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Neuraminidase inhibitors slightly beneficial for shortening flu symptoms
Oseltamivir (Tamiflu) and zanamivir (Relenza) are effective for reducing the duration of symptoms of influenza by about 1 day when given to healthy individuals aged <65 years, and if given early in the course of the disease. Benefit to individuals aged >65 years and those with chronic medical conditions were not established.
Important outcomes, such as prevention of death and hospitalization due to influenza, were not discussed. No head-to-head trials were included, and these drugs could be considered interchangeable. Patients in the studies had laboratory confirmation of influenza, something that is not always done in general practice.
Given that these drugs are expensive (about $60 for a typical course), routine use for all flu patients may not be cost-effective. Rather, balancing the cost of treatment against risks and benefits need to be individualized. Use of these drugs should not replace primary prevention strategies.
Oseltamivir (Tamiflu) and zanamivir (Relenza) are effective for reducing the duration of symptoms of influenza by about 1 day when given to healthy individuals aged <65 years, and if given early in the course of the disease. Benefit to individuals aged >65 years and those with chronic medical conditions were not established.
Important outcomes, such as prevention of death and hospitalization due to influenza, were not discussed. No head-to-head trials were included, and these drugs could be considered interchangeable. Patients in the studies had laboratory confirmation of influenza, something that is not always done in general practice.
Given that these drugs are expensive (about $60 for a typical course), routine use for all flu patients may not be cost-effective. Rather, balancing the cost of treatment against risks and benefits need to be individualized. Use of these drugs should not replace primary prevention strategies.
Oseltamivir (Tamiflu) and zanamivir (Relenza) are effective for reducing the duration of symptoms of influenza by about 1 day when given to healthy individuals aged <65 years, and if given early in the course of the disease. Benefit to individuals aged >65 years and those with chronic medical conditions were not established.
Important outcomes, such as prevention of death and hospitalization due to influenza, were not discussed. No head-to-head trials were included, and these drugs could be considered interchangeable. Patients in the studies had laboratory confirmation of influenza, something that is not always done in general practice.
Given that these drugs are expensive (about $60 for a typical course), routine use for all flu patients may not be cost-effective. Rather, balancing the cost of treatment against risks and benefits need to be individualized. Use of these drugs should not replace primary prevention strategies.
Revascularization not superior to conservative treatment of acute coronary syndromes
ABSTRACT
BACKGROUND: Current guidelines suggest treating acute coronary syndromes (unstable angina, non-Q-wave myocardial infarction) with either coronary angiography followed by revascularization or conservative treatment with symptom-driven angiography. The goal of this study was to determine which approach is superior.
POPULATION STUDIED: The investigators enrolled 1810 patients presenting with acute coronary syndromes. Patients were eligible for the study if they had suspected cardiac chest pain. They also had to have evidence of coronary artery disease with at least 1 of following indicators of an acute coronary syndrome: evidence of ischemia on electrocardiogram, pathological Q waves suggesting previous myocardial infarction, or angiographic evidence of coronary artery disease on previous angiography. Patients were excluded if they had evidence of evolving myocardial infarction, myocardial infarction within the previous month, percutaneous intervention during the preceding 12 months, or coronary bypass at any time.
STUDY DESIGN AND VALIDITY: This study was a randomized, multicenter controlled trial. Patients were randomized to receive either conservative treatment with antianginal and antithrombotic treatment (n=915) or immediate intervention with catheterization and further intervention at the discretion of the treating cardiologist (n=895). The conservative treatment group received antianginal treatment, antithrombotic medications (aspirin and enoxaparin), and beta-blockers if not contraindicated. Additional treatments with glycoprotein IIb/IIIa inhibitors or other antiplatelet therapy were left to the discretion of the treating physician. The intervention group also received antianginal therapy and antithrombotic agents, but also received cardiac angiograms within 72 hours of presentation. Based on the findings at catheterization, additional intervention was left to the discretion of the treating cardiologist (stents, angioplasty, bypass, or medical management). Patient status was monitored for a median follow-up period of 2 years.
