Our Acquired Knowledge at Coastal Family Medicine.

Silver Nitrate for Apthous Ulcers

2011-04-15T08:05:00.000-04:00

Original Question: Patient with apthous ulcer in clinic.

P- In patients with apthous ulcers

I -does silver nitrate application

C- time (doing nothing)

O- decrease patient discomfort

Search terms: apthous ulcer Silver nitrate

Where searched: "http://www.ncbi.nlm.nih.gov/pubmed/ http://www.aafp.org https://www.google.com

RESULTS: In the treatment group, 33 of 47 patients (70%) evaluated and in the placebo group, four of 38 patients (11%) evaluated had reduction in severity of pain 1 day after the procedure. The difference was statistically significant (P < 0.001). On the seventh day after the procedure, the ulcers were completely re-epithelialized in 39 patients (83%) in the treatment group and in 34 patients (89%) in the placebo group. The difference was not statistically significant (P = 0.39).

CONCLUSIONS: one application of silver nitrate can decrease the severity of pain in aphthous ulceration without significantly shortening or prolonging healing time. We did not observe any side-effects in our study. The effect is rapid and lasts for the duration of the lesion. The treatment is simple and cost-effective in patients with infrequent recurrences.

Sources: Br J Dermatol. 2005 Sep;153(3):521-5.

Silver nitrate cautery in aphthous stomatitis: a randomized controlled trial.

Alidaee MR, Taheri A, Mansoori P, Ghodsi SZ.

SOR A Consistent, good-quality patient-oriented evidence*

Completed By Claude Roofian, M.D.

Last updated 3/18/2011

Cranberry for UTI Prophylaxis

2011-04-15T07:57:00.000-04:00

P: Adult Women

I: Cranberry Supplement

C: No Supplement

O: Prevention of UTI?

Most recently in 2001, a randomized, placebo-controlled trial of 150 women over a 12-month period found that cranberry juice and cranberry extract tablets significantly decreased the number of patients having at least one symptomatic UTI per year.

Findings were statistically significant. There was a twenty percent reduction in absolute risk of infection in women receiving cranberry vs those without cranberry prophylaxis. (NNT = 5)

SOR A

Resources: “Cranberry for prevention of urinary tract infections”. www. AAFP.org

www.altmed.creighton.edu

Completd by Erin Griffin DO

Date Last updated 4/14/2011

Magnets for Pain

2011-04-15T07:52:00.002-04:00

Original Question:Does magnetic therapy work for pain relief?

Question in PICO Format:is there evidence that magnetic therapy can improve musculoskeletal pain in adults seeking alternative medicine practices?

Searched Terms:"is there evidence that magnetic therapy can improve musculoskeletal pain in adults seeking alternative medicine" which directed me to Pubmed.gov and a list of similar article topics.

Where searched:bing.com, pubmed.gov

Answer:No, any benefit perceived was non-specific placebo effect. But no evidence of causing harm either.

Source: Richmond SJ, Brown SR, et al. "Therapeutic effects of magnetic and copper bracelets in osteoarthritis: a randomised placebo-controlled crossover trial." Complement Ther Med. 2009 Oct-Dec;17(5-6):249-56. Epub 2009 Aug 28.

Level of Evidence 2b

SOR:B Inconsistent or limited-quality patient-oriented evidence*

Completed by:Jodie Calain, D.O.

Date last updated:4/13/2011

Epi for digital blocks

2011-04-15T07:50:00.000-04:00

Original Question:We are taught to avoid using epinephrine in body parts with terminal vasculature (lips, fingertips, toes, penis, ears). But, is epinephrine still contraindicated in digital blocks? (It has theoretical use in constricting vessels and allowing anesthetic to stay in tissues longer).

Question in PICO Format:P = patients with digital (fingers/hand) injections

I = lidocaine with epinephrine

C = lidocaine

O = number of ischemic events (digital infarction (tissue/skin loss), use of phentolamine rescue to reverse vasoconstriction)

Searched Terms:lidocaine, epinephrine

Where searched:UpToDate

Answer:**Epinephrine is not contraindicated in digital blocks.**

9 hand surgeons in 6 cities prospectively recorded cases of elective hand (1770) and finger (1340) epinephrine injection (total n = 3110 cases). Used low-dose epinephrine (1:100,000 adrenaline); 391 received bupivicaine, and remainder received lidocaine. None produced ischemic event. (*Elective injection was avoided in uncommon patients with pre-existing vascular problems in hand/fingers). Interestingly, no authors saw a difference in epi hemostasis from what they had seen with tourniquet hemostasis. True incidence of finger infarction in elective low-dose epinephrine injection into the hand and finger is likely to be remote.

Source: Lalonde D, Bell M, Benoit P, et al. A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase. J Hand Surg Am 2005; 30:1061.

SOR: B Inconsistent or limited-quality patient-oriented evidence*

Completed by:Karen Isaacs MD, MPH

Date last updated:4/14/2011

Diabetic Women and Boric Acid for Vaginal Yeast Infections

2011-03-18T10:42:00.000-04:00

Original Question: In diabetic women with recurrent symptomatic vaginal yeast infections...can boric acid play a role in treatment?

