Essential Evidence

Author: David Slawson, Allen Shaughnessy, Mark Ebell, Henry Barry
Affiliation: University of VA Health System, Charlottesville, USA
Publisher: Wiley-Blackwell
Publication Date: 2007
ISBN 10: 0470178906
ISBN 13: 9780470178904
eISBN: 9780470484814
Edition: 1st

Description:

Essential Evidence: Medicine that Matters is a collection of more than 350 of the most influential, compelling InfoPOEMs (Patient-Oriented Evidence that Matters) available, selected and organized by a panel of some of the world's most recognized leaders in evidence-based medicine.

Table of Contents

Front Matter

  • ABOUT
  • THE WILEY BICENTENNIAL—KNOWLEDGE FOR GENERATIONS
  • Preface
  • Taking an Evidence-Based Approach to the Care of Patients
  • How to Become an Information Master: Feeling Good about NOT Knowing Everything

Cancer

    Breast Cancer

    • Most women with breast cancer have no risk factors
    • Raloxifene reduces breast cancer risk (CORE)
    • Raloxifene and tamoxifen equally effective in reducing breast cancer risk
    • Raloxifene decreases breast cancer risk, no effect on cardiovascular disease risk (RUTH)
    • MRI more accurate than mammogram in high-risk patients
    • MRI more sensitive than mammography in high-risk women (MARIBS)
    • Digital mammography more sensitive for younger women
    • Mammography results in overdiagnosis
    • Annual mammography starting at 40 doesn’t lower breast cancer mortality

    Gynecologic cancers

    • Many unnecessary Pap smears are performed after hysterectomy
    • Specific HPV strains are associated with cervical cancer risk
    • Vaccine effective against HPV
    • Bivalent vaccine against HPV effective for 4.5 years
    • Liquid-based not better than conventional Pap
    • Endometrial sampling adequate for diagnosing endometrial cancer

    Melanoma

    • Melanoma incidence really not rising
    • Lifetime risk of mole transforming to melanoma very low
    • 0.7% of congenital melanocytic nevi become malignant
    • Dermoscopy with validated criteria more sensitive than unaided eye
    • Larger margins better in melanoma >2 mm thick

    Prevention and screening

    • Antioxidants don’t prevent GI cancers, and may increase overall mortality
    • Vitamin E doesn’t lower women’s risk of cardiovascular disease or cancer
    • Antioxidants don’t prevent colorectal cancer
    • Mammography, FOBT and CXR don’t reduce all-cause mortality
    • Spiral CT detects early lung cancer, but screening use is premature
    • Cancer linked to some diabetes treatments

    Prostate cancer

    • Finasteride of mixed benefit in preventing prostate cancer
    • Prostate cancer screening every 4 years as good as annually
    • False-positive PSA associated with increased worry, fears
    • Elevated PSA should be confirmed before biopsy
    • Radical prostatectomy improves outcomes in symptom-detected prostate cancer

Cardiology

    Acute myocardial infarction and acute coronary syndromes

    • Early metoprolol in acute MI: no benefit, possible harm (COMMIT; CCS-2)
    • Insulin/dextrose infusion ineffective in AMI (HI-5)
    • Early initiation of statins following ACS does not improve outcomes
    • Antibiotics not effective in acute coronary syndromes
    • ABCDE approach to non-ST-segment elevation ACS
    • Door-to-balloon time important in STEMI
    • Routine invasive strategy may be preferred for ACS
    • Intensive medical tx + selective PCI preferred for non-ST ACS
    • Invasive tx slightly better in non-ST-elevation ACS (RITA3)
    • In ACS, 5 years of invasive tx decreases MI but not all cause mortality (FRISC-II)
    • Captopril = losartan for reducing all-cause mortality after MI
    • Captopril better than valsartan or combination post-MI
    • Implantable defibrillators are not effective post-MI

    Anticoagulation management

    • Start warfarin at 10 mg faster for outpatient anticoagulation
    • Use an algorithm to start warfarin in older patients
    • Self-monitoring of anticoagulation safe, effective
    • Self-monitoring anticoagulation superior at preventing venous thromboembolics events
    • INR 1.5–1.9 less effective than 2.0–3.0 for idiopathic DVT
    • Oral vitamin K works faster than subcutaneous
    • Oral vitamin K effective for warfarin overdose

