Remember the cause as well as the cure #WILTW

This is the 183th #WILTW

Medical research is about doing things better for patients. It’s exciting to see new treatments and interventions develop (even when the evidence eventually suggests doing nothing at all is the best thing to do!)

Although I’m biased, in paediatric research simple changes can have quite profound effects on children and their families. Take a common condition such as asthma; treatment of acute exacerbations has traditionally taken the form of inhalers and a course of steroids (prednisolone) given over three days. The need for multiple daily doses, with the resulting challenges for families and children, has recently been challenged.  It is proposed a single dose of strong steroid (dexamethasone) may be adequate. A brilliant review of a paper on this topic by the Skeptics guide to Emergency Medicine (SGEM) prompted debate this week about why practice hasn’t changed.

In the UK a bottle of dexamethasone is far more expensive than a packet of prednisolone tablets (which can be crushed to give to children) so the argument on the equity and equivalence of treatments will continue for some time yet I suspect. However in the comments section one of the blog’s authors highlighted a potentially far more challenging debate.

Here is great graph looking at asthma rates and area in NY city. As you can see it is quite serioulsy overrepresented in the areas with the highest endemic poverty rates (or I can see it knowing the city, sorry)

The relationship between deprivation and asthma (and many other medical conditions) is well described. Clearly the causes are multi-factorial but regardless, the variability in attendances and outcomes must be of concern.

The same unexplained variation equally applies in the UK

via Atlas of Variation (click to link to document)

Clearly we need to continue to deliver the best treatments to children and young people most in need of care. But if there are underlying reasons behind why they need that treatment, we must not forgot to concentrate on ameliorating these as well.

What have you learnt this week? #WILTW

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6 thoughts on “Remember the cause as well as the cure #WILTW”

  1. Thanks for calling our review “brilliant”, sharing the FOAMed and helping cut the knowledge translation down from over ten years to less than one year.

    The ultimate goal of the Skeptics’ Guide to Emergency Medicine is for patients to get the best care based on the best evidence.

    What I learned this week…follow Rolobot Rambles

    Ken

  2. Thank you for the kind words on our review of the Cronin paper. I loved your thoughts on how something so simple can have a really dramatic impact on practice and would concur that the shift towards dexamethasone may well be one of those changes.

    And thank you for highlighting the link between asthma and deprivation. Sadly, as you brilliantly noted, dealing with this issue is far larger and more complicated, but we must never lose track if these links. I have spent most of my career serving underserved communities in the US and Canada, and feel that we have done so much to improve care. But there are so many more battles that need to be fought.

    Thanks….and I will be following you as well!

    1. Thanks Michael – the battles analogy is well made. So much of our work is at the so-called ‘front line’ but efforts behind the lines (diplomatic or otherwise) if we had the time/resources would perhaps reduce the need for the front line..

  3. As always an interesting blog – thank you. So often there is cross over with ED and primary care. There are both soluble prednisolone and liquid pred which are still cheaper than dexamethasone – and better tolerated than the pred tablets crushed. The problem we have in primary care is that dex only comes in relatively large bottles – it’s expensive and gets wasted – we don’t see kids who need it often enough. It would be great if they produced plastic ampoules as they do for prednisolone.

  4. “Dex – plastic ampoules”

    I was speaking to an innovation lead from a pharmaceutical company recently about how often we don’t need super drugs but need pharma to look at common drugs (even those out patent) and provide better delivery mechanisms for children. Don’t think this is a lot of money to be made so people won’t invest. Sad really…

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