P = diabetic women with vaginal yeast infections

I = boric acid

C = diflucan

O = recurrence of symptomatic vaginal yeast infections

Searched Terms: boric acid vaginitis

Where searched: PubMed, AFP

Answer: Diabetic women are at higher risk of non-albicans Candida species, such as glabrata. Glabrata has reduced susceptibility to azole drugs. Authors did a randomized trial (open label, non-blinded) comparing single dose po 150mg fluconazole vs 14 days boric acid vaginal suppositories 600mg/day. n= 112 (DM I and II), 59.9% with glabrata; randomized to treatment after candida species identified. On day 15, statistical significance seen in mycologic cure of glabrata growth in 56.1% of boric acid group, and in 18.7% of fluconazole group (had to adjust for lower mean A1c in boric acid group; but still p = 0.01). But for overall mycological cure, as well as signs observed/symptoms reported, the clinical difference between the 2 treatment groups is not statistically significant. Of the women taking boric acid, 2 stopped due to vaginal burning sensation on day 7. Boric acid alone seems to be helpful in reducing organism burden of candida glabrata in diabetic women, but there is a need for further investigation on the utility of boric acid in combination with other therapy, for symptomatic improvement in acute episodes and also reduction of recurrence through maintenance regimens. (This is disease-oriented evidence).

http://care.diabetesjournals.org Ray D, et al. “Prevalence of Candida glabrata and Its Response to Boric Acid Vaginal Suppositories in Comparison with Oral Fluconazole in Patients with Diabetes and Vulvovaginal Candidiasis”. Diabetes Care. Feb 2007, vol 30(2):312-317.

SOR: C Consensus, disease-oriented evidence,* usual practice, expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening

Completed by: Karen Isaacs MD, MPH

Date last updated:12/13/2010

Depo Provera and Osteoporosis

2011-03-17T09:19:00.000-04:00

original question: Is there an increased risk of osteoporosis while taking Depo Provera?

Population: women taking Depo for contraception

Intervention: Depo

Compared to: No Depo

Outcome: Increased risk of osteoporosis?

Search terms: risk of osteoporosis while on depo?

Where searched: Up-to-date, goggle

Answer: The best available data show that Depo use does not reduce peak bone mass and does not increase the risk of osteoporosis fracture in later life in women at average risk of osteoporosis. Bone loss occurring with Depo use is reversible and is not likely to be an important risk factor for low bone density and fractures in older women, although data on fracture risk in Depo users are lacking.

Sources:

Kaunitz, AM, Arias, R, McClung, M. Bone density recovery after depot medroxyprogesterone acetate inject able contraception use. Contraception 2008; 77:67.
ACOG Committee Opinion No. 415: Depot medroxyprogesterone acetate and bone effects.

American College of Obstetricians and Gynecologists Committee on Gynecologic Practice

Obstet Gynecol. 2008;112(3):727-30.

ACOG practice bulletin. No. 73: Use of hormonal contraception in women with coexisting medical conditions. ACOG Committee on Practice Bulletins-Gynecology

Obstet Gynecol. 2006;107(6):1453-72.

World Health Organization. WHO Statement on Hormonal Contraception and Bone Health 2005; 1-2.

LOE C

B Blockers for Cocaine Associated MI

2010-09-17T07:49:00.002-04:00

Original Question: Discussion in clinic of a known cocaine abuser who is currently on a B blocker.

Question in PICO Format: Do B-blockers increase mortality in cocaine abusers?

Searched Terms: cocaine abuse B blocker

Where searched: Google.com

Answer: Indeterminate, there is conflicting evidence. The evidence to not use B-blockers is based on non-selective B blockers. The studies were done on patients with small amounts of cocaine not reflective of what is typically used.

Beta-blockers were given in 60 of 348 admissions. The incidence of myocardial infarction after administration of beta-blocker was significantly lower than without treatment (6.1% versus 26.0%; difference in proportion 19.9%; 95% confidence interval [CI] 10.3% to 30.0%). One of 14 deaths occurred in patients who received beta-blockade (incidence 1.7% versus 4.5% without beta-blockade; difference in proportion 2.8%; 95% CI -1.2% to 6.7%). Multivariate analysis showed that use of beta-blockers significantly reduced the risk of myocardial infarction (odds ratio 0.06; 95% CI 0.01 to 0.61). In the cohort, administration of beta-blockers was associated with reduction in incidence of myocardial infarction after cocaine use. The benefit of beta-blockers on myocardial function may offset the risk of coronary artery spasm.

Sources: http://www.ncbi.nlm.nih.gov/pubmed/16627850

http://www.bestbets.org/bets/bet.php?id=468

http://www.ncbi.nlm.nih.gov/pubmed/17583376 (Ann Emerg Med. 2008 Jul;52(1):90. )

SORT: B Inconsistent or limited-quality patient-oriented evidence*

Completed by: Claude Roofian, M.D.

Date last updated: 9/16/2010

Vitamins for Dry Macular Degeneration

2010-09-17T07:48:00.000-04:00

Original Question: Vitamins are often recommended by Opthalmologists to prevent age-related macular degeneration. Is this recommendation evidence based?

Question in PICO Format: Do vitamin supplements help prevent dry age-related macular degeneration in people with a family history of macular degeneration?