    Atrial fibrillation

    • Clinical decision rules accurately predict stroke risk in atrial fibrillation
    • Thromboembolism just as likely with atrial flutter
    • Warfarin prevents more strokes than clopidorel + ASA in atrial fibrillation (ACTIVE)
    • Ximelagatran effective in preventing stroke in atrial fibrillation
    • Quality of life with rate or rhythm control in atrial fibrillation (AFFIRM)
    • Rate control better than rhythm control in atrial fibrillation (AFFIRM)
    • Amiodarone > sotalol > placebo for maintaining NSR in atrial fibrillation (SAFE-T)

    Coronary artery disease

    • Mediterranean diet associated with lower all cause mortality
    • Coffee does not increase risk of developing CAD
    • Vitamin E has no effect on cardiovascular disease
    • Lowering homocysteine does not reduce cardiovascular disease (HOPE 2)
    • Omega 3 fatty acids do not affect mortality
    • Folic acid supplementation does not reduce cardiovascular disease risk nor mortality
    • Fenofibrate doesn’t prevent coronary events in DM (FIELD)
    • Optimal oral antiplatelet therapy for vascular disease
    • Clopidogrel + ASA no better than ASA alone for high-risk patients
    • Clopidogrel beneficial added to ASA, fibrinolytic in STEMI
    • Aspirin reduces risk of CV events, increases risk of bleeding
    • Aspirin + PPI safer than clopidogrel if history of GI bleed
    • Electron beam tomography not helpful
    • Chest pain relief by NTG doesn’t predict active CAD
    • Ranolazine adds little to maximum antianginal therapy (ERICA)
    • Better outcomes with CABG than PCI with stent for 2, 3 vessel disease
    • Adding ACEI doesn’t improve outcomes in stable angina w/nl LVEF (PEACE)

    COX-2 inhibitors and heart disease

    • Rofecoxib increases risk of cardiovascular events
    • Celecoxib increases risk of cardiovascular complications
    • Rofecoxib, diclofenac and indomethacin increase risk of CVD

    Heart failure

    • BNP improves outcomes in evaluation of dyspnea
    • BNP testing beneficial with CHF + pulmonary dx
    • Serial BNP levels predict risk of death and CHF after ACS
    • Higher BNP and N-ANP predict CV events
    • ARBs = ACEIs for all-cause mortality in heart failure
    • Optimal digoxin range for men 0.5 to 0.8 ng/ml
    • Digoxin increases mortality in women with heart failure
    • Nesiritide for CHF may increase mortality risk
    • Implantable defibrillators reduces mortality in NYHA Class II heart failure

    Hyperlipidemia

    • Herbs may reduce cholesterol, no data on clinical outcomes
    • Statins prevent CAD
    • Cholesterol lowering cost-effective in high-risk elderly
    • Intensive lipid lowering of marginal benefit even if high-risk
    • Cardiology Varying effects of lipid drugs on overall mortality
    • Statins equivalent for CVD prevention
    • Intensive lipid lowering with statins unnecessary with stable CAD (IDEAL)

    Hypertension

    • JNC 7 report on prevention/evaluation/treatment of hypertension
    • Work stress has no meaningful effect on blood pressure
    • Pseudoephedrine has a minimal effect on blood pressure
    • Habitual caffeine intake does not increase risk of hypertension in women
    • Home blood pressure monitoring valuable
    • Office measurements usually overestimate blood pressure
    • Hypertension follow-up: 3 months = 6 months
    • Patients with HTN + high lipids may benefit less from statins (ALLHAT)
    • Excessive lowering of blood pressure causes more harm than good
    • Diuretics clearly first line agent for HTN (ALLHAT)
    • Meta-analysis supports diuretics as first line for HTN
    • Outcomes for thiazides similar
    • ACEI better than diuretic in older men for hypertension
    • Atenolol of questionable efficacy for HTN
    • Beta-blockers > placebo, not other drugs, in preventing HTN complications
    • Renal function similarly affected by antihypertensives (ALLHAT)

    Peripheral vascular disease and aneurysm

    • Screening program for abdominal aortic aneurysm ineffective
    • Fewer aneurysm deaths but not overall deaths with AAA screening
    • CABG not helpful before AAA or peripheral vascular surgery
    • EVAR worse than open repair of AAA (EVAR Trial 1)
    • Bypass = angioplasty for severe leg ischemia, but costs more (BASIL)

