1. health and fitness
2. disease

CME
Evidence-Based Practice
Answering clinical questions with the best sources
FROM THE EDITOR
3 Healthy heft
HELPDESK ANSWERS
4What screening should immigrants have
during their first medical visit in the US?
5What are the benefits of treating subclinical
hypothyroidism?
6What is the best initial treatment
for phimosis?
6What therapies are effective for relief
of chronic vertigo symptoms?
7What preoperative evaluation is indicated
in a patient with left bundle branch block?
8What treatments are effective
for chronic prostatitis?
9How can we best manage chronic pain for
patients taking long-term narcotic analgesics?
10Without spirometry, how accurate is the
clinical diagnosis of COPD?
11At what level of eGFR are patient-oriented
outcomes affected?
12How often should a patient with
diverticulosis but a normal colonoscopy
be rescreened?
12What is the role of laboratory testing in
diagnosing SLE? UPDATE
PATIENT EDUCATION
Best treatment for arthritis of the knee
Topics in maternity care
14Are selective serotonin reuptake inhibitors
(SSRIs) safe in pregnancy?
SPOTLIGHT ON pharmacy
15What is most effective for medicationinduced recurrent headaches?
Volume 12
N u m b er 7
ju ly 2009
TRANSFORMING PRACTICE
Zoledronic acid infusion after hip fracture
decreases new fracture rate and mortality
About 10 million people in the United States have osteoporosis. Most
of these people are older than 55, and about 80% are women.1 Osteoporosis is estimated to contribute to more than 2 million fractures each
year, and about 25% of people who sustain osteoporosis-related fractures will die within a year of the fracture.2
After a fracture, treatment of osteoporosis with a bisphosphonate
can reduce the risk of a subsequent fracture, but compliance with oral
bisphosphonates is low. One study of 35,537 women prescribed oral
bisphosphonates found that 57% of them did not consistently take the
medication. Only 20% were still taking the medication regularly 2 years
after the study began.3 Intravenous (IV) bisphosphonates are a relatively new treatment option for osteoporosis. Zoledronic acid (Reclast)
and ibandronate (Boniva IV) are the only IV bisphosphonates currently
indicated for the treatment of osteoporosis.
Study details
A recent randomized controlled trial studied the effectiveness of a yearly IV bisphosphonate for the prevention of future fractures and mortality.4 This study randomized 2,127 previously ambulatory patients
older than 50 who had undergone surgery for a hip fracture. All of the
study participants were unable or unwilling to take an oral bisphosphonate. Patients with active cancer, bone diseases other than osteoporosis,
hypercalcemia, or chronic kidney disease were excluded from the trial.
The patients were randomized to receive a yearly infusion with
either zoledronic acid 5 mg (n=1,065) or placebo (n=1,062). All
patients received calcium (1,000–1,500 mg) and vitamin D (800–1,200
IU) supplements daily. All participants also underwent serum vitamin
D analysis; those with overt vitamin D deficiency received additional
vitamin D.
The primary outcome was any new, nonvertebral fracture; all-cause
mortality was studied as a secondary endpoint. The study followed
patients for a median of 1.9 years before being stopped early because
of clear benefits in the intervention group. The study found the patients
in the placebo arm had significantly more fractures and significantly
higher death rates than those in the zoledronic acid group (TABLE ).
Evidence-Based Practice / Vol. 12, No. 7
1
Transforming Practice
TABLe
Zoledronic acid infusion for hip fracture patients
helps minimize new fracture and death rates4
Outcome
Placebo, n (%)
Zoledronic acid,
n (%)
Hazard ratio
95% CI
P
Any fracture
139 (13.9)
92 (8.6)
0.65
0.50–0.84
.001
Nonvertebral fracture
107 (10.7)
79 (7.6)
0.73
0.55–0.98
.03
Hip fracture
33 (3.5)
23 (2.0)
0.70
0.41–1.19
.18
Vertebral fracture
39 (3.8)
21 (1.7)
0.54
0.32–0.92
.02
141 (13.3)
101 (9.6)
0.72
0.56–0.93
.01
Death
CI=confidence interval.
Adverse events
Adverse events were common in both groups, with
more than 80% of patients in both groups reporting
at least one adverse event. The zoledronic acid group
reported significantly more postinfusion myalgias (33
vs 9, P<.001) and more fevers (73 vs 9, P<.001) than
the control group. Other adverse events, including incidence of atrial fibrillation, renal events, stroke, and
myocardial infarction, were similar in both groups.
No cases of osteonecrosis of the jaw occurred in either
group. Both groups had similar rates of delayed healing
of the initial hip fracture (34 vs 29, P=.61).
Once-yearly dosing advantageous
This study demonstrated that IV zoledronic acid is an
effective method of reducing fractures and mortality in
patients with osteoporosis who have sustained a hip
fracture. Oral bisphosphonates remain the most common method of treating osteoporosis, but zoledronic
acid has the benefit of being dosed just once yearly.
Adherence to the prescription is therefore high, because
once it is infused, the patient will not need another
dose for a year. This regimen is in contrast to daily,
weekly, or monthly dosing of oral bisphosphonates,
and every-3-month dosing of the other IV bisphosphonate, ibandronate. Also, patients admitted to the hospital with osteoporotic fractures can receive zoledronic
acid soon after a fracture. One prior study found that
only between 2% and 10% of patients hospitalized for
hip fracture received a bisphosphonate at discharge,
suggesting that many more patients could benefit from
osteoporosis treatment prior to discharge. Zoledronic
acid is infused over 15 minutes, a time frame acceptable to both inpatient and outpatient treatment.
2
Evidence-Based Practice / July 2009
Main barrier to implementation: cost
Some physicians may hesitate to prescribe zoledronic
acid because of the cost, but previous research has
found that the cost of zoledronic acid (about $1,200
per dose) is similar to oral and other IV bisphosphonates continued for 1 year.5 The cost is generally reimbursed by Medicare and private insurance companies.
However, physicians who provide the service in the
office would have to front the cost of the medication
and wait for reimbursement. Likewise, the practice
setting has to be set up for IV infusions. This may not
be possible in all offices.
Conclusion
For patients who are unwilling or unable to take
an oral bisphosphonate, or for those who prefer the
convenience of once-yearly dosing, zoledronic acid
is a good choice for treating osteoporosis after a
EBP
fracture.
Kate Rowland, MD
UIC Illinois Masonic FMR
Chicago, IL
RE F ERE N C E S
1.National Osteoporosis Foundation. Fast facts on osteoporosis. http://www.nof.org/
osteoporosis/diseasefacts.htm. Accessed May 11, 2009. [LOE 2c]
2.Empana JP, Dargent-Molina P, Bréart G, for the EPIDOS Group. Effect of hip fracture
on mortality in elderly women: the EPIDOS prospective study. J Am Geriatr Soc. 2004;
52(5):685–690. [LOE 1b]
3.Siris ES, Harris ST, Rosen CJ, et al. Adherence to bisphosphonate therapy and fracture
rates in osteoporotic women: relationship to vertebral and nonvertebral fractures from 2
US claims databases. Mayo Clin Proc. 2006; 81(8):1013–1022. [LOE 1b]
4.Lyles KW, Colón-Emeric CS, Magaziner JS, et al, for the HORIZON Recurrent Fracture
Trial. Zoledronic acid and clinical fractures and mortality after hip fracture. N Engl J Med.
2007; 357(18):1799–1809. [LOE 1b]
5.Schumann SA, Hickner J. Annual zoledronic acid infusion lowers risk of fracture, death.
J Fam Pract. 2007; 56(12):1013–1016.
Evidence-Based Practice
Editor-in-Chief
Jon O. Neher, MD
University of Washington
Executive Editor
Bernard Ewigman, MD, MSPH
University of Chicago
Section Editors
Drug Profile
Rex Force, PharmD
Idaho State University
Maternity Care
Lee Dresang, MD
University of Wisconsin
Pharmacy HDAs
Connie Kraus, PharmD, BCPS
University of Wisconsin
Behavioral Health Matters
Vanessa Rollins, PhD
University of Colorado
Patient Education
Janet Hale, RN
Rockbridge Baths, VA
Dana Abbey, MLS
University of Colorado
Valerie King, MD, MPH
Oregon Health & Science University
Carmen G. Strickland, MD
MAYO Clinic Family Medicine – Thunderbird
Scottsdale, AZ
Consulting Editor
Sarah Lovinger, MD
Chicago, IL
Production
Medical Copy Editor
Melissa L. Bogen, ELS
Chester, NY
Layout and Design
Project Manager
Genny Jacks
Columbia, MO
[email protected]
Robert Thatcher
New York, NY
Statement of Purpose
Evidence-Based Practice (EBP) addresses the most important patient care questions
asked by practicing family physicians, using the best sources of evidence in a brief,
clinically useful format.
Newsletter Topics
Transforming Practice: Research evidence on diagnostic testing or treatment periodically
accumulates to a “tipping point” that warrants a change in practice. Each month the
editors select one topic for which a substantial change in clinical practice seems justified.
HelpDesk: EBP authors search the highest quality sources for best evidence (PrimeEvidence and the TRIPS database) in a concise, clinically useful format.
If definitive answers are not available from these sources, the editors turn to high-quality, well-referenced sources. Other resources are used at the editors’ discretion.
Topics in Maternity Care: To keep readers current with trends and new evidence regarding obstetrics and maternity care
Behavioral Health Matters: Presenting the most current evidence related to behavioral
and mental health.
Drug Profile: Pharmaceutical information is promoted directly to consumers as well as
physicians, and is readily available on the Internet and in other mass media. In each
issue of EBP, the editors objectively review the advantages and disadvantages
of a featured medication based on scientific evidence.
Patient Education: An evidence-based patient summary of a Clinical Inquiry,
provided as a tear-out page to be copied and distributed to your patients.
CME CREDIT
Evidence-Based Practice (2009) has been reviewed and is acceptable for up to 24
Prescribed credits by the American Academy of Family Physicians. AAFP accreditation begins
01/01/2009. Term of approval is for one year from this date. Each issue
is approved for 2 Prescribed credits. Credit must be claimed by March 31, 2010.
Note: Total credit is subject to change based on topic selection and article length.
It is estimated that this educational activity will require 3 hours to complete.
Each physician should claim only those hours of credit that he/she actually spent
in the activity.
