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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

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Evidence-based Medicine Literature Review


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ebm key concepts
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
Evidenced-based Sources
  • Dynamed
  • Essential Evidence Plus
  • Cochrane Database
  • ACP Journal Club
  • US Preventive task force
  • Trip database
  • Some specialty guidelines
oxford centre evidence levels
Oxford Centre Evidence Levels
  • 1A- Systematic reviews
  • 1B - Randomized controlled trials
  • 2 - Cohort studies
  • 3 - Case-control
  • 4 - Case series
  • 5 - Expert Opinion
  • A,B,C, and D
ebm key concepts1
EBM – Key Concepts
  • Keep track of systematic reviews and randomized controlled trials with patient-oriented results
  • Consider using synthesized database to keep up with literature
  • Evaluate new information in context and for practice change
mediterranean diet
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 diet1
Mediterranean diet
  • 7447 people in Spain
  • 55-80 yrs oldwith type 2 DM or 3 risk factors followed for 4.8 yrs
  • Mediterranean diet + olive oil or + nuts (mix of hazelnuts, almonds, and walnuts)
  • Low fat diet
  • Scores for diet adherence similar
  • Combined endpoint of MI, stroke and death – both arms did better than low fat
mediterranean diet2
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 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 supplements1
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
d dimer
D-Dimer
  • Very good at excluding DVT and PE if negative (<500)
  • Not good in elderly
  • ADJUST-PE study – JAMA March 19, 2014
  • Multicenter, consecutive ER patients
  • Age-adjusted D-Dimer level (age x 10 mcg/dl)
  • 3346 patients suspected PE (53-74)
d dimer age adjusted
D-Dimer age adjusted
  • 19% PE rate
  • High clinical likelihood – CTA
  • 2898 – D-dimer, 337 in age-adjust
  • 1 of 331 patients had confirmed VTE in 3 months
  • Similar to rates with negative workup
  • No CTA in negative group
migraine treatment
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 treatment1
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 treatment2
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
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 throat1
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
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%)
tias minor strokes
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 strokes1
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 strokes2
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