    Pulmonary hypertension

    • Sildenafil effective for primary pulmonary hypertension
    • Sildenafil = bosentan in pulmonary hypertension (SERAPH)

    Thrombophilias

    • Testing for prothrombotic defects not necessary after first DVT
    • Management of antiphospholipid antibody syndrome

    Venous thromboembolism

    • Fixed-dose, subcutaneous, unfractionated heparin effective for VTE
    • Compression stockings prevent post-thrombotic syndrome
    • Routine use of vena cava filters doesn’t reduce mortality
    • At least 6 months of anticoagulation optimal to prevent recurrent VTE
    • LMWH better than warfarin in preventing recurrent DVT in cancer patients

    Venous thromboembolism diagnosis and prognosis

    • Best tests to rule in, rule out PE
    • Clinical prediction rules accurate for PE diagnosis
    • Validated algorithm for evaluating suspected PE
    • Optimal algorithm for evaluating suspected DVT
    • Multidetector CT accurate for PE, but requires clinical context
    • Negative CT scan to rule out PE equal to angiography
    • Determining major bleeding risk with warfarin for DVT
    • D-dimer useful for excluding DVT and PE
    • D-dimer < 250 ng/mL predicts low risk of VTE recurrence

Care of Infants and Children

    ADHD

    • Restricted diet improves parental perception of hyperactive behavior
    • Stimulants similarly effective for ADHD
    • Responders to atomoxetine do well with lower doses

    Anemia

    • Anemia not prevented by iron in infants
    • Care of Infants and Children Anemia doesn’t predict iron deficiency among toddlers

    Asthma

    • Long-term budesonide does not effect adrenal function in children
    • Care of Infants and Children Amoxicillin for 3 days effective for pediatric pneumonia
    • Educational programs effective for young asthmatics

    Diarrhea

    • Nitazoxanide reduces rotavirus duration in hospitalized kids
    • Oral rotavirus vaccines safe and effective
    • Intense diet-behavior-physical activity effective for obese children
    • Evidence lacking for milk’s benefit in children

    Prevention

    • Vaccine exposure does not increase risk of infectious disease hospitalization
    • Dental restoration with amalgam (mercury) safe in children
    • School-based violence prevention programs not proved

    Otitis media

    • Delayed prescription for AOM reduces unnecessary antibiotics
    • Care of Infants and Children Parent satisfaction okay with no treatment of AOM
    • Parents prefer shared decision-making for AOM
    • Care of Infants and Children Tubes marginally effective in otitis media with effusion
    • Early tympanostomy tubes do not improve outcomes after 3 or more years
    • Care of Infants and Children Prompt tympanostomy tube insertion doesn’t improve 9 year outcomes

    Other pediatric problems

    • Bed and pillow covers ineffective for allergic rhinitis
    • Care of Infants and Children Risk scoring system predicts mortality in pediatric ICU
    • Petroleum jelly doesn’t reduce recurrent pediatric epistaxis
    • Care of Infants and Children Effective and ineffective interventions for infant colic

    Respiratory infections and fever

    • Ear thermometry is unreliable in detecting fever
    • Care of Infants and Children Acetaminophen, ibuprofen comparable for pain, fever in children
    • Cough suppressants ineffective in children
    • Care of Infants and Children Delayed prescriptions for URIs reduce antibiotic use
    • Amoxicillin for 3 days effective for pediatric pneumonia

    Sore throat

    • Care of Infants and Children Herbal tea effective for symptoms of acute pharyngitis
    • Steroids provide brief relief of pain in mononucleosis
    • Care of Infants and Children Echinacea purpurea ineffective for treating URI in kids

Complementary and Alternative Medicine

    Diarrhea

    • Yogurt prevents antibiotic-associated diarrhea
    • Probiotics helpful for antibiotic-associated diarrhea
    • Probiotics effective in preventing acute diarrhea, but not traveler’s diarrhea

    Diet and exercise

    • Popular diets equally effective for losing weight
    • Mediterranean diet associated with lower all cause mortality
    • Omega 3 fatty acids do not affect mortality
    • Diet and exercise prevent diabetes in high-risk patients

