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