Effective and evidence-based management strategies for rosacea: summary of a Cochrane systematic review.

Rosacea is a common chronic skin disease affecting the face. There are numerous treatment options, but it is unclear which are the most effective. The aim of this review was to assess the evidence for the efficacy and safety of treatments for rosacea. Searches included the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index, and Ongoing Trials Registers (updated February 2011). Randomized controlled trials in people with moderate to severe rosacea were included. Fifty-eight trials, including 27 from the original review, comprising 6633 participants were included in this updated review. Interventions included topical metronidazole, oral antibiotics, topical azelaic cream or gel, topical benzoyl peroxide and/or combined with topical antibiotics, sulphacetamide/sulphur, and others. There was some evidence that topical metronidazole and azelaic acid were more effective than placebo. Two trials indicated that doxycycline 40mg was more effective than placebo. There was no statistically significant difference in effectiveness between doxycycline 40mg and 100mg but there were fewer adverse effects. One study reported that ciclosporin ophthalmic emulsion was significantly more effective than artificial tears for treating ocular rosacea. Although the majority of included studies were assessed as being at high or unclear risk of bias, there was some evidence to support the effectiveness of topical metronidazole, azelaic acid and doxycycline (40mg) in the treatment of moderate to severe rosacea, and ciclosporin 0·05% ophthalmic emulsion for ocular rosacea. Further well-designed, adequately powered randomized controlled trials are required.

Interventions for rosacea.

BACKGROUND: Rosacea is a common chronic skin condition affecting the face, characterised by flushing, redness, pimples, pustules, and dilated blood vessels. The eyes are often involved. Frequently it can be controlled, but it is not clear which treatments are most effective. OBJECTIVES: To assess the evidence for the efficacy and safety of treatments for rosacea. SEARCH STRATEGY: We searched the Skin Group Specialised Register (February 2005), Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to February 2005), EMBASE (1980 to February 2005), BIOSIS (1970 to March 2002) and the Science Citation Index (1988 to February 2005). Reference lists of trials and key review articles were searched. Relevant manufacturers and experts were contacted. SELECTION CRITERIA: Randomised controlled trials in people with moderate to severe rosacea were included. Studies judged by the authors to have seriously flawed methodology were excluded. DATA COLLECTION AND ANALYSIS: Study selection, assessment of methodological quality, data extraction and analysis were carried out by two independent authors. Disagreements were resolved by discussion and consensus. MAIN RESULTS: The evidence provided by twenty-nine included studies was generally weak because of poor methodology and reporting. One of our primary outcome measures, 'quality of life', was not assessed in any of the studies. Only two studies of ocular rosacea were included. Pooled data from two trials involving 174 participants indicated that according to the participants, topical metronidazole is more effective than placebo (odds ratio (OR) 5.96, 95% confidence interval (CI) 2.95 to 12.06). Data pooled from three between-patient trials showed a clear improvement in the azelaic acid group; the rates of treatment success were approximately 70 to 80% versus 50% to 55% (OR 2.45, 95% CI 1.82 to 3.28). A within-patient trial of azelaic cream versus placebo could not be pooled with the other three studies, but also showed good evidence of efficacy. Data pooled from three studies of oral tetracycline versus placebo involving 152 participants showed that, according to physicians, tetracycline was effective (OR 6.06, 95% CI 2.96 to 12.42). Some evidence of efficacy of oral metronidazole was provided by one small study. AUTHORS' CONCLUSIONS: The quality of studies evaluating rosacea treatments was generally poor. There is evidence that topical metronidazole and azelaic acid are effective. There is some evidence that oral metronidazole and tetracycline are effective. There is insufficient evidence concerning the effectiveness of other treatments. Good RCTs looking at these treatments are urgently needed.

Interventions for rosacea.