    Mental health problems

    • Restricted diet improves parental perception of hyperactive behavior
    • Variable support for CAM therapies for anxiety
    • Antioxidants do not prevent dementia
    • Lowering homocysteine with B vitamins doesn’t improve cognition
    • Vitamin E, donepezil ineffective for mild cognitive impairment
    • Light therapy as effective as fluoxetine for seasonal affective disorder

    Musculoskeletal problems

    • Acupuncture effective for chronic back pain
    • Tai chi improves symptoms of osteoarthritis
    • Acupuncture effective for OA of the knee
    • Acupuncture ineffective for fibromyalgia
    • Acupuncture better than sham treatment for neck pain

    Prevention of cancer

    • Vitamin E not helpful, perhaps harmful
    • Vitamin E doesn’t lower women’s risk of cardiovascular disease or cancer
    • Vitamin E has no effect on cardiovascular disease
    • Antioxidants don’t prevent GI cancers, and may increase overall mortality
    • Antioxidants don’t prevent colorectal cancer
    • Green tea consumption is associated with reduced mortality
    • DHEA, testosterone not effective in aging patients
    • Lowering homocysteine does not reduce cardiovascular disease (HOPE 2)
    • Folic acid supplementation does not reduce cardiovascular disease risk nor mortality
    • Herbs may reduce cholesterol, no data on clinical outcomes

    Upper respiratory problems

    • Herbal tea effective for symptoms of acute pharyngitis
    • Petroleum jelly doesn’t reduce recurrent pediatric epistaxis
    • Saline nasal irrigation effective for frequent sinusitis
    • Forcing fluids during a respiratory infection unsupported by studies
    • Zinc nasal gel reduces duration of common cold
    • Echinacea purpurea ineffective for treating URI in kids
    • Echinacea doesn’t shorten or lessen cold symptoms

    Women’s health

    • Black cohosh ineffective for vasomotor symptoms
    • Acupuncture ineffective for hot flashes
    • Lactobacillus doesn’t prevent post-antibiotic vaginitis
    • Immersion exercise reduces leg edema in pregnancy

Endocrinology

    Diabetes

    • Diet and exercise prevent diabetes in high-risk patients
    • Treating prediabetes does not affect progression
    • Rosiglitazone delays developing diabetes mellitus (DREAM)
    • Hypertension control most important aspect of diabetes care
    • Fenofibrate doesn’t prevent coronary events in diabetes mellitus (FIELD)
    • Home glucose monitoring makes little difference in type 2 diabetes
    • Rosiglitazone more likely to succeed as monotherapy clinical outcomes no better
    • ACE inhibitors beneficial in diabetics
    • ARB no better than ACEI for prevention of nephropathy progression
    • Pioglitazone ineffective in secondary prevention of macrovascular complications (PROactive)
    • Cancer linked to some diabetes treatments
    • Duloxetine decreases pain of diabetic neuropathy

    Obesity

    • Weight loss interventions have little effect on quality of life
    • Popular diets equally effective for losing weight
    • Intense diet-behavior-physical activity effective for obese children
    • Rimonabant minimally effective for weight loss
    • Topiramate beneficial for binge eating disorder with obesity
    • Bariatric surgery effective for morbid obesity

Eye, Ear, Nose and Throat

    Allergic rhinitis

    • Bed and pillow covers ineffective for allergic rhinitis
    • Pollen blocker cream effective for allergic rhinitis
    • Montelukast alone ineffective for allergic rhinitis

    Epistaxis

    • Petroleum jelly doesn’t reduce recurrent pediatric epistaxis

    Eye problems

    • Lutein improves vision with macular degeneration in men
    • Three indicators herald bacterial conjunctivitis in adults
    • Antibiotics for conjunctivitis decreases symptom duration
    • Diet high in beta carotene, vitamins C and E, and zinc may reduce risk of macular degeneration

    Otitis media

    • Parent satisfaction okay with no treatment of AOM
    • Parents prefer shared decision-making for AOM
    • Delayed prescription for AOM reduces unnecessary antibiotics
    • Tubes marginally effective in otitis media with effusion
    • Early tympanostomy tubes do not improve outcomes after 3 or more years
    • Prompt tympanostomy tube insertion doesn’t improve 9 year outcomes

