Top POEMs of 2017 Consistent with the Principles of the Choosing Wisely Campaign: Miscellaneous

Top 20 POEMs of 2017 Consistent with the Principles of the Choosing Wisely Campaign

Steroid Treatment Adds No Benefit to Antihistamines for Acute Hives

Clinical question
In patients presenting with acute urticaria, is combination antihistamine/corticosteroid treatment more effective than antihistamine alone?

Bottom line
The belt-and-suspenders approach of steroids and antihistamines offers no added benefit to antihistamines alone for the treatment of simple urticaria. (LOE = 1b-)(www.essentialevidenceplus.com)

Reference
Barniol C, Dehours E, Mallet J, Houze-Cerfon CH, Lauque D, Charpentier S. Levocetirizine and prednisone are not superior to levocetirizine alone for the treatment of acute urticaria: a randomized double-blind clinical trial. Ann Emerg Med 2017;pii:S0196-0644(17)30264-0.

Study design: Randomized controlled trial (double-blinded)

Funding source: Foundation

Setting: Emergency department

Synopsis
The investigators enrolled 100 adults who presented to an emergency department with a generalized rash for less than a day with fleeting wheals and itching but without angioedema or anaphylaxis. All patients were treated with the antihistamine levocetirizine (Xyzal, Levazyr) 5 mg daily for 5 days, and they were all randomized, using concealed allocation, to additionally receive placebo or prednisone 40 mg daily for 4 days. On follow-up by telephone, 62% of patients treated with antihistamine/prednisone and 76% receiving antihistamine/placebo were asymptomatic (difference not significant). Relapse of urticaria was similar in both groups. The study had 80% power to find a difference of 28 percentage points if a difference existed, and analysis was by intention to treat.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

The Quick-Wee Method Gets Infant Urine Flowing

Clinical question
Is there an effective way to quickly collect a successful urine sample from infants?

Bottom line
In infants aged 1 month to 12 months from whom a urine sample is needed for culture (usually for fever), the Quick-Wee method—gentle stimulation of the suprapubic areas with a cold wet gauze for up to 5 minutes—was significantly more likely to be effective than the wait-and-catch method, generating a useful urine sample 30% of the time. One-in-four samples were contaminated, which is a rate similar to usual clean-catch urine in infants. Still, a few minutes of cold stimulation might save nearly one third of patients from needing suprapubic catheterization. (LOE = 1b)(www.essentialevidenceplus.com)

Reference
Kaufman J, Fitzpatrick P, Tosif S, et al. Faster clean catch urine collection (Quick-Wee method) from infants: randomised controlled trial. BMJ 2017;357:j1341.

Study design: Randomized controlled trial (nonblinded)

Funding source: Foundation

Allocation: Concealed

Setting: Emergency department

Synopsis
These investigators enrolled 354 infants aged 1 month to 12 months who presented to an emergency department and needed to provide a clean-catch urine sample. Infants were randomized, using concealed allocation, to receive usual care (waiting until spontaneous voiding occurred) or the Quick-Wee method (gentle cutaneous suprapubic stimulation using gauze soaked in refrigerated saline). The gentle, circular rubbing continued until the infant voided or for 5 minutes. The authors included children in both groups who voided while their genital area was cleaned. Infants getting the "cold stimulation" were significantly more likely to void as compared with the "exposed to air" group (31% vs 12%; P < .001). The Quick-Wee approach also improved the likelihood of catching a successful urine sample (30% vs 9%). The rate of contamination—approximately 1 in 4—was similar in both groups.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

POEMs are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com(www.essentialevidenceplus.com).

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