BACKGROUND: Rosacea is a common skin condition affecting the face, characterised by flushing, redness, pimples, pustules and dilated blood vessels. The eyes are often also involved. The cause of rosacea is unclear. It is a chronic disease, which can be controlled in most cases with appropriate treatment. Numerous treatments are in use although it is unclear which are best, and which are most appropriate for the different types of rosacea. OBJECTIVES: To assess and summarise current evidence for the efficacy and safety of treatments for rosacea. SEARCH STRATEGY: We searched the Skin Group Specialised Trials Register (March 2002), Cochrane Central Register of Controlled Trials (CENTRAL, March 2002), MEDLINE (from 1966 to March 2002), EMBASE (from 1980 to March 2002), Biosis (from 1970 to March 2002) and the Science Citation Index (from 1988 to March 2002). Reference lists of trials and key review articles were also searched. Relevant manufacturers and experts were contacted. SELECTION CRITERIA: Randomised controlled trials in people with moderate to severe rosacea were included. Studies judged by the reviewers to have seriously flawed methodology were excluded. DATA COLLECTION AND ANALYSIS: Study selection, assessment of methodological quality, data extraction and analysis were carried out by two independent reviewers. MAIN RESULTS: The evidence provided by twenty-two included studies was generally weak because of poor methodology and reporting. One of our primary outcome measures, 'quality of life', was not assessed in any of the studies. Only two studies of ocular rosacea could be included. Pooled data from two trials involving 174 participants indicated that topical metronidazole is more effective than placebo (odds ratio 5.96, 95% confidence interval 2.95 to 12.06). Data from a between-patient trial (114 patients) and a within-patient trial (33 patients) of azelaic cream versus placebo were not pooled, but both showed good evidence of efficacy. Data pooled from three studies of oral tetracycline versus placebo involving 152 participants showed that, according to physicians' ratings, tetracycline was effective (odds ratio 6.06, 95% confidence interval 2.96 to 12.42). Some evidence of efficacy of oral metronidazole was provided by one small study. REVIEWER'S CONCLUSIONS: The quality of studies evaluating rosacea treatments was generally poor. There is evidence that topical metronidazole and azelaic acid cream have a therapeutic effect. There is some evidence that oral metronidazole and tetracycline are effective. There is insufficient evidence concerning the effectiveness of other treatments. As many of these treatments are used for rosacea, good RCTs are urgently needed.

How well does decision support software perform in the emergency department?

OBJECTIVE: To determine how well general decision support systems perform given the data collected in an emergency department (ED). METHODS: A convenience sample of 25 patients was selected from those patients having a diagnostic question on presentation to the ED. All interactions with the patients were audiotaped and abstracted into a structured data form. All other data such as written notes, laboratory, and EKG results were also abstracted. All data were entered into two general diagnostic decision support programs (Quick Medical Reference (QMR Version 3.82, Knowledge Base 10-07-1998 Copyright University of Pittsburgh and The Hearst Corporation) and Iliad (Version 4.5 Copyright 1996 Applied Medical Informatics)). The diagnoses generated by the computer programs were compared with the final diagnoses of the ED attending. RESULTS: The final ED diagnosis was found in the differential diagnosis generated by Iliad and QMR 72% and 52% of the time respectively. The final ED diagnosis was found in the top 10 diagnoses 51% and 44% of the time and in the top five diagnoses 36% and 32% of the time for each program respectively. This approximates to the performance of these programs in other clinical settings. CONCLUSIONS: Diagnostic decision support software has the same success in finding the "correct" diagnosis in the ED as in other clinical settings where more extensive clinical data are available. The accuracy is not sufficiently high to permit the use of these programs as an arbiter in any individual case. However, they may be useful, prompting additional investigation in particularly difficult cases.

Usage analysis of a primary care medical resource on the Internet.

Physicians and patients need convenient access to quality medical information. This study's goal was to place a medical resource on the World-Wide Web (WWW), allow access to it through a simple to use interface, and analyze the usage of such a resource. The Family Practice Handbook (TFPH) was digitized and placed onto the WWW. Usage data was obtained from June 1995-June 1996. 118,804 individuals accessed TFPH viewing 409,711 pages of information. A broad spectrum of topics was accessed. TFPH proved to be an extremely popular resource, servicing the broad information needs of an international audience. These preliminary findings suggest the future promise of Internet medical resources.