OUTCOMES MEASURED: The primary outcomes measured were combined rate of death, myocardial infarction, or refractory angina.
RESULTS: Of the 915 patients initially assigned to conservative treatment, 142 went on to have angiograms due to persistent symptoms. Ninety-two of these patients underwent angioplasty. Of patients in the intervention group, 311 had angioplasty, 184 had bypass surgery, and 388 were not deemed to need any surgical intervention and were treated medically. No difference was noted between the groups in overall mortality (approximately 11% in either group) or subsequent acute myocardial infarction. Patients in the intervention group were less likely to have refractory angina within 4 months (4.3% vs 9.3%, NNT=20) and within 1 year (6.5% vs 11.6%, NNT=20).
Conservative treatment was nearly as effective as immediate catheterization and surgical intervention in patients presenting with acute coronary syndrome. No difference was noted in the risk of death or myocardial infarction in either group. Patients were less likely to experience refractory angina when evaluated at 4 months and after 1 year when treated aggressively (numbers needed to treat [NNT]=20). Saving 1 readmission for refractory angina at the cost of performing 19 interventions that have no effect on the patient may not be reasonable.
ABSTRACT
BACKGROUND: Current guidelines suggest treating acute coronary syndromes (unstable angina, non-Q-wave myocardial infarction) with either coronary angiography followed by revascularization or conservative treatment with symptom-driven angiography. The goal of this study was to determine which approach is superior.
POPULATION STUDIED: The investigators enrolled 1810 patients presenting with acute coronary syndromes. Patients were eligible for the study if they had suspected cardiac chest pain. They also had to have evidence of coronary artery disease with at least 1 of following indicators of an acute coronary syndrome: evidence of ischemia on electrocardiogram, pathological Q waves suggesting previous myocardial infarction, or angiographic evidence of coronary artery disease on previous angiography. Patients were excluded if they had evidence of evolving myocardial infarction, myocardial infarction within the previous month, percutaneous intervention during the preceding 12 months, or coronary bypass at any time.
STUDY DESIGN AND VALIDITY: This study was a randomized, multicenter controlled trial. Patients were randomized to receive either conservative treatment with antianginal and antithrombotic treatment (n=915) or immediate intervention with catheterization and further intervention at the discretion of the treating cardiologist (n=895). The conservative treatment group received antianginal treatment, antithrombotic medications (aspirin and enoxaparin), and beta-blockers if not contraindicated. Additional treatments with glycoprotein IIb/IIIa inhibitors or other antiplatelet therapy were left to the discretion of the treating physician. The intervention group also received antianginal therapy and antithrombotic agents, but also received cardiac angiograms within 72 hours of presentation. Based on the findings at catheterization, additional intervention was left to the discretion of the treating cardiologist (stents, angioplasty, bypass, or medical management). Patient status was monitored for a median follow-up period of 2 years.
OUTCOMES MEASURED: The primary outcomes measured were combined rate of death, myocardial infarction, or refractory angina.
RESULTS: Of the 915 patients initially assigned to conservative treatment, 142 went on to have angiograms due to persistent symptoms. Ninety-two of these patients underwent angioplasty. Of patients in the intervention group, 311 had angioplasty, 184 had bypass surgery, and 388 were not deemed to need any surgical intervention and were treated medically. No difference was noted between the groups in overall mortality (approximately 11% in either group) or subsequent acute myocardial infarction. Patients in the intervention group were less likely to have refractory angina within 4 months (4.3% vs 9.3%, NNT=20) and within 1 year (6.5% vs 11.6%, NNT=20).
Conservative treatment was nearly as effective as immediate catheterization and surgical intervention in patients presenting with acute coronary syndrome. No difference was noted in the risk of death or myocardial infarction in either group. Patients were less likely to experience refractory angina when evaluated at 4 months and after 1 year when treated aggressively (numbers needed to treat [NNT]=20). Saving 1 readmission for refractory angina at the cost of performing 19 interventions that have no effect on the patient may not be reasonable.