    Sinusitis

    • Saline nasal irrigation effective for frequent sinusitis
    • Intranasal steroids alone effective for acute uncomplicated sinusitis

    Sore throat

    • Herbal tea effective for symptoms of acute pharyngitis
    • Steroids provide brief relief of pain in mononucleosis

    URI

    • Gargling with water prevents colds
    • Delayed prescriptions for URIs reduce antibiotic use
    • Forcing fluids during a respiratory infection unsupported by studies
    • Zinc nasal gel reduces duration of common cold
    • Echinacea purpurea ineffective for treating URI in kids
    • Antibiotics slightly effective for purulent rhinitis
    • Echinacea doesn’t shorten or lessen cold symptoms

Gastrointestinal Problems

    Diarrhea and gastroenteritis

    • Yogurt prevents antibiotic-associated diarrhea
    • Probiotics helpful for antibiotic-associated diarrhea
    • Probiotics effective in preventing acute diarrhea, but not traveler’s diarrhea
    • Nitazoxanide reduces rotavirus duration in hospitalized kids
    • Oral rotavirus vaccines safe and effective
    • Ondansetron effective for gastroenteritis with vomiting

    Dyspepsia and gastrointestinal bleeding

    • Omeprazole 20 mg = 40 mg for primary care acid-related dyspepsia
    • Omeprazole, ranitidine effective for HP negative dyspepsia (CADET-HN)
    • 4 drugs for 1 day eliminates H. pylori
    • Aspirin + PPI safer than clopidogrel if history of GI bleed

    Gastroesophageal reflux disease

    • A PPI test does not improve diagnosis of GERD
    • Gastrointestinal Problems Lifestyle changes of little benefit in GERD
    • All PPIs equivalent for treatment of GERD

    Hepatobiliary disorders

    • Acetaminophen does not affect liver function in alcoholics
    • Evaluation of abnormal liver chemistries
    • Enteral nutrition preferred in pancreatitis
    • Antibiotic prophylaxis reduces mortality in hospitalized cirrhotics

Gynecology

    Cervical and endometrial cancer

    • Many unnecessary Pap smears are performed after hysterectomy
    • Specific HPV strain are associated with cervical cancer risk
    • Vaccine effective against HPV
    • Bivalent vaccine against HPV effective for 4.5 years
    • Liquid-based not better than conventional Pap
    • Endometrial sampling adequate for diagnosing endometrial cancer

    Infertility and contraception

    • Avoid nonoxynol-9 spermicides with less than 100 g per dose
    • Metformin increases fertility in PCOS

    Menopause

    • HRT with estrogen alone increases stroke, decreases fractures
    • Clonidine, gabapentin, and some SSRIs effective for hot flashes
    • Black cohosh ineffective for vasomotor symptoms
    • Acupuncture ineffective for hot flashes
    • HRT increases risk of stress, urge urinary incontinence

    Vaginitis

    • Weekly fluconazole reduces recurrent candidiasis, though costly
    • Lactobacillus doesn’t prevent post-antibiotic vaginitis

Hematology

    Anemia

    • Anemia not prevented by iron in infants
    • Anemia doesn’t predict iron deficiency among toddlers
    • Repeated blood testing causes anemia
    • Oral as good as IM vitamin B12 replacement

    Thrombophilias

    • LMWH better than warfarin in preventing recurrent DVT in cancer patients
    • Testing for prothrombotic defects not necessary after first DVT
    • Management of antiphospholipid antibody syndrome

Infectious Disease

    Prevention

    • Oral rotavirus vaccines safe and effective
    • Acellular pertussis vaccine 63% to 92% effective
    • Vaccine exposure does not increase risk of infectious disease hospitalization
    • Antibacterial household products don’t reduce infectious symptoms

    Prescribing practices

    • Cephalosporins often safe in PCN-allergic patients
    • Prescribing antibiotics does not save time
    • Delayed prescription for AOM reduces unnecessary antibiotics
    • Delayed prescriptions for URIs reduce antibiotic use

    Respiratory infections

    • Flu shots are effective in elderly
    • Useful signs and symptoms for diagnosis of influenza
    • Steroids provide brief relief of pain in mononucleosis

Kidney Diseases

    Diabetic nephropathy

    • ACE inhibitors beneficial in diabetics
    • ARB no better than ACEI for prevention of nephropathy progression

