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Medical Forum / Diseases and Disorders / Sinusitis / January 2008Chronic Sinus Problems Require Treatment (JAMA got it wrong)
http://www.consumeraffairs.com/news04/2007/12/sinus_treatment2.html or http://tinyurl.com/3dwrr7 I don't know the authors of the study, but if they are not idiots they are paid flunkies of the insurance industry. YOU'RE BACK!!!! I posted at least twice that people need to read the abstract: only 240 patients/4 years with flawed clincial criteria. (Each practice contributed one or less patient.The four arms studied 60 people.) The JAMA editorial blasted the study: poorly designed, underpowered, selection bias, and said it proved nothing, except they likely studied people with early URI's and --go figure--antibiotics and steroids weren't helpful in those situations. Duh. It was done in the UK--no idea if they're all in the pocket of pharma there, but bottom line, lousy study and the press misunderstood it--deliberately??--and ran the sensationalist headline. Glad you're back, we needed your cutting edge, scientific input. Hope all is well with you and your family. Judy > I don't know the authors of the study, but if they are not idiots they > are paid flunkies of the insurance industry. > YOU'RE BACK!!!! > I posted at least twice that people need to read the abstract: only > 240 patients/4 years with flawed clincial criteria. (Each practice > contributed one or less patient.The four arms studied 60 people.) > The JAMA editorial blasted the study: poorly designed, underpowered, > selection bias, and said it proved nothing, Where did he say that??? In the part of the editorial I saw, Dr. Lindbaek said this: “The study by Williamson et al has implications for clinicians who treat patients with acute sinusitis–like symptoms. This study reinforces the lack of benefit from antibiotics shown in a number of other studies that recruited patients based on clinical symptoms and findings. Most patients with acute purulent sinusitis recover without antibiotic treatment, as was also observed in a study that used sinus computed tomography scans as the diagnostic standard. But some patients with sinusitis are more ill than others with fever, malaise, and deteriorated general condition. These patients still are in need of antibiotics, although they are relatively uncommon in general practice. So far there is no reliable way to distinguish viral sinusitis from bacterial sinusitis in the general practice setting, and a point of care test that could single out patients who could benefit from antibiotic treatment is not available.” JAMA would never have accepted a paper for publication that "proved nothing." They just wouldn't publish it, not publish it and then attack it as worthless in an editorial.  SignatureSteven L. Email: sdlitvin@earthlinkNOSPAM.net Remove the NOSPAM before replying to me. Did you read when it was qualified as useful, with significant limitations: "....his study is a useful contribution to the evidence on the effect of antibiotics and topical steroids in treating sinusitis but has some limitations. First, an objective reference standard was not used. Patients were included who had at least 2 of 4 Berg and Carenfeldt criteria,11 which have not been validated in a primary care setting. Second, the positive likelihood ratio of 6.75 is fairly high, but depends on a high pretest probability of patients with purulent sinusitis. With a possible pretest probability of 20%, the proportion of purulent sinusitis would be 65%, leaving 35% with a possible viral infection. Therefore, it cannot be ruled out that a number of viral cases were included in the study. Third, the recruitment of patients for each clinician was low, around 1 case per primary care physician during 1 year, whereas most primary care physicians might be expected to see as many as 50 cases of sinusitis per year. This may imply a selection bias and limits the external validity of the study." Clearly I over-simplified when I called the study worthless: but the press and this group have over-simplified the study without reading it, or the editorial. Antibiotics are over-prescribed, in some settings (I would argue more in urgent care than primary care settings, where there is continuity) and should not be used to treat viral infections, but we have limited clinical ability to determine which patients will benefit from antibiotics, and which won't. This was a very limited study, of a few patients with an isolated illness: it doesn't address recurrent sinusitis, chronic sinusitis, patients who are quite ill with their illness. Most likely, as stated above, a significant number of the subjects had an isolated viral illness. The editorial pointed out the weaknesses of the study, and basically said it continues the dialogue, but doesn't offer the solution of determining which patients require antibiotics. It suggested other forms of diagnosis: C reactive protein, and other, larger studies. It is not the last word. How do you know JAMA"s agenda? You need to read articles carefully and completely to fully understand them: the abstract isn't sufficient. Judy > > YOU'RE BACK!!!! > > I posted at least twice that people need to read the abstract: only [quoted text clipped - 29 lines] > Email: sdlit...