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By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for GlaxoSmithKline and is on the speaker's bureau of GlaxoSmithKline, 3M, Wyeth-Ayerst, Pfizer, Novartis, Bristol-Myers Squibb, AstraZeneca, Jones Pharma, and Boehringer Ingelheim.
Best management of acute ankle sprain
Source: Lamb SE, et al. Mechanical supports for acute ankle sprain. Lancet 2009;375:575-581.
A severe ankle sprain (ANK-S) might seem like a minor injury, but clinicians may be underestimating the burden of consequence. In addition to the immediate period of limited mobility, full functional restoration takes between 3-9 months for as many as 70% of affected individuals. Indeed, it is not uncommon to see long-term symptoms referable to the ankle sprain, including recurrent swelling, pain, and limitation of activity. Because ANK-S is a commonplace event, confirming the best approach to initial management merits investigation.
Lamb et al randomized participants presenting to EDs in the United Kingdom with severe ANK-S (n = 584) to 1 of 4 treatments: an Aircast® brace, Bledsoe boot, below-knee cast, or double-layer tubular compression bandage.
Participants generally used treatments short-term, i.e., 10 days, and then PRN. Tubular compression bandage was the least efficacious method at 1, 3, and 9 months and was similar in efficacy to the Bledsoe boot. The below-knee cast was the most effective treatment, but Aircast outcomes were similar for ankle functionality at 3 months. Overall, the below-knee cast showed the best early symptomatic recovery, as well as functional recovery by 3 months. Although the philosophy of early mobilization has achieved some popularity, these data would suggest that tools that limit mobilization early (i.e., cast, Aircast), should be considered preferential. (Note: There is more than one Bledsoe boot; because Bledsoe provides boots with either flexion-extension mobility or full immobilization, it is possible that other versions of the Bledsoe boot might be more efficacious).
Low back radiology: Roadmap or mirage?
Source: Chou R, et al. Imaging strategies for low-back pain. Lancet 2009;373:463-472.
Low back pain (LBP) is responsible for as much as one-third of all disability dollars spent in the United States. When patients present with acute LBP, clinicians are tempted to perform radiographic studies (MRI, CT, plain films) to try to identify the source of the symptomatology. Unfortunately, the preponderance of current evidence suggests that findings commonly reported on radiographic studies such as narrowed disk space, loss of lumbar lordosis, and osteoarthritic changes, are just as common in asymptomatic volunteers as in symptomatic LBP sufferers.
Chou et al performed a meta-analysis of clinical trials which enrolled patients and included immediate imaging (CT, MRI, or plain films) and compared them with trials of similar patients who did not undergo imaging (total n = 1804). In addition to reporting radiography utilization, included trials had to provide information on outcomes of pain or function, quality of life, mental health, overall improvement, and patient satisfaction.
Chou et al found that in the absence of signs of a serious underlying condition (e.g., fever, weight loss, history of cancer), immediate imaging was not associated with improved outcomes. Indicative of the need for more public education, the article also reminds us that in one study, patient preference to undergo radiography was as high as 80%.
Routine radiography for acute LBP does not improve outcomes, is associated with substantial cost, and may suggest pathology which is, in effect, unrelated to the symptomatology.
Source: Dharan NJ, et al. Infections with oseltamivir-resistant influenza A(H1N1) virus in the United States. JAMA 2009;301:1034-1041.
Progressive resistance of influenza A virus (FLU-A) to adamantanes (i.e., amantadine, rimantadine) led to the 2006 CDC recommendation against their use. Initial resistance patterns of next-generation pharmacotherapies for FLU-A, the neuraminidase inhibitors (i.e., oseltamivir, zanamivir), were very reassuring. Recently, growing resistance patterns to oseltamivir (OSTV) are shaping revised CDC recommendations.
Volunteer clinicians around the United States, known as sentinel physicians, monitor patients who present with influenza-like illness and send samples to the CDC for confirmation of influenza virus status. Among FLU-A viruses assessed in the 2007-2008 influenza season, only 12.3% were OSTV-resistant. Comparison of the demographics of subjects with OSTV-resistant FLU-A to subjects with non-resistant profiles did not provide any insight into particular at-risk groups (or protected groups), including age, geography, symptoms, etc.
OSTV resistance profiles changed dramatically in the FLU-A samples from Sept. 28, 2008, to Feb. 19, 2009: 98.5% of H1N1 FLU-A samples (264/268) were OSTV-resistant! Experts are uncertain about the mechanism by which OSTV resistance has proliferated. Current options in an environment of high OSTV resistance include zanamivir, or OSTV plus rimantadine.