The learning objectives of the Evidence-Based Practice newsletter are to become knowledgeable
about evidence-based solutions to commonly encountered clinical problems, to understand how
ground-breaking research is changing the practice of family medicine, and to become conversant with balanced appraisals of drugs that are currently being marketed to physicians and/or
consumers. The editors of this educational material may review studies that discuss commercial
products or devices as well as the unapproved/investigative use of commercial products/devices.
The editors of this educational material report that they do not have significant relationships
that create, or may be perceived as creating, a conflict relating to this educational material.
Statements and opinions expressed in abstracts and communications herein are those of the
author(s) and not necessarily those of the Publisher. The Publisher of this newsletter does not
guarantee, warrant, or endorse any methods, product, instructions, procedures, techniques, or
ideas mentioned in the newsletter. The Publisher and Editors disclaim any liability, loss or risk,
personal or otherwise, which may arise, directly or indirectly, from any use or operation of any
methods, products, instructions, procedures, techniques, or ideas contained in the material
herein.
Evidence-Based Practice (ISSN 1095-4120) is published monthly by the Family Physicians
Inquiries Network, Inc., 409 W. Vandiver Drive, Bldg 4, Suite 202, Columbia, MO 65202.
Telephone: 573-256-2066, Fax: 573-256-2078. E-mail: [email protected].
Subscription rates for 2009: U.S. Individual $149, CME upgrade $75 annually; U.S. Institutions $159; International Individual $179; International Institutions $209. Back issues: U.S.
$17; International $19. Third Class postage paid at Columbia, MO 65202. The GST number for
Canadian subscribers is 124002536. Postmaster: Send address changes to FPIN, Inc.,
409 W. Vandiver Drive, Bldg 4, Suite 202, Columbia, MO 65202;
Attn: Genny Jacks. Copyright © 2009 by Family Physicians Inquiries Network, Inc.
From the Editor
Healthy heft
Dear EBP Readers,
Gaining weight is as American as apple pie, fries, and a shake.
A greater percentage of Americans are obese now than last
decade and, indeed, than the decade before that. Since obesity
is linked to a host of morbidities, weight gain in adulthood has
taken on some seriously negative connotations.
But weight gain is not always a bad thing. You may have noticed
that your print copy of Evidence-Based Practice has suddenly
gained a bit of weight (and your digital copy has gained a few
kilobytes). But I’d never want anyone thinking of Evidence-Based
Practice as “fat.” That noticeable new weight is because we
have started publishing more HDAs with every issue. Because
we at the editorial office believe that our member-produced
HDAs are the core of our little journal, having more of them is
surely a sign of good health.
I am tempted, then, to state that adding more HDAs to EvidenceBased Practice is more like adding muscle. But that metaphor
might rather quickly degenerate into visions of the “Governator”
in his movie heyday, posing for the camera. It might also conjure
up visions of androgenic steroid abuse, fibs before congressional
committees, and asterisks in the baseball record books. Again,
all of this is as American as apple pie, but it is not exactly how
we’d like to commemorate our added heft.
So let’s instead think of Evidence-Based Practice as the youngster it truly is, one that is growing and changing rapidly. And like
many youngsters, it wants to stand tall next to the door jam of
the closet and have us write the date and put a pencil mark on
the wall to mark its progress. According to the last pencil mark,
on June 2009, Evidence-Based Practice grew from 4-6 HDAs
and 12 pages an issue to 12 HDAs and 16 pages an issue. And
the weight gain that went along with that milestone was due
to every part of this enterprise becoming healthier and more
mature. Surely that is something to proudly celebrate.
And additional healthy changes are coming soon.
EBP
Regards,
Jon O. Neher, MD
Evidence-Based Practice / Vol. 12, No. 7
3
The HelpDesk Search Strategy
HelpDesk Answers are intended to provide the same quality
response to a clinical question as would be achieved by a searchsavvy physician spending an hour or so on the Internet. Authors
of HelpDesk Answers are required to search PrimeEvidence
(http://www.primeanswers.org) and the TRIP database
(www.tripdatabase.com). These portals provide access to more
than a dozen sources of the highest quality evidence-based
clinical information, including BMJ Clinical Evidence, the
Guide to Clinical Preventive Services, AHRQ Evidence Reports,
and others. Searches of the Cochrane Database, Medline, and
other databases are also included, as needed.
What screening should immigrants have during
their first medical visit in the United States?
Evidence-Based Answer
Screening for tuberculosis (TB) with a purified protein
derivative (PPD) is probably indicated for all immigrants
over 6 months of age. Screening for hepatitis B and
anemia may also be indicated depending on region of
origin. HIV and syphilis screening should be done if not
carried out prior to immigration. (SOR C, extrapolation
from cohort studies.) Immigrants should also receive
routine health screening appropriate for their age and
sex. (SOR A, based on guidelines from the US Preventive Services Task Force.)
Potential immigrants to the United States must undergo
a medical examination by a physician certified by the
Centers for Disease Control and Prevention as part of the
immigration application process. For immigrants aged
15 years and older, this examination includes screening for TB with a chest x-ray, serology tests for syphilis
and HIV, and review of routine vaccination status. It
also includes a complete history and physical, including
screening questions for chancroid, gonorrhea, granuloma inguinale, lymphogranuloma venereum, Hansen’s
disease, mental disorders, and substance abuse.
Screening for TB using a PPD may be indicated
for every immigrant older than 6 months regardless of
bacille Calmette-Guérin (BCG) vaccine status. In 2003,
14,874 cases of active TB infection were recorded in
the United States, 6,903 (41%) of which were in people
born outside the United States.1 DNA fingerprinting
of 546 TB strains isolated in New York City between
1990 and 1998 suggested that patients born outside
4
Evidence-Based Practice / July 2009
the United States had an odds ratio (OR) of 0.31 (95%
confidence interval [CI], 0.14–0.66) for a newly transmitted infection, compared with having a reactivation
of a latent infection.2 This finding suggests foreign-born
patients with active TB have more reactivation of the
disease than new infections.
A large study from the Netherlands compared cases
of latent TB discovered through screening with those
discovered passively in immigrants. Cases discovered
through screening were less likely to have positive sputum cytology (OR 0.5; 95% CI, 0.3–0.8) and less likely
to require hospitalization (OR 0.2; 95% CI, 0.1–0.2).3
This study also found that 302 of 454 (66%) of new
TB cases found through screening were discovered during the first 6 months that the immigrant resided in the
Netherlands, compared with 114/368 (31%) of cases
discovered passively. The authors estimated that screening decreased the total infectious time by 30%.
Screening for hepatitis B is another consideration
for high-risk patients. Hepatitis B is endemic in many
parts of the world, including Asia (8%–10% chronic
infection rate), Eastern Europe, the Middle East, the
Amazon basin, and the Indian subcontinent (2%–5%
chronic infection rate). Because there is a vaccine for
this disease, screening will allow the physician to identify and vaccinate household contacts of infected persons, thereby preventing transmission.4
Testing stool for ova and parasites is indicated if
height or weight is less than the fifth percentile or if
anemia or gastrointestinal symptoms are present. Prevalence of parasites in refugees of all ages in Minnesota
was found to be 22%.5 The highest prevalence is found
in Southeast Asian and Latin American populations.
One study of Southeast Asian refugees in Canada found
that screening and treatment of clinically significant
intestinal parasitic infections decreased the prevalence
from 70% to 31% (P<.01) over 6 months.6
A higher prevalence of anemia is often found in
immigrants secondary to iron deficiency, hemoglobinopathies, infection with hookworm, and malaria. A
study from Denmark comparing pregnant women from
eastern Mediterranean and Asian regions with pregnant ethnic Danish women found a higher prevalence
of anemia in the immigrant group (20.0%) compared
with the Danish group (4.9%) (P<.0001).7 Most of the
anemic immigrant women were found to have iron deficiency anemia. Women found to have hemoglobinopathies were excluded from this study.
Besides the tests that are indicated based on the
patient’s country of origin, all patients should receive
screening examinations and preventive care appropriate for their age and sex.8
Anita Bednarz, MD
Kate Rowland, MD
UIC Illinois Masonic FMR
Chicago, IL
1.Schneider E, Moore M, Castro KG. Epidemiology of tuberculosis in the United States. Clin
Chest Med. 2005; 26(2):183–195. [LOE 1b]
2.Geng E, Kreiswirth B, Driver C, et al. Changes in the transmission of tuberculosis in New
York City from 1990 to 1999. N Engl J Med. 2002; 346(19):1453–1458. [LOE 2b]
3.Verver S, Bwire R, Borgdorff MW. Screening for pulmonary tuberculosis among immigrants: estimated effect on severity of disease and duration of infectiousness. Int J Tuberc
Lung Dis. 2001; 5(5):419–425. [LOE 2b]
4.World Health Organization. Hepatitis B. Fact sheet number 204. http://www.who.int/
mediacentre/factsheets/fs204/en/. Accessed June 8, 2009. [LOE 2a]
5.Lifson AR, Thai D, O’Fallon A, Mills WA, Hang K. Prevalence of tuberculosis, hepatitis B
virus, and intestinal parasitic infections among refugees to Minnesota. Public Health Rep.
2002; 117(1):69–77. [LOE 1b]
6.Gyorkos TW, Frappier-Davignon L, MacLean JD, Viens P. Effect of screening and treatment
on imported intestinal parasite infections: results from a randomized, controlled trial. Am
J Epidemiol. 1989; 129(4):753–761. [LOE 1b]
7.Nybo M, Friis-Hansen L, Felding P, Milman N. Higher prevalence of anemia among pregnant immigrant women compared to pregnant ethnic Danish women. Ann Hematol. 2007;
86(9):647–651. [LOE 2b]
8.Agency for Healthcare Research and Quality. Guide to clinical preventive services, 2008:
recommendations of the US Preventive Services Task Force. AHRQ publication 0805122. http://www.ahrq.gov/clinic/pocketgd.htm. Published September 2008. Accessed
June 8, 2009. [LOE 1a]
What are the benefits of treating subclinical
hypothyroidism?
Evidence-Based Answer
While subclinical hypothyroidism (SCH) has been
associated with increased cardiovascular morbidity,
no clear evidence exists to suggest that treatment
improves patient-oriented outcomes. In the short
term, treating SCH improves diastolic function and
cardiac relaxation time, but the clinical significance
of these changes is uncertain. (SOR A, based on a
systematic review.)