    Gout

    • Meat, seafood, and little dairy are risk factors for gout
    • Febuxostat = allopurinol for gout prophylaxis

    Renal failure

    • Low-dose dopamine ineffective for acute renal failure
    • Furosemide doesn’t prevent acute renal failure

    Urinary tract infection and dysuria

    • Treating negative dipstick dysuria decreases symptoms
    • Immediate-and extended-release ciprofloxacin similar for UTI

Musculoskeletal Problems

    Back and neck pain

    • Acupuncture effective for chronic back pain
    • Surgery better than no surgery for spinal stenosis
    • Acupuncture better than sham treatment for neck pain
    • Useful treatments for fibromyalgia syndrome
    • Acupuncture ineffective for fibromyalgia

    Degenerative joint disease

    • Acetaminophen = celecoxib in DJD
    • Knee taping useful for osteoarthritis pain
    • Tai chi improves symptoms of osteoarthritis
    • Study Design
    • Acupuncture effective for OA of the knee
    • Rofecoxib increases risk of cardiovascular events
    • Celecoxib increases risk of cardiovascular complications
    • Rofecoxib, diclofenac and indomethacin increase risk of CVD
    • Rofecoxib cardiovascular risks known in 2000
    • Arthroscopy ineffective for osteoarthritis of knee
    • Obesity does not effect 5-year knee replacement outcomes

    Osteoporosis and fractures

    • Musculoskeletal Problems Monthly vitamin D prevents fractures
    • Calcium/vitamin D effective for prevention of first fracture
    • Calcium/vitamin D not effective for secondary prevention of fracture (RECORD)
    • 1000 mg calcium/400 IU vit D not very effective for fracture prevention (WHI)
    • HRT with estrogen alone increases stroke, decreases fractures
    • Long-term PPI use increases hip fracture risk
    • Most women quickly stop taking bisphosphonates
    • Evidence lacking for milk’s benefit in children
    • Folate and vitamin B12 lowers fracture risk after stroke
    • Falls prevented in elderly by formal assessment or exercise program
    • Early mobilization better for acute limb injuries

    Other musculoskeletal problems

    • Nonsurgical treatment effective for carpal tunnel
    • PET scan best in chronic osteomyelitis diagnosis
    • Extracorporeal shock wave therapy is ineffective for tennis elbow
    • Tennis elbow: injection better short-term, worse long-term

Neurology

    Headache

    • Metoclopramide (Reglan) effective in migraine
    • Intranasal zolmitriptan effective for cluster headaches
    • Specific headache criteria useful for migraine diagnose, neuroimaging

    Herpes zoster

    • Herpes zoster vaccine safe and effective for older adults
    • Tricyclics drug of choice for post-herpetic neuralgia

    Insomnia

    • Melatonin effective for some sleep disorders
    • Cognitive therapy superior to zopiclone for insomnia

    Syncope and vertigo

    • Simple maneuvers can decrease vasovagal syncope episodes
    • Steroid effective for vestibular neuritis, valacyclovir is not

    Stroke

    • ASA prevents stroke, not MI, in women
    • ASA + dipyridamole better than ASA for cerebral ischemia (ESPRIT)
    • Warfarin increases mortality in intracranial arterial stenosis
    • Lipid-lowering prevents stroke in patients with or without CHD
    • High-dose atorvastatin reduces recurrent stroke, not mortality (SPARCL)
    • ABCD rule predicts 7 -day stroke risk in TIA
    • ABCD rule predicts 7- and 30-day stroke risk in patients with TIA
    • Eight clinical findings distinguish stroke from stroke mimics
    • Noninvasive carotid imaging can replace invasive imaging
    • Three percent of TIA patients have a stroke within 30 days (BASIC)
    • Endarterectomy best within 2 weeks of stroke or TIA
    • Carotid stent inferior to carotid endarterectomy
    • PEG tubes worsen quality of life in stroke (FOOD)

Pregnancy Care

    Labor management

    • Fetal pulse oximetry does not reduce operative delivery
    • Suction before delivery of shoulders doesn’t prevent meconium aspiration
    • VBAC with prior vaginal delivery safer than cesarean

    Prenatal care

    • Risk-based screening for GDM effective
    • Steroids effective for hyperemesis gravidarum
    • Immersion exercise reduces leg edema in pregnancy
    • Aspirin = enoxaparin for prevention of recurrent miscarriage