@earthlinkNOSPAM.net > Remove the NOSPAM before replying to me. YOU'RE BACK !!!!! I tried to post earlier, but it didn't work. It was a lousy study, and the editorial in JAMA blasted it: underpowered, poor clinical criteria, 240 patients studied over 4 years with obvious selection bias--one or less patient from each participating practice. The criteria they used for inclusion had poor predictive value--they most likely studied people with early viral infections, and--surprise-- antibiotics and steroids were'nt helpful. The press was so biased: they ignored the editorial which said it was a lousy study, and ran with the sensationalized headline. I've posted this before. Hope all is well with you and your family. The editorial said that clearly there are patients who require antibiotics to treat their sinusitis, and this study did not clarify how to select those patients. Judy > I don't know the authors of the study, but if they are not idiots they > are paid flunkies of the insurance industry. Oops, the post did go through, just not for a while. Still glad you're back. Judy > YOU'RE BACK !!!!! > I tried to post earlier, but it didn't work. [quoted text clipped - 16 lines] > > I don't know the authors of the study, but if they are not idiots they > > are paid flunkies of the insurance industry. > Oops, the post did go through, just not for a while. > Still glad you're back. [quoted text clipped - 20 lines] > > > I don't know the authors of the study, but if they are not idiots they > > > are paid flunkies of the insurance industry. Glad to hear from you too Judy. Happy Holidays. Elizabeth > I don't know the authors of the study, but if they are not idiots they > are paid flunkies of the insurance industry. elizabeth! so glad to hear from you again. missed you & hope all is well. ellen > > I don't know the authors of the study, but if they are not idiots they > > are paid flunkies of the insurance industry. [quoted text clipped - 3 lines] > > ellen Ellen: All is miserable to outstanding! Life, generally grand in it's complexity and cussedness!!!!!! Judy: I don't know that I agree that antibiotics are over proscribed. If you prescribe antibotics which prevent bacteria from moving into the area where a viral infection has killed off or seriously comprimised the cillia and it saves the person from years of goo, then I would argue that those antibotics were highly effective. I did not have the kind or quanity of mucus that completly blocked my breathing until I had the flu and was refused antibotics. (And let us not forget that all antibotics are not created equal by a long shot, the fact that a penicillian is not effective for CHRONIC sinusitis, says nothing about what macrolides, sulfa drugs, or floroquinolones would do.) Elizabeth: I agree with you. I find the movement to restrict antibiotics is pervasisve theme, and some people are being really dogmatic about it, and getting very "holier than thou" about withholding antibiotics for the patient's own good. I don't see people begging for unnecessary antibiotics. I have seen physicians and mid-levels refusing to prescribe, and calling it evidence based. It scares me. Because one size does not fit all, and the move to withhold antibiotics in response to increased resistance focuses on people, not all the farm animals who are the primary cause of the resistance--IMO. Judy > > > I don't know the authors of the study, but if they are not idiots they > > > are paid flunkies of the insurance industry. [quoted text clipped - 20 lines] > sinusitis, says nothing about what macrolides, sulfa drugs, or > floroquinolones would do.) > Elizabeth: I agree with you. I find the movement to restrict > antibiotics is pervasisve theme, and some people are being really [quoted text clipped - 3 lines] > I have seen physicians and mid-levels refusing to prescribe, and > calling it evidence based. Yes and that evidence is almost always a trial done with amoxicillian. They don't have any trials saying that clindiamycian (Biaxin) is ineffective for sinusitis. >> Elizabeth: I agree with you. I find the movement to restrict >> antibiotics is pervasisve theme, and some people are being really [quoted text clipped - 9 lines] > They don't have any trials saying that clindiamycian (Biaxin) is > ineffective for sinusitis. I know one thing empirically: When I'm taking Biaxin, both my sinusitis and asthma improve. I