A recent Cochrane review evaluated the effects of
thyroid hormone replacement for SCH.1 This review
included 12 randomized controlled trials involving 350
patients. The results were as follows:
•None of the 7 studies that assessed health-related
quality of life demonstrated a significant difference
between intervention groups.
•Six studies assessed serum lipids and found a change
from baseline of total cholesterol favoring placebo
(–15 vs –3.1 mg/dL in the levothyroxine group).
•Three trials assessed cardiac function and found
significant improvement in diastolic function in
isovolumic relaxation time (weighted mean difference –8.5 ms, 95% confidence interval [CI], –15 to
–1.1) and left ventricular relaxation time with thyroid hormone replacement. However, these studies
included individuals with high serum thyroid-stimulating hormone (TSH) levels and previous thyroid
disease. The clinical significance of these cardiac
changes was not described.
The Cochrane review also summarized 2 large
cohort studies that evaluated cardiovascular morbidity
and mortality. One was a 12-year cohort study of 3,233
people older than 65 years. This study did not find any
difference in the risk of coronary heart disease, cerebrovascular disease, or cardiovascular death between
euthyroid and SCH patients. In another cohort study
of 2,730 men aged 70 to 79 years, over a 4-year period,
the rate of congestive heart failure was increased among
patients whose TSH was higher than 7 mU/L (hazard
ratio 2.49; 95% CI, 1.2–5.18); the rate of coronary
heart disease events, strokes, and mortality did not differ among TSH levels.
A recent meta-analysis2 published since the Cochrane
review identified 15 studies (2,531 SCH patients and
26,491 euthyroid patients) investigating whether age
and sex influence ischemic heart disease (IHD) prevalence and mortality in people with SCH. Among patients
younger than 65 years, patients with SCH had a higher prevalence of IHD (odds ratio [OR] 1.57; 95% CI,
1.19–2.06) and a slightly increased risk of cardiovascular mortality (OR 1.37; 95% CI, 1.04–1.79) compared
with euthyroid patients in the same age group. For
patients older than 65, the presence or absence of SCH
did not affect the incidence of IHD (OR 1.01; 95% CI,
0.87–1.18) or cardiovascular mortality (OR 0.85; 95%
CI, 0.56–1.29). However, this review did not evaluate if
treatment decreases this risk, or which vascular risk factors would benefit from treating SCH.
Gerard Bitar, MD
Corey Lyon, DO
Research Family Medicine
Kansas City, MO
1.Villar HC, Saconato H, Valente O, Atallah AN. Thyroid hormone replacement for subclinical hypothyroidism. Cochrane Database Syst Rev. 2007; (3):CD003419. [LOE 1a ]
2.Razvi S, Shakoor A, Vanderpump M, Weaver JU, Pearce SH. The influence of age on the
relationship between subclinical hypothyroidism and ischemic heart disease: a metaanalysis. J Clin Endocrinol Metab. 2008; 93(8):2998–3007. [LOE 1a]
Evidence-Based Practice / Vol. 12, No. 7
5
What is the best initial treatment for phimosis?
Evidence-Based Answer
When treatment is necessary for phimosis, application
of topical steroid seems to be an effective first-line
treatment. (SOR B, based on a high-quality randomized
control trial.)
Phimosis refers to difficulty retracting the prepuce
secondary to a tight distal preputial ring. While
relatively common at birth, this condition normally resolves spontaneously by 3 to 4 years of age.
Over time, phimosis can lead to chronic inflammation, dyspareunia, or even penile carcinoma. Surgical treatment is often performed on boys suffering
from persistent phimosis, but the procedure carries
the risk of postoperative complications. Conservative treatment with topical steroids is a nonsurgical
option.
In 2002, a prospective, randomized double-blind
study examined 137 boys (aged 3–15 years) randomly assigned to receive either topical 0.1% betamethasone cream or placebo (aqueous cream) for 4 weeks.
Patients were instructed to apply the cream twice daily,
after retracting the prepuce as much as possible without
causing harm and pain. After the 4-week assessment, all
nonresponders in both groups were offered a course of
steroid cream.
The first follow-up cure rate with steroid cream was
74% compared with 44% in the placebo group (number needed to treat=3; P<.01). The overall cure rate was
86% by 18 months.1
An unblinded, prospective cohort study enrolled
247 boys (treatment group) and 90 boys (placebo
group) aged 4 to 14 years. In the treatment group,
patients received 0.05% betamethasone cream applied
twice daily for the first 15 days, then once daily for
15 more days. Preputial stretching started 1 week after
topical application. A control group used preputial
stretching only. Follow-up examinations were carried
out at 10 days after the end of each 30-day treatment
cycle. If initially unsuccessful, the treatment cycle could
be repeated up to a total of 3 times.
Treatment with steroid creams plus stretching was
successful in 96% of patients compared with 76% with
stretching alone (P<.001) after a maximum of 3 cycles.
These results were maintained at 3- and 6-month follow-up visits.2
6
Evidence-Based Practice / July 2009
A case series reported on the progress of 194 boys
(aged 1–16 years) with phimosis. A 6-week course of
0.1% betamethasone ointment was applied twice daily
for 6 weeks. Patients were reexamined by the consultant urologist at 3 months after initiation of treatment.
In this series, 87% of patients with phimosis treated
with topical steroid were able to retract the foreskin
appropriately after treatment.3
Ho Je Lee, MD
Jeff Levine, MD, MPH
Elizabeth C. Clark, MD, MPH
Beatrix Roemheld-Hamm, MD, PhD
UMDNJ-RWJMS FMR
New Brunswick NJ
1.Lund L, Wai KH, Mui LM, Yeung CK. An 18-month follow-up study after randomized
treatment of phimosis in boys with topical steroid versus placebo. Scand J Urol Nephrol.
2005; 39(1):78–81. [LOE 1b]
2.Zampieri N, Corroppolo M, Camoglio FS, Giacomello L, Ottolenghi A. Phimosis: stretching
methods with or without application of topical steroids? J Pediatr. 2005; 147(5):705–
706. [LOE 2b]
3.Ashfield JE, Nickel KR, Siemens DR, MacNeily AE, Nickel JC. Treatment of phimosis with
topical steroids in 194 children. J Urol. 2003; 169(3):1106–1108. [LOE 2c]
What therapies are effective for relief
of chronic vertigo symptoms?
Evidence-Based Answer
It depends on the cause of the vertigo. For unilateral
peripheral vestibular dysfunction, vestibular rehabilitation (VR) improves subjective dizziness. In benign
paroxysmal positional vertigo (BPPV), canalith repositioning maneuvers are associated with excellent shortterm relief. (SOR A, based on a systematic review.)
In patients with Ménière’s disease, instruction in VR
and symptom control are equally effective; the Meniett
device can produce symptom relief in refractory cases.
(SOR B, based on randomized controlled trials [RCTs].)
Antihistamines, anticholinergics, benzodiazepines,
diuretics, calcium channel blockers, and topiramate
may also help relieve symptoms. (SOR C, based on
expert opinion.)
Twenty-one RCTs including 1,383 adults with unilateral peripheral vestibular dysfunction were analyzed in a
Cochrane review. Of those, 10 trials compared VR with
control (placebo, no treatment, sham, or usual care).
Four of the 10 studies had subjective improvement in
dizziness as an outcome measure. All 4 studies showed
VR is associated with subjective improvement in dizziness (136/278 patients in treatment groups reported
improvement vs 76/287 patients in control groups;
P=.0001).1
Five other studies compared VR with other treatments (including canalith repositioning maneuvers such
as the Semont and Epley), with dizziness cure rate as the
reported outcome. One of these studies was in patients
BPPV. Here, canalith repositioning maneuvers were better than VR (39/42 cured in the canalith repositioning
maneuver group vs 18/29 with VR; odds ratio 0.13;
95% CI, 0.03–0.51; P=.004). Another study reviewed
selected patients with BPPV and found the Semont
maneuver to be superior to VR alone at 15 days, but at
3 months VR with the Semont maneuver was superior
to either intervention alone. The Semont maneuver is
performed by moving the patient into a lying position
that provokes the vertigo for 4 minutes. The patient is
then rotated to the opposite position for an additional 4 minutes, after which the patient rises slowly. The
somewhat similar Epley maneuver involves a series of
4 movements of the head and body aimed at alleviating
vertigo caused from displaced otoliths. Reported difficulties with these treatments include inability to tolerate the positioning maneuvers and emesis.1
A 6-month RCT of 360 patients with vertigo from
Ménière’s disease compared an intervention using selfhelp booklets on VR or symptom control to waiting list
controls. Symptom control consisted of applied relaxation, controlled breathing, and cognitive-behavioral
strategies to reduce the amplification of symptoms by
anxiety. The study was not controlled for medication
use. Patients were recruited by mail and were randomized to receive the VR booklet, the symptom control
booklet, or to be on the waiting list. They were evaluated at 3 and 6 months after receiving the booklets,
using the 36-item Vertigo Symptom Scale, short form
(VSS-SF).2
At 3 months, 35% of both intervention groups
reported symptom improvement, compared with 19.2%
of controls (P=.006). At 6 months, 37.5% of the VR
group and 39.2% of the symptom control group reported
improvement compared with 15.8% of waiting list controls (P=.01 for each intervention vs the wait list; number
needed to treat=5). No statistically significant difference
was noted between VR and symptom control.2
A prospective cohort study of 21 patients with
refractory chronic vertigo from Ménière’s disease
showed that of patients using a Meniett device, 71%
had either relief or resolution of symptoms at 1 year,
and 63% at 3 years. The Meniett device is placed in the
middle ear with a myringotomy tube, sending pulsations
to the inner ear. Side effects include otitis media and
permanent perforation from placement of the myringotomy tube.3
Medical therapies are frequently tried, although no
RCTs support their use for chronic vertigo. Experts recommend antihistamines (meclizine) to limit the nausea
associated with vertigo. Anticholinergics (scopolamine)
are not thought to be effective after symptoms have begun.