Searched Terms: same as above (PICO)

Where searched: www.Google.com

Answer: The National Eye Institute's Age-Related Eye Disease Study (AREDS) found that taking a specific high-dose formulation of antioxidants and zinc significantly reduces the risk of advanced AMD and its associated vision loss in persons with intermediate ADM. The study did not find that the formulation provided a benefit to those with early stage AMD. (A:I)

(The specific daily amounts of antioxidants and zinc used by the study researchers were 500 milligrams of vitamin C, 400 International Units of vitamin E, 15 milligrams of beta-carotene (often labeled as equivalent to 25,000 International Units of vitamin A), 80 milligrams of zinc as zinc oxide, and two milligrams of copper as cupric oxide. Copper was added to the AREDS formulation containing zinc to prevent copper deficiency anemia, a condition associated with high levels of zinc intake).

Source: NIH National Eye Institute

SORT: A Consistent, good-quality patient-oriented evidence*

Acorns(1-3):

Completed by: Jodie Calain, D.O.

Date last updated: 9/16/2010

Wellbutrin for SSRI Induced Sexual Dysfunction

2010-09-17T07:47:00.000-04:00

Original Question: Does the addition of Wellbutrin to SSRI help alleviate sexual dysfuntion?

Question in PICO Format:

P: Patient taking SSRIs and suffering from sexual dysfunction.

I: Adding Wellbutrin

C: No Wellbutrin

O: Alleviate sexual dysfunction

Searched Terms: sexual side effects if SSRIs

Where searched: google

up to date

Answer: Twenty-four subjects treated with serotonin reuptake inhibitors for a depressive disorder who had new-onset sexual side effects coincident with antidepressant treatment were treated with escalating doses of bupropion SR up to 300 mg daily for 7 weeks. Global response rates were 46% for women and 75% for men. All sexual side effects improved in response to bupropion SR in both men and women with no differential effect on any one sexual side effect. Most of the improvement (more than 50%) occurred within the first 2 weeks and at low dose (100-200 mg/day). When prescribed in an open fashion, bupropion SR appeared to be effective in treating all the major categories of sexual side effects.

Source: Bupropion-sustained release as a treatment for SSRI-induced sexual side effects.AUGitlin MJ; Suri R; Altshuler L; Zuckerbrow-Miller J; Fairbanks LSOJ Sex Marital Ther 2002 Mar-Apr;28(2):131-8.

Department of Psychiatry, University of California School of Medicine, Los Angeles, California, USA. mgitlin@mednet.ucla.edu

SORT: B Inconsistent or limited-quality patient-oriented evidence*

Completed by: Heather Merlo, M.D.

Date last updated: 9/15/2010

Steroids for HELLP

2010-09-17T07:45:00.000-04:00

Original Question: Is Dexamethasone presently indicated for women with HELLP syndrome in the post-partum course?

Question in PICO Format: P-Women with HELLP syndrome post-partum who had not received antenatal corticoids for fetal lung maturity

I-Dexamethasone Q 12 hours x 4 days

C-Placebo, same dosing schedule

O- Difference between the groups in duration of hospitalization, platelet recovery, use of blood products or a more rapid improvement in lab values.

Searched Terms: HELLP syndrome

Where searched: Up to Date initially, then a searched the library docs online to find a specific study.

Answer: There was no difference in duration of hospitalization, platelet recovery, use of blood products or improvement in lab values in the treatment group vs. the control group.

Source: American Journal of Obstetrics and Gynecology.

SORT: A Consistent, good-quality patient-oriented evidence*

Acorns(1-3):

Completed by: Monique Moona

Date last updated: 9/15/2010

Early Enteral Feeding vs. NPO

2010-09-17T07:43:00.000-04:00

Original Question: Does feeding post-op patients early decrease their hospital length of stay?

Question in PICO Format: P post-op patients

I early feeding

C kept NPO (traditional)

O length of hospital stay

Searched Terms: does feeding post surgical patients early decrease their length of hospital stay?

Where searched: google

Answer: yes, early feeding reduced the risk of any type of infection (P=0.036) and the mean length of stay in hospital(P=0.001). Risk reductions were also seen for anastomotic dehiscence, wound infection, pneumonia, intra-abdominal abscess and mortality....but these failed to reach significance (P>0.10). The risk of vomiting was increased among patients fed early however (P=0.046).

Source: BMJ Volume 323 6October2001

Early enteral feeding versus 'nil by mouth' after gastrointestinal surgery: systematic review and meta-analysis of controlled trials.

Lewis, S.J et al.

SORT: A Consistent, good-quality patient-oriented evidence*

Acorns(1-3):

Completed by: Mindy A. Fairbanks

Date last updated: 9/15/2010

Probiotics to Prevent Antibiotic Induced Diarrhea

2010-09-17T07:42:00.000-04:00

Original Question: is there any evidence to support the use of probiotics to prevent diarrhea when prescribing antibiotics to patients?

Question in PICO Format: In patients on antibiotics will patients given probiotics have less diarrhea than patients not on probiotics.