Respiratory syncytial virus infection in infants and young children.

Respiratory syncytial virus (RSV) is the most common cause of lower respiratory tract infections in infants and young children. Epidemics occur yearly from December to March or April, leading to 100,000 hospitalizations in the United States at an estimated cost of $300 million. Physical examination findings may include clear coryza, evidence of respiratory distress, wheezing, and dehydration. Complications include apnea. Mortality runs as high as 0.5% to 1.5% in hospitalized patients. Diagnosis is based on clinical presentation, seasonal pattern, and microbiologic testing. Therapy remains largely supportive. The preponderance of evidence argues for the use of bronchodilators, especially epinephrine or albuterol, in the treatment of acute bronchiolitis. Steroids do not seem to confer any advantage. Ribavirin is expensive and should be used very selectively in infants at high risk for serious RSV disease. These infants may benefit from prophylaxis with RSV immune globulin.

Using the World Wide Web to answer clinical questions: how efficient are different methods of information retrieval?

BACKGROUND: The World Wide Web (Web) has the potential to revolutionize information retrieval in medicine. However, the best method of information retrieval from the Web is not known. The purpose of our study was to compare medical search engines, general-purpose search engines, medical meta-lists, and commercial sites on the Web with regard to their efficiency in retrieving medical information. METHODS: Ten questions were identified from a database of questions posed by primary care clinicians. Authoritative answers were identified. Searches were performed using 1 commercial site, 4 general search engines, 9 medicine-specific search engines, and 2 medical meta-lists. The main outcome measures were the number of questions answered by each Web site, the correctness of the answers, the number of links followed to get an answer, and how well documented the answer was using the Health on the Net criteria. RESULTS: MD Consult, a commercial site, answered 6 of 10 questions. Hardin MD (a meta-list) and Excite and HotBot (general search engines) each answered 5 questions. The medicine-specific search engines performed poorly, answering an average of only 1 question. MD Consult and HotBot required the least number of links to find an answer. MD Consult and Hardin MD had the best documented answers. CONCLUSIONS: Medicine-specific search engines on the Web fare poorly in answering clinical questions when compared with general search engines. MD Consult, Excite, HotBot, and Hardin MD found the greatest number of answers.

Readability levels of patient education material on the World Wide Web.

BACKGROUND: Patient education is an important component of family practice. Pamphlets, verbal instructions, and physicians' self-created materials have been the most common resources for patient education. Today, however, the popularity of the World Wide Web (Web) as a ready source of educational materials is increasing. The reading skills required by a patient to understand that information has not been determined. The objective of our study was to assess the readability of medical information on the Web that is specifically intended for patients. METHODS: An investigator downloaded 50 sequential samples of patient education material from the Web. This information was then evaluated for readability using the Flesch reading score and Flesch-Kinkaid reading level. RESULTS: On average, the patient information from the Web in our sample is written at a 10th grade, 2nd month reading level. Previous studies have shown that this readability level is not comprehensible to the majority of patients. CONCLUSIONS: Much of the medical information targeted for the general public on the Web is written at a reading level higher than is easily understood by much of the patient population.

Diagnosing left lower lobe pneumonia: usefulness of the 'spine sign' on lateral chest radiographs.

BACKGROUND: Left lower lobe pneumonia may be obscured by the heart on the postero-anterior (PA) chest radiograph. In such cases, the lateral projection may be helpful, especially if it exhibits the "spine sign", which is an interruption in the progressive increase in lucency of the vertebral bodies from superior to inferior. We investigated whether the spine sign would help family physicians diagnose left lower lobe pneumonia on chest radiographs. METHODS: We selected the chest radiographs of all patients with left lower lobe pneumonia who were seen between 1983 and 1995 at a family practice training program (N = 78) and an equal number of chest radiographs of patients without pneumonia. Six family physicians read these radiographs under two viewing conditions: PA only vs PA and lateral. We used receiver operating characteristic (ROC) curve methodology to compare the two viewing conditions. RESULTS: There was no significant difference in performance between the two viewing conditions. The lateral view was helpful in some patients but misleading in others. Among patients with pneumonia, the lateral view was helpful when the spine sign was present, but it was misleading when the spine sign was absent. CONCLUSIONS: In this study of family physicians, the lateral chest radiograph did not improve overall diagnostic accuracy in patients with left lower lobe pneumonia. Among pneumonia patients with the spine sign, however, the lateral view was often helpful.