Small-dose benzodiazepines, diuretics, and calcium channel blockers have been used, but care must be given for
potential adverse side effects. Topiramate has also been
used, with the favorable side effect of weight loss.4
Veronita Crawford, MS
José E. Rodríguez, MD
Florida State University
Tallahassee, FL
1.Hillier SL, Hollohan V. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2007; (4):CD005397. [LOE 1a]
2.Yardley L, Kirby S. Evaluation of booklet-based self-management of symptoms in Ménière disease: a randomized controlled trial. Psychosom Med. 2006; 68(5):762–769.
[LOE 1b]
3.Mattox DE, Reichert M. Meniett device for Ménière’s disease: use and compliance at 3 to
5 years. Otol Neurotol. 2008; 29(1):29–32. [LOE 2b]
4.Hain TC, Yacovino D. Pharmacologic treatment of persons with dizziness. Neurol Clin.
2005; 23(3):831–853. [LOE 5]
What preoperative evaluation is indicated in a
patient with left bundle branch block?
Evidence-Based Answer
Patients with left bundle branch block (LBBB) who do
not have signs or symptoms of coronary artery disease
(CAD) or congestive heart failure (CHF) and who have
normal functional capacity do not require extensive
preoperative cardiac evaluation. (SOR C, based on
expert opinion.)
A case-controlled study followed 17,361 subjects over a
40-year period to assess the incidence and course of LBBB.
Although LBBB did not alter all-cause mortality, it was
associated with increased mortality from CHF (relative
risk [RR] 2.4; 95% confidence interval [CI], 1.31–4.41)
and myocardial infarction (RR 2.9; 95%CI, 1.27-6.60).1
A cohort study of 7,073 patients (150 of whom had
preexisting LBBB) referred for symptom-limited nuclear
exercise testing followed patients for 6.7 years, with the
primary outcome of all-cause mortality. After adjusting
Evidence-Based Practice / Vol. 12, No. 7
7
for confounders (clinical, exercise, and nuclear scintigraphic variables), LBBB was an independent predictor
of mortality (hazard ratio [HR] 1.5; 95% CI, 1.0–2.0).2
One study specifically evaluated bundle branch
block as a risk factor in noncardiac, nonemergent
surgery. This retrospective cohort study investigated
patients with LBBB (n=119) or right bundle branch
block (RBBB; n=336) undergoing preoperative evaluation for noncardiac surgery. Mean age was 67 years
(range 40–93), 64% had hypertension, 18% CHF, 18%
a history of CAD, and 22% angina. No cardiovascular complications were observed in the patients with a
bundle branch block intraoperatively. Postoperatively,
no patients with a bundle branch block experienced
myocardial infarction, pulmonary edema, or ventricular
dysrhythmias. One patient with LBBB developed atrial
fibrillation postoperatively. Four patients (0.9%) with
bundle branch blocks (1 with RBBB, 3 with LBBB) died
postoperatively compared with 2 (0.4%) in the control
cohort. All 3 of the LBBB deaths were due to sepsis (2
after prolonged postoperative hospitalization) and all
had known heart disease. Hence, LBBB may be associated with increased noncardiac postoperative complications; however, a larger cohort study is needed to
validate this finding.3
The ACC/AHA 2007 Perioperative Executive Summary considers the presence of a LBBB a “minor clinical predictor.” In the absence of clinically active cardiac
conditions, such individuals may proceed to low-risk
surgery. In patients undergoing other than low-risk surgery, further workup is not required if their functional
capacity is greater than 4 metabolic equivalent tests
(METs). Patients with poor (<4 METs) or unknown
functional capacity undergoing other than low-risk surgery require a clinical risk factor assessment to determine if further evaluation is warranted.4
Robert Gauer, MD
Womack FMR Clinic
Fort Bragg, NC
1.Imanishi R, Seto S, Ichimaru S, Nakashima E, Yano K, Akahoshi M. Prognostic significance of incident complete left bundle branch block observed over a 40-year period. Am
J Cardiol. 2006; 98(5):644–648. [LOE 2b]
2.Hesse B, Diaz LA, Snader CE, Blackstone EH, Lauer MS. Completed bundle branch block
as an independent predictor of all-cause mortality: report of 7,073 patients referred for
nuclear exercise testing. Am J Med. 2001; 110(4):253–259. [LOE 2b]
3.Dorman T, Breslow MJ, Pronovost PJ, Rock P, Rosenfeld BA. Bundle-branch block as a
risk factor in noncardiac surgery. Arch Intern Med. 2000; 160(8):1149–1152. [LOE 2b]
4.Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative
cardiovascular evaluation and care for noncardiac surgery: executive summary: a report
of the American College of Cardiology/American Heart Association Task Force on Practice
Guidelines. Circulation. 2007; 116(17):1971–1996. [LOE 5]
8
Evidence-Based Practice / July 2009
What treatments are effective for chronic
prostatitis?
Evidence-Based Answer
No treatments for chronic prostatitis/chronic pelvic
pain syndrome have been proven effective. Ciprofloxacin, tamsulosin, corticosteroids, and rofecoxib have all
failed to show benefit. (SOR B, based on a single study
for each agent.)
Chronic prostatitis/chronic pelvic pain syndrome is a
common disorder that is defined clinically by inflammation of the prostate and discomfort or pain in the
perineal or pelvis region, and lower urinary tract symptoms with or without bacteriuria.
In 2001, a double-blind, double-dummy trial compared the effectiveness of ciprofloxacin, tamsulosin,
a combination of both drugs, and placebo in patients
with chronic prostatitis/chronic pelvic pain syndrome.
This trial evaluated 196 men with a score of at least
15 on the National Institute of Health Chronic Prostatitis Symptom Index (the NIH-CPSI, with a maximum
of 43 points) and a mean of 6.2 years of symptoms.
They were randomized to 1 of 4 groups: 49 were given
ciprofloxacin 500 mg twice daily, 49 were given tamsulosin 0.4 mg once daily, 49 were given combination of
both drugs, and 49 were given placebo. The NIH-CPSI
was readministered at the end of 6 weeks of treatment.
Despite a slight decrease in the NIH-CPSI total score
in all treatment groups, no statistically significant outcomes were noted.1
In 2002, a randomized controlled trial (RCT) evaluated the effectiveness of a short course of oral prednisone therapy for chronic prostatitis/chronic pelvic pain
syndrome. The trial enrolled 21 men with the condition
for at least 6 months, for whom antibiotic therapy had
failed. They were randomized to oral prednisone (20 mg
daily for 1 week, 15 mg daily for 1 week, 10 mg daily
for 1 week, and 5 mg daily for 1 week) or an equivalent
placebo. No difference was noted between the groups in
outcomes measured by the McGill Pain Questionnaire,
the Hospital Anxiety and Depression Scale, General
Health Questionnaire-30, and the NIH-CPSI score. A
significant limitation in this study was the small number
of patients and failure to use intent-to-treat analysis.2
A 2003 multicenter RCT evaluated the effects of
rofecoxib therapy for 161 patients with chronic prostatitis: 53 were given rofecoxib 25 mg PO, 49 were
given rofecoxib 50 mg PO, and 59 were given a placebo PO. NIH-CPSI pain scores were used to evaluate
the patients at baseline and after 6 weeks of treatment. The NIH-CPSI total scores were lowered by
–4.18, –4.92, and –6.22 points in the placebo, rofecoxib 25-mg, and rofecoxib 50-mg groups, respectively, compared with baseline. None of these changes
was statistically significant.3
Bryant Huy Nguyen, MD
Barbara Jo McGarry, MD
Beatrix Roemheld-Hamm, MD, PhD
UMDNJ-RWJMS FMR
New Brunswick, NJ
1.Alexander RB, Propert KJ, Schaeffer AJ, et al, for the Chronic Prostatitis Collaborative Research Network. Ciprofloxacin or tamsulosin in men with chronic prostatitis/chronic pelvic
pain syndrome: a randomized, double-blind trial. Ann Intern Med. 2004; 141(8):581–
589. [LOE 1b]
2.Bates SM, Hill VA, Anderson JB, et al. A prospective, randomized, double-blind trial to
evaluate the role of a short reducing course of oral corticosteroid therapy in the treatment
of chronic prostatitis/chronic pelvic pain syndrome. BJU Int. 2007; 99(2):355–359.
[LOE 1b–]
3.Nickel JC, Pontari M, Moon T, et al, for the Rofecoxib Prostatitis Investigator Team. A randomized, placebo controlled, multicenter study to evaluate the safety and efficacy of rofecoxib in the treatment of chronic nonbacterial prostatitis. J Urol. 2003; 169(4):1401–
1405. [LOE 1b]
How can we best manage chronic pain
for patients taking long-term narcotic
analgesics?
Evidence-Based Answer
Tramadol has proven efficacy up to 6 months and less
abuse potential than hydrocodone over 1 year. (SOR B,
based on randomized controlled trials [RCTs].) Transdermal fentanyl and sustained-release morphine have been
proven effective for longer-term use, although constipation is more common with morphine. (SOR A, based on
consistent RCTs.) Tricyclic and tetracyclic antidepressants appear to be moderately effective for reduction
of chronic back pain. (SOR B, based on a systematic
review with heterogeneity.)
The long-term management of chronic noncancer pain
is challenging as no consistent, high-quality data are
available to guide therapeutic decisions.
Tramadol, an analgesic that is not a controlled substance but binds weakly to opioid receptors and inhibits
the reuptake of serotonin and norepinephrine, has the
most evidence supporting its use for noncancer pain.
However, studies are primarily short-term and sponsored by the manufacturer.
A Cochrane review pooled data from 3 RCTs
(N=914) lasting 7 to 12 weeks that compared tramadol with placebo among patients with chronic low back
pain.1 Tramadol was more effective than placebo for
pain relief (standardized mean difference [SMD] 0.71;
95% CI, 0.39–1.02) and for improving function (SMD
0.17; 95% CI, 0.04–0.30).
In a separate RCT with 11,352 chronic pain patients,
a series of structured interviews was performed over a
12-month period to calculate an “abuse index” for each
patient randomized to tramadol, nonsteroidal antiinflammatory drugs (NSAIDs), or hydrocodone.2 The
percentage of patients who scored positive for abuse
at least once during the 12-month period was 2.5%
for NSAIDs, 2.7% for tramadol, and 4.9% for hydrocodone. The percentages of patients scoring positive for
abuse more than once (indicating persistent abuse) were
0.5% for NSAIDs, 0.7% for tramadol, and 1.2% for
hydrocodone. Tramadol had similar rates of abuse as
NSAIDS, but significantly less abuse than hydrocodone
(P<.01).