Searched Terms: probiotics AND antiobiotics AND diarrhea AND meta-analysis

Where searched: Google & PubMed to search : findings

(1) Of 31 randomized, placebo-controlled treatment arms in 27 trials (encompassing 5029 study patients), S. boulardii was found to be significantly efficacious and safe in 84% of those treatment arms. A meta-analysis found a significant therapeutic efficacy for S. boulardii in the prevention of antibiotic-associated diarrhea (AAD) (RR = 0.47, 95% CI: 0.35-0.63, P < 0.001). (World J Gastroenterol 2010 May 14)

(2) Meta-analysis of 10 randomized, blinded, placebo-controlled trials. A total of 1862 pediatric and adult patients who received a Lactobacillus single-agent regimen or placebo for the prevention of AAD. Ten studies with a total of 1862 patients (50.4% male) met all criteria. Six studies included patients aged 18 years or older, whereas four included patients younger than 18 years (range 2 wks-14 yrs). Jadad scores ranged from 2-5 (out of 5). The total daily dose of Lactobacillus ranged from 2 x 10(9)-4 x 10(10) colony-forming units and was administered throughout the entire antibiotic treatment (5-14 days) for all patients. The follow-up period varied from 2 days-3 months after the end of the probiotic regimen. The combined risk ratio (RR) of developing AAD was significantly lower with Lactobacillus compared with placebo (RR 0.35, 95% confidence interval [CI] 0.19-0.67). In a subgroup analysis, this held true for adults but not pediatric patients (RR 0.24, 95% CI 0.08-0.75 and RR 0.44, 95% CI 0.18-1.08, respectively).

CONCLUSION: Administration of a Lactobacillus single-agent regimen as a prophylactic agent during antibiotic treatment reduced the risk of developing AAD compared with placebo in adults but not pediatric patients.

(3) Five meta-analyses of trials of probiotics for the prevention of AAD have been performed. The results showed an overall reduction in the risk of AAD when probiotics were coadministered with antibiotics. McFarland conducted the largest meta-analysis to date analyzing 25 randomized controlled trials of probiotics for the prevention of AAD including 2810 subjects. More than half of the trials demonstrated efficacy of the probiotic. In particular, Lactobacillus GG, Saccharomyces boulardii, and the probiotic mixtures were effective. The Cochrane Database of Systematic Reviews published a review of the literature on the use of probiotics for the prevention of pediatric AAD, including 10 randomized trials testing 1986 children. The per protocol pooled analysis, but not the intent-to-treat analysis, showed that probiotics are effective for preventing AAD with the number needed to treat to prevent 1 case of diarrhea being 10. Lactobacillus GG, Bacillus coagulans, and S. boulardii appeared to be most effective. (J Clin Gastroenterol 2008 July)

(4) From 25 randomized controlled trials (RCTs), probiotics significantly reduced the relative risk of AAD (RR = 0.43, 95% CI 0.31, 0.58, p < 0.001). Using meta-analyses, three types of probiotics (Saccharomyces boulardii, Lactobacillus rhamnosus GG, and probiotic mixtures) significantly reduced the development of antibiotic-associated diarrhea. (published in Am J Gastro 2006 Apr)

Answer: Several meta analysis from 2006-2010 show statistically significant reduction in relative risk of (ADD) antibiotic associated diarrhea (RR ranging from 0.34 to 0.43) with one analysis showing number needed to treat being 10. Reduced ADD was shown specifically with Lactobacillus and S. Boulardii compared to placebo. One sub-group analysis did show failure to duplicate results in pediatric population defined as age under 18yo.

CONCLUSION: Probiotics, specifically Lactobacillus and S. Boulardii, have been shown to statistically reduce antibiotic associated diarrhea compared to placebo in adult patients with NNT =10.

Source: http://www.ncbi.nlm.nih.gov/pubmed/16635227 then used link for PubMed retrieval of articles :

http://www.ncbi.nlm.nih.gov/pubmed?term=probiotics%20AND%20antibiotics%20AND%20diarrhea%20AND%20meta%20analysis&itool=QuerySuggestion

SORT: A Consistent, good-quality patient-oriented evidence*

Acorns(1-3):

Completed by: Amanda Ruxton, D.O.

Date last updated: 9/14/2010

Iron therapy for Restless Leg Syndrome

2010-08-20T01:01:00.004-04:00

Original Question: Does iron therapy reduce symptoms in adults with Restless Leg Syndrome?

Question in PICO format:

-Population – adults with Restless Leg Syndrome

-Intervention – iron therapy

-Comparison – adults with Restless Leg Syndrome getting no iron thearpy

-Outcome – restless leg symptoms

Searched Terms: Restless Legs Syndrome AND iron

Where searched: Dynamed, PubMed, UpToDate

The answer is at: Dynamed; PubMed; UpToDate

Answer:

Short version:

Evidence favors the measurement of serum ferritin levels in patients with RLS and a trial of oral iron therapy when ferritin levels are low, and even in some patients whose ferritin levels are normal up to <75mcg/L.
SOR A

Long version:

-Dynamed:

level 4 evidence:

In 8 patients with RLS (met 4 criteria of International RL study group), iron deficiency (ferritin <20 mcg/L, mean 8.1), and frequent blood donations (3x/year in past 3yrs)…

•3 of 8 had resolution of all symptoms, and

•5 of 8 had marked symptom improvement.

