild Vik
- Department of Emergency General Practice, Oslo Accident and Emergency Outpatient Clinic, Oslo, Norway
- Antibiotic Centre of Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
- * E-mail:
| | - Marianne Bollestad
- Antibiotic Centre of Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
- Division of Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Nils Grude
- Antibiotic Centre of Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Medical Microbiology, Vestfold Hospital Trust, Tønsberg, Norway
| | - Anders Bærheim
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Eivind Damsgaard
- Bergen Accident and Emergency Department, Bergen City Council, Bergen, Norway
| | - Thomas Neumark
- Primary Health Care and Planning Division, Kalmar County Council, Kalmar, Sweden
| | - Lars Bjerrum
- Section of General Practice and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Gloria Cordoba
- Section of General Practice and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | - Morten Lindbæk
- Antibiotic Centre of Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
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Little P, Stuart B, Wingrove Z, Mullee M, Thomas T, Johnson S, Leydon G, Richards-Hall S, Williamson I, Yao L, Zhu S, Moore M. Probiotic capsules and xylitol chewing gum to manage symptoms of pharyngitis: a randomized controlled factorial trial. CMAJ 2017; 189:E1543-E1550. [PMID: 29255098 DOI: 10.1503/cmaj.170599] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Reducing the use of antibiotics for upper respiratory tract infections is needed to limit the global threat of antibiotic resistance. We estimated the effectiveness of probiotics and xylitol for the management of pharyngitis. METHODS In this parallel-group factorial randomized controlled trial, participants in primary care (aged 3 years or older) with pharyngitis underwent randomization by nurses who provided sequential intervention packs. Pack contents for 3 kinds of material and advice were previously determined by computer-generated random numbers: no chewing gum, xylitol-based chewing gum (15% xylitol; 5 pieces daily) and sorbitol gum (5 pieces daily). Half of each group were also randomly assigned to receive either probiotic capsules (containing 24 × 109 colony-forming units of lactobacilli and bifidobacteria) or placebo. The primary outcome was mean self-reported severity of sore throat and difficulty swallowing (scale 0-6) in the first 3 days. We used multiple imputation to avoid the assumption that data were missing completely at random. RESULTS A total of 1009 individuals consented, 934 completed the baseline assessment, and 689 provided complete data for the primary outcome. Probiotics were not effective in reducing the severity of symptoms: mean severity scores 2.75 with no probiotic and 2.78 with probiotic (adjusted difference -0.001, 95% confidence interval [CI] -0.24 to 0.24). Chewing gum was also ineffective: mean severity scores 2.73 without gum, 2.72 with sorbitol gum (adjusted difference 0.07, 95% CI -0.23 to 0.37) and 2.73 with xylitol gum (adjusted difference 0.01, 95% CI -0.29 to 0.30). None of the secondary outcomes differed significantly between groups, and no harms were reported. INTERPRETATION Neither probiotics nor advice to chew xylitol-based chewing gum was effective for managing pharyngitis. Trial registration: ISRCTN, no. ISRCTN51472596.
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Affiliation(s)
- Paul Little
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Beth Stuart
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Zoe Wingrove
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Mark Mullee
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Tammy Thomas
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Sophie Johnson
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Gerry Leydon
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Samantha Richards-Hall
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Ian Williamson
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Lily Yao
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Shihua Zhu
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
| | - Michael Moore
- Primary Care Group (Little, Stuart, Wingrove, Mullee, Thomas, Johnson, Leydon, Williamson, Moore); Health Economic Analyses Team (Yao, Zhu), Primary Care and Population Sciences Unit, University of Southampton; Patient and Public Involvement Collaborator (Richards-Hall), Southampton, UK
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McDermott L, Leydon GM, Halls A, Kelly J, Nagle A, White J, Little P. Qualitative interview study of antibiotics and self-management strategies for respiratory infections in primary care. BMJ Open 2017; 7:e016903. [PMID: 29180593 PMCID: PMC5719297 DOI: 10.1136/bmjopen-2017-016903] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To explore perceptions of illness, the decisions to consult and the acceptability of delayed antibiotic prescriptions and self-help treatments for respiratory tract infections (RTIs). DESIGN Qualitative semistructured interview study. SETTING UK primary care. PARTICIPANTS 20 adult patients who had been participating in the 'PIPS' (Pragmatic Ibuprofen Paracetamol and Steam) trial in the South of England. METHOD Semistructured telephone interviews were conducted with participants to explore their experiences and views on various treatments for RTI. RESULTS Participants had concerns about symptoms that were not clinically serious and were mostly unaware of the natural history of RTIs, but were aware of the limitations of antibiotics and did not expect them with every consultation. Most viewed delayed prescriptions positively and had no strong preference over which technique is used to deliver the delayed antibiotic, but some patients received mixed messages, such as being told their infection was viral then being given an antibiotic, or were sceptical about the rationale. Participants disliked self-help treatments that involved taking medication and were particularly concerned about painkillers in combination. Steam inhalation was viewed as only moderately helpful for mild symptoms. CONCLUSION Delayed prescribing is acceptable no matter how the delay is operationalised, but explanation of the rationale is needed and care taken to minimise mixed messages about the severity of illnesses and causation by viruses or bacteria. Better access is needed to good natural history information, and the signs and symptoms requiring or not requiring general practitioner advice. Significant concerns about paracetamol, ibuprofen and steam inhalation are likely to need careful exploration in the consultation.