The only evidence supporting long-term use of tramadol was a 6-month open extension trial of 117 patients
with diabetic neuropathy that followed a 6-week RCT
and demonstrated continued pain relief.3
According to a recent evidence-based guideline, the
opioids with the best evidence for efficacy with therapy 6 months or longer are sustained-release morphine
and transdermal fentanyl.4 This guideline referenced 5
studies with a total of 688 patients that demonstrated
persistent improvement of pain scores and quality of
life with sustained-release morphine in chronic noncancer pain. For transdermal fentanyl, 3 studies with
a total of 1,399 patients demonstrated persistent
improvement of pain scores and quality of life. All of
the long-term studies were open-label and used variable outcome measures, making it difficult to quantify
the pooled results.
One open RCT over 13 months compared sustained-release morphine and transdermal fentanyl in
the treatment of chronic low back pain.5 This study
found similar improvement in pain relief and quality
of life with the 2 treatments, but significantly less constipation with fentanyl. At the study endpoint, 31% of
the transdermal fentanyl patients and 48% of the sustained-release morphine patients reported constipation
(P<.001). Baseline levels constipation were similar for
both groups at 23% and 26%, respectively.
continued
Evidence-Based Practice / Vol. 12, No. 7
9
A systematic review evaluated the use of antidepressants for treatment of patients with chronic low back
pain.6 Three of the 5 RCTs evaluating tricyclic or tetracyclic antidepressants demonstrated significant pain relief
at 6 to 8 weeks, but could not determine whether these
treatments improved function. One RCT with 78 patients
showed 22% reduction in pain intensity at 8 weeks with
nortriptyline versus 9% with placebo (P=.05). Another
RCT with 103 patients had 45% reduction in pain intensity at 8 weeks with maprotiline versus 27% with placebo
(P=.023). A third RCT with 16 patients demonstrated a
46% reduction in analgesic use per week after 6 weeks
with amitriptyline versus placebo (P<.005). One RCT with
50 patients showed less significant pain relief. The only
RCT that did not demonstrate pain relief using a tricyclic
or tetracyclic antidepressant included 59 patients admitted for inpatient treatment of low back pain and lasted for
only 1 month. The authors concluded that tricyclic and tetracyclic antidepressants appear to be moderately effective
for reduction of chronic back pain.
Gina G. Glass, MD, FAAFP
Underwood-Memorial Hospital FMR
Woodbury, NJ
1.Deshpande A, Furlan A, Mailis-Gagnon A, Atlas S, Turk D. Opioids for chronic low-back
pain. Cochrane Database Syst Rev. 2007; (3):CD004959. [LOE 1a]
2.Adams EH, Breiner S, Cicero TJ, et al. A comparison of the abuse liability of tramadol,
NSAIDs, and hydrocodone in patients with chronic pain. J Pain Symptom Manage. 2006;
31(5):465–476. [LOE 2b]
3.Harati Y, Gooch C, Swenson M, et al. Maintenance of the long-term effectiveness of tramadol in treatment of the pain of diabetic neuropathy. J Diabetes Complications. 2000;
14(2):65–70. [LOE 2b]
4.Trescot A, Helm S, Hansen H, et al. Opioids in the management of chronic non-cancer
pain: an update of American Society of the Interventional Pain Physicians’ (ASIPP) guidelines. Pain Physician. 2008; 11(2 suppl):S5–S62. [LOE 2b]
5.Allan L, Richarz U, Simpson K, Slappendel R. Transdermal fentanyl versus sustained
release oral morphine in strong-opioid naïve patients with chronic low back pain. Spine.
2005; 30(22):2484–2490. [LOE 2b]
6.Staiger TO, Gaster B, Sullivan MD, Deyo RA. Systematic review of antidepressants in the
treatment of chronic low back pain. Spine. 2003; 28(22):2540–2545. [LOE 1a]
Without spirometry, how accurate is the clinical
diagnosis of COPD?
Evidence-Based Answer
It’s not good. Only about half of patients thought to
have chronic obstructive pulmonary disease (COPD)
clinically will be found to have the disease with spirometry. (SOR A, based on 2 diagnostic cohort studies.)
The 2008 Global Initiative for Chronic Obstructive Lung
Disease update noted that a clinical diagnosis of COPD
should be considered in any patient who has dyspnea,
10
Evidence-Based Practice / July 2009
chronic cough or sputum production, or a history of exposure to risk factors for the disease.1 The diagnosis should
then be confirmed by spirometry. Despite these recommendations, many diagnoses continue to be made solely on a
clinical basis.
A 2006 prospective cohort trial included 597 people
age 40 and older with patient-reported evidence of obstructive lung disease.2 Evidence of obstructive disease was
defined as any lifetime prior diagnosis of asthma, chronic
bronchitis or emphysema, or receiving chronic prescription respiratory medication within the past year. Clinical
diagnoses were compared with a study diagnosis based on
pre- and postbronchodilator spirometry. The study diagnosis of COPD was defined as a postbronchodilator ratio of
forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) of less than 0.70.
Of the 597 patients included, 235 (39.4%) were given
a study diagnosis of COPD. Of the 235 with spirometryproven COPD, 89 (37.9%) reported a prior diagnosis of
chronic bronchitis or emphysema, 121 (51.5%) reported
a prior diagnosis of asthma without chronic bronchitis or
emphysema, and 25 (10.6%) reported no prior diagnosis
of obstructive lung disease.2 Upon entry into the study, 184
of the 597 participants had a clinical diagnosis of chronic
bronchitis or emphysema; 89 (48%) of the 184 were confirmed as having COPD with spirometry, while 95 (52%)
did not meet the criteria for COPD.
A 2005 prospective cohort study in the United Kingdom assessed 125 participants with a previous clinical
diagnosis of COPD.3 Previous diagnoses were based on
history and physical examination. The mean age was
64 years. COPD was defined as a postbronchodilator
FEV1/FVC of less than 0.70. When spirometry was
used to confirm the COPD diagnosis, only 49% met
diagnostic criteria. Of the remaining participants, 20%
had reversible airway obstruction, 4% had restrictive
obstruction, and 27% had normal spirometry.
Josh Merok, MD
Elizabeth Salisbury Afshar, MD
UIC Illinois Masonic FMR
Chicago, IL
1.Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the
Diagnosis, Management, and Prevention of COPD (Updated 2008). Gig Harbor, WA:
Medical Communications Resources, Inc; November 2008. http://www.goldcopd.org/
Guidelineitem.asp?l1=2&l2=1&intId=2003 . Accessed June 8, 2009. [LOE 5]
2.Tinkelman DG, Price DB, Nordyke RJ, Halbert RJ. Misdiagnosis of COPD and asthma
in primary care patients 40 years of age and over. J Asthma. 2006; 43(1):75–80.
[LOE 1b]
3.Bolton CE, Ionescu AA, Edwards PH, Faulkner TA, Edwards SM, Shale DJ Attaining
a correct diagnosis of COPD in general practice. Respir Med. 2005; 99(4):493–500.
[LOE 1b]
At what level of eGFR are patient-oriented
outcomes affected?
(95% CI, 2.6–2.9) for eGFR 15–29 mL/min/1.73 m2; and
5.9 (95% CI, 5.4–6.5) and 3.4 (95% CI, 3.1–3.8) for
eGFR <15 mL/min/1.73 m2, respectively.
A 2006 a cross-sectional health survey followed the
eGFR of 65,604 subjects over an 8-year period. Adjusted
CV mortality rates were 0.4, 3.5, 7.4, and 10.1 per 100
person-years for eGFR groups of >75, 45–59, 30–44,
and <30 mL/min/1.73 m2, respectively.3
In 2009 a secondary analysis of a randomized controlled trial of 5,804 elderly subjects with a mean age of
76 years over a 3.2-year period was performed. Patients
with an eGFR of >60 mL/min/1.73 m2 were used as
the reference range. All-cause mortality HRs were 1.25
(95% CI, 0.97–1.62) and 2.04 (95% CI, 1.48–2.80) for
eGFR of 40–49 and 20–39 mL/min/1.73 m2, respectively.
CV mortality HRs were 1.45 (95% CI, 1.01–2.07) and
2.37 (95% CI, 1.53–3.67) for the same eGFR groupings,
respectively.4
Recently, a nonconcurrent cohort study was published involving 34,982 outpatients with a mean age
of 61 years who were followed for up to 2.5 years.
Patients with an eGFR >60 mL/min/1.73 m2 were the
reference group.5 The CV mortality rate did not increase
until the eGFR was <45 mL/min/1.73 m2, rising to 1.77
(95% CI, 1.65–1.89) for eGFR 30–44 mL/min/1.73 m2
and 3.75 (95% CI, 3.47–4.06) for eGFR 15–29 mL/
min/1.73 m2.
Evidence-Based Answer
Consistent evidence shows that, in comparison to
patients with an estimated glomerular filtration rate
(eGFR) of >60 mL/min/1.73 m2, patients with an eGFR
<45–50 mL/min/1.73 m2 have an increased risk in allcause and cardiovascular (CV) mortality and cardiovascular events. (SOR B, based on multiple retrospective
cohort studies.)
A 2006 retrospective cohort study1 reviewed 4 years of
records for the eGFR of 2,583,911 subjects with a mean
age of 63 years. Analysis was subdivided by age grouping
and eGFR levels, with an eGFR of >60 mL/min/1.73 m2
as the reference in respective age groupings. Adjusted
hazard ratios (HRs) of risk for death were significantly
increased for any eGFR <60 mL/min/1.73 m2 in ages <65,
but not for ages >65. All age group adjusted HRs of risk
for death increased with an eGFR <50 mL/min/1.73 m2
(TABLE ).