Researchers suggest repleting iron until ferritin >50 ug/L (CSF ferritin can be low even if serum ferritin is normal).

http://www.mayoclinicproceedings.com/content/78/1/52.long

-PubMed:

level 1 evidence:

n = 60 RLS, mean ferritin <45, all randomized to

iron sucrose or saline placebo therapy. Outcome

measured by RLS severity scale.

•At week 11, there was no superiority as iron therapy reduced the severity score from 24 to 7, and placebo reduced severity score from 26 to 17.

•But at 7 weeks (acute phase) and at 12mo (long-term), iron was superior to placebo (5/29 dropouts for iron, vs 19/31 for placebo).

Even placebo has an effect, but iron appears to have greater long term effect.

Abstract: A randomized, double-blind, placebo controlled, multi-center study of intravenous iron sucrose and placebo in the treatment of restless legs syndrome.

Grote L, Leissner L, Hedner J, Ulfberg J. Mov Disord. 2009 Jul 30;24(10):1445-52.

Sleep Disorders Center, Department of Pulmonary Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden. ludger.grote@lungall.gu.se

Level 3 evidence…

Case control: 18 elderly with RLS (median ferritin 33), 18 matched controls (mean ferritin 59). Rating scale to assess RLS symptom severity (max 10).

15 RLS patients were treated with FeSO4 x2 mo; the severity score dropped by a median value of:

•4 points in six patients with an initial ferritin of <18

•3 points in four patients with ferritin 18-45

•1 point in five patients with ferritin 45-100 ug/L.

This is an improvement with iron therapy in 8 of 15 RLS patients. Ferritin inversely related with RLS severity.

Iron deficiency, with or without anemia, is an important contributor to the development of RLS in elderly patients, and iron supplements can reduce symptoms.

O'Keeffe, ST, Gavin, K, Lavan, JN. Iron status and restless leg syndrome in the elderly. Age Ageing 1994; 23:200.

Uptodate:

Level 1 evidence:

Randomized double-blind, placebo-controlled trial, (n=?) …showed that oral iron treatment significantly reduced RLS severity, even at normal ferritin levels (<75).

Consider iron therapy even if ferritin levels are within normal range (up to ferritin <75).

Salas RE, Gamaldo CE, Allen RP. Update in restless legs syndrome. Current Opinion in Neurology. 2010 Aug; 23(4):401-6. (not accessible.)

(Wang J, O’Reilly B, Venkataraman R, et al. Efficacy of oral iron in patients with restless legs syndrome and a low-normal ferritin: a randomized, double-blind, placebo-controlled study. Sleep Med 2009; 10:973–975.)

Level of Evidence: see above…SOR A for a trial of iron therapy if ferritin is ever <75 mcg/L

Completed by: Karen Isaacs MD, MPH

Date last updated: 9/8/10

stroke prevention, aggrenox vs. plavix in ASA failure

2010-08-20T00:56:00.001-04:00

Original Question : is there any increased efficacy in secondary stroke prevention using aggrenox vs plavix in patients who have failed asa therapy

Question in PICO Format:

Population = adults with failed asa therapy for stroke prevention

Intervention = aggrenox

Compared to = plavix

Outcome= decreased rate of additional strokes

In adults who have failed asa therapy for stroke prevention does treatment with aggrenox decrease rate of additional strokes versus treatment with plavix.

Searched Terms : “aggrenox versus clopidegrol in stroke prevention”

“ secondary stroke prevention guidelines”

Where did you search: Google – scholarly articles – ASA and extended release (then used AHEC to look at article in NEJM)

Google – secondary stroke prevention summary page –update to AHA/ASA Recommendations

Answer: No evidence showing either of the 2 treatments superior to the other in prevention of recurrent stroke.

Data Search Findings:

PRoFESS trial 2008 - first recurrence of stroke occurred in 9.0% of ASA-ERDP recipients and 8.8% of clopidogrel (95% CI 0.92-1.11). 25 fewer ischemic stokes in ASA-ERDP but 38 more hemorrhagic strokes but no significant difference in the risk of fatal or disabling stroke. No evidence that either of the 2 treatments was superior to the other in prevention of recurrent stroke

Although aspirin is known to confer a benefit in terms of reducing the risk of recurrent stroke, clopidogrel has also been implicated in a role for reducing stroke recurrence by approximately 8% compared with aspirin,¹⁶ while the combination of aspirin plus extended-release dipyridamole compared with aspirin have indicated an RR reduction of 20–23%^22,28 From indirect comparisons alone, one would gather that aspirin plus extended release dipyridamole would be superior to clopidogrel in secondary stroke prevention. With no guideline recommendations for any one of these therapies over the other,^5,6,44 the antiplatelet segments of the PRoFESS study aimed to compare the efficacy and safety of aspirin plus extendedrelease dipyridamole versus clopidogrel in patients who had recently suffered an ischaemic stroke.⁴¹

The much anticipated head-to-head comparison between aspirin plus extended-release dipyridamole and clopidogrel demonstrated comparable efficacy in secondary stroke prevention, with similar ability in preventing cardiovascular events, contrary to any advantage that may have been assumed through indirect comparisons. With this in mind, patients and physicians have a choice in their antiplatelet therapy after initial stroke, and may not have to base their decisions on efficacy alone, but possibly also on frequency of dosing, tolerability, adverse effects and cost. Notably, aspirin plus extended-release dipyridamole conferred a significant advantage over clopidogrel in reducing the risk of new or worsening congestive heart failure, an unexpected but welcome benefit that warrants further research.