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Affiliation(s)
- Lisa McDermott
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Geraldine M Leydon
- Department of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Amy Halls
- Department of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Jo Kelly
- Department of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Amanda Nagle
- Department of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Jennifer White
- Department of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Paul Little
- Department of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
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Kronenberg A, Bütikofer L, Odutayo A, Mühlemann K, da Costa BR, Battaglia M, Meli DN, Frey P, Limacher A, Reichenbach S, Jüni P. Symptomatic treatment of uncomplicated lower urinary tract infections in the ambulatory setting: randomised, double blind trial. BMJ 2017; 359:j4784. [PMID: 29113968 PMCID: PMC5672899 DOI: 10.1136/bmj.j4784] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective To investigate whether symptomatic treatment with non-steroidal anti-inflammatory drugs (NSAIDs) is non-inferior to antibiotics in the treatment of uncomplicated lower urinary tract infection (UTI) in women, thus offering an opportunity to reduce antibiotic use in ambulatory care.Design Randomised, double blind, non-inferiority trial.Setting 17 general practices in Switzerland.Participants 253 women with uncomplicated lower UTI were randomly assigned 1:1 to symptomatic treatment with the NSAID diclofenac (n=133) or antibiotic treatment with norfloxacin (n=120). The randomisation sequence was computer generated, stratified by practice, blocked, and concealed using sealed, sequentially numbered drug containers.Main outcome measures The primary outcome was resolution of symptoms at day 3 (72 hours after randomisation and 12 hours after intake of the last study drug). The prespecified principal secondary outcome was the use of any antibiotic (including norfloxacin and fosfomycin as trial drugs) up to day 30. Analysis was by intention to treat.Results 72/133 (54%) women assigned to diclofenac and 96/120 (80%) assigned to norfloxacin experienced symptom resolution at day 3 (risk difference 27%, 95% confidence interval 15% to 38%, P=0.98 for non-inferiority, P<0.001 for superiority). The median time until resolution of symptoms was four days in the diclofenac group and two days in the norfloxacin group. A total of 82 (62%) women in the diclofenac group and 118 (98%) in the norfloxacin group used antibiotics up to day 30 (risk difference 37%, 28% to 46%, P<0.001 for superiority). Six women in the diclofenac group (5%) but none in the norfloxacin group received a clinical diagnosis of pyelonephritis (P=0.03).Conclusion Diclofenac is inferior to norfloxacin for symptom relief of UTI and is likely to be associated with an increased risk of pyelonephritis, even though it reduces antibiotic use in women with uncomplicated lower UTI.Trial registration ClinicalTrials.gov NCT01039545.