A 2004 retrospective cohort study2 reviewed the outpatient records for eGFR of 1,120,295 subjects with a
mean age of 52 years over a 2.8-year period. Patients with
an eGFR of >60 mL/min/1.73 m2 were used as the reference group. Adjusted all-cause mortality and CV events
HRs were increased in all subgroups: 1.8 (95% confidence
interval [CI], 1.7–1.9) and 2.0 (95% CI, 1.9–2.1) for eGFR
30–44 mL/min/1.73 m2; 3.2 (95% CI, 3.1–3.4) and 2.8
CPT Ryan Withrow, DO
Womack FMR Clinic
Fort Bragg, NC
TABLe
Risk for death by eGFR and age group1
eGFR (mL/min/1.73 m2)
Age, y
>60
50–59
40–49
30–39
15–29
<15
18–44
1
1.56 (1.30–1.88)
1.9 (1.35–2.67)
3.58 (2.54–5.05)
4.92 (3.65–6.63)
5.86 (3.91–8.80)
45–54
1
1.27 (1.19–1.36)
1.89 (1.74–2.06)
2.89 (2.63–3.18)
3.95 (3.59–4.35)
4.47 (3.84–5.21)
55–64
1
1.18 (1.13–1.23)
1.75 (1.65–1.85)
2.43 (2.27–2.59)
3.19 (2.97–3.42)
4.29 (3.81–4.84)
65–74
1
1.02 (0.99–1.05)
1.35 (1.32–1.39)
1.81 (1.75–1.87)
2.61 (2.51–2.72)
3.82 (3.50–4.16)
75–84
1
1.02 (0.99–1.04)
1.21 (1.18–1.23)
1.55 (1.51–1.58)
2.21 (2.14–2.27)
3.68 (3.44–3.95)
>85
1
1.02 (0.97–1.06)
1.10 (1.05–1.15)
1.36 (1.29–1.44)
1.86 (1.74–1.98)
3.6 (3.05–4.26)
eGFR >60 mL/min/1.73 m2 is given as the reference. All other values are given as HR (95% CI).
CI=confidence interval; eGFR=estimated glomerular filtration rate; HR=hazard ratio.
continued
Evidence-Based Practice / Vol. 12, No. 7
11
1.O’Hare AM, Bertenthal D, Covinsky KE, et al. Mortality risk stratification in chronic kidney
disease: one size for all ages? J Am Soc Nephrol. 2006; 17(3):846–853. [LOE 2b]
2.Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks
of death, cardiovascular events, and hospitalization. N Engl J Med. 2004; 351(13):1296–
1305. [LOE 1b]
3.Hallan SI, Dahl K, Oien CM, et al. Screening strategies for chronic kidney disease
in the general population: follow-up of cross sectional health survey. BMJ. 2006;
333(7577):1047. [LOE 1b]
4.Ford I, Bezlyak V, Stott DJ, et al. Reduced glomerular filtration rate and its association
with clinical outcome in older patients at risk of vascular events: secondary analysis. PLoS
Med. 2009; 6(1):e16. [LOE 2b]
5.Ryan TP, Fisher SG, Elder JL, et al. Increased cardiovascular risk associated with reduced
kidney function. Am J Nephrol. 2009; 29(6):620–625. [LOE 2b]
How often should a patient with diverticulosis
but a normal colonoscopy be rescreened?
Evidence-Based Answer
The presence or absence of diverticulosis should not
alter the follow-up interval for patients undergoing
colonoscopy for the detection of colorectal cancer.
(SOR C, based on expert opinion.) The frequency for
colonoscopy screening in individuals between the ages
of 50 and 75 years recommended by the US Preventive
Services Task Force is every 10 years.
A recent narrative review discussed several lines of
evidence suggesting that more intensive colon cancer
screening might be important for patients with diverticulitis.1 The review noted that patients with diverticulosis have an elevated lifetime risk of colorectal
carcinoma. Pathologic studies show colonic epithelial
alterations in diverticulosis that are similar to colorectal carcinoma. Theoretically, diverticular inflammation and aberrant crypt foci could initiate a chronic
inflammation–cancer sequence seen in inflammatory
bowel disease. However, the review also found conflicting evidence regarding the relationship of diverticulosis and left-sided colorectal carcinoma, with
positive and negative effects found in different epidemiological studies. Ultimately, the authors concluded
that patients with diverticulosis should be screened
for colorectal carcinoma according to the same guidelines as patients without the condition.
Some uncertainty remains, however, about what
the standard guidelines should be for the screening
interval for colonoscopy. A cohort study of 1,256
patients with no adenomatous polyps on initial
screening evaluated outcomes after repeat colonoscopy 5.3±1.3 years later.2 One or more adenomas were
seen in 16.0% (201/1,256). Advanced adenomas (a
tubular adenoma >1 cm or a polyp with villous his12
Evidence-Based Practice / July 2009
tologic features or high grade dysplasia) were seen in
1.3% (16/1,256).
Another cohort study correlated colonoscopic
findings over time.3 Among 298 patient who were
neoplasia-free at baseline, 7 (2.4%) had advanced
neoplasia at follow-up 5.5 years later. Among the 895
patients with some form of neoplasia at baseline, 86
(9.6%) had advanced neoplasia at follow-up.
Two microsimulation models were applied to
available data to update the USPSTF colon cancer
screening recommendations.4,5 The models were used
to formulate different strategies of colorectal carcinoma screening compared to no screening. The models
showed that the optimum colonoscopy frequency was
every 10 years if adherence was 80% to 100%.
Philipp Narciso, MD
Angela Norman, APN
UAMS/AHEC, South Arkansas
El Dorado, AR
1.Morini S, Zullo A, Hassan C, Tomao S, Campo SM. Diverticulosis and colorectal cancer:
between lights and shadows. J Clin Gastroenterol. 2008; 42(7):763–770. [LOE 5]
2.Imperiale TF, Glowinski EA, Lin-Cooper C, Larkin GN, Rogge JD, Ransohoff DF. Five-year
risk of colorectal neoplasia after negative screening colonoscopy. N Engl J Med. 2008;
359(12):1218–1224. [LOE 2b]
3.Lieberman DA, Weiss DG, Harford WV, et al. Five-year colon surveillance after screening
colonoscopy. Gastroenterology. 2007; 133(4):1077–1085. [LOE 2b]
4.Zauber AG, Lansdorp-Vogelaar I, Knudsen AB, Wilschut J, van Ballegooijen M, Kuntz KM.
Evaluating test strategies for colorectal cancer screening: a decision analysis for the U.S.
Preventive Service Task Force. Ann Intern Med. 2008; 149(9):659–669. [LOE 1a]
5.US Preventive Services Task Force (USPSTF). Screening for colorectal cancer: recommendation statement. AHRQ publication 08-05124-EF-3. http://www.ahrq.gov/clinic/uspstf08/
colocancer/colors.htm. Published October 2008. Accessed June 8, 2009. [LOE 1a]
What is the role of laboratory testing
in the diagnosis of systemic lupus
erythematosus? UPDATE*
Evidence-Based Answer
An initial urinalysis, complete blood count with differential and platelet count, and antinuclear antibody
(ANA) are appropriate for evaluating patients suspected
of having systemic lupus erythematosus (SLE). Further
testing should be based on initial laboratory findings
and clinical features. (SOR C, based on a consensus
panel guideline.)
Diagnosis of SLE is based on both clinical and laboratory findings. The American College of Rheumatology
(ACR) has established criteria for the classification of
*T
his article is an update to: White D. What is the role of laboratory testing in the diagnosis
of systemic lupus erythematosus? Evidence-Based Practice. 2004;7(8):6–7.
TABLe
Classification criteria for SLE
Criteria (“SOAP BRAIN MD”)
Description
Serositis
Pleuritis (pleuritic pain, pleuritic rub, or pleural effusion) or pericarditis (on ECG, rub,
or pericardial effusion)
Oral or nasopharyngeal ulcers
Usually painless, observed by physician
Arthritis, nonerosive
Involving 2 or more peripheral joints with tenderness, swelling, or effusion
Photosensitivity
Skin rash resulting from unusual reaction to sunlight
Blood (hematologic) disorders
•
•
•
•
Renal involvement
Persistent proteinuria (>500 mg/d or 3+ on dipstick) or cellular casts (red cell, hemoglobin, granular,
tubular, or mixed)
Positive antinuclear antibody (ANA)
Abnormal titer in absence of drugs associated with “drug-induced lupus”
Immunologic disorder
• Anti-DNA antibody to dsDNA (native DNA) in abnormal titer, OR
• Antibody to SM nuclear antigen, OR
• Abnormal serum level of immunoglobulin G or M anticardiolipin antibodies, a positive test result for lupus
anticoagulant using standard method, or false-positive serologic test for syphilis (VDRL or RPR),
lasting 6 months, confirmed by Treponema pallidum immobilization or fluorescent treponemal antibody
absorption test
Neurologic disorder
Seizures or psychosis without other organic cause
Malar (butterfly) rash
Fixed erythema, flat or raised, over malar eminences, tending to spare nasolabial folds
Discoid lupus
Erythematous raised patches with adherent keratotic scaling and follicular plugging; atrophic scarring
may occur
Hemolytic anemia with reticulocytosis, OR
White blood cells <4,000 at least twice, OR
Absolute lymphocyte count <1,500/mm3 at least twice, OR
Platelet count <100,000/mm3 without thrombocytopenic drugs
ECG=electrocardiogram; SLE=systemic lupus erythematosus
SLE.1 These criteria were originally developed to define
patients for inclusion in research studies. Although not
originally used for diagnostic purposes, they commonly serve that function for clinicians. The ACR criteria
are presented in the “SOAP BRAIN MD” acronym2 in
the TABLE .
The presence of any 4 of the 11 criteria is 96%
sensitive and 96% specific for diagnosing SLE.3 Four
of these criteria are determined by laboratory testing.
An initial urinalysis, complete blood count with differential and platelet count, and ANA are appropriate for evaluating patients suspected of having SLE.
Further testing, including immunologic tests, would
be based on initial laboratory findings and clinical
features.
A medical literature review was conducted to
update this clinical question, which was first answered
in August 2004. No changes to the diagnostic criteria
for SLE have been made since then. Growing knowledge of anti-DNA antibodies and new laboratory
assays have been developed since the revision of the
ACR criteria in 1982. The Systemic Lupus International Collaborating Clinics (SLICC) has undertaken
EBP
the process of revising the criteria.4
Danette B. Null, MD
Memorial/LSUHSC-New Orleans FMR
Lake Charles, LA
1.Tan EM, Cohen AS, Fries JF, et al. The 1982 revised criteria for the classification of
systemic lupus erythematosus. Arthritis Rheum. 1982; 25(11):1271–1277. [LOE 5]
2.Bartels CM, Muller D. Systemic lupus erythematosus. Emedicine.medscape.com. Updated January 22, 2009. [LOE 5]
3.Hochberg MC. Updating the American College of Rheumatology revised criteria for the
classification of systemic lupus erythematosus. Arthritis Rheum. 1997; 40(9):1725.