Where is the answer:

1) N Engl J med 359;12 www.nejm.org September 18, 2008

2) stroke.ahajournals.org/cgi/reprint/STROKEAHA.107.189063

Strength of Recommendation: SOR A

Completed by: Amanda Ruxton D.O. PGY3

Date Completed: 8/17/10

Breast Cancer and Dense Breasts

2010-08-20T00:29:00.001-04:00

Question: Are woman with dense breasts at increased risk of breast cancer?

search AAFP

search term: breast cancer risk

Answer: breast density is an independent non-modifiable risk factor for breast cancer. Woman who have a breast density of at least 75% on mammography have an odds ratio of breast cancer of 4.7% (95% CI, 3.0-7.4), compared with woman who have breast density of 10 % or less.

Source: AAFP Dec 15, 2008 vol 78, Number 12

Boyd NF, Guo H, Martin LJ, et al. Mammographic density and the risk and detection of breast cancer N Engl J Med. 2007;356(3):227–236.

LOE

Claude Roofian MD

Diverticulitis and Antibiotics

2010-08-20T00:18:00.001-04:00

Original: do antibiotics improve M/M in acute diverticulitis

Question in PICO format: In adults with acute diverticulitis (uncomplicated) do
antibiotics compared with supportive care reduce short-term morbidity
and mortality?

Searched terms antibiotics and diverticulitis and guidelines and
observation

where searched google

Answer: Inflammation in patients treated with antibiotics was more
pronounced (laboratory parameters (C-reactive protein, white blood cell
count) were higher (p<0.01), fever was more common (p<0.01) and CT
grading of inflammation was classified as severe in a higher proportion
(p<0.01)) compared with patients treated without antibiotics. When
initially treated with antibiotics,
3 patients (3%) failed to respond to treatment and had to undergo
surgery.
There were 7 (4%) failures in patients initially treated without
antibiotics, and antibiotics were then added. During FU, 29% of patients
treated with antibiotics had further events (recurrent AD and/or
subsequent surgery) compared with 28% (NS) among those treated without
antibiotics. In a multivariate analysis, the risk of a further event was
not influenced by antibiotic treatment (OR 1.03, CI 95% 0.61-1.74).
CONCLUSIONS: Our results indicate that antibiotics are not mandatory in
mild AD. Treatment without antibiotics appears to be safe and seems not
to change the rate of further events. These results warrant further
randomized prospective studies.

located at:
http://informahealthcare.com/doi/abs/10.1080/00365520600780650

SOR: B

Adrienne Fehr, DO

8/19/2010

Otitis and xylitol

2010-08-19T23:50:00.002-04:00

Original Question: Does xylitol prevent acute otitis media?

Question in PICO format: In children with recurrent otitis media does chewing gum with xylitol effectively prevent acute otitis media (AOM) compared to placebo

Searched Terms: xylitol AND acute otitis media

Answer: Children who received xylitol chewing gum had a 40% lower occurrence of AOM than those who received a control chewing gum, and children who received a xyltiol mixture had a reduced AOM occurrence by 30% compared to a control mixture (5 doses per day x 2-3 months). Xylitol administered only during an acute respiratory infection was ineffective in preventing AOM.

Answer located at: BMJ 1996;313:1181-1184; Pediatrics 2002;109(2)

SOR: A Consistent, good-quality patient-oriented evidence*

Submitted by: Jodie Calain, D.O.

Reynold's vs Framingham low risk Females?

2010-08-19T23:36:00.001-04:00

Original Question: Is the Reynold's risk score a better predictor of 10 year coronary heart disease risk in women with no previous CAD history, as compared to Framingham risk score?

Question in PICO Format:
Population- women age 45 and older with no previous history of CAD
Intervention- Reynold's risk calculator
Comparison- Framingham Risk calculator
Outcome- 10 year CHD prediction, allowing for more intensive risk reduction therapy.

Searched Terms: Reynold's risk score + Framingham + CAD + women

Where searched: pubmed.gov

Answer: While Framingham risk calculator remains the most widely used. Women with intermediate CAD risk as determined by Framingham, may be further stratified into a higher or lower risk category with use of the Reynold's risk score. This is especially important in women with a family history of CAD or those with other risk factors such as diabetes, which Framingham fails to take into account. The Framingham risk score (FRS)is based on HTN, age, smoking, and LDL levels. Whereas, Reynold's risk score (RRS) is calculated using age, HTN, HBA1C, smoking, family history of MI < 60, hs-CRP, and HDL. A cohort study conducted by the Women's Health Initiative followed 24,558 randomly selected, initially healthy US women 45 years to 75 years old, for a median of 10.2 years for occurance of cardiovascular events. The RRS was proven to accurately reclassify 40-50% of women who fell into the intermediate category using ATP-III risk scores (ie. Framingham) into lower or higher risk categories. Therefore, RRS is especially usefull in determining an LDL treatment goal, calling for more aggressive management, as well as providing patients with a greater incentive for lifestyle modification.

