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Evidence-based Medicine Literature Review

Evidence-based Medicine Literature Review. Jauch Symposium, May 2014. EBM – Key Concepts. POEMS - Patient Oriented Evidence that Matters - changes our practice Strategies to keep up - 50,000 RCTs by 2019 Evaluating articles in context. Evidenced-based Sources. Dynamed

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Evidence-based Medicine Literature Review

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  1. Evidence-based Medicine Literature Review Jauch Symposium, May 2014

  2. EBM – Key Concepts • POEMS - Patient Oriented Evidence that Matters - changes our practice • Strategies to keep up - 50,000 RCTs by 2019 • Evaluating articles in context

  3. Evidenced-based Sources • Dynamed • Essential Evidence Plus • Cochrane Database • ACP Journal Club • US Preventive task force • Trip database • Some specialty guidelines

  4. Oxford Centre Evidence Levels • 1A- Systematic reviews • 1B - Randomized controlled trials • 2 - Cohort studies • 3 - Case-control • 4 - Case series • 5 - Expert Opinion • A,B,C, and D

  5. EBM – Key Concepts • Keep track of systematic reviews and randomized controlled trials with patient-oriented results • Consider using synthesized database to keep up with literature • Evaluate new information in context and for practice change

  6. Diets/Supplements

  7. Mediterranean diet • What we know – • Observational studies and a secondary prevention trial showed decrease cv risk • Low fat diets standard treatment • Takes extreme decrease in cholesterol intake to create plaque reversal • Study for primary prevention vs low fat diet

  8. Mediterranean diet • 7447 people in Spain • 55-80 yrs oldwith type 2 DM or 3 risk factors followed for 4.8 yrs • Mediterranean diet + olive oil or + nuts (mix of hazelnuts, almonds, and walnuts) • Low fat diet • Scores for diet adherence similar • Combined endpoint of MI, stroke and death – both arms did better than low fat

  9. Mediterranean diet • But… all the benefit was in the prevention of ischemic strokes, and no sign women • Reduction from 2.4% to 1.6% event rate • Subgroups better if BMI > 30, nonsmokers, better adherence, htn, dyslipids, neg FH • And the nuts or the olive oil was donated by food companies • More intensive diet counseling control after 3 years

  10. Omega-3 FA Supplements • Omega-3 FA and fish oil • What we know – recent studies indicating no benefit – cholesterol, dementia, • The new Vit E – touted for everything but nothing panning out • But wait…

  11. Omega-3 FA Supplements • Patients with RA < 12 mo, DMARD – naïve started on triple DMARD therapy • 86 on high dose Fish oil supplement and 53 low dose fish oil supplement • Previous meta analysis subj & obj benefits • High dose fish oil group 22% less failure of triple therapy, remission 2x more in a year • 88% f/u, only 122 pts finished, trend SAEs

  12. Diagnostic studies

  13. D-Dimer • Very good at excluding DVT and PE if negative (<500) • Not good in elderly • ADJUST-PE study – JAMA March 19, 2014 • Multicenter, consecutive ER patients • Age-adjusted D-Dimer level (age x 10 mcg/dl) • 3346 patients suspected PE (53-74)

  14. D-Dimer age adjusted • 19% PE rate • High clinical likelihood – CTA • 2898 – D-dimer, 337 in age-adjust • 1 of 331 patients had confirmed VTE in 3 months • Similar to rates with negative workup • No CTA in negative group

  15. Treatment Studies

  16. Migraine Treatment • Abortive therapy options – NSAIDS, Ergotamines, Triptans, Combo agents, Narcotics, Barbituates • Significant risk of rebound headaches • Patients often develop tolerance to meds • Have to take meds right away to get benefit • OTCs often used, most Rxs expensive

  17. Migraine Treatment • Cochrane Database Meta-analysis of 13 RCTs, noted in a PURL in The Journal of Family Practice, Feb 2014 • 3 aspirin tabs with/without 10 mg metoclopramide • 5 placebo studies, 4 against common treatments, 4 both • > 3200 patients, 2 hour pain-free, 2 hour headache relief, 24 hour headache relief

  18. Migraine Treatment • NNT vs placebo – 9 for pain free status • Equivalent to sumatriptan 50 mg 2 hour measures 2/4 studies • Metoclopramide reduced nausea and vomiting • No GI bleeds, NNH 34 vs placebo for GI upset • No comments about rebound headaches

  19. Sore throat • Cochrane systematic review 2012 • Eight studies, 743 pts 369 kids, 374 adults • Antibiotic with/without steroids • Studies used one dose oral, three days oral, one dose IM and three days IM • One day course oral probably enough – all were similar in effectiveness

  20. Sore throat • The Results: • Reduced pain faster 8 vs 14 hours • Mean time to resolution of pain 14 hours faster • More pain resolved at 24 hours (27%) and 48 hours (30%) • Not clear if would work without antibiotics • No difference in risks, adverse events

  21. Forearm fractures in kids • UK study – 317 kids, mostly falls, mostly radius fractures, all minimally displaced • Bone Joint Journal Dec 2013 • Half fiberglass cast for 3 weeks (std care) • Half soft cast tape for 3 weeks • 2 patients had increased pain converted • No complications at 6 mo f/u (91%)

  22. Forearm fractures

  23. Prevention news

  24. TIAs/Minor Strokes • What we know: • Patients with TIAs and minor strokes at higher risk or another stroke (10-20% in 3 months) • Clopidogrel + asa not better than either alone and increase risk of bleeding • Asa benefits post TIA/stroke

  25. TIAs/Minor Strokes • Randomized, double-blind, in China • 5170 patients with TIA/minor stroke • All patients asa first day 75 – 300 mg • Had to begin in study in first 24 hours • Asa group 75 mg daily and placebo • Clopidogrel group – 300 mg load, 75 mg daily + asa day 2-21, then placebo • Only 90 day f/u

  26. TIAs/Minor Strokes • 8% strokes in 90 days in combined group, 11.7% in aspirin group, no sign difference in bleeding risks • NNT 29, stroke rate in China 5x US • Only included high risk TIAs – score based on age, blood pressure, clinical features, duration and diabetes • Minor stroke < 4 stroke scale

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