[LOE 5]
4.Petri M. Review of classification criteria for systemic lupus erythematosus. Rheum Dis
Clin North Am. 2005; 31(2):245–254. [LOE 5]
Evidence-Based Practice / Vol. 12, No. 7
13
Topics in Maternity Care
Are selective serotonin reuptake inhibitors (SSRIs) safe in pregnancy?
Bottom line
SSRIs have been accepted by many as the treatment of
choice for depression in pregnancy. Overall use of SSRIs
in the first trimester is not associated with congenital
malformations, but 2 SSRIs (sertraline and paroxetine)
have been associated with omphalocele and congenital
cardiac defects when given in the first trimester. Use of
SSRIs in the third trimester has been associated with
neonatal withdrawal syndrome. Paroxetine use in late
pregnancy has also been associated with persistent pulmonary hypertension of the newborn (PPHN). The absolute risk of anomalies with use of SSRIs in pregnancy,
however, is small. Some experts recommend sertraline
over other SSRIs because of its record of relative safety.
Review of the evidence
A 2005 meta-analysis estimated that as many as
18.4% of women are depressed during their pregnancy, including 12.7% of women having an episode of
major depression.1 Many such women are started on
antidepressants.2 No randomized controlled trials or
Cochrane reviews have assessed antidepressant medication use in pregnancy. SSRIs have long been considered
the first-line treatment for depression in pregnancy, but
their safety has been called into question.
Concerns have been raised about first-trimester
exposure to individual SSRIs. A 2007 case-control study
involving 15,709 infants found no association between
use of SSRIs and craniosynostosis (115 infants, 2 exposed
to SSRIs; odds ratio [OR] 0.8; 95% confidence interval
[CI], 0.2–3.5), omphalocele (127 infants, 3 exposed; OR
1.4; 95% CI, 0.4–4.5), or heart defects overall (3,724
infants, 100 exposed; OR 1.2; 95% CI, 0.9–1.6).
Analyses of the associations between individual
SSRIs and specific defects showed significant associations between the use of sertraline and omphalocele (3
exposed infants; OR 5.7; 95% CI, 1.6–20.7) and septal
defects (13 exposed infants; OR 2.0; 95% CI, 1.2–4.0)
and between the use of paroxetine and right ventricular outflow tract obstruction defects (6 exposed infants;
OR 3.3; 95% CI, 1.3–8.8).2 A 2007 meta-analysis associated first-trimester use of paroxetine with cardiac
malformation (OR 1.72; 95% CI, 1.22–2.42).3 Despite
concerns with the use of specific SSRIs in the first trimester, “specific defects implicated are rare and the
absolute risks are small.”2
14
Evidence-Based Practice / July 2009
Use of SSRIs late in pregnancy has been associated
with PPHN. A large case-control showed an increased
risk of PPHN in infants exposed to SSRIs late in pregnancy (OR 6.1; 95% CI, 2.2–16.8).4 Absolute risk was
small (6–12 per 1,000 vs 1–2 per 1,000 in general population) and numbers of cases were too small to find an
association with specific SSRIs.
Third-trimester exposure to SSRIs has also been
associated with a neonatal withdrawal syndrome, consisting of jitteriness, tremors, increased muscle tone, irritability, respiratory distress, and feeding difficulties.4–7
The frequency of this syndrome ranges from 10% to
30% of exposed infants and is generally mild and selflimited, resolving in the first 2 weeks of life.5 Paroxetine
appears to pose the greatest risk of this condition.8
A 2006 American College of Obstetricians and
Gynecologists committee opinion recommends “that
treatment with all SSRIs . . . during pregnancy be individualized and paroxetine use among pregnant women
or women planning to become pregnant be avoided, if
possible.”9 Because of its safety record to date, sertraline
is recommended over other SSRIs by some experts.6,10 EBP
Andrew Oleszkowicz, MD
Lee Dresang, MD
U of WI School of Medicine and Public Health
Madison, WI
RE F ERE N C E S
1.Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol. 2005; 106(5
Pt 1):1071–1083. [LOE 3a]
2.Louik C, Lin AE, Werler MM, Hernández-Díaz S, Mitchell AA. First-trimester use of selective serotonin-reuptake inhibitors and the risk of birth defects. N Engl J Med. 2007;
356(26):2675–2683. [LOE 3b]
3.Bar-Oz B, Einarson T, Einarson A, et al. Paroxetine and congenital malformations: metaanalysis and consideration of potential confounding factors. Clin Ther. 2007; 29(5):918–
926. [LOE 3b]
4.Chambers CD, Hernandez-Diaz S, Van Marter LJ, et al. Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn. N Engl J Med.
2006; 354(6):579–587. [LOE 3b]
5.Way CM. Safety of newer antidepressants in pregnancy. Pharmacotherapy. 2007;
27(4):546–552. [LOE 5]
6.Raudzus J, Misri S. Managing unipolar depression in pregnancy. Curr Opin Psychiatry.
2009; 22(1):13–18. [LOE 5]
7.ACOG Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin: clinical
management guidelines for obstetrician-gynecologists number 92, April 2008 (replaces
practice bulletin number 87, November 2007). Use of psychiatric medications during
pregnancy and lactation. Obstet Gynecol. 2008; 111(4):1001–1020. [LOE 5]
8.Sanz EJ, De-las-Cuevas C, Kiuru A, Bate A, Edwards R. Selective serotonin reuptake
inhibitors in pregnant women and neonatal withdrawal syndrome: a database analysis.
Lancet. 2005; 365(9458):482–487. [LOE 4]
9.ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 354: treatment
with selective serotonin reuptake inhibitors during pregnancy. Obstet Gynecol. 2006;
108(6):1601–1603.
10.Misri S, Kendrick K. Treatment of perinatal mood and anxiety disorders: a review. Can J
Psychiatry. 2007; 52(8):489–498. [LOE 5]
Spotlight on Pharmacy
What is most effective for medication-induced recurrent headaches?
Bottom line
Complete withdrawal of the overused medication is the
treatment of choice for medication-induced headaches
in adults. Adjuvant medications such as amitriptyline
may further improve symptom control, but are not a
substitute for withdrawal. (SOR B, based on results
from limited-quality clinical trials.)
Evidence summary
A systematic review of treatment approaches for medication-induced headache examined 18 studies from
1966 to 1998.1 The studies were small and generally
uncontrolled or nonrandomized. Only 3 trials evaluated abrupt discontinuation alone or compared abrupt
discontinuation with pharmacological interventions.
In 1 uncontrolled, inpatient study, 139 patients
with medication induced-headache (95% caffeine, 89%
ergot, 64% barbiturates, 45% acetaminophen or muscle
relaxants) abruptly withdrew from the offending agent
and received only antiemetic treatment.1 At discharge
(12–14 days after admission), 45% were headache-free,
and 42% were headache-free at 2.9 years.
In another study in the review, 200 outpatients
overusing acetaminophen, aspirin, opioids, barbiturates, sedatives, or muscle relaxants were randomized to
abrupt discontinuation versus continued use and further
randomized to amitriptyline 50 mg/d versus no amitriptyline.1 Abrupt discontinuation alone resulted in a 60%
improvement; abrupt discontinuation with addition of
amitriptyline resulted in a 72% improvement in a headache pain index (no P value provided). Amitriptyline in
addition to continued use of the offending agent resulted in only a 24% improvement in the headache index
(P<.01 compared with discontinuation).
In another study in the review, 200 outpatients who
overused analgesics were assigned to 1 of 2 groups:
Patients in group 1 used only symptomatic agents for
headache and patients in group 2 used prophylactic
agents in addition to the symptomatic agents.1,2
Five subgroups were assembled in a nonrandomized fashion: 1a (continued offending agent), 1b
(offending agent stopped abruptly), 1c (offending
agent stopped abruptly and preventive agent started),
2a (offending agent stopped abruptly and same preventive agent continued), and 2b (offending agent
stopped abruptly and preventive agent dose or drug
changed). All patients also followed low-tyramine,
low-caffeine diets and received biofeedback. Preventive agents used in patients assigned to group 2
included beta-blockers (43%), tricyclic antidepressants (26%), calcium channel blockers (11%), methysergide (8%), or other agents (12%).
The greatest improvement at week 12 was seen in
groups 1c and 2b (where offending analgesics were
abruptly stopped and some adjustment to preventive agents made), each with an 85% improvement
in a headache index. The lowest improvement (24%)
was (not surprisingly) seen in group 1a, in which the
offending agent was continued; group 1b had a 58%
improvement.
The authors of this systematic review concluded
that complete withdrawal should be attempted in all
patients with medication-induced headaches.1 Some
offending agents should be tapered because of the risk
of serious withdrawal syndromes, while others can be
abruptly discontinued.
National Headache Foundation guidelines
National Headache Foundation guidelines state that
many people experiencing medication-induced headache may be treated as outpatients.3 Avoidance of
the overused agent is recommended, as patients may
become refractory to preventive agents if the overused analgesic is continued. Clonidine may be used
for symptomatic treatment of opioid withdrawal,
while phenobarbital may be substituted for butalbital to prevent seizures. Acute analgesic treatments
with other agents should be limited to 2 to 3 days per
week. Nonpharmacologic treatments (biofeedback,
stress management, and cognitive behavioral therapy)
EBP
should also be considered.
Lisa Oikarinen, PharmD candidate
Connie Kraus, PharmD
U of WI School of Pharmacy
Madison, WI
RE F ERE N C E S
1.Zed PJ, Loewen PS, Robinson G. Medication-induced headache: overview and systematic
review of therapeutic approaches. Ann Pharmacother. 1999; 33(1):61–72. [LOE 2a]
2.Mathew NT, Kurman R, Perez F. Drug induced refractory headache—clinical features and
management. Headache. 1990; 30(10):634–638. [LOE 2b]
3.Mathew N, Ward T. Treatment of primary headache: chronic daily headache. In: Standards of Care for Headache Diagnosis and Treatment. Chicago, IL: National Headache
Foundation; 2004:73–80. http://www.guideline.gov/summary/summary.aspx?doc_
id=6583&nbr=4143&ss=6&xl=999. Accessed February 11, 2009. [LOE 5]
Evidence-Based Practice / Vol. 12, No. 7
15
Evidence-Based Practice
Family Physicians Inquiries Network, Inc.