Source: Ferdinant, Keith C., M.D, "Achieving Treatment Goals in Low Risk Asymptomatic Patients." JAOS, Vol 110, No.4, April, 2010, page 7-13.
Ridker, et al., Development and Validation of Improved Algorithms for the Assessment of Global Cardiovascular Risk in Women. JAMA, 2007; 297: 611-619

LOE: C Consensus, disease-oriented evidence,* usual practice, expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening

Completed by: Noha Mataoui, M.D

Date last updated: 8/18/2010

Premarin Cream and DVT Risk?

2010-08-19T23:28:00.001-04:00

Original Question: Are postmenopausal women who smoke and use Premarin at risk for blood clots?

Question in PICO Format:

P: postmenopausal women on premarin who smoke
I: smokers
C: non-smokers
O: increased risk of blood clots

Searched Terms: dangers of postmenopausal women who smoke and use premarin cream

Where searched: google.com

Answer: YES, postmenopausal women who smoke and use Premarin vaginal cream are a higher risk for blood clots. These women should be counseled to quit smoking. Those women who are not willing to quit smoking should not be started on estrogen creams.

Source: medlineplus.gov

Susan Storck, MD, FACOG, Chief, Eastside Department of Obstetrics and Gynecology, Group Health Cooperative of Puget Sound, Redmond, Washington; Clinical Teaching Faculty, Department of Obstetrics and Gynecology, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

LOE: A Consistent, good-quality patient-oriented evidence*

Completed by: Heather Merlo, M.D.

Date last updated: 8/18/2010

risk of untreated bipolar disorder in pregnancy

2010-08-19T23:24:00.001-04:00

Original Question: What is the risk of untreated bipolar disorder in pregnancy?

Question in PICO Format:
Population: women with Bipolar I or Bipolar II disorder who are receiving treatment with a mood stabilizer and are currently pregnant.
Intervention: Continuing with mood stabilizer during pregnancy
Control: Discontinuing mood stabilizer during pregnancy (no treatment)
Outcome: Was there a difference in mood episode occurrence

Searched Terms: Bipolar Disorder Pregnancy Treatment

Where searched: Google

Answer: The risk of recurrence of at least one mood episode was significantly higher in those who chose to discontinue treatment with a mood stabilizer. The relapse rates were higher after rapid versus slow discontinuation of mood stabilizers.

Source: American Journal of Psychiatry

LOE: A Consistent, good-quality patient-oriented evidence*

Completed by: Monique Moona

Date last updated: 8/18/2010

VBAC after second C/S

2010-08-19T23:20:00.001-04:00

Original Question: A patient presented to OB triage to rule out labor. In discussing her pregnancy course she mentioned that she really wanted a VBAC but she had already had 2 prior cesareans.

Question in PICO Format:
P: What is the recommendation for VBAC after Cesarean?
I: TOLAC after 2 cesarean deliveries
C: repeat cesarean
O: A TOLAC is an appropriate recommendation for a woman after 2 prior cesareans. A successful VBAC has fewer complications than a repeat cesarean, however a failed TOLAC may carry more complications than a repeat cesarean.

Searched Terms: VBAC,TOLAC

Where searched: ACOG, MD Consult, PubMED

Answer: In the past, a VBAC was a safe and appropriate recommendation for a patient with one prior lower transverse cesarean section. The new recommendations now state that a VBAC is an appropriate recommendation for women with two prior cesareans, women carrying twins, and women with an unknown uterine scar type.
A 60-80% of women attempting VBAC will be successful. A VBAC avoids major surgery, shortens the post-partum hospital course, and avoids potential complications of repeat cesarean surgeries. Women should be counseled about their increased risk of uterine rupture

Source: ACOG practice bulletin #115, August 2010 ACOG practice bulletin #54, July 2004

LOE: B Inconsistent or limited-quality patient-oriented evidence*

Completed by: Jennifer White

Date last updated: 8/18/2010

2nd Dose IVIG for Kawasaki Disease

2010-08-19T23:07:00.001-04:00

Original Question: How to treat treatment resistant Kawasaki disease

Question in PICO Format:
population - 70KD patients who received IVIG were reviewed
intervention - IVIG 2 g/kg, second dose if persistent fever, then iv methylprednisolone
comparison - group responded to first dose IVIG, group that responded to second dose IVIG, and group who go IV methylprednisolone; evaluated with echo two months later for coronary artery lesions
outcome - those who responded to IVIG had significantly fewer coronary artery lesions
Searched Terms: Kawasaki treatment, Kawasaki resistant treatment, Kawasaki resistance

Where searched: pubmed

Answer: You can use second dose of IVIG and possibly methylprednisolone for resistant KD but they have a higher rate of coronary lesions in the future.

Source: Singapore Medical Journal

LOE: A Consistent, good-quality patient-oriented evidence*

Completed by: Jessica Knapp DO

Date last updated: 8/17/2010

Acupuncture for Migraines

2010-04-20T16:14:00.001-04:00

Original Question: Is acupuncture effective in migraine prophylaxis –

Question in PICO format: In pregnant patient with migraines who did not want oral medications. In patients in family medicine is acupuncture, compared to proven prophylactic drug treatment, effective for migraine prophylaxis.

