Faculty/Presenter Disclosure Faculty/Presenter: Mike Allan, Where - - PDF document

2018-04-11 1

Family Medicine Jeopardy

• G. Michael Allan

Professor, Dept of Family Medicine, University of Alberta, Director of Evidence and CPD, Alberta College of Family Physicians

Faculty/Presenter Disclosure

• Faculty/Presenter: Mike Allan,
• Where we get Personal $: U of A, Alberta Health, CFPC
• Where we get Grant/ Program $: Alberta College of Family

Physicians, Other Colleges of Family Physicians, Toward Optimized Practice, Other non-profit organizer

• Relationships with commercial interests:

– Grants/Research Support: Not applicable – Speakers Bureau/Honoraria: Not applicable – Consulting Fees: Not applicable – Other: None

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Flashes of Evidence for Menopauses Honey, I have cough Coffee: Nice Vice or poor health choice? Santa, Kids and Kindness Melatonin: Sleepy time Sterile wounds: “All you need is glove” Omega-3 & a world without CVD Glucosamine for Rusty Joints

Small Adults Big Kids Now Grab Bag

Lipoproteins & Biomarkers: (over)Interpreting Do sore knees need steroids Overactive Bladder & Underactive Medicines Screening CBC test: Help or Harm. Steroid shots for Tennis Elbow I know you’re sick, just wait 2 days for these Antibiotics What is after after 3rd line for hypertension? Best rheumatoid lab Test My infant won’t sleep: Time to train MSK Pain in kids, KISS principles Lipid Guidelines: By & For Primary Care Back to the Spasm: Cyclobenzaprine & pain Ready, Fire, Aim: Treating to target Poor Sleep: Don’t go to bed! From Swimmer mistake to rhino-sinusitis cure Chocolate: It tastes so good, it must good for you. Manipulation of the Spine (and Research) AOM: Who to Treat, Who to watch BMI The secrets of normal Rusty Knees, Trial some Viscous supplementation

Do OTC cough suppressants or Honey improve cough due to URTI in children?

• Evidence: 3 RCTs if Honey, all find the same

– At 24 hrs: 59% honey, 45% DM & DPH, 31% no-drug – 8 RCTs of cough med (616 children): No effect – Health Canada recommends against OTC cough in <6

• Bottom-line: OTC cough suppressants should not

be used in children under 6 and do not appear to be effective in older children. There is sufficient evidence to support the use of honey in acute pediatric cough.

#24 April 12, 2010. Updated October 22, 2013

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Do non-sterile gloves increase infections in minor lacerations or excisions.

• Minor excision/laceration studies (infection rates):

– Primary care RCT 493 pts for ~2 cm excision:

• 8.7% non-sterile vs 9.3% sterile gloves, not statistically different.

– Mohs RCT 60 pts (age ~73) for ~2.2 cm excisions:

• 3% non-sterile vs 7% sterile gloves, not statistically significant.

– Canadian ER RCT 816 pts, suture of lacerations.

• 4.3% non-sterile vs sterile gloves 6%, not statistically different.

– Older laceration ?RCTs (50 & 408 pts), no gloves vs sterile, No diff. – Sterile Gloves 3.5 to 16x more expensive that non-sterile.

• Bottom-line: Using non-sterile gloves does not increase the

number of infections when compared to sterile gloves for

• utpatient minor/uncomplicated skin excisions (not flap excisions)

and laceration repair in immune-competent adults. Unclear if this applies to sebaceous cyst excision, as these weren’t studied.

TFP #2 (updated August 2016); TFP #178 (Jan 9, 2017) & upcoming CFP http://chd.bestsciencemedi cine.com/calc2html#basic

Simplified Lipid Guideline

Can Fam Physician. 2015;61:857-67.

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What happens to kids who stop believing?

• Is Santa linked to kindness?

– 52 adults found Santa “ kinder” than a doctor: 9.2 v 8.7 – 25 six y.o. gave more gum when Santa v Easter bunny or pets (3.6 pieces vs 1.3-1.6).

• Are children excited to see Mall Santa?

– 150-300 children x 5 yrs: 58-82% appeared indifferent (v parents ~90%) higher if closer to 25th

• When do children stop believing?

– Age 6.4-8.3, Later if parents push or believed ≥ age 10

• How do children feel?

– Minimal distress (rating <10%). Generally gradual, proud, & positive. Only 8% say they won’t promote Santa to their kids. – Parents more sad (40% vs 6% glad)

#177 Dec 19, 2016

Hot flash treatment with SSRI as good as HRT

• Evidence: Well-designed Meta-analysis of 43 RCT’s

– SSRI/SNRI (mid dose)= 1.13 ↓Hot Flashes/d (vs placebo) – Clonidine (≤0.075mg BID) = 0.95 - 1.63 ↓Hot flashes/d – Gabapentin (300mg TID) = 2.05 ↓Hot flashes/d – Soy Isoflavone Extract (50-70mg/d)= 0.97-1.22 ↓ – Endometrial safety with Isoflavone still unresolved. – Estrogen best (2.5-3 ↓ Hot flashes/d)

• Bottom-line: All drugs for hot flashes are

generally equivalent in effectiveness except HRT which is better. Select based on side-effects and patient preference.