Autonomy, consent, and limiting healthcare costs.

While protection of autonomy is crucial to the practice of medicine, there is the persistent risk of a disconnect between the notion of self-determination and the need for a socially responsible medical system. An example of unbridled autonomy is the preferential use of costly medications without an appreciation of the impact of using these more expensive drugs on the resource pool of others. In the USA, costly medications of questionable incremental benefit are frequently prescribed with the complicity of both doctors and patients. Limiting self-determination in medication choices via an appreciation of the principle of justice reaches a better moral balance, while at the same time acknowledging the goals of doing good and avoiding harm in patient care.

Polyglandular autoimmune syndrome: a cause of multiple and sequential endocrine emergencies.

The polyglandular autoimmune syndromes are a rare, inherited constellation of disorders characterized by multiple endocrine end-organ failures. Since these individuals have more than one endocrine failure, it is important to recognize these syndromes in clinical practice and be alert to the possibility of a second major endocrine organ failure after one has been diagnosed.

Kalkipyrone, a toxic gamma-pyrone from an assemblage of the marine cyanobacteria Lyngbya majuscula and Tolypothrix sp.

Kalkipyrone, a novel alpha-methoxy-beta,beta'-dimethyl-gamma-pyrone possessing an alkyl side chain, was isolated from an assemblage of the marine cyanobacteria Lyngbyamajuscula and Tolypothrix sp. Its structure, including stereochemistry, was determined by NMR, UV, and IR analysis and by GC-MS of the natural product and key derivatives. Kalkipyrone is toxic to brine shrimp (LD50 1 microg/mL) and gold fish (LD50 2 microg/mL) and is structurally related to the actinopyrones that were previously isolated from Streptomyces spp.

Methylxanthine use in anaphylaxis: what does the evidence tell us?

OBJECTIVE: To review the literature examining the use of methylxanthines in the treatment of anaphylaxis. DATA SOURCES: A MEDLINE search (January 1966-December 1998) was performed using the terms aminophylline, theophylline, and anaphylaxis. STUDY SELECTION AND DATA EXTRACTION: Articles discussing methylxanthine use in anaphylaxis were independently examined by each author. Additional information was obtained through the references of these articles. Articles not written in English were excluded. DATA SYNTHESIS: No human studies were identified. Limited published data were found in animal models of anaphylaxis. CONCLUSIONS: Safer agents with proven efficacy exist for the treatment of bronchoconstriction in anaphylaxis. Until data are available in humans, methylxanthines should not be recommended in the treatment of anaphylactic reactions.

Cervical spine radiographs in the trauma patient.

Significant cervical spine injury is very unlikely in a case of trauma if the patient has normal mental status (including no drug or alcohol use) and no neck pain, no tenderness on neck palpation, no neurologic signs or symptoms referable to the neck (such as numbness or weakness in the extremities), no other distracting injury and no history of loss of consciousness. Views required to radiographically exclude a cervical spine fracture include a posteroanterior view, a lateral view and an odontoid view. The lateral view must include all seven cervical vertebrae as well as the C7-T1 interspace, allowing visualization of the alignment of C7 and T1. The most common reason for a missed cervical spine injury is a cervical spine radiographic series that is technically inadequate. The "SCIWORA" syndrome (spinal cord injury without radiographic abnormality) is common in children. Once an injury to the spinal cord is diagnosed, methylprednisolone should be administered as soon as possible in an attempt to limit neurologic injury.