ABSTRACT
BACKGROUND: Current guidelines suggest treating acute coronary syndromes (unstable angina, non-Q-wave myocardial infarction) with either coronary angiography followed by revascularization or conservative treatment with symptom-driven angiography. The goal of this study was to determine which approach is superior.
POPULATION STUDIED: The investigators enrolled 1810 patients presenting with acute coronary syndromes. Patients were eligible for the study if they had suspected cardiac chest pain. They also had to have evidence of coronary artery disease with at least 1 of following indicators of an acute coronary syndrome: evidence of ischemia on electrocardiogram, pathological Q waves suggesting previous myocardial infarction, or angiographic evidence of coronary artery disease on previous angiography. Patients were excluded if they had evidence of evolving myocardial infarction, myocardial infarction within the previous month, percutaneous intervention during the preceding 12 months, or coronary bypass at any time.
STUDY DESIGN AND VALIDITY: This study was a randomized, multicenter controlled trial. Patients were randomized to receive either conservative treatment with antianginal and antithrombotic treatment (n=915) or immediate intervention with catheterization and further intervention at the discretion of the treating cardiologist (n=895). The conservative treatment group received antianginal treatment, antithrombotic medications (aspirin and enoxaparin), and beta-blockers if not contraindicated. Additional treatments with glycoprotein IIb/IIIa inhibitors or other antiplatelet therapy were left to the discretion of the treating physician. The intervention group also received antianginal therapy and antithrombotic agents, but also received cardiac angiograms within 72 hours of presentation. Based on the findings at catheterization, additional intervention was left to the discretion of the treating cardiologist (stents, angioplasty, bypass, or medical management). Patient status was monitored for a median follow-up period of 2 years.
OUTCOMES MEASURED: The primary outcomes measured were combined rate of death, myocardial infarction, or refractory angina.
RESULTS: Of the 915 patients initially assigned to conservative treatment, 142 went on to have angiograms due to persistent symptoms. Ninety-two of these patients underwent angioplasty. Of patients in the intervention group, 311 had angioplasty, 184 had bypass surgery, and 388 were not deemed to need any surgical intervention and were treated medically. No difference was noted between the groups in overall mortality (approximately 11% in either group) or subsequent acute myocardial infarction. Patients in the intervention group were less likely to have refractory angina within 4 months (4.3% vs 9.3%, NNT=20) and within 1 year (6.5% vs 11.6%, NNT=20).
Conservative treatment was nearly as effective as immediate catheterization and surgical intervention in patients presenting with acute coronary syndrome. No difference was noted in the risk of death or myocardial infarction in either group. Patients were less likely to experience refractory angina when evaluated at 4 months and after 1 year when treated aggressively (numbers needed to treat [NNT]=20). Saving 1 readmission for refractory angina at the cost of performing 19 interventions that have no effect on the patient may not be reasonable.
How useful is cognitive behavioral therapy (CBT) for the treatment of chronic insomnia?
BACKGROUND: Persistent primary insomnia is common (affecting up to 5% of the general population) and predicts both depression and increased health care use. Common treatments include sedative hypnotics and antidepressants, both of which have numerous side effects and often lead to a relapse once they are stopped. Behavioral treatments have shown more durable improvements but only address sleep onset problems. It is not known whether CBT, by addressing both sleep onset and sleep maintenance problems, can provide a better outcome.
POPULATION STUDIED: The study included 75 adults (aged 40-80 years) with a mean duration of symptoms of 14 years who were recruited by a single academic medical center primarily through newspaper ads. Multiple exclusion criteria included anyone meeting criteria for an Axis I psychiatric disorder (including major depression).
STUDY DESIGN AND VALIDITY: Patients were randomly assigned (uncertain allocation concealment) to a therapist offering CBT, relaxation training (RT), or placebo treatment (PT) on a weekly basis for 6 weeks (3-6 hours of total contact). Those in the CBT arm were educated to misconceptions about sleep requirements and the effects of aging, circadian rhythms, and sleep loss on sleep/wake functioning, followed by instructions to: (1) establish a standard wake-up time; (2) get out of bed during extended awakenings; (3) avoid sleep-incompatible behaviors in bed; and (4) eliminate daytime napping. They also received sleep prescriptions with weekly adjustments based on sleep efficiency. RT recipients received progressive muscle relaxation training and were encouraged to use these skills to help return to sleep on awakening. PT recipients received “quasi-desensitization treatment” involving imagined scenes of neutral activities to eliminate conditioned arousals. The subjects completed pretreatment assessment, 6 weeks of therapy, 2 weeks of post-treatment assessment, and a 6-month follow-up assessment.