Searched Terms: Acupuncture AND migraine prophylaxis

Where Searched: google

Answer: According to 4 Cochrane Review articles acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment for migraine headaches and has fewer adverse effects.

Answer located at: www.cochrane.org/reviews/en/ab001218.html

SOR: A Consistent, good-quality patient-oriented evidence*

ACORNs : 2

By: Amanda Ruxton, D.O. PGY2 3/30/2010

Anemia and Cord Clamping in Newborns

2010-02-12T09:56:00.000-05:00

Original Question: Does delayed cord clamping decrease risk of anemia in the newborn?

Question in PICO Format: Population- newborn infants

Intervention- delayed cord clamping

Compared to: early cord clamping

Outcome- decreased risk of anemia

Searched Terms: Delayed cord clamping + anemia + AAFP

Where did you search? google.com

Answer: Delayed cord clamping reduces risk of anemia in infants by increasing blood volume, ferritin levels and iron stores. This is evident in the first 24 hours and lasts well into six months of age.

Where is the source? AAFP. "Evidence Favors Late Cord Clamping in Infants," Caroline Wellbery, MD. Jan 15, 2008.

Strength of Recommendation: A Consistent, good-quality patient-oriented evidence*

ACORN Rating : 1

Completed By: Noha Mataoui, M.D

Date Completed: 2/12/2009

CPR 30:2 Is Better

2010-02-12T09:54:00.000-05:00

Original Question: What is the evidence behind the change in CPR guidelines from 15:2 to 30:2.

Question in PICO Format: P. General population I. More compressions C.15:2 vs 30:2

O. More compressions equals better survival rate,

Retrospective cohort study. Ongoing studies new guidelines to come out this year.

Searched Terms: CPR changes

New CPR guidelines and evidence

Where did you search? American Heart Association

AAFP

Google Scholar

Answer: A study at Kansas City Emergency Medical Services (EMS) in 2006 with increased compressions from 15 to 50 with 2 breaths revealed survival from out-of-hospital cardiac arrest increased from 7.5 to 13.9 percent. Of patients whose cardiac arrest was witnessed by bystanders and who were initially in ventricular fibrillation, the success of resuscitation in restoring a heartbeat and getting the patient to the hospital alive improved from 37.8 percent (54 of 143) to 59.6 percent (34 of 57 patients).

Of patients whose cardiac arrest was witnessed by bystanders and who were in ventricular fibrillation, survival to hospital discharge rose from 22.4 percent (32 of 143) to 43.9 percent (25 of 57). Of the 25 discharged patients, 88 percent scored well on measures of brain function. Also discussed was the fact that with more compressions and more blood flow to the heart AED is more likely to be successful.

Where is the source? American Heart Association

" Have the latest CPR guidelines improved cardiac arrest outcomes? " Review article by Klocko, MPAS, PA-C http://media.jaapa.com/documents/11/review-emergency1109_2665.pdf

Strength of Recommendation: A Consistent, good-quality patient-oriented evidence*

ACORN Rating : 1

Completed By: Erin Griffin, DO

Date Completed: 2/11/2010

Vitamin D and Infants

2010-02-12T09:52:00.001-05:00

Original Question: Is vitamin D supplementation for all infants necessary?

Question in PICO Format: Infants

Searched Terms: Supplementation of Vitamin D and infants

Where did you search? Pub Med

Medline

Answer: the serum concentration of vitamin D falls rapidly after birth unless additional sources are available. AAP RECOMMENDS 400IU daily of vitamin D for all infants.All infant formulas sold in the United States have at least 400 IU/L of vitamin D3. Because most formula-fed infants ingest nearly 1 L or 1 qt of formula per day after the first month of life, they will achieve a vitamin D intake of 400 IU/day. Infants who are both breastfed and formula should get a vitamin D supplement of 400 IU/day to ensure an adequate intake. As

infants are weaned from breastfeeding and/or formula,intake of vitamin D–fortified milk should be encouraged to provide at least 400 IU/day of vitamin D. If an infant has a risk factor for a decrease in vitamin D (mother deficient in vitamin D) supplementation is indicated.

Where is the source? American Academy of Pediatrics: Prevention of Rickets and Vitamin D deficiency in Infants, Children, and Adolescents 2008.

Strength of Recommendation: C Consensus, disease-oriented evidence,* usual practice, expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening

ACORN Rating : 1

Completed By: Shalini K Vaid, MD

Date Completed: 2/11/2010

Constipation in Children

2010-02-12T09:29:00.001-05:00

Original Question: Clinic patient with constipation.

Question in PICO Format: Population-children aged 6-12 years old.

Intervention-medication and behavioral therapy

Comparision-medication alone

Outcome-behavioral treatment is recommended as an adjunct to medical therapy in children with functional constipation.

Searched Terms: constipation, children, treatment

Where did you search? AAFP

Answer: Behavioral therapy is recommended as an adjunct to medical therapy in children with functional constipation.

Where is the source? AAFP.

Strength of Recommendation: A Consistent, good-quality patient-oriented evidence*

ACORN Rating : 1

Completed By: Beena Patel, DO.

Date Completed: 12:00:00 AM