Intrapleural streptokinase is no better than placebo for patients with pleural infection

Intrapleural streptokinase is a well established treatment for infected pleural effusion, but a large randomised trial in 427 patients suggests that it doesn't work. Compared with placebo, intrapleural streptokinase did not reduce deaths or the need for surgery (64/206, 31% of the streptokinase group, v 60/221, 27% of the placebo group; relative risk 1.14; 95% CI 0.85 to 1.54). Streptokinase didn't reduce hospital stay either (figure), but it did increase the risk of serious adverse effects, including chest pain, allergy, and fever (14/208, 7% with streptokinase v 6/222, 3% with placebo; relative risk, 2.49; 0.98 to 6.36).

The patients in this trial were recruited from hospitals all over the United Kingdom, where national guidelines recommend intrapleural streptokinase as part of a package of measures that includes antibiotics and chest drainage. The recommendations were based on promising results from smaller trials, along with the biological plausibility of a treatment that clears fibrin adhesions, allowing an effusion to drain more easily. In this long awaited trial, the theoretical benefits did not translate into better outcomes for patients, and the authors counsel against routine intrapleural streptokinase for patients with pleural infection.

New England Journal of Medicine 2005;352: 865-74

Lifestyle intervention increased the risk of type 2 diabetes in middle aged smokers

We already know that losing weight and exercising more can help prevent type 2 diabetes in people with impaired glucose tolerance. The picture is less straightforward in people without it, according to a new analysis of data from a cardiovascular prevention trial. A package of interventions including lifestyle advice to eat less, exercise more, and stop smoking had no overall effect on the risk of type 2 diabetes in nearly 12 000 middle aged men with normal glucose tolerance. During six years of follow-up, 11.5% of men who were given the advice and 10.8% of men who weren't developed diabetes (hazard ratio 1.08, …