No evidence that N95 respirators are better than surgical masks

From NinjaCat14 on  Deviant Art  I can't make this stuff up!

From NinjaCat14 on Deviant Art
I can't make this stuff up!

Specialized technologies are always sexier than their basic alternatives.

We often think that new and complicated is better. Or that if something is more expensive if must work better, right? 

One small trial found that a more expensive placebo was much more effective than the cheap one in Parkinson's patients. There is a lot of interesting research around how cost influences thinking and choice, and much of it is applied by manufacturers to influence their markets (see for example: Relative thinking in consumer choice between differentiated goods and services and its implications for business strategy).

Sometimes we think again about something that is not new, but an existing technology or process that we just use by habit, having assumed for years that it was better than the alternatives. Rarely are these things scrutinized, but sometimes when they are, we find out we are  "all wrong." For example, we have long assumed that acetaminophen is helpful for lower back pain but a meta-analysis in the BMJ in March 2015 found this is not the case.

In a recent Canadian Medical Association Journal (CMAJ) article, Effectiveness of N95 respirators versus surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis, we learned that there really is not a lot of clinical research that supports the effectiveness of N95 masks. In the lab, yes, surrogate markers suggest the N95 masks could be "better" than normal surgical masks, but the data in practice is so lacking. 

Smith et al. concluded that "Although N95 respirators appeared to have a protective advantage over surgical masks in laboratory settings, our meta-analysis showed that there were insufficient data to determine definitively whether N95 respirators are superior to surgical masks in protecting health care workers against transmissible acute respiratory infections in clinical settings."

Of course 'insufficient data' doesn't mean we should abandon these masks. While I will still wear N95s for seeing TB patients and for performing high risk interventions on patients with influenza like illness, I now begin to wonder if this is really necessary.

There are so many 'fancy' technologies that we have discovered are no better than the old ones, and our knowledge of the waste, cost, and sometimes harms associated with them makes it hard to  not carefully scrutinize every 'new alternative' and 'innovation.' 

As I head to Toronto for a meeting of the CMA's Joule Innovation Council this week, I must laugh a bit. I imagine my experience in critical review of medical literature and knowledge of the harms from overtesting/treating/diagnosis, will make me one of the toughest judges of our colleagues' submissions! We are reviewing grant proposals for development of innovations from Canadian physicians.

I hope that with this privilege, I can be both enthusiastic and measured in my assessments, though I won't be surprised if I'm one of the more, uh 'fiery,' of the dragons in the den. With the collective wisdom of the group, I'm certain we will support some elegant, thoughtful, and effective innovations to make a positive difference for patients and health care systems.


VIDEO: What causes antibiotic resistance? Kevin Wu | TED-Ed

It is goofy (there are butt-faces, silly monsters, Salmonella shooting lasers, and even a fart scene at 2:22) and informative. It is bound to be a classic!!!

Watch this fun video explaining What Causes Antibiotic Resistance thanks the Kevin Wu and Ted Ed.

View full lesson: Right now, you are inhabited by trillions of microorganisms. Many of these bacteria are harmless (or even helpful!), but there are a few strains of 'super bacteria' that are pretty nasty -- and they're growing resistant to our antibiotics. Why is this happening?


Myths and MSUs

Urinary tract infections (UTIs) are common in the elderly. They are also commonly overtreated. This can result in adverse reactions to medication including side effects like upset stomach or diarrhea, interactions with other drugs like coumadin (a blood thinner), or allergic reactions. There is also the potential loss of normal flora (good bacteria in our body) leading to overgrowth of C. difficile (bad gut bacteria) or Candida spp. (yeast) and development of antibiotic resistant organisms (AROs). Assuming someone has a UTI when they don't might also mean missing the real diagnosis.

This issue is unsurprisingly #1 on the Canadian Geriatric Society's Choosing Wisely hitlist: "Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present."

The Association for Elderly Medicine Education (AEME) has released a handful of excellent Mini-GEMs (Geriatrics E-learning Modules) on their youtube channel. This one, on "Myths and MSUs", where MSU = mid-stream urine test, was recently brought to my attention. It's aimed at physicians, but the take away for patients would be to ask "I feel fine and don't have any symptoms - do I really need an antibiotic for my bladder?"

I think it's a really clear walk-through of how to manage bladder infections, with a view to understand colonization (bacteria hanging out in the bladder that isn't causing harm) and interpreting the dip-stick test so as to avoid overtreatment. It's also a good reminder that, although common, a UTI is not always the cause of delirium, a temporary state of confusion secondary to underlying illness usually in the elderly.

Here's the video:

This MiniGEM explains how and when to diagnose UTI in older patients, and common pitfalls to avoid!