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Affiliation(s)
- Andreas Kronenberg
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
- Medix General Practice Network, Bern, Switzerland
| | - Lukas Bütikofer
- CTU Bern, University of Bern, Bern, Switzerland
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Ayodele Odutayo
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Canada
| | - Kathrin Mühlemann
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Bruno R da Costa
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Canada
- Institute of Primary Health Care, University of Bern, Bern, Switzerland
| | | | - Damian N Meli
- Medix General Practice Network, Bern, Switzerland
- Institute of Primary Health Care, University of Bern, Bern, Switzerland
| | - Peter Frey
- Institute of Primary Health Care, University of Bern, Bern, Switzerland
| | - Andreas Limacher
- CTU Bern, University of Bern, Bern, Switzerland
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Stephan Reichenbach
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Department of Rheumatology, Immunology and Allergology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Canada
- Institute of Primary Health Care, University of Bern, Bern, Switzerland
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Zuidgeest MG, Welsing PM, van Thiel GJ, Ciaglia A, Alfonso-Cristancho R, Eckert L, Eijkemans MJ, Egger M. Series: Pragmatic trials and real world evidence: Paper 5. Usual care and real life comparators. J Clin Epidemiol 2017; 90:92-98. [DOI: 10.1016/j.jclinepi.2017.07.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 05/11/2017] [Accepted: 07/03/2017] [Indexed: 11/28/2022]
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Moore M, Stuart B, Hobbs FR, Butler CC, Hay AD, Campbell J, Delaney BC, Broomfield S, Barratt P, Hood K, Everitt HA, Mullee M, Williamson I, Mant D, Little P. Symptom response to antibiotic prescribing strategies in acute sore throat in adults: the DESCARTE prospective cohort study in UK general practice. Br J Gen Pract 2017; 67:e634-e642. [PMID: 28808075 PMCID: PMC5569743 DOI: 10.3399/bjgp17x692321] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/15/2017] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND A delayed or 'just in case' prescription has been identified as having potential to reduce antibiotic use in sore throat. AIM To determine the symptomatic outcome of acute sore throat in adults according to antibiotic prescription strategy in routine care. DESIGN AND SETTING A secondary analysis of the DESCARTE (Decision rule for the Symptoms and Complications of Acute Red Throat in Everyday practice) prospective cohort study comprising adults aged ≥16 years presenting with acute sore throat (≤2 weeks' duration) managed with treatment as usual in primary care in the UK. METHOD A random sample of 2876 people from the full cohort were requested to complete a symptom diary. A brief clinical proforma was used to collect symptom severity and examination findings at presentation. Outcome details were collected by notes review and a detailed symptom diary. The primary outcome was poorer 'global' symptom control (defined as longer than the median duration or higher than median symptom severity). Analyses controlled for confounding by indication (propensity to prescribe antibiotics). RESULTS A total of 1629/2876 (57%) of those requested returned a symptom diary, of whom 1512 had information on prescribing strategy. The proportion with poorer global symptom control was greater in those not prescribed antibiotics 398/587 (68%) compared with those prescribed immediate antibiotics 441/728 (61%) or delayed antibiotic prescription 116/197 59%); adjusted risk ratio (RR) (95% confidence intervals [CI]): immediate RR 0.87 (95% CI = 0.70 to 0.96), P = 0.006; delayed RR 0.88 (95% CI = 0.78 to 1.00), P = 0.042. CONCLUSION In the routine care of adults with sore throat, a delayed antibiotic strategy confers similar symptomatic benefits to immediate antibiotics compared with no antibiotics. If a decision is made to prescribe an antibiotic, a delayed antibiotic strategy is likely to yield similar symptomatic benefit to immediate antibiotics.