am lucky to have both an excellent ENT and pulmo. They are familiar with the studies and potential of macrolides, and have not been reluctant to prescribe when necessary. As Judy says, many doctors are dogmatic about their fear of resistance, and unfamiliar with the work that has been done with macrolides. The media have had their role in this as well, with their frenzied and often uninformed reporting about resistance. Of course, they're in the Panic Profession. Well put: you are lucky to have physicians who get it. Macrolides are anti-inflammatory and don't allow viruses and bacteria to stick--they interfere with the CAM-1 protein, at doses below antimicrobial levels. I like the term Panic Profession. And, the need to over simplify is pervasive. Judy > >> Elizabeth: I agree with you. I find the movement to restrict > >> antibiotics is pervasisve theme, and some people are being really [quoted text clipped - 18 lines] > well, with their frenzied and often uninformed reporting about resistance. > Of course, they're in the Panic Profession. > Well put: you are lucky to have physicians who get it. Macrolides are > anti-inflammatory and don't allow viruses and bacteria to stick--they [quoted text clipped - 30 lines] > > well, with their frenzied and often uninformed reporting about resistance. > > Of course, they're in the Panic Profession. And staph A has the superantigens to keep the neighborhood inflamed without having to resort to any theory of autoimmunity. Just like staph A has the an enzyme that destroys CFTMCF, it is one vicious little animalcule. Role of staphylococcal superantigens in upper airway disease. Bachert C, Zhang N, Patou J, van Zele T, Gevaert P. Upper Airway Research Laboratory, Ear Nose and Throat Department, University Hospital Ghent, Ghent, Belgium. PURPOSE OF REVIEW: Chronic rhinosinusitis with nasal polyps often represents a chronic severe inflammatory disease of the upper airways and may serve as a model for lower airway diseases such as late-onset intrinsic asthma. Enterotoxins derived from Staphylococcus aureus have been implicated in the pathophysiology of nasal polyps as disease- modifying factors; recent findings using therapeutic proof-of-concept approaches support this hypothesis. RECENT FINDINGS: Nasal polyps (chronic rhinosinusitis with nasal polyps) are characterized by a T- helper-2 dominated cytokine pattern that includes interleukin-5 and formation of immunoglobulin E. This is in contrast to chronic rhinosinusitis without polyps, which exhibits T-helper-1 biased cytokine release. It is now evident that the cytokine environment is decisive regarding the impact of S. aureus derived enterotoxins, which function as superantigens. S. aureus enterotoxin B further shifts the cytokine pattern in nasal polyps toward T-helper-2 cytokines (increases greater than twofold for interleukin-2, interleukin-4 and interleukin-5), but it disfavours the T-regulatory cytokines interleukin-10 and transforming growth factor-beta1. Furthermore, S. aureus derived enterotoxins influence local immunoglobulin synthesis and induce polyclonal immunoglobulin E production, which may contribute to severe inflammation via activation of mast cells. SUMMARY: From this new understanding of chronic rhinosinusitis with nasal polyps, new therapeutic approaches emerge such as anti- interleukin-5, anti-immunoglobulin E, and antibiotic treatment. These may enlarge the nonsurgical armentarium. PMID: 18188015 [PubMed - in process] > > Well put: you are lucky to have physicians who get it. Macrolides are > > anti-inflammatory and don't allow viruses and bacteria to stick--they [quoted text clipped - 69 lines] > > PMID: 18188015 [PubMed - in process] "Elizabeth: I agree with you. I find the movement to restrict antibiotics is pervasisve theme, and some people are being really dogmatic about it, and getting very "holier than thou" about withholding antibiotics for the patient's own good. I don't see people begging for unnecessary antibiotics. I have seen physicians and mid-levels refusing to prescribe, and calling it evidence based. ..." I am very glad to see some one else say this -- I am surprised how angry i am still at a physician who five years ago refused to continue to prescribe me antibiotics after five months off and on 10 day courses - clearly did not listen when I talked (too busy reading notes) - got angry when I gave him typed notes because I said he was clearly more comfortable reading than listening and alluded to reading literature which suggested long courses of antibiotics were in order - had decided I had an allergy despite there being no evidence on RAST tests and at that stage the area of secretion only affected one part of one sinus and promptly declared me in need a therapist ... and I might need a therapist everyone can benefit from sessions with a good one (he