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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 - PowerPoint PPT Presentation
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Evidence-based Medicine Literature ReviewJauch Symposium, May 2014
EBM – Key ConceptsPOEMS - Patient Oriented
Evidence that Matters - changes our practice
Strategies to keep up - 50,000 RCTs by 2019
Evaluating articles in context
Evidenced-based SourcesDynamedEssential Evidence PlusCochrane DatabaseACP Journal ClubUS Preventive task forceTrip databaseSome specialty guidelines
Oxford Centre Evidence Levels1A- Systematic reviews1B - Randomized controlled trials2 - Cohort studies3 - Case-control4 - Case series5 - Expert Opinion
A,B,C, and D
EBM – Key ConceptsKeep 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
Diets/Supplements
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
Mediterranean diet 7447 people in Spain 55-80 yrs old with 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
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
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…
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
Diagnostic studies
D-DimerVery good at excluding DVT and PE if
negative (<500)Not good in elderlyADJUST-PE study – JAMA March 19, 2014Multicenter, consecutive ER patientsAge-adjusted D-Dimer level (age x 10
mcg/dl)3346 patients suspected PE (53-74)
D-Dimer age adjusted19% PE rateHigh clinical likelihood – CTA2898 – D-dimer, 337 in age-adjust1 of 331 patients had confirmed VTE
in 3 months Similar to rates with negative workupNo CTA in negative group
Treatment Studies
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
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
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
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
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
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%)
Forearm fractures
Prevention news
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
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
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