JAMA 2006; 295: 2057-71..

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Will steroid injections improve or worsen tennis elbow (epicondylitis)?

• Evidence: 1 Sys Rev + 2 RCTs:

– Sys Rev: 12 RCTs, 1171 patients

• 3-7 wks: pain & function: steroid > no intervention or NSAIDs .
• 26-52 wks: Steroid injections < no intervention.

– RCT 198 patients: 3 wks steroid > physio or wait-&-see NNT 2

• At 52 weeks: NNT=4 steroid worse outcomes than physio.

– RCT 165: steroid vs steroid/physio vs physio vs placebo.

• 4 wks: Steroid >physio NNT 4; 52 wks: physio/placebo > steroid NNT 10
• Bottom-line: Corticosteroid injections are effective for

symptom management of lateral epicondylitis in the short- term, however in the long term they appear to result in poorer outcomes than no intervention at all.

TFP #48: July 27, 2011. JAMA 2013; 309(5): 461-9.

How well do steroid shots work for knee OA?

• Evidence: 6 sys revs, (5-13 RCTs, 207-648 pts). often triamcinolone 20-

40mg or methylprednisolone 40-120mg). Baseline pain 54 (out of 100) – Pain reduced: 21-22 points 1 wk, 16.5 points 2 wks, 7.4 points 3-4 wks

• Average ~15 points better between 1-4 weeks, peak at 1.5 weeks

– Global improve or pain reduction target: 74-78% steroid vs 45-54% placebo, NNT=3-5 at 1-4 weeks – After week 4, inconsistent results: most favorable was NNT 5 at 16-24 weeks (1 of 3 rev) – Function and stiffness: no consistent difference

• Bottom-line: Corticosteroid knee injections improve osteoarthritis

pain ~40% more than placebo & one in every 3-5 patients will have global improvement x4 weeks. Long-term uncertain but serious adverse events are very rare (joint infection 1 in >14,000).

Unpublished TFP. Jamieson and Allan

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Will chocolate improve cardiovascular risk?

• CVD sys Rev: 5-9 observational studies (75-157,000 adults x8-16 yrs)

– CVD RR 0.63 (0.40-0.90); MI/angina RR 0.90 (0.82-0.97), Stroke RR 0.81 (0.73-0.90); CHF RR 0.81 (0.66-1.01)

• Risk Factors (10-20 BP RCTs & 8-10 lipid RCTs):

– BP: down ~3.5 mmHg SBP & ~2.5 DBP. Less if study longer or ‘0’ if vs milk chocolate – Lipid: LDL down 0.15mmol/L but no change in any other lipid parameter

• Others: Mood unstudied and no clear association for causing headache.

– Acne: 2 RCTs (67 acne pts): 4-5 more lesions 2-3 days after chocolate ingestion

• Bottom-line: Chocolate consumption is associated with no change or

a small reduction in cardiovascular disease in cohort studies. Evidence is too weak to recommend chocolate consumption for health benefits. Surrogate marker changes are minimal and perhaps

• unreliable. Chocolate likely increases acne lesions in susceptible

individuals.

TFP #175: Nov 21, 2016.

Does Spinal Manipulation Therapy (SMT) improve Back Pain?

• >20 SRs of RCTs: multiple analysis (91 in 1 SR!)

– RCT issues: low quality, SMT added to other interventions.

• Acute LBP: 20 RCTs, ~2600 pts,

– 3/17 compared SS (One ↓ pain 0.6 in 1 mon), No recovery diff

• Chronic LBP: 26 RCTs, ~6,000 pts,

– 11/29 comparisons SS (↓ pain ~0.3-0.9 in 1 month) – Possibly ↑ recovery (best NNT: 11 @ 1 month)

• Bottom-line: Research around SMT is poor, consistently

inconsistent, and almost impossible to interpret. Likely no reliable effects in acute LBP, but possible small effects in chronic LBP, at best improved pain (≤0.9 points out of 10) and recovery (for one in ~11 patients at one month) but two thirds of comparisons found no effect.

TFP #181, Feb 2017. Can Fam Physician. 2017 Apr;63(4):294.

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Is the Ideal BMI for survival 18.5-25?

• 97 studies, 2.88 million pts: vs normal (BMI 18.5-24.9)

– Overweight (BMI 25-29.9): RR=0.94 – Obese Grade I (BMI 30-35): RR=0.95 – Obese Grade ≥II (BMI >35): RR=1.29

• 8 studies, 5.8 million pts, vs high normal BMI (22.5-25):

– BMI <18.5 (HR=1.88); BMI 18.5-20 (HR=1.39); BMI 20-22.5 (HR=1.15) – BMI 25-27.5 (HR=0.97); BMI 27.5-30 (HR=1.04); BMI 30-35 (HR=1.18)

• If Elderly (age ≥65): BMI ~27.5 best.
• Bottom-line: Normal (20-25) to overweight (25-30) BMI

carry the lowest risk of mortality, with ~25 appearing lowest (in elderly ~27.5). Mortality increases when BMI is below “low-normal” (BMI<20) and obese (BMI≥30), more at the extremes.

TFP #138. May 11, 2015.