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Affiliation(s)
- Michael Moore
- Primary Care and Population Sciences Division, University of Southampton
| | - Beth Stuart
- Primary Care and Population Sciences Division, University of Southampton
| | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford
| | - Chris C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford
| | - Alastair D Hay
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol
| | | | - Brendan C Delaney
- Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London
| | - Sue Broomfield
- Primary Care and Population Sciences Division, University of Southampton
| | - Paula Barratt
- Primary Care and Population Sciences Division, University of Southampton
| | - Kerenza Hood
- Centre for trials research, South East Wales Trials Unit, Institute of Primary Care and Public Health, School of Medicine, Cardiff University
| | - Hazel A Everitt
- Primary Care and Population Sciences Division, University of Southampton
| | - Mark Mullee
- Primary Care and Population Sciences Division, University of Southampton
| | - Ian Williamson
- Primary Care and Population Sciences Division, University of Southampton
| | - David Mant
- Nuffield Department of Primary Care Health Sciences, University of Oxford
| | - Paul Little
- Primary Care and Population Sciences Division, University of Southampton
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Influence of the duration of penicillin prescriptions on outcomes for acute sore throat in adults: the DESCARTE prospective cohort study in UK general practice. Br J Gen Pract 2017; 67:e623-e633. [PMID: 28808076 DOI: 10.3399/bjgp17x692333] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/15/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Guidelines recommend 10-day treatment courses for acute sore throat, but shorter courses may be used in practice. AIM To determine whether antibiotic duration predicts adverse outcome of acute sore throat in adults in routine care. DESIGN AND SETTING A secondary analysis of the DESCARTE (Decision rule for the Symptoms and Complications of Acute Red Throat in Everyday practice) prospective cohort study of 12 829 adults presenting in UK general practice with acute sore throat. METHOD A brief clinical proforma was used to collect symptom severity and examination findings at presentation. Outcomes were collected by notes review, a sample also completed a symptom diary. The primary outcome was re-consultation with new/non-resolving symptoms within 1 month. The secondary outcome was 'global' poorer symptom control (longer than the median duration or higher than median severity). RESULTS Antibiotics were prescribed for 62% (7872/12 677) of participants. The most commonly prescribed antibiotic was phenoxymethylpenicillin (76%, 5656/7474) and prescription durations were largely for 5 (20%), 7 (57%), or 10 (22%) days. Compared with 5-day courses, those receiving longer courses were less likely to re-consult with new or non-resolving symptoms (5 days 15.3%, 7 days 13.9%, 10 days 12.2%, 7-day course adjusted risk ratio (RR) 0.92 [95% confidence interval [CI] = 0.76 to 1.11] and 10-days RR 0.86 [95% CI = 0.59 to 1.23]) but these differences did not reach statistical significance. CONCLUSION In adults prescribed antibiotics for sore throat, the authors cannot rule out a small advantage in terms of reduced re-consultation for a 10-day course of penicillin, but the effect is likely to be small.
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Management of respiratory tract infections in young children-A qualitative study of primary care providers' perspectives. NPJ Prim Care Respir Med 2017; 27:15. [PMID: 28258279 PMCID: PMC5434780 DOI: 10.1038/s41533-017-0018-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 02/01/2017] [Accepted: 02/10/2017] [Indexed: 11/24/2022] Open
Abstract
Respiratory tract infections in young children are the most common cause of general practice visits in Australia. Despite the availability of clinical practice guidelines, the treatment and management of respiratory tract infections in young children is inconsistent. The aim of the study was to explore the management of respiratory tract infections in young children from a multi-disciplinary perspective using across-sectional qualitative research design based on the theoretical domains framework and the Capability, Opportunity and Motivation-B model. In-depth interviews were conducted with 30 primary care providers to explore their knowledge, views and management of respiratory tract infections in young children. Interviews focused on symptomatic management, over-the-counter medications and antibiotic use, and data were thematically analysed. Our findings showed that factors such as primary care providers’ time constraints, parental anxiety, general practitioners’ perception of what parents want, perceived parental pressure, and fear of losing patients were some of the reasons why primary care providers did not always adhere to guideline recommendations. Primary care providers also provided conflicting advice to parents concerning over-the-counter medications and when children should resume normal activities. Overall, this study showed that complex interactions involving emotional and psychological factors influenced the decision making process of primary care providers’ management of respiratory tract infections in young children. A team care approach with consistent advice, and improved communication between primary care providers and parents is vital to overcome some of these barriers and improve guideline adherence. The findings of this research will inform the development of interventions to better manage respiratory tract infections in young children. The emotions and psychology of both parents and clinicians influence how respiratory tract infections (RTIs) are managed in young children. Researchers in Australia, led by Ruby Biezen from Monash University, interviewed 30 primary care clinicians about their views on how to care for children with RTIs, such as the common cold. The interviews focused on symptomatic management, over-the-counter medications and antibiotic use. Despite the availability of best-practice guidelines, clinicians did not always follow the recommendations owing to factors such as time constraints, parental anxiety, perceived parental pressure, and fear of losing patients. These are some of the reasons why clinicians sometimes advise or prescribe unnecessary medications. The authors suggest that a team approach involving multiple healthcare professionals who deliver consistent advice could improve guideline adherence.
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Affiliation(s)
- Paul Little
- University of Southampton Southampton, United Kingdom
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