    Preterm labor

    • Prenatal vaginal infection screening + treating reduces preterm delivery
    • Oral clindamycin for BV prevents prematurity

Psychology and Substance Abuse

    ADHD

    • Restricted diet improves parental perception of hyperactive behavior
    • Stimulants similarly effective for ADHD
    • Responders to atomoxetine do well with lower doses

    Antipsychotics and schizophrenia

    • Newer antipsychotics similar to older agents (CATIE)
    • Atypical antipsychotics minimally effective, poorly tolerated in Alzheimer’s disease
    • Older, newer antipsychotics both increase mortality in elderly

    Anxiety and stress

    • Variable support for CAM therapies for anxiety
    • Work stress has no meaningful effect on blood pressure

    Dementia

    • Antioxidants do not prevent dementia
    • Lowering homocysteine with B vitamins doesn’t improve cognition
    • Reasoning training slows age-related functional decline
    • Statins not associated with decreased dementia
    • Vitamin E, donepezil ineffective for mild cognitive impairment
    • Drug therapy minimally effective for neuropsych symptoms of dementia
    • Minimal effect of cholinesterase inhibitors for Alzheimer’s
    • Haloperidol shortens duration, intensity but not frequency of post -op delirium
    • Small increased risk of death with atypical antipsychotics for dementia
    • Older, newer antipsychotics both increase mortality in elderly

    Depression

    • Two question screening for depression effective
    • No difference among new antidepressants
    • Alternative medications are similarly effective for depression treatment failures (STAR*D)
    • Suicide rates equal regardless of antidepressant type
    • Antidepressant drugs increase suicidal behavior in children
    • Newer antidepressants increase suicidality in youths
    • Light therapy as effective as fluoxetine for seasonal affective disorder

    Tobacco abuse

    • Smoking cessation 6–8 weeks before surgery reduces complications
    • 12 weeks of varenicline is effective for smoking cessation
    • 6 weeks of varenicline is also effective for smoking cessation

Respiratory Problems

    Asthma

    • Educational programs effective for young asthmatics
    • Bed and pillow covers ineffective for asthma
    • Exhaled nitric oxide and sputum analysis useful for asthma diagnosis
    • Intermittent = continuous therapy for mild persistent asthma
    • Salmeterol + fluticasone better than fluticasone for asthma (GOAL)
    • Don’t double steroid dose in deteriorating asthma
    • Long-term budesonide does not effect adrenal function in children

    COPD

    • Procalcitonin test can reduce antibiotic use in COPD
    • Corticosteroids benefit patients with moderate to severe COPD
    • Anticholinergics are better than beta-agonists in COPD treatment

    Lower respiratory infections

    • Cough suppressants ineffective in children
    • No antibiotics necessary for lower respiratory infection
    • “Chest cold” instead of “bronchitis” decreases unnecessary antibiotic use
    • Pelargonium effective for acute bronchitis symptoms
    • Single oral dose dexamethasone effective for even mild croup
    • Data on treating bronchiolitis severely limited

    Pneumonia

    • Blood cultures add little to pneumonia care
    • Antibiotics with atypical bacteria coverage unnecessary
    • Outpatient = inpatient for low -risk patients with pneumonia
    • Antibiotic choice makes little difference in community -acquired pneumonia
    • Pneumonia: 3 days of antibiotics for uncomplicated course
    • Amoxicillin for 3 days effective for pediatric pneumonia
    • 7-day levofloxacin slightly better than 1-day azithromycin for pneumonia

Skin Diseases

    Acne vulgaris

    • Milk intake correlates with increased risk of acne in women
    • Dapsone gel effective for acne vulgaris treatment

    Dermatitis

    • Effective prevention and treatment of contact dermatitis
    • Immunosuppressives = steroids for atopic dermatitis
    • Once-daily topical steroid dosing just as effective for atopic eczema

    Herpes zoster

    • Herpes zoster vaccine safe and effective for older adults
    • Tricyclics drug of choice for post-herpetic neuralgia

    Melanoma

    • Melanoma incidence really not rising
    • Lifetime risk of mole transforming to melanoma very low
    • 0.7% of congenital melanocytic nevi become malignant
    • Dermoscopy with validated criteria more sensitive than unaided eye

