Monthly Archives: March 2014

Does a hearty breakfast help you lose weight?

OBJECTIVE: Few studies examined the association between time-of-day of nutrient intake and the metabolic syndrome. Our goal was to compare a weight loss diet with high caloric intake during breakfast to an isocaloric diet with high caloric intake at dinner.

DESIGN AND METHODS: Overweight and obese women (BMI 32.4 +/- 1.8 kg/m(2) ) with metabolic syndrome were randomized into two isocaloric (~1400 kcal) weight loss groups, a breakfast (BF) (700 kcal breakfast, 500 kcal lunch, 200 kcal dinner) or a dinner (D) group (200 kcal breakfast, 500 kcal lunch, 700 kcal dinner) for 12 weeks.

RESULTS: The BF group showed greater weight loss and waist circumference reduction. Although fasting glucose, insulin, and ghrelin were reduced in both groups, fasting glucose, insulin, and HOMA-IR decreased significantly to a greater extent in the BF group. Mean triglyceride levels decreased by 33.6% in the BF group, but increased by 14.6% in the D group. Oral glucose tolerance test led to a greater decrease of glucose and insulin in the BF group. In response to meal challenges, the overall daily glucose, insulin, ghrelin, and mean hunger scores were significantly lower, whereas mean satiety scores were significantly higher in the BF group.

CONCLUSIONS: High-calorie breakfast with reduced intake at dinner is beneficial and might be a useful alternative for the management of obesity and metabolic syndrome.

Jakubowicz D, Barnea M, Wainstein J, et al. High Caloric intake at breakfast vs. dinner differentially influences weight loss of overweight and obese women. Obesity (Silver Spring). 2013 Dec;21(12):2504-12. doi: 10.1002/oby.20460. Epub 2013 Jul 2.

Do antiviral medications prevent post herpetic neuralgia?

BACKGROUND: Postherpetic neuralgia (PHN) is a painful and refractory complication of herpes zoster. Treatments are either partially or totally ineffective for many people with PHN. Antiviral agents, used at the time of the rash, have been proposed as an intervention to prevent the development of PHN. This is the first update since the first publication of the review in 2009.
OBJECTIVES: To assess the effectiveness of antiviral agents in preventing PHN. SEARCH
METHODS: On 26 April 2013, we updated the searches in the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, EMBASE, LILACS, and the Chinese Biomedical Retrieval System. We checked the references of published studies to identify additional trials, and contacted authors to obtain additional data. We searched other databases in The Cochrane Library for information for the Discussion and two clinical trials registries for ongoing trials.
SELECTION CRITERIA: We considered all randomised controlled trials (RCTs) of antiviral treatment given within 72 hours after the onset of herpes zoster for preventing PHN. There were no language restrictions.
DATA COLLECTION AND ANALYSIS: Two authors independently selected trials, evaluated the risk of bias in included trials, and extracted and analysed data.
MAIN RESULTS: Six RCTs with a total of 1211 participants were eligible; five trials evaluated oral aciclovir, and one, with 419 participants, evaluated oral famciclovir. We were able to conduct meta-analyses as there were sufficient similarities in the included studies, such as the reporting of the presence of PHN, duration of rash before treatment initiation and treatment regimen. For our primary outcome, based on three trials (609 participants) we found no significant difference between the aciclovir and control groups in the incidence of PHN four months after the onset of the acute herpetic rash (risk ratio (RR) 0.75, 95% confidence interval (CI) 0.51 to 1.11), nor was there a significant difference at six months (RR 1.05, 95% CI 0.87 to 1.27, two trials, 476 participants). In four of the trials (692 participants), there was some evidence for a reduction in the incidence of pain four weeks after the onset of rash. In the trial of famciclovir versus placebo, neither 500 mg nor 750 mg doses of famciclovir reduced the incidence of herpetic neuralgia significantly. The most commonly reported adverse events were nausea, vomiting, diarrhoea and headache for aciclovir, and headache and nausea for famciclovir. For neither treatment was the incidence of adverse events significantly different from placebo. None of the studies were at high risk of bias, although the risk of bias was unclear in at least one domain for all but one study. We found no new RCTs when we updated the searches in April 2013.
AUTHORS’ CONCLUSIONS: There is high quality evidence that oral aciclovir does not reduce the incidence of PHN significantly. In addition, there is insufficient evidence to determine the effect of other antiviral treatments; therefore, further well-designed RCTs are needed to investigate famciclovir or other new antiviral agents in preventing PHN. Future trials should pay more attention to the severity of pain and quality of life of participants, and should be conducted among different subgroups of people, such as people who are immunocompromised.