OUTCOME MEASURED: The outcomes measured included objective (polysomnography) and subjective (sleep logs) evaluations of total sleep time, wake time after sleep onset (WASO), and sleep efficiency. Questionnaires were used to assess subjective insomnia symptoms, changes in perceived control over sleep, and mood disturbances.
RESULTS: Overall, CBT was superior to both RT and PT in treating chronic insomnia. CBT recipients reported a 54% reduction in WASO compared with 16% and 12% for RT and PT patients, respectively (P=.02). CBT also produced greater improvements in sleep efficiency and improved subjective insomnia symptoms. An objective increase in total sleep time measured by polysomnography in the CBT group (approximately 12 minutes) persisted through the 6-month follow-up period. The PT group showed a decrease in objective sleep time (approximately 9 minutes). Objective (polysomnographic) differences were less dramatic than those derived from the sleep log, although both favored CBT.
CBT is an effective method for treating chronic insomnia. Given the cost, side effects, and temporary benefits of pharmacologic interventions, these CBT methods deserve consideration as first-line therapy for chronic insomnia. Although chronic insomnia is predictive of depression and increased medical use, these endpoints were not specifically addressed. Since those patients were excluded, using CBT to improve insomnia in depressed patients may not be appropriate. Symptoms that might be a consequence of insomnia, such as daytime fatigue and poor job performance, were not studied. Although improvement of these symptoms with increased sleep might be expected, this remains to be proved.
BACKGROUND: Persistent primary insomnia is common (affecting up to 5% of the general population) and predicts both depression and increased health care use. Common treatments include sedative hypnotics and antidepressants, both of which have numerous side effects and often lead to a relapse once they are stopped. Behavioral treatments have shown more durable improvements but only address sleep onset problems. It is not known whether CBT, by addressing both sleep onset and sleep maintenance problems, can provide a better outcome.
POPULATION STUDIED: The study included 75 adults (aged 40-80 years) with a mean duration of symptoms of 14 years who were recruited by a single academic medical center primarily through newspaper ads. Multiple exclusion criteria included anyone meeting criteria for an Axis I psychiatric disorder (including major depression).
STUDY DESIGN AND VALIDITY: Patients were randomly assigned (uncertain allocation concealment) to a therapist offering CBT, relaxation training (RT), or placebo treatment (PT) on a weekly basis for 6 weeks (3-6 hours of total contact). Those in the CBT arm were educated to misconceptions about sleep requirements and the effects of aging, circadian rhythms, and sleep loss on sleep/wake functioning, followed by instructions to: (1) establish a standard wake-up time; (2) get out of bed during extended awakenings; (3) avoid sleep-incompatible behaviors in bed; and (4) eliminate daytime napping. They also received sleep prescriptions with weekly adjustments based on sleep efficiency. RT recipients received progressive muscle relaxation training and were encouraged to use these skills to help return to sleep on awakening. PT recipients received “quasi-desensitization treatment” involving imagined scenes of neutral activities to eliminate conditioned arousals. The subjects completed pretreatment assessment, 6 weeks of therapy, 2 weeks of post-treatment assessment, and a 6-month follow-up assessment.
OUTCOME MEASURED: The outcomes measured included objective (polysomnography) and subjective (sleep logs) evaluations of total sleep time, wake time after sleep onset (WASO), and sleep efficiency. Questionnaires were used to assess subjective insomnia symptoms, changes in perceived control over sleep, and mood disturbances.