409 West Vandiver Drive
Building 4, Suite 202
Columbia, MO 65202
PRESORTED
STANDARD
U.S. POSTAGE
PAID
LINCOLN, NE
PERMIT # 365
Change Service Requested
Evidence-Based Medicine Ratings
Evidence-Based Practice utilizes a simplified rating system known as the
“Strength of Recommendation Taxonomy” (SORT).
1Strength of Recommendation (SOR) ratings are given as
key recommendations for readers. SORs should be based
upon the highest quality evidence available.
A.Recommendation based on consistent and goodquality patient-oriented evidence
B.Recommendation based on inconsistent or limitedquality,
patient-oriented evidence
C.Recommendation based on consensus, usual
practice, opinion, disease-oriented evidence, or case
series for studies of diagnosis, treatment, prevention,
or screening
2.Lower-quality, patient-oriented evidence (eg,
unvalidated clinical decision rules, lower-quality
clinical trials, retrospective cohort studies, case
control studies, case series)
3.Other evidence (eg, consensus guidelines,
usual practice, opinion, case series for studies
of diagnosis, treatment, prevention,
or screening)
Consistency Across Studies
• Consistent – Most studies found similar or at
least coherent conclusions (coherence means
that differences are explainable); or
If high-quality and up-to-date systematic
reviews or meta-analyses exist, they support the
recommendation.
• Inconsistent – Considerable variation among
study findings and lack of coherence; or
If high-quality and up-to-date systematic
reviews or meta-analyses exist, they do not
find consistent evidence in favor of the
recommendation.
2Levels of Evidence (LOE) determine whether a study
measuring patient-oriented outcomes is of good or
limited quality, and whether the results
are consistent or inconsistent between studies.
Study Quality
1.Good-quality, patient-oriented evidence (eg,
validated clinical decision rules, systematic reviews,
and meta-analyses of randomized controlled trials
[RCTs] with consistent results, high-quality RCTs, or
diagnostic cohort studies)
16
Evidence-Based Practice / July 2009
Who is FPIN?
The Family Physicians Inquiries Network
The Family Physicians Inquiries Network (FPIN) is a national, not-for-profit consortium of
more than 140 academic family medicine departments, residency programs, and academic health
science libraries dedicated to providing evidence-based answers to physicians’ questions at the
point-of-care, through print media, online, and handheld applications. FPIN is revolutionizing
primary care practice by:
•Integrating individual clinical experience with the best available clinical evidence
•Using information technology to translate research evidence into practice
•Teaching primary care clinicians the art and science of clinical scholarship
FPIN provides four avenues for publication of evidence-based research for members:
Evidence-Based Practice
•Print and electronic monthly journal
•Featuring HelpDesk Answers, Drug
Profiles, and feature articles of interest to family medicine
Clinical Inquiries
•Rigorous evidence-based articles based on systematic review of the literature.
•Published in:
The Journal of Family Practice
American Family Physician
PURLs (Priority Updates from the Research
Literature)
•Published in The Journal of Family Practice
•Reality Checker, for instant polling on
potential practice-changing PURLs
eMedRef (PEPID project)
•Handheld and web-based comprehensive
resource
•Comprehensive evidence-based primary
care e-reference for providers in practice
Do you EBP?
Subscribe or Renew Today!
Subscription Rates:
1 Year 2 Year
Individual print or electronic, with CME upgrade $224
$403
Individual print or electronic, without CME
$149
$268
International print copy
$179
$322
For institutional pricing, please visit our website at fpin.org. Resident/student pricing also available.
Renew or subscribe to Evidence-Based Practice at FPIN.org or call 573-256-2066
Evidence-Based Practice
cme
CONTINUING MEDICAL EDUCATION TEST
July 2009
For each question, please mark the single best answer by checking the appropriate box.
1.A 55-year-old Caucasian man has an estimated glomerular
filtration rate (eGFR) of 44 mL/min/1.73 m2. What would
be appropriate counseling regarding prognosis, based on his
current level of kidney function?
o a. He will require dialysis within the next year
o b. His eGFR is associated with an increased risk of a cardiovascular event or even death
o c. The eGFR level provides no further meaningful
information regarding his health status
o d. The eGFR level can be improved with regular exercise
2.Which opioid has the best evidence for long-term treatment
of chronic noncancer pain with the least side effects?
o a. Tramadol
o b. Sustained-release morphine
o c. Oxycodone
o d. Transdermal fentanyl
3.Which of the following factors is a benefit of zoledronic acid
infusion after a hip fracture?
o a. Decreased all-cause mortality rate
o b. Yearly dosing
o c. Ability to treat during inpatient stay
o d. All of the above
4.Which selective serotonin reuptake inhibitor has been most
strongly linked with congenital cardiac defects when taken
during the first trimester?
o a. Paroxetine
o b. Citalopram
o c. Fluoxetine
o d. Fluvoxamine
5.Which of the following treatments is likely to be most
effective in reducing the frequency and intensity
of headaches in a patient with frequent migraine
headache who overuses acetaminophen?
o a. Amitriptyline + withdrawal of acetaminophen
o b. Metoclopramide + withdrawal of acetaminophen
o c. Dihydroergotamine
o d. Valproic acid
6.What is the most effective treatment for long-term symptom
reduction in benign paroxysmal positional vertigo?
o a. Diuretic medications
o b. Calcium channel blockers
o c. Vestibular rehabilitation and scopolamine
o d. Vestibular rehabilitation and Semont maneuver
7.What is the best initial treatment for phimosis
in an 8-year-old boy?
o a. Circumcision
o b. Preputial stretching
o c. Watchful waiting
o d. Steroid cream
8.Only about half of patients thought to have chronic
obstructive pulmonary disease (COPD) clinically will meet
spirographic criteria for the disease. For the other half,
spirometry finds which of the following conditions?
o a. Normal spirometry
o b. Restrictive lung disease
o c. Reversible obstruction
o d. All of the above
For 2009, all AAFP members who subscribe to EBP CME are eligible to earn 2 Prescribed Academy credits monthly
toward their AAFP membership. Please complete and return the CME activity by March 31, 2010.
This test must be received by March 31, 2010 to be accepted for credit
Answer key: 1. b; 2. d; 3. d; 4. a; 5. a; 6. d; 7. d; 8. d
A maximum of 2 prescribed AAFP credits per month are available to EBP subscribers. For each test submitted, send no
money if you have the enhanced EBP subscription with CME upgrade; if you have a regular EBP subscription without CME,
include a check for $15.00 per test submitted, payable to “Family Physicians Inquiries Network”.
To ensure proper credit for your CME test, please provide the following information:
Title (MD, DO, etc) Name (Please print)
SSN (last 4 digits)
Address
City
State
Zip Code Daytime Phone Number
Ext.
Email address (to notify you of credits earned)
Please return your test to the address on the reverse side of this insert. Please be sure to seal this mailer and affix proper postage.
If you have questions about your CME credits, please contact our EBP project Manager, Genny Jacks, by email [email protected] or
telephone 573-256-2066.
Renew or Subscribe to EBP at fpin.org or call 573-256-2066
FEEDBACK
How useful do you find the information in Evidence-Based Practice (EBP)?
What topics would you like to see addressed more frequently in EBP?
How can we improve EBP in future issues?
If you would prefer, email us your feedback at [email protected]
Participate in our brief online survey at: http://www.fpin.org/EBP/ebpsurvey.aspx
(fold here)
Place stamp here.
Post Office will
not deliver mail
without
proper postage.
Family Physicians Inquiries Network
409 W. Vandiver Drive, Bldg. #4, Ste 202
Columbia, MO 65202
(fold here)
Copy for your patients
CLINICAL INQUIRIES: PATIENT EDUCATION
Information you can trust. Information you can use.
Based on the PURLs® (Priority Updates from the Research Literature) from the Family Physicians Inquiries Network:
Arthroscopic surgery for knee osteoarthritis? Just say no.
Journal of Family Practice, March 2009, Vol. 58, No. 3
Best Treatment for Arthritis of the Knee
Arthritis of the knee is the most common cause of knee pain. Up to 80% of people middle-aged
or older have some degree of arthritis, a slow destructive process that gradually wears away the
protective lining and fluid between the bones of the upper leg (femur) and the lower leg (tibia).
What causes arthritis?
Previous injury related to sports, repetitive exercises such as running or trauma to the knees,
inflammatory diseases such as rheumatoid arthritis or a family tendency toward arthritis
(heredity) can all cause these damaging changes. Being overweight contributes greatly to stress
on the knees. The result is pain that can be achy or sharp with certain movements, stiffness in
the morning, and sometimes swelling, noise when bending the knee (crepitus), and decreased
range of motion.
What can you do for arthritis of the knee?
• Losing some weight can make a big difference.
• Moderate strength training to build up the muscles around the knee is very helpful.
Swimming, cycling, and weight training under the guidance of a therapist are examples of
strength training.
• Taking over-the-counter medicines such as aspirin, acetaminophen (Tylenol®), or
nonsteroidal anti-inflammatory drugs such as Aleve® or Advil® are effective in reducing
pain. If you need to take these medications on a daily basis because of persistent pain, check
with your doctor.
• Using ice after exercising or heat for pain relief is helpful for some people.
• See your doctor for possible supportive devices to help stabilize the knee and injections of
corticosteroids (which temporarily reduce inflammation) or hyaluronic acid (which provides
lubrication to the knee joint).
What’s new about treating arthritis of the knee?
Although many operations are available for arthritis of the knee (arthroscopic surgery) to clean
out bone fragments and smooth bone surfaces, recent studies show no clear benefit or long-term
pain relief from these surgeries. People who used conservative measures, such as those listed
above, did just as well.
For more information
Arthritis of the Knee (American Academy of Orthopaedic Surgeons)
http://orthoinfo.aaos.org/topic.cfm?topic=A00212
Osteoarthritis (National Institute of Arthritis and Musculoskeletal and Skin Diseases)
http://www.niams.nih.gov/Health_Info/Osteoarthritis
Osteoarthritis of the Knee: A Guide for Adults (Agency for Healthcare Research and Quality)
http://effectivehealthcare.ahrq.gov/healthInfo.cfm?infotype=sg&DocID=132&ProcessID=89
JULY 2009