Chen N, Li Q, Yang J, et al. Antiviral treatment for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2014 Feb 6;2:CD006866. (Review) PMID: 24500927

Respiratory tract symptoms in children last longer than expected


For common respiratory tract infections in children, what is the best guidance we can give parents regarding the time to symptom resolution?

Bottom Line

No one has come up with a quick-fix-acillin for children with respiratory tract infections, which last longer than we expect and certainly longer than we want. The time for half the children with earache to be pain free is 3 days, but the time for 9 of 10 children to be pain free is 7 to 8 days. Sore throat symptoms will linger for at least 3 days in one third of children and 72% will have fever for at least 2 days. Cough will resolve in 50% of children within 10 days, but for the rest it will be another 2 weeks. For half the children, general symptoms of a common cold will last for at least 10 days. (LOE = 1a-)


Thompson M, Vodicka TA, Blair PS, et al, for the TARGET Programme Team. Duration of symptoms of respiratory tract infections in children: systematic review. BMJ 2013;347:f2027.


To determine the duration of symptoms in children seeking treatment for earache, sore throat, cough, and common cold, these authors identified 23 randomized trials and 25 observational studies by searching 3 databases, including DARE. They only included studies published in English and conducted in high-income countries. They excluded studies of children with chronic infection or medical conditions associated with a high risk of serious infections. Two authors reviewed articles for inclusion and also assessed the quality of the included studies. Most studies had a low risk of bias, but the researchers were often unable to combine data because of differences in outcomes. Earache was reported to resolve in 50% of children within 3 days and in 90% by 7 to 8 days. Fever lasted an average of 3 days. For children with sore throat, approximately one third will still have pain at day 3 and 72% will have fever for at least 2 days. Cough resolved in 50% of children at 10 days, but it took 25 days for 90% of children to be cough free. Similarly, 50% of children with bronchiolitis will improve by day 13. For nonspecific respiratory tract infections (ie, the common cold), 50% of children will improve by 10 days.

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

Sputum purulence and CRP predict poor prognosis with COPD exacerbation

POEMs Research Summaries

Clinical Question

Is it possible to identify exacerbations of mild to moderate chronic obstructive pulmonary disease that do not require antibiotic treatment?

Bottom Line

Among patients with an exacerbation of mild to moderate chronic obstructive pulmonary disease (COPD), those with a C-reactive protein (CRP) level greater than 40 mg/L and those with sputum purulence are at increased risk for treatment failure without antibiotics. Other patients are unlikely to benefit from antibiotics and would be candidates for symptomatic therapy and close follow-up. (LOE = 1b)


Miravitlles M, Moragas A, Hernández S, Bayona C, Llor C. Is it possible to identify exacerbations of mild to moderate COPD that do not require antibiotic treatment? Chest 2013;144(5):1571-1577.


A recent randomized controlled trial compared amoxicillin/clavulanate with placebo in 310 patients with an exacerbation of mild to moderate COPD (Am J Respir Crit Care Med 2012; 186: 716-23). Clinical failure was defined as incomplete resolution, persistence, or worsening of symptoms on days 9 to 11 that required additional treatment. In that trial, 19% in the placebo group and 10% in the antibiotic group were classified as clinical failures (number needed to treat = 9). In this study, the authors looked only at those who had received placebo (n = 152), all of whom had experienced either increased dyspnea, increased sputum volume, and/or increased sputum purulence as inclusion criteria for the study. Patients with increased dyspnea and/or sputum volume had a 5.6% failure rate, those with sputum purulence alone or sputum purulence with increased dyspnea or sputum volume had a 20.3% failure rate, and those with all 3 symptoms had a 33% failure rate. Patients with a CRP level of less than 40 mg/L had a 12.4% failure rate, compared with a 65% failure rate for those with CRP levels of 40 mg/L or higher. A multivariate analysis found that CRP levels equal to or greater than 40 mg/L (odds ratio [OR] = 13.4; 95% CI, 4.6 – 39) and increased sputum purulence (OR = 6.1; 1.5 – 25) were independent predictors of treatment failure.

Mark H. Ebell, MD, MS
Associate Professor
University of Georgia
Athens, GA