RESULTS: Overall, CBT was superior to both RT and PT in treating chronic insomnia. CBT recipients reported a 54% reduction in WASO compared with 16% and 12% for RT and PT patients, respectively (P=.02). CBT also produced greater improvements in sleep efficiency and improved subjective insomnia symptoms. An objective increase in total sleep time measured by polysomnography in the CBT group (approximately 12 minutes) persisted through the 6-month follow-up period. The PT group showed a decrease in objective sleep time (approximately 9 minutes). Objective (polysomnographic) differences were less dramatic than those derived from the sleep log, although both favored CBT.
CBT is an effective method for treating chronic insomnia. Given the cost, side effects, and temporary benefits of pharmacologic interventions, these CBT methods deserve consideration as first-line therapy for chronic insomnia. Although chronic insomnia is predictive of depression and increased medical use, these endpoints were not specifically addressed. Since those patients were excluded, using CBT to improve insomnia in depressed patients may not be appropriate. Symptoms that might be a consequence of insomnia, such as daytime fatigue and poor job performance, were not studied. Although improvement of these symptoms with increased sleep might be expected, this remains to be proved.
BACKGROUND: Persistent primary insomnia is common (affecting up to 5% of the general population) and predicts both depression and increased health care use. Common treatments include sedative hypnotics and antidepressants, both of which have numerous side effects and often lead to a relapse once they are stopped. Behavioral treatments have shown more durable improvements but only address sleep onset problems. It is not known whether CBT, by addressing both sleep onset and sleep maintenance problems, can provide a better outcome.
POPULATION STUDIED: The study included 75 adults (aged 40-80 years) with a mean duration of symptoms of 14 years who were recruited by a single academic medical center primarily through newspaper ads. Multiple exclusion criteria included anyone meeting criteria for an Axis I psychiatric disorder (including major depression).
STUDY DESIGN AND VALIDITY: Patients were randomly assigned (uncertain allocation concealment) to a therapist offering CBT, relaxation training (RT), or placebo treatment (PT) on a weekly basis for 6 weeks (3-6 hours of total contact). Those in the CBT arm were educated to misconceptions about sleep requirements and the effects of aging, circadian rhythms, and sleep loss on sleep/wake functioning, followed by instructions to: (1) establish a standard wake-up time; (2) get out of bed during extended awakenings; (3) avoid sleep-incompatible behaviors in bed; and (4) eliminate daytime napping. They also received sleep prescriptions with weekly adjustments based on sleep efficiency. RT recipients received progressive muscle relaxation training and were encouraged to use these skills to help return to sleep on awakening. PT recipients received “quasi-desensitization treatment” involving imagined scenes of neutral activities to eliminate conditioned arousals. The subjects completed pretreatment assessment, 6 weeks of therapy, 2 weeks of post-treatment assessment, and a 6-month follow-up assessment.
OUTCOME MEASURED: The outcomes measured included objective (polysomnography) and subjective (sleep logs) evaluations of total sleep time, wake time after sleep onset (WASO), and sleep efficiency. Questionnaires were used to assess subjective insomnia symptoms, changes in perceived control over sleep, and mood disturbances.
RESULTS: Overall, CBT was superior to both RT and PT in treating chronic insomnia. CBT recipients reported a 54% reduction in WASO compared with 16% and 12% for RT and PT patients, respectively (P=.02). CBT also produced greater improvements in sleep efficiency and improved subjective insomnia symptoms. An objective increase in total sleep time measured by polysomnography in the CBT group (approximately 12 minutes) persisted through the 6-month follow-up period. The PT group showed a decrease in objective sleep time (approximately 9 minutes). Objective (polysomnographic) differences were less dramatic than those derived from the sleep log, although both favored CBT.
CBT is an effective method for treating chronic insomnia. Given the cost, side effects, and temporary benefits of pharmacologic interventions, these CBT methods deserve consideration as first-line therapy for chronic insomnia. Although chronic insomnia is predictive of depression and increased medical use, these endpoints were not specifically addressed. Since those patients were excluded, using CBT to improve insomnia in depressed patients may not be appropriate. Symptoms that might be a consequence of insomnia, such as daytime fatigue and poor job performance, were not studied. Although improvement of these symptoms with increased sleep might be expected, this remains to be proved.