    Other skin problems

    • Effective methods for preventing pressure ulcers
    • Duct tape seems effective for warts
    • Skin Diseases Effective treatments for rosacea

Surgery + Procedures

    Cancer

    • Larger margins better in melanoma >2 mm thick
    • Radical prostatectomy improves outcomes in symptom -detected prostate cancer

    Implantable defibrillators

    • Implantable defibrillators are not effective post-MI
    • Implantable defibrillators reduce mortality in NYHA Class II heart failure

    Minor procedures

    • Small punch biopsies don’t require sutures
    • Suturing of hand lacerations not necessary
    • Sterile gloves not necessary for laceration repair
    • Hot water (45 C) immersion best for jellyfish, man-of-war stings

    Orthopeidcs and sports medicine

    • Surgery better than no surgery for spinal stenosis
    • Knee taping useful for osteoarthritis pain
    • Arthroscopy ineffective for osteoarthritis of knee
    • Extracorporeal shock wave therapy is ineffective for tennis elbow
    • Tennis elbow: injection better short -term, worse long -term

    Otitis media

    • Tubes marginally effective in otitis media with effusion
    • Early tympanostomy tubes do not improve outcomes after 3 or more years
    • Prompt tympanostomy tube insertion doesn’t improve 9 year outcomes

    Preoperative care

    • Beta-blockade reduces cardiac events in major noncardiac surgery
    • High-risk but not low-risk patients benefit from perioperative beta-blockade
    • Smoking cessation 6–8 weeks before surgery reduces complications

    Vascular surgery and procedures

    • Better outcomes with CABG than PCI with stent for 2, 3 vessel disease
    • Routine invasive strategy may be preferred for ACS
    • In ACS, 5 years of invasive tx decreases MI but not all cause mortality (FRISC -II)
    • CABG not helpful before AAA or peripheral vascular surgery
    • EVAR worse than open repair of AAA (EVAR Trial 1)
    • Bypass = angioplasty for severe leg ischemia, but costs more (BASIL)
    • Endarterectomy best within 2 weeks of stroke or TIA
    • Carotid stent inferior to carotid endarterectomy
    • Routine use of vena cava filters doesn’t reduce mortality

Systems of Care

    Care of children

    • School-based violence prevention programs not proved
    • Risk scoring system predicts mortality in pediatric ICU
    • Parent satisfaction okay with no treatment of AOM
    • Parents prefer shared decision -making for AOM

    Critical care

    • Intensive insulin only helpful if MICU stay 3 days or longer
    • Normal saline similar to 4% albumin in ICU fluid resuscitation
    • No benefit from pulmonary artery catheters for critically ill patients
    • Pulmonary artery catheters: no harm, no benefit (PAC -Man)
    • Door-to-balloon time important in STEMI

    Prescribing practices

    • Pharmaceutical ads are often inaccurate
    • Prescribing antibiotics does not save time
    • Delayed prescription for AOM reduces unnecessary antibiotics
    • Delayed prescriptions for URIs reduce antibiotic use

    Process of care

    • Quality of care not related to spending
    • Disclosure of errors preferred by patients
    • Hypertension follow -up: 3 months = 6 months
    • Watchful waiting acceptable option for inguinal hernia

    Self-monitoring

    • Self-monitoring of anticoagulation safe, effective
    • Self-monitoring anticoagulation superior at preventing venous thromboembolic events

Urology

    Dysuria and urinary tract infection

    • Immediate- and extended-release ciprofloxacin similar for UTI
    • Treating negative dipstick dysuria decreases symptoms

    Incontinence

    • Urinary incontinence diagnosis with 3 questions
    • HRT increases risk of stress, urge urinary incontinence
    • PT cures postpartum stress incontinence
    • No long -term continence with pelvic floor muscle training
    • Fewer complications with condom than Foley catheters

    Nephrolithiasis

    • Tamsulosin effective for renal colic
    • Renal colic: NSAIDs more effective, less noxious than opioid analgesics
    • Medications help passage of kidney stones

    Prostate cancer

    • Finasteride of mixed benefit in preventing prostate cancer
    • Prostate cancer screening every 4 years as good as annually
    • False-positive PSA associated with increased worry, fears
    • Elevated PSA should be confirmed before biopsy

Glossary: Statistics Definitions