did not get the joke when I said I had been married in Manhattan so that there would have been something wrong with me had I not consulted a Psychiatrist) But I had an observable physical problem that differed from his conclusions. I was shocked by the simple stupidity -- even if the man had only 15/20 minutes of time to spend with me couldn't he at least review evidence in front of him and see that his "'allergy' affected only one part of one mucous membrane on only one side of the body and I was describing multiple symptoms (lethargy, poor cognition, loss of mental focus, gastric problems, frequent 'colds' that would not go away, swollen glands on the one side, etc., etc.) My only prior experiences with the US medical profession had been collaborating on a project with a group at a major research institution all highly competent (some MD some not). They as a group did not take the medical profession seriously, one joke about the MD/ Phd program was that the degree after MD was really BMW! I did not take them seriously until my encounters as an ordinary retail consumer of medicine. Obviously I realize every trade has its variables and by definition 50% are going to be worse than average but I am shocked that after a significant number of years of training the average competence in my experience now is so low. My only consolation has been thinking about the member of the public who consults an average 'professional' in my own trade with anything the slightest bit unusual, frankly God help em -- and often she does not ! Apologies for the rant and consequent emotional self indulgence. Apologies also to the MD members of this forum for any offense, its very clear to me from your posts that you are exceptional for the trade and I only wish I had encountered physicians like yourselves! Michael > > > Well put: you are lucky to have physicians who get it. Macrolides are > > > anti-inflammatory and don't allow viruses and bacteria to stick--they [quoted text clipped - 124 lines] > > Michael Michael; I blame the medical schools. I am an engineer and see multispecies biofilms in on surfaces water systems and biologically accelerated corrosion all the time. It never occurred to me that the medical community had let the handy simplification of growing bacteria in pure cultures in planktonic ( free floating) form conceptually get away from them to the point they forgot that this is a simplification. It led them to believe that this is how bacteria normally live and do business as single cells. I have tremendous respect for the rigors of medical education and the complexity of the systems, but teaching them that most bacteria live as colonies of single free floating individuals produces a number of clinical conclusions that have nothing to do with the reality of lichen-like multispecies communities living in extracellular polysacride of their own making with some species like e-coli providing the anchor, fungi the strength, and staph the hyaluronase to spread the host cell walls apart to allow access to host plasma. > > > > Well put: you are lucky to have physicians who get it. Macrolides are > > > > anti-inflammatory and don't allow viruses and bacteria to stick--they [quoted text clipped - 143 lines] > providing the anchor, fungi the strength, and staph the hyaluronase to > spread the host cell walls apart to allow access to host plasma. Thanks for the acknowledgment. I should add as a contrast that with some trepidation I recently asked the physician I am seeing currently (whose attitude has been try this, lets try that and see what happens -- and was the first to schedule regular follow up appointments to see if his suggestions were working rather than me having to call up & eventually feeling that I had failed as a 'good patient' rather than the treatment had failed) -- if he minded since treatment had reached a stasis if I put together a review of what's gone on, what the situation is now and treatment possibilities (with supporting literature) to consider pursuing in the future. He said he would be delighted to take a look at same and encouraged me. So despite a run of bad experiences there are good and serious MD people out there in my universe also! Michael Michael, When you find the people who are willing to admit to uncertainity, and that this is a partnership, you stick with them. I teach at medical school, but I"m a clinician, so I teach how to talk to patients, not hard science like Elizabeth. Personally, I blame the whole climate of medicine--driven by third party payors, with nonsense quality evaluations (how many of your patients get a pap smear--those who are willing and who don't have a prohibitive deductible--but insurance companies measure the percentage as a quality parameter.) Judy > > > > > Well put: you are lucky to have physicians who get it. Macrolides are > > > > > anti-inflammatory and don't allow viruses and bacteria to stick--they [quoted text clipped - 162 lines] > > Michael > Michael, > When you find the people who are willing to admit to uncertainity, [quoted text clipped - 7 lines] > quality parameter.) > Judy ObThat: I met with a Kaiser psychologist yesterday. Just joined Kaiser on 1/1, and wanted to know what sort of support they offered for chronic pain and/or chronic illness. The psychologist told me that Kaiser HAD a pretty darned good program, but ... [wait for it] ... it was killing their "efficacy numbers." They weren't curing people. Patients required ongoing visits, virtually in perpetuity, so it made them look bad. Chronic pain patients. Chronic illness patients. Can you /stand/ it? Kaiser, the institution where my younger sister is an upper level adminstrator, (I once asked if it bothered her to have a parasitic job--I was post-call was my only excuse) and who had a program where high school educated receptionists were paid a bonus if they got patients off the phone in less than a minute AND refused them an appointment. They settled the ensuing law suit. On the other hand, they provided my mother with liver transplant at USCF--I think she's the reason they're cutting other programs... I coach my other sister on what to say to get an appointment. After years of frustration, she does work the system to get what she needs: including chronic biaxin--I just emailed her doctor with articles, and she found a receptive PCP. Neil, it makes me sick that the fact that the chronicity of an illness is an excuse not to provide services. I can't stand it. Judy On Jan 15, 11:26 am, neil0...@yahoo.com wrote: > > Michael, > > When you find the people who are willing to admit to uncertainity, [quoted text clipped - 21 lines] > > Can you /stand/ it? >> Well put: you are lucky to have physicians who get it. Macrolides are >> anti-inflammatory and don't allow viruses and bacteria to stick--they [quoted text clipped - 75 lines] > > PMID: 18188015 [PubMed - in process] Very interesting citation. Thanks. Elizabeth, When you think about how staph is considered a fairly common colonizer of nasal mucosa, it really makes you wonder. Very interesting article. Clearly the answer isn't "to cut is to cure": it's so much more complex, and medical. I once did some preliminary research on back pain when I was working at the residency, and was amazed at how little was known: there was some thoughts that it's not just simply mechanical--the disc pushes on the nerve,etc--but more of an inflammatory process. And this was several years ago. I was shocked at the lack of studies. Judy > >> Well put: you are lucky to have physicians who get it. Macrolides are > >> anti-inflammatory and don't allow viruses and bacteria to stick--they [quoted text clipped - 77 lines] > > Very interesting citation. Thanks. > Elizabeth, When you think about how staph is considered a fairly > common colonizer of nasal mucosa, it really makes you wonder. [quoted text clipped - 93 lines] > > > Very interesting citation. Thanks. Judy: It gives me hope that there is so much to know. I think a lot of things we associate with ageing are the result of bacterially injected DNA, bacteria (not viruses but little tiny nano- bacteria) locating themselves inside our cells and the like. All this is "controversial" because the limits for the minimum size of bacteria are much smaller than thought. Why this should be so controversial when they can be observed by anyone skilled in the art with a desire and an instrument powerful enough to look, is I guess a measure of how much easier it is to talk and speculate than to go through the 15 months of proposals and permission requests and begging to get money and samples to do the work for just a small study of surgical pathology samples. Elizabeth, there was a horrifying article in the New Yorker, called "guinea pigs" about the current state of drug testing: often phase 1 trials are done on homeless people, in run down motels, and indigent people will make a risky living partipating in these trials which involve only risk. If they suffer an adverse event, they are kicked out of the trial, with no compensation. A study in England of monoclonal antibodies resulted in multiple deaths and irreversible disabiliy. Really scary stuff. This is the stage of current drug trials. The IRB boards are corporate. University/Academic trials are a small minority, because the IRB's are so much tougher. So, it makes me understand why trials aren't done. Judy > > Elizabeth, When you think about how staph is considered a fairly > > common colonizer of nasal mucosa, it really makes you wonder. [quoted text clipped - 107 lines] > and samples to do the work for just a small study of surgical > pathology samples. |
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